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Printable Formulary - AmeriHealth Caritas Louisiana
Formulary Drug List AmeriHealth Caritas Louisiana PerformRxSM Pharmacy Services: Phone 1-800-684-5502 Fax 1-855-452-9131 Pharmacy Member Services: Phone 1-866-452-1040 Providers may request the addition or deletion of a medication to this list. Requests for additions must include the drug name, rationale for inclusion on the list, role in therapy and medications that may be replaced by the addition. Please direct such requests to: AmeriHealth Caritas P&T Committee P.O. Box 40849 Charleston, SC 29423 Members may request changes to the list by calling Pharmacy Member Services. For the most current formulary, please use the searchable formulary on our website, www.amerihealthcaritasla.com/pharmacy/formulary.aspx. September 2016 ACLA-1322-07 www.amerihealthcaritasla.com Drug Name Antihistamine Drugs Ethanolamine Derivatives Note Requirements/Limits clemastine oral tablet Diphenhist oral tablet 50 mg diphenhydramine HCl injection solution 50 mg/mL diphenhydramine HCl injection syringe diphenhydramine HCl oral capsule 50 mg diphenhydramine HCl oral syrup First Gen. Antihist. Derivatives, Misc. cyproheptadine First Generation Antihistamines clemastine oral tablet cyproheptadine Diphenhist oral tablet 50 mg diphenhydramine HCl injection solution 50 mg/mL diphenhydramine HCl injection syringe diphenhydramine HCl oral capsule 50 mg diphenhydramine HCl oral syrup ED Chlorped Jr Phenothiazine Derivatives promethazine injection promethazine oral syrup promethazine oral tablet 25 mg, 50 mg promethazine rectal suppository 12.5 mg, 25 mg Promethazine VC Piperazine Derivatives meclizine oral tablet 12.5 mg, 25 mg Propylamine Derivatives ED Chlorped Jr AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 1 Drug Name Second Generation Antihistamines Note Requirements/Limits Alavert Alavert D-12 Allergy-Sinus cetirizine oral solution 1 mg/mL cetirizine oral tablet cetirizine-pseudoephedrine levocetirizine oral tablet ST loratadine oral solution loratadine oral tablet Loratadine-D oral tablet extended release 24 hr Anti-Infective Agents Adamantanes amantadine HCl oral capsule amantadine HCl oral solution Allylamines terbinafine HCl oral QL Amebicides metronidazole in NaCl (iso-os) PA metronidazole oral tablet paromomycin PA; QL Yodoxin Aminoglycosides amikacin injection solution 1,000 mg/4 mL, 500 mg/2 mL PA gentamicin in NaCl (iso-osm) intravenous piggyback 100 mg/100 mL, 100 mg/50 mL, 80 mg/100 mL, 80 mg/50 mL PA gentamicin injection PA gentamicin sulfate (PF) PA paromomycin PA; QL Tobi PA Tobi Podhaler PA tobramycin sulfate PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 2 Drug Name Aminopenicillins Note Requirements/Limits amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet,chewable ampicillin ampicillin sodium PA ampicillin-sulbactam PA Anthelmintics Biltricide Antifungals, Miscellaneous griseofulvin microsize griseofulvin ultramicrosize SSKI Antimalarials atovaquone-proguanil chloroquine phosphate oral Daraprim PA hydroxychloroquine oral mefloquine primaquine quinidine gluconate oral quinidine sulfate Antimycobacterials, Miscellaneous dapsone Antiprotozoals, Miscellaneous atovaquone PA dapsone metronidazole in NaCl (iso-os) PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 3 Drug Name Note Requirements/Limits metronidazole oral tablet Nebupent PA Pentam PA Antituberculosis Agents amikacin injection solution 1,000 mg/4 mL, 500 mg/2 mL PA Cipro oral suspension,microcapsule recon 500 mg/5 mL ciprofloxacin (mixture) ciprofloxacin HCl oral tablet 100 mg ciprofloxacin HCl oral tablet 250 mg, 500 mg, 750 mg QL ciprofloxacin in 5 % dextrose intravenous piggyback 400 mg/200 mL PA ciprofloxacin oral suspension,microcapsule recon 250 mg/5 mL clarithromycin QL ethambutol isoniazid oral Levaquin in 5 % dextrose PA levofloxacin oral solution QL levofloxacin oral tablet QL moxifloxacin QL Mycobutin pyrazinamide rifampin intravenous PA rifampin oral Antivirals, Miscellaneous foscarnet PA Azoles fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 mL PA fluconazole in NaCl (iso-osm) intravenous piggyback 200 mg/100 mL, 400 mg/200 mL PA fluconazole oral suspension for reconstitution AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 4 Drug Name Note Requirements/Limits fluconazole oral tablet 100 mg, 200 mg, 50 mg fluconazole oral tablet 150 mg QL itraconazole PA ketoconazole oral Sporanox oral solution PA Vfend IV PA Carbapenems Doribax PA Invanz PA meropenem PA Primaxin IV intravenous recon soln 250 mg PA Cephamycins cefotetan PA cefotetan in dextrose, iso-osm PA Cyclic Lipopeptides Cubicin PA Echinocandins Cancidas PA Eraxis(Water Diluent) PA Mycamine PA Erythromycins erythromycin-sulfisoxazole Extended-Spectrum Penicillins piperacillin-tazobactam PA Timentin PA Zosyn in dextrose (iso-osm) PA First Generation Cephalosporins cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 mL, 500 mg/5 mL cefadroxil oral tablet cefazolin injection recon soln 1 gram, 10 gram, 500 mg PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 5 Drug Name Note Requirements/Limits cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution Fourth Generation Cephalosporins cefepime PA cefepime in dextrose 5 % PA cefepime in dextrose,iso-osm PA Glycopeptides vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 mL, 750 mg/150 mL PA vancomycin intravenous PA vancomycin oral ST Vibativ intravenous recon soln 750 mg PA Glycylcyclines Tygacil PA Hcv Polymerase Inhibitors Epclusa PA Harvoni PA Sovaldi PA Viekira Pak PA Viekira XR PA Hcv Protease Inhibitors Olysio PA Technivie PA Viekira Pak PA Viekira XR PA Zepatier PA Hcv Replication Complex Inhibitors Daklinza PA Epclusa PA Harvoni PA Technivie PA Viekira Pak PA Viekira XR PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 6 Drug Name Zepatier Note Requirements/Limits PA Hiv Entry And Fusion Inhibitors Fuzeon subcutaneous recon soln Selzentry Hiv Integrase Inhibitors Genvoya Isentress Stribild Tivicay Triumeq Vitekta Hiv Nonnucleoside Rev.Transcrip. Inhib. ATRIPLA Complera Edurant Intelence nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 400 mg Odefsey Rescriptor Sustiva Viramune XR oral tablet extended release 24 hr 100 mg Hiv Nucleoside & Nucleotide Rt Inhibitor abacavir ATRIPLA Complera Descovy didanosine Emtriva AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 7 Drug Name Note Requirements/Limits Epivir HBV Epivir oral solution Epzicom Genvoya lamivudine oral tablet 150 mg, 300 mg lamivudine-zidovudine Odefsey Retrovir intravenous stavudine Stribild Triumeq Trizivir Truvada Videx 2 gram Pediatric Viread Ziagen oral solution zidovudine Hiv Protease Inhibitors Aptivus Crixivan oral capsule 200 mg, 400 mg Evotaz Invirase Kaletra Lexiva Norvir Prezcobix Prezista Reyataz oral capsule 150 mg, 200 mg, 300 mg Reyataz oral powder in packet Technivie PA Viekira Pak PA Viekira XR PA Viracept oral tablet AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 8 Drug Name Interferons Note Requirements/Limits Alferon N PA Intron A injection PA Pegasys PA Pegasys ProClick PA PegIntron PA PegIntron Redipen PA Sylatron 4-Pack subcutaneous kit 200 mcg, 300 mcg PA Lincomycins Cleocin in 5 % dextrose PA clindamycin HCl oral capsule 150 mg, 300 mg clindamycin palmitate HCl clindamycin phosphate injection PA clindamycin phosphate intravenous solution 900 mg/6 mL PA Lincocin PA Macrolides E.E.S. Granules Ery-Tab Erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(DR/EC) erythromycin oral tablet Monobactams Azactam in dextrose (iso-osm) PA aztreonam PA Cayston PA Monoclonal Antibodies Synagis PA Natural Penicillins Bicillin L-A AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 9 Drug Name penicillin G potassium Note Requirements/Limits PA penicillin V potassium Neuraminidase Inhibitors Relenza Diskhaler QL Tamiflu QL Nucleosides And Nucleotides acyclovir oral capsule acyclovir oral suspension 200 mg/5 mL acyclovir oral tablet adefovir PA Cytovene PA entecavir Hepsera PA REBETOL oral solution PA Ribasphere oral tablet 400 mg, 600 mg PA Ribasphere RibaPak oral tablets,dose pack 400400 mg (28)-mg (28), 600-400 mg (28)-mg (28), 600-600 mg (28)-mg (28) PA ribavirin oral capsule PA ribavirin oral tablet 200 mg PA valacyclovir Vistide PA Other Macrolides azithromycin oral packet QL azithromycin oral suspension for reconstitution QL azithromycin oral tablet 250 mg, 500 mg, 600 mg QL clarithromycin QL Zmax QL Oxazolidinones Zyvox intravenous PA Penicillinase-Resistant Penicillins dicloxacillin AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 10 Drug Name Note Requirements/Limits nafcillin in dextrose iso-osm intravenous piggyback 2 gram/100 mL PA nafcillin injection PA oxacillin injection PA Polyenes Abelcet PA AmBisome PA Amphotec PA nystatin oral Polymyxins colistin (colistimethate Na) PA Quinolones Cipro oral suspension,microcapsule recon 500 mg/5 mL ciprofloxacin (mixture) ciprofloxacin HCl oral tablet 100 mg ciprofloxacin HCl oral tablet 250 mg, 500 mg, 750 mg QL ciprofloxacin in 5 % dextrose intravenous piggyback 400 mg/200 mL PA ciprofloxacin oral suspension,microcapsule recon 250 mg/5 mL Levaquin in 5 % dextrose PA levofloxacin oral solution QL levofloxacin oral tablet QL moxifloxacin QL ofloxacin oral tablet 400 mg GL; QL Rifamycins Mycobutin rifampin intravenous PA rifampin oral Xifaxan oral tablet 550 mg PA Second Generation Cephalosporins cefaclor oral capsule AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 11 Drug Name Note Requirements/Limits cefotetan PA cefotetan in dextrose, iso-osm PA cefprozil Ceftin oral suspension for reconstitution 250 mg/5 mL cefuroxime axetil oral suspension for reconstitution 125 mg/5 mL cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 1.5 gram PA cefuroxime sodium intravenous PA Zinacef intravenous recon soln 1.5 gram, 750 mg PA Streptogramins Synercid PA Sulfonamides (Systemic) sulfadiazine oral sulfamethoxazole-trimethoprim intravenous PA sulfamethoxazole-trimethoprim oral sulfasalazine Tetracyclines doxycycline hyclate intravenous PA doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg minocycline oral capsule minocycline oral tablet tetracycline Third Generation Cephalosporins cefdinir QL cefotaxime PA cefpodoxime oral suspension for reconstitution ceftazidime PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 12 Drug Name Note Requirements/Limits ceftriaxone PA ceftriaxone in dextrose,iso-os PA ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg PA Claforan intravenous recon soln PA Fortaz in dextrose 5 % PA Suprax oral capsule QL Suprax oral suspension for reconstitution 100 mg/5 mL, 200 mg/5 mL TAZICEF intravenous PA Urinary Anti-Infectives nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitrofurantoin oral trimethoprim Antineoplastic Agents Antineoplastic Agents Abraxane PA Adcetris PA Adriamycin intravenous recon soln PA Afinitor PA Afinitor Disperz PA Alecensa PA Alferon N PA Alimta PA Alkeran oral anastrozole Arranon PA Arzerra intravenous solution 100 mg/5 mL PA Avastin PA bexarotene PA Bexxar 131 Iodine PA Bexxar Therapeutic PA bicalutamide AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 13 Drug Name Note Requirements/Limits BiCNU PA bleomycin PA Bosulif PA Busulfex PA Camptosar intravenous solution 300 mg/15 mL PA capecitabine PA Caprelsa PA carboplatin PA cisplatin PA cladribine PA Clolar PA Cometriq PA Cosmegen PA cyclophosphamide intravenous PA cyclophosphamide oral tablet cytarabine PA cytarabine (PF) PA dacarbazine PA Dacogen PA daunorubicin intravenous solution PA DaunoXome PA DepoCyt (PF) PA Docefrez PA docetaxel intravenous solution 160 mg/16 mL (10 mg/mL), 160 mg/8 mL (20 mg/mL), 20 mg/2 mL (10 mg/mL), 20 mg/mL (1 mL), 80 mg/4 mL (20 mg/mL), 80 mg/8 mL (10 mg/mL), 80 mg/8 mL (Final) PA Doxil PA doxorubicin intravenous solution PA Droxia Eligard PA Eligard (3 month) PA Eligard (4 month) PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 14 Drug Name Note Requirements/Limits Eligard (6 month) PA Eloxatin intravenous solution 200 mg/40 mL PA Elspar PA Emcyt epirubicin intravenous recon soln 50 mg PA epirubicin intravenous solution PA Erbitux PA Erivedge PA Erwinaze PA Etopophos PA etoposide PA exemestane PA Fareston PA Faslodex PA Firmagon PA floxuridine PA fludarabine PA fluorouracil intravenous PA flutamide GL Folotyn PA gemcitabine PA Gliadel Wafer PA Halaven PA Herceptin PA Hexalen Hycamtin oral PA hydroxyurea Ibrance PA Iclusig PA idarubicin PA ifosfamide PA ifosfamide-mesna intravenous kit 1-1 gram PA imatinib PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 15 Drug Name Note Requirements/Limits Inlyta PA Intron A injection PA irinotecan PA Istodax PA Ixempra PA Jakafi PA Jevtana PA Kadcyla PA Kyprolis intravenous recon soln 60 mg PA letrozole QL Leukeran leuprolide subcutaneous kit PA lomustine Lupron Depot PA Lupron Depot (3 Month) PA Lupron Depot (4 month) PA Lupron Depot (6 Month) PA Lupron Depot-Ped PA Lupron Depot-Ped (3 month) PA Lysodren Matulane megestrol oral suspension 400 mg/10 mL (40 mg/mL) megestrol oral suspension 625 mg/5 mL QL megestrol oral tablet melphalan HCl PA mercaptopurine methotrexate sodium methotrexate sodium (PF) mitomycin PA mitoxantrone PA Mustargen PA Myleran Nexavar PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 16 Drug Name Note Requirements/Limits nilutamide PA Oncaspar PA oxaliplatin PA paclitaxel PA pentostatin PA Perjeta PA Photofrin PA Pomalyst PA Proleukin PA Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25 mg, 5 mg PA Rheumatrex Rituxan PA Sprycel PA Stivarga PA Supprelin LA PA Sutent oral capsule 12.5 mg, 25 mg, 50 mg PA Sylatron 4-Pack subcutaneous kit 200 mcg, 300 mcg PA Synribo PA Tabloid tamoxifen GL Tarceva PA Tasigna PA Temodar PA teniposide PA thiotepa PA topotecan PA Torisel PA Treanda intravenous recon soln PA Trelstar intramuscular syringe PA tretinoin (chemotherapy) PA Trexall oral tablet 7.5 mg Trisenox PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 17 Drug Name Note Requirements/Limits Tykerb PA Valstar PA Vantas PA Vectibix PA Velcade PA Vidaza PA vinblastine PA vincristine PA vinorelbine PA Votrient PA Xalkori PA Xtandi PA Yervoy PA Zaltrap PA Zanosar PA Zelboraf PA Zevalin (Y-90) PA Zoladex PA Zolinza PA Zykadia PA Zytiga PA Autonomic Drugs Alpha- And Beta-Adrenergic Agonists Alavert D-12 Allergy-Sinus cetirizine-pseudoephedrine epinephrine injection solution epinephrine injection syringe 0.1 mg/mL EpiPen 2-Pak QL EpiPen Jr 2-Pak QL Loratadine-D oral tablet extended release 24 hr Alpha-Adrenergic Agonists clonidine clonidine HCl oral tablet AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 18 Drug Name Note Requirements/Limits Clorpres methyldopa methyldopa-hydrochlorothiazide midodrine Promethazine VC Antimuscarinics/Antispasmodics Anoro Ellipta Atrovent HFA Combivent Respimat dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet diphenoxylate-atropine glycopyrrolate oral hyoscyamine sulfate oral Incruse Ellipta ipratropium bromide inhalation ipratropium-albuterol propantheline Spiriva Respimat Antiparkinsonian Agents benztropine oral trihexyphenidyl Autonomic Drugs, Miscellaneous Chantix QL Chantix Starting Month Box QL Nicotrol PA Nicotrol NS PA; QL Centrally Acting Skeletal Muscle Relaxnt carisoprodol oral tablet 350 mg ST; QL chlorzoxazone cyclobenzaprine oral tablet 10 mg, 5 mg AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 19 Drug Name Note Requirements/Limits methocarbamol oral tizanidine oral tablet Gaba-Derivative Skeletal Muscle Relaxant baclofen Lioresal PA Non-Sel. Beta-Adrenergic Blocking Agents carvedilol labetalol oral nadolol nadolol-bendroflumethiazide pindolol propranolol oral propranolol-hydrochlorothiazid Sotalol AF oral tablet 160 mg, 80 mg sotalol oral tablet 120 mg, 240 mg timolol maleate oral Non-Sel.Alpha-1-Adrenergic Blocking Agts doxazosin prazosin oral terazosin Non-Sel.Alpha-Adrenergic Blocking Agents dihydroergotamine injection Ergomar ergotamine-caffeine Migranal QL phenoxybenzamine Parasympathomimetic (Cholinergic Agents) bethanechol chloride AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 20 Drug Name Note Requirements/Limits donepezil oral tablet 10 mg, 5 mg AL donepezil oral tablet,disintegrating AL Exelon transdermal AL Mestinon oral syrup Prostigmin AL pyridostigmine bromide rivastigmine tartrate AL Selective Alpha-1-Adrenergic Block.Agent alfuzosin carvedilol labetalol oral tamsulosin GL Selective Beta-2-Adrenergic Agonists albuterol sulfate inhalation solution for nebulization albuterol sulfate oral syrup albuterol sulfate oral tablet Anoro Ellipta Breo Ellipta Combivent Respimat Dulera QL; AL ipratropium-albuterol metaproterenol oral syrup Serevent Diskus terbutaline oral Ventolin HFA QL Xopenex HFA ST Selective Beta-Adrenergic Blocking Agent acebutolol atenolol atenolol-chlorthalidone AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 21 Drug Name Note Requirements/Limits bisoprolol fumarate bisoprolol-hydrochlorothiazide metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg Skeletal Muscle Relaxants, Miscellaneous Botox PA Dysport PA Myobloc PA Xeomin PA Blood Formation,Coagulation & Thrombosis Coumarin Derivatives warfarin Direct Factor Xa Inhibitors Eliquis Xarelto Direct Thrombin Inhibitors Pradaxa Hematopoietic Agents Aranesp (in polysorbate) PA Epogen injection solution 10,000 unit/mL, 2,000 unit/mL, 20,000 unit/2 mL, 20,000 unit/mL, 3,000 unit/mL, 4,000 unit/mL PA Granix PA Leukine injection recon soln PA Mozobil PA Neulasta PA Neumega PA Neupogen PA Nplate PA Omontys PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 22 Drug Name Note Requirements/Limits Procrit PA Promacta PA Zarxio PA Hemorrheologic Agents pentoxifylline Hemostatics Advate PA Alphanate intravenous recon soln 1,000 (400 vWF) unit/10 mL, 1,500 (600 vWF) unit/10 mL, 250 (100 vWF) unit/5 mL, 500 (200 vWF) unit/5 mL PA AlphaNine SD PA Amicar oral solution aminocaproic acid intravenous PA aminocaproic acid oral tablet BeneFIX PA Corifact PA desmopressin nasal solution PA desmopressin nasal spray,non-aerosol PA desmopressin oral PA Feiba NF PA Hemofil M High PA Hemofil M Low PA Hemofil M Mid PA Hemofil M Super High PA Humate-P intravenous kit 1,000-2,400 unit PA Kogenate FS intravenous recon soln 2,000 (+/-) unit, 3,000 (+/-) unit PA Monoclate-P intravenous recon soln 1,000 (+/-) unit PA Mononine PA Novoseven RT PA Profilnine PA Recombinate intravenous recon soln 1,000 (+/-) unit, 1,500 (+/-) unit, 250 (+/-) unit, 500 (+/-) unit PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 23 Drug Name Note Requirements/Limits Wilate intravenous kit PA Xyntha PA Xyntha Solofuse PA Heparins enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 100 mg/mL, 120 mg/0.8 mL, 150 mg/mL, 30 mg/0.3 mL, 40 mg/0.4 mL, 60 mg/0.6 mL, 80 mg/0.8 mL QL heparin (porcine) in 5 % dex PA heparin (porcine) in NaCl (PF) intravenous parenteral solution 1,000 unit/500 mL, 2,000 unit/1,000 mL PA heparin (porcine) injection solution heparin, porcine (PF) injection solution 5,000 unit/0.5 mL heparin, porcine (PF) intravenous solution 25,000 unit/10 mL PA Iron Preparations Adults' Daily Formula Atabex EC Dexferrum PA FE C Plus Feraheme PA Ferrlecit PA iNatal Advance iNatal Ultra Infed PA Injectafer PA Multigen Multigen Folic Multigen Plus Multi-Vit with Fluoride-Iron M-Vit Mynatal oral capsule Mynatal Plus AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 24 Drug Name Note Requirements/Limits Mynatal-Z Natalvit Obstetrix DHA Obstetrix EC O-Cal FA O-Cal Prenatal PNV Folic Acid + Iron PrenaPlus Prenatabs FA Prenatal 19 Prenatal 19 (with docusate) Prenatal AD Prenatal Plus Prenatal Plus with Iron (Ca) prenatal vit-iron fumarate-FA Se-Natal 19 TriAdvance Trinatal Rx 1 Trinatal Ultra Trinate Triveen-Duo DHA Tri-Vit with Fluoride and Iron Venofer intravenous solution 100 mg iron/5 mL, 50 mg iron/2.5 mL PA Vinate GT Vinate II Vinate One Vinate Ultra Vol-Nate Platelet-Aggregation Inhibitors aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (DR/EC) 325 mg, 500 mg, 81 mg AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 25 Drug Name Note Requirements/Limits aspirin rectal aspirin-dipyridamole butalbital-aspirin-caffeine cilostazol clopidogrel dipyridamole oral ticlopidine Thrombolytic Agents Activase intravenous recon soln 50 mg PA aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (DR/EC) 325 mg, 500 mg, 81 mg aspirin rectal butalbital-aspirin-caffeine Cathflo Activase PA Cardiovascular Drugs Alpha-Adrenergic Blocking Agents carvedilol doxazosin labetalol oral prazosin oral terazosin Alpha-Adrenergic Blocking Agt.(Hypoten) doxazosin labetalol oral prazosin oral terazosin Angiotensin Ii Receptor Antagon.(Hypotn) Avalide oral tablet 150-12.5 mg ST irbesartan ST AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 26 Drug Name irbesartan-hydrochlorothiazide Note Requirements/Limits ST losartan losartan-hydrochlorothiazide valsartan ST valsartan-hydrochlorothiazide ST Angiotensin Ii Receptor Antagonists Avalide oral tablet 150-12.5 mg ST irbesartan ST irbesartan-hydrochlorothiazide ST losartan losartan-hydrochlorothiazide valsartan ST valsartan-hydrochlorothiazide ST Angiotensin-Convert.Enzyme Inhib(Hypotn) amlodipine-benazepril benazepril benazepril-hydrochlorothiazide captopril captopril-hydrochlorothiazide enalapril maleate enalapril-hydrochlorothiazide fosinopril fosinopril-hydrochlorothiazide lisinopril lisinopril-hydrochlorothiazide moexipril moexipril-hydrochlorothiazide perindopril erbumine quinapril quinapril-hydrochlorothiazide ramipril trandolapril AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 27 Drug Name Angiotensin-Converting Enzyme Inhibitors Note Requirements/Limits amlodipine-benazepril benazepril benazepril-hydrochlorothiazide captopril captopril-hydrochlorothiazide enalapril maleate enalapril-hydrochlorothiazide fosinopril fosinopril-hydrochlorothiazide lisinopril lisinopril-hydrochlorothiazide moexipril moexipril-hydrochlorothiazide perindopril erbumine quinapril quinapril-hydrochlorothiazide ramipril trandolapril Antiarrhythmics, Miscellaneous Digox digoxin oral solution magnesium sulfate injection PA Antilipemic Agents, Miscellaneous Juxtapid PA Kynamro PA niacin oral capsule, extended release 250 mg niacin oral tablet 500 mg niacin oral tablet extended release 250 mg, 500 mg, 750 mg Beta-Adrenergic Blocking Agents acebutolol AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 28 Drug Name Note Requirements/Limits atenolol atenolol-chlorthalidone bisoprolol fumarate bisoprolol-hydrochlorothiazide carvedilol labetalol oral metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol nadolol-bendroflumethiazide pindolol propranolol oral propranolol-hydrochlorothiazid Sotalol AF oral tablet 160 mg, 80 mg sotalol oral tablet 120 mg, 240 mg timolol maleate oral Beta-Adrenergic Blocking Agt.(Hypoten) acebutolol atenolol atenolol-chlorthalidone bisoprolol fumarate bisoprolol-hydrochlorothiazide labetalol oral metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol nadolol-bendroflumethiazide pindolol propranolol oral AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 29 Drug Name Note Requirements/Limits propranolol-hydrochlorothiazid Sotalol AF oral tablet 160 mg, 80 mg sotalol oral tablet 120 mg, 240 mg timolol maleate oral Bile Acid Sequestrants cholestyramine (with sugar) Cholestyramine Light oral powder in packet colestipol Prevalite oral powder WelChol Calcium-Channel Block.Agt,Misc(Hypoten) diltiazem HCl oral capsule, extended release diltiazem HCl oral capsule,ext release degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem HCl oral tablet verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release Calcium-Channel Blocking Agents, Misc. diltiazem HCl oral capsule, extended release diltiazem HCl oral capsule,ext release degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem HCl oral tablet verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release Carbonic Anhydrase Inhibitors(Hypoten) AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 30 Drug Name Note Requirements/Limits acetazolamide Cardiotonic Agents Digox digoxin oral solution Central Alpha-Agonists clonidine clonidine HCl oral tablet Clorpres guanfacine oral tablet guanfacine oral tablet extended release 24 hr AL methyldopa methyldopa-hydrochlorothiazide Class Ia Antiarrhythmics disopyramide phosphate oral capsule quinidine gluconate oral quinidine sulfate Class Ib Antiarrhythmics Dilantin mexiletine phenytoin oral suspension phenytoin oral tablet,chewable phenytoin sodium extended oral capsule 100 mg Class Ic Antiarrhythmics flecainide propafenone oral tablet Class Ii Antiarrhythmics acebutolol atenolol atenolol-chlorthalidone bisoprolol fumarate bisoprolol-hydrochlorothiazide carvedilol labetalol oral AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 31 Drug Name Note Requirements/Limits metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol nadolol-bendroflumethiazide pindolol propranolol oral propranolol-hydrochlorothiazid Sotalol AF oral tablet 160 mg, 80 mg sotalol oral tablet 120 mg, 240 mg timolol maleate oral Class Iii Antiarrhythmics amiodarone oral tablet 200 mg, 400 mg Pacerone oral tablet 100 mg Sotalol AF oral tablet 160 mg, 80 mg sotalol oral tablet 120 mg, 240 mg Class Iv Antiarrhythmics diltiazem HCl oral capsule, extended release diltiazem HCl oral capsule,ext release degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem HCl oral tablet verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release Dihydropyridines amlodipine amlodipine-benazepril felodipine nicardipine oral Nifediac CC oral tablet extended release 30 mg, 60 mg AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 32 Drug Name Note Requirements/Limits nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 90 mg Dihydropyridines (Hypotensive Agents) amlodipine amlodipine-benazepril felodipine nicardipine oral Nifediac CC oral tablet extended release 30 mg, 60 mg nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 90 mg Direct Vasodilators hydralazine oral minoxidil oral Diuretics, Miscellaneous (Hypotensive) Theo-24 theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 24 hr Fibric Acid Derivatives fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized fenofibrate oral tablet 160 mg, 54 mg gemfibrozil oral Hmg-Coa Reductase Inhibitors atorvastatin lovastatin pravastatin simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Hypotensive Agents, Miscellaneous AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 33 Drug Name Note Requirements/Limits acebutolol carvedilol doxazosin nicardipine oral phenoxybenzamine pindolol propranolol oral Sotalol AF oral tablet 160 mg, 80 mg sotalol oral tablet 120 mg, 240 mg terazosin timolol maleate oral Loop Diuretics (Hypotensive Agents) bumetanide oral furosemide oral torsemide oral Mineralocorticoid (Aldosterone) Antagnts Aldactazide oral tablet 50-50 mg spironolactone spironolacton-hydrochlorothiaz Mineralocorticoid(Aldoster.)Antag(Hyp ot) Aldactazide oral tablet 50-50 mg spironolactone spironolacton-hydrochlorothiaz Nitrates And Nitrites Isordil isosorbide dinitrate oral isosorbide mononitrate Nitro-Bid Nitro-Dur transdermal patch 24 hour 0.3 mg/hr, 0.8 mg/hr nitroglycerin oral capsule, extended release 2.5 mg, 6.5 mg AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 34 Drug Name Note Requirements/Limits nitroglycerin transdermal patch 24 hour Nitrostat Nitro-Time oral capsule, extended release 9 mg Pcsk9 Inhibitors Praluent Pen PA Praluent Syringe PA Repatha Pushtronex PA Repatha SureClick PA Repatha Syringe PA Peripheral Adrenergic Inhibitors reserpine Phosphodiesterase Type 5 Inhibitors Adcirca PA cilostazol Revatio intravenous PA Revatio oral suspension for reconstitution PA sildenafil oral PA Potassium-Sparing Diuretics (Hypoten) Aldactazide oral tablet 50-50 mg amiloride amiloride-hydrochlorothiazide Dyrenium spironolactone spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid Thiazide Diuretics(Hypotensive Agents) Aldactazide oral tablet 50-50 mg amiloride-hydrochlorothiazide Avalide oral tablet 150-12.5 mg ST benazepril-hydrochlorothiazide bisoprolol-hydrochlorothiazide captopril-hydrochlorothiazide chlorothiazide AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 35 Drug Name Note Requirements/Limits Diuril enalapril-hydrochlorothiazide fosinopril-hydrochlorothiazide hydrochlorothiazide irbesartan-hydrochlorothiazide ST lisinopril-hydrochlorothiazide losartan-hydrochlorothiazide methyclothiazide methyldopa-hydrochlorothiazide metoprolol ta-hydrochlorothiaz moexipril-hydrochlorothiazide nadolol-bendroflumethiazide propranolol-hydrochlorothiazid quinapril-hydrochlorothiazide spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid valsartan-hydrochlorothiazide ST Thiazide-Like Diuretics(Hypotensive Agt) atenolol-chlorthalidone chlorthalidone oral tablet 25 mg, 50 mg Clorpres indapamide metolazone Vasodilating Agents, Miscellaneous Adempas PA amlodipine amlodipine-benazepril aspirin-dipyridamole diltiazem HCl oral capsule, extended release diltiazem HCl oral capsule,ext release degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 36 Drug Name Note Requirements/Limits diltiazem HCl oral tablet dipyridamole oral epoprostenol (glycine) PA Letairis PA nicardipine oral Nifediac CC oral tablet extended release 30 mg, 60 mg nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 90 mg Opsumit PA Orenitram PA Remodulin PA Tracleer PA Tyvaso PA Tyvaso Refill Kit PA Tyvaso Starter Kit PA Uptravi PA Veletri PA Ventavis PA verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release Cellular Therapy Cellular Therapy Provenge PA Central Nervous System Agents Adamantanes (Cns) amantadine HCl oral capsule amantadine HCl oral solution Amphetamines dextroamphetamine oral capsule, extended release AL dextroamphetamine oral tablet AL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 37 Drug Name Note Requirements/Limits dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg AL dextroamphetamine-amphetamine oral tablet AL Vyvanse AL Analgesics And Antipyretics, Misc. acetaminophen oral drops 100 mg/mL acetaminophen oral elixir acetaminophen oral liquid 160 mg/5 mL acetaminophen oral suspension 160 mg/5 mL acetaminophen oral tablet 500 mg acetaminophen rectal acetaminophen-codeine oral solution 120-12 mg/5 mL acetaminophen-codeine oral tablet butalbital-acetaminop-caf-cod oral capsule 50325-40-30 mg butalbital-acetaminophen butalbital-acetaminophen-caff oral tablet 50-32540 mg gabapentin oral capsule gabapentin oral solution 250 mg/5 mL gabapentin oral tablet 600 mg, 800 mg hydrocodone-acetaminophen oral solution 7.5325 mg/15 mL, 7.5-500 mg/15 mL hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg Non-Aspirin Jr Strength oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg QL Prialt PA tramadol-acetaminophen Anticholinergic Agents (Cns) benztropine oral trihexyphenidyl AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 38 Drug Name Anticonvulsants, Miscellaneous Banzel Note Requirements/Limits PA carbamazepine oral suspension 100 mg/5 mL carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable divalproex gabapentin oral capsule gabapentin oral solution 250 mg/5 mL gabapentin oral tablet 600 mg, 800 mg Lamictal Starter (Blue) Kit Lamictal Starter (Green) Kit Lamictal Starter (Orange) Kit lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible levetiracetam intravenous PA levetiracetam oral solution 100 mg/mL levetiracetam oral tablet magnesium sulfate injection PA oxcarbazepine oral tablet Sabril PA topiramate oral capsule, sprinkle topiramate oral tablet valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 mL zonisamide Antidepressants, Miscellaneous bupropion HCl mirtazapine Antimanic Agents divalproex lithium carbonate AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 39 Drug Name Note Requirements/Limits lithium citrate oral solution 8 mEq/5 mL valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 mL Antimigraine Agents, Miscellaneous aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (DR/EC) 325 mg, 500 mg, 81 mg aspirin rectal Butalbital Compound W/Codeine butalbital-acetaminop-caf-cod oral capsule 50325-40-30 mg butalbital-acetaminophen-caff oral tablet 50-32540 mg butalbital-aspirin-caffeine dihydroergotamine injection divalproex Ergomar ergotamine-caffeine Migranal QL propranolol oral timolol maleate oral tramadol-acetaminophen valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 mL Antipsychotics, Miscellaneous loxapine succinate AL pimozide AL Anxiolytics, Sedatives & Hypnotics,Misc. buspirone droperidol injection solution AL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 40 Drug Name eszopiclone Note Requirements/Limits ST meprobamate promethazine injection promethazine oral syrup promethazine oral tablet 25 mg, 50 mg promethazine rectal suppository 12.5 mg, 25 mg zaleplon zolpidem oral tablet Atypical Antipsychotics Abilify Maintena PA; AL aripiprazole oral solution AL aripiprazole oral tablet AL Aristada PA; AL clozapine AL Fanapt AL Geodon intramuscular AL Invega Sustenna PA; AL Invega Trinza PA; AL Latuda AL olanzapine intramuscular AL olanzapine oral AL olanzapine-fluoxetine AL paliperidone AL quetiapine AL Risperdal Consta PA; AL risperidone oral solution AL risperidone oral tablet AL risperidone oral tablet,disintegrating AL Seroquel XR oral tablet extended release 24 hr AL ziprasidone HCl AL Zyprexa Relprevv PA; AL Barbiturates (Anticonvulsants) phenobarbital AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 41 Drug Name Note Requirements/Limits primidone Barbiturates (Anxiolytic, Sedative/Hyp) Butalbital Compound W/Codeine butalbital-acetaminop-caf-cod oral capsule 50325-40-30 mg butalbital-acetaminophen butalbital-acetaminophen-caff oral tablet 50-32540 mg butalbital-aspirin-caffeine phenobarbital Benzodiazepines (Anticonvulsants) clonazepam oral tablet clorazepate dipotassium Diazepam Intensol diazepam oral solution diazepam oral tablet diazepam rectal QL lorazepam oral Benzodiazepines (Anxiolytic,Sedativ/Hyp) alprazolam oral tablet amitriptyline-chlordiazepoxide chlordiazepoxide HCl clonazepam oral tablet clorazepate dipotassium Diazepam Intensol diazepam oral solution diazepam oral tablet diazepam rectal QL estazolam lorazepam oral oxazepam temazepam oral capsule 15 mg, 30 mg triazolam AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 42 Drug Name Butyrophenones Note Requirements/Limits haloperidol AL haloperidol decanoate AL haloperidol lactate AL Central Nervous System Agents, Misc. guanfacine oral tablet guanfacine oral tablet extended release 24 hr AL memantine oral tablet AL memantine oral tablets,dose pack riluzole PA Strattera AL Xenazine PA Cyclooxygenase-2 (Cox-2) Inhibitors celecoxib ST Dopamine Precursors carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release Ergot-Deriv. Dopamine Receptor Agonists bromocriptine cabergoline PA Fibromyalgia Agents duloxetine oral capsule,delayed release(DR/EC) 20 mg, 30 mg, 60 mg Savella Hydantoins Dilantin phenytoin oral suspension phenytoin oral tablet,chewable phenytoin sodium extended oral capsule 100 mg Monoamine Oxidase B Inhibitors selegiline HCl Monoamine Oxidase Inhibitors AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 43 Drug Name Note Requirements/Limits phenelzine selegiline HCl tranylcypromine Nonergot-Deriv.Dopamine Receptor Agonist APOKYN PA pramipexole oral tablet ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg Opiate Agonists acetaminophen-codeine oral solution 120-12 mg/5 mL acetaminophen-codeine oral tablet Butalbital Compound W/Codeine butalbital-acetaminop-caf-cod oral capsule 50325-40-30 mg codeine sulfate oral tablet Endodan QL fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr QL hydrocodone-acetaminophen oral solution 7.5325 mg/15 mL, 7.5-500 mg/15 mL hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg hydromorphone oral liquid hydromorphone oral tablet hydromorphone rectal meperidine oral methadone oral concentrate methadone oral solution methadone oral tablet morphine concentrate oral solution morphine oral solution morphine oral tablet morphine oral tablet extended release AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 44 Drug Name Note Requirements/Limits morphine rectal oxycodone oral capsule QL oxycodone oral concentrate oxycodone oral tablet QL oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg QL tramadol oral tablet tramadol-acetaminophen Opiate Antagonists Evzio PA naltrexone Narcan QL Vivitrol PA Opiate Partial Agonists buprenorphine-naloxone PA butorphanol tartrate nasal PA; QL nalbuphine Suboxone PA Zubsolv PA Other Nonsteroidal Anti-Inflam. Agents diclofenac potassium diclofenac sodium oral diflunisal etodolac oral capsule etodolac oral tablet fenoprofen oral tablet Ibuprofen IB oral tablet ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule ketoprofen oral capsule ketorolac oral QL meclofenamate oral AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 45 Drug Name Note Requirements/Limits meloxicam oral tablet nabumetone naproxen naproxen sodium oral tablet oxaprozin piroxicam sulindac oral Phenothiazines chlorpromazine AL fluphenazine decanoate AL fluphenazine HCl injection AL fluphenazine HCl oral tablet AL perphenazine AL perphenazine-amitriptyline AL prochlorperazine AL prochlorperazine Edisylate AL prochlorperazine maleate oral AL thioridazine trifluoperazine AL Respiratory And Cns Stimulants Butalbital Compound W/Codeine butalbital-acetaminop-caf-cod oral capsule 50325-40-30 mg butalbital-acetaminophen-caff oral tablet 50-32540 mg butalbital-aspirin-caffeine caffeine citrated oral dexmethylphenidate AL Focalin XR oral capsule,ER biphasic 50-50 25 mg, 35 mg AL methylphenidate oral solution 10 mg/5 mL AL methylphenidate oral tablet AL methylphenidate oral tablet extended release 20 mg AL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 46 Drug Name Note Requirements/Limits methylphenidate oral tablet extended release 24hr AL methylphenidate oral tablet,chewable AL Salicylates aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (DR/EC) 325 mg, 500 mg, 81 mg aspirin rectal aspirin-dipyridamole Butalbital Compound W/Codeine butalbital-aspirin-caffeine choline,magnesium salicylate Endodan QL salsalate Sel. Serotonin & Norepi Reuptake Inhibtr duloxetine oral capsule,delayed release(DR/EC) 20 mg, 30 mg, 60 mg Savella venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet Selective Serotonin Agonists Imitrex nasal spray,non-aerosol 5 mg/actuation QL naratriptan rizatriptan QL sumatriptan nasal spray,non-aerosol 20 mg/actuation QL sumatriptan succinate oral QL sumatriptan succinate subcutaneous cartridge QL sumatriptan succinate subcutaneous pen injector QL sumatriptan succinate subcutaneous solution QL Selective-Serotonin Reuptake Inhibitors citalopram escitalopram oxalate AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 47 Drug Name Note Requirements/Limits fluoxetine oral capsule fluoxetine oral solution fluvoxamine oral tablet olanzapine-fluoxetine AL paroxetine HCl oral tablet paroxetine HCl oral tablet extended release 24 hr AL Paxil oral suspension sertraline Serotonin Modulators nefazodone trazodone Succinimides ethosuximide Thioxanthenes thiothixene AL Trycyclics & Other Norepineph.-Ru Inhib amitriptyline amitriptyline-chlordiazepoxide amoxapine clomipramine desipramine oral doxepin oral imipramine HCl maprotiline nortriptyline perphenazine-amitriptyline AL Contraceptives (E.G. Foams, Devices) Contraceptives (E.G. Foams, Devices) Vaginal Contraceptive Foam Devices Devices Accu-Chek Aviva Control Soln AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 48 Drug Name Note Requirements/Limits Accu-Chek Aviva Plus Meter QL Accu-Chek FastClix QL Accu-Chek FastClix kit Accu-Chek Multiclix Lancet QL Accu-Chek Multiclix Lancet kit Accu-Chek Nano QL Accu-Chek SmartView Contrl Sol Accu-Chek Soft Dev Lancets Accu-Chek Softclix Lancet Dev Accu-Chek Softclix Lancets Aerochamber Plus Flow-Vu Euflexxa PA Gel-One PA Hyalgan PA Insulin Syringe syringe 0.5 mL 29 gauge x 1/2" lancets Monovisc PA ORTHOVISC PA pen needle, diabetic needle 29 gauge x 1/2" sodium chloride inhalation solution for nebulization 0.9 % QL Soft Touch Lancets Solesta PA Supartz FX PA Synvisc PA Synvisc-One PA Diagnostic Agents Adrenocortical Insufficiency Acthar H.P. PA cosyntropin injection PA Diabetes Mellitus Accu-Chek Aviva Plus test strp QL Accu-Chek SmartView Test Strip QL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 49 Drug Name Thyroid Function Thyrogen Note Requirements/Limits PA Electrolytic, Caloric, And Water Balance Alkalinizing Agents Oracit potassium citrate oral tablet extended release 10 mEq (1,080 mg), 5 mEq (540 mg) sodium citrate-citric acid Ammonia Detoxicants Carbaglu PA lactulose oral solution 10 gram/15 mL Caloric Agents Clinisol SF 15 % PA D5 %-0.45 % sodium chloride PA dextrose 70 % in water (D70W) PA Intralipid intravenous emulsion 20 % PA Liposyn III intravenous emulsion 10 %, 30 % PA Prosol 20 % PA Travasol 10 % PA TrophAmine 10 % PA Carbonic Anhydrase Inhibitors acetazolamide Diuretics, Miscellaneous Theo-24 theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 24 hr Loop Diuretics bumetanide oral furosemide oral torsemide oral Phosphate-Removing Agents calcium acetate oral capsule AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 50 Drug Name Note Requirements/Limits Renvela oral tablet Potassium-Removing Agents sodium polystyrene (sorb free) SPS rectal Potassium-Sparing Diuretics Aldactazide oral tablet 50-50 mg amiloride amiloride-hydrochlorothiazide Dyrenium spironolactone spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid Replacement Preparations Atabex EC iNatal Advance iNatal Ultra Klor-Con Klor-Con/25 Mynatal oral capsule Mynatal Plus Mynatal-Z Natalvit O-Cal FA O-Cal Prenatal potassium bicarb-citric acid potassium chloride oral capsule, extended release 10 mEq potassium chloride oral liquid potassium chloride oral tablet extended release 10 mEq, 8 mEq potassium chloride oral tablet,ER particles/crystals PrenaPlus Prenatabs FA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 51 Drug Name Note Requirements/Limits Prenatal AD Prenatal Plus Prenatal Plus with Iron (Ca) prenatal vit-iron fumarate-FA sodium chloride inhalation solution for nebulization 0.9 % QL TPN Electrolytes PA TPN Electrolytes II PA TriAdvance Trinatal Rx 1 Trinatal Ultra Trinate Triveen-Duo DHA Vinate II Vinate One Vinate Ultra Vol-Nate Thiazide Diuretics Aldactazide oral tablet 50-50 mg amiloride-hydrochlorothiazide Avalide oral tablet 150-12.5 mg ST benazepril-hydrochlorothiazide bisoprolol-hydrochlorothiazide captopril-hydrochlorothiazide chlorothiazide Diuril enalapril-hydrochlorothiazide fosinopril-hydrochlorothiazide hydrochlorothiazide irbesartan-hydrochlorothiazide ST lisinopril-hydrochlorothiazide losartan-hydrochlorothiazide methyclothiazide methyldopa-hydrochlorothiazide AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 52 Drug Name Note Requirements/Limits metoprolol ta-hydrochlorothiaz moexipril-hydrochlorothiazide nadolol-bendroflumethiazide propranolol-hydrochlorothiazid quinapril-hydrochlorothiazide spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid valsartan-hydrochlorothiazide ST Thiazide-Like Diuretics atenolol-chlorthalidone chlorthalidone oral tablet 25 mg, 50 mg Clorpres indapamide metolazone Uricosuric Agents colchicine-probenecid probenecid Vasopressin Antagonists Samsca PA Enzymes Enzymes Activase intravenous recon soln 50 mg PA Adagen PA Aldurazyme PA Cathflo Activase PA Cerezyme PA Elaprase PA Elelyso PA Elitek PA Fabrazyme PA Myozyme PA Naglazyme PA Pulmozyme PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 53 Drug Name Note Requirements/Limits Sucraid PA Voraxaze PA VPRIV PA Xiaflex PA Eye, Ear, Nose And Throat (Eent) Preps. Alpha-Adrenergic Agonists (Eent) brimonidine Antiallergic Agents azelastine nasal cromolyn ophthalmic ketotifen fumarate Pataday ST; QL Antibacterials (Eent) bacitracin-polymyxin B ophthalmic Ciprodex ciprofloxacin HCl ophthalmic doxycycline hyclate oral tablet 20 mg erythromycin ophthalmic Gentak ophthalmic ointment gentamicin ophthalmic drops Moxeza neomycin-bacitracin-poly-HC neomycin-bacitracin-polymyxin neomycin-polymyxin B-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-HC ofloxacin ophthalmic ofloxacin otic polymyxin B sulf-trimethoprim sulfacetamide sodium ophthalmic drops sulfacetamide-prednisolone tobramycin AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 54 Drug Name Note Requirements/Limits tobramycin-dexamethasone Tobrex ophthalmic ointment Vigamox Antivirals (Eent) trifluridine Beta-Adrenergic Blocking Agents (Eent) carteolol dorzolamide-timolol QL levobunolol metipranolol timolol maleate ophthalmic Carbonic Anhydrase Inhibitors (Eent) acetazolamide Azopt dorzolamide dorzolamide-timolol QL Corticosteroids (Eent) Ciprodex dexamethasone sodium phosphate ophthalmic Flarex fluorometholone fluticasone nasal FML Forte FML S.O.P. Maxidex neomycin-bacitracin-poly-HC neomycin-polymyxin B-dexameth neomycin-polymyxin-HC ophthalmic Ozurdex PA Pred Mild prednisolone acetate prednisolone sodium phosphate ophthalmic Retisert PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 55 Drug Name Note Requirements/Limits tobramycin-dexamethasone Eent Anti-Infectives, Miscellaneous Acetasol HC acetic acid otic acetic acid-aluminum acetate chlorhexidine gluconate mucous membrane Eent Anti-Inflammatory Agents, Misc. Restasis PA Eent Drugs, Miscellaneous apraclonidine Eylea PA Iopidine ophthalmic dropperette ipratropium bromide nasal Jetrea (PF) PA Lucentis PA Macugen PA Visudyne PA Eent Nonsteroidal Anti-Inflam. Agents diclofenac sodium ophthalmic flurbiprofen sodium ketorolac ophthalmic Local Anesthetics (Eent) antipyrine-benzocaine otic drops 5.4-1.4 % lidocaine HCl mucous membrane jelly in applicator lidocaine HCl mucous membrane solution 4 % (40 mg/mL) Lidocaine Viscous proparacaine tetracaine HCl tetracaine HCl (PF) ophthalmic Miotics Isopto Carbachol AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 56 Drug Name Note Requirements/Limits Phospholine Iodide pilocarpine HCl ophthalmic drops 1 %, 2 %, 4 % Mydriatics atropine ophthalmic cyclopentolate ophthalmic drops 1 %, 2 % tropicamide ophthalmic Prostaglandin Analogs latanoprost Vasoconstrictors naphazoline phenylephrine HCl ophthalmic Gastrointestinal Drugs 5-Ht3 Receptor Antagonists Aloxi PA Anzemet intravenous PA granisetron (PF) PA granisetron HCl intravenous PA ondansetron QL ondansetron HCl (PF) injection solution PA ondansetron HCl intravenous PA ondansetron HCl oral solution QL ondansetron HCl oral tablet 4 mg, 8 mg QL Antidiarrhea Agents diphenoxylate-atropine loperamide oral capsule Antiemetics, Miscellaneous Diclegis PA; GL Antihistamines (Gi Drugs) Diclegis PA; GL meclizine oral tablet 12.5 mg, 25 mg prochlorperazine AL prochlorperazine Edisylate AL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 57 Drug Name prochlorperazine maleate oral Note Requirements/Limits AL trimethobenzamide intramuscular solution trimethobenzamide oral Anti-Inflammatory Agents (Gi Drugs) balsalazide Canasa Delzicol oral capsule,delayed release(DR/EC) Dipentum Lialda mesalamine rectal Pentasa sulfasalazine Cathartics And Laxatives Amitiza Atabex EC iNatal Ultra Obstetrix EC peg 3350-electrolytes peg-electrolyte soln polyethylene glycol 3350 oral powder Trinatal Ultra Vinate Ultra Cholelitholytic Agents ursodiol Digestants Creon Pancrelipase 5000 Zenpep oral capsule,delayed release(DR/EC) 10,000-34,000 -55,000 unit, 15,000-51,000 82,000 unit, 20,000-68,000 -109,000 unit, 25,00085,000- 136,000 unit, 3,000-10,000- 16,000 unit, 40,000-136,000- 218,000 unit Gi Drugs, Miscellaneous Cimzia PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 58 Drug Name Note Requirements/Limits Cimzia Powder for Reconst PA Entyvio PA Gattex 30-Vial PA Humira PA Humira Pen Crohn's-UC-HS Start PA Linzess AL Remicade PA Histamine H2-Antagonists cimetidine cimetidine HCl oral famotidine oral nizatidine ranitidine HCl injection solution 50 mg/2 mL (25 mg/mL) PA ranitidine HCl oral syrup ranitidine HCl oral tablet Neurokinin-1 Receptor Antagonists Emend oral capsule 125 mg, 80 mg Emend oral capsule 40 mg QL Emend oral capsule,dose pack Prokinetic Agents metoclopramide HCl oral solution metoclopramide HCl oral tablet Prostaglandins misoprostol Protectants sucralfate oral tablet Proton-Pump Inhibitors lansoprazole oral capsule,delayed release(DR/EC) ST omeprazole oral capsule,delayed release(DR/EC) omeprazole-sodium bicarbonate oral capsule 201.1 mg-gram ST pantoprazole oral AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 59 Drug Name Note Requirements/Limits Prevacid SoluTab AL Protonix oral granules DR for susp in packet AL Gold Compounds Gold Compounds Ridaura Heavy Metal Antagonists Heavy Metal Antagonists Chemet deferoxamine PA Exjade PA Ferriprox oral tablet PA Galzin PA Jadenu PA Syprine PA Hormones And Synthetic Substitutes Adrenals Arnuity Ellipta Asmanex HFA Asmanex Twisthaler inhalation aerosol powdr breath activated 110 mcg (30 doses), 110 mcg (7 doses), 220 mcg (120 doses), 220 mcg (14 doses), 220 mcg (30 doses), 220 mcg (60 doses) QL Breo Ellipta budesonide inhalation QL; AL cortisone dexamethasone Dexamethasone Intensol dexamethasone sodium phos (PF) dexamethasone sodium phosphate injection solution Dulera QL; AL Flovent Diskus inhalation blister with device 100 mcg/actuation, 250 mcg/actuation, 50 mcg/actuation QL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 60 Drug Name Flovent HFA inhalation HFA aerosol inhaler 110 mcg/actuation, 220 mcg/actuation, 44 mcg/actuation Note Requirements/Limits QL fludrocortisone hydrocortisone oral Medrol oral tablet 2 mg methylprednisolone methylprednisolone sodium succ intravenous PA prednisolone oral solution 15 mg/5 mL prednisolone sodium phosphate oral solution 15 mg/5 mL (3 mg/mL), 5 mg base/5 mL (6.7 mg/5 mL) Prednisone Intensol prednisone oral Pulmicort Flexhaler Qvar inhalation aerosol 40 mcg/actuation, 80 mcg/actuation QL Solu-Cortef (PF) injection recon soln 100 mg/2 mL Androgens AndroGel transdermal gel in metered-dose pump 20.25 mg/1.25 gram (1.62 %) PA AndroGel transdermal gel in packet 1.62 % (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram) PA danazol oral PA fluoxymesterone PA Methitest PA methyltestosterone oral capsule PA Testopel PA testosterone cypionate PA testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation PA Antidiabetic Agents, Miscellaneous WelChol Antithyroid Agents AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 61 Drug Name Note Requirements/Limits methimazole oral tablet 10 mg, 5 mg propylthiouracil SSKI Biguanides glipizide-metformin glyburide-metformin Janumet ST Janumet XR ST metformin oral tablet metformin oral tablet extended release 24 hr Contraceptives Apri Aranelle (28) Aviane Balziva (28) Camila Jolessa Kariva (28) levonorgestrel oral tablet 1.5 mg Levora-28 Liletta GL Low-Ogestrel (28) Microgestin 1.5/30 (21) Microgestin 1/20 (21) Microgestin Fe 1.5/30 (28) Microgestin FE 1/20 (28) Mirena GL Necon 1/50 (28) Necon 10/11 (28) Nexplanon GL norgestrel-ethinyl estradiol Nortrel 0.5/35 (28) Nortrel 1/35 (21) AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 62 Drug Name Note Requirements/Limits Nortrel 7/7/7 (28) NuvaRing ParaGard T 380A GL Skyla GL Sprintec (28) Tri-Sprintec (28) Trivora (28) Velivet Triphasic Regimen (28) Xulane Zovia 1/35E (28) Zovia 1/50E (28) Dipeptidyl Peptidase-4(Dpp-4) Inhibitors Janumet ST Janumet XR ST Januvia ST Estrogen Agonist-Antagonists raloxifene GL Estrogens estradiol oral estradiol transdermal patch semiweekly estradiol transdermal patch weekly 0.025 mg/24 hr, 0.075 mg/24 hr QL estradiol transdermal patch weekly 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.1 mg/24 hr estropipate Femhrt Low Dose GL Jinteli Menest Premarin oral GL Premarin vaginal GL Premphase GL Prempro GL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 63 Drug Name Glycogenolytic Agents Glucagon Emergency Kit (human) Note Requirements/Limits QL Gonadotropins Eligard PA Eligard (3 month) PA Eligard (4 month) PA Eligard (6 month) PA leuprolide subcutaneous kit PA Lupron Depot PA Lupron Depot (3 Month) PA Lupron Depot (4 month) PA Lupron Depot (6 Month) PA Lupron Depot-Ped PA Lupron Depot-Ped (3 month) PA Supprelin LA PA Synarel PA Vantas PA Zoladex PA Incretin Mimetics Victoza 2-Pak ST Victoza 3-Pak ST Insulins Apidra QL Apidra SoloStar QL Humalog QL Humalog KwikPen subcutaneous insulin pen 100 unit/mL QL Humalog Mix 50-50 QL Humalog Mix 50-50 KwikPen QL Humalog Mix 75-25 QL Humalog Mix 75-25 KwikPen QL Humulin 70/30 QL Humulin 70/30 Pen QL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 64 Drug Name Note Requirements/Limits Humulin N QL Humulin N KwikPen QL Humulin R QL Humulin R U-500 (Concentrated) QL Lantus QL Lantus Solostar QL Novolin 70/30 QL Novolin N QL Novolin R QL Novolog QL Novolog Flexpen QL Novolog Mix 70-30 QL Novolog Mix 70-30 FlexPen QL Novolog PenFill QL Parathyroid calcitonin (salmon) Forteo PA Pituitary Acthar H.P. PA desmopressin nasal solution PA desmopressin nasal spray,non-aerosol PA desmopressin oral PA Genotropin PA Genotropin MiniQuick PA Humatrope PA Norditropin FlexPro subcutaneous pen injector 10 mg/1.5 mL (6.7 mg/mL), 15 mg/1.5 mL (10 mg/mL), 5 mg/1.5 mL (3.3 mg/mL) PA Norditropin Nordiflex PA Nutropin AQ PA Nutropin AQ Nuspin subcutaneous pen injector 5 mg/2 mL (2.5 mg/mL) PA Omnitrope PA Saizen click.easy PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 65 Drug Name Note Requirements/Limits Saizen subcutaneous recon soln 8.8 mg PA Serostim subcutaneous recon soln 4 mg, 5 mg, 6 mg PA Progestins Crinone Depo-Provera intramuscular solution GL Femhrt Low Dose GL hydroxyprogesterone capr(bulk) hydroxyprogesterone caproate Jinteli Makena medroxyprogesterone GL norethindrone acetate GL progesterone micronized oral capsule 100 mg GL progesterone micronized oral capsule 200 mg Somatostatin Agonists octreotide acetate PA Sandostatin LAR Depot intramuscular kit PA Signifor PA Somatuline Depot PA Somatotropin Agonists Increlex PA Somatotropin Antagonists Somavert subcutaneous recon soln 10 mg, 15 mg, 20 mg PA Sulfonylureas chlorpropamide glimepiride glipizide glipizide-metformin glyburide micronized glyburide oral glyburide-metformin AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 66 Drug Name Note Requirements/Limits tolazamide tolbutamide Thyroid Agents Armour Thyroid levothyroxine oral liothyronine oral Nature-Throid oral tablet 130 mg, 16.25 mg, 195 mg, 32.5 mg, 65 mg Thyrolar-1 Thyrolar-1/2 Thyrolar-1/4 Thyrolar-2 Thyrolar-3 Miscellaneous Therapeutic Agents 5-Alpha-Reductase Inhibitors finasteride oral tablet 5 mg Alcohol Deterrents disulfiram naltrexone Vivitrol PA Antidotes Chemet deferoxamine PA Evzio PA Glucagon Emergency Kit (human) QL leucovorin calcium injection PA leucovorin calcium oral levoleucovorin calcium intravenous recon soln PA magnesium sulfate injection PA Mephyton Narcan QL Renvela oral tablet sodium polystyrene (sorb free) AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 67 Drug Name Note Requirements/Limits SPS rectal SSKI Voraxaze PA Antigout Agents allopurinol colchicine-probenecid indomethacin oral capsule Krystexxa PA naproxen naproxen sodium oral tablet probenecid Bone Resorption Inhibitors alendronate oral tablet Boniva intravenous PA calcitonin (salmon) etidronate disodium pamidronate PA Prolia PA raloxifene GL Xgeva PA zoledronic acid intravenous solution PA zoledronic acid-mannitol-water intravenous solution PA Zometa PA Cariostatic Agents Clinpro 5000 AL Fluoritab oral drops AL Multi-Vit with Fluoride-Iron Multivitamin With Fluoride Multi-Vitamin With Fluoride oral drops Multi-Vitamin With Fluoride oral tablet,chewable 0.25 mg, 1 mg Multivitamins With Fluoride oral tablet,chewable 1 mg AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 68 Drug Name Note Requirements/Limits SF AL SF 5000 Plus AL sodium fluoride dental AL sodium fluoride oral drops AL sodium fluoride oral tablet,chewable AL Tri-Vit with Fluoride and Iron Tri-Vitamin With Fluoride Complement Inhibitors Berinert intravenous kit PA Cinryze PA Firazyr PA Kalbitor PA Soliris PA Disease-Modifying Antirheumatic Agents Actemra PA azathioprine Cimzia PA Cimzia Powder for Reconst PA cyclosporine intravenous PA cyclosporine modified oral capsule cyclosporine oral capsule Enbrel PA Enbrel SureClick PA Humira PA Humira Pen Crohn's-UC-HS Start PA hydroxychloroquine oral Kineret PA leflunomide methotrexate sodium methotrexate sodium (PF) Orencia PA Orencia (with maltose) PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 69 Drug Name Note Requirements/Limits Orencia ClickJect PA Otezla PA Otezla Starter PA Remicade PA Rheumatrex Ridaura Sandimmune intravenous PA Sandimmune oral solution Simponi PA Simponi ARIA PA Stelara subcutaneous syringe PA sulfasalazine Trexall oral tablet 7.5 mg Xeljanz PA Xeljanz XR PA Gonadotropin-Releasing Hormone Antagnts Firmagon PA Immunomodulatory Agents Actemra PA Actimmune PA Aubagio PA Avonex (with albumin) PA Avonex intramuscular pen injector kit PA Avonex intramuscular syringe kit PA azathioprine Betaseron subcutaneous kit PA Cimzia PA Cimzia Powder for Reconst PA Copaxone subcutaneous syringe PA cyclosporine intravenous PA cyclosporine modified oral capsule cyclosporine oral capsule AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 70 Drug Name Note Requirements/Limits Enbrel PA Enbrel SureClick PA Entyvio PA Extavia PA Gilenya PA Humira PA Humira Pen Crohn's-UC-HS Start PA hydroxychloroquine oral Intron A injection PA Kineret PA leflunomide Lemtrada PA methotrexate sodium methotrexate sodium (PF) Orencia PA Orencia (with maltose) PA Orencia ClickJect PA Plegridy PA Pomalyst PA Proleukin PA Rebif (with albumin) PA Rebif Titration Pack PA Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25 mg, 5 mg PA Rheumatrex Ridaura Sandimmune intravenous PA Sandimmune oral solution Simponi PA Simponi ARIA PA Stelara subcutaneous syringe PA sulfasalazine Tecfidera PA Thalomid PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 71 Drug Name Note Requirements/Limits Trexall oral tablet 7.5 mg Tysabri PA Immunosuppressive Agents Atgam PA azathioprine Benlysta PA CellCept Intravenous PA CellCept oral suspension for reconstitution cyclophosphamide intravenous PA cyclophosphamide oral tablet cyclosporine intravenous PA cyclosporine modified oral capsule cyclosporine oral capsule Elidel PA mercaptopurine methotrexate sodium methotrexate sodium (PF) mycophenolate mofetil mycophenolate sodium PA Prograf intravenous PA Rapamune oral solution PA Rheumatrex Sandimmune intravenous PA Sandimmune oral solution Simulect PA sirolimus PA tacrolimus oral Thymoglobulin PA Trexall oral tablet 7.5 mg Zortress PA Other Miscellaneous Therapeutic Agents acetylcysteine AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 72 Drug Name Note Requirements/Limits Ampyra PA Arcalyst PA Botox PA Cerdelga PA Demser PA Dysport PA Evotaz Ilaris (PF) PA Kuvan PA levocarnitine (with sugar) PA levocarnitine oral tablet Myobloc PA Orfadin PA Panhematin PA Prezcobix Remicade PA Tybost Xeomin PA Zavesca PA Protective Agents amifostine crystalline PA dexrazoxane HCl PA mesna PA Oxytocics Oxytocics methylergonovine oral Respiratory Tract Agents Alpha And Beta Adrenergic Agonist(Respr) Alavert D-12 Allergy-Sinus cetirizine-pseudoephedrine epinephrine injection solution epinephrine injection syringe 0.1 mg/mL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 73 Drug Name Note Requirements/Limits EpiPen 2-Pak QL EpiPen Jr 2-Pak QL Loratadine-D oral tablet extended release 24 hr Anticholinergic Agents (Respir.Tract) Anoro Ellipta Atrovent HFA Combivent Respimat diphenoxylate-atropine Incruse Ellipta ipratropium bromide inhalation ipratropium-albuterol Spiriva Respimat inhalation mist 1.25 mcg/actuation Anti-Inflammatory Agents (Respiratory) Nucala PA Antitussives codeine sulfate oral tablet Cystic Fibrosis (Cftr) Correctors Orkambi PA Cystic Fibrosis (Cftr) Potentiators Kalydeco PA Orkambi PA Expectorants SSKI First Generation Antihist.(Respir Tract) clemastine oral tablet cyproheptadine Diclegis PA; GL Diphenhist oral tablet 50 mg diphenhydramine HCl injection solution 50 mg/mL diphenhydramine HCl injection syringe AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 74 Drug Name Note Requirements/Limits diphenhydramine HCl oral capsule 50 mg diphenhydramine HCl oral syrup ED Chlorped Jr promethazine injection promethazine oral syrup promethazine oral tablet 25 mg, 50 mg Promethazine VC Leukotriene Modifiers montelukast oral granules in packet AL montelukast oral tablet montelukast oral tablet,chewable Mast-Cell Stabilizers cromolyn inhalation cromolyn ophthalmic Mucolytic Agents acetylcysteine Pulmozyme PA Nasal Preparations (Steroids) fluticasone nasal Orally Inhaled Preparations (Steroids) Arnuity Ellipta Asmanex HFA Asmanex Twisthaler inhalation aerosol powdr breath activated 110 mcg (30 doses), 110 mcg (7 doses), 220 mcg (120 doses), 220 mcg (14 doses), 220 mcg (30 doses), 220 mcg (60 doses) QL Breo Ellipta budesonide inhalation QL; AL Dulera QL; AL Flovent Diskus inhalation blister with device 100 mcg/actuation, 250 mcg/actuation, 50 mcg/actuation QL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 75 Drug Name Flovent HFA inhalation HFA aerosol inhaler 110 mcg/actuation, 220 mcg/actuation, 44 mcg/actuation Note Requirements/Limits QL Pulmicort Flexhaler Qvar inhalation aerosol 40 mcg/actuation, 80 mcg/actuation QL Phosphodiesterase Type 4 Inhibitors Daliresp ST Respiratory Tract Agents, Miscellaneous Aralast NP PA Glassia PA Prolastin-C PA Xolair PA Zemaira PA Second Generation Antihist(Respir Tract) Alavert Alavert D-12 Allergy-Sinus cetirizine oral solution 1 mg/mL cetirizine oral tablet cetirizine-pseudoephedrine levocetirizine oral tablet ST loratadine oral solution loratadine oral tablet Loratadine-D oral tablet extended release 24 hr Select.Beta-2-Adrenergic Agonist(Respir) albuterol sulfate inhalation solution for nebulization albuterol sulfate oral syrup albuterol sulfate oral tablet Anoro Ellipta Breo Ellipta AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 76 Drug Name Note Requirements/Limits Combivent Respimat Dulera QL; AL ipratropium-albuterol metaproterenol oral syrup Serevent Diskus terbutaline oral Ventolin HFA QL Xopenex HFA ST Vasodilating Agents (Respiratory Tract) Adcirca PA Adempas PA epoprostenol (glycine) PA Letairis PA Opsumit PA Orenitram PA Remodulin PA Revatio intravenous PA Revatio oral suspension for reconstitution PA sildenafil oral PA Tracleer PA Tyvaso PA Tyvaso Refill Kit PA Tyvaso Starter Kit PA Uptravi PA Veletri PA Ventavis PA Xanthine Derivatives Theo-24 theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 24 hr Serums, Toxoids, And Vaccines Serums Carimune NF Nanofiltered PA AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 77 Drug Name Note Requirements/Limits CytoGam intravenous solution 50 mg/mL PA Flebogamma DIF intravenous solution 5 % PA GamaSTAN S/D PA Gammagard S/D PA Gamunex-C injection solution 1 gram/10 mL (10 %), 10 gram/100 mL (10 %), 2.5 gram/25 mL (10 %), 20 gram/200 mL (10 %), 5 gram/50 mL (10 %) PA Hizentra subcutaneous solution 1 gram/5 mL (20 %), 2 gram/10 mL (20 %), 4 gram/20 mL (20 %) PA MICRhoGAM Ultra-Filtered PLUS Privigen PA RhoGAM Ultra-Filtered PLUS Rhophylac PA WinRho SDF PA Vaccines Afluria 2016-2017 AL Afluria 2016-2017 (PF) AL Flucelvax Quad 2016-2017 (PF) AL Flulaval Quad 2016-2017 AL Fluvirin 2016-2017 (PF) AL Fluzone High-Dose 2016-17 (PF) AL Fluzone Quad 2016-2017 AL Fluzone Quad 2016-2017 (PF) AL Theracys PA Tice BCG PA Skin And Mucous Membrane Agents Antibacterials (Skin & Mucous Membrane) Cleocin vaginal suppository clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 78 Drug Name Note Requirements/Limits clindamycin phosphate vaginal Ery Pads erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycin-benzoyl peroxide gentamicin topical Metrogel topical gel 1 % metronidazole topical cream metronidazole topical gel 0.75 % metronidazole vaginal mupirocin Anti-Inflammatory Agents (Skin & Mucous) amcinonide topical cream Anucort-HC betamethasone dipropionate betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented clobetasol scalp clobetasol topical cream clobetasol topical gel clobetasol topical ointment clobetasol-emollient topical cream clotrimazole-betamethasone desonide desoximetasone topical cream desoximetasone topical gel desoximetasone topical ointment 0.25 % diflorasone fluocinolone topical cream fluocinolone topical ointment AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 79 Drug Name Note Requirements/Limits fluocinolone topical solution fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution Fluocinonide-E fluticasone topical cream fluticasone topical ointment hydrocortisone acetate rectal suppository 25 mg hydrocortisone butyrate hydrocortisone rectal enema hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate hydrocortisone-min oil-wht pet hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 % mometasone topical cream QL mometasone topical ointment QL mometasone topical solution Oralone PramCort Proctofoam HC triamcinolone acetonide dental triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % U-Cort Antipruritics And Local Anesthetics hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 % lidocaine HCl topical cream 3 % AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 80 Drug Name lidocaine-prilocaine topical cream Note Requirements/Limits QL phenazopyridine oral tablet 100 mg, 200 mg PramCort Proctofoam HC Antivirals (Skin & Mucous Membrane) acyclovir topical PA Denavir QL Zovirax topical cream PA Astringents Hypercare topical solution Azoles (Skin & Mucous Membrane) clotrimazole mucous membrane clotrimazole topical clotrimazole-betamethasone econazole topical ketoconazole topical cream ketoconazole topical shampoo Miconazole-3 vaginal suppository terconazole Basic Lotions And Liniments ammonium lactate topical lotion Basic Ointments And Protectants ammonium lactate topical cream Cell Stimulants And Proliferants Kepivance PA tretinoin topical cream AL tretinoin topical gel 0.01 %, 0.025 % AL Hydroxypyridones(Skin & Mucous Membrane) ciclopirox topical suspension Keratolytic Agents sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w) AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 81 Drug Name Note Requirements/Limits sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v) urea topical cream 40 %, 50 % urea topical gel 40 % urea topical lotion 40 % Keratoplastic Agents Drithocreme HP Local Anti-Infectives, Miscellaneous selenium sulfide topical shampoo 2.5 % silver sulfadiazine sulfacetamide sodium (acne) sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w) sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v) Pigmenting Agents 8-Mop PA Oxsoralen Ultra PA Polyenes (Skin & Mucous Membrane) nystatin topical nystatin-triamcinolone Scabicides And Pediculicides Cutter Backwoods topical aerosol,spray QL; AL Cutter Skinsations QL; AL lindane ST malathion ST Off Active QL; AL Off Deep Woods Dry QL; AL Off Deep Woods topical aerosol,spray QL; AL Off FamilyCare QL; AL permethrin topical cream QL Repel Sportsmen QL; AL Repel Sportsmen Max topical aerosol,spray QL; AL AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 82 Drug Name spinosad Note Requirements/Limits ST Skin And Mucous Membrane Agents, Misc. Condylox topical gel Cosentyx PA Cosentyx (2 Syringes) PA Cosentyx Pen PA Cosentyx Pen (2 Pens) PA Cutter Backwoods topical aerosol,spray QL; AL Cutter Skinsations QL; AL Elidel PA imiquimod QL Insect Repellent (picaridin) QL; AL Natrapel QL; AL Off Active QL; AL Off Deep Woods Dry QL; AL Off Deep Woods topical aerosol,spray QL; AL Off FamilyCare QL; AL podofilox Protopic PA Rectiv Repel Sportsmen QL; AL Repel Sportsmen Max topical aerosol,spray QL; AL Santyl Stelara subcutaneous syringe PA Taltz Autoinjector PA Taltz Syringe PA Targretin topical PA Smooth Muscle Relaxants Antimuscarinics flavoxate oxybutynin chloride oral tolterodine AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 83 Drug Name Toviaz Note Requirements/Limits ST trospium oral tablet Respiratory Smooth Muscle Relaxants Theo-24 theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 24 hr Vitamins Multivitamin Preparations Adults' Daily Formula Atabex EC Children's Chewable Multivitmn Complete Natal DHA iNatal Advance iNatal Ultra Multi-Vit with Fluoride-Iron Multivitamin With Fluoride Multi-Vitamin With Fluoride oral drops Multi-Vitamin With Fluoride oral tablet,chewable 0.25 mg, 1 mg Multivitamins With Fluoride oral tablet,chewable 1 mg M-Vit Mynatal Mynatal Plus Mynatal-Z Mynate 90 Plus Natalvit Obstetrix DHA Obstetrix EC O-Cal FA O-Cal Prenatal One Daily Essential oral tablet 0.4 mg PNV Folic Acid + Iron Poly-Vita AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 84 Drug Name Note Requirements/Limits PrenaPlus Prenatabs FA Prenatal 19 Prenatal 19 (with docusate) Prenatal AD Prenatal Plus Prenatal Plus with Iron (Ca) prenatal vit-iron fumarate-FA Prenatal-U Se-Natal 19 TriAdvance Trinatal Rx 1 Trinatal Ultra Trinate Triveen-Duo DHA Tri-Vit with Fluoride and Iron Tri-Vitamin With Fluoride Vinate GT Vinate II Vinate M Vinate One Vinate Ultra Vol-Nate Vitamin A Tri-Vitamin With Fluoride Vitamin B Complex Adults' Daily Formula Atabex EC Children's Chewable Multivitmn cyanocobalamin (vitamin B-12) injection FE C Plus folic acid oral capsule 0.8 mg GL; AL folic acid oral tablet 1 mg AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 85 Drug Name folic acid oral tablet 400 mcg, 800 mcg Note Requirements/Limits GL; AL iNatal Advance iNatal Ultra Multigen Folic Multigen Plus M-Vit Mynatal oral capsule Mynatal Plus Mynatal-Z Natalvit Nicomide Obstetrix DHA Obstetrix EC O-Cal FA O-Cal Prenatal One Daily Essential oral tablet 0.4 mg PNV Folic Acid + Iron PrenaPlus Prenatabs FA Prenatal 19 Prenatal 19 (with docusate) Prenatal AD Prenatal Plus Prenatal Plus with Iron (Ca) prenatal vit-iron fumarate-FA pyridoxine (vitamin B6) oral tablet 100 mg Se-Natal 19 TriAdvance Trinatal Rx 1 Trinatal Ultra Trinate Triveen-Duo DHA Vinate GT AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 86 Drug Name Note Requirements/Limits Vinate II Vinate One Vinate Ultra Vol-Nate Vitamin C FE C Plus Multigen Folic Multigen Plus Tri-Vitamin With Fluoride Vitamin D calcitriol intravenous solution 1 mcg/mL calcitriol oral capsule cholecalciferol (vitamin D3) oral capsule 400 unit AL cholecalciferol (vitamin D3) oral tablet 400 unit AL cholecalciferol (vitamin D3) oral tablet,chewable 400 unit AL ergocalciferol (vitamin D2) oral capsule Tri-Vitamin With Fluoride Vitamin K Activity Mephyton AL = Age Limit GL = Gender Limit PA = Prior Authoirzation QL = Quantity Limit ST = Step Therapy 87 Index 8 8-Mop ...................................... 82 A abacavir ..................................... 7 Abelcet .................................... 11 Abilify Maintena ..................... 41 Abraxane ................................. 13 Accu-Chek Aviva Control Soln ............................................. 48 Accu-Chek Aviva Plus Meter 49 Accu-Chek Aviva Plus test strp ............................................. 49 Accu-Chek FastClix ............... 49 Accu-Chek Multiclix Lancet.. 49 Accu-Chek Nano .................... 49 Accu-Chek SmartView Contrl Sol ........................................ 49 Accu-Chek SmartView Test Strip ..................................... 49 Accu-Chek Soft Dev Lancets. 49 Accu-Chek Softclix Lancet Dev ............................................. 49 Accu-Chek Softclix Lancets .. 49 acebutolol . 21, 28, 29, 31, 33, 34 acetaminophen ........................ 38 acetaminophen-codeine .... 38, 44 Acetasol HC ............................ 56 acetazolamide........30, 31, 50, 55 acetic acid ................................ 56 acetic acid-aluminum acetate . 56 acetylcysteine .................... 72, 75 Actemra ............................. 69, 70 Acthar H.P. ........................ 49, 65 Actimmune .............................. 70 Activase ............................. 26, 53 acyclovir ............................ 10, 81 Adagen .................................... 53 Adcetris ................................... 13 Adcirca .............................. 35, 77 adefovir.................................... 10 Adempas ............................ 36, 77 Adriamycin.............................. 13 Adults' Daily Formula 24, 84, 85 Advate ..................................... 23 Aerochamber Plus Flow-Vu .. 49 Afinitor .................................... 13 Afinitor Disperz ...................... 13 Afluria 2016-2017................... 78 Afluria 2016-2017 (PF) .......... 78 Alavert ................................. 2, 76 Alavert D-12 Allergy-Sinus .... 2, 18, 73, 76 albuterol sulfate ................. 21, 76 Aldactazide ........... 34, 35, 51, 52 Aldurazyme ............................. 53 Alecensa................................... 13 alendronate .............................. 68 Alferon N ............................. 9, 13 alfuzosin................................... 21 Alimta ...................................... 13 Alkeran .................................... 13 allopurinol................................ 68 Aloxi ........................................ 57 Alphanate ................................. 23 AlphaNine SD ......................... 23 alprazolam ............................... 42 amantadine HCl ................... 2, 37 AmBisome ............................... 11 amcinonide .............................. 79 Amicar ..................................... 23 amifostine crystalline .............. 73 amikacin................................. 2, 4 amiloride ............................ 35, 51 amiloride-hydrochlorothiazide ..................................35, 51, 52 aminocaproic acid ................... 23 amiodarone .............................. 32 Amitiza .................................... 58 amitriptyline ............................ 48 amitriptyline-chlordiazepoxide ........................................ 42, 48 amlodipine ...................32, 33, 36 amlodipine-benazepril .....27, 28, 32, 33, 36 ammonium lactate ................... 81 amoxapine................................ 48 amoxicillin ................................. 3 amoxicillin-pot clavulanate ...... 3 Amphotec ................................ 11 ampicillin ................................... 3 ampicillin sodium...................... 3 ampicillin-sulbactam ................. 3 Ampyra .................................... 73 anastrozole ............................... 13 AndroGel ..................................61 Anoro Ellipta......... 19, 21, 74, 76 antipyrine-benzocaine .............56 Anucort-HC .............................79 Anzemet ...................................57 Apidra .......................................64 Apidra SoloStar .......................64 APOKYN .................................44 apraclonidine ............................56 Apri ...........................................62 Aptivus .......................................8 Aralast NP ................................76 Aranelle (28) ............................62 Aranesp (in polysorbate) .........22 Arcalyst ....................................73 aripiprazole ..............................41 Aristada ....................................41 Armour Thyroid .......................67 Arnuity Ellipta .................. 60, 75 Arranon ....................................13 Arzerra......................................13 Asmanex HFA .................. 60, 75 Asmanex Twisthaler ......... 60, 75 aspirin .................... 25, 26, 40, 47 aspirin-dipyridamole .. 26, 36, 47 Atabex EC .......24, 51, 58, 84, 85 atenolol ........................ 21, 29, 31 atenolol-chlorthalidone ... 21, 29, 31, 36, 53 Atgam .......................................72 atorvastatin ...............................33 atovaquone .................................3 atovaquone-proguanil ................3 ATRIPLA ...................................7 atropine .....................................57 Atrovent HFA ................... 19, 74 Aubagio ....................................70 Avalide .................. 26, 27, 35, 52 Avastin .....................................13 Aviane ......................................62 Avonex .....................................70 Avonex (with albumin) ...........70 Azactam in dextrose (iso-osm) .9 azathioprine ................. 69, 70, 72 azelastine ..................................54 azithromycin ............................10 Azopt ........................................55 88 aztreonam .................................. 9 B bacitracin-polymyxin B .......... 54 baclofen ................................... 20 balsalazide ............................... 58 Balziva (28) ............................. 62 Banzel ...................................... 39 benazepril .......................... 27, 28 benazepril-hydrochlorothiazide ...........................27, 28, 35, 52 BeneFIX .................................. 23 Benlysta ................................... 72 benztropine ........................ 19, 38 Berinert .................................... 69 betamethasone dipropionate... 79 betamethasone valerate .......... 79 betamethasone, augmented .... 79 Betaseron ................................. 70 bethanechol chloride............... 20 bexarotene ............................... 13 Bexxar 131 Iodine .................. 13 Bexxar Therapeutic ................ 13 bicalutamide ............................ 13 Bicillin L-A ............................... 9 BiCNU ..................................... 14 Biltricide .................................... 3 bisoprolol fumarate ..... 22, 29, 31 bisoprolol-hydrochlorothiazide .................... 22, 29, 31, 35, 52 bleomycin ................................ 14 Boniva ..................................... 68 Bosulif ..................................... 14 Botox ................................. 22, 73 Breo Ellipta ...........21, 60, 75, 76 brimonidine ............................. 54 bromocriptine .......................... 43 budesonide ........................ 60, 75 bumetanide ........................ 34, 50 buprenorphine-naloxone ........ 45 bupropion HCl ........................ 39 buspirone ................................. 40 Busulfex .................................. 14 Butalbital Compound W/Codeine . 40, 42, 44, 46, 47 butalbital-acetaminop-caf-cod .................... 38, 40, 42, 44, 46 butalbital-acetaminophen . 38, 42 butalbital-acetaminophen-caff ...........................38, 40, 42, 46 butalbital-aspirin-caffeine 26, 40, 42, 46, 47 butorphanol tartrate ................. 45 C cabergoline .............................. 43 caffeine citrated ....................... 46 calcitonin (salmon)............ 65, 68 calcitriol ................................... 87 calcium acetate ........................ 50 Camila ...................................... 62 Camptosar ................................ 14 Canasa ...................................... 58 Cancidas..................................... 5 capecitabine ............................. 14 Caprelsa ................................... 14 captopril ............................. 27, 28 captopril-hydrochlorothiazide27, 28, 35, 52 Carbaglu................................... 50 carbamazepine ......................... 39 carbidopa-levodopa ................. 43 carboplatin ............................... 14 Carimune NF Nanofiltered ..... 77 carisoprodol ............................. 19 carteolol ................................... 55 carvedilol .. 20, 21, 26, 29, 31, 34 Cathflo Activase ................ 26, 53 Cayston ...................................... 9 cefaclor .................................... 11 cefadroxil ................................... 5 cefazolin..................................... 5 cefdinir ..................................... 12 cefepime..................................... 6 cefepime in dextrose 5 % ......... 6 cefepime in dextrose,iso-osm ... 6 cefotaxime ............................... 12 cefotetan............................... 5, 12 cefotetan in dextrose, iso-osm . 5, 12 cefpodoxime ............................ 12 cefprozil ................................... 12 ceftazidime .............................. 12 Ceftin ....................................... 12 ceftriaxone ............................... 13 ceftriaxone in dextrose,iso-os . 13 cefuroxime axetil..................... 12 cefuroxime sodium.................. 12 celecoxib .................................. 43 CellCept ................................... 72 CellCept Intravenous .............. 72 cephalexin ..................................6 Cerdelga ...................................73 Cerezyme .................................53 cetirizine .............................. 2, 76 cetirizine-pseudoephedrine 2, 18, 73, 76 Chantix .....................................19 Chantix Starting Month Box ...19 Chemet .............................. 60, 67 Children's Chewable Multivitmn ....................................... 84, 85 chlordiazepoxide HCl ..............42 chlorhexidine gluconate ..........56 chloroquine phosphate ..............3 chlorothiazide ................... 35, 52 chlorpromazine ........................46 chlorpropamide ........................66 chlorthalidone ................... 36, 53 chlorzoxazone ..........................19 cholecalciferol (vitamin D3) ...87 cholestyramine (with sugar)....30 Cholestyramine Light ..............30 choline,magnesium salicylate .47 ciclopirox .................................81 cilostazol ........................... 26, 35 cimetidine .................................59 cimetidine HCl .........................59 Cimzia ......................... 58, 69, 70 Cimzia Powder for Reconst .. 59, 69, 70 Cinryze .....................................69 Cipro .................................... 4, 11 Ciprodex ............................ 54, 55 ciprofloxacin ....................... 4, 11 ciprofloxacin (mixture) ...... 4, 11 ciprofloxacin HCl ......... 4, 11, 54 ciprofloxacin in 5 % dextrose ..4, 11 cisplatin ....................................14 citalopram ................................47 cladribine ..................................14 Claforan ....................................13 clarithromycin ..................... 4, 10 clemastine ........................... 1, 74 Cleocin .....................................78 Cleocin in 5 % dextrose ............9 clindamycin HCl ........................9 clindamycin palmitate HCl .......9 clindamycin phosphate . 9, 78, 79 Clinisol SF 15 % ......................50 89 Clinpro 5000 ........................... 68 clobetasol................................. 79 clobetasol-emollient ............... 79 Clolar ....................................... 14 clomipramine .......................... 48 clonazepam.............................. 42 clonidine ............................ 18, 31 clonidine HCl .................... 18, 31 clopidogrel .............................. 26 clorazepate dipotassium ......... 42 Clorpres .................19, 31, 36, 53 clotrimazole............................. 81 clotrimazole-betamethasone . 79, 81 clozapine ................................. 41 codeine sulfate .................. 44, 74 colchicine-probenecid ...... 53, 68 colestipol ................................. 30 colistin (colistimethate Na) .... 11 Combivent Respimat . 19, 21, 74, 77 Cometriq .................................. 14 Complera ................................... 7 Complete Natal DHA ............. 84 Condylox ................................. 83 Copaxone................................. 70 Corifact .................................... 23 cortisone .................................. 60 Cosentyx .................................. 83 Cosentyx (2 Syringes) ............ 83 Cosentyx Pen .......................... 83 Cosentyx Pen (2 Pens)............ 83 Cosmegen ................................ 14 cosyntropin .............................. 49 Creon ....................................... 58 Crinone .................................... 66 Crixivan ..................................... 8 cromolyn ........................... 54, 75 Cubicin ...................................... 5 Cutter Backwoods............. 82, 83 Cutter Skinsations ............. 82, 83 cyanocobalamin (vitamin B-12) ............................................. 85 cyclobenzaprine ...................... 19 cyclopentolate ......................... 57 cyclophosphamide ............ 14, 72 cyclosporine ................ 69, 70, 72 cyclosporine modified 69, 70, 72 cyproheptadine .................... 1, 74 cytarabine ................................ 14 cytarabine (PF) ........................ 14 CytoGam.................................. 78 Cytovene .................................. 10 D D5 %-0.45 % sodium chloride50 dacarbazine .............................. 14 Dacogen ................................... 14 Daklinza ..................................... 6 Daliresp .................................... 76 danazol ..................................... 61 dapsone ...................................... 3 Daraprim .................................... 3 daunorubicin ............................ 14 DaunoXome............................. 14 deferoxamine ..................... 60, 67 Delzicol .................................... 58 Demser ..................................... 73 Denavir .................................... 81 DepoCyt (PF) .......................... 14 Depo-Provera .......................... 66 Descovy ..................................... 7 desipramine ............................. 48 desmopressin ..................... 23, 65 desonide ................................... 79 desoximetasone ....................... 79 dexamethasone ........................ 60 Dexamethasone Intensol ......... 60 dexamethasone sodium phos (PF) ...................................... 60 dexamethasone sodium phosphate ....................... 55, 60 Dexferrum................................ 24 dexmethylphenidate ................ 46 dexrazoxane HCl ..................... 73 dextroamphetamine ................. 37 dextroamphetamineamphetamine ....................... 38 dextrose 70 % in water (D70W) .............................................. 50 diazepam .................................. 42 Diazepam Intensol .................. 42 Diclegis .............................. 57, 74 diclofenac potassium............... 45 diclofenac sodium ............. 45, 56 dicloxacillin ............................. 10 dicyclomine ............................. 19 didanosine .................................. 7 diflorasone ............................... 79 diflunisal .................................. 45 Digox ................................. 28, 31 digoxin............................... 28, 31 dihydroergotamine............ 20, 40 Dilantin .............................. 31, 43 diltiazem HCl ........ 30, 32, 36, 37 Dipentum ..................................58 Diphenhist ........................... 1, 74 diphenhydramine HCl .. 1, 74, 75 diphenoxylate-atropine .... 19, 57, 74 dipyridamole ..................... 26, 37 disopyramide phosphate ..........31 disulfiram .................................67 Diuril ................................. 36, 52 divalproex ......................... 39, 40 Docefrez ...................................14 docetaxel ..................................14 donepezil ..................................21 Doribax .......................................5 dorzolamide .............................55 dorzolamide-timolol ................55 doxazosin .................... 20, 26, 34 doxepin .....................................48 Doxil .........................................14 doxorubicin ..............................14 doxycycline hyclate .......... 12, 54 doxycycline monohydrate .......12 Drithocreme HP .......................82 droperidol .................................40 Droxia .......................................14 Dulera .................... 21, 60, 75, 77 duloxetine .......................... 43, 47 Dyrenium .......................... 35, 51 Dysport .............................. 22, 73 E E.E.S. Granules ..........................9 econazole ..................................81 ED Chlorped Jr ................... 1, 75 Edurant .......................................7 Elaprase ....................................53 Elelyso ......................................53 Elidel ................................. 72, 83 Eligard ............................... 14, 64 Eligard (3 month) ............. 14, 64 Eligard (4 month) ............. 14, 64 Eligard (6 month) ............. 15, 64 Eliquis.......................................22 Elitek ........................................53 Eloxatin ....................................15 Elspar ........................................15 Emcyt .......................................15 90 Emend ...................................... 59 Emtriva ...................................... 7 enalapril maleate ............... 27, 28 enalapril-hydrochlorothiazide 27, 28, 36, 52 Enbrel ................................ 69, 71 Enbrel SureClick ............... 69, 71 Endodan ............................. 44, 47 enoxaparin ............................... 24 entecavir .................................. 10 Entyvio .............................. 59, 71 Epclusa ...................................... 6 epinephrine ........................ 18, 73 EpiPen 2-Pak ..................... 18, 74 EpiPen Jr 2-Pak................. 18, 74 epirubicin................................. 15 Epivir ......................................... 8 Epivir HBV ............................... 8 Epogen ..................................... 22 epoprostenol (glycine) ...... 37, 77 Epzicom ..................................... 8 Eraxis(Water Diluent) .............. 5 Erbitux ..................................... 15 ergocalciferol (vitamin D2) .... 87 Ergomar ............................. 20, 40 ergotamine-caffeine .......... 20, 40 Erivedge .................................. 15 Erwinaze .................................. 15 Ery Pads................................... 79 Ery-Tab...................................... 9 Erythrocin (as stearate)............. 9 erythromycin ....................... 9, 54 erythromycin ethylsuccinate .... 9 erythromycin with ethanol ..... 79 erythromycin-benzoyl peroxide ............................................. 79 erythromycin-sulfisoxazole ...... 5 escitalopram oxalate ............... 47 estazolam ................................. 42 estradiol ................................... 63 estropipate ............................... 63 eszopiclone .............................. 41 ethambutol ................................. 4 ethosuximide ........................... 48 etidronate disodium ................ 68 etodolac ................................... 45 Etopophos................................ 15 etoposide ................................. 15 Euflexxa .................................. 49 Evotaz .................................. 8, 73 Evzio .................................. 45, 67 Exelon ...................................... 21 exemestane .............................. 15 Exjade ...................................... 60 Extavia ..................................... 71 Eylea ........................................ 56 F Fabrazyme ............................... 53 famotidine ................................ 59 Fanapt ...................................... 41 Fareston ................................... 15 Faslodex ................................... 15 FE C Plus .....................24, 85, 87 Feiba NF .................................. 23 felodipine ........................... 32, 33 Femhrt Low Dose ............. 63, 66 fenofibrate................................ 33 fenofibrate micronized ............ 33 fenofibrate nanocrystallized ... 33 fenoprofen................................ 45 fentanyl .................................... 44 Feraheme ................................. 24 Ferriprox .................................. 60 Ferrlecit .................................... 24 finasteride ................................ 67 Firazyr ...................................... 69 Firmagon............................ 15, 70 Flarex ....................................... 55 flavoxate .................................. 83 Flebogamma DIF .................... 78 flecainide ................................. 31 Flovent Diskus .................. 60, 75 Flovent HFA ...................... 61, 76 floxuridine ............................... 15 Flucelvax Quad 2016-2017 (PF) .............................................. 78 fluconazole ............................ 4, 5 fluconazole in dextrose(iso-o) .. 4 fluconazole in NaCl (iso-osm) . 4 fludarabine ............................... 15 fludrocortisone ........................ 61 Flulaval Quad 2016-2017 ....... 78 fluocinolone ....................... 79, 80 fluocinonide ............................. 80 Fluocinonide-E ........................ 80 Fluoritab................................... 68 fluorometholone ...................... 55 fluorouracil .............................. 15 fluoxetine ................................. 48 fluoxymesterone ...................... 61 fluphenazine decanoate ...........46 fluphenazine HCl .....................46 flurbiprofen sodium .................56 flutamide ..................................15 fluticasone ................... 55, 75, 80 Fluvirin 2016-2017 (PF) .........78 fluvoxamine .............................48 Fluzone High-Dose 2016-17 (PF) .......................................78 Fluzone Quad 2016-2017 ........78 Fluzone Quad 2016-2017 (PF) ..............................................78 FML Forte ................................55 FML S.O.P. ..............................55 Focalin XR ...............................46 folic acid ............................ 85, 86 Folotyn .....................................15 Fortaz in dextrose 5 %.............13 Forteo .......................................65 foscarnet .....................................4 fosinopril ........................... 27, 28 fosinopril-hydrochlorothiazide ........................... 27, 28, 36, 52 furosemide......................... 34, 50 Fuzeon ........................................7 G gabapentin ......................... 38, 39 Galzin .......................................60 GamaSTAN S/D ......................78 Gammagard S/D ......................78 Gamunex-C ..............................78 Gattex 30-Vial .........................59 Gel-One ....................................49 gemcitabine ..............................15 gemfibrozil ...............................33 Genotropin ...............................65 Genotropin MiniQuick ............65 Gentak ......................................54 gentamicin ..................... 2, 54, 79 gentamicin in NaCl (iso-osm) ...2 gentamicin sulfate (PF) .............2 Genvoya ................................ 7, 8 Geodon .....................................41 Gilenya .....................................71 Glassia ......................................76 Gliadel Wafer...........................15 glimepiride ...............................66 glipizide ....................................66 glipizide-metformin .......... 62, 66 91 Glucagon Emergency Kit (human) ......................... 64, 67 glyburide ................................. 66 glyburide micronized .............. 66 glyburide-metformin ........ 62, 66 glycopyrrolate ......................... 19 granisetron (PF) ...................... 57 granisetron HCl ....................... 57 Granix ...................................... 22 griseofulvin microsize .............. 3 griseofulvin ultramicrosize ...... 3 guanfacine ......................... 31, 43 H Halaven.................................... 15 haloperidol .............................. 43 haloperidol decanoate ............. 43 haloperidol lactate................... 43 Harvoni ...................................... 6 Hemofil M High ..................... 23 Hemofil M Low ...................... 23 Hemofil M Mid ....................... 23 Hemofil M Super High ........... 23 heparin (porcine) ..................... 24 heparin (porcine) in 5 % dex .. 24 heparin (porcine) in NaCl (PF) ............................................. 24 heparin, porcine (PF) .............. 24 Hepsera .................................... 10 Herceptin ................................. 15 Hexalen.................................... 15 Hizentra ................................... 78 Humalog .................................. 64 Humalog KwikPen ................. 64 Humalog Mix 50-50 ............... 64 Humalog Mix 50-50 KwikPen64 Humalog Mix 75-25 ............... 64 Humalog Mix 75-25 KwikPen64 Humate-P................................. 23 Humatrope ............................... 65 Humira ......................... 59, 69, 71 Humira Pen Crohn's-UC-HS Start ......................... 59, 69, 71 Humulin 70/30 ........................ 64 Humulin 70/30 Pen ................. 64 Humulin N............................... 65 Humulin N KwikPen .............. 65 Humulin R ............................... 65 Humulin R U-500 (Concentrated) .................... 65 Hyalgan ................................... 49 Hycamtin ................................. 15 hydralazine .............................. 33 hydrochlorothiazide .......... 36, 52 hydrocodone-acetaminophen 38, 44 hydrocortisone ................... 61, 80 hydrocortisone acetate ............ 80 hydrocortisone butyrate .......... 80 hydrocortisone valerate........... 80 hydrocortisone-min oil-wht pet .............................................. 80 hydrocortisone-pramoxine...... 80 hydromorphone ....................... 44 hydroxychloroquine ......3, 69, 71 hydroxyprogesterone capr(bulk) .............................................. 66 hydroxyprogesterone caproate 66 hydroxyurea ............................. 15 hyoscyamine sulfate ................ 19 Hypercare ................................ 81 I Ibrance ..................................... 15 ibuprofen.................................. 45 Ibuprofen IB ............................ 45 Iclusig ...................................... 15 idarubicin ................................. 15 ifosfamide ................................ 15 ifosfamide-mesna .................... 15 Ilaris (PF) ................................. 73 imatinib .................................... 15 imipramine HCl....................... 48 imiquimod................................ 83 Imitrex...................................... 47 iNatal Advance ..... 24, 51, 84, 86 iNatal Ultra ..... 24, 51, 58, 84, 86 Increlex .................................... 66 Incruse Ellipta ................... 19, 74 indapamide ........................ 36, 53 indomethacin ..................... 45, 68 Infed ......................................... 24 Injectafer .................................. 24 Inlyta ........................................ 16 Insect Repellent (picaridin) .... 83 Insulin Syringe ........................ 49 Intelence..................................... 7 Intralipid .................................. 50 Intron A..........................9, 16, 71 Invanz ........................................ 5 Invega Sustenna ...................... 41 Invega Trinza........................... 41 Invirase .......................................8 Iopidine ....................................56 ipratropium bromide ... 19, 56, 74 ipratropium-albuterol 19, 21, 74, 77 irbesartan ........................... 26, 27 irbesartan-hydrochlorothiazide ................................. 27, 36, 52 irinotecan ..................................16 Isentress ......................................7 isoniazid .....................................4 Isopto Carbachol ......................56 Isordil .......................................34 isosorbide dinitrate ..................34 isosorbide mononitrate ............34 Istodax ......................................16 itraconazole ................................5 Ixempra ....................................16 J Jadenu .......................................60 Jakafi ........................................16 Janumet ............................. 62, 63 Janumet XR....................... 62, 63 Januvia......................................63 Jetrea (PF) ................................56 Jevtana ......................................16 Jinteli ................................. 63, 66 Jolessa.......................................62 Juxtapid ....................................28 K Kadcyla ....................................16 Kalbitor ....................................69 Kaletra ........................................8 Kalydeco ..................................74 Kariva (28) ...............................62 Kepivance.................................81 ketoconazole ....................... 5, 81 ketoprofen ................................45 ketorolac ............................ 45, 56 ketotifen fumarate ....................54 Kineret ............................... 69, 71 Klor-Con ..................................51 Klor-Con/25 .............................51 Kogenate FS .............................23 Krystexxa .................................68 Kuvan .......................................73 Kynamro...................................28 Kyprolis ....................................16 L labetalol ...........20, 21, 26, 29, 31 92 lactulose ................................... 50 Lamictal Starter (Blue) Kit .... 39 Lamictal Starter (Green) Kit .. 39 Lamictal Starter (Orange) Kit 39 lamivudine ................................. 8 lamivudine-zidovudine ............. 8 lamotrigine .............................. 39 lancets ...................................... 49 lansoprazole ............................ 59 Lantus ...................................... 65 Lantus Solostar ....................... 65 latanoprost ............................... 57 Latuda ...................................... 41 leflunomide ....................... 69, 71 Lemtrada ................................. 71 Letairis ............................... 37, 77 letrozole ................................... 16 leucovorin calcium ................. 67 Leukeran .................................. 16 Leukine .................................... 22 leuprolide........................... 16, 64 Levaquin in 5 % dextrose ... 4, 11 levetiracetam ........................... 39 levobunolol.............................. 55 levocarnitine ............................ 73 levocarnitine (with sugar) ...... 73 levocetirizine ....................... 2, 76 levofloxacin......................... 4, 11 levoleucovorin calcium .......... 67 levonorgestrel.......................... 62 Levora-28 ................................ 62 levothyroxine .......................... 67 Lexiva ........................................ 8 Lialda ....................................... 58 lidocaine HCl .................... 56, 80 Lidocaine Viscous .................. 56 lidocaine-prilocaine ................ 81 Liletta....................................... 62 Lincocin ..................................... 9 lindane ..................................... 82 Linzess ..................................... 59 Lioresal .................................... 20 liothyronine ............................. 67 Liposyn III............................... 50 lisinopril ............................ 27, 28 lisinopril-hydrochlorothiazide ...........................27, 28, 36, 52 lithium carbonate .................... 39 lithium citrate .......................... 40 lomustine ................................. 16 loperamide ............................... 57 loratadine ............................. 2, 76 Loratadine-D .......... 2, 18, 74, 76 lorazepam ................................ 42 losartan..................................... 27 losartan-hydrochlorothiazide . 27, 36, 52 lovastatin.................................. 33 Low-Ogestrel (28) ................... 62 loxapine succinate ................... 40 Lucentis ................................... 56 Lupron Depot .................... 16, 64 Lupron Depot (3 Month) .. 16, 64 Lupron Depot (4 month) ... 16, 64 Lupron Depot (6 Month) .. 16, 64 Lupron Depot-Ped ............. 16, 64 Lupron Depot-Ped (3 month) 16, 64 Lysodren .................................. 16 M Macugen .................................. 56 magnesium sulfate ......28, 39, 67 Makena .................................... 66 malathion ................................. 82 maprotiline............................... 48 Matulane .................................. 16 Maxidex ................................... 55 meclizine.............................. 1, 57 meclofenamate ........................ 45 Medrol...................................... 61 medroxyprogesterone ............. 66 mefloquine ................................. 3 megestrol ................................. 16 meloxicam ............................... 46 melphalan HCl ........................ 16 memantine ............................... 43 Menest...................................... 63 meperidine ............................... 44 Mephyton ........................... 67, 87 meprobamate ........................... 41 mercaptopurine .................. 16, 72 meropenem ................................ 5 mesalamine .............................. 58 mesna ....................................... 73 Mestinon .................................. 21 metaproterenol................... 21, 77 metformin ................................ 62 methadone................................ 44 methimazole ...................... 61, 62 Methitest .................................. 61 methocarbamol ........................20 methotrexate sodium . 16, 69, 71, 72 methotrexate sodium (PF)16, 69, 71, 72 methyclothiazide............... 36, 52 methyldopa ........................ 19, 31 methyldopa-hydrochlorothiazide ........................... 19, 31, 36, 52 methylergonovine ....................73 methylphenidate................ 46, 47 methylprednisolone .................61 methylprednisolone sodium succ ..............................................61 methyltestosterone ...................61 metipranolol .............................55 metoclopramide HCl ...............59 metolazone ........................ 36, 53 metoprolol succinate .. 22, 29, 32 metoprolol ta-hydrochlorothiaz .....................22, 29, 32, 36, 53 metoprolol tartrate ...... 22, 29, 32 Metrogel ...................................79 metronidazole ................. 2, 4, 79 metronidazole in NaCl (iso-os)2, 3 mexiletine .................................31 Miconazole-3 ...........................81 MICRhoGAM Ultra-Filtered PLUS ....................................78 Microgestin 1.5/30 (21) ...........62 Microgestin 1/20 (21) ..............62 Microgestin Fe 1.5/30 (28) .....62 Microgestin FE 1/20 (28) ........62 midodrine .................................19 Migranal ............................ 20, 40 minocycline ..............................12 minoxidil ..................................33 Mirena ......................................62 mirtazapine ...............................39 misoprostol ...............................59 mitomycin ................................16 mitoxantrone ............................16 moexipril ........................... 27, 28 moexipril-hydrochlorothiazide ........................... 27, 28, 36, 53 mometasone .............................80 Monoclate-P .............................23 Mononine .................................23 Monovisc ..................................49 93 montelukast ............................. 75 morphine ........................... 44, 45 morphine concentrate ............. 44 Moxeza .................................... 54 moxifloxacin ....................... 4, 11 Mozobil ................................... 22 Multigen .................................. 24 Multigen Folic............. 24, 86, 87 Multigen Plus .............. 24, 86, 87 Multi-Vit with Fluoride-Iron. 24, 68, 84 Multivitamin With Fluoride .. 68, 84 Multi-Vitamin With Fluoride 68, 84 Multivitamins With Fluoride 68, 84 mupirocin ................................ 79 Mustargen................................ 16 M-Vit ........................... 24, 84, 86 Mycamine.................................. 5 Mycobutin ........................... 4, 11 mycophenolate mofetil ........... 72 mycophenolate sodium ........... 72 Myleran ................................... 16 Mynatal..................24, 51, 84, 86 Mynatal Plus .........24, 51, 84, 86 Mynatal-Z..............25, 51, 84, 86 Mynate 90 Plus ....................... 84 Myobloc ............................ 22, 73 Myozyme................................. 53 N nabumetone ............................. 46 nadolol ......................... 20, 29, 32 nadolol-bendroflumethiazide 20, 29, 32, 36, 53 nafcillin.................................... 11 nafcillin in dextrose iso-osm .. 11 Naglazyme .............................. 53 nalbuphine ............................... 45 naltrexone .......................... 45, 67 naphazoline ............................. 57 naproxen ............................ 46, 68 naproxen sodium ............... 46, 68 naratriptan ............................... 47 Narcan ............................... 45, 67 Natalvit ..................25, 51, 84, 86 Natrapel ................................... 83 Nature-Throid ......................... 67 Nebupent ................................... 4 Necon 1/50 (28)....................... 62 Necon 10/11 (28) .................... 62 nefazodone............................... 48 neomycin-bacitracin-poly-HC ........................................ 54, 55 neomycin-bacitracin-polymyxin .............................................. 54 neomycin-polymyxin Bdexameth ....................... 54, 55 neomycin-polymyxingramicidin ............................ 54 neomycin-polymyxin-HC . 54, 55 Neulasta ................................... 22 Neumega .................................. 22 Neupogen ................................. 22 nevirapine .................................. 7 Nexavar .................................... 16 Nexplanon................................ 62 niacin ........................................ 28 nicardipine ............ 32, 33, 34, 37 Nicomide ................................. 86 Nicotrol .................................... 19 Nicotrol NS.............................. 19 Nifediac CC .................32, 33, 37 nifedipine ........................... 33, 37 nilutamide ................................ 17 Nitro-Bid.................................. 34 Nitro-Dur ................................. 34 nitrofurantoin ........................... 13 nitrofurantoin macrocrystal .... 13 nitrofurantoin monohyd/m-cryst .............................................. 13 nitroglycerin ...................... 34, 35 Nitrostat ................................... 35 Nitro-Time ............................... 35 nizatidine ................................. 59 Non-Aspirin Jr Strength.......... 38 Norditropin FlexPro ................ 65 Norditropin Nordiflex ............. 65 norethindrone acetate .............. 66 norgestrel-ethinyl estradiol ..... 62 Nortrel 0.5/35 (28) .................. 62 Nortrel 1/35 (21) ..................... 62 Nortrel 7/7/7 (28) .................... 63 nortriptyline ............................. 48 Norvir ......................................... 8 Novolin 70/30.......................... 65 Novolin N ................................ 65 Novolin R ................................ 65 Novolog ................................... 65 Novolog Flexpen .....................65 Novolog Mix 70-30 .................65 Novolog Mix 70-30 FlexPen ..65 Novolog PenFill .......................65 Novoseven RT .........................23 Nplate .......................................22 Nucala.......................................74 Nutropin AQ ............................65 Nutropin AQ Nuspin ...............65 NuvaRing .................................63 nystatin .............................. 11, 82 nystatin-triamcinolone.............82 O Obstetrix DHA ............ 25, 84, 86 Obstetrix EC ......... 25, 58, 84, 86 O-Cal FA ............... 25, 51, 84, 86 O-Cal Prenatal ...... 25, 51, 84, 86 octreotide acetate .....................66 Odefsey ................................. 7, 8 Off Active ......................... 82, 83 Off Deep Woods ............... 82, 83 Off Deep Woods Dry ....... 82, 83 Off FamilyCare ................. 82, 83 ofloxacin............................ 11, 54 olanzapine ................................41 olanzapine-fluoxetine ....... 41, 48 Olysio .........................................6 omeprazole ...............................59 omeprazole-sodium bicarbonate ..............................................59 Omnitrope ................................65 Omontys ...................................22 Oncaspar...................................17 ondansetron ..............................57 ondansetron HCl ......................57 ondansetron HCl (PF)..............57 One Daily Essential .......... 84, 86 Opsumit ............................. 37, 77 Oracit ........................................50 Oralone .....................................80 Orencia .............................. 69, 71 Orencia (with maltose) ..... 69, 71 Orencia ClickJect.............. 70, 71 Orenitram .......................... 37, 77 Orfadin .....................................73 Orkambi....................................74 ORTHOVISC ..........................49 Otezla .......................................70 Otezla Starter ...........................70 oxacillin ....................................11 94 oxaliplatin................................ 17 oxaprozin ................................. 46 oxazepam................................. 42 oxcarbazepine ......................... 39 Oxsoralen Ultra ....................... 82 oxybutynin chloride ................ 83 oxycodone ............................... 45 oxycodone-acetaminophen.... 38, 45 Ozurdex ................................... 55 P Pacerone .................................. 32 paclitaxel ................................. 17 paliperidone............................. 41 pamidronate............................. 68 Pancrelipase 5000 ................... 58 Panhematin .............................. 73 pantoprazole ............................ 59 ParaGard T 380A .................... 63 paromomycin ............................ 2 paroxetine HCl ........................ 48 Pataday .................................... 54 Paxil ......................................... 48 peg 3350-electrolytes ............. 58 Pegasys ...................................... 9 Pegasys ProClick ...................... 9 peg-electrolyte soln ................ 58 PegIntron ................................... 9 PegIntron Redipen .................... 9 pen needle, diabetic ................ 49 penicillin G potassium ............ 10 penicillin V potassium ............ 10 Pentam ....................................... 4 Pentasa ..................................... 58 pentostatin ............................... 17 pentoxifylline .......................... 23 perindopril erbumine ........ 27, 28 Perjeta ...................................... 17 permethrin ............................... 82 perphenazine ........................... 46 perphenazine-amitriptyline ... 46, 48 phenazopyridine ...................... 81 phenelzine ......................... 43, 44 phenobarbital..................... 41, 42 phenoxybenzamine ........... 20, 34 phenylephrine HCl.................. 57 phenytoin ........................... 31, 43 phenytoin sodium extended .. 31, 43 Phospholine Iodide.................. 57 Photofrin .................................. 17 pilocarpine HCl ....................... 57 pimozide .................................. 40 pindolol ................. 20, 29, 32, 34 piperacillin-tazobactam ............ 5 piroxicam ................................. 46 Plegridy .................................... 71 PNV Folic Acid + Iron ....25, 84, 86 podofilox.................................. 83 polyethylene glycol 3350 ....... 58 polymyxin B sulf-trimethoprim .............................................. 54 Poly-Vita.................................. 84 Pomalyst ............................ 17, 71 potassium bicarb-citric acid.... 51 potassium chloride .................. 51 potassium citrate ..................... 50 Pradaxa .................................... 22 Praluent Pen ............................. 35 Praluent Syringe ...................... 35 PramCort............................ 80, 81 pramipexole ............................. 44 pravastatin................................ 33 prazosin .............................. 20, 26 Pred Mild ................................. 55 prednisolone ............................ 61 prednisolone acetate ................ 55 prednisolone sodium phosphate ........................................ 55, 61 prednisone................................ 61 Prednisone Intensol ................. 61 Premarin................................... 63 Premphase................................ 63 Prempro ................................... 63 PrenaPlus .............. 25, 51, 85, 86 Prenatabs FA ........ 25, 51, 85, 86 Prenatal 19 ...................25, 85, 86 Prenatal 19 (with docusate) ... 25, 85, 86 Prenatal AD .......... 25, 52, 85, 86 Prenatal Plus ......... 25, 52, 85, 86 Prenatal Plus with Iron (Ca) .. 25, 52, 85, 86 prenatal vit-iron fumarate-FA 25, 52, 85, 86 Prenatal-U ................................ 85 Prevacid SoluTab .................... 60 Prevalite ................................... 30 Prezcobix ............................. 8, 73 Prezista .......................................8 Prialt .........................................38 primaquine .................................3 Primaxin IV................................5 primidone .................................42 Privigen ....................................78 probenecid ......................... 53, 68 prochlorperazine ............... 46, 57 prochlorperazine Edisylate.... 46, 57 prochlorperazine maleate . 46, 58 Procrit .......................................23 Proctofoam HC ................. 80, 81 Profilnine ..................................23 progesterone micronized .........66 Prograf ......................................72 Prolastin-C ...............................76 Proleukin ........................... 17, 71 Prolia ........................................68 Promacta...................................23 promethazine ................. 1, 41, 75 Promethazine VC.......... 1, 19, 75 propafenone .............................31 propantheline ...........................19 proparacaine .............................56 propranolol ......20, 29, 32, 34, 40 propranolol-hydrochlorothiazid .............. 20, 29, 30, 32, 36, 53 propylthiouracil .......................62 Prosol 20 % ..............................50 Prostigmin ................................21 Protonix ....................................60 Protopic ....................................83 Provenge...................................37 Pulmicort Flexhaler .......... 61, 76 Pulmozyme ....................... 53, 75 pyrazinamide ..............................4 pyridostigmine bromide ..........21 pyridoxine (vitamin B6) ..........86 Q quetiapine .................................41 quinapril ............................ 27, 28 quinapril-hydrochlorothiazide ........................... 27, 28, 36, 53 quinidine gluconate ............ 3, 31 quinidine sulfate ................. 3, 31 Qvar ................................... 61, 76 R raloxifene .......................... 63, 68 95 ramipril .............................. 27, 28 ranitidine HCl ......................... 59 Rapamune................................ 72 REBETOL ............................... 10 Rebif (with albumin) .............. 71 Rebif Titration Pack ............... 71 Recombinate ........................... 23 Rectiv....................................... 83 Relenza Diskhaler ................... 10 Remicade ..................... 59, 70, 73 Remodulin ......................... 37, 77 Renvela .............................. 51, 67 Repatha Pushtronex ................ 35 Repatha SureClick .................. 35 Repatha Syringe ...................... 35 Repel Sportsmen ............... 82, 83 Repel Sportsmen Max ...... 82, 83 Rescriptor .................................. 7 reserpine .................................. 35 Restasis .................................... 56 Retisert .................................... 55 Retrovir...................................... 8 Revatio .............................. 35, 77 Revlimid ............................ 17, 71 Reyataz ...................................... 8 Rheumatrex ...........17, 70, 71, 72 RhoGAM Ultra-Filtered PLUS ............................................. 78 Rhophylac ............................... 78 Ribasphere ............................... 10 Ribasphere RibaPak................ 10 ribavirin ................................... 10 Ridaura ........................ 60, 70, 71 rifampin ............................... 4, 11 riluzole ..................................... 43 Risperdal Consta ..................... 41 risperidone ............................... 41 Rituxan .................................... 17 rivastigmine tartrate ................ 21 rizatriptan ................................ 47 ropinirole ................................. 44 S Sabril ....................................... 39 Saizen ...................................... 66 Saizen click.easy ..................... 65 salsalate ................................... 47 Samsca ..................................... 53 Sandimmune ............... 70, 71, 72 Sandostatin LAR Depot ......... 66 Santyl ....................................... 83 Savella................................ 43, 47 selegiline HCl .................... 43, 44 selenium sulfide ...................... 82 Selzentry .................................... 7 Se-Natal 19 ..................25, 85, 86 Serevent Diskus................. 21, 77 Seroquel XR ............................ 41 Serostim ................................... 66 sertraline .................................. 48 SF ............................................. 69 SF 5000 Plus............................ 69 Signifor .................................... 66 sildenafil ............................ 35, 77 silver sulfadiazine ................... 82 Simponi .............................. 70, 71 Simponi ARIA .................. 70, 71 Simulect ................................... 72 simvastatin ............................... 33 sirolimus .................................. 72 Skyla ........................................ 63 sodium chloride ................. 49, 52 sodium citrate-citric acid ........ 50 sodium fluoride ....................... 69 sodium polystyrene (sorb free) ........................................ 51, 67 Soft Touch Lancets ................. 49 Solesta ...................................... 49 Soliris ....................................... 69 Solu-Cortef (PF) ...................... 61 Somatuline Depot.................... 66 Somavert .................................. 66 sotalol .............. 20, 29, 30, 32, 34 Sotalol AF ....... 20, 29, 30, 32, 34 Sovaldi ....................................... 6 spinosad ................................... 83 Spiriva Respimat ............... 19, 74 spironolactone .............34, 35, 51 spironolacton-hydrochlorothiaz ..................... 34, 35, 36, 51, 53 Sporanox .................................... 5 Sprintec (28) ............................ 63 Sprycel ..................................... 17 SPS ..................................... 51, 68 SSKI ........................ 3, 62, 68, 74 stavudine .................................... 8 Stelara ..........................70, 71, 83 Stivarga .................................... 17 Strattera .................................... 43 Stribild ................................... 7, 8 Suboxone ................................. 45 Sucraid......................................54 sucralfate ..................................59 sulfacetamide sodium ..............54 sulfacetamide sodium (acne) ..82 sulfacetamide sodium-sulfur . 81, 82 sulfacetamide-prednisolone ....54 sulfadiazine ..............................12 sulfamethoxazole-trimethoprim ..............................................12 sulfasalazine .......... 12, 58, 70, 71 sulindac ....................................46 sumatriptan ...............................47 sumatriptan succinate ..............47 Supartz FX ...............................49 Supprelin LA..................... 17, 64 Suprax.......................................13 Sustiva ........................................7 Sutent ........................................17 Sylatron 4-Pack................... 9, 17 Synagis .......................................9 Synarel......................................64 Synercid....................................12 Synribo .....................................17 Synvisc .....................................49 Synvisc-One .............................49 Syprine .....................................60 T Tabloid .....................................17 tacrolimus .................................72 Taltz Autoinjector ....................83 Taltz Syringe ............................83 Tamiflu .....................................10 tamoxifen .................................17 tamsulosin ................................21 Tarceva .....................................17 Targretin ...................................83 Tasigna .....................................17 TAZICEF .................................13 Tecfidera ..................................71 Technivie ............................... 6, 8 temazepam ...............................42 Temodar ...................................17 teniposide .................................17 terazosin ...................... 20, 26, 34 terbinafine HCl ..........................2 terbutaline ......................... 21, 77 terconazole ...............................81 Testopel ....................................61 testosterone ..............................61 96 testosterone cypionate ............ 61 tetracaine HCl ......................... 56 tetracaine HCl (PF) ................. 56 tetracycline .............................. 12 Thalomid ................................. 71 Theo-24 .................33, 50, 77, 84 theophylline...........33, 50, 77, 84 Theracys .................................. 78 thioridazine.............................. 46 thiotepa .................................... 17 thiothixene ............................... 48 Thymoglobulin........................ 72 Thyrogen ................................. 50 Thyrolar-1 ............................... 67 Thyrolar-1/2 ............................ 67 Thyrolar-1/4 ............................ 67 Thyrolar-2 ............................... 67 Thyrolar-3 ............................... 67 Tice BCG ................................ 78 ticlopidine................................ 26 Timentin .................................... 5 timolol maleate ....20, 29, 30, 32, 34, 40, 55 Tivicay ....................................... 7 tizanidine ................................. 20 Tobi............................................ 2 Tobi Podhaler ............................ 2 tobramycin .............................. 54 tobramycin sulfate .................... 2 tobramycin-dexamethasone .. 55, 56 Tobrex ..................................... 55 tolazamide ............................... 67 tolbutamide.............................. 67 tolterodine ............................... 83 topiramate................................ 39 topotecan ................................. 17 Torisel ...................................... 17 torsemide ........................... 34, 50 Toviaz ...................................... 84 TPN Electrolytes ..................... 52 TPN Electrolytes II ................. 52 Tracleer.............................. 37, 77 tramadol ................................... 45 tramadol-acetaminophen . 38, 40, 45 trandolapril ........................ 27, 28 tranylcypromine ...................... 44 Travasol 10 % ......................... 50 trazodone ................................. 48 Treanda .................................... 17 Trelstar ..................................... 17 tretinoin .................................... 81 tretinoin (chemotherapy) ........ 17 Trexall ..........................17, 70, 72 TriAdvance ........... 25, 52, 85, 86 triamcinolone acetonide .......... 80 triamterene-hydrochlorothiazid ........................... 35, 36, 51, 53 triazolam .................................. 42 trifluoperazine ......................... 46 trifluridine ................................ 55 trihexyphenidyl ................. 19, 38 trimethobenzamide .................. 58 trimethoprim ............................ 13 Trinatal Rx 1......... 25, 52, 85, 86 Trinatal Ultra .. 25, 52, 58, 85, 86 Trinate ................... 25, 52, 85, 86 Trisenox ................................... 17 Tri-Sprintec (28) ..................... 63 Triumeq ................................. 7, 8 Triveen-Duo DHA 25, 52, 85, 86 Tri-Vit with Fluoride and Iron ..................................25, 69, 85 Tri-Vitamin With Fluoride .... 69, 85, 87 Trivora (28) ............................. 63 Trizivir ....................................... 8 TrophAmine 10 %................... 50 tropicamide .............................. 57 trospium ................................... 84 Truvada ...................................... 8 Tybost ...................................... 73 Tygacil ....................................... 6 Tykerb ...................................... 18 Tysabri ..................................... 72 Tyvaso................................ 37, 77 Tyvaso Refill Kit ............... 37, 77 Tyvaso Starter Kit ............. 37, 77 U U-Cort ...................................... 80 Uptravi ............................... 37, 77 urea ........................................... 82 ursodiol .................................... 58 V Vaginal Contraceptive Foam .. 48 valacyclovir ............................. 10 valproic acid ...................... 39, 40 valproic acid (as sodium salt) 39, 40 valsartan ...................................27 valsartan-hydrochlorothiazide ................................. 27, 36, 53 Valstar ......................................18 vancomycin ................................6 vancomycin in dextrose 5 % .....6 Vantas ................................ 18, 64 Vectibix ....................................18 Velcade .....................................18 Veletri ................................ 37, 77 Velivet Triphasic Regimen (28) ..............................................63 venlafaxine ...............................47 Venofer .....................................25 Ventavis............................. 37, 77 Ventolin HFA ................... 21, 77 verapamil ..................... 30, 32, 37 Vfend IV ....................................5 Vibativ ........................................6 Victoza 2-Pak...........................64 Victoza 3-Pak...........................64 Vidaza.......................................18 Videx 2 gram Pediatric..............8 Viekira Pak............................ 6, 8 Viekira XR ............................ 6, 8 Vigamox ...................................55 Vinate GT.................... 25, 85, 86 Vinate II ................ 25, 52, 85, 87 Vinate M ..................................85 Vinate One ............ 25, 52, 85, 87 Vinate Ultra.....25, 52, 58, 85, 87 vinblastine ................................18 vincristine .................................18 vinorelbine ...............................18 Viracept ......................................8 Viramune XR .............................7 Viread .........................................8 Vistide ......................................10 Visudyne ..................................56 Vitekta ........................................7 Vivitrol .............................. 45, 67 Vol-Nate ................ 25, 52, 85, 87 Voraxaze ........................... 54, 68 Votrient ....................................18 VPRIV ......................................54 Vyvanse ....................................38 W warfarin ....................................22 WelChol ............................ 30, 61 Wilate .......................................24 97 WinRho SDF ........................... 78 X Xalkori ..................................... 18 Xarelto ..................................... 22 Xeljanz .................................... 70 Xeljanz XR .............................. 70 Xenazine .................................. 43 Xeomin .............................. 22, 73 Xgeva....................................... 68 Xiaflex ..................................... 54 Xifaxan .................................... 11 Xolair ....................................... 76 Xopenex HFA ................... 21, 77 Xtandi ...................................... 18 Xulane ..................................... 63 Xyntha ..................................... 24 Xyntha Solofuse...................... 24 Y Yervoy ..................................... 18 Yodoxin ..................................... 2 Z zaleplon .................................... 41 Zaltrap ...................................... 18 Zanosar .................................... 18 Zarxio ....................................... 23 Zavesca .................................... 73 Zelboraf ................................... 18 Zemaira .................................... 76 Zenpep ..................................... 58 Zepatier .................................. 6, 7 Zevalin (Y-90) ......................... 18 Ziagen ........................................ 8 zidovudine ................................. 8 Zinacef ..................................... 12 ziprasidone HCl....................... 41 Zmax ........................................ 10 Zoladex .............................. 18, 64 zoledronic acid ........................ 68 zoledronic acid-mannitol-water ..............................................68 Zolinza......................................18 zolpidem ...................................41 Zometa......................................68 zonisamide ...............................39 Zortress .....................................72 Zosyn in dextrose (iso-osm) .....5 Zovia 1/35E (28)......................63 Zovia 1/50E (28)......................63 Zovirax .....................................81 Zubsolv .....................................45 Zykadia .....................................18 Zyprexa Relprevv ....................41 Zytiga .......................................18 Zyvox .......................................10 98
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