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HEALTH INSURANCE MARKETPLACE INDIVIDUAL FORMULARY

Effective January 2014

Provided by Catamaran

Introduction

The Total Health Care (THC) Health Insurance Marketplace Individual Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management. Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications.

Notice

The information contained in this formulary is provided by THC & Catamaran, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information.

How to Read the Formulary All drugs are listed first by their generic names (in lowercase) in each category. The preferred brand name drugs are listed next, and non-preferred brand drugs are listed last. Brand name drugs (preferred and non-preferred) are displayed in proper name form (first letter of the name capitalized). Specific drug listings may be accessed by using the index, by using the generic name or brand name and by therapeutic drug category (in uppercase white letters). Any drug not found in this Formulary listing, or any Formulary updates published by Total Health Care, shall be considered a non-formulary drug.

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Tier Guidelines

The Certificate of Coverage provided upon enrollment has specific information regarding co-payments, co-insurance, annual deductible requirements and maximum out of pocket limits associated with the corresponding pharmacy benefit.

Prescribing Guidelines

Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include:

Saving on Out-Of-Pocket Costs Total Health Care has designed its prescription drug plan to encourage the use of generic and preferred brand name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance and co-payments) or not receiving coverage at all. Members may also pay less for generic drugs or they may be asked to pay the cost difference between brand-name drugs and their generic alternatives, which are preferred by the plan.

Benefit Coverage and Limitations This formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments, coinsurance or a lack of coverage, which are not reflected in the Total Health Care Health Insurance Marketplace Individual Formulary. Members should contact Total Health Care at 1-800- 826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year.

Generic Tier 1

Preferred Brand

Tier 2

Non-Preferred Brand and Non- Preferred Generic

Tier 3

Specialty Tier 4 Preventive $0 co-pay at in-network pharmacies Medical Benefit Benefit may be available under medical coverage.

Prior Authorization (PA)

Requires prior authorization through a specific physician request process.

Quantity Limit (QL)

Coverage may be limited to specific quantities per prescription &/or time period.

Step Therapy (ST)

Coverage requires that an alternative or trial of another drug be used before the medication is covered.

Age Limitation (AL)

Coverage may depend on patient age.

Gender Edit (GE)

Coverage may depend on patient gender.

Over the Counter (OTC)

Coverage is available for drugs that are available OTC with an authorized prescription from your provider.

Specialty Requires that the drug be processed using THC’s contracted specialty pharmacy CVS/Caremark.

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Preventive Medications Total Health Care covers certain preventive services for $0 co-pay when delivered by in-network providers. These drugs are indicated on the THC Health Insurance Marketplace Individual Formulary under the Preventive Tier. Examples of preventive medications include aspirin, contraceptives, iron supplementations, smoking cessation products and Vitamin D drugs. These drugs are available with standard drug coverage recommendations and are only available for certain populations. Medical Benefit Drugs indicated on the THC Health Insurance Marketplace Individual Formulary under the Medical Benefit Tier are not available for coverage as a pharmacy benefit. Please refer to the Certificate of Coverage to determine if drugs listed as a Medical Benefit on the formulary are covered through the Medical Benefit. Prior Authorization (PA) Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care and Catamaran websites at www.THCmi.com or https://www.catalystrx.com/www/public/physicianLogin.jsp. You may also request a form by calling Catamaran Member Services Department at 1-877-634-9202 or Total Health Care at 1-800-826-2862. Completed prior authorization forms should be faxed to 1-888-852-1832. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not located on the Total Health Care Health Insurance Marketplace Individual Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non-formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review:

• The patient has failed an appropriate trial of formulary or preferred agents. • The use of preferred or formulary agent is contraindicated in the patient. • The formulary drug or preferred agents are not suited for the present patient care need, and the

drug selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to:

• OTC medications or their equivalents unless otherwise specified in the Formulary listing. • Drug products used for cosmetic purposes • Drug products for infertility treatment • Experimental drug products, or any drug product used in an experimental manner • Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA)

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Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA- approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted as “generic” wherever an FDA-approved generic drug product is available. If a member or physician requests a brand-name product in lieu of an approved generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic drug, plus the brand copay.

Total Health Care Pharmacy and Therapeutics (P&T) Committee

Total Health Care’s Pharmacy & Therapeutic Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel. Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutic Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862.

Diabetic Testing Supplies

Total Health Care works exclusively with Healthy Living Pharmacy to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Advocate Redi-Code glucometer, Advocate test strips, Advocate lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through Healthy Living Pharmacy. If you have any questions about our diabetic supply program, please contact Healthy Living Pharmacy at 1-866-779-8512.

Specialty Bio-Pharmaceutical Pharmacy Program

Total Health Care works with CVS/Caremark Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through CVS/Caremark Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to Catamaran at 1-888-852-1832 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care and Catamaran websites at www.THCmi.com or https://www.catalystrx.com/www/public/physicianLogin.jsp. Once the order is received, Catamaran obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies CVS/Caremark. Then the CVS/Caremark staff ships the medication directly to the physician's office or the patient’s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty

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Bio-Pharmaceutical Pharmacy program, please contact Catamaran at 1-877-634-9202 or CVS/Caremark at 1-800-753-2777.

Medication Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction; quantity/day supply limitation, and/or a limitation on the duration of therapy. In most instances topical steroids are limited to the two largest commercially available tubes per month, with some products limited to one package size per month. Quantity Limitations

Drug Label Name Quantity Limit ABACAVIR TAB 300MG Max Daily Dose of 2 ADVAIR DISKUS 1 inhaler per month

ADVAIR HFA Max Daily Dose of 2; 1 inhaler per month ADVOCATE LANCETS 100 per month ADVOCATE STRIPS 100 per month ALCOHOL SWABS 100 per month ALENDRONATE TAB 70MG 4 tabs per 28 days ALTAVERA TAB Max Daily Dose of 1 ALVESCO AER Max of 2 inhalers per month ALYACEN TAB 1/35 Max Daily Dose of 1 ALYACEN TAB 7/7/7 Max Daily Dose of 1 AMLODIPINE TAB Max Daily Dose of 1 AMOX/K CLAV TAB Limit to 28 tablets per 14 days AMPHETAMINE CAP ER Max Daily Dose of 1 APEXICON E CRE 0.05% 120gm per month APRI TAB Max Daily Dose of 1 APTIVUS CAP 250MG Max Daily Dose of 4 APTIVUS SOL Max Daily Dose of 10ml per day ARCAPTA CAP 75MCG Max Daily Dose of 1 ASMANEX 2 inhalers per month

ASPIRIN 81MG Max Daily Dose of 2; Covered for ages 40-79

ASPIRIN TAB 325MG Max Daily Dose of 1; Covered for ages 40-79

ASPIRIN TAB 325MG EC Max Daily Dose of 1; Covered for ages 40-79

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ATORVASTATIN TAB Max Daily Dose of 1

ATOVAQ/PROGU TAB Max Daily Dose of 1 ATRIPLA TAB Max Daily Dose of 1

ATROVENT HFA AER 17MCG 26gm per month (2 inhalers per month) AUG BETAMET CRE 0.05% 100gm per month AUG BETAMET GEL 0.05% 100gm per month AUG BETAMET LOT 0.05% 120ml per month

AUG BETAMET OIN 0.05% 100gm per month

AVIANE TAB; FALMINA; LESSINA; LUTERA; ORSYTHIA; SRONYX Max Daily Dose of 1; female only AZITHROMYCIN POW 1GM PAK Max Daily Dose of 1 AZITHROMYCIN TAB 250MG Max Daily Dose of 4 AZITHROMYCIN TAB 500MG & 600 Max Daily Dose of 2 BETAMETH DIP CRE 0.05% 90gm per month BETAMETH DIP LOT 0.05% 120ml per month BETAMETH DIP OIN 0.05% 90gm per month BETAMETH VAL CRE 0.1% 90gm per month BETAMETH VAL LOT 0.1% 120ml per month BETAMETH VAL OIN 0.1% 90gm per month BEYAZ TAB Max Daily Dose of 1 BRONCHO SAL AER 0.9% 180ml per month BUDEPRION TAB SR Max Daily Dose of 2; 90 days per 365 days

BUDESONIDE SUS 60 vials/120ml per month; Covered for members up to age 8

BYDUREON INJ 4 injections per month CAMILA TAB 0.35MG Max Daily Dose of 1 CAPEX SHA 0.01% 120ml per month CAZIANT PAK Max Daily Dose of 1 CESIA PAK Max Daily Dose of 1 CHANTIX PAK 0.5& 1MG Max Daily Dose of 2; limit to a 90 day supply per year CHANTIX TAB Max Daily Dose of 2; limit to a 90 day supply per year CHATEAL TAB 0.15/30 Max Daily Dose of 1 CITALOPRAM TAB Max Daily Dose of 1.7; Limited to 51 tablets per month

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CLOBETASOL CRE 0.05% 120gm per month CLOBETASOL GEL 0.05% 120gm per month CLOBETASOL OIN 0.05% 120gm per month CLOBETASOL SOL 0.05% 100ml per month CLOPIDOGREL TAB Max Daily Dose of 1 CLOTRIM/BETA CRE DIPROP 90gm per month CLOTRIM/BETA LOT DIPROP 60ml per month COLCHICINE TAB 0.6MG 20 tablets per month COMBIVENT AER 30gm per month (2 inhalers per month) COMBIVENT AER RESPIMAT 4gm per month (1 inhalers per month) COMPLERA TAB Max Daily Dose of 1 CORDRAN 24X3 TAP 4MCG/CM 1 per month CRESTOR TAB Max Daily Dose of 1 CRIXIVAN CAP 200MG Max Daily Dose of 12 CRIXIVAN CAP 400MG Max Daily Dose of 6 CRYSELLE-28 TAB 28 TABS Max Daily Dose of 1 CVS NASAL SPR MIST 254ml per month CYCLAFEM TAB 1/35 Max Daily Dose of 1 CYCLAFEM TAB 7/7/7 Max Daily Dose of 1 DASETTA TAB 1/35 Max Daily Dose of 1 DASETTA TAB 7/7/7 Max Daily Dose of 1 DAYTRANA DIS Max Daily Dose of 1 DESIPRAMINE TAB Max Daily Dose of 2 DESONATE GEL 0.05% 120gm per month DESONIDE CRE 0.05% 120gm per month DESONIDE LOT 0.05% 120ml per month DESONIDE OIN 0.05% 120gm per month DESOXIMETAS CRE 200gm per month DESOXIMETAS GEL 0.05% 120gm per month DESOXIMETAS OIN 0.05% 120gm per month DESOXIMETAS OIN 0.25% 200gm per month DIDANOSINE CAP 125MG Max Daily Dose of 2 DIDANOSINE CAP 200MG Max Daily Dose of 2 DIDANOSINE CAP 250MG Max Daily Dose of 1 DIDANOSINE CAP 400MG Max Daily Dose of 1 DIFLORASONE CRE 0.05% 120gm per month DIFLORASONE OIN 0.05% 120gm per month DILTIA XT CAP 120MG/24 Max Daily Dose of 1 DILTIAZEM CAP ER Max Daily Dose of 2 DILTIAZEM HCL 24HR CAP (Cartia XT, Dilt-CD) Max Daily Dose of 1

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DILTIAZEM HCL 24HR CAP (Taztia XT, Diltzac) Max Daily Dose of 1 DILTIAZEM HCL ER TAB (Matzim LA, Cardizem LA) Max Daily Dose of 1 DULERA AER 13gm per month (1 inhaler per month) EASIVENT Mask 2 per 365 days ECONAZOLE CRE 1% 85gm per month EDURANT TAB 25MG Max Daily Dose of 1 ELINEST TAB Max Daily Dose of 1 EMOQUETTE TAB Max Daily Dose of 1 EMTRIVA CAP 200MG Max Daily Dose of 1 EMTRIVA SOL 10MG/ML Max Daily Dose of 20ml per day ENPRESSE-28 TAB Max Daily Dose of 1 EPINEPHRINE INJ Limit to 2 syringes every 3 months EPIPEN-JR INJ 2-PAK Limit to 2 syringes every 3 months EPIVIR SOL 10MG/ML Max Daily Dose of 30ml per day EPIVIR HBV SOL 5MG/ML Max Daily Dose of 60ml per day EPIVIR HBV TAB 100MG Max Daily Dose of 3 EPZICOM TAB 600-300 Max Daily Dose of 1 ERRIN TAB 0.35MG Max Daily Dose of 1 ESTARYLLA TAB 0.25-35 Max Daily Dose of 1 ESTRADIOL DIS 4 patches per 28 days FELODIPINE TAB ER Max Daily Dose of 1 FER-IRON DRO 15MG/ML 50ml per month FLOVENT DISK AER 100MCG 1 inhaler per month FLUCONAZOLE SUS 3.5 ml per day FLUCONAZOLE TAB Max Daily Dose of 1 FLUNISOLIDE SPR 0.025% 50ml per month (limited to 2 inhalers per month) FLUOCIN ACET CRE 120gm per month FLUOCIN ACET OIL SCALP 120ml per month FLUOCIN ACET OIN 0.025% 120gm per month FLUOCIN ACET SOL 0.01% 120ml per month FLUOCINONIDE CRE 0.05% 120gm per month FLUOCINONIDE GEL 0.05% 120gm per month FLUOCINONIDE OIN 0.05% 120gm per month FLUOCINONIDE SOL 0.05% 120ml per month FLUTICASONE CRE 0.05% 120gm per month FLUTICASONE OIN 0.05% 120gm per month FLUTICASONE SPR 50MCG 16ml per month (1 inhaler per month) FOCALIN XR CAP Max Daily Dose of 1 FOLIC ACID TAB Max Daily Dose of 1 FORADIL CAP AEROLIZE 1 package (60 doses) per month

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GILDESS 1/20 TAB Max Daily Dose of 1 GILDESS FE TAB 1.5/30 Max Daily Dose of 1 GILDESS FE TAB 1/20 Max Daily Dose of 1 GLIPIZIDE ER TAB Max Daily Dose of 2 GLUCAGON KIT 1MG 2 kits per month GRANISETRON TAB 1MG 10 tablets per month GRANISOL SOL 2MG/10ML 60ml per month HALOBETASOL CRE 0.05% 100gm per month HALOBETASOL OIN 0.05% 100gm per month HALOG CRE 0.1% 100gm per month HALOG OIN 0.1% 100gm per month HC PRAMOXINE CRE 1-2.5% 60gm per month HC VALERATE CRE 0.2% 120gm per month HC VALERATE OIN 0.2% 120gm per month HEATHER TAB 0.35MG Max Daily Dose of 1 HYDROCORT CRE 1% 120gm per month HYDROCORT CRE 2.5% 90gm per month HYDROCORT LOT 1% 240ml per month HYDROCORT LOT 2.5% 120ml per month HYDROCORT OIN 1% 90gm per month HYDROCORT OIN 2.5% 90gm per month INTELENCE TAB 100MG Max Daily Dose of 4 INTELENCE TAB 200MG Max Daily Dose of 2 INTELENCE TAB 25MG Max Daily Dose of 16 INTERMEZZO SUB 3.5MG Max Daily Dose of 1 INVIRASE CAP 200MG Max Daily Dose of 10 INVIRASE TAB 500MG Max Daily Dose of 4 IPRATROPIUM SPR 0.03% 30ml per month (1 inhaler per month) IPRATROPIUM SPR 0.06% 15ml per month (1 inhaler per month) ISENTRESS Max Daily Dose of 2 per day JANUMET TAB Max Daily Dose of 2 JANUMET XR TAB Max Daily Dose of 1 JANUVIA TAB Max Daily Dose of 1 JENTADUETO TAB Max Daily Dose of 2 JEVANTIQUE TAB 1MG-5MCG; JINTELI TAB 1MG-5MCG Max Daily Dose of 1; female only JOLIVETTE TAB 0.35MG Max Daily Dose of 1 JUNEL 1.5/30 TAB Max Daily Dose of 1 JUNEL 1/20 TAB Max Daily Dose of 1 JUNEL FE TAB 1.5/30 Max Daily Dose of 1

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JUNEL FE TAB 1/20 Max Daily Dose of 1 KALETRA SOL Max Daily Dose of 15ml per day KALETRA TAB 100-25MG Max Daily Dose of 12 KALETRA TAB 200-50MG Max Daily Dose of 6 KELNOR TAB 1/35; ZOVIA 1/35E TAB Max Daily Dose of 1; female only KETOPROFEN CAP 200MG ER Max Daily Dose of 1 KETOPROFEN CAP 50MG Max Daily Dose of 6 KETOPROFEN CAP 75MG Max Daily Dose of 4

KETOROLAC TAB 10MG Max Daily Dose of 4; Limited to 5 day supply (20 tablets per month)

KETOSTIX 50 per month KOMBIGLYZE TAB Max Daily Dose of 1 KURVELO TAB 0.15/30 Max Daily Dose of 1 LAMIVUD/ZIDO TAB 150-300 Max Daily Dose of 2

LAMIVUDINE TAB 150MG Max Daily Dose of 2 LAMIVUDINE TAB 300MG Max Daily Dose of 1 LANSOPRAZOLE CAP Max Daily Dose of 1 per day LANSOPRAZOLE SUS 3MG/ML Max Daily Dose of 5ml per day LANSOPRAZOLE TAB Max Daily Dose of 2 per day LATANOPROST SOL 0.005% 5ml per month LETROZOLE TAB 2.5MG 1 tablet daily LEVETIRACETA TAB 1000MG Max Daily Dose of 3 LEVETIRACETA TAB 250MG Max Daily Dose of 12 LEVETIRACETA TAB 500MG Max Daily Dose of 6 LEVETIRACETA TAB 750MG Max Daily Dose of 4 LEVOFLOXACIN TAB Max Daily Dose of 1; limit to 14 tabs per month LEVONEST TAB Max Daily Dose of 1 LEVONOR/ETHI TAB ESTRADIO Max Daily Dose of 1 LEVONORGESTR TAB 0.75MG; NEXT CHOICE TAB 0.75MG 2 tablets per month; female only LEVORA-28 TAB 0.15/30 Max Daily Dose of 1 LEXIVA SUS 50MG/ML Max Daily Dose of 60ml per day LEXIVA TAB 700MG Max Daily Dose of 4 LIDOCAINE CRE 3% 85gm per month

LIDOCAINE GEL 2% 90ml per month LIDOCAINE LOT 3% 100ml per month LIDOCAINE OIN 5% 70.8gm per month LIDOCAINE SOL VISC 100ml per month LO LOESTRIN TAB Max Daily Dose of 1

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LOESTRIN 24 TAB FE Max Daily Dose of 1; female only LOSARTAN POT TAB Max Daily Dose of 1 LOSARTAN/HCT TAB Max Daily Dose of 1 LOW-OGESTREL TAB Max Daily Dose of 1 LUNESTA TAB Max Daily Dose of 1 MARLISSA TAB 0.15/30 Max Daily Dose of 1 MAXAIR AUTOH AER 200MCG 1 inhaler (14 gm) per month MEDROXYPR AC INJ 150MG/ML 1 injection every 3 months MEPRON SUS 210ml per 18 days METADATE CD CAP 20MG Max Daily Dose of 1 METHYLPHENID TAB ER Max Daily Dose of 1 METOPROLOL ER TAB Max Daily Dose of 1 MICROGESTIN TAB 1.5/30 Max Daily Dose of 1 MICROGESTIN TAB 1/20 Max Daily Dose of 1 MICROGESTIN TAB FE 1/20 Max Daily Dose of 1 MICROGESTIN TAB FE1.5/30 Max Daily Dose of 1 MONO-LINYAH TAB 0.25-35 Max Daily Dose of 1 MONONESSA TAB Max Daily Dose of 1 MYZILRA TAB Max Daily Dose of 1 NABUMETONE TAB 500MG Max Daily Dose of 4 NABUMETONE TAB 750MG Max Daily Dose of 2 NECON TAB 0.5/35 Max Daily Dose of 1 NECON TAB 1/35 Max Daily Dose of 1 NECON TAB 7/7/7 Max Daily Dose of 1 NEVIRAPINE SUS 50MG/5ML Max Daily Dose of 40ml per day NEVIRAPINE TAB 200MG Max Daily Dose of 2 NICOTINE DIS Max Daily Dose of 1; limited to 90 day supply per year NICOTINE GUM Max Daily Dose of 9; limited to 90 day supply per year NIFEDIAC CC TAB ER Max Daily Dose of 1 NORA-BE TAB 0.35MG Max Daily Dose of 1 NORETHINDRON TAB 0.35MG Max Daily Dose of 1 NORGEST/ETH TAB ESTRAD Max Daily Dose of 1 NORGEST/ETHI TAB 0.25/35 Max Daily Dose of 1 NORGEST/ETHI TAB ESTRADIO Max Daily Dose of 1 NORTREL TAB 0.5/35 Max Daily Dose of 1 NORTREL TAB 1/35 Max Daily Dose of 1 NORTREL TAB 7/7/7 Max Daily Dose of 1 NORVIR CAP 100MG Max Daily Dose of 12 NORVIR SOL 80MG/ML Max Daily Dose of 15ml per day NORVIR TAB 100MG Max Daily Dose of 12 OMEPRA/BICAR CAP Max Daily Dose of 1

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OMEPRAZOLE CAP Max Daily Dose of 2 per day ONDANSETRON SOL 50ml per month ONDANSETRON TAB 24MG 5 tablets per month ONDANSETRON TAB 4MG 15 tablets per month ONDANSETRON TAB 8MG 15 tablets per month ONDANSETRON TAB ODT 10 films per month ONGLYZA TAB Max Daily Dose of 1 ORTHO FLAT DIAPHRAGM 1 per year ORTHO FLEX DIAPHRAGM 1 per year PANTOPRAZOLE TAB 20MG Max Daily Dose of 2 per day PANTOPRAZOLE TAB 40MG Max Daily Dose of 1 per day PENTOXIFYLLI TAB 400MG ER Max Daily Dose of 3 PIOGLITAZONE TAB 1 tablet daily PORTIA-28 TAB Max Daily Dose of 1 PRECISN XTRA TES KETONE 10 per month PREDNICARBAT CRE 0.1% 120gm per month PREDNICARBAT OIN 0.1% 120gm per month PREVIFEM TAB Max Daily Dose of 1 PREZISTA SUS 100MG/ML Max Daily Dose of 16ml per day PREZISTA TAB 150MG Max Daily Dose of 8 per day PREZISTA TAB 400MG, 600MG & 800MG Max Daily Dose of 2 per day PREZISTA TAB 75MG Max Daily Dose of 16 per day PROAIR HFA AER 2 inhalers (8.5 gm each) per month PROVENTIL AER HFA 2 inhalers (6.7 gm each) per month PULMICORT INH 1 inhaler per month (qty 1) PULMOZYME SOL 1MG/ML 60 vials per month QVAR AER 8.7g per month (1 inhaler per month) RECLIPSEN TAB Max Daily Dose of 1 RELENZA MIS DISKHALE Max Daily Dose of 4 per day; limit to 5 day supply RESCRIPTOR TAB 100 MG Max Daily Dose of 12 RESCRIPTOR TAB 200MG Max Daily Dose of 6 REYATAZ CAP 100MG Max Daily Dose of 4 REYATAZ CAP 150MG & 200MG Max Daily Dose of 2 REYATAZ CAP 300MG Max Daily Dose of 1 ROZEREM TAB 8MG Max Daily Dose of 1 SAFYRAL TAB Max Daily Dose of 1 SANCUSO DIS 3.1MG 1 patch per month SCALACORT LOT 2% 120ml per month SELZENTRY TAB Max Daily Dose of 4 SEREVENT DIS AER 1 per month

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SILENOR TAB Max Daily Dose of 1 SIMPLY SALIN AER BABY 88ml per month SOLIA TAB Max Daily Dose of 1 SPIRIVA CAP HANDIHLR Max Daily Dose of 1 SPRINTEC 28 TAB 28 DAY Max Daily Dose of 1 STAVUDINE CAP Max Daily Dose of 2 STAVUDINE SOL 1MG/ML Max Daily Dose of 40ml per day STRIBILD TAB Max Daily Dose of 1 SUMATRIPTAN INJ 5 kits (10 syringes) per month SUMATRIPTAN SPR 18 spray unit devices per month SUMATRIPTAN TAB 9 tabs per month SUMAVEL DOSE INJ 6MG/0.5 QL of 6 syringes per month SUSTIVA CAP 200MG Max Daily Dose of 3 SUSTIVA CAP 50MG Max Daily Dose of 12 SUSTIVA TAB 600MG Max Daily Dose of 1 SYMBICORT AER 10.2gm per month (1 inhaler per month) TAMIFLU CAP Max Daily Dose of 2 per day; limit to 5 day supply

TAMIFLU SUS 12MG/ML Max Daily Dose of 15ml; limit to 5 day supply; allow for members < 13 years of age

TAMIFLU SUS 6MG/ML Max of 120 ml per 10 days; limit of 2 bottles per fill TAMSULOSIN CAP 0.4MG Max Daily Dose of 2 TESTOST CYP INJ 2 injections per month TIZANIDINE Max Daily Dose of 3

TOBRADEX OIN 0.3-0.1% 1 vial per 10 days TOBRADEX ST SUS 1 bottle per 10 days TRADJENTA TAB 5MG Max Daily Dose of 1 TRAMADOL HCL TAB 50MG Max Daily Dose of 8 TRANDOLAPRIL TAB Max Daily Dose of 1 TRIAMCINOLON CRE 0.025% 160gm per month TRIAMCINOLON CRE 0.1% 160gm per month TRIAMCINOLON CRE 0.5% 60gm per month TRIAMCINOLON LOT 120ml per month TRIAMCINOLON OIN 0.025% 160gm per month TRIAMCINOLON OIN 0.05% 60gm per month TRIAMCINOLON OIN 0.1% 160gm per month TRIAMCINOLON OIN 0.5% 60gm per month TRI-ESTARYLL TAB Max Daily Dose of 1 TRI-LINYAH TAB Max Daily Dose of 1 TRINESSA TAB Max Daily Dose of 1 TRI-PREVIFEM TAB Max Daily Dose of 1

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TRI-SPRINTEC TAB Max Daily Dose of 1 TRIVORA-28 TAB Max Daily Dose of 1 TRIZIVIR TAB Max Daily Dose of 2 TRUVADA TAB 200-300 Max Daily Dose of 1 TUDORZA PRES AER 400/ACT 1 pouch (60 doses) per month VALACYCLOVIR TAB 1GM Allow #21 tablets for first fill, additional fills require PA VALACYCLOVIR TAB 500MG Allow #10 tablets for first fill, additional fills require PA VANOS CRE 0.1% 120gm per month VELIVET PAK Max Daily Dose of 1 VENTOLIN HFA AER Limited to 2 inhalers (8gm each)/month VERAPAMIL TAB ER Max Daily Dose of 1 VIDEX SOL 2GM Max Daily Dose of 20.1ml per day VIRACEPT TAB 250MG Max Daily Dose of 10 VIRACEPT TAB 625MG Max Daily Dose of 4 VIRAMUNE XR TAB 400MG Max Daily Dose of 1 VIREAD TAB Max Daily Dose of 1 VITAMIN D CAP 400UNIT Max Daily Dose of 2 VIVELLE-DOT DIS; ALORA; MINIVELLE 8 patches per 28 days WERA TAB 0.5/35 Max Daily Dose of 1

XARELTO TAB Max Daily Dose of 1 for up to 35 days, after 35 days PA required

XOPENEX HFA AER 2 inhalers (15 gm each) per month ZEGERID POW Max Daily Dose of 1 ZIAGEN SOL 20MG/ML Max Daily Dose of 30ml per day ZIDOVUDINE CAP 100MG Max Daily Dose of 6

ZIDOVUDINE SYP 50MG/5ML Max Daily Dose of 60ml per day ZIDOVUDINE TAB 300MG Max Daily Dose of 2 ZOLPIDEM TAB Max Daily Dose of 1 ZOLPIDEM ER TAB Max Daily Dose of 1 ZONISAMIDE CAP 100MG Max Daily Dose of 6 ZONISAMIDE 25MG CAP Max Daily Dose of 12 ZONISAMIDE 50MG CAP Max Daily Dose of 12 ZUPLENZ MIS 10 films per month

Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit.

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Age Limitations

Generic Name Brand Name Limitation Description

Other limitations

acyclovir 200mg/5ml suspension Zovirax Susp Covered for members up to age 12

amitriptyline Elavil PA for members over age 65

amoxipine Asendin PA for members over age 65

amphetamine/dextroamphetamine mix salt

Adderall Covered for members age 6-17

aspirin 81mg and 325mg Aspirin Covered for members age 40-79 $0, QL,

OTC

budesonide inhaled susp Pulmicort Respules

Covered for Members Up to Age 8 QL

cefdinir suspension OmniCef Covered up to age 11

cefuroxime suspension Ceftin

Covered up to age 11

chlordiazepoxide

Librium

PA for members over age 65

dexmethlyphenidate Focalin Covered for members age 6-17

dextroamphetamine Dexedrine Covered for members age 6-17

xvi

dextroamphetamine SR Dexedrine Spans

Covered for members age 6-17

diazepam Valium PA for members over age 65

diphenhydramine (all forms) Benadryl (OTC)

Covered up to age 65, then PA required

OTC

doxepin Sinequin PA for members over age 65

enoxaparin Lovenox Females ages 17-42 will require PA QL, AL,

PA

ferrous sulfate drops 15mg/ml Iron drops Covered for members up to age 1

$0, QL, OTC

fluticasone inhaler Flovent Diskus (50, 100) Flovent HFA (44mcg)

Covered for members ages 4-11

QL

flurazepam Dalmane PA for members over age 65

folic acid Folic Acid Covered for members age 14-50 $0, QL,

OTC

imipramine Tofranil PA required for members over age 65

letrozole Femara Covered for members 18 or older

lidocaine/prilocaine Emla Covered up to age 15

xvii

lisdexamfetamine Vyvanse Covered for members age 6-17

methylphenidate Ritalin Covered for members age 6-17

methylphenidate SR Concerta, Ritalin SR

Covered for members age 6-17 QL-

Concerta

oseltamivir Tamiflu 6mg/ml suspension

Covered up to age 13 QL

temazepam Restoril PA for members over age 65

tretinoin topical Retin-A, Avita

Covered for members under age 29 (QL applies)

QL

triazolam Halcion PA for members over age 65

Zostavax Herpes Zoster Vaccine

Covered for age 60 and over

15mg and 30mg only

Gender edits are indicated with a “GE” on the formulary and require the member to be a specific gender for coverage. Gender Edits

Generic Name Brand Name Gender requirement

Enoxaparin Lovenox PA is required for females ages 17-42

Estradiol transdermal patches

Alora Female

Oral estrogen Premarin Female

letrozole Femara Female

Levonorgesterol Plan B, Next Choice Female

Medroxyprogesterone injection

Depo-Provera Female

Anastrozole Arimidex Female

xviii

Oral Contraceptives Various generic oral contraceptives

Female

Androgens Depo-Testosterone Male

Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled. Step Therapy Criteria

Therapy Class First Line Second Line Step Therapy Criteria Antimigraine Sumatriptan

(Imitrex) Axert, Relpax, Frova, Naratriptan, Zomig

Prior use of sumatriptan or rizatriptan in the last 90 days

Nasal Corticosteriods

Flunisolide, Fluticasone, Nasonex

Beconase AQ, QNASL, Rhinocort, Veramyst, Zetonna

Prior use of flunisolide, fluticasone or Nasonex in last 180 days

Osteoporosis Alendronate (Fosamax)

Actonel, Altelvia Prior use of alendronate within the last 90 days.

Urinary Antispasmodics

Oxybutynin

Oxybutynin-ER

Detrol/Detrol LA, Enablex, Sanctura, Trospium, Vesicare

Prior use of Oxybutynin/oxybutynin-ER within past 90 days.

*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of catamaran. The presence of a medication on this formulary list does not guarantee coverage.

Table of Contents

ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

CEPHALOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

FIRST GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SECOND GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

THIRD GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

MACROLIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

QUINOLONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SULFONAMIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

AMEBICIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

MISC. ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTINEOPLASTICS, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ALKYLATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTIBIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTINEOPLASTIC ENZYMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ANTIMETABOLITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ANGIOGENESIS INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ANTIBODIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

MITOTIC INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ENZYME INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

TOPOISOMERASE I INHIBITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTINEOPLASTICS MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CHEMOTHERAPY RESCUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CHEMOTHERAPY ADJUNCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CARDIOVASCULAR DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CARDIAC GLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTIANGINAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CALCIUM CHANNEL BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTIARRHYTHMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ACE INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ANGIOTENSIN RCPTR BLOCKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

DIRECT RENIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ANTIHYPERTENSIVES MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ANTIHYPERTENSIVE COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

DIURETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

CARDIOVASCULAR - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

DERMATOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ACNE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ROSACEA AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ANTIBIOTICS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ANTIFUNGALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ANTIVIRALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ANTI-INFLAMMATORY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTIPRURITICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTIPSORIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTISEBORRHEIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

CORTICOSTEROIDS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

IMMUNOMODULATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

DERMATOLOGICALS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ENDOCRINE AND METABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

CORTICOSTEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

ESTROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

PROGESTINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

ANTIDIABETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

AMYLIN ANALOGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

INCRETIN MIMETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

SULFONYLUREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

BIGUANIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

MEGLITINIDE ANALOGUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

DIABETIC OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

ALPHA-GLUCOSIDASE INHIBIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

DPP-4 INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

INSULIN SENSITIZING AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

ANTIDIABETIC COMBINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

BISPHOSPHONATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

CALCITONINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

PARATHYROID HORMONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

RANK LIGAND INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

HORMONE RECEPTOR MDLTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

FERTILITY REGULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

LHRH/GNRH AGONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

GNRH/LHRH ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

GROWTH HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

SOMATOMEDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

SOMATOSTATIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

GH RECEPTOR ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

POSTERIOR PITUITARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

CORTICOTROPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

PROLACTIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

VASOPRESSIN ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

METABOLIC MODIFIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

THYROID AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

GASTROINTESTINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GASTROINTESTINAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GENITOURINARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

URINARY ANTISPASMODICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

VAGINAL PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GENITOURINARY - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

HEMATOLOGICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

HEMATOLOGICAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

MOUTH/THROAT/DENTAL AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

NEUROLOGY, CNS, PSYCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANTIANXIETY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ADHD, NARCOLEPSY, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ANTICONVULSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ANTIPARKINSON AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

NEUROLOGY, PSYCH - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

MUSCULOSKELETAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

OPHTHALMOLOGY AND OTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

ARTIFICIAL TEAR/LUBRICANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

BETA-BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

OPHTHALMIC STEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

PROSTAGLANDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

CYCLOPLEGIC MYDRIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

DECONGESTANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

MIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

ADRENERGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

LOCAL ANESTHETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

OPHTHALMICS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ANALGESICS - NONNARCOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ANALGESICS - OPIOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ANTI-INFLAMMATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

RESPIRATORY, ALLERGY, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

NASAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

COUGH/COLD/ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

ANTIASTHMATIC/COPD AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

RESPIRATORY AGENTS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

MULTIVITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

MISCELLANEOUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

ZithromaxQL

TETRACYCLINES

GENERIC

January 2014

demeclocycline HCL

doxycycline

ANTI-INFECTIVES

doxycycline hyclate

doxycycline hyclate DR

PENICILLINS

doxycycline monohydrate

GENERIC

minocycline HCL

amoxicillin

minocycline HCL ER

amoxicillin/clavulanate potassium

Tetracycline HCL

amoxicillin/clavulanate potassium ER

NON PREFERRED

amoxicillin/potassium clavulanateQL

Alodox Convenience KitPA

ampicillin

OcudoxPA

dicloxacillin sodium

SolodynPA

penicillin v potassium

Amoxicillin

QUINOLONES

Ampicillin

GENERIC

PREFERRED BRAND

ciprofloxacin ER

Augmentin

ciprofloxacin HCL

MEDICAL BENEFIT

levofloxacinQL

ampicillin sodium

ofloxacin

Ampicillin Sodium

NON PREFERRED

Bicillin L-a

Avelox

Avelox Abc Pack

CEPHALOSPORIN

Cipro

FIRST GENERATION

Factive

GENERIC

Noroxin

cefadroxil

cephalexin

AMINOGLYCOSIDES

Cephalexin

GENERIC

MEDICAL BENEFIT

neomycin sulfate

cefazolin sodium

SECOND GENERATION

SULFONAMIDES

GENERIC

cefaclor

GENERIC

cefprozil

Sulfadiazine

cefuroxime axetil

Cefaclor

ANTIMYCOBACTERIAL AGENTS

Cefaclor ER

GENERIC

MEDICAL BENEFIT

ethambutol HCL

Mefoxin

isoniazid

THIRD GENERATION

pyrazinamide

GENERIC

PREFERRED BRAND

cefdinirAL

Mycobutin

cefpodoxime proxetil

NON PREFERRED

ceftriaxone sodium

Rifamate

NON PREFERRED

Rifater

Suprax

MEDICAL BENEFIT

MEDICAL BENEFIT

rifampin

Ceftriaxone/Dextrose

Isoniazid

MACROLIDES

ANTIFUNGALS

GENERIC

GENERIC

azithromycin

fluconazoleQL

clarithromycin

griseofulvin microsize

clarithromycin ER

griseofulvin ultramicrosize

erythromycin

ketoconazole

E.e.s. 400

nystatin

Erythrocin Stearate

terbinafine HCL

Erythromycin Base

NON PREFERRED

Erythromycin Ethylsuccinate

TerbinexPA

NON PREFERRED

AzithromycinQL

ANTIVIRALS

DificidPA

GENERIC

Ery-TAB

abacavirQL

PCE

Acyclovi AL (on suspension)

didanosineQL

famciclovir

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 1

lamivudineQL

quinine sulfate

lamivudine/zidovudineQL

PREFERRED BRAND

nevirapineQL

Daraprim

rimantadine HCL

NON PREFERRED

stavudineQL

Atovaquone/Proguanil HCLQL

valacyclovir HCLQL, PA

MalaroneQL

zidovudineQL

Primaquine Phosphate

PREFERRED BRAND

AptivusQL

AMEBICIDES

AtriplaPA,QL

NON PREFERRED

CompleraPA,QL

Yodoxin

CrixivanQL

EdurantQL

ANTHELMINTICS

EmtrivaQL

PREFERRED BRAND

EpivirQL

Albenza

Epivir HBVQL

EpzicomPA,QL

MISC. ANTI-INFECTIVES

IntelencePA,QL

GENERIC

InviraseQL

clindamycin palmitate HCL

IsentressQL

clindamycin HCL

KaletraQL

erythromycin/sulfisoxazole

LexivaQL

metronidazole

NevirapineQL

sulfamethoxazole/trimethoprim

NorvirQL

sulfamethoxazole/trimethoprim DS

PrezistaQL

tinidazole

Relenza DiskhalerQL

trimethoprim

RescriptorQL

vancomycin HCLPA

ReyatazQL

Dapsone

SelzentryQL

PREFERRED BRAND

StribildPA,QL

AliniaPA

SustivaQL

MepronQL

TamifluQL (6mg/ml suspension requires AL)

ZyvoxPA

TrizivirPA,QL

NON PREFERRED

TruvadaPA,QL

CubicinPA

Videx PediatricQL

Flagyl ER

ViraceptQL

Ketek

ViramuneQL

Nebupent

Viramune XRQL

Pentam 300

VireadQL

Primsol

ZiagenQL

Vancomycin HCLPA

NON PREFERRED

MEDICAL BENEFIT

adefovir dipivoxilPA

Azactam IN Iso-osmotic Dextrose

SPECIALTY

Sulfamethoxazole/Trimethoprim

ribavirinPA

Tygacil

BaracludePA

IncivekPA

ANTINEOPLASTICS, ETC

InfergenPA

ALKYLATING AGENTS

Peg-intronPA

GENERIC

Peg-intron RedipenPA

Cyclophosphamide

Peg-intron Redipen PAK 4PA

PREFERRED BRAND

PegasysPA

LeukeranPA

Pegasys ProclickPA

LomustinePA

RebetolPA

SPECIALTY

RibapakPA

MyleranPA

RibaspherePA

MEDICAL BENEFIT

RibatabPA

carboplatin

TyzekaPA

cisplatin

ValcytePA

oxaliplatin

VictrelisPA

Mustargen

VirazolePA

Treanda

MEDICAL BENEFIT

ganciclovir

ANTIBIOTICS

MEDICAL BENEFIT

ANTIMALARIALS

bleomycin sulfate

GENERIC

dactinomycin

atovaquone/proguanil HCLQL

daunorubicin HCL

chloroquine phosphatePA

doxorubicin HCL

hydroxychloroquine sulfate

doxorubicin HCL liposome

mefloquine HCL

epirubicin HCL

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 2

idarubicin HCL

MEDICAL BENEFIT

mitomycin

FaslodexPA

mitoxantrone HCL

FirmagonPA

Daunoxome

Trelstar DepotPA

Trelstar Depot MixjectPA

ANTINEOPLASTIC ENZYMES

Trelstar LAPA

Trelstar LA MixjectPA

MEDICAL BENEFIT

Trelstar MixjectPA

Elspar

VantasPA

Erwinaze

ZoladexPA

Oncaspar

IMMUNOMODULATORS

ANTIMETABOLITES

GENERIC

GENERIC

azathioprinePA

mercaptopurine

cyclosporine modified

methotrexate

mycophenolate mofetil

methotrexate sodium

tacrolimus

PREFERRED BRAND

Azathioprine Sodium

TabloidPA

Cyclosporine Modified

NON PREFERRED

PREFERRED BRAND

TrexallPA

CellceptPA

SPECIALTY

NON PREFERRED

XelodaPA

AzasanPA

MEDICAL BENEFIT

MyforticPA

cladribine

PomalystPA

cytarabine

Prograf

cytarabine aqueous

RapamunePA

decitabine

SandimmunePA

floxuridine

ZortressPA

fludarabine phosphate

SPECIALTY

fluorouracil

RevlimidPA

gemcitabine HCL

ThalomidPA

Clolar

MEDICAL BENEFIT

Vidaza

cyclosporine

Atgam

ANGIOGENESIS INHIBITORS

Cellcept Intravenous

MEDICAL BENEFIT

Simulect

Avastin

Thymoglobulin

ANTIBODIES

MITOTIC INHIBITORS

MEDICAL BENEFIT

MEDICAL BENEFIT

Adcetris

paclitaxel

Arzerra

vincristine sulfate

Campath

vinorelbine tartrate

Erbitux

Abraxane

Kadcyla

Docefrez

Rituxan

Docetaxel

Halaven

HORMONAL AGENTS

Taxotere

GENERIC

Vinblastine Sulfate

anastrozoleGE

bicalutamide

ENZYME INHIBITORS

exemestaneGE

PREFERRED BRAND

flutamidePA

IclusigPA

letrozoleQL,GE

SPECIALTY

leuprolide acetatePA

AfinitorPA

megestrol acetate

BosulifPA

tamoxifen citrate

CaprelsaPA

PREFERRED BRAND

CometriqPA

FarestonPA

GleevecPA

Lysodren

InlytaPA

NON PREFERRED

JakafiPA

Depo-proveraGE

KyprolisPA

Emcyt

NexavarPA

Soltamox

SprycelPA

SPECIALTY

StivargaPA

EligardPA

SutentPA

Lupron DepotPA

TarcevaPA

ZytigaPA

TasignaPA

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 3

TykerbPA

NON PREFERRED

VandetanibPA

Dilatrate SR

VotrientPA

Nitro-dur

XalkoriPA

Nitroglycerin Lingual

ZolinzaPA

Nitrolingual Pumpspray

MEDICAL BENEFIT

Nitromist

Istodax

MEDICAL BENEFIT

Velcade

Nitroglycerin

TOPOISOMERASE I INHIBITOR

BETA BLOCKERS

MEDICAL BENEFIT

GENERIC

irinotecan

acebutolol HCL

atenolol

ANTINEOPLASTICS MISC.

bisoprolol fumarate

carvedilol

GENERIC

labetalol HCL

hydroxyurea

metoprolol succinate ERQL

tretinoinPA

metoprolol tartrate

SPECIALTY

nadolol

Intron-aPA

propranolol HCL ER

Intron-a W/DiluentPA

sotalol HCL

MatulanePA

Pindolol

SylatronPA

Propranolol HCL

TargretinPA

Timolol Maleate

MEDICAL BENEFIT

PREFERRED BRAND

pentostatin

BystolicPA

Actimmune

NON PREFERRED

Alferon N

Coreg CR

Proleukin

Innopran XL

Synribo

Levatol

Trisenox

MEDICAL BENEFIT

betaxolol HCL

CHEMOTHERAPY RESCUE

esmolol HCL

NON PREFERRED

propranolol HCL

leucovorin calcium

Sotalol Hydrochloride

Leucovorin Calcium

MesnexPA

CALCIUM CHANNEL BLOCKERS

TotectPA

GENERIC

MEDICAL BENEFIT

amlodipine besylateQL

amifostine

diltiazem CD

dexrazoxane

diltiazem HCL

mesna

diltiazem HCL ERQL

Calcium Folinate

felodipine ERQL

Fusilev

nicardipine HCL

Voraxaze

nifedipine

nifedipine ERQL

CHEMOTHERAPY ADJUNCTS

nimodipine

MEDICAL BENEFIT

nisoldipine

Elitek

verapamil HCL

Kepivance

verapamil HCL ERQL

verapamil HCL SR

CARDIOVASCULAR DRUGS

Isradipine

CARDIAC GLYCOSIDES

Nisoldipine

GENERIC

Nisoldipine ER

digoxin

Verapamil HCL

Digoxin

PREFERRED BRAND

Cardizem LAQL

ANTIANGINAL AGENTS

MEDICAL BENEFIT

GENERIC

Cardene IV

isosorbide dinitrate

Diltiazem HCL

isosorbide dinitrate ER

isosorbide mononitrate

ANTIARRHYTHMICS

isosorbide mononitrate ER

GENERIC

nitroglycerin

amiodarone HCL

nitroglycerin transdermal

disopyramide phosphate

Isosorbide Dinitrate

flecainide acetate

PREFERRED BRAND

mexiletine HCL

Nitro-bid

propafenone HCL

Nitrostat

propafenone HCL ER

RanexaPA

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 4

quinidine gluconate CR

enalapril maleate/hydrochlorothiazide

quinidine gluconate ER

fosinopril sodium/hydrochlorothiazide

quinidine sulfate

irbesartan/hydrochlorothiazide

Quinidine Sulfate ER

lisinopril/hydrochlorothiazide

NON PREFERRED

losartan potassium/hydrochlorothiazideQL

MultaqPA

metoprolol/hydrochlorothiazide

Norpace CR

moexipril/hydrochlorothiazide

MEDICAL BENEFIT

nadolol/bendroflumethiazide

ibutilide fumarate

quinapril/hydrochlorothiazide

Procainamide HCL

valsartan/hydrochlorothiazide

Quinidine Gluconate

Captopril/Hydrochlorothiazide

Propranolol/Hydrochlorothiazide

ACE INHIBITORS

PREFERRED BRAND

Amturnide

GENERIC

Azor

benazepril HCL

NON PREFERRED

captopril

Benicar HCT

enalapril maleate

Exforge

fosinopril sodium

Exforge HCT

lisinopril

Micardis HCT

moexipril HCL

Tarka

perindopril erbumine

Tekamlo

quinapril HCL

Tekturna HCT

ramipril

Tribenzor

trandolaprilQL

Twynsta

Valturna

ANGIOTENSIN RCPTR BLOCKER

GENERIC

DIURETICS

candesartan cilexetil

GENERIC

eprosartan mesylate

acetazolamide

irbesartan

acetazolamide sodium

losartan potassiumQL

acetazolamide ER

PREFERRED BRAND

amiloride HCL

Diovan

amiloride/hydrochlorothiazide

NON PREFERRED

bumetanide

Benicar

chlorothiazide

Edarbi

chlorothiazide sodium

Micardis

furosemide

hydrochlorothiazide

DIRECT RENIN INHIBITORS

indapamide

NON PREFERRED

metolazone

Tekturna

spironolactone

spironolactone/hydrochlorothiazide

ANTIHYPERTENSIVES MISC.

torsemide

GENERIC

triamterene/hydrochlorothiazide

clonidine HCLAL

Acetazolamide

doxazosin mesylateAL

Chlorthalidone

eplerenone

Furosemide

guanfacine HCLAL

Methyclothiazide

hydralazine HCL

NON PREFERRED

methyldopa

Dyrenium

minoxidil

Edecrin

prazosin HCLAL

MEDICAL BENEFIT

terazosin HCLAL

mannitol

Methyldopate HCL

Sodium Edecrin

Reserpine

NON PREFERRED

VASOPRESSORS

DemserPA

GENERIC

Dibenzyline

midodrine HCL

MEDICAL BENEFIT

EpinephrineQL

fenoldopam mesylate

PREFERRED BRAND

Epipen 2-PAKQL

ANTIHYPERTENSIVE COMBO

Epipen-JR 2-PAKQL

GENERIC

NON PREFERRED

amlodipine besylate/benazepril hydrochloride

AdrenaclickQL

amlodipine besylate/benazepril HCL

Auvi-qQL

atenolol/chlorthalidone

TwinjectQL

benazepril HCL/hydrochlorothiazide

MEDICAL BENEFIT

bisoprolol fumarate/hydrochlorothiazide

ephedrine sulfate

candesartan cilexetil/hydrochlorothiazide

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 5

norepinephrine bitartrate

sodium sulfacetamide/sulfur

sulfacetamide sodium

ANTIHYPERLIPIDEMICS

tretinoinQL

Clindareach

GENERIC

Erythromycin

atorvastatin calciumQL

Lavoclen-4 Creamy Wash

cholestyramine light

Lavoclen-8 Creamy Wash

colestipol HCL

Panoxyl-4 Creamy Wash

colestipol HCL for oral suspension

Panoxyl-8 Creamy Wash

fenofibrate

PREFERRED BRAND

fenofibrate micronized

Veltin

fenofibric acid DR

NON PREFERRED

fluvastatin

AcanyaPA

gemfibrozil

AtralinQL

lovastatin

Epiduo

pravastatin sodium

Retin-a Micro

simvastatin

Retin-a Micro P.M.

Fenofibric Acid

Tretin-xQL

Niacor

Tretinoin Microsphere

NON PREFERRED

Tretinoin Microsphere P.M.

Altoprev

Ziana

CrestorQL

Fenoglide

ROSACEA AGENTS

Fibricor

Lescol XL

GENERIC

Lipofen

metronidazole

Livalo

NON PREFERRED

Lovaza

Finacea

Niaspan

Oracea

Simcor

Triglide

ANTIBIOTICS - TOPICAL

Vascepa

GENERIC

Vytorin

mupirocin

Welchol

mupirocin calcium

Zetia

Centany

Gentamicin Sulfate

CARDIOVASCULAR - MISC.

NON PREFERRED

GENERIC

Altabax

papaverine HCL

Cortisporin

sildenafil citratePA

PREFERRED BRAND

ANTIFUNGALS - TOPICAL

Bidil

GENERIC

NON PREFERRED

clotrimazole

Amlodipine Besylate/Atorvastatin Calcium

clotrimazole/betamethasone dipropionateQL

Caduet

econazole nitrateQL

CialisPA

ketoconazole

MusePA

miconazole

SPECIALTY

miconazole nitrate

AdcircaPA

nystatin

LetairisPA

nystatin/triamcinolone

TyvasoPA

Nystatin/Triamcinolone

Tyvaso RefillPA

NON PREFERRED

Tyvaso StarterPA

Cnl8 Nail Kit

VentavisPA

Ertaczo

MEDICAL BENEFIT

Lotrimin Ultra

epoprostenol sodium

Mentax

Remodulin

Naftin

Revatio

Oxistat

Veletri

Pedipirox-4 Nail

Xolegel

DERMATOLOGICALS

ANTIVIRALS - TOPICAL

ACNE PRODUCTS

GENERIC

GENERIC

acyclovir

benzoyl peroxide

PREFERRED BRAND

benzoyl peroxide SHORT contact

Zovirax

clindamycin phosphate

NON PREFERRED

clindamycin/benzoyl peroxide

Denavir

erythromycin

erythromycin/benzoyl peroxide

sodium sulfacetamide

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 6

ANTI-INFLAMMATORY AGENTS

Cordran TapeQL

DesonateQL

NON PREFERRED

Desowen Cream/Cetaphil Lotion

Flector

Desowen Lotion/Cetaphil Cream

Voltaren

Desowen Ointment/Cetaphil Lotion

DesoximetasoneQL

ANTIPRURITICS

Diflorasone DiacetateQL

NON PREFERRED

HalogQL

Prudoxin

Hydrocortisone Butyrate (lipid)

Zonalon

Kenalog

Locoid

ANTIPSORIATICS

Locoid Lipocream

GENERIC

Pediaderm HC

calcipotriene

Pediaderm Ta

Dritho-creme HP

Pramosone

NON PREFERRED

Taclonex

acitretinPA

Texacort

Amevive

TopicortQL

Calcitriol

Triamcinolone AcetonideQL

Dritho-scalp

Ultravate PAC

Oxsoralen Ultra

VanosQL

Tazorac

Verdeso

Vectical

8-mop

IMMUNOMODULATING AGENTS

SPECIALTY

NON PREFERRED

StelaraPA

imiquimod

Elidel

ANTISEBORRHEIC AGENTS

Protopic

GENERIC

Zyclara

selenium sulfide

Zyclara P.M.

sodium sulfacetamide wash

Sodium Sulfacetamide/Urea

DERMATOLOGICALS - MISC.

NON PREFERRED

GENERIC

Ovace Plus

ammonium lactate

lactic acid

CORTICOSTEROIDS - TOPICAL

lactic acid e

GENERIC

lactic acid w/vitamin e

alclometasone dipropionate

lidocaineQL

amcinonide

lidocaine HCL

augmented betamethasone dipropionateQL

lidocaine HCL jellyQL

betamethasone dipropionateQL

lidocaine/prilocaine

betamethasone valerateQL

malathion

clobetasol propionateQL

permethrin

desonideQL

podofilox

desoximetasoneQL

salicylic acid

diflorasone diacetateQL

sodium hyaluronate

fluocinolone acetonideQL

urea

fluocinonideQL

urea topical

fluticasone propionateQL

urea IN zinc undecylenate/lactic acid vehicle

halobetasol propionateQL

urea 40% nail film

hydrocortisoneQL

Benzoin Compound Tincture

hydrocortisone acetate/aloe

Cem-urea

hydrocortisone butyrate

Coal TAR

hydrocortisone maximum strengthQL

Cocaine HCL

hydrocortisone valerateQL

Delazinc

hydrocortisone IN absorbaseQL

Ethyl Chloride

mometasone furoate

Ethyl Chloride/Fine Pinpoint

prednicarbateQL

Ethyl Chloride/Fine Stream

triamcinolone acetonideQL

Ethyl Chloride/Medium Jet Stream

Amcinonide

Ethyl Chloride/Medium Stream

TrianexQL

Ethyl Chloride/Mist

PREFERRED BRAND

Pyrogallic Acid

CapexQL

Salicylic Acid

NON PREFERRED

Uramaxin

Apexicon EQL

PREFERRED BRAND

Clobex

Eurax

Cloderm

NON PREFERRED

Cloderm P.M.

lindane

Cordran

Condylox

Cordran SP

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 7

Lidocaine HCLQL

NON PREFERRED

Natroba

CenestinGE

Oxsoralen

Depo-estradiolGE

Sklice

EnjuviaGE

Spinosad

EstrogelGE

Synera

EvamistGE

Veregen

MenestGE

ENDOCRINE AND METABOLIC

CONTRACEPTIVES

GENERIC

CORTICOSTEROIDS

norethindroneGE

GENERIC

NON PREFERRED

betamethasone sodium phosphate/betamethasone acetate

BeyazQL,GE

budesonide

Depo-subq Provera 104PA

dexamethasone

EllaGE

dexamethasone sodium phosphate

Loestrin 24 FEQL, GE

fludrocortisone acetate

LO Loestrin FEQL, GE

hydrocortisone

SafyralQL, GE

methylprednisolone

PREVENTIVE

methylprednisolone dose pack

levonorgestrelQL, GE

prednisolone

levonorgestrel/ethinyl estradiolQL, GE

prednisolone sodium phosphate

medroxyprogesterone acetateQL, GE

prednisone

norgestimate/ethinyl estradiolQL, GE

Cortisone Acetate

norgestrel/ethinyl estradiolQL, GE

Prednisolone Sodium Phosphate

Prednisone

PROGESTINS

NON PREFERRED

GENERIC

Depo-medrol

medroxyprogesterone acetate

Dexamethasone

norethindrone acetate

Dexamethasone Intensol

MEDICAL BENEFIT

Dexpak 10 Day

Makena

Dexpak 13 Day

Dexpak 6 Day

ANTIDIABETIC AGENTS

Millipred

INSULIN

Millipred DP

PREFERRED BRAND

Orapred Odt

Apidra

Prednisone Intensol

Lantus

Rayos

Levemir

Solu-cortef

Novolin N

Veripred 20

Novolin N Relion

Novolin R

ANDROGENS-ANABOLIC

Novolin R Relion

GENERIC

Novolin 70/30

testosterone cypionateQL

Novolin 70/30 Relion

PREFERRED BRAND

NON PREFERRED

Androxy

Apidra Solostar

NON PREFERRED

Humalog

Anadrol-50

Humalog Kwikpen

AndrodermPA

Humalog Mix 50/50

AndrogelPA

Humalog Mix 50/50 Kwikpen

AxironPA

Humalog Mix 75/25

FortestaST

Humalog Mix 75/25 Kwikpen

Humulin N

ESTROGENS

Humulin N U-100 Pen

GENERIC

Humulin R

estradiolGE

Humulin R U-500 (concentrated)

estradiol valerateGE

Humulin 70/30

estradiol/norethindrone acetateGE

Humulin 70/30 Pen

estropipateGE

Lantus Solostar

estropipateGE

Levemir Flexpen

JinteliQL,GE

Novolog

PREFERRED BRAND

Novolog Flexpen

AloraGE,QL

Novolog Mix 70/30

Combipatch

Novolog Mix 70/30 Prefilled Flexpen

MinivelleGE,QL

Novolog Penfill

PremarinGE

Relion N

Premphase

Relion N Innolet

PremproGE

Relion R

Vivelle-dotGE,QL

AMYLIN ANALOGS

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 8

NON PREFERRED

Prandimet

Symlinpen 120

Symlinpen 60

BISPHOSPHONATES

INCRETIN MIMETIC AGENTS

GENERIC

PREFERRED BRAND

alendronate sodium

BydureonPA,QL

ibandronate sodium

NON PREFERRED

Alendronate Sodium

Byetta

Etidronate Disodium

VictozaPA

PREFERRED BRAND

SULFONYLUREAS

ActonelST,QL

GENERIC

NON PREFERRED

glimepiride

AtelviaST,QL

glipizide

Binosto

glipizide ERQL

Fosamax Plus D

glyburide

MEDICAL BENEFIT

glyburide micronized

pamidronate disodium

tolazamide

Pamidronate Disodium

Chlorpropamide

Tolazamide

CALCITONINS

Tolbutamide

GENERIC

NON PREFERRED

calcitonin salmon

Diabeta

calcitonin-salmon

Glyburide

Fortical

BIGUANIDES

NON PREFERRED

GENERIC

Miacalcin

metformin HCL

metformin HCL ER

PARATHYROID HORMONE

NON PREFERRED

SPECIALTY

Glumetza

ForteoPA

Riomet

MEGLITINIDE ANALOGUES

RANK LIGAND INHIBITORS

GENERIC

SPECIALTY

nateglinide

ProliaPA

repaglinide

DIABETIC OTHER

HORMONE RECEPTOR MDLTR

NON PREFERRED

NON PREFERRED

Glucagen

Evista

Glucagen Hypokit

Glucagon Emergency KitQL

FERTILITY REGULATORS

Proglycem

GENERIC

ALPHA-GLUCOSIDASE INHIBIT

chorionic gonadotropinPA

GENERIC

acarbose

LHRH/GNRH AGONIST

NON PREFERRED

SPECIALTY

Glyset

Lupron Depot-PEDPA

DPP-4 INHIBITORS

PREFERRED BRAND

GNRH/LHRH ANTAGONISTS

JanuviaQL

NON PREFERRED

NON PREFERRED

Ganirelix AcetatePA

OnglyzaQL

SPECIALTY

TradjentaQL

CetrotidePA

INSULIN SENSITIZING AGENT

GENERIC

GROWTH HORMONES

pioglitazone HCLPA,QL

SPECIALTY

NON PREFERRED

GenotropinPA

Avandia

Genotropin MiniquickPA

ANTIDIABETIC COMBINATIONS

HumatropePA

GENERIC

Humatrope Combo PackPA

glipizide/metformin HCL

Norditropin CartridgePA

glyburide/metformin HCL

Norditropin FlexproPA

pioglitazone HCL-glimepiride

Norditropin Nordiflex PenPA

pioglitazone HCL/metformin HCLPA

NutropinPA

PREFERRED BRAND

Nutropin AQPA

JanumetQL

Nutropin AQ Nuspin 10PA

NON PREFERRED

Nutropin AQ Nuspin 20PA

Actoplus Met XR

Nutropin AQ Nuspin 5PA

Janumet XRQL

Nutropin AQ PenPA

JentaduetoQL

OmnitropePA

Juvisync

Kombiglyze XRQL

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 9

SaizenPA

Thyrolar-2

Saizen Click.easyPA

Thyrolar-3

SerostimPA

Tev-tropinPA

GASTROINTESTINAL

ZorbtivePA

LAXATIVES

GENERIC

SOMATOMEDINS

lactulose

SPECIALTY

peg 3350

IncrelexPA

peg 3350/electrolytes

peg-3350/electrolytes

SOMATOSTATIC AGENTS

peg-3350/NACL/NA bicarbonate/KCL

GENERIC

polyethylene glycol 3350

octreotide acetatePA

polyethylene glycol 3350-grx

SPECIALTY

NON PREFERRED

Sandostatin Lar DepotPA

Colyte-flavor Packs

Somatuline DepotPA

Golytely

Halflytely Bowel Prep/Flavor Packs

GH RECEPTOR ANTAGONISTS

Kristalose

SPECIALTY

Moviprep

SomavertPA

Osmoprep

PrepopikPA

POSTERIOR PITUITARY

Suprep Bowel Prep

Visicol

GENERIC

desmopressin acetate

ANTIDIARRHEALS

vasopressin

SPECIALTY

GENERIC

StimatePA

diphenoxylate/atropine

loperamide HCL

CORTICOTROPIN

Diphenoxylate/Atropine

Paregoric

SPECIALTY

PREFERRED BRAND

Acthar HPPA

Motofen

PROLACTIN INHIBITORS

ULCER DRUGS

GENERIC

GENERIC

cabergoline

cimetidine

cimetidine HCL

VASOPRESSIN ANTAGONISTS

dicyclomine HCLAL

SPECIALTY

glycopyrrolate

SamscaPA

hyoscyamine sulfateAL

hyoscyamine sulfate odtAL

METABOLIC MODIFIERS

hyoscyamine sulfate ERAL

GENERIC

hyoscyamine sulfate SRAL

calcitriol

lansoprazoleQL

PREFERRED BRAND

lansoprazole/amoxicillin/clarithromycin

Hectorol

methscopolamine bromideAL

SensiparPA

misoprostol

SPECIALTY

nizatidine

CystadanePA

omeprazoleQL

OrfadinPA

omeprazole/sodium bicarbonateQL

MEDICAL BENEFIT

pantoprazole sodiumQL

levocarnitine

ranitidine HCL

Zemplar

sucralfate

Belladonna & OpiumAL

THYROID AGENTS

Belladonna Alkaloids & OpiumAL

GENERIC

Dicyclomine HCLAL

levothyroxine sodium

Propantheline Bromide

liothyronine sodium

NON PREFERRED

methimazole

Atropen

propylthiouracil

BentylPA

Levothyroxine Sodium

Cantil

Nature-throid

Carafate

Westhroid

Cuvposa

Westhroid-p

DexilantST,QL

Wp Thyroid

First-lansoprazoleQL

NON PREFERRED

Prevacid SolutabQL

Thyrolar-1

ZegeridQL

Thyrolar-1/2

MEDICAL BENEFIT

Thyrolar-1/4

famotidine

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 10

Famotidine Premixed

nitrofurantoin

nitrofurantoin macrocrystal

ANTIEMETICS

nitrofurantoin macrocrystalline

nitrofurantoin macrocrystals

GENERIC

Methenamine Mandelate

dronabinolPA

NON PREFERRED

granisetron HCLQL

Monurol

meclizine HCL

ondansetron odtQL

URINARY ANTISPASMODICS

ondansetron HCL

Dimenhydrinate

GENERIC

NON PREFERRED

bethanechol chloride

Anzemet

flavoxate HCL

Cesamet

oxybutynin chloride

GranisolPA,QL

oxybutynin chloride ER

SancusoPA,QL

tolterodine tartrate

ZuplenzPA,QL

trospium chlorideST

MEDICAL BENEFIT

trospium chloride ERST

trimethobenzamide HCL

PREFERRED BRAND

Detrol LAST

DIGESTIVE AIDS

EnablexST

VesicareST

PREFERRED BRAND

NON PREFERRED

Creon

Gelnique

Zenpep

MyrbetriqPA

SPECIALTY

Oxytrol

SucraidPA

Toviaz

GASTROINTESTINAL - MISC.

VAGINAL PRODUCTS

GENERIC

GENERIC

balsalazide disodium

clindamycin phosphate

calcium acetate

clotrimazole

cromolyn sodium

metronidazole vaginal

hydrocort ene 100MG

terconazole

hydrocortisone

Nystatin Vaginal

hydrocortisone acetate/pramoxine

PREFERRED BRAND

lactulose

Estrace

lidocaine HCL/hydrocortisone acetate

Gynazole-1

mesalamine

NON PREFERRED

metoclopramide HCL

Avc

sulfasalazine

Cleocin

ursodiol

Endometrin

Lidocaine HCL-hydrocortisone Acetate With Aloe

Estring

PREFERRED BRAND

Vagifem

Asacol

SPECIALTY

Asacol HD

CrinonePA

Canasa

Pentasa

GENITOURINARY - MISC.

RenvelaPA

NON PREFERRED

GENERIC

AmitizaPA

alfuzosin HCL ER

Analpram-HC

citric acid/sodium citrate

Apriso

finasteride

Cortifoam

phenazopyridine HCL

Dipentum

potassium citrate/citric acid

FosrenolPA

tamsulosin HCLQL

Giazo

Cytra-3

Lidocaine HCL/Hydrocortisone Acetate

Tricitrates

Linzess

PREFERRED BRAND

Lotronex

ElmironPA

Phoslyra

NON PREFERRED

Proctofoam HCPA

Avodart

Rectiv

Cardura XL

RenagelPA

Oracit

MEDICAL BENEFIT

Potassium Citrate

Dexpanthenol

RapafloPA

Urocit-k 10

GENITOURINARY

Urocit-k 15

Urocit-k 5

URINARY ANTI-INFECTIVES

SPECIALTY

GENERIC

CystagonPA

methenamine hippurate

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 11

HEMATOLOGICAL

cilostazol

clopidogrelQL

HEMATOPOIETIC AGENTS

dipyridamole

GENERIC

pentoxifylline ERQL

cyanocobalamin

ticlopidine HCL

folic acidQL

Protamine Sulfate

folic acid/vitamin b-6/vitamin b-12

PREFERRED BRAND

B-6 Folic Acid

Aggrenox

Folic Acid

NON PREFERRED

Hematogen Fa

BrilintaPA

Hydroxocobalamin

SPECIALTY

Tandem F

FirazyrPA

PREFERRED BRAND

KalbitorPA

Droxia

MEDICAL BENEFIT

NON PREFERRED

Integrilin

OmontysPA

Soliris

SPECIALTY

Aranesp Albumin FreePA

MOUTH/THROAT/DENTAL AGENT

EpogenPA

LeukinePA

GENERIC

NeumegaPA

chlorhexadine gluconate oral rinse

NeupogenPA

chlorhexidine gluconate

ProcritPA

chlorhexidine gluconate oral rinse

PREVENTIVE

clotrimazole

ferrous dropsQL

lidocaine viscousQL

ferrous gluconate

lidocaine HCLQL

ferrous sulfate

nystatin

iron

pilocarpine hydrochloride

MEDICAL BENEFIT

pilocarpine HCL

Mozobil

stannous fluoride oral rinse

Neulasta

triamcinolone acetonide

triamcinolone IN orabase

ANTICOAGULANTS

NON PREFERRED

GENERIC

Aphthasol

enoxaparin sodiumPA,QL

Oravig

fondaparinux sodiumPA

heparin lock

NEUROLOGY, CNS, PSYCH

heparin lock flush

heparin lock flush for flushing vascular access devices

ANTIANXIETY AGENTS

heparin lock flush/NACL for flushing vascular access devices

GENERIC

alprazolam

heparin sodium

alprazolam ERAL

heparin sodium dcu

buspirone HCL

heparin sodium lock flush

chlordiazepoxide HCLAL

warfarin sodium

clorazepate dipotassiumAL

Heparin Lock Flush

diazepamAL

Heparin Sodium

droperidol

NON PREFERRED

gene-xene TAB 15MGPA

EliquisPA

gene-xene TAB 3.75MGPA

FragminPA

gene-xene TAB 7.5MGPA

PradaxaPA

hydroxyzine pamoateAL

XareltoPA,QL

hydroxyzine HCLAL

MEDICAL BENEFIT

lorazepam

argatroban

MeprobamateAL

heparin sodium/sodium chloride 0.9% premix

oxazepam

heparin sodium/D5W

DiazepamAL

heparin sodium/NACL 0.9%

Hydroxyzine HCLAL

Argatroban

Hydroxyzine PamoateAL

Heparin Sodium/NACL 0.45%

NON PREFERRED

alprazolam odt

HEMOSTATICS

GENERIC

ANTIDEPRESSANTS

aminocaproic acid

GENERIC

tranexamic acid

amitriptyline HCLAL

Amicar

bupropion HCL

Aminocaproic Acid

bupropion HCL ERQL

bupropion HCL SRQL

HEMATOLOGICAL - MISC.

bupropion HCL XL

GENERIC

citalopram hydrobromide

anagrelide hydrochloride

clomipramine HCL AL

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 12

desipramine HCLQL

NON PREFERRED

doxepin HCLAL

olanzapinePA

escitalopram oxalate

olanzapine odtPA

fluoxetine DR

AbilifyPA

fluoxetine HCL

Abilify DiscmeltPA

fluvoxamine maleate

Abilify MaintenaPA

imipramine pamoateAL

FanaptPA

imipramine HCLAL

GeodonPA

MirtazapineAL

InvegaPA

mirtazapine odtAL

Invega SustennaPA

nefazodone HCL

LatudaPA

nortriptyline HCL

SaphrisPA

paroxetine HCL

Seroquel XRPA

paroxetine HCL ER

phenelzine sulfate

HYPNOTICS

sertraline HCL

GENERIC

tranylcypromine sulfate

estazolam

trazodone HCL

flurazepam HCLAL

trimipramine maleate

phenobarbital

venlafaxine HCL

temazepamAL

venlafaxine HCL ER

triazolamAL

AmoxapineAL

zaleplonAL

Desvenlafaxine ER

zolpidem tartrateQL

Doxepin HCLAL

zolpidem tartrate ERAL,QL

Fluoxetine HCL

Phenobarbital

Maprotiline HCL

NON PREFERRED

Nefazodone HCL

IntermezzoAL,QL

Nortriptyline HCL

LunestaAL,QL

Venlafaxine HCL ER

RozeremQL

PREFERRED BRAND

SilenorQL

PaxilPA

MEDICAL BENEFIT

NON PREFERRED

phenobarbital sodium

AplenzinPA

Phenobarbital Sodium

CymbaltaPA

Emsam

ADHD, NARCOLEPSY, ETC.

Forfivo XLPA

GENERIC

Marplan

amphetamine/dextroamphetamineAL,QL

PristiqPA

caffeine citrate

Viibryd

dexmethylphenidate HCLAL

dextroamphetamine sulfateAL

ANTIPSYCHOTICS

dextroamphetamine sulfate ERAL

GENERIC

doxapram HCL

chlorpromazine HCL

methamphetamine HCLAL

clozapine

methylphenidate hydrochlorideAL

fluphenazine HCL

methylphenidate HCLAL

haloperidol

methylphenidate HCL CDAL

haloperidol decanoate

methylphenidate HCL ERAL,QL

haloperidol lactate

methylphenidate HCL SRAL,QL

lithium carbonate

Caffeine/Sodium Benzoate

lithium carbonate ER

Methylphenidate HCL ERAL,QL

loxapine

NON PREFERRED

loxapine succinate

modafinilPA

perphenazine

DaytranaPA,QL

prochlorperazine

Focalin XRAL,QL

prochlorperazine maleate

IntunivPA

quetiapine fumaratePA

KapvayPA

risperidone

Kapvay Dose PackPA

risperidone odt

NuvigilPA

thiothixene

Quillivant XRPA

trifluoperazine HCL

StratteraPA

ziprasidone HCLPA

Chlorpromazine HCL

ANTICONVULSANTS

Clozapine Odt

GENERIC

Fazaclo

carbamazepine

Fluphenazine Decanoate

carbamazepine ER

Fluphenazine HCL

clonazepam

Lithium Citrate

clonazepam odt

Prochlorperazine Edisylate

divalproex sodium

divalproex sodium DR

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 13

divalproex sodium ER

GENERIC

ethosuximide

acamprosate calcium DR

felbamate

disulfiram

gabapentin

donepezil HCL

lamotrigine

galantamine

lamotrigine ER

galantamine hydrobromide

levetiracetamQL

olanzapine/fluoxetine

levetiracetam ER

rivastigmine tartratePA

oxcarbazepine

Chlordiazepoxide/Amitriptyline

phenytoin

Ergoloid Mesylates

phenytoin sodium

Perphenazine/Amitriptyline

phenytoin sodium extended

NON PREFERRED

primidone

ExelonPA

tiagabine hydrochloride

Gralise

topiramate

Gralise Starter

valproic acid

Horizant

zonisamideQL

NamendaPA

PREFERRED BRAND

Namenda Titration PAKPA

Celontin

NuedextaPA

Dilantin

Orap

Tegretol-XR

Savella

NON PREFERRED

SPECIALTY

Banzel

AmpyraPA

Diastat Acudial

AvonexPA

Diastat Pediatric

Avonex PenPA

Diazepam

BetaseronPA

Gabitril

CopaxonePA

Lamictal

ExtaviaPA

Lamictal Odt

GilenyaPA

Lamictal Starter/Not Taking Carbamazepine

RebifPA

Lamictal Starter/Taking Carbamazepine/Not Taking Valproate

Rebif RebidosePA

Rebif Rebidose Titration PackPA

Lamictal Starter/Taking Valproate

Rebif Titration PackPA

Lyrica

XenazinePA

Peganone

XyremPA

Potiga

PREVENTIVE

Stavzor

bupropion HCL SR

SPECIALTY

nicotineQL

SabrilPA

nicotine polacrilexQL

MEDICAL BENEFIT

nicotine polacrilex refillQL

valproate sodium

nicotine polacrilex starter kitQL

Levetiracetam

nicotine transdermal systemQL

ChantixQL

ANTIPARKINSON AGENTS

Chantix Continuing Month PAKQL

GENERIC

Chantix Starting Month PAKQL

amantadine HCL

Nicotrol Inhaler

benztropine mesylateAL

Nicotrol Ns

bromocriptine mesylate

carbidopa/levodopa

NEUROMUSCULAR AGENTS

carbidopa/levodopa odt

GENERIC

carbidopa/levodopa CR

riluzole

carbidopa/levodopa ER

MEDICAL BENEFIT

carbidopa/levodopa SR

Dysport

entacapone

pramipexole dihydrochloride

MUSCULOSKELETAL AGENTS

ropinirole ER

GENERIC

ropinirole HCL

baclofen

selegiline HCL

chlorzoxazoneAL

Amantadine HCL

cyclobenzaprine HCLAL

PREFERRED BRAND

MetaxaloneAL

Azilect

MethocarbamolAL

Lodosyn

orphenadrine citrateAL

Mirapex ER

orphenadrine citrate ERAL

NON PREFERRED

orphenadrine/asa/caffeineAL

Neupro

tizanidine HCLQL

Tasmar

NON PREFERRED

AmrixPA

NEUROLOGY, PSYCH - MISC.

Lorzone

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 14

ANTIMYASTHENIC AGENTS

neomycin/polymyxin/dexamethasone

prednisolone acetate

GENERIC

sulfacetamide sodium/prednisolone sodium phosphate

pyridostigmine bromide

tobramycin/dexamethasoneQL

PREFERRED BRAND

Neomycin/Polymyxin/Hydrocortisone

Mestinon

Prednisolone Sodium Phosphate

Mestinon Timespan

PREFERRED BRAND

NON PREFERRED

Blephamide S.o.p.

Mytelase

Durezol

MEDICAL BENEFIT

FML

Regonol

Pred Mild

TobradexQL

OPHTHALMOLOGY AND OTIC

Tobradex STQL

ANTI-INFECTIVES

Zylet

GENERIC

NON PREFERRED

bacitracin/polymyxin b

Flarex

ciprofloxacin HCL

Lotemax

erythromycin

Vexol

gentamicin sulfate

levofloxacin

PROSTAGLANDINS

neomycin/bacitracin/polymyxin

GENERIC

neomycin/polymyxin/bacitracin zinc

latanoprostQL

neomycin/polymyxin/gramicidin

NON PREFERRED

ofloxacin

Lumigan

polymyxin b sulfate/trimethoprim sulfate

Travatan Z

sodium sulfacetamide

Zioptan

sulfacetamide sodium

tobramycin sulfate

CYCLOPLEGIC MYDRIATICS

trifluridine

GENERIC

trimethoprim sulfate/polymyxin b sulfate

atropine sulfate

Bacitracin

cyclopentolate HCL

Sulfacetamide Sodium

homatropine HBR

PREFERRED BRAND

Atropine Sulfate

Besivance

Ciloxan

DECONGESTANTS

Tobrex

GENERIC

Zymaxid

Naphazoline HCL

NON PREFERRED

Azasite

MIOTICS

Moxeza

Natacyn

GENERIC

Vigamox

pilocarpine HCL

Zirgan

PREFERRED BRAND

Isopto Carbachol

ARTIFICIAL TEAR/LUBRICANT

Phospholine Iodide

NON PREFERRED

PREFERRED BRAND

Pilopine HS

Lacrisert

ADRENERGIC AGENTS

BETA-BLOCKERS

GENERIC

GENERIC

apraclonidine

betaxolol HCL

brimonidine tartrate

carteolol HCL

PREFERRED BRAND

dorzolamide HCL/timolol maleate

Alphagan P

levobunolol HCL

NON PREFERRED

metipranolol

Iopidine

timolol maleate

timolol maleate ophthalmic gel forming

LOCAL ANESTHETICS

Istalol

Levobunolol HCL

GENERIC

PREFERRED BRAND

proparacaine HCL

Betoptic-s

tetracaine HCL

Combigan

NON PREFERRED

OPHTHALMICS - MISC.

Betimol

GENERIC

azelastine HCL

OPHTHALMIC STEROIDS

cromolyn sodium

GENERIC

diclofenac sodium

dexamethasone sodium phosphate

dorzolamide HCL

fluorometholone

epinastine HCL

neomycin/polymyxin/bacitracin/hydrocortisone

flurbiprofen sodium

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 15

ketorolac tromethamine

ANALGESICS - OPIOID

Bromfenac

GENERIC

PREFERRED BRAND

acetaminophen/codeine

Bromday

acetaminophen/codeine #2

NON PREFERRED

acetaminophen/codeine #3

Acuvail

acetaminophen/codeine #4

Alocril

acetaminophen/codeine phosphate

Alomide

butalbital/acetaminophen/caffeine/codeine

Bepreve

butalbital/aspirin/caffeine/codeine

Cystaran

butorphanol tartrate

Lastacaft

fentanylPA

Nevanac

hydrocodone bitartrate/acetaminophen

Pataday

hydrocodone/acetaminophen

Patanol

hydrocodone/ibuprofen

hydromorphone HCL

OTIC AGENTS

meperidine HCL

GENERIC

methadone HCL

acetic acid

morphine sulfate

antipyrine/benzocaine

oxycodone HCL

fluocinolone acetonide

oxycodone/acetaminophen

fluocinolone acetonide ear drops

oxycodone/aspirin

hydrocortisone/acetic acid

oxycodone/ibuprofen

neomycin/polymyxin/hydrocortisone

pentazocine/acetaminophen

neomycin/polymyxin/HC

pentazocine/naloxone HCL

ofloxacin

tramadol hydrochloride/acetaminophen

Cetraxal

tramadol HCLQL

Ciprofloxacin

Acetaminophen/Caffeine/Dihydrocodeine Bitartrate

PREFERRED BRAND

Codeine Sulfate

Ciprodex

Hydrocodone Bitartrate/Acetaminophen

NON PREFERRED

Hydrocodone/Acetaminophen

Cipro HC

Hydromorphone HCL

Coly-mycin S

Levorphanol Tartrate

Cortisporin-tc

Meperidine HCL

Morphine Sulfate

OXYTOCICS

Zamicet

NON PREFERRED

buprenorphine HCLPA

MEDICAL BENEFIT

buprenorphine HCL/naloxone HCLPA

methylergonovine maleate

nalbuphine HCL

oxytocin

oxymorphone hydrochloride ERPA

tramadol HCL ER

PAIN MANAGEMENT

ButransPA

ANALGESICS - NONNARCOTIC

Codeine Phosphate

GENERIC

ConzipPA

butal/asa/caff

LazandaPA

butalbital/acetaminophen

Methadone HCL

butalbital/acetaminophen/caffeine

Morphine Sulfate Add-vantage

butalbital/asa/caffeine

Nucynta ERPA

choline magnesium trisalicylate

OnsolisPA

diflunisal

Opana ER (crush Resistant)PA

salsalate

OxectaPA

Anabar

Rybix OdtPA

Bupap

SuboxonePA

Butalbital/Aspirin/Caffeine

SubsysPA

Frenadol

TalwinPA

Mst 600

Tramadol HCL ER

Rhinoflex-650

Trezix

Tencon

PREVENTIVE

ANTI-INFLAMMATORY

aspirinQL,AL

GENERIC

aspirin ECQL,AL

diclofenac potassium

aspirin EC low doseQL,AL

diclofenac sodium DR

aspirin 81QL,AL

diclofenac sodium ER

aspirin/entericQL,AL

diclofenac sodium XR

enteric coated aspirinQL,AL

diclofenac sodium/misoprostol

Halfprin

etodolac

MEDICAL BENEFIT

etodolac ER

clonidine HCLAL

flurbiprofen

ibuprofen

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 16

indomethacinAL

PREFERRED BRAND

indomethacin ERAL

ColcrysQL

ketoprofenQL

ketorolac tromethamineQL

RESPIRATORY, ALLERGY, ETC

leflunomide

ANTIHISTAMINES

meloxicam

GENERIC

nabumetoneQL

carbinoxamine maleateAL

naproxen

cetirizine HCL

naproxen sodium

clemastine fumarateAL

oxaprozin

cyproheptadine HCLAL

piroxicam

diphenhydramine HCLAL

sulindac

fexofenadine HCL

tolmetin sodium

loratadine

Fenoprofen Calcium

promethazine HCLAL

Meclofenamate Sodium

promethazine HCL plainAL

Meloxicam

Allegra Allergy Childrens

Mobic

Claritin

Tolmetin Sodium

Clemastine FumarateAL

NON PREFERRED

Dexchlorpheniramine MaleateAL

Ketoprofen ERQL

PrometheganAL

NaprelanPA

Respa-BR

Rheumatrex

Ridaura

NASAL AGENTS

SprixPA

GENERIC

SPECIALTY

azelastine HCL

ArcalystPA

flunisolideQL

EnbrelPA

fluticasone propionateQL

Enbrel SureclickPA

ipratropium bromideQL

HumiraPA

triamcinolone acetonide

Humira PenPA

Flunisolide

Humira Pen-crohns DiseasestarterPA

NON PREFERRED

Humira Pen-psoriasis StarterPA

Astepro

KineretPA

Bactroban Nasal

MEDICAL BENEFIT

Beconase AQST

Actemra

Nasonex

Patanase

MIGRAINE PRODUCTS

QnaslST

GENERIC

Rhinocort AquaST

dihydroergotamine mesylate

Tyzine

naratriptan HCLST,QL

Tyzine Pediatric Nasal Drops

rizatriptan benzoate

VeramystST

rizatriptan benzoate odt

ZetonnaST

sumatriptan succinateQL

Dihydroergotamine Mesylate

COUGH/COLD/ALLERGY

Migranal

GENERIC

PREFERRED BRAND

acetylcysteine

Cafergot

benzonatate

NON PREFERRED

brom/PSE/DM

sumatriptan succinate refillPA,QL

dextromethorphan HBR/chlorpheniramine/phenylephrine HCL

zolmitriptanST,QL

zolmitriptan odtST,QL

hydrocodone bitartrate/homatropine methylbromide

AlsumaPA,QL

hydrocodone polistirex and chlorpheniramine polistirex

AxertST,QL

hydrocodone polistirex/chlorpheniramine polistirex

FrovaST,QL

hydrocodone/homatropine

ImitrexQL

nasal mist

RelpaxST,QL

phenylephrine/guaifenesin

SumatriptanQL

promethazine-DM

Sumavel DoseproQL

promethazine/codeine

TreximetST

promethazine/dextromethorphan

ZomigST,QL

sodium chloride

Zomig ZMTST,QL

Rescon-JR

PREFERRED BRAND

GOUT AGENTS

Rezira

GENERIC

Zutripro

allopurinol

NON PREFERRED

allopurinol sodium

Clarinex-d 12 HOUR

probenecid

Clarinex-d 24 HOUR

probenecid/colchicine

Tussicaps

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 17

ANTIASTHMATIC/COPD AGENTS

ergocalciferol

niacin

GENERIC

phytonadione

albuterol sulfate

thiamine HCL

albuterol sulfate ER

vitamin c 222MG

albuterol TAB 4MG

vitamin d

aminophylline

vitamin k1

budesonideQL

Niacin TR

cromolyn sodium

Pyridoxine HCL

epinephrine HCL

PREFERRED BRAND

ipratropium bromide

Mephyton

ipratropium bromide/albuterol sulfate

PREVENTIVE

levalbuterol

d3

levalbuterol HCL

d3 ultra strength

montelukast sodium

vitamin d 400

terbutaline sulfate

vitamin d-1000

theophylline

vitamin d-3

theophylline CR

vitamin d3

theophylline ER

Dialyvite Vitamin D3 Max

zafirlukast

D3QL

Aminophylline

Replesta

Metaproterenol Sulfate

Replesta Childrens

PREFERRED BRAND

Replesta Nx

Advair DiskusQL

Thera-d 4000

Atrovent HFAQL

Vitamin DQL

CombiventQL

Vitamin D3QL

DuleraQL

Vitamin D3 400QL

Elixophyllin

Foradil AerolizerQL

MULTIVITAMINS

QvarQL

Serevent DiskusQL

GENERIC

Spiriva HandihalerQL

nicotinamide w/zinc oxide/cupric oxide/folic acid

SymbicortQL

nicotinamide/zinc oxide/cupric oxide/folic acid

Tudorza PressairQL

nicotinamide/zinc/copper/fa

Ventolin HFAQL

Folbecal

NON PREFERRED

Taron-prex

Advair HFAQL

NON PREFERRED

AlvescoQL

Alive Mens Energy

Arcapta NeohalerQL

Alive Once Daily Womens 50+ Ultra Potency

Asmanex 120 Metered DosesQL

Alive Womens Energy

Asmanex 14 Metered DosesQL

Alive Womens 50+

Asmanex 30 Metered DosesQL

Bacmin

Asmanex 60 Metered DosesQL

Centrum Cardio

Asmanex 7 Metered DosesQL

Centrum Silver Ultra Mens

Brovana

Centrum Silver Ultra Womens

Combivent RespimatQL

Centrum Specialist Heart

Flovent DiskusPA,QL

Centrum Specialist Immune Support

Lufyllin

Centrum Specialist Vision

Maxair AutohalerQL

Centrum Ultra Womens

Perforomist

Certavite Senior/Antioxidant Nutrients

Proair HFAQL

Clinical Nutrients For Female Teens

Proventil HFAQL

Clinical Nutrients For Male Teens

PulmicortQL

Clinical Nutrients For Men

Pulmicort FlexhalerQL

Clinical Nutrients For Women

Theo-24

Clinical Nutrients 45-plus Women

Xopenex HFAQL

Clinical Nutrients 50-plus Men

SPECIALTY

CAL-day 1000

XolairPA

Dermavite

ZyfloPA

Fitness TABS For Men AM/PM/Lycopene

Zyflo CRPA

Fitness TABS For Women A M/PM/Lycopene

Hyalex

RESPIRATORY AGENTS - MISC

Icaps Areds Formula

Icaps Plus

SPECIALTY

K-pax Immune Support Formula Professional Strength

KalydecoPA

M.v.i. Adult

PulmozymePA,QL

M.v.i. Pediatric

M.v.i.-12 Without Vitamin K

VITAMINS

Multi-betic

VITAMINS

Multi-betic Diabetes

GENERIC

Nicazel

ascorbic acid

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 18

Nutricap

Oncovite

One-a-day Energy

One-a-day Menopause Formula

One-a-day Mens Health Formula

One-a-day Mens Pro Edge

One-a-day Mens 50+ Advantage

One-a-day Teen Advantage For Him

Pro-CAL

Procerv HP

Renaplex-d

Req 49+

Siderol

Strovite One

Thera M Plus

Therabetic Multi-vitamin

Theragran-m

Theragran-m Advanced

Theragran-m Advanced 50 Plus

Theragran-m Premier

Theragran-m Premier 50 Plus

Therems-h

Therems-m

Vitaline Total Formula 2

Vitaline Total Formula 3

Vitasana

Yelets Teenage Formula

PREVENTIVE

Right Step Prenatal

MISCELLANEOUS

GENERIC

Pentetate Calcium Trisodium

Pentetate Zinc Trisodium

PREFERRED BRAND

Chemet

SPECIALTY

FerriproxPA

Effective January 1, 2014

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limits; GE=Gender Edits 19

Index

A

Alsuma, 17

Asacol, 11

Altabax, 6

Asacol HD, 11

abacavir, 1

Altoprev, 6

ascorbic acid, 18

Abilify, 13

Alvesco, 18

Asmanex 120 Metered Doses, 18

Abilify Discmelt, 13

amantadine HCL, 14

Asmanex 14 Metered Doses, 18

Abilify Maintena, 13

Amantadine HCL, 14

Asmanex 30 Metered Doses, 18

Abraxane, 3

amcinonide, 7

Asmanex 60 Metered Doses, 18

acamprosate calcium DR, 14

Amcinonide, 7

Asmanex 7 Metered Doses, 18

Acanya, 6

Amevive, 7

aspirin, 16

acarbose, 9

Amicar, 12

aspirin 81, 16

acebutolol HCL, 4

amifostine, 4

aspirin EC, 16

Acetaminophen/Caffeine/Dihydrocodeine Bitartrate, 16

amiloride HCL, 5

aspirin EC low dose, 16

amiloride/hydrochlorothiazide, 5

aspirin/enteric, 16

acetaminophen/codeine, 16

aminocaproic acid, 12

Astepro, 17

acetaminophen/codeine #2, 16

Aminocaproic Acid, 12

Atelvia, 9

acetaminophen/codeine #3, 16

aminophylline, 18

atenolol, 4

acetaminophen/codeine #4, 16

Aminophylline, 18

atenolol/chlorthalidone, 5

acetaminophen/codeine phosphate, 16

amiodarone HCL, 4

Atgam, 3

acetazolamide, 5

Amitiza, 11

atorvastatin calcium, 6

Acetazolamide, 5

amitriptyline HCL, 12

atovaquone/proguanil HCL, 2

acetazolamide ER, 5

amlodipine besylate, 4

Atovaquone/Proguanil HCL, 2

acetazolamide sodium, 5

Amlodipine Besylate/Atorvastatin Calcium, 6

Atralin, 6

acetic acid, 16

Atripla, 2

acetylcysteine, 17

amlodipine besylate/benazepril HCL, 5

Atropen, 10

acitretin, 7

amlodipine besylate/benazepril hydrochloride, 5

atropine sulfate, 15

Actemra, 17

Atropine Sulfate, 15

Acthar HP, 10

ammonium lactate, 7

Atrovent HFA, 18

Actimmune, 4

Amoxapine, 13

augmented betamethasone dipropionate, 7

Actonel, 9

amoxicillin, 1

Actoplus Met XR, 9

Amoxicillin, 1

Augmentin, 1

Acuvail, 16

amoxicillin/clavulanate potassium, 1

Auvi-q, 5

acyclovir, 1, 6

amoxicillin/clavulanate potassium ER, 1

Avandia, 9

Adcetris, 3

amoxicillin/potassium clavulanate, 1

Avastin, 3

Adcirca, 6

amphetamine/dextroamphetamine, 13

Avc, 11

adefovir dipivoxil, 2

ampicillin, 1

Avelox, 1

Adrenaclick, 5

Ampicillin, 1

Avelox Abc Pack, 1

Advair Diskus, 18

ampicillin sodium, 1

Avodart, 11

Advair HFA, 18

Ampicillin Sodium, 1

Avonex, 14

Afinitor, 3

Ampyra, 14

Avonex Pen, 14

Aggrenox, 12

Amrix, 14

Axert, 17

Albenza, 2

Amturnide, 5

Axiron, 8

albuterol sulfate, 18

Anabar, 16

Azactam IN Iso-osmotic Dextrose, 2

albuterol sulfate ER, 18

Anadrol-50, 8

Azasan, 3

albuterol TAB 4MG, 18

anagrelide hydrochloride, 12

Azasite, 15

alclometasone dipropionate, 7

Analpram-HC, 11

azathioprine, 3

alendronate sodium, 9

anastrozole, 3

Azathioprine Sodium, 3

Alendronate Sodium, 9

Androderm, 8

azelastine HCL, 15, 17

Alferon N, 4

Androgel, 8

Azilect, 14

alfuzosin HCL ER, 11

Androxy, 8

azithromycin, 1

Alinia, 2

antipyrine/benzocaine, 16

Azithromycin, 1

Alive Mens Energy, 18

Anzemet, 11

Azor, 5

Alive Once Daily Womens 50+ Ultra Potency, 18

Apexicon E, 7

B

Aphthasol, 12

Alive Womens 50+, 18

B-6 Folic Acid, 12

Apidra, 8

Alive Womens Energy, 18

Bacitracin, 15

Apidra Solostar, 8

Allegra Allergy Childrens, 17

bacitracin/polymyxin b, 15

Aplenzin, 13

allopurinol, 17

baclofen, 14

apraclonidine, 15

allopurinol sodium, 17

Bacmin, 18

Apriso, 11

Alocril, 16

Bactroban Nasal, 17

Aptivus, 2

Alodox Convenience Kit, 1

balsalazide disodium, 11

Aranesp Albumin Free, 12

Alomide, 16

Banzel, 14

Arcalyst, 17

Alora, 8

Baraclude, 2

Arcapta Neohaler, 18

Alphagan P, 15

Beconase AQ, 17

argatroban, 12

alprazolam, 12

Belladonna & Opium, 10

Argatroban, 12

alprazolam ER, 12

Belladonna Alkaloids & Opium, 10

Arzerra, 3

alprazolam odt, 12

benazepril HCL, 5

benazepril HCL/hydrochlorothiazide, 5

calcipotriene, 7

chlordiazepoxide HCL, 12

Benicar, 5

calcitonin salmon, 9

Chlordiazepoxide/Amitriptyline, 14

Benicar HCT, 5

calcitonin-salmon, 9

chlorhexadine gluconate oral rinse, 12

Bentyl, 10

Calcitriol, 7

chlorhexidine gluconate, 12

Benzoin Compound Tincture, 7

calcitriol, 10

chlorhexidine gluconate oral rinse, 12

benzonatate, 17

calcium acetate, 11

chloroquine phosphate, 2

benzoyl peroxide, 6

Calcium Folinate, 4

chlorothiazide, 5

benzoyl peroxide SHORT contact, 6

Campath, 3

chlorothiazide sodium, 5

benztropine mesylate, 14

Canasa, 11

chlorpromazine HCL, 13

Bepreve, 16

candesartan cilexetil, 5

Chlorpromazine HCL, 13

Besivance, 15

candesartan cilexetil/hydrochlorothiazide, 5

Chlorpropamide, 9

betamethasone dipropionate, 7

Chlorthalidone, 5

betamethasone sodium phosphate/betamethasone acetate, 8

Cantil, 10

chlorzoxazone, 14

Capex, 7

cholestyramine light, 6

betamethasone valerate, 7

Caprelsa, 3

choline magnesium trisalicylate, 16

Betaseron, 14

captopril, 5

chorionic gonadotropin, 9

betaxolol HCL, 4, 15

Captopril/Hydrochlorothiazide, 5

Cialis, 6

bethanechol chloride, 11

Carafate, 10

cilostazol, 12

Betimol, 15

carbamazepine, 13

Ciloxan, 15

Betoptic-s, 15

carbamazepine ER, 13

cimetidine, 10

Beyaz, 8

carbidopa/levodopa, 14

cimetidine HCL, 10

bicalutamide, 3

carbidopa/levodopa CR, 14

Cipro, 1

Bicillin L-a, 1

carbidopa/levodopa ER, 14

Cipro HC, 16

Bidil, 6

carbidopa/levodopa odt, 14

Ciprodex, 16

Binosto, 9

carbidopa/levodopa SR, 14

Ciprofloxacin, 16

bisoprolol fumarate, 4

carbinoxamine maleate, 17

ciprofloxacin ER, 1

bisoprolol fumarate/hydrochlorothiazide, 5

carboplatin, 2

ciprofloxacin HCL, 1, 15

Cardene IV, 4

cisplatin, 2

bleomycin sulfate, 2

Cardizem LA, 4

citalopram hydrobromide, 12

Blephamide S.o.p., 15

Cardura XL, 11

citric acid/sodium citrate, 11

Bosulif, 3

carteolol HCL, 15

cladribine, 3

Brilinta, 12

carvedilol, 4

Clarinex-d 12 HOUR, 17

brimonidine tartrate, 15

cefaclor, 1

Clarinex-d 24 HOUR, 17

brom/PSE/DM, 17

Cefaclor, 1

clarithromycin, 1

Bromday, 16

Cefaclor ER, 1

clarithromycin ER, 1

Bromfenac, 16

cefadroxil, 1

Claritin, 17

bromocriptine mesylate, 14

cefazolin sodium, 1

clemastine fumarate, 17

Brovana, 18

cefdinir, 1

Clemastine Fumarate, 17

budesonide, 8, 18

cefpodoxime proxetil, 1

Cleocin, 11

bumetanide, 5

cefprozil, 1

clindamycin HCL, 2

Bupap, 16

ceftriaxone sodium, 1

clindamycin palmitate HCL, 2

buprenorphine HCL, 16

Ceftriaxone/Dextrose, 1

clindamycin phosphate, 6, 11

buprenorphine HCL/naloxone HCL, 16

cefuroxime axetil, 1

clindamycin/benzoyl peroxide, 6

bupropion HCL, 12

Cellcept, 3

Clindareach, 6

bupropion HCL ER, 12

Cellcept Intravenous, 3

Clinical Nutrients 45-plus Women, 18

bupropion HCL SR, 12, 14

Celontin, 14

Clinical Nutrients 50-plus Men, 18

bupropion HCL XL, 12

Cem-urea, 7

Clinical Nutrients For Female Teens, 18

buspirone HCL, 12

Cenestin, 8

Clinical Nutrients For Male Teens, 18

butal/asa/caff, 16

Centany, 6

Clinical Nutrients For Men, 18

butalbital/acetaminophen, 16

Centrum Cardio, 18

Clinical Nutrients For Women, 18

butalbital/acetaminophen/caffeine, 16

Centrum Silver Ultra Mens, 18

clobetasol propionate, 7

butalbital/acetaminophen/caffeine/codeine, 16

Centrum Silver Ultra Womens, 18

Clobex, 7

Centrum Specialist Heart, 18

Cloderm, 7

butalbital/asa/caffeine, 16

Centrum Specialist Immune Support, 18

Cloderm P.M., 7

Butalbital/Aspirin/Caffeine, 16

Centrum Specialist Vision, 18

Clolar, 3

butalbital/aspirin/caffeine/codeine, 16

Centrum Ultra Womens, 18

clomipramine HCL, 12

butorphanol tartrate, 16

cephalexin, 1

clonazepam, 13

Butrans, 16

Cephalexin, 1

clonazepam odt, 13

Bydureon, 9

Certavite Senior/Antioxidant Nutrients, 18

clonidine HCL, 5, 16

Byetta, 9

clopidogrel, 12

Bystolic, 4

Cesamet, 11

clorazepate dipotassium, 12

C

cetirizine HCL, 17

clotrimazole, 6, 11, 12

Cetraxal, 16

clotrimazole/betamethasone dipropionate, 6

cabergoline, 10

Cetrotide, 9

Caduet, 6

Chantix, 14

clozapine, 13

Cafergot, 17

Chantix Continuing Month PAK, 14

Clozapine Odt, 13

caffeine citrate, 13

Chantix Starting Month PAK, 14

Cnl8 Nail Kit, 6

Caffeine/Sodium Benzoate, 13

Chemet, 19

Coal TAR, 7

CAL-day 1000, 18

Cocaine HCL, 7

desmopressin acetate, 10

divalproex sodium, 13

Codeine Phosphate, 16

Desonate, 7

divalproex sodium DR, 13

Codeine Sulfate, 16

desonide, 7

divalproex sodium ER, 14

Colcrys, 17

Desowen Cream/Cetaphil Lotion, 7

Docefrez, 3

colestipol HCL, 6

Desowen Lotion/Cetaphil Cream, 7

Docetaxel, 3

colestipol HCL for oral suspension, 6

Desowen Ointment/Cetaphil Lotion, 7

donepezil HCL, 14

Coly-mycin S, 16

desoximetasone, 7

dorzolamide HCL, 15

Colyte-flavor Packs, 10

Desoximetasone, 7

dorzolamide HCL/timolol maleate, 15

Combigan, 15

Desvenlafaxine ER, 13

doxapram HCL, 13

Combipatch, 8

Detrol LA, 11

doxazosin mesylate, 5

Combivent, 18

dexamethasone, 8

doxepin HCL, 13

Combivent Respimat, 18

Dexamethasone, 8

Doxepin HCL, 13

Cometriq, 3

Dexamethasone Intensol, 8

doxorubicin HCL, 2

Complera, 2

dexamethasone sodium phosphate, 8, 15

doxorubicin HCL liposome, 2

Condylox, 7

doxycycline, 1

Conzip, 16

Dexchlorpheniramine Maleate, 17

doxycycline hyclate, 1

Copaxone, 14

Dexilant, 10

doxycycline hyclate DR, 1

Cordran, 7

dexmethylphenidate HCL, 13

doxycycline monohydrate, 1

Cordran SP, 7

Dexpak 10 Day, 8

Dritho-creme HP, 7

Cordran Tape, 7

Dexpak 13 Day, 8

Dritho-scalp, 7

Coreg CR, 4

Dexpak 6 Day, 8

dronabinol, 11

Cortifoam, 11

Dexpanthenol, 11

droperidol, 12

Cortisone Acetate, 8

dexrazoxane, 4

Droxia, 12

Cortisporin, 6

dextroamphetamine sulfate, 13

Dulera, 18

Cortisporin-tc, 16

dextroamphetamine sulfate ER, 13

Durezol, 15

Creon, 11

dextromethorphan HBR/chlorpheniramine/phenylephrine HCL, 17

Dyrenium, 5

Crestor, 6

Dysport, 14

Crinone, 11

E

Crixivan, 2

Diabeta, 9

E.e.s. 400, 1

cromolyn sodium, 11, 15, 18

Dialyvite Vitamin D3 Max, 18

econazole nitrate, 6

Cubicin, 2

Diastat Acudial, 14

Edarbi, 5

Cuvposa, 10

Diastat Pediatric, 14

Edecrin, 5

cyanocobalamin, 12

diazepam, 12

Edurant, 2

cyclobenzaprine HCL, 14

Diazepam, 12, 14

Elidel, 7

cyclopentolate HCL, 15

Dibenzyline, 5

Eligard, 3

Cyclophosphamide, 2

diclofenac potassium, 16

Eliquis, 12

cyclosporine, 3

diclofenac sodium, 15

Elitek, 4

cyclosporine modified, 3

diclofenac sodium DR, 16

Elixophyllin, 18

Cyclosporine Modified, 3

diclofenac sodium ER, 16

Ella, 8

Cymbalta, 13

diclofenac sodium XR, 16

Elmiron, 11

cyproheptadine HCL, 17

diclofenac sodium/misoprostol, 16

Elspar, 3

Cystadane, 10

dicloxacillin sodium, 1

Emcyt, 3

Cystagon, 11

dicyclomine HCL, 10

Emsam, 13

Cystaran, 16

Dicyclomine HCL, 10

Emtriva, 2

cytarabine, 3

didanosine, 1

Enablex, 11

cytarabine aqueous, 3

Dificid, 1

enalapril maleate, 5

Cytra-3, 11

diflorasone diacetate, 7

enalapril maleate/hydrochlorothiazide, 5

D

Diflorasone Diacetate, 7

Enbrel, 17

diflunisal, 16

d3, 18

Enbrel Sureclick, 17

digoxin, 4

D3, 18

Endometrin, 11

Digoxin, 4

d3 ultra strength, 18

Enjuvia, 8

dihydroergotamine mesylate, 17

dactinomycin, 2

enoxaparin sodium, 12

Dihydroergotamine Mesylate, 17

Dapsone, 2

entacapone, 14

Dilantin, 14

Daraprim, 2

enteric coated aspirin, 16

Dilatrate SR, 4

daunorubicin HCL, 2

ephedrine sulfate, 5

diltiazem CD, 4

Daunoxome, 3

Epiduo, 6

diltiazem HCL, 4

Daytrana, 13

epinastine HCL, 15

Diltiazem HCL, 4

decitabine, 3

Epinephrine, 5

diltiazem HCL ER, 4

Delazinc, 7

epinephrine HCL, 18

Dimenhydrinate, 11

demeclocycline HCL, 1

Epipen 2-PAK, 5

Diovan, 5

Demser, 5

Epipen-JR 2-PAK, 5

Dipentum, 11

Denavir, 6

epirubicin HCL, 2

diphenhydramine HCL, 17

Depo-estradiol, 8

Epivir, 2

diphenoxylate/atropine, 10

Depo-medrol, 8

Epivir HBV, 2

Diphenoxylate/Atropine, 10

Depo-provera, 3

eplerenone, 5

dipyridamole, 12

Depo-subq Provera 104, 8

Epogen, 12

disopyramide phosphate, 4

Dermavite, 18

epoprostenol sodium, 6

disulfiram, 14

desipramine HCL, 13

eprosartan mesylate, 5

Epzicom, 2

Fibricor, 6

Ganirelix Acetate, 9

Erbitux, 3

Finacea, 6

Gelnique, 11

ergocalciferol, 18

finasteride, 11

gemcitabine HCL, 3

Ergoloid Mesylates, 14

Firazyr, 12

gemfibrozil, 6

Ertaczo, 6

Firmagon, 3

gene-xene TAB 15MG, 12

Erwinaze, 3

First-lansoprazole, 10

gene-xene TAB 3.75MG, 12

Ery-TAB, 1

Fitness TABS For Men AM/PM/Lycopene, 18

gene-xene TAB 7.5MG, 12

Erythrocin Stearate, 1

Genotropin, 9

erythromycin, 1, 6, 15

Fitness TABS For Women A M/PM/Lycopene, 18

Genotropin Miniquick, 9

Erythromycin, 6

Gentamicin Sulfate, 6

Erythromycin Base, 1

Flagyl ER, 2

gentamicin sulfate, 15

Erythromycin Ethylsuccinate, 1

Flarex, 15

Geodon, 13

erythromycin/benzoyl peroxide, 6

flavoxate HCL, 11

Giazo, 11

erythromycin/sulfisoxazole, 2

flecainide acetate, 4

Gilenya, 14

escitalopram oxalate, 13

Flector, 7

Gleevec, 3

esmolol HCL, 4

Flovent Diskus, 18

glimepiride, 9

estazolam, 13

floxuridine, 3

glipizide, 9

Estrace, 11

fluconazole, 1

glipizide ER, 9

estradiol, 8

fludarabine phosphate, 3

glipizide/metformin HCL, 9

estradiol valerate, 8

fludrocortisone acetate, 8

Glucagen, 9

estradiol/norethindrone acetate, 8

flunisolide, 17

Glucagen Hypokit, 9

Estring, 11

Flunisolide, 17

Glucagon Emergency Kit, 9

Estrogel, 8

fluocinolone acetonide, 7, 16

Glumetza, 9

estropipate, 8

fluocinolone acetonide ear drops, 16

glyburide, 9

Estropipate, 8

fluocinonide, 7

Glyburide, 9

ethambutol HCL, 1

fluorometholone, 15

glyburide micronized, 9

ethosuximide, 14

fluorouracil, 3

glyburide/metformin HCL, 9

Ethyl Chloride, 7

fluoxetine DR, 13

glycopyrrolate, 10

Ethyl Chloride/Fine Pinpoint, 7

fluoxetine HCL, 13

Glyset, 9

Ethyl Chloride/Fine Stream, 7

Fluoxetine HCL, 13

Golytely, 10

Ethyl Chloride/Medium Jet Stream, 7

Fluphenazine Decanoate, 13

Gralise, 14

Ethyl Chloride/Medium Stream, 7

fluphenazine HCL, 13

Gralise Starter, 14

Ethyl Chloride/Mist, 7

Fluphenazine HCL, 13

granisetron HCL, 11

Etidronate Disodium, 9

flurazepam HCL, 13

Granisol, 11

etodolac, 16

flurbiprofen, 16

griseofulvin microsize, 1

etodolac ER, 16

flurbiprofen sodium, 15

griseofulvin ultramicrosize, 1

Eurax, 7

flutamide, 3

guanfacine HCL, 5

Evamist, 8

fluticasone propionate, 7, 17

Gynazole-1, 11

Evista, 9

fluvastatin, 6

H

Exelon, 14

fluvoxamine maleate, 13

Halaven, 3

exemestane, 3

FML, 15

Halflytely Bowel Prep/Flavor Packs, 10

Exforge, 5

Focalin XR, 13

Halfprin, 16

Exforge HCT, 5

Folbecal, 18

halobetasol propionate, 7

Extavia, 14

folic acid, 12

Halog, 7

F

Folic Acid, 12

haloperidol, 13

folic acid/vitamin b-6/vitamin b-12, 12

Factive, 1

haloperidol decanoate, 13

fondaparinux sodium, 12

famciclovir, 1

haloperidol lactate, 13

Foradil Aerolizer, 18

famotidine, 10

Hectorol, 10

Forfivo XL, 13

Famotidine Premixed, 11

Hematogen Fa, 12

Forteo, 9

Fanapt, 13

heparin lock, 12

Fortesta, 8

Fareston, 3

heparin lock flush, 12

Fortical, 9

Faslodex, 3

Heparin Lock Flush, 12

Fosamax Plus D, 9

Fazaclo, 13

heparin lock flush for flushing vascular access devices, 12

fosinopril sodium, 5

felbamate, 14

fosinopril sodium/hydrochlorothiazide, 5

felodipine ER, 4

heparin lock flush/NACL for flushing vascular access devices, 12

Fosrenol, 11

fenofibrate, 6

Fragmin, 12

fenofibrate micronized, 6

heparin sodium, 12

Frenadol, 16

Fenofibric Acid, 6

Heparin Sodium, 12

Frova, 17

fenofibric acid DR, 6

heparin sodium dcu, 12

furosemide, 5

Fenoglide, 6

heparin sodium lock flush, 12

Furosemide, 5

fenoldopam mesylate, 5

heparin sodium/D5W, 12

Fusilev, 4

Fenoprofen Calcium, 17

Heparin Sodium/NACL 0.45%, 12

G

fentanyl, 16

heparin sodium/NACL 0.9%, 12

Ferriprox, 19

gabapentin, 14

heparin sodium/sodium chloride 0.9% premix, 12

ferrous drops, 12

Gabitril, 14

ferrous gluconate, 12

galantamine, 14

homatropine HBR, 15

ferrous sulfate, 12

galantamine hydrobromide, 14

Horizant, 14

fexofenadine HCL, 17

ganciclovir, 2

Humalog, 8

Humalog Kwikpen, 8

Imitrex, 17

L

Humalog Mix 50/50, 8

Incivek, 2

labetalol HCL, 4

Humalog Mix 50/50 Kwikpen, 8

Increlex, 10

Lacrisert, 15

Humalog Mix 75/25, 8

indapamide, 5

lactic acid, 7

Humalog Mix 75/25 Kwikpen, 8

indomethacin, 17

lactic acid e, 7

Humatrope, 9

indomethacin ER, 17

lactic acid w/vitamin e, 7

Humatrope Combo Pack, 9

Infergen, 2

lactulose, 10, 11

Humira, 17

Inlyta, 3

Lamictal, 14

Humira Pen, 17

Innopran XL, 4

Lamictal Odt, 14

Humira Pen-crohns Diseasestarter, 17

Integrilin, 12

Lamictal Starter/Not Taking Carbamazepine, 14

Humira Pen-psoriasis Starter, 17

Intelence, 2

Humulin 70/30, 8

Intermezzo, 13

Lamictal Starter/Taking Carbamazepine/Not Taking Valproate, 14

Humulin 70/30 Pen, 8

Intron-a, 4

Humulin N, 8

Intron-a W/Diluent, 4

Humulin N U-100 Pen, 8

Intuniv, 13

Lamictal Starter/Taking Valproate, 14

Humulin R, 8

Invega, 13

lamivudine, 2

Humulin R U-500 (concentrated), 8

Invega Sustenna, 13

lamivudine/zidovudine, 2

Hyalex, 18

Invirase, 2

lamotrigine, 14

hydralazine HCL, 5

Iopidine, 15

lamotrigine ER, 14

hydrochlorothiazide, 5

ipratropium bromide, 17, 18

lansoprazole, 10

hydrocodone bitartrate/acetaminophen, 16

ipratropium bromide/albuterol sulfate, 18

lansoprazole/amoxicillin/clarithromycin, 10

irbesartan, 5

Hydrocodone Bitartrate/Acetaminophen, 16

irbesartan/hydrochlorothiazide, 5

Lantus, 8

irinotecan, 4

Lantus Solostar, 8

hydrocodone bitartrate/homatropine methylbromide, 17

iron, 12

Lastacaft, 16

Isentress, 2

latanoprost, 15

hydrocodone polistirex and chlorpheniramine polistirex, 17

isoniazid, 1

Latuda, 13

Isoniazid, 1

Lavoclen-4 Creamy Wash, 6

hydrocodone polistirex/chlorpheniramine polistirex, 17

Isopto Carbachol, 15

Lavoclen-8 Creamy Wash, 6

isosorbide dinitrate, 4

Lazanda, 16

hydrocodone/acetaminophen, 16

Isosorbide Dinitrate, 4

leflunomide, 17

Hydrocodone/Acetaminophen, 16

isosorbide dinitrate ER, 4

Lescol XL, 6

hydrocodone/homatropine, 17

isosorbide mononitrate, 4

Letairis, 6

hydrocodone/ibuprofen, 16

isosorbide mononitrate ER, 4

letrozole, 3

hydrocort ene 100MG, 11

Isradipine, 4

leucovorin calcium, 4

hydrocortisone, 7, 8, 11

Istalol, 15

Leucovorin Calcium, 4

hydrocortisone acetate/aloe, 7

Istodax, 4

Leukeran, 2

hydrocortisone acetate/pramoxine, 11

J

Leukine, 12

hydrocortisone butyrate, 7

Jakafi, 3

leuprolide acetate, 3

Hydrocortisone Butyrate (lipid), 7

Janumet, 9

levalbuterol, 18

hydrocortisone IN absorbase, 7

Janumet XR, 9

levalbuterol HCL, 18

hydrocortisone maximum strength, 7

Januvia, 9

Levatol, 4

hydrocortisone valerate, 7

Jentadueto, 9

Levemir, 8

hydrocortisone/acetic acid, 16

Jinteli, 8

Levemir Flexpen, 8

hydromorphone HCL, 16

Juvisync, 9

levetiracetam, 14

Hydromorphone HCL, 16

K

Levetiracetam, 14

Hydroxocobalamin, 12

levetiracetam ER, 14

hydroxychloroquine sulfate, 2

K-pax Immune Support Formula Professional Strength, 18

levobunolol HCL, 15

hydroxyurea, 4

Levobunolol HCL, 15

hydroxyzine HCL, 12

Kadcyla, 3

levocarnitine, 10

Hydroxyzine HCL, 12

Kalbitor, 12

levofloxacin, 1, 15

hydroxyzine pamoate, 12

Kaletra, 2

levonorgestrel, 8

Hydroxyzine Pamoate, 12

Kalydeco, 18

levonorgestrel/ethinyl estradiol, 8

hyoscyamine sulfate, 10

Kapvay, 13

Levorphanol Tartrate, 16

hyoscyamine sulfate ER, 10

Kapvay Dose Pack, 13

levothyroxine sodium, 10

hyoscyamine sulfate odt, 10

Kenalog, 7

Levothyroxine Sodium, 10

hyoscyamine sulfate SR, 10

Kepivance, 4

Lexiva, 2

I

Ketek, 2

lidocaine, 7

ketoconazole, 1, 6

ibandronate sodium, 9

lidocaine HCL, 7, 12

ketoprofen, 17

ibuprofen, 16

Lidocaine HCL, 8

Ketoprofen ER, 17

ibutilide fumarate, 5

lidocaine HCL jelly, 7

ketorolac tromethamine, 16, 17

Icaps Areds Formula, 18

Lidocaine HCL-hydrocortisone Acetate With Aloe, 11

Kineret, 17

Icaps Plus, 18

Kombiglyze XR, 9

Iclusig, 3

lidocaine HCL/hydrocortisone acetate, 11

Kristalose, 10

idarubicin HCL, 3

Lidocaine HCL/Hydrocortisone Acetate, 11

Kyprolis, 3

imipramine HCL, 13

imipramine pamoate, 13

lidocaine viscous, 12

imiquimod, 7

lidocaine/prilocaine, 7

lindane, 7

Mestinon, 15

Moxeza, 15

Linzess, 11

Mestinon Timespan, 15

Mozobil, 12

liothyronine sodium, 10

Metaproterenol Sulfate, 18

Mst 600, 16

Lipofen, 6

metaxalone, 14

Multaq, 5

lisinopril, 5

metformin HCL, 9

Multi-betic, 18

lisinopril/hydrochlorothiazide, 5

metformin HCL ER, 9

Multi-betic Diabetes, 18

lithium carbonate, 13

methadone HCL, 16

mupirocin, 6

lithium carbonate ER, 13

Methadone HCL, 16

mupirocin calcium, 6

Lithium Citrate, 13

methamphetamine HCL, 13

Muse, 6

Livalo, 6

methenamine hippurate, 11

Mustargen, 2

LO Loestrin FE, 8

Methenamine Mandelate, 11

Mycobutin, 1

Locoid, 7

methimazole, 10

mycophenolate mofetil, 3

Locoid Lipocream, 7

methocarbamol, 14

Myfortic, 3

Lodosyn, 14

methotrexate, 3

Myleran, 2

Loestrin 24 FE, 8

methotrexate sodium, 3

Myrbetriq, 11

Lomustine, 2

methscopolamine bromide, 10

Mytelase, 15

loperamide HCL, 10

Methyclothiazide, 5

N

loratadine, 17

methyldopa, 5

nabumetone, 17

lorazepam, 12

Methyldopate HCL, 5

nadolol, 4

Lorzone, 14

methylergonovine maleate, 16

nadolol/bendroflumethiazide, 5

losartan potassium, 5

methylphenidate HCL, 13

Naftin, 6

losartan potassium/hydrochlorothiazide, 5

methylphenidate HCL CD, 13

nalbuphine HCL, 16

methylphenidate HCL ER, 13

Namenda, 14

Lotemax, 15

Methylphenidate HCL ER, 13

Namenda Titration PAK, 14

Lotrimin Ultra, 6

methylphenidate HCL SR, 13

Naphazoline HCL, 15

Lotronex, 11

methylphenidate hydrochloride, 13

Naprelan, 17

lovastatin, 6

methylprednisolone, 8

naproxen, 17

Lovaza, 6

methylprednisolone dose pack, 8

naproxen sodium, 17

loxapine, 13

metipranolol, 15

naratriptan HCL, 17

loxapine succinate, 13

metoclopramide HCL, 11

nasal mist, 17

Lufyllin, 18

metolazone, 5

Nasonex, 17

Lumigan, 15

metoprolol succinate ER, 4

Natacyn, 15

Lunesta, 13

metoprolol tartrate, 4

nateglinide, 9

Lupron Depot, 3

metoprolol/hydrochlorothiazide, 5

Natroba, 8

Lupron Depot-PED, 9

metronidazole, 2, 6

Nature-throid, 10

Lyrica, 14

metronidazole vaginal, 11

Nebupent, 2

Lysodren, 3

mexiletine HCL, 4

nefazodone HCL, 13

M

Miacalcin, 9

Nefazodone HCL, 13

Micardis, 5

M.v.i. Adult, 18

neomycin sulfate, 1

Micardis HCT, 5

M.v.i. Pediatric, 18

neomycin/bacitracin/polymyxin, 15

miconazole, 6

M.v.i.-12 Without Vitamin K, 18

neomycin/polymyxin/bacitracin zinc, 15

miconazole nitrate, 6

Makena, 8

neomycin/polymyxin/bacitracin/hydrocortisone, 15

midodrine HCL, 5

Malarone, 2

Migranal, 17

malathion, 7

neomycin/polymyxin/dexamethasone, 15

Millipred, 8

mannitol, 5

neomycin/polymyxin/gramicidin, 15

Millipred DP, 8

Maprotiline HCL, 13

neomycin/polymyxin/HC, 16

Minivelle, 8

Marplan, 13

Neomycin/Polymyxin/Hydrocortisone, 15

minocycline HCL, 1

Matulane, 4

neomycin/polymyxin/hydrocortisone, 16

minocycline HCL ER, 1

Maxair Autohaler, 18

Neulasta, 12

minoxidil, 5

meclizine HCL, 11

Neumega, 12

Mirapex ER, 14

Meclofenamate Sodium, 17

Neupogen, 12

mirtazapine, 13

medroxyprogesterone acetate, 8(2)

Neupro, 14

mirtazapine odt, 13

mefloquine HCL, 2

Nevanac, 16

misoprostol, 10

Mefoxin, 1

nevirapine, 2

mitomycin, 3

megestrol acetate, 3

Nevirapine, 2

mitoxantrone HCL, 3

meloxicam, 17

Nexavar, 3

Mobic, 17

Meloxicam, 17

niacin, 18

modafinil, 13

Menest, 8

Niacin TR, 18

moexipril HCL, 5

Mentax, 6

Niacor, 6

moexipril/hydrochlorothiazide, 5

meperidine HCL, 16

Niaspan, 6

mometasone furoate, 7

Meperidine HCL, 16

nicardipine HCL, 4

montelukast sodium, 18

Mephyton, 18

Nicazel, 18

Monurol, 11

meprobamate, 12

nicotinamide w/zinc oxide/cupric oxide/folic acid, 18

morphine sulfate, 16

Mepron, 2

Morphine Sulfate, 16

mercaptopurine, 3

nicotinamide/zinc oxide/cupric oxide/folic acid, 18

Morphine Sulfate Add-vantage, 16

mesalamine, 11

Motofen, 10

mesna, 4

nicotinamide/zinc/copper/fa, 18

Moviprep, 10

Mesnex, 4

nicotine, 14

nicotine polacrilex, 14

olanzapine, 13

peg 3350/electrolytes, 10

nicotine polacrilex refill, 14

olanzapine odt, 13

peg-3350/electrolytes, 10

nicotine polacrilex starter kit, 14

olanzapine/fluoxetine, 14

peg-3350/NACL/NA bicarbonate/KCL, 10

nicotine transdermal system, 14

omeprazole, 10

Peg-intron, 2

Nicotrol Inhaler, 14

omeprazole/sodium bicarbonate, 10

Peg-intron Redipen, 2

Nicotrol Ns, 14

Omnitrope, 9

Peg-intron Redipen PAK 4, 2

nifedipine, 4

Omontys, 12

Peganone, 14

nifedipine ER, 4

Oncaspar, 3

Pegasys, 2

nimodipine, 4

Oncovite, 19

Pegasys Proclick, 2

nisoldipine, 4

ondansetron HCL, 11

penicillin v potassium, 1

Nisoldipine, 4

ondansetron odt, 11

Pentam 300, 2

Nisoldipine ER, 4

One-a-day Energy, 19

Pentasa, 11

Nitro-bid, 4

One-a-day Menopause Formula, 19

pentazocine/acetaminophen, 16

Nitro-dur, 4

One-a-day Mens 50+ Advantage, 19

pentazocine/naloxone HCL, 16

nitrofurantoin, 11

One-a-day Mens Health Formula, 19

Pentetate Calcium Trisodium, 19

nitrofurantoin macrocrystal, 11

One-a-day Mens Pro Edge, 19

Pentetate Zinc Trisodium, 19

nitrofurantoin macrocrystalline, 11

One-a-day Teen Advantage For Him, 19

pentostatin, 4

nitrofurantoin macrocrystals, 11

Onglyza, 9

pentoxifylline ER, 12

nitroglycerin, 4

Onsolis, 16

Perforomist, 18

Nitroglycerin, 4

Opana ER (crush Resistant), 16

perindopril erbumine, 5

Nitroglycerin Lingual, 4

Oracea, 6

permethrin, 7

nitroglycerin transdermal, 4

Oracit, 11

perphenazine, 13

Nitrolingual Pumpspray, 4

Orap, 14

Perphenazine/Amitriptyline, 14

Nitromist, 4

Orapred Odt, 8

phenazopyridine HCL, 11

Nitrostat, 4

Oravig, 12

phenelzine sulfate, 13

nizatidine, 10

Orfadin, 10

phenobarbital, 13

Norditropin Cartridge, 9

orphenadrine citrate, 14

Phenobarbital, 13

Norditropin Flexpro, 9

orphenadrine citrate ER, 14

phenobarbital sodium, 13

Norditropin Nordiflex Pen, 9

orphenadrine/asa/caffeine, 14

Phenobarbital Sodium, 13

norepinephrine bitartrate, 6

Osmoprep, 10

phenylephrine/guaifenesin, 17

norethindrone, 8

Ovace Plus, 7

phenytoin, 14

norethindrone acetate, 8

oxaliplatin, 2

phenytoin sodium, 14

norgestimate/ethinyl estradiol, 8

oxaprozin, 17

phenytoin sodium extended, 14

norgestrel/ethinyl estradiol, 8

oxazepam, 12

Phoslyra, 11

Noroxin, 1

oxcarbazepine, 14

Phospholine Iodide, 15

Norpace CR, 5

Oxecta, 16

phytonadione, 18

nortriptyline HCL, 13

Oxistat, 6

pilocarpine HCL, 12, 15

Nortriptyline HCL, 13

Oxsoralen, 8

pilocarpine hydrochloride, 12

Norvir, 2

Oxsoralen Ultra, 7

Pilopine HS, 15

Novolin 70/30, 8

oxybutynin chloride, 11

Pindolol, 4

Novolin 70/30 Relion, 8

oxybutynin chloride ER, 11

pioglitazone HCL, 9

Novolin N, 8

oxycodone HCL, 16

pioglitazone HCL-glimepiride, 9

Novolin N Relion, 8

oxycodone/acetaminophen, 16

pioglitazone HCL/metformin HCL, 9

Novolin R, 8

oxycodone/aspirin, 16

piroxicam, 17

Novolin R Relion, 8

oxycodone/ibuprofen, 16

podofilox, 7

Novolog, 8

oxymorphone hydrochloride ER, 16

polyethylene glycol 3350, 10

Novolog Flexpen, 8

oxytocin, 16

polyethylene glycol 3350-grx, 10

Novolog Mix 70/30, 8

Oxytrol, 11

polymyxin b sulfate/trimethoprim sulfate, 15

Novolog Mix 70/30 Prefilled Flexpen, 8

P

Novolog Penfill, 8

Pomalyst, 3

paclitaxel, 3

Nucynta ER, 16

Potassium Citrate, 11

pamidronate disodium, 9

Nuedexta, 14

potassium citrate/citric acid, 11

Pamidronate Disodium, 9

Nutricap, 19

Potiga, 14

Panoxyl-4 Creamy Wash, 6

Nutropin, 9

Pradaxa, 12

Panoxyl-8 Creamy Wash, 6

Nutropin AQ, 9

pramipexole dihydrochloride, 14

pantoprazole sodium, 10

Nutropin AQ Nuspin 10, 9

Pramosone, 7

papaverine HCL, 6

Nutropin AQ Nuspin 20, 9

Prandimet, 9

Paregoric, 10

Nutropin AQ Nuspin 5, 9

pravastatin sodium, 6

paroxetine HCL, 13

Nutropin AQ Pen, 9

prazosin HCL, 5

paroxetine HCL ER, 13

Nuvigil, 13

Pred Mild, 15

Pataday, 16

nystatin, 1, 6, 12

prednicarbate, 7

Patanase, 17

Nystatin Vaginal, 11

prednisolone, 8

Patanol, 16

nystatin/triamcinolone, 6

prednisolone acetate, 15

Paxil, 13

Nystatin/Triamcinolone, 6

prednisolone sodium phosphate, 8

PCE, 1

O

Prednisolone Sodium Phosphate, 8, 15

Pediaderm HC, 7

prednisone, 8

octreotide acetate, 10

Pediaderm Ta, 7

Prednisone, 8

Ocudox, 1

Pedipirox-4 Nail, 6

Prednisone Intensol, 8

ofloxacin, 1, 15, 16

peg 3350, 10

Premarin, 8

ranitidine HCL, 10

Samsca, 10

Premphase, 8

Rapaflo, 11

Sancuso, 11

Prempro, 8

Rapamune, 3

Sandimmune, 3

Prepopik, 10

Rayos, 8

Sandostatin Lar Depot, 10

Prevacid Solutab, 10

Rebetol, 2

Saphris, 13

Prezista, 2

Rebif, 14

Savella, 14

Primaquine Phosphate, 2

Rebif Rebidose, 14

selegiline HCL, 14

primidone, 14

Rebif Rebidose Titration Pack, 14

selenium sulfide, 7

Primsol, 2

Rebif Titration Pack, 14

Selzentry, 2

Pristiq, 13

Rectiv, 11

Sensipar, 10

Pro-CAL, 19

Regonol, 15

Serevent Diskus, 18

Proair HFA, 18

Relenza Diskhaler, 2

Seroquel XR, 13

probenecid, 17

Relion N, 8

Serostim, 10

probenecid/colchicine, 17

Relion N Innolet, 8

sertraline HCL, 13

Procainamide HCL, 5

Relion R, 8

Siderol, 19

Procerv HP, 19

Relpax, 17

sildenafil citrate, 6

prochlorperazine, 13

Remodulin, 6

Silenor, 13

Prochlorperazine Edisylate, 13

Renagel, 11

Simcor, 6

prochlorperazine maleate, 13

Renaplex-d, 19

Simulect, 3

Procrit, 12

Renvela, 11

simvastatin, 6

Proctofoam HC, 11

repaglinide, 9

Sklice, 8

Proglycem, 9

Replesta, 18

sodium chloride, 17

Prograf, 3

Replesta Childrens, 18

Sodium Edecrin, 5

Proleukin, 4

Replesta Nx, 18

sodium hyaluronate, 7

Prolia, 9

Req 49+, 19

sodium sulfacetamide, 6, 15

promethazine HCL, 17

Rescon-JR, 17

sodium sulfacetamide wash, 7

promethazine HCL plain, 17

Rescriptor, 2

sodium sulfacetamide/sulfur, 6

promethazine-DM, 17

Reserpine, 5

Sodium Sulfacetamide/Urea, 7

promethazine/codeine, 17

Respa-BR, 17

Soliris, 12

promethazine/dextromethorphan, 17

Retin-a Micro, 6

Solodyn, 1

Promethegan, 17

Retin-a Micro P.M., 6

Soltamox, 3

propafenone HCL, 4

Revatio, 6

Solu-cortef, 8

propafenone HCL ER, 4

Revlimid, 3

Somatuline Depot, 10

Propantheline Bromide, 10

Reyataz, 2

Somavert, 10

proparacaine HCL, 15

Rezira, 17

sotalol HCL, 4

Propranolol HCL, 4

Rheumatrex, 17

Sotalol Hydrochloride, 4

propranolol HCL, 4

Rhinocort Aqua, 17

Spinosad, 8

propranolol HCL ER, 4

Rhinoflex-650, 16

Spiriva Handihaler, 18

Propranolol/Hydrochlorothiazide, 5

Ribapak, 2

spironolactone, 5

propylthiouracil, 10

Ribasphere, 2

spironolactone/hydrochlorothiazide, 5

Protamine Sulfate, 12

Ribatab, 2

Sprix, 17

Protopic, 7

ribavirin, 2

Sprycel, 3

Proventil HFA, 18

Ridaura, 17

stannous fluoride oral rinse, 12

Prudoxin, 7

Rifamate, 1

stavudine, 2

Pulmicort, 18

rifampin, 1

Stavzor, 14

Pulmicort Flexhaler, 18

Rifater, 1

Stelara, 7

Pulmozyme, 18

Right Step Prenatal, 19

Stimate, 10

pyrazinamide, 1

riluzole, 14

Stivarga, 3

pyridostigmine bromide, 15

rimantadine HCL, 2

Strattera, 13

Pyridoxine HCL, 18

Riomet, 9

Stribild, 2

Pyrogallic Acid, 7

risperidone, 13

Strovite One, 19

Q

risperidone odt, 13

Suboxone, 16

Rituxan, 3

Subsys, 16

Qnasl, 17

rivastigmine tartrate, 14

Sucraid, 11

quetiapine fumarate, 13

rizatriptan benzoate, 17

sucralfate, 10

Quillivant XR, 13

rizatriptan benzoate odt, 17

sulfacetamide sodium, 6, 15

quinapril HCL, 5

ropinirole ER, 14

Sulfacetamide Sodium, 15

quinapril/hydrochlorothiazide, 5

ropinirole HCL, 14

sulfacetamide sodium/prednisolone sodium phosphate, 15

Quinidine Gluconate, 5

Rozerem, 13

quinidine gluconate CR, 5

Rybix Odt, 16

Sulfadiazine, 1

quinidine gluconate ER, 5

S

sulfamethoxazole/trimethoprim, 2

quinidine sulfate, 5

Sulfamethoxazole/Trimethoprim, 2

Quinidine Sulfate ER, 5

Sabril, 14

sulfamethoxazole/trimethoprim DS, 2

quinine sulfate, 2

Safyral, 8

sulfasalazine, 11

Qvar, 18

Saizen, 10

sulindac, 17

R

Saizen Click.easy, 10

Sumatriptan, 17

salicylic acid, 7

sumatriptan succinate, 17

ramipril, 5

Salicylic Acid, 7

sumatriptan succinate refill, 17

Ranexa, 4

salsalate, 16

Sumavel Dosepro, 17

ticlopidine HCL, 12

Tudorza Pressair, 18

Suprax, 1

Timolol Maleate, 4

Tussicaps, 17

Suprep Bowel Prep, 10

timolol maleate, 15

Twinject, 5

Sustiva, 2

timolol maleate ophthalmic gel forming, 15

Twynsta, 5

Sutent, 3

Tygacil, 2

Sylatron, 4

tinidazole, 2

Tykerb, 4

Symbicort, 18

tizanidine HCL, 14

Tyvaso, 6

Symlinpen 120, 9

Tobradex, 15

Tyvaso Refill, 6

Symlinpen 60, 9

Tobradex ST, 15

Tyvaso Starter, 6

Synera, 8

tobramycin sulfate, 15

Tyzeka, 2

Synribo, 4

tobramycin/dexamethasone, 15

Tyzine, 17

T

Tobrex, 15

Tyzine Pediatric Nasal Drops, 17

tolazamide, 9

U

Tabloid, 3

Tolazamide, 9

Taclonex, 7

Ultravate PAC, 7

Tolbutamide, 9

tacrolimus, 3

Uramaxin, 7

tolmetin sodium, 17

Talwin, 16

urea, 7

Tolmetin Sodium, 17

Tamiflu, 2

urea 40% nail film, 7

tolterodine tartrate, 11

tamoxifen citrate, 3

urea IN zinc undecylenate/lactic acid vehicle, 7

Topicort, 7

tamsulosin HCL, 11

topiramate, 14

Tandem F, 12

urea topical, 7

torsemide, 5

Tarceva, 3

Urocit-k 10, 11

Totect, 4

Targretin, 4

Urocit-k 15, 11

Toviaz, 11

Tarka, 5

Urocit-k 5, 11

Tradjenta, 9

Taron-prex, 18

ursodiol, 11

tramadol HCL, 16

Tasigna, 3

V

tramadol HCL ER, 16

Tasmar, 14

Tramadol HCL ER, 16

Vagifem, 11

Taxotere, 3

tramadol hydrochloride/acetaminophen, 16

valacyclovir HCL, 2

Tazorac, 7

Valcyte, 2

Tegretol-XR, 14

trandolapril, 5

valproate sodium, 14

Tekamlo, 5

tranexamic acid, 12

valproic acid, 14

Tekturna, 5

tranylcypromine sulfate, 13

valsartan/hydrochlorothiazide, 5

Tekturna HCT, 5

Travatan Z, 15

Valturna, 5

temazepam, 13

trazodone HCL, 13

vancomycin HCL, 2

Tencon, 16

Treanda, 2

Vancomycin HCL, 2

terazosin HCL, 5

Trelstar Depot, 3

Vandetanib, 4

terbinafine HCL, 1

Trelstar Depot Mixject, 3

Vanos, 7

Terbinex, 1

Trelstar LA, 3

Vantas, 3

terbutaline sulfate, 18

Trelstar LA Mixject, 3

Vascepa, 6

terconazole, 11

Trelstar Mixject, 3

vasopressin, 10

testosterone cypionate, 8

Tretin-x, 6

Vectical, 7

tetracaine HCL, 15

tretinoin, 4, 6

Velcade, 4

Tetracycline HCL, 1

Tretinoin Microsphere, 6

Veletri, 6

Tev-tropin, 10

Tretinoin Microsphere P.M., 6

Veltin, 6

Texacort, 7

Trexall, 3

venlafaxine HCL, 13

Thalomid, 3

Treximet, 17

venlafaxine HCL ER, 13

Theo-24, 18

Trezix, 16

Venlafaxine HCL ER, 13

theophylline, 18

triamcinolone acetonide, 7, 12, 17

Ventavis, 6

theophylline CR, 18

Triamcinolone Acetonide, 7

Ventolin HFA, 18

theophylline ER, 18

triamcinolone IN orabase, 12

Veramyst, 17

Thera M Plus, 19

triamterene/hydrochlorothiazide, 5

verapamil HCL, 4

Thera-d 4000, 18

Trianex, 7

Verapamil HCL, 4

Therabetic Multi-vitamin, 19

triazolam, 13

verapamil HCL ER, 4

Theragran-m, 19

Tribenzor, 5

verapamil HCL SR, 4

Theragran-m Advanced, 19

Tricitrates, 11

Verdeso, 7

Theragran-m Advanced 50 Plus, 19

trifluoperazine HCL, 13

Veregen, 8

Theragran-m Premier, 19

trifluridine, 15

Veripred 20, 8

Theragran-m Premier 50 Plus, 19

Triglide, 6

Vesicare, 11

Therems-h, 19

trimethobenzamide HCL, 11

Vexol, 15

Therems-m, 19

trimethoprim, 2

Victoza, 9

thiamine HCL, 18

trimethoprim sulfate/polymyxin b sulfate, 15

Victrelis, 2

thiothixene, 13

Vidaza, 3

Thymoglobulin, 3

trimipramine maleate, 13

Videx Pediatric, 2

Thyrolar-1, 10

Trisenox, 4

Vigamox, 15

Thyrolar-1/2, 10

Trizivir, 2

Viibryd, 13

Thyrolar-1/4, 10

trospium chloride, 11

Vinblastine Sulfate, 3

Thyrolar-2, 10

trospium chloride ER, 11

vincristine sulfate, 3

Thyrolar-3, 10

Truvada, 2

vinorelbine tartrate, 3

tiagabine hydrochloride, 14

Viracept, 2

Zonalon, 7

Viramune, 2

zonisamide, 14

Viramune XR, 2

Zorbtive, 10

Virazole, 2

Zortress, 3

Viread, 2

Zovirax, 6

Visicol, 10

Zuplenz, 11

Vitaline Total Formula 2, 19

Zutripro, 17

Vitaline Total Formula 3, 19

Zyclara, 7

vitamin c 222MG, 18

Zyclara P.M., 7

vitamin d, 18

Zyflo, 18

Vitamin D, 18

Zyflo CR, 18

vitamin d 400, 18

Zylet, 15

vitamin d-1000, 18

Zymaxid, 15

vitamin d-3, 18

Zytiga, 3

vitamin d3, 18

Zyvox, 2

Vitamin D3, 18

8

Vitamin D3 400, 18

8-mop, 7

vitamin k1, 18

Vitasana, 19

Vivelle-dot, 8

Voltaren, 7

Voraxaze, 4

Votrient, 4

Vytorin, 6

W

warfarin sodium, 12

Welchol, 6

Westhroid, 10

Westhroid-p, 10

Wp Thyroid, 10

X

Xalkori, 4

Xarelto, 12

Xeloda, 3

Xenazine, 14

Xolair, 18

Xolegel, 6

Xopenex HFA, 18

Xyrem, 14

Y

Yelets Teenage Formula, 19

Yodoxin, 2

Z

zafirlukast, 18

zaleplon, 13

Zamicet, 16

Zegerid, 10

Zemplar, 10

Zenpep, 11

Zetia, 6

Zetonna, 17

Ziagen, 2

Ziana, 6

zidovudine, 2

Zioptan, 15

ziprasidone HCL, 13

Zirgan, 15

Zithromax, 1

Zoladex, 3

Zolinza, 4

zolmitriptan, 17

zolmitriptan odt, 17

zolpidem tartrate, 13

zolpidem tartrate ER, 13

Zomig, 17

Zomig ZMT, 17