bcbsri 5-tier formulary (drug list)*however, pharmacists cannot substitute a preferred brand‐name...
TRANSCRIPT
A Reference Guide
INTRODUCTION
Below you’ll find the BCBSRI formulary, which is a list of all the prescription drugs covered under your health plan. Our formulary offers a wide range of medications from which to choose and is reviewed periodically by BCBSRI’s Pharmacy and Therapeutics Committee. This committee, which is made up of local, community‐based practicing physicians and pharmacists, evaluates the medications on the formulary for safety and effectiveness and helps to ensure that BCBSRI members have access to medications that support their health.
CONTROLLING COSTS
The BCBSRI formulary divides covered drugs into five “tiers.” Each tier has a corresponding copayment. This allows us to better manage the overall cost of providing prescription drug benefits to our members, while also helping you control what you pay out of pocket for your medications.
We realize that the BCBSRI formulary may not include every drug from every manufacturer. However, choosing medications from the BCBSRI formulary, when appropriate, can provide you with access to the medications you need—at the most affordable cost.
THE FIVE TIERS
• First Tier: Includes generic prescription drugs that have the lowest copayment.
• Second Tier: Includes generic prescription drugs that have a higher copayment than the first tier.
• Third Tier: Includes high‐cost generic prescription drugs and preferred brand‐name prescription drugs, which have a higher copayment than the second tier.
• Fourth Tier: Includes highest cost generic drugs and non‐preferred brand name drugs that have a higher copayment than the third tier.
• Fifth Tier: Includes specialty prescription drugs that have the highest copayment.
HOW TO USE THE FORMULARY REFERENCE GUIDE
This formulary reference guide lists generic drugs first in each drug category. The preferred brand name products are listed next, and non‐preferred brand products are listed last.
PLEASE NOTE: If a generic drug is listed in the “generics” section and its corresponding brand‐name product is not listed in the “preferred brand‐name” section, then only the generic drug is on the formulary. If a brand name
BCBSRI 5-Tier Formulary (Drug List)* Effective October 1, 2016 to December 31, 2016
product is listed in the “preferred brand‐name” section and its corresponding generic product is not listed in the “generics” section, then a generic version of the medication is not available.
CONSIDERING PREFERRED ALTERNATIVES This formulary reference guide lists possible preferred alternatives for commonly prescribed non‐ preferred medications. However, pharmacists cannot substitute a preferred brand‐name drug without the prescriber’s approval and will contact the prescriber to obtain authorization to dispense an alternative preferred product when a non‐preferred product has been prescribed.
SAVING ON OUT‐OF‐POCKET COSTS Your health plan’s prescription drug coverage encourages the use of generic and preferred brand‐ name drugs. Choosing non‐preferred drugs may mean paying higher out‐of‐pocket expenses (such as coinsurance, copayments, and deductible amounts) or not receiving coverage at all. You will have lower copayments when you use generic drugs. If you use a brand‐name drug when there is a generic alternative available, you may be asked to pay the cost difference.
CONSULTING THE PRESCRIBER’S OFFICE WHEN APPROPRIATE BCBSRI’s formulary may provide coverage only for certain medications or for particular uses, time periods, doses, or quantities (e.g., the formulary may exclude coverage for medications for unapproved, unproven, or cosmetic indications, as well as over‐the‐counter medications).
When prescription drug coverage is provided based on use or quantity, certain limits may apply. Your prescriber may request an exception based upon your individual circumstances. Contact BCBSRI for additional information to determine whether coverage is available under your plan. Patients who are unsure whether these coverage rules apply for a particular medication can consult their BCBSRI subscriber agreement or contact a BCBSRI member services representative to determine specific coverage requirements.
*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your health plan’s benefit design determines what is covered and the applicable copayment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of BCBSRI. The presence of a medication on this formulary list does not guarantee coverage. Certain therapeutic classes are routinely designated as formulary exclusions and are not eligible for coverage, these classes include Weight Loss, Erectile Dysfunction, Smoking Cessation, OTC status products and drugs with OTC equivalents, Vaccines, products with DESI designations and experimental drugs. Most brand name drugs with generic equivalents are not covered. To see the most up‐to‐date formulary, please visit your member home page on BCBSRI.com. You may also call Member Services at the number listed on the back of your member ID card.
Table of Contents
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CEPHALOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
FIRST GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
SECOND GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
THIRD GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
FOURTH GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
MACROLIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
QUINOLONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
SULFONAMIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
AMEBICIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
MISC. ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTINEOPLASTICS, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ALKYLATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTIMETABOLITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
MITOTIC INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ENZYME INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
TOPOISOMERASE I INHIBITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTINEOPLASTICS MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CHEMOTHERAPY RESCUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTINEOPLASTIC COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CARDIOVASCULAR DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CARDIAC GLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIANGINAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CALCIUM CHANNEL BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIARRHYTHMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ACE INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANGIOTENSIN RCPTR BLOCKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DIRECT RENIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANTIHYPERTENSIVES MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANTIHYPERTENSIVE COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DIURETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CARDIOVASCULAR - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
DERMATOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ACNE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ROSACEA AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIBIOTICS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIFUNGALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIVIRALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTI-INFLAMMATORY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIPRURITICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIPSORIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTISEBORRHEIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CORTICOSTEROIDS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
IMMUNOMODULATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DERMATOLOGICALS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ENDOCRINE AND METABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CORTICOSTEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ESTROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
PROGESTINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ANTIDIABETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
AMYLIN ANALOGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
INCRETIN MIMETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
SULFONYLUREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
BIGUANIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
MEGLITINIDE ANALOGUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DIABETIC OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ALPHA-GLUCOSIDASE INHIBIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DPP-4 INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
INSULIN SENSITIZING AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ANTIDIABETIC COMBINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
BISPHOSPHONATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
CALCITONINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PARATHYROID HORMONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
RANK LIGAND INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
HORMONE RECEPTOR MDLTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
FERTILITY REGULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
LHRH/GNRH AGONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
GNRH/LHRH ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
GROWTH HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
SOMATOMEDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
SOMATOSTATIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
GH RECEPTOR ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
POSTERIOR PITUITARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
CORTICOTROPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PROLACTIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
VASOPRESSIN ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PROGESTERONE ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
METABOLIC MODIFIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
THYROID AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
GASTROINTESTINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ANTACIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
GASTROINTESTINAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
GENITOURINARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
URINARY ANTISPASMODICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
VAGINAL PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
GENITOURINARY - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
HEMATOLOGICAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
HEMATOLOGICAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
MOUTH/THROAT/DENTAL AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
NEUROLOGY, CNS, PSYCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ANTIANXIETY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ADHD, NARCOLEPSY, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ANTICONVULSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ANTIPARKINSON AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
NEUROLOGY, PSYCH - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
MUSCULOSKELETAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
OPHTHALMOLOGY AND OTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ARTIFICIAL TEAR/LUBRICANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
BETA-BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
OPHTHALMIC STEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
PROSTAGLANDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
CYCLOPLEGIC MYDRIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
DECONGESTANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
MIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ADRENERGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
LOCAL ANESTHETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
OPHTHALMICS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ANALGESICS - NONNARCOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ANALGESICS - OPIOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ANTI-INFLAMMATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
LOCAL ANESTHETICS-INJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
RESPIRATORY, ALLERGY, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
NASAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
COUGH/COLD/ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ANTIASTHMATIC/COPD AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
RESPIRATORY AGENTS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
MULTIVITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
MISCELLANEOUS AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
FOURTH GENERATION
TIER 01 GENERIC
cefepime
TIER 04 NON PREFERRED
April 2016
ANTI-INFECTIVES MACROLIDES
TIER 02 GENERIC
PENICILLINS
azithromycin
TIER 01 GENERIC
clarithromycin
amoxicillin
clarithromycin ER
amoxicillin ER
erythromycin
ampicillin
erythromycin base
ampicillin sodium
erythromycin ethylsuccinate
ampicillin-sulbactam
TIER 04 NON PREFERRED
dicloxacillin sodium
DificidST
nafcillin sodium
E.E.S. Granules
oxacillin sodium
Ery-TAB
penicillin v potassium
Eryped 200
penicillin G procaine
Eryped 400
penicillin G sodium
Erythrocin Stearate
TIER 02 GENERIC
PCE
amoxicillin/clavulanate potassium
Zmax
amoxicillin/clavulanate potassium ER
penicillin G potassium
TETRACYCLINES
TIER 04 NON PREFERRED
TIER 01 GENERIC
Augmentin
demeclocycline HCL
Bicillin C-R
doxycycline hyclate
Bicillin L-A
minocycline HCL
Moxatag
tetracycline HCL
TIER 02 GENERIC
CEPHALOSPORIN
doxycycline
FIRST GENERATION
doxycycline hyclate DR
TIER 01 GENERIC
doxycycline monohydrate
cefadroxil
minocycline HCL ER
cefazolin sodium
TIER 04 NON PREFERRED
cephalexin
Ocudox
SECOND GENERATION
Targadox
TIER 01 GENERIC
Vibramycin
cefaclor ER
cefotetan
QUINOLONES
cefoxitin sodium
TIER 01 GENERIC
cefprozil
ciprofloxacin
cefuroxime axetil
ciprofloxacin HCL
cefuroxime sodium
levofloxacin
TIER 02 GENERIC
moxifloxacin HCL
cefaclor
TIER 02 GENERIC
TIER 04 NON PREFERRED
ciprofloxacin ER
Cefotan
ofloxacin
Ceftin
TIER 04 NON PREFERRED
THIRD GENERATION
Factive
TIER 01 GENERIC
Noroxin
cefditoren pivoxil
cefixime
AMINOGLYCOSIDES
cefotaxime sodium
ceftibuten TIER 01 GENERIC
ceftriaxone sodium gentamicin sulfate pediatric
TIER 02 GENERIC neomycin sulfate
cefdinir streptomycin sulfate
cefpodoxime proxetil tobramycin sulfate
ceftazidime TIER 02 GENERIC
TIER 03 FORMULARY amikacin sulfate
Suprax gentamicin sulfate
paromomycin sulfate
TIER 04 NON PREFERRED TIER 05 SPECIALTY
Cedax tobramycin
Fortaz BethkisPA
Spectracef
Tobi PodhalerPA
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 1
SULFONAMIDES Epivir HBV
Intelence
TIER 02 GENERIC
Invirase
sulfadiazine
Isentress
Kaletra
ANTIMYCOBACTERIAL AGENTS
Lexiva
TIER 01 GENERIC
Norvir
cycloserine
Prezista
isoniazid
Rebetol
pyrazinamide
Rescriptor
rifabutin
Reyataz
TIER 02 GENERIC
Rimantalist
ethambutol HCL
Selzentry
rifampin
Sustiva
TIER 03 FORMULARY
Truvada
Paser
Priftin
Viracept
Rifater
Viramune
Trecator
Virazole
TIER 04 NON PREFERRED
Viread
Capastat Sulfate
TIER 04 NON PREFERRED
Rifamate
Atripla
Sirturo
Baraclude
Complera
ANTIFUNGALS
Epzicom
TIER 01 GENERIC
Evotaz
amphotericin b
Genvoya
flucytosine
Moderiba
ketoconazole
terbinafine HCL
TIER 02 GENERIC
Odefsey
fluconazole
Prezcobix
griseofulvin microsize
Relenza Diskhaler
griseofulvin ultramicrosize
Ribasphere Ribapak
itraconazolePA
SitavigQL,PA
nystatin
Stribild
voriconazole
Tamiflu
TIER 04 NON PREFERRED
Tivicay
Cresemba
Triumeq
LamisilPA
Tyzeka
Noxafil
Videx Pediatric
SporanoxPA
Vitekta
Terbinex
Ziagen
TIER 05 SPECIALTY
ANTIVIRALS
DaklinzaPA
TIER 01 GENERIC
Fuzeon
acyclovir
HarvoniPA
didanosine
Peg-intronPA
entecavir
Peg-intron RedipenPA
lamivudine
nevirapine
PegasysPA
nevirapine ER
Pegasys ProclickPA
rimantadine HCL
PegintronPA
stavudine
SovaldiPA
valacyclovir HCL
VictrelisQL,PA
valganciclovir
TIER 02 GENERIC
ANTIMALARIALS
abacavir
TIER 01 GENERIC
abacavir sulfate/lamivudine/zidovudine
chloroquine phosphate
adefovir dipivoxil
hydroxychloroquine sulfate
famciclovir
TIER 02 GENERIC
lamivudine/zidovudine
atovaquone/proguanil HCL
ribavirin
mefloquine HCL
zidovudine
primaquine phosphate
quinine sulfate
TIER 03 FORMULARY
TIER 03 FORMULARY
Aptivus
Daraprim
Crixivan
TIER 04 NON PREFERRED
Edurant
Coartem
Emtriva
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 2
AMEBICIDES GENERIC
mercaptopurine
TIER 03 FORMULARY
methotrexate
Yodoxin
methotrexate sodium
TIER 03 FORMULARY
ANTHELMINTICS
Trexall
TIER 01 GENERIC
TIER 04 NON PREFERRED
ivermectin
Purixan
TIER 03 FORMULARY
Tabloid
Albenza
TIER 05 SPECIALTY
Biltricide
capecitabinePA
TIER 04 NON PREFERRED
Emverm
HORMONAL AGENTS
TIER 01 GENERIC
MISC. ANTI-INFECTIVES
anastrozole
TIER 01 GENERIC
letrozole
atovaquone
tamoxifen citrate
aztreonam
TIER 02 GENERIC
bacitracin
bicalutamide
clindamycin phosphate
exemestane
flutamide
clindamycin HCL
leuprolide acetate
lincomycin HCL
megestrol acetate
lincomycin/lidocaine
TIER 03 FORMULARY
linezolid
Emcyt
metronidazole
Lysodren
polymyxin b sulfate
Nilandron
sulfamethoxazole/trimethoprim
Soltamox
sulfamethoxazole/trimethoprim DS
TIER 04 NON PREFERRED
trimethoprim
Depo-provera
TIER 02 GENERIC
Fareston
clindamycin palmitate HCL
TIER 05 SPECIALTY
colistimethate sodium
EligardPA
dapsone
Firmagon
tinidazole
Lupron DepotPA
vancomycin HCL
Trelstar
TIER 03 FORMULARY
Trelstar Mixject
Flagyl ER
Vantas
Nebupent
XtandiQL,PA
Primsol
Zoladex
TIER 04 NON PREFERRED
ZytigaQL,PA
Alinia
Invanz
IMMUNOMODULATORS
Ketek
TIER 01 GENERIC
azathioprine
Pentam 300
mycophenolic acid DR
Sivextro
sirolimus
XifaxanPA
TIER 02 GENERIC
TIER 05 SPECIALTY
cyclosporine
Cayston
cyclosporine modified
mycophenolate mofetil
ANTINEOPLASTICS, ETC.
tacrolimus
ALKYLATING AGENTS
TIER 03 FORMULARY
TIER 01 GENERIC
Azasan
cyclophosphamide
TIER 04 NON PREFERRED
TIER 02 GENERIC
Astagraf XL
lomustine
Cellcept
TIER 03 FORMULARY
Imuran
Alkeran
Neoral
Hexalen
Prograf
Leukeran
Rapamune
Myleran
Sandimmune
TIER 04 NON PREFERRED
Zortress
Gleostine
TIER 05 SPECIALTY
TIER 05 SPECIALTY
PomalystQL,PA
temozolomidePA
RevlimidQL,PA
ValchlorPA
ThalomidPA
ANTIMETABOLITES
TIER 02
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 3
MITOTIC INHIBITORS ANTINEOPLASTIC COMBO
TIER 02 GENERIC TIER 05 SPECIALTY
etoposide LonsurfPA
ENZYME INHIBITORS CARDIOVASCULAR DRUGS
TIER 05 SPECIALTY
CARDIAC GLYCOSIDES
imatinib mesylatePA
TIER 02 GENERIC
AfinitorPA
digoxin
Afinitor DisperzPA
TIER 04 NON PREFERRED
AlecensaPA
BosulifPA
CaprelsaQL,PA
CometriqPA
CotellicPA
ANTIANGINAL AGENTS
FarydakPA
TIER 01 GENERIC
GilotrifQL,PA
isosorbide dinitrate
isosorbide mononitrate
IbrancePA
isosorbide mononitrate ER
IclusigPA
nitroglycerin ER
ImbruvicaPA
TIER 02 GENERIC
InlytaPA
isosorbide dinitrate ER
IressaPA
nitroglycerin lingual
JakafiPA
nitroglycerin transdermal
Lenvima 10MG Daily DosePA
TIER 03 FORMULARY
Lenvima 14MG Daily DosePA
Dilatrate SR
Lenvima 20MG Daily DosePA
Nitro-bid
Lenvima 24MG Daily DosePA
Nitro-Dur
LynparzaPA
Nitrostat
MekinistPA
TIER 04 NON PREFERRED
NexavarPA
Nitromist
NinlaroPA
Ranexa
SprycelPA
StivargaPA
BETA BLOCKERS
SutentPA
TIER 01 GENERIC
TafinlarPA
acebutolol HCL
TagrissoPA
atenolol
TarcevaPA
carvedilol
Tasigna
labetalol HCL
TykerbPA
metoprolol tartrate
VotrientPA
pindolol
XalkoriQL,PA
propranolol HCL
ZelborafQL,PA
sotalol HCL
ZolinzaPA
sotalol HCL (AF)
ZydeligPA
TIER 02 GENERIC
ZykadiaPA
betaxolol HCL
bisoprolol fumarate
TOPOISOMERASE I INHIBITOR
metoprolol succinate ER
TIER 04 NON PREFERRED
nadolol
Hycamtin
propranolol HCL ER
timolol maleate
ANTINEOPLASTICS MISC.
TIER 04 NON PREFERRED
TIER 02 GENERIC
Bystolic
hydroxyurea
Coreg CR
tretinoin
Hypertenevide-12.5
TIER 03 FORMULARY
Inderal XL
Matulane
Innopran XL
TIER 05 SPECIALTY
Levatol
bexarotenePA
Sotylize
ActimmunePA
Intron A
CALCIUM CHANNEL BLOCKERS
Intron A W/Diluent
TIER 01 GENERIC
SylatronPA
amlodipine besylate
diltiazem HCL
CHEMOTHERAPY RESCUE
nicardipine HCL
TIER 01 GENERIC
verapamil HCL
leucovorin calcium
verapamil HCL ER
TIER 03 FORMULARY
Mesnex
TIER 02 GENERIC
diltiazem CD
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 4
diltiazem HCL ER ANTIHYPERTENSIVES MISC.
felodipine ER
TIER 01 GENERIC
isradipine
clonidine HCL
nifedipine
doxazosin
nifedipine ER
doxazosin mesylate
nimodipine
guanfacine HCL
nisoldipine
hydralazine HCL
nisoldipine ER
methyldopa
verapamil HCL SR
minoxidil
TIER 04 NON PREFERRED
phenoxybenzamine hydrochloride
Cardene SR
phentolamine mesylate
prazosin HCL
Hypertenipine-2.5
reserpine
Nymalize
terazosin HCL
TIER 02 GENERIC
ANTIARRHYTHMICS
eplerenone
TIER 01 GENERIC TIER 03 FORMULARY
amiodarone HCL Demser
flecainide acetate TIER 04 NON PREFERRED
procainamide HCL Vecamyl
quinidine gluconate
quinidine sulfate ANTIHYPERTENSIVE COMBO
quinidine sulfate ER
TIER 01 GENERIC
TIER 02 GENERIC
amlodipine besylate/valsartan
disopyramide phosphate
amlodipine/valsartan/hctz
mexiletine HCL
atenolol/chlorthalidone
propafenone HCL
benazepril HCL/hydrochlorothiazide
propafenone HCL ER
bisoprolol fumarate/hydrochlorothiazide
quinidine gluconate CR
captopril/hydrochlorothiazide
quinidine gluconate ER
enalapril maleate/hydrochlorothiazide
TIER 03 FORMULARY
lisinopril/hydrochlorothiazide
Norpace CR
losartan potassium/hydrochlorothiazide
Tikosyn
methyldopa/hydrochlorothiazide
TIER 04 NON PREFERRED
propranolol/hydrochlorothiazide
Multaq
telmisartan/amlodipine
telmisartan/hydrochlorothiazideQL
ACE INHIBITORS
trandolapril/verapamil HCL
TIER 01 GENERIC trandolapril/verapamil HCL ER
benazepril HCL TIER 02 GENERIC
captopril amlodipine besylate/benazepril hydrochloride
enalapril maleate amlodipine besylate/benazepril HCL
fosinopril sodium candesartan cilexetil/hydrochlorothiazide
lisinopril fosinopril sodium/hydrochlorothiazide
quinapril HCL irbesartan/hydrochlorothiazideQL
ramipril metoprolol/hydrochlorothiazide
trandolapril moexipril/hydrochlorothiazide
TIER 02 GENERIC nadolol/bendroflumethiazide
moexipril HCL quinapril/hydrochlorothiazide
perindopril erbumine valsartan/hydrochlorothiazide
TIER 04 NON PREFERRED TIER 03 FORMULARY
Epaned Benicar HCT
TIER 04 NON PREFERRED
ANGIOTENSIN RCPTR BLOCKER AmturnideQL
Azor
TIER 01 GENERIC
Clorpres
losartan potassiumQL
Dutoprol
telmisartanQL
EdarbyclorST
TIER 02 GENERIC
Hypertensolol
candesartan cilexetilQL
eprosartan mesylate
irbesartanQL
TekamloQL
valsartanQL
Tekturna HCTST
TIER 03 FORMULARY
Teveten HCTST
BenicarQL
TribenzorQL
TIER 04 NON PREFERRED
EdarbiST
DIURETICS
DIRECT RENIN INHIBITORS TIER 01 GENERIC
acetazolamide
TIER 04 NON PREFERRED
acetazolamide sodium
TekturnaST
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 5
amiloride/hydrochlorothiazide Vascepa
bumetanide Vytorin
chlorothiazide TIER 05 SPECIALTY
furosemide JuxtapidQL,PA
hydrochlorothiazide KynamroQL,PA
indapamide
metolazone CARDIOVASCULAR - MISC.
spironolactone
TIER 01 GENERIC
spironolactone/hydrochlorothiazide
papaverine HCL
torsemide
TIER 02 GENERIC
triamterene/hydrochlorothiazide
amlodipine besylate/atorvastatin calcium
TIER 02 GENERIC
TIER 03 FORMULARY
acetazolamide ER
amiloride HCL
TIER 04 NON PREFERRED
chlorthalidone
Cialis RR
methazolamide
CorlanorPA
methyclothiazide
EntrestoPA
TIER 03 FORMULARY
Levitra RR
Aldactazide
Muse
Diuril
StaxynRR
Edecrin
ViagraRR
TIER 04 NON PREFERRED
TIER 05 SPECIALTY
sildenafilQL,PA (for pulmonary hypertension only)
Dyrenium
sildenafil citrateQL,PA (for pulmonary hypertension only)
AdcircaQL,PA
VASOPRESSORS
AdempasPA
TIER 01 GENERIC LetairisQL,PA
ephedrine sulfate
epinephrine OrenitramPA
phenylephrine HCL RemodulinPA
TIER 02 GENERIC TracleerQL,PA
midodrine HCL TyvasoPA
TIER 03 FORMULARY
Epipen 2-PAKQL
Epipen-JR 2-PAKQL VentavisPA
TIER 04 NON PREFERRED
AdrenaclickQL DERMATOLOGICALS
Adrenalin
ACNE PRODUCTS
TIER 05 SPECIALTY
TIER 01 GENERIC
NortheraPA
clindamycin phosphate
sulfacetamide sodium/sulfur
ANTIHYPERLIPIDEMICS
tretinoin microsphere
TIER 01 GENERIC
TIER 02 GENERIC
atorvastatin calcium
adapalene
fluvastatin sodium ER
adapalene P.M.
gemfibrozil
benzoyl peroxide
lovastatin
omega-3-acid ethyl esters
clindamycin/benzoyl peroxide
pravastatin sodium rosuvastatin
erythromycin
simvastatin
erythromycin/benzoyl peroxide
TIER 02 GENERIC
sodium sulfacetamide
cholestyramine
sodium sulfacetamide/sulfur
cholestyramine light
sodium sulfacetamide/sulfur cleanser
colestipol HCL
sodium sulfacetamide/sulfur cleanser IN urea
fenofibrate
sodium sulfacetamide/sulfur cleansing cloths
fenofibrate micronized
sodium sulfacetamide/sulfur green
fenofibric acid DR
sodium sulfacetamide/sulfur wash
fluvastatin
sodium sulfacetamide/sulfur IN urea
niacin ER
sulfacetamide sodium
TIER 03 FORMULARY
sulfacetamide sodium/sulfur cleanser
tretinoin
Welchol
tretinoin microsphere P.M.
Zetia
TIER 04 NON PREFERRED
TIER 04 NON PREFERRED
Avar
Advicor
Avar LS
Altoprev
Clinoin
Fenoglide
Epiduo Forte
Livalo
Fabior
Simcor
Tretin-X
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; RR= Requires Rider for coverage 6
ROSACEA AGENTS PennsaidPA
Xrylix
TIER 01 GENERIC
doxycycline
ANTIPRURITICS
TIER 02 GENERIC
metronidazole TIER 02 GENERIC
TIER 04 NON PREFERRED doxepin hydrochloride
Finacea TIER 04 NON PREFERRED
Prudoxin
ANTIBIOTICS - TOPICAL Zonalon
TIER 02 GENERIC
ANTIPSORIATICS
gentamicin sulfate
mupirocin TIER 01 GENERIC
mupirocin calcium methoxsalen
TIER 03 FORMULARY TIER 02 GENERIC
Cortisporin acitretin
TIER 04 NON PREFERRED calcipotriene
centany calcitriol
Altabax TIER 03 FORMULARY
Centany AT 8-mop
Neo-synalar TIER 04 NON PREFERRED
Sorilux
ANTIFUNGALS - TOPICAL Taltz
Tazorac
TIER 01 GENERIC
Vectical
ciclopirox nail lacquer
Zithranol
ciclopirox olamine
Zithranol-rr
TIER 05 SPECIALTY
econazole nitrate
CosentyxPA
ketoconazole
Cosentyx Sensoready PenPA
naftifine hydrochloride
StelaraQL,PA
naftifine HCL
nystatin
ANTISEBORRHEIC AGENTS
oxiconazole nitrate
TIER 02 GENERIC TIER 01 GENERIC
ciclopirox glycolic acid
clotrimazole/betamethasone dipropionate glycolic acid 70% high purity
nystatin/triamcinolone sodium sulfacetamide
TIER 03 FORMULARY TIER 02 GENERIC
Exelderm selenium sulfide
Halotin sodium sulfacetamide wash
Lamisil Spray TIER 04 NON PREFERRED
Ovace Plus
Xolegel Promiseb
TIER 04 NON PREFERRED Promiseb Complete
Selrx
Ecoza Tersi Foam
TL Triseb
Luzu
Mentax CORTICOSTEROIDS - TOPICAL
TIER 01 GENERIC
alclometasone dipropionate
Recura
augmented betamethasone dipropionate
Vusion
calcipotriene/betamethasone dipropionate
clobetasol propionate
Xolegel Duo/Head & Shoulders
clobetasol propionate emollient
Xolegel Duo/Xolex
clocortolone pivalate
clocortolone pivalate P.M.
ANTIVIRALS - TOPICAL
desonide
TIER 02 GENERIC fluocinonide
acyclovir fluocinonide-e
TIER 04 NON PREFERRED fluticasone propionate
DenavirQL halobetasol propionate
ANTI-INFLAMMATORY AGENTS hydrocortisone IN absorbase
mometasone furoate
TIER 01 GENERIC
TIER 02 GENERIC
diclofenac sodium gel
amcinonide
TIER 03 FORMULARY
betamethasone dipropionate
betamethasone valerate
TIER 04 NON PREFERRED
desoximetasone
FlectorST
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 7
diflorasone diacetate sulfurated lime
fluocinolone acetonide TIER 02 GENERIC
hydrocortisone acetate/aloe coal TAR
hydrocortisone butyrate ethyl chloride
hydrocortisone butyrate (lipid) ethyl chloride/fine pinpoint
hydrocortisone butyrate (lipophilic) ethyl chloride/fine stream
hydrocortisone valerate ethyl chloride/medium jet stream
prednicarbate ethyl chloride/medium stream
triamcinolone acetonide ethyl chloride/mist
TIER 04 NON PREFERRED lidocaine
Capex lidocaine HCL
Cloderm lindane
Cloderm P.M. malathion
permethrin
Cordran Tape podofilox
Dermasorb HC salicylic acid
Dermasorb TA salicylic acid cream
Desonate salicylic acid lotion
Desowen Cream/Cetaphil Lotion
Desowen Lotion/Cetaphil Cream spinosad
Desowen Ointment/Cetaphil Lotion urea
Enstilar urea topical
Epifoam
Halog
Halonate TIER 03 FORMULARY
Locoid Anacaine
Pandel Atopiclair
Pediaderm HC Condylox
Pediaderm TA Eurax
Scalacort DK
Gordofilm
Gordons Urea
Synalar Ts Kerafoam
Taclonex Kerafoam 42
Texacort Xerac Ac
Topicort TIER 04 NON PREFERRED
Trianex
Alevicyn Antipruritic SG
Verdeso
IMMUNOMODULATING AGENTS Avenova
Clever Choice Comfort EZ Patch
TIER 01 GENERIC
Copasil
tacrolimus
Eletone
TIER 02 GENERIC
Eletone Twinpack
imiquimod
TIER 03 FORMULARY
Emulsion SB
Elidel
Epiceram
TIER 04 NON PREFERRED
Hylatopic
Zyclara
Hylatopic Plus
Zyclara P.M.
DERMATOLOGICALS - MISC.
TIER 01 GENERIC
arnica flower
IV Infusion Cpi
benzoin compound tincture
Keralyt Scalp
benzoin tincture
Lido-RX 4.1
boric acid
Lycelle
capsaicin
Mb Hydrogel
cocaine HCL
Medi-derm/L-RX
lactic acid
Megrix
lactic acid e
Neosalus
lactic acid w/vitamin e
Neosalus CP
lidocaine and tetracaine cream
Neuvaxin
lidocaine HCL jelly
Nivatopic Plus
lidocaine-prilocaine-cream base
Nuvail
lidocaine/prilocaine
Pliaglis
pyrogallic acid
Pr Cream
sodium hyaluronate
Presera
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 8
Pruclair GENERIC
Prumyx methyltestosterone
Qutenza oxandrolone
Relyyt testosterone 1% gel
Salvax Duo Plus testosterone P.M.
Sinelee TIER 02 GENERIC
Sklice danazol
Solaice testosterone cypionate
Synera testosterone enanthate
Tetrix TIER 03 FORMULARY
Tropazone Androgel 1.62%
Ulesfia
Androxy
Umecta Axiron
Umecta PD TIER 04 NON PREFERRED
Veregen Anadrol-50
AndrodermST
ENDOCRINE AND METABOLIC Fortesta
StriantST
CORTICOSTEROIDS
Testim
TIER 01 GENERIC
Vogelxo
dexamethasone
Vogelxo P.M.
dexamethasone sodium phosphate
hydrocortisone tabs
ESTROGENS
methylprednisolone acetate
TIER 01 GENERIC
methylprednisolone sodiumsuccinate
estradiol
methylprednisolone PF
estropipate
prednisolone
norethindrone acetate/ethinyl estradiol
prednisolone sodium phosphate
TIER 02 GENERIC
prednisolone sodium phosphate ODT
estradiol valerate
prednisone
estradiol/norethindrone acetate
triamcinolone
TIER 03 FORMULARY
TIER 02 GENERIC
Alora
betamethasone sodium phosphate/betamethasone acetate
Cenestin
budesonide Climara Pro
cortisone acetate Combipatch
fludrocortisone acetate Depo-estradiol
methylprednisolone Enjuvia
methylprednisolone dose pack Menest
TIER 03 FORMULARY Prefest
Dexamethasone Intensol Premphase
Orapred ODT Prempro
Prednisone Intensol TIER 04 NON PREFERRED
TIER 04 NON PREFERRED Angeliq
Delestrogen
Divigel
Depo-medrol Duavee
Elestrin
Estrasorb
Estrogel
Dyural-l Evamist
FLO-pred Menostar
Medrol Minivelle
Millipred Premarin
Millipred DP
CONTRACEPTIVES
TIER 01 GENERIC
norethindrone & ethinyl estradiol ferrous fumarate
norgestimate/ethinyl estradiol
TIER 02 GENERIC
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
levonorgestrel
Solu-medrol
levonorgestrel and ethinyl estradiol
Uceris
levonorgestrel/ethinyl estradiol
Veripred 20
norethindrone
norethindrone acetate/ethinyl estradiol
ANDROGENS-ANABOLIC (May require PA for < 40 yo use )
norethindrone acetate/ethinyl estradiol/ferrous fumarate
TIER 01
TIER 04
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 9
NON PREFERRED GENERIC
Beyaz nateglinide
Ella repaglinide
Falessa DIABETIC OTHER
LO Loestrin FE TIER 01 FORMULARY- LIFESCAN PRODUCTS PREFERRED
Minastrin 24 FE ONE Touch Test Strips – Ultra, Ultra Mini, UltraSmart,Verio IQ, Verios Sync
Natazia TIER 04 NON PREFERRED
Norinyl 1+50 FarxigaQL,ST
Quartette Glucagen Hypokit
Safyral Glucagon Emergency Kit
InvokanaQL,ST
PROGESTINS JardianceQL,ST
TIER 05 SPECIALTY
TIER 01 GENERIC
KorlymPA
medroxyprogesterone acetate
ALPHA-GLUCOSIDASE INHIBIT
medroxyprogesterone/lidocaine
TIER 01 GENERIC
megestrol acetate
acarbose
TIER 02 GENERIC
TIER 03 FORMULARY
norethindrone acetate
progesterone
DPP-4 INHIBITORS
TIER 05 SPECIALTY
TIER 01 GENERIC
MakenaPA
alogliptin
TIER 03 FORMULARY
ANTIDIABETIC AGENTS
Januvia
INSULIN
Tradjenta
TIER 03 FORMULARY (Lilly Products preferred)
TIER 04 NON PREFERRED
Humulin N, R, all forms preferred
NesinaST
Humalog Kwikpen
OnglyzaST
Humalog Mix 50/50
INSULIN SENSITIZING AGENT
Humalog Mix 50/50 Kwikpen
TIER 02 GENERIC
Humalog Mix 75/25
pioglitazone HCL
Humalog Mix 75/25 Kwikpen
TIER 04 NON PREFERRED
Humulin R U-500 (concentrated)
Avandia
Lantus
ANTIDIABETIC COMBINATIONS
Lantus Solostar
TIER 01 GENERIC
Levemir
alogliptin/metformin HCL
Levemir Flexpen
alogliptin/pioglitazone
Levemir Flextouch
glyburide/metformin HCL
TIER 04 NON PREFERRED
repaglinide/metformin hydrochloride
TIER 02 GENERIC
AMYLIN ANALOGS
glipizide/metformin HCL
TIER 04 NON PREFERRED
pioglitazone HCL-glimepiride
Symlinpen 120
pioglitazone HCL/metformin HCL
Symlinpen 60
TIER 03 FORMULARY
INCRETIN MIMETIC AGENTS
Actoplus Met XR
TIER 03 FORMULARY
Janumet
Byetta
Janumet XR
Tanzeum
Jentadueto
TIER 04 NON PREFERRED
TIER 04 NON PREFERRED
Bydureon
Appformin
VictozaPA
Appformin-d
SULFONYLUREAS
Avandamet
TIER 01 GENERIC
Avandaryl
chlorpropamide
InvokametQL,ST
glimepiride
KazanoST
glipizide
Kombiglyze XRST
glipizide ER
OseniST
glyburide
Xigduo XRST
glyburide micronized
tolazamide
BISPHOSPHONATES
tolbutamide
TIER 01 GENERIC
TIER 04 NON PREFERRED
alendronate sodium
Diabeta
risedronate sodium
BIGUANIDES
risedronate sodium DR
TIER 01 GENERIC
TIER 02 GENERIC
metformin HCL
etidronate disodium
metformin HCL ER
ibandronate sodium
TIER 04 NON PREFERRED
TIER 04 NON PREFERRED
Riomet
Binosto
MEGLITINIDE ANALOGUES
TIER 02
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 10
Fosamax Plus DST SerostimPA
Tev-tropinPA
CALCITONINS ZomactonPA
ZorbtivePA
TIER 02 GENERIC
calcitonin salmon
SOMATOMEDINS
calcitonin-salmon
TIER 04 NON PREFERRED TIER 05 SPECIALTY
fortical IncrelexPA
Miacalcin
SOMATOSTATIC AGENTS
PARATHYROID HORMONE
TIER 02 GENERIC
TIER 05 SPECIALTY octreotide acetate
ForteoPA TIER 05 SPECIALTY
Sandostatin Lar Depot
RANK LIGAND INHIBITORS SigniforQL,PA
Signifor LARPA
TIER 05 SPECIALTY
Somatuline Depot
ProliaPA
XgevaPA
GH RECEPTOR ANTAGONISTS
HORMONE RECEPTOR MDLTR TIER 05 SPECIALTY
Somavert
TIER 01 GENERIC
raloxifene hydrochloride
POSTERIOR PITUITARY
TIER 04 NON PREFERRED
Osphena TIER 01 GENERIC
vasopressin
FERTILITY REGULATORS TIER 02 GENERIC
desmopressin acetate
TIER 01 GENERIC
TIER 03 FORMULARY
clomiphene citrate
Stimate
TIER 05 SPECIALTY
chorionic gonadotropin
Bravelle
Follistim AQ
Gonal-fST
Gonal-f RFFST
Gonal-f RFF PenPA PROLACTIN INHIBITORS
Gonal-f RFF RedijectPA
TIER 02 GENERIC
Menopur
cabergoline
Ovidrel
Repronex
VASOPRESSIN ANTAGONISTS
TIER 04 NON PREFERRED
LHRH/GNRH AGONIST
Samsca
TIER 03 FORMULARY
Synarel
PROGESTERONE ANTAGONISTS
TIER 05 SPECIALTY
TIER 03 FORMULARY
Lupaneta Pack
Mifeprex
Lupron Depot-PED
Supprelin LA
METABOLIC MODIFIERS
TIER 01 GENERIC
GNRH/LHRH ANTAGONISTS
calcitriol
TIER 05 SPECIALTY
doxercalciferol
ganirelix acetate
sodium phenylbutyrate
Cetrotide
TIER 02 GENERIC
levocarnitine
GROWTH HORMONES
paricalcitol
TIER 05 SPECIALTY
TIER 03 FORMULARY
GenotropinPA
Buphenyl
Genotropin MiniquickPA
Orfadin
HumatropePA
Sensipar
TIER 04 NON PREFERRED
Norditropin CartridgePA
Cystadane
Norditropin FlexproPA
Xuriden
Norditropin Nordiflex PenPA
TIER 05 SPECIALTY
Nutropin AQ Nuspin 10PA
CarbagluPA
Nutropin AQ Nuspin 20PA
Kuvan
Nutropin AQ Nuspin 5PA
RavictiPA
Nutropin AQ PenPA
OmnitropePA
THYROID AGENTS
SaizenPA
TIER 01
Saizen Click.easyPA
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 11
GENERIC belladonna alkaloids & opium
levothyroxine sodium chlordiazepoxide HCL/clidinium bromide
levothyroxine sodium TAB 0.075MG cimetidine
methimazole dicyclomine hci
TIER 02 GENERIC dicyclomine HCL
liothyronine sodium famotidine
propylthiouracil glycopyrrolate
TIER 03 FORMULARY hyoscyamine sulfate ODT
Thyrolar-1 omeprazole
Thyrolar-1/2 omeprazole/sodium bicarbonate
Thyrolar-1/4 pantoprazole sodium
Thyrolar-2 scopolamine hydrobromide
Thyrolar-3 TIER 02 GENERIC
TIER 04 NON PREFERRED belladonna & opium
Armour Thyroid cimetidine HCL
Cytomel hyoscyamine sulfate
Nature-throid hyoscyamine sulfate ER
Nature-throid NT-2.5 hyoscyamine sulfate SR
Synthroid lansoprazole
Tirosint lansoprazole/amoxicillin/clarithromycin
Westhroid methscopolamine bromide
Wp Thyroid misoprostol
nizatidine
GASTROINTESTINAL propantheline bromide
rabeprazole sodium
LAXATIVES
ranitidine HCL
TIER 01 GENERIC
sucralfate
cascara sagrada
lactulose
TIER 03 FORMULARY
mineral oil heavy
Carafate
polyethylene glycol 3350
TIER 04 NON PREFERRED
senna plus
Aciphex SprinklePA
TIER 02 GENERIC
Atropen
peg 3350/electrolytes
Cantil
peg-3350/electrolytes
Cuvposa
peg-3350/NACL/NA bicarbonate/KCL
Gabitidine
TIER 03 FORMULARY
Levsin
Golytely
Moviprep
Pamine FQ
Osmoprep
Prevacid SolutabPA
Suclear
ProtonixPA
TIER 04 NON PREFERRED
Pylera
Colyte-flavor Packs
Kristalose
Symax Duotab
Prepopik
Suprep Bowel Prep
ANTIEMETICS
TIER 01 GENERIC
ANTIDIARRHEALS
dimenhydrinate
TIER 01 GENERIC
ondansetron ODT
paregoric
trimethobenzamide HCL
TIER 02 GENERIC
TIER 02 GENERIC
diphenoxylate/atropine
dronabinol
opium
granisetron HCLQL
opium tincture
ondansetron HCL
TIER 03 FORMULARY
TIER 03 FORMULARY
Motofen
Transderm-scop
VSL#3 DS
TIER 04 NON PREFERRED
TIER 04 NON PREFERRED
Akynzeo
FulyzaqPA
Anzemet
Restora RX
Cesamet
Rezyst IM
Emend
Rezyst SB
Granisol
Sancuso
ANTACIDS
Zuplenz
TIER 01 GENERIC
sodium bicarbonate
DIGESTIVE AIDS
TIER 02 GENERIC
ULCER DRUGS
pancrelipase
TIER 01 GENERIC
TIER 03
atropine sulfate
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 12
FORMULARY methenamine mandelate
Creon nitrofurantoin
Pancreaze nitrofurantoin macrocrystals
SucraidPA nitrofurantoin monohydrate
Ultresa nitrofurantoin monohydrate/macrocrystals
Viokace TIER 04 NON PREFERRED
Zenpep Monurol
TIER 04 NON PREFERRED Uretron D/S
Pertzye Uroqid #2
GASTROINTESTINAL - MISC. URINARY ANTISPASMODICS
TIER 01 GENERIC TIER 01 GENERIC
alosetron hydrochloride bethanechol chloride
dexpanthenol darifenacin hydrobromide ER
lactulose darifenacin ER
metoclopramide ODT oxybutynin chloride
metoclopramide HCL tolterodine tartrate ER
sevelamer carbonate TIER 02 GENERIC
TIER 02 GENERIC flavoxate HCL
balsalazide disodium oxybutynin chloride ER
calcium acetate tolterodine tartrate
cromolyn sodium trospium chloride
hydrocortisone tabs trospium chloride ER
hydrocortisone acetate/lidocaine HCL TIER 03 FORMULARY
hydrocortisone acetate/pramoxine Vesicare
lidocaine HCL-hydrocortisone acetate with aloe TIER 04 NON PREFERRED
lidocaine HCL/hydrocortisone acetate Gelnique
mesalamine Myrbetriq
sulfasalazine Toviaz
ursodiol
TIER 03 FORMULARY VAGINAL PRODUCTS
Apriso
TIER 01 GENERIC
Asacol HD
terconazole
Canasa
TIER 02 GENERIC
Fosrenol
clindamycin phosphate
Lialda
metronidazole vaginal
Pentasa
TIER 03 FORMULARY
Cleocin
Renagel
Estring
Renvela
TIER 04 NON PREFERRED
auryxia
Amitiza
Premarin
Chenodal
Vagifem
Cortifoam
TIER 04 NON PREFERRED
Delzicol
AVC
Dipentum
Clindesse
Entereg
Crinone
Giazo
Endometrin
Linzess
Estrace
MovantikQL,PA
Femring
Phoslyra
Gynazole-1
Procort
Relagard
Rectiv
Relistor
GENITOURINARY - MISC.
Sfrowasa
TIER 01 GENERIC
Uceris
alfuzosin HCL ER
Velphoro
dutasteride
TIER 05 SPECIALTY
dutasteride/tamsulosin hydrochloride
CimziaQL,PA
finasteride
Cimzia Starter KitQL,PA
phenazopyridine HCL
GattexPA
potassium citrate/sodium citrate/citric acid
tamsulosin HCL
GENITOURINARY
tricitrates
URINARY ANTI-INFECTIVES TIER 02 GENERIC
citric acid/sodium citrate
TIER 02 GENERIC
potassium citrate ER
methenamine hippurate
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 13
potassium citrate-citric acid crystals HEMOSTATICS
potassium citrate/citric acid
TIER 02 GENERIC
sodium citrate/citric acid
aminocaproic acid
TIER 03 FORMULARY
tranexamic acid
Cystagon
TIER 03 FORMULARY
Elmiron
Artiss
K-phos NO 2
Astringyn
Lithostat
Oracit
TIER 04 NON PREFERRED
Cardura XL
Rapaflo
Thrombogen
TIER 05 SPECIALTY
TIER 04 NON PREFERRED
Procysbi
Evicel
ThiolaPA
Evithrom
Recothrom
HEMATOLOGICAL AGENTS
Tisseel
HEMATOPOIETIC AGENTS
Tisseel VH
TIER 01 GENERIC
HEMATOLOGICAL - MISC.
cyanocobalamin
TIER 01 GENERIC
folic acid
aspirin/dipyridamole
TIER 02 GENERIC
clopidogrel
hydroxocobalamin
dipyridamole
TIER 03 FORMULARY
TIER 02 GENERIC
Droxia
anagrelide hydrochloride
TIER 04 NON PREFERRED
cilostazol
Ciferex
pentoxifylline ER
Feriva 21/7
ticlopidine HCL
Mozobil
TIER 03 FORMULARY
Nascobal
Aggrenox
Omontys
TIER 04 NON PREFERRED
TIER 05 SPECIALTY
Brilinta
Aranesp Albumin FreePA
Cathflo Activase
Cerdelga
Effient
EpogenPA
Kalbitor
Granix
Kinlytic
Mircera
Kovaltry
NeulastaPA
Novoeight
Nuwiq
NeumegaPA
Xyntha Solofuse
NeupogenPA,ST
TIER 05 SPECIALTY
NplatePA
Benefix
ProcritPA
FirazyrPA
PromactaPA
Helixate FS
ZavescaPA
Ixinity
Kogenate FS
ANTICOAGULANTS
Kogenate FS Bio-set
TIER 01 GENERIC
Recombinate
Xyntha
MOUTH/THROAT/DENTAL AGENT
warfarin sodium
TIER 02 GENERIC
enoxaparin sodium TIER 01 GENERIC
fondaparinux sodium chlorhexidine gluconate
heparin sodium chlorhexidine gluconate oral rinse
heparin sodium dcu lidocaine viscous
TIER 03 FORMULARY Eliquis
lidocaine HCL
Xarelto lidocaine HCL viscous
TIER 04 NON PREFERRED TIER 02 GENERIC
Arixtra cevimeline HCL
clotrimazole
Fragmin nystatin
Iprivask pilocarpine hydrochloride
Pradaxa pilocarpine HCL
SavaysaQL stannous fluoride oral rinse
triamcinolone acetonide
triamcinolone IN orabase
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 14
TIER 03 FORMULARY mirtazapine ODT
Caphosol nefazodone HCL
Debacterol paroxetine HCL ERQL
TIER 04 NON PREFERRED phenelzine sulfate
Aquoral protriptyline HCL
tranylcypromine sulfate
Gelclair TIER 03 FORMULARY
Nafrinse Daily/Acidulated duloxetine HCLPA
Nafrinse Daily/Neutral Appbutamone
Nafrinse Weekly Gaboxetine
Neutrasal Marplan
Oravig Sentroxatine
Salivamax TIER 04 NON PREFERRED
NEUROLOGY, CNS, PSYCH Emsam
FetzimaST
ANTIANXIETY AGENTS
TIER 01 GENERIC
Khedezla
alprazolam
Oleptro
buspirone HCL
chlordiazepoxide HCL
Paxil Susp PA
clorazepate dipotassium
PexevaQL,ST
droperidol
PristiqST
hydroxyzine pamoate
hydroxyzine HCL
lorazepam
meprobamate
Trazamine
TIER 02 GENERIC
ViibrydST
alprazolam ODT
alprazolam ER
diazepam
ANTIPSYCHOTICS
oxazepam
TIER 01 GENERIC
TIER 03 FORMULARY
aripiprazole ODTPA
Alprazolam Intensol
chlorpromazine HCL
TIER 04 NON PREFERRED
clozapine ODT
fluphenazine HCL
haloperidol
haloperidol lactate
lithium carbonate
loxapine
ANTIDEPRESSANTS
loxapine succinate
TIER 01 GENERIC
molindone hydrochloride
amitriptyline HCL
paliperidone ER
amoxapine
prochlorperazine edisylate
doxepin HCL
prochlorperazine maleate
escitalopram oxalateQL
quetiapine fumarate
fluoxetine HCL
thiothixene
fluvoxamine maleate
mirtazapine
TIER 02 GENERIC
nortriptyline HCL
clozapine
paroxetine HCL
fluphenazine decanoate
sertraline HCLQL
haloperidol decanoate
trazodone HCL
lithium
trimipramine maleate
lithium carbonate ER
venlafaxine HCL
olanzapine
venlafaxine HCL ERQL
olanzapine ODT
TIER 02 GENERIC
perphenazine
bupropion HCL
prochlorperazine
bupropion HCL ER
risperidone
bupropion HCL SR
risperidone ODT
bupropion HCL XL
thioridazine HCL
citalopram hydrobromideQL
trifluoperazine HCL
clomipramine HCL
ziprasidone HCL
desipramine HCL
TIER 03 FORMULARY
desvenlafaxine ER
Equetro
fluoxetine DR
Risperdal Consta
fluvoxamine maleate ERPA
Seroquel XRST
imipramine pamoate
Zyprexa Relprevv
imipramine HCL
TIER 04
maprotiline HCL
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 15
NON PREFERRED Adzenys XR-ODT
aripiprazolePA Daytrana
AbilifyPA Dexedrine
Abilify DiscmeltPA Dyanavel XR
Abilify Maintena Focalin
FanaptST Focalin XR
Metadate CD
FazacloST Methylin
Geodon Procentra
Invega Sustenna Quillivant XR
Invega TrinzaPA Ritalin
LatudaST Ritalin LA
SaphrisST
VersaclozST Zenzedi
Vraylar
ANTICONVULSANTS
HYPNOTICS
TIER 01 GENERIC
TIER 01 GENERIC carbamazepine
estazolam clonazepam
eszopiclone divalproex sodium DR
flurazepam HCL divalproex sodium ER
phenobarbital sodium lamotrigine
quazepam lamotrigine ODT
temazepam lamotrigine titrationQL
triazolam oxcarbazepine
zolpidem tartrate phenytoin sodium
TIER 02 GENERIC primidone
phenobarbital topiramate
zaleplon valproic acid
zolpidem tartrate ER TIER 02 GENERIC
TIER 03 FORMULARY carbamazepine ER
Butisol Sodium clonazepam ODT
TIER 04 NON PREFERRED diazepam
Amytal Sodium divalproex sodium
Doral ethosuximide
felbamate
Nembutal Sodium gabapentin
Rozerem lamotrigine ER
levetiracetam
Strazepam levetiracetam ER
Zolpimist phenytoin
phenytoin sodium extended
ADHD, NARCOLEPSY, ETC. tiagabine hydrochloride
zonisamide
TIER 01 GENERIC
TIER 03 FORMULARY
caffeine/sodium benzoate
Gabitril
dexmethylphenidate HCL ER
Lamictal ODT
guanfacine ER
methylphenidate HCL
TIER 02 GENERIC
Stavzor
caffeine citrate
Tegretol-XR
dexmethylphenidate HCL
dextroamphetamine sulfate
dextroamphetamine sulfate ER
TIER 04 NON PREFERRED
methamphetamine HCL
Aptiom
methylphenidate hydrochloride
Banzel
methylphenidate HCL CD
Carbatrol
methylphenidate HCL ER
Celontin
Depakene
TIER 03 FORMULARY
Depakote
armodafinil PA Adderall XR
Depakote ER
Concerta
Depakote Sprinkles
modafinil PA
Dilantin
Ritalin SR
Dilantin Infatabs
Strattera
Dilantin-125
Vyvanse
Felbatol
TIER 04 NON PREFERRED
Fycompa
amphetamine/dextroamphetamineST
Keppra
methylphenidate HCL SRST
Keppra XR
Adderall
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 16
Lamictal GENERIC
Lamictal Chewable Dispersible acamprosate calcium DR
chlordiazepoxide/amitriptyline
disulfiram
Lamictal XR olanzapine/fluoxetine
LyricaPA rivastigmine tartrate
Mysoline TIER 03 FORMULARY
OnfiST Namenda XR
Oxtellar XR
Peganone
Phenytek TIER 04 NON PREFERRED
Potiga
Spritam NamzaricPA
Tegretol Sarafem
Topamax SavellaPA
Topamax Sprinkle
Trileptal
Trokendi XR TIER 05 SPECIALTY
Vimpat tetrabenazinePA
Zarontin AmpyraQL,PA
TIER 05 SPECIALTY AubagioPA,ST
SabrilPA Avonex
Avonex Pen
ANTIPARKINSON AGENTS Betaseron
ExtaviaPA,ST
TIER 01 GENERIC
benztropine mesylate
glatiramer acetate 20mg/ml
carbidopa
NuedextaPA
carbidopa/levodopa
Plegridy
carbidopa/levodopa ODT
carbidopa/levodopa/entacapone
RebifPA,ST
pramipexole dihydrochloride
Rebif RebidosePA,ST
pramipexole dihydrochloride ER
ropinirole HCL
selegiline HCL
TecfideraQL,ST
tolcapone
TIER 02 GENERIC
XyremPA
amantadine HCL
bromocriptine mesylate
NEUROMUSCULAR AGENTS
carbidopa/levodopa ER
entacapone TIER 02 GENERIC
ropinirole ER riluzole
trihexyphenidyl HCL TIER 04 NON PREFERRED
TIER 04 NON PREFERRED Quelicin 1000
Apokyn TIER 05 SPECIALTY
Azilect BotoxPA
Mirapex ER DysportPA
Neupro MyoblocPA
Rytary XeominPA
Stalevo 100
Stalevo 125 MUSCULOSKELETAL AGENTS
Stalevo 150
TIER 01 GENERIC
Stalevo 200
baclofen
Stalevo 50
chlorzoxazone
Stalevo 75
cyclobenzaprine HCL
Zelapar
methocarbamol
orphenadrine/asa/caffeine
NEUROLOGY, PSYCH - MISC.
tizanidine HCL
TIER 01 GENERIC TIER 02 GENERIC
donepezil HCL dantrolene sodium
ergoloid mesylates metaxalone
fluoxetine orphenadrine citrate
galantamine hydrobromide orphenadrine citrate ER
memantine hydrochloride TIER 03 FORMULARY
memantine HCL Prazolamine
perphenazine/amitriptyline
pimozide TIER 04 NON PREFERRED
rivastigmine transdermal system
TIER 02
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 17
Lorzone OPHTHALMIC STEROIDS
TIER 01 GENERIC
dexamethasone sodium phosphate
fluorometholone
ANTIMYASTHENIC AGENTS
neomycin/polymyxin/dexamethasone
TIER 01 GENERIC prednisolone acetate
guanidine HCL sulfacetamide sodium/prednisolone sodium phosphate
neostigmine methylsulfate TIER 02 GENERIC
pyridostigmine bromide neomycin/polymyxin/bacitracin/hydrocortisone
TIER 03 FORMULARY neomycin/polymyxin/hydrocortisone
prednisolone sodium phosphate
TIER 04 NON PREFERRED tobramycin/dexamethasone
Enlon TIER 03 FORMULARY
Alrex
OPHTHALMOLOGY AND OTIC Blephamide
Blephamide S.O.P.
ANTI-INFECTIVES
FML
TIER 01 GENERIC
FML Forte
ciprofloxacin HCL
Lotemax
ofloxacin
Maxidex
sodium sulfacetamide
Pred Mild
tobramycin sulfate
Pred-G
TIER 02 GENERIC
Pred-G S.O.P.
bacitracin
Tobradex
bacitracin/polymyxin b
TIER 04 NON PREFERRED
erythromycin
Durezol
gatifloxacin
Flarex
gentamicin sulfate
Tobradex ST
levofloxacin
Vexol
neomycin/bacitracin/polymyxin
Zylet
neomycin/polymyxin/bacitracin zinc
neomycin/polymyxin/gramicidin
PROSTAGLANDINS
polymyxin b sulfate/trimethoprim sulfate
TIER 02 GENERIC
sulfacetamide sodium
latanoprost
trifluridine
travoprost
trimethoprim sulfate/polymyxin b sulfate
TIER 03 FORMULARY
TIER 03 FORMULARY
Travatan Z
Betadine Ophthalmic Prep
TIER 04 NON PREFERRED
Ciloxan
Lumigan
Natacyn
Rescula
Tobrex
Zioptan
Vigamox
TIER 04 NON PREFERRED
CYCLOPLEGIC MYDRIATICS
Azasite
TIER 01 GENERIC
Besivance
cyclopentolate hydrochloride
Mitosol
TIER 02 GENERIC
Moxeza
atropine sulfate
Zirgan
cyclopentolate HCL
homatropine HBR
ARTIFICIAL TEAR/LUBRICANT
TIER 03 FORMULARY
TIER 04 NON PREFERRED
Cyclomydril
Lacrisert
Isopto Homatropine
Isopto Hyoscine
BETA-BLOCKERS
TIER 04 NON PREFERRED
TIER 01 GENERIC
timolol maleate
TIER 02 GENERIC
DECONGESTANTS
betaxolol HCL
TIER 01 GENERIC
carteolol HCL
naphazoline HCL
dorzolamide HCL/timolol maleate
TIER 02 GENERIC
levobunolol HCL
phenylephrine HCL
metipranolol
timolol maleate ophthalmic gel forming
MIOTICS
TIER 03 FORMULARY
TIER 02 GENERIC
Betoptic-S
pilocarpine HCL
TIER 04 NON PREFERRED
TIER 04 NON PREFERRED
Betimol
Isopto Carbachol
Combigan
Phospholine Iodide
Cosopt PF
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 18
ADRENERGIC AGENTS
TIER 01 GENERIC
TIER 01 GENERIC
methylergonovine maleate
brimonidine tartrate
TIER 02 GENERIC
TIER 02 GENERIC
oxytocin
apraclonidine
TIER 03 FORMULARY
TIER 03 FORMULARY
Cervidil
Iopidine
Prostin E2
TIER 04 NON PREFERRED
TIER 04 NON PREFERRED
Alphagan P
Hemabate
Simbrinza
Prepidil
LOCAL ANESTHETICS
PAIN MANAGEMENT
TIER 01 GENERIC
proparacaine HCL ANALGESICS - NONNARCOTIC
tetracaine HCL
TIER 01 GENERIC
TIER 04 NON PREFERRED
butalbital/acetaminophen/caffeine
Akten
choline magnesium trisalicylate
TIER 02 GENERIC
OPHTHALMICS - MISC.
butalbital/acetaminophen
TIER 01 GENERIC butalbital/aspirin/caffeine
cromolyn sodium diflunisal
flurbiprofen sodium salsalate
olopatadine HCL TIER 04 NON PREFERRED
TIER 02 GENERIC Allzital
azelastine HCL Bupap
bromfenac Equagesic
diclofenac sodium Levacet
dorzolamide HCL
epinastine HCL ANALGESICS – OPIOID (May require Prior Authorization for New Starts )
ketorolac tromethamine
TIER 01 GENERIC
TIER 03 FORMULARY
acetaminophen/caffeine/dihydrocodeine
Azopt
acetaminophen/codeine
Nevanac
acetaminophen/codeine #2
TIER 04 NON PREFERRED
acetaminophen/codeine #3
Acuvail
acetaminophen/codeine #4
Alocril
acetaminophen/codeine phosphate
Alomide
alfentanil
Bepreve
aspirin-caffeine-dihydrocodeine
Emadine
butalbital/acetaminophen/caffeine/codeine
Ilevro
hydrocodone/acetaminophen
Lastacaft
hydromorphone HCL ERPA
Pataday
morphine sulfate
Prolensa
morphine sulfate ERQL,PA
TIER 05 SPECIALTY
nalbuphine HCL
CystaranQL,PA
oxycodone HCL
oxycodone HCL ERQL,PA
OTIC AGENTS
oxycodone/acetaminophen
TIER 01 GENERIC oxycodone/ibuprofen
acetic acid/aluminum acetate tramadol hydrochloride/acetaminophen
antipyrine/benzocaine tramadol HCL
TIER 02 GENERIC
acetic acid TIER 02 GENERIC
ciprofloxacin buprenorphine HCLPA
fluocinolone acetonide buprenorphine HCL/naloxone HCLQL
fluocinolone acetonide ear drops butalbital/aspirin/caffeine/codeine
hydrocortisone/acetic acid butorphanol tartrate
neomycin/polymyxin/hydrocortisone codeine sulfate
neomycin/polymyxin/HC fentanylPA
ofloxacin fentanyl citrate oral transmucosalQL,PA
TIER 03 FORMULARY hydrocodone bitartrate/acetaminophen
Ciprodex hydrocodone/ibuprofen
Coly-mycin S hydromorphone HCL
TIER 04 NON PREFERRED hydromorphone HCL dosette
Cetraxal levorphanol tartrate
Cipro HC meperidine HCL
Cortisporin-tc methadone HCLPA
Otiprio oxycodone/aspirin
oxymorphone hydrochloride
OXYTOCICS oxymorphone hydrochloride ERPA
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 19
pentazocine/naloxone HCL
tramadol HCL ER Mobic
TIER 03 FORMULARY Nalfon
Capital/Codeine
SuboxoneQL,PA
TIER 04 NON PREFERRED Rasuvo
AbstralPA Rheumatrex
Conzip SprixPA
Dilaudid-HP
Embeda
ExalgoPA
FentoraPA
KadianQL,PA
LazandaPA
Lortab
Nucynta
Nucynta ERPA TIER 05 SPECIALTY
Opana ER (crush Resistant)PA ActemraPA
Oxaydo Arcalyst
Oxecta EnbrelPA
OxycontinQL,PA Enbrel SureclickPA
Primlev HumiraQL,PA
Roxicet Humira Pediatric Crohns Disease Starter Pack
SubsysPA Humira PenQL,PA
Synalgos-dc Humira Pen-Crohns DiseasestarterQL,PA
Trezix Humira Pen-Psoriasis StarterQL,PA
Zamicet Ilaris
KineretPA
ANTI-INFLAMMATORY OrenciaQL,PA
OtezlaQL,PA
TIER 01 GENERIC
SimponiPA
diclofenac potassium
XeljanzQL,PA
etodolac
Xeljanz XR
etodolac ER
fenoprofen calcium
MIGRAINE PRODUCTS
flurbiprofen
ibuprofen TIER 01 GENERIC
indomethacin almotriptan malate
ketoprofen frovatriptan succinate
ketorolac tromethamine TIER 02 GENERIC
meclofenamate sodium dihydroergotamine mesylate
nabumetone naratriptan HCL
naproxen rizatriptan benzoate
naproxen sodium rizatriptan benzoate ODT
naproxen sodium ER sumatriptan
sulindac sumatriptan succinate
TIER 02 GENERIC sumatriptan succinate refill
diclofenac sodium DR zolmitriptan
diclofenac sodium ER zolmitriptan ODT
diclofenac sodium/misoprostol TIER 03 FORMULARY
indomethacin ER Migral
ketoprofen ER Relpax
leflunomide TIER 04 NON PREFERRED
mefenamic acid AlsumaST
meloxicam Cafergot
oxaprozin Ergomar
piroxicam
tolmetin sodium Imitrex
TIER 03 FORMULARY Migergot
Indocin Sumavel DoseproST
Ridaura TreximetST
TIER 04 NON PREFERRED Zembrace Symtouch
celecoxib Zomig
Zomig Nasal Spray
GOUT AGENTS
TIER 01 GENERIC
IC 400
allopurinol
IC 800
colchicine
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 20
TIER 02 GENERIC flunisolide
probenecid fluticasone propionate
probenecid/colchicine ipratropium bromide
TIER 03 FORMULARY triamcinolone acetonide
Colcrys TIER 03 FORMULARY
TIER 04 NON PREFERRED Adrenalin
Mitigare Bactroban Nasal
Uloric
Tyzine
Tyzine Pediatric Nasal Drops
TIER 04 NON PREFERRED
Beconase AQ
Dymista
Omnaris
Qnasl
Qnasl Childrens
Veramyst
Zetonna
COUGH/COLD/ALLERGY
TIER 01 GENERIC
benzonatate
dextromethorphan HBR/chlorpheniramine/phenylephrine HCL
guaifenesin/codeine
hydrocodone bitartrate/chlorpheniramine maleate/PSE
phenylephrine/guaifenesin
promethazine-DM
promethazine/codeine
promethazine/dextromethorphan
promethazine/phenylephrine
TIER 02 GENERIC
acetylcysteine
bromphen/pseudoephedrine HCL/dextromethorphan HBR
hydrocodone bitartrate/homatropine methylbromide
hydrocodone polistirex/chlorpheniramine polistirex
hydrocodone/homatropine
promethazine/phenylephrine/codeine
sodium chloride
TIER 03 FORMULARY
Vituz
RESPIRATORY, ALLERGY, ETC
TIER 04 NON PREFERRED
ANTIHISTAMINES Carbaphen 12
Carbaphen 12 PED
TIER 01 GENERIC
Codar AR
brompheniramine
Codar D
brompheniramine tannate
Cpb Wc
carbinoxamine maleate
Decon-a
cetirizine HCL
Gilphex TR
cyproheptadine HCL
Giltuss PED-c
desloratadine ODT
Giltuss TR
dexchlorpheniramine maleate
Hypersal
diphenhydramine HCL
Lortuss EX
levocetirizine dihydrochloride
M-end PE
promethazine HCL
Mar-cof Bp
promethazine HCL plain
Nebusal
TIER 02 GENERIC
Neotuss Plus
clemastine fumarate
Panatuss Dxp
desloratadine
Pediatex TDM
TIER 04 NON PREFERRED
Pro-clear Ac
Karbinal ER
Relhist
Phenergan Fortis
Rescon-JR
Rescon-MX
NASAL AGENTS
Rezira
TIER 01 GENERIC
Semprex-d
budesonide
Statuss Green
Tricode AR
olopatadine HCL
Tricode GF
TIER 02 GENERIC
azelastine HCL mometasone furoate nasal
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 21
Tuzistra XR Zyflo CR
Vanacof CD TIER 05 SPECIALTY
Z-tuss AC XolairPA
ANTIASTHMATIC/COPD AGENTS RESPIRATORY AGENTS - MISC
TIER 01 GENERIC TIER 04 NON PREFERRED
albuterol Curosurf
albuterol sulfate Infasurf
epinephrine HCL
ipratropium bromide TIER 05 SPECIALTY
metaproterenol sulfate EsbrietPA
theophylline CR KalydecoQL,PA
theophylline ER OfevPA
TIER 02 GENERIC OrkambiPA
albuterol sulfate ER Pulmozyme
budesonide
cromolyn sodium VITAMINS
ipratropium bromide/albuterol sulfate
MULTIVITAMINS (Coverage limited to Rx Legend status)
levalbuterol
TIER 02 GENERIC
levalbuterol HCL
b-complex 100
montelukast sodium
TIER 03 FORMULARY
terbutaline sulfate
Mykidz Iron Fl
theophylline
TIER 04 NON PREFERRED
zafirlukast
Atabex EC
TIER 03 FORMULARY
Bal-care DHA
Asmanex HFA
Citranatal Assure
Asmanex Twisthaler 120 Metered Doses
Citranatal B-calm
Asmanex Twisthaler 14 Metered Doses
Citranatal DHA
Asmanex Twisthaler 30 Metered Doses
Citranatal Harmony
Asmanex Twisthaler 60 Metered Doses
Citranatal RX
Asmanex Twisthaler 7 Metered Doses
Citranatal 90 DHA
Atrovent HFA
Concept DHA
Breo ElliptaQL,ST
Concept OB
Combivent Respimat
Crnatal
Dulera
Duet DHA Balanced
Elixophyllin
Duet DHA 400
Foradil Aerolizer
Duet DHA 400EC
Incruse Ellipta
Duet DHA 430
Lufyllin
Duet DHA 430EC
Proair HFA
Escavite
Qvar
Escavite D
Serevent Diskus
Floriva
Spiriva Handihaler
Focalgin CA
Symbicort
Focalgin 90 DHA
Theo-24
Folcaps Omega 3
Ventolin HFA
Folet DHA
TIER 04 NON PREFERRED
Folivane-prx DHA NF
Advair DiskusST
Folivane-OB
Advair HFAST
Gesticare DHA
Alvesco
Marnatal-f
Anoro Ellipta
Mynatal
Arcapta Neohaler
Natachew
Arnuity ElliptaST
Natalvirt CA
Brovana
Natalvirt 90 DHA
DalirespPA
Natalvit
Flovent DiskusST
Natelle One
Flovent HFAST
Neevo DHA
Isuprel
Nestabs
Perforomist
Nestabs Abc
Proair Respiclick
Nestabs DHA
Proventil HFAST
Newgen
Pulmicort FlexhalerST
Nexa Plus
Pulmophylline
Nicomide
Spiriva Respimat
Niva-plus
Stiolto Respimat
O-CAL Fa
Tudorza Pressair
O-CAL Prenatal
Obstetrix DHA
Xopenex HFAST
Ocuvel
Zyflo
OB Complete
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 22
OB Complete One
OB Complete Petite
OB Complete Premier
OB Complete 400
OB Complete/DHA
Paire OB
Poly-VI-flor
Poly-VI-flor/Iron
Prefera OB
Prefera OB + DHA
Preferaob +dha
Preferaob One
Prefol-DHA
Prenata
Prenate
Prenate AM
Prenate DHA
Prenate Elite
Prenate Enhance
Prenate Essential
Prenate Mini
Prenate Pixie
Prenate Restore
Prenate Star
Preque 10
Provida OB
R-natal OB
Select-ob+dha
Select-OB
Taron-bc
Taron-c DHA
Texavite LQ
Tri-VI-flor
Tricare Prenatal Compleat
Tricare Prenatal DHA One
Triveen-duo DHA
Triveen-prx RNF
Vemavite-prx 2
Vinacal B
Vinate AZ Extra
Vinate Calcium
Vinate DHA RF
Vita-pren
Vitafol Ultra
Vitafol-nano
Vitafol-ob+dha
Vitafol-one
Vitamedmd One RX/Quatrefolic
Vitamedmd Plus RX/Quatre Folic
Vitamedmd Redichew RX
Vitamedmd Redichew RX/Quatrefolic
Vitapearl
Viva DHA
Zatean-pn
Zatean-pn DHA
Zatean-pn Plus
Zatean-CH
MISCELLANEOUS AGENTS
TIER 01 GENERIC
pentetate calcium trisodium
pentetate zinc trisodium
TIER 04 NON PREFERRED
Chemet
TIER 05 SPECIALTY
Exjade
FerriproxPA
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 23
Index
A
almotriptan malate, 20 Appformin, 10
Alocril, 19 Appformin-d, 10
abacavir, 2
alogliptin, 10 apraclonidine, 19
abacavir sulfate/lamivudine/zidovudine, 2
alogliptin/metformin HCL, 10 Apriso, 13
Abilify, 16
alogliptin/pioglitazone, 10 Aptiom, 16
Abilify Discmelt, 16
Alomide, 19 Aptivus, 2
Abilify Maintena, 16
Alora, 9 Aquoral, 15
Abstral, 20
alosetron hydrochloride, 13 Aranesp Albumin Free, 14
acamprosate calcium DR, 17
Alphagan P, 19 Arcalyst, 20
acarbose, 10
alprazolam, 15 Arcapta Neohaler, 22
acebutolol HCL, 4
alprazolam ER, 15 aripiprazole, 16
acetaminophen/caffeine/dihydrocodeine, 19
Alprazolam Intensol, 15 aripiprazole ODT, 15
alprazolam ODT, 15 armodafinil, 16
acetaminophen/codeine, 19
Alrex, 18
acetaminophen/codeine #2, 19
Alsuma, 20 Arixtra, 14
acetaminophen/codeine #3, 19
Altabax, 7 Armour Thyroid, 12
acetaminophen/codeine #4, 19
Altoprev, 6 arnica flower, 8
acetaminophen/codeine phosphate, 19
Alvesco, 22 Arnuity Ellipta, 22
acetazolamide, 5
amantadine HCL, 17 Artiss, 14
acetazolamide ER, 6
amcinonide, 7 Asacol HD, 13
acetazolamide sodium, 5
amikacin sulfate, 1 Asmanex HFA, 22
acetic acid, 19
amiloride HCL, 6 Asmanex Twisthaler 120 Metered Doses, 22
acetic acid/aluminum acetate, 19
amiloride/hydrochlorothiazide, 6
acetylcysteine, 21
aminocaproic acid, 14 Asmanex Twisthaler 14 Metered Doses, 22
Aciphex Sprinkle, 12
amiodarone HCL, 5
acitretin, 7
Amitiza, 13 Asmanex Twisthaler 30 Metered Doses, 22
Actemra, 20
amitriptyline HCL, 15
Actimmune, 4
amlodipine besylate, 4 Asmanex Twisthaler 60 Metered Doses, 22
Actoplus Met XR, 10
amlodipine besylate/atorvastatin calcium, 6
Asmanex Twisthaler 7 Metered Doses, 22
amlodipine besylate/benazepril HCL, 5
Acuvail, 19
amlodipine besylate/benazepril hydrochloride, 5
aspirin-caffeine-dihydrocodeine, 19
acyclovir, 2, 7
aspirin/dipyridamole, 14
adapalene, 6
amlodipine besylate/valsartan, 5 Astagraf XL, 3
adapalene P.M., 6
amlodipine/valsartan/hctz, 5 Astringyn, 14
Adcirca, 6
amoxapine, 15 Atabex EC, 22
Adderall, 16
amoxicillin, 1 atenolol, 4
Adderall XR, 16
amoxicillin ER, 1 atenolol/chlorthalidone, 5
adefovir dipivoxil, 2
amoxicillin/clavulanate potassium, 1 Atopiclair, 8
Adempas, 6
amoxicillin/clavulanate potassium ER, 1 atorvastatin calcium, 6
Adrenaclick, 6
amphetamine/dextroamphetamine, 16 atovaquone, 3
Adrenalin, 6, 21
amphotericin b, 2 atovaquone/proguanil HCL, 2
Advair Diskus, 22
ampicillin, 1 Atripla, 2
Advair HFA, 22
ampicillin sodium, 1 Atropen, 12
Advicor, 6
ampicillin-sulbactam, 1 atropine sulfate, 12, 18
Adzenys XR-ODT, 16
Ampyra, 17 Atrovent HFA, 22
Afinitor, 4
Amturnide, 5 Aubagio, 17
Afinitor Disperz, 4
Amytal Sodium, 16 augmented betamethasone dipropionate, 7
Aggrenox, 14
Anacaine, 8
Akten, 19
Anadrol-50, 9 Augmentin, 1
Akynzeo, 12
anagrelide hydrochloride, 14
Albenza, 3
albuterol, 22
auryxia, 13
albuterol sulfate, 22
anastrozole, 3 Avandamet, 10
albuterol sulfate ER, 22
Androderm, 9 Avandaryl, 10
alclometasone dipropionate, 7
Androgel 1.62%, 9 Avandia, 10
Aldactazide, 6
Avar, 6
Alecensa, 4
Androxy, 9 Avar LS, 6
alendronate sodium, 10
Angeliq, 9 Avc, 13
Alevicyn Antipruritic SG, 8
Anoro Ellipta, 22 Avenova, 8
alfentanil, 19
antipyrine/benzocaine, 19 Avonex, 17
alfuzosin HCL ER, 13
Anzemet, 12 Avonex Pen, 17
Alinia, 3
Axiron, 9
Alkeran, 3
Apokyn, 17 Azasan, 3
allopurinol, 20
Appbutamone, 15 Azasite, 18
Allzital, 19
azathioprine, 3
HCL/dextromethorphan HBR, 21
azelastine HCL, 19, 21
brompheniramine, 21 Cardura XL, 14
Azilect, 17
brompheniramine tannate, 21 carteolol HCL, 18
azithromycin, 1
Brovana, 22 carvedilol, 4
Azopt, 19
budesonide, 9, 21, 22 cascara sagrada, 12
Azor, 5
bumetanide, 6 Cathflo Activase, 14
aztreonam, 3
Bupap, 19 Cayston, 3
B
Buphenyl, 11 Cedax, 1
bupivacaine HCL, 21 cefaclor, 1
bupivacaine/epinephrine, 21 cefaclor ER, 1
b-complex 100, 22
buprenorphine HCL, 19 cefadroxil, 1
bacitracin, 3, 18
buprenorphine HCL/naloxone HCL, 19 cefazolin sodium, 1
bacitracin/polymyxin b, 18
bupropion HCL, 15 cefdinir, 1
baclofen, 17
bupropion HCL ER, 15 cefditoren pivoxil, 1
Bactroban Nasal, 21
bupropion HCL SR, 15 cefepime, 1
Bal-care DHA, 22
bupropion HCL XL, 15 cefixime, 1
balsalazide disodium, 13
buspirone HCL, 15
Banzel, 16
butalbital/acetaminophen, 19 cefotaxime sodium, 1
Baraclude, 2
butalbital/acetaminophen/caffeine, 19 cefotetan, 1
Beconase AQ, 21
butalbital/acetaminophen/caffeine/codeine, 19
cefoxitin sodium, 1
belladonna & opium, 12
cefpodoxime proxetil, 1
belladonna alkaloids & opium, 12
butalbital/aspirin/caffeine, 19 cefprozil, 1
benazepril HCL, 5
butalbital/aspirin/caffeine/codeine, 19 ceftazidime, 1
benazepril HCL/hydrochlorothiazide, 5
Butisol Sodium, 16 ceftibuten, 1
Benefix, 14
butorphanol tartrate, 19 Ceftin, 1
Benicar, 5
Bydureon, 10 ceftriaxone sodium, 1
Benicar HCT, 5
Byetta, 10 cefuroxime axetil, 1
benzoin compound tincture, 8
Bystolic, 4 cefuroxime sodium, 1
benzoin tincture, 8
C celecoxib, 20
benzonatate, 21
Cellcept, 3
benzoyl peroxide, 6
cabergoline, 11
Celontin, 16
Cafergot, 20
Cenestin, 9
benztropine mesylate, 17
caffeine citrate, 16
centany, 7
Bepreve, 19
caffeine/sodium benzoate, 16
Centany AT, 7
Besivance, 18
calcipotriene, 7
cephalexin, 1
Betadine Ophthalmic Prep, 18
calcipotriene/betamethasone dipropionate, 7
Cerdelga, 14
betamethasone dipropionate, 7
Cervidil, 19
betamethasone sodium phosphate/betamethasone acetate, 9
calcitonin salmon, 11
Cesamet, 12
calcitonin-salmon, 11
cetirizine HCL, 21
betamethasone valerate, 7
calcitriol, 7, 11
Cetraxal, 19
Betaseron, 17
calcium acetate, 13
Cetrotide, 11
betaxolol HCL, 4, 18
Canasa, 13
cevimeline HCL, 14
bethanechol chloride, 13
candesartan cilexetil, 5
Chemet, 23
Bethkis, 1
candesartan cilexetil/hydrochlorothiazide, 5
Chenodal, 13
Betimol, 18
chlordiazepoxide HCL, 15
Betoptic-s, 18
Cantil, 12
chlordiazepoxide HCL/clidinium bromide, 12
bexarotene, 4
Capastat Sulfate, 2
Beyaz, 10
capecitabine, 3
chlordiazepoxide/amitriptyline, 17
bicalutamide, 3
Capex, 8
chlorhexidine gluconate, 14
Bicillin C-R, 1
Caphosol, 15
chlorhexidine gluconate oral rinse, 14
Bicillin L-a, 1
Capital/Codeine, 20
chloroprocaine HCL, 21
Caprelsa, 4
chloroquine phosphate, 2
Biltricide, 3
capsaicin, 8
chlorothiazide, 6
Binosto, 10
captopril, 5
chlorpromazine HCL, 15
bisoprolol fumarate, 4
captopril/hydrochlorothiazide, 5
chlorpropamide, 10
bisoprolol fumarate/hydrochlorothiazide, 5
Carafate, 12
chlorthalidone, 6
Carbaglu, 11
chlorzoxazone, 17
Blephamide, 18
carbamazepine, 16
cholestyramine, 6
Blephamide S.o.p., 18
carbamazepine ER, 16
cholestyramine light, 6
boric acid, 8
Carbaphen 12, 21
choline magnesium trisalicylate, 19
Bosulif, 4
Carbaphen 12 PED, 21
chorionic gonadotropin, 11
Botox, 17
Carbatrol, 16
Cialis, 6
Bravelle, 11
carbidopa, 17
Breo Ellipta, 22
carbidopa/levodopa, 17
ciclopirox, 7
Brilinta, 14
carbidopa/levodopa ER, 17
ciclopirox nail lacquer, 7
brimonidine tartrate, 19
carbidopa/levodopa ODT, 17
ciclopirox olamine, 7
bromfenac, 19
carbidopa/levodopa/entacapone, 17
bromocriptine mesylate, 17
carbinoxamine maleate, 21
Ciferex, 14
bromphen/pseudoephedrine
Cardene SR, 5
cilostazol, 14
Combivent Respimat, 22 Depakote, 16
Ciloxan, 18
Cometriq, 4 Depakote ER, 16
cimetidine, 12
Complera, 2 Depakote Sprinkles, 16
cimetidine HCL, 12
Concept DHA, 22 Depo-estradiol, 9
Cimzia, 13
Concept OB, 22 Depo-medrol, 9
Cimzia Starter Kit, 13
Concerta, 16 Depo-provera, 3
Cipro HC, 19
Condylox, 8
Ciprodex, 19
ciprofloxacin, 1, 19
Conzip, 20 Dermasorb HC, 8
ciprofloxacin ER, 1
Copasil, 8 Dermasorb Ta, 8
ciprofloxacin HCL, 1, 18
desipramine HCL, 15
citalopram hydrobromide, 15
desloratadine, 21
Cordran Tape, 8 desloratadine ODT, 21
Coreg CR, 4 desmopressin acetate, 11
Citranatal 90 DHA, 22
Corlanor, 6 desogestrel/ethinyl estradiol, 9
Citranatal Assure, 22
Cortifoam, 13 Desonate, 8
Citranatal B-calm, 22
cortisone acetate, 9 desonide, 7
Citranatal DHA, 22
Cortisporin, 7 Desowen Cream/Cetaphil Lotion, 8
Citranatal Harmony, 22
Cortisporin-tc, 19 Desowen Lotion/Cetaphil Cream, 8
Citranatal RX, 22
Cosentyx, 7 Desowen Ointment/Cetaphil Lotion, 8
citric acid/sodium citrate, 13
Cosentyx Sensoready Pen, 7 desoximetasone, 7
clarithromycin, 1
Cosopt PF, 18 desvenlafaxine ER, 15
clarithromycin ER, 1
Cotellic, 4 dexamethasone, 9
clemastine fumarate, 21
Cpb Wc, 21 Dexamethasone Intensol, 9
Cleocin, 13
Creon, 13 dexamethasone sodium phosphate, 9, 18
Clever Choice Comfort EZ Patch, 8
Cresemba, 2
Climara Pro, 9
dexchlorpheniramine maleate, 21
clindamycin HCL, 3
Crinone, 13 Dexedrine, 16
clindamycin palmitate HCL, 3
Crixivan, 2 dexmethylphenidate HCL, 16
clindamycin phosphate, 3, 6, 13
Crnatal, 22 dexmethylphenidate HCL ER, 16
cromolyn sodium, 13, 19, 22
Curosurf, 22
clindamycin/benzoyl peroxide, 6
Cuvposa, 12
Clindesse, 13
cyanocobalamin, 14 dexpanthenol, 13
Clinoin, 6
dextroamphetamine sulfate, 16
clobetasol propionate, 7
cyclobenzaprine HCL, 17 dextroamphetamine sulfate ER, 16
clobetasol propionate emollient, 7
dextromethorphan HBR/chlorpheniramine/phenylephrine HCL, 21
clocortolone pivalate, 7
Cyclomydril, 18
clocortolone pivalate P.M., 7
cyclopentolate HCL, 18
Cloderm, 8
cyclopentolate hydrochloride, 18
Diabeta, 10
Cloderm P.M., 8
cyclophosphamide, 3
diazepam, 15, 16
clomiphene citrate, 11
cycloserine, 2
diclofenac potassium, 20 diclofenac sodium, 19
clomipramine HCL, 15
cyclosporine, 3
diclofenac sodium gel, 7
clonazepam, 16
cyclosporine modified, 3
diclofenac sodium DR, 20
clonazepam ODT, 16
cyproheptadine HCL, 21
diclofenac sodium ER, 20
clonidine HCL, 5
Cystadane, 11
diclofenac sodium/misoprostol, 20
clopidogrel, 14
Cystagon, 14
dicloxacillin sodium, 1
clorazepate dipotassium, 15
Cystaran, 19
dicyclomine hci, 12
Clorpres, 5
Cytomel, 12
dicyclomine HCL, 12
clotrimazole, 14
D
didanosine, 2
clotrimazole/betamethasone dipropionate, 7
Dificid, 1
Daklinza, 2
diflorasone diacetate, 8
Daliresp, 22
clozapine, 15
diflunisal, 19
danazol, 9
clozapine ODT, 15
digoxin, 4
dantrolene sodium, 17
coal TAR, 8
dihydroergotamine mesylate, 20
dapsone, 3
Coartem, 2
Dilantin, 16
Daraprim, 2
cocaine HCL, 8
Dilantin Infatabs, 16
darifenacin ER, 13
Codar AR, 21
Dilantin-125, 16
darifenacin hydrobromide ER, 13
Codar D, 21
Dilatrate SR, 4
Daytrana, 16
codeine sulfate, 19
Dilaudid-HP, 20
Debacterol, 15
colchicine, 20
diltiazem CD, 4
Decon-a, 21
Colcrys, 21
diltiazem HCL, 4
Delestrogen, 9
colestipol HCL, 6
diltiazem HCL ER, 5
Delzicol, 13
colistimethate sodium, 3
dimenhydrinate, 12
Coly-mycin S, 19
Dipentum, 13
demeclocycline HCL, 1
Colyte-flavor Packs, 12
diphenhydramine HCL, 21
Demser, 5
Combigan, 18
diphenoxylate/atropine, 12
Denavir, 7
Combipatch, 9
dipyridamole, 14
Depakene, 16
disopyramide phosphate, 5
Emadine, 19 ethyl chloride/medium stream, 8
disulfiram, 17
Embeda, 20 ethyl chloride/mist, 8
Diuril, 6
Emcyt, 3 etidronate disodium, 10
divalproex sodium, 16
Emend, 12 etodolac, 20
divalproex sodium DR, 16
Emsam, 15 etodolac ER, 20
divalproex sodium ER, 16
Emtriva, 2 etoposide, 4
Divigel, 9
Emulsion SB, 8 Eurax, 8
donepezil HCL, 17
Emverm, 3 Evamist, 9
Doral, 16
enalapril maleate, 5 Evicel, 14
dorzolamide HCL, 19
enalapril maleate/hydrochlorothiazide, 5 Evithrom, 14
dorzolamide HCL/timolol maleate, 18
Enbrel, 20 Evotaz, 2
doxazosin, 5
Enbrel Sureclick, 20 Exalgo, 20
doxazosin mesylate, 5
Endometrin, 13 Exelderm, 7
doxepin HCL, 15
Enjuvia, 9 exemestane, 3
doxepin hydrochloride, 7
Enlon, 18 Exjade, 23
doxercalciferol, 11
enoxaparin sodium, 14
doxycycline, 1, 7
Enstilar, 8 Extavia, 17
doxycycline hyclate, 1
entacapone, 17 F
doxycycline hyclate DR, 1
entecavir, 2
Fabior, 6
doxycycline monohydrate, 1
Entereg, 13
Factive, 1
dronabinol, 12
Entresto, 6
Falessa, 10
droperidol, 15
Epaned, 5
famciclovir, 2
drospirenone/ethinyl estradiol, 9
ephedrine sulfate, 6
famotidine, 12
Droxia, 14
Epiceram, 8
Fanapt, 16
Duavee, 9
Epiduo Forte, 6
Duet DHA 400, 22
Epifoam, 8
Fareston, 3
Duet DHA 400EC, 22
epinastine HCL, 19
Farxiga, 10
Duet DHA 430, 22
epinephrine, 6
Farydak, 4
Duet DHA 430EC, 22
epinephrine HCL, 22
Fazaclo, 16
Duet DHA Balanced, 22
Epipen 2-PAK, 6
felbamate, 16
Dulera, 22
Epipen-JR 2-PAK, 6
Felbatol, 16
duloxetine HCL, 15
Epivir HBV, 2
felodipine ER, 5
eplerenone, 5
Femring, 13
Epogen, 14
fenofibrate, 6
eprosartan mesylate, 5
fenofibrate micronized, 6
Epzicom, 2
fenofibric acid DR, 6
Equagesic, 19
Fenoglide, 6
Equetro, 15
fenoprofen calcium, 20
ergoloid mesylates, 17
fentanyl, 19
Ergomar, 20
fentanyl citrate oral transmucosal, 19
Durezol, 18
Ery-TAB, 1
Fentora, 20
dutasteride, 13
Eryped 200, 1
Feriva 21/7, 14
dutasteride/tamsulosin hydrochloride, 13
Eryped 400, 1
Ferriprox, 23
Dutoprol, 5
Erythrocin Stearate, 1
Fetzima, 15
Dyanavel XR, 16
erythromycin, 1, 6, 18
Finacea, 7
Dymista, 21
erythromycin base, 1
finasteride, 13
Dyrenium, 6
erythromycin ethylsuccinate, 1
Firazyr, 14
Dysport, 17
erythromycin/benzoyl peroxide, 6
Firmagon, 3
Dyural-l, 9
Esbriet, 22
E
Escavite, 22
Escavite D, 22
E.E.S. Granules, 1
escitalopram oxalate, 15
econazole nitrate, 7
estazolam, 16
Ecoza, 7
Estrace, 13
Edarbi, 5
estradiol, 9
Edarbyclor, 5
estradiol valerate, 9
Edecrin, 6
estradiol/norethindrone acetate, 9
Edurant, 2
Estrasorb, 9
Effient, 14
Estring, 13
Elestrin, 9
Estrogel, 9
Eletone, 8
Flagyl ER, 3
estropipate, 9
Eletone Twinpack, 8
eszopiclone, 16
Elidel, 8
Flarex, 18
ethambutol HCL, 2
Eligard, 3
flavoxate HCL, 13
ethosuximide, 16
flecainide acetate, 5
ethyl chloride, 8
Eliquis, 14
Flector, 7
ethyl chloride/fine pinpoint, 8
Elixophyllin, 22
FLO-pred, 9
ethyl chloride/fine stream, 8
Ella, 10
Floriva, 22
ethyl chloride/medium jet stream, 8
Elmiron, 14
Flovent Diskus, 22
Flovent HFA, 22
homatropine HBR, 18
fluconazole, 2
Gelclair, 15
flucytosine, 2
Gelnique, 13
fludrocortisone acetate, 9
gemfibrozil, 6
flunisolide, 21
Genotropin, 11 Humulin N, R all forms, 10
fluocinolone acetonide, 8, 19
Genotropin Miniquick, 11 Humalog, 10
fluocinolone acetonide ear drops, 19
gentamicin sulfate, 1, 7, 18 Humalog Kwikpen, 10
fluocinonide, 7
gentamicin sulfate pediatric, 1 Humalog Mix 50/50, 10
fluocinonide-e, 7
Genvoya, 2 Humalog Mix 50/50 Kwikpen, 10
fluorometholone, 18
Geodon, 16 Humalog Mix 75/25, 10
fluoxetine, 17
Gesticare DHA, 22 Humalog Mix 75/25 Kwikpen, 10
fluoxetine DR, 15
Giazo, 13 Humatrope, 11
fluoxetine HCL, 15
Gilenya, 17 Humatrope Combo Pack, 11
fluphenazine decanoate, 15
Gilotrif, 4 Humira, 20
fluphenazine HCL, 15
Gilphex TR, 21 Humira Pediatric Crohns Disease Starter Pack, 20
flurazepam HCL, 16
Giltuss PED-c, 21
flurbiprofen, 20
Giltuss TR, 21 Humira Pen, 20
flurbiprofen sodium, 19
glatiramer acetate 20mg/ml, 17 Humira Pen-crohns Diseasestarter, 20
flutamide, 3
Gleostine, 3 Humira Pen-psoriasis Starter, 20
fluticasone propionate, 7, 21
glimepiride, 10 Humulin R U-500 (concentrated), 10
fluvastatin, 6
glipizide, 10 Humulin R U-500 Kwikpen, 10
fluvastatin sodium ER, 6
glipizide ER, 10 Hycamtin, 4
fluvoxamine maleate, 15
glipizide/metformin HCL, 10 hydralazine HCL, 5
fluvoxamine maleate ER, 15
Glucagen Hypokit, 10 hydrochlorothiazide, 6
FML, 18
Glucagon Emergency Kit, 10 hydrocodone bitartrate/acetaminophen, 19
FML Forte, 18
glyburide, 10
Focalgin 90 DHA, 22
glyburide micronized, 10 hydrocodone bitartrate/chlorpheniramine maleate/PSE, 21
Focalgin CA, 22
glyburide/metformin HCL, 10
Focalin, 16
glycolic acid, 7 hydrocodone bitartrate/homatropine methylbromide, 21
Focalin XR, 16
glycolic acid 70% high purity, 7
Folcaps Omega 3, 22
glycopyrrolate, 12 hydrocodone polistirex/chlorpheniramine polistirex, 21
Folet DHA, 22
folic acid, 14
Golytely, 12 hydrocodone/acetaminophen, 19
Folivane-OB, 22
Gonal-f, 11 hydrocodone/homatropine, 21
Folivane-PRX DHA NF, 22
Gonal-f RFF, 11 hydrocodone/ibuprofen, 19
Follistim AQ, 11
Gonal-f RFF Pen, 11 hydrocortisone tabs, 7, 9, 13
fondaparinux sodium, 14
Gonal-f RFF Rediject, 11 hydrocortisone acetate/aloe, 8
Foradil Aerolizer, 22
Gordofilm, 8 hydrocortisone acetate/lidocaine HCL, 13
Gordons Urea, 8 hydrocortisone acetate/pramoxine, 13
Fortaz, 1
granisetron HCL, 12 hydrocortisone butyrate, 8
Forteo, 11
Granisol, 12 hydrocortisone butyrate (lipid), 8
Fortesta, 9
Granix, 14 hydrocortisone butyrate (lipophilic), 8
fortical, 11
griseofulvin microsize, 2 hydrocortisone IN absorbase, 7
Fosamax Plus D, 11
griseofulvin ultramicrosize, 2 hydrocortisone valerate, 8
fosinopril sodium, 5
guaifenesin/codeine, 21 hydrocortisone/acetic acid, 19
fosinopril sodium/hydrochlorothiazide, 5
guanfacine ER, 16 hydromorphone HCL, 19
Fosrenol, 13
guanfacine HCL, 5 hydromorphone HCL dosette, 19
Fragmin, 14
guanidine HCL, 18 hydromorphone HCL ER, 19
Gynazole-1, 13 hydroxocobalamin, 14
frovatriptan succinate, 20
H hydroxychloroquine sulfate, 2
Fulyzaq, 12
hydroxyurea, 4
furosemide, 6
hydroxyzine HCL, 15
halobetasol propionate, 7
Fuzeon, 2
hydroxyzine pamoate, 15
Halog, 8
Fycompa, 16
Hylatopic, 8
Halonate, 8
G
Hylatopic Plus, 8
haloperidol, 15
hyoscyamine sulfate, 12
gabapentin, 16
haloperidol decanoate, 15
hyoscyamine sulfate ER, 12
haloperidol lactate, 15
hyoscyamine sulfate ODT, 12
Halotin, 7
hyoscyamine sulfate SR, 12
Harvoni, 2
Hypersal, 21
Helixate FS, 14
Hypertenevide-12.5, 4
Gabitidine, 12
Hemabate, 19
Hypertenipine-2.5, 5
Gabitril, 16
heparin sodium, 14
Hypertensolol, 5
Gaboxetine, 15
I
galantamine hydrobromide, 17
ganirelix acetate, 11
ibandronate sodium, 10
gatifloxacin, 18
Ibrance, 4
Gattex, 13
ibuprofen, 20
Hexalen, 3
IC 400, 20
Karbinal ER, 21 letrozole, 3
IC 800, 20
Kazano, 10 leucovorin calcium, 4
Iclusig, 4
Keppra, 16 Leukeran, 3
Ilaris, 20
Keppra XR, 16 leuprolide acetate, 3
Ilevro, 19
Kerafoam, 8 Levacet, 19
imatinib mesylate, 4
Kerafoam 42, 8 levalbuterol, 22
Imbruvica, 4
Keralyt Scalp, 8 levalbuterol HCL, 22
imipramine HCL, 15
Ketek, 3 Levatol, 4
imipramine pamoate, 15
ketoconazole, 2, 7 Levemir, 10
imiquimod, 8
Levemir Flexpen, 10
Imitrex, 20
ketoprofen, 20 Levemir Flextouch, 10
Imuran, 3
ketoprofen ER, 20 levetiracetam, 16
Increlex, 11
ketorolac tromethamine, 19, 20 levetiracetam ER, 16
Incruse Ellipta, 22
Khedezla, 15 Levitra, 6
indapamide, 6
Kineret, 20 levobunolol HCL, 18
Inderal XL, 4
Kinlytic, 14 levocarnitine, 11
Indocin, 20
levocetirizine dihydrochloride, 21
indomethacin, 20
Kogenate FS, 14 levofloxacin, 1, 18
indomethacin ER, 20
Kogenate FS Bio-set, 14 levonorgestrel, 9
Infasurf, 22
Kombiglyze XR, 10 levonorgestrel and ethinyl estradiol, 9
Inlyta, 4
Korlym, 10 levonorgestrel/ethinyl estradiol, 9
Innopran XL, 4
Kovaltry, 14 levorphanol tartrate, 19
Intelence, 2
Kristalose, 12 levothyroxine sodium, 12
Intron A, 4
Kuvan, 11 levothyroxine sodium TAB 0.075MG, 12
Intron A W/Diluent, 4
Kynamro, 6 Levsin, 12
Invanz, 3
L Lexiva, 2
Invega Sustenna, 16
Lialda, 13
labetalol HCL, 4
Invega Trinza, 16
Lido-RX 4.1, 8
Lacrisert, 18
Invirase, 2
lidocaine, 8
lactic acid, 8
Invokamet, 10
lidocaine and tetracaine cream, 8
lactic acid e, 8
Invokana, 10
lidocaine HCL, 8, 14, 21
lactic acid w/vitamin e, 8
Iopidine, 19
lidocaine HCL jelly, 8
lactulose, 12, 13
ipratropium bromide, 21, 22
lidocaine HCL viscous, 14
Lamictal, 17
ipratropium bromide/albuterol sulfate, 22
lidocaine HCL-hydrocortisone acetate with aloe, 13
Lamictal Chewable Dispersible, 17
Iprivask, 14
Lamictal ODT, 16
irbesartan, 5
lidocaine HCL/hydrocortisone acetate, 13
irbesartan/hydrochlorothiazide, 5
lidocaine viscous, 14
Iressa, 4
lidocaine-prilocaine-cream base, 8
Isentress, 2
lidocaine/epinephrine, 21
isoniazid, 2
lidocaine/prilocaine, 8
Isopto Carbachol, 18
Isopto Homatropine, 18
lincomycin HCL, 3
Lamictal XR, 17
Isopto Hyoscine, 18
lincomycin/lidocaine, 3
Lamisil, 2
isosorbide dinitrate, 4
lindane, 8
Lamisil Spray, 7
isosorbide dinitrate ER, 4
linezolid, 3
lamivudine, 2
isosorbide mononitrate, 4
Linzess, 13
lamivudine/zidovudine, 2
isosorbide mononitrate ER, 4
liothyronine sodium, 12
lamotrigine, 16
isradipine, 5
lisinopril, 5
lamotrigine ER, 16
Isuprel, 22
lisinopril/hydrochlorothiazide, 5
lamotrigine ODT, 16
itraconazole, 2
lithium, 15
lamotrigine titration, 16
IV Infusion Cpi, 8
lithium carbonate, 15
ivermectin, 3
lithium carbonate ER, 15
Ixinity, 14
Lithostat, 14
J
Livalo, 6
lansoprazole, 12
LO Loestrin FE, 10
Jakafi, 4
lansoprazole/amoxicillin/clarithromycin, 12
Locoid, 8
Janumet, 10
lomustine, 3
Janumet XR, 10
Lantus, 10
Lonsurf, 4
Januvia, 10
Lantus Solostar, 10
lorazepam, 15
Jardiance, 10
Lastacaft, 19
Lortab, 20
Jentadueto, 10
latanoprost, 18
Lortuss EX, 21
Juxtapid, 6
Latuda, 16
K
Lazanda, 20
Lorzone, 18
leflunomide, 20
losartan potassium, 5
K-phos NO 2, 14
Lenvima 10MG Daily Dose, 4
losartan potassium/hydrochlorothiazide, 5
Kadian, 20
Lenvima 14MG Daily Dose, 4
Kalbitor, 14
Lenvima 20MG Daily Dose, 4
Lotemax, 18
Kaletra, 2
Lenvima 24MG Daily Dose, 4
lovastatin, 6
Kalydeco, 22
Letairis, 6
loxapine, 15
methyldopa, 5 Motofen, 12
loxapine succinate, 15
methyldopa/hydrochlorothiazide, 5 Movantik, 13
Lufyllin, 22
methylergonovine maleate, 19 Moviprep, 12
Lumigan, 18
Methylin, 16 Moxatag, 1
Lupaneta Pack, 11
methylphenidate HCL, 16 Moxeza, 18
Lupron Depot, 3
methylphenidate HCL CD, 16 moxifloxacin HCL, 1
Lupron Depot-PED, 11
methylphenidate HCL ER, 16 Mozobil, 14
Luzu, 7
methylphenidate HCL SR, 16 Multaq, 5
Lycelle, 8
methylphenidate hydrochloride, 16 mupirocin, 7
Lynparza, 4
methylprednisolone, 9 mupirocin calcium, 7
Lyrica, 17
methylprednisolone acetate, 9 Muse, 6
Lysodren, 3
methylprednisolone dose pack, 9 mycophenolate mofetil, 3
methylprednisolone PF, 9 mycophenolic acid DR, 3
methylprednisolone sodiumsuccinate, 9 Mykidz Iron Fl, 22
M
methyltestosterone, 9 Myleran, 3
metipranolol, 18 Mynatal, 22
M-end PE, 21
metoclopramide HCL, 13 Myobloc, 17
Makena, 10
metoclopramide ODT, 13 Myrbetriq, 13
malathion, 8
metolazone, 6 Mysoline, 17
maprotiline HCL, 15
metoprolol succinate ER, 4 N
Mar-cof Bp, 21
metoprolol tartrate, 4
Marnatal-f, 22
nabumetone, 20
metoprolol/hydrochlorothiazide, 5
Marplan, 15
nadolol, 4
metronidazole, 3, 7
Matulane, 4
nadolol/bendroflumethiazide, 5
metronidazole vaginal, 13
Maxidex, 18
nafcillin sodium, 1
mexiletine HCL, 5
Nafrinse Daily/Acidulated, 15
Miacalcin, 11
Mb Hydrogel, 8
Nafrinse Daily/Neutral, 15
midodrine HCL, 6
meclofenamate sodium, 20
Nafrinse Weekly, 15
Mifeprex, 11
Medi-derm/L-RX, 8
naftifine HCL, 7
Migergot, 20
Medrol, 9
naftifine hydrochloride, 7
Migral, 20
medroxyprogesterone acetate, 10
Millipred, 9
medroxyprogesterone/lidocaine, 10
nalbuphine HCL, 19
Millipred DP, 9
mefenamic acid, 20
Nalfon, 20
Minastrin 24 FE, 10
mefloquine HCL, 2
Namenda XR, 17
mineral oil heavy, 12
megestrol acetate, 3, 10
Minivelle, 9
Megrix, 8
Namzaric, 17
minocycline HCL, 1
Mekinist, 4
naphazoline HCL, 18
minocycline HCL ER, 1
meloxicam, 20
naproxen, 20
minoxidil, 5
Mirapex ER, 17
memantine HCL, 17
naproxen sodium, 20
Mircera, 14
naproxen sodium ER, 20
mirtazapine, 15
memantine hydrochloride, 17
naratriptan HCL, 20
mirtazapine ODT, 15
Menest, 9
Nascobal, 14
misoprostol, 12
Menopur, 11
Mitigare, 21
Menostar, 9
Natachew, 22
Mitosol, 18
Mentax, 7
Natacyn, 18
meperidine HCL, 19
Natalvirt 90 DHA, 22
Mobic, 20
meprobamate, 15
Natalvirt CA, 22
modafinil, 16
mercaptopurine, 3
Natalvit, 22
Moderiba, 2
mesalamine, 13
Natazia, 10
Mesnex, 4
nateglinide, 10
Natelle One, 22
moexipril HCL, 5
Metadate CD, 16
Nature-throid, 12
moexipril/hydrochlorothiazide, 5
metaproterenol sulfate, 22
Nature-throid Nt-2.5, 12
molindone hydrochloride, 15
metaxalone, 17
Nebupent, 3
mometasone furoate, 7, 21
metformin HCL, 10
Nebusal, 21
metformin HCL ER, 10
Neevo DHA, 22
methadone HCL, 19
nefazodone HCL, 15
methamphetamine HCL, 16
Nembutal Sodium, 16
methazolamide, 6
Neo-synalar, 7
methenamine hippurate, 13
neomycin sulfate, 1
methenamine mandelate, 13
neomycin/bacitracin/polymyxin, 18
methimazole, 12
neomycin/polymyxin/bacitracin zinc, 18
methocarbamol, 17
neomycin/polymyxin/bacitracin/hydrocortisone, 18
montelukast sodium, 22
methotrexate, 3
Monurol, 13
methotrexate sodium, 3
neomycin/polymyxin/dexamethasone, 18
morphine sulfate, 19
methoxsalen, 7
neomycin/polymyxin/gramicidin, 18
morphine sulfate ER, 19
methscopolamine bromide, 12
neomycin/polymyxin/HC, 19
methyclothiazide, 6
neomycin/polymyxin/hydrocortisone, 18,
19
Noxafil, 2 oxacillin sodium, 1
Neoral, 3
Nplate, 14 oxandrolone, 9
Neosalus, 8
Nucynta, 20 oxaprozin, 20
Neosalus CP, 8
Nucynta ER, 20 Oxaydo, 20
neostigmine methylsulfate, 18
Nuedexta, 17 oxazepam, 15
Neotuss Plus, 21
Nutropin AQ Nuspin 10, 11 oxcarbazepine, 16
Nesacaine, 21
Nutropin AQ Nuspin 20, 11 Oxecta, 20
Nesina, 10
Nutropin AQ Nuspin 5, 11 oxiconazole nitrate, 7
Nestabs, 22
Nutropin AQ Pen, 11
Nestabs Abc, 22
Nuvail, 8 Oxtellar XR, 17
Nestabs DHA, 22
oxybutynin chloride, 13
Neulasta, 14
Nuwiq, 14 oxybutynin chloride ER, 13
Nymalize, 5 oxycodone HCL, 19
Neumega, 14
nystatin, 2, 7, 14 oxycodone HCL ER, 19
Neupogen, 14
nystatin/triamcinolone, 7 oxycodone/acetaminophen, 19
Neupro, 17
O oxycodone/aspirin, 19
Neutrasal, 15
oxycodone/ibuprofen, 19
O-CAL Fa, 22
Neuvaxin, 8
Oxycontin, 20
O-CAL Prenatal, 22
Nevanac, 19
oxymorphone hydrochloride, 19
OB Complete, 22
nevirapine, 2
oxymorphone hydrochloride ER, 19
OB Complete 400, 23
nevirapine ER, 2
oxytocin, 19
OB Complete One, 23
Newgen, 22
P
OB Complete Petite, 23
Nexa Plus, 22
OB Complete Premier, 23 Paire OB, 23
Nexavar, 4
OB Complete/DHA, 23 paliperidone ER, 15
niacin ER, 6
Obstetrix DHA, 22 Pamine FQ, 12
nicardipine HCL, 4
octreotide acetate, 11 Panatuss Dxp, 21
Nicomide, 22
Ocudox, 1 Pancreaze, 13
nifedipine, 5
Ocuvel, 22 pancrelipase, 12
nifedipine ER, 5
Odefsey, 2 Pandel, 8
Nilandron, 3
Ofev, 22 pantoprazole sodium, 12
nimodipine, 5
ofloxacin, 1, 18, 19 papaverine HCL, 6
Ninlaro, 4
olanzapine, 15 paregoric, 12
nisoldipine, 5
olanzapine ODT, 15 paricalcitol, 11
nisoldipine ER, 5
olanzapine/fluoxetine, 17
Nitro-bid, 4
Oleptro, 15 paromomycin sulfate, 1
Nitro-dur, 4
olopatadine HCL, 19, 21 paroxetine HCL, 15
nitrofurantoin, 13
paroxetine HCL ER, 15
nitrofurantoin macrocrystals, 13
omega-3-acid ethyl esters, 6 Paser, 2
nitrofurantoin monohydrate, 13
omeprazole, 12 Pataday, 19
nitrofurantoin monohydrate/macrocrystals, 13
omeprazole/sodium bicarbonate, 12 Paxil Susp, 15
Omnaris, 21 PCE, 1
nitroglycerin ER, 4
Omnitrope, 11
nitroglycerin lingual, 4
Omontys, 14 Pediaderm HC, 8
nitroglycerin transdermal, 4
ondansetron HCL, 12 Pediaderm TA, 8
Nitromist, 4
ondansetron ODT, 12 Pediatex TDM, 21
Nitrostat, 4
One Touch Test Strips, 10 peg 3350/electrolytes, 12
Niva-plus, 22
Onfi, 17 peg-3350/electrolytes, 12
Nivatopic Plus, 8
Onglyza, 10 peg-3350/NACL/NA bicarbonate/KCL, 12
nizatidine, 12
Opana ER (crush Resistant), 20 Peg-intron, 2
Norditropin Cartridge, 11
opium, 12 Peg-intron Redipen, 2
Norditropin Flexpro, 11
opium tincture, 12
Norditropin Nordiflex Pen, 11
Oracit, 14 Peganone, 17
norethindrone, 9
Orapred ODT, 9 Pegasys, 2
norethindrone & ethinyl estradiol ferrous fumarate, 9
Oravig, 15 Pegasys Proclick, 2
Orencia, 20 Pegintron, 2
norethindrone acetate, 10
Orenitram, 6 penicillin G potassium, 1
norethindrone acetate/ethinyl estradiol, 9(2)
Orfadin, 11 penicillin G procaine, 1
Orkambi, 22 penicillin G sodium, 1
norethindrone acetate/ethinyl estradiol/ferrous fumarate, 9
orphenadrine citrate, 17 penicillin v potassium, 1
orphenadrine citrate ER, 17 Pennsaid, 7
norgestimate/ethinyl estradiol, 9
orphenadrine/asa/caffeine, 17 Pentam 300, 3
Norinyl 1+50, 10
Oseni, 10 Pentasa, 13
Noroxin, 1
Osmoprep, 12 pentazocine/naloxone HCL, 20
Norpace CR, 5
Osphena, 11 pentetate calcium trisodium, 23
Northera, 6
Otezla, 20 pentetate zinc trisodium, 23
nortriptyline HCL, 15
Otiprio, 19 pentoxifylline ER, 14
Norvir, 2
Ovace Plus, 7 Perforomist, 22
Novoeight, 14
Ovidrel, 11 perindopril erbumine, 5
permethrin, 8
Prefol-DHA, 23 propranolol/hydrochlorothiazide, 5
perphenazine, 15
Premarin, 9, 13 propylthiouracil, 12
perphenazine/amitriptyline, 17
Premphase, 9 Prostin E2, 19
Pertzye, 13
Prempro, 9 Protonix, 12
Pexeva, 15
Prenata, 23 protriptyline HCL, 15
phenazopyridine HCL, 13
Prenate, 23 Proventil HFA, 22
phenelzine sulfate, 15
Prenate AM, 23 Provida OB, 23
Phenergan Fortis, 21
Prenate DHA, 23 Pruclair, 9
phenobarbital, 16
Prenate Elite, 23 Prudoxin, 7
phenobarbital sodium, 16
Prenate Enhance, 23 Prumyx, 9
phenoxybenzamine hydrochloride, 5
Prenate Essential, 23 Pulmicort Flexhaler, 22
phentolamine mesylate, 5
Prenate Mini, 23 Pulmophylline, 22
phenylephrine HCL, 6, 18
Prenate Pixie, 23 Pulmozyme, 22
phenylephrine/guaifenesin, 21
Prenate Restore, 23 Purixan, 3
Phenytek, 17
Prenate Star, 23 Pylera, 12
phenytoin, 16
Prepidil, 19 pyrazinamide, 2
phenytoin sodium, 16
Prepopik, 12 pyridostigmine bromide, 18
phenytoin sodium extended, 16
Preque 10, 23 pyrogallic acid, 8
Phoslyra, 13
Presera, 8 Q
Phospholine Iodide, 18
Prevacid Solutab, 12
Qnasl, 21
pilocarpine HCL, 14, 18
Qnasl Childrens, 21
pilocarpine hydrochloride, 14
Prezcobix, 2
Quartette, 10
pimozide, 17
Prezista, 2
quazepam, 16
pindolol, 4
Priftin, 2
Quelicin 1000, 17
pioglitazone HCL, 10
primaquine phosphate, 2
quetiapine fumarate, 15
pioglitazone HCL-glimepiride, 10
primidone, 16
Quillivant XR, 16
pioglitazone HCL/metformin HCL, 10
Primlev, 20
quinapril HCL, 5
piroxicam, 20
Primsol, 3
quinapril/hydrochlorothiazide, 5
Plegridy, 17
Pristiq, 15
quinidine gluconate, 5
quinidine gluconate CR, 5
Pliaglis, 8
quinidine gluconate ER, 5
podofilox, 8
quinidine sulfate, 5
Poly-VI-flor, 23
quinidine sulfate ER, 5
Poly-VI-flor/Iron, 23
Pro-clear Ac, 21
quinine sulfate, 2
polyethylene glycol 3350, 12
Proair HFA, 22
Qutenza, 9
polymyxin b sulfate, 3
Proair Respiclick, 22
Qvar, 22
polymyxin b sulfate/trimethoprim sulfate, 18
probenecid, 21
R
probenecid/colchicine, 21
Pomalyst, 3
procainamide HCL, 5
R-natal OB, 23
potassium citrate ER, 13
Procentra, 16
rabeprazole sodium, 12
potassium citrate-citric acid crystals, 14
prochlorperazine, 15
raloxifene hydrochloride, 11
potassium citrate/citric acid, 14
prochlorperazine edisylate, 15
ramipril, 5
potassium citrate/sodium citrate/citric acid, 13
prochlorperazine maleate, 15
Ranexa, 4
Procort, 13
ranitidine HCL, 12
Potiga, 17
Procrit, 14
Rapaflo, 14
PR Cream, 8
Rapamune, 3
Pradaxa, 14
Procysbi, 14
Rasuvo, 20
pramipexole dihydrochloride, 17
progesterone, 10
Ravicti, 11
pramipexole dihydrochloride ER, 17
Prograf, 3
pravastatin sodium, 6
Prolensa, 19
Prazolamine, 17
Prolia, 11
prazosin HCL, 5
Promacta, 14
Rebetol, 2
Pred Mild, 18
promethazine HCL, 21
Rebif, 17
Pred-G, 18
promethazine HCL plain, 21
Rebif Rebidose, 17
Pred-G S.o.p., 18
promethazine-DM, 21
prednicarbate, 8
promethazine/codeine, 21
prednisolone, 9
promethazine/dextromethorphan, 21
Recombinate, 14
prednisolone acetate, 18
promethazine/phenylephrine, 21
Recothrom, 14
prednisolone sodium phosphate, 9, 18
promethazine/phenylephrine/codeine, 21
prednisolone sodium phosphate ODT, 9
Promiseb, 7
Rectiv, 13
prednisone, 9
Promiseb Complete, 7
Recura, 7
Prednisone Intensol, 9
propafenone HCL, 5
Relagard, 13
Prefera OB, 23
propafenone HCL ER, 5
Relenza Diskhaler, 2
Prefera OB + DHA, 23
propantheline bromide, 12
Relhist, 21
Preferaob +dha, 23
proparacaine HCL, 19
Relistor, 13
Preferaob One, 23
propranolol HCL, 4
Relpax, 20
Prefest, 9
propranolol HCL ER, 4
Relyyt, 9
Remodulin, 6
Scalacort DK, 8 spinosad, 8
Renagel, 13
scopolamine hydrobromide, 12 Spiriva Handihaler, 22
Renvela, 13
Select-OB, 23 Spiriva Respimat, 22
repaglinide, 10
Select-ob+dha, 23 spironolactone, 6
repaglinide/metformin hydrochloride, 10
selegiline HCL, 17 spironolactone/hydrochlorothiazide, 6
Repronex, 11
selenium sulfide, 7 Sporanox, 2
Rescon-JR, 21
Selrx, 7 Spritam, 17
Rescon-MX, 21
Selzentry, 2 Sprix, 20
Rescriptor, 2
Semprex-d, 21 Sprycel, 4
Rescula, 18
senna plus, 12 Stalevo 100, 17
reserpine, 5
Sensipar, 11 Stalevo 125, 17
Restora RX, 12
Sensorcaine-mpf/Epinephrine, 21 Stalevo 150, 17
Revlimid, 3
Stalevo 200, 17
Reyataz, 2
Stalevo 50, 17
Rezira, 21
Stalevo 75, 17
Rezyst IM, 12
stannous fluoride oral rinse, 14
Rezyst SB, 12
Statuss Green, 21
Rheumatrex, 20
stavudine, 2
Ribasphere Ribapak, 2
Stavzor, 16
ribavirin, 2
Sentroxatine, 15 Staxyn, 6
Ridaura, 20
Serevent Diskus, 22 Stelara, 7
rifabutin, 2
Seroquel XR, 15 Stimate, 11
Rifamate, 2
Serostim, 11 Stiolto Respimat, 22
rifampin, 2
sertraline HCL, 15 Stivarga, 4
Rifater, 2
sevelamer carbonate, 13 Strattera, 16
riluzole, 17
Sfrowasa, 13 Strazepam, 16
rimantadine HCL, 2
Signifor, 11 streptomycin sulfate, 1
Rimantalist, 2
Signifor LAR, 11 Striant, 9
Riomet, 10
sildenafil, 6 Stribild, 2
risedronate sodium, 10
sildenafil citrate, 6 Suboxone, 20
risedronate sodium DR, 10
Simbrinza, 19 Subsys, 20
Risperdal Consta, 15
Simcor, 6 Suclear, 12
risperidone, 15
Simponi, 20 Sucraid, 13
risperidone ODT, 15
simvastatin, 6 sucralfate, 12
Ritalin, 16
Sinelee, 9 sulfacetamide sodium, 6, 18
Ritalin LA, 16
sirolimus, 3 sulfacetamide sodium/prednisolone sodium phosphate, 18
Ritalin SR, 16
Sirturo, 2
rivastigmine tartrate, 17
Sitavig, 2 sulfacetamide sodium/sulfur, 6
rivastigmine transdermal system, 17
Sivextro, 3 sulfacetamide sodium/sulfur cleanser, 6
rizatriptan benzoate, 20
Sklice, 9 sulfadiazine, 2
rizatriptan benzoate ODT, 20
sulfamethoxazole/trimethoprim, 3
ropinirole ER, 17
sodium bicarbonate, 12 sulfamethoxazole/trimethoprim DS, 3
ropinirole HCL, 17 rosuvastatin, 6
sodium chloride, 21 sulfasalazine, 13
Roxicet, 20
sodium citrate/citric acid, 14 sulfurated lime, 8
Rozerem, 16
sodium hyaluronate, 8 sulindac, 20
Rytary, 17
sodium phenylbutyrate, 11 sumatriptan, 20
S
sodium sulfacetamide, 6, 7, 18 sumatriptan succinate, 20
sodium sulfacetamide wash, 7 sumatriptan succinate refill, 20
Sabril, 17
sodium sulfacetamide/sulfur, 6 Sumavel Dosepro, 20
Safyral, 10
sodium sulfacetamide/sulfur cleanser, 6 Supprelin LA, 11
Saizen, 11
sodium sulfacetamide/sulfur cleanser IN urea, 6
Suprax, 1
Saizen Click.easy, 11
Suprep Bowel Prep, 12
salicylic acid, 8
sodium sulfacetamide/sulfur cleansing cloths, 6
salicylic acid cream, 8
Sustiva, 2
sodium sulfacetamide/sulfur green, 6 Sutent, 4
sodium sulfacetamide/sulfur IN urea, 6 Sylatron, 4
salicylic acid lotion, 8
sodium sulfacetamide/sulfur wash, 6 Symax Duotab, 12
Salivamax, 15
Solaice, 9 Symbicort, 22
salsalate, 19
Soltamox, 3 Symlinpen 120, 10
Salvax Duo Plus, 9
Solu-medrol, 9 Symlinpen 60, 10
Samsca, 11
Somatuline Depot, 11
Sancuso, 12
Somavert, 11
Sandimmune, 3
Sorilux, 7 Synalar Ts, 8
Sandostatin Lar Depot, 11
sotalol HCL, 4 Synalgos-dc, 20
Saphris, 16
sotalol HCL (AF), 4 Synarel, 11
Sarafem, 17
Sotylize, 4 Synera, 9
Savaysa, 14
Sovaldi, 2 Synthroid, 12
Savella, 17
Spectracef, 1
T
tretinoin microsphere, 6
tretinoin microsphere P.M., 6
Tabloid, 3
Trexall, 3
Taclonex, 8
Treximet, 20
tacrolimus, 3, 8
Trezix, 20
Tafinlar, 4
Thrombogen, 14 Tri-VI-flor, 23
Tagrisso, 4
Thyrolar-1, 12 triamcinolone, 9
Taltz, 7
Thyrolar-1/2, 12 triamcinolone acetonide, 8, 14, 21
Tamiflu, 2
Thyrolar-1/4, 12 triamcinolone IN orabase, 14
tamoxifen citrate, 3
Thyrolar-2, 12 triamterene/hydrochlorothiazide, 6
tamsulosin HCL, 13
Thyrolar-3, 12 Trianex, 8
Tanzeum, 10
tiagabine hydrochloride, 16 triazolam, 16
Tarceva, 4
ticlopidine HCL, 14 Tribenzor, 5
Targadox, 1
Tikosyn, 5 Tricare Prenatal Compleat, 23
Taron-bc, 23
timolol maleate, 4, 18 Tricare Prenatal DHA One, 23
Taron-c DHA, 23
timolol maleate ophthalmic gel forming, 18
tricitrates, 13
Tasigna, 4
Tricode AR, 21
Tazorac, 7
Tricode GF, 21
Tecfidera, 17
tinidazole, 3 trifluoperazine HCL, 15
Tirosint, 12 trifluridine, 18
Tegretol, 17
Tisseel, 14 trihexyphenidyl HCL, 17
Tegretol-XR, 16
Tisseel VH, 14 Trileptal, 17
Tekamlo, 5
Tivicay, 2 trimethobenzamide HCL, 12
Tekturna, 5
trimethoprim, 3
Tekturna HCT, 5
tizanidine HCL, 17 trimethoprim sulfate/polymyxin b sulfate, 18
telmisartan, 5
TL Triseb, 7
telmisartan/amlodipine, 5
Tobi Podhaler, 1 trimipramine maleate, 15
telmisartan/hydrochlorothiazide, 5
Tobradex, 18 Triumeq, 2
temazepam, 16
Tobradex ST, 18 Triveen-duo DHA, 23
temozolomide, 3
tobramycin, 1 Triveen-prx RNF, 23
terazosin HCL, 5
tobramycin sulfate, 1, 18 Trokendi XR, 17
terbinafine HCL, 2
tobramycin/dexamethasone, 18 Tropazone, 9
Terbinex, 2
Tobrex, 18 trospium chloride, 13
terbutaline sulfate, 22
tolazamide, 10 trospium chloride ER, 13
terconazole, 13
tolbutamide, 10 Truvada, 2
Tersi Foam, 7
tolcapone, 17 Tudorza Pressair, 22
Testim, 9
tolmetin sodium, 20
testosterone 1% gel, 9
tolterodine tartrate, 13
testosterone cypionate, 9
tolterodine tartrate ER, 13
testosterone enanthate, 9
Topamax, 17 Tuzistra XR, 22
testosterone P.M., 9
Topamax Sprinkle, 17 Tykerb, 4
tetrabenazine, 17
Topicort, 8 Tyvaso, 6
topiramate, 16
tetracycline HCL, 1
torsemide, 6
Tetrix, 9
Toviaz, 13 Tyzeka, 2
Tev-tropin, 11
Tracleer, 6 Tyzine, 21
Teveten HCT, 5
Tradjenta, 10 Tyzine Pediatric Nasal Drops, 21
Texacort, 8
tramadol HCL, 19 U
Texavite LQ, 23
tramadol HCL ER, 20
Thalomid, 3
Uceris, 9, 13
tramadol hydrochloride/acetaminophen, 19
Theo-24, 22
Ulesfia, 9
theophylline, 22
Uloric, 21
trandolapril, 5
theophylline CR, 22
trandolapril/verapamil HCL, 5
theophylline ER, 22
trandolapril/verapamil HCL ER, 5
Ultresa, 13
tranexamic acid, 14
Umecta, 9
Transderm-scop, 12
Umecta PD, 9
tranylcypromine sulfate, 15
urea, 8
Travatan Z, 18
travoprost, 18
Trazamine, 15
trazodone HCL, 15
urea topical, 8
Trecator, 2
Uretron D/S, 13
Trelstar, 3
Uroqid #2, 13
Trelstar Mixject, 3
ursodiol, 13
Trepadiclofen-25, 20
V
Trepoxicam-7.5, 20
Thiola, 14
Tretin-X, 6
Vagifem, 13
thioridazine HCL, 15
tretinoin, 4, 6
valacyclovir HCL, 2
thiothixene, 15
Valchlor, 3
Vytorin, 6 Zomacton, 11
Vyvanse, 16 Zomig, 20
valganciclovir, 2
W Zomig Nasal Spray, 20
valproic acid, 16
Zonalon, 7
warfarin sodium, 14
valsartan, 5
zonisamide, 16
Welchol, 6
valsartan/hydrochlorothiazide, 5
Zorbtive, 11
Westhroid, 12
Vanacof CD, 22
Zortress, 3
Wp Thyroid, 12
vancomycin HCL, 3
Zuplenz, 12
X
Vantas, 3
Zyclara, 8
Vascepa, 6
Zyclara P.M., 8
Xalkori, 4
vasopressin, 11
Zydelig, 4
Xarelto, 14
Vecamyl, 5
Zyflo, 22
Xeljanz, 20
Vectical, 7
Zyflo CR, 22
Xeljanz XR, 20
Velphoro, 13
Zykadia, 4
Xeomin, 17
Vemavite-prx 2, 23
Zylet, 18
Xerac Ac, 8
venlafaxine HCL, 15
Zyprexa Relprevv, 15
Xgeva, 11
venlafaxine HCL ER, 15
Zytiga, 3
Xifaxan, 3
Ventavis, 6
8
Xigduo XR, 10
Ventolin HFA, 22
Xolair, 22
8-mop, 7
Veramyst, 21
Xolegel, 7
verapamil HCL, 4
verapamil HCL ER, 4
Xolegel Duo/Head & Shoulders, 7
verapamil HCL SR, 5
Xolegel Duo/Xolex, 7
Verdeso, 8
Veregen, 9
Xopenex HFA, 22
Veripred 20, 9
Xrylix, 7
Versacloz, 16
Xtandi, 3
Vesicare, 13
Xuriden, 11
Vexol, 18
Viagra, 6
Xyntha, 14
Vibramycin, 1
Xyntha Solofuse, 14
Victoza, 10
Xyrem, 17
Victrelis, 2
Y
Videx Pediatric, 2
Yodoxin, 3
Vigamox, 18
Viibryd, 15
Z
Z-tuss Ac, 22
Vimpat, 17
zafirlukast, 22
Vinacal B, 23
zaleplon, 16
Vinate AZ Extra, 23
Zamicet, 20
Vinate Calcium, 23
Zarontin, 17
Vinate DHA RF, 23
Zatean-CH, 23
Viokace, 13
Zatean-pn, 23
Viracept, 2
Zatean-pn DHA, 23
Viramune, 2
Zatean-pn Plus, 23
Virazole, 2
Zavesca, 14
Viread, 2
Zelapar, 17
Vita-pren, 23
Zelboraf, 4
Vitafol Ultra, 23
Zembrace Symtouch, 20
Vitafol-nano, 23
Zenpep, 13
Vitafol-ob+dha, 23
Zenzedi, 16
Vitafol-one, 23
Zetia, 6
Vitamedmd One RX/Quatrefolic, 23
Zetonna, 21
Vitamedmd Plus RX/Quatre Folic, 23
Ziagen, 2
Vitamedmd Redichew RX, 23
zidovudine, 2
Vitamedmd Redichew RX/Quatrefolic, 23
Zioptan, 18
Vitapearl, 23
ziprasidone HCL, 15
Vitekta, 2
Zirgan, 18
Vituz, 21
Zithranol, 7
Viva DHA, 23
Zithranol-RR, 7
Vogelxo, 9
Zmax, 1
Vogelxo P.M., 9
Zoladex, 3
Zolinza, 4
voriconazole, 2
zolmitriptan, 20
Votrient, 4
zolmitriptan ODT, 20
Vraylar, 16
zolpidem tartrate, 16
Vsl#3 DS, 12
zolpidem tartrate ER, 16
Vusion, 7
Zolpimist, 16
RX-114513 10/2016