university of minnesota uplan formulary july...

4258 © Prime Therapeutics LLC 07/14

Click to search for a drug name in this document

July 2014

University of Minnesota UPlan Formulary

Contents

Preface ............................................................................ I

Prescription drug guide key ........................................... I

Introduction to Uplan formulary ...................................... I

Using this formulary (finding your drugs) ...................... II

Over-the-counter (OTC) products tier 1

($10 Copay) ............................................................ III

Preventive drug list under affordable care

act ($0 copay) ......................................................... IV

Contraceptive coverage under

the affordable care act – $0 copay ......................... IV

Pharmacy and Therapeutics (P&T)

Committee ................................................................ V

Generic plus drugs ....................................................... V

Generic drug products: generic substitution ................. V

Less than effective drugs: drug efficacy

study implementation (DESI) drugs ....................... VII

Compounded prescriptions ......................................... VII

Prior Authorization (PA) .............................................. VII

Step Therapy program (ST) ....................................... VIII

Mail service delivery ................................................... VIII

Specialty drugs........................................................... VIII

Therapeutic Class Drug List ...................................... 1

Anti-Infective Drugs .................................................... 1

Immunizing Agents .................................................... 3

Cancer Drugs ............................................................. 3

Hormones, Diabetes and Related Drugs ................... 4

Heart and Circulatory Drugs ...................................... 6

Respiratory Agents .................................................... 8

Gastrointestinal Drugs ............................................... 9

Genitourinary Drugs ................................................. 10

Central Nervous System Drugs ............................... 11

Pain Relief Drugs ..................................................... 12

Neuromuscular Drugs .............................................. 14

Supplements ............................................................ 15

Blood Modifying Drugs ............................................. 15

Topical Drugs ........................................................... 15

Miscellaneous Categories ........................................ 18

Index ........................................................................... 20

Therapeutic weblinks ................................................... IX

Please consider talking to your prescriber about prescribing formulary medications, which may help reduce your

out-of-pocket costs. This formulary may help guide you and your doctor in selecting an appropriate medication

for you.

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit

in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

This University of Minnesota UPlan Formulary was current at time of printing and is subject to change.

Please visit our website, www.MyPrime.com, for the most current information.

University of Minnesota UPlan July 2014 Formulary Drug List I

Prescription drug guide key

caps .................................................................... capsules

chew tabs ............................................. chewable tablets

conc .............................................................. concentrate

crm ......................................................................... cream

ext-release ........................................... extended-release

inhal................................................................... inhalation

inj ......................................................................... injection

liq .............................................................................. liquid

lotn ........................................................................... lotion

NF ............................................................. Non-Formulary

ODT ....................................... orally disintegrating tablets

oint ..................................................................... ointment

OSM ......................................................... osmotic-release

OTC ............................................... over-the-counter drug

PA ....................................................... Prior Authorization

SL...................................................................... sublingual

soln ....................................................................... solution

SP .............................................................. Specialty Drug

ST.................................................. Step Therapy Program

supp ............................................................ suppositories

susp ................................................................ suspension

tabs .........................................................................tablets

Brand name drugs

Shown in CAPITAL letters (if Tier 1, $10 copay; if Tier 2, $30 copay)

Generic drugs

Shown in bolded lower case letters (Tier 1, $10 copay)

Non-formulary drugs

Not included in this formulary listing (Tier 3, $75 copay)

Introduction to UPlan formulary

The University of Minnesota and Prime Therapeutics are pleased to provide this formulary as a reference and

informational tool that will assist in selecting safe and cost-effective drug products. This formulary applies to

employees, early retirees, and dependents of the University of Minnesota who elect to participate in the UPlan

Medical and Pharmacy Program. Specific drug selection for an individual patient rests solely with the physician

and the patient.

University of Minnesota UPlan July 2014 Formulary Drug List II

Using this formulary (finding your drugs)

Most of the drugs covered by the University of Minnesota UPlan Medical and Pharmacy Program are listed in

this formulary. This is not a complete listing of all covered drugs. The University of Minnesota reserves the right

to modify this formulary at any time.

The UPlan Formulary is organized into broad therapeutic categories (e.g., Anti-Infective Drugs). Within most

categories, drugs are subgrouped based upon drug class (e.g., Penicillins), or for a specific medical condition

(e.g., Diabetes).

Most Generic drugs are followed by a Brand name (in parentheses) to help you recognize the drug.

The brand name is listed for information only. Some Generic drugs have no brand name available.

Example: simvastatin (Zocor)

Formulary Brand drugs are shown in capital letters.

Example: ASACOL HD

A Generic or Formulary Brand entry will typically include all strengths and dosage forms available for that

product. Exceptions are typically noted.

Example: atenolol (Tenormin)

Tenormin is marketed as 25 mg, 50 mg and 100 mg tablets. Each strength is available generically.

Generic atenolol is Tier 1. Tenormin is noted for reference only, and is not listed in the UPlan Formulary.

Tenormin is available at a generic copay and difference in cost between the brand drug and the generic

drug.

If you know the name of the drug your doctor has prescribed, or a drug that you think you may need, look first in

the index at the end of the formulary. Participants who look for a particular drug and cannot find it within this

formulary should consider the following reasons:

The drug may be a Non-Formulary drug and available to participants at a $75 copay.

The drug may be a Compounded Prescription (see section titled “COMPOUNDED PRESCRIPTIONS”).

The drug may be covered as a Medical benefit and may be provided directly by your physician under the

Medical portion of the UPlan Medical and Pharmacy Program.

The drug may be excluded from UPlan coverage

Please note: You can use your member ID to log on to www.MyPrime.com to get the most current copay

information.

Drugs represented in the UPlan Formulary may have varying cost to the plan participant. Generic drugs typically

are available at the lowest cost; brand-name drugs on the UPlan Formulary will generally cost more than

generics; and brand-name drugs not on the list will generally cost the most. Generics should be considered the

first line of prescribing.

University of Minnesota UPlan July 2014 Formulary Drug List III

The tiered format places drugs into tiers or levels of cost sharing by the plan participant in the following manner:

Tier 1:

Generic Plus

Lowest plan participant copayment: All generic drugs and selected brand-name

drugs. Generic drugs shown in lowercase, boldface type and brand drugs shown

in CAPITAL, non-bold type and marked as Tier 1 ($10 copay).

Tier 2:

Formulary Brand-Name drugs

Intermediate plan participant copayment: Brand-name products on the

UPlan Formulary selected for Tier 2. Shown in CAPITAL letters, non-bold type,

and marked as Tier 2 ($30 copay).

Tier 3:

Non-Formulary drugs

Highest plan participant copayment: All brand-name products not selected for

Tier 2. In most cases, there will be reasonable alternatives in Tier 1 or Tier 2

for products found in this highest tier. Non-formulary drugs are not listed in the

formulary ($75 copay).

Over-the-counter (OTC) products tier 1 ($10 copay)

Certain over-the-counter (OTC) products are covered at Tier 1 ($10 copay) in the pharmacy benefit with a

prescription. Please see the table below for commonly used OTC products covered but not listed in the formulary.

Please note that not all OTC products are available at Prime Mail.

acetaminophen

Allegra (fexofenadine)

Allegra Allergy (fexofenadine)

Allegra-D 12 hr (fexofenadine/pseudoephedrine

ext-release)

Allegra-D 24 hr (fexofenadine/pseudoephedrine

ext-release)

aspirin

aspirin delayed-release

aspirin low dose

Benadryl (diphenhydramine)

benzoyl peroxide

Claritin (loratadine)

Claritin-D 12 hr (loratadine/pseudoephedrine

ext-release)

Claritin-D 24 hr (loratadine/pseudoephedrine

ext-release)

docusate sodium

Dulcolax (bisacodyl delayed-release)

ferrous gluconate

ferrous sulfate

folic acid

ibuprofen

Lotrimin AF (clotrimazole)

meclizine

Miralax (polyethylene glycol)

Nasacort Allergy 24HR (triamcinolone acetonide)

Nizoral (ketoconazole)

omeprazole delayed-release

Senokot (sennosides/docusate)

Prenatal Vitamins – various names

Prevacid 24 hr (lansoprazole delayed-release)

Prilosec OTC (omeprazole delayed-release)

pseudoephedrine

pseudoephedrine ext-release – 12 hr

Robitussin DM (dextromethorphan/guaifenesin)

vitamin B-12 inj – cyanocobalamin

vitamin D

vitamin D3 – cholecalciferol

Zantac (ranitidine)

Zyrtec Allergy (cetirizine)

Zyrtec-D Allergy/Congestion (cetirizine/pseudoephedrine ext-release)

Zyrtec Children’s Allergy (cetirizine)

University of Minnesota UPlan July 2014 Formulary Drug List IV

Preventive drug list under affordable care act ($0 copay)

In accordance with requirements put forth through the Affordable Care Act (ACA), the UPlan has elected to

provide evidence-based Preventive Drug coverage at $0 in the pharmacy benefit with a prescription. Below are

the drug categories available under your ACA Preventive Drug coverage.

This list will be reviewed periodically and is subject to change.

Drug/category

ASPIRIN 81 MG (OTC)

BREAST CANCER (EVISTA/TAMOXIFEN)

FLUORIDE SUPPLEMENTS (RX & OTC)

FOLIC ACID SUPPLEMENTS (OTC)

IRON SUPPLEMENTS (OTC)

TOBACCO CESSATION (RX & OTC)

VACCINES (ROUTINE IMMUNIZATIONS)

VITAMIN D SUPPLEMENTS (OTC)

Qualifications

MEN: AGE 45-79 YEARS, WOMEN: AGE 55-79 YEARS

WOMEN ONLY

CHILDREN: AGE 6 MONTHS – 6 YEARS

WOMEN ONLY

CHILDREN: AGE 6-12 MONTHS

PRESCRIPTION

ADULTS: AGE 65 YEARS AND OLDER

Contraceptive coverage under the Affordable Care Act – $0 copay

Contraceptives in the Generic Plus tier are covered for women at a $0 copay in the pharmacy benefit with a

prescription. Generic Plus contraceptives will be available in the following categories:

Oral combination contraceptives

Oral progestin

Oral extended cycle/continuous use contraceptives

Patch

Ring

Injections

Cervical Caps

Diaphragms

IUDs (Mirena, Skyla)

Implantables

Emergency contraceptives

For a complete listing of drugs covered under the UPlan, please visit www.MyPrime.com.

http://www.myprime.com/

V University of Minnesota UPlan July 2014 Formulary Drug List

Pharmacy and therapeutics (P&T) committee

The University’s UPlan Pharmacy Program Clinical Review Committee, consisting of University employees with

clinical, drug therapy, and policy expertise, selects drugs for this formulary based on recommendations of an

independent Prime Therapeutics’ Pharmacy & Therapeutics (P&T) Committee that includes practicing physicians

and pharmacists. Decisions on which drugs to include in the formulary are based on safety, efficacy, uniqueness,

and cost. When a new drug is considered for formulary inclusion, it will be reviewed and compared to similar drugs

currently included in the University of Minnesota Formulary. New drugs that are generics will be added as soon

as possible at the Generic Plus level. New brand drugs will be Non-Formulary until they are reviewed by the

Prime Therapeutics P&T committee and the UPlan Pharmacy Program Clinical Review Committee. Formulary

decisions are communicated quarterly on the Web site at www.MyPrime.com.

Generic plus drugs

The Generic Plus program is offered by the University of Minnesota to provide preferred drug products at a lower

copay of $10 per 30-day supply. All generics and select brand-name drugs are included at the $10 copay level. Other

brand-name drug products covered by the University of Minnesota UPlan Medical and Pharmacy Program and listed

in this formulary have a copay of $30 per 30-day supply. Drugs not listed in this formulary, if otherwise covered by the

University of Minnesota UPlan Medical and Pharmacy Program, have a copay of $75 per 30-day supply.

Generic Plus drugs which are considered preferred within each therapeutic category based upon safety, effectiveness,

uniqueness, and cost, are highlighted in this formulary with bold type. In many therapeutic categories, the Generic

Plus drugs are available as a generic. When there are therapeutic categories that do not have a generic available,

one or more brand-name drugs have been designated as Generic Plus products and will be available at the lower $10

copay. Note, however, that the lower copay may not apply to all strengths or dosage forms of the drug name in bold

type. In some cases, a drug may have a brand name and still be considered a generic drug.

Generic drug products: generic substitution

Generic substitution is the action by a pharmacist to select the source (manufacturer) of a drug product from among those

drug products (brand and generic) that are considered to be therapeutically equivalent. Unless expressly indicated by the

prescriber as “dispense as written” or D.A.W., pharmacists in Minnesota may dispense generic drug products that, in their

professional judgment, are therapeutically equivalent unless the patient requests otherwise. In instances where the

prescriber indicates D.A.W. or the patient requests D.A.W., the cost difference between the brand and the generic will be

applied to the Generic Plus copay.

Generic drug approvals by the U.S. Food and Drug Administration (FDA) since 1984, and most generic approvals

prior to 1984, have been based upon a demonstration that the generic drug product is therapeutically equivalent to

the brand name product. To gain FDA approval as a therapeutically equivalent product:

1. The generic drug must contain the same active ingredient(s), be the same strength, and the same dosage

form as the reference (brand name) product, and

2. The manufacturer of the generic drug must demonstrate to the FDA that it has the same rate and extent of

absorption as the brand-name product.

University of Minnesota UPlan July 2014 Formulary Drug List VI

Generic drug products that meet these FDA requirements are given an “A” rating indicating that they are considered

by the FDA to be therapeutically equivalent. “Products evaluated as therapeutically equivalent can be expected to

have equivalent clinical effect whether the product is a brand-name or generic drug product.” (FDA Letter to Health

Practitioners, “Therapeutic Equivalence of Generic Drugs,” January 28, 1998). The ratings of brand and generic drug

products are available in the FDA publication known as the “Orange Book,” or Approved Drug Products with

Therapeutic Equivalence Evaluations (http://www.fda.gov/cder/ob/default.htm).

When a generic drug product has met the FDA requirements for therapeutic equivalence, the generic drug product

can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety

profile as the prescribed product.

Certain drug products have a narrow therapeutic index (NTI), but even these drug products must meet these same

FDA requirements for therapeutic equivalence and can be substituted with assurance that the generic will have the

same safety and effectiveness as the brand name drug product. Health care providers do not need to approach any

one therapeutic class of drug products (e.g., NTI drugs) differently than any other class when there has been a

determination of therapeutic equivalence by the FDA for the drug products under consideration. Additional clinical

tests or examinations by the prescriber are not needed when a therapeutically equivalent generic drug product is

substituted for the brand name product.

In addition to the “A” rated products, there are some marketed products that are “unrated.” Unrated products are

generally pre-1938 drugs that were not required to undergo the FDA review and approval process. Also, many cough

and cold products and multivitamin products do not require FDA review. Most of these products would be suitable for

generic substitution. There are now many brand-name products that are repackaged or distributed under a generic

label. The generic label version should always be considered therapeutically equivalent and substitutable for the

source-branded product, irrespective of rating.

Some generic drug products reviewed by the FDA and listed in the Orange Book are given a “B” rating, indicating that

these drug products are not considered to be therapeutically equivalent to the brand-name product. In some cases,

generic substitution of “B” rated drug products for “A” rated drug products is not recommended. State law or

regulations may affect the ability to practice generic substitution for selected products or categories of drugs.

University of Minnesota UPlan July 2014 Formulary Drug List VII

Less than effective drugs: drug efficacy study implementation (DESI) drugs

Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for

FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be

approved and marketed. This legislation also applied retroactively to all drugs approved as safe from 1938 to 1962.

The DESI (Drug Efficacy Study Implementation) program was established by the FDA to review the effectiveness of

these pre-1962 drugs for their labeled indications. Most of these pre-1962 drug products were determined to be fully

effective, and they remain in the marketplace.

A few DESI products, however, were classified as “less than fully effective” and also remain in the marketplace.

There are also drug products that are identical, similar, or related to actual DESI products that have been classified

as “less than fully effective.” These “less than fully effective” DESI drug products are not a covered benefit under the

University of Minnesota UPlan Medical and Pharmacy Program.

Compounded prescriptions

In some cases, a prescriber may write a prescription that needs to be prepared by the pharmacist by mixing two or

more drug ingredients. Most powders and other ingredients that are commonly used in compounding a prescription

drug are covered. Most compounded prescriptions are covered under the University of Minnesota’s formulary and

will process according to the member’s benefit.

Prior Authorization (PA)

Prior Authorization may be required in the UPlan Pharmacy Program for the following reasons:

1. Certain drugs require prior authorization to encourage safe and clinically appropriate use (drugs

indicated with PA in the formulary). It will be necessary for your prescriber or Medication Therapy

Management (MTM) pharmacist to complete and submit a PA form to Prime Therapeutics to request

continued coverage of the selected drug. If the prior authorization is approved by Prime Therapeutics,

you can continue to take your drug at the $10 Generic Plus copay. If the prior authorization is not

approved by Prime Therapeutics, you can continue to take your drug at the $30 Brand Formulary copay

if the drug is on the formulary or the $75 Non-Formulary copay. If either you or your prescriber decides

not to apply for the prior authorization, you can continue to take your drug, but you will be charged the

full price of the drug. The following Tier 3 drugs not listed in the formulary require PA: Abstral, Actemra,

Actiq, Adcirca, Adipex-P, Aldara, Ampyra, Arcalyst, Atralin, Aubagio, Avonex, Belviq, Bontril SR, Cimzia,

Didrex, Diethylpropion, Entyvio, Extavia, Fentora, Genotropin, Genotropin Miniquick, Gilenya, Humatrope,

Incivek, Ketek, Kineret, Lazanda, Nutropin, Nutropin AQ, Omontys, Orencia, Peg-Intron, Phentermine,

Qsymia, Regimex, Saizen, Serostim, Simponi, Simponi Aria, Stelara, Suprenza, Tev-Tropin, Tysabri,

Victrelis, Xeljanz, Zorbtive, Zubsolv, and Zyclara. The following medications are Tier 3 drugs not listed in

the formulary and require a PA for patients 40 years of age and older: Differin, Fabior, and Tretin-X.

2. Occasionally, a UPlan Medical and Pharmacy Program participant, for reason of medical necessity,

may need to take a drug that is ordinarily subject to a higher copay under the benefit structure. When this

occurs, the copay for that participant may be reduced to the lowest level copay available under the drug

benefit. Such an exception is achieved through an appeal process whereby the participant’s prescriber

provides adequate evidence to Prime Therapeutics that the requested drug is medically necessary.

Upon approval by Prime Therapeutics, the $30 Brand Formulary copay, or the $75 Non-Formulary

copay, will be reduced to the Generic Plus copay of $10 for that drug.

You can find out if your drug has Prior Authorization, designated by PA after the drug name, by looking in the

formulary that begins on page 1. You can also get more information about your Prior Authorization program

at www.MyPrime.com.

University of Minnesota UPlan July 2014 Formulary Drug List VIII

Step Therapy program (ST)

A process called Step Therapy is used in certain therapeutic drug categories to encourage use of safe, clinically

appropriate or more cost-effective drugs. With Step Therapy, your prescriber is encouraged to prescribe a more

cost-effective Step 1 drug before trying a less cost-effective Step 2 drug. Most drugs at Step 1 are available as the

$10 Generic Plus copayment.

If you have already taken the Step 1 drug, or if there is some medical reason why you cannot do so, your prescriber

can submit a prior authorization request to Prime Therapeutics on your behalf. The prior authorization form is

available on the Web site at www.MyPrime.com. Approved Step 2 drugs are also available at the

$10 Generic Plus copayment.

If the prior authorization request is not approved by the pharmacy staff at Prime Therapeutics, you will pay the $30

Brand Formulary copayment for the Step 2 formulary drug.

If you decide that you prefer to remain on the higher Step 2 drug and do not try the Step 1 drug or request that your

prescriber submit a prior authorization, you can continue to take your Step 2 drug. However, the UPlan will not cover

the Step 2 drug, and you will pay the full cost of the prescription drug.

You can find out if your drug has Step Therapy, designated by ST after the drug name, by looking in the

formulary that begins on page 1. You can also get more information about your Step Therapy program

at www.MyPrime.com.

Mail service delivery

Mail Service Delivery offers participants the opportunity to submit prescriptions by mail or have prescribing prescribers

fax in prescriptions. The prescription is then processed and delivered directly to the participant. Employees can

receive a 90-day supply for two copays through Mail Service Delivery. Mail order forms and contact information can

be found at www.MyPrime.com.

Specialty drugs

Specialty drugs are generally prescribed for people with complex or ongoing medical conditions such as multiple

sclerosis, hemophilia, hepatitis C, rheumatoid arthritis and other complex conditions. Specialty drugs are high cost

and have one or more of the following characteristics:

They are often injected or infused, but some may be taken by mouth.

They have unique storage or shipment requirements.

Members using specialty medications need additional education and support from a health care professional

due to the complexity of use and the potential for some serious side effects.

They are often not stocked at all retail pharmacies.

Specialty drugs are most frequently available only through Fairview Specialty Pharmacy, Fairview Clinic or

Hospital Pharmacies, or St. Luke’s or SMDC pharmacies in Duluth. A limited set of specialty medications are also

available at other retail pharmacies. Details are available by calling 612.672.5289 or toll free at 1.877.509.5115.

University of Minnesota UPlan July 2014 Formulary Drug List IX

Therapeutic Weblinks

The following links are to websites that provide information concerning a variety of different conditions.

The U of M provides these links solely as a service for general information and convenience, and the links should not

be used for the diagnosis or treatment of any medical condition. The U of M is not responsible for and does not control,

approve, or endorse any site listed below, and the U of M is not responsible for and does not control, approve, or

endorse any content existing therein. External links to non-U of M resources are in no way intended to represent an

exhaustive listing.

Therapeutic Class Sub-Therapeutic Class Weblink

ANTI-INFECTIVE http://www.americanheart.org

http://www.cdc.gov/ncidod/guidelines/guidelines_topic_ar.htm

http://www.idsociety.org

Hepatitis http://www.cdc.gov/hepatitis/index.htm

http://www.aasld.org

HIV/AIDS http://www.aidsinfo.nih.gov

Influenza http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm

BLOOD MODIFYING

DRUGS

http://www.hemophilia.org

http://www.asco.org

http://www.kidney.org/professionals/kdoqi/guidelines_

commentaries.cfm#guidelines

CANCER http://www.asco.org

http://www.nccn.org

CENTRAL NERVOUS

SYSTEM DRUGS

http://www.psych.org

Depression http://www.psych.org

Psychotic and Bipolar Disorders http://www.psych.org

Sleep Aids http://www.aasmnet.org

Hyperactivity/Narcolepsy http://www.aacap.org

http://www.aap.org

Multiple Sclerosis Practice http://www.aan.com

Obesity http://www.aace.com

http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

Other Central Nervous System Drugs

http://www.aan.com

University of Minnesota UPlan July 2014 Formulary Drug List X


GASTROINTESTINAL

DRUGS

http://www.acg.gi.org

http://www.gastro.org

Other Genitourinary Drugs http://www.auanet.org/guidelines

HEART AND

CIRCULATORY DRUGS

http://www.nof.org

Angiotensin Converting

Enzyme (ACE) Inhibitors and

Combinations

http://professional.diabetes.org

http://www.acc.org

http://www.americanheart.org

http://www.nhlbi.nih.gov/guidelines/hypertension

Angiotensin II Receptor

Antagonists (ARBS) and

Combinations

http://professional.diabetes.org


Beta Blockers and

Combinations

http://www.acc.org


Cholesterol Lowering http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

Other Heart Related Drugs http://www.nhlbi.nih.gov/guidelines/hypertension

http://www.acc.org

http://www.americanheart.org

http://www.heartfailureguideline.org


http://www.acc.org

HORMONES,

DIABETES AND

RELATED DRUGS

http://www.menopause.org

Male Hormones http://www.aace.com

Growth Hormone http://www.aace.com

Other Hormones and Related

Drugs

http://www.aace.com

Erectile Dysfunction http://www.auanet.org/guidelines

XI University of Minnesota UPlan July 2014 Formulary Drug List


NEUROMUSCULAR

DRUGS

Seizures http://www.aan.com

Parkinson’s Disease http://www.aan.com

PAIN RELIEF DRUGS http://www.asahq.org

http://www.rheumatology.org

Narcotic Drugs http://www.asahq.org

http://www.nccn.org

http://www.asipp.org/Guidelines.htm

Rheumatoid and Osteoarthritis http://www.rheumatology.org

http://www.asahq.org

Migraine Headaches http://www.aan.com

RESPIRATORY AGENTS http://www.aaaai.org

Asthma http://www.aaaai.org

http://www.ginasthma.com

http://www.goldcopd.com

http://www.nhlbi.nih.gov

TOPICAL DRUGS

Ear http://www.aap.org

Skin Conditions/

Products – Acne

http://www.aad.org

Other Skin Products http://www.aad.org

2014

University of Minnesota UPlan July 2014 Formulary Drug List 1

Drug Name Dru

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Spe

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Ste

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ANTI-INFECTIVE DRUGS

PENICILLINS

amoxicillin caps, susp, tabs 1

AMOXICILLIN chew tabs, 250 mg 1

amoxicillin/potassium clavulanate(Augmentin)

1

amoxicillin/potassium clavulanateext-release (Augmentin XR)

1

ampicillin 1

AMPICILLIN susp 2

AUGMENTIN susp, 125 mg/5 mL 2

dicloxacillin 1

penicillin v potassium 1

CEPHALOSPORINS

cefaclor caps 1

cefadroxil 1

cefdinir 1

cefpodoxime 1

cefprozil 1

CEFTIN susp, 250 mg/5 mL 2

ceftriaxone (Rocephin) 1

cefuroxime (Ceftin) 1

cephalexin, NF = tabs (Keflex) 1

MACROLIDES

AZITHROMYCIN powder packets 2

azithromycin susp, tabs (Zithromax) 1

clarithromycin (Biaxin) 1

clarithromycin ext-release (BiaxinXL)

1

E.E.S. GRANULES 2

E.E.S. 400 1

ERY-TAB 2

ERYPED 2

ERYTHROCIN STEARATE 2

erythromycin delayed-release caps 1

ERYTHROMYCIN ETHYLSUCCINATE 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

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Ste

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ZITHROMAX powder packets 2

TETRACYCLINES

demeclocycline 1

doxycycline hyclate caps(Vibramycin)

1

doxycycline hyclate tabs 1

doxycycline monohydrate (Adoxa,Monodox)

1

minocycline (Dynacin, Minocin) 1

FLUOROQUINOLONES

CIPRO susp 2

ciprofloxacin (Cipro) 1

ciprofloxacin ext-release (Cipro XR) 1

levofloxacin (Levaquin) 1

ofloxacin tabs 1

AMINOGLYCOSIDES

neomycin sulfate 1

paromomycin 1

TUBERCULOSIS

ethambutol (Myambutol) 1

ISONIAZID syrup 1

isoniazid tabs 1

PRIFTIN 2

pyrazinamide 1

rifabutin (Mycobutin) 1

rifampin (Rifadin) 1

FUNGAL INFECTIONSPA – Prior Authorization program information available at:www.MyPrime.com/MyPrime/UMN

fluconazole (Diflucan) 1

flucytosine (Ancobon) 1

griseofulvin microsize (Grifulvin V) 1

itraconazole (Sporanox) 1

NOXAFIL 1 •nystatin oral 1

terbinafine (Lamisil) 1

2014

2 University of Minnesota UPlan July 2014 Formulary Drug List

Drug Name Dru

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VFEND 2 •voriconazole (Vfend) 1 •VIRAL INFECTIONS

Cytomegalovirus

VALCYTE 1

HepatitisPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

adefovir (Hepsera) 1

BARACLUDE 1

COPEGUS 2 •lamivudine (Epivir HBV) 1

OLYSIO 1 • •PEGASYS 1 • •REBETOL soln 2 •RIBASPHERE 1 •ribavirin (Copegus, Rebetol) 1 •SOVALDI 1 • •Herpes

acyclovir (Zovirax) 1

famciclovir (Famvir) 1

valacyclovir (Valtrex) 1

HIV/AIDS

abacavir (Ziagen) 1

abacavir/lamivudine/zidovudine(Trizivir)

1

APTIVUS 1

ATRIPLA 1

COMBIVIR 1

COMPLERA 1

CRIXIVAN 1

didanosine delayed-release (VidexEC)

1

EDURANT 1

EMTRIVA 1

EPIVIR 1

Drug Name Dru

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EPZICOM 1

FUZEON 1 •INTELENCE 1

INVIRASE 1

ISENTRESS 1

KALETRA 1

lamivudine (Epivir) 1

lamivudine/zidovudine (Combivir) 1

LEXIVA 1

NEVIRAPINE susp 1

nevirapine tabs (Viramune) 1

nevirapine ext-release (Viramune XR) 1

NORVIR 1

PREZISTA 1

RESCRIPTOR 1

REYATAZ 1

SELZENTRY 1

stavudine (Zerit) 1

STRIBILD 1 •SUSTIVA 1

TIVICAY 1

TRIZIVIR 1

TRUVADA 1

VIDEX 1

VIRACEPT 1

VIRAMUNE 1

VIRAMUNE XR 1

VIREAD 1

ZIAGEN 1

zidovudine (Retrovir) 1

Influenza

TAMIFLU 2

MALARIA

atovaquone/proguanil (Malarone) 1

chloroquine phosphate (Aralen) 1

2014


Drug Name Dru

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DARAPRIM 1

hydroxychloroquine (Plaquenil) 1

mefloquine 1

PRIMAQUINE 1

WORM INFECTIONS

ALBENZA 1

BILTRICIDE 1

STROMECTOL 1

OTHER ANTI-INFECTIVESPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

ALINIA 2

clindamycin (Cleocin, CleocinPediatric)

1

DAPSONE 1

erythromycin/sulfisoxazole 1

metronidazole (Flagyl) 1

sulfamethoxazole/trimethoprim(Bactrim)

1

trimethoprim 1

vancomycin (Vancocin) 1

XIFAXAN 550 mg 1

ZYVOX 1

IMMUNIZING AGENTSPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

SYNAGIS 2 • •CANCER DRUGSPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

ACTIMMUNE 1 •AFINITOR 2 •AFINITOR DISPERZ 2 •ALKERAN 2 •anastrozole (Arimidex) 1 •ARIMIDEX 2 •AROMASIN 2 •

Drug Name Dru

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bicalutamide (Casodex) 1

BOSULIF 2 •capecitabine (Xeloda) 1 •CAPRELSA 2 •COMETRIQ 2 •EMCYT 2

ERIVEDGE 1 •ETOPOSIDE caps 2 •exemestane (Aromasin) 1 •FARESTON 2

FEMARA 1 •flutamide 1

GILOTRIF 2 •GLEEVEC 1 •HEXALEN 2 •HYCAMTIN caps 2 •hydroxyurea (Hydrea) 1

ICLUSIG 2 •INLYTA 1 •letrozole (Femara) 1 •leucovorin calcium tabs, 5 mg,

25 mg1

LEUKERAN 2

LYSODREN 2 •MATULANE 2 •megestrol (Megace) 1

MEKINIST 2 •mercaptopurine (Purinethol) 1 •MESNEX tabs 2

methotrexate tabs 1

MYLERAN 2 •NEXAVAR 1 •NILANDRON 2

SPRYCEL 2 •STIVARGA 2 •

2014


Drug Name Dru

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SUTENT 1 •SYLATRON 1 •TABLOID 2

TAFINLAR 2 •tamoxifen 1

TARCEVA 1 •TARGRETIN caps 2 •TASIGNA 2 •TEMODAR caps 1 •temozolomide caps (Temodar) 1 •tretinoin caps 1 •TYKERB 2 •VOTRIENT 2 •XALKORI 1 •XELODA 1 •XTANDI 2 •ZELBORAF 1 •ZOLINZA 2 •ZYKADIA 2

ZYTIGA 1 •HORMONES, DIABETES AND RELATED DRUGS

CORTICOSTEROIDS

budesonide ext-release (EntocortEC)

1

CORTISONE 1

dexamethasone elixir; tabs, 0.5 mg,0.75 mg, 1.5 mg, 4 mg, 6 mg

1

DEXAMETHASONE tabs, 1 mg, 2 mg 1

fludrocortisone 1

hydrocortisone (Cortef) 1

methylprednisolone (Medrol) 1

prednisolone (Prelone) 1

prednisolone sodium phosphate(Orapred)

1

prednisolone sodium phosphatesoln, 5 mg/5 mL (Pediapred)

1

Drug Name Dru

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PREDNISONE dose pack; soln,5 mg/5 mL; tabs, 50 mg

2

prednisone tabs, 1 mg, 2.5 mg, 5 mg,10 mg, 20 mg

1

MALE HORMONESST – Step Therapy program information available atwww.MyPrime.com/MyPrime/UMN

ANDRODERM 1

ANDROGEL 1

AXIRON 2 •danazol 1

FIRST-TESTOSTERONE 2 •FIRST-TESTOSTERONE MC 2 •FORTESTA 2 •STRIANT 2 •TESTIM 2

testosterone cypionate (Depo-Testosterone)

1

testosterone enanthate 1

ESTROGENS

CENESTIN 2

CLIMARA PRO 2

COMBIPATCH 2

DIVIGEL 2

estradiol (Climara, Estrace) 1

estradiol/norethindrone acetate(Activella)

1

estropipate 0.75 mg, 1.5 mg 1

FEMHRT LOW DOSE 2

MENOSTAR 2

PREMARIN tabs 2

PREMPHASE 2

PREMPRO 2

VIVELLE-DOT 2

PROGESTINS

medroxyprogesterone acetate tabs(Provera)

1

2014


Drug Name Dru

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MEGACE ES 2

norethindrone acetate (Aygestin) 1

progesterone micronized(Prometrium)

1

BIRTH CONTROL

ELLA 1

IMPLANON 1

levonorgestrel (Plan B, Plan B One-Step)

1

LOESTRIN 24 FE 2

MIRENA 1

NATAZIA 2

NECON 10/11 2

NEXPLANON 1

NORINYL 1+50 2

NUVARING 1

oral contraceptives – all generics 1

ORTHO TRI-CYCLEN LO 2

SKYLA 1

INFERTILITYPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

BRAVELLE 20% • •CETROTIDE 20% •chorionic gonadotropin 1 •clomiphene (Clomid) 1 •FOLLISTIM AQ 20% •GANIRELIX ACETATE 20% •GONAL-F 20% • •MENOPUR 2 •OVIDREL 20% •REPRONEX 20% •SYNAREL 2

DIABETESST – Step Therapy program information available atwww.MyPrime.com/MyPrime/UMN

Drug Name Dru

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acarbose (Precose) 1

ACTOPLUS MET XR 2

AVANDAMET 2

AVANDARYL 2

AVANDIA 2

DIABETA 2

glimepiride (Amaryl) 1

glipizide (Glucotrol) 1

glipizide ext-release (Glucotrol XL) 1

glipizide/metformin 1

GLUCAGON EMERGENCY KIT 1

glyburide (Micronase) 1

glyburide micronized (Glynase) 1

glyburide/metformin (Glucovance) 1

JANUMET 1

JANUVIA 1

metformin (Glucophage) 1

metformin ext-release (GlucophageXR)

1

metformin ext-release OSM(Fortamet)

1

nateglinide (Starlix) 1

pioglitazone (Actos) 1

pioglitazone/metformin (ActoplusMet)

1

repaglinide (Prandin) 1

VICTOZA 2

DIABETES - INSULINSA listing of diabetic supplies can be found in theMiscellaneous category under Diabetic Supplies.

Rapid-Acting Insulins

NOVOLOG 1

Short-Acting Insulins

NOVOLIN R 1

Intermediate-Acting Insulins

NOVOLIN N 1

2014


Drug Name Dru

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NOVOLIN 70/30 1

NOVOLOG MIX 70/30 1

Basal Insulins

LANTUS 1

LEVEMIR 2

THYROID REGULATION

levothyroxine (Synthroid) 1

liothyronine (Cytomel) 1

methimazole (Tapazole) 1

propylthiouracil 1

GROWTH HORMONEPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

INCRELEX 1 •NORDITROPIN 1 • •OMNITROPE 1 • •OTHER HORMONES AND RELATED DRUGSPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

ACTHAR HP 2 • •ALDURAZYME 1 •alendronate, NF = soln; tabs, 40 mg

(Fosamax)1

cabergoline 1

calcitonin-salmon (Miacalcin) 1

calcitriol (Rocaltrol) 1

desmopressin (DDAVP) 1

ELAPRASE 1 •FORTEO 1 • •ibandronate (Boniva) 1

KUVAN 2 •levocarnitine (Carnitor) 1

LUMIZYME 1 •methylergonovine 1

MIACALCIN inj 2 •NAGLAZYME 1 •

Drug Name Dru

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ORFADIN 1 •paricalcitol (Zemplar) 1

raloxifene (Evista) 1

SENSIPAR 1

SOMAVERT 2 •STIMATE 1

HEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONS

benazepril (Lotensin) 1

benazepril/hydrochlorothiazide(Lotensin HCT)

1

captopril 1

enalapril (Vasotec) 1

enalapril/hydrochlorothiazide(Vaseretic)

1

fosinopril 1

fosinopril/hydrochlorothiazide 1

lisinopril (Prinivil, Zestril) 1

lisinopril/hydrochlorothiazide(Prinzide, Zestoretic)

1

moexipril (Univasc) 1

moexipril/hydrochlorothiazide(Uniretic)

1

perindopril (Aceon) 1

quinapril (Accupril) 1

quinapril/hydrochlorothiazide(Accuretic)

1

ramipril (Altace) 1

trandolapril (Mavik) 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONS

DIOVAN 2

irbesartan (Avapro) 1

irbesartan/hydrochlorothiazide(Avalide)

1

losartan (Cozaar) 1

2014


Drug Name Dru

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ty

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losartan/hydrochlorothiazide(Hyzaar)

1

valsartan/hydrochlorothiazide(Diovan HCT)

1

BETA BLOCKERS AND COMBINATIONS

acebutolol (Sectral) 1

atenolol (Tenormin) 1

atenolol/chlorthalidone (Tenoretic) 1

bisoprolol (Zebeta) 1

bisoprolol/hydrochlorothiazide (Ziac) 1

BYSTOLIC 2

carvedilol (Coreg) 1

INNOPRAN XL 2

labetalol (Trandate) 1

metoprolol succinate ext-release(Toprol XL)

1

metoprolol tartrate (Lopressor) 1

nadolol (Corgard) 1

pindolol 1

propranolol tabs 1

propranolol ext-release (Inderal LA) 1

sotalol (Betapace, Betapace AF) 1

CALCIUM CHANNEL BLOCKERS ANDCOMBINATIONS

amlodipine (Norvasc) 1

amlodipine/benazepril (Lotrel) 1

CARDIZEM LA tabs, 120 mg 2

diltiazem (Cardizem) 1

diltiazem ext-release (Cardizem CD,Cardizem LA, Tiazac)

1

felodipine ext-release 1

nifedipine ext-release (Adalat CC,Procardia XL)

1

verapamil 80 mg, 120 mg (Calan) 1

verapamil ext-release (Calan SR,Isoptin SR, Verelan, Verelan PM)

1

CHEST PAIN

Drug Name Dru

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ISORDIL TITRADOSE 40 mg 2

isosorbide dinitrate tabs, 5 mg,10 mg, 20 mg (Isordil)

1

ISOSORBIDE DINITRATE 30 mg 1

isosorbide mononitrate (Monoket) 1

isosorbide mononitrate ext-release(Imdur)

1

NITRO-DUR patches, 0.3 mg/hr,0.8 mg/hr

2

nitroglycerin 0.1 mg/hr, 0.2 mg/hr,0.4 mg/hr, 0.6 mg/hr (Nitro-Dur)

1

NITROSTAT 1

CHOLESTEROL LOWERING

atorvastatin (Lipitor) 1

cholestyramine (Questran, QuestranLight)

1

colestipol (Colestid) 1

fenofibrate (Lofibra, Tricor) 1

fenofibrate micronized (Lofibra) 1

fenofibric acid delayed-release(Trilipix)

1

gemfibrozil (Lopid) 1

lovastatin (Mevacor) 1

niacin ext-release (Niaspan) 1

pravastatin (Pravachol) 1

simvastatin (Zocor) 1

VYTORIN 2

WELCHOL 2

ZETIA 2

FLUID RETENTION

acetazolamide 250 mg 1

acetazolamide ext-release (DiamoxSequels)

1

ALDACTAZIDE tabs, 50-50 mg 2

amiloride 1

amiloride/hydrochlorothiazide 1

bumetanide 1

2014


Drug Name Dru

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ty

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chlorothiazide tabs, 500 mg 1

CHLORTHALIDONE, NF = 100 mg 1

furosemide, NF = soln, 8 mg/mL(Lasix)

1

hydrochlorothiazide caps (Microzide) 1

hydrochlorothiazide tabs 1

indapamide 1

methazolamide (Neptazane) 1

metolazone (Zaroxolyn) 1

spironolactone (Aldactone) 1

spironolactone/hydrochlorothiazide(Aldactazide)

1

torsemide (Demadex) 1

triamterene/hydrochlorothiazide,NF = 50-25 mg (Dyazide, Maxzide,Maxzide-25)

1

HEART RHYTHM

amiodarone (Cordarone) 1

disopyramide (Norpace) 1

flecainide 1

mexiletine 1

NORPACE CR 2

propafenone (Rythmol) 1

propafenone ext-release (RythmolSR)

1

quinidine gluconate ext-release 1

QUINIDINE SULFATE ext-release 2

quinidine sulfate 300 mg 1

OTHER HEART RELATED DRUGSPA – Prior Authorization program information available at:www.MyPrime.com/MyPrime/UMN

amlodipine/atorvastatin (Caduet) 1

clonidine (Catapres, Catapres-TTS) 1

DIBENZYLINE 1

digoxin tabs (Lanoxin) 1

doxazosin (Cardura) 1

eplerenone (Inspra) 1

Drug Name Dru

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guanfacine (Tenex) 1

hydralazine 1

LANOXIN 0.625 mg, 0.1875 mg 2

methyldopa 1

midodrine (Proamatine) 1

minoxidil 1

OPSUMIT 2 •prazosin (Minipress) 1

REVATIO 2 • •sildenafil (Revatio) 1 • •terazosin 1

TRACLEER 2 •VELETRI 2 •ERECTILE DYSFUNCTION

CAVERJECT 2

CIALIS 2

EDEX 2

VIAGRA 1

BEE STING KITS

EPIPEN 1

EPIPEN-JR 1

RESPIRATORY AGENTS

ANTIHISTAMINES

cetirizine syrup 1

cyproheptadine 1

promethazine, NF = supp, 50 mg 1

NASAL PRODUCTS

azelastine (Astepro) 1

BACTROBAN NASAL 2

flunisolide spray, 0.025%(Flunisolide)

1

fluticasone propionate (Flonase) 1

ipratropium spray (Atrovent) 1

NASONEX 2

triamcinolone (Nasacort AQ) 1

2014


Drug Name Dru

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COUGH/COLD/ALLERGY

acetylcysteine 1

ASTHMA/COPDPA – Prior Authorization program information availableat www.MyPrime.com/MyPrime/UMN ST – Step Therapyprogram information available at www.MyPrime.com/MyPrime/UMN

ADVAIR DISKUS 2

ADVAIR HFA 2

albuterol ext-release (Vospire ER) 1

albuterol inhal soln, syrup, tabs 1

ANORO ELLIPTA 2

ASMANEX 1

ATROVENT HFA 1

BREO ELLIPTA 2

budesonide (Pulmicort Respules) 1

COMBIVENT RESPIMAT 2

cromolyn sodium inhal soln 1

DULERA 2

FLOVENT DISKUS 2

FLOVENT HFA 2

FORADIL AEROLIZER 1

ipratropium inhal soln 1

ipratropium/albuterol (Duoneb) 1

levalbuterol (Xopenex, XopenexConcentrate)

1

montelukast (Singulair) 1

PROAIR HFA 1

PULMICORT RESPULES 1 mg/2 mL 2

QVAR 1

SPIRIVA HANDIHALER 2

SYMBICORT 2

terbutaline 1

theophylline ext-release 1

VENTOLIN HFA 1

XOLAIR 1 • •

Drug Name Dru

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zafirlukast (Accolate) 1

OTHER RESPIRATORY DRUGSPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

FIRAZYR 1 •KALYDECO 1 • •PULMOZYME 1 •tobramycin inhal soln (Tobi) 1 •GASTROINTESTINAL DRUGS

LAXATIVES

COLYTE-FLAVOR PACKS for soln,227.1 g

2

GOLYTELY packet, 227.1 g 2

lactulose 1

OSMOPREP 2

PEG – electrolytes for soln (Colyte,Golytely, Nulytely)

1

diphenoxylate/atropine tabs(Lomotil)

1

loperamide 1

ULCER/GERD

CARAFATE susp 2

cimetidine 1

dicyclomine caps, tabs (Bentyl) 1

DONNATAL EXTENTABS 2

famotidine (Pepcid) 1

glycopyrrolate (Robinul) 1

hyoscyamine (Anaspaz, Levsin,Levsin/SL)

1

hyoscyamine ext-release (Levbid) 1

lansoprazole delayed-release(Prevacid)

1

methscopolamine (Pamine, PamineForte)

1

misoprostol (Cytotec) 1

OMECLAMOX-PAK 2

2014


Drug Name Dru

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omeprazole delayed-release(Prilosec)

1

pantoprazole delayed-release(Protonix)

1

ranitidine (Zantac) 1

sucralfate (Carafate) 1

NAUSEA AND VOMITINGPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

ALOXI 1

EMEND – Prior authorization requiredafter 14 days

1 •

granisetron 1

meclizine 1

ondansetron (Zofran, Zofran ODT) 1

ondansetron tabs, 24 mg 1

SANCUSO 2 •trimethobenzamide (Tigan) 1

DIGESTIVE ENZYMES

CREON 1

OTHER GASTROINTESTINAL DRUGS

ASACOL HD 2

balsalazide (Colazal) 1

calcium acetate (Eliphos, Phoslo) 1

CANASA 2

CHENODAL 1 •DELZICOL 2

DIPENTUM 2

lactulose 1

LIALDA 2

mesalamine 1

metoclopramide soln, tabs (Reglan) 1

PENTASA 2

RENVELA 2

SFROWASA 2

sulfasalazine (Azulfidine) 1

Drug Name Dru

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sulfasalazine delayed-release(Azulfidine EN-Tabs)

1

ursodiol (Actigall, Urso 250, UrsoForte)

1

GENITOURINARY DRUGS

URINARY TRACT INFECTIONS

MACRODANTIN caps, 25 mg 2

nitrofurantoin (Furadantin) 1

nitrofurantoin macrocrystalline(Macrodantin)

1

nitrofurantoin monohydrate/macrocrystalline (Macrobid)

1

URINARY TRACT SPASMSST – Step Therapy program information available atwww.MyPrime.com/MyPrime/UMN

DETROL 2 •DETROL LA 2 •oxybutynin 1

oxybutynin ext-release (Ditropan XL) 1

tolterodine (Detrol) 1

tolterodine ext-release (Detrol LA) 1

VAGINAL PRODUCTS

CLEOCIN supp 2

clindamycin (Cleocin) 1

ESTRACE crm 1

ESTRING 2

metronidazole (MetroGel-Vaginal) 1

terconazole (Terazol) 1

VAGIFEM 1

OTHER GENITOURINARY DRUGS

alfuzosin ext-release (Uroxatral) 1

CYSTAGON 1 •finasteride (Proscar) 1

POTASSIUM CITRATE 540 mg,1080 mg

1

potassium citrate/citric acid 1

sodium citrate/citric acid (Shohl's) 1

2014


Drug Name Dru

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tamsulosin (Flomax) 1

CENTRAL NERVOUS SYSTEM DRUGS

ANXIETY

alprazolam (Xanax) 1

alprazolam ext-release (Xanax XR) 1

buspirone 1

DIAZEPAM oral soln, 1 mg/mL 2

diazepam tabs (Valium) 1

hydroxyzine 1

hydroxyzine pamoate 25 mg, 50 mg(Vistaril)

1

lorazepam (Ativan) 1

lorazepam conc (LorazepamIntensol)

1

DEPRESSIONST – Step Therapy program information available atwww.MyPrime.com/MyPrime/UMN

amitriptyline 1

bupropion (Wellbutrin) 1

bupropion ext-release (WellbutrinSR, Wellbutrin XL)

1

citalopram (Celexa) 1

clomipramine (Anafranil) 1

desipramine (Norpramin) 1

doxepin, NF = 75 mg 1

duloxetine delayed-release(Cymbalta)

1

escitalopram (Lexapro) 1

fluoxetine, NF = 60 mg (Prozac) 1

fluvoxamine 1

imipramine (Tofranil) 1

mirtazapine (Remeron, RemeronSolTab)

1

nortriptyline caps (Pamelor) 1

paroxetine (Paxil) 1

paroxetine ext-release (Paxil CR) 1

PAXIL susp 2

Drug Name Dru

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phenelzine (Nardil) 1

sertraline (Zoloft) 1

tranylcypromine (Parnate) 1

trazodone 1

venlafaxine (Effexor) 1

venlafaxine ext-release caps (EffexorXR)

1

venlafaxine ext-release tabs,37.5 mg, 75 mg, 150 mg – allmanufacturers other than Schwarzand Upstate

1

PSYCHOTIC AND BIPOLAR DISORDERS

ABILIFY 2

ABILIFY MAINTENA 2 •chlorpromazine 1

clozapine (Clozaril) 1

fluphenazine tabs 1

haloperidol 1

haloperidol lactate 1

lithium carbonate 1

lithium carbonate ext-release(Lithobid)

1

LITHIUM CITRATE 2

loxapine (Loxitane) 1

olanzapine (Zyprexa, Zyprexa Zydis) 1

perphenazine 1

prochlorperazine 1

quetiapine (Seroquel) 1

risperidone (Risperdal, Risperdal M-Tab)

1

thiothixene 1

trifluoperazine 1

ziprasidone (Geodon) 1

SLEEP AIDS

estazolam 1

phenobarbital soln; tabs, 16.2 mg,32.4 mg

1

2014


Drug Name Dru

g T

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temazepam (Restoril) 1

zaleplon (Sonata) 1

zolpidem (Ambien) 1

zolpidem ext-release (Ambien CR) 1

HYPERACTIVITY/NARCOLEPSYPA – Prior Authorization information available atwww.MyPrime.com/MyPrime/UMN

amphetamine/dextroamphetamine(Adderall)

1

amphetamine/dextroamphetamineext-release (Adderall XR)

1

caffeine citrate (Cafcit) 1

dextroamphetamine 1

dextroamphetamine ext-release(Dexedrine Spansule)

1

INTUNIV 2

methylphenidate (Ritalin) 1

methylphenidate ext-release caps;tabs, 20 mg (Ritalin LA, Ritalin SR)

1

METHYLPHENIDATE ext-release tabs,10 mg

1

modafinil (Provigil) 1 •NUVIGIL 2 •RITALIN LA 10 mg 2

STRATTERA 2

VYVANSE 2

MULTIPLE SCLEROSISPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

BETASERON 1 • •COPAXONE 1 • •REBIF 1 • •TECFIDERA 1 • •OBESITYPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

XENICAL 2 •

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OTHER CENTRAL NERVOUS SYSTEM DRUGSPA – Prior Authorization program information available at:www.MyPrime.com/MyPrime/UMN

acamprosate delayed-release(Campral)

1

bupropion ext-release (Zyban) 1

CHANTIX 2

disulfiram (Antabuse) 1

donepezil (Aricept, Aricept ODT) 1

galantamine (Razadyne) 1

galantamine ext-release (RazadyneER)

1

NAMENDA 2

NAMENDA XR 2

NICOTROL INHALER 2

NICOTROL NS 2

rivastigmine (Exelon) 1

XYREM 2 • •PAIN RELIEF DRUGS

NON-NARCOTIC DRUGS

butalbital/acetaminophen 1

butalbital/acetaminophen/caffeine(Esgic, Fioricet)

1

butalbital/aspirin/caffeine (Fiorinal) 1

BUTALBITAL/ASPIRIN/CAFFEINE tabs 1

salsalate 1

NARCOTIC DRUGSPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

acetaminophen/codeine (Tylenol w/Codeine)

1

buprenorphine 1 •buprenorphine/naloxone 1 •butalbital/aspirin/caffeine/codeine

(Fiorinal w/Codeine)1

CODEINE SULFATE 1

DURAGESIC 2 •

2014


Drug Name Dru

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fentanyl (Actiq, Duragesic) 1 •hydrocodone-acetaminophen soln,

7.5-325 mg/15 mL (Hycet)1

hydrocodone/acetaminophen, NF =tabs, 2.5-325 mg

1

hydrocodone/ibuprofen (Ibudone,Reprexain, Vicoprofen)

1

hydromorphone soln, tabs (Dilaudid) 1

HYDROMORPHONE supp 2

methadone conc, soln 1

methadone tabs (Dolophine) 1

morphine sulfate inj, 0.5 mg/mL,1 mg/mL, 8 mg/mL, 10 mg/mL,15 mg/mL; oral conc; soln

1

MORPHINE SULFATE inj, 2 mg/mL,5 mg/mL

2

MORPHINE SULFATE supp, tabs 1

morphine sulfate ext-release (Avinza,Kadian, MS Contin)

1

NUCYNTA ER 2

oxycodone conc; soln; tabs, 10 mg,20 mg

1

oxycodone tabs, 5 mg, 15 mg, 30 mg(Roxicodone)

1

oxycodone/acetaminophen(Percocet)

1

oxycodone/acetaminophen caps,5-500 mg

1

oxycodone/aspirin (Percodan) 1

OXYCONTIN 2

SUBOXONE film 2 •tramadol (Ultram) 1

tramadol ext-release (Ultram ER) 1

tramadol/acetaminophen (Ultracet) 1

RHEUMATOID AND OSTEOARTHRITISST – Step Therapy program information available atwww.MyPrime.com/MyPrime/UMN

CELEBREX 2 •

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diclofenac potassium (Cataflam) 1

diclofenac sodium delayed-release 1

diclofenac sodium ext-release(Voltaren-XR)

1

ENBREL 2 • •ENBREL SURECLICK 2 • •etodolac 1

etodolac ext-release 1

flurbiprofen 1

HUMIRA 2 • •ibuprofen 1

ILARIS 2 • •indomethacin 1

ketoprofen 1

leflunomide (Arava) 1

MELOXICAM susp 2

meloxicam tabs (Mobic) 1

MOBIC susp 2

nabumetone 1

naproxen (Naprosyn) 1

naproxen delayed-release (EC-Naprosyn)

1

naproxen sodium (Anaprox) 1

oxaprozin (Daypro) 1

piroxicam (Feldene) 1

RIDAURA 2

sulindac 1

MIGRAINE HEADACHES

acetaminophen/isometheptene/dichloralphenazone

1

CAFERGOT 2

MIGRANAL 2

naratriptan (Amerge) 1

rizatriptan (Maxalt, Maxalt-MLT) 1

sumatriptan auto-injector; cartridge;inj, 6 mg/0.5 mL; tabs (Imitrex)

1

2014


Drug Name Dru

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SUMATRIPTAN nasal spray 1

GOUT

allopurinol (Zyloprim) 1

COLCRYS 2

probenecid 1

probenecid/colchicine 1

NEUROMUSCULAR DRUGS

SEIZURES

carbamazepine (Tegretol) 1

carbamazepine ext-release(Carbatrol, Tegretol-XR)

1

clonazepam (Klonopin) 1

DIASTAT 2

DILANTIN caps, 30 mg 2

divalproex delayed-release(Depakote, Depakote Sprinkles)

1

divalproex ext-release (Depakote ER) 1

ethosuximide (Zarontin) 1

gabapentin (Neurontin) 1

lamotrigine (Lamictal) 1

levetiracetam (Keppra) 1

LYRICA 2

oxcarbazepine (Trileptal) 1

phenytoin (Dilantin) 1

phenytoin sodium ext-release(Dilantin, Phenytek)

1

primidone (Mysoline) 1

SABRIL 1

TEGRETOL-XR tabs, 100 mg 2

topiramate (Topamax, TopamaxSprinkles)

1

valproic acid (Depakene) 1

zonisamide (Zonegran) 1

PARKINSON'S DISEASE

amantadine caps, syrup 1

AMANTADINE tabs 1

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AZILECT 2

benztropine 1

bromocriptine (Parlodel) 1

carbidopa/levodopa (Parcopa,Sinemet)

1

carbidopa/levodopa ext-release(Sinemet CR)

1

entacapone (Comtan) 1

pramipexole (Mirapex) 1

ropinirole (Requip) 1

selegiline caps (Eldepryl) 1

selegiline tabs 1

trihexyphenidyl 1

MUSCLE RELAXANTS

baclofen 1

chlorzoxazone (Parafon Forte DSC) 1

cyclobenzaprine (Fexmid, Flexeril) 1

dantrolene (Dantrium) 1

EUFLEXXA 1 •HYALGAN 1 •metaxalone (Skelaxin) 1

methocarbamol (Robaxin) 1

orphenadrine citrate ext-release 1

orphenadrine/aspirin/caffeine25-385-30 mg

1

ORTHOVISC 2

ROBAXIN inj 2

SUPARTZ 1 •SYNVISC/ONE 2 •tizanidine (Zanaflex) 1

OTHER NEUROMUSCULAR DRUGS

MESTINON syrup 2

MESTINON TIMESPAN 2

MYOBLOC 1 •pyridostigmine (Mestinon) 1

riluzole (Rilutek) 1

2014


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SUPPLEMENTS

VITAMINS

ergocalciferol (Drisdol) 1

MEPHYTON 1

MULTIVITAMINS

pediatric multivitamins 1

PRENATAL VITAMINS 2

MINERALS AND ELECTROLYTES

K-TAB 20 mEq 2

potassium bicarbonate/chlorideeffervescent tabs, 25 mEq

1

potassium chloride packets, soln 1

potassium chloride ext-release(Micro-K)

1

potassium chloride ext-release tabs,NF = 20 mEq

1

potassium phosphate/sodiumphosphates (K-Phos Neutral)

1

sodium fluoride chew tabs, soln 1

BLOOD MODIFYING DRUGSPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

ADVATE 1 •AGGRENOX 2

ALPHANATE/VON WILLEBRAND 1 •ALPHANINE SD 1 •anagrelide (Agrylin) 1

ARANESP 2 • •BENEFIX 2 •CEREZYME 1 •cilostazol (Pletal) 1

CINRYZE 1 •clopidogrel (Plavix) 1

cyanocobalamin inj 1

dipyridamole (Persantine) 1

enoxaparin (Lovenox) 1 •

Drug Name Dru

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EPOGEN 2 • •FEIBA NF 1 •folic acid tabs, 1 mg 1

FRAGMIN 2 •GRANIX 1 •HELIXATE FS 1 •HEMOFIL M 1 •HUMATE-P 1 •KOATE-DVI 1 •KOGENATE FS 1 •LEUKINE 2 •MONOCLATE-P 1 •MONONINE 1 •NASCOBAL 2

NEULASTA 2 •NEUMEGA 2 •NEUPOGEN 1 •NOVOSEVEN RT 1 •pentoxifylline ext-release (Trental) 1

PROCRIT 1 • •PROFILNINE SD 1 •RECOMBINATE 1 •VENOFER 2

warfarin (Coumadin) 1

WILATE 1 •TOPICAL DRUGS

EYEST – Step Therapy program information available atwww.MyPrime.com/MyPrime/UMN

Anti-infectives

BACITRACIN oint 2

bacitracin/polymyxin B oint 1

ciprofloxacin soln (Ciloxan) 1

erythromycin oint, soln 1

gentamicin oint, soln (Garamycin) 1

2014


Drug Name Dru

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neomycin/polymyxin B/bacitracinoint

1

neomycin/polymyxin B/gramicidinsoln (Neosporin)

1

ofloxacin soln (Ocuflox) 1

polymyxin B/trimethoprim soln(Polytrim)

1

sulfacetamide sodium soln(Bleph-10)

1

tobramycin soln (Tobrex) 1

TOBREX oint 2

trifluridine soln (Viroptic) 1

ZYMAXID 2 •Steroids and Combination Products

BLEPHAMIDE S.O.P. 2

dexamethasone sodium phosphatesoln

1

fluorometholone susp (FMLLiquifilm)

1

neomycin/polymyxin B/bacitracin/hydrocortisone oint

1

neomycin/polymyxin B/dexamethasone oint, susp(Maxitrol)

1

prednisolone acetate susp (PredForte)

1

PREDNISOLONE SODIUMPHOSPHATE soln, 1%

2

sulfacetamide sodium/prednisolonesoln

1

TOBRADEX oint 2

tobramycin/dexamethasone susp(Tobradex)

1

Glaucoma

brimonidine soln, 0.15% (AlphaganP)

1

brimonidine soln, 0.2% 1

carteolol soln 1

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dorzolamide soln (Trusopt) 1

dorzolamide/timolol maleate soln(Cosopt)

1

latanoprost soln (Xalatan) 1

levobunolol soln (Betagan) 1

LUMIGAN 2

pilocarpine soln (Isopto Carpine) 1

SIMBRINZA 2

timolol maleate soln (Timoptic,Timoptic-XE)

1

Other Eye ProductsPA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

atropine sulfate soln (IsoptoAtropine)

1

azelastine soln (Optivar) 1

cromolyn sodium soln 1

cyclopentolate soln (Cyclogyl) 1

diclofenac soln (Voltaren) 1

flurbiprofen soln (Ocufen) 1

homatropine soln (IsoptoHomatropine)

1

ketorolac soln (Acular, Acular LS) 1

PATADAY 2

RESTASIS 2

tropicamide (Mydriacyl) 1

EAR

acetic acid soln 1

benzocaine/antipyrine soln 1

CIPRO HC 2

CIPRODEX 2

hydrocortisone/acetic acid soln(VoSol HC)

1

neomycin/polymyxin B/hydrocortisone soln, susp(Cortisporin)

1

ofloxacin soln 1

2014


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MOUTH AND THROAT (local)

cevimeline (Evoxac) 1

chlorhexidine (Peridex) 1

clotrimazole troche 1

lidocaine viscous 1

nystatin susp 1

pilocarpine (Salagen) 1

sodium fluoride (Prevident) 1

triamcinolone dental paste 1

ANORECTAL AGENTS

CORTIFOAM 2

hydrocortisone enema (Cortenema) 1

hydrocortisone acetate (Anusol-HC,Proctocort)

1

SKIN CONDITIONS/PRODUCTS

AcnePA – Prior Authorization program information available atwww.MyPrime.com/MyPrime/UMN

adapalene (Differin) 1 •clindamycin (Cleocin-T) 1

clindamycin/benzoyl peroxide(Benzaclin, Duac)

1

erythromycin (Erygel) 1

erythromycin pads, soln 1

erythromycin/benzoyl peroxide(Benzamycin)

1

FINACEA 2

isotretinoin 10 mg, 20 mg, 40 mg –Amnesteem, Claravis

1

metronidazole (Metrocream,Metrogel, Metrolotion)

1

RETIN-A – Prior Authorization isrequired for patients 40 years of ageand older

2 •

RETIN-A MICRO – Prior Authorizationis required for patients 40 years ofage and older

2 •

sulfacetamide sodium (Klaron) 1

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SULFACETAMIDE SODIUM/SULFURsusp, 10-5%

2

sulfacetamide sodium/sulfur, crm;emul; lotn, 10-5%

1

TAZORAC 1

tretinoin – Avita – PriorAuthorization is required forpatients 40 years of age and older(Retin-A)

1 •

tretinoin microsphere – PriorAuthorization is required forpatients 40 years of age and older(Retin-A Micro)

1 •

Anti-infectives

ciclopirox (Loprox, Penlac) 1

econazole 1

ketoconazole (Nizoral) 1

mupirocin (Bactroban) 1

nystatin topical 1

silver sulfadiazine (Silvadene) 1

ZOVIRAX crm 2

Corticosteroids

alclometasone (Aclovate) 1

amcinonide crm 1

APEXICON E 2

betamethasone dipropionate 1

betamethasone dipropionate,augmented (Diprolene)

1

betamethasone valerate 1

clobetasol (Olux, Temovate) 1

CORDRAN 2

desonide (Desowen) 1

desoximetasone crm, 0.25%; gel;oint (Topicort)

1

diflorasone oint 1

fluocinolone (Derma-Smoothe/FS,Synalar)

1

fluocinonide 1

2014


Drug Name Dru

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fluticasone propionate (Cutivate) 1

halobetasol (Ultravate) 1

hydrocortisone topical 1

hydrocortisone valerate (Westcort) 1

mometasone (Elocon) 1

nystatin/triamcinolone 1

TOPICORT 2

triamcinolone crm; lotn; oint,0.025%, 0.1%

1

Other Skin ProductsPA – Prior Authorization program information availableat www.MyPrime.com/MyPrime/UMN ST – Step Therapyprogram information available at www.MyPrime.com/MyPrime/UMN

acitretin (Soriatane) 1

aluminum chloride (Drysol) 1

AMEVIVE 2 •calcipotriene crm, soln (Dovonex) 1

CARAC 2

diclofenac sodium (Solaraze) 1

ELIDEL 2 •FLUOROPLEX crm, 1% 2

fluorouracil (Efudex) 1

imiquimod (Aldara) 1 •lidocaine jelly, 2%; oint, 5%; soln

(Xylocaine)1

lidocaine patches (Lidoderm) 1 •lidocaine/prilocaine crm (Emla) 1

LIDODERM 2 •lindane 1

malathion (Ovide) 1

OXSORALEN ULTRA 2

permethrin (Elimite) 1

podofilox soln (Condylox) 1

PROTOPIC 2 •REGRANEX 2

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SELENIUM SULFIDE 1

selenium sulfide 1

MISCELLANEOUS CATEGORIES (includes suppliesand devices)

DIABETIC SUPPLIES

BLOOD GLUCOSE CALIBRATIONLIQUID – VARIOUS

1

LANCETS, PEN NEEDLES,SYRINGES – VARIOUS

1

TRUERESULT Blood Glucose Kit withDevice – covered at $0 copay

n/a

TRUETEST, TRUETRACK BloodGlucose Test Strips

1

TRUE2GO Blood Glucose Kit withDevice – covered at $0 copay

n/a

RESPIRATORY INHALER-ASSIST DEVICES

CHAMBERS, MASKS, SPACERS –VARIOUS

2

MISCELLANEOUS DRUGS

ATGAM 1

AZASAN 1

azathioprine (Imuran) 1

AZATHIOPRINE inj 1

CELLCEPT oral susp 2 •CHEMET 1

CUPRIMINE 2 •cyclosporine (Sandimmune) 1 •cyclosporine modified caps, soln;

NF = 50 mg (Neoral)1 •

mycophenolate mofetil (Cellcept) 1 •mycophenolate sodium delayed-

release (Myfortic)1 •

MYFORTIC 1 •naltrexone (ReVia) 1

RAPAMUNE 1 •REVLIMID 1 •SANDIMMUNE soln 2 •

2014


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sirolimus (Rapamune) 1 •sodium polystyrene sulfonate 1

tacrolimus (Prograf) 1 •THALOMID 1 •THYROGEN 1 •ZORTRESS 1 •

2014


INDEX

A

abacavir/lamivudine/zidovudine (Trizivir)....................... 2abacavir (Ziagen)...............................................................2ABILIFY............................................................................. 11ABILIFY MAINTENA......................................................... 11acamprosate delayed-release (Campral).......................12acarbose (Precose)........................................................... 5acebutolol (Sectral)........................................................... 7acetaminophen/codeine (Tylenol w/Codeine)...............12acetaminophen/isometheptene/dichloralphenazone....................................................... 13

acetazolamide 250 mg...................................................... 7acetazolamide ext-release (Diamox Sequels)................. 7acetic acid ear soln.........................................................16acetylcysteine.................................................................... 9acitretin (Soriatane).........................................................18ACTHAR HP........................................................................6ACTIMMUNE....................................................................... 3ACTOPLUS MET XR.......................................................... 5acyclovir (Zovirax).............................................................2adapalene (Differin).........................................................17adefovir (Hepsera).............................................................2ADVAIR DISKUS.................................................................9ADVAIR HFA.......................................................................9ADVATE............................................................................ 15AFINITOR............................................................................ 3AFINITOR DISPERZ........................................................... 3AGGRENOX...................................................................... 15ALBENZA............................................................................ 3albuterol ext-release (Vospire ER)...................................9albuterol inhal soln, syrup, tabs......................................9alclometasone (Aclovate)............................................... 17ALDACTAZIDE tabs, 50-50 mg.......................................... 7ALDURAZYME.................................................................... 6alendronate, NF = soln; tabs, 40 mg (Fosamax).............6alfuzosin ext-release (Uroxatral)....................................10ALINIA................................................................................. 3ALKERAN............................................................................ 3allopurinol (Zyloprim)......................................................14ALOXI................................................................................ 10ALPHANATE/VON WILLEBRAND.................................... 15ALPHANINE SD................................................................ 15alprazolam (Xanax)..........................................................11alprazolam ext-release (Xanax XR)................................11aluminum chloride (Drysol)............................................18amantadine caps, syrup................................................. 14AMANTADINE tabs........................................................... 14amcinonide crm...............................................................17AMEVIVE...........................................................................18amiloride.............................................................................7amiloride/hydrochlorothiazide......................................... 7amiodarone (Cordarone)...................................................8

amitriptyline..................................................................... 11amlodipine/atorvastatin (Caduet).....................................8amlodipine/benazepril (Lotrel)......................................... 7amlodipine (Norvasc)........................................................7amoxicillin/potassium clavulanate (Augmentin)............ 1amoxicillin/potassium clavulanate ext-release(Augmentin XR)................................................................1

amoxicillin caps, susp, tabs............................................ 1AMOXICILLIN chew tabs, 250 mg...................................... 1amphetamine/dextroamphetamine (Adderall)...............12amphetamine/dextroamphetamine ext-release(Adderall XR)..................................................................12

ampicillin............................................................................ 1AMPICILLIN susp................................................................1anagrelide (Agrylin).........................................................15anastrozole (Arimidex)......................................................3ANDRODERM..................................................................... 4ANDROGEL.........................................................................4ANORO ELLIPTA................................................................9APEXICON E.................................................................... 17APTIVUS............................................................................. 2ARANESP..........................................................................15ARIMIDEX........................................................................... 3AROMASIN..........................................................................3ASACOL HD......................................................................10ASMANEX........................................................................... 9atenolol/chlorthalidone (Tenoretic)................................. 7atenolol (Tenormin)...........................................................7ATGAM.............................................................................. 18atorvastatin (Lipitor)......................................................... 7atovaquone/proguanil (Malarone)....................................2ATRIPLA..............................................................................2atropine sulfate eye soln (Isopto Atropine).................. 16ATROVENT HFA.................................................................9AUGMENTIN susp, 125 mg/5 mL.......................................1AVANDAMET...................................................................... 5AVANDARYL....................................................................... 5AVANDIA............................................................................. 5AXIRON............................................................................... 4AZASAN............................................................................ 18azathioprine (Imuran)......................................................18AZATHIOPRINE inj........................................................... 18azelastine eye soln (Optivar)..........................................16azelastine nasal (Astepro)................................................8AZILECT............................................................................ 14AZITHROMYCIN powder packets.......................................1azithromycin susp, tabs (Zithromax)...............................1

B

bacitracin/polymyxin B eye oint.................................... 15BACITRACIN eye oint.......................................................15baclofen............................................................................ 14BACTROBAN NASAL......................................................... 8balsalazide (Colazal)....................................................... 10BARACLUDE.......................................................................2benazepril/hydrochlorothiazide (Lotensin HCT).............6

2014


benazepril (Lotensin)........................................................ 6BENEFIX........................................................................... 15benzocaine/antipyrine ear soln......................................16benztropine...................................................................... 14betamethasone dipropionate......................................... 17betamethasone dipropionate, augmented(Diprolene)...................................................................... 17

betamethasone valerate..................................................17BETASERON.....................................................................12bicalutamide (Casodex).................................................... 3BILTRICIDE......................................................................... 3bisoprolol/hydrochlorothiazide (Ziac)............................. 7bisoprolol (Zebeta)............................................................ 7BLEPHAMIDE S.O.P.........................................................16BLOOD GLUCOSE CALIBRATION LIQUID –VARIOUS.........................................................................18

BOSULIF............................................................................. 3BRAVELLE.......................................................................... 5BREO ELLIPTA...................................................................9brimonidine eye soln, 0.15% (Alphagan P)................... 16brimonidine eye soln, 0.2%............................................16bromocriptine (Parlodel).................................................14budesonide (Pulmicort Respules)................................... 9budesonide ext-release (Entocort EC)............................ 4bumetanide.........................................................................7buprenorphine................................................................. 12buprenorphine/naloxone.................................................12bupropion (Wellbutrin)....................................................11bupropion ext-release (smoking deterrent)(Zyban)............................................................................ 12

bupropion ext-release (Wellbutrin SR, WellbutrinXL)................................................................................... 11

buspirone......................................................................... 11butalbital/acetaminophen............................................... 12butalbital/acetaminophen/caffeine (Esgic, Fioricet).....12butalbital/aspirin/caffeine/codeine (Fiorinal w/Codeine)..........................................................................12

butalbital/aspirin/caffeine (Fiorinal)...............................12BUTALBITAL/ASPIRIN/CAFFEINE tabs........................... 12BYSTOLIC........................................................................... 7

C

cabergoline.........................................................................6CAFERGOT.......................................................................13caffeine citrate (Cafcit)................................................... 12calcipotriene crm, soln (Dovonex).................................18calcitonin-salmon (Miacalcin).......................................... 6calcitriol (Rocaltrol)...........................................................6calcium acetate (Eliphos, Phoslo)................................. 10CANASA............................................................................ 10capecitabine (Xeloda)....................................................... 3CAPRELSA..........................................................................3captopril..............................................................................6CARAC.............................................................................. 18CARAFATE susp.................................................................9carbamazepine (Tegretol)...............................................14

carbamazepine ext-release (Carbatrol, Tegretol-XR)...................................................................................14

carbidopa/levodopa (Parcopa, Sinemet)....................... 14carbidopa/levodopa ext-release (Sinemet CR)............. 14CARDIZEM LA tabs, 120 mg..............................................7carteolol eye soln............................................................16carvedilol (Coreg)..............................................................7CAVERJECT....................................................................... 8cefaclor caps..................................................................... 1cefadroxil............................................................................1cefdinir................................................................................1cefpodoxime.......................................................................1cefprozil.............................................................................. 1CEFTIN susp, 250 mg/5 mL............................................... 1ceftriaxone (Rocephin)......................................................1cefuroxime (Ceftin)............................................................1CELEBREX........................................................................13CELLCEPT oral susp........................................................ 18CENESTIN...........................................................................4cephalexin, NF = tabs (Keflex).........................................1CEREZYME.......................................................................15cetirizine syrup.................................................................. 8CETROTIDE........................................................................ 5cevimeline (Evoxac)........................................................ 17CHAMBERS, MASKS, SPACERS – VARIOUS................ 18CHANTIX........................................................................... 12CHEMET............................................................................18CHENODAL.......................................................................10chlorhexidine (Peridex)...................................................17chloroquine phosphate (Aralen)...................................... 2chlorothiazide tabs, 500 mg.............................................8chlorpromazine................................................................ 11CHLORTHALIDONE, NF = 100 mg.................................... 8chlorzoxazone (Parafon Forte DSC).............................. 14cholestyramine (Questran, Questran Light)................... 7chorionic gonadotropin.................................................... 5CIALIS................................................................................. 8ciclopirox (Loprox, Penlac)............................................ 17cilostazol (Pletal)............................................................. 15cimetidine........................................................................... 9CINRYZE........................................................................... 15CIPRODEX........................................................................ 16ciprofloxacin ext-release (Cipro XR)............................... 1ciprofloxacin eye soln (Ciloxan).................................... 15ciprofloxacin tabs (Cipro).................................................1CIPRO HC.........................................................................16CIPRO susp........................................................................ 1citalopram (Celexa)......................................................... 11clarithromycin (Biaxin)......................................................1clarithromycin ext-release (Biaxin XL)............................ 1CLEOCIN supp..................................................................10CLIMARA PRO....................................................................4clindamycin/benzoyl peroxide (Benzaclin, Duac).........17clindamycin oral (Cleocin, Cleocin Pediatric).................3clindamycin topical (Cleocin-T)..................................... 17clindamycin vaginal crm (Cleocin)................................ 10

2014


clobetasol (Olux, Temovate).......................................... 17clomiphene (Clomid).........................................................5clomipramine (Anafranil)................................................ 11clonazepam (Klonopin)...................................................14clonidine (Catapres, Catapres-TTS)................................ 8clopidogrel (Plavix)......................................................... 15clotrimazole troche......................................................... 17clozapine (Clozaril)..........................................................11CODEINE SULFATE.........................................................12COLCRYS......................................................................... 14colestipol (Colestid).......................................................... 7COLYTE-FLAVOR PACKS for soln, 227.1 g...................... 9COMBIPATCH.....................................................................4COMBIVENT RESPIMAT....................................................9COMBIVIR........................................................................... 2COMETRIQ......................................................................... 3COMPLERA.........................................................................2COPAXONE...................................................................... 12COPEGUS...........................................................................2CORDRAN.........................................................................17CORTIFOAM..................................................................... 17CORTISONE....................................................................... 4CREON..............................................................................10CRIXIVAN............................................................................2cromolyn sodium eye soln.............................................16cromolyn sodium inhal soln............................................ 9CUPRIMINE.......................................................................18cyanocobalamin inj......................................................... 15cyclobenzaprine (Fexmid, Flexeril)................................14cyclopentolate eye soln (Cyclogyl)............................... 16cyclosporine (Sandimmune).......................................... 18cyclosporine modified caps, soln; NF = 50 mg(Neoral)........................................................................... 18

cyproheptadine.................................................................. 8CYSTAGON.......................................................................10

D

danazol............................................................................... 4dantrolene (Dantrium).....................................................14DAPSONE........................................................................... 3DARAPRIM..........................................................................3DELZICOL......................................................................... 10demeclocycline.................................................................. 1desipramine (Norpramin)................................................11desmopressin (DDAVP).................................................... 6desonide (Desowen)....................................................... 17desoximetasone crm, 0.25%; gel; oint (Topicort).........17DETROL............................................................................ 10DETROL LA...................................................................... 10dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4mg, 6 mg.......................................................................... 4

dexamethasone sodium phosphate eye soln............... 16DEXAMETHASONE tabs, 1 mg, 2 mg................................4dextroamphetamine.........................................................12dextroamphetamine ext-release (DexedrineSpansule)........................................................................12

DIABETA............................................................................. 5DIASTAT............................................................................14DIAZEPAM oral soln, 1 mg/mL.........................................11diazepam tabs (Valium).................................................. 11DIBENZYLINE..................................................................... 8diclofenac eye soln (Voltaren)....................................... 16diclofenac potassium (Cataflam)................................... 13diclofenac sodium delayed-release...............................13diclofenac sodium ext-release (Voltaren-XR)............... 13diclofenac sodium gel (Solaraze).................................. 18dicloxacillin........................................................................ 1dicyclomine caps, tabs (Bentyl)...................................... 9didanosine delayed-release (Videx EC).......................... 2diflorasone oint............................................................... 17digoxin tabs (Lanoxin)......................................................8DILANTIN caps, 30 mg.....................................................14diltiazem (Cardizem)......................................................... 7diltiazem ext-release (Cardizem CD, Cardizem LA,Tiazac)...............................................................................7

DIOVAN............................................................................... 6DIPENTUM........................................................................ 10diphenoxylate/atropine tabs (Lomotil)............................ 9dipyridamole (Persantine).............................................. 15disopyramide (Norpace)................................................... 8disulfiram (Antabuse)......................................................12divalproex delayed-release (Depakote, DepakoteSprinkles)........................................................................14

divalproex ext-release (Depakote ER)........................... 14DIVIGEL...............................................................................4donepezil (Aricept, Aricept ODT)...................................12DONNATAL EXTENTABS...................................................9dorzolamide/timolol maleate eye soln (Cosopt)........... 16dorzolamide eye soln (Trusopt).....................................16doxazosin (Cardura)..........................................................8doxepin, NF = 75 mg.......................................................11doxycycline hyclate caps (Vibramycin).......................... 1doxycycline hyclate tabs..................................................1doxycycline monohydrate (Adoxa, Monodox)................1DULERA.............................................................................. 9duloxetine delayed-release (Cymbalta)......................... 11DURAGESIC..................................................................... 12

E

E.E.S. 400........................................................................... 1E.E.S. GRANULES............................................................. 1econazole......................................................................... 17EDEX................................................................................... 8EDURANT........................................................................... 2ELAPRASE..........................................................................6ELIDEL.............................................................................. 18ELLA.................................................................................... 5EMCYT................................................................................ 3EMEND – Prior authorization required after 14 days........ 10EMTRIVA.............................................................................2enalapril/hydrochlorothiazide (Vaseretic)....................... 6enalapril (Vasotec)............................................................ 6

2014


ENBREL............................................................................ 13ENBREL SURECLICK.......................................................13enoxaparin (Lovenox)..................................................... 15entacapone (Comtan)......................................................14EPIPEN................................................................................8EPIPEN-JR.......................................................................... 8EPIVIR................................................................................. 2eplerenone (Inspra)........................................................... 8EPOGEN........................................................................... 15EPZICOM............................................................................ 2ergocalciferol (Drisdol)................................................... 15ERIVEDGE.......................................................................... 3ERYPED.............................................................................. 1ERY-TAB............................................................................. 1ERYTHROCIN STEARATE.................................................1erythromycin/benzoyl peroxide (Benzamycin)............. 17erythromycin/sulfisoxazole.............................................. 3erythromycin delayed-release caps................................ 1ERYTHROMYCIN ETHYLSUCCINATE.............................. 1erythromycin eye oint, soln........................................... 15erythromycin gel (Erygel)...............................................17erythromycin pads, soln.................................................17escitalopram (Lexapro)...................................................11estazolam......................................................................... 11ESTRACE crm.................................................................. 10estradiol/norethindrone acetate (Activella).....................4estradiol (Climara, Estrace)..............................................4ESTRING...........................................................................10estropipate 0.75 mg, 1.5 mg.............................................4ethambutol (Myambutol)...................................................1ethosuximide (Zarontin)..................................................14etodolac............................................................................ 13etodolac ext-release........................................................13ETOPOSIDE caps...............................................................3EUFLEXXA........................................................................ 14exemestane (Aromasin)....................................................3

F

famciclovir (Famvir).......................................................... 2famotidine (Pepcid)........................................................... 9FARESTON......................................................................... 3FEIBA NF.......................................................................... 15felodipine ext-release........................................................7FEMARA..............................................................................3FEMHRT LOW DOSE.........................................................4fenofibrate (Lofibra, Tricor)..............................................7fenofibrate micronized (Lofibra)...................................... 7fenofibric acid delayed-release (Trilipix).........................7fentanyl (Actiq, Duragesic).............................................13FINACEA........................................................................... 17finasteride (Proscar)....................................................... 10FIRAZYR............................................................................. 9FIRST-TESTOSTERONE....................................................4FIRST-TESTOSTERONE MC............................................. 4flecainide............................................................................ 8FLOVENT DISKUS............................................................. 9

FLOVENT HFA....................................................................9fluconazole (Diflucan)....................................................... 1flucytosine (Ancobon).......................................................1fludrocortisone.................................................................. 4flunisolide spray, 0.025% (Flunisolide)........................... 8fluocinolone (Derma-Smoothe/FS, Synalar)................. 17fluocinonide..................................................................... 17fluorometholone eye susp (FML Liquifilm)...................16FLUOROPLEX crm, 1%....................................................18fluorouracil (Efudex)....................................................... 18fluoxetine, NF = 60 mg (Prozac).................................... 11fluphenazine tabs............................................................ 11flurbiprofen eye soln (Ocufen).......................................16flurbiprofen tabs..............................................................13flutamide.............................................................................3fluticasone propionate nasal spray (Flonase)................ 8fluticasone propionate topical (Cutivate)......................18fluvoxamine......................................................................11folic acid tabs, 1 mg....................................................... 15FOLLISTIM AQ....................................................................5FORADIL AEROLIZER....................................................... 9FORTEO..............................................................................6FORTESTA..........................................................................4fosinopril............................................................................ 6fosinopril/hydrochlorothiazide......................................... 6FRAGMIN.......................................................................... 15furosemide, NF = soln, 8 mg/mL (Lasix)......................... 8FUZEON.............................................................................. 2

G

gabapentin (Neurontin)...................................................14galantamine (Razadyne)................................................. 12galantamine ext-release (Razadyne ER)....................... 12GANIRELIX ACETATE........................................................5gemfibrozil (Lopid)............................................................ 7gentamicin eye oint, soln (Garamycin)......................... 15GILOTRIF............................................................................ 3GLEEVEC............................................................................3glimepiride (Amaryl)..........................................................5glipizide/metformin............................................................5glipizide (Glucotrol)...........................................................5glipizide ext-release (Glucotrol XL)................................. 5GLUCAGON EMERGENCY KIT......................................... 5glyburide/metformin (Glucovance).................................. 5glyburide (Micronase)....................................................... 5glyburide micronized (Glynase).......................................5glycopyrrolate (Robinul)...................................................9GOLYTELY packet, 227.1 g............................................... 9GONAL-F.............................................................................5granisetron....................................................................... 10GRANIX............................................................................. 15griseofulvin microsize (Grifulvin V).................................1guanfacine (Tenex)............................................................8

H

halobetasol (Ultravate)....................................................18

2014


haloperidol....................................................................... 11haloperidol lactate...........................................................11HELIXATE FS................................................................... 15HEMOFIL M...................................................................... 15HEXALEN............................................................................ 3homatropine eye soln (Isopto Homatropine)................16HUMATE-P........................................................................ 15HUMIRA.............................................................................13HYALGAN..........................................................................14HYCAMTIN caps................................................................. 3hydralazine......................................................................... 8hydrochlorothiazide caps (Microzide).............................8hydrochlorothiazide tabs..................................................8hydrocodone/acetaminophen, NF = tabs, 2.5-325mg....................................................................................13

hydrocodone/ibuprofen (Ibudone, Reprexain,Vicoprofen)..................................................................... 13

hydrocodone-acetaminophen soln, 7.5-325 mg/15 mL(Hycet).............................................................................13

hydrocortisone/acetic acid ear soln (VoSol HC).......... 16hydrocortisone acetate (Anusol-HC, Proctocort).........17hydrocortisone enema (Cortenema)..............................17hydrocortisone oral (Cortef).............................................4hydrocortisone topical....................................................18hydrocortisone valerate (Westcort)...............................18hydromorphone soln, tabs (Dilaudid)........................... 13HYDROMORPHONE supp................................................13hydroxychloroquine (Plaquenil).......................................3hydroxyurea (Hydrea)....................................................... 3hydroxyzine......................................................................11hydroxyzine pamoate 25 mg, 50 mg (Vistaril).............. 11hyoscyamine (Anaspaz, Levsin, Levsin/SL)................... 9hyoscyamine ext-release (Levbid)...................................9

I

ibandronate (Boniva)........................................................ 6ibuprofen.......................................................................... 13ICLUSIG.............................................................................. 3ILARIS............................................................................... 13imipramine (Tofranil).......................................................11imiquimod (Aldara)..........................................................18IMPLANON.......................................................................... 5INCRELEX...........................................................................6indapamide.........................................................................8indomethacin................................................................... 13INLYTA................................................................................ 3INNOPRAN XL.................................................................... 7INTELENCE.........................................................................2INTUNIV............................................................................ 12INVIRASE............................................................................ 2ipratropium/albuterol (Duoneb)........................................9ipratropium inhal soln...................................................... 9ipratropium nasal spray (Atrovent)................................. 8irbesartan/hydrochlorothiazide (Avalide)........................6irbesartan (Avapro)........................................................... 6ISENTRESS........................................................................ 2

ISONIAZID syrup.................................................................1isoniazid tabs.....................................................................1ISORDIL TITRADOSE 40 mg............................................. 7ISOSORBIDE DINITRATE 30 mg.......................................7isosorbide dinitrate tabs, 5 mg, 10 mg, 20 mg(Isordil)..............................................................................7

isosorbide mononitrate (Monoket).................................. 7isosorbide mononitrate ext-release (Imdur)................... 7isotretinoin 10 mg, 20 mg, 40 mg – Amnesteem,Claravis........................................................................... 17

itraconazole (Sporanox)....................................................1

J

JANUMET............................................................................5JANUVIA..............................................................................5

K

KALETRA............................................................................ 2KALYDECO......................................................................... 9ketoconazole crm, shampoo (Nizoral)...........................17ketoprofen........................................................................ 13ketorolac eye soln (Acular, Acular LS)......................... 16KOATE-DVI....................................................................... 15KOGENATE FS.................................................................15K-TAB 20 mEq.................................................................. 15KUVAN................................................................................ 6

L

labetalol (Trandate)........................................................... 7lactulose............................................................................. 9lactulose........................................................................... 10lamivudine/zidovudine (Combivir)................................... 2lamivudine (Epivir)............................................................ 2lamivudine (Epivir HBV)................................................... 2lamotrigine (Lamictal)..................................................... 14LANCETS, PEN NEEDLES, SYRINGES – VARIOUS...... 18LANOXIN 0.625 mg, 0.1875 mg......................................... 8lansoprazole delayed-release (Prevacid)........................ 9LANTUS...............................................................................6latanoprost eye soln (Xalatan)....................................... 16leflunomide (Arava).........................................................13letrozole (Femara)............................................................. 3leucovorin calcium tabs, 5 mg, 25 mg............................ 3LEUKERAN......................................................................... 3LEUKINE........................................................................... 15levalbuterol (Xopenex, Xopenex Concentrate)............... 9LEVEMIR............................................................................. 6levetiracetam (Keppra)....................................................14levobunolol eye soln (Betagan)..................................... 16levocarnitine (Carnitor).....................................................6levofloxacin (Levaquin).....................................................1levonorgestrel (Plan B, Plan B One-Step).......................5levothyroxine (Synthroid).................................................6LEXIVA................................................................................ 2LIALDA.............................................................................. 10lidocaine/prilocaine crm (Emla)..................................... 18

2014


lidocaine jelly, 2%; oint, 5%; soln (Xylocaine)..............18lidocaine patches (Lidoderm)........................................ 18lidocaine viscous............................................................ 17LIDODERM........................................................................18lindane.............................................................................. 18liothyronine (Cytomel)...................................................... 6lisinopril/hydrochlorothiazide (Prinzide, Zestoretic)......6lisinopril (Prinivil, Zestril)................................................. 6lithium carbonate............................................................ 11lithium carbonate ext-release (Lithobid)....................... 11LITHIUM CITRATE............................................................11LOESTRIN 24 FE................................................................5loperamide..........................................................................9lorazepam conc (Lorazepam Intensol).......................... 11lorazepam tabs (Ativan)..................................................11losartan/hydrochlorothiazide (Hyzaar)............................ 7losartan (Cozaar)............................................................... 6lovastatin (Mevacor)..........................................................7loxapine (Loxitane)..........................................................11LUMIGAN.......................................................................... 16LUMIZYME.......................................................................... 6LYRICA..............................................................................14LYSODREN......................................................................... 3

M

MACRODANTIN caps, 25 mg...........................................10malathion (Ovide)............................................................ 18MATULANE......................................................................... 3meclizine...........................................................................10medroxyprogesterone acetate tabs (Provera)................ 4mefloquine..........................................................................3MEGACE ES....................................................................... 5megestrol (Megace)...........................................................3MEKINIST............................................................................3MELOXICAM susp............................................................ 13meloxicam tabs (Mobic)................................................. 13MENOPUR.......................................................................... 5MENOSTAR........................................................................ 4MEPHYTON...................................................................... 15mercaptopurine (Purinethol)............................................ 3mesalamine...................................................................... 10MESNEX tabs..................................................................... 3MESTINON syrup..............................................................14MESTINON TIMESPAN.................................................... 14metaxalone (Skelaxin).....................................................14metformin (Glucophage)...................................................5metformin ext-release (Glucophage XR).........................5metformin ext-release OSM (Fortamet)........................... 5methadone conc, soln.................................................... 13methadone tabs (Dolophine)..........................................13methazolamide (Neptazane)............................................. 8methimazole (Tapazole)....................................................6methocarbamol (Robaxin).............................................. 14methotrexate tabs............................................................. 3methscopolamine (Pamine, Pamine Forte).....................9methyldopa.........................................................................8

methylergonovine..............................................................6methylphenidate (Ritalin)................................................12methylphenidate ext-release caps; tabs, 20 mg (RitalinLA, Ritalin SR)............................................................... 12

METHYLPHENIDATE ext-release tabs, 10 mg.................12methylprednisolone (Medrol)........................................... 4metoclopramide soln, tabs (Reglan)............................. 10metolazone (Zaroxolyn).................................................... 8metoprolol succinate ext-release (Toprol XL)................ 7metoprolol tartrate (Lopressor)....................................... 7metronidazole oral (Flagyl)...............................................3metronidazole topical (Metrocream, Metrogel,Metrolotion).................................................................... 17

metronidazole vaginal gel (MetroGel-Vaginal)..............10mexiletine........................................................................... 8MIACALCIN inj.................................................................... 6midodrine (Proamatine).................................................... 8MIGRANAL........................................................................ 13minocycline (Dynacin, Minocin).......................................1minoxidil............................................................................. 8MIRENA...............................................................................5mirtazapine (Remeron, Remeron SolTab).....................11misoprostol (Cytotec)....................................................... 9MOBIC susp...................................................................... 13modafinil (Provigil)..........................................................12moexipril/hydrochlorothiazide (Uniretic)........................ 6moexipril (Univasc)........................................................... 6mometasone (Elocon).....................................................18MONOCLATE-P................................................................ 15MONONINE....................................................................... 15montelukast (Singulair).....................................................9morphine sulfate ext-release (Avinza, Kadian, MSContin)............................................................................ 13

morphine sulfate inj, 0.5 mg/mL, 1 mg/mL, 8 mg/mL,10 mg/mL, 15 mg/mL; oral conc; soln.........................13

MORPHINE SULFATE inj, 2 mg/mL, 5 mg/mL................. 13MORPHINE SULFATE supp, tabs.................................... 13mupirocin (Bactroban)....................................................17mycophenolate mofetil (Cellcept)..................................18mycophenolate sodium delayed-release (Myfortic)..... 18MYFORTIC........................................................................ 18MYLERAN........................................................................... 3MYOBLOC.........................................................................14

N

nabumetone..................................................................... 13nadolol (Corgard).............................................................. 7NAGLAZYME.......................................................................6naltrexone (ReVia)...........................................................18NAMENDA.........................................................................12NAMENDA XR.................................................................. 12naproxen (Naprosyn)...................................................... 13naproxen delayed-release (EC-Naprosyn).................... 13naproxen sodium (Anaprox).......................................... 13naratriptan (Amerge).......................................................13NASCOBAL....................................................................... 15

2014


NASONEX........................................................................... 8NATAZIA..............................................................................5nateglinide (Starlix)........................................................... 5NECON 10/11..................................................................... 5neomycin/polymyxin B/bacitracin/hydrocortisone eyeoint.................................................................................. 16

neomycin/polymyxin B/bacitracin eye oint...................16neomycin/polymyxin B/dexamethasone eye oint, susp(Maxitrol).........................................................................16

neomycin/polymyxin B/gramicidin eye soln(Neosporin).....................................................................16

neomycin/polymyxin B/hydrocortisone ear soln, susp(Cortisporin)................................................................... 16

neomycin sulfate............................................................... 1NEULASTA........................................................................15NEUMEGA.........................................................................15NEUPOGEN...................................................................... 15nevirapine ext-release (Viramune XR).............................2NEVIRAPINE susp.............................................................. 2nevirapine tabs (Viramune).............................................. 2NEXAVAR............................................................................3NEXPLANON.......................................................................5niacin ext-release (Niaspan).............................................7NICOTROL INHALER....................................................... 12NICOTROL NS..................................................................12nifedipine ext-release (Adalat CC, Procardia XL)........... 7NILANDRON........................................................................3NITRO-DUR patches, 0.3 mg/hr, 0.8 mg/hr........................ 7nitrofurantoin (Furadantin)............................................. 10nitrofurantoin macrocrystalline (Macrodantin).............10nitrofurantoin monohydrate/macrocrystalline(Macrobid).......................................................................10

nitroglycerin 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr(Nitro-Dur).........................................................................7

NITROSTAT........................................................................ 7NORDITROPIN....................................................................6norethindrone acetate (Aygestin).................................... 5NORINYL 1+50................................................................... 5NORPACE CR.................................................................... 8nortriptyline caps (Pamelor)...........................................11NORVIR...............................................................................2NOVOLIN 70/30.................................................................. 6NOVOLIN N.........................................................................5NOVOLIN R.........................................................................5NOVOLOG...........................................................................5NOVOLOG MIX 70/30.........................................................6NOVOSEVEN RT..............................................................15NOXAFIL............................................................................. 1NUCYNTA ER................................................................... 13NUVARING..........................................................................5NUVIGIL............................................................................ 12nystatin/triamcinolone.................................................... 18nystatin oral....................................................................... 1nystatin susp................................................................... 17nystatin topical................................................................ 17

O

ofloxacin ear soln............................................................16ofloxacin eye soln (Ocuflox).......................................... 16ofloxacin tabs.................................................................... 1olanzapine (Zyprexa, Zyprexa Zydis)............................ 11OLYSIO............................................................................... 2OMECLAMOX-PAK............................................................. 9omeprazole delayed-release (Prilosec)......................... 10OMNITROPE....................................................................... 6ondansetron ODT, soln, tabs (Zofran, Zofran ODT)..... 10ondansetron tabs, 24 mg............................................... 10OPSUMIT............................................................................ 8oral contraceptives – all generics................................... 5ORFADIN.............................................................................6orphenadrine/aspirin/caffeine 25-385-30 mg................ 14orphenadrine citrate ext-release....................................14ORTHO TRI-CYCLEN LO...................................................5ORTHOVISC..................................................................... 14OSMOPREP........................................................................ 9OVIDREL............................................................................. 5oxaprozin (Daypro)..........................................................13oxcarbazepine (Trileptal)................................................ 14OXSORALEN ULTRA....................................................... 18oxybutynin........................................................................10oxybutynin ext-release (Ditropan XL)............................10oxycodone/acetaminophen caps, 5-500 mg................. 13oxycodone/acetaminophen tabs (Percocet)................. 13oxycodone/aspirin (Percodan)....................................... 13oxycodone conc; soln; tabs, 10 mg, 20 mg..................13oxycodone tabs, 5 mg, 15 mg, 30 mg(Roxicodone).................................................................. 13

OXYCONTIN..................................................................... 13

P

pantoprazole delayed-release (Protonix)...................... 10paricalcitol (Zemplar)........................................................ 6paromomycin..................................................................... 1paroxetine (Paxil)............................................................ 11paroxetine ext-release (Paxil CR).................................. 11PATADAY.......................................................................... 16PAXIL susp........................................................................11pediatric multivitamins................................................... 15PEGASYS............................................................................2PEG – electrolytes for soln (Colyte, Golytely,Nulytely)............................................................................9

penicillin v potassium.......................................................1PENTASA.......................................................................... 10pentoxifylline ext-release (Trental)................................ 15perindopril (Aceon)........................................................... 6permethrin (Elimite)........................................................ 18perphenazine....................................................................11phenelzine (Nardil).......................................................... 11phenobarbital soln; tabs, 16.2 mg, 32.4 mg..................11phenytoin (Dilantin).........................................................14phenytoin sodium ext-release (Dilantin, Phenytek)..... 14

2014


pilocarpine eye soln (Isopto Carpine)........................... 16pilocarpine tabs (Salagen)..............................................17pindolol...............................................................................7pioglitazone/metformin (Actoplus Met)........................... 5pioglitazone (Actos).......................................................... 5piroxicam (Feldene)........................................................ 13podofilox soln (Condylox)..............................................18polymyxin B/trimethoprim eye soln (Polytrim).............16potassium bicarbonate/chloride effervescent tabs, 25mEq................................................................................. 15

potassium chloride ext-release caps (Micro-K)............15potassium chloride ext-release tabs, NF = 20 mEq......15potassium chloride packets, soln................................. 15potassium citrate/citric acid...........................................10POTASSIUM CITRATE 540 mg, 1080 mg........................10potassium phosphate/sodium phosphates (K-PhosNeutral)........................................................................... 15

pramipexole (Mirapex).................................................... 14pravastatin (Pravachol).....................................................7prazosin (Minipress)......................................................... 8prednisolone acetate eye susp (Pred Forte).................16prednisolone oral soln, 15 mg/5 mL (Prelone)............... 4PREDNISOLONE SODIUM PHOSPHATE eye soln,1%....................................................................................16

prednisolone sodium phosphate oral soln, 15 mg/5 mL(Orapred)...........................................................................4

prednisolone sodium phosphate oral soln, 5 mg/5 mL(Pediapred)....................................................................... 4

PREDNISONE dose pack; soln, 5 mg/5 mL; tabs, 50mg...................................................................................... 4

prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg......4PREMARIN tabs..................................................................4PREMPHASE...................................................................... 4PREMPRO...........................................................................4PRENATAL VITAMINS......................................................15PREZISTA........................................................................... 2PRIFTIN...............................................................................1PRIMAQUINE...................................................................... 3primidone (Mysoline)...................................................... 14PROAIR HFA...................................................................... 9probenecid....................................................................... 14probenecid/colchicine.....................................................14prochlorperazine..............................................................11PROCRIT...........................................................................15PROFILNINE SD...............................................................15progesterone micronized (Prometrium).......................... 5promethazine, NF = supp, 50 mg.....................................8propafenone (Rythmol).....................................................8propafenone ext-release (Rythmol SR)........................... 8propranolol ext-release (Inderal LA)................................7propranolol tabs................................................................ 7propylthiouracil..................................................................6PROTOPIC........................................................................ 18PULMICORT RESPULES 1 mg/2 mL.................................9PULMOZYME...................................................................... 9pyrazinamide......................................................................1

pyridostigmine (Mestinon)..............................................14

Q

quetiapine (Seroquel)......................................................11quinapril/hydrochlorothiazide (Accuretic)...................... 6quinapril (Accupril)........................................................... 6quinidine gluconate ext-release.......................................8quinidine sulfate 300 mg.................................................. 8QUINIDINE SULFATE ext-release......................................8QVAR...................................................................................9

R

raloxifene (Evista)............................................................. 6ramipril (Altace)................................................................. 6ranitidine (Zantac)........................................................... 10RAPAMUNE...................................................................... 18REBETOL soln.................................................................... 2REBIF................................................................................ 12RECOMBINATE................................................................ 15REGRANEX.......................................................................18RENVELA.......................................................................... 10repaglinide (Prandin)........................................................ 5REPRONEX.........................................................................5RESCRIPTOR..................................................................... 2RESTASIS......................................................................... 16RETIN-A MICRO – Prior Authorization is required forpatients 40 years of age and older..................................17

RETIN-A – Prior Authorization is required for patients 40years of age and older.................................................... 17

REVATIO............................................................................. 8REVLIMID..........................................................................18REYATAZ............................................................................ 2RIBASPHERE......................................................................2ribavirin (Copegus, Rebetol)............................................ 2RIDAURA...........................................................................13rifabutin (Mycobutin).........................................................1rifampin (Rifadin)...............................................................1riluzole (Rilutek).............................................................. 14risperidone (Risperdal, Risperdal M-Tab)..................... 11RITALIN LA 10 mg............................................................12rivastigmine (Exelon)...................................................... 12rizatriptan (Maxalt, Maxalt-MLT).....................................13ROBAXIN inj......................................................................14ropinirole (Requip).......................................................... 14

S

SABRIL.............................................................................. 14salsalate............................................................................12SANCUSO......................................................................... 10SANDIMMUNE soln.......................................................... 18selegiline caps (Eldepryl)............................................... 14selegiline tabs..................................................................14selenium sulfide.............................................................. 18SELENIUM SULFIDE........................................................18SELZENTRY........................................................................2SENSIPAR...........................................................................6

2014


sertraline (Zoloft).............................................................11SFROWASA...................................................................... 10sildenafil (Revatio)............................................................ 8silver sulfadiazine (Silvadene)....................................... 17SIMBRINZA....................................................................... 16simvastatin (Zocor)........................................................... 7sirolimus (Rapamune).....................................................19SKYLA................................................................................. 5sodium citrate/citric acid (Shohl's)................................10sodium fluoride (Prevident)............................................17sodium fluoride chew tabs, soln................................... 15sodium polystyrene sulfonate....................................... 19SOMAVERT.........................................................................6sotalol (Betapace, Betapace AF)..................................... 7SOVALDI............................................................................. 2SPIRIVA HANDIHALER...................................................... 9spironolactone/hydrochlorothiazide (Aldactazide)........ 8spironolactone (Aldactone).............................................. 8SPRYCEL............................................................................ 3stavudine (Zerit)................................................................ 2STIMATE............................................................................. 6STIVARGA...........................................................................3STRATTERA..................................................................... 12STRIANT............................................................................. 4STRIBILD.............................................................................2STROMECTOL....................................................................3SUBOXONE film............................................................... 13sucralfate (Carafate)........................................................10sulfacetamide sodium/prednisolone eye soln..............16sulfacetamide sodium/sulfur, crm; emul; lotn,10-5%...............................................................................17

SULFACETAMIDE SODIUM/SULFUR susp, 10-5%.........17sulfacetamide sodium eye soln (Bleph-10)...................16sulfacetamide sodium lotn (Klaron).............................. 17sulfamethoxazole/trimethoprim (Bactrim).......................3sulfasalazine (Azulfidine)................................................10sulfasalazine delayed-release (Azulfidine EN-Tabs)............................................................................... 10

sulindac............................................................................ 13sumatriptan auto-injector; cartridge; inj, 6 mg/0.5 mL;tabs (Imitrex).................................................................. 13

SUMATRIPTAN nasal spray............................................. 14SUPARTZ.......................................................................... 14SUSTIVA............................................................................. 2SUTENT.............................................................................. 4SYLATRON......................................................................... 4SYMBICORT....................................................................... 9SYNAGIS.............................................................................3SYNAREL............................................................................ 5SYNVISC/ONE.................................................................. 14

T

TABLOID............................................................................. 4tacrolimus (Prograf)........................................................ 19TAFINLAR........................................................................... 4TAMIFLU............................................................................. 2

tamoxifen............................................................................4tamsulosin (Flomax)....................................................... 11TARCEVA............................................................................4TARGRETIN caps............................................................... 4TASIGNA............................................................................. 4TAZORAC..........................................................................17TECFIDERA...................................................................... 12TEGRETOL-XR tabs, 100 mg...........................................14temazepam (Restoril)...................................................... 12TEMODAR caps..................................................................4temozolomide caps (Temodar)........................................ 4terazosin............................................................................. 8terbinafine (Lamisil).......................................................... 1terbutaline.......................................................................... 9terconazole crm (Terazol)...............................................10TESTIM................................................................................4testosterone cypionate (Depo-Testosterone)................. 4testosterone enanthate.....................................................4THALOMID........................................................................ 19theophylline ext-release....................................................9thiothixene........................................................................11THYROGEN...................................................................... 19timolol maleate eye soln (Timoptic, Timoptic-XE)........16TIVICAY...............................................................................2tizanidine (Zanaflex)........................................................14TOBRADEX oint................................................................16tobramycin/dexamethasone eye susp (Tobradex)....... 16tobramycin eye soln (Tobrex)........................................ 16tobramycin inhal soln (Tobi)............................................9TOBREX oint.....................................................................16tolterodine (Detrol).......................................................... 10tolterodine ext-release (Detrol LA)................................ 10TOPICORT........................................................................ 18topiramate (Topamax, Topamax Sprinkles).................. 14torsemide (Demadex)........................................................8TRACLEER..........................................................................8tramadol/acetaminophen (Ultracet)............................... 13tramadol (Ultram)............................................................ 13tramadol ext-release (Ultram ER).................................. 13trandolapril (Mavik)........................................................... 6tranylcypromine (Parnate)..............................................11trazodone..........................................................................11tretinoin – Avita – Prior Authorization is required forpatients 40 years of age and older (Retin-A).............. 17

tretinoin caps.....................................................................4tretinoin microsphere – Prior Authorization is requiredfor patients 40 years of age and older (Retin-AMicro).............................................................................. 17

triamcinolone crm; lotn; oint, 0.025%, 0.1%................. 18triamcinolone dental paste.............................................17triamcinolone nasal spray (Nasacort AQ).......................8triamterene/hydrochlorothiazide, NF = 50-25 mg(Dyazide, Maxzide, Maxzide-25)..................................... 8

trifluoperazine.................................................................. 11trifluridine eye soln (Viroptic)........................................ 16trihexyphenidyl................................................................ 14

2014


trimethobenzamide (Tigan).............................................10trimethoprim.......................................................................3TRIZIVIR..............................................................................2tropicamide eye soln (Mydriacyl).................................. 16TRUE2GO Blood Glucose Kit with Device – covered at $0copay............................................................................... 18

TRUERESULT Blood Glucose Kit with Device – coveredat $0 copay......................................................................18

TRUETEST, TRUETRACK Blood Glucose Test Strips..... 18TRUVADA............................................................................2TYKERB.............................................................................. 4

U

ursodiol (Actigall, Urso 250, Urso Forte)...................... 10

V

VAGIFEM...........................................................................10valacyclovir (Valtrex)........................................................ 2VALCYTE............................................................................ 2valproic acid (Depakene)................................................14valsartan/hydrochlorothiazide (Diovan HCT)..................7vancomycin (Vancocin).................................................... 3VELETRI..............................................................................8venlafaxine (Effexor)....................................................... 11venlafaxine ext-release caps (Effexor XR).................... 11venlafaxine ext-release tabs, 37.5 mg, 75 mg, 150mg – all manufacturers other than Schwarz andUpstate............................................................................11

VENOFER......................................................................... 15VENTOLIN HFA.................................................................. 9verapamil 80 mg, 120 mg (Calan).................................... 7verapamil ext-release (Calan SR, Isoptin SR, Verelan,Verelan PM)...................................................................... 7

VFEND.................................................................................2VIAGRA............................................................................... 8VICTOZA............................................................................. 5VIDEX.................................................................................. 2VIRACEPT...........................................................................2VIRAMUNE..........................................................................2VIRAMUNE XR................................................................... 2VIREAD............................................................................... 2VIVELLE-DOT..................................................................... 4voriconazole (Vfend)......................................................... 2VOTRIENT...........................................................................4VYTORIN.............................................................................7VYVANSE..........................................................................12

W

warfarin (Coumadin)........................................................15WELCHOL........................................................................... 7WILATE............................................................................. 15

X

XALKORI............................................................................. 4XELODA.............................................................................. 4XENICAL........................................................................... 12

XIFAXAN 550 mg................................................................3XOLAIR................................................................................9XTANDI................................................................................4XYREM.............................................................................. 12

Y

Z

zafirlukast (Accolate)........................................................ 9zaleplon (Sonata).............................................................12ZELBORAF..........................................................................4ZETIA...................................................................................7ZIAGEN............................................................................... 2zidovudine (Retrovir)........................................................ 2ziprasidone (Geodon)......................................................11ZITHROMAX powder packets.............................................1ZOLINZA..............................................................................4zolpidem (Ambien).......................................................... 12zolpidem ext-release (Ambien CR)................................ 12zonisamide (Zonegran)................................................... 14ZORTRESS....................................................................... 19ZOVIRAX crm....................................................................17ZYKADIA............................................................................. 4ZYMAXID...........................................................................16ZYTIGA................................................................................4ZYVOX.................................................................................3

university of minnesota uplan formulary july...

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