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PrimeChoice™ Plus Formulary, April 2016
PrimeChoice™ Plus Formulary, April 2016 Your prescription drug benefit plan may not cover certain products or drug categories, regardless of their appearance in this document. Questions may be directed to Prime Therapeutics LLC, P.O. Box 64812, St. Paul, MN 55164-0812, Phone 800.858.0723. Thank you for your cooperation. DR ........................................................................ Delayed-release ER ...................................................................... Extended-release IR ...................................................................... Immediate-release NF ............................................................................ Non-formulary ODT .................................................... Orally disintegrating tablets SL .................................................................................. Sublingual This formulary list was current at time of printing and is subject to change. To access a searchable version of this formulary visit our website at MyPrime.com. GENERIC BRAND ANTI-INFECTIVE AGENTS AMOXICILLIN chew tabs AMOXICILLIN/CLAVULANATE chew tabs AMPICILLIN susp AUGMENTIN susp, 125 mg/5 mL CEPHALOSPORINS cefaclor caps cefadroxil cefdinir cefixime cefpodoxime cefprozil ceftriaxone cefuroxime cephalexin, NF = tabs CEFTIN susp, 125 mg/5 mL SUPRAX caps; chews; susp, 500 mg/5 mL MACROLIDES azithromycin susp, tabs clarithromycin IR, ER erythromycin DR caps AMINOGLYCOSIDES neomycin sulfate paromomycin tobramycin inhal soln ethambutol isoniazid tabs pyrazinamide rifabutin rifampin AZITHROMYCIN packets DIFICID E.E.S. 400 ERY-TAB ERYTHROCIN STEARATE ERYTHROMYCIN BASE ERYTHROMYCIN ETHYLSUCCINATE fluconazole flucytosine griseofulvin microsize itraconazole nystatin oral terbinafine voriconazole TETRACYCLINE FLUOROQUINOLONES ciprofloxacin IR, ER ciprofloxacin susp levofloxacin moxifloxacin ivermectin ISONIAZID syrup PRIFTIN RIFAMATE LAMISIL granules NOXAFIL SPORANOX soln CIPROFLOXACIN tabs, 100 mg OFLOXACIN tabs, 400 mg ATRIPLA BARACLUDE soln COMPLERA DAKLINZA EPIVIR HBV soln EPZICOM EVOTAZ HARVONI INTELENCE ISENTRESS KALETRA NORVIR soln, tabs PEG-INTRON PEGASYS PREZCOBIX PREZISTA REYATAZ caps SOVALDI STRIBILD SUSTIVA TAMIFLU TIVICAY TRIUMEQ TRUVADA VIDEX VIRAMUNE susp VIREAD ZIAGEN soln ANTIMALARIALS atovaquone/proguanil BRAND DARAPRIM PRIMAQUINE ALBENZA BILTRICIDE ANTI-INFECTIVE AGENTS - MISC. clindamycin linezolid metronidazole, NF = caps sulfamethoxazole/trimethoprim trimethoprim vancomycin DAPSONE NEBUPENT SIVEXTRO tabs XIFAXAN 550 mg BIOLOGICALS SYNAGIS ANTINEOPLASTIC AGENTS ANTIVIRALS abacavir abacavir/lamivudine/zidovudine acyclovir adefovir didanosine DR entecavir famciclovir lamivudine lamivudine/zidovudine nevirapine IR, ER ribavirin stavudine valacyclovir valganciclovir tabs zidovudine GENERIC chloroquine phosphate hydroxychloroquine mefloquine ANTHELMINTICS ANTIMYCOBACTERIAL AGENTS TETRACYCLINES demeclocycline doxycycline hyclate IR doxycycline monohydrate, NF = susp minocycline IR BRAND ANTIFUNGALS PENICILLINS amoxicillin caps, susp, tabs amoxicillin/potassium clavulanate IR, ER ampicillin caps dicloxacillin penicillin v potassium GENERIC ofloxacin COARTEM anastrozole bexarotene bicalutamide capecitabine exemestane flutamide hydroxyurea imatinib letrozole leucovorin calcium tabs, 5 mg, 25 mg megestrol mercaptopurine methotrexate tamoxifen temozolomide tretinoin caps ACTIMMUNE AFINITOR AFINITOR DISPERZ ALECENSA ALKERAN tabs BOSULIF CAPRELSA COMETRIQ COTELLIC CYCLOPHOSPHAMIDE EMCYT ERIVEDGE ETOPOSIDE caps FARESTON FARYDAK GILOTRIF GLEEVEC GLEOSTINE HEXALEN HYCAMTIN caps IBRANCE ICLUSIG IMBRUVICA INLYTA IRESSA JAKAFI LENVIMA LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg LEUKERAN LONSURF LYNPARZA LYSODREN MATULANE (continued) 4550 © Prime Therapeutics LLC 04/16 PrimeChoice™ Plus Page 1 of 6 GENERIC BRAND MEKINIST MESNEX tabs MYLERAN NEXAVAR NILANDRON NINLARO ODOMZO POMALYST PURIXAN SOLTAMOX SPRYCEL STIVARGA SUTENT SYLATRON TABLOID TAFINLAR TAGRISSO TARCEVA TASIGNA TYKERB VOTRIENT XALKORI XTANDI ZELBORAF ZOLINZA ZYDELIG ZYKADIA ZYTIGA ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS budesonide ER dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, 6 mg fludrocortisone hydrocortisone methylprednisolone prednisolone soln, 5 mg/5 mL, 15 mg/5 mL; syrup prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg CORTISONE DEXAMETHASONE soln; tabs, 1 mg, 2 mg DEXAMETHASONE INTENSOL PREDNISONE dose pack; soln, 5 mg/5 mL; tabs, 50 mg GENERIC levonorgestrel tabs 1.5 mg medroxyprogesterone inj, 150 mg/mL oral contraceptive generics ELLA LO LOESTRIN FE MIRENA NECON 10/11, 1/50 NUVARING OGESTREL ORTHO TRI-CYCLEN LO SKYLA XULANE ZOVIA 1/50E OXYTOCICS ENDOCRINE and METABOLIC AGENTS - MISC. alendronate tabs cabergoline calcitonin-salmon calcitriol chorionic gonadotropin clomiphene desmopressin ibandronate levocarnitine octreotide paricalcitol raloxifene risedronate medroxyprogesterone acetate tabs norethindrone acetate progesterone micronized ANTIDIABETICS acarbose glimepiride glipizide IR, ER glipizide/metformin glyburide micronized glyburide/metformin glyburide, generics of Micronase metformin IR, ER; NF = OSM nateglinide pioglitazone pioglitazone/metformin repaglinide BYDUREON BYETTA GLUCAGON EMERGENCY KIT GLYBURIDE, distributor of Diabeta INVOKAMET INVOKANA JANUMET JANUMET XR JANUVIA JARDIANCE KOMBIGLYZE XR ONGLYZA SYNJARDY VICTOZA HUMALOG MIX 50/50, 75/25 HUMULIN N HUMULIN 70/30 NOVOLIN N NOVOLIN 70/30 NOVOLOG MIX 70/30 LANTUS LEVEMIR TOUJEO SOLOSTAR TRESIBA FLEXTOUCH levothyroxine liothyronine DIGOXIN soln LANOXIN tabs ANTIANGINAL AGENTS isosorbide dinitrate IR, 5 mg, 10 mg, 20 mg isosorbide mononitrate IR, ER nitroglycerin patches acebutolol atenolol bisoprolol carvedilol labetalol metoprolol succinate ER metoprolol tartrate nadolol pindolol propranolol IR, ER sotalol sotalol AF Intermediate-Acting Insulins THYROID AGENTS digoxin tabs BETA BLOCKERS Basal Insulins CLIMARA PRO DIVIGEL ENJUVIA ESTROPIPATE 3 mg PREMARIN tabs PREMPHASE CARDIOTONICS HUMALOG NOVOLOG HUMULIN R NOVOLIN R ALENDRONATE 40 mg CETROTIDE FOLLISTIM AQ FORTEO GONAL-F INCRELEX LUPRON DEPOT-PED NORDITROPIN NUTROPIN AQ ORFADIN OVIDREL PROLIA REPRONEX SANDOSTATIN LAR DEPOT SENSIPAR STIMATE STRENSIQ CARDIOVASCULAR AGENTS Rapid-Acting Insulins Short-Acting Insulins ANDRODERM ANDROGEL 1.62% ANDROXY TESTIM BRAND methylergonovine PROGESTINS ESTROGENS estradiol estradiol/norethindrone acetate estropipate 0.75 mg, 1.5 mg norethindrone acetate/ethinyl estradiol GENERIC methimazole propylthiouracil CONTRACEPTIVES ANDROGEN-ANABOLIC danazol testosterone cypionate testosterone enanthate testosterone gel, 12.5 mg/ actuation testosterone gel, 25 mg/2.5 g, 50 mg/2.5 g BRAND PREMPRO ISOSORBIDE DINITRATE IR, 30 mg NITRO-BID NITROSTAT RANEXA BYSTOLIC PROPRANOLOL soln TIMOLOL CALCIUM CHANNEL BLOCKERS amlodipine diltiazem IR; ER caps – 24 hr dosing felodipine ER nifedipine ER verapamil IR; ER, NF = caps, 100 mg, 200 mg, 300 mg (continued) 4550 © Prime Therapeutics LLC 04/16 PrimeChoice™ Plus Page 2 of 6 GENERIC BRAND ANTIARRHYTHMICS amiodarone disopyramide flecainide mexiletine propafenone IR, ER quinidine gluconate ER MULTAQ NORPACE CR 100 mg QUINIDINE SULFATE IR, ER ANTIHYPERTENSIVES amlodipine/benazepril amlodipine/valsartan amlodipine/valsartan/ hydrochlorothiazide atenolol/chlorthalidone benazepril benazepril/hydrochlorothiazide bisoprolol/hydrochlorothiazide candesartan candesartan/hydrochlorothiazide captopril clonidine doxazosin enalapril enalapril/hydrochlorothiazide eplerenone fosinopril fosinopril/hydrochlorothiazide guanfacine hydralazine irbesartan irbesartan/hydrochlorothiazide lisinopril lisinopril/hydrochlorothiazide losartan losartan/hydrochlorothiazide methyldopa minoxidil moexipril moexipril/hydrochlorothiazide perindopril phenoxybenzamine prazosin quinapril quinapril/hydrochlorothiazide ramipril telmisartan telmisartan/hydrochlorothiazide terazosin trandolapril valsartan valsartan/hydrochlorothiazide AZOR BENICAR BENICAR HCT CAPTOPRIL/ HYDROCHLOROTHIAZIDE DUTOPROL PROPRANOLOL/ HYDROCHLOROTHIAZIDE BRAND TRIAMTERENE/ HYDROCHLOROTHIAZIDE caps, 50-25 mg midodrine EPIPEN EPIPEN-JR ANTIHYPERLIPIDEMICS atorvastatin cholestyramine colestipol fenofibrate fenofibrate micronized 67 mg, 134 mg, 200 mg fenofibric acid DR gemfibrozil lovastatin niacin ER omega-3-acid ethyl esters pravastatin simvastatin amlodipine/atorvastatin sildenafil 20 mg CRESTOR PRALUENT REPATHA REPATHA SURECLICK VASCEPA WELCHOL ZETIA ADCIRCA CIALIS LETAIRIS OPSUMIT TRACLEER ANTIHISTAMINES cetirizine syrup cyproheptadine desloratadine tabs, ODT levocetirizine tabs, soln promethazine supp, syrup, tabs NASAL AGENTS - SYSTEMIC and TOPICAL azelastine flunisolide fluticasone propionate ipratropium triamcinolone spray BACTROBAN NASAL NASONEX RESPIRATORY AGENTS - MISC. KALYDECO PULMOZYME GASTROINTESTINAL AGENTS lactulose PEG-electrolytes for soln, generics of Colyte, Golytely, Nulytely MOVIPREP ANTIDIARRHEALS diphenoxylate/atropine tabs loperamide DIPHENOXYLATE/ATROPINE soln ULCER DRUGS cimetidine, NF = 200 mg dicyclomine esomeprazole magnesium caps famotidine tabs glycopyrrolate hyoscyamine IR, ER; NF = Duotab lansoprazole DR methscopolamine misoprostol omeprazole DR pantoprazole DR ranitidine sucralfate tabs CARAFATE susp NEXIUM packets OMECLAMOX-PAK PROPANTHELINE ANTIEMETICS COUGH/COLD/ALLERGY acetylcysteine inhal soln ANTIASTHMATIC and BRONCHODILATOR AGENTS albuterol, NF = ER budesonide inhal susp ipratropium inhal soln ipratropium/albuterol inhal soln levalbuterol inhal soln BRAND ASMANEX TWISTHALER ATROVENT HFA BREO ELLIPTA COMBIVENT RESPIMAT CROMOLYN SODIUM inhal soln DULERA FLOVENT DISKUS FLOVENT HFA FORADIL AEROLIZER INCRUSE ELLIPTA PROAIR HFA PROAIR RESPICLICK QVAR SEREVENT DISKUS SPIRIVA HANDIHALER SPIRIVA RESPIMAT SYMBICORT VENTOLIN HFA LAXATIVES RESPIRATORY AGENTS ACETAZOLAMIDE 125 mg CHLOROTHIAZIDE 250 mg CHLORTHALIDONE 25 mg, 50 mg GENERIC montelukast terbutaline theophylline ER zafirlukast VASOPRESSORS CARDIOVASCULAR AGENTS - MISC. DIURETICS acetazolamide IR, 250 mg; ER amiloride amiloride/hydrochlorothiazide bumetanide chlorothiazide 500 mg furosemide, NF = soln, 8 mg/mL GENERIC hydrochlorothiazide indapamide methazolamide metolazone spironolactone spironolactone/ hydrochlorothiazide torsemide triamterene/hydrochlorothiazide caps, 37.5-25 mg; tabs ADVAIR DISKUS ADVAIR HFA ANORO ELLIPTA ARNUITY ELLIPTA ASMANEX HFA granisetron meclizine 12.5 mg, 25 mg ondansetron trimethobenzamide EMEND TRANSDERM-SCOP DIGESTIVE AIDS CREON ZENPEP (continued) 4550 © Prime Therapeutics LLC 04/16 PrimeChoice™ Plus Page 3 of 6 GENERIC BRAND GASTROINTESTINAL AGENTS- MISC. balsalazide calcium acetate lactulose mesalamine metoclopramide sulfasalazine sulfasalazine DR ursodiol ASACOL HD CANASA CHENODAL DELZICOL LIALDA LINZESS PENTASA RENVELA GENITOURINARY AGENTS URINARY ANTI-INFECTIVES nitrofurantoin susp nitrofurantoin macrocrystalline nitrofurantoin monohydrate/ macrocrystalline URINARY ANTISPASMODICS oxybutynin IR, ER tolterodine IR, ER MYRBETRIQ TOVIAZ VESICARE VAGINAL PRODUCTS clindamycin crm metronidazole gel terconazole CLEOCIN supp CRINONE ESTRACE crm VAGIFEM GENITOURINARY AGENTS - MISC. alfuzosin ER dutasteride finasteride pot & sod citrates/cit ac soln potassium citrate potassium citrate/citric acid sodium citrate/citric acid tamsulosin CYSTAGON CYTRA-3 ELMIRON K-PHOS NO. 2 GENERIC mirtazapine, NF = ODT nortriptyline caps paroxetine hcl IR, ER phenelzine sertraline tranylcypromine trazodone venlafaxine IR, ER; NF = 225 mg BRAND ANALGESICS - NON-NARCOTIC ANTIPSYCHOTICS aripiprazole tabs chlorpromazine clozapine fluphenazine decanoate fluphenazine hcl tabs haloperidol haloperidol decanoate haloperidol lactate conc lithium carbonate IR, ER loxapine olanzapine IR, ODT perphenazine prochlorperazine quetiapine risperidone IR, ODT thiothixene trifluoperazine ziprasidone FLUPHENAZINE HCL conc, elixir LITHIUM LITHIUM CARBONATE caps, 150 mg SEROQUEL XR HYPNOTICS estazolam PHENOBARBITAL tabs, 15 mg, eszopiclone tabs 30 mg, 60 mg, 100 mg phenobarbital soln; tabs, 16.2 mg, 32.4 mg temazepam zaleplon zolpidem IR, ER ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS ANTIANXIETY AGENTS amphetamine/ dextroamphetamine IR, ER caffeine citrate dexmethylphenidate ER dextroamphetamine IR, ER guanfacine ER methylphenidate IR tabs; ER tabs, 10 mg, 20 mg modafinil DIAZEPAM soln HYDROXYZINE PAMOATE 100 mg ANTIDEPRESSANTS amitriptyline bupropion IR, ER citalopram clomipramine desipramine doxepin, NF = 150 mg duloxetine DR escitalopram fluoxetine, NF = 60 mg; ER fluvoxamine IR imipramine hcl DOXEPIN 75 mg NORTRIPTYLINE soln PRISTIQ ADDERALL XR CONCERTA STRATTERA VYVANSE PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC. acamprosate DR bupropion ER – smoking deterrent disulfiram donepezil galantamine IR, ER glatiramer memantine pimozide rivastigmine BRAND TECFIDERA ANALGESICS AND ANESTHETICS CENTRAL NERVOUS SYSTEM DRUGS alprazolam, IR, ER; NF = ODT buspirone, NF = 7.5 mg diazepam tabs hydroxyzine hcl hydroxyzine pamoate 25 mg, 50 mg lorazepam GENERIC tetrabenazine BETASERON CHANTIX COPAXONE GALANTAMINE soln NAMENDA XR NICOTROL INHALER NICOTROL NS NUEDEXTA PLEGRIDY REBIF butalbital/acetaminophen butalbital/acetaminophen/ caffeine, NF = caps, 50-300-40 mg butalbital/aspirin/caffeine caps salsalate ANALGESICS - NARCOTIC acetaminophen/codeine buprenorphine butalbital/aspirin/caffeine/codeine codeine sulfate tabs fentanyl fentanyl citrate hydrocodone/acetaminophen tabs, 5-235 mg, 7.5-235 mg, 10-325 mg; soln, 7.5-325 mg hydrocodone/ibuprofen, NF = 2.5-200 mg hydromorphone soln, tabs methadone conc, soln, tabs morphine sulfate conc, ER, caps/ tabs; soln oxycodone oxycodone/acetaminophen, NF = 2.5-325 mg oxycodone/aspirin tramadol IR, ER; NF = biphasic tramadol/acetaminophen HYDROMORPHONE supp MORPHINE SULFATE IR, supp, ER bead caps NUCYNTA ER OXYCODONE conc OXYCONTIN ANALGESICS - ANTI-INFLAMMATORY celecoxib diclofenac potassium diclofenac sodium DR, ER etodolac IR, ER flurbiprofen ibuprofen indomethacin, NF = ER ketoprofen, NF = ER leflunomide meloxicam nabumetone naproxen IR tabs, DR naproxen sodium oxaprozin piroxicam sulindac ENBREL ENBREL SURECLICK HUMIRA ILARIS NAPROXEN susp SIMPONI VIMOVO ZORVOLEX MIGRAINE PRODUCTS acetaminophen/isometheptene/ dichloralphenazone naratriptan rizatriptan IR, ODT sumatriptan auto-injector; cartridge; inj, 6 mg/0.5 mL; tabs IMITREX nasal MIGRANAL (continued) 4550 © Prime Therapeutics LLC 04/16 PrimeChoice™ Plus Page 4 of 6 GENERIC BRAND GENERIC GOUT AGENTS allopurinol probenecid probenecid/colchicine COLCRYS NEUROMUSCULAR DRUGS MINERALS and ELECTROLYTES ANTICONVULSANTS carbamazepine IR, ER clonazepam, NF = ODT divalproex DR, ER ethosuximide gabapentin lamotrigine levetiracetam IR, ER oxcarbazepine phenytoin phenytoin sodium ER primidone topiramate valproic acid zonisamide BANZEL tabs CELONTIN DIASTAT DILANTIN-125 DILANTIN, NF = INFATABS LYRICA SABRIL TEGRETOL-XR 100 mg potassium bicarbonate/chloride effervescent, 25 mEq potassium chloride ER, packets, soln potassium phosphate/sodium phosphates sodium fluoride chew tabs; soln, 0.275 mg/drop, 1.1 mg/mL HEMATOPOIETIC AGENTS cyanocobalamin inj folic acid 1 mg AZILECT CARBIDOPA/LEVODOPA/ ENTACAPONE riluzole MUSCULOSKELETAL THERAPY AGENTS DANTROLENE caps, 100 mg ANTIMYASTHENIC AGENTS pyridostigmine NUTRITIONAL PRODUCTS VITAMINS ergocalciferol MEPHYTON MULTIVITAMINS pediatric multivitamins pediatric vitamins ADC ARANESP GRANIX NEULASTA NEULASTA ONPRO KIT NEUMEGA PROCRIT ZARXIO acetic acid benzocaine/antipyrine hydrocortisone/acetic acid neomycin/polymyxin B/ hydrocortisone ofloxacin ANTICOAGULANTS enoxaparin warfarin ESCAVITE LQ PRENATABS FA/RX PRENATAL VITAMINS PLUS LOW anagrelide cilostazol clopidogrel 75 mg dipyridamole pentoxifylline ER ELIQUIS PRADAXA XARELTO BRAND CIPRO HC CIPRODEX MOUTH/THROAT/DENTAL AGENTS cevimeline chlorhexidine clotrimazole troche lidocaine viscous nystatin oral pilocarpine tabs sodium fluoride crm, gel triamcinolone dental paste BRILINTA CINRYZE EFFIENT FIRAZYR TOPICAL PRODUCTS ANORECTAL AGENTS OPHTHALMIC AGENTS atropine sulfate soln azelastine soln bacitracin/polymyxin B oint brimonidine soln, 0.15%, 0.2% carteolol soln ciprofloxacin soln cromolyn sodium soln cyclopentolate soln, 1% diclofenac soln dorzolamide soln dorzolamide/timolol maleate soln erythromycin oint fluorometholone susp, 0.1% flurbiprofen soln gentamicin oint, soln homatropine soln ketorolac soln latanoprost soln levobunolol soln, 0.5% GENERIC neomycin/polymyxin B/bacitracin oint neomycin/polymyxin B/bacitracin/ hydrocortisone oint neomycin/polymyxin B/ dexamethasone oint, susp neomycin/polymyxin B/gramicidin soln ofloxacin soln pilocarpine soln polymyxin B/trimethoprim soln prednisolone acetate susp sulfacetamide sodium soln sulfacetamide sodium/ prednisolone soln timolol maleate soln tobramycin soln tobramycin/dexamethasone susp trifluridine soln OTIC AGENTS HEMATOLOGICAL AGENTS - MISC. NEUROMUSCULAR AGENTS baclofen chlorzoxazone cyclobenzaprine 5 mg, 10 mg dantrolene metaxalone methocarbamol orphenadrine ER orphenadrine/aspirin/caffeine tabs, 25-385-30 mg tizanidine tabs FLUOR-A-DAY FLURA-DROPS 0.55 mg/drop K-PHOS POTASSIUM CHLORIDE ER tabs, 8 mEq SODIUM FLUORIDE tabs SSKI HEMATOLOGICAL AGENTS ANTIPARKINSON AGENTS amantadine, NF = tabs benztropine bromocriptine carbidopa/levodopa IR, ER, ODT entacapone pramipexole ropinirole selegiline trihexyphenidyl BRAND PRENATAL 19/PLUS/U SE-NATAL 19 TRI-VIT/FLUORIDE/IRON TRINATE VINATE/II/M/ONE ALPHAGAN P 0.1% ALREX ATROPINE SULFATE oint AZOPT BACITRACIN oint CILOXAN oint DEXAMETHASONE SODIUM PHOS soln LEVOBUNOLOL soln, 0.25% LOTEMAX LUMIGAN METIPRANOLOL NATACYN PATADAY PAZEO SIMBRINZA TOBREX oint TRAVATAN Z VIGAMOX ZYLET hydrocortisone crm, 2.5%; enema CORTIFOAM hydrocortisone acetate supp DERMATOLOGICALS acitretin adapalene crm, gel alclometasone betamethasone dipropionate betamethasone dipropionate, augmented betamethasone valerate crm, lotn, oint calcipotriene crm, soln, oint calcipotriene/betamethasone ciclopirox, NF = topical kit clindamycin clindamycin/benzoyl peroxide clobetasol desonide desoximetasone crm, 0.25%; gel; oint, 0.25% AMCINONIDE CARAC DESOXIMETASONE crm, 0.05% DIFFERIN lotn DIFLORASONE crm, oint ELIDEL EPIDUO EPIDUO FORTE FINACEA FLUOROPLEX GENTAMICIN topical ORACEA PICATO STELARA SULFACETAMIDE SODIUM/ SULFUR susp, 10%-5% TACLONEX susp (continued) 4550 © Prime Therapeutics LLC 04/16 PrimeChoice™ Plus Page 5 of 6 GENERIC diclofenac sodium gel econazole erythromycin erythromycin/benzoyl peroxide fluocinolone fluocinonide fluorouracil fluticasone propionate halobetasol hydrocortisone 2.5% hydrocortisone valerate imiquimod isotretinoin caps ketoconazole crm; shampoo, 2% lidocaine/prilocaine crm; kit lidocaine, NF = crm, lotn lindane malathion metronidazole topical mometasone mupirocin nystatin topical nystatin/triamcinolone permethrin podofilox selenium sulfide silver sulfadiazine sulfacetamide sodium lotn sulfacetamide sodium/sulfur crm; emulsion; lotn, 10%-5% tacrolimus oint tretinoin microsphere tretinoin, NF = emollient crm; Avita gel triamcinolone, crm; lotn; oint, 0.025%, 0.1% BRAND TAZORAC TRIAMCINOLONE oint, 0.5% VALCHLOR VOLTAREN ZYCLARA BRAND LIFESCAN SURESTEP calibration liquid LIFESCAN UNISTIK 2 lancets ROCHE ACCU-CHEK ACTIVE, AVIVA, AVIVA PLUS, COMPACT, COMPACT PLUS, SMARTVIEW test strips ROCHE ACCU-CHEK ACTIVE, AVIVA, COMPACT, COMPACT PLUS, INSTANT SMARTVIEW calibration liquid ROCHE ACCU-CHEK AVIVA CONNECT, AVIVA PLUS, COMPACT PLUS, NANO SMARTVIEW, VOICEMATE blood glucose meters ROCHE ACCU-CHEK FASTCLIX, MULTICLIX, SAFE-TPRO, SAFE-T-PRO PLUS, SOFTCLIX, SOFT TOUCH lancets ROCHE ACCUTREND calibration liquid; test strips MEDICAL DEVICES INHALER ASSIST DEVICES – SPACERS ASSORTED CLASSES azathioprine buprenorphine/naloxone cyclosporine cyclosporine modified caps, 25 mg, 100 mg; soln mycophenolate mofetil mycophenolate sodium DR sirolimus sodium polystyrene sulfonate tacrolimus caps MISCELLANEOUS PRODUCTS ANTIDOTES naloxone inj, 0.4 mg/mL naltrexone GENERIC CUPRIMINE CYCLOSPORINE MODIFIED caps, 50 mg RAPAMUNE soln REVLIMID SUBOXONE film THALOMID ZORTRESS CHEMET DIABETIC SUPPLIES INSULIN PEN NEEDLES various INSULIN SYRINGES various LANCETS various LIFESCAN ULTRA BLUE, VERIO test strips LIFESCAN ONETOUCH COMBO PACK, DELICA, FINEPOINT, ULTRASOFT lancets LIFESCAN ONETOUCH ULTRA, ULTRA 2, ULTRA MINI, ULTRALINK, ULTRA SMART, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC blood glucose meters LIFESCAN ONETOUCH ULTRA, VERIO calibration liquid 4550 © Prime Therapeutics LLC 04/16 PrimeChoice™ Plus Page 6 of 6
