Preferred Drug List (PDL) - uhccommunityplan.com Drug List (PDL) Louisiana Effective Date: 5/15/18....

© 2018 United Healthcare Services, Inc. All rights reserved.

Preferred Drug List (PDL)LouisianaEffective Date: 7/1/18

UnitedHealthcare Community Plan does not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to:

Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130

[email protected]

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, Monday through Friday, 7:00 a.m. to 7:00 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

If you need help with your complaint, please call the toll-free member phone number listed on your member ID card.

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, Monday through Friday, 7:00 a.m. to 7:00 p.m.

CSLA15MC3944286_000

UnitedHealthcare Community Plan no da un tratamiento diferente a sus miembros en base a su sexo, edad, raza, color, discapacidad o nacionalidad.

Si usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color, discapacidad o nacionalidad, puede enviar una queja a:

Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130

[email protected]

Usted tiene que enviar la queja dentro de los 60 días de la fecha cuando se enteró de ella. Se le enviará la decisión en un plazo de 30 días. Si no está de acuerdo con la decisión, tiene 15 días para solicitar que la consideremos de nuevo.

Si usted necesita ayuda con su queja, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, de lunes a viernes, de 7:00 a.m. a 7:00 p.m.

Usted también puede presentar una queja con el Departamento de Salud y Servicios Humanos de los Estados Unidos.

Internet: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Formas para las quejas se encuentran disponibles en: http://www.hhs.gov/ocr/office/file/index.html

Teléfono: Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD)

Correo: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

Si necesita ayuda para presentar su queja, por favor llame al número gratuito para miembros anotado en su tarjeta de identificación como miembro.

Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros. Tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, de lunes a viernes, de 7:00 a.m. a 7:00 p.m.

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INTRODUCTION UnitedHealthcare Community Plan is pleased to provide this Preferred Drug List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered by UnitedHealthcare Community Plan. The drugs listed in this PDL are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the UnitedHealthcare Community Plan PDL have been reviewed and approved by the UnitedHealthcare Community Plan Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the Medical prior authorization process.

The drugs represented have been reviewed by the UnitedHealthcare Community Plan Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice as of the date of review.

This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare Community Plan PDL is reflective of current medical practice.

NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare Community Plan, solely for the convenience of medical providers. UnitedHealthcare Community Plan does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature.

This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs.

UnitedHealthcare Community Plan assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information.

National guidelines can be found on the Web sites listed in the Web site section or go to the National Guideline Clearinghouse site at http://www.guideline.gov.

The PDL and quarterly updates are also available on our web site at www.uhccommunityplan.com.

PREFACE The UnitedHealthcare Community Plan PDL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state.

Products are listed by generic name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing.

The UnitedHealthcare Community Plan PDL covers selected over-the-counter (OTC) products. Many are noted in the drug lists; a complete list is included on page 44. You are encouraged to prescribe OTC medications when clinically appropriate.

Preferred Drug List

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PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The UnitedHealthcare Community Plan P&T Committee includes physicians and pharmacists who are not employees or agents of UnitedHealthcare Community Plan or its affiliates. They must adhere to the Ethics Policy standards of the P&T Committee. UnitedHealthcare Community Plan medical directors and pharmacists also participate in the P&T Committee. UnitedHealthcare Community Plan’s P&T Committee meets quarterly to discuss a variety of issues. Those issues pertaining to pharmaceutical selection and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating physicians who have received UnitedHealthcare Community Plan’s PDL. PDL decisions are also communicated quarterly on the UnitedHealthcare Community Plan internet site.

OUTPATIENT PRESCRIPTION DRUG BENEFIT-COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Drug Benefits is based on the individual member’s benefit plan.

PRODUCT SELECTION CRITERIA The UnitedHealthcare Community Plan P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following:

• Safety• Efficacy• Comparison studies• Approved indications• Adverse effects• Contraindications/Warnings/Precautions• Pharmacokinetics• Patient administration/compliance considerations• Medical outcome and pharmacoeconomic

studiesWhen a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare Community Plan PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents.

All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the

PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered.

Products covered include all strengths associated with the dosage form of the cited brand name product.

carvedilol Coreg

All strengths of Coreg would be covered by this listing.

Extended-release and delayed-release products require their own entry.

diltiazem sustained release CARDIZEM SR

Dosage forms covered will be consistent with the category and use where listed.

Neomycin/polymyxin B/ Cortisporin Hydrocortisone

As listed in the OTIC section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the OPHTHALMIC and DERMATOLOGY sections of the PDL.

When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not

citalopram 40 mg tabs Celexa tabs

DRUG TIERS

The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.

Tier Name Drug Tier Tier 1 Generic Tier 2 Brand

GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires generic substitution on the majority of products when a generic equivalent is available.

Generic substitution is a pharmacy action whereby a generic equivalent is dispensed rather than the brand name product. The PDL indicates generic availability in the “Covered Drug” column.

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If a brand name drug is medically necessary, please submit a prior authorization request.

The UnitedHealthcare Community Plan MAC list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most generics but not branded versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA’s review and approval process. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand product. To gain FDA approval:

1. The generic drug must contain the same activeingredient(s), be the same strength and the same dosageform as the brand name product.

2. The FDA has given the generic an “A” rating comparedto the branded product indicating bioequivalence, andhas determined the generic is therapeutically equivalentto the reference brand. The ratings of generic drugs areavailable by referring to the FDA reference, ApprovedDrug Products with Therapeutic EquivalenceEvaluations (Orange Book).

When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand name product.

There are now many brand name products that are repackaged or distributed under a generic label. The generic label version should always be considered therapeutically equivalent and substitutable for the source branded product.

DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled

indications, and a determination of “fully effective” was made for most of these products and they remain in the marketplace. A few DESI products remain classified as “less than fully effective” while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare Community Plan’s PDL does not cover DESI “less than fully effective” drug products.

PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare Community Plan PDL.

• DESI drugs• Anti-obesity agents• Experimental / research drugs• Cosmetic drugs• Nutritional / diet supplements• Blood and blood plasma products• Agents used to promote fertility• Agents used for erectile dysfunction• Agents used for cosmetic hair growth• Drugs from manufacturers that do not participate

in the FFS Medicaid Drug Rebate Program• Diagnostic products• Medical supplies and DME except as listed:

insulin syringes, insulin needles, lancets, alcoholswabs, spacers, preferred diabetes test strips, peakflow meters (Astech, Assess, Peak Air brands,max two per year), vaporizer (limit of 1 per 3years), humidifier (limit of 1 per 3 years)

DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare Community Plan members mayreceive up to a one- month supply of a specificmedication per prescription order or prescriptionrefill. A medication may be reordered or refilledwhen ninety percent (90%) of the medication has been utilized for a controlled substance and eighty-fivepercent (85%) of the medication has been utilized for a non-controlled substance. If a claim is submitted before 90% of the medication has been used for a controlled substance or submitted before 85% of the medication has been used for a non-controlledsubstance, based on the original day supply submitted on the claim, the claim will reject with a “refill too soon” message.Please call the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions or for help with dosage change authorization. MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires mandatory generic substitution on the vast majority of products when a generic equivalent is available; however, brand name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare Community Plan PDL prior authorization (PA) list does not include branded items where a generic equivalent is covered.

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PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare Community Plan PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management.

Requests for these exceptions should be made in writing by the physician and faxed or mailed to:

UnitedHealthcare Community Plan Pharmacy Services Department Fax 866-940-7328 Phone 800-310-6826

A prior authorization request form is available in the UnitedHealthcare Community Plan provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical necessity of the non-PDL request. The UnitedHealthcare Community Plan Pharmacy Department will respond to all requests in accordance with state requirements.

Physicians are requested to adhere to this PDL when prescribing for patients covered by their pharmacy benefit plan offered by UnitedHealthcare Community Plan. If a pharmacist receives a prescription for a non-PDL drug, the pharmacist should contact the prescribing physician and request that the prescription be changed to a medication included in this PDL. If a PDL alternative is not appropriate the physician should then be instructed to contact the Plan for a prior authorization. Please contact the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions concerning the prior authorization process.

NON-PDL DRUGS 7-DAY AND 15-DAY OVERRIDES To ensure the use of PDL drugs, all non- PDL drugs should be discussed with the prescribing physician. If you cannot speak to the physician immediately, and there is an immediate need for the medication, the claim processing system will accept an override to permit a one-time dispensing of a 7-day supply of the newly prescribed non-PDL drug. The pharmacy should submit a claim for a 7 day supply, with a PA Type of 8 and Prior Authorization number of “00000000120”.

Please note that non-preferred drugs are available for a 7-day supply, however availability is subject to the benefit design. For assistance, pharmacies may call 800-310-6826.

Pharmacies may dispense a one-time, 15-day supply to members requiring an immediate supply of an ongoing medication. The pharmacist must contact the plan to obtain a manual 15-day override. Before the next dispensing, the pharmacy must contact the physician to discuss a PDL drug or if a prior authorization request is warranted. If the prescribing physician feels a drug is medically necessary, the physician may fax a request for prior authorization to UnitedHealthcare Community Plan at 866-940-7328, Attn: Pharmacy Department.

QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request.

Quantity limits based on Efficient Medication Dosing The Efficient Medication Dosing Program is designed to consolidate medication dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily. Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the physician.

Controlled Substances You may fill any FOUR medications from the following classes in a 30-day period:

• benzodiazepines• sedative hypnotic agents• barbiturates• select muscle relaxants

Additional fills will require prior authorization. Medications in these classes may also be subject to individual quantity limits.

Additions to the QL program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the medical exception (prior authorization) process. Please contact the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions.

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MEDICATIONS REQUIRING DIAGNOSIS UnitedHealthcare Community Plan requires that the diagnosis for prescriptions in certain classes match the FDA-approved use or a use supported by current published evidence. Drugs in scope will list “Diagnosis required” in the Requirements and Limits section on the PDL.

The diagnosis will be verified at the point-of-sale by the pharmacy claims processing system. If a matching diagnosis is not found in the medical claim file or on the pharmacy drug claim, the prescription will be rejected at the pharmacy. The pharmacist may then contact the prescriber to verify the diagnosis and submit it on the claim.

If the diagnosis provided still does not match the approved use, prior authorization may be requested through the standard process by faxing a request to 866-940-7328.

STEP THERAPY (ST) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line agent has been adequately tried and failed. These medications may also be requested through the Prior authorization process. While lower cost PDL alternatives may be appropriate in many instances, other non- PDL alternatives are available with prior authorization (PA).

STEP Drug First-Line Agent(s)

Amerge Trial at a minimum dose of 50mg of sumatriptan tablets.

Aricept 23mg 90 day trial of Aricept 10mg daily

Breo Ellipta 1) 30 day trial of one inhaledcorticosteroid (e.g. Arnuity Ellipta,Asmanex) OR 2) 30 day trial of a longactingbeta2- agonist (e.g. Arcapta,Striverdi) OR 30 day trial of an orallyinhaled anticholinergic agent (e.g. IncruseEllipta, Atrovent, Combivent, AnoroEllipta).

calcipotriene cream & oint 0.005%

calcitriol Trial of two topical corticosteroids 3mcg/gm

DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Nesina, metformin. Kazano, Oseni)

Elidel

Eucrisa

fenofibrate

Minimum age of 2. Trial of one topical corticosteroid.

Trial of a topical corticosteroid AND one of the following: Elidel or tacrolimus ointment.

Fill of a statin or 90 days of gemfibrozil within the previous 180 days.

GLP-1 Agonists At least a 90 day trial of 1500mg/day of (Adlyxin, metformin. Tanzeum, Trulicity)

GLP-1/Insulin Trial of one drug from the following Combinations classes: GLP-1 or Basal Insulin (Soliqua)

Optivar 14 day trial of ketotifen within previous 90 days required first.

Ranexa Trial of one drug from the following classes: beta blockers, calcium channel blockers, long acting nitrates

Renvela 8 week trial of calcium acetate.

SGLT-2 At least a 90 day trial of 1500mg/day of Inhibitors metformin (Jardiance, Invokana, Invokamet, Invokamet XR, Synjardy, Synjardy XR)

tacrolimus 0.03% Minimum age of 2. Trial of one topical corticosteroid.

tacrolimus 0.1% Minimum age of 16. Trial of one

tolterodine

topical corticosteroid.

30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age.

tretinoin cream Trial of Differin OTC Gel 0.1%. (tretinoin cream 0.025%, 0.05%, 0.1%, and Avita cream 0.025%)

trospium 30 day trial of oxybutynin immediatee release. Step The

ra

rapy only applies

t

to members less than

6

65 years of age.o

f

f

8 week trial of up to 600mg of allopurinol required first.

One fill of metronidazole tabs or cap

30 day trial of Albuterol .083% or .5% respules.

Uloric

Vancocin

XopenxRespules

Trial of two medium to high potency corticosteroid topical treatments

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PDL SUGGESTIONS Providers who wish to propose PDL suggestions should forward the information to the UnitedHealthcare Community Plan Director of Pharmacy Services by either mail or fax.

Attn: Director of Pharmacy Services UnitedHealthcare Community Plan 2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Fax: 866-940-7328

Providers should furnish adequate documentation, such as clinical studies from the medical literature, in order for the request to be considered for PDL addition. This literature should include information documenting clinical necessity as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare Community Plan will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting.

EDITOR Your comments and suggestions regarding the UnitedHealthcare Community Plan PDL are encouraged. Your input is vital to this PDL’s continued success. All responses will be reviewed and considered. Please send your comments to:

UnitedHealthcare Community Plan Director of Pharmacy Services 2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Phone: 800-310-6826 Email: [email protected] Internet: http://www.uhccommunityplan.com

LEGEND

# Only the dosage forms/strengths of the brand name products noted are on the PDL

OTC over-the-counter delayed-rel delayed-release (also known as enteric coated)

EC ext-rel

PA

QL

ST

enteric-coated extended-release (also known as sustained-

release) Prior Authorization required Quantity Limits apply Step Therapy, see pages V-VI for details

NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare Community Plan. All rights reserved.

The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare Community Plan. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare Community Plan and such third-party pharmaceutical companies.

If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification.

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Table of ContentsAntineoplastics & Immunosuppressants . . . 4Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4Hormonal Antineoplastic Agents. . . . . . . . . . . . . 5Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 6Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 6Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Blood Modifiers - Anticoagulants . . . . . . . . . 7Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Blood Cell Formation . . . . . . . . . . . . . . . . . . . . . . 7Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . 7Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Cardiovascular Agents . . . . . . . . . . . . . . . . . . 8Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Ace Inhibitor/Diuretic Combinations. . . . . . . . . . 8Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 8Alpha Blockers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Angiotensin II Receptor Blocker (Antagonists) . 8Angiotensin II Receptor Blocker Combinations. 8Antiarrhythmics and Cardiac Glycosides . . . . . . 9Beta Blockers and Beta Blocker/Diuretic

Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Calcium Channel Blockers. . . . . . . . . . . . . . . . . . 9Calcium Channel Blockers/ACE Inhibitor

Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Central Monoamine-Depleting Agent . . . . . . . . 10Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 11Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Potassium-Removing Agents . . . . . . . . . . . . . . . 11Pulmonary Arterial Hypertension . . . . . . . . . . . 12Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Central Nervous System. . . . . . . . . . . . . . . .12Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 12Amyotrophic Lateral Sclerosis (ALS) . . . . . . . . 12Analeptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 14Migraine Prophylactic Therapy . . . . . . . . . . . . . 15Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . 15Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . 15Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 15Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . .17Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 18Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . 18Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 19Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Scabies and Pediculosis. . . . . . . . . . . . . . . . . . . 19Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . .21Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 22

Endocrinology . . . . . . . . . . . . . . . . . . . . . . . .22Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 22Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 23Growth Stimulating Agents. . . . . . . . . . . . . . . . . 24Lipodystropy Agents . . . . . . . . . . . . . . . . . . . . . . 24Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 25Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Gastrointestinal. . . . . . . . . . . . . . . . . . . . . . .25Constipation/Laxatives . . . . . . . . . . . . . . . . . . . . 25Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Emesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Gastroesophageal Reflux Disease (Gerd)/

Peptic Ulcers. . . . . . . . . . . . . . . . . . . . . . . . . . . 26Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . . 27Inflammatory Bowel Disease . . . . . . . . . . . . . . . 27Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 27Probiotic Supplementation. . . . . . . . . . . . . . . . . 27Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Infectious Diseases . . . . . . . . . . . . . . . . . . .28Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antiprotozoals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

3

Musculoskeletal . . . . . . . . . . . . . . . . . . . . . .33Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 35

OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Hormone Therapy/Menopause. . . . . . . . . . . . . 37Ovulation Stimulants . . . . . . . . . . . . . . . . . . . . . . 38Vaginal Infections. . . . . . . . . . . . . . . . . . . . . . . . . 38Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . .38Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 39Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Immunologic Agents . . . . . . . . . . . . . . . . . . . . . . 40Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Miscellaneous Ophthalmics . . . . . . . . . . . . . . . . 41

Psychiatric. . . . . . . . . . . . . . . . . . . . . . . . . . .41Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . . 41Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Attention Deficit Hyperactivity Disorder

(ADHD) – Diagnosis required . . . . . . . . . . . . . 41Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . 42Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . . 43Psychoses - Diagnosis Required . . . . . . . . . . . . 43Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . 44

Respiratory Drugs. . . . . . . . . . . . . . . . . . . . .44Antifibrotic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Antitussives, Decongestants, Expectorants

and Combinations . . . . . . . . . . . . . . . . . . . . . . 44Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Urological . . . . . . . . . . . . . . . . . . . . . . . . . . .49Symptomatic Benign Prostatic Hypertrophy . . 49Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Vitamins and Minerals . . . . . . . . . . . . . . . . .50Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . .53Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 53Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 53Immune Thrombocytopenic Purpura . . . . . . . . 53Medical Devices. . . . . . . . . . . . . . . . . . . . . . . . . . 53Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . . 53Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

OTC MEDICATIONS . . . . . . . . . . . . . . . . . . .56Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 56Cough/Cold Allergy. . . . . . . . . . . . . . . . . . . . . . . 56Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Earwax Removal Products . . . . . . . . . . . . . . . . . 57Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 57First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 58Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Motion Sickness. . . . . . . . . . . . . . . . . . . . . . . . . . 58Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Smoking Cessation Products . . . . . . . . . . . . . . 59Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 59Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Index of covered drugs. . . . . . . . . . . . . . . . .61

4

OTC = Over the CounterPA = Prior Authorization required

QL = Quantity LimitST = Step Therapy

Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits

Antineoplastics & Immunosuppressants

Antineoplastic AgentsAlkylating Agentsaltretamine HEXALEN brand 2busulfan MYLERAN brand 2chlorambucil LEUKERAN brand 2cyclophosphamide CYTOXAN generic 1estramustine

phosphate sodium EMCYT brand 2

lomustine GLEOSTINE brand 2melphalan ALKERAN brand 2temozolomide TEMODAR generic 1 PAAntimetabolitescapecitabine XELODA generic 1mercaptopurine PURINETHOL generic 1thioguanine TABLOID brand 2 QLtrifluridine/tipiracil LONSURF brand 2 PAHistone Deacetylase Inhibitorspanobinostat FARYDAK brand 2 PAvorinostat ZOLINZA brand 2 PAKinase Inhibitorabemaciclib VERZENIO brand 2 PA, QLacalabrutinib CALQUENCE brand 2 PA, QLafatinib GILOTRIF brand 2 PAalectinib ALECENSA brand 2 PAaxitinib INLYTA brand 2 PAbosutinib BOSULIF brand 2 PAbrigatinib ALUNBRIG brand 2 PA

cabozantinibCABOMETYXCOMETRIQ

brand 2 PA

ceritinib ZYKADIA brand 2 PAcobimetinib COTELLIC brand 2 PAcrizotinib XALKORI brand 2 PAdabrafenib TAFINLAR brand 2 PAdasatinib SPRYCEL brand 2 PAerlotinib TARCEVA brand 2 PA

everolimusAFINITORAFINITOR DISPERZ

brand 2 PA

gefitinib IRESSA brand 2 PAibrutinib IMBRUVICA brand 2 PAidelalisib ZYDELIG brand 2 PA

5




imatinib mesylate GLEEVEC generic 1 PA, QLlapatinib ditosylate TYKERB brand 2 PAlenvatinib LENVIMA brand 2 PAmidostaurin RYDAPT brand 2 PAnilotinib TASIGNA brand 2 PApalbociclib IBRANCE brand 2 PApazopanib VOTRIENT brand 2 PAponatinib ICLUSIG brand 2 PAregorafenib STIVARGA brand 2 PAruxolitinib JAKAFI brand 2 PAsorafenib NEXAVAR brand 2 PAsunitinib SUTENT brand 2 PAtrametinib MEKINIST brand 2 PAvandetanib CAPRELSA brand 2 PAvemurafenib ZELBORAF brand 2 PAMiscellaneousleucovorin LEUCOVORIN generic 1 QL, tabsmesna MESNEX brand 2 tabletsvenetoclax VENCLEXTA brand 2 PAProteasome Inhibitorsixazomib NINLARO brand 2 PAHormonal Antineoplastic AgentsAndrogen Biosynthesis Inhibitorsabiraterone ZYTIGA brand 2 PAAntiandrogensbicalutamide CASODEX generic 1flutamide EULEXIN generic 1Antiestrogenstamoxifen NOLVADEX generic 1toremifene FARESTON brand 2Aromatase Inhibitorsanastrozole ARIMIDEX generic 1exemestane AROMASIN generic 1letrozole FEMARA generic 1Gonadotropin Releasing Hormone Analogleuprolide LUPRON generic 1 PA

leuprolideLUPRON DEPOTLUPRON DEPOT 6-MONTHLUPRON DEPOT-PED

brand 2 PA

6




Progestinmegestrol acetate MEGACE generic 1ImmunomodulatorsInterferonsinterferon alfa-2b INTRON A brand 2 PApeginterferon alfa-2b SYLATRON brand 2 PAMiscellaneouslenalidomide REVLIMID brand 2 PApomalidomide POMALYST brand 2 PAthalidomide THALOMID brand 2 PA, QLImmunosuppressantsAntimetabolitesazathioprine IMURAN generic 1mycophenolate mofetil CELLCEPT generic 1mycophenolate sodium MYFORTIC generic 1Calcineurin Inhibitorscyclosporine SANDIMMUNE generic 1

cyclosporine, modifiedNEORALGENGRAF

generic 1 caps, QL

tacrolimusHECORIA PROGRAF

generic 1

Rapamycin Derivativesirolimus RAPAMUNE generic 1 tabssirolimus RAPAMUNE brand 2 solnMiscellaneouseverolimus ZORTRESS brand 2Miscellaneousalitretinoin 1% gel PANRETIN brand 2 PAbexarotene caps and

topical gel TARGRETIN brand 2 PA

cysteamine bitartrate CYSTAGON brand 2etoposide VEPESID generic 1hydroxyurea DROXIA brand 2hydroxyurea HYDREA generic 1mitotane LYSODREN brand 2niraparib ZEJULA brand 2 PAoctreotide SANDOSTATIN generic 1olaparib LYNPARZA brand 2 PApasireotide SIGNIFOR brand 2 PAprocarbazine MATULANE brand 2rucaparib RUBRACA brand 2 PA

7




sonidegib ODOMZO brand 2 PAtopotecan HYCAMTIN brand 2 PAtretinoin VESANOID generic 1 capsvismodegib ERIVEDGE brand 2 PA

Blood Modifiers - Anticoagulants

Anticoagulantsapixaban ELIQUIS brand 2 QLbetrixaban BEVYXXA brand 2 QLedoxaban SAVAYSA brand QLenoxaparin LOVENOX generic 1 QL

heparin HEPARIN generic 1INJ 5000 UNIT/ML, PF INJ 5000 UNIT/0.5ML, INJ 10000 UNIT/ML

rivaroxaban XARELTO brand 2 QLwarfarin COUMADIN generic 1Blood Cell Formationdarbepoetin alfa ARANESP brand 2 PA

epoetin alfaEPOGENPROCRIT

brand 2 PA

filgrastim ZARXIO brand 2 PAoprelvekin NEUMEGA brand 2 PApegfilgrastim NEULASTA brand 2 PAplerixafor MOZOBIL brand 2 PAsargramostim LEUKINE brand 2 PAPlatelet Inhibitorsanagrelide AGRYLIN generic 1aspirin tabs, EC, Tabs,

chew tabsBAYERECOTRIN

generic 1 OTC

cilostazol PLETAL generic 1clopidogrel PLAVIX generic 1 QLdipyridamole PERSANTINE generic 1prasugrel EFFIENT generic 1 Diagnosis Requiredticagrelor BRILINTA brand 2 Diagnosis Required, QLMiscellaneousaminocaproic acid AMICAR brand 2

deferasiroxEXJADEJADENU

brand 2 PA

emicizumab-kxwh HEMLIBRA brand 2 PA, QLpentoxifylline

extended-release TRENTAL generic 1

8




Cardiovascular Agents

Ace Inhibitorsbenazepril LOTENSIN generic 1captopril CAPOTEN generic 1enalapril VASOTEC generic 1

enalapril oral soln EPANED brand 2Members ≥ 8 years of age will require prior

authorization.fosinopril MONOPRIL generic 1 QLlisinopril ZESTRIL generic 1 QLquinapril ACCUPRIL generic 1 QLramipril ALTACE generic 1trandolapril MAVIK generic 1Ace Inhibitor/Diuretic Combinationsbenazepril/

hydrochlorothiazide LOTENSIN HCT generic 1

captopril/ hydrochlorothiazide CAPOZIDE generic 1

enalapril/ hydrochlorothiazide VASERETIC generic 1

fosinopril/ hydrochlorothiazide MONOPRIL-HCT generic 1 QL

lisinopril/ hydrochlorothiazide ZESTORETIC generic 1 QL

quinapril/ hydrochlorothiazide ACCURETIC generic 1 QL

Adrenolytics, Centralclonidine CATAPRES generic 1 tabletsguanfacine TENEX generic 1Alpha Blockersdoxazosin CARDURA generic 1prazosin MINIPRESS generic 1terazosin HYTRIN generic 1Angiotensin II Receptor Blocker (Antagonists)irbesartan AVAPRO generic 1losartan COZAAR generic 1 QLAngiotensin II Receptor Blocker Combinationslosartan/HCTZ HYZAAR generic 1 QLsacubitril/valsartan ENTRESTO brand 2 PA, QL

9




Antiarrhythmics and Cardiac Glycosidesamiodarone tabs CORDARONE generic 1 200 mg and 400 mgdigoxin LANOXIN generic 1disopyramide NORPACE generic 1disopyramide

extended-release NORPACE CR brand 2

dofetilide TIKOSYN generic 1flecainide TAMBOCOR generic 1mexiletine MEXITIL generic 1propafenone RYTHMOL generic 1 IR onlyquinidine gluconate

extended-releaseQUINIDINE GLUCONATE

EXT-REL generic 1

quinidine sulfate QUINIDINE SULFATE generic 1quinidine sulfate

extended-releaseQUINIDINE SULFATE

EXT-REL generic 1

Beta Blockers and Beta Blocker/Diuretic Combinationsacebutolol SECTRAL generic 1 QLatenolol TENORMIN generic 1atenolol/chlorthalidone TENORETIC generic 1betaxolol KERLONE generic 1bisoprolol ZEBETA generic 1bisoprolol/

hydrochlorothiazide ZIAC generic 1

carvedilol COREG generic 1 QLlabetalol TRANDATE generic 1metoprolol LOPRESSOR generic 1 25, 50, 100mg tabletsmetoprolol/

hydrochlorothiazide LOPRESSOR HCT generic 1

metoprolol succinate TOPROL XL generic 1pindolol PINDOLOL generic 1propranolol INDERAL generic 1propranolol/HCTZ INDERIDE generic 1sotalol BETAPACE generic 1sotalol HCL (afib/afl) BETAPACE AF generic 1timolol maleate generic 1 tabletsCalcium Channel BlockersDihydropyridinesamlodipine NORVASC generic 1 QLfelodipine

extended-release PLENDIL generic 1 QL

10




nicardipine CARDENE generic 1nifedipine PROCARDIA generic 1nifedipine

extended-releaseADALAT CCPROCARDIA XL

generic 1 QL

nimodipine NIMOTOP generic 1 QLnimodipine oral soln NYMALIZE brand 2Nondihydropyridinesdiltiazem CARDIZEM generic 1diltiazem

extended-release CARDIZEM CD generic 1 QL

diltiazem extended-release

DILACOR XR TIAZAC

generic 1 QL

diltiazem sustained-release CARDIZEM SR generic 1 QL

verapamil CALAN generic 1verapamil

extended-release CALAN SR generic 1 QL

Calcium Channel Blockers/ACE Inhibitor Combinationamlodipine/benazepril LOTREL generic 1 2.5/10 mg, 5/10 mg,

5/20 mg, 10/20 mg, QLCentral Monoamine-Depleting Agentreserpine SERPASIL generic 1Diureticsamiloride MIDAMOR generic 1amiloride/

hydrochlorothiazide MODURETIC generic 1

bumetanide BUMEX genericchlorothiazide DIURIL generic 1

chlorothiazide DIURIL ORAL SUSPENSION brand 2 QL

chlorthalidone CHLORTHALIDONE generic 1furosemide LASIX generic 1hydrochlorothiazide HYDROCHLOROTHIAZIDE generic 1 soln, tabshydrochlorothiazide MICROZIDE generic 1 12.5 mg capsindapamide LOZOL generic 1metolazone ZAROXOLYN generic 1spironolactone ALDACTONE generic 1spironolactone/

hydrochlorothiazide ALDACTAZIDE generic 1

torsemide DEMADEX generic 1triamterene/

hydrochlorothiazideDYAZIDEMAXZIDE

generic 1

11




Lipid Lowering AgentsBile Acid Resin

cholestyramineQUESTRANQUESTRAN-LIGHT

generic 1

Only the bulk products are covered (cans).

Individual packets are not covered.

Fibratesfenofibrate LOFIBRA generic 1 STgemfibrozil LOPID generic 1HMG-CoA Reductase Inhibitors and Combinationsatorvastatin LIPITOR generic 1 QLlovastatin MEVACOR generic 1 QLpravastatin PRAVACHOL generic 1 QLsimvastatin ZOCOR generic 1 QLNiacinsniacin NIACOR generic 1niacin extended-release NIASPAN generic 1Miscellaneousalirocumab PRALUENT brand 2 PAezetimibe ZETIA generic 1 PAomega 3 acid ethyl esters LOVAZA generic 1 PANitratesOralisosorbide dinitrate ISORDIL generic 1isosorbide dinitrate

extended-releaseISOSORBIDE

DINITRATE ER generic 1

isosorbide mononitrate ISMO generic 1isosorbide mononitrate

extended-release IMDUR generic 1

Sublingualisosorbide dinitrate ISORDIL S.L. generic 1nitroglycerin NITROLINGUAL generic 1nitroglycerin NITROSTAT generic 1Transdermal

nitroglycerinNITREK NITRO-DUR

generic 1 transdermal, QL

nitroglycerin NITRO-BID generic 1 ointPotassium-Removing Agentspatiromer VELTASSA brand 2 PAsodium polystyrene

sulfonate KAYEXALATE generic 1 susp only

12




Pulmonary Arterial Hypertensionambrisentan LETAIRIS brand 2 Diagnosis Requiredbosentan TRACLEER brand 2 Diagnosis Requiredmacitentan OPSUMIT brand 2 Diagnosis Requiredriociguat ADEMPAS brand 2 Diagnosis Requiredsildenafil REVATIO generic 1 Diagnosis Required, tabs

sildenafil REVATIO SUSPENSION brand 2 Diagnosis Required, suspension

Miscellaneousguanabenz WYTENSIN generic 1hydralazine APRESOLINE generic 1methyldopa ALDOMET generic 1methyldopa/HCTZ ALDORIL generic 1midodrine PROAMATINE generic 1minoxidil LONITEN generic 1ranolazine RANEXA brand 2 ST

Central Nervous System

Alzheimer’s Disease

donepezil ARICEPT generic 1

5 mg and 10 mg, QL, Members <18 years of age will require prior

authorization.

donepezil ARICEPT generic 123 mg, ST, Members <18 years of age will require

prior authorization.

galantamine RAZADYNE generic 1QL, Members <18 years of age will require prior

authorization.

memantine NAMENDA generic 1QL, Members <18 years of age will require prior

authorization.

rivastigmine EXELON generic 1QL, Members <18 years of age will require prior

authorization.Amyotrophic Lateral Sclerosis (ALS)riluzole RILUTEK generic 1 PA, QLAnalepticsarmodafinil NUVIGIL generic 1 Diagnosis Required

13




AnalgesicsBarbiturate Non-Narcotic Analgesicsbutalbital/acetaminophen PHRENILIN generic 1 QLbutalbital/acetaminophen SEDAPAP generic 1 QL

butalbital/acetaminophen/caffeine

FIORICETESGICZEBUTAL

generic 1 QL

butalbital/aspirin/caffeine FIORINAL generic 1 QLNon-Narcotic Analgesicsacetaminophen TYLENOL generic 1 OTCaspirin/acetaminophen/

caffeine EXCEDRIN MIGRAINE generic 1 250-250-65 mg, OTC

aspirin suppository ASPIRIN SUPPOSITORY generic 1 OTC, 300 mg and 600 mg only

NSAIDSdiclofenac potassium CATAFLAM generic 1 QLdiclofenac sodium

delayed-release VOLTAREN generic 1 QL

diclofenac sodium extended-release VOLTAREN XR generic 1 QL

etodolac LODINE generic 1 IR Only

ibuprofen ADVIL generic 1 tabs, caps, chew tabs, and susp, OTC

ibuprofen MOTRIN generic 1 tabs, chew tabs and susp

indomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlyketorolac tromethamine TORADOL generic 1 QLmeloxicam MOBIC generic 1 QLnabumetone RELAFEN generic 1

naproxen NAPROSYN generic 1 250mg and 500mg tablets

naproxen delayed release ENTERIC COATED- NAPROSYN generic 1

oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1sulindac CLINORIL generic 1Opioids - Narcotic Analgesicsbutalbital/apap/caff/cod FIORICET W/CODEINE generic 1 QLbutalbital/asa/caff/cod FIORINAL W/CODEINE generic 1 QL

14




butorphanol STADOL generic 1 nasal spray, QLcodeine/acetaminophen TYLENOL W/CODEINE generic 1 QLcodeine sulfate generic 1 QLfentanyl transdermal DURAGESIC generic 1 QL

hydrocodone/ acetaminophen

LORCETLORTABLORTAB ELIXIRNORCOVICODINVICODIN ES

generic 1 QL

hydrocodone ER ZOHYDRO ER brand 2hydromorphone DILAUDID generic 1 QLmeperidine DEMEROL generic 1 QLmorphine MSIR generic 1 QLmorphine RMS generic 1 QLmorphine

extended-release MS CONTIN generic 1 QL

oxycodone OXYFAST generic 1 soln, QLoxycodone ROXICODONE generic 1 tabs, QLoxycodone/

acetaminophen PERCOCET generic 1 5/325 mg, 7.5/325 mg, 10/325 mg, QL

oxycodone/aspirin PERCODAN generic 1 QL

oxymorphone ER OXYMORPHONE ER generic 1 PA, QL, non-crush resistant

pentazocine/naloxone TALWIN NX generic 1 QLtramadol ULTRAM generic 1 QLMigraine Acute TherapyErgotamine Derivativesdihydroergotamine D.H.E. 45 generic 1 inj, QLergotamine/caffeine CAFERGOT generic 1ergotamine tartrate/

caffeineMIGERGOT

SUPPOSITORIES brand 2 QL

Selective Serotonin Agonistsnaratriptan AMERGE generic 1rizatriptan MAXALT/MAXALT MLT generic 1 QLsumatriptan IMITREX generic 1 QL

sumatriptan IMITREX 4 MG AND 6 MG INJ generic 1 4 mg and 6 mg inj

15




Migraine Prophylactic Therapyamitriptyline ELAVIL generic 1

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1

Members ≥ 8 years of age will require prior

authorization. divalproex sodium

delayed-release DEPAKOTE generic 1 Minimum age 2

divalproex sodium tab sr 24 hr DEPAKOTE ER generic 1 Minimum age 2

propranolol INDERAL generic 1 IR onlyverapamil CALAN generic 1Multiple Sclerosisdaclizumab ZINBRYTA brand 2 Diagnosis Required,

QL, STdimethyl fumarate TECFIDERA brand 2 Diagnosis Required, QLfingolimod GILENYA brand 2 Diagnosis Required, QLglatiramer acetate COPAXONE generic 1 Diagnosis Required, QLglatiramer acetate GLATOPA generic 1 Diagnosis Required, QLpeginterferon beta-1a PLEGRIDY brand 2 Diagnosis Required, QLteriflunomide AUBAGIO brand 2 Diagnosis Required, QLMyasthenia Gravispyridostigmine MESTINON generic 1 tabspyridostigmine MESTINON brand 2 syruppyridostigmine

extended-release MESTINON TIMESPAN generic 1

Parkinson’s Diseaseamantadine SYMMETREL generic 1 except tabsbenztropine COGENTIN generic 1carbidopa/levodopa SINEMET generic 1carbidopa/levodopa

extended-release SINEMET CR generic 1

entacapone COMTAN generic 1pramipexole MIRAPEX generic 1ropinirole REQUIP generic 1selegiline ELDEPRYL generic 1tolcapone TASMAR generic 1trihexyphenidyl ARTANE generic 1

16




Seizurescarbamazepine TEGRETOL generic 1carbamazepine

extended-releaseCARBATROL TEGRETOL-XR

generic 1

clobazam ONFI brand 2 Diagnosis Required, QLclonazepam KLONOPIN generic 1 tabsdiazepam DIASTAT ACUDIAL brand 2 rectal gel, QL

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1


authorization. divalproex sodium


divalproex sodium tab SR 24 HR DEPAKOTE ER generic 1

ethosuximide ZARONTIN generic 1exogabine POTIGA brand 2 Age Limits Applyfelbamate FELBATOL generic 1 QL

felbamate oral susp FELBATOL ORAL SUSP generic 1

QL, suspension, Members ≥ 8 years of age will require prior

authorization. gabapentin NEURONTIN generic 1lacosamide VIMPAT brand 2 Age Limits Apply, PAlamotrigine LAMICTAL generic 1 QL

lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB generic 1


authorization.lamotrigine starter kit LAMICTAL STARTER KIT brand 2

levetiracetam KEPPRA QL, Maximum age of 9 for solution

methsuximide CELONTIN brand 2

oxcarbazepine TRILEPTAL generic 1 QL, Maximum age of 9 for suspension

pentobarbital sodium inj NEMBUTAL SOD INJ brand 2 PAphenobarbital PHENOBARBITAL generic 1phenobarbital sodium inj LUMINAL INJ generic 1 PAphenytoin DILANTIN INFATABS generic 1phenytoin sodium

extendedDILANTINPHENYTEK

generic 1

phenytoin sodium inj DILANTIN INJ generic 1 PApregabalin LYRICA brand 2 PA

17




pregabalin LYRICA SOLUTION brand 2 oral solution, PAprimidone MYSOLINE generic 1rufinamide BANZEL brand 2 Diagnosis Required

tiagabine GABITRIL generic 1 Age Limits Apply, PA, 2mg & 4mg

tiagabine GABITRIL brand 2 Age Limits Apply, PA, 12mg & 16mg

topiramate TOPAMAX generic 1 QL

topiramate sprinkle caps TOPAMAX SPRINKLE generic 1QL, Members ≥ 8 years of age will require prior

authorization.valproic acid DEPAKENE generic 1vigabatrin oral solution SABRIL SOLUTION brand 2 PAzonisamide ZONEGRAN generic 1 QLMiscellaneoustetrabenazine XENAZINE generic 1 Diagnosis Requiredvalbenazine INGREZZA brand 2 PA, QL

Dermatology

Acne VulgarisOral

isotretinoin

ABSORICA AMNESTEEMCLARAVISMYORISANZENATANE

generic 1 PA

Topicaladapalene gel DIFFERIN OTC GEL 0.1% generic 1azelaic acid FINACEA brand 2benzoyl peroxide BENZAC AC generic 1clindamycin CLEOCIN T generic 1 gelclindamycin CLEOCIN T generic 1 lotionclindamycin CLEOCIN T generic 1 solnerythromycin ERYGEL generic 1 gel 2% erythromycin T-STAT generic 1 soln

salicylic acid NEUTROGENA OIL FREE ACNE WASH generic 1 liquid 2%, OTC

sulfacetamide/sulfur SULFACET-R generic 1 lotionsulfacetamide/sulfur PLEXION generic 1

tretinoin AVITA RETIN-A

generic 1 cream, ST

18




Bacterial Infectionsbacitracin BACITRACIN generic 1 OTCgentamicin GENTAK generic 1

mupirocin BACTROBAN generic 1 ointment, 22 gram tube only

neomycin/polymyxin B/bacitracin NEOSPORIN generic 1 OTC

silver sulfadiazine SILVADENE generic 1CorticosteroidsLow Potencyalclometasone ACLOVATE generic 1 0.05% crm/oint

fluocinolone acetonide DERMA-SMOOTHE OIL/FS generic 1 oil 0.01%

fluocinolone acetonide SYNALAR generic 1 soln/crm 0.01% hydrocortisone CORTIZONE generic 1 crm, oint, lot OTChydrocortisone HYTONE generic 1 lotion 1% & 2.5%hydrocortisone HYTONE generic 1 crm 0.5%, 1%, & 2.5%

hydrocortisone/aloe CORTIZONE-10 INTENSIVE HEALING generic 1 crm 0.5% & 1%, OTC

Medium Potencybetamethasone val BETA-VAL generic 1 crm/oint/lotion 0.1%

fluocinolone acetonide DERMA-SMOOTHE OIL/FS generic 1 oil 0.01%

fluocinolone acetonide SYNALAR generic 1 crm, oint 0.025%fluticasone propionate CUTIVATE generic 1 crm 0.05%, oint 0.005%hydrocortisone butyrate LOCOID generic 1 crm/oint/soln 0.1%hydrocortisone valerate WESTCORT generic 1 crm 0.2%mometasone furoate ELOCON generic 1 crm/oint/soln 0.1%prednicarbate DERMATOP generic 1 crm 0.1%triamcinolone acetonide KENALOG generic 1 crm/lot/oint 0.025%triamcinolone acetonide KENALOG generic 1 crm/oint/lotion 0.1%High Potencybetamethasone

dipropionate generic 1 crm/lotion/oint 0.05%

betamethasone augmented dip DIPROLENE generic 1 lotion 0.05%

betamethasone augmented dip DIPROLENE AF generic 1 crm 0.05%

fluocinonide LIDEX generic 1 crm/oint/gel/soln 0.05%fluocinonide emulsified

base LIDEX E generic 1 crm 0.05%

triamcinolone acetonide KENALOG generic 1 crm 0.5%

19




Very High Potencybetamethasone dip

augmented DIPROLENE generic 1 gel 0.05%

betamethasone dip augmented DIPROLENE generic 1 oint 0.05%

clobetasol propionate TEMOVATE generic 1 soln 0.05%halobetasol ULTRAVATE generic 1 creamFungal Infectionsciclopirox PENLAC SOLUTION 8% generic 1clotrimazole LOTRIMIN AF generic 1 OTCclotrimazole MYCELEX generic 1clotrimazole with

betamethasone LOTRISONE generic 1

ketoconazole NIZORAL generic 1miconazole DESENEX generic 1 2% OTCmiconazole MICATIN generic 1 OTCmiconazole MONISTAT-DERM generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL AT generic 1 OTCtolnaftate TINACTIN generic 1 OTCPsoriasisacitretin SORIATANE generic 1 oral caps, PAcalcipotriene DOVONEX generic 1 crm/oint, STcalcipotriene DOVONEX generic 1 solncalcitriol VECTICAL generic 1 STmethoxsalen OXSORALEN-ULTRA generic 1salicylic acid SCALPICIN generic 1 liquid 3%Rosaceabrimonidine MIRVASO brand 2 PA

metronidazoleMETROCREAMMETROGELMETROLOTION

generic 1

Scabies and Pediculosiscrotamiton EURAX brand 2malathion OVIDE generic 1permethrin ELIMITE generic 1 5%, QLpermethrin NIX CREME RINSE generic 1 1%, OTCpyrethrins/piperonyl

butoxide shampoo RID SHAMPOO generic 1 4% OTC

20




Viral Infectionspodofilox CONDYLOX SOL generic 1 solsalicylic acid 17%/

collodion DUOFILM generic 1 OTC

Miscellaneousaluminum acetate brand 2 soln/cream, OTCaluminum chloride

topical solution HYPERCARE 15% brand 2

ammonium lactate LAC-HYDRIN generic 1 crm 12%, lotion 5% & 12%

ammonium lactate LACTINOL generic 1 lotion 10%becaplermin gel REGRANEX brand 2 PAcalamine brand 2 lotion/ointment, OTCcollagenase oint SANTYL brand 2 QLcrisaborole EUCRISA brand 2 2% ointment, QL, STfluorouracil EFUDEX generic 1imiquimod ALDARA generic 1hydrocortisone PROCTOCREAM-HC 2.5% generic 1 creamketoconazole NIZORAL SHAMPOO generic 1 shampoo 2%lidocaine LIDAMANTEL generic 1 3% cream

lidocaine LMX-4 generic 1 4% cream (15 gm tubes), QL

lidocaine XYLOCAINE generic 1 jelly 2%lidocaine patch LIDODERM generic 1 Diagnosis Requiredlidocaine/prilocaine EMLA generic 1 2.5% cream

nitroglycerin RECTIV brand 2 Diagnosis Required, 0.4% rectal ointment

pimecrolimus ELIDEL brand 2

cream QL, ST, not covered for members less

than 2 years of age

selenium sulfide SELSUN generic 1 lotion 2.5%

tacrolimus PROTOPIC 0.03% generic 1ointment 0.03%, QL, ST; not covered for members less than 2 years of age

tacrolimus PROTOPIC 0.1% generic 1 ointment 0.1%, ST (minimum age 16)

urea 10%, urea 20%UREA 10% CREAMUREA 20% CREAMUREA 10% LOTION

brand 2

urea 40% UREA 40% LOTION generic 1 lotion

21




Ear, Nose & Throat

Earacetic acid VOSOL OTIC generic 1 oticacetic acid/

aluminum acetate DOMEBORO OTIC generic 1

acetic acid/ hydrocortisone VOSOL HC OTIC generic 1

benzocaine/antipyrine BENZOTIC generic 1carbamide peroxide DEBROX generic 1 6.5%, OTCciprofloxacin/

dexamethasone CIPRODEX brand 2 Diagnosis Required

neomycin/polymyxin B/hydrocortisone CORTISPORIN OTIC generic 1 otic

ofloxacin FLOXIN OTIC generic 1NoseAntihistamines - First Generation, Sedatingchlorpheniramine

extended-releaseCHLOR-TRIMETON

ALLERGY generic 1 12 mg, OTC

chlorpheniramine maleate CHLOR-TRIMETON SYRUP generic 1 2 mg/5 ml, OTC

clemastine CLEMASTINE generic 1cyproheptadine CYPROHEPTADINE generic 1diphenhydramine generic 1diphenhydramine BENADRYL generic 1 OTChydroxyzine HCL ATARAX generic 1hydroxyzine pamoate VISTARIL generic 1Antihistamines - Second Generation, Nonsedatingcetirizine ZYRTEC generic 1 OTC

cetirizine chew tab ZYRTEC CHEWABLE TABLET generic 1

OTC, Members ≥ 8 years of age will require prior

authorization.levocetirizine XYZAL generic 1 tabs

loratadineALAVERTCLARITIN

generic 1 OTC

Antihistamines - Others Antihistamine/Decongestant Combinationsazelastine ASTELIN generic 1 sprayAntihistamine/Decongestant Combinations - First Generationchlorpheniramine/

phenylephrine/ pyrilamine

TRIOTANN generic 1

22




chlorpheniramine/ pseudoephedrine ACTIFED generic 1 OTC

Antihistamine/Decongestant Combinations - Second Generationcetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release

ZYRTEC-D generic 1 5 mg-120 mg tablet

loratadine/ pseudoephedrine ext-rel

ALAVERT-DALAVERT ALRG

TAB/SINUSALLERY/CONG

generic 1 OTC

Nasal Steroidsfluticasone FLONASE generic 1

triamcinolone nasal spray NASACORT ALLERGY 24 HOUR brand 2 OTC

Miscellaneous Nasalcromolyn sodium NASALCROM generic 1 OTCipratropium nasal ATROVENT NASAL SPRAY generic 1 QLsaline nasal spray 0.65% OCEAN NASAL SPRAY generic 1 OTCMiscellaneous Nasal Decongestantsoxymetazoline AFRIN generic 1 OTC

phenylephrineNEO-SYNEPHRINE DIMEATAPP DRO

DECONGESgeneric 1 OTC

Throat and Mouthchlorhexidine gluconate PERIDEX generic 1lidocaine viscous XYLOCAINE generic 1

phenol liquidCHERACOL SORE THROATPAIN-A-LAY

generic 1

pilocarpine SALAGEN generic 1triamcinolone KENALOG IN ORABASE generic 1 paste

Endocrinology

Adrenal Corticosteroidscortisone acetate generic 1dexamethasone DECADRON generic 1fludrocortisone FLORINEF generic 1hydrocortisone CORTEF generic 1methylprednisolone MEDROL generic 1 4mg, 8mg, 16mg, 32mgmethylprednisolone MEDROL brand 2 2mgprednisolone

23




prednisolone PRELONE generic 1 syrupprednisolone sodium

phosphateORAPREDPEDIAPRED

generic 1

prednisone DELTASONE generic 1Androgenstestosterone TESTOSTERONE 1% GEL generic 1 PAtestosterone cypionate DEPO-TESTOSTERONE generic 1

testosterone enanthate DELATESTRYL generic 1 Vials only. Disposable syringes not covered.

Diabetes MellitusGlucose Elevating Agentsglucagon, human

recombinant GLUCAGON brand 2 QL

Insulin Combinationsinsulin glargine/lixisenatide SOLIQUA brand 2 STInsulinsinsulin aspart

protamine 70%/ insulin aspart 30%

NOVOLOG MIX 70/30 brand 2 QL, vials

insulin glargineBASAGLARTOUJEO

brand 2

insulin humanNOVOLIN RRELION R

brand 2 OTC, QL, vials

insulin isophane HUMULIN N brand 2 OTC, QL, vials

insulin isophane humanNOVOLIN NRELION N

brand 2 OTC, QL, vials

insulin isophane human 70%/regular 30% NOVOLIN 70/30 brand 2 OTC, QL, vials

insulin isophane human 70%/regular 30% RELION 70/30 brand 2 OTC, QL, vials

insulin isophane/regular HUMULIN 70/30 brand 2 OTC, QL, vialsinsulin lisopro pro/lispro HUMALOG MIX 50/50 brand 2 QL, vialsinsulin lisopro prot/lispro HUMALOG MIX 75/25 brand 2 QL, vialsinsulin lispro ADMELOG SOLOSTAR brand 2 PA, QLinsulin lispro ADMELOG VIALS brand 2 QLinsulin regular HUMULIN R brand 2 OTC, QL, vialsMonitoring - Strips and Kits/Diabetic Supplies

ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC) brand 2

QL for insulin dependent or pregnant members:

allow testing up to 6 times per day

24




ONE TOUCH TEST STRIPS (ULTRA, VERIO) brand 2QL for non-insulin

dependent members: allow twice daily testing

Oral Agentsacarbose PRECOSE generic 1alogliptin NESINA generic 1 STalogliptin/metformin KAZANO generic 1 STalogliptin/pioglitazone OSENI generic 1 STchlorpropamide DIABINESE generic 1ertugliflozin STEGLATRO brand 2 QL, STertugliflozin/metformin SEGLUROMET brand 2 QL, STglimepiride AMARYL generic 1glipizide GLUCOTROL generic 1glipizide extended-release GLUCOTROL XL generic 1glipizide/metformin METAGLIP generic 1glyburide MICRONASE generic 1glyburide, micronized GLYNASE generic 1metformin GLUCOPHAGE generic 1metformin ER GLUCOPHAGE ER generic 1metformin/glyburide GLUCOVANCE generic 1nateglinide STARLIX generic 1pioglitazone ACTOS generic 1 QLrepaglinide PRANDIN generic 1tolazamide TOLINASE generic 1tolbutamide TOLBUTAMIDE generic 1Miscellaneous Antidiabetic Agentsalbiglutide TANZEUM brand 2dulaglutide TRULICITY brand 2liraglutide VICTOZA brand 2lixisenatide ADLYXIN brand 2 STpramlintide SYMLIN brand 2 PAGrowth Stimulating Agentsmecasermin INCRELEX brand 2 PAsomatropin ZOMACTON brand 2 PA, QLLipodystropy Agentstesamorelin EGRIFTA brand 2 Diagnosis RequiredOsteoporosisalendronate FOSAMAX generic 1 QLcalcitonin-salmon MIACALCIN generic 1 nasal spray, QLcalcitonin-salmon FORTICAL brand 2 nasal spray, QLetidronate DIDRONEL generic 1raloxifene EVISTA generic 1

25




Thyroid Diseaselevothyroxine LEVOXYL generic 1levothyroxine SYNTHROID generic 1liothyronine CYTOMEL generic 1liotrix THYROLAR brand 2methimazole TAPAZOLE generic 1propylthiouracil PROPYLTHIOURACIL generic 1Miscellaneousasfotase alfa STRENSIQ brand 2 PAcabergoline DOSTINEX generic 1cholic acid CHOLBAM brand 2 PAdesmopressin DDAVP generic 1 QLmethylergonovine METHERGINE generic 1mifepristone KORLYM brand 2 PAnitisinone NITYR brand 2 Diagnosis Required, QLpegvisomant SOMAVERT brand 2 PAsapropterin KUVAN brand 2 Diagnosis Required

sapropterin powder KUVAN POWDER FOR SOLUTION brand 2 Diagnosis Required

uridine VISTOGARD brand 2

Gastrointestinal

Constipation/Laxativescasanthranol-docusate

sodium generic 1 OTC

docusate calcium plus generic 1 OTCdocusate potasssium generic 1 OTCdocusate sodium COLACE generic 1 OTCglycerin GLYCERIN SUPPOSITORY generic 1 suppository, OTClactulose ENULOSE generic 1linaclotide LINZESS brand 2 Diagnosis Required, QL

magnesium citrate soln MAGNESIUM CITRATE SOLN generic 1

peg 3350/electrolytes COLYTE generic 1peg 3350/sodium

bicarbonate/sodium chloride

TRILYTE generic 1

peg 3350/sodium bicarbonate/sodium chloride/potassium chloride

NULYTELY generic 1

26




polyethylene glycol 3350 MIRALAX generic 1sennosides SENOKOT generic 1 8.6 mg tab, OTCDiarrheacrofelemer MYTESI brand 2 Diagnosis Requireddiphenoxylate/atropine LOMOTIL generic 1loperamide IMODIUM A-D generic 1 OTCloperamide LOPERAMIDE generic 1Emesisaprepitant EMEND generic 1 QL applies to 40 mg, 80

mg and 80-125 mgdronabinol MARINOL generic 1 PAdroperidol inj INAPSINE INJ generic 1 PAmeclizine ANTIVERT generic 1metoclopramide REGLAN generic 1

ondansetronZOFRANZOFRAN ODT

generic 1 QL, 4mg & 8mg

prochlorperazine COMPAZINE generic 1promethazine PHENERGAN generic 1rolapitant VARUBI brand 2trimethobenzamide TIGAN generic 1 300 mg capsGastroesophageal Reflux Disease (Gerd)/Peptic Ulcersalginic acid/sodium

bicarbonate brand 2 OTC

alumina/magnesia MAALOX generic 1 OTCalumina/magnesia/

simethicone MYLANTA generic 1 OTC

cimetidine TAGAMET generic 1esomeprazole NEXIUM 24HR OTC brand 2 PA

esomeprazole granules NEXIUM DELAYED- RELEASE PACKET brand 2

Members ≥ 2 yearsof age will require prior

authorization.

famotidinePEPCIDPEPCID AC

generic 1

OTC Pepcid AC 10 mg and 20 mg also covered/encouraged with written

prescription.lansoprazole PREVACID generic 1

lansoprazole delayed-release PREVACID SOLUTAB generic 1

orally disintegrating tabs, Members ≥ 2 years

of age will require priorauthorization. QL

27




omeprazole delayed-release PRILOSEC generic 1 Capsules only, QL

pantoprazole PROTONIX generic 1ranitidine ZANTAC generic 1 150 mg & 300 mg tabsranitidine syrup ZANTAC generic 1sucralfate CARAFATE generic 1

sulcralfate CARAFATE SUSPENSION brand 2

suspension, Members 10 years of age up to 65 years of age will require

prior authorization.Gastrointestinal Spasmdicyclomine BENTYL generic 1 tablets onlyglycopyrrolate ROBINUL generic 1hyoscyamine sulfate LEVSIN generic 1hyoscyamine sulfate

extended-release LEVSINEX generic 1

Inflammatory Bowel Diseasebalsalazide COLAZAL generic 1budesonide ENTOCORT EC generic 1 Diagnosis Requiredhydrocortisone COLOCORT generic 1 enemamesalamine ROWASA generic 1 enema onlymesalamine

extended-releaseAPRISODELZICOL

brand 2

mesalamine supp CANASA brand 2olsalazine sodium DIPENTUM brand 2sulfasalazine AZULFIDINE generic 1sulfasalazine

delayed-release AZULFIDINE EN-TABS generic 1

Pancreatic Enzymes

pancrelipaseCREONCREON 3000 UNITZENPEP

brand 2

Probiotic Supplementationacidophilus ACIDOPHILUS XTRA brand 2 OTCacidophilus ACIDOPHILUS brand 2 caps and tabs, OTC

acidophilus/bifidus ACIDOPHILUS/BIFIDUS WAFER generic 1 OTC

acidophilus/citrus pectin ACIDOPHILUS/CITRUS PECTIN generic 1 tabs, OTC

acidophilus/pectin ACIDOPHILUS/PECTIN generic 1 caps, OTC

28




probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

brand 2 OTC

Miscellaneousatropine sulfate SAL-TROPINE brand 2misoprostol CYTOTEC generic 1naloxegol MOVANTIK brand 2 Diagnosis Requiredteduglutide GATTEX brand 2 PA

ursodiolACTIGALL URSO URSO FORTE

generic 1

Infectious Diseases

Anthelminticsalbendazole ALBENZA brand 2 PAivermectin STROMECTOL brand 2praziquantel BILTRICIDE brand 2 Diagnosis Required

pyrantel pamoate PIN-X brand 2 chewable tablets, suspension

pyrantel pamoate REESE’S PINWORM MEDICINE brand 2 tablets, suspension

AntibacterialsAntituberculosis Agentsaminosalicyclic acid PASER brand 2cycloserine SEROMYCIN generic 1ethambutol MYAMBUTOL generic 1ethionamide TRECATOR brand 2isoniazid ISONIAZID generic 1pyrazinamide PYRAZINAMIDE generic 1rifabutin MYCOBUTIN generic 1rifampin RIFADIN generic 1rifapentine PRIFTIN brand 2

29




Cephalosporins - First Generationcefadroxil DURICEF generic 1cephalexin KEFLEX generic 1 tabs are not coveredCephalosporins - Second Generationcefaclor CECLOR generic 1cefprozil CEFZIL generic 1cefuroxime axetil CEFTIN generic 1 tabscefuroxime axetil CEFTIN brand 2 suspensionCephalosporins - Third Generationcefdinir OMNICEF generic 1cefixime SUPRAX brand 2 400 mg caps only, QLceftriaxone ROCEPHIN INJ generic 1 QLFluoroquinolonesciprofloxacin CIPRO generic 1levofloxacin LEVAQUIN generic 1 tablets onlyofloxacin FLOXIN generic 1 tabsMacrolidesazithromycin ZITHROMAX generic 1 QLclarithromycin BIAXIN generic 1clarithromycin ER BIAXIN XL generic 1erythromycin

delayed-release ERY-TAB brand 2

erythromycin delayed-release ERYC generic 1

erythromycin ethylsuccinate E.E.S. generic 1

erythromycin stearate ERYTHROCIN generic 1erythromycin/sulfisoxazole PEDIAZOLE generic 1fidaxomicin DIFICID brand 2 PAPenicillins

amoxicillin AMOXICILLIN generic 1 Except 875 mg film-coated tabs.

amoxicillin AMOXIL SUSP generic 1 suspensionamoxicillin/clavulanate AUGMENTIN generic 1 Except 125 mg/5 ml suspamoxicillin/clavulanate AUGMENTIN ES-600 brand 2ampicillin PRINCIPEN generic 1dicloxacillin DICLOXACILLIN generic 1penicillin g benzathine IM

susp BICILLIN L-A INJ generic 1

penicillin VK VEETIDS generic 1

30




Sulfonamidessulfamethoxazole/

trimethoprim, DSBACTRIMBACTRIM DS

generic 1

Tetracyclines

doxycycline monohydrate DOXYCYCLINE MONOHYDRATE generic 1

minocycline MINOCIN generic 1 capsules, except 75 mgtetracycline SUMYCIN generic 1Miscellaneousvancomycin HCl VANCOCIN HCL generic 1 cap, STAntifungalsclotrimazole MYCELEX generic 1 trochesfluconazole DIFLUCAN generic 1 QLgriseofulvin microsize GRIFULVIN V generic 1griseofulvin ultramicrosize GRIS-PEG generic 1itraconazole SPORANOX generic 1 caps, PA, QLitraconazole SPORANOX brand 2 soln, PA, QLketoconazole NIZORAL generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL generic 1 QLvoriconazole VFEND generic 1 PAAntiprotozoalsatovaquone MEPRON generic 1 PAbenznidazole BENZNIDAZOLE brand 2 PA, QLmiltefosine IMPAVIDO brand 2 PA

nitazoxanide suspension ALINIA SUSPENSION brand 2Members ≥ 8 years of age will require prior

authorization.nitazoxanide tablet ALINIA brand 2 PApentamidine isethionate

for nebulization NEBUPENT brand 2

AntiviralsCytomegalovirus Treatmentganciclovir CYTOVENE generic 1valganciclovir VALCYTE generic 1 tabs onlyFusion Inhibitorsenfuvirtide FUZEON brand 2 QL

31




Hepatitis Treatmententecavir BARACLUDE generic 1

glecaprevir/pibrentasvir MAVYRET brand 2PA, preferred for

Genotypes 1, 2, 3, 4, 5, & 6

interferon alfa-2b INTRON A brand 2 PAlamivudine EPIVIR HBV generic 1 tabs, QLlamivudine EPIVIR HBV brand 2 solution, QLpeginterferon alfa-2a PEGASYS brand 2 PApeginterferon alfa-2a PEGASYS PROCLICK brand 2 PA

ribavirin REBETOL/COPEGUS generic 1 PA

simeprevir OLYSIO brand 2 PAHerpes Treatmentacyclovir ZOVIRAX generic 1 caps, tabs, suspensiondocosanol ABREVA OTC CREAM brand 2valacyclovir VALTREX generic 1Influenza Treatmentamantadine SYMMETREL generic 1 except tabsoseltamivir TAMIFLU generic 1 capsules, QLrimantadine FLUMADINE generic 1zanamivir RELENZA brand 2 QLIntegrase Inhibitors- Diagnosis Requireddolutegravir TIVICAY brand 2elvitegravir VITEKTA brand 2raltegravir ISENTRESS brand 2raltegravir ISENTRESS CHEWABLE brand 2 chewable tablet

raltegravir susp ISENTRESS SUSP brand 2Members ≥ 2 years of age will require prior

authorization. Non-Nucleoside Reverse Transcriptase Inhibitors - Diagnosis Requireddelavirdine RESCRIPTOR brand 2efavirenz SUSTIVA brand 2etravirine INTELENCE brand 2nevirapine VIRAMUNE generic 1nevirapine ER VIRAMUNE XR brand 2rilpivirine EDURANT brand 2Nucleoside Reverse Transcriptase Inhibitors and Combinations - Diagnosis Requiredabacavir ZIAGEN generic 1abacavir/lamivudine EPZICOM generic 1abacavir/lamivudine/

zidovudine TRIZIVIR generic 1

32




didanosine VIDEX brand 2didanosine

delayed-release VIDEX EC generic 1

emtricitabine EMTRIVA brand 2emtricitabine/rilpivirine/

tenofovir COMPLERA brand 2

lamivudine EPIVIR generic 1lamivudine/zidovudine COMBIVIR generic 1stavudine ZERIT generic 1zidovudine RETROVIR generic 1Nucleoside/Nucleotide Reverse Transcriptase Inhibitor Combination - Diagnosis Requiredefavirenz/emtricitabine/

tenofovir ATRIPLA brand 2

emtricitabine/rilpivirine/tenofovir ODEFSEY brand 2

emtricitabine/tenofovir alafenamide DESCOVY brand 2 QL

emtricitabine/tenofovir disoproxil TRUVADA brand 2

Nucleotide Analog Reverse Transcriptase Inhibitor - Diagnosis Requiredtenofovir VIREAD brand 2Protease Inhibitors - Diagnosis Requiredatazanavir REYATAZ brand 2

atazanavir REYATAZ POWDER PACKET brand 2

Members ≥ 8 years of age will require priorauthorization

darunavir PREZISTA brand 2fosamprenavir LEXIVA brand 2indinavir CRIXIVAN brand 2lopinavir/ritonavir KALETRA brand 2 tabletslopinavir/ritonavir KALETRA generic 1 solutionnelfinavir VIRACEPT brand 2ritonavir NORVIR brand 2saquinavir mesylate INVIRASE brand 2tipranavir APTIVUS brand 2Miscellaneous- Diagnosis Requiredabacavir/dolutegravir/

lamivudine TRIUMEQ brand 2

atazanavir/cobicistat EVOTAZ brand 2 QLcobicistat TYBOST brand 2cobicistat/elvitegravir/

emtricitabine/tenofovir STRIBILD brand 2

33




darunavir/cobicistat PREZCOBIX brand 2dolutegravir/rilpivirine JULUCA brand 2elvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate

GENVOYA brand 2

Miscellaneousbedaquiline SIRTURO brand 2chloroquine phosphate ARALEN generic 1clindamycin CLEOCIN generic 1 150 mg and 300 mg onlydapsone DAPSONE brand 2darunavir/cobicistat PREZCOBIX brand 2hydroxychloroquine PLAQUENIL generic 1linezolid ZYVOX generic 1 PAmaraviroc SELZENTRY brand 2 Diagnosis Requiredmefloquine LARIAM generic 1metronidazole FLAGYL generic 1 tabs onlyneomycin sulfate brand 2nitrofurantoin

extended-release MACROBID generic 1

nitrofurantoin macrocrystals MACRODANTIN generic 1

nitrofurantoin susp FURADANTIN SUSP 25 MG/5 ML generic 1


authorization.palivizumab SYNAGIS brand 2 PAparomomycin HUMATIN generic 1povidone-iodine generic 1 OTCprimaquine generic 1pyrimethamine DARAPRIM brand 2 PAtrimethoprim TRIMETHOPRIM generic 1 tabs only

Musculoskeletal

ArthritisDisease Modifying Anti-Rheumatic Drugsadalimumab HUMIRA brand 2 PAanakinra KINERET brand 2 PAapremilast OTEZLA brand 2 PAauranofin RIDAURA brand 2azathioprine IMURAN generic 1canakinumab ILARIS brand 2 PAcertolizumab pegol CIMZIA brand 2 PAetanercept ENBREL brand 2 PA

34




hydroxychloroquine PLAQUENIL generic 1leflunomide ARAVA generic 1methotrexate generic 1penicillamine DEPEN TITRATABLE brand 2 Diagnosis Requiredsecukinumab COSENTYX brand 2 PAsulfasalazine AZULFIDINE generic 1sulfasalazine

delayed-release AZULFIDINE EN-TABS generic 1

NSAIDs and Other Analgesicsacetaminophen tabs,

liquid, drops, suppositories, elixir, syrup

TYLENOL generic 1 OTC

aspirin suppository ASPIRIN SUPPOSITORY generic 1 OTC, 300 mg and 600 mg only

aspirin tabs, EC, tabs, chew tabs

BAYERECOTRIN

generic 1 OTC

capsaicinCAPSAGELCAPZASIN-PCASTIVA

brand 2 OTC, gel, lotion, 0.035% cream

capsaicin generic 1 OTC, 0.025%, 0.075%, & 0.1% cream

celecoxib CELEBREX generic 1 PA, QL

diclofenac 1% gel VOLTAREN 1% TOPICAL GEL generic 1 PA

diclofenac potassium CATAFLAM generic 1 QLdiclofenac sodium

delayed-release VOLTAREN generic 1 QL

diclofenac sodium extended-release VOLTAREN XR generic 1 QL

etodolac LODINE generic 1 IR only

ibuprofen ADVIL generic 1 tabs, caps, chew tabs, and susp, OTC

ibuprofen MOTRIN generic 1 tabs, chew tabs and suspindomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlymeloxicam MOBIC generic 1 QLnaproxen NAPROSYN generic 1 250mg and 500mg tablets

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

oxaprozin DAYPRO generic 1

35




piroxicam FELDENE generic 1salsalate DISALCID generic 1 QLsulindac CLINORIL generic 1Goutallopurinol ZYLOPRIM generic 1colchicine MITIGARE brand 2febuxostat ULORIC brand 2 STprobenecid PROBENECID generic 1Skeletal Muscle RelaxantsMuscle Spasmchlorzoxazone PARAFON FORTE DSC generic 1cyclobenzaprine FLEXERIL generic 1 5mg & 10mgmethocarbamol ROBAXIN generic 1orphenadrine

extended-release NORFLEX generic 1

Spasticitybaclofen BACLOFEN generic 1dantrolene DANTRIUM generic 1diazepam VALIUM generic 1 QLtizanidine ZANAFLEX generic 1 tabs only, QL

OB-GYN

ContraceptivesBiphasicdesogestrel/EE MIRCETTE generic 1 QLnorethindrone/EE ORTHO-NOVUM 10/11 generic 1 QLEmergency Contraceptionlevonorgestrel PLAN B ONE STEP generic 1Extended Cyclelevonorgestrel/EE SEASONALE generic 1 QLInjectableetonogestrel subdermal

implant NEXPLANON brand 2

medroxyprogesterone acetate DEPO-PROVERA generic 1 QL

Intrauterine Devicecopper IUD PARAGARD IUD brand 2

levonorgestrel releasing IUD

SKYLALILETTAMIRENA

brand 2

36




Intravaginaletonogestrel/EE NUVARING brand 2 ring, QL

ortho diaphragmORTHO COILORTHO FLATORTHO FLEX

brand 2 QL

Monophasic - 20 mcg Estrogenlevonorgestrel/EE ALESSE generic 1 0.1/20, QLnorethindrone acetate/EE LOESTRIN 1/20 generic 1 1/20, QLnorethindrone acetate/EE/

iron LOESTRIN FE 1/20 generic 1 1/20, QL

Monophasic - 30 mcg Estrogendesogestrel/EE ORTHO-CEPT generic 1 0.15/30, QLlevonorgestrel/EE NORDETTE generic 1 0.15/30, QLnorethindrone acetate/EE LOESTRIN 1.5/30 generic 1 1.5/30, QLnorethindrone acetate/EE/

iron LOESTRIN FE 1.5/30 generic 1 1.5/30, QL

norgestrel/EE LO/OVRAL generic 1 0.3/30, QLMonophasic - 35 mcg Estrogenethynodiol diacetate/EE ZOVIA 1/35 generic 1 1/35, QLnorethindrone/EE BALZIVA generic 1 0.4/35, QLnorethindrone/EE MODICON generic 1 0.5/35, QLnorethindrone/EE ORTHO-NOVUM 1/35 generic 1 1/35, QLnorgestimate/EE ORTHO-CYCLEN generic 1 0.25/35, QLMonophasic - 50 mcg Estrogenethynodiol diacetate/EE ZOVIA 1/50 generic 1 1/50, QLnorethindrone/EE OVCON 50 generic 1 1/50, QLnorethindrone/ME ORTHO-NOVUM 1/50 generic 1 1/50, QLnorgestrel/EE OVRAL generic 1 0.5/50, QLProgestinnorethindrone ORTHO MICRONOR generic 1Transdermal

norelgestromin/EEORTHO EVRAXULANE

generic 1

Triphasicdesogestrel/EE CYCLESSA generic 1 QLlevonorgestrel/EE TRIVORA generic 1 QLnorethindrone

acetate/EE/iron ESTROSTEP FE generic 1 QL

norethindrone/EE ORTHO-NOVUM 7/7/7 generic 1 QLnorethindrone/EE TRI-NORINYL generic 1 QLnorgestimate/EE ORTHO TRI-CYCLEN generic 1 QL

37




Endometriosisdanazol DANOCRINE generic 1Hormone Therapy/MenopauseEstrogens - Intravaginalestradiol ESTRACE CRM brand 2estradiol vaginal tablet VAGIFEM, YUVAFEM generic 1 QLestrogens, conjugated PREMARIN brand 2 crmEstrogens - Oralestradiol ESTRACE generic 1estrogens, conjugated PREMARIN brand 2estrogens, conjugated,

synthetic A CENESTIN brand 2

estropipate OGEN generic 1Estrogens - Transdermalestradiol CLIMARA generic 1 QLEstrogen/Progestinestradiol-estriol-

progesterone micronized cream (cmpd kit)

BIEST/PROGESTERONE brand 2

estrogens, conjugated/medroxyprogesterone

PREMPHASEPREMPRO

brand 2

Progestinshydroxyprogesterone

caproate (bulk) powder

HYDROXYPROGESTEONE CAPROATE (BULK) POWDER

brand 2

medroxyprogesterone acetate PROVERA generic 1

norethindrone acetate AYGESTIN generic 1progesterone PROGESTERONE POWDER brand 2progesterone IM in oil

50MG/MLPROGESTERONE INJ

50MG/ML generic 1

progesterone micronized cap PROMETRIUM generic 1 Diagnosis Required

progesterone micronized powder

PROGESTERONE MICRONIZED POWDER

brand 2

progesterone micronized td cream 10% (cmpd kit)

PROGESTERONE CREAM 10% KIT brand 2

progesterone vaginal gel CRINONE GEL brand 2

38




progesterone vaginal insert ENDOMETRIN SUP brand 2

progesterone vaginal suppository FIRST-PROGESTERONE brand 2

Ovulation Stimulantschoriogonadotropin alfa OVIDREL brand 2 Diagnosis Requiredchorionic gonadotropin NOVAREL brand 2 Diagnosis RequiredVaginal InfectionsOralfluconazole DIFLUCAN generic 1 QLmetronidazole FLAGYL generic 1 tabsVaginalclindamycin CLEOCIN generic 1 crmclotrimazole GYNE-LOTRIMIN generic 1 OTC

metronidazoleMETROGEL-VAGINAL METROGEL 1%

generic 1

miconazole MONISTAT generic 1 OTCmiconazole MONISTAT 3 generic 1terconazole TERAZOL 3/7 generic 1 crmMiscellaneousconjugated estrogen/

bazedoxifene DUAVEE brand 2

hydroxyprogesterone caproate IM MAKENA brand 2

methylergonovine METHERGINE generic 1tranexamic acid LYSTEDA generic 1 PA

Ophthalmic

Allergyazelastine OPTIVAR generic 1 STcromolyn sodium CROLOM generic 1 QLketotifen ALAWAY OTC generic 1

naphazoline/glycerin CLEAR EYES REDNESS RELIEF generic 1

naphazoline HCL VASOCLEAR generic 1 soln 0.02%naphazoline/zinc sulfate VASOCLEAR A brand 2 OTCtetrahydrozoline/

zinc sulfate VISINE-AC generic 1

39




Anti-InflammatoriesAnti-Infective/Anti-Inflammatory Combinationsbacitracin/polymyxin/

neomycin/hc CORTISPORIN generic 1 ointment

gentamicin/prednisolone acetate PRED-G brand 2

neomycin/polymyxin B/dexamethasone MAXITROL generic 1

neomycin/polymyxin B/hydrocortisone CORTISPORIN generic 1 suspension

sulfacetamide/pred. phos. VASOCIDIN generic 1 10%/0.25%tobramycin/

dexamethasone TOBRADEX generic 1

Nonsteroidaldiclofenac sodium VOLTAREN generic 1flurbiprofen OCUFEN generic 1ketorolac ACULAR/ACULAR LS generic 1Steroidaldexamethasone sodium

phosphate DEXASOL generic 1

fluorometholone FML brand 2 oint 0.1%fluorometholone FML FORTE brand 2 susp 0.25%fluorometholone FML LIQUIFILM generic 1 susp 0.1%prednisolone acetate PRED FORTE generic 1 1%prednisolone acetate PRED MILD brand 2 0.12%prednisolone phosphate INFLAMASE FORTE generic 1 1%rimexolone VEXOL brand 2GlaucomaBeta-Blockerscarteolol generic 1levobunolol BETAGAN generic 1 ophthalmic solutionmetipranolol OPTIPRANOLOL generic 1 0.3% ophthalmic solutiontimolol TIMOPTIC XE generic 1 gel forming solutiontimolol maleate TIMOPTIC generic 1Carbonic Anhydrase Inhibitorsdorzolamide TRUSOPT generic 1Carbonic Anhydrase Inhibitor/Beta-Blocker Combinationdorzolamide/

timolol maleate COSOPT generic 1

40




Cholinesterase Inhibitorecothiophate PHOSPHOLINE IODINE brand 2Mydriaticsatropine ISOPTO ATROPINE generic 1cyclopentolate CYCLOGYL generic 1 1%homatropine ISOPTO HOMATROPINE generic 1 5%homatropine ISOPTO HOMATROPINE brand 2 2%scopolamine ISOPTO HYOSCINE brand 2Oralacetazolamide ACETAZOLAMIDE generic 1acetazolamide

extended-release DIAMOX SEQUELS generic 1

methazolamide NEPTAZANE generic 1Prostaglandinslatanoprost XALATAN generic 1 QLTopical - Parasympathomimeticspilocarpine ISOPTO CARPINE generic 1pilocarpine PILOPINE HS GEL brand 2Topical - Sympathomimeticsbrimonidine ALPHAGAN P brand 2 0.1%brimonidine ALPHAGAN P generic 1 0.15%brimonidine ALPHAGAN generic 1 0.2%Immunologic Agentslifitegrast XIIDRA brand 2 PAInfectionsBacterialbacitracin generic 1ciprofloxacin CILOXAN generic 1 solutionciprofloxacin CILOXAN brand 2 ointmenterythromycin ERYTHROMYCIN generic 1gatifloxin ZYMAR brand 2 PAgentamicin GENTAK generic 1neomycin/bacitracin/

polymyxin NEOSPORIN generic 1 ointment

neomycin/polymyxin B/gramicidin NEOSPORIN generic 1 solution

ofloxacin OCUFLOX generic 1polymyxin B/bacitracin POLYSPORIN generic 1polymyxin B/trimethoprim POLYTRIM generic 1sulfacetamide BLEPH-10 generic 1 oint/solntobramycin TOBREX generic 1

41




Viral trifluridine VIROPTIC generic 1Miscellaneous Ophthalmicscysteamine 0.44%

ophthalmic solution CYSTARAN brand 2 Diagnosis Required

sodium chloride hypertonic MURO 128 generic 1 soln 5%

Psychiatric

Alcohol Deterrentsacamprosate CAMPRAL brand 2disulfiram ANTABUSE generic 1naltrexone REVIA generic 1AnxietyBenzodiazepinesalprazolam XANAX generic 1 QL, IR onlychlordiazepoxide LIBRIUM generic 1clonazepam KLONOPIN generic 1 not wafersclorazepate TRANXENE generic 1diazepam VALIUM generic 1 QLlorazepam ATIVAN generic 1 QLlorazepam inj ATIVAN INJ generic 1 PAmidazolam hcl inj MIDAZOLAM HCL INJ generic 1 PAoxazepam SERAX generic 1 QLMiscellaneousbuspirone BUSPAR generic 1fluvoxamine LUVOX generic 1Attention Deficit Hyperactivity Disorder (ADHD) – Diagnosis requiredamphetamine/

dextroamphetamine mixed salts

ADDERALL generic 1 QL

amphetamine/ dextroamphetamine mixed salts extended-release

ADDERALL XR (BRAND ADDERALL XR IS PREFERRED)

brand 2 QL

dextroamphetamine extended-release DEXEDRINE SPANSULE generic 1 PA, QL

guanfacine ER INTUNIV generic 1lisdexamfetamine VYVANSE brand 2 QL

lisdexamfetamine VYVANSE CHEWABLE brand 2 Age Limit Applies, Diagnosis Required

methylphenidate RITALIN generic 1 tabs only, QL

42




methylphenidate extended-release RITALIN LA generic 1 20 mg, 30 mg, & 40 mg

only, Age Limit Applies, QL

methylphenidate HCL ER 24hr generic 1

Age Limit Applies, QL, 18mg, 27mg,

36mg, 54mg tablets, Mallinckrodt and Kremers

Urban labelersBipolar Disorderdivalproex sodium cap

sprinkle DEPAKOTE SPRINKLE generic 1Members ≥ 8 years of age will require prior

authorization.divalproex sodium


divalproex sodium tab sr 24 hr DEPAKOTE ER generic 1

lithium carbonate LITHIUM CARBONATE generic 1lithium carbonate

extended-releaseESKALITH CR LITHOBID

generic 1

DepressionMonoamine Oxidase Inhibitor (MAOI)phenelzine NARDIL generic 1tranylcypromine PARNATE generic 1Selective Serotonin Reuptake Inhibitor (SSRIs)citalopram CELEXA generic 1 QLescitalopram LEXAPRO generic 1 tablets, QL

fluoxetine PROZAC generic 1 capsules, solution, and 10 mg tabs only

fluoxetine HCL (PMDD) cap SARAFEM, SELFEMRA generic 1

paroxetine PAXIL generic 1 tabletssertraline ZOLOFT generic 1 tablets, QLSerotonin Norepinephrine Reuptake Inhibitors (SNRIs)duloxetine CYMBALTA generic 1 QL, 20mg, 30mg, 60mgvenlafaxine EFFEXOR generic 1 QLvenlafaxine XR EFFEXOR XR generic 1 QLTricyclic Antidepressants (TCAs)amitriptyline ELAVIL generic 1 tabletsamoxapine generic 1desipramine NORPRAMIN generic 1doxepin SINEQUAN generic 1imipramine HCL TOFRANIL generic 1 tabletsnortriptyline PAMELOR generic 1

43




Tricyclic Antidepressant/Phenothiazine Combinationamitriptyline/perphenazine TRIAVIL generic 1Miscellaneous Agentsbupropion WELLBUTRIN generic 1bupropion

extended-release WELLBUTRIN SR generic 1 QL

bupropion extended-release WELLBUTRIN XL generic 1 150 mg and 300 mg

maprotiline LUDIOMIL generic 1mirtazapine REMERON generic 1 tabs (not soltabs)trazodone DESYREL generic 1InsomniaBenzodiazepinesflurazepam DALMANE generic 1 QL

temazepam RESTORIL generic 1 15 mg and 30 mg only, QL

triazolam HALCION generic 1 QLNon-Benzodiazepineschloral hydrate CHLORAL HYDRATE generic 1diphenhydramine NYTOL QUICK CAPS generic 1 OTCdoxylamine succinate UNISOM generic 1 25mg, OTC, QLzaleplon SONATA generic 1 QLzolpidem AMBIEN generic 1 QLNarcotic Antagonistsbuprenorphine SUBUTEX generic 1 PA, QL

buprenorphine/naloxone SUBOXONE brand 2 2 mg and 8 mg film only, PA, QL

naloxone NALOXONE INJ generic 1 QLnaloxone NARCAN NASAL SPRAY brand 2naltrexone REVIA generic 1Psychoses - Diagnosis RequiredAtypicals

aripiprazole ABILIFY TABLETS generic 1 Age Limit Applies, tablets, QL, ST

aripiprazole ER injection ABILIFY MAINTENA brand 2 Age Limit Applies, PA, QLaripiprazole injection ARISTADA brand 2 PA, QLclozapine CLOZARIL generic 1 Age Limit Applies, QL

olanzapine ZYPREXA generic 1 Age Limit Applies, tablets, QL

paliperidone INVEGA SUSTENNA brand 2 Age Limit Applies, PA, QLpaliperidone INVEGA TRINZA brand 2 Age Limit Applies, PA, QLquetiapine SEROQUEL generic 1 Age Limit Applies, QL

44




risperidone RISPERDAL generic 1 Age Limit Applies, QL, (Not M-Tabs)

risperidone RISPERDAL CONSTA brand 2 Age Limit Applies, PA, QL

risperidone oral soln RISPERDAL SOLUTION generic 1QL, Members ≥ 8 years of age will require prior

authorization.ziprasidone GEODON generic 1 Age Limit Applies, QLziprasidone mesylate

for inj GEODON INJ brand 2 PA, QL

Miscellaneouschlorpromazine THORAZINE generic 1dextromethorphan/

quinidine NUEDEXTA brand 2 Diagnosis Required

fluphenazine PROLIXIN generic 1fluphenazine decanoate PROLIXIN DECANOATE generic 1haloperidol HALDOL generic 1haloperidol decanoate HALDOL DECANOATE generic 1haloperidol lactate oral

conc HALDOL CONCENTRATE generic 1

loxapine LOXITANE generic 1perphenazine TRILAFON generic 1pimozide ORAP generic 1thioridazine MELLARIL generic 1thiothixene NAVANE generic 1trifluoperazine STELAZINE generic 1Smoking Cessationnicotine NICODERM CQ generic 1 patches, QLnicotine polacrilex gum NICORETTE OTC generic 1 QLnicotine polacrilex lozenge COMMITT OTC generic 1 QLvarenicline CHANTIX brand 2 QL

Respiratory Drugs

Antifibroticnintedanib OFEV brand 2 PApirfenidone ESBRIET brand 2 PAAntitussives, Decongestants, Expectorants and Combinationsbenzonatate TESSALON generic 1brompheniramine &

phenylephrineDIMETAPP CLD ELX/

ALLERGY generic 1

brompheniramine/ pseudoephedrine

UNI-HIST DROPSACCUHIST DROPS

generic 1

45




brompheniramine/ pseudoephedrine/ dextromethorphan

BROMFED DM generic 1 syrup

chlorphen tan/ carbetapentane tan TUSSI-12 S generic 1 susp

chlorphen tan/pyrilamine tan/PE tan

TRIOTANN PEDIATRIC SUSP

R-TANNAMINEgeneric 1 susp

chlorpheniramine/ dextromethorphan

ROBITUSSIN PED LIQ CGH/COLD

ROBITUSSIN LIQ CGH/CLD

DIMETAPP SYP CGH/CLDCORICIDIN TAB

CGH/CLD

generic 1

chlorpheniramine maleate phenylephrine HCL

ED A-HIST TABLETS AND LIQUID generic 1

chlorpheniramine/ pseudoephedrine LOHIST-D generic 1

chlorpheniramine/ phenylephrine

RONDEC DROPSCARDEC DRO

generic 1 liquid

chlorpheniramine/ phenylephrine

RONDEC SYRUPCARDEC SYP

generic 1 syrup

chlorpheniramine tan/ phenylephrine tan RYNATAN PEDIATRIC SUSP generic 1 susp

codeine/ chlorpheniramine/pseudoephedrine

DIHISTINE DH PHENYLHIST LIQ DH

generic 1

codeine/guaifenesinGUIATUSS AC GG/CODEINE M-CLEAR WC

generic 1 QL

codeine/guaifenesin/pseudoephedrine GUIATUSS DAC generic 1

codeine/promethazine PROMETHAZINE W/CODEINE generic 1 QL

codeine/promethazine/phenylephrine

PROMETHAZINE VC W/CODEINE generic 1 QL

dextromethorphan/ brompheniramine/pseudoephedrine

BROMETANE DX generic 1

46




dextromethorphan- doxylamine-apap liquid

VICKS NYQUIL COLD & FLU NIGHTTIME RELIEF, CLEAR COUGH PM MULTI-SYMPTOM

generic 1 OTC

dextromethorphan- guaifenesin

DURATUSS DM ELX, PERTUSSIN generic 1 soln 25-225 mg/5 ml,

3.5-25 mg/5ml

dextromethorphan/ guaifenesin

GG/DM CRMUCINEX DMROBITUSSIN DMTUSSIN DM

generic 1 OTC

dextromethorphan- guaifenesin

ROBITUSSIN LIQ CGH/CONG generic 1 liq 10-200 mg/ 5 ml

dextromethorphan hbrROBITUSSIN SYP MAX-STROBITUSSIN PED SYP

generic 1 syrup

dextromethorphan- phenylephrine-apap

TYLENOL COLD MULTI-SYMPTOM DAYTIME, VICK DAYQUIL LIQ COLD/FLU

generic 1 OTC

dextromethorphan polistirex extended-release

DELSYM brand 2 OTC

dextromethorphan/ promethazine

PHENERGAN DMPROMETHAZINE SYP DM

generic 1

guaifenesin ROBITUSSIN generic 1 OTC

guaifenesin ROBITUSSIN SYP CHST CNG generic 1 syrup 100 mg/5 ml

guaifenesin extended-release MUCINEX generic 1 OTC

guaifenesin/ pseudoephedrine

ROBITUSSIN PE PSE/GG

generic 1 syrup, OTC

guaifenesin/ pseudoephedrine/ dextromethorphan

ROBITUSSIN CF generic 1

guaifenesin/ pseudoephedrine extended-release

MUCINEX D generic 1 OTC

47




hydrocodone/homatropine

HYCODANHYDROMET SYPHYDROCODONE/

TAB HOMATROP

generic 1

loratadine & pseudoephedrine SR 24hr

CLARITIN-D generic 1

phenylephrine/ brompheniramine/ dextromethorphan

generic 1 OTC

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DMSTATUSS DM SYPCARDEC DM SYPMINUTUSS DR SYP

generic 1 syrup

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DM DROPSCARDEC DM DROROBITUSSIN LIQ

CGH/ALRG

generic 1 liquid

phenylephrine/ chlorpheniramine/ dihydrocodeine

DIHYDRO-PE SYP generic 1

phenylephrine/ dextromethorphan

DIMETAPP DRO DCON/CGH generic 1

phenylephrine/ dextromethorphan/guaifenesin

ROBITUSSIN LIQ CGH/CLD generic 1

phenylephrine/ephed/CPM w/carbetapentane

RYNATUSS PEDIATRIC SUSP generic 1 susp

phenylephrine/guaifenesin ROBITUSSIN LIQ HD/CHST generic 1

phenylephrine/pyrilamine w/hydrocodone CODIMAL DH generic 1 syrup

promethazine & phenylephrine

PROMETH VC SYP 6.25-5/5 generic 1 syrup 6.25-5 mg/ 5 mg

pseudoephedrine/ acetaminophen/ dextromethorphan

MAPAP COLD TAB generic 1

48




pseudoephedrine/ chlorpheniramine/ dextromethorphan

PEDIACARE LIQ MULTI-SY

ROBITUSSIN LIQ PED NGHT

generic 1

pseudoephedrine/ dextromethorphan/guaifenesin

MULTI SYMPTOM TAB COLD RLF generic 1

pseudoephedrine/ iburprofen

CHILD IBUPRO SUS COLD

IBUOROFEN TAB COLD/SIN

generic 1

pseudoephedrine tan/ dexchlorphen tan/ DM tan

TANAFED DMX SUSPENSION

TRI-FED Xgeneric 1 susp

pyrilamine tan/phenyleph tan RYNA-12 S generic 1 susp

tripolidine/ pseudoephedrine

TRIPROL/PSE SYPAPHEDRID TAB

generic 1

Asthma/COPDInhalers - Beta Agonistsalbuterol HFA VENTOLIN HFA brand 2 QLindacaterol ARCAPTA NEOHALER brand 2olodaterol STRIVERDI RESPIMAT brand 2salmeterol xinafoate SEREVENT DISKUS brand 2 QLInhalers - Corticosteroidsbeclomethasone QVAR REDIHALER brand 2 QLbudesonide PULMICORT FLEXHALER brand 2fluticasone furoate ARNUITY ELLIPTA brand 2 QLfluticasone HFA FLOVENT HFA brand 2 QLfluticasone propionate FLOVENT DISKUS brand 2 QL

mometasone ASMANEX HFA brand 2Patients 8 years and

older will require prior authorization, QL

Inhalers - Corticosteroid/Beta Agonist Combinationsfluticasone/salmeterol AIRDUO RESPICLICK generic 1 QLfluticasone/vilanterol BREO ELLIPTA brand 2 STInhalers - Othersipratropium/albuterol COMBIVENT brand 2 QLipratropium/albuterol COMBIVENT RESPIMAT brand 2 inhaleripratropium HFA ATROVENT HFA brand 2

49




omalizumab XOLAIR brand 2 PAtiotropium/olodaterol STIOLTO RESPIMAT brand 2 QLumeclidinium inhalation INCRUSE ELLIPTA brand 2Inhalers for Nebulization

albuterol ACCUNEB generic 1

0.63 mg/3 ml and 1.25 mg /3 ml, Covered for members less than 8

years of age. Members ≥ 8 years of age will require

prior authorization.albuterol PROVENTIL generic 1 soln 0.083%, 0.5%

budesonide PULMICORT RESPULES generic 1susp, Members ≥ 5 yearsof age will require prior

authorization. QLcromolyn INTAL generic 1 soln, QLipratropium ATROVENT generic 1 soln, QLipratropium/albuterol DUONEB generic 1 solnlevalbuterol HCl XOPENEX RESPULES generic 1 QL, STOral Agents - Beta Agonistsalbuterol sulfate tab PROVENTIL generic 1metaproterenol METAPROTERENOL SYRUP generic 1terbutaline BRETHINE generic 1Oral Agents - Leukotriene Modifiersmontelukast SINGULAIR generic 1 QLOral Agents - Theophyllinetheophylline THEOPHYLLINE generic 1 liquidtheophylline

extended-release THEO-24 brand 2 caps

theophylline extended-release

THEOCHRONUNIPHYL

generic 1 tabs

Urological

Symptomatic Benign Prostatic Hypertrophyalfuzosin ER UROXATRAL generic 1doxazosin CARDURA generic 1finasteride PROSCAR generic 1tamsulosin FLOMAX generic 1terazosin HYTRIN generic 1Miscellaneousbethanechol URECHOLINE generic 1flavoxate FLAVOXATE generic 1

50




hyoscyamine, methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue

UTIRA C brand 2

methenamine hippurateHIPREXUREX

generic 1

oxybutynin chloride DITROPAN XL generic 1 QLoxybutynin IR DITROPAN generic 1

oxybutynin patch OXYTROL FOR WOMEN OTC PATCH brand 2

pentosan polysulfate sodium ELMIRON brand 2 Diagnosis Required

phenazopyridine PYRIDIUM generic 1potassium citrate UROCIT-K generic 1propantheline generic 1sodium citrate/citric acid BICITRA generic 1tolterodine DETROL generic 1 STtrospium SANCTURA generic 1 ST

Vitamins and Mineralscalcitriol ROCALTROL generic 1

calcitriol oral soln ROCALTROL SOLUTION generic 1Members ≥ 8 years of age will require prior

authorization.calcium OS-CAL generic 1 OTC

cholecalciferol BIO-D DRO-MULSION generic 1 drops 400 unit/0.03 ml, OTC

cholecalciferol BIO-D-MULSIO DRO FORTE generic 1 drops 2000 unit/0.03 ml,

OTCcholecalciferol D3-50 CAP generic 1 cap 50000 unit, OTC

cholecalciferol VITAMIN D 400 UNIT generic 1 caps & tabs 400 unit, OTC



cyanocobalamin VITAMIN B-12 generic 1 injelectrolyte PEDIALYTE generic 1 soln, oral, OTCergocalciferol (D2) DRISDOL generic 1

51




ferrous bisglycinate/ polysaccarides iron NIFEREX generic 1 caps, OTC

ferrous sulfate FEOSOL generic 1 OTC

fluoride

GEL-KAMLURIDE LURIDE LOZI-TABSPREVIDENTPHOS-FLUR

generic 1

folic acid FOLIC ACID generic 1magnesium oxide MAG-OX generic 1 OTCmultivitamins/

fluoride/±iron POLY-VI-FLOR generic 1

multivitamins/minerals CENTRUM generic 1 OTCphytonadione MEPHYTON brand 2polysaccharide iron

complex NIFEREX generic 1 elixir, OTC

prenat-FE Bis-FE prot succ-FA-CA & omega 3

COMPLETE NATALCARE PAK DHA brand 2


TRUST NATALCARE PAK DHA brand 2


PRUET DHA PAK SETONET PAK brand 2

prenat-FE bis-FE prot succ-FA-CA & omega DR

PRUET DHAEC PAK brand 2

prenat w/o A w/fecbn-fegl-DSS-FA & DHA

FOLTABS PAK PLUS DHA RE OB + DHA PAK brand 2

prenatal vit w/FE bisglycinate chelate-FA

VINATE II brand 2


GENTEX ADE 28-1 MG brand 2


VINATE AZ EX brand 2

52




prenatal vit w/FE polysac cmplx-FA

EDGE OB CHW brand 2

prenatal vit w/iron carbonyl-FA ATABEX PRENATAL brand 2

prenatal vitamins w/folic acid

PRENATAL VITAMINS W/ FOLIC ACID

CENOGEN OB/ULTRAMATERNANATALCARENESTABSCBF/FA/RXNIFEREX-PN FORTE

generic 1 QL

prenatal w/o A w/FE carbonyl-FE gluc-DSS-FA

FOLTABS PRENATALTRI RX

brand 2

vitamin A generic 1 OTCvitamin ADC/fluoride/±iron

drops TRI-VI-FLOR generic 1

vitamin B complex/ vitamin C/folic acid NEPHROCAPS generic 1

vitamin B-1 generic 1 OTCvitamin B-6 generic 1 OTCvitamin C generic 1 OTC

vitamins pediatric TRI-VI-SOL generic 1 members <3 years old, OTC

zinc generic 1 OTCPotassiumphosphorus K-PHOS NEUTRAL generic 1 tabspotassium acid phosphate K-PHOS ORIGINAL brand 2potassium bicarbonate/

potassium citrate effervescent

K-LYTE generic 1 tabs

potassium chloride K-LOR generic 1 powderpotassium chloride POTASSIUM CHLORIDE generic 1 liquid

potassium chloride extended-release

K-DUR 10, K-DUR 20KLOR-CON 8,

KLOR-CON 10K-TAB 20

generic 1 tabs

potassium chloride extended-release MICRO-K 10 generic 1 caps

53




Miscellaneous

Anaphylaxis

epinephrineEPIPEN EPIPEN JR.

generic 1 QL

Antidotesacetylcysteine CETYLEV brand 2succimer CHEMET brand 2 QLCystic Fibrosisacetylcysteine MUCOMYST generic 1aztreonam CAYSTON brand 2 Diagnosis Requireddornase alfa PULMOZYME brand 2 Diagnosis Required

ivacaftorKALYDECOKALYDECO GRANULES

brand 2 PA

lumacaftor/ivacaftor ORKAMBI brand 2 PAsodium chloride for

nebulizerHYPERSALNEBUSAL

generic 1

tobramycin neb soln BETHKIS brand 2 Diagnosis RequiredHereditary Angioedemaicatibant FIRAZYR brand 2 PAc1 esterase inhibitor,

human BERINERT brand 2 PA

c1 esterase inhibitor, human HAEGARDA brand 2 PA

Hyperphosphatemiacalcium acetate generic 1 667 mg tablet onlycinacalcet SENSIPAR brand 2 PAsevelamer RENVELA generic 1 STImmune Thrombocytopenic Purpuraeltrombopag PROMACTA brand 2 PAMedical Devicesinsulin syringes QLlancets QLspacers QLMetabolic Modifierscarglumic acid CARBAGLU brand 2 PAglycerol phenylbutyrate RAVICTI brand 2 PAsodium phenylbutyrate BUPHENYL generic 1 Diagnosis Required

54




Vaccinediphtheria-tetanus tox

adsorbed (dt) im DIP/TET PED INJ brand 2 QL

hepatitis a vaccine suspHAVRIXVAQTA

brand 2 QL

hepatitis b vaccine (recombinant)

ENGERIX-BRECOMBIVAX HB

brand 2 QL

hepatitis b vaccine recombinant adjuvanted

HEPLISAV-B brand 2 Age Limits Apply

human papillomavirus (hpv) 9-valent recomb vac

GARDASIL 9 brand 2 QL

human papillomavirus (hpv) quadrivalent recombinant vac

GARDASILbrand 2 QL

influenza virus vaccine recombinant hemagglutinin (ha)

FLUBLOK brand 2 QL

influenza virus vaccine split

AFLURIAFLUZONE SPLT

brand 2 QL

influenza virus vaccine split high-dose pf FLUZONE HD PF brand 2 QL

influenza virus vaccine split pf AFLURIA PF brand 2 QL

influenza virus vaccine split quadrivalent

FLUARIX QUADFLULAVAL QUADFLUZONE QUAD

brand 2 QL

influenza virus vaccine tiss-cult subunit FLUCELVAX brand 2 QL

influenza virus vaccine types a&b surface antigen

FLUVIRIN brand 2 QL

measles, mumps & rubella virus vaccines for inj M-M-R II brand 2 QL

meningococcal (a, c, y, and w-135) MENOMUNE brand 2 QL

meningococcal (a, c, y, and w-135) conjugate vaccine

MENACTRA brand 2 QL

55




meningococcal (a, c, y, and w-135) oligo conj vac for inj

MENVEO brand 2 QL

pneumococcal 13-valent conjugate PREVNAR 13 brand 2 QL

pneumococcal vaccine polyvalent

PNEUMOVAXPNEUMOVAX 23

brand 2 QL

tet tox-diph-acell pertuss ad

ADACELBOOSTRIX

brand 2 QL

tetanus-diphtheria toxoids (td)

TENIVACTET/DIP TOX INJ

brand 2 QL

tetanus immune globulin (human) HYPERTET S/D brand 2 QL

typhoid vaccine VIVOTIF BERNA brand 2 capsulesvaricella virus vac live for

subcutaneous VARIVAX brand 2 QL

zoster vaccine live ZOSTAVAX brand 2 QL, Age Limits Apply

56



Generic Drug Name Brand Drug Name Examples

OTC MEDICATIONS

The following is a list of OTC products on the PDL. Some OTC products are listed on the drug

list. OTC products covered are restricted to generics when available. Brand names are provided

as reference only.Acneadapalene gel DIFFERIN OTC GEL 0.1%benzoyl peroxide crm, gel, lotion CLEARASILAntifungalsclotrimazolemiconazole crmtolnaftate

MICATINLOTRIMIN AFTINACTIN

vaginal productsMONISTATGYNE-LOTRIMIN

Antiviralsdocosanol ABREVA OTC CREAMAtopic Dermatitis

emollients

BETACARE CREAM AND LOTIONCETAPHIL CREAM AND LOTIONDERMAPHOR OINTMENTE-OINTMENTGLYCERIN TOPICAL

Cough/Cold AllergyAntihistamine

antihistamines

CHLOR-TRIMETONBENADRYLCLARITINALAVERTZYRTEC

Antihistamine/Decongestant Combinationsbrompheniramine/pseudoephedrine DIMETAPPcetirizine/pseudoephedrine OTC ZYRTEC Dchlorpheniramine/pseudoephedrine ACTIFED

loratadine/pseudoephedrineALAVERT ALRG TAB/SINUSALAVERT D ALLERGY/CONG

57




Cough/Cold

antitussives Age edit applied. Not covered for members under the age 2.

ROBITUSSINROBITUSSIN DMROBITUSSIN PEROBITUSSIN CFDELSYM

dextromethorphan-doxylamine-apap liquidVICKS NYQUIL COLD & FLU NIGHTTIME

RELIEF, CLEAR COUGH PM MULTI-SYMPTOM

dextromethorphan-phenylephrine-apapTYLENOL COLD MULTI-SYMPTOM

DAYTIME, VICK DAYQUIL LIQ COLD/FLU

nasal spraysNEO-SYNEPHRINEAFRINDIMETAPP DRO DECONGES

phenol liquid CHERACOL SORE THROAT, PAIN-A-LAY Diabetesalcohol swabs CURITY ALCOHOL PADSglucose oral tablets

insulin (vials only) HUMULINNOVOLIN

Earwax Removal Productscarbamide peroxide DEBROXFamily Planning

condoms-male

KIMONOLIFESTYLESTRUSTEXDUREXFANTASYTROJAN

contraceptive foam DELFENcontraceptive gel GYNOL IIFirst AidBurow’s soln, wet dressings DOMEBOROdermatological baths COLLOIDAL OATMEAL BATHShydrocortisone crm, oint CORTAID

topical antibacterialsNEOSPORINBACITRACIN

wound dressings - pads 2ND SKIN MOIST, ACTICOAT, ALLEVYN, DERMAGRAN

58




Gastrointestinal

antacids liquids, chew tabsMYLANTA LIQUIDMAALOX LIQUIDTUMS

antidiarrhealsIMODIUM A-DKAOPECTATE

electrolyte rehydrating soln PEDIALYTEfamotidine PEPCID AClaxative enemas FLEET ENEMA

laxativesDULCOLAXFLEET PHOSPHO-SODA

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

psyllium METAMUCILrectal hydrocortisone crm, suppositories PREPARATION Hsimethicone MYLICONstool softeners COLACEsugar+orthophosphoric acid EMETROLInsomniadoxylamine succinate UNISOMLice Productspermethrin NIXpyrethrins/piperonyl butoxide shampoo RID SHAMPOOMotion Sicknessdimenhydrinate DRAMAMINEmeclizine BONINE

59




Ophthalmicsallergic conjunctivitis ALAWAYartificial tears HYPOTEARS

decongestantsVISINEMURINENAPHCON A

Painacetaminophen tabs, liquid, drops, suppositories,

elixir, syrup, chew tabs TYLENOL

aspirin suppository ASPIRIN SUPPOSITORY

aspirin tabs, EC tabs, chew tabsBAYERECOTRIN

aspirin with buffers tabs

ibuprofen tabs, chew tabs, drops, suspADVILMOTRIN IB

phenol liquid CHERACOL SORE THROAT, PAIN-A-LAY Smoking Cessation Products

nicotine

COMMIT LOZENGES (QUANTITY LIMIT)NICODERM CQ (QUANTITY LIMIT)NICOTINE GUM (QUANTITY LIMIT)NICOTROL (QUANTITY LIMIT)

Urologicaloxybutynin patch OXYTROL FOR WOMEN OTC PATCHVitamins/Minerals

calciumOS-CALCALTRATETUMS

iron ferrous fumarate, ferrous gluconate, ferrous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps

FERGONFEOSOL

iron polysaccharides NIFEREXmagnesium oxide MAG-OXvitamin D 400 IU VITAMIN D 400 IU

vitamins pediatric members <3 years oldVI-DAYLINPOLY-VI-SOLTRI-VI-SOL

vitamins prenatal STUART PRENATAL

60




Multivitaminmultivitamin with calcium ONE A DAY WOMEN’S

speciality vitamin miscCENTRUM PERFORMANCE, CENTRUM

SPECIALIST ENERGY, TAB-A-VITE TAB WOMENS, ALLERWELL

Wartssalicylic acid 17%/collodion DUOFILMMiscellaneousfluoride dental rinse PHOS-FLUR

61

ALL CAPS = Brand-name drug Lower case = Generic drug

Index of covered drugs

A2ND SKIN MOIST . . . . . . . . . . 57abacavir . . . . . . . . . . . . . . .31, 32abacavir/dolutegravir/

lamivudine . . . . . . . . . . . . . 32abacavir/lamivudine . . . . . . . . 31abacavir/lamivudine/

zidovudine . . . . . . . . . . . . . 31abemaciclib . . . . . . . . . . . . . . . . 4ABILIFY MAINTENA . . . . . . . . 43ABILIFY TABLETS . . . . . . . . . 43abiraterone . . . . . . . . . . . . . . . . . 5ABREVA OTC CREAM . . .31, 56ABSORICA . . . . . . . . . . . . . . . 17acalabrutinib . . . . . . . . . . . . . . . 4acamprosate . . . . . . . . . . . . . . 41acarbose . . . . . . . . . . . . . . . . . 24ACCUHIST DROPS . . . . . . . . 44ACCUNEB . . . . . . . . . . . . . . . . 49ACCUPRIL . . . . . . . . . . . . . . . . . 8ACCURETIC . . . . . . . . . . . . . . . 8acebutolol . . . . . . . . . . . . . . . . . 9acetaminophen

. . . . . . . . 13, 14, 34, 47, 59acetaminophen tabs, liquid,

drops, suppositories, elixir, syrup. . . . . . . . . . . . . . .34, 59

acetaminophen tabs, liquid, drops, suppositories, elixir, syrup, chew tabs . . . . . . . . 59

acetazolamide . . . . . . . . . . . . . 40acetazolamide

extended-release . . . . . . . 40acetic acid . . . . . . . . . . . . . . . . 21acetic acid/aluminum acetate 21acetic acid/hydrocortisone . . 21acetylcysteine . . . . . . . . . . . . . 53acidophilus . . . . . . . . . . . . . . . 27ACIDOPHILUS XTRA . . . . . . . 27acidophilus/bifidus . . . . . . . . . 27ACIDOPHILUS/BIFIDUS

WAFER . . . . . . . . . . . . . . . . 27acidophilus/citrus pectin . . . . 27acidophilus/pectin . . . . . . . . . 27acitretin . . . . . . . . . . . . . . . . . . . 19

ACLOVATE . . . . . . . . . . . . . . . . 18ACTICOAT . . . . . . . . . . . . . . . . 57ACTIFED . . . . . . . . . . . . . .22, 56ACTIGALL . . . . . . . . . . . . . . . . 28ACTOS . . . . . . . . . . . . . . . . . . . 24ACULAR/ACULAR LS . . . . . . 39acyclovir . . . . . . . . . . . . . . . . . . 31ADACEL . . . . . . . . . . . . . . . . . . 55ADALAT CC . . . . . . . . . . . . . . . 10adalimumab . . . . . . . . . . . . . . . 33adapalene gel . . . . . . . . . .17, 56ADDERALL . . . . . . . . . . . . . . . 41ADDERALL XR . . . . . . . . . . . . 41ADEMPAS . . . . . . . . . . . . . . . . 12ADLYXIN . . . . . . . . . . . . . . . . . 24ADMELOG SOLOSTAR . . . . . 23ADMELOG VIALS . . . . . . . . . . 23ADVIL . . . . . . . . . . . . . 13, 34, 59afatinib . . . . . . . . . . . . . . . . . . . . 4AFINITOR . . . . . . . . . . . . . . . . . . 4AFINITOR DISPERZ . . . . . . . . . 4AFLURIA . . . . . . . . . . . . . . . . . 54AFLURIA PF . . . . . . . . . . . . . . . 54AFRIN . . . . . . . . . . . . . . . . .22, 57AGRYLIN . . . . . . . . . . . . . . . . . . 7AIRDUO RESPICLICK . . . . . . 48ALAVERT . . . . . . . . . . 21, 22, 56ALAVERT ALRG TAB/

SINUS . . . . . . . . . . . . . .22, 56ALAVERT D . . . . . . . . . . . . . . . 56ALAVERT-D . . . . . . . . . . . . . . . 22ALAWAY . . . . . . . . . . . . . . .38, 59ALAWAY OTC . . . . . . . . . . . . . 38albendazole . . . . . . . . . . . . . . . 28ALBENZA . . . . . . . . . . . . . . . . 28albiglutide . . . . . . . . . . . . . . . . 24albuterol . . . . . . . . . . . . . . .48, 49albuterol HFA . . . . . . . . . . . . . . 48albuterol sulfate tab . . . . . . . . 49alclometasone . . . . . . . . . . . . . 18alcohol swabs . . . . . . . . . . . . . 57ALDACTAZIDE . . . . . . . . . . . . 10ALDACTONE . . . . . . . . . . . . . . 10ALDARA . . . . . . . . . . . . . . . . . . 20ALDOMET . . . . . . . . . . . . . . . . 12

ALDORIL . . . . . . . . . . . . . . . . . 12ALECENSA . . . . . . . . . . . . . . . . 4alectinib . . . . . . . . . . . . . . . . . . . 4alendronate . . . . . . . . . . . . . . . 24ALESSE . . . . . . . . . . . . . . . . . . 36alfuzosin ER . . . . . . . . . . . . . . . 49alginic acid/sodium

bicarbonate . . . . . . . . . . . . 26ALIGN . . . . . . . . . . . . . . . . .28, 58ALINIA . . . . . . . . . . . . . . . . . . . 30ALINIA SUSPENSION . . . . . . 30alirocumab . . . . . . . . . . . . . . . . 11alitretinoin 1% gel . . . . . . . . . . . 6ALKERAN . . . . . . . . . . . . . . . . . 4allergic conjunctivitis . . . . . . . 59ALLERGY/CONG . . . . . . . . . . 56ALLERY/CONG . . . . . . . . . . . 22ALLEVYN . . . . . . . . . . . . . . . . . 57allopurinol . . . . . . . . . . . . . . . . 35alogliptin . . . . . . . . . . . . . . . . . . 24alogliptin/metformin . . . . . . . . 24alogliptin/pioglitazone . . . . . . 24ALPHAGAN . . . . . . . . . . . . . . . 40ALPHAGAN P . . . . . . . . . . . . . 40alprazolam . . . . . . . . . . . . . . . . 41ALTACE . . . . . . . . . . . . . . . . . . . 8altretamine . . . . . . . . . . . . . . . . . 4alumina/magnesia . . . . . . . . . 26alumina/magnesia/

simethicone . . . . . . . . . . . . 26aluminum acetate . . . . . . .20, 21aluminum chloride topical

solution . . . . . . . . . . . . . . . 20ALUNBRIG . . . . . . . . . . . . . . . . . 4amantadine . . . . . . . . . . . .15, 31AMARYL . . . . . . . . . . . . . . . . . 24AMBIEN . . . . . . . . . . . . . . . . . . 43ambrisentan . . . . . . . . . . . . . . . 12AMERGE . . . . . . . . . . . . . . . . . 14AMICAR . . . . . . . . . . . . . . . . . . . 7amiloride . . . . . . . . . . . . . . . . . 10amiloride/

hydrochlorothiazide . . . . . 10aminocaproic acid . . . . . . . . . . 7aminosalicyclic acid . . . . . . . . 28

62


Index of Covered Drugsamiodarone tabs . . . . . . . . . . . . 9amitriptyline . . . . . . . . 15, 42, 43amitriptyline/perphenazine . . 43amlodipine . . . . . . . . . . . . . . 9, 10amlodipine/benazepril . . . . . . 10ammonium lactate . . . . . . . . . 20AMNESTEEM . . . . . . . . . . . . . 17amoxapine . . . . . . . . . . . . . . . . 42amoxicillin . . . . . . . . . . . . . . . . 29amoxicillin/clavulanate . . . . . . 29AMOXIL SUSP. . . . . . . . . . . . . 29amphetamine/

dextroamphetamine mixed salts . . . . . . . . . . . . . . . . . . 41

amphetamine/dextroamphetamine mixed salts extended-release . . . 41

ampicillin . . . . . . . . . . . . . . . . . 29anagrelide . . . . . . . . . . . . . . . . . 7anakinra . . . . . . . . . . . . . . . . . . 33anastrozole. . . . . . . . . . . . . . . . . 5ANTABUSE . . . . . . . . . . . . . . . 41antacids liquids, chew tabs . . 58antidiarrheals . . . . . . . . . . . . . . 58antihistamines . . . . . . . . . .21, 56antitussives . . . . . . . . . . . . . . . 57ANTIVERT . . . . . . . . . . . . . . . . 26APHEDRID TAB . . . . . . . . . . . 48apixaban . . . . . . . . . . . . . . . . . . 7apremilast . . . . . . . . . . . . . . . . 33aprepitant . . . . . . . . . . . . . . . . . 26APRESOLINE . . . . . . . . . . . . . 12APRISO . . . . . . . . . . . . . . . . . . 27APTIVUS . . . . . . . . . . . . . . . . . 32ARALEN . . . . . . . . . . . . . . . . . . 33ARANESP . . . . . . . . . . . . . . . . . 7ARAVA . . . . . . . . . . . . . . . . . . . 34ARCAPTA NEOHALER . . . . . 48ARICEPT . . . . . . . . . . . . . . . . . 12ARIMIDEX . . . . . . . . . . . . . . . . . 5aripiprazole . . . . . . . . . . . . . . . 43aripiprazole ER injection . . . . 43aripiprazole injection . . . . . . . 43ARISTADA . . . . . . . . . . . . . . . . 43

armodafinil . . . . . . . . . . . . . . . . 12ARNUITY ELLIPTA . . . . . . . . . 48AROMASIN . . . . . . . . . . . . . . . . 5ARTANE . . . . . . . . . . . . . . . . . . 15artificial tears . . . . . . . . . . . . . . 59asfotase alfa . . . . . . . . . . . . . . . 25ASMANEX HFA . . . . . . . . . . . . 48aspirin suppository . . 13, 34, 59aspirin tabs, EC tabs,

chew tabs . . . . . . . 7, 34, 59aspirin tabs, EC, Tabs, chew

tabs . . . . . . . . . . . . . 7, 34, 59aspirin with buffers tabs . . . . . 59aspirin/acetaminophen/

caffeine . . . . . . . . . . . . . . . 13ASTELIN. . . . . . . . . . . . . . . . . . 21ATABEX PRENATAL . . . . . . . . 52ATARAX . . . . . . . . . . . . . . . . . . 21atazanavir . . . . . . . . . . . . . . . . . 32atazanavir/cobicistat . . . . . . . 32atenolol . . . . . . . . . . . . . . . . . . . . 9atenolol/chlorthalidone . . . . . . 9ATIVAN . . . . . . . . . . . . . . . . . . . 41ATIVAN INJ . . . . . . . . . . . . . . . 41atorvastatin . . . . . . . . . . . . . . . 11atovaquone . . . . . . . . . . . . . . . 30ATRIPLA . . . . . . . . . . . . . . . . . . 32atropine . . . . . . . . . . . 26, 28, 40atropine sulfate . . . . . . . . . . . . 28ATROVENT . . . . . . . . 22, 48, 49ATROVENT HFA . . . . . . . . . . . 48ATROVENT NASAL SPRAY . 22AUBAGIO . . . . . . . . . . . . . . . . . 15AUGMENTIN . . . . . . . . . . . . . . 29AUGMENTIN ES-600 . . . . . . . 29auranofin . . . . . . . . . . . . . . . . . 33AVAPRO . . . . . . . . . . . . . . . . . . . 8AVITA . . . . . . . . . . . . . . . . . . . . 17axitinib . . . . . . . . . . . . . . . . . . . . 4AYGESTIN . . . . . . . . . . . . . . . . 37azathioprine . . . . . . . . . . . . . 6, 33azelaic acid . . . . . . . . . . . . . . . 17azelastine . . . . . . . . . . . . . .21, 38azithromycin . . . . . . . . . . . . . . 29aztreonam . . . . . . . . . . . . . . . . 53

AZULFIDINE . . . . . . . . . . .27, 34AZULFIDINE EN-TABS . . .27, 34

BBACID . . . . . . . . . . . . . . . . .28, 58bacitracin . . . . . . . 18, 39, 40, 57bacitracin/polymyxin/

neomycin/hc . . . . . . . . . . . 39baclofen . . . . . . . . . . . . . . . . . . 35BACTRIM . . . . . . . . . . . . . . . . . 30BACTRIM DS . . . . . . . . . . . . . . 30BACTROBAN . . . . . . . . . . . . . 18balsalazide . . . . . . . . . . . . . . . . 27BALZIVA . . . . . . . . . . . . . . . . . . 36BANZEL . . . . . . . . . . . . . . . . . . 17BARACLUDE . . . . . . . . . . . . . . 31BASAGLAR . . . . . . . . . . . . . . . 23BAYER . . . . . . . . . . . . . 7, 34, 59becaplermin gel . . . . . . . . . . . 20beclomethasone . . . . . . . . . . . 48bedaquiline . . . . . . . . . . . . . . . 33BENADRYL . . . . . . . . . . . .21, 56benazepril . . . . . . . . . . . . . . 8, 10benazepril/

hydrochlorothiazide . . . . . . 8BENTYL . . . . . . . . . . . . . . . . . . 27BENZAC AC . . . . . . . . . . . . . . 17benznidazole . . . . . . . . . . . . . . 30benzocaine/antipyrine . . . . . . 21benzonatate . . . . . . . . . . . . . . . 44BENZOTIC . . . . . . . . . . . . . . . . 21benzoyl peroxide . . . . . . . .17, 56benzoyl peroxide crm, gel,

lotion . . . . . . . . . . . . . . . . . . 56benztropine . . . . . . . . . . . . . . . 15BERINERT . . . . . . . . . . . . . . . . 53BETA-VAL . . . . . . . . . . . . . . . . 18BETACARE CREAM AND

LOTION . . . . . . . . . . . . . . . 56BETAGAN . . . . . . . . . . . . . . . . 39betamethasone augmented

dip . . . . . . . . . . . . . . . . . . . . 18betamethasone dip

augmented . . . . . . . . . . . . 19betamethasone dipropionate 18

63

Index of Covered Drugs


betamethasone val . . . . . . . . . 18BETAPACE . . . . . . . . . . . . . . . . 9BETAPACE AF . . . . . . . . . . . . . . 9betaxolol . . . . . . . . . . . . . . . . . . . 9bethanechol . . . . . . . . . . . . . . . 49BETHKIS . . . . . . . . . . . . . . . . . 53betrixaban . . . . . . . . . . . . . . . . . 7BEVYXXA . . . . . . . . . . . . . . . . . 7bexarotene caps and

topical gel . . . . . . . . . . . . . . 6BIAXIN . . . . . . . . . . . . . . . . . . . 29BIAXIN XL . . . . . . . . . . . . . . . . 29bicalutamide . . . . . . . . . . . . . . . 5BICILLIN L-A INJ . . . . . . . . . . . 29BICITRA . . . . . . . . . . . . . . . . . . 50BIEST/PROGESTERONE . . . 37BILTRICIDE . . . . . . . . . . . . . . . 28BIO-D DRO-MULSION . . . . . . 50BIO-D-MULSIO DRO FORTE 50BIOGAIA . . . . . . . . . . . . . . .28, 58bisoprolol . . . . . . . . . . . . . . . . . . 9bisoprolol/

hydrochlorothiazide . . . . . . 9BLEPH-10 . . . . . . . . . . . . . . . . 40BONINE . . . . . . . . . . . . . . . . . . 58BOOSTRIX . . . . . . . . . . . . . . . . 55bosentan . . . . . . . . . . . . . . . . . 12BOSULIF . . . . . . . . . . . . . . . . . . 4bosutinib . . . . . . . . . . . . . . . . . . 4BREO ELLIPTA . . . . . . . . . . . . 48BRETHINE . . . . . . . . . . . . . . . . 49brigatinib . . . . . . . . . . . . . . . . . . 4BRILINTA . . . . . . . . . . . . . . . . . . 7brimonidine . . . . . . . . . . . .19, 40BROMETANE DX . . . . . . . . . . 45BROMFED DM . . . . . . . . . . . . 45brompheniramine &

phenylephrine . . . . . . . . . . 44brompheniramine/

pseudoephedrine 44, 45, 56brompheniramine/

pseudoephedrine/dextromethorphan . . . . . . 45

budesonide . . . . . . . . 27, 48, 49bumetanide . . . . . . . . . . . . . . . 10

BUMEX . . . . . . . . . . . . . . . . . . . 10BUPHENYL . . . . . . . . . . . . . . . 53buprenorphine . . . . . . . . . . . . 43buprenorphine/naloxone . . . . 43bupropion . . . . . . . . . . . . . . . . 43bupropion extended-release . 43Burow’s soln, wet dressings . 57BUSPAR . . . . . . . . . . . . . . . . . . 41buspirone . . . . . . . . . . . . . . . . . 41busulfan . . . . . . . . . . . . . . . . . . . 4butalbital/acetaminophen . . . 13butalbital/acetaminophen/

caffeine . . . . . . . . . . . . . . . 13butalbital/apap/caff/cod . . . . 13butalbital/asa/caff/cod . . . . . 13butalbital/aspirin/caffeine . . . 13butorphanol . . . . . . . . . . . . . . . 14

Cc1 esterase inhibitor, human . 53cabergoline . . . . . . . . . . . . . . . 25CABOMETYX . . . . . . . . . . . . . . 4cabozantinib . . . . . . . . . . . . . . . 4CAFERGOT . . . . . . . . . . . . . . . 14calamine . . . . . . . . . . . . . . . . . . 20CALAN . . . . . . . . . . . . . . . .10, 15CALAN SR . . . . . . . . . . . . . . . . 10calcipotriene . . . . . . . . . . . . . . 19calcitonin-salmon . . . . . . . . . . 24calcitriol . . . . . . . . . . . . . . .19, 50calcitriol oral soln . . . . . . . . . . 50calcium

.2, 9, 10, 25, 50, 53, 59, 60calcium acetate . . . . . . . . . . . . 53CALQUENCE . . . . . . . . . . . . . . 4CALTRATE . . . . . . . . . . . . . . . . 59CAMPRAL . . . . . . . . . . . . . . . . 41canakinumab . . . . . . . . . . . . . 33CANASA. . . . . . . . . . . . . . . . . . 27capecitabine . . . . . . . . . . . . . . . 4CAPOTEN . . . . . . . . . . . . . . . . . 8CAPOZIDE . . . . . . . . . . . . . . . . . 8CAPRELSA . . . . . . . . . . . . . . . . 5CAPSAGEL . . . . . . . . . . . . . . . 34capsaicin . . . . . . . . . . . . . . . . . 34

captopril . . . . . . . . . . . . . . . . . . . 8captopril/hydrochlorothiazide . 8CAPZASIN-P . . . . . . . . . . . . . . 34CARAFATE . . . . . . . . . . . . . . . . 27CARAFATE SUSPENSION . . 27CARBAGLU . . . . . . . . . . . . . . . 53carbamazepine . . . . . . . . . . . . 16carbamazepine

extended-release . . . . . . . 16carbamide peroxide . . . . .21, 57CARBATROL . . . . . . . . . . . . . . 16carbidopa/levodopa . . . . . . . . 15carbidopa/levodopa extended-

release . . . . . . . . . . . . . . . . 15CARDEC DM DRO . . . . . . . . . 47CARDEC DM SYP . . . . . . . . . 47CARDEC DRO . . . . . . . . . . . . . 45CARDEC SYP . . . . . . . . . . . . . 45CARDENE . . . . . . . . . . . . . . . . 10CARDIZEM . . . . . . . . . . . . . . . 10CARDIZEM CD . . . . . . . . . . . . 10CARDIZEM SR . . . . . . . . . . . . 10CARDURA . . . . . . . . . . . . . . 8, 49carglumic acid . . . . . . . . . . . . . 53carteolol . . . . . . . . . . . . . . . . . . 39carvedilol . . . . . . . . . . . . . . . . . . 9casanthranol-docusate

sodium . . . . . . . . . . . . . . . . 25CASODEX . . . . . . . . . . . . . . . . . 5CASTIVA . . . . . . . . . . . . . . . . . 34CATAFLAM . . . . . . . . . . . .13, 34CATAPRES . . . . . . . . . . . . . . . . . 8CAYSTON . . . . . . . . . . . . . . . . 53CECLOR . . . . . . . . . . . . . . . . . 29cefaclor . . . . . . . . . . . . . . . . . . . 29cefadroxil . . . . . . . . . . . . . . . . . 29cefdinir . . . . . . . . . . . . . . . . . . . 29cefixime . . . . . . . . . . . . . . . . . . 29cefprozil . . . . . . . . . . . . . . . . . . 29CEFTIN . . . . . . . . . . . . . . . . . . . 29ceftriaxone . . . . . . . . . . . . . . . . 29cefuroxime axetil . . . . . . . . . . . 29CEFZIL . . . . . . . . . . . . . . . . . . . 29CELEBREX . . . . . . . . . . . . . . . 34celecoxib . . . . . . . . . . . . . . . . . 34

64


Index of Covered DrugsCELEXA . . . . . . . . . . . . . . . . . . 42CELLCEPT . . . . . . . . . . . . . . . . . 6CELONTIN . . . . . . . . . . . . . . . . 16CENESTIN . . . . . . . . . . . . . . . . 37CENOGEN OB/ULTRA . . . . . 52CENTRUM . . . . . . . . . . . . .51, 60CENTRUM PERFORMANCE,

CENTRUM SPECIALIST ENERGY, TAB-A-VITE TAB WOMENS, ALLERWELL . 60

cephalexin . . . . . . . . . . . . . . . . 29ceritinib . . . . . . . . . . . . . . . . . . . . 4certolizumab pegol . . . . . . . . . 33CETAPHIL CREAM AND

LOTION . . . . . . . . . . . . . . . 56cetirizine . . . . . . . . . . . 21, 22, 56cetirizine chew tab . . . . . . . . . 21cetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release . . . . . . . 22

cetirizine/pseudoephedrine OTC . . . . . . . . . . . . . . . . . . 56

CETYLEV . . . . . . . . . . . . . . . . . 53CHANTIX . . . . . . . . . . . . . . . . . 44CHEMET . . . . . . . . . . . . . . . . . 53CHERACOL SORE

THROAT . . . . . . . . 22, 57, 59CHERACOL SORE THROAT,

PAIN-A-LAY . . . . . 22, 57, 59CHILD IBUPRO SUS COLD . 48CHLOR-TRIMETON . . . . .21, 56CHLOR-TRIMETON

ALLERGY . . . . . . . . . . . . . 21CHLOR-TRIMETON SYRUP . 21chloral hydrate . . . . . . . . . . . . . 43chlorambucil . . . . . . . . . . . . . . . 4chlordiazepoxide. . . . . . . . . . . 41chlorhexidine gluconate. . . . . 22chloroquine phosphate . . . . . 33chlorothiazide . . . . . . . . . . . . . 10chlorphen tan/carbetapentane

tan . . . . . . . . . . . . . . . . . . . . 45chlorphen tan/pyrilamine tan/

PE tan . . . . . . . . . . . . . . . . . 45

chlorpheniramine extended-release . . . . . . . . . . . . . . . . 21

chlorpheniramine maleate . . .21, 45

chlorpheniramine maleate phenylephrine HCL . . . . . 45

chlorpheniramine tan/phenylephrine tan. . . . . . . 45

chlorpheniramine/dextromethorphan 45, 47, 48

chlorpheniramine/phenylephrine . . . . . . .21, 45

chlorpheniramine/phenylephrine/pyrilamine 21

chlorpheniramine/pseudoephedrine 22, 45, 56

chlorpromazine . . . . . . . . . . . . 44chlorpropamide. . . . . . . . . . . . 24chlorthalidone . . . . . . . . . . . 9, 10chlorzoxazone . . . . . . . . . . . . . 35CHOLBAM . . . . . . . . . . . . . . . . 25cholecalciferol . . . . . . . . . . . . . 50cholestyramine . . . . . . . . . . . . 11cholic acid . . . . . . . . . . . . . . . . 25choriogonadotropin alfa . . . . . 38chorionic gonadotropin . . . . . 38ciclopirox . . . . . . . . . . . . . . . . . 19cilostazol . . . . . . . . . . . . . . . . . . 7CILOXAN . . . . . . . . . . . . . . . . . 40cimetidine . . . . . . . . . . . . . . . . 26CIMZIA . . . . . . . . . . . . . . . . . . . 33cinacalcet . . . . . . . . . . . . . . . . . 53CIPRO . . . . . . . . . . . . . . . . . . . 29CIPRODEX . . . . . . . . . . . . . . . . 21ciprofloxacin . . . . . . . 21, 29, 40ciprofloxacin/

dexamethasone . . . . . . . . 21citalopram . . . . . . . . . . . . . . . . 42CLARAVIS . . . . . . . . . . . . . . . . 17clarithromycin . . . . . . . . . . . . . 29clarithromycin ER . . . . . . . . . . 29CLARITIN . . . . . . . . . . . . . .21, 56CLARITIN-D . . . . . . . . . . . . . . . 47CLEAR EYES REDNESS

RELIEF . . . . . . . . . . . . . . . . 38

CLEARASIL . . . . . . . . . . . . . . . 56clemastine . . . . . . . . . . . . . . . . 21CLEOCIN . . . . . . . . . . 17, 33, 38CLEOCIN T . . . . . . . . . . . . . . . 17CLIMARA . . . . . . . . . . . . . . . . . 37clindamycin . . . . . . . . 17, 33, 38CLINORIL . . . . . . . . . . . . . .13, 35clobazam . . . . . . . . . . . . . . . . . 16clobetasol propionate. . . . . . . 19clonazepam . . . . . . . . . . . .16, 41clonidine. . . . . . . . . . . . . . . . . . . 8clopidogrel . . . . . . . . . . . . . . . . . 7clorazepate . . . . . . . . . . . . . . . 41clotrimazole . . . . . 19, 30, 38, 56clotrimazole with

betamethasone . . . . . . . . . 19clozapine . . . . . . . . . . . . . . . . . 43CLOZARIL . . . . . . . . . . . . . . . . 43cobicistat . . . . . . . . . . . . . .32, 33cobicistat/elvitegravir/

emtricitabine/tenofovir . . . 32cobimetinib . . . . . . . . . . . . . . . . 4codeine sulfate . . . . . . . . . . . . 14codeine/acetaminophen . . . . 14codeine/chlorpheniramine/

pseudoephedrine . . . . . . . 45codeine/guaifenesin. . . . . . . . 45codeine/guaifenesin/

pseudoephedrine . . . . . . . 45codeine/promethazine. . . . . . 45codeine/promethazine/

phenylephrine . . . . . . . . . . 45CODIMAL DH . . . . . . . . . . . . . 47COGENTIN . . . . . . . . . . . . . . . 15COLACE . . . . . . . . . . . . . .25, 58COLAZAL . . . . . . . . . . . . . . . . 27colchicine . . . . . . . . . . . . . . . . . 35collagenase oint . . . . . . . . . . . 20COLLOIDAL OATMEAL

BATHS . . . . . . . . . . . . . . . . 57COLOCORT. . . . . . . . . . . . . . . 27COLYTE . . . . . . . . . . . . . . . . . . 25COMBIVENT . . . . . . . . . . . . . . 48COMBIVENT RESPIMAT . . . . 48COMBIVIR . . . . . . . . . . . . . . . . 32

65



COMETRIQ . . . . . . . . . . . . . . . . 4COMMIT LOZENGES . . . . . . . 59COMMITT OTC . . . . . . . . . . . . 44COMPAZINE . . . . . . . . . . . . . . 26COMPLERA . . . . . . . . . . . . . . 32COMPLETE NATALCARE PAK

DHA . . . . . . . . . . . . . . . . . . 51COMTAN . . . . . . . . . . . . . . . . . 15condoms-male . . . . . . . . . . . . 57CONDYLOX SOL . . . . . . . . . . 20conjugated estrogen/

bazedoxifene . . . . . . . . . . . 38contraceptive foam . . . . . . . . . 57contraceptive gel . . . . . . . . . . . 57COPAXONE . . . . . . . . . . . . . . . 15copper IUD . . . . . . . . . . . . . . . 35CORDARONE . . . . . . . . . . . . . . 9COREG . . . . . . . . . . . . . . . . . . . 9CORICIDIN TAB CGH/CLD . . 45CORTAID . . . . . . . . . . . . . . . . . 57CORTEF . . . . . . . . . . . . . . . . . . 22cortisone acetate . . . . . . . . . . 22CORTISPORIN . . . . . . . . .21, 39CORTISPORIN OTIC . . . . . . . 21CORTIZONE . . . . . . . . . . . . . . 18CORTIZONE-10 INTENSIVE

HEALING . . . . . . . . . . . . . . 18COSENTYX . . . . . . . . . . . . . . . 34COSOPT . . . . . . . . . . . . . . . . . 39COTELLIC . . . . . . . . . . . . . . . . . 4COUMADIN . . . . . . . . . . . . . . . . 7COZAAR . . . . . . . . . . . . . . . . . . 8CREON . . . . . . . . . . . . . . . . . . . 27CREON 3000 UNIT . . . . . . . . 27CRINONE GEL . . . . . . . . . . . . 37crisaborole . . . . . . . . . . . . . . . . 20CRIXIVAN . . . . . . . . . . . . . . . . . 32crizotinib . . . . . . . . . . . . . . . . . . . 4crofelemer . . . . . . . . . . . . . . . . 26CROLOM . . . . . . . . . . . . . . . . . 38cromolyn . . . . . . . . . . 22, 38, 49cromolyn sodium . . . . . . .22, 38crotamiton . . . . . . . . . . . . . . . . 19CULTURELLE . . . . . . . . . .28, 58CURITY ALCOHOL PADS . . . 57

CUTIVATE . . . . . . . . . . . . . . . . 18cyanocobalamin . . . . . . . . . . . 50CYCLESSA . . . . . . . . . . . . . . . 36cyclobenzaprine . . . . . . . . . . . 35CYCLOGYL . . . . . . . . . . . . . . . 40cyclopentolate . . . . . . . . . . . . . 40cyclophosphamide . . . . . . . . . . 4cycloserine . . . . . . . . . . . . . . . . 28cyclosporine . . . . . . . . . . . . . . . 6cyclosporine, modified . . . . . . . 6CYMBALTA . . . . . . . . . . . . . . . 42cyproheptadine . . . . . . . . . . . . 21CYSTAGON . . . . . . . . . . . . . . . . 6CYSTARAN . . . . . . . . . . . . . . . 41cysteamine 0.44% ophthalmic

solution . . . . . . . . . . . . . . . 41cysteamine bitartrate . . . . . . . . 6CYTOMEL . . . . . . . . . . . . . . . . 25CYTOTEC . . . . . . . . . . . . . . . . 28CYTOVENE . . . . . . . . . . . . . . . 30CYTOXAN . . . . . . . . . . . . . . . . . 4

DD3-50 CAP . . . . . . . . . . . . . . . . 50D.H.E. 45 . . . . . . . . . . . . . . . . . 14dabrafenib . . . . . . . . . . . . . . . . . 4daclizumab . . . . . . . . . . . . . . . 15DALMANE . . . . . . . . . . . . . . . . 43danazol . . . . . . . . . . . . . . . . . . . 37DANOCRINE . . . . . . . . . . . . . . 37DANTRIUM . . . . . . . . . . . . . . . 35dantrolene . . . . . . . . . . . . . . . . 35dapsone . . . . . . . . . . . . . . . . . . 33DARAPRIM . . . . . . . . . . . . . . . 33darbepoetin alfa . . . . . . . . . . . . 7darunavir . . . . . . . . . . . . . .32, 33darunavir/cobicistat . . . . . . . . 33dasatinib . . . . . . . . . . . . . . . . . . . 4DAYPRO . . . . . . . . . . . . . . .13, 34DDAVP . . . . . . . . . . . . . . . . . . . 25DEBROX . . . . . . . . . . . . . .21, 57DECADRON . . . . . . . . . . . . . . 22decongestants . . . 3, 22, 44, 59deferasirox . . . . . . . . . . . . . . . . . 7DELATESTRYL . . . . . . . . . . . . 23

delavirdine . . . . . . . . . . . . . . . . 31DELFEN . . . . . . . . . . . . . . . . . . 57DELSYM . . . . . . . . . . . . . . .46, 57DELTASONE . . . . . . . . . . . . . . 23DELZICOL . . . . . . . . . . . . . . . . 27DEMADEX . . . . . . . . . . . . . . . . 10DEMEROL . . . . . . . . . . . . . . . . 14DEPAKENE . . . . . . . . . . . . . . . 17DEPAKOTE . . . . . . . . 15, 16, 42DEPAKOTE ER . . . . . 15, 16, 42DEPAKOTE

SPRINKLE . . . . . . 15, 16, 42DEPEN TITRATABLE . . . . . . . 34DEPO-PROVERA . . . . . . . . . . 35DEPO-TESTOSTERONE . . . . 23DERMA-SMOOTHE OIL/FS . 18DERMAGRAN . . . . . . . . . . . . . 57DERMAPHOR OINTMENT . . 56dermatological baths . . . . . . . 57DERMATOP . . . . . . . . . . . . . . . 18DESCOVY . . . . . . . . . . . . . . . . 32DESENEX . . . . . . . . . . . . . . . . 19desipramine . . . . . . . . . . . . . . . 42desmopressin . . . . . . . . . . . . . 25desogestrel/EE . . . . . . . . .35, 36DESYREL . . . . . . . . . . . . . . . . . 43DETROL . . . . . . . . . . . . . . . . . . 50dexamethasone . . . . 21, 22, 39dexamethasone sodium

phosphate . . . . . . . . . . . . . 39DEXASOL . . . . . . . . . . . . . . . . 39DEXEDRINE SPANSULE . . . . 41dextroamphetamine extended-

release . . . . . . . . . . . . . . . . 41dextromethorphan hbr . . . . . . 46dextromethorphan polistirex

extended-release . . . . . . . 46dextromethorphan-doxylamine-

apap liquid . . . . . . . . . . . . . 57dextromethorphan-

guaifenesin . . . . . . . . . . . . 46dextromethorphan-

phenylephrine-apap . . . . . 57

66


Index of Covered Drugsdextromethorphan/

brompheniramine/pseudoephedrine . . . . . . . 45

dextromethorphan/ guaifenesin . . . . . . . . . 46-48

dextromethorphan/promethazine . . . . . . . . . . 46

dextromethorphan/quinidine 44DIABINESE . . . . . . . . . . . . . . . 24DIAMOX SEQUELS . . . . . . . . 40DIASTAT ACUDIAL . . . . . . . . . 16diazepam . . . . . . . . . . 16, 35, 41diclofenac 1% gel . . . . . . . . . . 34diclofenac potassium . . . .13, 34diclofenac sodium . . 13, 34, 39diclofenac sodium delayed-

release . . . . . . . . . . . . .13, 34diclofenac sodium extended-

release . . . . . . . . . . . . .13, 34dicloxacillin . . . . . . . . . . . . . . . 29dicyclomine . . . . . . . . . . . . . . . 27didanosine . . . . . . . . . . . . . . . . 32didanosine delayed-release . . 32DIDRONEL. . . . . . . . . . . . . . . . 24DIFFERIN OTC GEL 0.1% 17, 56DIFICID . . . . . . . . . . . . . . . . . . . 29DIFLUCAN . . . . . . . . . . . . .30, 38DIGESTIVE PROBIOTIC .28, 58digoxin . . . . . . . . . . . . . . . . . . . . 9DIHISTINE DH . . . . . . . . . . . . . 45DIHYDRO-PE SYP . . . . . . . . . 47dihydroergotamine . . . . . . . . . 14DILACOR XR . . . . . . . . . . . . . . 10DILANTIN . . . . . . . . . . . . . . . . . 16DILANTIN INFATABS . . . . . . . 16DILANTIN INJ . . . . . . . . . . . . . 16DILAUDID . . . . . . . . . . . . . . . . 14diltiazem . . . . . . . . . . . . . . . . . . 10diltiazem extended-release . . 10diltiazem sustained-release . . 10DIMEATAPP DRO

DECONGES . . . . . . . . . . . 22dimenhydrinate . . . . . . . . . . . . 58DIMETAPP . . 44, 45, 47, 56, 57

DIMETAPP CLD ELX/ ALLERGY . . . . . . . . . . . . . 44

DIMETAPP DRO DCON/ CGH . . . . . . . . . . . . . . . . . . 47

DIMETAPP DRO DECONGES . . . . . . . . . . . 57

DIMETAPP SYP CGH/CLD . . 45dimethyl fumarate . . . . . . . . . . 15DIP/TET PED INJ . . . . . . . . . . 54DIPENTUM . . . . . . . . . . . . . . . 27diphenhydramine . . . . . . .21, 43diphenoxylate/atropine . . . . . 26diphtheria-tetanus tox adsorbed

(dt) im . . . . . . . . . . . . . . . . . 54DIPROLENE . . . . . . . . . . .18, 19DIPROLENE AF . . . . . . . . . . . 18dipyridamole . . . . . . . . . . . . . . . 7DISALCID . . . . . . . . . . . . . . . . . 35disopyramide . . . . . . . . . . . . . . . 9disopyramide

extended-release . . . . . . . . 9disulfiram . . . . . . . . . . . . . . . . . 41DITROPAN . . . . . . . . . . . . . . . . 50DITROPAN XL . . . . . . . . . . . . . 50DIURIL . . . . . . . . . . . . . . . . . . . 10DIURIL ORAL SUSPENSION 10divalproex sodium cap

sprinkle . . . . . . . . 15, 16, 42divalproex sodium delayed-

release . . . . . . . . . 15, 16, 42divalproex sodium tab sr

24 hr . . . . . . . . . . . 15, 16, 42docosanol . . . . . . . . . . . . .31, 56docusate calcium plus . . . . . . 25docusate potasssium . . . . . . . 25docusate sodium . . . . . . . . . . 25dofetilide. . . . . . . . . . . . . . . . . . . 9dolutegravir . . . . . . . . . . . . 31-33dolutegravir/rilpivirine . . . . . . . 33DOMEBORO . . . . . . . . . . .21, 57DOMEBORO OTIC . . . . . . . . . 21donepezil . . . . . . . . . . . . . . . . . 12dornase alfa . . . . . . . . . . . . . . . 53dorzolamide . . . . . . . . . . . . . . . 39dorzolamide/timolol maleate 39

DOSTINEX . . . . . . . . . . . . . . . . 25DOVONEX . . . . . . . . . . . . . . . . 19doxazosin . . . . . . . . . . . . . . . 8, 49doxepin . . . . . . . . . . . . . . . . . . 42doxycycline monohydrate . . . 30doxylamine succinate . . . .43, 58DRAMAMINE . . . . . . . . . . . . . 58DRISDOL . . . . . . . . . . . . . . . . . 50dronabinol . . . . . . . . . . . . . . . . 26droperidol inj . . . . . . . . . . . . . . 26DROXIA . . . . . . . . . . . . . . . . . . . 6DUAVEE . . . . . . . . . . . . . . . . . . 38dulaglutide . . . . . . . . . . . . . . . . 24DULCOLAX . . . . . . . . . . . . . . . 58duloxetine . . . . . . . . . . . . . . . . 42DUOFILM . . . . . . . . . . . . . .20, 60DUONEB . . . . . . . . . . . . . . . . . 49DURAGESIC . . . . . . . . . . . . . . 14DURATUSS DM ELX,

PERTUSSIN . . . . . . . . . . . 46DUREX . . . . . . . . . . . . . . . . . . . 57DURICEF . . . . . . . . . . . . . . . . . 29DYAZIDE . . . . . . . . . . . . . . . . . 10

EE-OINTMENT . . . . . . . . . . . . . 56E.E.S. . . . . . . . . . . . . . . . . . . . . 29ecothiophate . . . . . . . . . . . . . . 40ECOTRIN . . . . . . . . . . . 7, 34, 59ED A-HIST TABLETS AND

LIQUID . . . . . . . . . . . . . . . . 45EDGE OB CHW . . . . . . . . . . . 52edoxaban . . . . . . . . . . . . . . . . . . 7EDURANT . . . . . . . . . . . . . . . . 31efavirenz . . . . . . . . . . . . . . .31, 32efavirenz/emtricitabine/

tenofovir . . . . . . . . . . . . . . . 32EFFEXOR . . . . . . . . . . . . . . . . . 42EFFEXOR XR . . . . . . . . . . . . . . 42EFFIENT . . . . . . . . . . . . . . . . . . . 7EFUDEX . . . . . . . . . . . . . . . . . . 20EGRIFTA . . . . . . . . . . . . . . . . . 24ELAVIL . . . . . . . . . . . . . . . .15, 42ELDEPRYL . . . . . . . . . . . . . . . . 15electrolyte . . . . . . . . . . . . . .50, 58

67



electrolyte rehydrating soln . . 58ELIDEL . . . . . . . . . . . . . . . . . . . 20ELIMITE . . . . . . . . . . . . . . . . . . 19ELIQUIS . . . . . . . . . . . . . . . . . . . 7ELMIRON . . . . . . . . . . . . . . . . . 50ELOCON . . . . . . . . . . . . . . . . . 18eltrombopag . . . . . . . . . . . . . . 53elvitegravir . . . . . . . . . . . . . 31-33elvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate . . . 33

EMCYT . . . . . . . . . . . . . . . . . . . . 4EMEND . . . . . . . . . . . . . . . . . . 26EMETROL . . . . . . . . . . . . . . . . 58emicizumab-kxwh . . . . . . . . . . . 7EMLA . . . . . . . . . . . . . . . . . . . . 20emollients . . . . . . . . . . . . . . . . . 56emtricitabine . . . . . . . . . . .32, 33emtricitabine/rilpivirine/

tenofovir . . . . . . . . . . . . . . . 32emtricitabine/tenofovir

alafenamide . . . . . . . . .32, 33emtricitabine/tenofovir

disoproxil . . . . . . . . . . . . . . 32EMTRIVA . . . . . . . . . . . . . . . . . 32enalapril . . . . . . . . . . . . . . . . . . . 8enalapril oral soln . . . . . . . . . . . 8enalapril/hydrochlorothiazide . 8ENBREL . . . . . . . . . . . . . . . . . . 33ENDOMETRIN SUP . . . . . . . . 38enfuvirtide . . . . . . . . . . . . . . . . 30ENGERIX-B . . . . . . . . . . . . . . . 54enoxaparin . . . . . . . . . . . . . . . . . 7entacapone . . . . . . . . . . . . . . . 15entecavir . . . . . . . . . . . . . . . . . . 31Enteric COATED-

NAPROSYN . . . . . . . . . . . . 13ENTERIC COATED-

NAPROSYN . . . . . . . . . . . . 34ENTOCORT EC . . . . . . . . . . . . 27ENTRESTO . . . . . . . . . . . . . . . . 8ENULOSE . . . . . . . . . . . . . . . . 25EPANED . . . . . . . . . . . . . . . . . . . 8epinephrine . . . . . . . . . . . . . . . 53EPIPEN . . . . . . . . . . . . . . . . . . . 53

EPIPEN JR. . . . . . . . . . . . . . . . 53EPIVIR . . . . . . . . . . . . . . . .31, 32EPIVIR HBV . . . . . . . . . . . . . . . 31epoetin alfa . . . . . . . . . . . . . . . . 7EPOGEN . . . . . . . . . . . . . . . . . . 7EPZICOM . . . . . . . . . . . . . . . . . 31ergocalciferol (D2) . . . . . . . . . 50ergotamine tartrate/caffeine . 14ergotamine/caffeine . . . . . . . . 14ERIVEDGE . . . . . . . . . . . . . . . . . 7erlotinib . . . . . . . . . . . . . . . . . . . 4ertugliflozin . . . . . . . . . . . . . . . 24ertugliflozin/metformin . . . . . . 24ERY-TAB . . . . . . . . . . . . . . . . . . 29ERYC . . . . . . . . . . . . . . . . . . . . 29ERYGEL . . . . . . . . . . . . . . . . . . 17ERYTHROCIN . . . . . . . . . . . . . 29erythromycin . . . . . . . 17, 29, 40erythromycin delayed-release 29erythromycin ethylsuccinate . 29erythromycin stearate . . . . . . . 29erythromycin/sulfisoxazole . . 29ESBRIET . . . . . . . . . . . . . . . . . 44escitalopram . . . . . . . . . . . . . . 42ESGIC . . . . . . . . . . . . . . . . . . . . 13ESKALITH CR . . . . . . . . . . . . . 42esomeprazole . . . . . . . . . . . . . 26esomeprazole granules . . . . . 26ESTRACE . . . . . . . . . . . . . . . . . 37ESTRACE CRM. . . . . . . . . . . . 37estradiol . . . . . . . . . . . . . . . . . . 37estradiol vaginal tablet . . . . . . 37estradiol-estriol-progesterone

micronized cream (cmpd kit) . . . . . . . . . . . . . 37

estramustine phosphate sodium . . . . . . . . . . . . . . . . . 4

estrogens, conjugated . . . . . . 37estrogens, conjugated/

medroxyprogesterone . . . 37estrogens, conjugated,

synthetic A . . . . . . . . . . . . . 37estropipate . . . . . . . . . . . . . . . . 37ESTROSTEP FE . . . . . . . . . . . 36etanercept . . . . . . . . . . . . . . . . 33

ethambutol . . . . . . . . . . . . . . . . 28ethionamide . . . . . . . . . . . . . . . 28ethosuximide . . . . . . . . . . . . . . 16ethynodiol diacetate/EE . . . . . 36etidronate . . . . . . . . . . . . . . . . . 24etodolac . . . . . . . . . . . . . . .13, 34etonogestrel subdermal

implant . . . . . . . . . . . . . . . . 35etonogestrel/EE . . . . . . . . . . . 36etoposide . . . . . . . . . . . . . . . . . . 6etravirine . . . . . . . . . . . . . . . . . . 31EUCRISA . . . . . . . . . . . . . . . . . 20EULEXIN . . . . . . . . . . . . . . . . . . 5EURAX . . . . . . . . . . . . . . . . . . . 19everolimus . . . . . . . . . . . . . . . 4, 6EVISTA . . . . . . . . . . . . . . . . . . . 24EVOTAZ . . . . . . . . . . . . . . . . . . 32EXCEDRIN MIGRAINE . . . . . . 13EXELON . . . . . . . . . . . . . . . . . . 12exemestane . . . . . . . . . . . . . . . . 5EXJADE . . . . . . . . . . . . . . . . . . . 7exogabine . . . . . . . . . . . . . . . . 16ezetimibe . . . . . . . . . . . . . . . . . 11

Ffamotidine . . . . . . . . . . . . .26, 58FANTASY . . . . . . . . . . . . . . . . . 57FARESTON . . . . . . . . . . . . . . . . 5FARYDAK . . . . . . . . . . . . . . . . . . 4febuxostat . . . . . . . . . . . . . . . . 35felbamate . . . . . . . . . . . . . . . . . 16felbamate oral susp . . . . . . . . 16FELBATOL . . . . . . . . . . . . . . . . 16FELBATOL ORAL SUSP . . . . 16FELDENE . . . . . . . . . . . . . .13, 35felodipine extended-release . . 9FEMARA . . . . . . . . . . . . . . . . . . 5fenofibrate . . . . . . . . . . . . . . . . 11fentanyl transdermal . . . . . . . . 14FEOSOL . . . . . . . . . . . . . . .51, 59FERGON . . . . . . . . . . . . . . . . . 59ferrous bis-glycinate chelate . 59ferrous bisglycinate/

polysaccarides iron . . . . . 51ferrous fumarate . . . . . . . . . . . 59

68


Index of Covered Drugsferrous gluconate . . . . . . . . . . 59ferrous sulfate . . . . . . . . . .51, 59fidaxomicin . . . . . . . . . . . . . . . 29filgrastim . . . . . . . . . . . . . . . . . . . 7FINACEA . . . . . . . . . . . . . . . . . 17finasteride . . . . . . . . . . . . . . . . 49fingolimod . . . . . . . . . . . . . . . . 15FIORICET . . . . . . . . . . . . . . . . . 13FIORICET W/CODEINE . . . . . 13FIORINAL . . . . . . . . . . . . . . . . . 13FIORINAL W/CODEINE . . . . . 13FIRAZYR . . . . . . . . . . . . . . . . . 53FIRST-PROGESTERONE . . . . 38FLAGYL . . . . . . . . . . . . . . .33, 38flavoxate . . . . . . . . . . . . . . . . . . 49flecainide . . . . . . . . . . . . . . . . . . 9FLEET ENEMA . . . . . . . . . . . . 58FLEET PHOSPHO-SODA . . . 58FLEXERIL . . . . . . . . . . . . . . . . . 35FLOMAX. . . . . . . . . . . . . . . . . . 49FLONASE . . . . . . . . . . . . . . . . . 22FLORAJEN . . . . . . . . . . . .28, 58FLORANEX . . . . . . . . . . . .28, 58FLORASTOR . . . . . . . . . . .28, 58FLORINEF . . . . . . . . . . . . . . . . 22FLOVENT DISKUS . . . . . . . . . 48FLOVENT HFA . . . . . . . . . . . . 48FLOXIN . . . . . . . . . . . . . . . .21, 29FLOXIN OTIC . . . . . . . . . . . . . . 21FLUARIX QUAD . . . . . . . . . . . 54FLUBLOK . . . . . . . . . . . . . . . . . 54FLUCELVAX . . . . . . . . . . . . . . . 54fluconazole . . . . . . . . . . . .30, 38fludrocortisone . . . . . . . . . . . . 22FLULAVAL QUAD . . . . . . . . . . 54FLUMADINE . . . . . . . . . . . . . . 31fluocinolone acetonide . . . . . . 18fluocinonide . . . . . . . . . . . . . . . 18fluocinonide emulsified base 18fluoride . . . . . . . . . . . . 51, 52, 60fluoride dental rinse . . . . . . . . 60fluorometholone . . . . . . . . . . . 39fluorouracil . . . . . . . . . . . . . . . . 20fluoxetine . . . . . . . . . . . . . . . . . 42fluoxetine HCL (PMDD) cap . 42

fluphenazine . . . . . . . . . . . . . . 44fluphenazine decanoate . . . . 44flurazepam . . . . . . . . . . . . . . . . 43flurbiprofen . . . . . . . . . . . . . . . 39flutamide . . . . . . . . . . . . . . . . . . 5fluticasone . . . . . . . . . 18, 22, 48fluticasone furoate . . . . . . . . . 48fluticasone HFA . . . . . . . . . . . . 48fluticasone propionate . . .18, 48fluticasone/salmeterol . . . . . . 48fluticasone/vilanterol . . . . . . . 48FLUVIRIN . . . . . . . . . . . . . . . . . 54fluvoxamine . . . . . . . . . . . . . . . 41FLUZONE HD PF . . . . . . . . . . 54FLUZONE QUAD. . . . . . . . . . . 54FLUZONE SPLT . . . . . . . . . . . 54FML . . . . . . . . . . . . . . . . . . . . . . 39FML FORTE . . . . . . . . . . . . . . . 39FML LIQUIFILM . . . . . . . . . . . . 39folic acid . . . . . . . . . . . . . . .51, 52FOLTABS PAK PLUS DHA RE

OB + DHA PAK . . . . . . . . . 51FOLTABS PRENATAL . . . . . . . 52FORTICAL . . . . . . . . . . . . . . . . 24FOSAMAX . . . . . . . . . . . . . . . . 24fosamprenavir . . . . . . . . . . . . . 32fosinopril. . . . . . . . . . . . . . . . . . . 8fosinopril/hydrochlorothiazide 8FURADANTIN SUSP

25 MG/5 ML . . . . . . . . . . . 33furosemide . . . . . . . . . . . . . . . . 10FUZEON . . . . . . . . . . . . . . . . . . 30

Ggabapentin . . . . . . . . . . . . . . . . 16GABITRIL . . . . . . . . . . . . . . . . . 17galantamine . . . . . . . . . . . . . . . 12ganciclovir . . . . . . . . . . . . . . . . 30GARDASIL . . . . . . . . . . . . . . . . 54GARDASIL 9 . . . . . . . . . . . . . . 54gatifloxin . . . . . . . . . . . . . . . . . . 40GATTEX . . . . . . . . . . . . . . . . . . 28gefitinib . . . . . . . . . . . . . . . . . . . . 4GEL-KAM . . . . . . . . . . . . . . . . . 51gemfibrozil . . . . . . . . . . . . . . . . 11

GENGRAF . . . . . . . . . . . . . . . . . 6GENTAK . . . . . . . . . . . . . . .18, 40gentamicin . . . . . . . . . 18, 39, 40gentamicin/prednisolone

acetate . . . . . . . . . . . . . . . . 39GENTEX ADE 28-1 MG . . . . . 51GENVOYA . . . . . . . . . . . . . . . . 33GEODON . . . . . . . . . . . . . . . . . 44GEODON INJ . . . . . . . . . . . . . 44GG/CODEINE . . . . . . . . . . . . . 45GG/DM CR . . . . . . . . . . . . . . . 46GILENYA . . . . . . . . . . . . . . . . . 15GILOTRIF . . . . . . . . . . . . . . . . . . 4glatiramer acetate . . . . . . . . . . 15GLATOPA . . . . . . . . . . . . . . . . . 15glecaprevir/pibrentasvir . . . . . 31GLEEVEC . . . . . . . . . . . . . . . . . 5GLEOSTINE . . . . . . . . . . . . . . . . 4glimepiride . . . . . . . . . . . . . . . . 24glipizide . . . . . . . . . . . . . . . . . . 24glipizide extended-release . . . 24glipizide/metformin. . . . . . . . . 24GLUCAGON . . . . . . . . . . . . . . 23glucagon, human

recombinant . . . . . . . . . . . 23GLUCOPHAGE . . . . . . . . . . . . 24GLUCOPHAGE ER . . . . . . . . . 24glucose oral tablets . . . . . . . . 57GLUCOTROL . . . . . . . . . . . . . 24GLUCOTROL XL . . . . . . . . . . . 24GLUCOVANCE . . . . . . . . . . . . 24glyburide . . . . . . . . . . . . . . . . . 24glyburide, micronized . . . . . . . 24glycerin . . . . . . . . . . . . 25, 38, 56GLYCERIN SUPPOSITORY . . 25GLYCERIN TOPICAL . . . . . . . 56glycerol phenylbutyrate . . . . . 53glycopyrrolate . . . . . . . . . . . . . 27GLYNASE . . . . . . . . . . . . . . . . . 24GRIFULVIN V . . . . . . . . . . . . . . 30GRIS-PEG . . . . . . . . . . . . . . . . 30griseofulvin microsize . . . . . . . 30griseofulvin ultramicrosize . . . 30guaifenesin . . . . . . . . . . . . 45-48guaifenesin extended-release 46

69



guaifenesin/pseudoephedrine .45, 46

guaifenesin/pseudoephedrine extended-release . . . . . . . 46

guaifenesin/pseudoephedrine/dextromethorphan . . . . . . 46

guanabenz . . . . . . . . . . . . . . . . 12guanfacine . . . . . . . . . . . . . . 8, 41guanfacine ER . . . . . . . . . . . . . 41GUIATUSS AC . . . . . . . . . . . . . 45GUIATUSS DAC . . . . . . . . . . . 45GYNE-LOTRIMIN . . . . . . .38, 56GYNOL II . . . . . . . . . . . . . . . . . 57

HHAEGARDA . . . . . . . . . . . . . . . 53HALCION . . . . . . . . . . . . . . . . . 43HALDOL . . . . . . . . . . . . . . . . . . 44HALDOL CONCENTRATE . . 44HALDOL DECANOATE . . . . . 44halobetasol . . . . . . . . . . . . . . . 19haloperidol . . . . . . . . . . . . . . . . 44haloperidol decanoate . . . . . . 44haloperidol lactate oral conc . 44HAVRIX . . . . . . . . . . . . . . . . . . . 54HECORIA . . . . . . . . . . . . . . . . . . 6HEMLIBRA . . . . . . . . . . . . . . . . 7heparin . . . . . . . . . . . . . . . . . . . . 7hepatitis a vaccine susp . . . . . 54hepatitis b vaccine

(recombinant) . . . . . . . . . . 54hepatitis b vaccine

recombinant adjuvanted . 54HEPLISAV-B . . . . . . . . . . . . . . 54HEXALEN . . . . . . . . . . . . . . . . . 4HIPREX . . . . . . . . . . . . . . . . . . 50homatropine . . . . . . . . . . .40, 47HUMALOG MIX 50/50. . . . . . 23HUMALOG MIX 75/25. . . . . . 23human papillomavirus (hpv)

9-valent recomb vac . . . . . 54human papillomavirus (hpv)

quadrivalent recombinant vac . . . . . . . . . . . . . . . . . . . 54

HUMATIN . . . . . . . . . . . . . . . . . 33

HUMIRA . . . . . . . . . . . . . . . . . . 33HUMULIN. . . . . . . . . . . . . .23, 57HUMULIN 70/30 . . . . . . . . . . 23HUMULIN N . . . . . . . . . . . . . . . 23HUMULIN R . . . . . . . . . . . . . . . 23HYCAMTIN . . . . . . . . . . . . . . . . 7HYCODAN . . . . . . . . . . . . . . . . 47hydralazine. . . . . . . . . . . . . . . . 12HYDREA . . . . . . . . . . . . . . . . . . 6hydrochlorothiazide . . . . . . 8-10hydrocodone ER . . . . . . . . . . . 14hydrocodone/acetaminophen 14hydrocodone/homatropine . . 47HYDROCODONE/TAB

HOMATROP . . . . . . . . . . . 47hydrocortisone . . 18, 20-22, 27,

39, 57, 58hydrocortisone butyrate . . . . . 18hydrocortisone crm, oint . . . . 57hydrocortisone valerate . . . . . 18hydrocortisone/aloe . . . . . . . . 18HYDROMET SYP . . . . . . . . . . 47hydromorphone . . . . . . . . . . . 14hydroxychloroquine . . . . .33, 34HYDROXYPROGESTEONE

CAPROATE (BULK) POWDER . . . . . . . . . . . . . . 37

hydroxyprogesterone caproate (bulk) powder . . . . . . . . . . 37

hydroxyprogesterone caproate IM . . . . . . . . . . . . . . . . . . . . 38

hydroxyurea . . . . . . . . . . . . . . . . 6hydroxyzine HCL . . . . . . . . . . . 21hydroxyzine pamoate . . . . . . . 21hyoscyamine . . . . . . . . . . .27, 50hyoscyamine sulfate . . . . . . . . 27hyoscyamine sulfate extended-

release . . . . . . . . . . . . . . . . 27HYPERCARE 15% . . . . . . . . . 20HYPERSAL . . . . . . . . . . . . . . . 53HYPERTET S/D . . . . . . . . . . . 55HYPOTEARS . . . . . . . . . . . . . . 59HYTONE . . . . . . . . . . . . . . . . . 18HYTRIN . . . . . . . . . . . . . . . . 8, 49HYZAAR . . . . . . . . . . . . . . . . . . 8

IIBRANCE . . . . . . . . . . . . . . . . . . 5ibrutinib . . . . . . . . . . . . . . . . . . . 4IBUOROFEN TAB COLD/

SIN . . . . . . . . . . . . . . . . . . . 48ibuprofen . . . . . . . . . . 13, 34, 59ibuprofen tabs, chew tabs,

drops, susp . . . . . . . . . . . . 59icatibant . . . . . . . . . . . . . . . . . . 53ICLUSIG . . . . . . . . . . . . . . . . . . . 5idelalisib . . . . . . . . . . . . . . . . . . . 4ILARIS . . . . . . . . . . . . . . . . . . . 33imatinib mesylate . . . . . . . . . . . 5IMBRUVICA . . . . . . . . . . . . . . . . 4IMDUR . . . . . . . . . . . . . . . . . . . 11imipramine HCL . . . . . . . . . . . 42imiquimod . . . . . . . . . . . . . . . . 20IMITREX . . . . . . . . . . . . . . . . . . 14IMITREX 4 MG AND

6 MG INJ . . . . . . . . . . . . . . 14IMODIUM A-D . . . . . . . . . .26, 58IMPAVIDO . . . . . . . . . . . . . . . . 30IMURAN . . . . . . . . . . . . . . . . 6, 33INAPSINE INJ . . . . . . . . . . . . . 26INCRELEX . . . . . . . . . . . . . . . . 24INCRUSE ELLIPTA . . . . . . . . . 49indacaterol . . . . . . . . . . . . . . . . 48indapamide . . . . . . . . . . . . . . . 10INDERAL . . . . . . . . . . . . . . . 9, 15INDERIDE . . . . . . . . . . . . . . . . . 9indinavir . . . . . . . . . . . . . . . . . . 32INDOCIN . . . . . . . . . . . . . .13, 34indomethacin . . . . . . . . . .13, 34INFLAMASE FORTE . . . . . . . . 39influenza virus vaccine

recombinant hemagglutinin (ha) . . . . . . . . . . . . . . . . . . . 54

influenza virus vaccine split . . 54influenza virus vaccine split

high-dose pf . . . . . . . . . . . 54influenza virus vaccine

split pf . . . . . . . . . . . . . . . . . 54influenza virus vaccine split

quadrivalent . . . . . . . . . . . . 54

70


Index of Covered Drugsinfluenza virus vaccine tiss-cult

subunit . . . . . . . . . . . . . . . . 54influenza virus vaccine types

a&b surface antigen . . . . . 54INGREZZA . . . . . . . . . . . . . . . . 17INLYTA . . . . . . . . . . . . . . . . . . . . 4insulin (vials only) . . . . . . . . . . 57insulin aspart protamine 70%/

insulin aspart 30% . . . . . . 23insulin glargine . . . . . . . . . . . . 23insulin glargine/lixisenatide . . 23insulin human . . . . . . . . . . . . . 23insulin isophane . . . . . . . . . . . 23insulin isophane human . . . . . 23insulin isophane human 70%/

regular 30% . . . . . . . . . . . . 23insulin isophane/regular . . . . 23insulin lisopro pro/lispro . . . . 23insulin lisopro prot/lispro . . . . 23insulin lispro . . . . . . . . . . . . . . . 23insulin regular . . . . . . . . . . . . . 23insulin syringes . . . . . . . . . . . . 53INTAL . . . . . . . . . . . . . . . . . . . . 49INTELENCE . . . . . . . . . . . . . . . 31interferon alfa-2b . . . . . . . . . 6, 31INTRON A . . . . . . . . . . . . . . 6, 31INTUNIV . . . . . . . . . . . . . . . . . . 41INVEGA SUSTENNA . . . . . . . 43INVEGA TRINZA . . . . . . . . . . . 43INVIRASE . . . . . . . . . . . . . . . . . 32ipratropium . . . . . . . . 22, 48, 49ipratropium HFA . . . . . . . . . . . 48ipratropium nasal . . . . . . . . . . 22ipratropium/albuterol . . . .48, 49irbesartan . . . . . . . . . . . . . . . . . . 8IRESSA . . . . . . . . . . . . . . . . . . . . 4iron . . . . . . . . . . . . 36, 51, 52, 59iron polysaccharides . . . . . . . 59ISENTRESS . . . . . . . . . . . . . . . 31ISENTRESS CHEWABLE . . . 31ISENTRESS SUSP . . . . . . . . . 31ISMO . . . . . . . . . . . . . . . . . . . . . 11isoniazid . . . . . . . . . . . . . . . . . . 28ISOPTO ATROPINE . . . . . . . . 40ISOPTO CARPINE . . . . . . . . . 40

ISOPTO HOMATROPINE. . . . 40ISOPTO HYOSCINE . . . . . . . . 40ISORDIL . . . . . . . . . . . . . . . . . . 11ISORDIL S.L. . . . . . . . . . . . . . . 11isosorbide dinitrate . . . . . . . . . 11ISOSORBIDE DINITRATE ER 11isosorbide dinitrate extended-

release . . . . . . . . . . . . . . . . 11isosorbide mononitrate . . . . . 11isosorbide mononitrate

extended-release . . . . . . . 11isotretinoin . . . . . . . . . . . . . . . . 17itraconazole . . . . . . . . . . . . . . . 30ivacaftor . . . . . . . . . . . . . . . . . . 53ivermectin . . . . . . . . . . . . . . . . 28ixazomib . . . . . . . . . . . . . . . . . . . 5

JJADENU . . . . . . . . . . . . . . . . . . . 7JAKAFI . . . . . . . . . . . . . . . . . . . . 5JULUCA . . . . . . . . . . . . . . . . . . 33

KK-DUR 10, K-DUR 20 . . . . . . . 52K-LOR . . . . . . . . . . . . . . . . . . . . 52K-LYTE . . . . . . . . . . . . . . . . . . . 52K-PHOS NEUTRAL . . . . . . . . . 52K-PHOS ORIGINAL . . . . . . . . 52K-TAB 20 . . . . . . . . . . . . . . . . . 52KALETRA . . . . . . . . . . . . . . . . 32KALYDECO . . . . . . . . . . . . . . . 53KALYDECO GRANULES . . . . 53KAOPECTATE . . . . . . . . . . . . . 58KAYEXALATE . . . . . . . . . . . . . 11KAZANO . . . . . . . . . . . . . . . . . 24KEFLEX . . . . . . . . . . . . . . . . . . 29KENALOG . . . . . . . . . . . . .18, 22KENALOG IN ORABASE . . . . 22KEPPRA . . . . . . . . . . . . . . . . . . 16KERLONE . . . . . . . . . . . . . . . . . 9ketoconazole . . . . . . . 19, 20, 30ketoprofen . . . . . . . . . . . . .13, 34ketorolac . . . . . . . . . . . . . .13, 39ketorolac tromethamine . . . . . 13ketotifen . . . . . . . . . . . . . . . . . . 38

KIMONO. . . . . . . . . . . . . . . . . . 57KINERET . . . . . . . . . . . . . . . . . 33KLONOPIN . . . . . . . . . . . .16, 41KLOR-CON 8,

KLOR-CON 10 . . . . . . . . . 52KORLYM . . . . . . . . . . . . . . . . . 25KUVAN . . . . . . . . . . . . . . . . . . . 25KUVAN POWDER FOR

SOLUTION . . . . . . . . . . . . 25

Llabetalol . . . . . . . . . . . . . . . . . . . 9LAC-HYDRIN . . . . . . . . . . . . . . 20lacosamide . . . . . . . . . . . . . . . 16LACTINEX . . . . . . . . . . . . .28, 58LACTINOL . . . . . . . . . . . . . . . . 20lactulose . . . . . . . . . . . . . . . . . . 25LAMICTAL . . . . . . . . . . . . . . . . 16LAMICTAL CD CHEW TAB . . 16LAMICTAL STARTER KIT . . . 16LAMISIL . . . . . . . . . . . . . . .19, 30LAMISIL AT . . . . . . . . . . . . . . . 19lamivudine . . . . . . . . . . . . .31, 32lamivudine/zidovudine . . .31, 32lamotrigine . . . . . . . . . . . . . . . . 16lamotrigine chew dispersable

tab . . . . . . . . . . . . . . . . . . . . 16lamotrigine starter kit . . . . . . . 16lancets . . . . . . . . . . . . . . . . . . . 53LANOXIN . . . . . . . . . . . . . . . . . . 9lansoprazole . . . . . . . . . . . . . . 26lansoprazole delayed-release 26lapatinib ditosylate . . . . . . . . . . 5LARIAM . . . . . . . . . . . . . . . . . . 33LASIX . . . . . . . . . . . . . . . . . . . . 10latanoprost . . . . . . . . . . . . . . . . 40laxative enemas . . . . . . . . . . . 58laxatives . . . . . . . . . . . . 2, 25, 58leflunomide . . . . . . . . . . . . . . . 34lenalidomide . . . . . . . . . . . . . . . 6lenvatinib . . . . . . . . . . . . . . . . . . 5LENVIMA . . . . . . . . . . . . . . . . . . 5LETAIRIS . . . . . . . . . . . . . . . . . 12letrozole . . . . . . . . . . . . . . . . . . . 5leucovorin . . . . . . . . . . . . . . . . . 5

71



LEUKERAN . . . . . . . . . . . . . . . . 4LEUKINE . . . . . . . . . . . . . . . . . . 7leuprolide . . . . . . . . . . . . . . . . . . 5levalbuterol HCl . . . . . . . . . . . . 49LEVAQUIN . . . . . . . . . . . . . . . . 29levetiracetam . . . . . . . . . . . . . . 16levobunolol . . . . . . . . . . . . . . . 39levocetirizine . . . . . . . . . . . . . . 21levofloxacin . . . . . . . . . . . . . . . 29levonorgestrel . . . . . . . . . .35, 36levonorgestrel releasing IUD . 35levonorgestrel/EE . . . . . . .35, 36levothyroxine . . . . . . . . . . . . . . 25LEVOXYL . . . . . . . . . . . . . . . . . 25LEVSIN . . . . . . . . . . . . . . . . . . . 27LEVSINEX . . . . . . . . . . . . . . . . 27LEXAPRO . . . . . . . . . . . . . . . . 42LEXIVA . . . . . . . . . . . . . . . . . . . 32LIBRIUM . . . . . . . . . . . . . . . . . . 41LIDAMANTEL . . . . . . . . . . . . . 20LIDEX . . . . . . . . . . . . . . . . . . . . 18LIDEX E . . . . . . . . . . . . . . . . . . 18lidocaine . . . . . . . . . . . . . . .20, 22lidocaine patch . . . . . . . . . . . . 20lidocaine viscous . . . . . . . . . . 22lidocaine/prilocaine . . . . . . . . 20LIDODERM . . . . . . . . . . . . . . . 20LIFESTYLES . . . . . . . . . . . . . . 57lifitegrast . . . . . . . . . . . . . . . . . . 40LILETTA . . . . . . . . . . . . . . . . . . 35linaclotide . . . . . . . . . . . . . . . . . 25linezolid . . . . . . . . . . . . . . . . . . 33LINZESS . . . . . . . . . . . . . . . . . . 25liothyronine . . . . . . . . . . . . . . . 25liotrix . . . . . . . . . . . . . . . . . . . . . 25LIPITOR . . . . . . . . . . . . . . . . . . 11liraglutide . . . . . . . . . . . . . . . . . 24lisdexamfetamine . . . . . . . . . . 41lisinopril . . . . . . . . . . . . . . . . 8, 83lisinopril/hydrochlorothiazide . 8lithium carbonate . . . . . . . . . . 42lithium carbonate extended-

release . . . . . . . . . . . . . . . . 42LITHOBID . . . . . . . . . . . . . . . . . 42lixisenatide . . . . . . . . . . . . .23, 24

LMX-4 . . . . . . . . . . . . . . . . . . . . 20LO/OVRAL . . . . . . . . . . . . . . . . 36LOCOID . . . . . . . . . . . . . . . . . . 18LODINE . . . . . . . . . . . . . . .13, 34LOESTRIN 1/20 . . . . . . . . . . . 36LOESTRIN 1.5/30 . . . . . . . . . 36LOESTRIN FE 1/20 . . . . . . . . 36LOESTRIN FE 1.5/30 . . . . . . . 36LOFIBRA . . . . . . . . . . . . . . . . . 11LOHIST-D . . . . . . . . . . . . . . . . . 45LOMOTIL . . . . . . . . . . . . . . . . . 26lomustine . . . . . . . . . . . . . . . . . . 4LONITEN . . . . . . . . . . . . . . . . . 12LONSURF . . . . . . . . . . . . . . . . . 4loperamide . . . . . . . . . . . . . . . . 26LOPID . . . . . . . . . . . . . . . . . . . . 11lopinavir/ritonavir . . . . . . . . . . 32LOPRESSOR . . . . . . . . . . . . . . . 9LOPRESSOR HCT . . . . . . . . . . 9loratadine . . . . . . . 21, 22, 47, 56loratadine & pseudoephedrine

SR 24hr . . . . . . . . . . . . . . . 47loratadine/

pseudoephedrine 22, 47, 56loratadine/pseudoephedrine

ext-rel . . . . . . . . . . . . . . . . . 22lorazepam . . . . . . . . . . . . . . . . 41lorazepam inj . . . . . . . . . . . . . . 41LORCET . . . . . . . . . . . . . . . . . . 14LORTAB . . . . . . . . . . . . . . . . . . 14LORTAB ELIXIR . . . . . . . . . . . 14losartan . . . . . . . . . . . . . . . . . . . 8losartan/HCTZ . . . . . . . . . . . . . 8LOTENSIN . . . . . . . . . . . . . . . . . 8LOTENSIN HCT . . . . . . . . . . . . 8LOTREL . . . . . . . . . . . . . . . . . . 10LOTRIMIN AF . . . . . . . . . .19, 56LOTRISONE . . . . . . . . . . . . . . . 19lovastatin . . . . . . . . . . . . . . . . . 11LOVAZA . . . . . . . . . . . . . . . . . . 11LOVENOX . . . . . . . . . . . . . . . . . 7loxapine . . . . . . . . . . . . . . . . . . 44LOXITANE . . . . . . . . . . . . . . . . 44LOZOL . . . . . . . . . . . . . . . . . . . 10LUDIOMIL . . . . . . . . . . . . . . . . 43

lumacaftor/ivacaftor . . . . . . . . 53LUMINAL INJ . . . . . . . . . . . . . . 16LUPRON . . . . . . . . . . . . . . . . . . 5LUPRON DEPOT . . . . . . . . . . . 5LUPRON DEPOT 6-MONTH . . 5LUPRON DEPOT-PED . . . . . . . 5LURIDE . . . . . . . . . . . . . . . . . . . 51LURIDE LOZI-TABS. . . . . . . . . 51LUVOX . . . . . . . . . . . . . . . . . . . 41LYNPARZA . . . . . . . . . . . . . . . . 6LYRICA . . . . . . . . . . . . . . . .16, 17LYRICA SOLUTION . . . . . . . . 17LYSODREN . . . . . . . . . . . . . . . . 6LYSTEDA . . . . . . . . . . . . . . . . . 38

MM-CLEAR WC . . . . . . . . . . . . . 45M-M-R II . . . . . . . . . . . . . . . . . . 54MAALOX . . . . . . . . . . . . . .26, 58MAALOX LIQUID . . . . . . . . . . 58macitentan . . . . . . . . . . . . . . . . 12MACROBID . . . . . . . . . . . . . . . 33MACRODANTIN . . . . . . . . . . . 33MAG-OX . . . . . . . . . . . . . . .51, 59magnesium citrate soln . . . . . 25magnesium oxide . . . . . . .51, 59MAKENA . . . . . . . . . . . . . . . . . 38malathion . . . . . . . . . . . . . . . . . 19MAPAP COLD TAB . . . . . . . . 47maprotiline . . . . . . . . . . . . . . . . 43maraviroc . . . . . . . . . . . . . . . . . 33MARINOL . . . . . . . . . . . . . . . . . 26MATERNA . . . . . . . . . . . . . . . . 52MATULANE . . . . . . . . . . . . . . . . 6MAVIK . . . . . . . . . . . . . . . . . . . . . 8MAVYRET . . . . . . . . . . . . . . . . 31MAXALT/MAXALT MLT . . . . . 14MAXITROL. . . . . . . . . . . . . . . . 39MAXZIDE . . . . . . . . . . . . . . . . . 10measles, mumps & rubella virus

vaccines for inj . . . . . . . . . 54mecasermin . . . . . . . . . . . . . . . 24meclizine . . . . . . . . . . . . . .26, 58MEDROL . . . . . . . . . . . . . . . . . 22

72


Index of Covered Drugsmedroxyprogesterone

acetate . . . . . . . . . . . . .35, 37mefloquine . . . . . . . . . . . . . . . . 33MEGACE . . . . . . . . . . . . . . . . . . 6megestrol acetate . . . . . . . . . . . 6MEKINIST . . . . . . . . . . . . . . . . . 5MELLARIL . . . . . . . . . . . . . . . . 44meloxicam . . . . . . . . . . . . .13, 34melphalan . . . . . . . . . . . . . . . . . 4memantine . . . . . . . . . . . . . . . . 12MENACTRA . . . . . . . . . . . . . . . 54meningococcal (a, c, y, and

w-135) . . . . . . . . . . . . .54, 55meningococcal (a, c, y, and

w-135) conjugate vaccine . . . . . . . . . . . . . . . . 54

meningococcal (a, c, y, and w-135) oligo conj vac for inj . . . . . . . . . . . . . . 55

MENOMUNE . . . . . . . . . . . . . . 54MENVEO . . . . . . . . . . . . . . . . . 55meperidine . . . . . . . . . . . . . . . . 14MEPHYTON . . . . . . . . . . . . . . 51MEPRON . . . . . . . . . . . . . . . . . 30mercaptopurine . . . . . . . . . . . . . 4mesalamine . . . . . . . . . . . . . . . 27mesalamine extended-release 27mesalamine supp . . . . . . . . . . 27mesna . . . . . . . . . . . . . . . . . . . . . 5MESNEX . . . . . . . . . . . . . . . . . . 5MESTINON . . . . . . . . . . . . . . . 15MESTINON TIMESPAN . . . . . 15METAGLIP . . . . . . . . . . . . . . . . 24METAMUCIL . . . . . . . . . . . . . . 58metaproterenol . . . . . . . . . . . . 49METAPROTERENOL

SYRUP . . . . . . . . . . . . . . . . 49metformin . . . . . . . . . . . . . . . . . 24metformin ER . . . . . . . . . . . . . 24metformin/glyburide . . . . . . . . 24methazolamide . . . . . . . . . . . . 40methenamine . . . . . . . . . . . . . 50methenamine hippurate . . . . . 50METHERGINE . . . . . . . . . .25, 38methimazole . . . . . . . . . . . . . . 25

methocarbamol . . . . . . . . . . . . 35methotrexate . . . . . . . . . . . . . . 34methoxsalen . . . . . . . . . . . . . . 19methsuximide . . . . . . . . . . . . . 16methyldopa . . . . . . . . . . . . . . . 12methyldopa/HCTZ . . . . . . . . . 12methylene blue . . . . . . . . . . . . 50methylergonovine . . . . . . .25, 38methylphenidate . . . . . . . .41, 42methylphenidate extended-

release . . . . . . . . . . . . . . . . 42methylphenidate HCL ER

24hr . . . . . . . . . . . . . . . . . . 42methylprednisolone . . . . . . . . 22metipranolol . . . . . . . . . . . . . . . 39metoclopramide . . . . . . . . . . . 26metolazone . . . . . . . . . . . . . . . 10metoprolol . . . . . . . . . . . . . . . . . 9metoprolol succinate . . . . . . . . 9metoprolol/hydrochlorothiazide 9METROCREAM . . . . . . . . . . . 19METROGEL . . . . . . . . . . . .19, 38METROGEL 1% . . . . . . . . . . . 38METROGEL-VAGINAL . . . . . . 38METROLOTION . . . . . . . . . . . 19metronidazole . . . . . . 19, 33, 38MEVACOR . . . . . . . . . . . . . . . . 11mexiletine . . . . . . . . . . . . . . . . . . 9MEXITIL . . . . . . . . . . . . . . . . . . . 9MIACALCIN . . . . . . . . . . . . . . . 24MICATIN . . . . . . . . . . . . . . .19, 56miconazole . . . . . . . . 19, 38, 56miconazole crm . . . . . . . . . . . 56MICRO-K 10 . . . . . . . . . . . . . . 52MICRONASE . . . . . . . . . . . . . . 24MICROZIDE . . . . . . . . . . . . . . . 10MIDAMOR . . . . . . . . . . . . . . . . 10midazolam hcl inj . . . . . . . . . . 41midodrine . . . . . . . . . . . . . . . . . 12midostaurin . . . . . . . . . . . . . . . . 5mifepristone . . . . . . . . . . . . . . . 25MIGERGOT

SUPPOSITORIES . . . . . . . 14miltefosine . . . . . . . . . . . . . . . . 30MINIPRESS . . . . . . . . . . . . . . . . 8

MINOCIN . . . . . . . . . . . . . . . . . 30minocycline . . . . . . . . . . . . . . . 30minoxidil . . . . . . . . . . . . . . . . . . 12MINUTUSS DR SYP . . . . . . . . 47MIRALAX . . . . . . . . . . . . . . . . . 26MIRAPEX . . . . . . . . . . . . . . . . . 15MIRCETTE . . . . . . . . . . . . . . . . 35MIRENA . . . . . . . . . . . . . . . . . . 35mirtazapine . . . . . . . . . . . . . . . 43MIRVASO . . . . . . . . . . . . . . . . . 19misoprostol . . . . . . . . . . . . . . . 28MITIGARE . . . . . . . . . . . . . . . . 35mitotane . . . . . . . . . . . . . . . . . . . 6MOBIC . . . . . . . . . . . . . . . .13, 34MODICON . . . . . . . . . . . . . . . . 36MODURETIC . . . . . . . . . . . . . . 10mometasone . . . . . . . . . . .18, 48mometasone furoate . . . . . . . 18MONISTAT . . . . . . . . . . . . .38, 56MONISTAT 3 . . . . . . . . . . . . . . 38MONISTAT-DERM . . . . . . . . . . 19MONOPRIL . . . . . . . . . . . . . . . . 8MONOPRIL-HCT . . . . . . . . . . . . 8montelukast . . . . . . . . . . . . . . . 49morphine . . . . . . . . . . . . . . . . . 14morphine extended-release . . 14MOTRIN . . . . . . . . . . . 13, 34, 59MOTRIN IB . . . . . . . . . . . . . . . 59MOVANTIK . . . . . . . . . . . . . . . 28MOZOBIL . . . . . . . . . . . . . . . . . . 7MS CONTIN . . . . . . . . . . . . . . . 14MSIR . . . . . . . . . . . . . . . . . . . . . 14MUCINEX . . . . . . . . . . . . . . . . . 46MUCINEX D . . . . . . . . . . . . . . . 46MUCINEX DM . . . . . . . . . . . . . 46MUCOMYST . . . . . . . . . . . . . . 53MULTI SYMPTOM TAB COLD

RLF . . . . . . . . . . . . . . . . . . . 48multivitamin with calcium. . . . 60multivitamins/fluoride/±iron . 51multivitamins/minerals . . . . . . 51mupirocin . . . . . . . . . . . . . . . . . 18MURINE . . . . . . . . . . . . . . . . . . 59MURO 128 . . . . . . . . . . . . . . . 41MYAMBUTOL . . . . . . . . . . . . . 28

73



MYCELEX . . . . . . . . . . . . .19, 30MYCOBUTIN . . . . . . . . . . . . . . 28mycophenolate mofetil . . . . . . . 6mycophenolate sodium . . . . . . 6MYCOSTATIN . . . . . . . . . .19, 30MYFORTIC. . . . . . . . . . . . . . . . . 6MYLANTA . . . . . . . . . . . . .26, 58MYLANTA LIQUID . . . . . . . . . 58MYLERAN . . . . . . . . . . . . . . . . . 4MYLICON . . . . . . . . . . . . . . . . . 58MYORISAN . . . . . . . . . . . . . . . 17MYSOLINE . . . . . . . . . . . . . . . . 17MYTESI . . . . . . . . . . . . . . . . . . 26

Nnabumetone . . . . . . . . . . . . . . 13naloxegol . . . . . . . . . . . . . . . . . 28naloxone . . . . . . . . . . . . . . .14, 43NALOXONE INJ . . . . . . . . . . . 43naltrexone . . . . . . . . . . . . .41, 43NAMENDA . . . . . . . . . . . . . . . . 12naphazoline HCL . . . . . . . . . . 38naphazoline/glycerin . . . . . . . 38naphazoline/zinc sulfate . . . . 38NAPHCON A . . . . . . . . . . . . . . 59NAPROSYN . . . . . . . . . . . .13, 34naproxen . . . . . . . . . . . . . .13, 34naproxen delayed release 13, 34naratriptan . . . . . . . . . . . . . . . . 14NARCAN NASAL SPRAY . . . 43NARDIL . . . . . . . . . . . . . . . . . . 42NASACORT ALLERGY

24 HOUR . . . . . . . . . . . . . . 22nasal sprays . . . . . . . . . . . . . . . 57NASALCROM . . . . . . . . . . . . . 22NATALCARE . . . . . . . . . . .51, 52nateglinide . . . . . . . . . . . . . . . . 24NAVANE . . . . . . . . . . . . . . . . . . 44NEBUPENT . . . . . . . . . . . . . . . 30NEBUSAL . . . . . . . . . . . . . . . . 53nelfinavir . . . . . . . . . . . . . . . . . . 32NEMBUTAL SOD INJ . . . . . . . 16NEO-SYNEPHRINE . . . . .22, 57neomycin sulfate . . . . . . . . . . . 33

neomycin/bacitracin/ polymyxin . . . . . . . . . . . . . . 40

neomycin/polymyxin B/bacitracin . . . . . . . . . . . . . . 18

neomycin/polymyxin B/dexamethasone . . . . . . . . 39

neomycin/polymyxin B/gramicidin . . . . . . . . . . . . . 40

neomycin/polymyxin B/hydrocortisone . . . . . .21, 39

NEORAL . . . . . . . . . . . . . . . . . . 6NEOSPORIN . . . . . . . 18, 40, 57NEPHROCAPS . . . . . . . . . . . . 52NEPTAZANE . . . . . . . . . . . . . . 40NESINA . . . . . . . . . . . . . . . . . . 24NESTABSCBF/FA/RX . . . . . . 52NEULASTA . . . . . . . . . . . . . . . . 7NEUMEGA . . . . . . . . . . . . . . . . . 7NEURONTIN . . . . . . . . . . . . . . 16NEUTROGENA OIL FREE

ACNE WASH . . . . . . . . . . . 17nevirapine . . . . . . . . . . . . . . . . 31nevirapine ER . . . . . . . . . . . . . 31NEXAVAR . . . . . . . . . . . . . . . . . 5NEXIUM 24HR OTC . . . . . . . . 26NEXIUM DELAYED-RELEASE

PACKET . . . . . . . . . . . . . . 26NEXPLANON . . . . . . . . . . . . . 35niacin . . . . . . . . . . . . . . . . . . . . 11niacin extended-release . . . . . 11NIACOR . . . . . . . . . . . . . . . . . . 11NIASPAN . . . . . . . . . . . . . . . . . 11nicardipine . . . . . . . . . . . . . . . . 10NICODERM CQ . . . . . . . .44, 59NICORETTE OTC . . . . . . . . . . 44nicotine . . . . . . . . . . . . . . . .44, 59NICOTINE GUM . . . . . . . . . . . 59nicotine polacrilex gum . . . . . 44nicotine polacrilex lozenge . . 44NICOTROL . . . . . . . . . . . . . . . 59nifedipine . . . . . . . . . . . . . . . . . 10nifedipine extended-release . 10NIFEREX . . . . . . . . . . . . . .51, 59NIFEREX-PN FORTE . . . . . . . 52nilotinib . . . . . . . . . . . . . . . . . . . . 5

nimodipine . . . . . . . . . . . . . . . . 10nimodipine oral soln . . . . . . . . 10NIMOTOP. . . . . . . . . . . . . . . . . 10NINLARO . . . . . . . . . . . . . . . . . . 5nintedanib . . . . . . . . . . . . . . . . 44niraparib . . . . . . . . . . . . . . . . . . . 6nitazoxanide suspension . . . . 30nitazoxanide tablet . . . . . . . . . 30nitisinone . . . . . . . . . . . . . . . . . 25NITREK . . . . . . . . . . . . . . . . . . 11NITRO-BID . . . . . . . . . . . . . . . . 11NITRO-DUR . . . . . . . . . . . . . . . 11nitrofurantoin

extended-release . . . . . . . 33nitrofurantoin macrocrystals . 33nitrofurantoin susp . . . . . . . . . 33nitroglycerin . . . . . . . . . . . .11, 20NITROLINGUAL . . . . . . . . . . . 11NITROSTAT . . . . . . . . . . . . . . . 11NITYR . . . . . . . . . . . . . . . . . . . . 25NIX 19, 58NIX CREME RINSE . . . . . . . . . 19NIZORAL . . . . . . . . . . 19, 20, 30NIZORAL SHAMPOO. . . . . . . 20NOLVADEX . . . . . . . . . . . . . . . . 5NORCO . . . . . . . . . . . . . . . . . . 14NORDETTE . . . . . . . . . . . . . . . 36norelgestromin/EE . . . . . . . . . 36norethindrone . . . . . . . . . . 35-37norethindrone acetate . . .36, 37norethindrone acetate/EE . . . 36norethindrone acetate/EE/

iron . . . . . . . . . . . . . . . . . . . 36norethindrone/EE . . . . . . .35, 36norethindrone/ME . . . . . . . . . 36NORFLEX . . . . . . . . . . . . . . . . 35norgestimate/EE . . . . . . . . . . . 36norgestrel/EE . . . . . . . . . . . . . 36NORPACE . . . . . . . . . . . . . . . . . 9NORPACE CR . . . . . . . . . . . . . . 9NORPRAMIN . . . . . . . . . . . . . . 42nortriptyline . . . . . . . . . . . . . . . 42NORVASC . . . . . . . . . . . . . . . . . 9NORVIR . . . . . . . . . . . . . . . . . . 32NOVAREL . . . . . . . . . . . . . . . . 38

74


Index of Covered DrugsNOVOLIN . . . . . . . . . . . . . .23, 57NOVOLIN 70/30 . . . . . . . . . . . 23NOVOLIN N . . . . . . . . . . . . . . . 23NOVOLIN R . . . . . . . . . . . . . . . 23NOVOLOG MIX 70/30 . . . . . . 23NUEDEXTA . . . . . . . . . . . . . . . 44NULYTELY . . . . . . . . . . . . . . . . 25NUVARING . . . . . . . . . . . . . . . 36NUVIGIL . . . . . . . . . . . . . . . . . . 12NYMALIZE . . . . . . . . . . . . . . . . 10nystatin . . . . . . . . . . . . . . . .19, 30NYTOL QUICK CAPS . . . . . . . 43

OOCEAN NASAL SPRAY . . . . . 22octreotide . . . . . . . . . . . . . . . . . . 6OCUFEN . . . . . . . . . . . . . . . . . 39OCUFLOX . . . . . . . . . . . . . . . . 40ODEFSEY. . . . . . . . . . . . . . . . . 32ODOMZO . . . . . . . . . . . . . . . . . . 7OFEV . . . . . . . . . . . . . . . . . . . . 44ofloxacin . . . . . . . . . . . 21, 29, 40OGEN . . . . . . . . . . . . . . . . . . . . 37olanzapine . . . . . . . . . . . . . . . . 43olaparib . . . . . . . . . . . . . . . . . . . 6olodaterol . . . . . . . . . . . . . .48, 49olsalazine sodium . . . . . . . . . . 27OLYSIO . . . . . . . . . . . . . . . . . . . 31omalizumab . . . . . . . . . . . . . . . 49omega 3 acid ethyl esters . . . 11omeprazole delayed-release . 27OMNICEF . . . . . . . . . . . . . . . . . 29ondansetron . . . . . . . . . . . . . . 26ONE A DAY WOMEN’S . . . . . 60One Touch Systems . . . . . . . . 23One Touch Test Strips . . . . . . 24ONFI . . . . . . . . . . . . . . . . . . . . . 16oprelvekin . . . . . . . . . . . . . . . . . 7OPSUMIT . . . . . . . . . . . . . . . . . 12OPTIPRANOLOL . . . . . . . . . . 39OPTIVAR . . . . . . . . . . . . . . . . . 38ORAP . . . . . . . . . . . . . . . . . . . . 44ORAPRED . . . . . . . . . . . . . . . . 23ORKAMBI . . . . . . . . . . . . . . . . 53

orphenadrine extended-release . . . . . . . 35

ORTHO COIL . . . . . . . . . . . . . 36ortho diaphragm . . . . . . . . . . . 36ORTHO EVRA . . . . . . . . . . . . . 36ORTHO FLAT . . . . . . . . . . . . . 36ORTHO FLEX . . . . . . . . . . . . . 36ORTHO MICRONOR . . . . . . . 36ORTHO TRI-CYCLEN . . . . . . . 36ORTHO-CEPT . . . . . . . . . . . . . 36ORTHO-CYCLEN . . . . . . . . . . 36ORTHO-NOVUM 1/35 . . . . . . 36ORTHO-NOVUM 1/50 . . . . . . 36ORTHO-NOVUM 10/11 . . . . 35ORTHO-NOVUM 7/7/7 . . . . . 36ORUDIS . . . . . . . . . . . . . . .13, 34OS-CAL . . . . . . . . . . . . . . .50, 59oseltamivir . . . . . . . . . . . . . . . . 31OSENI . . . . . . . . . . . . . . . . . . . . 24OTEZLA . . . . . . . . . . . . . . . . . . 33OVCON 50 . . . . . . . . . . . . . . . . 36OVIDE . . . . . . . . . . . . . . . . . . . . 19OVIDREL . . . . . . . . . . . . . . . . . 38OVRAL . . . . . . . . . . . . . . . . . . . 36oxaprozin . . . . . . . . . . . . . .13, 34oxazepam . . . . . . . . . . . . . . . . 41oxcarbazepine . . . . . . . . . . . . . 16OXSORALEN-ULTRA . . . . . . . 19oxybutynin chloride . . . . . . . . 50oxybutynin IR . . . . . . . . . . . . . . 50oxybutynin patch. . . . . . . .50, 59oxycodone . . . . . . . . . . . . . . . . 14oxycodone/acetaminophen . 14oxycodone/aspirin . . . . . . . . . 14OXYFAST . . . . . . . . . . . . . . . . . 14oxymetazoline . . . . . . . . . . . . . 22oxymorphone ER . . . . . . . . . . 14OXYTROL FOR WOMEN OTC

PATCH . . . . . . . . . . . . .50, 59

PPAIN-A-LAY . . . . . . . . 22, 57, 59palbociclib . . . . . . . . . . . . . . . . . 5paliperidone . . . . . . . . . . . . . . . 43palivizumab . . . . . . . . . . . . . . . 33

PAMELOR . . . . . . . . . . . . . . . . 42pancrelipase . . . . . . . . . . . . . . 27panobinostat . . . . . . . . . . . . . . . 4PANRETIN . . . . . . . . . . . . . . . . . 6pantoprazole . . . . . . . . . . . . . . 27PARAFON FORTE DSC . . . . . 35PARAGARD IUD . . . . . . . . . . . 35PARNATE . . . . . . . . . . . . . . . . . 42paromomycin . . . . . . . . . . . . . 33paroxetine . . . . . . . . . . . . . . . . 42PASER . . . . . . . . . . . . . . . . . . . 28pasireotide . . . . . . . . . . . . . . . . . 6patiromer . . . . . . . . . . . . . . . . . 11PAXIL . . . . . . . . . . . . . . . . . . . . 42pazopanib . . . . . . . . . . . . . . . . . 5PEDIACARE LIQ MULTI-SY . . 48PEDIALYTE . . . . . . . . . . . .50, 58PEDIAPRED . . . . . . . . . . . . . . . 23PEDIAZOLE . . . . . . . . . . . . . . . 29peg 3350/electrolytes . . . . . . 25peg 3350/sodium bicarbonate/

sodium chloride . . . . . . . . 25peg 3350/sodium bicarbonate/

sodium chloride/potassium chloride . . . . . . . . . . . . . . . 25

PEGASYS . . . . . . . . . . . . . . . . . 31PEGASYS PROCLICK . . . . . . 31pegfilgrastim . . . . . . . . . . . . . . . 7peginterferon alfa-2a . . . . . . . 31peginterferon alfa-2b . . . . . . . . 6peginterferon beta-1a . . . . . . . 15pegvisomant . . . . . . . . . . . . . . 25penicillamine . . . . . . . . . . . . . . 34penicillin g benzathine

IM susp . . . . . . . . . . . . . . . 29penicillin VK . . . . . . . . . . . . . . . 29PENLAC SOLUTION 8% . . . . 19pentamidine isethionate for

nebulization . . . . . . . . . . . . 30pentazocine/naloxone . . . . . . 14pentobarbital sodium inj . . . . 16pentosan polysulfate sodium 50pentoxifylline extended-release 7PEPCID . . . . . . . . . . . . . . .26, 58PEPCID AC . . . . . . . . . . . .26, 58

75



PERCOCET . . . . . . . . . . . . . . . 14PERCODAN . . . . . . . . . . . . . . . 14PERIDEX . . . . . . . . . . . . . . . . . 22permethrin . . . . . . . . . . . . .19, 58perphenazine . . . . . . . . . .43, 44PERSANTINE . . . . . . . . . . . . . . 7phenazopyridine . . . . . . . . . . . 50phenelzine . . . . . . . . . . . . . . . . 42PHENERGAN . . . . . . . . . .26, 46PHENERGAN DM . . . . . . . . . . 46phenobarbital . . . . . . . . . . . . . 16phenobarbital sodium inj . . . . 16phenol liquid . . . . . . . 22, 57, 59phenyl salicylate . . . . . . . . . . . 50phenylephrine 21, 22, 44, 45, 47phenylephrine/

brompheniramine/dextromethorphan . . . . . . 47

phenylephrine/chlorpheniramine/ dextromethorphan . . . . . . 47

phenylephrine/chlorpheniramine/dihydrocodeine . . . . . . . . . 47

phenylephrine/dextromethorphan . . . . . . 47

phenylephrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 47

phenylephrine/ephed/CPM w/carbetapentane . . . . . . . . 47

phenylephrine/guaifenesin . . 47phenylephrine/pyrilamine w/

hydrocodone . . . . . . . . . . . 47PHENYLHIST LIQ DH . . . . . . 45PHENYTEK . . . . . . . . . . . . . . . 16phenytoin . . . . . . . . . . . . . . . . . 16phenytoin sodium extended . 16phenytoin sodium inj . . . . . . . 16PHILLIPS COLON

HEALTH . . . . . . . . . . . .28, 58PHOS-FLUR . . . . . . . . . . .51, 60PHOSPHOLINE IODINE . . . . 40phosphorus . . . . . . . . . . . . . . . 52PHRENILIN . . . . . . . . . . . . . . . 13

phytonadione. . . . . . . . . . . . . . 51pilocarpine . . . . . . . . . . . . .22, 40PILOPINE HS GEL . . . . . . . . . 40pimecrolimus . . . . . . . . . . . . . . 20pimozide . . . . . . . . . . . . . . . . . 44PIN-X . . . . . . . . . . . . . . . . . . . . . 28pindolol . . . . . . . . . . . . . . . . . . . 9pioglitazone . . . . . . . . . . . . . . . 24pirfenidone . . . . . . . . . . . . . . . 44piroxicam . . . . . . . . . . . . . .13, 35PLAN B ONE STEP . . . . . . . . 35PLAQUENIL . . . . . . . . . . . .33, 34PLAVIX . . . . . . . . . . . . . . . . . . . . 7PLEGRIDY . . . . . . . . . . . . . . . . 15PLENDIL . . . . . . . . . . . . . . . . . . 9plerixafor . . . . . . . . . . . . . . . . . . 7PLETAL . . . . . . . . . . . . . . . . . . . 7PLEXION . . . . . . . . . . . . . . . . . 17pneumococcal 13-valent

conjugate . . . . . . . . . . . . . . 55pneumococcal vaccine

polyvalent. . . . . . . . . . . . . . 55PNEUMOVAX . . . . . . . . . . . . . 55PNEUMOVAX 23 . . . . . . . . . . 55podofilox . . . . . . . . . . . . . . . . . 20POLY-VI-FLOR . . . . . . . . . . . . . 51POLY-VI-SOL . . . . . . . . . . . . . . 59polyethylene glycol 3350 . . . . 26polymyxin B/bacitracin . .18, 40polymyxin B/trimethoprim . . . 40polysaccharide iron caps . . . . 59polysaccharide iron complex 51POLYSPORIN . . . . . . . . . . . . . 40POLYTRIM . . . . . . . . . . . . . . . . 40pomalidomide . . . . . . . . . . . . . . 6POMALYST . . . . . . . . . . . . . . . . 6ponatinib . . . . . . . . . . . . . . . . . . 5potassium acid phosphate . . 52potassium bicarbonate/

potassium citrate effervescent . . . . . . . . . . . . 52

potassium chloride . . . . . .25, 52potassium chloride extended-

release . . . . . . . . . . . . . . . . 52potassium citrate . . . . . . . .50, 52

POTIGA . . . . . . . . . . . . . . . . . . 16povidone-iodine . . . . . . . . . . . 33PRALUENT . . . . . . . . . . . . . . . 11pramipexole . . . . . . . . . . . . . . . 15pramlintide . . . . . . . . . . . . . . . . 24PRANDIN . . . . . . . . . . . . . . . . . 24prasugrel . . . . . . . . . . . . . . . . . . 7PRAVACHOL . . . . . . . . . . . . . . 11pravastatin . . . . . . . . . . . . . . . . 11praziquantel . . . . . . . . . . . . . . . 28prazosin . . . . . . . . . . . . . . . . . . . 8PRECOSE . . . . . . . . . . . . . . . . 24PRED FORTE . . . . . . . . . . . . . 39PRED MILD . . . . . . . . . . . . . . . 39PRED-G . . . . . . . . . . . . . . . . . . 39prednicarbate . . . . . . . . . . . . . 18prednisolone . . . . . . . 22, 23, 39prednisolone acetate . . . . . . . 39prednisolone phosphate . . . . 39prednisolone sodium

phosphate . . . . . . . . . . . . . 23prednisone . . . . . . . . . . . . . . . . 23pregabalin . . . . . . . . . . . . .16, 17PRELONE . . . . . . . . . . . . . . . . 23PREMARIN . . . . . . . . . . . . . . . 37PREMPHASE . . . . . . . . . . . . . 37PREMPRO . . . . . . . . . . . . . . . . 37prenat w/o A w/fecbn-fegl-

DSS-FA & DHA . . . . . . . . . 51prenat-FE Bis-FE prot succ-FA-

CA & omega 3 . . . . . . . . . 51prenat-FE bis-FE prot succ-FA-

CA & omega DR . . . . . . . . 51prenatal vit w/FE bisglycinate

chelate-FA . . . . . . . . . . . . . 51prenatal vit w/FE polysac

cmplx-FA . . . . . . . . . . . . . . 52prenatal vit w/iron

carbonyl-FA . . . . . . . . . . . . 52PRENATAL VITAMINS

W/ FOLIC ACID . . . . . . . . 52prenatal vitamins w/folic acid 52prenatal w/o A w/FE carbonyl-

FE gluc-DSS-FA . . . . . . . . 52PREPARATION H . . . . . . . . . . 58

76


Index of Covered DrugsPREVACID . . . . . . . . . . . . . . . . 26PREVACID SOLUTAB . . . . . . 26PREVIDENT . . . . . . . . . . . . . . . 51PREVNAR 13 . . . . . . . . . . . . . 55PREZCOBIX . . . . . . . . . . . . . . 33PREZISTA . . . . . . . . . . . . . . . . 32PRIFTIN . . . . . . . . . . . . . . . . . . 28PRILOSEC . . . . . . . . . . . . . . . . 27primaquine. . . . . . . . . . . . . . . . 33primidone . . . . . . . . . . . . . . . . . 17PRINCIPEN . . . . . . . . . . . . . . . 29PROAMATINE . . . . . . . . . . . . . 12probenecid . . . . . . . . . . . . . . . 35probiotics . . . . . . . . . . . . . .28, 58procarbazine . . . . . . . . . . . . . . . 6PROCARDIA . . . . . . . . . . . . . . 10PROCARDIA XL . . . . . . . . . . . 10prochlorperazine . . . . . . . . . . . 26PROCRIT . . . . . . . . . . . . . . . . . . 7PROCTOCREAM-HC 2.5% . . 20progesterone . . . . . . . . . . .37, 38PROGESTERONE CREAM

10% KIT . . . . . . . . . . . . . . . 37progesterone IM in oil

50MG/ML . . . . . . . . . . . . . 37PROGESTERONE INJ

50MG/ML . . . . . . . . . . . . . 37progesterone micronized cap 37progesterone micronized

powder . . . . . . . . . . . . . . . . 37progesterone micronized td

cream 10% (cmpd kit) . . . 37PROGESTERONE POWDER 37progesterone vaginal gel . . . . 37progesterone vaginal insert . . 38progesterone vaginal

suppository . . . . . . . . . . . . 38PROGRAF . . . . . . . . . . . . . . . . . 6PROLIXIN . . . . . . . . . . . . . . . . . 44PROLIXIN DECANOATE . . . . 44PROMACTA . . . . . . . . . . . . . . . 53PROMETH VC

SYP 6.25-5/5 . . . . . . . . . . 47promethazine . . . . . . . 26, 45-47

promethazine & phenylephrine . . . . . . .45, 47

PROMETHAZINE SYP DM . . 46PROMETHAZINE VC

W/CODEINE . . . . . . . . . . . 45PROMETHAZINE

W/CODEINE . . . . . . . . . . . 45PROMETRIUM . . . . . . . . . . . . 37propafenone . . . . . . . . . . . . . . . 9propantheline . . . . . . . . . . . . . 50propranolol . . . . . . . . . . . . . 9, 15propranolol/HCTZ . . . . . . . . . . 9propylthiouracil . . . . . . . . . . . . 25PROSCAR . . . . . . . . . . . . . . . . 49PROTONIX . . . . . . . . . . . . . . . . 27PROTOPIC 0.03% . . . . . . . . . 20PROTOPIC 0.1% . . . . . . . . . . . 20PROVENTIL . . . . . . . . . . . . . . . 49PROVERA . . . . . . . . . . . . . . . . 37PROZAC . . . . . . . . . . . . . . . . . 42PRUET DHA PAK SETONET

PAK . . . . . . . . . . . . . . . . . . . 51PRUET DHAEC PAK . . . . . . . 51PSE/GG . . . . . . . . . . . . . . . . . . 46pseudoephedrine tan/

dexchlorphen tan/ DM tan . . . . . . . . . . . . . . . . 48

pseudoephedrine/acetaminophen/dextromethorphan . . . . . . 47

pseudoephedrine/chlorpheniramine/dextromethorphan . . . . . . 48

pseudoephedrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 48

pseudoephedrine/iburprofen 48psyllium . . . . . . . . . . . . . . . . . . 58PULMICORT FLEXHALER . . 48PULMICORT RESPULES . . . 49PULMOZYME . . . . . . . . . . . . . 53PURINETHOL . . . . . . . . . . . . . . 4pyrantel pamoate . . . . . . . . . . 28pyrazinamide . . . . . . . . . . . . . . 28

pyrethrins/piperonyl butoxide shampoo . . . . . . . . . . .19, 58

PYRIDIUM . . . . . . . . . . . . . . . . 50pyridostigmine . . . . . . . . . . . . . 15pyridostigmine

extended-release . . . . . . . 15pyrilamine tan/phenyleph tan 48pyrimethamine . . . . . . . . . . . . 33

QQUESTRAN . . . . . . . . . . . . . . . 11QUESTRAN-LIGHT . . . . . . . . . 11quetiapine . . . . . . . . . . . . . . . . 43quinapril . . . . . . . . . . . . . . . . . . . 8quinapril/hydrochlorothiazide . 8QUINIDINE GLUCONATE

EXT-REL . . . . . . . . . . . . . . . 9quinidine gluconate extended-

release . . . . . . . . . . . . . . . . . 9quinidine sulfate . . . . . . . . . . . . 9QUINIDINE SULFATE

EXT-REL . . . . . . . . . . . . . . . 9quinidine sulfate extended-

release . . . . . . . . . . . . . . . . . 9QVAR REDIHALER . . . . . . . . . 48

RR-TANNAMINE . . . . . . . . . . . . 45raloxifene . . . . . . . . . . . . . . . . . 24raltegravir . . . . . . . . . . . . . . . . . 31raltegravir susp . . . . . . . . . . . . 31ramipril . . . . . . . . . . . . . . . . . . . . 8RANEXA . . . . . . . . . . . . . . . . . 12ranitidine . . . . . . . . . . . . . . . . . 27ranitidine syrup . . . . . . . . . . . . 27ranolazine . . . . . . . . . . . . . . . . 12RAPAMUNE. . . . . . . . . . . . . . . . 6RAVICTI . . . . . . . . . . . . . . . . . . 53RAZADYNE . . . . . . . . . . . . . . . 12REBETOL/COPEGUS . . . . . . 31RECOMBIVAX HB . . . . . . . . . 54rectal hydrocortisone crm,

suppositories . . . . . . . . . . . 58RECTIV . . . . . . . . . . . . . . . . . . . 20

77



REESE’S PINWORM MEDICINE . . . . . . . . . . . . . 28

REGLAN . . . . . . . . . . . . . . . . . 26regorafenib . . . . . . . . . . . . . . . . 5REGRANEX . . . . . . . . . . . . . . . 20RELAFEN . . . . . . . . . . . . . . . . . 13RELENZA. . . . . . . . . . . . . . . . . 31RELION 70/30 . . . . . . . . . . . . 23RELION N . . . . . . . . . . . . . . . . 23RELION R . . . . . . . . . . . . . . . . 23REMERON . . . . . . . . . . . . . . . . 43RENVELA . . . . . . . . . . . . . . . . 53repaglinide . . . . . . . . . . . . . . . . 24REQUIP . . . . . . . . . . . . . . . . . . 15RESCRIPTOR . . . . . . . . . . . . . 31reserpine . . . . . . . . . . . . . . . . . 10RESTORIL . . . . . . . . . . . . . . . . 43RETIN-A . . . . . . . . . . . . . . . . . . 17RETROVIR . . . . . . . . . . . . . . . . 32REVATIO . . . . . . . . . . . . . . . . . 12REVATIO SUSPENSION . . . . 12REVIA . . . . . . . . . . . . . . . . .41, 43REVLIMID . . . . . . . . . . . . . . . . . 6REYATAZ . . . . . . . . . . . . . . . . . 32REYATAZ POWDER

PACKET . . . . . . . . . . . . . . . 32ribavirin . . . . . . . . . . . . . . . . . . . 31RID SHAMPOO . . . . . . . . .19, 58RIDAURA . . . . . . . . . . . . . . . . . 33rifabutin . . . . . . . . . . . . . . . . . . 28RIFADIN . . . . . . . . . . . . . . . . . . 28rifampin . . . . . . . . . . . . . . . . . . 28rifapentine . . . . . . . . . . . . . . . . 28rilpivirine . . . . . . . . . . . . . . . 31-33RILUTEK . . . . . . . . . . . . . . . . . 12riluzole . . . . . . . . . . . . . . . . . . . 12rimantadine . . . . . . . . . . . . . . . 31rimexolone . . . . . . . . . . . . . . . . 39riociguat . . . . . . . . . . . . . . . . . . 12RISA-BID . . . . . . . . . . . . . .28, 58RISAQUAD . . . . . . . . . . . . .28, 58RISPERDAL . . . . . . . . . . . . . . . 44RISPERDAL CONSTA . . . . . . 44RISPERDAL SOLUTION . . . . 44risperidone . . . . . . . . . . . . . . . . 44

risperidone oral soln . . . . . . . . 44RITALIN . . . . . . . . . . . . . . .41, 42RITALIN LA . . . . . . . . . . . . . . . 42ritonavir . . . . . . . . . . . . . . . . . . . 32rivaroxaban . . . . . . . . . . . . . . . . 7rivastigmine . . . . . . . . . . . . . . . 12rizatriptan . . . . . . . . . . . . . . . . . 14RMS . . . . . . . . . . . . . . . . . . . . . 14ROBAXIN . . . . . . . . . . . . . . . . . 35ROBINUL . . . . . . . . . . . . . . . . . 27ROBITUSSIN . . . . . . . . 45-48, 57ROBITUSSIN CF . . . . . . . .46, 57ROBITUSSIN DM . . . . . . .46, 57ROBITUSSIN LIQ CGH/ALRG 47ROBITUSSIN LIQ

CGH/CLD . . . . . . . . . .45, 47ROBITUSSIN LIQ

CGH/CONG . . . . . . . . . . . 46ROBITUSSIN LIQ HD/CHST . 47ROBITUSSIN LIQ PED NGHT 48ROBITUSSIN PE . . . . . . . .46, 57ROBITUSSIN PED LIQ CGH/

COLD . . . . . . . . . . . . . . . . . 45ROBITUSSIN PED SYP . . . . . 46ROBITUSSIN SYP CHST CNG 46ROBITUSSIN SYP MAX-ST . . 46ROCALTROL . . . . . . . . . . . . . . 50ROCALTROL SOLUTION . . . 50ROCEPHIN INJ . . . . . . . . . . . . 29rolapitant . . . . . . . . . . . . . . . . . 26RONDEC DM . . . . . . . . . . . . . 47RONDEC DM DROPS . . . . . . 47RONDEC DROPS . . . . . . . . . . 45RONDEC SYRUP . . . . . . . . . . 45ropinirole . . . . . . . . . . . . . . . . . 15ROWASA . . . . . . . . . . . . . . . . . 27ROXICODONE . . . . . . . . . . . . 14RUBRACA . . . . . . . . . . . . . . . . . 6rucaparib . . . . . . . . . . . . . . . . . . 6rufinamide . . . . . . . . . . . . . . . . 17ruxolitinib . . . . . . . . . . . . . . . . . . 5RYDAPT . . . . . . . . . . . . . . . . . . . 5RYNA-12 S . . . . . . . . . . . . . . . 48RYNATAN PEDIATRIC SUSP 45

RYNATUSS PEDIATRIC SUSP . . . . . . . . . . . . . . . . . 47

RYTHMOL . . . . . . . . . . . . . . . . . 9

SSABRIL SOLUTION . . . . . . . . 17sacubitril/valsartan . . . . . . . . . . 8SAL-TROPINE . . . . . . . . . . . . . 28SALAGEN . . . . . . . . . . . . . . . . 22salicylic acid . . . . 17, 19, 20, 60salicylic acid 17%/

collodion . . . . . . . . . . .20, 60saline nasal spray 0.65% . . . . 22salmeterol xinafoate . . . . . . . . 48salsalate . . . . . . . . . . . . . . . . . . 35SANCTURA . . . . . . . . . . . . . . . 50SANDIMMUNE . . . . . . . . . . . . . 6SANDOSTATIN . . . . . . . . . . . . . 6SANTYL . . . . . . . . . . . . . . . . . . 20sapropterin . . . . . . . . . . . . . . . . 25sapropterin powder . . . . . . . . 25saquinavir mesylate . . . . . . . . 32SARAFEM, SELFEMRA . . . . . 42sargramostim. . . . . . . . . . . . . . . 7SAVAYSA . . . . . . . . . . . . . . . . . . 7SCALPICIN . . . . . . . . . . . . . . . 19scopolamine . . . . . . . . . . . . . . 40SEASONALE . . . . . . . . . . . . . . 35SECTRAL . . . . . . . . . . . . . . . . . . 9secukinumab . . . . . . . . . . . . . . 34SEDAPAP . . . . . . . . . . . . . . . . . 13SEGLUROMET . . . . . . . . . . . . 24selegiline . . . . . . . . . . . . . . . . . 15selenium sulfide . . . . . . . . . . . 20SELSUN . . . . . . . . . . . . . . . . . . 20SELZENTRY . . . . . . . . . . . . . . 33sennosides . . . . . . . . . . . . . . . 26SENOKOT . . . . . . . . . . . . . . . . 26SENSIPAR . . . . . . . . . . . . . . . . 53SERAX . . . . . . . . . . . . . . . . . . . 41SEREVENT DISKUS . . . . . . . . 48SEROMYCIN . . . . . . . . . . . . . . 28SEROQUEL . . . . . . . . . . . . . . . 43SERPASIL . . . . . . . . . . . . . . . . 10sertraline . . . . . . . . . . . . . . . . . 42

78


Index of Covered Drugssevelamer . . . . . . . . . . . . . . . . . 53SIGNIFOR . . . . . . . . . . . . . . . . . 6sildenafil . . . . . . . . . . . . . . . . . . 12SILVADENE . . . . . . . . . . . . . . . 18silver sulfadiazine . . . . . . . . . . 18simeprevir . . . . . . . . . . . . . . . . 31simethicone . . . . . . . . . . . .26, 58simvastatin . . . . . . . . . . . . . . . . 11SINEMET . . . . . . . . . . . . . . . . . 15SINEMET CR . . . . . . . . . . . . . . 15SINEQUAN . . . . . . . . . . . . . . . 42SINGULAIR . . . . . . . . . . . . . . . 49sirolimus . . . . . . . . . . . . . . . . . . . 6SIRTURO . . . . . . . . . . . . . . . . . 33SKYLA . . . . . . . . . . . . . . . . . . . 35sodium chloride for

nebulizer . . . . . . . . . . . . . . 53sodium chloride hypertonic . 41sodium citrate/citric acid . . . . 50sodium phenylbutyrate . . . . . 53sodium phosphate

monobasic . . . . . . . . . . . . . 50sodium polystyrene sulfonate 11SOLIQUA . . . . . . . . . . . . . . . . . 23somatropin . . . . . . . . . . . . . . . . 24SOMAVERT . . . . . . . . . . . . . . . 25SONATA . . . . . . . . . . . . . . . . . . 43sonidegib . . . . . . . . . . . . . . . . . . 7sorafenib . . . . . . . . . . . . . . . . . . 5SORIATANE . . . . . . . . . . . . . . . 19sotalol . . . . . . . . . . . . . . . . . . . . . 9sotalol HCL (afib/afl) . . . . . . . . 9spacers . . . . . . . . . . . . . . . . . . . 53speciality vitamin misc . . . . . . 60spironolactone. . . . . . . . . . . . . 10spironolactone/

hydrochlorothiazide . . . . . 10SPORANOX . . . . . . . . . . . . . . . 30SPRYCEL . . . . . . . . . . . . . . . . . . 4STADOL . . . . . . . . . . . . . . . . . . 14STARLIX . . . . . . . . . . . . . . . . . . 24STATUSS DM SYP . . . . . . . . . 47stavudine . . . . . . . . . . . . . . . . . 32STEGLATRO . . . . . . . . . . . . . . 24STELAZINE . . . . . . . . . . . . . . . 44

STIOLTO RESPIMAT . . . . . . . 49STIVARGA . . . . . . . . . . . . . . . . . 5stool softeners . . . . . . . . . . . . . 58STRENSIQ . . . . . . . . . . . . . . . . 25STRIBILD . . . . . . . . . . . . . . . . . 32STRIVERDI RESPIMAT . . . . . 48STROMECTOL . . . . . . . . . . . . 28STUART PRENATAL . . . . . . . 59SUBOXONE . . . . . . . . . . . . . . . 43SUBUTEX . . . . . . . . . . . . . . . . 43succimer . . . . . . . . . . . . . . . . . 53sucralfate . . . . . . . . . . . . . . . . . 27sugar+orthophosphoric acid 58sulcralfate . . . . . . . . . . . . . . . . . 27SULFACET-R . . . . . . . . . . . . . . 17sulfacetamide . . . . . . 17, 39, 40sulfacetamide/pred. phos. . . 39sulfacetamide/sulfur . . . . . . . . 17sulfamethoxazole/

trimethoprim, DS . . . . . . . 30sulfasalazine . . . . . . . . . . .27, 34sulfasalazine

delayed-release . . . . . .27, 34sulindac . . . . . . . . . . . . . . .13, 35sumatriptan . . . . . . . . . . . . . . . 14SUMYCIN . . . . . . . . . . . . . . . . . 30sunitinib . . . . . . . . . . . . . . . . . . . 5SUPRAX . . . . . . . . . . . . . . . . . . 29SUSTIVA . . . . . . . . . . . . . . . . . . 31SUTENT . . . . . . . . . . . . . . . . . . . 5SYLATRON . . . . . . . . . . . . . . . . 6SYMLIN . . . . . . . . . . . . . . . . . . 24SYMMETREL . . . . . . . . . .15, 31SYNAGIS . . . . . . . . . . . . . . . . . 33SYNALAR . . . . . . . . . . . . . . . . 18SYNTHROID . . . . . . . . . . . . . . 25

TT-STAT . . . . . . . . . . . . . . . . . . . 17TABLOID . . . . . . . . . . . . . . . . . . 4tacrolimus . . . . . . . . . . . . . . 6, 20TAFINLAR . . . . . . . . . . . . . . . . . 4TAGAMET . . . . . . . . . . . . . . . . 26TALWIN NX . . . . . . . . . . . . . . . 14TAMBOCOR . . . . . . . . . . . . . . . 9

TAMIFLU . . . . . . . . . . . . . . . . . 31tamoxifen . . . . . . . . . . . . . . . . . . 5tamsulosin . . . . . . . . . . . . . . . . 49TANAFED DMX

SUSPENSION . . . . . . . . . . 48TANZEUM . . . . . . . . . . . . . . . . 24TAPAZOLE . . . . . . . . . . . . . . . . 25TARCEVA . . . . . . . . . . . . . . . . . . 4TARGRETIN . . . . . . . . . . . . . . . . 6TASIGNA . . . . . . . . . . . . . . . . . . 5TASMAR . . . . . . . . . . . . . . . . . . 15TECFIDERA . . . . . . . . . . . . . . . 15teduglutide . . . . . . . . . . . . . . . . 28TEGRETOL . . . . . . . . . . . . . . . 16TEGRETOL-XR . . . . . . . . . . . . 16temazepam . . . . . . . . . . . . . . . 43TEMODAR . . . . . . . . . . . . . . . . . 4TEMOVATE . . . . . . . . . . . . . . . 19temozolomide . . . . . . . . . . . . . . 4TENEX . . . . . . . . . . . . . . . . . . . . 8TENIVAC . . . . . . . . . . . . . . . . . 55tenofovir . . . . . . . . . . . . . . .32, 33TENORETIC . . . . . . . . . . . . . . . 9TENORMIN . . . . . . . . . . . . . . . . 9TERAZOL 3/7 . . . . . . . . . . . . . 38terazosin . . . . . . . . . . . . . . . . 8, 49terbinafine . . . . . . . . . . . . .19, 30terbutaline . . . . . . . . . . . . . . . . 49terconazole . . . . . . . . . . . . . . . 38teriflunomide . . . . . . . . . . . . . . 15tesamorelin . . . . . . . . . . . . . . . 24TESSALON . . . . . . . . . . . . . . . 44testosterone . . . . . . . . . . . . . . . 23TESTOSTERONE 1% GEL . . 23testosterone cypionate . . . . . . 23testosterone enanthate . . . . . . 23tet tox-diph-acell pertuss ad . 55TET/DIP TOX INJ . . . . . . . . . . 55tetanus immune globulin

(human) . . . . . . . . . . . . . . . 55tetanus-diphtheria toxoids

(td) . . . . . . . . . . . . . . . . . . . 55tetrabenazine . . . . . . . . . . . . . . 17tetracycline . . . . . . . . . . . . . . . . 30tetrahydrozoline/zinc sulfate . 38

79



thalidomide . . . . . . . . . . . . . . . . 6THALOMID . . . . . . . . . . . . . . . . 6THEO-24 . . . . . . . . . . . . . . . . . 49THEOCHRON . . . . . . . . . . . . . 49theophylline . . . . . . . . . . . . . . . 49theophylline extended-release 49thioguanine . . . . . . . . . . . . . . . . 4thioridazine . . . . . . . . . . . . . . . 44thiothixene . . . . . . . . . . . . . . . . 44THORAZINE . . . . . . . . . . . . . . 44THYROLAR . . . . . . . . . . . . . . . 25tiagabine . . . . . . . . . . . . . . . . . 17TIAZAC . . . . . . . . . . . . . . . . . . . 10ticagrelor . . . . . . . . . . . . . . . . . . 7TIGAN . . . . . . . . . . . . . . . . . . . . 26TIKOSYN . . . . . . . . . . . . . . . . . . 9timolol . . . . . . . . . . . . . . . . . . 9, 39timolol maleate . . . . . . . . . . 9, 39TIMOPTIC . . . . . . . . . . . . . . . . 39TIMOPTIC XE . . . . . . . . . . . . . 39TINACTIN . . . . . . . . . . . . . .19, 56tiotropium/olodaterol . . . . . . . 49tipranavir . . . . . . . . . . . . . . . . . 32TIVICAY . . . . . . . . . . . . . . . . . . 31tizanidine . . . . . . . . . . . . . . . . . 35TOBRADEX . . . . . . . . . . . . . . . 39tobramycin . . . . . . . . . 39, 40, 53tobramycin neb soln . . . . . . . . 53tobramycin/dexamethasone . 39TOBREX . . . . . . . . . . . . . . . . . . 40TOFRANIL . . . . . . . . . . . . . . . . 42tolazamide . . . . . . . . . . . . . . . . 24tolbutamide . . . . . . . . . . . . . . . 24tolcapone . . . . . . . . . . . . . . . . . 15TOLINASE . . . . . . . . . . . . . . . . 24tolnaftate . . . . . . . . . . . . . .19, 56tolterodine . . . . . . . . . . . . . . . . 50TOPAMAX . . . . . . . . . . . . . . . . 17TOPAMAX SPRINKLE . . . . . . 17topical antibacterials . . . . . . . . 57topiramate . . . . . . . . . . . . . . . . 17topiramate sprinkle caps . . . . 17topotecan . . . . . . . . . . . . . . . . . . 7TOPROL XL . . . . . . . . . . . . . . . . 9TORADOL . . . . . . . . . . . . . . . . 13

toremifene . . . . . . . . . . . . . . . . . 5torsemide . . . . . . . . . . . . . . . . . 10TOUJEO . . . . . . . . . . . . . . . . . . 23TRACLEER . . . . . . . . . . . . . . . 12tramadol . . . . . . . . . . . . . . . . . . 14trametinib . . . . . . . . . . . . . . . . . . 5TRANDATE . . . . . . . . . . . . . . . . 9trandolapril . . . . . . . . . . . . . . . . . 8tranexamic acid . . . . . . . . . . . . 38TRANXENE . . . . . . . . . . . . . . . 41tranylcypromine . . . . . . . . . . . . 42trazodone . . . . . . . . . . . . . . . . . 43TRECATOR . . . . . . . . . . . . . . . 28TRENTAL . . . . . . . . . . . . . . . . . . 7tretinoin . . . . . . . . . . . . . . . . 7, 17TRI RX . . . . . . . . . . . . . . . . . . . 52TRI-FED X. . . . . . . . . . . . . . . . . 48TRI-NORINYL . . . . . . . . . . . . . 36TRI-VI-FLOR . . . . . . . . . . . . . . . 52TRI-VI-SOL . . . . . . . . . . . . .52, 59triamcinolone . . . . . . . . . . .18, 22triamcinolone acetonide . . . . 18triamcinolone nasal spray . . . 22triamterene/

hydrochlorothiazide . . . . . 10TRIAVIL . . . . . . . . . . . . . . . . . . 43triazolam . . . . . . . . . . . . . . . . . . 43trifluoperazine . . . . . . . . . . . . . 44trifluridine . . . . . . . . . . . . . . . 4, 41trifluridine/tipiracil . . . . . . . . . . . 4trihexyphenidyl . . . . . . . . . . . . 15TRILAFON . . . . . . . . . . . . . . . . 44TRILEPTAL . . . . . . . . . . . . . . . 16TRILYTE . . . . . . . . . . . . . . . . . . 25trimethobenzamide . . . . . . . . 26trimethoprim . . . . . . . 30, 33, 40TRIOTANN . . . . . . . . . . . . .21, 45TRIOTANN PEDIATRIC SUSP 45tripolidine/pseudoephedrine 48TRIPROL/PSE SYP . . . . . . . . 48TRIUMEQ . . . . . . . . . . . . . . . . . 32TRIVORA . . . . . . . . . . . . . . . . . 36TRIZIVIR . . . . . . . . . . . . . . . . . . 31TROJAN . . . . . . . . . . . . . . . . . . 57trospium . . . . . . . . . . . . . . . . . . 50

TRULICITY . . . . . . . . . . . . . . . . 24TRUSOPT . . . . . . . . . . . . . . . . 39TRUST NATALCARE PAK

DHA . . . . . . . . . . . . . . . . . . 51TRUSTEX . . . . . . . . . . . . . . . . . 57TRUVADA . . . . . . . . . . . . . . . . 32TUMS . . . . . . . . . . . . . . . . .58, 59TUSSI-12 S . . . . . . . . . . . . . . . 45TUSSIN DM . . . . . . . . . . . . . . . 46TYBOST . . . . . . . . . . . . . . . . . . 32TYKERB . . . . . . . . . . . . . . . . . . . 5TYLENOL 13, 14, 34, 46, 57, 59TYLENOL COLD MULTI-

SYMPTOM DAYTIME, VICK DAYQUIL LIQ COLD/ FLU . . . . . . . . . . . . . . . .46, 57

TYLENOL W/CODEINE . . . . . 14typhoid vaccine . . . . . . . . . . . . 55

UULORIC . . . . . . . . . . . . . . . . . . 35ULTRA . . . . . . . . . . . . 23, 24, 52ULTRA 2, ULTRAMINI . . . . . . 23ULTRAM . . . . . . . . . . . . . . . . . . 14ULTRAVATE . . . . . . . . . . . . . . . 19umeclidinium inhalation . . . . . 49UNI-HIST DROPS . . . . . . . . . . 44UNIPHYL . . . . . . . . . . . . . . . . . 49UNISOM . . . . . . . . . . . . . . .43, 58UREA 10% CREAM . . . . . . . . 20UREA 10% LOTION . . . . . . . . 20urea 10%, urea 20% . . . . . . . . 20UREA 20% CREAM . . . . . . . . 20urea 40% . . . . . . . . . . . . . . . . . 20UREA 40% LOTION . . . . . . . . 20URECHOLINE . . . . . . . . . . . . . 49UREX . . . . . . . . . . . . . . . . . . . . 50uridine . . . . . . . . . . . . . . . . . . . 25UROCIT-K . . . . . . . . . . . . . . . . 50UROXATRAL . . . . . . . . . . . . . . 49URSO . . . . . . . . . . . . . . . . . . . . 28URSO FORTE . . . . . . . . . . . . . 28ursodiol . . . . . . . . . . . . . . . . . . 28UTIRA C . . . . . . . . . . . . . . . . . . 50

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Index of Covered DrugsV

VAGIFEM . . . . . . . . . . . . . . . . . 37vaginal products . . . . . . . . . . . 56valacyclovir . . . . . . . . . . . . . . . . 31valbenazine . . . . . . . . . . . . . . . 17VALCYTE . . . . . . . . . . . . . . . . . 30valganciclovir . . . . . . . . . . . . . . 30VALIUM . . . . . . . . . . . . . . .35, 41valproic acid . . . . . . . . . . . . . . 17VALTREX . . . . . . . . . . . . . . . . . 31VANCOCIN HCL . . . . . . . . . . . 30vancomycin HCl . . . . . . . . . . . 30vandetanib . . . . . . . . . . . . . . . . . 5VAQTA . . . . . . . . . . . . . . . . . . . 54varenicline . . . . . . . . . . . . . . . . 44varicella virus vac live for

subcutaneous . . . . . . . . . . 55VARIVAX . . . . . . . . . . . . . . . . . 55VARUBI . . . . . . . . . . . . . . . . . . 26VASERETIC . . . . . . . . . . . . . . . . 8VASOCIDIN . . . . . . . . . . . . . . . 39VASOCLEAR . . . . . . . . . . . . . . 38VASOCLEAR A . . . . . . . . . . . . 38VASOTEC . . . . . . . . . . . . . . . . . . 8VECTICAL . . . . . . . . . . . . . . . . 19VEETIDS . . . . . . . . . . . . . . . . . 29VELTASSA . . . . . . . . . . . . . . . . 11vemurafenib . . . . . . . . . . . . . . . . 5VENCLEXTA . . . . . . . . . . . . . . . 5venetoclax . . . . . . . . . . . . . . . . . 5venlafaxine . . . . . . . . . . . . . . . . 42venlafaxine XR . . . . . . . . . . . . . 42VENTOLIN HFA . . . . . . . . . . . . 48VEPESID . . . . . . . . . . . . . . . . . . 6verapamil . . . . . . . . . . . . . .10, 15verapamil extended-release . . 10VERIO . . . . . . . . . . . . . . . . .23, 24VERIO, VERIO FLEX, VERIO IQ,

VERIO SYNC . . . . . . . . . . . 23VERZENIO . . . . . . . . . . . . . . . . . 4VESANOID . . . . . . . . . . . . . . . . . 7VEXOL . . . . . . . . . . . . . . . . . . . 39VFEND . . . . . . . . . . . . . . . . . . . 30VI-DAYLIN . . . . . . . . . . . . . . . . . 59

VICKS NYQUIL COLD & FLU NIGHTTIME RELIEF, CLEAR COUGH PM MULTI-SYMPTOM . . .46, 57

VICODIN . . . . . . . . . . . . . . . . . . 14VICODIN ES . . . . . . . . . . . . . . . 14VICTOZA . . . . . . . . . . . . . . . . . 24VIDEX . . . . . . . . . . . . . . . . . . . . 32VIDEX EC . . . . . . . . . . . . . . . . . 32vigabatrin oral solution . . . . . . 17VIMPAT . . . . . . . . . . . . . . . . . . . 16VINATE AZ EX . . . . . . . . . . . . . 51VINATE II . . . . . . . . . . . . . . . . . 51VIRACEPT . . . . . . . . . . . . . . . . 32VIRAMUNE . . . . . . . . . . . . . . . 31VIRAMUNE XR . . . . . . . . . . . . 31VIREAD . . . . . . . . . . . . . . . . . . 32VIROPTIC . . . . . . . . . . . . . . . . . 41VISINE . . . . . . . . . . . . . . . . . . . 59VISINE-AC . . . . . . . . . . . . . . . . 38vismodegib . . . . . . . . . . . . . . . . 7VISTARIL . . . . . . . . . . . . . . . . . 21VISTOGARD . . . . . . . . . . . . . . 25vitamin A . . . . . . . . . . . . . . . . . 52vitamin ADC/fluoride/±iron

drops . . . . . . . . . . . . . . . . . 52vitamin B complex/vitamin C/

folic acid . . . . . . . . . . . . . . . 52vitamin B-1 . . . . . . . . . . . . . . . . 52VITAMIN B-12 . . . . . . . . . . . . . 50vitamin B-6 . . . . . . . . . . . . . . . . 52vitamin C . . . . . . . . . . . . . . . . . 52VITAMIN D 1000 UNIT . . . . . . 50VITAMIN D 2000 UNIT . . . . . . 50vitamin D 400 IU . . . . . . . . . . . 59VITAMIN D 400 UNIT . . . . . . . 50vitamins pediatric . . . . . . .52, 59vitamins pediatric members <3

years old . . . . . . . . . . . . . . 59vitamins prenatal . . . . . . . . . . . 59VITEKTA . . . . . . . . . . . . . . . . . . 31VIVOTIF BERNA . . . . . . . . . . . 55VOLTAREN . . . . . . . . 13, 34, 39VOLTAREN 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 34

VOLTAREN XR . . . . . . . . .13, 34voriconazole . . . . . . . . . . . . . . 30vorinostat . . . . . . . . . . . . . . . . . . 4VOSOL HC OTIC . . . . . . . . . . 21VOSOL OTIC . . . . . . . . . . . . . . 21VOTRIENT . . . . . . . . . . . . . . . . . 5VYVANSE . . . . . . . . . . . . . . . . 41VYVANSE CHEWABLE . . . . . 41

Wwarfarin . . . . . . . . . . . . . . . . . . . 7WELLBUTRIN . . . . . . . . . . . . . 43WELLBUTRIN SR . . . . . . . . . . 43WELLBUTRIN XL . . . . . . . . . . 43WESTCORT . . . . . . . . . . . . . . . 18wound dressings - pads . . . . . 57WYTENSIN . . . . . . . . . . . . . . . 12

XXALATAN . . . . . . . . . . . . . . . . . 40XALKORI . . . . . . . . . . . . . . . . . . 4XANAX . . . . . . . . . . . . . . . . . . . 41XARELTO . . . . . . . . . . . . . . . . . . 7XELODA . . . . . . . . . . . . . . . . . . . 4XENAZINE . . . . . . . . . . . . . . . . 17XIIDRA . . . . . . . . . . . . . . . . . . . 40XOLAIR . . . . . . . . . . . . . . . . . . 49XOPENEX RESPULES . . . . . . 49XULANE . . . . . . . . . . . . . . . . . . 36XYLOCAINE . . . . . . . . . . . .20, 22XYZAL . . . . . . . . . . . . . . . . . . . 21

YYUVAFEM . . . . . . . . . . . . . . . . 37

Zzaleplon . . . . . . . . . . . . . . . . . . 43ZANAFLEX . . . . . . . . . . . . . . . 35zanamivir . . . . . . . . . . . . . . . . . 31ZANTAC . . . . . . . . . . . . . . . . . . 27ZARONTIN . . . . . . . . . . . . . . . 16ZAROXOLYN . . . . . . . . . . . . . . 10ZARXIO . . . . . . . . . . . . . . . . . . . 7ZEBETA . . . . . . . . . . . . . . . . . . . 9ZEBUTAL . . . . . . . . . . . . . . . . . 13

81



ZEJULA . . . . . . . . . . . . . . . . . . . 6ZELBORAF . . . . . . . . . . . . . . . . 5ZENATANE . . . . . . . . . . . . . . . 17ZENPEP . . . . . . . . . . . . . . . . . . 27ZERIT . . . . . . . . . . . . . . . . . . . . 32ZESTORETIC . . . . . . . . . . . . . . 8ZESTRIL . . . . . . . . . . . . . . . . . . . 8ZETIA . . . . . . . . . . . . . . . . . . . . 11ZIAC . . . . . . . . . . . . . . . . . . . . . . 9ZIAGEN . . . . . . . . . . . . . . . . . . 31zidovudine . . . . . . . . . . . . .31, 32ZINBRYTA . . . . . . . . . . . . . . . . 15zinc . . . . . . . . . . . . . . . . . . .38, 52ziprasidone . . . . . . . . . . . . . . . 44ziprasidone mesylate for inj . . 44ZITHROMAX . . . . . . . . . . . . . . 29ZOCOR. . . . . . . . . . . . . . . . . . . 11ZOFRAN . . . . . . . . . . . . . . . . . . 26ZOFRAN ODT . . . . . . . . . . . . . 26ZOHYDRO ER . . . . . . . . . . . . . 14ZOLINZA . . . . . . . . . . . . . . . . . . 4ZOLOFT . . . . . . . . . . . . . . . . . . 42zolpidem . . . . . . . . . . . . . . . . . 43ZOMACTON . . . . . . . . . . . . . . 24ZONEGRAN . . . . . . . . . . . . . . 17zonisamide . . . . . . . . . . . . . . . 17ZORTRESS . . . . . . . . . . . . . . . . 6ZOSTAVAX . . . . . . . . . . . . . . . . 55zoster vaccine live . . . . . . . . . . 55ZOVIA 1/35 . . . . . . . . . . . . . . . 36ZOVIA 1/50 . . . . . . . . . . . . . . . 36ZOVIRAX . . . . . . . . . . . . . . . . . 31ZYDELIG . . . . . . . . . . . . . . . . . . 4ZYKADIA . . . . . . . . . . . . . . . . . . 4ZYLOPRIM . . . . . . . . . . . . . . . . 35ZYMAR . . . . . . . . . . . . . . . . . . . 40ZYPREXA . . . . . . . . . . . . . . . . 43ZYRTEC . . . . . . . . . . . . . . .21, 56ZYRTEC CHEWABLE

TABLET . . . . . . . . . . . . . . . 21ZYRTEC D . . . . . . . . . . . . . . . . 56ZYRTEC-D . . . . . . . . . . . . . . . . 22ZYTIGA . . . . . . . . . . . . . . . . . . . 5ZYVOX . . . . . . . . . . . . . . . . . . . 33

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“My Medications” worksheetTake this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicineand Strength

DrugTier

I Take ThisMedicine For Directions Doctor

Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr. Johnson

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