HAMP Formulary

ph-comform-0913

DRUG FORMULARY EFFECTIVE JANUARY 1, 2013

LAST UPDATED SEPTEMBER 16, 2013

INTRODUCTION ................................................................................................................................................................. 2

HOW TO USE THIS LIST .................................................................................................................................................. 2

COVERAGE AND LIMITATIONS ................................................................................................................................... 3

PHARMACY SAVINGS PROGRAMS .............................................................................................................................. 4

CONTACT US ...................................................................................................................................................................... 5

DRUG FORMULARY LIST ............................................................................................................................................... 6

ANTI-INFECTIVE DRUGS ................................................................................................................................................ 6

AUTOIMMUNE INFLAMMATORY DISORDERS ........................................................................................................ 8

BLOOD MODIFYING DRUGS .......................................................................................................................................... 8

CANCER DRUGS ................................................................................................................................................................ 9

CENTRAL NERVOUS SYSTEM ....................................................................................................................................... 9

GASTROINTESTINAL DRUGS ...................................................................................................................................... 12

GENITOURINARY DRUGS ............................................................................................................................................. 13

HEART AND CIRCULATORY DRUGS ......................................................................................................................... 14

HORMONES, DIABETES, TEST SUPPLIES, AND RELATED DRUGS ................................................................... 17

MISCELLANEOUS CATEGORIES (INCLUDES SUPPLIES AND DEVICES) ....................................................... 20

MULTIPLE SCLEROSIS .................................................................................................................................................. 20

NEUROMUSCULAR DRUGS .......................................................................................................................................... 20

PAIN-RELIEF DRUGS ...................................................................................................................................................... 22

RESPIRATORY AGENTS ................................................................................................................................................ 24

SUPPLEMENTS ................................................................................................................................................................. 25

TOPICAL DRUGS ............................................................................................................................................................. 25

MANAGED DOSE LIMITATIONS (MDL) .................................................................................................................... 30

PREAUTHORIZATION (PA) ........................................................................................................................................... 32

STEP-THERAPY (ST) ....................................................................................................................................................... 34

SPECIALTY DRUG LIST ................................................................................................................................................. 36

INDEX .................................................................................................................................................................................. 38

TABLE OF CONTENTS

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INTRODUCTION This is the 2013 Health Alliance Drug

Formulary. In order to assist members and providers in choosing covered prescription drugs for treatment, we encourage members to show this list to their physicians and pharmacists. In addition, we encourage prescribers to use this list when considering treatment options. Final decisions regarding treatment options are made between the physician and patient.

The formulary is subject to change at any time. Members can access the most up-to-date version of this list by visiting the Pharmacy section of HealthAlliance.org. In addition, members can login to CatamaranRx.com to access specific drug coverage and pricing information.

The formulary does not provide information about an individual’s specific coverage. Please refer to your plan documents for complete coverage details.

HOW TO USE THIS LIST

This drug list is organized in sections by drug class or medical condition. Within each section are subsections to help locate medications. Most drugs listed, whether generic or brand, are formulary drugs. There are a few nonformulary drugs listed and designated as Tier 3.

To search within the PDF, choose the search function, enter a drug name and click “search” or “find.” You can also search using the index, which lists drugs alphabetically. The list is organized first by therapeutic class.

THERAPEUTIC CLASS

Then by sub-type (if applicable).

SUB-TYPE

And last by additional sub-type (if applicable).

ADDITIONAL SUB-TYPE

Covered brand-name drugs are listed in all CAPITAL letters, followed by the generic name.

Example: VESICARE - solefenacin

Covered generic drugs appear in lowercase bold type, followed by their reference brand drug in parentheses.

Example: atenolol (Tenormin)

Generics Like brand drugs, generic drugs go through an

approval process by the Food and Drug Administration (FDA) and must meet similar standards of effectiveness and chemical make-up as branded drugs.

The main difference between the reference brand drug and its generic equivalent is that the generic often costs much less.

As a general rule, generic drugs have the lowest member copayment. Typically, when a generic enters the market the brand drug moves to Tier 3.

Members who choose the brand name after the release of a generic version may pay the copayment plus the difference in cost between the brand and generic drug. Generic drugs can help members save on out-of-pocket medication costs.

Generic Equivalent vs. Generic Alternative Generic equivalents are medications that contain

the same active ingredient, with the same strength and dosage form as the brand medication. Generic equivalents are as safe and effective and produce the same results as the brand counterpart.

Generic alternatives can produce the same intended effect on the body as the comparable brand. Generic alternatives are medications that work like a particular brand drug and are used to treat the same condition. However, the active ingredient in a generic alternative is different from the brand medication.

Talk to Your Doctor If your doctor writes a prescription for a brand

drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available.

As a patient, you can tell your pharmacist you are interested in generics. In most situations, your pharmacist can substitute a generic equivalent for its brand counterpart without a new prescription from your doctor.

For more information on generics, visit AskForGenerics.org.

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Drugs to Treat Multiple Conditions Doctors use some drugs to treat more than one

medical condition. Within this document, each drug is listed according to its first FDA-approved use. Please check the index if you do not find your medication in the therapeutic class that corresponds to your condition.

COVERAGE AND LIMITATIONS

Tier Information A drug’s copayment tier indicates what you will

pay for the medication with each fill.

The majority of generics are Tier 1. These are your least expensive prescription drugs.

Formulary brands listed in this document are available at the lowest brand tier, unless otherwise noted.

Specialty drugs in this list may have a different copayment. For a complete listing of specialty drugs, please refer to page 36.

Depending on your plan, you may have a three-

tier or a six-tier copayment structure. Refer to your description of coverage documents for details. Your pharmacy benefit includes coverage for the majority of prescription drugs, though some exclusions may apply.

Utilization Management Some drugs on this list require utilization

management (UM), i.e. preauthorization, managed dose limitations and step-therapy. If UM applies to a drug, it is indicated with one of the following symbols in the column next to the drug name.

MDL- Managed Dose Limitations PA- Preauthorization ST- Step-Therapy

Medical Exception (varies by plan design)

Medical exception is a process for reviewing coverage for drugs not on our formulary. Members may qualify for a medical exception if they meet one of these:

A. Documented failure of all formulary drugs within the same therapeutic class

B. Documented allergy to a formulary drug, with no other formulary choices

C. Successfully maintained condition on a specific drug where switching to an alternative drug may cause a health risk:

o Antiarrhythmics o Theophylline products o Seizure medications o Antipsychotics o Antidepressants

Physicians—Requesting a Medical Exception

To request a Medical Exception for a medication on behalf of a member, or to request further information, please call the Health Alliance Pharmacy department at 1-800-851-3379, option 4, or fax the Preauthorization/Medical Exception form to 217-255-4598. Please provide the following information when requesting a Medical Exception:

Patient name and Health Alliance identification number

Physician name, address and phone number Drug name and strength Patient diagnosis Chart documentation/documentation of

previous medical history pertaining to the requested drug

Contraceptive Coverage Under Preventive Health Wellness Benefit

A female member age 10–50 years old has coverage of some FDA-approved contraceptives for no out-of-pocket cost.

Free contraceptives are listed below: Tier 1 oral contraceptives Limit of three units on condoms (male or

female) Limit of 2.7 units of spermicidal product

Only one Tier 1 prescription drug (like a generic

oral contraceptive) or one over-the-counter (OTC) product (like male and female condoms or spermicides) is covered per 30-day period for no cost to the member.

Brand-name contraceptives that are Tier 2 or higher are covered with the appropriate member cost share/quantity restrictions according to the member’s plan.

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Emergency contraception is covered at Tier 1 using generic levonorgestrel/ethinyl estradiol-containing products. Brand-name emergency contraception is covered according to the member’s plan.

Quantities above a 30-day supply, including vacation overrides and commercially available extended-cycle contraceptives (like Seasonale), are subject to appropriate member cost-sharing according to the member’s plan. General Exclusions

A. Over-the-counter (OTC) medications and their equivalents are not covered, unless otherwise specified within the Formulary. Nicotine smoking-cessation products (e.g., transdermal nicotine, nicotine gum, nicotine inhaler) coverage is based on specific member benefits.

B. Any drugs used for cosmetic purposes are not covered.

C. Experimental drugs, or any drug product used in an experimental manner, are not covered.

D. Replacement of lost or stolen medication is not covered.

E. Non-self-administered injectable drugs, unless otherwise noted, are not covered through the pharmacy benefit. Refer to your description of coverage materials for details.

F. Foreign drugs and drugs not approved by the FDA are not covered.

PHARMACY SAVINGS PROGRAMS Health Alliance offers members several

programs to lower the drug costs and to help members take their medications safely and correctly.

Rxtra Health Alliance members with prescription

coverage can save money based on where they have their 30-day-supply of prescriptions filled.

The Rxtra program is simple.

Preferred—At Preferred pharmacies, members can get hundreds of common prescriptions FREE.

Preferred Plus—At Preferred Plus pharmacies, members have the same benefits as the Preferred pharmacies mentioned above. In addition, simvastatin, pravastatin and Ventolin HFA are FREE.

For a list of participating pharmacies and

available drugs in the Rxtra program, visit the pharmacy section of HealthAlliance.org.

Split the Pill, Split the Bill For members willing to split their pills in half,

we offer a designated list of maintenance medications for half the copayment.

For Example: Benicar 20mg taken once daily for a 30 day

supply – Tier 2 copayment Benicar 40mg split in half to dose at 20mg

once daily – ½ of Tier 2 copayment Members can receive a FREE pill splitter with a

prescription from their doctor. Retail 90

The Retail 90 program allows members to purchase a 90-day supply of maintenance medication at a discounted copayment from participating retail pharmacies. Because this is a voluntary program designed to increase flexibility, members who prefer may continue purchasing the traditional 30-day supply from their pharmacy with their regular copayment.

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Value-Based Benefit The value-based benefit is designed so that

member copayments are aligned with the value the drug has for keeping members healthy.

Medications listed below are used to treat common conditions like asthma, high cholesterol, high blood pressure and diabetes and are available to members at a lower cost than other similar medications.

Blood Glucose Monitors FREE By Mail Members with diabetes are eligible to receive a

FREE blood glucose meter if they choose one of the preferred meters listed below and obtain the meter by mail. If a member picks up a blood glucose meter at their local pharmacy, the member’s Tier 2 copayment will apply when obtained with a prescription. Free meters are limited to one meter per member per year. The FreeStyle InsuLinx System is limited to one meter every three years. ACCU-CHEK® ACCU-CHEK® Aviva System ACCU-CHEK® Nano System ACCU-CHEK® Compact Plus System To get an ACCU-CHEK® product, call 1-888-605-9872 Or visit meters.accu-chek.com Freestyle Lite and Freestyle InsuLinx FreeStyle Lite System FreeStyle Freedom Lite System FreeStyle InsuLinx System To get an Abbott product, call 1-866-224-8892 and mention Health Alliance Or visit www.myfreestyle.com/meterprogram *InsuLinx systems are limited to one free product per member every three years. Not all benefit plans include each of the programs listed above. Please refer to your description of coverage documents for more detail or contact the Pharmacy department at 1-800-851-3379, option 4. CONTACT US Health Alliance Pharmacy Department 301 S. Vine St. Urbana, IL 61801-3347 1-800-851-3379, option 4 HealthAlliance.org

Value-Based Benefit Drug Class Drug Name Formulary

Status Diabetes All generics Tier 1

Vials, pens and cartridges for Lilly insulin

$20 copayment

Asthma All generics, Ventolin HFA Tier 1

QVAR $20 copayment Hypertension All generics Tier 1 High Cholesterol All generics Tier 1

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DRUG FORMULARY LIST

UTILIZATION MANAGEMENT

OTHER COVERAGE NOTES

ANTI-INFECTIVE DRUGS

CEPHALOSPORINS cefdinir (Omnicef) cefpodoxime (Vantin) cefprozil (Cefzil) cefuroxime (Ceftin)

FLUOROQUINOLONES ciprofloxacin (Cipro) CIPRO SUSPENSION—ciprofloxacin suspension levofloxacin (Levaquin)

FUNGAL INFECTIONS fluconazole (Diflucan) flucytosine (Ancoban) griseofulvin microsize (Fulvicin, Grisfulvin) GRIFULVIN V—griseofulvin GRIS-PEG—griseofulvin itraconazole (Sporanox) ketoconazole tablets (Nizoral) nystatin oral (Mycostatin) terbinafine (Lamisil) voriconazole (Vfend) PA Specialty

HEPATITIS EPIVIR HBV—lamivudine

MACROLIDES azithromycin (Zithromax) clarithromycin (Biaxin) clarithromycin ER (Biaxin XL) E.E.S. GRANULES—erythromycin ethylsuccinate

OTHER ANTI-INFECTIVES erythromycin/sulfisoxazole (Pediazole) MEPRON—atovaquone suspension metronidazole (Flagyl) sulfamethoxazole/trimethoprim (Bactrim) trimethoprim TINDAMAX—tinidazole

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vancomycin (Vancocin)

PENICILLINS amoxicillin/potassium clavulanate (Augmentin) amoxicillin/potassium clavulanate ER (Augmentin XR) amoxicillin (Amoxil) dicloxacillin (Dicloxacillin) penicillin v potassium (Veetids)

TETRACYCLINES VIBRAMYCIN SYRUP—doxycycline syrup minocycline (Minocin) doxycycline hyclate (Vibramycin)

TUBERCULOSIS ethambutol (Myambutol) isoniazid (Laniazid, Nydrazid) isoniazid/rifampin (Rifamate) MYCOBUTIN—rifabutin pyrazinamide rifampin (Rifadin)

VIRAL INFECTIONS HEPATITIS C PEGASYS—peginterferon alfa-2a PA Specialty PEG INTRON—peginterferon-2a PA Specialty HERPES acyclovir (Zovirax) famciclovir (Famvir) valacyclovir (Valtrex) HIV/AIDS APTIVUS—tipranavir ATRIPLA—efavirenz-emtricitabine-tenofovir CRIXIVAN—indinavir didanosine DR (Videc EC) EMTRIVA—emtricitabine EPZICOM—abacavir-lamivudine INVIRASE—saquinavir ISENTRESS—raltegravir KALETRA—lopinavir-ritonavir lamivudine (Epivir)

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lamivudine/zidovudine (Combivir) NORVIR SOLUTION—ritonavir stavudine (Zerit) RESCRIPTOR—delavirdine REYATAZ—atazanavir SELZENTRY—maraviroc PA SUSTIVA—efavirenz TRIZIVIR—abacavir sulfate-lamivudine-zidovudine TRUVADA—emtricitabine-tenofovir disoproxil fumarate VIDEX PEDIATRIC—didanosine solution VIRAMUNE—nevirapine VIRAMUNE XR—nevirapine VIREAD—tenofovir ZIAGEN—abacavir zidovudine (Retrovir)

MALARIA atovaquone/proguanil 250-100 mg (Malarone) chloroquine phosphate (Aralen) COARTEM—artemether-lumefantrine hydroxychloroquine (Plaquenil) mefloquine (Larium) primaquine

AUTOIMMUNE INFLAMMATORY DISORDERS ENBREL—etanercept PA Specialty HUMIRA—adalimumab PA Specialty REMICADE—infliximab PA Specialty

BLOOD MODIFYING DRUGS anagrelide (Agrylin) cilostazol (Pletal) clopidogrel (Plavix) COUMADIN—warfarin sodium cyanocobalamin injection dipyridamole (Persantine) DROXIA—hydroxyurea enoxaparin (Lovenox) folic acid tablets FRAGMIN—dalteparin sodium, injection

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LOVENOX—enoxaparin sodium, injection LYSTEDA—tranexamic acid pentoxifylline ER (Trental) PROMACTA—eltrombopag PA Specialty warfarin (Coumadin)

CANCER DRUGS ALKERAN—melphalan anastrozole (Arimidex) bicalutamide (Casodex) CEENU—lomustine EMCYT— estramustine exemestane (Aromasin) flutamide (Eulexin) FARESTON—toremifene HEXALEN— altretamine hydroxyurea (Hydrea) letrozole (Femara) leucovorin calcium tablets (Folinic acid) LEUKERAN— chlorambucil LYSODREN—mitotane MATULANE— procarbazine megestrol (Megace) mercaptopurine (Purinethol) MESNEX—mesna methotrexate (Trexall) MYLERAN—busulfan NILANDRON—nilutamide TABLOID—thioguanine tamoxifen (Nolvadex) TARGRETIN—bexarotene TREXALL—methotrexate

CENTRAL NERVOUS SYSTEM

ANXIETY amitriptyline (Elavil) bupropion (Wellbutrin) alprazolam (Xanax) buspirone (Buspar)

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diazepam (Valium) hydroxyzine (Atarax, Vistaril) lorazepam (Ativan)

DEPRESSION bupropion ext-release (Wellbutrin SR, Wellbutrin XL) citalopram (Celexa) MDL clomipramine (Anafranil) desipramine (Norpramin) doxepin (Sinequan) escitalopram (Lexapro) fluoxetine (Prozac) imipramine hcl (Tofranil) mirtazapine (Remeron, Remeron SolTab) nortriptyline (Pamelor) paroxetine hcl (Paxil) paroxetine hcl ER (Paxil CR) PAXIL—paroxetine HCL, oral suspension phenelzine (Nardil) sertraline (Zoloft) MDL tranylcypromine (Parnate) trazodone (Desyrel) venlafaxine (Effexor) venlafaxine ER (Effexor XR)

HYPERACTIVITY/NARCOLEPSY amphetamine/detroamphetamine (Adderall) dextroamphetamine dextroamphetamine ER (Dexedrine Spansule) METADATE CD—methylphenidate HCL METHYLIN—methylphenidate HCL methylphenidate ER capsules, tablets (Ritalin LA, Ritalin SR) methylphenidate tablets (Ritalin)

OTHER CENTRAL NERVOUS SYSTEM DRUGS ARICEPT—donepezil hydrochloride bupropion ER (Zyban) CHANTIX—varenicline tartrate MDL disulfiram (Antabuse) donepezil (Aricept, Aricept ODT) EMSAM—selegiline

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EXELON—rivastigmine galantamine (Razadyne) galantamine ER (Razadyne ER) naltrexone (ReVia) NAMENDA—memantine NICOTROL INHALER—nicotine inhaler system MDL NICOTROL NS—nicotine, nasal spray MDL SARAFEM—fluoxetine ST

PSYCHOTIC AND BIPOLAR DISORDER chlorpromazine (Thorazine) clozapine (Clozaril) EQUETRO—carbamazepine FAZACLO—clozapine fluphenazine (Prolixin) haloperidol (Haldol) LATUDA—lurasidone ST Tier 3 LITHOBID—lithium carbonate lithium carbonate lithium carbonate ER (Lithobid, Eskalith CR) loxapine (Loxitane) olanzapine (Zyprexa, Zyprexa Zydis) perphenazine (Trilafon) prochlorperazine (Compazine) quetiapine (Seroquel) risperidone (Risperdal, Risperdal-M tablets) SEROQUEL XR—quetiapine fumarate ST thiothixene (Navane) trifluoperazine (Stelazine) ziprasidone (Geodon)

SLEEP AIDS estazolam (Prosom) phenobarbital temazepam (Restoril) zaleplon (Sonata) zolpidem (Ambien) zolpidem ER (Ambien CR)

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GASTROINTESTINAL DRUGS

DIGESTIVE ENZYMES CREON—pancrelipase ZENPEP—pancrelipase

NAUSEA AND VOMITING ANZEMET—dolasetron desylate EMEND—aprepitant MDL granisetron (Kytril) meclizine (Antivert) ondansetron (Zofran, Zofran ODT) SANCUSO—granisetron MDL trimethobenzamide (Tigan)

OTHER GASTROINTESTINAL DRUGS 5-AMINOSALICYLIC ACID—mesalamine powder APRISO—mesalamine ASACOL—mesalamine balsalazide (Colazal) CANASA—mesalamine DELZICOL—mesalamine DIPENTUM—olsalazine sodium diphenoxylate/atropine tablets (Lomotil) lactulose (Enulose) LIALDA—mesalamine mesalamine (Asacol) mesalamine powder (5-aminosalicylic acid) metoclopramide (Reglan) PENTASA—mesalamine RELISTOR—methylnaltrexone bromide, injection PA ROWASA—mesalamine sulfasalazine (Azulfidine) sulfasalazine DR (Azulfidine EN-Tabs) ursodiol (Actigall, Urso 250, Urso Forte)

ULCER/REFLUX CARAFATE SUSPENSION—sucralfate cimetidine (Tagamet) dicyclomine (Bentyl)

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famotidine (Pepcid) glycopyrrolate (Robinul) hyoscyamine (Anaspaz, Levsin/SL) hyoscyamine ER (Levbid, Symax Duotab) lansoprazole DR (Prevacid) methscopolamine (Pamine, Pamine Forte) misoprostol (Cytotec) omeprazole DR (Prilosec) pantoprazole DR (Protonix) ranitidine (Zantac) sucralfate tablets (Carafate)

GENITOURINARY DRUGS alfuzosin (Uroxatral) AVODART—dutasteride CARDURA XL-doxazosin mesylate finasteride (Proscar) JALYN—dutasteride-tamsulosin tamsulosin (Flomax)

OTHER GENITOURINARY DRUGS ORACIT—sodium citrate and citric acid potassium citrate ER (Urocit-K) potassium citrate/citric acid (Polycitra-K) sodium citrate/citric acid (Shohls) UROCIT-K 15—potassium citrate

URINARY TRACT INFECTIONS MACRODANTIN—nitrofurantoin macrocrystalline nitrofurantoin (Furadantin) nitrofurantoin macrocrystalline (Macrodantin) nitrofurantoin monohydrate/macrocrystalline (Macrobid)

URINARY TRACT SPASMS VESICARE— solifenacin succinate oxybutynin (Ditropan) oxybutynin ER (Ditropan XL)

VAGINAL PRODUCTS CLEOCIN—clindamycin phosphate clindamycin vaginal cream (Cleocin) ENDOMETRIN—progesterone

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ESTRACE—estradiol ESTRING—estradiol metronidazole (MetroGel-Vaginal) terconazole (Terazol)

HEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS benazepril (Lotensin) benazepril/hydrochlorothiazide (Lotensin HCT) captopril (Capoten) captopril/hydrochlorothiazide (Capozide) enalapril (Vasotec) enalapril/hydrochlorothiazide (Vaseretic) fosinopril (Monopril) fosinopril/hydrochlorothiazide (Monopril HCT) lisinopril (Prinivil) lisinopril/hydrochlorothiazide (Prinizide) moexipril (Univasc) moexipril/hydrochlorothiazide (Uniretic) perindopril (Aceon) quinapril (Accupril) quinapril/hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik)

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS AZOR—amlodipine-olmesartan BENICAR—olmesartan-hydrochlorothiazide DIOVAN—valsartan DIOVAN HCT—valsartan-hydrochlorothiazide EXFORGE-amlodipine-valsartan EXFORGE HCT—amlodipine-valsartan-hydrochlorothiazide irbesartan (Avapro) irbesartan/hydrochlorothiazide (Avalide) losartan (Cozaar) losartan/hydrochlorothiazide (Hyzaar) TRIBENZOR—olmesartan-amlodipine-hydrochlorothiazide

BETA BLOCKERS AND COMBINATION AGENTS acebutolol (Sectral)

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atenolol (Tenormin) atenolol/chlorthalidone (Tenoretic) bisoprolol (Zebeta) bisoprolol/hydrochlorothiazide (Ziac) carvedilol (Coreg) COREG CR—carvedilol labetalol (Trandate) metoprolol succinate ER (Toprol XL) metoprolol tartrate (Lopressor) nadolol (Corgard) propranolol ER (Inderal LA) propranolol tablets (Inderal)

CALCIUM CHANNEL BLOCKERS AND COMBINATIONS amlodipine (Norvasc) amlodipine/benazepril (Lotrel) diltiazem ER (Cardizem CD, Cardizem LA, Dilacor XR, Tiazac) diltiazem (Cardizem) felodipine ER (Plendil) nifedipine ER (Adalat CC, Procardia XL) verapamil (Calan) verapamil ER (Calan SR, Isoptin SR, Verelan, Verelan PM)

CHEST PAIN DILATRATE SR—isosorbide dinitrate CR isosorbide dinitrate (Isordil) isosorbide mononitrate (Monoket) isosorbide mononitrate ER (Imdur) ISORDIL TITRADOSE—isosorbide dinitrate NITRO-BID—nitroglycerin NITRO-DUR—nitroglycerin patch nitroglycerin (Nitro-Dur) NITROMIST—nitroglycerin lingual NITROSTAT—nitroglycerin SL

CHOLESTEROL LOWERING ADVICOR—niacin-lovastatin ST atorvastatin (Lipitor) cholestyramine (Questran, Questran Light) colestipol (Colestid) CRESTOR—rosuvastatin ST

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fenofibrate, micronized (Lofibra) gemfibrozil (Lopid) LOVAZA—omega-3-acid ethyl esters lovastatin (Mevacor) NIASPAN—niacin tablet CR pravastatin (Pravachol) SIMCOR—niacin-simvastatin SR 24-hour ST simvastatin (Zocor) WELCHOL—olesevelam

ERECTILE DYSFUNCTION CAVERJECT—alprostadil for injection CIALIS—tadalafil ST Tier 3 EDEX—alprostadil for injection kit MUSE—alprostadil urethral pellet

FLUID RETENTION acetazolamide (Diamox) acetazolamide ER (Diamox Sequels) amiloride (Midamor) amiloride/hydrochlorothiazide (Moduretic) bumetanide (Bumex) chlorthalidone (Thalitone) furosemide (Lasix) hydrochlorothiazide (Microzide, Hydrodiuril) indapamide (Lozol) methazolamide (Neprazane) metolazone (Zaroxolyn) spironolactone (Aldactone) spironolactone/hydrochlorothiazide (Aldactazide) THALITONE—chlorthalidone torsemide (Demadex)

HEART RHYTHM amiodarone (Cordarone, Pacerone) clonidine (Catapres, Catapres-TTS) disopyramide (Norpace) flecainide (Tambocor) MULTAQ—dronedarone NORPACE CR—disopyramide propafenone (Rythmol)

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propafenone ER (Rythmol SR) quinidine gluconate ER (Quinaglute) quinidine sulfate (Quinidex) sotalol (Betapace, Betapace AF)

OTHER RELATED DRUGS digoxin (Lanoxin) doxazosin (Cardura) eplerenone (Inspra) guanfacine (Tenex) hydralazine (Apresolutionine) LANOXIN—digoxin methyldopa (Aldomet) minoxidil (Loniten) prazosin (Minipress) terazosin (Hytrin)

RENIN INHIBITORS AND COMBINATIONS AMTURNIDE—aliskiren-amlodipine-hydrochlorothiazide TEKAMLO—aliskiren-amlodipine TEKTURNA—aliskiren TEKTURNA HCT—aliskiren-hydrochlorothiazide

HORMONES, DIABETES, TEST SUPPLIES, AND RELATED DRUGS

BIRTH CONTROL levonorgestrel (Plan B) oral contraceptives - all generics

CORTICOSTEROIDS budesonide ER (Entocort EC) dexamethasone DEXAMETHASONE INTENSOL—dexamethasone fludrocortisones (Florinef) hydrocortisone (Cortef) methylprednisolone (Medrol) MILLIPRED— prednisolone PREDNISONE INTENSOL—prednisone prednisolone (Prelone) prednisolone sodium phosphate (Orapred, Pediapred) prednisone tablets

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DIABETES acarbose (Precose) DUETACT—pioglitazone -glimepiride glimepiride (Amaryl) glipizide (Glucotrol) glipizide ER (Glucotrol XL) GLUCAGEN—glucagon GLUCAGON EMERGENCY KIT—glucagon glyburide (Micronase) glyburide micronized (Glynase) glyburide/metformin (Glucovance) JENTADUETO—linagliptin/metformin PA metformin (Glucophage) metformin ER (Glucophage XR, Fortamet) nateglinide (Starlix) pioglitazone (Actos) ST pioglitazone-metformin (Actoplus met) ST pioglitazone-metformin SR (Actoplus met XR) ST TRADJENTA—linagliptin ST VICTOZA—liraglutide ST

DIABETES-INSULINS BASAL INSULIN LANTUS—insulin glargine MDL LANTUS SOLOSTAR—insulin glargine MDL RAPID ACTING INSULIN APIDRA—insulin glulisine MDL APIDRA SOLOSTAR—insulin glulisine MDL HUMALOG—insulin lispro MDL SHORT ACTING INSULIN HUMULIN—insulin human nph, reg MDL

DIABETES—TESTING SUPPLIES ACCU-CHEK NANO METER (Free by mail) MDL ACCU-CHEK AVIVA METER (Free by mail) MDL ACCU-CHEK COMPACT PLUS METER (Free by mail) MDL ACCU-CHEK COMPACT TEST STRIPS MDL ACCU-CHEK SMART VIEW TEST STRIPS MDL ACCU-CHEK AVIVA PLUS TESTS STRIPS MDL ACCU-CHEK COMFORT CURVE TEST STRIPS MDL

19



ACCU-CHEK ACTIVE TEST STRIPS MDL FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM (Free by mail)

MDL

FREESTYLE FREEDOM LITE BLOOD GLUCOSE SYSTEM (Free by mail)

MDL

FREESTYLE LITE TEST STRIPS MDL FREESTYLE INSULINX BLOOD GLUCOSE SYSTEM (Free by mail)

MDL

FREESTYLE INSULINX TEST STRIPS MDL PRECISION XTRA BLOOD GLUCOSE SYSTEM (Free by mail) MDL

ESTROGENS ALORA—estradiol estradiol (Climara, Estrace) estradiol/norethindrone acetate (Activella) estropiopate (Ogen, Ortho-Est) FEMHRT LOW DOSE—norethindrone acetate-ethinyl estradiol MENEST—esterified estrogens MENOSTAR—estradiol norethindrone acetate/ethinyl estradiol VIVELLE-DOT—estradiol

INFERTILITY clomiphene (Clomid) PA FOLLISTIM AQ—follitropin PA Specialty

MALE HORMONES ANDROGEL—testosterone gel danazol (Danocrine)

OTHER HORMONES alendronate tablets (Fosamax) cabergoline (Dostinex) calcitonin-salmon (Miacalcin) calcitriol (Rocaltrol) desmopressin (DDVAP) etidronate (Didronal) EVISTA—raloxifene ibandronate oral (Boniva) propylthiouracil RECLAST—zoledronic acid PA Specialty STIMATE—desmopressin

20



SYNAREL—nafarelin TEV TROPIN—somatropin PA Specialty

PROGESTINS medroxyprogesterone acetate (Provera) norethindrone acetate (Aygestin) progesterone micronized (Prometrium)

THYROID REGULATION ARMOUR THYROID—thyroid levothyroxine (Synthroid, Levoxyl) liothyronine (Cytomel) methimazole (Tapazole) SYNTHROID—levothyroxine THYROLAR—liotrix (T3-T4)

MISCELLANEOUS CATEGORIES (INCLUDES SUPPLIES AND DEVICES)

MISCELLANEOUS DRUGS azathioprine (Imuran) CELLCEPT—mycophenolate mofetil cyclosporine (Sandimmune) cyclosporine modified capsules mycophenolate mofetil (Cellcept) NEORAL—cyclosporine modified PROGRAF—tacrolimus RAPAMUNE—sirolimust SANDIMMUNE—cyclosporine sodium polystyrene sulfonate tacrolimus (Prograf)

MULTIPLE SCLEROSIS AVONEX—interferon beta-1a PA Specialty BETASERON—interferon beta-1b PA Specialty COPAXONE—glaitamer PA Specialty

NEUROMUSCULAR DRUGS

MUSCLE RELAXANTS baclofen (Lioresal) chlorzoxazone (Parafon) cyclobenzaprine (Flexeril, Fexmid)

21



dantrolene (Dantrium) metaxalone (Skelaxin) methocarbamol (Robaxin) orphenadrine citrate ER (Norflex) orphenadrine/aspirin/caffeine (Norgesic) tizanidine (Zanaflex)

OTHER NEUROMUSCULAR DRUGS MESTINON—pyridostigmine bromide MESTINON TIMESPAN—pyridostigmine bromide POTABA— potassium aminobenzoate POTASSIUM P-AMINOBENZOATE—potassium aminobenzoate powder

pyridostigmine (Mestinon)

PARKINSON'S DISEASE amantadine (Symmetrel) benztropine (Cogentin) bromocriptine (Parlodel) carbidopa/levodopa (Parcopa, Sinemet) carbidopa/levodopa ER (Sinemet CR) pramipexole (Mirapex) REQUIP XL—ropinirole hydrochloride ropinirole (Requip) selegiline (Eldepryl) trihexyphenidyl (Artane)

SEIZURES BANZEL— rufinamide carbamazepine (Tegretol) carbamazepine ER (Carbatrol, Tegretol-XR) CARBATROL—carbamazepine clonazepam (Klonopin) DEPAKENE—valproic acid DEPAKOTE—divalproex sodium DEPAKOTE SPRINKLES—divalproex sodium DILANTIN—phenytoin sodium extended divalproex DR (Depakote Sprinkles, Depakote) divalproex ER (Depakote ER) ethosuximide (Zarontin) FELBATOL— felbamate gabapentin (Neurontin)

22



GABITRIL—tiagabine HCL KLONOPIN—clonazepam LAMICTAL—lamotrigine LAMICTAL XR—lamotrigine lamotrigine (Lamictal) levetiracetam (Keppra) MYSOLINE—primidone NEURONTIN—gabapentin oxcarbazepine (Trileptal) phenytoin sodium ER (Dilantin, Phenytek) phenytoin suspenion (Dilantin) primidone (Mysolutionine) TEGRETOL—carbamazepine TEGRETOL-XR—carbamazepine topiramate (Topamax Sprinkle, Topamax) TOPAMAX—topiramate valproic acide (Depakene) ZARONTIN—ethosuximide ZONEGRAN—zonisamide zonisamide (Zonegran)

PAIN-RELIEF DRUGS

GOUT allopurinol (Zyloprim) COLCRYS— colchicine probenecid (Benemid) ULORIC--febuxostat Tier 3

MIGRAINE HEADACHES acetaminophen/isometheptene/dichloralphenazone (Midrin) naratriptan (Amerge) MDL MIGRANAL—dihydroergotamine mesylate sumatriptan injection, tablets (Imitrex) MDL TREXIMET—sumatriptan-naproxen sodium MDL

NARCOTIC DRUGS acetaminophen/codeine (Tylenol w/Codeine) buprenorphine (Subutex)

23



butalbital/aspirin/caffeine/codeine (Fiorinal w/Codeine) DILAUDID-5—hydromorphone HCL fentanyl oral lozenge (Actiq) PA fentanyl patch (Duragesic) MDL hydrocodone/acetaminophen (Vicodin, Lorcet, Lortab, Norco) hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen) hydromorphone tablets (Dilaudid) methadone solution methadone tablets (Dolophine) morphine sulfate ER (MS Contin) MDL OPANA ER (CRUSH RESISTANT) —oxymorphone HCL oxycodone (Roxicodone) oxycodone/acetaminophen (Percocet, Tylox) oxycodone/aspirin (Percodan) tramadol (Ultram) tramadol/acetaminophen (Ultracet)

NON-NARCOTIC DRUGS butalbital/acetaminophen (Sedapap) butalbital/acetaminophen/caffeine (Esgic, Esgic Plus, Fioricet) butalbital/aspirin/caffeine (Fiorinal) PHRENILIN FORTE—butalbital-acetaminophen salsalate (Disalcid)

RHEUMATOID AND OSTEOARTHRITIS diclofenac potassium (Cataflam) diclofenac sodium DR (Voltaren) diclofenac sodium ER (Voltaren-XR) etodolac (Lodine) ibuprofen (Motrin) indomethacin (Indocin) ketoprofen (Oruvail) leflunomide (Arava) meloxicam (Mobic) NALFON—fenoprofen naproxen (Naprosyn) naproxen DR (EC-Naprosyn) naproxen sodium (Anaprox) oxaprozin (Daypro) piroxicam (Feldene) RIDAURA—auranofin

24



sulindac (Clinoril)

RESPIRATORY AGENTS

ASTHMA/COPD ADVAIR—fluticasone-salmeterol albuterol 0.63 mg/3 mL, 1.25 mg/3 ml (Accuneb) albuterol inhaler solution, 0.0835, 0.5% (Ventolin) albuterol syrup, tablets (Ventolin) ATROVENT HFA—ipratropium bromide HFA budesonide ER (Pulmicort Respules) COMBIVENT RESPIMAT—ipratropium-albuterol cromolym sodium inhal solution (Intal) ELIXOPHYLLIN—theophylline FLOVENT—fluticasone propionate MDL FORADIL AEROLIZER—formoterol fumarate ipratropium inhalersolution (Atrovent, Aerovent) ipratropium/albuterol (Duoneb) MAXAIR AUTOHALER—pirbuterol acetate montelukast sodium (Singulair) PULMICORT FLEXHALER—budesonide QVAR—beclomethasone dipropionate MDL SEREVENT DISKUS—salmeterol xinafoate SPIRIVA—tiotropium bromide SPIRIVA HANDIHALER—tiotropium SYMBICORT—budesonide-formoterol terbutaline (Brethine) THEO-24—theophylline theophylline ER (Theo-Dur) TUDORZA —aclidinium bromide VENTOLIN HFA—albuterol HFA zafirlukast (Accolate)

BEE STING KITS EPINEPHRINE EPIPEN—epinephrine EPIPEN-JR 2-PAK—epinephrine

NASAL ANTIHISTAMINE ASTEPRO—azelastine HCL nasal azelastine (Astelin)

25



NASAL ANTI-INFLAMMATORY STEROIDS fluticasone (Flonase) triamcinolone (Nasacort AQ)

SUPPLEMENTS

VITAMINS ergocalciferol (Drisdol) GALZIN—zinc acetate MEPHYTON—phytonadione NASCOBAL—cyanocobalamin

MINERALS AND ELECTROLYTES potassium bicarbonate/chloride effervescent tablets potassium chloride potassium chloride ER potassium phosphate/sodium phosphates (K-Phos Neutral) sodium fluoride

MULTIVITAMINS prenatal vitamin/folic acid - all generics

TOPICAL DRUGS

ANORECTAL AGENTS ANALPRAM E—HC-pramoxine CORTIFOAM—hydrocortisone acetate rectal foam hydrocortisone acetate rectal cream, suppository (Anusolution-HC, Proctocort)

hydrocortisone enema (Cortenema)

EAR acetic acid ear solution benzocaine/antipyrine ear solution hydrocortisone/acetic acid ear solution neomycin/polymyxin B/hydrocortisone ear solution, suspension (Cortisporin)

ofloxacin ear solution (Floxin otic)

EYE ANTI-INFECTIVE bacitracin/polymyxin B eye ointment ciprofloxacin eye solution (Ciloxan) erythromycin eye ointment

26



gentamicin eye ointment, solution (Garamycin) neomycin/polymyxin B/gramicidin eye solution (Neosporin) neomycin/polymyxin/bacitracin eye ointment ofloxacin eye solution (Ocuflox) polymyxin B/trimethoprim eye solution (Polytrim) sulfacetamide sodium eye solution (Bleph-10) tobramycin eye solution (Tobrex) trifluridine eye solution (Viroptic) TOBREX—tobramycin sulfate, ophthalmic ointment 0.3% ZYMAXID—gatifloxacin Tier 3 GLAUCOMA BETOPTIC-S—betaxolol HCL, ophthalmic suspension 0.25% brimonidine eye solution, 0.15% (Alphagan P) brimonidine eye solution, 0.2% carteolol eye solution (Ocupress) dorzolamide eye solution (Trusopt) dorzolamide/timolol maleate eye solution (Cosopt) lantanoprost eye solution (Xalatan) levobunolol eye solution, 0.5% (Betagan) LUMIGAN—bimatoprost, ophthalmic solution metipranolol eye solution (Optipranolol) pilocarpine eye solution, 1%, 2%, 4% (Isopto Carpine) timolol maleate eye solution (Timoptic, Timoptic XE) TIMOPTIC OCUDOSE—timolol maleate, ophthalmic solution 0.25%

TRAVATAN—travopost OTHER EYE PRODUCTS ALOMIDE—lodoxamide tromethamine ALPHAGAN P—brimonidine tartrate atropine sulfate eye ointment, solution (Isopto Atropine) azelastine eye solution (Optivar) cromolyn sodium eye solution (Opticrom) CYCLOGYL—cyclopentolate HCL CYCLOMYDRIL—cyclopentolate wtih phenylephrine cyclopentolate eye solution (Cyclogyl) diclofenac eye solution (Voltaren) flurbiprofen eye solution (Ocufen) homatropine eye solution (Isopto Homatropine) ISOPTO CARBACHOL—carbachol ISOPTO HOMATROPINE—homatropine

27



ketorolac eye solution (Acular, Acular LS) LASTACAFT—alcaftadine Tier 3 PHOSPHOLINE IODIDE—echothiophate iodide PILOPINE HS—pilocarpine HCL tropicamide eye solution (Mydriacyl) STEROIDS AND COMBINATION PRODUCTS BLEPHAMIDE S.O.P. —sulfacetamide sodium-prednisolone dexamethasone sodium phosphate eye solution FLAREX—fluorometholone acetate FML FORTE—fluorometholone fluorometholone eye suspension, 0.1% (FML Liquifilm) neomycin/polymyxin B/bacitracin/hydrocortisone eye ointment

neomycin/polymyxin B/dexamethasone eye ointment, suspenion (Maxitrol)

PRED MILD—prednisolone acetate PRED-G—gentamicin-prednisolone PRED-G S.O.P.—gentamicin-prednisolone prednisolone acetate eye suspenion (Pred Forte) sulfacetamide sodium/prednisolone eye solution TOBRADEX—tobramycin-dexamethasone TOBRADEX ST—tobramycin-dexamethasone tobramycin/dexamethasone eye suspenion (Tobradex) VEXOL—rimexolone, ophthalmic suspension 1%

MOUTH AND THROAT—LOCAL chlorhexidine oral rinse (Peridex) clotrimazole troche (Mycelex Troche) lidocaine viscous nystatin suspension pilocarpine (Salagen) sodium fluoride (Prevident) triamcinolone dental paste (Kenalog in Orabase)

SKIN CONDITIONS/PRODUCTS ACNE adapalene (Differin) clindamycin (Cleocin-T) erythromycin gel, pads, solution metronidazole (Metrocream, Metrolotion)

28



metronidazole topical gel (Metrogel) sulfacetamide sodium/sulfur cloth, cream, emulsion, lotion tretinoin (Retin-A) PA ANTI-INFECTIVES ciclopirox gel, shampoo (Loprox) ciclopirox solution (Penlac) econazole (Spectazole) ketoconazole (Nizoral) mupirocin ointment (Bactroban) nystatatin topical silver sulfadiazine (Silvadene) CORTICOSTEROIDS alclometasone (Aclovate) amcinonide cream (Cyclocort) betamethasone dipropionate (Diprosone) betamethasone dipropionate, augmented (Diprolene) betamethasone valerate cream, lotion clobetasol (Olux, Temovate) desonide (Desowen) desoximetasone cream, 0.25%; gel; ointment 0.25% (Topicort) diflorasone ointment fluocinolone acetonide oil (Derma-Smoothe/FS) fluocinonide fluticasone propionate (Cutivate) halobetasol (Ultravate) hydrcortisone valerate (Westcort) hydrocortisone topical mometasone (Elocon) triamcinolone cream; lotion; ointment, 0.025%, 0.1% OTHER SKIN PRODUCTS 8-MOP—methoxsalen, capsule 10 mg aluminum chloride (Drysol) calcipotriene solution (Dovonex) fluorouracil (Efudex) imiquimod (Aldara) lidocaine topical (Xylocaine) lindane OXSORALEN ULTRA—methoxsalen permethrin podofilox (Condylox) PROTOPIC—tacrolimus

29



selenium sulfide (Selsun) SORIATANE—acitretin, capsule 10 mg MDL VOLTAREN GEL—diclofenac Tier 3

The table below contains the list of drugs with managed dose limitations. Certain products are subject to managed drug limitations based on FDA-approved dosage recommendations and the drug manufacturer’s package size. The pupose of these limitations is to encourage safe and cost-eff ective use of drug therapies. MDL quantities may vary depending on plan design.

Drug Class Drug Name 30-Day Supply90-Day Supply (Mail Order)*

ACNE isotretinoin oral (Claravis™ and Amnesteem®)

N/A *maximum of 6 months of treatment

ASTHMA Arcapta Neohaler™Asmanex®

Flovent® HFAQVAR™Ventolin® HFA

30 caps1 inhaler24gm (2 inhalers)2 inhalers3 inhalers

90 caps3 inhalers72gm (6 inhalers)6 inhalers9 inhalers

BEHAVIORAL HEALTH:ADHD

Quillivant XRTM 180ml N/A

BEHAVIORAL HEALTH: Depression

citalopramCymbalta®, 30mg or 60mgCymbalta®, 20mgsertraline

30 tablets30 capsules60 capsules60 tablets

90 tablets90 capsules180 capsules180 tablets

ENDOCRINE:Diabetes

blood glucose test stripsinsulin vialsinsulin pensJanuvia®, JuvisyncTM, Janumet® XR, OnglyzaTM, KobmiglyzeTM XR, Tradjenta®

Janumet®, Jentadueto®

150 test strips60ml (6 vials)4 boxes30 tablets

60 tablets

450 test strips180ml (18 vials)12 boxes90 tablets

180 tabletsENDOCRINE: Impotency

Caverject®/Edex®/Muse®

Cialis®

Levitra®

StaxynTM

Viagra®

6 units4 tablets1

4 tablets1

4 tablets1

4 tablets1

18 units12 tablets1

12 tablets1

12 tablets1

12 tablets1

GASTROINTESTINAL: Emesis

Emend®

Sancuso®6 tablets1 patch

18 tablets3 patches

HEMATOLOGICAL DISORDERS

Xarelto® 10 mg 35 tablets/6 months N/A

INFECTIOUS DISEASE:Hepatitis C

Incivek®

Victrelis®180 tablets360 tablets

N/AN/A

INFECTIOUS DISEASE: Infl uenza

Relenza® 1 rx/6 months, max quant 20 doses

N/A

Tamifl u® 1 rx/6 months, max quant 10 caps

N/A

LOWER GI DISORDERS: Irritable Bowel Syndrome

Amitiza®

LinzessTM60 capsules30 capsules

180 capsules90 capsules

continued on next page

DRUGS WITH MANAGED DOSE LIMITATIONS (MDL)

ph-MDLdrugs-0613

Drug Class Drug Name 30-Day Supply90-Day Supply (Mail Order)*

NEUROLOGY:Migraine

Axert®

Amerge® (naratriptan)Frova®

Imitrex®/Sumavel® (sumatriptan) - injectableImitrex® (sumatriptan) - nasal

Imitrex® (sumatriptan) - tabletsMaxalt®, Maxalt-MLT®

Migranal®

Relpax®

Treximet®

Zomig®

9 tablets9 tablets9 tablets2 kits (4 injections)6 nasal spray devices

9 tablets12 tablets8 units9 tablets9 tablets9 tablets

27 tablets27 tablets27 tablets6 kits (12 injections)18 nasal spray devices27 tablets36 tablets24 units27 tablets27 tablets27 tablets

NEUROLOGY: Narcolepsy

Nuvigil®

Provigil®30 tablets30 tablets

90 tablets90 tablets

PAIN MANAGEMENT

Avinza®

Embeda®

Exalgo®

fentanyl patchKadian®

Nucynta® ERNucynta®

Oxycontin®

Toradol® (ketorolac)tramadol ERSprix® (ketorolac) nasal spray

60 tablets60 tablets60 tablets15 patches60 tablets60 tablets120 tablets60 tablets20 tablets60 tablets5 nasal spray units

N/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A

SMOKING CESSATION

nicotine replacement therapy2

Zyban® (bupropion)230 units60 tablets

N/A180 tabs/0 refi ll

Please Note: This applies to most Health Alliance plans. If you have questions, please contact the Pharmacy Department at 1-800-851-3379, option 4.

1 Quantity may vary depending on plan setup Iowa State = 6/12 Horizon = 6/12 Federal = 6/122 3 months per year for most plans 9 months per lifetime for most plans


Drug Class Drug Name CommentsASTHMA Advair® (fl uticasone-salmeterol)

500/50mcg onlyDocumentation of asthma diagnosis

BEHAVIORAL HEALTH:ADHD

Quillivant XR™ (methylphenidate suspension)

Preauthorization required for age 13 years and older.

BEHAVIORAL HEALTH:Antidepressants

Pristiq® (desvenlafaxine)Viibryd® (vilazodone)

See behavioral health policy; Two SSRI and venlafaxine, or venlafaxine SR and buproprion, buproprion XL or buproprion SR

Cymbalta® (duloxetine) See Cymbalta policyBEHAVIORAL HEALTH:Narcolepsy

Provigil® (modafi nil)Nuvigil® (armodafi nil)

See Provigil and Nuvigil policy, only medically necessary FDA label diagnosis covered

CARDIOVASCULAR:Lipotropics

Vytorin® (simvastatin/ezetimibe) Zetia® (ezetimibe)

See Zetia and Vytorin policy; LDL goal not met with maximum tolerated statin OR intolerance/contraindication to statins

DERMATOLOGY tretinoinFinacea® (azelaic acid)Picato® (ingenol mebutate)Tazorac® (tazarotene)Aczone® (dapsone)

Documentation of a non-cosmetic diagnosis (acne, actinic keratosis, ect). Trial of a Tier 1 agent.

DIABETES:DPP4 Inhibitors

Januvia® (sitagliptin)Janumet® (sitagliptin-metformin) Janumet XR® (sitagliptin-metformin ER) Juvisync® (sitagliptin-simvastatin)Onglyza® (saxagliptin) Kombiglyze® (saxagliptin-metformin) Kombiglyze XR® (saxagliptin-metformin ER)

See diabetes drug therapy policy; Type 2 DM; metformin or a sulfonylurea; HBA1c greater than 6.5% and less than 9%; trial of Tradjenta required on new starts and existing members not at goal on non-preferred DPP4

DIABETES:GLP1

Byetta® (exenatide) Bydureon® (exenatide ER)

See diabetes drug therapy policy;Type 2 DM; metformin or a sulfonylurea; HBA1c greater than 6.5% and less than 9%; trial of Victoza on new starts and existing members not at goal on current non-preferred GLP1

DIABETES, MISC. Becaplermin® (Regranex) Diagnosis of diabetic ulcers with failure on conventional (dressings, soaks, debridement, etc.).

The table below outlines the medications requiring a review by the Clinical Pharmacist, and if necessary, a Health Alliance Medical Director. If a provider wished for coverage of a drug designated as preauthorization required (PA), they must provide documentation to meet criteria for that particular medication. Provider must request prior authorization from Health Alliance for drugs on the following list:

DRUGS REQUIRING PREAUTHORIZATION

Drug Class Drug Name CommentsINFECTIOUS DISEASE: Antibacterial, Misc

Xifaxan® 550mg (rifaximin) See separate policy on Xifaxan550 in hepatic encephalopathy

INFLAMMATORY DISEASE: NSAIDs

Celebrex® (celecoxib) See COX-2 inhibitor policy, age greater than 65 exempt. Trial of three NSAID classes or a qualifying risk factor (see policy)

LOWER GI DISORDERS:Irritable Bowel Syndrome

Amitiza® (lubiprostone) Linzess™ (linaclotide) Lotronex® (alosetron)

See Amitiza and Linzess for chronic constipation policy; 12 week initial therapy

LOWER GI DISORDERS:Narcotic antagonists

Relistor® (methylnaltrexone) See Relistor policy for opioid induced constipation

NASAL AGENTS Dymista™ (azelastine/fl uticasone) See Dymista policyNEUROLOGICAL DISEASE: GABA analogs

Lyrica® (Pregabalin)Gratise® (Gabapentin ER)Horizant® (Gabapentin ER)

See Gabapentin Coverage Requirement Policy; FDA label diagnosis specifi c to product, and trial of Gabapentin

NEUROLOGICAL DISEASE: Botulinum toxins

Botox® (onabotulinumtoxinA)Xeomin® (incoboluminumtoxinA)Myobloc® (rimabotulinumtoxinB)

Medical benefi t see botulinum toxins policy

NEUROLOGICAL DISEASE:Fibromyalgia agents

Savella® (milnacipran) Trial of TCA, muscle relaxant, gabapentin and non-pharmacologic therapy

PAIN MANAGEMENT:Analgesics, Narcotics

Actiq® (fentanyl citrate) Fentora® (fentanyl citrate)Onsolis® (fentalyl buccal fi lm)Abstral® (fentanyl sublingual tablet)Subsys® (fentanyl sublingual spray)

See Fentanyl® oral dosage formulation policy; limited to cancer diagnosis and inability to swallow and concurrent long acting agent requiring breakthrough agent

Butrans® (buprenorphine) See Butrans policy

UPPER GI DISORDERS;Anti-ulcer preparations

Aciphex® (rabeprazole); Dexilant® (dexlansoprazole); Nexium® (esomeprazole); Zegerid® (omeprazole/sod bicarb)

See PPI policy; trial of three generic PPI (at least 14 day in duration) in addition to qualifying diagnosis

ph-preauthdrugs-0613

Note: This is an incomplete list. Products with one year or less from the date of product launch are excluded from coverage.

Please Note: This applies to most Health Alliance plans. If you have questions, please contact the Pharmacy Department at 1-800-851-3379, option 4.

Step-Therapy (ST)If a drug is covered as a “step-therapy” medication, one or more “prerequisite” medications must be tried fi rst before the step-therapy medication will be covered under the pharmacy benefi t. Prerequisite medications and their corresponding step-therapy medications are used to treat the same conditions. If it is medically necessary, a step-therapy medication can be obtained without trying a prerequisite medication fi rst. In this case, the member’s physician must request coverage for a step-therapy medication as a medical exception.


DRUGS REQUIRING STEP-THERAPY

Drug ClassStep-Therapy (ST) Medication Prerequisite Medication

ASTHMA Bronchodilating

ProAir® HFA (albuterol)Proventil® HFA (albuterol)

Ventolin® HFA

BEHAVIORAL HEALTH Anti-anxiety

Niravam® (alprazolam) alprazolam

BEHAVIORAL HEALTH Atypical antipsychotic

Symbyax® (olanzapine and fl uoxetine)

olanzapine and fl uoxetine

Abilify® (aripiprazole)Invega® (paliperidone)Seroquel® XR (quetiapine)Fanapt® (iloperidone)Latuda® (lurasidone)Saphris® (asenapine)

risperidone, olanzapine, quetiapine or ziprasidone

BEHAVIORAL HEALTH Antidepressants NDRI

Aplenzin® (bupropion) bupropion

BEHAVIORAL HEALTHAntidepressants SARI

Oleptro™ (trazodone) trazodone

BEHAVIORAL HEALTHOpioid dependence

Suboxone® Film (buprenorphine and naloxone)

generic buprenorphine/naloxone tablets

CARDIOVASCULARStatins

Advicor® (lovastatin/niacin)Altoprev® (lovastatin ER)Crestor® (rosuvastatin)Caduet® (atorvastatin/amlodipine)Livalo® (pitavastatin)Lescol® XL (fl uvastatin)

atorvastatin

COPD (Chronic Obstructive Pulmonary Disease)

Daliresp® (rofl umilast) ICS (inhaled corticosteroid) or ICS combo, Asmanex®, Flovent®, QVar®, Aerobid®, Aerobid-M®, Alvesco®, Azmacort®, Pulmicort®, Advair®, Symbicort® or Dulera®

DERMATOLOGYTopical anti-infective

Denavir® (penciclovir) acyclovirAll brand name topical anti-fungal Tier 1 generic topical antifungal

DERMATOLOGYLocal anesthetic

Lidoderm® (lidocaine) gabapentin

DERMATOLOGYTopical anti-infl ammatory

Flector® patch (diclofenac)Pennsaid® (diclofenac)

Voltaren® gel

Drug ClassStep-Therapy (ST) Medication Prerequisite Medication

DIABETESTZDs (Thiazolidinedione)

Actos® (pioglitazone)Actoplus Met® Actoplus Met® XR Duetact®

Avandia® (rosiglitazone)Avandaryl®

Avandamet®

metformin or a sulfonylurea (glimepiride, chlorpropamide, glipizide, glyburide, tolbutamide, tolazamide)

DIABETESDPP4 (Dipeptidyl/Peptidase IV)

Tradjenta® (linagliptin) Jentadueto® (linagliptin/metformin)

metformin or a sulfonylurea

DIABETESGLP-1 (Glucagon-like peptide-1)

Victoza® (liraglutide) metformin or a sulfonylurea

ENDOCRINEBone

Actonel® (risedronate) Atelvia® (risedronate) Binosto™ (alendronate)

alendronate or ibandronate

ENDOCRINETestosterone replacement

Androderm® (testosterone transdermal)Axiron® (testosterone topical)Fortesta® (testosterone gel)Testim® (testosterone gel)Striant® (testosterone buccal)

Androgel® (testosterone gel)

HEMATOLOGICAL DISORDERAnti-Platelet

Brilinta® (ticagrelor)Effi ent® (prasugrel)

New start prescriptions are restricted to cardiologists

Plavix® (clopidogrel) clopidogrel

HEMATOLOGICAL DISORDERThrombin Inhibitors

Eliquis® (apixaban)Pradaxa® (dabigatran)Xarelto® (rivaroxaban)

warfarin

HYPERPARATHYROID AGENT Zemplar® (paricalcitol) calcitriol or Vitamin DINFECTIOUS DISEASEAntibiotic

Difi cid® (fi daxomicin) metronidazole or vancomycin

INFLAMMATORY DISEASE Vimovo™ (esomeprazole/naproxen)

naproxen and Nexium®

PAIN MANAGEMENTLong Acting Opioid

Avinza® (morphine ER)Embeda® (morphine-naltrexone)Exalgo® (hydromorphone ER)Kadian® (morphine ER)Nucynta® ER (tapentadol ER)Oxycontin® (oxycodone)

morphine sulfate ER, fentanyl and Opana® ER

PAIN MANAGEMENTShort Acting Opioid

Nucynta® (tapentadol) Tier 1 opioid

Ryzolt® (tramadol)tramadol ER

tramadol IR

SEDATIVE-HYPNOTICS Lunesta® (eszopiclone)ZolpiMist™ (zolpidem)Silenor® (doxepin)

zolpidem/zolpidem ER and zaleplon

SKELETAL MUSCLE DISORDER Fexmid® (cyclobenzaprine) cyclobenzaprineURINARY TRACTBPH (Benign Prostatic Hypertrophy)

Cialis® (tadalafi l) once daily tamsulosin, alfuzosin, Rapafl o®, fi nasteride, Avodart® or Jalyn® (dutasteride/tamsulosin)

ph-stdruglistMEMB-0413

Specialty medications are usually prescribed for complex, ongoing conditions. To be eff ective, they often have special instructions or need to be administered by a health care professional. The medications Health Alliance classifi es as specialty are listed below.

SPECIALTY DRUG LIST

Age-Related Macular EdemaEylea® (M)*Lucentis® (M)*Macugen® (M)*Visudyne® (M)*

Antiemetic – IntravenousAloxi® (M)Anzemet® (M)Emend® (M)granisetron (M)Kytril® (M)

Autoimmune Infl ammatory DisordersActemra® (M)*Amevive® (M)*Arcalyst™ (M)*Benlysta® (M)*(NF)Cimzia™*Enbrel®*Humira®*Ilaris® (M)*Kineret®*Orencia® (M)*Orencia Sub Q®* Remicade® (M)*Simponi®*Stelara™* (M)

Blood Modifi ersAranesp®*Epogen®*Leukine®*Neulasta®*Neumega®*Neupogen®*Nplate® (M)*Procrit®*Promacta®*

Bone Resorption Aredia® (M)*Boniva® IV (M)*Forteo®*Prolia® (M)*Xgeva® (M)*zoledronic acid (M)*

Clotting DisordersAdvate® (M)*Alphanate®/VWF (M)*Alphanine® SD (M)*Bebulin® VH (M)*BeneFIX® (M)*Feiba® NF (M)*Feiba® VH (M)*Helixate® FS (M)*Hemofi l® M (M)*Humate-P® (M)*Koate®-DVI (M)*

Kogenate® FS (M)*Monoclate-P® (M)*Mononine® (M)*NovoSeven® RT (M)*Profi lnine® SD (M)*Recombinate® (M)*Wilate® (M)*Xyntha® (M)*

Cystic FibrosisCayston®*Kalydeco™*Pulmozyme®*TOBI®*

Enzyme Defi cienciesAldurazyme® (M)*Carbaglu®* (NF)Ceredase® (M)*(NF)Cerezyme® (M)*(NF)Cinryze® (M)*(NF)Elaprase™ (M)*(NF)Fabrazyme® (M)*(NF)Kuvan®* (NF)Lumizyme® (M)*(NF)Myozyme® (M)*(NF)Naglazyme® (M)*(NF)Orfadin®* (NF)Sucraid®* (NF)Vpriv® (M)*(NF)Zavesca®*(NF)

Growth HormoneGenotropin®*Humatrope®*Increlex®*Norditropin®*Nutropin® AQ*Omnitrope®*Protropin®*Saizen®*Serostim®*Tev-Tropin®*Zorbtive®*

Hepatitis CCopegus®*Incivek*Infergen®*Pegasys®*Peg-Intron®*Rebetrol®*Rebetron™*Ribapak®*Ribasphere®*RibaTab®*ribavirin*Roferon®-A*Sylatron™ injection (M)Victrelis™*

Hereditary AngioedemaBerinert® (M)*(NF)Kalbitor® (M)*(NF) Firazyr®*(NF)

HIVAtripla®

Complera®

Fuzeon®

Selzentry®

Stribild™Trizivir™Truvada®

HIV LipodystrophyEgrifta®* (NF)

Immune GlobulinCarimune® NF (M)* CytoGam® (M)*Flebogamma® DIF (M)*Gamastan® S/D (M)*Gammagard® (M)*Gammaplex® (M)*Gamunex® (M)*Gamunex-C® (M)*Hizentra™*Hyperrho® S/D (M)*Nabi-HB® (M)*Octagam® (M)*Privigen® (M)*RhoGAM® Plus (M)Rhophylac® (M)WinRho® SDF (M)

InfertilityBravelle®*Cetrotide®*chorionic gonadotropin*Delestrogen®*Follistim® AQ*ganirelix*Gonal-F®*Lupron subQ®*Luveris®*Menopur®*Novarel®*Ovidrel®*Pregnyl®*progesterone in oil*Repronex®*

Key(M) Medical Benefi t* Requires PreauthorizationBolded items are preferred agents(NF) Non-Formulary drugs

ph-memspeclist-0713

Lung DisordersActimmune®*Aralast® (M)*(NF)Aralast® NP (M)*(NF)Glassia™ (M)*(NF)Prolastin® C (M)*(NF)Synagis® (M)*Xolair® (M)*Zemaira® (M)*(NF)

Multiple SclerosisAmpyra®* (NF)Avonex®*Betaseron®*Copaxone®*Extavia®*Gilenya™*Rebif®*Tysabri® (M)*

OncologyAbraxane® (M)Adcetris® (M)Adriamycin® (M)Adrucil® (M)Afi nitor®*Alferon N® (M)*Alimta® (M)Alkeran® (M)Ara-C (M)Arranon® (M)Arzerra™ (M)Avastin® (M)*Bexxar® (M)BiCNU® (M)Blenoxane® (M)Busulfex™ (M)calcium folinate (M)Campath® (M)Camptosar® (M)CARBOplatin (M)Cerubidine® (M)cisplatin (M)Clolar® (M)Cosmegen® (M)Cytoxan® (M)Dacogen® (M)Daunoxome® (M)DepoCyt® (M)Doxil® (M)DTIC-Dome® (M)Efudex® (M)Eligard® (M)*Elitek® (M)*Ellence® (M)Eloxatin® (M)Elspar® (M)Erbitux® (M)*Erivedge™*Erwinaze™ (M)Etopophos® (M)Faslodex® (M)Firmagon® (M)Fludara® injectable (M)Fludara® oral*Folotyn® (M)FUDR® (M)Fusilev™ (M)Gemzar® (M)Gleevec®*

Halaven® (M)Herceptin® (M)*Hycamtin® (M)Idamycin® PFS (M)Ifex® (M)Inlyta®*Intron A® (M) Istodax® (M)Ixempra® (M)Jakafi *Jevtana® (M)Kepivance® (M)Leustatin® (M)Mekinist™* (NF)methotrexate (M)Mitomycin® (M)Mozobil™ (M)*Mustargen® (M)Mylotarg™ (M)Navelbine® (M)Nexavar®*Nipent™ (M)Oncaspar® (M)Ontak® (M)Onxol® (M)Orthoclone® OKT 3 (M)Paraplatin® (M)Perjeta™ (M)*Platinol-AQ® (M)Proleukin® (M)Provenge® (M)*(NF)Revlimid®*Rituxan® (M)*Sprycel®*Sutent®*Tafi nlar®* (NF)Tarceva®*Targretin®*Tasigna®*Taxol® (M)Taxotere® (M)Temodar™*Tespa (M)Thalomid®*Thioplex® (M)Torisel® (M)Treanda® (M)Trelstar® Depot (M)*Trisenox® (M)Tykerb®*Valstar® (M)Vectibix® (M)*Velban® (M)Velcade® (M)VePesid® (M)Vidaza® (M)Vincasar® (M)Votrient™*Vumon® (M)Xalkori®*Xeloda®*Yervoy™ (M)Zanosar® (M)Zelboraf®* Zevalin® (M)Zoladex® (M)*Zolinza®*Zostress®*Zytiga®*

Oncology – Adjuvantamifostine (M)Duraclon® (M)Ethyol® (M)Ganite® (M)Kepivance® (M)pamidronate (M)

OtherActhar® HP*(NF)Adagen® (M)*Apokyn™*chenodiol*Exjade®*Ferriprox®*Jetrea® (M)*(NF)Korlym™*Krystexxa® (M)*Lupron Depot® (M)*Novantrone® (M)octreotide*Procysbi™* (NF)Rilutek®

Sabril®*Samsca®*Sandostatin®*Sandostatin® LAR depot (M)*Sensipar®*Sirturo™* (NF)Soliris® (M)*Somatuline® Depot (M)*Somavert™* (NF)Supprelin® LA (M)*(NF)Vantas® (M)Vivitrol® (M)voriconazole*Xenazine®* (NF)Xiafl ex® (M)*(NF)Xyrem®* (NF)

Pregnancy SupportMakena™* (NF)

Pulmonary HypertensionAdcirca®*epoprostenol sodium (M)*Flolan® (M)*Letairis™*Remodulin® (M)*sildenafi l*Tracleer®*Tyvaso®*Veletri® (M)*Ventavis®*

ViscosupplementationEufl exxa® (M)Hyalgan® (M)OrthoVisc® (M)Supartz® (M)Synvisc® (M) Synvisc One® (NF)

Please contact CVS Caremark at 1-800-237-2767 or the Health Alliance Pharmacy department at 1-800-851-3379, option 4 for more information.

38

INDEX

#

5-AMINOSALICYLIC ACID ......................................................... 12 8-MOP ............................................................................................. 28

A

acarbose (Precose) ....................................................................... 18 ACCU-CHEK ACTIVE TEST STRIPS ........................................ 19 ACCU-CHEK AVIVA METER ....................................................... 18 ACCU-CHEK AVIVA PLUS TESTS STRIPS ............................. 18 ACCU-CHEK COMFORT CURVE TEST STRIPS .................... 18 ACCU-CHEK COMPACT PLUS METER ................................... 18 ACCU-CHEK COMPACT TEST STRIPS ................................... 18 ACCU-CHEK NANO METER ....................................................... 18 ACCU-CHEK SMART VIEW TEST STRIPS .............................. 18 acebutolol (Sectral) ........................................................................ 14 acetaminophen (Ultracet) ............................................................ 23 acetaminophen/codeine ................................................................ 22 acetaminophen/isometheptene/dichloralphenazone (Midrin) . 22 acetazolamide (Diamox) ............................................................... 16 acetazolamide ER (Diamox Sequels) ......................................... 16 acetic acid ear solution .................................................................. 25 acyclovir (Zovirax) ........................................................................... 7 ADVAIR ........................................................................................... 24 ADVICOR........................................................................................ 15 ainocycline (Minocin) ....................................................................... 7 albuterol ........................................................................................... 24 albuterol inhaler solution ............................................................... 24 albuterol syrup, tablets .................................................................. 24 alclometasone (Aclovate) ............................................................. 28 alendronate tablets (Fosamax) .................................................... 19 alfuzosin (Uroxatral) ..................................................................... 13 ALKERAN ........................................................................................ 9 allopurinol (Zyloprim) ..................................................................... 22 ALOMIDE........................................................................................ 26 ALORA ............................................................................................ 19 ALPHAGAN P ................................................................................ 26 alprazolam (Xanax).......................................................................... 9 amantadine (Symmetrel)............................................................... 21 amiloride (Midamor) ....................................................................... 16 amiloride/hydrochlorothiazide (Moduretic) ................................ 16 amiodarone (Cordarone, Pacerone) ......................................... 16 amitriptyline ....................................................................................... 9 amlodipine (Norvasc) .................................................................... 15 amlodipine/benazepril (Lotrel) ...................................................... 15 amoxicillin (Amoxil) ......................................................................... 7 amoxicillin/potassium clavulanate (Augmentin) ........................... 7 amoxicillin/potassium clavulanate ER (Augmentin XR) .............. 7 amphetamine/detroamphetamine (Adderall) .............................. 10 AMTURNIDE .................................................................................. 17

anagrelide (Agrylin) ......................................................................... 8 ANALPRAM E ............................................................................... 25 anastrozole (Arimidex) .................................................................... 9 ANDROGEL ................................................................................... 19 ANZEMET ...................................................................................... 12 APIDRA .......................................................................................... 18 APIDRA SOLOSTAR ................................................................... 18 APRISO .......................................................................................... 12 APTIVUS .......................................................................................... 7 ARICEPT ........................................................................................ 10 ARMOUR THYROID ..................................................................... 20 ASACOL ......................................................................................... 12 ASTEPRO ...................................................................................... 24 atenolol (Tenormin) ....................................................................... 15 atenolol/chlorthalidone (Tenoretic) .............................................. 15 atorvastatin (Lipitor)....................................................................... 15 atovaquone/proguanil 250-100 mg (Malarone) .......................... 8 ATRIPLA .......................................................................................... 7 atropine sulfate eye ointment, solution (Isopto Atropine) ......... 26 ATROVENT HFA .......................................................................... 24 AVODART ...................................................................................... 13 AVONEX ......................................................................................... 20 azathioprine (Imuran) .................................................................... 20 azelastine (Astelin) ....................................................................... 24 azelastine eye solution (Optivar) ................................................. 26 azithromycin (Zithromax) ............................................................ 6 AZOR .............................................................................................. 14

B

baclofen (Lioresal) ......................................................................... 20 balsalazide (Colazal) ..................................................................... 12 BANZEL ......................................................................................... 21 benazepril (Lotensin) ..................................................................... 14 benazepril/hydrochlorothiazide (Lotensin HCT) ........................ 14 BENICAR ....................................................................................... 14 benztropine (Cogentin) ................................................................. 21 betamethasone dipropionate (Diprosone) .................................. 28 betamethasone dipropionate, augmented (Diprolene) ............. 28 betamethasone valerate cream, lotion ....................................... 28 BETASERON ................................................................................. 20 BETOPTIC-S.................................................................................. 26 bicalutamide (Casodex) .................................................................. 9 bisoprolol (Zebeta)......................................................................... 15 bisoprolol/hydrochlorothiazide (Ziac) .......................................... 15 BLEPHAMIDE S.O.P. ................................................................... 27 brimonidine eye solution, 0.2% .................................................... 26 bromocriptine (Parlodel) ............................................................... 21 budesonide ER (Entocort EC) ..................................................... 17 budesonide ER (Pulmicort Respules) ......................................... 24 bumetanide (Bumex) ..................................................................... 16

39

buprenorphine (Subutex) .............................................................. 22 bupropion (Wellbutrin) ................................................................... 9 bupropion ER (Zyban) .................................................................. 10 bupropion ext-release (Wellbutrin SR, Wellbutrin XL) .......... 10 buspar (Valium) .............................................................................. 10 buspirone (Buspar) .......................................................................... 9 butalbital/acetaminophen .............................................................. 23 butalbital/acetaminophen/caffeine (Esgic, Esgic Plus,

Fioricet) ..................................................................................... 23 butalbital/aspirin/caffeine (Fiorinal) .............................................. 23 butalbital/aspirin/caffeine/codeine ............................................... 23

C

cabergoline (Dostinex) .................................................................. 19 calcipotriene solution (Dovonex) .................................................. 28 calcitonin-salmon (Miacalcin) ....................................................... 19 calcitriol (Rocaltrol) ........................................................................ 19 CANASA ......................................................................................... 12 captopril (Capoten) ........................................................................ 14 captopril/hydrochlorothiazide (Capozide) ................................... 14 CARAFATE SUSPENSION ......................................................... 12 carbamazepine (Tegretol)............................................................. 21 carbamazepine ER (Carbatrol, Tegretol-XR) ............................. 21 CARBATROL ................................................................................. 21 carbidopa/levodopa (Parcopa, Sinemet) .................................... 21 carbidopa/levodopa ER (Sinemet CR) ........................................ 21 CARDURA XL ................................................................................ 13 carteolol eye solution (Ocupress) ................................................ 26 carvedilol (Coreg) ........................................................................... 15 CAVERJECT .................................................................................. 16 CEENU .............................................................................................. 9 cefdinir (Omnicef) .......................................................................... 6 cefpodoxime (Vantin) .................................................................... 6 cefprozil (Cefzil) ............................................................................. 6 cefuroxime (Ceftin) ........................................................................ 6 CELLCEPT ..................................................................................... 20 CHANTIX ........................................................................................ 10 chlorhexidine oral rinse (Peridex) ................................................ 27 chloroquine phosphate (Aralen) .................................................... 8 chlorpromazine (Thorazaine) ....................................................... 11 chlorthalidone 25 mg, 50 mg (Thalitone) .................................... 16 chlorzoxazone (Parafon) .............................................................. 20 cholestyramine (Questran, Questran Light) ............................... 15 CIALIS ............................................................................................. 16 ciclopirox gel, shampoo (Loprox) ................................................. 28 cilostazol (Pletal) .............................................................................. 8 cimetidine (cimetidine) .................................................................. 12 CIPRO SUSPENSION .................................................................... 6 ciprofloxacin (Cipro) ..................................................................... 6 citalopram (Celexa)........................................................................ 10 clarithromycin (Biaxin) ................................................................. 6 clarithromycin ER (Biaxin XL) .................................................... 6 CLEOCIN ........................................................................................ 13

clindamycin vaginal cream (Cleocin) .......................................... 13 clobetasolution (Olux, Temovate) ............................................... 28 clomiphene (Clomid) ..................................................................... 19 clomipramine (Anafranil) ............................................................... 10 clonazepam (Klonopin) ................................................................. 21 clonidine (Catapres, Catapres-TTS) ........................................... 16 clopidogrel (Plavix) .......................................................................... 8 clozapine (Clozaril) ........................................................................ 11 COARTEM ....................................................................................... 8 COLCRYS ...................................................................................... 22 colestipol (Colestid) ....................................................................... 15 COMBIVENT .................................................................................. 24 COPAXONE ................................................................................... 20 COREG CR—carvedilol .............................................................. 15 CORTIFOAM.................................................................................. 25 COUMADIN ...................................................................................... 8 CREON ........................................................................................... 12 CRESTOR ...................................................................................... 15 CRIXIVAN ......................................................................................... 7 cromolym sodium inhal solution (Intal) ....................................... 24 cyanocobalmin injection.................................................................. 8 cyclobenzaprine (Flexeril, Fexmid) ........................................... 20 CYCLOGYL ................................................................................... 26 CYCLOMYDRIL ............................................................................ 26 cyclopentolate eye solution (Cyclogyl) ....................................... 26 cyclosporine (Sandimmune) ........................................................ 20 cyclosporine modified capsules ................................................... 20

D

danazol (Danocrine) ...................................................................... 19 dantrolene (Dantrium) ................................................................... 21 DELZICOL ...................................................................................... 12 DEPAKENE ................................................................................... 21 DEPAKOTE ................................................................................... 21 DEPAKOTE SPRINKLES ............................................................ 21 desipramine (Norpramin) .............................................................. 10 desmopressin (DDVAP)................................................................ 19 desonide (Desowen) ..................................................................... 28 desoximetasone cream, 0.25%; gel; ointment 0.25% (Topicort)

.................................................................................................... 28 DEXAMETHASONE INTENSOL ................................................ 17 dextroamphetamine....................................................................... 10 dextroamphetamine ER (Dexedrine Spansule) ......................... 10 diclofenac eye solution (Voltaren) ............................................... 26 diclofenac potassium ..................................................................... 23 diclofenac sodium DR (Voltaren) ............................................... 23 diclofenac sodium ER ................................................................... 23 dicloxacillin (Dicloxacillin) ............................................................. 7 dicyclomine (Bentyl) ...................................................................... 12 didanosine DR (Videc EC) ............................................................. 7 diflorasone ointment ...................................................................... 28 digoxin (Lanoxin) ........................................................................... 17 DILANTIN ....................................................................................... 21

40

DILATRATE SR ............................................................................. 15 DILAUDID-5 ................................................................................... 23 diltiazem ER .................................................................................... 15 diltizaem (Cardizem)...................................................................... 15 DIOVAN .......................................................................................... 14 DIOVAN HCT ................................................................................. 14 DIPENTUM ..................................................................................... 12 diphenoxylate/atropine tablets (Lomotil) ..................................... 12 dipyridamole (Persantine) ............................................................... 8 disopyramide (Norpace) ................................................................ 16 disulfiram (Antabuse) .................................................................... 10 divalproex DR (Depakote Sprinkles, Depakote) ........................ 21 divalproex ER (Depakote ER) ...................................................... 21 donepezil (Aricept, Aricept ODT) ................................................. 10 dorzolamide eye solution (Trusopt) ............................................. 26 dorzolamide/timolol maleate eye solution (Cosopt) .................. 26 doxazosin (Cardura) ...................................................................... 17 doxepin (Sinequan) ...................................................................... 10 doxycycline hyclate (Vibramycin) ................................................. 7 DROXIA ............................................................................................ 8 DUETACT ....................................................................................... 18

E

E.E.S. GRANULES ......................................................................... 6 econazole (Spectazole) ................................................................ 28 EDEX ............................................................................................... 16 ELIXOPHYLLIN ............................................................................. 24 EMCYT .............................................................................................. 9 EMEND ........................................................................................... 12 EMSAM ........................................................................................... 10 EMTRIVA .......................................................................................... 7 enalapril (Vasotec) ......................................................................... 14 enalapril/hydrochlorothiazide (Vaseretic) ................................... 14 ENBREL ............................................................................................ 8 ENDOMETRIN ............................................................................... 13 enoxaparin (Lovenox)...................................................................... 8 EPIPEN ........................................................................................... 24 EPIPEN-JR 2-PAK ........................................................................ 24 EPIVIR HBV ..................................................................................... 6 eplerenone (Inspra) ....................................................................... 17 EPZICOM .......................................................................................... 7 EQUETRO ...................................................................................... 11 erythromycin eye ointment ........................................................... 25 erythromycin gel, pads, solution .................................................. 27 erythromycin/sulfisoxazole (Pediazole) ................................... 6 escitalopram (Lexapro) ................................................................. 10 estazolam (Prosom) ...................................................................... 11 ESTRACE ....................................................................................... 14 estradiol (Climara, Estrace) .......................................................... 19 estradiol/norethindrone acetate (Activella) ............................... 19 ESTRING ........................................................................................ 14 estropiopate (Ogen, Ortho-Est).................................................... 19

ethambutol (Myambutol) ................................................................. 7 ethosuximide (Zarontin) ................................................................ 21 etidronate (Didronal) ..................................................................... 19 etodolac (Lodine) .......................................................................... 23 EVISTA ........................................................................................... 19 EVISTA—raloxifene ..................................................................... 19 EXELON ......................................................................................... 11 exemestane (Aromasin).................................................................. 9 EXFORGE ...................................................................................... 14 EXFORGE HCT ............................................................................. 14

F

famciclovir (Famvir) ......................................................................... 7 famotidine (Pepcid) ....................................................................... 13 FARESTON ...................................................................................... 9 FAZACLO ....................................................................................... 11 FELBATOL .................................................................................... 21 felodipine ER (Plendil) .................................................................. 15 FEMHRT LOW DOSE .................................................................. 19 fenofibrate, micronized (Liofibra) ................................................. 16 fentanyl oral lozenge (Actiq) ....................................................... 23 fentanyl patch (Duragesic) .......................................................... 23 finasteride (Proscar) ................................................................... 13 FLAREX .......................................................................................... 27 flecainide (Tambocor) ................................................................... 16 FLOVENT ....................................................................................... 24 fluconazole (Diflucan) .................................................................. 6 flucytosine (Ancoban) .................................................................. 6 fludrocortisones (Florinef) ............................................................. 17 fluocinonide .................................................................................... 28 fluorometholone eye suspenion, 0.1% (FML Liquifilm) ............ 27 FLUOROQUINOLONES ................................................................. 6 fluorouracil (Efudex) ...................................................................... 28 fluoxetine (Prozac)......................................................................... 10 fluphenazine hcl tablets (Prolixin)................................................ 11 flurbiprofen eye solution (Ocufen) ............................................... 26 flutamide (Eulexin) ........................................................................... 9 fluticasone propionate (Cutivate) ................................................. 28 FML FORTE ................................................................................... 27 folic acid tablets, 1 mg .................................................................... 8 FOLLISTIM AQ .............................................................................. 19 FORADIL AEROLIZER ................................................................ 24 fosinopril (Monopril) ....................................................................... 14 FRAGMIN ......................................................................................... 8 FREESTYLE FREEDOM LITE BLOOD GLUCOSE SYSTEM 19 FREESTYLE INSULINX BLOOD GLUCOSE SYST ............... 19 FREESTYLE INSULINX TEST STRIPS..................................... 19 FREESTYLE LITE BLOOD GLUCOSE MONITORING

SYSTEM .................................................................................... 19 FREESTYLE LITE TEST STRIPS .............................................. 19 furosemide (Lasix) ......................................................................... 16

41

G

gabapentin (Neurontin) ................................................................. 21 GABITRIL ....................................................................................... 22 galantamine (Razadyne) ............................................................... 11 galantamine ER (Razadyne ER) .................................................. 11 GALZIN ........................................................................................... 25 gemfibrozil (Lopid) ........................................................................ 16 gentamicin eye ointment, solution (Garamycin) ........................ 26 glimepiride (Amaryl) ....................................................................... 18 glipizde (Glucotrol) ......................................................................... 18 glipizde ER (Glucotrol XL) ............................................................ 18 GLUCAGEN ................................................................................... 18 GLUCAGON EMERGENCY KIT ................................................. 18 glyburide (Micronase) .................................................................... 18 glyburide micronized (Glynase) ................................................... 18 glyburide/metformin (Glucovance)............................................... 18 granisetron (Kytril) ......................................................................... 12 GRIFULVIN V ................................................................................... 6 griseofulvin microsize (Fulvicin, Grisfulvin) ........................... 6 GRIS-PEG ........................................................................................ 6 guanfacine (Tenex) ........................................................................ 17

H

halobetasolution (Ultravate) ......................................................... 28 haloperidol (Haldol)........................................................................ 11 HEXALEN ......................................................................................... 9 hlycopyrrolate (Robinul) ................................................................ 13 homatropine eye solution (Isopto Homatropine) ....................... 26 HUMALOG ..................................................................................... 18 HUMIRA ............................................................................................ 8 HUMULIN........................................................................................ 18 hydralazine (Apresolutionine) ....................................................... 17 hydrcortisone valerate (Westcort) ................................................ 28 hydrochlorothiazide (Microzide, Hydrodiuril) .......................... 16 hydrocodone/acetaminophen (Vicodin, Lorcet, Lortab,

Norco) ........................................................................................ 23 hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen) .. 23 hydrocortisone (Cortef) ................................................................ 17 hydrocortisone acetate .................................................................. 25 hydrocortisone enema (Cortenema) ........................................... 25 hydrocortisone topical ................................................................... 28 hydrocortisone/acetic acid ear solution ....................................... 25 hydromorphone tablets ................................................................. 23 hydroxychloroquine.......................................................................... 8 hydroxyurea (Hydrea) ...................................................................... 9 hydroxyzine (Atarax, Vistaril) ....................................................... 10 hyoscyamine (Anaspaz, Levsin/SL) ............................................ 13 hyoscyamine ER (Levbid, Symax Duotab) ................................. 13

I

ibandronate oral (Boniva) ............................................................. 19

ibuprofen (Motrin) ......................................................................... 23 imipramine hcl (Tofranil) ............................................................... 10 imiquimod (Aldara) ........................................................................ 28 indapamide (Lozol) ........................................................................ 16 INVIRASE ......................................................................................... 7 ipratropium inhale rsolution (Atrovent, Aerovent) ...................... 24 ipratropium/albuterol (Duoneb) .................................................... 24 irbesartan (Avapro) ........................................................................ 14 irbesartan/hydrochlorothiazide (Avalide) .................................... 14 ISENTRESS ..................................................................................... 7 isoniazid (Laniazid, Nydrazid) ........................................................ 7 isoniazid/rifampin (Rifamate) ......................................................... 7 ISOPTO CARBACHOL ................................................................ 26 ISOPTO HOMATROPINE ............................................................ 26 ISORDIL TITRADOSE—isosorbide dinitrate ......................... 15 isosorbide dinitrate (Isordil) .......................................................... 15 isosorbide mononitrate (Monoket) ............................................... 15 isosorbide mononitrate ER (Imdur) ............................................. 15 itraconazole (Sporonox) .............................................................. 6

J

JALYN ............................................................................................ 13

K

KALETRA ......................................................................................... 7 ketoconazole (Nizoral) .................................................................. 28 ketoconazole tablets (Nizoral) .................................................... 6 ketoprofen (Oruvail) ..................................................................... 23 ketorolac eye solution (Acular, Acular LS) ................................. 27 KLONOPIN— ................................................................................. 22

L

labetalol (Trandate) ....................................................................... 15 lactulose (Enulose) ....................................................................... 12 LAMICTAL ..................................................................................... 22 LAMICTAL XR ............................................................................... 22 lamivudine (Epivir) ........................................................................... 7 lamivudine/zidovudine (Combivir) ................................................ 8 lamotrigine (Lamictal) .................................................................... 22 LANOXIN ........................................................................................ 17 lansoprazole DR ............................................................................ 13 lantanoprost eye solution (Xalatan) ............................................ 26 LANTUS ......................................................................................... 18 LANTUS SOLOSTAR .................................................................. 18 LASTACAFT —alcaftadine ........................................................ 27 LATUDA—lurasidone ................................................................. 11 leflunomide (Arava)....................................................................... 23 letrozole (Femara) ........................................................................... 9 leucovorin calcium tablets .............................................................. 9 LEUKERAN ..................................................................................... 9 levetiracetam (Keppra) ................................................................. 22

42

levobunolol eye solution, 0.5% (Betagan) .................................. 26 levofloxacin (Levaquin) ................................................................ 6 levonorgestrel (Plan B) .................................................................. 17 levothyroxine (Synthroid, Levoxyl) ........................................... 20 LIALDA ........................................................................................... 12 lidocaine topical (Xylocaine) ......................................................... 28 lidocaine viscous ............................................................................ 27 lindane ............................................................................................. 28 liothyronine (Cytomel) ................................................................... 20 lisinopril ........................................................................................... 14 lisinopril/hydrochlorothiazide (Prinizide) ..................................... 14 lithium carbonate ............................................................................ 11 lithium carbonate ER (Lithobid, Eskalith CR) ............................. 11 LITHOBID ....................................................................................... 11 lorazepam (Ativan) ......................................................................... 10 losartan (Cozaar) ........................................................................... 14 losartan/hydrochlorothiazide (Hyzaar) ........................................ 14 lovastatin (Mevacor) ...................................................................... 16 LOVAZA.......................................................................................... 16 LOVENOX ........................................................................................ 9 loxapine (Loxitane) ........................................................................ 11 LUMIGAN—bimatoprost, ophthalmic solution 0.03% ............... 26 LYSODREN ...................................................................................... 9 LYSTEDA ......................................................................................... 9

M

MACRODANTIN ............................................................................ 13 MATULANE ...................................................................................... 9 MAXAIR AUTOHALER ................................................................ 24 meclizine (Antivert) ....................................................................... 12 medroxyprogesterone acetate (Provera) ................................... 20 mefloquine (Larium)........................................................................ 8 megestrol (Megace) ......................................................................... 9 meloxicam (Mobic) ........................................................................ 23 MENEST ......................................................................................... 19 MENOSTAR ................................................................................... 19 MEPHYTON ................................................................................... 25 MEPRON—atovaquone suspension ......................................... 6 mercaptopurine (Purinethol) ........................................................... 9 mesalamine (Asacol) ..................................................................... 12 mesalamine powder (5-aminosalicylic acid) ......................... 12 MESNEX ........................................................................................... 9 MESTINON ..................................................................................... 21 MESTINON TIMESPAN ............................................................... 21 METADATE CD ............................................................................. 10 metaxalone (Skelaxin) ................................................................... 21 metformin (Glucophage) ............................................................... 18 metformin ER (Glucophage XR) .................................................. 18 methadone solution ....................................................................... 23 methadone tablets ......................................................................... 23 methazolamide (Neprazane) ........................................................ 16 methimazole (Tapaxzole) ............................................................. 20

methocarbamol (Robaxin) ............................................................ 21 methotrexate (Trexall) ..................................................................... 9 methyldopa (Aldomet) ................................................................... 17 METHYLIN ..................................................................................... 10 methylphenidate ER capsules, tablets (Ritalin LA, Ritalin SR)10 methylphenidate tablets (Ritalin) ................................................. 10 methylprednisolone (Medrol)....................................................... 17 metipranolol eye solution (Optipranolol) ..................................... 26 metoclopramide (Reglan) ............................................................. 12 metolazone (Zaroxolyn) ................................................................ 16 metoprolol succinate ER ............................................................... 15 metoprolol tartrate (Lopressor) .................................................... 15 metronidazole (Flagyl).................................................................. 6 metronidazole (Metrocream, Metrolotion) .................................. 27 metronidazole (MetroGel-Vaginal) .............................................. 14 metronidazole topical gel (Metrogel) ........................................... 28 MIGRANAL .................................................................................... 22 MILLIPRED .................................................................................... 17 minoxidil (Loniten) ......................................................................... 17 mirtazapine (Remeron, Remeron SolTab) ................................. 10 misoprostol (Cytotec) .................................................................... 13 moexipril (Univasc) ........................................................................ 14 moexipril/hydrochlorothiazide (Uniretic) ..................................... 14 mometasone ................................................................................... 28 montelukast sodium ...................................................................... 24 MOP ................................................................................................ 28 morphine sulfate ER (MS Contin) .............................................. 23 MULTAQ......................................................................................... 16 mupirocin ointment (Bactroban) .................................................. 28 MUSE .............................................................................................. 16 MYCOBUTIN.................................................................................... 7 mycophenolate mofetil (Cellcept) ................................................ 20 MYLERAN ........................................................................................ 9 MYSOLINE ..................................................................................... 22

N

nadolol (Corgard) ........................................................................... 15 NALFON ......................................................................................... 23 naltrexone (ReVia)......................................................................... 11 NAMENDA ..................................................................................... 11 naproxen (Naprosyn) ................................................................... 23 naproxen DR (EC-Naprosyn) ..................................................... 23 naproxen sodium (Anaprox) ....................................................... 23 naratriptan (Amerge) ..................................................................... 22 NASCOBAL ................................................................................... 25 nateglinide (Starlix) ........................................................................ 18 neomycin/polymyxin B/bacitracin/hydrocortisone eye ointment

.................................................................................................... 27 neomycin/polymyxin B/dexamethasone eye ointment,

suspenion (Maxitrolo) .............................................................. 27 neomycin/polymyxin B/gramicidin eye solution (Neosporin) ... 26 neomycin/polymyxin B/hydrocortisone ear solution, suspension

(Cortisporin) .............................................................................. 25

43

neomycin/polymyxin/bacitracin eye ointment............................. 26 NEORAL ......................................................................................... 20 NEURONTIN .................................................................................. 22 NIASPAN ........................................................................................ 16 NICOTROL INHALER .................................................................. 11 NICOTROL NS............................................................................... 11 nifedipine ER (Adalat CC, Procardia XL).................................... 15 NILANDRON .................................................................................... 9 NITRO-BID—nitroglycerin ......................................................... 15 NITRO-DUR—nitroglycerin patch ............................................ 15 nitrofurantoin (Furadantin) ............................................................ 13 nitrofurantoin macrocrystalline (Macrodantin) .......................... 13 nitrofurantoin monohydrate/macrocrystalline (Macrobid) ......... 13 nitroglycerin (Nitro-Dur) ................................................................. 15 NITROMIST .................................................................................... 15 NITROSTAT—nitroglycerin SL ................................................. 15 norethindrone acetate (Aygestin) ................................................ 20 norethindrone acetate/ethinyl estradiol ....................................... 19 NORPACE CR— ........................................................................... 16 nortriptyline (Pamelor) ................................................................... 10 NORVIR SOLUTION ....................................................................... 8 nystatatin topical ............................................................................ 28 nystatin oral (Mycostatin) ............................................................ 6 nystatin suspenion ......................................................................... 27

O

ofloxacin ear solution (Floxin otic) ............................................... 25 ofloxacin eye solution (Ocuflox) ................................................... 26 triamcinolone cream; lotion ........................................................... 28 olanzapine (Zyprexa, Zyprexa Zydis) .......................................... 11 omeprazole DR (Prilosec)............................................................. 13 ondansetron (Zofran, Zofran ODT) .............................................. 12 OPANA ER ..................................................................................... 23 ORACIT ........................................................................................... 13 oral contraceptives...................................................................... 17 orphenadrine citrate ER (Norflex) ................................................ 21 orphenadrine/aspirin/caffeine (Norgesic).................................... 21 oxaprozin (Daypro) ....................................................................... 23 oxcarbazepine (Trileptal) .............................................................. 22 OXSORALEN ULTR ..................................................................... 28 oxybutynin (Ditropan) .................................................................... 13 oxybutynin ER (Ditropan XL) ...................................................... 13 oxycodone (Roxicodone) ............................................................ 23 oxycodone/acetaminophen........................................................... 23 oxycodone/aspirin (Percodan) ..................................................... 23

P

pantoprazole DR (Protonix) .......................................................... 13 paroxetine hcl (Paxil) ..................................................................... 10 paroxetine hcl ER (Paxil CR) ....................................................... 10 PAXIL .............................................................................................. 10 PEG INTRON ................................................................................... 7

PEGASYS......................................................................................... 7 penicillin v potassium (Veetids) .................................................... 7 PENTASA ....................................................................................... 12 pentoxifylline ER (Trental) .............................................................. 9 perindopril (Aceon) ........................................................................ 14 permethrin....................................................................................... 28 perphenazine (Trilafon) ................................................................. 11 phenelzine (Nardil) ....................................................................... 10 phenobarbital ................................................................................. 11 phenytoin sodium ER (Dilantin, Phenytek) ................................ 22 phenytoin suspenion (Dilantin) .................................................... 22 PHOSPHOLINE IODIDE .............................................................. 27 PHRENILIN FORTE ...................................................................... 23 pilocarpine (Salagen) .................................................................... 27 pilocarpine eye solution, 1%, 2%, 4% (Isopto Carpine) ........... 26 PILOPINE HS ................................................................................ 27 pioglitazone (Actos) ...................................................................... 18 pioglitazone-metformin (Actoplus met) ..................................... 18 pioglitazone-metformin SR ........................................................... 18 piroxicam (Feldene) ...................................................................... 23 podofilox (Condylox) ..................................................................... 28 polymyxin B/trimethoprim eye solution (Polytrim) ..................... 26 POTABA ......................................................................................... 21 potassium chloride ER .................................................................. 25 potassium citrate ER (Urocit-K) ............................................... 13 potassium citrate/citric acid .......................................................... 13 potassium citrate/citric acid (Polycitra-K) ................................... 13 POTASSIUM P-AMINOBENZOATE .......................................... 21 potassium phosphate/sodium phosphates (K-Phos Neutral) .. 25 pramipexole (Mirapex) .................................................................. 21 pravastatin (Pravachol) ................................................................. 16 prazosin (Minipress) ...................................................................... 17 PRECISION XTRA BLOOD GLUCOSE SYSTEM ................... 19 PRED MILD .................................................................................... 27 PRED-G .......................................................................................... 27 PRED-G S.O.P. ............................................................................. 27 prednisolone (Prelone) ................................................................. 17 prednisolutionone acetate eye suspenion (Pred Forte) ........... 27 prednisolutionone sodium phosphate (Orapred, Pediapred) .. 17 PREDNISONE INTENSOL .......................................................... 17 prednisone tablets ......................................................................... 17 prenatal vitamin/folic acid - all generics ...................................... 25 primaquine ........................................................................................ 8 primidone (Mysolutionine) ............................................................ 22 probenecid (Benemid) ................................................................... 22 prochlorperazine (Compazine) .................................................... 11 progesterone micronized (Prometrium) .................................... 20 PROGRAF ...................................................................................... 20 PROMACTA ..................................................................................... 9 propafenone (Rythmol) ................................................................. 16 propafenone ER (Rythmol SR) .................................................... 17 propranolol ER (Inderal LA) ......................................................... 15 propranolol tablets (Inderal) ......................................................... 15

44

propylthiouracil ............................................................................... 19 PULMICORT FLEXHALER ......................................................... 24 pyrazinamide .................................................................................... 7 pyridostigmine (Mestinon)............................................................. 21

Q

quetiapine (Seroquel) .................................................................... 11 quinapril (Accupril) ......................................................................... 14 quinapril/hydrochlorothiazide (Accuretic).................................... 14 quinidine gluconate ER (Quinaglute) .......................................... 17 quinidine sulfate (Quinidex) ......................................................... 17 QVAR .............................................................................................. 24

R

ramipril (Altace) .............................................................................. 14 ranitidine (Zantac) .......................................................................... 13 RAPAMUNE ................................................................................... 20 RECLAST ....................................................................................... 19 RELISTOR ...................................................................................... 12 REMICADE ....................................................................................... 8 REQUIP XL .................................................................................... 21 RESCRIPTOR .................................................................................. 8 REYATAZ ......................................................................................... 8 RIDAURA........................................................................................ 23 rifampin (Rifadin) .............................................................................. 7 risperidone (Risperdal, Risperdal-M tablets) .............................. 11 ropinirole (Requip) ......................................................................... 21

S

salsalate (Disalcid) ....................................................................... 23 SANCUSO ...................................................................................... 12 SANDIMMUNE............................................................................... 20 SARAFEM ...................................................................................... 11 selegiline (Eldepryl) ....................................................................... 21 selenium sulfide (Selsun) .............................................................. 29 SELZENTRY .................................................................................... 8 SEREVENT DISKUS .................................................................... 24 SEROQUEL XR ............................................................................. 11 sertraline (Zoloft) ............................................................................ 10 SFROWASA ................................................................................... 12 silver sulfadiazine (Silvadene)...................................................... 28 SIMCOR .......................................................................................... 16 simvastatin (Zocor) ........................................................................ 16 sodium citrate/citric acid ................................................................ 13 sodium citrate/citric acid (Shohls) .......................................... 13 sodium fluoride ............................................................................... 25 sodium fluoride (Prevident) ........................................................... 27 sodium polystyrene sulfonate ....................................................... 20 SORIATANE .................................................................................. 29 sotalol (Betapace, Betapace AF) ................................................. 17 SPIRIVA .......................................................................................... 24

SPIRIVA HANDIHALER .............................................................. 24 spironolactone (Aldactone) .......................................................... 16 spironolactone/hydrochlorothiazide ............................................ 16 stavudine (Zerit) ............................................................................... 8 STIMATE ........................................................................................ 19 sucralfate (Carafate) ..................................................................... 13 sulfacetamide sodium eye solution (Bleph-10).......................... 26 sulfacetamide sodium/prednisolutionone eye solution ............. 27 sulfacetamide sodium/sulfur cloth, cream, emulsion, lotion ... 28 sulfamethoxazole/trimethoprim (Bactrim) .............................. 6 sulfasalazine (Azulfidine) .............................................................. 12 sulfasalazine DR (Azulfidine EN-Tabs) ...................................... 12 sulindac (Clinoril) .......................................................................... 24 sumatriptan injection, tablets (Imitrex) ....................................... 22 SUSTIVA .......................................................................................... 8 SUSTIVA—efavirenz ..................................................................... 8 SYMBICORT .................................................................................. 24 SYNAREL ....................................................................................... 20 SYNTHROID .................................................................................. 20

T

TABLOID .......................................................................................... 9 tacrolimus (Prograf) ....................................................................... 20 tamoxifen (Nolvadex) ...................................................................... 9 tamsulosin (Flomax) ...................................................................... 13 TARGRETIN .................................................................................... 9 TEGRETOL .................................................................................... 22 TEGRETOL-XR ............................................................................. 22 TEKAMLO ...................................................................................... 17 TEKTURNA .................................................................................... 17 TEKTURNA HCT........................................................................... 17 temazepam (Restoril) .................................................................... 11 terazosin (Hytrin) ........................................................................... 17 terbinafine (Lamisil) ...................................................................... 6 terbutaline (Brethine) ..................................................................... 24 terconazole (Terazol) .................................................................... 14 TEV TROPIN .................................................................................. 20 THALITONE ................................................................................... 16 THEO-24 ......................................................................................... 24 theophylline ER (Theo-Dur) ......................................................... 24 thiothixene (Navane) ..................................................................... 11 THYROLAR ................................................................................... 20 timolol maleate eye solution (Timoptic, Timoptic XE) ............... 26 TIMOPTIC OCUDOSE.................................................................. 26 TINDAMAX ....................................................................................... 6 tizanidine (Zanaflex) ...................................................................... 21 TOBRADEX ................................................................................... 27 TOBRADEX ST ............................................................................. 27 tobramycin eye solution (Tobrex) ................................................ 26 tobramycin/dexamethasone eye suspenion (Tobradex) .......... 27 TOBREX ......................................................................................... 26 TOPAMAX ...................................................................................... 22

45

topiramate (Topamax Sprinkle, Topamax) ................................. 22 torsemide (Demadex) .................................................................... 16 TRADJENTA .................................................................................. 18 tramadol (Ultram) .......................................................................... 23 trandolapril (Mavik) ........................................................................ 14 tranylcypromine (Parnate) ............................................................ 10 TRAVATAN ..................................................................................... 26 trazodone (Desyrel) ....................................................................... 10 tretinoin (Retin-A) ........................................................................... 28 TREXALL.......................................................................................... 9 TREXIMET ...................................................................................... 22 triamcinolone (Nasacort AQ) ........................................................ 25 triamcinolone dental paste (Kenalog in Orabase) ..................... 27 TRIBENZOR ................................................................................... 14 trifluoperazine (Stelazine) ............................................................. 11 trifluridine eye solution (Viroptic) .................................................. 26 trihexyphenidyl (Artane) ................................................................ 21 trimethobenzamide (Tigan) ........................................................... 12 trimethoprim ...................................................................................... 6 TRIZIVIR ........................................................................................... 8 tropicamide eye solution (Mydriacyl) ........................................... 27 TRUVADA ........................................................................................ 8 TUDORZA ...................................................................................... 24

U

ULORIC ........................................................................................... 22 UROCIT-K 15— ............................................................................. 13 urosdiol (Actigall, Urso 250, Urso Forte) .................................... 12

V

valacyclovir (Valtrex) ...................................................................... 7 valproic acide (Depakene) ............................................................ 22 vancomycin (Vancocin) ................................................................ 7 venlafaxine (Effexor)...................................................................... 10

venlafaxine ER (Effexor XR) ........................................................ 10 VENTOLIN HFA ............................................................................ 24 verapamil (Calan) .......................................................................... 15 verapamil ER (Calan SR, Isoptin SR, Verelan, Verelan PM) .. 15 VESICARE ..................................................................................... 13 VEXOL ............................................................................................ 27 VIBRAMYCIN SYRUP .................................................................... 7 VICTOZA ........................................................................................ 18 VIDEX PEDIATRIC ......................................................................... 8 VIRAMUNE ...................................................................................... 8 VIRAMUNE XR ................................................................................ 8 VIREAD............................................................................................. 8 VIVELLE-DOT ............................................................................... 19 VOLTAREN GEL .......................................................................... 29 voriconazole (Vfend) ..................................................................... 6

W

warfarin (Coumadin) ........................................................................ 9 WELCHOL ..................................................................................... 16

Z

zafirlukast (Accolate ..................................................................... 24 zaleplon (Sonata) .......................................................................... 11 ZARONTIN ..................................................................................... 22 ZENPEP .......................................................................................... 12 ZIAGEN............................................................................................. 8 zidovudine (Retrovir) ....................................................................... 8 ziprasidone (Geodon) ................................................................... 11 zolpidem (Ambien)......................................................................... 11 zolpidem ER(Ambien CR) ............................................................ 11 ZONEGRAN ................................................................................... 22 zonisamide (Zonegran) ................................................................. 22 ZYMAXID —gatifloxacin ............................................................. 26

Documents

HAMP Formulary