preferred drug list (pdl) · 2020-04-02 · • agents used for cosmetic hair growth • drugs from...

© 2020 United HealthCare Services, Inc. All rights reserved. CSEX15MC3664728_034

Preferred Drug List (PDL)Washington – Apple Health Effective Date: 4/1/20

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INTRODUCTION UnitedHealthcare Community Plan is pleased to provide this Preferred Drug List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered by UnitedHealthcare Community Plan. The drugs listed in this PDL are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the by UnitedHealthcare Community Plan PDL 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 by 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. The drugs represented have been reviewed by the Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice as of the date of review. This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare Community Plan PDL is reflective of current medical practice. NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare Community Plan, solely for the convenience of medical providers. UnitedHealthcare Community Plan does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs.

UnitedHealthcare Community Plan assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information. National guidelines can be found on the Web sites listed in the Web site section or go to the National Guideline Clearinghouse site at http://www.guideline.gov. PREFACE The UnitedHealthcare Community Plan PDL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by generic name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing. The UnitedHealthcare Community Plan PDL covers selected over-the-counter (OTC) products. You are encouraged to prescribe OTC medications when clinically appropriate. 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 PDL. PDL decisions are also communicated quarterly on the UnitedHealthcare Community Plan internet site.

Preferred Drug List

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OUTPATIENT PRESCRIPTION DRUG BENEFIT-COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Drug Benefits is based on the individual member’s benefit plan. PRODUCT SELECTION CRITERIA The 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

When a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare Community Plan PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents. All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered. Products covered include all strengths associated with the dosage form of the cited brand name product. carvedilol Coreg All strengths of Coreg would be covered by this listing. Extended-release and delayed-release products require their own entry.

diltiazem sustained release CARDIZEM SR

Dosage forms covered will be consistent with the category and use where listed. Neomycin/polymyxin B/ Cortisporin Hydrocortisone As listed in the OTIC section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the OPHTHALMIC and DERMATOLOGY sections of the PDL. When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not citalopram 40 mg tabs Celexa tabs DRUG TIERS The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.

Tier Name Drug Tier Tier 1 Generic Tier 2 Brand

GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires generic substitution on the majority of products when a generic equivalent is available. Generic substitution is a pharmacy action whereby a generic equivalent is dispensed rather than the brand name product. The PDL indicates generic availability in the “Covered Drug” column. 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:

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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.

2. The FDA has given the generic an “A” rating compared

to the branded product indicating bioequivalence, and 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).

When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand name product. There are now many brand name products that are repackaged or distributed under a generic label. The generic label version should always be considered therapeutically equivalent and substitutable for the source branded product. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of “fully effective” was made for most of these products and they remain in the marketplace. A few DESI products remain classified as “less than fully effective” while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare Community Plan PDL does not cover DESI “less than fully effective” drug products. PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare Community Plan.

• DESI drugs • Anti-obesity agents

• Experimental / research drugs • Cosmetic drugs • Nutritional / diet supplements • Blood and blood plasma products • Agents used to promote fertility • Agents used for erectile dysfunction • Agents used for cosmetic hair growth • Drugs from manufacturers that do not participate

in the FFS Medicaid Drug Rebate Program • Diagnostic products • Medical supplies and DME except as listed:

insulin syringes, insulin needles, lancets, 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)

DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare Community Plan members may receive up to a one month supply of a specific medication per prescription order or prescription refill. A medication may be reordered or refilled when eighty-five percent (85%) of the medication has been utilized. If a claim is submitted before 85% of the medication has been used, based on the original day supply submitted on the claim, the claim will reject with a "refill too soon" message. Please call the UnitedHealthcare Community Plan Pharmacy Department at 1-800-310-6826 with questions or help with dosage change authorization. MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires mandatory generic substitution on the vast majority of products when a generic equivalent is available; however, brand name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare Community Plan PDL prior authorization (PA) list does not include branded items where a generic equivalent is covered. PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare Community Plan PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management. Requests for these exceptions should be either made in writing by the physician and faxed or called into:

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UnitedHealthcare Community Plan Pharmacy Services Department Fax 1-866-940-7328 Phone 1-800-310-6826

A prior authorization request form is available in the UnitedHealthcare Community Plan provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical necessity of the non-PDL request. The UnitedHealthcare Community Plan Pharmacy Department will respond to all requests in accordance with state requirements. Physicians are requested to adhere to this PDL when prescribing for patients covered by their pharmacy benefit plan offered by UnitedHealthcare Community Plan. If a pharmacist receives a prescription for a non-PDL drug, the pharmacist should contact the prescribing physician and request that the prescription be changed to a medication included in this PDL. If a PDL alternative is not appropriate the physician should then be instructed to contact the Plan for a prior authorization. Please contact the UnitedHealthcare Community Plan at 1-800-800-310-6826 with questions concerning the prior authorization process. NON-PDL 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 1-800-310-6826. The pharmacy should contact the physician to discuss a PDL drug or if a prior authorization request is warranted. If the prescribing physician feels a drug is medically necessary, the physician may fax a request for prior authorization to the UnitedHealthcare Community Plan at 1-800-310-6826. 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. Controlled Substances You may fill any FOUR medications from the following classes in a 30-day period:

• benzodiazepines • sedative hypnotic agents • barbiturates • select muscle relaxants

Additional fills will require prior authorization. Exceptions apply in opiate class for some diagnoses. Medications in these classes may also be subject to individual quantity limits. Additions to the QL program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the medical exception (prior authorization) process. Please contact the UnitedHealthcare Community Plan at 1-800-310-6826 with questions. Specialty Pharmaceutical Management Program UnitedHealthcare Community Plan is continuously looking for ways to provide high quality cost effective care for Plan members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare Community Plan to achieve these goals. Injectable medications that are part of this program require plan authorization and are not available through the retail pharmacy network. To obtain authorization, the provider must submit the appropriate Prior Authorization form to the UnitedHealthcare Community Plan via fax at 1-866-940-7328. The UnitedHealthcare Community Plan Pharmacy Department will review and respond to all requests in accordance with state requirements, and if authorized for payment, UnitedHealthcare Community Plan will coordinate the delivery of the product to the member or provider. Drugs that are part of this program and are on the PDL are identified in this booklet by the designation "SP". Prior Authorization request forms can be requested by calling the UnitedHealthcare Community Plan at 1-800-310-6826. MEDICATIONS REQUIRING DIAGNOSIS UnitedHealthcare Community Plan requires that the diagnosis for prescriptions in certain classes match the FDA-approved use or a use supported by current published evidence. Drugs in scope will list “Diagnosis required” in the Requirements and Limits section on the PDL.

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The diagnosis will be verified at the point-of-sale by the pharmacy claims processing system. If a matching diagnosis is not found in the medical claim file or on the pharmacy drug claim, the prescription will be rejected at the pharmacy. The pharmacist may then contact the prescriber to verify the diagnosis and submit it on the claim. If the diagnosis provided still does not match the approved use, prior authorization may be requested through the standard process by faxing a request to 1-866-940-7328. STEP THERAPY (ST) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line agent has been adequately tried and failed. These medications may also be requested through the Prior authorization process. While lower cost PDL alternatives may be appropriate in many instances, other non- PDL alternatives are available with prior authorization (PA). STEP Drug First-Line Agent(s)

Aricept 23mg 90 day trial of Aricept 10mg daily

Calcitriol 3mcg/gm Trial of two topical corticosteroids Eucrisa Trial of a topical corticosteroid

AND one of the following: Elidel or tacrolimus ointment

tolterodine 30 day trial of oxybutynin immediate release or extended release. Step Therapy only applies to members less than 65 years of age.

Trentinoin Cream (Trentinoin cream 0.025%, 0.05%, 0.1% and Avita cream 0.025%)

Trial of Differin OTC Gel 0.1%.

Trospium 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age.

PDL SUGGESTIONS Providers who wish to propose PDL suggestions should forward the information to the United Healthcare Community Plan Director of Pharmacy Services by either mail or fax.

Attn: Director of Pharmacy Services United Healthcare Community Plan 2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Phone: 1-800-310-6826

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 PDL addition. This literature should include information documenting clinical necessity as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare Community Plan will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting. EDITOR Your comments and suggestions regarding the UnitedHealthcare Community Plan PDL are encouraged. Your input is vital to this PDL’s continued success. All responses will be reviewed and considered. Please send your comments to:

United Healthcare Community Plan

Director of Pharmacy Services 2 Allegheny Center Suite 600 Pittsburgh, PA 15212

Phone: 1-800-310-6826 LEGEND # Only the dosage forms/strengths of the brand

name products noted are on the PDL OTC over-the-counter Delayed-rel delayed-release (also known as enteric coated) EC enteric-coated ext-rel extended-release (also known as sustained-

release) PA Prior Authorization required QL Quantity Limits apply ST Step Therapy, see pages V-VI for details SP Specialty Pharmaceuticals, see pages IV-V for

details NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare Community Plan. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare Community Plan. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare Community Plan and such third-party pharmaceutical companies.

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If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification.

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Table of ContentsAntineoplastics & Immunosuppressants . . . 4Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4Hormonal Antineoplastic Agents . . . . . . . . . . . . . 6Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 7Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 7Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Blood Modifiers - Anticoagulants . . . . . . . . . 8Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Blood Cell Formation . . . . . . . . . . . . . . . . . . . . . . 8Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . 8Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Cardiovascular Agents . . . . . . . . . . . . . . . . . . 9Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Ace Inhibitor/Calcium Channel Blocker

Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Ace Inhibitor/Diuretic Combinations . . . . . . . . . . 9Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 8Alpha Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Angiotensin II Receptor Blockers

(Antagonists) . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Angiotensin II Receptor Blocker

Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antiarrhythmics and Cardiac Glycosides . . . . . 10Beta Blockers and Beta Blocker/Diuretic

Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . 10Calcium Channel Blockers . . . . . . . . . . . . . . . . . 11Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 12Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Potassium-Removing Agents . . . . . . . . . . . . . . . 13Pulmonary Arterial Hypertension . . . . . . . . . . . 13Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Central Nervous System. . . . . . . . . . . . . . . .14Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 14Amyotrophic Lateral Sclerosis (ALS) . . . . . . . . . 14Analeptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 16Migraine Prophylactic Therapy . . . . . . . . . . . . . 17Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . 17Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . 17Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 17Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . .19Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 19Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 20Pruritus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Scabies and Pediculosis . . . . . . . . . . . . . . . . . . . 21Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . .22Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 24

Endocrinology . . . . . . . . . . . . . . . . . . . . . . . .24Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 24Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 25Growth Stimulating Agents . . . . . . . . . . . . . . . . . 26Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 27Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Gastrointestinal. . . . . . . . . . . . . . . . . . . . . . .27Constipation/Laxatives . . . . . . . . . . . . . . . . . . . 27Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Emesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Gastroesophageal Reflux Disease (Gerd)/

Peptic Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . . 29Inflammatory Bowel Disease . . . . . . . . . . . . . . . 29Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 30Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Infectious Diseases . . . . . . . . . . . . . . . . . . .30Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Antiprotozoals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Respiratory Syncytial Virus (RSV) . . . . . . . . . . . 35Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

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Musculoskeletal . . . . . . . . . . . . . . . . . . . . . .35Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 37

OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Hormone Therapy/Menopause . . . . . . . . . . . . . 41Vaginal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 42Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . .43Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 43Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Immunologic Agents . . . . . . . . . . . . . . . . . . . . . . 45Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Psychiatric. . . . . . . . . . . . . . . . . . . . . . . . . . .45Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . . 45Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Attention Deficit Hyperactivity Disorder

(ADHD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . 47Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . . 48Psychoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . 49Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Respiratory Drugs. . . . . . . . . . . . . . . . . . . . .50Antitussives, Decongestants, Expectorants

and Combinations . . . . . . . . . . . . . . . . . . . . . . 50Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Urological . . . . . . . . . . . . . . . . . . . . . . . . . . .52Symptomatic Benign Prostatic Hypertrophy . . 52Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Vitamins, Minerals, and Supplements. . . . .53Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . .55Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 56Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 56Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 56Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . . 57Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . . 57Thrombopoietin Receptor Agonists . . . . . . . . . 57Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

OTC MEDICATIONS . . . . . . . . . . . . . . . . . . .59Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Cough/Cold Allergy . . . . . . . . . . . . . . . . . . . . . . . 59Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Earwax Removal Products . . . . . . . . . . . . . . . . . 60Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 60First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 60Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . . 61Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Smoking Cessation Products . . . . . . . . . . . . . . 61Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Vitamins, Minerals, and Supplements . . . . . . . . 61

Index of Covered Drugs . . . . . . . . . . . . . . . .62

4

OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit

ST = Step TherapySP = Specialty Pharmacy

Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits

Antineoplastics & Immunosuppressants

Antineoplastic AgentsAlkylating Agentsaltretamine HEXALEN brand 2 PAbusulfan MYLERAN brand 2 PAchlorambucil LEUKERAN brand 2 PAcyclophosphamide CYTOXAN generic 1estramustine

phosphate sodium EMCYT brand 2 PA

lomustine GLEOSTINE brand 2mechlorethamine VALCHLOR brand 2 PA, QL, SPmelphalan ALKERAN generic 1temozolomide TEMODAR generic 1 QL, SPAntimetabolitescapecitabine XELODA generic 1 PA, SPmercaptopurine PURINETHOL generic 1 QLmercaptopurine PURIXAN SUS brand 2 PA, QLthioguanine TABLOID brand 2trifluridine/tipiracil LONSURF brand 2 PA, QL, SPHistone Deacetylase Inhibitorspanobinostat FARYDAK brand 2 PA, QL, SPvorinostat ZOLINZA brand 2 PA, QL, SPKinase Inhibitorabemaciclib VERZENIO brand 2 PA, QL, SPacalabrutinib CALQUENCE brand 2 PA, QL, SPafatinib GILOTRIF brand 2 PA, QL, SPalectinib ALECENSA brand 2 PA, QL, SPalpelisib PIQRAY brand 2 PA, QL, SPaxitinib INLYTA brand 2 PA, QL, SPbinimetinib MEKTOVI brand 2 PA, QL, SPbosutinib BOSULIF brand 2 PA, QL, SPbrigatinib ALUNBRIG brand 2 PA, QL, SP

cabozantinibCOMETRIQCABOMETYX

brand 2 PA, QL, SP

ceritinib ZYKADIA brand 2 PA, QL, SPcobimetinib COTELLIC brand 2 PA, QL, SPcrizotinib XALKORI brand 2 PA, QL, SPdabrafenib TAFINLAR brand 2 PA, QL, SPdacomitinib VIZIMPRO brand 2 PA, QL, SP

5




dasatinib SPRYCEL brand 2 PA, QL, SPduvelisib COPIKTRA brand 2 PA, QL, SPencorafenib BRAFTOVI brand 2 PA, QL, SPerlotinib TARCEVA generic 1 PA, QL, SP

everolimus AFINITORAFINITOR DISPERZ brand 2 PA, QL, SP

gefitinib IRESSA brand 2 PA, QL, SPgilteritinib XOSPATA brand 2 PA, QL, SPibrutinib IMBRUVICA brand 2 PA, QL, SPidelalisib ZYDELIG brand 2 PA, QL, SPimatinib mesylate GLEEVEC generic 1 PA, QL, SPlapatinib ditosylate TYKERB brand 2 PA, QL, SPlarotrectinib VITRAKVI brand 2 PA, QL, SPlenvatinib LENVIMA brand 2 PA, QL, SPlorbrena LORLATINIB brand 2 PA, QL, SPmidostaurin RYDAPT brand 2 PA, QL, SPneratinib NERLYNX brand 2 PA, QL, SPnilotinib TASIGNA brand 2 PA, QL, SPosimertinib TAGRISSO brand 2 PA, QL, SPpalbociclib IBRANCE brand 2 PA, QL, SPpazopanib VOTRIENT brand 2 PA, QL, SPponatinib ICLUSIG brand 2 PA, QL, SPregorafenib STIVARGA brand 2 PA, QL, SPribociclib KISQALI brand 2 PA, QLruxolitinib JAKAFI brand 2 PA, QL, SPsorafenib NEXAVAR brand 2 PA, QL, SPsunitinib SUTENT brand 2 PA, QL, SPtrametinib MEKINIST brand 2 PA, QL, SPvandetanib CAPRELSA brand 2 PA, QL, SPvemurafenib ZELBORAF brand 2 PA, QL, SPMiscellaneous

leucovorin LEUCOVORIN generic 1 QL, 5 mg and 25 mg tabs

mesna MESNEX brand 2 SP, tabletsvenetoclax VENCLEXTA brand 2 PA, QL, SPMonoclonal Antibodies

denosumab injPROLIAXGEVA

brand 2 PA

eculizumab iv soln SOLIRIS brand 2 PAravulizumab-cwvz iv soln ULTOMIRIS INJ brand 2 PA

6




Proteasome Inhibitorsixazomib NINLARO brand 2 PA, QL, SPHormonal Antineoplastic AgentsAndrogen Biosynthesis Inhibitorsabiraterone ZYTIGA brand 2 QL, SP, 250 mg tabAntiandrogensapalutamide ERLEADA brand 2 PA, QL, SPbicalutamide CASODEX generic 1 QLenzalutamide XTANDI brand 2 PA, QL, SPflutamide EULEXIN generic 1 QLnilutamide NILANDRON generic 1 QLAntiestrogensribociclib/letrozole KISQALI/FEMARA brand 2 PA, QLtamoxifen NOLVADEX generic 1 QLAromatase Inhibitorsanastrozole ARIMIDEX generic 1 QLexemestane AROMASIN generic 1 QLletrozole FEMARA generic 1 QLGonadotropin Releasing Hormone Analoggoserelin ZOLADEX brand 2 PA, QL

histrelinSUPPRELIN LAVANTAS

brand 2 PA, QL

leuprolide LUPRON generic 1 PA, SP

leuprolide

ELIGARD LUPRON DEPOTLUPRON DEPOT 6-MONTHLUPRON DEPOT-PED

brand 2 PA, QL, SP

leuprolide/norethindrone LUPANETA brand 2 PA, QL, SPnafarelin nasal SYNAREL brand 2 PA, QLtriptorelin TRELSTAR brand 2 PA, QLtriptorelin TRIPTODUR brand 2 PA, QL, SPIsocitrate Dehydrogenase (IDH) Inhibitorsenasidenib IDHIFA brand 2 PA, QL, SPivosidenib TIBSOVO brand 2 PA, QL, SPProgestin

megestrol acetateMEGACEMEGACE ES

generic 1

7




ImmunomodulatorsInterferonsinterferon gamma-1b ACTIMMUNE brand 2 PA, SPMiscellaneousfostamatinib TAVALISSE brand 2 PA, QL, SPlenalidomide REVLIMID brand 2 PA, QL, SPpomalidomide POMALYST brand 2 PA, QL, SPthalidomide THALOMID brand 2 PA, SP, QLImmunosuppressantsAntimetabolitesazathioprine IMURAN generic 1 50 mg tab, QLmycophenolate mofetil CELLCEPT generic 1 QLCalcineurin Inhibitorscyclosporine SANDIMMUNE generic 1 QL

cyclosporine, modifiedGENGRAF NEORAL

generic 1 25 mg & 100 mg caps, soln, QL

tacrolimus PROGRAF generic 1 capstacrolimus PROGRAF brand 2 inj, PARapamycin Derivativesirolimus RAPAMUNE generic 1 tabsMiscellaneousalitretinoin 1% gel PANRETIN brand 2 PAbexarotene caps and

topical gel TARGRETIN brand 2 PA, SP

cysteamine bitartrate CYSTAGON brand 2 SP, QLetoposide VEPESID generic 1 PA, QLglasdegib DAURISMO brand 2 PA, QL, SPhydroxyurea DROXIA brand 2hydroxyurea HYDREA generic 1 QLhydroxyurea SIKLOS brand 2 PA, QLmitotane LYSODREN brand 2 PA, QLniraparib ZEJULA brand 2 PA, QL, SPoctreotide SANDOSTATIN generic 1 SP, QLolaparib LYNPARZA brand 2 PA, QL, SPpasireotide SIGNIFOR brand 2 PA, SPrucaparib RUBRACA brand 2 PA, QL, SPsonidegib ODOMZO brand 2 PA, QL, SP

8




talazoparib TALZENNA brand 2 PA, QL, SPtopotecan HYCAMTIN brand 2 PA, QL, SPtretinoin VESANOID generic 1 caps, PA, SP, QLvismodegib ERIVEDGE brand 2 PA, QL, SP

Blood Modifiers - Anticoagulants

Anticoagulantsapixaban ELIQUIS brand 2 QLdabigatran etexilate

mesylate PRADAXA brand 2 QL

enoxaparin LOVENOX generic 1 QL

heparin HEPARIN generic 1INJ 5000 UNIT/ML, PF INJ 5000 UNIT/0 .5ML, INJ 10000 UNIT/ML

rivaroxaban XARELTO brand 2 QLwarfarin COUMADIN generic 1Blood Cell Formationdarbepoetin alfa ARANESP brand 2 PA, SPepoetin alfa EPOGEN brand 2 PA, SPfilgrastim NEUPOGEN brand 2 PA, SPoprelvekin NEUMEGA brand 2 PA, SPplerixafor MOZOBIL brand 2 PA, SPtbo-filgrastim GRANIX brand 2 PA, SPPlatelet Inhibitorsanagrelide AGRYLIN generic 1

aspirinBAYERECOTRIN

generic 1 OTC

aspirin/dypridamole AGGRENOX generic 1 QLcilostazol PLETAL generic 1clopidogrel PLAVIX generic 1 QLdipyridamole PERSANTINE generic 1ticagrelor BRILINTA brand 2 QLMiscellaneousaminocaproic acid AMICAR brand 2 soln aminocaproic acid AMICAR generic 1 tab

9




deferasiroxEXJADEJADENUJADENU SPRKL GRA

brand 2 QL, SP

pentoxifylline extended-release TRENTAL generic 1

Cardiovascular Agents

Ace Inhibitorsbenazepril LOTENSIN generic 1captopril CAPOTEN generic 1enalapril VASOTEC generic 1fosinopril MONOPRIL generic 1 QLlisinopril ZESTRIL generic 1 QLramipril ALTACE generic 1Ace Inhibitor/Calcium Channel Blocker Combinationsamlodipine/benazepril LOTREL generic 1 PA, QLAce Inhibitor/Diuretic Combinationsbenazepril/

hydrochlorothiazide LOTENSIN HCT generic 1

enalapril/ hydrochlorothiazide VASERETIC generic 1

fosinopril/ hydrochlorothiazide MONOPRIL-HCT generic 1 QL

lisinopril/ hydrochlorothiazide ZESTORETIC generic 1 QL

quinapril/ hydrochlorothiazide ACCURETIC generic 1 QL

Adrenolytics, Centralclonidine CATAPRES generic 1guanfacine TENEX generic 1Alpha Blockersdoxazosin CARDURA generic 1prazosin MINIPRESS generic 1terazosin HYTRIN generic 1

10




Angiotensin II Receptor Blockers (Antagonists)irbesartan AVAPRO generic 1 QLlosartan COZAAR generic 1 QLolmesartan BENICAR generic 1 QLvalsartan DIOVAN generic 1 QLAngiotensin II Receptor Blocker Combinationsamlodipine/valsartan EXFORGE generic 1 PA, QLirbesartan/

hydrochlorothiazide AVALIDE generic 1 QL

losartan/HCTZ HYZAAR generic 1 QLolmesartan/

hydrochlorothiazide BENICAR HCT generic 1 QL

sacubitril/valsartan ENTRESTO brand 2 PA, QLvalsartan/

hydrochlorothiazide DIOVAN HCT generic 1 QL

Antiarrhythmics and Cardiac Glycosidesamiodarone tabs CORDARONE brand &

generic 1 & 2digoxin LANOXIN generic 1digoxin LANOXIN SOLUTION generic 1disopyramide NORPACE generic 1dofetilide TIKOSYN generic 1flecainide TAMBOCOR generic 1lidocaine hcl iv inj XYLOCAINE INJ generic 1 PAmexiletine MEXITIL generic 1propafenone/propafenone

ERRYTHMOLRYTHMOL SR

generic 1

quinidine gluconate extended-release

QUINIDINE GLUCONATE EXT-REL generic 1

quinidine sulfate extended-release

QUINIDINE SULFATE EXT-REL generic 1

Beta Blockers and Beta Blocker/Diuretic Combinationsacebutolol SECTRAL generic 1atenolol TENORMIN generic 1

11




atenolol/chlorthalidone TENORETIC generic 1betaxolol KERLONE generic 1bisoprolol ZEBETA generic 1bisoprolol/

hydrochlorothiazide ZIAC generic 1

carvedilol COREG generic 1 QLcarvedilol ER COREG CR generic 1 QLlabetalol TRANDATE generic 1metoprolol LOPRESSOR generic 1 25, 50, 100 mg onlymetoprolol/

hydrochlorothiazide LOPRESSOR HCT generic 1

metoprolol succinate TOPROL XL generic 1nadolol CORGARD generic 1 QLpropranolol INDERAL generic 1 IR onlypropranolol ER INDERAL LA generic 1propranolol/HCTZ INDERIDE generic 1Calcium Channel BlockersDihydropyridinesamlodipine NORVASC generic 1 QLfelodipine

extended-release PLENDIL generic 1 QL

nifedipine PROCARDIA generic 1nifedipine

extended-releaseADALAT CCPROCARDIA XL

generic 1 QL

Nondihydropyridinesdiltiazem CARDIZEM generic 1diltiazem

extended-release CARDIZEM CD generic 1 QL

diltiazem extended-release

DILACOR XR TIAZAC

generic 1 QL

diltiazem sustained-release CARDIZEM SR generic 1 QL

verapamil CALAN generic 1verapamil

extended-release CALAN SR generic 1 QL

12




Diureticsamiloride MIDAMOR generic 1amiloride/

hydrochlorothiazide MODURETIC generic 1

bumetanide BUMEX generic 1bumetanide inj BUMEX generic 1 PAchlorthalidone CHLORTHALIDONE generic 1chlorothiazide DIURIL generic 1ethacrynic acid EDECRIN generic 1furosemide LASIX generic 1furosemide inj LASIX INJ generic 1 PAhydrochlorothiazide HYDROCHLOROTHIAZIDE generic 1 soln, tabshydrochlorothiazide MICROZIDE generic 1 12 .5 mg capsindapamide LOZOL generic 1methyclothiazide ENDURON generic 1metolazone ZAROXOLYN generic 1spironolactone ALDACTONE generic 1spironolactone/

hydrochlorothiazide ALDACTAZIDE generic 1

torsemide DEMADEX generic 1triamterene/

hydrochlorothiazideDYAZIDEMAXZIDE

generic 1

Lipid Lowering AgentsBile Acid Resin

cholestyramineQUESTRANQUESTRAN-LIGHT

generic 1

colestipol COLESTID generic 1Fibrates

fenofibrateFENOGLIDETRICORTRIGLIDE

generic 1 QL

gemfibrozil LOPID generic 1HMG-CoA Reductase Inhibitors and Combinationsatorvastatin LIPITOR generic 1lovastatin MEVACOR generic 1 QLpravastatin PRAVACHOL generic 1rosuvastatin CRESTOR generic 1 QLsimvastatin ZOCOR generic 1 QL

13




Niacinsniacin NIACOR generic 1niacin extended-release NIASPAN generic 1Miscellaneousevolocumab REPATHA brand 2 PA, QL, SPezetimibe ZETIA generic 1lomitapide JUXTAPID brand 2 PA, QLNitratesOralisosorbide dinitrate

extended-releaseISOSORBIDE

DINITRATE ER generic 1

isosorbide mononitrate ISMO generic 1isosorbide mononitrate

extended-release IMDUR generic 1

Sublingualisosorbide dinitrate ISORDIL S.L. generic 1nitroglycerin NITROSTAT generic 1Transdermal

nitroglycerinNITREK NITRO-DUR

generic 1 transdermal, QL, except 0 .3 & 0 .8 mg strengths

nitroglycerin NITRO-BID generic 1Potassium-Removing Agentspatiromer VELTASSA brand 2 QLsodium polystyrene

sulfonate KAYEXALATE generic 1 susp (susp only)

Pulmonary Arterial Hypertensionambrisentan LETAIRIS generic 1 PA, SPbosentan TRACLEER brand 2 PA, SPiloprost inhalation solution VENTAVIS brand 2 PA, SPriociguat ADEMPAS brand 2 PA, SPselexipag UPTRAVI brand 2 PA, SPsildenafil REVATIO generic 1 PA, SP, QLtadalafil (PAH) ADCIRCA brand 2 PA, SPtreprostinil inhalation

solution TYVASO brand 2 PA, SP

14




Miscellaneousdroxidopa NORTHERA brand 2eplerenone INSPRA generic 1guanabenz WYTENSIN generic 1hydralazine APRESOLINE generic 1isoxsuprine VASODILAN generic 1ivabradine CORLANOR brand 2 PA, QLmethyldopa ALDOMET generic 1midodrine PROAMATINE generic 1minoxidil LONITEN generic 1phenylephrine PHENYLEPHRIN SOL generic 1 PAranolazine RANEXA brand 2 PA

Central Nervous System

Alzheimer’s Disease

donepezil ARICEPT generic 1

5 mg and 10 mg, QL, Members <18 years of age will require prior

authorization .

donepezil ARICEPT generic 123 mg, ST, Members <18 years of age will require

prior authorization .ergoloid mesylates HYDERGINE generic 1

galantamine RAZADYNE generic 1QL, Members <18 years of age will require prior

authorization .

memantine NAMENDA generic 1QL, Members <18 years of age will require prior

authorization .

rivastigmine EXELON generic 1QL, Members <18 years of age will require prior

authorization .Amyotrophic Lateral Sclerosis (ALS)riluzole RILUTEK generic 1 QLAnalepticsarmodafinil NUVIGIL generic 1 PA, QLmodafinil PROVIGIL generic 1 PA, QL

15




AnalgesicsBarbiturate Non-Narcotic Analgesicsbutalbital/acetaminophen PHRENILIN generic 1 QLbutalbital/acetaminophen SEDAPAP generic 1 QLbutalbital/acetaminophen/

caffeine FIORICET generic 1 QL

butalbital/aspirin/caffeine FIORINAL generic 1 QLNon-Narcotic Analgesicsacetaminophen TYLENOL generic 1 OTCtramadol ULTRAM generic 1 Age Limits Apply, QLtramadol ER ULTRAM ER generic 1 Age Limits Apply, QLNSAIDSdiclofenac potassium CAMBIA brand 2 PAdiclofenac potassium CATAFLAM generic 1diclofenac sodium

delayed-release VOLTAREN generic 1

diclofenac sodium extended-release VOLTAREN XR generic 1

etodolac LODINE generic 1 IR Only

ibuprofen ADVIL generic 1 tabs, chew tabs and susp, OTC

ibuprofen MOTRIN generic 1 tabs, chew tabs and susp

indomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlyketorolac tromethamine TORADOL generic 1 QLmeloxicam MOBIC generic 1 QLnabumetone RELAFEN generic 1naproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1sulindac CLINORIL generic 1Opioids - Narcotic Analgesicsbuprenorphine hcl buccal

film BELBUCA brand 2 PA, QL

16




buprenorphine td patch weekly BUTRANS generic 1 QL

butalbital/apap/caff/cod FIORICET W/CODEINE generic 1 QLbutalbital/asa/caff/cod FIORINAL W/CODEINE generic 1 QLcodeine/acetaminophen TYLENOL W/CODEINE generic 1 Age Limits Apply, QLcodeine sulfate CODEINE SULFATE generic 1 Age Limits Apply, QLfentanyl transdermal DURAGESIC generic 1 PA, QL

hydrocodone/ acetaminophen

LORCETLORTABLORTAB ELIXIRNORCOVICODINVICODIN ES

generic 1 QL

hydrocodone/ibuprofen IBUDONE generic 1 QLhydromorphone DILAUDID generic 1 tabs, QLmorphine RMS generic 1 QLmorphine

extended-release MS CONTIN generic 1 PA, QL

morphine sulfate MORPHINE SULFATE generic 1 PA, QLoxycodone ROXICODONE generic 1 tabs, QLoxycodone/

acetaminophen PERCOCET generic 1 tabs, QL

oxycodone/aspirin PERCODAN generic 1 QL

oxymorphone ER OXYMORPHONE ER generic 1 PA, QL, non-crush resistant

tramadol/acetaminophen ULTRACET generic 1 Age Limits Apply, PA, QLMigraine Acute TherapyErgotamine Derivativesdihydroergotamine D.H.E. 45 generic/

brand 1/2 inj, PA, QLdihydroergotamine MIGRANAL generic 1 PAergotamine/caffeine CAFERGOT generic 1 PAergotamine tartrate ERGOMAR generic 1 PAergotamine tartrate/

caffeineMIGERGOT

SUPPOSITORIES brand 2 PA, QL

Selective Serotonin Agonistsnaratriptan AMERGE generic 1rizatriptan MAXALT/MAXALT MLT generic 1 QLsumatriptan IMITREX generic 1 QL

17




sumatriptan IMITREX 4 MG AND 6 MG INJ generic 1 4 mg and 6 mg inj

sumatriptan/camphor/menthol gel MIGRANOW brand 2 PA, QL

sumatriptan/naproxen sodium TREXIMET brand 2 PA, QL

Miscellaneousisomethptene/dichloral/

acetaminophen MIDRIN generic 1 PA

Migraine Prophylactic Therapyamitriptyline ELAVIL generic 1divalproex sodium

cap sprinkle DEPAKOTE SPRINKLE generic 1 Members ≥ 8 years of age will require prior authorization .

divalproex sodium delayed-release DEPAKOTE generic 1 Minimum age 2

galcanezumab-gnlm EMGALITY brand 2 PA, QLpropranolol INDERAL generic 1 IR onlyverapamil CALAN generic 1Multiple Sclerosisdimethyl fumarate TECFIDERA brand 2 QL, SPfingolimod GILENYA brand 2 QL, SPglatiramer acetate COPAXONE brand 2 QL, SPinterferon beta-1a AVONEX brand 2 QL, SPinterferon beta-1a REBIF/REBIF REBIDOSE brand 2 QL, SPinterferon beta-1b BETASERON brand 2 QL, SPMyasthenia Gravispyridostigmine MESTINON generic 1 tabspyridostigmine

extended-release MESTINON TIMESPAN generic 1

Parkinson’s Diseaseamantadine SYMMETREL generic 1 except tabsbenztropine COGENTIN generic 1benztropine inj COGENTIN generic 1 PAcarbidopa LODOSYN generic 1carbidopa/levodopa SINEMET generic 1carbidopa/levodopa

extended-release SINEMET CR generic 1

entacapone COMTAN generic 1pramipexole MIRAPEX generic 1ropinirole REQUIP generic 1

18




selegiline ELDEPRYL generic 1tolcapone TASMAR generic 1trihexyphenidyl ARTANE generic 1Seizurescarbamazepine EQUETRO brand 2 PAcarbamazepine TEGRETOL generic 1carbamazepine

extended-releaseCARBATROL TEGRETOL-XR

generic 1

clonazepam KLONOPIN generic 1 tabsdiazepam DIASTAT ACUDIAL generic 1 rectal gel, PA, QL

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1

Members ≥ 8 years of age will require prior

authorization . divalproex sodium

delayed-release DEPAKOTE generic 1 QL

divalproex sodium extended-release DEPAKOTE ER generic 1 QL

exogabine POTIGA brand 2 Age Limits Applyfelbamate FELBATOL generic 1 PAfosphenytoin inj CEREBYX generic/

brand 1/2gabapentin NEURONTIN generic 1 QLlacosamide VIMPAT brand 2 Age Limits Applylamotrigine LAMICTAL QL

levetiracetam KEPPRA generic 1 QL, Maximum age of 9 for solution

levetiracetam ER KEPPRA XR generic 1 QL

oxcarbazepine TRILEPTAL generic 1 QL, Maximum age of 9 for suspension

perampanel FYCOMPA brand 2 PA, QLphenobarbital PHENOBARBITAL generic 1phenytoin DILANTIN INFATABS generic 1phenytoin sodium

extendedDILANTINPHENYTEK

generic 1

primidone MYSOLINE generic 1

tiagabine GABITRIL generic 1 Age Limits Apply, PA, 2mg & 4mg

tiagabine GABITRIL brand 2 Age Limits Apply, PA, 12mg & 16mg

19




topiramate TOPAMAX generic 1 QLtopiramate ER cap TROKENDI XR brand 2 QL

topiramate sprinkle caps TOPAMAX SPRINKLE generic 1QL, Members ≥ 8 years of age will require prior

authorization .valproic acid DEPAKENE generic 1vigabatrin oral solution SABRIL SOLUTION generic 1 PA, SPvigabatrin tabs SABRIL brand 2 PA, SPzonisamide ZONEGRAN generic 1 QLMiscellaneoustetrabenazine XENAZINE generic 1 Age Limits Apply, PA, SP

Dermatology

Acne VulgarisOral

isotretinoin

AMNESTEEMCLARAVISMYORISANZENTANE

generic 1 PA

Topicalazelaic acid FINACEA generic/

brand 1/2 gel

azelaic acid foam FINACEA brand 2 QLadapalene gel DIFFERIN OTC GEL 0.1% brand 2clindamycin CLEOCIN T generic 1 gelclindamycin CLEOCIN T generic 1 lotionclindamycin CLEOCIN T generic 1 solnerythromycin ERYGEL generic 1 gel 2% erythromycin T-STAT generic 1 soln

tretinoinAVITA RETIN-A

generic 1 cream, ST

Bacterial Infectionsbacitracin BACITRACIN generic 1 OTCgentamicin GENTAK generic 1mafenide acetate SULFAMYLON CRE brand 2 PAmafenide acetate SULFAMYLON PAK generic 1 PA

20




mupirocin BACTROBAN generic 1 ointment, 22 gram tube only

mupirocin CENTANY generic 1 QLsilver sulfadiazine SILVADENE generic 1CorticosteroidsLow Potencyalclometasone ACLOVATE generic 1 0 .05% crm/ointhydrocortisone CORTIZONE generic 1 crm, oint, lot OTChydrocortisone HYTONE generic 1 crm 0 .5%, 1%, & 2 .5%hydrocortisone HYTONE generic 1 lotion 1% & 2 .5%

hydrocortisone/aloe CORTIZONE-10 INTENSIVE HEALING generic 1 crm 0 .5% & 1%, OTC

Medium Potencybetamethasone val BETA-VAL generic 1 crm/oint/lotion 0 .1%fluticasone propionate CUTIVATE generic 1 crm 0 .05%, oint 0 .005%mometasone furoate ELOCON generic 1 crm/oint/soln 0 .1%triamcinolone acetonide KENALOG generic 1 crm/lot/oint 0 .025%triamcinolone acetonide KENALOG generic 1 crm/oint/lotion 0 .1%High Potencytriamcinolone acetonide KENALOG generic 1 crm 0 .5%Very High Potency

clobetasol propionate TEMOVATE generic 1 crm 0 .05%, gel 0 .05%, oint 0 .05%, soln 0 .05%

halobetasol ULTRAVATE generic 1 cream, ointmentFungal Infectionsciclopirox LOPROX generic 1 Shampoo, SUSP, creamclotrimazole LOTRIMIN AF generic 1 OTCclotrimazole MYCELEX generic 1clotrimazole with

betamethasone LOTRISONE generic 1 QL

ketoconazole NIZORAL generic 1 QLmiconazole MICATIN generic 1 OTC, 2% cream

miconazole MONISTAT-DERM generic 1 OTC, 2% & 4% vaginal cream

nystatin MYCOSTATIN generic 1nystatin/triamcinolone MYCOLOG-II generic 1 QLterbinafine LAMISIL AT generic 1 OTCtolnaftate TINACTIN generic 1 OTCPruritusdoxepin ZONALON brand 2 PA

21




Psoriasisacitretin SORIATANE generic 1 oral caps, QLcalcipotriene CALCITRENE generic/

brand 1/2 oint, QLcalcipotriene DOVONEX generic 1 cream, QLcalcipotriene DOVONEX generic 1 solncalcipotriene/

betamethasone dipropionate

TACLONEX generic 1 oint

Rosacea

metronidazoleMETROCREAMMETROGELMETROLOTION

generic 1

Scabies and Pediculosiscrotamiton EURAX brand 2crotamiton lot CROTAN LOT generic 1ivermectin lotion SKLICE LOT brand 2permethrin ELIMITE generic 1 5%, QLpermethrin NIX CREME RINSE generic 1 1%, OTCpermethrin lotion SM LICE LOT generic 1pyrethrins/piperonyl

butoxide RID SHAMPOO generic 1 4% OTC

pyrethrins/piperonyl butoxide gel VANALICE GEL brand 2 0 .3-3 .5% OTC

pyrethrins/piperonyl butoxide liq PRONTO SHA W/CR RI generic 1 0 .3-3% OTC

pyrethrins/piperonyl butoxide shampoo RID LICE KIL generic 1 0 .33-4% OTC

Viral Infectionspodofilox CONDYLOX SOL generic 1 solMiscellaneousaminolevulinic acid gel

10% AMELUZ brand 2 PA

aminolevulinic acid soln 20% LEVULAN KERASTICK brand 2 PA

ammonium lactate LAC-HYDRIN generic 1 crm 12%, lotion 12%becaplermin gel REGRANEX brand 2 PAdiclofenac sodium (actinic

keratosis) SOLARAZE generic 1 QL

fluorouracil EFUDEX generic 1 PAfluorouracil soln FLUOROURACIL generic 1 PAhydrocortisone PROCTOCORT brand 2

22




hydrocortisone

PROCTOSOL HC CREAM 2.5%

PROCTOZONE CREAM-HC 2.5%

generic 1

hydrocortisone acetate/pramoxine ANALPRAM-HC generic 1

hydrocortisone suppository ANUSOL-HC generic/

brand 1/2 Age Limits Apply

ingenol mebutate PICATO generic 1 PA, QLketoconazole NIZORAL SHAMPOO generic 1 shampoo 2%lidocaine LIDAMANTEL generic 1 3% creamlidocaine XYLOCAINE generic 1 jelly 2%lidocaine/hydrocortisone

acetate rectal ANAMANTLE HC generic 1

lidocaine/prilocaine EMLA generic 1 2 .5% creamnitroglycerin RECTIV brand 2 PA, 0 .4% rectal ointmentpimecrolimus ELIDEL generic/

brand 1/2 cream, PA, QLselenium sulfide SELSUN generic 1 lotion 2 .5%urea 40% UREA 40% LOTION generic 1 lotion

Ear, Nose & Throat

Earacetic acid VOSOL OTIC generic 1 oticacetic acid/

aluminum acetate DOMEBORO OTIC generic 1

acetic acid/ hydrocortisone VOSOL HC OTIC brand &

generic 1 & 2

benzocaine/antipyrine BENZOTIC generic 1carbamide peroxide DEBROX generic 1 6 .5%, OTCciprofloxacin/

dexamethasone CIPRODEX brand 2

ciprofloxacin/hydrocortisone CIPRO HC brand 2

neomycin/polymyxin B/hydrocortisone CORTISPORIN OTIC generic 1 otic

ofloxacin FLOXIN OTIC generic 1

23




pramoxine/chloroxylenol PRAMOTIC brand 2pramoxine/

hydrocortisone/chloroxylenol

OTICIN HC generic 1

NoseAntihistamines - First Generation, Sedatingclemastine CLEMASTINE generic 1cyproheptadine CYPROHEPTADINE generic 1diphenhydramine generic 1diphenhydramine BENADRYL generic 1 OTChydroxyzine HCL ATARAX generic 1hydroxyzine pamoate VISTARIL generic 1Antihistamines - Second Generation, Nonsedatingcetirizine ZYRTEC generic 1 OTC

cetirizine chew tab ZYRTEC CHEWABLE TABLET generic 1

OTC, Members ≥ 8 years of age will require prior

authorization .levocetirizine XYZAL generic 1 tabs

loratadineALAVERTCLARITIN

generic 1 OTC

Antihistamines - Others Antihistamine/Decongestant Combinations

azelastineASTELINASTEPRO

generic 1 spray

Antihistamine/Decongestant Combinations - Second Generationcetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release

ZYRTEC-D generic 1 5 mg-120 mg tablet

loratadine/ pseudoephedrine extended-release

ALAVERT-DALAVERT ALRG

TAB/SINUSALLERGY/CONG

generic 1 OTC

Nasal Steroidsfluticasone FLONASE generic 1

triamcinolone nasal spray NASACORT ALLERGY 24 HOUR brand 2

24




Miscellaneous Nasalipratropium nasal ATROVENT NASAL SPRAY generic 1 QLsaline nasal spray 0 .65% OCEAN NASAL SPRAY generic 1 OTCThroat and Mouthchlorhexidine gluconate PERIDEX generic 1lidocaine viscous XYLOCAINE generic 1pilocarpine SALAGEN generic 1triamcinolone KENALOG IN ORABASE generic 1 paste

Endocrinology

Adrenal Corticosteroidscortisone acetate generic 1dexamethasone DECADRON generic 1dexamethasone sodium

phosphate inj DECADRON generic 1 PA

dexamethasone soln DEXAMETHASONE SOL generic 1 PAfludrocortisone FLORINEF generic 1hydrocortisone CORTEF generic 1hydrocortisone sodium

succinate pf for inj SOLU-CORTEF generic 1 PA

methylprednisolone MEDROL generic 1 4mg, 8mg, 16mg, 32mgmethylprednisolone

acetate inj susp DEPO-MEDROL INJ generic 1 PA

methylprednisolone sod succ for inj SOLU-MEDROL INJ generic 1 PA

prednisoloneprednisolone PRELONE generic 1 syrup

prednisolone sodium phosphate

MILLIPREDORAPREDPEDIAPREDVERIPRED 20

generic 1

prednisone DELTASONE generic 1prednisone conc PREDNISONE INTENSOL generic 1Androgenstestosterone cypionate DEPO-TESTOSTERONE generic 1

testosterone enanthate DELATESTRYL generic 1 Vials only . Disposable syringes not covered .

25




testosterone gel topical tube, packet, and pump bottle

TESTOSTERONE 1% TOPICAL GEL generic 1 PA

testosterone TD patch ANDRODERM brand 2 PADiabetes MellitusGlucose Elevating Agentsglucagon, human

recombinant GLUCAGON brand 2 QL

InsulinsInsulin preparations covered include the specific brands of human insulins noted in the list. The PDL also includes all syringes and needles.insulin aspart NOVOLOG brand 2 QLinsulin aspart

protamine 70%/ insulin aspart 30%

NOVOLOG MIX 70/30 brand 2 QL

insulin determirLEVEMIRLEVEMIR FLEXTOUCH

brand 2 QL

insulin glargineLANTUSLANTUS SOLOSTAR

brand 2 QL

insulin isophane HUMULIN N brand 2 OTC, QLinsulin isophane/regular HUMULIN 70/30 brand 2 OTC, QLinsulin lisopro pro/lispro HUMALOG MIX 50/50 brand 2 QLinsulin lisopro prot/lispro HUMALOG MIX 75/25 brand 2 QL

insulin lisproHUMALOGHUMALOG KWIKPEN

brand 2 QL

insulin regular HUMULIN R brand 2 OTC, QLinsulin regular

(concentrated)HUMULIN R

CONCENTRATED brand 2 QL

insulin regular HUMULIN R KWIKPEN brand 2 QLMonitoring - Strips and Kits/Diabetic Supplies

ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC) brand 2

QL for insulin dependent or pregnant members:

allow testing up to 6 times per day

ONE TOUCH TEST STRIPS (ULTRA, VERIO) brand 2QL for non-insulin

dependent members: allow twice daily testing

26




Oral Agentsacarbose PRECOSE generic 1alogliptin/pioglitazone OSENI generic 1 PAcanagliflozin INVOKANA brand 2canagliflozin/metformin INVOKAMET brand 2dapagliflozin FARXIGA brand 2 QLdapagliflozin/metformin XIGDUO XR brand 2 QLempagliflozin JARDIANCE brand 2glimepiride AMARYL generic 1glipizide GLUCOTROL generic 1glipizide extended-release GLUCOTROL XL generic 1glipizide/metformin METAGLIP generic 1glyburide MICRONASE generic 1glyburide, micronized GLYNASE generic 1linagliptan TRADJENTA brand 2linagliptan/metformin JENTADUETO brand 2metformin GLUCOPHAGE generic 1metformin ER GLUCOPHAGE ER generic 1metformin/glyburide GLUCOVANCE generic 1nateglinide STARLIX generic 1pioglitazone ACTOS generic 1 QLrepaglinide PRANDIN generic 1sitagliptan JANUVIA brand 2sitagliptan/metformin JANUMET brand 2sitagliptan/metformin ER JANUMET XR brand 2Miscellaneous Antidiabetic Agentsexenatide BYETTA brand 2exenatide extended-

release BYDUREON brand 2

liraglutide VICTOZA brand 2pramlintide SYMLIN brand 2 PAGrowth Stimulating Agents

somatropinGENOTROPINNORDITROPIN

brand 2 PA, SP

tesamorelin EGRIFTA brand 2 PAOsteoporosisalendronate FOSAMAX generic 1 QLcalcitonin-salmon MIACALCIN generic 1 nasal spray, QLcalcitonin-salmon FORTICAL brand 2 nasal spray, QL

27




ibandronate sodium BONIVA generic 1Thyroid Diseaselevothyroxine LEVOXYL generic 1levothyroxine SYNTHROID generic 1liothyronine CYTOMEL generic 1methimazole TAPAZOLE generic 1propylthiouracil PROPYLTHIOURACIL generic 1thyroid ARMOUR THYROID generic 1 QLMiscellaneousasfotase alfa STRENSIQ brand 2 PA, SPcabergoline DOSTINEX generic 1 QLcorticotropin H.P. ACTHAR brand 2 PAdesmopressin DDAVP generic 1 tabs, spray, QLdesmopressin acetate inj DDAVP INJ generic 1 PAmethylergonovine METHERGINE generic 1mifepristone KORLYM brand 2 PA, SPmiglustat ZAVESCA generic/

brand 1/2 PAnitisinone NITYR brand 2 PA, QL, SPnitisinone ORFADIN brand 2 PA, SPpegvisomant SOMAVERT brand 2 PA, SPsapropterin KUVAN brand 2 PA, SP

sapropterin powder KUVAN POWDER FOR SOLUTION brand 2 PA, SP

tolvaptanJYNARQUE SAMSCA

brand 2 tabs, PA, QL, SP

uridine VISTOGARD brand 2 SPvasopressin IV soln VASOSTRICT brand 2 PA

Gastrointestinal

Constipation/Laxatives docusate calcium plus generic 1 OTCdocusate sodium COLACE generic 1 OTCglycerin GLYCERIN SUPPOSITORY generic 1 suppository, OTClactulose ENULOSE generic 1linaclotide LINZESS brand 2 PAlubiprostone AMITIZA brand 2 Age Limits Apply, PA, QL

magnesium citrate soln MAGNESIUM CITRATE SOLN generic 1

naloxegol MOVANTIK brand 2 PApeg 3350/electrolytes COLYTE generic 1

28




peg 3350/sodium bicarbonate/sodium chloride

TRILYTE generic 1

peg 3350/sodium bicarbonate/sodium chloride/potassium chloride

NULYTELY generic 1

polyethylene glycol 3350 MIRALAX generic 1sennosides SENOKOT generic 8 .6 mg tab, OTCDiarrheadiphenoxylate/atropine LOMOTIL generic 1loperamide IMODIUM A-D generic 1 OTCloperamide LOPERAMIDE generic 1rifaximin XIFAXAN brand 2 PA, QLEmesisaprepitant EMEND generic 1 QLdoxylamine/pyridoxine DICLEGIS brand 2 PA, QLdronabinol MARINOL generic 1 PAgranisetron KYTRIL generic 1 QLmeclizine ANTIVERT generic 1metoclopramide REGLAN generic 1

ondansetronZOFRANZOFRAN ODT

generic 1 QL

prochlorperazine COMPAZINE generic 1promethazine PHENERGAN generic 1trimethobenzamide TIGAN generic 1 300 mg capsGastroesophageal Reflux Disease (Gerd)/Peptic Ulcersalumina/magnesia MAALOX generic 1 OTCcimetidine TAGAMET generic 1

esomeprazole granules NEXIUM DELAYED RELEASE PACKET brand 2

Members ≥ 2 yearsof age will require prior

authorization .

famotidinePEPCIDPEPCID AC

generic 1

OTC Pepcid AC 10 mg and 20 mg also covered/encouraged with written

prescription .lansoprazole PREVACID generic 1

29




lansoprazole delayed-release PREVACID SOLUTAB generic 1

orally disintegrating tabs, Members ≥ 2 years

of age will require priorauthorization . QL

methscopolamine bromide PAMINE generic 1omeprazole

delayed-release PRILOSEC generic 1 Capsules only, QL

pantoprazole PROTONIX generic 1ranitidine ZANTAC generic 1 150 mg tabsranitidine syrup ZANTAC generic 1sucralfate CARAFATE generic 1

sulcralfate CARAFATE SUSPENSION generic/brand 1/2

suspension, Members 10 years of age up to 65 years of age will require

prior authorization .Gastrointestinal Spasmdicyclomine BENTYL generic 1

glycopyrrolateROBINULROBINUL FORTE

generic 1

hyoscyamine sulfate LEVSIN generic 1hyoscyamine sulfate

extended-release LEVSINEX generic 1

Inflammatory Bowel Diseasebalsalazide COLAZAL generic 1budesonide ENTOCORT EC generic 1budesonide UCERIS generic 1hydrocortisone COLOCORT generic 1 enemamesalamine ROWASA generic 1 enema onlymesalamine cap ER PENTASA brand 2mesalamine

extended-releaseAPRISODELZICOL

brand 2

mesalamine supp CANASA generic/brand 1/2

mesalamine tab DR LIALDA brand 2sulfasalazine AZULFIDINE generic 1sulfasalazine

delayed-release AZULFIDINE EN-TABS generic 1

30




Pancreatic Enzymes

pancrelipaseCREONCREON 3000 UNITZENPEP

brand 2

Miscellaneousatropine sulfate SAL-TROPINE brand 2bismuth subcitrate/

metronidazole/tetracycline

PYLERA brand 2

misoprostol CYTOTEC generic 1teduglutide GATTEX brand 2 PA, SP

ursodiolACTIGALL URSO URSO FORTE

generic 1

Infectious Diseases

Anthelminticsalbendazole ALBENZA generic 1 QL, Only NDC 54505-

0055-22 ivermectin STROMECTOL generic 1 QL

pyrantel pamoate PIN-X brand 2 chewable tablets, suspension

pyrantel pamoate REESE’S PINWORM MEDICINE brand 2 tablets, suspension

triclabendazole EGATEN brand 2AntibacterialsAntituberculosis Agentscycloserine SEROMYCIN generic 1ethambutol MYAMBUTOL generic 1ethionamide TRECATOR brand 2isoniazid ISONIAZID generic 1pyrazinamide PYRAZINAMIDE generic 1rifabutin MYCOBUTIN generic 1rifampin RIFADIN generic 1rifapentine PRIFTIN brand 2

31




Cephalosporins - First Generationcefadroxil DURICEF generic 1

cefazolin sodium for injANCEF INJKEFZOL INJ

generic 1 PA

cephalexin KEFLEX generic 1Cephalosporins - Second Generationcefaclor CECLOR generic 1 QLcefprozil CEFZIL generic 1cefuroxime axetil CEFTIN generic 1 tabsCephalosporins - Third Generationcefdinir OMNICEF generic 1cefixime SUPRAX brand 2 caps, chew tabs, QL

cefixime SUPRAX generic 1 suspension; Age Limits Apply; QL

cefpodoxime axetil VANTIN generic 1 QLceftriazone sodium for inj ROCEPHIN generic 1 PAFluoroquinolonesciprofloxacin CIPRO generic 1 tabslevofloxacin LEVAQUIN generic 1 tablets onlyMacrolidesazithromycin ZITHROMAX generic 1 QLclarithromycin BIAXIN generic 1erythromycin

delayed-release ERYC generic 1

erythromycin delayed-release ERY-TAB brand 2

erythromycin ethylsuccinate E.E.S. generic 1

erythromycin stearate ERYTHROCIN generic 1erythromycin/sulfisoxazole PEDIAZOLE generic 1Penicillinsamoxicillin AMOXICILLIN generic 1amoxicillin AMOXIL SUSP generic 1 suspension

amoxicillin/clavulanate AUGMENTINAUGMENTIN XR generic 1

ampicillin PRINCIPEN generic 1dicloxacillin DICLOXACILLIN generic 1

32




penicillin VK VEETIDS generic 1Sulfonamidessulfadiazine SULFADIAZINE generic 1sulfamethoxazole/

trimethoprim, DSBACTRIMBACTRIM DS generic 1

Tetracyclines

doxycycline hyclateACTICLATE VIBRAMYCIN

generic 1 caps, tabs

doxycycline monohydrate DOXYCYCLINE MONOHYDRATE generic 1

minocycline MINOCIN generic 1 capsulestetracycline TETRACYCLINE generic 1Miscellaneoustigecycline for IV soln TYGACIL generic 1 PAvancomycin hcl FIRVANQ generic 1 QLvancomycin hcl VANCOCIN HCL generic 1 capAntifungalsclotrimazole MYCELEX generic 1 trochesfluconazole DIFLUCAN generic 1 QLgriseofulvin microsize GRIFULVIN V generic 1griseofulvin ultramicrosize GRIS-PEG generic 1itraconazole SPORANOX brand 2 soln, PA, QLketoconazole NIZORAL generic 1 QLnystatin MYCOSTATIN generic 1terbinafine LAMISIL generic 1 QLtinidazole TINDAMAX generic 1 QLAntiprotozoalsatovaquone MEPRON generic 1 QLmiltefosine IMPAVIDO brand 2 PA

nitazoxanide suspension ALINIA SUSPENSION brand 2Members ≥ 8 years of age will require prior

authorization .nitazoxanide tablet ALINIA brand 2 PApentamidine isethionate

for nebulization NEBUPENT brand 2 PA

AntiviralsCytomegalovirus Treatmentganciclovir CYTOVENE generic 1letermovir PREVYMIS brand 2 PAvalganciclovir VALCYTE generic 1

33




Hepatitis A & B Treatmentlamivudine EPIVIR HBV generic 1 tabs, SP, QLlamivudine EPIVIR HBV brand 2 solution, SP, QLHerpes Treatmentacyclovir ZOVIRAX generic 1 caps, tabs, suspensiondocosanol ABREVA OTC CREAM brand 2famciclovir FAMVIR generic 1valacyclovir VALTREX generic 1Influenza Treatmentamantadine SYMMETREL generic 1 except tabsoseltamivir TAMIFLU generic 1peramivir RAPIVAB brand 2rimantadine FLUMADINE generic 1Integrase Inhibitorsdolutegravir TIVICAY brand 2 QLraltegravir ISENTRESS brand 2 QLraltegravir ISENTRESS CHEWABLE brand 2 chewable tablet, QL

raltegravir susp ISENTRESS SUSP brand 2Members ≥ 2 years of age will require prior

authorization, QLNon-Nucleoside Reverse Transcriptase Inhibitorsdelavirdine RESCRIPTOR brand 2 QLefavirenz SUSTIVA brand 2 QLetravirine INTELENCE brand 2 QLnevirapine VIRAMUNE generic 1 tabs, QLnevirapine ER VIRAMUNE XR generic 1 QL

nevirapine susp VIRAMUNEgeneric

and brand

1 and

2QL

rilpivirine EDURANT brand 2 QLNucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinationsabacavir ZIAGEN generic 1 QLabacavir/lamivudine EPZICOM generic 1 QLabacavir/lamivudine/

zidovudine TRIZIVIR generic 1 QL

didanosine VIDEX brand 2 QLdidanosine

delayed-release VIDEX EC generic 1 QL

emtricitabine EMTRIVA brand 2 QL

34




emtricitabine/rilpivirine/tenofovir COMPLERA brand 2 QL

lamivudine EPIVIR generic 1 QL, SPlamivudine/zidovudine COMBIVIR generic 1 QLstavudine ZERIT generic 1 QLzidovudine RETROVIR generic 1 QLNucleoside/Nucleotide Reverse - Transcriptase Inhibitor Combinationefavirenz/emtricitabine/

tenofovir ATRIPLA brand 2 QL

emtricitabine/rilpivirine/tenofovir ODEFSEY brand 2 QL

emtricitabine/tenofovir alafenamide DESCOVY brand 2 QL

emtricitabine/tenofovir disoproxil TRUVADA brand 2 QL

Nucleotide Analogues Nucleotide Reverse - Transcriptase Inhibitoradefovir dipivoxil HEPSERA generic 1tenofovir VIREAD brand 2 QLProtease Inhibitorsatazanavir REYATAZ generic 1 QL

atazanavir REYATAZ POWDER PACKET brand 2


authorization, QLatazanavir/cobicistat EVOTAZ brand 2 QLdarunavir PREZISTA brand 2 QLfosamprenavir LEXIVA brand 2 QLindinavir CRIXIVAN brand 2 QLlopinavir/ritonavir KALETRA brand 2 tablets, QLlopinavir/ritonavir KALETRA generic 1 solution, QLnelfinavir VIRACEPT brand 2 QLsaquinavir mesylate INVIRASE brand 2 QLtipranavir APTIVUS brand 2Miscellaneousabacavir/dolutegravir/

lamivudine TRIUMEQ brand 2 QL

cobicistat TYBOST brand 2 QLcobicistat/elvitegravir/

emtricitabine/tenofovir STRIBILD brand 2 QL

35




darunavir/cobicistat PREZCOBIX brand 2 QLelvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate

GENVOYAbrand 2 QL

enfuvirtide FUZEON brand 2 QLibalizumab-uiyk IV soln TROGARZO brand 2 PA, SPmaraviroc SELZENTRY brand 2 QLRespiratory Syncytial Virus (RSV)ribavirin VIRAZOLE generic 1 PAMiscellaneousartemether/lumefantrine COARTEM brand 2atovaquone/proguanil MALARONE generic 1bedaquiline SIRTURO brand 2chloroquine phosphate ARALEN generic 1clindamycin CLEOCIN generic 1 QLdapsone DAPSONE brand 2hydroxychloroquine PLAQUENIL generic 1linezolid ZYVOX generic 1mefloquine LARIAM generic 1metronidazole FLAGYL generic 1 tabs onlyneomycin sulfate brand 2nitrofurantoin

extended-release MACROBID generic 1

nitrofurantoin macrocrystals MACRODANTIN generic 1

nitrofurantoin susp FURADANTIN SUSP 25 MG/5 ML generic 1


authorization .palivizumab SYNAGIS brand 2 PA, SPparomomycin HUMATIN generic 1primaquine generic 1quinine sulfate QUALAQUIN generic 1 QLtrimethoprim TRIMETHOPRIM generic 1 tabs only

Musculoskeletal

ArthritisDisease Modifying Anti-Rheumatic Drugsadalimumab HUMIRA brand 2 PA, SPauranofin RIDAURA brand 2azathioprine IMURAN generic 1

36




etanercept ENBREL brand 2 PA, SPhydroxychloroquine PLAQUENIL generic 1leflunomide ARAVA generic 1methotrexate generic 1methotrexate auto inj RASUVO brand 2 PA, QLmethotrexate oral solution XATMEP brand 2methotrexate sodium TREXALL brand 2

penicillamineCUPRIMINE DEPEN TITRATABLE

generic 1 PA, SP

sulfasalazine AZULFIDINE generic 1sulfasalazine

delayed-release AZULFIDINE EN-TABS generic 1

NSAIDs and Other Analgesicsacetaminophen TYLENOL generic 1 OTC

aspirinBAYERECOTRIN

generic 1 OTC

celecoxib CELEBREX generic 1 PA, QL

diclofenac 1% gel VOLTAREN 1% TOPICAL GEL generic 1 PA

diclofenac potassium CATAFLAM generic 1diclofenac sodium

delayed-release VOLTAREN generic 1

diclofenac sodium extended-release VOLTAREN XR generic 1

etodolac LODINE generic 1 IR only

ibuprofen ADVIL generic 1 tabs, chew tabs and susp, OTC

ibuprofen MOTRIN generic 1 tabs, chew tabs and suspindomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlymeloxicam MOBIC generic 1 QLnaproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1salsalate DISALCID generic 1 QLsulindac CLINORIL generic 1

37




Goutallopurinol ZYLOPRIM generic 1colchicine MITIGARE generic 1colchine/probenecid COLBENEMID generic 1 QLprobenecid PROBENECID generic 1Skeletal Muscle RelaxantsMuscle Spasmcyclobenzaprine FEXMID generic 1cyclobenzaprine FLEXERIL generic 1 5mg & 10mgmethocarbamol ROBAXIN generic 1Spasticitybaclofen BACLOFEN generic 1 10mg & 20mgdiazepam VALIUM generic 1 QLtizanidine ZANAFLEX generic tabs only, QL

OB-GYN

ContraceptivesBarrier Contraception

cervical capFEMCAPPRENTIF CAVITY-RIM

CERVICAL CAPbrand 2

condoms-female FC FEMALE CONDOM brand 2 OTC

condoms-male

LIFESTYLESTROJANTRUSTEXKIMONODUREXFANTASY

brand 2 OTC

diaphragm

OMNIFLEX DIAPHRAGMCAYAWIDE-SEAL SILICONE

DIAPHRAGM KIT

brand 2

Biphasicdesogestrel/EE MIRCETTE generic/

brand 1/2 Age Limits Apply, QL

38




norethindrone/EE ORTHO-NOVUM 10/11 generic/brand 1/2 Age Limits Apply, QL

norethindrone/EE-FE tab LO LOESTRIN FE brand 2 Age Limits Apply, QLEmergency Contraception

levonorgestrel

PLAN B ONE STEP (BRAND AND GENERIC PLAN B ONE STEP ARE PREFERRED)

brand 2 Age Limits Apply

ulipristal acetate ELLA brand 2Extended Cyclelevonorgestrel/EE SEASONALE generic 1 Age Limits Apply, QL

levonorgestrel/EE SEASONIQUE generic/brand 1/2 Age Limits Apply,

0 .15-0 .03mg, QLlevonorgestrel/EE LYBREL generic 1 Age Limits Apply, QL

levonorgestrel/EE LOSEASONIQUE generic/brand 1/2 Age Limits Apply,

0 .1-0 .02mg, QL

levonorgestrel/EE QUARTETTE generic/brand 1/2

Age Limits Apply, 0 .15-0 .02/0 .025/0 .03,

QLInjectable

medroxyprogesterone acetate

DEPO-PROVERADEPO-PROVERA

PREFILLED SYRINGE

generic/brand 1/2 Age Limits Apply, QL

medroxyprogesterone acetate DEPO-PROVERA 104 brand 2 QL

Intrauterine Devicecopper IUD PARAGARD IUD brand 2 Age Limits Applylevonorgestrel releasing

IUD KYLEENA brand 2 Age Limits Apply

levonorgestrel releasing IUD

LILETTAMIRENASKYLA

brand 2 Age Limits Apply, QL

Intravaginaletonogestrel/EE NUVARING generic/

brand 1/2 ring, QL

nonoxynol-9 foamVCF VAGINAL

CONTRACEPTIVE FOAM

brand 2 OTC, 12 .5%

39




nonoxynol-9 gel

SHUR-SEAL GEL 2%, OPTIONS GYNOL II VAGINAL CONTRACEPTIVE

brand 2 OTC, 2% & 3%

nonoxynol-9 gel VCF VAGINAL CONTRACEPTIVE GEL

generic/brand 1/2 OTC, 4%

nonoxynol-9 vaginal film VCF VAGINAL CONTRACEPTIVE FILM brand 2 OTC, 28%

nonoxynol-9 vaginal sponge TODAY SPONGE brand 2 OTC, 1000mg

nonoxynol-9 vaginal suppository ENCARE SUPP generic 1 OTC, 100mg

ortho diaphragmORTHO COILORTHO FLATORTHO FLEX

brand 2

Monophasic - 20 mcg Estrogendrospirenone/EE YAZ generic/

brand 1/2 Age Limits Apply, QLdrospirenone/EE-

levomefolate BEYAZ generic/brand 1/2 Age Limits Apply,

3/0 .02-0 .451mg, QL

levonorgestrel/EE ALESSE generic 1 Age Limits Apply, 0 .1/20, QL

levonorgestrel/EE & FA kit FALESSA brand 2 Age Limits Apply, QL

levonorgestrel/EE- FE BALCOLTRA brand 2 Age Limits Apply, 0 .1/20, QL

norethindrone acetate/EE LOESTRIN 1/20 generic/brand 1/2 Age Limits Apply, 1/20,

QLnorethindrone acetate/EE-

FE cap TAYTULLA brand 2 Age Limits Apply, QL

norethindrone acetate/EE-FE chew MINASTRIN 24 CHEW FE generic/


norethindrone acetate/EE/iron LOESTRIN FE 1/20 generic/

brand 1/2 Age Limits Apply, 1/20, QL

norethindrone acetate/EE-FE tab LOESTRIN 24 FE generic/


Monophasic - 25 mcg Estrogendrospirenone/estradiol ANGELIQ brand 2

40




Monophasic - 30 mcg Estrogen

desogestrel/EEDESOGEN ORTHO-CEPT

generic/brand 1/2 Age Limits Apply

drospirenone/EE YASMIN generic/brand 1/2 Age Limits Apply, QL

drospirenone/EE-levomefolate SAFYRAL generic/

brand 1/2 Age Limits Apply, 3/0 .03- .0451mg, QL

levonorgestrel/EE NORDETTE generic 1 Age Limits Apply, 0 .15/30, QL

norethindrone acetate/EE LOESTRIN 1.5/30 generic/brand 1/2 Age Limits Apply,

1 .5/30, QLnorethindrone acetate/EE/

iron LOESTRIN FE 1.5/30 generic/brand 1/2 1 .5/30, QL

norgestrel/EE LO/OVRAL generic/brand 1/2 Age Limits Apply,

0 .3/30, QLMonophasic - 35 mcg Estrogen

ethynodiol diacetate/EE ZOVIA 1/35 generic/brand 1/2 Age Limits Apply,

1/35, QLnorethindrone/EE BALZIVA generic 1 0 .4/35, QL

norethindrone/EE MODICON generic 1 Age Limits Apply, 0 .5/35, QL

norethindrone/EE ORTHO-NOVUM 1/35 generic 1 1/35, QLnorethindrone/EE-FE

chew tabFEMCON FEGENERESS FE

generic/brand 1/2 Age Limits Apply, QL

norgestimate/EE ORTHO-CYCLEN generic/brand 1/2 Age Limits Apply,

0 .25/35, QLMonophasic - 50 mcg Estrogen

ethynodiol diacetate/EE ZOVIA 1/50 generic/brand 1/2 Age Limits Apply,

1/50, QL

norethindrone/EE OVCON 50 generic 1 Age Limits Apply, 1/50, QL

norethindrone/ME ORTHO-NOVUM 1/50 generic 1 1/50, QL

norgestrel/EE OVRAL generic 1 Age Limits Apply, 0 .5/50, QL

Progestinnorethindrone ORTHO MICRONOR generic/

brand 1/2 Age Limits Apply

41




Quadriphasicdienogest/estradiol

valerate NATAZIA brand 2 Age Limits Apply, QL

Subdermal Implantsetonogestrel subdermal

implant NEXPLANON brand 2 Age Limits Apply, QL

Transdermal

norelgestromin/EEORTHO EVRAXULANE

generic 1 Age Limits Apply

Triphasicdesogestrel/EE CYCLESSA generic 1 Age Limits Apply, QLlevonorgestrel/EE TRIVORA generic 1 Age Limits Apply, QLnorethindrone

acetate/EE/iron ESTROSTEP FE generic/brand 1/2 Age Limits Apply, QL

norethindrone/EE ORTHO-NOVUM 7/7/7 generic 1 QLnorethindrone/EE TRI-NORINYL generic/


norgestimate/EE ORTHO TRI-CYCLEN generic/brand 1/2 Age Limits Apply, QL

norgestimate/EE ORTHO TRI-CYCLEN LO generic/brand 1/2 Age Limits Apply, QL

Endometriosisdanazol DANOCRINE generic 1Hormone Therapy/MenopauseEstrogens - Injectableestradiol valerate DELESTROGEN generic 1 QLEstrogens - Intravaginalestradiol ESTRACE CRM generic 1estradiol vaginal ring ESTRING brand 2estradiol vaginal tab VAGIFEM generic 1 QLestrogens, conjugated PREMARIN brand 2 crmEstrogens - Oralesterfied estrogens MENEST generic 1 QLesterfied estrogens/

methyltestosterone hs ESTRATEST generic 1 QL

estradiol ESTRACE generic 1estrogens, conjugated PREMARIN brand 2estropipate OGEN generic 1norethindrone acetate/EE FEMHRT LOW DOSE generic 1 QL

42




norethindrone acetate/estradiol ACTIVELLA generic 1 QL

Estrogens - Transdermal

estradiol

ALORACLIMARAMINIVELLEVIVELLE-DOT

generic 1 QL

estradiol/norethindrone acetate patch COMBIPATCH brand 2 QL

Estrogen/Progestinestrogens, conjugated/

medroxyprogesteronePREMPHASEPREMPRO

brand 2

Progestinsmedroxyprogesterone

acetate PROVERA generic 1

norethindrone acetate AYGESTIN generic 1progesterone IM inj generic 1progesterone micronized

caps PROMETRIUM generic 1

Vaginal InfectionsOralfluconazole DIFLUCAN generic 1 QLmetronidazole FLAGYL generic 1 tabssecnidazole granules SOLOSEC brand 2Vaginalclindamycin CLEOCIN generic 1clotrimazole GYNE-LOTRIMIN generic 1 OTC

metronidazoleMETROGEL-VAGINAL METROGEL 1%

generic 1

miconazole MONISTAT generic 1 OTCmiconazole MONISTAT 3 generic 1terconazole TERAZOL 3/7 generic 1 crmMiscellaneousconjugated estrogen/

bazedoxifene DUAVEE brand 2 PA

elagolix ORILISSA brand 2 PA, QL

43




hydroxyprogesterone caproate IM

HYDROXYPROGESTERONE CAPROATE generic 1 PA

hydroxyprogesterone caproate IM MAKENA generic/

brand 1/2 Age Limits Apply, PA, QL, SP

methylergonovine METHERGINE generic 1 QLtranexamic acid LYSTEDA generic 1

Ophthalmic

Allergycromolyn sodium CROLOM generic 1 QL

ketotifen ALAWAY OTC generic/brand 1/2 QL

ketotifen ZADITOR generic 1 OTC, QL

naphazoline/glycerin CLEAR EYES REDNESS RELIEF generic 1

naphazoline HCL VASOCLEAR generic 1 soln 0 .02%naphazoline/zinc sulfate VASOCLEAR A brand 2 OTCtetrahydrozoline/

zinc sulfate VISINE-AC generic 1

Anti-InflammatoriesNonsteroidaldiclofenac sodium VOLTAREN generic 1flurbiprofen OCUFEN generic 1ketorolac ACULAR/ACULAR LS generic 1nepafenac ILEVRO generic 1Steroidaldexamethasone sodium

phosphate DEXASOL generic 1

difluprednate DUREZOL brand 2fluorometholone FML LIQUIFILM generic 1 susp 0 .1%prednisolone acetate PRED FORTE generic 1 1%Anti-Infective/Anti-Inflammatory Combinationsneomycin/polymyxin B/

dexamethasone MAXITROL generic 1

sulfacetamide/pred phos VASOCIDIN generic 1 10%/0 .25%tobramycin/

dexamethasone TOBRADEX generic 1

44




GlaucomaBeta-Blockerslevobunolol BETAGAN generic 1 ophthalmic solutionmetipranolol OPTIPRANOLOL generic 1 0 .3% ophthalmic solution

timolol TIMOPTIC XEgeneric

and brand

1 and

2gel forming solution

timolol maleate TIMOPTIC generic 1Beta-Blocker/Topical - Sympathomimetics Combinationbrimonide/timolol COMBIGAN brand 2Carbonic Anhydrase Inhibitorsbrinzolamide AZOPT brand 2dorzolamide TRUSOPT generic 1Carbonic Anhydrase Inhibitor/Beta-Blocker Combinationdorzolamide/

timolol maleate COSOPT generic 1

Carbonic Anhydrase Inhibitors/Topical - Sympathomimetics Combinationsbrinzolamide/brimonidine SIMBRINZA brand 2Mydriaticsatropine ISOPTO ATROPINE generic 1cyclopentolate CYCLOGYL generic 1cyclopentolate w/

phenylephrine CYCLOMYDRIL brand 2

Oralacetazolamide ACETAZOLAMIDE generic 1acetazolamide

extended-release DIAMOX SEQUELS generic 1

methazolamide NEPTAZANE generic 1Prostaglandinslatanoprost XALATAN generic 1 QLtravoprost TRAVATAN-Z brand 2Topical - Parasympathomimeticspilocarpine PILOPINE HS GEL brand 2Topical - Sympathomimeticsbrimonidine ALPHAGAN P brand 2 0 .1%

brimonidine ALPHAGAN Pgeneric

and brand

1 and

20 .15%

brimonidine ALPHAGAN generic 1 0 .2%

45




Immunologic Agentscyclosporine emulsion RESTASIS brand 2 QLInfectionsBacterialciprofloxacin CILOXAN generic 1 solutiongentamicin generic 1 solution

moxifloxacinMOXEZA VIGAMOX

brand 2

ofloxacin OCUFLOX generic 1polymyxin B/trimethoprim POLYTRIM generic 1sulfacetamide BLEPH-10 generic 1 oint/solntobramycin TOBREX generic 1 solutionFungalnatamycin NATACYN brand 2Viral trifluridine VIROPTIC generic 1Miscellaneouscenegermin-bkbj OXERVATE brand 2 PAcysteamine 0 .44%

ophthalmic solution CYSTARAN brand 2 PA, SP

proparacaine ALCAINE brand 2 PAsodium chloride

hypertonic MURO 128 generic 1 soln 5%

Psychiatric

Alcohol Deterrentsacamprosate CAMPRAL brand 2disulfiram ANTABUSE generic 1

naltrexone REVIA generic 1 <18 years of age will require prior authorization

naltrexone inj VIVITROL brand 2 QLAnxietyBenzodiazepinesalprazolam XANAX generic 1 QL, IR onlychlordiazepoxide LIBRIUM generic 1clonazepam KLONOPIN generic 1 not wafersdiazepam VALIUM generic 1 QLdiazepam inj VALIUM generic 1 PAlorazepam ATIVAN generic 1 QLlorazepam inj ATIVAN INJ generic 1 PA

46




midazolam inj VERSED generic 1 PAMiscellaneousbuspirone BUSPAR generic 1fluvoxamine LUVOX generic 1Attention Deficit Hyperactivity Disorder (ADHD) amphetamine/

dextroamphetamine mixed salts

ADDERALL generic 1 Age Limits Apply, QL

amphetamine/ dextroamphetamine mixed salts extended-release

ADDERALL XR generic 1 Age Limits Apply, QL

atomoxetine STRATTERA generic 1 Age Limits Apply, QLclonidine ER KAPVAY generic 1 Age Limits Apply, QLdexmethylphenidate FOCALIN generic 1 Age Limits Apply, QLdexmethylphenidate ER FOCALIN XR generic 1 Age Limits Apply, QLdextroamphetamine

sulfate ER DEXEDRINE generic 1 Age Limits Apply, QL

guanfacine ER INTUNIV generic 1 Age Limits Apply, QLlisdexamfetamine VYVANSE brand 2 Age Limits Apply, QLlisdexamfetamine

chewable tab VYVANSE CHEWABLE brand 2 Age Limits Apply, QL

methylphenidate RITALIN generic 1 Age Limits Apply, tabs only, QL

methylphenidate chew tab extended-release QUILLICHEW brand 2 Age Limits Apply, QL

methylphenidate chew tab/solution METHYLIN generic 1 Age Limits Apply, QL

methylphenidate ER susp QUILLIVANT XR brand 2 Age Limits Apply, QLmethylphenidate ER (XR)

caps APTENSIO XR brand 2 Age Limits Apply, QL

methylphenidate extended-release CONCERTA generic 1 Age Limits Apply, QL

methylphenidate extended-release

METADATE CDMETADATE ER

generic 1 Age Limits Apply, QL

methylphenidate extended-release RITALIN LA generic 1 Age limits apply, QL

47




methylphenidate hcl ER 24hr generic 1

Age limits apply, QL, 18 mg, 27 mg, 36 mg,

54 mg tablets, Mallinckrodt and Kremers Urban

labelersBipolar Disorderdivalproex sodium

cap sprinkle DEPAKOTE SPRINKLE generic 1Members ≥ 8 years of age will require prior

authorization .divalproex sodium

delayed-release DEPAKOTE generic 1 Minimum age 2

lithium carbonate LITHIUM CARBONATE generic 1lithium carbonate

extended-releaseESKALITH CR LITHOBID

generic 1

DepressionMonoamine Oxidase Inhibitor (MAOI)phenelzine NARDIL generic 1tranylcypromine PARNATE generic 1Selective Serotonin Reuptake Inhibitor (SSRIs)citalopram CELEXA generic 1 tabs, QLescitalopram LEXAPRO generic 1 tablets, QLfluoxetine PROZAC generic 1paroxetine PAXIL generic 1 tabletsSerotonin Norepinephrine Reuptake Inhibitors (SNRIs)

duloxetine CYMBALTA generic 1 QL, 20mg, 30mg, 60mg only

duloxetine IRENKA generic 1venlafaxine EFFEXOR generic 1venlafaxine XR EFFEXOR XR generic 1Tricyclic Antidepressants (TCAs)amitriptyline ELAVIL generic 1 tabletsamoxapine generic 1desipramine NORPRAMIN generic 1doxepin SINEQUAN generic 1imipramine HCL TOFRANIL generic 1 tabletsTricyclic Antidepressant/Phenothiazine Combinationamitriptyline/perphenazine TRIAVIL generic 1 Age Limit Applies, QLMiscellaneous Agentsbupropion WELLBUTRIN generic 1

48




bupropion extended-release FORFIVO XL generic 1 QL

bupropion extended-release WELLBUTRIN SR generic 1

bupropion extended-release WELLBUTRIN XL generic 1 150 mg and 300 mg

mirtazapine REMERON generic 1selegiline td patch 24 hr EMSAM brand 2trazodone DESYREL generic 1InsomniaBenzodiazepinestemazepam RESTORIL generic 1 Age Limit Applies triazolam HALCION generic 1 Age Limit Applies, QLNon-Benzodiazepineschloral hydrate CHLORAL HYDRATE generic 1diphenhydramine NYTOL QUICK CAPS generic 1 OTCramelteon ROZEREM brand 2 PAzolpidem AMBIEN generic 1 Age Limit Applies, QLzolpidem sl INTERMEZZO generic 1Narcotic Antagonists

buprenorphine/naloxone SUBOXONE brand 2<16 years of age will

require prior authorization, QL

naloxone NALOXONE INJ generic 1 QLnaloxone NARCAN NASAL SPRAY brand 2 QLnaloxone hcl nasal spray NARCAN brand 2 QL

naltrexone REVIA generic 1 <18 years of age will require prior authorization

PsychosesAtypicals

aripiprazole ABILIFY TABLETS generic 1 Age Limit Applies, tablets, QL

aripiprazole ER injection ABILIFY MAINTENA brand 2 Age Limit Applies, QL

aripiprazole lauroxil ARISTADA brand 2 Age Limit Applies, QLasenapine SAPHRIS brand 2 Age Limit Applies, QLbrexpiprazole REXULTI brand 2 QLcariprazine hcl VRAYLAR brand 2 PA, QL

49




clozapine CLOZARIL generic 125mg, 50mg, 100mg

only, Age Limit Applies, QL

clozapine susp VERSACLOZ brand 2 QLiloperidone FANAPT brand 2 Age Limit Applies, QLlurasidone LATUDA brand 2 Age Limit Applies, QL

olanzapine ZYPREXA generic 1 Age Limit Applies, tablets, QL

olanzapine for IM inj ZYPREXA INJ brand 2 10 mg, Age Limit Applies, QL

olanzapine IM susp ZYPREXA RELPREVV brand 2 Age Limit Applies, QLpaliperidone INVEGA SUSTENNA brand 2 Age Limit Applies, QLpaliperidone palmitate INVEGA TRINZA brand 2 Age Limit Applies, QLpimavanserin NUPLAZID brand 2 PAquetiapine SEROQUEL generic 1 Age Limit Applies, QLquetiapine SR SEROQUEL XR generic 1 Age Limit Applies, QLrisperidone RISPERDAL generic 1 Age Limit Applies, QLrisperidone RISPERDAL CONSTA brand 2 Age Limit Applies, QL

risperidone oral soln RISPERDAL SOLUTION generic 1QL, Members < 3 years of age will require prior

authorization .ziprasidone GEODON generic 1 Age Limit Applies, QLziprasidone mesylate

for inj GEODON INJ brand 2 20 mg, Age Limit Applies, QL

Smoking Cessationbupropion hcl (smoking

deterrent) SR 12hr ZYBAN generic 1 QL

nicotine NICODERM CQ generic 1 patches, QLnicotine polacrilex gum NICORETTE OTC generic 1 QLnicotine polacrilex lozenge COMMITT OTC generic 1 QLvarenicline CHANTIX brand 2 QLMiscellaneouschlorpromazine THORAZINE generic 1fluphenazine PROLIXIN generic 1fluphenazine decanoate PROLIXIN DECANOATE generic 1haloperidol HALDOL generic 1haloperidol decanoate HALDOL DECANOATE generic 1loxapine LOXITANE generic 1perphenazine TRILAFON generic 1 Age Limit Applies, QLpimozide ORAP generic 1

50




thioridazine MELLARIL generic 1thiothixene NAVANE generic 1trifluoperazine STELAZINE generic 1

Respiratory DrugsAntitussives, Decongestants, Expectorants and Combinationsbenzonatate TESSALON generic 1brompheniramine/

pseudoephedrine/ dextromethorphan

BROMFED DM generic 1 syrup

brompheniramine/ pseudoephedrine ANDEHIST generic 1 syrup

codeine/promethazine PROMETHAZINE W/CODEINE generic 1 Age Limits Apply, QL

codeine/promethazine/phenylephrine

PROMETHAZINE VC W/CODEINE generic 1 Age Limits Apply, QL

dextromethorphan/ brompheniramine/pseudoephedrine

BROMFED DM generic 1

dextromethorphan/ guaifenesin

ROBITUSSIN DMTUSSIN DM

generic 1 10-100mg/5ml, OTC

dextromethorphan hbrROBITUSSIN SYP MAX-STROBITUSSIN PED SYP

generic 1 syrup

dextromethorphan/ promethazine

PHENERGAN DMPROMETHAZINE SYP DM

generic 1

guaifenesin ROBITUSSIN generic 1 OTC

guaifenesin ROBITUSSIN SYP CHST CNG generic 1 syrup 100 mg/5 ml

hydrocodone/ homatropine

HYCODANHYDROMET SYPHYDROCODONE/

TAB HOMATROP

generic 1

loratadine & pseudoephedrine SR 24hr

CLARITIN-D generic 1

51




promethazine & phenylephrine

PROMETH VC SYP 6.25-5/5 generic 1 syrup 6 .25-5 mg/ 5 mg

Asthma/COPDInhalers - Beta Agonists

albuterol sulfatePROVENTIL HFAPROAIR HFA

brand 2 QL

Inhalers - Corticosteroidsbudesonide inhal aero

powd PULMICORT FLEXHALER brand 2 QL

fluticasone propionateFLOVENT DISKUSFLOVENT HFA

brand 2 QL

Inhalers - Corticosteroid/Beta Agonist Combinationsbudesonide/formoterol SYMBICORT brand 2 QLfluticasone/salmeterol ADVAIR DISKUS generic/

brand 1/2 QLfluticasone/salmeterol ADVAIR HFA generic 1 QLmometasone furoate/

formoterol DULERA brand 2 QL

Inhalers - Others

benralizumab FASENRA brand 2 Age Limit Applies, PA, QL, SP

ipratropium/albuterol COMBIVENT RESPIMAT brand 2 inhaleripratropium HFA ATROVENT HFA brand 2

mepolizumab NUCALA brand 2 Age Limit Applies, PA, QL, SP

omalizumab XOLAIR brand 2 PA, QL, SPreslizumab CINQAIR brand 2 Age Limit Applies, PA, SProflumilast DALIRESP brand 2 PAsalmeterol SEREVENT brand 2 QLtiotropium SPIRIVA HANDIHALER brand 2 QLtiotropium/olodaterol STIOLTO brand 2 QLInhalers for Nebulization

albuterol ACCUNEB generic 1

0 .63 mg/3 ml and 1 .25 mg /3 ml, Covered for members less than 8

years of age . Members ≥ 8 years of age will require

prior authorization .albuterol PROVENTIL generic 1 soln 0 .083%, 0 .5%

52




budesonide PULMICORT RESPULES generic 1 susp, QLcromolyn sodium nebules INTAL generic 1ipratropium ATROVENT generic 1 soln, QLipratropium/albuterol DUONEB generic 1 solnOral Agents - Beta Agonistsalbuterol sulfate VOSPIRE generic 1 QLalbuterol sulfate er VOSPIRE ER generic 1metaproterenol METAPROTERENOL SYRUP generic 1Oral Agents - Leukotriene Modifiersmontelukast SINGULAIR generic 1 QLzafirlukast ACCOLATE generic 1Oral Agents - Theophyllinetheophylline THEOPHYLLINE generic 1 liquidtheophylline

extended-releaseTHEOCHRONUNIPHYL

generic 1 tabs

Miscellaneousgrass mixed pollen ORALAIR brand 2 Age Limit Applies, PA, QL

Urological

Symptomatic Benign Prostatic Hypertrophyalfuzosin ER UROXATRAL generic 1doxazosin CARDURA generic 1dutasteride AVODART generic 1finasteride PROSCAR generic 1tamsulosin FLOMAX generic 1terazosin HYTRIN generic 1Miscellaneousacetohydroxamic acid LITHOSTAT brand 2bethanechol URECHOLINE generic 1hyoscyamine,

methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue

UTIRA C brand 2

methenamine hippurateHIPREXUREX

generic 1

oxybutynin chloride DITROPAN XL generic 1 QL

53




oxybutynin IR DITROPAN generic 1

oxybutynin patch OXYTROL FOR WOMEN OTC PATCH brand 2

pentosan polysulfate sodium ELMIRON brand 2 PA

phenazopyridine PYRIDIUM generic 1potassium citrate UROCIT-K generic 1propantheline generic 1sodium citrate/citric acid BICITRA generic 1tiopronin THIOLA brand 2 PAtolterodine DETROL generic 1 STtrospium SANCTURA generic 1 ST

Vitamins, Minerals, and Supplementsb-complex B-COMPLEX VITAMIN TAB generic 1 QLcalcitriol ROCALTROL generic 1

calcitriol oral soln ROCALTROL SOLUTION generic 1Members ≥ 8 years of age will require prior

authorization .calcium OS-CAL generic 1 OTCcholecalciferol VITAMIN D TAB 1000 UNIT brand 2 tab 1000 unit, OTCcyanocobalamin VITAMIN B-12 generic 1 injelectrolyte PEDIALYTE generic 1 soln, oral, OTCergocalciferol (D2) DRISDOL generic 1ferrous sulfate FEOSOL generic 1 OTC

fluoride

GEL-KAMLURIDE LURIDE LOZI-TABSPREVIDENTPHOS-FLUR

generic 1

folic acid FOLIC ACID generic 1levocarnitine CARNITOR generic 1levocarnitine CARNITOR SOL generic 1 QLmultivitamins/

fluoride/±iron POLY-VI-FLOR generic 1

phytonadione MEPHYTON brand 2

54




prenat-FE Bis-FE prot succ-FA-CA & omega 3

COMPLETE NATALCARE PAK DHA brand 2


TRUST NATALCARE PAK DHA brand 2


PRUET DHA PAK SETONET PAK brand 2

prenat-FE bis-FE prot succ-FA-CA & omega DR

PRUET DHAEC PAK brand 2

prenat w/o A w/fecbn-fegl-DSS-FA & DHA

FOLTABS PAK PLUS DHA RE OB + DHA PAK brand 2

prenatal vit w/FE bisglycinate chelate-FA

GENTEX ADE 28-1 MG brand 2


VINATE AZ EX brand 2


VINATE II brand 2

prenatal vit w/FE polysac cmplx-FA EDGE OB CHW brand 2

prenatal vit w/iron carbonyl-FA ATABEX PRENATAL brand 2

prenatal vit w/o vit a w/FE bisglycinate-fa tab brand 2 32-1 mg, OTC

prenatal w/o A w/FE carbonyl-FE gluc-DSS-FA

FOLTABS PRENATALTRI RX

brand 2

prenatal vitamins w/folic acid

PRENATAL VITAMINS W/ FOLIC ACID

MATERNANESTABS

generic 1 QL

55




vitamin ADC/fluoride/±iron drops TRI-VI-FLOR generic 1

vitamin B complex/ vitamin C/folic acid NEPHROCAPS generic 1

vitamin B-1 generic 1 OTCvitamin B-6 generic 1 OTC

vitamins pediatric TRI-VI-SOL generic 1 members <3 years old, OTC

Potassiumphosphorus K-PHOS NEUTRAL generic 1 tabspotassium acid phosphate K-PHOS ORIGINAL brand 2potassium bicarbonate/

potassium citrate effervescent

K-LYTE generic 1 tabs

potassium chloride K-LOR generic 1 powderpotassium chloride POTASSIUM CHLORIDE generic 1 liquid

potassium chloride extended-release

K-DUR 10K-DUR 20K-TABKLOR-CON 8 KLOR-CON 10

generic 1 tabs

potassium chloride extended-release MICRO-K 10 generic 1 caps

Miscellaneous

Anaphylaxis

epinephrineEPIPEN EPIPEN JR.

generic 1 QL

epinephrine pf prefilled syringe EPINEPHRINE generic 1 PA

epinephrine solution prefilled syringe SYMJEPI brand 2 PA

Androgenoxandrolone OXANDRIN generic 1 PAAntidotesacetylcysteine CETYLEV brand 2deferiprone FERRIPROX brand 2 PA, QL, SPphenoxybenzamine DIBENZYLINE generic 1succimer CHEMET brand 2 QLtrientine SYPRINE generic 1 SP

56




Cystic Fibrosisacetylcysteine MUCOMYST generic 1

aztreonam CAYSTON brand 2 Age Limits Apply, PA, QL, SP

dornase alfa PULMOZYME brand 2 PA, SP

ivacaftorKALYDECOKALYDECO GRANULES

brand 2 Age Limits Apply, PA, SP

lumacaftor/ivacaftor ORKAMBI brand 2 Age Limits Apply, PA, SPsodium chloride for

nebulizerHYPERSALNEBUSAL

generic 1

tezacaftor/ivcaftor SYMDEKO brand 2 PA, SP

tobramycin inh caps TOBI PODHALER brand 2 Age Limits Apply, PA, QL, SP

tobramycin neb soln BETHKIS brand 2 Age Limits Apply, PA, QL, SP

tobramycin neb soln KITABISgeneric

and brand

1 and

2

Age Limits Apply, PA, QL, SP

Hereditary Angioedemac1 esterase inhibitor

(human) for subcutaneous inj

HAEGARDA brand 2 PA

c1 esterase inhibitor (recombinant) for iv inj RUCONEST brand 2 PA

icatibant FIRAZYR brand 2 PA, SPHyperphosphatemiacalcium acetate generic 1 667 mg tablet onlycalcium acetate PHOSLO generic 1 OTC, caps and tabscalcium acetate solution PHOSLYRA brand 2cinacalcet SENSIPAR generic 1 PA, QLlanthanum carbonate

chew tabs FOSRENOL brand 2 PA

sevelamer carbonate RENVELA brand 2 PAsevelamer hcl RENAGEL brand 2 PAIdiopathic Pulmonary Fibrosis (IPF)nintedanib OFEV brand 2 PA, SPpirfenidone ESBRIET brand 2 tabs, caps, PA, SP, QL

57




Medical Devicesinsulin pen needle BD brand only, QLinsulin syringes BD brand only, QLlancets QLSpacers QLMetabolic Modifierscarglumic acid CARBAGLU brand 2 PA, SPmigalastat GALAFOLD brand 2 PA, QL, SPsodium betaine powder for

oral solution CYSTADANE brand 2 PA, QL, SP

sodium phenylbutyrate BUPHENYL generic 1 PA, QL, SPsodium phenylbutyrate

oral powderBUPHENYL ORAL

POWDER generic 1 PA, SP

Thrombopoietin Receptor Agonistsavatrombopag DOPTELET brand 2 PA, QL, SPeltrombopag PROMACTA brand 2 PA, SPlusutrombopag MULPLETA brand 2 PA, QL, SPVaccinediphtheria-tetanus tox

adsorbed (dt) im DIP/TET PED INJ brand 2 QL

hepatitis a vaccine suspHAVRIXVAQTA

brand 2 QL

hepatitis b vaccine (recombinant)

ENGERIX-BRECOMBIVAX HB

brand 2 QL

hepatitis b vaccine recombinant adjuvanted

HEPLISAV-B brand 2 Age Limits Apply, QL

human papillomavirus (hpv) 9-valent recomb vac

GARDASIL 9 brand 2 QL

human papillomavirus (hpv) quadrivalent recombinant vac

GARDASIL brand 2 QL

influenza virus vaccine recombinant hemagglutinin (ha)

FLUBLOK brand 2 QL

influenza virus vaccine split AFLURIA, FLUZONE SPLT brand 2 QL

58




influenza virus vaccine split high-dose pf FLUZONE HD PF brand 2 QL

influenza virus vaccine split pf AFLURIA PF brand 2 QL

influenza virus vaccine split quadrivalent

FLUARIX QUADFLULAVAL QUADFLUZONE QUAD

brand 2 QL

influenza virus vaccine tiss-cult subunit FLUCELVAX brand 2 QL

influenza virus vaccine types a&b surface antigen

FLUVIRIN brand 2 QL

measles, mumps & rubella virus vaccines for inj M-M-R II brand 2 QL

meningococcal (a, c, y, and w-135) MENOMUNE brand 2 QL

meningococcal (a, c, y, and w-135) conjugate vaccine

MENACTRA brand 2 QL

meningococcal (a, c, y, and w-135) oligo conj vac for inj

MENVEO brand 2 QL

pneumococcal 13-valent conjugate PREVNAR 13 brand 2 QL

pneumococcal vaccine polyvalent

PNEUMOVAXPNEUMOVAX 23

brand 2 QL

tet tox-diph-acell pertuss ad

ADACELBOOSTRIX

brand 2 QL

tetanus-diphtheria toxoids (td)

TENIVACTET/DIP TOX INJ

brand 2 QL

tetanus immune globulin (human) HYPERTET S/D brand 2 QL

typhoid vaccine VIVOTIF BERNA brand 2 capsulesvaricella virus vac live for

subcutaneous VARIVAX brand 2 QL

zoster vaccine live ZOSTAVAX brand 2 Age Limits Apply, QLzoster vaccine

recombinant adjuvanted

SHINGRIX brand 2 Age Limits Apply, QL

59



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.

Antifungalsadapalene gel DIFFERIN OTC GEL 0.1%clotrimazole

miconazole crm

tolnaftate

MICATINLOTRIMIN AFTINACTIN

vaginal productsMONISTATGYNE-LOTRIMIN

Antiviralsdocosanol ABREVA OTC CREAMCough/Cold Allergy

antihistamines

CHLOR-TRIMETONBENADRYLCLARITINALAVERTZYRTEC

Antihistamine/Decongestant Combinationscetirizine/pseudoephedrine OTC ZYRTEC D

loratadine/pseudoephedrineALAVERT ALRG TAB/SINUSALAVERT D ALLERGY/CONG

Cough/Cold

antitussives Age edit applied . Not covered for members under the age 2 .

dextromethorphan 15mg/5ml liquid or syrup dextromethorphan/guaifenesin

10-100mg/5ml syrup ROBITUSSINROBITUSSIN DM

decongestant pseudoephedrine 30mg or 60mg tab

expectorant GUAIFENESIN 100MG/5ML LIQUID OR SYRUP

nasal sprayssaline nasal spray 0 .65% OCEAN NASAL SPRAY SALINE NASAL SPRAY

60




Diabetesalcohol swabs CURITY ALCOHOL PADSglucose oral tabletsinsulin (vials only) HUMULINEarwax Removal Productscarbamide peroxide DEBROXFamily Planning

condoms-male

KIMONO LIFESTYLESTROJANTRUSTEXDUREX FANTASY

condoms-female FC FEMALE CONDOM

nonoxynol-9 foam VCF VAGINAL CONTRACEPTIVE FOAM 12.5%

nonoxynol-9 gel VCF CONTRACEPTIVE GEL 4%

nonoxynol-9 gel SHUR-SEAL GEL 2%, OPTIONS GYNOL II VAGINAL CONTRACEPTIVE 2% & 3%

nonoxynol-9 vaginal film VCF VAGINAL CONTRACEPTIVE FILM 28%nonoxynol-9 vaginal sponge TODAY SPONGE 1000MGnonoxynol-9 vaginal suppository ENCARE SUPP 100MGFirst Aidhydrocortisone crm, oint CORTAIDtopical antibacterials BACITRACINGastrointestinal

antacids liquids, chew tabsMYLANTA LIQUIDMAALOX LIQUIDTUMS

antidiarrhealsIMODIUM A-DKAOPECTATE

electrolyte rehydrating soln PEDIALYTEfamotidine PEPCID AClaxative enemas FLEET ENEMA

laxativesDULCOLAXFLEET PHOSPHO-SODA

psyllium METAMUCILsimethicone MYLICONstool softeners COLACE

61




Lice Productspermethrin NIXpyrethrins/piperonyl butoxide RID SHAMPOOMotion Sicknessdimenhydrinate DRAMAMINEmeclizine BONINEOphthalmics

allergic conjunctivitisALAWAYZADITOR

artificial tears HYPOTEARS

decongestantsVISINEMURINENAPHCON A

Painacetaminophen tabs, liquid,

drops, suppositories, chew tabs TYLENOL

aspirin tabs, EC tabs, chew tabsBAYERECOTRIN

aspirin with buffers tabs

ibuprofen tabs, chew tabs, drops, suspADVILMOTRIN IB

Smoking Cessation Products

nicotineCOMMIT LOZENGES (QUANTITY LIMIT)NICODERM CQ (QUANTITY LIMIT)NICOTINE GUM (QUANTITY LIMIT)

Urologicaloxybutynin patch OXYTROL FOR WOMEN OTC PATCHVitamins/Mineralsb-complex B-COMPLEX VITAMIN TAB

calciumOS-CALCALTRATETUMS

iron ferrous fumarate, ferrous gluconate, ferrous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps

FERGONFEOSOL

vitamins pediatric members <3 years oldVI-DAYLINPOLY-VI-SOLTRI-VI-SOL

vitamins prenatal STUART PRENATAL

62

ALL CAPS = Brand-name drug lower case = Generic drug

Index of Covered Drugs

Aabacavir . . . . . . . . . . . . . . .33, 34abacavir/dolutegravir/

lamivudine . . . . . . . . . . . . . 34abacavir/lamivudine . . . . . . . . 33abacavir/lamivudine/

zidovudine . . . . . . . . . . . . . 33abemaciclib . . . . . . . . . . . . . . . . 4ABILIFY MAINTENA . . . . . . . . 48ABILIFY TABLETS . . . . . . . . . 48abiraterone . . . . . . . . . . . . . . . . . 6ABREVA OTC CREAM . . .33, 59acalabrutinib . . . . . . . . . . . . . . . 4acamprosate . . . . . . . . . . . . . . 45acarbose . . . . . . . . . . . . . . . . . 26ACCOLATE . . . . . . . . . . . . . . . 52ACCUNEB . . . . . . . . . . . . . . . . 51ACCURETIC . . . . . . . . . . . . . . . 9acebutolol . . . . . . . . . . . . . . . . 10acetaminophen . . 15-17, 36, 61acetaminophen tabs, liquid,

drops, suppositories, chew tabs . . . . . . . . . . . . . . . . . . . 61

acetazolamide . . . . . . . . . . . . . 44acetazolamide

extended-release . . . . . . . 44acetic acid . . . . . . . . . . . . . . . . 22acetic acid/aluminum acetate 22acetic acid/hydrocortisone . . 22acetohydroxamic acid . . . . . . 52acetylcysteine . . . . . . . . . .55, 56acitretin . . . . . . . . . . . . . . . . . . . 21ACLOVATE . . . . . . . . . . . . . . . . 20ACTICLATE . . . . . . . . . . . . . . . 32ACTIGALL . . . . . . . . . . . . . . . . 30ACTIMMUNE . . . . . . . . . . . . . . . 7ACTIVELLA . . . . . . . . . . . . . . . 42ACTOS . . . . . . . . . . . . . . . . . . . 26ACULAR/ACULAR LS . . . . . . 43acyclovir . . . . . . . . . . . . . . . . . . 33ADACEL . . . . . . . . . . . . . . . . . . 58ADALAT CC . . . . . . . . . . . . . . . 11adalimumab . . . . . . . . . . . . . . . 35adapalene gel . . . . . . . . . .19, 59ADCIRCA . . . . . . . . . . . . . . . . . 13

ADDERALL . . . . . . . . . . . . . . . 46ADDERALL XR . . . . . . . . . . . . 46adefovir dipivoxil . . . . . . . . . . . 34ADEMPAS . . . . . . . . . . . . . . . . 13ADVAIR DISKUS . . . . . . . . . . . 51ADVAIR HFA . . . . . . . . . . . . . . 51ADVIL . . . . . . . . . . . . . 15, 36, 61afatinib . . . . . . . . . . . . . . . . . . . . 4AFINITOR . . . . . . . . . . . . . . . . . . 5AFINITOR DISPERZ . . . . . . . . . 5AFLURIA PF . . . . . . . . . . . . . . . 58AFLURIA, FLUZONE SPLT . . 57AGGRENOX . . . . . . . . . . . . . . . 8AGRYLIN . . . . . . . . . . . . . . . . . . 8ALAVERT . . . . . . . . . . . . . .23, 59ALAVERT ALRG TAB/

SINUS . . . . . . . . . . . . . .23, 59ALAVERT D . . . . . . . . . . . . . . . 59ALAVERT-D . . . . . . . . . . . . . . . 23ALAWAY . . . . . . . . . . . . . . .43, 61ALAWAY OTC . . . . . . . . . . . . . 43albendazole . . . . . . . . . . . . . . . 30ALBENZA . . . . . . . . . . . . . . . . 30albuterol . . . . . . . . . . . . . . .51, 52albuterol sulfate . . . . . . . . .51, 52albuterol sulfate er . . . . . . . . . 52ALCAINE . . . . . . . . . . . . . . . . . 45alclometasone . . . . . . . . . . . . . 20alcohol swabs . . . . . . . . . . . . . 60ALDACTAZIDE . . . . . . . . . . . . 12ALDACTONE . . . . . . . . . . . . . . 12ALDOMET . . . . . . . . . . . . . . . . 14ALECENSA . . . . . . . . . . . . . . . . 4alectinib . . . . . . . . . . . . . . . . . . . 4alendronate . . . . . . . . . . . . . . . 26ALESSE . . . . . . . . . . . . . . . . . . 39alfuzosin ER . . . . . . . . . . . . . . . 52ALINIA . . . . . . . . . . . . . . . . . . . 32ALINIA SUSPENSION . . . . . . 32alitretinoin 1% gel . . . . . . . . . . . 7ALKERAN . . . . . . . . . . . . . . . . . 4allergic conjunctivitis . . . . . . . 61ALLERGY/CONG . . . . . . .23, 59allopurinol . . . . . . . . . . . . . . . . 37alogliptin/pioglitazone . . . . . . 26

ALORA . . . . . . . . . . . . . . . . . . . 42alpelisib . . . . . . . . . . . . . . . . . . . 4ALPHAGAN . . . . . . . . . . . . . . . 44ALPHAGAN P . . . . . . . . . . . . . 44alprazolam . . . . . . . . . . . . . . . . 45ALTACE . . . . . . . . . . . . . . . . . . . 9altretamine . . . . . . . . . . . . . . . . . 4alumina/magnesia . . . . . . . . . 28ALUNBRIG . . . . . . . . . . . . . . . . . 4amantadine . . . . . . . . . . . .17, 33AMARYL . . . . . . . . . . . . . . . . . 26AMBIEN . . . . . . . . . . . . . . . . . . 48ambrisentan . . . . . . . . . . . . . . . 13AMELUZ . . . . . . . . . . . . . . . . . . 21AMERGE . . . . . . . . . . . . . . . . . 16AMICAR . . . . . . . . . . . . . . . . . . . 8amiloride . . . . . . . . . . . . . . . . . 12amiloride/

hydrochlorothiazide . . . . . 12aminocaproic acid . . . . . . . . . . 8aminolevulinic acid gel 10% . 21aminolevulinic acid soln

20% . . . . . . . . . . . . . . . . . . 21amiodarone tabs . . . . . . . . . . . 10AMITIZA . . . . . . . . . . . . . . . . . . 27amitriptyline . . . . . . . . . . . .17, 47amitriptyline/perphenazine . . 47amlodipine . . . . . . . . . . . . . . 9-11amlodipine/benazepril . . . . . . . 9amlodipine/valsartan . . . . . . . 10ammonium lactate . . . . . . . . . 21AMNESTEEM . . . . . . . . . . . . . 19amoxapine . . . . . . . . . . . . . . . . 47amoxicillin . . . . . . . . . . . . . . . . 31amoxicillin/clavulanate . . . . . . 31AMOXIL SUSP . . . . . . . . . . . . . 31amphetamine/

dextroamphetamine mixed salts . . . . . . . . . . . . . . . . . . 46

amphetamine/dextroamphetamine mixed salts extended-release . . . 46

ampicillin . . . . . . . . . . . . . . . . . 31anagrelide . . . . . . . . . . . . . . . . . 8ANALPRAM-HC . . . . . . . . . . . 22

63



ANAMANTLE HC . . . . . . . . . . 22anastrozole . . . . . . . . . . . . . . . . . 6ANCEF INJ . . . . . . . . . . . . . . . . 31ANDEHIST . . . . . . . . . . . . . . . . 50ANDRODERM . . . . . . . . . . . . . 25ANGELIQ . . . . . . . . . . . . . . . . . 39ANTABUSE . . . . . . . . . . . . . . . 45antacids liquids, chew tabs . . 60antidiarrheals . . . . . . . . . . . . . . 60antihistamines . . . . . . . . . .23, 59antitussives . . . . . . . . . . . .50, 59ANTIVERT . . . . . . . . . . . . . . . . 28ANUSOL-HC . . . . . . . . . . . . . . 22apalutamide . . . . . . . . . . . . . . . . 6apixaban . . . . . . . . . . . . . . . . . . 8aprepitant . . . . . . . . . . . . . . . . . 28APRESOLINE . . . . . . . . . . . . . 14APRISO . . . . . . . . . . . . . . . . . . 29APTENSIO XR . . . . . . . . . . . . . 46APTIVUS . . . . . . . . . . . . . . . . . 34ARALEN . . . . . . . . . . . . . . . . . . 35ARANESP . . . . . . . . . . . . . . . . . 8ARAVA . . . . . . . . . . . . . . . . . . . 36ARICEPT . . . . . . . . . . . . . . . . . 14ARIMIDEX . . . . . . . . . . . . . . . . . 6aripiprazole . . . . . . . . . . . . . . . 48aripiprazole ER injection . . . . 48aripiprazole lauroxil . . . . . . . . . 48ARISTADA . . . . . . . . . . . . . . . . 48armodafinil . . . . . . . . . . . . . . . . 14ARMOUR THYROID . . . . . . . . 27AROMASIN . . . . . . . . . . . . . . . . 6ARTANE . . . . . . . . . . . . . . . . . . 18artemether/lumefantrine . . . . 35artificial tears . . . . . . . . . . . . . . 61asenapine . . . . . . . . . . . . . . . . 48asfotase alfa . . . . . . . . . . . . . . . 27aspirin . . . . . . . .8, 15, 16, 36, 61aspirin tabs, EC tabs, chew

tabs . . . . . . . . . . . . . . . . . . . 61aspirin with buffers tabs . . . . . 61aspirin/dypridamole . . . . . . . . . 8ASTELIN . . . . . . . . . . . . . . . . . . 23ASTEPRO . . . . . . . . . . . . . . . . 23ATABEX PRENATAL . . . . . . . . 54

ATARAX . . . . . . . . . . . . . . . . . . 23atazanavir . . . . . . . . . . . . . . . . . 34atazanavir/cobicistat . . . . . . . 34atenolol . . . . . . . . . . . . . . . .10, 11atenolol/chlorthalidone . . . . . 11ATIVAN . . . . . . . . . . . . . . . . . . . 45ATIVAN INJ . . . . . . . . . . . . . . . 45atomoxetine . . . . . . . . . . . . . . . 46atorvastatin . . . . . . . . . . . . . . . 12atovaquone . . . . . . . . . . . .32, 35atovaquone/proguanil . . . . . . 35ATRIPLA . . . . . . . . . . . . . . . . . . 34atropine . . . . . . . . . . . 28, 30, 44atropine sulfate . . . . . . . . . . . . 30ATROVENT . . . . . . . . 24, 51, 52ATROVENT HFA . . . . . . . . . . . 51ATROVENT NASAL SPRAY . 24AUGMENTIN . . . . . . . . . . . . . . 31AUGMENTIN XR . . . . . . . . . . . 31auranofin . . . . . . . . . . . . . . . . . 35AVALIDE . . . . . . . . . . . . . . . . . . 10AVAPRO . . . . . . . . . . . . . . . . . . 10avatrombopag . . . . . . . . . . . . . 57AVITA . . . . . . . . . . . . . . . . . . . . 19AVODART . . . . . . . . . . . . . . . . 52AVONEX . . . . . . . . . . . . . . . . . . 17axitinib . . . . . . . . . . . . . . . . . . . . 4AYGESTIN . . . . . . . . . . . . . . . . 42azathioprine . . . . . . . . . . . . . 7, 35azelaic acid . . . . . . . . . . . . . . . 19azelaic acid foam . . . . . . . . . . 19azelastine . . . . . . . . . . . . . . . . . 23azithromycin . . . . . . . . . . . . . . 31AZOPT . . . . . . . . . . . . . . . . . . . 44aztreonam . . . . . . . . . . . . . . . . 56AZULFIDINE . . . . . . . . . . .29, 36AZULFIDINE EN-TABS . . .29, 36

Bb-complex . . . . . . . . . . . . .53, 61B-COMPLEX VITAMIN

TAB . . . . . . . . . . . . . . . .53, 61bacitracin . . . . . . . . . . . . . .19, 60baclofen . . . . . . . . . . . . . . . . . . 37BACTRIM . . . . . . . . . . . . . . . . . 32

BACTRIM DS . . . . . . . . . . . . . . 32BACTROBAN . . . . . . . . . . . . . 20BALCOLTRA . . . . . . . . . . . . . . 39balsalazide . . . . . . . . . . . . . . . . 29BALZIVA . . . . . . . . . . . . . . . . . . 40BAYER . . . . . . . . . . . . . 8, 36, 61becaplermin gel . . . . . . . . . . . 21bedaquiline . . . . . . . . . . . . . . . 35belbuca . . . . . . . . . . . . . . . . . . 15BENADRYL . . . . . . . . . . . .23, 59benazepril . . . . . . . . . . . . . . . . . 9benazepril/

hydrochlorothiazide . . . . . . 9BENICAR . . . . . . . . . . . . . . . . . 10BENICAR HCT . . . . . . . . . . . . 10benralizumab . . . . . . . . . . . . . . 51BENTYL . . . . . . . . . . . . . . . . . . 29benzocaine/antipyrine . . . . . . 22benzonatate . . . . . . . . . . . . . . . 50BENZOTIC . . . . . . . . . . . . . . . . 22benztropine . . . . . . . . . . . . . . . 17benztropine inj . . . . . . . . . . . . . 17BETA-VAL . . . . . . . . . . . . . . . . 20BETAGAN . . . . . . . . . . . . . . . . 44betamethasone val . . . . . . . . . 20BETASERON . . . . . . . . . . . . . . 17betaxolol . . . . . . . . . . . . . . . . . . 11bethanechol . . . . . . . . . . . . . . . 52BETHKIS . . . . . . . . . . . . . . . . . 56bexarotene caps and

topical gel . . . . . . . . . . . . . . 7BEYAZ . . . . . . . . . . . . . . . . . . . 39BIAXIN . . . . . . . . . . . . . . . . . . . 31bicalutamide . . . . . . . . . . . . . . . 6BICITRA . . . . . . . . . . . . . . . . . . 53binimetinib . . . . . . . . . . . . . . . . . 4bismuth subcitrate/

metronidazole/ tetracycline . . . . . . . . . . . . 30

bisoprolol . . . . . . . . . . . . . . . . . 11bisoprolol/

hydrochlorothiazide . . . . . 11BLEPH-10 . . . . . . . . . . . . . . . . 45BONINE . . . . . . . . . . . . . . . . . . 61BONIVA . . . . . . . . . . . . . . . . . . 27

64


Index of Covered DrugsBOOSTRIX . . . . . . . . . . . . . . . . 58bosentan . . . . . . . . . . . . . . . . . 13BOSULIF . . . . . . . . . . . . . . . . . . 4bosutinib . . . . . . . . . . . . . . . . . . 4BRAFTOVI . . . . . . . . . . . . . . . . . 5brexpiprazole . . . . . . . . . . . . . . 48brigatinib . . . . . . . . . . . . . . . . . . 4BRILINTA . . . . . . . . . . . . . . . . . . 8brimonide/timolol . . . . . . . . . . 44brimonidine . . . . . . . . . . . . . . . 44brinzolamide . . . . . . . . . . . . . . 44brinzolamide/brimonidine . . . 44BROMFED DM . . . . . . . . . . . . 50brompheniramine/

pseudoephedrine . . . . . . . 50brompheniramine/

pseudoephedrine/dextromethorphan . . . . . . 50

budesonide . . . . . . . . 29, 51, 52budesonide inhal aero powd 51budesonide/formoterol . . . . . 51bumetanide . . . . . . . . . . . . . . . 12bumetanide inj . . . . . . . . . . . . 12BUMEX . . . . . . . . . . . . . . . . . . . 12BUPHENYL . . . . . . . . . . . . . . . 57BUPHENYL ORAL

POWDER . . . . . . . . . . . . . . 57buprenorphine hcl buccal

film . . . . . . . . . . . . . . . . . . . 15buprenorphine td patch

weekly . . . . . . . . . . . . . . . . 16buprenorphine/naloxone . . . . 48bupropion . . . . . . . . . . . . . 47-49bupropion extended-release . 48bupropion hcl (smoking

deterrent) SR 12hr . . . . . . 49BUSPAR . . . . . . . . . . . . . . . . . . 46buspirone . . . . . . . . . . . . . . . . . 46busulfan . . . . . . . . . . . . . . . . . . . 4butalbital/acetaminophen . . . 15butalbital/acetaminophen/

caffeine . . . . . . . . . . . . . . . 15butalbital/apap/caff/cod . . . . 16butalbital/asa/caff/cod . . . . . 16butalbital/aspirin/caffeine . . . 15

BUTRANS . . . . . . . . . . . . . . . . 16BYDUREON . . . . . . . . . . . . . . . 26BYETTA . . . . . . . . . . . . . . . . . . 26

Cc1 esterase inhibitor (human) for

subcutaneous inj . . . . . . . 56c1 esterase inhibitor

(recombinant) for iv inj . . . 56cabergoline . . . . . . . . . . . . . . . 27CABOMETYX . . . . . . . . . . . . . . 4cabozantinib . . . . . . . . . . . . . . . 4CAFERGOT . . . . . . . . . . . . . . . 16CALAN . . . . . . . . . . . . . . . .11, 17CALAN SR . . . . . . . . . . . . . . . . 11calcipotriene . . . . . . . . . . . . . . 21calcipotriene/betamethasone

dipropionate . . . . . . . . . . . 21calcitonin-salmon . . . . . . . . . . 26CALCITRENE . . . . . . . . . . . . . 21calcitriol . . . . . . . . . . . . . . . . . . 53calcitriol oral soln . . . . . . . . . . 53calcium . . . 9, 11, 27, 53, 56, 61calcium acetate . . . . . . . . . . . . 56calcium acetate solution . . . . 56CALQUENCE . . . . . . . . . . . . . . 4CALTRATE . . . . . . . . . . . . . . . . 61CAMBIA . . . . . . . . . . . . . . . . . . 15CAMPRAL . . . . . . . . . . . . . . . . 45canagliflozin . . . . . . . . . . . . . . . 26canagliflozin/metformin . . . . . 26CANASA . . . . . . . . . . . . . . . . . . 29capecitabine . . . . . . . . . . . . . . . 4CAPOTEN . . . . . . . . . . . . . . . . . 9CAPRELSA . . . . . . . . . . . . . . . . 5captopril . . . . . . . . . . . . . . . . . . . 9CARAFATE . . . . . . . . . . . . . . . . 29CARAFATE SUSPENSION . . 29CARBAGLU . . . . . . . . . . . . . . . 57carbamazepine . . . . . . . . . . . . 18carbamazepine extended-

release . . . . . . . . . . . . . . . . 18carbamide peroxide . . . . .22, 60CARBATROL . . . . . . . . . . . . . . 18carbidopa . . . . . . . . . . . . . . . . . 17

carbidopa/levodopa . . . . . . . . 17carbidopa/levodopa extended-

release . . . . . . . . . . . . . . . . 17CARDIZEM . . . . . . . . . . . . . . . 11CARDIZEM CD . . . . . . . . . . . . 11CARDIZEM SR . . . . . . . . . . . . 11CARDURA . . . . . . . . . . . . . . 9, 52carglumic acid . . . . . . . . . . . . . 57cariprazine hcl . . . . . . . . . . . . . 48CARNITOR . . . . . . . . . . . . . . . 53CARNITOR SOL . . . . . . . . . . . 53carvedilol . . . . . . . . . . . . . . . . . 11carvedilol ER . . . . . . . . . . . . . . 11CASODEX . . . . . . . . . . . . . . . . . 6CATAFLAM . . . . . . . . . . . .15, 36CATAPRES . . . . . . . . . . . . . . . . . 9CAYA . . . . . . . . . . . . . . . . . . . . . 37CAYSTON . . . . . . . . . . . . . . . . 56CECLOR . . . . . . . . . . . . . . . . . 31cefaclor . . . . . . . . . . . . . . . . . . . 31cefadroxil . . . . . . . . . . . . . . . . . 31cefazolin sodium for inj . . . . . 31cefdinir . . . . . . . . . . . . . . . . . . . 31cefixime . . . . . . . . . . . . . . . . . . 31cefpodoxime axetil . . . . . . . . . 31cefprozil . . . . . . . . . . . . . . . . . . 31CEFTIN . . . . . . . . . . . . . . . . . . . 31ceftriazone sodium for inj . . . 31cefuroxime axetil . . . . . . . . . . . 31CEFZIL . . . . . . . . . . . . . . . . . . . 31CELEBREX . . . . . . . . . . . . . . . 36celecoxib . . . . . . . . . . . . . . . . . 36CELEXA . . . . . . . . . . . . . . . . . 47CELLCEPT . . . . . . . . . . . . . . . . . 7cenegermin-bkbj . . . . . . . . . . 45CENTANY . . . . . . . . . . . . . . . . 20cephalexin . . . . . . . . . . . . . . . . 31CEREBYX . . . . . . . . . . . . . . . . 18ceritinib . . . . . . . . . . . . . . . . . . . . 4cervical cap . . . . . . . . . . . . . . . 37cetirizine . . . . . . . . . . . . . . .23, 59cetirizine chew tab . . . . . . . . . 23

65



cetirizine hydrochloride/pseudoephedrine hydrochloride 12 hours extended-release . . . . . . . 23

cetirizine/pseudoephedrine OTC . . . . . . . . . . . . . . . . . . 59

CETYLEV . . . . . . . . . . . . . . . . . 55CHANTIX . . . . . . . . . . . . . . . . . 49CHEMET . . . . . . . . . . . . . . . . . 55CHLOR-TRIMETON . . . . . . . . 59chloral hydrate . . . . . . . . . . . . . 48chlorambucil . . . . . . . . . . . . . . . 4chlordiazepoxide . . . . . . . . . . . 45chlorhexidine gluconate . . . . . 24chloroquine phosphate . . . . . 35chlorothiazide . . . . . . . . . . . . . 12chlorpromazine . . . . . . . . . . . . 49chlorthalidone . . . . . . . . . .11, 12cholecalciferol . . . . . . . . . . . . . 53cholestyramine . . . . . . . . . . . . 12ciclopirox . . . . . . . . . . . . . . . . . 20cilostazol . . . . . . . . . . . . . . . . . . 8CILOXAN . . . . . . . . . . . . . . . . . 45cimetidine . . . . . . . . . . . . . . . . 28cinacalcet . . . . . . . . . . . . . . . . . 56CINQAIR . . . . . . . . . . . . . . . . . 51CIPRO . . . . . . . . . . . . . . . .22, 31CIPRO HC . . . . . . . . . . . . . . . . 22CIPRODEX . . . . . . . . . . . . . . . . 22ciprofloxacin . . . . . . . 22, 31, 45ciprofloxacin/dexamethasone 22ciprofloxacin/hydrocortisone 22citalopram . . . . . . . . . . . . . . . . 47CLARAVIS . . . . . . . . . . . . . . . . 19clarithromycin . . . . . . . . . . . . . 31CLARITIN . . . . . . . . . . . . . .23, 59CLARITIN-D . . . . . . . . . . . . . . . 50CLEAR EYES REDNESS

RELIEF . . . . . . . . . . . . . . . . 43clemastine . . . . . . . . . . . . . . . . 23CLEOCIN . . . . . . . . . . 19, 35, 42CLEOCIN T . . . . . . . . . . . . . . . 19CLIMARA . . . . . . . . . . . . . . . . . 42clindamycin . . . . . . . . 19, 35, 42CLINORIL . . . . . . . . . . . . . .15, 36

clobetasol propionate . . . . . . . 20clonazepam . . . . . . . . . . . .18, 45clonidine . . . . . . . . . . . . . . . . 9, 46clonidine ER . . . . . . . . . . . . . . 46clopidogrel . . . . . . . . . . . . . . . . . 8clotrimazole . . . . . 20, 32, 42, 59clotrimazole with

betamethasone . . . . . . . . . 20clozapine . . . . . . . . . . . . . . . . . 49clozapine susp . . . . . . . . . . . . 49CLOZARIL . . . . . . . . . . . . . . . . 49COARTEM . . . . . . . . . . . . . . . . 35cobicistat . . . . . . . . . . . . . .34, 35cobicistat/elvitegravir/

emtricitabine/tenofovir . . . 34cobimetinib . . . . . . . . . . . . . . . . 4codeine/acetaminophen . . . . 16codeine/promethazine . . . . . . 50codeine/promethazine/

phenylephrine . . . . . . . . . . 50codeine sulfate . . . . . . . . . . . . 16COGENTIN . . . . . . . . . . . . . . . 17COLACE . . . . . . . . . . . . . .27, 60COLAZAL . . . . . . . . . . . . . . . . 29COLBENEMID . . . . . . . . . . . . . 37colchicine . . . . . . . . . . . . . . . . . 37colchine/probenecid . . . . . . . 37COLESTID . . . . . . . . . . . . . . . . 12colestipol . . . . . . . . . . . . . . . . . 12COLOCORT . . . . . . . . . . . . . . . 29COLYTE . . . . . . . . . . . . . . . . . . 27COMBIGAN . . . . . . . . . . . . . . . 44COMBIPATCH . . . . . . . . . . . . . 42COMBIVENT RESPIMAT . . . . 51COMBIVIR . . . . . . . . . . . . . . . . 34COMETRIQ . . . . . . . . . . . . . . . . 4COMMIT LOZENGES

(QUANTITY LIMIT) . . . . . . 61COMMITT OTC . . . . . . . . . . . . 49COMPAZINE . . . . . . . . . . . . . . 28COMPLERA . . . . . . . . . . . . . . 34COMPLETE NATALCARE PAK

DHA . . . . . . . . . . . . . . . . . . 54COMTAN . . . . . . . . . . . . . . . . . 17CONCERTA . . . . . . . . . . . . . . . 46

condoms-female . . . . . . . .37, 60condoms-male . . . . . . . . .37, 60CONDYLOX SOL . . . . . . . . . . 21conjugated estrogen/

bazedoxifene . . . . . . . . . . . 42COPAXONE . . . . . . . . . . . . . . . 17COPIKTRA . . . . . . . . . . . . . . . . . 5copper IUD . . . . . . . . . . . . . . . 38CORDARONE . . . . . . . . . . . . . 10COREG . . . . . . . . . . . . . . . . . . 11COREG CR . . . . . . . . . . . . . . . 11CORGARD . . . . . . . . . . . . . . . . 11CORLANOR . . . . . . . . . . . . . . 14CORTAID . . . . . . . . . . . . . . . . . 60CORTEF . . . . . . . . . . . . . . . . . . 24corticotropin . . . . . . . . . . . . . . 27cortisone acetate . . . . . . . . . . 24CORTISPORIN OTIC . . . . . . . 22CORTIZONE . . . . . . . . . . . . . . 20CORTIZONE-10 INTENSIVE

HEALING . . . . . . . . . . . . . . 20COSOPT . . . . . . . . . . . . . . . . . 44COTELLIC . . . . . . . . . . . . . . . . . 4COUMADIN . . . . . . . . . . . . . . . . 8COZAAR . . . . . . . . . . . . . . . . . 10CREON . . . . . . . . . . . . . . . . . . . 30CREON 3000 UNIT . . . . . . . . 30CRESTOR . . . . . . . . . . . . . . . . 12CRIXIVAN . . . . . . . . . . . . . . . . . 34crizotinib . . . . . . . . . . . . . . . . . . . 4CROLOM . . . . . . . . . . . . . . . . . 43cromolyn sodium . . . . . . .43, 52cromolyn sodium nebules . . . 52crotamiton . . . . . . . . . . . . . . . . 21crotamiton lot . . . . . . . . . . . . . 21CROTAN LOT . . . . . . . . . . . . . 21CUPRIMINE . . . . . . . . . . . . . . . 36CURITY ALCOHOL PADS . . . 60CUTIVATE . . . . . . . . . . . . . . . . 20cyanocobalamin . . . . . . . . . . . 53CYCLESSA . . . . . . . . . . . . . . . 41cyclobenzaprine . . . . . . . . . . . 37CYCLOGYL . . . . . . . . . . . . . . . 44CYCLOMYDRIL . . . . . . . . . . . . 44cyclopentolate . . . . . . . . . . . . . 44

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Index of Covered Drugscyclopentolate

w/phenylephrine . . . . . . . 44cyclophosphamide . . . . . . . . . . 4cycloserine . . . . . . . . . . . . . . . . 30cyclosporine . . . . . . . . . . . . 7, 45cyclosporine emulsion . . . . . . 45cyclosporine, modified . . . . . . . 7CYMBALTA . . . . . . . . . . . . . . . 47cyproheptadine . . . . . . . . . . . . 23CYSTADANE . . . . . . . . . . . . . . 57CYSTAGON . . . . . . . . . . . . . . . . 7CYSTARAN . . . . . . . . . . . . . . . 45cysteamine 0 .44% ophthalmic

solution . . . . . . . . . . . . . . . 45cysteamine bitartrate . . . . . . . . 7CYTOMEL . . . . . . . . . . . . . . . . 27CYTOTEC . . . . . . . . . . . . . . . . 30CYTOVENE . . . . . . . . . . . . . . . 32CYTOXAN . . . . . . . . . . . . . . . . . 4

DD .H .E . 45 . . . . . . . . . . . . . . . . . 16dabigatran etexilate mesylate . 8dabrafenib . . . . . . . . . . . . . . . . . 4dacomitinib . . . . . . . . . . . . . . . . 4DALIRESP . . . . . . . . . . . . . . . . 51danazol . . . . . . . . . . . . . . . . . . . 41DANOCRINE . . . . . . . . . . . . . . 41dapagliflozin . . . . . . . . . . . . . . 26dapagliflozin/metformin . . . . . 26dapsone . . . . . . . . . . . . . . . . . . 35darbepoetin alfa . . . . . . . . . . . . 8darunavir . . . . . . . . . . . . . .34, 35darunavir/cobicistat . . . . . . . . 35dasatinib . . . . . . . . . . . . . . . . . . . 5DAURISMO . . . . . . . . . . . . . . . . 7DAYPRO . . . . . . . . . . . . . . .15, 36DDAVP . . . . . . . . . . . . . . . . . . . 27DDAVP INJ . . . . . . . . . . . . . . . 27DEBROX . . . . . . . . . . . . . .22, 60DECADRON . . . . . . . . . . . . . . 24decongestant . . . . . . . . . .23, 59deferasirox . . . . . . . . . . . . . . . . . 9deferiprone . . . . . . . . . . . . . . . 55DELATESTRYL . . . . . . . . . . . . 24

delavirdine . . . . . . . . . . . . . . . . 33DELESTROGEN . . . . . . . . . . . 41DELTASONE . . . . . . . . . . . . . . 24DELZICOL . . . . . . . . . . . . . . . . 29DEMADEX . . . . . . . . . . . . . . . . 12denosumab inj . . . . . . . . . . . . . 5DEPAKENE . . . . . . . . . . . . . . . 19DEPAKOTE . . . . . . . . 17, 18, 47DEPAKOTE ER . . . . . . . . . . . . 18DEPAKOTE

SPRINKLE . . . . . . 17, 18, 47DEPEN TITRATABLE . . . . . . . 36DEPO-MEDROL INJ . . . . . . . . 24DEPO-PROVERA . . . . . . . . . . 38DEPO-PROVERA 104 . . . . . . 38DEPO-PROVERA PREFILLED

SYRINGE . . . . . . . . . . . . . . 38DEPO-TESTOSTERONE . . . . 24DESCOVY . . . . . . . . . . . . . . . . 34desipramine . . . . . . . . . . . . . . . 47desmopressin . . . . . . . . . . . . . 27desmopressin acetate inj . . . 27DESOGEN . . . . . . . . . . . . . . . . 40desogestrel/EE . . . . . 37, 40, 41DESYREL . . . . . . . . . . . . . . . . . 48DETROL . . . . . . . . . . . . . . . . . . 53dexamethasone . . . . 22, 24, 43dexamethasone sodium

phosphate . . . . . . . . . .24, 43dexamethasone sodium

phosphate inj . . . . . . . . . . 24DEXAMETHASONE SOL . . . 24dexamethasone soln . . . . . . . 24DEXASOL . . . . . . . . . . . . . . . . 43DEXEDRINE . . . . . . . . . . . . . . 46dexmethylphenidate . . . . . . . . 46dexmethylphenidate ER . . . . . 46dextroamphetamine

sulfate ER . . . . . . . . . . . . . . 46dextromethorphan 15mg/5ml

liquid or syrup . . . . . . . . . . 59dextromethorphan hbr . . . . . . 50dextromethorphan/

brompheniramine/pseudoephedrine . . . . . . . 50

dextromethorphan/guaifenesin 50, 59

dextromethorphan/guaifenesin 10-100mg/5ml syrup . . . . 59

dextromethorphan/promethazine . . . . . . . . . . 50

DIAMOX SEQUELS . . . . . . . . 44diaphragm . . . . . . . . . . . . .37, 39DIASTAT ACUDIAL . . . . . . . . . 18diazepam . . . . . . . . . . 18, 37, 45diazepam inj . . . . . . . . . . . . . . 45DIBENZYLINE . . . . . . . . . . . . . 55DICLEGIS . . . . . . . . . . . . . . . . . 28diclofenac 1% gel . . . . . . . . . . 36diclofenac potassium . . . .15, 36diclofenac

sodium . . . . . . 15, 21, 36, 43diclofenac sodium (actinic

keratosis) . . . . . . . . . . . . . . 21diclofenac sodium delayed-

release . . . . . . . . . . . . .15, 36diclofenac sodium extended-

release . . . . . . . . . . . . .15, 36dicloxacillin . . . . . . . . . . . . . . . 31dicyclomine . . . . . . . . . . . . . . . 29didanosine . . . . . . . . . . . . . . . . 33didanosine delayed-release . . 33dienogest/estradiol valerate . 41DIFFERIN OTC GEL

0 .1% . . . . . . . . . . . . . . .19, 59DIFLUCAN . . . . . . . . . . . . .32, 42difluprednate . . . . . . . . . . . . . . 43digoxin . . . . . . . . . . . . . . . . . . . 10dihydroergotamine . . . . . . . . . 16DILACOR XR . . . . . . . . . . . . . . 11DILANTIN . . . . . . . . . . . . . . . . . 18DILANTIN INFATABS . . . . . . . 18DILAUDID . . . . . . . . . . . . . . . . 16diltiazem . . . . . . . . . . . . . . . . . . 11diltiazem extended-release . . 11diltiazem sustained-release . . 11dimenhydrinate . . . . . . . . . . . . 61dimethyl fumarate . . . . . . . . . . 17DIOVAN . . . . . . . . . . . . . . . . . . 10DIOVAN HCT . . . . . . . . . . . . . . 10

67



DIP/TET PED INJ . . . . . . . . . . 57diphenhydramine . . . . . . .23, 48diphenoxylate/atropine . . . . . 28diphtheria-tetanus tox adsorbed

(dt) im . . . . . . . . . . . . . . . . . 57dipyridamole . . . . . . . . . . . . . . . 8DISALCID . . . . . . . . . . . . . . . . . 36disopyramide . . . . . . . . . . . . . . 10disulfiram . . . . . . . . . . . . . . . . . 45DITROPAN . . . . . . . . . . . . .52, 53DITROPAN XL . . . . . . . . . . . . . 52DIURIL . . . . . . . . . . . . . . . . . . . 12divalproex sodium cap

sprinkle . . . . . . . . 17, 18, 47divalproex sodium delayed-

release . . . . . . . . . 17, 18, 47divalproex sodium extended-

release . . . . . . . . . . . . . . . . 18docosanol . . . . . . . . . . . . .33, 59docusate calcium plus . . . . . . 27docusate sodium . . . . . . . . . . 27dofetilide . . . . . . . . . . . . . . . . . . 10dolutegravir . . . . . . . . . . . .33, 34DOMEBORO OTIC . . . . . . . . . 22donepezil . . . . . . . . . . . . . . . . . 14DOPTELET . . . . . . . . . . . . . . . 57dornase alfa . . . . . . . . . . . . . . . 56dorzolamide . . . . . . . . . . . . . . . 44dorzolamide/timolol maleate 44DOSTINEX . . . . . . . . . . . . . . . . 27DOVONEX . . . . . . . . . . . . . . . . 21doxazosin . . . . . . . . . . . . . . . 9, 52doxepin . . . . . . . . . . . . . . .20, 47doxycycline hyclate . . . . . . . . . 32doxycycline monohydrate . . . 32doxylamine/pyridoxine . . . . . . 28DRAMAMINE . . . . . . . . . . . . . 61DRISDOL . . . . . . . . . . . . . . . . . 53dronabinol . . . . . . . . . . . . . . . . 28drospirenone/EE . . . . . . .39, 40drospirenone/EE-

levomefolate . . . . . . . .39, 40drospirenone/estradiol . . . . . . 39DROXIA . . . . . . . . . . . . . . . . . . . 7droxidopa . . . . . . . . . . . . . . . . . 14

DUAVEE . . . . . . . . . . . . . . . . . . 42DULCOLAX . . . . . . . . . . . . . . . 60DULERA . . . . . . . . . . . . . . . . . . 51duloxetine . . . . . . . . . . . . . . . . 47DUONEB . . . . . . . . . . . . . . . . . 52DURAGESIC . . . . . . . . . . . . . . 16DUREX . . . . . . . . . . . . . . . .37, 60DUREZOL . . . . . . . . . . . . . . . . 43DURICEF . . . . . . . . . . . . . . . . . 31dutasteride . . . . . . . . . . . . . . . . 52duvelisib . . . . . . . . . . . . . . . . . . . 5DYAZIDE . . . . . . . . . . . . . . . . . 12

EE .E .S . . . . . . . . . . . . . . . . . . . . . 31ECOTRIN . . . . . . . . . . . 8, 36, 61eculizumab iv soln . . . . . . . . . . 5EDECRIN . . . . . . . . . . . . . . . . . 12EDGE OB CHW . . . . . . . . . . . 54EDURANT . . . . . . . . . . . . . . . . 33efavirenz . . . . . . . . . . . . . . .33, 34efavirenz/emtricitabine/

tenofovir . . . . . . . . . . . . . . . 34EFFEXOR . . . . . . . . . . . . . . . . . 47EFFEXOR XR . . . . . . . . . . . . . . 47EFUDEX . . . . . . . . . . . . . . . . . . 21EGRIFTA . . . . . . . . . . . . . . . . . 26elagolix . . . . . . . . . . . . . . . . . . . 42ELAVIL . . . . . . . . . . . . . . . .17, 47ELDEPRYL . . . . . . . . . . . . . . . . 18electrolyte . . . . . . . . . . . . . .53, 60electrolyte rehydrating soln . . 60ELIDEL . . . . . . . . . . . . . . . . . . . 22ELIGARD . . . . . . . . . . . . . . . . . . 6ELIMITE . . . . . . . . . . . . . . . . . . 21ELIQUIS . . . . . . . . . . . . . . . . . . . 8ELLA . . . . . . . . . . . . . . . . . . . . . 38ELMIRON . . . . . . . . . . . . . . . . . 53ELOCON . . . . . . . . . . . . . . . . . 20eltrombopag . . . . . . . . . . . . . . 57elvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate . . . 35

EMCYT . . . . . . . . . . . . . . . . . . . . 4EMEND . . . . . . . . . . . . . . . . . . 28

EMGALITY . . . . . . . . . . . . . . . . 17EMLA . . . . . . . . . . . . . . . . . . . . 22empagliflozin . . . . . . . . . . . . . . 26EMSAM . . . . . . . . . . . . . . . . . . 48emtricitabine . . . . . . . . . . . 33-35emtricitabine/rilpivirine/

tenofovir . . . . . . . . . . . . . . . 34emtricitabine/tenofovir

alafenamide . . . . . . . . .34, 35emtricitabine/tenofovir

disoproxil . . . . . . . . . . . . . . 34EMTRIVA . . . . . . . . . . . . . . . . . 33enalapril . . . . . . . . . . . . . . . . . . . 9enalapril/hydrochlorothiazide . 9enasidenib . . . . . . . . . . . . . . . . . 6ENBREL . . . . . . . . . . . . . . . . . . 36ENCARE SUPP . . . . . . . . .39, 60ENCARE SUPP 100mg . . . . . 60encorafenib . . . . . . . . . . . . . . . . 5ENDURON . . . . . . . . . . . . . . . . 12enfuvirtide . . . . . . . . . . . . . . . . 35EGATEN . . . . . . . . . . . . . . . . . 30ENGERIX-B . . . . . . . . . . . . . . . 57enoxaparin . . . . . . . . . . . . . . . . . 8entacapone . . . . . . . . . . . . . . . 17ENTERIC COATED-

NAPROSYN . . . . . . . . .15, 36ENTOCORT EC . . . . . . . . . . . . 29ENTRESTO . . . . . . . . . . . . . . . 10ENULOSE . . . . . . . . . . . . . . . . 27enzalutamide . . . . . . . . . . . . . . . 6epinephrine . . . . . . . . . . . . . . . 55epinephrine pf prefilled

syringe . . . . . . . . . . . . . . . . 55epinephrine solution prefilled

syringe . . . . . . . . . . . . . . . . 55EPIPEN . . . . . . . . . . . . . . . . . . . 55EPIPEN JR . . . . . . . . . . . . . . . . 55EPIVIR . . . . . . . . . . . . . . . .33, 34EPIVIR HBV . . . . . . . . . . . . . . . 33eplerenone . . . . . . . . . . . . . . . . 14epoetin alfa . . . . . . . . . . . . . . . . 8EPOGEN . . . . . . . . . . . . . . . . . . 8EPZICOM . . . . . . . . . . . . . . . . . 33EQUETRO . . . . . . . . . . . . . . . . 18

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Index of Covered Drugsergocalciferol (D2) . . . . . . . . . 53ergoloid mesylates . . . . . . . . . 14ERGOMAR . . . . . . . . . . . . . . . 16ergotamine tartrate . . . . . . . . . 16ergotamine tartrate/caffeine . 16ergotamine/caffeine . . . . . . . . 16ERIVEDGE . . . . . . . . . . . . . . . . . 8ERLEADA . . . . . . . . . . . . . . . . . 6erlotinib . . . . . . . . . . . . . . . . . . . 5ERY-TAB . . . . . . . . . . . . . . . . . . 31ERYC . . . . . . . . . . . . . . . . . . . . 31ERYGEL . . . . . . . . . . . . . . . . . . 19ERYTHROCIN . . . . . . . . . . . . . 31erythromycin . . . . . . . . . . .19, 31erythromycin

delayed-release . . . . . . . . . 31erythromycin ethylsuccinate . 31erythromycin stearate . . . . . . . 31erythromycin/sulfisoxazole . . 31ESBRIET . . . . . . . . . . . . . . . . . 56escitalopram . . . . . . . . . . . . . . 47ESKALITH CR . . . . . . . . . . . . . 47esomeprazole granules . . . . . 28esterfied estrogens . . . . . . . . . 41esterfied estrogens/

methyltestosterone hs . . . 41ESTRACE . . . . . . . . . . . . . . . . . 41ESTRACE CRM . . . . . . . . . . . . 41estradiol . . . . . . . . . . . 39, 41, 42estradiol vaginal ring . . . . . . . 41estradiol vaginal tab . . . . . . . . 41estradiol valerate . . . . . . . . . . . 41estradiol/norethindrone acetate

patch . . . . . . . . . . . . . . . . . 42estramustine phosphate

sodium . . . . . . . . . . . . . . . . . 4ESTRATEST . . . . . . . . . . . . . . . 41estring . . . . . . . . . . . . . . . . . . . . 41estrogens, conjugated . . .41, 42estrogens, conjugated/

medroxyprogesterone . . . 42estropipate . . . . . . . . . . . . . . . . 41ESTROSTEP FE . . . . . . . . . . . 41etanercept . . . . . . . . . . . . . . . . 36ethacrynic acid . . . . . . . . . . . . 12

ethambutol . . . . . . . . . . . . . . . . 30ethionamide . . . . . . . . . . . . . . . 30ethynodiol diacetate/EE . . . . . 40etodolac . . . . . . . . . . . . . . .15, 36etonogestrel subdermal

implant . . . . . . . . . . . . . . . . 41etonogestrel/EE . . . . . . . . . . . 38etoposide . . . . . . . . . . . . . . . . . . 7etravirine . . . . . . . . . . . . . . . . . . 33EULEXIN . . . . . . . . . . . . . . . . . . 6EURAX . . . . . . . . . . . . . . . . . . . 21everolimus . . . . . . . . . . . . . . . . . 5evolocumab . . . . . . . . . . . . . . . 13EVOTAZ . . . . . . . . . . . . . . . . . . 34EXELON . . . . . . . . . . . . . . . . . . 14exemestane . . . . . . . . . . . . . . . . 6exenatide . . . . . . . . . . . . . . . . . 26exenatide extended-release . . 26EXFORGE . . . . . . . . . . . . . . . . 10EXJADE . . . . . . . . . . . . . . . . . . . 9exogabine . . . . . . . . . . . . . . . . 18expectorant . . . . . . . . . . . . . . . 59ezetimibe . . . . . . . . . . . . . . . . . 13

FFALESSA . . . . . . . . . . . . . . . . . 39famciclovir . . . . . . . . . . . . . . . . 33famotidine . . . . . . . . . . . . .28, 60FAMVIR . . . . . . . . . . . . . . . . . . 33FANAPT . . . . . . . . . . . . . . . . . . 49FANTASY . . . . . . . . . . . . . .37, 60FARXIGA . . . . . . . . . . . . . . . . . 26FARYDAK . . . . . . . . . . . . . . . . . . 4FASENRA . . . . . . . . . . . . . . . . . 51FC FEMALE CONDOM . .37, 60felbamate . . . . . . . . . . . . . . . . . 18FELBATOL . . . . . . . . . . . . . . . . 18FELDENE . . . . . . . . . . . . . .15, 36felodipine extended-release . 11FEMARA . . . . . . . . . . . . . . . . . . 6FEMCAP . . . . . . . . . . . . . . . . . 37FEMCON FE . . . . . . . . . . . . . . 40FEMHRT LOW DOSE . . . . . . . 41fenofibrate . . . . . . . . . . . . . . . . 12FENOGLIDE . . . . . . . . . . . . . . 12

fentanyl transdermal . . . . . . . . 16FEOSOL . . . . . . . . . . . . . . .53, 61FERGON . . . . . . . . . . . . . . . . . 61FERRIPROX . . . . . . . . . . . . . . . 55ferrous bis-glycinate chelate . 61ferrous fumarate . . . . . . . . . . . 61ferrous gluconate . . . . . . . . . . 61ferrous sulfate . . . . . . . . . .53, 61FEXMID . . . . . . . . . . . . . . . . . . 37filgrastim . . . . . . . . . . . . . . . . . . . 8FINACEA . . . . . . . . . . . . . . . . . 19finasteride . . . . . . . . . . . . . . . . 52fingolimod . . . . . . . . . . . . . . . . 17FIORICET . . . . . . . . . . . . . .15, 16FIORICET W/CODEINE . . . . . 16FIORINAL . . . . . . . . . . . . . .15, 16FIORINAL W/CODEINE . . . . . 16FIRAZYR . . . . . . . . . . . . . . . . . 56FIRVANQ . . . . . . . . . . . . . . . . . 32FLAGYL . . . . . . . . . . . . . . .35, 42flecainide . . . . . . . . . . . . . . . . . 10FLEET ENEMA . . . . . . . . . . . . 60FLEET PHOSPHO-SODA . . . 60FLEXERIL . . . . . . . . . . . . . . . . . 37FLOMAX . . . . . . . . . . . . . . . . . . 52FLONASE . . . . . . . . . . . . . . . . . 23FLORINEF . . . . . . . . . . . . . . . . 24FLOVENT DISKUS . . . . . . . . . 51FLOVENT HFA . . . . . . . . . . . . 51FLOXIN OTIC . . . . . . . . . . . . . . 22FLUARIX QUAD . . . . . . . . . . . 58FLUBLOK . . . . . . . . . . . . . . . . . 57FLUCELVAX . . . . . . . . . . . . . . . 58fluconazole . . . . . . . . . . . .32, 42fludrocortisone . . . . . . . . . . . . 24FLULAVAL QUAD . . . . . . . . . . 58FLUMADINE . . . . . . . . . . . . . . 33fluoride . . . . . . . . . . . . . . . .53, 55fluorometholone . . . . . . . . . . . 43fluorouracil . . . . . . . . . . . . . . . . 21fluorouracil soln . . . . . . . . . . . . 21fluoxetine . . . . . . . . . . . . . . . . . 47fluphenazine . . . . . . . . . . . . . . 49fluphenazine decanoate . . . . 49flurbiprofen . . . . . . . . . . . . . . . 43

69



flutamide . . . . . . . . . . . . . . . . . . 6fluticasone . . . . . . . . . 20, 23, 51fluticasone propionate . . .20, 51fluticasone/salmeterol . . . . . . 51FLUVIRIN . . . . . . . . . . . . . . . . . 58fluvoxamine . . . . . . . . . . . . . . . 46FLUZONE HD PF . . . . . . . . . . 58FLUZONE QUAD . . . . . . . . . . . 58FML LIQUIFILM . . . . . . . . . . . . 43FOCALIN . . . . . . . . . . . . . . . . . 46FOCALIN XR . . . . . . . . . . . . . . 46folic acid . . . . . . . . . . . . . . . 53-55FOLTABS PAK PLUS DHA RE

OB + DHA PAK . . . . . . . . . 54FOLTABS PRENATAL . . . . . . . 54FORFIVO XL . . . . . . . . . . . . . . 48FORTICAL . . . . . . . . . . . . . . . . 26FOSAMAX . . . . . . . . . . . . . . . . 26fosamprenavir . . . . . . . . . . . . . 34fosinopril . . . . . . . . . . . . . . . . . . . 9fosinopril/hydrochlorothiazide 9fosphenytoin inj . . . . . . . . . . . . 18FOSRENOL . . . . . . . . . . . . . . . 56fostamatinib . . . . . . . . . . . . . . . . 7FURADANTIN SUSP

25 MG/5 ML . . . . . . . . . . . 35furosemide . . . . . . . . . . . . . . . . 12furosemide inj . . . . . . . . . . . . . 12FUZEON . . . . . . . . . . . . . . . . . . 35FYCOMPA . . . . . . . . . . . . . . . . 18

Ggabapentin . . . . . . . . . . . . . . . . 18GABITRIL . . . . . . . . . . . . . . . . . 18GALAFOLD . . . . . . . . . . . . . . . 57galantamine . . . . . . . . . . . . . . . 14galcanezumab-gnlm . . . . . . . . 17ganciclovir . . . . . . . . . . . . . . . . 32GARDASIL . . . . . . . . . . . . . . . . 57GARDASIL 9 . . . . . . . . . . . . . . 57GATTEX . . . . . . . . . . . . . . . . . . 30gefitinib . . . . . . . . . . . . . . . . . . . . 5GEL-KAM . . . . . . . . . . . . . . . . . 53gemfibrozil . . . . . . . . . . . . . . . . 12GENERESS FE . . . . . . . . . . . . 40

GENGRAF . . . . . . . . . . . . . . . . . 7GENOTROPIN . . . . . . . . . . . . . 26GENTAK . . . . . . . . . . . . . . . . . . 19gentamicin . . . . . . . . . . . . .19, 45GENTEX ADE 28-1 MG . . . . . 54GENVOYA . . . . . . . . . . . . . . . . 35GEODON . . . . . . . . . . . . . . . . . 49GEODON INJ . . . . . . . . . . . . . 49GILENYA . . . . . . . . . . . . . . . . . 17GILOTRIF . . . . . . . . . . . . . . . . . . 4gilteritinib . . . . . . . . . . . . . . . . . . 5glasdegib . . . . . . . . . . . . . . . . . . 7glatiramer acetate . . . . . . . . . . 17GLEEVEC . . . . . . . . . . . . . . . . . 5GLEOSTINE . . . . . . . . . . . . . . . . 4glimepiride . . . . . . . . . . . . . . . . 26glipizide . . . . . . . . . . . . . . . . . . 26glipizide extended-release . . . 26glipizide/metformin . . . . . . . . . 26GLUCAGON . . . . . . . . . . . . . . 25glucagon, human

recombinant . . . . . . . . . . . 25GLUCOPHAGE . . . . . . . . . . . . 26GLUCOPHAGE ER . . . . . . . . . 26glucose oral tablets . . . . . . . . 60GLUCOTROL . . . . . . . . . . . . . 26GLUCOTROL XL . . . . . . . . . . . 26GLUCOVANCE . . . . . . . . . . . . 26glyburide . . . . . . . . . . . . . . . . . 26glyburide, micronized . . . . . . . 26glycerin . . . . . . . . . . . . . . . .27, 43GLYCERIN SUPPOSITORY . . 27glycopyrrolate . . . . . . . . . . . . . 29GLYNASE . . . . . . . . . . . . . . . . . 26goserelin . . . . . . . . . . . . . . . . . . . 6granisetron . . . . . . . . . . . . . . . . 28GRANIX . . . . . . . . . . . . . . . . . . . 8grass mixed pollen . . . . . . . . . 52GRIFULVIN V . . . . . . . . . . . . . . 32GRIS-PEG . . . . . . . . . . . . . . . . 32griseofulvin microsize . . . . . . . 32griseofulvin ultramicrosize . . . 32guaifenesin . . . . . . . . . . . .50, 59guaifenesin 100mg/5ml liquid

or syrup . . . . . . . . . . . . . . . 59

guanabenz . . . . . . . . . . . . . . . . 14guanfacine . . . . . . . . . . . . . . 9, 46guanfacine ER . . . . . . . . . . . . . 46GYNE-LOTRIMIN . . . . . . .42, 59

HH .P . ACTHAR . . . . . . . . . . . . . 27HAEGARDA . . . . . . . . . . . . . . . 56HALCION . . . . . . . . . . . . . . . . . 48HALDOL . . . . . . . . . . . . . . . . . . 49HALDOL DECANOATE . . . . . 49halobetasol . . . . . . . . . . . . . . . 20haloperidol . . . . . . . . . . . . . . . . 49haloperidol decanoate . . . . . . 49HAVRIX . . . . . . . . . . . . . . . . . . . 57heparin . . . . . . . . . . . . . . . . . . . . 8hepatitis a vaccine susp . . . . . 57hepatitis b vaccine

(recombinant) . . . . . . . . . . 57hepatitis b vaccine recombinant

adjuvanted . . . . . . . . . . . . . 57HEPLISAV-B . . . . . . . . . . . . . . 57HEPSERA . . . . . . . . . . . . . . . . 34HEXALEN . . . . . . . . . . . . . . . . . 4HIPREX . . . . . . . . . . . . . . . . . . 52histrelin . . . . . . . . . . . . . . . . . . . . 6HUMALOG . . . . . . . . . . . . . . . . 25HUMALOG KWIKPEN . . . . . . 25HUMALOG MIX 50/50 . . . . . . 25HUMALOG MIX 75/25 . . . . . . 25human papillomavirus (hpv)

9-valent recomb vac . . . . . 57human papillomavirus (hpv)

quadrivalent recombinant vac . . . . . . . . . . . . . . . . . . . 57

HUMATIN . . . . . . . . . . . . . . . . . 35HUMIRA . . . . . . . . . . . . . . . . . . 35HUMULIN . . . . . . . . . . . . . .25, 60HUMULIN 70/30 . . . . . . . . . . 25HUMULIN N . . . . . . . . . . . . . . . 25HUMULIN R . . . . . . . . . . . . . . . 25HUMULIN R

CONCENTRATED . . . . . . 25HUMULIN R KWIKPEN . . . . . 25HYCAMTIN . . . . . . . . . . . . . . . . 8

70


Index of Covered DrugsHYCODAN . . . . . . . . . . . . . . . . 50HYDERGINE . . . . . . . . . . . . . . 14hydralazine . . . . . . . . . . . . . . . . 14HYDREA . . . . . . . . . . . . . . . . . . 7hydrochlorothiazide . . . . . . 9-12hydrocodone/

acetaminophen . . . . . . . . . 16hydrocodone/homatropine . . 50hydrocodone/ibuprofen . . . . . 16HYDROCODONE/TAB

HOMATROP . . . . . . . . . . . 50hydrocortisone . . 20-24, 29, 60hydrocortisone acetate/

pramoxine . . . . . . . . . . . . . 22hydrocortisone crm, oint . . . . 60hydrocortisone sodium

succinate pf for inj . . . . . . 24hydrocortisone suppository . . 22hydrocortisone/aloe . . . . . . . . 20HYDROMET SYP . . . . . . . . . . 50hydromorphone . . . . . . . . . . . 16hydroxychloroquine . . . . .35, 36HYDROXYPROGESTERONE

CAPROATE . . . . . . . . . . . . 43hydroxyprogesterone

caproate IM . . . . . . . . . . . . 43hydroxyurea . . . . . . . . . . . . . . . . 7hydroxyzine HCL . . . . . . . . . . . 23hydroxyzine pamoate . . . . . . . 23hyoscyamine . . . . . . . . . . . . . . 52hyoscyamine sulfate . . . . . . . . 29hyoscyamine sulfate extended-

release . . . . . . . . . . . . . . . . 29HYPERSAL . . . . . . . . . . . . . . . 56HYPERTET S/D . . . . . . . . . . . 58HYPOTEARS . . . . . . . . . . . . . . 61HYTONE . . . . . . . . . . . . . . . . . 20HYTRIN . . . . . . . . . . . . . . . . 9, 52HYZAAR . . . . . . . . . . . . . . . . . 10

Iibalizumab-uiyk IV soln . . . . . 35ibandronate sodium . . . . . . . . 27IBRANCE . . . . . . . . . . . . . . . . . . 5ibrutinib . . . . . . . . . . . . . . . . . . . 5

IBUDONE . . . . . . . . . . . . . . . . . 16ibuprofen . . . . . . . 15, 16, 36, 61ibuprofen tabs, chew tabs,

drops, susp . . . . . . . . . . . . 61icatibant . . . . . . . . . . . . . . . . . . 56ICLUSIG . . . . . . . . . . . . . . . . . . . 5idelalisib . . . . . . . . . . . . . . . . . . . 5IDHIFA . . . . . . . . . . . . . . . . . . . . 6ILEVRO . . . . . . . . . . . . . . . . . . 43iloperidone . . . . . . . . . . . . . . . . 49iloprost inhalation solution . . . 13imatinib mesylate . . . . . . . . . . . 5IMBRUVICA . . . . . . . . . . . . . . . . 5IMDUR . . . . . . . . . . . . . . . . . . . 13imipramine HCL . . . . . . . . . . . 47IMITREX . . . . . . . . . . . . . . .16, 17IMITREX 4 MG AND

6 MG INJ . . . . . . . . . . . . . . 17IMODIUM A-D . . . . . . . . . .28, 60IMPAVIDO . . . . . . . . . . . . . . . . 32IMURAN . . . . . . . . . . . . . . . . 7, 35indapamide . . . . . . . . . . . . . . . 12INDERAL . . . . . . . . . . . . . .11, 17INDERAL LA . . . . . . . . . . . . . . 11INDERIDE . . . . . . . . . . . . . . . . 11indinavir . . . . . . . . . . . . . . . . . . 34INDOCIN . . . . . . . . . . . . . .15, 36indomethacin . . . . . . . . . .15, 36influenza virus vaccine

recombinant hemagglutinin (ha) . . . . . . . . . . . . . . . . . . . 57

influenza virus vaccine split . . . . . . . . . . . . . . . .57, 58

influenza virus vaccine split high-dose pf . . . . . . . . . . . . . . . . 58

influenza virus vaccine split pf . . . . . . . . . . . . . . . . . 58

influenza virus vaccine split quadrivalent . . . . . . . . . . . . 58

influenza virus vaccine tiss-cult subunit . . . . . . . . . . . . . . . . 58

influenza virus vaccine types a&b surface antigen . . . . . 58

ingenol mebutate . . . . . . . . . . 22INLYTA . . . . . . . . . . . . . . . . . . . . 4

INSPRA . . . . . . . . . . . . . . . . . . 14insulin (vials only) . . . . . . . . . . 60insulin aspart . . . . . . . . . . . . . . 25insulin aspart protamine 70%/

insulin aspart 30% . . . . . . 25insulin determir . . . . . . . . . . . . 25insulin glargine . . . . . . . . . . . . 25insulin isophane . . . . . . . . . . . 25insulin isophane/regular . . . . 25insulin lisopro pro/lispro . . . . 25insulin lisopro prot/lispro . . . . 25insulin lispro . . . . . . . . . . . . . . . 25insulin pen needle . . . . . . . . . 57insulin regular . . . . . . . . . . . . . 25insulin regular (concentrated) 25insulin syringes . . . . . . . . . . . . 57INTAL . . . . . . . . . . . . . . . . . . . . 52INTELENCE . . . . . . . . . . . . . . . 33interferon beta-1a . . . . . . . . . . 17interferon beta-1b . . . . . . . . . . 17interferon gamma-1b . . . . . . . . 7INTERMEZZO . . . . . . . . . . . . . 48INTUNIV . . . . . . . . . . . . . . . . . . 46INVEGA SUSTENNA . . . . . . . 49INVEGA TRINZA . . . . . . . . . . . 49INVIRASE . . . . . . . . . . . . . . . . . 34INVOKAMET . . . . . . . . . . . . . . 26INVOKANA . . . . . . . . . . . . . . . 26ipratropium . . . . . . . . 24, 51, 52ipratropium HFA . . . . . . . . . . . 51ipratropium nasal . . . . . . . . . . 24ipratropium/albuterol . . . .51, 52irbesartan . . . . . . . . . . . . . . . . . 10irbesartan/

hydrochlorothiazide . . . . . 10IRENKA . . . . . . . . . . . . . . . . . . 47IRESSA . . . . . . . . . . . . . . . . . . . . 5iron . . . . . . . . . .39-41, 53-55, 61ISENTRESS . . . . . . . . . . . . . . . 33ISENTRESS CHEWABLE . . . 33ISENTRESS SUSP . . . . . . . . . 33ISMO . . . . . . . . . . . . . . . . . . . . . 13isomethptene/dichloral/

acetaminophen . . . . . . . . . 17isoniazid . . . . . . . . . . . . . . . . . . 30

71



ISOPTO ATROPINE . . . . . . . . 44ISORDIL S .L . . . . . . . . . . . . . . . 13isosorbide dinitrate . . . . . . . . . 13ISOSORBIDE DINITRATE ER 13isosorbide dinitrate extended-

release . . . . . . . . . . . . . . . . 13isosorbide mononitrate . . . . . 13isosorbide mononitrate

extended-release . . . . . . . 13isotretinoin . . . . . . . . . . . . . . . . 19isoxsuprine . . . . . . . . . . . . . . . 14itraconazole . . . . . . . . . . . . . . . 32ivabradine . . . . . . . . . . . . . . . . 14ivacaftor . . . . . . . . . . . . . . . . . . 56ivermectin . . . . . . . . . . . . . . . . 30ivermectin lotion . . . . . . . . . . . 21ivosidenib . . . . . . . . . . . . . . . . . . 6ixazomib . . . . . . . . . . . . . . . . . . . 6

JJADENU . . . . . . . . . . . . . . . . . . . 9JADENU SPRKL GRA . . . . . . . 9JAKAFI . . . . . . . . . . . . . . . . . . . . 5JANUMET . . . . . . . . . . . . . . . . 26JANUMET XR . . . . . . . . . . . . . 26JANUVIA . . . . . . . . . . . . . . . . . 26JARDIANCE . . . . . . . . . . . . . . . 26JENTADUETO . . . . . . . . . . . . . 26JUXTAPID . . . . . . . . . . . . . . . . 13JYNARQUE . . . . . . . . . . . . . . . 27

KK-DUR 10 . . . . . . . . . . . . . . . . . 55K-DUR 20 . . . . . . . . . . . . . . . . . 55K-LOR . . . . . . . . . . . . . . . . . . . . 55K-LYTE . . . . . . . . . . . . . . . . . . . 55K-PHOS NEUTRAL . . . . . . . . . 55K-PHOS ORIGINAL . . . . . . . . 55K-TAB . . . . . . . . . . . . . . . . . . . . 55KALETRA . . . . . . . . . . . . . . . . 34KALYDECO . . . . . . . . . . . . . . . 56KALYDECO GRANULES . . . . 56KAOPECTATE . . . . . . . . . . . . . 60KAPVAY . . . . . . . . . . . . . . . . . . 46KAYEXALATE . . . . . . . . . . . . . 13

KEFLEX . . . . . . . . . . . . . . . . . . 31KEFZOL INJ . . . . . . . . . . . . . . . 31KENALOG . . . . . . . . . . . . .20, 24KENALOG IN ORABASE . . . . 24KEPPRA . . . . . . . . . . . . . . . . . . 18KEPPRA XR . . . . . . . . . . . . . . . 18KERLONE . . . . . . . . . . . . . . . . 11ketoconazole . . . . . . . 20, 22, 32ketoprofen . . . . . . . . . . . . .15, 36ketorolac . . . . . . . . . . . . . .15, 43ketorolac tromethamine . . . . . 15ketotifen . . . . . . . . . . . . . . . . . . 43KIMONO . . . . . . . . . . . . . . .37, 60KISQALI . . . . . . . . . . . . . . . . . 5, 6KISQALI/FEMARA . . . . . . . . . . 6KITABIS . . . . . . . . . . . . . . . . . . 56KLONOPIN . . . . . . . . . . . .18, 45KLOR-CON 10 . . . . . . . . . . . . 55KLOR-CON 8 . . . . . . . . . . . . . 55KORLYM . . . . . . . . . . . . . . . . . 27KUVAN . . . . . . . . . . . . . . . . . . . 27KUVAN POWDER FOR

SOLUTION . . . . . . . . . . . . 27KYLEENA . . . . . . . . . . . . . . . . . 38KYTRIL . . . . . . . . . . . . . . . . . . . 28

Llabetalol . . . . . . . . . . . . . . . . . . 11LAC-HYDRIN . . . . . . . . . . . . . . 21lacosamide . . . . . . . . . . . . . . . 18lactulose . . . . . . . . . . . . . . . . . . 27LAMICTAL . . . . . . . . . . . . . . . . 18LAMISIL . . . . . . . . . . . . . . .20, 32LAMISIL AT . . . . . . . . . . . . . . . 20lamivudine . . . . . . . . . . . . .33, 34lamivudine/zidovudine . . .33, 34lamotrigine . . . . . . . . . . . . . . . . 18lancets . . . . . . . . . . . . . . . . . . . 57LANOXIN . . . . . . . . . . . . . . . . . 10LANOXIN SOLUTION . . . . . . . 10lansoprazole . . . . . . . . . . .28, 29lansoprazole delayed-release 29lanthanum carbonate

chew tabs . . . . . . . . . . . . . 56LANTUS . . . . . . . . . . . . . . . . . . 25

LANTUS SOLOSTAR . . . . . . . 25lapatinib ditosylate . . . . . . . . . . 5LARIAM . . . . . . . . . . . . . . . . . . 35larotrectinib . . . . . . . . . . . . . . . . 5LASIX . . . . . . . . . . . . . . . . . . . . 12LASIX INJ . . . . . . . . . . . . . . . . . 12latanoprost . . . . . . . . . . . . . . . . 44LATUDA . . . . . . . . . . . . . . . . . . 49laxative enemas . . . . . . . . . . . 60laxatives . . . . . . . . . . . . . . .27, 60leflunomide . . . . . . . . . . . . . . . 36lenalidomide . . . . . . . . . . . . . . . 7lenvatinib . . . . . . . . . . . . . . . . . . 5LENVIMA . . . . . . . . . . . . . . . . . . 5LETAIRIS . . . . . . . . . . . . . . . . . 13letermovir . . . . . . . . . . . . . . . . . 32letrozole . . . . . . . . . . . . . . . . . . . 6leucovorin . . . . . . . . . . . . . . . . . 5LEUKERAN . . . . . . . . . . . . . . . . 4leuprolide . . . . . . . . . . . . . . . . . . 6leuprolide/norethindrone . . . . . 6LEVAQUIN . . . . . . . . . . . . . . . . 31LEVEMIR . . . . . . . . . . . . . . . . . 25LEVEMIR FLEXTOUCH . . . . . 25levetiracetam . . . . . . . . . . . . . . 18levetiracetam ER . . . . . . . . . . . 18levobunolol . . . . . . . . . . . . . . . 44levocarnitine . . . . . . . . . . . . . . 53levocetirizine . . . . . . . . . . . . . . 23levofloxacin . . . . . . . . . . . . . . . 31levonorgestrel . . . . . . . . . . 38-41levonorgestrel releasing IUD . 38levonorgestrel/EE . . . . . . . 38-41levonorgestrel/EE & FA kit . . . 39levonorgestrel/EE- FE . . . . . . . 39levothyroxine . . . . . . . . . . . . . . 27LEVOXYL . . . . . . . . . . . . . . . . . 27LEVSIN . . . . . . . . . . . . . . . . . . . 29LEVSINEX . . . . . . . . . . . . . . . . 29LEVULAN KERASTICK . . . . . 21LEXAPRO . . . . . . . . . . . . . . . . 47LEXIVA . . . . . . . . . . . . . . . . . . . 34LIALDA . . . . . . . . . . . . . . . . . . . 29LIBRIUM . . . . . . . . . . . . . . . . . . 45LIDAMANTEL . . . . . . . . . . . . . 22

72


Index of Covered Drugslidocaine . . . . . . . . . . . 10, 22, 24lidocaine hcl iv inj . . . . . . . . . . 10lidocaine viscous . . . . . . . . . . 24lidocaine/hydrocortisone

acetate rectal . . . . . . . . . . . 22lidocaine/prilocaine . . . . . . . . 22LIFESTYLES . . . . . . . . . . .37, 60LILETTA . . . . . . . . . . . . . . . . . . 38linaclotide . . . . . . . . . . . . . . . . . 27linagliptan . . . . . . . . . . . . . . . . . 26linagliptan/metformin . . . . . . . 26linezolid . . . . . . . . . . . . . . . . . . 35LINZESS . . . . . . . . . . . . . . . . . . 27liothyronine . . . . . . . . . . . . . . . 27LIPITOR . . . . . . . . . . . . . . . . . . 12liraglutide . . . . . . . . . . . . . . . . . 26lisdexamfetamine . . . . . . . . . . 46lisdexamfetamine chewable

tab . . . . . . . . . . . . . . . . . . . . 46lisinopril . . . . . . . . . . . . . . . . 9, 82lisinopril/hydrochlorothiazide . 9lithium carbonate . . . . . . . . . . 47lithium carbonate extended-

release . . . . . . . . . . . . . . . . 47LITHOBID . . . . . . . . . . . . . . . . . 47LITHOSTAT . . . . . . . . . . . . . . . 52LO LOESTRIN FE . . . . . . . . . . 38LO/OVRAL . . . . . . . . . . . . . . . . 40LODINE . . . . . . . . . . . . . . .15, 36LODOSYN . . . . . . . . . . . . . . . . 17LOESTRIN 1/20 . . . . . . . . . . . 39LOESTRIN 1 .5/30 . . . . . . . . . 40LOESTRIN 24 FE . . . . . . . . . . 39LOESTRIN FE 1/20 . . . . . . . . 39LOESTRIN FE 1 .5/30 . . . . . . . 40lomitapide . . . . . . . . . . . . . . . . 13LOMOTIL . . . . . . . . . . . . . . . . . 28lomustine . . . . . . . . . . . . . . . . . . 4LONITEN . . . . . . . . . . . . . . . . . 14LONSURF . . . . . . . . . . . . . . . . . 4loperamide . . . . . . . . . . . . . . . . 28LOPID . . . . . . . . . . . . . . . . . . . . 12lopinavir/ritonavir . . . . . . . . . . 34LOPRESSOR . . . . . . . . . . . . . . 11LOPRESSOR HCT . . . . . . . . . 11

LOPROX . . . . . . . . . . . . . . . . . . 20loratadine . . . . . . . . . . 23, 50, 59loratadine & pseudoephedrine

SR 24hr . . . . . . . . . . . . . . . 50loratadine/

pseudoephedrine 23, 50, 59loratadine/pseudoephedrine

extended-release . . . . . . . 23lorazepam . . . . . . . . . . . . . . . . 45lorazepam inj . . . . . . . . . . . . . . 45lorbrena . . . . . . . . . . . . . . . . . . . 5LORCET . . . . . . . . . . . . . . . . . . 16LORLATINIB . . . . . . . . . . . . . . . 5LORTAB . . . . . . . . . . . . . . . . . . 16LORTAB ELIXIR . . . . . . . . . . . 16losartan . . . . . . . . . . . . . . . . . . 10losartan/HCTZ . . . . . . . . . . . . 10LOSEASONIQUE . . . . . . . . . . 38LOTENSIN . . . . . . . . . . . . . . . . . 9LOTENSIN HCT . . . . . . . . . . . . 9LOTREL . . . . . . . . . . . . . . . . . . . 9LOTRIMIN AF . . . . . . . . . .20, 59LOTRISONE . . . . . . . . . . . . . . . 20lovastatin . . . . . . . . . . . . . . . . . 12LOVENOX . . . . . . . . . . . . . . . . . 8loxapine . . . . . . . . . . . . . . . . . . 49LOXITANE . . . . . . . . . . . . . . . . 49LOZOL . . . . . . . . . . . . . . . . . . . 12lubiprostone . . . . . . . . . . . . . . . 27lumacaftor/ivacaftor . . . . . . . . 56LUPANETA . . . . . . . . . . . . . . . . . 6LUPRON . . . . . . . . . . . . . . . . . . 6LUPRON DEPOT . . . . . . . . . . . 6LUPRON DEPOT 6-MONTH . . 6LUPRON DEPOT-PED . . . . . . . 6lurasidone . . . . . . . . . . . . . . . . 49LURIDE . . . . . . . . . . . . . . . . . . . 53LURIDE LOZI-TABS . . . . . . . . . 53lusutrombopag . . . . . . . . . . . . 57LUVOX . . . . . . . . . . . . . . . . . . . 46LYBREL . . . . . . . . . . . . . . . . . . 38LYNPARZA . . . . . . . . . . . . . . . . 7LYSODREN . . . . . . . . . . . . . . . . 7LYSTEDA . . . . . . . . . . . . . . . . . 43

MM-M-R II . . . . . . . . . . . . . . . . . . 58MAALOX . . . . . . . . . . . . . .28, 60MAALOX LIQUID . . . . . . . . . . 60MACROBID . . . . . . . . . . . . . . . 35MACRODANTIN . . . . . . . . . . . 35mafenide acetate . . . . . . . . . . 19magnesium citrate soln . . . . . 27MAKENA . . . . . . . . . . . . . . . . . 43MALARONE . . . . . . . . . . . . . . 35maraviroc . . . . . . . . . . . . . . . . . 35MARINOL . . . . . . . . . . . . . . . . . 28MATERNA . . . . . . . . . . . . . . . . 54MAXALT/MAXALT MLT . . . . . 16MAXITROL . . . . . . . . . . . . . . . . 43MAXZIDE . . . . . . . . . . . . . . . . . 12measles, mumps & rubella virus

vaccines for inj . . . . . . . . . 58mechlorethamine . . . . . . . . . . . 4meclizine . . . . . . . . . . . . . .28, 61MEDROL . . . . . . . . . . . . . . . . . 24medroxyprogesterone

acetate . . . . . . . . . . . . .38, 42mefloquine . . . . . . . . . . . . . . . . 35MEGACE . . . . . . . . . . . . . . . . . . 6MEGACE ES . . . . . . . . . . . . . . . 6megestrol acetate . . . . . . . . . . . 6MEKINIST . . . . . . . . . . . . . . . . . 5MEKTOVI . . . . . . . . . . . . . . . . . . 4MELLARIL . . . . . . . . . . . . . . . . 50meloxicam . . . . . . . . . . . . .15, 36melphalan . . . . . . . . . . . . . . . . . 4memantine . . . . . . . . . . . . . . . . 14MENACTRA . . . . . . . . . . . . . . . 58MENEST . . . . . . . . . . . . . . . . . 41meningococcal (a, c, y, and

w-135) . . . . . . . . . . . . . . . . 58meningococcal (a, c, y, and

w-135) conjugate vaccine . . . . . . . . . . . . . . . . 58

meningococcal (a, c, y, and w-135) oligo conj vac for inj . . . . . . . . . . . . . . . . . . 58

MENOMUNE . . . . . . . . . . . . . . 58MENVEO . . . . . . . . . . . . . . . . . 58

73



MEPHYTON . . . . . . . . . . . . . . 53mepolizumab . . . . . . . . . . . . . . 51MEPRON . . . . . . . . . . . . . . . . . 32mercaptopurine . . . . . . . . . . . . . 4mesalamine . . . . . . . . . . . . . . . 29mesalamine cap ER . . . . . . . . 29mesalamine

extended-release . . . . . . . 29mesalamine supp . . . . . . . . . . 29mesalamine tab DR . . . . . . . . 29mesna . . . . . . . . . . . . . . . . . . . . . 5MESNEx . . . . . . . . . . . . . . . . . . . 5MESTINON . . . . . . . . . . . . . . . 17MESTINON TIMESPAN . . . . . 17METADATE CD . . . . . . . . . . . . 46METADATE ER . . . . . . . . . . . . 46METAGLIP . . . . . . . . . . . . . . . . 26METAMUCIL . . . . . . . . . . . . . . 60metaproterenol . . . . . . . . . . . . 52METAPROTERENOL

SYRUP . . . . . . . . . . . . . . . . 52metformin . . . . . . . . . . . . . . . . . 26metformin ER . . . . . . . . . . . . . 26metformin/glyburide . . . . . . . . 26methazolamide . . . . . . . . . . . . 44methenamine . . . . . . . . . . . . . 52 methenamine hippurate . . . . . 52METHERGINE . . . . . . . . . .27, 43methimazole . . . . . . . . . . . . . . 27methocarbamol . . . . . . . . . . . . 37methotrexate . . . . . . . . . . . . . . 36methotrexate auto inj . . . . . . . 36methotrexate oral solution . . . 36methotrexate sodium . . . . . . . 36methscopolamine bromide . . 29methyclothiazide . . . . . . . . . . . 12methyldopa . . . . . . . . . . . . . . . 14methylene blue . . . . . . . . . . . . 52methylergonovine . . . . . . .27, 43METHYLIN . . . . . . . . . . . . . . . . 46methylphenidate . . . . . . . .46, 47methylphenidate chew tab

extended-release . . . . . . . 46methylphenidate chew tab/

solution . . . . . . . . . . . . . . . 46

methylphenidate ER (XR) caps . . . . . . . . . . . . . . . . . . 46

methylphenidate ER susp . . . 46methylphenidate extended-

release . . . . . . . . . . . . . . . . 46methylphenidate hcl ER

24hr . . . . . . . . . . . . . . . . . . 47methylprednisolone . . . . . . . . 24methylprednisolone acetate inj

susp . . . . . . . . . . . . . . . . . . 24methylprednisolone sod succ

for inj . . . . . . . . . . . . . . . . . . 24metipranolol . . . . . . . . . . . . . . . 44metoclopramide . . . . . . . . . . . 28metolazone . . . . . . . . . . . . . . . 12metoprolol . . . . . . . . . . . . . . . . 11metoprolol succinate . . . . . . . 11metoprolol/

hydrochlorothiazide . . . . . 11METROCREAM . . . . . . . . . . . 21METROGEL . . . . . . . . . . . .21, 42METROGEL 1% . . . . . . . . . . . 42METROGEL-VAGINAL . . . . . . 42METROLOTION . . . . . . . . . . . 21metronidazole . . . 21, 30, 35, 42MEVACOR . . . . . . . . . . . . . . . . 12mexiletine . . . . . . . . . . . . . . . . . 10MEXITIL . . . . . . . . . . . . . . . . . . 10MIACALCIN . . . . . . . . . . . . . . . 26MICATIN . . . . . . . . . . . . . . .20, 59miconazole . . . . . . . . 20, 42, 59miconazole crm . . . . . . . . . . . 59MICRO-K 10 . . . . . . . . . . . . . . 55MICRONASE . . . . . . . . . . . . . . 26MICROZIDE . . . . . . . . . . . . . . . 12MIDAMOR . . . . . . . . . . . . . . . . 12midazolam inj . . . . . . . . . . . . . 46midodrine . . . . . . . . . . . . . . . . . 14midostaurin . . . . . . . . . . . . . . . . 5MIDRIN . . . . . . . . . . . . . . . . . . . 17mifepristone . . . . . . . . . . . . . . . 27migalastat . . . . . . . . . . . . . . . . . 57MIGERGOT

SUPPOSITORIES . . . . . . . 16miglustat . . . . . . . . . . . . . . . . . . 27

MIGRANAL . . . . . . . . . . . . . . . 16MIGRANOW . . . . . . . . . . . . . . 17MILLIPRED . . . . . . . . . . . . . . . 24miltefosine . . . . . . . . . . . . . . . . 32MINASTRIN 24 CHEW FE . . . 39MINIPRESS . . . . . . . . . . . . . . . . 9MINIVELLE . . . . . . . . . . . . . . . 42MINOCIN . . . . . . . . . . . . . . . . . 32minocycline . . . . . . . . . . . . . . . 32minoxidil . . . . . . . . . . . . . . . . . . 14MIRALAX . . . . . . . . . . . . . . . . . 28MIRAPEX . . . . . . . . . . . . . . . . . 17MIRCETTE . . . . . . . . . . . . . . . . 37MIRENA . . . . . . . . . . . . . . . . . . 38mirtazapine . . . . . . . . . . . . . . . 48misoprostol . . . . . . . . . . . . . . . 30MITIGARE . . . . . . . . . . . . . . . . 37mitotane . . . . . . . . . . . . . . . . . . . 7MOBIC . . . . . . . . . . . . . . . .15, 36modafinil . . . . . . . . . . . . . . . . . 14MODICON . . . . . . . . . . . . . . . . 40MODURETIC . . . . . . . . . . . . . . 12mometasone furoate . . . .20, 51mometasone furoate/

formoterol . . . . . . . . . . . . . 51MONISTAT . . . . . . . . . . . . .42, 59MONISTAT 3 . . . . . . . . . . . . . . 42MONISTAT-DERM . . . . . . . . . . 20MONOPRIL . . . . . . . . . . . . . . . . 9MONOPRIL-HCT . . . . . . . . . . . . 9montelukast . . . . . . . . . . . . . . . 52morphine . . . . . . . . . . . . . . . . . 16morphine extended-release . . 16morphine sulfate . . . . . . . . . . 16MOTRIN . . . . . . . . . . . 15, 36, 61MOTRIN IB . . . . . . . . . . . . . . . 61MOVANTIK . . . . . . . . . . . . . . . 27MOXEZA . . . . . . . . . . . . . . . . . 45moxifloxacin . . . . . . . . . . . . . . . 45MOZOBIL . . . . . . . . . . . . . . . . . . 8MS CONTIN . . . . . . . . . . . . . . . 16MUCOMYST . . . . . . . . . . . . . . 56MULPLETA . . . . . . . . . . . . . . . 57multivitamins/fluoride/±iron . 53mupirocin . . . . . . . . . . . . . . . . . 20

74


Index of Covered DrugsMURINE . . . . . . . . . . . . . . . . . . 61MURO 128 . . . . . . . . . . . . . . . 45MYAMBUTOL . . . . . . . . . . . . . 30MYCELEX . . . . . . . . . . . . .20, 32MYCOBUTIN . . . . . . . . . . . . . . 30MYCOLOG-II . . . . . . . . . . . . . . 20mycophenolate mofetil . . . . . . . 7MYCOSTATIN . . . . . . . . . .20, 32MYLANTA LIQUID . . . . . . . . . 60MYLERAN . . . . . . . . . . . . . . . . . 4MYLICON . . . . . . . . . . . . . . . . . 60MYORISAN . . . . . . . . . . . . . . . 19MYSOLINE . . . . . . . . . . . . . . . . 18

Nnabumetone . . . . . . . . . . . . . . 15nadolol . . . . . . . . . . . . . . . . . . . 11nafarelin nasal . . . . . . . . . . . . . . 6naloxegol . . . . . . . . . . . . . . . . . 27naloxone . . . . . . . . . . . . . . . . . . 48naloxone hcl nasal spray . . . . 48NALOXONE INJ . . . . . . . . . . . 48naltrexone . . . . . . . . . . . . .45, 48naltrexone inj . . . . . . . . . . . . . . 45NAMENDA . . . . . . . . . . . . . . . . 14naphazoline HCL . . . . . . . . . . 43naphazoline/glycerin . . . . . . . 43naphazoline/zinc sulfate . . . . 43NAPHCON A . . . . . . . . . . . . . . 61NAPROSYN . . . . . . . . . . . .15, 36naproxen . . . . . . . . . . 15, 17, 36naproxen delayed

release . . . . . . . . . . . . .15, 36naratriptan . . . . . . . . . . . . . . . . 16NARCAN . . . . . . . . . . . . . . . . . 48NARCAN NASAL SPRAY . . . 48NARDIL . . . . . . . . . . . . . . . . . . 47NASACORT ALLERGY 24

HOUR . . . . . . . . . . . . . . . . . 23nasal sprays . . . . . . . . . . . . . . . 59NATACYN . . . . . . . . . . . . . . . . . 45natamycin . . . . . . . . . . . . . . . . . 45NATAZIA . . . . . . . . . . . . . . . . . . 41nateglinide . . . . . . . . . . . . . . . . 26NAVANE . . . . . . . . . . . . . . . . . . 50

NEBUPENT . . . . . . . . . . . . . . . 32NEBUSAL . . . . . . . . . . . . . . . . 56nelfinavir . . . . . . . . . . . . . . . . . . 34neomycin sulfate . . . . . . . . . . . 35neomycin/polymyxin B/

dexamethasone . . . . . . . . 43neomycin/polymyxin B/

hydrocortisone . . . . . . . . . 22NEORAL . . . . . . . . . . . . . . . . . . 7nepafenac . . . . . . . . . . . . . . . . 43NEPHROCAPS . . . . . . . . . . . . 55NEPTAZANE . . . . . . . . . . . . . . 44neratinib . . . . . . . . . . . . . . . . . . . 5NERLYNX . . . . . . . . . . . . . . . . . . 5NESTABS . . . . . . . . . . . . . . . . . 54NEUMEGA . . . . . . . . . . . . . . . . . 8NEUPOGEN . . . . . . . . . . . . . . . 8NEURONTIN . . . . . . . . . . . . . . 18nevirapine . . . . . . . . . . . . . . . . 33nevirapine ER . . . . . . . . . . . . . 33nevirapine susp . . . . . . . . . . . . 33NEXAVAR . . . . . . . . . . . . . . . . . 5NEXIUM DELAYED RELEASE

PACKET . . . . . . . . . . . . . . . 28NEXPLANON . . . . . . . . . . . . . 41niacin . . . . . . . . . . . . . . . . . . . . 13niacin extended-release . . . . . 13NIACOR . . . . . . . . . . . . . . . . . . 13NIASPAN . . . . . . . . . . . . . . . . . 13NICODERM CQ . . . . . . . .49, 61NICODERM CQ . . . . . . . . . . . 61NICORETTE OTC . . . . . . . . . . 49nicotine . . . . . . . . . . . . . . . .49, 61NICOTINE GUM . . . . . . . . . . . 61nicotine polacrilex gum . . . . . 49nicotine polacrilex lozenge . . 49nifedipine . . . . . . . . . . . . . . . . . 11nifedipine extended-release . 11NILANDRON . . . . . . . . . . . . . . . 6nilotinib . . . . . . . . . . . . . . . . . . . . 5nilutamide . . . . . . . . . . . . . . . . . 6NINLARO . . . . . . . . . . . . . . . . . . 6nintedanib . . . . . . . . . . . . . . . . 56niraparib . . . . . . . . . . . . . . . . . . . 7nitazoxanide suspension . . . . 32

nitazoxanide tablet . . . . . . . . . 32nitisinone . . . . . . . . . . . . . . . . . 27NITREK . . . . . . . . . . . . . . . . . . 13NITRO-BID . . . . . . . . . . . . . . . . 13NITRO-DUR . . . . . . . . . . . . . . . 13nitrofurantoin

extended-release . . . . . . . 35nitrofurantoin macrocrystals . 35nitrofurantoin susp . . . . . . . . . 35nitroglycerin . . . . . . . . . . . .13, 22NITROSTAT . . . . . . . . . . . . . . . 13NITYR . . . . . . . . . . . . . . . . . . . . 27NIX . . . . . . . . . . . . . . . . . . .21, 61NIX CREME RINSE . . . . . . . . . 21NIZORAL . . . . . . . . . . 20, 22, 32NIZORAL SHAMPOO . . . . . . . 22NOLVADEX . . . . . . . . . . . . . . . . 6nonoxynol-9 foam . . . . . . .38, 60nonoxynol-9 gel . . . . . . . . .39, 60nonoxynol-9 vaginal

film . . . . . . . . . . . . . . . .39, 60nonoxynol-9 vaginal

sponge . . . . . . . . . . . . .39, 60nonoxynol-9 vaginal suppository

39, 60NORCO . . . . . . . . . . . . . . . . . . 16NORDETTE . . . . . . . . . . . . . . . 40NORDITROPIN . . . . . . . . . . . . 26norelgestromin/EE . . . . . . . . . 41norethindrone . . . . . . . . 6, 38-42norethindrone acetate . . . 39-42norethindrone acetate/

EE . . . . . . . . . . . . . . . . . 39-41norethindrone acetate/EE-FE

cap . . . . . . . . . . . . . . . . . . . 39norethindrone acetate/EE-FE

chew . . . . . . . . . . . . . . . . . . 39norethindrone acetate/EE-FE

tab . . . . . . . . . . . . . . . . . . . . 39norethindrone acetate/

EE/iron . . . . . . . . . . . . . 39-41norethindrone acetate/

estradiol . . . . . . . . . . . . . . . 42norethindrone/EE . . . 38, 40, 41

75



norethindrone/EE-FE chew tab . . . . . . . . . . . . . . 40

norethindrone/EE-FE tab . . . . 38norethindrone/ME . . . . . . . . . 40norgestimate/EE . . . . . . . .40, 41norgestrel/EE . . . . . . . . . . . . . 40NORPACE . . . . . . . . . . . . . . . . 10NORPRAMIN . . . . . . . . . . . . . . 47NORTHERA . . . . . . . . . . . . . . . 14NORVASC . . . . . . . . . . . . . . . . 11NOVOLOG . . . . . . . . . . . . . . . . 25NOVOLOG MIX 70/30 . . . . . . 25NUCALA . . . . . . . . . . . . . . . . . 51NULYTELY . . . . . . . . . . . . . . . . 28NUPLAZID . . . . . . . . . . . . . . . . 49NUVARING . . . . . . . . . . . . . . . 38NUVIGIL . . . . . . . . . . . . . . . . . . 14nystatin . . . . . . . . . . . . . . . .20, 32nystatin/triamcinolone . . . . . . 20NYTOL QUICK CAPS . . . . . . . 48

OOCEAN NASAL SPRAY . .24, 59octreotide . . . . . . . . . . . . . . . . . . 7OCUFEN . . . . . . . . . . . . . . . . . 43OCUFLOX . . . . . . . . . . . . . . . . 45ODEFSEY . . . . . . . . . . . . . . . . . 34ODOMZO . . . . . . . . . . . . . . . . . . 7OFEV . . . . . . . . . . . . . . . . . . . . 56ofloxacin . . . . . . . . . . . . . . .22, 45OGEN . . . . . . . . . . . . . . . . . . . . 41olanzapine . . . . . . . . . . . . . . . . 49olanzapine for IM inj . . . . . . . . 49olanzapine IM susp . . . . . . . . . 49olaparib . . . . . . . . . . . . . . . . . . . 7olmesartan . . . . . . . . . . . . . . . . 10olmesartan/

hydrochlorothiazide . . . . . 10omalizumab . . . . . . . . . . . . . . . 51omeprazole delayed-release . 29OMNICEF . . . . . . . . . . . . . . . . . 31OMNIFLEX DIAPHRAGM . . . 37ondansetron . . . . . . . . . . . . . . 28One Touch Systems . . . . . . . . 25One Touch Test Strips . . . . . . 25

oprelvekin . . . . . . . . . . . . . . . . . 8OPTIPRANOLOL . . . . . . . . . . 44ORALAIR . . . . . . . . . . . . . . . . . 52ORAP . . . . . . . . . . . . . . . . . . . . 49ORAPRED . . . . . . . . . . . . . . . . 24ORFADIN . . . . . . . . . . . . . . . . . 27ORILISSA . . . . . . . . . . . . . . . . . 42ORKAMBI . . . . . . . . . . . . . . . . 56ORTHO COIL . . . . . . . . . . . . . 39ortho diaphragm . . . . . . . . . . . 39ORTHO EVRA . . . . . . . . . . . . . 41ORTHO FLAT . . . . . . . . . . . . . 39ORTHO FLEX . . . . . . . . . . . . . 39ORTHO MICRONOR . . . . . . . 40ORTHO TRI-CYCLEN . . . . . . . 41ORTHO TRI-CYCLEN LO . . . 41ORTHO-CEPT . . . . . . . . . . . . . 40ORTHO-CYCLEN . . . . . . . . . . 40ORTHO-NOVUM 1/35 . . . . . . 40ORTHO-NOVUM 1/50 . . . . . . 40ORTHO-NOVUM 10/11 . . . . 38ORTHO-NOVUM 7/7/7 . . . . . 41ORUDIS . . . . . . . . . . . . . . .15, 36OS-CAL . . . . . . . . . . . . . . .53, 61oseltamivir . . . . . . . . . . . . . . . . 33OSENI . . . . . . . . . . . . . . . . . . . . 26osimertinib . . . . . . . . . . . . . . . . . 5OTICIN HC . . . . . . . . . . . . . . . . 23OVCON 50 . . . . . . . . . . . . . . . . 40OVRAL . . . . . . . . . . . . . . . . . . . 40OXANDRIN . . . . . . . . . . . . . . . 55oxandrolone . . . . . . . . . . . . . . 55oxaprozin . . . . . . . . . . . . . .15, 36oxcarbazepine . . . . . . . . . . . . . 18OXERVATE . . . . . . . . . . . . . . . 45oxybutynin chloride . . . . . . . . 52oxybutynin IR . . . . . . . . . . . . . . 53oxybutynin patch . . . . . . . .53, 61oxycodone . . . . . . . . . . . . . . . . 16oxycodone/acetaminophen . 16oxycodone/aspirin . . . . . . . . . 16oxymorphone ER . . . . . . . . . . 16OXYTROL FOR WOMEN OTC

PATCH . . . . . . . . . . . . .53, 61

Ppalbociclib . . . . . . . . . . . . . . . . . 5paliperidone . . . . . . . . . . . . . . . 49paliperidone palmitate . . . . . . 49palivizumab . . . . . . . . . . . . . . . 35PAMINE . . . . . . . . . . . . . . . . . . 29pancrelipase . . . . . . . . . . . . . . 30panobinostat . . . . . . . . . . . . . . . 4PANRETIN . . . . . . . . . . . . . . . . . 7pantoprazole . . . . . . . . . . . . . . 29PARAGARD IUD . . . . . . . . . . . 38PARNATE . . . . . . . . . . . . . . . . . 47paromomycin . . . . . . . . . . . . . 35paroxetine . . . . . . . . . . . . . . . . 47pasireotide . . . . . . . . . . . . . . . . . 7patiromer . . . . . . . . . . . . . . . . . 13PAXIL . . . . . . . . . . . . . . . . . . . . 47pazopanib . . . . . . . . . . . . . . . . . 5PEDIALYTE . . . . . . . . . . . .53, 60PEDIAPRED . . . . . . . . . . . . . . . 24PEDIAZOLE . . . . . . . . . . . . . . . 31peg 3350/electrolytes . . . . . . 27peg 3350/sodium bicarbonate/

sodium chloride . . . . . . . . 28peg 3350/sodium bicarbonate/

sodium chloride/potassium chloride . . . . . . . . . . . . . . . 28

pegvisomant . . . . . . . . . . . . . . 27penicillamine . . . . . . . . . . . . . . 36penicillin VK . . . . . . . . . . . . . . . 32pentamidine isethionate for

nebulization . . . . . . . . . . . . 32PENTASA . . . . . . . . . . . . . . . . . 29pentosan polysulfate sodium 53pentoxifylline

extended-release . . . . . . . . 9PEPCID . . . . . . . . . . . . . . .28, 60PEPCID AC . . . . . . . . . . . .28, 60peramivir . . . . . . . . . . . . . . . . . 33perampanel . . . . . . . . . . . . . . . 18PERCOCET . . . . . . . . . . . . . . . 16PERCODAN . . . . . . . . . . . . . . . 16PERIDEX . . . . . . . . . . . . . . . . . 24permethrin . . . . . . . . . . . . .21, 61permethrin lotion . . . . . . . . . . 21

76


Index of Covered Drugsperphenazine . . . . . . . . . .47, 49PERSANTINE . . . . . . . . . . . . . . 8phenazopyridine . . . . . . . . . . . 53phenelzine . . . . . . . . . . . . . . . . 47PHENERGAN . . . . . . . . . .28, 50PHENERGAN DM . . . . . . . . . . 50phenobarbital . . . . . . . . . . . . . 18phenoxybenzamine . . . . . . . . 55phenyl salicylate . . . . . . . . . . . 52phenylephrine . . . . . . . . . . . . 14PHENYLEPHRIN SOL . . . . . . 14PHENYTEK . . . . . . . . . . . . . . . 18phenytoin . . . . . . . . . . . . . . . . . 18phenytoin sodium extended . 18PHOS-FLUR . . . . . . . . . . . . . . 53PHOSLO . . . . . . . . . . . . . . . . . 56PHOSLYRA . . . . . . . . . . . . . . . 56phosphorus . . . . . . . . . . . . . . . 55PHRENILIN . . . . . . . . . . . . . . . 15phytonadione . . . . . . . . . . . . . . 53PICATO . . . . . . . . . . . . . . . . . . . 22pilocarpine . . . . . . . . . . . . .24, 44PILOPINE HS GEL . . . . . . . . . 44pimavanserin . . . . . . . . . . . . . . 49pimecrolimus . . . . . . . . . . . . . . 22pimozide . . . . . . . . . . . . . . . . . 49PIN-X . . . . . . . . . . . . . . . . . . . . . 30pioglitazone . . . . . . . . . . . . . . . 26PIQRAY . . . . . . . . . . . . . . . . . . . 4pirfenidone . . . . . . . . . . . . . . . 56piroxicam . . . . . . . . . . . . . .15, 36PLAN B ONE STEP . . . . . . . . 38PLAQUENIL . . . . . . . . . . . .35, 36PLAVIX . . . . . . . . . . . . . . . . . . . . 8PLENDIL . . . . . . . . . . . . . . . . . 11plerixafor . . . . . . . . . . . . . . . . . . 8PLETAL . . . . . . . . . . . . . . . . . . . 8pneumococcal 13-valent

conjugate . . . . . . . . . . . . . . 58pneumococcal vaccine

polyvalent . . . . . . . . . . . . . . 58PNEUMOVAX . . . . . . . . . . . . . 58PNEUMOVAX 23 . . . . . . . . . . 58podofilox . . . . . . . . . . . . . . . . . 21POLY-VI-FLOR . . . . . . . . . . . . . 53

POLY-VI-SOL . . . . . . . . . . . . . . 61polyethylene glycol 3350 . . . . 28polymyxin B/trimethoprim . . . 45polysaccharide iron caps . . . . 61POLYTRIM . . . . . . . . . . . . . . . . 45pomalidomide . . . . . . . . . . . . . . 7POMALYST . . . . . . . . . . . . . . . . 7ponatinib . . . . . . . . . . . . . . . . . . 5potassium acid phosphate . . 55potassium bicarbonate/

potassium citrate effervescent . . . . . . . . . . . . 55

potassium chloride . . . . . .28, 55potassium chloride extended-

release . . . . . . . . . . . . . . . . 55potassium citrate . . . . . . . .53, 55POTIGA . . . . . . . . . . . . . . . . . . 18PRADAXA . . . . . . . . . . . . . . . . . 8pramipexole . . . . . . . . . . . . . . . 17pramlintide . . . . . . . . . . . . . . . . 26PRAMOTIC . . . . . . . . . . . . . . . 23pramoxine/chloroxylenol . . . . 23pramoxine/hydrocortisone/

chloroxylenol . . . . . . . . . . . 23PRANDIN . . . . . . . . . . . . . . . . . 26PRAVACHOL . . . . . . . . . . . . . . 12pravastatin . . . . . . . . . . . . . . . . 12prazosin . . . . . . . . . . . . . . . . . . . 9PRECOSE . . . . . . . . . . . . . . . . 26PRED FORTE . . . . . . . . . . . . . 43prednisolone . . . . . . . . . . .24, 43prednisolone acetate . . . . . . . 43prednisolone sodium

phosphate . . . . . . . . . . . . . 24prednisone . . . . . . . . . . . . . . . . 24prednisone conc . . . . . . . . . . . 24PREDNISONE INTENSOL . . . 24PRELONE . . . . . . . . . . . . . . . . 24PREMARIN . . . . . . . . . . . . . . . 41PREMPHASE . . . . . . . . . . . . . 42PREMPRO . . . . . . . . . . . . . . . . 42prenat w/o A w/fecbn-fegl-DSS-

FA & DHA . . . . . . . . . . . . . . 54prenat-FE Bis-FE prot succ-FA-

CA & omega 3 . . . . . . . . . 54

prenat-FE bis-FE prot succ-FA-CA & omega DR . . . . . . . . 54

prenatal vit w/FE bisglycinate chelate-FA . . . . . . . . . . . . . 54

prenatal vit w/FE polysac cmplx-FA . . . . . . . . . . . . . . 54

prenatal vit w/iron carbonyl-FA . . . . . . . . . . . . 54

prenatal vit w/o vit a w/FE bisglycinate-fa tab . . . . . . . 54

PRENATAL VITAMINS W/ FOLIC ACID . . . . . . . . 54

prenatal vitamins w/folic acid 54prenatal w/o A w/FE carbonyl-

FE gluc-DSS-FA . . . . . . . . 54PRENTIF CAVITY-RIM

CERVICAL CAP . . . . . . . . 37PREVACID . . . . . . . . . . . . .28, 29PREVACID SOLUTAB . . . . . . 29PREVIDENT . . . . . . . . . . . . . . . 53PREVNAR 13 . . . . . . . . . . . . . 58PREVYMIS . . . . . . . . . . . . . . . . 32PREZCOBIX . . . . . . . . . . . . . . 35PREZISTA . . . . . . . . . . . . . . . . 34PRIFTIN . . . . . . . . . . . . . . . . . . 30PRILOSEC . . . . . . . . . . . . . . . . 29primaquine . . . . . . . . . . . . . . . . 35primidone . . . . . . . . . . . . . . . . . 18PRINCIPEN . . . . . . . . . . . . . . . 31PROAIR HFA . . . . . . . . . . . . . . 51PROAMATINE . . . . . . . . . . . . . 14probenecid . . . . . . . . . . . . . . . 37PROCARDIA . . . . . . . . . . . . . . 11PROCARDIA XL . . . . . . . . . . . 11prochlorperazine . . . . . . . . . . . 28PROCTOCORT . . . . . . . . . . . . 21PROCTOSOL HC

CREAM 2 .5% . . . . . . . . . . 22PROCTOZONE CREAM-HC

2 .5% . . . . . . . . . . . . . . . . . . 22progesterone IM inj . . . . . . . . . 42progesterone micronized

caps . . . . . . . . . . . . . . . . . . 42PROGRAF . . . . . . . . . . . . . . . . . 7PROLIA . . . . . . . . . . . . . . . . . . . 5

77



PROLIXIN . . . . . . . . . . . . . . . . . 49PROLIXIN DECANOATE . . . . 49PROMACTA . . . . . . . . . . . . . . . 57PROMETH VC SYP 6 .25-5/5 51promethazine . . . . . . 28, 50, 51promethazine & phenylephrine .

50, 51PROMETHAZINE SYP DM . . 50PROMETHAZINE VC

W/CODEINE . . . . . . . . . . . 50PROMETHAZINE

W/CODEINE . . . . . . . . . . . 50Prometrium . . . . . . . . . . . . . . . 42PRONTO SHA W/CR RI . . . . 21propafenone/

propafenone ER . . . . . . . . 10propantheline . . . . . . . . . . . . . 53proparacaine . . . . . . . . . . . . . 45propranolol . . . . . . . . . . . .11, 17propranolol ER . . . . . . . . . . . . 11propranolol/HCTZ . . . . . . . . . 11propylthiouracil . . . . . . . . . . . . 27PROSCAR . . . . . . . . . . . . . . . . 52PROTONIX . . . . . . . . . . . . . . . . 29PROVENTIL . . . . . . . . . . . . . . . 51PROVENTIL HFA . . . . . . . . . . 51PROVERA . . . . . . . . . . . . . . . . 42PROVIGIL . . . . . . . . . . . . . . . . . 14PROZAC . . . . . . . . . . . . . . . . . 47PRUET DHA PAK SETONET

PAK . . . . . . . . . . . . . . . . . . . 54PRUET DHAEC PAK . . . . . . . 54pseudoephedrine 30mg or

60mg tab . . . . . . . . . . . . . . 59psyllium . . . . . . . . . . . . . . . . . . 60PULMICORT FLEXHALER . . 51PULMICORT RESPULES . . . 52PULMOZYME . . . . . . . . . . . . . 56PURINETHOL . . . . . . . . . . . . . . 4PURIXAN SUS . . . . . . . . . . . . . . 4PYLERA . . . . . . . . . . . . . . . . . . 30pyrantel pamoate . . . . . . . . . . 30pyrazinamide . . . . . . . . . . . . . . 30pyrethrins/piperonyl

butoxide . . . . . . . . . . . .21, 61

pyrethrins/piperonyl butoxide gel . . . . . . . . . . . . . . . . . . . 21

pyrethrins/piperonyl butoxide liq . . . . . . . . . . . . . . . . . . . . 21

pyrethrins/piperonyl butoxide shampoo . . . . . . . . . . . . . . 21

PYRIDIUM . . . . . . . . . . . . . . . . 53pyridostigmine . . . . . . . . . . . . . 17pyridostigmine

extended-release . . . . . . . 17

QQUALAQUIN . . . . . . . . . . . . . . 35QUARTETTE . . . . . . . . . . . . . . 38QUESTRAN . . . . . . . . . . . . . . . 12QUESTRAN-LIGHT . . . . . . . . . 12quetiapine . . . . . . . . . . . . . . . . 49quetiapine SR . . . . . . . . . . . . . 49QUILLICHEW . . . . . . . . . . . . . 46QUILLIVANT XR . . . . . . . . . . . 46quinapril/

hydrochlorothiazide . . . . . . 9QUINIDINE GLUCONATE

EXT-REL . . . . . . . . . . . . . . 10quinidine gluconate

extended-release . . . . . . . 10QUINIDINE SULFATE

EXT-REL . . . . . . . . . . . . . . 10quinidine sulfate extended-

release . . . . . . . . . . . . . . . . 10quinine sulfate . . . . . . . . . . . . . 35

Rraltegravir . . . . . . . . . . . . . . . . . 33raltegravir susp . . . . . . . . . . . . 33ramelteon . . . . . . . . . . . . . . . . . 48ramipril . . . . . . . . . . . . . . . . . . . . 9RANEXA . . . . . . . . . . . . . . . . . 14ranitidine . . . . . . . . . . . . . . . . . 29ranitidine syrup . . . . . . . . . . . . 29ranolazine . . . . . . . . . . . . . . . . 14RAPAMUNE . . . . . . . . . . . . . . . . 7RAPIVAB . . . . . . . . . . . . . . . . . 33RASUVO . . . . . . . . . . . . . . . . . 36ravulizumab-cwvz iv soln . . . . . 5

RAZADYNE . . . . . . . . . . . . . . . 14REBIF/REBIF REBIDOSE . . . 17RECOMBIVAX HB . . . . . . . . . 57RECTIV . . . . . . . . . . . . . . . . . . . 22REESE’S PINWORM

MEDICINE . . . . . . . . . . . . . 30REGLAN . . . . . . . . . . . . . . . . . 28regorafenib . . . . . . . . . . . . . . . . 5REGRANEX . . . . . . . . . . . . . . . 21RELAFEN . . . . . . . . . . . . . . . . . 15REMERON . . . . . . . . . . . . . . . . 48RENAGEL . . . . . . . . . . . . . . . . 56RENVELA . . . . . . . . . . . . . . . . 56repaglinide . . . . . . . . . . . . . . . . 26REPATHA . . . . . . . . . . . . . . . . . 13REQUIP . . . . . . . . . . . . . . . . . . 17RESCRIPTOR . . . . . . . . . . . . . 33reslizumab . . . . . . . . . . . . . . . . 51RESTASIS . . . . . . . . . . . . . . . . 45RESTORIL . . . . . . . . . . . . . . . . 48RETIN-A . . . . . . . . . . . . . . . . . . 19RETROVIR . . . . . . . . . . . . . . . . 34REVATIO . . . . . . . . . . . . . . . . . 13REVIA . . . . . . . . . . . . . . . . .45, 48REVLIMID . . . . . . . . . . . . . . . . . 7REXULTI . . . . . . . . . . . . . . . . . . 48REYATAZ . . . . . . . . . . . . . . . . . 34REYATAZ POWDER

PACKET . . . . . . . . . . . . . . . 34ribavirin . . . . . . . . . . . . . . . . . . . 35ribociclib . . . . . . . . . . . . . . . . . 5, 6ribociclib/letrozole . . . . . . . . . . 6RID LICE KIL . . . . . . . . . . . . . 21RID SHAMPOO . . . . . . . . .21, 61RIDAURA . . . . . . . . . . . . . . . . . 35rifabutin . . . . . . . . . . . . . . . . . . 30RIFADIN . . . . . . . . . . . . . . . . . . 30rifampin . . . . . . . . . . . . . . . . . . 30rifapentine . . . . . . . . . . . . . . . . 30rifaximin . . . . . . . . . . . . . . . . . . 28rilpivirine . . . . . . . . . . . . . . .33, 34RILUTEK . . . . . . . . . . . . . . . . . 14riluzole . . . . . . . . . . . . . . . . . . . 14rimantadine . . . . . . . . . . . . . . . 33riociguat . . . . . . . . . . . . . . . . . . 13

78


Index of Covered DrugsRISPERDAL . . . . . . . . . . . . . . . 49RISPERDAL CONSTA . . . . . . 49RISPERDAL SOLUTION . . . . 49risperidone . . . . . . . . . . . . . . . . 49risperidone oral soln . . . . . . . . 49RITALIN . . . . . . . . . . . . . . . . . . 46RITALIN LA . . . . . . . . . . . . . . . 46rivaroxaban . . . . . . . . . . . . . . . . 8rivastigmine . . . . . . . . . . . . . . . 14rizatriptan . . . . . . . . . . . . . . . . . 16RMS . . . . . . . . . . . . . . . . . . . . . 16ROBAXIN . . . . . . . . . . . . . . . . . 37ROBINUL . . . . . . . . . . . . . . . . . 29ROBINUL FORTE . . . . . . . . . . 29ROBITUSSIN . . . . . . . . . . .50, 59ROBITUSSIN DM . . . . . . .50, 59ROBITUSSIN PED SYP . . . . . 50ROBITUSSIN SYP CHST

CNG . . . . . . . . . . . . . . . . . . 50ROBITUSSIN SYP MAX-ST . . 50ROCALTROL . . . . . . . . . . . . . . 53ROCALTROL SOLUTION . . . 53ROCEPHIN . . . . . . . . . . . . . . . 31roflumilast . . . . . . . . . . . . . . . . 51ropinirole . . . . . . . . . . . . . . . . . 17rosuvastatin . . . . . . . . . . . . . . . 12ROWASA . . . . . . . . . . . . . . . . . 29ROXICODONE . . . . . . . . . . . . 16ROZEREM . . . . . . . . . . . . . . . . 48RUBRACA . . . . . . . . . . . . . . . . . 7rucaparib . . . . . . . . . . . . . . . . . . 7RUCONEST . . . . . . . . . . . . . . . 56ruxolitinib . . . . . . . . . . . . . . . . . . 5RYDAPT . . . . . . . . . . . . . . . . . . . 5RYTHMOL . . . . . . . . . . . . . . . . 10RYTHMOL SR . . . . . . . . . . . . . 10

SSABRIL . . . . . . . . . . . . . . . . . . . 19SABRIL SOLUTION . . . . . . . . 19sacubitril/valsartan . . . . . . . . . 10SAFYRAL . . . . . . . . . . . . . . . . . 40SAL-TROPINE . . . . . . . . . . . . . 30SALAGEN . . . . . . . . . . . . . . . . 24SALINE NASAL SPRAY . .24, 59

saline nasal spray 0 .65% . . . . . . . . . . . . . .24, 59

salmeterol . . . . . . . . . . . . . . . . 51salsalate . . . . . . . . . . . . . . . . . . 36SAMSCA . . . . . . . . . . . . . . . . . 27SANCTURA . . . . . . . . . . . . . . . 53SANDIMMUNE . . . . . . . . . . . . . 7SANDOSTATIN . . . . . . . . . . . . . 7SAPHRIS . . . . . . . . . . . . . . . . . 48sapropterin . . . . . . . . . . . . . . . . 27sapropterin powder . . . . . . . . 27saquinavir mesylate . . . . . . . . 34SEASONALE . . . . . . . . . . . . . . 38SEASONIQUE . . . . . . . . . . . . . 38secnidazole granules . . . . . . . 42SECTRAL . . . . . . . . . . . . . . . . . 10SEDAPAP . . . . . . . . . . . . . . . . . 15selegiline . . . . . . . . . . . . . .18, 48selegiline td patch 24 hr . . . . 48selenium sulfide . . . . . . . . . . . 22selexipag . . . . . . . . . . . . . . . . . 13SELSUN . . . . . . . . . . . . . . . . . . 22SELZENTRY . . . . . . . . . . . . . . 35sennosides . . . . . . . . . . . . . . . 28SENOKOT . . . . . . . . . . . . . . . . 28SENSIPAR . . . . . . . . . . . . . . . . 56SEREVENT . . . . . . . . . . . . . . . 51SEROMYCIN . . . . . . . . . . . . . . 30SEROQUEL . . . . . . . . . . . . . . . 49SEROQUEL XR . . . . . . . . . . . . 49sevelamer carbonate . . . . . . . 56sevelamer hcl . . . . . . . . . . . . . 56SHINGRIX . . . . . . . . . . . . . . . . 58SHUR-SEAL GEL 2%,

OPTIONS GYNOL II VAGINAL CONTRACEPTIVE . . .39, 60

SHUR-SEAL GEL 2%, OPTIONS GYNOL II VAGINAL CONTRACEPTIVE 2% & 3% . . . . . . . . . . . . . . 60

SIGNIFOR . . . . . . . . . . . . . . . . . 7SIKLOS . . . . . . . . . . . . . . . . . . . . 7sildenafil . . . . . . . . . . . . . . . . . . 13SILVADENE . . . . . . . . . . . . . . . 20

silver sulfadiazine . . . . . . . . . . 20SIMBRINZA . . . . . . . . . . . . . . . 44simethicone . . . . . . . . . . . . . . . 60simvastatin . . . . . . . . . . . . . . . . 12SINEMET . . . . . . . . . . . . . . . . . 17SINEMET CR . . . . . . . . . . . . . . 17SINEQUAN . . . . . . . . . . . . . . . 47SINGULAIR . . . . . . . . . . . . . . . 52sirolimus . . . . . . . . . . . . . . . . . . . 7SIRTURO . . . . . . . . . . . . . . . . . 35sitagliptan . . . . . . . . . . . . . . . . . 26sitagliptan/metformin . . . . . . . 26sitagliptan/metformin ER . . . . 26SKYLA . . . . . . . . . . . . . . . . . . . 38SKLICE LOT . . . . . . . . . . . . . . 21SM LICE LOT . . . . . . . . . . . . . 21sodium betaine powder for

oral solution . . . . . . . . . . . . 57sodium chloride for

nebulizer . . . . . . . . . . . . . . 56sodium chloride hypertonic . 45sodium citrate/citric acid . . . . 53sodium phenylbutyrate . . . . . 57sodium phenylbutyrate oral

powder . . . . . . . . . . . . . . . . 57sodium phosphate

monobasic . . . . . . . . . . . . . 52sodium polystyrene

sulfonate . . . . . . . . . . . . . . 13SOLARAZE . . . . . . . . . . . . . . . 21SOLIRIS . . . . . . . . . . . . . . . . . . . 5SOLOSEC . . . . . . . . . . . . . . . . 42SOLU-CORTEF . . . . . . . . . . . . 24SOLU-MEDROL INJ . . . . . . . . 24somatropin . . . . . . . . . . . . . . . . 26SOMAVERT . . . . . . . . . . . . . . . 27sonidegib . . . . . . . . . . . . . . . . . . 7sorafenib . . . . . . . . . . . . . . . . . . 5SORIATANE . . . . . . . . . . . . . . . 21Spacers . . . . . . . . . . . . . . . . . . 57SPIRIVA HANDIHALER . . . . . 51spironolactone . . . . . . . . . . . . . 12spironolactone/

hydrochlorothiazide . . . . . 12SPORANOX . . . . . . . . . . . . . . . 32

79



SPRYCEL . . . . . . . . . . . . . . . . . . 5STARLIX . . . . . . . . . . . . . . . . . . 26stavudine . . . . . . . . . . . . . . . . . 34STELAZINE . . . . . . . . . . . . . . . 50STIOLTO . . . . . . . . . . . . . . . . . . 51STIVARGA . . . . . . . . . . . . . . . . . 5stool softeners . . . . . . . . . . . . . 60STRATTERA . . . . . . . . . . . . . . 46STRENSIQ . . . . . . . . . . . . . . . . 27STRIBILD . . . . . . . . . . . . . . . . . 34STROMECTOL . . . . . . . . . . . . 30STUART PRENATAL . . . . . . . 61SUBOXONE . . . . . . . . . . . . . . . 48succimer . . . . . . . . . . . . . . . . . 55sucralfate . . . . . . . . . . . . . . . . . 29sulcralfate . . . . . . . . . . . . . . . . . 29sulfacetamide . . . . . . . . . .43, 45sulfacetamide/pred phos . . . 43sulfadiazine . . . . . . . . . . . .20, 32sulfamethoxazole/

trimethoprim, DS . . . . . . . 32SULFAMYLON CRE . . . . . . . 19SULFAMYLON PAK . . . . . . . . 19sulfasalazine . . . . . . . . . . .29, 36sulfasalazine

delayed-release . . . . . .29, 36sulindac . . . . . . . . . . . . . . .15, 36sumatriptan . . . . . . . . . . . .16, 17sumatriptan/camphor/

menthol gel . . . . . . . . . . . . 17sumatriptan/naproxen

sodium . . . . . . . . . . . . . . . . 17sunitinib . . . . . . . . . . . . . . . . . . . 5SUPPRELIN LA . . . . . . . . . . . . . 6SUPRAX . . . . . . . . . . . . . . . . . . 31SUSTIVA . . . . . . . . . . . . . . . . . . 33SUTENT . . . . . . . . . . . . . . . . . . . 5SYMBICORT . . . . . . . . . . . . . . 51SYMDEKO . . . . . . . . . . . . . . . . 56SYMJEPI . . . . . . . . . . . . . . . . . 55SYMLIN . . . . . . . . . . . . . . . . . . 26SYMMETREL . . . . . . . . . .17, 33SYNAGIS . . . . . . . . . . . . . . . . . 35SYNAREL . . . . . . . . . . . . . . . . . . 6SYNTHROID . . . . . . . . . . . . . . 27

SYPRINE . . . . . . . . . . . . . . . . . 55

TT-STAT . . . . . . . . . . . . . . . . . . . 19TABLOID . . . . . . . . . . . . . . . . . . 4TACLONEX . . . . . . . . . . . . . . . 21tacrolimus . . . . . . . . . . . . . . . . . 7tadalafil (PAH) . . . . . . . . . . . . . 13TAFINLAR . . . . . . . . . . . . . . . . . 4TAGAMET . . . . . . . . . . . . . . . . 28TAGRISSO . . . . . . . . . . . . . . . . . 5talazoparib . . . . . . . . . . . . . . . . . 8TALZENNA . . . . . . . . . . . . . . . . 8TAMBOCOR . . . . . . . . . . . . . . 10TAMIFLU . . . . . . . . . . . . . . . . . 33tamoxifen . . . . . . . . . . . . . . . . . . 6tamsulosin . . . . . . . . . . . . . . . . 52TAPAZOLE . . . . . . . . . . . . . . . . 27TARCEVA . . . . . . . . . . . . . . . . . . 5TARGRETIN . . . . . . . . . . . . . . . . 7TASIGNA . . . . . . . . . . . . . . . . . . 5TASMAR . . . . . . . . . . . . . . . . . . 18TAVALISSE . . . . . . . . . . . . . . . . . 7TAYTULLA . . . . . . . . . . . . . . . . 39tbo-filgrastim . . . . . . . . . . . . . . . 8TECFIDERA . . . . . . . . . . . . . . . 17teduglutide . . . . . . . . . . . . . . . . 30TEGRETOL . . . . . . . . . . . . . . . 18TEGRETOL-XR . . . . . . . . . . . . 18temazepam . . . . . . . . . . . . . . . 48TEMODAR . . . . . . . . . . . . . . . . . 4TEMOVATE . . . . . . . . . . . . . . . 20temozolomide . . . . . . . . . . . . . . 4TENEX . . . . . . . . . . . . . . . . . . . . 9TENIVAC . . . . . . . . . . . . . . . . . 58tenofovir . . . . . . . . . . . . . . .34, 35TENORETIC . . . . . . . . . . . . . . 11TENORMIN . . . . . . . . . . . . . . . 10TERAZOL 3/7 . . . . . . . . . . . . . 42terazosin . . . . . . . . . . . . . . . . 9, 52terbinafine . . . . . . . . . . . . .20, 32terconazole . . . . . . . . . . . . . . . 42tesamorelin . . . . . . . . . . . . . . . 26TESSALON . . . . . . . . . . . . . . . 50

TESTOSTERONE 1% TOPICAL GEL . . . . . . . . . . . . . . . . . . 25

testosterone cypionate . . . . . . 24testosterone enanthate . . . . . . 24testosterone gel topical tube,

packet, and pump bottle . 25testosterone TD patch . . . . . . 25tet tox-diph-acell pertuss ad . 58TET/DIP TOX INJ . . . . . . . . . . 58tetanus immune globulin

(human) . . . . . . . . . . . . . . . 58tetanus-diphtheria toxoids

(td) . . . . . . . . . . . . . . . . . . . 58tetrabenazine . . . . . . . . . . . . . . 19tetracycline . . . . . . . . . . . . .30, 32tetrahydrozoline/zinc sulfate . 43tezacaftor/ivcaftor . . . . . . . . . . 56thalidomide . . . . . . . . . . . . . . . . 7THALOMID . . . . . . . . . . . . . . . . 7THEOCHRON . . . . . . . . . . . . . 52theophylline . . . . . . . . . . . . . . . 52theophylline

extended-release . . . . . . . 52thioguanine . . . . . . . . . . . . . . . . 4THIOLA . . . . . . . . . . . . . . . . . . 53thioridazine . . . . . . . . . . . . . . . 50thiothixene . . . . . . . . . . . . . . . . 50THORAZINE . . . . . . . . . . . . . . 49thyroid . . . . . . . . . . . . . . . . . . . . 27tiagabine . . . . . . . . . . . . . . . . . 18TIAZAC . . . . . . . . . . . . . . . . . . . 11TIBSOVO . . . . . . . . . . . . . . . . . . 6ticagrelor . . . . . . . . . . . . . . . . . . 8TIGAN . . . . . . . . . . . . . . . . . . . . 28tigecycline for IV soln . . . . . . . 32TIKOSYN . . . . . . . . . . . . . . . . . 10timolol . . . . . . . . . . . . . . . . . . . . 44timolol maleate . . . . . . . . . . . . 44TIMOPTIC . . . . . . . . . . . . . . . . 44TIMOPTIC XE . . . . . . . . . . . . . 44TINACTIN . . . . . . . . . . . . . .20, 59TINDAMAX . . . . . . . . . . . . . . . 32tinidazole . . . . . . . . . . . . . . . . . 32tiopronin . . . . . . . . . . . . . . . . . . 53tiotropium . . . . . . . . . . . . . . . . . 51

80


Index of Covered Drugstiotropium/olodaterol . . . . . . . 51tipranavir . . . . . . . . . . . . . . . . . 34TIVICAY . . . . . . . . . . . . . . . . . . 33tizanidine . . . . . . . . . . . . . . . . . 37TOBI PODHALER . . . . . . . . . . 56TOBRADEX . . . . . . . . . . . . . . . 43tobramycin . . . . . . . . . 43, 45, 56tobramycin inh caps . . . . . . . . 56tobramycin neb soln . . . . . . . . 56tobramycin/dexamethasone . 43TOBREX . . . . . . . . . . . . . . . . . . 45TODAY SPONGE . . . . . . .39, 60TODAY SPONGE 1000mg . . 60TOFRANIL . . . . . . . . . . . . . . . . 47tolcapone . . . . . . . . . . . . . . . . . 18tolnaftate . . . . . . . . . . . . . .20, 59tolterodine . . . . . . . . . . . . . . . . 53tolvaptan . . . . . . . . . . . . . . . . . . 27TOPAMAX . . . . . . . . . . . . . . . . 19TOPAMAX SPRINKLE . . . . . . 19topical antibacterials . . . . . . . . 60topiramate . . . . . . . . . . . . . . . . 19topiramate ER cap . . . . . . . . . 19topiramate sprinkle caps . . . . 19topotecan . . . . . . . . . . . . . . . . . . 8TOPROL XL . . . . . . . . . . . . . . . 11TORADOL . . . . . . . . . . . . . . . . 15torsemide . . . . . . . . . . . . . . . . . 12TRACLEER . . . . . . . . . . . . . . . 13TRADJENTA . . . . . . . . . . . . . . 26tramadol . . . . . . . . . . . . . . .15, 16tramadol ER . . . . . . . . . . . . . . . 15tramadol/acetaminophen . . . 16trametinib . . . . . . . . . . . . . . . . . . 5TRANDATE . . . . . . . . . . . . . . . 11tranexamic acid . . . . . . . . . . . . 43tranylcypromine . . . . . . . . . . . . 47TRAVATAN-Z . . . . . . . . . . . . . . 44travoprost . . . . . . . . . . . . . . . . . 44trazodone . . . . . . . . . . . . . . . . . 48TRECATOR . . . . . . . . . . . . . . . 30TRELSTAR . . . . . . . . . . . . . . . . . 6TRENTAL . . . . . . . . . . . . . . . . . . 9treprostinil inhalation solution 13tretinoin . . . . . . . . . . . . . . . . 8, 19

TREXALL . . . . . . . . . . . . . . . . . 36TREXIMET . . . . . . . . . . . . . . . . 17TRI RX . . . . . . . . . . . . . . . . . . . 54TRI-NORINYL . . . . . . . . . . . . . 41TRI-VI-FLOR . . . . . . . . . . . . . . . 55TRI-VI-SOL . . . . . . . . . . . . .55, 61triamcinolone . . . . . . . 20, 23, 24triamcinolone acetonide . . . . 20triamcinolone nasal spray . . . 23triamterene/

hydrochlorothiazide . . . . . 12TRIAVIL . . . . . . . . . . . . . . . . . . 47triazolam . . . . . . . . . . . . . . . . . . 48triclabendazole . . . . . . . . . . . . 30TRICOR . . . . . . . . . . . . . . . . . . 12trientine . . . . . . . . . . . . . . . . . . 55trifluoperazine . . . . . . . . . . . . . 50trifluridine . . . . . . . . . . . . . . . 4, 45trifluridine/tipiracil . . . . . . . . . . . 4TRIGLIDE . . . . . . . . . . . . . . . . . 12trihexyphenidyl . . . . . . . . . . . . 18TRILAFON . . . . . . . . . . . . . . . . 49TRILEPTAL . . . . . . . . . . . . . . . 18TRILYTE . . . . . . . . . . . . . . . . . . 28trimethobenzamide . . . . . . . . 28trimethoprim . . . . . . . 32, 35, 45TRIPTODUR . . . . . . . . . . . . . . . 6triptorelin . . . . . . . . . . . . . . . . . . 6TRIUMEQ . . . . . . . . . . . . . . . . . 34TRIVORA . . . . . . . . . . . . . . . . . 41TRIZIVIR . . . . . . . . . . . . . . . . . . 33TROGARZO . . . . . . . . . . . . . . 35TROJAN . . . . . . . . . . . . . . .37, 60TROKENDI XR . . . . . . . . . . . . 19trospium . . . . . . . . . . . . . . . . . . 53TRUSOPT . . . . . . . . . . . . . . . . 44TRUST NATALCARE PAK

DHA . . . . . . . . . . . . . . . . . . 54TRUSTEX . . . . . . . . . . . . . .37, 60TRUVADA . . . . . . . . . . . . . . . . 34TUMS . . . . . . . . . . . . . . . . .60, 61TUSSIN DM . . . . . . . . . . . . . . . 50TYBOST . . . . . . . . . . . . . . . . . . 34TYGACIL . . . . . . . . . . . . . . . . . 32TYKERB . . . . . . . . . . . . . . . . . . . 5

TYLENOL . . . . . . . 15, 16, 36, 61TYLENOL W/CODEINE . . . . . 16typhoid vaccine . . . . . . . . . . . . 58TYVASO . . . . . . . . . . . . . . . . . . 13

UUCERIS . . . . . . . . . . . . . . . . . . 29ulipristal acetate . . . . . . . . . . . 38ULTOMIRIS INJ . . . . . . . . . . . . . 5ULTRA . . . . . . . . . . . . . . . . . . . 25ULTRA 2, ULTRAMINI . . . . . . 25ULTRACET . . . . . . . . . . . . . . . 16ULTRAM . . . . . . . . . . . . . . . . . . 15ULTRAM ER . . . . . . . . . . . . . . 15ULTRAVATE . . . . . . . . . . . . . . . 20UNIPHYL . . . . . . . . . . . . . . . . . 52UPTRAVI . . . . . . . . . . . . . . . . . 13urea 40% . . . . . . . . . . . . . . . . . 22UREA 40% LOTION . . . . . . . . 22URECHOLINE . . . . . . . . . . . . . 52UREX . . . . . . . . . . . . . . . . . . . . 52uridine . . . . . . . . . . . . . . . . . . . 27UROCIT-K . . . . . . . . . . . . . . . . 53UROXATRAL . . . . . . . . . . . . . . 52URSO . . . . . . . . . . . . . . . . . . . . 30URSO FORTE . . . . . . . . . . . . . 30ursodiol . . . . . . . . . . . . . . . . . . 30UTIRA C . . . . . . . . . . . . . . . . . . 52

VVAGIFEM . . . . . . . . . . . . . . . . . 41vaginal products . . . . . . . . . . . 59valacyclovir . . . . . . . . . . . . . . . . 33VALCHLOR . . . . . . . . . . . . . . . . 4VALCYTE . . . . . . . . . . . . . . . . . 32valganciclovir . . . . . . . . . . . . . . 32VALIUM . . . . . . . . . . . . . . .37, 45valproic acid . . . . . . . . . . . . . . 19valsartan . . . . . . . . . . . . . . . . . . 10valsartan/

hydrochlorothiazide . . . . . 10VALTREX . . . . . . . . . . . . . . . . . 33VANALICE GEL . . . . . . . . . . . 21VANCOCIN HCL . . . . . . . . . . . 32vancomycin hcl . . . . . . . . . . . . 32

81



vandetanib . . . . . . . . . . . . . . . . . 5VANTAS . . . . . . . . . . . . . . . . . . . 6VANTIN . . . . . . . . . . . . . . . . . . . 31VAQTA . . . . . . . . . . . . . . . . . . . 57varenicline . . . . . . . . . . . . . . . . 49varicella virus vac live for

subcutaneous . . . . . . . . . . 58VARIVAX . . . . . . . . . . . . . . . . . 58VASERETIC . . . . . . . . . . . . . . . . 9VASOCIDIN . . . . . . . . . . . . . . . 43VASOCLEAR . . . . . . . . . . . . . . 43VASOCLEAR A . . . . . . . . . . . . 43VASODILAN . . . . . . . . . . . . . . 14vasopressin IV soln . . . . . . . . 27VASOSTRICT . . . . . . . . . . . . . 27VASOTEC . . . . . . . . . . . . . . . . . . 9VCF CONTRACEPTIVE

GEL 4% . . . . . . . . . . . . . . . 60VCF VAGINAL

CONTRACEPTIVE FILM . . . . . . . . . . . . . . .39, 60

VCF VAGINAL CONTRACEPTIVE FILM 28% 60

VCF VAGINAL CONTRACEPTIVE FOAM . . . . . . . . . . . . . .38, 60

VCF VAGINAL CONTRACEPTIVE FOAM 12 .5% . . . . . . . . . . . . . . . . . 60

VCF VAGINAL CONTRACEPTIVE GEL . . 39

VEETIDS . . . . . . . . . . . . . . . . . 32VELTASSA . . . . . . . . . . . . . . . . 13vemurafenib . . . . . . . . . . . . . . . . 5VENCLEXTA . . . . . . . . . . . . . . . 5venetoclax . . . . . . . . . . . . . . . . . 5venlafaxine . . . . . . . . . . . . . . . . 47venlafaxine XR . . . . . . . . . . . . . 47VENTAVIS . . . . . . . . . . . . . . . . 13VEPESID . . . . . . . . . . . . . . . . . . 7verapamil . . . . . . . . . . . . . .11, 17verapamil extended-release . . 11VERIO . . . . . . . . . . . . . . . . . . . . 25

VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC . 25

VERIPRED 20 . . . . . . . . . . . . . 24VERSACLOZ . . . . . . . . . . . . . . 49VERSED . . . . . . . . . . . . . . . . . . 46VERZENIO . . . . . . . . . . . . . . . . . 4VESANOID . . . . . . . . . . . . . . . . . 8VI-DAYLIN . . . . . . . . . . . . . . . . . 61VIBRAMYCIN . . . . . . . . . . . . . 32VICODIN . . . . . . . . . . . . . . . . . . 16VICODIN ES . . . . . . . . . . . . . . . 16VICTOZA . . . . . . . . . . . . . . . . . 26VIDEX . . . . . . . . . . . . . . . . . . . . 33VIDEX EC . . . . . . . . . . . . . . . . . 33vigabatrin oral solution . . . . . . 19vigabatrin tabs . . . . . . . . . . . . . 19VIGAMOX . . . . . . . . . . . . . . . . . 45VIMPAT . . . . . . . . . . . . . . . . . . . 18VINATE AZ EX . . . . . . . . . . . . . 54VINATE II . . . . . . . . . . . . . . . . . 54VIRACEPT . . . . . . . . . . . . . . . . 34VIRAMUNE . . . . . . . . . . . . . . . 33VIRAMUNE XR . . . . . . . . . . . . 33VIRAZOLE . . . . . . . . . . . . . . . . 35VIREAD . . . . . . . . . . . . . . . . . . 34VIROPTIC . . . . . . . . . . . . . . . . . 45VISINE . . . . . . . . . . . . . . . . . . . 61VISINE-AC . . . . . . . . . . . . . . . . 43vismodegib . . . . . . . . . . . . . . . . 8VISTARIL . . . . . . . . . . . . . . . . . 23VISTOGARD . . . . . . . . . . . . . . 27vitamin ADC/fluoride/±iron

drops . . . . . . . . . . . . . . . . . 55vitamin B complex/vitamin C/

folic acid . . . . . . . . . . . . . . . 55vitamin B-1 . . . . . . . . . . . . . . . . 55VITAMIN B-12 . . . . . . . . . . . . . 53vitamin B-6 . . . . . . . . . . . . . . . . 55VITAMIN D TAB 1000 UNIT . 53vitamins pediatric . . . . . . .55, 61vitamins pediatric members

<3 years old . . . . . . . . . . . . 61vitamins prenatal . . . . . . . . . . . 61VITRAKVI . . . . . . . . . . . . . . . . . . 5VIVELLE-DOT . . . . . . . . . . . . . 42

VIVITROL . . . . . . . . . . . . . . . . . 45VIVOTIF BERNA . . . . . . . . . . . 58VIZIMPRO . . . . . . . . . . . . . . . . . 4VOLTAREN . . . . . . . . 15, 36, 43VOLTAREN 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 36VOLTAREN XR . . . . . . . . .15, 36vorinostat . . . . . . . . . . . . . . . . . . 4VOSOL HC OTIC . . . . . . . . . . 22VOSOL OTIC . . . . . . . . . . . . . . 22VOSPIRE . . . . . . . . . . . . . . . . . 52VOSPIRE ER . . . . . . . . . . . . . . 52VOTRIENT . . . . . . . . . . . . . . . . . 5VRAYLAR . . . . . . . . . . . . . . . . . 48VYVANSE . . . . . . . . . . . . . . . . 46vyvanse chewable . . . . . . . . . . 46

Wwarfarin . . . . . . . . . . . . . . . . . . . 8WELLBUTRIN . . . . . . . . . .47, 48WELLBUTRIN SR . . . . . . . . . . 48WELLBUTRIN XL . . . . . . . . . . 48WIDE-SEAL SILICONE

DIAPHRAGM KIT . . . . . . . 37WYTENSIN . . . . . . . . . . . . . . . 14

XXALATAN . . . . . . . . . . . . . . . . . 44XALKORI . . . . . . . . . . . . . . . . . . 4XANAX . . . . . . . . . . . . . . . . . . . 45XARELTO . . . . . . . . . . . . . . . . . . 8XATMEP . . . . . . . . . . . . . . . . . . 36XELODA . . . . . . . . . . . . . . . . . . . 4XENAZINE . . . . . . . . . . . . . . . . 19XGEVA . . . . . . . . . . . . . . . . . . . . 5XIFAXAN . . . . . . . . . . . . . . . . . 28XIGDUO XR . . . . . . . . . . . . . . . 26XOLAIR . . . . . . . . . . . . . . . . . . 51XOSPATA . . . . . . . . . . . . . . . . . . 5XTANDI . . . . . . . . . . . . . . . . . . . . 6XULANE . . . . . . . . . . . . . . . . . . 41XYLOCAINE . . . . . . . . 10, 22, 24XYLOCAINE INJ . . . . . . . . . . . 10XYZAL . . . . . . . . . . . . . . . . . . . 23

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Index of Covered DrugsY

YASMIN . . . . . . . . . . . . . . . . . . 40YAZ . . . . . . . . . . . . . . . . . . . . . . 39

ZZADITOR . . . . . . . . . . . . . .43, 61zafirlukast . . . . . . . . . . . . . . . . . 52ZANAFLEX . . . . . . . . . . . . . . . 37ZANTAC . . . . . . . . . . . . . . . . . . 29ZAROXOLYN . . . . . . . . . . . . . . 12ZAVESCA . . . . . . . . . . . . . . . . . 27ZEBETA . . . . . . . . . . . . . . . . . . 11ZEJULA . . . . . . . . . . . . . . . . . . . 7ZELBORAF . . . . . . . . . . . . . . . . 5ZENPEP . . . . . . . . . . . . . . . . . . 30ZENTANE . . . . . . . . . . . . . . . . . 19ZERIT . . . . . . . . . . . . . . . . . . . . 34ZESTORETIC . . . . . . . . . . . . . . 9ZESTRIL . . . . . . . . . . . . . . . . . . . 9ZETIA . . . . . . . . . . . . . . . . . . . . 13ZIAC . . . . . . . . . . . . . . . . . . . . . 11ZIAGEN . . . . . . . . . . . . . . . . . . 33zidovudine . . . . . . . . . . . . .33, 34ziprasidone . . . . . . . . . . . . . . . 49ziprasidone mesylate for inj . . 49ZITHROMAX . . . . . . . . . . . . . . 31ZOCOR . . . . . . . . . . . . . . . . . . . 12ZOFRAN . . . . . . . . . . . . . . . . . . 28ZOFRAN ODT . . . . . . . . . . . . . 28ZOLADEX . . . . . . . . . . . . . . . . . 6ZOLINZA . . . . . . . . . . . . . . . . . . 4zolpidem . . . . . . . . . . . . . . . . . 48zolpidem sl . . . . . . . . . . . . . . . . 48ZONALON . . . . . . . . . . . . . . . . 20ZONEGRAN . . . . . . . . . . . . . . 19zonisamide . . . . . . . . . . . . . . . 19ZOSTAVAX . . . . . . . . . . . . . . . . 58zoster vaccine live . . . . . . . . . . 58zoster vaccine recombinant

adjuvanted . . . . . . . . . . . . . 58ZOVIA 1/35 . . . . . . . . . . . . . . . 40ZOVIA 1/50 . . . . . . . . . . . . . . . 40ZOVIRAX . . . . . . . . . . . . . . . . . 33ZYBAN . . . . . . . . . . . . . . . . . . . 49ZYDELIG . . . . . . . . . . . . . . . . . . 5

ZYKADIA . . . . . . . . . . . . . . . . . . 4ZYLOPRIM . . . . . . . . . . . . . . . . 37ZYPREXA . . . . . . . . . . . . . . . . 49ZYPREXA INJ . . . . . . . . . . . . . 49ZYPREXA RELPREVV . . . . . . 49ZYRTEC . . . . . . . . . . . . . . .23, 59ZYRTEC CHEWABLE

TABLET . . . . . . . . . . . . . . . 23ZYRTEC D . . . . . . . . . . . . . . . . 59ZYRTEC-D . . . . . . . . . . . . . . . . 23ZYTIGA . . . . . . . . . . . . . . . . . . . 6ZYVOX . . . . . . . . . . . . . . . . . . . 35

83

“My Medications” worksheetTake this worksheet with you each time you visit a doctor . Each of your doctors should be aware of every drug you take and you should have a list as well .

Name of 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

preferred drug list (pdl) · 2020-04-02 · • agents used for cosmetic hair growth • drugs from...

Documents