2014 Rx Preferred Drug Guide (3-Tier) Please bring this guide with you to your next doctor visit.
30692 (Ed. 09/13)
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Do you have questions?
Call Assurant Health Customer Service at the phone number
printed on your ID card.
Dear Member,
To help you know how drugs are covered by your plan, we are
pleased to provide you with a copy of our 2014 Rx Preferred Drug
Guide.
This document provides helpful information on the Assurant Rx
Preferred Drug Guide and your pharmacy benefit plan. You may
want to take this guide with you when you see your doctor to talk
about what is covered under your plan.
Many commonly prescribed drugs are listed in this guide. Please
remember this is not a complete list of drugs covered under your
plan. Because thousands of drugs are included in your pharmacy
benefits plan, we only list the most commonly prescribed ones.
Please note that not all drugs listed in this guide are covered by all
pharmacy benefit programs. Check your benefit materials for the
specific covered drugs and your co-payment program.
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What is the Assurant Rx Preferred Drug Guide?
Our Rx Preferred Drug Guide is meant to give you a general view of drugs covered by your plan. Changes to the list are based on the latest medical findings as well as information from the Food and Drug Administration (FDA) and drug makers.
This list includes both brand-name and generic drugs and is updated regularly. Assurant will generally cover the drugs listed on our Rx Preferred Drug Guide as long as they are medically necessary and plan rules are followed. Coverage is not limited to drugs on the Rx Preferred Drug Guide.
Your plan has different copay or coinsurance tiers for generic, brand-name, preferred and non-preferred drugs. Usually, preferred drugs are covered at a lower copay or coinsurance tier, which means you pay less out of pocket for those drugs.
The Rx Preferred Drug Guide is subject to change. Drugs on the list are based on reliable medical data, safety and cost. When you talk to your doctor about what drug may be right for you, it is important to remember that you and your doctor are responsible for making the final decision on your drug therapy.
Why is the Rx Preferred Drug Guide subject to change?
During the year, we may add or remove drugs from the Rx Preferred Drug Guide. These changes happen for various reasons and may move a drug from one coverage tier to another.
As brand-name drugs lose their patents, generic versions may become available. When this happens, the brand-name drug may move to a higher copayment or coinsurance tier. The generic drug may be added to the list and available at a lower copayment or coinsurance tier.
The FDA approves many new drugs throughout the year. Your plan generally covers new FDA-approved drugs; however, you may pay a higher copayment or coinsurance tier for these drugs. The new drug(s) also may be subject to precertification or step-therapy requirements.
Some drugs may also no longer require a prescription. If your drug becomes available over-the-counter (OTC), the drug will generally no longer be covered under your prescription plan.
If the FDA removes a drug from the market it will also no longer be covered under your prescription plan.
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Why do some drugs have quantity limits?
Your plan may limit the amount of a drug you can receive at one time. These limits help your doctor and pharmacist check that the drugs are used appropriately while promoting patient safety. We use medical guidelines, FDA approval and guidance from drug makers to set these coverage limits. The quantity limits program includes:
Dose Efficiency Edits – Limits coverage of prescriptions to one dose per day for drugs that are approved for once-daily dosing.
Maximum Daily Dose – A message is sent to the pharmacy if a prescription is higher than the maximum allowed dose.
Quantity Limits Over Time – Limits coverage of prescriptions to a specific number of units in a defined amount of time.
To get coverage for amounts over the allowed quantity, you, your doctor or the person you appoint to manage your care must request a coverage override by calling the phone number located on your ID card. The quantity limit list is subject to change.
What is step-therapy?
With step-therapy you must try one or more alternate drugs before your plan will cover a step-therapy drug. These drugs are FDA-approved, treat the same condition(s) and, they may also be available to you at a lower copay or coinsurance tier.
If it is necessary for you to use a drug on the step therapy list, you, your doctor, or the person you appoint to manage your care may request a coverage override by calling the phone number located on your ID card.
What is the Prior Authorization program?
The Prior Authorization program encourages appropriate and cost-effective use of drugs by allowing coverage only when certain conditions are met.
• A physician, a patient, or a person appointed to manage the patient’s care must request prior authorization before drugs on the Prior Authorization List will be covered under a member’s pharmacy benefits plan. If the request is approved, the drug will then be covered at the applicable costs associated with the member’s plan.
• The Prior Authorization program is based upon current medical findings, FDA-approved manufacturer labeling information, and cost.
• To determine if a drug requires prior authorization, refer to the column titled Prior Authorization next to the list of drugs in this guide. You can also call the phone number on the back of the member identification card to obtain more information on the prior authorization review process.
• The list of drugs requiring prior authorization is subject to change.
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What are generic drugs?
Drug manufacturers develop and release new drugs under a brand name. When the patent expires, other manufacturers are then able to make duplicate versions of the same drug. Generic drugs are chemically the same as their branded counterparts. They are also the same in dosage, safety, strength, form and intended use. Plus, generics usually cost less than brand-name drugs.
Generic drugs are only available after the FDA approves them. When filling your prescription, your pharmacist generally can substitute a generic drug for a brand-name drug when the generic is rated by the FDA as equivalent and also where it is permitted by your doctor and state law.
Table of Contents – Preferred Drugs by Therapeutic Class
Therapeutic Class Page(s)
Antineoplastic Agents 6 Blood Products – Modifiers – Volume Expanders 8 Cardiovascular System 9 Central Nervous System 18 Dermatological Agents 30 Endocrine System 36 Gastrointestinal System 45 Genitourinary System 48 Infections and Infestations 50 Musculoskeletal System 56 Ophthalmic Agents 58 Otic Agents 61 Respiratory Tract Agents 62 Miscellaneous 64
THERAPEUTIC CLASS LIST KEY (on following pages)
lower case– Generic medication – lowest co-payment
UPPERCASE – Brand-name medication – Higher co-payment
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Medication Name
3-Tier G = Generic
P = Preferred Brand
NP = Non Preferred
Brand Prior
Authorization Quantity
Limit Step
Therapy
Antineoplastic Agents
Alkylating Agents
ALKERAN P
CEENU P
lomustine G
cyclophosphamide G
HEXALEN P
LEUKERAN P
MYLERAN P
TEMODAR capsule P √
temozolomide G √
Antimetabolites
mercaptopurine G
methotrexate G
PURINETHOL NP
TABLOID P
TREXALL NP
XELODA NP √
Antineoplastic – Enzyme Inhibitors
AFINITOR NP √
BOSULIF NP √
CAPRELSA NP √
COMETRIQ NP √
GILOTRIF NP √
GLEEVEC P √
ICLUSIG NP √
INLYTA NP √
IRESSA NP
JAKAFI NP √
MEKINIST NP √
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NEXAVAR NP √
POMALYST NP √
SPRYCEL NP √
STIVARGA NP √
SUTENT P √
TAFINLAR NP √
TARCEVA P √
TASIGNA P √
TYKERB NP √
VOTRIENT NP √
XALKORI NP √
ZELBORAF NP √
ZOLINZA NP √
Antineoplastic – Hormonal Agents
anastrozole G
ARIMIDEX NP
AROMASIN NP
bicalutamide G
CASODEX NP
EMCYT P
exemestane G
FARESTON NP
FEMARA NP
flutamide G
letrozole G
LYSODREN NP
MEGACE NP
MEGACE ES NP
megestrol G
NILANDRON P
tamoxifen G
XTANDI NP √
ZYTIGA P √
Antineoplastics – Miscellaneous
ERIVEDGE NP √
HYDREA NP
hydroxyurea G
MATULANE P
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TARGRETIN P
tretinoin 10 mg G √
Chemotherapy Rescue/Antidote Agents
leucovorin calcium G
MESNEX NP
Immunomodulators
REVLIMID NP
THALOMID NP
Topoisomerase I Inhibitor
HYCAMTIN NP √
Blood Products – Modifiers – Volume Expanders
Anticoagulants – Coumarin
COUMADIN NP
jantoven G
warfarin G
Anticoagulants – Direct Thrombin Inhibitors/Factor Xa Inhibitor
ELIQUIS NP √ √
IPRIVASK NP
PRADAXA P √
XARELTO P √
Anticoagulants – Heparins
ARIXTRA NP
fondaparinux G
FRAGMIN NP
heparin sodium G
LOVENOX NP
enoxaparin G
Hemostatics – Systemic
AMICAR NP
aminocaproic acid G
LYSTEDA NP √
tranexamic acid G √
Platelet Aggregation Inhibitors
AGGRENOX P
AGRYLIN NP
anagrelide G
BRILINTA NP √
cilostazol G
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clopidogrel G
dipyridamole G
EFFIENT P √
PERSANTINE NP
PLAVIX NP
PLETAL NP
ticlopidine G
Cardiovascular System
Alpha-Beta Blockers
carvedilol G
COREG NP
COREG CR P
labetalol G
TRANDATE NP
Anaphylaxis Therapy Agents
ADRENACLICK NP
AUVI-Q NP √
epinephrine G
EPIPEN P
EPIPEN-JR P
TWINJECT NP
Angiotensin Converting Enzyme (ACE) Inhibitors and Combinations
ACCUPRIL NP
ACCURETIC NP
ACEON NP
ALTACE NP
benazepril G
benazepril/hydrochlorothiazide G
captopril G
captopril/hydrochlorothiazide G
enalapril G
enalapril/hydrochlorothiazide G
EPANED NP √
fosinopril G
fosinopril/hydrochlorothiazide G
lisinopril G
lisinopril/hydrochlorothiazide G
moexipril G
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moexipril/hydrochlorothiazide G
LOTENSIN NP
LOTENSIN HCT NP
MAVIK NP
perindopril G
PRINIVIL NP
PRINZIDE NP
quinapril G
quinapril/hydrochlorothiazide G
ramipril G
trandolapril G
UNIRETIC NP
UNIVASC NP
VASERETIC NP
VASOTEC NP
ZESTORETIC NP
ZESTRIL NP
Angiotensin II Receptor Antagonists and Combinations
ATACAND NP √
candesartan G √
ATACAND HCT NP √
candesartan/hydrochlorothiazide G √
AVALIDE NP √
AVAPRO NP √
AZOR NP √ √
BENICAR NP √ √
BENICAR HCT NP √ √
COZAAR NP √
DIOVAN NP √ √
DIOVAN HCT NP √ √
EDARBI NP √ √
EDARBYCLOR NP √ √
eprosartan G √
EXFORGE P √
EXFORGE HCT P √
HYZAAR NP √
irbesartan G √
irbesartan/hydrochlorothiazide G √
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losartan G √
losartan/hydrochlorothiazide G √
MICARDIS P √
MICARDIS HCT P √
TEVETEN NP √
TEVETEN HCT NP
TRIBENZOR NP √ √
TWYNSTA NP √ √
valsartan/hydrochlorothiazide G √
Antiadrenergic Antihypertensives
CARDURA NP
CATAPRES NP
CATAPRES-TTS NP
clonidine G
doxazosin G
guanabenz G
guanfacine G
methyldopa G
MINIPRESS NP
NEXICLON NP √
prazosin G
reserpine G
TENEX NP
terazosin G
Antianginals – Nitrates
amyl nitrite G
DILATRATE SR NP
IMDUR NP
ISORDIL NP
isosorbide dinitrate G
isosorbide mononitrate G
MONOKET NP
NITRO-BID NP
NITRO-DUR NP
nitroglycerin G
nitroglycerin CR G
nitroglycerin SL G
NITROLINGUAL NP
12
NITROMIST NP
NITROSTAT P
Antianginals – Other
RANEXA P √
Antiarrhythmics Type I-A
disopyramide G
NORPACE NP
procainamide G
quinidine gluconate G
quinidine sulfate G
Antiarrhythmics Type I-B
mexiletine G
Antiarrhythmics Type I-C
flecainide G
propafenone G
RYTHMOL NP
RYTHMOL SR NP
TAMBOCOR NP
Antiarrhythmics Type III
amiodarone G
CORDARONE NP
MULTAQ P
PACERONE NP
TIKOSYN NP
Antihyperlipidemics – Bile Sequestrants
cholestyramine G
cholestyramine light G
COLESTID NP
colestipol G
prevalite G
QUESTRAN NP
QUESTRAN LITE NP
WELCHOL P
Antihyperlipidemics – Fibric Acid Derivatives
ANTARA NP √
fenofibrate G
fenofibrate choline G
fenofibrate micronized G
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fenofibric acid G
FENOGLIDE NP √
FIBRICOR NP √
gemfibrozil G
LOFIBRA NP √
LOPID NP √
LIPOFEN NP √
TRICOR NP √
TRIGLIDE NP √
TRILIPIX NP √
fenofibrate delayed-release G
Antihyperlipidemics – HMG CoA Reductase Inhibitors
ADVICOR NP √
ALTOPREV NP √ √
amlodipine/atorvastatin G √
atorvastatin G √
CADUET NP √ √
CRESTOR P √
fluvastatin G √
LESCOL NP √
LESCOL XL NP √ √
LIPITOR NP √ √
LIPTRUZET P √
LIVALO NP √
lovastatin G √
MEVACOR NP √
PRAVACHOL NP √
pravastatin G √
SIMCOR P √
simvastatin G √
VYTORIN NP √
ZOCOR NP √
Antihyperlipidemics – Intestinal Cholesterol Absorption Inhibitor
ZETIA P √
Antihyperlipidemics – Miscellaneous
JUXTAPID NP √ √
LOVAZA P
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VASCEPA P
Antihyperlipidemics – Nicotinic Acid Derivatives
niacin ER tablet G
NIASPAN NP
Antihypertensives-Miscellaneous
VECAMYL NP √ √
Beta Blockers Cardioselective and Combinations
acebutolol G
atenolol G
atenolol/chlorthalidone G
betaxolol G
bisoprolol G
bisoprolol/hydrochlorothiazide G
BYSTOLIC P
DUTOPROL P
KERLONE NP
LOPRESS HCT NP
LOPRESSOR NP
metoprolol G
metoprolol ER G
metoprolol/hydrochlorothiazide G
SECTRAL NP
TENORETIC NP
TENORMIN NP
TOPROL XL NP
ZEBETA NP
ZIAC NP
Beta Blockers Non-Selective and Combinations
BETAPACE NP
BETAPACE AF NP
CORGARD NP
CORZIDE NP
INDERAL LA NP
INNOPRAN XL NP
LEVATOL NP
nadolol G
nadolol/bendroflumethiazide G
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pindolol G
propranolol G
propranolol SR G
propranolol/hydrochlorothiazide G
sorine G
sotalol G
sotalol AF G
timolol G
Calcium Blockers
ADALAT CC NP
afeditab G
amlodipine G
CALAN NP
CALAN SR NP
CARDENE SR NP
CARDIZEM NP
CARDIZEM CD NP
CARDIZEM LA NP
cartia XT G
COVERA-HS NP
DILACOR XR NP
dilt-CD G
dilt-XR G
diltiazem G
diltiazem CD/ER/CR/XT G
diltiazem SR extended release beads G
DYNACIRC CR NP
felodipine G
ISOPTIN SR NP
isradipine G
matzim LA G
nicardipine G
nifediac CC G
nifedical XL G
nifedipine G
nifedipine CR/ER/SR G
nimodipine G
nisoldipine G
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NIMOTOP NP
NORVASC NP
NYMALIZE NP √
PROCARDIA NP
PROCARDIA XL NP
SULAR NP
taztia XT G
TIAZAC NP
verapamil G
verapamil CR/ER/SR G
VERELAN NP
VERELAN PM NP
VERELAN SR NP
Cardiac Glycosides
digoxin G
LANOXIN NP
Cardiovascular Combinations – Miscellaneous
amlodipine/benazepril G
BIDIL NP
CLORPRES NP
hydralazine/hydrochlorothiazide G
LOTREL NP
methyldopa/hydrochlorothiazide G
rauwolfia/bendroflumethiazide G
TARKA NP
Direct Renin Inhibitor and Combinations
AMTURNIDE NP √
TEKAMLO NP √
TEKTURNA NP √
TEKTURNA HCT NP √
Diuretics – Carbonic Anhydrase Inhibitors
acetazolamide G
DIAMOX NP
methazolamide G
Diuretics – Loop
bumetanide G
DEMADEX NP
EDECRIN NP
17
furosemide G
LASIX NP
torsemide G
Diuretics – Potassium Sparing and Combinations
ALDACTAZIDE NP
ALDACTONE NP
amiloride G
amiloride/hydrochlorothiazide G
DYAZIDE NP
DYRENIUM NP
MAXZIDE NP
MIDAMOR NP
spironolactone G
spironolactone/hydrochlorothiazide G
triamterene/hydrochlorothiazide G
Diuretics – Selective Aldosterone Receptor Antagonists (SARAs)
eplerenone G
INSPRA NP
Diuretics – Thiazide and Thiazide-Like
chlorothiazide G
chlorthalidone G
DIURIL NP
hydrochlorothiazide G
indapamide G
methychlothiazide G
metolazone G
MICROZIDE NP
THALITONE NP
ZAROXOLYN NP
Pheochromocytoma Agents
DEMSER NP
DIBENZYLINE P
Pulmonary Hypertension Agents
ADCIRCA NP √
LETAIRIS P
REVATIO NP √
sildenafil G √
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TRACLEER P
TYVASO NP
VENTAVIS NP
Vasodilators
hydralazine G
isoxsuprine G
minoxidil G
papaverine ER G
Central Nervous System
ALS Agents
RILUTEK NP
riluzole G
Alzheimer's Disease – Antidementia
ARICEPT 5 and 10 mg NP
ARICEPT 23 mg NP
ARICEPT ODT NP
donepezil G
donepezil ODT G
EXELON capsule NP
EXELON patch P
EXELON solution P
galantamine G
galantamine SR G
NAMENDA P
NAMENDA XR P
RAZADYNE NP
RAZADYNE ER NP
rivastigmine G
Antianxiety – Benzodiazepines
alprazolam G
alprazolam ER G
alprazolam ODT G
chlordiazepoxide G
clorazepate G
diazepam G
lorazepam G
NIRAVAM NP
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oxazepam G
XANAX XR NP
Antianxiety – Miscellaneous
buspirone G
hydroxyzine hydrochloride G
hydroxyzine pamoate G
meprobamate G
Anticonvulsants – Benzodiazepines
clonazepam G
clonazepam orally disintegrating tablet G
DIASTAT NP
diazepam rectal gel G
KLONOPIN NP
ONFI NP
Anticonvulsants – Carbamates
felbamate G
FELBATOL NP
Anticonvulsants – GABA Modulators
GABITRIL NP
SABRIL powder NP
SABRIL tablet NP
tiagabine G
Anticonvulsants – Hydantoins
DILANTIN NP
phenytoin extended G
phenytoin sodium G
Anticonvulsants – Miscellaneous
BANZEL NP
carbamazepine G
carbamazepine SR G
carbamazepine XR G
CARBATROL NP
gabapentin G √
KEPPRA NP
KEPPRA XR NP
LAMICTAL NP
LAMICTAL ODT NP
LAMICTAL ER NP
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lamotrigine G
lamotrigine ER G
levetiracetam G
levetiracetam ER G
LYRICA NP √ √
NEURONTIN NP √
oxcarbazepine G
OXTELLAR XR NP
POTIGA NP √
primidone G
TEGRETOL NP
TEGRETOL XR NP
TOPAMAX NP
topiramate G
TRILEPTAL NP
TROKENDI XR NP √ √
VIMPAT NP √
ZONEGRAN NP
zonisamide G
Anticonvulsants – Succinimides
CELONTIN NP
ethosuximide G
ZARONTIN NP
Anticonvulsants – Valproic Acid
DEPAKENE NP
DEPAKOTE NP
DEPAKOTE ER NP
DEPAKOTE SPRINKLE NP
divalproex sodium delayed-release G
divalproex sodium sprinkle G
divalproex sodium SR G
STAVZOR NP
valproic acid G
Antidepressants – Alpha-2 Receptor Antagonists
mirtazapine G √
mirtazapine ODT G √
REMERON NP √
REMERON SOLUTAB NP √
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Antidepressants – MAO Inhibitors
EMSAM NP √
MARPLAN NP
NARDIL NP
PARNATE NP
phenelzine G
tranylcypromine sulfate G
Antidepressants – Miscellaneous
APLENZIN NP √ √
budeprion G √
budeprion XL G √
bupropion G √
bupropion SR G √
FORFIVO XL NP √ √
maprotiline G √
WELLBUTRIN NP √
WELLBUTRIN SR NP √
WELLBUTRIN XL P √
Antidepressants – Modified Cyclics
nefazodone G
OLEPTRO NP √ √
trazodone G
VIIBRYD NP √ √
VIIBRYD KIT NP √ √
Antidepressants – Serotonin-Norepinephrine Reuptake Inhibitors
CYMBALTA NP √ √
DESVENLAFAXINE ER NP √ √
EFFEXOR XR NP √
PRISTIQ NP √ √
venlafaxine G √
venlafaxine ER capsule G √
VENLAFAXINE ER tablet NP √ √
venlafaxine ER tablet G √
Antidepressants – Selective Serotonin Reuptake Inhibitors
CELEXA NP √
citalopram G √
escitalopram G √
fluoxetine G √
22
FLUOXETINE 60 MG NP √ √
fluoxetine delayed-release G √
fluvoxamine G √
LEXAPRO NP √
LUVOX CR NP √
paroxetine G √
paroxetine ER G √
PAXIL NP √
PAXIL CR NP √
PEXEVA NP √ √
PROZAC NP √
PROZAC WEEKLY NP √
sertraline G √
ZOLOFT NP √
Antidepressants – Tricyclic Agents
ANAFRANIL NP
amitriptyline G
amoxapine G
clomipramine G
desipramine G
doxepin G
imipramine G
NORPRAMIN NP
nortriptyline G
PAMELOR NP
protriptyline G
SURMONTIL NP
TOFRANIL NP
TOFRANIL-PM NP
trimipramine G
VIVACTIL NP
Antiparkinsonian Adjuvant
LODOSYN NP
Antiparkinsonian Anticholinergic
benztropine G
trihexyphenidyl G
Antiparkinsonian COMT Inhibitors
COMTAN NP
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entacapone G
TASMAR NP
Antiparkinsonian Dopaminergic
amantadine G
bromocriptine G
carbidopa/levodopa G
carbidopa/levodopa ODT G
carbidopa/levodopa SR G
carbidopa/levodopa/entacapone G
MIRAPEX NP
MIRAPEX ER P √
NEUPRO NP
PARCOPA NP
PARLODEL NP
pramipexole G
REQUIP NP
REQUIP XL NP
ropinirole G
ropinirole ER G
SINEMET NP
SINEMET CR NP
STALEVO NP
Antiparkinsonian Monoamine Oxidase Inhibitor
AZILECT P
ELDEPRYL NP
selegiline G
Antipsychotics – Atypical
ABILIFY NP √
ABILIFY DISC NP √
clozapine G √
CLOZARIL NP √
FANAPT NP √ √
FAZACLO NP √
GEODON NP √
INVEGA NP √ √
LATUDA NP √
olanzapine G √
olanzapine ODT G √
24
quetiapine G √
RISPERDAL NP √
RISPERDAL M NP √
risperidone G √
risperidone ODT G √
SAPHRIS NP √
SEROQUEL NP √
SEROQUEL XR P √
ZYPREXA NP √
ZYPREXA ZYDIS NP √
ziprasidone G √
Antipsychotics – Combinations
chlordiazepoxide/amitriptyline G
olanzapine/fluoxetine G √
perphenazine/amitriptyline G
SYMBYAX NP √
Antipsychotics – First Generation
chlorpromazine G
compro G
fluphenazine G
haloperidol G
loxapine G
perphenazine G
prochlorperazine G
thioridazine G
thiothixene G
trifluoperazine G
Antipsychotics – Miscellaneous
EQUETRO NP
Attention Deficit Disorder
ADDERALL NP √ √
ADDERALL XR NP √ √
amphetamine/dextroamphetamine G √
amphetamine/dextroamphetamine SR G √
CONCERTA NP √ √
DAYTRANA P √
DESOXYN NP √ √
DEXEDRINE NP √ √
25
DEXEDRINE CR NP √ √
dexmethylphenidate G √
dextroamphetamine G √
dextroamphetamine CR G √
dextroamphetamine sulfate solution G √
FOCALIN NP √ √
FOCALIN XR NP √ √
INTUNIV NP √ √
KAPVAY NP √ √
KAPVAY DOSE PACK NP √ √
METADATE CD NP √ √
metadate ER G √
methamphetamine G √
methylin G √
METHYLIN chew/soln NP √ √
methylin ER G √
methylphenidate G √
methylphenidate SR G √
PROCENTRA NP √ √
QUILLIVANT XR NP √ √
RITALIN NP √ √
RITALIN LA NP √ √
RITALIN SR NP √ √
STRATTERA P √
VYVANSE P √
ZENZEDI 2.5MG and 7.5MG NP √ √
zenzedi 5MG and 10MG G √
Chemical Dependency
acampro cal G
ANTABUSE NP
CAMPRAL NP
naltrexone G
Fibromyalgia
CYMBALTA NP √ √
LYRICA NP √ √
SAVELLA P √
Huntington's Disease – Chorea
XENAZINE P √
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Lithium
lithium carbonate G
lithium carbonate CR G
lithium citrate G
LITHOBID NP
Migraine Products
ALSUMA NP √
AMERGE NP √
AXERT NP √ √
CAMBIA NP √
dihydroergotamine nasal G √
FROVA NP √ √
IMITREX NP √
MAXALT NP √
rizatriptan G √
MAXALT MLT NP √
rizatriptan MLT G √
MIGRANAL NP √
naratriptan G √
RELPAX NP √ √
sumatriptan G √
SUMAVEL NP √ √
TREXIMET NP √ √
ZOMIG NP √
zolmitriptan G √
ZOMIG ZMT NP √
zolmitriptan ZMT G √
Multiple Sclerosis Agents
AMPYRA P √
AUBAGIO NP √
GILENYA NP √
TECFIDERA NP √
Narcotic Agonists
ABSTRAL NP √ √
ACTIQ NP √ √
AVINZA NP √
codeine phosphate G
codeine sulfate G
27
CONZIP NP √
DEMEROL NP
DILAUDID NP
DURAGESIC NP √
EXALGO NP √ √
fentanyl lozenge G √ √
fentanyl patch G √
FENTORA NP √ √
hydromorphone G
KADIAN NP √
LAZANDA NP √ √
levorphanol G
meperidine G
methadone G √
methadose G √
morphine sulfate G
morphine sulfate CR G √
MS CONTIN NP √
NUCYNTA P √
NUCYNTA ER P √
ONSOLIS NP √ √
OPANA NP
OPANA ER NP √
ORAMORPH SR NP √
OXECTA NP
oxycodone G
OXYCONTIN CR P √
oxymorphone ER G √
RYBIX ODT NP
SUBSYS SPRAY NP √ √
tramadol G
tramadol ER G √
ULTRAM NP
ULTRAM ER NP √
XOLOX NP
Narcotic Combinations
acetaminophen/codeine G
butalbital/acetaminophen/caffeine/codeine G
28
butalbital/aspirin/caffeine/codeine G
BUPAP NP
CAPITAL/CODEINE NP
COCET NP
COCET PLUS NP
FIORICET/CODEINE NP
FIORINAL/CODEINE NP
hydrocodone/acetaminophen G
hydrocodone/ibuprofen G
IBUDONE NP
LIQUICET NP
LORCET NP
LORCET PLUS NP
LORTAB NP
MAGNACET NP
MAXIDONE NP
NORCO NP
oxycodone/acetaminophen G
oxycodone/aspirin G
oxycodone/ibuprofen G √
ORBIVAN NP
ORBIVAN CF NP
pentazocine/acetaminophen G
PERCOCET NP
PERCODAN NP
PHRENILIN NP
REPREXAIN NP
ROXICET NP
stagesic G
STAFLEX NP
SYNALGOS DC NP
dihydrocodeine compound cap G
TYLENOL/CODEINE NP
TYLOX NP
ULTRACET NP
VICODIN NP
VICODIN ES NP
29
vicodin HP G
VICOPROFEN NP
XODOL NP
ZOLVIT NP
ZYDONE NP
Narcotic Partial Agonists
buprenorphine G √
butorphanol G √
buprenorphine/naloxone sublingual tablet G √
BUTRANS P √
pentazocine/naloxone G
SUBOXONE film NP √ √
SUBOXONE sublingual tablet NP √
SUBUTEX NP √
ZUBSOLV NP √ √
Postherpetic Neuralgia (PHN) Agents
GRALISE NP √
Premenstrual Dysphoric Disorder
SARAFEM NP √
fluoxetine (PMDD) G √
Psychotherapeutic and Neurological Agents
ergoloid mesylate G
ORAP NP
modafinil G √
NUVIGIL NP √
PROVIGIL NP √
XYREM NP √
Restless Leg Syndrome
HORIZANT NP √
Sedative/Hypnotics – Barbiturate
BUTISOL SODIUM NP
MEBARAL NP
phenobarbital G
SECONAL NP
Sedative/Hypnotics – Nonbarbiturates
AMBIEN NP √
AMBIEN CR NP √
chloral hydrate G
30
DORAL NP
quazepam G
EDLUAR NP √ √
estazolam G
flurazepam G
HALCION NP
INTERMEZZO NP √ √
LUNESTA NP √
midazolam G
ROZEREM NP √ √
SILENOR NP √ √
SONATA NP √ √
temazepam G
triazolam G
zaleplon G √
zolpidem G √
zolpidem ER G √
ZOLPIMIST NP √ √
Miscellaneous
CUVPOSA NP
NUEDEXTA NP √
Dermatological Agents
Acne Products
ABSORICA NP
ACANYA NP √
ACZONE NP
adapalene G
AKNE-MYCIN NP
amnesteem G
ATRALIN NP √
avita G
AZELEX NP
BENZACLIN NP √
BENZAMYCIN NP √
BENZEFOAM NP
BENZEFOAM ULTRA NP √
BENZIQ NP
BENZIQ LS NP
31
BENZIQ wash NP
benzoyl peroxide G
claravis G
CLARIFOAM EF NP
clindamax G
clindamycin G
clindamycin/benzoyl peroxide G
DIFFERIN 0.1% cream/gel/lotion NP √
DIFFERIN 0.3% gel P
DUAC NP √
clindamycin/benzoyl peroxide 1.2-5% gel G
EPIDUO P
erythromycin G
erythromycin/benzoyl peroxide G
EVOCLIN NP
FABIOR NP √ √
isotretinoin G
KLARON NP
lavoclen G
METROCREAM NP
METROGEL 1% only NP
metronidazole gel 1% G
METROLOTION NP
metronidazole G
myorisan G
NEOBENZ NP
NORITATE NP
NUOX NP
pacnex wash G
PACNEX HP NP
PACNEX LP NP
PACNEX MX NP
PLEXION cloth NP
PLEXION emulsion NP
PLEXION SCT NP
RETIN-A NP √
RETIN-A MICRO P
RIAX NP √
32
sodium sulfacetamide/sulfur G
SODIUM SULFA LIQ 10% WASH NP
sotret G
SSS 10-4 NP
SUMADAN WASH NP
SUMAXIN NP
SUMAXIN TS NP
tretinoin G
TRETIN-X NP √
TRIAZ NP
VANOXIDE NP
VELTIN NP √
ZACARE NP
Z-CLINZ NP
ZIANA P
Antibiotics – Topical
ALTABAX NP
BACTROBAN NP
CENTANY NP
gentamicin G
mupirocin G
Antifungals – Topical
ALOQUIN NP
ciclopirox G
clotrimazole/betamethasone G
econazole G
ERTACZO NP
EXELDERM NP
HALOTIN NP
hydrocortisone/iodoquinol G
ketoconazole G
LOPROX NP
LOTRISONE NP
NAFTIN NP
nystatin G
nystatin/triamcinolone G
OXISTAT NP
PENLAC NP
33
VUSION NP
XOLEGEL NP
Antineoplastics and Keratolytics – Topical
CARAC NP
EFUDEX NP
FLUOROPLEX NP
fluorouracil G
LEVULAN KERA NP
METVIXIA NP
PANRETIN P
PICATO NP √
SOLARAZE NP
TARGRETIN P
UTOPIC NP
Antipruritics and Topical Anesthetics
cocaine hydrochloride G
lidocaine G
lidocaine pad G √
lidocaine/prilocaine G
LIDODERM NP √
PLIAGLIS NP
prudoxin G
QUTENZA NP
SYNERA NP
ZONALON NP
Antipsoriatics
8-MOP NP
acitretin G
calcipotriene G
CALCITRENE NP
calcitriol G
DOVONEX NP
DRITHO-SCALP NP
OXSORALEN-UL NP
SORIATANE P
SORILUX NP
TACLONEX NP
TAZORAC P
34
VECTICAL NP
Antiseborrheic Products
EXTINA NP
ketoconazole foam G
SCALACORT DK NP
selenium sulfide G
SELRIX NP
sulfacetamide sodium G
Antiviral – Topical
acyclovir G
DENAVIR NP
XERESE NP
ZOVIRAX NP
Corticosteroids – Topical
alclometasone G
amcinonide G
augmented betamethasone dipropionate G
betamethasone valerate G
clobetasol G
CLOBEX spray P
CLOBEX lotion/shampoo NP
CLODERM NP
CORDRAN NP
CUTIVATE NP
DERMATOP NP
DESONATE NP
desonide G
desoximetasone G
diflorasone G
DIPROLENE AF NP
ELOCON NP
fluocinolone acetonide G
fluocinonide G
fluticasone G
HALOG NP
hydrocortisone G
hydrocortisone butyrate G
35
hydrocortisone valerate G
hydrocortisone/pramoxine G
lidocaine/hydrocortisone G
LOCOID NP
LOCOID LIPOCREAM NP
LUXIQ NP
mometasone G
NUZON NP
OLUX NP
OLUX-E NP
prednicarbate G
TACLONEX NP
triamcinolone G
ULTRAVATE NP
VANOS NP
VERDESO NP
VYTONE NP
Keratolytic/Antimitotic Agents
CONDYLOX NP
podofilox G
Immunomodulating Agents – Topical
ALDARA NP √
ELIDEL P
imiquimod G √
PROTOPIC P
ZYCLARA NP √
Rosacea Agents
FINACEA NP
metronidazole G
MIRVASO NP √
ORACEA P √
Scabicides & Pediculicides
EURAX NP
lindane G
NATROBA NP
permethrin G
SKLICE NP
spinosad G
36
ULESFIA NP
Sinecatechin
VEREGEN NP
Endocrine System
Antidiuretic Agents
DDAVP NP
desmopressin G
minirin G
STIMATE NP
Contraceptives – Emergency-(Applies only to plans with contraceptive coverage)
ELLA NP
next choice G
PLAN B NP
levonorgesterol tablet 0.75 mg G
Contraceptives – Oral-(Applies only to plans with contraceptive coverage)
altavera G
amethia lo G
amethyst G
apri G
aranelle G
aviane G
BEYAZ NP
BREVICON NP
briellyn G
camrese G
camrese lo G
cesia G
cryselle G
CYCLESSA NP
DESOGEN NP
ELLA NP
emoquette G
enpresse G
ESTROSTEP FE NP
FEMCON NP
GENERESS FE NP
gianvi G
gildess FE G
37
jolessa G
junel 1.5/30 G
junel 1/20 G
junel FE 1.5/30 G
junel FE 1/20 G
kariva G
kelnor G
leena G
lessina G
levora G
LO LOESTRIN FE NP
LO/OVRAL NP
LOESTRIN 1.5/30 NP
LOESTRIN 1/20 NP
LOESTRIN FE NP
LOESTRIN FE 1.5/30 NP
LOESTRIN-24 NP
LOMINISTRIN PAK FE NP
loryna G
LOSEASONIQUE NP
low-ogestrel G
lutera G
LYBREL NP
microgestin 1.5/30 G
microgestin 1/20 G
microgestin FE 1.5/30 G
microgestin FE 1/20 G
MINASTRIN 24 FE NP
MIRCETTE NP
MODICON 0.5/35 NP
mononessa G
NATAZIA NP
necon 0.5/35 G
necon 1/35 G
necon 1/50 G
necon 10/11 G
necon 7/7/7 G
NORDETTE NP
38
NORINYL 1+35 NP
NORINYL 1+50 NP
nortrel 0.5/35 G
nortrel 1/35 G
nortrel 7/7/7 G
ocella G
ogestrel G
ORTHO TRI-CYCLEN NP
ORTHO TRI-CYCLEN LO NP
ORTHO-CEPT NP
ORTHO-CYCLEN NP
ORTHO-NOVUM 1/35 NP
ORTHO-NOVUM 7/7/7 NP
OVCON 35 NP
OVCON 50 NP
portia G
previfem G
QUARTETTE NP
quasense G
reclipsen G
SEASONALE NP
SEASONIQUE NP
amethia G
solia G
sprintec G
sronyx G
syedah G
trinessa G
TRI-NORINYL NP
tri-previfem G
tri-sprintec G
trivora G
velivet G
YASMIN NP
YAZ NP
zarah G
zenchent FE G
zeosa G
39
zovia 1/35E G
zovia 1/50E G
Contraceptives – Oral Progestins-(Applies only to plans with contraceptive coverage)
camila G
errin G
jolivette G
nora-be G
NOR-QD NP
ORTHO MICRONOR NP
Contraceptives – Transdermal-(Applies only to plans with contraceptive coverage)
ORTHO EVRA NP
Contraceptives – Vaginal-(Applies only to plans with contraceptive coverage)
NUVARING NP
Diabetes – Alpha-Glucosidase Inhibitors
acarbose G
GLYSET NP
PRECOSE NP
Diabetes – Amylin Analogs
SYMLIN P
SYMLINPEN P
Diabetes – Biguanides and Combinations
FORTAMET NP
glipizide/metformin G
GLUCOPHAGE NP
GLUCOPHAGE XR NP
GLUCOVANCE NP
GLUMETZA NP
glyburide/metformin G
METAGLIP NP
metformin G
metformin ER G
RIOMET NP
Diabetes – Dopamine Receptor Agonists
CYCLOSET P
Diabetes – DPP-IV Inhibitors and Combinations
JANUMET P
JANUMET XR P
JANUVIA P
40
JENTADUETO P
KOMBIGLYZE XR P
KAZANO NP √ √
NESINA NP √ √
ONGLYZA P
OSENI NP √ √
TRADJENTA P
Diabetes – Glucocorticoid Receptor Antagonist
KORLYM NP √
Diabetes – Incretin Mimetic Agents
BYDUREON P √
BYETTA NP √
VICTOZA P √
Diabetes – Insulin
APIDRA NP
HUMALOG products P
HUMULIN products P
LANTUS P
LANTUS SOLOSTAR P
LEVEMIR P
LEVEMIR FLEXPEN P
NOVOLIN products NP √
NOVOLOG products P
RELION products NP √
Diabetes – Meglitinides and Combinations
nateglinide G
PRANDIMET NP
PRANDIN NP
repaglinide G
STARLIX NP
Diabetes - Sodium-glucose co-transporter 2 (SGLT2) inhibitor
INVOKANA NP √ √
Diabetes – Sulfonylureas
AMARYL NP
chlorpropamide G
DIABETA NP
glimepiride G
glipizide G
41
glipizide ER G
glipizide XL G
GLUCOTROL NP
GLUCOTROL XL NP
glyburide G
glyburide micronized G
GLYNASE NP
tolazamide G
tolbutamide G
Diabetic Supplies
BD insulin syringes P
BD lancets P
BD pen needles P
FREESTYLE glucose test strips P √
FREESTYLE LITE glucose test strips P √
FREESTYLE INSULINX P √
glucose test strips (any other brand name) NP √ √
All Brand insulin syringes NP
insulin syringes (any generic) G
All Brand lancets NP
lancets (any generic) G
ONE TOUCH FAST TAKE glucose test strips P √
ONE TOUCH ULTRA glucose test strips P √
ONE TOUCH VERIO IQ glucose test strips P √
All Brand pen needles NP
pen needles (any generic) G
PRECISION QID glucose test strips P √
PRECISION SOF-TACT glucose test strips P √
PRECISION XTRA glucose test strips P √
PRECISION XTRA ketone test strips P √
Diabetes – Thiazolidinediones (TZDs) and Combinations
ACTOPLUS MET NP
pioglitazone/metformin G
ACTOPLUS MET XR NP
ACTOS NP
pioglitazone G
AVANDAMET NP
AVANDARYL NP
42
AVANDIA NP
DUETACT NP
pioglitazone/glimepiride G
JUVISYNC P
Gaucher Disease
ZAVESCA NP
Glucose Elevating Agent
PROGLYCEM P
Gout Agents
allopurinol G
COLCRYS P
probenecid G
probenecid/colchicine G
ULORIC NP √
ZYLOPRIM NP
Hereditary Tyrosinemia
ORFADIN P
Homocystinuria
CYSTADANE P
Hormone Replacement – Androgens
ANDRODERM NP √ √
ANDROGEL P √
AXIRON NP √ √
danazol G
FORTESTA NP √ √
STRIANT NP √ √
TESTIM P √
Hormone Replacement – Estrogens
ALORA NP √
CENESTIN P
CLIMARA NP √
DIVIGEL P
ELESTRIN NP
ENJUVIA P
ESTRACE NP
ESTRADERM NP √
estradiol patch G √
estradiol tablet G
43
ESTRASORB NP
ESTROGEL NP
estropipate G
EVAMIST P
MENEST NP
MENOSTAR NP √
MINIVELLE NP √
ortho-est G
PREMARIN NP
VIVELLE-DOT NP √
Hormone Replacement – Estrogen Combinations
ACTIVELLA NP
ANGELIQ NP
CLIMARA PRO NP √
COMBIPATCH NP √
estradiol/norethindrone acetate G
FEMHRT NP
FEMHRT LOW DOSE NP
FEMTRACE NP
jinteli G
PREFEST NP
PREMPHASE NP
PREMPRO NP
Hormone Replacement – Progestins
medroxyprogesterone acetate G
norethindrone acetate G
progesterone micronized capsule G
PROMETRIUM NP
Hyperammonemia
RAVICTI NP √
sodium phenylbutyrate G
Hyperparathyroidism
HECTOROL NP
SENSIPAR NP
ZEMPLAR P
LHRH/GnRH Agonist Analog Pituitary Suppressants
SYNAREL NP
44
Metabolic Modifiers
CARNITOR NP
SUCRAID NP
Phenylketonuria
KUVAN P
Steroids – Glucocorticosteroids
budesonide SR G √
cortisone AC G
dexamethasone G
ENTOCORT EC NP √
FLO-PRED NP
hydrocortisone G
methylprednisolone G
MILLIPRED NP
ORAPRED NP
prednisolone G
prednisone G
RAYOS NP √
VERIPRED NP
Steroids – Mineralocorticoid
fludrocort G
Thyroid Hormones
ARMOUR THYROID NP
CYTOMEL NP
levothroid G
levothyroxine G
levoxyl G
liothyronine sodium G
SYNTHROID NP
THYROLAR NP
TIROSINT NP
unithroid G
Thyroid – Antithyroid Agents
methimazole G
propylthiouracil G
TAPAZOLE NP
Vasopressin Receptor Antagonist
SAMSCA P
45
Gastrointestinal System
Acid Suppressants – H-2 Antagonists
AXID NP
cimetidine G
famotidine G
nizatidine G
PEPCID NP
ranitidine G
ZANTAC NP
Acid Suppressants – Proton Pump Inhibitors
ACIPHEX NP √ √
DEXILANT P √
ESOMEPRAZOLE STRONTIUM NP √ √
lansoprazole G √
lansoprazole ODT G √
NEXIUM P √
omeprazole G √
omeprazole/bicarbonate G √
pantoprazole G √
PREVACID NP √ √
PREVACID SOLUTAB NP √ √
PRILOSEC NP √ √
PROTONIX NP √ √
ZEGERID NP √ √
Anal Fissure
RECTIVE NP
HIV-Related Antidiarrheal
FULYZAQ NP √
Antiemetics – 5-HT3 Receptor Antagonists
ANZEMET tablet NP √
DICLEGIS NP √
granisetron G √
GRANISOL NP √
ondansetron G √
ondansetron ODT G √
SANCUSO PAD NP √
ZOFRAN NP √
ZOFRAN ODT NP √
46
ZUPLENZ NP √
Antiemetics – Anticholinergic
TRANSDERM-SCOP NP
trimethobenzamide G
Antiemetics – Miscellaneous
CESAMET NP √
dronabinol G
EMEND capsule P √
MARINOL NP
Anti-Ulcer Drugs
misoprostol G
sucralfate G
Bowel Evacuants
COLYTE NP
gavilyte-g G
GOLYTELY NP
HALFLYTELY NP
MOVIPREP P
NULYTELY NP
OSMOPREP NP
peg 3350 G
polyethylene glycol G
PREPOPIK NP
trilyte G
SUCLEAR KIT NP
SUPREP NP
VISICOL NP
Chronic Constipation Agents
AMITIZA P
LINZESS NP √
Gallstone Solubilizing Agents
CHENODAL NP
URSO 250 NP
URSO FORTE NP
ursodiol G
GI Antiallergy Agents
cromolyn sodium concentrate G
47
GASTROCROM NP
GI Stimulants
metoclopramide G
METOZOLV ODT NP
H. pylori Agents
HELIDAC NP
lansoprazole/amoxicillin/clarithromycin P
OMECLAMOX-PAK P
PREVPAC NP
PYLERA P
Inflammatory Bowel Agents
APRISO P √
ASACOL P √
ASACOL HD P √
AZULFIDINE NP √
AZULFIDINE ENTAB NP √
balsalazide G √
CANASA P √
COLAZAL NP √
DELZICOL P √
DIPENTUM NP √
GIAZO NP √
LIALDA P √
mesalamine G
PENTASA NP √
sulfasalazine G √
sulfasalazine ER G √
sulfazine G √
sulfazine EC G √
UCERIS NP √
Irritable Bowel Syndrome (IBS) Agent
LOTRONEX NP
Laxatives
KRISTALOSE NP
lactulose G
Pancreatic Enzymes
CREON P
DIGEX NP
48
PANCRELIPASE NP
PANCREAZE NP
PERTZYE NP √
ULTRESA NP √
VIOKACE NP √
ZENPEP P
Rectal Steroids
colocort G
CORTIFOAM NP
Genitourinary System
Cystinosis Agents
CYSTAGON NP
PROCYSBI NP √ √
Interstitial Cystitis Agent
ELMIRON P √
Phosphate Binders
calcium acetate G
ELIPHOS NP
FOSRENOL P
PHOSLO NP
PHOSLYRA P
RENAGEL NP √
RENVELA P
Prostatic Hypertrophy Agents
alfuzosin G
AVODART P
CARDURA XL NP
CIALIS 2.5 mg, 5 mg P √
finasteride G
FLOMAX NP
JALYN P
PROSCAR NP
RAPAFLO P
tamsulosin G
UROXATRAL NP
Urinary Antispasmodics
bethanechol G
DETROL NP √
49
DETROL LA NP √
DITROPAN XL NP √
ENABLEX P
flavoxate G
hyoscyamine G
oxybutynin G
oxybutynin ER G
GELNIQUE NP
MYRBETRIQ NP √
OXYTROL NP √
SANCTURA NP √
SANCTURA XR NP √
tolterodine G
TOVIAZ NP √
trospium G
trospium ER
URECHOLINE NP
VESICARE P
Urinary Anti-infectives and Combinations
MACROBID NP
methenamine hippurate G
methenamine mandelate G
MONUROL NP
nitrofurantoin G
nitrofurantoin monohydrate macrocrystal G
UREX NP
URIBEL NP
URIMAR-T NP
UTA NP
Vaginal Anti-infectives
CLEOCIN VAGINAL NP
clindamax G
METROGEL VAGINAL NP
nystatin vaginal G
TERAZOL NP
terconazole G
tioconazole G
vandazole G
50
zazole G
Vaginal Estrogens
ESTRACE VAGINAL NP
ESTRING NP
FEMRING P
PREMARIN VAGINAL NP
VAGIFEM NP
Vaginal Progestins
CRINONE P
ENDOMETRIN P
PROGESTERONE VAGINAL NP
Infections and Infestations
Antibacterials – Aminoglycosides
neomycin G
paromomycin G
Antibacterials – Ampicillins and Combinations
amoxicillin G
amoxicillin/K clavulanate G
amoxicillin/K clavulanate SR G
ampicillin G
AUGMENTIN NP
AUGMENTIN ES NP
AUGMENTIN XR NP
MOXATAG NP
Antibacterials – Cephalosporins, 1st Generation
cefadroxil G
cephalexin G
Antibacterials – Cephalosporins, 2nd Generation
cefaclor G
cefaclor ER G
cefprozil G
CEFTIN NP
cefuroxime G
Antibacterials – Cephalosporins, 3rd Generation
CEDAX NP
cefdinir G
cefditoren G
51
cefpodoxime G
SPECTRACEF NP
SUPRAX NP
Antibacterials – Fluoroquinolones
AVELOX P
AVELOX ABC P
CIPRO NP
ciprofloxacin G
ciprofloxacin ER G
FACTIVE NP
LEVAQUIN NP
levofloxacin G
NOROXIN NP
ofloxacin G
Antibacterials – Ketolide
KETEK NP
Antibacterials – Macrolides
azithromycin G
BIAXIN NP
BIAXIN XL NP
clarithromycin G
clarithromycin SR G
DIFICID NP √
e.e.s. G
erythrocin G
erythromycin G
erythromycin delayed-release particles G
erythromycin ethylsuccinate G
PCE NP
ZITHROMAX NP
ZMAX NP
Antibacterials – Miscellaneous
clindamycin G
metronidazole G
NEBUPENT P
tinidazole G
TINDAMAX NP
trimethoprim G
52
XIFAXAN NP √
ZYVOX P
Antibacterials – Penicillins
dicloxacillin sodium G
penicillin VK G
Antibacterials – Sulfonamide
sulfadiazine G
Antibacterials – Tetracyclines
ADOXA NP
avidoxy G
demeclocycline G
DORYX NP
doxycycline hyclate G
doxycycline monohydrate G
DYNACIN NP
MINOCIN NP
minocycline G
MONODOX NP
NUTRIDOX NP
ORAXYL NP
SOLODYN NP
tetracycline G
VIBRAMYCIN NP
Antifungals
ANCOBON NP
BIO-STATIN NP
clotrimazole troche G
DIFLUCAN (all other strengths) NP
DIFLUCAN 150 mg NP √
fluconazole (all other strengths) G
fluconazole 150 mg G √
flucytosine G
GRIFULVIN V NP
GRIS-PEG NP
itraconazole G
ketoconazole G
LAMISIL NP
NOXAFIL NP
53
nystatin G
ONMEL NP
ORAVIG NP √
SPORANOX NP
terbinafine G
VFEND NP
voriconazole G
Anti-infective Agents – Miscellaneous
colistimethate sodium G
COLY-MYCIN M NP
Antimalarials and Combinations
ARALEN NP √
atovaquone/proguanil G
chloroquine G √
COARTEM NP
DARAPRIM NP
hydroxychloroquine G √
MALARONE NP
mefloquine G
PLAQUENIL NP √
primaquine G
QUALAQUIN NP √
quinine sulfate G √
Antimycobacterial Agents
dapsone G
ethambutol G
isonarif G
isoniazid G
MYAMBUTOL P
pyrazinamide G
RIFAMATE NP
rifampin G
RIFATER NP
Antiprotozoal Agents
ALINIA NP
MEPRON P
Antiretrovirals – Chemokine Receptor Antagonist
SELZENTRY NP
54
Antiretrovirals – Integrase Inhibitors
ISENTRESS NP
TIVICAY NP
Antiretrovirals – NRTI/NNRTI Combination
ATRIPLA NP
Antiretrovirals – NRTI/NNRTI/HIV integrase Combination
STRIBILD NP
Antiretrovirals – Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
EDURANT NP
INTELENCE NP
nevirapine G
RESCRIPTOR NP
SUSTIVA P
VIRAMUNE NP
VIRAMUNE XR NP
Antiretrovirals – Nucleoside (NRTI) and Nucleotide (NtRTI) Analogs
abacavir G
COMBIVIR NP
COMPLERA NP
didanosine delayed-release G
EMTRIVA P
EPIVIR NP
EPZICOM NP
lamivudine G
lamivudine/zidovudine G
RETROVIR NP
stavudine G
TRIZIVIR NP
TRUVADA P
VIDEX P
VIDEX EC NP
VIREAD P
ZERIT NP
ZIAGEN NP
zidovudine G
Antiretrovirals – Protease Inhibitors
APTIVUS P
CRIXIVAN NP
55
INVIRASE NP
KALETRA P
LEXIVA P
NORVIR P
PREZISTA P
REYATAZ P
VIRACEPT NP
Antituberculin
SIRTURO NP √
Antivirals – CMV Agent
VALCYTE P √
Antivirals – Hepatitis Agents
adefovir dipivoxil P
BARACLUDE NP
COPEGUS NP
EPIVIR HBV NP
HEPSERA NP
INCIVEK NP √
REBETOL NP
ribatab G
ribapak G
ribasphere G
ribavirin G
TYZEKA NP
VICTRELIS NP √
Antivirals – Herpes Agents
acyclovir G
FAMVIR NP √
famciclovir G √
valacyclovir G
VALTREX NP
ZOVIRAX NP
Antivirals – Influenza Agents
FLUMADINE NP
RELENZA NP √
rimantadine G
TAMIFLU NP √
56
Antivirals – Respiratory Syncytial Virus (RSV) Agent
VIRAZOLE NP
Musculoskeletal System
Antimyasthenic Agents
MESTINON P
MESTINON TIMESPAN P
pyridostigmine G
Antirheumatic Agents
ARAVA NP
leflunomide G
RHEUMATREX NP
RIDAURA NP
Muscle Relaxants and Combinations
AMRIX NP √
baclofen G
carisoprodol G
carisoprodol/aspirin G
carisoprodol/aspirin/codeine G
chlorzoxazone G
cyclobenzaprine G
cyclobenzaprine ER G
DANTRIUM NP
dantrolene G
FEXMID NP √
LORZONE NP
metaxalone G
methocarbamol G
orphenadrine ER G
orphenadrine/aspirin/caffeine G
SKELAXIN NP
tizanidine G
ZANAFLEX NP
NSAIDs
ARTHROTEC NP
CELEBREX NP √
DAYPRO NP
DUEXIS NP √ √
diclofenac G
57
diclofenac potassium G
diclofenac sodium XR G
etodolac G
etodolac ER G
fenoprofen G
FLECTOR patch P √
flurbiprofen G
ibuprofen G
indomethacin G
indomethacin ER G
ketoprofen G
ketoprofen ER G
ketorolac G √
meclofenamate sodium G
mefenamic acid G √
meloxicam G
MOBIC NP
nabumetone G
NAPRELAN NP
naproxen G
oxaprozin G
piroxicam G
PENNSAID NP √ √
PONSTEL NP √
SPRIX NP √
sulindac G
tolmetin sodium G
VIMOVO P √ √
VOLTAREN NP
VOLTAREN GEL P √ √
VOLTAREN XR NP
ZIPSOR NP
Osteoporosis/Bone Modifying Agents
ACTONEL P √
alendronate G √
ATELVIA P √
BINOSTO NP √ √
BONIVA tablet NP √ √
58
calcitonin salmon nasal G
DIDRONEL NP
etidronate G
fortical G
FOSAMAX NP √
FOSAMAX PLUS D NP √ √
ibandronate tablet G √
MIACALCIN NASAL NP
SKELID NP
Rheumatoid Arthritis
XELJANZ NP √
Selective Estrogen Receptor Modulator (SERM)
EVISTA P
Ophthalmic Agents
Glaucoma – Adrenergic Agents
ALPHAGAN P P
apraclonidine G
brimonidine G
IOPIDINE NP
Glaucoma – Beta-blockers
betaxolol ophthalmic G
BETIMOL NP
BETOPTIC-S NP
carteolol G
ISTALOL NP
levobunolol G
metipranolol G
OPTIPRANOLOL NP
timolol ophthalmic G
Glaucoma – Carbonic Anhydrase Inhibitors
AZOPT P
dorzolamide G
dorzolamide/timolol G
COSOPT NP
COSOPT PF NP
COMBIGAN P
SIMBRINZA NP
TRUSOPT NP
59
Glaucoma – Miotics
ISO CARBACHOL NP
ISOPTO CARPINE NP
PHOSPHOLINE NP
pilocarpine G
PILOPINE HS NP
Glaucoma – Prostaglandins
latanoprost G
LUMIGAN 0.01% P
LUMIGAN 0.03% P
TRAVATAN Z P
XALATAN NP
ZIOPTAN NP √
Ophthalmic Miscellaneous
CYSTARAN NP √
Ophthalmic Antihistamines and NSAIDs
ACULAR NP
ACULAR LS NP
ACUVAIL NP
ALAMAST NP
ALOCRIL NP
ALOMIDE NP
azelastine ophthalmic G
BEPREVE NP
BROMDAY NP
bromfenac G
cromolyn sodium ophthalmic G
diclofenac ophthalmic G
ELESTAT NP
EMADINE NP
epinastine G
flurbiprofen ophthalmic G
ILEVRO NP
ketorolac tromethamine ophthalmic G
LASTACAFT NP
NEVANAC NP
OPTIVAR NP
PATADAY P
60
PATANOL NP √
PROLENSA NP
VOLTAREN NP
Ophthalmic Anti-infectives
AZASITE P
bacitracin G
bacitracin/neomycin/polymyxin G
bacitracin/polymyxin G
BESIVANCE NP
ciprofloxacin G
erythromycin G
gentamicin G
IQUIX NP
levofloxacin G
neomycin/polymyxin/gramicidin G
ofloxacin G
polymyxin B/trimethoprim G
QUIXIN NP
sulfacetamide sodium G
tobramycin G
trifluridine G
triple antibiotic G
VIGAMOX NP
ZIRGAN NP
ZYMAXID NP
Ophthalmic Immunomodulator
RESTASIS P
Ophthalmic Steroidal Anti-inflammatory Drugs
ALREX P
bacitracin/polymyxin/neomycin/hydrocortisone
G
BLEPHAMIDE S.O.P. NP
dexamethasone phosphate G
dexamethasone/neomycin/polymyxin G
DUREZOL NP
fluorometholone G
fluor-op G
FML FORTE NP
61
FML LIQUIFILM NP
FML S.O.P. NP
LOTEMAX OINTMENT NP
LOTEMAX SUSPENSION NP
neomycin/polymyxin/hydrocortisone G
poly-dex G
PRED-G NP
PRED-G S.O.P NP
prednisolone G
sulfacetamide sodium/prednisolone G
tobramycin/dexamethasone G
TOBRADEX NP
TOBRADEX ST NP
VEXOL NP
ZYLET NP
Otic Agents
Otic Analgesics
PINNACAINE NP
Otic Anti-infectives
ciprofloxacin otic G
ofloxacin otic G
Otic Combinations
acetic acid/antipyrine/benzocaine/polycosanol
G
antipyrine/benzocaine G
CETRAXAL NP
CIPRO HC NP
CIPRODEX P
COLY-MYCIN S NP
cortomycin G
myoxin G
neomycin/polymyxin/hydrocortisone G
NEOTIC NP
otozin G
TREAGAN NP
TRIOXIN NP
ZINOTIC NP
ZINOTIC ES NP
62
Respiratory Tract Agents
Antiasthmatics – Anticholinergics
ATROVENT HFA NP
ipratropium inhaler G
SPIRIVA P
TUDORZA NP
Anti-Inflammatory Agents (nebulizer)
cromolyn sodium nebulizer G
Bronchodilators – Sympathomimetics
ACCUNEB NP
ADVAIR DISKUS NP √
ADVAIR HFA NP √
albuterol G
ARCAPTA NP
BREO ELLIPTA NP √ √
BROVANA NP
COMBIVENT RESPIMAT P
COMBIVENT NP
DULERA P
DUONEB NP
FORADIL P
ipratropium/albuterol G
levalbuterol G
MAXAIR AUTOHALER NP √
metaproterenol G
PERFOROMIST P
PROAIR HFA P
PROVENTIL HFA P
SEREVENT DISKUS P
SYMBICORT P
terbutaline G
VENTOLIN HFA NP √
VOSPIRE ER NP
XOPENEX NP √
XOPENEX HFA NP √
Bronchodilators – Xanthines
aminophylline G
THEO-24 NP
63
theochron G
theophylline ER G
Cystic Fibrosis Agents
CAYSTON NP
KALYDECO NP √
PULMOZYME P
TOBI NP
TOBI PODHALER NP √
Inhaled Corticosteroids
ALVESCO NP
ASMANEX P
budesonide inhalation suspension G
FLOVENT DISKUS P
FLOVENT HFA P
PULMICORT FLEXHALER NP
PULMICORT RESPULES NP
QVAR P
Leukotriene Modulators
ACCOLATE NP √
zafirlukast G √
SINGULAIR NP √
montelukast G √
ZYFLO NP √
ZYFLO CR NP √
Mouth and Throat Products
cevimeline G
EVOXAC NP
pilocarpine G
SALAGEN NP
Nasal Antiallergy
ASTELIN NASAL NP
ASTEPRO P
azelastine nasal G
DYMISTA NP
PATANASE NP
Nasal Anti-infective
BACTROBAN NASAL NP
Nasal Anticholinergics
64
ATROVENT NASAL NP
ipratropium nasal G
Nasal Steroids
BECONASE AQ NP
FLONASE NP
flunisolide G
fluticasone nasal G
NASACORT AQ NP √
NASONEX P
QNASL NP
OMNARIS NP
RHINOCORT AQ NP √
triamcinolone nasal G
VERAMYST P
ZETONNA NP √
Non-Sedating Antihistamines and Combinations
CLARINEX NP √
CLARINEX-D NP √
CLARINEX REDITAB NP √
desloratadine G √
desloratadine ODT G √
levocetirizine G √
XYZAL NP √
Selective Phosphodiesterase 4 (PDE4) Inhibitors
DALIRESP NP √
Upper Respiratory – Cough/Cold/Allergy Combinations
hydrocodone/chlorpheniramine polistirex G
SEMPREX-D NP √
TUSSICAPS NP
TUSSIONEX NP
VITUZ NP
Miscellaneous
Immunosuppressive Agents
ASTAGRAF XL NP
AZASAN NP
azathioprine G
CELLCEPT NP