FL PDL COVER SHEET 2015 - Florida | WellCareduratuss dm elixir su-tuss dm elixir simuc-dm elixir mucus relief cough liquid diabetic tussin dm liquid guaifenesin dm syrup q-tussin-dm

2015 Florida Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

WellCare of Florida 00 Please read: This document contains information about the drugs we cover in this plan. Please note that the Florida Medicaid Preferred Drug List is updated quarterly. Providers, please visit our website at https://florida.wellcare.com/provider/pharmacy to view updates to the preferred drug list. Members, please visit our website at https://florida.wellcare.com/member/default to view updates to the preferred drug list. Last updated (4/01/2015)

Florida Medicaid Cough & Cold Drug List

PLEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger.

Last updated 07/31/14 Page 1 of 2

Non-Preferred Drugs Preferred Drugs

ANTITUSSIVES,NON-NARCOTIC Benzonatate

TESSALON 200 MG CAPSULE BENZONATATE 100 MG CAPSULE BENZONATATE 200 MG CAPSULE

Dextromethorphan PolistirexDELSYM 30 MG/5 ML EXTENDED-RELEASE SUSPENSION

Dextromethorphan HBrROBITUSSIN PEDIATRIC COUGH SYP

Dextromethorphan HBr/MentholDELSYM COUGH RELIEF PLUS LOZENGE

NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTBrompheniramine/Dextromethorphan HBr/Pseudoephedrine HCl

ALLANHIST PDX DROPS BROMHIST PDX DROPS

BROMFED DM SYRUP ENDACOF-PD DROPS

BROTAPP DM LIQUID Q-TAPP DM ELIXIR

Brophenaramine/Dextromethorphan HBr/Phenylephrine HCl

COLD/COUGH CHILDRENS ELIXIR

RYNEX DM DIMAPHEN DM ELIXIR

Chlorpheniramine/Dextromethorphan HBr/Phenylephrine HClC-PHEN DM RONDEX-DM SYRUP

PD-COF SYRUP SILDEC PE-DM SYRUP

DE-CHLOR DM LIQUID NOHIST-DM

CORFEN DM TRI-DEX PE

Chlorpheniramine/Dextromethorphan HBr/Pseudoephedrine HCl

PEDIATRIC COUGH-COLD LIQUID MESEHIST DM

KIDKARE COUGH/COLD Dexchlorpheniramine/Pseudoephedrine HCl/Chlophedianol HCl

VANACOF LIQUID

Chlorpheniramine/Dextromethorphan HBr DIMETAPP LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID

Promethazine HCl/Dextromethorphan HBr PROMETHAZINE-DM SYRUP

NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATIONDextromethorphan HBr/Acetaminophen/Doxylamine

DELSYM NIGHTTIME MULTI-SYMPTOM

EXPECTORANTSDECONGESTANT-EXPECTORANT COMBINATIONS

Guaifenesin/Phenylephrine HClDONATUSSIN DROPS PE-GUAI DROPS DESPEC LIQUID RESCON-GG LIQUID

NON-NARCOTIC DECONGESTANT-EXPECTORANT-ANTITUSSIVEGuaifenesin/Dextromethorphan HBr/Phenylephreine

ROBAFEN CF SYRUP

Florida Medicaid Cough & Cold Drug List

PLEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger.

Last updated 07/31/14 Page 2 of 2

Non-Preferred Drugs Preferred Drugs

NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB.Dextromethorphan HBr/Guaifenesin

DURATUSS DM ELIXIR SU-TUSS DM ELIXIR

SIMUC-DM ELIXIR MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID

GUAIFENESIN DM SYRUP Q-TUSSIN-DM SYRUP EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRUP REFENESEN DM SILTUSSIN DM DAS COUGH SYRUP MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID

NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINEChlorpheniramine/Hydrocodone Polistirex

TUSSIONEX PENNKINETIC SUSP TUSSICAPS (min. age 6 years old) HYDROCODONE-CHLORPHENIRAMINE SUSPENSION (min. age 6 years old)

Codeine Phosphate/Promethazine HCl PROMETHAZINE-CODEINE SYRUP (min. age 6 years old)

NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANTDexbrompheniramine/Hydrocodone Bit/Phenylephrine HCl Codeine/Phenylephrine HCl/Promethazine

CYTUSS-HC NR SYRUP HC/PE/DBROM SYRUP

HC 2.5-PE 5-DBROM 1 MG SYRUP PROMETH VC W/COD SYRUP PROMETHAZINE VC/COD SYRUP

Pseudoephedrine HCl/Codeine/Chlorpheniramine PHENYLHISTINE DH

NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONHydrocodone Bit/Homatropine

HYDROMET SYRUP HYDROCODONE-HOMATROPINE

NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATIONGuaifenesin/Hydrocodone Bit Codeine Phosphate/Guaifenesin

HYDROCODONE-GUAIFENESIN SYRUP

NARCOF SYRUP TUSSICLEAR DH SYRUP CHERATUSSIN AC SYRUP

GUAIFENESIN-CODEINE SYRUP IOPHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS

Codeine Phosphate/Guaifenesin/Pseudoephedrine HClCHERATUSSIN DAC SYRUP

Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the PA process.

This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit.

Drug Name Preference Details Coverage Details*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

*Amphetamines**-*Amphetamine Mixtures***

amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

PQL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years)

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg

P

amphetamine-dextroamphetamine oral tablet 20 mg

P QL (93 EA per 31 days)

amphetamine-dextroamphetamine oral tablet 30 mg


*Amphetamines**-*Amphetamines***

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

P

ST; Notes (Must fail preferred Vyvanse or Amphetamine-dextroamphetamine ER capsules within the past 100 days.); QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years)

dextroamphetamine sulfate oral tablet 10 mg, 5 mg

P

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG


*Stimulants - Misc.**-*Stimulants - Misc.***

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg

PQL (62 EA per 31 days); AL (Min 6 Years)

METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG

P AL (Min 6 Years)

methylphenidate hcl er oral tablet extendedrelease* 10 mg

P AL (Min 6 Years)

P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs

1

Drug Name Preference Details Coverage Detailsmethylphenidate hcl er oral tablet extendedrelease* 18 mg, 27 mg, 36 mg






methylphenidate hcl oral tablet 10 mg, 5 mg P AL (Min 6 Years)

methylphenidate hcl oral tablet 20 mg PQL (93 EA per 31 Days); AL (Min 6 Years)

*Alternative Medicines*

*Alternative Medicine - M's**-*Alternative Medicine - Me's***

melatonin maximum strength oral tablet 5 mg P OTC

melatonin oral tablet 5 mg P OTC

*Aminoglycosides*

*Aminoglycosides**-*Aminoglycosides***

BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML

P PA

*Analgesics - Anti-Inflammatory*

*Anti-Tnf-Alpha - Monoclonal Antibodies**-*Anti-Tnf-Alpha - Monoclonal Antibodies***

HUMIRA PEN SUBCUTANEOUS* KIT 40 MG/0.8ML

P PA

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML

P PA

HUMIRA SUBCUTANEOUS* 10 MG/0.2ML P PA

HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML

P PA

SIMPONI SUBCUTANEOUS* 100 MG/ML, 50 MG/0.5ML

P PA

*Gold Compounds**-*Gold Compounds***

RIDAURA ORAL CAPSULE 3 MG P

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors***

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

P

ST; Notes (Must fail preferred meloxicam and one other generic PDL NSAID within the past 100 days); QL (31 EA per 31 days)

P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs2

Drug Name Preference Details Coverage Details*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)***

childrens ibuprofen oral suspension 40 mg/ml P OTC

diclofenac potassium oral tablet 50 mg P

diclofenac sodium er oral tablet extended release 24 hr* 100 mg

P

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

P

etodolac oral capsule 200 mg, 300 mg P

etodolac oral tablet 400 mg, 500 mg P

fenoprofen calcium oral tablet 600 mg P

flurbiprofen oral tablet 100 mg, 50 mg P

ibuprofen oral suspension 100 mg/5ml P OTC

ibuprofen oral tablet 200 mg P OTC

ibuprofen oral tablet 400 mg, 600 mg, 800 mg P

indomethacin oral capsule 25 mg, 50 mg P

ketoprofen oral capsule 50 mg, 75 mg P

ketorolac tromethamine oral tablet 10 mg PNotes (Maximum of a 5 day supply per Rx per month); QL (20 EA per 31 days)

meloxicam oral tablet 15 mg, 7.5 mg P

nabumetone oral tablet 500 mg, 750 mg P

naproxen dr oral tablet delayed release 500 mg P

naproxen oral suspension 125 mg/5ml P QL (2000 ML per 31 days)

naproxen oral tablet 250 mg, 375 mg, 500 mg P

naproxen sodium oral tablet 275 mg, 550 mg P

oxaprozin oral tablet 600 mg P

piroxicam oral capsule 10 mg, 20 mg P

sulindac oral tablet 150 mg, 200 mg P

tolmetin sodium oral capsule 400 mg P

*Pyrimidine Synthesis Inhibitors**-*Pyrimidine Synthesis Inhibitors***

leflunomide oral tablet 10 mg, 20 mg P


3

Drug Name Preference Details Coverage Details*Analgesics - Nonnarcotic*

*Analgesic Combinations**-*Analgesics-Sedatives***

butalbital-acetaminophen oral tablet 50-325 mg P QL (186 EA per 31 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg


butalbital-apap-caffeine oral tablet 50-325-40 mg P QL (186 EA per 31 days)

butalbital-asa-caffeine oral capsule 50-325-40 mg

P

*Analgesics Other**-*Analgesics Other***

acetaminophen oral solution 160 mg/5ml P OTC

acetaminophen oral tablet 325 mg P OTC; QL (279 EA per 31 days)

acetaminophen oral tablet 500 mg P OTC; QL (186 EA per 31 days)

mapap oral liquid† 160 mg/5ml P OTC

pain & fever childrens oral solution 160 mg/5ml P OTC

pain & fever childrens oral suspension 160 mg/5ml

P OTC

*Salicylates**-*Salicylates***

aspirin adult low strength oral tablet delayed release 81 mg

P OTC

aspirin ec oral tablet delayed release 325 mg P OTC

aspirin oral tablet 325 mg P OTC

aspirin oral tablet chewable 81 mg P OTC

aspirin suppository 600 mg P OTC

diflunisal oral tablet 500 mg P

eq aspirin low dose oral tablet delayed release 81 mg

P OTC

salsalate oral tablet 500 mg, 750 mg P

*Analgesics - Opioid*

*Opioid Agonists**-*Opioid Agonists***

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg P QL (248 EA per 31 days)

fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

P PA; QL (10 EA per 30 days)

hydromorphone hcl oral liquid† 1 mg/ml P

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg P QL (248 EA per 31 days)

hydromorphone hcl suppository 3 mg P

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml P

methadone hcl oral tablet 10 mg, 5 mg P QL (248 EA per 31 days)


Drug Name Preference Details Coverage Detailsmorphine sulfate (concentrate) oral solution 20 mg/ml

P

morphine sulfate (pf) injection solution 0.5 mg/ml P

morphine sulfate (pf) intravenous* solution 2 mg/ml, 4 mg/ml, 8 mg/ml

P

morphine sulfate er oral tablet extendedrelease*100 mg, 15 mg, 200 mg, 30 mg, 60 mg


morphine sulfate injection solution 10 mg/ml, 15 mg/ml, 5 mg/ml, 8 mg/ml

P

morphine sulfate intravenous* solution 1 mg/ml, 25 mg/ml, 50 mg/ml

P

morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml

P

morphine sulfate oral tablet 15 mg, 30 mg P QL (248 EA per 31 days)

morphine sulfate suppository 10 mg, 20 mg, 30 mg, 5 mg

P

oxycodone hcl oral capsule 5 mg P QL (248 EA per 31 days)

oxycodone hcl oral solution 5 mg/5ml P

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg


tramadol hcl oral tablet 50 mg P QL (248 EA per 31 days)

*Opioid Combinations**-*Codeine Combinations***

acetaminophen-codeine #2 oral tablet 300-15 mg P QL (248 EA per 31 days)



acetaminophen-codeine oral solution 120-12 mg/5ml

P

ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG


butalbital-apap-caff-cod oral capsule50-325-40-30 mg


butalbital-asa-caff-codeine oral capsule50-325-40-30 mg


*Opioid Combinations**-*Hydrocodone Combinations***

hydrocodone-acetaminophen oral solution7.5-325 mg/15ml

P QL (3720 ML per 31 days)

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg



5

Drug Name Preference Details Coverage Detailshydrocodone-ibuprofen oral tablet 7.5-200 mg P QL (155 EA per 31 days)

*Opioid Combinations**-*Opioid Combinations***

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG


oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg


oxycodone-aspirin oral tablet 4.8355-325 mg P QL (186 EA per 31 days)

ROXICET ORAL TABLET 5-325 MG P QL (248 EA per 31 days)

*Opioid Partial Agonists**-*Opioid Partial Agonists***

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg

P PA

butorphanol tartrate nasal solution 10 mg/ml P QL (2.5 ML per 31 days)

pentazocine-naloxone hcl oral tablet 50-0.5 mg P

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG, 8.6-2.1 MG

P PA

*Androgens-Anabolic*

*Anabolic Steroids**-*Anabolic Steroids***

oxandrolone oral tablet 10 mg, 2.5 mg P PA

*Androgens**-*Androgens***

danazol oral capsule 100 mg, 200 mg, 50 mg P

methitest oral tablet 10 mg P

TESTIM TRANSDERMAL 50 MG/5GM P PA

testosterone cypionate intramuscular* solution100 mg/ml, 200 mg/ml

P

testosterone enanthate intramuscular* solution200 mg/ml

P

testosterone transdermal 12.5 mg/act (1%), 50 mg/5gm

P PA

*Anorectal Agents*

*Intrarectal Steroids**-*Intrarectal Steroids***

hydrocortisone enema 100 mg/60ml P

*Rectal Steroids**-*Rectal Steroids***

PROCTOSOL HC CREAM 2.5 % P

PROCTOZONE-HC CREAM 2.5 % P


Drug Name Preference Details Coverage Details*Antacids*

*Antacid Combinations**-*Antacid & Simethicone***

aluminum-magnesium-simethicone oral suspension 200-200-20 mg/5ml

P OTC

MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION 400-400-40 MG/5ML

P OTC

*Antacids - Aluminum Salts**-*Antacids - Aluminum Salts***

aluminum hydroxide gel oral suspension 320 mg/5ml

P OTC

*Antacids - Bicarbonate**-*Antacids - Bicarbonate***

sodium bicarbonate oral tablet 325 mg, 650 mg P OTC

*Antacids - Calcium Salts**-*Antacids - Calcium Salts***

calcium carbonate antacid oral tablet chewable500 mg

P OTC

*Antacids - Magnesium Salts**-*Antacids - Magnesium Salts***

magnesium oxide oral tablet 250 mg, 400 mg, 420 mg

P OTC

*Anthelmintics*

*Anthelmintics**-*Anthelmintics***

ALBENZA ORAL TABLET 200 MG P PA

BILTRICIDE ORAL TABLET 600 MG P PA

ivermectin oral tablet 3 mg P QL (10 EA per 31 days)

PIN-X ORAL SUSPENSION 50 MG/ML P OTC

reeses pinworm medicine oral suspension 144 mg/ml

P OTC

*Antianginal Agents*

*Nitrates**-*Nitrates***

isosorbide dinitrate er oral tablet extendedrelease* 40 mg

P

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

P

isosorbide mononitrate er oral tablet extended release 24 hr* 120 mg, 30 mg, 60 mg

P

isosorbide mononitrate oral tablet 10 mg, 20 mg P


7

Drug Name Preference Details Coverage DetailsNITRO-BID TRANSDERMAL OINTMENT 2 % P

nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

P

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG

P

*Antianxiety Agents*

*Antianxiety Agents - Misc.**-*Antianxiety Agents - Misc.***

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

P

hydroxyzine hcl oral solution 10 mg/5ml P QL (450 ML per 31 days)

hydroxyzine hcl oral syrup 10 mg/5ml P QL (450 ML per 31 days)

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg P

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

P

meprobamate oral tablet 200 mg, 400 mg P

*Benzodiazepines**-*Benzodiazepines***

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

P

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

P

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

P AL (Min 9 Years)

diazepam injection solution 5 mg/ml P

diazepam oral solution 1 mg/ml P QL (1240 ML per 31 days)

diazepam oral tablet 10 mg, 2 mg, 5 mg P

lorazepam injection solution 2 mg/ml, 4 mg/ml P

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg P

oxazepam oral capsule 10 mg, 15 mg, 30 mg P

*Antiarrhythmics*

*Antiarrhythmics Type I-A**-*Antiarrhythmics Type I-A***

disopyramide phosphate oral capsule 100 mg, 150 mg

P

procainamide hcl injection solution 100 mg/ml, 500 mg/ml

P

quinidine gluconate er oral tablet extendedrelease* 324 mg

P

quinidine gluconate injection solution 80 mg/ml P


Drug Name Preference Details Coverage Detailsquinidine sulfate oral tablet 300 mg P

*Antiarrhythmics Type I-B**-*Antiarrhythmics Type I-B***

lidocaine hcl (cardiac) intravenous* solution 20 mg/ml

P

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

P

*Antiarrhythmics Type I-C**-*Antiarrhythmics Type I-C***

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

P

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

P

*Antiarrhythmics Type Iii**-*Antiarrhythmics Type Iii***

amiodarone hcl intravenous* solution 150 mg/3ml

P

amiodarone hcl oral tablet 200 mg, 400 mg P

PACERONE ORAL TABLET 200 MG, 400 MG P

*Antiasthmatic And Bronchodilator Agents*

*Antiasthmatic - Monoclonal Antibodies**-*Anti-Ige Monoclonal Antibodies***

XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG

P PA

*Anti-Inflammatory Agents**-*Anti-Inflammatory Agents***

cromolyn sodium inhalation nebulization solution20 mg/2ml

P

*Bronchodilators - Anticholinergics**-*Bronchodilators - Anticholinergics***

ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT

P QL (25.8 GM per 31 days)

ipratropium bromide inhalation solution 0.02 % P QL (480 ML per 31 days)

TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT



9

Drug Name Preference Details Coverage Details*Leukotriene Modulators**-*Leukotriene Receptor Antagonists***

montelukast sodium oral packet 4 mg PAL (Min 1 Months and Max 2 Years)

montelukast sodium oral tablet 10 mg P

montelukast sodium oral tablet chewable 4 mg, 5 mg

P

zafirlukast oral tablet 10 mg, 20 mg P

*Steroid Inhalants**-*Steroid Inhalants***

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH


ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH


ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH


ASMANEX HFA INHALATION AEROSOL† 100 MCG/ACT, 200 MCG/ACT

P

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml

PQL (120 ML per 31 days); AL (Max 8 Years)

FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT, 220 MCG/ACT

P QL (12 GM per 30 days)

FLOVENT HFA INHALATION AEROSOL† 44 MCG/ACT


PULMICORT INHALATION SUSPENSION 1 MG/2ML


*Sympathomimetics**-*Adrenergic Combinations***

ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT


COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT



Drug Name Preference Details Coverage DetailsDULERA INHALATION AEROSOL† 100-5 MCG/ACT, 200-5 MCG/ACT


ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml


SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT, 80-4.5 MCG/ACT


*Sympathomimetics**-*Beta Adrenergics***

albuterol sulfate inhalation nebulization solution(2.5 mg/3ml) 0.083%


albuterol sulfate inhalation nebulization solution(5 mg/ml) 0.5%


albuterol sulfate inhalation nebulization solution0.63 mg/3ml, 1.25 mg/3ml


albuterol sulfate oral syrup 2 mg/5ml P QL (2480 ML per 31 days)

albuterol sulfate oral tablet 2 mg, 4 mg P

FORADIL AEROLIZER INHALATION CAPSULE 12 MCG


metaproterenol sulfate oral syrup 10 mg/5ml P

SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE


terbutaline sulfate injection solution 1 mg/ml P

terbutaline sulfate oral tablet 2.5 mg, 5 mg P

VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT


*Xanthines**-*Xanthines***

aminophylline intravenous* solution 25 mg/ml P

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML P

theophylline er oral tablet extended release 12 hr* 100 mg, 200 mg, 300 mg, 450 mg

P

theophylline er oral tablet extended release 24 hr* 400 mg, 600 mg

P

theophylline oral solution 80 mg/15ml P

*Anticoagulants*

*Coumarin Anticoagulants**-*Coumarin Anticoagulants***

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

P


11

Drug Name Preference Details Coverage Detailswarfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

P

*Direct Factor Xa Inhibitors**-*Direct Factor Xa Inhibitors***

XARELTO ORAL TABLET 10 MG P QL (35 EA per 365 days)

*Heparins And Heparinoid-Like Agents**-*Low Molecular Weight Heparins***

enoxaparin sodium injection solution 300 mg/3ml P QL (24 ML per 31 days)

enoxaparin sodium subcutaneous* solution 100 mg/ml, 150 mg/ml


enoxaparin sodium subcutaneous* solution 120 mg/0.8ml, 80 mg/0.8ml

P QL (22.4 ML per 31 days)

enoxaparin sodium subcutaneous* solution 30 mg/0.3ml, 40 mg/0.4ml


enoxaparin sodium subcutaneous* solution 60 mg/0.6ml


*Heparins And Heparinoid-Like Agents**-*Synthetic Heparinoid-Like Agents***

fondaparinux sodium subcutaneous* solution 10 mg/0.8ml


fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml


fondaparinux sodium subcutaneous* solution 5 mg/0.4ml


fondaparinux sodium subcutaneous* solution 7.5 mg/0.6ml


*Anticonvulsants*

*Anticonvulsants - Benzodiazepines**-*Anticonvulsants - Benzodiazepines***

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg P

diazepam 10 mg, 2.5 mg, 20 mg P QL (3 EA per 31 days)

*Anticonvulsants - Misc.**-*Anticonvulsants - Misc.***

carbamazepine oral suspension 100 mg/5ml P QL (2480 ML per 31 days)

carbamazepine oral tablet 200 mg P QL (248 EA per 31 days)

carbamazepine oral tablet chewable 100 mg P QL (310 EA per 31 days)

EPITOL ORAL TABLET 200 MG P QL (248 EA per 31 days)


Drug Name Preference Details Coverage Detailsgabapentin oral capsule 100 mg P QL (310 EA per 31 days)

gabapentin oral capsule 300 mg P QL (372 EA per 31 days)

gabapentin oral capsule 400 mg P QL (279 EA per 31 days)

gabapentin oral solution 250 mg/5ml P QL (2230 ML per 31 days)

gabapentin oral tablet 600 mg, 800 mg P

lamotrigine oral tablet 100 mg, 150 mg, 200 mg P

lamotrigine oral tablet 25 mg P QL (310 EA per 31 days)

lamotrigine oral tablet chewable 25 mg, 5 mg P QL (310 EA per 31 days)

levetiracetam intravenous* solution 500 mg/5ml P

levetiracetam oral solution 100 mg/ml P QL (1000 ML per 31 days)

levetiracetam oral tablet 1000 mg, 500 mg, 750 mg

P

levetiracetam oral tablet 250 mg P QL (372 EA per 31 days)

oxcarbazepine oral suspension 300 mg/5ml P QL (1240 ML per 31 days)

oxcarbazepine oral tablet 150 mg P QL (310 EA per 31 days)

oxcarbazepine oral tablet 300 mg P QL (248 EA per 31 days)

oxcarbazepine oral tablet 600 mg P

primidone oral tablet 250 mg P QL (248 EA per 31 days)

primidone oral tablet 50 mg P QL (310 EA per 31 days)

topiramate oral capsule sprinkle 15 mg, 25 mg P QL (310 EA per 31 days)

topiramate oral tablet 100 mg, 25 mg, 50 mg P QL (310 EA per 31 days)

topiramate oral tablet 200 mg P QL (248 EA per 31 days)

zonisamide oral capsule 100 mg P QL (186 EA per 31 days)



*Gaba Modulators**-*Gaba Modulators***

GABITRIL ORAL TABLET 12 MG, 16 MG P

tiagabine hcl oral tablet 2 mg, 4 mg P

*Hydantoins**-*Hydantoins***

DILANTIN ORAL CAPSULE 30 MG P QL (310 EA per 31 days)

fosphenytoin sodium injection solution 100 mg pe/2ml

P

PEGANONE ORAL TABLET 250 MG P QL (372 EA per 31 days)

phenytoin oral suspension 125 mg/5ml P QL (930 ML per 31 days)

phenytoin oral tablet chewable 50 mg P QL (372 EA per 31 days)

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

P


13

Drug Name Preference Details Coverage Detailsphenytoin sodium injection solution 50 mg/ml P

*Succinimides**-*Succinimides***

ethosuximide oral capsule 250 mg P

ethosuximide oral solution 250 mg/5ml P QL (930 ML per 31 days)

*Valproic Acid**-*Valproic Acid***

divalproex sodium er oral tablet extended release 24 hr* 250 mg


divalproex sodium er oral tablet extended release 24 hr* 500 mg


divalproex sodium oral capsule sprinkle 125 mg P QL (310 EA per 31 days)

divalproex sodium oral tablet delayed release 125 mg, 250 mg


divalproex sodium oral tablet delayed release 500 mg


valproic acid oral capsule 250 mg P QL (310 EA per 31 days)

valproic acid oral solution 250 mg/5ml P QL (2790 ML per 31 days)

valproic acid oral syrup 250 mg/5ml P QL (2790 ML per 31 days)

*Antidepressants*

*Alpha-2 Receptor Antagonists (Tetracyclics)**-*Alpha-2 Receptor Antagonists (Tetracyclics)***

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

P

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg

P

*Antidepressants - Misc.**-*Antidepressants - Misc.***

bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 150 mg, 200 mg

P

bupropion hcl er (xl) oral tablet extended release 24 hr* 150 mg, 300 mg

P

bupropion hcl oral tablet 100 mg, 75 mg P

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg P

*Monoamine Oxidase Inhibitors (Maois)**-*Monoamine Oxidase Inhibitors (Maois)***

phenelzine sulfate oral tablet 15 mg P

tranylcypromine sulfate oral tablet 10 mg P


Drug Name Preference Details Coverage Details*Selective Serotonin Reuptake Inhibitors (Ssris)**-*Selective Serotonin Reuptake Inhibitors (Ssris)***

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

P

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

P

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg P

fluoxetine hcl oral solution 20 mg/5ml P

fluoxetine hcl oral tablet 10 mg, 20 mg P

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg

P

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

P

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg P

*Serotonin Modulators**-*Serotonin Modulators***

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

P

trazodone hcl oral tablet 100 mg, 150 mg, 50 mg P

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**-*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)***

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg


venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

P

*Tricyclic Agents**-*Tricyclic Agents***

amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

P

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg

P

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg

P

desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

P

doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

P

doxepin hcl oral concentrate 10 mg/ml P


15

Drug Name Preference Details Coverage Detailsimipramine hcl oral tablet 10 mg, 25 mg, 50 mg P

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

P

nortriptyline hcl oral solution 10 mg/5ml P QL (2325 ML per 31 days)

protriptyline hcl oral tablet 10 mg, 5 mg P

*Antidiabetics*

*Alpha-Glucosidase Inhibitors**-*Alpha-Glucosidase Inhibitors***

acarbose oral tablet 100 mg, 25 mg, 50 mg P

*Antidiabetic Combinations**-*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations***

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG

PST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-1000 MG, 50-500 MG


JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG

P

ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (62 EA per 31 days)

*Antidiabetic Combinations**-*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb***

INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG

PST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days. )

*Antidiabetic Combinations**-*Sulfonylurea-Biguanide Combinations***

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

P

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

P


Drug Name Preference Details Coverage Details*Antidiabetic Combinations**-*Sulfonylurea-Thiazolidinedione Combinations***

AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 8-4 MG


*Antidiabetic Combinations**-*Thiazolidinedione-Biguanide Combinations***

AVANDAMET ORAL TABLET 2-1000 MG, 4-500 MG


pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg


*Biguanides**-*Biguanides***

metformin hcl er (osm) oral tablet extended release 24 hr* 500 mg

P

metformin hcl er oral tablet extended release 24 hr* 500 mg, 750 mg

P

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

P

RIOMET ORAL SOLUTION 500 MG/5ML P QL (900 ML per 31 days)

*Diabetic Other**-*Diabetic Other***

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG


GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 MG


GLUCAGON EMERGENCY INJECTION KIT 1 MG


glucose oral tablet chewable 4 gm P OTC

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors**-*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


TRADJENTA ORAL TABLET 5 MG P

ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (31 EA per 31 Days)


17

Drug Name Preference Details Coverage Details*Incretin Mimetic Agents (Glp-1 Receptor Agonists)**-*Incretin Mimetic Agents (Glp-1 Receptor Agonists)***

BYDUREON SUBCUTANEOUS* 2 MG PST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days)

BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED 2 MG

PST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days)

*Insulin Sensitizing Agents**-*Thiazolidinediones***

AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG PST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg PST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)

*Insulin**-*Human Insulin***

APIDRA INJECTION SOLUTION 100 UNIT/ML


APIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML


HUMALOG KWIKPEN SUBCUTANEOUS* 100 UNIT/ML


HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML


HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* (75-25) 100 UNIT/ML


HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML


HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML


HUMULIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML

P OTC; QL (60 ML per 31 days)

humulin n kwikpen subcutaneous* 100 unit/ml P QL (60 ML per 31 days)

HUMULIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML


HUMULIN R INJECTION SOLUTION 100 UNIT/ML


HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML



Drug Name Preference Details Coverage DetailsLANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML


LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML


*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors**-*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors***

INVOKANA ORAL TABLET 100 MG, 300 MG PST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days. )

JARDIANCE ORAL TABLET 10 MG, 25 MG PST; Notes ( Must fail preferred metformin, metformin er, or riomet within the past 100 days. )

*Sulfonylureas**-*Sulfonylureas***

chlorpropamide oral tablet 100 mg, 250 mg P

glimepiride oral tablet 1 mg, 2 mg, 4 mg P

glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg

P

glipizide oral tablet 10 mg, 5 mg P

GLIPIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG

P

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

P

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg P

*Antidiarrheals*

*Antiperistaltic Agents**-*Antiperistaltic Agents***

diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml

P

diphenoxylate-atropine oral tablet 2.5-0.025 mg P

LOPERAMIDE A-D ORAL TABLET 2 MG P OTC

loperamide hcl oral capsule 2 mg P

*Antidotes*

*Antidotes - Chelating Agents**-*Antidotes - Chelating Agents***

EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG

P PA

*Antidotes**-*Antidotes***

deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg

P


19

Drug Name Preference Details Coverage Details*Opioid Antagonists**-*Opioid Antagonists***

naltrexone hcl oral tablet 50 mg P

*Antiemetics*

*5-Ht3 Receptor Antagonists**-*5-Ht3 Receptor Antagonists***

ondansetron hcl oral solution 4 mg/5ml P

ondansetron hcl oral tablet 4 mg, 8 mg P

ondansetron oral tablet dispersible 4 mg, 8 mg P

*Antiemetics - Anticholinergic**-*Antiemetics - Anticholinergic***

meclizine hcl oral tablet 12.5 mg, 25 mg P OTC

meclizine hcl oral tablet chewable 25 mg P OTC

travel sickness oral tablet chewable 25 mg P OTC

*Antifungals*

*Antifungals**-*Antifungals***

griseofulvin microsize oral suspension 125 mg/5ml


griseofulvin microsize oral tablet 500 mg P

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

P

nystatin oral tablet 500000 unit P

terbinafine hcl oral tablet 250 mg P

*Imidazole-Related Antifungals**-*Imidazoles***

ketoconazole oral tablet 200 mg P

*Imidazole-Related Antifungals**-*Triazoles***

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

P

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

P

*Antihistamines*

*Antihistamines - Alkylamines**-*Antihistamines - Alkylamines***

allergy oral tablet 4 mg P OTC


Drug Name Preference Details Coverage Details*Antihistamines - Ethanolamines**-*Antihistamines - Ethanolamines***

aler-dryl oral tablet 50 mg P OTC

BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML

P OTC

diphenhydramine hcl oral capsule 25 mg, 50 mg P OTC

diphenhydramine hcl oral tablet 25 mg P OTC

*Antihistamines - Non-Sedating**-*Antihistamines - Non-Sedating***

allergy oral tablet dispersible 10 mg P OTC

cetirizine hcl childrens oral solution 1 mg/ml P OTC; QL (300 ML per 31 days)

cetirizine hcl oral syrup 1 mg/ml, 5 mg/5ml P OTC; QL (300 ML per 31 days)

cetirizine hcl oral tablet 10 mg, 5 mg P OTC

childrens loratadine oral syrup 5 mg/5ml P OTC; QL (310 ML per 31 days)

fexofenadine hcl childrens oral suspension 30 mg/5ml

P OTC

fexofenadine hcl oral tablet 180 mg, 60 mg P OTC

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

PST; Notes (Must fail preferred loratadine solution and cetirizine syrup within the past 100 days)

levocetirizine dihydrochloride oral tablet 5 mg P

loratadine hives relief oral solution 5 mg/5ml P OTC

loratadine oral tablet 10 mg P OTC

*Antihistamines - Phenothiazines**-*Antihistamines - Phenothiazines***

promethazine hcl oral syrup 6.25 mg/5ml P

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

P

promethazine hcl suppository 25 mg, 50 mg P

PROMETHEGAN SUPPOSITORY 12.5 MG, 25 MG

P

*Antihistamines - Piperidines**-*Antihistamines - Piperidines***

cyproheptadine hcl oral syrup 2 mg/5ml P QL (300 ML per 31 days)

cyproheptadine hcl oral tablet 4 mg P


21

Drug Name Preference Details Coverage Details*Antihyperlipidemics*

*Bile Acid Sequestrants**-*Bile Acid Sequestrants***

cholestyramine light oral packet 4 gm P

cholestyramine light oral powder 4 gm/dose P

cholestyramine oral packet 4 gm P

cholestyramine oral powder 4 gm/dose P

*Fibric Acid Derivatives**-*Fibric Acid Derivatives***

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

P

fenofibrate oral tablet 160 mg, 54 mg P

gemfibrozil oral tablet 600 mg P

*Hmg Coa Reductase Inhibitors**-*Hmg Coa Reductase Inhibitors***

atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

P

lovastatin oral tablet 10 mg, 20 mg, 40 mg P

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

P

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

P

*Intestinal Cholesterol Absorption Inhibitors**-*Intestinal Cholesterol Absorption Inhibitors***

ZETIA ORAL TABLET 10 MG P PA

*Nicotinic Acid Derivatives**-*Nicotinic Acid Derivatives***

NIACOR ORAL TABLET 500 MG P

*Antihypertensives*

*Ace Inhibitors**-*Ace Inhibitors***

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

P

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

P

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

P

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg P


Drug Name Preference Details Coverage Detailslisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

P

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

P

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

P

*Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists***

losartan potassium oral tablet 100 mg, 25 mg, 50 mg


*Antiadrenergic Antihypertensives**-*Antiadrenergics - Centrally Acting***

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg P

guanfacine hcl oral tablet 1 mg, 2 mg P

methyldopa oral tablet 250 mg, 500 mg P

*Antiadrenergic Antihypertensives**-*Antiadrenergics - Peripherally Acting***

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

P

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg P

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

P

*Antihypertensive Combinations**-*Ace Inhibitors & Thiazide/Thiazide-Like***

benazepril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

P

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

P

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

P

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

P

*Antihypertensive Combinations**-*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like***

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg



23

Drug Name Preference Details Coverage Details*Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations***

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

P

bisoprolol-hydrochlorothiazide oral tablet10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

P

propranolol-hctz oral tablet 40-25 mg, 80-25 mg P

*Vasodilators**-*Vasodilators***

hydralazine hcl injection solution 20 mg/ml P

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

P

minoxidil oral tablet 10 mg, 2.5 mg P

*Anti-Infective Agents - Misc.*

*Anti-Infective Agents - Misc.**-*Anti-Infective Agents - Misc.***

metronidazole oral tablet 250 mg, 500 mg P

trimethoprim oral tablet 100 mg P

vancomycin hcl intravenous* solution reconstituted 1000 mg, 500 mg, 750 mg

P

vancomycin hcl oral capsule 125 mg, 250 mg P PA

*Anti-Infective Misc. - Combinations**-*Anti-Infective Misc. - Combinations***

sulfamethoxazole-tmp ds oral tablet 800-160 mg P

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml


sulfamethoxazole-trimethoprim oral tablet 400-80 mg

P

*Antiprotozoal Agents**-*Antiprotozoal Agents***

atovaquone oral suspension 750 mg/5ml P

*Leprostatics**-*Leprostatics***

dapsone oral tablet 100 mg, 25 mg P

*Lincosamides**-*Lincosamides***

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

P

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml



Drug Name Preference Details Coverage Detailsclindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml

P

clindamycin phosphate intravenous* solution 300 mg/2ml

P

*Oxazolidinones**-*Oxazolidinones***

SIVEXTRO ORAL TABLET 200 MG P PA

*Antimalarials*

*Antimalarial Combinations**-*Antimalarial Combinations***

atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

P

*Antimalarials**-*Antimalarials***

DARAPRIM ORAL TABLET 25 MG P

hydroxychloroquine sulfate oral tablet 200 mg P

mefloquine hcl oral tablet 250 mg P

primaquine phosphate oral tablet 26.3 mg P

*Antimyasthenic/Cholinergic Agents*

*Antimyasthenic/Cholinergic Agents**-*Antimyasthenic/Cholinergic Agents***

MESTINON ORAL SYRUP 60 MG/5ML P

MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG

P

pyridostigmine bromide oral tablet 60 mg P

*Antimycobacterial Agents*

*Antimycobacterial Agents**-*Antimycobacterial Agents***

ethambutol hcl oral tablet 100 mg, 400 mg P

isoniazid injection solution 100 mg/ml P

isoniazid oral tablet 100 mg, 300 mg P

pyrazinamide oral tablet 500 mg P

rifabutin oral capsule 150 mg P

rifampin intravenous* solution reconstituted 600 mg

P

rifampin oral capsule 150 mg, 300 mg P

*Antineoplastics And Adjunctive Therapies*

*Alkylating Agents**-*Alkylating Agents***

HEXALEN ORAL CAPSULE 50 MG P PA


25

Drug Name Preference Details Coverage DetailsMYLERAN ORAL TABLET 2 MG P PA

*Alkylating Agents**-*Imidazotetrazines***

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

P PA

*Alkylating Agents**-*Nitrogen Mustards***

ALKERAN ORAL TABLET 2 MG P PA

cyclophosphamide oral capsule 25 mg, 50 mg P PA

LEUKERAN ORAL TABLET 2 MG P PA

*Alkylating Agents**-*Nitrosoureas***

lomustine oral capsule 10 mg, 100 mg, 40 mg P PA

*Antimetabolites**-*Antimetabolites***

ADRUCIL INTRAVENOUS* SOLUTION 500 MG/10ML

P PA

capecitabine oral tablet 150 mg, 500 mg P PA

fluorouracil intravenous* solution 500 mg/10ml P PA

gemcitabine hcl intravenous* solution 1 gm/26.3ml, 2 gm/52.6ml, 200 mg/5.26ml

P PA

gemcitabine hcl intravenous* solution reconstituted 1 gm, 2 gm, 200 mg

P PA

mercaptopurine oral tablet 50 mg P

methotrexate oral tablet 2.5 mg P

methotrexate sodium (pf) injection solution 1 gm/40ml, 25 mg/ml, 250 mg/10ml, 50 mg/2ml

P

methotrexate sodium injection solution 25 mg/ml P

methotrexate sodium injection solution reconstituted 1 gm

P

TABLOID ORAL TABLET 40 MG P PA

*Antineoplastic - Angiogenesis Inhibitors**-*Vascular Endothelial Growth Factor (Vegf) Inhibitors***

AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML

P PA

*Antineoplastic - Hedgehog Pathway Inhibitors**-*Antineoplastic - Hedgehog Pathway Inhibitors***

ERIVEDGE ORAL CAPSULE 150 MG P PA

*Antineoplastic - Hormonal And Related Agents**-*Antiadrenals***

LYSODREN ORAL TABLET 500 MG P PA


Drug Name Preference Details Coverage Details*Antineoplastic - Hormonal And Related Agents**-*Antiandrogens***

XTANDI ORAL CAPSULE 40 MG P PA

*Antineoplastic - Hormonal And Related Agents**-*Antiestrogens***

tamoxifen citrate oral tablet 10 mg, 20 mg P

*Antineoplastic - Hormonal And Related Agents**-*Aromatase Inhibitors***

anastrozole oral tablet 1 mg P

letrozole oral tablet 2.5 mg P

*Antineoplastic - Hormonal And Related Agents**-*Estrogens-Antineoplastic***

EMCYT ORAL CAPSULE 140 MG P PA

*Antineoplastic - Hormonal And Related Agents**-*Lhrh Analogs***

TRELSTAR DEPOT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG

P PA

TRELSTAR DEPOT MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG

P PA

TRELSTAR LA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG

P PA

TRELSTAR LA MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG

P PA

TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 22.5 MG

P PA

*Antineoplastic - Hormonal And Related Agents**-*Progestins-Antineoplastic***

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml


megestrol acetate oral tablet 20 mg, 40 mg P

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Braf Kinase Inhibitors***

ZELBORAF ORAL TABLET 240 MG P PA

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Histone Deacetylase Inhibitors***

ZOLINZA ORAL CAPSULE 100 MG P PA


27

Drug Name Preference Details Coverage Details*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Mtor Kinase Inhibitors***

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG

P PA

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Multikinase Inhibitors***

STIVARGA ORAL TABLET 40 MG P PA

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

P PA

*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Tyrosine Kinase Inhibitors***

BOSULIF ORAL TABLET 100 MG, 500 MG P PA

CAPRELSA ORAL TABLET 100 MG, 300 MG P PA

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG

P PA; QL (31 EA per 31 days)

GLEEVEC ORAL TABLET 100 MG, 400 MG P PA

ICLUSIG ORAL TABLET 15 MG, 45 MG P PA

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

P PA

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

P PA

TASIGNA ORAL CAPSULE 150 MG, 200 MG P PA

TYKERB ORAL TABLET 250 MG P PA

XALKORI ORAL CAPSULE 200 MG, 250 MG P PA

ZYKADIA ORAL CAPSULE 150 MG P PA; QL (155 EA per 31 days)

*Antineoplastic Enzyme Inhibitors**-*Janus Associated Kinase (Jak) Inhibitors***

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

P PA

*Antineoplastic Enzymes**-*Antineoplastic Enzymes***

ERWINAZE INTRAMUSCULAR* SOLUTION RECONSTITUTED 10000 UNIT

P PA

*Antineoplastics Misc.**-*Antineoplastics Misc.***

hydroxyurea oral capsule 500 mg P


Drug Name Preference Details Coverage Details*Chemotherapy Rescue/Antidote Agents**-*Folic Acid Antagonists Rescue Agents***

leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg

P

leucovorin calcium intravenous* solution 10 mg/ml

P

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

P

*Mitotic Inhibitors**-*Mitotic Inhibitors***

etoposide oral capsule 50 mg P PA

*Antiparkinson Agents*

*Antiparkinson Anticholinergics**-*Antiparkinson Anticholinergics***

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

P

trihexyphenidyl hcl oral elixir 0.4 mg/ml P

trihexyphenidyl hcl oral tablet 2 mg, 5 mg P

*Antiparkinson Dopaminergics**-*Antiparkinson Dopaminergics***

amantadine hcl oral capsule 100 mg P

amantadine hcl oral syrup 50 mg/5ml P

amantadine hcl oral tablet 100 mg P

bromocriptine mesylate oral capsule 5 mg P

bromocriptine mesylate oral tablet 2.5 mg P

*Antiparkinson Dopaminergics**-*Levodopa Combinations***

carbidopa-levodopa er oral tablet extendedrelease* 50-200 mg

P

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

P

*Antiparkinson Dopaminergics**-*Nonergoline Dopamine Receptor Agonists***

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

PST; Notes (Must fail preferred ropinirole within the past 100 days.)


29

Drug Name Preference Details Coverage Detailsropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

P

*Antiparkinson Monoamine Oxidase Inhibitors**-*Antiparkinson Monoamine Oxidase Inhibitors***

selegiline hcl oral capsule 5 mg P

selegiline hcl oral tablet 5 mg P

*Antipsychotics/Antimanic Agents*

*Antimanic Agents**-*Antimanic Agents***

lithium carbonate er oral tablet extendedrelease*300 mg, 450 mg

P

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

P

lithium carbonate oral tablet 300 mg P

lithium oral solution 8 meq/5ml P

*Benzisoxazoles**-*Benzisoxazoles***

INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML

PPA; QL (0.75 ML per 28 days); AL (Min 18 Years)

INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 156 MG/ML

PPA; QL (1 ML per 28 days); AL (Min 18 Years)


PPA; QL (1.5 ML per 28 Days); AL (Min 18 Years)





RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG


risperidone oral solution 1 mg/ml PQL (496 ML per 31 days); AL (Min 5 Years)

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg


risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg


*Butyrophenones**-*Butyrophenones***

haloperidol decanoate intramuscular* solution100 mg/ml, 50 mg/ml

P AL (Min 18 Years)

haloperidol lactate injection solution 5 mg/ml P AL (Min 3 Years)

haloperidol lactate oral concentrate 2 mg/ml P AL (Min 3 Years)


Drug Name Preference Details Coverage Detailshaloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 5 mg

P AL (Min 3 Years)

*Dibenzapines**-*Dibenzodiazepines***

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

P AL (Min 18 Years)

clozapine oral tablet dispersible 12.5 mg PQL (31 EA per 31 days); AL (Min 18 Years)

*Dibenzapines**-*Dibenzo-Oxepino Pyrroles***

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG

P

ST; Notes (Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.); AL (Min 18 Years)

*Dibenzapines**-*Dibenzothiazepines***

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

P AL (Min 10 Years)

*Dibenzapines**-*Dibenzoxazepines***

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

P AL (Min 18 Years)

*Dibenzapines**-*Thienbenzodiazepines***

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg


*Phenothiazines**-*Phenothiazines***

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

P AL (Min 6 Months)

fluphenazine decanoate injection solution 25 mg/ml

P AL (Min 12 Years)

fluphenazine hcl oral concentrate 5 mg/ml PQL (248 ML per 31 days); AL (Min 18 Years)

fluphenazine hcl oral elixir 2.5 mg/5ml PQL (2480 ML per 31 days); AL (Min 18 Years)

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

P AL (Min 18 Years)

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg P AL (Min 12 Years)

prochlorperazine maleate oral tablet 10 mg, 5 mg P AL (Min 2 Years)

prochlorperazine suppository 25 mg P AL (Min 2 Years)

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

P AL (Min 2 Years)

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

P AL (Min 6 Years)


31

Drug Name Preference Details Coverage Details*Quinolinone Derivatives**-*Quinolinone Derivatives***

ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG, 400 MG

P PA

ABILIFY ORAL SOLUTION 1 MG/ML P

ST; Notes (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone within the past 100 days.)

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG

P

ST; Notes (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone within the past 100 days.)

*Thioxanthenes**-*Thioxanthenes***

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg P AL (Min 12 Years)

*Antiseptics & Disinfectants*

*Chlorine Antiseptics**-*Chlorine Antiseptics***

chlorhexidine gluconate external liquid† 4 % P OTC; QL (480 ML per 31 days)

*Antivirals*

*Antiretrovirals**-*Antiretroviral Combinations***

abacavir-lamivudine-zidovudine oral tablet300-150-300 mg


ATRIPLA ORAL TABLET 600-200-300 MG P

COMPLERA ORAL TABLET 200-25-300 MG P

EPZICOM ORAL TABLET 600-300 MG P QL (31 EA per 31 days)

KALETRA ORAL SOLUTION 400-100 MG/5ML

P

KALETRA ORAL TABLET 100-25 MG, 200-50 MG

P

lamivudine-zidovudine oral tablet 150-300 mg P

STRIBILD ORAL TABLET 150-150-200-300 MG


TRUVADA ORAL TABLET 200-300 MG P QL (31 EA per 31 days)

*Antiretrovirals**-*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)***

SELZENTRY ORAL TABLET 150 MG, 300 MG

P


Drug Name Preference Details Coverage Details*Antiretrovirals**-*Antiretrovirals - Fusion Inhibitors***

FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG

P

*Antiretrovirals**-*Antiretrovirals - Integrase Inhibitors***

ISENTRESS ORAL PACKET 100 MG P

ISENTRESS ORAL TABLET 400 MG P

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG

P

TIVICAY ORAL TABLET 50 MG P QL (62 EA per 31 days)

*Antiretrovirals**-*Antiretrovirals - Protease Inhibitors***

APTIVUS ORAL CAPSULE 250 MG P

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG P

INVIRASE ORAL CAPSULE 200 MG P

INVIRASE ORAL TABLET 500 MG P

LEXIVA ORAL SUSPENSION 50 MG/ML P

LEXIVA ORAL TABLET 700 MG P QL (124 EA per 31 days)

NORVIR ORAL CAPSULE 100 MG P

NORVIR ORAL SOLUTION 80 MG/ML P

NORVIR ORAL TABLET 100 MG P

PREZISTA ORAL SUSPENSION 100 MG/ML P

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

P

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG


VIRACEPT ORAL TABLET 250 MG, 625 MG P QL (310 EA per 31 days)

*Antiretrovirals**-*Antiretrovirals - Rti-Non-Nucleoside Analogues***

EDURANT ORAL TABLET 25 MG P QL (31 EA per 31 days)

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

P

nevirapine oral suspension 50 mg/5ml P

nevirapine oral tablet 200 mg P

RESCRIPTOR ORAL TABLET 100 MG, 200 MG

P

SUSTIVA ORAL CAPSULE 200 MG, 50 MG P


33

Drug Name Preference Details Coverage DetailsSUSTIVA ORAL TABLET 600 MG P

*Antiretrovirals**-*Antiretrovirals - Rti-Nucleoside Analogues-Purines***

abacavir sulfate oral tablet 300 mg P

didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg

P

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM

P

ZIAGEN ORAL SOLUTION 20 MG/ML P

*Antiretrovirals**-*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines***

EMTRIVA ORAL CAPSULE 200 MG P QL (31 EA per 31 days)

EMTRIVA ORAL SOLUTION 10 MG/ML P QL (170 ML per 31 days)

EPIVIR HBV ORAL SOLUTION 5 MG/ML P

lamivudine oral solution 10 mg/ml P

lamivudine oral tablet 100 mg, 150 mg, 300 mg P

*Antiretrovirals**-*Antiretrovirals - Rti-Nucleoside Analogues-Thymidines***

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

P

stavudine oral solution reconstituted 1 mg/ml P

zidovudine oral capsule 100 mg P

zidovudine oral syrup 50 mg/5ml P QL (1860 ML per 31 days)

zidovudine oral tablet 300 mg P

*Antiretrovirals**-*Antiretrovirals - Rti-Nucleotide Analogues***

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG

P

*Antiretrovirals**-*Antiretrovirals Adjuvants***

tybost oral tablet 150 mg P QL (31 EA per 31 days)

*Hepatitis Agents**-*Hepatitis B Agents***

entecavir oral tablet 0.5 mg, 1 mg P PA

*Hepatitis Agents**-*Hepatitis C Agent - Combinations***

HARVONI ORAL TABLET 90-400 MG P PA; QL (28 EA per 28 days)

*Hepatitis Agents**-*Hepatitis C Agents***

OLYSIO ORAL CAPSULE 150 MG P PA; QL (28 EA per 28 days)


Drug Name Preference Details Coverage DetailsPEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML

P PA

PEGASYS SUBCUTANEOUS* KIT 180 MCG/0.5ML

P PA

PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML, 180 MCG/ML

P PA

RIBASPHERE ORAL TABLET 200 MG P

ribavirin oral tablet 200 mg P

SOVALDI ORAL TABLET 400 MG P PA; QL (28 EA per 28 days)

*Herpes Agents**-*Herpes Agents - Purine Analogues***

acyclovir oral capsule 200 mg P

acyclovir oral suspension 200 mg/5ml P QL (3500 ML per 31 days)

acyclovir oral tablet 400 mg, 800 mg P

valacyclovir hcl oral tablet 1 gm, 500 mg P QL (62 EA per 31 days)

*Influenza Agents**-*Influenza Agents***

rimantadine hcl oral tablet 100 mg P

*Influenza Agents**-*Neuraminidase Inhibitors***

RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER


TAMIFLU ORAL CAPSULE 30 MG P QL (40 EA per 365 days)

TAMIFLU ORAL CAPSULE 45 MG, 75 MG P QL (20 EA per 365 days)

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML


*Assorted Classes*

*Immunomodulators**-*Antileprotics***

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

P PA

*Immunomodulators**-*Immunomodulators For Myelodysplastic Syndromes***

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

P PA

*Immunosuppressive Agents**-*Cyclosporine Analogs***

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

P

cyclosporine modified oral solution 100 mg/ml P


35

Drug Name Preference Details Coverage Detailscyclosporine oral capsule 100 mg, 25 mg P

GENGRAF ORAL CAPSULE 100 MG, 25 MG P

GENGRAF ORAL SOLUTION 100 MG/ML P

SANDIMMUNE ORAL SOLUTION 100 MG/ML

P

*Immunosuppressive Agents**-*Inosine Monophosphate Dehydrogenase Inhibitors***

mycophenolate mofetil oral capsule 250 mg P

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

P

mycophenolate mofetil oral tablet 500 mg P

*Immunosuppressive Agents**-*Macrolide Immunosuppressants***

HECORIA ORAL CAPSULE 0.5 MG, 1 MG, 5 MG

P

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg P

*Immunosuppressive Agents**-*Purine Analogs***

azathioprine oral tablet 50 mg P

*Potassium Removing Resins**-*Potassium Removing Resins***

sodium polystyrene sulfonate oral powder P QL (454 GM per 31 days)

SPS ORAL SUSPENSION 15 GM/60ML P

*Beta Blockers*

*Alpha-Beta Blockers**-*Alpha-Beta Blockers***

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

P

labetalol hcl intravenous* solution 5 mg/ml P

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg P

*Beta Blockers Cardio-Selective**-*Beta Blockers Cardio-Selective***

atenolol oral tablet 100 mg, 25 mg, 50 mg P

bisoprolol fumarate oral tablet 10 mg, 5 mg P

metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 50 mg

P

metoprolol tartrate intravenous* solution 1 mg/ml P

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

P


Drug Name Preference Details Coverage Details*Beta Blockers Non-Selective**-*Beta Blockers Non-Selective***

nadolol oral tablet 20 mg, 40 mg, 80 mg P

pindolol oral tablet 10 mg, 5 mg P

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

P

propranolol hcl intravenous* solution 1 mg/ml P

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

P

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG

P

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg P

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg

P

timolol maleate oral tablet 10 mg, 20 mg, 5 mg P

*Calcium Channel Blockers*

*Calcium Channel Blockers**-*Calcium Channel Blockers***

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg

P

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG

P

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

P

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

P

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

P

diltiazem hcl intravenous* solution 125 mg/25ml, 25 mg/5ml, 50 mg/10ml

P

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

P

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

P

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

P


37

Drug Name Preference Details Coverage DetailsNIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG

P

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG

P

nifedipine er oral tablet extended release 24 hr*90 mg

P

nifedipine er osmotic oral tablet extended release 24 hr* 30 mg, 60 mg, 90 mg

P

nifedipine oral capsule 10 mg P

verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg

P

verapamil hcl er oral tablet extendedrelease* 120 mg, 180 mg, 240 mg

P

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg P

*Cardiotonics*

*Cardiac Glycosides**-*Cardiac Glycosides***

digoxin injection solution 0.25 mg/ml P

digoxin oral solution 0.05 mg/ml P

digoxin oral tablet 0.125 mg, 250 mcg P

*Cardiovascular Agents - Misc.*

*Peripheral Vasodilators**-*Peripheral Vasodilators***

no flush niacin oral tablet 500 mg P OTC

*Pulmonary Hypertension - Endothelin Receptor Antagonists**-*Pulmonary Hypertension - Endothelin Receptor Antagonists***

LETAIRIS ORAL TABLET 10 MG, 5 MG P PA

*Pulmonary Hypertension - Phosphodiesterase Inhibitors**-*Pulmonary Hypertension - Phosphodiesterase Inhibitors***

sildenafil citrate oral tablet 20 mg P PA

*Cephalosporins*

*Cephalosporins - 1St Generation**-*Cephalosporins - 1St Generation***

cefadroxil oral capsule 500 mg P


Drug Name Preference Details Coverage Detailscefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

P

cefadroxil oral tablet 1 gm P

cephalexin oral capsule 250 mg, 500 mg, 750 mg P

cephalexin oral suspension reconstituted 125 mg/5ml

P

cephalexin oral suspension reconstituted 250 mg/5ml


*Cephalosporins - 2Nd Generation**-*Cephalosporins - 2Nd Generation***

cefaclor oral capsule 250 mg, 500 mg P

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

P

cefprozil oral tablet 250 mg, 500 mg P

cefuroxime axetil oral suspension reconstituted125 mg/5ml

P

cefuroxime axetil oral tablet 250 mg, 500 mg P

*Cephalosporins - 3Rd Generation**-*Cephalosporins - 3Rd Generation***

cefdinir oral capsule 300 mg P

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

P

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

P

cefpodoxime proxetil oral tablet 100 mg, 200 mg P

*Contraceptives*

*Combination Contraceptives - Oral**-*Biphasic Contraceptives - Oral***

AZURETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5)

P

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5)

P

*Combination Contraceptives - Oral**-*Combination Contraceptives - Oral***

ALTAVERA ORAL TABLET 0.15-30 MG-MCG

P

APRI ORAL TABLET 0.15-30 MG-MCG P


39

Drug Name Preference Details Coverage DetailsAVIANE ORAL TABLET 0.1-20 MG-MCG P

BALZIVA ORAL TABLET 0.4-35 MG-MCG P

briellyn oral tablet 0.4-35 mg-mcg P

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG

P

CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG

P

EMOQUETTE ORAL TABLET 0.15-30 MG-MCG

P

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG

P

GIANVI ORAL TABLET 3-0.02 MG P

GILDESS 1.5/30 ORAL TABLET 1.5-30 MG-MCG

P

GILDESS 1/20 ORAL TABLET 1-20 MG-MCG P

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG

P

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG P

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

P

JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG P

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG P

LESSINA ORAL TABLET 0.1-20 MG-MCG P

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG

P

LORYNA ORAL TABLET 3-0.02 MG P

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG

P

LUTERA ORAL TABLET 0.1-20 MG-MCG P

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG

P

MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG

P

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

P

MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG

P

MONONESSA ORAL TABLET 0.25-35 MG-MCG

P


Drug Name Preference Details Coverage DetailsNECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

P

NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG

P

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

P

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

P

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG

P

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG

P

OCELLA ORAL TABLET 3-0.03 MG P

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG P

PORTIA-28 ORAL TABLET 0.15-30 MG-MCG P

PREVIFEM ORAL TABLET 0.25-35 MG-MCG P

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG

P

SOLIA ORAL TABLET 0.15-30 MG-MCG P

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG

P

SRONYX ORAL TABLET 0.1-20 MG-MCG P

SYEDA ORAL TABLET 3-0.03 MG P

VESTURA ORAL TABLET 3-0.02 MG P

ZARAH ORAL TABLET 3-0.03 MG P

ZENCHENT FE ORAL TABLET CHEWABLE 0.4-35 MG-MCG

P

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG

P

*Combination Contraceptives - Oral**-*Extended-Cycle Contraceptives - Oral***

QUASENSE ORAL TABLET 0.15-0.03 MG P QL (91 EA per 91 days)

*Combination Contraceptives - Oral**-*Triphasic Contraceptives - Oral***

CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG

P

ENPRESSE-28 ORAL TABLET P

NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

P


41

Drug Name Preference Details Coverage DetailsNORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

P

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

P

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

P

TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

P

TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

P

TRIVORA (28) ORAL TABLET P

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG

P

*Combination Contraceptives - Vaginal**-*Combination Contraceptives - Vaginal***

NUVARING VAGINAL RING 0.12-0.015 MG/24HR

P

*Emergency Contraceptives**-*Emergency Contraceptives***

levonorgestrel oral tablet 0.75 mg P QL (4 EA per 31 days)

NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG

P OTC

PLAN B ONE-STEP ORAL TABLET 1.5 MG P OTC

*Progestin Contraceptives - Injectable**-*Progestin Contraceptives - Injectable***

medroxyprogesterone acetate intramuscular* suspension 150 mg/ml


*Progestin Contraceptives - Oral**-*Progestin Contraceptives - Oral***

CAMILA ORAL TABLET 0.35 MG P

ERRIN ORAL TABLET 0.35 MG P

JOLIVETTE ORAL TABLET 0.35 MG P

NORA-BE ORAL TABLET 0.35 MG P

norethindrone oral tablet 0.35 mg P


Drug Name Preference Details Coverage Details*Corticosteroids*

*Glucocorticosteroids**-*Glucocorticosteroids***

A-METHAPRED INJECTION SOLUTION RECONSTITUTED 125 MG, 40 MG

P

cortisone acetate oral tablet 25 mg P

dexamethasone oral elixir 0.5 mg/5ml P

dexamethasone oral solution 0.5 mg/5ml P

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

P

dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml

P

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg P

methylprednisolone (pak) oral tablet 4 mg P

methylprednisolone acetate injection suspension40 mg/ml, 80 mg/ml

P

methylprednisolone oral tablet 16 mg, 32 mg, 8 mg

P

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg

P

prednisolone oral solution 15 mg/5ml P

prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 base) mg/5ml

P

prednisone oral solution 5 mg/5ml P

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg

P

*Mineralocorticoids**-*Mineralocorticoids***

fludrocortisone acetate oral tablet 0.1 mg P

*Cough/Cold/Allergy*

*Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine***

ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

P OTC

ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG

P OTC

allergy relief/nasal decongest oral tablet extended release 24 hr* 10-240 mg

P OTC


43

Drug Name Preference Details Coverage Detailscetirizine-pseudoephedrine er oral tablet extended release 12 hr* 5-120 mg

P OTC

DELSYM NGHT TIME CGH/CLD CHILD ORAL LIQUID† 12.5-5 MG/5ML

P OTC; AL (Max 20 Years)

DELSYM NIGHT TIME COUGH/COLD ORAL LIQUID† 6.25-2.5 MG/5ML

P OTC; AL (Max 20 Years)

fexofenadine-pseudoephed er oral tablet extended release 24 hr* 180-240 mg

P OTC

triprolidine-pse oral tablet 2.5-60 mg P OTC

*Expectorants**-*Expectorants***

guaifenesin oral solution 100 mg/5ml P OTC

mucus relief oral tablet 400 mg P OTC

refenesen 400 oral tablet 400 mg P OTC

refenesen oral tablet 200 mg P OTC

robafen oral syrup 100 mg/5ml P OTC

*Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants***

BRONCHO SALINE INHALATION AEROSOL, SOLUTION 0.9 %

P OTC

sodium chloride inhalation nebulization solution0.9 %

P OTC

*Mucolytics**-*Mucolytics***

acetylcysteine inhalation solution 10 %, 20 % P

*Dermatologicals*

*Acne Products**-*Acne Antibiotics***

clindamycin phosphate external 1 % P

clindamycin phosphate external lotion 1 % P

clindamycin phosphate external solution 1 % P

ery external pad 2 % P

erythromycin external 2 % P

erythromycin external solution 2 % P

sulfacetamide sodium external suspension 10 % P

*Acne Products**-*Acne Combinations***

benzoyl peroxide-erythromycin external 5-3 % P

*Acne Products**-*Acne Products***

acne medication 5 external lotion 5 % P OTC

acne medication external lotion 10 % P OTC


Drug Name Preference Details Coverage Details

AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG

P

ST; Notes (Must fail preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks); QL (62 EA per 31 days); AL (Min 12 Years and Max 20 Years)

AVITA EXTERNAL 0.025 % PQL (45 GM per 31 days); AL (Max 20 Years)

AVITA EXTERNAL CREAM 0.025 % PQL (45 GM per 31 days); AL (Max 20 Years)

benzoyl peroxide external 10 %, 5 % P OTC

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

P

ST; Notes (Must fail preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks); QL (62 EA per 31 days); AL (Min 12 Years and Max 20 Years)

LAVOCLEN-4 CREAMY WASH EXTERNAL LIQUID† 4 %

P

LAVOCLEN-8 CREAMY WASH EXTERNAL LIQUID† 8 %

P

tretinoin external 0.01 %, 0.025 % PQL (45 GM per 31 days); AL (Max 20 Years)

tretinoin external cream 0.025 %, 0.05 %, 0.1 % PQL (45 GM per 31 days); AL (Max 20 Years)

*Antibiotics - Topical**-*Antibiotic Mixtures Topical***

bacitracin-neomycin-polymyxin external ointment400-5-5000

P OTC

cvs triple antibiotic external ointment3.5-400-5000

P OTC

double antibiotic external ointment 500-10000 unit/gm

P OTC

*Antibiotics - Topical**-*Antibiotic Steroid Combinations - Topical***

CORTISPORIN EXTERNAL OINTMENT 1 % P

*Antibiotics - Topical**-*Antibiotics - Topical***

bacitracin zinc external ointment 500 unit/gm P OTC

gentamicin sulfate external cream 0.1 % P

gentamicin sulfate external ointment 0.1 % P


45

Drug Name Preference Details Coverage Detailsmupirocin external ointment 2 % P

*Antifungals - Topical**-*Antifungals - Topical***

ciclopirox external solution 8 % P

ciclopirox olamine external cream 0.77 % P

ciclopirox olamine external suspension 0.77 % P

nystatin external cream 100000 unit/gm P

nystatin external ointment 100000 unit/gm P

nystatin external powder 100000 unit/gm P

terbinafine hcl external cream 1 % P OTC

*Antifungals - Topical**-*Imidazole-Related Antifungals - Topical***

baza antifungal external cream 2 % P OTC

clotrimazole external cream 1 % P OTC

clotrimazole external solution 1 % P OTC

econazole nitrate external cream 1 % P

ketoconazole external cream 2 % P

ketoconazole external shampoo 2 % P

*Anti-Inflammatory Agents - Topical**-*Anti-Inflammatory Agents - Topical***

VOLTAREN TRANSDERMAL 1 % P QL (300 GM per 31 days)

*Antineoplastic Or Premalignant Lesion Agents - Topical**-*Antineoplastic Antimetabolites - Topical***

fluorouracil external cream 5 % P PA

fluorouracil external solution 2 %, 5 % P PA

*Antipsoriatics**-*Antipsoriatics***

calcipotriene external cream 0.005 % P

calcipotriene external ointment 0.005 % P

calcipotriene external solution 0.005 % P

DRITHO-CREME HP EXTERNAL CREAM 1 %

P

TAZORAC EXTERNAL 0.05 %, 0.1 % PQL (30 GM per 31 days); AL (Max 20 Years)

TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % PQL (30 GM per 31 days); AL (Max 20 Years)


Drug Name Preference Details Coverage Details*Antiseborrheic Products**-*Antiseborrheic Products***

selenium sulfide external lotion 2.5 % P

*Antivirals - Topical**-*Antivirals - Topical***

DENAVIR EXTERNAL CREAM 1 % PST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.)

ZOVIRAX EXTERNAL CREAM 5 % PST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.)

*Burn Products**-*Burn Products***

silver sulfadiazine external cream 1 % P QL (400 GM per 31 days)

SSD EXTERNAL CREAM 1 % P QL (400 GM per 31 days)

*Corticosteroids - Topical**-*Corticosteroids - Topical***

alclometasone dipropionate external cream 0.05 %

P

alclometasone dipropionate external ointment0.05 %

P

betamethasone dipropionate aug external cream0.05 %

P

betamethasone dipropionate external cream 0.05 %

P

betamethasone dipropionate external lotion 0.05 %

P

betamethasone dipropionate external ointment0.05 %

P

betamethasone valerate external cream 0.1 % P

betamethasone valerate external lotion 0.1 % P

betamethasone valerate external ointment 0.1 % P

clobetasol propionate external 0.05 % P

clobetasol propionate external cream 0.05 % P

clobetasol propionate external ointment 0.05 % P

desonide external cream 0.05 % P

fluocinolone acetonide body external oil 0.01 % P

fluocinolone acetonide external cream 0.01 %, 0.025 %

P

fluocinolone acetonide external ointment 0.025 % P


47

Drug Name Preference Details Coverage Detailsfluocinolone acetonide external solution 0.01 % P

fluocinolone acetonide scalp external oil 0.01 % P

fluocinonide external 0.05 % P

fluocinonide external cream 0.05 % P

fluocinonide external ointment 0.05 % P

fluocinonide external solution 0.05 % P

fluocinonide-e external cream 0.05 % P

fluticasone propionate external cream 0.05 % P

fluticasone propionate external ointment 0.005 % P

halobetasol propionate external cream 0.05 % P

halobetasol propionate external ointment 0.05 % P

hydrocortisone external cream 1 % P OTC

hydrocortisone external lotion 1 % P OTC

hydrocortisone external lotion 2.5 % P

hydrocortisone external ointment 1 % P OTC

hydrocortisone external ointment 2.5 % P

hydrocortisone valerate external cream 0.2 % P

hydrocortisone valerate external ointment 0.2 % P

mometasone furoate external cream 0.1 % P

mometasone furoate external ointment 0.1 % P

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %

P

triamcinolone acetonide external ointment 0.1 % P

*Emollient/Keratolytic Agents**-*Emollient/Keratolytic Agents***

REMEVEN EXTERNAL CREAM 50 % P

urea external cream 40 % P

X-VIATE EXTERNAL CREAM 40 % P

*Emollients**-*Emollients***

AMLACTIN EXTERNAL LOTION 12 % P OTC; QL (400 GM per 31 days)

ammonium lactate external cream 12 % P OTC; QL (400 GM per 31 days)

ammonium lactate external lotion 12 % P OTC; QL (400 GM per 31 days)

*Enzymes - Topical**-*Enzymes - Topical***

SANTYL EXTERNAL OINTMENT 250 UNIT/GM

P PA


Drug Name Preference Details Coverage Details*Immunosuppressive Agents - Topical**-*Macrolide Immunosuppressants - Topical***

ELIDEL EXTERNAL CREAM 1 % P

ST; Notes (Must fail preferred topical corticosteroid with use for at least 4 weeks or with 90 days of history.); QL (30 GM per 31 days); AL (Min 2 Years)

*Keratolytic/Antimitotic Agents**-*Keratolytic/Antimitotic Agents***

CLEAR AWAY 1-STEP WART REMOVER EXTERNAL PAD 40 %

P OTC

COMPOUND W EXTERNAL LIQUID† 17 % P OTC

COMPOUND W MAXIMUM STRENGTH EXTERNAL 17 %

P OTC

CONDYLOX EXTERNAL 0.5 % P PA

podofilox external solution 0.5 % P

SALACTIC FILM EXTERNAL SOLUTION 17 %

P OTC

*Local Anesthetics - Topical**-*Local Anesthetics - Topical***

capsaicin external cream 0.025 % P OTC

lidocaine external ointment 5 % P

lidocaine hcl external 2 % P

lidocaine hcl external solution 4 % P

*Local Anesthetics - Topical**-*Topical Anesthetic Combinations***

lidocaine-prilocaine external cream 2.5-2.5 % P

lidocaine-prilocaine external kit 2.5-2.5 % P

*Misc. Topical**-*Misc. Topical***

HYPERCARE EXTERNAL SOLUTION 20 % P

*Rosacea Agents**-*Rosacea Agents***

metronidazole external 1 % P

metronidazole external cream 0.75 % P

*Scabicides & Pediculicides**-*Scabicides & Pediculicides***

ACTICIN EXTERNAL CREAM 5 % P QL (60 GM per 31 days)

malathion external lotion 0.5 % PQL (118 ML per 31 days); AL (Min 6 Years)


49

Drug Name Preference Details Coverage Detailspermethrin external cream 5 % P QL (60 GM per 31 days)

permethrin external lotion 1 % P OTC; QL (60 ML per 31 days)

spinosad external suspension 0.9 % P AL (Min 4 Years)

*Diagnostic Products*

*Diagnostic Drugs**-*Diagnostic Drugs***

dipyridamole intravenous* solution 5 mg/ml P

*Diagnostic Tests**-*Diagnostic Tests***

ACCU-CHEK ACTIVE IN VITRO STRIP P

Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC

ACCU-CHEK AVIVA PLUS IN VITRO STRIP P

Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 ds for Members over 21 years old); OTC

ACCU-CHEK COMFORT CURVE IN VITRO STRIP

P


ACCU-CHEK COMPACT TEST DRUM IN VITRO STRIP

P


ACCU-CHEK SMARTVIEW IN VITRO STRIP P


CLINISTIX IN VITRO STRIP P OTC; QL (100 EA per 31 days)

DIASTIX IN VITRO STRIP P OTC; QL (100 EA per 31 days)

FREESTYLE INSULINX TEST IN VITRO STRIP

P


FREESTYLE LITE TEST IN VITRO STRIP P


FREESTYLE TEST IN VITRO STRIP P


KETOSTIX IN VITRO STRIP P OTC; QL (100 EA per 31 days)


Drug Name Preference Details Coverage Details

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP

P


PRECISION XTRA KETONE IN VITRO STRIP P OTC

*Digestive Aids*

*Digestive Enzymes**-*Digestive Enzymes***

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

P

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 8000 UNIT

P

*Diuretics*

*Carbonic Anhydrase Inhibitors**-*Carbonic Anhydrase Inhibitors***

acetazolamide oral tablet 125 mg, 250 mg P

methazolamide oral tablet 25 mg, 50 mg P

*Diuretic Combinations**-*Diuretic Combinations***

amiloride-hydrochlorothiazide oral tablet 5-50 mg

P

spironolactone-hctz oral tablet 25-25 mg P

triamterene-hctz oral capsule 37.5-25 mg P

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg P

*Loop Diuretics**-*Loop Diuretics***

bumetanide injection solution 0.25 mg/ml P

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg P

furosemide oral solution 10 mg/ml, 8 mg/ml P

furosemide oral tablet 20 mg, 40 mg, 80 mg P

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg P

*Potassium Sparing Diuretics**-*Potassium Sparing Diuretics***

spironolactone oral tablet 100 mg, 25 mg, 50 mg P

*Thiazides And Thiazide-Like Diuretics**-*Thiazides And Thiazide-Like Diuretics***

chlorothiazide oral tablet 250 mg, 500 mg P


51

Drug Name Preference Details Coverage Detailschlorthalidone oral tablet 25 mg, 50 mg P

hydrochlorothiazide oral capsule 12.5 mg P

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

P

indapamide oral tablet 1.25 mg, 2.5 mg P

metolazone oral tablet 10 mg, 2.5 mg, 5 mg P

*Endocrine And Metabolic Agents - Misc.*

*Bone Density Regulators**-*Bisphosphonates***

alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg

P

*Bone Density Regulators**-*Calcitonins***

calcitonin (salmon) nasal solution 200 unit/act P

FORTICAL NASAL SOLUTION 200 UNIT/ACT

P

*Bone Density Regulators**-*Rank Ligand (Rankl) Inhibitors***

PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML

P PA

*Growth Hormones**-*Growth Hormones***

TEV-TROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG

P PA

*Hormone Receptor Modulators**-*Selective Estrogen Receptor Modulators (Serms)***

raloxifene hcl oral tablet 60 mg P

*Metabolic Modifiers**-*Carnitine Replenisher - Agents***

levocarnitine intravenous* solution 200 mg/ml P

levocarnitine oral solution 1 gm/10ml P QL (900 ML per 31 days)

levocarnitine oral tablet 330 mg P

*Metabolic Modifiers**-*Gaa Deficiency Treatment - Agents***

LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

P PA

*Metabolic Modifiers**-*Hyperparathyroid Treatment - Vitamin D Analogs***

calcitriol intravenous* solution 1 mcg/ml P

calcitriol oral capsule 0.25 mcg, 0.5 mcg P

calcitriol oral solution 1 mcg/ml P


Drug Name Preference Details Coverage Details*Posterior Pituitary Hormones**-*Vasopressin***

desmopressin ace rhinal tube nasal solution 0.01 %

P

desmopressin ace spray refrig nasal solution 0.01 %

P

desmopressin acetate oral tablet 0.1 mg, 0.2 mg P

desmopressin acetate spray nasal solution 0.01 % P

*Estrogens*

*Estrogen Combinations**-*Estrogen & Progestin***

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

P

PREMPHASE ORAL TABLET 0.625-5 MG P

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

P

*Estrogens**-*Estrogens***

ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

P

estradiol oral tablet 0.5 mg, 1 mg, 2 mg P

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

P

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg P

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG

P

PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG

P

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

P

*Fluoroquinolones*

*Fluoroquinolones**-*Fluoroquinolones***

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

P

levofloxacin oral tablet 250 mg, 500 mg, 750 mg P

*Gastrointestinal Agents - Misc.*

*Antiflatulents**-*Antiflatulents***

gas relief oral suspension 20 mg/0.3ml P OTC

simethicone oral suspension 40 mg/0.6ml P OTC


53

Drug Name Preference Details Coverage Detailssimethicone oral tablet chewable 80 mg P OTC

*Gallstone Solubilizing Agents**-*Gallstone Solubilizing Agents***

ursodiol oral capsule 300 mg P

*Gastrointestinal Stimulants**-*Gastrointestinal Stimulants***

metoclopramide hcl oral solution 5 mg/5ml P QL (1500 ML per 31 days)

metoclopramide hcl oral tablet 10 mg, 5 mg P

*Inflammatory Bowel Agents**-*Inflammatory Bowel Agents***

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

P

balsalazide disodium oral capsule 750 mg P

mesalamine enema 4 gm P QL (1800 ML per 31 days)

sulfasalazine oral tablet 500 mg P

sulfasalazine oral tablet delayed release 500 mg P

*Intestinal Acidifiers**-*Intestinal Acidifiers***

generlac oral solution 10 gm/15ml P QL (4185 ML per 31 days)

*Phosphate Binder Agents**-*Phosphate Binder Agents***

calcium acetate oral capsule 667 mg P QL (372 EA per 31 days)

ELIPHOS ORAL TABLET 667 MG P QL (372 EA per 31 days)

RENVELA ORAL PACKET 0.8 GM, 2.4 GM P

RENVELA ORAL TABLET 800 MG P

*Genitourinary Agents - Miscellaneous*

*Alkalinizers**-*Citrates***

cytra-2 oral solution 500-334 mg/5ml P QL (3600 ML per 31 days)

CYTRA-3 ORAL SYRUP 550-500-334 MG/5ML


*Genitourinary Irrigants**-*Genitourinary Irrigants***

ARGYLE STERILE SALINE IRRIGATION SOLUTION 0.9 %


sodium chloride irrigation solution 0.9 % P QL (1000 ML per 31 days)

*Interstitial Cystitis Agents**-*Interstitial Cystitis Agents***

ELMIRON ORAL CAPSULE 100 MG P PA


Drug Name Preference Details Coverage Details*Prostatic Hypertrophy Agents**-*5-Alpha Reductase Inhibitors***

AVODART ORAL CAPSULE 0.5 MG P

finasteride oral tablet 5 mg P

*Prostatic Hypertrophy Agents**-*Alpha 1-Adrenoceptor Antagonists***

tamsulosin hcl oral capsule 0.4 mg P

*Urinary Analgesics**-*Urinary Analgesics***

phenazopyridine hcl oral tablet 100 mg, 200 mg P

*Gout Agents*

*Gout Agent Combinations**-*Gout Agent Combinations***

colchicine-probenecid oral tablet 0.5-500 mg P

*Gout Agents**-*Gout Agents***

allopurinol oral tablet 100 mg, 300 mg P

colchicine oral tablet 0.6 mg P

COLCRYS ORAL TABLET 0.6 MG P

*Uricosurics**-*Uricosurics***

probenecid oral tablet 500 mg P

*Hematological Agents - Misc.*

*Bradykinin B2 Receptor Antagonists**-*Bradykinin B2 Receptor Antagonists***

FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML

P PA

*Hematorheologic Agents**-*Hematorheologic Agents***

pentoxifylline er oral tablet extendedrelease* 400 mg

P

*Platelet Aggregation Inhibitors**-*Phosphodiesterase Iii Inhibitors***

cilostazol oral tablet 100 mg, 50 mg P

*Platelet Aggregation Inhibitors**-*Platelet Aggregation Inhibitors***

dipyridamole oral tablet 25 mg, 50 mg, 75 mg P


55

Drug Name Preference Details Coverage Details*Platelet Aggregation Inhibitors**-*Quinazoline Agents***

anagrelide hcl oral capsule 0.5 mg, 1 mg P

*Platelet Aggregation Inhibitors**-*Thienopyridine Derivatives***

clopidogrel bisulfate oral tablet 75 mg P

*Hematopoietic Agents*

*Cobalamins**-*Cobalamins***

cyanocobalamin injection solution 1000 mcg/ml P

vitamin b-12 oral tablet 1000 mcg P OTC

*Folic Acid/Folates**-*Folic Acid/Folates***

folic acid oral tablet 1 mg, 400 mcg, 800 mcg P OTC

*Hematopoietic Growth Factors**-*Erythropoiesis-Stimulating Agents (Esas)***

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

P PA

*Hematopoietic Growth Factors**-*Granulocyte Colony-Stimulating Factors (G-Csf)***

NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML

P PA

*Hematopoietic Mixtures**-*Iron Combinations***

CENTRATEX ORAL CAPSULE 106-1 MG P

ferrex 150 forte oral capsule 150-25-1 mg-mcg-mg

P OTC

*Iron**-*Iron***

ferrex 150 oral capsule 150 mg P OTC

ferrous sulfate oral elixir 220 (44 fe) mg/5ml P OTC

ferrous sulfate oral liquid† 220 (44 fe) mg/5ml P OTC

ferrous sulfate oral solution 75 (15 fe) mg/ml P OTC

ferrous sulfate oral tablet 325 (65 fe) mg P OTC

ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg

P OTC

slow release iron oral tablet extendedrelease*160 (50 fe) mg

P OTC


Drug Name Preference Details Coverage Details*Hypnotics/Sedatives/Sleep Disorder Agents*

*Antihistamine Hypnotics**-*Antihistamine Hypnotics***

diphenhydramine hcl (sleep) oral tablet 50 mg P OTC

*Barbiturate Hypnotics**-*Barbiturate Hypnotics***

phenobarbital oral elixir 20 mg/5ml P QL (2000 ML per 31 days)

phenobarbital oral tablet 100 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

P

phenobarbital oral tablet 15 mg P QL (310 EA per 31 days)

phenobarbital oral tablet 16.2 mg P QL (383 EA per 31 days)

phenobarbital sodium injection solution 130 mg/ml, 65 mg/ml

P

*Non-Barbiturate Hypnotics**-*Benzodiazepine Hypnotics***

estazolam oral tablet 1 mg, 2 mg P

temazepam oral capsule 15 mg, 30 mg P

triazolam oral tablet 0.125 mg, 0.25 mg P AL (Min 18 Years)

*Non-Barbiturate Hypnotics**-*Non-Benzodiazepine - Gaba-Receptor Modulators***

zolpidem tartrate oral tablet 10 mg, 5 mg PQL (31 EA per 31 days); AL (Min 18 Years)

*Laxatives*

*Bulk Laxatives**-*Bulk Laxatives***

fiber oral tablet 625 mg P OTC

METAMUCIL ORAL CAPSULE 0.52 GM P OTC

METAMUCIL ORAL POWDER 48.57 % P OTC

METAMUCIL ORAL WAFER P OTC

METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %

P OTC

*Laxative Combinations**-*Bowel Evacuant Combinations***

GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM


GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM


GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM



57

Drug Name Preference Details Coverage Detailspeg 3350/electrolytes oral solution reconstituted240 gm


peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm


peg-3350/electrolytes oral solution reconstituted236 gm


TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM


*Laxative Combinations**-*Laxatives & Dss***

senna s oral tablet 8.6-50 mg P OTC

*Laxatives - Miscellaneous**-*Laxatives - Miscellaneous***

lactulose oral solution 10 gm/15ml P QL (4185 ML per 31 days)

polyethylene glycol 3350 oral packet P OTC; QL (527 EA per 31 days)

polyethylene glycol 3350 oral powder P OTC; QL (527 GM per 31 days)

sorbitol oral solution 70 % P OTC

*Saline Laxatives**-*Saline Laxative Mixtures***

enema disposable enema P OTC

*Saline Laxatives**-*Saline Laxatives***

milk of magnesia oral suspension 1200 mg/15ml P OTC

*Stimulant Laxatives**-*Stimulant Laxatives***

bisacodyl ec oral tablet delayed release 5 mg P OTC

bisacodyl suppository 10 mg P OTC

senna laxative oral tablet 8.6 mg P OTC

senna oral syrup 8.8 mg/5ml P OTC

*Surfactant Laxatives**-*Surfactant Laxatives***

docusate sodium oral liquid† 50 mg/5ml P OTC

docusate sodium oral tablet 100 mg P OTC

stool softener laxative dc oral capsule 240 mg P OTC

stool softener oral capsule 100 mg, 250 mg P OTC

*Local Anesthetics-Parenteral*

*Local Anesthetics - Amides**-*Local Anesthetics - Amides***

lidocaine hcl (pf) injection solution 2 % P


Drug Name Preference Details Coverage Detailslidocaine hcl injection solution 0.5 %, 1 %, 1.5 % P

*Macrolides*

*Azithromycin**-*Azithromycin***

azithromycin hydrogencitrate intravenous* solution reconstituted 2.5 gm

P

azithromycin intravenous* solution reconstituted500 mg

P

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

P

azithromycin oral tablet 250 mg P QL (6 EA per 31 days)

azithromycin oral tablet 500 mg, 600 mg P

*Clarithromycin**-*Clarithromycin***

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

P

clarithromycin oral tablet 250 mg, 500 mg P

*Erythromycins**-*Erythromycins***

E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

P

ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

P

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

P

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

P

ERYTHROCIN STEARATE ORAL TABLET 250 MG

P

erythromycin base oral capsule delayed release particles 250 mg

P

erythromycin base oral tablet 250 mg, 500 mg P

erythromycin ethylsuccinate oral tablet 400 mg P

*Medical Devices*

*Diabetic Supplies**-*Glucose Monitoring Test Supplies***

ACCU-CHEK AVIVA PLUS KIT W/DEVICE P OTC; QL (1 EA per 365 days)

ACCU-CHEK COMPACT PLUS CARE KIT P OTC; QL (1 EA per 365 days)

ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE

P OTC; QL (1 EA per 365 days)

FREESTYLE FREEDOM LITE KIT W/DEVICE P OTC; QL (1 EA per 365 days)


59

Drug Name Preference Details Coverage DetailsFREESTYLE INSULINX SYSTEM KIT W/DEVICE

P OTC; QL (1 EA per 365 days)

FREESTYLE LITE DEVICE P OTC; QL (1 EA per 365 days)

glucose control in vitro solution P OTC

lancet device P OTC

lancets P

Notes (Accu-Chek Multiclix lancets: QL (204.00 per 31 days); All other lancets: QL (200.00 per 31 days)); OTC

PRECISION XTRA DEVICE P OTC; QL (1 EA per 365 days)

*Misc. Devices**-*Applicators,Cotton Balls,Etc***

alcohol pads pad 70 % P OTC

*Parenteral Therapy Supplies**-*Needles & Syringes***

BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 1 ML

PNotes (All Syringes Are Covered); OTC; QL (100 EA per 31 days)

EXEL PEN NEEDLES 1/3" 31G X 8 MM PNotes (All Syringes Are Covered); OTC; QL (100 EA per 31 days)

insulin syringe 29g x 1/2" 0.3 ml, 30g x 5/16" 0.3 ml

PNotes (All Syringes Are Covered); OTC; QL (100 EA per 31 days)

*Respiratory Therapy Supplies**-*Peak Flow Meters***

peak flow meter device P OTC; QL (2 EA per 365 days)

*Respiratory Therapy Supplies**-*Respiratory Therapy Supplies***

IN-CHECK DIAL FLOW TRAINER DEVICE P QL (2 EA per 365 days)

*Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies***

AEROCHAMBER PLUS FLO-VU P QL (2 EA per 365 days)

AEROCHAMBER PLUS FLO-VU LARGE P QL (2 EA per 365 days)

AEROCHAMBER PLUS FLO-VU SMALL P QL (2 EA per 365 days)

AEROCHAMBER PLUS FLO-VU W/MASK P QL (2 EA per 365 days)

E-Z SPACER DEVICE P QL (2 EA per 365 days)

MICROCHAMBER P QL (2 EA per 365 days)

MICROSPACER P QL (2 EA per 365 days)

OPTICHAMBER ADVANTAGE P QL (2 EA per 365 days)

OPTICHAMBER ADVANTAGE-LG MASK P QL (2 EA per 365 days)


Drug Name Preference Details Coverage DetailsOPTICHAMBER ADVANTAGE-MED MASK P QL (2 EA per 365 days)

OPTICHAMBER ADVANTAGE-SM MASK P QL (2 EA per 365 days)

OPTICHAMBER FACE MASK-LARGE P OTC; QL (2 EA per 365 days)

OPTICHAMBER FACE MASK-MEDIUM P OTC; QL (2 EA per 365 days)

OPTICHAMBER FACE MASK-SMALL P OTC; QL (2 EA per 365 days)

OPTIHALER P QL (2 EA per 365 days)

*Migraine Products*

*Serotonin Agonists**-*Selective Serotonin Agonists 5-Ht(1)***

naratriptan hcl oral tablet 1 mg, 2.5 mg PST; Notes (Must fail preferred sumatriptan tablets within the past 100 days.); QL (9 EA per 31 days)

sumatriptan nasal solution 20 mg/act, 5 mg/act P QL (12 EA per 31 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg


sumatriptan succinate subcutaneous* 6 mg/0.5ml P QL (4 ML per 31 days)

sumatriptan succinate subcutaneous* solution 4 mg/0.5ml, 6 mg/0.5ml


*Minerals & Electrolytes*

*Calcium**-*Calcium Combinations***

calcium carbonate-vitamin d oral tablet 600-400 mg-unit

P OTC

*Calcium**-*Calcium***

calcium acetate (phos binder) oral tablet 667 mg P QL (372 EA per 31 days)

calcium carbonate oral suspension 1250 mg/5ml P OTC

calcium carbonate oral tablet 1250 mg, 600 mg P OTC

calcium lactate oral tablet 648 mg P OTC

cal-lac oral capsule 500 mg P OTC

cvs oyster shell calcium oral tablet 500 mg P OTC

oyst-cal oral tablet 500 mg P OTC

oyster calcium oral tablet 500 mg P OTC

oyster shell calcium oral tablet 500 mg P OTC

ra oyster shell calcium oral tablet 500 mg P OTC

sb oyster shell calcium oral tablet 500 mg P OTC

*Electrolyte Mixtures**-*Electrolytes Oral***

ORALYTE FREEZER POPS ORAL SOLUTION P OTC; QL (4000 ML per 31 days)

ORALYTE ORAL SOLUTION P OTC; QL (4000 ML per 31 days)


61

Drug Name Preference Details Coverage Details*Electrolyte Mixtures**-*Electrolytes Parenteral***

lactated ringers intravenous* solution P

potassium chloride in nacl intravenous* solution20-0.9 meq/l-%

P

*Fluoride**-*Fluoride Combinations***

FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79 MG, 0.5 (F)-236.79 MG, 1 (F)-236.79 MG

P

*Fluoride**-*Fluoride***

sodium fluoride oral solution 1.1 (0.5 f) mg/ml P

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

P

*Iodine Products**-*Iodine Products***

SSKI ORAL SOLUTION 1 GM/ML P

*Magnesium**-*Magnesium***

mag-delay oral tablet extendedrelease* 535 (64 mg) mg

P OTC

magnesium dr oral tablet extendedrelease* 535 (64 mg) mg

P OTC

magnesium oxide oral tablet 400 (240 mg) mg, 400 (241.3 mg) mg, 500 mg

P OTC

mag-sr oral tablet extendedrelease* 535 (64 mg) mg

P OTC

MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ)

P OTC

sm magnesium oxide oral tablet 250 mg P OTC

*Potassium**-*Potassium***

KLOR-CON 10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ

P

KLOR-CON M10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ

P

KLOR-CON M20 ORAL TABLET EXTENDEDRELEASE* 20 MEQ

P

KLOR-CON ORAL TABLET EXTENDEDRELEASE* 8 MEQ

P

potassium chloride crys er oral tablet extendedrelease* 10 meq, 20 meq

P

potassium chloride er oral capsule extended release* 10 meq, 8 meq

P


Drug Name Preference Details Coverage Detailspotassium chloride er oral tablet extendedrelease* 10 meq, 20 meq, 8 meq

P

potassium chloride intravenous* solution 0.4 meq/ml, 10 meq/100ml, 2 meq/ml, 40 meq/100ml

P

potassium chloride oral liquid† 20 meq/15ml (10%), 40 meq/15ml (20%)

P

potassium chloride oral solution 20 meq/15ml (10%)

P

*Sodium**-*Sodium***

normal saline flush intravenous* solution 0.9 % P QL (310 ML per 31 days)

saline flush intravenous* solution 0.9 % P QL (310 ML per 31 days)

sodium chloride injection solution 0.9 % P QL (310 ML per 31 days)

sodium chloride intravenous* solution 0.45 %, 0.9 %

P

sodium chloride oral tablet 1 gm P OTC

*Zinc**-*Zinc***

zinc sulfate oral capsule 220 mg P OTC

zinc sulfate oral tablet 220 (50 zn) mg P OTC

zinc-220 oral capsule 220 mg P OTC

zincate oral capsule 220 mg P

*Mouth/Throat/Dental Agents*

*Anesthetics Topical Oral**-*Anesthetics Topical Oral***

lidocaine viscous mouth/throat solution 2 % P

*Anti-Infectives - Throat**-*Anti-Infectives - Throat***

clotrimazole mouth/throat lozenge 10 mg P

clotrimazole mouth/throat troche 10 mg P

nystatin mouth/throat suspension 100000 unit/ml P QL (300 ML per 31 days)

*Antiseptics - Mouth/Throat**-*Antiseptics - Mouth/Throat***

chlorhexidine gluconate mouth/throat solution0.12 %


PERIOGARD MOUTH/THROAT SOLUTION 0.12 %


*Dental Products**-*Fluoride Dental Products***

CAVAREST DENTAL 1.1 % P

DENTAGEL DENTAL 1.1 % P


63

Drug Name Preference Details Coverage DetailsFLUORIDEX DAILY DEFENSE DENTAL 1.1 %

P

KARIGEL DENTAL 1.1 % P

KARIGEL-N DENTAL 1.1 % P

NEUTRAGARD ADVANCED DENTAL 1.1 % P

PHOS-FLUR DENTAL 1.1 % P

sf dental 1.1 % P

*Steroids - Mouth/Throat**-*Steroids - Mouth/Throat***

triamcinolone acetonide mouth/throat paste 0.1 % P

*Throat Products - Misc.**-*Saliva Stimulants***

pilocarpine hcl oral tablet 5 mg, 7.5 mg P

*Multivitamins*

*B-Complex W/ C**-*B-Complex W/ C***

vitamin b complex-c oral capsule P OTC

*B-Complex W/ Folic Acid**-*B-Complex W/ C & Folic Acid***

rena-vite oral tablet P OTC

*Multivitamins**-*Multivitamins***

multi-vitamins oral tablet P OTC

*Ped Multi Vitamins W/Fl & Fe**-*Ped Multi Vitamins W/Fl & Fe***

multi-vit/fluoride/iron oral solution 0.25-10 mg/ml

P AL (Max 12 Years)

*Ped Multi Vitamins W/Fl & Fe**-*Ped Vitamins Acd Fluoride & Iron***

tri-vit/fluoride/iron oral solution 0.25-10 mg/ml P AL (Max 12 Years)

*Ped Mv W/ Fluoride**-*Ped Mv W/ Fluoride***

multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

P AL (Max 12 Years)

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg

P AL (Max 12 Years)

multi-vitamin/fluoride oral tablet chewable 0.5 mg

P AL (Max 12 Years)

*Ped Mv W/ Fluoride**-*Ped Vitamins Acd W/ Fluoride***

tri-vit/fluoride oral solution 0.25 mg/ml P AL (Max 12 Years)


Drug Name Preference Details Coverage Detailstri-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

P AL (Max 12 Years)

vitamins acd-fluoride oral solution 0.25 mg/ml P AL (Max 12 Years)

*Ped Mv W/ Iron**-*Ped Mv W/ Iron***

polyvitamin/iron oral solution 10 mg/ml P OTC

*Pediatric Multiple Vitamins**-*Pediatric Multiple Vitamins W/ C***

polyvitamin oral solution 35 mg/ml P OTC

*Pediatric Vitamins**-*Pediatric Vitamins A & D W/ C***

tri-vitamin oral solution 1500-400-35 P OTC

*Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa***

ELITE-OB ORAL TABLET 50-1.25 MG P

MYNATAL ADVANCE ORAL TABLET P

mynatal-z oral tablet P

mynate 90 plus oral tablet extendedrelease* P

PRENATABS RX ORAL TABLET 29-1 MG P

prenatal low iron oral tablet 27-0.8 mg P OTC

prenatal plus iron oral tablet 29-1 mg P

prenatal plus oral tablet 27-1 mg P

prenatal vitamins oral tablet 28-0.8 mg P OTC

PRENATAL-U ORAL CAPSULE 106.5-1 MG P

se-natal 19 oral tablet chewable 29-1 mg P

trinatal rx 1 oral tablet 60-1 mg P

VINATE AZ EXTRA ORAL TABLET 29-1 MG P

VINATE II ORAL TABLET 29-1 MG P

VINATE M ORAL TABLET 27-1 MG P

*Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil***

PR NATAL 400 EC ORAL 29-1-200 & 400 MG (DR)

P

*Musculoskeletal Therapy Agents*

*Central Muscle Relaxants**-*Central Muscle Relaxants***

baclofen oral tablet 10 mg, 20 mg P

carisoprodol oral tablet 350 mg P QL (124 EA per 31 days)

chlorzoxazone oral tablet 500 mg P


65

Drug Name Preference Details Coverage Detailscyclobenzaprine hcl oral tablet 10 mg, 5 mg P QL (93 EA per 31 days)

methocarbamol oral tablet 500 mg, 750 mg P

tizanidine hcl oral tablet 2 mg, 4 mg PST; Notes (Must fail preferred baclofen and cyclobenzaprine within the past 100 days)

*Direct Muscle Relaxants**-*Direct Muscle Relaxants***

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg

P

*Viscosupplements**-*Viscosupplements***

SUPARTZ INTRA-ARTICULAR* 25 MG/2.5ML

P PA

*Nasal Agents - Systemic And Topical*

*Nasal Agents - Misc.**-*Nasal Agents - Misc.***

saline mist spray nasal solution 0.65 % P OTC

saline nasal spray nasal solution 0.65 % P OTC

*Nasal Antiallergy**-*Nasal Antihistamines***

azelastine hcl nasal solution 137 mcg/spray P

*Nasal Antiallergy**-*Nasal Mast Cell Stabilizers***

cromolyn sodium nasal aerosol, solution 5.2 mg/act

P OTC

*Nasal Anticholinergics**-*Nasal Anticholinergics***

ipratropium bromide nasal solution 0.03 %, 0.06 %

P

*Nasal Steroids**-*Nasal Steroids***

flunisolide nasal solution 25 mcg/act (0.025%) P

fluticasone propionate nasal suspension 50 mcg/act

P

*Sympathomimetic Decongestants**-*Systemic Decongestants***

pseudoephedrine hcl oral tablet 30 mg, 60 mg P OTC

*Nutrients*

*Misc. Nutritional Substances**-*Misc. Nutritional Substances***

cvs fish oil oral capsule 1000 mg P OTC


Drug Name Preference Details Coverage Detailscvs natural fish oil oral capsule 1000 mg P OTC

epa oral capsule 1000 mg P OTC

eql fish oil oral capsule 1000 mg P OTC

fish oil burp-less oral capsule 1000 mg P OTC

fish oil concentrate oral capsule 1000 mg P OTC

fish oil oral capsule 1000 mg P OTC

fish oil ultra oral capsule 1000 mg P OTC

fish oil/super potent/no burp oral capsule 1000 mg

P OTC

gnp fish oil oral capsule 1000 mg P OTC

hm fish oil oral capsule 1000 mg P OTC

maxepa oral capsule 1000 mg P OTC

norwegian salmon oil oral capsule 1000 mg P OTC

omega 3 oral capsule 1000 mg P OTC

omega iii epa+dha oral capsule 1000 mg P OTC

omega-3 cf oral capsule 1000 mg P OTC

omega-3 fish oil oral capsule 1000 mg P OTC

omega-3 oral capsule 1000 mg P OTC

omega-3 plus oral capsule 1000 mg P OTC

pa fish oil oral capsule 1000 mg P OTC

px fish oil oral capsule 1000 mg P OTC

ra fish oil oral capsule 1000 mg P OTC

sb omega-3 fish oil oral capsule 1000 mg P OTC

sea-omega 50 oral capsule 1000 mg P OTC

sm fish oil oral capsule 1000 mg P OTC

super omega 3 epa/dha oral capsule 1000 mg P OTC

super omega-epa oral capsule 1000 mg P OTC

th omega-3 fish oil oral capsule 1000 mg P OTC

*Ophthalmic Agents*

*Artificial Tears And Lubricants**-*Artificial Tears And Lubricants***

artificial tears ophthalmic solution 1.4 % P OTC; QL (15 ML per 31 days)

*Beta-Blockers - Ophthalmic**-*Beta-Blockers - Ophthalmic Combinations***

dorzolamide hcl-timolol mal ophthalmic solution22.3-6.8 mg/ml

P


67

Drug Name Preference Details Coverage Details*Beta-Blockers - Ophthalmic**-*Beta-Blockers - Ophthalmic***

betaxolol hcl ophthalmic solution 0.5 % P

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

P

carteolol hcl ophthalmic solution 1 % P

levobunolol hcl ophthalmic solution 0.25 %, 0.5 %

P

metipranolol ophthalmic solution 0.3 % P

timolol maleate ophthalmic gel forming solution0.25 %, 0.5 %

P

timolol maleate ophthalmic solution 0.25 %, 0.5 %

P

*Cycloplegic Mydriatics**-*Cycloplegic Mydriatics***

atropine sulfate ophthalmic ointment 1 % P

atropine sulfate ophthalmic solution 1 % P

*Miotics**-*Miotics - Direct Acting***

pilocarpine hcl ophthalmic solution 2 % P

*Ophthalmic Adrenergic Agents**-*Ophthalmic Selective Alpha Adrenergic Agonists***

brimonidine tartrate ophthalmic solution 0.2 % P

*Ophthalmic Anti-Infectives**-*Ophthalmic Antibiotics***

ciprofloxacin hcl ophthalmic solution 0.3 % P

erythromycin ophthalmic ointment 5 mg/gm P

gentamicin sulfate ophthalmic ointment 0.3 % P

gentamicin sulfate ophthalmic solution 0.3 % P

ofloxacin ophthalmic solution 0.3 % P

tobramycin ophthalmic solution 0.3 % P

*Ophthalmic Anti-Infectives**-*Ophthalmic Anti-Infective Combinations***

ak-poly-bac ophthalmic ointment 500-10000 unit/gm

P

bacitracin-polymyxin b ophthalmic ointment500-10000 unit/gm

P


Drug Name Preference Details Coverage Detailsneomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

P

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-0.25

P

polycin b ophthalmic ointment 500-10000 unit/gm P

polymyxin b-trimethoprim ophthalmic solution10000-0.1 unit/ml-%

P

*Ophthalmic Anti-Infectives**-*Ophthalmic Antivirals***

trifluridine ophthalmic solution 1 % P

*Ophthalmic Anti-Infectives**-*Ophthalmic Sulfonamides***

sulfacetamide sodium ophthalmic solution 10 % P

*Ophthalmic Immunomodulators**-*Ophthalmic Immunomodulators***

RESTASIS OPHTHALMIC EMULSION 0.05 % P

*Ophthalmic Steroids**-*Ophthalmic Steroid Combinations***

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

P

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

P

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

P

poly-dex ophthalmic ointment 3.5-10000-0.1 P

PRED-G OPHTHALMIC SUSPENSION 0.3-1 % P

sulfacetamide-prednisolone ophthalmic solution10-0.23 %

P

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

P

*Ophthalmic Steroids**-*Ophthalmic Steroids***

dexamethasone sodium phosphate ophthalmic solution 0.1 %

P

fluorometholone ophthalmic suspension 0.1 % P

FML FORTE OPHTHALMIC SUSPENSION 0.25 %

P

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

P


69

Drug Name Preference Details Coverage DetailsMAXIDEX OPHTHALMIC SUSPENSION 0.1 %

P

prednisolone acetate ophthalmic suspension 1 % P

VEXOL OPHTHALMIC SUSPENSION 1 % P

*Ophthalmics - Misc.**-*Ophthalmic Antiallergic***

cromolyn sodium ophthalmic solution 4 % P

ketotifen fumarate ophthalmic solution 0.025 % P OTC

*Ophthalmics - Misc.**-*Ophthalmic Carbonic Anhydrase Inhibitors***

AZOPT OPHTHALMIC SUSPENSION 1 % P

dorzolamide hcl ophthalmic solution 2 % P

*Ophthalmics - Misc.**-*Ophthalmic Nonsteroidal Anti-Inflammatory Agents***

diclofenac sodium ophthalmic solution 0.1 % P

flurbiprofen sodium ophthalmic solution 0.03 % P

*Prostaglandins - Ophthalmic**-*Prostaglandins - Ophthalmic***

latanoprost ophthalmic solution 0.005 % P QL (5 ML per 31 days)

*Otic Agents*

*Otic Agents - Miscellaneous**-*Otic Agents - Miscellaneous***

acetic acid-aluminum acetate otic solution 2 % P

*Otic Anti-Infectives**-*Otic Anti-Infectives***

ofloxacin otic solution 0.3 % P

*Otic Combinations**-*Otic Analgesic Combinations***

antipyrine-benzocaine otic solution 5.4-1.4 %, 5.5-1.4 %, 54-14 mg/ml

P

oticin otic liquid† 1-0.1 % P

*Otic Combinations**-*Otic Steroid-Anti-Infective Combinations***

CIPRODEX OTIC SUSPENSION 0.3-0.1 % P

ST; Notes (Preferred for members 6 years old and younger; Members 7 years old and older: Covered w/step edit: Must fail ofloxacin 0.3% ear drops within the past 100 days.); AL (Max 6 Years)


Drug Name Preference Details Coverage Detailsneomycin-polymyxin-hc otic solution 3.5-10000-1 P

neomycin-polymyxin-hc otic suspension3.5-10000-1

P

*Oxytocics*

*Oxytocics**-*Oxytocics***

methylergonovine maleate injection solution 0.2 mg/ml

P

methylergonovine maleate oral tablet 0.2 mg P

*Passive Immunizing Agents*

*Monoclonal Antibodies**-*Antiviral Monoclonal Antibodies***

SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/0.5ML

P PA

*Penicillins*

*Aminopenicillins**-*Aminopenicillins***

amoxicillin oral capsule 250 mg, 500 mg P

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml


amoxicillin oral tablet 500 mg, 875 mg P

amoxicillin oral tablet chewable 125 mg, 250 mg P

ampicillin oral capsule 250 mg, 500 mg P

ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

P

*Natural Penicillins**-*Natural Penicillins***

BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML

P

penicillin g procaine intramuscular* suspension600000 unit/ml

P

penicillin v potassium oral solution reconstituted125 mg/5ml, 250 mg/5ml


penicillin v potassium oral tablet 250 mg, 500 mg P

PFIZERPEN-G INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT

P

*Penicillin Combinations**-*Penicillin Combinations***

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml



71

Drug Name Preference Details Coverage Detailsamoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

P

amoxicillin-pot clavulanate oral tablet chewable200-28.5 mg, 400-57 mg

P

BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION 900000-300000 UNIT/2ML

P

BICILLIN C-R INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML

P

*Penicillinase-Resistant Penicillins**-*Penicillinase-Resistant Penicillins***

dicloxacillin sodium oral capsule 250 mg, 500 mg P

oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm

P

*Progestins*

*Progestins**-*Progestins***

MAKENA INTRAMUSCULAR* OIL 250 MG/ML

P PA

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

P

norethindrone acetate oral tablet 5 mg P

*Psychotherapeutic And Neurological Agents - Misc.*

*Agents For Chemical Dependency**-*Alcohol Deterrents***

acamprosate calcium oral tablet delayed release333 mg


disulfiram oral tablet 250 mg, 500 mg P

*Antidementia Agents**-*Cholinomimetics - Ache Inhibitors***

donepezil hcl oral tablet 10 mg, 5 mg P

EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR

P

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

P

*Antidementia Agents**-*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists***

NAMENDA ORAL SOLUTION 10 MG/5ML P

NAMENDA ORAL TABLET 10 MG, 5 MG P


Drug Name Preference Details Coverage DetailsNAMENDA TITRATION PAK ORAL TABLET 5 (28)-10 (21) MG

P

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG

P

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21

P

*Combination Psychotherapeutics**-*Benzodiazepines & Tricyclic Agents***

chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

P

*Combination Psychotherapeutics**-*Phenothiazines & Tricyclic Agents***

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

P

*Fibromyalgia Agents**-*Fibromyalgia Agent - Snris***

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

P

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG

P

*Multiple Sclerosis Agents**-*Ms Agents - Pyrimidine Synthesis Inhibitors***

AUBAGIO ORAL TABLET 14 MG, 7 MG P PA

*Multiple Sclerosis Agents**-*Multiple Sclerosis Agents - Interferons***

EXTAVIA SUBCUTANEOUS* KIT 0.3 MG P PA

REBIF REBIDOSE SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML

P PA

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG

P PA

REBIF SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML

P PA

REBIF TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG

P PA


73

Drug Name Preference Details Coverage Details*Multiple Sclerosis Agents**-*Multiple Sclerosis Agents***

COPAXONE SUBCUTANEOUS* 40 MG/ML P PA; QL (12 ML per 28 days)

COPAXONE SUBCUTANEOUS* KIT 20 MG/ML

P PA

*Psychotherapeutic And Neurological Agents - Misc.**-*Psychotherapeutic And Neurological Agents - Misc.***

ORAP ORAL TABLET 1 MG, 2 MG P AL (Min 12 Years)

*Smoking Deterrents**-*Smoking Deterrents***

nicotine polacrilex mouth/throat gum 2 mg, 4 mg P OTC; QL (4032 EA per 365 days)

nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr

PNotes (Max 6 months per year); OTC; QL (140 EA per 365 days)

*Respiratory Agents - Misc.*

*Cystic Fibrosis Agents**-*Cftr Potentiators***

KALYDECO ORAL TABLET 150 MG P PA

*Cystic Fibrosis Agents**-*Hydrolytic Enzymes***

PULMOZYME INHALATION SOLUTION 1 MG/ML

P PA

*Tetracyclines*

*Tetracyclines**-*Tetracyclines***

doxycycline hyclate oral capsule 100 mg, 50 mg P

ST; Notes (Members must have trial of doxycycline monohydrate 50 mg or 100 mg capsules within the last 100 days.)

doxycycline hyclate oral tablet 100 mg P

ST; Notes (Members must have trial of doxycycline monohydrate 50 mg or 100 mg capsules within the last 100 days.)

doxycycline hyclate oral tablet 20 mg P

doxycycline monohydrate oral capsule 100 mg, 50 mg

P

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg

P

tetracycline hcl oral capsule 250 mg, 500 mg P


Drug Name Preference Details Coverage Details*Thyroid Agents*

*Antithyroid Agents**-*Antithyroid Agents***

methimazole oral tablet 10 mg, 5 mg P

propylthiouracil oral tablet 50 mg P QL (558 EA per 31 days)

*Thyroid Hormones**-*Thyroid Hormones***

ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

P

levothyroxine sodium intravenous* solution reconstituted 100 mcg, 500 mcg

P

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

P

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

P

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

P

np thyroid oral tablet 30 mg, 60 mg, 90 mg P

THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)

P

THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)

P

THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG)

P

THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)

P

THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG)

P

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

P

WESTHROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

P


75

Drug Name Preference Details Coverage Details*Ulcer Drugs*

*Antispasmodics**-*Antispasmodics***

dicyclomine hcl oral capsule 10 mg P

dicyclomine hcl oral solution 10 mg/5ml P

dicyclomine hcl oral tablet 20 mg P

*Antispasmodics**-*Quaternary Anticholinergics***

glycopyrrolate oral tablet 1 mg, 2 mg P

propantheline bromide oral tablet 15 mg P

*H-2 Antagonists**-*H-2 Antagonists***

acid reducer oral tablet 75 mg P OTC

cimetidine hcl oral solution 300 mg/5ml P

cimetidine oral tablet 200 mg P OTC

cimetidine oral tablet 300 mg, 400 mg, 800 mg P

famotidine oral tablet 10 mg P OTC

famotidine oral tablet 20 mg, 40 mg P

famotidine premixed intravenous* solution 20-0.9 mg/50ml-%

P

ranitidine acid reducer oral tablet 75 mg P OTC

ranitidine hcl injection solution 1000 mg/40ml, 150 mg/6ml, 50 mg/2ml

P

ranitidine hcl oral capsule 150 mg, 300 mg P

ranitidine hcl oral syrup 15 mg/ml P QL (620 ML per 31 Days)

ranitidine hcl oral tablet 150 mg P OTC

ranitidine hcl oral tablet 300 mg P

*Misc. Anti-Ulcer**-*Misc. Anti-Ulcer***

CARAFATE ORAL SUSPENSION 1 GM/10ML P QL (1240 ML per 31 days)

sucralfate oral tablet 1 gm P

*Proton Pump Inhibitors**-*Proton Pump Inhibitors***

lansoprazole oral capsule delayed release 15 mg PST; Notes (Must fail preferred omeprazole or pantoprazole within the past 100 days.); OTC

lansoprazole oral capsule delayed release 30 mg PST; Notes (Must fail preferred omeprazole or pantoprazole within the past 100 days.)

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

P


Drug Name Preference Details Coverage Detailspantoprazole sodium oral tablet delayed release20 mg, 40 mg

P

*Ulcer Drugs - Prostaglandins**-*Ulcer Drugs - Prostaglandins***

misoprostol oral tablet 100 mcg, 200 mcg P

*Urinary Anti-Infectives*

*Urinary Anti-Infective Combinations**-*Urinary Antiseptic-Antispasmodic &/Or Analgesics***

URETRON D/S ORAL TABLET P

uticap oral capsule 120 mg P

*Urinary Anti-Infectives**-*Urinary Anti-Infectives***

MACRODANTIN ORAL CAPSULE 25 MG P AL (Max 8 Years)

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

P

nitrofurantoin monohyd macro oral capsule 100 mg

P

*Urinary Antispasmodics*

*Urinary Antispasmodics**-*Urinary Antispasmodics***

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

P

oxybutynin chloride er oral tablet extended release 24 hr* 10 mg, 15 mg, 5 mg

P

oxybutynin chloride oral syrup 5 mg/5ml P

oxybutynin chloride oral tablet 5 mg P

trospium chloride oral tablet 20 mg PST; Notes (Must fail preferred oxybutinin er tablets within the past 100 days)

*Vaginal Products*

*Vaginal Anti-Infectives**-*Imidazole-Related Antifungals***

3 day vaginal vaginal cream 2 % P OTC

clotrimazole 3 vaginal cream 2 % P OTC

clotrimazole vaginal cream 1 % P OTC

miconazole 3 combo pack vaginal kit 200-2 mg-% (9gm)

P OTC

miconazole 3 vaginal suppository 200 mg P


77

Drug Name Preference Details Coverage Detailsmiconazole nitrate vaginal cream 2 % P OTC

miconazole nitrate vaginal suppository 100 mg P OTC

MONISTAT 3 VAGINAL CREAM 4 % P OTC

terconazole vaginal cream 0.4 %, 0.8 % P

terconazole vaginal suppository 80 mg P

*Vaginal Anti-Infectives**-*Vaginal Anti-Infectives***

clindamycin phosphate vaginal cream 2 % P

metronidazole vaginal 0.75 % P

VANDAZOLE VAGINAL 0.75 % P

*Vaginal Estrogens**-*Vaginal Estrogens***

PREMARIN VAGINAL CREAM 0.625 MG/GM P

*Vaginal Progestins**-*Vaginal Progestins***

ENDOMETRIN VAGINAL INSERT 100 MG P

*Vasopressors*

*Anaphylaxis Therapy Agents**-*Anaphylaxis Therapy Agents***

EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML P QL (6 EA per 180 days)

EPIPEN JR 2-PAK INJECTION 0.15 MG/0.3ML P QL (6 EA per 180 days)

*Vasopressors**-*Vasopressors***

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg P

*Vitamins*

*Oil Soluble Vitamins**-*Vitamin A***

vitamin a oral capsule 10000 unit, 8000 unit P OTC

*Oil Soluble Vitamins**-*Vitamin D***

cvs vitamin d oral capsule 2000 unit P OTC

d 1000 oral tablet 1000 unit P OTC

d 400 oral tablet 400 unit P OTC

d-1000 extra strength oral tablet 1000 unit P OTC

d-1000 oral tablet 1000 unit P OTC

d2000 ultra strength oral capsule 2000 unit P OTC

d3 super strength oral capsule 2000 unit P OTC

d3-1000 oral tablet 1000 unit P OTC

d-400 oral tablet 400 unit P OTC

delta d3 oral tablet 400 unit P OTC

eql vitamin d3 oral tablet 1000 unit P OTC


Drug Name Preference Details Coverage Detailseql vitamin d-3 oral tablet 400 unit P OTC

gnp vitamin d oral tablet 1000 unit P OTC

gnp vitamin d3 extra strength oral tablet 1000 unit

P OTC

hm vitamin d oral tablet 1000 unit, 400 unit P OTC

hm vitamin d3 oral capsule 2000 unit P OTC

kp vitamin d oral capsule 2000 unit P OTC

nat-rul vitamin d oral tablet 1000 unit P OTC

pa vitamin d-3 oral capsule 2000 unit P OTC

pa vitamin d-3 oral tablet 1000 unit P OTC

ra vitamin d-3 oral capsule 2000 unit P OTC

ra vitamin d-3 oral tablet 1000 unit P OTC

sm vitamin d oral tablet 400 unit P OTC

sm vitamin d3 oral capsule 2000 unit P OTC

sm vitamin d3 oral tablet 1000 unit P OTC

th vitamin d3 oral capsule 2000 unit P OTC

vitamin d (cholecalciferol) oral tablet 1000 unit P OTC

vitamin d (ergocalciferol) oral capsule 50000 unit P QL (4 EA per 28 Days)

vitamin d oral capsule 2000 unit P OTC

vitamin d oral tablet 1000 unit, 400 unit P OTC

vitamin d3 oral capsule 2000 unit P OTC

vitamin d3 oral tablet 1000 unit, 400 unit P OTC

vitamin d-400 oral tablet 400 unit P OTC

*Oil Soluble Vitamins**-*Vitamin E***

alph-e oral capsule 400 unit P OTC

alph-e-mixed oral capsule 400 unit P OTC

cvs vitamin e oral capsule 400 unit P OTC

e 400 blended oral capsule 400 unit P OTC

e400 mixed oral capsule 400 unit P OTC

e400 oral capsule 400 unit P OTC

e-400 oral capsule 400 unit P OTC

e-400-clear oral capsule 400 unit P OTC

e-400-mixed oral capsule 400 unit P OTC

eql vitamin e oral capsule 400 unit P OTC

gnp vitamin e oral capsule 400 unit P OTC

hm vitamin e oral capsule 400 unit P OTC


79

Drug Name Preference Details Coverage Detailsnatural blend e-400 oral capsule 400 unit P OTC

natural vitamin e oral capsule 400 unit P OTC

pa vitamin e oral capsule 400 unit P OTC

px vitamin e oral capsule 400 unit P OTC

ra natural vitamin e oral capsule 400 unit P OTC

ra vitamin e blend oral capsule 400 unit P OTC

ra vitamin e oral capsule 400 unit P OTC

sm vitamin e oral capsule 400 unit P OTC

th vitamin e oral capsule 400 unit P OTC

vitamin e blend oral capsule 400 unit P OTC

vitamin e complex oral capsule 400 unit P OTC

vitamin e natural oral capsule 400 unit P OTC

vitamin e oral capsule 400 unit P OTC

vitamin e water soluble oral capsule 400 unit P OTC

vitamin e/d-alpha natural oral capsule 400 unit P OTC

vitamin e-400 oral capsule 400 unit P OTC

vita-plus e oral capsule 400 unit P OTC

yl vitamin e oral capsule 400 unit P OTC

*Oil Soluble Vitamins**-*Vitamin K***

MEPHYTON ORAL TABLET 5 MG P

vitamin k (phytonadione) oral tablet 100 mcg P OTC

*Water Soluble Vitamins**-*Biotin***

biotin 5000 oral capsule 5 mg P OTC

biotin maximum strength oral capsule 5000 mcg P OTC

biotin oral capsule 5 mg, 5000 mcg P OTC

*Water Soluble Vitamins**-*Vitamin B-1***

thiamine hcl injection solution 100 mg/ml P

vitamin b-1 oral tablet 100 mg, 250 mg, 50 mg P OTC


niacin er oral capsule extended release* 500 mg P OTC

niacin er oral tablet extendedrelease* 500 mg P OTC

niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg P OTC

NIACOR ORAL TABLET 500 MG P


vitamin b-6 er oral tablet extendedrelease* 200 mg

P OTC


Drug Name Preference Details Coverage Detailsvitamin b-6 oral tablet 100 mg, 25 mg, 250 mg, 50 mg, 500 mg

P OTC

*Water Soluble Vitamins**-*Vitamin C***

ascorbic acid oral tablet 500 mg P OTC

c 500 oral tablet 500 mg P OTC

c 500/rose hips oral tablet 500 mg P OTC

c-500 oral tablet 500 mg P OTC

c-500/rose hips oral tablet 500 mg P OTC

cvs vitamin c oral tablet 500 mg P OTC

cvs vitamin c-rose hips oral tablet 500 mg P OTC

eql vitamin c oral tablet 500 mg P OTC

eql vitamin c/rose hips oral tablet 500 mg P OTC

gnp vitamin c oral tablet 500 mg P OTC

gnp vitamin c w/rose hips oral tablet 500 mg, 500-37 mg

P OTC

hm vitamin c oral tablet 500 mg P OTC

meijer c oral tablet 500 mg P OTC

natural c/rose hips oral tablet 500 mg P OTC

px vitamin c oral tablet 500 mg P OTC

ra vitamin c oral tablet 500 mg P OTC

ra vitamin c/rose hips oral tablet 500 mg P OTC

sb vitamin c oral tablet 500 mg P OTC

sm vitamin c oral tablet 500 mg P OTC

sm vitamin c/rose hips oral tablet 500 mg P OTC

th vitamin c oral tablet 500 mg P OTC

vitamin c oral tablet 500 mg P OTC

vitamin c/rose hips oral tablet 500 mg P OTC

vitamin c-acerola oral tablet 500 mg P OTC

vitamin c-rose hips oral tablet 500 mg P OTC

yl vitamin c oral tablet 500 mg P OTC

yl vitamin c-rose hips oral tablet 500 mg P OTC


81


Index

Index

3 day vaginal ........................................................... 77abacavir sulfate ................................................... 34abacavir-lamivudine-zidovudine....................................................................................................... 32ABILIFY ....................................................................... 32ABILIFY MAINTENA .......................... 32acamprosate calcium .................................. 72acarbose ......................................................................... 16ACCU-CHEK ACTIVE ........................ 50ACCU-CHEK AVIVA PLUS........................................................................................... 50, 59ACCU-CHEK COMFORT CURVE ........................................................................... 50ACCU-CHEK COMPACT PLUS CARE ................................................................................. 59ACCU-CHEK COMPACT TEST DRUM .............................................................................. 50ACCU-CHEK NANO SMARTVIEW ...................................................... 59ACCU-CHEK SMARTVIEW ..... 50acetaminophen ......................................................... 4acetaminophen-codeine .............................. 5acetaminophen-codeine #2 .................... 5acetaminophen-codeine #3 .................... 5acetaminophen-codeine #4 .................... 5acetazolamide ........................................................ 51acetic acid-aluminum acetate ........ 70acetylcysteine ......................................................... 44acid reducer .............................................................. 76acne medication .................................................. 44acne medication 5 ............................................ 44ACTICIN ...................................................................... 49acyclovir ......................................................................... 35ADRUCIL ................................................................... 26ADVAIR DISKUS ........................................ 10ADVAIR HFA ..................................................... 10AEROCHAMBER PLUS FLO-VU ......................................................................... 60AEROCHAMBER PLUS FLO-VU LARGE ............................................ 60AEROCHAMBER PLUS FLO-VU SMALL ............................................ 60AEROCHAMBER PLUS FLO-VU W/MASK ...................................... 60AFINITOR ................................................................. 28ak-poly-bac ................................................................ 68ALAVERT ALLERGY/SINUS....................................................................................................... 43ALBENZA ..................................................................... 7albuterol sulfate .................................................. 11

Index

alclometasone dipropionate ............. 47alcohol pads ............................................................. 60alendronate sodium ....................................... 52aler-dryl .......................................................................... 21ALKERAN ................................................................ 26ALLEGRA-D ALLERGY & CONGESTION ................................................... 43allergy .................................................................... 20, 21allergy relief/nasal decongest ....... 43allopurinol .................................................................. 55alph-e .................................................................................. 79alph-e-mixed ............................................................ 79alprazolam ...................................................................... 8ALTAVERA ........................................................... 39aluminum hydroxide gel ............................. 7aluminum-magnesium-simethicone........................................................................................................... 7amantadine hcl ..................................................... 29A-METHAPRED ............................................. 43amiloride-hydrochlorothiazide .... 51aminophylline ......................................................... 11amiodarone hcl ........................................................ 9amitriptyline hcl ................................................. 15AMLACTIN ............................................................ 48amlodipine besylate ...................................... 37ammonium lactate ........................................... 48AMNESTEEM ..................................................... 45amoxapine ................................................................... 15amoxicillin .................................................................. 71amoxicillin-pot clavulanate........................................................................................... 71, 72amphetamine-dextroamphet er ........ 1amphetamine-dextroamphetamine........................................................................................................... 1ampicillin ...................................................................... 71anagrelide hcl ........................................................ 56anastrozole ................................................................. 27antipyrine-benzocaine ............................... 70APIDRA ......................................................................... 18APIDRA SOLOSTAR ............................. 18APRI .................................................................................... 39APRISO .......................................................................... 54APTIVUS ..................................................................... 33ARGYLE STERILE SALINE ..... 54ARMOUR THYROID ............................. 75artificial tears ........................................................ 67ASCOMP-CODEINE .................................... 5ascorbic acid ........................................................... 81ASMANEX 120 METERED DOSES ............................................................................. 10

Index

ASMANEX 30 METERED DOSES ............................................................................. 10ASMANEX 60 METERED DOSES ............................................................................. 10ASMANEX HFA ............................................. 10aspirin .................................................................................... 4aspirin adult low strength ....................... 4aspirin ec ........................................................................... 4atenolol ............................................................................ 36atenolol-chlorthalidone .......................... 24atorvastatin calcium .................................... 22atovaquone ................................................................. 24atovaquone-proguanil hcl ................... 25ATRIPLA ..................................................................... 32atropine sulfate .................................................... 68ATROVENT HFA ............................................. 9AUBAGIO ................................................................. 73AVANDAMET ................................................... 17AVANDARYL .................................................... 17AVANDIA ................................................................. 18AVASTIN ................................................................... 26AVIANE ........................................................................ 40AVITA ............................................................................. 45AVODART ............................................................... 55azathioprine .............................................................. 36azelastine hcl ........................................................... 66azithromycin ............................................................. 59azithromycin hydrogencitrate ....... 59AZOPT ............................................................................. 70AZURETTE ............................................................. 39bacitracin zinc ....................................................... 45bacitracin-neomycin-polymyxin....................................................................................................... 45bacitracin-polymyxin b ............................ 68baclofen ........................................................................... 65balsalazide disodium .................................. 54BALZIVA ................................................................... 40baza antifungal .................................................... 46BD INSULIN SYRINGE ULTRAFINE .......................................................... 60BENADRYL ALLERGY CHILDRENS ......................................................... 21benazepril hcl ......................................................... 22benazepril-hydrochlorothiazide....................................................................................................... 23benzoyl peroxide ................................................ 45benzoyl peroxide-erythromycin ... 44benztropine mesylate ................................... 29betamethasone dipropionate ........... 47


83

Index

betamethasone dipropionate aug....................................................................................................... 47betamethasone valerate .......................... 47betaxolol hcl ............................................................. 68bethanechol chloride ................................... 77BETHKIS ......................................................................... 2BETOPTIC-S ......................................................... 68BICILLIN C-R ..................................................... 72BICILLIN C-R 900/300 ......................... 72BICILLIN L-A ..................................................... 71BILTRICIDE .............................................................. 7biotin .................................................................................... 80biotin 5000 .................................................................. 80biotin maximum strength ...................... 80bisacodyl ........................................................................ 58bisacodyl ec ............................................................... 58bisoprolol fumarate ...................................... 36bisoprolol-hydrochlorothiazide....................................................................................................... 24BOSULIF ..................................................................... 28briellyn ............................................................................. 40brimonidine tartrate ..................................... 68bromocriptine mesylate ........................... 29BRONCHO SALINE ................................. 44budesonide .................................................................. 10bumetanide ................................................................. 51buprenorphine hcl ............................................... 6bupropion hcl ......................................................... 14bupropion hcl er (sr) ................................... 14bupropion hcl er (xl) ................................... 14buspirone hcl ............................................................... 8butalbital-acetaminophen ........................ 4butalbital-apap-caff-cod ............................ 5butalbital-apap-caffeine ............................. 4butalbital-asa-caff-codeine ................... 5butalbital-asa-caffeine ................................. 4butorphanol tartrate ........................................ 6BYDUREON .......................................................... 18c 500 ..................................................................................... 81c 500/rose hips ..................................................... 81c-500 .................................................................................... 81c-500/rose hips ..................................................... 81calcipotriene ............................................................ 46calcitonin (salmon) ........................................ 52calcitriol ......................................................................... 52calcium acetate .................................................... 54calcium acetate (phos binder) ....... 61calcium carbonate ........................................... 61calcium carbonate antacid ..................... 7calcium carbonate-vitamin d .......... 61calcium lactate ..................................................... 61cal-lac ................................................................................ 61

Index

CAMILA ....................................................................... 42capecitabine ............................................................. 26CAPRELSA ............................................................. 28capsaicin ........................................................................ 49captopril ......................................................................... 22captopril-hydrochlorothiazide ..... 23CARAFATE ............................................................ 76carbamazepine ..................................................... 12carbidopa-levodopa ..................................... 29carbidopa-levodopa er ............................. 29carisoprodol ............................................................. 65carteolol hcl .............................................................. 68CARTIA XT ............................................................ 37carvedilol ...................................................................... 36CAVAREST ............................................................ 63CAZIANT ................................................................... 41cefaclor ............................................................................ 39cefadroxil .......................................................... 38, 39cefdinir ............................................................................. 39cefpodoxime proxetil ................................... 39cefprozil .......................................................................... 39cefuroxime axetil ............................................... 39celecoxib ............................................................................ 2CENTRATEX ....................................................... 56cephalexin .................................................................... 39cetirizine hcl ............................................................. 21cetirizine hcl childrens ............................. 21cetirizine-pseudoephedrine er ....... 44childrens ibuprofen ........................................... 3childrens loratadine ..................................... 21chlordiazepoxide hcl ....................................... 8chlordiazepoxide-amitriptyline ... 73chlorhexidine gluconate ............. 32, 63chlorothiazide ........................................................ 51chlorpromazine hcl ........................................ 31chlorpropamide ................................................... 19chlorthalidone ....................................................... 52chlorzoxazone ........................................................ 65cholestyramine ..................................................... 22cholestyramine light ..................................... 22ciclopirox ...................................................................... 46ciclopirox olamine .......................................... 46cilostazol ........................................................................ 55cimetidine ..................................................................... 76cimetidine hcl ......................................................... 76CIPRODEX .............................................................. 70ciprofloxacin hcl .................................... 53, 68citalopram hydrobromide .................... 15CLARAVIS .............................................................. 45clarithromycin ....................................................... 59CLEAR AWAY 1-STEP WART REMOVER ............................................................... 49

Index

clindamycin hcl ................................................... 24clindamycin palmitate hcl ................... 24clindamycin phosphate .... 25, 44, 78CLINISTIX ............................................................... 50clobetasol propionate ................................ 47clomipramine hcl .............................................. 15clonazepam ................................................................ 12clonidine hcl ............................................................. 23clopidogrel bisulfate .................................... 56clorazepate dipotassium ............................ 8clotrimazole ...................................... 46, 63, 77clotrimazole 3 ........................................................ 77clozapine ........................................................................ 31codeine sulfate .......................................................... 4colchicine ..................................................................... 55colchicine-probenecid ............................... 55COLCRYS ................................................................. 55COMBIVENT RESPIMAT ............. 10COMPLERA ........................................................... 32COMPOUND W ............................................... 49COMPOUND W MAXIMUM STRENGTH ............................................................. 49CONDYLOX ......................................................... 49COPAXONE ........................................................... 74cortisone acetate ............................................... 43CORTISPORIN .................................................. 45CREON ........................................................................... 51CRIXIVAN ............................................................... 33cromolyn sodium ........................... 9, 66, 70CRYSELLE-28 ................................................... 40cvs fish oil .................................................................... 66cvs natural fish oil .......................................... 67cvs oyster shell calcium .......................... 61cvs triple antibiotic ........................................ 45cvs vitamin c ............................................................. 81cvs vitamin c-rose hips ............................. 81cvs vitamin d ............................................................ 78cvs vitamin e ............................................................. 79cyanocobalamin ................................................. 56CYCLAFEM 1/35 .......................................... 40cyclobenzaprine hcl ...................................... 66cyclophosphamide ........................................... 26cyclosporine ............................................................. 36cyclosporine modified ............................... 35cyproheptadine hcl ......................................... 21cytra-2 ............................................................................... 54CYTRA-3 ..................................................................... 54d 1000 ................................................................................ 78d 400 .................................................................................... 78d-1000 ................................................................................ 78d-1000 extra strength ................................. 78d2000 ultra strength .................................... 78


Index

d3 super strength .............................................. 78d3-1000 ............................................................................ 78d-400 .................................................................................... 78danazol ................................................................................. 6dantrolene sodium ........................................... 66dapsone ............................................................................ 24DARAPRIM ............................................................ 25deferoxamine mesylate ............................. 19DELSYM NGHT TIME CGH/CLD CHILD ......................................... 44DELSYM NIGHT TIME COUGH/COLD .................................................. 44delta d3 ............................................................................ 78DENAVIR .................................................................. 47DENTAGEL ............................................................ 63desipramine hcl ................................................... 15desmopressin ace rhinal tube ........ 53desmopressin ace spray refrig ...... 53desmopressin acetate .................................. 53desmopressin acetate spray .............. 53desonide .......................................................................... 47dexamethasone ..................................................... 43dexamethasone sodium phosphate........................................................................................... 43, 69dexmethylphenidate hcl ............................... 1dextroamphetamine sulfate ................... 1dextroamphetamine sulfate er ........... 1DIASTIX ...................................................................... 50diazepam ................................................................ 8, 12diclofenac potassium ....................................... 3diclofenac sodium .................................... 3, 70diclofenac sodium er ....................................... 3dicloxacillin sodium ..................................... 72dicyclomine hcl .................................................... 76didanosine ................................................................... 34diflunisal ............................................................................ 4digoxin .............................................................................. 38DILANTIN ................................................................ 13diltiazem hcl ............................................................. 37diltiazem hcl er ..................................................... 37diltiazem hcl er beads ................................ 37diltiazem hcl er coated beads ......... 37dilt-xr .................................................................................. 37diphenhydramine hcl ................................... 21diphenhydramine hcl (sleep) ........... 57diphenoxylate-atropine ............................ 19dipyridamole ................................................ 50, 55disopyramide phosphate ............................ 8disulfiram ..................................................................... 72divalproex sodium ........................................... 14divalproex sodium er .................................. 14docusate sodium ................................................. 58

Index

donepezil hcl ............................................................ 72dorzolamide hcl ................................................... 70dorzolamide hcl-timolol mal ........... 67double antibiotic ................................................ 45doxazosin mesylate ........................................ 23doxepin hcl ................................................................. 15doxycycline hyclate ....................................... 74doxycycline monohydrate .................... 74DRITHO-CREME HP .............................. 46DULERA ...................................................................... 11e 400 blended ......................................................... 79E.E.S. GRANULES ..................................... 59e400 ....................................................................................... 79e-400 .................................................................................... 79e400 mixed .................................................................. 79e-400-clear ................................................................. 79e-400-mixed .............................................................. 79econazole nitrate ............................................... 46EDURANT ................................................................ 33ELIDEL .......................................................................... 49ELIPHOS ..................................................................... 54ELITE-OB .................................................................. 65ELIXOPHYLLIN ............................................ 11ELMIRON .................................................................. 54EMCYT .......................................................................... 27EMOQUETTE ..................................................... 40EMTRIVA .................................................................. 34enalapril maleate .............................................. 22enalapril-hydrochlorothiazide ..... 23ENDOCET ..................................................................... 6ENDOMETRIN ................................................. 78enema disposable ............................................. 58ENJUVIA ..................................................................... 53enoxaparin sodium ......................................... 12ENPRESSE-28 .................................................... 41entecavir ......................................................................... 34epa ........................................................................................... 67EPIPEN 2-PAK ................................................... 78EPIPEN JR 2-PAK ........................................ 78EPITOL ........................................................................... 12EPIVIR HBV .......................................................... 34EPZICOM ................................................................... 32eq aspirin low dose ............................................ 4eql fish oil .................................................................... 67eql vitamin c ............................................................. 81eql vitamin c/rose hips .............................. 81eql vitamin d3 ......................................................... 78eql vitamin d-3 ...................................................... 79eql vitamin e ............................................................. 79ERIVEDGE .............................................................. 26ERRIN .............................................................................. 42ERWINAZE ............................................................. 28

Index

ery ............................................................................................ 44ERYPED 200 ......................................................... 59ERYPED 400 ......................................................... 59ERY-TAB .................................................................... 59ERYTHROCIN STEARATE ........ 59erythromycin ................................................ 44, 68erythromycin base ........................................... 59erythromycin ethylsuccinate ............ 59escitalopram oxalate ................................... 15ESTARYLLA ........................................................ 40estazolam ...................................................................... 57estradiol .......................................................................... 53estradiol-norethindrone acet .......... 53estropipate .................................................................. 53ethambutol hcl ....................................................... 25ethosuximide ............................................................ 14etodolac ............................................................................... 3etoposide ........................................................................ 29EXEL PEN NEEDLES 1/3" ............ 60EXELON ...................................................................... 72EXJADE ........................................................................ 19EXTAVIA ................................................................... 73E-Z SPACER .......................................................... 60famotidine .................................................................... 76famotidine premixed .................................... 76fenofibrate ................................................................... 22fenofibrate micronized .............................. 22fenoprofen calcium ............................................ 3fentanyl ................................................................................. 4ferrex 150 ..................................................................... 56ferrex 150 forte .................................................... 56ferrous sulfate ........................................................ 56fexofenadine hcl .................................................. 21fexofenadine hcl childrens .................. 21fexofenadine-pseudoephed er ........ 44fiber ....................................................................................... 57finasteride .................................................................... 55FIRAZYR .................................................................... 55fish oil ................................................................................ 67fish oil burp-less ................................................ 67fish oil concentrate ......................................... 67fish oil ultra ............................................................... 67fish oil/super potent/no burp ........... 67flecainide acetate .................................................. 9FLOVENT DISKUS ................................... 10FLOVENT HFA ................................................ 10fluconazole ................................................................. 20fludrocortisone acetate ............................ 43flunisolide .................................................................... 66fluocinolone acetonide ................. 47, 48fluocinolone acetonide body ............ 47fluocinolone acetonide scalp .......... 48


85

Index

fluocinonide .............................................................. 48fluocinonide-e ........................................................ 48FLUOR-A-DAY ................................................ 62FLUORIDEX DAILY DEFENSE....................................................................................................... 64fluorometholone ................................................. 69fluorouracil .................................................... 26, 46fluoxetine hcl ........................................................... 15fluphenazine decanoate ........................... 31fluphenazine hcl .................................................. 31flurbiprofen .................................................................... 3flurbiprofen sodium ...................................... 70fluticasone propionate .................. 48, 66fluvoxamine maleate .................................... 15FML FORTE .......................................................... 69folic acid ........................................................................ 56fondaparinux sodium .................................. 12FORADIL AEROLIZER ..................... 11FORTICAL ............................................................... 52fosinopril sodium .............................................. 22fosphenytoin sodium .................................... 13FREESTYLE FREEDOM LITE....................................................................................................... 59FREESTYLE INSULINX SYSTEM ....................................................................... 60FREESTYLE INSULINX TEST....................................................................................................... 50FREESTYLE LITE ....................................... 60FREESTYLE LITE TEST ................. 50FREESTYLE TEST ..................................... 50furosemide ................................................................... 51FUZEON ....................................................................... 33gabapentin .................................................................. 13GABITRIL ................................................................. 13gas relief ........................................................................ 53GAVILYTE-G ..................................................... 57GAVILYTE-N WITH FLAVOR PACK ................................................................................. 57gemcitabine hcl ................................................... 26gemfibrozil .................................................................. 22generlac .......................................................................... 54GENGRAF ................................................................. 36gentamicin sulfate ............................... 45, 68GIANVI .......................................................................... 40GILDESS 1.5/30 ............................................... 40GILDESS 1/20 ..................................................... 40GILOTRIF .................................................................. 28GLEEVEC .................................................................. 28glimepiride ................................................................. 19glipizide ........................................................................... 19glipizide er .................................................................. 19GLIPIZIDE XL ................................................... 19

Index

glipizide-metformin hcl ........................... 16GLUCAGEN .......................................................... 17GLUCAGEN HYPOKIT ..................... 17GLUCAGON EMERGENCY ...... 17glucose .............................................................................. 17glucose control ..................................................... 60glyburide ........................................................................ 19glyburide micronized .................................. 19glyburide-metformin .................................... 16glycopyrrolate ....................................................... 76gnp fish oil .................................................................. 67gnp vitamin c ........................................................... 81gnp vitamin c w/rose hips .................... 81gnp vitamin d .......................................................... 79gnp vitamin d3 extra strength ........ 79gnp vitamin e ........................................................... 79GOLYTELY ............................................................ 57griseofulvin microsize ............................... 20griseofulvin ultramicrosize ................ 20guaifenesin ................................................................. 44guanfacine hcl ....................................................... 23halobetasol propionate ............................ 48haloperidol ................................................................. 31haloperidol decanoate .............................. 30haloperidol lactate ......................................... 30HARVONI ................................................................. 34HECORIA ................................................................... 36HEXALEN ................................................................. 25hm fish oil .................................................................... 67hm vitamin c ............................................................. 81hm vitamin d ............................................................. 79hm vitamin d3 ......................................................... 79hm vitamin e ............................................................. 79HUMALOG ............................................................. 18HUMALOG KWIKPEN ....................... 18HUMALOG MIX 50/50 ........................ 18HUMALOG MIX 75/25 ........................ 18HUMALOG MIX 75/25 KWIKPEN ................................................................. 18HUMIRA .......................................................................... 2HUMIRA PEN ......................................................... 2HUMIRA PEN-CROHNS STARTER ....................................................................... 2HUMULIN 70/30 ............................................ 18HUMULIN N ......................................................... 18humulin n kwikpen .......................................... 18HUMULIN R ......................................................... 18HUMULIN R U-500 (CONCENTRATED) ................................. 18hydralazine hcl ..................................................... 24hydrochlorothiazide ..................................... 52hydrocodone-acetaminophen ............. 5

Index

hydrocodone-ibuprofen ............................... 6hydrocortisone .................................. 6, 43, 48hydrocortisone valerate .......................... 48hydromorphone hcl ........................................... 4hydroxychloroquine sulfate ............... 25hydroxyurea .............................................................. 28hydroxyzine hcl ........................................................ 8hydroxyzine pamoate ...................................... 8HYPERCARE ....................................................... 49ibuprofen ........................................................................... 3ICLUSIG ....................................................................... 28imipramine hcl ...................................................... 16IN-CHECK DIAL FLOW TRAINER .................................................................... 60indapamide ................................................................. 52indomethacin ............................................................... 3insulin syringe ....................................................... 60INTELENCE .......................................................... 33INVEGA SUSTENNA ............................ 30INVIRASE ................................................................. 33INVOKAMET ...................................................... 16INVOKANA ........................................................... 19ipratropium bromide ........................... 9, 66ipratropium-albuterol ................................ 11ISENTRESS ............................................................ 33isoniazid ......................................................................... 25isosorbide dinitrate ........................................... 7isosorbide dinitrate er ................................... 7isosorbide mononitrate ................................ 7isosorbide mononitrate er ....................... 7ivermectin ......................................................................... 7JAKAFI ........................................................................... 28JANTOVEN ............................................................. 11JANUMET ................................................................. 16JANUMET XR .................................................... 16JANUVIA .................................................................... 17JARDIANCE .......................................................... 19JENTADUETO ................................................... 16JOLIVETTE ............................................................. 42JUNEL 1.5/30 ........................................................ 40JUNEL 1/20 .............................................................. 40JUNEL FE 1.5/30 ............................................ 40JUNEL FE 1/20 .................................................. 40KALETRA ................................................................. 32KALYDECO .......................................................... 74KARIGEL ................................................................... 64KARIGEL-N ........................................................... 64KARIVA ....................................................................... 39KELNOR 1/35 ...................................................... 40ketoconazole ................................................. 20, 46ketoprofen ........................................................................ 3ketorolac tromethamine .............................. 3


Index

KETOSTIX ............................................................... 50ketotifen fumarate ............................................ 70KLOR-CON ............................................................. 62KLOR-CON 10 ................................................... 62KLOR-CON M10 ............................................ 62KLOR-CON M20 ............................................ 62kp vitamin d ............................................................... 79labetalol hcl .............................................................. 36lactated ringers ................................................... 62lactulose ......................................................................... 58lamivudine ................................................................... 34lamivudine-zidovudine ............................. 32lamotrigine ................................................................. 13lancet device ............................................................ 60lancets ................................................................................ 60lansoprazole ............................................................. 76LANTUS ....................................................................... 19LANTUS SOLOSTAR ........................... 19latanoprost ................................................................. 70LAVOCLEN-4 CREAMY WASH....................................................................................................... 45LAVOCLEN-8 CREAMY WASH....................................................................................................... 45leflunomide ..................................................................... 3LESSINA ..................................................................... 40LETAIRIS ................................................................... 38letrozole .......................................................................... 27leucovorin calcium ......................................... 29LEUKERAN ........................................................... 26levetiracetam ........................................................... 13levobunolol hcl ..................................................... 68levocarnitine ............................................................ 52levocetirizine dihydrochloride ...... 21levofloxacin ............................................................... 53levonorgestrel ........................................................ 42LEVORA 0.15/30 (28) ............................ 40levothyroxine sodium .................................. 75LEXIVA ......................................................................... 33lidocaine ......................................................................... 49lidocaine hcl ................................................. 49, 59lidocaine hcl (cardiac) ................................. 9lidocaine hcl (pf) ............................................... 58lidocaine viscous ............................................... 63lidocaine-prilocaine ..................................... 49liothyronine sodium ...................................... 75lisinopril ......................................................................... 23lisinopril-hydrochlorothiazide ..... 23lithium ................................................................................ 30lithium carbonate ............................................. 30lithium carbonate er ..................................... 30lomustine ....................................................................... 26LOPERAMIDE A-D ................................... 19

Index

loperamide hcl ...................................................... 19loratadine ..................................................................... 21loratadine hives relief ................................ 21lorazepam ......................................................................... 8LORYNA ..................................................................... 40losartan potassium ......................................... 23losartan potassium-hctz .......................... 23LOTEMAX ............................................................... 69lovastatin ....................................................................... 22LOW-OGESTREL ......................................... 40loxapine succinate ........................................... 31LUMIZYME ........................................................... 52LUTERA ....................................................................... 40LYSODREN ............................................................ 26MAALOX MULTI SYMPTOM MAX ST ............................................................................ 7MACRODANTIN .......................................... 77mag-delay ..................................................................... 62magnesium dr ......................................................... 62magnesium oxide ....................................... 7, 62mag-sr ................................................................................ 62MAG-TAB SR ..................................................... 62MAKENA ................................................................... 72malathion ...................................................................... 49mapap ..................................................................................... 4maprotiline hcl ..................................................... 14MATZIM LA ......................................................... 37maxepa ............................................................................. 67MAXIDEX ................................................................. 70meclizine hcl ............................................................ 20medroxyprogesterone acetate........................................................................................... 42, 72mefloquine hcl ....................................................... 25megestrol acetate .............................................. 27meijer c ............................................................................ 81melatonin .......................................................................... 2melatonin maximum strength ............. 2meloxicam ........................................................................ 3MENEST ...................................................................... 53MEPHYTON .......................................................... 80meprobamate .............................................................. 8mercaptopurine ................................................... 26mesalamine ................................................................ 54MESTINON ............................................................. 25METAMUCIL ...................................................... 57METAMUCIL SMOOTH TEXTURE .................................................................. 57metaproterenol sulfate .............................. 11metformin hcl .......................................................... 17metformin hcl er ................................................. 17metformin hcl er (osm) ............................. 17methadone hcl ........................................................... 4

Index

methazolamide ...................................................... 51methimazole .............................................................. 75methitest ............................................................................. 6methocarbamol .................................................... 66methotrexate ............................................................. 26methotrexate sodium ................................... 26methotrexate sodium (pf) ...................... 26methyldopa ................................................................. 23methylergonovine maleate .................. 71METHYLIN ................................................................. 1methylphenidate hcl .......................................... 2methylphenidate hcl er ......................... 1, 2methylprednisolone ....................................... 43methylprednisolone (pak) .................... 43methylprednisolone acetate .............. 43methylprednisolone sodium succ....................................................................................................... 43metipranolol ............................................................. 68metoclopramide hcl ....................................... 54metolazone .................................................................. 52metoprolol succinate er .......................... 36metoprolol tartrate ......................................... 36metronidazole ................................. 24, 49, 78mexiletine hcl .............................................................. 9miconazole 3 ............................................................ 77miconazole 3 combo pack ................... 77miconazole nitrate ........................................... 78MICROCHAMBER .................................... 60MICROGESTIN 1.5/30 ......................... 40MICROGESTIN 1/20 ............................... 40MICROGESTIN FE 1.5/30 .............. 40MICROGESTIN FE 1/20 .................... 40MICROSPACER .............................................. 60midodrine hcl .......................................................... 78milk of magnesia ................................................ 58minocycline hcl .................................................... 74minoxidil ........................................................................ 24mirtazapine ................................................................ 14misoprostol ................................................................ 77mometasone furoate ..................................... 48MONISTAT 3 ....................................................... 78MONONESSA ..................................................... 40montelukast sodium ....................................... 10morphine sulfate .................................................... 5morphine sulfate (concentrate) ....... 5morphine sulfate (pf) ....................................... 5morphine sulfate er ............................................ 5mucus relief ............................................................... 44multi-vit/fluoride ................................................ 64multi-vit/fluoride/iron ................................ 64multivitamin/fluoride .................................. 64multi-vitamin/fluoride ................................ 64


87

Index

multi-vitamins ........................................................ 64mupirocin ..................................................................... 46mycophenolate mofetil .............................. 36MYLERAN ............................................................... 26MYNATAL ADVANCE ..................... 65mynatal-z ....................................................................... 65mynate 90 plus ...................................................... 65nabumetone ................................................................... 3nadolol .............................................................................. 37naltrexone hcl ........................................................ 20NAMENDA ............................................................. 72NAMENDA TITRATION PAK....................................................................................................... 73NAMENDA XR ................................................ 73NAMENDA XR TITRATION PACK ................................................................................. 73naproxen ............................................................................ 3naproxen dr ................................................................... 3naproxen sodium ................................................... 3naratriptan hcl ...................................................... 61nat-rul vitamin d ................................................ 79natural blend e-400 ....................................... 80natural c/rose hips .......................................... 81natural vitamin e ............................................... 80NATURE-THROID ..................................... 75NECON 0.5/35 (28) ..................................... 41NECON 1/35 (28) ........................................... 41NECON 7/7/7 ........................................................ 41nefazodone hcl ...................................................... 15neomycin-bacitracin zn-polymyx....................................................................................................... 69neomycin-polymyxin-dexameth ... 69neomycin-polymyxin-gramicidin....................................................................................................... 69neomycin-polymyxin-hc .............. 69, 71NEUPOGEN ........................................................... 56NEUTRAGARD ADVANCED....................................................................................................... 64nevirapine .................................................................... 33NEXT CHOICE ONE DOSE ........ 42niacin .................................................................................. 80niacin er .......................................................................... 80NIACOR ............................................................ 22, 80nicotine ............................................................................. 74nicotine polacrilex .......................................... 74NIFEDIAC CC .................................................... 38NIFEDICAL XL ............................................... 38nifedipine ...................................................................... 38nifedipine er .............................................................. 38nifedipine er osmotic ................................... 38NITRO-BID ................................................................. 8nitrofurantoin macrocrystal ............. 77

Index

nitrofurantoin monohyd macro ... 77nitroglycerin ................................................................. 8NITROSTAT .............................................................. 8no flush niacin ....................................................... 38NORA-BE ................................................................... 42norethindrone ......................................................... 42norethindrone acetate ............................... 72norgestimate-eth estradiol .................. 41normal saline flush ........................................ 63NORTREL 0.5/35 (28) ............................ 41NORTREL 1/35 (21) .................................. 41NORTREL 1/35 (28) .................................. 41NORTREL 7/7/7 ............................................... 42nortriptyline hcl .................................................. 16NORVIR ........................................................................ 33norwegian salmon oil ................................ 67np thyroid ..................................................................... 75NUVARING ............................................................ 42nystatin ..................................................... 20, 46, 63OCELLA ....................................................................... 41ofloxacin ............................................................. 68, 70olanzapine ................................................................... 31OLYSIO ......................................................................... 34omega 3 ........................................................................... 67omega iii epa+dha ......................................... 67omega-3 .......................................................................... 67omega-3 cf ................................................................... 67omega-3 fish oil .................................................. 67omega-3 plus ........................................................... 67omeprazole ................................................................. 76ondansetron .............................................................. 20ondansetron hcl ................................................... 20OPTICHAMBER ADVANTAGE....................................................................................................... 60OPTICHAMBER ADVANTAGE-LG MASK .............. 60OPTICHAMBER ADVANTAGE-MED MASK ....... 61OPTICHAMBER ADVANTAGE-SM MASK ............. 61OPTICHAMBER FACE MASK-LARGE .................................................. 61OPTICHAMBER FACE MASK-MEDIUM ........................................... 61OPTICHAMBER FACE MASK-SMALL ................................................. 61OPTIHALER .......................................................... 61ORALYTE ................................................................. 61ORALYTE FREEZER POPS ....... 61ORAP ................................................................................. 74ORSYTHIA .............................................................. 41oticin .................................................................................... 70

Index

oxacillin sodium ................................................. 72oxandrolone .................................................................. 6oxaprozin .......................................................................... 3oxazepam .......................................................................... 8oxcarbazepine ........................................................ 13oxybutynin chloride ....................................... 77oxybutynin chloride er .............................. 77oxycodone hcl ............................................................ 5oxycodone-acetaminophen ..................... 6oxycodone-aspirin ............................................... 6oyst-cal ............................................................................. 61oyster calcium ....................................................... 61oyster shell calcium ...................................... 61pa fish oil ...................................................................... 67pa vitamin d-3 ........................................................ 79pa vitamin e ............................................................... 80PACERONE ................................................................ 9pain & fever childrens .................................. 4pantoprazole sodium ................................... 77paroxetine hcl ........................................................ 15peak flow meter ................................................... 60peg 3350/electrolytes .................................. 58peg 3350-kcl-na bicarb-nacl ........... 58peg-3350/electrolytes ................................. 58PEGANONE ........................................................... 13PEGASYS ................................................................... 35PEGASYS PROCLICK ......................... 35penicillin g procaine .................................... 71penicillin v potassium ................................ 71pentazocine-naloxone hcl ........................ 6pentoxifylline er .................................................. 55PERIOGARD ......................................................... 63permethrin ................................................................... 50perphenazine ........................................................... 31perphenazine-amitriptyline ............... 73PERTZYE ................................................................... 51PFIZERPEN-G .................................................... 71phenazopyridine hcl ..................................... 55phenelzine sulfate ............................................. 14phenobarbital ......................................................... 57phenobarbital sodium ................................ 57phenytoin ....................................................................... 13phenytoin sodium .............................................. 14phenytoin sodium extended ............... 13PHOS-FLUR ........................................................... 64pilocarpine hcl .......................................... 64, 68pindolol ............................................................................ 37PIN-X ..................................................................................... 7pioglitazone hcl ................................................... 18pioglitazone hcl-metformin hcl .... 17piroxicam .......................................................................... 3PLAN B ONE-STEP .................................. 42


Index

podofilox ........................................................................ 49polycin b ......................................................................... 69poly-dex ........................................................................... 69polyethylene glycol 3350 ...................... 58polymyxin b-trimethoprim ................... 69polyvitamin ................................................................. 65polyvitamin/iron ................................................. 65PORTIA-28 ............................................................... 41potassium chloride ......................................... 63potassium chloride crys er ................. 62potassium chloride er ..................... 62, 63potassium chloride in nacl ................. 62PR NATAL 400 EC ..................................... 65pramipexole dihydrochloride ......... 29pravastatin sodium ......................................... 22prazosin hcl ............................................................... 23PRECISION XTRA ..................................... 60PRECISION XTRA BLOOD GLUCOSE ................................................................. 51PRECISION XTRA KETONE ... 51PRED-G ......................................................................... 69prednisolone ............................................................. 43prednisolone acetate ................................... 70prednisolone sodium phosphate....................................................................................................... 43prednisone ................................................................... 43PREMARIN ................................................. 53, 78PREMPHASE ....................................................... 53PREMPRO ................................................................. 53PRENATABS RX .......................................... 65prenatal low iron .............................................. 65prenatal plus ............................................................ 65prenatal plus iron ............................................ 65prenatal vitamins .............................................. 65PRENATAL-U .................................................... 65PREVIFEM ............................................................... 41PREZISTA ................................................................. 33primaquine phosphate ............................... 25primidone ..................................................................... 13probenecid .................................................................. 55procainamide hcl .................................................. 8prochlorperazine ............................................... 31prochlorperazine maleate ................... 31PROCRIT .................................................................... 56PROCTOSOL HC .............................................. 6PROCTOZONE-HC ........................................ 6PROLIA ......................................................................... 52promethazine hcl ............................................... 21PROMETHEGAN .......................................... 21propafenone hcl ...................................................... 9propantheline bromide ............................. 76propranolol hcl .................................................... 37

Index

propranolol hcl er ........................................... 37propranolol-hctz ................................................ 24propylthiouracil .................................................. 75protriptyline hcl .................................................. 16pseudoephedrine hcl .................................... 66PULMICORT ........................................................ 10PULMOZYME .................................................... 74px fish oil ....................................................................... 67px vitamin c ............................................................... 81px vitamin e ............................................................... 80pyrazinamide ........................................................... 25pyridostigmine bromide .......................... 25QUASENSE ............................................................. 41quetiapine fumarate ...................................... 31quinapril hcl ............................................................. 23quinidine gluconate ........................................... 8quinidine gluconate er .................................. 8quinidine sulfate ..................................................... 9ra fish oil ....................................................................... 67ra natural vitamin e ...................................... 80ra oyster shell calcium ............................. 61ra vitamin c ................................................................ 81ra vitamin c/rose hips ................................ 81ra vitamin d-3 ......................................................... 79ra vitamin e ................................................................ 80ra vitamin e blend ............................................ 80raloxifene hcl .......................................................... 52ramipril ............................................................................ 23ranitidine acid reducer ............................ 76ranitidine hcl ........................................................... 76REBIF ................................................................................ 73REBIF REBIDOSE ...................................... 73REBIF REBIDOSE TITRATION PACK ................................................................................. 73REBIF TITRATION PACK ............ 73RECLIPSEN ............................................................ 41reeses pinworm medicine ......................... 7refenesen ........................................................................ 44refenesen 400 .......................................................... 44RELENZA DISKHALER ................... 35REMEVEN ................................................................ 48rena-vite ......................................................................... 64RENVELA ................................................................. 54RESCRIPTOR ...................................................... 33RESTASIS ................................................................. 69REVLIMID ............................................................... 35REYATAZ ................................................................. 33RIBASPHERE ..................................................... 35ribavirin .......................................................................... 35RIDAURA ...................................................................... 2rifabutin .......................................................................... 25rifampin ........................................................................... 25

Index

rimantadine hcl ................................................... 35RIOMET ........................................................................ 17risperidone ................................................................. 30RISPERIDONE M-TAB ....................... 30rivastigmine tartrate .................................... 72robafen ............................................................................. 44ropinirole hcl .......................................................... 30ROXICET ........................................................................ 6SALACTIC FILM .......................................... 49saline flush .................................................................. 63saline mist spray ................................................ 66saline nasal spray ............................................ 66salsalate .............................................................................. 4SANDIMMUNE ............................................... 36SANTYL ....................................................................... 48SAPHRIS ..................................................................... 31SAVELLA .................................................................. 73SAVELLA TITRATION PACK....................................................................................................... 73sb omega-3 fish oil ......................................... 67sb oyster shell calcium ............................. 61sb vitamin c ................................................................ 81sea-omega 50 .......................................................... 67selegiline hcl ............................................................ 30selenium sulfide ................................................... 47SELZENTRY ......................................................... 32se-natal 19 ................................................................... 65senna .................................................................................... 58senna laxative ........................................................ 58senna s ............................................................................... 58SEREVENT DISKUS ............................... 11sertraline hcl ........................................................... 15sf ................................................................................................. 64sildenafil citrate .................................................. 38silver sulfadiazine ............................................ 47simethicone .................................................... 53, 54SIMPONI ......................................................................... 2simvastatin .................................................................. 22SIVEXTRO ............................................................... 25slow release iron ............................................... 56sm fish oil ..................................................................... 67sm magnesium oxide .................................... 62sm vitamin c .............................................................. 81sm vitamin c/rose hips ............................... 81sm vitamin d ............................................................. 79sm vitamin d3 ......................................................... 79sm vitamin e .............................................................. 80sodium bicarbonate ........................................... 7sodium chloride ........................... 44, 54, 63sodium fluoride .................................................... 62sodium polystyrene sulfonate ......... 36SOLIA ............................................................................... 41


89

Index

sorbitol ............................................................................. 58SORINE ......................................................................... 37sotalol hcl ..................................................................... 37sotalol hcl (af) ....................................................... 37SOVALDI ................................................................... 35spinosad .......................................................................... 50spironolactone ...................................................... 51spironolactone-hctz ....................................... 51SPRINTEC 28 ...................................................... 41SPRYCEL ................................................................... 28SPS ......................................................................................... 36SRONYX ..................................................................... 41SSD ........................................................................................ 47SSKI ..................................................................................... 62stavudine ........................................................................ 34STIVARGA .............................................................. 28stool softener ........................................................... 58stool softener laxative dc ...................... 58STRIBILD .................................................................. 32sucralfate ...................................................................... 76sulfacetamide sodium ..................... 44, 69sulfacetamide-prednisolone ............. 69sulfamethoxazole-tmp ds ....................... 24sulfamethoxazole-trimethoprim....................................................................................................... 24sulfasalazine ............................................................ 54sulindac ............................................................................... 3sumatriptan ................................................................ 61sumatriptan succinate ............................... 61SUPARTZ ................................................................... 66super omega 3 epa/dha ........................... 67super omega-epa ............................................... 67SUSTIVA ......................................................... 33, 34SUTENT ........................................................................ 28SYEDA ............................................................................ 41SYMBICORT ........................................................ 11SYNAGIS .................................................................... 71TABLOID ................................................................... 26tacrolimus .................................................................... 36TAMIFLU ................................................................... 35tamoxifen citrate ................................................ 27tamsulosin hcl ........................................................ 55TARCEVA ................................................................. 28TASIGNA ................................................................... 28TAZORAC ................................................................. 46temazepam .................................................................. 57temozolomide .......................................................... 26terazosin hcl ............................................................. 23terbinafine hcl ........................................... 20, 46terbutaline sulfate ............................................ 11terconazole ................................................................. 78TESTIM ............................................................................. 6

Index

testosterone .................................................................... 6testosterone cypionate ................................... 6testosterone enanthate .................................. 6tetracycline hcl ..................................................... 74TEV-TROPIN ....................................................... 52th omega-3 fish oil .......................................... 67th vitamin c ................................................................. 81th vitamin d3 ............................................................ 79th vitamin e ................................................................. 80THALOMID ............................................................ 35theophylline ............................................................... 11theophylline er ...................................................... 11thiamine hcl ............................................................... 80thioridazine hcl .................................................... 31thiothixene ................................................................... 32THYROLAR-1 .................................................... 75THYROLAR-1/2 .............................................. 75THYROLAR-1/4 .............................................. 75THYROLAR-2 .................................................... 75THYROLAR-3 .................................................... 75tiagabine hcl ............................................................ 13timolol maleate ........................................ 37, 68TIVICAY ..................................................................... 33tizanidine hcl ........................................................... 66TOBRADEX ........................................................... 69tobramycin .................................................................. 68tolmetin sodium ....................................................... 3topiramate ................................................................... 13torsemide ....................................................................... 51TRADJENTA ........................................................ 17tramadol hcl ................................................................. 5tranylcypromine sulfate .......................... 14travel sickness ....................................................... 20trazodone hcl ........................................................... 15TRELSTAR DEPOT .................................. 27TRELSTAR DEPOT MIXJECT....................................................................................................... 27TRELSTAR LA ................................................. 27TRELSTAR LA MIXJECT ............. 27TRELSTAR MIXJECT .......................... 27tretinoin ........................................................................... 45triamcinolone acetonide ............ 48, 64triamterene-hctz ................................................. 51triazolam ........................................................................ 57TRI-ESTARYLLA ........................................ 42trifluoperazine hcl ........................................... 31trifluridine ................................................................... 69trihexyphenidyl hcl ......................................... 29TRILYTE ..................................................................... 58trimethoprim ............................................................ 24trinatal rx 1 ................................................................ 65TRINESSA (28) ................................................. 42

Index

TRI-PREVIFEM ............................................... 42triprolidine-pse .................................................... 44TRI-SPRINTEC ................................................. 42tri-vit/fluoride ........................................................ 64tri-vit/fluoride/iron ......................................... 64tri-vitamin .................................................................... 65tri-vitamin/fluoride ........................................ 65TRIVORA (28) ................................................... 42trospium chloride ............................................. 77TRUVADA ............................................................... 32TUDORZA PRESSAIR ............................. 9tybost ................................................................................... 34TYKERB ...................................................................... 28UNITHROID .......................................................... 75urea ........................................................................................ 48URETRON D/S .................................................. 77ursodiol ............................................................................ 54uticap .................................................................................. 77valacyclovir hcl ................................................... 35valproic acid ............................................................ 14vancomycin hcl .................................................... 24VANDAZOLE ..................................................... 78VELIVET ..................................................................... 42venlafaxine hcl ...................................................... 15venlafaxine hcl er ............................................. 15VENTOLIN HFA ............................................ 11verapamil hcl .......................................................... 38verapamil hcl er ................................................. 38VESTURA ................................................................. 41VEXOL ........................................................................... 70VIDEX ............................................................................. 34VINATE AZ EXTRA ............................... 65VINATE II ................................................................. 65VINATE M ............................................................... 65VIRACEPT ............................................................... 33VIREAD ........................................................................ 34vitamin a ........................................................................ 78vitamin b complex-c ..................................... 64vitamin b-1 .................................................................. 80vitamin b-12 .............................................................. 56vitamin b-6 .................................................................. 81vitamin b-6 er ......................................................... 80vitamin c ......................................................................... 81vitamin c/rose hips ......................................... 81vitamin c-acerola .............................................. 81vitamin c-rose hips ......................................... 81vitamin d ........................................................................ 79vitamin d (cholecalciferol) ................. 79vitamin d (ergocalciferol) .................... 79vitamin d3 .................................................................... 79vitamin d-400 .......................................................... 79vitamin e ......................................................................... 80


Index

vitamin e blend ..................................................... 80vitamin e complex ............................................ 80vitamin e natural ............................................... 80vitamin e water soluble ........................... 80vitamin e/d-alpha natural .................... 80vitamin e-400 .......................................................... 80vitamin k (phytonadione) ...................... 80vitamins acd-fluoride .................................. 65vita-plus e ..................................................................... 80VOLTAREN ........................................................... 46VYVANSE .................................................................... 1warfarin sodium ................................................. 12WESTHROID ....................................................... 75XALKORI .................................................................. 28XARELTO ................................................................. 12XOLAIR ............................................................................ 9XTANDI ........................................................................ 27X-VIATE ...................................................................... 48yl vitamin c ................................................................. 81yl vitamin c-rose hips ................................. 81yl vitamin e ................................................................. 80zafirlukast .................................................................... 10ZARAH ........................................................................... 41ZELBORAF ............................................................. 27ZENCHENT FE ................................................. 41ZETIA ............................................................................... 22ZIAGEN ......................................................................... 34zidovudine .................................................................... 34zinc sulfate .................................................................. 63zinc-220 ........................................................................... 63zincate ................................................................................ 63ZOLINZA .................................................................... 27zolpidem tartrate ............................................... 57zonisamide .................................................................. 13ZOVIA 1/35E (28) ......................................... 41ZOVIRAX .................................................................. 47ZUBSOLV ..................................................................... 6ZYKADIA .................................................................. 28


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