state of michigan commercial formulary...state of michigan commercial formulary oct 2016 table of...

STATE OF MICHIGAN COMMERCIAL FORMULARY OCT 2016

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Foreword This document represents the efforts of the MedImpact Healthcare Systems Pharmacy and Therapeutics (P & T) and Formulary Committees to provide physicians and pharmacists with a method to evaluate the safety, efficacy and cost-effectiveness of commercially available drug products. A structured approach to the drug selection process is essential in ensuring continuing patient access to rational drug therapies. The ultimate goal of the Formulary is to provide a process and framework to support the dynamic evolution of this document to guide prescribing decisions that reflect the most current clinical consensus associated with drug therapy decisions. This is accomplished through the auspices of the MedImpact P & T and Formulary Committees. These committees meet quarterly and more often as warranted to ensure clinical relevancy of the Formulary. To accommodate changes to this document, updates are made accessable as necessary. Search for a specific drug by visiting https://mp.medimpact.com/som As you use this Formulary, you are encouraged to review the information and provide your input and comments to the MedImpact P & T and Formulary Committees. The MedImpact P & T and Formulary Committees use the following criteria in the evaluation of drug selection for the Formulary:

• Drug safety profile • Drug efficacy • Comparison of relevant therapeutic benefits to current formulary agents of

similar use, and to minimize therapeutic duplication where possible • Cost-effectiveness relative to comparable therapies

How to Use the Formulary The Formulary is a list of medications available to MedImpact members under their pharmacy benefit. All drugs are listed by their generic names and most common proprietary (branded) name. The Formulary may be accessed by using the index, either by generic or proprietary name (in capital letters) and by therapeutic drug category. In situations where an FDA approved generic equivalent is available, brand names are listed for reference purposes only, and do not denote coverage for the brand, unless specifically noted. Any drug not found in this Formulary listing, or any Formulary updates published by MedImpact shall be considered a Non-Formulary drug. All drugs are listed in each category in alphabetical order by generic name. Where an FDA approved generic is available for the listed generic name, the generic name is bolded. For certain agents within the Formulary, a recommended prescribing guideline may apply. These are denoted throughout the document using the following symbols: AGE Age Edit Coverage may depend on patient age CU Concurrent Use

Edit Coverage or lack thereof may depend upon concurrent use of another drug

G Gender Edit Coverage may depend on patient gender MD Physician

Specialty Edit Coverage may depend on prescribing physician’s specialty or board certification

PA Prior Authorization

Requires specific physician request process

QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period

SCC Split Cycle Co-Pay

Products are available for 15 day supply charging the member ½ of the typical co-pay

ST Step Therapy Coverage may depend on previous use of another drug

Please refer to the prescribing guideline appendix within this document for details regarding specific agents. Benefit Coverage and Limitations This printed Formulary does not provide information regarding the specific coverage and limitations an individual member may be subject to. Many members have specific benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in the Formulary. The Formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact their Plan Sponsor or MedImpact at (800) 788-2949. Depending upon a member’s specific benefit parameters, the following topics may apply:

1. Generic Substitution

When available, FDA approved generic drugs are to be used in all situations, regardless of the brand name indicated. The generic names are bolded in the formulary listing wherever an FDA approved generic drug product is available. Greater economy is realized through the use of generic equivalents. This policy is not meant to preclude or supplant any state statutes that may exist. All drugs that are or become available generically are subject to review by MedImpact’s Pharmacy and Therapeutics Committee. MedImpact approves such multi-source drugs for addition to the MAC list based on the following criteria:

• A multi-source drug product manufactured by at least one (1) nationally marketed company.

• At least one (1) of the generic manufacturer’s products must have an “A” rating or the generic product has been determined to be unassociated with efficacy, safety or bioequivalency concerns by the MedImpact P & T Committee.

• Drug product will be approved for generic substitution by the MedImpact P & T Committee.

This list is reviewed and updated periodically based on the clinical literature and pharmacokinetic characteristics of currently available versions of these drug products. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic. If a physician determines that there is a documented medical need for the brand equivalent, a request for coverage may be made using the medication request process.

2. Three Tier Benefit The Formulary may be applied to a three tier benefit design, where the member shares the cost of prescription drug therapy at three levels of copayment. In most instances, generically available drugs will be covered under the first or lowest copay tier, branded drugs listed on the Formulary will be covered under the second copay tier, and branded drugs not on the Formulary will be covered under the third or highest copay tier.

3. Medication Request Process Depending upon plan benefit design, a medication request process may apply as follows:

A. Formulary Agents Drugs that are listed in the Formulary with associated Prior Authorization (PA) require evaluation, per MedImpact P & T Committee Prior Authorization guidelines prior to dispensing at a network pharmacy. Each request will be reviewed on an individual patient need basis. If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy may be recommended.

B. Non-Formulary Agents Any drug not found in the Formulary listing, or any Formulary updates published by MedImpact, shall be considered a Non-Formulary drug. Coverage for non-formulary agents may be applied for in advance. When a member gives a prescription order for a non-formulary drug to a pharmacist, the pharmacist will evaluate the patient’s drug history and contact the physician to determine if there is a reasonable medical need for a non-formulary drug. Each request will be reviewed on an individual patient need basis. Approval will be given if a documented medical need exists. The following basic guidelines are used:

• The use of Formulary Drugs is contraindicated in the patient. • The patient has failed an appropriate trial of Formulary or related

agents. • The choices available in the Formulary are not suited for the

present patient care need, and the drug selected is required for patient safety.

• The use of a Formulary drug may provoke an underlying condition, which would be detrimental to patient care.

If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy may be recommended.

C. Obtaining Coverage Coverage, questions or information regarding the medication request or formulary process may be obtained by:

1. Faxing a completed Medication Request Form to MedImpact at (858) 790-7100.

2. Contacting MedImpact at (800) 788-2949 and providing all necessary information requested.

MedImpact will provide an authorization number, specific for the medical need, for all approved requests. Non-approved requests may be appealed. The prescriber must provide information to support the appeal on the basis of medical necessity. Prior Authorization is

https://mp.medimpact.com/som


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804PA, oct 2016 i

generally not available for drugs that are specifically excluded by benefit design.

4. General Exclusions A. Over the Counter (OTC) medications or their equivalents, unless

otherwise specified in the Formulary listing. B. Nicotine Smoking Cessation products (i.e., transdermal nicotine,

nicotine gum, nicotine inhaler). C. Drugs specifically listed as not covered. D. Any drug products used for cosmetic purposes. E. Experimental drug products or any drug product used in an

experimental manner. F. Replacement of lost or stolen medication. G. Non self-administered injectable drug products unless otherwise

specified in the Formulary listing. H. Foreign sourced drugs or drugs not approved by the United States

Food & Drug Administration.

The P & T and Formulary Committees recognize that not all medical needs can be met with this document and encourage inquiries about alternative therapies.

5. Pharmacist and Physician Communication The Formulary is a tool to promote cost-effective prescription drug use. The P & T and Formulary Committees have made every attempt to create a document that meets all therapeutic needs; however, the art of medicine makes this a formidable task. MedImpact welcomes the participation of physicians, pharmacists, and ancillary medical providers, in this dynamic process. Physicians and pharmacists are highly encouraged to direct any suggestions, comments or formulary additions to MedImpact at the following address:

Chairperson, Pharmacy & Therapeutics Committee MedImpact Healthcare Systems, Inc. 10181 Scripps Gateway Court San Diego, CA 92131

Medication Request Form (MRF)

MedImpact Healthcare Systems, Inc.

DO NOT WRITE IN BLOCKED AREAS

FOR INTERNAL USE ONLY

Attn: Prior Authorization Department

DO NOT WRITE IN BLOCKED AREAS

FOR INTERNAL USE ONLY

Contacted: 10680 Treena Street, Ste 500

Approved:

Physician: San Diego, CA 92131 Denied: Pharmacy: Phone: 1-800-788-2949 Returned: Patient: Fax: 858-790-7100 PA #:

Instructions: This form is to be used by participating physicians and providers to obtain coverage for a non-formulary drug for which there is no suitable alternative available. Please complete this form and fax to MedImpact Healthcare Systems, Inc. at (858) 790-7100 or please call (800) 788-2949 with this information. If you have any questions regarding this process, please contact MedImpact’s Customer Service at (800) 788-2949.

Review Criteria: The following guidelines are used in reviewing medication requests: 1. The use of Formulary Drug Products is contraindicated in the patient. 2. The patient has failed an appropriate trial of Formulary or related agents. 3. The choices available in the Formulary are not suited for the present patient

care need and the drug selected is required for patient safety. 4. The use of a Formulary Drug Product may provoke an underlying medical

condition, which would be detrimental to patient care.

Medication Request Information (please complete each section of this form

prior to transmittal):

Patient Name (required):

Patient’s Health Plan (required):

Patient ID # (required):

Physician Name/Specialty:

Physician ID#/DEA#:

Patient DOB (required):

Physician Area Code and Telephone Number: ( ) -

Diagnosis (required):

Physician Area Code and Fax Number (required): ( ) -

Pharmacy used by Member:

Pharmacy Area Code and Telephone Number: ( ) -

Drug Requested:

Quantity (per month):

Dose:

Length of Treatment (please be specific):

Strength:

Dosage Form (e.g., Oral, Injection):

Reason for Medication Request (please be specific, give detail): Other Medications Tried and/or Failed (please be specific, give detail including reason for failure): Other Pertinent History (relative or pertaining to this request):


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Foreword .............................................................................................................. 1. Generic Substitution .......................................................................... 2. Three Tier Benefit .............................................................................. 3. Medication Request Process ............................................................ 4. General Exclusions .......................................................................... i 5. Pharmacist and Physician Communication ..................................... i

ALLERGY ................................................................................................................. 5 Allergenic extracts .............................................................................................. 5 2nd Gen Antihistamine & Decongestant Combinations .................................... 5 Antihistamines - 1st Generation ......................................................................... 5 Antihistamines - 2nd Generation ....................................................................... 5 Nasal Anti-Inflammatory Steroids ...................................................................... 5 Nasal Antihistamine ........................................................................................... 5

ANTIEMESIS/ANTIVERTIGO .................................................................................. 5 Antiemetic/Antivertigo Agents ............................................................................ 5

ASTHMA ................................................................................................................... 5 Beta-Adrenergic Agents ..................................................................................... 5 Beta-Adrenergic & Anticholinergic Combinations .............................................. 5 Beta-Adrenergic & Glucocorticoid Combinations .............................................. 5 General Bronchodilator Agents .......................................................................... 5 Leukotriene Receptor Antagonists ..................................................................... 5 Mast Cell Stabilizers........................................................................................... 5 Phosphodiesterase-4 (PD-4) Inhibitors.............................................................. 5 Monoclonal Antibodies To Immunoglobulin E(ige) ............................................ 5 Oral Inhaled Corticosteroids .............................................................................. 5 Xanthines ........................................................................................................... 5

AUTONOMIC NERVOUS SYSTEM DISORDERS .................................................. 5 Alzheimer's Therapy, Nmda Receptor Antagonists ........................................... 5 Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines Inhibitors ........ 5 Cholinesterase Inhibitors ................................................................................... 5

BEHAVIORAL HEALTH - ANTIDEPRESSANTS .................................................... 5 Alpha-2 Receptor Antagonist Antidepressants .................................................. 5 Maois - Non-Selective & Irreversible ................................................................. 5 Norepinephrine & Dopamine Reuptake Inhib (ndris) ......................................... 5 Selective Serotonin Reuptake Inhibitors (SSRIs) .............................................. 5 SSRI & Antipsychotic,ATYP,(DA & Serotonin) Comb. ...................................... 5 Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) ........................................ 6 Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) .......................................... 6 Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib .......................................... 6

BEHAVIORAL HEALTH - OTHER ........................................................................... 6 Adrenergics, Aromatic, Non-Catecholamine ..................................................... 6 Anti-Alcoholic Preparations ................................................................................ 6 Anti-Anxiety Drugs ............................................................................................. 6 Anti-Mania Drugs ............................................................................................... 6 Anti-Psychotics, Phenothiazines ........................................................................ 6 Antipsychotics, Atyp, D2 Partial Agonist/5HT Mixed ......................................... 6 Antipsychotics, Dopamine & Serotonin Antagonists ......................................... 6 Antipsychotics, Atypical, Dopamine,& Serotonin Antag .................................... 6 Antipsychotics, Dopamine Antagonists, Thioxanthenes .................................... 6 Antipsychotics, Dopamine Antagonists, Butyrophenones ................................. 6 Barbiturates ........................................................................................................ 6 Narcotic Antagonists .......................................................................................... 6 Sedative-Hypnotics, Non-Barbiturate ................................................................ 6 Tx For Attention Deficit-Hyperact (ADHD)/Narcolepsy ...................................... 6 Tx For Attention Deficit-Hyperact.(ADHD), NRI-Type ....................................... 6

CARDIOVASCULAR DISEASE - ARRHYTHMIA .................................................... 6 Antiarrhythmics .................................................................................................. 6

CARDIOVASCULAR DISEASE - CARDIAC STIMULANT ...................................... 6 Digitalis Glycosides ............................................................................................ 6

CARDIOVASCULAR DISEASE - HYPERTENSION ............................................... 6 Ace Inhibitor/Calcium Channel Blocker Combination ........................................ 6 Ace Inhibitor/Thiazide & Thiazide-Like Diuretic ................................................. 6 Alpha-Adrenergic Blocking Agents .................................................................... 7 Alpha/Beta-Adrenergic Blocking Agents ............................................................ 7 Angioten. Receptr Antag./Cal. Chanl Blkr/Thiazide Comb ................................ 7 Angiotensin Receptor Antag./Thiazide Diuretic Comb ...................................... 7 Angiotensin Receptor Antgnst & Calc. Channel Blockr ..................................... 7 Antihypertensives, ACE Inhibitors ..................................................................... 7 Antihypertensives, Angiotensin Receptor Antagonist ........................................ 7 Antihypertensives, Sympatholytic ...................................................................... 7 Antihypertensives, Vasodilators ......................................................................... 7 Beta-Adrenergic Blocking Agents ...................................................................... 7 Beta-Adrenergic Blocking Agents/Thiazide & Related ...................................... 7 Calcium Channel Blocking Agents ..................................................................... 7 Loop Diuretics .................................................................................................... 7 Potassium Sparing Diuretics .............................................................................. 7 Potassium Sparing Diuretics In Combination .................................................... 7 Pulm. Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhib .............................. 7 Pulmonary Anti-HTN, Endothelin Receptor Antagonist ..................................... 7 Pulmonary Anti-HTN, Prostacyclin-Type ........................................................... 7 Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators ......................... 7 Thiazide & Related Diuretics.............................................................................. 7

CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ....................................... 7 Antihyperlipidemic – Apo-B 100 synthesis Inhibitor .......................................... 7

Antihyperlipidemic - HMG CoA Reductase Inhibitors ........................................ 7 Antihyperlipidemic-HMG CoA Reductase Inhib. & Niacin ................................. 8 Antihyperlipidemic- MTP Inhibitor ...................................................................... 8 Antihyperlipidemic –PCSK9 Inhibitors ............................................................... 8 Bile Salt Sequestrants........................................................................................ 8 Lipotropics .......................................................................................................... 8 Niacin Preparations ............................................................................................ 8

CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ............................. 8 Adrenergic Vasopressor Agents ........................................................................ 8 Antianginal & Anti-Ischemic Agents, Non-Hemodynamic ................................. 8 Antihyperlip - HMG-CoA & Calcium Channel Blocker Comb ............................ 8

Heart Rate Reducing, Selective I(F) Current Inhib. ................................................. 8 CARDIOVASCULAR DISEASE - VASODILATION ................................................. 8 Vasodilators, Combination ....................................................................................... 8

Vasodilators, Coronary ...................................................................................... 8 CONTRACEPTION/OXYTOCICS ............................................................................ 8

Contraceptives, Injectable ................................................................................. 8 Contraceptives, Oral .......................................................................................... 8 Contraceptives, Transdermal ............................................................................. 8 Oxytocics ............................................................................................................ 8

COUGH AND COLD ................................................................................................ 8 1st Gen Antihistamine & Decongestant Combinations ..................................... 8 Narcotic Antituss-1st Gen. Antihistamine-Decongest ....................................... 8 Narcotic Antituss-Decongestant-Expectorant Comb ......................................... 8 Narcotic Antitussive-1st Generation Antihistamine ........................................... 8 Narcotic Antitussive-Anticholinergic Comb. ....................................................... 8 Narcotic Antitussive-Expectorant Combination ................................................. 8 Non-Narcotic Antitussive-1st Gen Antihistamine Combination ......................... 8 Non-Narcotic Antitussive & Expectorant Comb. ................................................ 8

DERMATOLOGY - ACNE ........................................................................................ 8 Acne Agents, Systemic ...................................................................................... 8 Acne Agents, Topical ......................................................................................... 9 Keratolytic-Glucocorticoid Combinations ........................................................... 9 Keratolytics......................................................................................................... 9 Rosacea Agents, Topical ................................................................................... 9 Topical Preparations, Antibacterials .................................................................. 9 Vitamin A Derivatives ......................................................................................... 9

DERMATOLOGY - ANTIINFECTIVE ....................................................................... 9 Topical Antibiotics .............................................................................................. 9 Topical Antifungals ............................................................................................. 9 Topical Antiparasitics ......................................................................................... 9 Topical Antivirals ................................................................................................ 9 Topical Sulfonamides......................................................................................... 9

DERMATOLOGY - ANTIINFLAMMATORY ............................................................. 9 Topical Anti-Inflammatory Steroidal ................................................................... 9 Topical Anti-Inflammatory, NSAIDs ................................................................... 9 Topical Antibiotics/Antiinflammatory,Steroidal .................................................. 9

DERMATOLOGY - MISCELLANEOUS ................................................................... 9 Antiperspirants ................................................................................................... 9 Antiseborrheic Agents ........................................................................................ 9 Topical Antineoplastic & Premalignant Lesion Agnts ........................................ 9 Topical Local Anesthetics .................................................................................. 9

DERMATOLOGY - PIGMENTATION DISORDERS ................................................ 9 Topical Hyperpigmentation Agents .................................................................... 9

DERMATOLOGY - PSORIASIS/ECZEMA .............................................................. 9 Antipsoriatic Agents, Systemic .......................................................................... 9 Antipsoriatics Agents ....................................................................................... 10 Topical Immunosuppressive Agents ................................................................ 10

DIABETES .............................................................................................................. 10 Antihyperglycemic, Alpha-Glucosidase Inhib (Non-Sulfonylurea) ................... 10 Antihyperglycemic, Amylin Analog-Type ......................................................... 10 Antihyperglycemic, DPP-4 Inhibitors ............................................................... 10 Antihyperglycemic DPP-4 Inhibitor & Biguanide Combination ........................ 10 Antihyperglycemic DPP-4 Inhibitor & Statin Combination ............................... 10 Antihyperglycemic,Glucocorticoid Receptor Antagonist .................................. 10 Antihyperglycemic, Incretin Mimetic (GLP-1 Recep. Agonist) ......................... 10 Antihyperglycemic, Insulin-Release Stimulant Type ....................................... 10 Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea) ............. 10 Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) ................................. 10 Antihyperglycemic, Insulin-Rel Stim.& Biguanide Comb ................................. 10 Antihyperglycemic, Insulin-Response & Release Comb. ................................ 10 Antihyperglycemic Insul-Resp. Enhancer & Biguanide Comb ........................ 10 Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor ........... 10 Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Biguanide Combination .................................................................................... 10 Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination .......................... 10 Diabetic Supplies ............................................................................................. 10 Diabetic Ulcer Preparations, Topical ............................................................... 10 Hyperglycemics ................................................................................................ 10 Insulins ............................................................................................................. 10 Syringes & Accessories ................................................................................... 10

EAR - GENERAL DISORDERS ............................................................................. 10 Ear Preparations, Misc. Anti-Infectives ............................................................ 10 Ear Preparations, Antibiotics ........................................................................... 10


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Otic Preparations, Anti-Inflammatory-Antibiotics ............................................. 10 Otic Preparations, Local anesthetics ............................................................... 10

ELECTROLYTE REGULATION ............................................................................. 11 Electrolyte Depleters ........................................................................................ 11 Potassium Replacement .................................................................................. 11

ENDOCRINE DISORDER - FERTILITY ................................................................ 11 Drugs to Treat Impotency ................................................................................ 11 Fertility Stimulating Preparations, Non-FSH .................................................... 11 Follicle Stim./Luteinizing Hormones ................................................................. 11 Pregnancy Facilitating/Maintaining Agent, Hormonal ...................................... 11

ENDOCRINE DISORDER - OTHER ...................................................................... 11 Antidiuretic & Vasopressor Hormones ............................................................. 11 Antineoplastic LHRH (GNRH) agonist, Pituitary Suppressant ........................ 11 Bone Formation Stim. Agents - Parathyroid Hormone .................................... 11 Bone Resorption Inhibitor & Calcium Combinations ....................................... 11 Bone Resorption Inhibitor & Vitamin D Combinations ..................................... 11 Bone Resorption Inhibitors ............................................................................... 11 Growth Hormone Receptor Antagonists .......................................................... 11 Growth Hormones ............................................................................................ 11 Hyperparathyroid Tx Agents, Vitamin D Analog-Type ..................................... 11 LHRH (GnRH) Antagonist, Pituitary Suppressant Agents ............................... 11 Luteinizing Hormone Releasing Hormone –LHRH (GnRH) ............................ 11 Pituitary Suppressive Agents ........................................................................... 11

ENDOCRINE DISORDER - THYROID .................................................................. 11 Antithyroid Preparations ................................................................................... 11 Iodine Containing Agents ................................................................................. 11 Thyroid Hormones............................................................................................ 11

EYE - GENERAL DISORDERS ............................................................................. 11 Eye Antibiotic-Corticoid Combinations............................................................. 11 Eye Antihistamines........................................................................................... 11 Eye Antiinflammatory Agents ........................................................................... 11 Eye Antivirals ................................................................................................... 11 Eye Sulfonamides ............................................................................................ 11 Ophthalmic Anti-Inflammatory Immunomodulator-Type .................................. 12 Ophthalmic Antibiotics ..................................................................................... 12 Ophthalmic Mast Cell Stabilizers ..................................................................... 12

EYE - GLAUCOMA ................................................................................................ 12 Carbonic Anhydrase Inhibitors ......................................................................... 12 Miotics/Other Intraoc. Pressure Reducers ....................................................... 12 Mydriatics ......................................................................................................... 12

GOUT AND RELATED DISEASES ....................................................................... 12 Colchicine ......................................................................................................... 12 Hyperuricemia Tx - Purine Inhibitors ............................................................... 12 Uricosuric Agents ............................................................................................. 12

HEMATOLOGICAL DISORDERS .......................................................................... 12 Anticoagulants, Coumarin Type ....................................................................... 12 Direct Factor XA Inhibitors ............................................................................... 12 Hematinics, Other ............................................................................................ 12 Hemorrheologic Agents ................................................................................... 12 Heparin & Related Preparations ...................................................................... 12 Leukocyte (WBC) Stimulants ........................................................................... 12 Platelet Aggregation Inhibitors ......................................................................... 12 Platelet Reducing Agents ................................................................................. 12 Thrombopoietin Receptor Agonists ................................................................. 12 Vitamin K Preparations .................................................................................... 12

HORMONAL DEFICIENCY .................................................................................... 12 Androgenic Agents ........................................................................................... 12 Estrogen/Androgen Combinations ................................................................... 12 Estrogenic Agents ............................................................................................ 12 Progestational Agents ...................................................................................... 13

IMMUNOSUPPRESSION/MODULATION ............................................................. 13 Immunomodulators .......................................................................................... 13 Immunosuppressives ....................................................................................... 13

INFECTIOUS DISEASE - BACTERIAL ................................................................. 13 Absorbable Sulfonamides ................................................................................ 13 Beta lactams, inhaled ....................................................................................... 13 Cephalosporins - 1st Generation ..................................................................... 13 Cephalosporins - 2nd Generation .................................................................... 13 Cephalosporins - 3rd Generation ..................................................................... 13 Chemotherapeutics, Antibacterial, Misc. ......................................................... 13 Ketolides........................................................................................................... 13 Macrolides ........................................................................................................ 13 Nitrofuran Derivatives ...................................................................................... 13 Oxazolidinones ................................................................................................. 13 Penicillins ......................................................................................................... 13 Quinolones ....................................................................................................... 13 Tetracyclines .................................................................................................... 13

INFECTIOUS DISEASE - FUNGAL ....................................................................... 13 Antifungal Agents ............................................................................................. 13 Antifungal Antibiotics ........................................................................................ 13

INFECTIOUS DISEASE - MISCELLANEOUS ....................................................... 13 Rifamycin and Related Derivative Antibiotics ........................................................ 13

Aminoglycosides .............................................................................................. 13 Anti-Mycobacterium Agents ............................................................................. 13

Antileprotics...................................................................................................... 14 Antitubercular Antibiotics ................................................................................. 14 Vancomycin & Derivatives ............................................................................... 14

INFECTIOUS DISEASE - PARASITIC .................................................................. 14 Amebacides ..................................................................................................... 14 Anaerobic Antiprotozoal-Antibacterial Agents ................................................. 14 Anthelmintics .................................................................................................... 14 Antimalarial Drugs ............................................................................................ 14 Antiprotozoal Drugs, Miscellaneous ................................................................ 14

INFECTIOUS DISEASE - VIRAL ........................................................................... 14 All oral, non-experimental antiviral agents used for the treatment of AIDS or HIV-related diseases are considered a formulary benefit. ............................................ 14

Antivirals, General ............................................................................................ 14 Antivirals, HIV-Spec, Non-Peptidic Protease Inhib .......................................... 14 Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog ...................................... 14 Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb ..................................... 14 Antivirals, HIV-Specific, CCR5 Co-Receptor Antag. ....................................... 14 Antivirals, HIV-Specific, Fusion Inhibitors ........................................................ 14 Antivirals, HIV-Specific, Non-Nucleoside, RTI ................................................. 14 Antivirals, HIV-Specific, Nucleoside Analog, RTI ............................................ 14 Antivirals, HIV-Specific, Nucleotide Analog, RTI ............................................. 14 Antivirals, HIV-Specific, Protease Inhibitor Comb ........................................... 14 Antivirals, HIV-Specific, Protease Inhibitors .................................................... 14 Antivirals, HIV-1 Integrase Strand Transfer Inhibtr.......................................... 14 Antiviral Comb Nucleoside, Nucleotide & Non-Nucleoside RTI ...................... 14 Cytochrome P450 Inhibitors ............................................................................ 14 ARV CMB-NRTI, N(T)RTI, Integrase Inhibitor ................................................. 14 Hepatitis B Treatment Agents .......................................................................... 14 Hepatitis C Combination Agents ...................................................................... 14 Hepatitis C Treatment Agents .......................................................................... 14

INFLAMMATORY DISEASE .................................................................................. 14 Anti-Arthritic & Chelating Agents ..................................................................... 14 Anti-Arthritic, Folate Antagonist Agents ........................................................... 14 Anti-Inflammatory,Tumor Necrosis Factor Inhibitor ......................................... 14 Anti-Inflammatory, Bradykinin B2 receptor antagonists .................................. 14 Anti-Inflammatory, Pyrimidine Synthesis Inhibitor ........................................... 14 Glucocorticoids ................................................................................................ 15 Mineralocorticoids ............................................................................................ 15 Monoclonal antibody-human interleukin .......................................................... 15 NSAIDs, Cyclooxygenase Inhibitor-Type ........................................................ 15

LOCAL ANESTHESIA ............................................................................................ 15 Local Anesthetics ............................................................................................. 15

LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT ................ 15 Bowel Antiinflamatory Agents .......................................................................... 15 Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ......................................... 15 Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat ...................................... 15 Irritable Bowel Agents, Guanylate Cyclase-C Agonist .................................... 15 Hemorrhoidal Preparations .............................................................................. 15 Rectal Preparations ......................................................................................... 15 Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) ..................................... 15

LOWER GASTROINTESTINAL DISORDERS - OTHER ...................................... 15 Ammonia Inhibitors .......................................................................................... 15 Antidiarrheals ................................................................................................... 15 Bile Salts .......................................................................................................... 15 Glucagon-like Peptide-2 (GLP-2) Analogs ...................................................... 15 Laxatives & Cathartics ..................................................................................... 15 Narcotic Antagonists, Peripherally-Acting ....................................................... 15

MISCELLANEOUS AGENTS ................................................................................. 15 Anaphylaxis Therapy Agents ........................................................................... 15 Parasympathetic Agents .................................................................................. 15 Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase ................................... 15

NEOPLASTIC DISEASE ........................................................................................ 15 Alkylating Agents ............................................................................................. 15 Antiandrogenic Agents ..................................................................................... 15 Antimetabolites ................................................................................................ 15 Antineoplastic Aromatase Inhibitors ................................................................ 16 Antineoplastic -B Cell Lymphoma-2(bcl-2) Inhibitors ...................................... 16 Antineoplastic, Hedgehog Pathway Inhibitor ................................................... 16 Antineoplastic, Janus Kinase (JAK) Inhibitors ................................................. 16 Antineoplastic - MEK1 and MEK2 Kinase Inhibitors ....................................... 16 Antineoplastic - Topoisomerase I Inhibitors..................................................... 16 Antineoplastic Immunomodulator Agents ........................................................ 16 Antineoplastic Systemic Enzyme Inhibitors ..................................................... 16 Antineoplastic, Histone Deacetylase Inhibitors, HDIS ..................................... 16 Antineoplastics, Miscellaneous ........................................................................ 16 Chemotherapy Rescue/Antidote Agents ......................................................... 16 Selective Estrogen Receptor Modulators (SERM) .......................................... 16 Selective Retinoid X Receptor Agonists (RXR) ............................................... 16 Steroid Antineoplastics .................................................................................... 16

NEUROLOGICAL DISEASE - MISCELLANEOUS ................................................ 16 Agents To Treat Multiple Sclerosis .................................................................. 16 Fibromyalgia Agents, Serotonin-Norepineph RU Inhib ................................... 16

Movement Disorders (Drug Therapy) .................................................................... 16 ORAL/PHARYNGEAL DISORDERS ..................................................................... 16


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Dental Aids & Preparations .............................................................................. 16 Nose Preparations, Antibiotics ......................................................................... 16 Nose Preparations, Miscellaneous (Rx) .......................................................... 16

OTHER DRUGS ..................................................................................................... 16 Appetite Stim. For Anorexia, Cachexia, Wasting Synd. .................................. 16 Metabolic disease enzyme replace, hypophosphatasia .................................. 17 Needles/Needleless Devices ........................................................................... 17 Nucleic Acid/Nucleotide Supplements ............................................................. 17

Antifibrotic Therapy – Pyridone Analogs ................................................................ 17 Cystic Fibrosis-Cftr Potentiator & Corrector Comb. ......................................... 17 Mucolytics......................................................................................................... 17 Pulmonary Fibrosis – Systemic Enzyme Inhibitors.......................................... 17

PAIN MANAGEMENT - ANALGESICS .................................................................. 17 Analgesic, Non-Salicylate & Barbiturate Comb. .............................................. 17 Analgesic, Salicylate, Barbiturate & Xanthine Comb ....................................... 17 Analgesic, Non-Salicylate, Barbiturate & Xanthine Comb ............................... 17 Analgesic/Antipyretics, Salicylates .................................................................. 17 Analgesics, Narcotics ....................................................................................... 17 Antimigraine Preparations ................................................................................ 17 Narc. & Non-Sal. Analgesic, Barbiturate & Xanthine Comb ............................ 17 Narcotic & Salicylate Analgesics, Barb. & Xanthine ........................................ 17 Narcotic Analgesic & Non-Salicylate Analgesic Comb .................................... 17

PARKINSONS DISEASE ....................................................................................... 17 Antiparkinsonism Drugs, Anticholinergic ......................................................... 17 Antiparkinsonism Drugs, Other ........................................................................ 17 Decarboxylase Inhibitors .................................................................................. 18

SEIZURE DISORDER ............................................................................................ 18 Anticonvulsants ................................................................................................ 18

SKELETAL MUSCLE DISORDER ......................................................................... 18 Agents To Treat Periodic Paralysis ................................................................. 18 Skeletal Muscle Relaxants ............................................................................... 18

UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ................................ 18 Pancreatic Enzymes ........................................................................................ 18

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ................... 18 Anticholinergics/Antispasmodics ..................................................................... 18 Belladonna Alkaloids ........................................................................................ 18

UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ....................... 18 Anti-Ulcer Preparations .................................................................................... 18 Anti-Ulcer-H.pylori Agents ................................................................................ 18 Anticholinergics, Quaternary Ammonium ........................................................ 18 Histamine H2-Receptor Inhibitors .................................................................... 18 Intestinal Motility Stimulants............................................................................. 18 Proton-Pump Inhibitors .................................................................................... 18

URINARY TRACT - FUNCTIONAL DISORDERS ................................................. 18 Benign Prostatic Hypertrophy/Micturition Agents ............................................ 18 Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag combination agents ............................................................................................................... 18 Kidney Stone Agents ....................................................................................... 18 Overactive Bladder Agents, Beta-3 Adrenergic Recep ................................... 18 Urinary Tract Analgesic Agents ....................................................................... 18 Urinary Tract Anesthetic/Analgesic Agent (Azo-Dye) ...................................... 18 Urinary Tract Antispasmodic, M(3) Selective Antag. ....................................... 18 Urinary Tract Antispasmodic/Antiincontinence Agent ..................................... 18

VAGINAL DISORDERS ......................................................................................... 18 Vaginal Antibiotics ............................................................................................ 18 Vaginal Antifungals .......................................................................................... 18 Vaginal Estrogen Preparations ........................................................................ 18 Vaginal Sulfonamides ...................................................................................... 19

VITAMIN AND/OR MINERAL DEFICIENCY ......................................................... 19 Fluoride Preparations ....................................................................................... 19 Folic Acid Preparations .................................................................................... 19 Multivitamin Preparations ................................................................................. 19 Pediatric Vitamin Preparations ........................................................................ 19 Prenatal Vitamin Preparations ......................................................................... 19 Vitamin B Preparations .................................................................................... 19 Vitamin D Preparations .................................................................................... 19


804PA, oct 2016 5

ALLERGY Allergenic extracts PA 5-grass pollen extract ORALAIR PA short ragweed pollen extract RAGWITEK PA timothy grass pollen extract GRASTEK 2nd Gen Antihistamine & Decongestant Combinations p-ephed hcl/cetirizine hcl

(OTC) ZYRTEC-D (OTC)

p-ephed hcl/fexofenadine hcl

ALLEGRA-D 12 HOUR

p-ephed sul/loratadine CLARITIN-D 12 HOUR CLARITIN-D 24 HOUR

p-ephed hcl/fexofenadine hcl ALLEGRA-D 24 HOUR Antihistamines - 1st Generation chlorpheniramine maleate CHLOR-TRIMETON chlorpheniramine tannate PEDIATAN dexchlorpheniramine

maleate POLARAMINE

hydroxyzine hcl ATARAX hydroxyzine pamoate VISTARIL promethazine hcl PHENERGAN Antihistamines - 2nd Generation cetirizine tablets (OTC) ZYRTEC (OTC) cetirizine solution (OTC) ZYRTEC SOLUTION

(OTC)

fexofenadine hcl tablet ALLEGRA loratadine (OTC) CLARITIN (OTC) levocetirizine dihydrochloride XYZAL Nasal Anti-Inflammatory Steroids QL flunisolide NASAREL QL fluticasone propionate FLONASE QL triamcinolone acetonide NASACORT AQ QL + ST

beclomethasone dipropionate QNASL

QL mometasone furoate NASONEX Nasal Antihistamine QL azelastine hcl ASTELIN

QL azelastine hcl ASTEPRO ANTIEMESIS/ANTIVERTIGO Antiemetic/Antivertigo Agents dronabinol MARINOL meclizine hcl ANTIVERT 12.5MG,

25MG

ondansetron ZOFRAN ODT ondansetron hcl (QL on

solution only) ZOFRAN

prochlorperazine maleate COMPAZINE promethazine hcl PHENERGAN netupitant/palonosetron hcl AKYNZEO aprepitant EMEND meclizine hcl ANTIVERT 50MG prochlorperazine edisylate COMPAZINE SYRUP ASTHMA Beta-Adrenergic Agents albuterol sulfate ALBUTEROL SULFATE metaproterenol sulfate ALUPENT terbutaline sulfate BRETHINE albuterol sulfate PROAIR HFA

PROAIR RESPICLICK VENTOLIN HFA

QL formoterol fumarate PERFOROMIST QL olodaterol hcl STRIVERDI RESPIMAT QL salmeterol xinafoate SEREVENT DISKUS Beta-Adrenergic & Anticholinergic Combinations ipratropium/albuterol sulfate DUONEB

ipratropium/albuterol sulfate COMBIVENT ipratropium/albuterol sulfate COMBIVENT

RESPIMAT

QL tiotropium br/olodaterol hcl STIOLTO RESPIMAT Beta-Adrenergic & Glucocorticoid Combinations QL budesonide/formoterol fumarate SYMBICORT QL fluticasone/salmeterol ADVAIR DISKUS

ADVAIR HFA QL fluticasone/vilanterol BREO ELLIPTA QL mometasone/formoterol DULERA General Bronchodilator Agents ipratropium bromide ATROVENT QL ipratropium bromide ATROVENT HFA QL tiotropium bromide SPIRIVA Leukotriene Receptor Antagonists montelukast sodium SINGULAIR Mast Cell Stabilizers cromolyn sodium INTAL Phosphodiesterase-4 (PD-4) Inhibitors QL roflumilast DALIRESP Monoclonal Antibodies To Immunoglobulin E(ige) Oral Inhaled Corticosteroids QL beclomethasone dipropionate QVAR QL budesonide PULMICORT

RESPULES

QL budesonide PULMICORT FLEXHALER

QL mometasone furoate ASMANEX Xanthines aminophylline AMINOPHYLLIN theophylline anhydrous UNIPHYL theophylline anhydrous THEO-24 AUTONOMIC NERVOUS SYSTEM DISORDERS Alzheimer's Therapy, Nmda Receptor Antagonists memantine hcl

memantine hcl NAMENDA NAMENDA XR

Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines Inhibitors memantine hcl/donepezil hcl NAMZARIC Cholinesterase Inhibitors donepezil hcl ARICEPT, ARICEPT

ODT

galantamine hydrobromide RAZADYNE pyridostigmine bromide MESTINON neostigmine bromide PROSTIGMIN rivastigmine patch EXELON PATCH rivastigmine tartrate EXELON BEHAVIORAL HEALTH - ANTIDEPRESSANTS Alpha-2 Receptor Antagonist Antidepressants mirtazapine REMERON Maois - Non-Selective & Irreversible tranylcypromine sulfate PARNATE phenelzine sulfate NARDIL Norepinephrine & Dopamine Reuptake Inhib (ndris) bupropion hcl WELLBUTRIN

WELLBUTRIN SR WELLBUTRIN XL

Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hydrobromide CELEXA escitalopram oxalate LEXAPRO fluoxetine hcl PROZAC PROZAC WEEKLY fluvoxamine maleate LUVOX paroxetine hcl PAXIL

sertraline hcl ZOLOFT SSRI & Antipsychotic,ATYP,(DA & Serotonin) Comb.


804PA, oct 2016 6

olanzapine/fluoxetine HCl SYMBYAX Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) trazodone hcl DESYREL 300MG Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) venlafaxine hcl EFFEXOR desvenlafaxine succinate PRISTIQ desvenlafaxine DESVENLAFAXINE

ER(RANBAXY)

duloxetine hcl CYMBALTA venlafaxine hcl EFFEXOR XR Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib amitriptyline hcl ELAVIL amoxapine ASENDIN clomipramine hcl ANAFRANIL desipramine hcl NORPRAMIN doxepin hcl SINEQUAN imipramine hcl TOFRANIL maprotiline hcl LUDIOMIL nortriptyline hcl PAMELOR BEHAVIORAL HEALTH - OTHER Adrenergics, Aromatic, Non-Catecholamine amphet asp/amphet/d-

amphet ADDERALL ADDERALL XR

dextroamphetamine sulfate DEXEDRINE dextroamphetamine sulfate ZENZEDI 5mg, 10mg dextroamphetamine sulfate ZENZEDI 2.5mg, 7.5mg lisdexamfetamine dimesylate VYVANSE Anti-Alcoholic Preparations disulfiram ANTABUSE Anti-Anxiety Drugs alprazolam XANAX

ALPRAZOLAM INTENSOL

buspirone hcl BUSPAR VANSPAR

chlordiazepoxide hcl LIBRIUM clorazepate dipotassium TRANXENE T-TAB diazepam VALIUM lorazepam ATIVAN

LORAZEPAM INTENSOL

meprobamate MILTOWN oxazepam SERAX Anti-Mania Drugs lithium carbonate ESKALITH

LITHOBID

lithium citrate CIBALITH-S Anti-Psychotics, Phenothiazines chlorpromazine hcl THORAZINE fluphenazine hcl PROLIXIN perphenazine TRILAFON thioridazine hcl MELLARIL trifluoperazine hcl STELAZINE Antipsychotics, Atyp, D2 Partial Agonist/5HT Mixed aripiprazole ABILIFY aripiprazole ABILIFY DISCMELT Antipsychotics, Dopamine & Serotonin Antagonists loxapine succinate LOXITANE Antipsychotics, Atypical, Dopamine,& Serotonin Antag clozapine CLOZARIL olanzapine ZYPREXA olanzapine ODT ZYPREXA ZYDIS risperidone RISPERDAL risperidone ODT RISPERDAL M-TAB quetiapine fumarate SEROQUEL quetiapine fumarate extended SEROQUEL XR

ziprasidone hcl GEODON Antipsychotics, Dopamine Antagonists, Thioxanthenes thiothixene NAVANE Antipsychotics, Dopamine Antagonists, Butyrophenones haloperidol HALDOL haloperidol lactate HALDOL ORAL CONC. Barbiturates phenobarbital PHENOBARBITAL Narcotic Antagonists naltrexone hcl REVIA QL naloxone hcl NARCAN NASAL Sedative-Hypnotics, Non-Barbiturate chloral hydrate NOCTEC estazolam PROSOM QL eszopiclone LUNESTA flurazepam hcl DALMANE temazepam RESTORIL triazolam HALCION QL zolpidem tartrate AMBIEN QL zaleplon SONATA QL + ST

zolpidem tartrate CR AMBIEN CR

Tx For Attention Deficit-Hyperact (ADHD)/Narcolepsy PA modafinil PROVIGIL dexmethylphenidate hcl FOCALIN ,FOCALIN XR methylphenidate hcl METADATE ER

METADATE CD RITALIN RITALIN-SR RITALIN LA

methylphenidate hcl CONCERTA METHYLIN METHYLIN CHEW TABS

methylphenidate hcl ER suspension

QUILLIVANT XR

Tx For Attention Deficit-Hyperact.(ADHD), NRI-Type atomoxetine hcl STRATTERA CARDIOVASCULAR DISEASE - ARRHYTHMIA Antiarrhythmics amiodarone hcl CORDARONE disopyramide phosphate NORPACE flecainide acetate TAMBOCOR mexiletine hcl MEXITIL procainamide hcl PRONESTYL propafenone hcl RYTHMOL quinidine gluconate QUINAGLUTE quinidine sulfate QUINIDEX disopyramide phosphate NORPACE CR dofetilide TIKOSYN dronedarone hcl MULTAQ propafenone hcl RYTHMOL SR CARDIOVASCULAR DISEASE - CARDIAC STIMULANT Digitalis Glycosides digoxin LANOXIN DIGOXIN ORAL SOLN. CARDIOVASCULAR DISEASE - HYPERTENSION Ace Inhibitor/Calcium Channel Blocker Combination amlodipine

besylate/benazepril LOTREL

Ace Inhibitor/Thiazide & Thiazide-Like Diuretic benazepril/hydrochlorothiaz

ide LOTENSIN HCT

captopril/hydrochlorothiazide

CAPOZIDE

enalapril/hydrochlorothiazid VASERETIC


804PA, oct 2016 7

e fosinopril/hydrochlorothiazi

de MONOPRIL HCT

lisinopril/hydrochlorothiazide

PRINZIDE ZESTORETIC

moexipril/hydrochlorothiazide

UNIRETIC

quinapril/hydrochlorothiazide

ACCURETIC

Alpha-Adrenergic Blocking Agents doxazosin mesylate CARDURA prazosin hcl MINIPRESS terazosin hcl HYTRIN phenoxybenzamine hcl DIBENZYLINE Alpha/Beta-Adrenergic Blocking Agents carvedilol COREG labetalol hcl TRANDATE carvedilol phosphate COREG CR Angioten. Receptr Antag./Cal. Chanl Blkr/Thiazide Comb ST amlodipine/valsartan/hctz EXFORGE HCT ST olmesartan/amlodipin/hcthiazid TRIBENZOR Angiotensin Receptor Antag./Thiazide Diuretic Comb irbesartan/

hydrochlorothiazide AVALIDE

losartan/hydrochlorothiazide

HYZAAR

valsartan/hydrochlorothiazide

DIOVAN HCT

ST olmesartan/hydrochlorothiazide

BENICAR HCT

Angiotensin Receptor Antgnst & Calc. Channel Blockr ST amlodipine/valsartan EXFORGE ST amlodipine bes/olmesartan

med AZOR

Antihypertensives, ACE Inhibitors benazepril hcl LOTENSIN captopril CAPOTEN enalapril maleate VASOTEC fosinopril sodium MONOPRIL lisinopril PRINIVIL

ZESTRIL

moexipril hcl UNIVASC quinapril hcl ACCUPRIL ramipril ALTACE trandolapril MAVIK Antihypertensives, Angiotensin Receptor Antagonist irbesartan AVAPRO losartan potassium COZAAR ST olmesartan medoxomil BENICAR ST valsartan DIOVAN Antihypertensives, Sympatholytic clonidine hcl CATAPRES guanfacine hcl TENEX methyldopa ALDOMET reserpine SERPASIL Antihypertensives, Vasodilators hydralazine hcl APRESOLINE Beta-Adrenergic Blocking Agents acebutolol hcl SECTRAL atenolol TENORMIN bisoprolol fumarate ZEBETA metoprolol succinate TOPROL XL metoprolol tartrate LOPRESSOR nadolol CORGARD pindolol VISKEN propranolol hcl INDERAL LA sotalol hcl BETAPACE

BETAPACE AF timolol maleate BLOCADREN nebivolol hcl BYSTOLIC Beta-Adrenergic Blocking Agents/Thiazide & Related atenolol/chlorthalidone TENORETIC 100

TENORETIC 50

bisoprolol fumarate/hctz ZIAC metoprolol/hctz LOPRESSOR HCT propranolol/hydrochlorothia

zid INDERIDE-40/25

Calcium Channel Blocking Agents amlodipine besylate NORVASC diltiazem hcl CARDIZEM

CARDIZEM CD DILACOR XR TIAZAC

felodipine PLENDIL isradipine IR capsules ISRADIPINE nicardipine hcl IR NICARDIPINE HCL nifedipine ADALAT CC

PROCARDIA PROCARDIA XL

nimodipine NIMOTOP verapamil hcl CALAN SR

VERELAN VERELAN PM

Loop Diuretics bumetanide BUMEX furosemide LASIX torsemide DEMADEX Potassium Sparing Diuretics eplerenone INSPRA spironolactone ALDACTONE Potassium Sparing Diuretics In Combination triamterene/hydrochlorothia

zid DYAZIDE MAXZIDE MAXZIDE-25MG

Pulm. Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhib PA sildenafil citrate REVATIO TABLET PA tadalafil ADCIRCA Pulmonary Anti-HTN, Endothelin Receptor Antagonist PA ambrisentan LETAIRIS PA bosentan TRACLEER PA macitentan OPSUMIT Pulmonary Anti-HTN, Prostacyclin-Type PA selexipag UPTRAVI Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators PA riociguat ADEMPAS Thiazide & Related Diuretics chlorthalidone HYGROTON hydrochlorothiazide MICROZIDE indapamide LOZOL metolazone ZAROXOLYN chlorthalidone THALITONE CARDIOVASCULAR DISEASE - LIPID IRREGULARITY Antihyperlip.Hmg Coa Reduct Inhib&Cholest.Ab.Inhib

QL ezetimibe/simvastatin VYTORIN 10/10mg, 10/20mg, 10/40mg

QL ezetimibe/simvastatin VYTORIN 10/80mg Antihyperlipidemic – Apo-B 100 synthesis Inhibitor PA mipomersen sodium KYNAMRO Antihyperlipidemic - HMG CoA Reductase Inhibitors atorvastatin LIPITOR lovastatin MEVACOR pravastatin sodium PRAVACHOL


804PA, oct 2016 8

simvastatin ZOCOR QL rosuvastatin calcium CRESTOR Antihyperlipidemic-HMG CoA Reductase Inhib. & Niacin QL niacin/simvastatin SIMCOR Antihyperlipidemic- MTP Inhibitor PA+ QL

lomitapide mesylate JUXTAPID

Antihyperlipidemic –PCSK9 Inhibitors PA alirocumab PRALUENT PA evolocumab REPATHA Bile Salt Sequestrants cholestyramine/aspartame QUESTRAN LIGHT cholestyramine/sucrose QUESTRAN colestipol COLESTID COLESTID GRANULES colesevelam hcl WELCHOL

WELCHOL POWDER PACKETS

Lipotropics fenofibrate LOFIBRA TABS

FENOGLIDE

fenofibrate TRIGLIDE fenofibrate, micronized LOFIBRA CAPS gemfibrozil LOPID QL ezetimibe ZETIA fenofibrate nanocrystallized TRICOR QL icosapent ethyl VASCEPA niacin NIASPAN QL omega-3 acid ethyl esters LOVAZA Niacin Preparations niacin SLO-NIACIN CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS Adrenergic Vasopressor Agents midodrine hcl PROAMATINE Angiotensin Recept-Neprilysin Inhibitor Comb(Arni) QL sacubitril/valsartan ENTRESTO Antianginal & Anti-Ischemic Agents, Non-Hemodynamic QL ranolazine RANEXA Antihyperlip - HMG-CoA & Calcium Channel Blocker Comb QL amlodipine/atorvastatin CADUET Heart Rate Reducing, Selective I(F) Current Inhib. PA

+ QL

ivabradine hcl CORLANOR

CARDIOVASCULAR DISEASE - VASODILATION Vasodilators, Combination isosorb dinit/hydralazine hcl BIDIL Vasodilators, Coronary isosorbide dinitrate ISOCHRON

ISORDIL ISORDIL TITRADOSE

isosorbide mononitrate IMDUR ISMO MONOKET

nitroglycerin NITRO-DUR nitroglycerin NITRO-BID

NITROLINGUAL NITROSTAT

CONTRACEPTION/OXYTOCICS QL etonogestrel/ethinyl estradiol NUVARING Contraceptives, Injectable medroxyprogesterone acet DEPO-PROVERA Contraceptives, Oral desog-et estra/ethin estra MIRCETTE desogestrel-ethinyl CYCLESSA

estradiol DESOGEN ORTHO-CEPT

ethinyl estradiol/drospirenone

YASMIN 28 YAZ

ethynodiol d-ethinyl estradiol

DEMULEN 1-50-21

levonorgestrel PLAN B QL

levonorgestrel-eth estra NORDETTE-28 SEASONALE

noreth a-et estra/fe fumarate LOESTRIN FE norethindrone NOR-Q-D

ORTHO MICRONOR

norethindrone a-e estradiol LOESTRIN

norethindrone-ethinyl estrad

NORINYL 1+35 ORTHO-NOVUM TRI-NORINYL

norethindrone-mestranol NORINYL 1+50 norgestimate-ethinyl

estradiol ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO ORTHO-CYCLEN

norgestrel-ethinyl estradiol LO-OVRAL-28 norethindrone-e.estradiol-iron MINASTRIN 24 FE Contraceptives, Transdermal QL norelgestromin/ethin.estradi

ol ORTHO EVRA

Oxytocics methylergonovine maleate METHERGINE COUGH AND COLD 1st Gen Antihistamine & Decongestant Combinations phenylephrine hcl/prometh

hcl PHENERGAN VC

phenylephrine/brompheniramine

BROMFED BROMFED-PD

phenylephrine/chlor-tan RYNATAN RYNATAN PEDIATRIC

phenylephrine/pyril tan/cp NALEX A 12 pseudoephedrine hcl/chlor-

mal DECONAMINE KLERIST-D

Narcotic Antituss-1st Gen. Antihistamine-Decongest p-ephed hcl/cod/chlorphenir NOVAHISTINE DH phenylephrine

hcl/cod/prometh PHENERGAN VC W/CODEINE

phenylephrine/hydrocodone/cp

MAXI-TUSS HCX

Narcotic Antituss-Decongestant-Expectorant Comb p-ephed hcl/codeine/guaifen SUTTAR-2

SUTTAR-SF TUSNEL C

Narcotic Antitussive-1st Generation Antihistamine codeine/promethazine hcl PHENERGAN

W/CODEINE

hydrocodone/chlorphen polis TUSSIONEX Narcotic Antitussive-Anticholinergic Comb. hydrocodone/homatrop me-

br HYCODAN

Narcotic Antitussive-Expectorant Combination guaifenesin/codeine phos MYCI-GC Non-Narcotic Antitussive-1st Gen Antihistamine Combination d-methorphan hb/prometh

hcl PHENERGAN W/DEXTROMETHORPHA

Non-Narcotic Antitussive & Expectorant Comb. guaifenesin/d-methorphan

hb TUSNEL DIABETIC

DERMATOLOGY - ACNE Acne Agents, Systemic isotretinoin ACCUTANE


804PA, oct 2016 9

Acne Agents, Topical clindamycin phos/benzoyl

perox BENZACLIN

sulfacetamide sodium KLARON clindamycin phos/benzoyl

perox ACANYA

clindamycin/benzoyl prx/skn #5

DUAC CS

clindamycin/tretinoin ZIANA Keratolytic-Glucocorticoid Combinations benzoyl

peroxide/hydrocortison VANOXIDE-HC

Keratolytics benz perox/hc/skin clnsr

no.14 VANOXIDE HC

benzoyl peroxide BREVOXYL-4 BREVOXYL-8 TRIAZ

podofilox CONDYLOX benzoyl peroxide shave cream BENZASHAVE benzoyl peroxide gel CLINAC BPO Rosacea Agents, Topical metronidazole METROCREAM

METROLOTION

Topical Preparations, Antibacterials hydrocortisone/iodoquinol VYTONE Vitamin A Derivatives AGE adapalene DIFFERIN AGE tazorotene foam FABIOR DERMATOLOGY - ANTIINFECTIVE Topical Antibiotics clindamycin phosphate CLEOCIN T erythromycin base/benz per BENZAMYCIN erythromycin base/ethanol EMGEL

ERYGEL

gentamicin sulfate GARAMYCIN mupirocin BACTROBAN

CENTANY

clindamycin phosphate EVOCLIN erythromycin base/benz per BENZAMYCIN PAK mupirocin calcium BACTROBAN Topical Antifungals ciclopirox olamine LOPROX ciclopirox 8% solution CICLOPIROX clotrimazole/betamet diprop LOTRISONE ketoconazole KURIC

NIZORAL

nystatin MYCOSTATIN nystatin/triamcin MYCOLOG II naftifine hcl NAFTIN sulconazole nitrate EXELDERM terbinafine hcl LAMISIL Topical Antiparasitics lindane KWELL malathion OVIDE permethrin ELIMITE crotamiton EURAX Topical Antivirals acyclovir ZOVIRAX Topical Sulfonamides silver sulfadiazine SILVADENE

THERMAZENE

DERMATOLOGY - ANTIINFLAMMATORY Topical Anti-Inflammatory Steroidal alclometasone dipropionate ACLOVATE amcinonide CYCLOCORT betamet diprop/prop gly DIPROLENE

DIPROLENE AF betamethasone

dipropionate DEL-BETA DIPROSONE

betamethasone valerate VALISONE clobetasol propionate OLUX

TEMOVATE

clobetasol propionate/emoll TEMOVATE EMOLLIENT

desonide DESOWEN TRIDESILON

desoximetasone TOPICORT TOPICORT LP

diflorasone diacetate APEXICON fluocinolone acetonide SYNALAR fluocinonide LIDEX fluocinonide/emollient LIDEX-E fluticasone propionate CUTIVATE halobetasol propionate ULTRAVATE hydrocortisone LACTICARE-HC

REDERM SCALACORT

hydrocortisone acetate/urea CARMOL HC hydrocortisone butyrate LOCOID hydrocortisone valerate WESTCORT mometasone furoate ELOCON triamcinolone acetonide KENALOG

TRIDERM

clobetasol propionate CLOBEX diflorasone diacetate/emoll APEXICON E fluocinonide VANOS flurandrenolide CORDRAN

CORDRAN SP

hydrocort/sal acid/sulf/shmp#1 SCALACORT DK hydrocortisone FIRST-

HYDROCORTISONE TEXACORT

hydrocortisone butyrate/emoll LOCOID LIPOCREAM hydrocortisone probutate PANDEL Topical Anti-Inflammatory, NSAIDs diclofenac sodium VOLTAREN GEL Topical Antibiotics/Antiinflammatory,Steroidal neomy sulf/polymyx b sulf/hc CORTISPORIN CREAM neomycin/bacitra/polymyxin/h

c CORTISPORIN OINTMENT

DERMATOLOGY - MISCELLANEOUS Antiperspirants aluminum chloride DRYSOL Antiseborrheic Agents selenium sulfide SELSUN RX sulfacetamide sodium OVACE PLUS

SUSPENSION

Topical Antineoplastic & Premalignant Lesion Agnts fluorouracil EFUDEX PA + SCC

bexarotene TARGRETIN

QL ingenol PICATO PA mechlorethamine gel VALCHLOR Topical Local Anesthetics hc acetate/pramoxine hcl PRAMOSONE DERMATOLOGY - PIGMENTATION DISORDERS Topical Hyperpigmentation Agents methoxsalen OXSORALEN DERMATOLOGY - PSORIASIS/ECZEMA Antipsoriatic Agents, Systemic acitretin SORIATANE methoxsalen 8-MOP methoxsalen, rapid OXSORALEN-ULTRA


804PA, oct 2016 10

PA secukinumab COSENTYX Antipsoriatics Agents calcipotriene DOVONEX anthralin DRITHO-SCALP anthralin DRITHOCREME HP calcitriol VECTICAL tazarotene TAZORAC Topical Immunosuppressive Agents tacrolimus PROTOPIC DIABETES Antihyperglycemic, Alpha-Glucosidase Inhib (Non-Sulfonylurea) acarbose PRECOSE Antihyperglycemic, Amylin Analog-Type pramlintide acetate SYMLIN

SYMLINPEN 120 SYMLINPEN 60

Antihyperglycemic, DPP-4 Inhibitors QL linagliptin TRADJENTA QL sitagliptin JANUVIA Antihyperglycemic DPP-4 Inhibitor & Biguanide Combination QL linagliptin/metformin JENTADUETO QL sitagliptin/metformin hcl JANUMET QL sitagliptin/metformin ER JANUMET XR Antihyperglycemic DPP-4 Inhibitor & Statin Combination sitagliptin/simvastatin JUVISYNC Antihyperglycemic,Glucocorticoid Receptor Antagonist PA + QL

mifepristone KORLYM

Antihyperglycemic, Incretin Mimetic (GLP-1 Recep. Agonist) QL dulaglutide TRULICITY

QL liraglutide VICTOZA

Antihyperglycemic, Insulin-Release Stimulant Type chlorpropamide DIABINESE glimepiride AMARYL glipizide GLUCOTROL

GLUCOTROL XL

glipizide/metformin hcl METAGLIP glyburide DIABETA glyburide MICRONASE nateglinide STARLIX repaglinide PRANDIN tolazamide TOLINASE tolbutamide ORINASE Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea) pioglitazone hcl ACTOS Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) metformin hcl GLUCOPHAGE

GLUCOPHAGE XR

metformin hcl RIOMET Antihyperglycemic, Insulin-Rel Stim.& Biguanide Comb glyburide, micro/metformin

hcl GLUCOVANCE

repaglinide/metformin hcl PRANDIMET Antihyperglycemic, Insulin-Response & Release Comb. pioglitazone/glimepiride DUETACT Antihyperglycemic Insul-Resp. Enhancer & Biguanide Comb pioglitazone hcl/metformin

hcl ACTOPLUS MET

pioglitazone hcl/metformin hcl ER

ACTOPLUS MET XR

Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor QL canagliflozin INVOKANA

QL empagliflozin JARDIANCE

Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Biguanide Combination QL canagliflozin/metformin hcl INVOKAMET QL empagliflozin/metformin hcl SYNJARDY Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination QL empagliflozin/linagliptin GLYXAMBI Diabetic Supplies blood-glucose calib. control ALL ABBOTT

CONTROL PRODUCTS (e.g., FREESTYLE, PRECISION) ALL LIFESCAN CONTROL PRODUCTS (e.g., ONETOUCH)

blood-glucose meter ALL ABBOTT METERS(e.g., FREESTYLE, PRECISION) ALL LIFESCAN METERS (e.g., ONETOUCH)

blood sugar diagnostics ALL ABBOTT TEST STRIPS (e.g., FREESTYLE, PRECISION) ALL LIFESCAN TEST STRIPS (e.g., ONETOUCH)

lancing device/lancets ALL ABBOTT AND LIFESCAN (e.g., ONETOUCH) LANCETS

Diabetic Ulcer Preparations, Topical becaplermin REGRANEX Hyperglycemics glucagon,human recombinant GLUCAGEN

GLUCAGON EMERGENCY KIT

Insulins QL hum insulin nph/reg insulin hm HUMULIN 70-30 QL hum insulin nph/reg insulin hm HUMULIN 50-50 QL QL

insulin glargine,hum.rec.anlog LANTUS TOUJEO

QL insulin lispro HUMALOG QL insulin npl/insulin lispro HUMALOG MIX 50-50

HUMALOG MIX 75-25

QL insulin regular, human HUMULIN R QL insulin regular, human HUMULIN R U-500 QL nph, human insulin isophane HUMULIN N Syringes & Accessories syringes & needles ALL COMMERCIALLY

AVAILABLE SYRINGES AND NEEDLES

EAR - GENERAL DISORDERS Ear Preparations, Misc. Anti-Infectives acetic acid VOSOL acetic acid/aluminum

acetate DOMEBORO

acetic acid/hydrocortisone VOSOL HC Ear Preparations, Antibiotics neomy sulf/polymyx b

sulf/hc CORTISPORIN OTIC OTICIN HC

ofloxacin FLOXIN Otic Preparations, Anti-Inflammatory-Antibiotics ciprofloxacin hcl/dexameth CIPRODEX Otic Preparations, Local anesthetics antipyrine/benzocaine otic A/B OTIC


804PA, oct 2016 11

ELECTROLYTE REGULATION Electrolyte Depleters calcium acetate PHOSLO sodium polystyrene

sulfonate KAYEXALATE

sevelamer carbonate RENVELA sevelamer hcl RENAGEL Potassium Replacement pot chloride/pot bicarb/cit

ac K-LYTE-CL

potassium bicarbonate/cit ac

K-LYTE

potassium chloride K-DUR K-TAB MICRO-K

ENDOCRINE DISORDER - FERTILITY Drugs to Treat Impotency QL sildenafil citrate VIAGRA Fertility Stimulating Preparations, Non-FSH clomiphene citrate CLOMID

SEROPHENE

Follicle Stim./Luteinizing Hormones follitropin alpha, recomb GONAL-F

GONAL-F RFF

follitropin beta, recomb FOLLISTIM AQ gonadotropin,chorionic,

human NOVAREL PREGNYL PROFASI

hcg alpha, recombinant OVIDREL menotropins MENOPUR

REPRONEX

urofollitropin (fsh) BRAVELLE FERTINEX

Pregnancy Facilitating/Maintaining Agent, Hormonal progesterone, micronized CRINONE

PROCHIEVE

progesterone, micronized CRINONE ENDOMETRIN PROCHIEVE

ENDOCRINE DISORDER - OTHER Antidiuretic & Vasopressor Hormones desmopressin

(nonrefrigerated) DDAVP

Antineoplastic LHRH (GNRH) agonist, Pituitary Suppressant PA leuprolide ELIGARD Bone Formation Stim. Agents - Parathyroid Hormone QL teriparatide FORTEO Bone Resorption Inhibitor & Calcium Combinations Bone Resorption Inhibitor & Vitamin D Combinations alendronate sodium/vitamin

d3 FOSAMAX PLUS D

Bone Resorption Inhibitors alendronate sodium FOSAMAX etidronate disodium DIDRONEL ibandronate BONIVA QL raloxifene hcl EVISTA Growth Hormone Receptor Antagonists pegvisomant SOMAVERT Growth Hormones PA somatropin NORDITROPIN NORDITROPIN

FLEXPRO NORDITROPIN

NORDIFLEX PA somatropin OMNITROPE

Hyperparathyroid Tx Agents, Vitamin D Analog-Type paricalcitol ZEMPLAR LHRH (GnRH) Antagonist, Pituitary Suppressant Agents cetrorelix acetate CETROTIDE ganirelix acetate GANIRELIX ACETATE Luteinizing Hormone Releasing Hormone –LHRH (GnRH) gonadorelin acetate LUTREPULSE Pituitary Suppressive Agents cabergoline DOSTINEX danazol DANOCRINE ENDOCRINE DISORDER - THYROID Antithyroid Preparations methimazole TAPAZOLE propylthiouracil PROPYLTHIOURACIL Iodine Containing Agents potassium iodide POTASSIUM IODIDE Thyroid Hormones levothyroxine sodium LEVOTHROID

LEVOXYL SYNTHROID

liothyronine sodium CYTOMEL thyroid, pork ARMOUR THYROID thyroid, pork NATURE-THROID EYE - GENERAL DISORDERS Eye Antibiotic-Corticoid Combinations neo/polymyx b

sulf/dexameth MAXITROL

neomy sulf/bacitrac zn/poly/hc

CORTISPORIN OPHTH OINTMENT

neomy sulf/polymyx b sulf/hc

CORTISPORIN OPHTH SUSPENSION

neomycin sulfate/dex na ph NEODECADRON tobramycin

sulfate/dexameth TOBRADEX

neomy sulf/polymyx b sulf/pred

POLY-PRED

tobramycin/lotepred etab ZYLET Eye Antihistamines azelastine hcl OPTIVAR ketotifen fumarate (OTC) ALAWAY OTC olopatadine hcl PATADAY

PATANOL

Eye Antiinflammatory Agents diclofenac sodium VOLTAREN fluorometholone FML flurbiprofen sodium OCUFEN ketorolac tromethamine ACULAR

ACULAR LS

prednisolone acetate OMNIPRED PRED FORTE

prednisolone sod phosphate

PREDNISOL

difluprednate DUREZOL fluorometholone FML FORTE

FML S.O.P.

fluorometholone acetate FLAREX loteprednol etabonate ALREX

LOTEMAX

nepafenac ILEVRO nepafenac NEVANAC prednisolone acetate PRED MILD Eye Antivirals trifluridine VIROPTIC ganciclovir ZIRGAN Eye Sulfonamides na sulfacetm/prednis sp VASOCIDIN sulfacetamide sodium SULFAC


804PA, oct 2016 12

na sulfacetm/prednisol ac BLEPHAMIDE BLEPHAMIDE S.O.P.

Ophthalmic Anti-Inflammatory Immunomodulator-Type cyclosporine RESTASIS Ophthalmic Antibiotics bacitracin AK-TRACIN bacitracin/polymyxin b

sulfate POLYCIN-B

ciprofloxacin hcl CILOXAN erythromycin base ROMYCIN gentamicin sulfate GARAMYCIN neomycin/bacitracin/polymy

xin NEOSPORIN OPHTH OINTMENT

neomycin/polymyxn b/gramicidin

NEOSPORIN OPHTH DROPS

ofloxacin OCUFLOX polymyxin b sulfate/tmp POLYTRIM tobramycin sulfate TOBREX gatifloxacin ZYMAR

ZYMAXID

moxifloxacin hcl VIGAMOX Ophthalmic Mast Cell Stabilizers cromolyn sodium OPTICROM lodoxamide tromethamine ALOMIDE nedocromil sodium ALOCRIL pemirolast potassium ALAMAST EYE - GLAUCOMA Carbonic Anhydrase Inhibitors acetazolamide DIAMOX SEQUELS methazolamide NEPTAZANE Miotics/Other Intraoc. Pressure Reducers betaxolol hcl BETOPTIC brimonidine tartrate ALPHAGAN P carteolol hcl OCUPRESS dorzolamide hcl TRUSOPT dorzolamide hcl/timolol

maleat COSOPT

levobunolol hcl BETAGAN metipranolol OPTIPRANOLOL pilocarpine hcl ISOPTO CARPINE timolol maleate TIMOPTIC(except

Ocudose) TIMOPTIC-XE

betaxolol hcl BETOPTIC S bimatoprost 0.03%

bimatoprost 0.01% LUMIGAN

brimonidine/timolol COMBIGAN brinzolamide AZOPT brinzolamide/brimonidine SIMBRINZA carbachol ISOPTO CARBACHOL latanoprost XALATAN timolol BETIMOL travoprost TRAVATAN Z travoprost (benzalkonium) TRAVATAN Mydriatics atropine sulfate ISOPTO ATROPINE cyclopentolate hcl CYCLOGYL homatropine hbr ISOPTO

HOMATROPINE

dipivefrin hcl PROPINE Eye Miscellaneous PA cysteamine HCl CYSTARAN GOUT AND RELATED DISEASES Colchicine colchicine COLCRYS colchicine/probenecid COL-BENEMID Hyperuricemia Tx - Purine Inhibitors

allopurinol ZYLOPRIM febuxostat ULORIC Uricosuric Agents probenecid BENEMID HEMATOLOGICAL DISORDERS Anticoagulants, Coumarin Type warfarin sodium COUMADIN Direct Factor XA Inhibitors QL apixaban ELIQUIS QL rivaroxaban XARELTO Hematinics, Other PA epoetin alfa PROCRIT Hemorrheologic Agents pentoxifylline TRENTAL Heparin & Related Preparations heparin sodium, porcine HEP-LOCK

HEPARIN LOCK

heparin sodium, porcine/pf HEP-LOCK QL dalteparin sodium, porcine FRAGMIN QL enoxaparin sodium LOVENOX QL fondaparinux sodium ARIXTRA Leukocyte (WBC) Stimulants PA filgrastim NEUPOGEN PA pegfilgrastim NEULASTA PA sargramostim LEUKINE Platelet Aggregation Inhibitors cilostazol PLETAL dipyridamole PERSANTINE clopidogrel bisulfate PLAVIX QL clopidogrel bisulfate 300mg PLAVIX 300MG QL prasugrel hcl EFFIENT QL ticagrelor BRILINTA Platelet Reducing Agents anagrelide hcl AGRYLIN Thrombopoietin Receptor Agonists PA eltrombopag olamine PROMACTA Vitamin K Preparations phytonadione MEPHYTON HORMONAL DEFICIENCY Androgenic Agents fluoxymesterone ANDROXY,

HALOTESTIN

QL testosterone cypionate DEPO-TESTOSTERONE

QL testosterone enanthate DELATESTRYL methyltestosterone ANDROID

METHITEST

QL testosterone 1% testosterone gel 1.62%

ANDROGEL ANDROGEL

QL testosterone solution AXIRON Estrogen/Androgen Combinations estrogen, ester/me-

testosterone ESTRATEST H.S.

Estrogenic Agents QL estradiol patch CLIMARA estradiol tablet ESTRACE estropipate OGEN QL QL

estradiol

ALORA DIVIGEL ESTRADERM VIVELLE-DOT

QL estradiol/noreth ac COMBIPATCH estrogens, conj/bazedoxifene DUAVEE estrogen, con/m-progest acet PREMPHASE

PREMPRO

estrogens, conjugated PREMARIN estrogens, esterified MENEST


804PA, oct 2016 13

norethind ac/ethinyl estradiol

FEMHRT

Progestational Agents medroxyprogesterone acet PROVERA norethindrone acetate AYGESTIN progesterone, micronized PROMETRIUM IMMUNOSUPPRESSION/MODULATION Immunomodulators PA, QL

imiquimod ALDARA

PA interferon alfa-2b, recomb. INTRON A Immunosuppressives azathioprine IMURAN cyclosporine SANDIMMUNE cyclosporine, modified NEORAL mycophenolate mofetil CELLCEPT tacrolimus anhydrous PROGRAF everolimus ZORTRESS sirolimus RAPAMUNE INFECTIOUS DISEASE - BACTERIAL Absorbable Sulfonamides sulfadiazine SULFADIAZINE sulfamethoxazole/trimethop

rim BACTRIM DS SEPTRA SEPTRA DS

sulfisoxazole acetyl GANTRISIN Beta lactams, inhaled PA + QL

aztreonam lysine, inhaled CAYSTON

Cephalosporins - 1st Generation cefadroxil hydrate DURICEF cephalexin monohydrate KEFLEX Cephalosporins - 2nd Generation cefaclor CECLOR cefprozil CEFZIL cefuroxime axetil CEFTIN Cephalosporins - 3rd Generation cefdinir OMNICEF cefpodoxime proxetil VANTIN cefixime SUPRAX Chemotherapeutics, Antibacterial, Misc. trimethoprim PROLOPRIM meth/meth

blue/ba/salicy/hyos PROSED-DS

mth/me blue/salicy/na phos/hyo

URETRON D-S URIN D.S.

trimethoprim PRIMSOL Ketolides telithromycin KETEK Lincosamides clindamycin hcl capsules CLEOCIN HCL clindamycin palmitate solution CLEOCIN PALMITATE Macrolides azithromycin ZITHROMAX

ZITHROMAX TRI-PAK

clarithromycin BIAXIN BIAXIN XL

ery e-succ/sulfisoxazole PEDIAZOLE erythromycin base ERYC erythromycin ethylsuccinate ERYPED 200 erythromycin stearate ERYTHROCIN

STEARATE

azithromycin ZMAX ZMAX PEDIATRIC

erythromycin base ERY-TAB PCE

erythromycin ethylsuccinate E.E.S. 200

ERYPED 200 ERYPED 400

fidaxomicin DIFICID Nitrofuran Derivatives nitrofurantoin macrocrystal MACRODANTIN nitrofurantoin/nitrofuran

mac MACROBID

furazolidone FUROXONE nitrofurantoin FURADANTIN Oxazolidinones PA linezolid ZYVOX PA tedizolid phosphate tablet SIVEXTRO TABLET Penicillins amox tr/potassium

clavulanate AUGMENTIN AUGMENTIN ES-600

amoxicillin trihydrate AMOXIL ampicillin trihydrate POLYCILLIN dicloxacillin sodium PATHOCIL penicillin v potassium V-CILLIN K amox tr/potassium

clavulanate AUGMENTIN XR

Quinolones ciprofloxacin hcl CIPRO levofloxacin LEVAQUIN ofloxacin FLOXIN ciprofloxacin CIPRO ORAL

SUSPENSION

moxifloxacin hcl AVELOX AVELOX ABC PACK

Tetracyclines doxycycline hyclate VIBRA-TABS

VIBRAMYCIN

doxycycline monohydrate ADOXA doxycycline monohydrate VIBRAMYCIN ORAL

SUSPENSION

minocycline hcl DYNACIN MINOCIN

tetracycline hcl ALA-TET doxycycline calcium VIBRAMYCIN SYRUP INFECTIOUS DISEASE - FUNGAL Antifungal Agents clotrimazole MYCELEX fluconazole DIFLUCAN itraconazole SPORANOX ketoconazole NIZORAL terbinafine hcl LAMISIL terbinafine hcl LAMISIL GRANULES voriconazole VFEND Antifungal Antibiotics griseofulvin suspension GRISEOFULVIN nystatin MYCOSTATIN griseofulvin ultramicrosize GRIS-PEG INFECTIOUS DISEASE - MISCELLANEOUS

Rifamycin and Related Derivative Antibiotics rifaximin 550mg XIFAXAN Aminoglycosides neomycin sulfate MYCIFRADIN PA + QL

tobramycin for inhalation TOBI

PA + QL

tobramycin for inhalation(cap) TOBI PODHALER

PA tobramycin/nebulizer KITABIS PAK Anti-Mycobacterium Agents ethambutol hcl MYAMBUTOL isoniazid NYDRAZID pyrazinamide PYRAZINAMIDE


804PA, oct 2016 14

Antileprotics dapsone AVLOSULFON PA thalidomide THALOMID Antitubercular Antibiotics rifampin RIFADIN rifampin/isoniazid RIFAMATE Vancomycin & Derivatives vancomycin hcl VANCOCIN HCL INFECTIOUS DISEASE - PARASITIC Amebacides paromomycin sulfate HUMATIN iodoquinol YODOXIN Anaerobic Antiprotozoal-Antibacterial Agents metronidazole FLAGYL metronidazole FLAGYL ER Anthelmintics mebendazole VERMOX praziquantel BILTRICIDE VITEKTA PA mebendazole EMVERM Antimalarial Drugs chloroquine phosphate ARALEN PHOSPHATE hydroxychloroquine sulfate PLAQUENIL mefloquine hcl LARIAM primaquine phosphate PRIMAQUINE PA pyrimethamine DARAPRIM pyrimethamine/sulfadoxine FANSIDAR quinine sulfate QUALAQUIN Antiprotozoal Drugs, Miscellaneous pentamidine isethionate NEBUPENT PA miltefosine IMPAVIDO INFECTIOUS DISEASE - VIRAL All oral, non-experimental antiviral agents used for the treatment of AIDS or HIV-related diseases are considered a formulary benefit. Antivirals, General acyclovir ZOVIRAX ganciclovir CYTOVENE valacyclovir hcl VALTREX oseltamivir phosphate TAMIFLU ribavirin VIRAZOLE Antivirals, HIV-Spec, Non-Peptidic Protease Inhib darunavir ethanolate PREZISTA darunavir/cobicistat PREZCOBIX tipranavir APTIVUS tipranavir/vitamin e tpgs APTIVUS Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog emtricitabine/tenofovir TRUVADA emtricitabine/tenofov

alafenam DESCOVY

Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb abacavir sulfate/lamivudine EPZICOM abacavir/lamivudine/zidovu

dine TRIZIVIR

lamivudine/zidovudine COMBIVIR Antivirals, HIV-Specific, CCR5 Co-Receptor Antag. maraviroc SELZENTRY Antivirals, HIV-Specific, Fusion Inhibitors ST enfuvirtide FUZEON Antivirals, HIV-Specific, Non-Nucleoside, RTI delavirdine mesylate RESCRIPTOR efavirenz SUSTIVA etravirine INTELENCE nevirapine VIRAMUNE nevirapine Viramune XR rilpivirine EDURANT Antivirals, HIV-Specific, Nucleoside Analog, RTI

didanosine VIDEX EC stavudine ZERIT zidovudine RETROVIR abacavir sulfate ZIAGEN didanosine VIDEX emtricitabine EMTRIVA lamivudine EPIVIR Antivirals, HIV-Specific, Nucleotide Analog, RTI tenofovir disoproxil fumarate VIREAD Antivirals, HIV-Specific, Protease Inhibitor Comb lopinavir/ritonavir KALETRA Antivirals, HIV-Specific, Protease Inhibitors atazanavir sulfate REYATAZ atazanavir sulfate/cobicistat EVOTAZ fosamprenavir calcium LEXIVA indinavir sulfate CRIXIVAN nelfinavir mesylate VIRACEPT ritonavir NORVIR ST saquinavir mesylate INVIRASE Antivirals, HIV-1 Integrase Strand Transfer Inhibtr dolutegravir TIVICAY ST elvitegravir VITEKTA raltegravir potassium ISENTRESS Antiviral Comb Nucleoside, Nucleotide & Non-Nucleoside RTI efavirenz/emtricitab/tenofovir ATRIPLA emtricit/rilpivirine/tenofovir COMPLERA emtrictab/rilpiviri/tenof ala ODEFSEY Cytochrome P450 Inhibitors PA cobicistat TYBOST ARV CMB-NRTI, N(T)RTI, Integrase Inhibitor abacavir/dolutegravir/lamivudi

ne TRIUMEQ

elvitegravir, cobicistat, emtricitabine, tenofovir disoproxil fumarate

STRIBILD

elviteg/cobi/emtric/tenofo ala GENVOYA Hepatitis B Treatment Agents adefovir dipivoxil HEPSERA entecavir BARACLUDE lamivudine EPIVIR HBV lamivudine EPIVIR HBV SOLUTION telbivudine TYZEKA Hepatitis C Combination Agents PA ledipasvir/sofosbuvir HARVONI PA sofosbuvir/velpatasvir EPCLUSA Hepatitis C Treatment Agents ribavirin 200mg COPEGUS

REBETOL

PA peginterferon alfa-2a PEGASYS PEGASYS PROCLICK PA sofosbuvir SOVALDI INFLAMMATORY DISEASE Anti-Arthritic & Chelating Agents penicillamine

DEPEN

Anti-Arthritic, Folate Antagonist Agents methotrexate sodium RHEUMATREX QL methotrexate OTREXUP Anti-Inflammatory,Tumor Necrosis Factor Inhibitor PA adalimumab HUMIRA PA etanercept ENBREL Anti-Inflammatory, Bradykinin B2 receptor antagonists PA icatibant acetate FIRAZYR Anti-Inflammatory, Pyrimidine Synthesis Inhibitor leflunomide ARAVA


804PA, oct 2016 15

Glucocorticoids budesonide BUDESONIDE cortisone acetate CORTONE ACETATE dexamethasone DEXAMETHASONE

TABLET/ELIXIR

hydrocortisone CORTEF methylprednisolone MEDROL prednisolone MILLIPRED

MILLIPRED DP

prednisolone sod phosphate

ORAPRED PEDIAPRED

prednisone DELTASONE PREDNISONE INTENSOL

budesonide ENTOCORT EC Mineralocorticoids fludrocortisone acetate FLORINEF ACETATE Monoclonal antibody-human interleukin PA ustekinumab STELARA NSAIDs, Cyclooxygenase Inhibitor-Type diclofenac sodium VOLTAREN

VOLTAREN-XR

etodolac LODINE fenoprofen calcium NALFON TABLETS flurbiprofen ANSAID ibuprofen MOTRIN indomethacin INDOCIN

INDOCIN SR

ketoprofen ORUVAIL ketorolac tromethamine TORADOL meclofenamate sodium MECLOMEN meloxicam MOBIC nabumetone RELAFEN naproxen EC-NAPROSYN

NAPROSYN

naproxen sodium ANAPROX ANAPROX DS

oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL tolmetin sodium TOLECTIN 600 celecoxib CELEBREX fenoprofen calcium NALFON CAPSULES indomethacin INDOCIN SUPPOS.

INDOCIN ORAL SUSP.

LOCAL ANESTHESIA Local Anesthetics lidocaine hcl XYLOCAINE LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT Bowel Antiinflamatory Agents sulfasalazine AZULFIDINE Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx mesalamine SFROWASA mesalamine w/cleansing

wipes ROWASA

mesalamine CANASA Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat balsalazide disodium COLAZAL mesalamine APRISO,

LIALDA PENTASA

Irritable Bowel Agents, Guanylate Cyclase-C Agonist linaclotide LINZESS Hemorrhoidal Preparations hc acetate/pramoxine hcl PROCTOCREAM-HC hc acetate/pramoxine hcl ANALPRAM HC

Rectal Preparations hydrocortisone PROCTO-KIT

PROCTOCORT PROCTOCREAM-HC

hydrocortisone acetate ANUSOL-HC PROCTOCORT

hc acetate/pramoxine hcl PROCTOFOAM-HC Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) hydrocortisone CORTENEMA LOWER GASTROINTESTINAL DISORDERS - OTHER Ammonia Inhibitors lactulose CHRONULAC sodium phenylbutyrate BUPHENYL Antidiarrheals diphenoxylate hcl/atrop sulf LOMOTIL Bile Salts ursodiol ACTIGALL

URSO URSO FORTE

Farnesoid X Receptor (Fxr) Agonist, Bile Ac Analog PA obeticholic acid OCALIVA Glucagon-like Peptide-2 (GLP-2) Analogs PA teduglutide GATTEX Laxatives & Cathartics peg 3350/na

sulf,bicarb,cl/kcl COLYTE WITH FLAVOR PACKETS

polyethylene glycol 3350 MIRALAX sod

chloride/nahco3/kcl/peg's NULYTELY WITH FLAVOR PACKS

lactulose KRISTALOSE peg 3350/na sulf,bicarb,cl/kcl GOLYTELY

OCL

sod picosulf/mag ox/citric ac PREPOPIK sodium,potassium,&mag

sulfates SUPREP

Narcotic Antagonists, Peripherally-Acting naloxegol oxalate MOVANTIK MISCELLANEOUS AGENTS Anaphylaxis Therapy Agents epinephrine EPIPEN

EPIPEN JR TWINJECT

Parasympathetic Agents bethanechol chloride URECHOLINE cevimeline hcl EVOXAC pilocarpine hcl SALAGEN Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase PA sapropterin dihydrochloride KUVAN NEOPLASTIC DISEASE Alkylating Agents cyclophosphamide CYTOXAN hydroxyurea HYDREA altretamine HEXALEN busulfan MYLERAN chlorambucil LEUKERAN lomustine CEENU melphalan ALKERAN PA temozolomide TEMODAR Antiandrogenic Agents bicalutamide CASODEX flutamide EULEXIN PA+ SCC

abiraterone ZYTIGA

PA enzalutamide XTANDI QL nilutamide NILANDRON Antimetabolites


804PA, oct 2016 16

mercaptopurine PURINETHOL methotrexate sodium METHOTREXATE

TABLET

methotrexate sodium METHOTREXATE VIAL thioguanine THIOGUANINE PA capecitabine XELODA fludarabine phosphate OFORTA mercaptopurine PURIXAN methotrexate sodium TREXALL PA trifluridine/tipiracil hcl LONSURF Antineoplastic Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA Antineoplastic -B Cell Lymphoma-2(bcl-2) Inhibitors PA venetoclax VENCLEXTA Antineoplastic, Hedgehog Pathway Inhibitor PA + SCC

vismodegib ERIVEDGE

PA sonidegib phosphate ODOMZO

Antineoplastic, Janus Kinase (JAK) Inhibitors PA+ SCC

ruloxitinib JAKAFI

PA tofacitinib citrate XELJANZ PA tofacitinib citrate XR XELJANZ XR Antineoplastic - MEK1 and MEK2 Kinase Inhibitors PA

+ QL

cobimetinib fumarate COTELLIC

Antineoplastic - Topoisomerase I Inhibitors topotecan hcl HYCAMTIN Antineoplastic Immunomodulator Agents PA+ QL

lenalidomide REVLIMID

PA pomalidomide POMALYST Antineoplastic Systemic Enzyme Inhibitors PA+ SCC

imatinib mesylate GLEEVEC

PA afatinib GILOTRIF PA+ QL

alectinib hydrochloride ALECENSA

PA+ SCC

axitinib INLYTA

PA bosutinib BOSULIF PA cabozantinib s-malate CABOMETYX PA cabozantinib COMETRIQ PA ceritinib ZYKADIA PA+ SCC

crizotinib XALKORI

PA dabrafenib TAFINLAR PA+ SCC

dasatinib SPRYCEL

PA, QL+ SCC

erlotinib hcl TARCEVA

PA gefitinib IRESSA PA ibrutinib IMBRUVICA PA idelalisib ZYDELIG PA ixazomib citrate NINLARO PA lapatinib ditosylate TYKERB PA lenvatinib mesylate LENVIMA PA+ SCC

nilotinib hydrochloride TASIGNA

PA + QL

olaparib LYNPARZA

PA + osimertinib mesylate TAGRISSO

QL PA + SCC

pazopanib hydrochloride VOTRIENT

PA palbociclib IBRANCE PA ponatinib ICLUSIG PA regorafenib STIVARGA PA+ SCC

sorafenib tosylate NEXAVAR

PA+ SCC

sunitinib malate SUTENT

PA tramtinib dimethyl sulfoxide MEKINIST PA+ SCC

vemurafinib ZELBORAF

Antineoplastic, Histone Deacetylase Inhibitors, HDIS PA panobinostat lactate FARYDAK SCC vorinostat ZOLINZA Antineoplastics, Miscellaneous etoposide VEPESID mitotane LYSODREN procarbazine hcl MATULANE tretinoin VESANOID PA +QL SCC

everolimus AFINITOR, AFINITOR DISPERZ

Chemotherapy Rescue/Antidote Agents leucovorin calcium LEUCOVORIN

CALCIUM

QL uridine triacetate VISTOGARD Selective Estrogen Receptor Modulators (SERM) tamoxifen citrate NOLVADEX PA toremifene citrate FARESTON Selective Retinoid X Receptor Agonists (RXR) PA + SCC

bexarotene TARGRETIN

Steroid Antineoplastics megestrol acetate MEGACE estramustine phosphate

sodium EMCYT

NEUROLOGICAL DISEASE - MISCELLANEOUS Agents To Treat Multiple Sclerosis PA dimethyl fumarate TECFIDERA PA fingolimod hcl GILENYA PA glatiramer acetate COPAXONE PA interferon beta-1a AVONEX PA interferon beta-1a/albumin REBIF PA

peginterferon beta-1a PLEGRIDY PLEGRIDY PEN

Fibromyalgia Agents, Serotonin-Norepineph RU Inhib milnacipran hcl SAVELLA Movement Disorders (Drug Therapy) PA tetrabenazine XENAZINE ORAL/PHARYNGEAL DISORDERS Dental Aids & Preparations chlorhexidine gluconate PERIDEX

PERISOL

triamcinolone acetonide KENALOG IN ORABASE

Nose Preparations, Antibiotics mupirocin calcium BACTROBAN NASAL Nose Preparations, Miscellaneous (Rx) ipratropium bromide ATROVENT OTHER DRUGS Appetite Stim. For Anorexia, Cachexia, Wasting Synd. megestrol acetate MEGACE megestrol acetate MEGACE ES General Inhalation Agents sodium chloride for inhalation HYPER-SAL 7%


804PA, oct 2016 17

Metabolic disease enzyme replace, hypophosphatasia PA asfotase alfa STRENSIQ Needles/Needleless Devices needles, insulin disp., safety NOVOFINE

NOVOFINE 32 PEN NEEDLE

needles, insulin disp., safety NOVOFINE AUTOCOVER

Nucleic Acid/Nucleotide Supplements PA uridine triacetate XURIDEN octreotide acetate SANDOSTATIN Drugs To Treat Hereditary Tyrosinemia PA nitisinone ORFADIN Antifibrotic Therapy – Pyridone Analogs PA pirfenidone ESBRIET OTHER RESPIRATORY DISORDERS Cystic Fibrosis-Cftr Potentiator & Corrector Comb. PA lumacaftor/ivacaftor ORKAMBI Cystic Fibrosis Transmembrane Conduct. Regulator (CFTR) Potentiator PA + QL

ivacaftor KALYDECO

Mucolytics acetylcysteine MUCOMYST-10 PA + QL

dornase alfa for inhalation PULMOZYME

Pulmonary Fibrosis – Systemic Enzyme Inhibitors PA nintedanib esylate OFEV PAIN MANAGEMENT - ANALGESICS Analgesic, Non-Salicylate & Barbiturate Comb. butalbital/acetaminophen PHRENILIN butalbital/acetaminophen PHRENILIN FORTE Analgesic, Salicylate, Barbiturate & Xanthine Comb butalbital/aspirin/caffeine FIORINAL Analgesic, Non-Salicylate, Barbiturate & Xanthine Comb butalb/acetaminophen/caffei

ne ESGIC FIORICET

Analgesic/Antipyretics, Salicylates diflunisal DOLOBID salsalate DISALCID Analgesics, Narcotics codeine

phos/carisoprodol/asa SOMA COMPOUND WITH CODEINE

PA Fentanyl patch DURAGESIC QL fentanyl citrate lozenge ACTIQ QL hydrocodone

bit/acetaminophen (300mg) VICODIN,VICODIN ES, VICODIN HP

QL hydrocodone bit/acetaminophen (325mg)

LORCET LORCET PLUS LORTAB NORCO

QL hydrocodone bit/acetaminophen oral elixir (300mg/15ml)

LORTAB ELIXIR

QL hydrocodone bit/acetaminophen (325mg/15ml) oral solution

HYCET

QL hydrocodone bitartrate HYSINGLA ER hydromorphone hcl DILAUDID QL QL morphine sulfate MS CONTIN

morphine sulfate MSIR ORAMORPH SR ROXANOL

oxycodone hcl PERCOLONE

ROXICODONE ROXICODONE INTENSOL

QL oxycodone hcl/acetaminophen (325mg)

PERCOCET

QL oxycodone hcl/acetaminophen (325mg/5ml)

ROXICET

oxycodone hcl/aspirin PERCODAN tramadol hcl ULTRAM tramadol/acetaminophen ULTRACET buprenorphine transdermal BUTRANS QL hydrocodone

bit/acetaminophen (250mg) STAGESIC-10

QL hydrocodone bit/acetaminophen (300mg)

XODOL 10-300

hydromorphone hcl DILAUDID-5 QL oxycodone hcl OXYCONTIN QL tapentadol hcl NUCYNTA QL NUCYNTA ER Antimigraine Preparations ergotamine tartrate/caffeine CAFERGOT

MIGERGOT

isomethept/acetaminop/ dichlphn

MIDRIN

QL naratriptan AMERGE QL sumatriptan IMITREX NASAL

SPRAY

QL QL

sumatriptan succinate IMITREX TABLET IMITREX INJECTION

QL rizatriptan benzoate MAXALT, MAXALT MLT QL + ST QL + ST

zolmitriptan ZOMIG ZOMIG ZMT

Narc. & Non-Sal. Analgesic, Barbiturate & Xanthine Comb codeine/butalbit/acetamin/c

aff FIORICET WITH CODEINE

Narcotic & Salicylate Analgesics, Barb. & Xanthine codeine/butalbital/asa/caffein FIORINAL WITH

CODEINE #3

Narcotic Analgesic & Non-Salicylate Analgesic Comb acetaminophen with

codeine TYLENOL-CODEINE NO.3 TYLENOL-CODEINE NO.4

acetaminophen with codeine

TYLENOL-CODEINE NO.4

acetaminophen with codeine CAPITAL W-CODEINE

PARKINSONS DISEASE Narcotic Withdrawal Therapy Agents PA buprenorphine hcl SUBUTEX

PA buprenorphine hcl/naloxone hcl SUBOXONE TABLET

PA buprenorphine hcl/naloxone hcl ZUBSOLV PAa buprenorphine hcl/naloxone hcl SUBOXONE FILM Antiparkinsonism Drugs, Anticholinergic benztropine mesylate COGENTIN trihexyphenidyl hcl ARTANE Antiparkinsonism Drugs, Other amantadine hcl SYMMETREL bromocriptine mesylate PARLODEL carbidopa/levodopa PARCOPA

SINEMET 25-100 SINEMET CR

carbidopa/levodopa/entacap STALEVO


804PA, oct 2016 18

one entacapone COMTAN pramipexole di-hcl MIRAPEX ropinirole hcl REQUIP ropinirole hcl REQUIP XL selegiline hcl ELDEPRYL rasagiline mesylate AZILECT rotigotine NEUPRO Decarboxylase Inhibitors carbidopa LODOSYN SEIZURE DISORDER Anticonvulsants carbamazepine CARBATROL

TEGRETOL TEGRETOL XR

clonazepam KLONOPIN QL diazepam (rectal) DIASTAT divalproex sodium DEPAKOTE

DEPAKOTE ER DEPAKOTE SPRINKLE

ethosuximide ZARONTIN gabapentin NEURONTIN lamotrigine LAMICTAL levetiracetam KEPPRA oxcarbazepine TRILEPTAL phenytoin DILANTIN-125 phenytoin sodium extended DILANTIN

PHENYTEK

primidone MYSOLINE topiramate TOPAMAX

TOPAMAX SPRINKLE

valproate sodium DEPAKENE SYRUP valproic acid DEPAKENE

CAPSULES

zonisamide ZONEGRAN phenytoin DILANTIN CHEW TAB pregabalin LYRICA SKELETAL MUSCLE DISORDER Agents To Treat Periodic Paralysis PA dichlorphenamide KEVEYIS Skeletal Muscle Relaxants baclofen LIORESAL carisoprodol SOMA carisoprodol/aspirin SOMA COMPOUND chlorzoxazone PARAFON FORTE DSC cyclobenzaprine hcl FLEXERIL dantrolene sodium DANTRIUM metaxalone SKELAXIN methocarbamol ROBAXIN

ROBAXIN-750

orphenadrine citrate NORFLEX orphenadrine/aspirin/caffeine NORGESIC FORTE tizanidine hcl ZANAFLEX UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE Pancreatic Enzymes amylase/lipase/protease PANCRELIPASE 5,000 amylase/lipase/protease CREON

ULTRASE ULTRASE MT ZENPEP

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE Anticholinergics/Antispasmodics dicyclomine hcl BENTYL Belladonna Alkaloids belladonna

alkaloids/phenobarb DONNATAL

hyoscyamine sulfate ANASPAZ LEVBID LEVSIN-SL

UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE Anti-Ulcer Preparations misoprostol CYTOTEC sucralfate CARAFATE Anti-Ulcer-H.pylori Agents lansoprazole/amox tr/clarith PREVPAC Anticholinergics, Quaternary Ammonium chlordiazepoxide/clidinium br LIBRAX Histamine H2-Receptor Inhibitors cimetidine hcl TAGAMET famotidine PEPCID nizatidine AXID ranitidine hcl TALADINE

ZANTAC

famotidine PEPCID RPD ranitidine hcl ZANTAC 25 Intestinal Motility Stimulants metoclopramide hcl REGLAN

METOCLOPRAMIDE HCL INTENSOL

Proton-Pump Inhibitors esomeprazole magnesium NEXIUM ST lansoprazole PREVACID omeprazole PRILOSEC omeprazole magnesium PRILOSEC OTC pantoprazole sodium PROTONIX ST lansoprazole PREVACID SOLUTABS URINARY TRACT - FUNCTIONAL DISORDERS Benign Prostatic Hypertrophy/Micturition Agents alfuzosin UROXATRAL GEN finasteride PROSCAR tamsulosin hcl FLOMAX GEN, ST

dutasteride AVODART

Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag combination agents GEN, ST

dutasteride/tamsulosin JALYN

Kidney Stone Agents PA cysteamine bitartrate PROCYSBI Overactive Bladder Agents, Beta-3 Adrenergic Recep mirabegron MYRBETRIQ Urinary Tract Analgesic Agents pentosan polysulfate sodium ELMIRON Urinary Tract Anesthetic/Analgesic Agent (Azo-Dye) phenazopyridine hcl PYRIDIUM Urinary Tract Antispasmodic, M(3) Selective Antag. solifenacin succinate VESICARE Urinary Tract Antispasmodic/Antiincontinence Agent oxybutynin chloride DITROPAN XL tolterodine tartrate (IR) DETROL tolterodine tartrate (LA) DETROL LA fesoterodine fumarate TOVIAZ VAGINAL DISORDERS Vaginal Antibiotics metronidazole METROGEL-VAGINAL

VANDAZOLE

Vaginal Antifungals miconazole nitrate MONISTAT 3 butoconazole nitrate GYNAZOLE-1 Vaginal Estrogen Preparations estradiol ESTRACE


804PA, oct 2016 19

estradiol vaginal tablets VAGIFEM estrogens, conjugated PREMARIN Vaginal Sulfonamides sulfanilamide AVC VITAMIN AND/OR MINERAL DEFICIENCY Fluoride Preparations sodium fluoride FLUORITAB

FLURA-DROPS FLURA-TABS LURIDE

Folic Acid Preparations folic acid FOLIC ACID Multivitamin Preparations folic acid/mu-vits-min th VICON FORTE multivitamins with min

no.7/fa VICON FORTE

Pediatric Vitamin Preparations fluoride ion/iron/vit a,c&d TRI-VI-FLOR W/IRON fluoride ion/multivitamins POLY-VI-FLOR fluoride ion/multivits w-fe POLY-VI-FLOR W/IRON fluoride ion/vit a,c&d FLUORABON BASIC Prenatal Vitamin Preparations prenatal vit 15/iron cb/fa/dss TRIADVANCE prenatal vit 16/iron cb/fa/dss VINATE GT prenatal vit 18/iron cb/fa/dss VINATE ULTRA prenatal vit w/fe fum/fa PRENAVITE (protein-

coated) (OTC)

Vitamin B Preparations cyanocobalamin/fa/pyridoxine FOLGARD RX Vitamin D Preparations calcitriol ROCALTROL ergocalciferol DRISDOL dihydrotachysterol DHT


804PA, oct 2016 20

SPECIALTY INJECTABLE CROSS REFERENCE LISTING

The following cross reference is being provided as a guide to formulary choices within prominent “specialty” injectable drug categories. General specialty categories are cross referenced to their corresponding formulary classification status and page number. This cross reference is not meant to be all-inclusive. Please refer to the Table of Contents or Index to determine formulary status of injectable medications not listed in this cross reference (e.g., Antineoplastics, Leukocyte Stimulants, etc.). EPO Hematinics, Other Page 12 HEPATITIS C Hepatitis C Treatment Agents Page 14 HUMAN GROWTH FACTORS Growth Hormones Page 11 LOW MOLECULAR WEIGHT HEPARINS Heparin and Related Preparations Page 12 MULTIPLE SCLEROSIS Agents to Treat Multiple Sclerosis Page 16 RHEUMATOID ARTHRITIS Anti-Inflammatory, TNF Inhibitors and Others Page 14

MEDICATION PRESCRIBING LIMITATIONS 1. AGE RESTRICTION (FORMULARY) Covered for ages: • Differin ≤ 25 years old • Fabior ≥ 12 years old 2. AGE RESTRICTIONS (NON-FORMULARY) Covered for ages: • Oracea > 18 years old • Retin A ≤ 25 years old • Retin A Micro ≤ 25 years old • Retin A Micro Pump ≤ 25 years old • Solodyn >12 years 3. QUANTITY RESTRICTIONS (FORMULARY) • Advair Diskus 1 unit/month • • Advair HFA

• Afinitor 12g (1 inhaler) per 30 days

2.5, 5mg 7.5, 10mg

•

30 tablets per 30 days 60 tablets per 30 days

• Aldara 24 packets per 30 days • Alecensa 240 capsules per 30 days • Alendronate Sodium

35mg and 70mg 5mg, 10mg, 40mg Solution

4 tablets/month 30 tablets/month 4 vials/month

• Ambien 30 tablets/month • Ambien CR 30 tablets/month • Androgel

2.5g packet 5g packet Pump (1.62%)

150g/month 300g/month 150g/month

Pump (1%) 300g/month • Androxy 120tablets/30days • Asmanex 1 inhaler/month • Arixtra 10 syringes per 30 days • Astelin

• Astepro 2 bottles/month 2 bottles/month

• Atrovent HFA 2 inhalers/28days • Axiron 2 bottles/month • Azilect 30 tablets/30days • Breo Ellipta 60 units/30 days • Brilinta 60 tablets/month • Caduet 30 tablets/month • Cafergot 40 tablets/28 days • Cayston 84mL/56 days • Climara Patch 4 patches/month • Combipatch 8 patches/month

• Corlanor 60 tablets per 30 days • Cotellic 63 tablets per 28 days • Crestor 30 tablets/30 days • Daliresp 30 tablets/month • Delatestryl syringe (1mL) 2 syringes/month • Delatestryl vial (5mL) 1 vial/month • Depo-Testosterone

1ml vial 10ml vial

4 vials/month 1 vial/month

• Diastat One twin pack/month • Dulera 1 inhaler/month • Duragesic 10 patches/month • Effient 30 tablets/month • Eliquis 60 tablets per 30 days • Entresto 60 tablets per 30 days • Estradiol Patches 4 patches/month • Estraderm Patch 8 patches/month • Evista 30 tablets/month • Fentanyl citrate lozenge 120 lozenges/month • Flonase 1 unit/month • Flunisolide 1 unit/month • Forteo 2.4mls (1 pen)/28 days with a

max duration of 2 years per lifetime

• Fragmin 10 syringes per 30 days • Glyxambi 30 tablets per 30 days • Hydrocodone/acetaminophen Maximum of 4gm of acetaminophen per day • Humulin N

Vial Kwikpen

40mL (4 vials) per 28 days 30mL (10 pens) per 28 days

• Humulin R 100u/mL 500u/mL

40mL (4 vials) per 28 days 40mL (2 vials) per 28 days

• Humulin R U-500 Kwikpen 8 pens (4 boxes of 2 pens) per 28 days

• Humulin 70/30 Vial Kwikpen


• Humalog vial pen/cartridge

40mL (4 vials) per 28 days 30mL (10 pens/cartridges) per 28 days

• Humalog Mix 50/50 / 75/25 vial Kwikpen


• Hysingla ER 30 tablets per 30 days • Imitrex

6mg/0.5ml Kit and Refill Kit 6mg/0.5ml Vial Tablet (all strengths) Nasal Spray

4 kits/month 4 vials/month 18 tablets/month 12 sprays/month

• Invokamet 60 tablets per 30 days • Invokana 30 tablets/month • Janumet 60 tablets per 30 days • Janumet XR

100-1000mg 50-1000mg 50-500mg

30 tablets per 30 days 60 tablets per 30 days 60 tablets per 30 days

• Januvia 30 tablets per 30 days • Jardiance 30 tablets per 30 days • Jentadueto 60 tablets per 30 days • Juxtapid 30 capsules per 30 days • Kalydeco 2 tablets/day • Korlym 120 tablets/month • Lantus

vial Solostar


• Lovaza 120 capsules/month • Lovenox 20 syringes per 30 days • Lunesta 30 tablets/month • Lynparza 16 capsules per day • Maxalt / MLT 18 tablets/month • Migergot suppositories 20 units per 28 days • MS Contin 90 tablets per 30 days • Narcan Nasal 2 boxes (4 nasal sprays per 30

days • Nasacort AQ 1 unit/month • Nasarel 1 bottle/month • Nasonex 1 unit/month • Nilandron 2 tablets/day for the first 30

days, then 1 tablet/day thereafter


804PA, oct 2016 21

• Nucynta 180 tablets/30 days • Nucynta ER 60 tablets/30 days • Nuvaring 1 ring/28 days • Ortho Evra 3 patches/28 days

• Oxycontin 10mg, 15mg, 20mg, 30mg, 40mg, 60mg

80mg


• Oxycodone/acetaminophen [maximum of 4gm acetaminophen per day]

• Perforomist 60 vials/month • Picato 3 tubes (0.015%); 2 tubes

(0.05%) • Plavix 300mg tablet 4 tablets per 30 days • Pulmicort Flexhaler 1 inhaler per 30 days • Pulmicort Respules 30 units/month • Pulmozyme 2 ampules/day • QNasl 1 canister/30 days • QVAR 1 unit/month • Ranexa 500mg tablet 120 tablets/30 days • Ranexa 1000mg tablet 60 tablets/30 days • Revlimid 1 capsule per day • Seasonale 91 tablets/84 days • Serevent Diskus 1 unit/month • Simcor 500/20, 500/40, 1000/40 30 tablets/month • Simcor 750/20, 1000/20 60 tablets/month • Sonata 30 capsules/month • Spiriva 30 units/month • Stiolto Respimat 4g (60 inhalations) per 30 days • Striverdi Respimat 4g (1 inhaler) per 30 days • Symbicort 1 unit/month • Synjardy 60 capsules per 30 days • Tagrisso 1 tablet per day • Tarceva

25mg 100, 150mg


• Tradjenta 30 tablets per 30 days • Tobi/Tobi Podhaler 56 units/56 days • Toujeo 13.5mL (9 pens) per 28 days • Trulicity 2mL (4 pens) per 28 days • Vascepa 120 capsules/month • Viagra 12 tablets/month • Victoza 9ml(3pens)/30 days • Vivelle-DOT Patch 8 patches/month • Vytorin 30 tablets/month • Xarelto

10mg and 20mg 15mg

30 tablets/month 42 tablets for the first 21 days, followed by 30 tablets/month

• Zetia 30 tablets/month • Zomig / ZMT

Tablet Nasal Spray

12 tablets/month 12 sprays/month

4. QUANTITY RESTRICTIONS (NON-FORMULARY) • Abstral 120 tablets/month • Actiq 120 lozenges/month • Actonel

5mg and 30mg 35mg 150mg

30 tablets/month 1 tablet/week 1 tablet/month

• Advicor 500/20 or 1000/40 30 tablets/month • Advicor 750/20 or 1000/20 60 tablets/month • Aerospan 17.8g (2 inhalers) per 30 days • Afrezza

4 unit 30-4 unit + 60-8 unit 60-4 unit + 30-8 unit 60-8 unit + 30-12 unit

180 cartridges (2 kits) per 28 days 360 cartridges (4 kits) per 28 days 360 cartridges (4 kits) per 28 days 360 cartridges (4 kits) per 28 days

• Allegra 30mg/5ml oral susp

300ml/month

• Alsuma 4 units/month • Altoprev 30 tablets/month • Alvesco 2 inhalers/25 days • Allzital 360 tablets per 30 days • Androderm 2mg & 4mg patches 30 patches/month • Anoro Ellipta 60 blister packs per 30

days • Apidra

Vial Solostar/cartridge


• Aptiom 200, 400mg 600, 800mg


• Arcapta 30 capsules/month • Arnuity Ellipta 30 blister packs per 30 days • Atelvia 1 tablet/week • Avinza

30mg, 45mg, 60mg, 75mg, 90mg

120mg

1 capsule per day 2 capsules per day

• Aubagio • Auryxia

28 tablets/28days 12 tablets/day

• Axert 12 tablets/month • Banzel 200mg 480 tablets/month • Banzel 400mg 240 tablets/month • Banzel solution 2400mL/month • Basaglar 30mL (10 pens) per 28 days • Beconase AQ 1 unit/month • Belbuca 2 buccal films per day • Belsomra 30 tablets per 30 days • Berinert 4 units/365 days • Bevespi Aerosphere 1 inhaler per 30 days • Binosto 4 tablets/28 days • Brisdelle 30 capsules/30 days • Briviact

Tablets solution

60 tablets per 30 days 600ml (2 bottles) per 30 days

• Brovana 60 vials/month • Bupap 180 tablets per 30 days • Butrans 4 patches/28 days • Bydureon/Bydureon Pen 4 vials or 4 pens/28 days • Byetta

5mcg 10mcg

1.2mL (1 pen) per 30 days 2.4mL (1 pen) per 30 days

• Cambia 9 packets/30 days • Caverject 1 unit/5 days • Cialis 2.5mg 30 tablets/month • Cialis 5mg 30 tablets/month • Cialis 10mg & 20mg 12 tablets/month • Clarinex

Tablets Syrup

30 tablets/month 300ml/month

• Clarinex-D 12 HR 24 HR

60 tablets/month 30 tablets/month

• Climara Pro Patch 4 patches/month • Conzip 30 capsules/month • Demerol 180 tablets/month • Demerol solution 900mL/30 days • D.H.E. 45 injection 30 units/28 days • Duexis 90 tablets/month • Dymista 1 bottle/month • Edex 1 unit/3 days • Edluar 30 tablets/month • Egrifta 60 vials/30 days • Epaned 1200mL per 30 days • Ergomar 40 tablets/28 days • Estring 1 unit/90 days • Evzio 0.8mL (2 syringes) per 365

days • Farxiga 30 tablets per 30 days • Felbatol 400mg 270 tablets/month • Felbatol 600mg 180 tablets/month • Felbatol solution 900mL/month • Femring 1 ring/90 days • Fentora 120 tablets/month • Firmagon 80mg/vial 1 vial/month • Firmagon 120mg/vial 2 vials/365 days • Flovent Diskus

50mcg and 100mcg 250mcg

1 diskus 2 diskus

• Flovent HFA 44mcg and 220 mcg 110 mcg

2 inhalers/month 1 inhaler/month

• Foradil 60 units/month • Fortesta 2 bottles/month • Frova 18 tablets/month • Fycompa

2mg 4mg, 6mg



804PA, oct 2016 22

• 8mg, 10mg, 12mg 30 tablets per 30 days • Gabitril 2mg, 4mg, 12mg 120 tablets/month • Gabitril 16mg 90 tablets/month • Gilenya 1 capsule/day • Gralise 300mg, 600mg 90 tablets/month • Gralise starter pack 78 tablets/month • Hemangeol 360mL (3 bottles) per 30

days • Horizant 600mg 60 tablets/month • Hycofenix 473mL (1 bottle) per 30 days • Hydrocodone/acetaminophen maximum of 4gm

acetaminophen per day • Incruse Ellipta 30 blisters per 30 days • Intermezzo 30 tablets/month • Iprivask 60 vials/30 days • Kadian

10mg, 20mg, 30mg, 40mg, 50mg, 60mg 70mg, 80mg, 100mg

• 130mg, 150mg, 200mg

60 capsules per 30 days 60 capsules per 30 days 60 capsules per 30 days 30 capsules per 30 days

• Karbinal ER 960mL (2 bottles) per 30 days

• Kazano 60 tablets per 30 days • Kombiglyze XR

2.5-1000mg 5-500mg, 5-1000mg


• Lamictal ODT 25mg or 50mg 180 tablets/month • Lamictal ODT 100 90 tablets/month • Lamictal ODT 200mg 60 tablets/month • Lamictal XR 25mg or 50mg 180 tablets/month • Lamictal XR 100 90 tablets/month • Lamictal XR 200mg, 250mg, or

300mg 60 tablets/month

• Lescol 60 capsules/30 days • Lescol XL 30 tablets/30 days • Levemir

vial • Flextouch


• Levitra 12 tablets/month • Liptruzet 30 tablets/30 days • Livalo 30 tablets/month • Lo-Seasonique 91 tablets/84 days • Menostar Patch 4 patches/month • Methadone

5mg 10mg 5mg/5mL

10mg/5mL • Methadone Intensol

240 tablets per 30 days 120 tablets per 30 days 1200ml per 30 days 600ml per 30 days 120ml per 30 days

• Muse 1 unit/3 days • Nesina 30 tablets per 30 days

• Novolin N/Novolin R/ Novolin 70/30

40mL (4 vials) per 28 days

• Novolog Vial Flexpen/cartridge


• Novolog Mix 70/30 Vial Kwikpen


• Obredon 600mL per 10 days • Omnaris 1 unit/month • Onfi

Tablets Suspension

60 tablets per 30 days 480mL per 30 days

• Onglyza 30 tablets per 30 days • Onzetra Xsail 16 nose pieces (one dose-kit)

per 30 days • Opana ER

5mg, 7.5mg, 10mg, 15mg, 20mg 30mg, 40mg

60 tablets per 30 days 120 tablets per 30 day

• Oseni 30 tablets per 30 days • Osphena • 30 tablets/month • Otrexup • 1.6mL per 28 days

• Oxycodone/acetaminophen [maximum of 4gm acetaminophen per day]

• Patanase 30.5g (1 bottle) per 30 days • Potiga 50mg 270 tablets/month • Potiga 200mg, 300mg, 400mg 90 tablets/month • Pradaxa 60 tablets/30 days • Rasuvo

7.5mg/0.15mL 10mg/0.2mL 12.5mg/0.25mL 15mg/0.3mL 17.5mg/0.35mL 22.5mg/0.46mL 25mg/0.5mL 27.5mg/0.55mL

• 30mg/0.6mL

1.6mL (4 syringes) per 28 days 0.8mL (4 syringes) per 28 days 1mL (4 syringes) per 28 days 1.2mL (4 syringes) per 28 days 1.4mL (4 syringes) per 28 days 1.8mL (4 syringes) per 28 days 2mL (4 syringes) per 28 days 2.2mL (4 syringes) per 28 days 2.4mL (4 syringes) per 28 days

• Relpax 12 tablets/month • Rhinocort Aqua 5 canisters/75 days • Rozerem 30 tablets/month • Sabril 180 tablets/month • Ryzodeg 70/30 30mL (10 pens) per 28 days • Samsca 15mg tablet: 30 tablets/365

days 30mg tablet:60 tablets/365 days

• Savaysa 30 tablets per 30 days • Seasonique 91 tablets/84 days • Seebri Neohaler 60 blister packs (1 Seebri

inhaler) per 30 days • Silenor 30 capsules/month • Sotylize

250mL 480mL

2000mL (8 bottles) per 30 days 3840mL (8 bottles) per 30 days

• Spritam 250/500/750mg 1000mg


• Sprix 5 bottles/month • Staxyn 12 tablets/month • Stendra 12 tablets/month • Striant 60 buccal/month • Sucraid 8mL/day • Sumavel DosePro 4 injections/month • Tanzeum 4 pens per 28 days • Testim 60 packets/month • Tivorbex 90 capsules per 30 days • Tresiba (100 U) 30 mL (10 pens) per 28 days • Tresiba (200 U) 18 mL (6 pens) per 28 days • Treximet 9 tablets/month • Trezix 10 capsules per day • Trokendi XR

25mg, 50mg, 100mg 200mg

30 capsules per 30 days 60 capsules per 30 days

• Tudorza 1 inhaler/month • Tuzistra XR 600mL per 30 days • Utibron Neohaler 60 blister packs (Utibron

Inhaler) per 30 days • Veramyst 1 bottle/30 days • Vimpat 60 tablets/month • Vistogard granules 24 packets per 14 day • Xartemis XR 360 tablets per 30 days • Xigduo XR 60 tablets per 30 days • Xtampza ER

9,13.5,18mg 27mg

• 36mg

60 capsules per 30 days 120 capsules per 30 days 240 capsules per 30 days

• Xyzal 2.5mg/5ml oral soln 300ml/month • Zecuity 1 carton per 28 days • Zembrace Symtouch 8mL (16 auto-injectors) per

30 days • Zetonna 1 aerosol unit/month • Zipsor 120 capsules per 30 days • Zohydro ER 60 capsules per 30 days • Zolpimist 1 pump/month • Zontivity 30 tablets per 30 days • Zorvolex 90 capsules per 30 days • Zyclara 2.5%: 7.5 grams (1 bottle)

per 28 days. 3.75% pump:7.5 grams (1 bottle) per 28 days 3.75% packet: 28 packets per 28 days


804PA, oct 2016 23

5. STEP THERAPY RESTRICTIONS (FORMULARY)

• Azor Prior prescription for an ACE inhibitor or ACE inhibitor combination or formulary generic ARB or ARB combination within the past 120 days.

• Benicar / HCT

Prior prescription for an ACE inhibitor or ACE inhibitor combination or formulary generic ARB or ARB combination within the past 120 days.

• Diovan Prior prescription for an ACE inhibitor or ACE inhibitor combination or formulary generic ARB or ARB combination within the past 120 days.

• Exforge / HCT

Prior prescription for an ACE inhibitor or ACE inhibitor combination or formulary generic ARB or ARB combination within the past 120 days.

• Fuzeon Trial of any antiretroviral medication within the past 30 days

• Invirase Trial of Isentress, Reyataz, Prezista or Atripla (new starts only)

• Prevacid Solutabs

Trial of lansoprazole, omeprazole or pantoprazole within the past 120 days

• QNasl Previous prescription for fluticasone or flunisolide nasal product within the past 365 days.

• Tribenzor Prior prescription for an ACE inhibitor or ACE inhibitor combination or formulary generic ARB or ARB combination within the past 120 days.

• Vitekta Trial of previous HIV anti-retroviral therapy within the past 120 days

• Zomig / ZMT and Zomig Nasal

Previous prescription for sumatriptan or rizatriptan within the past 180 days is required.

6. STEP THERAPY RESTRICTIONS (NON-FORMULARY)

• Aciphex Previous prescription for omeprazole, lansoprazole, pantoprazole or rabeprazole within the past 120 days.

• Aciphex Sprinkle Trial of two of the following; omeprazole, lansoprazole, pantoprazole or rabeprazole within the past 365 days

• Actonel Previous prescription for alendronate and ibandronate within the past 365 days is required.

• Allzital Trial of generic butalbital/acetaminophen combination product required

• Atelvia Previous prescription for alendronate and ibandronate within the past 365 days is required.

• Axert Previous prescription for sumatriptan or rizatriptan within the past 180 days required.

• Beconase AQ Previous prescription for fluticasone or flunisolide nasal product within the past 365 days.

• Belsomra Trial of zolpidem IR (Ambien), zaleplon (Sonata) or eszopiclone (Lunesta) within the past 120 days

• Binosto Previous prescription for alendronate and ibandronate within the last 365 days required.

• Bupap Trial of generic butalbital/acetaminophen combination product required

• Dexilant/Kapidex Previous prescription for omeprazole, lansoprazole or pantoprazole within the past 120 days

• Dymista Previous prescription for fluticasone or flunisolide nasal product within the past 365 days.

• Edarbi Prior prescription for an ACE inhibitor or ACE inhibitor combination or formulary generic ARB or ARB combination within the past 120 days.

• Edarbyclor Prior prescription for an ACE inhibitor or ACE inhibitor

combination or formulary generic ARB or ARB combination within the past 120 days.

• Edluar Previous prescription for zolpidem within the past 180 days is required.

• Epaned If age ≥ 12 years, trial of enalapril tablets within the past 120 days

• Esomeprazole Strontium Trial of omeprazole, lansoprazole or pantoprazole within the past 120 days

• Frova Previous prescription for sumatriptan or rizatriptan within the past 180 days is required.

• Hemangeol For age over 1 year, trial of generic propranolol oral solution within the past 120 days

• Intermezzo Previous prescription for zolpidem IR (Ambien) within the past 120 days.

• • Neo-Synalar Trial of fluocinolone and bacitracin

within the past 365 days • Omnaris Previous prescription for fluticasone

or flunisolide nasal product within the past 365 days.

• Onzetra Xsail Trial of sumatriptan nasal spray • Relpax Previous prescription for

sumatriptan or rizatriptan in the past 180 days is required.

• Rhinocort Aqua Previous prescription for fluticasone or flunisolide nasal product within the past 365 days.

• Rozerem Trial of zolpidem IR (Ambien), zaleplon (Sonata) or eszopiclone (Lunesta) within the past 120 days

• Silenor Trial of zolpidem IR (Ambien), zaleplon (Sonata) or eszopiclone (Lunesta) within the past 120 days

• Sitavig Trial of oral acyclovir, valacyclovir or famciclovir within the past 120 days

• Sotylize Trial of sotolol tablets within the past 120 days

• Sumavel DosePro Previous prescription for generic or multisource injectable or nasal sumatriptan (Imitrex or equivalent) within the past 180 days.

• Teveten / HCT Prior prescription for an ACE inhibitor or ACE inhibitor combination or formulary generic ARB or ARB combination within the past 120 days.

• Treximet Previous prescription for sumatriptan within the past 180 days is required.

• Veramyst Previous prescription for fluticasone or flunisolide nasal product within the past 365 days.

• Vimovo Previous prescription for generic naproxen required in the past 120 days.

• Xerese Trial of oral acyclovir, valacyclovir or famciclovir within the past 120 days

• Zecuity Trial of generic/multisource sumatriptan and nasal sumatriptan within the past 365 days

• Zegerid Previous prescription for omeprazole, lansoprazole, or pantoprazole within the past 120 days is required.

• Zembrace Symtouch Trial of sumatriptan injection • Zetonna

Previous prescription for fluticasone or flunisolide nasal product within the past 365 days.

• Zolpmist Previous prescription for zolpidem IR within the past 120 days is required.


804PA, oct 2016 24

7. PA RESTRICTIONS (FORMULARY) • Adcirca

• Adempas • Afinitor, Afinitor Disperz • Aldara • Alecensa • Avonex • Bosulif • Cabometyx • Cayston • Cometriq • Copaxone • Corlanor • Cosentyx • Cystaran • Daraprim • Depen • Duragesic • Eligard • Emverm • Enbrel • Epclusa • Erivedge • Esbriet • Fareston • Farydak • Fentanyl citrate lozenge • Firazyr • Gattex • Gilenya • Gilotrif • Gleevec • Grastek • Harvoni • Humira • Ibrance • Iclusig • Imbruvica • Impavido • Inlyta • Intron A • Iressa • Jakafi • Juxtapid • Kalydeco • Keveyis • Korlym • Kynamro • Kuvan • Lenvima • Letairis • Leukine • Lonsurf • Lynparza • Menkinist • Neulasta • Neupogen • Nexavar • Ninlaro • Norditropin, Norditropin Flexpro, Norditropin

Nordiflex • Ocaliva • Odomzo • Ofev • Omnitrope • Opsumit • Oralair • Orfadin • Orkambi • Pegasys • Plegridyl, Plegridyl Pen • Pomalyst • Praluent • Procrit • Procysbi • Promacta • Provigil • Pulmozyme • Ragwitek • Repatha • Revlimid

• Rebif • Revatio tablet • Sovaldi • Sivextro • Sprycel • Stelara • Stivarga • Strensiq • Suboxone film, tab • Subutex • Sutent • Tafinlar • Tagrisso • Tarceva • Targretin • Tasigna • Tecfidera • Temodar capsules • Thalomid • Tobi/Tobi Podhaler • Tracleer • Tybost • Tykerb • Uptravi • Valchlor • Votrient • Xalkori • Xeljanz • Xeljanz XR • Xeloda • Xenazine • Xtandi • Xuriden • Zelboraf • Zydelig • Zykadia • Zytiga • Zyvox

8. PA RESTRICTIONS (NON-FORMULARY) • Abraxane

• Abstral • Actemra Iv • Actemra Sc • Actiq • Adcetris • Addyi • Alimta • Amevive • Ampyra • Apokyn • Aranesp • Arestin • Arzerra • Avastin • Aubagio • Beleodaq • Belviq • Berinert • Betaseron • Bethkis • Bivigam • Blincyto • Bunavail • Caprelsa • Carimune Nf Nanofiltered • Cerezyme • Cholbam • Cimzia • Cinryze • Contrave • Cosentyx • Cuprimine • Cyramza • Daklinza • Darzalex • Duopa • Dysport • Egrifta


804PA, oct 2016 25

• Elelyso • Elspar • Empliciti • Entyvio • Epogen • Erbitux • Erwinaze • Evekeo • Exalgo • Extavia • Faslodex • Fentora • Flebogamma Dif • Flolan/Veletri • Folotyn • Gamastan S-D • Gammagard • Gammagard S-D • Gammaked • Gammaplex • Gamunex-C • Gazyva • Genotropin • Granix • Halaven • Herceptin • Hetlioz • Hizentra • H.P. Acthar • Humatrope • Imlygic • Increlex • Istodax • Ixempra • Jublia • Kadcyla • Kalbitor • Kanuma • Kitabis Pak • Keytruda • Kineret • Kyprolis • Lazanda • Lemtrada • Lumizyme • Marqibo • Mircera • Mozobil • Natpara • Northera • Novatrone • Nucala • Nuedexta • Nuplazid • Nutropin, Nutropin Aq, Nutropin Aq Nuspin • Nuvigil • Nymalize • Octagam • Olysio • Omontys • Oncaspar • Onivyde • Onsolis • Opdivo • Orencia IV • Orencia SC • Orenitram • Otezla • Pegintron • Perjeta • Photofrin • Portrazza • Privigen • Prolia • Qutenza • Qsymia • Ravicti • Remicade • Remodulin • Revatio Liquid • Revatio Vial

• Rituxan • Saizen • Saxenda • Serostim • Simponi SC • Simponi Aria IV • Solaraze • Soliris • Stelara • Subsys • Sucraid • Suprenza ODT • Sylatron • Sylvant • Synagis • Synribo • Syprine • Taltz • Tecentriq • Technivie • Temodar (Vial) • Tev-Tropin • Thyrogen • Torisel • Tysabri • Tyvaso • Unituxin • Vecamyl • Vectibix • Velcade • Venclexta • Ventavis • Viekira Pak, Viekira XR • Vimizim • Vpriv • Xeomin • Xgeva • Xolair • Xyrem • Yervoy • Yondelis • Zaltrap • Zarxio • Zavesca • Zepatier • Zinbryta • Zoladex • Zomacton • Zorbtive • Zubsolv • Zyclara

9. SHORT CYCLE COPAY PRODUCTS

• Afinitor • Erivedge • Gleevec • Inlyta • Jakafi • Nexavar • Xalkori • Sprycel • Sutent • Tarceva • Targretin • Tasigna • Votrient • Zelboraf • Zolinza • Zytiga


INDEX

804PA, oct 2016 26

1st Gen Antihistamine & Decongestant Combinations ................................................. 8

2nd Gen Antihistamine & Decongestant Combinations ................................................. 5

5-grass pollen extract ........................................... 5 8-MOP .................................................................. 9 abacavir sulfate ................................................ 14 abacavir sulfate/lamivudine ................................ 14 abacavir/dolutegravir/lamivudine ....................... 14 abacavir/lamivudine/zidovudine ..................... 14 ABBOTT DIABETIC SUPPLIES......................... 10 ABILIFY ................................................................ 6 abiraterone ......................................................... 15 Absorbable Sulfonamides .................................. 13 ACANYA ............................................................... 9 acarbose ............................................................ 10 ACCUPRIL ........................................................... 7 ACCURETIC......................................................... 7 ACCUTANE .......................................................... 8 Ace Inhibitor/Calcium Channel Blocker

Combination ................................................... 6 Ace Inhibitor/Thiazide & Thiazide-Like Diuretic ... 6 acebutolol hcl ..................................................... 7 acetaminophen with codeine .......................... 17 acetazolamide ................................................... 12 acetic acid ......................................................... 10 acetic acid/aluminum acetate ......................... 10 acetic acid/hydrocortisone .............................. 10 acetylcysteine ................................................... 17 acitretin ................................................................. 9 ACLOVATE .......................................................... 9 Acne Agents, Systemic ........................................ 8 Acne Agents, Topical ........................................... 9 ACTIGALL .......................................................... 15 ACTIQ ................................................................. 17 ACTOPLUS MET ............................................... 10 ACTOPLUS MET XR ......................................... 10 ACTOS ............................................................... 10 ACULAR ............................................................. 11 ACULAR LS........................................................ 11 acyclovir .......................................................... 9, 14 ADALAT CC ......................................................... 7 adalimumab ........................................................ 14 adapalene ............................................................ 9 ADCIRCA ............................................................. 7 ADDERALL........................................................... 6 ADDERALL XR .................................................... 6 adefovir dipivoxil ................................................. 14 ADEMPAS ............................................................ 7 ADOXA ............................................................... 13 Adrenergic Vasopressor Agents .......................... 8 Adrenergics, Aromatic, Non-Catecholamine ........ 6 ADVAIR DISKUS .................................................. 5 ADVAIR HFA ........................................................ 5 afatinib ................................................................ 16 AFINITOR ........................................................... 16 AFINITOR DISPERZ .......................................... 16 Agents To Treat Multiple Sclerosis .................... 16 AGRYLIN ............................................................ 12 AK-TRACIN ........................................................ 12 AKYNZEO ............................................................ 5 ALAMAST ........................................................... 12 ALA-TET ............................................................. 13 ALAWAY OTC .................................................... 11 albuterol sulfate .................................................. 5 ALBUTEROL SULFATE ....................................... 5 alclometasone dipropionate ............................. 9 ALDACTONE ....................................................... 7 ALDARA ............................................................. 13 ALDOMET ............................................................ 7 ALECENSA ........................................................ 16 alectinib hydrochloride........................................ 16 alendronate sodium ......................................... 11 alendronate sodium/vitamin d3 .......................... 11 alfuzosin ............................................................. 18 alirocumab ............................................................ 8 ALKERAN ........................................................... 15 Alkylating Agents ................................................ 15 ALLEGRA ............................................................. 5 ALLEGRA-D 12 HOUR ........................................ 5 ALLEGRA-D 24 HOUR ........................................ 5 ALLERGY ............................................................. 5

allopurinol ......................................................... 12 ALOCRIL ............................................................ 12 ALOMIDE ........................................................... 12 ALORA ............................................................... 12 Alpha/Beta-Adrenergic Blocking Agents .............. 7 Alpha-2 Receptor Antagonist Antidepressants .... 5 Alpha-Adrenergic Blocking Agents ...................... 7 ALPHAGAN P .................................................... 12 alprazolam ........................................................... 6 ALPRAZOLAM INTENSOL .................................. 6 ALREX ................................................................ 11 ALTACE ................................................................ 7 altretamine .......................................................... 15 aluminum chloride ............................................. 9 ALUPENT ............................................................. 5 Alzheimer's Therapy, Nmda Receptor Antagonists

........................................................................ 5 amantadine hcl ................................................. 17 AMARYL ............................................................. 10 AMBIEN ................................................................ 6 AMBIEN CR.......................................................... 6 ambrisentan .......................................................... 7 amcinonide.......................................................... 9 Amebacides ........................................................ 14 AMERGE ............................................................ 17 Aminoglycosides ................................................ 13 AMINOPHYLLIN ................................................... 5 aminophylline ..................................................... 5 amiodarone hcl ................................................... 6 amitriptyline hcl .................................................. 6 amlodipine bes/olmesartan med .......................... 7 amlodipine besylate ........................................... 7 amlodipine besylate/benazepril ........................ 6 amlodipine/atorvast cal ..................................... 8 amlodipine/valsartan.......................................... 7 amlodipine/valsartan/hctz ................................. 7 Ammonia Inhibitors ............................................. 15 amox tr/potassium clavulanate ...................... 13 amoxapine ........................................................... 6 amoxicillin trihydrate ....................................... 13 AMOXIL .............................................................. 13 amphet asp/amphet/d-amphet .......................... 6 ampicillin trihydrate ......................................... 13 amylase/lipase/protease .................................. 18 Anaerobic Antiprotozoal-Antibacterial Agents ... 14 ANAFRANIL ......................................................... 6 anagrelide hcl ................................................... 12 Analgesic, Non-Salicylate & Barbiturate Comb. 17 Analgesic, Non-Salicylate, Barbiturate & Xanthine

Comb ............................................................ 17 Analgesic, Salicylate, Barbiturat & Xanthine Comb

...................................................................... 17 Analgesic/Antipyretics, Salicylates ..................... 17 Analgesics, Narcotics ......................................... 17 ANALPRAM HC ................................................. 15 Anaphylaxis Therapy Agents ............................. 15 ANAPROX .......................................................... 15 ANAPROX DS .................................................... 15 ANASPAZ ........................................................... 18 anastrozole ......................................................... 16 ANDROGEL ....................................................... 12 Androgenic Agents ............................................. 12 ANDROID ........................................................... 12 ANDROXY .......................................................... 12 Angioten. Receptr Antag./Cal. Chanl Blkr/Thiazide

Comb .............................................................. 7 Angiotensin Recept-Neprilysin Inhibitor

Comb(Arni) .................................................... 8 Angiotensin Receptor Antag./Thiazide Diuretic

Comb .............................................................. 7 Angiotensin Receptor Antgnst & Calc. Channel

Blockr ............................................................. 7 ANSAID .............................................................. 15 ANTABUSE .......................................................... 6 Anthelmintics ...................................................... 14 anthralin .............................................................. 10 Anti-Alcoholic Preparations .................................. 6 Antiandrogenic Agents ....................................... 15 Antianginal & Anti-Ischemic Agents, Non-

Hemodynamic ................................................ 8 Anti-Anxiety Drugs ................................................ 6 Antiarrhythmics ..................................................... 6

Anti-Arthritic & Chelating Agents ........................ 14 Anti-Arthritic, Folate Antagonist Agents ............. 14 Anticholinergics, Quaternary Ammonium........... 18 Anticholinergics/Antispasmodics ........................ 18 Anticoagulants, Coumarin Type ......................... 12 Anticonvulsants .................................................. 18 Antidiarrheals ..................................................... 15 Antidiuretic & Vasopressor Hormones ............... 11 ANTIEMESIS/ANTIVERTIGO .............................. 5 Antiemetic/Antivertigo Agents .............................. 5 Antifungal Agents ............................................... 13 Antifungal Antibiotics .......................................... 13 Antihistamines - 1st Generation ........................... 5 Antihistamines - 2nd Generation .......................... 5 Antihypergly, (DPP-4) Inhibitor & Biguanide

Comb. ........................................................... 10 Antihyperglycemic Insul-Resp. Enhancer &

Biguanide Comb ........................................... 10 Antihyperglycemic, Alpha-Glucosidase Inhib

(Non-Sulfonylurea) ....................................... 10 Antihyperglycemic, Amylin Analog-Type ............ 10 Antihyperglycemic, DPP-4 Inhibitors .................. 10 Antihyperglycemic, Insulin-Rel Stim.& Biguanide

Comb ............................................................ 10 Antihyperglycemic, Insulin-Release Stimulant

Type ............................................................. 10 Antihyperglycemic, Insulin-Response & Release

Comb. ........................................................... 10 Antihyperglycemic, Insulin-Response Enhancer

(Non-Sulfonylurea) ....................................... 10 Antihyperglycemic, Sodium/Glucose Cotransport-

2 (SGLT2) Inhibitor....................................... 10 Antihyperglycemic,Biguanide Type(Non-

Sulfonylurea) ................................................ 10 Antihyperglycemic,Glucocorticoid Receptor

Antagonist .................................................... 10 Antihyperglycemics, DPP-4 & Statin Combo ..... 10 Antihyperglycemics, Incretin Mimetic ................. 10 Antihyperlip - HMG-CoA & Calcium Channel

Blocker Comb ................................................. 8 Antihyperlip.Hmg Coa Reduct

Inhib&Cholest.Ab.Inhib .................................. 7 Antihyperlipidemic - HMG CoA Reductase

Inhibitors ......................................................... 7 Antihyperlipidemic-Apo B 100 synthesis inhibitor 7 Antihyperlipidemic-HMG CoA Reductase Inhib. &

Niacin ............................................................. 8 Antihypertensives, ACE Inhibitors ........................ 7 Antihypertensives, Angiotensin Receptor

Antagonist ...................................................... 7 Antihypertensives, Sympatholytic ........................ 7 Antihypertensives, Vasodilators ........................... 7 Anti-inflam, Bradykinin B2 receptor antagonists 14 Anti-Inflammatory Tumor Necrosis Factor Inhibitor

...................................................................... 14 Anti-Inflammatory, Pyrimidine Synthesis Inhibitor

...................................................................... 14 Antileprotics ........................................................ 14 Antimalarial Drugs .............................................. 14 Anti-Mania Drugs .................................................. 6 Antimetabolites ................................................... 15 Antimigraine Preparations .................................. 17 Anti-Mycobacterium Agents ............................... 13 Antineoplastic - Topoisomerase I Inhibitors ....... 16 Antineoplastic Aromatase Inhibitors ................... 16 Antineoplastic Immunomodulator Agents .......... 16 Antineoplastic Systemic Enzyme Inhibitors ....... 16 Antineoplastic, Hedgehog Pathway Inhibitor ..... 16 Antineoplastic, Histone Deacetylase Inhibitors,

HDIS ............................................................. 16 Antineoplastic, Januse Kinase Inhib. ................. 16 Antineoplastics, Miscellaneous .......................... 16 Antiparkinsonism Drugs, Anticholinergic............ 17 Antiparkinsonism Drugs, Other .......................... 17 Antiperspirants ..................................................... 9 Antiprotozoal Drugs, Miscellaneous ................... 14 Antipsoriatic Agents, Systemic ............................. 9 Antipsoriatics Agents .......................................... 10 Antipsychotics, Atyp, D2 Partial Agonist/5HT

Mixed .............................................................. 6 Antipsychotics, Atypical, Dopamine,& Serotonin

Antag .............................................................. 6


INDEX

804PA, oct 2016 27

Antipsychotics, Dopamine & Serotonin Antagonists .................................................... 6

Antipsychotics, Dopamine Antagonists, Butyrophenones ............................................. 6

Antipsychotics, Dopamine Antagonists, Thioxanthenes ................................................ 6

Anti-Psychotics, Phenothiazines .......................... 6 antipyrine/benzocaine otic .................................. 10 Antiseborrheic Agents .......................................... 9 Antithyroid Preparations ..................................... 11 Antitubercular Antibiotics .................................... 14 Anti-Ulcer Preparations ...................................... 18 Anti-Ulcer-H.pylori Agents .................................. 18 ANTIVERT 12.5MG, 25MG .................................. 5 ANTIVERT 50MG ................................................. 5 Antiviral Comb Nucleoside, Nucleotide & Non-

Nucleoside RTI ............................................. 14 Antivirals, General .............................................. 14 Antivirals, HIV-1 Integrase Strand Transfer Inhibtr

...................................................................... 14 Antivirals, HIV-Spec, Non-Peptidic Protease Inhib

...................................................................... 14 Antivirals, HIV-Spec, Nucleoside-Nucleotide

Analog .......................................................... 14 Antivirals, HIV-Spec., Nucleoside Analog, RTI

Comb ............................................................ 14 Antivirals, HIV-Specific, CCR5 Co-Receptor

Antag. ........................................................... 14 Antivirals, HIV-Specific, Fusion Inhibitors .......... 14 Antivirals, HIV-Specific, Non-Nucleoside, RTI ... 14 Antivirals, HIV-Specific, Nucleoside Analog, RTI

...................................................................... 14 Antivirals, HIV-Specific, Nucleotide Analog, RTI 14 Antivirals, HIV-Specific, Protease Inhibitor Comb

...................................................................... 14 Antivirals, HIV-Specific, Protease Inhibitors ...... 14 ANUSOL-HC ...................................................... 15 APEXICON ........................................................... 9 APEXICON E ....................................................... 9 apixaban ............................................................. 12 Appetite Stim. For Anorexia, Cachexia, Wasting

Synd. ............................................................ 16 aprepitant .............................................................. 5 APRESOLINE ...................................................... 7 APRISO .............................................................. 15 APTIVUS ............................................................ 14 ARALEN PHOSPHATE ...................................... 14 ARAVA ............................................................... 14 ARICEPT .............................................................. 5 ARICEPT ODT ..................................................... 5 ARIMIDEX .......................................................... 16 aripiprazole ......................................................... 6 ARIXTRA ............................................................ 12 ARMOUR THYROID .......................................... 11 arnesoid X Receptor (Fxr) Agonist, Bile Ac

Analog ......................................................... 15 AROMASIN ........................................................ 16 ARTANE ............................................................. 17 ASENDIN .............................................................. 6 asfotase alfa., ..................................................... 17 ASMANEX ............................................................ 5 ASTELIN ............................................................... 5 ASTEPRO ............................................................ 5 ASTHMA ............................................................... 5 ATARAX ............................................................... 5 atazanavir sulfate ............................................... 14 atazanavir sulfate/cobicistat ............................... 14 atenolol ................................................................ 7 atenolol/chlorthalidone ...................................... 7 ATIVAN ................................................................. 6 atomoxetine hcl .................................................... 6 atorvastatin ......................................................... 7 ATRIPLA ............................................................. 14 atropine sulfate ................................................. 12 ATROVENT .................................................... 5, 16 ATROVENT HFA .................................................. 5 AUGMENTIN ...................................................... 13 AUGMENTIN ES-600 ......................................... 13 AUGMENTIN XR ................................................ 13 AUTONOMIC NERVOUS SYSTEM DISORDERS

........................................................................ 5 AVALIDE .............................................................. 7 AVAPRO ............................................................... 7 AVC .................................................................... 19 AVELOX ............................................................. 13

AVELOX ABC PACK .......................................... 13 AVLOSULFON ................................................... 14 AVODART .......................................................... 18 AVONEX ............................................................. 16 AXID ................................................................... 18 axitinib ................................................................ 16 AYGESTIN ......................................................... 13 azathioprine ...................................................... 13 azelastine hcl ................................................ 5, 11 AZILECT ............................................................. 18 azithromycin ..................................................... 13 AZOPT ................................................................ 12 AZOR .................................................................... 7 aztreonam, inhaled ............................................. 13 AZULFIDINE....................................................... 15 bacitracin........................................................... 12 bacitracin/polymyxin b sulfate........................ 12 baclofen ............................................................. 18 BACTRIM DS ..................................................... 13 BACTROBAN ....................................................... 9 BACTROBAN NASAL ........................................ 16 balsalazide disodium ....................................... 15 BARACLUDE ..................................................... 14 Barbiturates .......................................................... 6 becaplermin ........................................................ 10 beclomethasone dipropionate .............................. 5 BEHAVIORAL HEALTH - ANTIDEPRESSANTS 5 BEHAVIORAL HEALTH - OTHER ....................... 6 Belladonna Alkaloids .......................................... 18 belladonna alkaloids/phenobarb .................... 18 benazepril hcl ..................................................... 7 benazepril/hydrochlorothiazide ........................ 6 BENEMID ........................................................... 12 BENICAR .............................................................. 7 BENICAR HCT ..................................................... 7 Benign Prostatic Hypertrophy/Micturition Agents

...................................................................... 18 BENTYL .............................................................. 18 benz perox/hc/skin clnsr no.14 ......................... 9 BENZACLIN ......................................................... 9 BENZAMYCIN ...................................................... 9 BENZAMYCIN PAK .............................................. 9 BENZASHAVE ..................................................... 9 benzoyl peroxide ................................................ 9 benzoyl peroxide gel ............................................ 9 benzoyl peroxide shave cream ............................ 9 benzoyl peroxide/hydrocortison ........................... 9 benztropine mesylate ...................................... 17 Beta lactams, inhaled ......................................... 13 Beta-Adrenergic & Anticholinergic Combinations 5 Beta-Adrenergic & Glucocorticoid Combinations. 5 Beta-Adrenergic Agents ....................................... 5 Beta-Adrenergic Blocking Agents ........................ 7 Beta-Adrenergic Blocking Agents/Thiazide &

Related ........................................................... 7 BETAGAN .......................................................... 12 betamet diprop/prop gly .................................... 9 betamethasone dipropionate ............................ 9 betamethasone valerate .................................... 9 BETAPACE .......................................................... 7 BETAPACE AF ..................................................... 7 betaxolol hcl ..................................................... 12 bethanechol chloride ....................................... 15 BETIMOL ............................................................ 12 BETOPTIC.......................................................... 12 BETOPTIC S ...................................................... 12 bexarotene...................................................... 9, 16 BIAXIN ................................................................ 13 BIAXIN XL .......................................................... 13 bicalutamide ..................................................... 15 BIDIL ..................................................................... 8 Bile Salt Sequestrants .......................................... 8 Bile Salts ............................................................. 15 BILTRICIDE ........................................................ 14 bimatoprost ......................................................... 12 bisoprolol fumarate ............................................ 7 bisoprolol fumarate/hctz ................................... 7 BLEPHAMIDE .................................................... 12 BLEPHAMIDE S.O.P.......................................... 12 BLOCADREN ....................................................... 7 blood sugar diagnostics ..................................... 10 blood-glucose calib. control ................................ 10 blood-glucose meter ........................................... 10 Bone Formation Stim. Agents - Parathyroid

Hormone....................................................... 11

Bone Resorption Inhibitor & Calcium Combinations ............................................... 11

Bone Resorption Inhibitor & Vitamin D Combinations ............................................... 11

Bone Resorption Inhibitors ................................. 11 BONIVA .............................................................. 11 bosentan ............................................................... 7 BOSULIF ............................................................ 16 bosutinib ............................................................. 16 Bowel Antiinflamatory Agents ............................ 15 BRAVELLE ......................................................... 11 BREO ELLIPTA .................................................... 5 BRETHINE ........................................................... 5 BREVOXYL-4 ....................................................... 9 BREVOXYL-8 ....................................................... 9 BRILINTA ........................................................... 12 brimonidine tartrate ......................................... 12 brimonidine/timolol ............................................. 12 brinzolamide ....................................................... 12 brinzolamide/brimonidine ................................... 12 BROMFED............................................................ 8 BROMFED-PD ..................................................... 8 bromocriptine mesylate ................................... 17 budesonide ................................................... 5, 15 BUDESONIDE .................................................... 15 budesonide/formoterol fumarate .......................... 5 bumetanide ......................................................... 7 BUMEX ................................................................. 7 BUPHENYL ........................................................ 15 buprenorphine .................................................... 17 bupropion hcl ..................................................... 5 BUSPAR ............................................................... 6 buspirone hcl ...................................................... 6 busulfan .............................................................. 15 butalb/acetaminophen/caffeine ...................... 17 butalbital/acetaminophen ................................ 17 butalbital/aspirin/caffeine ................................ 17 butoconazole nitrate ........................................... 18 BUTRANS .......................................................... 17 BYSTOLIC ............................................................ 7 cabergoline ....................................................... 11 CABOMETYX ..................................................... 16 cabozantinib ....................................................... 16 cabozantinib s-malate ........................................ 16 CADUET ............................................................... 8 CAFERGOT........................................................ 17 CALAN SR............................................................ 7 calcipotriene ..................................................... 10 calcitriol ......................................................... 10, 19 calcium acetate ................................................. 11 Calcium Channel Blocking Agents ....................... 7 CANAGLIFLOZIN ............................................... 10 canagliflozin/metformin hcl ................................. 10 CANASA ............................................................. 15 capecitabine ....................................................... 16 CAPITAL W-CODEINE ...................................... 17 CAPOTEN ............................................................ 7 CAPOZIDE ........................................................... 6 captopril .............................................................. 7 captopril/hydrochlorothiazide........................... 6 CARAFATE ........................................................ 18 carbachol ............................................................ 12 carbamazepine ................................................. 18 carbidopa ............................................................ 18 carbidopa/levodopa ......................................... 17 Carbonic Anhydrase Inhibitors ........................... 12 CARDIOVASCULAR DISEASE - ARRHYTHMIA 6 CARDIOVASCULAR DISEASE - CARDIAC

STIMULANT ................................................... 6 CARDIOVASCULAR DISEASE -

HYPERTENSION ........................................... 6 CARDIOVASCULAR DISEASE - LIPID

IRREGULARITY ............................................. 7 CARDIOVASCULAR DISEASE -

MISCELLANEOUS AGENTS......................... 8 CARDIOVASCULAR DISEASE - VASODILATION

........................................................................ 8 CARDIZEM ........................................................... 7 CARDIZEM CD .................................................... 7 CARDURA ............................................................ 7 carisoprodol ...................................................... 18 carisoprodol/aspirin ......................................... 18 CARMOL HC ........................................................ 9 carteolol hcl ...................................................... 12 carvedilol ............................................................. 7


INDEX

804PA, oct 2016 28

carvedilol phosphate ............................................ 7 CASODEX .......................................................... 15 CATAPRES .......................................................... 7 CAYSTON .......................................................... 13 CECLOR ............................................................. 13 CEENU ............................................................... 15 cefaclor .............................................................. 13 cefadroxil hydrate ............................................ 13 cefdinir ............................................................... 13 cefixime .............................................................. 13 cefpodoxime proxetil ....................................... 13 cefprozil ............................................................. 13 CEFTIN ............................................................... 13 cefuroxime axetil .............................................. 13 CEFZIL ............................................................... 13 CELEBREX ........................................................ 15 celecoxib ........................................................... 15 CELEXA ............................................................... 5 CELLCEPT ......................................................... 13 CENTANY ............................................................ 9 cephalexin monohydrate ................................. 13 Cephalosporins - 1st Generation ....................... 13 Cephalosporins - 2nd Generation ...................... 13 Cephalosporins - 3rd Generation ....................... 13 ceritinib ............................................................... 16 cetirizine hcl (OTC)............................................. 5 cetrorelix acetate ................................................ 11 CETROTIDE ....................................................... 11 cevimeline hcl ................................................... 15 Chemotherapeutics, Antibacterial, Misc............. 13 Chemotherapy Rescue/Antidote Agents ............ 16 chloral hydrate .................................................... 6 chlorambucil ....................................................... 15 chlordiazepoxide hcl .......................................... 6 chlordiazepoxide/clidinium br ............................. 18 chlorhexidine gluconate .................................. 16 chloroquine phosphate ................................... 14 chlorpheniramine maleate ................................. 5 chlorpheniramine tannate ................................. 5 chlorpromazine hcl ............................................ 6 chlorpropamide ................................................ 10 chlorthalidone ..................................................... 7 CHLOR-TRIMETON ............................................. 5 chlorzoxazone .................................................. 18 cholestyramine/aspartame ................................ 8 cholestyramine/sucrose .................................... 8 Cholinesterase Inhibitors ...................................... 5 Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx

...................................................................... 15 CHRONULAC ..................................................... 15 CIBALITH-S .......................................................... 6 ciclopirox ............................................................... 9 ciclopirox olamine .............................................. 9 cilostazol ........................................................... 12 CILOXAN ............................................................ 12 cimetidine hcl ................................................... 18 CIPRO ................................................................ 13 CIPRO ORAL SUSPENSION ............................ 13 CIPRODEX ......................................................... 10 ciprofloxacin........................................................ 13 ciprofloxacin hcl ......................................... 12, 13 ciprofloxacin hcl/dexameth ................................. 10 citalopram hydrobromide .................................. 5 clarithromycin ................................................... 13 CLARITIN (OTC) .................................................. 5 CLARITIN-D 12 HOUR......................................... 5 CLARITIN-D 24 HOUR......................................... 5 CLEOCIN ............................................................ 13 CLEOCIN T .......................................................... 9 CLIMARA ............................................................ 12 CLINAC BPO ........................................................ 9 clindamycin capsules ......................................... 13 clindamycin palmitate solution ........................... 13 clindamycin phos/benzoyl perox ..................... 9 clindamycin phosphate ..................................... 9 clindamycin/benzoyl prx/skn #5 ........................... 9 clindamycin/tretinoin ............................................. 9 CLINORIL ........................................................... 15 clobetasol propionate ........................................ 9 clobetasol propionate/emoll ............................. 9 CLOBEX ............................................................... 9 CLOMID .............................................................. 11 clomiphene citrate ............................................ 11 clomipramine hcl ................................................ 6 clonazepam ....................................................... 18

clonidine hcl ....................................................... 7 clopidogrel bisulfate ........................................ 12 clopidogrel bisulfate 300mg............................ 12 clorazepate dipotassium ................................... 6 clotrimazole....................................................... 13 clotrimazole/betamet diprop ............................. 9 clozapine ............................................................. 6 CLOZARIL ............................................................ 6 cobicistat ............................................................. 14 cobimetinib fumarate .......................................... 16 codeine phos/carisoprodol/asa ...................... 17 codeine/butalbit/acetamin/caff........................ 17 codeine/butalbital/asa/caffein ......................... 17 codeine/promethazine hcl ................................. 8 COGENTIN......................................................... 17 COLAZAL ........................................................... 15 COL-BENEMID .................................................. 12 colchicine .......................................................... 12 Colchicine ........................................................... 12 colchicine/probenecid ..................................... 12 COLCRYS .......................................................... 12 colesevelam hcl .................................................... 8 COLESTID............................................................ 8 colestipol ............................................................... 8 COLYTE WITH FLAVOR PACKETS ................. 15 COMBIGAN ........................................................ 12 COMBIPATCH ................................................... 12 COMBIVENT ........................................................ 5 COMBIVENT RESPIMAT .................................... 5 COMBIVIR .......................................................... 14 COMETRIQ ........................................................ 16 COMPAZINE ........................................................ 5 COMPAZINE SYRUP........................................... 5 COMTAN ............................................................ 18 CONCERTA ......................................................... 6 CONDYLOX ......................................................... 9 CONTRACEPTION/OXYTOCICS ........................ 8 Contraceptives, Injectable .................................... 8 Contraceptives, Oral............................................. 8 Contraceptives, Transdermal ............................... 8 COPAXONE ....................................................... 16 COPEGUS.......................................................... 14 CORDARONE ...................................................... 6 CORDRAN ........................................................... 9 CORDRAN SP ..................................................... 9 COREG ................................................................ 7 COREG CR .......................................................... 7 CORGARD ........................................................... 7 CORLANOR ......................................................... 8 CORTEF ............................................................. 15 CORTENEMA .................................................... 15 cortisone acetate .............................................. 15 CORTISPORIN CREAM ...................................... 9 CORTISPORIN OINTMENT ................................ 9 CORTISPORIN OPHTH OINTMENT ................. 11 CORTISPORIN OPHTH SUSPENSION ............ 11 CORTISPORIN OTIC ......................................... 10 CORTONE ACETATE ........................................ 15 COSENTYX ........................................................ 10 COSOPT ............................................................ 12 COTELLIC .......................................................... 16 COUGH AND COLD ............................................ 8 COUMADIN ........................................................ 12 COZAAR ............................................................... 7 CREON ............................................................... 18 CRESTOR ............................................................ 8 CRINONE ........................................................... 11 CRIXIVAN........................................................... 14 crizotinib ............................................................. 16 cromolyn sodium ......................................... 5, 12 crotamiton ............................................................. 9 CUTIVATE ............................................................ 9 cyanocobalamin/fa/pyridoxine ............................ 19 CYCLESSA .......................................................... 8 cyclobenzaprine hcl ......................................... 18 CYCLOCORT ....................................................... 9 CYCLOGYL ........................................................ 12 cyclopentolate hcl ............................................ 12 cyclophosphamide ........................................... 15 cyclosporine.................................................. 12, 13 cyclosporine, modified .................................... 13 CYMBALTA .......................................................... 6 cyproheptadine hcl ............................................ 5 CYSTARAN ........................................................ 12 cysteamine bitartrate .......................................... 18

cysteamine HCL ................................................. 12 Cystic Fibrosis Transmembrane Conduct.

Regulator (CFTR) Potentiator ................... 17 CYTOMEL .......................................................... 11 CYTOTEC .......................................................... 18 CYTOVENE ........................................................ 14 CYTOXAN .......................................................... 15 dabrafenib........................................................... 16 DALIRESP ............................................................ 5 DALMANE ............................................................ 6 dalteparin sodium,porcine .................................. 12 danazol .............................................................. 11 DANOCRINE ...................................................... 11 DANTRIUM......................................................... 18 dantrolene sodium ........................................... 18 dapsone ............................................................. 14 DARAPRIM......................................................... 14 darunavir ethanolate........................................... 14 darunavir/cobicistat ............................................ 14 dasatinib ............................................................. 16 DAYPRO ............................................................ 15 DDAVP ............................................................... 11 Decarboxylase Inhibitors .................................... 18 DECONAMINE ..................................................... 8 DELATESTRYL .................................................. 12 delavirdine mesylate........................................... 14 DEL-BETA ............................................................ 9 DELTASONE ...................................................... 15 DEMADEX ............................................................ 7 DEMULEN 1-50-21 .............................................. 8 Dental Aids & Preparations ................................ 16 DEPAKENE CAPSULES ................................... 18 DEPAKENE SYRUP .......................................... 18 DEPAKOTE ........................................................ 18 DEPAKOTE ER .................................................. 18 DEPAKOTE SPRINKLE ..................................... 18 DEPEN ............................................................... 14 DEPO-PROVERA ................................................ 8 DEPO-TESTOSTERONE .................................. 12 DERMATOLOGY - ACNE .................................... 8 DERMATOLOGY - ANTIINFECTIVE ................... 9 DERMATOLOGY - ANTIINFLAMMATORY ......... 9 DERMATOLOGY - MISCELLANEOUS ............... 9 DERMATOLOGY - PIGMENTATION

DISORDERS .................................................. 9 DERMATOLOGY - PSORIASIS/ECZEMA .......... 9 DESCOVY .......................................................... 14 desipramine hcl .................................................. 6 desmopressin (nonrefrigerated) ..................... 11 DESOGEN............................................................ 8 desogestrel-ethinyl estradiol ............................ 8 desog-et estra/ethin estra ................................. 8 desonide .............................................................. 9 DESOWEN ........................................................... 9 desoximetasone ................................................. 9 desvenlafaxine ..................................................... 6 DESVENLAFAXINE ER (RANBAXY) .................. 6 desvenlafaxine succinate ..................................... 6 DESYREL 300MG ................................................ 6 DETROL ............................................................. 18 dexamethasone .................................................. 15 dexchlorpheniramine maleate .......................... 5 DEXEDRINE......................................................... 6 dexmethylphenidate hcl .................................... 6 dextroamphetamine sulfate .............................. 6 DHT .................................................................... 19 DIABETA ............................................................ 10 DIABETES .......................................................... 10 Diabetic Ulcer Preparations, Topical .................. 10 DIABINESE ........................................................ 10 DIAMOX SEQUELS ........................................... 12 DIASTAT ............................................................ 18 diazepam ............................................................. 6 diazepam (rectal) ................................................ 18 DIBENZYLINE ...................................................... 7 dichlorphenamide ............................................... 18 diclofenac sodium .................................. 9, 11, 15 dicloxacillin sodium ......................................... 13 dicyclomine hcl ................................................ 18 didanosine......................................................... 14 DIDRONEL ......................................................... 11 DIFFERIN ............................................................. 9 DIFICID ............................................................... 13 diflorasone diacetate ......................................... 9 diflorasone diacetate/emoll .................................. 9


INDEX

804PA, oct 2016 29

DIFLUCAN.......................................................... 13 diflunisal ............................................................ 17 difluprednate ....................................................... 11 Digitalis Glycosides .............................................. 6 digoxin ................................................................. 6 DIGOXIN ORAL SOLN......................................... 6 dihydrotachysterol .............................................. 19 DILACOR XR ....................................................... 7 DILANTIN ........................................................... 18 DILANTIN CHEW TAB ....................................... 18 DILANTIN-125 .................................................... 18 DILAUDID ........................................................... 17 DILAUDID-5........................................................ 17 diltiazem hcl ........................................................ 7 dimethyl fumarate ............................................... 16 DIOVAN ................................................................ 7 DIOVAN HCT ....................................................... 7 diphenoxylate hcl/atrop sulf ........................... 15 dipivefrin hcl........................................................ 12 DIPROLENE ......................................................... 9 DIPROLENE AF ................................................... 9 DIPROSONE ........................................................ 9 dipyridamole ..................................................... 12 DISALCID ........................................................... 17 disopyramide phosphate ................................... 6 disulfiram .............................................................. 6 DITROPAN XL ................................................... 18 divalproex sodium ............................................ 18 DIVIGEL ............................................................. 12 d-methorphan hb/prometh hcl .......................... 8 dofetilide ............................................................... 6 DOLOBID ........................................................... 17 dolutegravir ......................................................... 14 DOMEBORO ...................................................... 10 DONNATAL ........................................................ 18 dornase alfa for inhalation .................................. 17 dorzolamide hcl ................................................ 12 dorzolamide hcl/timolol maleat ...................... 12 DOSTINEX ......................................................... 11 DOVONEX.......................................................... 10 doxazosin mesylate ........................................... 7 doxepin hcl.......................................................... 6 doxycycline calcium ............................................ 13 doxycycline hyclate ......................................... 13 doxycycline monohydrate ............................... 13 DRISDOL ............................................................ 19 DRITHOCREME HP........................................... 10 DRITHO-SCALP ................................................. 10 dronabinol ........................................................... 5 dronedarone hcl ................................................... 6 Drug Tx-Chronic Inflam. Colon Dx, 5-

Aminosalicylat .............................................. 15 Drugs To Treat Hereditary Tyrosinemia ........ 17 Drugs To Treat Impotency ................................. 11 DRYSOL ............................................................... 9 DUAC CS ............................................................. 9 DUAVEE ............................................................. 12 DUETACT ........................................................... 10 DULERA ............................................................... 5 duloxetine hcl ..................................................... 6 DUONEB .............................................................. 5 DURAGESIC ...................................................... 17 DUREZOL .......................................................... 11 DURICEF ............................................................ 13 dutasteride ........................................................ 18 dutasteride/tamsulosin ....................................... 18 DYAZIDE .............................................................. 7 DYNACIN ........................................................... 13 E.E.S. 200 .......................................................... 13 EAR - GENERAL DISORDERS ......................... 10 Ear Preparations, Antibiotics .............................. 10 Ear Preparations, Misc. Anti-Infectives .............. 10 EC-NAPROSYN ................................................. 15 efavirenz ............................................................. 14 efavirenz/emtricitab/tenofovir ............................. 14 EFFEXOR............................................................. 6 EFFEXOR XR ...................................................... 6 EFFIENT ............................................................. 12 EFUDEX ............................................................... 9 ELAVIL ................................................................. 6 ELDEPRYL ......................................................... 18 Electrolyte Depleters .......................................... 11 ELECTROLYTE REGULATION ......................... 11 ELIGARD ............................................................ 11 ELIMITE ................................................................ 9

ELIQUIS ............................................................. 12 ELMIRON ........................................................... 18 ELOCON .............................................................. 9 eltrombopag olamine .......................................... 12 elviteg/cobi/emtric/tenofo ala .............................. 14 elvitegravir .......................................................... 14 elvitegravir, cobicistat, emtricitabine, tenofovir

disoproxil fumarate ....................................... 14 EMCYT ............................................................... 16 EMEND ................................................................. 5 EMGEL ................................................................. 9 empagliflozin....................................................... 10 empagliflozin/linagliptin ...................................... 10 empagliflozin/metformin hcl ................................ 10 emtricitabine ....................................................... 14 emtricitabine/tenofov alafenam .......................... 14 emtricitabine/tenofovir ........................................ 14 emtrictab/rilpiviri/tenof ala .................................. 14 EMTRIVA ............................................................ 14 EMVERM ............................................................ 14 enalapril maleate ................................................ 7 enalapril/hydrochlorothiazide ........................... 6 ENBREL ............................................................. 14 ENDOCRINE DISORDER - FERTILITY ............ 11 ENDOCRINE DISORDER - OTHER .................. 11 ENDOCRINE DISORDER - THYROID .............. 11 ENDOMETRIN ................................................... 11 enfuvirtide ........................................................... 14 enoxaparin sodium .......................................... 12 entacapone........................................................ 18 entecavir ............................................................ 14 ENTOCORT EC ................................................. 15 ENTRESTO .......................................................... 8 enzalutamide ...................................................... 15 EPCLUSA ........................................................... 14 epinephrine ......................................................... 15 EPIPEN .............................................................. 15 EPIPEN JR ......................................................... 15 EPIVIR ................................................................ 14 EPIVIR HBV ....................................................... 14 EPIVIR HBV SOLUTION .................................... 14 eplerenone .......................................................... 7 epoetin alfa ......................................................... 12 EPZICOM ........................................................... 14 ergocalciferol .................................................... 19 ergotamine tartrate/caffeine ............................ 17 ERIVEDGE ......................................................... 16 erlotinib hcl ......................................................... 16 ery e-succ/sulfisoxazole .................................. 13 ERYC .................................................................. 13 ERYGEL ............................................................... 9 ERYPED 200 ...................................................... 13 ERYPED 400 ...................................................... 13 ERY-TAB ............................................................ 13 ERYTHROCIN STEARATE ............................... 13 erythromycin base ..................................... 12, 13 erythromycin base/benz per ............................. 9 erythromycin base/ethanol ............................... 9 erythromycin ethylsuccinate .......................... 13 erythromycin stearate ...................................... 13 ESBRIET ............................................................ 17 escitalopram ......................................................... 5 ESGIC ................................................................ 17 ESKALITH ............................................................ 6 esomeprazole magnesium .............................. 18 estazolam ............................................................ 6 ESTRACE..................................................... 12, 18 ESTRADERM ..................................................... 12 estradiol ....................................................... 12, 18 estradiol tablet .................................................. 12 estradiol/noreth ac .............................................. 12 estramustine phosphate sodium ........................ 16 ESTRATEST H.S. .............................................. 12 estrogen, con/m-progest acet ............................ 12 estrogen, ester/me-testosterone .................... 12 Estrogen/Androgen Combinations ..................... 12 Estrogenic Agents .............................................. 12 estrogens, conj/bazedoxifene ............................ 12 estrogens, conjugated .................................. 12, 19 estrogens, esterified ........................................... 12 estropipate ........................................................ 12 eszopiclone ......................................................... 6 etanercept........................................................... 14 ethambutol hcl .................................................. 13 ethinyl estradiol/drospirenone.......................... 8

ethosuximide .................................................... 18 ethynodiol d-ethinyl estradiol ........................... 8 etidronate disodium ......................................... 11 etodolac ............................................................. 15 etonogestrel/ethinyl estradiol ............................... 8 etoposide........................................................... 16 etravirine ............................................................. 14 EULEXIN ............................................................ 15 EURAX ................................................................. 9 everolimus .................................................... 13, 16 EVISTA ............................................................... 11 EVOCLIN .............................................................. 9 evolocumab .......................................................... 8 EVOTAZ ............................................................. 14 EVOXAC ............................................................. 15 EXELDERM .......................................................... 9 EXELON ............................................................... 5 EXELON PATCH .................................................. 5 exemestane ........................................................ 16 EXFORGE ............................................................ 7 EXFORGE HCT ................................................... 7 EYE - GENERAL DISORDERS ......................... 11 EYE - GLAUCOMA ............................................ 12 Eye Antibiotic-Corticoid Combinations ............... 11 Eye Antihistamines ............................................. 11 Eye Antiinflammatory Agents ............................. 11 Eye Antivirals ...................................................... 11 Eye Miscellaneous ............................................. 12 Eye Sulfonamides .............................................. 11 ezetimibe .............................................................. 8 ezetimibe/simvastatin ........................................ 7 FABIOR ................................................................ 9 famotidine ......................................................... 18 FANSIDAR ......................................................... 14 FARESTON ........................................................ 16 FARYDAK........................................................... 16 febuxostat ........................................................... 12 FELDENE ........................................................... 15 felodipine ............................................................. 7 FEMARA ............................................................. 16 FEMHRT ............................................................. 13 fenofibrate ........................................................... 8 fenofibrate nanocrystallized ............................. 8 fenofibrate, micronized ...................................... 8 FENOGLIDE ......................................................... 8 fenoprofen calcium .......................................... 15 fentanyl citrate .................................................. 17 fentanyl patch ................................................... 17 Fertility Stimulating Preparations, Non-FSH ...... 11 FERTINEX .......................................................... 11 fesoterodine fumarate ........................................ 18 fexofenadine hcl tablet ...................................... 5 Fibromyalgia Agents, Serotonin-Norepineph RU

Inhib .............................................................. 16 fidaxomicin.......................................................... 13 filgrastim ............................................................. 12 finasteride ......................................................... 18 fingolimod hcl ..................................................... 16 FIORICET ........................................................... 17 FIORICET WITH CODEINE ............................... 17 FIORINAL ........................................................... 17 FIORINAL WITH CODEINE #3 .......................... 17 FIRAZYR ............................................................ 14 FIRST-HYDROCORTISONE ............................... 9 FLAGYL .............................................................. 14 FLAGYL ER ........................................................ 14 FLAREX .............................................................. 11 flecainide acetate ............................................... 6 FLEXERIL........................................................... 18 FLOMAX ............................................................. 18 FLONASE ............................................................. 5 FLORINEF ACETATE ........................................ 15 FLOXIN ......................................................... 10, 13 fluconazole ........................................................ 13 fludarabine phosphate ........................................ 16 fludrocortisone acetate ................................... 15 flunisolide............................................................ 5 fluocinolone acetonide ...................................... 9 fluocinonide ........................................................ 9 fluocinonide/emollient ....................................... 9 FLUORABON BASIC ......................................... 19 fluoride ion/iron/vit a,c&d ................................ 19 fluoride ion/multivitamins ............................... 19 fluoride ion/multivits w-fe ................................ 19 fluoride ion/vit a,c&d ........................................ 19


INDEX

804PA, oct 2016 30

Fluoride Preparations ......................................... 19 FLUORITAB ....................................................... 19 fluorometholone ............................................... 11 fluorometholone acetate ..................................... 11 fluorouracil .......................................................... 9 fluoxetine hcl ...................................................... 5 fluoxymesterone ............................................... 12 fluphenazine hcl ................................................. 6 FLURA-DROPS .................................................. 19 flurandrenolide ...................................................... 9 FLURA-TABS ..................................................... 19 flurazepam hcl .................................................... 6 flurbiprofen ....................................................... 15 flurbiprofen sodium ......................................... 11 flutamide ............................................................ 15 fluticasone propionate ................................... 5, 9 fluticasone/salmeterol........................................... 5 fluticasone/vilanterol ............................................. 5 fluvoxamine maleate .......................................... 5 FML .................................................................... 11 FML FORTE ....................................................... 11 FML S.O.P. ......................................................... 11 FOCALIN .............................................................. 6 FOLGARD RX .................................................... 19 folic acid ............................................................ 19 FOLIC ACID ....................................................... 19 Folic Acid Preparations ...................................... 19 folic acid/mu-vits-min th .................................. 19 Follicle Stim./Luteinizing Hormones ................... 11 FOLLISTIM AQ ................................................... 11 follitropin alpha,recomb ...................................... 11 follitropin beta,recomb ........................................ 11 fondaparinux sodium ....................................... 12 formoterol fumarate .............................................. 5 FORTEO ............................................................. 11 FOSAMAX .......................................................... 11 FOSAMAX PLUS D ............................................ 11 fosamprenavir calcium ....................................... 14 fosinopril sodium ............................................... 7 fosinopril/hydrochlorothiazide ......................... 7 FRAGMIN ........................................................... 12 FURADANTIN .................................................... 13 furazolidone ........................................................ 13 furosemide .......................................................... 7 FUROXONE ....................................................... 13 FUZEON ............................................................. 14 gabapentin ........................................................ 18 galantamine .......................................................... 5 ganciclovir..................................................... 11, 14 ganirelix acetate ................................................. 11 GANIRELIX ACETATE....................................... 11 GANTRISIN ........................................................ 13 GARAMYCIN .................................................. 9, 12 gatifloxacin.......................................................... 12 GATTEX ............................................................. 15 gefitinib ............................................................... 16 gemfibrozil .......................................................... 8 General Bronchodilator Agents ............................ 5 gentamicin sulfate ........................................ 9, 12 GENVOYA .......................................................... 14 GEODON .............................................................. 6 GILENYA ............................................................ 16 GILOTRIF ........................................................... 16 glatiramer acetate ............................................... 16 GLEEVEC........................................................... 16 glimepiride ........................................................ 10 glipizide ............................................................. 10 glipizide/metformin hcl .................................... 10 GLUCAGEN ....................................................... 10 GLUCAGON EMERGENCY KIT ........................ 10 glucagon,human recombinant ............................ 10 Glucocorticoids ................................................... 15 GLUCOPHAGE .................................................. 10 GLUCOPHAGE XR ............................................ 10 GLUCOTROL ..................................................... 10 GLUCOTROL XL ................................................ 10 GLUCOVANCE .................................................. 10 glyburide ............................................................. 10 glyburide, micro/metformin hcl ...................... 10 GLYXAMBI ......................................................... 10 GOLYTELY......................................................... 15 gonadorelin acetate ............................................ 11 gonadotropin,chorionic, human .......................... 11 GONAL-F ............................................................ 11 GONAL-F RFF ................................................... 11

GOUT AND RELATED DISEASES ................... 12 GRASTEK ............................................................ 5 griseofulvin suspension ...................................... 13 griseofulvin ultramicrosize .................................. 13 GRIS-PEG .......................................................... 13 Growth Hormone Receptor Antagonists ............ 11 Growth Hormones .............................................. 11 guaifenesin/codeine phos ................................. 8 guaifenesin/d-methorphan hb........................... 8 guanfacine hcl .................................................... 7 GYNAZOLE-1 ..................................................... 18 HALCION .............................................................. 6 HALDOL ............................................................... 6 HALDOL ORAL CONC......................................... 6 halobetasol propionate ...................................... 9 haloperidol .......................................................... 6 haloperidol lactate .............................................. 6 HALOTESTIN ..................................................... 12 HARVONI ........................................................... 14 hc acetate/pramoxine hcl ............................ 9, 15 hcg alpha, recombinant ...................................... 11 Hematinics, Other ............................................... 12 HEMATOLOGICAL DISORDERS ...................... 12 Hemorrheologic Agents ...................................... 12 Hemorrhoidal Preparations ................................ 15 Heparin & Related Preparations ........................ 12 HEPARIN LOCK ................................................. 12 heparin sodium, porcine ................................. 12 heparin sodium, porcine/pf ............................. 12 Hepatitis B Treatment Agents ............................ 14 Hepatitis C Treatment Agents ............................ 14 HEP-LOCK ......................................................... 12 HEPSERA .......................................................... 14 HEXALEN ........................................................... 15 Histamine H2-Receptor Inhibitors ...................... 18 homatropine hbr ............................................... 12 HORMONAL DEFICIENCY ................................ 12 hum insulin nph/reg insulin hm........................... 10 HUMALOG ......................................................... 10 HUMALOG MIX 50-50........................................ 10 HUMALOG MIX 75-25........................................ 10 HUMATIN ........................................................... 14 HUMIRA ............................................................. 14 HUMULIN 50-50 ................................................. 10 HUMULIN 70-30 ................................................. 10 HUMULIN N........................................................ 10 HUMULIN R........................................................ 10 HUMULIN R U-500 ............................................. 10 HYCAMTIN ......................................................... 16 HYCET ............................................................... 17 HYCODAN............................................................ 8 hydralazine hcl ................................................... 7 HYDREA ............................................................. 15 hydrochlorothiazide ........................................... 7 hydrocodone bit/acetaminophen (250mg) ......... 17 hydrocodone bit/acetaminophen (300mg) .... 17 hydrocodone bit/acetaminophen (325mg) .... 17 hydrocodone bit/acetaminophen (325mg/15ml)

oral solution .................................................. 17 hydrocodone bit/acetaminophen oral elixir

(300mg/15ml) .............................................. 17 hydrocodone bit/homatrop me-br .................... 8 hydrocodone bitartrate ....................................... 17 hydrocodone/chlorphen polis ............................... 8 hydrocort/sal acid/sulf/shmp#1............................. 9 hydrocortisone ............................................. 9, 15 hydrocortisone acetate .................................... 15 hydrocortisone acetate/urea ............................. 9 hydrocortisone butyrate .................................... 9 hydrocortisone butyrate/emoll .............................. 9 hydrocortisone probutate ..................................... 9 hydrocortisone valerate .................................... 9 hydrocortisone/iodoquinol ................................ 9 hydromorphone hcl.......................................... 17 hydroxychloroquine sulfate ............................ 14 hydroxyurea ...................................................... 15 hydroxyzine hcl .................................................. 5 hydroxyzine pamoate ........................................ 5 HYGROTON ......................................................... 7 hyoscyamine sulfate ........................................ 18 Hyperglycemics .................................................. 10 HYPER-SAL 7% ................................................. 16 Hyperuricemia Tx - Purine Inhibitors .................. 12 HYSINGLA ER ................................................... 17 HYTRIN ................................................................ 7

HYZAAR ............................................................... 7 ibandronate ....................................................... 11 IBRANCE ............................................................ 16 ibrutinib ............................................................... 16 ibuprofen ........................................................... 15 icatibant .............................................................. 14 ICLUSIG ............................................................. 16 icosapent ethyl ..................................................... 8 idelalisib .............................................................. 16 ILEVRO .............................................................. 11 imatinib mesylate ............................................. 16 IMBRUVICA........................................................ 16 IMDUR .................................................................. 8 imipramine hcl .................................................... 6 imiquimod ......................................................... 13 IMITREX INJECTION ......................................... 17 IMITREX NASAL SPRAY ................................... 17 IMITREX TABLET .............................................. 17 Immunomodulators ............................................. 13 IMMUNOSUPPRESSION/MODULATION ......... 13 Immunosuppressives ......................................... 13 IMPAVIDO .......................................................... 14 IMURAN ............................................................. 13 indapamide.......................................................... 7 INDERAL LA......................................................... 7 INDERIDE-40/25 .................................................. 7 indinavir sulfate .................................................. 14 INDOCIN ............................................................ 15 INDOCIN ORAL SUSP. ..................................... 15 INDOCIN SR ...................................................... 15 INDOCIN SUPPOS ............................................ 15 indomethacin .................................................... 15 INFECTIOUS DISEASE - BACTERIAL ............. 13 INFECTIOUS DISEASE - FUNGAL ................... 13 INFECTIOUS DISEASE - MISCELLANEOUS ... 13 INFECTIOUS DISEASE - PARASITIC .............. 14 INFECTIOUS DISEASE - VIRAL ....................... 14 INFLAMMATORY DISEASE .............................. 14 ingenol .................................................................. 9 INLYTA ............................................................... 16 INSPRA ................................................................ 7 insulin glargine,hum.rec.anlog ........................... 10 insulin lispro ........................................................ 10 insulin npl/insulin lispro ...................................... 10 insulin regular, human ........................................ 10 Insulins ............................................................... 10 INTAL ................................................................... 5 INTELENCE ....................................................... 14 interferon alfa-2b, recomb. ................................. 13 interferon beta-1a ............................................... 16 interferon beta-1a/albumin ................................. 16 Intestinal Motility Stimulants ............................... 18 INTRON A .......................................................... 13 INVIRASE ........................................................... 14 INVOKAMET ...................................................... 10 INVOKANA ......................................................... 10 Iodine Containing Agents ................................... 11 iodoquinol ........................................................... 14 ipratropium bromide .................................... 5, 16 ipratropium/albuterol sulfate ............................ 5 irbesartan ............................................................ 7 irbesartan/ hydrochlorothiazide ....................... 7 IRESSA .............................................................. 16 ISENTRESS ....................................................... 14 ISMO .................................................................... 8 ISOCHRON .......................................................... 8 isomethept/acetaminop/dichlphn ................... 17 isoniazid ............................................................ 13 ISOPTO ATROPINE .......................................... 12 ISOPTO CARBACHOL ...................................... 12 ISOPTO CARPINE ............................................. 12 ISOPTO HOMATROPINE .................................. 12 ISORDIL ............................................................... 8 ISORDIL TITRADOSE ......................................... 8 isosorb dinit/hydralazine hcl ................................. 8 isosorbide dinitrate ............................................ 8 isosorbide mononitrate ..................................... 8 isotretinoin .......................................................... 8 isradipine .............................................................. 7 itraconazole....................................................... 13 ivabradine hcl ....................................................... 8 ivacaftor .............................................................. 17 ixazomib citrate .................................................. 16 JAKAFI ............................................................... 16 JALYN ................................................................ 18


INDEX

804PA, oct 2016 31

JANUMET ........................................................... 10 JANUMET XR .................................................... 10 JANUVIA ............................................................ 10 JARDIANCE ....................................................... 10 JENTADUETO ................................................... 10 JUVISYNC .......................................................... 10 JUXTAPID ............................................................ 8 KALETRA ........................................................... 14 KALYDECO ........................................................ 17 KAYEXALATE .................................................... 11 K-DUR ................................................................ 11 KEFLEX .............................................................. 13 KENALOG ............................................................ 9 KENALOG IN ORABASE ................................... 16 KEPPRA ............................................................. 18 Keratolytic-Glucocorticoid Combinations ............. 9 Keratolytics ........................................................... 9 KETEK ................................................................ 13 ketoconazole ................................................. 9, 13 Ketolides ............................................................. 13 ketoprofen ......................................................... 15 ketorolac tromethamine ............................ 11, 15 ketotifen fumarate (OTC) ................................. 11 KEVEYIS ............................................................ 18 KITABIS PAK ..................................................... 13 KLARON ............................................................... 9 KLERIST-D ........................................................... 8 KLONOPIN ......................................................... 18 K-LYTE ............................................................... 11 K-LYTE-CL ......................................................... 11 KORLYM ............................................................ 10 KRISTALOSE ..................................................... 15 K-TAB ................................................................. 11 KURIC .................................................................. 9 KUVAN ............................................................... 15 KWELL ................................................................. 9 KYNAMRO ........................................................... 7 labetalol hcl ......................................................... 7 LACTICARE-HC ................................................... 9 lactulose ............................................................ 15 LAMICTAL .......................................................... 18 LAMISIL .......................................................... 9, 13 LAMISIL GRANULES ......................................... 13 lamivudine ......................................................... 14 lamivudine/zidovudine ........................................ 14 lamotrigine ........................................................ 18 lancing device/lancets ........................................ 10 LANOXIN .............................................................. 6 lansoprazole ..................................................... 18 lansoprazole/amox tr/clarith ............................... 18 LANTUS ............................................................. 10 lapatinib ditosylate .............................................. 16 LARIAM .............................................................. 14 LASIX ................................................................... 7 latanoprost .......................................................... 12 Laxatives & Cathartics........................................ 15 ledipasvir/sofosbuvir ........................................... 14 leflunomide ....................................................... 14 lenalidomide ....................................................... 16 lenvatinib mesylate ............................................. 16 LENVIMA ............................................................ 16 LETAIRIS .............................................................. 7 letrozole .............................................................. 16 leucovorin calcium ........................................... 16 LEUCOVORIN CALCIUM .................................. 16 LEUKERAN ........................................................ 15 LEUKINE ............................................................ 12 Leukocyte (WBC) Stimulants ............................. 12 Leukotriene Receptor Antagonists ....................... 5 leuprolide ............................................................ 11 LEVAQUIN ......................................................... 13 LEVBID ............................................................... 18 levetiracetam .................................................... 18 levobunolol hcl ................................................. 12 levocetirizine dihydrochloride ............................... 5 levofloxacin ....................................................... 13 levonorgestrel ..................................................... 8 levonorgestrel-eth estra .................................... 8 LEVOTHROID .................................................... 11 levothyroxine sodium ...................................... 11 LEVOXYL ........................................................... 11 LEVSIN-SL ......................................................... 18 LEXAPRO............................................................. 5 LEXIVA ............................................................... 14

LHRH (GnRH) Antagonist, Pituitary Suppressant Agents .......................................................... 11

LIALDA ............................................................... 15 LIBRAX ............................................................... 18 LIBRIUM ............................................................... 6 LIDEX ................................................................... 9 LIDEX-E ................................................................ 9 lidocaine hcl ...................................................... 15 LIFESCAN DIABETIC SUPPLIES ..................... 10 linaclotide ............................................................ 15 lindane ................................................................. 9 linezolid ............................................................. 13 LINZESS ............................................................. 15 LIORESAL .......................................................... 18 liothyronine sodium ......................................... 11 LIPITOR ................................................................ 7 Lipotropics ............................................................ 8 liraglutide ............................................................ 10 lisdexamfetamine dimesylate ............................... 6 lisinopril ............................................................... 7 lisinopril/hydrochlorothiazide ........................... 7 lithium carbonate ............................................... 6 lithium citrate ...................................................... 6 LITHOBID ............................................................. 6 LOCAL ANESTHESIA ........................................ 15 Local Anesthetics ............................................... 15 LOCOID ................................................................ 9 LOCOID LIPOCREAM ......................................... 9 LODINE .............................................................. 15 LODOSYN .......................................................... 18 lodoxamide tromethamine .................................. 12 LOESTRIN............................................................ 8 LOESTRIN FE ...................................................... 8 LOFIBRA CAPS ................................................... 8 LOFIBRA TABS .................................................... 8 lomitapide mesylate.............................................. 8 LOMOTIL ............................................................ 15 lomustine ............................................................ 15 LONSURF .......................................................... 16 Loop Diuretics ...................................................... 7 LO-OVRAL-28 ...................................................... 8 LOPID ................................................................... 8 lopinavir/ritonavir ................................................ 14 LOPRESSOR ....................................................... 7 Lopressor HCT ..................................................... 7 LOPROX ............................................................... 9 loratadine (OTC .................................................. 5 lorazepam ............................................................ 6 LORAZEPAM INTENSOL .................................... 6 LORCET ............................................................. 17 LORCET PLUS .................................................. 17 LORTAB ............................................................. 17 LORTAB ELIXIR ................................................. 17 losartan potassium ............................................ 7 losartan/hydrochlorothiazide ............................ 7 LOTEMAX .......................................................... 11 LOTENSIN............................................................ 7 LOTENSIN HCT ................................................... 6 loteprednol etabonate......................................... 11 LOTREL ................................................................ 6 LOTRISONE ......................................................... 9 lovastatin ............................................................. 7 LOVAZA ............................................................... 8 LOVENOX .......................................................... 12 LOWER GASTROINTESTINAL DISORDERS -

BOWEL INFLAMMAT .................................. 15 LOWER GASTROINTESTINAL DISORDERS -

OTHER ......................................................... 15 loxapine succinate ............................................. 6 LOXITANE ............................................................ 6 LOZOL .................................................................. 7 LUDIOMIL............................................................. 6 lumacaftor/ivacaftor ............................................ 17 LUMIGAN ........................................................... 12 LUNESTA ............................................................. 6 LURIDE .............................................................. 19 Luteinizing Hormone Releasing Hormone –LHRH

(GnRH) ......................................................... 11 LUTREPULSE .................................................... 11 LUVOX ................................................................. 5 LYNPARZA......................................................... 16 LYRICA ............................................................... 18 LYSODREN ........................................................ 16 macitentan ............................................................ 7 MACROBID ........................................................ 13

MACRODANTIN ................................................. 13 Macrolides .......................................................... 13 malathion............................................................. 9 Maois - Non-Selective & Irreversible .................... 5 maprotiline hcl .................................................... 6 maraviroc ............................................................ 14 MARINOL ............................................................. 5 Mast Cell Stabilizers ............................................. 5 MATULANE ........................................................ 16 MAVIK .................................................................. 7 MAXALT ............................................................. 17 MAXALT MLT ..................................................... 17 MAXITROL ......................................................... 11 MAXI-TUSS HCX ................................................. 8 MAXZIDE .............................................................. 7 MAXZIDE-25MG .................................................. 7 mebendazole ..................................................... 14 mechlorethamine .................................................. 9 meclizine hcl ....................................................... 5 meclofenamate sodium ................................... 15 MECLOMEN ....................................................... 15 MEDICATION PRESCRIBING LIMITATIONS .. 20 Medication Request Form (MRF) ....................... i MEDROL ............................................................ 15 medroxyprogesterone acet ......................... 8, 13 mefloquine hcl .................................................. 14 MEGACE ............................................................ 16 MEGACE ES ...................................................... 16 megestrol acetate ............................................. 16 MEKINIST........................................................... 16 MELLARIL ............................................................ 6 meloxicam ......................................................... 15 melphalan ........................................................... 15 memantine hcl .................................................... 5 memantine hcl/donepezil hcl ................................ 5 MENEST ............................................................. 12 MENOPUR ......................................................... 11 menotropins ........................................................ 11 MEPHYTON ....................................................... 12 meprobamate ...................................................... 6 mercaptopurine ................................................ 16 mesalamine ....................................................... 15 mesalamine w/cleansing wipes ...................... 15 MESTINON........................................................... 5 METADATE CD .................................................... 6 METADATE ER .................................................... 6 METAGLIP ......................................................... 10 metaproterenol sulfate ...................................... 5 metaxalone ........................................................ 18 metformin hcl .................................................... 10 meth/meth blue/ba/salicy/hyos ........................... 13 methazolamide ................................................. 12 METHERGINE ..................................................... 8 methimazole ...................................................... 11 METHITEST ....................................................... 12 methocarbamol ................................................. 18 methotrexate ..................................................... 14 METHOTREXATE 2.5MG TABLET ................... 16 methotrexate sodium ................................. 14, 16 METHOTREXATE VIAL ..................................... 16 methoxsalen ......................................................... 9 methoxsalen, rapid ............................................... 9 methyldopa ......................................................... 7 methylergonovine maleate ................................... 8 METHYLIN ........................................................... 6 METHYLIN CHEW TABS ..................................... 6 methylphenidate hcl........................................... 6 methylphenidate hcl ER suspension .................... 6 methylprednisolone ......................................... 15 methyltestosterone ............................................. 12 metipranolol ...................................................... 12 metoclopramide hcl ......................................... 18 METOCLOPRAMIDE HCL INTENSOL .............. 18 metolazone .......................................................... 7 metoprolol succinate ......................................... 7 metoprolol tartrate ............................................. 7 metoprolol/hctz ..................................................... 7 METROCREAM ................................................... 9 METROGEL-VAGINAL ...................................... 18 METROLOTION ................................................... 9 metronidazole ......................................... 9, 14, 18 MEVACOR ........................................................... 7 mexiletine hcl ...................................................... 6 MEXITIL ................................................................ 6 miconazole nitrate ............................................ 18


INDEX

804PA, oct 2016 32

MICRO-K ............................................................ 11 MICRONASE ...................................................... 10 MICROZIDE ......................................................... 7 midodrine hcl ...................................................... 8 MIDRIN ............................................................... 17 mifepristone ........................................................ 10 MIGERGOT ........................................................ 17 MILLIPRED......................................................... 15 MILLIPRED DP .................................................. 15 milnacipran hcl ................................................... 16 miltefosine .......................................................... 14 MILTOWN ............................................................. 6 MINASTRIN 24 FE ............................................... 8 Mineralocorticoids .............................................. 15 MINIPRESS .......................................................... 7 MINOCIN ............................................................ 13 minocycline hcl ................................................ 13 Miotics/Other Intraoc. Pressure Reducers ......... 12 mipomersen sodium ............................................. 7 mirabegron ......................................................... 18 MIRALAX ............................................................ 15 MIRAPEX ........................................................... 18 MIRCETTE ........................................................... 8 mirtazapine.......................................................... 5 MISCELLANEOUS AGENTS ............................. 15 misoprostol ....................................................... 18 mitotane .............................................................. 16 MOBIC ................................................................ 15 modafinil .............................................................. 6 moexipril hcl ....................................................... 7 moexipril/hydrochlorothiazide .......................... 7 mometasone furoate ...................................... 5, 9 mometasone/formoterol ....................................... 5 MONISTAT 3 ...................................................... 18 Monoclonal Antibodies To Immunoglobulin E(ige)

........................................................................ 5 MONOKET ........................................................... 8 MONOPRIL .......................................................... 7 MONOPRIL HCT .................................................. 7 montelukast sodium .......................................... 5 morphine sulfate .............................................. 17 MOTRIN ............................................................. 15 MOVANTIK ......................................................... 15 moxifloxacin hcl ............................................ 12, 13 MS CONTIN ....................................................... 17 MSIR ................................................................... 17 mth/me blue/salicy/na phos/hyo ......................... 13 Mucolytics ........................................................... 17 MUCOMYST-10 ................................................. 17 MULTAQ ............................................................... 6 Multivitamin Preparations ................................... 19 multivitamins with min no.7/fa ........................ 19 mupirocin ............................................................ 9 mupirocin calcium ........................................... 9, 16 MYAMBUTOL ..................................................... 13 MYCELEX .......................................................... 13 MYCIFRADIN ..................................................... 13 MYCI-GC .............................................................. 8 MYCOLOG II ........................................................ 9 mycophenolate mofetil .................................... 13 MYCOSTATIN ................................................ 9, 13 Mydriatics ........................................................... 12 MYLERAN .......................................................... 15 MYRBETRIQ ...................................................... 18 MYSOLINE ......................................................... 18 na sulfacetm/prednis sp .................................. 11 na sulfacetm/prednisol ac .................................. 12 nabumetone ...................................................... 15 nadolol ................................................................. 7 naftifine hcl ......................................................... 9 NAFTIN ................................................................. 9 NALEX A 12 ......................................................... 8 NALFON CAPSULES......................................... 15 NALFON TABLETS ............................................ 15 naltrexone hcl ..................................................... 6 NAMENDA............................................................ 5 NAMENDA XR ..................................................... 5 NAMZARIC ........................................................... 5 NAPROSYN ....................................................... 15 naproxen ........................................................... 15 naproxen sodium ............................................. 15 naratriptan .......................................................... 17 Narc. & Non-Sal. Analgesic, Barbiturate &

Xanthine Comb ............................................ 17 NARCAN NASAL ................................................. 6

Narcotic & Salicylate Analgesics, Barb. & Xanthine ....................................................... 17

Narcotic Analgesic & Non-Salicylate Analgesic Comb ............................................................ 17

Narcotic Antagonists ............................................ 6 Narcotic Antagonists, Peripherally-Acting .......... 15 Narcotic Antituss-1st Gen. Antihistamine-

Decongest ...................................................... 8 Narcotic Antituss-Decongestant-Expectorant

Comb .............................................................. 8 Narcotic Antitussive-1st Generation Antihistamine

........................................................................ 8 Narcotic Antitussive-Expectorant Combination .... 8 Narcotic Withdrawal Therapy Agents ................. 17 NARDIL ................................................................ 5 NASACORT AQ ................................................... 5 Nasal Antihistamine.............................................. 5 Nasal Anti-Inflammatory Steroids ........................ 5 NASAREL ............................................................. 5 NASONEX ............................................................ 5 nateglinide......................................................... 10 NAVANE ............................................................... 6 nebivolol hcl .......................................................... 7 NEBUPENT ........................................................ 14 nedocromil sodium ............................................. 12 needles, insulin disp., safety .............................. 17 Needles/Needleless Devices ............................. 17 nelfinavir mesylate .............................................. 14 neo/polymyx b sulf/dexameth ......................... 11 NEODECADRON ............................................... 11 neomy sulf/bacitrac zn/poly/hc ....................... 11 neomy sulf/polymyx b sulf/hc ................... 9, 10, 11 neomy sulf/polymyx b sulf/pred .......................... 11 neomycin sulfate .............................................. 13 neomycin sulfate/dex na ph ............................ 11 neomycin/bacitra/polymyxin/hc ............................ 9 neomycin/bacitracin/polymyxin ..................... 12 neomycin/polymyxn b/gramicidin .................. 12 NEOPLASTIC DISEASE .................................... 15 NEORAL ............................................................. 13 NEOSPORIN OPHTH DROPS .......................... 12 NEOSPORIN OPHTH OINTMENT .................... 12 neostigmine bromide ............................................ 5 nepafenac ........................................................... 11 NEPTAZANE ...................................................... 12 netupitant/palonosetron hcl .................................. 5 NEULASTA......................................................... 12 NEUPOGEN ....................................................... 12 NEUPRO ............................................................ 18 NEUROLOGICAL DISEASE - MISCELLANEOUS

...................................................................... 16 NEURONTIN ...................................................... 18 NEVANAC .......................................................... 11 nevirapine.......................................................... 14 NEXAVAR .......................................................... 16 NEXIUM .............................................................. 18 niacin ................................................................... 8 Niacin Preparations .............................................. 8 niacin/simvastatin ................................................. 8 NIASPAN .............................................................. 8 nicardipine ............................................................ 7 nifedipine ............................................................. 7 NILANDRON ...................................................... 15 nilotinib hydrochloride......................................... 16 nilutamide ........................................................... 15 nimodipine .......................................................... 7 NIMOTOP ............................................................. 7 NINLARO ............................................................ 16 nintedanib esylate .............................................. 17 nitisinone ............................................................ 17 NITRO-BID ........................................................... 8 NITRO-DUR ......................................................... 8 Nitrofuran Derivatives ......................................... 13 nitrofurantoin ...................................................... 13 nitrofurantoin macrocrystal ............................ 13 nitrofurantoin/nitrofuran mac ......................... 13 nitroglycerin ........................................................ 8 NITROLINGUAL ................................................... 8 NITROSTAT ......................................................... 8 nizatidine ........................................................... 18 NIZORAL ........................................................ 9, 13 NOCTEC .............................................................. 6 NOLVADEX ........................................................ 16 Non-Narc Antitussive-1st Gen Antihistamine

Comb. ............................................................. 8

Non-Narcotic Antitussive & Expectorant Comb. .. 8 NORCO .............................................................. 17 NORDETTE-28 .................................................... 8 NORDITROPIN .................................................. 11 NORDITROPIN FLEXPRO ................................ 11 NORDITROPIN NORDIFLEX ............................ 11 norelgestromin/ethin.estradiol ......................... 8 Norepinephrine & Dopamine Reuptake Inhib

(ndris) ............................................................. 5 noreth a-et estra/fe fumarate............................. 8 norethind ac/ethinyl estradiol ......................... 13 norethindrone ..................................................... 8 norethindrone acetate ..................................... 13 norethindrone a-e estradiol ............................... 8 norethindrone-e.estradiol-iron .............................. 8 norethindrone-ethinyl estrad ............................ 8 norethindrone-mestranol .................................. 8 NORFLEX........................................................... 18 NORGESIC FORTE ........................................... 18 norgestimate-ethinyl estradiol .......................... 8 norgestrel-ethinyl estradiol ............................... 8 NORINYL 1+35 .................................................... 8 NORINYL 1+50 .................................................... 8 NORPACE ............................................................ 6 NORPACE CR ..................................................... 6 NORPRAMIN ....................................................... 6 NOR-Q-D .............................................................. 8 nortriptyline hcl .................................................. 6 NORVASC ............................................................ 7 NORVIR .............................................................. 14 Nose Preparations, Antibiotics ........................... 16 Nose Preparations, Miscellaneous (Rx)............. 16 NOVAHISTINE DH ............................................... 8 NOVAREL .......................................................... 11 NOVOFINE ......................................................... 17 NOVOFINE AUTOCOVER ................................. 17 nph, human insulin isophane ............................. 10 NSAIDs, Cyclooxygenase Inhibitor-Type ........... 15 NUCYNTA .......................................................... 17 NULYTELY WITH FLAVOR PACKS .................. 15 NUVARING........................................................... 8 NYDRAZID ......................................................... 13 nystatin .......................................................... 9, 13 nystatin/triamcin ................................................. 9 obeticholic acid ................................................... 15 OCALIVA ............................................................ 15 OCL .................................................................... 15 octreotide acetate ............................................. 17 OCUFEN ............................................................ 11 OCUFLOX .......................................................... 12 OCUPRESS ....................................................... 12 ODEFSEY .......................................................... 14 ODOMZO ........................................................... 16 OFEV .................................................................. 17 ofloxacin ................................................ 10, 12, 13 OFORTA ............................................................. 16 OGEN ................................................................. 12 olanzapine ............................................................ 6 olanzapine/fluoxetine HCl ................................. 6 olaparib ............................................................... 16 olmesartan medoxomil ......................................... 7 olmesartan/amlodipin/hcthiazid ............................ 7 olmesartan/hydrochlorothiazide ........................... 7 olodaterol hcl ........................................................ 5 olopatadine hcl ................................................. 11 OLUX .................................................................... 9 omega-3 acid ethyl esters .................................... 8 omeprazole........................................................ 18 omeprazole magnesium .................................. 18 OMNICEF ........................................................... 13 OMNIPRED ........................................................ 11 OMNITROPE ...................................................... 11 ondansetron ........................................................ 5 ondansetron hcl ................................................. 5 Ophthalmic Antibiotics ........................................ 12 Ophthalmic Anti-Inflammatory Immunomodulator-

Type ............................................................. 12 Ophthalmic Mast Cell Stabilizers ....................... 12 OPSUMIT ............................................................. 7 OPTICROM ........................................................ 12 OPTIPRANOLOL ............................................... 12 OPTIVAR ............................................................ 11 Oral Inhaled Corticosteroids ................................. 5 ORAL/PHARYNGEAL DISORDERS ................. 16 ORALAIR .............................................................. 5


INDEX

804PA, oct 2016 33

ORAMORPH SR ................................................ 17 ORAPRED .......................................................... 15 ORFADIN ........................................................... 17 ORINASE ........................................................... 10 ORKAMBI ........................................................... 17 orphenadrine citrate......................................... 18 orphenadrine/aspirin/caffeine ......................... 18 ORTHO EVRA ...................................................... 8 ORTHO MICRONOR ........................................... 8 ORTHO TRI-CYCLEN .......................................... 8 ORTHO TRI-CYCLEN LO .................................... 8 ORTHO-CEPT ...................................................... 8 ORTHO-CYCLEN ................................................. 8 ORTHO-NOVUM .................................................. 8 ORUVAIL ............................................................ 15 oseltamivir phosphate ........................................ 14 osimertinib mesylate........................................... 16 OTHER DRUGS ................................................. 16 Otic Preparations, Anti-Inflammatory-Antibiotics 10 Otic Preparations, Local anesthetics ................. 10 OTICIN HC ......................................................... 10 OTREXUP .......................................................... 14 OVACE PLUS SUSPENSION.............................. 9 OVIDE .................................................................. 9 OVIDREL ............................................................ 11 oxaprozin........................................................... 15 oxazepam ............................................................ 6 Oxazolidinones ................................................... 13 oxcarbazepine .................................................. 18 OXSORALEN ....................................................... 9 OXSORALEN-ULTRA .......................................... 9 oxybutynin chloride ......................................... 18 oxycodone hcl .................................................. 17 oxycodone hcl/acetaminophen (325mg) ....... 17 oxycodone hcl/acetaminophen (325mg/15ml)

...................................................................... 17 oxycodone hcl/aspirin ..................................... 17 OXYCONTIN ...................................................... 17 Oxytocics .............................................................. 8 PAIN MANAGEMENT - ANALGESICS .............. 17 palbociclib ........................................................... 16 PAMELOR ............................................................ 6 Pancreatic Enzymes........................................... 18 PANCRELIPASE 5,000 ...................................... 18 PANDEL ............................................................... 9 panobinostat lactate ........................................... 16 pantoprazole sodium ....................................... 18 PARAFON FORTE DSC .................................... 18 Parasympathetic Agents .................................... 15 PARCOPA .......................................................... 17 paricalcitol........................................................... 11 PARKINSONS DISEASE ................................... 17 PARLODEL ........................................................ 17 PARNATE............................................................. 5 paromomycin sulfate ....................................... 14 paroxetine hcl ..................................................... 5 PATADAY ........................................................... 11 PATANOL ........................................................... 11 PATHOCIL.......................................................... 13 PAXIL ................................................................... 5 PAXIL CR ............................................................. 5 pazopanib hydrochloride .................................... 16 PCE .................................................................... 13 PEDIAPRED ....................................................... 15 PEDIATAN............................................................ 5 Pediatric Vitamin Preparations ........................... 19 PEDIAZOLE ....................................................... 13 peg 3350/na sulf,bicarb,cl/kcl ......................... 15 PEGASYS .......................................................... 14 pegfilgrastim ....................................................... 12 peginterferon alfa-2a .......................................... 14 peginterferon beta-1a ......................................... 16 pegvisomant ....................................................... 11 pemirolast potassium ......................................... 12 penicillamine ....................................................... 14 penicillin v potassium ...................................... 13 Penicillins ............................................................ 13 pentamidine isethionate ..................................... 14 PENTASA ........................................................... 15 pentosan polysulfate sodium .............................. 18 pentoxifylline .................................................... 12 PEPCID .............................................................. 18 PEPCID RPD ..................................................... 18 p-ephed hcl/cetirizine hcl (OTC) ....................... 5 p-ephed hcl/cod/chlorphenir ............................. 8

p-ephed hcl/codeine/guaifen............................. 8 p-ephed hcl/fexofenadine hcl............................ 5 p-ephed sul/loratadine ....................................... 5 PERCOCET........................................................ 17 PERCODAN ....................................................... 17 PERCOLONE ..................................................... 17 PERFOROMIST ................................................... 5 PERIACTIN .......................................................... 5 PERIDEX ............................................................ 16 PERISOL ............................................................ 16 permethrin ........................................................... 9 perphenazine ...................................................... 6 PERSANTINE .................................................... 12 phenazopyridine hcl......................................... 18 phenelzine sulfate ................................................ 5 PHENERGAN ....................................................... 5 PHENERGAN VC ................................................. 8 PHENERGAN VC W/CODEINE........................... 8 PHENERGAN W/CODEINE ................................. 8 PHENERGAN W/DEXTROMETHORPHAN ........ 8 phenobarbital ...................................................... 6 PHENOBARBITAL ............................................... 6 phenoxybenzamine hcl ...................................... 7 phenylephrine hcl/cod/prometh ....................... 8 phenylephrine hcl/prometh hcl ......................... 8 phenylephrine/brompheniramine ..................... 8 phenylephrine/chlor-tan .................................... 8 phenylephrine/hydrocodone/cp ....................... 8 phenylephrine/pyril tan/cp ................................ 8 PHENYTEK ........................................................ 18 phenytoin .......................................................... 18 phenytoin sodium extended ........................... 18 PHOSLO ............................................................. 11 Phosphodiesterase-4 (PD-4) Inhibitors ................ 5 PHRENILIN ........................................................ 17 PHRENILIN FORTE ........................................... 17 phytonadione ...................................................... 12 PICATO ................................................................ 9 pilocarpine hcl ............................................ 12, 15 pindolol ................................................................ 7 pioglitazone hcl ................................................ 10 pioglitazone hcl/metformin hcl ............................ 10 pioglitazone/glimepiride ...................................... 10 pirfenidone .......................................................... 17 piroxicam........................................................... 15 Pituitary Suppressive Agents ............................. 11 PLAN B ................................................................. 8 PLAQUENIL ....................................................... 14 Platelet Aggregation Inhibitors ........................... 12 Platelet Reducing Agents ................................... 12 PLAVIX ............................................................... 12 PLAVIX 300MG .................................................. 12 PLEGRIDY ......................................................... 16 PLEGRIDY PEN ................................................. 16 PLENDIL ............................................................... 7 PLETAL .............................................................. 12 PODHALER ........................................................ 13 podofilox ............................................................. 9 POLARAMINE ...................................................... 5 POLYCILLIN ....................................................... 13 POLYCIN-B ........................................................ 12 polyethylene glycol 3350 ................................. 15 polymyxin b sulfate/tmp .................................. 12 POLY-PRED ....................................................... 11 POLYTRIM ......................................................... 12 POLY-VI-FLOR .................................................. 19 POLY-VI-FLOR W/IRON .................................... 19 pomalidomide ..................................................... 16 POMALYST ........................................................ 16 ponatinib ............................................................. 16 pot chloride/pot bicarb/cit ac .......................... 11 potassium bicarbonate/cit ac.......................... 11 potassium chloride .......................................... 11 potassium iodide .............................................. 11 POTASSIUM IODIDE ......................................... 11 Potassium Replacement .................................... 11 Potassium Sparing Diuretics ................................ 7 Potassium Sparing Diuretics In Combination ...... 7 PRALUENT .......................................................... 8 pramipexole di-hcl ............................................ 18 pramlintide acetate ............................................. 10 PRAMOSONE ...................................................... 9 PRANDIMET ...................................................... 10 PRANDIN ........................................................... 10 prasugrel hcl ....................................................... 12

PRAVACHOL ....................................................... 7 pravastatin sodium ............................................ 7 praziquantel ........................................................ 14 prazosin hcl......................................................... 7 PRECOSE .......................................................... 10 PRED FORTE .................................................... 11 PRED MILD ........................................................ 11 PREDNISOL ....................................................... 11 prednisolone ..................................................... 15 prednisolone acetate ....................................... 11 prednisolone sod phosphate .................... 11, 15 prednisone ........................................................ 15 PREDNISONE INTENSOL ................................ 15 pregabalin ........................................................... 18 Pregnancy Facilitating/Maintaining Agent,

Hormonal ...................................................... 11 PREGNYL .......................................................... 11 PREMARIN................................................... 12, 19 PREMPHASE ..................................................... 12 PREMPRO ......................................................... 12 prenatal vit 15/iron cb/fa/dss........................... 19 prenatal vit 16/iron cb/fa/dss........................... 19 prenatal vit 18/iron cb/fa/dss........................... 19 Prenatal Vitamin Preparations ........................... 19 PRENATE GT .................................................... 19 PREPOPIK ......................................................... 15 PREVACID ......................................................... 18 PREVACID SOLUTABS ..................................... 18 PREVPAC .......................................................... 18 PREZCOBIX ....................................................... 14 PREZISTA .......................................................... 14 PRILOSEC ......................................................... 18 PRILOSEC OTC ................................................. 18 PRIMAQUINE ..................................................... 14 primaquine phosphate ........................................ 14 primidone .......................................................... 18 PRIMSOL ........................................................... 13 PRINIVIL ............................................................... 7 PRINZIDE ............................................................. 7 PRISTIQ ............................................................... 6 PROAIR HFA ....................................................... 5 PROAIR RESPICLICK ......................................... 5 PROAMATINE ...................................................... 8 probenecid ........................................................ 12 procainamide hcl ................................................ 6 procarbazine hcl ................................................. 16 PROCARDIA ........................................................ 7 PROCARDIA XL ................................................... 7 PROCHIEVE ...................................................... 11 prochlorperazine edisylate ................................... 5 prochlorperazine maleate .................................. 5 PROCRIT ........................................................... 12 PROCTOCORT .................................................. 15 PROCTOCREAM-HC......................................... 15 PROCTOFOAM-HC ........................................... 15 PROCTO-KIT ..................................................... 15 PROCYSBI ......................................................... 18 PROFASI ............................................................ 11 Progestational Agents ........................................ 13 progesterone, micronized ............................. 11, 13 PROGRAF .......................................................... 13 PROLIXIN ............................................................. 6 PROLOPRIM ...................................................... 13 PROMACTA ....................................................... 12 promethazine hcl ................................................ 5 PROMETRIUM ................................................... 13 PRONESTYL ........................................................ 6 propafenone hcl ................................................. 6 PROPINE ........................................................... 12 propranolol hcl ................................................... 7 propranolol/hydrochlorothiazid ........................ 7 propylthiouracil ................................................... 11 PROPYLTHIOURACIL ....................................... 11 PROSCAR .......................................................... 18 PROSED-DS ...................................................... 13 PROSOM .............................................................. 6 PROSTIGMIN ....................................................... 5 PROTONIX ......................................................... 18 Proton-Pump Inhibitors ...................................... 18 PROTOPIC ......................................................... 10 PROVERA .......................................................... 13 PROVIGIL............................................................. 6 PROZAC ............................................................... 5 PROZAC WEEKLY .............................................. 5 pseudoephedrine hcl/chlor-mal ........................ 8


INDEX

804PA, oct 2016 34

Pulm. Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhib .......................................................... 7

PULMICORT FLEXHALER .................................. 5 PULMICORT RESPULES .................................... 5 Pulmonary Anti-HTN, Endothelin Receptor

Antagonist ...................................................... 7 Pulmonary Anti-HTN, Soluble Guanylate Cyclase

Stimulators ..................................................... 7 PULMOZYME ..................................................... 17 PURINETHOL .................................................... 16 PURIXAN ............................................................ 16 pyrazinamide .................................................... 13 PYRAZINAMIDE ................................................ 13 PYRIDIUM .......................................................... 18 pyridostigmine bromide .................................... 5 pyrimethamine .................................................... 14 pyrimethamine/sulfadoxine ................................ 14 QNASL ................................................................. 5 QUALAQUIN ...................................................... 14 QUESTRAN.......................................................... 8 QUESTRAN LIGHT .............................................. 8 quetiapine fumarate ........................................... 6 quetiapine fumarate extended.............................. 6 QUILLIVANT XR .................................................. 6 QUINAGLUTE ...................................................... 6 quinapril hcl ........................................................ 7 quinapril/hydrochlorothiazide........................... 7 QUINIDEX ............................................................ 6 quinidine gluconate ........................................... 6 quinidine sulfate ................................................. 6 quinine sulfate .................................................... 14 Quinolones ......................................................... 13 QVAR ................................................................... 5 RAGWITEK .......................................................... 5 raloxifene hcl .................................................... 11 raltegravir potassium .......................................... 14 ramipril ................................................................ 7 RANEXA ............................................................... 8 ranitidine hcl ..................................................... 18 ranolazine ............................................................. 8 RAPAMUNE ....................................................... 13 rasagiline mesylate ............................................. 18 RAZADYNE .......................................................... 5 REBETOL ........................................................... 14 REBIF ................................................................. 16 Rectal Preparations ............................................ 15 Rectal/Lower Bowel Prep., Glucocort. (Non-

Hemorr) ........................................................ 15 REDERM .............................................................. 9 REGLAN ............................................................. 18 regorafenib ......................................................... 16 REGRANEX ....................................................... 10 RELAFEN ........................................................... 15 REMERON ........................................................... 5 RENAGEL .......................................................... 11 RENVELA ........................................................... 11 repaglinide ........................................................ 10 repaglinide/metformin hcl ............................... 10 REPATHA............................................................. 8 REPRONEX ....................................................... 11 REQUIP .............................................................. 18 REQUIP XL ........................................................ 18 RESCRIPTOR .................................................... 14 reserpine ............................................................. 7 RESTASIS .......................................................... 12 RESTORIL............................................................ 6 RETROVIR ......................................................... 14 REVATIO TABLET ............................................... 7 REVIA ................................................................... 6 REVLIMID........................................................... 16 REYATAZ ........................................................... 14 RHEUMATREX .................................................. 14 ribavirin ............................................................... 14 RIFADIN ............................................................. 14 RIFAMATE ......................................................... 14 rifampin ............................................................. 14 rifampin/isoniazid ............................................. 14 Rifamycin and Related Derivative Antibiotics .... 13 rifaximin .............................................................. 13 riociguat ................................................................ 7 RIOMET .............................................................. 10 RISPERDAL ......................................................... 6 RISPERDAL M TAB ............................................. 6 risperidone .......................................................... 6 RITALIN ................................................................ 6

RITALIN LA .......................................................... 6 RITALIN-SR.......................................................... 6 ritonavir ............................................................... 14 rivaroxaban ......................................................... 12 rivastigmine patch .............................................. 5 rivastigmine tartrate ........................................... 5 rizatriptan benzoate ......................................... 17 ROBAXIN ........................................................... 18 ROBAXIN-750 .................................................... 18 ROCALTROL ..................................................... 19 roflumilast ............................................................. 5 ROMYCIN ........................................................... 12 ropinirole hcl ..................................................... 18 Rosacea Agents, Topical ..................................... 9 rosuvastatin calcium.......................................... 8 rotigotine ............................................................. 18 ROWASA ............................................................ 15 ROXANOL .......................................................... 17 ROXICET ............................................................ 17 ROXICODONE ................................................... 17 ROXICODONE INTENSOL ................................ 17 ruloxitinib ............................................................ 16 RYNATAN ............................................................ 8 RYNATAN PEDIATRIC ........................................ 8 RYTHMOL ............................................................ 6 RYTHMOL SR ...................................................... 6 sacubitril/valsartan............................................. 8 SALAGEN........................................................... 15 salmeterol xinafoate ............................................. 5 salsalate ............................................................ 17 SANDIMMUNE ................................................... 13 SANDOSTATIN .................................................. 17 sapropterin dihydrochloride ................................ 15 saquinavir mesylate............................................ 14 sargramostim ...................................................... 12 SAVELLA ............................................................ 16 SCALACORT ....................................................... 9 SCALACORT DK ................................................. 9 SEASONALE ........................................................ 8 SECTRAL ............................................................. 7 secukinumab .................................................... 10 Sedative-Hypnotics, Non-Barbiturate ................... 6 SEIZURE DISORDER ........................................ 18 Selective Estrogen Receptor Modulators (SERM)

...................................................................... 16 Selective Retinoid X Receptor Agonists (RXR) . 16 Selective Serotonin Reuptake Inhibitors (SSRIs) 5 selegiline hcl ..................................................... 18 selenium sulfide ................................................. 9 selexipag .............................................................. 7 SELSUN RX ......................................................... 9 SELZENTRY ...................................................... 14 SEPTRA ............................................................. 13 SEPTRA DS ....................................................... 13 SERAX ................................................................. 6 SEREVENT DISKUS............................................ 5 SEROPHENE ..................................................... 11 SEROQUEL.......................................................... 6 SEROQUEL XR ................................................... 6 Serotonin-2 Antagonist/Reuptake Inhibitors

(SARIs) ........................................................... 6 Serotonin-Norepinephrine Reuptake-Inhib

(SNRIs) ........................................................... 6 SERPASIL ............................................................ 7 sertraline hcl ....................................................... 5 sevelamer carbonate .......................................... 11 sevelamer hcl ..................................................... 11 SFROWASA ....................................................... 15 short ragweed pollen extract ................................ 5 sildenafil citrate ............................................ 7, 11 SILVADENE ......................................................... 9 silver sulfadiazine .............................................. 9 SIMBRINZA ........................................................ 12 SIMCOR ............................................................... 8 simvastatin .......................................................... 8 SINEMET 25-100 ............................................... 17 SINEMET CR ..................................................... 17 SINEQUAN ........................................................... 6 SINGULAIR .......................................................... 5 sirolimus ............................................................. 13 sitagliptin phos/metformin hcl ............................. 10 sitagliptin phosphate........................................... 10 sitagliptin/simvastatin ......................................... 10 SIVEXTRO ......................................................... 13 SKELAXIN .......................................................... 18

SKELETAL MUSCLE DISORDER ..................... 18 Skeletal Muscle Relaxants ................................. 18 SLO-NIACIN ......................................................... 8 sod chloride/nahco3/kcl/peg's ........................ 15 sod picosulf/mag ox/citric ac .............................. 15 sodium chloride for inhalation ............................ 16 sodium fluoride ................................................... 19 sodium phenylbutyrate ....................................... 15 sodium polystyrene sulfonate ........................ 11 sodium,potassium,&mag sulfates ...................... 15 sofosbuvir ........................................................... 14 sofosbuvir/velpatasvir ......................................... 14 SOMA ................................................................. 18 SOMA COMPOUND .......................................... 18 SOMA COMPOUND WITH CODEINE .............. 17 somatropin .......................................................... 11 SOMAVERT ....................................................... 11 SONATA ............................................................... 6 sonidegib phosphate .......................................... 16 sorafenib tosylate ............................................... 16 SORIATANE ......................................................... 9 sotalol hcl ............................................................ 7 SOVALDI ............................................................ 14 SPECIALTY INJECTABLE CROSS

REFERENCE LISTING ................................ 20 SPIRIVA ............................................................... 5 spironolactone .................................................... 7 SPORANOX ....................................................... 13 SPRYCEL ........................................................... 16 SSRI & Antipsychotic,ATYP,(DA & Serotonin)

Comb. ............................................................. 5 STAGESIC-10 .................................................... 17 STARLIX ............................................................. 10 stavudine ........................................................... 14 STELARA ........................................................... 15 STELAZINE .......................................................... 6 Steroid Antineoplastics ....................................... 16 STIOLTO RESPIMAT........................................... 5 STIVARGA ......................................................... 16 STRATTERA ........................................................ 6 STRENSIQ ......................................................... 17 STRIBILD ........................................................... 14 STRIVERDI RESPIMAT ....................................... 5 SUBOXONE FILM ............................................. 17 SUBOXONE TABLET........................................ 17 SUBUTEX .......................................................... 17 sucralfate........................................................... 18 sulconazole nitrate ............................................... 9 SULFAC ............................................................. 11 sulfacetamide sodium ................................. 9, 11 sulfadiazine ....................................................... 13 SULFADIAZINE .................................................. 13 sulfamethoxazole/trimethoprim ...................... 13 sulfanilamide....................................................... 19 sulfasalazine ..................................................... 15 sulfisoxazole acetyl ............................................ 13 sulindac ............................................................. 15 sumatriptan ....................................................... 17 sumatriptan succinate ..................................... 17 sunitinib malate .................................................. 16 SUPRAX ............................................................. 13 SUPREP ............................................................. 15 SUSTIVA ............................................................ 14 SUTENT ............................................................. 16 SUTTAR-2 ............................................................ 8 SUTTAR-SF ......................................................... 8 SYMBICORT ........................................................ 5 SYMBYAX ............................................................ 6 SYMLIN .............................................................. 10 SYMLINPEN 120 ................................................ 10 SYMLINPEN 60 .................................................. 10 SYMMETREL ..................................................... 17 SYNALAR ............................................................. 9 SYNJARDY ........................................................ 10 SYNTHROID ...................................................... 11 Syringes & Accessories ..................................... 10 syringes & needles ............................................. 10 tacrolimus ........................................................... 10 tacrolimus anhydrous ...................................... 13 tadalafil ................................................................. 7 TAFINLAR .......................................................... 16 TAGAMET .......................................................... 18 TAGRISSO ......................................................... 16 TALADINE .......................................................... 18 TAMBOCOR ......................................................... 6


INDEX

804PA, oct 2016 35

TAMIFLU ............................................................ 14 tamoxifen citrate ............................................... 16 tamsulosin hcl .................................................. 18 TAPAZOLE ......................................................... 11 tapentadol hcl ..................................................... 17 TARCEVA........................................................... 16 TARGRETIN ................................................... 9, 16 TASIGNA ............................................................ 16 tazarotene........................................................... 10 TAZORAC .......................................................... 10 tazorotene foam ................................................... 9 TECFIDERA ....................................................... 16 tedizolid phosphate ............................................ 13 teduglutide .......................................................... 15 TEGRETOL ........................................................ 18 TEGRETOL XR .................................................. 18 telbivudine .......................................................... 14 telithromycin ....................................................... 13 temazepam .......................................................... 6 TEMODAR.......................................................... 15 TEMOVATE .......................................................... 9 TEMOVATE EMOLLIENT .................................... 9 temozolomide ................................................... 15 TENEX .................................................................. 7 tenofovir disoproxil fumarate .............................. 14 TENORETIC 100 .................................................. 7 TENORETIC 50 .................................................... 7 TENORMIN .......................................................... 7 terazosin hcl ....................................................... 7 terbinafine hcl ................................................. 9, 13 terbutaline sulfate .............................................. 5 teriparatide.......................................................... 11 testosterone cypionate .................................... 12 testosterone enanthate .................................... 12 testosterone gel .................................................. 12 tetrabenazine ...................................................... 16 tetracycline hcl ................................................. 13 Tetracyclines ...................................................... 13 TEXACORT .......................................................... 9 thalidomide ......................................................... 14 THALITONE ......................................................... 7 THALOMID ......................................................... 14 THEO-24 .............................................................. 5 theophylline anhydrous ..................................... 5 THERMAZENE ..................................................... 9 Thiazide & Related Diuretics ................................ 7 thioguanine ....................................................... 16 THIOGUANINE .................................................. 16 thioridazine hcl ................................................... 6 thiothixene .......................................................... 6 THORAZINE ......................................................... 6 Thrombopoietin Receptor Agonists .................... 12 Thyroid Hormones .............................................. 11 thyroid, pork ........................................................ 11 TIAZAC ................................................................. 7 ticagrelor ............................................................. 12 TIKOSYN .............................................................. 6 timolol ................................................................. 12 timolol maleate ............................................. 7, 12 TIMOPTIC .......................................................... 12 TIMOPTIC-XE .................................................... 12 timothy grass pollen extract ................................. 5 tiotropium br/olodaterol hcl ................................... 5 tiotropium bromide ................................................ 5 tipranavir ............................................................. 14 tipranavir/vitamin e tpgs ..................................... 14 TIVICAY .............................................................. 14 tizanidine hcl ..................................................... 18 TOBI ................................................................... 13 TOBI PODHALER .............................................. 13 TOBRADEX ........................................................ 11 tobramycin for inhalation ................................ 13 tobramycin for inhalation (cap) ........................... 13 tobramycin sulfate ........................................... 12 tobramycin sulfate/dexameth ......................... 11 tobramycin/lotepred etab .................................... 11 tobramycin/nebulizer .......................................... 13 TOBREX ............................................................. 12 tofacitinib citrate ................................................. 16 tofacitinib citrate XR ........................................... 16 TOFRANIL ............................................................ 6 tolazamide ......................................................... 10 tolbutamide ....................................................... 10 TOLECTIN 600 ................................................... 15 TOLINASE .......................................................... 10

tolmetin sodium ................................................ 15 tolterodine tartrate ........................................... 18 TOPAMAX .......................................................... 18 TOPAMAX SPRINKLE ....................................... 18 Topical Antibiotics ................................................ 9 Topical Antibiotics/Antiinflammatory,Steroidal ..... 9 Topical Antifungals ............................................... 9 Topical Anti-Inflammatory Steroidal ..................... 9 Topical Anti-Inflammatory, NSAIDs ..................... 9 Topical Antineoplastic & Premalignant Lesion

Agnts .............................................................. 9 Topical Antiparasitics ........................................... 9 Topical Antivirals .................................................. 9 Topical Hyperpigmentation Agents ...................... 9 Topical Immunosuppressive Agents .................. 10 Topical Local Anesthetics .................................... 9 Topical Preparations, Antibacterials .................... 9 Topical Sulfonamides ........................................... 9 TOPICORT ........................................................... 9 TOPICORT LP ..................................................... 9 topiramate ......................................................... 18 topotecan hcl ...................................................... 16 TOPROL XL ......................................................... 7 TORADOL .......................................................... 15 toremifene citrate ................................................ 16 torsemide ............................................................ 7 TOUJEO ............................................................. 10 TOVIAZ ............................................................... 18 TRACLEER .......................................................... 7 tramadol hcl ...................................................... 17 tramtinib dimethyl sulfoxide ................................ 16 TRANDATE .......................................................... 7 trandolapril .......................................................... 7 TRANXENE T-TAB .............................................. 6 tranylcypromine sulfate ..................................... 5 TRAVATAN ........................................................ 12 TRAVATAN Z ..................................................... 12 travoprost ............................................................ 12 travoprost (benzalkonium) .................................. 12 trazodone hcl ...................................................... 6 TRENTAL ........................................................... 12 tretinoin ............................................................... 16 TREXALL ............................................................ 16 triamcinolone acetonide .......................... 5, 9, 16 triamterene/hydrochlorothiazid ........................ 7 TRIAZ ................................................................... 9 triazolam .............................................................. 6 TRIBENZOR ......................................................... 7 TRICOR ................................................................ 8 Tricyclic Antidepressants & Rel. Non-Sel. Ru-

Inhib ................................................................ 6 TRIDERM ............................................................. 9 TRIDESILON ........................................................ 9 trifluoperazine hcl .............................................. 6 trifluridine .......................................................... 11 trifluridine/tipiracil hcl .......................................... 16 TRIGLIDE ............................................................. 8 trihexyphenidyl hcl........................................... 17 TRILAFON ............................................................ 6 TRILEPTAL ........................................................ 18 trimethoprim ..................................................... 13 TRI-NORINYL ...................................................... 8 TRIUMEQ ........................................................... 14 TRI-VI-FLOR W/IRON ........................................ 19 TRIZIVIR ............................................................. 14 TRUSOPT .......................................................... 12 TRUVADA .......................................................... 14 TUSNEL C ............................................................ 8 TUSNEL DIABETIC .............................................. 8 TUSSIONEX ......................................................... 8 TWINJECT ......................................................... 15 Tx For Attention Deficit-Hyperact

(ADHD)/Narcolepsy........................................ 6 Tx For Attention Deficit-Hyperact.(ADHD), Nri-

Type ............................................................... 6 TYBOST ............................................................. 14 TYKERB ............................................................. 16 TYLENOL-CODEINE NO.3 ................................ 17 TYLENOL-CODEINE NO.4 ................................ 17 TYZEKA .............................................................. 14 ULORIC .............................................................. 12 ULTRAM ............................................................. 17 ULTRASE ........................................................... 18 ULTRASE MT ..................................................... 18 ULTRAVATE ........................................................ 9

UNIPHYL .............................................................. 5 UNIRETIC ............................................................. 7 UNIVASC .............................................................. 7 UPPER GASTROINTESTINAL DISORDERS -

DIGESTIVE .................................................. 18 UPPER GASTROINTESTINAL DISORDERS -

SPASTIC DISEASE ..................................... 18 UPPER GASTROINTESTINAL DISORDERS -

ULCER DISEASE ........................................ 18 UPTRAVI .............................................................. 7 URECHOLINE .................................................... 15 URETRON D-S .................................................. 13 Uricosuric Agents ............................................... 12 uridine triacetate ........................................... 16, 17 URIN D.S. ........................................................... 13 URINARY TRACT - FUNCTIONAL DISORDERS

...................................................................... 18 Urinary Tract Analgesic Agents.......................... 18 Urinary Tract Anesthetic/Analgesic Agnt (Azo-

Dye) .............................................................. 18 Urinary Tract Antispasmodic, M(3) Selective

Antag. ........................................................... 18 Urinary Tract Antispasmodic/Antiincontinence

Agent ............................................................ 18 urofollitropin (fsh) ................................................ 11 UROXATRAL ..................................................... 18 URSO ................................................................. 15 URSO FORTE .................................................... 15 ursodiol ............................................................. 15 ustekinumab ..................................................... 15 VAGIFEM ........................................................... 19 Vaginal Antibiotics .............................................. 18 Vaginal Antifungals ............................................. 18 VAGINAL DISORDERS ..................................... 18 Vaginal Estrogen Preparations .......................... 18 Vaginal Sulfonamides......................................... 19 valacyclovir hcl ................................................. 14 VALCHLOR .......................................................... 9 VALISONE............................................................ 9 VALIUM ................................................................ 6 valproate sodium .............................................. 18 valproic acid ..................................................... 18 valsartan .............................................................. 7 valsartan/hydrochlorothiazide .......................... 7 VALTREX ........................................................... 14 VANCOCIN HCL ................................................ 14 Vancomycin & Derivatives ................................. 14 vancomycin hcl ................................................ 14 VANDAZOLE ...................................................... 18 VANOS ................................................................. 9 VANOXIDE HC ..................................................... 9 VANOXIDE-HC .................................................... 9 VANSPAR ............................................................ 6 VANTIN .............................................................. 13 VASCEPA............................................................. 8 VASERETIC ......................................................... 6 VASOCIDIN ........................................................ 11 Vasodilators, Coronary ......................................... 8 VASOTEC ............................................................ 7 V-CILLIN K ......................................................... 13 VECTICAL .......................................................... 10 vemurafinib ......................................................... 16 VENCLEXTA ...................................................... 16 venetoclax .......................................................... 16 venlafaxine hcl .................................................... 6 VENTOLIN HFA ................................................... 5 VEPESID ............................................................ 16 verapamil hcl ...................................................... 7 VERELAN ............................................................. 7 VERELAN PM ...................................................... 7 VERMOX ............................................................ 14 VESANOID ......................................................... 16 VFEND ............................................................... 13 VIAGRA .............................................................. 11 VIBRAMYCIN ..................................................... 13 VIBRAMYCIN ORAL SUSPENSION ................. 13 VIBRAMYCIN SYRUP........................................ 13 VIBRA-TABS ...................................................... 13 VICODIN ............................................................. 17 VICODIN ES ....................................................... 17 VICODIN HP....................................................... 17 VICON FORTE ................................................... 19 VICTOZA ............................................................ 10 VIDEX ................................................................. 14 VIDEX EC ........................................................... 14


INDEX

804PA, oct 2016 36

VIGAMOX ........................................................... 12 VIRACEPT.......................................................... 14 VIRAMUNE......................................................... 14 VIRAZOLE .......................................................... 14 VIREAD .............................................................. 14 VIROPTIC........................................................... 11 VISKEN ................................................................ 7 vismodegib ......................................................... 16 VISTARIL .............................................................. 5 VISTOGARD ...................................................... 16 Vitamin A Derivatives ........................................... 9 VITAMIN AND/OR MINERAL DEFICIENCY ..... 19 Vitamin B Preparations ...................................... 19 Vitamin D Preparations ...................................... 19 Vitamin K Preparations ...................................... 12 VITEKTA ............................................................. 14 VIVELLE-DOT .................................................... 12 VOLTAREN .................................................. 11, 15 VOLTAREN GEL .................................................. 9 VOLTAREN-XR .................................................. 15 voriconazole ....................................................... 13 vorinostat ............................................................ 16 VOSOL ............................................................... 10 VOSOL HC ......................................................... 10 VOTRIENT ......................................................... 16 VYTONE ............................................................... 9 VYTORIN 10/10mg, 10/20mg, 10/40mg ............. 7 VYTORIN 10/80mg .............................................. 7 VYVANSE............................................................. 6 warfarin sodium ................................................ 12 WELCHOL ............................................................ 8 WELCHOL POWDER PACKETS ........................ 8 WELLBUTRIN ...................................................... 5 WELLBUTRIN SR ................................................ 5 WELLBUTRIN XL ................................................. 5 WESTCORT ......................................................... 9

XALATAN ........................................................... 12 XALKORI ............................................................ 16 XANAX ................................................................. 6 Xanthines .............................................................. 5 XARELTO ........................................................... 12 XELJANZ ............................................................ 16 XELJANZ XR ...................................................... 16 XELODA ............................................................. 16 XENAZINE.......................................................... 16 xifaxan ................................................................ 13 XODOL 10-300 ................................................... 17 XTANDI .............................................................. 15 XURIDEN ........................................................... 17 XYLOCAINE ....................................................... 15 XYZAL .................................................................. 5 YASMIN 28 ........................................................... 8 YAZ ....................................................................... 8 YODOXIN ........................................................... 14 zaleplon ................................................................ 6 ZANAFLEX ......................................................... 18 ZANTAC ............................................................. 18 ZANTAC 25 ........................................................ 18 ZARONTIN ......................................................... 18 ZAROXOLYN ....................................................... 7 ZEBETA ................................................................ 7 ZELBORAF......................................................... 16 ZEMPLAR........................................................... 11 ZENPEP ............................................................. 18 ZENZEDI .............................................................. 6 ZERIT ................................................................. 14 ZESTORETIC ....................................................... 7 ZESTRIL ............................................................... 7 ZETIA ................................................................... 8 ZIAC ..................................................................... 7 ZIAGEN .............................................................. 14 ZIANA ................................................................... 9

zidovudine ......................................................... 14 ziprasidone hcl ................................................... 6 ZIRGAN .............................................................. 11 ZITHROMAX ...................................................... 13 ZITHROMAX TRI-PAK ....................................... 13 ZMAX .................................................................. 13 ZMAX PEDIATRIC ............................................. 13 ZOCOR ................................................................. 8 ZOFRAN ............................................................... 5 ZOFRAN ODT ...................................................... 5 ZOLINZA ............................................................ 16 zolmitriptan ......................................................... 17 ZOLOFT ............................................................... 5 zolpidem tartrate ................................................ 6 zolpidem tartrate CR .......................................... 6 ZOMIG ................................................................ 17 ZOMIG ZMT ....................................................... 17 ZONEGRAN ....................................................... 18 zonisamide ........................................................ 18 ZORTRESS ........................................................ 13 ZOVIRAX ........................................................ 9, 14 ZUBSOLV .......................................................... 17 ZYDELIG ............................................................ 16 ZYKADIA ............................................................ 16 ZYLET ................................................................ 11 ZYLOPRIM ......................................................... 12 ZYMAR ............................................................... 12 ZYMAXID ............................................................ 12 ZYPREXA ............................................................. 6 ZYPREXA ZYDIS ................................................. 6 ZYRTEC (OTC) .................................................... 5 ZYRTEC-D (OTC) ................................................ 5 ZYTIGA ............................................................... 15 ZYVOX ............................................................... 13

state of michigan commercial formulary...state of michigan commercial formulary oct 2016 table of...

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