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© 2019 United HealthCare Services, Inc. All rights reserved.
Preferred Drug List (PDL)Ohio Effective Date: 1/1/19
UnitedHealthcare Community Plan of Ohio, Inc. no discrimina por motivos de sexo, edad, raza, color, discapacidad o nacionalidad.
Si considera que no hemos proporcionado estos servicios o hemos discriminado de otro modo en función del sexo, la edad, la raza, el color, la discapacidad o la nacionalidad, puede enviar una reclamación al Coordinador de derechos civiles.o En línea: [email protected] Por correo postal: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance.
P.O. Box 30608, Salt Lake City, UT 84130
Debe enviar la reclamación dentro de un plazo de 60 días desde que se enteró de la situación. Se le enviará una decisión dentro de un plazo de 30 días. Si no está de acuerdo con la decisión, tiene 15 días para pedirnos que analicemos la situación nuevamente. Si necesita ayuda con su reclamación, llame al 1-800-895-2017 (TTY 711), de 7 a. m. a 7 p. m., de lunes a viernes (correo de voz disponible las 24 horas del día, los 7 días de la semana).
También puede presentar una reclamación ante el Departamento de Salud y Servicios Humanos de los EE. UU. (U.S. Department of Health and Human Services).o En línea: https://ocrportal.hhs.gov/ocr/portal/lobby.jsfLos formularios de reclamación están disponibles en http://www.hhs.gov/ocr/office/file/index.html.o Por teléfono: línea gratuita 1-800-368-1019, 800-537-7697 (TDD)o Por correo postal: U.S. Dept. of Health and Human Services. 200 Independence Avenue,
SW Room 509F, HHH Building Washington, D.C. 20201
Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros, como cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para solicitar ayuda, llame a 1-800-895-2017 (TTY 711), de 7 a. m. a 7 p. m., de lunes a viernes (correo de voz disponible las 24 horas del día, los 7 días de la semana).
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call 1-800-895-2017, TTY 711.
ATENCIÓN: si habla español (Spanish), tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-895-2017, TTY 711.
注意:如果您說中文 (Chinese),您可獲得免費語言協助服務。請致電 1-800-895-2017,或聽障專線 (TTY) 711。
LƯU Ý: Nếu quý vị nói Tiếng Việt (Vietnamese), chúng tôi có các dịch vụ hỗ trợ ngôn ngữ miễn phí cho quý vị. Vui lòng gọi số 1-800-895-2017, TTY 711.
참고: 한국어(Korean)를 하시는 경우, 통역 서비스를 무료로 이용하실 수 있습니다. 1-800-895-2017, TTY 711 로 전화하십시오.
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CSOH15MC4045309_000
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تنبيه: إذا كنت تتحدث العربية (Arabic)، تتوفر لك خدمات المساعدة اللغوية مجاًنا. اتصل على الرقم 2017-895-800-1، الهاتف النصي 711.
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ATTENZIONE: se parla italiano (Italian), Le vengono messi gratuitamente a disposizione servizi di assistenza linguistica. Chiami il numero 1-800-895-2017, TTY 711.
HINWEIS: Wenn Sie Deutsch (German) sprechen, stehen Ihnen kostenlose Sprachendienste zur Verfügung. Wählen Sie: 1-800-895-2017, TTY 711.
ご注意:日本語 (Japanese) をお話しになる場合は、言語支援サービスを無料でご利用いただけます。電話番号1-800-895-2017、またはTTY 711(聴覚障害者・難聴者の方用)までご連絡ください。
توجه: اگر زبان شما فارسی (Farsi) است، خدمات امداد زبانی به طور رایگان در اختیار شما می باشد. .TTY 711 ،2017-895-800-1 تماس بگیرید
ध्यान दें: ्दद आप हिन्दी (Hindi) भयाषया बोलत ेहैं तो भयाषया सहया्तया सेवयाएं आपके ललए ननःशुलक उपलब्ध हैं। कॉल करें 1-800-895-2017, TTY 711.
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D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné ЁNavajoЂ Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-895-2017, TTY 711.
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LET OP: Als u Nederlands (Dutch) spreekt, kunt u gratis gebruikmaken van taalhulpdiensten. Bel 1-800-895-2017, TTY 711.
WICHTIG: Wann du Deitsch schwetzscht (Pennsylvania Dutch) un Hilf witt mit Englisch, kenne mer dich helfe, unni as es dich ennich ebbes koschte zellt. Ruf 1-800-895-2017, TTY 711 aa.
ATENȚIE: Dacă vorbiți limba română (Romanian), aveți la dispoziție servicii de asistență lingvistică gratuite. Sunați la 1-800-895-2017, TTY 711.
УВАГА: Якщо ви не говорите українською (Ukrainian) мовою, ви можете скористатися безкоштовними послугами перекладача. Телефонуйте за номером 1-800-895-2017, TTY 711.
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INTRODUCTION UnitedHealthcare Community Plan is pleased to provide this Preferred Drug List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered by UnitedHealthcare Community Plan. The drugs listed in this PDL are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the UnitedHealthcare Community Plan PDL have been reviewed and approved by the UnitedHealthcare Community Plan Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the Medical prior authorization process.
The drugs represented have been reviewed by the UnitedHealthcare Community Plan Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice as of the date of review.
This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare Community Plan PDL is reflective of current medical practice.
NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare Community Plan, solely for the convenience of medical providers. UnitedHealthcare Community Plan does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature.
This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs.
UnitedHealthcare Community Plan 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.
National guidelines can be found on the Web sites listed in the Web site section or go to the National Guideline Clearinghouse site at http://www.guideline.gov.
The PDL and quarterly updates are also available on our web site at www.uhccommunityplan.com.
PREFACE The UnitedHealthcare Community Plan PDL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state.
Products are listed by generic name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing.
The UnitedHealthcare Community Plan PDL covers selected over-the-counter (OTC) products. Many are noted in the drug lists; a complete list is included on page 44. You are encouraged to prescribe OTC medications when clinically appropriate.
Preferred Drug List
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PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The UnitedHealthcare Community Plan P&T Committee includes physicians and pharmacists who are not employees or agents of UnitedHealthcare Community Plan or its affiliates. They must adhere to the Ethics Policy standards of the P&T Committee. UnitedHealthcare Community Plan medical directors and pharmacists also participate in the P&T Committee. UnitedHealthcare Community Plan’s P&T Committee meets quarterly to discuss a variety of issues. Those issues pertaining to pharmaceutical selection and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating physicians who have received UnitedHealthcare Community Plan’s PDL. PDL decisions are also communicated quarterly on the UnitedHealthcare Community Plan internet site.
OUTPATIENT PRESCRIPTION DRUG BENEFIT-COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Drug Benefits is based on the individual member’s benefit plan.
PRODUCT SELECTION CRITERIA The UnitedHealthcare Community Plan P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following:
• Safety• Efficacy• Comparison studies• Approved indications• Adverse effects• Contraindications/Warnings/Precautions• Pharmacokinetics• Patient administration/compliance considerations• Medical outcome and pharmacoeconomic
studiesWhen a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare Community Plan PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents.
All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.
PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the
PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered.
Products covered include all strengths associated with the dosage form of the cited brand name product.
carvedilol Coreg
All strengths of Coreg would be covered by this listing.
Extended-release and delayed-release products require their own entry.
diltiazem sustained release CARDIZEM SR
Dosage forms covered will be consistent with the category and use where listed.
Neomycin/polymyxin B/ Cortisporin Hydrocortisone
As listed in the OTIC section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the OPHTHALMIC and DERMATOLOGY sections of the PDL.
When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not
citalopram 40 mg tabs Celexa tabs
DRUG TIERS
The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.
Tier Name Drug Tier Tier 1 Generic Tier 2 Brand
GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires generic substitution on the majority of products when a generic equivalent is available.
Generic substitution is a pharmacy action whereby a generic equivalent is dispensed rather than the brand name product. The PDL indicates generic availability in the “Covered Drug” column.
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If a brand name drug is medically necessary, please submit a prior authorization request.
The UnitedHealthcare Community Plan MAC list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most generics but not branded versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA’s review and approval process. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand product. To gain FDA approval:
1. The generic drug must contain the same activeingredient(s), be the same strength and the same dosageform as the brand name product.
2. The FDA has given the generic an “A” rating comparedto the branded product indicating bioequivalence, andhas determined the generic is therapeutically equivalentto the reference brand. The ratings of generic drugs areavailable by referring to the FDA reference, ApprovedDrug Products with Therapeutic EquivalenceEvaluations (Orange Book).
When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand name product.
There are now many brand name products that are repackaged or distributed under a generic label. The generic label version should always be considered therapeutically equivalent and substitutable for the source branded product.
DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled
indications, and a determination of “fully effective” was made for most of these products and they remain in the marketplace. A few DESI products remain classified as “less than fully effective” while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare Community Plan’s PDL does not cover DESI “less than fully effective” drug products.
PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare Community Plan PDL.
• DESI drugs• Anti-obesity agents• Experimental / research drugs• Cosmetic drugs• Nutritional / diet supplements• Blood and blood plasma products• Agents used to promote fertility• Agents used for erectile dysfunction• Agents used for cosmetic hair growth• Drugs from manufacturers that do not participate
in the FFS Medicaid Drug Rebate Program• Diagnostic products• Medical supplies and DME except as listed:
insulin syringes, insulin needles, lancets, alcoholswabs, spacers, preferred diabetes test strips, peakflow meters (Astech, Assess, Peak Air brands,max two per year), vaporizer (limit of 1 per 3years), humidifier (limit of 1 per 3 years)
DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare Community Plan members may receive up to a one month supply of a specific medication per prescription order or prescription refill. A medication may be reordered or refilled when eighty-five percent (85%) of the medication has been utilized. If a claim is submitted before 85% of the medication has been used, based on the original day supply submitted on the claim, the claim will reject with a "refill too soon" message. Please call the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions or for help with dosage change authorization.
MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires mandatory generic substitution on the vast majority of products when a generic equivalent is available; however, brand name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare Community Plan PDL prior authorization (PA) list does not include branded items where a generic equivalent is covered.
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PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare Community Plan PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management.
Requests for these exceptions should be made in writing by the physician and faxed or mailed to:
UnitedHealthcare Community Plan Pharmacy Services Department Fax 866-940-7328 Phone 800-310-6826
A prior authorization request form is available in the UnitedHealthcare Community Plan provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical necessity of the non-PDL request. The UnitedHealthcare Community Plan Pharmacy Department will respond to all requests in accordance with state requirements.
Physicians are requested to adhere to this PDL when prescribing for patients covered by their pharmacy benefit plan offered by UnitedHealthcare Community Plan. If a pharmacist receives a prescription for a non-PDL drug, the pharmacist should contact the prescribing physician and request that the prescription be changed to a medication included in this PDL. If a PDL alternative is not appropriate the physician should then be instructed to contact the Plan for a prior authorization. Please contact the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions concerning the prior authorization process.
NON-PDL DRUGS 7-DAY AND 15-DAY OVERRIDES To ensure the use of PDL drugs, all non- PDL drugs should be discussed with the prescribing physician. If you cannot speak to the physician immediately, and there is an immediate need for the medication, the claim processing system will accept an override to permit a one-time dispensing of a 7-day supply of the newly prescribed non-PDL drug. The pharmacy should submit a claim for a 7 day supply, with a PA Type of 8 and Prior Authorization number of “00000000120”.
Please note that non-preferred drugs are available for a 7-day supply, however availability is subject to the benefit design. For assistance, pharmacies may call 800-310-6826.
Pharmacies may dispense a one-time, 15-day supply to members requiring an immediate supply of an ongoing medication. The pharmacist must contact the plan to obtain a manual 15-day override. Before the next dispensing, the pharmacy must contact the physician to discuss a PDL drug or if a prior authorization request is warranted. If the prescribing physician feels a drug is medically necessary, the physician may fax a request for prior authorization to UnitedHealthcare Community Plan at 866-940-7328, Attn: Pharmacy Department.
QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request.
Quantity limits based on Efficient Medication Dosing The Efficient Medication Dosing Program is designed to consolidate medication dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily. Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the physician.
Controlled Substances You may fill any FOUR medications from the following classes in a 30-day period:
• benzodiazepines• sedative hypnotic agents• barbiturates• select muscle relaxants
Additional fills will require prior authorization. Medications in these classes may also be subject to individual quantity limits.
Additions to the QL program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the medical exception (prior authorization) process. Please contact the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions.
Specialty Pharmaceutical Management Program UnitedHealthcare Community Plan is continuously looking for ways to provide high quality cost effective care for Plan members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare Community Plan to achieve these goals. Injectable medications that are part of this program require plan authorization and are not available through the retail pharmacy network.
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To obtain authorization, the provider must submit the appropriate Prior Authorization form to the UnitedHealthcare Community Plan Pharmacy Department via fax at 866-940-7328. The UnitedHealthcare Community Plan Pharmacy Department will review and respond to all requests in accordance with state requirements, and if authorized for payment, UnitedHealthcare Community Plan will coordinate the delivery of the product to the member or provider. Drugs that are part of this program and are on the PDL are identified in this booklet by the designation "SP". Prior Authorization request forms can be requested by calling the UnitedHealthcare Community Plan Pharmacy Department 800-310-6826.
MEDICATIONS REQUIRING DIAGNOSIS UnitedHealthcare Community Plan requires that the diagnosis for prescriptions in certain classes match the FDA-approved use or a use supported by current published evidence. Drugs in scope will list “Diagnosis required” in the Requirements and Limits section on the PDL.
The diagnosis will be verified at the point-of-sale by the pharmacy claims processing system. If a matching diagnosis is not found in the medical claim file or on the pharmacy drug claim, the prescription will be rejected at the pharmacy. The pharmacist may then contact the prescriber to verify the diagnosis and submit it on the claim.
If the diagnosis provided still does not match the approved use, prior authorization may be requested through the standard process by faxing a request to 866-940-7328.
STEP THERAPY (ST) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line agent has been adequately tried and failed. These medications may also be requested through the Prior authorization process. While lower cost PDL alternatives may be appropriate in many instances, other non- PDL alternatives are available with prior authorization (PA).
STEP Drug First-Line Agent(s)
Amerge Trial at a minimum dose of 50mg of sumatriptan tablets.
Aricept 23mg 90 day trial of Aricept 10mg daily
calcipotriene Trial of two medium to high cream & oint potency corticosteroid topical 0.005% treatments
calcitriol Trial of two medium to high potency corticosteroid topical treatments 3mcg/gm
DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Nesina, metformin. Kazano, Oseni)
Elidel
Eucrisa
fenofibrate
Minimum age of 2. Trial of one topical corticosteroid.
Trial of a topical corticosteroid AND one of the following: Elidel or tacrolimus ointment.
Fill of a statin or 90 days of gemfibrozil within the previous 180 days.
GLP-1 Agonists At least a 90 day trial of 1500mg/day of (Adlyxin, metformin. , Trulicity)
GLP-1/Insulin Trial of one drug from the following Combinations classes: GLP-1 or Basal Insulin (Soliqua)
Optivar 14 day trial of ketotifen within previous 90 days required first.
Ranexa Trial of one drug from the following classes: beta blockers, calcium channel blockers, long acting nitrates
Renvela 8 week trial of calcium acetate.
SGLT-2 At least a 90 day trial of 1500mg/day of Inhibitors metformin (Jardiance, Invokana, Invokamet, Invokamet XR, Synjardy, Synjardy XR)
tacrolimus 0.03% Minimum age of 2. Trial of one topical corticosteroid.
tacrolimus 0.1% Minimum age of 16. Trial of one
tolterodine
topical corticosteroid.
30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age.
tretinoin cream Trial of Differin OTC Gel 0.1%. (tretinoin cream 0.025%, 0.05%, 0.1%, and Avita cream 0.025%)
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trospium
Uloric
Xopenex Respules
30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age.
8 week trial of up to 600mg of allopurinol required first.
30 day trial of Albuterol .083% or .5% respules.
PDL SUGGESTIONS Providers who wish to propose PDL suggestions should forward the information to the UnitedHealthcare Community Plan Director of Pharmacy Services by either mail or fax.
Attn: Director of Pharmacy Services UnitedHealthcare Community Plan 2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Fax: 866-940-7328
Providers should furnish adequate documentation, such as clinical studies from the medical literature, in order for the request to be considered for PDL addition. This literature should include information documenting clinical necessity as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare Community Plan will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting.
EDITOR Your comments and suggestions regarding the UnitedHealthcare Community Plan PDL are encouraged. Your input is vital to this PDL’s continued success. All responses will be reviewed and considered. Please send your comments to:
UnitedHealthcare Community Plan Director of Pharmacy Services 2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Phone: 800-310-6826 Email: [email protected] Internet: http://www.uhccommunityplan.com
LEGEND
# Only the dosage forms/strengths of the brand name products noted are on the PDL
OTC over-the-counter delayed-rel delayed-release (also known as enteric coated)
EC enteric-coated
ext-rel extended-release (also known as sustained-
release) PA Prior Authorization required QL Quantity Limits apply ST Step Therapy, see pages V-VI for details
SP Specialty Pharmaceuticals, see page V for details
NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare Community Plan. All rights reserved.
The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare Community Plan. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare Community Plan and such third-party pharmaceutical companies.
If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification.
2
Table of ContentsAntineoplastics & Immunosuppressants . . . 4Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4Hormonal Antineoplastic Agents. . . . . . . . . . . . . 5Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 6Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 6Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Blood Modifiers - Anticoagulants . . . . . . . . . 7Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Blood Cell Formation . . . . . . . . . . . . . . . . . . . . . . 7Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . 7Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Cardiovascular Agents . . . . . . . . . . . . . . . . . . 8Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Ace Inhibitor/Diuretic Combinations. . . . . . . . . . 8Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 9Alpha Blockers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Angiotensin II Receptor Blockers (Antagonists) . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Angiotensin II Receptor Blocker Combinations. . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antiarrhythmics and Cardiac Glycosides . . . . . . 9Beta Blockers and Beta Blocker/Diuretic Combinations. . . . . . . . . . . . . . . . . . . . . . . . . . . 9Calcium Channel Blockers. . . . . . . . . . . . . . . . . 10Calcium Channel Blockers/ACE Inhibitor Combination. . . . . . . . . . . . . . . . . . . . . . . . . . . 10Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 11Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Potassium-Removing Agents . . . . . . . . . . . . . . . 12Pulmonary Arterial Hypertension . . . . . . . . . . . 12Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Central Nervous System. . . . . . . . . . . . . . . .13Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 13Amyotrophic Lateral Sclerosis (ALS) . . . . . . . . 13Analeptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 15Migraine Prophylactic Therapy . . . . . . . . . . . . . 15Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . 15Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . 16Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 16Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . .18Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 18Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . 19Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 20Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Scabies and Pediculosis. . . . . . . . . . . . . . . . . . . 20Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . .22Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 23
Endocrinology . . . . . . . . . . . . . . . . . . . . . . . .24Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 24Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 24Growth Stimulating Agents. . . . . . . . . . . . . . . . . 26Lipodystropy Agents . . . . . . . . . . . . . . . . . . . . . . 26Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 26Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Gastrointestinal. . . . . . . . . . . . . . . . . . . . . . .27Constipation/Laxatives . . . . . . . . . . . . . . . . . . . . 27Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Emesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Gastroesophageal Reflux Disease (Gerd)/ Peptic Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . 28Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . . 28Inflammatory Bowel Disease . . . . . . . . . . . . . . . 29Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 29Probiotic Supplementation. . . . . . . . . . . . . . . . . 29Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Infectious Diseases . . . . . . . . . . . . . . . . . . .30Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Antiprotozoals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Musculoskeletal . . . . . . . . . . . . . . . . . . . . . .35Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 37
OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Hormone Therapy/Menopause. . . . . . . . . . . . . 38Ovulation Stimulants . . . . . . . . . . . . . . . . . . . . . . 39Vaginal Infections. . . . . . . . . . . . . . . . . . . . . . . . . 39Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . .40Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 40Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Immunologic Agents . . . . . . . . . . . . . . . . . . . . . . 42Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Psychiatric. . . . . . . . . . . . . . . . . . . . . . . . . . .42Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . . 42Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Attention Deficit Hyperactivity Disorder (ADHD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . 43Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Medications Coverable for Participating Behavioral Health Prescribers . . . . . . . . . . . . 45Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . . 47Psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . 48Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Respiratory Drugs. . . . . . . . . . . . . . . . . . . . .48Antitussives, Decongestants, Expectorants and Combinations . . . . . . . . . . . . . . . . . . . . . . 48Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Urological . . . . . . . . . . . . . . . . . . . . . . . . . . .53Symptomatic Benign Prostatic Hypertrophy . . 53Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Vitamins and Minerals . . . . . . . . . . . . . . . . .54Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . .57Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 57Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 57Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 57Immune Thrombocytopenic Purpura . . . . . . . . 57Medical Devices. . . . . . . . . . . . . . . . . . . . . . . . . . 57Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . . 58Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
OTC MEDICATIONS . . . . . . . . . . . . . . . . . . .60Acne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 60Cough/Cold Allergy. . . . . . . . . . . . . . . . . . . . . . . 60Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Earwax Removal Products . . . . . . . . . . . . . . . . . 61Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 61First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 62Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Motion Sickness. . . . . . . . . . . . . . . . . . . . . . . . . . 62Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Smoking Cessation Products . . . . . . . . . . . . . . 63Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 63Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Index of Covered Drugs . . . . . . . . . . . . . . . .64
4
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Antineoplastics & Immunosuppressants
Antineoplastic AgentsAlkylating Agentsaltretamine HEXALEN brand 2busulfan MYLERAN brand 2chlorambucil LEUKERAN brand 2cyclophosphamide CYCLOPHOSPH generic 1 inj 500 mg, PAcyclophosphamide CYTOXAN generic 1estramustine
phosphate sodium EMCYT brand 2
lomustine GLEOSTINE brand 2melphalan ALKERAN brand 2temozolomide TEMODAR generic 1 PA, SPAntimetabolitescapecitabine XELODA generic 1 SPmercaptopurine PURINETHOL generic 1thioguanine TABLOID brand 2 QLtrifluridine/tipiracil LONSURF brand 2 PA, SPHistone Deacetylase Inhibitorspanobinostat FARYDAK brand 2 PA, SPvorinostat ZOLINZA brand 2 PA, SPKinase Inhibitorsabemaciclib VERZENIO brand 2 PA, SPacalabrutinib CALQUENCE brand 2 PA, QL, SPafatinib GILOTRIF brand 2 PA, SPalectinib ALECENSA brand 2 PA, SPaxitinib INLYTA brand 2 PA, SPbosutinib BOSULIF brand 2 PA, SPbrigatinib ALUNBRIG brand 2 PA, SP
cabozantinibCABOMETYX COMETRIQ
brand 2 PA, SP
ceritinib ZYKADIA brand 2 PA, SPcobimetinib COTELLIC brand 2 PA, SPcrizotinib XALKORI brand 2 PA, SPdabrafenib TAFINLAR brand 2 PA, SPdasatinib SPRYCEL brand 2 PA, SPerlotinib TARCEVA brand 2 PA, SP
5
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
everolimusAFINITORAFINITOR DISPERZ
brand 2 PA, SP
gefitinib IRESSA brand 2 PA, SPibrutinib IMBRUVICA brand 2 PA, SPidelalisib ZYDELIG brand 2 PA, SPimatinib mesylate GLEEVEC generic 1 PA, QL, SPlapatinib ditosylate TYKERB brand 2 PA, SPlenvatinib LENVIMA brand 2 PA, SPmidostaurin RYDAPT brand 2 PA, SPnilotinib TASIGNA brand 2 PA, SPpalbociclib IBRANCE brand 2 PA, SPpazopanib VOTRIENT brand 2 PA, SPponatinib ICLUSIG brand 2 PA, SPregorafenib STIVARGA brand 2 PA, SPruxolitinib JAKAFI brand 2 PA, SPsorafenib NEXAVAR brand 2 PA, SPsunitinib SUTENT brand 2 PA, SPtrametinib MEKINIST brand 2 PA, SPvandetanib CAPRELSA brand 2 PA, SPvemurafenib ZELBORAF brand 2 PA, SPMiscellaneousleucovorin LEUCOVORIN generic 1 QL, tabs mesna MESNEX brand 2 SP, tabletsvenetoclax VENCLEXTA brand 2 PA, SPProteasome Inhibitors ixazomib NINLARO brand 2 PA, SPHormonal Antineoplastic AgentsAndrogen Biosynthesis Inhibitorsabiraterone ZYTIGA brand 2 PA, SPAntiandrogensapalutamide ERLEADA brand 2 PA, QL, SPbicalutamide CASODEX generic 1flutamide EULEXIN generic 1Antiestrogenstamoxifen NOLVADEX generic 1toremifene FARESTON brand 2Aromatase Inhibitorsanastrozole ARIMIDEX generic 1exemestane AROMASIN generic 1letrozole FEMARA generic 1
6
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Gonadotropin Releasing Hormone Analogleuprolide LUPRON generic 1 PA, SP
leuprolideLUPRON DEPOTLUPRON DEPOT 6-MONTHLUPRON DEPOT-PED
brand 2 PA, SP
Progestinmegestrol acetate MEGACE generic 1ImmunomodulatorsInterferonsinterferon gamma-1b ACTIMMUNE brand 2 PA, SP
interferon alfa-2b INTRON A brand 2 3,000,000 unit/0.2 ML only, PA, SP
peginterferon alfa-2b SYLATRON brand 2 PA, SPMiscellaneouslenalidomide REVLIMID brand 2 PA, SPpomalidomide POMALYST brand 2 PA, SPImmunosuppressantsAntimetabolitesazathioprine IMURAN generic 1mycophenolate mofetil CELLCEPT generic 1mycophenolate sodium MYFORTIC generic 1Calcineurin Inhibitorscyclosporine SANDIMMUNE generic 1
cyclosporine, modifiedGENGRAF NEORAL
generic 1 caps, QL
tacrolimusHECORIA PROGRAF
generic 1
Othereverolimus ZORTRESS brand 2Rapamycin Derivativesirolimus RAPAMUNE generic 1 tabssirolimus RAPAMUNE brand 2 solnMiscellaneousalitretinoin 1% gel PANRETIN brand 2 PAbexarotene caps and
topical gel TARGRETIN brand 2 PA, SP
cysteamine bitartrate CYSTAGON brand 2 SPetoposide VEPESID generic 1hydroxyurea DROXIA brand 2hydroxyurea HYDREA generic 1
7
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
leucovorin calcium WELLCOVORIN generic 1mitotane LYSODREN brand 2 PAniraparib ZEJULA brand 2 PA, SPoctreotide SANDOSTATIN generic 1 PA, SPolaparib LYNPARZA brand 2 PA, SPpasireotide SIGNIFOR brand 2 PA, SPprocarbazine MATULANE brand 2 SPrucaparib RUBRACA brand 2 PA, SP sonidegib ODOMZO brand 2 PA, SPthalidomide THALOMID brand 2 PA, SPtopotecan HYCAMTIN brand 2 PA, SPtretinoin VESANOID generic 1 caps, SPvismodegib ERIVEDGE brand 2 PA, SP
Blood Modifiers - Anticoagulants
Anticoagulantsapixaban ELIQUIS brand 2 QLbetrixaban BEVYXXA brand 2 QLedoxaban SAVAYSA brand 2 QLenoxaparin LOVENOX generic 1 QL
heparin HEPARIN generic 1INJ 5000 UNIT/ML, PF INJ 5000 UNIT/0.5ML, INJ 10000 UNIT/ML
warfarin generic 1Blood Cell Formationdarbepoetin alfa ARANESP brand 2 PA, SP
epoetin alfaEPOGENPROCRIT
brand 2 PA, SP
filgrastim ZARXIO brand 2 PA, SPoprelvekin NEUMEGA brand 2 PA, SPpegfilgrastim NEULASTA brand 2 PA, SPplerixafor MOZOBIL brand 2 PA, SPsargramostim LEUKINE brand 2 PA, SPPlatelet Inhibitorsanagrelide AGRYLIN generic 1
aspirinBAYER
ECOTRINgeneric 1 OTC
8
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
cilostazol PLETAL generic 1clopidogrel PLAVIX generic 1 QLdipyridamole PERSANTINE generic 1prasugrel EFFIENT generic 1 Diagnosis Requiredticagrelor BRILINTA generic 1 Diagnosis Required, QLMiscellaneousaminocaproic acid AMICAR brand 2 tabs
deferasiroxEXJADEJADENU
brand 2 PA, SP
emicizumab-kxwh HEMLIBRA brand 2 PA, QL, SPpentoxifylline
extended-release TRENTAL generic 1
Cardiovascular Agents
Ace Inhibitorsbenazepril LOTENSIN generic 1captopril CAPOTEN generic 1enalapril VASOTEC generic 1
enalapril oral soln EPANED brand 2Members ≥ 8 years of age will require prior
authorization.fosinopril MONOPRIL generic 1 QLlisinopril ZESTRIL generic 1 QLmoexipril hcl UNIVASC generic 1perindopril erbumine ACEON generic 1quinapril ACCUPRIL generic 1 QLramipril ALTACE generic 1trandolapril MAVIK generic 1Ace Inhibitor/Diuretic Combinationsbenazepril/
hydrochlorothiazide LOTENSIN HCT generic 1
captopril/ hydrochlorothiazide CAPOZIDE generic 1
enalapril/ hydrochlorothiazide VASERETIC generic 1
fosinopril/ hydrochlorothiazide MONOPRIL-HCT generic 1 QL
lisinopril/ hydrochlorothiazide ZESTORETIC generic 1 QL
9
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
moexipril- hydrochlorothiazide UNIRETIC generic 1
quinapril/ hydrochlorothiazide ACCURETIC generic 1 QL
Adrenolytics, Centralclonidine CATAPRES generic 1clonidine transdermal CATAPRES- TTS generic 1guanfacine TENEX generic 1Alpha Blockersdoxazosin CARDURA generic 1prazosin MINIPRESS generic 1terazosin HYTRIN generic 1Angiotensin II Receptor Blockers (Antagonists)losartan COZAAR generic 1 QLAngiotensin II Receptor Blocker Combinationslosartan/HCTZ HYZAAR generic 1 QLsacubitril/valsartan ENTRESTO brand 2 PA, QLAntiarrhythmics and Cardiac Glycosidesamiodarone tabs CORDARONE generic 1 200 mg and 400 mgdigoxin LANOXIN generic 1disopyramide NORPACE generic 1disopyramide
extended-release NORPACE CR brand 2
dofetilide TIKOSYN generic 1flecainide TAMBOCOR generic 1mexiletine MEXITIL generic 1propafenone RYTHMOL generic 1 IR onlyquinidine gluconate
extended-releaseQUINIDINE GLUCONATE
EXT-REL generic 1
quinidine sulfate QUINIDINE SULFATE generic 1quinidine sulfate
extended-releaseQUINIDINE SULFATE
EXT-REL generic 1
Beta Blockers and Beta Blocker/Diuretic Combinationsacebutolol SECTRAL generic 1atenolol TENORMIN generic 1atenolol/chlorthalidone TENORETIC generic 1betaxolol KERLONE generic 1bisoprolol ZEBETA generic 1bisoprolol/
hydrochlorothiazide ZIAC generic 1
carvedilol COREG generic 1 QL
10
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
labetalol TRANDATE generic 1metoprolol LOPRESSOR generic 1 25, 50, 100mg tabletsmetoprolol succinate TOPROL XL generic 1nadolol CORGARD generic 1propranolol INDERAL generic 1propranolol ER 24hr INDERAL LA generic 1 Diagnosis Required, QLpropranolol/HCTZ INDERIDE generic 1sotalol BETAPACE generic 1sotalol AF BETAPACE AF generic 1Calcium Channel BlockersDihydropyridinesamlodipine NORVASC generic 1 QLfelodipine
extended-release PLENDIL generic 1 QL
nicardipine CARDENE generic 1nifedipine PROCARDIA generic 1nifedipine
extended-releaseADALAT CCPROCARDIA XL
generic 1 QL
nimodipine NIMOTOP generic 1 QLnimodipine oral soln NYMALIZE brand 2Nondihydropyridinesdiltiazem CARDIZEM generic 1diltiazem
extended-release CARDIZEM CD generic 1 QL
diltiazem extended-release
DILACOR XR TIAZAC
generic 1 QL
diltiazem sustained-release CARDIZEM SR generic 1 QL
verapamil CALAN generic 1verapamil
extended-release CALAN SR generic 1 QL
Calcium Channel Blockers/ACE Inhibitor Combinationamlodipine-benazepril LOTREL generic 1Diureticsamiloride MIDAMOR generic 1amiloride/
hydrochlorothiazide MODURETIC generic 1
bumetanide BUMEX generic 1chlorothiazide DIURIL generic 1
11
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
chlorothiazide DIURIL ORAL SUSPENSION brand 2 QL
chlorthalidone CHLORTHALIDONE generic 1furosemide LASIX generic 1hydrochlorothiazide HYDROCHLOROTHIAZIDE generic 1 soln, tabshydrochlorothiazide MICROZIDE generic 1 12.5 mg capsindapamide LOZOL generic 1metolazone ZAROXOLYN generic 1spironolactone ALDACTONE generic 1spironolactone/
hydrochlorothiazide ALDACTAZIDE generic 1
torsemide DEMADEX generic 1triamterene/
hydrochlorothiazideDYAZIDEMAXZIDE
generic 1
Lipid Lowering AgentsBile Acid Resin
cholestyramineQUESTRANQUESTRAN-LIGHT
generic 1
Only the bulk products are covered (cans).
Individual packets are not covered.
Fibratesfenofibrate LIPOFEN brand 2 capfenofibrate LOFIBRA generic 1 STgemfibrozil LOPID generic 1HMG-CoA Reductase Inhibitors and Combinationsatorvastatin LIPITOR generic 1 QLlovastatin MEVACOR generic 1 QLsimvastatin ZOCOR generic 1 QLOthersfish oil caps FISH OIL generic 1 OTCinositol niacinate NIACINOL generic 1 500 mg caps only, OTCNiacinsniacin NIACOR generic 1niacin extended-release NIASPAN generic 1Miscellaneousalirocumab PRALUENT brand 2 PA, QL, SPezetimibe ZETIA generic 1 PAomega 3 acid
ethyl esters LOVAZA generic 1 PA
12
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
NitratesOralisosorbide dinitrate ISORDIL generic 1isosorbide dinitrate
extended-releaseISOSORBIDE
DINITRATE ER generic 1
isosorbide mononitrate ISMO generic 1isosorbide mononitrate
extended-release IMDUR generic 1
Sublingualisosorbide dinitrate ISORDIL S.L. generic 1nitroglycerin NITROLINGUAL generic 1nitroglycerin NITROSTAT generic 1Transdermal
nitroglycerinNITREK NITRO-DUR
generic 1 transdermal, not 0.3 mg or 0.8 mg, QL
nitroglycerin NITRO-BID generic 1 ointPotassium-Removing Agentspatiromer VELTASSA brand 2 PAsodium polystyrene
sulfonate KALEXATE generic 1 powder
sodium polystyrene sulfonate KAYEXALATE generic 1 susp only
Pulmonary Arterial Hypertensionambrisentan LETAIRIS brand 2 Diagnosis Required, SPbosentan TRACLEER brand 2 Diagnosis Required, SPmacitentan OPSUMIT brand 2 Diagnosis Required, SPriociguat ADEMPAS brand 2 Diagnosis Required, SP
sildenafil REVATIO generic 1 Diagnosis Required, SP, tablets
sildenafil REVATIO SUSPENSION brand 2 Diagnosis Required, SP, suspension
Miscellaneousguanabenz WYTENSIN generic 1hydralazine APRESOLINE generic 1methyldopa ALDOMET generic 1methyldopa/HCTZ ALDORIL generic 1midodrine PROAMATINE generic 1minoxidil LONITEN generic 1ranolazine RANEXA brand 2 ST
13
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Central Nervous System
Alzheimer’s Disease
donepezil ARICEPT generic 1
5 mg and 10 mg, QL, Members <18 years of age will require prior
authorization.
donepezil ARICEPT generic 123 mg, ST, Members <18 years of age will require
prior authorization.
galantamine RAZADYNE generic 1QL, Members <18 years of age will require prior
authorization.
memantine NAMENDA generic 1QL, Members <18 years of age will require prior
authorization.
rivastigmine EXELON generic 1
PA req for soln, QL, Members <18 years of age will require prior
authorization.Amyotrophic Lateral Sclerosis (ALS)riluzole RILUTEK brand 2Analepticsarmodafinil NUVIGIL generic 1 Diagnosis RequiredAnalgesicsBarbiturate Non-Narcotic Analgesicsbutalbital/acetaminophen/
caffeine ESGIC generic 1 QL
butalbital/aspirin/caffeine FIORINAL generic 1 QLNon-Narcotic Analgesicsacetaminophen TYLENOL generic 1 OTCaspirin/acetaminophen/
caffeine EXCEDRIN MIGRAINE generic 1 250-250-65 mg, OTC
tramadol ULTRAM generic 1 QLNSAIDSdiclofenac potassium CATAFLAM generic 1diclofenac sodium
delayed-release VOLTAREN generic 1 QL
14
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
diclofenac sodium extended-release VOLTAREN XR generic 1
etodolac LODINE generic 1
ibuprofen ADVIL generic 1 tabs, chew tabs and susp, OTC
ibuprofen MOTRIN generic 1 tabs, chew tabs and susp
indomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1ketorolac tromethamine TORADOL generic 1 QLmeloxicam MOBIC generic 1 QLnaproxen NAPROSYN generic 1
naproxen delayed release ENTERIC COATED-NAPROSYN generic 1
oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1sulindac CLINORIL generic 1Opioids — Narcotic Analgesicsbutalbital/apap/caff/cod FIORICET W/CODEINE generic 1 QL, 50-325-40-30 mgbutalbital/asa/caff/cod FIORINAL W/CODEINE generic 1 QLbutorphanol STADOL generic 1 nasal spray, QLcodeine/acetaminophen TYLENOL W/CODEINE generic 1 QLcodeine sulfate generic 1 QLfentanyl transdermal DURAGESIC generic 1 PA, QL
hydrocodone/ acetaminophen
LORCETLORTABLORTAB ELIXIRNORCOVICODINVICODIN ES
generic 1 QL
hydrocodone ER ZOHYDRO ER brand 2 PAhydromorphone DILAUDID generic 1 QLmeperidine DEMEROL generic 1 QLmorphine MSIR generic 1 QLmorphine RMS generic 1 PA, QLmorphine
extended-release MS CONTIN generic 1 PA, QL
oxycodone OXYFAST generic 1 soln, QL
15
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
oxycodone ROXICODONE generic 1 5mg, 10mg, 15mg, 20mg, 30mg, QL
oxycodone/ acetaminophen PERCOCET generic 1 5/325 mg, 7.5/325 mg,
10/325 mg, QLoxycodone/aspirin PERCODAN generic 1 QL
oxymorphone ER OXYMORPHONE ER generic 1 PA, QL, non-crush resistant
pentazocine/naloxone TALWIN NX generic 1 QLMigraine Acute TherapyErgotamine Derivativesdihydroergotamine D.H.E. 45 generic 1 inj, QLergotamine/caffeine CAFERGOT generic 1ergotamine tartrate/
caffeineMIGERGOT
SUPPOSITORIES brand 2 QL
Selective Serotonin Agonistsnaratriptan AMERGE generic 1 STrizatriptan MAXALT/MAXALT MLT generic 1 QLsumatriptan IMITREX generic 1 QL
sumatriptan IMITREX 4 MG AND 6 MG INJ generic 1 4 mg and 6 mg inj
sumatriptan-naproxen TREXIMET brand 2 PAMigraine Prophylactic Therapyamitriptyline ELAVIL generic 1
divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1
Members ≥ 8 years of age will require prior
authorization. divalproex sodium
delayed-release DEPAKOTE generic 1 Minimum age 2
propranolol INDERAL generic 1 IR onlyverapamil CALAN generic 1Multiple Sclerosisdaclizumab ZINBRYTA brand 2 Diagnosis Required,
QL, ST, SP
dimethyl fumarate TECFIDERA brand 2 Diagnosis Required, QL, SP
fingolimod GILENYA brand 2 Diagnosis Required, QL, SP
glatiramer acetate COPAXONE generic 1 Diagnosis Required, QL, SP
16
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
glatiramer acetate GLATOPA generic 1 Diagnosis Required, QL, SP
peginterferon beta-1a PLEGRIDY generic 1 Diagnosis Required, QL, SP
teriflunomide AUBAGIO brand 2 Diagnosis Required, QL, SP
Myasthenia Gravispyridostigmine MESTINON generic 1 tabspyridostigmine MESTINON brand 2 syruppyridostigmine
extended-release MESTINON TIMESPAN generic 1
Parkinson’s Diseaseamantadine SYMMETREL generic 1 except tabsbenztropine COGENTIN generic 1carbidopa/levodopa SINEMET generic 1carbidopa/levodopa
extended-release SINEMET CR generic 1
entacapone COMTAN generic 1pramipexole MIRAPEX generic 1ropinirole REQUIP generic 1selegiline ELDEPRYL generic 1tolcapone TASMAR generic 1trihexyphenidyl ARTANE generic 1Seizurescarbamazepine TEGRETOL generic 1carbamazepine
extended-releaseCARBATROL TEGRETOL-XR
generic 1
clobazam ONFI brand 2 tabs, PAclonazepam KLONOPIN generic 1 tabsdiazepam DIASTAT ACUDIAL generic 1 rectal gel, QL
divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1
Members ≥ 8 years of age will require prior
authorization.divalproex sodium
delayed-release DEPAKOTE generic 1 Minimum age 2
ethosuximide ZARONTIN generic 1ezogabine POTIGA brand 2 Age Limits Applyfelbamate FELBATOL generic 1 QL
17
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
felbamate oral susp FELBATOL ORAL SUSP generic 1
QL, suspension, Members ≥ 8 years of age will require prior
authorization. gabapentin NEURONTIN generic 1 caps and tabs onlylacosamide VIMPAT brand 2 Age Limits Apply*lamotrigine LAMICTAL generic 1 not chewable, QL
lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB generic 1
Members ≥ 8 years of age will require prior
authorization.lamotrigine starter kit LAMICTAL STARTER KIT generic 1
levetiracetam KEPPRA (NOT XR) generic 1 QL, Maximum age of 9 for solution
methsuximide CELONTIN brand 2
oxcarbazepine TRILEPTAL generic 1 QL, Maximum age of 9 for suspension
phenobarbital PHENOBARBITAL generic 1phenytoin DILANTIN INFATABS generic 1phenytoin sodium
extendedDILANTINPHENYTEK
generic 1
pregabalin LYRICA brand 2Diagnosis required for
seizures only, other diagnoses require PA, QL
pregabalin LYRICA SOLUTION brand 2
oral solution, Diagnosis required for seizures only, other diagnoses require
PA, QLprimidone MYSOLINE generic 1rufinamide BANZEL brand 2 Diagnosis Required, QL
tiagabine GABITRIL generic 1 Age Limits Apply, 2mg & 4mg*
tiagabine GABITRIL brand 2 Age Limits Apply, 12mg & 16mg*
topiramate TOPAMAX generic 1 QL
topiramate sprinkle caps TOPAMAX SPRINKLE generic 1QL, Members ≥ 8 years of age will require prior
authorization.valproic acid DEPAKENE generic 1vigabatrin oral solution SABRIL SOLUTION brand 2 PA, SPzonisamide ZONEGRAN generic 1 QL
18
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Miscellaneoustetrabenazine XENAZINE generic 1 Diagnosis Required, SPvalbenazine INGREZZA brand 2 PA, QL
Dermatology
Acne VulgarisOral
isotretinoin
ABSORICAAMNESTEEMCLARAVISMYORISANZENTANE
generic 1 PA
Topicaladapalene gel DIFFERIN OTC GEL 0.1% brand 2azelaic acid FINACEA brand 2 gelbenzoyl peroxide BENZAC AC generic 1clindamycin CLEOCIN T generic 1 gelclindamycin CLEOCIN T generic 1 lotionclindamycin CLEOCIN T generic 1 solnerythromycin ERYGEL generic 1 gel 2% erythromycin T-STAT generic 1 solnerythromycin/benzoyl
peroxide BENZAMYCIN generic 1
salicylic acid NEUTROGENA OIL FREE ACNE WASH generic 1 liquid 2%, OTC
sulfacetamide/sulfur SULFACET-R generic 1 lotionsulfacetamide sodium
lotion KLARON generic 1
sulfacetamide/sulfur SUMADAN WASH generic 1 PA
tretinoinAVITA RETIN-A
generic 1 cream, ST
Bacterial Infectionsbacitracin BACITRACIN generic 1 OTCgentamicin GENTAK generic 1
mupirocin BACTROBAN generic 1 ointment, 22 gram tube only
neomycin/polymyxin B/bacitracin NEOSPORIN generic 1 OTC
silver sulfadiazine SILVADENE generic 1
19
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
CorticosteroidsLow Potencyalclometasone ACLOVATE generic 1 0.05% crm/oint
fluocinolone acetonide DERMA-SMOOTHE OIL/FS generic 1 oil 0.01%
fluocinolone acetonide SYNALAR generic 1 soln/crm 0.01% hydrocortisone CORTIZONE generic 1 crm, oint, lot OTChydrocortisone HYTONE generic 1 crm 0.5%, 1%, & 2.5%hydrocortisone HYTONE generic 1 lotion 1% & 2.5%
hydrocortisone/aloe CORTIZONE-10 INTENSIVE HEALING generic 1 crm 0.5% & 1%, OTC
Medium Potencybetamethasone val BETA-VAL generic 1 crm/oint/lotion 0.1%fluocinolone acetonide SYNALAR generic 1 crm, oint 0.025%fluticasone propionate CUTIVATE generic 1 crm 0.05%, oint 0.005%hydrocortisone butyrate LOCOID generic 1 crm/oint/soln 0.1% hydrocortisone valerate WESTCORT generic 1 crm 0.2%mometasone furoate ELOCON generic 1 crm/oint/soln 0.1%prednicarbate DERMATOP generic 1 crm 0.1%triamcinolone acetonide KENALOG generic 1 crm/lot/oint 0.025%triamcinolone acetonide KENALOG generic 1 crm/oint/lotion 0.1%High Potencybetamethasone
augmented dip DIPROLENE generic 1 lotion 0.05%
betamethasone augmented dip DIPROLENE AF generic 1 crm 0.05%
betamethasone dipropionate generic 1 crm/lotion/oint 0.05%
fluocinonide LIDEX generic 1 crm/oint/gel/soln 0.05%fluocinonide emulsified
base LIDEX E generic 1 crm 0.05%
triamcinolone acetonide KENALOG generic 1 crm 0.5%Very High Potencybetamethasone dip
augmented DIPROLENE generic 1 gel 0.05%
betamethasone dip augmented DIPROLENE generic 1 oint 0.05%
clobetasol propionate TEMOVATE generic 1 crm/gel/oint/soln 0.05%halobetasol ULTRAVATE generic 1 cream
20
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Fungal Infectionsciclopirox PENLAC SOLUTION 8% generic 1clotrimazole LOTRIMIN AF generic 1 OTCclotrimazole MYCELEX generic 1clotrimazole with
betamethasone LOTRISONE generic 1
ketoconazole NIZORAL generic 1miconazole DESENEX generic 1 2% OTCmiconazole MICATIN generic 1 OTCmiconazole MONISTAT-DERM generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL AT generic 1 OTCtolnaftate TINACTIN generic 1 OTCPsoriasisacitretin SORIATANE generic 1 oral caps, PAcalcipotriene DOVONEX generic 1calcitriol VECTICAL generic 1 STsalicylic acid SCALPICIN generic 1 liquid 3%Rosaceabrimonidine MIRVASO brand 2 PA
metronidazoleMETROCREAMMETROGELMETROLOTION
generic 1
Scabies and Pediculosiscrotamiton EURAX brand 2malathion OVIDE generic 1 QLpermethrin ELIMITE generic 1 5%, QLpermethrin NIX CREME RINSE generic 1 1%, OTCpyrethrins/piperonyl
butoxide shampoo RID SHAMPOO generic 1 4% OTC
spinosad NATROBA generic 1Viral Infectionspodofilox CONDYLOX SOL generic 1 solsalicylic acid 17%/
collodion DUOFILM generic 1 OTC
Miscellaneousaluminum acetate brand 2 soln/cream, OTCaluminum chloride
topical solution HYPERCARE 15% brand 2
21
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
ammonium lactate LAC-HYDRIN generic 1 crm 12%, lotion 5% & 12%
ammonium lactate LACTINOL generic 1 lotion 10%becaplermin gel REGRANEX brand 2 Diagnosis Required, QLcalamine brand 2 lotion/ointment, OTCcollagenase oint SANTYL brand 2 QLcrisaborole EUCRISA brand 2 2% ointment, QL, STfluorouracil EFUDEX generic 1
hydrocortisone
PROCTOSOL HC CREAM 2.5%
PROCTOZONE CREAM-HC 2.5%
ANUSOL HC 2.5%
generic 1
imiquimod 5% cream ALDARA generic 1ketoconazole NIZORAL SHAMPOO generic 1 shampoo 2%lidocaine LIDAMANTEL generic 1 3% cream
lidocaine LMX-4 generic 1 4% cream (15 gm tubes), QL
lidocaine XYLOCAINE generic 1 jelly 2%lidocaine patch LIDODERM generic 1 Diagnosis Requiredlidocaine/prilocaine EMLA generic 2.5% cream
nitroglycerin RECTIV brand 2 Diagnosis Required, 0.4% rectal ointment
pimecrolimus ELIDEL brand 2
cream, QL, ST; not covered for members less
than 2 years of age
selenium sulfide SELSUN generic 1 lotion 2.5%
tacrolimus PROTOPIC 0.03% generic 1ointment 0.03%, QL, ST; not covered for members less than 2 years of age
tacrolimus PROTOPIC 0.1% generic 1 ointment 0.1%, ST (minimum age 16)
urea 10%, urea 20%UREA 10% CREAMUREA 20% CREAMUREA 10% LOTION
brand 2
urea 40% UREA 40% LOTION generic 1 lotion
22
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Ear, Nose & Throat
Earacetic acid VOSOL OTIC generic 1 oticacetic acid/
aluminum acetate DOMEBORO OTIC generic 1
acetic acid/ hydrocortisone VOSOL HC OTIC generic 1
benzocaine/antipyrine BENZOTIC generic 1carbamide peroxide DEBROX generic 1 6.5%, OTCciprofloxacin/
dexamethasone CIPRODEX brand 2 Diagnosis Required
neomycin/polymyxin B/hydrocortisone CORTISPORIN OTIC generic 1 otic
ofloxacin FLOXIN OTIC generic 1NoseAntihistamines - First Generation, Sedatingchlorpheniramine
extended-releaseCHLOR-TRIMETON
ALLERGY generic 1 12 mg, OTC
chlorpheniramine maleate CHLOR-TRIMETON SYRUP generic 1 2 mg/5 ml, OTC
clemastine CLEMASTINE generic 1cyproheptadine CYPROHEPTADINE generic 1diphenhydramine generic 1diphenhydramine BENADRYL generic 1 OTChydroxyzine HCL ATARAX generic 1hydroxyzine pamoate VISTARIL generic 1Antihistamines - Second Generation, Nonsedatingcetirizine ZYRTEC generic 1 OTC
cetirizine chew tab ZYRTEC CHEWABLE TAB-LET generic 1
OTC, Members ≥ 8 years of age will require prior
authorization.levocetirizine XYZAL generic 1 tabs
loratadineALAVERTCLARITIN
generic 1 OTC
Antihistamines - Others Antihistamine/Decongestant Combinationsazelastine ASTELIN generic 1 spray
23
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Antihistamine/Decongestant Combinations - First Generationchlorpheniramine/
phenylephrine/ pyrilamine
TRIOTANN generic 1
chlorpheniramine/ pseudoephedrine ACTIFED generic 1 OTC
diphenhydramine- phenylephrine soln BENADRYL-D brand 2 OTC
Antihistamine/Decongestant Combinations - Second Generationcetirizine hydrochloride/
pseudoephedrine hydrochloride 12 hours extended-release
ZYRTEC-D generic 1 5 mg-120 mg tablet
loratadine/ pseudoephedrine extended-release
ALAVERT-DALAVERT ALRG
TAB/SINUSALLERGY/CONG
generic 1 OTC
Nasal Steroidsfluticasone FLONASE generic 1
triamcinolone nasal spray NASACORT ALLERGY 24 HOUR brand 2 OTC
Miscellaneous Nasal Decongestantsoxymetazoline AFRIN generic 1 OTC
phenylephrineNEO-SYNEPHRINE DIMEATAPP DRO
DECONGESgeneric 1 OTC
Miscellaneous Nasalcromolyn sodium NASALCROM generic 1 OTCipratropium nasal ATROVENT NASAL SPRAY generic 1 QLsaline nasal spray 0.65% OCEAN NASAL SPRAY generic 1 OTCThroat and Mouthchlorhexidine gluconate PERIDEX generic 1lidocaine viscous XYLOCAINE generic 1pilocarpine SALAGEN generic 1triamcinolone KENALOG IN ORABASE generic 1 paste
24
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Endocrinology
Adrenal Corticosteroidscortisone acetate generic 1dexamethasone DECADRON generic 1fludrocortisone FLORINEF generic 1hydrocortisone CORTEF generic 1methylprednisolone MEDROL generic 1 4mg, 8mg, 16mg, 32mgmethylprednisolone MEDROL brand 2 2mgprednisoloneprednisolone PRELONE generic 1 syrupprednisolone sodium
phosphateORAPREDPEDIAPRED
generic 1
prednisone DELTASONE generic 1Androgenstestosterone cypionate DEPO-TESTOSTERONE generic 1
testosterone enanthate DELATESTRYL generic 1 Vials only. Disposable syringes not covered.
testosterone gel topical tube, packet, and pump bottle
TESTOSTERONE 1% TOPICAL GEL generic 1 PA
Diabetes MellitusGlucose Elevating Agentsglucagon, human
recombinant GLUCAGON brand 2 QL
Insulin Combinationsinsulin glargine/lixisenatide SOLIQUA brand 2 STInsulinsinsulin aspart
protamine 70%/ insulin aspart 30%
NOVOLOG MIX 70/30 brand 2 QL, vials
insulin glargine BASAGLAR brand 2insulin glargine
300 unit/ml TOUJEO SOLOSTAR brand 2
insulin humanNOVOLIN RRELION R
brand 2 OTC, QL, vials
insulin isophane HUMULIN N brand 2 OTC, QL, vials
insulin isophane humanNOVOLIN NRELION N
brand 2 OTC, QL, vials
25
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
insulin isophane human 70%/regular 30% NOVOLIN 70/30 brand 2 OTC, QL, vials
insulin isophane human 70%/regular 30% RELION 70/30 brand 2 OTC, QL, vials
insulin isophane/regular HUMULIN 70/30 brand 2 OTC, QL, vialsinsulin lisopro pro/lispro HUMALOG MIX 50/50 brand 2 QL, vialsinsulin lisopro prot/lispro HUMALOG MIX 75/25 brand 2 QL, vialsinsulin lispro ADMELOG SOLOSTAR brand 2 PA, QLinsulin lispro ADMELOG VIALS brand 2insulin regular HUMULIN R brand 2 OTC, QL, vialsMonitoring - Strips and Kits/Diabetic Supplies
ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC) brand 2
QL for insulin dependent or pregnant members:
allow testing up to 6 times per day
ONE TOUCH TEST STRIPS (ULTRA, VERIO) brand 2QL for non-insulin
dependent members: allow twice daily testing
Oral Agentsacarbose PRECOSE generic 1alogliptin NESINA generic 1 STalogliptin/metformin KAZANO generic 1 STalogliptin/pioglitazone OSENI generic 1 STchlorpropamide DIABINESE generic 1ertugliflozin STEGLATRO brand 2 QL, STertugliflozin/metformin SEGLUROMET brand 2 QL, STglimepiride AMARYL generic 1glipizide GLUCOTROL generic 1glipizide extended-release GLUCOTROL XL generic 1glipizide-metformin METAGLIP generic 1glyburide MICRONASE generic 1glyburide, micronized GLYNASE generic 1metformin GLUCOPHAGE generic 1metformin ER GLUCOPHAGE ER generic 1metformin/glyburide GLUCOVANCE generic 1nateglinide STARLIX generic 1pioglitazone ACTOS generic 1 QLrepaglinide PRANDIN generic 1tolazamide TOLINASE generic 1tolbutamide TOLBUTAMIDE generic 1
26
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Miscellaneous Antidiabetic Agentsdulaglutide TRULICITY brand 2 STlixisenatide ADLYXIN brand 2 STpramlintide SYMLINPEN 60 brand 2 PAGrowth Stimulating Agentsmecasermin INCRELEX brand 2 PA, SPsomatropin ZOMACTON brand 2 PA, SPLipodystropy Agentstesamorelin EGRIFTA brand 2 Diagnosis Required, SPOsteoporosisabaloparatide inj TYMLOS brand 2 PA, SPalendronate FOSAMAX generic 1 QLcalcitonin-salmon MIACALCIN generic 1 nasal spray, QLcalcitonin-salmon FORTICAL brand 2 nasal spray, QLetidronate DIDRONEL generic 1raloxifene EVISTA generic 1Thyroid Diseaselevothyroxine LEVOXYL generic 1levothyroxine SYNTHROID generic 1liothyronine CYTOMEL generic 1liotrix THYROLAR brand 2methimazole TAPAZOLE generic 1propylthiouracil PROPYLTHIOURACIL generic 1Miscellaneousasfotase alfa STRENSIQ brand 2 PA, SPcabergoline DOSTINEX generic 1cholic acid CHOLBAM brand 2 PA, SPdesmopressin DDAVP generic 1 QLdesmopressin NOCDURNA brand 2 PAdesmopressin acetate inj DDAVP generic 1 4 mcg/ml, PAmethylergonovine METHERGINE generic 1mifepristone KORLYM brand 2 PA, SP
nitisinone NITYR brand 2 Diagnosis Required, QL, SP
pegvisomant SOMAVERT brand 2 PA, SPsapropterin KUVAN brand 2 Diagnosis Required, SP
sapropterin powder KUVAN POWDER FOR SOLUTION brand 2 Diagnosis Required, SP
uridine VISTOGARD brand 2
27
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Gastrointestinal
Constipation/Laxativescasanthranol-docusate
sodium generic 1 OTC
docusate calcium plus generic 1 OTCdocusate potasssium generic 1 OTCdocusate sodium DOK generic 1 100 mg tabs only, OTCdocusate sodium COLACE generic 1 OTCglycerin GLYCERIN SUPPOSITORY generic 1 suppository, OTClactulose ENULOSE generic 1
magnesium citrate soln MAGNESIUM CITRATE SOLN generic 1
peg 3350/electrolytes COLYTE generic 1peg 3350/sodium
bicarbonate/sodium chloride
TRILYTE generic 1
peg 3350/sodium bicarbonate/sodium chloride/potassium chloride
NULYTELY generic 1
plecanatide TRULANCE brand 2 Diagnosis Required, QLpolyethylene glycol 3350 MIRALAX generic 1sennosides SENOKOT generic 1 8.6 mg tab, OTCDiarrheacrofelemer MYTESI brand 2 Diagnosis Requireddiphenoxylate/atropine LOMOTIL generic 1loperamide IMODIUM A-D generic 1 OTCloperamide LOPERAMIDE generic 1Emesisaprepitant EMEND generic 1 QL applies to 40 mg, 80
mg and 80-125 mgdronabinol MARINOL generic 1 PAmeclizine ANTIVERT generic 1metoclopramide REGLAN generic 1
ondansetronZOFRANZOFRAN ODT
generic 1 QL
prochlorperazine COMPAZINE generic 1promethazine PHENERGAN generic 1
28
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
rolapitant VARUBI brand 2trimethobenzamide TIGAN generic 1 300 mg capsGastroesophageal Reflux Disease (Gerd)/Peptic Ulcersalginic acid/sodium
bicarbonate brand 2 OTC
alumina/magnesia MAALOX generic 1 OTCalumina/magnesia/
simethicone MYLANTA generic 1 OTC
cimetidine TAGAMET generic 1esomeprazole NEXIUM 24HR OTC brand 2 PA
esomeprazole granules NEXIUM DELAYED RELEASE PACKET brand 2
Members ≥ 2 yearsof age will require prior
authorization
famotidinePEPCIDPEPCID AC
generic 1
OTC Pepcid AC 10 mg and 20 mg also covered/encouraged with written
prescription.lansoprazole PREVACID generic 1
lansoprazole delayed-release PREVACID SOLUTAB generic 1
orally disintegrating tabs, Members ≥ 2 years
of age will require priorauthorization. QL
omeprazole delayed-release PRILOSEC generic 1 Capsules only, QL
pantoprazole PROTONIX generic 1ranitidine ZANTAC generic 1 150 mg tabsranitidine syrup ZANTAC generic 1sucralfate CARAFATE generic 1
sulcralfate CARAFATE SUSPENSION brand 2
suspension, Members 10 years of age up to 65 years of age will require
prior authorization.Gastrointestinal Spasmdicyclomine BENTYL generic 1 tablets onlyglycopyrrolate ROBINUL generic 1hyoscyamine sulfate LEVSIN generic 1hyoscyamine sulfate
extended-release LEVSINEX generic 1
29
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Inflammatory Bowel Diseasebalsalazide COLAZAL generic 1budesonide ENTOCORT EC generic 1 Diagnosis Requiredhydrocortisone COLOCORT generic 1 enemamesalamine ROWASA generic 1 enema onlymesalamine
extended-releaseAPRISODELZICOL
brand 2
mesalamine supp CANASA brand 2olsalazine sodium DIPENTUM brand 2sulfasalazine AZULFIDINE generic 1sulfasalazine
delayed-release AZULFIDINE EN-TABS generic 1
Pancreatic Enzymes
pancrelipaseCREONCREON 3000 UNIT
brand 2
Probiotic Supplementationacidophilus ACIDOPHILUS XTRA brand 2 OTCacidophilus ACIDOPHILUS brand 2 caps and tabs, OTC
acidophilus/bifidus ACIDOPHILUS/BIFIDUS WAFER generic 1 OTC
acidophilus/citrus pectin ACIDOPHILUS/CITRUS PECTIN generic 1 tabs, OTC
acidophilus/pectin ACIDOPHILUS/PECTIN generic 1 caps, OTC
probiotics
ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD
brand 2 OTC
30
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Miscellaneousatropine sulfate SAL-TROPINE brand 2misoprostol CYTOTEC generic 1naloxegol MOVANTIK brand 2 Diagnosis Requiredteduglutide GATTEX brand 2 PA, SP
ursodiolURSO URSO FORTEACTIGALL
generic 1
Infectious Diseases
Anthelminticsalbendazole ALBENZA brand 2 PAivermectin STROMECTOL brand 2praziquantel BILTRICIDE brand 2 Diagnosis Required
pyrantel pamoate PIN-X brand 2 chewable tablets, suspension
pyrantel pamoate REESE’S PINWORM MEDICINE brand 2 tablets, suspension
AntibacterialsAntituberculosis Agentsaminosalicyclic acid PASER brand 2cycloserine SEROMYCIN generic 1ethambutol MYAMBUTOL generic 1ethionamide TRECATOR brand 2isoniazid ISONIAZID generic 1pyrazinamide PYRAZINAMIDE generic 1rifabutin MYCOBUTIN generic 1rifapin RIFADIN generic 1rifapentine PRIFTIN brand 2Cephalosporins - First Generationcefadroxil DURICEF generic 1
cephalexin KEFLEX generic 1 tabs are not covered, not 750 mg caps
Cephalosporins - Second Generationcefaclor CECLOR generic 1cefprozil CEFZIL generic 1cefuroxime axetil CEFTIN generic 1 tabs
31
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
cefuroxime axetil CEFTIN brand 2 suspensionCephalosporins - Third Generationcefdinir OMNICEF generic 1cefixime SUPRAX brand 2 400 mg caps only, QLFluoroquinolonesciprofloxacin CIPRO generic 1levofloxacin LEVAQUIN brand 2 tablets onlyofloxacin FLOXIN generic 1 tabsMacrolidesazithromycin ZITHROMAX generic 1 QLclarithromycin BIAXIN generic 1clarithromycin ER BIAXIN XL generic 1erythromycin delayed-
release ERYC generic 1
erythromycin delayed-release ERY-TAB brand 2
erythromycin ethylsuccinate E.E.S. generic 1
erythromycin stearate ERYTHROCIN generic 1erythromycin/sulfisoxazole PEDIAZOLE generic 1fidaxomicin DIFICID brand 2 PAPenicillins
amoxicillin AMOXICILLIN CAPSULES AND CHEWABLES generic 1 Except 500 mg and 875
mg film-coated tabs.amoxicillin AMOXIL SUSP generic 1 suspensionamoxicillin/clavulanate AUGMENTIN generic 1ampicillin PRINCIPEN generic 1dicloxacillin DICLOXACILLIN generic 1penicillin VK VEETIDS generic 1Sulfonamidessulfamethoxazole/
trimethoprim, DSBACTRIMBACTRIM DS generic 1
Tetracyclinesdoxycycline monohydrate DOXYCYCLINE
MONOHYDRATE generic 1 caps only
minocycline MINOCIN generic 1 capsulestetracycline SUMYCIN generic 1 caps
32
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Miscellaneousvancomycin powder for
oral solution FIRVANQ brand 2 Diagnosis Required, QL
Antifungalsclotrimazole MYCELEX generic 1 trochesfluconazole DIFLUCAN generic 1 QLgriseofulvin microsize GRIFULVIN V generic 1griseofulvin ultramicrosize GRIS-PEG generic 1itraconazole SPORANOX generic 1 caps, PA, QLitraconazole SPORANOX brand 2 soln, PA, QLketoconazole NIZORAL generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL generic 1 cream only, QLterbinafine LAMISIL AT SPRAY brand 2 soln 1%, PA, OTCvoriconazole VFEND generic 1 PAAntiprotozoalsatovaquone MEPRON generic 1benznidazole BENZNIDAZOLE brand 2 PA, QLmiltefosine IMPAVIDO brand 2 PA
nitazoxanide suspension ALINIA SUSPENSION brand 2Members ≥ 8 years of age will require prior
authorization.pentamidine isethionate
for nebulization NEBUPENT brand 2
ALINIA brand 2 PAAntiviralsCytomegalovirus Treatmentganciclovir CYTOVENE generic 1valganciclovir VALCYTE generic 1 tabs onlyHepatitis Treatmententecavir BARACLUDE generic 1 SP
glecaprevir/pibrentasvir MAVYRET brand 2 PA, SP, preferred for Genotypes 1, 2, 3, 4, 5, & 6
interferon alfa-2b INTRON A brand 2 PA, SPlamivudine EPIVIR HBV generic 1 tabs, SP, QLlamivudine EPIVIR HBV brand 2 solution, SP, QLpeginterferon alfa-2a PEGASYS brand 2 PA, SPpeginterferon alfa-2a PEGASYS PROCLICK brand 2 PA, SP
ribavirinREBETOLCOPEGUS
generic 1 200 mg caps and tabs only, PA, SP
33
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Herpes Treatmentacyclovir ZOVIRAX generic 1 caps, tabs, suspensiondocosanol ABREVA OTC CREAM brand 2valacyclovir VALTREX generic 1Influenza Treatmentamantadine SYMMETREL generic 1 except tabsoseltamivir TAMIFLU generic 1 capsules, QLrimantadine FLUMADINE generic 1zanamivir RELENZA brand 2 QLIntegrase Inhibitorsdolutegravir TIVICAY brand 2 Diagnosis requiredraltegravir ISENTRESS brand 2 Diagnosis required
raltegravir ISENTRESS CHEWABLE brand 2 Chewable tablet; Diagnosis required
raltegravir ISENTRESS HD brand 2
raltegravir susp ISENTRESS SUSP brand 2Members ≥ 2 years ofage will require prior
authorization; Diagnosis Required
Nucleoside Reverse Transcriptase Inhibitors and Combinations – Diagnosis Requiredabacavir ZIAGEN generic 1abacavir/lamivudine EPZICOM generic 1abacavir/lamivudine/
zidovudine TRIZIVIR generic 1
didanosine VIDEX brand 2didanosine
delayed-release VIDEX EC generic 1
efavirenz/lamivudine/tenofovir disoproxil fumarate
SYMFI, SYMFI LO brand 2 QL
emtricitabine EMTRIVA brand 2emtricitabine/rilpivirine/
tenofovir COMPLERA brand 2 PA
lamivudine EPIVIR generic 1lamivudine/tenofovir
disoproxil fumarate CIMDUO brand 2 QL
lamivudine/zidovudine COMBIVIR generic 1stavudine ZERIT generic 1zidovudine RETROVIR generic 1Nucleoside/Nucleotide Reverse Transcriptase Inhibitor Combination – Diagnosis Requiredemtricitabine/rilpivirine/
tenofovir ODEFSEY brand 2
emtricitabine/tenofovir TRUVADA brand 2
34
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
emtricitabine/tenofovir alafenamide DESCOVY brand 2 QL
Nucleotide Analogues Nucleotide Reverse Transcriptase Inhibitor – Diagnosis Requiredtenofovir VIREAD brand 2Protease Inhibitors – Diagnosis Requiredatazanavir REYATAZ brand 2
atazanavir REYATAZ POWDER PACKET brand 2
Members ≥ 8 years of age will require prior
authorizationdarunavir PREZISTA brand 2fosamprenavir LEXIVA brand 2indinavir CRIXIVAN brand 2lopinavir/ritonavir KALETRA brand 2 tabletslopinavir/ritonavir KALETRA generic 1 solutionnelfinavir VIRACEPT brand 2ritonavir NORVIR brand 2saquinavir mesylate INVIRASE brand 2tipranavir APTIVUS brand 2Reverse Transcriptase Inhibitors – Diagnosis Requireddelavirdine RESCRIPTOR brand 2efavirenz SUSTIVA brand 2etravirine INTELENCE brand 2nevirapine VIRAMUNE generic 1nevirapine ER VIRAMUNE XR brand 2rilpivirine EDURANT brand 2Miscellaneousabacavir/dolutegravir/
lamivudine TRIUMEQ brand 2 Diagnosis Required
atazanavir/cobicistat EVOTAZ brand 2 Diagnosis Required, QLbictegravir/emtricitabine/
tenofovir alafenamide BIKTARVY brand 2 PA, QL
cobicistat TYBOST brand 2 Diagnosis requiredcobicistat/elvitegravir/
emtricitabine/tenofovir STRIBILD brand 2 PA
darunavir/cobicistat PREZCOBIX brand 2 Diagnosis requireddolutegravir/rilpivirine JULUCA brand 2elvitegravir/cobicistat/
emtricitabine/tenofovir alafenamide fumarate
GENVOYA brand 2 PA
enfuvirtide FUZEON brand 2maraviroc SELZENTRY brand 2 Diagnosis required
35
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Miscellaneousbedaquiline SIRTURO brand 2chloroquine phosphate ARALEN generic 1clindamycin CLEOCIN generic 1 150 mg and 300 mg onlydapsone DAPSONE brand 2hydroxychloroquine PLAQUENIL generic 1linezolid ZYVOX generic 1 PAmefloquine LARIAM generic 1metronidazole FLAGYL generic 1 tabs onlyneomycin sulfate brand 2nitrofurantoin
extended-release MACROBID generic 1
nitrofurantoin macrocrystals MACRODANTIN generic 1
nitrofurantoin susp FURADANTIN SUSP 25 MG/5 ML generic 1
Members ≥ 8 years of age will require prior
authorization.palivizumab SYNAGIS brand 2 PA, SPparomomycin HUMATIN generic 1povidone-iodine generic 1 OTCprimaquine generic 1pyrimethamine DARAPRIM brand 2 PA, SPtrimethoprim TRIMETHOPRIM generic 1 tabs only
Musculoskeletal
ArthritisDisease Modifying Anti-Rheumatic Drugsadalimumab HUMIRA brand 2 PA, SPanakinra KINERET brand 2 PA, SPapremilast OTEZLA brand 2 PA, SPauranofin RIDAURA brand 2azathioprine IMURAN generic 1canakinumab ILARIS brand 2 PA, SPcertolizumab pegol CIMZIA brand 2 PA, SPetanercept ENBREL brand 2 PA, SPhydroxychloroquine PLAQUENIL generic 1leflunomide ARAVA generic 1methotrexate generic 1penicillamine DEPEN TITRATABLE brand 2 Diagnosis Required, SPsarilumab KEVZARA brand 2 PA, QL, SP
36
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
secukinumab COSENTYX brand 2 PA, SPsulfasalazine AZULFIDINE generic 1sulfasalazine
delayed-release AZULFIDINE EN-TABS generic 1
NSAIDs and Other Analgesicsacetaminophen TYLENOL generic 1 OTC
aspirinBAYERECOTRIN
generic 1 OTC
capsaicinCAPSAGELCAPZASIN-PCASTIVA
brand 2 OTC, gel, lotion, 0.035% cream
capsaicin generic 1 OTC, 0.025%, 0.075%, & 0.1% cream
celecoxib CELEBREX generic 1 PA, QL
diclofenac 1% gel VOLTAREN 1% TOPICAL GEL generic 1 PA
diclofenac potassium CATALFAM generic 1diclofenac sodium
delayed-release VOLTAREN generic 1 QL
diclofenac sodium extended-release VOLTAREN XR generic 1
diflunisal DOLOBID generic 1 500 mg tabs onlyetodolac LODINE generic 1 IR only
ibuprofen ADVIL generic 1 tabs, chew tabs and susp, OTC
ibuprofen MOTRIN generic 1 tabs, chew tabs and suspindomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlymeloxicam MOBIC generic 1 QLnabumetone RELAFEN generic 1naproxen NAPROSYN generic 1
naproxen delayed release ENTERIC COATED-NAPROSYN generic 1
oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1salsalate DISALCID generic 1 QLsulindac CLINORIL generic 1
37
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Goutallopurinol ZYLOPRIM generic 1colchicine MITIGARE brand 2colchicine w/ probenecid COLBENEMID generic 1febuxostat ULORIC brand 2 STprobenecid PROBENECID generic 1Skeletal Muscle RelaxantsMuscle Spasmchlorzoxazone PARAFON FORTE DSC generic 1cyclobenzaprine FLEXERIL generic 1 5mg, 10mg, QLmethocarbamol ROBAXIN generic 1orphenadrine
extended-release NORFLEX generic 1
Spasticitybaclofen BACLOFEN generic 1dantrolene DANTRIUM generic 1diazepam VALIUM generic 1 QLtizanidine ZANAFLEX generic 1 tabs only, QL
OB-GYN
ContraceptivesBiphasicdesogestrel/EE MIRCETTE generic 1 QLnorethindrone/EE ORTHO-NOVUM 10/11 generic 1 QLEmergency Contraceptionlevonorgestrel PLAN B ONE STEP generic 1Extended Cyclelevonorgestrel/EE SEASONALE generic 1 QLInjectablemedroxyprogesterone
acetate DEPO-PROVERA generic 1 QL
Intravaginaletonogestrel/EE NUVARING brand 2 ring, QL
ortho diaphragmORTHO COILORTHO FLATORTHO FLEX
brand 2 QL
Monophasic - 20 mcg Estrogenlevonorgestrel/EE ALESSE generic 1 0.1/20, QLnorethindrone acetate/EE LOESTRIN 1/20 generic 1 1/20, QL
38
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
norethindrone acetate/EE/iron LOESTRIN FE 1/20 generic 1 1/20, QL
Monophasic - 30 mcg Estrogendesogestrel/EE ORTHO-CEPT generic 1 0.15/30, QLlevonorgestrel/EE NORDETTE generic 1 0.15/30, QLnorethindrone acetate/EE LOESTRIN 1.5/30 generic 1 1.5/30, QLnorethindrone acetate/EE/
iron LOESTRIN FE 1.5/30 generic 1 1.5/30, QL
norgestrel/EE LO/OVRAL generic 1 0.3/30, QLMonophasic - 35 mcg Estrogenethynodiol diacetate/EE ZOVIA 1/35 generic 1 1/35, QLnorethindrone/EE BALZIVA generic 1 0.4/35, QLnorethindrone/EE MODICON generic 1 0.5/35, QLnorethindrone/EE ORTHO-NOVUM 1/35 generic 1 1/35, QLnorgestimate/EE ORTHO-CYCLEN generic 1 0.25/35, QLMonophasic - 50 mcg Estrogenethynodiol diacetate/EE ZOVIA 1/50 generic 1 1/50, QLnorethindrone/EE OVCON 50 generic 1 1/50, QLnorethindrone/ME ORTHO-NOVUM 1/50 generic 1 1/50, QLnorgestrel/EE OVRAL generic 1 0.5/50, QLProgestinnorethindrone ORTHO MICRONOR generic 1progesterone micronized
cap PROMETRIUM generic 1
Transdermal
norelgestromin/EEORTHO EVRAXULANE
generic 1
Triphasicdesogestrel/EE CYCLESSA generic 1levonorgestrel/EE TRIVORA generic 1 QLnorethindrone/EE ORTHO-NOVUM 7/7/7 generic 1 QLnorethindrone/EE TRI-NORINYL generic 1 QLnorgestimate/EE ORTHO TRI-CYCLEN generic 1 QLEndometriosisdanazol DANOCRINE generic 1Hormone Therapy/MenopauseEstrogens - Injectableestradiol cypionate DEPO-ESTRADIOL brand 2
39
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Estrogens - Intravaginalestradiol ESTRACE CRM generic 1
estradiol vaginal tabletVAGIFEMYUVAFEM
generic 1 QL
estrogens, conjugated PREMARIN brand 2 crmEstrogens - Oralestradiol ESTRACE generic 1estrogens, conjugated PREMARIN brand 2estrogens, conjugated,
synthetic A CENESTIN brand 2
estropipate OGEN generic 1Estrogens - Transdermalestradiol CLIMARA generic 1 QLestradiol td ALORA brand 2 patchEstrogen/Progestinestrogens, conjugated/
medroxyprogesteronePREMPHASEPREMPRO
brand 2
Progestinsmedroxyprogesterone
acetate PROVERA generic 1
norethindrone acetate AYGESTIN generic 1progesterone micronized PROMETRIUM generic 1Ovulation Stimulantschoriogonadotropin alfa OVIDREL brand 2 Diagnosis Requiredchorionic gonadotropin NOVAREL brand 2 Diagnosis RequiredVaginal InfectionsOralfluconazole DIFLUCAN generic 1 QLmetronidazole FLAGYL generic 1 tabsVaginalclotrimazole GYNE-LOTRIMIN generic 1 OTCclindamycin CLEOCIN brand 2 suppclindamycin CLEOCIN generic 1 crm
metronidazoleMETROGEL-VAGINAL METROGEL 1%
generic 1
miconazole MONISTAT generic 1 OTCmiconazole MONISTAT 3 generic 1terconazole TERAZOL 3/7 generic 1
40
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Miscellaneousconjugated estrogen/
bazedoxifene DUAVEE brand 2
methylergonovine METHERGINE generic 1tranexamic acid LYSTEDA generic 1 PA
Ophthalmic
Allergyazelastine OPTIVAR generic 1 STcromolyn sodium CROLOM generic 1 QLketotifen ALAWAY OTC generic 1ketotifen ZADITOR generic 1 QL
naphazoline/glycerin CLEAR EYES REDNESS RELIEF generic 1
naphazoline HCL VASOCLEAR generic 1 soln 0.02%naphazoline/zinc sulfate VASOCLEAR A brand 2 OTCtetrahydrozoline/
zinc sulfate VISINE-AC generic 1
Anti-InflammatoriesAnti-Infective/Anti-Inflammatory Combinationsbacitracin/polymyxin/
neomycin/hc CORTISPORIN generic 1 ointment
gentamicin/prednisolone acetate PRED-G brand 2
neomycin/polymyxin B/dexamethasone MAXITROL generic 1
neomycin/polymyxin B/hydrocortisone CORTISPORIN generic 1 suspension
sulfacetamide/pred phos VASOCIDIN generic 1 10%/0.25%tobramycin/
dexamethasone TOBRADEX generic 1
Nonsteroidaldiclofenac sodium VOLTAREN generic 1flurbiprofen OCUFEN generic 1ketorolac ACULAR/ACULAR LS genericSteroidaldexamethasone sodium
phosphate DEXASOL generic 1 soln 0.1%
fluorometholone FML brand 2 oint 0.1%
41
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
fluorometholone FML FORTE brand 2 susp 0.25%fluorometholone FML LIQUIFILM generic 1 susp 0.1%prednisolone acetate PRED FORTE generic 1 1%prednisolone acetate PRED MILD brand 2 0.12%prednisolone phosphate INFLAMASE FORTE generic 1 1%rimexolone VEXOL brand 2GlaucomaBeta-Blockerscarteolol generic 1 0.3% ophthalmic solutionlevobunolol BETAGAN generic 1 ophthalmic solutionmetipranolol OPTIPRANOLOL generic 1 0.3% ophthalmic solutiontimolol TIMOPTIC XE generic 1 gel forming solutiontimolol maleate TIMOPTIC generic 1Carbonic Anhydrase Inhibitorsdorzolamide TRUSOPT generic 1Carbonic Anhydrase Inhibitor/Beta-Blocker Combinationdorzolamide/
timolol maleate COSOPT generic 1
Cholinesterase Inhibitorecothiophate PHOSPHOLINE IODINE brand 2Mydriaticsatropine ISOPTO ATROPINE generic 1cyclopentolate CYCLOGYL generic 1 1%homatropine ISOPTO HOMATROPINE generic 1 5%homatropine ISOPTO HOMATROPINE brand 2 2%scopolamine ISOPTO HYOSCINE brand 2Oralacetazolamide ACETAZOLAMIDE generic 1acetazolamide
extended-release DIAMOX SEQUELS generic 1
methazolamide NEPTAZANE generic 1Prostaglandinslatanoprost XALATAN generic 1 QLTopical - Parasympathomimeticspilocarpine PILOPINE HS GEL brand 2pilocarpine ISOPTO CARPINE generic 1Topical - Sympathomimeticsbrimonidine ALPHAGAN P generic 1 0.15%brimonidine ALPHAGAN generic 1 0.2%
42
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Immunologic Agentslifitegrast XIIDRA brand 2 PAInfectionsBacterialbacitracin generic 1ciprofloxacin CILOXAN generic 1 solutionciprofloxacin CILOXAN brand 2 ointmenterythromycin ERYTHROMYCIN generic 1gentamicin GENTAK generic 1neomycin/bacitracin/
polymyxin NEOSPORIN generic 1 ointment
neomycin/polymyxin B/gramicidin NEOSPORIN generic 1 solution
ofloxacin OCUFLOX generic 1polymyxin B/bacitracin POLYSPORIN generic 1polymyxin B/trimethoprim POLYTRIM generic 1sulfacetamide BLEPH-10 generic 1 oint/solntobramycin TOBREX generic 1Viral trifluridine VIROPTIC generic 1Miscellaneouscysteamine 0.44%
ophthalmic solution CYSTARAN brand 2 Diagnosis Required, SP
sodium chloride hypertonic MURO 128 generic 1 soln 5%
sodium chloride hypertonic ophth soln ALTACHLORE generic 1 OTC
tetracaine hcl ophth soln ALTACAINE generic 1
Psychiatric
Alcohol Deterrentsacamprosate CAMPRAL brand 2disulfiram ANTABUSE generic 1naltrexone REVIA generic 1AnxietyBenzodiazepinesalprazolam XANAX generic 1 QL, IR onlychlordiazepoxide LIBRIUM generic 1
43
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
clonazepam KLONOPIN generic 1 not wafersclorazepate TRANXENE generic 1diazepam VALIUM generic 1 QLlorazepam ATIVAN generic 1 QLoxazepam SERAX generic 1 QLMiscellaneousbuspirone BUSPAR generic 1clomipramine ANAFRANIL generic 1fluvoxamine LUVOX generic 1Attention Deficit Hyperactivity Disorder (ADHD) – Diagnosis Requiredamphetamine/
dextroamphetamine mixed salts
ADDERALL generic 1 Age Limits Apply, QL
amphetamine/ dextroamphetamine mixed salts extended-release
ADDERALL XR (BRAND ADDERALL XR IS PREFERRED)
brand 2 Age Limits Apply, QL
atomoxetine STRATTERA generic 1 QLdexmethylphenidate FOCALIN generic 1 Age Limits Apply, QLguanfacine ER INTUNIV generic 1lisdexamfetamine VYVANSE brand 2 Age Limits Apply, QLlisdexamfetamine
chewable tab VYVANSE CHEWABLE brand 2 QL
methylphenidate RITALIN generic 1 Age Limits Apply, tabs only, QL
methylphenidate extended-release METADATE ER generic 1 Age Limits Apply, QL
methylphenidate extended-release RITALIN LA generic 1 Age Limits Apply, QL,
20 mg, 30 mg, 40 mg caps
methylphenidate HCL ER 24hr generic 1
Age Limits Apply, QL, 18 mg, 27 mg, 36 mg,
54 mg tablets, Mallinckrodt and Kremers
Urban labelersBipolar Disorderdivalproex sodium
cap sprinkle DEPAKOTE SPRINKLE generic 1Members ≥ 8 years of age will require prior
authorization.divalproex sodium
delayed-release DEPAKOTE generic 1 Minimum age 2
lithium carbonate LITHIUM CARBONATE generic 1lithium carbonate
extended-releaseESKALITH CR LITHOBID
generic 1
44
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Depression*Monoamine Oxidase Inhibitor (MAOI)tranylcypromine* PARNATE* generic 1Selective Serotonin Reuptake Inhibitor (SSRIs)citalopram* CELEXA* generic 1 QLescitalopram* LEXAPRO* generic 1 tablets, QL
fluoxetine* PROZAC* generic 1 10 mg and 20 mg caps and 20 mg soln only
paroxetine PAXIL* generic 1 QLsertraline* ZOLOFT* generic 1 tablets, QLSerotonin Norepinephrine Reuptake Inhibitors (SNRIs)duloxetine* CYMBALTA* generic 1 QLvenlafaxine* EFFEXOR* generic 1 QLvenlafaxine XR* EFFEXOR XR* generic 1 QLTricyclic Antidepressants (TCAs)amitriptyline* ELAVIL* generic 1 tabletsamoxapine* generic 1desipramine* NORPRAMIN* generic 1doxepin* SINEQUAN* generic 1imipramine HCL* TOFRANIL* generic 1 tabletsnortriptyline* PAMELOR* generic 1Tricyclic Antidepressant/Phenothiazine Combinationamitriptyline/
perphenazine* TRIAVIL* generic 1
Miscellaneous Agentsbupropion* WELLBUTRIN* generic 1bupropion
extended-release* WELLBUTRIN SR* generic 1 QL
bupropion extended-release* WELLBUTRIN XL* generic 1 150 mg and 300 mg
chlordiazepoxide- amitriptyline* LIMBITROL* generic 1
maprotiline* LUDIOMIL* generic 1mirtazapine* REMERON* generic 1 tabs (not soltabs)nefazodone hcl* SERZONE* generic 1
trazodone* DESYREL* generic 1 50mg, 100mg, 150mg only
45
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
InsomniaBenzodiazepinesestazolam PROSOM generic 1flurazepam DALMANE generic 1 QLtemazepam RESTORIL generic 1 QL triazolam HALCION generic 1 QLNon-Benzodiazepineschloral hydrate CHLORAL HYDRATE generic 1diphenhydramine NYTOL QUICK CAPS generic 1 OTCdoxylamine succinate UNISOM generic 1 25mg, OTC, QLzaleplon SONATA generic 1 QLzolpidem AMBIEN generic 1 QLMedications Coverable for Participating Behavioral Health Prescribers*apomorphine
hydrochloride inj* APOKYN* brand 2 SP
aripiprazole ODT* ABILIFY DISCMELT* brand 2 Age Limits Applyaripiprazole oral solution* ABILIFY SOLUTION* brand 2 Age Limits Applyasenapine maleate
sublingual* SAPHRIS* brand 2 Age Limits Apply, QL
brexpiprazole* REXULTI* brand 2 QLbupropion HCL tab SR
24HR* FORFIVO XL* brand 2
bupropion hydrobromide* APLENZIN* brand 2carbamazepine
(antipsychotic) cap SR 12HR*
EQUETRO* brand 2
chlorpromazine hcl inj* THORAZINE INJ* generic 1clozapine* CLOZARIL* generic 1 200 mg, Age Limits Applyclozapine ODT* FAZACLO* generic 1 Age Limits Applyclozapine susp* VERSACLOZ* brand 2
desvenlafaxine fumarate tab SR 24HR*
DESVENLAFAXINE FUMARATE TAB SR 24HR*
generic 1
desvenlafaxine succinate tab SR 24HR* PRISTIQ* generic 1
desvenlafaxine tab SR 24HR* KHEDEZLA* generic 1
46
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
duloxetine* IRENKA* generic 1escitalopram oxalate soln* LEXAPRO SOLUTION* generic 1escitalopram &
methylfolate-B12-B6-D cap thpk*
PRAMLYTE* brand 2
fluoxetine capsule* PROZAC* generic 1 40mgfluoxetine HCL cap
delayed release 90 mg* PROZAC WEEKLY* generic 1
fluvoxamine maleate cap SR 24HR* LUVOX CR* generic 1
fluoxetine tablet* FLUOXETINE* generic 1iloperidone* FANAPT* brand 2 Age Limits Apply, QLimipramine pamoate* TOFRANIL-PM* generic 1isocarboxazid* MARPLAN* brand 2levomilnacipran* FETZIMA* brand 2loxapine aerosol powder
breath activated* ADASUVE* brand 2
lurasidone* LATUDA* brand 2 Age Limits Apply, QLmetreleptin* MYALEPT* brand 2 SPmirtazapine ODT* REMERON SOLTAB* generic 1olanzapine for IM inj* ZYPREXA* generic 1 injectableolanzapine-fluoxetine* SYMBYAX* generic 1 Age Limits Applyolanzapine ODT* ZYPREXA ZYDIS* generic 1 Age Limits Applyolanzapine pamoate for
extended rel IM sus* ZYPREXA RELPREVV* brand 2 Diagnosis Required, QL
paliperidone tab SR 24HR* INVEGA* generic 1 Age Limits Apply
paroxetine HCL tab SR 24HR* PAXIL CR* generic 1
paroxetine mesylate tab* PEXEVA* brand 2phenelzine* NARDIL* generic 1pimavanserin* NUPLAZID* brand 2protriptyline* VIVACTIL* generic 1quetiapine fumarate tab
SR 24HR* SEROQUEL XR* generic 1 Age Limits Apply
risperidone microspheres for inj* RISPERDAL CONSTA* brand 2 Age Limits Apply, QL
risperidone ODT* RISPERDAL M-TAB* generic 1 Age Limits Apply
47
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
selegiline td patch* EMSAM* brand 2tasimelteon* HETLIOZ* brand 2 SPtrazodone* DESYREL* generic 1 300mgtrimipramine* SURMONTIL* brand 2venlafaxine HCL tab SR
24HR*VENLAFAXINE HCL TAB SR
24HR* generic 1
vilazodone* VIIBRYD* brand 2vortioxetine* TRINTELLIX* brand 2 tabsNarcotic Antagonistsbuprenorphine SUBUTEX generic 1 PA required for males
only, QLbuprenorphine/naloxone
buccal film BUNAVAIL brand 2
buprenorphine/naloxone SL ZUBSOLV brand 2
buprenorphine/naloxone SL film SUBOXONE brand 2 QL
buprenorphine/naloxone SL tab SUBOXONE generic 1
naloxone NALOXONE INJ generic 1 QLnaloxone NARCAN NASAL SPRAY brand 2naltrexone REVIA generic 1PsychosesAtypicals*
aripiprazole* ABILIFY TABLETS* generic 1 Age Limit Applies, tablets, QL
aripiprazole ER injection* ABILIFY MAINTENA* brand 2 Age Limit Applies, PA, QLaripiprazole lauroxil IM ER
susp* ARISTADA* brand 2 PA, QL
clozapine* CLOZARIL* generic 125mg, 50mg, 100mg
only, Age Limit Applies, QL
dextromethorphan/ quinidine* NUEDEXTA* brand 2 Diagnosis Required
olanzapine* ZYPREXA* generic 1 Age Limit Applies, tablets, QL
paliperidone* INVEGA SUSTENNA* brand 2 Age Limit Applies, PA, QLpaliperidone* INVEGA TRINZA* brand 2 Age Limit Applies, PA, QLquetiapine* SEROQUEL* generic 1 Age Limit Applies, QL
48
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
risperidone* RISPERDAL* generic 1 Age Limit Applies, QL, (Not M-Tabs)
risperidone* RISPERDAL CONSTA* brand 2 Age Limit Applies, PA, QL
risperidone oral soln* RISPERDAL SOLUTION* generic 1QL, Members ≥ 8 years of age will require prior
authorization.ziprasidone* GEODON* generic 1 Age Limit Applies, QLSmoking Cessationbupropion HCl ZYBAN brand 2nicotine NICODERM CQ generic 1 patches, QLnicotine inhaler system NICOTROL INHALER brand 2 QLnicotine nasal spray NICOTROL NASAL SPRAY brand 2 QLnicotine polacrilex gum NICORETTE OTC generic 1 QLnicotine polacrilex lozenge COMMITT OTC generic 1 QLvarenicline CHANTIX brand 2 PA, QLMiscellaneouschlorpromazine THORAZINE generic 1fluphenazine PROLIXIN generic 1fluphenazine decanoate PROLIXIN DECANOATE generic 1haloperidol HALDOL generic 1 tab, inj, decanoate onlyloxapine LOXITANE generic 1perphenazine TRILAFON generic 1pimozide ORAP generic 1thioridazine MELLARIL generic 1thiothixene NAVANE generic 1trifluoperazine STELAZINE generic 1
Respiratory DrugsAntitussives, Decongestants, Expectorants and Combinationsbenzonatate TESSALON generic 1brompheniramine &
phenylephrineDIMETAPP CLD ELX/
ALLERGY generic 1
brompheniramine/ pseudoephedrine
ACCUHIST DROPS UNI-HIST DROPS
generic 1
brompheniramine/ pseudoephedrine/ dextromethorphan
BROMFED DM generic 1 syrup
chlorphen tan/ carbetapentane tan TUSSI-12 S generic 1 susp
chlorphen tan/pyrilamine tan/PE tan
TRIOTANN PEDIATRIC SUSP
R-TANNAMINEgeneric 1 susp
49
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
chlorpheniramine/ dextromethorphan
ROBITUSSIN PED LIQ CGH/COLD
ROBITUSSIN LIQ CGH/CLD
DIMETAPP SYP CGH/CLDCORICIDIN TAB
CGH/CLD
generic 1
chlorpheniramine maleate phenylephrine HCL
ED A-HIST TABLETS AND LIQUID generic 1
chlorpheniramine/ phenylephrine
RONDEC DROPSCARDEC DRO
generic 1 liquid
chlorpheniramine/ phenylephrine
RONDEC SYRUPCARDEC SYP
generic 1 syrup
chlorpheniramine/ pseudoephedrine LOHIST-D generic 1
chlorpheniramine tan/ phenylephrine tan RYNATAN PEDIATRIC SUSP generic 1 susp
codeine/ chlorpheniramine/pseudoephedrine
DIHISTINE DH PHENYLHIST LIQ DH
generic 1 Age Limits Apply, QL
codeine/guaifenesinGUIATUSS AC GG/CODEINE M-CLEAR WC
generic 1 Age Limits Apply, QL
codeine/guaifenesin/pseudoephedrine GUIATUSS DAC generic 1
codeine/promethazine PROMETHAZINE W/CODEINE generic 1 Age Limits Apply, QL
codeine/promethazine/phenylephrine
PROMETHAZINE VC W/CODEINE generic 1 Age Limits Apply, QL
dextromethorphan/ brompheniramine/pseudoephedrine
BROMETANE DX generic 1
dextromethorphan- guaifenesin DURATUSS DM ELX generic 1 soln 25-225 mg/5 ml
dextromethorphan/ guaifenesin
GG/DM CRMUCINEX DMROBITUSSIN DMTUSSIN DM
generic 1 OTC
50
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
dextromethorphan- guaifenesin
ROBITUSSIN LIQ CGH/CONG generic 1 liq 10-200 mg/ 5 ml
dextromethorphan hbrROBITUSSIN SYP MAX-STROBITUSSIN PED SYP
generic 1 syrup
dextromethorphan polistirex extended-release
DELSYM brand 2 OTC
dextromethorphan/ promethazine
PHENERGAN DMPROMETHAZINE SYP DM
generic 1
guaifenesin ROBITUSSIN generic 1 OTC
guaifenesin ROBITUSSIN SYP CHST CNG generic 1 syrup 100 mg/5 ml
guaifenesin extended-release MUCINEX generic 1 OTC
guaifenesin/ pseudoephedrine
ROBITUSSIN PE PSE/GG
generic 1 syrup, OTC
guaifenesin/ pseudoephedrine/ dextromethorphan
ROBITUSSIN CF generic 1
guaifenesin/ pseudoephedrine extended-release
MUCINEX D generic 1 OTC
hydrocodone/ homatropine
HYCODANHYDROMET SYPHYDROCODONE/
TAB HOMATROP
generic 1 Age Limits Apply, QL
loratadine & pseudoephedrine SR 24hr
CLARITIN-D generic 1
phenylephrine/ brompheniramine/ dextromethorphan
generic 1 OTC
phenylephrine/ chlorpheniramine/ dextromethorphan
RONDEC DMSTATUSS DM SYPCARDEC DM SYPMINUTUSS DR SYP
generic 1 syrup
51
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
phenylephrine/ chlorpheniramine/ dextromethorphan
RONDEC DM DROPSCARDEC DM DROROBITUSSIN LIQ
CGH/ALRG
generic 1 liquid
phenylephrine/ chlorpheniramine/ dihydrocodeine
DIHYDRO-PE SYP generic 1
phenylephrine/ dextromethorphan
DIMETAPP DRO DCON/CGH generic 1
phenylephrine/ dextromethorphan/guaifenesin
ROBITUSSIN LIQ CGH/CLD generic 1
phenylephrine/ephed/CPM w/carbetapentane
RYNATUSS PEDIATRIC SUSP generic 1 susp
phenylephrine/guaifenesin ROBITUSSIN LIQ HD/CHST generic 1
phenylephrine/ pyrilamine w/hydrocodone
CODIMAL DH generic 1 syrup
potassium iodide SSKI brand 2 solnpromethazine &
phenylephrinePROMETH VC SYP
6.25-5/5 generic 1 syrup 6.25-5 mg/ 5 mg
pseudoephedrine/ acetaminophen/ dextromethorphan
MAPAP COLD TAB generic 1
pseudoephedrine/ chlorpheniramine/ dextromethorphan
PEDIACARE LIQ MULTI-SY
ROBITUSSIN LIQ PED NGHT
generic 1
pseudoephedrine/ dextromethorphan/guaifenesin
MULTI SYMPTOM TAB COLD RLF generic 1
pseudoephedrine/ iburprofen
CHILD IBUPRO SUS COLD
IBUOROFEN TAB COLD/SIN
generic 1
52
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
pseudoephedrine tan/ dexchlorphen tan/ DM tan
TANAFED DMX SUSPENSION
TRI-FED Xgeneric 1 susp
pyrilamine tan/phenyleph tan RYNA-12 S generic 1 susp
tripolidine/ pseudoephedrine
TRIPROL/PSE SYPAPHEDRID TAB
generic 1
Asthma/COPDInhalers - Beta Agonistsalbuterol sulfate VENTOLIN HFA brand 2 QLindacaterol ARCAPTA NEOHALER brand 2olodaterol STRIVERDI RESPIMAT brand 2Inhalers - Corticosteroidsbeclomethasone QVAR REDIHALER brand 2 QLfluticasone furoate ARNUITY ELLIPTA brand 2 QL
mometasone inhalation ASMANEX HFA brand 2Patients 8 years and
older will require prior authorization, QL
Inhalers - Corticosteroid/Beta Agonist Combinationsfluticasone/salmeterol AIRDUO RESPICLICK generic 1 QLInhalers - Othersipratropium/albuterol COMBIVENT brand 2 QLipratropium/albuterol COMBIVENT RESPIMAT brand 2 inhaleripratropium HFA ATROVENT HFA brand 2omalizumab XOLAIR brand 2 PA, SPtiotropium/olodaterol STIOLTO RESPIMAT brand 2umeclidinium inhalation INCRUSE ELLIPTA brand 2Inhalers for Nebulization
albuterol ACCUNEB generic 1
0.63 mg/3 ml and 1.25 mg /3 ml, Covered for members less than 8
years of age. Members ≥ 8 years of age will require
prior authorization.albuterol PROVENTIL generic 1 soln 0.083%, 0.5%albuterol sulfate ACCUNEB generic 1 soln nebu
budesonide PULMICORT RESPULES generic 1susp, Members ≥ 5 yearsof age will require prior
authorization. QL
53
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
cromolyn INTAL generic 1 soln, QLipratropium ATROVENT generic 1 soln, QLipratropium/albuterol DUONEB generic 1 solnlevalbuterol HCl XOPENEX RESPULES generic 1 QL, STOral Agents - Beta Agonistsalbuterol sulfate VOSPIRE ER generic 1 tabmetaproterenol METAPROTERENOL SYRUP generic 1terbutaline BRETHINE generic 1Oral Agents - Leukotriene Modifiersmontelukast SINGULAIR generic 1 QLOral Agents - Theophyllinetheophylline THEOPHYLLINE generic 1 liquidtheophylline
extended-release THEO-24 brand 2 caps
theophylline extended-release
THEOCHRONUNIPHYL
generic 1 tabs
Urological
Symptomatic Benign Prostatic Hypertrophyalfuzosin ER UROXATRAL generic 1doxazosin CARDURA generic 1finasteride PROSCAR generic 1tamsulosin FLOMAX generic 1terazosin HYTRIN generic 1Miscellaneousbethanechol URECHOLINE generic 1flavoxate hcl FLAVOXATE generic 1hyoscyamine,
methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue
UTIRA C brand 2
methenamine hippurateHIPREXUREX
generic 1
oxybutynin chloride DITROPAN XL generic 1 QLoxybutynin IR DITROPAN generic 1
54
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
oxybutynin patch OXYTROL FOR WOMEN OTC PATCH brand 2
pentosan polysulfate sodium ELMIRON brand 2 Diagnosis Required
phenazopyridine PYRIDIUM generic 1potassium citrate UROCIT-K generic 1propantheline generic 1sodium citrate/citric acid BICITRA generic 1tolterodine DETROL generic 1 STtrospium SANCTURA generic 1 ST
Vitamins and Mineralsb-complex w/c & e VI-STRESS generic 1 tab, OTCb-complex w/c & e + zn BEC/ZINC generic 1 tab, OTCb-complex w/ c &
folic acid EQL B COMPLEX generic 1 tab, OTC
b-complex w/minerals GERAVIM generic 1 liq, OTCcalcitriol ROCALTROL generic 1
calcitriol oral soln ROCALTROL SOLUTION generic 1Members ≥ 8 years of age will require prior
authorization.calcium OS-CAL generic 1 OTCcyanocobalamin VITAMIN B-12 generic 1 injelectrolyte PEDIALYTE generic 1 soln, oral, OTCergocalciferol (D2) DRISDOL generic 1ferrous bisglycinate/
polysaccarides iron NIFEREX generic 1 caps, OTC
ferrous sulfate FEOSOL generic 1 OTC
fluoride
GEL-KAMLURIDE LURIDE LOZI-TABSPREVIDENTPHOS-FLUR
generic 1
folic acid FOLIC ACID generic 1folic acid-vitamin
b6-vitamin b12 FABB brand 2 tab 2.2-25-1 mg, PA
magnesium chloride MAG64 generic 1 OTCmagnesium oxide MAG-OX generic 1 OTCmultiple vitamin THERA-PLUS generic 1 liquid, OTC
55
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
multivitamins/fluoride/±iron POLY-VI-FLOR generic 1
multivitamins/minerals CENTRUM generic 1 OTCphytonadione MEPHYTON brand 2polysaccharide iron
complex NIFEREX generic 1 elixir, OTC
prenat-FE Bis-FE prot succ-FA-CA & omega 3
COMPLETE NATALCARE PAK DHA brand 2
prenat-FE Bis-FE prot succ-FA-CA & omega 3
TRUST NATALCARE PAK DHA brand 2
prenat-FE Bis-FE prot succ-FA-CA & omega 3
PRUET DHA PAK SETONET PAK brand 2
prenat-FE bis-FE prot succ-FA-CA & omega DR
PRUET DHAEC PAK brand 2
prenat w/o A w/fecbn-fegl-DSS-FA & DHA
FOLTABS PAK PLUS DHA RE OB + DHA PAK brand 2
prenatal vit w/FE bisglycinate chelate-FA
VINATE II brand 2
prenatal vit w/FE bisglycinate chelate-FA
GENTEX ADE 28-1 MG brand 2
prenatal vit w/FE bisglycinate chelate-FA
VINATE AZ EX brand 2
prenatal vit w/FE polysac cmplx-FA EDGE OB CHW brand 2
prenatal vit w/iron carbonyl-FA ATABEX PRENATAL brand 2
56
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
prenatal vitamins w/folic acid
PRENATAL VITAMINS W/ FOLIC ACID
CENOGEN OB/ULTRAMATERNANATALCARENESTABSCBF/FA/RXNIFEREX-PN FORTE
generic 1 QL
prenatal w/o A w/FE carbonyl-FE gluc-DSS-FA
FOLTABS PRENATALTRI RX
brand 2
vitamin A generic 1 OTCvitamin ADC/fluoride/±iron
drops TRI-VI-FLOR generic 1
vitamin B complex/ vitamin C/folic acid NEPHROCAPS generic 1
vitamin B-1 generic 1 OTCvitamin B-6 generic 1 OTCvitamin C generic 1 OTCvitamin D generic 1 OTCvitamin E generic 1 OTC
vitamins pediatric TRI-VI-SOL generic 1 members <3 years old, OTC
zinc generic 1 OTCzinc sulfate ZINCATE generic 1 OTC, 220 mgPotassiumphosphorus K-PHOS NEUTRAL generic 1 tabspotassium acid phosphate K-PHOS ORIGINAL brand 2potassium bicarbonate/
potassium citrate effervescent
K-LYTE generic 1 tabs
potassium chloride K-LOR generic 1 powderpotassium chloride POTASSIUM CHLORIDE generic 1 liquid
potassium chloride extended-release
K-DUR 10K-DUR 20KLOR-CON 8 KLOR-CON 10
generic 1 tabs
potassium chloride extended-release K-TAB generic 1 QL
potassium chloride extended-release MICRO-K 10 generic 1 caps
57
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Miscellaneous
Anaphylaxis
epinephrineEPIPEN EPIPEN JR.
generic 1 QL
Antidotesacetylcysteine CETYLEV brand 2succimer CHEMET brand 2 QLCystic Fibrosisacetylcysteine MUCOMYST generic 1aztreonam CAYSTON brand 2 Diagnosis Required, SPdornase alfa PULMOZYME brand 2 Diagnosis Required, SP
ivacaftorKALYDECOKALYDECO GRANULES
brand 2 PA, SP
lumacaftor/ivacaftor ORKAMBI brand 2 PA, SPsodium chloride for
nebulizerHYPERSALNEBUSAL
generic 1
tezacaftor/ivcaftor SYMDEKO brand 2 PA, QL, SPtobramycin neb soln BETHKIS brand 2 Diagnosis Required, SPHereditary Angioedemac1 esterase inhibitor
(human) BERINERT brand 2 PA, SP
c1 esterase inhibitor (human) HAEGARDA brand 2 PA, QL, SP
icatibant FIRAZYR brand 2 PA, SPHyperphosphatemiacalcium acetate generic 1 667 mg tablet onlycinacalcet SENSIPAR brand 2 PAsevelamer RENVELA generic 1 ST, tabsIdiopathic Pulmonary Fibrosis (IPF)nintedanib OFEV brand 2 PA, SPpirfenidone capsule ESBRIET brand 2 PA, SPImmune Thrombocytopenic Purpuraeltrombopag PROMACTA brand 2 PA, SPMedical Devicesinsulin pen needle QL, BD brand onlyinsulin syringes QL, BD brand onlylancets QLspacers QL
58
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
Metabolic Modifierscarglumic acid CARBAGLU brand 2 PA, SPglycerol phenylbutyrate RAVICTI brand 2 PA, SP
sodium phenylbutyrate BUPHENYL ORAL POWDER generic 1 PA, SP
Vaccinediphtheria-tetanus tox
adsorbed (dt) im DIP/TET PED INJ brand 2 QL
hepatitis a vaccine suspHAVRIXVAQTA
brand 2 QL
hepatitis b vaccine (recombinant)
ENGERIX-BRECOMBIVAX HB
brand 2 QL
hepatitis b vaccine recombinant adjuvanted
HEPLISAV-B brand 2 Age Limits Apply
human papillomavirus (hpv) 9-valent recomb vac GARDASIL 9 brand 2 QL
human papillomavirus (hpv) quadrivalent recombinant vac
GARDASIL brand 2 QL
influenza virus vaccine recombinant hemagglutinin (ha)
FLUBLOK brand 2 QL
influenza virus vaccine split
AFLURIAFLUZONE SPLT
brand 2 QL
influenza virus vaccine split high-dose pf FLUZONE HD PF brand 2 QL
influenza virus vaccine split pf AFLURIA PF brand 2 QL
influenza virus vaccine split quadrivalent
FLUARIX QUADFLULAVAL QUAD FLUZONE QUAD
brand 2 QL
influenza virus vaccine tiss-cult subunit FLUCELVAX brand 2 QL
influenza virus vaccine types a&b surface antigen
FLUVIRIN brand 2 QL
59
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits
measles, mumps & rubella virus vaccines for inj M-M-R II brand 2 QL
meningococcal (a, c, y, and w-135) MENOMUNE brand 2 QL
meningococcal (a, c, y, and w-135) conjugate vaccine
MENACTRA brand 2 QL
meningococcal (a, c, y, and w-135) oligo conj vac for inj
MENVEO brand 2 QL
pneumococcal 13-valent conjugate PREVNAR 13 brand 2 QL
pneumococcal vaccine polyvalent
PNEUMOVAXPNEUMOVAX 23
brand 2 QL
tet tox-diph-acell pertuss ad
ADACELBOOSTRIX
brand 2 QL
tetanus immune globulin (human) HYPERTET S/D brand 2 QL
tetanus-diphtheria toxoids (td)
TENIVACTET/DIP TOX INJ
brand 2 QL
typhoid vaccine VIVOTIF BERNA brand 2 capsulesvaricella virus vac live for
subcutaneous VARIVAX brand 2 QL
zoster vaccine live ZOSTAVAX brand 2 QL, Age Limits Applyzoster vaccine
recombinant adjuvanted
SHINGRIX brand 2 Age Minimum 50
Miscellaneoussodium chloride irrigation
soln 0.9% generic 1
60
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Examples
OTC MEDICATIONS
The following is a list of OTC products on the PDL. Some OTC products are listed on the drug
list. OTC products covered are restricted to generics when available. Brand names are provided
as reference only.Acneadapalene gel DIFFERIN OTC GEL 0.1%benzoyl peroxide crm, gel, lotion CLEARASILsalicylic acid lotion 2% SALACAntifungalsclotrimazole
miconazole crm
tolnaftate
MICATINLOTRIMIN AFTINACTIN
vaginal productsMONISTATGYNE-LOTRIMIN
Antiviralsdocosanol ABREVA OTC CREAMAtopic Dermatitisdimethicone lotion 3% ALOE VESTA
emollients
BETACARE CREAM AND LOTIONCETAPHIL CREAM AND LOTIONDERMAPHOR OINTMENTE-OINTMENTGLYCERIN TOPICAL
Cough/Cold Allergy
antihistamines
CHLOR-TRIMETONBENADRYLCLARITINALAVERTZYRTEC
Antihistamine/Decongestant Combinationsbrompheniramine/pseudoephedrine DIMETAPPcetirizine/pseudoephedrine ZYRTEC Dchlorpheniramine/pseudoephedrine ACTIFED
61
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Examples
loratadine/pseudoephedrineALAVERT ALRG TAB/SINUSALAVERT D ALLERGY/CONG
Cough/Cold
antitussives
Age edit applied. Not covered for members under the age 2.
ROBITUSSINROBITUSSIN DMROBITUSSIN PEROBITUSSIN CFDELSYM
nasal spraysNEO-SYNEPHRINEAFRINDIMETAPP DRO DECONGES
Diabetesalcohol swabs CURITY ALCOHOL PADSglucose gel 40% GLUTOSE 15glucose oral tablets
insulin (vials only) HUMULINNOVOLIN
Earwax Removal Productscarbamide peroxide DEBROXFamily Planning
condom-male
TROJAN KIMONOLIFESTYLESTRUSTEXDUREXFANTASY
contraceptive foam DELFENcontraceptive gel GYNOL IIFirst AidBurow’s soln, wet dressings DOMEBOROdermatological baths COLLOIDAL OATMEAL BATHShydrocortisone crm, oint CORTAID
topical antibacterialsNEOSPORINBACITRACIN
62
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Examples
Gastrointestinalaluminum hydroxide gel susp (320 mg/5 ml only) ALUMINUM HYDROXIDE
antacids liquids, chew tabsMYLANTA LIQUIDMAALOX LIQUIDTUMS
antidiarrhealsIMODIUM A-DKAOPECTATE
electrolyte rehydrating soln PEDIALYTEfamotidine PEPCID AClaxative enemas FLEET ENEMA
laxativesDULCOLAXFLEET PHOSPHO-SODA
magnesium hydroxide susp MILK OF MAGNESIA
probiotics
ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD
psylliumMETAMUCILKONSYL-D
rectal crm, suppositories PREPARATION Hsimethicone MYLICONstool softeners COLACEsugar+orthophosphoric acid EMETROLInsomniadoxylamine succinate UNISOMLice Productspermethrin NIXpyrethrins/piperonyl butoxide shampoo RID SHAMPOOMotion Sicknessdimenhydrinate DRAMAMINEmeclizine BONINE
63
OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit
ST = Step TherapySP = Specialty Pharmacy
*Available without PA for participating Behavioral Health Prescribers
Generic Drug Name Brand Drug Name Examples
Ophthalmics
allergic conjunctivitisALAWAYZADITOR
artificial tears HYPOTEARS
decongestantsVISINEMURINENAPHCON A
Painacetaminophen tabs, liquid,
drops, suppositories, chew tabs TYLENOL
aspirin tabs, EC tabs, chew tabsBAYERECOTRIN
aspirin with buffers tabs
ibuprofen tabs, chew tabs, susp, and drops ADVILMOTRIN IB
Smoking Cessation Products
nicotineCOMMIT LOZENGES (QUANTITY LIMIT)NICODERM CQ (QUANTITY LIMIT)NICOTINE GUM (QUANTITY LIMIT)
Urologicaloxybutynin patch OXYTROL FOR WOMEN OTC PATCHVitamins/Minerals
calciumOS-CALCALTRATETUMS
iron ferrous fumarate, ferrous gluconate, ferrous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps
FERGONFEOSOL
iron polysaccharides NIFEREXmagnesium oxide MAG-OXvitamin D 400 IU VITAMIN D 400 IU
vitamins pediatric members <3 years oldVI-DAYLINPOLY-VI-SOLTRI-VI-SOL
vitamins prenatal STUART PRENATALWartssalicylic acid 17%/collodion DUOFILMMiscellaneousfluoride dental rinse PHOS-FLUR
64
ALL CAPS = Brand-name drug Lower case = Generic drug
Index of Covered Drugs
Aabacavir . . . . . . . . . . . . . . .33, 34abacavir/dolutegravir/
lamivudine . . . . . . . . . . . . . 34abacavir/lamivudine . . . . . . . . 33abacavir/lamivudine/
zidovudine . . . . . . . . . . . . . 33abaloparatide inj . . . . . . . . . . . 26abemaciclib . . . . . . . . . . . . . . . . 4ABILIFY DISCMELT . . . . . . . . 45ABILIFY MAINTENA . . . . . . . . 47ABILIFY SOLUTION . . . . . . . . 45ABILIFY TABLETS . . . . . . . . . 47abiraterone . . . . . . . . . . . . . . . . . 5ABREVA OTC CREAM . . .33, 60ABSORICA . . . . . . . . . . . . . . . 18acalabrutinib . . . . . . . . . . . . . . . 4acamprosate . . . . . . . . . . . . . . 42acarbose . . . . . . . . . . . . . . . . . 25ACCUHIST DROPS . . . . . . . . 48ACCUNEB . . . . . . . . . . . . . . . . 52ACCUPRIL . . . . . . . . . . . . . . . . . 8ACCURETIC . . . . . . . . . . . . . . . 9acebutolol . . . . . . . . . . . . . . . . . 9ACEON . . . . . . . . . . . . . . . . . . . . 8acetaminophen
. . . . . . . . . 13-15, 36, 51, 63acetaminophen tabs, liquid,
drops, suppositories, chew tabs . . . . . . . . . . . . . . . . . . . 63
acetazolamide . . . . . . . . . . . . . 41acetazolamide
extended-release . . . . . . . 41acetic acid . . . . . . . . . . . . . . . . 22acetic acid/aluminum
acetate . . . . . . . . . . . . . . . . 22acetic acid/hydrocortisone . . 22acetylcysteine . . . . . . . . . . . . . 57acidophilus . . . . . . . . . . . . . . . 29ACIDOPHILUS XTRA . . . . . . . 29acidophilus/bifidus . . . . . . . . . 29ACIDOPHILUS/BIFIDUS
WAFER . . . . . . . . . . . . . . . . 29acidophilus/citrus pectin . . . . 29acidophilus/pectin . . . . . . . . . 29acitretin . . . . . . . . . . . . . . . . . . . 20
ACLOVATE . . . . . . . . . . . . . . . . 19ACTIFED . . . . . . . . . . . . . .23, 60ACTIGALL . . . . . . . . . . . . . . . . 30ACTIMMUNE . . . . . . . . . . . . . . . 6ACTOS . . . . . . . . . . . . . . . . . . . 25ACULAR/ACULAR LS . . . . . . 40acyclovir . . . . . . . . . . . . . . . . . . 33ADACEL . . . . . . . . . . . . . . . . . . 59ADALAT CC . . . . . . . . . . . . . . . 10adalimumab . . . . . . . . . . . . . . . 35adapalene gel . . . . . . . . . .18, 60ADASUVE . . . . . . . . . . . . . . . . 46ADDERALL . . . . . . . . . . . . . . . 43ADDERALL XR . . . . . . . . . . . . 43ADEMPAS . . . . . . . . . . . . . . . . 12ADLYXIN . . . . . . . . . . . . . . . . . 26ADMELOG SOLOSTAR . . . . . 25ADMELOG VIALS . . . . . . . . . . 25ADVIL . . . . . . . . . . . . . 14, 36, 63afatinib . . . . . . . . . . . . . . . . . . . . 4AFINITOR . . . . . . . . . . . . . . . . . . 5AFINITOR DISPERZ . . . . . . . . . 5AFLURIA . . . . . . . . . . . . . . . . . 58AFLURIA PF . . . . . . . . . . . . . . . 58AFRIN . . . . . . . . . . . . . . . . .23, 61AGRYLIN . . . . . . . . . . . . . . . . . . 7AIRDUO RESPICLICK . . . . . . 52ALAVERT . . . . . . . 22, 23, 60, 61ALAVERT ALRG TAB/
SINUS . . . . . . . . . . . . . .23, 61ALAVERT D . . . . . . . . . . . . . . . 61ALAVERT-D . . . . . . . . . . . . . . . 23ALAWAY . . . . . . . . . . . . . . .40, 63ALAWAY OTC . . . . . . . . . . . . . 40albendazole . . . . . . . . . . . . . . . 30ALBENZA . . . . . . . . . . . . . . . . 30albuterol . . . . . . . . . . . . . . .52, 53albuterol sulfate . . . . . . . . .52, 53alclometasone . . . . . . . . . . . . . 19alcohol swabs . . . . . . . . . . . . . 61ALDACTAZIDE . . . . . . . . . . . . 11ALDACTONE . . . . . . . . . . . . . . 11ALDARA . . . . . . . . . . . . . . . . . . 21ALDOMET . . . . . . . . . . . . . . . . 12ALDORIL . . . . . . . . . . . . . . . . . 12ALECENSA . . . . . . . . . . . . . . . . 4
alectinib . . . . . . . . . . . . . . . . . . . 4alendronate . . . . . . . . . . . . . . . 26ALESSE . . . . . . . . . . . . . . . . . . 37alfuzosin ER . . . . . . . . . . . . . . . 53alginic acid/sodium
bicarbonate . . . . . . . . . . . . 28ALIGN . . . . . . . . . . . . . . . . .29, 62ALINIA . . . . . . . . . . . . . . . . . . . 32ALINIA SUSPENSION . . . . . . 32alirocumab . . . . . . . . . . . . . . . . 11alitretinoin 1% gel . . . . . . . . . . . 6ALKERAN . . . . . . . . . . . . . . . . . 4allergic conjunctivitis . . . . . . . 63ALLERGY/CONG . . . . . . .23, 61allopurinol . . . . . . . . . . . . . . . . 37ALOE VESTA . . . . . . . . . . . . . . 60alogliptin . . . . . . . . . . . . . . . . . . 25alogliptin/metformin . . . . . . . . 25alogliptin/pioglitazone . . . . . . 25ALORA . . . . . . . . . . . . . . . . . . . 39ALPHAGAN . . . . . . . . . . . . . . . 41ALPHAGAN P . . . . . . . . . . . . . 41alprazolam . . . . . . . . . . . . . . . . 42ALTACAINE . . . . . . . . . . . . . . . 42ALTACE . . . . . . . . . . . . . . . . . . . 8ALTACHLORE . . . . . . . . . . . . . 42altretamine . . . . . . . . . . . . . . . . . 4alumina/magnesia . . . . . . . . . 28alumina/magnesia/
simethicone . . . . . . . . . . . . 28aluminum acetate . . . . . . .20, 22aluminum chloride topical
solution . . . . . . . . . . . . . . . 20ALUMINUM HYDROXIDE . . . 62aluminum hydroxide gel susp
(320 mg/5 ml only) . . . . . 62alunbrig . . . . . . . . . . . . . . . . . . . 4amantadine . . . . . . . . . . . .16, 33AMARYL . . . . . . . . . . . . . . . . . 25AMBIEN . . . . . . . . . . . . . . . . . . 45ambrisentan . . . . . . . . . . . . . . . 12AMERGE . . . . . . . . . . . . . . . . . 15AMICAR . . . . . . . . . . . . . . . . . . . 8amiloride . . . . . . . . . . . . . . . . . 10amiloride/
hydrochlorothiazide . . . . . 10
65
Index of Covered Drugs
ALL CAPS = Brand-name drug Lower case = Generic drug
aminocaproic acid . . . . . . . . . . 8aminosalicyclic acid . . . . . . . . 30amiodarone tabs . . . . . . . . . . . . 9amitriptyline . . . . . . . . . . . .15, 44amitriptyline/perphenazine . . 44amlodipine . . . . . . . . . . . . . . . . 10amlodipine-benazepril . . . . . . 10ammonium lactate . . . . . . . . . 21AMNESTEEM . . . . . . . . . . . . . 18amoxapine . . . . . . . . . . . . . . . . 44amoxicillin . . . . . . . . . . . . . . . . 31AMOXICILLIN CAPSULES AND
CHEWABLES . . . . . . . . . . 31amoxicillin/clavulanate . . . . . . 31AMOXIL SUSP. . . . . . . . . . . . . 31amphetamine/
dextroamphetamine mixed salts . . . . . . . . . . . . . . . . . . 43
amphetamine/dextroamphetamine mixed salts extended-release . . . 43
ampicillin . . . . . . . . . . . . . . . . . 31ANAFRANIL . . . . . . . . . . . . . . . 43anagrelide . . . . . . . . . . . . . . . . . 7anakinra . . . . . . . . . . . . . . . . . . 35anastrozole. . . . . . . . . . . . . . . . . 5ANTABUSE . . . . . . . . . . . . . . . 42antacids liquids, chew tabs . . 62antidiarrheals . . . . . . . . . . . . . . 62antihistamines . . . . . . . . . .22, 60antitussives . . . . . . . . . 3, 48, 61ANTIVERT . . . . . . . . . . . . . . . . 27ANUSOL HC 2.5% . . . . . . . . . 21apalutamide . . . . . . . . . . . . . . . 5APHEDRID TAB . . . . . . . . . . . 52apixaban . . . . . . . . . . . . . . . . . . 7APLENZIN . . . . . . . . . . . . . . . . 45APOKYN . . . . . . . . . . . . . . . . . 45apomorphine hydrochloride
inj . . . . . . . . . . . . . . . . . . . . 45apremilast . . . . . . . . . . . . . . . . 35aprepitant . . . . . . . . . . . . . . . . . 27APRESOLINE . . . . . . . . . . . . . 12APRISO . . . . . . . . . . . . . . . . . . 29APTIVUS . . . . . . . . . . . . . . . . . 34ARALEN . . . . . . . . . . . . . . . . . . 35
ARANESP . . . . . . . . . . . . . . . . . 7ARAVA . . . . . . . . . . . . . . . . . . . 35ARCAPTA NEOHALER . . . . . 52ARICEPT . . . . . . . . . . . . . . . . . 13ARIMIDEX . . . . . . . . . . . . . . . . . 5aripiprazole . . . . . . . . . . . .45, 47aripiprazole ER injection . . . . 47aripiprazole lauroxil IM
ER susp . . . . . . . . . . . . . . . 47aripiprazole ODT . . . . . . . . . . . 45aripiprazole oral solution . . . . 45ARISTADA . . . . . . . . . . . . . . . . 47armodafinil . . . . . . . . . . . . . . . . 13ARNUITY ELLIPTA . . . . . . . . . 52AROMASIN . . . . . . . . . . . . . . . . 5ARTANE . . . . . . . . . . . . . . . . . . 16artificial tears . . . . . . . . . . . . . . 63asenapine maleate
sublingual . . . . . . . . . . . . . 45asfotase alfa . . . . . . . . . . . . . . . 26ASMANEX HFA . . . . . . . . . . . . 52aspirin . . . . . . . .7, 13, 15, 36, 63aspirin tabs, EC tabs,
chew tabs . . . . . . . . . . . . . 63aspirin with buffers tabs . . . . . 63aspirin/acetaminophen/
caffeine . . . . . . . . . . . . . . . 13ASTELIN. . . . . . . . . . . . . . . . . . 22ATABEX PRENATAL . . . . . . . . 55ATARAX . . . . . . . . . . . . . . . . . . 22atazanavir . . . . . . . . . . . . . . . . . 34atazanavir/cobicistat . . . . . . . 34atenolol . . . . . . . . . . . . . . . . . . . . 9atenolol/chlorthalidone . . . . . . 9ATIVAN . . . . . . . . . . . . . . . . . . . 43atomoxetine . . . . . . . . . . . . . . 43atorvastatin . . . . . . . . . . . . . . . 11atovaquone . . . . . . . . . . . . . . . 32atropine . . . . . . . . . . . 27, 30, 41atropine sulfate . . . . . . . . . . . . 30ATROVENT . . . . . . . . 23, 52, 53ATROVENT HFA . . . . . . . . . . . 52ATROVENT NASAL SPRAY . 23AUBAGIO . . . . . . . . . . . . . . . . . 16AUGMENTIN . . . . . . . . . . . . . . 31auranofin . . . . . . . . . . . . . . . . . 35
AVITA . . . . . . . . . . . . . . . . . . . . 18axitinib . . . . . . . . . . . . . . . . . . . . 4AYGESTIN . . . . . . . . . . . . . . . . 39azathioprine . . . . . . . . . . . . . 6, 35azelaic acid . . . . . . . . . . . . . . . 18azelastine . . . . . . . . . . . . . .22, 40azithromycin . . . . . . . . . . . . . . 31aztreonam . . . . . . . . . . . . . . . . 57AZULFIDINE . . . . . . . . . . .29, 36AZULFIDINE EN-TABS . . .29, 36
Bb-complex w/ c & folic acid . . 54b-complex w/c & e . . . . . . . . . 54b-complex w/c & e + zn . . . . . 54b-complex w/minerals . . . . . . 54BACID . . . . . . . . . . . . . . . . .29, 62bacitracin . . . . . . . 18, 40, 42, 61bacitracin/polymyxin/
neomycin/hc . . . . . . . . . . . 40baclofen . . . . . . . . . . . . . . . . . . 37BACTRIM . . . . . . . . . . . . . . . . . 31BACTRIM DS . . . . . . . . . . . . . . 31BACTROBAN . . . . . . . . . . . . . 18balsalazide . . . . . . . . . . . . . . . . 29BALZIVA . . . . . . . . . . . . . . . . . . 38BANZEL . . . . . . . . . . . . . . . . . . 17BARACLUDE . . . . . . . . . . . . . . 32BASAGLAR . . . . . . . . . . . . . . . 24BAYER . . . . . . . . . . . . . 7, 36, 63BEC/ZINC . . . . . . . . . . . . . . . . 54becaplermin gel . . . . . . . . . . . 21beclomethasone . . . . . . . . . . . 52bedaquiline . . . . . . . . . . . . . . . 35BENADRYL . . . . . . . . . . . .22, 60BENADRYL-D . . . . . . . . . . . . . 23benazepril . . . . . . . . . . . . . . . . . 8benazepril/
hydrochlorothiazide . . . . . . 8BENTYL . . . . . . . . . . . . . . . . . . 28BENZAC AC . . . . . . . . . . . . . . 18BENZAMYCIN . . . . . . . . . . . . . 18benznidazole . . . . . . . . . . . . . . 32benzocaine/antipyrine . . . . . . 22benzonatate . . . . . . . . . . . . . . . 48BENZOTIC . . . . . . . . . . . . . . . . 22
66
ALL CAPS = Brand-name drug Lower case = Generic drug
Index of Covered Drugsbenzoyl peroxide . . . . . . . .18, 60benzoyl peroxide crm, gel,
lotion . . . . . . . . . . . . . . . . . . 60benztropine . . . . . . . . . . . . . . . 16BERINERT . . . . . . . . . . . . . . . . 57BETA-VAL . . . . . . . . . . . . . . . . 19BETACARE CREAM AND
LOTION . . . . . . . . . . . . . . . 60BETAGAN . . . . . . . . . . . . . . . . 41betamethasone augmented
dip . . . . . . . . . . . . . . . . . . . . 19betamethasone dip
augmented . . . . . . . . . . . . 19betamethasone dipropionate 19betamethasone val . . . . . . . . . 19BETAPACE . . . . . . . . . . . . . . . 10BETAPACE AF . . . . . . . . . . . . . 10betaxolol . . . . . . . . . . . . . . . . . . . 9bethanechol . . . . . . . . . . . . . . . 53BETHKIS . . . . . . . . . . . . . . . . . 57betrixaban . . . . . . . . . . . . . . . . . 7BEVYXXA . . . . . . . . . . . . . . . . . 7bexarotene caps and
topical gel . . . . . . . . . . . . . . 6BIAXIN . . . . . . . . . . . . . . . . . . . 31BIAXIN XL . . . . . . . . . . . . . . . . 31bicalutamide . . . . . . . . . . . . . . . 5BICITRA . . . . . . . . . . . . . . . . . . 54bictegravir/emtricitabine/
tenofovir alafenamide . . . 34BIKTARVY . . . . . . . . . . . . . . . . 34BILTRICIDE . . . . . . . . . . . . . . . 30BIOGAIA . . . . . . . . . . . . . . .29, 62bisoprolol . . . . . . . . . . . . . . . . . . 9bisoprolol/
hydrochlorothiazide . . . . . . 9BLEPH-10 . . . . . . . . . . . . . . . . 42BONINE . . . . . . . . . . . . . . . . . . 62BOOSTRIX . . . . . . . . . . . . . . . . 59bosentan . . . . . . . . . . . . . . . . . 12BOSULIF . . . . . . . . . . . . . . . . . . 4bosutinib . . . . . . . . . . . . . . . . . . 4BRETHINE . . . . . . . . . . . . . . . . 53brexpiprazole . . . . . . . . . . . . . . 45brigatinib . . . . . . . . . . . . . . . . . . 4BRILINTA . . . . . . . . . . . . . . . . . . 8
brimonidine . . . . . . . . . . . .20, 41BROMETANE DX . . . . . . . . . . 49BROMFED DM . . . . . . . . . . . . 48brompheniramine &
phenylephrine . . . . . . . . . . 48brompheniramine/
pseudoephedrine 48, 49, 60brompheniramine/
pseudoephedrine/dextromethorphan . . . . . . 48
budesonide . . . . . . . . . . . .29, 52bumetanide . . . . . . . . . . . . . . . 10BUMEX . . . . . . . . . . . . . . . . . . . 10BUNAVAIL . . . . . . . . . . . . . . . . 47BUPHENYL ORAL
POWDER . . . . . . . . . . . . . . 58buprenorphine . . . . . . . . . . . . 47buprenorphine/naloxone
buccal film . . . . . . . . . . . . . 47buprenorphine/naloxone SL 47buprenorphine/naloxone SL
film . . . . . . . . . . . . . . . . . . . 47buprenorphine/naloxone
tab . . . . . . . . . . . . . . . . . . . 47bupropion . . . . . . . . . 44, 45, 48bupropion extended-release . 44bupropion HCl . . . . . . . . . .45, 48bupropion HCL tab SR
24HR . . . . . . . . . . . . . . . . . 45bupropion hydrobromide . . . 45Burow’s soln, wet dressings . 61BUSPAR . . . . . . . . . . . . . . . . . . 43buspirone . . . . . . . . . . . . . . . . . 43busulfan . . . . . . . . . . . . . . . . . . . 4butalbital/acetaminophen/
caffeine . . . . . . . . . . . . . . . 13butalbital/apap/caff/cod . . . . 14butalbital/asa/caff/cod . . . . . 14butalbital/aspirin/caffeine . . . 13butorphanol . . . . . . . . . . . . . . . 14
Cc1 esterase inhibitor (human) 57cabergoline . . . . . . . . . . . . . . . 26CABOMETYX . . . . . . . . . . . . . . 4cabozantinib . . . . . . . . . . . . . . . 4
CAFERGOT . . . . . . . . . . . . . . . 15calamine . . . . . . . . . . . . . . . . . . 21CALAN . . . . . . . . . . . . . . . .10, 15CALAN SR . . . . . . . . . . . . . . . . 10calcipotriene . . . . . . . . . . . . . . 20calcitonin-salmon . . . . . . . . . . 26calcitriol . . . . . . . . . . . . . . .20, 54calcitriol oral soln . . . . . . . . . . 54calcium . 2, 7, 10, 27, 54, 57, 63calcium acetate . . . . . . . . . . . . 57CALQUENCE . . . . . . . . . . . . . . 4CALTRATE . . . . . . . . . . . . . . . . 63CAMPRAL . . . . . . . . . . . . . . . . 42canakinumab . . . . . . . . . . . . . 35CANASA. . . . . . . . . . . . . . . . . . 29capecitabine . . . . . . . . . . . . . . . 4CAPOTEN . . . . . . . . . . . . . . . . . 8CAPOZIDE . . . . . . . . . . . . . . . . . 8CAPRELSA . . . . . . . . . . . . . . . . 5CAPSAGEL . . . . . . . . . . . . . . . 36capsaicin . . . . . . . . . . . . . . . . . 36captopril . . . . . . . . . . . . . . . . . . . 8captopril/hydrochlorothiazide . 8CAPZASIN-P . . . . . . . . . . . . . . 36CARAFATE . . . . . . . . . . . . . . . . 28CARAFATE SUSPENSION . . 28CARBAGLU . . . . . . . . . . . . . . . 58carbamazepine . . . . . . . . .16, 45carbamazepine (antipsychotic)
cap SR 12HR . . . . . . . . . . 45carbamazepine extended-
release . . . . . . . . . . . . . . . . 16carbamide peroxide . . . . .22, 61CARBATROL . . . . . . . . . . . . . . 16carbidopa/levodopa . . . . . . . . 16carbidopa/levodopa
extended-release . . . . . . . 16CARDEC DM DRO . . . . . . . . . 51CARDEC DM SYP . . . . . . . . . 50CARDEC DRO . . . . . . . . . . . . . 49CARDEC SYP . . . . . . . . . . . . . 49CARDENE . . . . . . . . . . . . . . . . 10CARDIZEM . . . . . . . . . . . . . . . 10CARDIZEM CD . . . . . . . . . . . . 10CARDIZEM SR . . . . . . . . . . . . 10CARDURA . . . . . . . . . . . . . . 9, 53
67
Index of Covered Drugs
ALL CAPS = Brand-name drug Lower case = Generic drug
carglumic acid . . . . . . . . . . . . . 58carteolol . . . . . . . . . . . . . . . . . . 41carvedilol . . . . . . . . . . . . . . . . . . 9casanthranol-docusate
sodium . . . . . . . . . . . . . . . . 27CASODEX . . . . . . . . . . . . . . . . . 5CASTIVA . . . . . . . . . . . . . . . . . 36CATAFLAM . . . . . . . . . . . . . . . 13CATALFAM. . . . . . . . . . . . . . . . 36CATAPRES . . . . . . . . . . . . . . . . . 9CATAPRES- TTS . . . . . . . . . . . . 9CAYSTON . . . . . . . . . . . . . . . . 57CECLOR . . . . . . . . . . . . . . . . . 30cefaclor . . . . . . . . . . . . . . . . . . . 30cefadroxil . . . . . . . . . . . . . . . . . 30cefdinir . . . . . . . . . . . . . . . . . . . 31cefixime . . . . . . . . . . . . . . . . . . 31cefprozil . . . . . . . . . . . . . . . . . . 30CEFTIN . . . . . . . . . . . . . . . .30, 31cefuroxime axetil . . . . . . . .30, 31CEFZIL . . . . . . . . . . . . . . . . . . . 30CELEBREX . . . . . . . . . . . . . . . 36celecoxib . . . . . . . . . . . . . . . . . 36CELEXA . . . . . . . . . . . . . . . . . . 44CELLCEPT . . . . . . . . . . . . . . . . . 6CELONTIN . . . . . . . . . . . . . . . . 17CENESTIN . . . . . . . . . . . . . . . . 39CENOGEN OB/ULTRA . . . . . 56CENTRUM . . . . . . . . . . . . . . . . 55cephalexin . . . . . . . . . . . . . . . . 30ceritinib . . . . . . . . . . . . . . . . . . . . 4certolizumab pegol . . . . . . . . . 35CETAPHIL CREAM AND
LOTION . . . . . . . . . . . . . . . 60cetirizine . . . . . . . . . . . 22, 23, 60cetirizine chew tab . . . . . . . . . 22cetirizine hydrochloride/
pseudoephedrine hydrochloride 12 hours extended-release . . . . . . . 23
cetirizine/pseudoephedrine . 60CETYLEV . . . . . . . . . . . . . . . . . 57CHANTIX . . . . . . . . . . . . . . . . . 48CHEMET . . . . . . . . . . . . . . . . . 57
CHILD IBUPRO SUS COLD . 51CHLOR-TRIMETON . . . . .22, 60CHLOR-TRIMETON
ALLERGY . . . . . . . . . . . . . 22CHLOR-TRIMETON SYRUP . 22chloral hydrate . . . . . . . . . . . . . 45chlorambucil . . . . . . . . . . . . . . . 4chlordiazepoxide. . . . . . . . . . . 42chlordiazepoxide-
amitriptyline . . . . . . . . . . . 44chlorhexidine gluconate. . . . . 23chloroquine phosphate . . . . . 35chlorothiazide . . . . . . . . . .10, 11chlorphen tan/carbetapentane
tan . . . . . . . . . . . . . . . . . . . . 48chlorphen tan/pyrilamine tan/
PE tan . . . . . . . . . . . . . . . . . 48chlorpheniramine extended-
release . . . . . . . . . . . . . . . . 22chlorpheniramine
maleate . . . . . . . . . . . .22, 49chlorpheniramine maleate
phenylephrine HCL . . . . . 49chlorpheniramine tan/
phenylephrine tan. . . . . . . 49chlorpheniramine/
dextromethorphan . . . 49-51chlorpheniramine/
phenylephrine . . . . . . .23, 49chlorpheniramine/
phenylephrine/pyrilamine 23chlorpheniramine/
pseudoephedrine 23, 49, 60chlorpromazine . . . . . . . . .45, 48chlorpromazine hcl inj . . . . . . 45chlorpropamide. . . . . . . . . . . . 25chlorthalidone . . . . . . . . . . . 9, 11chlorzoxazone . . . . . . . . . . . . . 37CHOLBAM . . . . . . . . . . . . . . . . 26cholestyramine . . . . . . . . . . . . 11cholic acid . . . . . . . . . . . . . . . . 26choriogonadotropin alfa . . . . . 39chorionic gonadotropin . . . . . 39ciclopirox . . . . . . . . . . . . . . . . . 20cilostazol . . . . . . . . . . . . . . . . . . 8CILOXAN . . . . . . . . . . . . . . . . . 42
CIMDUO . . . . . . . . . . . . . . . . . 33cimetidine . . . . . . . . . . . . . . . . 28CIMZIA . . . . . . . . . . . . . . . . . . . 35cinacalcet . . . . . . . . . . . . . . . . . 57CIPRO . . . . . . . . . . . . . . . . . . . 31CIPRODEX . . . . . . . . . . . . . . . . 22ciprofloxacin . . . . . . . 22, 31, 42ciprofloxacin/
dexamethasone . . . . . . . . 22citalopram . . . . . . . . . . . . . . . . 44CLARAVIS . . . . . . . . . . . . . . . . 18clarithromycin . . . . . . . . . . . . . 31clarithromycin ER . . . . . . . . . . 31CLARITIN . . . . . . . . . . . . . .22, 60CLARITIN-D . . . . . . . . . . . . . . . 50CLEAR EYES REDNESS
RELIEF . . . . . . . . . . . . . . . . 40CLEARASIL . . . . . . . . . . . . . . . 60clemastine . . . . . . . . . . . . . . . . 22CLEOCIN . . . . . . . . . . 18, 35, 39CLEOCIN T . . . . . . . . . . . . . . . 18CLIMARA . . . . . . . . . . . . . . . . . 39clindamycin . . . . . . . . 18, 35, 39CLINORIL . . . . . . . . . . . . . .14, 36clobazam . . . . . . . . . . . . . . . . . 16clobetasol propionate. . . . . . . 19clomipramine. . . . . . . . . . . . . . 43clonazepam . . . . . . . . . . . .16, 43clonidine. . . . . . . . . . . . . . . . . . . 9clonidine transdermal . . . . . . . . 9clopidogrel . . . . . . . . . . . . . . . . . 8clorazepate . . . . . . . . . . . . . . . 43clotrimazole . . . . . 20, 32, 39, 60clotrimazole with
betamethasone . . . . . . . . . 20clozapine . . . . . . . . . . . . . .45, 47clozapine ODT . . . . . . . . . . . . . 45clozapine susp . . . . . . . . . . . . 45CLOZARIL . . . . . . . . . . . . .45, 47cobicistat . . . . . . . . . . . . . . . . . 34cobicistat/elvitegravir/
emtricitabine/tenofovir . . . 34cobimetinib . . . . . . . . . . . . . . . . 4codeine sulfate . . . . . . . . . . . . 14codeine/acetaminophen . . . . 14
68
ALL CAPS = Brand-name drug Lower case = Generic drug
Index of Covered Drugscodeine/chlorpheniramine/
pseudoephedrine . . . . . . . 49codeine/guaifenesin. . . . . . . . 49codeine/guaifenesin/
pseudoephedrine . . . . . . . 49codeine/promethazine. . . . . . 49codeine/promethazine/
phenylephrine . . . . . . . . . . 49CODIMAL DH . . . . . . . . . . . . . 51COGENTIN . . . . . . . . . . . . . . . 16COLACE . . . . . . . . . . . . . .27, 62COLAZAL . . . . . . . . . . . . . . . . 29COLBENEMID . . . . . . . . . . . . . 37colchicine . . . . . . . . . . . . . . . . . 37colchicine w/ probenecid . . . 37collagenase oint . . . . . . . . . . . 21COLLOIDAL OATMEAL
BATHS . . . . . . . . . . . . . . . . 61COLOCORT. . . . . . . . . . . . . . . 29COLYTE . . . . . . . . . . . . . . . . . . 27COMBIVENT . . . . . . . . . . . . . . 52COMBIVENT RESPIMAT . . . . 52COMBIVIR . . . . . . . . . . . . . . . . 33COMETRIQ . . . . . . . . . . . . . . . . 4COMMIT LOZENGES . . . . . . . 63COMMITT OTC . . . . . . . . . . . . 48COMPAZINE . . . . . . . . . . . . . . 27COMPLERA . . . . . . . . . . . . . . 33COMPLETE NATALCARE PAK
DHA . . . . . . . . . . . . . . . . . . 55COMTAN . . . . . . . . . . . . . . . . . 16condom-male . . . . . . . . . . . . . 61CONDYLOX SOL . . . . . . . . . . 20conjugated estrogen/
bazedoxifene . . . . . . . . . . . 40contraceptive foam . . . . . . . . . 61contraceptive gel . . . . . . . . . . . 61COPAXONE . . . . . . . . . . . . . . . 15COPEGUS . . . . . . . . . . . . . . . . 32CORDARONE . . . . . . . . . . . . . . 9COREG . . . . . . . . . . . . . . . . . . . 9CORGARD . . . . . . . . . . . . . . . . 10CORICIDIN TAB CGH/CLD . . 49CORTAID . . . . . . . . . . . . . . . . . 61CORTEF . . . . . . . . . . . . . . . . . . 24cortisone acetate . . . . . . . . . . 24
CORTISPORIN . . . . . . . . .22, 40CORTISPORIN OTIC . . . . . . . 22CORTIZONE . . . . . . . . . . . . . . 19CORTIZONE-10 INTENSIVE
HEALING . . . . . . . . . . . . . . 19COSENTYX . . . . . . . . . . . . . . . 36COSOPT . . . . . . . . . . . . . . . . . 41COTELLIC . . . . . . . . . . . . . . . . . 4COZAAR . . . . . . . . . . . . . . . . . . 9CREON . . . . . . . . . . . . . . . . . . . 29CREON 3000 UNIT . . . . . . . . 29crisaborole . . . . . . . . . . . . . . . . 21CRIXIVAN . . . . . . . . . . . . . . . . . 34crizotinib . . . . . . . . . . . . . . . . . . . 4crofelemer . . . . . . . . . . . . . . . . 27CROLOM . . . . . . . . . . . . . . . . . 40cromolyn . . . . . . . . . . 23, 40, 53cromolyn sodium . . . . . . .23, 40crotamiton . . . . . . . . . . . . . . . . 20CULTURELLE . . . . . . . . . .29, 62CURITY ALCOHOL PADS . . . 61CUTIVATE . . . . . . . . . . . . . . . . 19cyanocobalamin . . . . . . . . . . . 54CYCLESSA . . . . . . . . . . . . . . . 38cyclobenzaprine . . . . . . . . . . . 37CYCLOGYL . . . . . . . . . . . . . . . 41cyclopentolate . . . . . . . . . . . . . 41CYCLOPHOSPH . . . . . . . . . . . . 4cyclophosphamide . . . . . . . . . . 4cycloserine . . . . . . . . . . . . . . . . 30cyclosporine . . . . . . . . . . . . . . . 6cyclosporine, modified . . . . . . . 6CYMBALTA . . . . . . . . . . . . . . . 44cyproheptadine . . . . . . . . . . . . 22CYSTAGON . . . . . . . . . . . . . . . . 6CYSTARAN . . . . . . . . . . . . . . . 42cysteamine 0.44% ophthalmic
solution . . . . . . . . . . . . . . . 42cysteamine bitartrate . . . . . . . . 6CYTOMEL . . . . . . . . . . . . . . . . 26CYTOTEC . . . . . . . . . . . . . . . . 30CYTOVENE . . . . . . . . . . . . . . . 32CYTOXAN . . . . . . . . . . . . . . . . . 4
DD.H.E. 45 . . . . . . . . . . . . . . . . . 15
dabrafenib . . . . . . . . . . . . . . . . . 4daclizumab . . . . . . . . . . . . . . . 15DALMANE . . . . . . . . . . . . . . . . 45danazol . . . . . . . . . . . . . . . . . . . 38DANOCRINE . . . . . . . . . . . . . . 38DANTRIUM . . . . . . . . . . . . . . . 37dantrolene . . . . . . . . . . . . . . . . 37dapsone . . . . . . . . . . . . . . . . . . 35DARAPRIM . . . . . . . . . . . . . . . 35darbepoetin alfa . . . . . . . . . . . . 7darunavir . . . . . . . . . . . . . . . . . 34darunavir/cobicistat . . . . . . . . 34dasatinib . . . . . . . . . . . . . . . . . . . 4DAYPRO . . . . . . . . . . . . . . .14, 36DDAVP . . . . . . . . . . . . . . . . . . . 26DEBROX . . . . . . . . . . . . . .22, 61DECADRON . . . . . . . . . . . . . . 24decongestants . . . 3, 23, 48, 63deferasirox . . . . . . . . . . . . . . . . . 8DELATESTRYL . . . . . . . . . . . . 24delavirdine . . . . . . . . . . . . . . . . 34DELFEN . . . . . . . . . . . . . . . . . . 61DELSYM . . . . . . . . . . . . . . .50, 61DELTASONE . . . . . . . . . . . . . . 24DELZICOL . . . . . . . . . . . . . . . . 29DEMADEX . . . . . . . . . . . . . . . . 11DEMEROL . . . . . . . . . . . . . . . . 14DEPAKENE . . . . . . . . . . . . . . . 17DEPAKOTE . . . . . . . . 15, 16, 43DEPAKOTE
SPRINKLE . . . . . . 15, 16, 43DEPEN TITRATABLE . . . . . . . 35DEPO-ESTRADIOL . . . . . . . . . 38DEPO-PROVERA . . . . . . . . . . 37DEPO-TESTOSTERONE . . . . 24DERMA-SMOOTHE OIL/FS . 19DERMAPHOR OINTMENT . . 60dermatological baths . . . . . . . 61DERMATOP . . . . . . . . . . . . . . . 19DESCOVY . . . . . . . . . . . . . . . . 34DESENEX . . . . . . . . . . . . . . . . 20desipramine . . . . . . . . . . . . . . . 44desmopressin . . . . . . . . . . . . . 26desmopressin acetate inj . . . . 26desogestrel/EE . . . . . . . . .37, 38
69
Index of Covered Drugs
ALL CAPS = Brand-name drug Lower case = Generic drug
desvenlafaxine fumarate tab SR 24HR . . . . . . . . . . . . . . 45
desvenlafaxine succinate tab SR 24HR . . . . . . . . . . . . . . 45
desvenlafaxine tab SR 24HR 45DESYREL . . . . . . . . . . . . . .44, 47DETROL . . . . . . . . . . . . . . . . . . 54dexamethasone . . . . 22, 24, 40dexamethasone sodium
phosphate . . . . . . . . . . . . . 40DEXASOL . . . . . . . . . . . . . . . . 40dexmethylphenidate . . . . . . . . 43dextromethorphan hbr . . . . . . 50dextromethorphan polistirex
extended-release . . . . . . . 50dextromethorphan-
guaifenesin . . . . . . . . .49, 50dextromethorphan/
brompheniramine/pseudoephedrine . . . . . . . 49
dextromethorphan/guaifenesin 49, 51
dextromethorphan/ promethazine . . . . . . . . . . 50
dextromethorphan/quinidine 47DIABINESE . . . . . . . . . . . . . . . 25DIAMOX SEQUELS . . . . . . . . 41DIASTAT ACUDIAL . . . . . . . . . 16diazepam . . . . . . . . . . 16, 37, 43diclofenac 1% gel . . . . . . . . . . 36diclofenac potassium . . . .13, 36diclofenac sodium 13, 14, 36, 40diclofenac sodium delayed-
release . . . . . . . . . . . . .13, 36diclofenac sodium extended-
release . . . . . . . . . . . . .14, 36dicloxacillin . . . . . . . . . . . . . . . 31dicyclomine . . . . . . . . . . . . . . . 28didanosine . . . . . . . . . . . . . . . . 33didanosine delayed-release . . 33DIDRONEL. . . . . . . . . . . . . . . . 26DIFFERIN OTC GEL 0.1% 18, 60DIFICID . . . . . . . . . . . . . . . . . . . 31DIFLUCAN . . . . . . . . . . . . .32, 39diflunisal . . . . . . . . . . . . . . . . . . 36DIGESTIVE PROBIOTIC .29, 62
digoxin . . . . . . . . . . . . . . . . . . . . 9DIHISTINE DH . . . . . . . . . . . . . 49DIHYDRO-PE SYP . . . . . . . . . 51dihydroergotamine . . . . . . . . . 15DILACOR XR . . . . . . . . . . . . . . 10DILANTIN . . . . . . . . . . . . . . . . . 17DILANTIN INFATABS . . . . . . . 17DILAUDID . . . . . . . . . . . . . . . . 14diltiazem . . . . . . . . . . . . . . . . . . 10diltiazem extended-release . . 10diltiazem sustained-release . . 10DIMEATAPP DRO
DECONGES . . . . . . . . . . . 23dimenhydrinate . . . . . . . . . . . . 62DIMETAPP . . 48, 49, 51, 60, 61DIMETAPP CLD ELX/
ALLERGY . . . . . . . . . . . . . 48DIMETAPP DRO DCON/
CGH . . . . . . . . . . . . . . . . . . 51DIMETAPP DRO
DECONGES . . . . . . . . . . . 61DIMETAPP SYP CGH/CLD . . 49dimethicone lotion 3% . . . . . . 60dimethyl fumarate . . . . . . . . . . 15DIP/TET PED INJ . . . . . . . . . . 58DIPENTUM . . . . . . . . . . . . . . . 29diphenhydramine . . . . . . .22, 45diphenhydramine-
phenylephrine soln . . . . . 23diphenoxylate/atropine . . . . . 27diphtheria-tetanus tox
adsorbed (dt) im . . . . . . . . 58DIPROLENE . . . . . . . . . . . . . . 19DIPROLENE AF . . . . . . . . . . . 19dipyridamole . . . . . . . . . . . . . . . 8DISALCID . . . . . . . . . . . . . . . . . 36disopyramide . . . . . . . . . . . . . . . 9disopyramide
extended-release . . . . . . . . 9disulfiram . . . . . . . . . . . . . . . . . 42DITROPAN . . . . . . . . . . . . . . . . 53DITROPAN XL . . . . . . . . . . . . . 53DIURIL . . . . . . . . . . . . . . . .10, 11DIURIL ORAL SUSPENSION 11
divalproex sodium cap sprinkle . . . . . . . . 15, 16, 43
divalproex sodium delayed-release . . . . . . . . . 15, 16, 43
docosanol . . . . . . . . . . . . .33, 60docusate calcium plus . . . . . . 27docusate potasssium . . . . . . . 27docusate sodium . . . . . . . . . . 27dofetilide. . . . . . . . . . . . . . . . . . . 9DOK . . . . . . . . . . . . . . . . . . . . . 27DOLOBID . . . . . . . . . . . . . . . . . 36dolutegravir . . . . . . . . . . . .33, 34dolutegravir/rilpivirine . . . . . . . 34DOMEBORO . . . . . . . . . . .22, 61DOMEBORO OTIC . . . . . . . . . 22donepezil . . . . . . . . . . . . . . . . . 13dornase alfa . . . . . . . . . . . . . . . 57dorzolamide . . . . . . . . . . . . . . . 41dorzolamide/timolol maleate 41DOSTINEX . . . . . . . . . . . . . . . . 26DOVONEX . . . . . . . . . . . . . . . . 20doxazosin . . . . . . . . . . . . . . . 9, 53doxepin . . . . . . . . . . . . . . . . . . 44doxycycline monohydrate . . . 31doxylamine succinate . . . .45, 62DRAMAMINE . . . . . . . . . . . . . 62DRISDOL . . . . . . . . . . . . . . . . . 54dronabinol . . . . . . . . . . . . . . . . 27DROXIA . . . . . . . . . . . . . . . . . . . 6DUAVEE . . . . . . . . . . . . . . . . . . 40dulaglutide . . . . . . . . . . . . . . . . 26DULCOLAX . . . . . . . . . . . . . . . 62duloxetine . . . . . . . . . . . . .44, 46DUOFILM . . . . . . . . . . . . . .20, 63DUONEB . . . . . . . . . . . . . . . . . 53DURAGESIC . . . . . . . . . . . . . . 14DURATUSS DM ELX . . . . . . . 49DUREX . . . . . . . . . . . . . . . . . . . 61DURICEF . . . . . . . . . . . . . . . . . 30DYAZIDE . . . . . . . . . . . . . . . . . 11
EE-OINTMENT . . . . . . . . . . . . . 60E.E.S. . . . . . . . . . . . . . . . . . . . . 31ecothiophate . . . . . . . . . . . . . . 41ECOTRIN . . . . . . . . . . . 7, 36, 63
70
ALL CAPS = Brand-name drug Lower case = Generic drug
Index of Covered DrugsED A-HIST TABLETS AND
LIQUID . . . . . . . . . . . . . . . . 49EDGE OB CHW . . . . . . . . . . . 55edoxaban . . . . . . . . . . . . . . . . . . 7EDURANT . . . . . . . . . . . . . . . . 34efavirenz . . . . . . . . . . . . . . .33, 34efavirenz/lamivudine/tenofovir
disoproxil fumarate . . . . . . 33EFFEXOR . . . . . . . . . . . . . . . . . 44EFFEXOR XR . . . . . . . . . . . . . . 44EFFIENT . . . . . . . . . . . . . . . . . . . 8EFUDEX . . . . . . . . . . . . . . . . . . 21EGRIFTA . . . . . . . . . . . . . . . . . 26ELAVIL . . . . . . . . . . . . . . . .15, 44ELDEPRYL . . . . . . . . . . . . . . . . 16electrolyte . . . . . . . . . . . . . .54, 62electrolyte rehydrating soln . . 62ELIDEL . . . . . . . . . . . . . . . . . . . 21ELIMITE . . . . . . . . . . . . . . . . . . 20ELIQUIS . . . . . . . . . . . . . . . . . . . 7ELMIRON . . . . . . . . . . . . . . . . . 54ELOCON . . . . . . . . . . . . . . . . . 19eltrombopag . . . . . . . . . . . . . . 57elvitegravir/cobicistat/
emtricitabine/tenofovir alafenamide fumarate . . . 34
EMCYT . . . . . . . . . . . . . . . . . . . . 4EMEND . . . . . . . . . . . . . . . . . . 27EMETROL . . . . . . . . . . . . . . . . 62emicizumab-kxwh . . . . . . . . . . . 8EMLA . . . . . . . . . . . . . . . . . . . . 21emollients . . . . . . . . . . . . . . . . . 60EMSAM . . . . . . . . . . . . . . . . . . 47emtricitabine . . . . . . . . . . .33, 34emtricitabine/rilpivirine/
tenofovir . . . . . . . . . . . . . . . 33emtricitabine/tenofovir . . .33, 34emtricitabine/tenofovir
alafenamide . . . . . . . . . . . . 34EMTRIVA . . . . . . . . . . . . . . . . . 33enalapril . . . . . . . . . . . . . . . . . . . 8enalapril oral soln . . . . . . . . . . . 8enalapril/hydrochlorothiazide . 8ENBREL . . . . . . . . . . . . . . . . . . 35enfuvirtide . . . . . . . . . . . . . . . . 34ENGERIX-B . . . . . . . . . . . . . . . 58
enoxaparin . . . . . . . . . . . . . . . . . 7entacapone . . . . . . . . . . . . . . . 16entecavir . . . . . . . . . . . . . . . . . . 32ENTERIC COATED-
NAPROSYN . . . . . . . . .14, 36ENTOCORT EC . . . . . . . . . . . . 29ENTRESTO . . . . . . . . . . . . . . . . 9ENULOSE . . . . . . . . . . . . . . . . 27EPANED . . . . . . . . . . . . . . . . . . . 8epinephrine . . . . . . . . . . . . . . . 57EPIPEN . . . . . . . . . . . . . . . . . . . 57EPIPEN JR. . . . . . . . . . . . . . . . 57EPIVIR . . . . . . . . . . . . . . . .32, 33EPIVIR HBV . . . . . . . . . . . . . . . 32epoetin alfa . . . . . . . . . . . . . . . . 7EPOGEN . . . . . . . . . . . . . . . . . . 7EPZICOM . . . . . . . . . . . . . . . . . 33EQL B COMPLEX . . . . . . . . . . 54EQUETRO . . . . . . . . . . . . . . . . 45ergocalciferol (D2) . . . . . . . . . 54ergotamine tartrate/caffeine . 15ergotamine/caffeine . . . . . . . . 15ERIVEDGE . . . . . . . . . . . . . . . . . 7ERLEADA . . . . . . . . . . . . . . . . . 5erlotinib . . . . . . . . . . . . . . . . . . . 4ertugliflozin . . . . . . . . . . . . . . . 25ertugliflozin/metformin . . . . . . 25ERY-TAB . . . . . . . . . . . . . . . . . . 31ERYC . . . . . . . . . . . . . . . . . . . . 31ERYGEL . . . . . . . . . . . . . . . . . . 18ERYTHROCIN . . . . . . . . . . . . . 31erythromycin . . . . . . . 18, 31, 42erythromycin delayed-release 31erythromycin ethylsuccinate . 31erythromycin stearate . . . . . . . 31erythromycin/benzoyl
peroxide . . . . . . . . . . . . . . . 18erythromycin/sulfisoxazole . . 31ESBRIET . . . . . . . . . . . . . . . . . 57escitalopram . . . . . . . . . . .44, 46escitalopram & methylfolate-
B12-B6-D cap thpk . . . . . 46escitalopram oxalate soln . . . 46ESGIC . . . . . . . . . . . . . . . . . . . . 13ESKALITH CR . . . . . . . . . . . . . 43esomeprazole . . . . . . . . . . . . . 28
esomeprazole granules . . . . . 28estazolam . . . . . . . . . . . . . . . . . 45ESTRACE . . . . . . . . . . . . . . . . . 39ESTRACE CRM. . . . . . . . . . . . 39estradiol . . . . . . . . . . . . . . .38, 39estradiol cypionate . . . . . . . . . 38estradiol td . . . . . . . . . . . . . . . . 39estradiol vaginal tablet . . . . . . 39estramustine phosphate
sodium . . . . . . . . . . . . . . . . . 4estrogens, conjugated . . . . . . 39estrogens, conjugated/
medroxyprogesterone . . . 39estrogens, conjugated,
synthetic A . . . . . . . . . . . . . 39estropipate . . . . . . . . . . . . . . . . 39etanercept . . . . . . . . . . . . . . . . 35ethambutol . . . . . . . . . . . . . . . . 30ethionamide . . . . . . . . . . . . . . . 30ethosuximide . . . . . . . . . . . . . . 16ethynodiol diacetate/EE . . . . . 38etidronate . . . . . . . . . . . . . . . . . 26etodolac . . . . . . . . . . . . . . .14, 36etonogestrel/EE . . . . . . . . . . . 37etoposide . . . . . . . . . . . . . . . . . . 6etravirine . . . . . . . . . . . . . . . . . . 34EUCRISA . . . . . . . . . . . . . . . . . 21EULEXIN . . . . . . . . . . . . . . . . . . 5EURAX . . . . . . . . . . . . . . . . . . . 20everolimus . . . . . . . . . . . . . . . 5, 6EVISTA . . . . . . . . . . . . . . . . . . . 26EVOTAZ . . . . . . . . . . . . . . . . . 34EXCEDRIN MIGRAINE . . . . . . 13EXELON . . . . . . . . . . . . . . . . . . 13exemestane . . . . . . . . . . . . . . . . 5EXJADE . . . . . . . . . . . . . . . . . . . 8ezetimibe . . . . . . . . . . . . . . . . . 11ezogabine . . . . . . . . . . . . . . . . 16
FFABB . . . . . . . . . . . . . . . . . . . . 54famotidine . . . . . . . . . . . . .28, 62FANAPT . . . . . . . . . . . . . . . . . . 46FANTASY . . . . . . . . . . . . . . . . . 61FARESTON . . . . . . . . . . . . . . . . 5FARYDAK . . . . . . . . . . . . . . . . . . 4
71
Index of Covered Drugs
ALL CAPS = Brand-name drug Lower case = Generic drug
FAZACLO . . . . . . . . . . . . . . . . . 45febuxostat . . . . . . . . . . . . . . . . 37felbamate . . . . . . . . . . . . . .16, 17felbamate oral susp . . . . . . . . 17FELBATOL . . . . . . . . . . . . .16, 17FELBATOL ORAL SUSP . . . . 17FELDENE . . . . . . . . . . . . . .14, 36felodipine extended-release . 10FEMARA . . . . . . . . . . . . . . . . . . 5fenofibrate . . . . . . . . . . . . . . . . 11fentanyl transdermal . . . . . . . . 14FEOSOL . . . . . . . . . . . . . . .54, 63FERGON . . . . . . . . . . . . . . . . . 63ferrous bis-glycinate chelate . 63ferrous bisglycinate/
polysaccarides iron . . . . . 54ferrous fumarate . . . . . . . . . . . 63ferrous gluconate . . . . . . . . . . 63ferrous sulfate . . . . . . . . . .54, 63FETZIMA . . . . . . . . . . . . . . . . . 46fidaxomicin . . . . . . . . . . . . . . . 31filgrastim . . . . . . . . . . . . . . . . . . . 7FINACEA . . . . . . . . . . . . . . . . . 18finasteride . . . . . . . . . . . . . . . . 53fingolimod . . . . . . . . . . . . . . . . 15FIORICET W/CODEINE . . . . . 14FIORINAL . . . . . . . . . . . . . .13, 14FIORINAL W/CODEINE . . . . . 14FIRAZYR . . . . . . . . . . . . . . . . . 57FIRVANQ . . . . . . . . . . . . . . . . . 32FISH OIL . . . . . . . . . . . . . . . . . . 11fish oil caps . . . . . . . . . . . . . . . 11FLAGYL . . . . . . . . . . . . . . .35, 39FLAVOXATE . . . . . . . . . . . . . . 53flavoxate hcl . . . . . . . . . . . . . . . 53flecainide . . . . . . . . . . . . . . . . . . 9FLEET ENEMA . . . . . . . . . . . . 62FLEET PHOSPHO-SODA . . . 62FLEXERIL . . . . . . . . . . . . . . . . . 37FLOMAX. . . . . . . . . . . . . . . . . . 53FLONASE . . . . . . . . . . . . . . . . . 23FLORAJEN . . . . . . . . . . . .29, 62FLORANEX . . . . . . . . . . . .29, 62FLORASTOR . . . . . . . . . . .29, 62FLORINEF . . . . . . . . . . . . . . . . 24FLOXIN . . . . . . . . . . . . . . . .22, 31
FLOXIN OTIC . . . . . . . . . . . . . . 22FLUARIX QUAD . . . . . . . . . . . 58FLUBLOK . . . . . . . . . . . . . . . . . 58FLUCELVAX . . . . . . . . . . . . . . . 58fluconazole . . . . . . . . . . . .32, 39fludrocortisone . . . . . . . . . . . . 24FLULAVAL QUAD . . . . . . . . . . 58FLUMADINE . . . . . . . . . . . . . . 33fluocinolone acetonide . . . . . . 19fluocinonide . . . . . . . . . . . . . . . 19fluocinonide emulsified base 19fluoride . . . . . . . . . . . . . 54-56, 63fluoride dental rinse . . . . . . . . 63fluorometholone . . . . . . . .40, 41fluorouracil . . . . . . . . . . . . . . . . 21fluoxetine . . . . . . . . . . . . . .44, 46fluoxetine capsule . . . . . . . . . . 46fluoxetine HCL cap delayed
release 90 mg . . . . . . . . . . 46fluoxetine tablet . . . . . . . . . . . . 46fluphenazine . . . . . . . . . . . . . . 48fluphenazine decanoate . . . . 48flurazepam . . . . . . . . . . . . . . . . 45flurbiprofen . . . . . . . . . . . . . . . 40flutamide . . . . . . . . . . . . . . . . . . 5fluticasone . . . . . . . . . 19, 23, 52fluticasone furoate . . . . . . . . . 52fluticasone propionate . . . . . . 19fluticasone/salmeterol . . . . . . 52FLUVIRIN . . . . . . . . . . . . . . . . . 58fluvoxamine . . . . . . . . . . . .43, 46fluvoxamine maleate cap SR
24HR . . . . . . . . . . . . . . . . . 46FLUZONE HD PF . . . . . . . . . . 58FLUZONE QUAD. . . . . . . . . . . 58FLUZONE SPLT . . . . . . . . . . . 58FML . . . . . . . . . . . . . . . . . . .40, 41FML FORTE . . . . . . . . . . . . . . . 41FML LIQUIFILM . . . . . . . . . . . . 41FOCALIN . . . . . . . . . . . . . . . . . 43folic acid . . . . . . . . . . . . . . .54, 56folic acid-vitamin b6-vitamin
b12 . . . . . . . . . . . . . . . . . . . 54FOLTABS PAK PLUS DHA RE
OB + DHA PAK . . . . . . . . . 55FOLTABS PRENATAL . . . . . . . 56
FORFIVO XL . . . . . . . . . . . . . . 45FORTICAL . . . . . . . . . . . . . . . . 26FOSAMAX . . . . . . . . . . . . . . . . 26fosamprenavir . . . . . . . . . . . . . 34fosinopril. . . . . . . . . . . . . . . . . . . 8fosinopril/hydrochlorothiazide 8FURADANTIN SUSP
25 MG/5 ML . . . . . . . . . . . 35furosemide . . . . . . . . . . . . . . . . 11FUZEON . . . . . . . . . . . . . . . . . . 34
Ggabapentin . . . . . . . . . . . . . . . . 17GABITRIL . . . . . . . . . . . . . . . . . 17galantamine . . . . . . . . . . . . . . . 13ganciclovir . . . . . . . . . . . . . . . . 32GARDASIL . . . . . . . . . . . . . . . . 58GARDASIL 9 . . . . . . . . . . . . . . 58GATTEX . . . . . . . . . . . . . . . . . . 30gefitinib . . . . . . . . . . . . . . . . . . . . 5GEL-KAM . . . . . . . . . . . . . . . . . 54gemfibrozil . . . . . . . . . . . . . . . . 11GENGRAF . . . . . . . . . . . . . . . . . 6GENTAK . . . . . . . . . . . . . . .18, 42gentamicin . . . . . . . . . 18, 40, 42gentamicin/prednisolone
acetate . . . . . . . . . . . . . . . . 40GENTEX ADE 28-1 MG . . . . . 55GENVOYA . . . . . . . . . . . . . . . . 34GEODON . . . . . . . . . . . . . . . . . 48GERAVIM . . . . . . . . . . . . . . . . . 54GG/CODEINE . . . . . . . . . . . . . 49GG/DM CR . . . . . . . . . . . . . . . 49GILENYA . . . . . . . . . . . . . . . . . 15GILOTRIF . . . . . . . . . . . . . . . . . . 4glatiramer acetate . . . . . . .15, 16GLATOPA . . . . . . . . . . . . . . . . . 16glecaprevir/pibrentasvir . . . . . 32GLEEVEC . . . . . . . . . . . . . . . . . 5GLEOSTINE . . . . . . . . . . . . . . . . 4glimepiride . . . . . . . . . . . . . . . . 25glipizide . . . . . . . . . . . . . . . . . . 25glipizide extended-release . . . 25glipizide-metformin . . . . . . . . . 25GLUCAGON . . . . . . . . . . . . . . 24
72
ALL CAPS = Brand-name drug Lower case = Generic drug
Index of Covered Drugsglucagon, human
recombinant . . . . . . . . . . . 24GLUCOPHAGE . . . . . . . . . . . . 25GLUCOPHAGE ER . . . . . . . . . 25glucose gel 40% . . . . . . . . . . . 61glucose oral tablets . . . . . . . . 61GLUCOTROL . . . . . . . . . . . . . 25GLUCOTROL XL . . . . . . . . . . . 25GLUCOVANCE . . . . . . . . . . . . 25GLUTOSE 15 . . . . . . . . . . . . . 61glyburide . . . . . . . . . . . . . . . . . 25glyburide, micronized . . . . . . . 25glycerin . . . . . . . . . . . . 27, 40, 60GLYCERIN SUPPOSITORY . . 27GLYCERIN TOPICAL . . . . . . . 60glycerol phenylbutyrate . . . . . 58glycopyrrolate . . . . . . . . . . . . . 28GLYNASE . . . . . . . . . . . . . . . . . 25GRIFULVIN V . . . . . . . . . . . . . . 32GRIS-PEG . . . . . . . . . . . . . . . . 32griseofulvin microsize . . . . . . . 32griseofulvin ultramicrosize . . . 32guaifenesin . . . . . . . . . . . . 49-51guaifenesin extended-release 50guaifenesin/
pseudoephedrine . . . .49, 50guaifenesin/pseudoephedrine
extended-release . . . . . . . 50guaifenesin/pseudoephedrine/
dextromethorphan . . . . . . 50guanabenz . . . . . . . . . . . . . . . . 12guanfacine . . . . . . . . . . . . . . 9, 43guanfacine ER . . . . . . . . . . . . . 43GUIATUSS AC . . . . . . . . . . . . . 49GUIATUSS DAC . . . . . . . . . . . 49GYNE-LOTRIMIN . . . . . . .39, 60GYNOL II . . . . . . . . . . . . . . . . . 61
HHAEGARDA . . . . . . . . . . . . . . . 57HALCION . . . . . . . . . . . . . . . . . 45HALDOL . . . . . . . . . . . . . . . . . . 48halobetasol . . . . . . . . . . . . . . . 19haloperidol . . . . . . . . . . . . . . . . 48HAVRIX . . . . . . . . . . . . . . . . . . . 58HECORIA . . . . . . . . . . . . . . . . . . 6
HEMLIBRA . . . . . . . . . . . . . . . . 8heparin . . . . . . . . . . . . . . . . . . . . 7hepatitis a vaccine susp . . . . . 58hepatitis b vaccine
(recombinant) . . . . . . . . . . 58hepatitis b vaccine recombinant
adjuvanted . . . . . . . . . . . . . 58HEPLISAV-B . . . . . . . . . . . . . . 58HETLIOZ . . . . . . . . . . . . . . . . . 47HEXALEN . . . . . . . . . . . . . . . . . 4HIPREX . . . . . . . . . . . . . . . . . . 53homatropine . . . . . . . . . . .41, 50HUMALOG MIX 50/50. . . . . . 25HUMALOG MIX 75/25. . . . . . 25human papillomavirus (hpv)
9-valent recomb vac . . . . . 58human papillomavirus (hpv)
quadrivalent recombinant vac . . . . . . . . . . . . . . . . . . . 58
HUMATIN . . . . . . . . . . . . . . . . . 35HUMIRA . . . . . . . . . . . . . . . . . . 35HUMULIN. . . . . . . . . . 24, 25, 61HUMULIN 70/30 . . . . . . . . . . 25HUMULIN N . . . . . . . . . . . . . . . 24HUMULIN R . . . . . . . . . . . . . . . 25HYCAMTIN . . . . . . . . . . . . . . . . 7HYCODAN . . . . . . . . . . . . . . . . 50hydralazine. . . . . . . . . . . . . . . . 12HYDREA . . . . . . . . . . . . . . . . . . 6hydrochlorothiazide . . . . . . 8-11hydrocodone ER . . . . . . . . . . . 14hydrocodone/
acetaminophen . . . . . . . . . 14hydrocodone/homatropine . . 50HYDROCODONE/TAB
HOMATROP . . . . . . . . . . . 50hydrocortisone
. .19, 21, 22, 24, 29, 40, 61hydrocortisone butyrate . . . . . 19hydrocortisone crm, oint . . . . 61hydrocortisone valerate . . . . . 19hydrocortisone/aloe . . . . . . . . 19HYDROMET SYP . . . . . . . . . . 50hydromorphone . . . . . . . . . . . 14hydroxychloroquine . . . . . . . . 35hydroxyurea . . . . . . . . . . . . . . . . 6
hydroxyzine HCL . . . . . . . . . . . 22hydroxyzine pamoate . . . . . . . 22hyoscyamine . . . . . . . . . . .28, 53hyoscyamine sulfate . . . . . . . . 28hyoscyamine sulfate extended-
release . . . . . . . . . . . . . . . . 28HYPERCARE 15% . . . . . . . . . 20HYPERSAL . . . . . . . . . . . . . . . 57HYPERTET S/D . . . . . . . . . . . 59HYPOTEARS . . . . . . . . . . . . . . 63HYTONE . . . . . . . . . . . . . . . . . 19HYTRIN . . . . . . . . . . . . . . . . 9, 53HYZAAR . . . . . . . . . . . . . . . . . . 9
IIBRANCE . . . . . . . . . . . . . . . . . . 5ibrutinib . . . . . . . . . . . . . . . . . . . 5IBUOROFEN TAB COLD/
SIN . . . . . . . . . . . . . . . . . . . 51ibuprofen . . . . . . . . . . 14, 36, 63ibuprofen tabs, chew tabs,
susp, and drops . . . . . . . . 63icatibant . . . . . . . . . . . . . . . . . . 57ICLUSIG . . . . . . . . . . . . . . . . . . . 5idelalisib . . . . . . . . . . . . . . . . . . . 5ILARIS . . . . . . . . . . . . . . . . . . . 35iloperidone . . . . . . . . . . . . . . . . 46imatinib mesylate . . . . . . . . . . . 5IMBRUVICA . . . . . . . . . . . . . . . . 5IMDUR . . . . . . . . . . . . . . . . . . . 12imipramine HCL . . . . . . . . . . . 44imipramine pamoate . . . . . . . 46imiquimod 5% cream . . . . . . . 21IMITREX . . . . . . . . . . . . . . . . . . 15IMITREX 4 MG AND
6 MG INJ . . . . . . . . . . . . . . 15IMODIUM A-D . . . . . . . . . .27, 62IMPAVIDO . . . . . . . . . . . . . . . . 32IMURAN . . . . . . . . . . . . . . . . 6, 35INCRELEX . . . . . . . . . . . . . . . . 26INCRUSE ELLIPTA . . . . . . . . . 52indacaterol . . . . . . . . . . . . . . . . 52indapamide . . . . . . . . . . . . . . . 11INDERAL . . . . . . . . . . . . . .10, 15INDERAL LA . . . . . . . . . . . . . . 10INDERIDE . . . . . . . . . . . . . . . . 10
73
Index of Covered Drugs
ALL CAPS = Brand-name drug Lower case = Generic drug
indinavir . . . . . . . . . . . . . . . . . . 34INDOCIN . . . . . . . . . . . . . .14, 36indomethacin . . . . . . . . . .14, 36INFLAMASE FORTE . . . . . . . . 41influenza virus vaccine
recombinant hemagglutinin (ha) . . . . . . . . . . . . . . . . . . . 58
influenza virus vaccine split . . 58influenza virus vaccine split
high-dose pf . . . . . . . . . . . 58influenza virus vaccine split
pf . . . . . . . . . . . . . . . . . . . . . 58influenza virus vaccine split
quadrivalent . . . . . . . . . . . . 58influenza virus vaccine tiss-cult
subunit . . . . . . . . . . . . . . . . 58influenza virus vaccine types
a&b surface antigen . . . . . 58INGREZZA . . . . . . . . . . . . . . . . 18INLYTA . . . . . . . . . . . . . . . . . . . . 4inositol niacinate . . . . . . . . . . . 11insulin (vials only) . . . . . . . . . . 61insulin aspart protamine 70%/
insulin aspart 30% . . . . . . 24insulin glargine . . . . . . . . . . . . 24insulin glargine 300 unit/ml . 24insulin glargine/lixisenatide . . 24insulin human . . . . . . . . . . . . . 24insulin isophane . . . . . . . .24, 25insulin isophane human . .24, 25insulin isophane human 70%/
regular 30% . . . . . . . . . . . . 25insulin isophane/regular . . . . 25insulin lisopro pro/lispro . . . . 25insulin lisopro prot/lispro . . . . 25insulin lispro . . . . . . . . . . . . . . . 25insulin pen needle . . . . . . . . . 57insulin regular . . . . . . . . . . . . . 25insulin syringes . . . . . . . . . . . . 57INTAL . . . . . . . . . . . . . . . . . . . . 53INTELENCE . . . . . . . . . . . . . . . 34interferon alfa-2b . . . . . . . . . 6, 32interferon gamma-1b . . . . . . . . 6INTRON A . . . . . . . . . . . . . . 6, 32INTUNIV . . . . . . . . . . . . . . . . . . 43INVEGA . . . . . . . . . . . . . . .46, 47
INVEGA SUSTENNA . . . . . . . 47INVEGA TRINZA . . . . . . . . . . . 47INVIRASE . . . . . . . . . . . . . . . . . 34ipratropium . . . . . . . . 23, 52, 53ipratropium HFA . . . . . . . . . . . 52ipratropium nasal . . . . . . . . . . 23ipratropium/albuterol . . . .52, 53IRENKA . . . . . . . . . . . . . . . . . . 46IRESSA . . . . . . . . . . . . . . . . . . . . 5iron . . . . . . . . . . . . 38, 54-56, 63iron polysaccharides . . . . . . . 63ISENTRESS . . . . . . . . . . . . . . . 33ISENTRESS CHEWABLE . . . 33ISENTRESS HD . . . . . . . . . . . 33ISENTRESS SUSP . . . . . . . . . 33ISMO . . . . . . . . . . . . . . . . . . . . . 12isocarboxazid . . . . . . . . . . . . . 46isoniazid . . . . . . . . . . . . . . . . . . 30ISOPTO ATROPINE . . . . . . . . 41ISOPTO CARPINE . . . . . . . . . 41ISOPTO HOMATROPINE. . . . 41ISOPTO HYOSCINE . . . . . . . . 41ISORDIL . . . . . . . . . . . . . . . . . . 12ISORDIL S.L. . . . . . . . . . . . . . . 12isosorbide dinitrate . . . . . . . . . 12ISOSORBIDE DINITRATE ER 12isosorbide dinitrate extended-
release . . . . . . . . . . . . . . . . 12isosorbide mononitrate . . . . . 12isosorbide mononitrate extended-
release . . . . . . . . . . . . . . . . 12isotretinoin . . . . . . . . . . . . . . . . 18itraconazole . . . . . . . . . . . . . . . 32ivacaftor . . . . . . . . . . . . . . . . . . 57ivermectin . . . . . . . . . . . . . . . . 30ixazomib . . . . . . . . . . . . . . . . . . . 5
JJADENU . . . . . . . . . . . . . . . . . . . 8JAKAFI . . . . . . . . . . . . . . . . . . . . 5JULUCA . . . . . . . . . . . . . . . . . . 34
KK-DUR 10 . . . . . . . . . . . . . . . . . 56K-DUR 20 . . . . . . . . . . . . . . . . . 56K-LOR . . . . . . . . . . . . . . . . . . . . 56
K-LYTE . . . . . . . . . . . . . . . . . . . 56K-PHOS NEUTRAL . . . . . . . . . 56K-PHOS ORIGINAL . . . . . . . . 56K-TAB . . . . . . . . . . . . . . . . . . . . 56KALETRA . . . . . . . . . . . . . . . . 34KALEXATE . . . . . . . . . . . . . . . . 12KALYDECO . . . . . . . . . . . . . . . 57KALYDECO GRANULES . . . . 57KAOPECTATE . . . . . . . . . . . . . 62KAYEXALATE . . . . . . . . . . . . . 12KAZANO . . . . . . . . . . . . . . . . . 25KEFLEX . . . . . . . . . . . . . . . . . . 30KENALOG . . . . . . . . . . . . .19, 23KENALOG IN ORABASE . . . . 23KEPPRA (NOT XR) . . . . . . . . . 17KERLONE . . . . . . . . . . . . . . . . . 9ketoconazole . . . . . . . 20, 21, 32ketoprofen . . . . . . . . . . . . .14, 36ketorolac . . . . . . . . . . . . . .14, 40ketorolac tromethamine . . . . . 14ketotifen . . . . . . . . . . . . . . . . . . 40KEVZARA . . . . . . . . . . . . . . . . 35KHEDEZLA . . . . . . . . . . . . . . . 45KIMONO. . . . . . . . . . . . . . . . . . 61KINERET . . . . . . . . . . . . . . . . . 35KLARON . . . . . . . . . . . . . . . . . 18KLONOPIN . . . . . . . . . . . .16, 43KLOR-CON 10 . . . . . . . . . . . . 56KLOR-CON 8 . . . . . . . . . . . . . 56KONSYL-D . . . . . . . . . . . . . . . . 62KORLYM . . . . . . . . . . . . . . . . . 26KUVAN . . . . . . . . . . . . . . . . . . . 26KUVAN POWDER FOR
SOLUTION . . . . . . . . . . . . 26
Llabetalol . . . . . . . . . . . . . . . . . . 10LAC-HYDRIN . . . . . . . . . . . . . . 21lacosamide . . . . . . . . . . . . . . . 17LACTINEX . . . . . . . . . . . . .29, 62LACTINOL . . . . . . . . . . . . . . . . 21lactulose . . . . . . . . . . . . . . . . . . 27LAMICTAL . . . . . . . . . . . . . . . . 17LAMICTAL CD CHEW TAB . . 17LAMICTAL STARTER KIT . . . 17LAMISIL . . . . . . . . . . . . . . .20, 32
74
ALL CAPS = Brand-name drug Lower case = Generic drug
Index of Covered DrugsLAMISIL AT . . . . . . . . . . . .20, 32LAMISIL AT SPRAY . . . . . . . . 32lamivudine . . . . . . . . . . . . . 32-34lamivudine/tenofovir disoproxil
fumarate . . . . . . . . . . . . . . 33lamivudine/zidovudine . . . . . . 33lamotrigine . . . . . . . . . . . . . . . . 17lamotrigine chew dispersable
tab . . . . . . . . . . . . . . . . . . . . 17lamotrigine starter kit . . . . . . . 17lancets . . . . . . . . . . . . . . . . . . . 57LANOXIN . . . . . . . . . . . . . . . . . . 9lansoprazole . . . . . . . . . . . . . . 28lansoprazole delayed-release 28lapatinib ditosylate . . . . . . . . . . 5LARIAM . . . . . . . . . . . . . . . . . . 35LASIX . . . . . . . . . . . . . . . . . . . . 11latanoprost . . . . . . . . . . . . . . . . 41LATUDA . . . . . . . . . . . . . . . . . . 46laxative enemas . . . . . . . . . . . 62laxatives . . . . . . . . . . . . 2, 27, 62leflunomide . . . . . . . . . . . . . . . 35lenalidomide . . . . . . . . . . . . . . . 6lenvatinib . . . . . . . . . . . . . . . . . . 5LENVIMA . . . . . . . . . . . . . . . . . . 5LETAIRIS . . . . . . . . . . . . . . . . . 12letrozole . . . . . . . . . . . . . . . . . . . 5leucovorin . . . . . . . . . . . . . . . 5, 7leucovorin calcium . . . . . . . . . . 7LEUKERAN . . . . . . . . . . . . . . . . 4LEUKINE . . . . . . . . . . . . . . . . . . 7leuprolide . . . . . . . . . . . . . . . . . . 6levalbuterol HCl . . . . . . . . . . . . 53LEVAQUIN . . . . . . . . . . . . . . . . 31levetiracetam . . . . . . . . . . . . . . 17levobunolol . . . . . . . . . . . . . . . 41levocetirizine . . . . . . . . . . . . . . 22levofloxacin . . . . . . . . . . . . . . . 31levomilnacipran . . . . . . . . . . . . 46levonorgestrel . . . . . . . . . .37, 38levonorgestrel/EE . . . . . . .37, 38levothyroxine . . . . . . . . . . . . . . 26LEVOXYL . . . . . . . . . . . . . . . . . 26LEVSIN . . . . . . . . . . . . . . . . . . . 28LEVSINEX . . . . . . . . . . . . . . . . 28LEXAPRO . . . . . . . . . . . . .44, 46
LEXAPRO SOLUTION . . . . . . 46LEXIVA . . . . . . . . . . . . . . . . . . . 34LIBRIUM . . . . . . . . . . . . . . . . . . 42LIDAMANTEL . . . . . . . . . . . . . 21LIDEX . . . . . . . . . . . . . . . . . . . . 19LIDEX E . . . . . . . . . . . . . . . . . . 19lidocaine . . . . . . . . . . . . . . .21, 23lidocaine patch . . . . . . . . . . . . 21lidocaine viscous . . . . . . . . . . 23lidocaine/prilocaine . . . . . . . . 21LIDODERM . . . . . . . . . . . . . . . 21LIFESTYLES . . . . . . . . . . . . . . 61lifitegrast . . . . . . . . . . . . . . . . . . 42LIMBITROL . . . . . . . . . . . . . . . 44linezolid . . . . . . . . . . . . . . . . . . 35liothyronine . . . . . . . . . . . . . . . 26liotrix . . . . . . . . . . . . . . . . . . . . . 26LIPITOR . . . . . . . . . . . . . . . . . . 11LIPOFEN . . . . . . . . . . . . . . . . . 11lisdexamfetamine . . . . . . . . . . 43lisdexamfetamine chewable
tab . . . . . . . . . . . . . . . . . . . . 43lisinopril . . . . . . . . . . . . . . . . 8, 85lisinopril/hydrochlorothiazide . 8lithium carbonate . . . . . . . . . . 43lithium carbonate extended-
release . . . . . . . . . . . . . . . . 43LITHOBID . . . . . . . . . . . . . . . . . 43lixisenatide . . . . . . . . . . . . .24, 26LMX-4 . . . . . . . . . . . . . . . . . . . . 21LO/OVRAL . . . . . . . . . . . . . . . . 38LOCOID . . . . . . . . . . . . . . . . . . 19LODINE . . . . . . . . . . . . . . .14, 36LOESTRIN 1/20 . . . . . . . . . . . 37LOESTRIN 1.5/30 . . . . . . . . . 38LOESTRIN FE 1/20 . . . . . . . . 38LOESTRIN FE 1.5/30 . . . . . . . 38LOFIBRA . . . . . . . . . . . . . . . . . 11LOHIST-D . . . . . . . . . . . . . . . . . 49LOMOTIL . . . . . . . . . . . . . . . . . 27lomustine . . . . . . . . . . . . . . . . . . 4LONITEN . . . . . . . . . . . . . . . . . 12LONSURF . . . . . . . . . . . . . . . . . 4loperamide . . . . . . . . . . . . . . . . 27LOPID . . . . . . . . . . . . . . . . . . . . 11lopinavir/ritonavir . . . . . . . . . . 34
LOPRESSOR . . . . . . . . . . . . . . 10loratadine . . . . . . . 22, 23, 50, 61loratadine & pseudoephedrine
SR 24hr . . . . . . . . . . . . . . . 50loratadine/
pseudoephedrine 23, 50, 61loratadine/pseudoephedrine
extended-release . . . . . . . 23lorazepam . . . . . . . . . . . . . . . . 43LORCET . . . . . . . . . . . . . . . . . . 14LORTAB . . . . . . . . . . . . . . . . . . 14LORTAB ELIXIR . . . . . . . . . . . 14losartan . . . . . . . . . . . . . . . . . . . 9losartan/HCTZ . . . . . . . . . . . . . 9LOTENSIN . . . . . . . . . . . . . . . . . 8LOTENSIN HCT . . . . . . . . . . . . 8LOTREL . . . . . . . . . . . . . . . . . . 10LOTRIMIN AF . . . . . . . . . .20, 60LOTRISONE . . . . . . . . . . . . . . . 20lovastatin . . . . . . . . . . . . . . . . . 11LOVAZA . . . . . . . . . . . . . . . . . . 11LOVENOX . . . . . . . . . . . . . . . . . 7loxapine . . . . . . . . . . . . . . .46, 48loxapine aerosol powder breath
activated . . . . . . . . . . . . . . . 46LOXITANE . . . . . . . . . . . . . . . . 48LOZOL . . . . . . . . . . . . . . . . . . . 11LUDIOMIL . . . . . . . . . . . . . . . . 44lumacaftor/ivacaftor . . . . . . . . 57LUPRON . . . . . . . . . . . . . . . . . . 6LUPRON DEPOT . . . . . . . . . . . 6LUPRON DEPOT 6-MONTH . . 6LUPRON DEPOT-PED . . . . . . . 6lurasidone . . . . . . . . . . . . . . . . 46LURIDE . . . . . . . . . . . . . . . . . . . 54LURIDE LOZI-TABS. . . . . . . . . 54LUVOX . . . . . . . . . . . . . . . .43, 46LUVOX CR . . . . . . . . . . . . . . . . 46LYNPARZA . . . . . . . . . . . . . . . . 7LYRICA . . . . . . . . . . . . . . . . . . . 17LYRICA SOLUTION . . . . . . . . 17LYSODREN . . . . . . . . . . . . . . . . 7LYSTEDA . . . . . . . . . . . . . . . . . 40
MM-CLEAR WC . . . . . . . . . . . . . 49
75
Index of Covered Drugs
ALL CAPS = Brand-name drug Lower case = Generic drug
M-M-R II . . . . . . . . . . . . . . . . . . 59MAALOX . . . . . . . . . . . . . .28, 62MAALOX LIQUID . . . . . . . . . . 62macitentan . . . . . . . . . . . . . . . . 12MACROBID . . . . . . . . . . . . . . . 35MACRODANTIN . . . . . . . . . . . 35MAG-OX . . . . . . . . . . . . . . .54, 63MAG64 . . . . . . . . . . . . . . . . . . . 54magnesium chloride. . . . . . . . 54magnesium citrate soln . . . . . 27magnesium hydroxide susp . 62magnesium oxide . . . . . . .54, 63malathion . . . . . . . . . . . . . . . . . 20MAPAP COLD TAB . . . . . . . . 51maprotiline . . . . . . . . . . . . . . . . 44maraviroc . . . . . . . . . . . . . . . . . 34MARINOL . . . . . . . . . . . . . . . . . 27MARPLAN . . . . . . . . . . . . . . . . 46MATERNA . . . . . . . . . . . . . . . . 56MATULANE . . . . . . . . . . . . . . . . 7MAVIK . . . . . . . . . . . . . . . . . . . . . 8MAVYRET . . . . . . . . . . . . . . . . 32MAXALT/MAXALT MLT . . . . . 15MAXITROL. . . . . . . . . . . . . . . . 40MAXZIDE . . . . . . . . . . . . . . . . . 11measles, mumps & rubella
virus vaccines for inj . . . . . 59mecasermin . . . . . . . . . . . . . . . 26meclizine . . . . . . . . . . . . . .27, 62MEDROL . . . . . . . . . . . . . . . . . 24medroxyprogesterone
acetate . . . . . . . . . . . . .37, 39mefloquine . . . . . . . . . . . . . . . . 35MEGACE . . . . . . . . . . . . . . . . . . 6megestrol acetate . . . . . . . . . . . 6MEKINIST . . . . . . . . . . . . . . . . . 5MELLARIL . . . . . . . . . . . . . . . . 48meloxicam . . . . . . . . . . . . .14, 36melphalan . . . . . . . . . . . . . . . . . 4memantine . . . . . . . . . . . . . . . . 13MENACTRA . . . . . . . . . . . . . . . 59meningococcal (a, c, y, and
w-135) . . . . . . . . . . . . . . . . 59meningococcal (a, c, y, and
w-135) conjugate vaccine . . . . . . . . . . . . . . . . 59
meningococcal (a, c, y, and w-135) oligo conj vac for inj . . . . . . . . . . . . . . . . . . 59
MENOMUNE . . . . . . . . . . . . . . 59MENVEO . . . . . . . . . . . . . . . . . 59meperidine . . . . . . . . . . . . . . . . 14MEPHYTON . . . . . . . . . . . . . . 55MEPRON . . . . . . . . . . . . . . . . . 32mercaptopurine . . . . . . . . . . . . . 4mesalamine . . . . . . . . . . . . . . . 29mesalamine
extended-release . . . . . . . 29mesalamine supp . . . . . . . . . . 29mesna . . . . . . . . . . . . . . . . . . . . . 5MESNEX . . . . . . . . . . . . . . . . . . 5MESTINON . . . . . . . . . . . . . . . 16MESTINON TIMESPAN . . . . . 16METADATE ER . . . . . . . . . . . . 43METAGLIP . . . . . . . . . . . . . . . . 25METAMUCIL . . . . . . . . . . . . . . 62metaproterenol . . . . . . . . . . . . 53METAPROTERENOL
SYRUP . . . . . . . . . . . . . . . . 53metformin . . . . . . . . . . . . . . . . . 25metformin ER . . . . . . . . . . . . . 25metformin/glyburide . . . . . . . . 25methazolamide . . . . . . . . . . . . 41methenamine . . . . . . . . . . . . . 53methenamine hippurate . . . . . 53METHERGINE . . . . . . . . . .26, 40methimazole . . . . . . . . . . . . . . 26methocarbamol . . . . . . . . . . . . 37methotrexate . . . . . . . . . . . . . . 35methsuximide . . . . . . . . . . . . . 17methyldopa . . . . . . . . . . . . . . . 12methyldopa/HCTZ . . . . . . . . . 12methylene blue . . . . . . . . . . . . 53methylergonovine . . . . . . .26, 40methylphenidate . . . . . . . . . . . 43methylphenidate extended-
release . . . . . . . . . . . . . . . . 43methylphenidate HCL ER
24hr . . . . . . . . . . . . . . . . . . 43methylprednisolone . . . . . . . . 24metipranolol . . . . . . . . . . . . . . . 41metoclopramide . . . . . . . . . . . 27
metolazone . . . . . . . . . . . . . . . 11metoprolol . . . . . . . . . . . . . . . . 10metoprolol succinate . . . . . . . 10metreleptin . . . . . . . . . . . . . . . . 46METROCREAM . . . . . . . . . . . 20METROGEL . . . . . . . . . . . .20, 39METROGEL 1% . . . . . . . . . . . 39METROGEL-VAGINAL . . . . . . 39METROLOTION . . . . . . . . . . . 20metronidazole . . . . . . 20, 35, 39MEVACOR . . . . . . . . . . . . . . . . 11mexiletine . . . . . . . . . . . . . . . . . . 9MEXITIL . . . . . . . . . . . . . . . . . . . 9MIACALCIN . . . . . . . . . . . . . . . 26MICATIN . . . . . . . . . . . . . . .20, 60miconazole . . . . . . . . 20, 39, 60miconazole crm . . . . . . . . . . . 60MICRO-K 10 . . . . . . . . . . . . . . 56MICRONASE . . . . . . . . . . . . . . 25MICROZIDE . . . . . . . . . . . . . . . 11MIDAMOR . . . . . . . . . . . . . . . . 10midodrine . . . . . . . . . . . . . . . . . 12midostaurin . . . . . . . . . . . . . . . . 5mifepristone . . . . . . . . . . . . . . . 26MIGERGOT
SUPPOSITORIES . . . . . . . 15MILK OF MAGNESIA . . . . . . . 62miltefosine . . . . . . . . . . . . . . . . 32MINIPRESS . . . . . . . . . . . . . . . . 9MINOCIN . . . . . . . . . . . . . . . . . 31minocycline . . . . . . . . . . . . . . . 31minoxidil . . . . . . . . . . . . . . . . . . 12MINUTUSS DR SYP . . . . . . . . 50MIRALAX . . . . . . . . . . . . . . . . . 27MIRAPEX . . . . . . . . . . . . . . . . . 16MIRCETTE . . . . . . . . . . . . . . . . 37mirtazapine . . . . . . . . . . . .44, 46mirtazapine ODT . . . . . . . . . . . 46MIRVASO . . . . . . . . . . . . . . . . . 20misoprostol . . . . . . . . . . . . . . . 30MITIGARE . . . . . . . . . . . . . . . . 37mitotane . . . . . . . . . . . . . . . . . . . 7MOBIC . . . . . . . . . . . . . . . .14, 36MODICON . . . . . . . . . . . . . . . . 38MODURETIC . . . . . . . . . . . . . . 10moexipril hcl . . . . . . . . . . . . . . . 8
76
ALL CAPS = Brand-name drug Lower case = Generic drug
Index of Covered Drugsmoexipril-hydrochlorothiazide 9mometasone furoate . . . . . . . 19mometasone inhalation . . . . . 52MONISTAT . . . . . . . . . . . . .39, 60MONISTAT 3 . . . . . . . . . . . . . . 39MONISTAT-DERM . . . . . . . . . . 20MONOPRIL . . . . . . . . . . . . . . . . 8MONOPRIL-HCT . . . . . . . . . . . . 8montelukast . . . . . . . . . . . . . . . 53morphine . . . . . . . . . . . . . . . . . 14morphine extended-release . . 14MOTRIN . . . . . . . . . . . 14, 36, 63MOTRIN IB . . . . . . . . . . . . . . . 63MOVANTIK . . . . . . . . . . . . . . . 30MOZOBIL . . . . . . . . . . . . . . . . . . 7MS CONTIN . . . . . . . . . . . . . . . 14MSIR . . . . . . . . . . . . . . . . . . . . . 14MUCINEX . . . . . . . . . . . . . .49, 50MUCINEX D . . . . . . . . . . . . . . . 50MUCINEX DM . . . . . . . . . . . . . 49MUCOMYST . . . . . . . . . . . . . . 57MULTI SYMPTOM TAB COLD
RLF . . . . . . . . . . . . . . . . . . . 51multiple vitamin . . . . . . . . . . . . 54multivitamins/fluoride/±iron . 55multivitamins/minerals . . . . . . 55mupirocin . . . . . . . . . . . . . . . . . 18MURINE . . . . . . . . . . . . . . . . . . 63MURO 128 . . . . . . . . . . . . . . . 42MYALEPT . . . . . . . . . . . . . . . . . 46MYAMBUTOL . . . . . . . . . . . . . 30MYCELEX . . . . . . . . . . . . .20, 32MYCOBUTIN . . . . . . . . . . . . . . 30mycophenolate mofetil . . . . . . . 6mycophenolate sodium . . . . . . 6MYCOSTATIN . . . . . . . . . .20, 32MYFORTIC. . . . . . . . . . . . . . . . . 6MYLANTA . . . . . . . . . . . . .28, 62MYLANTA LIQUID . . . . . . . . . 62MYLERAN . . . . . . . . . . . . . . . . . 4MYLICON . . . . . . . . . . . . . . . . . 62MYORISAN . . . . . . . . . . . . . . . 18MYSOLINE . . . . . . . . . . . . . . . . 17MYTESI . . . . . . . . . . . . . . . . . . 27
Nnabumetone . . . . . . . . . . . . . . 36nadolol . . . . . . . . . . . . . . . . . . . 10naloxegol . . . . . . . . . . . . . . . . . 30naloxone . . . . . . . . . . . . . . .15, 47NALOXONE INJ . . . . . . . . . . . 47naltrexone . . . . . . . . . . . . .42, 47NAMENDA . . . . . . . . . . . . . . . . 13naphazoline HCL . . . . . . . . . . 40naphazoline/glycerin . . . . . . . 40naphazoline/zinc sulfate . . . . 40NAPHCON A . . . . . . . . . . . . . . 63NAPROSYN . . . . . . . . . . . .14, 36naproxen . . . . . . . . . . . . . .14, 36naproxen delayed release 14, 36naratriptan . . . . . . . . . . . . . . . . 15NARCAN NASAL SPRAY . . . 47NARDIL . . . . . . . . . . . . . . . . . . 46NASACORT ALLERGY 24
HOUR . . . . . . . . . . . . . . . . . 23nasal sprays . . . . . . . . . . . . . . . 61NASALCROM . . . . . . . . . . . . . 23NATALCARE . . . . . . . . . . .55, 56nateglinide . . . . . . . . . . . . . . . . 25NATROBA . . . . . . . . . . . . . . . . 20NAVANE . . . . . . . . . . . . . . . . . . 48NEBUPENT . . . . . . . . . . . . . . . 32NEBUSAL . . . . . . . . . . . . . . . . 57nefazodone hcl . . . . . . . . . . . . 44nelfinavir . . . . . . . . . . . . . . . . . . 34NEO-SYNEPHRINE . . . . .23, 61neomycin sulfate . . . . . . . . . . . 35neomycin/bacitracin/
polymyxin . . . . . . . . . . . . . . 42neomycin/polymyxin B/
bacitracin . . . . . . . . . . . . . . 18neomycin/polymyxin B/
dexamethasone . . . . . . . . 40neomycin/polymyxin B/
gramicidin . . . . . . . . . . . . . 42neomycin/polymyxin B/
hydrocortisone . . . . . .22, 40NEORAL . . . . . . . . . . . . . . . . . . 6NEOSPORIN . . . . . . . 18, 42, 61NEPHROCAPS . . . . . . . . . . . . 56NEPTAZANE . . . . . . . . . . . . . . 41
NESINA . . . . . . . . . . . . . . . . . . 25NESTABSCBF/FA/RX . . . . . . 56NEULASTA . . . . . . . . . . . . . . . . 7NEUMEGA . . . . . . . . . . . . . . . . . 7NEURONTIN . . . . . . . . . . . . . . 17NEUTROGENA OIL FREE
ACNE WASH . . . . . . . . . . . 18nevirapine . . . . . . . . . . . . . . . . 34nevirapine ER . . . . . . . . . . . . . 34NEXAVAR . . . . . . . . . . . . . . . . . 5NEXIUM 24HR OTC . . . . . . . . 28NEXIUM DELAYED RELEASE
PACKET . . . . . . . . . . . . . . . 28niacin . . . . . . . . . . . . . . . . . . . . 11niacin extended-release . . . . . 11NIACINOL . . . . . . . . . . . . . . . . 11NIACOR . . . . . . . . . . . . . . . . . . 11NIASPAN . . . . . . . . . . . . . . . . . 11nicardipine . . . . . . . . . . . . . . . . 10NICODERM CQ . . . . . . . .48, 63NICORETTE OTC . . . . . . . . . . 48nicotine . . . . . . . . . . . . . . . .48, 63NICOTINE GUM . . . . . . . . . . . 63nicotine inhaler system . . . . . 48nicotine nasal spray . . . . . . . . 48nicotine polacrilex gum . . . . . 48nicotine polacrilex lozenge . . 48NICOTROL INHALER. . . . . . . 48NICOTROL NASAL SPRAY . . 48nifedipine . . . . . . . . . . . . . . . . . 10nifedipine extended-release . 10NIFEREX . . . . . . . . . . 54, 55, 63NIFEREX-PN FORTE . . . . . . . 56nilotinib . . . . . . . . . . . . . . . . . . . . 5nimodipine . . . . . . . . . . . . . . . . 10nimodipine oral soln . . . . . . . . 10NIMOTOP. . . . . . . . . . . . . . . . . 10NINLARO . . . . . . . . . . . . . . . . . . 5nintedanib . . . . . . . . . . . . . . . . 57niraparib . . . . . . . . . . . . . . . . . . . 7nitazoxanide suspension . . . . 32nitisinone . . . . . . . . . . . . . . . . . 26NITREK . . . . . . . . . . . . . . . . . . 12NITRO-BID . . . . . . . . . . . . . . . . 12NITRO-DUR . . . . . . . . . . . . . . . 12
77
Index of Covered Drugs
ALL CAPS = Brand-name drug Lower case = Generic drug
nitrofurantoin extended-release . . . . . . . 35
nitrofurantoin macrocrystals . 35nitrofurantoin susp . . . . . . . . . 35nitroglycerin . . . . . . . . . . . .12, 21NITROLINGUAL . . . . . . . . . . . 12NITROSTAT . . . . . . . . . . . . . . . 12NITYR . . . . . . . . . . . . . . . . . . . . 26NIX 20, 62NIX CREME RINSE . . . . . . . . . 20NIZORAL . . . . . . . . . . 20, 21, 32NIZORAL SHAMPOO. . . . . . . 21NOCDURNA . . . . . . . . . . . . . . 26NOLVADEX . . . . . . . . . . . . . . . . 5NORCO . . . . . . . . . . . . . . . . . . 14NORDETTE . . . . . . . . . . . . . . . 38norelgestromin/EE . . . . . . . . . 38norethindrone . . . . . . . . . . 37-39norethindrone acetate . . . 37-39norethindrone acetate/
EE . . . . . . . . . . . . . . . . .37, 38norethindrone acetate/
EE/iron . . . . . . . . . . . . . . . . 38norethindrone/EE . . . . . . .37, 38norethindrone/ME . . . . . . . . . 38NORFLEX . . . . . . . . . . . . . . . . 37norgestimate/EE . . . . . . . . . . . 38norgestrel/EE . . . . . . . . . . . . . 38NORPACE . . . . . . . . . . . . . . . . . 9NORPACE CR . . . . . . . . . . . . . . 9NORPRAMIN . . . . . . . . . . . . . . 44nortriptyline . . . . . . . . . . . . . . . 44NORVASC . . . . . . . . . . . . . . . . 10NORVIR . . . . . . . . . . . . . . . . . . 34NOVAREL . . . . . . . . . . . . . . . . 39NOVOLIN . . . . . . . . . . 24, 25, 61NOVOLIN 70/30 . . . . . . . . . . . 25NOVOLIN N . . . . . . . . . . . . . . . 24NOVOLIN R . . . . . . . . . . . . . . . 24NOVOLOG MIX 70/30 . . . . . . 24NUEDEXTA . . . . . . . . . . . . . . . 47NULYTELY . . . . . . . . . . . . . . . . 27NUPLAZID . . . . . . . . . . . . . . . . 46NUVARING . . . . . . . . . . . . . . . 37NUVIGIL . . . . . . . . . . . . . . . . . . 13NYMALIZE . . . . . . . . . . . . . . . . 10
nystatin . . . . . . . . . . . . . . . .20, 32NYTOL QUICK CAPS . . . . . . . 45
OOCEAN NASAL SPRAY . . . . . 23octreotide . . . . . . . . . . . . . . . . . . 7OCUFEN . . . . . . . . . . . . . . . . . 40OCUFLOX . . . . . . . . . . . . . . . . 42ODEFSEY. . . . . . . . . . . . . . . . . 33ODOMZO . . . . . . . . . . . . . . . . . . 7OFEV . . . . . . . . . . . . . . . . . . . . 57ofloxacin . . . . . . . . . . . 22, 31, 42OGEN . . . . . . . . . . . . . . . . . . . . 39olanzapine . . . . . . . . . . . . .46, 47olanzapine for IM inj . . . . . . . . 46olanzapine ODT . . . . . . . . . . . 46olanzapine pamoate for
extended rel IM sus . . . . . 46olanzapine-fluoxetine . . . . . . . 46olaparib . . . . . . . . . . . . . . . . . . . 7olodaterol . . . . . . . . . . . . . . . . . 52olsalazine sodium . . . . . . . . . . 29omalizumab . . . . . . . . . . . . . . . 52omega 3 acid ethyl esters . . . 11omeprazole delayed-release . 28OMNICEF . . . . . . . . . . . . . . . . . 31ondansetron . . . . . . . . . . . . . . 27One Touch Systems . . . . . . . . 25One Touch Test Strips . . . . . . 25ONFI . . . . . . . . . . . . . . . . . . . . . 16oprelvekin . . . . . . . . . . . . . . . . . 7OPSUMIT . . . . . . . . . . . . . . . . . 12OPTIPRANOLOL . . . . . . . . . . 41OPTIVAR . . . . . . . . . . . . . . . . . 40ORAP . . . . . . . . . . . . . . . . . . . . 48ORAPRED . . . . . . . . . . . . . . . . 24ORKAMBI . . . . . . . . . . . . . . . . 57orphenadrine
extended-release . . . . . . . 37ORTHO COIL . . . . . . . . . . . . . 37ortho diaphragm . . . . . . . . . . . 37ORTHO EVRA . . . . . . . . . . . . . 38ORTHO FLAT . . . . . . . . . . . . . 37ORTHO FLEX . . . . . . . . . . . . . 37ORTHO MICRONOR . . . . . . . 38ORTHO TRI-CYCLEN . . . . . . . 38
ORTHO-CEPT . . . . . . . . . . . . . 38ORTHO-CYCLEN . . . . . . . . . . 38ORTHO-NOVUM 1/35 . . . . . . 38ORTHO-NOVUM 1/50 . . . . . . 38ORTHO-NOVUM 10/11 . . . . 37ORTHO-NOVUM 7/7/7 . . . . . 38ORUDIS . . . . . . . . . . . . . . .14, 36OS-CAL . . . . . . . . . . . . . . .54, 63oseltamivir . . . . . . . . . . . . . . . . 33OSENI . . . . . . . . . . . . . . . . . . . . 25OTEZLA . . . . . . . . . . . . . . . . . . 35OVCON 50 . . . . . . . . . . . . . . . . 38OVIDE . . . . . . . . . . . . . . . . . . . . 20OVIDREL . . . . . . . . . . . . . . . . . 39OVRAL . . . . . . . . . . . . . . . . . . . 38oxaprozin . . . . . . . . . . . . . .14, 36oxazepam . . . . . . . . . . . . . . . . 43oxcarbazepine . . . . . . . . . . . . . 17oxybutynin chloride . . . . . . . . 53oxybutynin IR . . . . . . . . . . . . . . 53oxybutynin patch. . . . . . . .54, 63oxycodone . . . . . . . . . . . . .14, 15oxycodone/acetaminophen . 15oxycodone/aspirin . . . . . . . . . 15OXYFAST . . . . . . . . . . . . . . . . . 14oxymetazoline . . . . . . . . . . . . . 23oxymorphone ER . . . . . . . . . . 15OXYTROL FOR WOMEN OTC
PATCH . . . . . . . . . . . . .54, 63
Ppalbociclib . . . . . . . . . . . . . . . . . 5paliperidone . . . . . . . . . . . .46, 47paliperidone tab SR 24HR . . 46palivizumab . . . . . . . . . . . . . . . 35PAMELOR . . . . . . . . . . . . . . . . 44pancrelipase . . . . . . . . . . . . . . 29panobinostat . . . . . . . . . . . . . . . 4PANRETIN . . . . . . . . . . . . . . . . . 6pantoprazole . . . . . . . . . . . . . . 28PARAFON FORTE DSC . . . . . 37PARNATE . . . . . . . . . . . . . . . . . 44paromomycin . . . . . . . . . . . . . 35paroxetine . . . . . . . . . . . . .44, 46paroxetine HCL tab SR
24HR . . . . . . . . . . . . . . . . . 46
78
ALL CAPS = Brand-name drug Lower case = Generic drug
Index of Covered Drugsparoxetine mesylate tab . . . . . 46PASER . . . . . . . . . . . . . . . . . . . 30pasireotide . . . . . . . . . . . . . . . . . 7patiromer . . . . . . . . . . . . . . . . . 12PAXIL . . . . . . . . . . . . . . . . .44, 46PAXIL CR . . . . . . . . . . . . . . . . . 46pazopanib . . . . . . . . . . . . . . . . . 5PEDIACARE LIQ MULTI-SY . . 51PEDIALYTE . . . . . . . . . . . .54, 62PEDIAPRED . . . . . . . . . . . . . . . 24PEDIAZOLE . . . . . . . . . . . . . . . 31peg 3350/electrolytes . . . . . . 27peg 3350/sodium bicarbonate/
sodium chloride . . . . . . . . 27peg 3350/sodium bicarbonate/
sodium chloride/potassium chloride . . . . . . . . . . . . . . . 27
PEGASYS . . . . . . . . . . . . . . . . . 32PEGASYS PROCLICK . . . . . . 32pegfilgrastim . . . . . . . . . . . . . . . 7peginterferon alfa-2a . . . . . . . 32peginterferon alfa-2b . . . . . . . . 6peginterferon beta-1a . . . . . . . 16pegvisomant . . . . . . . . . . . . . . 26penicillamine . . . . . . . . . . . . . . 35penicillin VK . . . . . . . . . . . . . . . 31PENLAC SOLUTION 8% . . . . 20pentamidine isethionate for
nebulization . . . . . . . . . . . . 32pentazocine/naloxone . . . . . . 15pentosan polysulfate sodium 54pentoxifylline
extended-release . . . . . . . . 8PEPCID . . . . . . . . . . . . . . .28, 62PEPCID AC . . . . . . . . . . . .28, 62PERCOCET . . . . . . . . . . . . . . . 15PERCODAN . . . . . . . . . . . . . . . 15PERIDEX . . . . . . . . . . . . . . . . . 23perindopril erbumine . . . . . . . . 8permethrin . . . . . . . . . . . . .20, 62perphenazine . . . . . . . . . .44, 48PERSANTINE . . . . . . . . . . . . . . 8PEXEVA . . . . . . . . . . . . . . . . . . 46phenazopyridine . . . . . . . . . . . 54phenelzine . . . . . . . . . . . . . . . . 46PHENERGAN . . . . . . . . . .27, 50
PHENERGAN DM . . . . . . . . . . 50phenobarbital . . . . . . . . . . . . . 17phenyl salicylate . . . . . . . . . . . 53phenylephrine . . . . . . . 23, 48-51phenylephrine/
brompheniramine/dextromethorphan . . . . . . 50
phenylephrine/chlorpheniramine/ dextromethorphan . . .50, 51
phenylephrine/chlorpheniramine/dihydrocodeine . . . . . . . . . 51
phenylephrine/dextromethorphan . . . . . . 51
phenylephrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 51
phenylephrine/ephed/CPM w/carbetapentane . . . . . . . . 51
phenylephrine/guaifenesin . . 51phenylephrine/pyrilamine w/
hydrocodone . . . . . . . . . . . 51PHENYLHIST LIQ DH . . . . . . 49PHENYTEK . . . . . . . . . . . . . . . 17phenytoin . . . . . . . . . . . . . . . . . 17phenytoin sodium extended . 17PHILLIPS COLON
HEALTH . . . . . . . . . . . .29, 62PHOS-FLUR . . . . . . . . . . .54, 63PHOSPHOLINE IODINE . . . . 41phosphorus . . . . . . . . . . . . . . . 56phytonadione. . . . . . . . . . . . . . 55pilocarpine . . . . . . . . . . . . .23, 41PILOPINE HS GEL . . . . . . . . . 41pimavanserin . . . . . . . . . . . . . . 46pimecrolimus . . . . . . . . . . . . . . 21pimozide . . . . . . . . . . . . . . . . . 48PIN-X . . . . . . . . . . . . . . . . . . . . . 30pioglitazone . . . . . . . . . . . . . . . 25pirfenidone capsule . . . . . . . . 57piroxicam . . . . . . . . . . . . . .14, 36PLAN B ONE STEP . . . . . . . . 37PLAQUENIL . . . . . . . . . . . . . . . 35PLAVIX . . . . . . . . . . . . . . . . . . . . 8plecanatide . . . . . . . . . . . . . . . 27
PLEGRIDY . . . . . . . . . . . . . . . . 16PLENDIL . . . . . . . . . . . . . . . . . 10plerixafor . . . . . . . . . . . . . . . . . . 7PLETAL . . . . . . . . . . . . . . . . . . . 8pneumococcal 13-valent
conjugate . . . . . . . . . . . . . . 59pneumococcal vaccine
polyvalent. . . . . . . . . . . . . . 59PNEUMOVAX . . . . . . . . . . . . . 59PNEUMOVAX 23 . . . . . . . . . . 59podofilox . . . . . . . . . . . . . . . . . 20POLY-VI-FLOR . . . . . . . . . . . . . 55POLY-VI-SOL . . . . . . . . . . . . . . 63polyethylene glycol 3350 . . . . 27polymyxin B/bacitracin . .18, 42polymyxin B/trimethoprim . . . 42polysaccharide iron caps . . . . 63polysaccharide iron complex 55POLYSPORIN . . . . . . . . . . . . . 42POLYTRIM . . . . . . . . . . . . . . . . 42pomalidomide . . . . . . . . . . . . . . 6POMALYST . . . . . . . . . . . . . . . . 6ponatinib . . . . . . . . . . . . . . . . . . 5potassium acid phosphate . . 56potassium bicarbonate/
potassium citrate effervescent . . . . . . . . . . . . 56
potassium chloride . . . . . .27, 56potassium chloride extended-
release . . . . . . . . . . . . . . . . 56potassium citrate . . . . . . . .54, 56potassium iodide . . . . . . . . . . 51POTIGA . . . . . . . . . . . . . . . . . . 16povidone-iodine . . . . . . . . . . . 35PRALUENT . . . . . . . . . . . . . . . 11pramipexole . . . . . . . . . . . . . . . 16pramlintide . . . . . . . . . . . . . . . . 26PRAMLYTE . . . . . . . . . . . . . . . 46PRANDIN . . . . . . . . . . . . . . . . . 25prasugrel . . . . . . . . . . . . . . . . . . 8praziquantel . . . . . . . . . . . . . . . 30prazosin . . . . . . . . . . . . . . . . . . . 9PRECOSE . . . . . . . . . . . . . . . . 25PRED FORTE . . . . . . . . . . . . . 41PRED MILD . . . . . . . . . . . . . . . 41PRED-G . . . . . . . . . . . . . . . . . . 40
79
Index of Covered Drugs
ALL CAPS = Brand-name drug Lower case = Generic drug
prednicarbate . . . . . . . . . . . . . 19prednisolone . . . . . . . 24, 40, 41prednisolone acetate . . . .40, 41prednisolone phosphate . . . . 41prednisolone sodium
phosphate . . . . . . . . . . . . . 24prednisone . . . . . . . . . . . . . . . . 24pregabalin . . . . . . . . . . . . . . . . 17PRELONE . . . . . . . . . . . . . . . . 24PREMARIN . . . . . . . . . . . . . . . 39PREMPHASE . . . . . . . . . . . . . 39PREMPRO . . . . . . . . . . . . . . . . 39prenat w/o A w/fecbn-fegl-DSS-
FA & DHA . . . . . . . . . . . . . . 55prenat-FE Bis-FE prot succ-FA-
CA & omega 3 . . . . . . . . . 55prenat-FE bis-FE prot succ-FA-
CA & omega DR . . . . . . . . 55prenatal vit w/FE bisglycinate
chelate-FA . . . . . . . . . . . . . 55prenatal vit w/FE polysac cmplx-
FA . . . . . . . . . . . . . . . . . . . . 55prenatal vit w/iron carbonyl-
FA . . . . . . . . . . . . . . . . . . . . 55PRENATAL VITAMINS W/
FOLIC ACID . . . . . . . . . . . . 56prenatal vitamins w/folic acid 56prenatal w/o A w/FE carbonyl-
FE gluc-DSS-FA . . . . . . . . 56PREPARATION H . . . . . . . . . . 62PREVACID . . . . . . . . . . . . . . . . 28PREVACID SOLUTAB . . . . . . 28PREVIDENT . . . . . . . . . . . . . . . 54PREVNAR 13 . . . . . . . . . . . . . 59PREZCOBIX . . . . . . . . . . . . . . 34PREZISTA . . . . . . . . . . . . . . . . 34PRIFTIN . . . . . . . . . . . . . . . . . . 30PRILOSEC . . . . . . . . . . . . . . . . 28primaquine. . . . . . . . . . . . . . . . 35primidone . . . . . . . . . . . . . . . . . 17PRINCIPEN . . . . . . . . . . . . . . . 31PRISTIQ . . . . . . . . . . . . . . . . . . 45PROAMATINE . . . . . . . . . . . . . 12probenecid . . . . . . . . . . . . . . . 37probiotics . . . . . . . . . . . . . .29, 62procarbazine . . . . . . . . . . . . . . . 7
PROCARDIA . . . . . . . . . . . . . . 10PROCARDIA XL . . . . . . . . . . . 10prochlorperazine . . . . . . . . . . . 27PROCRIT . . . . . . . . . . . . . . . . . . 7PROCTOSOL HC CREAM
2.5% . . . . . . . . . . . . . . . . . . 21PROCTOZONE CREAM-HC
2.5% . . . . . . . . . . . . . . . . . . 21progesterone
micronized . . . . . . . . . .38, 39progesterone micronized
cap . . . . . . . . . . . . . . . . . . . 38PROGRAF . . . . . . . . . . . . . . . . . 6PROLIXIN . . . . . . . . . . . . . . . . . 48PROLIXIN DECANOATE . . . . 48PROMACTA . . . . . . . . . . . . . . . 57PROMETH VC SYP
6.25-5/5 . . . . . . . . . . . . . . . 51promethazine . . . . . . . 27, 49-51promethazine &
phenylephrine . . . . . . .49, 51PROMETHAZINE SYP DM . . 50PROMETHAZINE VC
W/CODEINE . . . . . . . . . . . 49PROMETHAZINE
W/CODEINE . . . . . . . . . . . 49PROMETRIUM . . . . . . . . .38, 39propafenone . . . . . . . . . . . . . . . 9propantheline . . . . . . . . . . . . . 54propranolol . . . . . . . . . . . .10, 15propranolol ER 24hr . . . . . . . . 10propranolol/HCTZ . . . . . . . . . 10propylthiouracil . . . . . . . . . . . . 26PROSCAR . . . . . . . . . . . . . . . . 53PROSOM . . . . . . . . . . . . . . . . . 45PROTONIX . . . . . . . . . . . . . . . . 28PROTOPIC 0.03% . . . . . . . . . 21PROTOPIC 0.1% . . . . . . . . . . . 21protriptyline . . . . . . . . . . . . . . . 46PROVENTIL . . . . . . . . . . . . . . . 52PROVERA . . . . . . . . . . . . . . . . 39PROZAC . . . . . . . . . . . . . .44, 46PROZAC WEEKLY . . . . . . . . . 46PRUET DHA PAK SETONET
PAK . . . . . . . . . . . . . . . . . . . 55PRUET DHAEC PAK . . . . . . . 55
PSE/GG . . . . . . . . . . . . . . . . . . 50pseudoephedrine tan/
dexchlorphen tan/DM tan 52pseudoephedrine/
acetaminophen/dextromethorphan . . . . . . 51
pseudoephedrine/chlorpheniramine/dextromethorphan . . . . . . 51
pseudoephedrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 51
pseudoephedrine/iburprofen 51psyllium . . . . . . . . . . . . . . . . . . 62PULMICORT RESPULES . . . 52PULMOZYME . . . . . . . . . . . . . 57PURINETHOL . . . . . . . . . . . . . . 4pyrantel pamoate . . . . . . . . . . 30pyrazinamide . . . . . . . . . . . . . . 30pyrethrins/piperonyl butoxide
shampoo . . . . . . . . . . .20, 62PYRIDIUM . . . . . . . . . . . . . . . . 54pyridostigmine . . . . . . . . . . . . . 16pyridostigmine
extended-release . . . . . . . 16pyrilamine tan/phenyleph
tan . . . . . . . . . . . . . . . . . . . . 52pyrimethamine . . . . . . . . . . . . 35
QQUESTRAN . . . . . . . . . . . . . . . 11QUESTRAN-LIGHT . . . . . . . . . 11quetiapine . . . . . . . . . . . . .46, 47quetiapine fumarate tab SR
24HR . . . . . . . . . . . . . . . . . 46quinapril . . . . . . . . . . . . . . . . . 8, 9quinapril/hydrochlorothiazide . 9QUINIDINE GLUCONATE
EXT-REL . . . . . . . . . . . . . . . 9quinidine gluconate
extended-release . . . . . . . . 9quinidine sulfate . . . . . . . . . . . . 9QUINIDINE SULFATE
EXT-REL . . . . . . . . . . . . . . . 9quinidine sulfate extended-
release . . . . . . . . . . . . . . . . . 9
80
ALL CAPS = Brand-name drug Lower case = Generic drug
Index of Covered DrugsQVAR REDIHALER . . . . . . . . . 52
RR-TANNAMINE . . . . . . . . . . . . 48raloxifene . . . . . . . . . . . . . . . . . 26raltegravir . . . . . . . . . . . . . . . . . 33raltegravir susp . . . . . . . . . . . . 33ramipril . . . . . . . . . . . . . . . . . . . . 8RANEXA . . . . . . . . . . . . . . . . . 12ranitidine . . . . . . . . . . . . . . . . . 28ranitidine syrup . . . . . . . . . . . . 28ranolazine . . . . . . . . . . . . . . . . 12RAPAMUNE. . . . . . . . . . . . . . . . 6RAVICTI . . . . . . . . . . . . . . . . . . 58RAZADYNE . . . . . . . . . . . . . . . 13REBETOL . . . . . . . . . . . . . . . . 32RECOMBIVAX HB . . . . . . . . . 58rectal crm, suppositories . . . . 62RECTIV . . . . . . . . . . . . . . . . . . . 21REESE’S PINWORM
MEDICINE . . . . . . . . . . . . . 30REGLAN . . . . . . . . . . . . . . . . . 27regorafenib . . . . . . . . . . . . . . . . 5REGRANEX . . . . . . . . . . . . . . . 21RELAFEN . . . . . . . . . . . . . . . . . 36RELENZA. . . . . . . . . . . . . . . . . 33RELION 70/30 . . . . . . . . . . . . 25RELION N . . . . . . . . . . . . . . . . 24RELION R . . . . . . . . . . . . . . . . 24REMERON . . . . . . . . . . . . .44, 46REMERON SOLTAB . . . . . . . . 46RENVELA . . . . . . . . . . . . . . . . 57repaglinide . . . . . . . . . . . . . . . . 25REQUIP . . . . . . . . . . . . . . . . . . 16RESCRIPTOR . . . . . . . . . . . . . 34RESTORIL . . . . . . . . . . . . . . . . 45RETIN-A . . . . . . . . . . . . . . . . . . 18RETROVIR . . . . . . . . . . . . . . . . 33REVATIO . . . . . . . . . . . . . . . . . 12REVATIO SUSPENSION . . . . 12REVIA . . . . . . . . . . . . . . . . .42, 47REVLIMID . . . . . . . . . . . . . . . . . 6REXULTI . . . . . . . . . . . . . . . . . . 45REYATAZ . . . . . . . . . . . . . . . . . 34REYATAZ POWDER
PACKET . . . . . . . . . . . . . . . 34
ribavirin . . . . . . . . . . . . . . . . . . . 32RID SHAMPOO . . . . . . . . .20, 62RIDAURA . . . . . . . . . . . . . . . . . 35rifabutin . . . . . . . . . . . . . . . . . . 30RIFADIN . . . . . . . . . . . . . . . . . . 30rifapentine . . . . . . . . . . . . . . . . 30rifapin . . . . . . . . . . . . . . . . . . . . 30rilpivirine . . . . . . . . . . . . . . .33, 34RILUTEK . . . . . . . . . . . . . . . . . 13riluzole . . . . . . . . . . . . . . . . . . . 13rimantadine . . . . . . . . . . . . . . . 33rimexolone . . . . . . . . . . . . . . . . 41riociguat . . . . . . . . . . . . . . . . . . 12RISA-BID . . . . . . . . . . . . . .29, 62RISAQUAD . . . . . . . . . . . . .29, 62RISPERDAL . . . . . . . . . . . .46, 48RISPERDAL CONSTA . . .46, 48RISPERDAL M-TAB . . . . . . . . 46RISPERDAL SOLUTION . . . . 48risperidone . . . . . . . . . . . . .46, 48risperidone microspheres
for inj . . . . . . . . . . . . . . . . . . 46risperidone ODT . . . . . . . . . . . 46risperidone oral soln . . . . . . . . 48RITALIN . . . . . . . . . . . . . . . . . . 43RITALIN LA . . . . . . . . . . . . . . . 43ritonavir . . . . . . . . . . . . . . . . . . . 34rivastigmine . . . . . . . . . . . . . . . 13rizatriptan . . . . . . . . . . . . . . . . . 15RMS . . . . . . . . . . . . . . . . . . . . . 14ROBAXIN . . . . . . . . . . . . . . . . . 37ROBINUL . . . . . . . . . . . . . . . . . 28ROBITUSSIN . . . . . . . . 49-51, 61ROBITUSSIN CF . . . . . . . .50, 61ROBITUSSIN DM . . . . . . .49, 61ROBITUSSIN LIQ
CGH/ALRG . . . . . . . . . . . . 51ROBITUSSIN LIQ
CGH/CLD . . . . . . . . . .49, 51ROBITUSSIN LIQ
CGH/CONG . . . . . . . . . . . 50ROBITUSSIN LIQ
HD/CHST . . . . . . . . . . . . . 51ROBITUSSIN LIQ
PED NGHT . . . . . . . . . . . . 51ROBITUSSIN PE . . . . . . . .50, 61
ROBITUSSIN PED LIQ CGH/COLD . . . . . . . . . . . . . . . . . 49
ROBITUSSIN PED SYP . . . . . 50ROBITUSSIN SYP
CHST CNG . . . . . . . . . . . . 50ROBITUSSIN SYP MAX-ST . . 50ROCALTROL . . . . . . . . . . . . . . 54ROCALTROL SOLUTION . . . 54rolapitant . . . . . . . . . . . . . . . . . 28RONDEC DM . . . . . . . . . .50, 51RONDEC DM DROPS . . . . . . 51RONDEC DROPS . . . . . . . . . . 49RONDEC SYRUP . . . . . . . . . . 49ropinirole . . . . . . . . . . . . . . . . . 16ROWASA . . . . . . . . . . . . . . . . . 29ROXICODONE . . . . . . . . . . . . 15RUBRACA . . . . . . . . . . . . . . . . . 7rucaparib . . . . . . . . . . . . . . . . . . 7rufinamide . . . . . . . . . . . . . . . . 17ruxolitinib . . . . . . . . . . . . . . . . . . 5RYDAPT . . . . . . . . . . . . . . . . . . . 5RYNA-12 S . . . . . . . . . . . . . . . 52RYNATAN PEDIATRIC SUSP 49RYNATUSS PEDIATRIC
SUSP . . . . . . . . . . . . . . . . . 51RYTHMOL . . . . . . . . . . . . . . . . . 9
SSABRIL SOLUTION . . . . . . . . 17sacubitril/valsartan . . . . . . . . . . 9SAL-TROPINE . . . . . . . . . . . . . 30SALAC . . . . . . . . . . . . . . . . . . . 60SALAGEN . . . . . . . . . . . . . . . . 23salicylic acid . . . . 18, 20, 60, 63salicylic acid 17%/
collodion . . . . . . . . . . .20, 63salicylic acid lotion 2% . . . . . . 60saline nasal spray 0.65% . . . . 23salsalate . . . . . . . . . . . . . . . . . . 36SANCTURA . . . . . . . . . . . . . . . 54SANDIMMUNE . . . . . . . . . . . . . 6SANDOSTATIN . . . . . . . . . . . . . 7SANTYL . . . . . . . . . . . . . . . . . . 21SAPHRIS . . . . . . . . . . . . . . . . . 45sapropterin . . . . . . . . . . . . . . . . 26sapropterin powder . . . . . . . . 26
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ALL CAPS = Brand-name drug Lower case = Generic drug
saquinavir mesylate . . . . . . . . 34sargramostim. . . . . . . . . . . . . . . 7sarilumab . . . . . . . . . . . . . . . . . 35SAVAYSA . . . . . . . . . . . . . . . . . . 7SCALPICIN . . . . . . . . . . . . . . . 20scopolamine . . . . . . . . . . . . . . 41SEASONALE . . . . . . . . . . . . . . 37SECTRAL . . . . . . . . . . . . . . . . . . 9secukinumab . . . . . . . . . . . . . . 36SEGLUROMET . . . . . . . . . . . . 25selegiline . . . . . . . . . . . . . .16, 47selegiline td patch . . . . . . . . . . 47selenium sulfide . . . . . . . . . . . 21SELSUN . . . . . . . . . . . . . . . . . . 21SELZENTRY . . . . . . . . . . . . . . 34sennosides . . . . . . . . . . . . . . . 27SENOKOT . . . . . . . . . . . . . . . . 27SENSIPAR . . . . . . . . . . . . . . . . 57SERAX . . . . . . . . . . . . . . . . . . . 43SEROMYCIN . . . . . . . . . . . . . . 30SEROQUEL . . . . . . . . . . . .46, 47SEROQUEL XR . . . . . . . . . . . . 46sertraline . . . . . . . . . . . . . . . . . 44SERZONE . . . . . . . . . . . . . . . . 44sevelamer . . . . . . . . . . . . . . . . . 57SHINGRIX . . . . . . . . . . . . . . . . 59SIGNIFOR . . . . . . . . . . . . . . . . . 7sildenafil . . . . . . . . . . . . . . . . . . 12SILVADENE . . . . . . . . . . . . . . . 18silver sulfadiazine . . . . . . . . . . 18simethicone . . . . . . . . . . . .28, 62simvastatin . . . . . . . . . . . . . . . . 11SINEMET . . . . . . . . . . . . . . . . . 16SINEMET CR . . . . . . . . . . . . . . 16SINEQUAN . . . . . . . . . . . . . . . 44SINGULAIR . . . . . . . . . . . . . . . 53sirolimus . . . . . . . . . . . . . . . . . . . 6SIRTURO . . . . . . . . . . . . . . . . . 35sodium chloride for
nebulizer . . . . . . . . . . . . . . 57sodium chloride hypertonic . 42sodium chloride hypertonic
ophth soln . . . . . . . . . . . . . 42sodium chloride irrigation soln
0.9% . . . . . . . . . . . . . . . . . . 59sodium citrate/citric acid . . . . 54
sodium phenylbutyrate . . . . . 58sodium phosphate
monobasic . . . . . . . . . . . . . 53sodium polystyrene sulfonate 12SOLIQUA . . . . . . . . . . . . . . . . . 24somatropin . . . . . . . . . . . . . . . . 26SOMAVERT . . . . . . . . . . . . . . . 26SONATA . . . . . . . . . . . . . . . . . . 45sonidegib . . . . . . . . . . . . . . . . . . 7sorafenib . . . . . . . . . . . . . . . . . . 5SORIATANE . . . . . . . . . . . . . . . 20sotalol . . . . . . . . . . . . . . . . . . . . 10sotalol AF . . . . . . . . . . . . . . . . . 10spacers . . . . . . . . . . . . . . . . . . . 57spinosad . . . . . . . . . . . . . . . . . 20spironolactone. . . . . . . . . . . . . 11spironolactone/
hydrochlorothiazide . . . . . 11SPORANOX . . . . . . . . . . . . . . . 32SPRYCEL . . . . . . . . . . . . . . . . . . 4SSKI . . . . . . . . . . . . . . . . . . . . . 51STADOL . . . . . . . . . . . . . . . . . . 14STARLIX . . . . . . . . . . . . . . . . . . 25STATUSS DM SYP . . . . . . . . . 50stavudine . . . . . . . . . . . . . . . . . 33STEGLATRO . . . . . . . . . . . . . . 25STELAZINE . . . . . . . . . . . . . . . 48STIOLTO RESPIMAT . . . . . . . 52STIVARGA . . . . . . . . . . . . . . . . . 5stool softeners . . . . . . . . . . . . . 62STRATTERA . . . . . . . . . . . . . . 43STRENSIQ . . . . . . . . . . . . . . . . 26STRIBILD . . . . . . . . . . . . . . . . . 34STRIVERDI RESPIMAT . . . . . 52STROMECTOL . . . . . . . . . . . . 30STUART PRENATAL . . . . . . . 63SUBOXONE . . . . . . . . . . . . . . . 47SUBUTEX . . . . . . . . . . . . . . . . 47succimer . . . . . . . . . . . . . . . . . 57sucralfate . . . . . . . . . . . . . . . . . 28sugar+orthophosphoric acid 62sulcralfate . . . . . . . . . . . . . . . . . 28SULFACET-R . . . . . . . . . . . . . . 18sulfacetamide . . . . . . 18, 40, 42sulfacetamide sodium lotion . 18sulfacetamide/pred phos . . . 40
sulfacetamide/sulfur . . . . . . . . 18sulfamethoxazole/
trimethoprim, DS . . . . . . . 31sulfasalazine . . . . . . . . . . .29, 36sulfasalazine
delayed-release . . . . . .29, 36sulindac . . . . . . . . . . . . . . .14, 36SUMADAN WASH . . . . . . . . . 18sumatriptan . . . . . . . . . . . . . . . 15sumatriptan-naproxen . . . . . . 15SUMYCIN . . . . . . . . . . . . . . . . . 31sunitinib . . . . . . . . . . . . . . . . . . . 5SUPRAX . . . . . . . . . . . . . . . . . . 31SURMONTIL . . . . . . . . . . . . . . 47SUSTIVA . . . . . . . . . . . . . . . . . . 34SUTENT . . . . . . . . . . . . . . . . . . . 5SYLATRON . . . . . . . . . . . . . . . . 6SYMBYAX . . . . . . . . . . . . . . . . 46SYMDEKO . . . . . . . . . . . . . . . 57SYMFI, SYMFI LO . . . . . . . . . 33SYMLINPEN 60 . . . . . . . . . . . 26SYMMETREL . . . . . . . . . .16, 33SYNAGIS . . . . . . . . . . . . . . . . . 35SYNALAR . . . . . . . . . . . . . . . . 19SYNTHROID . . . . . . . . . . . . . . 26
TT-STAT . . . . . . . . . . . . . . . . . . . 18tabloid . . . . . . . . . . . . . . . . . . . . . 4tacrolimus . . . . . . . . . . . . . . 6, 21TAFINLAR . . . . . . . . . . . . . . . . . 4TAGAMET . . . . . . . . . . . . . . . . 28TALWIN NX . . . . . . . . . . . . . . . 15TAMBOCOR . . . . . . . . . . . . . . . 9TAMIFLU . . . . . . . . . . . . . . . . . 33tamoxifen . . . . . . . . . . . . . . . . . . 5tamsulosin . . . . . . . . . . . . . . . . 53TANAFED DMX
SUSPENSION . . . . . . . . . . 52TAPAZOLE . . . . . . . . . . . . . . . . 26TARCEVA . . . . . . . . . . . . . . . . . . 4TARGRETIN . . . . . . . . . . . . . . . . 6TASIGNA . . . . . . . . . . . . . . . . . . 5tasimelteon . . . . . . . . . . . . . . . 47TASMAR . . . . . . . . . . . . . . . . . . 16TECFIDERA . . . . . . . . . . . . . . . 15
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Index of Covered Drugs
teduglutide . . . . . . . . . . . . . . . . 30TEGRETOL . . . . . . . . . . . . . . . 16TEGRETOL-XR . . . . . . . . . . . . 16temazepam . . . . . . . . . . . . . . . 45TEMODAR . . . . . . . . . . . . . . . . . 4TEMOVATE . . . . . . . . . . . . . . . 19temozolomide . . . . . . . . . . . . . . 4TENEX . . . . . . . . . . . . . . . . . . . . 9TENIVAC . . . . . . . . . . . . . . . . . 59tenofovir . . . . . . . . . . . . . . .33, 34TENORETIC . . . . . . . . . . . . . . . 9TENORMIN . . . . . . . . . . . . . . . . 9TERAZOL 3/7 . . . . . . . . . . . . . 39terazosin . . . . . . . . . . . . . . . . 9, 53terbinafine . . . . . . . . . . . . .20, 32terbutaline . . . . . . . . . . . . . . . . 53terconazole . . . . . . . . . . . . . . . 39teriflunomide . . . . . . . . . . . . . . 16tesamorelin . . . . . . . . . . . . . . . 26TESSALON . . . . . . . . . . . . . . . 48TESTOSTERONE 1% TOPICAL
GEL . . . . . . . . . . . . . . . . . . 24testosterone cypionate . . . . . . 24testosterone enanthate . . . . . . 24testosterone gel topical tube,
packet, and pump bottle . 24tet tox-diph-acell pertuss ad . 59TET/DIP TOX INJ . . . . . . . . . . 59tetanus immune globulin
(human) . . . . . . . . . . . . . . . 59tetanus-diphtheria toxoids
(td) . . . . . . . . . . . . . . . . . . . 59tetrabenazine . . . . . . . . . . . . . . 18tetracaine hcl ophth soln . . . . 42tetracycline . . . . . . . . . . . . . . . . 31tetrahydrozoline/zinc sulfate . 40tezacaftor/ivcaftor . . . . . . . . . 57thalidomide . . . . . . . . . . . . . . . . 7THALOMID . . . . . . . . . . . . . . . . 7THEO-24 . . . . . . . . . . . . . . . . . 53THEOCHRON . . . . . . . . . . . . . 53theophylline . . . . . . . . . . . . . . . 53theophylline extended-release 53THERA-PLUS . . . . . . . . . . . . . 54thioguanine . . . . . . . . . . . . . . . . 4thioridazine . . . . . . . . . . . . . . . 48
thiothixene . . . . . . . . . . . . . . . . 48THORAZINE . . . . . . . . . . .45, 48THORAZINE INJ . . . . . . . . . . . 45THYROLAR . . . . . . . . . . . . . . . 26tiagabine . . . . . . . . . . . . . . . . . 17TIAZAC . . . . . . . . . . . . . . . . . . . 10ticagrelor . . . . . . . . . . . . . . . . . . 8TIGAN . . . . . . . . . . . . . . . . . . . . 28TIKOSYN . . . . . . . . . . . . . . . . . . 9timolol . . . . . . . . . . . . . . . . . . . . 41timolol maleate . . . . . . . . . . . . 41TIMOPTIC . . . . . . . . . . . . . . . . 41TIMOPTIC XE . . . . . . . . . . . . . 41TINACTIN . . . . . . . . . . . . . .20, 60tiotropium/olodaterol . . . . . . . 52tipranavir . . . . . . . . . . . . . . . . . 34TIVICAY . . . . . . . . . . . . . . . . . . 33tizanidine . . . . . . . . . . . . . . . . . 37TOBRADEX . . . . . . . . . . . . . . . 40tobramycin . . . . . . . . . 40, 42, 57tobramycin neb soln . . . . . . . . 57tobramycin/dexamethasone . 40TOBREX . . . . . . . . . . . . . . . . . . 42TOFRANIL . . . . . . . . . . . . . . . . 44TOFRANIL-PM . . . . . . . . . . . . . 46tolazamide . . . . . . . . . . . . . . . . 25tolbutamide . . . . . . . . . . . . . . . 25tolcapone . . . . . . . . . . . . . . . . . 16TOLINASE . . . . . . . . . . . . . . . . 25tolnaftate . . . . . . . . . . . . . .20, 60tolterodine . . . . . . . . . . . . . . . . 54TOPAMAX . . . . . . . . . . . . . . . . 17TOPAMAX SPRINKLE . . . . . . 17topical antibacterials . . . . . . . . 61topiramate . . . . . . . . . . . . . . . . 17topiramate sprinkle caps . . . . 17topotecan . . . . . . . . . . . . . . . . . . 7TOPROL XL . . . . . . . . . . . . . . . 10TORADOL . . . . . . . . . . . . . . . . 14toremifene . . . . . . . . . . . . . . . . . 5torsemide . . . . . . . . . . . . . . . . . 11TOUJEO SOLOSTAR . . . . . . . 24TRACLEER . . . . . . . . . . . . . . . 12tramadol . . . . . . . . . . . . . . . . . . 13trametinib . . . . . . . . . . . . . . . . . . 5TRANDATE . . . . . . . . . . . . . . . 10
trandolapril . . . . . . . . . . . . . . . . . 8tranexamic acid . . . . . . . . . . . . 40TRANXENE . . . . . . . . . . . . . . . 43tranylcypromine . . . . . . . . . . . . 44trazodone . . . . . . . . . . . . . .44, 47TRECATOR . . . . . . . . . . . . . . . 30TRENTAL . . . . . . . . . . . . . . . . . . 8tretinoin . . . . . . . . . . . . . . . . 7, 18TREXIMET . . . . . . . . . . . . . . . . 15TRI RX . . . . . . . . . . . . . . . . . . . 56TRI-FED X. . . . . . . . . . . . . . . . . 52TRI-NORINYL . . . . . . . . . . . . . 38TRI-VI-FLOR . . . . . . . . . . . . . . . 56TRI-VI-SOL . . . . . . . . . . . . .56, 63triamcinolone . . . . . . . . . . .19, 23triamcinolone acetonide . . . . 19triamcinolone nasal spray . . . 23triamterene/
hydrochlorothiazide . . . . . 11TRIAVIL . . . . . . . . . . . . . . . . . . 44triazolam . . . . . . . . . . . . . . . . . . 45trifluoperazine . . . . . . . . . . . . . 48trifluridine . . . . . . . . . . . . . . . 4, 42trifluridine/tipiracil . . . . . . . . . . . 4trihexyphenidyl . . . . . . . . . . . . 16TRILAFON . . . . . . . . . . . . . . . . 48TRILEPTAL . . . . . . . . . . . . . . . 17TRILYTE . . . . . . . . . . . . . . . . . . 27trimethobenzamide . . . . . . . . 28trimethoprim . . . . . . . 31, 35, 42trimipramine . . . . . . . . . . . . . . 47TRINTELLIX . . . . . . . . . . . . . . . 47TRIOTANN . . . . . . . . . . . . .23, 48TRIOTANN PEDIATRIC
SUSP . . . . . . . . . . . . . . . . . 48tripolidine/pseudoephedrine 52TRIPROL/PSE SYP . . . . . . . . 52TRIUMEQ . . . . . . . . . . . . . . . . . 34TRIVORA . . . . . . . . . . . . . . . . . 38TRIZIVIR . . . . . . . . . . . . . . . . . . 33TROJAN . . . . . . . . . . . . . . . . . . 61trospium . . . . . . . . . . . . . . . . . . 54TRULANCE . . . . . . . . . . . . . . 27TRULICITY . . . . . . . . . . . . . . . . 26
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ALL CAPS = Brand-name drug Lower case = Generic drug
TRUSOPT . . . . . . . . . . . . . . . . 41TRUST NATALCARE
PAK DHA . . . . . . . . . . . . . . 55TRUSTEX . . . . . . . . . . . . . . . . . 61TRUVADA . . . . . . . . . . . . . . . . 33TUMS . . . . . . . . . . . . . . . . .62, 63TUSSI-12 S . . . . . . . . . . . . . . . 48TUSSIN DM . . . . . . . . . . . . . . . 49tybost . . . . . . . . . . . . . . . . . . . . 34TYKERB . . . . . . . . . . . . . . . . . . . 5TYLENOL . . . . . . . 13, 14, 36, 63TYLENOL W/CODEINE . . . . . 14TYMLOS . . . . . . . . . . . . . . . . . 26typhoid vaccine . . . . . . . . . . . . 59
UULORIC . . . . . . . . . . . . . . . . . . 37ULTRA . . . . . . . . . . . . . . . .25, 56ULTRA 2, ULTRAMINI . . . . . . 25ULTRAM . . . . . . . . . . . . . . . . . . 13ULTRAVATE . . . . . . . . . . . . . . . 19umeclidinium inhalation . . . . . 52UNI-HIST DROPS . . . . . . . . . . 48UNIPHYL . . . . . . . . . . . . . . . . . 53UNIRETIC . . . . . . . . . . . . . . . . . 9UNISOM . . . . . . . . . . . . . . .45, 62UNIVASC . . . . . . . . . . . . . . . . . . 8UREA 10% CREAM . . . . . . . . 21UREA 10% LOTION . . . . . . . . 21urea 10%, urea 20% . . . . . . . . 21UREA 20% CREAM . . . . . . . . 21urea 40% . . . . . . . . . . . . . . . . . 21UREA 40% LOTION . . . . . . . . 21URECHOLINE . . . . . . . . . . . . . 53UREX . . . . . . . . . . . . . . . . . . . . 53uridine . . . . . . . . . . . . . . . . . . . 26UROCIT-K . . . . . . . . . . . . . . . . 54UROXATRAL . . . . . . . . . . . . . . 53URSO . . . . . . . . . . . . . . . . . . . . 30URSO FORTE . . . . . . . . . . . . . 30ursodiol . . . . . . . . . . . . . . . . . . 30UTIRA C . . . . . . . . . . . . . . . . . . 53
VVAGIFEM . . . . . . . . . . . . . . . . . 39vaginal products . . . . . . . . . . . 60
valacyclovir . . . . . . . . . . . . . . . . 33valbenazine . . . . . . . . . . . . . . . 18VALCYTE . . . . . . . . . . . . . . . . . 32valganciclovir . . . . . . . . . . . . . . 32VALIUM . . . . . . . . . . . . . . .37, 43valproic acid . . . . . . . . . . . . . . 17VALTREX . . . . . . . . . . . . . . . . . 33vancomycin powder for oral
solution . . . . . . . . . . . . . . . 32vandetanib . . . . . . . . . . . . . . . . . 5VAQTA . . . . . . . . . . . . . . . . . . . 58varenicline . . . . . . . . . . . . . . . . 48varicella virus vac live for
subcutaneous . . . . . . . . . . 59VARIVAX . . . . . . . . . . . . . . . . . 59VARUBI . . . . . . . . . . . . . . . . . . 28VASERETIC . . . . . . . . . . . . . . . . 8VASOCIDIN . . . . . . . . . . . . . . . 40VASOCLEAR . . . . . . . . . . . . . . 40VASOCLEAR A . . . . . . . . . . . . 40VASOTEC . . . . . . . . . . . . . . . . . . 8VECTICAL . . . . . . . . . . . . . . . . 20VEETIDS . . . . . . . . . . . . . . . . . 31VELTASSA . . . . . . . . . . . . . . . . 12vemurafenib . . . . . . . . . . . . . . . . 5VENCLEXTA . . . . . . . . . . . . . . . 5venetoclax . . . . . . . . . . . . . . . . . 5venlafaxine . . . . . . . . . . . . .44, 47venlafaxine HCL tab
SR 24HR . . . . . . . . . . . . . . 47venlafaxine XR . . . . . . . . . . . . . 44VENTOLIN HFA . . . . . . . . . . . . 52VEPESID . . . . . . . . . . . . . . . . . . 6verapamil . . . . . . . . . . . . . .10, 15verapamil extended-release . . 10VERIO . . . . . . . . . . . . . . . . . . . . 25VERIO, VERIO FLEX, VERIO IQ,
VERIO SYNC . . . . . . . . . . . 25VERSACLOZ . . . . . . . . . . . . . . 45VERZENIO . . . . . . . . . . . . . . . . . 4VESANOID . . . . . . . . . . . . . . . . . 7VEXOL . . . . . . . . . . . . . . . . . . . 41VFEND . . . . . . . . . . . . . . . . . . . 32VI-DAYLIN . . . . . . . . . . . . . . . . . 63VI-STRESS . . . . . . . . . . . . . . . . 54VICODIN . . . . . . . . . . . . . . . . . . 14
VICODIN ES . . . . . . . . . . . . . . . 14VIDEX . . . . . . . . . . . . . . . . . . . . 33VIDEX EC . . . . . . . . . . . . . . . . . 33vigabatrin oral solution . . . . . . 17VIIBRYD . . . . . . . . . . . . . . . . . . 47vilazodone . . . . . . . . . . . . . . . . 47VIMPAT . . . . . . . . . . . . . . . . . . . 17VINATE AZ EX . . . . . . . . . . . . . 55VINATE II . . . . . . . . . . . . . . . . . 55VIRACEPT . . . . . . . . . . . . . . . . 34VIRAMUNE . . . . . . . . . . . . . . . 34VIRAMUNE XR . . . . . . . . . . . . 34VIREAD . . . . . . . . . . . . . . . . . . 34VIROPTIC . . . . . . . . . . . . . . . . . 42VISINE . . . . . . . . . . . . . . . . . . . 63VISINE-AC . . . . . . . . . . . . . . . . 40vismodegib . . . . . . . . . . . . . . . . 7VISTARIL . . . . . . . . . . . . . . . . . 22VISTOGARD . . . . . . . . . . . . . . 26vitamin A . . . . . . . . . . . . . . . . . 56vitamin ADC/fluoride/±iron
drops . . . . . . . . . . . . . . . . . 56vitamin B complex/vitamin C/
folic acid . . . . . . . . . . . . . . . 56vitamin B-1 . . . . . . . . . . . . . . . . 56VITAMIN B-12 . . . . . . . . . . . . . 54vitamin B-6 . . . . . . . . . . . . . . . . 56vitamin C . . . . . . . . . . . . . . . . . 56vitamin D . . . . . . . . . . . . . .56, 63vitamin D 400 IU . . . . . . . . . . . 63vitamin E. . . . . . . . . . . . . . . . . . 56vitamins pediatric . . . . . . .56, 63vitamins pediatric members <3
years old . . . . . . . . . . . . . . 63vitamins prenatal . . . . . . . . . . . 63VIVACTIL . . . . . . . . . . . . . . . . . 46VIVOTIF BERNA . . . . . . . . . . . 59VOLTAREN . . . . . 13, 14, 36, 40VOLTAREN 1% TOPICAL
GEL . . . . . . . . . . . . . . . . . . 36VOLTAREN XR . . . . . . . . .14, 36voriconazole . . . . . . . . . . . . . . 32vorinostat . . . . . . . . . . . . . . . . . . 4vortioxetine. . . . . . . . . . . . . . . . 47VOSOL HC OTIC . . . . . . . . . . 22VOSOL OTIC . . . . . . . . . . . . . . 22
84
ALL CAPS = Brand-name drug Lower case = Generic drug
Index of Covered DrugsVOSPIRE ER . . . . . . . . . . . . . . 53VOTRIENT . . . . . . . . . . . . . . . . . 5VYVANSE . . . . . . . . . . . . . . . . 43VYVANSE CHEWABLE . . . . . 43
Wwarfarin . . . . . . . . . . . . . . . . . . . 7WELLBUTRIN . . . . . . . . . . . . . 44WELLBUTRIN SR . . . . . . . . . . 44WELLBUTRIN XL . . . . . . . . . . 44WELLCOVORIN . . . . . . . . . . . . 7WESTCORT . . . . . . . . . . . . . . . 19WYTENSIN . . . . . . . . . . . . . . . 12
XXALATAN . . . . . . . . . . . . . . . . . 41XALKORI . . . . . . . . . . . . . . . . . . 4XANAX . . . . . . . . . . . . . . . . . . . 42XELODA . . . . . . . . . . . . . . . . . . . 4XENAZINE . . . . . . . . . . . . . . . . 18XIIDRA . . . . . . . . . . . . . . . . . . . 42XOLAIR . . . . . . . . . . . . . . . . . . 52XOPENEX RESPULES . . . . . . 53XULANE . . . . . . . . . . . . . . . . . . 38XYLOCAINE . . . . . . . . . . . .21, 23XYZAL . . . . . . . . . . . . . . . . . . . 22
YYUVAFEM . . . . . . . . . . . . . . . . 39
ZZADITOR . . . . . . . . . . . . .40, 63zaleplon . . . . . . . . . . . . . . . . . . 45ZANAFLEX . . . . . . . . . . . . . . . 37zanamivir . . . . . . . . . . . . . . . . . 33ZANTAC . . . . . . . . . . . . . . . . . . 28ZARONTIN . . . . . . . . . . . . . . . 16ZAROXOLYN . . . . . . . . . . . . . . 11ZARXIO . . . . . . . . . . . . . . . . . . . 7ZEBETA . . . . . . . . . . . . . . . . . . . 9ZEJULA . . . . . . . . . . . . . . . . . . . 7ZELBORAF . . . . . . . . . . . . . . . . 5ZENTANE . . . . . . . . . . . . . . . . . 18ZERIT . . . . . . . . . . . . . . . . . . . . 33ZESTORETIC . . . . . . . . . . . . . . 8ZESTRIL . . . . . . . . . . . . . . . . . . . 8
zetia . . . . . . . . . . . . . . . . . . . . . . 11ZIAC . . . . . . . . . . . . . . . . . . . . . . 9ZIAGEN . . . . . . . . . . . . . . . . . . 33zidovudine . . . . . . . . . . . . . . . . 33ZINBRYTA . . . . . . . . . . . . . . . . 15zinc . . . . . . . . . . . . . . . 40, 54, 56zinc sulfate . . . . . . . . . . . . .40, 56ZINCATE . . . . . . . . . . . . . . . . . 56ziprasidone . . . . . . . . . . . . . . . 48ZITHROMAX . . . . . . . . . . . . . . 31ZOCOR. . . . . . . . . . . . . . . . . . . 11ZOFRAN . . . . . . . . . . . . . . . . . . 27ZOFRAN ODT . . . . . . . . . . . . . 27ZOHYDRO ER . . . . . . . . . . . . . 14ZOLINZA . . . . . . . . . . . . . . . . . . 4ZOLOFT . . . . . . . . . . . . . . . . . . 44zolpidem . . . . . . . . . . . . . . . . . 45ZOMACTON . . . . . . . . . . . . . . 26ZONEGRAN . . . . . . . . . . . . . . 17zonisamide . . . . . . . . . . . . . . . 17ZORTRESS . . . . . . . . . . . . . . . . 6ZOSTAVAX . . . . . . . . . . . . . . . . 59zoster vaccine live . . . . . . . . . . 59zoster vaccine recombinant
adjuvanted . . . . . . . . . . . . 59ZOVIA 1/35 . . . . . . . . . . . . . . . 38ZOVIA 1/50 . . . . . . . . . . . . . . . 38ZOVIRAX . . . . . . . . . . . . . . . . . 33ZUBSOLV . . . . . . . . . . . . . . . . 47ZYBAN . . . . . . . . . . . . . . . . . . . 48ZYDELIG . . . . . . . . . . . . . . . . . . 5ZYKADIA . . . . . . . . . . . . . . . . . . 4ZYLOPRIM . . . . . . . . . . . . . . . . 37ZYPREXA . . . . . . . . . . . . .46, 47ZYPREXA RELPREVV . . . . . . 46ZYPREXA ZYDIS . . . . . . . . . . 46ZYRTEC . . . . . . . . . . . . . . .22, 60ZYRTEC CHEWABLE
TABLET . . . . . . . . . . . . . . . 22ZYRTEC D . . . . . . . . . . . . . . . . 60ZYRTEC-D . . . . . . . . . . . . . . . . 23ZYTIGA . . . . . . . . . . . . . . . . . . . 5ZYVOX . . . . . . . . . . . . . . . . . . . 35
85
“My Medications” worksheetTake this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.
Name of Medicineand Strength
DrugTier
I Take ThisMedicine For Directions Doctor
Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr. Johnson
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