INDEPENDENT HEALTH THREE-TIER FORMULARY...INDEPENDENT HEALTH THREE-TIER FORMULARY Dear Prescriber:...

January 2013 1

INDEPENDENT HEALTH THREE-TIER FORMULARY Dear Prescriber: This Drug Formulary represents the list of drugs and their appropriate copayment tiers for most members enrolled in an Independent Health Pharmacy rider to their medical contract. Independent Health also provides Pharmacy coverage that may be subject to other formularies, including Medicare Part D and Self Insured employer-sponsored benefits. It is important for the presciber to understand your patient’s coverage when using this formulary. This formulary lists all covered Tier 1 and Tier 2 drugs but only lists representative products in Tier 3. Additional copies of this or other formularies that may apply to your patient may be obtained by calling Independent Health at (716) 631-2934 or (800) 247-1466, ext. 5311. For questions, or to obtain Prior Authorization/Non-Formulary Request Forms, an Independent Health representative may be contacted at (716) 631-2934 or (800) 247-1466 ext. 5311. Thank you for your cooperation. Prior Authorization Forms are also available to be printed from our website: www.independenthealth.com. Introduction to The Drug Formulary Generic drugs appear in lower case, brand name drugs start with a capital letter. Formulary/preferred generic drugs and select Over the Counter (OTC) and select Brand Name drugs listed on the Formulary

are assigned to copay Tier 1. The formulary follows a “Mandatory Generic” policy which means that in most instances, once a generic product is available for which there are no bioequivalence concerns, the branded product is assigned to Copay Tier 3, and the generic product is assigned to Copay Tier 1. Certain non-preferred generic drugs may also be covered in the 3rd tier when efficacy, safety or cost factors suggest that better alternatives exist on the formulary. Generic substitution is used only as required by state pharmacy laws.

Independent Health reserves the right to modify the copay tier of a particular drug as necessary. For example, the copay tier of a brand drug will be raised from Tier 2 to Tier 3 when a generic drug becomes available (the generic drug will be placed in copay Tier 1). The copay of a brand drug may be lowered from Tier 3 to Tier 2 if the generic equivalents are discontinued or no longer available.

Compounded prescriptions (medications that are not commercially manufactured) must be prepared by a participating pharmacy and contain at least one prescription component. The dispensing pharmacy is required to submit for prior approval and when covered, will take a Tier 2 copayment. Coverage is provided in accordance with our Compounding Drug Products Policy. Bulk products and powders are excluded from coverage because they are not prescription drug products that are approved under sections 505, 505(j) or 507 of the Federal Food Drug and Cosmetic Act.

Most self-administered injectable drugs require prior authorization. Some exceptions are: insulin, glucagon, epinephrine emergency kits, etc. Drugs not intended for self administration are not covered under the pharmacy benefit and should be obtained and administered by an appropriate healthcare professional.

Certain drugs which are either self-injectable, require special distribution, handling and/or are at limited supply are restricted to designated pharmacies that specialize in biotech injectables. These drugs are listed in the formulary under their therapeutic category as well as in the Specialty Drug section of the formulary (Chapter 23).

Over the Counter (OTC) drugs listed on the formulary must have a prescription (written or verbal) from a participating prescriber.

Not all tier 3 non-preferred drugs are listed in the formulary. For members with a 3 tier plan, most drugs not listed may be obtained, but the member will be responsible for their third tier copayment. Therapeutic interchange is not utilized.

Not all the drugs listed are covered by all pharmacy benefit programs, including Medicare Part D, Healthy New York, and certain self-funded employer groups.

The Medicare Part D formularies can be found on our website at www.independenthealth.com. NOTE REGARDING HEALTHY NEW YORK MEMBERS: Covered services for the Healthy New York (HNY) Program are

set by law. Independent Health will not provide coverage for any service or care that is not specifically described as a covered service even when a participating provider considers the service or care to be medically necessary and appropriate. In addition, medications used to treat excluded services are not covered. Examples of services not covered include mental health (ex: ADHD, depression, anxiety), alcohol and substance abuse (ex: suboxone, smoking cessation), devices and supplies of any kind (ex: aerochambers, peak flow meters), prescriptions written by a dentist, weight loss medications, infertility medications, and medications used in connection with transgender procedures. The above listed exclusions are examples only. HNY members should refer to their contract for additional information.

Certain self-funded employer groups may not follow this base formulary. Members in these pharmacy benefit management groups should refer to their summary plan description and/or their benefit administrator.

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Please note that some drugs and/or drug classes, even though not listed on the Formulary, may require prior authorization. The physician simply completes a prior authorization request form and faxes it to Independent Health. This form can also be used by physicians to submit information to support a request for an exception to the formulary. The details of the request will be reviewed and Independent Health will generally respond within 24 hours. This list does not guarantee coverage. The following Drugs are excluded from the Formulary (not covered):

Antara® fenofibrate 48mg, 145mg (Generic Tricor®) Fenoglide® Fibricor® Lipofen® Lopid® Tricor® Triglide® Trilipix®

Benefit Exclusions:

Appetite suppressants/weight loss medications are excluded from coverage unless otherwise specified in a member’s contract.

Smoking cessation products may not be covered under all pharmacy programs including Healthy NY and certain self-funded employer groups.

Addiction maintenance/detox drugs may be excluded from coverage if specified in a member’s contract. Not all drugs listed are covered by all pharmacy programs including Child Health Plus, Family Health Plus,

Medicare Part D, MediSource, Healthy New York, and certain self-funded employer groups. Medical devices (which may or may not require a prescription) Medical foods other than PKU supplements (which may or may not require a prescription)

Note: Benefit exclusions may vary per employer group. Replacement of lost, stolen or damaged medications is the responsibility of the member. Emergency Room scripts are limited to a 10 day supply.

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TABLE OF CONTENTS

CHAPTER 1 - ALLERGY/COUGH & COLD ................................................................................................................. 4 CHAPTER 2 – ASTHMA/RESPIRATORY ..................................................................................................................... 5 CHAPTER 3 – BLADDER/KIDNEY ................................................................................................................................ 6 CHAPTER 4 – BLOOD ....................................................................................................................................................... 7 CHAPTER 5 – CANCER .................................................................................................................................................... 8 CHAPTER 6 – CARDIOVASCULAR – HYPERTENSION ......................................................................................... 9 CHAPTER 7 – CARDIOVASCULAR – LIPID LOWERING .................................................................................... 11 CHAPTER 8 – CARDIOVASCULAR/HEART ............................................................................................................ 12 CHAPTER 9 – DERMATOLOGICAL MEDICATIONS............................................................................................ 13 CHAPTER 10 – DIABETES ............................................................................................................................................. 15 CHAPTER 11 – EAR/THROAT MEDICATIONS ....................................................................................................... 16 CHAPTER 12 – EYE .......................................................................................................................................................... 17 CHAPTER 13 – HORMONES/STEROIDS ................................................................................................................... 18 CHAPTER 14 – INFECTION ........................................................................................................................................... 19 CHAPTER 15 – MEN’S HEALTH .................................................................................................................................. 21 CHAPTER 16 – MENTAL HEALTH .............................................................................................................................. 22 CHAPTER 17 – NERVOUS SYSTEM ............................................................................................................................ 24 CHAPTER 18 – PAIN ....................................................................................................................................................... 26 CHAPTER 19 – SMOKING CESSATION .................................................................................................................... 28 CHAPTER 20 – STOMACH/INTESTINAL ................................................................................................................. 28 CHAPTER 21 – VITAMINS/MINERALS ..................................................................................................................... 30 CHAPTER 22 – WOMEN’S HEALTH ........................................................................................................................... 30 CHAPTER 23 – DENTAL FORMULARY ..................................................................................................................... 32 CHAPTER 24 – SPECIALTY DRUG SUMMARY ...................................................................................................... 33 SYMBOLS ........................................................................................................................................................................... 36 STEP THERAPY PROTOCOLS ..................................................................................................................................... 37 INDEX ................................................................................................................................................................................. 41

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CHAPTER 1 - ALLERGY/COUGH & COLD

1.A. Sedating Antihistamines

TIER 1 TIER 2 TIER 3 clemastine fumarate syrup cyproheptadine + diphenhydramine 50mg + generic Poly-Histine® hydroxyzine HCl + (Max age of 64) hydroxyzine pamoate + (Max age of 64) promethazine +, PAR age < 2

clemastine fumarate tabs Ryneze® liquid Tavist® Vistaril®

1.B. Non-Sedating Antihistamines

TIER 1 TIER 2 TIER 3 Clarinex® PAR

Clarinex® Reditab 2.5mg (Ages 6-11 only) PAR desloratidine PAR levocetirizine dihydrochloride PAR Xyzal® PAR

1.C. Sedating Antihistamine/Decongestant Combinations

TIER 1 TIER 2 TIER 3 chlorpheniramine/pseudoephedrine 1mg/15mg per 5 ml OTC, QL

chlorpheniramine/pseudoephedrine tabs 4mg/60mg OTC, QL

chlorpheniramine/pseudoephedrine SR tabs 8mg/120mg OTC, QL

chlorpheniramine tan-phenylephrine tannate susp QL

promethazine VC triprolidine/pseudoephedrine liquid 1.25mg/30mg per 5 ml OTC, QL

triprolidine/pseudoephedrine tabs 2.5mg/60mg OTC, QL

Accuhist® PDX Restricted to ages 2-11 only chlorphen/DM/PE

Restricted to ages 2-11 only Donatuss® XP Minimum age of 6 Rescon® JR Rescon-MX® Min age of 6 Rynatan® susp

1.D. Nasal Steroids/Other Nasal Products

TIER 1 TIER 2 TIER 3 azelastine nasal spray flunisolide nasal fluticasone propionate nasal ipratropium triamcinolone acetonide

Nasonex®

Astelin® ST Astepro® ST

Atrovent® 0.06% nasal spray Atrovent® 0.03% spray Atrovent® nasal solution 0.06% Beconase® AQ PAR if patient age < 6 ST Dymista® ST QL Flonase® ST Nasacort® AQ Nasarel® Omnaris® ST Patanase® Qnasl® ST QL Rhinocort® Aqua ST Veramyst® ST

ZetonnaTM ST

1.E. Narcotic-containing Cough Products

TIER 1 TIER 2 TIER 3 generic Hycodan® (syrup only) generic Novahistine® expt phenylephrine chlorpheniramine w/hydrocodone syrup

promethazine with codeine promethazine/phenylephrine/codiene syrup generic Robitussin® DAC codeine-guaifenesin

Allfen® CDX liquid Brontex® Donatuss® DC Endal® CD syrup Hycodan® syrup Mar-cof® BP

Neo®AC Pro-Clear® Tussionex® Zodryl® Zodryl® AC susp Zodryl® DAC

QL, Patients ages > 6

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1.F. Non-Narcotic-containing Cough Products

TIER 1 TIER 2 TIER 3 generic benzonatate promethazine/dextromethorphan

PAR age < 2 pseudoephedrine/guaifenesin SSKI

Albatussin® Carbaphen®12 Corzall® liquid Corzall® Plus Entex® Exall® liquid Exall® D Giltuss®

Giltuss® TR J-Tan® D Maxifed® DM liquid Prolex® DMX liquid Min age of 6 Pyril® DM Respa® CC Semprex-D® Tekral® Tessalon® Zotex-EX®

1.G. Other Allergy

TIER 1 TIER 2 TIER 3

Epipen® Twinject®

Auvi-QTM

CHAPTER 2 – ASTHMA/RESPIRATORY

2.A. Sympathomimetics

TIER 1 TIER 2 TIER 3 albuterol sulfate tabs + albuterol nebs albuterol tabs; syrup metaproterenol tabs +; syrup terbutaline tabs +

Arcapta® Neohaler + Min patient age of 45 years old

Foradil® + , ST Maxair® Autohaler Proair® HFA Proventil HFA® Serevent® Diskus + , ST Ventolin HFA®

Accuneb® Alupent® Brethine® Isuprel® Perforomist® PAR Proventil® Xopenex®

2.B. Xanthine Derivatives

TIER 1 TIER 2 TIER 3 aminophylline + theophylline SR + theophylline ER +

Dyphylline-GG® Lufyllin®

Quibron® Uniphyl® 400mg, 600mg

2.C. Inhaled Corticosteroids and Combinations

TIER 1 TIER 2 TIER 3 Alvesco® Asmanex® + budesonide respules 0.25mg, 0.5mg (Ages ≤ 8) + Flovent® Diskus 50mcg, 100mcg, 250mg Flovent® HFA + Pulmicort® Flexhaler Pulmicort® Respules 1mg (Ages ≤ 8) + QVar® +

Advair® + Advair® HFA + Azmacort® + Dulera® Ages > 12 years Symbicort® +

Aerobid®/Aerobid-M® Daliresp® PAR except Pulmonology Pulmicort Respules® 0.25mg, 0.5mg

(Ages ≤ 8) Zetonna® PAR

2.D. Mast Cell Stabilizers

TIER 1 TIER 2 TIER 3 cromolyn sodium 10mg/ml nebs + Intal® nebs

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2.E. Leukotriene Modifiers

TIER 1 TIER 2 TIER 3 montelukast sodium chews (ages 1-5 only) + , ST montelukast sodium tabs + , ST

Accolate® Singulair® chews ST (ages 1-5 only) Singulair® ST zafirlukast Zyflo® CR PAR

2.F. Other Respiratory Drugs

TIER 1 TIER 2 TIER 3 acetylcysteine ipratropium 200mcg/ml nebs + sodium chloride for inhalation

Atrovent® HFA + Combivent® Kalydeco® PAR ‡ Pulmozyme® Spiriva® + (ages ≥ 45 years only) TudorzaTM Pressair (ages ≥ 45 years only)

albuterol-ipratropium neb soln Atrovent® Neb Duoneb®

CHAPTER 3 – BLADDER/KIDNEY

3.A. Antispasmodics

TIER 1 TIER 2 TIER 3 flavoxate hcl + hyoscyamine + (Max pt age of 64) oxybutynin + oxybutynin chloride SR +

Enablex® + , ST except ages >65

Anturol® ST except ages > 65 Detrol® ST except ages > 65, QL Detrol LA® ST except ages > 65, QL Ditropan® Ditropan® XL ST except ages >65 Levsin®/SL MyrbetriqTM ST except ages >65 Oxytrol® ST except ages >65, QL Sanctura®/Sanctura XR®

ST except ages > 65 tolterodine tartrate ST except ages > 65, QL Toviaz® ST trospium ST except ages > 65 Urispas® Vesicare® ST except ages > 65

3.B. Cholinergic Stimulants

TIER 1 TIER 2 TIER 3 bethanechol chloride +

Urecholine®

3.C. Urinary Anesthetics

TIER 1 TIER 2 TIER 3 phenazopyridine Pyridium®

3.D. Other Urinary Products

TIER 1 TIER 2 TIER 3 generic Bicitra® potassium citrate potassium citrate/citric acid +

Elmiron® PAR except Urology, QL Renacidin®

Bicitra® Polycitra® Urocit-K®

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CHAPTER 4 – BLOOD

4.A. Anticoagulants

TIER 1 TIER 2 TIER 3 enoxaparin sodium

PAR required for duration of greater than 14 days except when written by an oncologist

fondaparinox PAR except for duration of therapy < 14 days

heparin sodium jantoven + warfarin sodium +

Fragmin® PAR except for duration of therapy < 14 days

Mephyton® + PradaxaTM

Xarelto®

Arixtra® PAR except for duration of therapy < 14 days Coumadin® Lovenox®

PAR required for duration of greater than 14 days except when written by an oncologist

4.B. Antiplatelets

TIER 1 TIER 2 TIER 3 aspirin/dipyridamole + clopidigrel bisulfate + dipyridamole + sulfinpyrazone +

Aggrenox® PAR except Neurology Brilinta® + Effient® + (Max. age of 75)

Persantine® Plavix® Ticlid® ticlopidine

4.C. Hematopoietic Agents

TIER 1 TIER 2 TIER 3 Aranesp® PAR ‡

Epogen® PAR ‡ Neulasta® PAR ‡ Neupogen® PAR ‡ Procrit® PAR ‡ Promacta® PAR ‡

Leukine® PAR Neumega® PAR

4.D. Other Blood Modifiers

TIER 1 TIER 2 TIER 3 aminocaproic acid anagrelide +

PAR except Oncology and Hematology cilostazol + pentoxifylline +

Arcalyst® PAR ‡ Must be obtained through Accredo or Caremark Pharmacy

Exjade® PAR ‡ Revlimid® PAR ‡

Agrylin® PAR except Oncology and Hematology

Ferriprox® PAR ‡ Firazyr® PAR ‡ Pletal® Trental®

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CHAPTER 5 – CANCER

5.A. Cancer Drugs

TIER 1 TIER 2 TIER 3 anastrozole + ‡

PAR except Oncology, Oncology Surgery and Breast Surgeons. Restricted to female patients only.

bicalutamide ‡ (Restricted to males) cyclophosphamide etoposide (caps only) ‡ exemestane ‡ +


flutamide ‡ Restricted to male patients only hydroxyurea 500mg ‡ letrozole ‡ +

PAR except Oncology, breast and oncologic surgery or fertility specialists; QL = 10 tablets per fill for 6 cycles for fertility specialists. Restricted to female patients. Maximum age limit for fertility is 44 years old.

leucovorin calcium tabs megestrol acetate ‡ mercaptopurine methotrexate tabs + octreotide PAR tamoxifen + tretinoin ‡

Actimmune® PAR ‡ Afinitor® PAR ‡ Alkeran® ‡ Caprelsa®

PAR Must be obtained through Biologics, Inc. only CeeNu® Emcyt® ‡ ErivedgeTM PAR ‡ Fareston® + ‡

(Restricted to females only) Gleevec® PAR ‡ Hexalen® ‡ Hycamtin® cap PAR ‡ Jakafi® PAR ‡ Leukeran® Lysodren® ‡ Matulane® ‡ Mesnex® ‡

PAR except Oncology Myleran® ‡ Nilandron®

PAR except Oncology and Urology Oforta® PAR ‡ Proleukin® PAR Sprycel® ST ‡ Sutent® PAR ‡ Tabloid® Tarceva® ‡

PAR except Oncology Tasigna® ST ‡ Temodar® ‡ Teslac® Thalomid® ‡ Tykerb® PAR ‡ Votrient® PAR ‡ Xeloda®

PAR except Oncology Zolinza® PAR ‡ Zortress®

PAR except Nephrology and transplant surgeons Zytiga® PAR ‡

Arimidex® ‡ PAR except Oncology, Oncology Surgery and Breast Surgeons. Restricted to female patients only.

Aromasin® ‡ PAR except Oncology, Oncology Surgery and Breast Surgeons. Restricted to female patients only.

Bosulif® PAR ‡ Drug restricted to hematology and medical oncology prescribers only.

Casodex® ‡ (Restricted to males) Cytoxan® ‡ Droxia® ‡ Femara® ‡


Hydrea® ‡ Inlyta® PAR, ‡ Iressa®

Must be obtained though CuraScript Pharmacy Only Megace® ES ‡ Nexavar® ‡

PAR for non-FDA approved uses Sandostatin® PAR Stivarga® PAR ‡

Drug restricted to hematology and medical oncology prescribers only.

SylatronTM PAR, ‡ Vesanoid® ‡ Xalkori® PAR ‡ Xtandi® PAR ‡


ZelborafTM PAR, ‡

5.B. Immunosuppressant Drugs

TIER 1 TIER 2 TIER 3 azathioprine + cyclosporine capsules cyclosporine modified + cyclosporine oral solution mycophenolate + prednisolone prednisone tacrolimus

Azasan® + Myfortic® +

PAR except Nephrology and Renal Transplant Surgeons

Rapamune® PAR except Nephrology and Renal Transplant Surgeons

CellCept® Imuran® Neoral® Orapred® Prograf® Rayos® ST Sandimmune®

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CHAPTER 6 – Cardiovascular – Hypertension

6.A. ACE Inhibitors

TIER 1 TIER 2 TIER 3 benazepril + captopril + enalapril + , HT fosinopril + , HT lisinopril + , HT moexipril+ , HT quinapril + , HT perindopril +, HT ramipril + trandolapril + , HT

Accupril® Aceon® Altace® caps Capoten® Lotensin® Mavik®

Prinivil® Univasc® Vasotec® Zestril®

6.B. Angiotensin II Receptor Blockers

TIER 1 TIER 2 TIER 3 irbesartan +, ST, HT losartan +, ST

Diovan® +, ST, HT Atacand® ST Avapro® ST, HT Benicar® ST Cozaar® ST Edarbi® ST eprosartan ST Micardis® ST Teveten® ST

6.C. Beta Blockers

TIER 1 TIER 2 TIER 3 acebutolol HCl + atenolol + bisoprolol fumerate +, HT carvedilol + Dutoprol® + labetalol + metoprolol + metoprolol succinate SR +

nadolol + pindolol+ propranolol + propranolol ER + timolol +

Betaxolol® Bystolic® Cartrol® Coreg® Corgard® Inderal® LA Innopran XL® Kerlone® Levatol® Lopressor® Sectral® Tenormin® Toprol® XL Trandate® Zebeta®

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6.D. Calcium Channel Blockers

TIER 1 TIER 2 TIER 3 amlodipine + amlodipine besylate-benazepril hcl + generic Cardizem® CD + Cartia XT + generic Dilacor® XR + diltiazem ER bead caps + diltiazem HCl + diltiazem SR + felodipine er + Nifediac CC Nifedical XL nifedipine ER + nimodipine PAR nisoldipine verapamil + verapamil ER caps + verapamil SR tablets+

Adalat® CC Calan® Calan® SR Cardene® Cardene® SR Cardizem® Cardizem® SR Cardizem® LA Cardizem® CD Covera® HS Dilacor® XR DynaCirc® CR Isoptin® SR Kerlone® Lotrel® Nicardipine® Nimotop® PAR Norvasc® Plendil® Procardia® XL Sular® Tiazac® Verelan® PM

6.E. Diuretics 6.E.i. Loop Diuretic

TIER 1 TIER 2 TIER 3 bumetanide + furosemide + torsemide +

Bumex® Demadex® Edecrin® Lasix®

6.E.ii. Thiazide and Related Drugs

TIER 1 TIER 2 TIER 3 chlorothiazide tabs + chlorthalidone + 25mg, 50mg, 100mg tabs hydrochlorothiazide + indapamide + methyclothiazide + metolazone +

Diuril® susp Zaroxolyn®

6.E.iii. Potassium Sparing Diuretics

TIER 1 TIER 2 TIER 3 amiloride hcl + generic Dyazide® generic Maxzide® + spironolactone +

Aldactazide® 50/50 + Aldactazide 25/25® Aldactone® Dyazide® Dyrenium® Maxzide® Midamor®

6.F. Vasodilators

TIER 1 TIER 2 TIER 3 doxazosin+ hydralazine HCl + minoxidil tabs + prazosin HCl + terazosin (capsules only) +

Cardura® Cardura® XL Hytrin® Minipress®

6.G. Centrally Acting Hypertensives

TIER 1 TIER 2 TIER 3 clonidine HCl + clonidine HCl TD patch guanfacine HCl + methyldopa +

Catapres® Catapres®-TTS guanabenz acetate NexiclonTM ST Tenex®

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6.H. Hypertensive Combinations

TIER 1 TIER 2 TIER 3 amlodipine besylate-benazepril hcl + atenolol/chlorthalidone + benazepril/hctz + captopril/hctz + enalapril/hctz +, HT irbesartan/hctz +, ST, HT lisinopril/hctz +, HT losartan/hctz ST metoprolol/hctz + moexipril/hctz +, HT propranolol/hctz + quinapril/hctz +, HT valsartan/hctz +, ST, HT generic Ziac®+

Accuretic® Atacand HCT® ST Avalide® ST, HT Azor® ST Benicar HCT® ST Capozide® Corzide® Diovan® HCT ST, HT Edarbyclor® ST Exforge® ST Exforge® HCT ST Hyzaar® ST Lopressor HCT® Lotensin HCT® Lotrel® methyldopa/hctz Micardis® HCT ST Prinzide® Tarka® trandolapril/verapamil hcl Tenoretic® TribenzorTM ST Twynsta® ST Uniretic® Vaseretic® Zestoretic® Ziac®

6.I. Renin-Angiotensin Inhibitor

TIER 1 TIER 2 TIER 3 AmturnideTM ST

Tekamlo® ST Tekturna® ST Tekturna® HCT ST Valturna® ST

CHAPTER 7 – Cardiovascular – Lipid Lowering

7.A. Bile Acid Sequestrants

TIER 1 TIER 2 TIER 3 cholestyramine/cholestyramine light (bulk) + colestipol granules(bulk) + colestipol tab 1gm +

Welchol® + Colestid® (bulk) Colestid® tab

Questran® Questran Light®

7.B. HMG-CoA Reductase Inhibitors

TIER 1 TIER 2 TIER 3 atorvastatin calcium +, HT lovastatin +, HT pravastatin +, HT simvastatin +, HT

Crestor® +, HT

fluvastatin Lescol® Lipitor® Livalo® Mevacor® Pravachol® Zocor®

7.C. Fibric Acid Derivatives

TIER 1 TIER 2 TIER 3 fenofibrate + gemfibrozil + Lofibra +

7.D. Other Antihyperlipidemic

TIER 1 TIER 2 TIER 3 Lovaza® +

Niaspan® + Zetia® +

VascepaTM

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7.E. Antihyperlipidemic Combination Products

TIER 1 TIER 2 TIER 3 Simcor® +

Advicor® atorvastatin/amlodipine Caduet® Vytorin®

CHAPTER 8 – Cardiovascular/Heart

8.A. Antiarrhythmics

TIER 1 TIER 2 TIER 3 amiodarone + digoxin + disopyramide + disopyramide CR 150mg + flecainide acetate + mexiletine HCl + phenytoin sodium ext + procainamide caps + procainamide sr + propafenone hcl + propafenone hcl sr + quinidine gluconate SR + quinidine sulfate + quinidine sulfate SR + sotalol +

Norpace CR® 100mg + Tikosyn® +

Lanoxin® Multaq® Norpace® Pronestyl® Rythmol® SR Tambocor®

8.B. Nitrates

TIER 1 TIER 2 TIER 3 isosorbide dinitrate + isosorbide mononitrate + isosorbide mononitrate SR + Minitran® + nitroglycerin long-acting + nitroglycerin ointment nitroglycerin patch + nitroglycerin sublingual + Nitro-Dur® +

Nitrostat® QL Imdur® Ismo® Isordil® Monoket® Nitro-Bid® Nitrolingual aerosol spray

8.C. Other Cardiovascular Drugs

TIER 1 TIER 2 TIER 3 eplerenone +, PAR midodrine hcl phentolamine inj PAR sildenafil PAR Minimum age of 18 years

Adcirca® PAR, ‡ Dibenzyline® Letairis® ‡, PAR Tracleer® PAR, ‡

Inspra® PAR ProAmatine® Ranexa® Revatio® PAR Minimum age of 18 years

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CHAPTER 9 – Dermatological Medications

9.A. Topical Corticosteroid Drugs

TIER 1 TIER 2 TIER 3 alclometasone diproprionate augmented betamethasone diproprionate (and AF)

augmented betamethasone betamethasone diproprionate bethamethasone valerate clobetasol proprionate oint; cream desonide 0.05% cream; oint; lotion desoximetasone diflorasone diacetate fluticasone cr; oint fluocinonide fluocinolone acetonide fluticasone propionate lotion 0.05% halobetasol propionate hydrocortisone rectal cream 2.5% hydrocortisone 25mg rectal hydrocortisone 2.5% cream; oint; lotion hydrocortisone valerate mometasone furoate + prednicarbate cr, oint triamcinolone acetonide

Capex® Cordran® Tape only Halog®

Aclovate® Apexicon E® Carmol-HC® Clobex® Clobex® Spray Cordran® lotion Cutivate® cream; oint Cutivate® 0.05% lotion DermAtop®

Desowen® lotion Diprolene® (and AF) Diprolene® 0.05% lotion Elocon® Halonate® Lidex® Luxiq® foam Novacort® Olux® foam Pediderm® HC Pramosone® E Temovate® Topicort® Ultravate® Verdeso® Westcort®

9.B. Antiacne Drugs

TIER 1 TIER 2 TIER 3 adapalene generic Avita® benzoyl peroxide cr,gel,lot OTC clindamax clindamycin phosphate gel 1% clindamycin phosphate-benzoyl peroxide gel clindamycintopical erythromycin gel erythromycin pads erythromycin/benzoyl peroxide gel isotretinoin PAR except Dermatology metronidazole cream, lotion generic Retin-A® generic Sulfacet-R® rosadan sulfacetamide sodium lotion sulfacetamide sodium w/sulfur emulsion/cleanser

Azelex® Derma-Smoothe/FS® Differin® 0.3% Finacea® Finacea® Plus Kit Metrogel® 1% Noritate® Retin-A® Micro Ziana®

Absorbica® PAR except dermatology Accutane® PAR except dermatology Avar-E® LS Avita® BenzaClin® Benzefoam® Brevoxyl® benzoyl peroxide (prescription) benzoyl peroxide cloths benzoyl peroxide foam 5.3% Cleocin-T® Clindagel® Differin® cream, gel Duac® Klaron® Metrocream® Metrogel® 0.75% Metrolotion® minocycline hcl er PAR minocycline hcl tabs PAR Myorisan® PAR except dermatology Plexion® cleanser Retin-A® Rosula® Emulsion Cleanser Solodyn® PAR SumadanTM Sumaxin® Wash Tretin® X QL Triaz® Cloths 3% VeltinTM

January 2013 14

9.C. Antipsoriasis and Antieczema Drugs

TIER 1 TIER 2 TIER 3 calcipotriene soln, oint, cream

PAR except Dermatology methotrexate tabs + selenium sulfide sulfacetamide sodium lotion

Elidel® PAR except for members 2-18 years of age or when prescribed by dermatology or allergy

Protopic® PAR except for members 2-18 years of age or when prescribed by dermatology or allergy

Soriatane® PAR except Dermatology Tazorac® PAR except Dermatology

8-Mop® Dovonex® PAR except Dermatology Keralyt® scalp Salvax® Duo Kit PAR SoriluxTM PAR except Dermatology Taclonex® PAR except Dermatology Zithranol-RR® cream

PAR except Dermatology, QL

9.D. Antifungal Drugs

TIER 1 TIER 2 TIER 3 ciclopirox olamine 0.77% suspension ltn & crm ciclopirox gel 0.77% clotrimazole cream, lotion, soln OTC econazole nitrate cream 1% ketoconazole 2% shampoo ketoconazole cream Lamisil AT® cream OTC miconazole cream, lotion, aerosol, soln OTC Nizoral A-D® shampoo OTC nystatin 100,000u/1g cream; oint nystatin pwd nystatin-triamcinolone Nystop®

ciclopirox soln ciclopirox shampoo Extina®

ketoconazole foam 2% Ketodan® Loprox® Loprox® Shampoo Mentax® Micatin® Naftin® Nizoral® shampoo Oxistat® Penlac® Vusion®

9.E. Other Dermatological Products

TIER 1 TIER 2 TIER 3 aluminum chloride 20% ammonium lactate cr ammonium lactate lotion calcitriol ointment PAR except Dermatology clotrimazole with betamethasone cream 1-0.05% fluorouracil imiquimod cream

PAR except Dermatology, Urology,OB/GYN, Colorectal Surgery

lidocaine cr lidocaine HC cr lidocaine viscous soln lidocaine-prilocaine cream lindane normal saline for irrigation permethrin cream podofilox solution

Carac® Eurax® Oxsoralen-Ultra® (oral only) Solaraze® PAR except Dermatology Veregen®

Aldara® PAR except Dermatology, Urology,OB/GYN, Colorectal Surgery

Analpram® E Drysol® Efudex® Epiduo® PAR except Dermatology Evoclin® Foam Lidoderm® Medrox-RX® PAR Momexin® Natroba® ST QL Panretin® Gel PAR Picato® Gel PAR Regranex® PAR spinosad suspension 0.9% ST QL Sklice® ST QL Targretin® Gel PAR Ulesfia® Uramaxin® urea Vectical® PAR except Dermatology Vytone® Zyclara® PAR except Dermatology

Maxium of 4 fills per year Zypram® 2.35-1% cream and kit

9.F. Antibiotics

TIER 1 TIER 2 TIER 3 gentamicin silver sulfadiazine mupirocin oint

Bactroban® cream Zovirax® ointment

Aczone® PAR except Dermatology Altabax® ST Bactroban® nasal oint Bactroban® oint XereseTM

January 2013 15

CHAPTER 10 – Diabetes NOTE: Insulin and oral anti-diabetic agents that are not listed on the formulary or are listed in tier 3 require prior authorization and if authorized, will be covered in accordance with the member’s contract. Copayments vary by plan.

10.A. Insulin

TIER 1 TIER 2 TIER 3 Humulin® Insulins

Humalog® Lantus® Levemir® Novolin® insulins Novolog® insulins

Apidra® PAR, QL Apidra® Solostar PAR

10.B. Oral Hypoglycemic Drugs

TIER 1 TIER 2 TIER 3 acarbose + glimepiride + glipizide + glipizide-metformin glipizide CR tablets + glyburide + glyburide-metformin + glyburide micronized + metformin hcl (500mg, 850mg, 1,000mg) + metformin tb24 + metformin SR + nateglinide +, PAR except endocrinology pioglitazone hcl + pioglitazone hcl/metformin hcl +

Actoplus Met® XR Duetact® + Glumetza® ST Janumet® + Janumet® XR + Januvia® +, HT Kombiglyze® XR Onglyza® +, HT Proglycem® PAR except Endocrinology Prandin® + Prandimet® + Riomet®

Actos® Actoplus Met® Amaryl® Avandamet® PAR Avandaryl® PAR Avandia® PAR Cycloset® Diabeta® PAR Fortamet® PAR Glucophage/Glucophage XR® PAR Glucotrol® PAR Glucotrol XL® PAR Glucovance® PAR Glyset® PAR Glynase® PAR Jentadueto® Juvisync® Metaglip® Precose® Starlix® PAR except Endocrinology Tradjenta®

10.B.i Other Drugs Affecting Glucose

TIER 1 TIER 2 TIER 3 glucagon

Bydureon® ST except for endocrinology Byetta® ST except for endocrinology Symlin®

PAR except for endocrinology. Patients must be receiving insulin therapy concurrently

Victoza® ST except Endocrinologists Welchol® +

10.C. Diabetic Supplies


NovoFine® Needles

10.C.i Blood Glucose Monitors

TIER 1 TIER 2 TIER 3 Accu-Chek® Aviva

Accu-Chek® Compact Plus OneTouch® UltraMini® Meter OneTouch® Ultra®2 Meter OneTouch® Verio IQ Precision Xtra®

PAR, used for members requiring ketone testing capability

Sof-Tact® PAR, integrated lancet device and meter for alternate site testing

Ascensia Dex® PAR Assure II® PAR Freestyle® PAR Quicktek® PAR

January 2013 16

10.C.ii Test Strips

TIER 1 TIER 2 TIER 3 Accu-Chek® Active

Accu-Chek® Aviva Accu-Chek® Advantage or Comfort Curve Accu-Chek® Compact Drum Chemstrip® K Chemstrip® UGK Fasttake® OneTouch® OneTouch® Ultra OneTouch® Ultra Mini

OneTouch® Verio IQ Precision Xtra®

PAR; used for members requiring ketone testing capability

Sof-Tact® PAR, integrated lancet device and meter for alternate site testing

SureStep®

Ascensia® PAR Assure II® PAR Exactech® PAR Freestyle® PAR Glucodex® PAR

CHAPTER 11 – Ear/Throat Medications

11.A. Drugs Affecting the Ear

TIER 1 TIER 2 TIER 3 acetic acid otic soln antyipyrine/benzocaine otic soln ciprofloxacin otic

PAR except for members < 18 years of age or when prescribed by Otolaryngology

generic Cortisporin® Otic sol, susp generic Domeboro® Otic hydrocortisone w/acetic acid otic soln ofloxacin otic


Ciprodex® PAR except for members < 18 years of age or when prescribed by Otolaryngology

Chloromycetin® Otic

Auralgan® Otic Soln Cipro HC® Otic


colistimethate Coly-Mycin-M® Coly-Mycin-S® Cortane B® Otic Cortisporin® otic sol, susp Cortisporin® Otic-TC Cresylate® Otic Domeboro® Otic Floxin® Otic


Neotic® Trioxin® Otic susp Zinotic®/Zinotic® ES

11.B. Drugs Affecting the Throat and Mouth

TIER 1 TIER 2 TIER 3 cevimeline QL chlorhexidine oral rinse triamcinolonein Orabase lidocaine viscous pilocarpine tab

Evoxac® QL Kenalog® in Orabase Peridex® Salagen®

January 2013 17

CHAPTER 12 – Eye

12.A. Ophthalmic Antiinfective drugs

TIER 1 TIER 2 TIER 3 bacitracin ophthalmic chloramphenicol ciprofloxacin ophth soln erythromycin ophthalmic gentamicin ophthalmic generic Neosporin® ophthalmic levofloxacin opth soln ofloxacin ophth soln generic Polytrim® generic Polysporin® ophthalmic sulfacetamide sodium 10% tobramycin trifluridine

Natacyn® PAR except Ophthamology Zirgan®

Azasite® PAR, QL Besivance® Ciloxan® Moxeza® PAR except Ophthamology Ocuflox® QL Quixin® Vigamox® PAR except Ophthamology Viroptic® Zymaxid® PAR except Ophthalmology

12.B. Ophthalmic Corticosteroid Drugs

TIER 1 TIER 2 TIER 3 dexamethasone ophthalmic hydrocortisone w/acetic acid otic soln generic FML® Liquifilm generic Econopred® Plus generic Pred Forte® generic Inflamase® Forte

Acuvail® PAR except ophthalmology Alrex® 5ml only

PAR except Allergy and Ophthamology Flarex® FML-Forte® ophthalmic Lotemax® 5ml only Lotemax® ointment Pred Mild® Vexol® 5ml only

Acetasol® HC otic soln Acuvail® PAR HMS® Pred Forte®

12.C. Ophthalmic Antiinfective/Steroid Combination Drugs

TIER 1 TIER 2 TIER 3 dexamethasone/tobramycin generic Cortisporin® ophthalmic generic Maxitrol® ophthalmic generic Metimyd® generic NeoDecadron®

Blephamide® Liquifilm Poly-Pred® Tobradex® ST

Pred-G® Pred-G S.O.P. ® Tobradex® Zylet®

12.D. Glaucoma Drugs

TIER 1 TIER 2 TIER 3 acetazolamide tab + apraclonidine brimonidine tartrate 0.2% brimonidine solution carteolol dipivefrin dorzolamide hcl soln dorzolamide/timolol ophth soln + latanoprost ophth soln

PAR for patients less than 50 years of age levobunolol HCl methazolamide + metipranolol pilocarpine soln timolol maleate generic Timoptic-XE®

Alphagan P® 0.1% Azopt® Betimol® 5ml only Betoptic® S Combigan® 5ml only Isopto Carbachol® Lumigan® PAR for patients less than 50 years of age Phospholine® iodide Pilopine® H.S. Travatan® PAR for patients less than 50 years of age Travatan® Z

PAR for patients less than 50 years of age

Alphagan P® 0.15% Betagan® Cosopt® Cosopt® PF Diamox® Iopidine® Optipranolol® Timoptic® Timoptic XE® Trusopt® Xalatan®

PAR for patients less than 50 years of age Zioptan® PAR for patients less than 50 years of age

January 2013 18

12.E. Other Ophthalmic Drugs

TIER 1 TIER 2 TIER 3 Alaway®

(A prescription is required for this OTC product) atropine azelastine bromfenac PAR except Ophthalomology cromolyn sodium + PAR except Ophthalomology diclofenac sodium ophth soln +

PAR except Ophthalomology epinastine homatropine ketorolac tromethamine ophth soln 0.4% and 0.5%

PAR except Ophthalmology naphazoline OTC, QL phenylephrine ophthalmic 2.5% tropicamide Zaditor®

(A prescription is required for this OTC product)

Alomide® PAR except Ophthalmology BromdayTM ® PAR except Ophthalmology,

Maximum of 2 fills per year Lacrisert® Nevanac® PAR except Ophthalmology,

Maximum of 2 fills per year Restasis® PAR except Ophthalmology

Acular® PAR except Ophthalmology

Acular® LS PAR except Ophthalmology

Akten® Alamast® Alocril® ST Bepreve® opth ST Cyclogyl® Durezol® Elestat® ST

Emadine®

flurbiprofen ophth soln

ketotifen fumerate ophth soln (rx only)

LastacaftTM ST Mydfrin® Ocufen® ophth soln

Pataday® ST Patanol® ST Optivar® ST Voltaren®ophth soln PAR except Ophthalmology

CHAPTER 13 – Hormones/Steroids

13.A. Oral Steroids

TIER 1 TIER 2 TIER 3 dexamethasone cortisone acetate + fludrocortisone acetate + hydrocortisone tab + methylprednisolone generic prednisolone oral syrup prednisone

Celestone® Cortef® Decadron® Medrol® Orapred® Pediapred® Prelone®

13.B. Thyroid and Antithyroid Drugs

TIER 1 TIER 2 TIER 3 levothroid + levothyroxine + levoxyl + liothyronine + methimazole + propylthiouracil + thyroid + unithroid +

Armour Thyroid® + Synthroid® +

Cytomel® Tapazole® TirosintTM

13.C. Growth Hormone Products

TIER 1 TIER 2 TIER 3 Nutropin®/Nutropin® AQ PAR, ‡

Somavert® PAR Must be obtained at CuraScript Only

Genotropin® PAR, ST, ‡ Humatrope® PAR, ST, ‡ Saizen® PAR, ‡ Serostim® PAR

January 2013 19

13.D. Osteoporosis

TIER 1 TIER 2 TIER 3 alendronate tabs + calcitonin calcitonin-salmon Fortical®

Actonel® + Actonel® with Calcium + AtelviaTM Forteo® PAR, ‡ (limited to 26 fills/lifetime) Fosamax® plus D + Miacalcin® inj. PAR

Binosto® ST Boniva® tabs QL Fosamax® tabs ibandronate sodium tabs QL Miacalcin® nasal spray

13.E. Other Endocrine Drugs

TIER 1 TIER 2 TIER 3 cabergoline PAR except Endocrinology, QL desmopressin +

CarbagluTM PAR

Chemet® Cystagon® PAR Didronel® Increlex® PAR, ‡ Korlym® PAR, ‡ Menostar® + (limited to women > 45 years of age) Orfadin® PAR, ‡ Sensipar® + Stimate® Syprine® + Zavesca® PAR

Must be obtainedthrough CuraScript Pharmacy only

DDAVP® Oxandrin® Samsca® PAR

CHAPTER 14 – Infection

14.A. Antibiotics (Antibiotics are generally limited to a 10 day supply with one refill within 15 days of original fill.)

TIER 1 TIER 2 TIER 3 amoxicillin caps, susp amoxicillin clavulanate ampicillin caps, susp azithromycin

(250mg & 500mg tabs, QL; 600mg tabs, PAR except Infectious Disease, QL)

azithromycin® susp QL cefaclor caps, susp cefadroxil cefprozil cefuroxime 250mg & 500mg tabs cephalexin caps, susp cephradine capsules ciprofloxacin tabs clarithromycin clarithromycin SR QL clindamycin 75mg, 150mg, 300mg dicloxacillin caps doxycycline hyclate caps, tabs erythromycin base enteric pellets erythromycin estolate caps, susp erythromycin ethylsuccinate tabs, susp

erythromycin stearate erythromycin/ sulfisoxazole susp

levofloxacin minocycline caps (50mg & 100mg only) nitrofurantoin PAR age > 12macrocrystals penicillin VK tabs, soln sulfamethoxazole/trimethoprim sulfisoxazole tabs tetracycline caps, susp trimethoprim tabs

Avelox® Ery-Tab® Suprax® tabs, susp Vibramycin® susp

amoxicillin/ clavulanate er

Augmentin® XRBiaxin® Biaxin XL® tabs QL cefdinir Ceftin® 125mg tabs, susp Cefzil® Cetraxal® PAR, QL Max. 7 day supply Cipro® ciprofloxacin hcl SR 24 hr tabs Cleocin® pediatric granules Doryx® QL doxycycline DR QL doxycycline hyclate TBEC dr QL doxycycline monohydrate Furadantin® susp

PAR age > 12 Keflex® Ketek® Noroxin® Levaquin® Macrobid®

Minocin® Minocin Pac® PAR Monodox® 75mg Moxatag® Proquin® XR Zithromax®

(250mg & 500mg tabs QL; 600mg tabs PAR except Infectious Disease, QL)

Zithromax® susp QL ZMax® Zyvox® PAR

January 2013 20

14.B. Antifungals

TIER 1 TIER 2 TIER 3 clotrimazole troche fluconazole 150mg tab (QL, females only) fluconazole tabs/oral suspension griseofulvin suspension itraconazole caps PAR except Infectious Disease ketoconazole tabs nystatin oral suspension nystatin tabs terbinafine hcl PAR except Infectious Disease voriconazole PAR except Infectious Disease

Gris-Peg® 250 mg Lamisil® oral granules

PAR except Infectious Disease Noxafil® PAR, +

Ancobon® Diflucan® 150mg (QL, females only) Diflucan tabs/oral suspension Ertaczo® QL flucytosine Grifulvin® V Gris-Peg® 125 mg Lamisil® PAR except Infectious Disease Mycelex® Troche Nizoral® Oravig® ST; Min age of 16 Sporanox®

PAR except Infectious Disease Terbinex® PAR, QL Vfend® PAR except Infectious Disease

14.C. HIV Drugs

TIER 1 TIER 2 TIER 3 abacavir sulfate tabs + didanosine DR lamivudine + lamivudine/zidovudine nevirapine stavudine zidovudine

Aptivus® Atripla® CompleraTM Crixivan® Emtriva® Epzicom® Fuzeon® PAR, ‡ Intelence® Invirase® Isentress® Kaletra® Lexiva® Norvir® Prezista® ST Rescriptor® Reyataz® Selzentry® StribildTM Sustiva® Trizivir® PAR Truvada® Videx® Viramune® XR Viread® Viracept® Ziagen® soln

Combivir® EdurantTM Epivir® Retrovir® Videx® EC Viramune® Zerit® Ziagen® tabs

14.D. Other Antiviral Drugs

TIER 1 TIER 2 TIER 3 acyclovir amantadine + famciclovir QL ganciclovir

PAR except Infectious Disease and Ophthalmology ribavirin ‡, PAR valacyclovir QL

Alferon N® PAR Baraclude®

PAR except for Gastroenterology or Infectious Disease

Epivir-HBV® PAR except Gastroenterology or Infectious Disease

Hepsera® PAR except Gastroenterology or Infectious Disease

Relenza® (Age limited to > 5 years; QL) Tamiflu® QL Tyzeka®

PAR except Gastroenterology or Infectious Disease Valcyte®

PAR except Infectious Disease, Ophthalmology, Nephrology and Renal Transplant Specialists

Copegus®‡, PAR Famvir® QL flumadine Rebetol® ‡ , PAR Valtrex® QL Zovirax®

January 2013 21

14.E. Antituberculosis Drugs

TIER 1 TIER 2 TIER 3 ethambutol isoniazid+ pyrazinamide rifampin

Mycobutin® PAR except Infectious Disease

Rifater®

Myambutol® Rifadin® Seromycin® Trecator®

14.F. Other Specialized Antiinfective Drugs

TIER 1 TIER 2 TIER 3 chloroquine phosphate Dapsone hydroxychloroquine sulfate + mebendazole QL metronidazole mefloquine hcl QL neomycin sulfate paromomycin primaquine phosphate quinine sulfate caps

PAR except Infectious Disease, QL, limited to age > 16

tinidazole tabs vancomycin caps

PAR except Infectious Disease

Alinia® tabs, soln PAR except Infectious Disease and Gastro-enterology. Soln limited to patients ages 1-11yrs

Cayston® (QL, PAR except Cystic Fibrosis Specialists. Min age of 7. Must be obtained from Cystic Fibrosis Services)

Coartem® QL Daraprim® Mepron®

PAR except Infectious Disease Nebupent®

PAR except Infectious Disease Stromectol® Tobi®

PAR except Cystic Fibrosis Specialists; QL Yodoxin®

Aralen® phosphate atovaquone/proguanil Dificid® PAR Flagyl® Malarone® Qualaquin®

PAR except Infectious Disease, QL, limited to age > 16

Tindamax® Vancocin® capsules

PAR except Infectious Disease Xifaxan® 200mg QL Xifaxan® 550mg PAR

CHAPTER 15 – Men’s Health

15.A. Drugs for Benign Prostatic Dysplasia

TIER 1 TIER 2 TIER 3 alfuzosin + Restricted to male patients only doxazosin + finasteride + Restricted to male patients only. tamsulosin hcl sr + Restricted to male patients only terazosin (capsules only) +

Avodart® + Restricted to male patients only.

Cardura® Cardura® XL Cialis® 2.5mg & 5mg

Duplicate therapy with ED drugs is not allowed. Restricted to male patients only.

Flomax® Restricted to male patients only. Hytrin® Proscar® Restricted to male patients only.

Rapaflo® Restricted to male patients only. Uroxatral® Restricted to male patients only.

15.B. Erectile Dysfunction Drugs in this category are limited to male patients only. Duplicate therapy with other ED medications is not allowed.

TIER 1 TIER 2 TIER 3 yohimbine

Caverject® PAR except urology, QL = 6 per fill/48 per year

Edex® PAR except urology, QL = 6 per fill/48 per year

Muse® PAR except urology, QL = 6 per fill/48 per year

Viagra® QL = 6 tabs/month and 72 per year

Cialis® 10mg & 20mg QL = 4 tabs/month and 48 per year

Levitra® QL = 4 tabs/month and 48 per year

Staxyn® QL = 4 tabs/month and 48 per year/12 fills per year

Stendra® QL = 4 tabs/month and 48 per year/12 fills per year

January 2013 22

15.C. Male Hormones

TIER 1 TIER 2 TIER 3 testosterone cypionate PAR Androderm®

PAR except Endocrinology and Urology, restricted to male patients

Androgel® PAR except endocrinology and urology, restricted to male patients

Android® + Androxy® + Methitest® + Striant®

PAR except Endocrinology and Urology Testim®

PAR except Endocrinology and Urology. Limited to males only.

Testred® +

AxironTM


Bio-T-Gel® PAR except Endocrinology and Urology. Limited to males only.

Depo-Testosterone® PAR FortestaTM


CHAPTER 16 – Mental Health

16.A. Antianxiety Drugs

TIER 1 TIER 2 TIER 3 alprazolam buspirone clorazepate chlordiazepoxide diazepam (Max age of 64)

lorazepam oxazepam

alprazolam xr Ativan® Tranxene®

Valium® Xanax®

Xanax® XR

16.B. Sedative/Hypnotic Drugs

TIER 1 TIER 2 TIER 3 diphenhydramine 50mg only + flurazepam ♦

PAR for age > 65 hydroxyzine HCl + (Max age of 64) hydroxyzine (Max age of 64) pamoate +

temazepam ♦ triazolam 0.125mg, 0.25mg ♦

zaleplon ♦ zolpidem tartrate ♦

Rozerem® ♦

Ambien® ♦ Ambien® CR ♦ ST Edular® SL

ST, QL, ♦ Halcion® ♦ Intermezzo® ST, QL Lunesta®

PAR except for sleep specialists meprobamate

Max patient age of 64, PAR for age >65 Restoril® ♦ Sonata® ♦ Vistaril®

zolpidem er ♦, ST

January 2013 23

16.C. Depression/Mania

TIER 1 TIER 2 TIER 3 amitriptyline amitriptyline/perphenazine bupropion + bupropion hcl SR 12 hr + bupropion hcl SR 24hr + citalopram +, HT clomipramine desipramine doxepin escitalopram oxalate +, HT fluoxetine hcl 10mg & 20mg tabs/capsules + fluoxetine liquid fluvoxamine imipramine HCl (PM non-form) lithium carbonate + lithium carbonate CR tab maprotiline PAR except Psychiatry mirtazapine +, HT mirtazapine ODT +, HT nefazodone hcl +, PAR nortriptyline paroxetine tabs +, HT paroxetine er + ST paroxetine hcl sr + ST protriptyline sertraline +, HT tranylcypromine trazodone + trimipramine venlafaxine + venlafaxine er caps +

Cymbalta® Nardil® Savella® +

Amoxapine® Anafranil® Celexa® Effexor® XR Emsam® PAR fluoxetine 40mg capsules fluoxetine PMDD fluoxetine 90mg Forfivo® XL Lexapro® +, HT Oleptro® ST Pamelor® Parnate® Paxil® Paxil® CR ST Prozac® Prozac® Weekly Niravam® PAR Norpramin® Pristiq® ST Remeron® Remeron Sol-Tab® Sarafem® Silenor® QL Surmontil® Tofranil® Tofranil® PM ViibrydTM Vivactil® Wellbutrin® Wellbutrin SR® Wellbutrin XL® Zoloft®

16.D. Antipsychotic drugs

TIER 1 TIER 2 TIER 3 chlorpromazine + clozapine QL fluphenazine haloperidol + loxapine + olanzapine olanzapine odt PAR perphenazine + risperidone + risperidone odt + PAR risperidone solution Age limited to < 12 years thioridazine + Maximum patient age of 64 thiothixene + trifluoperazine + quetiapine fumarate ziprasidone +

Abilify® 5mg & 15mg PAR except Psychiatry

Abilify® 10mg HT PAR except Psychiatry Abilify® 20mg & 30mg HT, QL PAR except Psychiatry Abilify® oral solution

PAR except Psychiatry Orap®

Abilify® Discmelt PAR Fanapt® PAR except Psychiatry Fazaclo® QL Geodon® Haldol® LatudaTM Navane® olanzapine-fluoxetine PAR except Psychiatry Risperdal® Risperdal® M PAR Risperdal® solution (Age limited to < 12 years) Saphris® Seroquel® Seroquel® XR ST Symbyax® PAR except Psychiatry Thorazine® Zyprexa® Zyprexa®/Zydis®PAR

January 2013 24

16.E. CNS Stimulant Drugs (Generally for Hyperkinesis or Narcolepsy only. Not covered as appetite suppressant.)

TIER 1 TIER 2 TIER 3 amphetamine mixture + (Ages >3) amphetamine-dextroamphetamine sr + (Ages>3) dextroamphetamine tabs & SR + (Ages >3) methamphetamine + (Min age of 6, Max age of 64)

Max patient age of 64 years methylphenidate + (Ages >6) methylphenidate er (Ages >3) methylphenidate SR tabs + (Ages >6)

Nuvigil® + (PAR; Ages > 16)

Strattera® + (Ages >6) Adderall® (Ages > 3) Adderall XR® (Ages > 3) Concerta® (Ages >3) Daytrana® (Ages > 6) Dexedrine®//Spansules (Ages > 3)

Dextrostat® (Ages > 3) Focalin® XR (Ages > 6)

Max patient age of 64 years KapvayTM Metadate CD® (Ages > 6) Methylin® (Ages > 6) methylphenidate er (Ages >6) modafinil (PAR; Ages > 16) Provigil® (PAR; Ages > 16) Quillivant® XR ST (Ages > 6) Ritalin®/Ritalin LA® (Ages >6) Vyvanse® (Ages > 6)

CHAPTER 17 – Nervous System

17.A. Anticonvulsants

TIER 1 TIER 2 TIER 3 carbamazepine + carbamazepine er + clonazepam tabs divalproex sodium tabs + divalproex sodium sr + divalproex sodium sprinkles + ethosuximide 250mg/5ml syrup ethosuximide capsules + felbamate gabapentin + lamotrigine tablets + lamotrigine chewable tablets + levetiracetam +

PAR except for Neurology, Physical Medicine or neurosurgery

oxcarbazepine + phenobarbital + phenytoin sodium + phenytoin sodium extended + phenytoin sodium susp + primidone + tiagabine + PAR except Neurology topiramate + topiramate sprinkle + PAR Age > 12 valproic acid + zonisamide + PAR except Neurology and age > 16

Banzel® PAR except Neurology, age restricted > 4 years including Neurology

Celontin® + Diastat® PAR except Neurology Dilantin® Infatab + Lyrica® Peganone® + Phenytek® + Sabril® PAR

Available through CuraScript Pharmacy only Vimpat®

PAR except Neurology, restricted to patients > 17 years of age

Carbatrol® clonazepam odt Depakene® Depakote® Depakote ER® Depakote® Sprinkles Dilantin® Dilantin® 125 suspension Felbatol® FycompaTM PAR except Neurology Gabitril® PAR except Neurology Gralise® ST Horizant® PAR Keppra®/Keppra® XR

PAR except Neurology, Physical Medicine or neuro-surgery

Klonopin® Klonopin® Wafers Lamictal® tabs Lamictal® chewable tablets Lamictal® ODT PAR Lamictal® ODT Titration Kit PAR, QL Lamictal® Starter Kit QL Lamictal® XR Age > 13 Lamictal® XR Starter Kit PAR, QL , Age > 13 levetiracetam xr

PAR except Neurology, Physical Medicine or neuro-surgery

Mebaral® Mysoline® Neurontin® Phenytek® Potiga® Tegretol®/Tegretol® XR Topamax® Topamax® Sprinkles PAR Ages > 12 Trileptal® Zarontin® Zonegran® PAR except Neurology and age > 16

January 2013 25

17.B. Antiparkinson Drugs

TIER 1 TIER 2 TIER 3 amantadine hcl + benztropine + bromocriptine mesylate + carbidopa/levodopa + carbidopa/levodopa CR + carbidopa/levodopa/entacapone tabs + diphenhydramine 50mg + entacapone +, ST pramipexole dihydrochloride +

PAR except Neurology ropinirole hydrochloride tabs

PAR except Neurology ropinirole hcl tabs 24 hour

PAR except Neurology selegiline + trihexyphenidyl +

Apokyn® PAR except Neurology ‡ Azilect® +, PAR except Neurology Zelapar® +

PAR except Neurology; concurrent use of Levodopa required

Cogentin® Comtan® +, ST Eldepryl® Kemadrin® Lodosyn® Mirapex®/ Mirapex® ER PAR except Neurology Neupro® PAR Parlodel® Parcopa® Requip® PAR except Neurology Requip® XL PAR except Neurology Sinemet® Sinemet CR® Stalevo® Tasmar® ST

17.C. Alzheimer’s Drugs

TIER 1 TIER 2 TIER 3 donepezil + galantamine + galantamine SR + galantamine oral solution

Aricept® 23mg ST Namenda® tabs, soln +

Aricept® Aricept® ODT Cognex® Exelon® Razadyne®

Razadyne® ER rivastigmine

17.D. Multiple Sclerosis Drugs

TIER 1 TIER 2 TIER 3 AmpyraTM ER PAR, ‡

Avonex® ‡, PAR except Neurology Copaxone® ‡, PAR except Neurology Rebif® ‡, PAR except Neurology

Aubagio® ‡, PAR Betaseron® ‡, PAR except Neurology

ST (all prescribers) Extavia® PAR, ‡ ST (all prescribers) GilenyaTM PAR, ‡

17.E. Other CNS/Autonomic Drugs

TIER 1 TIER 2 TIER 3 buprenorphine hcl PAR disulfiram naltrexone pyridostigmine bromide 60mg tab

Campral® PAR Mestinon® 60mg syrup, 180mg CR tab NuedextaTM XR PAR except Neurology. OnfiTM PAR Prostigmin® Suboxone® Suboxone® SL Filmtab Xenazine® PAR, QL

Must be obtained through CuraScript Xyrem®

PAR except Pulmonary and Neurology. Must be obtained through Express Scripts Pharmacy

Antabuse® ButransTM PAR except Pain Medicine specialists

Intuniv® (Min age of 6) Revia® Subutex® PAR

January 2013 26

CHAPTER 18 – Pain

18.A. Narcotic Pain Relieving

TIER 1 TIER 2 TIER 3 acetaminophen w/codeine aspirin w/codeine belladonna/opium supp codeine sulfate fentanyl TD patch 12mcg, 25mcg fentanyl TD patch 50mcg, 75mg, 100mcg ST hydrocodone w/acetaminophen 2.5/500,5/500,5/325, 7.5/325, 7.5/500, 7.5/650,7.5/750, 10/325, 10/500, 10/650,10/660

hydrocodone/APAP soln 7.5/500 mg per 15ml hydrocodone w/ibuprofen 2.5/200

PAR except Pain Medicine Specialists hydromorphone hcl PAR methadone hcl 5mg,10mg morphine sulfate ir morphine sulfate cap sr 24hr 10mg, 20mg, 30mg, 50mg, 60mg, 80mg

morphine sulfate cap sr 24hr 100mg, 200mg ST morphine sulfate supp morphine sulfate tablets oral solution morphine sulfate ER oxycodone 5mg tablets/soln oxycodone w/acetaminophen generic Percodan® tramadol tramadol er tablets ST generic Tylox®

Embeda® Exalgo® ST Nucynta® Nucynta® ER Opana ER® Oxycontin® 10mg, 15mg, 20mg, 30mg, 40mg Oxycontin® 60mg, 80mg ST

AbstralTM PAR except oncology. Min age of 18. Limited distribution via REMS program.

Actiq® PAR except for oncology Avinza® 30mg Avinza® 45mg, 60mg, 75mg, 90mg, 120mg ST B&O Supprettes® Maximum patient age of 64 Combunox® QL Conzip® ST Demerol® PAR for Age >65 Dilaudid® PAR Duragesic® ST Fentora® PAR except for oncology Kadian® 10mg, 20mg, 30mg, 50mg, 60mg, 80mg Kadian® 100mg, 200mg ST Lazanda® PAR Lortab® Magnacet® meperidine HCl

Maximum patient age of 64 MS Contin® Norco® Onsolis®

PAR except oncology, Min age 18. Must be obtained through Express Scripts Pharmacy

Opana® PAR except for pain medicine specialists

Oramorph®

Oxecta®

PAR except for pain medicine specialists oxycodone w/ibuprofen QL oxymorphone

PAR except pain medicinespecialists Percocet® Percodan® Reprexain®

PAR except for pain medicine specialists Roxicodone® Rybix® ODT PAR Ryzolt® ST Subsys®

PAR except for oncologists Talwin NX® PAR for ages >65 tramadol/apap

PAR except pain medicine spec. Tylenol w/Codeine® Tylox® Ultracet®

PAR except for pain medicine specialists Ultram® ER ST Vicodin® Vicoprofen® 7.5mg/200mg

PAR except pain medicine specialists Xodol®

January 2013 27

18.B. Antiinflammatory, i.e. NSAIDs

TIER 1 TIER 2 TIER 3 aspirin CR 800mg + diclofenac sodium enteric coated tablets + diclofenac sodium SR 24-hr 100 mg + diflunisal + etodolac + flurbiprofen tabs + ibuprofen +

(prescription strengths only, OTC not covered) indomethacin + indomethacin SR + ketoprofen + ketorolac PAR, QL

Maximum patient age of 64 meclofenamate + meloxicam + nabumetone + naproxen + naproxen sodium + oxaprozin + piroxicam + salsalate + sulindac + tolmetin sodium + (200mg PAR age > 16)

Celebrex® +, ST fenoprofen +

Anaprox® Daypro® Duexis® PAR EC Naprosyn® Flector® patch Indocin® ketoprofen extended release mefenamic acid Motrin® Mobic® Nalfon® Naprelan® QL Naprelan® SR Naprosyn®

Pennsaid® QL Ponstel® Meloxicam® Comfort PacKit QL SprixTM PAR, QL Vimovo® PAR Voltaren-XR®

Voltaren® gel QL Zipsor®

18.C. Migraine Drugs

TIER 1 TIER 2 TIER 3 butorphanol tartrate NS PAR divalproex sodium sr ergotamine w/caffeine generic Esgic® generic Esgic® Plus generic Fioricet® generic Forinal®w/codeine No.3

generic Fiorinal® generic Midrin® generic Phrenilin® sumatriptan inj QL sumatriptan nasal spray QL sumatriptan tabs QL

Cafergot® Ergomar® Phrenilin® Forte Migranal® PAR except Neurology, QL Relpax® tablets QL Zomig®/Zomig® ZMT QL Zomig® Nasal Spray QL

Alsuma® QL Amerge® QL Axert® QL Cambia® PAR; QL; Min age of 18 Depakote ER® DHE® 45 QL , PAR except Neurology Esgic® Esgic Plus® Fiorinal® Fioricet® Frova® QL Imitrex® QL Maxalt® QL Maxalt-MLT® QL Midrin® naratriptan QL Phrenilin® Stadol NS® Sumavel® QL Treximet® ST; QL Zelrix® QL

18.D. Antirheumatics

TIER 1 TIER 2 TIER 3 hydroxychloroquine sulfate + leflunomide +, PAR except Rheumatology methotrexate tabs + methotrexate inj

PAR except Rheumatology and Dermatology

Arthrotec® QL Cuprimine® + Depen® Titratabs Enbrel® ‡, PAR Humira® ‡, PAR Ridaura® Trexall®

Arava® 10mg, 20mg PAR except Rheumatology Cimzia® ‡, PAR Kineret® ‡ PAR except Neurology Orencia® SQ ‡, PAR Simponi® ‡, PAR Xeljanz® ‡, PAR

Limited to Rheumatology prescribers only

18.E. Gout

TIER 1 TIER 2 TIER 3 allopurinol + colchicine w/probenicid + probenicid + sulfinpyrazone +

Colcrys® + Uloric® ST

Zyloprim®

January 2013 28

18.F. Muscle Relaxants

TIER 1 TIER 2 TIER 3 baclofen + carisoprodol chlorzoxazone (max age of 64) cyclobenzaprine 5mg, 10mg tabs (max age of 64)

dantrolene caps diazepam (max age of 64)

methocarbamol tizanidine tablets +

Rilutek® +

Amrix® PAR cyclobenzaprine er PAR Dantrium® Equagesic® Max patient age of 64 Flexeril® Lioresal® PAR meprobamate/aspirin metaxalone

(Min age of 12) Norflex® Robaxin® Skelaxin® (Min age of 12) tizanidine caps Zanaflex®

CHAPTER 19 – Smoking Cessation

Smoking cessation products are not covered under all pharmacy programs

19.A. Smoking Cessation

TIER 1 TIER 2 TIER 3 bupropion SR QL Chantix® QL Nicotrol® Inhaler QL

Nicotrol® NS QL Zyban® QL

CHAPTER 20 – Stomach/Intestinal

20.A. Antiulcer/Reflux Drugs

TIER 1 TIER 2 TIER 3 cimetidine + famotidine 10mg, 20mg, 40mg +, QL misoprostol 100mcg, 200mcg + omeprazole 10mg, 20mg caps omeprazole 40mg caps

PAR except gastroenterology and otolaryngology pantoprazole ranitidine tabs + ranitidine syrup sucralfate +

Aciphex® PAR Dexilant® PAR lansoprazole PAR Nexium® PAR omeprazole sodium bicarbonate PAR Prevacid®/ Prevacid Solutab PAR

Prilosec® Protonix® PAR ranitidine hcl capsules Zantac® tabs/syrup Zantac® capsules Zegerid® PAR

20.B. Drugs affecting GI Motility

TIER 1 TIER 2 TIER 3 bethanechol chloride+ chlordiazepoxide/clidinium dicyclomine generic Donnatal® hyoscyamine sulfate + (Max pt age of 64) generic Lomotil® metoclopramide propantheline

Amitiza® ST except for Gastroenterology and Colon-rectal surgery

Bentyl® Donnatal® Levsin® Librax® Linzess®

ST except for Gastroenterology and Colon-rectal surgery

Metozolv® ODT PAR ProBanthine® Reglan®

January 2013 29

20.C. Antiemetics

TIER 1 TIER 2 TIER 3 meclizine 12.5mg, 25mg + ondansetron 24mg QL ondansetron 4mg, 8mg QL ondansetron odt QL ondansetron susp QL promethazine hcl supp PAR age < 2 prochlorperazine tab + Min age of 2 years prochlorperazine supp trimethobenzamide PAR for age >65

Emend® (Therapy pack only) ST except hematology and oncology, QL

Emend® 40mg capsules Emend® 80mg, 125mg capsules

ST except hematology and oncology, QL

Antivert® Anzemet® ST, QL Compazine® granisetron ST, QL Kytril® ST, QL Marinol® Phenergan® suppositories Sancuso® Patch ST, QL Tigan® PAR for age > 65 Transderm-Scop® QL Zofran® 4mg, 8mg QL Zofran® ODT QL Zofran® susp QL ZuplenzTM ST, QL

20.D. Other GI Drugs

TIER 1 TIER 2 TIER 3 balsalazide

(Minimum age of 5) budesonide PAR except Gastroenterology and colon/rectal specialists Colocort® cromolyn sodium oral generic Colyte® generic Golytely® QL glycopyrrolate hydrocortisone enema hydrocortisone cream, supp lactulose syrup mesalamine enema Procto-Pak® 1% Proctocream-HC® 2.5% Proctosol-HC® 2.5% Proctosone® 2.5% sulfasalazine + sulfasalazine DR + ursodiol

AprisoTM Asacol® + Asacol® HD + Canasa® suppositories Creon® + Cystadane® ‡, PAR Kuvan® ‡, PAR, QL Pancreaze® + Pentasa® + Pertzye® + Relistor® Sucraid® PAR

Available through CuraScript Pharmacy only Ultresa® Viokace® Zenpep® +

Actigall® Anusol HC® 2.5% Azulfidine® Azulfidine EN® ChenodalTM

PAR, must be obtained through Centric Specialty Pharmacy

Colazal® (Minimum age of 5) Colyte® Cortenema® Cortifoam®

CuvposaTM ST Dipentum® Entocort® EC

PAR except Gastroenterology and colon/rectal specialists

Gastrocrom® Golytely® QL Halflytely® Bowel Prep Kit Lialda® Omeclamox-Pak® OsmoPrep® Prepopik® Proctocort® 1% Proctofoam HC® Robinul® Rowasa® Enema Urso® Urso® Forte

20.E. Hepatitis

TIER 1 TIER 2 TIER 3 ribavirin ‡ , PAR

Epivir-HBV® PAR except Gastroenterology or Infectious Disease

Hepsera® PAR except Gastroenterology or Infectious Disease

Incivek® ‡, PAR Infergen® ‡, PAR Intron A® ‡, PAR Pegasys® ‡, PAR Peg-Intron® ‡, PAR Victrelis® PAR, ‡

Copegus® ‡, PAR Rebetol® ‡, PAR

January 2013 30

CHAPTER 21 – Vitamins/Minerals

21.A. Vitamins/Minerals (Multivitamins are NOT included in the Formulary as various OTC products are available.)

TIER 1 TIER 2 TIER 3 calcitriol + calcium acetate caps + Cavan-Heme® ergocalciferol + fe-fumarate vit C/vit B12/folic acid + folic acid + iron polysaccharide complex/folic acid/vitamin B12 +

Klor-Con-25® poly-vitamin w/fluoride + potassium bicarbonate/chloride+ potassium chloride tab, cap, liquid + potassium chloride extended release tabs 20mEq +

brand and generic prenatalvitamins + (restricted to female patients, ages 13-45 only) Rena-Vite Rx®+ PAR except Nephrology sodium fluoride + sodium polystyrene sulfonate tri-vitamin w/fluoride + vitamin B12 inj.

DHT® + Fosrenol® + Galzin® +, QL PhoslyraTM Renagel® + Renvela® Zemplar® +, ST

B-Complex vitamin plus® doxercalciferol ST Drisdol® Hectorol® ST Kayexalate® Luride® Micro-K® Phoslo® Poly-Vi-Sol® Prevident 5000® Rocaltrol® Tri-Vi-Sol®

CHAPTER 22 – Women’s Health

22.A. Estrogen Related Products

TIER 1 TIER 2 TIER 3 danazol estradiol + estradiol weekly patch + estropipate +

Alora® + Estrace® cream Estraderm® + Estring® Evista® + Premarin® + Premarin® cream Vagifem® Vivelle-Dot® +

Cenestin® Climara® Estrace® Estrogel® Femring® Menest®

22.B. Estrogen Combinations

TIER 1 TIER 2 TIER 3 estradiol/norethindrone acetate + norethindrone acetate-ethinyl estradiol +

Restricted to females

Combipatch® + Estratest® HS + Estratest® + Femhrt Low Dose® + Premphase® + Prempro® + progesterone suppositories

Activella® Femhrt® + Restricted to females Angeliq® Prefest®

22.C. Progestins

TIER 1 TIER 2 TIER 3 medroxyprogesterone + norethindrone acetate + progesterone micronized caps +

Aygestin® Crinone® PAR Endometrin® PAR Prochieve® PAR Prometrium® Provera®

January 2013 31

22.D. Contraceptives (For members with contraceptive coverage)

TIER 1 TIER 2 TIER 3 Apri® + Altavera® + Amethia® Amethyst® Aranelle® + Aviane® + Balziva® + Camila® + Camrese® Cesia® + Cryselle® + drospirenone/estradiol Emoquette® Enpresse® + Errin® + estradiol/norethindrone + Gianvi® + Jolessa® + Jolivette® + Junel®/Junel FE® + Kariva® + Kelnor® + Leena® + Lessina® + levonorgestrel QL Levora® + Loryna® + Low-Ogestrel® + Lutera® + medoxyprogesterone PAR Microgestin®/Microgestin FE® + Mononessa® + Necon® + Next Choice® QL Nora-Be® + Nortrel® + Ocella® + Ogestrel® + Portia® + Previfem® + Quasense® + Reclipsen® + Solia® + Sprintec® + Sronyx® + Tilia FE® + Tri-Legest FE®+ Trinessa® + Tri-Previfem® + Tri-Sprintec® + Trivora® + Velivet® + Zenchent® + Zovia® +

Cervical caps Diaphragms EllaTM QL NuvaRing® +, QL OrthoEvra® + Ortho Tri-Cyclen® Lo +

BeyazTM Brevicon® Camrese® Lo Cyclessa® Depo-Provera® PAR Desogen® estradiol/levonorgesterel Estrostep FE® Femcon FE® Generess® FE Loestrin® Loestrin FE® Loestrin® 24 Fe Lo/Ovral® Loseasonique® QL Mircette® Modicon® Natazia® PAR Nordette® Nor-QD® Ortho-Cept® Norinyl® Ortho-Cyclen® Ortho Micronor® Ortho-Novum® Ortho Tri-Cyclen® Ovcon® Plan B® QL Plan B® One Step QL SafyralTM Seasonale® Seasonique® Tri-Norinyl® Yasmin® Yaz®

Zeosa®

22.E. Fertility (Other coverage restrictions may apply)

TIER 1 TIER 2 TIER 3 chorionic gonadotropin ST clomiphene citrate

QL = 10 tabs/cycle up to 4 cycles except for infertility specialists, restricted to female patients only

Bravelle® PAR Menopur® PAR Repronex® PAR

Follistim®/AQ PAR Ganirelix® PAR Gonal-F® PAR Gonal-F RFF® PAR Luveris® PAR Ovidrel® ST Pregnyl® PAR

January 2013 32

22.F. Vaginal Antiinfectives

TIER 1 TIER 2 TIER 3 clindamycin phosphate vaginal cream clotrimazole vaginal cream OTC metronidazole vaginal gel miconazole vaginal cream OTC

AVC® Cream Cleocin® vaginal suppositories

Cleocin® Vaginal Gyne-Lotrimin® Metrogel® Vaginal Monistat® Terazol® QL

22.G. Other Women’s Health Drugs TIER 1 TIER 2 TIER 3

nifedipine PAR except OB/GYN terbutaline

Alferon N® PAR Lupron® Methergine® Synarel® PAR

Lysteda® PAR; minimum patient age of 18

CHAPTER 23 – Dental Formulary Note: Drugs in this category are reserved for dental providers only. Unless otherwise specified, all products are limited to a 10 day supply with 1 refill. Drugs not on the list below will not be covered.

23.A. Antiinfectives

TIER 1 TIER 2 TIER 3 amoxicillin amoxicillin susp azithromycin cephalexin clarithromycin 500mg QL clindamycin 75mg, 150mg, 300mg

clotrimazole troche doxycycline hyclate doxycycline hyclate 20mg QL

erythromycin erythromycin susp nystatin oral suspension penicillin VK tetracycline capsules

Cleocin® 75mg, 150mg Keflex® Periostat® QL Sumycin®

23.B. Analgesics

TIER 1 TIER 2 TIER 3 acetaminophen w/codeine acetaminophen w/codeine susp acetaminophen w/hydrocodone apap/codeine tabs hydrocodone w/acetaminophen hydrocodone-ibuprofen tab 7.5-200mg

PAR except pain medicine, ER physicians, dentists and oral surgeons

ibuprofen (Rx strengths only) ibuprofen suspension (Rx strengths only) naproxen naproxen sodium

Anaprox® Lortab® Motrin® Tylenol w/ Codeine® Vicodin® Vicoprofen®

PAR except pain medicine, ER physicians, dentists and oral surgeons

23.C. Fluoride Products

TIER 1 TIER 2 TIER 3 poly-vitamin w/fluoride sodium fluoride QL tri-vitamin w/fluoride

Luride® Poly-ViSol® Prevident 5000® Tri-Vi-Sol®

23.D. Glucocorticoid Drugs

TIER 1 TIER 2 TIER 3 dexamethasone triamcinolone in orabase methylprednisolone prednisone

January 2013 33

23.E. Other Drugs Affecting the Throat and Mouth

TIER 1 TIER 2 TIER 3 chlorhexidine QL lidocaine viscous

Peridex® QL

CHAPTER 24 – Specialty Drug Summary Note: Drugs in this chapter are a summary of specialty drugs which appear throughout the formulary and are either self-injectable, require special distribution, handling, and/or are at limited supply. These drugs are restricted to designated pharmacies that specialize in biotech injectables.

24.A. Blood - Hematopoietic Agents

TIER 1 TIER 2 TIER 3 Aranesp® PAR, ‡

Epogen® PAR, ‡ Neulasta® PAR, ‡ Neupogen® PAR, ‡ Procrit® PAR, ‡ Promacta® PAR, ‡

24.B. Blood – Other Blood Modifiers

TIER 1 TIER 2 TIER 3 Arcalyst® PAR

Must be obtained through Accredo or Caremark Pharmacy

Exjade® PAR ‡ Revlimid® PAR, ‡

Ferriprox® PAR ‡ Firazyr® PAR ‡

24.C. Cancer – Must be obtained through Reliance Rx Specialty Pharmacy only

(unless otherwise noted)

TIER 1 TIER 2 TIER 3 anastrozole + ‡


bicalutamide ‡ (Restricted to Males) etoposide (caps only) ‡ exemestane + ‡

PAR except oncology, oncology surgery and breast surgeons. Restricted to female patients only.

flutamide ‡ Restricted to male patients only hydroxyurea 500mg ‡ letrozole ‡ +


megestrol acetate ‡ tretinoin ‡

Actimmune® PAR, ‡ Afinitor® PAR, ‡ Alkeran® ‡ Caprelsa®

PAR Must be obtained through Biologics, Inc. only Emcyt® ‡ ErivedgeTM PAR ‡ Fareston® + ‡ Restricted to female patients Gleevec® PAR, ‡ Hexalen® ‡ Hycamtin® cap

PAR, ‡ Jakafi® PAR ‡ Lysodren® ‡ Matulane® ‡ Mesnex® ‡ PAR except Oncology Myleran® ‡ Oforta® PAR, ‡ Sprycel® ST, ‡ Sutent® PAR, ‡ Tarceva® ‡ PAR except Oncology Tasigna® ST, ‡ Temodar® ‡ Thalomid® ‡ Tykerb® PAR, ‡ Votrient® PAR ‡ Zolinza® PAR ‡ Zytiga® PAR ‡

Arimidex® ‡ PAR except Oncology, Oncology Surgery and Breast Surgeons. Restricted to female patients only

Aromasin® ‡ PAR except oncology, oncology surgery and breast surgeons. Restricted to female patients only.

Bosulif® PAR ‡ Drug restricted to hematology and medical oncology prescribers only.

Casodex® ‡ (Restricted to Males) Cytoxan® ‡ Droxia® ‡ Femara® ‡


Hydrea® ‡ Inlyta® PAR, ‡ Iressa®

Must be obtained through CuraScript Pharmacy only

Megace® ES ‡ Nexavar® ‡ PAR for non-FDA approved uses Stivarga® PAR ‡


SylatronTM PAR, ‡ Vesanoid® ‡ Xalkori® PAR ‡ Xtandi® PAR ‡


ZelborafTM PAR, ‡

January 2013 34

24.D. Cardiovascular/Heart – Other Cardiovascular Drugs

TIER 1 TIER 2 TIER 3 Adcirca® PAR, ‡

Letairis® PAR, ‡ Tracleer® PAR, ‡

24.E. Hormones/Steroids – Growth Hormone Products

TIER 1 TIER 2 TIER 3 Nutropin®/Nutropin® AQ PAR, ‡

Somavert® PAR Must be obtained through CuraScript only

Genotropin® PAR, ‡ Humatrope® PAR, ‡ Saizen® PAR, ‡

24.F. Hormones/Steroids – Osteoporosis

TIER 1 TIER 2 TIER 3 Forteo® PAR, ‡ (limited to 26 fills/lifetime)

24.G. Hormones/Steroids – Other Endocrine Drugs TIER 1 TIER 2 TIER 3

Increlex® PAR, ‡ Korlym® PAR, ‡ Zavesca® PAR

Must be obtained through CuraScript

24.H. Infection – HIV Drugs TIER 1 TIER 2 TIER 3

Fuzeon® PAR, ‡

24.I. Infection – Other Antiviral Drugs TIER 1 TIER 2 TIER 3

ribavirin PAR, ‡ Cayston® QL, PAR except Cystic Fibrosis Specialists. Min age of 7. Must be obtained from Cystic Fibrosis Services.

Copegus® PAR, ‡ Rebetol® PAR, ‡

24.J. Nervous System – Anticonvulsants TIER 1 TIER 2 TIER 3

Sabril® (PAR) Available through CuraScript Pharmacy only

24.K. Nervous System – Antiparkinson Drugs TIER 1 TIER 2 TIER 3

Apokyn® PAR except Neurology ‡

24.L. Nervous System – Multiple Sclerosis Drugs TIER 1 TIER 2 TIER 3

AmpyraTM ER PAR, ‡ Avonex® PAR except Neurology, ‡ Copaxone® PAR except Neurology, ‡ Rebif® PAR except Neurology, ‡

Aubagio® ‡, PAR Betaseron® ‡, PAR except Neurology

ST (all prescribers) Extavia® PAR, ‡

ST (all prescribers) GilenyaTM PAR, ‡

24.M. Nervous System - Other CNS/Autonomic Drugs

TIER 1 TIER 2 TIER 3 Xenazine® PAR, QL

Must be obtained through CuraScript Xyrem® PAR except Pulmonary and Neurology

Must be obtained through Express Scripts Pharmacy only

24.N. Pain - Antirheumatics

TIER 1 TIER 2 TIER 3 Enbrel® PAR, ‡

Humira® PAR, ‡ Cimzia® PAR, ‡ Kineret® PAR except Neurology, ‡ Orencia® SQ ‡, PAR Simponi® PAR, ‡ Xeljanz® ‡, PAR

Limited to Rheumatology prescribers only

January 2013 35

24.O. Pain – Narcotic Pain Relieving

TIER 1 TIER 2 TIER 3 Onsolis®

PAR except oncology. Minimum patient age of 18. Must be obtained through Express Scripts pharmacy only.

24.P. Respiratory - Other


Kalydeco® PAR ‡

24.Q. Stomach/Intestinal - Hepatitis

TIER 1 TIER 2 TIER 3 ribavirin 200mg tabs PAR, ‡

Incivek® ‡, PAR Infergen® PAR, ‡ Intron® A PAR

Must be obtained through Reliance or Walgreens Specialty Pharmacy only for Hepatitis therapy

Pegasys® PAR, ‡ Peg-Intron® PAR, ‡ Victrelis® PAR, ‡

Copegus® PAR, ‡ Rebetol® PAR, ‡

24.R. Stomach/Intestinal - PKU

TIER 1 TIER 2 TIER 3 Kuvan® ‡, PAR, QL

Sucraid® PAR Available through CuraScript Pharmacy only

25.S. Other GI Drugs


ChenodalTM PAR, must be obtained through Centric Specialty Pharmacy

Below are the names and phone numbers of the pharmacies listed in the specialty drug formulary. These phone numbers are provided for specific questions related to the specialty pharmacy vendor. All other questions related to Independent Health policies or prior authorization requests should be directed to (716) 631-2934 or (800) 247-1466. extension 5311.

Accredo SpecialtyPharmacy 866-489-1875 Biologics Inc. 800-850-4306 BioScript 888-903-7277 Centric Specialty Pharmacy 866-849-4481 CVS/Caremark Specialty Pharmacy 800-237-2767 CuraScript Specialty Pharmacy 866-815-4774 Express Scripts Specialty Pharmacy Onsolis® Xyrem®

877-536-4340 866-997-3688

Reliance Rx Specialty Pharmacy 800-809-4763 Walgreens Specialty Pharmacy 888-282-5166

January 2013 36

SYMBOLS

+ Maintenance Drug – A 90 day supply may be prescribed and dispensed. Copayment is dependent on member’s plan.

PAR Prior Authorization Required

prior authorization must be obtained in order for the drug to be covered. Copies of policies are available upon request, or are available on our website at www.independenthealth.com – refer to the Health Care Professionals tab.

Note: A drug labeled as “PAR except…” means that the physician specialties listed may prescribe the drug without requesting prior authorization. All other physicians may prescribe the drug, but must submit a prior authorization request for review.

QL Quantity Limit

Limits may be set by number of tablets/capsules per fill, number of fills per month/year, maximum daily dose (MDD), etc. NOTE: Certain drugs are dose limited by a maximum daily dose. Limits may be set by the number of tablets/capsules per day or the total daily dose in mg. Not all dose limitations are indicated in the formulary document, where a package size exists those products will be limited to one package size per fill.

‡ Drug available through Reliance Rx Specialty Pharmacy only, unless otherwise noted.

♦ Sedative/Hypnotic drugs are limited for all prescribers except sleep specialists to 14 tablets/capsules per month with a maximum of 3 fills per year (3 fills/365 days).

OTC Over The Counter

certain drugs listed in the formulary are over the counter. A prescription is required for coverage of the OTC products.

HT Voluntary Tablet Splitting Program

Physicians may write a prescription for a quantity of 30 tablets of double the required daily dose to provide a 60

day supply once the tablets are halved. The patient will pay only 1 copayment for the prescription that will last up to 60 days. Note: Some restrictions may apply based on strength of medication.

ST Pharmacy Step Therapy Program

January 2013 37

STEP THERAPY PROTOCOLS Alocril®/Bepreve®/Elestat®/LastacaftTM/Optivar®/Pataday®/Patanol® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of Zaditor® or Alaway® OTC. Prior authorization is required when the pharmacy profile does not meet this criteria. Altabax® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for use of generic mupirocin. Prior authorization is required when the pharmacy profile does not meet this criteria. Ambien CR® (zolpidem er)/Edular®/Intermezzo® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of Ambien® (zolpidem). Prior authorization is required when the pharmacy profile does not meet this criteria. Amitiza®/Linzess® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of lactulose. Prior authorization is required when the pharmacy profile does not meet this criteria. Angiotensin II Receptor Antagonist Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for an Angiotensin Converting Enzyme (ACE) inhibitor. Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. Anzemet®/granisetron/Kytril®/Zuplenz® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for use of a ondansetron. Prior authorization is required when the pharmacy profile does not meet this criteria. Aricept® 23mg Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of donepezil 10mg once daily for three months. Prior authorization is required when the pharmacy profile does not meet this criteria. Astelin®/Astepro® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of generic azelastine. Prior authorization is required when the pharmacy profile does not meet this criteria. Azor®/Exforge®/Exforge® HCT/Twynsta®/TribenzorTM Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for an Angiotensin Converting Enzyme (ACE) Inhibitor, an Antiotensin Receptor Blocker (ARB) and a Calcium Channel Blocker (CCB). Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. Beconase® AQ/Flonase®/Omnaris®/Qnasl®/Rhinocort® Aqua/Veramyst®/ZetonnaTM Step Therapy Program: The dispending pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex. Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. Betaseron®/Extavia® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of Avonex® or Rebif®. Prior authorization is required when the pharmacy profile does not meet this criteria. Binosto® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of alendronate. Prior authorization is required when the pharmacy profile does not meet this criteria. Bydureon®/Byetta®/Victoza® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for concurrent use of metformin, a sulfonylurea or a thiazolodonedione (TZD). Prior authorization is required for patients or who are not currently receiving metformin or a sulfonfylurea or a TZD and for those also receiving other antidiabetic medications.

January 2013 38

STEP THERAPY PROTOCOLS, Continued Celebrex® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for previously having tried and failed 2 nonsteroidal anti-inflammatory agents. Chorionic Gonadatropin, Ovidrel® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for previously having used clomiphene, menotropin or urofollitropin within the previous 20 days. Prior authorization is required if the member does not meet this criteria. Comtan®/Tasmar® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for a concurrent prescription of levodopa/carbidopa. Physicians will be contacted by the dispensing pharmacy if the member does not meet these criteria. Conzip®/tramadol er/Ultram® ER Step Therapy Program: This dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of immediate release tramadol. Prior authorization is required for patients not previously using immediate release tramadol. CuvposaTM Step Thearpy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of glycopyrrolate. Prior authorization is required for patients not previously using glycopyrrolate. Anturol®,Ditropan® XL, Detrol®, Detrol LA®, Enablex®, MyrbetriqTM, Oxytrol®, Sanctura®/Sanctura XR®, tolterodine tartrate, Toviaz®, Vesicare® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for a prescription for oxybutynin or use of Tier 2 overactive bladder medications. Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. No Step Therapy required for ages >65. Dymista® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of azelastine orfluticasone propionate. Prior authorization required if the member does not meet these criteria. Emend® Therapy Pack/Emend® 80mg, 125mg Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for concurrent use of dexamethasone. Prior authorization is required for patients not currently receiving dexamethasone. Foradil®, Serevent® Diskus Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for concurrent use of an inhaled corticosteroid. Prior authorization is required when the pharmacy profile does not meet this criteria. Genotropin®/Humatrope® Step Thearpy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of Nutropin® or Nutropin® AQ. Prior authorization is required when the pharmacy profile does not meet this criteria. Glumetza® Step Thearpy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of extended release metformin. Prior authorization is required for patients not previously using extended release metformin. Gralise® Step Thearpy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of gabapentin. Prior authorization is required for patients’ not previously using gabapentin. Hectorol®, Zemplar® Step Thearpy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of calcitriol. Prior authorization is required for patients’ not previously using calcitriol. Narcotic (Avinza®/fentanyl /Duragesic®/Exalgo®/Fentora®/Kadian®/Oyxcontin®) Step Therapy Program: These high potency narcotics pose serious risks if started in a narcotic naïve patient. Therefore, the dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of narcotic medications. Prior authorization is required when the pharmacy profile does not meet this criteria.

January 2013 39

STEP THERAPY PROTOCOLS, Continued Natroba®/Sklice® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of generic permethrin or Lindane. Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. NexiclonTM XR Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of generic immediate release clonidine. Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. Oleptro® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of generic trazodone. Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. Oravig® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of clotrimazole troche, fluconazole or nystatin. Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. Paxil® CR (paroxetine er) Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patients for prior use of paroxetine. Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. Prezista® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for concurrent use of Norvir®. Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. Pristiq® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of venlafaxine ER. Prior authorization is required when the pharmacy profile does not meet this criteria. Quillivant® XR Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of generic methylphenidate sr. Prior authorization is required when the pharmacy profile does not meet this criteria. Rayos® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of immediate release prednisone. Prior authorization is required when the pharmacy profile does not meet this criteria. Renin-Angiotensin Inhibitor Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for an Angiotensin Converting Enzyme (ACE) inhibitor and an Angiotensin Receptor Blocker (ARB). Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria. Sancuso® Patch Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of ondansetron. Prior authorization required if the member does not meet these criteria. Seroquel® XR Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of immediate release Seroquel®. Prior authorization required if the member does not meet these criteria. Singulair® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for use of a beta agonist or asthma controller medication in the past 12 months. Prior authorization required if the member does not meet these criteria. Sprycel®/Tasigna® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of Gleevec® within previous 90 day period. Prior authorization is required if the member does not meet this criteria.

January 2013 40

STEP THERAPY PROTOCOLS, Continued Treximet® Step Therapy Program: The dispensing pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for prior use of Imitrex® within previous 90 day period. Prior authorization is required if the member does not meet this criteria. Uloric® Step Therapy Program: The dispending pharmacy in conjunction with the Independent Health Pharmacy Help Desk will screen patient profiles for past use of allopurinol. Prior Authorization is required. Physicians will be contacted by the dispensing pharmacy if the member does not meet this criteria.

January 2013 41

INDEX

8 8-Mop® ............................................................................................ 14

A

abacavir sulfate .............................................................................. 20 Abilify®............................................................................................ 23 Abilify® Discmelt ........................................................................... 23 Abilify® oral solution .................................................................... 23 Absorbica® ...................................................................................... 13 AbstralTM ......................................................................................... 26 acarbose ........................................................................................... 15 Accolate® ........................................................................................... 6 Accu-Chek® .............................................................................. 15, 16 Accu-Chek® Active ........................................................................ 16 Accu-Chek® Aviva ................................................................... 15, 16 Accuhist® PDX ................................................................................. 4 Accuneb® .......................................................................................... 5 Accupril® ........................................................................................... 9 Accuretic® ....................................................................................... 11 Accutane® ....................................................................................... 13 acebutolol HCl ................................................................................. 9 Aceon® ............................................................................................... 9 acetaminophen w/codeine ..................................................... 26, 32 acetaminophen w/codeine susp .................................................. 32 acetaminophen w/hydrocodone ................................................. 32 Acetasol® HC otic soln .................................................................. 17 acetazolamide tab .......................................................................... 17 acetic acid otic soln ........................................................................ 16 acetylcysteine ................................................................................... 6 Aciphex® ......................................................................................... 28 Aclovate® ........................................................................................ 13 Actigall® .......................................................................................... 29 Actimmune® ............................................................................... 8, 33 Actiq® .............................................................................................. 26 Actonel® .......................................................................................... 19 Actonel® with Calcium ................................................................. 19 Actoplus Met® ................................................................................ 15 Actoplus Met® XR .......................................................................... 15 Actos® .............................................................................................. 15 Acular® ............................................................................................ 18 Acular® LS ...................................................................................... 18 Acuvail® .......................................................................................... 17 acyclovir .......................................................................................... 20 Aczone® ........................................................................................... 14 Adalat® CC ..................................................................................... 10 adapalene ........................................................................................ 13 Adcirca® .................................................................................... 12, 34 Adderall XR® .................................................................................. 24 Adderall® ........................................................................................ 24 Advair® ............................................................................................. 5 Advair® HFA .................................................................................... 5 Advicor® ......................................................................................... 12 Aerobid® ........................................................................................... 5 Aerobid-M® ...................................................................................... 5 Afinitor® ...................................................................................... 8, 33 Aggrenox® ........................................................................................ 7 Agrylin® ............................................................................................ 7 Akten® ............................................................................................. 18

Alamast® ......................................................................................... 18 Alaway® .......................................................................................... 18 Albatussin® ....................................................................................... 5 albuterol nebs ................................................................................... 5 albuterol sulfate tabs ....................................................................... 5 albuterol tabs; syrup ....................................................................... 5 albuterol-ipratropium neb soln ..................................................... 6 alclometasone ................................................................................. 13 Aldactazide 25/25® ....................................................................... 10 Aldactazide® 50/50 ....................................................................... 10 Aldactone® ..................................................................................... 10 Aldara® ........................................................................................... 14 alendronate tabs ............................................................................ 19 Alferon N® ................................................................................ 20, 32 alfuzosin ......................................................................................... 21 Alinia® tabs, soln ........................................................................... 21 Alkeran® ..................................................................................... 8, 33 Allfen® CDX ..................................................................................... 4 allopurinol ...................................................................................... 27 Alocril® ........................................................................................... 37 Alomide® ........................................................................................ 18 Alora®.............................................................................................. 30 Alphagan P® 0.1% ......................................................................... 17 Alphagan P® 0.15% ....................................................................... 17 alprazolam ...................................................................................... 22 alprazolam xr ................................................................................. 22 Alrex® .............................................................................................. 17 Altabax® .................................................................................... 14, 37 Altace® caps ...................................................................................... 9 Altavera® ........................................................................................ 31 aluminum chloride 20%................................................................ 14 Alupent® ........................................................................................... 5 Alvesco® ........................................................................................... 5 alwin NX® ....................................................................................... 26 amantadine ..................................................................................... 20 amantadine hcl .............................................................................. 25 Amaryl® .......................................................................................... 15 Ambien CR® ................................................................................... 37 Ambien® ......................................................................................... 22 Ambien® CR ................................................................................... 22 Amerge® ......................................................................................... 27 Amethia® ........................................................................................ 31 Amethyst® ...................................................................................... 31 amiloride hcl .................................................................................. 10 aminocaproic acid ........................................................................... 7 aminophylline .................................................................................. 5 amiodarone .................................................................................... 12 Amitiza® ................................................................................... 28, 37 amitriptyline .................................................................................. 23 amitriptyline/ perphenazine ....................................................... 23 amlodipine besylate- ..................................................................... 10 amlodipine besylate-benazepril hcl ............................................ 11 ammonium lactate cr .................................................................... 14 ammonium lactate lotion .............................................................. 14 Amoxapine® ................................................................................... 23 amoxicillin ...................................................................................... 32 amoxicillin caps, susp ................................................................... 19 amoxicillin clavulanate ................................................................. 19 amoxicillin susp ............................................................................. 32 amoxicillin/ .................................................................................... 19

January 2013 42

amphetamine mixture ................................................................... 24 amphetamine-dextroamphetamine sr ......................................... 24 ampicillin caps, susp ..................................................................... 19 AmpyraTM ER ........................................................................... 25, 34 Amrix® ............................................................................................ 28 AmturnideTM .................................................................................. 11 Anafranil® ....................................................................................... 23 anagrelide ......................................................................................... 7 Analpram® E .................................................................................. 14 Anaprox® .................................................................................. 27, 32 anastrozole .................................................................................. 8, 33 Ancobon® ........................................................................................ 20 Androderm® ................................................................................... 22 Androgel® ....................................................................................... 22 Android® ......................................................................................... 22 Androxy® ........................................................................................ 22 Antabuse® ....................................................................................... 25 Antara® .............................................................................................. 2 Antivert® ......................................................................................... 29 Anturol® ............................................................................................ 6 antyipyrine/benzocaine otic soln ................................................ 16 Anusol HC® 2.5% ........................................................................... 29 Anzemet® .................................................................................. 29, 37 apap/codeine tabs ......................................................................... 32 Apexicon E® .................................................................................... 13 Apidra® ........................................................................................... 15 Apidra® Solostar ............................................................................ 15 Apokyn® ................................................................................... 25, 34 apraclonidine .................................................................................. 17 Apri® ................................................................................................ 31 AprisoTM .......................................................................................... 29 Aptivus® .......................................................................................... 20 Aralen® phosphate ........................................................................ 21 Aranelle® ......................................................................................... 31 Aranesp® ..................................................................................... 7, 33 Arava® ............................................................................................. 27 Arcalyst® ..................................................................................... 7, 33 Arcapta® Neohaler ........................................................................... 5 Aricept® ........................................................................................... 25 Aricept® 23mg ............................................................................... 37 Aricept® ODT ................................................................................. 25 Arimidex® ................................................................................... 8, 33 Arixtra® ............................................................................................. 7 Armour Thyroid® .......................................................................... 18 Aromasin® .................................................................................. 8, 33 Arthrotec ® ...................................................................................... 27 Asacol® ............................................................................................ 29 Asacol® HD ..................................................................................... 29 Ascensia Dex® ................................................................................ 15 Ascensia® ........................................................................................ 16 Asmanex® ......................................................................................... 5 aspirin CR 800mg ........................................................................... 27 aspirin w/codeine ......................................................................... 26 aspirin/dipyridamole ..................................................................... 7 Assure II® .................................................................................. 15, 16 Astelin® ....................................................................................... 4, 37 Astepro® ...................................................................................... 4, 37 Atacand HCT® ............................................................................... 11 Atacand® ........................................................................................... 9 AtelviaTM ......................................................................................... 19 atenolol .............................................................................................. 9 atenolol/chlorthalidone ................................................................ 11 Ativan® ............................................................................................ 22

atorvastatin calcium ...................................................................... 11 atorvastatin/amlodipine .............................................................. 12 atovaquone/proguanil ................................................................. 21 Atripla® ........................................................................................... 20 atropine ........................................................................................... 18 Atrovent® 0.03% .............................................................................. 4 Atrovent® 0.06% .............................................................................. 4 Atrovent® HFA ................................................................................ 6 Atrovent® nasal ................................................................................ 4 Atrovent® Neb ................................................................................. 6 Aubagio® .................................................................................. 25, 34 augmented betamethasone .......................................................... 13 Augmentin® XR ............................................................................. 19 Auralgan® Otic Soln ...................................................................... 16 Auvi-QTM .......................................................................................... 5 Avalide® .......................................................................................... 11 Avandamet® ................................................................................... 15 Avandaryl® ..................................................................................... 15 Avandia® ........................................................................................ 15 Avapro® ............................................................................................ 9 Avar-E® LS ..................................................................................... 13 AVC® Cream .................................................................................. 32 Avelox® ........................................................................................... 19 Aviane® ........................................................................................... 31 Avinza® ..................................................................................... 26, 38 Avita® .............................................................................................. 13 Avodart® ......................................................................................... 21 Avonex® .................................................................................... 25, 34 Axert® .............................................................................................. 27 AxironTM ......................................................................................... 22 Aygestin® ........................................................................................ 30 Azasan® ............................................................................................ 8 Azasite® .......................................................................................... 17 azathioprine ..................................................................................... 8 azelastine ........................................................................................ 18 azelastine nasal spray ..................................................................... 4 Azelex® ........................................................................................... 13 Azilect® ........................................................................................... 25 azithromycin ............................................................................ 19, 32 azithromycin® susp ...................................................................... 19 Azmacort® ........................................................................................ 5 Azopt® ............................................................................................. 17 Azor® ......................................................................................... 11, 37 Azulfidine EN® .............................................................................. 29 Azulfidine® ..................................................................................... 29

B B&O Supprettes® ........................................................................... 26 bacitracin ophthalmic ................................................................... 17 baclofen ........................................................................................... 28 Bactroban® cream .......................................................................... 14 Bactroban® nasal oint .................................................................... 14 Bactroban® oint .............................................................................. 14 balsalazide ...................................................................................... 29 Balziva® ........................................................................................... 31 Banzel® ............................................................................................ 24 Baraclude® ...................................................................................... 20 B-Complex vitamin plus ............................................................... 30 Beconase® AQ ............................................................................ 4, 37 belladonna/opium supp .............................................................. 26 benazepril ......................................................................................... 9 benazepril/hctz ............................................................................. 11

January 2013 43

Benicar HCT® ................................................................................. 11 Benicar® ............................................................................................. 9 Bentyl® ............................................................................................ 28 BenzaClin® ...................................................................................... 13 Benzefoam® .................................................................................... 13 benzoyl peroxide ........................................................................... 13 benzoyl peroxide cr,gel,lot ........................................................... 13 benzoyl peroxide foam 5.3% ........................................................ 13 benztropine ..................................................................................... 25 Bepreve® ......................................................................................... 37 Bepreve® opth ................................................................................ 18 Besivance® ...................................................................................... 17 Betagan® .......................................................................................... 17 betamethasone ............................................................................... 13 Betaseron® ........................................................................... 25, 34, 37 Betaxolol®.......................................................................................... 9 bethamethasone valerate .............................................................. 13 bethanechol chloride ................................................................. 6, 28 Betimol® .......................................................................................... 17 Betoptic® S ...................................................................................... 17 BeyazTM ........................................................................................... 31 Biaxin XL® tabs ............................................................................... 19 Biaxin® ............................................................................................. 19 bicalutamide ............................................................................... 8, 33 Bicitra® .............................................................................................. 6 Binosto® ..................................................................................... 19, 37 Bio-T-Gel® ....................................................................................... 22 bisoprolol fumerate ......................................................................... 9 Blephamide® Liquifilm ................................................................. 17 Boniva® tabs ................................................................................... 19 Bosulif® ........................................................................................ 8, 33 brand and generic prenatal .......................................................... 30 Bravelle® ......................................................................................... 31 Brethine® ........................................................................................... 5 Brevicon® ........................................................................................ 31 Brevoxyl® ........................................................................................ 13 Brilinta® ............................................................................................. 7 brimonidine solution ..................................................................... 17 brimonidine tartrate 0.2% ............................................................. 17 BromdayTM ..................................................................................... 18 bromfenac ....................................................................................... 18 bromocriptine mesylate ................................................................ 25 Brontex® ............................................................................................ 4 budesonide ..................................................................................... 29 budesonide respules 0.25mg, 0.5mg .............................................. 5 bumetanide ..................................................................................... 10 Bumex®............................................................................................ 10 buprenorphine hcl ......................................................................... 25 bupropion ....................................................................................... 23 bupropion hcl SR 12 hr ................................................................. 23 bupropion hcl SR 24hr .................................................................. 23 bupropion SR ................................................................................. 28 buspirone ........................................................................................ 22 butorphanol tartrate NS ................................................................ 27 ButransTM ........................................................................................ 25 Bydureon® ................................................................................ 15, 37 Byetta® ....................................................................................... 15, 37 Bystolic® ............................................................................................ 9

C

cabergoline ...................................................................................... 19 Caduet® ........................................................................................... 12

Cafergot® ........................................................................................ 27 Calan® ............................................................................................. 10 Calan® SR........................................................................................ 10 calciprotiene soln, oint, cream ..................................................... 14 calcitonin ........................................................................................ 19 calcitonin-salmon .......................................................................... 19 calcitriol .......................................................................................... 30 calcitriol ointment.......................................................................... 14 calcium acetate caps ...................................................................... 30 Cambia® .......................................................................................... 27 Camila® ........................................................................................... 31 Campral® ........................................................................................ 25 Camrese® ........................................................................................ 31 Camrese® Lo ................................................................................... 31 Canasa® suppositories .................................................................. 29 Capex® ............................................................................................ 13 Capoten® ........................................................................................... 9 Capozide® ....................................................................................... 11 Caprelsa® .................................................................................... 8, 33 captopril ............................................................................................ 9 captopril/hctz ................................................................................ 11 Carac® ............................................................................................. 14 CarbagluTM ..................................................................................... 19 carbamazepine ............................................................................... 24 carbamazepine er .......................................................................... 24 Carbaphen®12 .................................................................................. 5 Carbatrol® ....................................................................................... 24 carbidopa/levodopa ..................................................................... 25 carbidopa/levodopa CR ............................................................... 25 carbidopa/levodopa/entacapone tabs ....................................... 25 Cardene® ......................................................................................... 10 Cardene® SR ................................................................................... 10 Cardizem® ...................................................................................... 10 Cardizem® LA ................................................................................ 10 Cardizem® SR ................................................................................ 10 Cardizem®CD ................................................................................ 10 Cardura® ................................................................................... 10, 21 Cardura® XL ............................................................................. 10, 21 carisoprodol ................................................................................... 28 Carmol-HC® ................................................................................... 13 carteolol .......................................................................................... 17 Cartia XT ......................................................................................... 10 Cartrol® ............................................................................................. 9 carvedilol .......................................................................................... 9 Casodex® .................................................................................... 8, 33 Catapres® ........................................................................................ 10 Catapres®-TTS ................................................................................ 10 Cavan-Heme® ................................................................................ 30 Caverject® ....................................................................................... 21 Cayston® ................................................................................... 21, 34 CeeNu® ............................................................................................. 8 cefaclor caps, susp ......................................................................... 19 cefadroxil ........................................................................................ 19 cefdinir ............................................................................................ 19 cefprozil .......................................................................................... 19 cefuroxime ...................................................................................... 19 Cefzil® ............................................................................................. 19 Celebrex® .................................................................................. 27, 38 Celestone® ...................................................................................... 18 Celexa® ............................................................................................ 23 CellCept® .......................................................................................... 8 Celontin® ........................................................................................ 24 Cenestin® ........................................................................................ 30

January 2013 44

cephalexin ....................................................................................... 32 cephalexin caps, susp .................................................................... 19 cephradine capsules ...................................................................... 19 Cervical caps .................................................................................. 31 Cesia® .............................................................................................. 31 Cetraxal® ......................................................................................... 19 cevimeline ....................................................................................... 16 Chantix® .......................................................................................... 28 Chemet® .......................................................................................... 19 Chemstrip® K ................................................................................. 16 Chemstrip® UGK ........................................................................... 16 ChenodalTM ............................................................................... 29, 35 chloramphenicol ............................................................................ 17 chlordiazepoxide ........................................................................... 22 chlordiazepoxide/clidinium ........................................................ 28 chlorhexidine .................................................................................. 33 chlorhexidine oral rinse ................................................................ 16 Chloromycetin® Otic ..................................................................... 16 chloroquine phosphate ................................................................. 21 chlorothiazide tabs ........................................................................ 10 chlorphen/DM/PE .......................................................................... 4 chlorpheniramine tan-phenylephrine tannate susp .................... 4 chlorpheniramine/pseudoephedrine 1mg/15mg per 5 ml ....... 4 chlorpheniramine/pseudoephedrine SR tabs 8mg/120mg ....... 4 chlorpheniramine/pseudoephedrine tabs 4mg/60mg ............... 4 chlorpromazine .............................................................................. 23 chlorthalidone ................................................................................ 10 chlorzoxazone ................................................................................ 28 cholestyramine/cholestyramine light (bulk) ............................. 11 Chorionic Gonadatropin ............................................................... 38 chorionic gonadotropin ................................................................ 31 Cialis® 10mg &20mg ....................................................................... 21 Cialis® 2.5mg & 5mg ...................................................................... 21 ciclopirox gel 0.77% ....................................................................... 14 ciclopirox shampoo ....................................................................... 14 ciclopirox soln ................................................................................ 14 cilostazol ........................................................................................... 7 Ciloxan® .......................................................................................... 17 cimetidine ....................................................................................... 28 Cimzia® ..................................................................................... 27, 34 Cipro HC® Otic .............................................................................. 16 Cipro® .............................................................................................. 19 Cipro® XR ....................................................................................... 19 Ciprodex® ....................................................................................... 16 ciprofloxacin hcl SR ....................................................................... 19 ciprofloxacin ophth soln ............................................................... 17 ciprofloxacin otic ............................................................................ 16 ciprofloxacin tabs ........................................................................... 19 citalopram ....................................................................................... 23 Clarinex® ........................................................................................... 4 Clarinex®Reditab 2.5mg .................................................................. 4 clarithromycin ................................................................................ 19 clarithromycin 500mg ................................................................... 32 clarithromycin SR .......................................................................... 19 clemastine ......................................................................................... 4 clemastine fumarate tabs ................................................................ 4 Cleocin® 150mg .............................................................................. 32 Cleocin® 75mg ................................................................................ 32 Cleocin® pediatric granules .......................................................... 19 Cleocin® Vaginal ............................................................................ 32 Cleocin® vaginal suppositories .................................................... 32 Cleocin-T® ....................................................................................... 13 Climara® .......................................................................................... 30

Clindagel® ...................................................................................... 13 clindamax ....................................................................................... 13 clindamycin .............................................................................. 19, 32 clindamycin phosphate gel 1% .................................................... 13 clindamycin phosphate vaginal cream ....................................... 32 clindamycin phosphate-benzoyl peroxide gel ........................... 13 clindamycintopical ........................................................................ 13 clobetasol proprionate .................................................................. 13 Clobex® ........................................................................................... 13 Clobex® Spray ................................................................................ 13 clomiphene citrate ......................................................................... 31 clomipramine ................................................................................. 23 clonazepam odt .............................................................................. 24 clonazepam tabs ............................................................................ 24 clonidine HCl ................................................................................. 10 clonidine HCl TD patch ................................................................ 10 clopidigrel bisulfate ........................................................................ 7 clorazepate ..................................................................................... 22 clotrimazole cream, lotion, soln ................................................... 14 clotrimazole troche .................................................................. 20, 32 clotrimazole vaginal cream .......................................................... 32 clotrimazole with betamethasone cream 1-0.05% ..................... 14 clozapine ......................................................................................... 23 Coartem® ........................................................................................ 21 codeine sulfate ............................................................................... 26 codeine-guaifenesin ........................................................................ 4 Cogentin® ....................................................................................... 25 Cognex® .......................................................................................... 25 Colazal® .......................................................................................... 29 colchicine w/probenicid .............................................................. 27 Colcrys® .......................................................................................... 27 Colestid® (bulk) ............................................................................. 11 Colestid® tab .................................................................................. 11 colestipol granules(bulk) .............................................................. 11 colestipol tab 1gm .......................................................................... 11 colistimethate ................................................................................. 16 Colocort® ........................................................................................ 29 Coly-Mycin-M® .............................................................................. 16 Coly-Mycin-S® ............................................................................... 16 Colyte® ............................................................................................ 29 Combigan® ..................................................................................... 17 Combipatch® .................................................................................. 30 Combivent® ...................................................................................... 6 Combivir® ....................................................................................... 20 Combunox® .................................................................................... 26 Compazine® ................................................................................... 29 CompleraTM .................................................................................... 20 Comtan® ................................................................................... 25, 38 Concerta® ........................................................................................ 24 Conzip® ..................................................................................... 26, 38 Copaxone® ................................................................................ 25, 34 Copegus® ...................................................................... 20, 29, 34, 35 Cordran® lotion ............................................................................. 13 Cordran® Tape only ...................................................................... 13 Coreg® ............................................................................................... 9 Corgard® ........................................................................................... 9 Cortane B® Otic .............................................................................. 16 Cortef® ............................................................................................ 18 Cortenema® .................................................................................... 29 Cortifoam® ...................................................................................... 29 cortisone acetate ............................................................................ 18 Cortisporin® otic sol, susp ........................................................... 16 Cortisporin® Otic-TC .................................................................... 16

January 2013 45

Corzall® Plus .................................................................................... 5 Corzall®liquid................................................................................... 5 Corzide® .......................................................................................... 11 Cosopt® ........................................................................................... 17 Coumadin® ....................................................................................... 7 Covera® HS ..................................................................................... 10 Cozaar® ............................................................................................. 9 Creon® ............................................................................................. 29 Crestor® ........................................................................................... 11 Cresylate® Otic ............................................................................... 16 Crinone® .......................................................................................... 30 Crixivan® ......................................................................................... 20 cromolyn sodium ........................................................................... 18 cromolyn sodium 10mg/ml nebs .................................................. 5 cromolyn sodium oral ................................................................... 29 Cryselle® ......................................................................................... 31 Cuprimine® ..................................................................................... 27 Cutivate® 0.05% lotion .................................................................. 13 Cutivate® cream; oint .................................................................... 13 Cyclessa® ......................................................................................... 31 cyclobenzaprine 5mg, 10mg tabs ................................................. 28 cyclobenzaprine er ......................................................................... 28 Cyclogyl® ........................................................................................ 18 cyclophosphamide ........................................................................... 8 Cycloset® ......................................................................................... 15 cyclosporine capsules ...................................................................... 8 cyclosporine modified ..................................................................... 8 cyclosporine oral solution ............................................................... 8 Cymbalta® ....................................................................................... 23 cyproheptadine ................................................................................ 4 Cystadane® ..................................................................................... 29 Cystagon® ....................................................................................... 19 Cytomel® ......................................................................................... 18 Cytoxan® ..................................................................................... 8, 33

D

Daliresp® ........................................................................................... 5 danazol ............................................................................................ 30 Dantrium® ....................................................................................... 28 dantrolene caps .............................................................................. 28 Dapsone .......................................................................................... 21 Daraprim® ....................................................................................... 21 Daypro® .......................................................................................... 27 Daytrana® ....................................................................................... 24 DDAVP® ......................................................................................... 19 Decadron® ....................................................................................... 18 Demadex® ....................................................................................... 10 Demerol® ......................................................................................... 26 Depakene® ...................................................................................... 24 Depakote ER® ........................................................................... 24, 27 Depakote® ....................................................................................... 24 Depakote® Sprinkles ...................................................................... 24 Depen® Titratabs ............................................................................ 27 Depo-Provera® ............................................................................... 31 Depo-Testosterone® ....................................................................... 22 Derma-Smoothe/FS® .................................................................... 13 desipramine .................................................................................... 23 desloratidine ..................................................................................... 4 desmopressin ................................................................................. 19 Desogen® ......................................................................................... 31 desonide0.05% ................................................................................ 13 Desowen® lotion ............................................................................ 13

desoximetasone ............................................................................. 13 Detrol LA® .................................................................................. 6, 38 Detrol® ........................................................................................ 6, 38 dexamethasone ........................................................................ 18, 32 dexamethasone ophthalmic ......................................................... 17 dexamethasone/tobramycin ........................................................ 17 Dexedrine® ..................................................................................... 24 Dexilant® ......................................................................................... 28 dextroamphetamine tabs & SR .................................................... 24 Dextrostat® ..................................................................................... 24 DHE® 45 ......................................................................................... 27 DHT® ............................................................................................... 30 Diabeta® .......................................................................................... 15 Diamox® .......................................................................................... 17 Diaphragms .................................................................................... 31 Diastat® ........................................................................................... 24 diazepam .................................................................................. 22, 28 Dibenzyline® .................................................................................. 12 diclofenac sodium enteric coated tablets .................................... 27 diclofenac sodium ophth soln ...................................................... 18 diclofenac sodium SR 24-hr 100 mg ............................................ 27 dicloxacillin caps ........................................................................... 19 dicyclomine .................................................................................... 28 didanosine DR ............................................................................... 20 Didronel® ........................................................................................ 19 Differin® 0.3% ............................................................................... 13 Differin® cream, gel ....................................................................... 13 Dificid® ........................................................................................... 21 diflorasone diacetate ..................................................................... 13 Diflucan tabs/oral suspension .................................................... 20 Diflucan® 150mg ............................................................................ 20 diflunisal ......................................................................................... 27 digoxin ............................................................................................ 12 Dilacor® XR .................................................................................... 10 Dilantin® ......................................................................................... 24 Dilantin® Infatab ............................................................................ 24 Dilantin®125 suspension ............................................................... 24 Dilaudid® ........................................................................................ 26 diltiazem ER bead ......................................................................... 10 diltiazem HCl ................................................................................. 10 diltiazem SR ................................................................................... 10 Diovan® ............................................................................................. 9 Diovan® HCT ................................................................................. 11 Dipentum® ..................................................................................... 29 diphenhydramine .......................................................................... 22 diphenhydramine 50mg ........................................................... 4, 25 dipivefrin ........................................................................................ 17 Diprolene® ...................................................................................... 13 Diprolene® (and AF) ..................................................................... 13 dipyridamole.................................................................................... 7 disopyramide ................................................................................. 12 disopyramide CR 150mg .............................................................. 12 disulfiram ....................................................................................... 25 Ditropan® .......................................................................................... 6 Ditropan® XL .............................................................................. 6, 38 Diuril® susp .................................................................................... 10 divalproex sodium sprinkles ....................................................... 24 divalproex sodium sr .............................................................. 24, 27 divalproex sodium tabs ................................................................ 24 Domeboro® Otic ............................................................................ 16 Donatuss® DC .................................................................................. 4 Donatuss® XP ................................................................................... 4 donepezil ........................................................................................ 25

January 2013 46

Donnatal® ........................................................................................ 28 Doryx® ............................................................................................. 19 dorzolamide hcl soln ..................................................................... 17 dorzolamide/timolol ophth soln ................................................. 17 Dovonex® soln ................................................................................ 14 doxazosin ........................................................................................ 21 doxepin ........................................................................................... 23 doxercalciferol ................................................................................ 30 doxycycline hyclate caps, tabs .................................................... 19 doxycycline DR .............................................................................. 19 doxycycline hyclate ....................................................................... 32 doxycycline hyclate 20mg ............................................................. 32 doxycycline monohydrate ............................................................ 19 Drisdol® ........................................................................................... 30 drospirenone/estradiol ................................................................. 31 Droxia® ........................................................................................ 8, 33 Drysol® ............................................................................................ 14 Duac® ............................................................................................... 13 Duetact® .......................................................................................... 15 Duexis® ............................................................................................ 27 Dulera® .............................................................................................. 5 Duoneb® ............................................................................................ 6 Duragesic® ................................................................................ 26, 38 Durezol® .......................................................................................... 18 Dutoprol® .......................................................................................... 9 Dyazide® ......................................................................................... 10 Dymista® ..................................................................................... 4, 38 DynaCirc® CR................................................................................. 10 Dyphylline-GG® ............................................................................... 5 Dyrenium® ...................................................................................... 10

E EC Naprosyn® ................................................................................ 27 econazole nitrate cream 1% .......................................................... 14 Edarbi® .............................................................................................. 9 Edarbyclor® .................................................................................... 11 Edecrin® .......................................................................................... 10 Edex® ............................................................................................... 21 Edular® ............................................................................................ 37 Edular® SL ...................................................................................... 22 EdurantTM ....................................................................................... 20 Effexor® XR ..................................................................................... 23 Effient® .............................................................................................. 7 Efudex® ........................................................................................... 14 Eldepryl® ......................................................................................... 25 Elestat® ...................................................................................... 18, 37 Elidel® .............................................................................................. 14 EllaTM ............................................................................................... 31 Elmiron®............................................................................................ 6 Elocon® ............................................................................................ 13 Emadine® ........................................................................................ 18 Embeda® ......................................................................................... 26 Emcyt® ......................................................................................... 8, 33 Emend® ..................................................................................... 29, 38 Emoquette® ..................................................................................... 31 Emsam® ........................................................................................... 23 Emtriva® .......................................................................................... 20 Enablex® ...................................................................................... 6, 38 enalapril ............................................................................................ 9 Enbrel® ...................................................................................... 27, 34 Endal® CD syrup ............................................................................. 4 Endometrin® ................................................................................... 30

enoxaparin sodium ......................................................................... 7 Enpresse® ........................................................................................ 31 Entex® ............................................................................................... 5 Entocort® EC .................................................................................. 29 Epiduo® ........................................................................................... 14 epinastine ....................................................................................... 18 Epipen® ............................................................................................. 5 Epivir® ............................................................................................. 20 Epivir-HBV® ............................................................................. 20, 29 eplerenone ...................................................................................... 12 Epogen® ...................................................................................... 7, 33 eprosartan ......................................................................................... 9 Epzicom® ........................................................................................ 20 Equagesic® ...................................................................................... 28 ergocalciferol .................................................................................. 30 Ergomar® ........................................................................................ 27 ergotamine w/caffeine ................................................................. 27 ErivedgeTM .................................................................................. 8, 33 Errin® .............................................................................................. 31 Ertaczo® .......................................................................................... 20 Ery-Tab® ......................................................................................... 19 erythromycin .................................................................................. 32 erythromycin base enteric pellets ................................................ 19 erythromycin estolate caps, susp ................................................ 19 erythromycin ethylsuccinate tabs, susp ..................................... 19 erythromycin gel ........................................................................... 13 erythromycin ophthalmic ............................................................. 17 erythromycin pads ........................................................................ 13 erythromycin stearate ................................................................... 19 erythromycin susp......................................................................... 32 erythromycin/benzoyl peroxide gel ........................................... 13 erythromycin/sulfisoxazole susp ............................................... 19 escitalopram oxalate ...................................................................... 23 Esgic Plus® ...................................................................................... 27 Esgic® .............................................................................................. 27 Estrace® ........................................................................................... 30 Estrace® cream ............................................................................... 30 Estraderm® ..................................................................................... 30 estradiol .......................................................................................... 30 estradiol weekly patch .................................................................. 30 estradiol/levonorgesterel ............................................................. 31 estradiol/norethindrone ............................................................... 31 Estratest® ........................................................................................ 30 Estratest® HS .................................................................................. 30 Estring® ........................................................................................... 30 Estrogel® ......................................................................................... 30 estropipate ...................................................................................... 30 Estrostep FE®.................................................................................. 31 ethambutol ..................................................................................... 21 ethosuximide 250mg/5ml syrup ................................................. 24 ethosuximide capsules .................................................................. 24 etodolac ........................................................................................... 27 etoposide (caps only) ................................................................ 8, 33 Eurax® ............................................................................................. 14 evetiracetam ................................................................................... 24 Evista® ............................................................................................. 30 Evoclin® Foam ............................................................................... 14 Evoxac® ........................................................................................... 16 Exactech® ........................................................................................ 16 Exalgo® ..................................................................................... 26, 38 Exall® D ............................................................................................. 5 Exall® liquid ..................................................................................... 5 Exelon® ........................................................................................... 25

January 2013 47

exemestane ................................................................................. 8, 33 Exforge® .................................................................................... 11, 37 Exforge® HCT ........................................................................... 11, 37 Exjade® ........................................................................................ 7, 33 Extavia® ............................................................................... 25, 34, 37 Extina® ............................................................................................. 14

F famciclovir ...................................................................................... 20 famotidine ....................................................................................... 28 Famvir® ........................................................................................... 20 Fanapt® ............................................................................................ 23 Fareston® ..................................................................................... 8, 33 Fasttake® ......................................................................................... 16 Fazaclo® ........................................................................................... 23 fe-fumarate vitamin C/vitamin B12/folic acid.......................... 30 felbamate ......................................................................................... 24 Felbatol® .......................................................................................... 24 felodipine er.................................................................................... 10 Femara® ....................................................................................... 8, 33 Femcon FE® .................................................................................... 31 Femhrt Low Dose® ........................................................................ 30 Femhrt® ........................................................................................... 30 Femring® ......................................................................................... 30 fenofibrate ....................................................................................... 11 fenofibrate 48mg, 145mg................................................................. 2 Fenoglide® ........................................................................................ 2 fentanyl ........................................................................................... 38 fentanyl TD patch .......................................................................... 26 Fentora® .................................................................................... 26, 38 Ferriprox® ................................................................................... 7, 33 Fibricor® ............................................................................................ 2 Finacea® .......................................................................................... 13 Finacea® Plus Kit ............................................................................ 13 finasteride ....................................................................................... 21 Fioricet® ........................................................................................... 27 Fiorinal® .......................................................................................... 27 Firazyr® ....................................................................................... 7, 33 Flagyl® ............................................................................................. 21 Flarex® ............................................................................................. 17 flavoxate hcl ...................................................................................... 6 flecainide acetate ............................................................................ 12 Flector® patch ................................................................................. 27 Flexeril® ........................................................................................... 28 Flomax® ........................................................................................... 21 Flonase® ...................................................................................... 4, 37 Flovent® Diskus 50mcg, 100mcg, 250mg ..................................... 5 Flovent® HFA ................................................................................... 5 Floxin® Otic .................................................................................... 16 fluconazole 150mg tab................................................................... 20 fluconazole tabs/oral suspension ................................................ 20 flucytosine ...................................................................................... 20 fludrocortisone acetate .................................................................. 18 flumadine ........................................................................................ 20 flunisolide nasal ............................................................................... 4 fluocinolone acetonide .................................................................. 13 fluocinonide .................................................................................... 13 fluorouracil ..................................................................................... 14 fluoxetine ........................................................................................ 23 fluoxetine 90mg .............................................................................. 23 fluoxetine hcl .................................................................................. 23 fluoxetine liquid ............................................................................. 23

fluoxetine PMDD ........................................................................... 23 fluphenazine .................................................................................. 23 flurazepam ..................................................................................... 22 flurbiprofen ophth soln ................................................................ 18 flurbiprofen tabs ............................................................................ 27 flutamide .................................................................................... 8, 33 fluticasone cr; oint ......................................................................... 13 fluticasone propionate lotion 0.05% ............................................ 13 fluticasone propionate nasal .......................................................... 4 fluvastatin ....................................................................................... 11 fluvoxamine ................................................................................... 23 FML-Forte® ophthalmic ................................................................ 17 Focalin XR ...................................................................................... 24 folic acid .......................................................................................... 30 Follistim®/AQ ............................................................................... 31 fondaparinox .................................................................................... 7 Foradil® ....................................................................................... 5, 38 Forfivo® XL ..................................................................................... 23 Fortamet® ........................................................................................ 15 Forteo® ...................................................................................... 19, 34 FortestaTM ....................................................................................... 22 Fortical ............................................................................................ 13 Fortical® .......................................................................................... 19 Fosamax® tabs ............................................................................... 19 Fosamax® plus D ........................................................................... 19 fosinopril .......................................................................................... 9 Fosrenol® ........................................................................................ 30 Fragmin® ........................................................................................... 7 Freestyle® .................................................................................. 15, 16 Frova® ............................................................................................. 27 Furadantin® susp ........................................................................... 19 furosemide...................................................................................... 10 Fuzeon®........................................................................................... 34 FycompaTM ..................................................................................... 24

G

gabapentin ...................................................................................... 24 Gabitril® .......................................................................................... 24 galantamine .................................................................................... 25 galantamine oral solution ............................................................. 25 galantamine SR .............................................................................. 25 Galzin® ............................................................................................ 30 ganciclovir ...................................................................................... 20 Ganirelix® ....................................................................................... 31 Gastrocrom® ................................................................................... 29 gemfibrozil ..................................................................................... 11 Generess® FE .................................................................................. 31 generic Avita® ................................................................................ 13 generic benzonatate ........................................................................ 5 generic Bicitra® ................................................................................ 6 generic Cardizem® CD .................................................................. 10 generic Colyte® .............................................................................. 29 generic Cortisporin® ophthalmic ................................................ 17 generic Cortisporin® Otic sol, susp ............................................. 16 generic Dilacor® XR ....................................................................... 10 generic Domeboro® Otic ............................................................... 16 generic Donnatal® ......................................................................... 28 generic Dyazide® ........................................................................... 10 generic Econopred® Plus .............................................................. 17 generic Esgic®................................................................................. 27 generic Esgic® Plus ........................................................................ 27 generic Fioricet® ............................................................................. 27

January 2013 48

generic Fiorinal® ............................................................................ 27 generic Fiorinal® w/codeine No.3 ............................................... 27 generic FML® Liquifilm ................................................................ 17 generic Golytely® ........................................................................... 29 generic Hycodan® ............................................................................ 4 generic Inflamase® Forte ............................................................... 17 generic Lomotil® ............................................................................ 28 generic Maxitrol® ophthalmic ...................................................... 17 generic Maxzide® ........................................................................... 10 generic Metimyd® .......................................................................... 17 generic Midrin® .............................................................................. 27 generic NeoDecadron® .................................................................. 17 generic Neosporin® ....................................................................... 17 generic Novahistine® expt ............................................................. 4 generic Percodan® .......................................................................... 26 generic Phrenilin® .......................................................................... 27 generic Poly-Histine® ...................................................................... 4 generic Polysporin® ....................................................................... 17 generic Polytrim® ........................................................................... 17 generic Pred Forte® ........................................................................ 17 generic Retin-A® ............................................................................ 13 generic Robitussin® DAC................................................................ 4 generic Sulfacet-R® ........................................................................ 13 generic Timoptic-XE® .................................................................... 17 generic Tylox® ................................................................................ 26 generic Vasocidin® ......................................................................... 17 generic Ziac® .................................................................................. 11 Genotropin® .............................................................................. 18, 34 gentamicin ...................................................................................... 14 gentamicin ophthalmic ................................................................. 17 Geodon® .......................................................................................... 23 Gianvi® ............................................................................................ 31 GilenyaTM .................................................................................. 25, 34 Giltuss® ............................................................................................. 5 Giltuss® TR ....................................................................................... 5 Gleevec® ...................................................................................... 8, 33 glimepiride ..................................................................................... 15 glipizide .......................................................................................... 15 glipizide CR tablets ....................................................................... 15 glipizide-metformin ...................................................................... 15 glucagon .......................................................................................... 15 Glucodex® ....................................................................................... 16 Glucophage ..................................................................................... 15 Glucophage XR® ............................................................................ 15 Glucotrol XL® ................................................................................. 15 Glucotrol® ....................................................................................... 15 Glucovance® ................................................................................... 15 glyburide ......................................................................................... 15 glyburide micronized .................................................................... 15 glyburide-metformin ..................................................................... 15 glycopyrrolate ................................................................................ 29 Glynase® .......................................................................................... 15 Glyset®............................................................................................. 15 Golytely® ......................................................................................... 29 Gonal-F RFF® .................................................................................. 31 Gonal-F® .......................................................................................... 31 Gralise® ..................................................................................... 24, 38 granisetron ................................................................................ 29, 37 Grifulvin® V .................................................................................... 20 griseofulvin suspension ................................................................ 20 Gris-Peg® 125 mg ........................................................................... 20 Gris-Peg® 250 mg ........................................................................... 20 guanabenz acetate.......................................................................... 10

guanfacine HCl .............................................................................. 10 Gyne-Lotrimin® ............................................................................. 32

H

Halcion® .......................................................................................... 22 Haldol® ........................................................................................... 23 Halflytely® Bowel Prep Kit .......................................................... 29 halobetasol propionate ................................................................. 13 Halog® ............................................................................................. 13 Halonate® ....................................................................................... 13 haloperidol ..................................................................................... 23 Hectorol® .................................................................................. 30, 38 heparin sodium ................................................................................ 7 Hepsera® ................................................................................... 20, 29 Hexalen® ..................................................................................... 8, 33 HMS® .............................................................................................. 17 homatropine ................................................................................... 18 Horizant® ........................................................................................ 24 Humalog® ....................................................................................... 15 Humatrope® ............................................................................. 18, 34 Humira® .................................................................................... 27, 34 Humulin® Insulins ........................................................................ 15 Hycamtin® cap ........................................................................... 8, 33 Hycodan® syrup .............................................................................. 4 hydralazine HCl ............................................................................ 10 Hydrea® ...................................................................................... 8, 33 hydrochlorothiazide ...................................................................... 10 hydrocodone w/acetaminophen ........................................... 26, 32 hydrocodone w/ibuprofen .......................................................... 26 hydrocodone/APAP soln ............................................................. 26 hydrocodone-ibuprofen tab 7.5-200mg ...................................... 32 hydrocortisone 2.5% ...................................................................... 13 hydrocortisone 25mg rectal .......................................................... 13 hydrocortisone cream, supp ........................................................ 29 hydrocortisone enema .................................................................. 29 hydrocortisone rectal .................................................................... 13 hydrocortisone tab ........................................................................ 18 hydrocortisone valerate ................................................................ 13 hydrocortisone w/acetic acid otic soln ................................. 16, 17 hydromorphone hcl ...................................................................... 26 hydroxychloroquine sulfate ................................................... 21, 27 hydroxyurea 500mg .................................................................. 8, 33 hydroxyzine HCl ....................................................................... 4, 22 hydroxyzine pamoate ............................................................... 4, 22 hyoscyamine .................................................................................... 6 hyoscyamine sulfate ...................................................................... 28 Hytrin® ...................................................................................... 10, 21 Hyzaar® .......................................................................................... 11

I ibandronate sodium tabs .............................................................. 19 ibuprofen .................................................................................. 27, 32 ibuprofen suspension .................................................................... 32 Imdur® ............................................................................................ 12 imipramine HCl ............................................................................. 23 imiquimod cream .......................................................................... 14 Imitrex® ........................................................................................... 27 Imuran® ............................................................................................ 8 Incivek® ..................................................................................... 29, 35 Increlex®.......................................................................................... 34 indapamide .................................................................................... 10

January 2013 49

Inderal® LA ....................................................................................... 9 Indocin® .......................................................................................... 27 indomethacin .................................................................................. 27 indomethacin SR ............................................................................ 27 Infergen® ................................................................................... 29, 35 Inlyta®.......................................................................................... 8, 33 Innopran XL® ................................................................................... 9 Inspra®............................................................................................. 12 Inta® nebs .......................................................................................... 5 Intelence® ........................................................................................ 20 Intermezzo® .............................................................................. 22, 37 Intron A® ................................................................................... 29, 35 Intuniv® ........................................................................................... 25 Invirase® .......................................................................................... 20 Iopidine® ......................................................................................... 17 ipratropium ...................................................................................... 4 ipratropium 200mcg/ml nebs ........................................................ 6 irbesartan .......................................................................................... 9 irbesartan/hctz .............................................................................. 11 Iressa® .......................................................................................... 8, 33 iron polysaccharide complex/folic acid/vitamin B12 .............. 30 Isentress® ........................................................................................ 20 Ismo® ............................................................................................... 12 isoniazid .......................................................................................... 21 Isoptin®SR ....................................................................................... 10 Isopto Carbachol® .......................................................................... 17 Isordil® ............................................................................................ 12 isosorbide dinitrate ........................................................................ 12 isosorbide mononitrate ................................................................. 12 isotretinoin ...................................................................................... 13 Isuprel® ............................................................................................. 5 itraconazole caps ............................................................................ 20

J Jakafi® .......................................................................................... 8, 33 jantoven ............................................................................................. 7 Janumet® ......................................................................................... 15 Janumet® XR ................................................................................... 15 Januvia® .......................................................................................... 15 Jentadueto® ..................................................................................... 15 Jolessa® ............................................................................................ 31 J-Tan® D ............................................................................................ 5 Junel FE® ......................................................................................... 31 Junel® ............................................................................................... 31 Juvisync® ......................................................................................... 15

K

Kadian® ........................................................................................... 38 Kadian® 100mg, 200mg .................................................................. 26 Kadian® 10mg, 20mg, 30mg, 50mg, 60mg, 80mg ........................... 26 Kaletra® ........................................................................................... 20 Kalydeco® ................................................................................... 6, 35 KapvayTM ........................................................................................ 24 Kariva® ............................................................................................ 31 Kayexalate® .................................................................................... 30 Keflex® ....................................................................................... 19, 32 Kelnor® ............................................................................................ 31 Kemadrin® ...................................................................................... 25 Kenalog® in Orabase ..................................................................... 16 Keppra® ........................................................................................... 24 Keppra® XR .................................................................................... 24

Keralyt® scalp ................................................................................. 14 Kerlone® ...................................................................................... 9, 10 Ketek® ............................................................................................. 19 ketoconazole 2% shampoo ........................................................... 14 ketoconazole cream ....................................................................... 14 ketoconazole foam 2% .................................................................. 14 ketoconazole tabs .......................................................................... 20 Ketodan® ......................................................................................... 14 ketoprofen ...................................................................................... 27 ketoprofen extended release ........................................................ 27 ketorolac ......................................................................................... 27 ketorolac tromethamine ophth soln 0.4% and 0.5% .................. 18 ketotifen fumerate ophth soln...................................................... 18 Kineret® .................................................................................... 27, 34 Klaron® ........................................................................................... 13 Klonopin® ....................................................................................... 24 Klonopin® Wafers .......................................................................... 24 Klor-Con-25® ................................................................................. 30 Kombiglyze® XR ............................................................................ 15 Korlym® .................................................................................... 19, 34 Kuvan® ...................................................................................... 29, 35 Kytril® ....................................................................................... 29, 37

L labetalol ............................................................................................ 9 Lacrisert® ........................................................................................ 18 lactulose syrup ............................................................................... 29 Lamictal® chewable tablets .......................................................... 24 Lamictal® ODT ............................................................................... 24 Lamictal® ODT Titration Kit ........................................................ 24 Lamictal® Starter Kit ..................................................................... 24 Lamictal® tabs ................................................................................ 24 Lamictal® XR .................................................................................. 24 Lamictal® XR Starter Kit ............................................................... 24 Lamisil AT® cream ........................................................................ 14 Lamisil® .......................................................................................... 20 Lamisil® oral granules.................................................................. 20 lamivudine ..................................................................................... 20 lamivudine/zidovudine ............................................................... 20 lamotrigine chewable tablets ....................................................... 24 lamotrigine tablets ......................................................................... 24 Lanoxin® ......................................................................................... 12 lansoprazole ................................................................................... 28 Lantus® ........................................................................................... 15 Lasix® .............................................................................................. 10 LastacaftTM ................................................................................ 18, 37 latanoprost ophth soln .................................................................. 17 LatudaTM ......................................................................................... 23 Lazanda® ........................................................................................ 26 Leena® ............................................................................................. 31 leflunomide .................................................................................... 27 Lescol® ............................................................................................ 11 Lessina® .......................................................................................... 31 Letairis® .................................................................................... 12, 34 letrozole ...................................................................................... 8, 33 leucovorin calcium tabs .................................................................. 8 Leukeran® ......................................................................................... 8 Leukine® ........................................................................................... 7 Levaquin® ....................................................................................... 19 Levatol® ............................................................................................ 9 Levemir® ......................................................................................... 15 levetiracetam xr ............................................................................. 24

January 2013 50

Levitra® ........................................................................................... 21 levobunolol HCl ............................................................................. 17 levocetirizine dihydrochloride ....................................................... 4 levofloxacin .................................................................................... 19 levofloxacin opth soln ................................................................... 17 levonorgestrel ................................................................................. 31 Levora®............................................................................................ 31 levothroid ....................................................................................... 18 levothyroxine ................................................................................. 18 levoxyl ............................................................................................. 18 Levsin® ............................................................................................ 28 Levsin®/SL ....................................................................................... 6 Lexapro® ......................................................................................... 23 Lexiva® ............................................................................................ 20 Lialda® ............................................................................................. 29 Librax® ............................................................................................ 28 Lidex® .............................................................................................. 13 lidocaine cr ..................................................................................... 14 lidocaine HC cr .............................................................................. 14 lidocaine viscous ...................................................................... 16, 33 lidocaine viscous soln .................................................................... 14 lidocaine-prilocaine cream ........................................................... 14 Lidoderm® ...................................................................................... 14 lindane ............................................................................................. 14 Linzess® ........................................................................................... 28 Lioresal® .......................................................................................... 28 liothyronine .................................................................................... 18 Lipitor® ............................................................................................ 11 Lipofen® ............................................................................................ 2 lisinopril ............................................................................................ 9 lisinopril/hctz ................................................................................ 11 lithium carbonate ........................................................................... 23 lithium carbonate CR tab .............................................................. 23 Livalo® ............................................................................................. 11 Lo/Ovral® ....................................................................................... 31 Lodosyn® ........................................................................................ 25 Loestrin FE® .................................................................................... 31 Loestrin® ......................................................................................... 31 Loestrin® 24 Fe ............................................................................... 31 Lofibra ............................................................................................. 11 Lopid® ............................................................................................... 2 Lopressor HCT® ............................................................................. 11 Lopressor® ........................................................................................ 9 Loprox® ........................................................................................... 14 Loprox® Shampoo .......................................................................... 14 lorazepam ....................................................................................... 22 Lortab® ...................................................................................... 26, 32 Loryna® ........................................................................................... 31 losartan .............................................................................................. 9 losartan/hctz .................................................................................. 11 Loseasonique® ................................................................................ 31 Lotemax® ........................................................................................ 17 Lotemax® ointment ........................................................................ 17 Lotensin® ........................................................................................... 9 LotensinHCT® ................................................................................ 11 Lotrel® ....................................................................................... 10, 11 lovastatin ......................................................................................... 11 Lovaza® ........................................................................................... 11 Lovenox® ........................................................................................... 7 Low-Ogestrel® ................................................................................ 31 loxapine ........................................................................................... 23 Lufyllin® ............................................................................................ 5 Lumigan® ........................................................................................ 17

Lunesta® ......................................................................................... 22 Lupron® .......................................................................................... 32 Luride® ...................................................................................... 30, 32 Lutera® ............................................................................................ 31 Luveris® .......................................................................................... 31 Luxiq® foam ................................................................................... 13 Lyrica® ............................................................................................ 24 Lysodren® ................................................................................... 8, 33 Lysteda® .......................................................................................... 32

M

Macrobid® ...................................................................................... 19 Magnacet® ...................................................................................... 26 Malarone® ....................................................................................... 21 maprotiline ..................................................................................... 23 Mar-cof® BP ...................................................................................... 4 Marinol® ......................................................................................... 29 Matulane® ................................................................................... 8, 33 Mavik® .............................................................................................. 9 Maxair® Autohaler .......................................................................... 5 Maxalt® ........................................................................................... 27 Maxalt-MLT® ................................................................................. 27 Maxifed® DM liquid ........................................................................ 5 Maxzide® ........................................................................................ 10 Mebaral® ......................................................................................... 24 mebendazole .................................................................................. 21 meclizine ......................................................................................... 29 meclofenamate ............................................................................... 27 medoxyprogesterone .................................................................... 31 Medrol®........................................................................................... 18 Medrox-RX®.................................................................................... 14 medroxyprogesterone ................................................................... 30 mefenamic acid .............................................................................. 27 mefloquine hcl ............................................................................... 21 Megace® ES................................................................................. 8, 33 megestrol acetate ....................................................................... 8, 33 meloxicam ...................................................................................... 27 Meloxicam® Comfort PacKit ........................................................ 27 Menest® ........................................................................................... 30 Menopur® ....................................................................................... 31 Menostar® ....................................................................................... 19 Mentax® .......................................................................................... 14 meperidine HCl ............................................................................. 26 Mephyton® ....................................................................................... 7 meprobamate ................................................................................. 22 meprobamate/aspirin ................................................................... 28 Mepron® ......................................................................................... 21 mercaptopurine ............................................................................... 8 mesalamine enema ........................................................................ 29 Mesnex® ...................................................................................... 8, 33 Mestinon® ....................................................................................... 25 Metadate CD® ................................................................................ 24 Metaglip® ........................................................................................ 15 metaproterenol tabs ........................................................................ 5 metaxalone ..................................................................................... 28 metformin hcl ................................................................................. 15 metformin SR ................................................................................. 15 metformin tb24 .............................................................................. 15 methadone hcl ................................................................................ 26 methamphetamine ........................................................................ 24 methazolamide .............................................................................. 17 Methergine® ................................................................................... 32

January 2013 51

methimazole ................................................................................... 18 Methitest® ....................................................................................... 22 methocarbamol .............................................................................. 28 methotrexate inj ............................................................................. 27 methotrexate tabs ................................................................. 8, 14, 27 methyclothiazide ........................................................................... 10 methyldopa..................................................................................... 10 methyldopa/hctz ........................................................................... 11 Methylin® ........................................................................................ 24 methylphenidate ............................................................................ 24 methylphenidate er ....................................................................... 24 methylphenidate SR tabs .............................................................. 24 methylprednisolone ...................................................................... 32 methylprednisolone generic ......................................................... 18 metipranolol ................................................................................... 17 metoclopramide ............................................................................. 28 metoprolol ........................................................................................ 9 metoprolol succinate SR.................................................................. 9 metoprolol/hctz ............................................................................. 11 Metozolv® ODT .............................................................................. 28 Metrocream® .................................................................................. 13 Metrogel® 0.75% ............................................................................. 13 Metrogel® 1% .................................................................................. 13 Metrogel® Vaginal ......................................................................... 32 Metrolotion® ................................................................................... 13 metronidazole ................................................................................ 21 metronidazole cream, lotion ......................................................... 13 metronidazole vaginal gel ............................................................ 32 Mevacor® ........................................................................................ 11 mexiletine HCl ............................................................................... 12 Miacalcin® inj. ................................................................................ 19 Miacalcin® nasal spray .................................................................. 19 Micardis® .......................................................................................... 9 Micardis® HCT ............................................................................... 11 Micatin® .......................................................................................... 14 miconazole cream, lotion, aerosol, soln ...................................... 14 miconazole vaginal cream ............................................................ 32 Microgestin FE® ............................................................................. 31 Microgestin® ................................................................................... 31 Micro-K® ......................................................................................... 30 Midamor® ....................................................................................... 10 midodrine hcl ................................................................................. 12 Midrin® ........................................................................................... 27 Migranal® ........................................................................................ 27 Minipress® ...................................................................................... 10 Minitran® ........................................................................................ 12 Minocin Pac® .................................................................................. 19 Minocin® ......................................................................................... 19 minocycline caps (50mg & 100mg only) ..................................... 19 minocycline hcl er .......................................................................... 13 minocycline hcl tabs ...................................................................... 13 minoxidil tabs ................................................................................. 10 Mirapex® ......................................................................................... 25 Mirapex® ER ................................................................................... 25 Mircette® ......................................................................................... 31 mirtazapine ODT ........................................................................... 23 misoprostol ..................................................................................... 28 Mobic® ............................................................................................. 27 modafinil ......................................................................................... 24 Modicon® ........................................................................................ 31 moexipril/hctz ............................................................................... 11 mometasone furoate ...................................................................... 13 Momexin® ....................................................................................... 14

Monistat® ........................................................................................ 32 Monodox® ...................................................................................... 19 Monoket® ........................................................................................ 12 Mononessa® .................................................................................... 31 montelukast sodium chews............................................................ 6 montelukast sodium tabs ............................................................... 6 morphine sulfate cap sr 24hr 100mg, 200mg ............................. 26 morphine sulfate cap sr 24hr 10mg, 20mg, ................................ 26 morphine sulfate ER...................................................................... 26 morphine sulfate ir ........................................................................ 26 morphine sulfate supp .................................................................. 26 morphine sulfate tablets, oral solution ....................................... 26 Motrin® ..................................................................................... 27, 32 Moxatag® ........................................................................................ 19 Moxeza® .......................................................................................... 17 MS Contin® ..................................................................................... 26 Multaq® ........................................................................................... 12 mupirocin oint ............................................................................... 14 Muse® .............................................................................................. 21 Myambutol® ................................................................................... 21 Mycelex® Troche ............................................................................ 20 Mycobutin® .................................................................................... 21 mycophenolate................................................................................. 8 Mydfrin® ......................................................................................... 18 Myfortic® .......................................................................................... 8 Myleran® ..................................................................................... 8, 33 Myorisan® ....................................................................................... 13 MyrbetriqTM ................................................................................ 6, 38 Mysoline® ....................................................................................... 24

N

nabumetone .................................................................................... 27 nadolol .............................................................................................. 9 Naftin® ............................................................................................ 14 Nalfon® ........................................................................................... 27 naltrexone ....................................................................................... 25 Namenda® soln .............................................................................. 25 naphazoline .................................................................................... 18 Naprelan® ....................................................................................... 27 Naprelan® SR ................................................................................. 27 Naprosyn® ...................................................................................... 27 naproxen ................................................................................... 27, 32 naproxen sodium ..................................................................... 27, 32 naratriptan ...................................................................................... 27 Nardil® ............................................................................................ 23 Nasacort® AQ ................................................................................... 4 Nasarel® ............................................................................................ 4 Nasonex® .......................................................................................... 4 Natacyn® ......................................................................................... 17 Natazia® .......................................................................................... 31 nateglinide ...................................................................................... 15 Natroba® ................................................................................... 14, 38 Navane® .......................................................................................... 23 Nebupent® ...................................................................................... 21 Necon® ............................................................................................ 31 nefazodone hcl ............................................................................... 23 Neo® AC ........................................................................................... 4 neomycin sulfate............................................................................ 21 Neoral® ............................................................................................. 8 Neotic® ............................................................................................ 16 Neulasta® .................................................................................... 7, 33 Neumega® ........................................................................................ 7

January 2013 52

Neupogen® ................................................................................. 7, 33 Neupro® .......................................................................................... 25 Neurontin® ..................................................................................... 24 Nevanac® ........................................................................................ 18 nevirapine ....................................................................................... 20 Nexavar® ..................................................................................... 8, 33 NexiclonTM ...................................................................................... 10 NexiclonTM XR ................................................................................ 39 Nexium®.......................................................................................... 28 Next Choice® .................................................................................. 31 Niaspan® ......................................................................................... 11 Nicardipine® ................................................................................... 10 Nicotrol® Inhaler ............................................................................ 28 Nicotrol® NS ................................................................................... 28 Nifediac CC .................................................................................... 10 Nifedical XL .................................................................................... 10 nifedipine ........................................................................................ 32 nifedipine ER .................................................................................. 10 Nilandron® ....................................................................................... 8 nimodipine ..................................................................................... 10 Nimotop® ........................................................................................ 10 Niravam® ........................................................................................ 23 nislodipine ...................................................................................... 10 Nitro-Bid® ....................................................................................... 12 Nitro-Dur® ...................................................................................... 12 nitrofurantoin macrocrystals ........................................................ 19 nitroglycerin ointment .................................................................. 12 nitroglycerin patch ........................................................................ 12 nitroglycerin sublingual ................................................................ 12 Nitrolingual aerosol spray ............................................................ 12 Nitrostat® ........................................................................................ 12 Nizoral A-D® shampoo ................................................................. 14 Nizoral® .......................................................................................... 20 Nizoral® shampoo ......................................................................... 14 Nora-Be® ......................................................................................... 31 Norco® ............................................................................................. 26 Nordette® ........................................................................................ 31 norethindrone acetate ................................................................... 30 norethindrone acetate-ethinyl estradiol ...................................... 30 Norflex® .......................................................................................... 28 Norinyl® .......................................................................................... 31 Noritate® ......................................................................................... 13 Noroxin® ......................................................................................... 19 Norpace CR® 100mg ...................................................................... 12 Norpace® ......................................................................................... 12 Norpramin® .................................................................................... 23 Nor-QD® ......................................................................................... 31 Nortrel® ........................................................................................... 31 nortriptyline ................................................................................... 23 Norvasc® ......................................................................................... 10 Norvir® ............................................................................................ 20 Novacort® ....................................................................................... 13 NovoFine® Needles ....................................................................... 15 Novolin® insulins ........................................................................... 15 Novolog® insulins .......................................................................... 15 Noxafil® ........................................................................................... 20 Nucynta® ......................................................................................... 26 Nucynta® ER ................................................................................... 26 NuedextaTM XR .............................................................................. 25 Nutropin® ................................................................................. 18, 34 Nutropin® AQ .......................................................................... 18, 34 NuvaRing® ...................................................................................... 31 Nuvigil® .......................................................................................... 24

nystatin 100,000u/1g cream; oint ................................................ 14 nystatin oral suspension ......................................................... 20, 32 nystatin pwd .................................................................................. 14 nystatin tabs ................................................................................... 20 nystatin-triamcinolone .................................................................. 14 Nystop® .......................................................................................... 14

O

Ocella® ............................................................................................ 31 octreotide .......................................................................................... 8 Ocufen® ophth soln ....................................................................... 18 Ocuflox®.......................................................................................... 17 ofloxacin ophth soln ...................................................................... 17 ofloxacin otic .................................................................................. 16 Oforta® ........................................................................................ 8, 33 Ogestrel® ......................................................................................... 31 olanzapine ...................................................................................... 23 olanzapine odt ............................................................................... 23 olanzapine-fluoxetine ................................................................... 23 Oleptro® .................................................................................... 23, 39 Olux® foam ..................................................................................... 13 Omeclamox-Pak® ........................................................................... 29 omeprazole ..................................................................................... 28 omeprazole sodium bicarbonate ................................................. 28 Omnaris® .................................................................................... 4, 37 ondansetron ................................................................................... 29 ondansetron odt ............................................................................. 29 ondansetron susp .......................................................................... 29 One Touch® .................................................................................... 16 One Touch® Ultra .......................................................................... 16 OneTouch® ..................................................................................... 15 OneTouch® Ultra Mini .................................................................. 16 OneTouch® Verio IQ ............................................................... 15, 16 OnfiTM ............................................................................................. 25 Onglyza®......................................................................................... 15 Onsolis® .................................................................................... 26, 35 Opana ER® ...................................................................................... 26 Opana® ............................................................................................ 26 Optipranolol® ................................................................................. 17 Optivar® .................................................................................... 18, 37 Oramorph® ..................................................................................... 26 Orap® .............................................................................................. 23 Orapred® ..................................................................................... 8, 18 Oravig® ..................................................................................... 20, 39 Orencia® SQ .............................................................................. 27, 34 Orfadin® .......................................................................................... 19 Ortho Micronor® ............................................................................ 31 Ortho Tri-Cyclen® ......................................................................... 31 Ortho Tri-Cyclen® Lo .................................................................... 31 Ortho-Cept® ................................................................................... 31 Ortho-Cyclen® ................................................................................ 31 OrthoEvra® ..................................................................................... 31 Ortho-Novum® .............................................................................. 31 OsmoPrep® ..................................................................................... 29 Ovcon® ............................................................................................ 31 Ovidrel® .................................................................................... 31, 38 Oxandrin® ................................................................................... 8, 19 oxaprozin ........................................................................................ 27 oxazepam ........................................................................................ 22 oxcarbazepine ................................................................................ 24 Oxecta® ........................................................................................... 26 Oxistat® ........................................................................................... 14

January 2013 53

Oxsoralen-Ultra® ............................................................................ 14 oxybutynin ........................................................................................ 6 oxybutynin chloride SR .................................................................. 6 oxycodone 5mg tablets/soln ........................................................ 26 oxycodone w/acetaminophen 5/325mg .................................... 26 oxycodone w/ibuprofen ............................................................... 26 Oxycontin® ..................................................................................... 26 oxymorphone ................................................................................. 26 Oxytrol® ...................................................................................... 6, 38 Oyxcontin® ..................................................................................... 38

P Pamelor® ......................................................................................... 23 Pancreaze® ...................................................................................... 29 Panretin® Gel .................................................................................. 14 pantoprazole ................................................................................... 28 Parcopa® .......................................................................................... 25 Parlodel® ......................................................................................... 25 Parnate® .......................................................................................... 23 paromomycin ................................................................................. 21 paroxetine er ................................................................................... 39 paroxetine hcl sr ............................................................................. 23 paroxetine tabs ............................................................................... 23 Pataday®.......................................................................................... 37 Patanase® .......................................................................................... 4 Patanol®........................................................................................... 18 Paxil CR® ......................................................................................... 23 Paxil® ............................................................................................... 23 Paxil® CR ......................................................................................... 39 Pediapred® ...................................................................................... 18 Pediderm® HC ............................................................................... 13 Peganone® ....................................................................................... 24 Pegasys® .................................................................................... 29, 35 Peg-Intron® ............................................................................... 29, 35 penicillin VK ................................................................................... 32 penicillin VK tabs, soln ................................................................. 19 Penlac® ............................................................................................ 14 Pennsaid® ........................................................................................ 27 Pentasa® .......................................................................................... 29 pentoxifylline ................................................................................... 7 Percocet® ......................................................................................... 26 Percodan® ....................................................................................... 26 Perforomist® ..................................................................................... 5 Peridex® .................................................................................... 16, 33 perindopril ........................................................................................ 9 Periostat® ........................................................................................ 32 permethrin cream .......................................................................... 14 perphenazine .................................................................................. 23 Persantine® ....................................................................................... 7 Pertzye® ........................................................................................... 29 phenazopyridine .............................................................................. 6 Phenergan suppositories® ............................................................ 29 phenobarbital ................................................................................. 24 phentolamine inj ............................................................................ 12 phenylephrine .................................................................................. 4 phenylephrine ophthalmic 2.5% .................................................. 18 Phenytek® ....................................................................................... 24 phenytoin ........................................................................................ 24 phenytoin sodium .......................................................................... 24 phenytoin sodium ext ................................................................... 12 phenytoin sodium susp ................................................................ 24 Phoslo® ............................................................................................ 30

PhoslyraTM ...................................................................................... 30 Phospholine® iodide ..................................................................... 17 Phrenilin® ....................................................................................... 27 Phrenilin® Forte ............................................................................. 27 Picato® Gel ...................................................................................... 14 pilocarpine soln ............................................................................. 17 pilocarpine tab ............................................................................... 16 Pilopine® H.S. ................................................................................. 17 pioglitazone hcl ............................................................................. 15 pioglitazone hcl/metformin hcl .................................................. 15 piroxicam ........................................................................................ 27 Plan B® ............................................................................................ 31 Plan B® One Step ........................................................................... 31 Plavix®............................................................................................... 7 Plendil® ........................................................................................... 10 Pletal® ................................................................................................ 7 Plexion® cleanser ........................................................................... 13 podofilox solution ......................................................................... 14 Polycitra® .......................................................................................... 6 Poly-Pred® ...................................................................................... 17 Poly-ViSol® ..................................................................................... 32 Poly-Vi-Sol®.................................................................................... 30 poly-vitamin w/fluoride ........................................................ 30, 32 Ponstel® ........................................................................................... 27 Portia® ............................................................................................. 31 potassium bicarbonate/chloride ................................................. 30 potassium chloride extended release tabs .................................. 30 potassium chloride tab, cap, liquid ............................................. 30 potassium citrate ............................................................................. 6 potassium citrate/citric acid .......................................................... 6 Potiga® ............................................................................................ 24 PradaxaTM ......................................................................................... 7 pramipexole dihydrochloride ...................................................... 25 Pramosone® E ................................................................................ 13 Prandimet® ..................................................................................... 15 Prandin® ......................................................................................... 15 Pravachol® ...................................................................................... 11 pravastatin ...................................................................................... 11 prazosin HCl .................................................................................. 10 Precision Xtra® ......................................................................... 15, 16 Precose® .......................................................................................... 15 Pred Forte® ..................................................................................... 17 Pred Mild® ...................................................................................... 17 Pred-G S.O.P. ® ............................................................................... 17 Pred-G® ........................................................................................... 17 prednicarbate cr,oint ..................................................................... 13 prednisolone .................................................................................... 8 prednisolone oral syrup ............................................................... 18 prednisone ............................................................................ 8, 18, 32 Prefest® ........................................................................................... 30 Pregnyl® .......................................................................................... 31 Prelone® .......................................................................................... 18 Premarin® ....................................................................................... 30 Premarin® cream ........................................................................... 30 Premphase® .................................................................................... 30 Prempro® ........................................................................................ 30 Prepopik® ....................................................................................... 29 Prevacid Solutab ............................................................................ 28 Prevacid® ........................................................................................ 28 Prevident 5000® ....................................................................... 30, 32 Previfem®........................................................................................ 31 Prezista®.................................................................................... 20, 39 Prilosec® .......................................................................................... 28

January 2013 54

primaquine phosphate .................................................................. 21 primidone ....................................................................................... 24 Prinivil® ............................................................................................. 9 Prinzide® ......................................................................................... 11 Pristiq® ...................................................................................... 23, 39 Proair® HFA ..................................................................................... 5 ProAmatine® .................................................................................. 12 ProBanthine® .................................................................................. 28 probenicid ....................................................................................... 27 procainamide caps ......................................................................... 12 procainamide sr ............................................................................. 12 Procardia® XL ................................................................................. 10 Prochieve® ...................................................................................... 30 prochlorperazine tab, supp .......................................................... 29 Pro-Clear® ......................................................................................... 4 Procrit® ........................................................................................ 7, 33 Proctocort® 1% ............................................................................... 29 Proctocream-HC®2.5% .................................................................. 29 Proctofoam HC® ............................................................................ 29 Procto-Pak® 1% .............................................................................. 29 Proctosol-HC® 2.5% ....................................................................... 29 Proctosone® 2.5% ........................................................................... 29 progesterone suppositories .......................................................... 30 Proglycem® ..................................................................................... 15 Prograf® ............................................................................................. 8 Proleukin® ......................................................................................... 8 Prolex® DMX liquid ......................................................................... 5 Promacta® ................................................................................... 7, 33 promethazine ................................................................................... 4 promethazine hcl supp ................................................................. 29 promethazine VC ............................................................................. 4 promethazine/ ................................................................................. 4 promethazine/dextromethorphan ................................................ 5 Prometrium® .................................................................................. 30 Pronestyl® ....................................................................................... 12 propafenone hcl ............................................................................. 12 propafenone hcl sr ......................................................................... 12 propantheline ................................................................................. 28 propranolol ....................................................................................... 9 propranolol ER ................................................................................. 9 propranolol/hctz ........................................................................... 11 propylthiouracil ............................................................................. 18 Proquin® XR ................................................................................... 19 Proscar® ........................................................................................... 21 Prostigmin® .................................................................................... 25 Protonix® ......................................................................................... 28 Protopic® ......................................................................................... 14 protriptyline ................................................................................... 23 Proventil HFA® ................................................................................ 5 Proventil® .......................................................................................... 5 Provera® .......................................................................................... 30 Provigil® .......................................................................................... 24 Prozac® ............................................................................................ 23 Prozac® Weekly .............................................................................. 23 pseudoephedrine/guaifenesin ...................................................... 5 Pulmicort Respules® 0.25mg, 0.5mg .............................................. 5 Pulmicort® Flexhaler ....................................................................... 5 Pulmicort® Respules 1mg ............................................................... 5 Pulmozyme® ..................................................................................... 6 pyrazinamide ................................................................................. 21 Pyridium® ......................................................................................... 6 pyridostigmine bromide 60mg tab .............................................. 25 Pyril® DM.......................................................................................... 5

Q

Qnasl® ......................................................................................... 4, 37 Qualaquin® ..................................................................................... 21 Quasense® ....................................................................................... 31 Questran Light® ............................................................................. 11 Questran® ....................................................................................... 11 quetiapine fumarate ...................................................................... 23 Quibron® ........................................................................................... 5 Quicktek® ....................................................................................... 15 Quillivant® XR ............................................................................... 24 quinapril ........................................................................................... 9 quinapril/hctz ............................................................................... 11 quinidine gluconate SR ................................................................. 12 quinidine sulfate ............................................................................ 12 quinidine sulfate SR ...................................................................... 12 quinine sulfate caps ....................................................................... 21 Quixin® ........................................................................................... 17 QVar® ................................................................................................ 5

R

ramipril ............................................................................................. 9 Ranexa® ........................................................................................... 12 ranitidine hcl capsules .................................................................. 28 ranitidine syrup ............................................................................. 28 ranitidine tabs ................................................................................ 28 Rapaflo® .................................................................................... 10, 21 Rapamune® ...................................................................................... 8 Rayos® ............................................................................................ 39 Razadyne® ...................................................................................... 25 Razadyne® ER ................................................................................ 25 Rebetol® ........................................................................ 20, 29, 34, 35 Rebif® ........................................................................................ 25, 34 Reclipsen® ....................................................................................... 31 Reglan® ........................................................................................... 28 Regranex® ....................................................................................... 14 Relenza® .......................................................................................... 20 Relistor® .......................................................................................... 29 Relpax® tablets ............................................................................... 27 Remeron Sol-Tab® ......................................................................... 23 Remeron® ....................................................................................... 23 Renacidin® ........................................................................................ 6 Renagel® ......................................................................................... 30 Renvela® ......................................................................................... 30 Reprexain® ...................................................................................... 26 Repronex® ....................................................................................... 31 Requip® ........................................................................................... 25 Requip® XL ..................................................................................... 25 Rescon® JR ........................................................................................ 4 Rescon-MX® ..................................................................................... 4 Rescriptor® ..................................................................................... 20 Respa® CC ........................................................................................ 5 Restasis® ......................................................................................... 18 Restoril® .......................................................................................... 22 Retin-A® .......................................................................................... 13 Retin-A® Micro .............................................................................. 13 Retrovir® ......................................................................................... 20 Revatio® .......................................................................................... 12 Revia® .............................................................................................. 25 Revlimid® ................................................................................... 7, 33 Reyataz® ......................................................................................... 20 Rhinocort® Aqua........................................................................ 4, 37

January 2013 55

ribavirin ........................................................................ 20, 29, 34, 35 Ridaura® .......................................................................................... 27 Rifadin® ........................................................................................... 21 rifampin .......................................................................................... 21 Rifater® ............................................................................................ 21 Rilutek® ........................................................................................... 28 Riomet® ........................................................................................... 15 Risperdal® ....................................................................................... 23 Risperdal® M .................................................................................. 23 Risperdal® solution ........................................................................ 23 risperidone ...................................................................................... 23 risperidone odt ............................................................................... 23 Ritalin LA® ...................................................................................... 24 Ritalin® ............................................................................................ 24 rivastigmine .................................................................................... 25 Robaxin® ......................................................................................... 28 Robinul® .......................................................................................... 29 Rocaltrol® ........................................................................................ 30 ropinirole hcl tabs 24 hour ............................................................ 25 ropinirole hydrochloride .............................................................. 25 rosadan ............................................................................................ 13 Rosula® Emulsion Cleanser .......................................................... 13 Rowasa® Enema ............................................................................. 29 Roxicodone® ................................................................................... 26 Rozerem® ........................................................................................ 22 Rybix® ODT .................................................................................... 26 Rynatan® susp .................................................................................. 4 Ryneze® liquid ................................................................................. 4 Rythmol® SR ................................................................................... 12 Ryzolt® ............................................................................................ 26

S Sabril® ........................................................................................ 24, 34 Saizen® ...................................................................................... 18, 34 Salagen® .......................................................................................... 16 salsalate ........................................................................................... 27 Salvax® Duo Kit ............................................................................. 14 Samsca® ........................................................................................... 19 Sanctura XR® .............................................................................. 6, 38 Sanctura® .................................................................................... 6, 38 Sancuso® Patch ............................................................................... 29 Sandimmune® .................................................................................. 8 Sandostatin® ..................................................................................... 8 Saphris® ........................................................................................... 23 Sarafem® ......................................................................................... 23 Savella® ........................................................................................... 23 Seasonale® ....................................................................................... 31 Seasonique® .................................................................................... 31 Sectral® .............................................................................................. 9 selegiline ......................................................................................... 25 selenium sulfide ............................................................................. 14 Selzentry® ....................................................................................... 20 Semprex-D® ...................................................................................... 5 Sensipar® ......................................................................................... 19 Serevent® Diskus ....................................................................... 5, 38 Seromycin® ..................................................................................... 21 Seroquel® ........................................................................................ 23 Seroquel® XR .................................................................................. 23 Serostim® ........................................................................................ 18 sertraline ......................................................................................... 23 sildenafil .......................................................................................... 12 Silenor® ........................................................................................... 23

silver sulfadiazine ......................................................................... 14 Simcor® ........................................................................................... 12 Simponi® ................................................................................... 27, 34 simvastatin ..................................................................................... 11 Sinemet CR® ................................................................................... 25 Sinemet® ......................................................................................... 25 Singulair®.................................................................................... 6, 39 Singulair® chews .............................................................................. 6 Skelaxin® ......................................................................................... 28 Sklice® ............................................................................................ 38 sodium chloride for inhalation ...................................................... 6 sodium fluoride ....................................................................... 30, 32 sodium polystyrene sulfonate ..................................................... 30 Sof-Tact® ................................................................................... 15, 16 Solaraze® ......................................................................................... 14 Solia® ............................................................................................... 31 Solodyn® ......................................................................................... 13 Somavert® ................................................................................. 18, 34 Sonata® ............................................................................................ 22 Soriatane® ....................................................................................... 14 SoriluxTM ......................................................................................... 14 sotalol .............................................................................................. 12 spinosad suspension 0.9% ............................................................ 14 Spiriva® ............................................................................................. 6 spironolactone ................................................................................ 10 Sporanox® ....................................................................................... 20 Sprintec® ......................................................................................... 31 SprixTM ............................................................................................ 27 Sprycel® ................................................................................ 8, 33, 39 Sronyx® ........................................................................................... 31 SSKI ................................................................................................... 5 Stadol NS® ...................................................................................... 27 Stalevo® ........................................................................................... 25 Starlix® ............................................................................................ 15 stavudine ........................................................................................ 20 Staxyn® ............................................................................................ 21 Stendra® .......................................................................................... 21 Stimate® .......................................................................................... 19 Stivarga® ..................................................................................... 8, 33 Strattera®......................................................................................... 24 Striant® ............................................................................................ 22 StribildTM ........................................................................................ 20 Stromectol® ..................................................................................... 21 Suboxone® ...................................................................................... 25 Suboxone® SL Filmtab .................................................................. 25 Subsys® ........................................................................................... 26 Subutex® ......................................................................................... 25 Sucraid® .................................................................................... 29, 35 sucralfate ........................................................................................ 28 Sular® .............................................................................................. 10 sulfacetamide sodium 10% ........................................................... 17 sulfacetamide sodium lotion .................................................. 13, 14 sulfacetamide sodium w/sulfur emulsion/cleanser ................ 13 sulfamethoxazole/ ........................................................................ 19 sulfamethoxazole/trimethoprim ................................................. 19 sulfasalazine ................................................................................... 29 sulfasalazine DR ............................................................................ 29 sulfinpyrazone ........................................................................... 7, 27 sulfisoxazole tabs ........................................................................... 19 sulindac ........................................................................................... 27 SumadanTM ..................................................................................... 13 sumatriptan inj ............................................................................... 27 sumatriptan nasal spray ............................................................... 27

January 2013 56

sumatriptan tabs ............................................................................ 27 Sumavel® ......................................................................................... 27 Sumaxin® ........................................................................................ 13 Sumycin® ........................................................................................ 32 Suprax® tabs, susp ......................................................................... 19 SureStep® ........................................................................................ 16 Surmontil® ...................................................................................... 23 Sustiva® ........................................................................................... 20 Sutent®......................................................................................... 8, 33 SylatronTM ................................................................................... 8, 33 Symbicort® ........................................................................................ 5 Symbyax® ........................................................................................ 23 Symlin® ........................................................................................... 15 Synarel® ........................................................................................... 32 Synthroid® ...................................................................................... 18 Syprine® .......................................................................................... 19

T Tabloid® ............................................................................................ 8 Taclonex® ........................................................................................ 14 tacrolimus ......................................................................................... 8 Tambocor® ...................................................................................... 12 Tamiflu® .......................................................................................... 20 tamoxifen .......................................................................................... 8 tamsulosin hcl sr ............................................................................ 21 Tapazole® ........................................................................................ 18 Tarceva® ...................................................................................... 8, 33 Targretin® Gel ................................................................................ 14 Tarka® .............................................................................................. 11 Tasigna® ................................................................................ 8, 33, 39 Tasmar® ..................................................................................... 25, 38 Tavist® ............................................................................................... 4 Tazorac® .......................................................................................... 14 Tegretol® ......................................................................................... 24 Tegretol® XR ................................................................................... 24 Tekamlo® ........................................................................................ 11 Tekral® ............................................................................................... 5 Tekturna® ........................................................................................ 11 Tekturna® HCT .............................................................................. 11 temazepam ..................................................................................... 22 Temodar® .................................................................................... 8, 33 Temovate® ...................................................................................... 13 Tenex® ............................................................................................. 10 Tenoretic® ....................................................................................... 11 Tenormin® ........................................................................................ 9 Terazol® ........................................................................................... 32 terazosin .......................................................................................... 21 terazosin (capsules only)............................................................... 10 terbinafine hcl ................................................................................. 20 Terbinex® ........................................................................................ 20 terbutaline ....................................................................................... 32 terbutaline tabs ................................................................................. 5 Teslac® ............................................................................................... 8 Tessalon® .......................................................................................... 5 Testim® ............................................................................................ 22 testosterone cypionate ................................................................... 22 Testred® ........................................................................................... 22 tetracycline caps, susp ................................................................... 19 tetracycline capsules ...................................................................... 32 Teveten® ............................................................................................ 9 Thalomid® ................................................................................... 8, 33 theophylline ER ................................................................................ 5

theophylline SR ................................................................................ 5 thioguanine ...................................................................................... 8 thioridazine .................................................................................... 23 thiothixene ...................................................................................... 23 Thorazine® ...................................................................................... 23 thyroid ............................................................................................ 18 tiagabine ......................................................................................... 24 Tiazac® ............................................................................................ 10 Ticlid® ............................................................................................... 7 ticlopidine ......................................................................................... 7 Tigan® ............................................................................................. 29 Tikosyn® ......................................................................................... 12 Tilia FE® .......................................................................................... 31 timolol ............................................................................................... 9 timolol maleate .............................................................................. 17 Timoptic XE® .................................................................................. 17 Timoptic® ........................................................................................ 17 Tindamax® ...................................................................................... 21 tinidazole tabs ................................................................................ 21 TirosintTM ........................................................................................ 18 tizanidine caps ............................................................................... 28 tizanidine tablets ........................................................................... 28 Tobradex® ....................................................................................... 17 Tobradex® ST ................................................................................. 17 tobramycin ..................................................................................... 17 Tofranil® ......................................................................................... 23 Tofranil® PM .................................................................................. 23 tolmetin sodium ............................................................................ 27 tolterodine tartrate .................................................................... 6, 38 Topamax® ....................................................................................... 24 Topamax® Sprinkles ...................................................................... 24 Topicort® ......................................................................................... 13 topiramate ...................................................................................... 24 topiramate sprinkle ....................................................................... 24 Toprol® XL ........................................................................................ 9 torsemide ........................................................................................ 10 Toviaz®........................................................................................ 6, 38 Tracer® BG ...................................................................................... 16 Tracleer® ................................................................................... 12, 34 Tradjenta® ....................................................................................... 15 tramadol ......................................................................................... 26 tramadol er ............................................................................... 26, 38 Trandate® .......................................................................................... 9 trandolapril ...................................................................................... 9 trandolapril/ .................................................................................. 11 Transderm-Scop® .......................................................................... 29 Tranxene® ....................................................................................... 22 tranylcypromine ............................................................................ 23 Travatan® ........................................................................................ 17 Travatan® Z .................................................................................... 17 trazodone ........................................................................................ 23 Trecator® ......................................................................................... 21 Trental® ............................................................................................. 7 Tretin® X ......................................................................................... 13 tretinoin ...................................................................................... 8, 33 Trexall® ........................................................................................... 27 Treximet® .................................................................................. 27, 39 triamcinolone in orabase ............................................................. 16 triamcinolone acetonide ........................................................... 4, 13 triamcinolone in orabase .............................................................. 32 Triaz® Cloths 3% ............................................................................ 13 triazolam ......................................................................................... 22 TribenzorTM .............................................................................. 11, 37

January 2013 57

Tricor® ............................................................................................... 2 trifluoperazine ................................................................................ 23 trifluridine ...................................................................................... 17 Triglide® ............................................................................................ 2 trihexyphenidyl .............................................................................. 25 Tri-Legest FE® ................................................................................ 31 Trileptal® ......................................................................................... 24 Trilipix® ............................................................................................ 2 trimethobenzamide ....................................................................... 29 trimethoprim tabs .......................................................................... 19 trimipramine .................................................................................. 23 Trinessa® ......................................................................................... 31 Tri-Norinyl® ................................................................................... 31 Trioxin® Otic susp .......................................................................... 16 Tri-Previfem® ................................................................................. 31 triprolidine/pseudoephedrine liquid 1.25mg/30mg per 5 ml .. 4 triprolidine/pseudoephedrine tabs 2.5mg/60mg ....................... 4 Tri-Sprintec® ................................................................................... 31 Tri-Vi-Sol® ................................................................................. 30, 32 tri-vitamin w/fluoride ............................................................ 30, 32 Trivora® ........................................................................................... 31 Trizivir® ........................................................................................... 20 tropicamide ..................................................................................... 18 trospium ............................................................................................ 6 Trusopt® .......................................................................................... 17 Truvada® ......................................................................................... 20 TudorzaTM Pressair .......................................................................... 6 Tussionex® ........................................................................................ 4 Twinject® ........................................................................................... 5 Twynsta® ................................................................................... 11, 37 Tykerb® ....................................................................................... 8, 33 Tylenol w/ Codeine® .................................................................... 32 Tylenol w/Codeine® ..................................................................... 26 Tylox® .............................................................................................. 26 Tyzeka® ........................................................................................... 20

U

Ulesfia®............................................................................................ 14 Uloric® ....................................................................................... 27, 40 Ultracet® .......................................................................................... 26 Ultram® ER ............................................................................... 26, 38 Ultravate® ....................................................................................... 13 Ultresa® ........................................................................................... 29 Uniphyl® ........................................................................................... 5 Uniretic® .......................................................................................... 11 unithroid ......................................................................................... 18 Univasc® ............................................................................................ 9 Uramaxin® ...................................................................................... 14 urea .................................................................................................. 14 Urecholine®....................................................................................... 6 Urispas® ............................................................................................ 6 Urocit-K® ........................................................................................... 6 Uroxatral® ......................................................................................... 21 Urso® ............................................................................................... 29 Urso® Forte ..................................................................................... 29 ursodiol ........................................................................................... 29

V

Vagifem® ......................................................................................... 30 valacyclovir .................................................................................... 20 Valcyte® ........................................................................................... 20

Valium® .......................................................................................... 22 valproic acid ................................................................................... 24 valsartan/hctz ................................................................................ 11 Valtrex® ........................................................................................... 20 Valturna® ........................................................................................ 11 Vancocin® capsules ....................................................................... 21 vancomycin caps ........................................................................... 21 VascepaTM ....................................................................................... 11 Vaseretic® ....................................................................................... 11 Vasotec® ............................................................................................ 9 Vectical® .......................................................................................... 14 Velivet® ........................................................................................... 31 VeltinTM ........................................................................................... 13 venlafaxine ..................................................................................... 23 venlafaxine er caps ........................................................................ 23 Ventolin HFA® ................................................................................. 5 Veramyst® .................................................................................. 4, 37 verapamil ........................................................................................ 10 verapamil ER caps ......................................................................... 10 Verdeso® ......................................................................................... 13 Veregen® ......................................................................................... 14 Verelan® PM ................................................................................... 10 Vesanoid® ................................................................................... 8, 33 Vesicare® ..................................................................................... 6, 38 Vexol® ............................................................................................. 17 Vfend® ............................................................................................. 20 Viagra® ............................................................................................ 21 Vibramycin® susp .......................................................................... 19 Vicodin® .................................................................................... 26, 32 Vicoprofen® .............................................................................. 26, 32 Victoza® .................................................................................... 15, 37 Victrelis® ................................................................................... 29, 35 Videx® ............................................................................................. 20 Videx® EC ....................................................................................... 20 Vigamox® ........................................................................................ 17 ViibrydTM ........................................................................................ 23 Vimovo® ......................................................................................... 27 Vimpat® .......................................................................................... 24 Viokace® ......................................................................................... 29 Viracept® ......................................................................................... 20 Viramune® ...................................................................................... 20 Viramune® XR ................................................................................ 20 Viread® ............................................................................................ 20 Viroptic® ......................................................................................... 17 Vistaril® ....................................................................................... 4, 22 vitamin B12 inj. .............................................................................. 30 Vivactil® .......................................................................................... 23 Vivelle-Dot® ................................................................................... 30 Voltaren® gel .................................................................................. 27 Voltaren® ophth soln ..................................................................... 18 Voltaren-XR® .................................................................................. 27 voriconazole ................................................................................... 20 Votrient® ..................................................................................... 8, 33 Vusion® ........................................................................................... 14 Vytone® ........................................................................................... 14 Vytorin® .......................................................................................... 12 Vyvanse® ........................................................................................ 24

W

warfarin sodium .............................................................................. 7 Welchol® ................................................................................... 11, 15 Wellbutrin SR® ............................................................................... 23

January 2013 58

Wellbutrin XL® ............................................................................... 23 Wellbutrin® ..................................................................................... 23 Westcort® ........................................................................................ 13

X

Xalatan® .......................................................................................... 17 Xalkori® ....................................................................................... 8, 33 Xanax® ............................................................................................. 22 Xanax® XR ....................................................................................... 22 Xarelto® ............................................................................................. 7 Xeljanz® ..................................................................................... 27, 34 Xeloda®.............................................................................................. 8 Xenazine® .................................................................................. 25, 34 XereseTM .......................................................................................... 14 Xifaxan® .......................................................................................... 21 Xodol® ............................................................................................. 26 Xopenex® .......................................................................................... 5 Xtandi® ........................................................................................ 8, 33 Xylocaine Viscous® .................................................................. 16, 33 Xyrem® ...................................................................................... 25, 34 Xyzal® ................................................................................................ 4

Y

Yasmin®........................................................................................... 31 Yaz® ................................................................................................. 31 Yodoxin® ......................................................................................... 21 yohimbine ....................................................................................... 21

Z Zaditor® ........................................................................................... 18 zafirlukast ......................................................................................... 6 zaleplon ........................................................................................... 22 Zanaflex® ........................................................................................ 28 Zantac® capsules ............................................................................ 28 Zantac® tabs/syrup ....................................................................... 28 Zarontin® ........................................................................................ 24 Zaroxolyn® ...................................................................................... 10 Zavesca® .................................................................................... 19, 34 Zebeta® .............................................................................................. 9 Zegerid® .......................................................................................... 28 Zelapar® .......................................................................................... 25 ZelborafTM ................................................................................... 8, 33 Zelrix® ............................................................................................. 27 Zemplar® ................................................................................... 30, 38 Zenchent® ....................................................................................... 31 Zenpep® .......................................................................................... 29 Zeosa® ............................................................................................. 31 Zerit® ............................................................................................... 20 Zestoretic® ...................................................................................... 11 Zestril® .............................................................................................. 9

Zetia® .............................................................................................. 11 Zetonna® ........................................................................................... 5 ZetonnaTM ................................................................................... 4, 37 Ziac® ................................................................................................ 11 Ziagen® soln .................................................................................... 20 Ziagen® tabs ................................................................................... 20 Ziana® ............................................................................................. 13 zidovudine ..................................................................................... 20 Zinotic® ........................................................................................... 16 Zinotic® ES...................................................................................... 16 Zioptan® .......................................................................................... 17 ziprasidone ..................................................................................... 23 Zipsor® ............................................................................................ 27 Zirgan® ............................................................................................ 17 Zithranol-RR® cream ..................................................................... 14 Zithromax® ..................................................................................... 19 ZMax® ............................................................................................. 19 Zocor® ............................................................................................. 11 Zodryl ............................................................................................... 4 Zodryl® AC susp ............................................................................. 4 Zodryl® DAC ................................................................................... 4 Zofran® ........................................................................................... 29 Zofran® ODT .................................................................................. 29 Zofran® susp .................................................................................. 29 Zolinza® ...................................................................................... 8, 33 Zoloft® ............................................................................................. 23 zolpidem er .................................................................................... 22 zolpidem tartrate ........................................................................... 22 Zomig® ............................................................................................ 27 Zomig® Nasal Spray ...................................................................... 27 Zomig® ZMT .................................................................................. 27 Zonegran® ...................................................................................... 24 zonisamide ..................................................................................... 24 Zortress® ........................................................................................... 8 Zotex-EX® ......................................................................................... 5 Zovia® ............................................................................................. 31 Zovirax® .......................................................................................... 20 Zovirax® ointment ......................................................................... 14 Zuplenz® ......................................................................................... 37 ZuplenzTM ....................................................................................... 29 Zyban® ............................................................................................ 28 Zyclara® .......................................................................................... 14 Zyflo® CR .......................................................................................... 6 Zylet® .............................................................................................. 17 Zyloprim® ....................................................................................... 27 Zymaxid®........................................................................................ 17 Zypram® 2.35-1% cream and kit .................................................. 14 Zyprexa® ......................................................................................... 23 Zyprexa®/Zydis® .......................................................................... 23 Zytiga® ........................................................................................ 8, 33 Zyvox® ............................................................................................ 19

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INDEPENDENT HEALTH THREE-TIER FORMULARY...INDEPENDENT HEALTH THREE-TIER FORMULARY Dear Prescriber:...

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