presbyterian sci 2013 presbyterian state coverage insurance...
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Presbyterian SCI
Drug Name Dosage Form Note
acetaminophen/codeine #2 TABS (QL)
acetaminophen/codeine #3 TABS (QL)
acetaminophen/codeine #4 TABS (QL)
ADULT ASPIRIN LOW STRENGTH TBDP (AG)
aspirin CHEW (AG)
aspirin ec TBEC (AG)
aspirin low dose TABS (AG)
AVINZA (120MG) CP24 (QL) (ST)
AVINZA (30MG) CP24 (QL) (ST)
AVINZA (45MG) CP24 (QL) (ST)
AVINZA (60MG) CP24 (QL) (ST)
AVINZA (75MG) CP24 (QL) (ST)
AVINZA (90MG) CP24 (QL) (ST)
butalbital/acetaminophen/caffeine * (QL)
butalbital/acetaminophen/caffeine CAPS (QL)
butalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)
butalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)
butalbital/acetaminophen/caffeine (500mg; 50mg; 40mg) TABS (QL)
butalbital/acetaminophen/caffeine/codeine CAPS (QL)
butalbital/aspirin/caffeie/codeine CAPS
carisoprodol/aspirin TABS
carisoprodol/aspirin/codeine TABS
CELEBREX CAPS (QL) (ST)
CODEINE SULFATE TABS (QL)
diclofenac sodium dr TBEC
diclofenac sodium er TB24
diflunisal TABS
DOLGIC PLUS TABS
endocet TABS (QL)
etodolac *
etodolac er TB24
fentanyl PT72 (ST) (QL)
2013 Presbyterian State Coverage Insurance (SCI) Formulary/Preferred Drug Listing - By Therapeutic Class
Some medications may be excluded as determined by benefit.
Analgesics
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Drug Name Dosage Form Note
flurbiprofen TABS
hydrocodone bitartrate/acetaminophen TABS (QL)
hydrocodone/acetaminophen SOLN (QL)
hydrocodone/acetaminophen (325mg; 10mg) TABS (QL)
hydrocodone/acetaminophen (325mg; 5mg) TABS (QL)
hydrocodone/acetaminophen (325mg; 7.5mg) TABS (QL)
hydrocodone/acetaminophen (500mg; 10mg) TABS (QL)
hydrocodone/acetaminophen (500mg; 2.5mg) TABS (QL)
hydrocodone/acetaminophen (500mg; 5mg) TABS (QL)
hydrocodone/acetaminophen (500mg; 7.5mg) TABS (QL)
hydrocodone/acetaminophen (650mg; 10mg) TABS (QL)
hydrocodone/acetaminophen (650mg; 7.5mg) TABS (QL)
hydrocodone/acetaminophen (660mg; 10mg) TABS (QL)
hydrocodone/acetaminophen (750mg; 7.5mg) TABS (QL)
hydrocodone/ibuprofen TABS
hydrogesic CAPS (QL)
hydromorphone hcl TABS (QL)
hydromorphone hcl LIQD (QL)
ibuprofen *
ibuprofen TABS
ibuprofen SUSP
INDOCIN *
indomethacin CAPS
indomethacin er CPCR
KADIAN CP24 (QL) (ST)
ketoprofen CAPS
KETOPROFEN ER CP24
MELOXICAM *
meloxicam *
MEPERIDINE HCL SOLN
meperidine hcl TABS (QL)
methadone hcl TABS (PA) (QL)
METHADONE HCL SOLN (PA)
MORPHINE SULFATE TABS (QL)
morphine sulfate (10mg/5ml) SOLN (QL)
morphine sulfate (20mg/5ml) SOLN (QL)
morphine sulfate (20mg/ml) SOLN (QL)
morphine sulfate er CP24 (QL) (ST)
morphine sulfate er TBCR (QL)
nabumetone TABS
naproxen *
naproxen dr TBEC
naproxen sodium TABS
oxaprozin TABS
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Drug Name Dosage Form Note
OXYCODONE HCL SOLN (QL)
OXYCODONE HCL CONC (QL)
oxycodone hcl TABS (QL)
oxycodone/acetaminophen * (QL)
oxycodone/acetaminophen (325mg; 10mg) TABS (QL)
oxycodone/acetaminophen (325mg; 5mg) TABS (QL)
oxycodone/acetaminophen (325mg; 7.5mg) TABS (QL)
oxycodone/acetaminophen (500mg; 7.5mg) TABS (QL)
oxycodone/acetaminophen (650mg; 10mg) TABS (QL)
oxycodone/aspirin TABS
OXYMORPHONE HYDROCHLORIDE ER TB12 (ST) (QL)
OXYMORPHONE HYDROCHLORIDE ER TB12 (QL) (ST)
oxymorphone hydrochloride er TB12 (ST) (QL)
piroxicam CAPS
ROXICET SOLN (QL)
ROXICET TABS (QL)
salsalate TABS
ST JOSEPH ADULT CHEW (AG)
sulindac TABS
tramadol hcl TABS (QL)
Drug Name Dosage Form Note
antipyrine/benzocaine SOLN
lidocaine OINT
lidocaine CREA
LIDOCAINE HCL LOTN
lidocaine viscous SOLN
lidocaine/prilocaine CREA
LIDODERM PTCH (PA) (QL)
Drug Name Dosage Form Note
acamprosate calcium dr TBEC (PA) (QL)
buprenorphine hcl SUBL (PA) (QL)
buproban TB12 (QL)
bupropion hcl sr TB12 (QL)
CHANTIX TABS (QL)
CHANTIX STARTING MONTH PAK TABS (QL)
disulfiram TABS
Anesthetics
Anti-Addiction/Substance Abuse Treatment Agents
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Drug Name Dosage Form Note
naltrexone hcl TABS
SUBOXONE * (PA) (QL)
SUBOXONE (12MG; 3MG) FILM (PA) (QL)
SUBOXONE (2MG; 0.5MG) FILM (PA) (QL)
SUBOXONE (4MG; 1MG) FILM (PA) (QL)
SUBOXONE (8MG; 2MG) FILM (PA) (QL)
VIVITROL SUSR (PA) (QL) (SP)
Drug Name Dosage Form Note
ADULT ASPIRIN LOW STRENGTH TBDP (AG)
aspirin CHEW (AG)
aspirin ec TBEC (AG)
aspirin low dose TABS (AG)
CELEBREX CAPS (QL) (ST)
COLY-MYCIN S SUSP
diclofenac sodium dr TBEC
diclofenac sodium er TB24
diflunisal TABS
etodolac *
etodolac er TB24
flurbiprofen TABS
hydrocortisone/acetic acid SOLN
ibuprofen *
ibuprofen TABS
ibuprofen SUSP
INDOCIN *
indomethacin CAPS
indomethacin er CPCR
ketoprofen CAPS
KETOPROFEN ER CP24
meloxicam *
MELOXICAM *
nabumetone TABS
naproxen *
naproxen dr TBEC
naproxen sodium TABS
NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP
neomycin/polymyxin/hydrocortisone SOLN
neomycin/polymyxin/hydrocortisone SUSP
nystatin/triamcinolone *
NYSTATIN/TRIAMCINOLONE *
Anti-inflammatory Agents
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Drug Name Dosage Form Note
oxaprozin TABS
piroxicam CAPS
ST JOSEPH ADULT CHEW (AG)
sulindac TABS
Drug Name Dosage Form Note
ak-poly-bac OINT
AKNE-MYCIN OINT
AMOXICILLIN *
amoxicillin *
amoxicillin/clavulanate potassium *
amoxicillin/potassium clavulanate SUSR
AMPICILLIN *
ampicillin *
azithromycin *
BACITRACIN OINT
bacitracin/polymyxin b OINT
BACTROBAN NASAL OINT
BLEPHAMIDE SUSP
BLEPHAMIDE S.O.P. OINT
cefaclor CAPS
cefdinir *
cefpodoxime proxetil *
cefprozil *
cefuroxime axetil *
cephalexin *
CIPRO SUSR
CIPRODEX SUSP (AG) (PA) (QL)
ciprofloxacin hcl SOLN
ciprofloxacin hcl TABS
clarithromycin SUSR
clarithromycin TABS (QL)
CLEOCIN SUPP
clindamycin hcl CAPS
clindamycin palmitate hcl SOLR
clindamycin phosphate CREA
COLY-MYCIN S SUSP
CORTISPORIN CREA
CORTISPORIN OINT
dicloxacillin sodium CAPS
DIFICID TABS (PA) (QL)
Antibacterials
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Drug Name Dosage Form Note
doxycycline hyclate *
doxycycline hyclate TABS (QL)
E.E.S. 400 TABS
E.E.S. GRANULES SUSR
ERY-TAB TBEC
ERYPED 200 SUSR
ERYPED 400 SUSR
ERYTHROCIN STEARATE TABS
erythromycin OINT
ERYTHROMYCIN *
erythromycin *
ERYTHROMYCIN BASE TABS
ERYTHROMYCIN ETHYLSUCCINATE TABS
erythromycin/sulfisoxazole SUSR
garamycin OINT
gentak OINT
gentamicin sulfate SOLN
GENTAMICIN SULFATE *
levofloxacin *
MACRODANTIN CAPS
methenamine hippurate TABS
METHENAMINE MANDELATE TABS
methenamine mandelate TABS
metronidazole *
metronidazole TABS
metronidazole vaginal GEL
minocycline hcl CAPS
mupirocin OINT
neomycin sulfate TABS
neomycin/bacitracin/polymyxin OINT
neomycin/polymyxin b sulfates SOLN
neomycin/polymyxin/bacitracin/hydrocortisone OINT
neomycin/polymyxin/dexamethasone *
neomycin/polymyxin/gramicidin SOLN
NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP
neomycin/polymyxin/hydrocortisone SOLN
neomycin/polymyxin/hydrocortisone SUSP
nitrofurantoin SUSP
nitrofurantoin macrocrystalline CAPS
nitrofurantoin monohydrate CAPS
ofloxacin SOLN
penicillin v potassium *
polycin b OINT
polymyxin b sulfate/trimethoprim sulfate SOLN
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Drug Name Dosage Form Note
silver sulfadiazine CREA
sulfacetamide sodium SOLN
sulfamethoxazole/trimethoprim *
sulfamethoxazole/trimethoprim ds TABS
TETRACYCLINE HCL CAPS
TOBI NEBU
TOBI PODHALER CAPS (QL)
tobramycin sulfate SOLN
trimethoprim TABS
vancomycin hcl SOLR
vancomycin hcl CAPS (PA)
VIBRAMYCIN SUSR
XIFAXAN TABS (PA) (QL)
ZYVOX * (PA)
Drug Name Dosage Form Note
carbamazepine *
carbamazepine er *
clonazepam TABS (QL)
clonazepam odt TBDP (QL)
diazepam TABS (QL)
DIAZEPAM GEL (ST)
DILANTIN CAPS
divalproex sodium CPSP
divalproex sodium dr TBEC
divalproex sodium er TB24
ethosuximide *
gabapentin *
LAMICTAL CHEW (QL)
lamotrigine CHEW (QL)
lamotrigine (100mg) TABS (QL)
lamotrigine (150mg) TABS (QL)
lamotrigine (200mg) TABS (QL)
lamotrigine (25mg) TABS (QL)
levetiracetam *
LYRICA (100MG) CAPS (PA) (QL)
LYRICA (150MG) CAPS (PA) (QL)
LYRICA (200MG) CAPS (PA) (QL)
LYRICA (225MG) CAPS (PA) (QL)
LYRICA (25MG) CAPS (PA) (QL)
LYRICA (300MG) CAPS (PA) (QL)
Anticonvulsants
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Drug Name Dosage Form Note
LYRICA (50MG) CAPS (PA) (QL)
LYRICA (75MG) CAPS (PA) (QL)
oxcarbazepine TABS
PHENOBARBITAL *
phenobarbital *
phenytoin CHEW
phenytoin SUSP
phenytoin sodium extended CAPS
POTIGA TABS (PA) (QL)
primidone TABS
TEGRETOL-XR TB12
topiramate *
valproic acid CAPS
valproic acid SYRP
zonisamide CAPS
Drug Name Dosage Form Note
donepezil hcl * (QL)
ERGOLOID MESYLATES TABS
galantamine hydrobromide CP24
galantamine hydrobromide *
Drug Name Dosage Form Note
ABILIFY SOLN (PA) (QL)
ABILIFY TABS (PA) (QL)
ABILIFY DISCMELT TBDP (PA) (QL)
ABILIFY MAINTENA SUSR (MB) (PA) (SP)
amitriptyline hcl TABS
AMOXAPINE TABS
budeprion sr TB12 (QL)
bupropion hcl TABS (QL)
bupropion hcl sr TB12 (QL)
bupropion hcl xl TB24 (QL)
citalopram hydrobromide SOLN (QL)
citalopram hydrobromide (10mg) TABS (QL)
citalopram hydrobromide (20mg) TABS (QL)
citalopram hydrobromide (40mg) TABS (QL)
clomipramine hcl CAPS
Antidementia Agents
Antidepressants
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Drug Name Dosage Form Note
CYMBALTA (20MG) CPEP (PA) (QL)
CYMBALTA (30MG) CPEP (PA) (QL)
CYMBALTA (60MG) CPEP (PA) (QL)
desipramine hcl TABS
doxepin hcl *
DOXEPIN HCL *
EMSAM PT24 (PA) (QL)
escitalopram oxalate SOLN (QL)
escitalopram oxalate (10mg) TABS (QL)
escitalopram oxalate (20mg) TABS (QL)
escitalopram oxalate (5mg) TABS (QL)
FLUOXETINE HCL * (QL)
fluoxetine hcl SOLN (QL)
fluoxetine hcl * (QL)
fluoxetine hcl (10mg) CAPS (QL)
fluoxetine hcl (20mg) CAPS (QL)
fluoxetine hcl (40mg) CAPS (QL)
fluvoxamine maleate (100mg) TABS (QL) (ST)
fluvoxamine maleate (25mg) TABS (QL) (ST)
fluvoxamine maleate (50mg) TABS (QL) (ST)
imipramine hcl TABS
MAPROTILINE HCL TABS
mirtazapine * (QL)
mirtazapine odt TBDP (QL)
NEFAZODONE HCL TABS (QL)
nefazodone hcl TABS (QL)
nortriptyline hcl CAPS
paroxetine hcl (10mg) TABS (QL)
paroxetine hcl (20mg) TABS (QL)
paroxetine hcl (30mg) TABS (QL)
paroxetine hcl (40mg) TABS (QL)
paroxetine hcl er TB24 (ST)
PAXIL SUSP (QL)
PERPHENAZINE/AMITRIPTYLINE TABS
phenelzine sulfate TABS
quetiapine fumarate (100mg) TABS (AG) (QL)
quetiapine fumarate (200mg) TABS (AG) (QL)
quetiapine fumarate (25mg) TABS (AG) (QL)
quetiapine fumarate (300mg) TABS (AG) (QL)
quetiapine fumarate (400mg) TABS (AG) (QL)
quetiapine fumarate (50mg) TABS (AG) (QL)
selegiline hcl *
sertraline hcl CONC (QL)
sertraline hcl (100mg) TABS (QL)
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Drug Name Dosage Form Note
sertraline hcl (25mg) TABS (QL)
sertraline hcl (50mg) TABS (QL)
tranylcypromine sulfate TABS
trazodone hcl TABS
venlafaxine hcl TABS (QL)
venlafaxine hcl er (150mg) TB24 (QL)
venlafaxine hcl er (150mg) CP24 (QL)
venlafaxine hcl er (37.5mg) CP24 (QL)
venlafaxine hcl er (37.5mg) TB24 (QL)
venlafaxine hcl er (75mg) CP24 (QL)
venlafaxine hcl er (75mg) TB24 (QL)
VIIBRYD TABS (PA) (QL)
Drug Name Dosage Form Note
ALOXI SOLN (PA) (QL)
ANZEMET TABS (PA) (QL)
chlorpromazine hcl TABS
compro SUPP
EMEND SOLR (PA) (QL) (SP)
EMEND (0) CAPS (PA) (QL)
EMEND (125MG) CAPS (PA) (QL)
EMEND (40MG) CAPS (PA) (QL)
EMEND (80MG) CAPS (PA) (QL)
granisetron hcl SOLN
granisetron hcl TABS (QL) (ST)
hydroxyzine hcl *
hydroxyzine pamoate CAPS
HYDROXYZINE PAMOATE CAPS
metoclopramide hcl *
ondansetron hcl TABS (QL)
ondansetron odt TBDP (QL)
perphenazine TABS
phenadoz SUPP
prochlorperazine SUPP
PROCHLORPERAZINE EDISYLATE SOLN
prochlorperazine maleate TABS
promethazine hcl *
promethazine hcl plain SYRP
PROMETHEGAN SUPP
trimethobenzamide hcl CAPS
Antiemetics
[MPC021249] Page 10 of 46 August 15, 2013
Drug Name Dosage Form Note
Drug Name Dosage Form Note
BIO-STATIN CAPS
ciclopirox SUSP
ciclopirox GEL
ciclopirox nail lacquer SOLN (QL)
ciclopirox olamine CREA
clotrimazole TROC
clotrimazole/betamethasone dipropionate *
econazole nitrate CREA
fluconazole *
GRIFULVIN V TABS
GRIS-PEG TABS
griseofulvin microsize SUSP
ketoconazole TABS
ketoconazole *
nyamyc POWD
nystatin SUSP
nystatin *
nystatin TABS
NYSTATIN VAGINAL TABS
nystatin/triamcinolone *
NYSTATIN/TRIAMCINOLONE *
nystop POWD
pedi-dri POWD
terbinafine hcl TABS (QL)
terconazole *
VFEND SUSR (PA) (QL)
voriconazole TABS (PA) (QL)
Drug Name Dosage Form Note
allopurinol TABS
COLCRYS TABS
probenecid TABS
probenecid/colchicine TABS
ULORIC TABS (PA) (QL)
Antigout Agents
Antimigraine Agents
Antifungals
[MPC021249] Page 11 of 46 August 15, 2013
Drug Name Dosage Form Note
Drug Name Dosage Form Note
butalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)
butalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)
butalbital/acetaminophen/caffeine (500mg; 50mg; 40mg) TABS (QL)
CAFERGOT TABS
divalproex sodium CPSP
divalproex sodium dr TBEC
divalproex sodium er TB24
MIGERGOT SUPP
naratriptan hcl TABS (QL) (ST)
rizatriptan benzoate TABS (ST) (QL)
SUMATRIPTAN SOLN (QL)
sumatriptan succinate SOLN (QL)
sumatriptan succinate TABS (QL)
topiramate *
valproic acid CAPS
Drug Name Dosage Form Note
MESTINON SYRP
pyridostigmine bromide TABS
Drug Name Dosage Form Note
CYCLOSERINE CAPS
DAPSONE TABS
ethambutol hcl TABS
ISONIAZID SYRP
isoniazid TABS
MYCOBUTIN CAPS
PASER PACK
pyrazinamide TABS
rifampin CAPS
SEROMYCIN CAPS
Antimyasthenic Agents
Antimycobacterials
Antineoplastics
[MPC021249] Page 12 of 46 August 15, 2013
Drug Name Dosage Form Note
Drug Name Dosage Form Note
AFINITOR TABS (PA) (SP)
AFINITOR DISPERZ TBSO (PA) (SP)
ALIMTA SOLR (PA)
ALKERAN TABS
anastrozole TABS
AVASTIN SOLN (PA)
BOSULIF TABS (PA) (QL) (SP)
CAMPATH SOLN (PA)
CAPRELSA TABS (PA)
CEENU CAPS (PA) (SP)
COMETRIQ KIT (PA)
CYCLOPHOSPHAMIDE TABS
EMCYT CAPS (PA) (SP)
ERIVEDGE CAPS (PA) (QL) (SP)
ERWINAZE SOLR (PA) (SP)
ETHYOL SOLR (PA)
ETOPOSIDE CAPS (SP)
FARESTON TABS (PA) (SP)
GLEEVEC TABS (PA) (SP)
HEXALEN CAPS (PA) (SP)
HYCAMTIN CAPS (PA) (SP)
hydroxyurea CAPS
INLYTA TABS (PA) (SP)
IRESSA TABS (PA)
JAKAFI TABS (PA) (SP)
KADCYLA SOLR (MB) (PA) (SP)
KYPROLIS SOLR (PA) (SP)
leucovorin calcium TABS
LEUCOVORIN CALCIUM TABS
LEUKERAN TABS (PA) (SP)
MATULANE CAPS (PA) (SP)
MEKINIST TABS (PA) (QL) (SP)
mercaptopurine TABS
MYLERAN TABS (PA) (SP)
NEXAVAR TABS (PA) (SP)
PERJETA SOLN (PA) (SP)
POMALYST CAPS (PA) (SP) (QL)
REVLIMID CAPS (PA) (SP)
RITUXAN CONC (PA)
SPRYCEL TABS (PA) (SP)
STIVARGA TABS (PA) (QL) (SP)
SUTENT CAPS (PA) (SP)
SYLATRON KIT (PA) (SP)
[MPC021249] Page 13 of 46 August 15, 2013
Drug Name Dosage Form Note
TABLOID TABS (PA) (SP)
TAFINLAR CAPS (PA) (QL) (SP)
tamoxifen citrate TABS
TARCEVA TABS (PA) (SP)
TARGRETIN CAPS (PA) (SP)
TASIGNA CAPS (PA) (SP)
temozolomide CAPS (PA) (SP)
THALOMID CAPS (PA)
TYKERB TABS (PA) (SP)
VOTRIENT TABS (PA) (SP)
XALKORI (200MG) CAPS (PA) (SP)
XALKORI (250MG) CAPS (PA) (SP)
XELODA TABS (PA) (SP)
YERVOY SOLN (PA)
ZALTRAP SOLN (PA) (SP)
ZELBORAF TABS (PA) (SP)
ZOLINZA CAPS (PA) (SP)
ZYTIGA TABS (PA) (SP)
Drug Name Dosage Form Note
chloroquine phosphate TABS
hydroxychloroquine sulfate TABS
lindane *
MEPRON SUSP
NEBUPENT SOLR
NEUTREXIN SOLR
PENTAM 300 SOLR
permethrin CREA
PRIMAQUINE PHOSPHATE TABS
Drug Name Dosage Form Note
amantadine hcl *
AMANTADINE HCL *
APOKYN SOLN (PA) (SP)
benztropine mesylate TABS
bromocriptine mesylate *
carbidopa/levodopa TABS
carbidopa/levodopa er TBCR
Antiparasitics
Antiparkinson Agents
[MPC021249] Page 14 of 46 August 15, 2013
Drug Name Dosage Form Note
carbidopa/levodopa odt TBDP
COGENTIN SOLN
COMTAN TABS
EMSAM PT24 (PA) (QL)
pramipexole dihydrochloride (0.125mg) TABS
pramipexole dihydrochloride (0.25mg) TABS
pramipexole dihydrochloride (0.5mg) TABS
pramipexole dihydrochloride (0.75mg) TABS
pramipexole dihydrochloride (1.5mg) TABS
pramipexole dihydrochloride (1mg) TABS
ropinirole hcl TABS
selegiline hcl *
trihexyphenidyl hcl *
Drug Name Dosage Form Note
ABILIFY SOLN (PA) (QL)
ABILIFY TABS (PA) (QL)
ABILIFY DISCMELT TBDP (PA) (QL)
ABILIFY MAINTENA SUSR (MB) (PA) (SP)
chlorpromazine hcl TABS
clozapine (100mg) TABS (QL)
clozapine (200mg) TABS (QL)
clozapine (25mg) TABS (QL)
clozapine (50mg) TABS (QL)
CLOZAPINE ODT (100MG) TBDP (QL)
CLOZAPINE ODT (12.5MG) TBDP (QL)
CLOZAPINE ODT (25MG) TBDP (QL)
compro SUPP
fluphenazine hcl *
FLUPHENAZINE HCL *
haloperidol TABS
loxapine succinate CAPS
olanzapine (10mg) TABS (AG) (QL)
olanzapine (15mg) TABS (AG) (QL)
olanzapine (2.5mg) TABS (AG) (QL)
olanzapine (20mg) TABS (AG) (QL)
olanzapine (5mg) TABS (AG) (QL)
olanzapine (7.5mg) TABS (AG) (QL)
olanzapine odt TBDP (PA) (QL)
perphenazine TABS
PERPHENAZINE/AMITRIPTYLINE TABS
Antipsychotics
[MPC021249] Page 15 of 46 August 15, 2013
Drug Name Dosage Form Note
prochlorperazine SUPP
PROCHLORPERAZINE EDISYLATE SOLN
prochlorperazine maleate TABS
quetiapine fumarate (100mg) TABS (AG) (QL)
quetiapine fumarate (200mg) TABS (AG) (QL)
quetiapine fumarate (25mg) TABS (AG) (QL)
quetiapine fumarate (300mg) TABS (AG) (QL)
quetiapine fumarate (400mg) TABS (AG) (QL)
quetiapine fumarate (50mg) TABS (AG) (QL)
RISPERDAL CONSTA SUSR (PA) (QL) (SP)
risperidone odt (0.25mg) TBDP (PA) (QL)
thioridazine hcl TABS
thiothixene CAPS
trifluoperazine hcl TABS
ziprasidone hcl CAPS (AG) (QL)
Drug Name Dosage Form Note
baclofen TABS
tizanidine hcl TABS
Drug Name Dosage Form Note
abacavir TABS (QL)
acyclovir *
ALFERON N SOLN (SP)
amantadine hcl *
AMANTADINE HCL *
APTIVUS SOLN (QL)
APTIVUS CAPS (QL)
ATRIPLA TABS (QL)
COMPLERA TABS (SP)
CRIXIVAN CAPS (QL)
didanosine CPDR (QL)
EDURANT TABS (SP)
EMTRIVA SOLN
EMTRIVA CAPS (QL)
EPIVIR SOLN (QL)
EPIVIR HBV *
EPZICOM TABS (QL)
Antispasticity Agents
Antivirals
[MPC021249] Page 16 of 46 August 15, 2013
Drug Name Dosage Form Note
famciclovir TABS
FUZEON KIT (QL)
INCIVEK TABS (PA) (QL) (SP)
INFERGEN INJ (SP)
INTELENCE (100MG) TABS (QL) (SP)
INTELENCE (200MG) TABS (QL) (SP)
INTELENCE (25MG) TABS (QL) (SP)
INTRON-A SOLN (SP)
INTRON-A W/DILUENT SOLR (SP)
INVIRASE * (QL)
ISENTRESS TABS (QL)
KALETRA SOLN
KALETRA TABS (QL)
lamivudine TABS (QL)
lamivudine/zidovudine TABS (QL)
LEXIVA TABS (QL)
LEXIVA SUSP
NEVIRAPINE SUSP (QL)
nevirapine TABS (QL)
NORVIR * (QL)
NORVIR SOLN (QL)
PEG-INTRON KIT (PA) (SP)
PEG-INTRON REDIPEN PAK 4 KIT (PA) (SP)
PEGASYS * (PA) (SP)
PREZISTA SUSP (QL)
PREZISTA (150MG) TABS (QL)
PREZISTA (400MG) TABS (QL)
PREZISTA (600MG) TABS (QL)
PREZISTA (75MG) TABS (QL)
PREZISTA (800MG) TABS (QL)
RELENZA DISKHALER AEPB (QL)
RESCRIPTOR TABS (QL) (SP)
RESCRIPTOR TABS (QL)
REYATAZ CAPS (QL)
ribasphere CAPS (SP)
ribavirin TABS (SP)
SELZENTRY TABS (QL)
SELZENTRY TABS (QL) (SP)
stavudine CAPS (QL)
stavudine SOLR (QL)
STRIBILD TABS (QL) (SP)
SUSTIVA * (QL)
TAMIFLU CAPS (QL)
TAMIFLU SUSR (QL)
[MPC021249] Page 17 of 46 August 15, 2013
Drug Name Dosage Form Note
trifluridine SOLN
TRIZIVIR TABS (QL)
TRUVADA TABS
VALCYTE TABS (PA) (QL)
VALCYTE SOLR (PA) (QL)
VICTRELIS CAPS (PA) (QL) (SP)
VIDEX PEDIATRIC SOLR (QL) (SP)
VIRACEPT TABS (QL)
VIRAMUNE XR TB24 (QL)
VIREAD * (QL)
VIREAD (150MG) TABS (QL)
VIREAD (200MG) TABS (QL)
VIREAD (250MG) TABS (QL)
VIREAD (300MG) TABS (QL)
ZIAGEN SOLN (QL)
zidovudine * (QL)
zidovudine SYRP
ZOVIRAX CREA
ZOVIRAX OINT (QL)
Drug Name Dosage Form Note
alprazolam (0.25mg) TABS (QL)
alprazolam (0.5mg) TABS (QL)
alprazolam (1mg) TABS (QL)
alprazolam (2mg) TABS (QL)
ALPRAZOLAM INTENSOL CONC
buspirone hcl TABS (QL)
chlordiazepoxide hcl CAPS (QL)
clonazepam TABS (QL)
clonazepam odt TBDP (QL)
CYMBALTA (20MG) CPEP (PA) (QL)
CYMBALTA (30MG) CPEP (PA) (QL)
CYMBALTA (60MG) CPEP (PA) (QL)
diazepam TABS (QL)
DOXEPIN HCL *
doxepin hcl *
escitalopram oxalate SOLN (QL)
escitalopram oxalate (10mg) TABS (QL)
escitalopram oxalate (20mg) TABS (QL)
escitalopram oxalate (5mg) TABS (QL)
hydroxyzine hcl *
Anxiolytics
[MPC021249] Page 18 of 46 August 15, 2013
Drug Name Dosage Form Note
hydroxyzine pamoate CAPS
HYDROXYZINE PAMOATE CAPS
lorazepam TABS (QL)
lorazepam CONC
meprobamate TABS
paroxetine hcl (10mg) TABS (QL)
paroxetine hcl (20mg) TABS (QL)
paroxetine hcl (30mg) TABS (QL)
paroxetine hcl (40mg) TABS (QL)
paroxetine hcl er TB24 (ST)
PAXIL SUSP (QL)
sertraline hcl CONC (QL)
sertraline hcl (100mg) TABS (QL)
sertraline hcl (25mg) TABS (QL)
sertraline hcl (50mg) TABS (QL)
venlafaxine hcl TABS (QL)
venlafaxine hcl er (150mg) TB24 (QL)
venlafaxine hcl er (150mg) CP24 (QL)
venlafaxine hcl er (37.5mg) CP24 (QL)
venlafaxine hcl er (37.5mg) TB24 (QL)
venlafaxine hcl er (75mg) CP24 (QL)
venlafaxine hcl er (75mg) TB24 (QL)
Drug Name Dosage Form Note
ABILIFY TABS (PA) (QL)
ABILIFY SOLN (PA) (QL)
ABILIFY DISCMELT TBDP (PA) (QL)
ABILIFY MAINTENA SUSR (MB) (PA) (SP)
carbamazepine *
carbamazepine er *
divalproex sodium CPSP
divalproex sodium dr TBEC
divalproex sodium er TB24
LAMICTAL CHEW (QL)
lamotrigine CHEW (QL)
lamotrigine (100mg) TABS (QL)
lamotrigine (150mg) TABS (QL)
lamotrigine (200mg) TABS (QL)
lamotrigine (25mg) TABS (QL)
lithium carbonate *
lithium carbonate er TBCR
Bipolar Agents
[MPC021249] Page 19 of 46 August 15, 2013
Drug Name Dosage Form Note
LITHIUM CITRATE SOLN
olanzapine (10mg) TABS (AG) (QL)
olanzapine (15mg) TABS (AG) (QL)
olanzapine (2.5mg) TABS (AG) (QL)
olanzapine (20mg) TABS (AG) (QL)
olanzapine (5mg) TABS (AG) (QL)
olanzapine (7.5mg) TABS (AG) (QL)
olanzapine odt TBDP (PA) (QL)
quetiapine fumarate (100mg) TABS (AG) (QL)
quetiapine fumarate (200mg) TABS (AG) (QL)
quetiapine fumarate (25mg) TABS (AG) (QL)
quetiapine fumarate (300mg) TABS (AG) (QL)
quetiapine fumarate (400mg) TABS (AG) (QL)
quetiapine fumarate (50mg) TABS (AG) (QL)
RISPERDAL CONSTA SUSR (PA) (QL) (SP)
risperidone SOLN (AG) (QL)
risperidone (0.25mg) TABS (AG) (QL)
risperidone (0.5mg) TABS (AG) (QL)
risperidone (1mg) TABS (AG) (QL)
risperidone (2mg) TABS (AG) (QL)
risperidone (3mg) TABS (AG) (QL)
risperidone (4mg) TABS (AG) (QL)
risperidone odt (0.25mg) TBDP (PA) (QL)
risperidone odt (0.5mg) TBDP (PA) (QL)
risperidone odt (1mg) TBDP (PA) (QL)
risperidone odt (2mg) TBDP (PA) (QL)
risperidone odt (3mg) TBDP (PA) (QL)
risperidone odt (4mg) TBDP (PA) (QL)
TEGRETOL-XR TB12
valproic acid CAPS
ziprasidone hcl CAPS (AG) (QL)
Drug Name Dosage Form Note
acarbose TABS
AVANDAMET TABS (ST)
AVANDIA TABS (ST)
BYETTA (10MCG/0.04ML) SOLN (PA) (QL)
BYETTA (5MCG/0.02ML) SOLN (PA) (QL)
CHLORPROPAMIDE TABS
glimepiride TABS
glipizide TABS
Blood Glucose Regulators
[MPC021249] Page 20 of 46 August 15, 2013
Drug Name Dosage Form Note
glipizide er TB24
glipizide/metformin hcl TABS
GLUCAGEN SOLR
GLUCAGON EMERGENCY KIT KIT
glyburide TABS
glyburide/metformin hcl TABS
JANUMET TABS (QL) (ST)
JANUMET XR (1000MG; 100MG) TB24 (QL) (ST)
JANUMET XR (1000MG; 50MG) TB24 (QL) (ST)
JANUMET XR (500MG; 50MG) TB24 (QL) (ST)
JANUVIA TABS (QL) (ST)
KOMBIGLYZE XR TB24 (PA)
LANTUS SOLN (QL)
LANTUS SOLOSTAR SOLN (QL)
LEVEMIR SOLN (QL)
LEVEMIR FLEXPEN SOLN (QL)
metformin hcl TABS
metformin hcl er TB24
nateglinide TABS
NOVOLIN 70/30 SUSP (QL)
NOVOLIN N SUSP (QL)
NOVOLIN R SOLN (QL)
NOVOLOG SOLN (QL)
NOVOLOG FLEXPEN SOLN (QL)
NOVOLOG MIX 70/30 SUSP (QL)
NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUSP (QL)
NOVOLOG PENFILL SOLN (QL)
ONGLYZA TABS (PA) (QL)
pioglitazone hcl TABS (ST)
pioglitazone hcl-glimepiride TABS (ST)
pioglitazone hcl/metformin hcl TABS (ST)
PRANDIMET TABS (ST)
SYMLINPEN 120 SOLN (PA)
tolazamide TABS
TOLAZAMIDE TABS
VICTOZA SOLN (PA) (QL)
WELCHOL *
Drug Name Dosage Form Note
anagrelide hydrochloride CAPS
ARANESP ALBUMIN FREE SOLN (PA) (SP)
Blood Products/Modifiers/Volume Expanders
[MPC021249] Page 21 of 46 August 15, 2013
Drug Name Dosage Form Note
BERINERT KIT (PA) (SP)
BRILINTA TABS (PA) (QL)
cilostazol TABS
CINRYZE SOLR (PA)
clopidogrel TABS
dipyridamole TABS
EFFIENT TABS (PA)
enoxaparin sodium (100mg/ml) SOLN (QL)
enoxaparin sodium (120mg/0.8ml) SOLN (QL)
enoxaparin sodium (150mg/ml) SOLN (QL)
enoxaparin sodium (300mg/3ml) SOLN (QL)
enoxaparin sodium (30mg/0.3ml) SOLN (QL)
enoxaparin sodium (40mg/0.4ml) SOLN (QL)
enoxaparin sodium (60mg/0.6ml) SOLN (QL)
enoxaparin sodium (80mg/0.8ml) SOLN (QL)
EPOGEN SOLN (PA) (SP)
fondaparinux sodium SOLN (PA)
HEPARIN LOCK FLUSH SOLN
heparin lock flush SOLN
HEPARIN SODIUM SOLN
heparin sodium SOLN
heparin sodium lock flush SOLN
heparin sodium lock flush KIT
HEPARIN SODIUM/D5W SOLN
heparin sodium/d5w SOLN
HEPARIN SODIUM/NACL 0.45% SOLN
heparin sodium/sodium chloride 0.9% premix SOLN
jantoven TABS
NEULASTA SOLN (PA) (SP)
NEUMEGA SOLR (PA) (SP)
NEUPOGEN SOLN (PA) (SP)
PROCRIT SOLN (PA) (SP)
SOLIRIS SOLN PA, SP
ticlopidine hcl TABS
warfarin sodium TABS
XARELTO TABS (QL)
Drug Name Dosage Form Note
acebutolol hcl CAPS
acetazolamide TABS
ACETAZOLAMIDE TABS
Cardiovascular Agents
[MPC021249] Page 22 of 46 August 15, 2013
Drug Name Dosage Form Note
ADVICOR TB24 (ST)
ALDACTAZIDE TABS
amiloride hcl TABS
amiloride/hydrochlorothiazide TABS
amiodarone hcl TABS
amlodipine besylate TABS
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM TABS (QL) (ST)
amlodipine besylate/benazepril hcl CAPS
amlodipine besylate/benazepril hydrochloride CAPS
atenolol TABS
atorvastatin calcium TABS (QL) (ST)
benazepril hcl TABS
benazepril hcl/hydrochlorothiazide TABS
betaxolol hcl TABS
bisoprolol fumarate TABS
bisoprolol fumarate/hydrochlorothiazide TABS
bumetanide TABS
candesartan cilexetil TABS (ST)
candesartan cilexetil/hydrochlorothiazide TABS (ST)
captopril TABS
CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS
cartia xt CP24
carvedilol TABS
CHLORTHALIDONE TABS
cholestyramine *
cholestyramine light *
clonidine hcl TABS
digoxin *
DIGOXIN *
DILATRATE SR CPCR
dilt-cd CP24
diltiazem cd CP24
diltiazem hcl *
diltiazem hcl CP24
diltiazem hcl er *
diltiazem hcl er CP24
diltiazem hcl er CP24
diltzac CP24
DIOVAN TABS (ST)
disopyramide phosphate CAPS
doxazosin mesylate TABS
DUTOPROL TB24
DYRENIUM CAPS
EDECRIN TABS
[MPC021249] Page 23 of 46 August 15, 2013
Drug Name Dosage Form Note
enalapril maleate TABS
enalapril maleate/hydrochlorothiazide TABS
felodipine er TB24
fenofibrate TABS
fenofibrate micronized CAPS
FIRAZYR SOLN (PA) (SP)
flecainide acetate TABS
fosinopril sodium TABS
fosinopril sodium/hydrochlorothiazide TABS
FUROSEMIDE *
furosemide *
gemfibrozil TABS
guanfacine hcl TABS
hydralazine hcl TABS
hydrochlorothiazide *
indapamide TABS
ISOSORBIDE DINITRATE *
isosorbide dinitrate *
isosorbide dinitrate er TBCR
isosorbide mononitrate TABS
isosorbide mononitrate er TB24
labetalol hcl TABS
lisinopril TABS
lisinopril/hydrochlorothiazide TABS
losartan potassium TABS
losartan potassium/hydrochlorothiazide TABS
lovastatin TABS
methyldopa TABS
metolazone TABS
metoprolol succinate er TB24
metoprolol tartrate TABS
metoprolol/hydrochlorothiazide TABS
mexiletine hcl CAPS
midodrine hcl TABS
minoxidil TABS
moexipril hcl TABS
moexipril/hydrochlorothiazide TABS
MULTAQ TABS (PA) (QL)
nadolol TABS
NIASPAN TBCR
nifediac cc TB24
nifedical xl TB24
nifedipine CAPS
nifedipine er TB24
[MPC021249] Page 24 of 46 August 15, 2013
Drug Name Dosage Form Note
nimodipine CAPS
NISOLDIPINE TB24
NITRO-BID OINT
NITRO-DUR PT24
nitroglycerin er CPCR
nitroglycerin transdermal (0.1mg/hr) PT24
nitroglycerin transdermal (0.2mg/hr) PT24
nitroglycerin transdermal (0.4mg/hr) PT24
nitroglycerin transdermal (0.6mg/hr) PT24
NITROSTAT SUBL
NORPACE CR CP12
pacerone TABS
pentoxifylline er TBCR
PINDOLOL TABS
pravastatin sodium TABS
prazosin hcl CAPS
prevalite POWD
propafenone hcl TABS
propranolol hcl *
PROPRANOLOL HCL *
propranolol hcl er CP24
quinapril hcl TABS
quinapril/hydrochlorothiazide TABS
quinidine gluconate er TBCR
quinidine sulfate TABS
ramipril CAPS
RANEXA TB12 (ST)
SIMCOR TB24 (ST)
simvastatin TABS
sotalol hcl TABS
sotalol hcl (af) TABS
spironolactone TABS
spironolactone/hydrochlorothiazide TABS
taztia xt CP24
terazosin hcl CAPS
TIMOLOL MALEATE TABS
triamterene/hydrochlorothiazide *
valsartan/hydrochlorothiazide TABS (ST)
verapamil hcl TABS
VERAPAMIL HCL TABS
verapamil hcl er *
verapamil hcl sr CP24
VYTORIN TABS (ST)
WELCHOL *
[MPC021249] Page 25 of 46 August 15, 2013
Drug Name Dosage Form Note
ZETIA TABS
Drug Name Dosage Form Note
amphetamine/dextroamphetamine CP24 (AG) (QL) (ST)
amphetamine/dextroamphetamine (1.25mg; 1.25mg;
1.25mg; 1.25mg)
TABS (AG) (QL)
amphetamine/dextroamphetamine (1.875mg; 1.875mg;
1.875mg; 1.875mg)
TABS (AG) (QL)
amphetamine/dextroamphetamine (2.5mg; 2.5mg;
2.5mg; 2.5mg)
TABS (AG) (QL)
amphetamine/dextroamphetamine (3.125mg; 3.125mg;
3.125mg; 3.125mg)
TABS (AG) (QL)
amphetamine/dextroamphetamine (3.75mg; 3.75mg;
3.75mg; 3.75mg)
TABS (AG) (QL)
amphetamine/dextroamphetamine (5mg; 5mg; 5mg; 5mg) TABS (AG) (QL)
amphetamine/dextroamphetamine (7.5mg; 7.5mg;
7.5mg; 7.5mg)
TABS (AG) (QL)
AMPYRA TB12 (PA) (QL) (SP)
AVONEX KIT (SP)
butalbital/acetaminophen/caffeine/codeine CAPS (QL)
butalbital/asa/caffeine CAPS
butalbital/aspirin/caffeie/codeine CAPS
BUTALBITAL/ASPIRIN/CAFFEINE TABS
caffeine citrate SOLN
COPAXONE KIT (SP)
CYMBALTA (20MG) CPEP (PA) (QL)
CYMBALTA (30MG) CPEP (PA) (QL)
CYMBALTA (60MG) CPEP (PA) (QL)
dextroamphetamine sulfate TABS (AG) (QL)
dextroamphetamine sulfate er CP24 (AG) (QL)
EXTAVIA SOLR (PA) (SP)
LYRICA (100MG) CAPS (PA) (QL)
LYRICA (150MG) CAPS (PA) (QL)
LYRICA (200MG) CAPS (PA) (QL)
LYRICA (225MG) CAPS (PA) (QL)
LYRICA (25MG) CAPS (PA) (QL)
LYRICA (300MG) CAPS (PA) (QL)
LYRICA (50MG) CAPS (PA) (QL)
LYRICA (75MG) CAPS (PA) (QL)
methylphenidate hcl TABS (AG) (QL)
methylphenidate hcl cd CPCR (AG) (QL)
METHYLPHENIDATE HCL ER (10MG) TBCR (AG) (QL)
methylphenidate hcl er (18mg) TBCR (AG) (QL) (ST)
methylphenidate hcl er (20mg) TBCR (AG) (QL)
methylphenidate hcl er (27mg) TBCR (AG) (QL) (ST)
Central Nervous System Agents
[MPC021249] Page 26 of 46 August 15, 2013
Drug Name Dosage Form Note
methylphenidate hcl er (36mg) TBCR (AG) (QL) (ST)
methylphenidate hcl er (54mg) TBCR (AG) (QL) (ST)
REBIF SOLN (PA) (SP)
REBIF TITRATION PACK SOLN (PA) (SP)
STRATTERA CAPS (QL) (ST)
TYSABRI CONC (PA) (SP)
VYVANSE (20MG) CAPS (AG) (QL) (ST)
VYVANSE (30MG) CAPS (AG) (QL) (ST)
VYVANSE (40MG) CAPS (AG) (QL) (ST)
VYVANSE (50MG) CAPS (AG) (QL) (ST)
VYVANSE (60MG) CAPS (AG) (QL) (ST)
VYVANSE (70MG) CAPS (AG) (QL) (ST)
Drug Name Dosage Form Note
chlorhexidine gluconate SOLN
clinpro 5000 PSTE
oralone PSTE (QL)
periogard SOLN
phos-flur GEL
pilocarpine hcl TABS (QL)
pilocarpine hydrochloride TABS (QL)
sf GEL
triamcinolone in orabase PSTE (QL)
Drug Name Dosage Form Note
ACZONE GEL (PA)
adapalene * (AG)
AKNE-MYCIN OINT
alclometasone dipropionate OINT
amnesteem CAPS (QL)
betamethasone dipropionate *
betamethasone valerate *
calcipotriene *
calcipotriene CREA
calcitrene OINT
claravis CAPS (QL)
CLARAVIS CAPS (QL)
clindamax *
Dental and Oral Agents
Dermatological Agents
[MPC021249] Page 27 of 46 August 15, 2013
Drug Name Dosage Form Note
clindamycin phosphate *
clobetasol propionate *
clobetasol propionate e CREA
clotrimazole/betamethasone dipropionate *
cormax scalp application SOLN
CORTISPORIN CREA
desonide *
ELIDEL CREA (PA)
ERYTHROMYCIN *
erythromycin *
erythromycin/benzoyl peroxide GEL
FINACEA GEL
fluocinolone acetonide *
fluocinolone acetonide OIL
fluocinolone acetonide body OIL
fluocinolone acetonide scalp OIL
fluocinonide *
fluorouracil *
fluticasone propionate *
hydrocortisone *
hydrocortisone valerate *
imiquimod CREA (QL)
lidocaine hcl/hydrocortisone acetate CREA
lokara LOTN
mometasone furoate *
NOVACORT GEL
OXSORALEN ULTRA CAPS
podofilox SOLN
proctocream hc CREA
proctosol hc CREA
PROTOPIC OINT (PA) (QL)
rosanil cleanser EMUL
selenium sulfide LOTN
SODIUM SULFACETAMIDE/SULFUR *
sodium sulfacetamide/sulfur *
sodium sulfacetamide/sulfur CREA
sotret CAPS (QL)
sulfacetamide sodium/sulfur cleanser EMUL
tretinoin CREA (AG)
tretinoin GEL (AG)
TRIAMCINOLONE ACETONIDE *
triamcinolone acetonide *
TRIANEX OINT
[MPC021249] Page 28 of 46 August 15, 2013
Drug Name Dosage Form Note
Drug Name Dosage Form Note
CREON CPEP
PANCREAZE CPEP
Drug Name Dosage Form Note
ACIPHEX TBEC (QL) (ST)
CARAFATE SUSP
cimetidine TABS
cimetidine hcl SOLN
COLYTE-FLAVOR PACKS SOLR
constulose SOLN
DICYCLOMINE HCL *
dicyclomine hcl *
DIPHENOXYLATE/ATROPINE LIQD
famotidine *
glycopyrrolate *
GOLYTELY SOLR
hyoscyamine sulfate *
hyoscyamine sulfate er TB12
ISOPTO HYOSCINE SOLN
lactulose SOLN
lactulose SOLN
lansoprazole CPDR (QL) (ST)
LINZESS CAPS (PA) (QL)
LOTRONEX TABS
metoclopramide hcl *
misoprostol TABS
omeprazole CPDR
omeprazole/sodium bicarbonate CAPS (QL) (ST)
pantoprazole sodium TBEC (QL)
peg 3350/electrolytes SOLR
peg-3350/electrolytes SOLR
polyethylene glycol 3350 POWD
PREVACID SOLUTAB TBDP (PA)
PROPANTHELINE BROMIDE TABS
ranitidine hcl *
sucralfate TABS
ursodiol *
Enzyme Replacement/Modifiers
Gastrointestinal Agents
[MPC021249] Page 29 of 46 August 15, 2013
Drug Name Dosage Form Note
XIFAXAN TABS (PA) (QL)
ZEGERID PACK (QL) (ST)
Drug Name Dosage Form Note
AVODART CAPS (ST)
bethanechol chloride TABS
CUPRIMINE CAPS
DEPEN TITRATABS TABS
DETROL LA CP24
doxazosin mesylate TABS
ENABLEX TB24 (ST)
finasteride TABS
oxybutynin chloride *
oxybutynin chloride er TB24
phenazopyridine hcl TABS
prazosin hcl CAPS
RENAGEL TABS
RENVELA TABS
tamsulosin hcl CAPS
terazosin hcl CAPS
tolterodine tartrate TABS
trospium chloride TABS (ST)
VESICARE TABS (ST)
Drug Name Dosage Form Note
a-hydrocort SOLR
alclometasone dipropionate OINT
augmented betamethasone dipropionate *
betamethasone dipropionate *
betamethasone valerate *
clobetasol propionate *
clobetasol propionate e CREA
clotrimazole/betamethasone dipropionate *
cormax scalp application SOLN
desonide *
DEXAMETHASONE *
dexamethasone *
DEXAMETHASONE INTENSOL CONC
Genitourinary Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
[MPC021249] Page 30 of 46 August 15, 2013
Drug Name Dosage Form Note
fludrocortisone acetate TABS
fluocinolone acetonide *
fluocinolone acetonide OIL
fluocinolone acetonide body OIL
fluocinolone acetonide scalp OIL
fluocinonide *
fluticasone propionate *
hydrocortisone ENEM
hydrocortisone TABS
hydrocortisone *
hydrocortisone valerate *
lidocaine hcl/hydrocortisone acetate CREA
lokara LOTN
MEDROL TABS
methylprednisolone TABS
methylprednisolone dose pack TABS
MILLIPRED TABS
MILLIPRED DP TABS
mometasone furoate *
prednisolone SOLN
prednisolone sodium phosphate SOLN
PREDNISONE *
prednisone *
proctocream hc CREA
proctosol hc CREA
SOLU-CORTEF SOLR
TRIAMCINOLONE ACETONIDE *
triamcinolone acetonide *
TRIANEX OINT
Drug Name Dosage Form Note
desmopressin acetate SOLN
desmopressin acetate TABS
desmopressin acetate SOLN
INCRELEX SOLN (PA) (SP)
NORDITROPIN FLEXPRO SOLN (PA) (SP)
NORDITROPIN NORDIFLEX PEN SOLN (PA) (SP)
OMNITROPE SOLN (PA) (SP)
TEV-TROPIN SOLR (PA) (SP)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
[MPC021249] Page 31 of 46 August 15, 2013
Drug Name Dosage Form Note
Drug Name Dosage Form Note
misoprostol TABS
Drug Name Dosage Form Note
ALORA PTTW (QL)
altavera TABS
alyacen 1/35 TABS
ANDRODERM (2MG/24HR) PT24 (PA) (QL)
ANDRODERM (4MG/24HR) PT24 (PA) (QL)
ANDROGEL (25MG/2.5GM) GEL (PA) (QL)
ANDROGEL (50MG/5GM) GEL (PA) (QL)
ANDROGEL PUMP (1%) GEL (PA) (QL)
ANDROGEL PUMP (1.62%) GEL (PA) (QL)
ANDROXY TABS (PA)
apri TABS
aranelle TABS
aviane TABS
azurette TABS
balziva TABS
camila TABS
caziant TABS
cesia TABS
COMBIPATCH PTTW (ST)
cryselle-28 TABS
cyclafem 1/35 TABS
cyclafem 7/7/7 TABS
danazol CAPS
drospirenone/ethinyl estradiol TABS
emoquette TABS
enpresse-28 TABS
enskyce TABS
errin TABS
ESTRACE CREA
estradiol *
estradiol/norethindrone acetate TABS
ESTROPIPATE TABS
estropipate TABS
EVISTA TABS
FORTESTA GEL (PA) (QL)
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
[MPC021249] Page 32 of 46 August 15, 2013
Drug Name Dosage Form Note
gildess fe 1.5/30 TABS
gildess fe 1/20 TABS
heather TABS
JINTELI TABS
jolivette TABS
junel 1.5/30 TABS
junel 1/20 TABS
junel fe 1.5/30 TABS
junel fe 1/20 TABS
kariva TABS
kelnor 1/35 TABS
kurvelo TABS
leena TABS
lessina TABS
levonorgestrel TABS (QL)
levora 0.15/30-28 TABS
LOESTRIN 24 FE TABS
low-ogestrel TABS
lutera TABS
marlissa TABS
medroxyprogesterone acetate SUSP
medroxyprogesterone acetate TABS
MEGACE ES SUSP (PA)
megestrol acetate *
MENEST TABS
microgestin 1.5/30 TABS
microgestin 1/20 TABS
microgestin fe TABS
microgestin fe 1.5/30 TABS
mimvey TABS
mononessa TABS
necon 0.5/35-28 TABS
necon 1/35 TABS
NECON 1/50-28 TABS
necon 7/7/7 TABS
NEXPLANON IMPL
next choice TABS (QL)
nora-be TABS
norethindrone TABS
norethindrone acetate TABS
norgestimate/ethinyl estradiol TABS
norgestimate/ethinyl estradiol TABS
nortrel 0.5/35 (28) TABS
nortrel 1/35 TABS
[MPC021249] Page 33 of 46 August 15, 2013
Drug Name Dosage Form Note
nortrel 7/7/7 TABS
ocella TABS
orsythia TABS
ORTHO TRI-CYCLEN LO TABS
ortho-est TABS
philith TABS
pirmella 1/35 TABS
pirmella 7/7/7 TABS
portia-28 TABS
PREFEST TABS
PREMARIN TABS
PREMARIN CREA
PREMPHASE TABS
PREMPRO TABS
previfem TABS
progesterone CAPS
reclipsen TABS
solia TABS
sprintec 28 TABS
sronyx TABS
syeda TABS
TESTIM GEL (PA) (QL)
TESTOPEL PLLT (PA) (QL)
testosterone cypionate OIL (PA)
testosterone enanthate OIL (PA)
tilia fe TABS
tri-legest fe TABS
tri-linyah TABS
tri-previfem TABS
tri-sprintec TABS
trinessa TABS
trivora-28 TABS
velivet TABS
VIVELLE-DOT PTTW (QL)
zarah TABS
zenchent TABS
zovia 1/35e TABS
ZOVIA 1/50E TABS
Drug Name Dosage Form Note
levothroid TABS
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
[MPC021249] Page 34 of 46 August 15, 2013
Drug Name Dosage Form Note
levothyroxine sodium TABS
levoxyl TABS
liothyronine sodium TABS
np thyroid 30 TABS
np thyroid 60 TABS
np thyroid 90 TABS
unithroid TABS
WESTHROID TABS
Drug Name Dosage Form Note
LYSODREN TABS
Drug Name Dosage Form Note
SENSIPAR TABS (PA)
Drug Name Dosage Form Note
bromocriptine mesylate *
ELIGARD KIT (SP)
ELIGARD KIT (SP)
ELIGARD KIT (SP)
ELIGARD KIT (SP)
leuprolide acetate KIT
LUPRON DEPOT-PED KIT
ZOLADEX IMPL
Drug Name Dosage Form Note
AVODART CAPS (ST)
bicalutamide TABS (ST)
finasteride TABS
flutamide CAPS
XTANDI CAPS (PA) (QL) (SP)
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
[MPC021249] Page 35 of 46 August 15, 2013
Drug Name Dosage Form Note
Drug Name Dosage Form Note
methimazole TABS
propylthiouracil TABS
Drug Name Dosage Form Note
ACTIMMUNE SOLN (SP)
AVONEX KIT (SP)
azathioprine TABS
BENLYSTA SOLR (PA)
BIVIGAM SOLN (PA)
CARIMUNE NANOFILTERED SOLR
CELLCEPT SUSR
CUPRIMINE CAPS
cyclosporine CAPS
CYCLOSPORINE MODIFIED *
cyclosporine modified *
cyclosporine modified (100mg/ml) SOLN
cyclosporine modified (100mg/ml) SOLN
CYTOGAM INJ (PA)
DEPEN TITRATABS TABS
ELIDEL CREA (PA)
ENBREL * (PA) (SP)
EXTAVIA SOLR (PA) (SP)
FLEBOGAMMA SOLN (PA)
FLEBOGAMMA DIF SOLN (PA)
GAMASTAN S/D INJ (PA)
GAMMAGARD LIQUID SOLN (PA)
GAMMAGARD S/D SOLR (PA)
GAMMAGARD S/D IGA LESS THAN 1MCG/ML SOLR (PA)
GAMMAPLEX SOLN
GAMUNEX SOLN (PA)
GAMUNEX-C SOLN (PA)
gengraf *
hecoria CAPS
HEPAGAM B SOLN (PA)
HIZENTRA SOLN (PA) (SP)
HUMIRA KIT (PA) (SP)
leflunomide TABS
Hormonal Agents, Suppressant (Thyroid)
Immunological Agents
[MPC021249] Page 36 of 46 August 15, 2013
Drug Name Dosage Form Note
mercaptopurine TABS
methotrexate TABS
methotrexate sodium *
mycophenolate mofetil *
ORENCIA * (PA) (SP)
PRIVIGEN SOLN (PA)
PROTOPIC OINT (PA) (QL)
PROVENGE SUSP
REBIF SOLN (PA) (SP)
REBIF TITRATION PACK SOLN (PA) (SP)
REMICADE SOLR (PA) (SP)
RIDAURA CAPS
SANDIMMUNE SOLN
SYNAGIS SOLN
tacrolimus CAPS
TREXALL TABS
TYSABRI CONC (PA) (SP)
ZOSTAVAX SOLR (AG)
Drug Name Dosage Form Note
a-hydrocort SOLR
APRISO CP24 (QL) (ST)
ASACOL TBEC (ST)
balsalazide disodium CAPS
CANASA SUPP
DEXAMETHASONE *
dexamethasone *
DEXAMETHASONE INTENSOL CONC
hydrocortisone ENEM
hydrocortisone TABS
MEDROL TABS
mesalamine ENEM
mesalamine KIT
methylprednisolone TABS
methylprednisolone dose pack TABS
MILLIPRED TABS
MILLIPRED DP TABS
PENTASA CPCR (ST)
prednisolone SOLN
prednisolone sodium phosphate SOLN
PREDNISONE *
Inflammatory Bowel Disease Agents
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Drug Name Dosage Form Note
prednisone *
SOLU-CORTEF SOLR
sulfasalazine *
Drug Name Dosage Form Note
alendronate sodium TABS
ALENDRONATE SODIUM TABS
calcitonin-salmon SOLN
calcitriol *
FORTEO SOLN (PA) (SP)
HECTOROL CAPS
ibandronate sodium TABS (QL) (ST)
PROLIA SOLN (PA) (SP)
XGEVA SOLN (PA) (SP)
zoledronic acid * (MB) (PA)
Drug Name Dosage Form Note
ACCU-CHEK ACTIVE STRIPS STRP (QL)
ACCU-CHEK AVIVA STRP (QL)
ACCU-CHEK COMFORT CURVE TEST STRIPS STRP (QL)
ACCU-CHEK COMPACT STRIPS STRP (QL)
ASSESS PEAK FLOW METER LOW RANGE DEVI
BD INSULIN SYRINGES MISC
BD PEN NEEDLES MISC
BOTOX SOLR (PA)
EUFLEXXA SOLN (SP)
KALBITOR SOLN (PA)
methylergonovine maleate TABS
NOVOFINE PEN NEEDLES MISC
NOVOTWIST PEN NEEDLES MISC
SYNVISC INJ (SP)
SYNVISC ONE INJ (SP)
Drug Name Dosage Form Note
acetazolamide TABS
Metabolic Bone Disease Agents
Miscellaneous Therapeutic Agents
Ophthalmic Agents
[MPC021249] Page 38 of 46 August 15, 2013
Drug Name Dosage Form Note
ACETAZOLAMIDE TABS
acetazolamide er CP12
ALPHAGAN P SOLN
ALREX SUSP (ST)
ATROPINE SULFATE *
atropine sulfate *
AZOPT SUSP
betaxolol hcl SOLN
BETOPTIC-S SUSP
BLEPHAMIDE SUSP
BLEPHAMIDE S.O.P. OINT
brimonidine tartrate SOLN
carteolol hcl SOLN
CIPRODEX SUSP (AG) (PA) (QL)
cromolyn sodium SOLN
dexamethasone sodium phosphate SOLN
diclofenac sodium SOLN
dorzolamide hcl SOLN
fluorometholone SUSP
FML OINT
FML FORTE SUSP
homatropaire SOLN
ISOPTO CARBACHOL SOLN
ISOPTO HOMATROPINE SOLN
ketorolac tromethamine SOLN
ketotifen fumarate SOLN
latanoprost SOLN
LEVOBUNOLOL HCL SOLN
levobunolol hcl SOLN
LOTEMAX SUSP (ST)
LUMIGAN SOLN
methazolamide TABS
NAPHCON-A SOLN
neomycin/polymyxin/bacitracin/hydrocortisone OINT
neomycin/polymyxin/dexamethasone *
OPCON-A SOLN
phenylephrine hcl SOLN
PHOSPHOLINE IODIDE SOLR
pilocarpine hcl SOLN
PRED MILD SUSP
prednisolone acetate SUSP
PREDNISOLONE SODIUM PHOSPHATE SOLN
RESTASIS EMUL (PA)
timolol maleate SOLN
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Drug Name Dosage Form Note
timolol maleate ophthalmic gel forming SOLG
tropicamide SOLN
Drug Name Dosage Form Note
acetic acid SOLN
ACETIC ACID/ALUMINUM ACETATE SOLN
antipyrine/benzocaine SOLN
COLY-MYCIN S SUSP
hydrocortisone/acetic acid SOLN
neomycin/polymyxin/hydrocortisone SOLN
NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP
neomycin/polymyxin/hydrocortisone SUSP
Drug Name Dosage Form Note
acetylcysteine SOLN
ADVAIR DISKUS AEPB (PA) (QL)
ADVAIR HFA AERO (PA) (QL)
albuterol sulfate *
albuterol sulfate er TB12
ASMANEX 30 METERED DOSES AEPB
ASMANEX 60 METERED DOSES AEPB
ATROVENT HFA AERS
AUVI-Q DEVI
azelastine hcl SOLN (PA)
budesonide SUSP (AG)
COMBIVENT AERO
COMBIVENT RESPIMAT AERS (QL)
cromolyn sodium NEBU
cyproheptadine hcl *
DALIRESP TABS (PA) (QL)
DULERA AERO (ST) (QL)
ELIXOPHYLLIN ELIX
FLOVENT DISKUS AEPB
FLOVENT HFA AERO
FLUNISOLIDE SOLN
fluticasone propionate SUSP
FORADIL AEROLIZER CAPS
hydroxyzine hcl *
Otic Agents
Respiratory Tract Agents
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Drug Name Dosage Form Note
hydroxyzine pamoate CAPS
HYDROXYZINE PAMOATE CAPS
ipratropium bromide SOLN
ipratropium bromide SOLN
ipratropium bromide/albuterol sulfate SOLN
LETAIRIS TABS (PA) (QL) (SP)
METAPROTERENOL SULFATE *
montelukast sodium * (QL)
phenadoz SUPP
PROAIR HFA AERS
promethazine hcl *
promethazine hcl plain SYRP
PROMETHEGAN SUPP
PULMICORT FLEXHALER AEPB
PULMOZYME SOLN
QVAR AERS
SEREVENT DISKUS AEPB
sildenafil citrate TABS (PA) (QL)
sodium chloride (0.9%) NEBU
sodium chloride (7%) NEBU
SPIRIVA HANDIHALER CAPS
SYMBICORT (160MCG/ACT; 4.5MCG/ACT) AERO (QL) (ST)
SYMBICORT (80MCG/ACT; 4.5MCG/ACT) AERO (QL) (ST)
terbutaline sulfate TABS
theophylline cr TB12
theophylline er *
triamcinolone acetonide INHA
TUDORZA PRESSAIR AEPB
VENTOLIN HFA AERS
XOLAIR SOLR (PA) (SP)
zafirlukast TABS
Drug Name Dosage Form Note
carisoprodol TABS
carisoprodol/aspirin TABS
carisoprodol/aspirin/codeine TABS
chlorzoxazone TABS
cyclobenzaprine hcl TABS
methocarbamol TABS
Skeletal Muscle Relaxants
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Drug Name Dosage Form Note
Drug Name Dosage Form Note
LUNESTA TABS (PA) (QL)
modafinil TABS (PA) (QL)
PHENOBARBITAL *
phenobarbital *
ROZEREM TABS (PA) (QL)
temazepam CAPS (QL)
triazolam TABS (QL)
XYREM SOLN
zaleplon CAPS (QL)
zolpidem tartrate TABS (QL)
zolpidem tartrate er TBCR (PA) (QL)
Drug Name Dosage Form Note
calcium acetate CAPS
clinpro 5000 PSTE
CUPRIMINE CAPS
cytra-2 SOLN
DEPEN TITRATABS TABS
dexferrum SOLN (PA)
dialyvite TABS
effervescent potassium TBEF
ferosul ELIX (AG)
FERRLECIT SOLN (PA)
FERROUS SULFATE SYRP (AG)
FLUORABON SOLN (AG)
FLURA-DROPS SOLN (AG)
flura-drops SOLN (AG)
folic acid TABS
gildess fe 1.5/30 TABS
gildess fe 1/20 TABS
infed SOLN (PA)
junel fe 1.5/30 TABS
junel fe 1/20 TABS
kalexate POWD
kionex *
klor-con PACK
klor-con 10 TBCR
KLOR-CON 25 PACK
Therapeutic Nutrients/Minerals/Electrolytes
Sleep Disorder Agents
[MPC021249] Page 42 of 46 August 15, 2013
Drug Name Dosage Form Note
klor-con 8 TBCR
klor-con m10 TBCR
KLOR-CON M15 TBCR
klor-con m20 TBCR
klor-con/ef TBEF
LOESTRIN 24 FE TABS
LOZI-FLUR LOZG (AG)
MEPHYTON TABS
microgestin fe TABS
microgestin fe 1.5/30 TABS
multi-vit/fluoride SOLN
multi-vit/iron/fluoride SOLN
multivitamins/fluoride CHEW
MYNATAL CAPS
nephronex TABS
NIACOR TABS
ORACIT SOLN
phos-flur GEL
PHOSLYRA SOLN
phospha 250 neutral TABS
potassium chloride LIQD
POTASSIUM CHLORIDE LIQD
potassium chloride er *
potassium chloride er TBCR
POTASSIUM CITRATE TBCR
rena-vite rx TABS
renal CAPS
renalpren CAPS
reno caps CAPS
sf GEL
sodium ferric gluconate complex/sucrose SOLN (PA)
sodium fluoride * (AG)
strovite plus TABS
tilia fe TABS
tri-legest fe TABS
triphrocaps CAPS
UROCIT-K 15 TBCR
VENOFER SOLN (PA)
vitamin d CAPS
vol-care rx TABS
UnClassified
[MPC021249] Page 43 of 46 August 15, 2013
Drug Name Dosage Form Note
Drug Name Dosage Form Note
ADCETRIS SOLR (PA)
CHEMSTRIP UGK STRP
FERAHEME SOLN (PA)
PRECISION XTRA STRP
Please see following page for disclaimer and explanation of terms.
[MPC021249] Page 44 of 46 August 15, 2013
DISCLAIMER Please be sure a prescription drug benefit is part of your specific coverage before consulting this list. If you do not know which list is correct, please contact the Presbyterian Customer Service Center at (505) 923-5225 or toll-free at 1-866-593-7434, Monday through Friday from 7:00 a.m. to 6:00 p.m. TTY users may call 1-888-872-7568. Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your benefit design determines what is covered for you and what your copayment will be. Please refer to your benefit materials for your specific coverage information. The medications listed on this Formulary/Preferred Drug Listing (PDL) are subject to change pursuant to the Formulary/PDL management activities of Presbyterian Health Plan. This list is not all-inclusive nor does it imply a guarantee of coverage. In addition, coverage for some drugs listed may be limited to specific dosage forms and/or strengths. Substitution of a generic product for a brand-name drug is mandatory when a generic equivalent is available. If a member requests the brand-name drug in this situation, a Prior Authorization may be required and the member must pay the difference in cost between the generic and branded versions. Non-formulary medications are not considered for coverage unless trial and failure of formulary alternatives are documented. Explanation of Terms in your Formulary You may see these indicators next to some drug names: 1 Explanation of Terms in your Formulary 1. Age Limitation (AG) -- a coverage limit based on minimum or maximum age of the member imposed as a result of safety, efficacy or dosage form considerations. 2. Generics preferred/Generic equivalent available (GP -- if there is a generic available and the patient receives the brand name product, the patient pays the copay for the generic drug plus the difference in cost between the brand and the generic. 3. Medical Drugs (MED) -- Medications obtained through the medical benefit. Medical drugs are defined as medications administered in the office or facility that require a health care professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution and may be provided by a specialty pharmacy vendor. Some Medical Drugs may require Benefit Certification before they can be obtained. Office administered applies to all outpatient settings including, but are not limited to, physician's offices, emergency rooms, urgent care facilities and outpatient surgery facilities. For a complete list of Medical Drugs and to determine which require Benefit Certification please see the Presbyterian Pharmacy web site at: http://www.phs.org/PHS/programs/pharmacy/formulary/index.htm 4. Prior Authorization (PA) -- a drug that requires prior approval before the Plan will cover it, and when the patient meets the established criteria. The doctor must submit a
[MPC021249] Page 45 of 46 August 15, 2013
Pharmacy Prior Authorization Form. The doctor can submit the request by fax, phone, or regular mail. 5. Quantity Limit (QL) -- a coverage limit on the medication quantity covered for a defined days' supply (usually 30 or 90 days) based on safety, efficacy and/or dose optimization issues. 6. Specialty (SP) -- Tier 4 medications obtained through the pharmacy benefit. Tier 4 medications are defined as high cost (greater than $600 per 30 day supply) injectable, infused, oral or inhaled drugs that generally require complex care and supervision. These medications involve unique distribution and are usually provided by a specialty pharmacy vendor. Specialty pharmaceuticals are self-administered, meaning they are administered by the patient or to the patient by a family member or caregiver. Non-formulary medications, when approved by prior authorization, may be subject to specialty pharmacy requirements. 7. Step Edit (ST) -- a drug that requires a prescription history of specific drugs in the pharmacy claims or data system, and these specific drugs must be taken during a given time frame. After the specific drugs have been taken within the given time frame, online coverage of the newly-prescribed drug occurs at the pharmacy. Step Edits make it easier to access drugs that would normally require a Prior Authorization. 8. Medical Exception -- a drug that is not on the Plan’s formulary. Non-formulary drugs require an Exception to the formulary due to allergy, adverse reactions, or no response to all formulary drugs.
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