2015 Drug Formulary

Transcription

2015 Drug Formulary

Commercial
Maximum Performance
Abridged Formulary
2015
LIST OF COVERED DRUGS
MDF15 Lists Updated 10/2015
GlobalHealth, Inc.
701 NE 10th St, Ste. 300
Oklahoma City, OK 73104-5403
2015 GLOBALHEALTH
MAXIMUM PERFORMANCE ABRIDGED FORMULARY
The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list
(formulary) that is at the core of your Prescription Drug benefits. The list is not all-inclusive and does not guarantee
coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever
appropriate. You can get information and updates to this document on our website.
Table of Contents
Helpful Numbers ................................................................................................................. 2
Types of Pharmacy Networks ............................................................................................. 3
GlobalHealth’s Preferred Drug List ..................................................................................... 3
Prior Authorization, Step Therapy, Quantity Limits, and Exceptions .................................. 4
Your Prescription Drug Benefits .......................................................................................... 6
Medication Therapy Management Program........................................................................ 7
Preventive Care .................................................................................................................. 7
Therapeutic Class Index ................................................................................................... 11
Alphabetical Listing Index ................................................................................................. 36
GlobalHealth, Inc. does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity,
sexual orientation, or health status in the administration of the Plan, including enrollment and benefit determinations.
2
Helpful Numbers and Information
Plan Issuer:
GlobalHealth, Inc.
PO Box 2328
GlobalHealth Customer Care:
State of Oklahoma Employees:
CommercialAnswers@globalhealth.com
405.280.5600 (local)
1.877.280.5600 (toll-free)
1.800.722.0353 or 711 (TTY/TDD/Voice)
www.globalhealth.com/state
Federal Employees Health Benefits
Program:
405.280.2989 (local)
1.877.280.2989 (toll-free)
1.800.722.0353 or 711 (TTY/TDD/Voice)
www.globalhealth.com/fehb
Commercial Employer Groups and
Individuals:
405.280.2964 (local)
1.877.280.2964 (toll-free)
1.800.722.0353 or 711 (TTY/TDD/Voice)
www.globalhealth.com/commercial
Marketplace Individuals and SHOP
Employer Groups:
MarketplaceAnswers@globalhealth.com
405.280.5583 (local)
1.877.280.5583 (toll-free)
1.800.722.0353 or 711 (TTY/TDD/Voice)
www.globalhealth.com/marketplace
Language Assistance –
just ask for an interpreter
24/7 Nurse Help Line
Nurse Help Line
1.877.280.2993 (toll-free)
Disease Management
Alere
1.855.894.7487 (toll-free)
Behavioral & Mental
Health/Chemical Dependency:
MHNet
- 1.866.904.5234 (toll-free)
1.866.200.3269 (TTY/TDD/Voice)
Pharmacy Benefits Manager:
Mail Claims to:
Express Scripts
PO Box 66583
St. Louis, MO 63166
Medication Prior Authorizations:
918.878.7361
Express Scripts Marketplace Help Desk:
1.866.211.7824 (toll-free)
1.800.899.2114 (TTY/TDD/Voice)
Express Scripts Help Desk:
1.866.274.1612 (toll-free)
1.800.899.2114 (TTY/TDD/Voice)
Mail Claims to:
Mental Health & Substance Abuse
Claims
MHNet Claims Department
PO Box 7802
London, KY 40742
Marketplace Mail Order Pharmacy:
Express Scripts Customer Care Center
1.866.211.7824 (toll-free)
1.800.899.2114 (TTY/TDD/Voice)
24 hours/7 days a week
www.express-scripts.com/globalhealth
Dental:
Delta Dental of Oklahoma
405.607.4722
1.855.203.5617 (toll-free)
www.DeltaDentalOK.org
Mail Order Pharmacy:
Express Scripts Customer Care Center
1.866.274.1612 (toll-free)
1.800.899.2114 (TTY/TDD/Voice)
24 hours/7 days a week
www.express-scripts.com
Mail Claims to:
Delta Dental of Oklahoma
Claims Processing Center
PO Box 548809
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GlobalHealth Compliance and Privacy
Officer
1.877.280.5852 (toll-free)
405.280.5852
compliance@globalhealth.com
Types of Pharmacy Networks
You have different options to receive your prescribed medications.
Preferred Retail Network Pharmacy
Your Plan may offer preferred and non-preferred pharmacy Networks. When you purchase your prescriptions at a
preferred retail Network pharmacy, you will pay your Plan’s published cost-share for each tier. This is where you
will experience the greatest savings. You may still go to non-preferred retail Network pharmacies, but you will pay
a higher cost-share for each prescription. A list of both preferred and non-preferred retail Network pharmacies can
be found on our website.
Home Delivery Pharmacy Service
Express Scripts, Inc. (“ESI”) offers the convenience of home delivery. Maintenance medications are mailed to your
home in a 90-day supply when prescribed as a 90-day supply by a Network Provider. You may receive a discount
on your medications, depending on the drug tier. See your Schedule of Benefits. Allow 14 days for your
prescription to reach you.
For more information about this optional service, contact ESI.
Express Scripts Commercial Customer
Service:
Express Scripts Marketplace Customer
Service:
1-866-274-1612 (toll-free)
www.express-scripts.com
1-866-211-7824 (toll-free)
www.express-scripts.com/globalhealth
Representatives are available 24 hours a
day, 7 days a week.
Extended Supply Retail Pharmacy Network
You may receive up to a 90-day supply of a maintenance drug at an extended supply retail Network pharmacy for
the applicable home delivery Copayment or Coinsurance. Medications must be prescribed as a 90-day supply by a
Network Provider. An extended supply retail Network pharmacy can be found on our website.
Sovereign Medical Solutions Medications by Mail
Sovereign Medical Solutions is a Native American-owned retail pharmacy located in Oklahoma. It provides
prescription medications to Native Americans. Complete the Native American Prescription Benefit Program Patient
Enrollment form available on our website and submit to Sovereign Medical Solutions. Proof of Native American
status in one of the federally recognized tribes is required. Once Native American heritage is established with
Sovereign Medical Solutions, Members may receive Copayment discounts. Medications are mailed directly to the
Member’s home or designated location.
Specialty Pharmacy
A contracted specialty pharmacy fills your specialty medications and delivers them to your home. Specialty
medications sent to and administered by your doctor are covered under your office visit cost-sharing responsibility.
Specialty medications sent to and administered by you are assessed your prescription drug Copayment or
Coinsurance. A specialty Network pharmacy can be found on our website.
GlobalHealth’s Preferred Drug List
The GlobalHealth preferred drugs are listed in this Drug Formulary. Medications on the list are selected based on
quality (effectiveness and safety) as well as cost-effectiveness. Doctors and pharmacists have worked together to
develop the formulary, which includes generics and brand name medications that are approved by the FDA. The
list of drugs is subject to change. Please check your Schedule of Benefits for detailed information regarding your
drug coverage, benefit limitations, and exclusions. For specific questions about your coverage, please call the
phone number printed on your Member ID card.

Tier One Copayment: Generic medications contain the same active ingredients in the same amounts as
brand name products. However, they may be a different color, shape, or size. You will pay the lowest
Copayment for select low-cost, preferred generics. Most generics are non-preferred medications and have
the corresponding cost-share. Please refer to your Schedule of Benefits.



Tier Two Copayment: Preferred brand name medications on the Formulary have the next highest cost.
Tier Three Copayment: Non-formulary medications have the highest cost of these three tiers. This tier
contains both non-preferred name brand and specified high-cost generic drugs.
Tier Four Copayment (if your Plan has a fourth tier): Specialty medications are filled through a specialty
pharmacy. Specialty drugs are limited to no more than a one-month supply per fill. These medications
must be pre-approved by GlobalHealth. Refer to your Schedule of Benefits.
The applicable Copayments or Coinsurance must be met each time a Prescription Drug is filled or refilled. You will
pay your cost-share or the cost of the Prescription Drug, whichever is less.
Please contact Customer Care if you need assistance locating a pharmacy, understanding your benefits, or printed
copies of the formulary.
Prior Authorization, Step Therapy, Quantity Limits, and Exceptions
Your Plan may include prior authorization, step therapy, or quantity limit requirements. These programs are based
on current medical findings, FDA (U.S. Food and Drug Administration) approved manufacturer labeling information,
cost, and manufacturer rate agreements.
PLEASE NOTE: Not all the drugs listed are covered by all Prescription Drug benefit programs; check your
Schedule of Benefits for specific exclusions and the Copayments for your Prescription Drug benefit
program. For specific questions about your coverage, please call the phone number printed on your
Member ID card.
For the Member: Generic medications contain the same active ingredients in the same amounts as brand name
products. However, they may be a different color, shape, or size.
For the physician: Please prescribe preferred products and allow generic substitutions when medically
appropriate. Thank you.
Prior Authorization:
Step Therapy:
Quantity Limits:
Requesting an Exception:
Medication Utilization Management
Call 918-878-7361
Physicians are required to obtain prior authorization for certain medications,
including compound drugs. This promotes appropriate, cost-effective use. Any
corresponding supplies or equipment also require prior authorization.
GlobalHealth may not cover the drug, supply, or equipment without prior
authorization.
Step therapy requires one or more prerequisite, clinically equivalent drugs to be
tried before a step therapy drug will be covered.
There are limits to the amount of certain medications that you may receive. These
drugs, if taken inappropriately for too long a time period, could be unsafe and
cause adverse effects.
You can request GlobalHealth to waive coverage restrictions and limits.
Generally, GlobalHealth will only approve your request for an exception if:
 The alternative drug is included on the Plan’s Formulary.
 The drug in the lower tier or additional utilization restrictions would not be as
effective in treating your condition.
 It would cause you to have adverse medical effects.
You or your physician should contact GlobalHealth for instructions on obtaining a
utilization restriction exception. Your physician may have to submit a prior
authorization request form with supporting information. Generally, a decision is
made within 72 hours of your request.
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Requesting an Expedited
Exception:
You, your designee, or your prescribing physician may request an expedited
exceptions process when:
 You are suffering from a health condition that may seriously jeopardize
your life, health, or ability to regain maximum function, or
 You are undergoing a current course of treatment using a non-formulary
drug.
We will provide a decision to you, your designee, or the prescribing physician
within 24 hours after receiving the request.
Compound Drugs
Compounds will be considered for coverage for GlobalHealth members after a prior authorization review:
1. For a member that is not able to swallow medications and requires a liquid or suppository dosage form for
alternative route of administration.
2. For a member that is sensitive to dyes, fillers or preservatives in commercially available medications.
3. When the originator medication has been removed from the market for reasons other than safety concerns and
the medication is compounded into the same route of administration as the originator medication.
Some compounded medications are not covered by GlobalHealth.
All claims for compounded medications MUST have a prior authorization in accordance with the GlobalHealth
Pharmacy and Therapeutics Committee requirements. For pharmacist compounded medication to be considered
for coverage all of the following criteria must be met:
1. Ingredients are not identified as for sale over-the-counter (“OTC”) by the Food and Drug Administration (“FDA”);
and
2. Must be prescribed for an indication that is supported by FDA-approval or identified within scientific evidence in
recognized medical literature; and
3. Not for sale by a third party who resells to individual patients, or offers compounded drug products at wholesale
to other state licensed persons or commercial entities for resale; and
4. Contains at least one FDA-approved prescription ingredient; and
5. Prescription ingredient is FDA-approved for medical use in the United States; and
6. If the compound is not being prescribed for the prescription ingredient’s FDA-approved indication then the
supportive medical evidence must be found within the following:
a. Nationally recognized peer-reviewed scientific studies published in American medical journals that meet
recognized requirements for scientific studies which submit most of their articles for review by experts.
These experts will not be part of the publisher’s editorial staff; or
b. Listing of nationally recognized publishing literature such as Medline, Medicus, STARs, National Institute of
Health, Medical Journals recognized by HHS Clinical Pharmacology, AHFS-DI, Centers of Medicare and
Medicaid, National Cancer Institute, Healthcare Research and Quality, or NCCN guidelines.
The following compounded preparations are examples of preparations that the GlobalHealth Pharmacy and
Therapeutics Committee considers to be experimental and/or investigational, because there is inadequate evidence
in the peer-reviewed published medical literature of their effectiveness: This list is not all inclusive and other
compounded medications may also be considered not covered after prior authorization review.
 Nebulized anti-infectives, nasal administration for the treatment of Sinusitis
 Implantable estradiol pellets
 Bioidentical hormones
 Topical verapamil
 Topical ketamine
 Topical flubiprofen
 Topical ketoprofen
 Topical lidocaine
 Topical testosterone
 Topical estrogen
Off-label Uses
Off-label uses of medication used in the treatment of cancer or the study of oncology are covered. Certain
investigational uses of chemotherapy for cancer treatment may be covered if administered as part of an Approved
Clinical Trial.
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GlobalHealth does not cover any other non-FDA approved off-label utilization of medications or medical devices.
This exclusion includes non-FDA approved:
 Indication;
 Dosage;
 Length of therapy;
 Safety and efficacy standards within clinical studies; and
 Warnings, precautions, and potential serious drug interactions.
Your Prescription Drug Benefits
Your Prescription Drug benefit covers outpatient, self-administered medications that require a prescription.
“Prescription” refers to an order written by any licensed physician, or others licensed to prescribe for a medicinal
substance which, under the Federal Food, Drug, and Cosmetic Act (FD&C Act), is required to bear on the
packaging label the following legend: “Caution: Federal law prohibits dispensing without a prescription” or “Rx
Only”.
The Affordable Care Act requires some over-the-counter medications be covered. Please see “Affordable Care
Act”.
How to use your prescription drug benefits:
1. Fill your prescription at any GlobalHealth participating pharmacy. A list of Network pharmacies can be found in
the GlobalHealth Physician & Health Providers Directory and on the website. You may also call Customer Care
for help in locating a pharmacy.
2. Present your GlobalHealth Member ID card to the pharmacist.
3. Pay the applicable Copayment.
Affordable Care Act – No Cost-Share OTC Drugs
Some FDA-approved over-the-counter (“OTC”) medicines and products are covered at no cost-share.
Iron supplements:
For children from birth through 12 months
Oral fluoride
For children from birth through 5 years
supplements:
Folic acid supplements:
For women capable of pregnancy up to age 50
Aspirin:
For men age 45 through 79 and women age 55 through 79
*Tobacco cessation
For adults age 18 and older
products:
Vitamin D supplement:
For adults age 65 and older
*Not all products that may be used for tobacco cessation are included.
Doctors may prescribe risk-reducing medications, such as tamoxifen or raloxifene, for women who are at increased
risk for breast cancer and at low risk for medication side effects. These medications are available at no cost-share,
subject to reasonable medical management.
To receive benefits, you must use an in-network retail pharmacy and present a written prescription from your
physician to the pharmacist. Benefits are limited to recommended prescribed limits.
Contraception Drugs and Devices for Women
Selected FDA-approved contraception prescriptions are provided with no cost-sharing for women. These
contraception drugs and devices are not subject to the Deductible. All others are subject to prescription
Copayment or Coinsurance and possible prior authorization. Over-the-counter contraceptives are not covered
unless they are FDA-approved and prescribed by a Network physician.
Prescriptions Received in an Emergency Room or Urgent Care Facility
Medications prescribed by ER physicians may be filled at either a preferred Network or a non-preferred Network
pharmacy. You will pay your pharmacy cost-share. Utilization management rules may apply.
Pharmacy Coordination of Benefits
Coordination of benefits for pharmacy benefits is handled the same as for medical benefits. See, “When You Are
Covered by More Than One Plan”, in your Member Handbook.
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Medication Therapy Management Program
If you are taking multiple medications for Chronic Conditions, you can receive support from our Medication Therapy
Management program. Enrollment in this program is automatic. You receive personalized service from registered
pharmacists and staff. The goal of this program is to help eliminate duplicate drug therapies, reduce potential for
negative drug interactions and side effects, and optimize Member benefits by advising of the lowest cost
alternatives.
GLOBALHEALTH 2015 DRUG FORMULARY INDEX
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2015 THROUGH DECEMBER 31, 2015. THIS LIST IS
SUBJECT TO CHANGE. You can get information and updates to this document on our website.
Preventive Care
Based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) in conjunction with the
recommendations of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control
and Prevention and the Health Resources and Services Administration.
Aspirin products (Generic OTC only)
ASPIRIN 81 MG
ASPIRIN 325 MG
Fluoride products (Generic OTC & Rx, including combination products)
EPIFLUR 0.25 MG TABLET CHEW
EPIFLUR 0.5 MG TABLET CHEWABLE
ETHEDENT 0.25 MG TAB CHEW
ETHEDENT 0.5 MG TAB CHEW
FLUORABON 0.25 MG/0.6 ML DROPS
FLUOR-A-DAY 2.5 MG/ML DROPS
FLUORIDE 0.25 MG TABLET CHEW
FLUORIDE 0.5 MG TABLET CHEW
FLUORITAB 0.25 MG TABLET CHEW
FLUORITAB 0.5 MG TABLET CHEW
FLURA-DROPS 0.125 MG/DROP
FLURA-DROPS 0.25 MG/DROP
LUDENT FLUORIDE 0.25 MG TB CHEW
LUDENT FLUORIDE 0.5 MG TB CHEW
LURIDE 0.5 MG/ML DROPS
LURIDE LOZI-TABS 0.25 MG CHEW
LURIDE LOZI-TABS 0.5 MG CHEW
MULTI-VITAMIN 0.25 MG/ML DROP
MULTIVIT-FL-IRON 0.5 MG DROP
MULTIVIT-FLUOR 0.25 MG TAB CHEW
MYKIDZ IRON FL SUSPENSION
NAFRINSE PED 0.25 MG/DROP
PHARMAFLUR 0.5MG(1.1MG) TAB
PHLUORIVIT + FE 0.25 MG DROPS
PHLUORIVIT 0.25 MG DROPS
PHLUORIVIT 0.5 MG DROPS
POLYVITAMIN-FLUOR 0.25 MG/ML
POLYVITAMIN-FLUOR 0.5 MG/ML
POLYVIT-FLUORIDE 0.25 MG DROP
POLYVIT-FLUORIDE 0.5 MG DROP
RENAF FLUORIDE 0.25 MG TB CHEW
RENAF FLUORIDE 0.5 MG TAB CHEW
SODIUM FLUORIDE 0.125 MG/DROP
SODIUM FLUORIDE 0.25 (0.55) MG
SODIUM FLUORIDE 0.5 MG(1.1 MG)
SODIUM FLUORIDE 0.5 MG/ML DROP
SODIUM FLUORIDE 0.5% DROPS
TRIPHLUORIVIT 0.25 MG DROPS
TRI-VIT-FLUOR 0.25 MG/ML DROP
TRI-VIT-FLUOR 0.5 MG/ML DROP
VIT A,D,C & FLUOR 0.25 MG/ML
Iron Supplements (Generic OTC & Rx, including combination products)
ED-IN-SOL 75 MG/0.6 ML DROPS
FER-GEN-SOL 15 MG/0.6 ML DROP
FER-IN-SOL 15 MG/ML DROPS
FER-IRON 15 MG/1 ML DROPS
FERRETTS IPS LIQUID
FERROUS SULF 15 MG IRON/ML DROP
FERROUS SULF 220 MG/5 ML ELIX
FERROUS SULF 300 MG/5 ML LIQ
FERROUS SULF 75 (15) MG/0.6 ML
FERROUS SULFATE DRIED POWDER
FERROUS SULFATE GRANULES
ICAR 15 MG/1.25 ML SUSPENSION
MULTI-DELYN WITH IRON LIQUID
MULTIVITAMIN WITH IRON DROP
MULTIVIT-FL-IRON 0.5 MG DROP
MULTIVIT-IRON-FL 0.25 MG/ML
MYKIDZ IRON SUSPENSION
NIFEREX 100 MG/5 ML ELIXIR
PHLUORIVIT + FE 0.25 MG DROPS
POLY VITAMIN W/IRON DROPS
POLY-VI-SOL-IRON DROPS
SIDEROL 75 MG/0.6 ML DROPS
TRI-VI-SOL-IRON DROPS
TRI-VIT-FLUOR-IRON 0.25 MG/ML
VIMAR W/IRON LIQUID
WEE CARE 15 MG/1.25 ML SUSP
Folic Acid Products (Generic OTC & Rx, including combination products)
B-COMPLEX TABLET
B-PLEX TABLET
CEFOL FILMTAB
CITRANATAL ASSURE COMBO PACK
CITRANATAL DHA PACK
CLASSIC PRENATAL TABLET
CORENATE-DHA COMBO PACK
DAILY PRENATAL COMBO PACK
DAILYVITE 800 TABLET
DAILYVITE 800 WITH IRON TAB
7
Folic Acid Products (Generic OTC & Rx, including combination products)
DAILYVITE 800 WITH ZINC
EXTRESS SUPER TABLET
EXTRESS TABLET
FOLIC ACID 0.4 MG TABLET
FOLIC ACID 0.8 MG TABLET
FOLTABS PRENATAL PLUS DHA
FORMULA-B TABLET
FULL SPECTRUM B WITH VIT C TAB
MAXINATE TABLET
MISSION PRENATAL FA TABLET
MISSION PRENATAL HP TABLET
MISSION PRENATAL TABLET
NATALCARE RX TABLET
NATELLE PLUS COMBO PACK
NEEVO CAPLET
NEEVO DHA CAPSULE
NEPHRO-VITE TABLET
NERVO B-12 TABLET SL
ONE-A-DAY PRENATAL DHA PACK
OPTINATE COMBO PACK
P-D NATAL PLUS TABLET
P-D NATAL PLUS-FOLIC ACID TAB
PERRY PRENATAL CAPSULE
PNV-DHA PLUS SOFTGEL
PNV-DHA SOFTGEL
PNV-IRON TABLET
PNV-SELECT TABLET
POTEN B-150 TABLET SA
PRENATAL COMPLETE CAPLET
PRENATAL PLUS DHA TABLET
PRENATAL RX TABLET
PRENATAL S TABLET
PRENATAL TABLET
PRENATAL WITH IRON TABLET
PRENATE ELITE TABLET
PREQUE 10 TABLET
RENAL MULTIVITAMIN TABLET
RENA-VITE TABLET
RIGHT STEP PRENATAL VIT TAB
ROVIN-NV DHA CAPSULE
ROVIN-NV TABLET
STRESS FORMULA VITAMINS TAB
STROVITE TABLET
STUART PRENATAL TABLET
SUPER B-100 TABLET SA
SUPER B-50 COMPLEX PLUS TAB
SUPER B-50 COMPLEX TABLET
SUPER B-COMP-LIVER-IRON TAB
SUPER QUINTS B-50 TABLETS
SUPERVITE LIQUID
TARON A PRENATAL DHA COMB PACK
THEROBEC TABLET
TRIVEEN-TEN TABLETS
VITAPHIL + DHA PACK
VITAPLEX TABLET
V-R BALANCED B-50 TABLET
V-R NATURAL B-100 TABLET
YL FOLIC ACID 0.4 MG TABLET
ZATEAN-PN DHA CAPSULE
ZATEAN-PN TABLET
Immunizations
ADACEL
AFLURIA
AGRIFLU
ATTENUVAX VACCINE WITH DILUENT
BOOSTRIX
CERVARIX
COMVAX
DAPTACEL
DECAVAC
DIPHTHERIA-TETANUS TOXOIDS-PED
DIPHTHERIA-TETANUS TOXOID
ENGERIX-B
FLUARIX
FLUCELVAX
FLULAVAL
FLUMIST
FLUVIRIN
FLUZONE
GARDASIL
HAVRIX
INFANRIX
INFLUENZA A (H1N1) 2009
IPOL
KINRIX
MENACTRA
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
MERUVAX II VACCINE W-DILUENT
M-M-R II VACCINE
MUMPSVAX VACCINE W-DILUENT
PEDIARIX
PEDVAXHIB
PENTACE
PENTACEL
PHYSICIAN EZ USE FLU 2012-2013
PNEUMOVAX 23
PREVNAR 13
PREVNAR
PROQUAD
RECOMBIVAX HB
ROTARIX
ROTATEQ
TE ANATOXAL BERNA
TENIVAC
TETANUS DIPHTHERIA TOXOIDS
TETANUS TOXOID (FLUID)
TETANUS TOXOID ADSORBED
TETANUS-DIPHTERIA-DECAVAC
TRIHIBIT
TRIPEDIA
TWINRIX
VAQTA
VARIVAX VACCINE
ZOSTAVAX
Travel Vaccines
BIOTHRAX
IMOVAX RABIES VACCINE
IXIARO
JE-VAX
RABAVERT
TYPHIM VI
VIVOTIF BERNA
YF-VAX
Barrier Contraceptive Methods
FEMCAP*
ORTHO-DIAPHRAGM*
WIDE SEAL DIAPHRAGM*
Implant Contraceptive Methods
IMPLANON*
MIRENA*
NEXPLANON*
PARAGARD T 380-A*
SKYLA*
Emergency Contraceptive Methods
ELLA
LEVONORGESTREL
MY WAY
NEXT CHOICE
NEXT CHOICE ONE DOSE
PLAN B**
PLAN B ONE-STEP**
Over-the-Counter Contraceptive Methods
ENCARE**
FC CONDOM, FEMALE*
TODAY CONTRACEPTIVE SPONGE*
VCF*
Hormonal Contraceptive Methods
ALTAVERA
ALYACEN
AMETHIA
AMETHIA LO
AMETHYST
APRI
ARANELLE
AVIANE
AZURETTE
BALZIVA
BEYAZ*
BREVICON**
BRIELLYN
CAMILA
CAMRESE
CAMRESE LO
CAZIANT
CESIA
CHATEAL
CRYSELLE
CYCLAFEM
CYCLESSA**
DASETTA
DAYSEE
DEMULEN**
DEPO-PROVERA**
DEPO-SUBQ PROVERA*
DESOGEN**
DROSPIRENONE-ETHINYL ESTRADIOL
ELINEST
EMOQUETTE
ENPRESSE
ERRIN
ESTARYLLA
ESTROSTEP FE**
FALMINA
FEMCON FE**
GENERESS FE*
GIANVI
GILDAGIA
GILDESS
GILDESS FE
HEATHER
INTROVALE
JOLESSA
JOLIVETTE
JUNEL
JUNEL FE
KARIVA
KELNOR
KURVELO
LEENA
LESSINA
LEVONEST
LEVONORGESTREL-ETH ESTRADIOL
LEVONORG-ETH ESTRAD ETH ESTRAD
LEVORA-28
LO LOESTRIN FE*
LO/OVRAL**
LOESTRIN**
LOESTRIN FE**
LOESTRIN 24 FE*
LORYNA
LOSEASONIQUE**
LOW-OGESTREL
LUTERA
LYBREL**
MARLISSA
MEDROXYPROGESTERONE ACETATE
MICROGESTIN
MICROGESTIN FE
MIRCETTE**
MODICON**
MONO-LINYAH
MONONESSA
MYZILRA
NATAZIA*
NECON
NORETHINDRONE-ETHINYL ESTRADIOL
NORGESTIMATE-ETHINYL ESTRADIOL
NORGESTREL-ETHINYL ESTRADIOL
NORINYL**
NOR-Q-D**
NORTREL
NUVARING*
OCELLA
OGESTREL
ORSYTHIA
ORTHO EVRA*
ORTHO MICRONOR**
ORTHO-NOVUM**
ORTHO-CEPT**
ORTHO-CYCLEN**
ORTHO TRI-CYCLEN**
ORTHO TRI-CYCLEN LO*
OVCON**
OVCON-50
OVRAL**
PHILITH
PORTIA PREVIFEM
QUASENSE
RECLIPSEN
SAFYRAL*
SEASONALE**
SOLIA
SPRINTEC
PREVIFEM
QUASENSE
RECLIPSEN
SAFYRAL*
9
Hormonal Contraceptive Methods cont.
SEASONALE**
SOLIA
SPRINTEC
SRONYX
SYEDA
TILIA FE
TRI-ESTARYLLA
TRI-LEGEST FE
TRI-LINYAH
TRINESSA
TRI-NORINYL**
TRI-PREVIFEM
TRIVORA-28
TRI-SPRINTEC
VELIVET
VESTURA
VIORELE
WERA
WYMZYA FE
YASMIN**
YAZ**
ZARAH
ZENCHENT
ZENCHENT FE
ZEOSA
ZOVIA
Smoking Cessation Products (Generic Rx & OTC plus Chantix)
BUDEPRION SR
BUPROBAN
BUPROPION HCL ER
BUPROPION HCL SR
CHANTIX
NICODERM CQ
NICORELIEF
NICOTINE GUM
NICOTINE LOZENGE
NICOTINE PATCH
THRIVE NICOTINE
Vitamin D Supplements (Generic Rx & OTC, including combination products)
BIO-D-MULSION
CALCARB 600 WITH VITAMIN D
CALCITRATE + VIT D
CALCIUM + D
CALCIUM 600+D PLUS MINERALS
CALCIUM CARBONATE/VITAMIN D3
CALCIUM CITRATE - VITAMIN D
CALTRATE 600 + D
CALTRATE 600+D PLUS
CALTRATE-600 PLUS
CALVITE P&D
CHILDREN'S VITAMIN D
CITRACAL + D
CITRACAL + D MAXIMUM
CITRUS CALCIUM-VITAMIN D
DELTA D3
DICAL-D
D-VI-SOL
D-VITA
HI-CAL
JUST D
OS-CAL 500+D
OS-CAL ULTRA
OYSCO D
OYST-CAL-D
OYSTER SHELL CALCIUM W/VIT D
POSTURE-D
RISACAL-D
SUPER CALCIUM-VITAMIN D
VITAMIN D
Bowel Preps
ALOPHEN PILLS
BISACODYL
BISA-LAX
CITRATE OF MAGNESIA
CITROMA
CLEARLAX
COLYTE
CORRECTIVE LAXATIVE
DUCODYL
DULCOLAX
EX-LAX
FEMATROL LAXATIVE
FEMININE LAXATIVE
GAVILAX
GAVILYTE-C
GAVILYTE-G
GAVILYTE-N
GENTLE LAXATIVE
GENTLELAX
GLYCOLAX
GOLYTELY
HALFLYTELY-BISACODYL
HEALTHYLAX
LAXA CLEAR
LO-SO PREP KIT
MAGNESIUM CITRATE
MILK OF MAGNESIA
MIRALAX
MOVIPREP
NULYTELY
OCL
ORAL SALINE LAXATIVE
OSMOPREP
PEG 3350-ELECTROLYTE
PEG 3350-GRX
PEG-3350 WITH FLAVOR PACKS
PHOSPHATE LAXATIVE
POLYETHYLENE GLYCOL
PREP KIT #1
PREP KIT #3
PREPARATION CLEANSING
PREPOPIK
PURELAX
SMOOTHLAX
SUCLEAR
SUPREP
TRIDRATE
TRILYTE WITH FLAVOR PACKETS
VISICO
*Indicates single source brand. **Indicates multi-source brand product.
Therapeutic Class Index
Tier 1
Therapeutic Class
1prior
Low-Cost Generic
Drugs
Generic Drugs
Tier 2
Tier 3
Preferred Brand
Name Drugs
Non-Formulary Drugs
authorization, 2step therapy, 3quantity limit, Ffertility, SPspecialty (see your plan for F and SP cost-sharing)
ANESTHETICS
ANESTHETICS - Topical
lidocaine hcl
lidocaine-prilocaine
LIDOCAINE HCL
patch1
LIDODERM1
ANTI-INFECTIVES
ANTI-INFECTIVES - Cephalosporins
cefaclor/er
CEDAX
cefadroxil
CEFTIN
cefdinir
SUPRAX
cefpodoxime proxetil
cefprozil
ceftibutin
cefuroxime
cephalexin
ANTI-INFECTIVES - Clindamycins
clindamycin hcl
clindamycin phosphate
ANTI-INFECTIVES - Erythromycins
erythromycin
ERY-TAB
ANTI-INFECTIVES - Other Macrolides
azithromycin
clarithromycin/er
ANTI-INFECTIVES - Penicillins
amoxicillin
125mg/5mL,
400mg/5mL syrup
amoxicillin 250mg
capsules
amoxicillin 875mg
tablets
dicloxacillin 500mg
capsule
penicillin v
potassium 250,
500mg tab
penicillin v
potassium
250mg/5mL susp
ANTI-INFECTIVES - Sulfonamides
sulfamethoxazoletrimethoprim DS
amoxicillin
dicloxacillin
penicillin v potassium
sulfamethoxazoletrimethoprim
AMOXICILLINPOTASSIUM
CLAVULANATE ER
ANTI-INFECTIVES - Tetracyclines
tetracycline hcl
250, 500mg cap
doxycycline hyclate
ACTICLATE2
doxycycline
monohydrate
DORYX2
minocycline hcl
tetracycline hcl
DOXYCYCLINE
HYCLATE DR2
MINOCYCLINE HCL
ER2
ORACEA2
SOLODYN2
ANTI-INFECTIVES - Urinary
nitrofurantoin
trimethoprim
ANTI-INFECTIVES - Quinolones
ciprofloxacin hcl
500mg tab
ciprofloxacin hcl/er
AVELOX/ABC PACK
levofloxacin
FACTIVE
ofloxacin
LEVAQUIN
NOROXIN
ANTI-INFECTIVES - Topical Antibacterial
gentamicin sulfate
ALTABAX
mupirocin
BACTROBAN
silver sulfadiazine
ANTI-INFECTIVES - Oral Antifungal
fluconazole 150mg
tab3
fluconazole
DIFLUCAN2
griseofulvin
GRIFULVIN V
itraconazole
LAMISIL2
ketoconazole
ONMEL
nystatin
ORAVIG
terbinafine hcl
voriconazole
ANTI-INFECTIVES - Vaginal Antifungal
clotrimazole
terconazole
ANTI-INFECTIVES - Other Topical Antifungal
ciclopirox
ERTACZO
clotrimazole
EXELDERM
econazole nitrate
NAFTIN
ketoconazole
OXISTAT
nystatin
ANTI-INFECTIVES - Topical Antifungal-Corticosteroid Combinations
clotrimazolebetamethasone
nystatin-triamcinolone
12
ANTI-INFECTIVES - Antiretrovirals & Protease Inhibitors
abacavir
ATRIPLA
COMBIVIR
lamivudine
EPIVIR SOLUTION
COMPLERA
lamivudine-zidovudine
EPZICOM
COMBIVIR
nevirapine
INTELENCE
COMPLERA
zidovudine
ISENTRESS
EPIVIR TABLET
KALETRA
VICTRELIS1,SP
LEXIVA
VIRAMUNE
NORVIR
ZIAGEN TABLET
PREZISTA
REYATAZ
STRIBILD
SUSTIVA
TRUVADA
VIRAMUNE XR
VIREAD
ZIAGEN SOLUTION
ANTI-INFECTIVES - Other Antiviral Drugs
acyclovir oral
BARACLUDE1
HBVSP
DENAVIR
amantadine
EPIVIR
ribapakSP
FAMCICLOVIR
RELENZA
RIBASPHERE1,SP
ribavirinSP
TAMIFLU
SOVALDI1,SP
VALCYTE1
VALACYCLOVIR HCL
VALTREX
ANTI-INFECTIVES - Topical Antiviral Drugs
ACYCLOVIR TOPICAL
XERESE
ZOVIRAX1
ANTI-INFECTIVES - Antituberculosis Drugs
isoniazid
rifampin
ANTI-INFECTIVES - Plasmodicides
atovaquone-proguanil
hcl
hydroxychloroquine
sulfate
MALARONE
QUALAQUIN
mefloquine hcl
quinine sulfate
ANTI-INFECTIVES - Sulfones
DAPSONE
ANTI-INFECTIVES - Trichomonocides
metronidazole
tinidazole
13
ANTI-INFECTIVES - Other Anti-Infective Drugs
atovaquone
CAYSTON1,3,SP
DIFICID
vancomycin hcl
XIFAXAN1
MEPRON1
ZYVOX1
VANCOCIN HCL
ANTI-INFECTIVES - Aminoglycosides
gentamicin sulfate
BETHKIS1,SP
tobramycin sulfate
inhalation1,SP
TOBI1,SP
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
anagrelide hcl
AFINITOR1,SP
ARIMIDEX
anastrozole
ELIGARD1,SP
CELLCEPT1,SP
azathioprineSP
ENBREL1,3,SP
CIMZIA1,3,SP
bicalutamide
HUMIRA1,3,SP
EXEMESTANE1
capecitabine1,SP
IMBRUVICA1,SP
FEMARA
cyclosporine modified
ORENCIA
125mg/mL1,SP
MEGACE ES1
gengraf
RAPAMUNE1,SP
MYFORTIC1,SP
hydroxyurea
REVLIMID1,SP
NEORAL1,SP
SANDOSTATIN
LAR1,SP
STIVARGA1,SP
OTEZLA1,3,SP
leucovorin calcium
tablets
TABLOID1,SP
SANDIMMUNE1,SP
megestrol acetate
TARCEVA1,SP
mercaptopurine
TASIGNA1,SP
SIMPONI1,3,SP
SOMATULINE
DEPOT1,SP
methotrexate
TYKERB1,SP
TEMODAR1,SP
methotrexate sodiumSP
VOTRIENT1,SP
TEMOZOLOMIDE1,SP
mycophenolate
mofetil1,SP
mycophenolic acid
dr1,SP
XTANDI1,SP
XELJANZ1,3,SP
leflunomide
letrozole
PROGRAF1,SP
XELODA1,SP
octreotide acetate1,SP
tacrolimus1,SP
tamoxifen citrate
tretinoin
CARDIOVASCULAR MEDICATIONS
CARDIOVASCULAR MEDICATIONS - Cardiac Glycosides
digoxin
LANOXIN
CARDIOVASCULAR MEDICATIONS - Calcium Antagonists
amlodipine besylate
CARDENE SR2
cartia xt
CARDIZEM LA
diltiazem/er
NISOLDIPINE ER
felodipine er
SULAR2
nifediac cc
nifedical xl
nifedipine er
nisoldipine ir
verapamil/er/pm
14
CARDIOVASCULAR MEDICATIONS - Loop Diuretics
bumetanide
furosemide
torsemide
CARDIOVASCULAR MEDICATIONS - Thiazide and Related Drugs
hydrochlorothiazid
e 25mg tab
chlorthalidone
hydrochlorothiazide
indapamide
metolazone
CARDIOVASCULAR MEDICATIONS - Potassium-Sparing Diuretics
amiloride hcl
eplerenone
spironolactone
spironolactone-hctz
triamterene-hctz
CARDIOVASCULAR MEDICATIONS - Beta-Adrenergic Antagonist Drugs
atenolol 25mg tab
acebutolol hcl
BYSTOLIC2
metoprolol tartrate
50mg tab
atenolol
COREG CR
bisoprolol fumarate
TOPROL XL
carvedilol
labetalol hcl
metoprolol succinate
metoprolol tartrate
nadolol
pindolol
propranolol hcl
timolol maleate
CARDIOVASCULAR MEDICATIONS - Vasodilator Antihypertensives
terazosin hcl
doxazosin mesylate
CARDURA XL
minoxidil
prazosin hcl
CARDIOVASCULAR MEDICATIONS - Centrally-Acting Antihypertensives
clonidine hcl tab
clonidine hcl er
guanfacine hcl
methyldopa
CARDIOVASCULAR MEDICATIONS - Angiotensin Converting Enzyme Inhibitors
lisinopril 10 &
20mg tab
benazepril hcl
captopril
enalapril maleate
fosinopril sodium
lisinopril
moexipril hcl
quinapril hcl
15
CLONIDINE PATCH
ramipril
trandolapril
CARDIOVASCULAR MEDICATIONS - Angiotensin II Receptor Antagonists
losartan potassium
candesartan cilexetil
ATACAND2
eprosartan mesylate
AVAPRO2
irbesartan
BENICAR2
valsartan
COZAAR2
DIOVAN2
EDARBI2
MICARDIS2
TELMISARTAN
TEVETEN2
CARDIOVASCULAR MEDICATIONS - Other Antihypertensives
bisoprolol-hctz
amlodipine besylatebenazepril
AMTURNIDE2
lisinopril-hctz 2025mg tab
atenolol-chlorthalidone
ATACAND HCT2
benazepril-hctz
AVALIDE2
candesartan-hctz
AZOR2
captopril-hctz
BENICAR HCT2
enalapril-hctz
DIOVAN HCT2
fosinopril-hctz
EDARBYCLOR2
irbesartan-hctz
HYZAAR2
lisinopril-hctz
EXFORGE/HCT2
losartan-hctz
LOTREL2
metoprolol-hctz
MICARDIS HCT2
moexipril-hctz
TARKA2
quinapril-hctz
TEKAMLO2
valsartan-hctz
TEKTURNA/HCT2
TEVETEN HCT2
TRIBENZOR2
TWYNSTA2
CARDIOVASCULAR MEDICATIONS - Nitrates
isosorbide/dinitrate
NITROSTAT
nitroglycerin/patch
CARDIOVASCULAR MEDICATIONS - Other Vasodilating Drugs
sildenafil citrate
(pulmonary
hypertension)1,SP
ADCIRCA1,SP
BIDIL
REVATIO1,SP
CARDIOVASCULAR MEDICATIONS - Endothelin Receptor Antagonists
LETAIRIS1,SP
TRACLEER1,SP
16
CARDIOVASCULAR MEDICATIONS - Class 1A
quinidine gluconate cr
quinidine sulfate
CARDIOVASCULAR MEDICATIONS - Class 1C
flecainide acetate
RYTHMOL SR
propafenone hcl
CARDIOVASCULAR MEDICATIONS - Amiodarones
amiodarone hcl
CARDIOVASCULAR MEDICATIONS - Other Antiarrhythmics
sotalol
TIKOSYN
MULTAQ
cholestyramine
VASCEPA1
ANTARA2
colestipol hcl
ZETIA
FENOGLIDE2
CARDIOVASCULAR MEDICATIONS - Hypolipoproteinemics
fenofibrate
LIPOFEN2
fenofibric acid
LOVAZA1
gemfibrozil
NIACIN ER
omega-3 acid ethyl
esters1
NIASPAN
TRICOR2
TRIGLIDE2
TRILIPIX2
WELCHOL2
CARDIOVASCULAR MEDICATIONS - HMG-COA Reductase Inhibitors
pravastatin sodium
10, 20, 40mg
simvastatin 5, 10,
20, 40mg
atorvastatin calcium
ALTOPREV2
fluvastatin sodium
CRESTOR2
lovastatin
LESCOL/XL2
pravastatin sodium
LIPITOR2
simvastatin
LIVALO2
CARDIOVASCULAR MEDICATIONS - HMG-COA Combinations
ADVICOR2
AMLODIPINEATORVASTATIN
CADUET2
LIPTRUZET2
SIMCOR2
VYTORIN2
CARDIOVASCULAR MEDICATIONS - Other Cardiovascular Drugs
midodrine hcl
RANEXA1
pentoxifylline
AUTONOMIC & CNS MEDICATIONS
AUTONOMIC & CNS MEDICATIONS - Analgesics
butorphanol tartrate
tramadol hclacetaminophen
tramadol hcl ir
17
TRAMADOL HCL ER
AUTONOMIC & CNS MEDICATIONS - Class II Narcotics
endocet
hydrocodoneacetaminophen
hydrocodone
bitartrate-ibuprofen
ABSTRAL1,3
hydromorphone hcl
EXALGO2,3
hydromorphone hcl er3
FENTANYL3
methadone hcl
FENTORA1,3
morphine sulfate
KADIAN2,3
morphine sulfate er3
LAZANDA1,3
oxycodone hcl
oxycodoneacetaminophen
NUCYNTA
reprexain
ONSOLIS1,3,SP
roxicet tabs
OPANA
zamicet
OXYCONTIN2,3
AVINZA2,3
DILAUDID2
NUCYNTA ER2,3
OXYMORPHONE HCL
OXYMORPHONE HCL
ER3
OPANA ER2,3
ROXICET solution
SUBSYS1,3
ZOHYDRO ER2,3
AUTONOMIC & CNS MEDICATIONS - Class III Narcotics
acetaminophencodeine
BUPRENORPHINE
HCL
BUPRENORPHINENALOXONE1
BUTRANS1
SUBOXONE1
ZUBSOLV1
AUTONOMIC & CNS MEDICATIONS - Class IV Narcotics
pentazocine-naloxone
AUTONOMIC & CNS MEDICATIONS - Drugs to Prevent and Treat Headaches
butalbital-aspirincaffeine
butalbital compoundcodeine
naratriptan hcl3
AXERT2,3
nodolor
MAXALT/MLT2,3
sumatriptan3
MIGRANAL3
zolmitriptan
RELPAX2,3
FROVA2,3
IMITREX2,3
RIZATRIPTAN3
SUMATRIPTAN
nasal/injectable3
SUMAVEL
DOSEPRO2,3
TREXIMET2,3
ZOLMITRIPTAN ODT3
ZOMIG/ZMT2,3
18
AUTONOMIC & CNS MEDICATIONS - Anxiolytics
VALIUM2
alprazolam/er/xr
buspirone hcl
chlordiazepoxide hcl
clorazepate
dipotassium
diazepam
lorazepam
oxazepam
AUTONOMIC & CNS MEDICATIONS - Sedative/Hypnotic Drugs
estazolam
ROZEREM3
AMBIEN/CR3
eszopiclone3
EDLUAR3
flurazepam hcl
INTERMEZZO3
temazepam
LUNESTA3
triazolam
SILENOR3
zaleplon3
ZOLPIMIST3
zolpidem tartrate/er3
AUTONOMIC & CNS MEDICATIONS - Antimania Drugs
lithium carbonate
AUTONOMIC & CNS MEDICATIONS - Carbamazepines
carbamazepine ir
CARBAMAZEPINE XR
CARBATROL
OXCARBAZEPINE
OXTELLAR XR1
TEGRETOL XR
AUTONOMIC & CNS MEDICATIONS - Anticonvulsant Benzodiazepines
clonazepam
ONFI
diazepam rectal gel
AUTONOMIC & CNS MEDICATIONS - Hydantoins
phenytoin sodium
extended
DILANTIN
PHENYTEK
AUTONOMIC & CNS MEDICATIONS - Valproic Acid and Derivatives
divalproex sodium dr
DEPAKOTE ER1
valproic acid
DIVALPROEX
SODIUM ER
AUTONOMIC & CNS MEDICATIONS - Anticonvulsant Barbiturates
phenobarbital
primidone
AUTONOMIC & CNS MEDICATIONS - Other Anticonvulsants
topiramate 15mg
sprinkle
zonisamide 50mg
cap
felbamate
LYRICA2
GRALISE2
gabapentin
POTIGA
HORIZANT2
lamotrigine ir
VIMPAT1
KEPPRA/XR2
levetiracetam
LAMICTAL/ODT
tiagabine hcl
LAMICTAL XR2
19
topiramate
LAMOTRIGINE ER
zonisamide
SABRIL1,SP
TOPAMAX2
ZONEGRAN1
AUTONOMIC & CNS MEDICATIONS - Tertiary Amines
amitriptyline hcl
doxepin hcl
doxepin hcl 10, 25,
50, 100mg cap
CLOMIPRAMINE HCL
imipramine pamoate
imipramine hcl
AUTONOMIC & CNS MEDICATIONS - Secondary Amines
desipramine hcl
nortriptyline hcl
AUTONOMIC & CNS MEDICATIONS - Selective Serotonin Reuptake Inhibitors
citalopram
hydrobromide3
fluoxetine 10,
20mg cap; 10mg
tab3
paroxetine hcl 10,
20mg tab3
sertraline hcl
tablet3
escitalopram oxalate3
LEXAPRO2,3
fluoxetine hcl3
LUVOX CR2,3
fluvoxamine maleate3
VIIBRYD2,3
fluvoxamine maleate
er2,3
paroxetine hcl3
sertraline hcl
concentrate3
AUTONOMIC & CNS MEDICATIONS - Other Antidepressants
trazodone hcl 50,
100, 150mg tab
venlafaxine hcl
25mg tab3
bupropion hcl/sr/xl3
CYMBALTA2,3
mirtazapine
DULOXETINE HCL2,3
trazodone hcl
EFFEXOR XR2,3
venlafaxine hcl3
PRISTIQ2,3
venlafaxine hcl er
caps3
SAVELLA2,3
VENLAFAXINE HCL
ER TABS2,3
WELLBUTRIN XL2,3
AUTONOMIC & CNS MEDICATIONS - MAO Inhibitors
tranylcypromine sulfate
AUTONOMIC & CNS MEDICATIONS - Antivertigo and Antiemetic Drugs
dronabinol1
EMEND3
MARINOL1
granisetron hcl3
SANCUSO3
meclizine hcl
TRANSDERM-SCOP
ondansetron
hcl/odt3
prochlorperazine
maleate
promethazine hcl
promethegan
AUTONOMIC & CNS MEDICATIONS - AntiParkinson Anticholinergic Drugs
benztropine mesylate
trihexyphenidyl hcl
20
ZUPLENZ3
AUTONOMIC & CNS MEDICATIONS - Other AntiParkinson Drugs
bromocriptine
mesylate
AZILECT
carbidopa-levodopa
COMTAN
carbidopa-levodopaentacapone
MIRAPEX/ER
entacapone
NEUPRO
pramipexole
dihydrochloride
REQUIP XL
ropinirole hcl
STALEVO
AUTONOMIC & CNS MEDICATIONS - Antipsychotic Drugs
haloperidol 1mg
tab
clozapine
ABILIFY/DISCMELT1
FANAPT
fluphenazine hcl
RISPERDAL CONSTA
GEODON
haloperidol
INVEGA1
perphenazine
LATUDA1
quetiapine fumarate
OLANZAPINE
risperidone/m-tab
SAPHRIS
thioridazine hcl
SEROQUEL
thiothixene
SEROQUEL XR1
trifluoperazine hcl
ZYPREXA/ZYDIS
ZIPRASIDONE HCL
AUTONOMIC & CNS MEDICATIONS - Aliphatic Phenothiazines
chlorpromazine hcl
AUTONOMIC & CNS MEDICATIONS - Psychotherapeutic Combinations
OLANZAPINEFLUOXETINE
SYMBYAX
AUTONOMIC & CNS MEDICATIONS - CNS Stimulant Drugs
methylphenidate
hcl 5, 10mg tab
amphetamine salt
combo
dexmethylphenidate
hcl
dextroamphetamineamphetamine er
methylin/er
methylphenidate
hcl/la/sr
VYVANSE2
ADDERALL XR2
CONCERTA2
DAYTRANA2
DEXMETHYLPHENIDA
TE ER
DEXTROAMPHETAMI
NE/ER
FOCALIN XR2
METADATE CD2
METHYLPHENIDATE
HCL CD/ER
MODAFINIL1,3
NUVIGIL1
PROVIGIL1
QUILLIVANT XR2
RITALIN LA2
21
AUTONOMIC & CNS MEDICATIONS - Other CNS/Autonomic Drugs
atropine sulfate
NUEDEXTA1
naltrexone hcl
XENAZINE1,SP
ACAMPROSATE
CALCIUM
pyridostigmine
bromide
AUTONOMIC & CNS MEDICATIONS - Antidementia Drugs
donepezil hcl
NAMENDA2
ARICEPT/ODT
galantamine
hydrobromide
EXELON
rivastigmine
NAMENDA XR2
AUTONOMIC & CNS MEDICATIONS - Drugs to Treat Multiple Sclerosis
AMPYRA1,SP
GILENYA1,SP
TECFIDERA1,SP
AUTONOMIC & CNS MEDICATIONS - Other Drugs for ADHD
STRATTERA2
INTUNIV2
KAPVAY2
DERMATOLOGICAL MEDICATIONS
DERMATOLOGIC MEDICATIONS - Topical Corticosteroid Drugs
alclomethasone
dipropionate
CLOBEX2
apexicon e
CLODERM
betamethasone
dipropionate
betamethasone
valerate
CORDRAN
HALOBETASOL
PROPIONATE
clobetasol emollient
HALOG
clobetasol propionate
KENALOG
desonide
LOCOID/LIPOCREAM
desoximetasone
OLUX/-E
diflorasone
PRAMOSONE/E
fluocinolone acetonide
ULTRAVATE PAC
fluocinonide
fluticasone propionate
hydrocortisone
hydrocortisone
butyrate
hydrocortisone
valerate
lidocaine hclhydrocortisone acetate
mometasone furoate
triamcinolone
acetonide
DERMATOLOGIC MEDICATIONS - Antipruritic Drugs
hydroxyzine
DERMATOLOGIC MEDICATIONS - Antiacne Drugs
benzoyl peroxide
ACANYA
ADAPALENE
erythromycin
ATRALIN2
22
erythromycin-benzoyl
peroxide
BENZACLIN
metronidazole
CLINDAMYCINBENZOYL PEROXIDE
sodium sulfacetamidesulfur
DIFFERIN2
tretinoin
DUAC
EPIDUO2
FINACEA
METROGEL
TRETINOIN
MICROSPHERE2
VELTIN2
ZIANA2
DERMATOLOGIC MEDICATIONS - Accutanes
isotretinoin2
ABSORICA2
myorisan2
AMNESTEEM2
zenatane2
CLARAVIS2
DERMATOLOGIC MEDICATIONS - Keratolytic Drugs
CONDYLOX
PODOCON-251
PODOFILOX
DERMATOLOGIC MEDICATIONS - Antipsoriasis and Antieczema Drugs
calcitrene
TAZORAC2,3
ACITRETIN2
selenium sulfide
CALCIPOTRIENE
sodium sulfacetamide
DOVONEX
SORIATANE1
SORILUX
TACLONEX1
VECTICAL
DERMATOLOGIC MEDICATIONS - Topical Dermatological Drugs
diclofenac sodium
PROTOPIC2
CARAC
fluorouracil
SANTYL
ELIDEL2
imiquimod
EPICERAM
FLUOROPLEX
MB HYDROGEL
METRONIDAZOLE
topical
PICATO2
PROMISEB
SOLARAZE
VEREGEN
ZYCLARA2
DERMATOLOGIC MEDICATIONS - Scabicides
permethrin 5%
EURAX
MALATHION
ULESFIA
23
DERMATOLOGIC MEDICATIONS - Topical Anti-inflammatory Drugs
FLECTOR2
PENNSAID2
VOLTAREN gel2
EAR-NOSE-THROAT MEDICATIONS
EAR-NOSE-THROAT MEDICATIONS - Drugs Affecting the Ear
antipyrine-benzocaine
CIPRODEX
CETRAXAL
neomycin-polymyxinhydrocortisone
CIPRO HC
ofloxacin
FLUOCINOLONE
EAR-NOSE-THROAT MEDICATIONS - Drugs Affecting the Nose
azelastine hcl
ASTELIN2,3
flunisolide
ASTEPRO2,3
BECONASE AQ2,3
ipratropium bromide
triamcinolone
acetonide
DYMISTA2,3
NASONEX2,3
OMNARIS2,3
PATANASE
QNASL2,3
RHINOCORT AQUA2,3
VERAMYST2,3
ZETONNA2,3
EAR-NOSE-THROAT MEDICATIONS - Drugs Affecting the Throat and Mouth
pilocarpine hcl
triamcinolone
acetonide
CEVIMELINE HCL
DOXYCYCLINE
HYCLATE
ENDOCRINE MEDICATIONS
ENDOCRINE MEDICATIONS - Insulin
HUMALOG products3
APIDRA/SOLOSTAR3
HUMALOG
KWIKPEN2,3
NOVOLIN products3
HUMULIN products3
NOVOLOG products3
NOVOLOG
FLEXPEN2,3
LANTUS/SOLOSTAR3
LEVEMIR/FLEXPEN3
ENDOCRINE MEDICATIONS - Oral Hypoglycemics and Combos
acarbose
glipizide
glipizide er
GLUMETZA2
glipizide er 2.5,
5mg tab
glipizide-metformin hcl
PRANDIMET
glipizide xl
glyburide-metformin
PRANDIN
glyburide/micronize
d
glyburidemetformin hcl 1.25250mg tab
metformin hcl
metformin hcl er
nateglinide
repaglinide
metformin hcl er
500mg tab
24
RIOMET
FORTAMET2
glimepiride
ENDOCRINE MEDICATIONS - Insulin Sensitizers and Combos
pioglitazone hcl
ACTOPLUS MET XR2
pioglitazone hclmetformin hcl
ACTOPLUS MET2
ACTOS2
DUETACT2
ENDOCRINE MEDICATIONS - Amylin Analogues
SYMLINPEN
ENDOCRINE MEDICATIONS - Incretin Mimetics
BYDUREON2,3
TANZEUM2,3
BYETTA2,3
VICTOZA2,3
JANUMET/XR2
KAZANO2
JANUVIA2
KOMBIGLYZE XR2
JENTADUETO2
NESINA2
TRADJENTA2
ONGLYZA2
ENDOCRINE MEDICATIONS - Dipeptidyl Peptidase-IV Inhibitors
OSENI2
ENDOCRINE MEDICATIONS - Sodium-Glucose Co-Transporter 2 Inhibitors
INVOKANA2
FARXIGA2
INVOKAMET2
ENDOCRINE MEDICATIONS - Glucose Elevating Drugs
GLUCAGEN
GLUCAGON
EMERGENCY KIT
ENDOCRINE MEDICATIONS - Glucocorticoid Drugs
prednisone 20mg
tab
dexamethasone
RAYOS
dexamethasone
sodium phosphate
hydrocortisone
methylprednisolone
prednisolone
prednisolone sodium
phosphate
prednisone
veripred 20
ENDOCRINE MEDICATIONS - Mineralocorticoid Drugs
fludrocortisone acetate
ENDOCRINE MEDICATIONS - Thyroid Supplements
levothyroxine sod
50, 100mcg tab
levothyroxine sodium
liothyronine
westhroid
ENDOCRINE MEDICATIONS - Antithyroid Drugs
methimazole
propylthiouracil
25
ARMOUR THYROID
CYTOMEL
SYNTHROID
ENDOCRINE MEDICATIONS - Other Endocrine Drugs
alendronate sodium3
FORTEO1,3,SP
ACTONEL2,3
cabergoline
SENSIPAR1
ATELVIA2,3
calcitonin nasal spray
BINOSTO2,3
desmopressin
acetate1,SP
BONIVA tabs2,3
etidronate disodium3
FOSAMAX PLUS D2,3
ibandronate sodium3
GASTROINTESTINAL MEDICATIONS
GASTROINTESTINAL MEDICATIONS - Antidiarrheal Drugs
diphenoxylate-atropine
GASTROINTESTINAL MEDICATIONS - Antispasmodics/Drugs Affecting GI Motility
dicyclomine hcl
chlordiazepoxideclidinium
metoclopramide
hyoscyamine sulfate
hcl
GASTROINTESTINAL MEDICATIONS - Antiulcer Drugs
cimetidine 300, 400,
800mg tab
cimetidine 300 mg/5
mL solution
famotidine 40mg tab
famotidine 40mg/5 mL
solution
nizatidine 150, 300mg
cap
nizatidine 15mg/mL sol
ranitidine hcl 300mg
cap, tab
ranitidine hcl 15mg/mL
syrup
GASTROINTESTINAL MEDICATIONS - Other Antiulcer Drugs
misoprostol
CARAFATE
sucralfate
GASTROINTESTINAL MEDICATIONS - Proton Pump Inhibitors
pantoprazole
sodium
lansoprazole 30mg
ACIPHEX2
omeprazole 10, 40mg
DEXILANT2
rabeprazole2
ESOMEPRAZOLE
MAGNESIUM 40mg2
ESOMEPRAZOLE
STRONTIUM
NEXIUM 40mg2
OMEPRAZOLESODIUM
BICARBONATE2
PREVACID2
PROTONIX2
ZEGERID2
26
GASTROINTESTINAL MEDICATIONS - Heliobacteria Pylori Drugs
HELIDAC
LANSOPRAZOLEAMOXICILLINCLARITHROMYCIN
OMECLAMOX-PAK
PREVPAC
PYLERA
GASTROINTESTINAL MEDICATIONS - Laxatives and Cathartics
peg-3350
OSMOPREP
GASTROINTESTINAL MEDICATIONS - Other GI Drugs
anucort-hc
APRISO
ANALPRAM
ADVANCED/E/HC
balsalazide disodium
CANASA
ASACOL HD2
hydrocortisone
BUDESONIDE EC
hydrocortisone acetate
CREON1
COLYTE WITH
FLAVOR PACKS
lidocaine hclhydrocortisone acetate
PENTASA1
DELZICOL
mesalamine
RECTIV
DIPENTUM
pancrelipase 5,000
RELISTOR
ENTOCORT EC2
peg 3350-electrolyte
GOLYTELY
proctozone-hc
HALFLYTELYBISACODYL
LIALDA1
sulfasalazine/dr
MOVIPREP
trilyte with flavor
packets
NULYTELY WITH
FLAVOR PACKS
ursodiol
PANCREAZE1
proctosol-hc
PERTZYE
PREPOPIK
SFROWASA
SUCLEAR
SUPREP
ULTRESA
ZENPEP1
GASTROINTESTINAL MEDICATIONS - Irritable Bowel Drugs
LINZESS1
AMITIZA1
IMMUNOLOGICALS & VACCINES
IMMUNOLOGICALS & VACCINES - Myeloid Stimulants
PROMACTA1
IMMUNOLOGICALS & VACCINES - Interferons
AVONEX/ADMINISTR
ATION PACK/
PEN1,3,SP
COPAXONE1,3,SP
BETASERON1,3,SP
EXTAVIA1,3,SP
PEGASYS/PROCLICK1
PEGINTRON/REDIPEN1,3,SP
,3,SP
REBIF/REBIDOSE1,3,SP
27
IMMUNOLOGICALS & VACCINES - Growth Hormones and Related Drugs
TEV-TROPIN1,SP
GENOTROPIN1,SP
HUMATROPE1,SP
NORDITROPIN
FLEXPRO/
NORDIFLEX1,SP
NUTROPIN/AQ/AQ
NUSPIN1,SP
OMNITROPE1,SP
SAIZEN1,SP
IMMUNOLOGICALS & VACCINES - Interleukin Receptor Antagonist
ARCALYST1,SP
KINERET1,3,SP
ILARIS1,SP
MUSCULOSKELETAL MEDICATIONS
MUSCULOSKELETAL MEDICATIONS - Salicylates and Related Drugs
aspirin/ec
choline mag
trisalicylate
diflunisal
salsalate
MUSCULOSKELETAL MEDICATIONS - Non-Steroidal Anti-Inflammatory Agents
ibuprofen 400, 600,
800mg tab
indomethacin
25mg cap
ketoprofen 50mg
cap
diclofenac potassium
CAMBIA2
diclofenac sodium
CELEBREX2
etodolac/er
CELECOXIB2
ketorolac 10mg tab
flurbiprofen
DUEXIS2
ketorolac 30mg/mL
vial
indomethacin/er
MEFENAMIC ACID
meloxicam3
ketoprofen
NAPRELAN2
ketoprofen er2
SPRIX2
ketorolac
VIMOVO2
naproxen 375,
500mg tab (nonenteric coated)
naproxen
125mg/5mL susp
nabumetone
naproxen 250mg
naproxen dr
naproxen ec
naproxen sodium 275,
550mg
oxaprozin
piroxicam
sulindac
MUSCULOSKELETAL MEDICATIONS - Drugs to Prevent and Treat Gout
allopurinol
probenecid
COLCRYS
ULORIC2
28
MUSCULOSKELETAL MEDICATIONS - Direct Muscle Relaxants
baclofen
tizanidine hcl
MUSCULOSKELETAL MEDICATIONS - CNS Muscle Relaxants
cyclobenzaprine
hcl 10mg tab
chlorzoxazone
AMRIX2
cyclobenzaprine hcl
CYCLOBENZAPRINE
ER
methocarbamol
METAXALONE
orphenadrine citrate
SKELAXIN
SOMA
MUSCULOSKELETAL MEDICATIONS - Other Musculoskeletal Drugs
RILUTEK1
NUTRITION, BLOOD
NUTRITION, BLOOD - Vitamins and Minerals and Related Products
ferocon
BIFERA RX
ferraplus
CEREFOLIN
folbee
FERRALET
multigen
INTEGRA F/PLUS
NUTRITION, BLOOD - Therapeutic Vitamins and Minerals
calcitriol
HECTOROL
calcium acetate
NASCOBAL
eliphos
PHOSLYRA
folic acid
ZEMPLAR
levocarnitine
NUTRITION, BLOOD - Fluoride Products
ludent fluoride
PREVIDENT
sodium fluoride
NUTRITION, BLOOD - Potassium Supplements
potassium chloride
NUTRITION, BLOOD - Oral Anticoagulants, Vitamin K
warfarin sod 1, 2.5,
3, 4, 5mg tab
warfarin sodium
COUMADIN
NUTRITION, BLOOD - Heparin and Heparin Antagonists
fondaparinux
sodium3,SP
ARIXTRA1,3,SP
heparin sodium
ENOXAPARIN
SODIUM3,SP
FRAGMIN3,SP
LOVENOX3,SP
NUTRITION, BLOOD - Other Drugs Affecting Coagulation
ELIQUIS2
XARELTO2
NUTRITION, BLOOD - Thrombin Inhibitors
PRADAXA1
29
NUTRITION, BLOOD - Antiplatelet Drugs
cilostazol
AGGRENOX2
clopidogrel
BRILINTA1
dipyridamole
EFFIENT1
PLAVIX
NUTRITION, BLOOD - Hemostatics
tranexamic acid
LYSTEDA
NUTRITION, BLOOD - Blood Detoxicants
RENVELA1
enulose
lactulose
FOSRENOL1
KRISTALOSE
RENAGEL1
NUTRITION, BLOOD - Nutritional/Supplement Products
CEREFOLIN NAC
FOLTX
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Specialized OB/GYN Drugs
chorionic
gonadotropin1,F
GANIRELIX
ACETATE1,F
NOVAREL1,F
OVIDREL1,F
PREGNYL1,F
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - OB/GYN Topical Anti-Infectives
CLEOCIN
metronidazole
CLINDESSE
vandazole
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Ovulatory Stimulants
GONAL-F RFF/REDIJECT1,F
clomiphene citrate
MENOPUR1,F
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Androgen Drugs
DEPOTESTOSTERONE1
oxandrolone
testosterone
cypionate1
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Estrogen Drugs
estradiol 1mg tab
estradiol
MENEST
CENESTIN
estropipate
estrogen &
methyltestosterone
VAGIFEM
CLIMARA
DIVIGEL
ELESTRIN
ENJUVIA
ESTRACE
ESTRASORB
ESTRING3
ESTROGEL
EVAMIST
FEMRING3
MENOSTAR
30
MINIVELLE
PREMARIN
VIVELLE-DOT
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Estrogen/Progestin Combinations
jinteli
ACTIVELLA
ANGELIQ
CLIMARA PRO
COMBIPATCH
FEMHRT
PREFEST
PREMPHASE
PREMPRO
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Selective Estrogen Receptor Modulator
raloxifene hcl
EVISTA
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Progestin Drugs
medroxyprogestero
ne acetate tab
norethindrone acetate
ENDOMETRIN1,F
CRINONE1,F
PROMETRIUM1,F
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Contraceptives
additional contraceptives can be found on the Preventive Care List
BEYAZ
FEMCON FE
GENERESS FE
LO LOESTRIN FE
LO MINASTRIN FE
LOSEASONIQUE
MINASTRIN 24 FE
NATAZIA
NUVARING
ORTHO EVRA
ORTHO TRICYCLEN/LO
QUARTETTE
SAFYRAL
SEASONIQUE
YASMIN 28
YAZ
OPHTHALMIC MEDICATIONS
OPHTHALMIC MEDICATIONS - Ophthalmic Topical Antibacterial Drugs
neomycinbacitracinpolymyxin
bacitracin
MOXEZA
AZASITE
bacitracin-polymyxin
BESIVANCE
ciprofloxacin hcl
VIGAMOX
erythromycin
ZYMAXID
gentamicin sulfate
ofloxacin
31
polymyxin b sultrimethoprim
sulfacetamide sodium
tobramycin
OPHTHALMIC MEDICATIONS - Ophthalmic Topical Antiviral Drugs
trifluridine
ZIRGAN
OPHTHALMIC MEDICATIONS - Ophthalmic Corticosteroid Drugs
fluorometholone
ALREX
prednisolone acetate
DUREZOL
FML FORTE
LOTEMAX3
VEXOL
OPHTHALMIC MEDICATIONS - Ophthalmic Anti-Infective/Corticosteroids
neomycin-polymyxindexamethasone
neomycin-polymyxinhydrocortisone
tobramycindexamethasone
TOBRADEX/ST
ZYLET
OPHTHALMIC MEDICATIONS - Antiglaucoma Drugs
acetazolamide/er
ALPHAGAN P
brimonidine tartrate
AZOPT
dorzolamide hcl
BETIMOL
dorzolamide-timolol
BETOPTIC S
latanoprost
COMBIGAN
levobunolol hcl
COSOPT PF
pilocarpine hcl
ISTALOL
timolol maleate
LUMIGAN
travoprost
RESCULA
SIMBRINZA
TIMOPTIC OCUDOSE
TRAVATAN Z
XALATAN
ZIOPTAN
OPHTHALMIC MEDICATIONS - Other Ophthalmic Drugs
atropine sulfate
RESTASIS1,3
ACUVAIL
azelastine hcl
ALOCRIL
cromolyn sodium
ALOMIDE
diclofenac sodium
BEPREVE3
epinastine hcl
EMADINE
ILEVRO
LASTACAFT
NEVANAC
PATADAY2
PATANOL
PROLENSA
32
RESPIRATORY MEDICATIONS
RESPIRATORY MEDICATIONS - Beta-2 Adrenergic Drugs
albuterol 2, 4mg
tab
albuterol 2mg/5mL
syrup
albuterol 0.083%
inhal sol
albuterol
FORADIL
ARCAPTA NEOHALER
metaproterenol sulfate
PERFOROMIST
BROVANA
PROAIR HFA
LEVALBUTEROL HCL
MAXAIR AUTOHALER
PROVENTIL HFA
SEREVENT DISKUS
VENTOLIN HFA
XOPENEX/CONCENT
RATE
XOPENEX HFA
RESPIRATORY MEDICATIONS - Methyl Xanthine Drugs
theophylline/anhydrous
RESPIRATORY MEDICATIONS - Other Drugs for Asthma
budesonide
ATROVENT HFA
ADVAIR DISKUS2,3
cromolyn sodium
COMBIVENT/RESPIM
AT1,3
ADVAIR HFA2,3
epinephrine
DULERA2,3
ALVESCO
ipratropium bromide
QVAR
ASMANEX
ipratropium-albuterol
SYMBICORT2,3
BREO ELLIPTA
TUDORZA PRESSAIR
EPIPEN/JR 2-PAK3
FLOVENT
DISKUS/HFA
PULMICORT/FLEXHA
LER
SPIRIVA
RESPIRATORY MEDICATIONS - Leukotriene Modifiers
montelukast sodium
ACCOLATE
zafirlukast
SINGULAIR
ZYFLO/CR2
RESPIRATORY MEDICATIONS - Antihistamines
promethazine hcl
25mg tab
promethazine hcldm
arbinoxa
CLARINEX
cyproheptadine hcl
XYZAL
levocetirizine
dihydrochloride
promethazine hcl
RESPIRATORY MEDICATIONS - Antihistamine/Decongestant Combinations
promethazine vc
RESPIRATORY MEDICATIONS - Antitussive and Expectorant Drugs
benzonatate
REZIRA
guaifenesin-codeine
TUSSICAPS
promethazine-codeine
TUSSIONEX
promethazine vccodeine
promethazinedextromethorphan
33
ZUTRIPRO
RESPIRATORY MEDICATIONS - Other Respiratory Drugs
PULMOZYME1,SP
DALIRESP
UROLOGICAL MEDICATIONS
UROLOGICAL MEDICATIONS - Anticholinergic Antispasmodics
oxybutynin chloride/er
DETROL/LA
tolterodine tartrate
ENABLEX
GELNIQUE
OXYTROL
SANCTURA XR
TOVIAZ
TROSPIUM
CHLORIDE
VESICARE2
UROLOGICAL MEDICATIONS - Cholinergic Stimulants
bethanechol chloride
UROLOGICAL MEDICATIONS - Urinary Anesthetics
phenazopyridine hcl
100, 200mg
UROLOGICAL MEDICATIONS - Other Genitourinary Products
alfuzosin hcl er
ELMIRON1
AVODART
finasteride
FLOMAX
potassium citrate
JALYN
tamsulosin hcl
MYRBETRIQ2
RAPAFLO
UROXATRAL
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS - Diagnostic Products
EXJADE1,SP
MINILINK REAL-TIME
TRANSMITTER
PARADIGM REALTIME
SOF-SENSOR
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS - Miscellaneous Drugs
THALOMID1,SP
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS - Appetite Suppressants
QSYMIA2
phentermine hcl
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS - Other Weight Loss Products
BELVIQ2
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS - Alcohol Antagonists
disulfiram
MEDICAL (MISCELLANEOUS) SUPPLIES
MEDICAL (MISCELLANEOUS) SUPPLIES - Medical (Miscellaneous) Supplies
CONCEPTION3
MINIMED/RESERVOIR
OPTICHAMBER
PARADIGM/INFUSION
/SILHOUETTE
34
POLYFIN/QR
PRIMABELLA
QUICK RELEASE
SOFT TEFLON
SILHOUETTE
SOF-SET/MICRO
SURE-T
MEDICAL (MISCELLANEOUS) SUPPLIES - Diabetic Supplies
ACCU-CHEK
FASTCLIX
ACCU-CHEK
SOFTCLIX
FORA LANCING
DEVICE
FORACARE LANCETS
FREESTYLE
FREEDOM LITE
FREESTYLE
INSULINX TEST
STRIPS3
FREESTYLE
LANCETS
FREESTYLE LITE
TEST STRIPS3
FREESTYLE TEST
STRIPS3
NOVOFINE/32/AUTOC
OVER
ACCU-CHEK
ACCU-CHEK ACTIVE
ACCU-CHEK
AVIVA/PLUS
ACCU-CHEK
COMFORT CURVE
ACCU-CHEK
COMPACT/BLUE
CONTROL
ACCU-CHEK NANO
SMARTVIEW
ACCU-CHEK
SMARTVIEW
ASCENSIA
AUTODISC3
AUTODISC NORMAL3
BREEZE 2
ONE TOUCH DELICA
CLEVER CHOICE
VOICE + TEST
STRIPS3
ONE TOUCH
LANCETS
CONTOUR/NEXT/EZ
PRECISION
CONTROL SOLUTION
PRODIGY INSULIN
SYRINGE
PRODIGY PEN
NEEDLES
SOFT TOUCH
DEXCOM G4
FORA TEST STRIPS3
FORA V30A
SURE COMFORT
LANCETS
GLUCOSE TEST
STRIPS3
ONE TOUCH TEST
STRIPS3
TRUEPLUS LANCETS
ONE TOUCH ULTRA 2
SOFTCLIX
ULTRA COMFORT
VGO 20/30/40
ONE TOUCH ULTRA
SMART
ONE TOUCH ULTRA
SYSTEM
ONE TOUCH ULTRA
TEST STRIPS3
ONE TOUCH
ULTRAMINI
ONE TOUCH
VERIO/IQ
PRECISION XTRA
PRODIGY/NO
CODING/POCKET
SURESTEP
35
TRUETEST TEST
STRIPS3
TRUETRACK TEST
STRIPS3
1prior
authorization, 2step therapy, 3quantity limit, Ffertility, SPspecialty (see your plan for SP cost-sharing)
36
Alphabetical Listing Index
DRUG/PRODUCT NAME
CLASS
abacavir
ABILIFY/DISCMELT1
ABSORICA2
ABSTRAL1,3
ACAMPROSATE CALCIUM
ACANYA
acarbose
ACCOLATE
ACCU-CHEK
ACCU-CHEK ACTIVE
ACCU-CHEK AVIVA/PLUS
ACCU-CHEK COMFORT CURVE
ACCU-CHEK COMPACT/BLUE CONTROL
ACCU-CHEK FASTCLIX
ACCU-CHEK NANO SMARTVIEW
ACCU-CHEK SMARTVIEW
ACCU-CHEK SOFTCLIX
acebutolol hcl
acetaminophen-codeine
acetazolamide/er
ACIPHEX2
ACITRETIN2
ACTIVELLA
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Estrogen/Progestin
Combinations
ACTONEL2,3
ACTOPLUS MET XR2
ACTOPLUS
MET2
ACTOS2
ACUVAIL
acyclovir oral
ACYCLOVIR TOPICAL
ADAPALENE
ADCIRCA1,SP
ADDERALL XR2
ADVAIR
DISKUS2,3
ADVAIR
HFA2,3
ADVICOR2
AFINITOR1,SP
AGGRENOX
albuterol
alclomethasone dipropionate
alendronate sodium3
alfuzosin hcl er
allopurinol
37
DRUG/PRODUCT NAME
CLASS
ALOCRIL
ALOMIDE
ALPHAGAN P
alprazolam/er/xr
ALREX
ALTABAX
ALTOPREV2
ALVESCO
amantadine
AMBIEN/CR3
amiloride hcl
amiodarone hcl
CARDIOVASCULAR MEDICATIONS - Amiodarones
AMITIZA1
amitriptyline hcl
amlodipine besylate
amlodipine besylate-benazepril
AMLODIPINE-ATORVASTATIN
AMNESTEEM2
amoxicillin
AMOXICILLIN-POTASSIUM CLAVULANATE/ER
amphetamine salt combo
AMPYRA1,SP
AMRIX2
AMTURNIDE
anagrelide hcl
ANALPRAM ADVANCED/E/HC
anastrozole
ANGELIQ
Combinations
ANTARA2
antipyrine-benzocaine
anucort-hc
apexicon e
APIDRA/SOLOSTAR3
arbinoxa
ARCALYST1,SP
ARCAPTA NEOHALER
ARICEPT/ODT
ARIMIDEX
ARIXTRA1,3,SP
ARMOUR THYROID
ASACOL
HD2
ASCENSIA AUTODISC
ASMANEX
aspirin/ec
ASTELIN2,3
38
DRUG/PRODUCT NAME
CLASS
ASTEPRO2,3
ATACAND
ATACAND HCT
ATELVIA2,3
atenolol
atenolol-chlorthalidone
atorvastatin calcium
atovaquone
atovaquone-proguanil hcl
ATRALIN2
ATRIPLA
atropine sulfate
atropine sulfate
ATROVENT HFA
AUTODISC NORMAL
AVALIDE
AVAPRO
AVELOX/ABC PACK
AVINZA2,3
AVODART
AVONEX/ADMINISTRATION PACK/PEN1,3,SP
AXERT2,3
AZASITE
azathioprineSP
azelastine hcl
azelastine hcl
AZILECT
azithromycin
AZOPT
AZOR
bacitracin
bacitracin-polymyxin
baclofen
BACTROBAN
balsalazide disodium
BARACLUDE
BECONASE AQ2,3
BELVIQ2
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS - Other Weight Loss Products
benazepril hcl
benazepril-hctz
BENICAR
BENICAR HCT
BENZACLIN
benzonatate
benzoyl peroxide
39
DRUG/PRODUCT NAME
CLASS
benztropine mesylate
BEPREVE3
BESIVANCE
betamethasone dipropionate
betamethasone valerate
BETASERON1,3,SP
bethanechol chloride
UROLOGICAL MEDICATIONS - Cholinergic Stimulants
BETHKIS1,SP
BETIMOL
BETOPTIC S
BEYAZ
bicalutamide
BIDIL
BIFERA RX
BINOSTO2,3
bisoprolol fumarate
bisoprolol-hctz
BONIVA
tabs2,3
BREEZE 2
BREO ELLIPTA
BRILINTA
brimonidine tartrate
bromocriptine mesylate
BROVANA
budesonide
BUDESONIDE EC
bumetanide
BUPRENORPHINE HCL
BUPRENORPHINE-NALOXONE1
bupropion
hcl/sr/xl3
buspirone hcl
butalbital compound-codeine
butalbital-aspirin-caffeine
butorphanol tartrate
BUTRANS
BYDUREON2,3
BYETTA2,3
BYSTOLIC
cabergoline
CADUET2
CALCIPOTRIENE
calcitonin nasal spray
calcitrene
calcitriol
calcium acetate
40
DRUG/PRODUCT NAME
CLASS
CAMBIA2
candesartan cilexetil
candesartan-hctz
capecitabine1,SP
captopril
captopril-hctz
CARAC
CARAFATE
carbamazepine ir
CARBAMAZEPINE/XR
CARBATROL
carbidopa-levodopa
carbidopa-levodopa-entacapone
SR2
CARDIZEM LA
CARDURA XL
cartia xt
carvedilol
CAYSTON1,3,SP
CEDAX
cefaclor/er
cefadroxil
cefdinir
cefpodoxime proxetil
cefprozil
ceftibutin
CEFTIN
cefuroxime
CELEBREX2
CELECOXIB
CELLCEPT1,SP
CENESTIN
cephalexin
CEREFOLIN
CEREFOLIN NAC
CETRAXAL
CEVIMELINE HCL
chlordiazepoxide hcl
chlordiazepoxide-clidinium
GASTROINTESTINAL MEDICATIONS - Antispasmodics/Drugs Affecting GI
Motility
chlorpromazine hcl
AUTONOMIC & CNS MEDICATIONS - Aliphatic Phenothiazines
chlorthalidone
chlorzoxazone
cholestyramine
choline mag trisalicylate
CARDENE
41
DRUG/PRODUCT NAME
chorionic gonadotropin1,F
CLASS
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Specialized OB/GYN
Drugs
ciclopirox
cilostazol
cimetidine 300 mg/5 mL solution
cimetidine 300, 400, 800mg tab
CIMZIA1,3,SP
CIPRO HC
CIPRODEX
ciprofloxacin hcl
ciprofloxacin hcl/er
citalopram
hydrobromide3
CLARAVIS2
CLARINEX
clarithromycin/er
CLEOCIN
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - OB/GYN Topical AntiInfectives
CLEVER CHOICE VOICE + TEST STRIPS
CLIMARA
CLIMARA PRO
Combinations
clindamycin hcl
CLINDAMYCIN-BENZOYL PEROXIDE
CLINDESSE
clobetasol emollient
clobetasol propionate
CLOBEX
CLODERM
clomiphene citrate
CLOMIPRAMINE HCL
clonazepam
clonidine hcl/er
CLONIDINE PATCH
clopidogrel
clorazepate dipotassium
clotrimazole
clotrimazole
clotrimazole-betamethasone
clozapine
COLCRYS
colestipol hcl
COLYTE WITH FLAVOR PACKS
COMBIGAN
42
DRUG/PRODUCT NAME
COMBIPATCH
CLASS
Combinations
COMBIVENT/RESPIMAT1,3
COMBIVIR
COMPLERA
COMTAN
CONCEPTION3
CONCERTA2
CONDYLOX
CONTOUR/NEXT/EZ
CONTROL SOLUTION
COPAXONE1,3,SP
CORDRAN
COREG CR
COSOPT PF
COUMADIN
COZAAR
CRESTOR2
CRINONE
cromolyn sodium
cromolyn sodium
CYCLOBENZAPRINE ER
cyclobenzaprine hcl
cyclosporine modified
CYMBALTA2,3
cyproheptadine hcl
CYTOMEL
DALIRESP
DAPSONE
ANTI-INFECTIVES - Sulfones
DAYTRANA2
DELZICOL
DENAVIR
DEPAKOTE ER1
DEPO-TESTOSTERONE1
desipramine hcl
desmopressin
acetate1,SP
desonide
desoximetasone
DETROL/LA
dexamethasone
dexamethasone sodium phosphate
DEXCOM G4
DEXILANT2
DEXMETHYLPHENIDATE ER
dexmethylphenidate hcl
DEXTROAMPHETAMINE/ER
43
DRUG/PRODUCT NAME
CLASS
dextroamphetamine-amphetamine er
diazepam
diazepam rectal gel
diclofenac potassium
diclofenac sodium
diclofenac sodium
diclofenac sodium
dicloxacillin
dicyclomine hcl
Motility
DIFFERIN2
DIFICID
diflorasone
DIFLUCAN
2
diflunisal
digoxin
DILANTIN
diltiazem/er
DIOVAN
DIOVAN HCT
DIPENTUM
diphenoxylate-atropine
GASTROINTESTINAL MEDICATIONS - Antidiarrheal Drugs
dipyridamole
disulfiram
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS - Alcohol Antagonists
divalproex sodium/dr
DIVALPROEX SODIUM/ER
DIVIGEL
donepezil hcl
DORYX2
dorzolamide hcl
dorzolamide-timolol
DOVONEX
doxazosin mesylate
doxepin hcl
doxycycline hyclate
doxycycline hyclate
DOXYCYCLINE HYCLATE
DR2
doxycycline monohydrate
dronabinol1
DUAC
DUETACT2
DUEXIS2
DULERA2,3
DULOXETINE
HCL2,3
DUREZOL
DYMISTA2,3
44
DRUG/PRODUCT NAME
CLASS
econazole nitrate
EDARBI
EDARBYCLOR
EDLUAR3
EFFEXOR XR2,3
EFFIENT1
ELESTRIN
ELIDEL2
ELIGARD1,SP
eliphos
ELIQUIS1
ELMIRON
EMADINE
EMEND3
ENABLEX
enalapril maleate
enalapril-hctz
ENBREL1,3,SP
endocet
ENDOMETRIN
ENJUVIA
ENOXAPARIN
SODIUM3,SP
entacapone
ENTOCORT
EC2
enulose
EPICERAM
EPIDUO
epinastine hcl
epinephrine
EPIPEN/JR
EPIVIR
2-PAK3
HBVSP
EPIVIR
eplerenone
eprosartan mesylate
EPZICOM
ERTACZO
ERY-TAB
erythromycin
erythromycin
erythromycin
erythromycin-benzoyl peroxide
escitalopram
oxalate3
esomeprazole magnesium
40mg2
ESOMEPRAZOLE STRONTIUM
estazolam
45
DRUG/PRODUCT NAME
CLASS
ESTRACE
estradiol
ESTRASORB
ESTRING3
ESTROGEL
estrogen & methyltestosterone
estropipate
eszopiclone3
etidronate
disodium3
etodolac/er
EURAX
EVAMIST
EVISTA
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Selective Estrogen
Receptor Modulator
EXALGO2,3
EXELDERM
EXELON
EXEMESTANE1
EXFORGE/HCT2
EXJADE1,SP
EXTAVIA1,3,SP
FACTIVE
FAMCICLOVIR
famotidine 40mg tab
famotidine 40mg/5 mL solution
FANAPT
FARXIGA2
felbamate
felodipine er
FEMARA
FEMCON FE
FEMHRT
Combinations
FEMRING3
fenofibrate
fenofibric acid
FENOGLIDE2
FENTANYL3
FENTORA1,3
ferocon
FERRALET
ferraplus
FINACEA
finasteride
flecainide acetate
FLECTOR2
46
DRUG/PRODUCT NAME
CLASS
FLOMAX
FLOVENT DISKUS/HFA
fluconazole
fludrocortisone acetate
ENDOCRINE MEDICATIONS - Mineralocorticoid Drugs
flunisolide
FLUOCINOLONE
fluocinolone acetonide
fluocinonide
fluorometholone
FLUOROPLEX
fluorouracil
fluoxetine hcl3
fluphenazine hcl
flurazepam hcl
flurbiprofen
fluvastatin sodium
fluvoxamine maleate
er2,3
fluvoxamine maleate3
FML FORTE
FOCALIN
XR2
folbee
folic acid
FOLTX
fondaparinux
sodium3,SP
FORA LANCING DEVICE
FORA TEST STRIPS
FORA V30A
FORACARE LANCETS
FORADIL
FORTAMET2
FORTEO1,3,SP
FOSAMAX PLUS
D2,3
fosinopril sodium
fosinopril-hctz
FOSRENOL1
FRAGMIN3,SP
FREESTYLE FREEDOM LITE
FREESTYLE INSULINX TEST STRIPS
FREESTYLE LANCETS
FREESTYLE LITE TEST STRIPS
FREESTYLE TEST STRIPS
FROVA2,3
furosemide
47
DRUG/PRODUCT NAME
CLASS
gabapentin
galantamine hydrobromide
GANIRELIX ACETATE1,F
Drugs
GELNIQUE
gemfibrozil
GENERESS FE
gengraf
GENOTROPIN1,SP
gentamicin sulfate
gentamicin sulfate
gentamicin sulfate
GEODON
GILENYA
1,SP
glimepiride
glipizide/er/xl
glipizide-metformin hcl
GLUCAGEN
GLUCAGON EMERGENCY KIT
GLUCOSE TEST STRIPS
GLUMETZA2
glyburide/micronized
glyburide-metformin hcl
GOLYTELY
GONAL-F RFF/REDI-JECT1,F
GRALISE2
granisetron
hcl3
GRIFULVIN V
griseofulvin
guaifenesin-codeine
guanfacine hcl
HALFLYTELY-BISACODYL
HALOBETASOL PROPIONATE
HALOG
haloperidol
HECTOROL
HELIDAC
heparin sodium
HORIZANT2
HUMALOG KWIKPEN2,3
HUMALOG products3
HUMATROPE1,SP
HUMIRA1,3,SP
HUMULIN
products3
hydrochlorothiazide
hydrocodone bitartrate-ibuprofen
48
DRUG/PRODUCT NAME
CLASS
hydrocodone-acetaminophen
hydrocortisone
hydrocortisone
hydrocortisone
hydrocortisone acetate
hydrocortisone butyrate
hydrocortisone valerate
hydromorphone hcl
hydromorphone hcl
er3
hydroxychloroquine sulfate
hydroxyurea
hydroxyzine
hyoscyamine sulfate
DERMATOLOGIC MEDICATIONS - Antipruritic Drugs
Motility
HYZAAR
ibandronate sodium3
ibuprofen 400, 600, 800mg tab
ILARIS1,SP
ILEVRO
IMBRUVICA1,SP
imipramine hcl
imipramine pamoate
imiquimod
IMITREX2,3
indapamide
indomethacin/er
INTEGRA F/PLUS
INTELENCE
INTERMEZZO3
INTUNIV2
INVEGA1
INVOKAMET2
INVOKANA2
ipratropium bromide
ipratropium bromide
ipratropium-albuterol
irbesartan
irbesartan-hctz
ISENTRESS
isoniazid
isosorbide/dinitrate
isotretinoin2
ISTALOL
itraconazole
JALYN
JANUMET/XR2
49
DRUG/PRODUCT NAME
CLASS
JANUVIA2
JENTADUETO2
jinteli
Combinations
KADIAN2,3
KALETRA
KAPVAY2
KAZANO2
KENALOG
KEPPRA/XR2
ketoconazole
ketoconazole
ketoprofen
ketoprofen er
2
ketorolac
KINERET1,3,SP
KOMBIGLYZE XR2
KRISTALOSE
labetalol hcl
lactulose
LAMICTAL
XR2
LAMICTAL/ODT
LAMISIL2
lamivudine
lamivudine-zidovudine
LAMOTRIGINE/ER
lamotrigine/ir
LANOXIN
lansoprazole 30mg
LANSOPRAZOLE-AMOXICILLINCLARITHROMYCIN
LANTUS/SOLOSTAR3
LASTACAFT
latanoprost
LATUDA1
LAZANDA1,3
leflunomide
LESCOL/XL2
LETAIRIS1,SP
letrozole
leucovorin calcium tablets
LEVALBUTEROL HCL
LEVAQUIN
LEVEMIR/FLEXPEN3
levetiracetam
levobunolol hcl
50
DRUG/PRODUCT NAME
CLASS
levocarnitine
levocetirizine dihydrochloride
levofloxacin
levothyroxine sodium
LEXAPRO3
LEXIVA
LIALDA1
lidocaine hcl
lidocaine hcl-hydrocortisone acetate
lidocaine hcl-hydrocortisone acetate
LIDOCAINE HCL
patch1
lidocaine patch1
lidocaine-prilocaine
LIDODERM1
LINZESS1
liothyronine
LIPITOR2
LIPOFEN2
LIPTRUZET2
lisinopril
lisinopril-hctz
lithium carbonate
AUTONOMIC & CNS MEDICATIONS - Antimania Drugs
LIVALO2
LO LOESTRIN FE
LO MINASTRIN FE
LOCOID/LIPOCREAM
lorazepam
losartan potassium
losartan-hctz
LOSEASONIQUE
LOTEMAX
LOTREL
lovastatin
LOVAZA1
LOVENOX3,SP
ludent fluoride
LUMIGAN
LUNESTA3
LUVOX
CR3
LYRICA2
LYSTEDA
MALARONE
MALATHION
MARINOL1
MAXAIR AUTOHALER
51
DRUG/PRODUCT NAME
CLASS
MAXALT/MLT2,3
MB HYDROGEL
meclizine hcl
medroxyprogesterone acetate tab
MEFENAMIC ACID
mefloquine hcl
MEGACE
ES1
megestrol acetate
meloxicam3
MENEST
MENOPUR1,F
MENOSTAR
MEPRON1
mercaptopurine
mesalamine
METADATE
CD2
metaproterenol sulfate
METAXALONE
metformin hcl/er
methadone hcl
methimazole
methocarbamol
methotrexate
methotrexate
sodiumSP
methyldopa
methylin/er
METHYLPHENIDATE HCL/CD/ER/LA/SR
methylprednisolone
metoclopramide hcl
Motility
metolazone
metoprolol succinate
metoprolol tartrate
metoprolol-hctz
METROGEL
metronidazole
metronidazole
metronidazole
METRONIDAZOLE topical
MICARDIS
MICARDIS HCT
midodrine hcl
MIGRANAL3
MINASTRIN 24 FE
MINILINK REAL-TIME TRANSMITTER
52
DRUG/PRODUCT NAME
CLASS
MINIMED/RESERVOIR
MINIVELLE
minocycline hcl
MINOCYCLINE HCL ER2
minoxidil
MIRAPEX/ER
mirtazapine
misoprostol
MODAFINIL1,3
moexipril hcl
moexipril-hctz
mometasone furoate
montelukast sodium
morphine sulfate
morphine sulfate
er3
MOVIPREP
MOXEZA
MULTAQ
multigen
mupirocin
mycophenolate mofetil1,SP
mycophenolic acid
dr1,SP
MYFORTIC1,SP
myorisan2
MYRBETRIQ
nabumetone
nadolol
NAFTIN
naltrexone hcl
NAMENDA
NAMENDA XR
NAPRELAN2
naproxen/dr/ec
naproxen sodium 275, 550mg
naratriptan
hcl3
NASCOBAL
NASONEX2,3
NATAZIA
nateglinide
neomycin-bacitracin-polymyxin
neomycin-polymyxin-dexamethasone
neomycin-polymyxin-hydrocortisone
neomycin-polymyxin-hydrocortisone
NEORAL1,SP
NESINA2
53
DRUG/PRODUCT NAME
CLASS
NEUPRO
NEVANAC
nevirapine
NEXIUM 40mg2
NIACIN ER
NIASPAN
nifediac cc
nifedical xl
nifedipine er
NISOLDIPINE ER
nisoldipine ir
nitrofurantoin
nitroglycerin/patch
NITROSTAT
nizatidine 150, 300mg cap
nizatidine 15mg/mL sol
nodolor
NORDITROPIN
FLEXPRO/NORDIFLEX1,SP
norethindrone acetate
NOROXIN
nortriptyline hcl
NORVIR
NOVAREL1,F
Drugs
NOVOFINE/32/AUTOCOVER
NOVOLIN
products3
NOVOLOG
FLEXPEN2,3
NOVOLOG
products3
NUCYNTA
NUCYNTA
ER2,3
NUEDEXTA1
NULYTELY WITH FLAVOR PACKS
NUTROPIN/AQ/AQ NUSPIN1,SP
NUVARING
NUVIGIL1
nystatin
nystatin
nystatin-triamcinolone
octreotide
acetate1,SP
ofloxacin
ofloxacin
ofloxacin
OLANZAPINE
OLANZAPINE-FLUOXETINE
OLUX/-E
OMECLAMOX-PAK
54
DRUG/PRODUCT NAME
omega-3 acid ethyl
esters1
omeprazole 10, 40mg
OMEPRAZOLE-SODIUM
BICARBONATE2
OMNARIS2,3
OMNITROPE1,SP
ondansetron
CLASS
hcl/odt3
ONE TOUCH DELICA
ONE TOUCH LANCETS
ONE TOUCH TEST STRIPS
ONE TOUCH ULTRA 2
ONE TOUCH ULTRA SMART
ONE TOUCH ULTRA SYSTEM
ONE TOUCH ULTRA TEST STRIPS
ONE TOUCH ULTRAMINI
ONE TOUCH VERIO/IQ
ONFI
ONGLYZA2
ONMEL
ONSOLIS1,3,SP
OPANA
OPANA ER2,3
OPTICHAMBER
ORACEA2
ORAVIG
ORENCIA
125mg/mL1,SP
orphenadrine citrate
ORTHO EVRA
ORTHO TRI-CYCLEN/LO
OSENI2
OSMOPREP
OTEZLA1,3,SP
OVIDREL1,F
Drugs
oxandrolone
oxaprozin
oxazepam
OXCARBAZEPINE
OXISTAT
OXTELLAR
XR1
oxybutynin chloride/er
oxycodone hcl
oxycodone-acetaminophen
OXYCONTIN2,3
OXYMORPHONE HCL
OXYMORPHONE HCL
OXYTROL
ER3
55
DRUG/PRODUCT NAME
CLASS
PANCREAZE1
pancrelipase 5,000
pantoprazole sodium
PARADIGM REAL-TIME
PARADIGM/INFUSION/SILHOUETTE
paroxetine hcl 10, 20mg
paroxetine
tab3
hcl3
PATADAY
PATANASE
PATANOL
peg 3350-electrolyte
peg-3350
PEGASYS/PROCLICK1,3,SP
PEG-INTRON/REDIPEN1,3,SP
penicillin v potassium
PENNSAID2
pentazocine-naloxone
AUTONOMIC & CNS MEDICATIONS - Class IV Narcotics
pentoxifylline
PERFOROMIST
permethrin 5%
perphenazine
PERTZYE
phenazopyridine hcl 100, 200mg
UROLOGICAL MEDICATIONS - Urinary Anesthetics
phenobarbital
phentermine hcl
PHENYTEK
phenytoin sodium extended
PHOSLYRA
PICATO2
pilocarpine hcl
pilocarpine hcl
pindolol
pioglitazone hcl
pioglitazone hcl-metformin hcl
piroxicam
PLAVIX
PODOCON-251
PODOFILOX
POLYFIN/QR
polymyxin b sul-trimethoprim
potassium chloride
NUTRITION, BLOOD - Potassium Supplements
potassium citrate
POTIGA
PRADAXA1
NUTRITION, BLOOD - Thrombin Inhibitors
pramipexole dihydrochloride
56
DRUG/PRODUCT NAME
CLASS
PRAMOSONE/E
PRANDIMET
PRANDIN
pravastatin sodium
prazosin hcl
PRECISION
PRECISION XTRA
prednisolone
prednisolone acetate
prednisolone sodium phosphate
prednisone
Combinations
Drugs
PREFEST
PREGNYL1,F
PREMARIN
PREMPRO
Combinations
Combinations
PREPOPIK
PREVACID2
PREVIDENT
PREVPAC
PREZISTA
PRIMABELLA
primidone
PRISTIQ2,3
PROAIR HFA
probenecid
prochlorperazine maleate
proctosol-hc
proctozone-hc
PRODIGY INSULIN SYRINGE
PRODIGY PEN NEEDLES
PRODIGY/NO CODING/POCKET
PROGRAF1,SP
PROLENSA
PROMACTA1
IMMUNOLOGICALS & VACCINES - Myeloid Stimulants
promethazine hcl
promethazine hcl
promethazine hcl-dm
promethazine vc
RESPIRATORY MEDICATIONS - Antihistamine/Decongestant Combinations
promethazine vc-codeine
promethazine-codeine
promethazine-dextromethorphan
promethegan
PROMETRIUM
PREMPHASE
57
DRUG/PRODUCT NAME
CLASS
PROMISEB
propafenone hcl
propranolol hcl
propylthiouracil
PROTONIX2
PROTOPIC2
PROVENTIL HFA
PROVIGIL1
PULMICORT/FLEXHALER
PULMOZYME1,SP
PYLERA
pyridostigmine bromide
QNASL2,3
QSYMIA2
QUALAQUIN
QUARTETTE
quetiapine fumarate
QUICK RELEASE SOFT TEFLON
QUILLIVANT
XR2
quinapril hcl
quinapril-hctz
quinidine gluconate cr
quinidine sulfate
quinine sulfate
QVAR
rabeprazole2
raloxifene hcl
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS - Selective Estrogen
Receptor Modulator
ramipril
RANEXA1
ranitidine hcl 15mg/mL syrup
ranitidine hcl 300mg cap, tab
RAPAFLO
RAPAMUNE1,SP
RAYOS
REBIF/REBIDOSE1,3,SP
RELENZA
RELPAX2,3
RENAGEL1
RENVELA1
repaglinide
reprexain
REQUIP XL
RESCULA
RESTASIS
REVATIO1,SP
58
DRUG/PRODUCT NAME
CLASS
REVLIMID1,SP
REYATAZ
REZIRA
RHINOCORT AQUA2,3
ribapakSP
RIBASPHERE1,SP
ribavirinSP
rifampin
RILUTEK1
MUSCULOSKELETAL MEDICATIONS - Other Musculoskeletal Drugs
RIOMET
RISPERDAL CONSTA
risperidone/m-tab
RITALIN LA2
rivastigmine
RIZATRIPTAN3
ropinirole hcl
ROXICET solution
roxicet tabs
ROZEREM3
RYTHMOL SR
SABRIL1,SP
SAFYRAL
SAIZEN1,SP
salsalate
SANCTURA XR
SANCUSO3
SANDIMMUNE1,SP
SANDOSTATIN LAR1,SP
SANTYL
SAPHRIS
SAVELLA2,3
SEASONIQUE
selenium sulfide
SENSIPAR
SEREVENT DISKUS
SEROQUEL
SEROQUEL XR1
sertraline
hcl3
SFROWASA
sildenafil citrate (pulmonary
hypertension)1,SP
SILENOR3
SILHOUETTE
silver sulfadiazine
SIMBRINZA
SIMCOR2
59
DRUG/PRODUCT NAME
CLASS
SIMPONI1,3,SP
simvastatin
SINGULAIR
SKELAXIN
sodium fluoride
sodium sulfacetamide
sodium sulfacetamide-sulfur
SOF-SENSOR
SOF-SET/MICRO
SOFT TOUCH
SOFTCLIX
SOLARAZE
SOLODYN2
SOMA
SOMATULINE
DEPOT1,SP
SORIATANE1
SORILUX
sotalol
SOVALDI1,SP
SPIRIVA
spironolactone
spironolactone-hctz
SPRIX2
STALEVO
STIVARGA1,SP
STRATTERA2
STRIBILD
SUBOXONE1
SUBSYS1,3
SUCLEAR
sucralfate
SULAR2
sulfacetamide sodium
sulfamethoxazole-trimethoprim/DS
ANTI-INFECTIVES - Sulfonamides
sulfasalazine/dr
sulindac
sumatriptan3
SUMATRIPTAN
SUMAVEL
nasal/injectable3
DOSEPRO2,3
SUPRAX
SUPREP
SURE COMFORT LANCETS
SURESTEP
SURE-T
SUSTIVA
60
DRUG/PRODUCT NAME
CLASS
SYMBICORT2,3
SYMBYAX
SYMLINPEN
ENDOCRINE MEDICATIONS - Amylin Analogues
SYNTHROID
TABLOID1,SP
TACLONEX1
tacrolimus1,SP
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TANZEUM2,3
TARCEVA1,SP
TARKA
TASIGNA1,SP
TAZORAC2
TECFIDERA1,SP
TEGRETOL XR
TEKAMLO
TEKTURNA/HCT
TELMISARTAN
temazepam
TEMODAR1,SP
TEMOZOLOMIDE1,SP
terazosin hcl
terbinafine hcl
terconazole
testosterone
cypionate1
tetracycline hcl
TEVETEN
TEVETEN HCT
TEV-TROPIN1,SP
THALOMID1,SP
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS - Miscellaneous Drugs
theophylline/anhydrous
RESPIRATORY MEDICATIONS - Methyl Xanthine Drugs
thioridazine hcl
thiothixene
tiagabine hcl
TIKOSYN
timolol maleate
timolol maleate
TIMOPTIC OCUDOSE
tinidazole
tizanidine hcl
TOBI1,SP
TOBRADEX/ST
tobramycin
61
DRUG/PRODUCT NAME
tobramycin sulfate
inhalation1,SP
CLASS
tobramycin-dexamethasone
tolterodine tartrate
TOPAMAX2
topiramate
TOPROL XL
torsemide
TOVIAZ
TRACLEER1,SP
TRADJENTA2
TRAMADOL HCL/ER
tramadol hcl/ir
tramadol hcl-acetaminophen
trandolapril
tranexamic acid
TRANSDERM-SCOP
tranylcypromine sulfate
AUTONOMIC & CNS MEDICATIONS - MAO Inhibitors
TRAVATAN Z
travoprost
trazodone hcl
tretinoin
tretinoin
TRETINOIN
MICROSPHERE2
TREXIMET2,3
triamcinolone acetonide
triamterene-hctz
triazolam
TRIBENZOR
TRICOR2
trifluoperazine hcl
trifluridine
TRIGLIDE2
trihexyphenidyl hcl
TRILIPIX2
trilyte with flavor packets
trimethoprim
TROSPIUM CHLORIDE
TRUEPLUS LANCETS
TRUETEST TEST STRIPS
TRUETRACK TEST STRIPS
TRUVADA
TUDORZA PRESSAIR
TUSSICAPS
62
DRUG/PRODUCT NAME
CLASS
TUSSIONEX
TWYNSTA
TYKERB1,SP
ULESFIA
ULORIC2
ULTRA COMFORT
ULTRAVATE PAC
ULTRESA
UROXATRAL
ursodiol
VAGIFEM
VALACYCLOVIR HCL
VALCYTE1
valproic acid
valsartan
valsartan-hctz
VALTREX
VANCOCIN HCL
vancomycin hcl
vandazole
VASCEPA1
VECTICAL
VELTIN2
VENLAFAXINE HCL ER TABS2,3
venlafaxine
hcl3
VENTOLIN HFA
VERAMYST2,3
verapamil/er/pm
VEREGEN
veripred 20
VESICARE2
VEXOL
VGO 20/30/40
VICTOZA2,3
VICTRELIS1,SP
VIGAMOX
VIIBRYD3
VIMOVO2
VIMPAT1
VIRAMUNE
VIRAMUNE XR
VIREAD
VIVELLE-DOT
VOLTAREN
voriconazole
gel2
63
DRUG/PRODUCT NAME
CLASS
VOTRIENT1,SP
VYTORIN2
VYVANSE2
warfarin sodium
WELCHOL2
WELLBUTRIN
XL2,3
westhroid
XALATAN
XARELTO1
XELJANZ1,3,SP
XELODA1,SP
XENAZINE1,SP
XERESE
XIFAXAN1
XOPENEX HFA
XOPENEX/CONCENTRATE
XTANDI1,SP
XYZAL
YASMIN 28
YAZ
zafirlukast
zaleplon3
zamicet
ZEGERID2
ZEMPLAR
zenatane2
ZENPEP1
ZETIA
ZETONNA2,3
ZIAGEN TABLET
ZIANA2
zidovudine
ZIOPTAN
ZIPRASIDONE HCL
ZIRGAN
zolmitriptan
ZOLMITRIPTAN/ODT3
zolpidem
tartrate/er3
ZOLPIMIST3
ZOMIG/ZMT2,3
ZONEGRAN1
zonisamide
ZOVIRAX
ZUBSOLV1
ZUPLENZ3
64
DRUG/PRODUCT NAME
CLASS
ZUTRIPRO
ZYCLARA2
ZYFLO/CR2
ZYLET
ZYMAXID
ZYPREXA/ZYDIS
ZYVOX1
65
66
PO Box 2328 – Oklahoma City, OK 73101-2328
MDF15 Lists Updated 10/2015
MDF15

2015 Drug Formulary

Transcription

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