effective may 1, 2012 - instantbenefits.com · prescription drugs when prescribed for experimental,...

HCR-0414-050812 NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1800-458-4600, extension 300, from the neighbor islands.

Preferred Drug Listing

Effective May 1, 2012

Effective 05/01/2012

NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands

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Table of Contents

UHA PREFERRED DRUG LISTING (PDL).............................................................................................................................................................. 1 COVERED MEDICATIONS ...................................................................................................................................................................................... 1 GENERIC MEDICATIONS ....................................................................................................................................................................................... 1 LEGEND ................................................................................................................................................................................................................... 1 ANALGESICS........................................................................................................................................................................................................... 2

NON-NARCOTIC ANALGESICS ................................................................................................................................................................... 2 NARCOTIC ANALGESICS ............................................................................................................................................................................. 2 NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (Over the counter strengths are not covered) ............................................................ 2 ANTIRHEUMATICS ....................................................................................................................................................................................... 2 DRUGS TO PREVENT AND TREAT GOUT ................................................................................................................................................. 2 FIBROMYALGIA............................................................................................................................................................................................. 3 MIGRAINE ...................................................................................................................................................................................................... 3 OTHER ........................................................................................................................................................................................................... 3

ANTI-INFECTIVES ................................................................................................................................................................................................... 3 PENICILLINS.................................................................................................................................................................................................. 3 CEPHALOSPORINS ...................................................................................................................................................................................... 3 MACROLIDES ................................................................................................................................................................................................ 3 TETRACYCLINES .......................................................................................................................................................................................... 3 QUINOLONES................................................................................................................................................................................................ 3 AMINOGLYCOSIDES .................................................................................................................................................................................... 3 SULFONAMIDES ........................................................................................................................................................................................... 4 ANTITUBERCULOSIS ................................................................................................................................................................................... 4 ANTIFUNGALS .............................................................................................................................................................................................. 4 ANTIVIRALS................................................................................................................................................................................................... 4 ANTIMALARIALS ........................................................................................................................................................................................... 5 AMEBICIDES ................................................................................................................................................................................................. 5 ANTHELMINTICS........................................................................................................................................................................................... 5 MISCELLANEOUS ANTI-INFECTIVES ......................................................................................................................................................... 5

ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS .......................................................................................................................................... 5 ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS ................................................................................................................................ 5

CARDIOVASCULAR ................................................................................................................................................................................................ 6 CARDIAC GLYCOSIDES ............................................................................................................................................................................... 6 NITRATES ...................................................................................................................................................................................................... 6 BETA-BLOCKERS ......................................................................................................................................................................................... 7 CALCIUM ANTAGONISTS ............................................................................................................................................................................ 7 ANTIDYSRHYTHMIC DRUGS ....................................................................................................................................................................... 7 ANGIOTENSIN CONVERTING ENZYME INHIBITOR .................................................................................................................................. 7 ANTIADRENERGIC AGENTS-CENTRALLY ACTING .................................................................................................................................. 8 ANTIADRENERGIC AGENTS-PERIPHERAL ACTING ................................................................................................................................. 8 ALPHA BLOCKERS ....................................................................................................................................................................................... 8 VASODILATORS............................................................................................................................................................................................ 8 DIURETICS .................................................................................................................................................................................................... 8 CHOLESTEROL LOWERING AGENTS ........................................................................................................................................................ 8 MISCELLANEOUS CARDIOVASCULAR DRUGS ........................................................................................................................................ 9

CENTRAL NERVOUS SYSTEM .............................................................................................................................................................................. 9 ANTIANXIETY DRUGS .................................................................................................................................................................................. 9 ANTIDEPRESSANTS .................................................................................................................................................................................... 9 ANTIMANIA AND MOOD STABILIZER DRUGS ........................................................................................................................................... 9 ANTIPSYCHOTICS ...................................................................................................................................................................................... 10 SEDATIVES & HYPNOTICS ........................................................................................................................................................................ 10 CNS STIMULANTS ...................................................................................................................................................................................... 10 OTHER CNS DRUGS .................................................................................................................................................................................. 10 SMOKING DETERRENTS ........................................................................................................................................................................... 11

EAR, NOSE, AND THROAT MEDICATIONS ........................................................................................................................................................ 11 OTIC STEROID - ANTI-INFECTIVE COMBINATIONS .............................................................................................................................. 11 THROAT MEDICATIONS/ORAL LESIONS/GINGIVITIS ............................................................................................................................. 11



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CORTICOSTEROIDS, INHALED NASAL .................................................................................................................................................... 11 MISCELLANEOUS NASAL .......................................................................................................................................................................... 11

ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 11 SYSTEMIC CORTICOSTEROIDS ............................................................................................................................................................... 11 ANDROGENS .............................................................................................................................................................................................. 11 ESTROGENS ............................................................................................................................................................................................... 11 ESTROGENS/PROGESTIN COMBINATIONS ............................................................................................................................................ 12 ORAL CONTRACEPTIVES .......................................................................................................................................................................... 12 TRANSDERMAL CONTRACEPTIVES ........................................................................................................................................................ 12 VAGINAL CONTRACEPTIVES .................................................................................................................................................................... 12 PROGESTINS .............................................................................................................................................................................................. 12 ORAL HYPOGLYCEMICS ........................................................................................................................................................................... 12 INSULINS & INSULIN TYPE INJECTABLES .............................................................................................................................................. 13 GLUCOSE TEST STRIPS ............................................................................................................................................................................ 13 GLUCAGON ................................................................................................................................................................................................. 13 ANTITHYROID DRUGS ............................................................................................................................................................................... 13 THYROID HORMONES ............................................................................................................................................................................... 13 OTHER ENDOCRINE DRUGS .................................................................................................................................................................... 13

GASTROINTESTINAL ........................................................................................................................................................................................... 13 ANTIDIARRHEAL PREPARATIONS ........................................................................................................................................................... 13 ANTIULCER DRUGS ................................................................................................................................................................................... 13 ANTIEMETICS ............................................................................................................................................................................................. 14 DIGESTANTS............................................................................................................................................................................................... 14 ANTISPASMODICS & DRUGS AFFECTING GI MOTILITY ........................................................................................................................ 14 SULFONAMIDE/MESALAMINE PRODUCTS ............................................................................................................................................. 14 OTHER ......................................................................................................................................................................................................... 14

GENITOURINARY .................................................................................................................................................................................................. 14 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 14 ANTICHOLINERGIC-ANTISPASMODICS ................................................................................................................................................... 15 CHOLINERGIC DRUGS .............................................................................................................................................................................. 15 URINARY ANALGESICS ............................................................................................................................................................................. 15 MISCELLANEOUS GENITOURINARY ........................................................................................................................................................ 15

HEMATOLOGICAL AGENTS ................................................................................................................................................................................ 15 HEMATOPOIETIC ........................................................................................................................................................................................ 15 ANTICOAGULANT DRUGS ......................................................................................................................................................................... 15 ANTIPLATELET DRUGS ............................................................................................................................................................................. 15 OTHER AGENTS ......................................................................................................................................................................................... 15

NEUROMUSCULAR .............................................................................................................................................................................................. 15 ANTICONVULSANTS .................................................................................................................................................................................. 15 ANTIPARKINSON DRUGS .......................................................................................................................................................................... 16 SKELETAL MUSCLE RELAXANTS ............................................................................................................................................................. 16 ANTICHOLINESTERASE MUSCLE STIMULANTS .................................................................................................................................... 16

NUTRITIONAL PRODUCTS .................................................................................................................................................................................. 16 PRENATAL VITAMINS ................................................................................................................................................................................ 16 VITAMINS ..................................................................................................................................................................................................... 16 MINERALS ................................................................................................................................................................................................... 16 POTASSIUM SUPPLEMENTS .................................................................................................................................................................... 17 MISCELLANEOUS NUTRITIONAL .............................................................................................................................................................. 17

OPHTHALMIC MEDICATIONS .............................................................................................................................................................................. 17 ALPHA-ADRENOCEPTOR AGONISTS ...................................................................................................................................................... 17 ALPHA-ADRENOCEPTOR AGONISTS COMBINATIONS ......................................................................................................................... 17 ANTI-INFLAMMATORY AGENTS ................................................................................................................................................................ 17 ANTI-ALLERGIC AGENTS .......................................................................................................................................................................... 17 ANTIMICROBIAL AGENTS .......................................................................................................................................................................... 17 ARTIFICIAL TEAR PRODUCTS/LUBRICANTS .......................................................................................................................................... 18 BETA-ADRENORECEPTOR ANTAGONISTS ............................................................................................................................................ 18 CARBONIC ANHYDRASE INHIBITORS ..................................................................................................................................................... 18 DILATING AGENTS ..................................................................................................................................................................................... 18 MIOTICS ....................................................................................................................................................................................................... 18 PROSTAGLANDINS .................................................................................................................................................................................... 18



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SYMPATHOMIMETICS ................................................................................................................................................................................ 18 RESPIRATORY ...................................................................................................................................................................................................... 19

ANTIHISTAMINES ....................................................................................................................................................................................... 19 ANTITUSSIVES & EXPECTORANTS.......................................................................................................................................................... 19 ANTIASTHMATICS ...................................................................................................................................................................................... 19

TOPICAL ................................................................................................................................................................................................................ 20 ANTI-ACNE MEDICATIONS ........................................................................................................................................................................ 20 ANTIFUNGALS ............................................................................................................................................................................................ 20 ANTI-INFECTIVES ....................................................................................................................................................................................... 20 ANTIPSORIATICS ....................................................................................................................................................................................... 20 CORTICOSTEROIDS .................................................................................................................................................................................. 20 CORTICOSTEROID COMBINATIONS ........................................................................................................................................................ 21 RECTAL ....................................................................................................................................................................................................... 21 SCABICIDES/PEDICULICIDES ................................................................................................................................................................... 21 MISCELLANEOUS ....................................................................................................................................................................................... 21

INDEX ..................................................................................................................................................................................................................... 22



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UHA PREFERRED DRUG LISTING (PDL)

We are pleased to present you with the UHA preferred drug listing. The preferred drug listing is the cornerstone for a progressive program of managed care pharmacotherapy. Prescription drug therapy is an integral component of your patient’s comprehensive treatment program. The preferred drug listing was created to ensure UHA members receive high quality, cost-effective, rational drug therapy.

UHA is responsible for developing and maintaining the preferred drug listing. In making its decisions, UHA utilizes local consultant physicians and pharmacists representing various medical specialties. In addition to clinical considerations, UHA evaluates the cost of treatment of therapeutically equivalent drugs and bioequivalency data provided by the Food and Drug Administration (FDA). With a primary consideration to provide a safe, effective, and comprehensive preferred drug listing, UHA evaluated all therapeutic categories and has selected the most cost effective agent(s) in each class.

The preferred drug listing development and maintenance is a dynamic process. UHA regularly reviews new and existing medications to ensure the preferred drug listing meets the needs of both members and providers.

We invite recommendations and comments on improving the content or format of the preferred drug listing. Physicians may request the addition of a new drug or a review of drugs for inclusion or exclusion from the UHA Preferred Drug Listing by submitting their request to:

UHA Health Care Services

700 Bishop St, Suite 300 Honolulu, HI 96813

COVERED MEDICATIONS

Unless otherwise limited by the plan, all dosage forms and strengths of a listed medication available at the time of printing are covered. In order to reduce the risk of adverse effects to our members, UHA will not cover prescription drugs when prescribed for experimental, investigational, or non-FDA approved indications unless they have sufficient peer-reviewed literature to support their use for the prescribed indication. Drugs that are newly introduced are subject to a review period. Prior to evaluation, these drugs may be not covered, or may be subject to a higher co-payment.

GENERIC MEDICATIONS

UHA encourages the use of generic medications whenever possible and our open formulary includes all generics unless the specific classification of medications is an excluded category, such as weight loss medications. Please note that this Preferred Drug Listing does not list all covered generics. In order to help the Prescriber, the generic medications are listed according to their generic/chemical name as well as their previous “Brand” name. Where only the generic is listed, the Brand has been discontinued, but the generic is available. Boldface type indicates generic availability. It is important to remember that this PDL’s intent is to cover only the generic form of the drugs (cephalexin or “generic of KEFLEX”) and not the Brand forms. There is a higher co-payment for brand-name drugs that have an approved generic available.

LEGEND

boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name

PA Prior Authorization required

**A generic $0 copay will apply to the Brand medications marked with an asterisk (*) under the Value Based Prescription Drug Plan, which can be found on page 19.**



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ANALGESICS

NON-NARCOTIC ANALGESICS

butalbital/acetaminophen/caffeine (generic of ESGIC-PLUS)

butalbital/acetaminophen/caffeine (generic of FIORICET)

butalbital/aspirin/caffeine (generic of FIORINAL)

tramadol HCL (generic of ULTRAM)

NARCOTIC ANALGESICS

acetaminophen/codeine (generic of TYLENOL w/CODEINE)

buprenorphine/naloxone (SUBOXONE)

butalbital/aspirin/caffeine/codeine (generic of FIORINAL/CODEINE)

fentanyl transdermal (generic of DURAGESIC patch)

hydrocodone/acetaminophen (generic of LORCET)

hydrocodone/acetaminophen (generic of LORCET PLUS)

hydrocodone/acetaminophen (generic of VICODIN)

hydrocodone/acetaminophen (generic of VICODIN ES)

hydromorphone (generic of DILAUDID)

methadone (generic of DOLOPHINE)

morphine sulfate

morphine sulfate ext-rel (generic of MS CONTIN)

oxycodone (generic of ROXICODONE)

PA oxycodone ext-rel (OXYCONTIN)

oxycodone/acetaminophen (generic of PERCOCET)

oxycodone/aspirin (generic of PERCODAN)

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (Over the counter strengths are not covered)

celecoxib (CELEBREX)

diclofenac (generic of VOLTAREN)

diclofenac patch (FLECTOR)

diflunisal

flurbiprofen (generic of ANSAID)

ibuprofen (generic of MOTRIN)

indomethacin

ketoprofen

nabumetone

naproxen (generic of NAPROSYN)

naproxen sodium (generic of ANAPROX)

naproxen sodium (generic of ANAPROX DS)

oxaprozin (generic of DAYPRO)

piroxicam (generic of FELDENE)

sulindac

ANTIRHEUMATICS

hydroxychloroquine (generic of PLAQUENIL)

leflunomide (generic of ARAVA)

methotrexate

DRUGS TO PREVENT AND TREAT GOUT

allopurinol (generic of ZYLOPRIM)

PA febuxostat (ULORIC)

colchicine (COLCRYS)

probenecid



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FIBROMYALGIA

milnacipran (SAVELLA)

pregabalin (LYRICA)

MIGRAINE

almotriptan (AXERT)

butalbital/acetaminophen/caffeine (generic of ESGIC-PLUS)

butalbital/aspirin/caffeine (generic of FIORINAL)

eletriptan (RELPAX)

ergoloid mesylates

isometheptene/dichloralphenazone/acetaminophen

naratriptan (generic of AMERGE)

rizatriptan dispersible tabs (MAXALT-MLT)

sumatriptan (generic of IMITREX)

OTHER

lidocaine HCl patch (LIDODERM)

ANTI-INFECTIVES

PENICILLINS

amoxicillin

amoxicillin/potassium clavulanate (generic of AUGMENTIN)

ampicillin

cloxacillin (generic of CLOXAPEN)

dicloxacillin

oxacillin

penicillin VK

CEPHALOSPORINS

cefaclor

cefaclor ext-rel (CEFACLOR ER)

cefadroxil

cefuroxime (generic of CEFTIN)

cephalexin (generic of KEFLEX)

cephradine

MACROLIDES

azithromycin (generic of ZITHROMAX)

erythromycin base (enteric coated) (ERY-TAB)

erythromycin estolate

erythromycin ethylsuccinate (generic of E.E.S.)

erythromycin stearate (generic of ERYTHROCIN)

TETRACYCLINES

doxycycline (generic of VIBRAMYCIN)

minocycline (generic of MINOCIN)

tetracycline

QUINOLONES

ciprofloxacin (generic of CIPRO)

moxifloxacin (AVELOX)

AMINOGLYCOSIDES

neomycin



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SULFONAMIDES

sulfamethoxazole/trimethoprim (generic of BACTRIM)

sulfamethoxazole/trimethoprim (generic of SEPTRA)

sulfisoxazole/erythromycin

ANTITUBERCULOSIS

ethambutol (generic of MYAMBUTOL)

isoniazid

pyrazinamide

rifampin (generic of RIFADIN)

ANTIFUNGALS

clotrimazole (generic of MYCELEX)

fluconazole (generic of DIFLUCAN)

griseofulvin ultramicrosize (GRIS-PEG)

ketoconazole (generic of NIZORAL)

nystatin (generic of MYCOSTATIN)

terbinafine tabs (generic of LAMISIL)

ANTIVIRALS Treatment of HIV

abacavir/lamivudine (EPZICOM)

abacavir/lamivudine/zidovudine (TRIZIVIR)

atazanavir (REYATAZ)

darunavir (PREZISTA)

delavirdine (RESCRIPTOR)

didanosine delayed-rel (generic of VIDEX EC)

didanosine soln (VIDEX soln)

efavirenz (SUSTIVA)

emtricitabine (EMTRIVA)

emtricitabine/rilpivirine/tenovir (COMPLERA)

emtricitabine/tenovir/efavirenz (ATRIPLA)

etravirine (INTELENCE)

fosamprenavir (LEXIVA)

indinavir (CRIXIVAN)

lamivudine (EPIVIR)

lamivudine/zidovudine (COMBIVIR)

lopinavir/ritonavir (KALETRA)

maraviroc (SELZENTRY)

nelfinavir mesylate (VIRACEPT)

nevirapine (VIRAMUNE)

raltegravir (ISENTRESS)

rilpivirine (EDURANT)

ritonavir (NORVIR)

saquinavir (INVIRASE)

stavudine (generic of ZERIT)

tenofovir (VIREAD)

tenofovir/emtricitabine (TRUVADA)

tipranavir (APTIVUS)

zidovudine (generic of RETROVIR)

Treatment of Hepatitis B

adefovir (HEPSERA)

entecavir (BARACLUDE)

lamivudine (EPIVIR HBV)



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PA telbivudine (TYZEKA)

Treatment of Hepatitis C

PA telaprevir (INCIVEK)

ribavirin (generic of COPEGUS/REBETOL)

Treatment of Herpes Simplex

acyclovir (generic of ZOVIRAX)

famciclovir (generic of FAMVIR)

valacyclovir (generic of VALTREX)

Treatment of Influenza

amantadine

oseltamivir (TAMIFLU)

rimantadine (generic of FLUMADINE)

zanamivir (RELENZA)

ANTIMALARIALS

atovaquone/proguanil (generic of MALARONE)

chloroquine (generic of ARALEN)

hydroxychloroquine (generic of PLAQUENIL)

mefloquine (generic of LARIAM)

AMEBICIDES

iodoquinol (YODOXIN)

tinidazole (TINDAMAX)

ANTHELMINTICS

mebendazole

praziquantel (BILTRICIDE)

MISCELLANEOUS ANTI-INFECTIVES

clindamycin (generic of CLEOCIN)

dapsone

metronidazole (generic of FLAGYL)

nitrofurantoin (generic of MACRODANTIN)

trimethoprim

ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS

All FDA-Approved, non-injectable Antineoplastics and Immunosuppressants are eligible for coverage provided that they are listed in the Compendia-Based Drug Bulletin as an indication for treatment of a specific neoplasm. The listing can be found at http://www.nccn.org/professionals/drug_compendium/content/contents.asp ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS

altretamine (HEXALEN)

anastrozole (generic of ARIMIDEX)

azathioprine (generic of IMURAN)

bexarotene caps (TARGRETIN caps)

bicalutamide (generic of CASODEX)

busulfan (MYLERAN)

capecitabine (XELODA)

chlorambucil (LEUKERAN)

PA crizotinib (XALKORI)

cyclophosphamide



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dasatinib (SPRYCEL)

PA erlotinib (TARCEVA)

estramustine (EMCYT)

etoposide

PA everolimus (AFINITOR)

exemestane (generic of AROMASIN)

flutamide

hydroxyurea (generic of HYDREA)

PA imatinib (GLEEVEC)

PA lapatinib (TYKERB)

PA lenalidomide (REVLIMID)

letrozole (generic of FEMARA)

leucovorin CA tabs

lomustine (CEENU)

megestrol (generic of MEGACE)

melphalan (ALKERAN)

mercaptopurine (generic of PURINETHOL)

methotrexate (TREXALL)

mesna tabs (MESNEX)

mitotane (LYSODREN)

mycophenolate mofetil (generic of CELLCEPT)

PA nilotinib (TASIGNA)

nilutamide (NILANDRON)

PA pazopanib (VOTRIENT)

procarbazine (MATULANE)

PA sorafenib (NEXAVAR)

PA sunitinib (SUTENT)

tamoxifen

temozolomide (TEMODAR)

PA thalidomide (THALOMID)

thioguanine (TABLOID)

PA topotecan caps (HYCAMTIN caps)

toremifene citrate (FARESTON)

tretinoin

PA vandetanib (CAPRELSA)

PA vorinostat (ZOLINZA)

CARDIOVASCULAR

CARDIAC GLYCOSIDES

digoxin

NITRATES

isosorbide dinitrate (generic of ISORDIL, excluding TEMBIDS)

isosorbide monohydrate (generic of IMDUR)

isosorbide monohydrate (generic of ISMO)

isosorbide monohydrate (generic of MONOKET)

nitroglycerin (generic of NITROSTAT)

nitroglycerin ext-rel

nitroglycerin oint (NITRO-BID)

nitroglycerin patch (generic of NITRO-DUR)

nitroglycerin sublingual spray (NITROLINGUAL spray)



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BETA-BLOCKERS Beta-1 Specific

atenolol (generic of TENORMIN)

atenolol/chlorthalidone (generic of TENORETIC)

bisoprolol (generic of ZEBETA)

bisoprolol/hydrochlorothiazide (generic of ZIAC)

metoprolol (generic of LOPRESSOR)

metoprolol ext-rel (generic of TOPROL-XL)

metoprolol tartrate/hydrochlorothiazide (generic of LOPRESSOR HCT)

Non-Selective

carvedilol (generic of COREG)

carvedilol phosphate ext-rel (COREG CR)

nadolol (generic of CORGARD)

pindolol

propranolol

propranolol ext-rel (generic of INDERAL LA)

CALCIUM ANTAGONISTS

amlodipine (generic of NORVASC)

diltiazem ext-rel (generic of DILACOR XR)

diltiazem ext-rel (generic of TIAZAC)

nifedipine ext-rel (generic of ADALAT CC)

verapamil (generic of CALAN)

verapamil ext-rel (generic of CALAN SR)

ANTIDYSRHYTHMIC DRUGS

amiodarone (generic of CORDARONE)

disopyramide (generic of NORPACE)

disopyramide ext-rel (generic of NORPACE CR)

dronedarone (MULTAQ)

flecainide (generic of TAMBOCOR)

propafenone (generic of RYTHMOL)

sotalol HCL (generic of BETAPACE AF)

ANGIOTENSIN CONVERTING ENZYME INHIBITOR Angiotensin Converting Enzyme Inhibitors

benazepril (generic of LOTENSIN)

captopril (generic of CAPOTEN)

enalapril (generic of VASOTEC)

fosinopril (generic of MONOPRIL)

lisinopril (generic of ZESTRIL)

moexipril (generic of UNIVASC)

perindopril (generic of ACEON)

quinapril (generic of ACCUPRIL)

ramipril (generic of ALTACE)

trandolapril (generic of MAVIK)

Angiotensin Converting Enzyme Inhibitor Combinations

benazepril/hydrochlorothiazide (generic of LOTENSIN HCT)

captopril/hydrochlorothiazide (generic of CAPOZIDE)

enalapril/hydrochlorothiazide (generic of VASERETIC)

fosinopril/hydrochlorothiazide (generic of MONOPRIL-HCT)

lisinopril/hydrochlorothiazide (generic of ZESTORETIC)

quinapril/hydrochlorothiazide (generic of ACCURETIC)



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Angiotensin II Antagonists (ARBs)

irbesartan (AVAPRO)

losartan (generic of COZAAR)

olmesartan (BENICAR)

valsartan (DIOVAN)

Angiotensin II Antagonist Combinations

amlodipine/olmesartan (AZOR)

irbesartan/hydrochlorothiazide (AVALIDE)

losartan/hydrochlorothiazide (generic of HYZAAR)

olmesartan/hydrochlorothiazide (BENICAR HCT)

valsartan/hydrochlorothiazide (DIOVAN HCT)

ANTIADRENERGIC AGENTS-CENTRALLY ACTING

clonidine tabs (generic of CATAPRES)

guanabenz acetate

guanfacine (generic of TENEX)

methyldopa

ANTIADRENERGIC AGENTS-PERIPHERAL ACTING

prazosin (generic of MINIPRESS)

terazosin

ALPHA BLOCKERS

phenoxybenzamine (DIBENZYLINE)

VASODILATORS

hydralazine

DIURETICS Loop Diuretics

bumetanide

furosemide (generic of LASIX)

torsemide (generic of DEMADEX)

Thiazides and Related Diuretics

chlorthalidone

hydrochlorothiazide

indapamide

methyclothiazide

metolazone (generic of ZAROXOLYN)

Potassium Sparing Diuretics

amiloride/hydrochlorothiazide

spironolactone (generic of ALDACTONE)

spironolactone/hydrochlorothiazide (generic of ALDACTAZIDE)

triamterene/hydrochlorothiazide (generic of DYAZIDE)

triamterene/hydrochlorothiazide (generic of MAXZIDE)

Carbonic Anhydrase Inhibitors

acetazolamide

methazolamide

CHOLESTEROL LOWERING AGENTS HMG-CoA Reductase Inhibitors

atorvastatin (generic of LIPITOR)



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lovastatin (generic of MEVACOR)

pravastatin (generic of PRAVACHOL)

rosuvastatin (CRESTOR)

simvastatin (generic of ZOCOR)

Other Cholesterol Lowering Agents

cholestyramine aspartame (generic of QUESTRAN LIGHT)

cholestyramine sucrose (generic of QUESTRAN)

ezetimibe (ZETIA)

gemfibrozil (generic of LOPID)

niacin timed release (NIASPAN)

MISCELLANEOUS CARDIOVASCULAR DRUGS

enoxaparin ( generic of LOVENOX)

pentoxifylline (generic of TRENTAL)

CENTRAL NERVOUS SYSTEM

ANTIANXIETY DRUGS

alprazolam (generic of XANAX)

buspirone (generic of BUSPAR)

chlordiazepoxide (generic of LIBRIUM)

clonazepam (generic of KLONOPIN)

clorazepate (generic of TRANXENE)

diazepam (generic of VALIUM)

lorazepam (generic of ATIVAN)

oxazepam

ANTIDEPRESSANTS

amitriptyline

amoxapine

bupropion (generic of WELLBUTRIN)

bupropion ext-rel (generic of WELLBUTRIN SR)

bupropion ext-rel (generic of WELLBUTRIN XL)

clomipramine (generic of ANAFRANIL)

desipramine (generic of NORPRAMIN)

doxepin

duloxetine HCL (CYMBALTA)

escitalopram (LEXAPRO)

fluoxetine (generic of PROZAC)

fluoxetine (generic of SARAFEM)

imipramine (generic of TOFRANIL)

maprotiline

mirtazapine (generic of REMERON)

nortriptyline (generic of PAMELOR)

paroxetine HCl ext-rel (generic of PAXIL CR)

protriptyline (generic of VIVACTIL)

sertraline (generic of ZOLOFT)

trazodone

venlafaxine (generic of EFFEXOR)

venlafaxine ext-rel (generic of EFFEXOR XR)

ANTIMANIA AND MOOD STABILIZER DRUGS

carbamazepine (generic of TEGRETOL)

carbamazepine ext-rel (generic of TEGRETOL-XR)



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divalproex sodium delayed-rel (generic of DEPAKOTE)

divalproex sodium ext-rel (generic of DEPAKOTE ER)

lamotrigine (generic of LAMICTAL)

lithium

ANTIPSYCHOTICS

aripiprazole (ABILIFY)

chlorpromazine

fluphenazine

fluphenazine decanoate

haloperidol

haloperidol decanoate (generic of HALDOL DECANOATE)

olanzapine (ZYPREXA)

paliperidone ext-rel (INVEGA)

perphenazine

quetiapine (SEROQUEL)

quetiapine ER (SEROQUEL XR)

risperidone (generic of RISPERDAL)

risperidone orally disintegrating tab (generic of RISPERDAL- M)

thioridazine

thiothixene (generic of NAVANE)

trifluoperazine

ziprasidone (GEODON)

SEDATIVES & HYPNOTICS

estazolam

flurazepam

ramelteon (ROZEREM)

temazepam (generic of RESTORIL)

triazolam (generic of HALCION)

zaleplon (generic of SONATA)

zolpidem (generic of AMBIEN)

zolpidem CR (generic of AMBIEN CR)

CNS STIMULANTS

amphetamine/dextroamphetamine mixed salts (generic of ADDERALL)

amphetamine/dextroamphetamine mixed salts ext-rel (generic of ADDERALL XR)

dextroamphetamine (generic of DEXEDRINE)

dextroamphetamine ext-rel (generic of DEXEDRINE SPANSULE)

methylphenidate (generic of RITALIN)

methylphenidate HCL (CONCERTA)

methylphenidate HCL (METADATE CD)

OTHER CNS DRUGS

disulfiram (generic of ANTABUSE)

donepezil HCL 23 mg tabs ONLY (ARICEPT)

galantamine (generic of RAZADYNE)

galantamine ext-rel (generic of RAZADYNE ER)

memantine (NAMENDA)

rivastigmine tartrate caps (generic of EXELON caps)

rivastigmine tartrate (EXELON patch, soln)



11

SMOKING DETERRENTS Coverage for Nicotine Replacement Therapy, such as patches, gums, lozenges, etc. are based on plan design. Refer to the member benefit guide for more information.

bupropion ext-rel (generic of ZYBAN)

varenicline (CHANTIX)

EAR, NOSE, AND THROAT MEDICATIONS

OTIC STEROID-ANTI-INFECTIVE COMBINATIONS

acetic acid

ciprofloxacin/dexamethasone otic (CIPRODEX)

ciprofloxacin/hydrocortisone otic (CIPRO HC)

hydrocortisone/neo/polymyxin B (generic of CORTISPORIN OTIC)

ofloxacin otic (generic of FLOXIN OTIC)

THROAT MEDICATIONS/ORAL LESIONS/GINGIVITIS

chlorhexidine gluconate (generic of PERIDEX)

clotrimazole (generic of MYCELEX)

lidocaine viscous

nystatin suspension (generic of MYCOSTATIN)

triamcinolone paste

CORTICOSTEROIDS, INHALED NASAL

flunisolide (generic of NASAREL)

fluticasone (generic of FLONASE)

triamcinolone (generic of NASACORT AQ)

MISCELLANEOUS NASAL

azelastine (generic of ASTELIN nasal spray)

ipratropium bromide 0.03% nasal spray (generic of ATROVENT)

ENDOCRINE AND METABOLIC

SYSTEMIC CORTICOSTEROIDS Glucocorticosteroids

dexamethasone

hydrocortisone

methylprednisolone (generic of MEDROL)

prednisolone

prednisolone syrup (generic of PRELONE)

prednisone

Mineralocorticoids

fludrocortisone

ANDROGENS

PA fluoxymesterone (ANDROXY)

PA testosterone gel (ANDROGEL, TESTIM)

PA testosterone transdermal (ANDRODERM)

ESTROGENS

estradiol (generic of ESTRACE)

estradiol transdermal (generic of CLIMARA)

estradiol transdermal (ESTRADERM)

estrogens, conjugated (PREMARIN)



12

ESTROGENS/PROGESTIN COMBINATIONS

estrogens, conjugated/medroxyprogesterone (PREMPHASE)

estrogens, conjugated/medroxyprogesterone (PREMPRO)

ORAL CONTRACEPTIVES Monophasic Oral Contraceptives

drospirenone/ethinyl estradiol (generic of YASMIN)

ethinyl estradiol/desogestrel (generic of DESOGEN)

ethinyl estradiol/norethindrone (generic of LOESTRIN FE)

ethinyl estradiol/norethindrone (generic of ORTHO-NOVUM 1/35)

ethinyl estradiol/norethindrone (generic of ORTHO-NOVUM 1/50)

levonorgestrel/ethinyl estradiol (generic of NORDETTE)

Biphasic Oral Contraceptives

ethinyl estradiol/desogestrel (generic of MIRCETTE)

Triphasic Oral Contraceptives

norethindrone/ethinyl estradiol (generic of ORTHO-NOVUM 7/7/7)

norethindrone/ethinyl estradiol (generic of TRI-NORINYL)

Progestin Only Oral Contraceptives

levonorgestrel (generic of PLAN B)

norethindrone (generic of ORTHO-MICRONOR)

TRANSDERMAL CONTRACEPTIVES

norelgestromin-ethinyl estradiol (ORTHO EVRA)

VAGINAL CONTRACEPTIVES

estradiol (ESTRING)

etonogestrel-ethinyl estradiol (NUVARING)

PROGESTINS

medroxyprogesterone (generic of PROVERA)

progesterone, micronized (PROMETRIUM)

ORAL HYPOGLYCEMICS

acarbose (generic of PRECOSE)

glimepiride (generic of AMARYL)

glipizide (generic of GLUCOTROL)

glipizide/metformin (generic of METAGLIP)

glyburide (generic of GLYNASE)

metformin (generic of GLUCOPHAGE)

metformin ext-rel (generic of GLUCOPHAGE XR)

pioglitazone (ACTOS)

pioglitazone/glimepiride (DUETACT)

pioglitazone/metformin (ACTOPLUS MET)

repaglinide (PRANDIN)

saxagliptin (ONGLYZA)

saxagliptin/metformin (KOMBIGLYZE XR)

sitagliptin (JANUVIA)

sitagliptin/metformin (JANUMET)

tolazamide

tolbutamide



13

INSULINS & INSULIN TYPE INJECTABLES This includes the mix, pens & vials.

exenatide (BYETTA)

insulin aspart (NOVOLOG)

insulin glargine (APIDRA)

insulin glargine (LANTUS)

insulin lispro (HUMALOG)

insulin/recom (HUMULIN)

insulin/recom (NOVOLIN)

liraglutide (VICTOZA)

pramlintide acetate (SYMLIN)

GLUCOSE TEST STRIPS

glucose test strips ALL BRANDS OF GLUCOMETERS AND TEST STRIPS ARE PREFERRED

GLUCAGON

glucagon (GLUCAGON EMERGENCY KIT)

ANTITHYROID DRUGS

methimazole (generic of TAPAZOLE)

propylthiouracil

THYROID HORMONES

levothyroxine (generic of LEVOTHROID)

levothyroxine (generic of LEVOXYL)

levothyroxine (generic of SYNTHROID)

liothyronine (generic of CYTOMEL)

OTHER ENDOCRINE DRUGS

alendronate (generic of FOSAMAX)

bromocriptine (generic of PARLODEL)

cabergoline (generic of DOSTINEX)

desmopressin (generic of DDAVP)

ibandronate (BONIVA 150 mg tab only)

raloxifene (EVISTA)

risedronate (ACTONEL)

GASTROINTESTINAL

ANTIDIARRHEAL PREPARATIONS Consider OTC Imodium as first line therapy

diphenoxylate/atropine (generic of LOMOTIL)

ANTIULCER DRUGS H2 Antagonists (Over the counter strengths are not covered)

cimetidine (generic of TAGAMET)

famotidine (generic of PEPCID)

nizatidine (generic of AXID)

ranitidine (generic of ZANTAC)

H. pylori treatments

bismuth subcitrate potassium+ metronidazole + tetracycline (PYLERA)

lansoprazole + amoxicillin + clarithromycin (PREVPAC)



14

Other anti-ulcer products

misoprostol (generic of CYTOTEC)

omeprazole (generic of PRILOSEC)

sucralfate (generic of CARAFATE)

ANTIEMETICS

aprepitant (EMEND)

granisetron (generic of KYTRIL)

meclizine (generic of ANTIVERT)

ondansetron (generic of ZOFRAN)

ondansetron orally disintegrating tabs (generic of ZOFRAN ODT)

prochlorperazine

promethazine

trimethobenzamide (generic of TIGAN)

DIGESTANTS

lipase/protease/amylase (CREON)

lipase/protease/amylase (PANCREAZE)

lipase/protease/amylase (ZENPEP)

ANTISPASMODICS & DRUGS AFFECTING GI MOTILITY

belladonna alkaloids/phenobarbital (generic of DONNATAL)

chlordiazepoxide/clidinium (generic of LIBRAX)

constulose

dicyclomine (generic of BENTYL)

enulose

hyoscyamine sulfate (generic of LEVSIN)

hyoscyamine sulfate (generic of LEVSIN-SL)

lactulose

metoclopramide (generic of REGLAN)

osmotic laxative (generic of SORBITOL SOLUTION 70 %)

PEG Solution (generic of COLYTE)

SULFONAMIDE/MESALAMINE PRODUCTS

balsalazide

budesonide (generic of ENTOCORT EC)

mesalamine delayed-rel tabs (ASACOL)

mesalamine delayed-rel tabs 800 mg (ASACOL HD)

mesalamine ext-rel caps (PENTASA)

mesalamine rectal susp (generic of ROWASA)

olsalazine sodium (DIPENTUM)

sulfasalazine (generic of AZULFIDINE)

OTHER

ursodiol (generic of URSO)

GENITOURINARY

VAGINAL ANTI-INFECTIVES OTC products may be used as first line therapy

clindamycin (generic of CLEOCIN VAGINAL CREAM)

fluconazole susp and tabs (generic of DIFLUCAN)

metronidazole gel (generic of METROGEL-VAGINAL)

miconazole (generic of MONISTAT)




15

terconazole vag cream (generic of TERAZOL 3)

ANTICHOLINERGIC-ANTISPASMODICS

flavoxate HCL (generic of URISPAS)

oxybutynin

oxybutynin ext-rel (generic of DITROPAN XL)

propantheline (generic of PRO-BANTHINE)

solifenacin succinate (VESICARE)

tolterodine ext-rel (DETROL LA)

CHOLINERGIC DRUGS

bethanechol (generic of URECHOLINE)

URINARY ANALGESICS

methylene blue (generic of PROSED)

phenazopyridine (generic of PYRIDIUM)

MISCELLANEOUS GENITOURINARY

alfuzosin HCl (generic of UROXATRAL)

doxazosin (generic of CARDURA)

dutasteride (AVODART)

finasteride (generic of PROSCAR)

imipramine (generic of TOFRANIL)

tamsulosin (generic of FLOMAX)

terazosin

HEMATOLOGICAL AGENTS

HEMATOPOIETIC

folic acid

B-12/vit C/folic acid/iron/succinic acid (FERREX 150 FORTE PLUS)

leucovorin calcium (folinic acid)

vitamin A caps

ANTICOAGULANT DRUGS

dabigatran (PRADAXA)

warfarin (generic of COUMADIN)

ANTIPLATELET DRUGS

clopidogrel (generic of PLAVIX)

dipyridamole (generic of PERSANTINE)

prasugrel (EFFIENT)

OTHER AGENTS

PA deferasirox (EXJADE)

PA eltrombopag (PROMACTA)

NEUROMUSCULAR

ANTICONVULSANTS

carbamazepine (generic of TEGRETOL)

carbamazepine ext-rel (generic of TEGRETOL-XR)

clonazepam (generic of KLONOPIN)

divalproex sodium delayed-rel (generic of DEPAKOTE)

divalproex sodium ext-rel (generic of DEPAKOTE ER)

ethosuximide (generic of ZARONTIN)



16

gabapentin (generic of NEURONTIN)

lacosamide (VIMPAT)

lamotrigine (generic of LAMICTAL)

levetiracetam (generic of KEPPRA)

oxcarbazepine (generic of TRILEPTAL)

phenobarbital

phenytoin (generic of DILANTIN)

pregabalin (LYRICA)

primidone (generic of MYSOLINE)

topiramate (generic of TOPAMAX)

valproic acid (generic of DEPAKENE)

zonisamide (generic of ZONEGRAN)

ANTIPARKINSON DRUGS

amantadine

benztropine

bromocriptine (generic of PARLODEL)

carbidopa/levodopa (generic of PARCOPA)

carbidopa/levodopa (generic of SINEMET)

carbidopa/levodopa ext-rel (generic of SINEMET CR)

carbidopa/levodopa/entacapone (STALEVO)

entacapone (COMTAN)

pramipexole (generic of MIRAPEX)

rasagiline mesylate (AZILECT)

ropinirole (generic of REQUIP)

selegiline (generic of ELDEPRYL)

trihexyphenidyl

SKELETAL MUSCLE RELAXANTS

baclofen

carisoprodol (generic of SOMA)

chlorzoxazone

cyclobenzaprine (generic of FLEXERIL)

metaxalone (generic of SKELAXIN)

methocarbamol (generic of ROBAXIN)

tizanidine (generic of ZANAFLEX)

ANTICHOLINESTERASE MUSCLE STIMULANTS

pyridostigmine (generic of MESTINON)

NUTRITIONAL PRODUCTS

PRENATAL VITAMINS

NEXA SELECT

PREFERA OB

PREFERA OB ONE

PREFEREA OB + DHA

PRENEXA

VITAMINS

multivitamins/fluoride

MINERALS

sodium fluoride drops (generic of LURIDE drops)

sodium fluoride tabs (generic of LURIDE tabs)



17

POTASSIUM SUPPLEMENTS

potassium chloride effervescent tablet

potassium chloride liquid

potassium chloride tablet

potassium chloride tablet (generic of K-TABS)

MISCELLANEOUS NUTRITIONAL

levocarnitine (generic of CARNITOR)

OPHTHALMIC MEDICATIONS

ALPHA-ADRENOCEPTOR AGONISTS

brimonidine 0.1% (ALPHAGAN P 0.1%)

brimonidine 0.15% (generic of ALPHAGAN P)

brimonidine 0.2%

ALPHA-ADRENOCEPTOR AGONISTS COMBINATIONS

brimonidine/timolol (COMBIGAN)

ANTI-INFLAMMATORY AGENTS Corticosteroids

dexamethasone

fluorometholone (FML)

fluorometholone (FML FORTE)

loteprednol etabonate (LOTEMAX)

prednisolone acetate 0.12% (PRED MILD)

prednisolone acetate 1% (generic of PRED FORTE)

rimexolone (VEXOL)

Non-steroidal Anti-inflammatory Drugs

diclofenac sodium (generic of VOLTAREN)

flurbiprofen (generic of OCUFEN)

ANTI-ALLERGIC AGENTS

loteprednol etabonate (ALREX)

olopatadine HCL (PATADAY, PATANOL)

ANTIMICROBIAL AGENTS Antibiotics and Antibiotic Combinations

azithromycin (AZASITE)

bacitracin 500 units/g

bacitracin/polymyxin B

chloramphenicol (generic of CHLOROPTIC)

ciprofloxacin ophth oint (CILOXAN ophth oint)

ciprofloxacin ophth soln (generic of CILOXAN)

erythromycin oint

gentamicin

moxifloxacin (VIGAMOX)

neomycin/polymyxin B/gramicidin (generic of NEOSPORIN)

sulfacetamide solution and ointment (generic of BLEPH-10)

tobramycin (generic of TOBREX)

trimethoprim/polymyxin B 10000 units/mL (generic of POLYTRIM)



18

Antibiotic-Corticosteroid Combinations

neomycin/dexamethasone

neomycin/polymyxin B/bacitracin/hydrocortisone (generic of CORTISPORIN)

neomycin/polymyxin B/bacitracin/hydrocortisone oint (generic of CORTISPORIN)

neomycin/polymyxin B/dexamethasone (generic of MAXITROL)

prednisolone acetate and sulfacetamide sodium 10% suspension and ointment (BLEPHAMIDE)

prednisolone and gentamicin sulfate ointment (PRED-G SOP)

tobramycin/dexamethasone oint (TOBRADEX oint)

tobramycin/dexamethasone susp (generic of TOBRADEX susp)

Antifungals

natamycin (NATACYN)

Antivirals

ganciclovir opthal (ZIRGAN)

trifluridine (generic of VIROPTIC)

ARTIFICIAL TEAR PRODUCTS/LUBRICANTS

cyclosporine, emulsion (RESTASIS)

BETA-ADRENORECEPTOR ANTAGONISTS

betaxolol solution

betaxolol suspension (BETOPTIC S)

levobunolol (generic of BETAGAN)

timolol maleate gel (generic of TIMOPTIC-XE)

timolol maleate solution (generic of TIMOPTIC)

CARBONIC ANHYDRASE INHIBITORS Note: Carbonic Anhydrase Inhibitors are not considered first-line agents for the treatment of glaucoma

dorzolamide (generic of TRUSOPT)

dorzolamide/timolol maleate (generic of COSOPT)

DILATING AGENTS Anticholinergic

atropine

cyclopentolate (generic of CYCLOGYL)

dipivefrin

homatropine (generic of ISOPTO HOMATROPINE)

tropicamide (generic of MYDRIACYL)

Sympathomimetic

phenylephrine (generic of NEO-SYNEPHRINE)

MIOTICS

carbachol (ISOPTO CARBACHOL)

pilocarpine hydrochloride opth

PROSTAGLANDINS

bimatoprost (LUMIGAN)

latanoprost (generic of XALATAN)

travoprost (TRAVATAN)

SYMPATHOMIMETICS

dipivefrin (generic of PROPINE)



19

epinephrine (generic of EPIFRIN)

RESPIRATORY

ANTIHISTAMINES Consider OTC products as first line therapy as prescription antihistamines are nonpreferred. Oral

cyproheptadine (generic of PERIACTIN)

hydroxyzine HCl

hydroxyzine pamoate (generic of VISTARIL)

ANTITUSSIVES & EXPECTORANTS

benzonatate

codeine/chlorpheniramine/pseudoephedrine

codeine/guaifenesin liquid

codeine/phenylephrine/promethazine

codeine/promethazine

dextromethorphan/brompheniramine/pseudoephedrine

dextromethorphan/chlorpheniramine/phenylephrine

dextromethorphan/promethazine

guaifenesin

phenylephrine/promethazine

ANTIASTHMATICS Adrenergic Stimulants-Inhalers

albuterol sulfate, CFC-free aerosol (VENTOLIN HFA, PROAIR HFA)*

formoterol (FORADIL)

pirbuterol (MAXAIR AUTOHALER)

salmeterol (SEREVENT)

Adrenergic Stimulants-Solutions

albuterol

Adrenergic Stimulants-Oral Tabs

albuterol

albuterol ext-rel (generic of VOSPIRE ER)

Xanthine Derivatives

theophylline (THEO-24)

theophylline ext-rel

theophylline ext-rel tabs (generic of UNIPHYL)

Corticosteroids for Inhalation

beclomethasone, CFC-free aerosol (QVAR)*

fluticasone (FLOVENT)*

mometasone (ASMANEX)*

Other Drugs for Asthma

albuterol/ipratropium (COMBIVENT)

budesonide/formoterol (SYMBICORT)

ipratropium, CFC-free aerosol (ATROVENT HFA)

montelukast (SINGULAIR)

salmeterol/fluticasone (ADVAIR)

tiotropium (SPIRIVA)



20

TOPICAL

ANTI-ACNE MEDICATIONS

adapalene cream and gel 0.1% (generic for DIFFERIN)

adapalene gel 0.3%, lotion 0.1% (DIFFERIN)

benzoyl peroxide gel (generic of DESQUAM-E)

clindamycin (generic of CLEOCIN T)

dapsone gel (ACZONE)

erythromycin topical solution (generic of ERYCETTE)

erythromycin topical solution (generic of T-STAT)

erythromycin/benzoyl peroxide gel (generic of BENZAMYCIN)

isotretinoin oral

tazarotene cream, gel (TAZORAC)

tretinoin topical (generic of RETIN-A)

ANTIFUNGALS

ciclopirox suspension (generic of LOPROX SUSPENSION)

clotrimazole

econazole

ketoconazole (generic of NIZORAL)


terbinafine cream 1% (generic of LAMISIL AT)

ANTI-INFECTIVES

gentamicin

metronidazole gel 1% (METROGEL)

mupirocin cream (BACTROBAN cream)

mupirocin ointment (generic of BACTROBAN)

retapamulin (ALTABAX)

silver sulfadiazine (generic of SILVADENE)

ANTIPSORIATICS

anthralin (DRITHOCREME)

calcipotriene (generic of DOVONEX)

tazarotene gel (TAZORAC)

CORTICOSTEROIDS Low Potency

alclometasone crm, oint 0.05% (generic of ACLOVATE)

desonide crm, oint 0.05% (generic of TRIDESILON)

hydrocortisone crm 2.5%

Medium Potency

betamethasone valerate

betamethasone valerate foam 0.12% (LUXIQ)

desonide foam 0.05% (VERDESO)

desoximetasone cream 0.05% (generic of TOPICORT LP)

fluocinolone acetonide crm, oint 0.025%

fluticasone propionate crm 0.05%, oint 0.005% (generic of CUTIVATE)

hydrocortisone valerate crm, oint 0.2% (generic of WESTCORT)

mometasone crm, lotion, oint 0.1% (generic of ELOCON)

triamcinolone acetonide crm, lotion 0.025%

triamcinolone acetonide crm, lotion, oint 0.1%



21

High Potency

betamethasone dipropionate (generic of DIPROSONE)

betamethasone dipropionate augmented crm 0.05% (generic of DIPROLENE AF)

betamethasone dipropionate augmented lotion 0.05% (generic of DIPROLENE)

desoximetasone crm, oint 0.25%, gel 0.05% (generic of TOPICORT)

fluocinonide crm, gel, oint, soln 0.05% (generic of LIDEX)

halcinonide crm, oint 0.1% (HALOG)

Very High Potency

betamethasone dipropionate augmented gel, oint 0.05% (generic of DIPROLENE)

clobetasol propionate crm, gel, lotion, oint 0.05% (generic of TEMOVATE)

clobetasol propionate foam 0.05% (generic of OLUX)

clobetasol propionate lotion, shampoo, spray 0.05% (CLOBEX)

halobetasol propionate crm, oint 0.05% (generic of ULTRAVATE)

CORTICOSTEROID COMBINATIONS

hydrocortisone/pramoxine (EPIFOAM)

RECTAL

hydrocortisone (generic of ANUSOL-HC 2.5%)

hydrocortisone acetate supp (generic of ANUSOL-HC)

hydrocortisone intrarectal foam (CORTIFOAM)

hydrocortisone retention enema (generic of CORTENEMA)

hydrocortisone/pramoxine (generic of ANALPRAM-HC)

hydrocortisone/pramoxine (PROCTOFOAM-HC)

SCABICIDES/PEDICULICIDES Treatment of choice is OTC Nix

ivermectin (STROMECTOL)

permethrin (generic of ELIMITE)

MISCELLANEOUS

aluminum chloride (generic of DRYSOL)

fluorouracil (generic of EFUDEX)

imiquimod (generic of ALDARA)

pimecrolimus (ELIDEL)

podofilox gel ONLY (CONDYLOX)

urea cream



22

INDEX

A abacavir/lamivudine, abacavir/lamivudine/zidovudine, 4 ABILIFY, 10 acarbose, 12 ACCU-CHEK, 13 ACCUPRIL, 7 ACCURETIC, 7 ACEON, 7 acetaminophen/codeine, 2 acetazolamide, 8 acetic acid, 11 ACLOVATE, 20 ACTONEL, 13 ACTOPLUS MET, 12 ACTOS, 12 acyclovir, 5 ACZONE, 20 ADALAT CC, 7 adapalene, 20 ADDERALL, 10 ADDERALL XR, 10 adefovir, 4 ADVAIR, 19 AFINITOR, 6 albuterol, 19 albuterol ext-rel, 19 albuterol sulfate, CFC-free aerosol, 18 albuterol/ipratropium, 19 alclometasone crm, oint 0.05%, 20 ALDACTAZIDE, 8 ALDACTONE, 8 ALDARA, 21 alendronate, 13 alfuzosin HCl, 15 ALKERAN, 6 allopurinol, 2 almotriptan, 3 ALPHAGAN P, 17 ALPHAGAN P 0.1%, 17 alprazolam, 9 ALREX, 17 ALTABAX, 20 ALTACE, 7 altretamine, 5 aluminum chloride, 21 amantadine, 5, 16 AMARYL, 12 AMBIEN, 10 AMBIEN CR, 10 AMERGE, 3 amiloride/hydrochlorothiazide, 8 amiodarone, 7 amitriptyline, 9 amlodipine, 7 amlodipine/olmesartan, 8 amoxapine, 9 amoxicillin, 3 amoxicillin/potassium clavulanate, 3 amphetamine/dextroamphetamine mixed salts, 10 amphetamine/dextroamphetamine mixed salts ext-rel, 10

ampicillin, 3 ANAFRANIL, 9 ANAPROX, 2 ANAPROX DS, 2 anastrozole, 5 ANDRODERM, 11 ANDROGEL, 11 ANDROXY, 11 ANSAID, 2 ANTABUSE, 10 anthralin, 20 ANTIVERT, 14 ANUSOL-HC, 21 APIDRA, 13 aprepitant, 14 APTIVUS, 4 ARALEN, 5 ARAVA, 2 ARICEPT, 10 ARIMIDEX, 5 aripiprazole, 10 AROMASIN, 6 ASACOL, 14 ASACOL HD, 14 ASMANEX, 19 ASTELIN nasal spray, 11 atazanavir, 4 atenolol, 7 atenolol/chlorthalidone, 7 ATIVAN, 9 atorvastatin, 8 atovaquone/proguanil, 5 atropine, 18 ATROVENT, 11 ATROVENT HFA, 19 AUGMENTIN, 3 AVALIDE, 8 AVAPRO, 8 AVELOX, 3 AVODART, 15 AXERT, 3 AXID, 13 AZASITE, 17 azathioprine, 5 azelastine, 11 AZILECT, 16 azithromycin, 3, 17 AZOR, 8 AZULFIDINE, 14

B B-12/vit c/folic acid/iron/succinic acid, 15 bacitracin 500 units/g, 17 bacitracin/polymyxin B, 17 baclofen, 16 BACTRIM, 4 BACTROBAN, 20 BACTROBAN cream, 20 balsalazide, 14



23

BARACLUDE, 4 beclomethasone, CFC-free aerosol, 19 belladonna alkaloids/phenobarbital, 14 benazepril, 7 benazepril/hydrochlorothiazide, 7 BENICAR, 8 BENICAR HCT, 8 BENTYL, 14 BENZAMYCIN, 20 benzonatate, 19 benzoyl peroxide gel, 20 benztropine, 16 BETAGAN, 18 betamethasone dipropionate, 21 betamethasone dipropionate augmented crm 0.05%, 21 betamethasone dipropionate augmented gel, oint 0.05%, 21 betamethasone dipropionate augmented lotion 0.05%, 21 betamethasone valerate, 20 betamethasone valerate foam 0.12%, 20 BETAPACE AF, 7 betaxolol solution, 18 betaxolol suspension, 18 bethanechol, 15 BETOPTIC S, 18 bexarotene caps, 5 bicalutamide, 5 BILTRICIDE, 5 bimatoprost, 18 bismuth subcitrate potassium/metronidazole/tetracycline, 13 bisoprolol, 7 bisoprolol/hydrochlorothiazide, 7 BLEPH-10, 17 BLEPHAMIDE, 18 BONIVA 150 mg tab only, 13 brimonidine 0.1%, 17 brimonidine 0.15%, 17 brimonidine 0.2%, 17 brimonidine/timolol, 17 bromocriptine, 13, 16 budesonide, 14 budesonide/formoterol, 19 bumetanide, 8 buprenorphine/naloxone, 2 bupropion, 9 bupropion ext-rel, 9, 11 BUSPAR, 9 buspirone, 9 busulfan, 5 butalbital/acetaminophen/caffeine, 2,3 butalbital/aspirin/caffeine, 2, 3 butalbital/aspirin/caffeine/codeine, 2 BYETTA, 13

C cabergoline, 13 CALAN, 7 CALAN SR, 7 calcipotriene, 20 capecitabine, 5 CAPOTEN, 7 CAPOZIDE, 7 CAPRELSA, 6 captopril, 7

captopril/hydrochlorothiazide, 7 CARAFATE, 14 carbachol, 18 carbamazepine, 9, 15 carbamazepine ext-rel, 9, 15 carbidopa/levodopa, 16 carbidopa/levodopa ext-rel, 16 carbidopa/levodopa/entacapone, 16 CARDURA, 15 carisoprodol, 16 CARNITOR, 17 carvedilol, 7 carvedilol phosphate ext-rel, 7 CASODEX, 5 CATAPRES, 8 CEENU, 6 cefaclor, 3 CEFACLOR ER, 3 cefaclor ext-rel, 3 cefadroxil, 3 CEFTIN, 3 cefuroxime, 3 CELEBREX, 2 celecoxib, 2 CELLCEPT, 6 cephalexin, 3 cephradine, 3 CHANTIX, 11 chlorambucil, 5 chloramphenicol, 17 chlordiazepoxide, 9 chlordiazepoxide/clidinium, 14 chlorhexidine gluconate, 11 CHLOROPTIC, 17 chloroquine, 5 chlorpromazine, 10 chlorthalidone, 8 chlorzoxazone, 16 cholestyramine aspartame, 9 cholestyramine sucrose, 9 ciclopirox suspension, 20 CILOXAN, 17 CILOXAN ophth oint, 17 cimetidine, 13 CIPRO, 3 CIPRO HC, 11 CIPRODEX, 11 ciprofloxacin, 3 ciprofloxacin ophth oint, 17 ciprofloxacin ophth soln, 17 ciprofloxacin/dexamethasone, 11 ciprofloxacin/hydrocortisone, 11 CLEOCIN, 5 CLEOCIN T, 20 CLEOCIN VAGINAL CREAM, 14 CLIMARA, 11 clindamycin, 5, 14, 20 clobetasol propionate crm, gel, lotion, oint 0.05%, 21 clobetasol propionate foam 0.05%, 21 clobetasol propionate lotion, shampoo, spray 0.05%, 21 CLOBEX, 21 clomipramine, 9 clonazepam, 9, 15



24

clonidine tabs, 8 clopidogrel, 15 clorazepate, 9 clotrimazole, 4, 11, 20 cloxacillin, 3 CLOXAPEN, 3 codeine/chlorpheniramine/pseudoephedrine, 19 codeine/guaifenesin liquid, 19 codeine/phenylephrine/promethazine, 19 codeine/promethazine, 19 colchicine, 2 COLCRYS, 2 COLYTE, 14 COMBIGAN, 17 COMBIVENT, 19 COMBIVIR, 4 COMPLERA, 4 COMTAN, 16 CONCERTA, 10 CONDYLOX, 21 constulose, 14 COPEGUS, 5 CORDARONE, 7 COREG, 7 COREG CR, 7 CORGARD, 7 CORTENEMA, 21 CORTIFOAM, 21 CORTISPORIN, 18 CORTISPORIN OTIC, 11 COSOPT, 18 COUMADIN, 15 COZAAR, 8 CREON, 14 CRESTOR, 9 CRIXIVAN, 4 crizotinib, 5 CUTIVATE, 20 cyclobenzaprine, 16 CYCLOGYL, 18 cyclopentolate, 18 cyclophosphamide, 5 cyclosporine, emulsion, 18 CYMBALTA, 9 cyproheptadine, 19 CYTOMEL, 13 CYTOTEC, 14

D dabigatran, 15 dapsone, 5 dapsone gel, 20 darunavir, 4 dasatinib, 6 DAYPRO, 2 DDAVP, 13 deferasirox, 15 delavirdine, 4 DEMADEX, 8 DEPAKENE, 16 DEPAKOTE, 10, 15 DEPAKOTE ER, 10, 15 desipramine, 9

desmopressin, 13 DESOGEN, 12 desonide crm, oint 0.05%, 20 desonide foam 0.05%, 20 desoximetasone cream 0.05%, 20 desoximetasone crm, oint 0.25%, gel 0.05%, 21 DESQUAM-E, 20 DETROL LA, 15 dexamethasone, 11, 17 DEXEDRINE, 10 DEXEDRINE SPANSULE, 10 dextroamphetamine, 10 dextroamphetamine ext-rel, 10 dextromethorphan/brompheniramine/pseudoephedrine, 19 dextromethorphan/chlorpheniramine/phenylephrine, 19 dextromethorphan/promethazine, 19 diazepam, 9 DIBENZYLINE, 8 diclofenac, 2 diclofenac patch, 2 diclofenac sodium, 17 dicloxacillin, 3 dicyclomine, 14 didanosine delayed-rel, 4 didanosine soln, 4 DIFFERIN, 20 DIFLUCAN, 4, 14 diflunisal, 2 digoxin, 6 DILACOR XR, 7 DILANTIN, 16 DILAUDID, 2 diltiazem ext-rel, 7 DIOVAN, 8 DIOVAN HCT, 8 DIPENTUM, 14 diphenoxylate/atropine, 13 dipivefrin, 18 DIPROLENE, 21 DIPROLENE AF, 21 DIPROSONE, 21 dipyridamole, 15 disopyramide, 7 disopyramide ext-rel, 7 disulfiram, 10 DITROPAN XL, 15 divalproex sodium delayed-rel, 10, 15 divalproex sodium ext-rel, 10, 15 DOLOPHINE, 2 donepezil HCL, 10 DONNATAL, 14 dorzolamide, 18 dorzolamide/timolol maleate, 18 DOSTINEX, 13 DOVONEX, 20 doxazosin, 15 doxepin, 9 doxycycline, 3 DRITHOCREME, 20 dronedarone, 7 drospirenone/ethinyl estradiol, 12 DRYSOL, 21 DUETACT, 12



25

duloxetine HCL, 9 DURAGESIC PATCH, 2 dutasteride, 15 DYAZIDE, 8

E E.E.S., 3 econazole, 20 EDURANT, 4 efavirenz, 4 EFFEXOR, 9 EFFEXOR XR, 9 EFFIENT, 15 EFUDEX, 21 ELDEPRYL, 16 eletriptan, 3 ELIDEL, 21 ELIMITE, 21 ELOCON, 20 eltrombopag, 15 EMCYT, 6 EMEND, 14 emtricitabine, 4 emtricitabine/rilpivirine/tenofovir, 4 EMTRIVA, 4 enalapril, 7 enalapril/hydrochlorothiazide, 7 enoxaparin, 9 entacapone, 16 entecavir, 4 ENTOCORT EC, 14 enulose, 14 EPIFOAM, 21 EPIFRIN, 19 epinephrine, 19 EPIVIR, 4 EPIVIR HBV, 4 EPZICOM, 4 ergoloid mesylates, 3 erlotinib, 6 ERYCETTE, 20 ERY-TAB, 3 ERYTHROCIN, 3 erythromycin base (enteric coated), 3 erythromycin estolate, 3 erythromycin ethylsuccinate, 3 erythromycin oint, 17 erythromycin stearate, 3 erythromycin topical solution, 20 erythromycin/benzoyl peroxide gel, 20 escitalopram, 9 ESGIC-PLUS, 2, 3 estazolam, 10 ESTRACE, 11 ESTRADERM, 11 estradiol, 11, 12 estradiol transdermal, 11 estradiol vaginal, 12 estramustine, 6 ESTRING, 12 estrogens, conjugated, 11 estrogens, conjugated/medroxyprogesterone, 12 ethambutol, 4

ethinyl estradiol/desogestrel, 12 ethinyl estradiol/norethindrone, 12 ethosuximide, 15 etonogestrel/ethinyl estradiol vaginal, 12 etoposide, 6 etravirine, 4 everolimus, 6 EVISTA, 13 EXELON, all forms, 10 exemestane, 6 exenatide, 13 EXJADE, 15 ezetimibe, 9

F famciclovir, 5 famotidine, 13 FAMVIR, 5 FARESTON, 6 febuxostat, 2 FELDENE, 2 FEMARA, 6 fentanyl transdermal, 2 FERREX 150 FORTE PLUS, 15 finasteride, 15 FIORICET, 2 FIORINAL, 2, 3 FIORINAL/CODEINE, 2 FLAGYL, 5 flavoxate HCL, 15 flecainide, 7 FLECTOR, 2 FLEXERIL, 16 FLOMAX, 15 FLONASE, 11 FLOVENT, 19 FLOXIN OTIC, 11 fluconazole, 4 fluconazole susp and tabs, 14 fludrocortisone, 11 FLUMADINE, 5 flunisolide, 11 fluocinolone acetonide crm, oint 0.025%, 20 fluocinonide crm, gel, oint, soln 0.05%, 21 fluorometholone, 17 fluorouracil, 21 fluoxetine, 9 fluoxymesterone, 11 fluphenazine, 10 fluphenazine decanoate, 10 flurazepam, 10 flurbiprofen, 2, 17 flutamide, 6 fluticasone, 11, 19 fluticasone propionate crm 0.05%, oint 0.005%, 20 FML, 17 FML FORTE, 17 folic acid, 15 FORADIL, 19 formoterol, 19 FOSAMAX, 13 fosamprenavir, 4 fosinopril, 7



26

fosinopril/hydrochlorothiazide, 7 furosemide, 8

G gabapentin, 16 galantamine, 10 galantamine ext-rel, 10 ganciclovir opthal, 18 gatifloxacin, 17 gemfibrozil, 9 gentamicin, 17, 20 GEODON, 10 GLEEVEC, 6 glimepiride, 12 glipizide, 12 glipizide/metformin, 12 glucagon, 13 GLUCAGON EMERGENCY KIT, 13 GLUCOPHAGE, 12 GLUCOPHAGE XR, 12 glucose test strips, 13 GLUCOTROL, 12 glyburide, 12 GLYNASE, 12 granisetron, 14 griseofulvin ultramicrosize, 4 GRIS-PEG, 4 guaifenesin, 19 guanabenz acetate, 8 guanfacine, 8

H halcinonide crm, oint 0.1%, 21 HALCION, 10 HALDOL DECANOATE, 10 halobetasol propionate crm, oint 0.05%, 21 HALOG, 21 haloperidol, 10 haloperidol decanoate, 10 HEPSERA, 4 HEXALEN, 5 homatropine, 18 HUMALOG, 13 HUMULIN, 13 HYCAMTIN caps, 6 hydralazine, 8 HYDREA, 5 hydrochlorothiazide, 8 hydrocodone/acetaminophen, 2 hydrocortisone, 11, 21 hydrocortisone acetate supp, 21 hydrocortisone crm 2.5%, 20 hydrocortisone intrarectal foam, 21 hydrocortisone retention enema, 21 hydrocortisone valerate crm, oint 0.2%, 20 hydrocortisone/neo/polymyxin B, 11 hydrocortisone/pramoxine, 21 hydromorphone, 2 hydroxychloroquine, 2, 5 hydroxyurea, 6 hydroxyzine HCl, 19 hydroxyzine pamoate, 19 hyoscyamine sulfate, 14

HYZAAR, 8

I ibandronate, 13 ibuprofen, 2 imatinib, 6 IMDUR, 6 imipramine, 9, 15 imiquimod, 21 IMITREX, 3 IMURAN, 5 INCIVEK, 5 indapamide, 8 INDERAL LA, 7 indinavir, 4 indomethacin, 2 insulin aspart, 13 insulin glargine, 13 insulin lispro, 13 insulin/recom, 13 INTELENCE, 4 INVEGA, 10 INVIRASE, 4 iodoquinol, 5 ipratropium bromide 0.03% nasal spray, 11 ipratropium, CFC-free aerosol, 19 irbesartan, 8 irbesartan/hydrochlorothiazide, 8 ISENTRESS, 4 ISMO, 6 isometheptene/dichloralphenazone/acetaminophen, 3 isoniazid, 4 ISOPTO CARBACHOL, 18 ISOPTO HOMATROPINE, 18 ISORDIL, excluding TEMBIDS, 6 isosorbide dinitrate, 6 isosorbide monohydrate, 6 isotretinoin oral, 20 ivermectin, 21

J JANUMET, 12 JANUVIA, 12

K KALETRA, 4 KEFLEX, 3 KEPPRA, 16 ketoconazole, 4, 20 ketoprofen, 2 KLONOPIN, 9, 15 KOMBIGLYZE XR, 12 K-TABS, 17 KYTRIL, 14

L lacosamide, 16 lactulose, 14 LAMICTAL, 10, 16 LAMISIL, 4 LAMISIL AT 1% cream, 20 lamivudine, 4



27

lamivudine/zidovudine, 4 lamotrigine, 10, 16 lansoprazole + amoxicillin + clarithromycin, 13 LANTUS, 13 lapatinib, 6 LARIAM, 5 LASIX, 8 latanoprost, 18 leflunomide, 2 lenalidomide, 6 letrozole, 6 leucovorin CA tabs, 6 leucovorin calcium (folinic acid), 15 LEUKERAN, 5 levetiracetam, 16 levobunolol, 18 levocarnitine, 17 levonorgestrel, 12 levonorgestrel/ethinyl estradiol, 12 LEVOTHROID, 13 levothyroxine, 13 LEVOXYL, 13 LEVSIN, 14 LEVSIN-SL, 14 LEXAPRO, 9 LEXIVA, 4 LIBRAX, 14 LIBRIUM, 9 LIDEX, 21 lidocaine HCl patch, 3 lidocaine viscous, 11 LIDODERM, 3 liothyronine, 13 lipase/protease/amylase, 14 LIPITOR, 8 liraglutide, 13 lisinopril, 7 lisinopril/hydrochlorothiazide, 7 lithium, 10 LOESTRIN FE, 12 LOMOTIL, 13 lomustine, 6 LOPID, 9 lopinavir/ritonavir, 4 LOPRESSOR, 7 LOPRESSOR HCT, 7 LOPROX SUSPENSION, 20 lorazepam, 9 LORCET, 2 LORCET PLUS, 2 losartan, 8 losartan/hydrochlorothiazide, 8 LOTEMAX, 17 LOTENSIN, 7 LOTENSIN HCT, 7 loteprednol etabonate, 17 lovastatin, 9 LOVENOX, 9 LUMIGAN, 18 LURIDE drops, 16 LURIDE tabs, 16 LUXIQ, 20 LYRICA, 3, 16

LYSODREN, 6

M MACRODANTIN, 5 MALARONE, 5 maprotiline, 9 maraviroc, 4 MATULANE, 6 MAVIK, 7 MAXAIR AUTOHALER, 19 MAXALT-MLT, 3 MAXITROL, 18 MAXZIDE, 8 mebendazole, 5 meclizine, 14 MEDROL, 11 medroxyprogesterone, 12 mefloquine, 5 MEGACE, 6 megestrol, 6 melphalan, 6 memantine, 10 mercaptopurine, 6 mesalamine delayed-rel tabs, 14 mesalamine ext-rel caps, 14 mesalamine rectal susp, 14 mesna tabs, 6 MESNEX, 6 MESTINON, 16 METADATE CD, 10 METAGLIP, 12 metformin, 12 metformin ext-rel, 12 methadone, 2 methazolamide, 8 methimazole, 13 methocarbamol, 16 methotrexate, 2, 6 methyclothiazide, 8 methyldopa, 8 methylene blue, 15 methylphenidate, 10 methylphenidate HCL, 10 methylprednisolone, 11 metoclopramide, 14 metolazone, 8 metoprolol, 7 metoprolol ext-rel, 7 metoprolol tartrate/hydrochlorothiazide, 7 METROGEL, 20 METROGEL-VAGINAL, 14 metronidazole, 5 metronidazole gel, 14 metronidazole gel 1%, 20 MEVACOR, 9 miconazole, 14 milnacipran, 3 MINIPRESS, 8 MINOCIN, 3 minocycline, 3 MIRAPEX, 16 MIRCETTE, 12 mirtazapine, 9



28

misoprostol, 14 mitotane, 6 moexipril, 7 mometasone, 19 mometasone crm, lotion, oint 0.1%, 20 MONISTAT, 14 MONOKET, 6 MONOPRIL, 7 MONOPRIL-HCT, 7 montelukast, 19 morphine sulfate, 2 morphine sulfate ext-rel, 2 MOTRIN, 2 moxifloxacin, 3, 17 MS CONTIN, 2 MULTAQ, 7 multivitamins/fluoride, 16 mupirocin cream, 20 mupirocin ointment, 20 MYAMBUTOL, 4 MYCELEX, 4, 11 mycophenolate mofetil, 6 MYCOSTATIN, 4, 11, 14, 20 MYDRIACYL, 18 MYLERAN, 5 MYSOLINE, 16

N nabumetone, 2 nadolol, 7 NAMENDA, 10 NAPROSYN, 2 naproxen, 2 naproxen sodium, 2 naratriptan, 3 NASACORT AQ, 11 NASAREL, 11 NATACYN, 18 natamycin, 18 NAVANE, 10 nelfinavir mesylate, 4 neomycin, 3 neomycin/dexamethasone, 18 neomycin/polymyxin B/bacitracin/hydrocortisone, 18 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 18 neomycin/polymyxin B/dexamethasone, 18 neomycin/polymyxin B/gramicidin, 17 NEOSPORIN, 17 NEO-SYNEPHRINE, 18 NEURONTIN, 16 nevirapine, 4 NEXAVAR, 6 NEXA SELECT, 16 niacin timed release, 9 NIASPAN, 9 nifedipine ext-rel, 7 NILANDRON, 6 nilotinib, 6 nilutamide, 6 NITRO-BID, 6 NITRO-DUR, 6 nitrofurantoin, 5 nitroglycerin, 6

nitroglycerin ext-rel, 6 nitroglycerin oint, 6 nitroglycerin patch, 6 nitroglycerin sublingual spray, 6 NITROLINGUAL SPRAY, 6 NITROSTAT, 6 nizatidine, 13 NIZORAL, 4, 20 NORDETTE, 12 norelgestromin-ethinyl estradiol transdermal, 12 norethindrone, 12 norethindrone/ethinyl estradiol, 12 NORPACE, 7 NORPACE CR, 7 NORPRAMIN, 9 nortriptyline, 9 NORVASC, 7 NORVIR, 4 NOVOLIN, 13 NOVOLOG, 13 NUVARING, 12 nystatin, 4, 14, 20 nystatin suspension, 11

O OCUFEN, 17 ofloxacin otic, 11 olanzapine, 10 olmesartan, 8 olmesartan/hydrochlorothiazide, 8 olopatadine HCL, 17 olsalazine sodium, 14 OLUX, 21 omeprazole, 14 ondansetron, 14 ondansetron orally disintegrating tabs, 14 ONGLYZA, 12 ORTHO EVRA, 12 ORTHO-MICRONOR, 12 ORTHO-NOVUM 1/35, 12 ORTHO-NOVUM 1/50, 12 ORTHO-NOVUM 7/7/7, 12 oseltamivir, 5 osmotic laxative, 14 oxacillin, 3 oxaprozin, 2 oxazepam, 9 oxcarbazepine, 16 oxybutynin, 15 oxybutynin ext-rel, 15 oxycodone, 2 oxycodone ext-rel, 2 oxycodone/acetaminophen, 2 oxycodone/aspirin, 2 OXYCONTIN, 2

P paliperidone ext-rel, 10 PAMELOR, 9 PANCREAZE, 14 PARCOPA, 16 PARLODEL, 13, 16 paroxetine HCl ext-rel, 9



29

PATADAY, 17 PATANOL, 17 PAXIL CR, 9 pazopanib, 6 PEG Solution, 14 penicillin VK, 3 PENTASA, 14 pentoxifylline, 9 PEPCID, 13 PERCOCET, 2 PERCODAN, 2 PERIACTIN, 19 PERIDEX, 11 perindopril, 7 permethrin, 21 perphenazine, 10 PERSANTINE, 15 phenazopyridine, 15 phenobarbital, 16 phenoxybenzamine, 8 phenylephrine, 18 phenylephrine/promethazine, 19 phenytoin, 16 pimecrolimus, 21 pindolol, 7 pioglitazone, 12 pioglitazone/glimepiride, 12 pioglitazone/metformin, 12 pirbuterol, 19 piroxicam, 2 PLAN B, 12 PLAQUENIL, 2, 5 PLAVIX, 15 podofilox gel, 21 POLYTRIM, 17 potassium chloride effervescent tablet, 17 potassium chloride liquid, 17 potassium chloride tablet, 17 PRADAXA, 15 pramipexole, 16 pramlinitide acetate, 13 PRANDIN, 12 prasugrel, 15 PRAVACHOL, 9 pravastatin, 9 praziquantel, 5 prazosin, 8 PRECOSE, 12 PRED FORTE, 17 PRED MILD, 17 PRED-G SOP, 18 prednisolone, 11 prednisolone acetate 0.12%, 17 prednisolone acetate 1%, 17 prednisolone acetate and sulfacetamide sodium 10%

suspension and ointment, 18 prednisolone and gentamicin sulfate ointment, 18 prednisolone syrup, 11 prednisone, 11 PREFERA OB, 16 PREFERA OB ONE, 16 PREFERA OB + DHA, 16 pregabalin, 3, 16

PRELONE, 11 PREMARIN, 11 PREMPHASE, 12 PREMPRO, 12 prenatal vitamins, 16 PRENEXA, 16 PREVPAC, 13 PREZISTA, 4 PRILOSEC, 14 primidone, 16 PRO-BANTHINE, 15 probenecid, 2 procarbazine, 6 prochlorperazine, 14 PROCTOFOAM-HC, 21 progesterone, micronized, 12 PROMACTA, 15 promethazine, 14 PROMETRIUM, 12 propafenone, 7 propantheline, 15 PROPINE, 18 propranolol, 7 propranolol ext-rel, 7 propylthiouracil, 13 PROSCAR, 15 PROSED, 15 protriptyline, 9 PROVERA, 12 PROZAC, 9 PURINETHOL, 6 PYLERA, 13 pyrazinamide, 4 PYRIDIUM, 15 pyridostigmine, 16

Q QUESTRAN, 9 QUESTRAN LIGHT, 9 quetiapine, 10 quinapril, 7 quinapril/hydrochlorothiazide, 7 QVAR, 19

R raloxifene, 13 raltegravir, 4 ramelteon, 10 ril, 7 ranitidine, 13 rasagiline mesylate, 16 RAZADYNE, 10 RAZADYNE ER, 10 REBETOL, 5 REGLAN, 14 RELENZA, 5 RELPAX, 3 REMERON, 9 repaglinide, 12 REQUIP, 16 RESCRIPTOR, 4 RESTASIS, 18 RESTORIL, 10



30

retapamulin, 20 RETIN-A, 20 RETROVIR, 4 REVLIMID, 6 REYATAZ, 4 ribavirin, 5 RIFADIN, 4 rifampin, 4 rilpivirine, 4 rimantadine, 5 rimexolone, 17 risedronate, 13 RISPERDAL, 10 risperidone, 10 RITALIN, 10 ritonavir, 4 rivastigmine tartrate, 10 rizatriptan dispersible, 3 ROBAXIN, 16 ropinirole, 16 rosuvastatin, 9 ROWASA, 14 ROXICODONE, 2 ROZEREM, 10 RYTHMOL, 7

S salmeterol, 19 salmeterol/fluticasone, 19 saquinavir, 4 SARAFEM, 9 SAVELLA, 3 saxagliptin, 12 saxagliptin/metformin, 12 selegiline, 16 SELZENTRY, 4 SEPTRA, 4 SEREVENT, 19 SEROQUEL, 10 sertraline, 9 SILVADENE, 20 silver sulfadiazine, 20 simvastatin, 9 SINEMET, 16 SINEMET CR, 16 SINGULAIR, 19 sitagliptin, 12 sitagliptin/metformin, 12 sodium fluoride drops, 16 sodium fluoride tabs, 16 solifenacin succinate, 15 SOMA, 16 SONATA, 10 sorafenib, 6 SORBITOL SOLUTION 70 %, 14 sotalol HCL, 7 SPIRIVA, 19 spironolactone, 8 spironolactone/hydrochlorothiazide, 8 SPRYCEL, 6 STALEVO, 16 stavudine, 4 STROMECTOL, 21

SUBOXONE, 2 sucralfate, 14 sulfacetamide solution and ointment, 17 sulfamethoxazole/trimethoprim, 4 sulfasalazine, 14 sulfisoxazole/erythromycin, 4 sulindac, 2 sumatriptan, 3 sunitinib, 6 SUSTIVA, 4 SUTENT, 6 SYMBICORT, 19 SYMLIN, 13 SYNTHROID, 13

T TABLOID, 6 TAGAMET, 13 TAMBOCOR, 7 TAMIFLU, 5 tamoxifen, 6 tamsulosin, 15 TAPAZOLE, 13 TARCEVA, 6 TARGRETIN caps, 5 TASIGNA, 6 tazarotene cream, gel, 20 tazarotene gel, 20 TAZORAC, 20 TEGRETOL, 9, 15 TEGRETOL-XR, 9, 15 telaprevir, 5 telbivudine, 5 temazepam, 10 TEMODAR, 6 TEMOVATE, 21 temozolomide, 6 TENEX, 8 tenofovir, 4 TENORETIC, 7 TENORMIN, 7 TERAZOL, 15 terazosin, 8, 15 terbinafine tabs, 4 terconazole vag cream, 15 TESTIM, 11 testosterone gel, 11 testosterone transdermal, 11 tetracycline, 3 thalidomide, 6 THALOMID, 6 THEO-24, 19 theophylline, 19 theophylline ext-rel, 19 theophylline ext-rel tabs, 19 thioguanine, 6 thioridazine, 10 thiothixene, 10 TIAZAC, 7 TIGAN, 14 timolol maleate gel, 18 timolol maleate solution, 18 TIMOPTIC, 18



31

TIMOPTIC-XE, 18 TINDAMAX, 5 tinidazole, 5 tiotropium, 20 tipranavir, 4 tizanidine, 16 TOBRADEX, 18 tobramycin, 17 tobramycin/dexamethasone, 18 TOBREX, 17 TOFRANIL, 9, 15 tolazamide, 12 tolbutamide, 12 tolterodine ext-rel, 15 TOPAMAX, 16 TOPICORT, 21 TOPICORT LP, 20 topiramate, 16 topotecan caps, 6 TOPROL-XL, 7 toremifene citrate, 6 torsemide, 8 tramadol HCL, 2 trandolapril, 7 TRANXENE, 9 TRAVATAN, 18 travoprost, 18 trazodone, 9 TRENTAL, 9 tretinoin, 6 tretinoin topical, 20 TREXALL, 6 triamcinolone, 11 triamcinolone acetonide crm, lotion 0.025%, 20 triamcinolone acetonide crm, lotion, oint 0.1%, 20 triamcinolone paste, 11 triamterene/hydrochlorothiazide, 8 triazolam, 10 TRIDESILON, 20 trifluoperazine, 10 trifluridine, 18 trihexyphenidyl, 16 TRILEPTAL, 16 trimethobenzamide, 14 trimethoprim, 5 trimethoprim/polymyxin B 10000 units/mL, 17 TRI-NORINYL, 12 TRIZIVIR, 4 tropicamide, 18 TRUERESULT, 13 TRUETEST, 13 TRUETRACK, 13 TRUSOPT, 18 T-STAT, 20 TYKERB, 6 TYLENOL w/CODEINE, 2 TYZEKA, 5

U ULORIC, 2 ULTRAM, 2 ULTRAVATE, 21 UNIPHYL, 19

UNIVASC, 7 urea cream, 21 URECHOLINE, 15 URISPAS, 15 UROXATRAL, 15 URSO, 14 ursodiol, 14

V valacyclovir, 5 valsartan, 8 valsartan/HCTZ, 8 VALIUM, 9 valproic acid, 16 VALTREX, 5 vandetanib, 6 varenicline, 11 VASERETIC, 7 VASOTEC, 7 venlafaxine, 9 venlafaxine ext-rel, 9 VENTOLIN HFA, 19 verapamil, 7 verapamil ext-rel, 7 VERDESO, 20 VESICARE, 15 VEXOL, 17 VIBRAMYCIN, 3 VICODIN, 2 VICODIN ES, 2 VICTOZA, 13 VIDEX EC, 4 VIDEX soln, 4 VIGAMOX, 17 VIMPAT, 16 VIRACEPT, 4 VIRAMUNE, 4 VIREAD, 4 VIROPTIC, 18 VISTARIL, 19 vitamin A, 15 VIVACTIL, 9 VOLTAREN, 2, 17 vorinostat, 6 VOSPIRE ER, 19 VOTRIENT, 6

W warfarin, 15 WELLBUTRIN, 9 WELLBUTRIN SR, 9 WELLBUTRIN XL, 9 WESTCORT, 20

X XALATAN, 18 XALKORI, 5 XANAX, 9 XELODA, 5



32

Y YASMIN, 12 YODOXIN, 5

Z zaleplon, 10 ZANAFLEX, 16 zanamivir, 5 ZANTAC, 13 ZARONTIN, 15 ZAROXOLYN, 8 ZEBETA, 7 ZENPEP, 14 ZERIT, 4 ZESTORETIC, 7 ZESTRIL, 7 ZETIA, 9 ZIAC, 7 zidovudine, 4 ziprasidone, 10 ZIRGAN, 18 ZITHROMAX, 3 ZOCOR, 9 ZOFRAN, 14 ZOFRAN ODT, 14 ZOLINZA, 6 ZOLOFT, 9 zolpidem, 10 zolpidem ER, 10 ZONEGRAN, 16 zonisamide, 16 ZOVIRAX, 5 ZYBAN, 11 ZYLOPRIM, 2 ZYPREXA, 10

effective may 1, 2012 - instantbenefits.com · prescription drugs when prescribed for experimental,...

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