Preferred
Drug List (PDL)
Maryland
Effective Date: 4/1/17
© 2017 United Healthcare Services, Inc. All rights reserved.
Listing of Preferred Drugs
INTRODUCTION
PREFACE
UnitedHealthcare Community Plan is pleased to provide
this Listing of Preferred Drugs to be used when
prescribing for patients covered by the pharmacy benefit
plan offered by UnitedHealthcare Community Plan. The
drugs listed in this Listing of Preferred Drugs are intended
to provide sufficient options to treat patients who require
treatment with a drug from that pharmacologic or
therapeutic class. The drugs listed in the UnitedHealthcare
Community Plan Listing of Preferred Drugs have been
reviewed and approved by the Pharmacy and Therapeutics
Committee. The drugs have been selected to provide the
most clinically appropriate and cost-effective medications
for patients who have their drug benefit administered
through UnitedHealthcare Community Plan. It is also
recognized there may be occasions where an unlisted drug
is desired for proper medical management of a specific
patient. In those infrequent instances, the unlisted
medication may be requested through the prior
authorization process.
UnitedHealthcare Community Plan assumes no
responsibility for the actions or omissions of any medical
provider based upon reliance, in whole or in part, on the
information contained herein. The medical provider should
consult the drug manufacturer’s product literature or
standard references for more detailed information.
National guidelines can be found on the Web sites listed in
the Web site section or go to the National Guideline
Clearinghouse site at http://www.guideline.gov.
The UnitedHealthcare Community Plan Listing of
Preferred Drugs is organized by sections. Each section
includes therapeutic groups identified by either a drug class
or disease state.
Products are listed by generic name. Brand names are
included as a reference to assist in product recognition.
Unless exceptions are noted, generally all applicable
dosage forms and strengths of the drug cited are included in
the Listing of Preferred Drugs. Generics should be
considered the first line of prescribing.
The drugs represented have been reviewed by the
Pharmacy and Therapeutics (P&T) Committee and are
approved for inclusion. The Listing of Preferred Drugs is
reflective of current medical practice as of the date of
review.
The UnitedHealthcare Community Plan Listing of
Preferred Drugs covers selected over-the-counter (OTC)
products. You are encouraged to prescribe OTC
medications when clinically appropriate.
This edition incorporates drugs added to the Listing of
Preferred Drugs since the last edition as well as numerous
revisions to the prescribing information based on changes
in pharmacotherapy. Comments and suggestions from
practicing physicians have also been incorporated to ensure
that the UnitedHealthcare Community Plan Listing of
Preferred Drugs is reflective of current medical practice.
PHARMACY AND THERAPEUTICS (P&T)
COMMITTEE
The P&T Committee includes physicians and pharmacists
who are not employees or agents of UnitedHealthcare
Community Plan or its affiliates. They must adhere to the
Ethics Policy standards of the P&T Committee.
UnitedHealthcare Community Plan medical directors and
pharmacists also participate in the P&T Committee. The
P&T Committee meets quarterly to discuss a variety of
issues. Those issues pertaining to pharmaceutical selection
and pharmacy program management are communicated
quarterly. This newsletter is distributed to all participating
physicians who have received the preferred drug listing.
Preferred drug listing decisions are also communicated
quarterly on the UnitedHealthcare Community Plan internet
site.
NOTICE
The information contained in this Listing of Preferred
Drugs and its appendices is provided by UnitedHealthcare
Community Plan, solely for the convenience of medical
providers. UnitedHealthcare Community Plan does not
warrant or assure accuracy of such information nor is it
intended to be comprehensive in nature.
This Listing of Preferred Drugs is not intended to be a
substitute for the knowledge, expertise, skill and judgment
of the medical provider in their choice of prescription
drugs.
i
OUTPATIENT PRESCRIPTION DRUG
BENEFIT-COVERED MEDICATIONS
Extended-release and delayed-release products
require their own entry.
Medically necessary outpatient prescription drugs are
covered when prescribed by a provider licensed to
prescribe federal legend drugs or medicines. Some items
are covered only with prior authorization. Eligibility for
Outpatient Prescription Drug Benefits and copays are based
on the individual member’s benefit plan.
diltiazem sustained release CARDIZEM SR
Dosage forms covered will be consistent with the
category and use where listed.
Neomycin/polymixin B/ Cortisporin
Hydrocortisone
PRODUCT SELECTION CRITERIA
The P&T Committee considers clinical information on
new-to-market drugs that are typically included in an
outpatient pharmacy benefit. The evaluation includes all or
part of the following:
• Safety
• Efficacy
• Comparison studies
• Approved indications
• Adverse effects
• Contraindications/Warnings/Precautions
• Pharmacokinetics
• Patient administration/compliance considerations
• Medical outcome and pharmacoeconomic
studies
As listed in the OTIC section, this is limited to the otic
solution and suspension. From this entry the ophthalmic
solution and ointment, and the topical cream cannot be
assumed to be on the list unless there are entries for these
products in the OPHTHALMIC and DERMATOLOGY
sections of the Listing of Preferred Drugs.
When a strength or dosage form is specified, only the
specified strength and dosage form is on the Listing of
Preferred Drugs. Other strengths/dosage forms of the
reference product are not
cefixime (400mg tabs only)
GENERIC SUBSTITUTION
When a new drug is considered for inclusion, it will be
reviewed relative to similar drugs currently included in the
UnitedHealthcare Community Plan Listing of Preferred
Drugs. This review process may result in deletion of
drug(s) in a particular therapeutic class in an effort to
continually promote the most clinically useful and costeffective agents.
The UnitedHealthcare Community Plan Listing of
Preferred Drugs requires generic substitution on the
majority of products when a generic equivalent is available.
Generic substitution is a pharmacy action whereby a
generic equivalent is dispensed rather than the brand name
product. The PDL indicates generic availability in the
“Covered Drug” column.
All the information in the Listing of Preferred Drugs is
provided as a reference for drug therapy selection. Specific
drug selection for an individual patient rests solely with the
prescriber.
If a brand name drug is medically necessary, please submit
a prior authorization request.
The UnitedHealthcare Community Plan MAC list sets a
ceiling price for the reimbursement of certain multisource
prescription drugs. This price will typically cover the
acquisition of most generics but not branded versions of the
same drug. The products selected for inclusion on the
MAC list are commonly prescribed and dispensed and have
usually gone through the FDA’s review and approval
process.
An important consideration for generic substitution is the
knowledge that all approvals of generic drugs by the FDA
since 1984, and many generic approvals prior to 1984, have
a showing of bioequivalence between the generic versions
and the reference brand product. To gain FDA approval:
LISTING OF PREFERRED DRUGS PRODUCT
DESCRIPTIONS
To assist in understanding which specific strengths and
dosage forms are covered on the Listing of Preferred
Drugs, examples are noted below. The general principles
shown in the examples can then usually be extended to
other entries in the book. Any exceptions are noted in the
drug list. There may also be a statement associated with a
drug list that gives additional information about which
specific products or dosage forms are covered.
Products covered include all strengths associated
with the dosage form of the cited brand name
product.
carvedilol
SUPRAX
1. The generic drug must contain the same active
ingredient(s), be the same strength and the same dosage
form as the brand name product.
Coreg
All strengths of Coreg would be covered by this listing.
2. The FDA has given the generic an “A” rating compared
to the branded product indicating bioequivalence, and
ii
has determined the generic is therapeutically equivalent
to the reference brand. The ratings of generic drugs are
available by referring to the FDA reference, Approved
Drug Products with Therapeutic Equivalence
Evaluations (Orange Book).
• Agents used for erectile dysfunction
• Agents used for cosmetic hair growth
• Drugs from manufacturers that do not participate
in the FFS Medicaid Drug Rebate Program
• Diagnostic products
• Medical supplies and DME except as listed:
insulin syringes, insulin needles, lancets, alcohol
swabs, spacers, preferred diabetes test strips, peak
flow meters (Astech, Assess, Peak Air brands,
max two per year), vaporizer (limit of 1 per 3
years), humidifier (limit of 1 per 3 years)
When the above two criteria are met, a generic can be
substituted with the full expectation that the substituted
product will produce the same clinical effect and safety
profile as the prescribed product. Drug products that have a
narrow therapeutic index (NTI) can also be guided by these
principles. It is not necessary for the health care provider to
approach any one therapeutic class of drug products (e.g.,
NTI drugs) differently from any other class, when there has
been a determination of therapeutic equivalence by the
FDA for the drug products under consideration. Also,
additional clinical tests or examinations by the physician
are not needed when a therapeutically equivalent generic
drug product is substituted for the brand name product.
DAYS SUPPLY DISPENSING LIMITATIONS
UnitedHealthcare Community Plan members may receive
up to a one month supply of a specific medication per
prescription order or prescription refill. A medication may
be reordered or refilled when eighty-five percent (85%) of
the medication has been utilized. If a claim is submitted
before 85% of the medication has been used, based on the
original day supply submitted on the claim, the claim will
reject with a "refill too soon" message.
There are now many brand name products that are
repackaged or distributed under a generic label. The generic
label version should always be considered therapeutically
equivalent and substitutable for the source branded product.
MANDATORY GENERIC SUBSTITUTION
The UnitedHealthcare Community Plan Listing of
Preferred Drugs requires mandatory generic substitution on
the vast majority of products when a generic equivalent is
available; however, brand name drugs may be covered in
certain situations by requesting a prior authorization. The
UnitedHealthcare Community Plan Listing of Preferred
Drugs prior authorization (PA) list does not include
branded items where a generic equivalent is covered.
DRUG EFFICACY STUDY IMPLEMENTATION
(DESI) DRUGS
Drugs first marketed between 1938 and 1962 were
approved as safe but required no showing of effectiveness
for FDA approval. Beginning in 1962, all new drugs were
required to be both safe and effective before they could be
marketed. This legislation also applied retroactively to all
drugs approved as safe from 1938-1962. The DESI
program was established by the FDA to review the
effectiveness of these pre-1962 drugs for their labeled
indications, and a determination of “fully effective” was
made for most of these products and they remain in the
marketplace. A few DESI products remain classified as
“less than fully effective” while awaiting final
administrative disposition. Also, classified as DESI are
many products listed as identical, similar, or related to
actual DESI products. UnitedHealthcare Community
Plan’s Listing of Preferred Drugs does not cover DESI
“less than fully effective” drug products.
PRIOR AUTHORIZATION OF NON-LISTING OF
PREFERRED DRUGS MEDICATIONS
The drugs in the UnitedHealthcare Community Plan Listing
of Preferred Drugs have been selected to provide the most
clinically appropriate and cost-effective medications for
patients who have their drug benefit administered through
UnitedHealthcare Community Plan. It is also recognized
that there may be occasions where an unlisted drug is
desired for the proper medical management of a specific
patient. In those infrequent instances, the prior
authorization process reviews requests for unlisted
medications the physician may consider medically
necessary for patient management.
Requests for these exceptions should be either made in
writing by the physician and faxed or called into:
PLAN EXCLUSIONS
The following drug categories are excluded from coverage
under the outpatient pharmacy benefit and are not part of
the UnitedHealthcare Community Plan Listing of Preferred
Drugs.
UnitedHealthcare Community Plan
Pharmacy Services Department
Fax 866-940-7328
Phone 800-310-6826
• DESI drugs
• Anti-obesity agents
• Experimental / research drugs
• Cosmetic drugs
• Nutritional / diet supplements
• Blood and blood plasma products
• Agents used to promote fertility
A prior authorization request form is available in the
UnitedHealthcare Community Plan provider manual and
should be used for all prior authorization requests if
possible. Appropriate documentation must be provided to
support the medical necessity of the non-preferred drug
request. The UnitedHealthcare Community Plan Pharmacy
iii
You may fill any FOUR medications from the following
classes in a 30-day period:
• opiate analgesics
• select muscle relaxants
Additional fills will require prior authorization.
Medications in these classes may also be subject to
individual quantity limits.
Department will respond to all requests in accordance with
state requirements.
Physicians are requested to adhere to this Listing of
Preferred Drugs when prescribing for patients covered by
their pharmacy benefit plan offered by UnitedHealthcare
Community Plan. If a pharmacist receives a prescription
for a non-preferred drug, the pharmacist should contact the
prescribing physician and request that the prescription be
changed to a medication included in this Listing of
Preferred Drugs. If a preferred alternative is not
appropriate the physician should then be instructed to
contact the Plan for a prior authorization.
Additions to the QL program drug list will be made from
time to time and providers notified accordingly. As always,
we recognize that a number of patient-specific variables
must be taken into consideration when drug therapy is
prescribed and therefore overrides will be available through
the medical exception (prior authorization) process. Please
contact the UnitedHealthcare Community Plan Pharmacy
Prior Notification Service at 800-310-6826 with questions.
Please contact the UnitedHealthcare Community Plan
Pharmacy Services Department at 800-310-6826 with
questions concerning the prior authorization process.
Specialty Pharmaceutical Management Program
UnitedHealthcare Community Plan is continuously looking
for ways to provide high quality cost effective care for Plan
members. The Specialty Pharmaceutical Management
Program helps UnitedHealthcare Community Plan to
achieve these goals. Injectable medications that are part of
this program require plan authorization and are not
available through the retail pharmacy network.
To obtain authorization, the provider must submit the
appropriate Prior Authorization form to the
UnitedHealthcare Community Plan Pharmacy Department
via fax at
866-940-7328.
The UnitedHealthcare Community Plan Pharmacy
Department will review and respond to all requests in
accordance with state requirements, and if authorized for
payment, UnitedHealthcare Community Plan will
coordinate the delivery of the product to the member or
provider.
Drugs that are part of this program and are on the Listing of
Preferred Drugs are identified in this booklet by the
designation "SP".
Prior Authorization request forms can be requested by
calling the UnitedHealthcare Community Plan Pharmacy
Department at 800-310-6826.
NON-PREFERRED DRUGS 5-DAY TEMPORARY
SUPPLY OVERRIDES
To ensure the use of PDL drugs, all non- PDL drugs should
be discussed with the prescribing physician. If you cannot
speak to the physician immediately, and there is an
immediate need for the medication, the claim processing
system will accept an override to permit a one-time
dispensing of a 5-day supply of the newly prescribed
non-PDL drug. The pharmacy should submit a claim for a
5 day supply, with a PA Type of 8 and Prior Authorization
number of “00000000120”. Please note that non-preferred
drugs are available for a 5-day supply, however availability
is subject to the benefit design. For assistance, pharmacies
may call 800-310-6826.
The pharmacy should contact the physician to discuss a
non-preferred drug or if a prior authorization request is
warranted. If the prescribing physician feels a drug is
medically necessary, the physician may fax a request for
prior authorization to UnitedHealthcare Community Plan at
800-310-6826.
QUANTITY LIMITATIONS (QL)
Prescriptions for monthly quantities greater than the
indicated limit require a prior authorization request.
Quantity limits based on Efficient Medication Dosing
The Efficient Medication Dosing Program is designed to
consolidate medication dosage to the most efficient daily
quantity to increase adherence to therapy and also promote
the efficient use of health care dollars.
The limits for the program are established based on FDA
approval for dosing and the availability of the total daily
dose in the least amount of tablets or capsules daily.
Quantity Limits in the prescription claims processing
system will limit the dispensing to consolidate dosing. The
pharmacy claims processing system will prompt the
pharmacist to request a new prescription order from the
physician.
STEP THERAPY (ST)
The following preferred drugs are routinely covered only
after a sufficient trial of an indicated first-line agent has
been adequately tried and failed. These medications may
also be requested through the Prior authorization process.
While lower cost preferred alternatives may be appropriate
in many instances, other non-preferred alternatives are
available with prior authorization (PA).
STEP Drug
Controlled Substances
iv
First-Line Agent(s)
Amerge
Trial at a minimum dose of 50mg of
sumatriptan tablets.
Aricept 23mg
90 day trial of Aricept 10mg daily
Breo Ellipta
tacrolimus 0.03%Trial of two different topical
corticosteroids. Step therapy only applies
to members 12 years of age and older.
1) 30 day trial of one inhaled
corticosteroid (e.g. Arnuity Ellipta,
Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta,
Striverdi) OR 60 day trial of an orally
inhaled anticholinergic agent (e.g. Incruse
Ellipta, Atrovent, Combivent, Anoro
Ellipta).
calcipotriene
cream & oint
0.005%
Trial of two topical corticosteroids
calcitriol
3mcg/gm
Trial of two topical corticosteroids
Ditropan XL
30 day trial of oxybutynin immediate
release. Step Therapy only applies to
members less than 65 years of age.
tacrolimus 0.1% Minimum age of 16. Trial of two
different topical corticosteroids.
DPP4 Inhibitors At least a 90 day trial of 1500mg/day of
(Nesina,
metformin.
Kazano, Oseni)
Dulera
Trial of two different topical
corticosteroids. Step therapy only applies
to members 12 years of age and older.
fenofibrate
Fill of a statin or 90 days of gemfibrozil
within the previous 180 days.
Trial of one drug from the following
classes: beta blockers, calcium channel
blockers, long acting nitrates
Renvela
8 week trial of calcium acetate
trospium
30 day trial of oxybutynin immediate
release. Step Therapy only applies to
members less than 65 years of age.
Uloric
8 week trial of up to 600mg of
allopurinol required first.
Vancocin
One fill of metronidazole tabs or caps
LISTING OF PREFERRED DRUGS SUGGESTIONS
Providers who wish to propose Listing of Preferred Drugs
suggestions should forward the information to the
UnitedHealthcare Community Plan Director of Pharmacy
Services by either mail or fax.
UnitedHealthcare Community Plan
Pharmacy Services Department
2 Allegheny Center
Suite 600
Pittsburgh, PA 15212
Fax 866-940-7328
Phone 800-310-6826
Email [email protected]
Providers should furnish adequate documentation, such as
clinical studies from the medical literature, in order for the
request to be considered for Listing of Preferred Drugs
addition. This literature should include information
documenting clinical necessity as well as therapeutic
advantages over current Listing of Preferred Drugs
products. Suggestions received by UnitedHealthcare
Community Plan will be reviewed by the Pharmacy and
Therapeutics Committee at the subsequent P&T Committee
meeting.
GLP-1 Agonists At least a 90 day trial of 1500mg/day of
(Tanzeum,
metformin
Victoza)
Optivar
14 day trial of ketotifen within previous
90 days required first.
Ranexa
30 day trial of oxybutynin immediate
release. Step Therapy only applies to
members less than 65 years of age.
Xopenex Respules 30 day trial of Albuterol .083% or .5%
respules.
1) 30 day trial of one inhaled
corticosteroid (e.g. Arnuity Ellipta,
Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta,
Striverdi) OR 60 day trial of an orally
inhaled anticholinergic agent (e.g. Incruse
Ellipta, Atrovent, Combivent, Anoro
Ellipta).
Elidel
tolterodine
SGLT-2
At least a 90 day trial of 1500mg/day of
Inhibitors
metformin
(Jardiance, Invokana,
Invokamet, Invokamet XR,
Synjardy, Synjardy XR)
v
EDITOR
NOTICE
Your comments and suggestions regarding the
UnitedHealthcare Community Plan Listing of Preferred
Drugs are encouraged. Your input is vital to this Listing of
Preferred Drugs’ continued success. All responses will be
reviewed and considered. Please send your comments to:
The information contained in this document is proprietary
information. The information may not be copied in whole
or in part without the written permission of
UnitedHealthcare Community Plan. All rights reserved.
The drug names listed here are the registered and/or
unregistered trademarks of third-party pharmaceutical
companies unrelated to and unaffiliated with
UnitedHealthcare Community Plan. These trademarked
brand names are included here for informational purposes
only and are not intended to imply or suggest any
affiliation between UnitedHealthcare Community Plan and
such third-party pharmaceutical companies.
UnitedHealthcare Community Plan
Pharmacy Services Department
2 Allegheny Center
Suite 600
Pittsburgh, PA 15212
Fax 866-940-7328
LEGEND
#
Only the dosage forms/strengths of the brand
name products noted are on the Listing of
Preferred Drugs
OTC
over-the-counter
delayed-rel delayed-release (also known as enteric coated)
EC
enteric-coated
ext-rel
extended-release (also known as sustainedrelease)
PA
Prior Authorization required
QL
Quantity Limits apply
ST
Step Therapy, see pages V-VI for details
SP
Specialty Pharmaceuticals, see pages IV-V for
details
If viewing this Listing of Preferred Drugs via the Internet,
please be advised that the Listing of Preferred Drugs is
updated periodically and changes may appear prior to their
effective date to allow for notification.
Mental health agents, specific anticonvulsants,
antiretroviral agents, nicotine replacement products,
and substance abuse deterrents are carved out of the
UnitedHealthcare Community Plan drug benefit and
are paid by the Department of Health and Mental
Hygiene (DHMH) Maryland Pharmacy Program. Refer
to the Maryland Medicaid Mental Health Preferred
Drug List for a complete listing
https://dhmh.maryland.gov/pap/Pages/paphome.aspx
vi
Table of Contents
Antineoplastics & Immunosuppressants . . . 4
Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4
Hormonal Antineoplastic Agents . . . . . . . . . . . . . 5
Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 5
Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 6
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . 14
Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 15
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 16
Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Scabies and Pediculosis . . . . . . . . . . . . . . . . . . 16
Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Blood Modifiers - Anticoagulants . . . . . . . . . 6
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Blood Cell Formation . . . . . . . . . . . . . . . . . . . . . . . 7
Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . . 18
Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 19
Cardiovascular Agents . . . . . . . . . . . . . . . . . 7
Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Ace Inhibitor/Diuretic Combinations . . . . . . . . . . 8
Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 8
Alpha Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Angiotensin II Receptor Blockers (Antagonists) . 8
Angiotensin II Receptor Blocker Combinations . 8
Antiarrhythmics and Cardiac Glycosides . . . . . . 8
Beta Blockers and Beta Blocker/Diuretic
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Calcium Channel Blockers . . . . . . . . . . . . . . . . . . 9
Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 10
Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Potassium-Removing Agents . . . . . . . . . . . . . . 11
Pulmonary Arterial Hypertension . . . . . . . . . . . 11
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Endocrinology . . . . . . . . . . . . . . . . . . . . . . . 19
Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 19
Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 20
Growth Stimulating Agents . . . . . . . . . . . . . . . . 21
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . 22
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . 22
Constipation/Laxatives . . . . . . . . . . . . . . . . . . . 22
Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Emesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Gastroesophageal Reflux Disease (Gerd)/
Peptic Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . 24
Inflammatory Bowel Disease . . . . . . . . . . . . . . . 24
Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 24
Probiotic Supplementation . . . . . . . . . . . . . . . . 24
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Central Nervous System . . . . . . . . . . . . . . . 11
Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 11
Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 13
Migraine Prophylactic Therapy . . . . . . . . . . . . . 13
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . 13
Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . 14
Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 14
Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Infectious Diseases . . . . . . . . . . . . . . . . . . . 25
Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Antiprotozoals . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2
Musculoskeletal . . . . . . . . . . . . . . . . . . . . . . 28
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 29
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Vitamins and Minerals . . . . . . . . . . . . . . . . . 40
Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 42
Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 42
Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 42
Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 43
Immune Thrombocytopenic Purpura . . . . . . . . 43
Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . 43
Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . 43
Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Hormone Therapy/Menopause . . . . . . . . . . . . 31
Vaginal Infections . . . . . . . . . . . . . . . . . . . . . . . . 31
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 32
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Immunologic Agents . . . . . . . . . . . . . . . . . . . . . 33
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
OTC MEDICATIONS . . . . . . . . . . . . . . . . . . . 45
Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 45
Cough/Cold Allergy . . . . . . . . . . . . . . . . . . . . . . 45
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Earwax Removal Products . . . . . . . . . . . . . . . . 46
Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 46
First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 48
Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Psychiatric . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Narcotic Antagonist . . . . . . . . . . . . . . . . . . . . . . 34
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Respiratory Drugs . . . . . . . . . . . . . . . . . . . . 34
Antitussives, Decongestants, Expectorants and
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . 34
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Symptomatic Benign Prostatic Hypertrophy . . 39
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Index of Covered Drugs . . . . . . . . . . . . . . . . 49
3
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Antineoplastics & Immunosuppressants
Antineoplastic Agents
Alkylating Agents
altretamine
busulfan
chlorambucil
cyclophosphamide
estramustine
phosphate sodium
lomustine
melphalan
temozolomide
HEXALEN
MYLERAN
LEUKERAN
CYTOXAN
GLEOSTINE
ALKERAN
TEMODAR
brand
brand
generic
capecitabine
mercaptopurine
thioguanine
trifluridine/tipiracil
XELODA
PURINETHOL
TABLOID
LONSURF
generic
generic
brand
brand
QL
PA, SP
panobinostat
vorinostat
FARYDAK
ZOLINZA
brand
brand
PA, SP
PA, SP
afatinib
alectinib
axitinib
bosutinib
GILOTRIF
ALECENSA
INLYTA
BOSULIF
CABOMETYX
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
brand
PA, SP
brand
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
brand
PA, SP
brand
brand
brand
generic
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, QL, SP
PA, SP
PA, SP
PA, SP
PA, SP
Antimetabolites
brand
brand
brand
generic
EMCYT
brand
Histone Deacetylase Inhibitors
Kinase Inhibitor
cabozantinib
ceritinib
cobimetinib
crizotinib
dabrafenib
dasatinib
erlotinib
everolimus
gefitinib
ibrutinib
idelalisib
imatinib mesylate
lapatinib ditosylate
lenvatinib
nilotinib
palbociclib
COMETRIQ
ZYKADIA
COTELLIC
XALKORI
TAFINLAR
SPRYCEL
TARCEVA
AFINITOR
AFINITOR DISPERZ
IRESSA
IMBRUVICA
ZYDELIG
GLEEVEC
TYKERB
LENVIMA
TASIGNA
IBRANCE
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
4
PA, SP
SP
Generic Drug Name
Brand Drug Name
pazopanib
ponatinib
regorafenib
ruxolitinib
sorafenib
sunitinib
trametinib
vandetanib
vemurafenib
VOTRIENT
ICLUSIG
STIVARGA
JAKAFI
NEXAVAR
SUTENT
MEKINIST
CAPRELSA
ZELBORAF
Covered
Drug
brand
brand
brand
brand
brand
brand
brand
brand
brand
leucovorin
mesna
venetoclax
LEUCOVORIN
MESNEX
VENCLEXTA
generic
brand
brand
QL, tabs
SP, tablets
PA, SP
ixazomib
NINLARO
brand
PA, SP
abiraterone
ZYTIGA
brand
PA, SP
bicalutamide
flutamide
CASODEX
EULEXIN
generic
generic
tamoxifen
toremifene
NOLVADEX
FARESTON
generic
brand
anastrozole
exemestane
letrozole
ARIMIDEX
AROMASIN
FEMARA
generic
generic
generic
leuprolide
LUPRON
LUPRON DEPOT
generic
PA, SP
leuprolide
LUPRON DEPOT 6-MONTH
brand
PA, SP
Miscellaneous
Proteasome Inhibitors
Hormonal Antineoplastic Agents
Androgen Biosynthesis Inhibitors
Antiandrogens
Antiestrogens
Aromatase Inhibitors
Gonadotropin Releasing Hormone Analog
Progestin
Requirements & Limits
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
LUPRON DEPOT-PED
megestrol acetate
MEGACE
interferon alfa-2b
peginterferon alfa-2b
INTRON A
SYLATRON
brand
brand
PA, SP
PA, SP
lenalidomide
pomalidomide
REVLIMID
POMALYST
brand
brand
PA, SP
PA, SP
Immunomodulators
Interferons
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
ST = Step Therapy
SP = Specialty Pharmacy
5
Generic Drug Name
Brand Drug Name
thalidomide
THALOMID
Covered
Drug
brand
azathioprine
mycophenolate mofetil
mycophenolate sodium
IMURAN
CELLCEPT
MYFORTIC
generic
generic
generic
cyclosporine
SANDIMMUNE
NEORAL
generic
Immunosuppressants
Antimetabolites
Calcineurin Inhibitors
cyclosporine, modified
tacrolimus
Rapamycin Derivative
Requirements & Limits
PA, QL
generic
GENGRAF
HECORIA
caps, QL
generic
PROGRAF
sirolimus
sirolimus
RAPAMUNE
RAPAMUNE
generic
brand
everolimus
ZORTRESS
brand
alitretinoin 1% gel
bexarotene caps and
topical gel
cysteamine bitartrate
etoposide
hydroxyurea
hydroxyurea
mitotane
octreotide
olaparib
pasireotide
procarbazine
sonidegib
topotecan
tretinoin
vismodegib
PANRETIN
brand
PA
TARGRETIN
brand
PA
Miscellaneous
Miscellaneous
CYSTAGON
VEPESID
DROXIA
HYDREA
LYSODREN
SANDOSTATIN
LYNPARZA
SIGNIFOR
MATULANE
ODOMZO
HYCAMTIN
VESANOID
ERIVEDGE
tabs
soln
brand
generic
brand
generic
brand
generic
brand
brand
brand
brand
brand
generic
brand
PA, SP
PA, SP
PA, SP
PA, SP
caps
PA, SP
Blood Modifiers - Anticoagulants
Anticoagulants
apixaban
edoxaban
ELIQUIS
SAVAYSA
brand
brand
enoxaparin
LOVENOX
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
PA, QL, PA only applies for
quantities greater than
14 days
ST = Step Therapy
SP = Specialty Pharmacy
6
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
INJ 5000 UNIT/ML, PF
INJ 5000 UNIT/0.5ML, INJ
10000 UNIT/ML
heparin
HEPARIN
generic
rivaroxaban
warfarin
XARELTO
COUMADIN
brand
generic
darbepoetin alfa
ARANESP
EPOGEN
Blood Cell Formation
epoetin alfa
filgrastim
oprelvekin
pegfilgrastim
plerixafor
sargramostim
Platelet Inhibitors
anagrelide
aspirin
PROCRIT
ZARXIO
NEUMEGA
NEULASTA
MOZOBIL
LEUKINE
AGRYLIN
BAYER
cilostazol
clopidogrel
dipyridamole
ECOTRIN
PLETAL
PLAVIX
PERSANTINE
aminocaproic acid
AMICAR
Miscellaneous
deferasirox
pentoxifylline
extended-release
brand
PA, SP
brand
PA, SP
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
generic
generic
OTC
generic
generic
generic
QL
brand
EXJADE
500 mg tabs & syrup only
brand
JADENU
TRENTAL
generic
benazepril
captopril
enalapril
LOTENSIN
CAPOTEN
VASOTEC
generic
generic
generic
enalapril oral soln
EPANED
fosinopril
lisinopril
quinapril
MONOPRIL
ZESTRIL
ACCUPRIL
PA, SP
Cardiovascular Agents
Ace Inhibitors
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
generic
generic
generic
Members ≥ 8 years of age will
require prior authorization.
QL
QL
QL
ST = Step Therapy
SP = Specialty Pharmacy
7
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Ace Inhibitor/Diuretic Combinations
benazepril/
hydrochlorothiazide
captopril/
hydrochlorothiazide
enalapril/
hydrochlorothiazide
fosinopril/
hydrochlorothiazide
lisinopril/
hydrochlorothiazide
quinapril/
hydrochlorothiazide
LOTENSIN HCT
generic
CAPOZIDE
generic
VASERETIC
generic
MONOPRIL-HCT
generic
QL
ZESTORETIC
generic
QL
ACCURETIC
generic
QL
clonidine
guanfacine
CATAPRES
TENEX
generic
generic
tablets
doxazosin
prazosin
terazosin
CARDURA
MINIPRESS
HYTRIN
generic
generic
generic
losartan
COZAAR
generic
QL
losartan/HCTZ
HYZAAR
generic
QL
amiodarone tabs
digoxin
disopyramide
disopyramide
extended-release
dofetilide
flecainide
mexiletine
propafenone
quinidine gluconate
extended-release
quinidine sulfate
quinidine sulfate
extended-release
sotalol
CORDARONE
LANOXIN
NORPACE
generic
generic
generic
200 mg and 400 mg
NORPACE CR
brand
TIKOSYN
TAMBOCOR
MEXITIL
RYTHMOL
QUINIDINE GLUCONATE
EXT-REL
QUINIDINE SULFATE
QUINIDINE SULFATE
EXT-REL
BETAPACE
generic
generic
generic
generic
acebutalol
atenolol
SECTRAL
TENORMIN
generic
generic
Adrenolytics, Central
Alpha Blockers
Angiotensin II Receptor Blockers (Antagonists)
Angiotensin II Receptor Blocker Combinations
Antiarrhythmics and Cardiac Glycosides
generic
generic
generic
generic
Beta Blockers and Beta Blocker/Diuretic Combinations
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
8
IR only
Generic Drug Name
Brand Drug Name
atenolol/chlorthalidone
bisoprolol
bisoprolol/
hydrochlorothiazide
carvedilol
labetalol
metoprolol
metoprolol succinate
pindolol
propranolol
propranolol/HCTZ
timolol maleate
TENORETIC
ZEBETA
Covered
Drug
generic
generic
ZIAC
generic
COREG
TRANDATE
LOPRESSOR
TOPROL XL
PINDOLOL
INDERAL
INDERIDE
generic
generic
generic
generic
generic
generic
generic
generic
amlodipine
felodipine
extended-release
nicardipine
nifedipine
nifedipine
extended-release
nimodipine
nimodipine oral soln
NORVASC
generic
QL
PLENDIL
generic
QL
CARDENE
PROCARDIA
ADALAT CC
generic
generic
diltiazem
diltiazem
extended-release
diltiazem
extended-release
diltiazem
sustained-release
verapamil
verapamil
extended-release
CARDIZEM
generic
CARDIZEM CD
generic
QL
generic
QL
CARDIZEM SR
generic
QL
CALAN
generic
CALAN SR
generic
amiloride
amiloride/
hydrochlorothiazide
bumetanide
chlorothiazide
MIDAMOR
generic
MODURETIC
generic
BUMEX
DIURIL
DIURIL ORAL
SUSPENSION
CHLORTHALIDONE
generic
generic
Calcium Channel Blockers
Dihydropyridines
Nondihydropyridines
Diuretics
chlorothiazide
chlorthalidone
PROCARDIA XL
NIMOTOP
NYMALIZE
DILACOR XR
TIAZAC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
Requirements & Limits
QL
25, 50, 100mg tablets
tablets
generic
QL
generic
brand
QL
brand
generic
ST = Step Therapy
SP = Specialty Pharmacy
9
IR only
QL
QL
Generic Drug Name
Brand Drug Name
furosemide
hydrochlorothiazide
hydrochlorothiazide
indapamide
metolazone
spironolactone
spironolactone/
hydrochlorothiazide
torsemide
triamterene/
hydrochlorothiazide
LASIX
HYDROCHLOROTHIAZIDE
MICROZIDE
LOZOL
ZAROXOLYN
ALDACTONE
Covered
Drug
generic
generic
generic
generic
generic
generic
ALDACTAZIDE
generic
DEMADEX
DYAZIDE
generic
Lipid Lowering Agents
Bile Acid Resin
cholestyramine
Fibrates
QUESTRAN
generic
QUESTRAN-LIGHT
LOFIBRA
LOPID
generic
generic
atorvastatin
lovastatin
simvastatin
LIPITOR
MEVACOR
ZOCOR
generic
generic
generic
niacin
niacin extended-release
NIACOR
NIASPAN
generic
generic
HMG-CoA Reductase Inhibitors and Combinations
Miscellaneous
alirocumab
PRALUENT
ezetimibe
ZETIA
omega 3 acid ethyl esters LOVAZA
Nitrates
Oral
ISORDIL
ISOSORBIDE
DINITRATE ER
ISMO
generic
IMDUR
generic
isosorbide dinitrate
ISORDIL S.L.
NITROLINGUAL
generic
nitroglycerin
generic
generic
generic
NITROSTAT
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
Only the bulk products are
covered (cans). Individual
packets are not covered.
brand
generic
generic
isosorbide dinitrate
isosorbide dinitrate
extended-release
isosorbide mononitrate
isosorbide mononitrate
extended-release
Sublingual
soln, tabs
12.5 mg caps
generic
MAXZIDE
fenofibrate
gemfibrozil
Niacins
Requirements & Limits
ST = Step Therapy
SP = Specialty Pharmacy
10
ST
QL
QL
PA, QL, SP
PA
PA
Generic Drug Name
Transdermal
nitroglycerin
nitroglycerin
Brand Drug Name
NITREK
NITRO-DUR
NITRO-BID
Potassium-Removing Agents
Covered
Drug
Requirements & Limits
generic
transdermal, QL
generic
oint
brand
PA
generic
susp only
patiromer
sodium polystyrene
sulfonate
VELTASSA
ambrisentan
bosentan
macitentan
riociguat
sildenafil
LETAIRIS
TRACLEER
OPSUMIT
ADEMPAS
REVATIO
brand
brand
brand
brand
generic
PA, SP
PA, SP
PA,SP
PA, SP
PA
guanabenz
hydralazine
methyldopa
methyldopa/HCTZ
midodrine
minoxidil
ranolazine
WYTENSIN
APRESOLINE
ALDOMET
ALDORIL
PROAMATINE
LONITEN
RANEXA
generic
generic
generic
generic
generic
generic
brand
ST
KAYEXALATE
Pulmonary Arterial Hypertension
Miscellaneous
Central Nervous System
Alzheimer’s Disease
donepezil
ARICEPT
generic
donepezil
ARICEPT
generic
galantamine
RAZADYNE
generic
memantine
NAMENDA
generic
rivastigmine
EXELON
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
5 mg and 10 mg, QL,
Members <18 years of age
will require prior authorization.
23 mg, ST, Members <18
years of age will require prior
authorization.
QL, Members <18 years
of age will require prior
authorization.
QL, Members <18 years
of age will require prior
authorization.
QL, Members <18 years
of age will require prior
authorization.
ST = Step Therapy
SP = Specialty Pharmacy
11
Generic Drug Name
Brand Drug Name
Analgesics
Barbiturate Non-Narcotic Analgesics
butalbital/acetaminophen PHRENILIN
butalbital/acetaminophen SEDAPAP
ESGIC
butalbital/acetaminophen/
FIORICET
caffeine
ZEBUTAL
butalbital/aspirin/caffeine FIORINAL
Non-Narcotic Analgesics
Covered
Drug
Requirements & Limits
generic
generic
QL
QL
generic
QL
generic
QL
acetaminophen
aspirin/acetaminophen/
caffeine
tramadol
TYLENOL
generic
OTC
EXCEDRIN MIGRAINE
generic
250-250-65 mg, OTC
ULTRAM
generic
QL
etodolac
LODINE
generic
ibuprofen
ADVIL
generic
ibuprofen
MOTRIN
generic
IR Only
tabs, chew tabs
and susp, OTC
tabs, chew tabs
and susp
NSAIDS
INDOCIN
ORUDIS
TORADOL
MOBIC
RELAFEN
NAPROSYN
ENTERIC COATEDnaproxen delayed release
NAPROSYN
oxaprozin
DAYPRO
piroxicam
FELDENE
sulindac
CLINORIL
indomethacin
ketoprofen
ketorolac tromethamine
meloxicam
nabumetone
naproxen
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
Opioids - Narcotic Analgesics
butalbital/apap/caff/cod
butalbital/asa/caff/cod
butorphanol
codeine/acetaminophen
codeine sulfate
fentanyl transdermal
FIORICET W/CODEINE
FIORINAL W/CODEINE
STADOL
TYLENOL W/CODEINE
DURAGESIC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
IR only
QL
QL
generic
generic
generic
generic
generic
generic
QL, 50-325-40-30 mg
QL
nasal spray, QL
QL
QL
PA, QL
ST = Step Therapy
SP = Specialty Pharmacy
12
Covered
Drug
Requirements & Limits
generic
QL
brand
generic
generic
PA
QL
QL
generic
QL
MS CONTIN
generic
PA, QL
OXYFAST
ROXICODONE
generic
generic
soln, QL
QL
PERCOCET
generic
5/325, QL
PERCODAN
OXYMORPHONE ER
TALWIN NX
generic
generic
generic
QL
PA, QL, non-crush resistant
QL
dihydroergotamine
dihydroergotamine
ergotamine/caffeine
ergotamine tartrate/
caffeine
D.H.E. 45
MIGRANAL
CAFERGOT
MIGERGOT
SUPPOSITORIES
generic
generic
generic
inj, QL
brand
QL
naratriptan
rizatriptan
sumatriptan
AMERGE
MAXALT/MAXALT MLT
IMITREX
IMITREX
4 MG AND 6 MG INJ
generic
generic
generic
ST
QL
QL
generic
4 mg and 6 mg inj
propranolol
verapamil
INDERAL
CALAN
generic
generic
IR only
dimethyl fumarate
fingolimod
glatiramer acetate
TECFIDERA
GILENYA
COPAXONE 40MG
brand
brand
brand
PA, QL, SP
PA, QL, SP
40 mg, PA, QL, SP
Generic Drug Name
Brand Drug Name
LORCET
LORTAB
hydrocodone/
acetaminophen
LORTAB ELIXIR
NORCO
VICODIN
hydrocodone ER
hydromorphone
meperidine
morphine
morphine
extended-release
oxycodone
oxycodone
oxycodone/
acetaminophen
oxycodone/aspirin
oxymorphone ER
pentazocine/naloxone
Migraine Acute Therapy
Ergotamine Derivatives
VICODIN ES
ZOHYDRO ER
DILAUDID
DEMEROL
MSIR
RMS
Selective Serotonin Agonists
sumatriptan
Migraine Prophylactic Therapy
Multiple Sclerosis
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
13
Generic Drug Name
Brand Drug Name
glatiramer acetate
peginterferon beta-1a
teriflunomide
GLATOPA
PLEGRIDY
AUBAGIO
Covered
Drug
generic
brand
brand
pyridostigmine
pyridostigmine
pyridostigmine
extended-release
MESTINON
MESTINON
generic
brand
MESTINON TIMESPAN
generic
amantadine
benztropine
carbidopa/levodopa
carbidopa/levodopa
extended-release
entacapone
pramipexole
ropinirole
selegiline
tolcapone
trihexyphenidyl
SYMMETREL
COGENTIN
SINEMET
generic
generic
generic
SINEMET CR
generic
COMTAN
MIRAPEX
REQUIP
ELDEPRYL
TASMAR
ARTANE
generic
generic
generic
generic
generic
generic
phenobarbital
phenytoin
phenytoin sodium
extended
primidone
PHENOBARBITAL
DILANTIN INFATABS
generic
generic
DILANTIN, PHENYTEK
generic
MYSOLINE
generic
tetrabenazine
XENAZINE
generic
PA, SP
isotretinoin
ACCUTANE
generic
PA
azelaic acid
benzoyl peroxide
clindamycin
clindamycin
clindamycin
erythromycin
erythromycin
FINACEA
BENZAC AC
CLEOCIN T
CLEOCIN T
CLEOCIN T
ERYGEL
T-STAT
NEUTROGENA OIL FREE
ACNE WASH
brand
generic
generic
generic
generic
generic
generic
gel
gel
lotion
soln
gel 2%
soln
generic
liquid 2%, OTC
Myasthenia Gravis
Parkinson’s Disease
Seizure
Miscellaneous
Requirements & Limits
PA, QL, SP
PA, SP
PA, QL, SP
tabs
syrup
except tabs
tabs
Dermatology
Acne Vulgaris
Oral
Topical
salicylic acid
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
14
Generic Drug Name
Brand Drug Name
sulfacetamide/sulfur
sulfacetamide/sulfur
SULFACET-R
PLEXION
AVITA
tretinoin
Bacterial Infections
Covered
Drug
generic
generic
Requirements & Limits
lotion
generic
RETIN-A
bacitracin
gentamicin
mupirocin
neomycin/polymyxin B/
bacitracin
silver sulfadiazine
BACITRACIN
GENTAK
BACTROBAN
generic
generic
generic
ointment, 22 gram tube only
NEOSPORIN
generic
OTC
SILVADENE
generic
alclometasone
ACLOVATE
DERMA-SMOOTHE
OIL/FS
SYNALAR
CORTIZONE
HYTONE
HYTONE
CORTIZONE-10 INTENSIVE
HEALING
generic
0.05% crm/oint
generic
oil 0.01%
generic
generic
generic
generic
soln/crm 0.01%
crm, oint, lot OTC
crm 0.5%, 1%, & 2.5%
lotion 1% & 2.5%
generic
crm 0.5% & 1%, OTC
BETA-VAL
SYNALAR
CORDRAN
CUTIVATE
LOCOID
WESTCORT
ELOCON
DERMATOP
KENALOG
KENALOG
generic
generic
brand
generic
generic
generic
generic
generic
generic
generic
crm/oint/lotion 0.1%
crm, oint 0.025%
tape
crm 0.05%, oint 0.005%
crm/oint/soln 0.1%
crm 0.2%
crm/oint/soln 0.1%
crm 0.1%
crm/lot/oint 0.025%
crm/oint/lotion 0.1%
DIPROLENE
generic
lotion 0.05%
DIPROLENE AF
generic
crm 0.05%
generic
crm/lotion/oint 0.05%
generic
crm/oint/gel/soln 0.05%
Corticosteroids
Low Potency
fluocinolone acetonide
fluocinolone acetonide
hydrocortisone
hydrocortisone
hydrocortisone
hydrocortisone/aloe
Medium Potency
betamethasone val
fluocinolone acetonide
flurandrenolide
fluticasone propionate
hydrocortisone butyrate
hydrocortisone valerate
mometasone furoate
prednicarbate
triamcinolone acetonide
triamcinolone acetonide
High Potency
betamethasone
augmented dip
betamethasone
augmented dip
betamethasone
dipropionate
fluocinonide
LIDEX
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
OTC
ST = Step Therapy
SP = Specialty Pharmacy
15
Brand Drug Name
Covered
Drug
Requirements & Limits
LIDEX E
generic
crm 0.05%
KENALOG
generic
crm 0.5%
DIPROLENE
generic
gel 0.05%
DIPROLENE
generic
oint 0.05%
TEMOVATE
ULTRAVATE
generic
generic
soln 0.05%
cream
ciclopirox
clotrimazole
clotrimazole
clotrimazole with
betamethasone
ketoconazole
miconazole
miconazole
miconazole
nystatin
terbinafine
tolnaftate
PENLAC SOLUTION 8%
LOTRIMIN AF
MYCELEX
generic
generic
generic
OTC
LOTRISONE
generic
NIZORAL
DESENEX
MICATIN
MONISTAT-DERM
MYCOSTATIN
LAMISIL AT
TINACTIN
generic
generic
generic
generic
generic
generic
generic
acitretin
calcipotriene
calcipotriene
calcitriol
methoxsalen
salicylic acid
SORIATANE
DOVONEX
DOVONEX
VECTICAL
OXSORALEN-ULTRA
SCALPICIN
generic
generic
generic
generic
generic
generic
oral caps, PA
crm/oint, ST
soln
ST
brimonidine
MIRVASO
METROCREAM
brand
PA
metronidazole
METROGEL
Generic Drug Name
fluocinonide emulsified
base
triamcinolone acetonide
Very High Potency
betamethasone dip
augmented
betamethasone dip
augmented
clobetasol propionate
halobetasol
Fungal Infections
Psoriasis
Rosacea
2% OTC
OTC
OTC
OTC
liquid 3%
generic
METROLOTION
Scabies and Pediculosis
crotamiton
malathion
permethrin
permethrin
pyrethrins/piperonyl but
EURAX
OVIDE
ELIMITE
NIX CREME RINSE
RID SHAMPOO/
BUTOXIDE SHAMPOO
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
generic
generic
generic
5%, QL
1%, OTC
generic
4% OTC
ST = Step Therapy
SP = Specialty Pharmacy
16
Generic Drug Name
Viral Infections
podofilox
salicylic acid 17%/
collodion
Brand Drug Name
Covered
Drug
Requirements & Limits
CONDYLOX SOL
generic
sol
DUOFILM
generic
OTC
brand
soln/cream, OTC
Miscellaneous
aluminum acetate
aluminum chloride topical
solution
ammonium lactate
ammonium lactate
becaplermin gel
calamine
collagenase oint
fluorouracil
fluorouracil
fluorouracil
hexachlorophene
hydrocortisone
imiquimod 5% cream
ketoconazole
lidocaine
lidocaine
lidocaine
lidocaine/prilocaine
nitroglycerin
HYPERCARE 15%
brand
LAC-HYDRIN
LACTINOL
REGRANEX
generic
generic
brand
brand
brand
generic
generic
brand
brand
SANTYL
CARAC
EFUDEX
FLUOROPLEX
PHISOHEX
PROCTOSOL HC
CREAM 2.5%
PROCTOZONE
CREAM-HC 2.5%
ANUSOL HC 2.5%
ALDARA
NIZORAL SHAMPOO
LIDAMANTEL
LMX-4
XYLOCAINE
EMLA
RECTIV
1% cream
generic
generic
generic
generic
generic
generic
generic
brand
PA
shampoo 2%
3% cream
4% cream (15 gm tubes), QL
jelly 2%
2.5% cream
0.4% rectal ointment, PA
cream, QL, ST, not covered for
members less than 2 years
of age
pimecrolimus
ELIDEL
brand
selenium sulfide
SELSUN
generic
tacrolimus
PROTOPIC 0.03%
generic
tacrolimus
PROTOPIC 0.1%
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
crm 12%, lotion 5% & 12%
lotion 10%
PA
lotion/ointment, OTC
QL
0.5% cream
lotion 2.5%
ointment 0.03%, QL, ST, not
covered for members less
than 2 years
of age
ointment 0.1%, ST
(minimum age 16)
ST = Step Therapy
SP = Specialty Pharmacy
17
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
UREA 10% CREAM
urea 10%, urea 20%
UREA 20% CREAM
brand
urea 40%
UREA 10% LOTION
UREA 40% LOTION
generic
lotion
VOSOL OTIC
generic
otic
DOMEBORO OTIC
generic
VOSOL HC OTIC
generic
BENZOTIC
DEBROX
generic
generic
6.5%, OTC
CIPRODEX
brand
PA
CORTISPORIN OTIC
generic
otic
FLOXIN OTIC
generic
Ear, Nose & Throat
Ear
acetic acid
acetic acid/
aluminum acetate
acetic acid/
hydrocortisone
benzocaine/antipyrine
carbamide peroxide
ciprofloxacin/
dexamethasone
neomycin/polymyxin B/
hydrocortisone
ofloxacin
Nose
Antihistamines - First Generation, Sedating
CHLOR-TRIMETON
ALLERGY
CHLOR-TRIMETON
chlorpheniramine maleate
SYRUP
clemastine
CLEMASTINE
cyproheptadine
CYPROHEPTADINE
diphenhydramine
diphenhydramine
BENADRYL
chlorpheniramine
extended-release
Antihistamines - Second Generation, Nonsedating
generic
12 mg, OTC
generic
2 mg/5 ml, OTC
generic
generic
generic
generic
OTC
cetirizine
ZYRTEC
generic
cetirizine chew tab
ZYRTEC CHEWABLE
TABLET
generic
levocetirizine
loratadine
XYZAL
ALAVERT
CLARITIN
generic
OTC
OTC, Members ≥ 8 years
of age will require prior
authorization.
tabs
generic
OTC
Antihistamines - Others Antihistamine/Decongestant Combinations
azelastine
ASTELIN
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
ST = Step Therapy
SP = Specialty Pharmacy
18
spray
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Antihistamine/Decongestant Combinations - First Generation
chlorpheniramine/
phenylephrine/
pyrilamine
chlorpheniramine/
pseudoephedrine
TRIOTANN
generic
ACTIFED
generic
OTC
Antihistamine/Decongestant Combinations - Second Generation
cetirizine hydrochloride/
pseudoephedrine
hydrochloride
12 hours
extended-release
ZYRTEC-D
loratadine/
pseudoephedrine
extended-release
ALAVERT ALRG
TAB/SINUS
Nasal Steroids
5 mg-120 mg tablet
generic
OTC
ALAVERT-D
ALLERGY/CONG
FLONASE
NASACORT ALLERGY 24
triamcinolone nasal spray
HOUR
fluticasone
Miscellaneous Nasal
generic
generic
brand
OTC
cromolyn sodium
ipratropium nasal
saline nasal spray 0.65%
NASALCROM
ATROVENT NASAL SPRAY
OCEAN NASAL SPRAY
generic
generic
generic
OTC
QL
OTC
oxymetazoline
AFRIN
NEO-SYNEPHRINE
generic
OTC
phenylephrine
DIMEATAPP DRO
DECONGES
generic
OTC
PERIDEX
XYLOCAINE
SALAGEN
KENALOG IN ORABASE
generic
generic
generic
generic
paste
DECADRON
FLORINEF
CORTEF
MEDROL
generic
generic
generic
generic
generic
4mg, 8mg, 16mg, 32mg
Miscellaneous Nasal Decongestants
Throat and Mouth
chlorhexidine gluconate
lidocaine viscous
pilocarpine
triamcinolone
Endocrinology
Adrenal Corticosteroids
cortisone acetate
dexamethasone
fludrocortisone
hydrocortisone
methylprednisolone
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
19
Covered
Drug
brand
Generic Drug Name
Brand Drug Name
methylprednisolone
prednisolone
prednisolone
prednisolone sodium
phosphate
prednisone
MEDROL
testosterone cypionate
DEPO-TESTOSTERONE
generic
testosterone enanthate
DELATESTRYL
generic
testosterone gel
topical tube, packet,
and pump bottle
Vials only. Disposable
syringes not covered.
TESTOSTERONE 1%
TOPICAL GEL
generic
PA
glucagon, human
recombinant
GLUCAGON
brand
QL
NOVOLOG
brand
QL, vials
NOVOLOG MIX 70/30
brand
QL, vials
BASAGLAR
brand
TOUJEO SOLOSTAR
brand
NOVOLIN R
RELION R
HUMULIN N
NOVOLIN N
RELION N
brand
brand
brand
brand
brand
OTC, QL, vials
OTC, QL, vials
OTC, QL, vials
OTC, QL, vials
OTC, QL, vials
NOVOLIN 70/30
brand
OTC, QL, vials
RELION 70/30
brand
OTC, QL, vials
HUMALOG MIX 50/50
HUMALOG MIX 75/25
HUMULIN 70/30
HUMALOG
HUMULIN R
brand
brand
brand
brand
brand
QL, vials
QL, vials
OTC, QL, vials
QL, vials
OTC, QL, vials
brand
QL for insulin dependent or
pregnant members: allow
testing up to 6 times per day
Androgens
PRELONE
ORAPRED
Requirements & Limits
2mg
generic
syrup
generic
PEDIAPRED
DELTASONE
generic
Diabetes Mellitus
Glucose Elevating Agents
Insulins
insulin aspart
insulin aspart
protamine 70%/
insulin aspart 30%
insulin glargine
insulin glargine
300 units/ml
insulin human
insulin human
insulin isophane
insulin isophane human
insulin isophane human
insulin isophane human
70%/regular 30%
insulin isophane human
70%/regular 30%
insulin lisopro pro/lispro
insulin lisopro prot/lispro
insulin isophane/regular
insulin lispro
insulin regular
Monitoring - Strips and Kits/Diabetic Supplies
ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI,
VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC)
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
20
Generic Drug Name
Brand Drug Name
ONE TOUCH TEST STRIPS (ULTRA, VERIO)
Oral Agents
Covered
Drug
Requirements & Limits
brand
QL for non-insulin
dependent members: allow
once daily testing
acarbose
alogliptin
alogliptin/metformin
alogliptin/pioglitazone
canagliflozin
canagliflozin/metformin
canagliflozin/metformin
extended-release
chlorpropamide
empagliflozin
empagliflozin/metformin
empagliflozin/metformin
extended-release
glimepiride
glipizide
glipizide extended-release
glyburide
glyburide, micronized
metformin
metformin ER
metformin/glyburide
nateglinide
pioglitazone
repaglinide
tolazamide
tolbutamide
PRECOSE
NESINA
KAZANO
OSENI
INVOKANA
INVOKAMET
albiglutide
liraglutide
pramlintide
TANZEUM
VICTOZA
SYMLIN
brand
brand
brand
ST
ST
PA
mecasermin
somatropin
INCRELEX
NUTROPIN AQ NUSPIN
brand
brand
PA, SP
PA, SP
alendronate
calcitonin-salmon
calcitonin-salmon
etidronate
raloxifene
teriparatide inj
FOSAMAX
MIACALCIN
FORTICAL
DIDRONEL
EVISTA
FORTEO
generic
generic
brand
generic
generic
brand
QL
nasal spray, QL
nasal spray, QL
INVOKAMET XR
DIABINESE
JARDIANCE
SYNJARDY
SYNJARDY XR
AMARYL
GLUCOTROL
GLUCOTROL XL
MICRONASE
GLYNASE
GLUCOPHAGE
GLUCOPHAGE ER
GLUCOVANCE
STARLIX
ACTOS
PRANDIN
TOLINASE
TOLBUTAMIDE
Growth Stimulating Agents
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST
ST
ST
ST
ST
brand
ST
generic
brand
brand
ST
ST
brand
ST
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
Miscellaneous Antidiabetic Agents
Osteoporosis
generic
generic
generic
generic
brand
brand
ST = Step Therapy
SP = Specialty Pharmacy
21
QL
PA, SP
Brand Drug Name
Covered
Drug
levothyroxine
levothyroxine
liothyronine
liotrix
methimazole
propylthiouracil
LEVOXYL
SYNTHROID
CYTOMEL
THYROLAR
TAPAZOLE
PROPYLTHIOURACIL
generic
generic
generic
brand
generic
generic
asfotase alfa
cabergoline
cholic acid
desmopressin
methylergonovine
mifepristone
nitisinone
pegvisomant
sapropterin
STRENSIQ
DOSTINEX
CHOLBAM
DDAVP
METHERGINE
KORLYM
ORFADIN
SOMAVERT
KUVAN
KUVAN POWDER FOR
SOLUTION
VISTOGARD
brand
generic
brand
generic
generic
brand
brand
brand
brand
PA, SP
brand
PA, SP
brand
SP
generic
OTC
COLACE
ENULOSE
LINZESS
GLYCERIN SUPPOSITORY
COLYTE
generic
generic
generic
generic
brand
generic
generic
OTC
OTC
OTC
TRILYTE
generic
NULYTELY
generic
MIRALAX
SENOKOT
generic
generic
Generic Drug Name
Thyroid Disease
Miscellaneous
sapropterin powder
uridine
Requirements & Limits
PA, SP
QL
PA, SP
PA, SP
PA, SP
PA, SP
Gastrointestinal
Constipation/Laxatives
casanthranol-docusate
sodium
docusate calcium plus
docusate potasssium
docusate sodium
lactulose
linaclotide
glycerin
peg 3350/electrolytes
peg 3350/sodium
bicarbonate/sodium
chloride
peg 3350/sodium
bicarbonate/sodium
chloride/potassium
chloride
polyethylene glycol 3350
sennosides
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
PA
suppository, OTC
ST = Step Therapy
SP = Specialty Pharmacy
22
8.6 mg tab, OTC
Brand Drug Name
Covered
Drug
Requirements & Limits
diphenoxylate/atropine
loperamide
loperamide
LOMOTIL
IMODIUM A-D
LOPERAMIDE
generic
generic
generic
OTC
aprepitant
EMEND
generic
dronabinol
meclizine
metoclopramide
MARINOL
ANTIVERT
REGLAN
ZOFRAN
generic
generic
generic
Generic Drug Name
Diarrhea
Emesis
ondansetron
prochlorperazine
promethazine
rolapitant
trimethobenzamide
QL applies to 40 mg, 80 mg
and 80-125 mg
PA
generic
QL
generic
generic
brand
generic
300 mg caps
brand
OTC
MAALOX
generic
OTC
MYLANTA
generic
OTC
TAGAMET
NEXIUM 24HR OTC
generic
brand
ZOFRAN ODT
COMPAZINE
PHENERGAN
VARUBI
TIGAN
Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcers
alginic acid/sodium
bicarbonate
alumina/magnesia
alumina/magnesia/
simethicone
cimetidine
esomeprazole
esomeprazole granules
famotidine
NEXIUM DELAYED
RELEASE PACKET
brand
PEPCID
generic
PEPCID AC
PA
Members ≥ 2 years
of age will require prior
authorization.
OTC Pepcid AC 10 mg
and 20 mg also covered/
encouraged with written
prescription.
lansoprazole
PREVACID
generic
lansoprazole
delayed-release
PREVACID SOLUTAB
generic
orally disintegrating tabs,
Members ≥ 2 years
of age will require prior
authorization. QL
PRILOSEC
generic
Capsules only, QL
PROTONIX
ZANTAC
ZANTAC
CARAFATE
generic
generic
generic
generic
omeprazole
delayed-release
pantoprazole
ranitidine
ranitidine syrup
sucralfate
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
23
150 mg tabs
Covered
Drug
Requirements & Limits
CARAFATE SUSPENSION
generic
suspension, Members 10
years of age up to 65 years
of age will require prior
authorization.
dicyclomine
glycopyrrolate
hyoscyamine sulfate
hyoscyamine sulfate
extended-release
BENTYL
ROBINUL
LEVSIN
generic
generic
generic
LEVSINEX
generic
balsalazide
budesonide
hydrocortisone
mesalamine
mesalamine
extended-release
mesalamine supp
olsalazine sodium
sulfasalazine
sulfasalazine
delayed-release
COLAZAL
ENTOCORT EC
COLOCORT
ROWASA
APRISO
Generic Drug Name
sulcralfate
Gastrointestinal Spasm
Brand Drug Name
Inflammatory Bowel Disease
Pancreatic Enzymes
pancrelipase
tablets only
generic
generic
generic
generic
PA
enema
enema only
brand
DELZICOL
CANASA
DIPENTUM
AZULFIDINE
brand
brand
generic
AZULFIDINE EN-TABS
generic
CREON
CREON 3000 UNIT
brand
ZENPEP
Probiotic Supplementation
acidophilus/pectin
lactobacillus
probiotic product
ACIDOPHILUS XTRA
ACIDOPHILUS
ACIDOPHILUS/BIFIDUS
WAFER
ACIDOPHILUS/CITRUS
PECTIN
ACIDOPHILUS/PECTIN
FLORANEX
PROBIOTIC FORMULA
atropine sulfate
misoprostol
naloxegol
teduglutide
SAL-TROPINE
CYTOTEC
MOVANTIK
GATTEX
acidophilus
acidophilus
acidophilus/bifidus
acidophilus/citrus pectin
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
brand
OTC
caps and tabs, OTC
generic
OTC
generic
tabs, OTC
generic
generic
brand
caps, OTC
chewable tabs, OTC
caps, OTC
brand
generic
brand
brand
PA
PA, SP
ST = Step Therapy
SP = Specialty Pharmacy
24
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
ACTIGALL
ursodiol
URSO
generic
URSO FORTE
Infectious Diseases
Anthelmintics
albendazole
ivermectin
praziquantel
pyrantel pamoate
pyrantel pamoate
Antibacterials
Antituberculosis Agents
aminosalicyclic acid
cycloserine
ethambutol
ethionamide
isoniazid
pyrazinamide
rifabutin
rifampin
rifapentine
ALBENZA
STROMECTOL
BILTRICIDE
PIN-X
REESE’S PINWORM
MEDICINE
PASER
SEROMYCIN
MYAMBUTOL
TRECATOR
ISONIAZID
PYRAZINAMIDE
MYCOBUTIN
RIFADIN
PRIFTIN
brand
brand
brand
brand
PA
PA
chewable tablets, suspension
brand
tablets, suspension
brand
generic
generic
brand
generic
generic
generic
generic
brand
Cephalosporins - First Generation
cefadroxil
cephalexin
DURICEF
KEFLEX
generic
generic
tabs are not covered
cefaclor
cefprozil
cefuroxime axetil
cefuroxime axetil
CECLOR
CEFZIL
CEFTIN
CEFTIN
generic
generic
generic
brand
tabs
suspension
cefdinir
cefixime
OMNICEF
SUPRAX
generic
brand
400 mg caps only, QL
ciprofloxacin
levofloxacin
ofloxacin
CIPRO
LEVAQUIN
FLOXIN
generic
generic
generic
tablets only
tabs
azithromycin
clarithromycin
clarithromycin ER
ZITHROMAX
BIAXIN
BIAXIN XL
generic
generic
generic
Cephalosporins - Second Generation
Cephalosporins - Third Generation
Fluoroquinolones
Macrolides
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
25
QL
Generic Drug Name
erythromycin
delayed-release
erythromycin
delayed-release
erythromycin
ethylsuccinate
erythromycin stearate
erythromycin/sulfisoxazole
fidaxomicin
Penicillins
amoxicillin
amoxicillin
amoxicillin/clavulanate
ampicillin
dicloxacillin
penicillin VK
Sulfonamides
sulfamethoxazole/
trimethoprim, DS
Tetracyclines
Brand Drug Name
Covered
Drug
ERYC
generic
ERY-TAB
brand
E.E.S.
generic
ERYTHROCIN
PEDIAZOLE
DIFICID
generic
generic
brand
AMOXICILLIN CAPSULES
AND CHEWABLES
AMOXIL SUSP
AUGMENTIN
PRINCIPEN
DICLOXACILLIN
VEETIDS
BACTRIM
generic
generic
generic
generic
generic
generic
PA
Except 500 mg and 875 mg
film-coated tabs.
suspension
generic
BACTRIM DS
minocycline
DOXYCYCLINE
MONOHYDRATE
MINOCIN
vancomycin HCl
doxycycline monohydrate
Requirements & Limits
generic
generic
capsules, except 75 mg
VANCOCIN HCL
generic
cap, ST
atovaquone
miltefosine
MEPRON
IMPAVIDO
generic
brand
nitazoxanide suspension
ALINIA SUSPENSION
brand
nitazoxanide tablet
ALINIA
brand
PA
PA
Members ≥ 8 years of age will
require prior authorization.
PA
clotrimazole
fluconazole
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
itraconazole
ketoconazole
nystatin
terbinafine
voriconazole
MYCELEX
DIFLUCAN
GRIFULVIN V
GRIS-PEG
SPORANOX
SPORANOX
NIZORAL
MYCOSTATIN
LAMISIL
VFEND
Miscellaneous
Antiprotozoals
Antifungals
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
generic
generic
generic
brand
generic
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
26
troches
QL
caps, PA, QL
soln, PA, QL
QL
PA
Generic Drug Name
Covered
Drug
Brand Drug Name
Antivirals
Cytomegalovirus Treatment
Requirements & Limits
ganciclovir
valganciclovir
CYTOVENE
VALCYTE
generic
generic
adefovir
HEPSERA
generic
elbasvir/grazoprevir
ZEPATIER
brand
entecavir
interferon alfa-2b
lamivudine
peginterferon alfa-2a
peginterferon alfa-2a
BARACLUDE
INTRON A
EPIVIR HBV
PEGASYS
PEGASYS PROCLICK
brand
brand
brand
brand
brand
ribavirin
REBETOL/COPEGUS
generic
sofosbuvir
SOVALDI
brand
sofosbuvir/velpatasvir
EPCLUSA
brand
acyclovir
valacyclovir
ZOVIRAX
VALTREX
generic
generic
caps, tabs, suspension
amantadine
oseltamivir
oseltamivir
rimantadine
zanamivir
SYMMETREL
TAMIFLU
TAMIFLU
FLUMADINE
RELENZA
generic
brand
generic
generic
brand
except tabs
suspension, QL
capsules, QL
bedaquiline
chloroquine phosphate
clindamycin
dapsone
hydroxychloroquine
linezolid
mefloquine
metronidazole
neomycin sulfate
nitrofurantoin
extended-release
nitrofurantoin
macrocrystals
SIRTURO
ARALEN
CLEOCIN
DAPSONE
PLAQUENIL
ZYVOX
LARIAM
FLAGYL
brand
generic
generic
brand
generic
generic
generic
generic
brand
MACROBID
generic
MACRODANTIN
generic
Hepatitis Treatment
Herpes Treatment
Influenza Treatment
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
tabs only
PA, SP, preferred for
Genotypes 1 or 4
PA, SP
PA, SP
PA, SP
200 mg caps and tabs only,
SP
PA, SP, preferred for
Genotype 2
PA, SP, preferred for
Genotypes 2, 3, 5, & 6
QL
150 mg and 300 mg only
ST = Step Therapy
SP = Specialty Pharmacy
27
PA
tabs only
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
nitrofurantoin susp
FURADANTIN SUSP
25 MG/5 ML
generic
Members ≥ 8 years of age will
require prior authorization.
palivizumab
paromomycin
povidone-iodine
primaquine
pyrimethamine
trimethoprim
SYNAGIS
HUMATIN
brand
generic
generic
generic
brand
generic
DARAPRIM
TRIMETHOPRIM
PA
OTC
PA
tabs only
Musculoskeletal
Arthritis
Disease Modifying Anti-Rheumatic Drugs
adalimumab
anakinra
auranofin
azathioprine
canakinumab
certolizumab
etanercept
hydroxychloroquine
leflunomide
methotrexate
penicillamine
secukinumab
sulfasalazine
sulfasalazine
delayed-release
HUMIRA
KINERET
RIDAURA
IMURAN
ILARIS
CIMZIA
ENBREL
PLAQUENIL
ARAVA
acetaminophen
TYLENOL
BAYER
DEPEN TITRATABLE
COSENTYX
AZULFIDINE
brand
brand
brand
generic
brand
brand
brand
generic
generic
generic
brand
brand
generic
AZULFIDINE EN-TABS
generic
NSAIDs and Other Analgesics
aspirin
capsaicin
ECOTRIN
CAPSAGEL
CAPZASIN-P
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
generic
OTC
generic
OTC
brand
OTC, gel, lotion, 0.035%
cream
CASTIVA
generic
generic
PA
etodolac
CELEBREX
VOLTAREN 1% TOPICAL
GEL
LODINE
OTC, 0.025%, 0.075%, &
0.1% cream
PA, QL
generic
ibuprofen
ADVIL
generic
IR only
tabs, chew tabs
and susp, OTC
capsaicin
celecoxib
diclofenac 1% gel
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
28
Generic Drug Name
Covered
Drug
generic
generic
generic
generic
generic
Brand Drug Name
MOTRIN
INDOCIN
ORUDIS
MOBIC
NAPROSYN
ENTERIC COATEDnaproxen delayed release
NAPROSYN
oxaprozin
DAYPRO
piroxicam
FELDENE
salsalate
DISALCID
sulindac
CLINORIL
ibuprofen
indomethacin
ketoprofen
meloxicam
naproxen
Gout
Requirements & Limits
tabs, chew tabs and susp
IR only
QL
generic
generic
generic
generic
generic
QL
allopurinol
colchicine
febuxostat
probenecid
ZYLOPRIM
MITIGARE
ULORIC
PROBENECID
generic
brand
brand
generic
chlorzoxazone
cyclobenzaprine
methocarbamol
orphenadrine
extended-release
PARAFON FORTE DSC
FLEXERIL
ROBAXIN
generic
generic
generic
NORFLEX
generic
baclofen
dantrolene
tizanidine
BACLOFEN
DANTRIUM
ZANAFLEX
generic
generic
generic
tabs only, QL
milnacipran
SAVELLA
brand
PA
QL
QL
Skeletal Muscle Relaxants
Muscle Spasm
Spasticity
Miscellaneous
ST
5mg & 10mg
OB-GYN
Contraceptives
Biphasic
desogestrel/EE
norethindrone/EE
MIRCETTE
ORTHO-NOVUM 10/11
generic
generic
levonorgestrel
PLAN B ONE STEP
generic
levonorgestrel/EE
SEASONALE
generic
Emergency Contraception
Extended Cycle
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
29
QL
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
DEPO-PROVERA
generic
QL
Injectable
medroxyprogesterone
acetate
Intravaginal
etonogestrel/EE
NUVARING
ORTHO COIL
brand
ring, QL
ortho diaphragm
ORTHO FLAT
brand
QL
generic
generic
0.1/20, QL
1/20, QL
generic
1/20, QL
ORTHO FLEX
Monophasic - 20 mcg Estrogen
levonorgestrel/EE
ALESSE
norethindrone acetate/EE LOESTRIN 1/20
norethindrone acetate/EE/
LOESTRIN FE 1/20
iron
Monophasic - 30 mcg Estrogen
desogestrel/EE
levonorgestrel/EE
norethindrone acetate/EE
norethindrone acetate/EE/
iron
norgestrel/EE
ORTHO-CEPT
NORDETTE
LOESTRIN 1.5/30
generic
generic
generic
0.15/30, QL
0.15/30, QL
1.5/30, QL
LOESTRIN FE 1.5/30
generic
1.5/30, QL
LO/OVRAL
generic
0.3/30, QL
ethynodiol diacetate/EE
norethindrone/EE
norethindrone/EE
norethindrone/EE
norgestimate/EE
ZOVIA 1/35
BALZIVA
MODICON
ORTHO-NOVUM 1/35
ORTHO-CYCLEN
generic
generic
generic
generic
generic
1/35, QL
0.4/35, QL
0.5/35, QL
1/35, QL
0.25/35, QL
ethynodiol diacetate/EE
norethindrone/EE
norethindrone/ME
norgestrel/EE
ZOVIA 1/50
OVCON 50
ORTHO-NOVUM 1/50
OVRAL
generic
generic
generic
generic
1/50, QL
1/50, QL
1/50, QL
0.5/50, QL
norethindrone
ORTHO MICRONOR
generic
Monophasic - 35 mcg Estrogen
Monophasic - 50 mcg Estrogen
Progestin
Transdermal
norelgestromin/EE
Triphasic
desogestrel/EE
levonorgestrel/EE
norethindrone/EE
norethindrone/EE
ORTHO EVRA
generic
XULANE
CYCLESSA
TRIVORA
TRI-NORINYL
ORTHO-NOVUM 7/7/7
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
30
QL
QL
QL
QL
Generic Drug Name
norethindrone
acetate/EE/iron
norgestimate/EE
Endometriosis
danazol
Brand Drug Name
Covered
Drug
Requirements & Limits
ESTROSTEP FE
generic
QL
ORTHO TRI-CYCLEN
generic
QL
DANOCRINE
generic
Gender edits apply: for female
patients only.
Hormone Therapy/Menopause
Estrogens - Intravaginal
estradiol
estrogens, conjugated
ESTRACE CRM
PREMARIN
estradiol
estrogens, conjugated
estrogens, conjugated,
synthetic A
estropipate
ESTRACE
PREMARIN
generic
brand
CENESTIN
brand
OGEN
generic
estradiol
CLIMARA
generic
Estrogens - Oral
Estrogens - Transdermal
Estrogen/Progestin
brand
brand
PREMPHASE
estrogens, conjugated/
medroxyprogesterone PREMPRO
crm
QL
brand
Progestins
medroxyprogesterone
acetate
norethindrone acetate
PROVERA
generic
AYGESTIN
generic
fluconazole
metronidazole
DIFLUCAN
FLAGYL
generic
generic
QL
tabs
clotrimazole
clindamycin
GYNE-LOTRIMIN
CLEOCIN
METROGEL-VAGINAL
generic
generic
OTC
crm
Vaginal Infections
Oral
Vaginal
metronidazole
miconazole
miconazole
terconazole
Miscellaneous
conjugated estrogen/
bazedoxifene
generic
METROGEL 1%
MONISTAT
MONISTAT 3
TERAZOL 3/7
generic
generic
generic
DUAVEE
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
ST = Step Therapy
SP = Specialty Pharmacy
31
OTC
crm
Generic Drug Name
Brand Drug Name
methylergonovine
tranexamic acid
METHERGINE
LYSTEDA
Covered
Drug
generic
generic
Requirements & Limits
PA
Ophthalmic
Allergy
azelastine
cromolyn sodium
ketotifen
naphazoline/glycerin
naphazoline HCL
naphazoline/zinc sulfate
tetrahydrozoline/
zinc sulfate
Anti-Inflammatories
Nonsteroidal
diclofenac sodium
flurbiprofen
ketorolac
Steroidal
dexamethasone sodium
phosphate
fluorometholone
fluorometholone
fluorometholone
prednisolone acetate
prednisolone acetate
prednisolone phosphate
rimexolone
OPTIVAR
CROLOM
ALAWAY OTC
CLEAR EYES REDNESS
RELIEF
VASOCLEAR
VASOCLEAR A
generic
generic
brand
VISINE-AC
generic
VOLTAREN
OCUFEN
ACULAR/ACULAR LS
generic
generic
generic
DEXASOL
generic
FML
FML FORTE
FML LIQUIFILM
PRED FORTE
PRED MILD
INFLAMASE FORTE
VEXOL
brand
brand
generic
generic
brand
generic
brand
oint 0.1%
susp 0.25%
susp 0.1%
1%
0.12%
1%
CORTISPORIN
generic
ointment
Anti-Infective/Anti-Inflammatory Combinations
bacitracin/polymyxin/
neomycin/hc
gentamicin/prednisolone
acetate
neomycin/polymyxin B/
dexamethasone
neomycin/polymyxin B/
hydrocortisone
sulfacetamide/pred phos
PRED-G
ST
QL
generic
generic
brand
soln 0.02%
OTC
brand
MAXITROL
generic
CORTISPORIN
generic
suspension
VASOCIDIN
generic
10%/0.25%
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
32
Generic Drug Name
Brand Drug Name
Covered
Drug
tobramycin/
dexamethasone
TOBRADEX
generic
carteolol
levobunolol
metipranolol
timolol
timolol maleate
BETAGAN
OPTIPRANOLOL
TIMOPTIC XE
TIMOPTIC
generic
generic
generic
generic
generic
dorzolamide
TRUSOPT
generic
dorzolamide/
timolol maleate
COSOPT
generic
ecothiophate
PHOSPHOLINE IODINE
brand
atropine
cyclopentolate
homatropine
homatropine
scopolamine
ISOPTO ATROPINE
CYCLOGYL
ISOPTO HOMATROPINE
ISOPTO HOMATROPINE
ISOPTO HYOSCINE
generic
generic
generic
brand
brand
acetazolamide
acetazolamide
extended-release
methazolamide
ACETAZOLAMIDE
generic
DIAMOX SEQUELS
generic
NEPTAZANE
generic
latanoprost
XALATAN
generic
pilocarpine
pilocarpine
PILOPINE HS GEL
ISOPTO CARPINE
brand
generic
brimonidine
brimonidine
brimonidine
ALPHAGAN P
ALPHAGAN P
ALPHAGAN
brand
generic
generic
0.1%
0.15%
0.2%
lifitegrast
XIIDRA
brand
PA
generic
generic
brand
generic
solution
ointment
Glaucoma
Beta-Blockers
Carbonic Anhydrase Inhibitors
Requirements & Limits
ophthalmic solution
0.3% ophthalmic solution
gel forming solution
Carbonic Anhydrase Inhibitor/Beta-Blocker Combination
Cholinesterase Inhibitor
Mydriatics
Oral
Prostaglandins
Topical - Parasympathomimetics
Topical - Sympathomimetics
Immunologic Agents
Infections
Bacterial
bacitracin
ciprofloxacin
ciprofloxacin
erythromycin
CILOXAN
CILOXAN
ERYTHROMYCIN
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
33
1%
5%
2%
QL
Generic Drug Name
Brand Drug Name
gatifloxin
gentamicin
neomycin/bacitracin/
polymyxin
neomycin/polymyxin B/
gramicidin
ofloxacin
polymyxin B/bacitracin
polymyxin B/trimethoprim
sulfacetamide
tobramycin
ZYMAR
GENTAK
Covered
Drug
brand
generic
NEOSPORIN
generic
ointment
NEOSPORIN
generic
solution
OCUFLOX
POLYSPORIN
POLYTRIM
BLEPH-10
TOBREX
generic
generic
generic
generic
generic
trifluridine
VIROPTIC
generic
Viral
Miscellaneous
cysteamine 0.44%
ophthalmic solution
sodium chloride
hypertonic
Requirements & Limits
PA
oint/soln
CYSTARAN
brand
PA, SP
MURO 128
generic
soln 5%
UNISOM
generic
25mg, OTC, QL
Psychiatric
Insomnia
doxylamine succinate
Narcotic Antagonist
naloxone
Miscellaneous
NARCAN NASAL SPRAY
dextromethorphan/
quinidine
NUEDEXTA
guanfacine ER
INTUNIV
brand
brand
PA
generic
PA, For recipients 6 – 17
years old, Intuniv is part of the
mental health formulary and
billed fee-for-service.
For individuals not in this age
range, Intuniv continues to be
part of the MCO pharmacy
benefit.
Respiratory Drugs
Antitussives, Decongestants, Expectorants and Combinations
benzonatate
brompheniramine &
phenylephrine
brompheniramine/
pseudoephedrine
TESSALON
DIMETAPP CLD ELX/
ALLERGY
ACCUHIST DROPS
generic
generic
generic
UNI-HIST DROPS
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
34
Generic Drug Name
brompheniramine/
pseudoephedrine/
dextromethorphan
chlorphen tan/
carbetapentane tan
chlorphen tan/pyrilamine
tan/PE tan
chlorpheniramine/
dextromethorphan
Brand Drug Name
Covered
Drug
Requirements & Limits
BROMFED DM
generic
syrup
TUSSI-12 S
generic
susp
TRIOTANN PEDIATRIC
SUSP
generic
susp
R-TANNAMINE
ROBITUSSIN PED LIQ
CGH/COLD
ROBITUSSIN LIQ
CGH/CLD
generic
DIMETAPP SYP CGH/CLD
CORICIDIN TAB
CGH/CLD
chlorpheniramine maleate ED A-HIST TABLETS AND
phenylephrine HCL
LIQUID
RONDEC DROPS
chlorpheniramine/
phenylephrine
CARDEC DRO
RONDEC SYRUP
chlorpheniramine/
phenylephrine
CARDEC SYP
chlorpheniramine/
LOHIST-D
pseudoephedrine
chlorpheniramine tan/
RYNATAN PEDIATRIC SUSP
phenylephrine tan
codeine/
DIHISTINE DH
chlorpheniramine/
PHENYLHIST LIQ DH
pseudoephedrine
GUIATUSS AC
codeine/guaifenesin
codeine/guaifenesin/
pseudoephedrine
codeine/promethazine
codeine/promethazine/
phenylephrine
dextromethorphan/
brompheniramine/
pseudoephedrine
GG/CODEINE
generic
generic
liquid
generic
syrup
generic
generic
susp
generic
generic
QL
M-CLEAR WC
GUIATUSS DAC
generic
PROMETHAZINE
W/CODEINE
PROMETHAZINE VC
W/CODEINE
BROMETANE DX
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
QL
generic
QL
generic
ST = Step Therapy
SP = Specialty Pharmacy
35
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
dextromethorphanguaifenesin
DURATUSS DM ELX
generic
soln 25-225 mg/5 ml
generic
OTC
generic
liq 10-200 mg/ 5 ml
generic
syrup
brand
OTC
dextromethorphan/
guaifenesin
dextromethorphanguaifenesin
dextromethorphan hbr
dextromethorphan
polistirex
extended-release
dextromethorphan/
promethazine
guaifenesin
guaifenesin
guaifenesin
extended-release
guaifenesin/
pseudoephedrine
guaifenesin/
pseudoephedrine/
dextromethorphan
guaifenesin/
pseudoephedrine
extended-release
GG/DM CR
MUCINEX DM
ROBITUSSIN DM
TUSSIN DM
ROBITUSSIN LIQ CGH/
CONG
ROBITUSSIN SYP MAX-ST
ROBITUSSIN PED SYP
DELSYM
PHENERGAN DM
PROMETHAZINE SYP DM
ROBITUSSIN
ROBITUSSIN SYP
CHST CNG
MUCINEX
ROBITUSSIN PE
PSE/GG
generic
generic
OTC
generic
syrup 100 mg/5 ml
generic
OTC
generic
syrup, OTC
ROBITUSSIN CF
generic
MUCINEX D
generic
OTC
HYCODAN
hydrocodone/homatropine
loratadine &
pseudoephedrine SR
24hr
phenylephrine/
brompheniramine/
dextromethorphan
HYDROMET SYP
generic
HYDROCODONE/
TAB HOMATROP
CLARITIN-D
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
36
OTC
Generic Drug Name
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dihydrocodeine
phenylephrine/
dextromethorphan
phenylephrine/
dextromethorphan/
guaifenesin
phenylephrine/
ephed/CPM
w/carbetapentane
phenylephrine/guaifenesin
phenylephrine/
pyrilamine
w/hydrocodone
promethazine &
phenylephrine
pseudoephedrine/
acetaminophen/
dextromethorphan
pseudoephedrine/
chlorpheniramine/
dextromethorphan
pseudoephedrine/
dextromethorphan/
guaifenesin
pseudoephedrine/
iburprofen
Brand Drug Name
Covered
Drug
Requirements & Limits
generic
syrup
generic
liquid
RONDEC DM
STATUSS DM SYP
CARDEC DM SYP
MINUTUSS DR SYP
RONDEC DM DROPS
CARDEC DM DRO
ROBITUSSIN LIQ
CGH/ALRG
DIHYDRO-PE SYP
generic
DIMETAPP DRO
DCON/CGH
generic
ROBITUSSIN LIQ
CGH/CLD
generic
RYNATUSS PEDIATRIC
SUSP
generic
ROBITUSSIN LIQ
HD/CHST
generic
CODIMAL DH
generic
syrup
PROMETH VC SYP
6.25-5/5
generic
syrup 6.25-5 mg/ 5 mg
MAPAP COLD TAB
generic
PEDIACARE LIQ
MULTI-SY
generic
ROBITUSSIN LIQ PED
NGHT
MULTI SYMPTOM TAB
COLD RLF
generic
CHILD IBUPRO
SUS COLD
generic
IBUOROFEN TAB
COLD/SIN
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
susp
ST = Step Therapy
SP = Specialty Pharmacy
37
Generic Drug Name
Brand Drug Name
pseudoephedrine tan/
dexchlorphen tan/
DM tan
pyrilamine tan/phenyleph
tan
tripolidine/
pseudoephedrine
TANAFED DMX
SUSPENSION
Asthma/COPD
Inhalers - Beta Agonists
Covered
Drug
Requirements & Limits
generic
susp
generic
susp
TRI-FED X
RYNA-12 S
TRIPROL/PSE SYP
generic
APHEDRID TAB
albuterol sulfate
indacaterol
olodaterol
VENTOLIN HFA
ARCAPTA NEOHALER
STRIVERDI RESPIMAT
brand
brand
brand
QL
fluticasone furoate
mometasone
mometasone inhalation
ARNUITY ELLIPTA
ASMANEX TWISTHALER
ASMANEX HFA
brand
brand
brand
QL
QL
QL
fluticasone/vilanterol
mometasone/formoterol
BREO ELLIPTA
DULERA
brand
brand
ST
ST
ipratropium/albuterol
ipratropium/albuterol
ipratropium HFA
omalizumab
umeclidinium/vilanterol
umeclidinium inhalation
COMBIVENT
COMBIVENT RESPIMAT
ATROVENT HFA
XOLAIR
ANORO ELLIPTA
INCRUSE ELLIPTA
brand
brand
brand
brand
brand
brand
QL
inhaler
Inhalers - Corticosteroids
Inhalers - Corticosteroid/Beta Agonist Combinations
Inhalers - Others
Inhalers for Nebulization
albuterol
ACCUNEB
generic
albuterol
PROVENTIL
generic
budesonide
PULMICORT RESPULES
generic
cromolyn
ipratropium
ipratropium/albuterol
levalbuterol HCl
INTAL
ATROVENT
DUONEB
XOPENEX RESPULES
generic
generic
generic
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
PA, SP
0.63 mg/3 ml and 1.25 mg /3
ml, Covered for members less
than 8 years of age. Members
≥ 8 years of age will require
prior authorization.
soln 0.083%, 0.5%
susp, Members ≥ 5 years
of age will require prior
authorization. QL
soln, QL
soln, QL
soln
QL, ST
ST = Step Therapy
SP = Specialty Pharmacy
38
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Oral Agents - Beta Agonists
metaproterenol
terbutaline
METAPROTERENOL SYRUP generic
BRETHINE
generic
montelukast
SINGULAIR
generic
QL
theophylline
theophylline
extended-release
theophylline
extended-release
THEOPHYLLINE
generic
liquid
brand
caps
generic
tabs
Oral Agents - Leukotriene Modifiers
Oral Agents - Theophylline
THEO-24
THEOCHRON
UNIPHYL
Urological
Symptomatic Benign Prostatic Hypertrophy
alfuzosin ER
doxazosin
finasteride
tamsulosin
terazosin
Miscellaneous
UROXATRAL
CARDURA
PROSCAR
FLOMAX
HYTRIN
generic
generic
generic
generic
generic
bethanechol
URECHOLINE
hyoscyamine,
methenamine,
phenyl salicylate,
UTIRA C
sodium phosphate
monobasic, methylene
blue
HIPREX
methenamine hippurate
UREX
oxybutynin chloride
DITROPAN XL
oxybutynin IR
DITROPAN
potassium citrate
UROCIT-K
phenazopyridine
PYRIDIUM
propantheline
sodium citrate/citric acid BICITRA
tolterodine
DETROL
trospium
SANCTURA
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
brand
generic
generic
generic
generic
generic
generic
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
39
QL, ST
ST
ST
Brand Drug Name
Covered
Drug
calcitriol
ROCALTROL
generic
calcitriol oral soln
ROCALTROL SOLUTION
generic
calcium
cholecalciferol
OS-CAL
BIO-D DRO-MULSION
BIO-D-MULSIO
DRO FORTE
D3-50 CAP
VITAMIN D 400 UNIT
VITAMIN D 2000 UNIT
VITAMIN D 1000 UNIT
VITAMIN B-12
PEDIALYTE
DRISDOL
generic
generic
NIFEREX
generic
caps, OTC
FEOSOL
GEL-KAM
generic
OTC
Generic Drug Name
Requirements & Limits
Vitamins and Minerals
cholecalciferol
cholecalciferol
cholecalciferol
cholecalciferol
cholecalciferol
cyanocobalamin
electrolyte
ergocalciferol (D2)
ferrous bisglycinate/
polysaccarides iron
ferrous sulfate
generic
brand
generic
generic
generic
generic
generic
generic
Members ≥ 8 years of age will
require prior authorization.
OTC
drops 400 unit/0.03 ml, OTC
drops 2000 unit/0.03 ml,
OTC
cap 50000 unit, OTC
caps & tabs 400 unit, OTC
caps & tabs 2000 unit, OTC
caps & tabs 1000 unit, OTC
inj
soln, oral, OTC
LURIDE
fluoride
LURIDE LOZI-TABS
generic
PREVIDENT
folic acid
magnesium oxide
multivitamins/
fluoride/±iron
multivitamins/minerals
phytonadione
polysaccharide iron
complex
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
PHOS-FLUR
FOLIC ACID
MAG-OX
generic
generic
POLY-VI-FLOR
generic
CENTRUM
MEPHYTON
generic
brand
OTC
NIFEREX
generic
elixir, OTC
COMPLETE NATALCARE
PAK DHA
brand
TRUST NATALCARE
PAK DHA
brand
PRUET DHA PAK
SETONET PAK
brand
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
40
OTC
Generic Drug Name
prenat-FE bis-FE
prot succ-FA-CA
& omega DR
prenat w/o A w/fecbn-feglDSS-FA & DHA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
polysac cmplx-FA
prenatal vit w/iron
carbonyl-FA
prenatal vit w/o vit a w/fe
bisglycinate-fa tab 32-1
mg
prenatal vitamins
w/folic acid
Brand Drug Name
Covered
Drug
PRUET DHAEC PAK
brand
FOLTABS PAK PLUS DHA
RE OB + DHA PAK
brand
GENTEX ADE 28-1 MG
brand
VINATE AZ EX
brand
VINATE II
brand
EDGE OB CHW
brand
ATABEX PRENATAL
brand
Requirements & Limits
brand
PRENATAL VITAMINS
W/ FOLIC ACID
CENOGEN OB/ULTRA
MATERNA
generic
QL
NATALCARE
NESTABSCBF/FA/RX
prenatal w/o A w/ FE
carbonyl-FE
gluc-DSS-FA
vitamin A
vitamin ADC/fluoride/
±iron drops
vitamin B complex/
vitamin C/folic acid
vitamin B-1
vitamin B-6
vitamin C
vitamins pediatric
NIFEREX-PN FORTE
FOLTABS PRENATAL
brand
TRI RX
generic
TRI-VI-FLOR
generic
NEPHROCAPS
generic
TRI-VI-SOL
generic
generic
generic
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
OTC
OTC
OTC
OTC
members <3 years old, OTC
ST = Step Therapy
SP = Specialty Pharmacy
41
Generic Drug Name
Covered
Drug
generic
Brand Drug Name
zinc
Potassium
Requirements & Limits
OTC
phosphorus
potassium acid phosphate
potassium bicarbonate/
potassium citrate
effervescent
potassium chloride
potassium chloride
K-PHOS NEUTRAL
K-PHOS ORIGINAL
generic
brand
tabs
K-LYTE
generic
tabs
K-LOR
POTASSIUM CHLORIDE
K-DUR 10
generic
generic
powder
liquid
potassium chloride
extended-release
K-DUR 20
generic
tabs
generic
caps
generic
QL
brand
brand
QL
generic
brand
brand
PA, SP
PA, SP
brand
PA, SP
brand
PA, SP
potassium chloride
extended-release
KLOR-CON 8
KLOR-CON 10
MICRO-K 10
Miscellaneous
Anaphylaxis
epinephrine
Antidotes
EPIPEN
EPIPEN JR.
acetylcysteine
succimer
CETYLEV
CHEMET
acetylcysteine
aztreonam
dornase alfa
MUCOMYST
CAYSTON
PULMOZYME
KALYDECO
Cystic Fibrosis
ivacaftor
lumacaftor/ivacaftor
sodium chloride for
nebulizer
tobramycin neb soln
Hereditary Angioedema
C1 Inhibitor, Human
icatibant
Hyperphosphatemia
calcium acetate
cinacalcet
sevelamer
KALYDECO GRANULES
ORKAMBI
HYPERSAL
NEBUSAL
BETHKIS
generic
brand
PA, SP
BERINERT
FIRAZYR
brand
brand
PA, SP
PA, SP
SENSIPAR
RENVELA
generic
brand
brand
667 mg tablet only
PA
ST
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
42
Generic Drug Name
Brand Drug Name
Idiopathic Pulmonary Fibrosis (IPF)
Covered
Drug
Requirements & Limits
nintedanib
pirfenidone capsule
OFEV
ESBRIET
brand
brand
PA, SP
PA, SP
eltrombopag
PROMACTA
brand
PA, SP
Immune Thrombocytopenic Purpura
Medical Devices
insulin syringes
lancets
spacers
Metabolic Modifiers
QL
QL
QL
carglumic acid
glycerol phenylbutyrate
sodium phenylbutyrate
oral powder
CARBAGLU
RAVICTI
BUPHENYL ORAL
POWDER
diphtheria-tetanus tox
adsorbed (dt) im
DIP/TET PED INJ
Vaccine
hepatitis a vaccine susp
hepatitis b vaccine
(recombinant)
human papillomavirus
(hpv) 9-valent recomb
vac
human papillomavirus
(hpv) quadrivalent
recombinant vac
influenza virus vaccine
recombinant
hemagglutinin (ha)
influenza virus vaccine
split
influenza virus vaccine
split high-dose pf
influenza virus vaccine
split pf
influenza virus vaccine
split quadrivalent
brand
brand
PA, SP
PA, SP
generic
PA
brand
QL
brand
QL
brand
QL
GARDASIL 9
brand
QL
GARDASIL
brand
QL
FLUBLOK
brand
QL
brand
QL
FLUZONE HD PF
brand
QL
AFLURIA PF
brand
QL
brand
QL
brand
QL
HAVRIX
VAQTA
ENGERIX-B
RECOMBIVAX HB
AFLURIA
FLUZONE SPLT
FLUARIX QUAD
FLULAVAL QUAD
FLUZONE QUAD
influenza virus vaccine tissFLUCELVAX
cult subunit
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
43
Generic Drug Name
influenza virus vaccine
types a&b surface
antigen
measles, mumps & rubella
virus vaccines for inj
meningococcal (a, c, y,
and w-135)
meningococcal (a, c, y,
and w-135) conjugate
vaccine
meningococcal (a, c, y,
and w-135) oligo conj
vac for inj
pneumococcal 13-valent
conjugate
pneumococcal vaccine
polyvalent
tet tox-diph-acell pertuss
ad
tetanus-diphtheria toxoids
(td)
tetanus immune globulin
(human)
typhoid vaccine
varicella virus vac live for
subcutaneous
zoster vaccine live
Covered
Drug
Requirements & Limits
FLUVIRIN
brand
QL
M-M-R II
brand
QL
MENOMUNE
brand
QL
MENACTRA
brand
QL
MENVEO
brand
QL
PREVNAR 13
brand
QL
brand
QL
brand
QL
brand
QL
HYPERTET S/D
brand
QL
VIVOTIF BERNA
brand
capsules
VARIVAX
brand
QL
ZOSTAVAX
brand
QL, Age Limits Apply
Brand Drug Name
PNEUMOVAX
PNEUMOVAX 23
ADACEL
BOOSTRIX
TENIVAC
TET/DIP TOX INJ
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
44
Generic Drug Name
Brand Drug Name Examples
OTC MEDICATIONS
The following is a list of OTC products on the PDL. Some OTC products are listed on the drug
list. OTC products covered are restricted to generics when available. Brand names are provided
as reference only.
Acne
CLEARASIL
benzoyl peroxide crm, gel, lotion
Antifungals
clotrimazole
MICATIN
miconazole crm
LOTRIMIN AF
tolnaftate
TINACTIN
MONISTAT
vaginal products
GYNE-LOTRIMIN
Atopic Dermatitis
BETACARE CREAM AND LOTION
CETAPHIL CREAM AND LOTION
DERMAPHOR OINTMENT
emollients
E-OINTMENT
GLYCERIN TOPICAL
Cough/Cold Allergy
Antihistamines
CHLOR-TRIMETON
BENADRYL
CLARITIN
antihistamines
ALAVERT
ZYRTEC
Antihistamine/Decongestant Combinations
brompheniramine/pseudoephedrine
cetirizine/pseudoephedrine OTC
chlorpheniramine/pseudoephedrine
DIMETAPP
ZYRTEC D
ACTIFED
ALAVERT ALRG TAB/SINUS
loratadine/pseudoephedrine
ALAVERT D
ALLERGY/CONG
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
45
Generic Drug Name
Brand Drug Name Examples
Cough/Cold
ROBITUSSIN
ROBITUSSIN DM
antitussives
Age edit applied. Not covered for members under ROBITUSSIN PE
the age 2.
ROBITUSSIN CF
DELSYM
NEO-SYNEPHRINE
AFRIN
nasal sprays
DIMETAPP DRO DECONGES
Diabetes
CURITY ALCOHOL PADS
alcohol swabs
glucose oral tablets
HUMULIN
insulin (vials only)
NOVOLIN
Earwax Removal Products
DEBROX
carbamide peroxide
Family Planning
TROJAN
KIMONO
LIFESTYLES
condoms - male
TRUSTEX
DUREX
contraceptive foam
contraceptive gel
FANTASY
DELFEN
GYNOL II
Burow’s soln, wet dressings
dermatological baths
hydrocortisone crm, oint
DOMEBORO
COLLOIDAL OATMEAL BATHS
CORTAID
First Aid
NEOSPORIN
topical antibacterials
BACITRACIN
Gastrointestinal
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
46
Generic Drug Name
Brand Drug Name Examples
MYLANTA LIQUID
MAALOX LIQUID
antacids liquids, chew tabs
TUMS
IMODIUM A-D
antidiarrheals
KAOPECTATE
PEDIALYTE
PEPCID AC
FLEET ENEMA
DULCOLAX
electrolyte rehydrating soln
famotidine
laxative enemas
laxatives
psyllium
rectal crm, suppositories
simethicone
stool softeners
sugar+orthophosphoric acid
FLEET PHOSPHO-SODA
METAMUCIL
PREPARATION H
MYLICON
COLACE
EMETROL
doxylamine succinate
UNISOM
permethrin
piperonyl butoxide gel, liquid shampoo
NIX
PIPERONYL BUTOXIDE
dimenhydrinate
meclizine
DRAMAMINE
BONINE
allergic conjunctivitis
artificial tears
ALAWAY
HYPOTEARS
VISINE
decongestants
MURINE
Insomnia
Lice Products
Motion Sickness
Ophthalmics
NAPHCON A
Pain
acetaminophen tabs, liquid,
drops, suppositories, chew tabs
TYLENOL
BAYER
aspirin tabs, EC tabs, chew tabs
ECOTRIN
aspirin with buffers tabs
ADVIL
ibuprofen tabs, chew tabs, susp, drops
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
MOTRIN IB
ST = Step Therapy
SP = Specialty Pharmacy
47
Generic Drug Name
Brand Drug Name Examples
Vitamins/Minerals
OS-CAL
CALTRATE
calcium
TUMS
iron
ferrous fumarate, ferrous, gluconate,
errous sulfate, ferrous bis-glycinate
chelate and polysaccharide iron caps
iron polysaccharides
magnesium oxide
vitamin D 400 IU
FERGON
FEOSOL
NIFEREX
MAG-OX
VITAMIN D 400 IU
VI-DAYLIN
vitamins pediatric members <3 years old
POLY-VI-SOL
vitamins prenatal
TRI-VI-SOL
STUART PRENATAL
salicylic acid 17%/collodion
DUOFILM
fluoride dental rinse
PHOS-FLUR
Warts
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
48
Index of Covered Drugs
A
abiraterone . . . . . . . . . . . 5
acarbose . . . . . . . . . . . . 21
ACCUHIST DROPS . . . . . . 34
ACCUNEB . . . . . . . . . . . 38
ACCUPRIL . . . . . . . . . . . .7
ACCURETIC . . . . . . . . . . .8
ACCUTANE . . . . . . . . . . 14
acebutalol . . . . . . . . . . . . 8
acetaminophen . . . . 12, 28, 47
acetazolamide . . . . . . . . . 33
ACETAZOLAMIDE . . . . . . . 33
acetazolamide
extended-release . . . . . 33
acetic acid . . . . . . . . . . . 18
acetic acid/aluminum acetate18
acetic acid/hydrocortisone . . 18
acetylcysteine . . . . . . . . . 42
acidophilus . . . . . . . . . . 24
ACIDOPHILUS . . . . . . . . . 24
acidophilus/bifidus . . . . . . 24
ACIDOPHILUS/
BIFIDUS WAFER . . . . . 24
acidophilus/citrus pectin . . . 24
ACIDOPHILUS/
CITRUS PECTIN . . . . . . 24
acidophilus/pectin . . . . . . 24
ACIDOPHILUS/PECTIN . . . . 24
ACIDOPHILUS XTRA . . . . . 24
acitretin . . . . . . . . . . . . 16
ACLOVATE . . . . . . . . . . . 15
ACTIFED . . . . . . . . . . 19, 45
ACTIGALL . . . . . . . . . . . 25
ACTOS . . . . . . . . . . . . . 21
ACULAR/ACULAR LS . . . . 32
acyclovir . . . . . . . . . . . . 27
ADACEL . . . . . . . . . . . . 44
ADALAT CC . . . . . . . . . . . 9
adalimumab . . . . . . . . . . 28
adefovir . . . . . . . . . . . . 27
ADEMPAS . . . . . . . . . . . 11
ADVIL . . . . . . . . . 12, 28, 47
afatinib . . . . . . . . . . . . . 4
AFINITOR . . . . . . . . . . . . .4
AFINITOR DISPERZ . . . . . . .4
AFLURIA . . . . . . . . . . . . 43
AFLURIA PF . . . . . . . . . . 43
AFRIN . . . . . . . . . . . 19, 46
AGRYLIN . . . . . . . . . . . . .7
ALAVERT . . . . . . . . . 18, 45
ALAVERT ALRG
TAB/SINUS . . . . . . 19, 45
ALAVERT D . . . . . . . . . . 45
ALAVERT-D . . . . . . . . . . . 19
ALAWAY . . . . . . . . . . . . 47
ALAWAY OTC . . . . . . . . . 32
albendazole . . . . . . . . . . 25
ALBENZA . . . . . . . . . . . . 25
albiglutide . . . . . . . . . . . 21
albuterol . . . . . . . . . . . . 38
albuterol sulfate . . . . . . . . 38
alclometasone . . . . . . . . 15
alcohol swabs . . . . . . . . . 46
ALDACTAZIDE . . . . . . . . . 10
ALDACTONE . . . . . . . . . . 10
ALDARA . . . . . . . . . . . . 17
ALDOMET . . . . . . . . . . . 11
ALDORIL . . . . . . . . . . . . 11
ALECENSA . . . . . . . . . . . .4
alectinib . . . . . . . . . . . . . 4
alendronate . . . . . . . . . . 21
ALESSE . . . . . . . . . . . . . 30
alfuzosin ER . . . . . . . . . . 39
alginic acid/sodium
bicarbonate . . . . . . . . 23
ALINIA . . . . . . . . . . . . . 26
ALINIA SUSPENSION . . . . . 26
alirocumab . . . . . . . . . . 10
alitretinoin 1% gel . . . . . . . 6
ALKERAN . . . . . . . . . . . . 4
allergic conjunctivitis . . . . . 47
ALLERGY/CONG . . . . 19, 45
allopurinol . . . . . . . . . . . 29
alogliptin . . . . . . . . . . . . 21
alogliptin/metformin . . . . . 21
alogliptin/pioglitazone . . . . 21
ALPHAGAN . . . . . . . . . . 33
ALPHAGAN P . . . . . . . . . 33
altretamine . . . . . . . . . . . 4
ALL CAPS = Brand-name drug
lower case = Generic drug
49
alumina/magnesia . . . . . . 23
alumina/magnesia/
simethicone . . . . . . . . 23
aluminum acetate . . . . . . . 17
aluminum chloride topical
solution . . . . . . . . . . 17
amantadine . . . . . . . . 14, 27
AMARYL . . . . . . . . . . . . 21
ambrisentan . . . . . . . . . . 11
AMERGE . . . . . . . . . . . . 13
AMICAR . . . . . . . . . . . . . 7
amiloride . . . . . . . . . . . . 9
amiloride/hydrochlorothiazide 9
aminocaproic acid . . . . . . . 7
aminosalicyclic acid . . . . . 25
amiodarone tabs . . . . . . . . 8
amlodipine . . . . . . . . . . . 9
ammonium lactate . . . . . . 17
amoxicillin . . . . . . . . . . . 26
AMOXICILLIN CAPSULES AND
CHEWABLES . . . . . . . 26
amoxicillin/clavulanate . . . . 26
AMOXIL SUSP . . . . . . . . . 26
ampicillin . . . . . . . . . . . 26
anagrelide . . . . . . . . . . . 7
anakinra . . . . . . . . . . . . 28
anastrozole . . . . . . . . . . . 5
ANORO ELLIPTA . . . . . . . 38
antacids liquids, chew tabs . 47
antidiarrheals . . . . . . . . . 47
antihistamines . . . . . . . . . 45
antitussives. . . . . . . . . . . 46
ANTIVERT . . . . . . . . . . . 23
ANUSOL HC 2.5% . . . . . . 17
APHEDRID TAB . . . . . . . . 38
apixaban . . . . . . . . . . . . 6
aprepitant . . . . . . . . . . . 23
APRESOLINE . . . . . . . . . 11
APRISO . . . . . . . . . . . . . 24
ARALEN . . . . . . . . . . . . 27
ARANESP . . . . . . . . . . . . 7
ARAVA . . . . . . . . . . . . . 28
ARCAPTA NEOHALER . . . . 38
ARICEPT . . . . . . . . . . . . 11
ARIMIDEX . . . . . . . . . . . . 5
Index of Covered Drugs
ARNUITY ELLIPTA . . . . . . . 38
AROMASIN . . . . . . . . . . . .5
ARTANE . . . . . . . . . . . . 14
artificial tears . . . . . . . . . 47
asfotase alfa . . . . . . . . . . 22
ASMANEX HFA . . . . . . . . 38
ASMANEX TWISTHALER . . . 38
aspirin . . . . . . . . . . . . 7, 28
aspirin/acetaminophen/
caffeine . . . . . . . . . . 12
aspirin tabs, EC tabs,
chew tabs . . . . . . . . . 47
aspirin with buffers tabs . . . 47
ASTELIN . . . . . . . . . . . . 18
ATABEX PRENATAL . . . . . . 41
atenolol . . . . . . . . . . . . . 8
atenolol/chlorthalidone . . . . 9
atorvastatin . . . . . . . . . . 10
atovaquone . . . . . . . . . . 26
atropine . . . . . . . . . . . . 33
atropine sulfate . . . . . . . . 24
ATROVENT . . . . . . . . . . . 38
ATROVENT HFA . . . . . . . . 38
ATROVENT NASAL SPRAY . . 19
AUBAGIO . . . . . . . . . . . . 14
AUGMENTIN . . . . . . . . . . 26
auranofin . . . . . . . . . . . 28
AVITA . . . . . . . . . . . . . . 15
axitinib . . . . . . . . . . . . . 4
AYGESTIN . . . . . . . . . . . 31
azathioprine . . . . . . . . 6, 28
azelaic acid . . . . . . . . . . 14
azelastine . . . . . . . . . 18, 32
azithromycin . . . . . . . . . . 25
aztreonam . . . . . . . . . . . 42
AZULFIDINE . . . . . . . 24, 28
AZULFIDINE EN-TABS . . 24, 28
B
bacitracin . . . . . . . . . 15, 33
BACITRACIN . . . . . . . 15, 46
bacitracin/polymyxin/
neomycin/hc . . . . . . . 32
baclofen . . . . . . . . . . . . 29
BACLOFEN . . . . . . . . . . . 29
BACTRIM . . . . . . . . . . . . 26
BACTRIM DS . . . . . . . . . . 26
BACTROBAN . . . . . . . . . 15
balsalazide . . . . . . . . . . 24
BALZIVA . . . . . . . . . . . . 30
BARACLUDE . . . . . . . . . . 27
BASAGLAR . . . . . . . . . . . 20
BAYER . . . . . . . . . 7, 28, 47
becaplermin gel . . . . . . . . 17
bedaquiline . . . . . . . . . . 27
BENADRYL . . . . . . . . 18, 45
benazepril . . . . . . . . . . . .7
benazepril/hydrochlorothiazide8
BENTYL . . . . . . . . . . . . 24
BENZAC AC . . . . . . . . . . 14
benzocaine/antipyrine . . . . 18
benzonatate . . . . . . . . . . 34
BENZOTIC . . . . . . . . . . . 18
benzoyl peroxide . . . . . 14, 45
benztropine . . . . . . . . . . 14
BERINERT . . . . . . . . . . . 42
BETACARE CREAM AND
LOTION . . . . . . . . . . . 45
BETAGAN . . . . . . . . . . . 33
betamethasone
augmented dip . . . . 15, 16
betamethasone dipropionate 15
betamethasone val . . . . . . 15
BETAPACE . . . . . . . . . . . .8
BETA-VAL . . . . . . . . . . . . 15
bethanechol . . . . . . . . . . 39
BETHKIS . . . . . . . . . . . . 42
bexarotene caps and
topical gel . . . . . . . . . . 6
BIAXIN . . . . . . . . . . . . . 25
BIAXIN XL . . . . . . . . . . . 25
bicalutamide . . . . . . . . . . 5
BICITRA . . . . . . . . . . . . 39
BILTRICIDE . . . . . . . . . . . 25
BIO-D DRO-MULSION . . . . 40
BIO-D-MULSIO
DRO FORTE . . . . . . . . 40
bisoprolol . . . . . . . . . . . . 9
bisoprolol/hydrochlorothiazide 9
ALL CAPS = Brand-name drug
lower case = Generic drug
50
BLEPH-10 . . . . . . . . . . . 34
BONINE . . . . . . . . . . . . 47
BOOSTRIX . . . . . . . . . . . 44
bosentan . . . . . . . . . . . 11
BOSULIF . . . . . . . . . . . . .4
bosutinib . . . . . . . . . . . . 4
BREO ELLIPTA . . . . . . . . . 38
BRETHINE . . . . . . . . . . . 39
brimonidine . . . . . . . . 16, 33
BROMETANE DX . . . . . . . 35
BROMFED DM . . . . . . . . . 35
brompheniramine &
phenylephrine . . . . . . . 34
brompheniramine/
pseudoephedrine . . 34, 45
brompheniramine/
pseudoephedrine/
dextromethorphan . . . . 35
budesonide . . . . . . . . 24, 38
bumetanide . . . . . . . . . . . 9
BUMEX . . . . . . . . . . . . . .9
BUPHENYL ORAL POWDER 43
Burow’s soln, wet dressings . 46
busulfan . . . . . . . . . . . . . 4
butalbital/acetaminophen . . 12
butalbital/acetaminophen/
caffeine . . . . . . . . . . 12
butalbital/apap/caff/cod . . . 12
butalbital/asa/caff/cod . . . . 12
butalbital/aspirin/caffeine . . 12
butorphanol . . . . . . . . . . 12
C
C1 Inhibitor, Human . . . . . 42
cabergoline . . . . . . . . . . 22
CABOMETYX . . . . . . . . . .4
cabozantinib . . . . . . . . . . 4
CAFERGOT . . . . . . . . . . 13
calamine . . . . . . . . . . . . 17
CALAN . . . . . . . . . . . 9, 13
CALAN SR . . . . . . . . . . . .9
calcipotriene . . . . . . . . . 16
calcitonin-salmon . . . . . . . 21
calcitriol . . . . . . . . . . 16, 40
calcium . . . . . . . . . . 40, 48
Index of Covered Drugs
calcium acetate . . . . . . . . 42
CALTRATE . . . . . . . . . . . 48
canagliflozin . . . . . . . . . . 21
canagliflozin/metformin . . . 21
canagliflozin/metformin
extended-release . . . . . 21
canakinumab . . . . . . . . . 28
CANASA . . . . . . . . . . . . 24
capecitabine . . . . . . . . . . 4
CAPOTEN . . . . . . . . . . . . 7
CAPOZIDE . . . . . . . . . . . .8
CAPRELSA . . . . . . . . . . . .5
CAPSAGEL . . . . . . . . . . . 28
capsaicin . . . . . . . . . . . 28
captopril . . . . . . . . . . . . .7
captopril/hydrochlorothiazide . 8
CAPZASIN-P . . . . . . . . . . 28
CARAC . . . . . . . . . . . . . 17
CARAFATE . . . . . . . . . . . 23
CARAFATE SUSPENSION . . 24
CARBAGLU . . . . . . . . . . 43
carbamide peroxide . . . 18, 46
carbidopa/levodopa . . . . . 14
carbidopa/levodopa
extended-release . . . . . 14
CARDEC DM DRO . . . . . . 37
CARDEC DM SYP . . . . . . . 37
CARDEC DRO . . . . . . . . . 35
CARDEC SYP . . . . . . . . . 35
CARDENE . . . . . . . . . . . . 9
CARDIZEM . . . . . . . . . . . .9
CARDIZEM CD . . . . . . . . . .9
CARDIZEM SR . . . . . . . . . .9
CARDURA . . . . . . . . . . . .8
CARDURA . . . . . . . . . . . 39
carglumic acid . . . . . . . . 43
carteolol . . . . . . . . . . . . 33
carvedilol . . . . . . . . . . . . 9
casanthranol-docusate
sodium . . . . . . . . . . 22
CASODEX . . . . . . . . . . . . 5
CASTIVA . . . . . . . . . . . . 28
CATAPRES . . . . . . . . . . . .8
CAYSTON . . . . . . . . . . . 42
CECLOR . . . . . . . . . . . . 25
cefaclor . . . . . . . . . . . . 25
cefadroxil . . . . . . . . . . . 25
cefdinir . . . . . . . . . . . . . 25
cefixime . . . . . . . . . . . . 25
cefprozil . . . . . . . . . . . . 25
CEFTIN . . . . . . . . . . . . . 25
cefuroxime axetil . . . . . . . 25
CEFZIL . . . . . . . . . . . . . 25
CELEBREX . . . . . . . . . . . 28
celecoxib . . . . . . . . . . . 28
CELLCEPT . . . . . . . . . . . .6
CENESTIN . . . . . . . . . . . 31
CENOGEN OB/ULTRA . . . . 41
CENTRUM . . . . . . . . . . . 40
cephalexin . . . . . . . . . . . 25
ceritinib . . . . . . . . . . . . . 4
certolizumab . . . . . . . . . 28
CETAPHIL CREAM AND
LOTION . . . . . . . . . . . 45
cetirizine . . . . . . . . . . . . 18
cetirizine chew tab . . . . . . 18
cetirizine hydrochloride/
pseudoephedrine
hydrochloride
extended-release . . . . . 19
cetirizine/pseudoephedrine
OTC . . . . . . . . . . . . 45
CETYLEV . . . . . . . . . . . . 42
CHEMET . . . . . . . . . . . . 42
CHILD IBUPRO SUS COLD . 37
chlorambucil . . . . . . . . . . 4
chlorhexidine gluconate . . . 19
chloroquine phosphate . . . . 27
chlorothiazide . . . . . . . . . 9
chlorothiazide . . . . . . . . . 9
chlorpheniramine/
dextromethorphan . . . . 35
chlorpheniramine
extended-release . . . . . 18
chlorpheniramine maleate . . 18
chlorpheniramine maleate
phenylephrine HCL . . . . 35
chlorpheniramine/
phenylephrine . . . . . . . 35
ALL CAPS = Brand-name drug
lower case = Generic drug
51
chlorpheniramine/
phenylephrine . . . . . . . 35
chlorpheniramine/
phenylephrine/
pyrilamine . . . . . . . . . 19
chlorpheniramine/
pseudoephedrine 19, 35, 45
chlorpheniramine tan/
phenylephrine tan . . . . 35
chlorphen tan/
carbetapentane tan . . . . 35
chlorphen tan/pyrilamine tan/
PE tan . . . . . . . . . . . 35
chlorpropamide . . . . . . . . 21
chlorthalidone . . . . . . . . . 9
CHLORTHALIDONE . . . . . . .9
CHLOR-TRIMETON . . . . . . 45
CHLOR-TRIMETON
ALLERGY . . . . . . . . . 18
CHLOR-TRIMETON SYRUP . 18
chlorzoxazone . . . . . . . . . 29
CHOLBAM . . . . . . . . . . . 22
cholecalciferol . . . . . . . . . 40
cholestyramine . . . . . . . . 10
cholic acid . . . . . . . . . . . 22
ciclopirox . . . . . . . . . . . 16
cilostazol . . . . . . . . . . . . 7
CILOXAN . . . . . . . . . . . . 33
cimetidine . . . . . . . . . . . 23
CIMZIA . . . . . . . . . . . . . 28
cinacalcet . . . . . . . . . . . 42
CIPRO . . . . . . . . . . . . . 25
CIPRODEX . . . . . . . . . . . 18
ciprofloxacin . . . . . . . 25, 33
ciprofloxacin/dexamethasone18
clarithromycin . . . . . . . . . 25
clarithromycin ER . . . . . . . 25
CLARITIN . . . . . . . . . 18, 45
CLARITIN-D . . . . . . . . . . 36
CLEARASIL . . . . . . . . . . 45
CLEAR EYES REDNESS
RELIEF . . . . . . . . . . . 32
clemastine . . . . . . . . . . . 18
CLEMASTINE . . . . . . . . . 18
CLEOCIN . . . . . . . . . 27, 31
Index of Covered Drugs
CLEOCIN T . . . . . . . . . . . 14
CLIMARA . . . . . . . . . . . . 31
clindamycin . . . . . . 14, 27, 31
CLINORIL . . . . . . . . . 12, 29
clobetasol propionate . . . . 16
clonidine . . . . . . . . . . . . 8
clopidogrel . . . . . . . . . . . 7
clotrimazole . . . .16, 26, 31, 45
clotrimazole with
betamethasone . . . . . . 16
cobimetinib . . . . . . . . . . . 4
codeine/acetaminophen . . . 12
codeine/chlorpheniramine/
pseudoephedrine . . . . . 35
codeine/guaifenesin . . . . . 35
codeine/guaifenesin/
pseudoephedrine . . . . . 35
codeine/promethazine . . . . 35
codeine/promethazine/
phenylephrine . . . . . . . 35
codeine sulfate . . . . . . . . 12
CODIMAL DH . . . . . . . . . 37
COGENTIN . . . . . . . . . . . 14
COLACE . . . . . . . . . 22, 47
COLAZAL . . . . . . . . . . . 24
colchicine . . . . . . . . . . . 29
collagenase oint . . . . . . . 17
COLLOIDAL OATMEAL
BATHS . . . . . . . . . . . 46
COLOCORT . . . . . . . . . . 24
COLYTE . . . . . . . . . . . . 22
COMBIVENT . . . . . . . . . . 38
COMBIVENT RESPIMAT . . . 38
COMETRIQ . . . . . . . . . . . 4
COMPAZINE . . . . . . . . . . 23
COMPLETE NATALCARE
PAK DHA . . . . . . . . . . 40
COMTAN . . . . . . . . . . . . 14
condoms - male . . . . . . . . 46
CONDYLOX SOL . . . . . . . 17
conjugated estrogen/
bazedoxifene . . . . . . . 31
contraceptive foam . . . . . . 46
contraceptive gel . . . . . . . 46
COPAXONE . . . . . . . . . . 13
CORDARONE . . . . . . . . . .8
CORDRAN . . . . . . . . . . . 15
COREG . . . . . . . . . . . . . .9
CORICIDIN TAB CGH/CLD . 35
CORTAID . . . . . . . . . . . . 46
CORTEF . . . . . . . . . . . . 19
cortisone acetate . . . . . . . 19
CORTISPORIN . . . . . . . . . 32
CORTISPORIN OTIC . . . . . 18
CORTIZONE . . . . . . . . . . 15
CORTIZONE-10 INTENSIVE
HEALING . . . . . . . . . . 15
COSENTYX . . . . . . . . . . 28
COSOPT . . . . . . . . . . . . 33
COTELLIC . . . . . . . . . . . . 4
COUMADIN . . . . . . . . . . . 7
COZAAR . . . . . . . . . . . . .8
CREON . . . . . . . . . . . . . 24
crizotinib . . . . . . . . . . . . 4
CROLOM . . . . . . . . . . . . 32
cromolyn . . . . . . . . . . . . 38
cromolyn sodium . . . . . 19, 32
crotamiton . . . . . . . . . . . 16
CURITY ALCOHOL PADS . . 46
CUTIVATE . . . . . . . . . . . 15
cyanocobalamin . . . . . . . 40
CYCLESSA . . . . . . . . . . . 30
cyclobenzaprine . . . . . . . 29
CYCLOGYL . . . . . . . . . . . 33
cyclopentolate . . . . . . . . . 33
cyclophosphamide . . . . . . . 4
cycloserine . . . . . . . . . . 25
cyclosporine . . . . . . . . . . 6
cyclosporine, modified . . . . . 6
cyproheptadine . . . . . . . . 18
CYPROHEPTADINE . . . . . . 18
CYSTAGON . . . . . . . . . . . 6
CYSTARAN . . . . . . . . . . . 34
cysteamine 0.44%
ophthalmic solution . . . . 34
cysteamine bitartrate . . . . . . 6
CYTOMEL . . . . . . . . . . . 22
CYTOTEC . . . . . . . . . . . 24
CYTOVENE . . . . . . . . . . . 27
CYTOXAN . . . . . . . . . . . . 4
ALL CAPS = Brand-name drug
lower case = Generic drug
52
D
D3-50 CAP . . . . . . . . . . . 40
dabrafenib . . . . . . . . . . . 4
danazol . . . . . . . . . . . . 31
DANOCRINE . . . . . . . . . . 31
DANTRIUM . . . . . . . . . . . 29
dantrolene . . . . . . . . . . . 29
dapsone . . . . . . . . . . . . 27
DAPSONE . . . . . . . . . . . 27
DARAPRIM . . . . . . . . . . . 28
darbepoetin alfa . . . . . . . . 7
dasatinib . . . . . . . . . . . . 4
DAYPRO . . . . . . . . . . 12, 29
DDAVP . . . . . . . . . . . . . 22
DEBROX . . . . . . . . . 18, 46
DECADRON . . . . . . . . . . 19
decongestants . . . . . . . . 47
deferasirox . . . . . . . . . . . 7
DELATESTRYL . . . . . . . . . 20
DELFEN . . . . . . . . . . . . 46
DELSYM . . . . . . . . . . 36, 46
DELTASONE . . . . . . . . . . 20
DELZICOL . . . . . . . . . . . 24
DEMADEX . . . . . . . . . . . 10
DEMEROL . . . . . . . . . . . 13
DEPEN TITRATABLE . . . . . 28
DEPO-PROVERA . . . . . . . 30
DEPO-TESTOSTERONE . . . 20
DERMAPHOR OINTMENT . . 45
DERMA-SMOOTHE OIL/FS . 15
dermatological baths . . . . . 46
DERMATOP . . . . . . . . . . 15
DESENEX . . . . . . . . . . . 16
desmopressin . . . . . . . . . 22
desogestrel/EE . . . . . . 29, 30
DETROL . . . . . . . . . . . . 39
dexamethasone . . . . . . . . 19
dexamethasone sodium
phosphate . . . . . . . . . 32
DEXASOL . . . . . . . . . . . 32
dextromethorphan/
brompheniramine/
pseudoephedrine . . . . . 35
dextromethorphanguaifenesin . . . . . . . . 36
Index of Covered Drugs
dextromethorphan/
guaifenesin . . . . . . . . 36
dextromethorphan hbr . . . . 36
dextromethorphan polistirex
extended-release . . . . . 36
dextromethorphan/
promethazine . . . . . . . 36
dextromethorphan/quinidine 34
D.H.E. 45 . . . . . . . . . . . . 13
DIABINESE . . . . . . . . . . . 21
DIAMOX SEQUELS . . . . . . 33
diclofenac 1% gel . . . . . . . 28
diclofenac sodium . . . . . . 32
dicloxacillin . . . . . . . . . . 26
DICLOXACILLIN . . . . . . . . 26
dicyclomine . . . . . . . . . . 24
DIDRONEL . . . . . . . . . . . 21
DIFICID . . . . . . . . . . . . . 26
DIFLUCAN . . . . . . . . 26, 31
digoxin . . . . . . . . . . . . . 8
DIHISTINE DH . . . . . . . . . 35
dihydroergotamine . . . . . . 13
DIHYDRO-PE SYP . . . . . . . 37
DILACOR XR . . . . . . . . . . 9
DILANTIN INFATABS . . . . . 14
DILANTIN, PHENYTEK . . . . 14
DILAUDID . . . . . . . . . . . . 13
diltiazem . . . . . . . . . . . . 9
diltiazem extended-release . . 9
diltiazem sustained-release . . 9
DIMEATAPP DRO
DECONGES . . . . . . . . 19
dimenhydrinate . . . . . . . . 47
DIMETAPP . . . . . . . . . . . 45
DIMETAPP CLD ELX/
ALLERGY . . . . . . . . . 34
DIMETAPP DRO DCON/CGH37
DIMETAPP DRO DECONGES 46
DIMETAPP SYP CGH/CLD . . 35
dimethyl fumarate . . . . . . . 13
DIPENTUM . . . . . . . . . . . 24
diphenhydramine . . . . . . . 18
diphenoxylate/atropine . . . . 23
diphtheria-tetanus tox adsorbed
(dt) im . . . . . . . . . . . 43
DIPROLENE . . . . . . . 15, 16
DIPROLENE AF . . . . . . . . 15
DIP/TET PED INJ . . . . . . . 43
dipyridamole . . . . . . . . . . 7
DISALCID . . . . . . . . . . . . 29
disopyramide . . . . . . . . . . 8
disopyramide extended-release8
DITROPAN . . . . . . . . . . . 39
DITROPAN XL . . . . . . . . . 39
DIURIL . . . . . . . . . . . . . . 9
DIURIL ORAL SUSPENSION . . 9
docusate calcium plus . . . . 22
docusate potasssium . . . . . 22
docusate sodium . . . . . . . 22
dofetilide . . . . . . . . . . . . 8
DOMEBORO . . . . . . . . . . 46
DOMEBORO OTIC . . . . . . 18
donepezil . . . . . . . . . . . 11
dornase alfa . . . . . . . . . . 42
dorzolamide . . . . . . . . . . 33
dorzolamide/timolol maleate 33
DOSTINEX . . . . . . . . . . . 22
DOVONEX . . . . . . . . . . . 16
doxazosin . . . . . . . . . . 8, 39
doxycycline monohydrate . . 26
DOXYCYCLINE
MONOHYDRATE . . . . . 26
doxylamine succinate . . 34, 47
DRAMAMINE . . . . . . . . . 47
DRISDOL . . . . . . . . . . . . 40
dronabinol . . . . . . . . . . . 23
DROXIA . . . . . . . . . . . . . .6
DUAVEE . . . . . . . . . . . . 31
DULCOLAX . . . . . . . . . . 47
DULERA . . . . . . . . . . . . 38
DUOFILM . . . . . . . . . 17, 48
DUONEB . . . . . . . . . . . . 38
DURAGESIC . . . . . . . . . . 12
DURATUSS DM ELX . . . . . 36
DUREX . . . . . . . . . . . . . 46
DURICEF . . . . . . . . . . . . 25
DYAZIDE . . . . . . . . . . . . 10
ALL CAPS = Brand-name drug
lower case = Generic drug
53
E
ecothiophate . . . . . . . . . 33
ECOTRIN . . . . . . . . 7, 28, 47
ED A-HIST TABLETS AND
LIQUID . . . . . . . . . . . 35
EDGE OB CHW . . . . . . . . 41
edoxaban . . . . . . . . . . . . 6
E.E.S. . . . . . . . . . . . . . . 26
EFUDEX . . . . . . . . . . . . 17
elbasvir/grazoprevir . . . . . . 27
ELDEPRYL . . . . . . . . . . . 14
electrolyte . . . . . . . . . 40, 47
ELIDEL . . . . . . . . . . . . . 17
ELIMITE . . . . . . . . . . . . . 16
ELIQUIS . . . . . . . . . . . . . .6
ELOCON . . . . . . . . . . . . 15
eltrombopag . . . . . . . . . . 43
EMCYT . . . . . . . . . . . . . .4
EMEND . . . . . . . . . . . . . 23
EMETROL . . . . . . . . . . . 47
EMLA . . . . . . . . . . . . . . 17
emollients . . . . . . . . . . . 45
empagliflozin . . . . . . . . . 21
empagliflozin/metformin . . . 21
empagliflozin/metformin
extended-release . . . . . 21
enalapril . . . . . . . . . . . . . 7
enalapril/hydrochlorothiazide . 8
ENBREL . . . . . . . . . . . . 28
ENGERIX-B . . . . . . . . . . . 43
enoxaparin . . . . . . . . . . . 6
entacapone . . . . . . . . . . 14
entecavir . . . . . . . . . . . . 27
ENTERIC COATEDNAPROSYN . . . . . . 12, 29
ENTOCORT EC . . . . . . . . 24
ENULOSE . . . . . . . . . . . 22
E-OINTMENT . . . . . . . . . 45
EPANED . . . . . . . . . . . . . 7
EPCLUSA . . . . . . . . . . . . 27
epinephrine . . . . . . . . . . 42
EPIPEN . . . . . . . . . . . . . 42
EPIPEN JR. . . . . . . . . . . . 42
EPIVIR HBV . . . . . . . . . . . 27
epoetin alfa . . . . . . . . . . . 7
Index of Covered Drugs
EPOGEN . . . . . . . . . . . . .7
ergocalciferol (D2) . . . . . . 40
ergotamine/caffeine . . . . . 13
ergotamine tartrate/
caffeine . . . . . . . . . . 13
ERIVEDGE . . . . . . . . . . . .6
erlotinib . . . . . . . . . . . . . 4
ERYC . . . . . . . . . . . . . . 26
ERYGEL . . . . . . . . . . . . 14
ERY-TAB . . . . . . . . . . . . 26
ERYTHROCIN . . . . . . . . . 26
erythromycin . . . . . . . 14, 33
ERYTHROMYCIN . . . . . . . 33
erythromycin
delayed-release . . . . . . 26
erythromycin delayed-release 26
erythromycin ethylsuccinate . 26
erythromycin stearate . . . . . 26
erythromycin/sulfisoxazole . . 26
ESBRIET . . . . . . . . . . . . 43
ESGIC . . . . . . . . . . . . . 12
esomeprazole . . . . . . . . . 23
ESTRACE . . . . . . . . . . . . 31
estradiol . . . . . . . . . . . . 31
estramustine
phosphate sodium . . . . . 4
estrogens, conjugated . . . . 31
estrogens, conjugated/
medroxyprogesterone . . 31
estrogens, conjugated,
synthetic A . . . . . . . . . 31
estropipate . . . . . . . . . . 31
ESTROSTEP FE . . . . . . . . 31
etanercept . . . . . . . . . . . 28
ethambutol . . . . . . . . . . 25
ethionamide . . . . . . . . . . 25
ethynodiol diacetate/EE . . . 30
etidronate . . . . . . . . . . . 21
etodolac . . . . . . . . . . 12, 28
etonogestrel/EE . . . . . . . . 30
etoposide . . . . . . . . . . . . 6
EULEXIN . . . . . . . . . . . . .5
EURAX . . . . . . . . . . . . . 16
everolimus . . . . . . . . . . 4, 6
EVISTA . . . . . . . . . . . . . 21
EXCEDRIN MIGRAINE . . . . 12
EXELON . . . . . . . . . . . . 11
exemestane . . . . . . . . . . . 5
EXJADE . . . . . . . . . . . . . .7
ezetimibe . . . . . . . . . . . 10
F
famotidine . . . . . . . . 23, 47
FANTASY . . . . . . . . . . . . 46
FARESTON . . . . . . . . . . . .5
FARYDAK . . . . . . . . . . . . .4
febuxostat . . . . . . . . . . . 29
FELDENE . . . . . . . . . 12, 29
felodipine extended-release . . 9
FEMARA . . . . . . . . . . . . .5
fenofibrate . . . . . . . . . . . 10
fentanyl transdermal . . . . . 12
FEOSOL . . . . . . . . . . 40, 48
FERGON . . . . . . . . . . . . 48
ferrous bisglycinate/
polysaccarides iron . . . . 40
ferrous sulfate . . . . . . . . . 40
fidaxomicin . . . . . . . . . . 26
filgrastim . . . . . . . . . . . . 7
FINACEA . . . . . . . . . . . . 14
finasteride . . . . . . . . . . . 39
fingolimod . . . . . . . . . . . 13
FIORICET . . . . . . . . . . . . 12
FIORICET W/CODEINE . . . . 12
FIORINAL . . . . . . . . . . . . 12
FIORINAL W/CODEINE . . . . 12
FIRAZYR . . . . . . . . . . . . 42
FLAGYL . . . . . . . . . . 27, 31
flecainide . . . . . . . . . . . . 8
FLEET ENEMA . . . . . . . . . 47
FLEET PHOSPHO-SODA . . . 47
FLEXERIL . . . . . . . . . . . . 29
FLOMAX . . . . . . . . . . . . 39
FLONASE . . . . . . . . . . . . 19
FLORANEX . . . . . . . . . . . 24
FLORINEF . . . . . . . . . . . 19
FLOXIN . . . . . . . . . . . . . 25
FLOXIN OTIC . . . . . . . . . . 18
FLUARIX QUAD . . . . . . . . 43
FLUBLOK . . . . . . . . . . . . 43
ALL CAPS = Brand-name drug
lower case = Generic drug
54
FLUCELVAX . . . . . . . . . . 43
fluconazole . . . . . . . . 26, 31
fludrocortisone . . . . . . . . 19
FLULAVAL QUAD . . . . . . . 43
FLUMADINE . . . . . . . . . . 27
fluocinolone acetonide . . . . 15
fluocinonide . . . . . . . . . . 15
fluocinonide emulsified base 16
fluoride . . . . . . . . . . . . . 40
fluoride dental rinse . . . . . 48
fluorometholone . . . . . . . 32
FLUOROPLEX . . . . . . . . . 17
fluorouracil . . . . . . . . . . 17
flurandrenolide . . . . . . . . 15
flurbiprofen . . . . . . . . . . 32
flutamide . . . . . . . . . . . . 5
fluticasone . . . . . . . . . . . 19
fluticasone furoate . . . . . . 38
fluticasone propionate . . . . 15
fluticasone/vilanterol . . . . . 38
FLUVIRIN . . . . . . . . . . . . 44
FLUZONE HD PF . . . . . . . 43
FLUZONE QUAD . . . . . . . 43
FLUZONE SPLT . . . . . . . . 43
FML . . . . . . . . . . . . . . . 32
FML FORTE . . . . . . . . . . 32
FML LIQUIFILM . . . . . . . . 32
folic acid . . . . . . . . . . . . 40
FOLIC ACID . . . . . . . . . . 40
FOLTABS PAK PLUS DHA RE
OB + DHA PAK . . . . . . 41
FOLTABS PRENATAL . . . . . 41
FORTEO . . . . . . . . . . . . 21
FORTICAL . . . . . . . . . . . 21
FOSAMAX . . . . . . . . . . . 21
fosinopril . . . . . . . . . . . . 7
fosinopril/hydrochlorothiazide 8
FURADANTIN SUSP . . . . . 28
furosemide . . . . . . . . . . 10
G
galantamine . . . . . . . . . . 11
ganciclovir . . . . . . . . . . . 27
GARDASIL . . . . . . . . . . . 43
GARDASIL 9 . . . . . . . . . . 43
Index of Covered Drugs
gatifloxin . . . . . . . . . . . . 34
GATTEX . . . . . . . . . . . . 24
gefitinib . . . . . . . . . . . . . 4
GEL-KAM . . . . . . . . . . . . 40
gemfibrozil . . . . . . . . . . . 10
GENGRAF . . . . . . . . . . . .6
GENTAK . . . . . . . . . . 15, 34
gentamicin . . . . . . . . 15, 34
gentamicin/prednisolone
acetate . . . . . . . . . . . 32
GENTEX ADE . . . . . . . . . 41
GG/CODEINE . . . . . . . . . 35
GG/DM CR . . . . . . . . . . . 36
GILENYA . . . . . . . . . . . . 13
GILOTRIF . . . . . . . . . . . . .4
glatiramer acetate . . . . 13, 14
GLATOPA . . . . . . . . . . . . 14
GLEEVEC . . . . . . . . . . . . 4
GLEOSTINE . . . . . . . . . . . 4
glimepiride . . . . . . . . . . 21
glipizide . . . . . . . . . . . . 21
glipizide extended-release . . 21
GLUCAGON . . . . . . . . . . 20
glucagon, human
recombinant . . . . . . . . 20
GLUCOPHAGE . . . . . . . . 21
GLUCOPHAGE ER . . . . . . 21
glucose oral tablets . . . . . . 46
GLUCOTROL . . . . . . . . . 21
GLUCOTROL XL . . . . . . . . 21
GLUCOVANCE . . . . . . . . 21
glyburide . . . . . . . . . . . . 21
glyburide, micronized . . . . . 21
glycerin . . . . . . . . . . . . 22
GLYCERIN SUPPOSITORY . . 22
GLYCERIN TOPICAL . . . . . 45
glycerol phenylbutyrate . . . . 43
glycopyrrolate . . . . . . . . . 24
GLYNASE . . . . . . . . . . . . 21
GRIFULVIN V . . . . . . . . . . 26
griseofulvin microsize . . . . . 26
griseofulvin ultramicrosize . . 26
GRIS-PEG . . . . . . . . . . . 26
guaifenesin . . . . . . . . . . 36
guaifenesin extended-release 36
guaifenesin/
pseudoephedrine . . . . . 36
guaifenesin/
pseudoephedrine/
dextromethorphan . . . . 36
guaifenesin/
pseudoephedrine
extended-release . . . . . 36
guanabenz . . . . . . . . . . 11
guanfacine . . . . . . . . . . . 8
guanfacine ER . . . . . . . . 34
GUIATUSS AC . . . . . . . . . 35
GUIATUSS DAC . . . . . . . . 35
GYNE-LOTRIMIN . . . . . 31, 45
GYNOL II . . . . . . . . . . . . 46
H
halobetasol . . . . . . . . . . 16
HAVRIX . . . . . . . . . . . . . 43
HECORIA . . . . . . . . . . . . 6
heparin . . . . . . . . . . . . . 7
HEPARIN . . . . . . . . . . . . .7
hepatitis a vaccine susp . . . 43
hepatitis b vaccine . . . . . . 43
HEPSERA . . . . . . . . . . . 27
hexachlorophene . . . . . . . 17
HEXALEN . . . . . . . . . . . . 4
HIPREX . . . . . . . . . . . . . 39
homatropine . . . . . . . . . . 33
HUMALOG . . . . . . . . . . . 20
HUMALOG MIX 50/50 . . . . 20
HUMALOG MIX 75/25 . . . . 20
human papillomavirus (hpv)
9-valent recomb vac . . . 43
human papillomavirus (hpv)
quadrivalent recombinant
vac . . . . . . . . . . . . . 43
HUMATIN . . . . . . . . . . . . 28
HUMIRA . . . . . . . . . . . . 28
HUMULIN . . . . . . . . . . . 46
HUMULIN 70/30 . . . . . . . 20
HUMULIN N . . . . . . . . . . 20
HUMULIN R . . . . . . . . . . 20
HYCAMTIN . . . . . . . . . . . .6
HYCODAN . . . . . . . . . . . 36
ALL CAPS = Brand-name drug
lower case = Generic drug
55
hydralazine . . . . . . . . . . 11
HYDREA . . . . . . . . . . . . . 6
hydrochlorothiazide . . . . . . 10
HYDROCHLOROTHIAZIDE . 10
hydrocodone/
acetaminophen . . . . . . 13
hydrocodone ER . . . . . . . 13
hydrocodone/homatropine . 36
HYDROCODONE/
TAB HOMATROP . . . . . 36
hydrocortisone . .15, 17, 19, 24
hydrocortisone/aloe . . . . . 15
hydrocortisone butyrate . . . 15
hydrocortisone crm, oint . . . 46
hydrocortisone valerate . . . 15
HYDROMET SYP . . . . . . . 36
hydromorphone . . . . . . . . 13
hydroxychloroquine . . . 27, 28
hydroxyurea . . . . . . . . . . 6
hyoscyamine, methenamine,
phenyl salicylate, sodium
phosphate monobasic,
methylene blue . . . . . . 39
hyoscyamine sulfate . . . . . 24
hyoscyamine sulfate
extended-release . . . . . 24
HYPERCARE 15% . . . . . . . 17
HYPERSAL . . . . . . . . . . . 42
HYPERTET S/D . . . . . . . . 44
HYPOTEARS . . . . . . . . . . 47
HYTONE . . . . . . . . . . . . 15
HYTRIN . . . . . . . . . . . 8, 39
HYZAAR . . . . . . . . . . . . . 8
I
IBRANCE . . . . . . . . . . . . .4
ibrutinib . . . . . . . . . . . . . 4
IBUOROFEN TAB COLD/SIN 37
ibuprofen . . . . .12, 28, 29, 47
icatibant . . . . . . . . . . . . 42
ICLUSIG . . . . . . . . . . . . . 5
idelalisib . . . . . . . . . . . . . 4
ILARIS . . . . . . . . . . . . . . 28
imatinib mesylate . . . . . . . . 4
IMBRUVICA . . . . . . . . . . . 4
Index of Covered Drugs
IMDUR . . . . . . . . . . . . . 10
imiquimod 5% cream . . . . . 17
IMITREX . . . . . . . . . . . . 13
IMODIUM A-D . . . . . . . 23, 47
IMPAVIDO . . . . . . . . . . . 26
IMURAN . . . . . . . . . . . 6, 28
INCRELEX . . . . . . . . . . . 21
INCRUSE ELLIPTA . . . . . . 38
indacaterol . . . . . . . . . . . 38
indapamide . . . . . . . . . . 10
INDERAL . . . . . . . . . . 9, 13
INDERIDE . . . . . . . . . . . . 9
INDOCIN . . . . . . . . . 12, 29
indomethacin . . . . . . . 12, 29
INFLAMASE FORTE . . . . . . 32
influenza virus vaccine
recombinant hemagglutinin
(ha) . . . . . . . . . . . . . 43
influenza virus vaccine split . 43
influenza virus vaccine split
high-dose pf . . . . . . . . 43
influenza virus vaccine split pf43
influenza virus vaccine split
quadrivalent . . . . . . . . 43
influenza virus vaccine tiss-cult
subunit . . . . . . . . . . . 43
influenza virus vaccine types
a&b surface antigen . . . 44
INLYTA . . . . . . . . . . . . . . 4
insulin aspart . . . . . . . . . 20
insulin aspart protamine 70%/
insulin aspart 30% . . . . 20
insulin glargine . . . . . . . . 20
insulin human . . . . . . . . . 20
insulin isophane . . . . . . . . 20
insulin isophane human . . . 20
insulin isophane human 70%/
regular 30% . . . . . . . . 20
insulin isophane/regular . . . 20
insulin lisopro pro/lispro . . . 20
insulin lisopro prot/lispro . . . 20
insulin lispro . . . . . . . . . . 20
insulin regular . . . . . . . . . 20
insulin syringes . . . . . . . . 43
insulin . . . . . . . . . . . . . 46
INTAL . . . . . . . . . . . . . . 38
interferon alfa-2b . . . . . . 5, 27
INTRON A . . . . . . . . . . 5, 27
INTUNIV . . . . . . . . . . . . 34
INVOKAMET . . . . . . . . . . 21
INVOKAMET XR . . . . . . . . 21
INVOKANA . . . . . . . . . . . 21
ipratropium . . . . . . . . . . 38
ipratropium/albuterol . . . . . 38
ipratropium HFA . . . . . . . 38
ipratropium nasal . . . . . . . 19
IRESSA . . . . . . . . . . . . . .4
iron . . . . . . . . . . . . . . . 48
iron polysaccharides . . . . . 48
ISMO . . . . . . . . . . . . . . 10
isoniazid . . . . . . . . . . . . 25
ISONIAZID . . . . . . . . . . . 25
ISOPTO ATROPINE . . . . . . 33
ISOPTO CARPINE . . . . . . . 33
ISOPTO HOMATROPINE . . . 33
ISOPTO HYOSCINE . . . . . . 33
ISORDIL . . . . . . . . . . . . 10
ISORDIL S.L. . . . . . . . . . . 10
isosorbide dinitrate . . . . . . 10
ISOSORBIDE
DINITRATE ER . . . . . . . 10
isosorbide dinitrate
extended-release . . . . . 10
isosorbide mononitrate . . . . 10
isosorbide mononitrate
extended-release . . . . . 10
isotretinoin . . . . . . . . . . . 14
itraconazole . . . . . . . . . . 26
ivacaftor . . . . . . . . . . . . 42
ivermectin . . . . . . . . . . . 25
ixazomib . . . . . . . . . . . . 5
J
JADENU . . . . . . . . . . . . . 7
JAKAFI . . . . . . . . . . . . . . 5
JARDIANCE . . . . . . . . . . 21
K
KALYDECO . . . . . . . . . . . 42
KALYDECO GRANULES . . . 42
ALL CAPS = Brand-name drug
lower case = Generic drug
56
KAOPECTATE . . . . . . . . . 47
KAYEXALATE . . . . . . . . . 11
KAZANO . . . . . . . . . . . . 21
K-DUR 10 . . . . . . . . . . . . 42
K-DUR 20 . . . . . . . . . . . . 42
KEFLEX . . . . . . . . . . . . . 25
KENALOG . . . . . . . . . 15, 16
KENALOG IN ORABASE . . . 19
ketoconazole . . . . . 16, 17, 26
ketoprofen . . . . . . . . 12, 29
ketorolac . . . . . . . . . . . . 32
ketorolac tromethamine . . . 12
ketotifen . . . . . . . . . . . . 32
KIMONO . . . . . . . . . . . . 46
KINERET . . . . . . . . . . . . 28
K-LOR . . . . . . . . . . . . . . 42
KLOR-CON 8 . . . . . . . . . 42
KLOR-CON 10 . . . . . . . . . 42
K-LYTE . . . . . . . . . . . . . 42
KORLYM . . . . . . . . . . . . 22
K-PHOS NEUTRAL . . . . . . 42
K-PHOS ORIGINAL . . . . . . 42
KUVAN . . . . . . . . . . . . . 22
L
labetalol . . . . . . . . . . . . . 9
LAC-HYDRIN . . . . . . . . . . 17
LACTINOL . . . . . . . . . . . 17
lactobacillus . . . . . . . . . . 24
lactulose . . . . . . . . . . . . 22
LAMISIL . . . . . . . . . . . . . 26
LAMISIL AT . . . . . . . . . . . 16
lamivudine . . . . . . . . . . . 27
lancets . . . . . . . . . . . . . 43
LANOXIN . . . . . . . . . . . . .8
lansoprazole . . . . . . . . . . 23
lansoprazole delayed-release 23
lapatinib ditosylate . . . . . . . 4
LARIAM . . . . . . . . . . . . . 27
LASIX . . . . . . . . . . . . . . 10
latanoprost . . . . . . . . . . 33
laxative enemas . . . . . . . . 47
laxatives . . . . . . . . . . . . 47
leflunomide . . . . . . . . . . 28
lenalidomide . . . . . . . . . . 5
Index of Covered Drugs
lenvatinib . . . . . . . . . . . . 4
LENVIMA . . . . . . . . . . . . .4
LETAIRIS . . . . . . . . . . . . 11
letrozole . . . . . . . . . . . . . 5
leucovorin . . . . . . . . . . . . 5
LEUCOVORIN . . . . . . . . . .5
LEUKERAN . . . . . . . . . . . .4
LEUKINE . . . . . . . . . . . . .7
leuprolide . . . . . . . . . . . . 5
levalbuterol HCl . . . . . . . . 38
LEVAQUIN . . . . . . . . . . . 25
levobunolol . . . . . . . . . . 33
levocetirizine . . . . . . . . . 18
levofloxacin . . . . . . . . . . 25
levonorgestrel . . . . . . . . . 29
levonorgestrel/EE . . . . 29, 30
levothyroxine . . . . . . . . . 22
LEVOXYL . . . . . . . . . . . . 22
LEVSIN . . . . . . . . . . . . . 24
LEVSINEX . . . . . . . . . . . 24
LIDAMANTEL . . . . . . . . . 17
LIDEX . . . . . . . . . . . . . . 15
LIDEX E . . . . . . . . . . . . . 16
lidocaine . . . . . . . . . . . . 17
lidocaine/prilocaine . . . . . 17
lidocaine viscous . . . . . . . 19
LIFESTYLES . . . . . . . . . . 46
lifitegrast . . . . . . . . . . . . 33
linaclotide . . . . . . . . . . . 22
linezolid . . . . . . . . . . . . 27
LINZESS . . . . . . . . . . . . 22
liothyronine . . . . . . . . . . 22
liotrix . . . . . . . . . . . . . . 22
LIPITOR . . . . . . . . . . . . . 10
liraglutide . . . . . . . . . . . 21
lisinopril . . . . . . . . . . . . . 7
lisinopril/hydrochlorothiazide . 8
LMX-4 . . . . . . . . . . . . . . 17
LOCOID . . . . . . . . . . . . . 15
LODINE . . . . . . . . . . 12, 28
LOESTRIN 1.5/30 . . . . . . . 30
LOESTRIN 1/20 . . . . . . . . 30
LOESTRIN FE 1.5/30 . . . . . 30
LOESTRIN FE 1/20 . . . . . . 30
LOFIBRA . . . . . . . . . . . . 10
LOHIST-D . . . . . . . . . . . . 35
LOMOTIL . . . . . . . . . . . . 23
lomustine . . . . . . . . . . . . 4
LONITEN . . . . . . . . . . . . 11
LONSURF . . . . . . . . . . . . 4
LO/OVRAL . . . . . . . . . . . 30
loperamide . . . . . . . . . . 23
LOPERAMIDE . . . . . . . . . 23
LOPID . . . . . . . . . . . . . . 10
LOPRESSOR . . . . . . . . . . .9
loratadine . . . . . . . . . . . 18
loratadine/pseudoephedrine 45
loratadine/pseudoephedrine
extended-release . . . . . 19
loratadine & pseudoephedrine
SR 24hr . . . . . . . . . . 36
LORCET . . . . . . . . . . . . 13
LORTAB . . . . . . . . . . . . 13
LORTAB ELIXIR . . . . . . . . 13
losartan . . . . . . . . . . . . . 8
losartan/HCTZ . . . . . . . . . 8
LOTENSIN . . . . . . . . . . . . 7
LOTENSIN HCT . . . . . . . . . 8
LOTRIMIN AF . . . . . . . 16, 45
LOTRISONE . . . . . . . . . . 16
lovastatin . . . . . . . . . . . . 10
LOVAZA . . . . . . . . . . . . 10
LOVENOX . . . . . . . . . . . . 6
LOZOL . . . . . . . . . . . . . 10
lumacaftor/ivacaftor . . . . . 42
LUPRON . . . . . . . . . . . . .5
LUPRON DEPOT . . . . . . . . 5
LUPRON DEPOT-PED . . . . . .5
LURIDE . . . . . . . . . . . . . 40
LURIDE LOZI-TABS . . . . . . 40
LYNPARZA . . . . . . . . . . . .6
LYSODREN . . . . . . . . . . . .6
LYSTEDA . . . . . . . . . . . . 32
M
MAALOX . . . . . . . . . 23, 47
macitentan . . . . . . . . . . 11
MACROBID . . . . . . . . . . 27
MACRODANTIN . . . . . . . . 27
magnesium oxide . . . . . . . 40
ALL CAPS = Brand-name drug
lower case = Generic drug
57
magnesium oxide . . . . . . . 48
MAG-OX . . . . . . . . . . 40, 48
malathion . . . . . . . . . . . 16
MAPAP COLD TAB . . . . . . 37
MARINOL . . . . . . . . . . . . 23
MATERNA . . . . . . . . . . . 41
MATULANE . . . . . . . . . . . 6
MAXALT/MAXALT MLT . . . . 13
MAXITROL . . . . . . . . . . . 32
MAXZIDE . . . . . . . . . . . . 10
M-CLEAR WC . . . . . . . . . 35
measles, mumps & rubella virus
vaccines for inj . . . . . . 44
mecasermin . . . . . . . . . . 21
meclizine . . . . . . . . . 23, 47
MEDROL . . . . . . . . . 19, 20
medroxyprogesterone
acetate . . . . . . . . 30, 31
mefloquine . . . . . . . . . . 27
MEGACE . . . . . . . . . . . . .5
megestrol acetate . . . . . . . 5
MEKINIST . . . . . . . . . . . . 5
meloxicam . . . . . . . . 12, 29
melphalan . . . . . . . . . . . 4
memantine . . . . . . . . . . 11
MENACTRA . . . . . . . . . . 44
meningococcal . . . . . . . . 44
meningococcal (a, c, y, and
w-135) conjugate vaccine 44
meningococcal (a, c, y, and
w-135) oligo conj vac
for inj . . . . . . . . . . . . 44
MENOMUNE . . . . . . . . . . 44
MENVEO . . . . . . . . . . . . 44
meperidine . . . . . . . . . . 13
MEPHYTON . . . . . . . . . . 40
MEPRON . . . . . . . . . . . . 26
mercaptopurine . . . . . . . . 4
mesalamine . . . . . . . . . . 24
mesalamine extended-release24
mesna . . . . . . . . . . . . . . 5
MESNEX . . . . . . . . . . . . .5
MESTINON . . . . . . . . . . . 14
MESTINON TIMESPAN . . . . 14
METAMUCIL . . . . . . . . . . 47
Index of Covered Drugs
metaproterenol . . . . . . . . 39
METAPROTERENOL SYRUP 39
metformin . . . . . . . . . . . 21
metformin ER . . . . . . . . . 21
metformin/glyburide . . . . . 21
methazolamide . . . . . . . . 33
methenamine hippurate . . . 39
METHERGINE . . . . . . 22, 32
methimazole . . . . . . . . . . 22
methocarbamol . . . . . . . . 29
methotrexate . . . . . . . . . 28
methoxsalen . . . . . . . . . . 16
methyldopa . . . . . . . . . . 11
methyldopa/HCTZ . . . . . . 11
methylergonovine . . . . 22, 32
methylprednisolone . . . 19, 20
metipranolol . . . . . . . . . . 33
metoclopramide . . . . . . . 23
metolazone . . . . . . . . . . 10
metoprolol . . . . . . . . . . . 9
metoprolol succinate . . . . . . 9
METROCREAM . . . . . . . . 16
METROGEL . . . . . . . . . . 16
METROGEL 1% . . . . . . . . 31
METROGEL-VAGINAL . . . . 31
METROLOTION . . . . . . . . 16
metronidazole . . . . 16, 27, 31
MEVACOR . . . . . . . . . . . 10
mexiletine . . . . . . . . . . . . 8
MEXITIL . . . . . . . . . . . . . .8
MIACALCIN . . . . . . . . . . 21
MICATIN . . . . . . . . . . 16, 45
miconazole . . . . . . . . 16, 31
miconazole crm . . . . . . . . 45
MICRO-K 10 . . . . . . . . . . 42
MICRONASE . . . . . . . . . . 21
MICROZIDE . . . . . . . . . . 10
MIDAMOR . . . . . . . . . . . . 9
midodrine . . . . . . . . . . . 11
mifepristone . . . . . . . . . . 22
MIGERGOT SUPPOSITORIES13
MIGRANAL . . . . . . . . . . . 13
milnacipran . . . . . . . . . . 29
miltefosine . . . . . . . . . . . 26
MINIPRESS . . . . . . . . . . . .8
MINOCIN . . . . . . . . . . . . 26
minocycline . . . . . . . . . . 26
minoxidil . . . . . . . . . . . . 11
MINUTUSS DR SYP . . . . . . 37
MIRALAX . . . . . . . . . . . . 22
MIRAPEX . . . . . . . . . . . . 14
MIRCETTE . . . . . . . . . . . 29
MIRVASO . . . . . . . . . . . . 16
misoprostol . . . . . . . . . . 24
MITIGARE . . . . . . . . . . . 29
mitotane . . . . . . . . . . . . . 6
M-M-R II . . . . . . . . . . . . . 44
MOBIC . . . . . . . . . . 12, 29
MODICON . . . . . . . . . . . 30
MODURETIC . . . . . . . . . . .9
mometasone . . . . . . . . . 38
mometasone/formoterol . . . 38
mometasone furoate . . . . . 15
mometasone inhalation . . . 38
MONISTAT . . . . . . . . 31, 45
MONISTAT 3 . . . . . . . . . . 31
MONISTAT-DERM . . . . . . . 16
MONOPRIL . . . . . . . . . . . 7
MONOPRIL-HCT . . . . . . . . .8
montelukast . . . . . . . . . . 39
morphine . . . . . . . . . . . 13
morphine extended-release . 13
MOTRIN . . . . . . . . . . 12, 29
MOTRIN IB . . . . . . . . . . . 47
MOVANTIK . . . . . . . . . . . 24
MOZOBIL . . . . . . . . . . . . .7
MS CONTIN . . . . . . . . . . 13
MSIR . . . . . . . . . . . . . . 13
MUCINEX . . . . . . . . . . . 36
MUCINEX D . . . . . . . . . . 36
MUCINEX DM . . . . . . . . . 36
MUCOMYST . . . . . . . . . . 42
MULTI SYMPTOM TAB
COLD RLF . . . . . . . . . 37
multivitamins/fluoride/±iron . 40
multivitamins/minerals . . . . 40
mupirocin . . . . . . . . . . . 15
MURINE . . . . . . . . . . . . 47
MURO 128 . . . . . . . . . . . 34
MYAMBUTOL . . . . . . . . . 25
ALL CAPS = Brand-name drug
lower case = Generic drug
58
MYCELEX . . . . . . . . . 16, 26
MYCOBUTIN . . . . . . . . . . 25
mycophenolate mofetil . . . . .6
mycophenolate sodium . . . . 6
MYCOSTATIN . . . . . . . 16, 26
MYFORTIC . . . . . . . . . . . .6
MYLANTA . . . . . . . . . 23, 47
MYLERAN . . . . . . . . . . . . 4
MYLICON . . . . . . . . . . . 47
MYSOLINE . . . . . . . . . . . 14
N
nabumetone . . . . . . . . . . 12
naloxegol . . . . . . . . . . . 24
naloxone . . . . . . . . . . . . 34
NAMENDA . . . . . . . . . . . 11
naphazoline/glycerin . . . . . 32
naphazoline HCL . . . . . . . 32
naphazoline/zinc sulfate . . . 32
NAPHCON A . . . . . . . . . . 47
NAPROSYN . . . . . . . . 12, 29
naproxen . . . . . . . . . 12, 29
naproxen delayed release 12, 29
naratriptan . . . . . . . . . . . 13
NARCAN NASAL SPRAY . . . 34
NASACORT ALLERGY . . . . 19
NASALCROM . . . . . . . . . 19
nasal sprays . . . . . . . . . . 46
NATALCARE . . . . . . . . . . 41
nateglinide . . . . . . . . . . . 21
NEBUSAL . . . . . . . . . . . 42
neomycin/bacitracin/
polymyxin . . . . . . . . . 34
neomycin/polymyxin B/
bacitracin . . . . . . . . . 15
neomycin/polymyxin B/
dexamethasone . . . . . . 32
neomycin/polymyxin B/
gramicidin . . . . . . . . . 34
neomycin/polymyxin B/
hydrocortisone . . . . 18, 32
neomycin sulfate . . . . . . . 27
NEORAL . . . . . . . . . . . . . 6
NEOSPORIN . . . . . 15, 34, 46
NEO-SYNEPHRINE . . . 19, 46
Index of Covered Drugs
NEPHROCAPS . . . . . . . . 41
NEPTAZANE . . . . . . . . . . 33
NESINA . . . . . . . . . . . . . 21
NESTABSCBF/FA/RX . . . . . 41
NEULASTA . . . . . . . . . . . .7
NEUMEGA . . . . . . . . . . . .7
NEUTROGENA OIL FREE
ACNE WASH . . . . . . . . 14
NEXAVAR . . . . . . . . . . . . .5
NEXIUM 24HR OTC . . . . . . 23
NEXIUM DELAYED
RELEASE PACKET . . . . 23
niacin . . . . . . . . . . . . . 10
niacin extended-release . . . 10
NIACOR . . . . . . . . . . . . 10
NIASPAN . . . . . . . . . . . . 10
nicardipine . . . . . . . . . . . 9
nifedipine . . . . . . . . . . . . 9
nifedipine extended-release . . 9
NIFEREX . . . . . . . . . 40, 48
NIFEREX-PN FORTE . . . . . 41
nilotinib . . . . . . . . . . . . . 4
nimodipine . . . . . . . . . . . 9
NIMOTOP . . . . . . . . . . . . 9
NINLARO . . . . . . . . . . . . .5
nintedanib . . . . . . . . . . . 43
nitazoxanide suspension . . . 26
nitazoxanide tablet . . . . . . 26
nitisinone . . . . . . . . . . . 22
NITREK . . . . . . . . . . . . 11
NITRO-BID . . . . . . . . . . . 11
NITRO-DUR . . . . . . . . . . 11
nitrofurantoin
extended-release . . . . . 27
nitrofurantoin macrocrystals . 27
nitrofurantoin susp . . . . . . 28
nitroglycerin . . . . . 10, 11, 17
NITROLINGUAL . . . . . . . . 10
NITROSTAT . . . . . . . . . . . 10
NIX . . . . . . . . . . . . . . . 47
NIX CREME RINSE . . . . . . 16
NIZORAL . . . . . . . . . 16, 26
NIZORAL SHAMPOO . . . . . 17
NOLVADEX . . . . . . . . . . . .5
NORCO . . . . . . . . . . . . . 13
NORDETTE . . . . . . . . . . 30
norelgestromin/EE . . . . . . 30
norethindrone . . . . . . . . . 30
norethindrone acetate . . . . 31
norethindrone acetate/EE . . 30
norethindrone
acetate/EE/iron . . . 30, 31
norethindrone/EE . . . . 29, 30
norethindrone/ME . . . . . . 30
NORFLEX . . . . . . . . . . . 29
norgestimate/EE . . . . . 30, 31
norgestrel/EE . . . . . . . . . 30
NORPACE . . . . . . . . . . . . 8
NORPACE CR . . . . . . . . . .8
NORVASC . . . . . . . . . . . . 9
NOVOLIN . . . . . . . . . . . . 46
NOVOLIN 70/30 . . . . . . . . 20
NOVOLIN N . . . . . . . . . . 20
NOVOLIN R . . . . . . . . . . 20
NOVOLOG . . . . . . . . . . . 20
NOVOLOG MIX 70/30 . . . . 20
NUEDEXTA . . . . . . . . . . . 34
NULYTELY . . . . . . . . . . . 22
NUTROPIN AQ NUSPIN . . . 21
NUVARING . . . . . . . . . . . 30
NYMALIZE . . . . . . . . . . . .9
nystatin . . . . . . . . . . 16, 26
O
OCEAN NASAL SPRAY . . . . 19
octreotide . . . . . . . . . . . . 6
OCUFEN . . . . . . . . . . . . 32
OCUFLOX . . . . . . . . . . . 34
ODOMZO . . . . . . . . . . . . .6
OFEV . . . . . . . . . . . . . . 43
ofloxacin . . . . . . . 18, 25, 34
OGEN . . . . . . . . . . . . . . 31
olaparib . . . . . . . . . . . . . 6
olodaterol . . . . . . . . . . . 38
olsalazine sodium . . . . . . . 24
omalizumab . . . . . . . . . . 38
omega 3 acid ethyl esters . . 10
omeprazole delayed-release 23
OMNICEF . . . . . . . . . . . . 25
ondansetron . . . . . . . . . . 23
ALL CAPS = Brand-name drug
lower case = Generic drug
59
ONE TOUCH SYSTEMS (ULTRA
2, ULTRAMINI, VERIO,
VERIO FLEX, VERIO IQ,
VERIO SYNC) . . . . . . . 20
ONE TOUCH TEST STRIPS
(ULTRA, VERIO) . . . . . . 21
oprelvekin . . . . . . . . . . . . 7
OPSUMIT . . . . . . . . . . . . 11
OPTIPRANOLOL . . . . . . . 33
OPTIVAR . . . . . . . . . . . . 32
ORAPRED . . . . . . . . . . . 20
ORFADIN . . . . . . . . . . . . 22
ORKAMBI . . . . . . . . . . . 42
orphenadrine
extended-release . . . . . 29
ORTHO-CEPT . . . . . . . . . 30
ORTHO COIL . . . . . . . . . 30
ORTHO-CYCLEN . . . . . . . 30
ortho diaphragm . . . . . . . 30
ORTHO EVRA . . . . . . . . . 30
ORTHO FLAT . . . . . . . . . 30
ORTHO FLEX . . . . . . . . . 30
ORTHO MICRONOR . . . . . 30
ORTHO-NOVUM 1/35 . . . . 30
ORTHO-NOVUM 1/50 . . . . 30
ORTHO-NOVUM 7/7/7 . . . . 30
ORTHO-NOVUM 10/11 . . . 29
ORTHO TRI-CYCLEN . . . . . 31
ORUDIS . . . . . . . . . . 12, 29
OS-CAL . . . . . . . . . . 40, 48
oseltamivir . . . . . . . . . . . 27
OSENI . . . . . . . . . . . . . . 21
OVCON 50 . . . . . . . . . . . 30
OVIDE . . . . . . . . . . . . . . 16
OVRAL . . . . . . . . . . . . . 30
oxaprozin . . . . . . . . . 12, 29
OXSORALEN-ULTRA . . . . . 16
oxybutynin chloride . . . . . . 39
oxybutynin IR . . . . . . . . . 39
oxycodone . . . . . . . . . . 13
oxycodone/acetaminophen . 13
oxycodone/aspirin . . . . . . 13
OXYFAST . . . . . . . . . . . . 13
oxymetazoline . . . . . . . . . 19
oxymorphone ER . . . . . . . 13
Index of Covered Drugs
OXYMORPHONE ER . . . . . 13
P
palbociclib . . . . . . . . . . . 4
palivizumab . . . . . . . . . . 28
pancrelipase . . . . . . . . . 24
panobinostat . . . . . . . . . . 4
PANRETIN . . . . . . . . . . . .6
pantoprazole . . . . . . . . . 23
PARAFON FORTE DSC . . . . 29
paromomycin . . . . . . . . . 28
PASER . . . . . . . . . . . . . 25
pasireotide . . . . . . . . . . . 6
patiromer . . . . . . . . . . . 11
pazopanib . . . . . . . . . . . 5
PEDIACARE LIQ MULTI-SY . . 37
PEDIALYTE . . . . . . . . 40, 47
PEDIAPRED . . . . . . . . . . 20
PEDIAZOLE . . . . . . . . . . 26
peg 3350/electrolytes . . . . 22
peg 3350/sodium bicarbonate/
sodium chloride . . . . . 22
peg 3350/sodium bicarbonate/
sodium chloride/potassium
chloride . . . . . . . . . . 22
PEGASYS . . . . . . . . . . . . 27
PEGASYS PROCLICK . . . . 27
pegfilgrastim . . . . . . . . . . 7
peginterferon alfa-2a . . . . . 27
peginterferon alfa-2b . . . . . . 5
peginterferon beta-1a . . . . 14
pegvisomant . . . . . . . . . 22
penicillamine . . . . . . . . . 28
penicillin VK . . . . . . . . . . 26
PENLAC SOLUTION 8% . . . 16
pentazocine/naloxone . . . . 13
pentoxifylline extended-release 7
PEPCID . . . . . . . . . . . . . 23
PEPCID AC . . . . . . . . 23, 47
PERCOCET . . . . . . . . . . 13
PERCODAN . . . . . . . . . . 13
PERIDEX . . . . . . . . . . . . 19
permethrin . . . . . . . . 16, 47
PERSANTINE . . . . . . . . . . 7
phenazopyridine . . . . . . . 39
PHENERGAN . . . . . . . . . 23
PHENERGAN DM . . . . . . . 36
phenobarbital . . . . . . . . . 14
PHENOBARBITAL . . . . . . . 14
phenylephrine . . . . . . . . . 19
phenylephrine/
brompheniramine/
dextromethorphan . . . . 36
phenylephrine/
chlorpheniramine/
dextromethorphan . . . . 37
phenylephrine/
chlorpheniramine/
dihydrocodeine . . . . . . 37
phenylephrine/
dextromethorphan . . . . 37
phenylephrine/
dextromethorphan/
guaifenesin . . . . . . . . 37
phenylephrine/ephed/CPM
w/carbetapentane . . . . 37
phenylephrine/guaifenesin . . 37
phenylephrine/pyrilamine
w/hydrocodone . . . . . . 37
PHENYLHIST LIQ DH . . . . . 35
phenytoin . . . . . . . . . . . 14
phenytoin sodium extended . 14
PHISOHEX . . . . . . . . . . . 17
PHOS-FLUR . . . . . . . . 40, 48
PHOSPHOLINE IODINE . . . 33
phosphorus . . . . . . . . . . 42
PHRENILIN . . . . . . . . . . . 12
phytonadione . . . . . . . . . 40
pilocarpine . . . . . . . . 19, 33
PILOPINE HS GEL . . . . . . . 33
pimecrolimus . . . . . . . . . 17
pindolol . . . . . . . . . . . . . 9
PINDOLOL . . . . . . . . . . . .9
PIN-X . . . . . . . . . . . . . . 25
pioglitazone . . . . . . . . . . 21
PIPERONYL BUTOXIDE . . . 47
piperonyl butoxide gel, liquid
shampoo . . . . . . . . . 47
pirfenidone capsule . . . . . 43
piroxicam . . . . . . . . . 12, 29
ALL CAPS = Brand-name drug
lower case = Generic drug
60
PLAN B ONE STEP . . . . . . 29
PLAQUENIL . . . . . . . . 27, 28
PLAVIX . . . . . . . . . . . . . . 7
PLEGRIDY . . . . . . . . . . . 14
PLENDIL . . . . . . . . . . . . . 9
plerixafor . . . . . . . . . . . . 7
PLETAL . . . . . . . . . . . . . .7
PLEXION . . . . . . . . . . . . 15
pneumococcal 13-valent
conjugate . . . . . . . . . 44
pneumococcal vaccine
polyvalent . . . . . . . . . 44
PNEUMOVAX . . . . . . . . . 44
PNEUMOVAX 23 . . . . . . . 44
podofilox . . . . . . . . . . . . 17
polyethylene glycol 3350 . . . 22
polymyxin B/bacitracin . . . . 34
polymyxin B/trimethoprim . . 34
polysaccharide iron complex 40
POLYSPORIN . . . . . . . . . 34
POLYTRIM . . . . . . . . . . . 34
POLY-VI-FLOR . . . . . . . . . 40
POLY-VI-SOL . . . . . . . . . . 48
pomalidomide . . . . . . . . . 5
POMALYST . . . . . . . . . . . .5
ponatinib . . . . . . . . . . . . 5
potassium acid phosphate . . 42
potassium bicarbonate/
potassium citrate
effervescent . . . . . . . . 42
potassium chloride . . . . . . 42
POTASSIUM CHLORIDE . . . 42
potassium chloride
extended-release . . . . . 42
potassium citrate . . . . . . . 39
povidone-iodine . . . . . . . . 28
PRALUENT . . . . . . . . . . . 10
pramipexole . . . . . . . . . . 14
pramlintide . . . . . . . . . . 21
PRANDIN . . . . . . . . . . . . 21
praziquantel . . . . . . . . . . 25
prazosin . . . . . . . . . . . . . 8
PRECOSE . . . . . . . . . . . 21
PRED FORTE . . . . . . . . . 32
PRED-G . . . . . . . . . . . . . 32
Index of Covered Drugs
PRED MILD . . . . . . . . . . 32
prednicarbate . . . . . . . . . 15
prednisolone . . . . . . . . . 20
prednisolone acetate . . . . . 32
prednisolone phosphate . . . 32
prednisolone sodium
phosphate . . . . . . . . . 20
prednisone . . . . . . . . . . 20
PRELONE . . . . . . . . . . . 20
PREMARIN . . . . . . . . . . . 31
PREMPHASE . . . . . . . . . 31
PREMPRO . . . . . . . . . . . 31
prenatal vitamins w/folic acid 41
PRENATAL VITAMINS
W/ FOLIC ACID . . . . . . 41
prenatal vit w/FE bisglycinate
chelate-FA . . . . . . . . . 41
prenatal vit w/FE
polysac cmplx-FA . . . . . 41
prenatal vit w/iron
carbonyl-FA . . . . . . . . 41
prenatal vit w/o vit a w/fe
bisglycinate-fa tab
32-1 mg . . . . . . . . . . 41
prenatal w/o A w/ FE carbonylFE gluc-DSS-FA . . . . . . 41
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3 . . . . . . . . 40
prenat-FE Bis-FE prot succ-FACA & omega 3 . . . . . . 40
prenat-FE bis-FE prot succ-FACA & omega DR . . . . . 41
prenat w/o A w/fecbn-feglDSS-FA & DHA . . . . . . 41
PREPARATION H . . . . . . . 47
PREVACID . . . . . . . . . . . 23
PREVIDENT . . . . . . . . . . 40
PREVNAR 13 . . . . . . . . . 44
PRIFTIN . . . . . . . . . . . . . 25
PRILOSEC . . . . . . . . . . . 23
primaquine . . . . . . . . . . 28
primidone . . . . . . . . . . . 14
PRINCIPEN . . . . . . . . . . . 26
PROAMATINE . . . . . . . . . 11
probenecid . . . . . . . . . . 29
PROBENECID . . . . . . . . . 29
PROBIOTIC FORMULA . . . . 24
probiotic product . . . . . . . 24
procarbazine . . . . . . . . . . 6
PROCARDIA . . . . . . . . . . .9
PROCARDIA XL . . . . . . . . .9
prochlorperazine . . . . . . . 23
PROCRIT . . . . . . . . . . . . .7
PROCTOSOL HC
CREAM 2.5% . . . . . . . 17
PROCTOZONE
CREAM-HC 2.5% . . . . . 17
PROGRAF . . . . . . . . . . . . 6
PROMACTA . . . . . . . . . . 43
promethazine . . . . . . . . . 23
promethazine &
phenylephrine . . . . . . . 37
PROMETHAZINE SYP DM . . 36
PROMETHAZINE VC
W/CODEINE . . . . . . . . 35
PROMETHAZINE
W/CODEINE . . . . . . . . 35
PROMETH VC SYP 6.25-5/5 . 37
propafenone . . . . . . . . . . 8
propantheline . . . . . . . . . 39
propranolol . . . . . . . . . 9, 13
propranolol/HCTZ . . . . . . . 9
propylthiouracil . . . . . . . . 22
PROPYLTHIOURACIL . . . . . 22
PROSCAR . . . . . . . . . . . 39
PROTONIX . . . . . . . . . . . 23
PROTOPIC 0.1% . . . . . . . . 17
PROTOPIC 0.03% . . . . . . . 17
PROVENTIL . . . . . . . . . . 38
PROVERA . . . . . . . . . . . 31
PRUET DHAEC PAK . . . . . 41
PRUET DHA PAK
SETONET PAK . . . . . . 40
PSE/GG . . . . . . . . . . . . 36
pseudoephedrine/
acetaminophen/
dextromethorphan . . . . 37
ALL CAPS = Brand-name drug
lower case = Generic drug
61
pseudoephedrine/
chlorpheniramine/
dextromethorphan . . . . 37
pseudoephedrine/
dextromethorphan/
guaifenesin . . . . . . . . 37
pseudoephedrine/iburprofen 37
pseudoephedrine tan/
dexchlorphen tan/
DM tan . . . . . . . . . . . 38
psyllium . . . . . . . . . . . . 47
PULMICORT RESPULES . . . 38
PULMOZYME . . . . . . . . . 42
PURINETHOL . . . . . . . . . . 4
pyrantel pamoate . . . . . . . 25
pyrazinamide . . . . . . . . . 25
PYRAZINAMIDE . . . . . . . . 25
pyrethrins/piperonyl but . . . 16
PYRIDIUM . . . . . . . . . . . 39
pyridostigmine . . . . . . . . 14
pyridostigmine
extended-release . . . . . 14
pyrilamine tan/phenyleph tan 38
pyrimethamine . . . . . . . . 28
Q
QUESTRAN . . . . . . . . . . 10
QUESTRAN-LIGHT . . . . . . 10
quinapril . . . . . . . . . . . . . 7
quinapril/hydrochlorothiazide . 8
quinidine gluconate
extended-release . . . . . . 8
QUINIDINE GLUCONATE
EXT-REL . . . . . . . . . . . 8
quinidine sulfate . . . . . . . . 8
QUINIDINE SULFATE . . . . . .8
quinidine sulfate extendedrelease . . . . . . . . . . . 8
QUINIDINE SULFATE EXT-REL 8
R
raloxifene . . . . . . . . . . . 21
RANEXA . . . . . . . . . . . . 11
ranitidine . . . . . . . . . . . . 23
ranolazine . . . . . . . . . . . 11
Index of Covered Drugs
RAPAMUNE . . . . . . . . . . . 6
RAVICTI . . . . . . . . . . . . . 43
RAZADYNE . . . . . . . . . . 11
REBETOL/COPEGUS . . . . 27
RECOMBIVAX HB . . . . . . . 43
rectal crm, suppositories . . . 47
RECTIV . . . . . . . . . . . . . 17
REESE’S PINWORM
MEDICINE . . . . . . . . . 25
REGLAN . . . . . . . . . . . . 23
regorafenib . . . . . . . . . . . 5
REGRANEX . . . . . . . . . . 17
RELAFEN . . . . . . . . . . . . 12
RELENZA . . . . . . . . . . . . 27
RELION 70/30 . . . . . . . . . 20
RELION N . . . . . . . . . . . 20
RELION R . . . . . . . . . . . 20
RENVELA . . . . . . . . . . . . 42
repaglinide . . . . . . . . . . 21
REQUIP . . . . . . . . . . . . . 14
RETIN-A . . . . . . . . . . . . 15
REVATIO . . . . . . . . . . . . 11
REVLIMID . . . . . . . . . . . . 5
ribavirin . . . . . . . . . . . . 27
RIDAURA . . . . . . . . . . . . 28
RID SHAMPOO/
BUTOXIDE SHAMPOO . . 16
rifabutin . . . . . . . . . . . . 25
RIFADIN . . . . . . . . . . . . . 25
rifampin . . . . . . . . . . . . 25
rifapentine . . . . . . . . . . 25
rimantadine . . . . . . . . . . 27
rimexolone . . . . . . . . . . . 32
riociguat . . . . . . . . . . . . 11
rivaroxaban . . . . . . . . . . . 7
rivastigmine . . . . . . . . . . 11
rizatriptan . . . . . . . . . . . 13
RMS . . . . . . . . . . . . . . . 13
ROBAXIN . . . . . . . . . . . . 29
ROBINUL . . . . . . . . . . . . 24
ROBITUSSIN . . . . . . . 36, 46
ROBITUSSIN CF . . . . . 36, 46
ROBITUSSIN DM . . . . . 36, 46
ROBITUSSIN LIQ
CGH/ALRG . . . . . . . . 37
ROBITUSSIN LIQ
CGH/CLD . . . . . . . 35, 37
ROBITUSSIN LIQ
CGH/CONG . . . . . . . . 36
ROBITUSSIN LIQ HD/CHST . 37
ROBITUSSIN LIQ PED NGHT 37
ROBITUSSIN PE . . . . . 36, 46
ROBITUSSIN PED LIQ
CGH/COLD . . . . . . . . 35
ROBITUSSIN PED SYP . . . . 36
ROBITUSSIN SYP
CHST CNG . . . . . . . . . 36
ROBITUSSIN SYP MAX-ST . . 36
ROCALTROL . . . . . . . . . . 40
rolapitant . . . . . . . . . . . . 23
RONDEC DM . . . . . . . . . 37
RONDEC DM DROPS . . . . 37
RONDEC DROPS . . . . . . . 35
RONDEC SYRUP . . . . . . . 35
ropinirole . . . . . . . . . . . 14
ROWASA . . . . . . . . . . . . 24
ROXICODONE . . . . . . . . . 13
R-TANNAMINE . . . . . . . . . 35
ruxolitinib . . . . . . . . . . . . 5
RYNA-12 S . . . . . . . . . . . 38
RYNATAN PEDIATRIC SUSP . 35
RYNATUSS PEDIATRIC SUSP37
RYTHMOL . . . . . . . . . . . .8
S
SALAGEN . . . . . . . . . . . 19
salicylic acid . . . . . . . 14, 16
salicylic acid 17%/
collodion . . . . . . . 17, 48
saline nasal spray 0.65% . . . 19
salsalate . . . . . . . . . . . . 29
SAL-TROPINE . . . . . . . . . 24
SANCTURA . . . . . . . . . . 39
SANDIMMUNE . . . . . . . . . .6
SANDOSTATIN . . . . . . . . . .6
SANTYL . . . . . . . . . . . . 17
sapropterin . . . . . . . . . . 22
sargramostim . . . . . . . . . . 7
SAVAYSA . . . . . . . . . . . . .6
SAVELLA . . . . . . . . . . . . 29
ALL CAPS = Brand-name drug
lower case = Generic drug
62
SCALPICIN . . . . . . . . . . . 16
scopolamine . . . . . . . . . 33
SEASONALE . . . . . . . . . . 29
SECTRAL . . . . . . . . . . . . .8
secukinumab . . . . . . . . . 28
SEDAPAP . . . . . . . . . . . . 12
selegiline . . . . . . . . . . . 14
selenium sulfide . . . . . . . . 17
SELSUN . . . . . . . . . . . . 17
sennosides . . . . . . . . . . 22
SENOKOT . . . . . . . . . . . 22
SENSIPAR . . . . . . . . . . . 42
SEROMYCIN . . . . . . . . . . 25
sevelamer . . . . . . . . . . . 42
SIGNIFOR . . . . . . . . . . . . 6
sildenafil . . . . . . . . . . . . 11
SILVADENE . . . . . . . . . . . 15
silver sulfadiazine . . . . . . . 15
simethicone . . . . . . . . . . 47
simvastatin . . . . . . . . . . . 10
SINEMET . . . . . . . . . . . . 14
SINEMET CR . . . . . . . . . . 14
SINGULAIR . . . . . . . . . . . 39
sirolimus . . . . . . . . . . . . 6
SIRTURO . . . . . . . . . . . . 27
sodium chloride fornebulizer 42
sodium chloride hypertonic . 34
sodium citrate/citric acid . . . 39
sodium phenylbutyrate oral
powder . . . . . . . . . . 43
sodium polystyrene sulfonate 11
sofosbuvir . . . . . . . . . . . 27
sofosbuvir/velpatasvir . . . . 27
somatropin . . . . . . . . . . 21
SOMAVERT . . . . . . . . . . 22
sonidegib . . . . . . . . . . . . 6
sorafenib . . . . . . . . . . . . 5
SORIATANE . . . . . . . . . . 16
sotalol . . . . . . . . . . . . . . 8
SOVALDI . . . . . . . . . . . . 27
spacers . . . . . . . . . . . . 43
spironolactone . . . . . . . . 10
spironolactone/
hydrochlorothiazide . . . 10
SPORANOX . . . . . . . . . . 26
Index of Covered Drugs
SPRYCEL . . . . . . . . . . . . .4
STADOL . . . . . . . . . . . . 12
STARLIX . . . . . . . . . . . . 21
STATUSS DM SYP . . . . . . . 37
STIVARGA . . . . . . . . . . . . 5
stool softeners . . . . . . . . 47
STRENSIQ . . . . . . . . . . . 22
STRIVERDI RESPIMAT . . . . 38
STROMECTOL . . . . . . . . . 25
STUART PRENATAL . . . . . . 48
succimer . . . . . . . . . . . 42
sucralfate . . . . . . . . . . . 23
sugar+orthophosphoric acid 47
sulcralfate . . . . . . . . . . . 24
sulfacetamide . . . . . . . . . 34
sulfacetamide/pred phos . . 32
sulfacetamide/sulfur . . . . . 15
SULFACET-R . . . . . . . . . . 15
sulfamethoxazole/
trimethoprim, DS . . . . . 26
sulfasalazine . . . . . . . . . . 24
sulfasalazine . . . . . . . . . . 28
sulfasalazine
delayed-release . . . . 24, 28
sulindac . . . . . . . . . . 12, 29
sumatriptan . . . . . . . . . . 13
sunitinib . . . . . . . . . . . . . 5
SUPRAX . . . . . . . . . . . . 25
SUTENT . . . . . . . . . . . . . 5
SYLATRON . . . . . . . . . . . .5
SYMLIN . . . . . . . . . . . . . 21
SYMMETREL . . . . . . . 14, 27
SYNAGIS . . . . . . . . . . . . 28
SYNALAR . . . . . . . . . . . 15
SYNJARDY . . . . . . . . . . . 21
SYNJARDY XR . . . . . . . . . 21
SYNTHROID . . . . . . . . . . 22
T
TABLOID . . . . . . . . . . . . . 4
tacrolimus . . . . . . . . . . 6, 17
TAFINLAR . . . . . . . . . . . . 4
TAGAMET . . . . . . . . . . . 23
TALWIN NX . . . . . . . . . . . 13
TAMBOCOR . . . . . . . . . . .8
TAMIFLU . . . . . . . . . . . . 27
tamoxifen . . . . . . . . . . . . 5
tamsulosin . . . . . . . . . . . 39
TANAFED DMX
SUSPENSION . . . . . . . 38
TANZEUM . . . . . . . . . . . 21
TAPAZOLE . . . . . . . . . . . 22
TARCEVA . . . . . . . . . . . . .4
TARGRETIN . . . . . . . . . . . 6
TASIGNA . . . . . . . . . . . . .4
TASMAR . . . . . . . . . . . . 14
TECFIDERA . . . . . . . . . . 13
teduglutide . . . . . . . . . . 24
TEMODAR . . . . . . . . . . . .4
TEMOVATE . . . . . . . . . . . 16
temozolomide . . . . . . . . . 4
TENEX . . . . . . . . . . . . . . 8
TENIVAC . . . . . . . . . . . . 44
TENORETIC . . . . . . . . . . .9
TENORMIN . . . . . . . . . . . .8
TERAZOL 3/7 . . . . . . . . . 31
terazosin . . . . . . . . . . . . 8
terazosin . . . . . . . . . . . . 39
terbinafine . . . . . . . . 16, 26
terbutaline . . . . . . . . . . . 39
terconazole . . . . . . . . . . 31
teriflunomide . . . . . . . . . 14
teriparatide inj . . . . . . . . . 21
TESSALON . . . . . . . . . . . 34
TESTOSTERONE 1%
TOPICAL GEL . . . . . . . 20
testosterone cypionate . . . . 20
testosterone enanthate . . . . 20
testosterone gel topical tube,
packet, and pump bottle 20
tetanus-diphtheria toxoids (td)44
tetanus immune globulin . . . 44
TET/DIP TOX INJ . . . . . . . 44
tetrabenazine . . . . . . . . . 14
tetrahydrozoline/zinc sulfate . 32
tet tox-diph-acell pertuss ad . 44
thalidomide . . . . . . . . . . . 6
THALOMID . . . . . . . . . . . .6
THEO-24 . . . . . . . . . . . . 39
THEOCHRON . . . . . . . . . 39
ALL CAPS = Brand-name drug
lower case = Generic drug
63
theophylline . . . . . . . . . . 39
THEOPHYLLINE . . . . . . . . 39
theophylline extended-release39
thioguanine . . . . . . . . . . . 4
THYROLAR . . . . . . . . . . 22
TIAZAC . . . . . . . . . . . . . .9
TIGAN . . . . . . . . . . . . . . 23
TIKOSYN . . . . . . . . . . . . .8
timolol . . . . . . . . . . . . . 33
timolol maleate . . . . . . . 9, 33
TIMOPTIC . . . . . . . . . . . 33
TIMOPTIC XE . . . . . . . . . 33
TINACTIN . . . . . . . . . 16, 45
tizanidine . . . . . . . . . . . 29
TOBRADEX . . . . . . . . . . 33
tobramycin . . . . . . . . . . 34
tobramycin/dexamethasone 33
tobramycin neb soln . . . . . 42
TOBREX . . . . . . . . . . . . 34
tolazamide . . . . . . . . . . . 21
tolbutamide . . . . . . . . . . 21
TOLBUTAMIDE . . . . . . . . 21
tolcapone . . . . . . . . . . . 14
TOLINASE . . . . . . . . . . . 21
tolnaftate . . . . . . . . . 16, 45
tolterodine . . . . . . . . . . . 39
topical antibacterials . . . . . 46
topotecan . . . . . . . . . . . . 6
TOPROL XL . . . . . . . . . . . 9
TORADOL . . . . . . . . . . . 12
toremifene . . . . . . . . . . . 5
torsemide . . . . . . . . . . . 10
TOUJEO SOLOSTAR . . . . . 20
TRACLEER . . . . . . . . . . . 11
tramadol . . . . . . . . . . . . 12
trametinib . . . . . . . . . . . . 5
TRANDATE . . . . . . . . . . . .9
tranexamic acid . . . . . . . . 32
TRECATOR . . . . . . . . . . . 25
TRENTAL . . . . . . . . . . . . .7
tretinoin . . . . . . . . . . . 6, 15
triamcinolone . . . . . . . . . 19
triamcinolone acetonide . 15, 16
triamcinolone nasal spray . . 19
Index of Covered Drugs
triamterene/
hydrochlorothiazide . . . 10
TRI-FED X . . . . . . . . . . . . 38
trifluridine . . . . . . . . . . . 34
trifluridine/tipiracil . . . . . . . 4
trihexyphenidyl . . . . . . . . 14
TRILYTE . . . . . . . . . . . . 22
trimethobenzamide . . . . . . 23
trimethoprim . . . . . . . . . . 28
TRIMETHOPRIM . . . . . . . . 28
TRI-NORINYL . . . . . . . . . 30
TRIOTANN . . . . . . . . . . . 19
TRIOTANN PEDIATRIC SUSP 35
tripolidine/pseudoephedrine 38
TRIPROL/PSE SYP . . . . . . 38
TRI RX . . . . . . . . . . . . . 41
TRI-VI-FLOR . . . . . . . . . . 41
TRI-VI-SOL . . . . . . . . 41, 48
TRIVORA . . . . . . . . . . . . 30
TROJAN . . . . . . . . . . . . 46
trospium . . . . . . . . . . . . 39
TRUSOPT . . . . . . . . . . . 33
TRUSTEX . . . . . . . . . . . . 46
TRUST NATALCARE
PAK DHA . . . . . . . . . . 40
T-STAT . . . . . . . . . . . . . 14
TUMS . . . . . . . . . . . 47, 48
TUSSI-12 S . . . . . . . . . . . 35
TUSSIN DM . . . . . . . . . . 36
TYKERB . . . . . . . . . . . . . 4
TYLENOL . . . . . . . 12, 28, 47
TYLENOL W/CODEINE . . . 12
typhoid vaccine . . . . . . . . 44
U
ULORIC . . . . . . . . . . . . . 29
ULTRAM . . . . . . . . . . . . 12
ULTRAVATE . . . . . . . . . . 16
umeclidinium inhalation . . . 38
umeclidinium/vilanterol . . . 38
UNI-HIST DROPS . . . . . . . 34
UNIPHYL . . . . . . . . . . . . 39
UNISOM . . . . . . . . . . 34, 47
UREA 10% CREAM . . . . . . 18
UREA 10% LOTION . . . . . . 18
urea 10%, urea 20% . . . . . 18
UREA 20% CREAM . . . . . . 18
urea 40% . . . . . . . . . . . 18
UREA 40% LOTION . . . . . . 18
URECHOLINE . . . . . . . . . 39
UREX . . . . . . . . . . . . . . 39
uridine . . . . . . . . . . . . . 22
UROCIT-K . . . . . . . . . . . 39
UROXATRAL . . . . . . . . . . 39
URSO . . . . . . . . . . . . . 25
ursodiol . . . . . . . . . . . . 25
URSO FORTE . . . . . . . . . 25
UTIRA C . . . . . . . . . . . . 39
V
vaginal products . . . . . . . 45
valacyclovir . . . . . . . . . . 27
VALCYTE . . . . . . . . . . . . 27
valganciclovir . . . . . . . . . 27
VALTREX . . . . . . . . . . . . 27
VANCOCIN HCL . . . . . . . . 26
vancomycin HCl . . . . . . . 26
vandetanib . . . . . . . . . . . 5
VAQTA . . . . . . . . . . . . . 43
varicella virus vac live for
subcutaneous . . . . . . . 44
VARIVAX . . . . . . . . . . . . 44
VARUBI . . . . . . . . . . . . . 23
VASERETIC . . . . . . . . . . . 8
VASOCIDIN . . . . . . . . . . . 32
VASOCLEAR . . . . . . . . . . 32
VASOCLEAR A . . . . . . . . 32
VASOTEC . . . . . . . . . . . . .7
VECTICAL . . . . . . . . . . . 16
VEETIDS . . . . . . . . . . . . 26
VELTASSA . . . . . . . . . . . 11
vemurafenib . . . . . . . . . . 5
VENCLEXTA . . . . . . . . . . .5
venetoclax . . . . . . . . . . . 5
VENTOLIN HFA . . . . . . . . 38
VEPESID . . . . . . . . . . . . . 6
verapamil . . . . . . . . . . 9, 13
verapamil extended-release . . 9
VESANOID . . . . . . . . . . . .6
VEXOL . . . . . . . . . . . . . 32
ALL CAPS = Brand-name drug
lower case = Generic drug
64
VFEND . . . . . . . . . . . . . 26
VICODIN . . . . . . . . . . . . 13
VICODIN ES . . . . . . . . . . 13
VICTOZA . . . . . . . . . . . . 21
VI-DAYLIN . . . . . . . . . . . . 48
VINATE AZ EX . . . . . . . . . 41
VINATE II . . . . . . . . . . . . 41
VIROPTIC . . . . . . . . . . . . 34
VISINE . . . . . . . . . . . . . 47
VISINE-AC . . . . . . . . . . . 32
vismodegib . . . . . . . . . . . 6
VISTOGARD . . . . . . . . . . 22
vitamin A . . . . . . . . . . . . 41
vitamin ADC/fluoride/
±iron drops . . . . . . . . 41
vitamin B-1 . . . . . . . . . . 41
vitamin B-6 . . . . . . . . . . 41
VITAMIN B-12 . . . . . . . . . 40
vitamin B complex/
vitamin C/folic acid . . . 41
vitamin C . . . . . . . . . . . 41
vitamin D 400 IU . . . . . . . 48
VITAMIN D . . . . . . . . . 40, 48
vitamins pediatric . . . . . . . 41
vitamins pediatric members <3
years old . . . . . . . . . . 48
vitamins prenatal . . . . . . . 48
VIVOTIF BERNA . . . . . . . . 44
VOLTAREN . . . . . . . . . . . 32
VOLTAREN 1% TOPICAL GEL28
voriconazole . . . . . . . . . . 26
vorinostat . . . . . . . . . . . . 4
VOSOL HC OTIC . . . . . . . 18
VOSOL OTIC . . . . . . . . . . 18
VOTRIENT . . . . . . . . . . . . 5
W
warfarin . . . . . . . . . . . . . 7
WESTCORT . . . . . . . . . . 15
WYTENSIN . . . . . . . . . . . 11
X
XALATAN . . . . . . . . . . . . 33
XALKORI . . . . . . . . . . . . .4
XARELTO . . . . . . . . . . . . .7
Index of Covered Drugs
XELODA . . . . . . . . . . . . . 4
XENAZINE . . . . . . . . . . . 14
XIIDRA . . . . . . . . . . . . . 33
XOLAIR . . . . . . . . . . . . . 38
XOPENEX RESPULES . . . . 38
XULANE . . . . . . . . . . . . 30
XYLOCAINE . . . . . . . . 17, 19
XYZAL . . . . . . . . . . . . . 18
Z
ZANAFLEX . . . . . . . . . . . 29
zanamivir . . . . . . . . . . . 27
ZANTAC . . . . . . . . . . . . 23
ZAROXOLYN . . . . . . . . . . 10
ZARXIO . . . . . . . . . . . . . .7
ZEBETA . . . . . . . . . . . . . .9
ZEBUTAL . . . . . . . . . . . . 12
ZELBORAF . . . . . . . . . . . .5
ZENPEP . . . . . . . . . . . . 24
ZEPATIER . . . . . . . . . . . . 27
ZESTORETIC . . . . . . . . . . .8
ZESTRIL . . . . . . . . . . . . . 7
ZETIA . . . . . . . . . . . . . . 10
ZIAC . . . . . . . . . . . . . . . .9
zinc . . . . . . . . . . . . . . . 42
ZITHROMAX . . . . . . . . . . 25
ZOCOR . . . . . . . . . . . . . 10
ZOFRAN . . . . . . . . . . . . 23
ZOFRAN ODT . . . . . . . . . 23
ZOHYDRO ER . . . . . . . . . 13
ZOLINZA . . . . . . . . . . . . .4
ZORTRESS . . . . . . . . . . . .6
ZOSTAVAX . . . . . . . . . . . 44
zoster vaccine live . . . . . . . 44
ZOVIA 1/35 . . . . . . . . . . 30
ZOVIA 1/50 . . . . . . . . . . 30
ZOVIRAX . . . . . . . . . . . . 27
ZYDELIG . . . . . . . . . . . . .4
ZYKADIA . . . . . . . . . . . . .4
ZYLOPRIM . . . . . . . . . . . 29
ZYMAR . . . . . . . . . . . . . 34
ZYRTEC . . . . . . . . . . 18, 45
ZYRTEC CHEWABLE
TABLET . . . . . . . . . . . 18
ZYRTEC D . . . . . . . . 19, 45
ZYTIGA . . . . . . . . . . . . . .5
ZYVOX . . . . . . . . . . . . . 27
ALL CAPS = Brand-name drug
lower case = Generic drug
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“My Medications” worksheet
Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of
every drug you take and you should have a list as well.
Name of Medicine
and Strength
Drug
Tier
I Take This
Medicine For
Directions
Doctor
Example: Lisinopril, 20 mg
Tier 1
High blood pressure
One tablet daily
Dr. Johnson
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