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Providence Health & Services Prescription Drug Formulary
List of Covered Prescription Drugs
www.ProvidenceHealthPlan.com
Effective January 1, 2015
Providence Health & Services Prescription Drug Plan | i
Providence prescription drug coverage
Providence Health Plan wants to help you to make the most of your prescription drug coverage. That’s why we strive to provide you with the information you need to make smart decisions about medications. Know more, save more
We encourage you to be knowledgeable about your prescription drug benefits. Information is available on your benefit summary, in your member handbook and on the Providence Health Plan website.
When you require a prescription, be sure to let your doctor know cost matters to you. Choosing a generic when possible can help manage your costs. Retail pharmacies
You have access to more than 25,000 participating pharmacies nationwide at discounted rates. Search the provider directory to locate participating pharmacies near you. Preventive drugs
Preventive drugs are those prescribed for the purpose of avoiding a condition or disease in individuals with risk factors. They may also be prescribed for the prevention of a reoccurrence of a disease or condition. Preventive medications are labeled as such in the “status” column of the formulary. Maintenance drugs Maintenance medications are those typically prescribed to treat long-term or chronic conditions, such as diabetes, high blood pressure and high cholesterol. A 90-day supply of maintenance medication is available through participating mail-order pharmacies, as well as through preferred retail pharmacies. Your 90-day supply copay or coinsurance applies. Not all covered prescription drugs are available in a 90-day supply.
Learn more about mail-order pharmacies and preferred retail pharmacies. Specialty drugs
Specialty drugs are prescriptions that require special delivery, handling, administration and monitoring by your pharmacist. These drugs are listed in the Providence formulary with a status of “Specialty,” and are available through Providence Specialty Pharmacy Services.
Learn more about specialty drugs. Generic drugs
Making the switch from brand to generic medication can save you money. Generic drugs, which are available only after the brand-name patent expires:
Providence Health & Services Prescription Drug Plan | ii
• Have the same active ingredient formula as the brand-name drug and • Are tested by the Food and Drug Administration (FDA) to be as safe and effective as the
brand-name drug.
There are two types of generic drugs:
• Generic equivalent - A generic equivalent is a generic drug that has the same active ingredient, dosage form and strength as its brand-name counterpart. The FDA assures sameness between brand-name and generic equivalent products. Generic equivalents are an important option to brand-name prescription drugs because they cost less. Example: Zocor®, a brand-name drug commonly used to treat high cholesterol, is now available in generic form under the name simvastatin. Zocor® and simvastatin are identical drugs – the only difference is that one costs more than the other.
• Generic alternative - A generic alternative is a generic drug used to treat the same
condition as a brand-name drug. It is not, however, the exact same medication as the brand-name drug. According to clinical evidence, a generic alternative can be expected to treat the same condition as well as the brand-name option. Example: Simvastatin, the generic form of Zocor®, may be prescribed instead of Crestor® in the treatment of high cholesterol. Generic alternatives are an important option for prescription drugs for which there is no generic available.
Visit the Consumer Reports Best-Buy Drug website for more information regarding safe and effective drug treatment options. The Providence formulary
Your prescription drug plan provides coverage for medications listed on the Providence formulary. Developed in collaboration with Providence Health Plans, physicians and pharmacists, the formulary includes FDA-approved prescription generic, brand-name and specialty medications. The formulary can help you and your physician choose effective, quality medications that minimize your out-of-pocket expense. Search the formulary
There are two ways to search the formulary. They include:
1. By medical condition category (e.g., drugs used to treat heart conditions are listed under the category, Cardiovascular Agents); and
2. By index (provides an alphabetical listing of drugs included in the formulary). Formulary updates
The formulary is updated every two months. Providence’s Oregon Regional Pharmacy and Therapeutics committee (comprised of doctors and pharmacists who practice in the communities we
Providence Health & Services Prescription Drug Plan | iii
serve) continuously reviews the latest evidence to identify opportunities to promote safe, effective and affordable drug therapy. Generally, the formulary status of a drug covered by your Providence Health Plan prescription drug coverage will not change during the year unless:
• The medication becomes available in generic form; • There are safety or effectiveness concerns raised about the prescription drug; or • The Pharmacy and Therapeutics committee determines that changes to the formulary would
be in the best overall interest of Providence Health Plan members.
If a change to the formulary results in a reduction of benefits or an increase in member copay, affected individuals are notified in writing. Formulary brand-name drugs
The Providence formulary includes prescription drugs that are proven safe, effective and that offer value. Refer to your benefit summary for your brand-name drug copay or coinsurance amount. Remember, even if a generic equivalent is not yet available, safe and effective generic alternatives may be available to treat most common conditions. Using these options can provide cost savings. Non-approved drugs
Your prescription drug benefit covers only FDA-approved prescription drugs. It is possible for medications to be on the market without FDA approval. The FDA is taking action to ensure these drugs become approved or are removed from the market. In the meantime, many remain on pharmacy shelves. If the drug you are taking is not FDA approved, know that there are likely approved prescription drugs available to treat your condition. We encourage you to discuss alternative medications with your doctor. Should you and your doctor determine that there is no covered alternative and you choose to continue to take a medication that is not FDA approved, your health plan will not cover that expense. More information regarding medications that are not FDA approved can be found on our website, in the related article and in the FAQ document, which includes links to the FDA website. You may also call the Providence Health Plan pharmacy team for more information and to discuss potential alternatives. Prior authorization
Prior authorization is a process to review a prescription drug for coverage before it is dispensed. The prior authorization process is initiated by the prescribing medical provider. Many factors – including the potential for serious health risks, FDA-approved indications and cost-effectiveness – are considered before making the decision to require prior authorization of a prescription medication. A limited number of medications require prior authorization review; any medications requiring prior authorization are indicated as such in the Providence formulary.
Providence Health & Services Prescription Drug Plan | iv
Keep in mind, the formulary may contain other suitable options. You and your doctor may wish to discuss the possibility of changing your prescription to an effective formulary alternative. Otherwise, your doctor may submit a prior authorization request on your behalf. Formulary exceptions
There may be times that you require a medication that is not on the Providence formulary. If you currently take a prescription drug that is not on the formulary, contact customer service to confirm that drug is not covered. If the prescription drug is not covered, your doctor may request a formulary exception. Step therapy
Step therapy is a form of prior authorization. Its purpose is to confirm if drugs generally considered "first-line" therapy based on clinical evidence already have been tried. If they have, the drug requiring prior authorization will automatically be approved. In the event these drugs are not tried first, cannot be tried first or the individual’s prescription medication history is not part of Providence Health Plan claims history, prior authorization is required. Quantity limit
For certain drugs, Providence Health Plan limits the amount of the drug covered for a specified time frame [e.g., Providence Health Plan provides two inhalers per 30 days for Proair® or Proventil® HFA (albuterol HFA)]. Quantity limits are in place to ensure safe and appropriate use of a drug. Answers to frequently asked questions Learn more about your prescription drug coverage by reviewing answers to frequently asked questions.
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Analgesics
alagesic lq Generic
butalbital/acetaminophen Generic
butalbital/acetaminophen/caffeine (50-325-40 capsule, 50-325-40 tablet, 50-500-40 tablet)
Generic
butalbital/aspirin/caffeine Generic
capacet Generic
fioricet 50-325-40 mg tablet Generic
tencon 50-325 mg tablet Generic
tramadol hcl/acetaminophen Generic QL (240 PER 30 DAYS)
Nonsteroidal Anti-inflammatory DrugsCELEBREX (50 MG, 100 MG, 200 MG) Brand PA, QL (60 PER 30 DAYS)
CELEBREX 400 MG CAPSULE Brand PA, QL (30 PER 30 DAYS)
diclofenac potassium Generic
diclofenac sodium (25 mg tablet dr, 50mg tablet dr, 75 mg tablet dr, 100 mgtab er 24h)
Generic
diflunisal Generic
etodolac (200 mg capsule, 300 mgcapsule, 400 mg tab er 24h, 400 mgtablet, 500 mg tab er 24h, 500 mgtablet, 600 mg tab er 24h)
Generic
fenoprofen calcium 600 mg tablet Generic
flurbiprofen (50 mg, 100 mg) Generic
ibuprofen (400 mg, 600 mg, 800 mg) Generic
ibuprofen/oxycodone hcl Generic
indomethacin (25 mg, 50 mg, 75 mg er) Generic
ketoprofen (50 mg capsule, 75 mgcapsule, 200 mg cap24h pel)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access1
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsketorolac tromethamine 10 mg tablet Generic
meclofenamate sodium (50 mg, 100mg)
Generic
meloxicam (7.5 mg tablet, 7.5 mg/5mloral susp, 15 mg tablet)
Generic
nabumetone (500 mg, 750 mg) Generic
NAPRELAN CR 500 MG TABLET Brand
naproxen (125 mg/5ml oral susp, 250mg tablet, 375 mg tablet, 375 mg tabletdr, 500 mg tablet, 500 mg tablet dr)
Generic
naproxen sodium (275 mg, 550 mg) Generic
oxaprozin Generic
piroxicam (10 mg, 20 mg) Generic
sulindac (150 mg, 200 mg) Generic
tolmetin sodium Generic
Opioid Analgesics, Long-actingfentanyl (12 mcg/hr, 25mcg/hr,50mcg/hr, 75mcg/hr, 100 mcg/hr)
Generic QL (15 PER 30 DAYS)
levorphanol tartrate 2 mg tablet Generic
methadone hcl (5 mg tablet, 5 mg/5 mlsolution, 10 mg tablet, 10 mg/5 mlsolution, 10 mg/ml oral conc, 40 mgtablet sol)
Generic
methadone intensol Generic
methadose 40 mg tablet dispr Generic
morphine sulfate (5 mg supp.rect, 10mg supp.rect, 15 mg tablet er, 20 mgsupp.rect, 30 mg supp.rect, 30 mgtablet er, 60 mg tablet er, 100 mgtablet er, 200 mg tablet er)
Generic
oxycodone hcl (10 mg er, 20 mg er, 40mg er, 80 mg er)
Generic PA, QL (90 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access2
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsOXYCONTIN (15 MG, 30 MG, 60 MG) Brand PA, QL (90 PER 30 DAYS)
tramadol hcl (100 mg tab er 24h, 100mg tbmp 24hr, 200 mg tab er 24h, 200mg tbmp 24hr, 300 mg tab er 24h, 300mg tbmp 24hr)
Generic
Opioid Analgesics, Short-actingacetaminophen with codeine phosphate(120-12mg/5 solution, 240-24/10solution, 300mg-15mg tablet, 300mg-30mg tablet, 300mg-60mg tablet,300mg/12.5 solution, 360-36/15solution)
Generic
ascomp with codeine Generic
butalbit/acetamin/caff/codeine 50-325-30 capsule
Generic
butorphanol tartrate 10 mg/ml spray Generic
co-gesic Generic
codeinephosphate/butalbital/aspirin/caffeine
Generic
codeine phosphate/carisoprodol/aspirin Generic
codeine sulfate (15 mg, 30 mg, 60 mg) Generic
dihydrocodeinebitartrate/acetaminophen/caffeine
Generic
endocet (5-325, 7.5-325 mg, 7.5-500mg, 10-325 mg, 10-650 mg)
Generic
endodan Generic
hydrocodone bit/acetaminophen Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access3
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitshydrocodone bitartrate/acetaminophen(2.5-167/5 solution, 2.5-500 mg tablet,5 mg-500mg tablet, 5-334mg/10solution, 5mg-325mg tablet, 7.5-325/15solution, 7.5-325mg tablet, 7.5-500/15solution, 7.5-500mg tablet, 7.5-650 mgtablet, 7.5-750mg tablet, 10-660mgtablet, 10-750mg tablet, 10mg-325mgtablet, 10mg-500mg tablet, 10mg-650mg tablet)
Generic
hydrocodone/ibuprofen Generic
hydromorphone hcl (1 mg/ml liquid, 2mg tablet, 3 mg supp.rect, 4 mg tablet,8 mg tablet)
Generic
ibudone 5-200 mg tablet Generic
lorcet Generic
lorcet hd Generic
lorcet plus 7.5-325 mg tablet Generic
lortab (5-325 mg, 5-500, 7.5-325 mg,10-325 mg)
Generic
meperidine hcl (50 mg, 100 mg) Generic
meperitab Generic
morphine sulfate (10 mg/5 ml solution,15 mg tablet, 20 mg/5 ml solution, 30mg tablet, 100 mg/5ml solution)
Generic
oxycodone hcl (5 mg capsule, 5 mgtablet, 5 mg/5 ml solution, 10 mgtablet, 15 mg tablet, 20 mg tablet, 20mg/ml oral conc, 30 mg tablet)
Generic
oxycodone hcl/acetaminophen (5 mg-500mg capsule, 5mg-325mg tablet, 7.5-325mg tablet, 7.5-500mg tablet, 10mg-325mg tablet, 10mg-650mg tablet)
Generic
oxycodone hcl/aspirin Generic
oxymorphone hcl (5 mg, 10 mg) Generic PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access4
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsreprexain 10-200 mg tablet Generic
ROXICET 5-325 ORAL SOLUTION Brand
roxicet 5-325 tablet Generic
stagesic Generic
tramadol hcl 50 mg tablet Generic
xylon 10 Generic
Anesthetics
Local Anestheticsglydo Generic
lidocaine 5 % oint. (g) Generic
lidocaine 5%(700mg) adh. patch Generic PA, QL (90 PER 30 DAYS)
lidocaine hcl (2 % jel (ml), 2 % jel/pfapp, 2 % solution, 4 % solution, 40mg/ml solution)
Generic
lidocaine/prilocaine (2.5 %-2.5% cream(g), 2.5 %-2.5% kit)
Generic
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-cravingacamprosate calcium Generic
disulfiram (250 mg, 500 mg) Generic
buprenorphine hcl/naloxone hcl Generic
SUBOXONE (2 MG-0.5 MG, 8 MG-2 MG) Brand
Opioid Antagonistsbuprenorphine hcl (2 mg, 8 mg) Generic QL (90 PER 30 DAYS)
depade Generic
naltrexone hcl 50 mg tablet Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access5
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsrevia Generic
Smoking Cessation Agentsbuproban Generic
CHANTIX Brand
Anti-inflammatory Agents
Glucocorticoidsalclometasone dipropionate Generic
amcinonide 0.1 % cream (g) Generic
apexicon e Generic
betamethasone dipropionate (0.05 %cream (g), 0.05 % gel (gram), 0.05 %lotion, 0.05 % oint. (g))
Generic
betamethasone dipropionate/propyleneglycol (0.05 % cream (g), 0.05 % lotion,0.05 % oint. (g))
Generic
betamethasone valerate (0.1 % cream(g), 0.1 % lotion, 0.1 % oint. (g))
Generic
clobetasol propionate (0.05 % cream(g), 0.05 % foam, 0.05 % gel (gram),0.05 % oint. (g), 0.05 % shampoo, 0.05% solution)
Generic
clobetasol propionate/emoll 0.05 %cream (g)
Generic
clobetasol propionate/emoll 0.05 %foam
Generic PA
clodan 0.05% shampoo Generic
cormax Generic
cortisone acetate 25 mg tablet Generic
desonide (0.05 % cream (g), 0.05 %lotion, 0.05 % oint. (g))
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access6
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsdesoximetasone Generic
diflorasone diacetate Generic
fludrocortisone acetate 0.1 mg tablet Generic
fluocinolone acetonide (0.01 % cream(g), 0.01 % solution, 0.025 % cream (g),0.025 % oint. (g))
Generic
fluocinonide (0.05 % cream (g), 0.05 %gel (gram), 0.05 % oint. (g), 0.05 %solution)
Generic
fluocinonide/emollient base Generic
fluticasone propionate (0.005 % oint.(g), 0.05 % cream (g), 0.05 % lotion)
Generic
halobetasol propionate Generic
hydrocortisone (2.5 % cream (g), 2.5 %lotion, 2.5 % oint. (g))
Generic
hydrocortisone butyrate 0.1 % cream(g)
Generic
millipred 5 mg tablet Generic
millipred dp Generic
nystatin/triamcinolone acetonide Generic
oralone Generic
ORAPRED ODT Brand
prednisolone 15 mg/5 ml solution Generic
prednisolone sod phosphate (5 ml, 15ml)
Generic
prednisone (1 mg tablet, 2.5 mg tablet,5 mg tab ds pk, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab ds pk, 10 mg tablet,20 mg tablet, 50 mg tablet)
Generic
prednisone intensol Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access7
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitstriamcinolone acetonide (0.025 %cream (g), 0.025 % lotion, 0.025 % oint.(g), 0.1 % cream (g), 0.1 % lotion, 0.1 %oint. (g), 0.1 % paste (g), 0.5 % cream(g), 0.5 % oint. (g))
Generic
triderm Generic
Antibacterials
Aminoglycosidesgaramycin 0.3% eye drops Generic
gentak (0.3 % ointment, 3 mg/ml drops) Generic
gentamicin sulfate (0.1 % cream (g), 0.1% oint. (g), 0.3 % drops, 0.3 % oint. (g))
Generic
neomycin sulfate 500 mg tablet Generic
TOBI PODHALER Specialty
tobramycin 0.3 % drops Generic
tobramycin in 0.225 % sodium chloride Generic LA
TOBREX 0.3% EYE OINTMENT Brand
Antibacterials, Otheracetasol hc Generic
acetic acid/aluminum acetate Generic
acetic acid/hydrocortisone Generic
bacitracin 500 unit/g oint. (g) Generic
chlorhexidine gluconate 0.12 %mouthwash
Generic
clinda-derm Generic
clindacin etz 1% pledget Generic
clindacin p Generic
clindamycin hcl (75 mg, 150 mg, 300mg)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access8
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsclindamycin palmitate hcl Generic
clindamycin phosphate (1 % foam, 1 %gel (gram), 1 % lotion, 1 % med. swab, 1% solution, 2 % cream/appl)
Generic
cycloserine 250 mg capsule Generic
methenamine hippurate Generic
metronidazole (0.75 % cream (g), 0.75% gel (gram))
Generic PA
metronidazole (0.75 % gel w/appl, 0.75% lotion, 250 mg tablet, 375 mgcapsule, 500 mg tablet)
Generic
MONUROL Brand
mupirocin 2 % oint. (g) Generic
nitrofurantoin (25 mg/5 ml oral susp, 50mg capsule)
Generic
nitrofurantoin macrocrystal (50 mg, 100mg)
Generic
nitrofurantoinmonohydrate/macrocrystals
Generic
paroex Generic
periogard Generic
rosadan (0.75% cream, 0.75% gel) Generic PA
trimethoprim 100 mg tablet Generic
vancomycin hcl (125 mg, 250 mg) Generic
vandazole Generic
vitazol Generic PA
XIFAXAN 200 MG TABLET Brand PA, QL (90 PER 30 DAYS)
XIFAXAN 550 MG TABLET Brand PA, QL (60 PER 30 DAYS)
ZYVOX (100 MG/5 ML SUSPENSION,600 MG TABLET)
Brand PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access9
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Beta-lactam, Cephalosporinscefaclor (125 mg/5ml susp recon, 250mg capsule, 250 mg/5ml susp recon,375 mg/5ml susp recon, 500 mgcapsule)
Generic
cefadroxil (1 g tablet, 250 mg/5ml susprecon, 500 mg capsule, 500 mg/5mlsusp recon)
Generic
cefdinir (125 mg/5ml susp recon, 250mg/5ml susp recon, 300 mg capsule)
Generic
cefpodoxime proxetil (50 mg/5 ml susprecon, 100 mg tablet, 100 mg/5ml susprecon, 200 mg tablet)
Generic
cefprozil (125 mg/5ml susp recon, 250mg tablet, 250 mg/5ml susp recon, 500mg tablet)
Generic
ceftibuten dihydrate (180 mg/5ml susprecon, 400 mg capsule)
Generic
CEFTIN (125 ML, 250 ML) Brand
cefuroxime axetil Generic
cephalexin (125 mg/5ml susp recon,250 mg capsule, 250 mg tablet, 250mg/5ml susp recon, 500 mg capsule,500 mg tablet)
Generic
Beta-lactam, Penicillinsamoxicillin (125 mg tab chew, 125mg/5ml susp recon, 200 mg/5ml susprecon, 250 mg capsule, 250 mg tabchew, 250 mg/5ml susp recon, 400 mgtab chew, 400 mg/5ml susp recon, 500mg capsule, 500 mg tablet, 875 mgtablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access10
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsamoxicillin/potassium clavulanate (200-28.5/5 susp recon, 200-28.5mg tabchew, 250-125 mg tablet, 250-62.5/5susp recon, 400-57mg tab chew, 400-57mg/5 susp recon, 500-125 mg tablet,600-42.9/5 susp recon, 875-125 mgtablet, 1000-62.5 tab er 12h)
Generic
ampicillin trihydrate (250 mg, 500 mg) Generic
dicloxacillin sodium Generic
penicillin v potassium (125 mg/5ml solnrecon, 250 mg tablet, 250 mg/5ml solnrecon, 500 mg tablet)
Generic
MacrolidesAZASITE Brand
azithromycin (1 g packet, 100 mg/5mlsusp recon, 200 mg/5ml susp recon, 250mg tablet, 500 mg tablet, 600 mgtablet)
Generic
clarithromycin (125 mg/5ml susp recon,250 mg tablet, 250 mg/5ml susp recon,500 mg tab er 24h, 500 mg tablet)
Generic
E.E.S. 200 Brand
ERY-TAB Brand
erygel Generic
ERYPED 200 Brand
erythromycin base (5 mg/g oint. (g),5mg/g oint. (g), 250 mg capsule dr, 250mg tablet, 500 mg tablet)
Generic
erythromycin base/ethyl alcohol (2 %gel (gram), 2 % solution)
Generic
erythromycin ethylsuccinate 400 mgtablet
Generic
erythromycinethylsuccinate/sulfisoxazole acetyl
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access11
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Quinolonesciprofloxacin hcl (0.3 % drops, 100 mgtablet, 250 mg tablet, 500 mg tablet,750 mg tablet)
Generic
ciprofloxacin/ciprofloxa hcl 500 mgtbmp 24hr
Generic
levofloxacin (0.5 % drops, 250 mgtablet, 250mg/10ml solution, 500 mgtablet, 750 mg tablet)
Generic
moxifloxacin hcl 400 mg tablet Generic
ofloxacin (0.3 % drops, 200 mg tablet,300 mg tablet, 400 mg tablet)
Generic
Sulfonamidesbleph-10 Generic
silver sulfadiazine 1 % cream (g) Generic
sulfacetamide sodium (10 % drops, 10 %suspension)
Generic
sulfadiazine 500 mg tablet Generic
sulfamethoxazole/trimethoprim (200-40mg/5 oral susp, 400mg-80mg tablet,800-160 mg tablet, 800-160/20 oralsusp)
Generic
sulfamide Generic
Tetracyclinesavidoxy Generic
demeclocycline hcl (150 mg, 300 mg) Generic
doxycycline hyclate (20 mg tablet, 50mg capsule, 100 mg capsule, 100 mgtablet)
Generic
doxycycline monohydrate (50 mgcapsule, 50 mg tablet, 75 mg tablet,100 mg capsule, 100 mg tablet, 150 mgtablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access12
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsdynacin 100 mg tablet Generic
minocycline hcl (50 mg capsule, 75 mgcapsule, 100 mg capsule, 100 mgtablet)
Generic
morgidox 100 mg capsule Generic
OCUDOX Brand
tetracycline hcl (250 mg, 500 mg) Generic
Anticonvulsants
Anticonvulsants, Otheracetazolamide (125 mg, 250 mg) Generic
levetiracetam (100 mg/ml solution, 250mg tablet, 500 mg tablet, 500 mg/5mlsolution, 750 mg tablet, 1000 mgtablet)
Generic
primidone (50 mg, 250 mg) Generic
Calcium Channel Modifying AgentsCELONTIN Brand
ethosuximide (250 mg capsule, 250mg/5ml solution)
Generic
LYRICA (20 MG/ML ORAL SOLUTION, 25MG CAPSULE, 50 MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE, 150 MGCAPSULE, 200 MG CAPSULE, 225 MGCAPSULE, 300 MG CAPSULE)
Brand PA
zonisamide Generic
Gamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam (0.125 mg tab rapdis, 0.25mg tab rapdis, 0.5 mg tab rapdis, 0.5mg tablet, 1 mg tab rapdis, 1 mg tablet,2 mg tab rapdis, 2 mg tablet)
Generic
clorazepate dipotassium Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access13
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsDIASTAT Brand
diazepam (2 mg tablet, 5 mg tablet, 5mg/5 ml solution, 5-7.5-10mg kit, 10mg tablet, 12.5-15-20 kit)
Generic
diazepam 2.5 mg kit Brand
divalproex sodium Generic
gabapentin (100 mg capsule, 250mg/5ml solution, 300 mg capsule, 400mg capsule, 600 mg tablet, 800 mgtablet)
Generic
GABITRIL (12 MG, 16 MG) Brand
lorazepam (0.5 mg tablet, 1 mg tablet,2 mg tablet, 2 mg/ml oral conc)
Generic
lorazepam intensol Generic
ONFI (5 MG, 10 MG, 20 MG) Brand PA, QL (60 PER 30 DAYS)
ONFI 2.5 MG/ML SUSPENSION Brand PA
phenobarbital (15 mg tablet, 16.2 mgtablet, 20 mg/5 ml elixir, 30 mg tablet,32.4 mg tablet, 60 mg tablet, 64.8 mgtablet, 97.2mg tablet, 100 mg tablet)
Generic
SABRIL Brand LA
tiagabine hcl Generic
valproic acid (as sodium salt) (valproatesodium) (250 mg/5ml solution, 500mg/5ml vial, 500mg/10ml solution)
Generic
valproic acid 250 mg capsule Generic
Glutamate Reducing Agentsfelbamate (400 mg tablet, 600 mgtablet, 600 mg/5ml oral susp)
Generic
lamotrigine (5 mg tb chw dsp, 25 mgtablet, 25 mg tb chw dsp, 25mg (35) tabds pk, 100 mg tablet, 150 mg tablet,200 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access14
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsQUDEXY XR 200 MG CAPSULE Brand PA
topiragen Generic
topiramate (15 mg cap sprink, 25 mgcap sprink, 25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet)
Generic
topiramate (25 mg 24, 50 mg 24, 100mg 24, 150 mg 24)
Generic PA
topiramate 200 mg cap spr 24 Brand PA
Sodium Channel AgentsAPTIOM Brand PA
BANZEL (40 MG/ML SUSPENSION, 200MG TABLET, 400 MG TABLET)
Brand PA
carbamazepine (100 mg cpmp 12hr,100 mg tab chew, 100 mg/5ml oralsusp, 200 mg cpmp 12hr, 200 mg tab er12h, 200 mg tablet, 300 mg cpmp 12hr,400 mg tab er 12h)
Generic
DILANTIN 30 MG CAPSULE Brand
epitol Generic
EQUETRO Brand
oxcarbazepine (150 mg tablet, 300 mgtablet, 300 mg/5ml oral susp, 600 mgtablet)
Generic
phenytoin (50 mg tab chew, 100mg/4ml oral susp, 125 mg/5ml oralsusp)
Generic
phenytoin sodium extended (100 mg,200 mg)
Generic
VIMPAT (10 MG/ML SOLUTION, 50 MGTABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)
Brand PA
ziprasidone hcl 20 mg capsule Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access15
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Antidementia Agents
Cholinesterase Inhibitorsdonepezil hcl (5 mg tab rapdis, 5 mgtablet, 10 mg tab rapdis, 10 mg tablet)
Generic
EXELON (2 MG/ML ORAL SOLUTION, 4.6MG/24HR PATCH, 9.5 MG/24HR PATCH,13.3 MG/24HR PATCH)
Brand
rivastigmine tartrate Generic
N-methyl-D-aspartate (NMDA) Receptor AntagonistNAMENDA (5 MG TABLET, 5-10 MGTITRATION PK, 10 MG TABLET)
Brand PA, QL (60 PER 30 DAYS)
NAMENDA 10 MG/5 ML SOLUTION Brand PA, QL (360 ML PER 30 DAYS)
Antidepressants
Antidepressants, OtherABILIFY (1 MG/ML SOLUTION, 2 MGTABLET, 5 MG TABLET, 10 MG TABLET,15 MG TABLET, 20 MG TABLET, 30 MGTABLET)
Brand
ABILIFY DISCMELT Brand
budeprion sr Generic
budeprion xl Generic
bupropion hcl (75 mg tablet, 100 mgtablet, 100 mg tablet er, 150 mg tab er24h, 150 mg tablet er, 200 mg tablet er,300 mg tab er 24h)
Generic
maprotiline hcl 75 mg tablet Generic
mirtazapine (7.5 mg tablet, 15 mg tabrapdis, 15 mg tablet, 30 mg tab rapdis,30 mg tablet, 45 mg tab rapdis, 45 mgtablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access16
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsnefazodone hcl Generic
trazodone hcl (50 mg, 100 mg, 150 mg,300 mg)
Generic
Monoamine Oxidase InhibitorsMARPLAN Brand
phenelzine sulfate 15 mg tablet Generic
tranylcypromine sulfate Generic
Serotonin/Norepinephrine Reuptake Inhibitorscitalopram hydrobromide (10 mg tablet,10 mg/5 ml solution, 20 mg tablet, 40mg tablet)
Generic
duloxetine hcl (20 mg, 30 mg) Generic QL (60 PER 30 DAYS)
duloxetine hcl 60 mg capsule dr Generic QL (30 PER 30 DAYS)
escitalopram oxalate (5 mg tablet, 5mg/5 ml solution, 10 mg tablet, 20 mgtablet)
Generic
fluoxetine hcl (10 mg capsule, 10 mgtablet, 20 mg capsule, 20 mg tablet, 20mg/5 ml solution, 40 mg capsule, 60 mgtablet, 90 mg capsule dr)
Generic
fluvoxamine maleate (25 mg, 50 mg,100 mg)
Generic
olanzapine/fluoxetine hcl Generic
paroxetine hcl (10 mg, 20 mg, 30 mg,40 mg)
Generic
PAXIL 10 MG/5 ML SUSPENSION Brand
sertraline hcl (20 mg/ml oral conc, 25mg tablet, 50 mg tablet, 100 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access17
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsvenlafaxine hcl (25 mg tablet, 37.5 mgcap er 24h, 37.5 mg tab er 24, 37.5 mgtablet, 50 mg tablet, 75 mg cap er 24h,75 mg tab er 24, 75 mg tablet, 100 mgtablet, 150 mg cap er 24h, 150 mg taber 24)
Generic
venlafaxine hcl 225 mg tab er 24 Brand
Tricyclicsamitriptyline hcl (10 mg, 25 mg, 50 mg,75 mg, 100 mg, 150 mg)
Generic
amoxapine Generic
clomipramine hcl (25 mg, 50 mg, 75mg)
Generic
desipramine hcl (10 mg, 25 mg, 50 mg,75 mg, 100 mg, 150 mg)
Generic
doxepin hcl (10 mg capsule, 10 mg/mloral conc, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mgcapsule, 150 mg capsule)
Generic
imipramine hcl (10 mg, 25 mg, 50 mg) Generic
imipramine pamoate Generic
nortriptyline hcl (10 mg capsule, 10mg/5 ml solution, 25 mg capsule, 50 mgcapsule, 75 mg capsule)
Generic
protriptyline hcl Generic
trimipramine maleate (25 mg, 50 mg) Generic
Antiemetics
Antiemetics, Otherchlorpromazine hcl (10 mg, 25 mg, 50mg, 100 mg, 200 mg)
Generic
COMPRO Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access18
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsDICLEGIS Preventive QL (60 PER 30 DAYS)
hydroxyzine hcl (10 mg tablet, 10 mg/5ml syrup, 25 mg tablet, 50 mg tablet)
Generic
hydroxyzine pamoate (25 mg, 50 mg,100 mg)
Generic
metoclopramide hcl (5 mg tablet, 5mg/5 ml solution, 10 mg tablet, 10mg/10ml solution)
Generic
perphenazine (2 mg, 4 mg, 8 mg, 16mg)
Generic
PHENADOZ Preventive
prochlorperazine maleate (5 mg tablet,10 mg tablet, 25 mg supp.rect)
Preventive
promethazine hcl (12.5 mg, 25 mg, 50mg)
Preventive
promethazine hcl (6.25mg/5ml syrup,12.5 mg tablet, 25 mg tablet, 50 mgtablet)
Generic
PROMETHEGAN Preventive
TRANSDERM-SCOP Preventive
trimethobenzamide hcl 300 mg capsule Preventive
Emetogenic Therapy AdjunctsEMEND (80 MG CAPSULE, 125 MGCAPSULE, TRIFOLD PACK)
Preventive QL (4 PER 30 DAYS)
granisetron hcl 1 mg tablet Preventive PA, QL (8 PER 30 DAYS)
ondansetron Preventive
ondansetron hcl (4 mg tablet, 4 mg/5ml solution, 8 mg tablet)
Preventive
Antifungals
ciclodan 0.77% cream Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access19
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsciclopirox (0.77 % gel (gram), 1 %shampoo)
Generic
ciclopirox olamine (0.77 % cream (g),0.77 % suspension)
Generic
clotrimazole 10 mg troche Generic
clotrimazole/betamethasonedipropionate (1 %-0.05 % cream (g), 1%-0.05 % lotion)
Generic
econazole nitrate 1 % cream (g) Generic
fluconazole (10 mg/ml susp recon, 40mg/ml susp recon, 50 mg tablet, 100mg tablet, 150 mg tablet, 200 mgtablet)
Generic
griseofulvin ultramicrosize 250 mgtablet
Generic
griseofulvin, microsize (125 mg/5ml oralsusp, 500 mg tablet)
Generic
itraconazole 100 mg capsule Generic PA
ketoconazole (2 % cream (g), 2 %shampoo)
Generic
LAMISIL 187.5 MG GRANULES PACK Brand PA
NATACYN Brand
NOXAFIL 40 MG/ML SUSPENSION Brand PA
nyamyc Generic
nystatin (50mm unit powder(ea), 100kunit tablet, 150mm unit powder(ea),500k unit tablet, 500mm unitpowder(ea), 100000/g cream (g),100000/g oint. (g), 100000/g powder,100000/ml oral susp)
Generic
nystop Generic
pedi-dri Generic
SPORANOX 10 MG/ML SOLUTION Brand PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access20
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsterbinafine hcl 250 mg tablet Generic
terconazole (0.4 % cream/appl, 0.8 %cream/appl, 80 mg supp.vag)
Generic
voriconazole 200 mg/5ml susp recon Generic
Antigout Agents
allopurinol (100 mg, 300 mg) Generic
colchicine/probenecid Generic
COLCRYS Brand QL (60 PER 30 DAYS)
probenecid Generic
Antimigraine Agents
Ergot Alkaloidscafergot Generic
dihydroergotamine mesylate0.5mg/spry spray/pump
Brand QL (3.5 ML PER 30 DAYS)
ergotamine tartrate/caffeine Generic
migergot Generic
MIGRANAL Brand QL (3.5 ML PER 30 DAYS)
Prophylactictimolol maleate (5 mg, 10 mg, 20 mg) Preventive
Serotonin (5-HT) 1b/1d Receptor Agonistsrizatriptan benzoate Generic QL (24 PER 30 DAYS)
sumatriptan (5 mg, 20 mg) Generic QL (6 PER 30 DAYS)
sumatriptan succinate (25 mg, 50 mg,100 mg)
Generic QL (18 PER 30 DAYS)
sumatriptan succinate (4 cartridge, 4pen injctr, 6 cartridge, 6 pen injctr, 6syringe, 6 vial)
Generic QL (2 ML PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access21
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitszolmitriptan (2.5 mg tab rapdis, 2.5 mgtablet, 5 mg tab rapdis, 5 mg tablet)
Generic QL (12 PER 30 DAYS)
ZOMIG (2.5 MG, 5 MG) Brand QL (12 PER 30 DAYS)
Antimyasthenic Agents
Parasympathomimeticsguanidine hcl Generic
MESTINON (60 MG/5 ML SYRUP, 180MG TIMESPAN)
Brand
pyridostigmine bromide 60 mg tablet Generic
Antimycobacterials
Antimycobacterials, Otherdapsone (25 mg, 100 mg) Generic
rifabutin Generic
Antitubercularsethambutol hcl Generic
isonarif Generic
isoniazid (50 mg/5 ml solution, 100 mgtablet, 300 mg tablet)
Generic
PRIFTIN Brand
rifampin (150 mg, 300 mg) Generic
RIFATER Brand
SIRTURO Specialty LA
TRECATOR Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access22
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Antineoplastics
Alkylating AgentsALKERAN 2 MG TABLET Brand
CEENU Brand
cyclophosphamide capsules Generic
cyclophosphamide tablets Generic
LEUKERAN Brand
lomustine Brand
MATULANE Specialty
Antiangiogenic AgentsREVLIMID Specialty PA, LA
THALOMID Specialty
Antiestrogens/ModifiersEMCYT Specialty
FARESTON Brand
SOLTAMOX Brand
tamoxifen citrate (10 mg, 20 mg) Generic
Antimetabolitescapecitabine Generic
decitabine Generic
DROXIA Brand
hydroxyurea 500 mg capsule Generic
mercaptopurine 50 mg tablet Generic
methotrexate sodium (2.5 mg tablet, 25mg/ml vial)
Generic
methotrexate sodium/pf (1 g, 25mg/ml)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access23
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsPURIXAN Brand
RHEUMATREX Brand
Antineoplastics, OtherHEXALEN Specialty
imiquimod 5 % cream pack Generic
leucovorin calcium (5 mg, 10 mg, 15mg, 25 mg)
Generic
MESNEX 400 MG TABLET Brand
temozolomide Specialty PA
VALCHLOR Specialty PA, LA
Aromatase Inhibitors, 3rd Generationanastrozole 1 mg tablet Generic
exemestane Generic
letrozole 2.5 mg tablet Generic
Enzyme InhibitorsGILOTRIF Specialty PA, LA
HYCAMTIN 0.25 MG CAPSULE Brand PA
HYCAMTIN 1 MG CAPSULE Specialty PA
IRESSA Specialty PA
JAKAFI Specialty PA, LA
MEKINIST Specialty PA
TAFINLAR Specialty PA
VOTRIENT Specialty PA
ZYDELIG Specialty PA, QL (60 PER 30 DAYS)
ZYTIGA Specialty PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access24
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Molecular Target InhibitorsAFINITOR (2.5 MG, 5 MG, 10 MG) Specialty PA, QL (30 PER 30 DAYS)
AFINITOR 7.5 MG TABLET Brand PA, QL (30 PER 30 DAYS)
AFINITOR DISPERZ Specialty PA, QL (30 PER 30 DAYS)
BOSULIF Specialty PA
CAPRELSA 100 MG TABLET Specialty PA
CAPRELSA 300 MG TABLET Brand PA
COMETRIQ Specialty PA, LA
ERIVEDGE Specialty PA, LA
GLEEVEC Specialty PA
ICLUSIG Specialty PA, LA
IMBRUVICA Specialty PA, LA
INLYTA Specialty PA, LA
NEXAVAR Specialty PA
SPRYCEL Specialty PA
STIVARGA Specialty PA
SUTENT Specialty PA
TARCEVA Specialty PA
TASIGNA Specialty PA
TYKERB Specialty PA
vandetanib Specialty PA
ZELBORAF Specialty PA
ZOLINZA Specialty PA
ZYKADIA Specialty PA
RetinoidsPANRETIN Brand
TARGRETIN (1% GEL, 75 MG CAPSULE,75 MG SOFTGEL)
Specialty PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access25
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitstretinoin 10 mg capsule Specialty PA
Antiparasitics
AnthelminticsALBENZA Brand
ivermectin 3 mg tablet Generic
AntiprotozoalsALINIA (100 MG/5 ML SUSPENSION,500 MG TABLET)
Brand
atovaquone Generic PA
chloroquine phosphate (250 mg, 500mg)
Generic PA
DARAPRIM Brand PA
hydroxychloroquine sulfate 200 mgtablet
Generic
mefloquine hcl Generic PA
tinidazole (250 mg, 500 mg) Generic PA
Pediculicides/Scabicideselimite Generic
lindane Generic
permethrin 5 % cream (g) Generic
ULESFIA Brand
Antiparkinson Agents
Anticholinergicsbenztropine mesylate (0.5 mg, 1 mg, 2mg)
Generic
trihexyphenidyl hcl (2 mg, 5 mg) Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access26
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Antiparkinson Agents, Otheramantadine hcl (50 mg/5 ml syrup, 100mg capsule, 100 mg tablet)
Preventive
carbidopa/levodopa/entacapone Preventive
entacapone Preventive
Dopamine Agonistsbromocriptine mesylate (2.5 mg tablet,5 mg capsule)
Preventive
pramipexole di-hcl Preventive
ropinirole hcl (0.25 mg, 0.5 mg, 1 mg, 2mg, 3 mg, 4 mg, 5 mg)
Preventive
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitorscarbidopa 25 mg tablet Generic
carbidopa/levodopa (10mg-100mg,25mg-100mg, 25mg-100mg er, 25mg-250mg, 50mg-200mg er)
Preventive
Monoamine Oxidase B (MAO-B) InhibitorsAZILECT Preventive
selegiline hcl (5 mg capsule, 5 mgtablet)
Preventive
Antipsychotics
1st Generation/Typicalfluphenazine hcl (1 mg, 2.5 mg, 5 mg,10 mg)
Generic
haloperidol (0.5 mg, 1 mg, 2 mg, 5 mg,10 mg, 20 mg)
Generic
haloperidol lactate 2 mg/ml oral conc Generic
loxapine succinate (5 mg, 10 mg, 25mg, 50 mg)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access27
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsORAP Brand
perphenazine/amitriptyline hcl Generic
thioridazine hcl (10 mg, 25 mg, 50 mg,100 mg)
Generic
thiothixene Generic
trifluoperazine hcl Generic
2nd Generation/AtypicalINVEGA Brand
LATUDA Brand PA, QL (30 PER 30 DAYS)
olanzapine (2.5 mg tablet, 5 mg tabrapdis, 5 mg tablet, 7.5 mg tablet, 10mg tab rapdis, 10 mg tablet, 15 mg tabrapdis, 15 mg tablet, 20 mg tab rapdis,20 mg tablet)
Generic
quetiapine fumarate Generic
RISPERDAL CONSTA 12.5 MG SYR Brand
risperidone (0.25 mg tablet, 0.5 mgtablet, 1 mg tablet, 1 mg/ml solution, 2mg tablet, 3 mg tab rapdis, 3 mg tablet,4 mg tablet)
Generic
SAPHRIS Brand PA
ziprasidone hcl (40 mg, 60 mg, 80 mg) Generic
Treatment-Resistantclozapine Generic
FAZACLO (150 MG, 200 MG) Brand
VERSACLOZ Brand
Antispasticity Agents
baclofen (10 mg, 20 mg) Generic
dantrolene sodium (25 mg, 50 mg) Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access28
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsMYRBETRIQ Brand PA
tizanidine hcl (2 mg, 4 mg) Generic
Antivirals
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase InhibitorsEDURANT Brand
INTELENCE Brand
nevirapine (200 mg tablet, 400 mg taber 24h)
Generic
SUSTIVA Brand
VIRAMUNE XR 100 MG TABLET Brand
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitorsabacavir sulfate Generic
abacavir sulfate/lamivudine/zidovudine Generic
didanosine Generic
EMTRIVA (10 MG/ML SOLUTION, 200MG CAPSULE)
Brand
EPZICOM Brand
lamivudine (150 mg, 300 mg) Generic
lamivudine/zidovudine Generic
stavudine (20 mg, 30 mg, 40 mg) Generic
TRUVADA Brand
VIREAD (150 MG TABLET, 200 MGTABLET, 250 MG TABLET, 300 MGTABLET, POWDER)
Brand
zidovudine (100 mg capsule, 300 mgtablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access29
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Anti-HIV Agents, OtherATRIPLA Brand
COMPLERA Brand
FUZEON Brand
ISENTRESS (100 MG POWDER PACKET,400 MG TABLET)
Brand
SELZENTRY Brand
STRIBILD Brand
TIVICAY Brand
Anti-HIV Agents, Protease InhibitorsAPTIVUS (100 MG/ML SOLUTION, 250MG CAPSULE)
Brand
CRIXIVAN 400 MG CAPSULE Brand
INVIRASE Brand
KALETRA (100-25 MG, 200-50 MG) Brand
LEXIVA (50 MG/ML SUSPENSION, 700MG TABLET)
Brand
NORVIR (100 MG SOFTGEL CAP, 100MG TABLET)
Brand
PREZISTA (75 MG TABLET, 100 MG/MLSUSPENSION, 150 MG TABLET, 400 MGTABLET, 600 MG TABLET, 800 MGTABLET)
Brand
REYATAZ Brand
VIRACEPT Brand
Anti-cytomegalovirus (CMV) AgentsVALCYTE 450 MG TABLET Brand QL (60 PER 30 DAYS)
VALCYTE 50 MG/ML SOLUTION Brand
ZIRGAN Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access30
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Anti-influenza Agentsrimantadine hcl Generic
TAMIFLU (6 MG/ML SUSPENSION, 30MG CAPSULE, 45 MG CAPSULE, 75 MGCAPSULE)
Preventive
Antihepatitis Agentsadefovir dipivoxil Specialty
BARACLUDE 0.05 MG/ML SOLUTION Specialty PA
entecavir Specialty PA
EPIVIR HBV 25 MG/5 ML SOLN Brand
INCIVEK Specialty PA
INFERGEN Specialty
INTRON A (6 MILLION UNIT/ML VL, 10MILLION UNIT/ML, 10 MILLION UNITSVIL, 18 MILLION UNITS VIL, 50 MILLIONUNITS VIL)
Specialty PA
lamivudine 100 mg tablet Generic
MODERIBA Specialty PA
OLYSIO Specialty PA
PEGASYS (180 MCG/0.5 ML SYRINGE,180 MCG/ML VIAL)
Specialty PA
PEGASYS PROCLICK Specialty PA
PEGINTRON Specialty PA
PEGINTRON REDIPEN Specialty PA
REBETOL 40 MG/ML SOLUTION Specialty PA
RIBAPAK Specialty PA
RIBASPHERE Specialty PA
RIBATAB Specialty PA
ribavirin (200 mg capsule, 200 mgtablet, 400 mg tablet, 600 mg tablet)
Specialty PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access31
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsSOVALDI Specialty PA
SYLATRON (296 MCG, 444 MCG, 888MCG)
Specialty PA, QL (1 PER 28 DAYS)
SYLATRON 4-PACK Specialty PA, QL (1 PER 28 DAYS)
TYZEKA Brand PA
VICTRELIS Specialty PA
Antiherpetic Agentsacyclovir (200 mg capsule, 200 mg/5mloral susp, 400 mg tablet, 800 mg tablet)
Generic
DENAVIR Brand PA
famciclovir Generic
trifluridine 1 % drops Generic
valacyclovir hcl (500 mg, 1000 mg) Generic
Anxiolytics
Anxiolytics, Otheralprazolam (0.25 mg tablet, 0.5 mg taber 24h, 0.5 mg tablet, 1 mg tab er 24h,1 mg tablet, 2 mg tab er 24h, 2 mgtablet, 3 mg tab er 24h)
Generic
buspirone hcl (5 mg, 7.5 mg, 10 mg, 15mg, 30 mg)
Generic
chlordiazepoxide hcl Generic
meprobamate 400 mg tablet Generic
oxazepam Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access32
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Bipolar Agents
Mood Stabilizerslithium carbonate (150 mg capsule, 300mg capsule, 300 mg tablet, 300 mgtablet er, 450 mg tablet er, 600 mgcapsule)
Generic
lithium citrate Generic
Blood Glucose Regulators
Antidiabetic Agentsacarbose Preventive
ACTOPLUS MET XR Preventive
BYDUREON Preventive PA
BYDUREON PEN Brand PA
BYETTA Preventive PA
chlorpropamide Preventive
FARXIGA Brand PA
glimepiride Preventive
glipizide (2.5 mg tab er 24, 5 mg tab er24, 5 mg tablet, 10 mg tab er 24, 10 mgtablet)
Preventive
glipizide/metformin hcl Preventive
glyburide Preventive
glyburide,micronized Preventive
glyburide/metformin hcl Preventive
INVOKANA Brand PA
JANUMET Preventive PA
JANUMET XR Preventive PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access33
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsJANUVIA Preventive PA
JENTADUETO Preventive PA
JUVISYNC (50-10 MG, 50-20 MG, 50-40MG)
Preventive
KAZANO Preventive PA
KOMBIGLYZE XR Preventive PA
metformin hcl (500 mg tab er 24h, 500mg tablet, 750 mg tab er 24h, 850 mgtablet, 1000 mg tablet)
Preventive
nateglinide Preventive
NESINA Preventive PA
ONGLYZA Preventive PA
OSENI Preventive PA
pioglitazone hcl Preventive
pioglitazone hcl/glimepiride Preventive
pioglitazone hcl/metformin hcl Preventive
RIOMET Preventive
SYMLINPEN 120 Preventive PA
SYMLINPEN 60 Preventive PA
TRADJENTA Preventive PA
VICTOZA 2-PAK Preventive PA
VICTOZA 3-PAK Preventive PA
Glycemic AgentsGLUCAGEN Brand
GLUCAGON EMERGENCY KIT Brand
PROGLYCEM Brand
InsulinsAPIDRA Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access34
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsAPIDRA SOLOSTAR Preventive
HUMALOG Preventive
HUMALOG MIX 50-50 Preventive
HUMALOG MIX 75-25 Preventive
HUMULIN R Preventive
LANTUS Preventive
LANTUS SOLOSTAR Preventive
LEVEMIR Preventive
LEVEMIR FLEXPEN Preventive
LEVEMIR FLEXTOUCH Preventive
NOVOLOG Preventive
NOVOLOG FLEXPEN Preventive
NOVOLOG MIX 70-30 Preventive
NOVOLOG MIX 70-30 FLEXPEN Preventive
Blood Products/Modifiers/ Volume Expanders
AnticoagulantsELIQUIS Preventive
enoxaparin sodium (30mg/0.3ml,40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml,100 mg/ml, 120mg/.8ml, 150 mg/ml)
Preventive
fondaparinux sodium Preventive
FRAGMIN Preventive
JANTOVEN Preventive
PRADAXA Preventive
warfarin sodium (1 mg, 2 mg, 2.5 mg, 3mg, 4 mg, 5 mg, 6 mg, 7.5 mg, 10 mg)
Preventive
XARELTO Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access35
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Blood Formation Modifiersanagrelide hcl Generic
ARANESP Specialty PA
EPOGEN Specialty PA
GRANIX Brand
LEUKINE (250 MCG, 500 MCG/ML) Specialty
NEULASTA Specialty
NEUMEGA Specialty
NEUPOGEN Specialty
PROCRIT Specialty PA
PROMACTA Specialty PA
Coagulantstranexamic acid 650 mg tablet Generic
Platelet Modifying AgentsAGGRENOX Preventive
BRILINTA Preventive
cilostazol Preventive
clopidogrel bisulfate 75 mg tablet Preventive
dipyridamole (25 mg, 50 mg, 75 mg) Preventive
EFFIENT Preventive
ticlopidine hcl Preventive
Cardiovascular Agents
Alpha-adrenergic Agonistsclonidine Preventive
clonidine hcl (0.1 mg, 0.2 mg, 0.3 mg) Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access36
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsguanfacine hcl Preventive
methyldopa Preventive
methyldopa/hydrochlorothiazide Preventive
midodrine hcl Generic
Alpha-adrenergic Blocking Agentsdoxazosin mesylate Preventive
prazosin hcl (1 mg, 2 mg, 5 mg) Preventive
terazosin hcl Preventive
Angiotensin II Receptor Antagonistscandesartan cilexetil Preventive
irbesartan Preventive
irbesartan/hydrochlorothiazide Preventive
losartan potassium Preventive
losartan potassium/hydrochlorothiazide Preventive
valsartan Preventive
valsartan/hydrochlorothiazide Preventive
Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl (5 mg, 10 mg, 20 mg, 40mg)
Preventive
benazepril hcl/hydrochlorothiazide Preventive
captopril (12.5 mg, 25 mg, 50 mg, 100mg)
Preventive
captopril/hydrochlorothiazide Preventive
enalapril maleate (2.5 mg, 5 mg, 10 mg,20 mg)
Preventive
enalapril maleate/hydrochlorothiazide Preventive
EPANED Preventive
fosinopril sodium Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access37
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsfosinopril sodium/hydrochlorothiazide Preventive
lisinopril (2.5 mg, 5 mg, 10 mg, 20 mg,30 mg, 40 mg)
Preventive
lisinopril/hydrochlorothiazide Preventive
moexipril hcl Preventive
moexipril hcl/hydrochlorothiazide Preventive
perindopril erbumine Preventive
quinapril hcl Preventive
quinapril hcl/hydrochlorothiazide Preventive
ramipril Preventive
trandolapril Preventive
Antiarrhythmicsamiodarone hcl (100 mg, 200 mg, 400mg)
Generic
disopyramide phosphate Generic
flecainide acetate Generic
mexiletine hcl (150 mg, 200 mg, 250mg)
Generic
MULTAQ Brand
NORPACE CR Brand
pacerone 200 mg tablet Generic
propafenone hcl Generic
quinidine gluconate 324 mg tablet er Generic
quinidine sulfate (200 mg, 300 mg, 300mg er)
Generic
SORINE Preventive
sotalol hcl (80 mg, 120 mg, 160 mg, 240mg)
Preventive
TIKOSYN Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access38
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsverapamil hcl (40 mg, 80 mg, 120 mg) Preventive
Beta-adrenergic Blocking Agentsacebutolol hcl (200 mg, 400 mg) Preventive
atenolol (25 mg, 50 mg, 100 mg) Preventive
atenolol/chlorthalidone Preventive
betaxolol hcl (10 mg, 20 mg) Preventive
bisoprolol fumarate Preventive
bisoprololfumarate/hydrochlorothiazide
Preventive
carvedilol Preventive
COREG CR Preventive
labetalol hcl (100 mg, 200 mg, 300 mg) Preventive
LEVATOL Preventive
metoprolol succinate Preventive
metoprolol tartrate (25 mg, 50 mg, 100mg)
Preventive
metoprololtartrate/hydrochlorothiazide
Preventive
nadolol (20 mg, 40 mg, 80 mg) Preventive
nadolol/bendroflumethiazide Preventive
pindolol Preventive
propranolol hcl (10 mg tablet, 20 mgtablet, 40 mg tablet, 40mg/5mlsolution, 60 mg cap sa 24h, 60 mgtablet, 80 mg cap sa 24h, 80 mg tablet,120 mg cap sa 24h, 160 mg cap sa 24h)
Preventive
propranolol hcl/hydrochlorothiazide Preventive
Calcium Channel Blocking AgentsAFEDITAB CR Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access39
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsamlodipine besylate (2.5 mg, 5 mg, 10mg)
Preventive
amlodipine besylate/benazepril hcl Preventive
CARTIA XT Preventive
DILT-CD Preventive
DILT-XR Preventive
DILTIA XT Preventive
diltiazem hcl (30 mg tablet, 60 mg caper 12h, 60 mg tablet, 90 mg cap er 12h,90 mg tablet, 120 mg cap er 12h, 120mg cap er 24h, 120 mg cap er deg, 120mg capsule er, 120 mg tablet, 180 mgcap er 24h, 180 mg cap er deg, 180 mgcapsule er, 180 mg tab er 24h, 240 mgcap er 24h, 240 mg cap er deg, 240 mgcapsule er, 240 mg tab er 24h, 300 mgcap er 24h, 300 mg capsule er, 300 mgtab er 24h, 360 mg cap er 24h, 360 mgcapsule er, 360 mg tab er 24h, 420mgcapsule er, 420mg tab er 24h)
Preventive
DILTZAC ER Preventive
felodipine Preventive
isradipine Preventive
MATZIM LA Preventive
nicardipine hcl (20 mg, 30 mg) Preventive
NIFEDIAC CC Preventive
NIFEDICAL XL Preventive
nifedipine (30 mg tab er 24, 30 mgtablet er, 60 mg tab er 24, 60 mg tableter, 90 mg tab er 24, 90 mg tablet er)
Preventive
nimodipine 30 mg capsule Preventive
nisoldipine Preventive
TAZTIA XT Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access40
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsverapamil hcl (100 mg cap24h pct, 120mg cap24h pel, 120 mg tablet er, 180mg cap24h pel, 180 mg tablet er, 200mg cap24h pct, 240 mg cap24h pel, 240mg tablet er, 300 mg cap24h pct, 360mg cap24h pel)
Preventive
Cardiovascular Agents, Otheramlodipine besylate/atorvastatincalcium
Preventive
digox Generic
digoxin (50 mcg/ml solution, 125 mcgtablet, 250 mcg tablet)
Generic
LANOXIN (62.5 MCG, 187.5 MCG) Brand
pentoxifylline 400 mg tablet er Preventive
RANEXA Brand
Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 500 mg capsule er Generic
methazolamide (25 mg, 50 mg) Generic
Diuretics, Loopbumetanide (0.5 mg, 1 mg, 2 mg) Preventive
EDECRIN Preventive
furosemide (10 mg/ml solution, 20 mgtablet, 40 mg tablet, 80 mg tablet)
Preventive
torsemide (5 mg, 10 mg, 20 mg, 100mg)
Preventive
Diuretics, Potassium-sparingamiloride hcl 5 mg tablet Preventive
amiloride hcl/hydrochlorothiazide Preventive
DYRENIUM Preventive
eplerenone Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access41
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsspironolactone (25 mg, 50 mg, 100 mg) Preventive
spironolactone/hydrochlorothiazide Preventive
triamterene/hydrochlorothiazide Preventive
Diuretics, Thiazidechlorothiazide Preventive
chlorthalidone Preventive
hydrochlorothiazide (12.5 mg capsule,12.5 mg tablet, 25 mg tablet, 50 mgtablet)
Preventive
indapamide Preventive
methyclothiazide Preventive
metolazone Preventive
Dyslipidemics, Fibric Acid Derivativesfenofibrate (54 mg, 160 mg) Preventive
fenofibrate nanocrystallized Preventive
fenofibrate,micronized (67 mg, 134mg,200 mg)
Preventive
fenofibric acid Preventive
fenofibric acid (choline) Preventive
gemfibrozil 600 mg tablet Preventive
LOFIBRA Preventive
TRIGLIDE 160 MG TABLET Preventive
Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium Preventive
fluvastatin sodium Preventive
lovastatin Preventive
pravastatin sodium Preventive
simvastatin (5 mg, 10 mg, 20 mg, 40mg)
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access42
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Dyslipidemics, Othercholestyramine (with sugar) (suar) 4powd pack, suar) 4 powder)
Preventive
cholestyramine/aspartame (4 powdpack, 4 powder)
Preventive
COLESTID (, FLAVORED) Preventive
colestipol hcl (1 tablet, 5 packet, 5ranules)
Preventive
JUXTAPID Specialty PA, LA
KYNAMRO Specialty PA, LA
PREVALITE (PACKET, POWDER) Preventive
Vasodilators, Direct-acting Arterialhydralazine hcl (10 mg, 25 mg, 50 mg,100 mg)
Generic
minoxidil (2.5 mg, 10 mg) Generic
RECTIV Brand
Vasodilators, Direct-acting Arterial/VenousDILATRATE-SR Brand
isochron Generic
isosorbide dinitrate Generic
isosorbide mononitrate Generic
minitran Generic
NITRO-BID Brand
NITRO-DUR (0.3, 0.8) Brand
nitro-time Generic
nitroglycerin (0.1mg/hr patch td24,0.2mg/hr patch td24, 0.4mg/hr patchtd24, 0.6mg/hr patch td24, 2.5 mgcapsule er, 6.5 mg capsule er, 9 mgcapsule er, 400mcg/spr spray)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access43
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsNITROSTAT Brand
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetaminesdextroamphetamine sulf-saccharate/amphetamine sulf-aspartate
Generic
dextroamphetamine sulfate (5 mg er,10 mg er, 15 mg er)
Generic
dextroamphetamine sulfate (5 mg, 10mg)
Generic PA
VYVANSE Brand
zenzedi (5 mg, 10 mg) Generic PA
Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesDAYTRANA Brand PA, QL (30 PER 30 DAYS)
dexmethylphenidate hcl (2.5 mg, 5 mg,10 mg)
Generic
dexmethylphenidate hcl (5 mg, 15 mg,30 mg, 40 mg)
Generic PA
FOCALIN XR (10 MG, 20 MG, 25 MG, 35MG)
Brand PA
metadate er Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access44
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsmethylphenidate hcl (5 mg tablet, 5mg/5 ml solution, 10 mg cpbp 30-70, 10mg tablet, 10 mg tablet er, 10 mg/5 mlsolution, 18 mg tab er 24, 20 mg cpbp30-70, 20 mg cpbp 50-50, 20 mg tablet,20 mg tablet er, 27 mg tab er 24, 30 mgcpbp 30-70, 30 mg cpbp 50-50, 36 mgtab er 24, 40 mg cpbp 30-70, 40 mgcpbp 50-50, 50 mg cpbp 30-70, 54 mgtab er 24, 60 mg cpbp 30-70)
Generic
RITALIN LA 10 MG CAPSULE Brand
STRATTERA Brand PA, QL (30 PER 30 DAYS)
Central Nervous System Agents, OtherNUEDEXTA Brand PA
riluzole Generic
XENAZINE Specialty PA
Fibromyalgia AgentsSAVELLA (12.5 MG, 25 MG, 50 MG, 100MG)
Brand PA, QL (60 PER 30 DAYS)
SAVELLA TITRATION PACK Brand PA, QL (55 PER 30 DAYS)
Multiple Sclerosis AgentsAMPYRA Specialty PA, LA, QL (60 PER 30 DAYS)
AUBAGIO Specialty PA, LA, QL (30 PER 30 DAYS)
AVONEX (30 MCG, 30 MCG KT) Specialty
AVONEX ADMINISTRATION PACK Specialty
AVONEX PEN Specialty
BETASERON 0.3 MG KIT Specialty PA, QL (14 PER 30 DAYS)
BETASERON 0.3 MG VIAL Specialty PA, QL (15 PER 30 DAYS)
COPAXONE 20 MG/ML SYRINGE Specialty QL (30 ML PER 30 DAYS)
COPAXONE 40 MG/ML SYRINGE Specialty QL (12 ML PER 28 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access45
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsEXTAVIA 0.3 MG KIT Specialty PA, QL (14 PER 30 DAYS)
EXTAVIA 0.3 MG VIAL Specialty PA, QL (15 PER 30 DAYS)
FIRAZYR Specialty PA, QL (9 ML PER 30 DAYS)
GILENYA Specialty PA, QL (30 PER 30 DAYS)
PLEGRIDY Specialty QL (1 ML PER 28 DAYS)
PLEGRIDY PEN Specialty QL (1 ML PER 28 DAYS)
REBIF (22 ML, 44 ML) Specialty QL (6 ML PER 30 DAYS)
REBIF REBIDOSE (22 ML, 44 ML) Specialty QL (6 ML PER 30 DAYS)
REBIF REBIDOSE TITRATION PACK Specialty QL (4.2 ML PER 30 DAYS)
REBIF TITRATION PACK Specialty QL (4.2 ML PER 30 DAYS)
TECFIDERA Specialty QL (60 PER 30 DAYS)
Dental and Oral Agents
pilocarpine hcl (5 mg, 7.5 mg) Generic
Dermatological Agents
acitretin Generic
adapalene (0.1 % cream (g), 0.1 % gel(gram), 0.3 % gel (gram))
Generic
adapalene 0.3 % gel w/pump Brand
ammonium lactate 12 % cream (g) Generic
amnesteem Generic
avita 0.025% cream Generic
calcipotriene (0.005 % cream (g), 0.005% solution)
Generic
claravis Generic
clindamycin phos/benzoyl perox 1 %-5% gel (gram)
Generic
DIFFERIN 0.3% GEL PUMP Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access46
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsELIDEL Brand PA
EPIFOAM Brand
erythromycin base/benzoyl peroxide Generic
FINACEA Brand PA
FLUOROPLEX Brand
fluorouracil (0.5 % cream (g), 2 %solution, 5 % cream (g), 5 % solution)
Generic
gengraf 100 mg capsule Generic
hypercare Generic
methoxsalen, rapid Specialty
mometasone furoate (0.1 % cream (g),0.1 % oint. (g), 0.1 % solution)
Generic
myorisan Generic
OTEZLA Specialty PA
OXSORALEN Brand
PICATO Brand PA
podofilox 0.5 % solution Generic
PROTOPIC Brand PA
refissa Generic
REGRANEX Brand PA
SANTYL Brand QL (30 GM PER 30 DAYS)
STELARA 45 MG/0.5 ML SYRINGE Specialty PA, QL (0.5 ML PER 30 DAYS)
STELARA 90 MG/ML SYRINGE Specialty PA, QL (1 ML PER 30 DAYS)
TAZORAC Brand
tretinoin (0.01 % gel (gram), 0.025 %cream (g), 0.025 % gel (gram), 0.05 %cream (g), 0.1 % cream (g))
Generic
tretinoin/emollient base Generic
trianex Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access47
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsVOLTAREN Brand
zenatane Generic
Enzyme Replacement/ Modifiers
ADAGEN Specialty
BUPHENYL 500 MG TABLET Specialty
CARBAGLU Brand
CEREZYME 400 UNITS VIAL Brand
CREON Brand
ELELYSO Specialty
KUVAN Specialty PA, LA
ORFADIN Specialty
pancrelipase 5,000 Generic
RAVICTI Specialty LA
sodium phenylbutyrate 0.94 g/g powder Specialty
SUCRAID Specialty
ZAVESCA Specialty
ZENPEP (3,000, 10,000, 15,000, 20,000,25,000)
Brand
Gastrointestinal Agents
Antispasmodics, GastrointestinalCUVPOSA Brand PA
dicyclomine hcl (10 mg capsule, 10mg/5 ml solution, 20 mg tablet)
Generic
glycopyrrolate (1 mg, 2 mg) Generic
Gastrointestinal Agents, OtherAPRISO Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access48
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsASACOL Brand
ASACOL HD Brand
CANASA Brand
DELZICOL Brand
diphenoxylate hcl/atropine sulfate (2.5-.025/5 liquid, 2.5-.025mg tablet)
Generic
FULYZAQ Brand PA
GATTEX Specialty PA, LA
gavilyte-c Generic
gavilyte-g Generic
gavilyte-n Generic
GOLYTELY PACKET Brand
LIALDA Brand
mesalamine 4 g/60 ml enema Generic
mesalamine with cleansing wipes Generic
nulytely with flavor packs Generic
peg 3350/sod sulf/sod bicarbonate/sodchloride/potassium chl
Generic
PENTASA Brand
propantheline bromide 15 mg tablet Generic
PYLERA Brand
sodium chloride/sodiumbicarbonate/potassium chloride/peg
Generic
sulfasalazine (500 mg, 500 mg dr) Generic
sulfazine Generic
sulfazine ec Generic
trilyte with flavor packets Generic
ursodiol (250 mg tablet, 300 mgcapsule, 500 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access49
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Histamine2 (H2) Receptor Antagonistscimetidine (300 mg, 400 mg, 800 mg) Generic
cimetidine hcl Generic
famotidine 40 mg tablet Generic
nizatidine (150 mg, 300 mg) Generic
ranitidine hcl (15 mg/ml syrup, 300 mgtablet)
Generic
Irritable Bowel Syndrome AgentsLOTRONEX Brand PA
Laxativesconstulose Generic
enulose Generic
generlac Generic
lactulose Generic
MOVIPREP Brand
SUPREP Brand
Protectantsmisoprostol (100 mcg, 200 mcg) Generic
sucralfate (1 g tablet, 1 g/10 ml oralsusp)
Generic
Proton Pump InhibitorsFIRST-LANSOPRAZOLE Brand
FIRST-OMEPRAZOLE Brand
lansoprazole 30 mg capsule dr Generic
lansoprazole/amoxicillintrihydrate/clarithromycin
Generic
omeprazole (10 mg, 20 mg, 40 mg) Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access50
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsOMEPRAZOLE+SYRSPEND SF ALKA Brand
pantoprazole sodium (20 mg, 40 mg) Generic
PROTONIX 40 MG SUSPENSION Brand
rabeprazole sodium Generic
Genitourinary Agents
Antispasmodics, Urinaryflavoxate hcl Generic
oxybutynin chloride (5 mg tab er 24, 5mg tablet, 5 mg/5 ml syrup, 10 mg taber 24, 15 mg tab er 24)
Generic
OXYTROL Brand
tolterodine tartrate Generic
trospium chloride 20 mg tablet Generic
Benign Prostatic Hypertrophy Agentsalfuzosin hcl Generic
finasteride 5 mg tablet Generic
tamsulosin hcl Generic
Genitourinary Agents, Otherbethanechol chloride (5 mg, 10 mg, 25mg, 50 mg)
Generic
CUPRIMINE Brand
CYSTAGON Specialty PA
DEPEN Brand
ELMIRON Brand
PROCYSBI Brand PA, LA
THIOLA Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access51
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Phosphate Binderscalcium acetate 667 mg capsule Generic
RENAGEL Brand PA
RENVELA Brand PA
sevelamer carbonate Brand PA
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Glucocorticoids/Mineralocorticoidsbetamethasoneacetate/betamethasone sodiumphosphate
Generic
budesonide 3 mg capdr - er Generic
CELESTONE 0.6 MG/5 ML SOLUTION Brand
dexamethasone (0.5 mg tablet, 0.5mg/5ml elixir, 0.5 mg/5ml solution, 0.75mg tablet, 1 mg tablet, 1.5 mg tablet, 2mg tablet, 4 mg tablet, 6 mg tablet)
Generic
FLAREX Brand
FLOVENT DISKUS Preventive
FLOVENT HFA Preventive
fluocinolone acetonide oil Generic
fluorometholone 0.1 % drops susp Generic
fluticasone propionate 50 mcg spraysusp
Generic
FML FORTE Brand
FML S.O.P. Brand
hydrocortisone (5 mg, 10 mg, 20 mg) Generic
hydrocortisone butyrate (0.1 % oint. (g),0.1 % solution)
Generic
hydrocortisone valerate Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access52
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsmethylprednisolone Generic
triamcinolone acetonide 55 mcg spray Generic
UCERIS 9 MG ER TABLET Brand PA
Hormonal Agents, Stimulant/Replacement/Modifying (Other)
MYALEPT Brand PA, LA
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acetate (0.1 mg tablet,0.2 mg tablet, 10/spray spray/pump)
Generic PA
desmopressin acetate (0.1 mg/mlsolution, 4mcg/ml ampul, 4mcg/ml vial)
Generic
desmopressin acetate (non-refrigerated)
Generic PA
EGRIFTA Specialty PA
GENOTROPIN Specialty PA
HUMATROPE Specialty PA
INCRELEX Specialty PA, LA
NORDITROPIN Specialty PA
NORDITROPIN FLEXPRO Specialty PA
NORDITROPIN NORDIFLEX (NORDIFLEX5, NORDIFLX 10, NORDIFLX 15)
Specialty PA
NUTROPIN Specialty PA
NUTROPIN AQ Specialty PA
NUTROPIN AQ NUSPIN Specialty PA
OMNITROPE 5 MG/1.5 ML CRTG Specialty PA
SAIZEN Specialty PA
SEROSTIM Specialty PA
STIMATE Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access53
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsTEV-TROPIN Specialty PA
ZORBTIVE Specialty PA
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Anabolic SteroidsANADROL-50 Specialty
oxandrolone 10 mg tablet Generic
AndrogensANDROGEL Brand
danazol (50 mg, 100 mg, 200 mg) Generic
testosterone (1.25g gel md pmp, 50 mggel packet)
Brand
testosterone 50 mg (1%) gel (gram) Generic
testosterone cypionate (100 mg/ml, 200mg/ml)
Generic
testosterone enanthate 200 mg/ml vial Generic
VOGELXO (12.5 MG/1.25 PUMP, 50MG/5 GEL PACKT)
Brand
EstrogensALORA Brand
ALTAVERA Preventive
ALYACEN Preventive
AMETHIA Preventive
AMETHIA LO Preventive
AMETHYST Preventive
APRI Preventive
ARANELLE Preventive
AUBRA Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access54
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsAVIANE Preventive
AZURETTE Preventive
BALZIVA Preventive
BRIELLYN Preventive
CAMRESE Preventive
CAMRESE LO Preventive
CAZIANT Preventive
CHATEAL Preventive
COMBIPATCH Brand
CRYSELLE Preventive
CYCLAFEM Preventive
DASETTA Preventive
DAYSEE Preventive
DELYLA Preventive
desogestrel-ethinyl estradiol Preventive
desogestrel-ethinyl estradiol/ethinylestradiol
Preventive
DUAVEE Brand
ELINEST Preventive
EMOQUETTE Preventive
ENPRESSE Preventive
ENSKYCE Preventive
ESTARYLLA Preventive
ESTRACE 0.01% CREAM Brand
estradiol (.025mg/24h patch tdwk,.0375mg/24 patch tdwk, 0.05mg/24hpatch tdwk, 0.06mg/24h patch tdwk,.075mg/24h patch tdwk, 0.1mg/24hrpatch tdwk, 0.5 mg tablet, 1 mg tablet,2 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access55
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsestradiol/norethindrone acet 1 mg-0.5mg tablet
Generic
ESTRING Brand
estropipate (0.75 mg, 1.5 mg, 3 mg) Generic
ethinyl estradiol/drospirenone Preventive
FALMINA Preventive
GIANVI Preventive
GILDAGIA Preventive
GILDESS Preventive
GILDESS FE Preventive
INTROVALE Preventive
JOLESSA Preventive
JUNEL Preventive
JUNEL FE Preventive
KARIVA Preventive
KELNOR 1-35 Preventive
KURVELO Preventive
LARIN Preventive
LARIN FE Preventive
LEENA Preventive
LESSINA Preventive
LEVONEST Preventive
levonorgestrel-eth estra/ethinylestradiol
Preventive
levonorgestrel-ethinyl estradiol Preventive
LEVORA-28 Preventive
LOMEDIA 24 FE Preventive
LORYNA Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access56
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsLOW-OGESTREL Preventive
LUTERA Preventive
MARLISSA Preventive
MICROGESTIN Preventive
MICROGESTIN FE Preventive
mimvey Generic
MINIVELLE Brand
MONO-LINYAH Preventive
MONONESSA Preventive
MYZILRA Preventive
NECON Preventive
NIKKI Preventive
norethindrone acetate-ethinyl estradiol Preventive
norethindrone acetate-ethinylestradiol/ferrous fumarate
Preventive
norgestimate-ethinyl estradiol Preventive
NORTREL Preventive
NUVARING Preventive
OCELLA Preventive
OGESTREL Preventive
ORSYTHIA Preventive
ORTHO TRI-CYCLEN LO Preventive
PHILITH Preventive
PIMTREA Preventive
PIRMELLA Preventive
PORTIA Preventive
PREMARIN (0.3 MG TABLET, 0.45 MGTABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET, VAGINALCREAM-APPL)
Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access57
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsPREMPHASE Brand
PREMPRO Brand
PREVIFEM Preventive
QUASENSE Preventive
RECLIPSEN Preventive
SPRINTEC Preventive
SRONYX Preventive
SYEDA Preventive
TARINA FE Preventive
TILIA FE Preventive
TRI-ESTARYLLA Preventive
TRI-LEGEST FE Preventive
TRI-LINYAH Preventive
TRI-PREVIFEM Preventive
TRI-SPRINTEC Preventive
TRINESSA Preventive
TRIVORA-28 Preventive
VAGIFEM Brand
VELIVET Preventive
VESTURA Preventive
VIORELE Preventive
VIVELLE-DOT Brand
VYFEMLA Preventive
WERA Preventive
XULANE Preventive
ZARAH Preventive
ZENCHENT Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access58
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsZOVIA 1-35E Preventive
ZOVIA 1-50E Preventive
ProgestinsCAMILA Preventive
DEBLITANE Preventive
DEPO-SUBQ PROVERA 104 Brand
ERRIN Preventive
HEATHER Preventive
JENCYCLA Preventive
JOLIVETTE Preventive
LYZA Preventive
medroxyprogesterone acetate (2.5 mgtablet, 5 mg tablet, 10 mg tablet, 150mg/ml syringe, 150 mg/ml vial)
Generic
megestrol acetate (20 mg tablet, 40 mgtablet, 400mg/10ml oral susp)
Generic
NORA-BE Preventive
norethindrone 0.35 mg tablet Preventive
norethindrone acetate 5 mg tablet Generic
NORLYROC Preventive
progesterone,micronized (100 mg, 200mg)
Generic
SHAROBEL Preventive
Selective Estrogen Receptor Modifying Agentsraloxifene hcl Preventive
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothroid Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access59
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitslevothyroxine sodium (25 mcg, 50 mcg,75 mcg, 88 mcg, 100 mcg, 112 mcg, 125mcg, 137 mcg, 150 mcg, 175mcg, 200mcg, 300 mcg)
Generic
levoxyl Generic
liothyronine sodium (5 mcg, 25 mcg, 50mcg)
Generic
unithroid (25 mcg, 50 mcg, 75 mcg, 88mcg, 100 mcg, 112 mcg, 125 mcg, 150mcg, 175 mcg, 200 mcg, 300 mcg)
Generic
Hormonal Agents, Suppressant (Adrenal)
LYSODREN Brand
SIGNIFOR Specialty PA, LA
Hormonal Agents, Suppressant (Parathyroid)
calcitriol (0.25 mcg capsule, 0.5 mcgcapsule, 1 mcg/ml solution)
Generic
paricalcitol (1 mcg, 2 mcg, 4mcg) Generic
SENSIPAR (30 MG, 60 MG) Specialty QL (60 PER 30 DAYS)
SENSIPAR 90 MG TABLET Specialty
ZEMPLAR (5 MCG/ML, 10 MCG/2 ML) Brand
Hormonal Agents, Suppressant (Pituitary)
cabergoline Generic
ELIGARD Brand PA
leuprolide acetate 1 mg/0.2ml kit Generic PA
octreotide acetate (50 mcg/ml ampul,50 mcg/ml vial, 100 mcg/ml ampul, 100mcg/ml vial, 200 mcg/ml vial, 500mcg/ml ampul, 500 mcg/ml vial,1000mcg/ml vial)
Specialty PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access60
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsSOMAVERT Specialty PA, LA
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Antiandrogensbicalutamide Generic
NILANDRON Brand
XTANDI Specialty PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agentsmethimazole (5 mg, 10 mg) Generic
propylthiouracil 50 mg tablet Generic
Immunological Agents
Angioedema (HAE) AgentsBERINERT 500 UNIT KIT Specialty PA, QL (3 PER 30 DAYS)
Immune SuppressantsASTAGRAF XL Brand
azathioprine 50 mg tablet Generic
CELLCEPT 200 MG/ML ORAL SUSP Brand
cyclosporine (25 mg, 100 mg) Generic
cyclosporine, modified (25 mg capsule,50 mg capsule, 100 mg capsule, 100mg/ml solution)
Generic
ENBREL (25 MG/0.5 ML SYRINGE, 50MG/ML SURECLICK SYR, 50 MG/MLSYRINGE)
Specialty QL (4 ML PER 28 DAYS)
ENBREL 25 MG KIT Specialty QL (8 PER 28 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access61
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsgengraf (25 mg capsule, 100 mg/mlsolution)
Generic
GRASTEK Brand PA
hecoria Generic
HUMIRA Specialty
HUMIRA PEDIATRIC Specialty
mycophenolate mofetil (250 mgcapsule, 500 mg tablet)
Generic
mycophenolate sodium Generic
ORALAIR Specialty PA, LA
PROGRAF 5 MG/ML AMPULE Brand
RAGWITEK Brand PA
RAPAMUNE 1 MG/ML ORAL SOLN Brand
RESTASIS Brand QL (60 PER 30 DAYS)
SANDIMMUNE 100 MG/ML SOLN Brand
sirolimus (0.5 mg, 1 mg, 2 mg) Generic
tacrolimus (0.5 mg, 1 mg, 5 mg) Generic
ZORTRESS Specialty
Immunizing Agents, PassiveGAMMAGARD S-D Brand PA
GAMMAKED Specialty PA
GAMUNEX-C Specialty PA
ImmunomodulatorsACTIMMUNE Specialty PA
ALFERON N Specialty
leflunomide Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access62
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Inflammatory Bowel Disease Agents
Aminosalicylatesbalsalazide disodium Generic
DIPENTUM Brand
Glucocorticoidsanusol-hc 2.5% cream Generic
procto-pak Generic
proctocream-hc Generic
PROCTOFOAM-HC Brand
proctosol-hc Generic
proctozone-hc Generic
Metabolic Bone Disease Agents
ACTONEL (5 MG, 30 MG, 35 MG) Preventive PA
alendronate sodium (5 mg tablet, 10mg tablet, 35 mg tablet, 40 mg tablet,70 mg tablet, 70 mg/75ml solution)
Preventive
calcitonin,salmon,synthetic Preventive
doxercalciferol (0.5 mcg capsule, 1 mcgcapsule, 2.5 mcg capsule, 4mcg/2mlvial)
Generic
etidronate disodium Preventive
FORTEO Preventive PA
ibandronate sodium 150 mg tablet Preventive
Miscellaneous
Glucose TestingACCU-CHECK (METERS & TEST STRIPS) DME Benefit QL
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access63
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsLIFESCAN (METERS & TEST STRIPS) DME Benefit QL
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogslatanoprost Generic
LUMIGAN Brand Step Therapy
TRAVATAN Z Brand
travoprost (benzalkonium) Generic
Ophthalmic Agents, Otherak-poly-bac Generic
bacitracin/polymyxin b sulfate Generic
BLEPHAMIDE Brand
BLEPHAMIDE S.O.P. Brand
CYSTARAN Brand PA, LA, QL (60 ML PER 30 DAYS)
gatifloxacin Generic
LACRISERT Brand
MOXEZA Brand
naphazoline hcl 0.1 % drops Generic
neo-polycin Generic
neo-polycin hc Generic
neomycin sulfate/bacitracinzinc/polymyxin b/hydrocortisone
Generic
neomycin sulfate/bacitracin/polymyxinb
Generic
neomycin sulfate/polymyxin bsulfate/gramicidin d
Generic
neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access64
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsneomycin/polymyxin bsulfate/dexamethasone (0.1 % dropssusp, 3.5-10k-.1 oint. (g))
Generic
neosporin Generic
polycin Generic
polymyxin b sulfate/trimethoprim Generic
sulfacetamide sodium/prednisolonesodium phosphate
Generic
TOBRADEX EYE OINTMENT Brand
TOBRADEX ST Brand
tobramycin/dexamethasone Generic
tropicamide (0.5 %, 1 %) Generic
VIGAMOX Brand
ZYLET Brand
Ophthalmic Anti-allergy AgentsALOMIDE Brand
azelastine hcl 0.05 % drops Generic
cromolyn sodium 4 % drops Generic
PATANOL Brand PA
Ophthalmic Anti-inflammatoriesALREX Brand
bromfenac sodium Generic
dexamethasone sod phosphate 0.1 %drops
Generic
diclofenac sodium 0.1 % drops Generic
flurbiprofen sodium Generic
ketorolac tromethamine (0.4 %, 0.5 %) Generic
LOTEMAX (0.5% EYE DROPS, 0.5% EYEOINTMENT, 0.5% OPHTHALMIC GEL)
Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access65
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsprednisolone acetate 1 % drops susp Generic
prednisolone sod phosphate 1 % drops Generic
VEXOL Brand
Ophthalmic Antiglaucoma AgentsALPHAGAN P 0.1% DROPS Brand
AZOPT Brand
betaxolol hcl 0.5 % drops Generic
BETIMOL Brand
BETOPTIC S Brand
brimonidine tartrate (0.15 %, 0.2 %) Generic
carteolol hcl Generic
dorzolamide hcl Generic
dorzolamide hcl/timolol maleate Generic
ISTALOL Brand
levobunolol hcl Generic
metipranolol Generic
pilocarpine hcl (1 %, 2 %, 4 %) Generic
PILOPINE HS Brand
timolol maleate (0.25 % drops, 0.25 %sol-gel, 0.5 % drops, 0.5 % sol-gel)
Generic
Otic Agents
antipyrine/benzocaine 5.4 %-1.4% drops Generic
aurodex Generic
auroguard Generic
CIPRO HC Brand
CIPRODEX Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access66
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsciprofloxacin hcl 0.2 % droperette Generic
neomycin sulfate/polymyxin bsulfate/hydrocortisone (drops susp,solution)
Generic
otic care Generic
Respiratory Tract Agents
Anti-inflammatories, Inhaled CorticosteroidsADVAIR DISKUS Preventive
ADVAIR HFA Preventive
AEROSPAN Preventive
ALVESCO Preventive
ASMANEX Preventive
BREO ELLIPTA Preventive
budesonide (0.25mg/2ml, 0.5 mg/2ml) Preventive
budesonide 32mcg spray/pump Generic
flunisolide (25 mcg, 29mcg) Generic
NASONEX Brand QL (17 GM PER 30 DAYS)
PULMICORT 1 MG/2 ML RESPULE Preventive
PULMICORT FLEXHALER Preventive
QVAR Preventive
Antihistaminesazelastine hcl 137 mcg spray/pump Generic
clemastine fumarate (0.67mg/5mlsyrup, 2.68 mg tablet)
Generic
cyproheptadine hcl (2 mg/5 ml syrup, 4mg tablet)
Generic
levocetirizine dihydrochloride (2.5mg/5ml solution, 5 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access67
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitspromethazine hcl/codeine Generic
promethazine/phenylephrinehcl/codeine
Generic
Antileukotrienesmontelukast sodium (4 mg gran pack, 4mg tab chew, 5 mg tab chew, 10 mgtablet)
Preventive
zafirlukast Preventive QL (60 PER 30 DAYS)
ZYFLO CR Preventive
Bronchodilators, AnticholinergicATROVENT HFA Brand
COMBIVENT Brand QL (14.7 GM PER 30 DAYS)
COMBIVENT RESPIMAT Brand QL (4 GM PER 30 DAYS)
hydrocodone bit/homatrop me-br 5-1.5mg/5 syrup
Generic
hydromet Generic
ipratropium bromide (0.2 mg/mlsolution, 21 mcg spray, 42mcg spray)
Generic
ipratropium bromide/albuterol sulfate Generic
SPIRIVA Brand
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)THEOCHRON Preventive
theophylline anhydrous (100 mg tab er12h, 200 mg tab er 12h, 300 mg tab er12h, 400 mg tablet er, 450 mg tab er12h, 600 mg tablet er)
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access68
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Bronchodilators, Sympathomimeticalbuterol sulfate (0.63mg/3ml vial-neb,1.25mg/3ml vial-neb, 2 mg tablet, 2mg/5 ml syrup, 2.5 mg/0.5 vial-neb, 2.5mg/3ml vial-neb, 4 mg tab er 12h, 4 mgtablet, 5 mg/ml solution, 8 mg tab er12h)
Preventive
EPIPEN 2-PAK Brand
EPIPEN JR 2-PAK Brand
levalbuterol hcl (0.31mg/3ml,0.63mg/3ml, 1.25mg/0.5, 1.25mg/3ml)
Preventive
PROAIR HFA Preventive QL (17 GM PER 30 DAYS)
SEREVENT DISKUS Preventive
terbutaline sulfate (2.5 mg, 5 mg) Preventive
VENTOLIN HFA Preventive QL (36 GM PER 30 DAYS)
XOPENEX HFA Preventive
Mast Cell Stabilizerscromolyn sodium (20 mg/2 ml ampul-neb, 20 mg/ml solution)
Generic
Pulmonary AntihypertensivesADCIRCA Specialty PA
ADEMPAS Specialty PA
LETAIRIS Specialty PA
OPSUMIT Specialty PA, LA
ORENITRAM ER Specialty PA, LA
sildenafil citrate 20 mg tablet Specialty PA, QL (90 PER 30 DAYS)
TRACLEER Specialty PA, LA
VELETRI 0.5 MG VIAL Specialty
VENTAVIS Specialty PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access69
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Respiratory Tract Agents, OtherANORO ELLIPTA Brand
benzonatate Generic
dextromethorphan hbr/promethazinehcl
Generic
HYPER-SAL 3.5% VIAL Brand
KALYDECO Specialty PA, LA, QL (60 PER 30 DAYS)
phenylephrine hcl/promethazine hcl Generic
pulmosal Generic
PULMOZYME Specialty
sodium chloride for inhalation 7 % vial-neb
Generic
sski Generic
SYMBICORT Preventive
TYZINE Brand
Skeletal Muscle Relaxants
carisoprodol (250 mg, 350 mg) Generic
carisoprodol/aspirin Generic
chlorzoxazone Generic
cyclobenzaprine hcl (5 mg, 7.5 mg, 10mg)
Generic
metaxalone Generic
methocarbamol (500 mg, 750 mg) Generic
orphenadrine citrate 100 mg tablet er Generic
orphenadrine/aspirin/caffeine 50-770-60 tablet
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access70
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limits
Sleep Disorder Agents
GABA Receptor Modulatorsestazolam Generic
eszopiclone Generic QL (30 PER 30 DAYS)
flurazepam hcl Generic
temazepam Generic
triazolam Generic
zaleplon Generic QL (30 PER 30 DAYS)
zolpidem tartrate (5 mg, 10 mg) Generic QL (30 PER 30 DAYS)
Sleep Disorders, Othermodafinil Generic PA, QL (30 PER 30 DAYS)
ROZEREM Brand PA, QL (30 PER 30 DAYS)
XYREM Specialty PA, LA, QL (540 ML PER 30 DAYS)
Therapeutic Nutrients/ Minerals/ Electrolytes
Electrolyte/Mineral ModifiersEXJADE Specialty
kionex 15 gm/60 ml suspension Generic
sodium polystyrene sulfonate(15g/60ml oral susp, 30g/120ml enema,50g/200ml enema)
Generic
sps 15 gm/60 ml suspension Generic
SYPRINE Brand
Electrolyte/Mineral Replacementcyanocobalamin (vitamin b-12)1000mcg/ml vial
Generic
ergocalciferol (vitamin d2) 50000 unitcapsule
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access71
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/LimitsFLUOR-A-DAY (0.25 MG TAB, 0.5 MGTAB, 1 MG TABLET)
Preventive
fluoride/iron/vitamins a,c,and d Preventive
FLUORITAB 0.5 MG TABLET CHEW Preventive
FLURA-DROPS Preventive
folic acid 1 mg tablet Preventive
klor-con 10 Generic
klor-con 8 Generic
klor-con m10 Generic
klor-con m20 Generic
levocarnitine 330 mg tablet Generic
LUDENT FLUORIDE Preventive
MATERNITY Preventive
multivitamins with fluoride Preventive
pediatric multivitamin combinationno.2/sodium fluoride
Preventive
pediatric multivitamins a,c,& d3 no.21with sodium fluoride
Preventive
pediatric multivitamins no.16 withsodium fluoride
Preventive
pediatric multivitamins no.17 withsodium fluoride
Preventive
pediatric multivitamins no.82 withsodium fluoride
Preventive
potassium chloride (8 meq capsule er, 8meq tablet er, 10 meq capsule er, 10meq tab er prt, 10 meq tablet er, 20meq tab er prt, 20 meq tablet er,20meq/15ml liquid, 40meq/15ml liquid)
Generic
potassium citrate (5 er, 10 er) Generic
PRENAPLUS Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access72
2015 Providence Health Plan Formulary(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name Status* Requirements/Limitsprenatal vitamins comb no.115/ironfumarate/folic acid
Preventive
prenatal vitamins comb no.115/ironfumarate/folic acid/dss
Preventive
prenatal vitamins combo no.60/ferrousfumarate/folic acid
Preventive
prenatal vits with calcium #72/ferrousfumarate/folic acid
Preventive
prenatal vits with calcium#72/iron,carbonyl/folic acid
Preventive
PREPLUS Preventive
QUFLORA (0.25 MG/ML, 0.5 MG/ML) Brand
SE-NATAL 19 Preventive
sodium fluoride (0.25(0.55) tab chew,0.5 mg/ml drops, 0.5(1.1)mg tab chew,1mg(2.2mg) tab chew, 1mg(2.2mg)tablet)
Preventive
TL-FLUORIVITE Preventive
TRICARE Preventive
TRINATAL RX 1 Preventive
VINATE ONE Preventive
VINATE-M Preventive
VOL-PLUS Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access73
Non-Formulary Drugs That Require Prior Authorization
ABSTRALACANYAACIPHEX SPRINKLEACTIQACTONEL 150 MG TABLETACYCLOVIR 5% OINTMENTACZONEADOXAALTABAXAMBIEN CRAMITIZAAMRIXANZEMET 100 MG TABLETANZEMET 50 MG TABLETAPLENZINAPOKYNARICEPT 23 MG TABLETARTHROTEC 50ARTHROTEC 75ASTEPROATELVIAATOVAQUONE-PROGUANIL HCLATRALINAVINZAAZACITIDINEAZELASTINE 0.15% NASAL SPRAYBENZACLIN GEL 35G PUMPBENZACLIN GEL 50G PUMPBEPREVEBIDILBINOSTOBRINTELLIXBRISDELLEBUTALB-ACETAMIN-CAFF 50-300-40BUTRANS 15 MCG/HR PATCHBUTRANS 10 MCG/HR PATCHBUTRANS 20 MCG/HR PATCHBUTRANS 5 MCG/HR PATCHBYSTOLICCALCIPOTRIENE-BETAMETHASONE DPCALCITRIOL 3 MCG/G OINTMENT
CAMBIACARDIZEM LA 120 MG TABLETCARDURA XLCENTANY ATCESAMETCIALIS 5 MG TABLETCIMZIACLARINEXCLARINEX-D 12 HOURCLARINEX-D 24 HOURCLOBEX 0.05% SPRAYCLONIDINE HCL ERCOARTEMCOMBIGANCONZIPCRESTORCRINONECYCLOSETDALIRESPDERMASORB HCDERMASORB TADESLORATADINEDESONATEDESVENLAFAXINE FUMARATE ERDEXILANTDICLOFENAC SODIUM 1.5% SOLNDICLOFENAC SODIUM 3% GELDICLOFENAC SODIUM-MISOPROSTOLDIFFERIN 0.1% LOTIONDIFICIDDONEPEZIL HCL 23 MG TABLETDORYXDOXYCYCLINE HYC DR 100 MG TABDOXYCYCLINE HYC DR 150 MG TABDOXYCYCLINE HYC DR 75 MG TABDOXYCYCLINE IR-DRDOXYCYCLINE MONO 75 MG CAPSULEDOXYCYCLINE MONO 150 MG CAPDRONABINOLDUEXISECOZA
74
EDARBIEDARBYCLOREDLUARENABLEXENDOMETRINEPIDUOEPROSARTAN MESYLATEESOMEPRAZOLE STRONTIUMEXALGOFENOFIBRATE 50 MG CAPSULEFENOFIBRATE 150 MG CAPSULEFENTANYL CITRATE OTFC 800 MCGFENTANYL CITRATE OTFC 600 MCGFENTANYL CITRATE OTFC 200 MCGFENTANYL CITRATE OTFC 400 MCGFENTANYL CIT OTFC 1600 MCGFENTANYL CIT OTFC 1200 MCGFENTORAFETZIMAFIORICET 50-300-40 MG CAPSULEFLECTORFLO-PREDFLUOCINONIDE 0.1% CREAMFLUVOXAMINE MALEATE ERFORFIVO XLFORTAMETFOSAMAX PLUS DFOSRENOLFYCOMPAGELNIQUEGLUMETZAGRALISEHETLIOZHORIZANTHYDROMORPHONE ERINTERMEZZOINTUNIVJALYNKAPVAY
KETEKKORLYMLAMICTAL ODTLAMICTAL ODT (BLUE)LAMICTAL ODT (GREEN)LAMICTAL ODT (ORANGE)LASTACAFTLAZANDALIPOFENLIPTRUZETLIVALOLOVAZALUPRON DEPOTLUPRON DEPOT-PEDLUVOX CRMALARONEMARINOLMETFORMIN ER 1000 MG OSM-TABMETFORMIN HCL ER 500 MG OSM-TBMETOZOLV ODTMETROGELMETRONIDAZOLE TOPICAL 1% GELMICARDISMICARDIS HCTMIRAPEX ERMONODOX 75 MG CAPSULEMORGIDOX 1X100 MG KITMORGIDOX 2X100 MG KITMORPHINE SULFATE ER 75 MG CAPMORPHINE SULFATE ER 120 MG CAPMORPHINE SULFATE ER 60 MG CAPMORPHINE SULFATE ER 90 MG CAPMORPHINE SULFATE ER 45 MG CAPMORPHINE SULFATE ER 30 MG CAPMOZOBILNAMENDA XRNATROBANEXIUMNIACIN ERNIASPAN
75
NORDITROPIN NORDIFLEX 30 MG/3NOXAFIL DR 100 MG TABLETNUCYNTANUCYNTA ERNUVIGILOCTREOTIDE ACET 500 MCG/ML SYROCTREOTIDE ACET 100 MCG/ML SYROCTREOTIDE ACET 50 MCG/ML SYROLEPTRO EROLOPATADINE HCLOMEGA-3 ACID ETHYL ESTERSOMNARISOMNITROPE 10 MG/1.5 ML CRTGOMNITROPE 5.8 MG VIALONSOLISOPANA ERORACEAORBIVANOXECTAOXTELLAR XROXYMORPHONE HCL ERPAROXETINE ER 37.5 MG TABLETPAROXETINE CR 37.5 MG TABLETPAROXETINE CR 12.5 MG TABLETPAROXETINE CR 25 MG TABLETPATADAYPATANASEPAXIL CRPENNSAIDPEXEVAPOMALYSTPOTIGAPRIMAQUINEPRISTIQ ERQUALAQUINQUININE SULFATE 324 MG CAPSULEQUTENZARAPAFLORELISTORRENOVARENOVA PUMP
REQUIP XLRETIN-A MICRORETIN-A MICRO PUMPRISEDRONATE SODIUMROPINIROLE HCL ER 2 MG TABLETROPINIROLE HCL ER 4 MG TABLETROPINIROLE HCL ER 12 MG TABLETROPINIROLE HCL ER 8 MG TABLETROPINIROLE HCL ER 6 MG TABLETROSADAN 0.75% CREAM KITROSADAN 0.75% GEL KITSAMSCASANCTURA XRSANCUSOSEROQUEL XRSILENORSIMPONISIMPONI ARIASIMVASTATIN 80 MG TABLETSOLARAZESOLODYN ER 115 MG TABLETSOLODYN ER 80 MG TABLETSOLODYN ER 105 MG TABLETSOLODYN ER 55 MG TABLETSOLODYN ER 65 MG TABLETSORILUXSPINOSADSTAVZORSUBSYSSUMAVEL DOSEPRO 6 MG/0.5 MLSYNALAR 0.025% OINTMENT KITSYNALAR 0.025% CREAM KITSYNALAR TSTACLONEXTELMISARTANTELMISARTAN-AMLODIPINETELMISARTAN-HYDROCHLOROTHIAZIDTEVETENTEVETEN HCT
76
TIZANIDINE HCL 4 MG CAPSULETIZANIDINE HCL 2 MG CAPSULETIZANIDINE HCL 6 MG CAPSULETOPICORT 0.25% SPRAYTOVIAZTRAMADOL HCL ER 150 MG CAPSULETRETIN-XTRETINOIN MICROSPHERETREXIMETTRIBENZORTROSPIUM CHLORIDE ERTWYNSTATYVASO INHALATION REFILL KITTYVASO 1.74 MG/2.9 ML SOLUTIONTYVASO INHALATION STARTER KITULORICULTRAVATE X CREAM COMBO PACKVANOSVASCEPAVECTICALVELPHOROVELTINVERAMYSTVERDESOVESICAREVIDAZAVIIBRYDVIMOVOVYTORINWELCHOLXALKORIXARTEMIS XRXERESEXOLEGELZANAFLEX 4 MG CAPSULEZANAFLEX 2 MG CAPSULEZANAFLEX 6 MG CAPSULEZELAPAR
ZENZEDI 2.5 MG TABLETZENZEDI 15 MG TABLETZENZEDI 7.5 MG TABLETZENZEDI 20 MG TABLETZENZEDI 30 MG TABLETZETIAZETONNAZIANAZIPSORZMAXZOCOR 80 MG TABLETZOHYDRO ERZOLPIDEM TARTRATE ERZOLPIMISTZORVOLEXZOVIRAX 5% CREAMZOVIRAX 5% OINTMENTZUPLENZZYCLARA 3.75% CREAMZYCLARA 3.75% CREAM PUMP
77
Alphabetical Listing
Aabacavir sulfate 29
abacavir sulfate/lamivudine/zidovudine 29
ABILIFY 16
ABILIFY DISCMELT 16
acamprosate calcium 5
acarbose 33
acebutolol hcl 39
acetaminophen with codeine phosphate 3
acetasol hc 8
acetazolamide 13,41
acetic acid/aluminum acetate 8
acetic acid/hydrocortisone 8
acitretin 46
ACTIMMUNE 62
ACTONEL 63
ACTOPLUS MET XR 33
acyclovir 32
ADAGEN 48
adapalene 46
ADCIRCA 69
adefovir dipivoxil 31
ADEMPAS 69
ADVAIR DISKUS 67
ADVAIR HFA 67
AEROSPAN 67
AFEDITAB CR 39
AFINITOR 25
AFINITOR DISPERZ 25
AGGRENOX 36
ak-poly-bac 64
alagesic lq 1
ALBENZA 26
albuterol sulfate 69
alclometasone dipropionate 6
alendronate sodium 63
ALFERON N 62
alfuzosin hcl 51
ALINIA 26
ALKERAN 23
allopurinol 21
ALOMIDE 65
ALORA 54
ALPHAGAN P 66
alprazolam 32
ALREX 65
ALTAVERA 54
ALVESCO 67
ALYACEN 54
amantadine hcl 27
amcinonide 6
AMETHIA 54
AMETHIA LO 54
AMETHYST 54
amiloride hcl 41
amiloride hcl/hydrochlorothiazide 41
amiodarone hcl 38
amitriptyline hcl 18
amlodipine besylate 40
amlodipine besylate/atorvastatin calcium 41
amlodipine besylate/benazepril hcl 40
ammonium lactate 46
amnesteem 46
amoxapine 18
amoxicillin 10
amoxicillin/potassium clavulanate 11
ampicillin trihydrate 11
AMPYRA 45
ANADROL-50 54
anagrelide hcl 36
anastrozole 24
ANDROGEL 54
ANORO ELLIPTA 70
antipyrine/benzocaine 66
anusol-hc 63
apexicon e 6
APIDRA 34
APIDRA SOLOSTAR 35
APRI 54
APRISO 48
APTIOM 15
78
APTIVUS 30
ARANELLE 54
ARANESP 36
ASACOL 49
ASACOL HD 49
ascomp with codeine 3
ASMANEX 67
ASTAGRAF XL 61
atenolol 39
atenolol/chlorthalidone 39
atorvastatin calcium 42
atovaquone 26
ATRIPLA 30
ATROVENT HFA 68
AUBAGIO 45
AUBRA 54
aurodex 66
auroguard 66
AVIANE 55
avidoxy 12
avita 46
AVONEX 45
AVONEX ADMINISTRATION PACK 45
AVONEX PEN 45
AZASITE 11
azathioprine 61
azelastine hcl 65,67
AZILECT 27
azithromycin 11
AZOPT 66
AZURETTE 55
Bbacitracin 8
bacitracin/polymyxin b sulfate 64
baclofen 28
balsalazide disodium 63
BALZIVA 55
BANZEL 15
BARACLUDE 31
benazepril hcl 37
benazepril hcl/hydrochlorothiazide 37
benzonatate 70
benztropine mesylate 26
BERINERT 61
betamethasone acetate/betamethasone sodium
phosphate 52
betamethasone dipropionate 6
betamethasone dipropionate/propylene glycol 6
betamethasone valerate 6
BETASERON 45
betaxolol hcl 39,66
bethanechol chloride 51
BETIMOL 66
BETOPTIC S 66
bicalutamide 61
bisoprolol fumarate 39
bisoprolol fumarate/hydrochlorothiazide 39
bleph-10 12
BLEPHAMIDE 64
BLEPHAMIDE S.O.P. 64
blood sugar diagnostic 63,64
BOSULIF 25
BREO ELLIPTA 67
BRIELLYN 55
BRILINTA 36
brimonidine tartrate 66
bromfenac sodium 65
bromocriptine mesylate 27
budeprion sr 16
budeprion xl 16
budesonide 52,67
bumetanide 41
BUPHENYL 48
buprenorphine hcl 5
buprenorphine hcl/naloxone hcl 5
buproban 6
bupropion hcl 16
buspirone hcl 32
butalbital/acetaminophen 1
butalbital/acetaminophen/caffeine 1
butalbital/acetaminophen/caffeine/codeine phosphate 3
79
butalbital/aspirin/caffeine 1
butorphanol tartrate 3
BYDUREON 33
BYDUREON PEN 33
BYETTA 33
Ccabergoline 60
cafergot 21
calcipotriene 46
calcitonin,salmon,synthetic 63
calcitriol 60
calcium acetate 52
CAMILA 59
CAMRESE 55
CAMRESE LO 55
CANASA 49
candesartan cilexetil 37
capacet 1
capecitabine 23
CAPRELSA 25
captopril 37
captopril/hydrochlorothiazide 37
CARBAGLU 48
carbamazepine 15
carbidopa 27
carbidopa/levodopa 27
carbidopa/levodopa/entacapone 27
carisoprodol 70
carisoprodol/aspirin 70
carteolol hcl 66
CARTIA XT 40
carvedilol 39
CAZIANT 55
CEENU 23
cefaclor 10
cefadroxil 10
cefdinir 10
cefpodoxime proxetil 10
cefprozil 10
ceftibuten dihydrate 10
CEFTIN 10
cefuroxime axetil 10
CELEBREX 1
CELESTONE 52
CELLCEPT 61
CELONTIN 13
cephalexin 10
CEREZYME 48
CHANTIX 6
CHATEAL 55
chlordiazepoxide hcl 32
chlorhexidine gluconate 8
chloroquine phosphate 26
chlorothiazide 42
chlorpromazine hcl 18
chlorpropamide 33
chlorthalidone 42
chlorzoxazone 70
cholestyramine (with sugar) 43
cholestyramine/aspartame 43
ciclodan 19
ciclopirox 20
ciclopirox olamine 20
cilostazol 36
cimetidine 50
cimetidine hcl 50
CIPRO HC 66
CIPRODEX 66
ciprofloxacin hcl 12,67
ciprofloxacin/ciprofloxacin hcl 12
citalopram hydrobromide 17
claravis 46
clarithromycin 11
clemastine fumarate 67
clinda-derm 8
clindacin etz 8
clindacin p 8
clindamycin hcl 8
clindamycin palmitate hcl 9
clindamycin phosphate 9
clindamycin phosphate/benzoyl peroxide 46
80
clobetasol propionate 6
clobetasol propionate/emollient base 6
clodan 6
clomipramine hcl 18
clonazepam 13
clonidine 36
clonidine hcl 36
clopidogrel bisulfate 36
clorazepate dipotassium 13
clotrimazole 20
clotrimazole/betamethasone dipropionate 20
clozapine 28
co-gesic 3
codeine phosphate/butalbital/aspirin/caffeine 3
codeine phosphate/carisoprodol/aspirin 3
codeine sulfate 3
colchicine/probenecid 21
COLCRYS 21
COLESTID 43
colestipol hcl 43
COMBIPATCH 55
COMBIVENT 68
COMBIVENT RESPIMAT 68
COMETRIQ 25
COMPLERA 30
COMPRO 18
constulose 50
COPAXONE 45
COREG CR 39
cormax 6
cortisone acetate 6
CREON 48
CRIXIVAN 30
cromolyn sodium 65,69
CRYSELLE 55
CUPRIMINE 51
CUVPOSA 48
cyanocobalamin (vitamin b-12) 71
CYCLAFEM 55
cyclobenzaprine hcl 70
cyclophosphamide capsules 23
cyclophosphamide tablets 23
cycloserine 9
cyclosporine 61
cyclosporine, modified 61
cyproheptadine hcl 67
CYSTAGON 51
CYSTARAN 64
Ddanazol 54
dantrolene sodium 28
dapsone 22
DARAPRIM 26
DASETTA 55
DAYSEE 55
DAYTRANA 44
DEBLITANE 59
decitabine 23
DELYLA 55
DELZICOL 49
demeclocycline hcl 12
DENAVIR 32
depade 5
DEPEN 51
DEPO-SUBQ PROVERA 104 59
desipramine hcl 18
desmopressin acetate 53
desmopressin acetate (non-refrigerated) 53
desogestrel-ethinyl estradiol 55
desogestrel-ethinyl estradiol/ethinyl estradiol 55
desonide 6
desoximetasone 7
dexamethasone 52
dexamethasone sod phosphate 65
dexmethylphenidate hcl 44
dextroamphetamine sulf-saccharate/amphetamine sulf-
aspartate 44
dextroamphetamine sulfate 44
dextromethorphan hbr/promethazine hcl 70
DIASTAT 14
diazepam 14
81
DICLEGIS 19
diclofenac potassium 1
diclofenac sodium 1,65
dicloxacillin sodium 11
dicyclomine hcl 48
didanosine 29
DIFFERIN 46
diflorasone diacetate 7
diflunisal 1
digox 41
digoxin 41
dihydrocodeine bitartrate/acetaminophen/caffeine 3
dihydroergotamine mesylate 21
DILANTIN 15
DILATRATE-SR 43
DILT-CD 40
DILT-XR 40
DILTIA XT 40
diltiazem hcl 40
DILTZAC ER 40
DIPENTUM 63
diphenoxylate hcl/atropine sulfate 49
dipyridamole 36
disopyramide phosphate 38
disulfiram 5
divalproex sodium 14
donepezil hcl 16
dorzolamide hcl 66
dorzolamide hcl/timolol maleate 66
doxazosin mesylate 37
doxepin hcl 18
doxercalciferol 63
doxycycline hyclate 12
doxycycline monohydrate 12
DROXIA 23
DUAVEE 55
duloxetine hcl 17
dynacin 13
DYRENIUM 41
EE.E.S. 200 11
econazole nitrate 20
EDECRIN 41
EDURANT 29
EFFIENT 36
EGRIFTA 53
ELELYSO 48
ELIDEL 47
ELIGARD 60
elimite 26
ELINEST 55
ELIQUIS 35
ELMIRON 51
EMCYT 23
EMEND 19
EMOQUETTE 55
EMTRIVA 29
enalapril maleate 37
enalapril maleate/hydrochlorothiazide 37
ENBREL 61
endocet 3
endodan 3
enoxaparin sodium 35
ENPRESSE 55
ENSKYCE 55
entacapone 27
entecavir 31
enulose 50
EPANED 37
EPIFOAM 47
EPIPEN 2-PAK 69
EPIPEN JR 2-PAK 69
epitol 15
EPIVIR HBV 31
eplerenone 41
EPOGEN 36
EPZICOM 29
EQUETRO 15
ergocalciferol (vitamin d2) 71
82
ergotamine tartrate/caffeine 21
ERIVEDGE 25
ERRIN 59
ERY-TAB 11
erygel 11
ERYPED 200 11
erythromycin base 11
erythromycin base/benzoyl peroxide 47
erythromycin base/ethyl alcohol 11
erythromycin ethylsuccinate 11
erythromycin ethylsuccinate/sulfisoxazole acetyl 11
escitalopram oxalate 17
ESTARYLLA 55
estazolam 71
ESTRACE 55
estradiol 55
estradiol/norethindrone acetate 56
ESTRING 56
estropipate 56
eszopiclone 71
ethambutol hcl 22
ethinyl estradiol/drospirenone 56
ethosuximide 13
etidronate disodium 63
etodolac 1
EXELON 16
exemestane 24
EXJADE 71
EXTAVIA 46
FFALMINA 56
famciclovir 32
famotidine 50
FARESTON 23
FARXIGA 33
FAZACLO 28
felbamate 14
felodipine 40
fenofibrate 42
fenofibrate nanocrystallized 42
fenofibrate,micronized 42
fenofibric acid 42
fenofibric acid (choline) 42
fenoprofen calcium 1
fentanyl 2
FINACEA 47
finasteride 51
fioricet 1
FIRAZYR 46
FIRST-LANSOPRAZOLE 50
FIRST-OMEPRAZOLE 50
FLAREX 52
flavoxate hcl 51
flecainide acetate 38
FLOVENT DISKUS 52
FLOVENT HFA 52
fluconazole 20
fludrocortisone acetate 7
flunisolide 67
fluocinolone acetonide 7
fluocinolone acetonide oil 52
fluocinonide 7
fluocinonide/emollient base 7
FLUOR-A-DAY 72
fluoride/iron/vitamins a,c,and d 72
FLUORITAB 72
fluorometholone 52
FLUOROPLEX 47
fluorouracil 47
fluoxetine hcl 17
fluphenazine hcl 27
FLURA-DROPS 72
flurazepam hcl 71
flurbiprofen 1
flurbiprofen sodium 65
fluticasone propionate 7,52
fluvastatin sodium 42
fluvoxamine maleate 17
FML FORTE 52
FML S.O.P. 52
FOCALIN XR 44
83
folic acid 72
fondaparinux sodium 35
FORTEO 63
fosinopril sodium 37
fosinopril sodium/hydrochlorothiazide 38
FRAGMIN 35
FULYZAQ 49
furosemide 41
FUZEON 30
Ggabapentin 14
GABITRIL 14
GAMMAGARD S-D 62
GAMMAKED 62
GAMUNEX-C 62
garamycin 8
gatifloxacin 64
GATTEX 49
gavilyte-c 49
gavilyte-g 49
gavilyte-n 49
gemfibrozil 42
generlac 50
gengraf 47,62
GENOTROPIN 53
gentak 8
gentamicin sulfate 8
GIANVI 56
GILDAGIA 56
GILDESS 56
GILDESS FE 56
GILENYA 46
GILOTRIF 24
GLEEVEC 25
glimepiride 33
glipizide 33
glipizide/metformin hcl 33
GLUCAGEN 34
GLUCAGON EMERGENCY KIT 34
glyburide 33
glyburide,micronized 33
glyburide/metformin hcl 33
glycopyrrolate 48
glydo 5
GOLYTELY 49
granisetron hcl 19
GRANIX 36
GRASTEK 62
griseofulvin ultramicrosize 20
griseofulvin, microsize 20
guanfacine hcl 37
guanidine hcl 22
Hhalobetasol propionate 7
haloperidol 27
haloperidol lactate 27
HEATHER 59
hecoria 62
HEXALEN 24
HUMALOG 35
HUMALOG MIX 50-50 35
HUMALOG MIX 75-25 35
HUMATROPE 53
HUMIRA 62
HUMIRA PEDIATRIC 62
HUMULIN R 35
HYCAMTIN 24
hydralazine hcl 43
hydrochlorothiazide 42
hydrocodone bit/acetaminophen 3
hydrocodone bitartrate/acetaminophen 4
hydrocodone bitartrate/homatropine methylbromide 68
hydrocodone/ibuprofen 4
hydrocortisone 7,52
hydrocortisone butyrate 7,52
hydrocortisone valerate 52
hydromet 68
hydromorphone hcl 4
hydroxychloroquine sulfate 26
hydroxyurea 23
84
hydroxyzine hcl 19
hydroxyzine pamoate 19
HYPER-SAL 70
hypercare 47
Iibandronate sodium 63
ibudone 4
ibuprofen 1
ibuprofen/oxycodone hcl 1
ICLUSIG 25
IMBRUVICA 25
imipramine hcl 18
imipramine pamoate 18
imiquimod 24
INCIVEK 31
INCRELEX 53
indapamide 42
indomethacin 1
INFERGEN 31
INLYTA 25
INTELENCE 29
INTRON A 31
INTROVALE 56
INVEGA 28
INVIRASE 30
INVOKANA 33
ipratropium bromide 68
ipratropium bromide/albuterol sulfate 68
irbesartan 37
irbesartan/hydrochlorothiazide 37
IRESSA 24
ISENTRESS 30
isochron 43
isonarif 22
isoniazid 22
isosorbide dinitrate 43
isosorbide mononitrate 43
isradipine 40
ISTALOL 66
itraconazole 20
ivermectin 26
JJAKAFI 24
JANTOVEN 35
JANUMET 33
JANUMET XR 33
JANUVIA 34
JENCYCLA 59
JENTADUETO 34
JOLESSA 56
JOLIVETTE 59
JUNEL 56
JUNEL FE 56
JUVISYNC 34
JUXTAPID 43
KKALETRA 30
KALYDECO 70
KARIVA 56
KAZANO 34
KELNOR 1-35 56
ketoconazole 20
ketoprofen 1
ketorolac tromethamine 2,65
kionex 71
klor-con 10 72
klor-con 8 72
klor-con m10 72
klor-con m20 72
KOMBIGLYZE XR 34
KURVELO 56
KUVAN 48
KYNAMRO 43
Llabetalol hcl 39
LACRISERT 64
lactulose 50
LAMISIL 20
85
lamivudine 29,31
lamivudine/zidovudine 29
lamotrigine 14
LANOXIN 41
lansoprazole 50
lansoprazole/amoxicillin trihydrate/clarithromycin 50
LANTUS 35
LANTUS SOLOSTAR 35
LARIN 56
LARIN FE 56
latanoprost 64
LATUDA 28
LEENA 56
leflunomide 62
LESSINA 56
LETAIRIS 69
letrozole 24
leucovorin calcium 24
LEUKERAN 23
LEUKINE 36
leuprolide acetate 60
levalbuterol hcl 69
LEVATOL 39
LEVEMIR 35
LEVEMIR FLEXPEN 35
LEVEMIR FLEXTOUCH 35
levetiracetam 13
levobunolol hcl 66
levocarnitine 72
levocetirizine dihydrochloride 67
levofloxacin 12
LEVONEST 56
levonorgestrel-eth estra/ethinyl estradiol 56
levonorgestrel-ethinyl estradiol 56
LEVORA-28 56
levorphanol tartrate 2
levothroid 59
levothyroxine sodium 60
levoxyl 60
LEXIVA 30
LIALDA 49
lidocaine 5
lidocaine hcl 5
lidocaine/prilocaine 5
lindane 26
liothyronine sodium 60
lisinopril 38
lisinopril/hydrochlorothiazide 38
lithium carbonate 33
lithium citrate 33
LOFIBRA 42
LOMEDIA 24 FE 56
lomustine 23
lorazepam 14
lorazepam intensol 14
lorcet 4
lorcet hd 4
lorcet plus 4
lortab 4
LORYNA 56
losartan potassium 37
losartan potassium/hydrochlorothiazide 37
LOTEMAX 65
LOTRONEX 50
lovastatin 42
LOW-OGESTREL 57
loxapine succinate 27
LUDENT FLUORIDE 72
LUMIGAN 64
LUTERA 57
LYRICA 13
LYSODREN 60
LYZA 59
Mmaprotiline hcl 16
MARLISSA 57
MARPLAN 17
MATERNITY 72
MATULANE 23
MATZIM LA 40
meclofenamate sodium 2
86
medroxyprogesterone acetate 59
mefloquine hcl 26
megestrol acetate 59
MEKINIST 24
meloxicam 2
meperidine hcl 4
meperitab 4
meprobamate 32
mercaptopurine 23
mesalamine 49
mesalamine with cleansing wipes 49
MESNEX 24
MESTINON 22
metadate er 44
metaxalone 70
metformin hcl 34
methadone hcl 2
methadone intensol 2
methadose 2
methazolamide 41
methenamine hippurate 9
methimazole 61
methocarbamol 70
methotrexate sodium 23
methotrexate sodium/pf 23
methoxsalen, rapid 47
methyclothiazide 42
methyldopa 37
methyldopa/hydrochlorothiazide 37
methylphenidate hcl 45
methylprednisolone 53
metipranolol 66
metoclopramide hcl 19
metolazone 42
metoprolol succinate 39
metoprolol tartrate 39
metoprolol tartrate/hydrochlorothiazide 39
metronidazole 9
mexiletine hcl 38
MICROGESTIN 57
MICROGESTIN FE 57
midodrine hcl 37
migergot 21
MIGRANAL 21
millipred 7
millipred dp 7
mimvey 57
minitran 43
MINIVELLE 57
minocycline hcl 13
minoxidil 43
mirtazapine 16
misoprostol 50
modafinil 71
MODERIBA 31
moexipril hcl 38
moexipril hcl/hydrochlorothiazide 38
mometasone furoate 47
MONO-LINYAH 57
MONONESSA 57
montelukast sodium 68
MONUROL 9
morgidox 13
morphine sulfate 2,4
MOVIPREP 50
MOXEZA 64
moxifloxacin hcl 12
MULTAQ 38
multivitamins with fluoride 72
mupirocin 9
MYALEPT 53
mycophenolate mofetil 62
mycophenolate sodium 62
myorisan 47
MYRBETRIQ 29
MYZILRA 57
Nnabumetone 2
nadolol 39
nadolol/bendroflumethiazide 39
naltrexone hcl 5
87
NAMENDA 16
naphazoline hcl 64
NAPRELAN 2
naproxen 2
naproxen sodium 2
NASONEX 67
NATACYN 20
nateglinide 34
NECON 57
nefazodone hcl 17
neo-polycin 64
neo-polycin hc 64
neomycin sulfate 8
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone 64
neomycin sulfate/bacitracin/polymyxin b 64
neomycin sulfate/polymyxin b sulfate/gramicidin d 64
neomycin sulfate/polymyxin b
sulfate/hydrocortisone 64,67
neomycin/polymyxin b sulfate/dexamethasone 65
neosporin 65
NESINA 34
NEULASTA 36
NEUMEGA 36
NEUPOGEN 36
nevirapine 29
NEXAVAR 25
nicardipine hcl 40
NIFEDIAC CC 40
NIFEDICAL XL 40
nifedipine 40
NIKKI 57
NILANDRON 61
nimodipine 40
nisoldipine 40
NITRO-BID 43
NITRO-DUR 43
nitro-time 43
nitrofurantoin 9
nitrofurantoin macrocrystal 9
nitrofurantoin monohydrate/macrocrystals 9
nitroglycerin 43
NITROSTAT 44
nizatidine 50
NORA-BE 59
NORDITROPIN 53
NORDITROPIN FLEXPRO 53
NORDITROPIN NORDIFLEX 53
norethindrone 59
norethindrone acetate 59
norethindrone acetate-ethinyl estradiol 57
norethindrone acetate-ethinyl estradiol/ferrous
fumarate 57
norgestimate-ethinyl estradiol 57
NORLYROC 59
NORPACE CR 38
NORTREL 57
nortriptyline hcl 18
NORVIR 30
NOVOLOG 35
NOVOLOG FLEXPEN 35
NOVOLOG MIX 70-30 35
NOVOLOG MIX 70-30 FLEXPEN 35
NOXAFIL 20
NUEDEXTA 45
nulytely with flavor packs 49
NUTROPIN 53
NUTROPIN AQ 53
NUTROPIN AQ NUSPIN 53
NUVARING 57
nyamyc 20
nystatin 20
nystatin/triamcinolone acetonide 7
nystop 20
OOCELLA 57
octreotide acetate 60
OCUDOX 13
ofloxacin 12
OGESTREL 57
olanzapine 28
88
olanzapine/fluoxetine hcl 17
OLYSIO 31
omeprazole 50
OMEPRAZOLE+SYRSPEND SF ALKA 51
OMNITROPE 53
ondansetron 19
ondansetron hcl 19
ONFI 14
ONGLYZA 34
OPSUMIT 69
ORALAIR 62
oralone 7
ORAP 28
ORAPRED ODT 7
ORENITRAM ER 69
ORFADIN 48
orphenadrine citrate 70
orphenadrine citrate/aspirin/caffeine 70
ORSYTHIA 57
ORTHO TRI-CYCLEN LO 57
OSENI 34
OTEZLA 47
otic care 67
oxandrolone 54
oxaprozin 2
oxazepam 32
oxcarbazepine 15
OXSORALEN 47
oxybutynin chloride 51
oxycodone hcl 2,4
oxycodone hcl/acetaminophen 4
oxycodone hcl/aspirin 4
OXYCONTIN 3
oxymorphone hcl 4
OXYTROL 51
Ppacerone 38
pancrelipase 5,000 48
PANRETIN 25
pantoprazole sodium 51
paricalcitol 60
paroex 9
paroxetine hcl 17
PATANOL 65
PAXIL 17
pedi-dri 20
pediatric multivitamin combination no.2/sodium
fluoride 72
pediatric multivitamins a,c,& d3 no.21 with sodium
fluoride 72
pediatric multivitamins no.16 with sodium fluoride 72
pediatric multivitamins no.17 with sodium fluoride 72
pediatric multivitamins no.82 with sodium fluoride 72
peg 3350/sod sulf/sod bicarbonate/sod
chloride/potassium chl 49
PEGASYS 31
PEGASYS PROCLICK 31
PEGINTRON 31
PEGINTRON REDIPEN 31
penicillin v potassium 11
PENTASA 49
pentoxifylline 41
perindopril erbumine 38
periogard 9
permethrin 26
perphenazine 19
perphenazine/amitriptyline hcl 28
PHENADOZ 19
phenelzine sulfate 17
phenobarbital 14
phenylephrine hcl/promethazine hcl 70
phenytoin 15
phenytoin sodium extended 15
PHILITH 57
PICATO 47
pilocarpine hcl 46,66
PILOPINE HS 66
PIMTREA 57
pindolol 39
pioglitazone hcl 34
pioglitazone hcl/glimepiride 34
89
pioglitazone hcl/metformin hcl 34
PIRMELLA 57
piroxicam 2
PLEGRIDY 46
PLEGRIDY PEN 46
podofilox 47
polycin 65
polymyxin b sulfate/trimethoprim 65
PORTIA 57
potassium chloride 72
potassium citrate 72
PRADAXA 35
pramipexole di-hcl 27
pravastatin sodium 42
prazosin hcl 37
prednisolone 7
prednisolone acetate 66
prednisolone sod phosphate 7,66
prednisone 7
prednisone intensol 7
PREMARIN 57
PREMPHASE 58
PREMPRO 58
PRENAPLUS 72
prenatal vitamins comb no.115/iron fumarate/folic
acid 73
prenatal vitamins comb no.115/iron fumarate/folic
acid/dss 73
prenatal vitamins combo no.60/ferrous fumarate/folic
acid 73
prenatal vits with calcium #72/ferrous fumarate/folic
acid 73
prenatal vits with calcium #72/iron,carbonyl/folic acid 73
PREPLUS 73
PREVALITE 43
PREVIFEM 58
PREZISTA 30
PRIFTIN 22
primidone 13
PROAIR HFA 69
probenecid 21
prochlorperazine maleate 19
PROCRIT 36
procto-pak 63
proctocream-hc 63
PROCTOFOAM-HC 63
proctosol-hc 63
proctozone-hc 63
PROCYSBI 51
progesterone,micronized 59
PROGLYCEM 34
PROGRAF 62
PROMACTA 36
promethazine hcl 19
promethazine hcl/codeine 68
promethazine/phenylephrine hcl/codeine 68
PROMETHEGAN 19
propafenone hcl 38
propantheline bromide 49
propranolol hcl 39
propranolol hcl/hydrochlorothiazide 39
propylthiouracil 61
PROTONIX 51
PROTOPIC 47
protriptyline hcl 18
PULMICORT 67
PULMICORT FLEXHALER 67
pulmosal 70
PULMOZYME 70
PURIXAN 24
PYLERA 49
pyridostigmine bromide 22
QQUASENSE 58
QUDEXY XR 15
quetiapine fumarate 28
QUFLORA 73
quinapril hcl 38
quinapril hcl/hydrochlorothiazide 38
quinidine gluconate 38
quinidine sulfate 38
90
QVAR 67
Rrabeprazole sodium 51
RAGWITEK 62
raloxifene hcl 59
ramipril 38
RANEXA 41
ranitidine hcl 50
RAPAMUNE 62
RAVICTI 48
REBETOL 31
REBIF 46
REBIF REBIDOSE 46
RECLIPSEN 58
RECTIV 43
refissa 47
REGRANEX 47
RENAGEL 52
RENVELA 52
reprexain 5
RESTASIS 62
revia 6
REVLIMID 23
REYATAZ 30
RHEUMATREX 24
RIBAPAK 31
RIBASPHERE 31
RIBATAB 31
ribavirin 31
rifabutin 22
rifampin 22
RIFATER 22
riluzole 45
rimantadine hcl 31
RIOMET 34
RISPERDAL CONSTA 28
risperidone 28
RITALIN LA 45
rivastigmine tartrate 16
rizatriptan benzoate 21
ropinirole hcl 27
rosadan 9
ROXICET 5
roxicet 5
ROZEREM 71
SSABRIL 14
SAIZEN 53
SANDIMMUNE 62
SANTYL 47
SAPHRIS 28
SAVELLA 45
SE-NATAL 19 73
selegiline hcl 27
SELZENTRY 30
SENSIPAR 60
SEREVENT DISKUS 69
SEROSTIM 53
sertraline hcl 17
sevelamer carbonate 52
SHAROBEL 59
SIGNIFOR 60
sildenafil citrate 69
silver sulfadiazine 12
simvastatin 42
sirolimus 62
SIRTURO 22
sodium chloride for inhalation 70
sodium chloride/sodium bicarbonate/potassium
chloride/peg 49
sodium fluoride 73
sodium phenylbutyrate 48
sodium polystyrene sulfonate 71
SOLTAMOX 23
SOMAVERT 61
SORINE 38
sotalol hcl 38
SOVALDI 32
SPIRIVA 68
spironolactone 42
91
spironolactone/hydrochlorothiazide 42
SPORANOX 20
SPRINTEC 58
SPRYCEL 25
sps 71
SRONYX 58
sski 70
stagesic 5
stavudine 29
STELARA 47
STIMATE 53
STIVARGA 25
STRATTERA 45
STRIBILD 30
SUBOXONE 5
SUCRAID 48
sucralfate 50
sulfacetamide sodium 12
sulfacetamide sodium/prednisolone sodium
phosphate 65
sulfadiazine 12
sulfamethoxazole/trimethoprim 12
sulfamide 12
sulfasalazine 49
sulfazine 49
sulfazine ec 49
sulindac 2
sumatriptan 21
sumatriptan succinate 21
SUPREP 50
SUSTIVA 29
SUTENT 25
SYEDA 58
SYLATRON 32
SYLATRON 4-PACK 32
SYMBICORT 70
SYMLINPEN 120 34
SYMLINPEN 60 34
SYPRINE 71
Ttacrolimus 62
TAFINLAR 24
TAMIFLU 31
tamoxifen citrate 23
tamsulosin hcl 51
TARCEVA 25
TARGRETIN 25
TARINA FE 58
TASIGNA 25
TAZORAC 47
TAZTIA XT 40
TECFIDERA 46
temazepam 71
temozolomide 24
tencon 1
terazosin hcl 37
terbinafine hcl 21
terbutaline sulfate 69
terconazole 21
testosterone 54
testosterone cypionate 54
testosterone enanthate 54
tetracycline hcl 13
TEV-TROPIN 54
THALOMID 23
THEOCHRON 68
theophylline anhydrous 68
THIOLA 51
thioridazine hcl 28
thiothixene 28
tiagabine hcl 14
ticlopidine hcl 36
TIKOSYN 38
TILIA FE 58
timolol maleate 21,66
tinidazole 26
TIVICAY 30
tizanidine hcl 29
TL-FLUORIVITE 73
92
TOBI PODHALER 8
TOBRADEX 65
TOBRADEX ST 65
tobramycin 8
tobramycin in 0.225 % sodium chloride 8
tobramycin/dexamethasone 65
TOBREX 8
tolmetin sodium 2
tolterodine tartrate 51
topiragen 15
topiramate 15
torsemide 41
TRACLEER 69
TRADJENTA 34
tramadol hcl 3,5
tramadol hcl/acetaminophen 1
trandolapril 38
tranexamic acid 36
TRANSDERM-SCOP 19
tranylcypromine sulfate 17
TRAVATAN Z 64
travoprost (benzalkonium) 64
trazodone hcl 17
TRECATOR 22
tretinoin 26,47
tretinoin/emollient base 47
TRI-ESTARYLLA 58
TRI-LEGEST FE 58
TRI-LINYAH 58
TRI-PREVIFEM 58
TRI-SPRINTEC 58
triamcinolone acetonide 8,53
triamterene/hydrochlorothiazide 42
trianex 47
triazolam 71
TRICARE 73
triderm 8
trifluoperazine hcl 28
trifluridine 32
TRIGLIDE 42
trihexyphenidyl hcl 26
trilyte with flavor packets 49
trimethobenzamide hcl 19
trimethoprim 9
trimipramine maleate 18
TRINATAL RX 1 73
TRINESSA 58
TRIVORA-28 58
tropicamide 65
trospium chloride 51
TRUVADA 29
TYKERB 25
TYZEKA 32
TYZINE 70
UUCERIS 53
ULESFIA 26
unithroid 60
ursodiol 49
VVAGIFEM 58
valacyclovir hcl 32
VALCHLOR 24
VALCYTE 30
valproic acid 14
valproic acid (as sodium salt) (valproate sodium) 14
valsartan 37
valsartan/hydrochlorothiazide 37
vancomycin hcl 9
vandazole 9
vandetanib 25
VELETRI 69
VELIVET 58
venlafaxine hcl 18
VENTAVIS 69
VENTOLIN HFA 69
verapamil hcl 39,41
VERSACLOZ 28
VESTURA 58
VEXOL 66
93
VICTOZA 2-PAK 34
VICTOZA 3-PAK 34
VICTRELIS 32
VIGAMOX 65
VIMPAT 15
VINATE ONE 73
VINATE-M 73
VIORELE 58
VIRACEPT 30
VIRAMUNE XR 29
VIREAD 29
vitazol 9
VIVELLE-DOT 58
VOGELXO 54
VOL-PLUS 73
VOLTAREN 48
voriconazole 21
VOTRIENT 24
VYFEMLA 58
VYVANSE 44
Wwarfarin sodium 35
WERA 58
XXARELTO 35
XENAZINE 45
XIFAXAN 9
XOPENEX HFA 69
XTANDI 61
XULANE 58
xylon 10 5
XYREM 71
Zzafirlukast 68
zaleplon 71
ZARAH 58
ZAVESCA 48
ZELBORAF 25
ZEMPLAR 60
zenatane 48
ZENCHENT 58
ZENPEP 48
zenzedi 44
zidovudine 29
ziprasidone hcl 15,28
ZIRGAN 30
ZOLINZA 25
zolmitriptan 22
zolpidem tartrate 71
ZOMIG 22
zonisamide 13
ZORBTIVE 54
ZORTRESS 62
ZOVIA 1-35E 59
ZOVIA 1-50E 59
ZYDELIG 24
ZYFLO CR 68
ZYKADIA 25
ZYLET 65
ZYTIGA 24
ZYVOX 9
94
Category ListingAnalgesics 1
Anesthetics 5
Anti-Addiction/Substance Abuse Treatment Agents 5
Anti-inflammatory Agents 6
Antibacterials 8
Anticonvulsants 13
Antidementia Agents 16
Antidepressants 16
Antiemetics 18
Antifungals 19
Antigout Agents 21
Antimigraine Agents 21
Antimyasthenic Agents 22
Antimycobacterials 22
Antineoplastics 23
Antiparasitics 26
Antiparkinson Agents 26
Antipsychotics 27
Antispasticity Agents 28
Antivirals 29
Anxiolytics 32
Bipolar Agents 33
Blood Glucose Regulators 33
Blood Products/Modifiers/ Volume Expanders 35
Cardiovascular Agents 36
Central Nervous System Agents 44
Dental and Oral Agents 46
Dermatological Agents 46
Enzyme Replacement/ Modifiers 48
Gastrointestinal Agents 48
Genitourinary Agents 51
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) 52
Hormonal Agents, Stimulant/Replacement/Modifying (Other) 53
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) 53
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) 54
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) 59
Hormonal Agents, Suppressant (Adrenal) 60
Hormonal Agents, Suppressant (Parathyroid) 60
Hormonal Agents, Suppressant (Pituitary) 60
Hormonal Agents, Suppressant (Sex Hormones/Modifiers) 61
Hormonal Agents, Suppressant (Thyroid) 61
Immunological Agents 61
95
Inflammatory Bowel Disease Agents 63
Metabolic Bone Disease Agents 63
Miscellaneous 63
Ophthalmic Agents 64
Otic Agents 66
Respiratory Tract Agents 67
Skeletal Muscle Relaxants 70
Sleep Disorder Agents 71
Therapeutic Nutrients/ Minerals/ Electrolytes 71
96