Formulary - Cloudfront.net
Transcription
Formulary - Cloudfront.net
Effective October 1, 2016 18 Quantity Limits 23 Index Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Abbreviations apap acetaminophen caps capsules ER extended release lot lotion neb nebulizer ODT dissolving Drug name Suggested preferred alternatives oint ointment pkt packet prod product pwd powder SL under the tongue soln solution supp suppositories susp suspension syr syringe tabs tablets ( sub-lingual ) 1.5.1 Penicillins amoxicillin amoxicillin/potassium clavulanate ampicillin dicloxacillin penicillin V Amoxicillin ER SP Bicillin CR/Bicillin LA Moxatag 1.2 1.6 1 1 1 1 1 2 2 amoxicillin Tetracyclines No kits or combination packages are covered; see individual products for coverage information. demeclocycline 1 doxycycline 1 doxycycline hyclate/ PA 3 monohydrate/ER/DR minocycline 1 minocycline ER PA 3 minocycline tetracycline 1 Acticlate PA 3 doxycycline Avidoxy PA 3 doxycycline Doryx PA 3 doxycycline Doryx MPC PA 3 doxycycline Doxycycline IR/DR PA 3 doxycycline Minocin 75 mg 3 minocycline Morgidox caps PA 3 doxycycline Oracea PA 3 doxycycline Solodyn ER PA 3 minocycline Targadox PA 3 doxycycline Adoxa, Acticlate, Doryx, Monodox, Morgidox, Oracea, Solodyn ER, Targadox, doxycycline hyclate/ monohydrate/ER. Minocycline ER: Trial and failure/intolerance to a total of 2 generic, immediate-release products must be documented, one minocycline and one doxycycline product. Trial of each should be a minimum of 1 month. Medical records documenting the trial and failure/intolerance to each of the generic products must accompany the prior authorization request. 1.3 cefaclor, cefaclor ER cefadroxil cefdinir cefditoren pivoxil cefixime susp cefpodoxime tabs cefprozil ceftibuten cefuroxime sodium cephalexin Suprax tabs 1.4.1 1.8.1 1 1 1 1 1 1 1 1 1 1 Zepatier 1.8.2 PA = Prior authorization required 1 1 1 1 1 2 generic antibiotic 1 SP 1 1 1 1 1 1 1 1 1 1 1 2 PA,QL,SP PA, QL, SP PA,QL,SP PA,QL,SP QL SP SP SP PA,QL,SP QL PA,QL,SP 3 3 Zovirax topical 3 Harvoni 2 2 3 3 ribavirin 3 ribavirin 3 ribavirin 2 3 3 2 PA, ST, SP, QL PA, ST, SP 3 Harvoni 3 Harvoni HIV/AIDS Therapy All oral antiretroviral medications and protease inhibitors without a generic equivalent are available at tier 2 copay. Those medications with a generic equivalent available are subject to mandatory substitution. Fuzeon 3 3 cefpodoxime, cefdinir 1.9 Erythromycins and Other Macrolides azithromycin azithromycin 1 gm pwd pkts azithromycin susp clarithromycin clarithromycin ER erythromycin PCE QL 1 Miscellaneous Antivirals acyclovir adefovir dipivoxil amantadine entecavir famciclovir ganciclovir lamivudine/HBV ribavirin rimantadine valacyclovir valganciclovir Cytovene Daklinza Denavir topical Epclusa Harvoni Olysio Relenza Ribapak dosepack Ribatab tabs/dosepak Ribasphere Sovaldi Tamiflu Technivie Tyzeka Viekira Pak/Viekira XR Cephalosporins 3 ciprofloxacin,levofloxacin Urinary Tract Agents methenamine nitrofurantoin nitrofurantoin macrocrystals nitrofurantoin susp trimethoprim Monurol QL Urogesic Blue 3 amoxicillin 1 1 1 1 1 Sulfa and Related Agents sulfamethoxazole/trimethoprim 1.7 Suggested preferred alternatives Fluoroquinolones ciprofloxacin tabs/susp ciprofloxacin ER levofloxacin tabs/oral soln moxifloxacin ofloxacin Factive QL Chapter 1: Anti-Infectives 1.1 Criteria Tier Antifungal Agents clotrimazole troche 1 fluconazole 1 flucytosine 1 griseofulvin microsize 1 griseofulvin ultramicrosize 1 itraconazole 1 nystatin tabs/susp 1 terbinafine tab 1 ST = Step therapy If criteria not met, PA required 1 1 1 1 1 1 3 erythromycin QL = Quantity limits If exceeded, PA required 1 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier voriconazole tab/susp Cresemba Noxafil Onmel Oravig Sporanox oral soln 1.11.1 Ketek Sivextro Xifaxan TOBI/TOBI Podhaler 3 3 3 itraconazole 3 clotrimazole troche 3 SP, QL QL 1 1 1 1 1 3 3 TOBI, tobramycin 3 84 doses/28 days per each 60 days 3 metronidazole, oral vancomycin caps/soln 3 azithromycin, clarithromycin 3 3 ciprofloxacin 2 tobramycin neb soln SP, QL SP, QL PA, QL QL PA, QL SP, QL 1 1 1 1 QL 3 3 Antimalarials atovaquone-proguanil chloroquine hydroxychloroquine quinine SO4 Coartem 1.11.4 PA PA PA, QL PA, QL 1 1 1 1 QL 3 Antimycobacterials rifabutin 1 Chapter 2: Antineoplastic and immunosuppressant drugs 2.1.2 Antimetabolites capecitabine Purixan susp 2.1.6 SP 1 3 Miscellaneous Antineoplastic Drugs anagrelide anastrozole azathioprine 50 mg bexarotene bicalutamide cyclophosphamide tabs cyclosporine exemestane flutamide gengraf hydroxyurea imatinib leflunomide letrozole leuprolide 1 mg megestrol mercaptopurine SP QL PA, SP PA, SP PA = Prior authorization required Criteria Tier methotrexate mycophenolate mofetil mycophenolate sodium nilutamide octreotide SP sirolimus tacrolimus tamoxifen citrate temozolomide SP tretinoin PA, QL, SP Alecensa PA,QL,SP Afinitor Astagraf XL PA,QL,SP Bosulif PA, QL, SP Cabometyx PA,QL,SP Caprelsa (vandetanib) PA,QL,SP Cometriq PA, QL, SP Cotellic Cyclosporine 50 mg softgel Cyclophosphamide caps Envarsus XR QL PA,QL,SP Erivedge 150 mg PA,QL,SP Farydak Gilotrif PA, SP SP Gleostine Hycamtin SP PA,QL,SP Ibrance Iclusig PA,QL,SP Imbruvica PA,QL,SP PA,QL,SP Inlyta Iressa SP PA,QL,SP Jakafi PA,QL,SP Lenvima PA,QL,SP Lonsurf PA,QL,SP Lynparza PA,QL,SP Mekinist Mesnex Neoral Nexavar SP Ninlaro PA, SP PA,QL,SP Odomzo Oforta SP Pomalyst PA,QL,SP Revlimid PA,QL,SP Sandimmune PA,QL,SP Signifor Sprycel PA, SP PA,QL,SP Stivarga PA,QL,SP Sutent PA,QL,SP Tafinlar PA,QL,SP Tagrisso Tarceva SP Tasigna PA, SP Thalomid SP Tykerb PA, SP Venclexta PA, SP, QL for starter PA,QL,SP Votrient PA,QL,SP Xalkori PA,QL,SP Xtandi PA,QL,SP Zelboraf Zolinza PA Zortress QL PA,QL,SP Zydelig Antiparasitics atovaquone ivermectin metronidazole tinidazole Emverm Impavido 1.11.3 1 Miscellaneous Anti-Infectives clindamycin HCl dapsone linezolid tobramycin neb soln vancomycin caps Alinia Bethkis Cayston Dificid 1.11.2 Drug name Suggested preferred alternatives 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 QL = Quantity limits If exceeded, PA required Suggested preferred alternatives 1 1 1 1 1 1 1 1 1 1 3 3 3 tacrolimus 3 3 2 3 3 2 3 3 2 3 3 3 3 3 3 3 3 2 2 3 3 3 3 2 2 3 3 3 3 3 2 2 3 3 3 3 3 3 2 3 2 3 3 2 3 3 3 3 3 3 ST = Step therapy If criteria not met, PA required 2 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Zykaydia Zytiga PA,QL,SP PA,QL,SP 2.2.1 Drug name Suggested preferred alternatives 3 3 Magnacet Maxidone Reprexain Vicoprofen Xartemis XR Xolox Zolvit Adjunctive Agents Vistogard PA,QL,SP 3 Chapter 3: Autonomic and CNS Drugs; Neurology and Psychiatry 3.1.1 Narcotics buprenorphine tabs fentanyl oral transmucosal fentanyl patches 12, 25, 50, 75, 100 hydromorphone hydromorphone ER (Exalgo equivalent) meperidine HCl morphine SO4/ER morphine SO4 ER 20, 30, 50, 60, 80, 100 mg (Kadian equivalent) morphine SO4 ER 30, 45, 60, 75, 90, 120 mg (Avinza equivalent) oxycodone Oxymorphone IR oxymorphone ER roxicet Abstral SL tabs Alcet Belbuca Butrans Patches Codeine SO4 Soln Embeda Fentanyl patches 37.5, 62.5, 87.5 mcg Fentora buccal tabs Hysingla ER Kadian ER, 10, 40, 70, 130, 150, 200 mg Lazanda nasal spray MSIR Nucynta/Nucynta ER Onsolis Opana ER PA, QL PA 1 1 QL 1 ST, QL 1 1 QL 1 1 1 QL 1 Oxaydo Oxycontin Oxycodone ER Oxy IR Roxicodone Subsys Xtampza XR Zohydro ER PA QL QL 3.1.2 ST 3.3.1 Oxycontin, oxycodone, morphine SO4/ER Oxycontin, oxycodone, morphine SO4/ER 1 1 1 1 PA, QL PA, QL QL 3 fentanyl transmucosal 3 oxycodone/apap 3 3 fentanyl patch, tramadol, NSAID 2 generics 3 morphine SO4 ER 3 generic fentanyl patches PA PA, QL QL 3 fentanyl oral transmucosal 3 generics 3 morphine SO4 ER, Oxycontin PA QL, PA PA, QL 3 fentanyl oral transmucosal 2 3 3 3 morphine SO4 ER, oxycodone ER/SA, generics 3 oxycodone IR PA,QL,SP ST PA, QL QL PA, QL mefenamic acid meloxicam nabumetone naproxen/ER piroxicam sulindac Cambia pwd pac ST, QL Duexis ST, QL Fenortho ST Fenoprofen 200 and 400 ST mg Flector patches QL Nalfon ST Naproxen CR ST Pennsaid 2% soln QL Prevacid NapraPac Sprix nasal spray QL, ST Tivorbex ST, QL Vimovo QL, PA Vivlodex ST, QL Zorvolex ST 1 1 1 1 1 1 3.3.3 3 3 3 3 3 3 3 oxycodone/apap hydrocodone/apap hydrocodone/apap hydrocodone/ibuprofen oxycodone/apap oxycodone/apap hydrocodone/apap 3 3 3 3 diclofenac, generic NSAID Ibuprofen + famotidine Generic NSAID generic NSAID 3 3 3 3 3 3 3 3 3 3 Voltaren Gel generic NSAID generic NSAID diclofenac drops,Voltaren gel generic NSAID + generic ppi generic NSAID generic NSAID generic NSAID+generic ppi generic NSAID Salicylates 3 Relagesic, OTC prods 3 generic Miscellaneous Analgesics butorphanol nasal spray QL 1 pentazocine/naloxone 1 tramadol HCL 1 tramadol/apap 1 tramadol ER QL 1 tramadol ER QL 1 (Ryzolt equivalent) tabs tramadol ER tabs QL 1 (Ultram ER equivalent) Conzip ER QL 3 tramadol, tramadol ER tabs Dologesic 2 LAGesic 1 Rhinoflex 3 Rybix ODT 3 tramadol Tramadol 150 mg caps QL 3 tramadol, tramadol ER tabs Zflex 3 ST = Step therapy If criteria not met, PA required SP = Specialty pharmacy 2 3 generics Combination Narcotic/Analgesics acetaminophen /codeine apap/caffeine/dihydrocodeine buprenorphine/ PA, QL naloxone SL tabs hydrocodone/apap hydrocodone/ibuprofen oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen Endocet Allzital PA = Prior authorization required 1 1 1 1 1 1 1 1 1 1 choline and magnesium trisalicylate 1 diflunisal 1 salsalate 1 Duraxin Zorprin Oxycontin oxycodone immediate release oxycodone immediate release fentanyl oral transmucosal Suggested preferred alternatives NSAIDs/COX II Inhibitors celecoxib QL diclofenac diclofenac topical drops diclofenac topical gel 1% QL diclofenac-misoprostol etodolac ibuprofen indomethacin/SR ketorolac QL ketoprofen 3.3.2 2 3 3 3 3 Criteria Tier 1 1 1 1 1 1 1 1 1 3 butabarbital/apap QL = Quantity limits If exceeded, PA required 3 Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Drug name Suggested preferred alternatives 3.3.4 Narcotic Antagonists Narcan Nasal Spray 3.4.1 Sumavel Dosepro Treximet Zembrace Zomig nasal spray QL QL QL 1 1 1 1 1 QL QL 1 1 1 1 QL QL 1 1 QL 1 QL 3 sumatriptan injection 2 3 3 3 sumatriptan nasal spray 2 sumatriptan, rizatriptan, zolmitriptan, naratriptan 3 sumatriptan injection 2 3 sumatriptan injection 2 QL QL QL QL QL QL 3.7 Antiparkinsonism Agents benztropine bromocriptine mesylate carbidopa carbidopa/levodopa carbidopa/levodopa/entacapone entacapone pramipexole pramipexole ER ropinirole/ropinirole ER selegiline HCl tolcapone trihexyphenidyl Azilect Apokyn SP PA,QL,SP Duopa Neupro QL Rytary 3.6 mephobarbital oxcarbazepine phenobarbital phenytoin phenytoin sodium extended primidone tiagabine topiramate/sprinkle valproic acid zonisamide Aptiom Banzel tabs/susp Briviact Diastat/Diastat Acudial QL Equetro Fycompa Gabitril 12, 16 mg Gralise PA, QL Horizant ER PA, QL Lyrica caps/oral soln ST Onfi Oxtellar XR Phenytek Qudexy XR Sabril SP Spritam Stavzor Topiramate ER Vimpat 3 Headache Therapy alagesic oral soln almotriptan butalbital compound butalbital/apap dihydroergotamine nasal spray frovatriptan isometh/caffeine/apap naratriptan rizatriptan/ rizatriptan ODT sumatriptan nasal spray sumatriptan tabs and injections zolmitriptan/ zolmitriptan ODT Alsuma injection Midrin Migralam Migraten Onzetra Xsail Relpax 3.5 QL 1 1 1 1 1 1 1 1 1 1 1 1 3 2 3 3 ropinirole, ropinirole ER 3 3.8.1 PA = Prior authorization required 1 1 1 1 1 1 1 3.8.2 1 1 1 3 2 3 2 3 carbamazapine, carbamazepine ER 3 2 3 3 3 3 3 3 3 gabapentin gabapentin, pramipexole gabapentin oxcarbazepine topiramate 2 3 3 valproic acid 3 topiramate 3 1 1 1 1 1 1 1 3 3 3 2 3 memantine+donepezil 2 2 3 1 1 1 1 1 1 1 1 1 3 3 chlorzoxazone 2 Myasthenia Gravis pyridostigmine/ER 3.9.1 QL = Quantity limits If exceeded, PA required 1 1 1 1 1 1 1 1 1 1 Muscle Relaxants and Antispasmotic Agents baclofen carisoprodol chlorzoxazone cyclobenzaprine/cyclo-benzaprine ER dantrolene metaxalone methocarbamol orphenadrine tizanidine Durabac Lorzone Relagesic 1 1 Suggested preferred alternatives Miscellaneous Neurological Therapy donepezil/donepezil ODT galantamine galantamine ER memantine/memantine QL dosepak (dosepk) rivastigmine rivastigmine patches QL tetrabenazine PA, SP PA,QL,SP Ampyra PA,QL,SP Aubagio PA,QL,SP Keveyis Namenda XR QL Namzaric QL PA,QL,SP Gilenya PA,QL,SP Tecfidera SP, QL Zinbryta Anticonvulsants carbamazepine/XR carbamazepine ER caps/tabs clonazepam/clonazepam wafers diazepam rectal gel QL divalproex/ER/sprinkles ethosuximide felbamate Gabapentin caps/tabs/oral soln lamotrigine/lamotrigine ODT/ lamotrigine ER lamotrigine starter kit QL levetiracetam levetiracetam ER Criteria Tier 1 Hypnotic Agents ST = Step therapy If criteria not met, PA required 4 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name estazolam eszopiclone flurazepam temazepam triazolam zaleplon zolpidem zolpidem ER zolpidem sublingual Belsomra Edluar Hetlioz Rozerem Silenor Zolpimist 3.9.2.1 Criteria Tier QL QL QL QL QL, ST QL, ST PA,QL,SP QL QL, ST QL, ST 3.9.2.4 3 3 3 3 3 3 zaleplon, zolpidem/ER, eszopiclone Rozerem zaleplon, zolpidem/ER, eszopiclone zaleplon, zolpidem/ER, eszopiclone zaleplon, zolpidem/ER, eszopiclone 1 1 1 1 1 1 1 1 1 PA = Prior authorization required (formerly Brintellix) Viibryd QL, ST 3 generics 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3 risperidone, quetiapine, olanzapine starter pack 1 1 1 1 1 1 1 1 3.9.4 3 3 3 3 3 3 3 Trazodone/generic SSRI generic SSRI/SNRI 2 1 1 1 3 selegiline tabs 2 3 3 3 3 QL PA, QL QL clozapine risperidone, quetiapine, olanzapine risperidone, quetiapine, olanzapine risperidone, quetiapine, olanzapine 2 3 clozapine 3 risperidone, quetiapine, olanzapine PA Miscellaneous Psychotherapeutic Agents amphetamine salt combo amphetamine salt combo ER armodafinil QL dexmethylphenidate dexmethylphenidate ER 5, 10, 15, 20, 30, 40 mg dextroamphetamine disulfiram guanfacine ER methylphenidate, tabs, oral soln, chewable tabs methylphenidate CD QL (Metadate CD equivalent) methylphenidate ER (Ritalin LA equivalent) methylphenidate ER (Concerta equivalent) modafinil QL Adderall 7.5,12.5, ST and 15 mg Adderall XR ST Addyi PA, QL Adzenys XR-ODT ST, QL SSRI, bupropion SR/XL generic SSRI/SNRI generic SSRI/SNRI bupropion SR/XL Suggested preferred alternatives Miscellaneous Antipsychotics Fazaclo ODT Latuda Rexulti Saphris Seroquel XR Versacloz Vraylar Selective Serotonin Reuptake Inhibitors citalopram escitalopram fluoxetine fluoxetine DR 90-mg cap fluvoxamine maleate fluvoxamine ER paroxetine paroxetine CR sertraline Brisdelle QL, ST Pexeva Trintellix QL, ST Criteria Tier aripiprazole/aripiprazole ODT clozapine/clozapine ODT fluphenazine haloperidol loxapine molindone olanzapine/olanzapine ODT olanzapine/fluoxetine paliperidone ER perphenazine pimozide quetiapine risperidone risperidone ODT thioridazine trifluoperazine ziprasidone Clozapine ODT, 150, 200 mg QL for Fanapt MAO Inhibitors phenelzine selegiline tranylcypromine sulfate Emsam QL Marplan Drug name 3.9.3.3 Miscellaneous Antidepressants bupropion HCl, bupropion SR buproprion XL QL duloxetine mirtazapine nefazodone trazodone HCl venlafaxine venlafaxine ER Aplenzin QL Desvenlafaxine QL, ST Fetzima ST Forfivo XL QL Nuplazid PA, QL Oleptro ER QL Pristiq QL, ST Savella QL 3.9.2.3 1 1 1 1 1 1 1 1 1 Tricyclics amitriptyline clomipramine doxepin imipramine imipramine PM trimipramine desipramine nortriptyline protriptyline 3.9.2.2 Suggested preferred alternatives 1 1 1 1 1 1 1 1 1 1 1 1 1 3 methylphenidate/ER, amphetamine combinations 3 amphetamine salt combo ER 3 3 methylphenidate/ER, amphetamine combinations Aptensio XR ST 3 methylphenidate/ER, amphetamine combinations Campral 3 Daytrana ST, QL 3 methylphenidate/ER, amphetamine combinations Desoxyn ST 3 methamphetamine Dexedrine tab 3 dextroamphetamine Dyanavel XR ST 3 methylphenidate/ER, amphetamine ST = Step therapy If criteria not met, PA required SP = Specialty pharmacy 1 1 1 1 1 1 1 1 1 3 generics 3 paroxetine or generics 3 generics QL = Quantity limits If exceeded, PA required 5 Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Evekeo Focalin XR 25, 35 mg Kapvay ER Nuedexta 20-10 mg Procentra oral soln ST QL PA, QL ST Quillichew ER ST Quillivant XR ST 3 3 3 3 3 3.9.5 Drug name Criteria Tier combinations dextroamphetamine dexmethylphneidate ER methylphenidate, Strattera clopidogrel 75 mg clopidogrel 300 mg dipyridamole ticlopidine HCl Brilinta Durlaza Effient Zontivity QL methylphenidate/ER, amphetamine combinations 3 methylphenidate/ER, amphetamine combinations 3 methylphenidate/ER, amphetamine combinations 3 methylphenidate ER Ritalin LA 10 mg, 60 mg ST Strattera QL Vyvanse ST Xyrem Zenzedi Suggested preferred alternatives 4.4.3 3 methylphenidate/ER, amphetamine combinations 3 3 dextroamphetamine 4.4.5 1 1 1 1 1 1 1 4.4.6 4.5.1 3 Antiarrhythmics disopyramide phosphate dofetilide procainamide HCl quinidine flecainide propafenone propafenone SR amiodarone sotalol/sotalol AF Multaq Sotylize liquid 4.2 4.3 1 1 1 1 1 1 1 1 1 3 amiodarone 3 sotalol tabs Cardiac Glycosides digoxin Lanoxin 62.5, 187.5 mcg 1 4.4.2 3 Anticoagulants 1 1 2 3 2 2 3 2 Antiplatelet Drugs aspirin/dipyridamole cilostazol PA = Prior authorization required 2 3 Heparin Hemostatics 1 1 1 1 1 1 1 1 1 1 1 1 1 torsemide triamterene /HCTZ Dyrenium 1 1 2 Beta Blockers amlodipine QL = Quantity limits If exceeded, PA required 2 2 Thiazide and Related Diuretics 4.5.3.2 1 1 2 1 1 Miscellaneous Coagulation Agents atenolol betaxolol bisoprolol fumarate carvedilol labetalol metoprolol succinate ER metoprolol tartrate nadolol pindolol propranolol propranolol ER timolol Bystolic Cartrol Coreg CR QL Hemangeol Innopran XL Levatol 3 Nitrates jantoven warfarin sodium Eliquis Iprivask PA, SP Mephyton Pradaxa QL Savaysa QL Xarelto/Xarelto dosepack 3 clopidogrel, Effient 3 amiloride amiloride /HCTZ bumetanide chlorothiazide ethacrynic acid furosemide hydrochlorothiazide indapamide metolazone eplerenone spironolactone spironolactone/HCTZ 4.5.2 isosorbide 1 nitroglycerin tabs, caps, oint, patches 1 nitroglycerin spray QL 1 Nitromist QL 4.4.1 QL QL QL pentoxifylline Chapter 4: Cardiovascular, Hypertension and Lipids 4.1 Not covered; in-hospital use only 1 1 All factor prods SP aminocaproic acid, 500-mg tabs tranexamic acid, 650 mg QL Aminocaproic Acid, 1000-mg tabs Promacta QL, SP Anxiolytics alprazolam alprazolam ER alprazolam ODT buspirone HCl diazepam lorazepam oxazepam Midazolam 1 Although these medications may be obtained through a retail pharmacy, they are considered specialty medications and the specialty copay will be charged. enoxaparin 1 fondaparinux 1 Fragmin 3 2 PA, SP Suggested preferred alternatives 1 1 1 1 1 1 1 1 1 1 1 1 3 atenolol, metoprolol 3 atenolol, metoprolol 2 3 Ages 2 yr and under 2 3 atenolol, metoprolol Calcium Channel Blockers/Dihydropyridines 1 ST = Step therapy If criteria not met, PA required 6 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier cartia XT diltiazem, diltiazem ER, diltiazem SR, diltiazem SA felodipine isradipine nicardipine HCl nifedipine, nifedipine ER nimodipine nisoldipine verapamil HCl/verapamil SR verapamil ER PM Cardene SR Cardizem LA Nymalize Verelan Verelan PM 4.5.4 2 3 nimodipine 3 verapamil, felodipine 3 verapamil ER PM 3 lisinopril tabs 1 1 1 QL Byvalson Dutoprol Lexxel Prestalia Teczem Tribenzor QL Vecamyl PA,QL,SP 4.5.9 1 SP SP PA,QL,SP 1 3 isosorbide dinitrate + hydralazine 3 3 3 Other Hypertensive Combinations amlodipine/benazepril amlodipine/valsartan amlodipine/valsartan/HCTZ atenolol/chlorthalidone benazepril HCT bisoprolol fumarate/HCTZ captopril/HCTZ enalapril maleate/HCTZ fosinopri/HCTZ PA = Prior authorization required 1 1 1 1 1 1 1 1 1 1 1 1 QL, ST QL, ST Benicar HCT Edarbyclor ST QL, ST Edarbi QL, ST Tekamlo Tekturna Tekturna HCT QL, ST QL,ST QL, ST 3 3 losartan, eprosartan, irbesartan, valsartan, candesartan 3 losartan/irbesartan/HCTZ valsartan/HCTZ 3 losartan/HCTZ, irbesartan /HCTZ losartan + chlorthalidone 3 losartan, eprosartan, irbesartan, valsartan, candesartan 3 3 3 Lipid/Cholesterol-Lowering Agent 4 preferred medications (simvastatin, pravastatin, lovastatin, atorvastatin, fluvastatin caps, Crestor) must be used within 180 days for a non-preferred medication (Altoprev, Lescol XL, Livalo) to process. atorvastatin 1 atorvastatin/amlodipine 1 cholestyramine/light 1 colestipol tabs 1 fenofibrate 1 fluvastatin 1 fluvastatin ER 1 gemfibrozil 1 lovastatin 1 omega-3 acid ethyl esters 1 pravastatin 1 rosuvastatin 1 simvastatin 1 Advicor QL 2 Altoprev QL, ST 3 lovastatin Colestid pwd 2 colestipol tabs Fenofibrate 50, 120, 150 mg 3 fenofibrate Fenofibric acid 3 fenofibrate 3 3 1 1 SP, PA SP PA, QL, SP 3 Exforge, valsartan + amlodipine, losartan + amlodipine 3 3 Metoprolol + HCTZ 3 benazepril/amlodipine 3 3 diltiazem + enalapril, irbesartan /HCTZ 3 losartan+amlodipine, valsartan/ HCTZ + amlodipine 3 Angiotensin II Receptor Blockers and Renin Inhibitors candesartan candesartan/HCTZ eprosartan eprosartan/HCTZ irbesartan irbesartan/HCTZ losartan losartan/HCTZ telmisartan telmisartan/HCTZ valsartan valsartan/HCTZ Amturnide Benicar 4.6 Vasodilators Suggested preferred alternatives 1 1 1 1 1 1 1 1 QL, ST 3 doxazosin mesylate 1 1 1 1 1 Agents for Pheochromocytoma epoprostenol epoprostenol diluent sildenafil 20 mg PAH BiDil hydralazine minoxidil Orenitram ER Remodulin Uptravi 4.5.8 3 felodipine, nicardipine, nifedipine 1 1 1 1 1 1 1 1 1 1 phenoxybenzamine 4.5.7 1 1 1 1 1 1 1 1 PA Criteria Tier lisinopril /HCTZ metoprolol /HCTZ moexipril/HCTZ Nadolol/bendroflumethiazide propranolol/HCTZ quinapril/HCTZ telmisartan/amlodipine trandolopril/verapamil Azor QL, ST Adrenergic Antagonists and Related Drugs doxazosin mesylate prazosin HCl terazosin Cardura XL clonidine clonidine weekly patch guanabenz acetate guanfacine methyldopa 4.5.5 1 1 ACE Inhibitors benazepril captopril enalapril maleate fosinopril lisinopril moexipril perindopril quinapril ramipril trandolapril Qbrelis 4.5.5 Drug name Suggested preferred alternatives 1 1 1 1 1 1 1 1 1 QL = Quantity limits If exceeded, PA required ST = Step therapy If criteria not met, PA required 7 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Fenoglide Fibricor Juxtapid Kynamro Lipofen Liptruzet Livalo Lofibra Niaspan Praluent Repatha Simcor Triglide Vascepa Vytorin Welchol tabs/pkts Zetia 4.7 Criteria Tier 3 3 3 3 3 3 3 PA,QL,SP PA,QL,SP Suggested preferred alternatives Drug name fenofibrate fenofibrate Desonate desonide desoximetasone fluocinolone hydrocortisone Verdeso foam fenofibrate Atorvastatin + Zeita simvastatin, pravastatin, lovastatin, atorvastatin, fluvastatin cap, Crestor 3 fenofibrate QL QL, ST 5.2 PA,QL,SP PA,QL,SP QL 3 3 2 3 fenofibrate 3 omega-3 acid ethyl esters 3 QL QL 5.3 QL Miscellaneous Cardiovascular Agents midodrine Corlanor Entresto Ranexa 1 QL PA, QL QL 3 3 3 Chapter 5: Dermatologicals, topical therapy 5.1 Topical Corticosteroids All brand-name topical corticosteroids without a generic equivalent will be available at a tier 3 copay. 5.1.1 Topical Corticosteroids, Very High Potency clobetasol propionate diflorasone diacetate halobetasol propionate Temovate Ultravate lotion 5.1.2 5.1.3 3 generics 3 generics 1 1 1 3 3 3 3 3 generics generics generics generics generics Topical Corticosteroids, Medium Potency flurandrenolide hydrocortisone butyrate triamcinolone acetonide Cloderm Cordran Dermatop E oint Elocon fluticasone Locoid Luxiq mometasone Pandel prednicarbate 5.1.4 1 1 1 Topical corticosteroids, High Potency amcinonide betamethasone fluocinonide Clocortolone Pivalate cream Diprolene, Diprolene AF Halog, Halog E Sernivo Topicort/Topicort LP/ Topicort spray 1 1 1 3 3 3 3 generics generics prednicarbate cream, generics generics 1 3 generics, HC butyrate cream 3 generics 1 3 generics 1 Topical Corticosteroids, Low Potency hydrocortisone /aloe alclometasone PA = Prior authorization required 3 generics 1 1 1 1 3 desonide cream/oint/lot, generics QL 1 1 QL = Quantity limits If exceeded, PA required 1 1 1 1 3 hydropramox gel Therapy for Acne adapalene cream, gel amnesteen benzoyl peroxide, various formulations benzoyl peroxide pads bpo 4, 8% gel bpo 3, 6, 9%, foaming cloths claravis clindamycin phosphate clindamycin/benzoyl peroxide clindamycin/tretinoin erythromycin erythromycin/benzoyl peroxide metronidazole cream/gel/lot myorisan oscion cleanser/pads prascion cleanser sodium sulfacetamide medicated pads/cleanser/cream/lot sotret sulfacetamide/sulfur topical prod sulfacleanse susp sulfatol gel tretinoin, tretinoin micro zenatane Absorbica Acanya Gel ST Aczone Adapalene Lot Apop Avar/Avar LS/Avar-E LS Avita . Azelex Benzefoam /Benzefoam Ultra BPS gel Benzoyl Peroxide 2.5% wash Brevoxyl acne wash Clindareach Delos cleanser/lot Differin lot and 0.3% gel Epiduo/Epiduo Forte Finacea Garimide Inova Easy Pads Metrogel Mirvaso Neobenz Micro Neuac Noritate Nuox gel 2 2 Suggested preferred alternatives Topical Anesthetics lidocaine HCI lidocaine patches lidocaine/prilocaine lidocaine/tetracaine Novacort gel 2 Criteria Tier 1 1 1 NO MAIL ORDER 1 1 1 1 1 1 1 1 1 1 1 1 1 1 NO MAIL ORDER NO MAIL ORDER 1 1 1 1 1 1 NO MAIL ORDER 3 3 3 3 3 3 3 3 3 3 3 NO MAIL ORDER NO MAIL ORDER clindamycin/benzoyl peroxide tretinoin Plexion, Prascion tretinoin tretinoin benzoyl peroxide benzoyl peroxide benzoyl peroxide 2 benzoyl peroxide creamy wash 3 clindamycin 3 benzoyl peroxide, OTC 2 generics (adapalene) for 0.1% gel/cream 2 3 metronidazole cream, tretinoin 3 sulfacetamide/sulfur, OTC 3 benzoyl peroxide, OTC 2 metronidazole gel 3 3 benzoyl peroxide 3 clindamycin/benzoyl peroxide 2 3 benzoyl peroxide/sulfacetamide ST = Step therapy If criteria not met, PA required 8 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Suggested preferred alternatives Drug name hydrocortisone acetate gel 2% clindamycin/benzoyl peroxide benzoyl peroxide pad/oscion prods shampoo Akurza cream/lot Durasal Salex 6% shampoo Salicylic 6% cream/lot Salvax 6% foam Virasal Nuzon gel Onexton Pacnex LP/HP cleansing pads Plexion cleansing cloths Retin-A 0.08% micro pump Rosac Rosula Rosula clarifying wash Rosula NS SE Benzoyl Peroxide 7% wash Sodium Sulfamide/Sulfur gel Soolantra Sumadan wash Sumaxin 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Synalar Tazorac Tretin-X Triaz Vanoxide HC Veltin gel Zencia wash Zoderm 3 3 3 3 3 3 clindamycin and/or tretinoin 3 sulfacetamide/sulfur 3 benzoyl peroxide 5.4 ST 1 1 1 1 1 3 3 3 mupirocin cream/oint 3 3 5.11 1 1 1 1 1 1 3 3 3 3 3 3 3 3 3 econazole cream ketoconazole, nystatin ketoconazole, nystatin ciclopirox ciclopirox econazole cream naftifine cream 5.12 1 3 Zovirax + hydrocortisone 2 1 Keratolytics salicylic acid 26% liquid salicylic acid ER film salicylic acid 6% foam/cream/lot/ PA = Prior authorization required 1 1 1 QL = Quantity limits If exceeded, PA required 1 1 1 1 1 1 1 3 calcipotriene 3 3 Enbrel, Humira 2 3 calcipotriene/betamethasone 3 Seb-Prev cream/gel 3 Seb-Prev 10% prods 3 pramoxine/HC 1 3 3 calcipotriene oint/soln 3 Enbrel, Humira 3 OTC selenium sulfide 3 3 Topical Scabicides/Pediculicides QL 1 1 1 2 2 QL 3 2 QL QL malathion 3 3 Miscellaneous Dermatologicals allanderm-T oint aluminum acetate soln cem-urea 45% doxepin cream imiquimod 5% cream pruclair cream prutect topical emulsion pruvel cream re-urea lot/gel/emulsion sodium hyaluronate lot tacrolimus oint PA Urea: different strengths/prods Alevicyn Aluvea cream Atopiclair cream Atrapro Dermal spray/hydrogel Aquaphilic /Triamcin Bionect Carac cream ketoconazole Re Sa 6% cream/lot salicylic acid 26% liquid OTC salicylic acid shampoo Re Sa 6% cream/lot salicylic acid foam 6% salicylic acid Antipsoriatic/Antiseborrheic malathion lot permethrin 5% cream spinosad 0.9% susp Eurax 10% cream/lot Lindane 1% lot/shampoo Lycelle removal kit Ovide lot Sklice 0.5% lot Ulesfia lot Burn Therapy silver sulfadiazine 5.9 sulfacetamide/sulfur OTC acne cleansing prod, sulfacleanse susp generics Dovonex, tretinoin tretinoin benzoyl peroxide pad, oscion prod Suggested preferred alternatives 3 3 3 3 3 3 acitretin calcipotriene oint/soln/cream calcipotriene/betamethasone drithocreme HP hydrocort-pramox gel re-sa 6% cream/lot selenium sulfide Calcitrene Calcitriol oint PA,QL,SP Cosentyx Dovonex Enstilar foam Ovace cream/gel Ovace Plus cream/wash/foam Pramosone/Pramosone E Seb-Prev cream/gel/wash Sodium Sulfacetamide cleanser Sorilux Taltz PA,SP,QL Tersi foam Vectical oint QL Zithranol shampoo Topical Antivirals acyclovir oint Xerese cream Zovirax cream 5.7 5.10 Topical Antifungals ciclopirox clotrimazole/betamethasone econazole cream ketoconazole cream/shampoo naftifine cream oxiconazole cream Ecoza Ertaczo Exelderm Jublia QL Kerydin QL Luzu Naftin Gel Vusion Xolegel 5.6 sulfacetamide/sulfur Prascion Sodium sulfacetamide medicated pads benzoyl peroxide or OTC sulfacetamide/sulfur Topical Antibacterials gentamicin hydro-iodoquinol 2-1 hydrocortisone/iodoquin ol/aloe mafenide pwd pkts mupirocin cream/oint Alcortin-A Aloquin Altabax Neo-Synalar Silvrstat dressing gel 5.5 tretinoin Criteria Tier 1 1 1 1 1 1 1 1 1 1 1 1 3 3 urea 3 pruclair cream 3 3 generics 3 2 ST = Step therapy If criteria not met, PA required 9 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Carb-o-philic Condylox Elidel PA Fluorouracil cream/soln HPR Plus HPR emollient foam/plus emollient Hydro 35/40 foam Hylase wound gel Hylira lot Kerafoam Keratol HC 1% Kerol AD emulsion Kerol Redi-Cloths Latrix XM emulsion MimyX cream Neosalus Picato gel QL Podofilox Radigel Acemannan hydrogel Regranex gel QL Solaraze Sonafine topical Tolak 4% Tropazone lot Umecta 40% nail film/mousse Umecta PD Urealac Uramaxin cream/foam/lot/ applicator Uramaxin GT Kit/Uramaxin GT pre-filled applicator Valchlor PA, SP Venelex Veregen Xclair Zyclara Drug name Suggested preferred alternatives 3 Aquoral spray Caphosol Gelx oral gel Mugard oral wound rinse Mucotrol gel wafer Numoisyn liquid Numoisyn lozenges Orafate Oralone paste Prothelial Salicept susp 2 3 generic topical corticosteroid 1 1 1 3 urea lot, cream, gel 3 3 sod hyaluronate lot 3 1 3 3 urea oint/lot 3 urea 3 Biafine RE 3 3 1 3 7.1 2 1 3 urea 3 urea 6.4 PA = Prior authorization required 1 1 7.4.1 2 3 3 antipyrine/benzocaine 3 antipyrine/benzocaine 3 3 antipyrine/benzocaine 1 1 1 1 1 QL = Quantity limits If exceeded, PA required 2 1 3 thyroid, levoxyl, levothroid, levothyroxine 2 3 levoxyl, levothroid, levothyroxine 3 thyroid, levoxyl, levothroid, levothyroxine 3 thyroid, levoxyl, levothroid, levothyroxine 1 1 1 1 1 1 1 1 2 3 methylprednisolone 3 prednisone 1 Androgens danazol methyltestosterone oxandrolone testosterone gel packs (Androgel pkt equiv) testosterone gel pump Anadrol-50 Androderm Androgel pump Axiron Fortesta Natesto Striant Testim 3 Ciprodex 1 1 1 1 1 1 1 1 Adrenal Hormones cortisone dexamethasone hydrocortisone methylprednisolone prednisolone prednisolone sodium phosphate ODT prednisone zema-pak 6- and 10-day Acthar H.P. gel PA, SP Medrol 2, 8, 32 mg Rayos PA,QL Veripred 20 Miscellaneous Agents cevimeline chlorhexidine rinse olopatadine nasal pilocarpine tabs triamcinolone dental paste SP Thyroid Hormones 7.3 1 1 1 1 1 1 1 2 QL, SP levoxyl levothroid levothyroxine sodium liothyronine sodium np thyroid thyroid unithroid westhroid Armour Thyroid Nature-Throid, 16, 32, 65, 130 Nature-Throid 97.5, 260 mg Thyrolar Tirosint Westhroid-P WP Thyroid 3 fluorouracil 3 3 fluorouracil 3 3 urea 40% 3 antipyrine/benzocaine 3 ciprofloxacin, ofloxacin 3 generics 3 3 OTC saliva substitutes 3 3 3 triamcinolone dental paste 3 3 OTC saliva substitutes Antithyroid Agents 7.2 Miscellaneous Otic Preparations acetic acid, acetic acid HC antipyrine/benzocaine borofair otic ciprofloxacin otic fluocinolone otic ofloxacin otic neomycin/polymyxin/HC Aurax otic Cetraxal otic Halog, Halog E Ciprodex otic Cipro HC otic Domeboro otic Myoxin otic susp Otic Care otic soln Otozin ear drops Pinnacaine otic drops TriOxin otic 3 OTC saliva substitutes 3 OTC saliva substitutes 3 3 QL, SP methimazole propylthiouracil (PTU) Chapter 6: Ear, Nose and Throat Medications 6.2 Suggested preferred alternatives Chapter 7: Endocrine/Diabetes 2 3 3 3 Aldara, Condylox 3 3 imiquimod Criteria Tier PA QL QL PA QL QL QL ST, QL ST, QL ST, QL 1 1 1 1 1 2 2 2 2 3 3 3 3 Androgel Androgel, Axiron, testosterone Androgel, Axiron, testosterone Androgel, Axiron, testosterone Androgel, Axiron, testosterone ST = Step therapy If criteria not met, PA required 10 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Testosterone gel Vogelxo ST, QL ST, QL 7.4.2 Drug name Suggested preferred alternatives 3 Androgel, Axiron, testosterone 3 Androgel, Axiron, testosterone glimepiride glipizide/glipizide ER glyburide metformin HCl, metformin ER metformin ER (Glumetza equiv)PA metformin/glipizide metformin/glyburide miglitol nateglinide pioglitazone pioglitazone/glimepiride pioglitazone/metformin repaglinide repaglinide/metformin Cycloset Glyxambi ST, QL Actoplus Met XR QL Avandamet Avandaryl Avandia Symlin PA Bydureon vials/pens QL Byetta QL Farxiga ST, QL Invokamet ST, QL Invokana ST, QL Janumet/Janumet XR QL Januvia QL Jardiance ST, QL Jentadueto QL Jentadueto XR QL Kazano and ST, QL alogliptin/metformin Nesina and alogliptin ST, QL Onglyza ST, QL Oseni and ST, QL alogliptin/pioglitazone Kombiglyze XR ST, QL Synjardy ST, QL Tanzeum ST, QL Tradjenta QL Trulicity ST, QL Victoza QL Xigduo XR ST, QL Ovulatory Stimulants Injectable drugs for infertility are not covered by many benefit plans. You must have a injectable fertility prescription rider in your BCNEPA Contract/Policy for any injectable fertility medication to be covered. A Fertility Drug Discount Progm is available through Freedom Fertility Pharmacy, a leading provider of specialty pharmacy services. The Freedom Advantage progm provides a discount for those that don’t have coverage for fertility drugs and FertilityAssist providing free medication for qualified patients. For more information, visit www.freedomfertility.com or call 1.800.660.4283. clomiphene 1 7.4.3 Miscellaneous Agents calcitriol desmopressin tabs/nasal soln cabergoline QL doxercalciferol paricalcitol Cerdelga PA, SP Cerezyme PA, SP DDAVP SP Elaprase PA, SP Elelyso PA, SP Fabrazyme PA, SP PA,QL,SP Korlym Kuvan PA, SP Lumizyme PA, SP PA,QL,SP Myalept Myozyme PA, SP Naglazyme PA, SP PA,QL,SP Natpara PA,QL,SP Samsca Sensipar SP Stimate SP Somavert PA, SP Strensiq PA, SP, QL Synarel PA, SP Vimizim PA, SP Vpriv PA, SP Zavesca PA, SP 7.4.4 7.5.1 1 1 1 1 1 3 2 2 3 3 2 3 2 3 3 3 2 3 3 2 2 2 3 2 3 3 Cerezyme 2 Gonadotropin and Related Agents Cetrotide Ganirelix Novarel Pregnyl PA, SP PA, SP PA, SP PA, SP 3 (injectable fertility med) 3 (injectable fertility med) 1 (injectable fertility med) 2 (injectable fertility med) Afrezza Apidra Humalog, Humalog Mix Humulin Lantus Lantus Solostar Levemir Levemir Flex Pen/Flex Touch Novolin Novolog Relion Toujeo Solostar Tresiba Flextouch 7.5.2 Glucagon PA = Prior authorization required 1 1 1 1 3 metformin, metformin ER 1 1 1 1 1 1 1 1 1 3 metformin, sulfonylurea 3 2 3 3 3 3 2 2 3 Invokana 2 2 2 2 3 Invokana 2 2 3 Janumet, Janumet XR, Jentadueto 3 Januvia, Tradjenta 3 Januvia, Tradjenta 3 Januvia or Tradjenta + pioglitazone 3 Janumet, Janumet XR, Jentadueto 3 Invokamet 3 Byetta, Bydureon, Victoza 2 3 Byetta, Bydureon, Victoza 2 3 Invokamet QL 3 Insulin Syringes/Misc. Durable Medical Equipment Asthma Pack III 2 AsTech 2 Asthma Mentor 2 EasiVent chamber 2 Easy Touch syrs 3 I-port QL 3 Minimed reservoirs PA 2 Opti chamber 2 Paradigm infusion sets PA 2 Paradigm silhouette sets PA 2 Polyfin infusion sets, PA 2 extension sets, QR infusion sets Quick-release teflon PA 2 cannula Silhouette infusion sets PA 2 Sof-Set infusion sets PA 2 Sof-Set mini infusion sets PA 2 ST = Step therapy If criteria not met, PA required 3 formulary insulins 3 Humalog, Novolog 2 2 2 2 2 2 2 2 3 Humulin, Novolin 3 Lantus, Levemir 3 Lantus, Levemir Non-Insulin Hypoglycemic Agents acarbose Suggested preferred alternatives 7.5.3 Glucose Elevating Agents 7.5.4 Insulin Therapy Criteria Tier 1 QL = Quantity limits If exceeded, PA required 11 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Drug name Suggested preferred alternatives Sure-T infusion sets 2 All insulin pumps and insulin pump supplies require prior authorization. All Bayer and Abbott meters listed may be obtained for free by taking a prescription to any participating pharmacy. This is a partial listing of available blood glucose meters. Any meter other than the Bayer and Abbott prods that are listed are considered non-preferred and must be obtained through your DME benefits. Products relating to meters other than Bayer and Abbott (i.e. control solutions, etc), are tier 3. Roche Meters: Accu-Chek Active, Compact Plus, Aviva Plus, Nano Smartview Meter and any other Roche meter Bayer Meters: Contour Next EZ, Contour USB, Contour Next, Contour Next USB, Breeze-2 . For Medtronic pump users: Contour Next EZ Link Continuous glucose monitoring system DexCom G4 Platinum Abbott Meters: FreeStyle Freedom Lite FreeStyle Lite, FreeStyle InsuLinX, FreeStyle Neo Guardian RT starter kit monitoring sensors (Medtronic, DexCom) Enlite sensors (Medtronic) PA, QL FreeStyle InsuLinX QL test strips (Abbott) Free Style Lite test strips QL (Abbott) FreeStyle Neo test strips QL LifeScan test strips/ PA,QL supplies: One Touch Ultra and Select, SureStep, One Touch Verio and any other LifeScan strips/supplies Monoject Novofine 30, 32 Novofine Autocover Precision Sure Dose Precision Xtra QL Prodigy No Coding PA, QL test strips Prodigy pen needles/mini pen needles/short pen needles/syrs G4 Platinum sensors PA, QL (for DexCom system) Soft Touch lancets Sure-T lancets Unistrip-1 PA, QL Other brands PA, QL Refer to DME benefits through DME providers; Covered alternatives: Bayer and Abbott products (see listing for covered products) Free Monitor Progm Take your Rx to any participating pharmacy. See MiniMed Paradigm Real-Time, Guardian RT or DexCom Refer to DME; prior authorization is required for the transmitter/receiver as well as the sensors. (Sensors go through pharmacy benefit). Covered alternatives: Bayer and Abbott prods (see listing for covered products) Free Monitor Progm Take your Rx to any participating pharmacy or call 1.866.224.8892 for home delivery Refer to DME; prior authorization is required for the transmitter as well as the sensors. (Sensor go through pharmacy benefit). Covered alternatives: Bayer products, Abbott products Life Scan Meters: One Touch ultra mini, Ultra 2 , Ultra Smart, Ultra Link, One Touch Verio IQ Meter, One Touch Verio Sync and any other Life Scan Monitors Refer to DME benefits through DME providers; Prodigy pocket meter Covered alternatives: Bayer and Abbott MiniMed Paradigm Real-Time products (see listing for covered products) Prodigy Autocode talking meter Prodigy voice meter Sidekick blood glucose monitor Solus V2 Unistrip-1 V-Go Insulin delivery system Tier 3, PA, QL of 30/30 Bayer and Abbott test strips and meters listed are preferred and first step in step therapy; all others are non-preferred and require prior authorization. If authorization is obtained, any test strip and supplies other than Bayer or Abbott products are subject to tier 3 copay. All blood glucose test strips are restricted to a quantity of 150/month. A prior authorization must be submitted for consideration for a larger quantity. Accu-Chek Active PA,QL 3 Abbott/Bayer test strips test strips Accu-Chek Aviva PA,QL 3 Abbott/Bayer test strips Plus/Connect test strips Accu-Chek Compack Plus PA,QL 3 Abbott/Bayer test strips test strips Accu-Chek Safe-T-Pro lancets 2 Accu-Chek Smartview PA,QL 3 Abbott/Bayer test strips test strips Accu-Chek Softclix 2 Accu-Chek SoftTouch 2 B-D prods 2 Contour test strips QL 2 (Bayer) Contour Next test strips QL (Bayer) Breeze-2 test strips QL (Bayer) Continuous glucose PA, QL 2 PA = Prior authorization required QL = Quantity limits If exceeded, PA required Suggested preferred alternatives 3 2 2 2 3 Abbott/Bayer test strips 2 2 2 2 2 3 Abbott/Bayer test strips 3 3 2 2 3 Abbott/Bayer test strips 3 Abbott/Bayer test strips Chapter 8: Gastroenterology 8.1.1 H2 Antagonists cimetidine famotidine nizatidine ranitidine 8.1.2 1 1 1 1 Prostaglandins misoprostol 8.1.3 8.1.4 1 Other Ulcer Therapy sucralfate Omeclamox-Pak Prevpac Pylera 1 QL QL 3 3 3 Proton Pump Inhibitors Use of 4 of our first-line meds—omeprazole, pantoprazole, rabeprazole, lansoprazole, omeprazole/bicarbonate, Dexilant—must be noted within past 180 days for Prevacid Solutabs, esomeprazole, Nexium, Zegerid pkts or Aciphex Sprinkles to be covered. Children ages 13 and under exempt from step therapy. esomeprazole 20, 40 mg QL, ST lansoprazole omeprazole omeprazole/ ST bicarbonate caps pantoprazole rabeprazole Aciphex sprinkles QL, ST Dexilant QL Nexium susp/pkt Prevacid solutabs Prilosec granules Zegerid pkts QL, ST ST QL, ST QL, ST 8.2.1 2 Criteria Tier pantoprazole, omeprazole, 3 rabeprazole, Dexilant 2 2 pantoprazole, omeprazole, rabeprazole, Dexilant 1 1 3 pantoprazole, omeprazole, rabeprazole, Dexilant 3 pantoprazole, omeprazole, rabeprazole 3 3 3 omeprazole 3 pantoprazole, omeprazole, Dexilant Antidiarrheals paregoric diphenoxylate/atropine 3 1 1 1 ST = Step therapy If criteria not met, PA required 12 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Fulyzaq ST, QL 8.2.2 1 2 3 hyoscyamine sulfate ER 1 1 Rectiv 0.4% gel Relistor tabs/injection Rowasa kit Sfrowasa Uceris Viberzi Visicol Zelnorm 1 1 1 1 2 3 generic antispasmodic 2 3 hyoscyamine, dispas 2 8.3.4 3 hyoscyamine, dispas 3 Creon, Pancreaze, Zenpep 3 Creon, Pancreaze, Zenpep 2 PA = Prior authorization required 1 1 1 1 1 females only 1 1 1 1 8.3.5 3 lidocaine-HC 3 1% cream 3 Delzicol, sulfasalazine, balsalazide 2 2 Lidocaine 3%/HC 2.5% gel 3 Delzicol, sulfasalazine, balsalazide 2 9.1.1 3 OTC hydrocortisone + lidocaine oint, AnaMantlle HC 3 Creon, Pancreaze, Zenpep 3 pramoxine/HC 3 Analpram HC 3 pramoxine/HC 3 OTC hydrocortisone + lidocaine oint, AnaMantle HC 3 3 2 mesalamine kit 2 3 budesonide 3 3 peg 3350/electrolytes, Moviprep 3 QL PA, QL QL PA QL QL 1 1 1 1 1 1 3 QL QL, ST PA, QL 2 3 3 3 3 3 PA QL, ST ondansetron, granisetron ondansetron, granisetron prochlorperazine, trimethobenzamide ondansetron ODT 1 2 QL 3 peg 3350/electrolytes/Moviprep 3 peg 3350/electrolytes, Moviprep 3 peg 3350/electrolytes, Moviprep Erythroid Stimulants Aranesp Epogen Procrit 9.1.2 SP SP SP 9.1.3 2 3 3 Delzicol, Asacol HD, Lialda 3 QL = Quantity limits If exceeded, PA required 3 Procrit 2 SP SP PA,QL,SP PA, SP PA, SP 2 2 PA, SP PA,QL,SP QL, SP QL, SP ST, QL, SP QL, SP SP PA,QL,SP PA, QL, SP, ST 2 2 3 Granix Granix 3 Interferons Actimmune Avonex Betaseron Copaxone Extavia Infergen Intron A Pegasys Peg-Intron: only after special consideration 1 2 Myeloid Stimulants Granix Leukine Neulasta Neupogen Zarxio 3 ursodiol 3 Enbrel, Humira 3 peg 3350/electrolytes, Moviprep 3 2 (reformulation of Asacol) 3 Delzicol, sulfasalazine, balsalazide 3 3 Delzicol, sulfasalazine, balsalazide 3 peg 3350/electrolytes, Moviprep 2 2 Chapter 9: Immunology, Vaccines and Biotechnology 3 2 3 peg 3350/electrolytes, Moviprep 3 PA, QL,SP Bowel Evacuants gavilyte soln Moviprep (8.3.5) Prepopik pwd pkt Suprep Bowel prep kit TriLyte 1 1 1 1 Suggested preferred alternatives Antivertigo and Antiemetic Agents dronabinol granisetron ondansetron prochlorperazine promethazine supp trimethobenzamide HCl Diclegis Emend caps/susp Anzemet Sancuso Patch Transderm-Scop Varubi Zuplenz Miscellaneous Gastrointestinal Agents alosetron balsalazide budesonide Ec hc-pramoxine hydrocortisone 2.5% cream lidocaine-HC 3 1% cream mesalamine kit metoclopramide HCl/ODT peg 3350 and electrolytes, peg 3350/electrolytes/flavor packs pramoxine/hydrocortisone sulfasalazine ursodiol z-pram cream Amitiza QL Analpram HC cream/lot AnaMantle HC Forte cream Apriso ST Asacol HD AnaMantle HC Azulfidine En-Tab Canasa Chenodal tabs PA, SP Cimzia PA, QL, SP, ST CoLyte Cystadane SP Delzicol Dipentum ST PA,QL,SP Gattex Giazo ST Halflytely Kristalose Lactulose Lialda Linzess QL Mesalamine 800 mg ST Movantik QL Criteria Tier Pertzye Pramcort cream Pramosone cream/ lot/oint Procort cream Rectagel HC gel Digestive Enzymes dicyclomine dispas glycopyrolate tabs methscopalamine bromide Creon Gastrinex NF IB-Stat QL Mar-Spas Pancreaze Pro-Hyo Ultresa Viokace Zenpep DR 8.3.3 Osmoprep Ocaliva Pentasa Peranex HC Combination Anticholinergics antispasmodic elixir belladonna/phenobarb 8.3.2 3 Antispasmodics hyoscyamine Cuvposa soln Symax Duotab 8.2.3 Drug name Suggested preferred alternatives 3 Betaseron, Rebif, Copaxone 2 2 3 Betaseron, Rebif, Copaxone 2 2 2 3 Pegasys ST = Step therapy If criteria not met, PA required 13 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Plegridy Rebif all dosage forms Sylatron 9.1.4 Criteria Tier PA, QL, SP, ST QL, SP PA,QL,SP Suggested preferred alternatives 9.1.5 2 Xeljanz/Xeljanz XR PA, QL, SP, ST 10.4 3 Suggested preferred alternatives 3 Enbrel. Humira, Orencia PA,QL,SP PA,QL,SP PA,QL,SP PA,QL,SP PA,QL,SP 3 3 Norditropin 3 Norditropin 2 3 Norditropin PA,QL,SP PA,QL,SP PA,QL,SP PA,QL,SP PA,QL,SP 3 3 3 3 3 Osteoporosis Therapy alendronate ibandronate raloxifene risedronate risedronate, dr Actonel with Calcium Binosto Fortical Forteo Fosamax plus D Norditropin Norditropin Norditropin Norditropin Norditropin QL QL 1 1 1 1 1 QL QL 3 alendronate, ibandronate, risedronate 3 alendronate, ibandronate, risedronate alendronate, ibandronate, risedronate 1 PA, SP QL 2 3 alendronate or ibandronate with OTC vitamin D 3 alendronate, ibandronate 3 Miacalcin Osphena Chapter 11: Obstetric and gynocology Interleukins PA,QL,SP PA,QL,SP QL, SP Arcalyst Ilaris Neumega Criteria Tier 3 Betaseron, Rebif, Copaxone Growth Hormones Egrifta Genotropin Humatrope Norditropin Nutropin, Nutropin AQ, Nutropin Depot Omnitrope Protropin Saizen Serostim Zomacton Drug name 3 3 1 dose/8 weeks; subject to 2 copays 11.1.1 Monophasic/Biphasic/Triphasic Agents Gammagard PA, SP Gammaked PA, SP Gamunex-C PA, SP Hizentra 20% PA, SP 3 SC through pharmacy benefit IV through medical benefit Both require PA 3 SC through pharmacy benefit IV through medical benefit Both require PA 3 SC through pharmacy benefit IV through medical benefit Both require PA 3 Hyqvia PA, SP 3 Grastek 3 Oralair PA, QL PA,QL,SP Please refer to the Women’s Health Care Reform Contraceptive Listing in the Index of this formulary. This lists all generic contraceptives that are available at zero-cost share for those groups currently covered under HCR. For those members not currently covered under health care reform, a tier 1 copay will apply to the generic contraceptives.The brand contraceptives /emergency contraceptives listed below as well as any others are subject to a tier 3 copay for those with or without HCR; they are not covered under HCR zero-cost share. All contraceptives are subject to quantity limits of one cycle per month. Beyaz 28 QL 3 Generess FE QL 3 Layolis FE QL 3 Lo Minastrin 24 Fe QL 3 Any FDA-approved generic or Minastrin 24 Fe QL 3 preferred contraceptive Natazia QL 3 Ovcon 50 QL 3 Safyral QL 3 3 11.2 Ragwitek PA, QL 3 methylergonovine 9.2 2 Vaccines and Miscellaneous Immunologicals Oxytocics Chapter 10: Musculoskeletal and Rheumatology 11.3.1 10.2 medroxyprogesterone acetate norethindrone acetate progesterone caps Crinone Depo-SubQ Provera QL Endometrin supp First-Progesterone vaginal supp Makena PA, SP,QL Progesterone in oil PA, SP Progesterone pwd Prochieve Gout Therapy allopurinol probenecid Colchicine Colcrys Mitigare Uloric Zurampic 10.3.2 1 1 3 Colcrys 2 QL PA 3 3 allopurinol 3 allopurinol Miscellaneous Rheumatological Agents Actemra infusion, Orencia infusion, Remicade, Simponi Aria and Stelara are covered under the medical benefit. They require step therapy and prior authorization. Actemra subcutaneous PA,QL,SP 3 Enbrel, Humira, Orencia PA,QL,SP Cimzia 3 Enbrel, Humira, Orencia PA,QL,SP Enbrel 2 PA,QL,SP Humira 2 PA,QL,SP 3 Enbrel, Humira, Orencia Kineret PA,QL,SP 2 Enbrel, Humira Orencia 125-mg syr/clickjet 3 Enbrel, Humira Otezla/Otezla dose pack PA,QL,ST PA 3 methotrexate tabs/injection Otrexup PA 3 methotrexate tabs/injection Rosuvo PA, QL, 3 Enbrel, Humira, Orencia Simponi SP, ST PA = Prior authorization required 11.3.2 Progestins 1 1 1 2 2 3 Crinone, Prochieve 3 Crinone, Prochieve 2 1 3 2 Estrogens estradiol tabs estradiol patches Alora QL estropipate Cenestin Climara QL Delestrogen Divigel Elestrin Subject to 3 copays, home delivery or retail Enjuvia QL = Quantity limits If exceeded, PA required 1 1 1 3 1 3 3 3 3 3 Premarin estradiol patches Premarin estradiol patches estradiol patches 3 Premarin ST = Step therapy If criteria not met, PA required 14 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Estraderm Estriol QL 2 12.4 2 2 2 1 1 1 1 12.5 2 3 Activella, Premphase, Prempro 3 3 Activella, Premphase, Prempro 2 2 QL 12.6 12.7 3 Cleocin vaginal gel 1 SP, QL Mirena SP, QL Skyla 12.1 Beta Blockers carteolol levobunolol HCl timolol maleate, timolol maleate XE betaxolol Betoptic S QL QL QL 1 1 1 QL QL 1 PA = Prior authorization required 1 1 1 1 1 1 1 2 3 3 3 3 ketorolac bromfenac bromfenac bromfenac bromfenac 1 1 1 1 1 1 1 1 2 3 3 3 ofloxacin, ciprofloxacin, levofloxacin 3 ofloxacin, ciprofloxacin, levofloxacin Sulfonamides 1 Steroids fluorometholone prednisolone acetate Alrex Durezol FML Forte Lotemax Pred Mild Vexol Chapter 12: Ophthalmology 3 latanoprost/ bimatoprost 3 latanoprost/ bimatoprost 3 latanoprost/ bimatoprost Antibiotics sulfacetamide sodium 12.11 1 1 1 1 Non-Steroidal Anti-Inflammatory Agents 3 OTC Prods 3 OTC Prods, teraconazole 3 OTC Prods, teraconazole 12.10 3 dorzolamide/timolol 3 latanoprost Cycloplegic Mydriatics ciprofloxin 0.3% erythromycin gatifloxacin gentamicin levofloxacin 0.5% ofloxacin opth soln polymyxin B/trimethoprim tobramycin sulfate Azasite Besivance Ciloxan ophthalmic oint Moxeza Vigamox 3 Must have contraceptive benefit; will be delivered from the specialty pharmacy to your physician for insertion Must have contraceptive benefit; 2 will be delivered from the specialty pharmacy to your physician for insertion Zero copay under HCR benefits. 3 Must have contraceptive benefit; will be delivered from the specialty pharmacy to your physician for insertion 2 Oral Drugs for Glaucoma 12.9 1 1 SP, QL QL QL QL QL ST, QL 3 metronidazole 1 Diaphragms and Other Non-Oral Contraceptives Lileta 3 betaxolol, timolol QL QL QL bromfenac 0.09% ketorolac 0.4% ketorolac 0.5% Acuvail Ilevro Nevanac Prolensa Voltaren 2 1 1 1 1 2 atropine cyclopentolate 1 1 1 QL QL QL 2 QL QL QL QL acetazolamide methazolamide 3 Activella, Premphase, Prempro Suggested preferred alternatives Other Glaucoma Drugs bimatoprost bromfenac 0.09% latanoprost travoprost Lumigan Travatan-Z Zioptan Vaginal Antifungals nystatin terconazole cream/supp 3, 7 Gynazole 1 Terazol 3 supp Zazole Vaginal supp 11.4.5 estradiol Premarin estradiol patch estradiol patch Vaginal Cleansers/Anti-Infectives amino acid vaginal cream clindamycin vaginal cream metronidazole vaginal cream Cleocin vaginal cream Clindesse Fem pH Nuvessa Vandazole 11.4.3 3 estradiol Estrogen Combinations covaryx covaryx HS estradiol/norethindrone jinteli Angeliq Climara Pro QL Combipatch Duavee Prefest Premphase Prempro 11.4.2 2 3 3 3 3 Criteria Tier Istalol metipranolol pilocarpine HCl dorzolamide HCl dorzolamide HCl/timolol Azopt Betimol Combigan Cosopt PF Rescula Any compound containing estriol will not be covered 3 estradiol patches 3 Premarin Estrogel QL Estring Subject to 3 copays, home delivery or retail Evamist QL Femring Subject to 3 copays, home delivery or retail Femtrace Menest Menostar Minivelle QL Ortho-Est Premarin Vagifem 11.3.3 Drug name Suggested preferred alternatives 1 1 3 Alocril 3 prednisolone acetate 2 3 2 2 2 QL = Quantity limits If exceeded, PA required ST = Step therapy If criteria not met, PA required 15 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name Criteria Tier Drug name Suggested preferred alternatives Criteria Tier Obredon Polytussin AC Tussionex Tuzistra XR 12.12 Steroid-Antibiotic Combinations neomycin/bacitracin/polymyxin/ hydrocortisone neomycin/polymyxin/ dexamethasone tobramycin/dexamethasone Pred-G Tobradex oint Zylet 12.14 1 13.3.3 2 3 1 1 2 3 brimonidine, Alphagan-P 13.3.3 2 3 3 3 3 3 azelastine 3 azelastine 3 azelastine QL PA,QL,SP QL 2 QL 3 Restasis 13.3.4 Antivirals trifluridine Zirgan 2 Chapter 31: Respiratory, Allergy and Cough and Cold 13.1.1 Antihistamines cyproheptadine desloratadine hydroxyzine levocetirizine levocetirizine oral soln 1 1 1 1 Covered only age 12 yrs promethazine HCl Aldex chewables 1 13.3.5 1 3 Allegra OTC, loratadine OTC cetirizine OTC 3 Allegra OTC, loratadine OTC cetirizine OTC Karbinal ER 13.2.1 Allegra OTC, loratadine OTC cetirizine OTC, desloratadine tabs Allegra OTC, loratadine OTC cetirizine OTC Antitussive Combinations benzonatate guaifenesin /codeine hydrocodone/cpm/pseudoephedrine phenylephrine/chlorpheniraminedrops promethazine /codeine promethazine /DM Flowtuss Hycofenix Ninjacof XG PA = Prior authorization required 1 1 1 1 1 1 3 Generic antitussive 3 Generic antitussive 3 Generic antitussive QL = Quantity limits If exceeded, PA required 3 Allegra-D OTC, other OTC prods 3 Allegra-D OTC, other OTC prods 3 Allegra-D OTC, other OTC prods 1 1 3 2 2 2 Beta Agonists QL QL QL QL QL, ST QL QL QL, ST QL QL QL 1 1 1 3 Foradil 2 2 3 Ventolin HFA, ProAir HFA 2 2 3 Ventolin HFA, ProAir HFA 2 3 Foradil, Serevent 2 2 QL 3 Ventolin HFA, ProAir HFA Inhaled Corticosteroids budesonide neb Aerospan Alvesco Arnuity Ellipta Asmanex HFA Asmanex Twisthaler Flovent Diskus Flovent HFA Pulmicort Flexhaler Qvar 1 1 Xanthines albuterol/ER tabs albuterol inhalant soln levalbuterol Arcapta Neohaler Brovana Foradil Maxair-Autohaler Perforomist ProAir HFA/Respiclick Proventil HFA Serevent Diskus Striverdi Respimat Ventolin HFA Volmax Xopenex HFA 1 1 1 1 Generic antitussive Generic antitussive Generic antitussive Generic antitussive Decongestant/Antihistamines dyphylline Theophylline ER Difil-G/Forte Theo-Dur Uni-Dur Uniphyl 2 Miscellaneous Ophthalmologics azelastine cromolyn sodium epinastine olopatadine Alocril Alomide Bepreve Cystaran Emadine Lastacaft Pataday Pazeo Restasis Xiidra 12.16 QL QL QL 3 3 3 3 pseudoephedrine HCL/chlor-mal Clarinex D 12 hr QL Rynatan Semprex-D 1 Sympathomimetics apraclonidine brimonidine tartrate Alphagan P 0.1% Iopidine 1% 12.15 13.2.3 1 Suggested preferred alternatives 1 QL, ST QL, ST QL QL QL QL QL QL QL, ST 3 Flovent, Pulmicort, Asmanex 3 Flovent, Pulmicort, Asmanex 3 2 2 2 2 2 3 Flovent, Pulmicort, Asmanex Intranasal Steroids budesonide flunisolide fluticasone ipratropium mometasone triamcinolone Beconase AQ QL QL QL QL QL QL QL, ST Children’s Qnasl QL, ST Omnaris QL, ST Qnasl QL, ST Veramyst QL, ST Zetonna QL, ST 1 1 1 1 1 1 3 flunisolide, fluticasone, budesonide Nasonex 3 flunisolide, fluticasone, budesonide Nasonex 3 flunisolide, fluticasone, budesonide Nasonex, triamcinolone 3 flunisolide, fluticasone, budesonide Nasonex, triamcinolone 3 flunisolide, fluticasone, budesonide Nasonex, triamcinolone 3 flunisolide, fluticasone, budesonide Nasonex, triamcinolone ST = Step therapy If criteria not met, PA required 16 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name 13.3.6 Criteria Tier Drug name Suggested preferred alternatives tolterodine tolterodine ER trospium Cl trospium Cl ER Gelnique Myrbetriq Oxytrol Miscellaneous Pulmonary Agents acetylcysteine cromolyn sodium epinephrine auto-inject ipratropium Ipratropium/albuterol montelukast sildenafil (PAH) zafirlukast Adcirca Adempas Adrenaclick Advair Diskus, Advair HFA Anoro Ellipta Atrovent HFA Auvi-Q Bevespi Aerosphere Breo Ellipta Cinryze Combivent Respimat Daliresp Dulera EpiPen/EpiPen Jr Esbriet Firazyr Hyper-Sal Incruse Ellipta Kalydeco Letairis Letairis Mucomyst Nebusal Ofev Opsumit Orkambi Pulmozyme Revatio oral susp Ruconest Seebri neohaler Spiriva/Respimat Stiolto Respimat Symbicort Tracleer Tudorza Tyvaso Utibron Neohaler Ventavis Zyflo 1 1 QL QL QL QL PA,QL,SP 3 EpiPen, EpiPen Jr, Auvi-Q 1 1 1 1 1 QL QL QL QL QL PA, SP QL QL, PA QL QL PA,QL,SP PA, SP 2 2 2 3 3 EpiPen, EpiPen Jr, Auvi-Q 3 2 3 2 3 2 2 3 3 3 3 2 2 2 2 2 14.2 PA = Prior authorization required 2 2 3 oxybutynin ER, trospium, Vesicare, Gelnique, trospium ER, tolterodine ER 3 oxybutynin ER, trospium, Vesicare, trospium ER, tolterodine ER 2 Urinary Anesthetics 2 3 sildenafil tabs 3 3 1 Miscellaneous Urologicals 1 1 1 1 1 QL QL QL 3 3 3 2 QL QL 3 3 3 re-methylphen 3 3 3 QL QL 1 3 phosenamine 3 QL Benign Prostatic Hyperplasia (BPH) Therapy alfuzosin dutasteride dutasteride/tamsulosin finasteride Rapaflo tamsulosin 3 3 Letairis 3 QL 1 1 1 1 3 tamsulosin, alfuzosin 1 Chapter 15: Vitamins, Hematinics and Electrolytes 15.1 Vitamins and Hematinics Most prenatal vitamins are available at a tier 1 or tier 2 copay. folic acid 1 mg 1 Bright Beginnings bar 3 Any FDA-approved generic or preferred prenatal vitamin Eligen B12 3 OTC B12 tabs Floriva 3 Nascobal Nasal spray 3 OTC B12 tabs Poly Vi Flor Film Strips 3 Generic chewable tabs Prefera-OB 2 Prenate Elite 3 Any FDA-approved generic or preferred prenatal vitamin Quflora 3 Texavite 3 Tricare Prenatal w/DHA 3 Any FDA-approved generic or preferred prenatal vitamin 2 3 2 3 2 3 3 2 3 montelukast 1 Anticholinergics and antispasmodics darifenacin flavoxate oxybutynin chloride oxybutynin chloride ER QL 14.5 Cholinergic stimulants bethanechol Vesicare phosenamine potassium citrate ER re methylphen uro-L uro-MP Caverject Cialis Edex Elmiron Levitra Muse Prosed DS Renacidin Staxyn Stendra Uritact-EC Uta cap Viagra Chapter 14: Urologicals 14.1 QL 14.4 2 PA,QL,SP PA,QL,SP PA,QL,SP SP PA, SP PA,QL,SP QL QL QL QL PA, SP, QL, ST QL PA,QL,SP QL PA, SP QL, ST QL QL phenazopyridine HCl 2 Suggested preferred alternatives 1 1 1 1 Toviaz 14.3 PA,QL,SP PA,QL,SP QL QL QL PA,QL,SP PA,QL,SP PA,QL,SP Criteria Tier 15.3.1 Potassium K-tab 8 mEq potassium chloride/SA Effer-K 1 1 1 1 QL = Quantity limits If exceeded, PA required 1 1 2 ST = Step therapy If criteria not met, PA required 17 SP = Specialty pharmacy Multi-tiered Prescription Drug Formulary Listing Drug name 15.3.2 Criteria Tier Drug name Suggested preferred alternatives Vashe wound therapy Other electrolytes calcium acetate Phoslyra 1 16.8 3 calcium acetate Cetylev 15.4.1 Miscellaneous Nutrition Products Arginaid Prekunil Criteria Tier Suggested preferred alternatives 3 Antidotes 3 In addition to the prescription medications listed in this formulary, a number of specific medications which are administered by your physician are covered under the medical portion of your policy. 3 Note: Only for patients diagnosed with phenylketonuria; no copay Chapter 16: Diagnostics and miscellaneous agents 16.1 Miscellaneous Agents etidronate disodium risedronate 30 mg sevelamer carbonate sodium phenylbutyrate Aralast Carbaglu Ferriprox Formaldehyde Fosrenol Glassia Increlex Jadenu Neutrasal Orfadin Prolastin Ravicti Renagel Renvela susp Skelid Veltassa Velphoro Xuriden Zemaira 16.2 1 1 1 1 SP PA,QL,SP PA,SP 2 2 3 1 3 sevelamer carbonate, Renagel SP PA, SP PA, SP 2 PA, SP SP, ST SP 2 2 3 3 3 Aralast, Glassia 3 2 2 3 3 3 3 PA, SP PA, SP SP 2 Aralast, Glassia Smoking Deterrents All generic and single source brand smoking cessation prods are available at zero copay under Health Care Reform benefits. You must present a prescription from your physician at the pharmacy to obtain these prods. bupropion SR No copay—HCR benefit nicotine patches (generic) No copay—HCR benefit nicotine gum (generic) No copay—HCR benefit nicotine lozenges (generic) No copay—HCR benefit Chantix No copay—HCR benefit Nicotrol No copay—HCR benefit Nicotrol NS No copay—HCR benefit 16.3 Anorexiants Weight loss medications are not covered by many benefit plans. You must have a weight loss prescription rider in your BCNPEA Policy/Contract for any weight loss medication to be covered. In addition, even with a weight loss rider in place, most plans require prior authorization. benzphetamine PA 1 diethylpropion PA 1 phendimetrazine PA 1 phentermine PA 1 Belviq PA 3 Contrave PA 3 Qsymia PA 3 Saxenda PA 3 Suprenza PA 3 Xenical PA 3 16.6 Irrgating Solutions PA = Prior authorization required QL = Quantity limits If exceeded, PA required ST = Step therapy If criteria not met, PA required 18 SP = Specialty pharmacy Quantity Limits: Drug prod Maximum quantity per 30-day supply Drug prod Maximum quantity per 30-day supply Abstral SL Aciphex Actemra Actonel with Calcium Actoplus Met XR 120 tabs of one strength 30 pkts of one strength 4 syrs 28 tabs (1 pkt) 60 tabs of 15/1,000 OR 30 tabs of 30/1,000 60 tabs 30 tablets Quantity will be determined at the time of auth approval 30 tablets 2 twinpacks (4 syr) 60 tabs Quantity will be determined at the time of auth approval 240 capsules 30 tabs 6 tablets 30 tabs 8 patches 60 caps 60 tabs 30 tabs 30 patches of one strength 150 gm (2 x 75-gm pumps) 1 tab 30 tabs of one strength 4 vials 30 tablets of one strength 28 tabs of one strength (28-tab bottle) 2 units 4 vials/pens for 28 days 2 pump bottles 30 tabs 30 tabs of one strength 15 vials 56 doses (224 ml) every 60 days 4 doses Quantity will be determined at the time of auth approval 60 tabs 30 tabs Max dose of 16 mg/day Quantity will be determined at time of auth approval Max dose of 24 mg/6 mg per day Quantity will be determined at time of auth approval 2 units 4 patches of one strength 4 doses 1 prefilled pen 30 tablets 10 tabs Quantity will be determined at the time of auth approval 9 pkts 30 tabs of 300 mg/ 60 tabs of 100 mg 30 tabs of either Caverject Impulse: 2 kits of 2 doses each Injection: 6 doses (1 carton) 84 doses/28 days per each 60 days 60 caps (age: 18 yrs and under) 30 caps 60 caps 30 caps 3 vials Adcirca 20 mg Addyi 100 mg Adempas Adzenys XR-ODT, all strengths Adrenaclick Advicor Afinitor Alecensa 150 mg alfuzosin almotriptan 6.25, 12.5 mg Altoprev Alora Amitiza Ampyra ER Amturnide Androderm Androgel Anzemet Aplenzin Arcalyst armodafinil 50, 150, 200, 250 mg Aubagio Auvi-Q Avonex Axiron soln Baraclude Belsomra 5, 10, 15, 20 mg Betaseron Bethkis 300 mg/4 ml Binosto 70 mg Bosulif 100, 500 mg Brilinta 60,90 mg Brisdelle 7.5 mg buprenorphine tabs all strengths buprenorphine/naloxone tabs all strengths butorphanol nasal spray Butrans patches all strengths Bydureon 2 mg Byetta Byvalson cabergoline 0.5 mg Cabometyx 20, 40, 60 mg Cambia 50 mg pwd pks Caprelsa (vandetanib) Cardura XL 4, 8 mg tabs Cayston celecoxib 50 mg celecoxib 100 mg celecoxib 200 mg celecoxib 400 mg Chorionic gonadotropin 5,000, 10,000 units, generic Cialis all strengths Cimzia 200 mg Cimzia starter kit Climara patches Climara Pro patches Coartem codeine Cometriq Continuous glucose sensors Contraceptives Conzip ER Copaxone 20 mg Copaxone 40 mg Cordran patch Cordran tape Corlanor 5, 7.5 mg Cosentyx syr/pens Cotellic 20 mg Cystaran Opth Daliresp 500 mcg Daklinza 30, 60, 90 mg Daytrana 10, 15, 20, 30 mg Desvenalafaxine ER 50 and 100 mg DexCom G4 sensors Diastat/Diastat Acudial/diazepam rectal gel diclofenac gel 1% Dificid 200 mg dihydroergotamine nasal spray 4 mg/ml Duexis 800-26.6 mg Duopa Durlaza Edarbi 40, 80 mg tabs Edarbyclor Edex Edluar 5, 10 mg Effient 5, 10 mg Egrifta 1 mg, 2 mg vials Eliquis 2.5, 5 mg Embeda all strengths Emend Emend Emend Suspension Emsam 6, 9, 12 mg patches 19 4 tabs 6 vials for the first month only; then 2 vials per month 1 starter kit to initiate therapy 4 patches 4 patches 24 tabs Daily doses greater than 480 mg require prior authorization 1 daily dose unit (dose is determined at time of auth) Sof-sensor 10 sensors/30 days Enlite sensors 5 sensors/30 days 1 cycle per month 30 tabs of one strength 30 syrs 12 syrs 24 patches (2 boxes) 2 rolls 60 tabs Quantity will be determined at the time of auth approval 63 tabs/28 days 4 bottles 30 tabs 28 tabs of one strength 30 patches of any strength 30 tabs of one strength 4 sensors 1 box of 2 rectal delivery systems each 5x100 gm tubes 20 tabs 8 units 90 tabs 28 cassettes 30 capsules 30 tabs of one strength 30 tabs of one strength 4 vials OR kits 30 tabs of any strength 36 tabs the first fill, 30 tabs thereafter 30 vials of one strength 60 tabs 60 tabs 125 mg2, 80 mg4 2 of the tri-fold pack 6 packets 30 patches of any strength Quantity Limits: Drug prod Maximum quantity per 30-day supply Drug prod Maximum quantity per 30-day supply Emverm 100 mg Enbrel 12 tablets 25 mg8 syrs, 50 mg4 syrs; greater requires prior authorization 60 tablets 30 tablets Quantity to be determined at time of auth approval Hetlioz 20 mg Horizant ER 300, 600 mg hydrocodone 30 caps 60 tabs of one strength Daily doses greater than 60 mg require prior authorization 30 tabs of one strength 30 tabs Quantity limit varies depending on the diagnosis for which prior authorization was approved 14 bottles (30 ml) 1 tab 21 caps Quantity will be determined at time of auth approval 1 vial every 60 days 90/120 caps (diagnosis determined) 12 nasal spray devices Entresto 49/51 mg and 97/103 mg Envarsus XR, all strengths Epclusa Epi E-Z Pen/EZ Pen Jr epinephrine auto-inject Epipen EpiPen Jr Erivedge 150 mg caps Esclim esomeprazole 20, 40 mg Estraderm Estrasorb Estrogel Evamist exemestane 25 mg Extavia Factive 320 mg Fanapt starter pack Farxiga 5, 10 mg Farydak 10, 15, 20 mg hydromorphone ER (Exalgo equiv) Hysingla ER Humira 2 units IB Oral Spray ibandronate 150 mg Ibrance 75, 100, 125 mg Iclusig 15, 45 mg 2 units 2 units 28 caps/28 days 8 patches 30 caps 8 patches 1 carton of 56 pouches One 50-gm pump 1 metered-dose pump 30 tabs 15 vials 7 tabs 1 pack 30 tabs of one strength Quantity to be determined at time of auth approval fentanyl patches 12, 25, 50, 75, 100 10 patches Fentanyl patches 37.5, 62.5, 87.5 10 patches Ferriprox Quantity to be determined at time of auth approval Fibricor 30 tabs Flector Patches 30 patches Forfivo XL 450 mg 30 tabs Fortesta Gel Pump, 60 gm 1 unit Fosamax Plus D 70 mg/2,800 IU 4 tabs frovatriptan 2.5 mg 9 tabs Fulyzaq 125 mg 60 tabs Gattex 30 doses Gelnique 10% 30 sachets Gelnique 3% 1 gel pump Gilenya 0.5 mg 28 caps/28 days Gleostine 10, 40, 100 mg Quantity to be determined at time of auth approval Golytely 1 pkt Glyxambi 10/5, 25/5 30 tabs Glucagon 2 vials Glucose meter 1 meter every 390 days Glucose meter strips 150 strips Glucose sensors, continuous 10 sensors Gralise 30 of the 300 mg tabs, 90 of the 600 mg tabs, 1 starter kit granisetron 10 tabs Grastek 30 tabs Growth hormone (all) Quantity to be determined at time of auth approval Gynazole 1 1 package Harvoni 28 tabs (length of therapy determined at time of approval) Hepsera 30 tabs Ilaris 180-mg vials Imbruvica 140 mg Imitrex/sumatriptan 5, 20 mg nasal spray Imitrex/sumatriptan/Alsumta syr (injection) 4, 6 mg Infergen 9, 15 mcg I-port Invokamet Invokana 100, 300 mg Jakafi 5, 10, 15, 20, 25 mg Janumet Januvia 25, 50 , 100 mg Jardiance 10, 25 mg Jentadueto all strengths Jentadueto XR 2.5-1000 Jentadueto XR 5-1000 Jublia Juxtapid all strengths Kadian ER 10, 40, 70, 130, 150, 200 mg Kalydeco 150 mg Kalydeco 50-, 75-mg pkts Kapvay ER Kazano and alogliptin/metformin all strengths Kerydin Ketek 300, 400 mg ketorolac Keveyis Kineret Kombiglyze XR 2.5/1,000 Kombiglyze XR 5/500, 5/1,000 Korlym 300 mg Kynamro lamotrigine starter pack Latuda 20, 40, 80, 120 mg Lazanda, all strengths Lenvima 8,10, 14, 18, 20, 24 mg 20 4 syrs/vials 12 vials OR syrs 1 box (10 systems) 60 tabs 30 tabs Quantity will be determined at time of auth approval 60 tabs 30 tabs of one strength 30 tabs 60 tabs of one strength 60 tablets 30 tablets 1 bottle Quantity will be determined at time of auth approval 30 caps of one strength 60 tabs 60 pkts of one strength 60 tabs of any strength/1 dose pack 60 tabs 1 bottle 20 tabs Maximum daily dosage of 40 mg and limited to a five-day supply within a 90-day period Quantity to be determined at time of auth approval Quantity to be determined at time of auth approval 60 tabs 30 tabs Quantity to be determined at time of auth approval 4 doses 1 pack of each strength 30 tabs of any one strength 90 doses Quantity to be determined at time of Quantity Limits: Drug prod Letairis 5, 10 mg Levitra Linzess 145, 290 mg Liptruzet all strengths Livalo 1, 2, 4 mg Lonsurf tablets Lynparza 50 mg Lyrica caps Lyrica oral soln Makena 250 mg/ml, 1 ml vial memantine dose pack methylphenidate CD all strengths Migranal 1 mg/ml Minivelle patch all strengths modafinil 100, 200 mg Monurol Morphine SO4 ER (Kadian equivalent) 20, 30, 50, 60, 80, 100 mg Movantik 12.5, 25 mg Moviprep MuGard Oral Rinse Muse Myalept Maximum quantity per 30-day supply Drug prod Maximum quantity per 30-day supply auth approval 30 tabs 4 tabs 30 caps of one strength 30 tabs of one strength 30 tabs Quantity to be determined at time of auth approval 480 caps Max of 600 mg/day 2x 473 ml 4x 1 ml 1 pack 30 caps of one strength 8 ampules 8 patches 30 tabs of the 100 mg OR 60 tabs of the 200 mg 1 sachet 30 caps Oravig 50 mg Orencia 125 mg syr or Clickjet Orkambi Oseni and alogliptin/pioglitazone- all strengths Osphena 60 mg Otezla 10, 20, 30 mg Otezla starter pack, 14 day/ 28 day oxycodone (short acting) 14 buccal tabs 4 doses 120 tablets 30 tabs Oxycodone ER Oxycontin (all strengths except 80 mg) Oxycontin 80 mg Oxytrol patches all strengths PEG-Intron all strengths Pegasys 180 mcg Peak Flow meters Pennsaid 2% soln Pexeva 10, 40 mg Pexeva 20, 30 mg Picato gel 0.015%, 0.05% Plan B Pomalyst 1, 2, 3, 4 mg 30 tabs 60 tabs 1 starter pack Daily doses greater than 50 mg require prior authorization 120 of the 80 mg OR 90 of all other strengths 120 of the 80 mg OR 90 of all other strengths 120 tabs 8 patches 4 units 4 syrs OR one convenience pack Maximum of 2 per year 2x 112 gm bottle 30 tabs 60 tabs 1 pkg of one strength 1 unit Quantity to be determined at time of auth approval Pradaxa 75, 110, 150 mg 60 caps of one strength Praluent 75 mg, 150 mg 2 doses of one strength Pregnyl 3 vials Prepopik pwd pkt 1 unit Prevacid solutabs 15, 30 mg 30 solutabs Prevpak patient pack 1 pack (14-package size) Pristiq 50, 100 mg 30 tabs of one strength Profasi 3 vials Promacta 12.5, 25, 50 mg 30 tabs of one or more strengths Pulmicort Respules 0.25, 0.5 mg/2ml 70 ampules Qsymia all strengths 30 caps Ragwitek 30 tabs Ranexa 500 mg 60 tabs Rayos 1, 2, 5 mg 30 of the 5 mg OR 60 of 1, 2 mg tabs Rebif all dosage forms 12 units per 28 days Rectiv 0.4% Gel 30 gm Regranex 0.01% gel 15 gm 15 gm/30 days, 45 gm/365 days Relenza 20 blisters (max of 2x 365 days) Relistor all strengths 2 kits (14 vials) OR 15 vials Relpax 20 mg 12 tabs Relpax 40 mg 6 tabs Repatha syringes Quantity to be determined at time of auth approval Repatha Pushtronex 1 unit Requip Starter Kit 1 kit (home delivery or retail) Revlimid all strengths Quantity to be determined at time of auth approval Rexulti 0.25, 0.5, 1,2,3,4 mg 30 tabs of one strength rivastigmine patches, all strengths 4 patches rizatriptan/rizatriptan ODT 5, 10 mg 12 tabs Rozerem 8 mg 30 tabs Samsca 30, 60 mg 10 tabs 30 tabs of one strength 1 bottle 6x 8-oz bottles 4 urethral supp Quantity will be determined at time of auth approval Myrbetriq 25, 50 mg 30 tabs of one strength Namenda XR 30 caps OR one titration pack Namzaric all strengths 30 caps of one strength naratriptan 1, 2.5 mg 9 tabs of one strength Narcan Nasal Spray 4 doses Natesto 3 pumps Natpara Quantity to be determined at time of auth approval Nesina and alogliptin all strengths 30 tabs Nebupent 1 container (inhaler) Neulasta 2 syrs Neumega 21 vials Neupro all strengths 30 patches Nexium pkts 30 pkts next choice 1 unit Nitromist/nitroglycerin spray 1 unit (only 4.1, 4.9 gm size covered) Nuedexta 20-10 mg 60 caps Nuplazid 17 mg 60 tablets Ocaliva 5,10 mg tabs 30 tablets of one strength Odomzo 200 mg capsules 30 capsules Oleptro ER 150, 300 mg tabs 60 of the 150 mg tabs OR 30 of the 300 mg tabs Olysio 150 mg 30 caps Omeclamox-Pack 1 pack Omnaris Nasal 2 units Onglyza 2.5, 5 mg 30 tabs of one strength Onmel 200 mg 28 tabs Onsolis 200, 400, 600, 800, 1200 mcg 90 soluble films of one strength Onzetra Xsail 1 pkt with 8 doses Opsumit 10 mg 30 tabs Oralair 30 tabs (also titrating dose for children) 21 Quantity Limits: Drug prod Maximum quantity per 30-day supply Drug prod Maximum quantity per 30-day supply Sancuso patch 3.1 mg Saphris 2.5, 5, 10 mg Savaysa 15, 30, 60 mg Savella 12.5, 25, 50, 100 mg Saxenda Sidekick monitor Signifor amps Sklice 0.5% Lot sildenafil 20 mg (for PAH) Silenor 3, 6 mg Simponi 50 mg Sivextro 200 mg 1 patch 60 tabs of one strength 30 tabs of one strength 60 tabs of one strength 5 pens 3 units 60 doses 1 tube (4 oz) 90 tabs 30 tabs of one strength One 0.5 ml syr 6 tabs Uptravi dose--pack Uptravi 200, 400, 600, 800, 1000, 1200,1400, 1600 mcg tabs V-go Insulin delivery device Valturna all strengths Vascepa 1 gm Vecamyl Sovaldi 400 mg 28 tabs (length of therapy determined at time of approval) Maximum of 2 per year 2x 120 ml bottles 30 caps 5 bottles ( 1 pkg) 4 ODT tabs 4 tabs 120 tabs 60 caps Qty determined at time of auth approval Qty determined at time of auth approval 4 injections Quantity to be determined at time of auth approval Quantity based on weight 60 tablets 30 tablets Qty determined at time of auth approval 10 caps (max of 2x/365 days) 3 bottles (max of 2x/365 days) 4 doses 1 starter pack OR 60 of the 240 mg caps 1 carton containing 28 days supply 30 tabs of one strength 30 tabs 30 tabs 1 tube of the 20 gm size 1 box of 3 suppositories One 45-gm tube 30 of the 25 mg OR 60 of the 50 mg OR 2x 75-gm bottles 56 ampules every 60 days OR Podhaler, box of 4 weekly packs/ 60 days 30 tabs 30 tabs/caps of one strength 30 tabs 9 tabs 30 tabs of one strength 30 tabs 6 bottles 30 tabs of one strength 1 starter dose-pack Quantity to be determined at the time of auth approval 30 units 30 tabs 120 caps Quantity to be determined at the time of auth approval 1 starting pack 30 tabs 4 tabs (males over 18) 28 day supply (length of therapy determined at time of approval) 30 tabs of one strength 1 package 2 or 3 pens (determined by PA) 360 caps, length of therapy determined by auth Quantity to be determined at the time of auth approval 60 tabs of one strength 20 packets 30 tablets 120 tabs Spacers for Inhalation spinosad 0.9% topical susp Spiriva Sprix nasal spray Staxyn Stendra Stivarga 40 mg Strattera (up to 100 mg daily) Strensiq 18, 28, 40, 80 mg Subsys all strengths Sumavel dosepro Sutent all strengths Sylatron Synjardy, all strengths Tagrisso 40, 80 mg Taltz syringes/pens Tamiflu 75 mg Tamiflu for oral susp 6 mg/ml Tanzeum Pen Injectors Tecfidera Technivie Tekamlo Tekturna all strengths Tekturna HCT all strengths terconazole 3 cream 0.8% Terazol 3 supp terconazole 7 cream 0.4% Testosterone gel TOBI/TOBI Podhaler/ tobramycin neb soln Tradjenta 5 mg tramadol ER tranexamic acid 650 mg Treximet Tribenzor Uceris 9 mg ER tabs Ulesfia lot Uloric 40, 80 mg Venclexta starting pack Vesicare Viagra Viekira Pak/Viekira XR Viibryd Viibryd Starter pack Victoza Victrelis 200 mg Viekira/Viekira XR Vimovo Vistogard 10 gm Vivlodex 5 mg, 10 mg Votrient 200 mg Vogelxo gel Vytorin Xalkori Xartemis XR Xeljanz 5 mg Xeljanz XR 11 mg Xiidra Eye Drops Xtampza XR 9, 13.5, 18, 27, 36 mg Xtandi 40 mg zaleplon 5 mg zaleplon 10 mg Zegerid Zelboraf 240 mg Zembrace 4 mg syr Zetia Zinbryta 150 mg syringes Zohydro ER zolmitriptan/zolmitriptan ODT 2.5, 5 mg tabs zolpidem 5, 10 mg zolpidem ER 6.25, 12.5 mg zolpidem sublingual, 1.75, 3.5 mg Zolpimist Zomig nasal spray Zortress 0.25, 0.5, 0.75 mg Zuplenz film strips Zydelig 100, 150 mg Zykaydia 150 mg Zytiga 250 mg 22 30 tubes OR 30 pkts OR 2x 75-gm gel pumps 30 tabs 60 caps of one strength 120 tabs 60 tabs 30 tabs 1 pkt of 60 90 capsules 120 caps 30 caps 60 caps 30 packs 240 tabs 2 pkts of 4 syringes 30 tabs 4 syringes 60 tabs 6 tabs 30 tabs 30 tabs 30 tabs 7.7 ml (1 bottle) 6 bottles 60 tabs 10 strips 60 tabs of one strength 150 caps 120 tabs Inhaler/Ophthalmic Quantity Limits: Drug prod Strength per dose Package size Maximum 30-day Maximum 90-day supply (retail) supply (home delivery) Advair Diskus Advair Diskus Aerospan Alvesco Alupent (metaproterenol) Anoro Ellipta (umeclidinium/vilanterol) Arcapta Neohaler /caps (indacaterol maleate) Arnuity Ellipta Asmanex (mometasone) Asmanex HFA (mometasone) azelastine Nasal Spray (astelin equiv) azelastine Nasal Spray (astepro equiv) Atrovent HFA Beconase AQ Bevespi Aerosphere Breo Ellipta Breo Ellipta Brovana Children’s Qnasl Combivent Respimat Dulera DuoNeb Flonase AQ flunisolide Foradil Aerolizer/Caps Foradil Aerolizer/Caps Incruse Ellipta Intal Inhaler Intal Inhaler ipratropium nasal inhaler 0.06% ipratropium nasal inhaler 0.03% Maxair Autohaler mometasone nasal Pazeo ophthmalic Perforomist ProAir HFA Proventil HFA Pulmicort Turbuhaler budesonide Respules Qnasal nasal spray ` Qvar Rhinocort AQ Seebri Neohaler Serevent Diskus Serevent Diskus Spiriva Respimat Stiolto Respimat Striverdi Respimat Symbicort 100/50, 250/50, 500/50 100/50, 250/50, 500/50 80 mcg 80 mcg and 160 mcg 0.65 mg 62.5 mcg/vilanterol 25 mcg 75 mcg 100 mcg, 200 mcg 220 mcg 100 mcg, 200 mcg 137 mcg 0.15% 14 mcg 42 mcg 9/4.8 mcg 100 mcg/25 mcg 200 mcg/25 mcg 15 mcg 40 mcg 20/120 mcg 100 mcg/5 mcg, 200 mcg/5 mcg 2.5-0.5/3 ml 50 mcg 25 mcg 12 mcg 12 mcg 62.5 mcg 800 mcg 800 mcg 42 mcg 21 mcg 200 mcg 50 mcg 0.7% 20 mcg 90 mcg 90 mcg 200 mcg 0.25, 0.5 mg, 1 mg 80 mcg 40 mcg and 80 mcg 32 mcg 15.6 mcg 50 mcg 50 mcg 1.25 mcg and 2.5 mcg 2.5 mcg/2.5 mcg 2.5 mcg 80/4.5, 160/4.5 28 blisters 60 blisters 8.9 gm (120 doses) 6.1 gm 14 gm 1 units (30 doses) 30 caps 30 doses 30, 60, 120 doses 13 gm (120 doses) 30 ml 30 ml 12.9 gm 25 gm 120 doses 60 doses 60 doses 60 doses 60 doses (1 unit) 4 gm 13 gm 3 ml 16 gm 25 ml 18 60 30 doses (1 unit) 8.1 gm 14.2 gm 15 ml 30 ml 14 gm 17 gm 4 ml 60 dose box 8.5 gm 6.7 gm 200-dose 30-dose box 8.7 gm 7.3 gm 8.6 gm 60 inhalations 28/box 60/box 60 doses 60 inhalations 60 inhalations 60 inhalations 1 2 2 2 3 1 1 1 2 1 2 bottles 2 bottles 2 2 1 canister 1 unit 1 unit 1x 60 1 unit 3 2 210 2 3 4 2 1 2 2 3 2 1 2 1 1 2 2 2 2 1 3 3 1 1 2 1 1 1 2 Symbicort Tilade Tudorza Pressair 400 mcg Utibron Neohaler Ventolin HFA 80/4.5, 160/4.5 1.75 mg 400 mcg 27.5/15.6 mcg 90 mcg 120 inhalations 16.2 gm 60 inhalations 60 inhalations 18 gm 2 3 1 1 2 Inhalers 23 0 6 6 6 9 3 3 3 6 3 6 bottles 6 bottles 6 6 3 canisters 2 units 2 units 3x 60 3 units 9 6 630 6 9 0 6 3 6 6 9 6 3 6 3 3 6 6 6 6 3 9 9 3 0 6 3 3 3 6 of the 120-inhalations (60-inhalation canister not covered by mail) 6 9 3 3 6 Inhaler/Ophthalmic Quantity Limits: Drug prod Strength per dose Package size Maximum 30-day Maximum 90-day supply (retail) supply (home delivery) Veramyst Nasal Spray Xopenex HFA inhaler Zetonna nasalsSpray 27.5 mcg 45 mcg 37 mcg 10 gm 15 gm 6.1 2 2 1 24 6 6 3 Index A Abilify, see aripiprazole Absorbica, 5.3 Abstral SL, 3.1.1 Acanya, 5.3 acarbose, 7.5.2 Accu-Chek, 7.5.4 Accu-Chek Active, 7.5.4 Accu-Chek Aviva Plus/Connect, 7.5.4 Accu-Chek Compact Plus, 7.5.4 Accu-Chek Safe-T-Pro, 7.5.4 Accu-Chek Smartview, 7.5.4 Accu-Chek Softclix, 7.5.4 Accu-Chek SoftTouch, 7.5.4 acetaminophen/codeine, 3.1.2 Acetazolamide, 12.5 acetic acid, acetic acid HC, 6.2 acetylcysteine, 13.3.6 Aciphex, 8.1.4 and see rabeprazole Aclovate, see alclometasone Actemra, 10.3.2 Acthar H.P., 7.3 Acticlate, 1.2 Actimmune, 9.1.3 actinin, 5.11 acitretin, 5.10 Actonel, see risedronate Actonel with Calcium, 10.4 Actoplus Met XR, 7.5.2 Acuvail , 12.7 acyclovir, 5.6 Aczone, 5.3 adapalene, 5.3 Adapalene, 5.3 Adcirca, 13.3.6 Adderall, 3.9.4 Adderall XR, 3.9.4 Addyi, 3.9.4 adefovir dipovoxil, 1.8.1 Adempas, 13.3.6 Adrenaclick, 13.3.6 Advair Diskus, Advair HFA, 13.3.6 Advicor, 4.6 Adzenys XR-ODT, 3.9.4 Aerospan, 13.3.4 Afrezza, 7.5.1 Afinitor, 2.1.6 Aggrenox, see aspirin/dipyridamole Akurza, 5.9 alagesic, 3.4.1 albuterol, 13.3.3 albuterol/ER tabs, 13.3.3 Alcet, 3.1.1 Alclometasone, 5.1.4 Alcortin-A, 5.4 Aldex Chewables, 13.1.1 Alecensa, 2.1.6 alendronate, 10.4 Alevicyn, 5.12 Alfuzosin , 14.5 Alinia, 1.11.1 All factor prods, 4.4.5 allanderm-T, 5.12 allopurinol, 10.2 Allzital, 3.1.2 almotriptan, 3.4.1 Alocril, 12.15 alogliptin, 7.5.2 alogliptin/metformin, 7.5.2 alogliptin/pioglitazone, 7.5.2 Alomide, 12.15 Alora, 11.3.2 alosetron, 8.3.3 alprazolam, 3.9.5 alprazolam ER, 3.9.5 alprazolam ODT, 3.9.5 Alrex, 12.11 Alsuma, 3.4.1 Altabax, 5.4 Altoprev, 4.6 aluminum acetate, 5.12 Aluvea, 5.12 Alvesco, 13.3.4 Amcinonide, 5.1.2 amiloride, 4.5.1 amiloride /HCTZ, 4.5.1 amino acid vaginal cream, 11.4.2 Aminocaproic Acid, 4.4.5 aminocaproic acid, 4.4.5 amiodarone, 4.1 Amitiza, 8.3.3 amitriptyline, 3.9.2.1 amlodipine, 4.5.3.2 amlodipine/benazepril, 4.5.8 amlodipine/valsartan, 4.5.8 amlodipine/valsartan/HCTZ, 4.5.8 amnesteem, 5.3 amoxicillin, 1.1 Amoxicillin ER, 1.1 amoxicillin/potassium clavulanate, 1.1 amphetamine salt combo, 3.9.4 amphetamine salt combo ER, 3.9.4 ampicillin, 1.1 Ampyra, 3.7 Amturnide, 4.5.9 Anadrol-50, 7.4.1 anagrelide, 2.1.6 Analpram HC, 8.3.3 AnaMantle HC, 8.3.3 AnaMantle HC Forte Cream, 8.3.3 anastrozole, 2.1.6 Androderm, 7.4.1 Androgel, 7.4.1 Androgel packets, see testosterone Angeliq, 11.3.3 Anoro Ellipta, 13.3.6 antipyrine/benzocaine, 6.2 antispasmodic elixir, 8.2.3 Anzemet, 8.3.4 apap/caffeine/dihydrocodeine, 3.1.2 Apidra, 7.5.1 Aplenzin, 3.9.2.2 Apokyn, 3.5 Apop, 5.3 Apriso, 8.3.3 Aptensio XR. 3.9.4 Aptiom, 3.6 Aquaphilic/Triamcin , 5.12 Aquoral, 6.4 Aptensio XR, 3.9.4 Aralast, 16.1 Aranesp, 9.1.1 Arcalyst, 9.1.5 Arcapta, 13.3.3 Arginaid, 15.4.1 Aricept, see donepezil aripiprazole/aripiprazole odt, 3.9.3.3 armodafinil, 3.9.4 Armour Thyroid, 7.2 Arnuity Ellipta, 13.3.4 Asacol HD, 8.3.3 Asmalpred Plus, 7.3 Asmanex/HFA, 13.3.4 aspirin/dipyridamole, 4.4.2 Astagraf XL, 2.1.6 AsTech, 7.5.4 Astepro, see azelastine nasal Asthma Mentor, 7.5.4 Asthma Pack III, 7.5.4 Atelvia, see risedronate, dr atenolol, 4.5.2 atenolol/chlorthalidone, 4.5.8 Atopiclair, 5.12 atorvastatin, 4.6 atorvastatin/amlodipine, 4.6 atovaquone, 1.11.2 atovaquone-proguanil, 1.11.3 Atrapro, 5.12 atropine, 12.6 Atrovent HFA, 13.3.6 Atrovent, 13.3.6 Aubagio, 3.7 Aurax, 6.2 Auvi-Q, 13.3.6 Avandamet, 7.5.2 Avandaryl, 7.5.2 Avandia, 7.5.2 Avar/Avar LS, 5.3 Avar-E LS, 5.3 Avelox, Avelox ABC, see moxifloxacin Avidoxy, 1.2 Avinza, see morphine SO4 ER Avita, 5.3 Avodart, see dutasteride Avonex, 9.1.3 Axert, see almotriptan Axiron, 7.4.1 Azasite, 12.9 azathioprine, 2.1.6 azelastine, 12.15 azelastine, 6.4 Azelex, 5.3 Azilect, 3.5 azithromycin, 1.4.1 Azmacort , 13.3.4 Azopt, 12.4 Azor, 4.5.8 Azulfidine En-Tab, 8.3.3 B baclofen, 3.8.1 balsalazide, 8.3.3 Banzel, 3.6 B-D prods, 7.5.4 Beconase AQ, 13.3.5 belladonna/phenobarb, 8.2.3 Belsomra, 3.9.1 Belviq, 16.3 benazepril, 4.5.4 benazepril HCT, 4.5.8 bendroflumethiazide, 4.5.8 Benicar, 4.5.9 Benicar HCT, 4.5.8 25 Benzaclin, see clindamycin/benzoyl peroxide Benzefoam Ultra, 5.3 Benzefoam, 5.3 benzonatate, 13.2.1 benzoyl peroxide, 5.3 benzphetamine, 16.3 benztropine, 3.5 Bepreve, 12.15 Besivance, 12.9 betamethasone, 1.9 Betamethasone, 5.1.2 Betaseron, 9.1.3 betaxolol, 4.5.2 Betaxolol, 12.1 bethanechol, 14.1 Bethkis, 1.11.1 Betimol, 12.1 Betoptic S, 12.1 Bevespi, 13.3.6 bexarotene, 2.1.6 Beyaz 28, 11.1.1 bicalutamide, 2.1.6 bicarbonate, 8.1.4 Bicillin CR/Bicillin LA, 1.1 BiDil, 4.5.7 bimatoprost, 12.4 Binosto, 10.4 bisoprolol fumarate, 4.5.2 bisoprolol fumarate /HCTZ, 4.5.8 borofair otic, 6.2 Bosulif, 2.1.6 BP wash, 5.3 Benzoyl, 5.3 Bevespi, 13.3.6 BPS gel, 5.3 Breeze-2 (Bayer), 7.5.4 Breo Ellipta, 13.3.6 Brevoxyl, 5.3 Bright Beginnings Bar, 15.1 Brilinta, 4.4.2 brimonidine tartrate , 12.14 Brintellix, see Trintellix Bionect, 5.12 Brisdelle, 3.9.2.4 Briviact, 3.6 bromfenac, 12.7 bromocriptine mesylate, 3.5 Briviact, 3.6 Brovana, 13.3.3 budesonide ec, 8.3.3 budesonide nasal, 13.3.5 budesonide neb, 13.3.4 bumetanide, 4.5.1 buprenorphine tabs, 3.1.1 buprenorphine/naloxone, 3.1.2 bupropion HCl, SR, XL, 3.9.2.2 bupropion SR, 16.2 buspirone HCl, 3.9.5 butalbital compound, 3.4.1 butalbital/apap, 3.4.1 butorphanol, 3.3.3 Butrans, 3.1.1 Bydureon, 7.5.2 Byetta, 7.5.2 Bystolic, 4.5.2 Byvalson, 4.5.8 C Cabergoline, 7.4.3 Cabometyx, 2.1.6 Index calcipotriene/betamethasone, 5.10 calcipotriene oint/soln/cream, 5.1 Calcitrene, 5.1 calcitriol, 7.4.3 Calcitriol, 5.1 calcium acetate , 15.3.2 Cambia, 3.3.1 Campral, 3.9.4 Canasa, 8.3.3 candesartan, 4.5.9 candesartan/HCTZ, 4.5.9 capecitabine, 2.1.2 Caphosol, 6.4 Caprelsa (vandetanib), 2.1.6 captopril, 4.5.4 captopril /HCTZ, 4.5.8 Carac, 5.12 Carbaglu, 16.1 carbamazepine ER, 3.6 carbamazepine/XR, 3.6 carbidopa/levodopa, 3.5 Carb-o-philic, 5.12 Cardene SR, 4.5.3.2 Cardizem LA, 4.5.3.2 Cardura XL, 4.5.5 carisoprodol, 3.8.1 carteolol HCl, 12.1 cartia XT, 4.5.3.2 Cartrol, 4.5.2 carvedilol, 4.5.2 Catapres-TTS, see clonidine Caverject, 14.4 Cayston, 1.11.1 Cedax, see ceftibuten cefaclor/cefaclor ER, 1.3 cefadroxil, 1.3 cefditoren pivoxil, 1.3 cefixime, 1.3 ceftibuten, 1.3 Celebrex, see celecoxib celecoxib, 3.3.1 Cellcept, see mycophenolate mofetil cem-urea, 5.12 Cenestin, 11.3.2 Cerdelga, 7.4.3 Cerezyme, 7.4.3 Cetraxal, 6.2 Cetrotide, 7.4.4 Cetylev, 16.8 cevimeline, 6.4 Chantix, 16.2 Chenodal, 8.3.3 Children’s Qnasl, 13.3.5 chlorhexidine rinse, 6.4 chloroquine, 1.11.3 chlorothiazide, 4.5.1 chlorpheniramine drops, 13.2.1 chlorzoxazone, 3.8.1 Cholbam, 8.3.1 cholestyramine/light, 4.6 choline and magnesium trisalicylate, 3.3.2 Cialis, 14.4 ciclopirox, 5.5 cilostazol, 4.4.2 Ciloxan, 12.9 cimetidine, 8.1.1 Cimzia, 8.3.3 Cinryze, 13.3.6 Cipro HC, 6.2 Cipro Susp, see ciprofloxacin Cipro XR, see ciprofloxacin ER Ciprodex, 6.2 ciprofloxacin, 1.5.1 ciprofloxacin ER, 1.5.1 ciprofloxacin, 6.2 ciprofloxin, 12.9 citalopram, 3.9.2.4 claravis, 5.3 Clarinex D, 13.2.3 clarithromycin, 1.4.1 clarithromycin ER, 1.4.1 Cleocin, 11.4.2 Climara , 11.3.2 Climara Pro, 11.3.3 clindamycin HCl, 1.11.1 clindamycin phosphate, 5.3 clindamycin vag cream, 11.4.2 clindamycin/benzoyl peroxide, 5.3 clindamycin/tretinoin, 5.3 Clindareach, 5.3 Clindesse, 11.4.2 clobetasol propionate , 5.1.1 Clocortolone Pivalate, 5.1.3 Cloderm, 5.1.3 clomiphene, 7.4.2 clomipramine, 3.9.2.1 clonazepam, 3.6 clonidine, 4.5.5 clonidine patch, 4.5.5 clopidogrel, 4.4.2 clopidogrel, 4.4.2 clotrimazole troche, 1.9 clotrimazole/betamethasone, 5.5 clozapine/clozapine ODT, 3.9.3.3 Coartem, 1.11.3 Codeine SO4, 3.1.1 Colchicine, 10.2 Colcrys, 10.2 Colestid, 4.6 colestipol, 4.6 CoLyte, 8.3.3 Combigan, 12.4 Combipatch, 11.3.3 Combivent Respimat, 13.3.6 Cometriq, 2.1.6 Compazine, see prochlorperazine Condylox, 5.12 Continuous glucose monitoring sensors, 7.5.4 Continuous glucose monitoring system, 7.5.4 Contour test strips, 7.5.4 Contour Next test strips, 7.5.4 Contrave, 16.3 Conzip ER, 3.3.3 Copaxone, 9.1.3 Cordran, 5.1.3 Coreg CR, 4.5.2 Corlanor, 4.7 cortisone, 7.3 Cosentyx, 5.10 Cosopt PF, 12.4 Cotellic, 2.1.6 covaryx, 11.3.3 covaryx HS, 11.3.3 Creon, 8.3.2 Cresemba, 1.9 Crestor, see rosuvastatin Crinone, 11.3.1 cromolyn sodium, 13.3.6 cromolyn sodium, 12.15 Cuvposa, 8.2.2 cyclobenzaprine/ cyclo-benzaprine ER, 3.8.1 cyclopentolate, 12.6 cyclophosphamide, 2.1.6 Cyclophosphamide, 2.1.6 Cycloset, 7.5.2 cyclosporine, 2.1.6 Cyclosporine, 2.1.6 Cymbalta, see duloxetine cyproheptadine, 13.1.1 Cystadane, 8.3.3 Cystaran, 12.15 D Daklinza, 1.8.1 Daliresp, 13.3.6 danazol, 7.4.1 dantrolene, 3.8.1 dapsone, 1.11.1 darifenacin, 14.2 Daytrana, 3.9.4 DDAVP, 7.4.3 Delestrogen, 11.3.2 Delos, 5.3 Delzicol, 8.3.3 demeclocycline, 1.2 Depo-SubQ Provera, 11.3.1 Dermatop E, 5.1.3 desipramine, 3.9.2.1 desloratadine, 13.1.1 desmopressin, 7.4.3 Desonate, 5.1.4 Desonide, 5.1.4 Desoximetasone, 5.1.4 Desoxyn, 3.9.4 Desvenlafaxine, 3.9.2.2 Detrol LA, see tolterodine ER dexamethasone, 7.3 dexamethasone, 12.11 DexCom SEVEN Plus/G4 Platinum, 7.5.4 Dexedrine, 3.9.4 Dexilant (formerly Kapidex), 8.1.4 dexmethylphenidate, 3.9.4 dexmethylphenidate ER, 3.9.4 dextroamphetamine, 3.9.4 Diastat/Diastat Acudial, 3.6 diazepam, 3.9.5 diazepam rectal gel, 3.6 Dibenzyline, see phenoxybenzamine Diclegis, 8.3.4 diclofenac, 3.3.1 diclofenac gel 1%, 3.3.1.1 diclofenac-misoprostol, 3.3.1 dicloxacillin, 1.1 dicyclomine, 8.3.2 Didronel, see etidronate diethylpropion, 16.3 Differin, 5.3 Differin, see adapalene Dificid, 1.11.1 Difil-G/Forte, 13.3.1 diflorasone diacetate , 5.1.1 diflunisal, 3.3.2 26 digoxin, 4.2 dihydroergotamine, 3.4.1 diltiazem, diltiazem ER, diltiazem SR, diltiazem SA, 4.5.3.2 Diovan, see valsartan Dipentum, 8.3.3 Diphenoxylate/atropine, 8.2.1 Diprolene, Diprolene AF, 5.1.2 dipyridamole, 4.4.2 disopyramide phosphate, 4.1 dispas, 8.3.2 disulfiram, 3.9.4 divalproex/ER/sprinkes, 3.6 Divigel, 11.3.2 dofetilide, 4.1 Dologesic, 3.3.3 Domeboro otic, 6.2 donepezil/donepezil ODT, 3.7 Doryx, 1.2 Doryx MPC, 1.2 dorzolamide HCl, 12.4 dorzolamide HCl/timolol, 12.4 Dovonex, 5.1 doxazosin mesylate, 4.5.5 doxepin, 3.9.2.1 doxepin cream 5.12 doxercalciferol, 7.4.3 doxycycline, 1.2 doxycycline hyclate/ monohydrate/ER/DR, 1.2 Doxycycline IR/ER, 1.2 drithocreme HP, 5.1 dronabinol, 8.3.4 Duavee, 11.3.3 Duexis, 3.3.1 Dulera, 13.3.6 duloxetine, 3.9.2.2 Duoneb, see ipratropium/ albuterol Duopa, 3.5 dutateride, 14.5 Durabac, 3.8.1 Durasal, 5.9 Duraxin, 3.3.2 Durezol, 12.11 Durlaza, 4.4.2+ dutasteride/tamsulosin, 14.5 Dutoprol, 4.5.8 Dyanavel XR, 3.9.4 dyphylline, 13.3.1 Dyrenium, 4.5.1 E EasiVent chamber, 7.5.4 Easy Touch syrs, 7.5.4 econazole, 5.5 Ecoza, 5.5 Edarbi, 4.5.9 Edarbyclor, 4.5.9 Edecrin , see ethacrynic acid Edex, 14.4 Edluar, 3.9.1 Effer-K, 15.3.1 Effient, 4.4.2 Egrifta, 9.1.4 Elaprase, 7.4.3 Elelyso, 10.4 Elestrin, 11.3.2 Elidel, 5.12 Eligen B12, 15.1 Eliquis, 4.4.1 Index Elmiron, 14.4 Elocon, 5.1.3 Emadine, 12.15 Embeda, 3.1.1 Emend, 8.3.4 Emsam, 3.9.2.3 Emverm, 1.11.2 Enablex, see darifenacin enalapril maleate, 4.5.4 enalapril maleate /HCTZ, 4.5.8 Enbrel , 10.3.2 Endocet, 3.1.2 Endometrin, 11.3.1 Enjuvia, 11.3.2 enoxaparin, 4.4.3 Enstilar, 5.10 entacapone, 3.5 entacapone, 3.5 entecavir, 1.8.1 Entresto, 4.7 Envarsus XR, 2.1.6 Epclusa, 1.8.1 Epiduo/Epiduo Forte, 5.3 Epinastine, 12.15 epinephrine, 13.3.6 EpiPen/EpiPen Jr, 13.3.6 Epivir-HBV, see lamivudine eplerenone, 4.5.1 Epogen, 9.1.1 epoprostenol, 4.5.7 eprosartan, 4.5.9 eprosartan/HCTZ, 4.5.9 Equetro, 3.6 Erivedge, 2.1.6 Ertaczo, 5.5 Erythromycin , 12.9 Erythromycin , 1.4.1 erythromycin , 5.3 erythromycin/benzoyl peroxide, 5.3 Esbriet, 13.3.6 escitalopram, 3.9.2.4 esomeprazole, 8.1.4 estazolam, 3.9.1 Estraderm, 11.3.2 estradiol, 11.3.2 estradiol/norethindrone, 11.3.3 Estrasorb, 11.3.2 Estring, 11.3.2 Estriol, 11.3.2 Estrogel, 11.3.2 estropipate, 11.3.2 eszopiclone, 3.9.1 ethacrynic acid, 4.5.1 ethosuximide, 3.6 etidronate, 16.1 etodolac, 3.3.1 Eurax, 5.11 Evamist, 11.3.2 Evekeo, 3.9.4 Evista, see raloxifene Exalgo ER, see hydromorphone ER Exelderm, 5.5 Exelon, see rivastigmine exemestane, 2.1.6 Exforge, see amlodipine/ valsartan Exforge HCT, see amlodipine/ valsartan/HCTZ Extavia, 9.1.3 Fragmin, 4.4.3 Free Style, 7.5.4 & 7.5.5 Frova, see frovatriptan frovatriptan, 3.4.1 Fulyzaq, 8.2.1 furosemide, 4.5.1 Fuzeon, 1.8.2 Fycompa, 3.6 F Fabrazyme, 7.4.3 Factive, 1.5.1 famotidine, 8.1.1 Fanapt, 3.9.3.3 Farxiga, 7.5.2 Farydak, 2.1.6 Fazaclo ODT, 3.9.3.3 felbamate, 3.6 felodipine, 4.5.3.2 Fem pH, 11.4.2 Femring, 11.3.2 Femtrace , 11.3.2 fenofibrate, 4.6 Fenofibrate, 4.6 Fenofibric Acid, 4.6 Fenoglide, 4.6 Fenoprofen, 3.3.1.1 Fenortho, 3.3.1.1 fentanyl oral transmucosal, 3.1.1 fentanyl, 3.1.1 Fentanyl, 3.1.1 Fentora buccal tabs, 3.1.1 Ferriprox, 16.1 Fetzima, 3.9.2.2 Fibricor, 4.6 Finacea, 5.3 finasteride , 14.5 Firazyr, 13.3.6 flavoxate, 14.2 flecainide, 4.1 Flector, 3.3.1 Floriva, 15.1 Flo-Pred, 7.3 Flovent Diskus, 13.3.4 Flovent HFA , 13.3.4 Flowtuss, 13.2.1 fluconazole, 1.9 flucytosine, 1.9 flunisolide, 13.3.5 fluocinolone, 5.1.4 fluocinolone, 6.2 fluocinonide, 5.1.2 fluorometholone, 12.11 Fluorouracil, 5.12 fluoxetine, 3.9.2.4 fluoxetine, 3.9.2.4 fluphenazine, 3.9.3.3 flurandrenolide, 5.1.3 flurazepam, 3.9.1 flutamide, 2.1.6 fluticasone, 13.3.5 fluticasone, 5.1.3 fluvastatin, 4.6 fluvastatin ER, 4.6 fluvoxamine ER, 3.9.2.4 fluvoxamine maleate, 3.9.2.4 FML Forte, 12.11 Focalin XR, 3.9.4, also see dexmethylphenidate ER fondaparinux, 4.4.3 Foradil, 13.3.3 Forfivo XL, 3.9.2.2 Formaldehyde, 16.1 Forteo, 10.4 Fortesta, 7.4.1 Fortical, 10.4 Fosamax plus D, 10.4 fosinopri/HCTZ, 4.5.8 fosinopril, 4.5.4 Fosrenol, 16.1 G gabapentin, 3.6 Gabitril, 3.6 galantamine, 3.7 galantamine ER, 3.7 Gammagard, 9.2 Gammaked, 9.2 Gamunex-C, 9.2 Ganirelix, 7.4.4 Garimide, 5.3 Gastrinex NF, 8.3.2 gatifloxacin, 12.9 Gattex, 8.3.3 gavilyte, 8.3.5 Gelnique, 14.2 Gelx, 6.4 gemfibrozil, 4.6 Generess FE, 11.1.1 gengraf, 2.1.5 Genotropin, 9.1.4 gentamicin, 5.4 gentamicin, 12.9 Giazo, 8.3.3 Gilotrif, 2.1.6 Gilenya, 3.7 Glassia , 16.1 Gleevec, see imatinib Gleostine, 2.1.6 glimepiride, 7.5.2 glipizide/glipizide ER, 7.5.2 Glucagon, 7.5.3 Glumetza, see metformin ER (glumetza equiv) glyburide, 7.5.2 glycopyrolate, 8.3.2 Glyset, see miglitol Glyxambi, 7.5.2 Gralise, 3.6 granisetron, 8.3.4 Granix, 9.1.2 Grastek, 9.2 griseofulvin, 1.9 guaifenesin /codeine, 13.2.1 guanabenz acetate, 4.5.5 guanfacine, 4.5.5 guanfacine ER, 3.9.4 Guardian RT, 7.5.4 Gynazole 1, 11.4.3 H Halflytely, 8.3.3 halobetasol propionate , 5.1.1 Halog, Halog E, 5.1.2 haloperidol, 3.9.3.3 HC, 8.3.3 hcl/chlor-mal, 13.2.3 hc-pramoxine, 8.3.3 Hectorol, see doxercalciferol Hemangeol, 4.5.2 Hepsera, see adefovir dipivoxil Hetlioz, 3.9.1 Hizentra, 9.2 27 Horizant ER, 3.6 HPR, HPR Plus, 5.12 Humalog, Humalog Mix, 7.5.1 Humatrope, 9.1.4 Humira, 10.3.2 Humulin, 7.5.1 Hycamtin, 2.1.6 Hycofenix, 13.2.1 Hydralazine, 4.5.7 Hydro, 5.12 hydrochlorothiazide, 4.5.1 hydrocodone/apap, 3.1.2 hydrocodone/cpm/ pseudoephedrine, 13.2.1 hydrocodone/ibuprofen, 3.1.2 hydrocortisone, 7.3 hydrocortisone rectal, 8.3.3 hydrocortisone, 5.1.4 hydrocortisone/aloe , 5.1.4 hydrocortisone butyrate, 5.1.3 hydrocort-pramox, 5.1 hydro-iodoquinol 2-1, 5.4 hydrocortisone/iodoquinol/aloe, 5.4 hydromorphone, 3.1.1 hydromorphone ER, 3.1.1 hydroxychloroquine, 1.11.3 hydroxyurea, 2.1.6 hydroxyzine, 13.1.1 Hylase, 5.12 Hylira, 5.12 Hyoscyamine, 8.2.2 Hyper-Sal, 13.3.6 Hyqvia, 9.2 Hysingla ER, 3.1.1 I ibandronate, 10.4 Ibrance, 2.1.1 IB-Stat, 8.3.2 ibuprofen, 3.3.1 Iclusig, 2.1.6 Ilaris, 9.1.5 Ilevro, 12.7 imatinib, 2.1.6 Imbruvica, 2.1.6 imipramine, 3.9.2.1 Imipramine PM, 3.9.2.1 imiquimod, 5.12 Impavido, 1.11.2 Increlex, 16.1 Incruse Ellipta, 13.3.6 indapamide, 4.5.1 Inderal LA, see propranolol LA indomethacin/SR, 3.3.1 Infergen, 9.1.3 Inlyta, 2.1.6 Innopran XL, 4.5.2 Inova Easy Pads, 5.3 Intermezzo, see zolpidem sublingual Intron A, 9.1.3 Intuniv ER, see guanfacine ER Invega, see paliperidone ER Invokamet, 7.5.2 Invokana, 7.5.2 Iopidine, 12.14 I-port, 7.5.4 ipratropium, 13.3.5 Index ipratropium, 13.3.6 Ipratropium/albuterol, 13.3.6 Iprivask, 4.4.1 irbesartan, 4.5.9 irbesartan /HCTZ, 4.5.9 Iressa, 2.1.6 isometh/caffeine/apap, 3.4.1 isosorbide, 4.3 isradipine, 4.5.3.2 Istalol, 12.1 itraconazole, 1.9 ivermectin, 1.11.2 J Jadenu, 16.1 Jakafi, 2.1.6 Jalyn, see dutasteride/tamsulosin jantoven, 4.4.1 Janumet/Janumet XR, 7.5.2 Januvia, 7.5.2 Jardiance, 7.5.2 Jentadueto, 7.5.2 Jentadueto XR, 7.5.2 jinteli, 11.3.3 Jublia, 5.5 Juxtapid, 4.6 K K-tabs 8 mEq, 15.3.1 Kadian ER, 3.1.1 Kalydeco, 13.3.6 Kapvay ER, 3.9.4 Karbinal ER, 13.1.1 Kazano, 7.5.2 Kerafoam, 5.12 Keralac, see urea Keratol HC, 5.12 Kerol AD, 5.12 Kerol Redi-Cloths, 5.12 Kerydin, 5.5 Ketek, 1.11.1 ketoconazole tab, 1.9 ketoconazole cream/shampoo, 5.5 ketoprofen, 3.3.1 ketorolac, 3.3.1 ketorolac, 12.7 Keveyis, 3.7 Kineret, 10.3.2 Kombiglyze XR, 7.5.2 Korlym, 7.4.3 Kristalose, 8.3.3 Kuvan, 7.4.3 Kynamro, 4.6 L labetalol, 4.5.2 Lactulose, 8.3.3 LAGesic, 3.3.3 Lamictal ODT, see lamotrigine ODT lamuvidine/HBV, 1.8.1 lamotrigine/lamotrigine ODT/lamotrigine ER, 3.6 Lanoxin, 4.2 and see digoxin lansoprazole, 8.1.4 lansoprazole ODT, 8.1.4 Lantus, 7.5.1 Lantus Solostar, 7.5.1 Lastacaft, 12.15 latanoprost, 12.4 Latrix XM, 5.12 Latuda, 3.9.3.3 Layolis FE, 11.1.1 Lazanda, 3.1.1 leflunomide, 2.1.6 Lenvima, 2.1.6 Lescol XL, see fluvastatin ER Letairis, 13.3.6 letrozole, 2.1.6 Leukine, 9.1.2 leuprolide, 2.1.6 levalbuterol, 13.3.3 Levatol, 4.5.2 Levemir, 7.5.1 Levemir Flex Pen/Flex Touch, 7.5.1 levetiracetam, 3.6 levetiracetam ER, 3.6 Levitra, 14.4 levobunolol HCl , 12.1 levocetirizine, 13.1.1 levocetirizine, 13.1.1 levofloxacin 0.5%, 12.9 levofloxacin, 1.5.1 levothroid, 7.2 levothyroxine sodium, 7.2 levoxyl, 7.2 Lexxel, 4.5.8 Lialda, 8.3.3 lidocaine, 5.2 Lidocaine 3%/, 8.3.3 lidocaine HCI, 5.2 lidocaine-HC, 8.3.3 lidocaine-prilocaine, 5.2 lidocaine-tetracaine, 5.2 Lidoderm, see lidocaine patches LifeScan, 7.5.4 Lileta, 11.4.5 Lindane, 5.11 linezolid, 1.11.1 Linzess, 8.3.3 liothyronine sodium, 7.2 Lipofen, 4.6 Liptruzet, 4.6 lisinopril, 4.5.4 lisinopril /HCTZ, 4.5.8 Livalo, 4.6 Locoid, 5.1.3 and see hydrocortisone butyrate lodocortisone, 5.3 Lodosyn, see carbidopa Lofibra, 4.6 Lonsurf, 2.1.6 lorazepam, 3.9.5 Lorzone, 3.8.1 losartan, 4.5.9 losartan/HCTZ, 4.5.9 Lotemax, 12.11 Lotronex, see alosetron lovastatin, 4.6 Lovaza, see omega-3 acid ethyl esters loxapine, 3.9.3.3 Lumigan, 12.4 Lumizyme, 7.4.3 Lunesta, see eszopiclone Luxiq, 5.1.3 Luzu, 5.5 Lycelle, 5.11 Lynparza, 2.1.6 Lyrica, 3.6 M mafenide, 5.4 Magnacet, 3.1.2 Makena, 11.3.1 malathion, 5.11 Marplan, 3.9.2.3 Mar-Spas, 8.3.2 Maxair, 13.3.3 Maxidone, 3.1.2 Medrol, 7.3 medroxyprogesterone acetate, 11.3.1 mefenamic acid, 3.3.1 Megace ES, see megestrol megestrol , 2.1.6 Mekinist, 2.1.6 meloxicam, 3.3.1 memantine, 3.7 Menest, 11.3.2 Menostar, 11.3.2 meperidine HCl, 3.1.1 mephobarbital, 3.6 Mephyton, 4.4.1 Mepron, see atovaquone mercaptopurine, 2.1.6 Meridia, 16.3 mesalamine, 8.3.3 Mesalamine, 8.3.3 Mesnex, 2.1.6 Mestinon, see pyridostigmine metaxalone, 3.8.1 metformin ER, 7.5.2 metformin ER (Glumetza equiva), 7.5.2 metformin HCl, 7.5.2 metformin/glipizide, 7.5.2 methazolamide, 12.5 methenamine, 1.7 methimazole, 7.1 methocarbamol, 3.8.1 methotrexate, 2.1.6 methscopalamine Br, 8.3.2 methyldopa, 4.5.5 methylergonovine, 11.2 Methylin, see methylphenidate methylphenidate, 3.9.4 methylphenidate CD, 3.9.4 methylphenidate ER, 3.9.4 methylphenidate ER, 3.9.4 methylprednisolone, 7.3 methyltestosterone, 7.4.1 Metipranolol, 12.1 metoclopramide HCl/ODT, 8.3.3 metolazone, 4.5.1 metoprolol succinate ER, 4.5.2 metoprolol tartrate, 4.5.2 metoprolol/HCTZ, 4.5.8 Metozolv ODT , see metoclopramide ODT Metrogel, 5.3 metronidazole, 1.11.2 metronidazole, 5.3 metronidazole vaginal cream, 11.4.2 Miacalcin, 10.4 Micardis, see telmisartan Micardis HCT, see telmisartan/HCTZ Midazolam, 3.9.5 midodrine, 4.7 28 Midrin, 3.4.1 miglitol, 7.5.2 Migralam, 3.4.1 Migraten, 3.4.1 MimyX, 5.12 Minastrin 24 FE, 11.1.1 MiniMed Paradigm Real-Time, 7.5.4 Minimed, 7.5.4 Minivelle, 11.3.2 Minocin, 1.2 minocycline , 1.2 minocycline ER, 1.2 minoxidil, 4.5.7 Mirapex ER, see pramipexole ER Mirena, 11.4.5 mirtazapine, 3.9.2.2 Mirvaso, 5.3 misoprostol, 8.1.2 Mitigare, 10.2 modafinil, 3.9.4 moexipril, 4.5.4 moexipril /HCTZ, 4.5.8 molindone, 3.9.3.3 mometasone, 5.1.3 mometasone nasal, 13.3.5 Monoject, 7.5.4 montelukast, 13.3.6 Monurol, 1.7 Morgidox, 1.2 morphine SO4 ER, 3.1.1 Movantik, 8.3.3 Moviprep, 8.3.5 Moxatag, 1.1 Moxeza, 12.9 moxifloxacin, 1.5.1 MSIR, 3.1.1 Mucomyst, 13.3.6 Mucotrol, 6.4 Mugard, 6.4 Multaq, 4.1 mupirocin, 5.4 Muse, 14.4 Myalept, 7.4.3 Mycobutin, see rifabutin mycophenolate mofetil, 2.1.6 mycophenolate sodium, 2.1.6 Myfortic, see mycophenolate sodium myorisan, 5.3 Myoxin, 6.2 Myozyme, 7.4.3 Myrebetriq, 14.2 N nabumetone, 3.3.1 nadolol, 4.5.2 nadolol, 4.5.8 naftifine cream, 5.5 Naftin gel, 5.5 Naglazyme, 7.4.3 Nalfon, 3.3.1 Namenda, see memantine Namenda XR, 3.7 Namzaric, 3.7 Naprelan, 3.3.1 Naprelan CR, see naproxen ER naproxen/ER, 3.3.1 naratriptan, 3.4.1 Narcan nasal. 3.3.4 Nascobal, 15.1 Index Nasonex, see mometasone nasal Natazia, 11.1.1 nateglinide, 7.5.2 Natesto, 7.4.1 Natpara, 7.4.3 Nature-Throid, 7.2 Nebusal, 13.3.6 Neevo/Neevo DHA, 15.1 nefazodone, 3.9.2.2 Neobenz Micro, 5.3 Neobenz Micro SD, 5.3 neomycin/bacitracin/, 12.12 neomycin/polymyxin/ examethasone, 12.12 neomycin/polymyxin/HC, 6.2 Neoral, 2.1.6 Neosalus, 5.12 Neo-Synalar, 5.4 Neptazane, see methazolamide Nesina, 7.5.2 Neulasta, 9.1.2 Neumega, 9.1.5 Neupogen, 9.1.2 Neupro, 3.5 Neutrasal, 16.1 Nevanac , 12.7 Nexavar, 2.1.6 Nexium susp/pkt, 8.1.4 Nexium caps, see esomeprazole Niaspan, 4.6 nicardipine HCl, 4.5.3.2 nifedipine, nifedipine ER, 4.5.3.2 Nilandron, see nilutamide nilutamide, 2.1.6 nimodipine, 4.5.3.2 Ninjacof-XG, 13.2.1 nisoldipine, 4.5.3.2 nitrofurantoin, 1.7 nitroglycerin, 4.3 Nitromist, 4.3 nizatidine, 8.1.1 Norditropin, 9.1.4 norethindrone acetate, 11.3.1 Noritate, 5.3 nortriptyline, 3.9.2.1 Novacort, 5.2 Novarel, 7.4.4 Novofine, 7.5.4 Novolin, 7.5.1 Novolog, 7.5.1 Noxafil, 1.9 np thyroid, 7.2 Nucynta/Nucynta ER, 3.1.1 Nuedexta, 3.9.4 Numoisyn, 6.4 Nuox gel, 5.3 Nuplazid, 3.9.2.2 Nutropin, Nutropin AQ, Nutropin Depot, 9.1.4 Nuvessa, 11.4.2 Nuvigil, see armodafinil Nuzon gel, 5.3 Nymalize, 4.5.3.2 nystatin troche/susp, 1.9 nystatin, 11.4.3 nystatin/triamcinolone, 5.5 O Obredon, 13.2.1 Ocaliva, 8.3.3 octreotide, 2.1.6 Odomzo, 2.1.6 Ofev, 13.3.6 ofloxacin, 1.5.1 ofloxacin opth soln, 12.9 ofloxacin otic, 6.2 Oforta, 2.1.6 olanzapine/fluoxetine, 3.9.3.3 olanzapine/olanzapine ODT, 3.9.3.3 Oleptro ER, 3.9.2.2 olopatadine, 6.4 olopatadine eye, 12.15 Olysio, 1.8.1 Omeclamox-Pak8.1.3 omega-3, 4.6 omeprazole, 8.1.4 Omnaris, 13.3.5 Omnitrope, 9.1.4 ondansetron, 8.3.4 One Touch, 7.5.4 Onexton, 5.3 Onfi, 3.6 Onglyza, 7.5.2 Onmel, 1.9 Onsolis, 3.1.1 Onzetra Xsail, 3.4.1 Opana ER, 3.1.1 Opti Chamber, 7.5.4 Opsumit, 13.3.6 Oracea, 1.2 Orafate, 6.4 Oralair, 9.2 Oralone, 6.4 Orap, see pimozide Orapred ODT, see prednisolone sodium phosphate Oravig, 1.9 Orencia, 10.3.2 Orenitram ER, 4.5.7 Orfadin, 16.1 Orkambi, 13.3.6 orphenadrine, 3.8.1 Ortho-Est, 11.3.3 Ortho-Prefest, 11.3.3 oscion, 5.3 Oseni, 7.5.2 Osmoprep, 8.3.3 Osphena, 10.4 Otezla, 10.3.2 Otic Care, 6.2 Otozin, 6.2 Otrexup, 10.3.2 Ovace, 5.10 Ovace Plus, 5.10 Ovcon 50, 11.1.1 Ovide, 5.11 oxandrolone, 7.4.1 oxaprozin, 3.3.1 Oxaydo, 3.1.1 oxazepam, 3.9.5 oxcarbazepine, 3.6 oxiconazole, 5.5 Oxistat, see oxiconazole Oxtellar XR, 3.6 Oxy IR, 3.1.1 oxybutynin chloride, 14.2 oxybutynin chloride ER, 14.2 oxycodone, 3.1.1 Oxycodone ER, 3.1.1 oxycodone/acetaminophen, 3.1.2 oxycodone/aspirin, 3.1.2 oxycodone/ibuprofen, 3.1.2 Oxycontin, 3.1.1 oxymorphone IR, 3.1.1 oxymorphone ER, 3.1.1 Oxytrol, 14.2 P Pacnex LP/HP, 5.3 paliperidone ER, 3.9.3.3 Pancreaze, 8.3.2 Pandel, 5.1.3 pantoprazole, 8.1.4 paricalcitol, 7.4.3 Paradigm, 7.5.4 paregoric, 8.2.1 paroxetine, 3.9.2.4 paroxetine CR, 3.9.2.4 Pataday, 12.15 Patanase, see olopatadine nasal Patanol, see olopatadine eye Pazeo, 12.15 PCE, 1.4.1 peg 3350, 8.3.3 Pegasys, 9.1.3 penicillin V, 1.1 Pennsaid 2% soln, 3.3.1 Pennsaid 1.5% soln, see diclofenac drops Pentasa, 8.3.3 pentazocine/naloxone, 3.3.3 Pentoxifylline, 4.4.6 Pepcid RPD, 8.1.1 Peranex HC, 8.3.3 Perforomist, 13.3.3 perindopril, 4.5.4 permethrin, 5.11 perphenazine, 3.9.3.3 Pertzye, 8.3.3 Pexeva, 3.9.2.4 phenazopyridine HCl, 14.3 phendimetrazine, 16.3 phenelzine, 3.9.2.3 phenobarbital, 3.6 phenoxybenzamine, 4.5.6 phentermine, 16.3 phenylephrine, 13.2.1 Phenytek, 3.6 phenytoin, 3.6 phenytoin sodium extended, 3.6 phosenamine, 14.4 Phoslyra, 15.3.2 Picato, 5.12 pilocarpine HCl , 12.3 pilocarpine, 6.4 pimozide, 3.9.3.3 pindolol, 4.5.2 Pinnacaine, 6.2 pioglitazone, 7.5.2 pioglitazone/glimepiride, 7.5.2 pioglitazone/metformin, 7.5.2 piroxicam, 3.3.1 Plexion, 5.3 Plexion/SCT/TS, see sodium sulfacetamide/sulfur Podofilox, 5.12 Polyfin, 7.5.4 Polymyxin B/Trimethoprim, 12.9 polymyxin/hydrocortisone, 12.12 Polytussin AC, 13.2.1 Poly Vi Flor filmstrips, 15.1 Pomalyst, 2.1.6 29 potassium chloride/SA, 15.3.1 potassium citrate ER, 14.4 Pradaxa, 4.4.1 Praluent, 4.6 Pramcort, 8.3.3 pramipexole/ pramipexole ER, 3.5 Pramosone, 8.3.3 Pramosone/Pramosone E, 5.1 pramoxine/hydrocortisone, 8.3.3 Prandimet, see repaglinide/metformin Prandin, see repaglinide prascion, 5.3 pravastatin, 4.6 prazosin HCl, 4.5.5 Precision Sure Dose, 7.5.4 Precision Xtra, 7.5.4 Pred Mild, 12.11 Pred-G, 12.12 Prednicarbate, 5.1.3 prednisolone, 7.3 prednisolone acetate, 12.11 prednisolone sodium phosphate, 7.3 prednisone, 7.3 Prefera-OB, 15.1 Pregnyl, 7.4.4 Prekunil, 15.4.1 Premarin, 11.3.2 Premphase, 11.3.3 Prempro, 11.3.3 Prenate Elite, 15.1 Prepopik, 8.3.5 Prestalia, 4.5.8 Prevacid NapraPac, 3.3.1 Prevpac, 8.1.3 Prilosec, 8.1.4 primidone, 3.6 Pristiq, 3.9.2.2 ProAir HFA/Respiclick, 13.3.3 probenecid, 10.2 procainamide HCl, 4.1 Procentra, 3.9.4 Prochieve, 11.3.1 prochlorperazine, 8.3.4 Procort, 8.3.3 Procrit, 9.1.1 Prodigy, 7.5.4 Prodrin, see isometh/caffeine/ apap progesterone caps, 11.3.1 Progesterone in oil, 11.3.1 Progesterone pwd, 11.3.1 Pro-Hyo, 8.3.2 Prolastin , 16.1 Prolensa, 12.7 Promacta, 4.4.5 promethazine HCl, 13.1.1 promethazine supp, 8.3.4 promethazine /codeine, 13.2.1 promethazine /DM, 13.2.1 propafenone, 4.1 propafenone SR, 4.1 propoxyphene/apap, 3.3.3 propranolol, 4.5.2 propranolol SA, 4.5.2 propranolol/HCTZ, 4.5.8 propylthiouracil (PTU), 7.1 Prosed DS, 14.4 Prothelial, 6.4 Protopic, see tacrolimus oint protriptyline, 3.9.2.1 Index Protropin, 9.1.4 Proventil HFA, 13.3.3 Prozac, 3.9.2.4 pruclair, 5.12 prutect, 5.12 pruvel, 5.12 pseudoephedrine , 13.2.3 Pulmicort Flexhaler , 13.3.4 Pulmicort Respules, see budesonide neb Pulmozyme , 13.3.6 Purixan, 2.1.2 Pylera, 8.1.3 pyridostigmine Br, 3.8.2 Q Qbrelis, 4.5.4 Qnasl, 13.3.5 Qsymia, 16.3 Qudexy XR, 3.6 quetiapine, 3.9.3.3 Quflora, 15.1 Quick Release Teflon Cannula, 7.5.4 Quillichew ER, 3.9.4 Quillivant XR, 3.9.4 quinapril, 4.5.4 quinapril /HCTZ, 4.5.8 quinidine, 4.1 quinine SO4, 1.11.3 Qvar , 13.3.4 R rabeprazole, 8.1.4 Radigel Acemannan, 5.12 Ragwitek, 9.2 raloxifene, 10.4 ramipril, 4.5.4 Ranexa, 4.7 ranitidine, 8.1.1 Rapaflo, 14.5 Rapamune, see sirolimus Rasuvo, 10.3.2 Ravicti, 16.1 Rayos, 7.3 re methylphen, 14.4 Rebif, 9.1.3 Rectagel HC Gel, 8.3.3 Rectiv, 8.3.3 Regimex, see benzphetamine Regranex, 5.12 Relagesic, 3.8.1 Relion, 7.5.1 Relistor, 8.3.3 Relpax, 3.4.1 Remodulin, 4.5.7 Renacidin, 14.4 Renagel, 16.1 Renvela susp, 16.1 Renvela tabs, see sevelamer carbonate repaglinide/metformin, 7.5.2 Repatha, 4.6 Reprexain, 3.1.2 re-sa, 5.1 Rescula, 12.4 Restasis, 12.15 Retin A, 5.3 re-urea, 5.12 Revatio, 13.3.6 Revlimid, 2.1.6 Rexulti, 3.9.3.3 Rhinocort Aqua, see budesonide Rhinoflex, 3.3.3 rifabutin, 1.11.4 risedronate, 10.4 risedronate 30 mg, 16.1 risedronate, dr, 10.4 risperidone, 3.9.3.3 risperidone ODT, 3.9.3.3 Ritalin LA, 3.9.4 rivastigmine, 3.7 rizatriptan/rizatriptan ODT, 3.4.1 ropinirole/ropinirole ER, 3.5 Rosac, 5.3 Rosula, Rosula NS, 5.3 Rosula NS, 5.3 rosuvastatin, 4.6 Rowasa kit, 8.3.3 roxicet, 3.1.1 Roxicodone, 3.1.1 Rozerem, 3.9.1 Ruconest, 13.3.6 Rybix ODT, 3.3.3 Rynatan, 13.2.3 Rytary, 3.5 Simponi, 10.3.2 simvastatin , 4.6 sirolimus, 2.1.6 Sivextro, 1.11.1 Skelid, 16.1 Sklice, 5.11 Skyla IUD, 11.4.5 Sod Sulf/Sulfur Gel, 5.3 sodium hyaluronate, 5.12 sodium phenylbutyrate, 16.1 sodium sulfacetamide cleanser, 5.10 sodium sulfacetamide medicated pads/lot/cream/cleanser 5.3 Sof-Set, 7.5.4 Soft Touch, 7.5.4 Solaraze, 5.12 Solodyn ER, 1.2 Solus V2, 7.5.4 Soln, 3.7 Somavert, 7.4.3 Sonafine, 5.12 Soolantra, 5.3 Soriatane, see acitretin Sorilux, 5.1 sotalol/sotalol AF, 4.1 sotret, 5.3 Sotylise, 4.1 Sovaldi, 1.8.1 spinosad, 5.11 Spiriva, 13.3.6 spironolactone, 4.5.1 spironolactone/HCTZ, 4.5.1 Sporanox, 1.9 Spritam, 3.6 Sprix, 3.3.1 Sprycel, 2.1.6 Stavzor, 3.6 Staxyn, 14.4 Stendra, 14.4 Stimate, 7.4.3 Stiolto Respimat, 13.3.6 Stivarga, 2.1.6 Strattera, 3.9.4 Strensiq, 7.4.3 Striant, 7.4.1 Striverdi Respimat, 13.3.3 Suboxone, see buprenorphine/ naloxone Subsys, 3.1.1 sucralfate, 8.1.3 sulfacetamide sodium, 12.9 sulfacetamide sodium lot/pads, 5.3 sulfacetamide/sulfur, 5.3 sulfacleanse, 5.3 sulfamethoxazole, 1.6 sulfasalazine, 8.3.3 sulfatol, 5.3 sulfisoxazole , 1.6 sulindac, 3.3.1 Sumadan, 5.3 sumatriptan, 3.4.1 Sumavel Dosepro, 3.4.1 Sumaxin, 5.3 Suprax tabs, 1.1, Suprax susp, see cefixime Suprenza ODT, 16.3 Suprep, 8.3.5 Sure-T, 7.5.4 Sutent, 2.1.6 Sylatron, 9.1.3 S Sabril, 3.6 Safyral, 11.1.1 Saizen, 9.1.4 Salex, 5.9 Salicept, 6.4 Salicylic 6%, 5.9 salicylic acid 26%, 5.9 salicylic acid 6%, 5.9 salicylic acid ER film, 5.9 salsalate, 3.3.2 Salvax, 5.9 Samsca, 7.4.3 Sancuso, 8.3.4 Sandimmune, 2.1.6 Sandostatin, see octreotide Saphris, 3.9.3.3 Sarafem, 3.9.2.4 Savaysa, 4.4.1 Savella, 3.9.2.2 Saxenda, 16.3 SE Benzoyl Peroxide, 5.3 Seb-Prev, 5.1 Seebri Neohaler, 13.3.6 selegiline, 3.9.2.3 selegiline HCl, 3.5 selenium sulfide, 5.1 Semprex-D, 13.2.3 Sensipar, 7.4.3 Serevent Diskus, 13.3.3 Sernivo, 5.1.2 Seroquel XR, 3.9.3.3 Serostim, 9.1.4 sertraline , 3.9.2.4 sevelamer carbonate, 16.1 Seven Plus 7.5.4 Sfrowasa, 8.3.3 Sidekick, 7.5.4 Signifor, 2.1.6 sildenafil 4.5.7 Silenor, 3.9.1 Silhouette, 7.5.4 silver sulfadiazine, 5.7 Silvrstat, 5.4 Simcor, 4.6 30 Symax, 8.2.2 Symbicort, 13.3.6 Symlin, 7.5.2 Synalar, 5.3 Synarel, 7.4.3 Synjardy, 7.5.2 T Taclonex, see calcipotriene/ betamethasone tacrolimus, 2.1.6 tacrolimus, 5.12 Tafinlar, 2.1.6 Tagrisso, 2.1.6 Taltz, 5.10 tamoxifen citrate, 2.1.6 Tamsulosin , 14.5 Tanzeum, 7.5.2 Tarceva, 2.1.6 Targadox, 1.2 Targretin, see bexarotene Tasigna, 2.1.6 Tasmar, see tolcapone Tazorac, 5.3 Tecfidera, 3.7 Technivie, 1.8.1 Teczem, 4.5.8 Tekamlo, 4.5.9 Tekturna, 4.5.9 Tekturna HCT, 4.5.9 telmisartan, 4.5.9 telmisartan/amlodipine, 4.5.8 telmisartan/HCTZ, 4.5.9 temazepam, 3.9.1 Temodar, see temozolomide temozolomide, 3.0 Temovate, 5.1.1 Terazol 3, 11.4.3 terazosin, 4.5.5 terbinafine, 1.9 terconazole, 11.4.3 Tersi, 5.1 Testim, 7.4.1 Testosterone, 7.4.1 tetrabenazine, 3.7 tetracycline, 1.2 Teveten HCT, see eprosartan/ HCTZ Texavite, 15.1 Thalomid, 2.1.6 Theo-Dur, 13.3.1 Theophylline ER, 13.3.1 thioridazine, 3.9.3.3 thyroid, 7.2 Thyrolar, 7.2 tiagabine, 3.6 ticlopidine HCl, 4.4.2 Tikosyn, see dofetilide timolol, 4.5.2 timolol maleate, 12.1 timolol maleate XE, 12.1 Tinidazole, 1.11.2 Tirosint, 7.2 Tivorbex, 3.3.1.1 tizanidine, 3.8.1 TOBI, 1.11.1 Tobradex, 12.12 tobramycin neb soln, 1.11.1 tobramycin sulfate, 12.9 tobramycin/dexamethasone, 12.12 Index Tolak, 5.12 tolcapone, 3.5 tolterodine, 14.2 tolterodine ER, 14.2 Topicort/Topicort LP, 5.1.2 topiramate, 3.6 Topiramate ER, 3.6 torsemide, 4.5.1 Toujeo, 7.5.1 Toviaz, 14.2 Tracleer, 13.3.6 Tradjenta, 7.5.2 Tramadol, 3.3.3 tramadol ER, 3.3.3 tramadol HCL, 3.3.3 tramadol/apap, 3.3.3 trandolapril, 4.5.4 trandolopril/verapamil, 4.5.8 tranexamic acid, 4.4.5 Transderm-Scop, 8.3.4 tranylcypromine sulfate, 3.9.2.3 Travatan-Z, 12.4 travoprost, 12.4 trazodone HCl, 3.9.2.2 Tresiba Flextouch, 7.5.1 tretinoin, 2.1.6 tretinoin, tretinoin micro, 5.3 Treximet, 3.4.1 Trezix, see apap/caffeine/dihydrocodeine triamcinolone, 13.3.5 triamcinolone acetonide , 5.1.3 triamcinolone, 6.4 triamterene /HCTZ, 4.5.1 Triaz, 5.3 Tricare Prenatal w/DHA, 15.1 Tricor, see fenofibrate triazolam, 3.9.1 Tribenzor, 4.5.8 trifluoperazine, 3.9.3.3 trifluridine opth, 12.16 Triglide, 4.6 trihexyphenidyl, 3.5 Trilipix, see fenofibrate TriLyte, 8.3.5 trimethobenzamide HCl, 8.3.4 trimethoprim, 1.6 trimethoprim, 1.7 trimipramine, 3.9.2.1 Trintellix, 3.9.2.4 TriOxin, 6.2 Trulicity, 7.5.2 Tropazone, 5.12 trospium Cl, 14.2 trospium Cl ER, 14.2 Tudorza, 13.3.6 Tussionex, 13.2.1 Tuzistra XR, 13.2.1 Twynsta, see telmisartan/amlodipine Tykerb, 2.1.6 Tyvaso , 13.3.6 U Uceris, 8.3.3 Ulesfia, 5.11 Uloric, 10.2 Ultrasal-ER, see salicylic acid ER Ultravate lotion, 5.1.1 Ultresa, 8.3.2 Umecta, 5.12 Umecta PD, 5.12 Uni-Dur, 13.3.1 Uniphyl, 13.3.1 Unistrip-1 device, 7.5.4 Unistrip -1 strips, 7.5.5 unithroid, 7.2 Uptravi, 4.5.7 Uramaxin 5.12 Uramaxin GT, 5.12 urea, 5.12 Urealac, 5.12 Urelle, see Uro-L Uribel, see Uro-MP Uritact-EC, 14.4 Urocit-K, see potassium citrate ER Urogesic Blue, 1.7 Uro-L, 14.4 Uro-MP, 14.4 ursodiol, 8.3.3 Uta cap, 14.4 Utibron Neohaler, 13.3.6 Vimpat, 3.6 Viokace, 8.3.2 Virasal, 5.9 Visicol , 8.3.3 Vistogard, 2.2.1 Vivelle Dot, see estradiol patches Vogelxo, 7.4.1 Volmax, 13.3.3 Voltaren , 12.7 Voltaren Gel, see diclofenac gel voriconazole, 1.9 Votrient, 2.1.6 Vpriv, 7.4.3 Vraylar, 3.9.3.3 Vusion, 5.5 Vytorin, 4.6 Vyvanse, 3.9.4 W warfarin sodium, 4.4.1 Welchol, 4.6 westhroid, 7.2 Westhroid-P, 7.2 WP Thyroid, 7.2 V Vagifem , 11.3.2 Valchlor, 5.12 Valcyte, see valganciclovir valganciclovir, 1.8.1 valproic acid, 3.6 valsartan, 4.5.9 valsartan /HCTZ, 4.5.9 vancomycin caps, 1.11.1 Vandazole, 11.4.2 Vanos, see fluocinonide Vanoxide HC, 5.3 Varubi, 8.3.4 Vascepa, 4.6 Vashe, 16.6 Vecamyl, 4.5.8 Vectical, 5.1 Velphoro, 16.1 Veltin, 5.3 Venclexta, 2.1.6 Venelex, 5.12 venlafaxine, 3.9.2.2 venlafaxine ER, 3.9.2.2 Ventavis, 13.3.6 Ventolin HFA, 13.3.3 Veracloz, 3.9.3.3 Veramyst, 13.3.5 verapamil ER PM, 4.5.3.2 verapamil HCl/, 4.5.3.2 verapamil SR, 4.5.3.2 Verdeso, 5.1.4 Veregen, 5.12 Verelan, 4.5.3.2 Verelan PM, 4.5.3.2 Veripred 20, 7.3 Vesicare, 14.2 Vexol, 12.11 Vfend, see voriconazole V-Go, 7.5.4 Viagra, 14.4 Viberzi, 8.3.3 Vicoprofen, 3.1.2 Victoza, 7.5.2 Viekira, Viekira XR, 1.8.1 Vigamox, 12.9 Viibryd, 3.9.2.4 Vimizim, 7.4.3 Vimovo, 3.3.1 X Xalkori, 2.1.6 Xarelto, 4.4.1 Xartemis XR, 3.1.2 Xclair, 5.12 Xeljanz/ Xeljanz XR, 10.3.2 Xeloda, see capecitabine Xenazine, see tetrabenazine Xenical, 16.3 Xerese, 5.6 Xifaxan, 1.11.1 Xiidra, 12.15 Xigduo XR, 7.5.2 Xolegel, 5.5 Xolox, 3.1.2 Xopenex HFA, 13.3.3 Xtampza XR, 3.1.1 Xtandi, 2.1.6 Xuriden, 16.1 Xyrem, 3.9.4 Z zafirlukast, 13.3.6 zaleplon, 3.9.1 Zantac, 8.1.1 Zarxio, 9.1.2 Zavesca, 7.4.3 Zazole, 11.4.3 Zegerid, 8.1.4 Zelboraf, 2.1.6 Zelnorm, 8.3.3 Zemaira , 16.1 zema-pak, 7.3 Zembrace, 3.4.1 Zemplar, see paricalcitol zenatane, 5.3 Zencia, 5.3 Zenpep DR, 8.3.2 Zenzedi, 3.9.4 Zepatier, 1.8.1 Zetia, 4.6 Zetonna, 13.3.5 Zflex, 3.3.3 Ziana Gel, see clindamycin/tretinoin 31 Zinbryta, 3.7 Zioptan, 12.4 ziprasidone, 3.9.3.3 Zirgan, 12.16 Zithranol, 5.1 Zmax, see azithromycin Zoderm, 5.3 Zohydro ER, 3.1.1 Zolinza, 2.1.6 zolmitriptan/zolmitriptan ODT, 3.4.1 zolpidem/ER/sl, 3.9.1 Zolpimist, 3.9.1 Zolvit, 3.1.2 Zonalon, see doxepin cream Zomacton, 9.1.4 Zomig, 3.4.1 zonisamide, 3.6 Zontivity, 4.4.2 Zorprin, 3.3.2 Zortress, 2.1.6 Zorvolex, 3.3.1.1 Zovirax, 5.6 z-pram, 8.3.3 Zuplenz, 8.3.4 Zurampic, 10.2 Zyclara, 5.12 Zydelig, 2.1.6 Zyflo, 13.3.6 Zykaydia, 2.1.6 Zylet, 12.12 Zymaxid, see gatifloxacin Zytiga, 2.1.6 Zyvox, see linezolid 06-F0503 6/12 03-B053A 2012. 11/15 . © Blue Cross of Northeastern Pennsylvania.
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