1. No category

October 20, 2014
This formulary does not apply to Unity State and Local Government members or Unity BadgerCare Plus
members. State and Local Government members should visit www.navitus.com for information about
your prescription drug benefits. BadgerCare Plus members may call the Wisconsin Department of
Health and Family Services at 800-362-3002 or visit www.forwardhealth.wi.gov for information about
your prescription drug benefits.
Table of Contents:
FORMULARY INFORMATION ......................................................................................................................3-7
CARDIOVASCULAR AGENTS (blood pressure, heart medications) ..........................................................8-10
ENDOCRINE AGENTS (diabetes, contraceptives, hormone replacement, cholesterol lowering)..............11-16
OPHTHALMIC/OTIC (eyes and ears) ....................................................................................................16-17
INFECTIOUS DISEASE (antibiotics, antifungals, antivirals) ....................................................................17-19
ONCOLOGY/IMMUNOLOGY (cancer, inflammation, rheumatology, multiple sclerosis) ..........................20-21
CENTRAL NERVOUS SYSTEM AGENTS (depression, anxiety, sleep, mood, behavioral health,
pain management)..........................................................................................................................22-26
DERMATOLOGIC AGENTS (acne, rosacea, any topicals) ........................................................................27-29
GASTROENTEROLOGY AGENTS (heartburn, ulcers, diarrhea, constipation, nausea) ..............................29-30
MISCELLANEOUS ORAL MEDICATIONS ......................................................................................................31
RESPIRATORY AGENTS (asthma, allergies) ..........................................................................................31-32
PREVENTIVE MEDICATIONS ........................................................................................................................32
MEDICAL BENEFIT MEDICATIONS ..............................................................................................................33
APPENDIX A..........................................................................................................................................34-37
INDEX ..................................................................................................................................................38-66
PRIOR AUTHORIZATION FORMULARY EXCEPTION REQUEST FORM ............................................................67
To search the on-line version, use “CONTROL-F” and enter the drug name. You may also use the binoculars
noted as “SEARCH” and enter the drug name. The name may be listed multiple times in the document
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2
Unity Drug Formulary Information
This document is to be used as a tool to help you understand how specific medications are covered
under Unity’s Prescription Drug Formulary and is not a guarantee of coverage. This document does not
include every prescription medication available and does not apply to State of Wisconsin employees
whose drug benefit is administered by Navitus or BadgerCare Plus members whose drug benefit is
administered by ForwardHealth. The most recent version is available at www.unityhealth.com, or
can be requested in hard copy format by calling (888) 450-4884. The formulary is also available on
www.epocrates.com for PDA devices. For a detailed explanation of the pharmacy benefit, refer to the
prescription drug benefit brochure available on the website.
Using This Document
This document is organized in three columns to assist you in determining what copay your medication
will require and if any specific requirements are needed for coverage of the medication.
FORMULARY
1 Tier (Generic)
estradiol tabs
2 Tier (Brand)
conjugated estrogen tabs
(Premarin, Cenestin)
NONFORMULARY
3 Tier
conjugated estrogen tabs
(Enjuvia)
• The left column lists formulary generic medications, or 1st Tier medications. Example: estradiol
tabs are available at 1st Tier.
• The middle column lists formulary brand medications, or 2nd Tier medications. These
medications do not have a generic equivalent at this time. Example: Premarin is on the
formulary, no generic is available, available at 2nd Tier.
• The right column lists medications that are not on the formulary, or 3rd Tier medications.
These may be brand or generic products. Example: Enjuvia is not on the formulary and a
generic is not available. Formulary alternatives would be either estradiol or Premarin; Enjuvia
would be available at the 3rd Tier. Members with closed plan benefits (such as high-deductible
plans) must have an approved prior authorization for coverage of drugs in Tier 3. Discuss with
your healthcare practitioner to see if other alternatives would be appropriate for you.
Medications grouped under the same drug class heading may be appropriate alternatives for you.
You can use this guide to identify alternatives in the same drug class that may be covered at a lower
copay or without prior authorization requirements. Then, discuss with your healthcare practitioner if
these alternatives are appropriate options for you.
Generic Substitution Policy states that when equivalent generics are available for a product, the brand
product is restricted. If your healthcare practitioner feels it is medically necessary to receive the brandname product, a prior authorization must be submitted for review. Approved brand name product
authorizations will process with a Tier 3 copay when filled at the pharmacy. Refer to the prescription
drug benefit brochure and the prior authorization criteria on the Unity website for more details.
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3
Coverage Indicators: Specific requirements for coverage or parameters for coverage of specific
medications are noted in the formulary listing after the listing for each medication. An explanation of
each type of requirement or parameter is listed below.
Restricted Medications (PA)
Medications designated with a “PA” are restricted medications and require prior authorization for
coverage. Unity Health Insurance requires the submission and approval of a Medication Prior
Authorization Request form before coverage is granted for restricted medications. For members with
closed formulary benefits (1 tier, 2 tier, or HSA), all non-formulary medications also require an
approved Prior Authorization before receiving coverage.
The Medication Prior Authorization Request Form can be obtained through Unity Customer Service or
via the Unity website at www.unityhealth.com. A copy can also be found on the last page of this
document. Requests must be submitted via fax to (888) 450-4711 or can be mailed to the address on
the form. The information will be reviewed and both the requesting physician and the member will be
notified regarding the decision. If you would like to discuss the specifics of a medication request
decision with a pharmacist, or have general questions about Unity’s prior authorization criteria, you may
call 1-888-450-4884.
Quantity Limits (Q)
Medications designated with a “Q” have specific quantity limits that are different than the general
limitations of your drug benefit. Your prescription drug benefit allows coverage for a maximum supply of
30 days per prescription claim. Appendix A lists the specific quantity limits for each medication
assigned a “Q”. Individually packaged items are limited to 2 units per copay (e.g. 2 inhalers,
2 bottles, etc.) not to exceed a 30 day supply. For medications with a quantity limit, if a member
requires a higher quantity per month, prior authorization is required.
Age Limits (A)
Medications designated with an “A” are covered without prior authorization up to the designated age
limits. The age up to which it will be covered is denoted by A<18 or A<35, for example, medications will
be covered without prior authorization for members who are less than 18 or 35 years of age,
respectively. Consideration for coverage of medications with age limits may be made for those outside
the age limits by submitting a prior authorization.
Step Therapy (ST)
Medications designated with a “ST” are included as part of a step-therapy protocol, which first requires a
trial of a prerequisite medication(s) before receiving coverage for the listed products. Step therapy
medications require prior authorization. Some medications listed do not require paper PA if Step
Therapy criteria are met as the criteria have been implemented within the pharmacy claims system as
on-line edits.
Half-Tab Program (H)
Medications designated with an “H” are eligible for a half-copay when a higher strength of the
medication is cut in half. For details on the program, please refer to www.unityhealth.com for
more details.
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4
Specialty Pharmaceuticals Program (SP)
Medications denoted by “SP” are required to be obtained from a pharmacy participating in the Unity
Specialty Pharmaceuticals network for coverage through Unity. The UW Health Pharmacies are currently
participating in the Unity Specialty Pharmaceuticals network. (This does not include the Arboretum or
Evjue locations.) You can contact the UW Health Pharmacy at 1-866-894-3784 to make arrangements
for receiving the medication (by mail or pick-up at one of the pharmacy locations). Many of these drugs
also require prior authorization (denoted by PA on the formulary). Please see the drug specific criteria
for each product at www.unityhealth.com. The majority of drugs included in Unity’s Specialty Pharmacy
network have pharmacist-run management programs to maximize patient knowledge and outcomes from
these medications. This may include additional follow-up from the pharmacist or partial dispensing.
The Unity Specialty Pharmacy program DOES NOT apply to medications administered in your physician’s
office, a hospital, or other health care facility. Coverage for medications administered in a health care
facility falls under your Unity medical benefit and may be subject to other requirements. Some
members have specific benefits that require a greater, Tier 4 cost share for medications in the Specialty
Pharmaceuticals Program. Antivirals used for the treatment of Human Immunodeficiency Virus (HIV) and
medications included in the Oral Oncology Program are included in the Unity Specialty Pharmaceuticals
Program, but are exempt from the Tier 4 copay for these members. Please refer to your Schedule of
Benefits to see if you are part of this program. Please refer to www.unityhealth.com for further details
on the Unity Specialty Pharmaceuticals Program.
Narrow Therapeutic Index Drugs (NTI)
Some medications do not require substitution when a generic product is available. These are
exemptions to the generic substitution policy and are designated by “NTI”. Medications that are
listed on the NTI list will be covered at the brand copay if the prescription is filled with the brand
name product.
Over-the-Counter (OTC)
Medications that do not require a prescription are not covered under the pharmacy benefit unless
specifically listed as approved by the Unity Pharmacy & Therapeutics Committee.
General Exclusions
Medications that are designated as excluded means that your prescription benefit plan does not cover
these medications. Examples of these medications include hair loss medications, sexual dysfunction
medications, infertility medications, most over-the-counter medications, cosmetic treatments and
nutritional supplements.
Oral Oncology Program
Medications listed in this section of the formulary have been identified as requiring additional
monitoring to provide the best patient outcomes and reduce waste. Prescriptions for these medications
must be filled at the UW Carbone Cancer Center Pharmacy (608-263-7025) and a pharmacist trained
in cancer therapies will assist a member through their treatment course. During the first three months
of treatment members will only receive two weeks of medication at a time.
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5
RX Outcomes (*)
Medications designated by an asterisks (*) are included in the RX Outcomes Benefit. These
medications have been shown to improve the overall health of patients with diseases like high blood
pressure (hypertension), high blood sugar (diabetes), and breathing difficulties (asthma) when taken on
a daily basis. For members whose employers have purchased the RX Outcomes Benefit, the designated
medications will process with a $5 copay.
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6
Where to find information when you have questions
Topic
Where Available
To check the formulary status or restriction status of unityhealth.com/drug formulary
a drug
To obtain a copy of Unity’s Prescription Drug
Formulary
unityhealth.com/drug formulary
To appeal a Prior Authorization denial
Unity Customer Service
800-362-3310
To speak to a clinical pharmacist about why a Prior
Authorization Request was denied
Unity Clinical Pharmacy Program
888-450-4884
For criteria for coverage of a medication
Unity Clinical Pharmacy Program
888-450-4884 or unityhealth.com/medpriorauth
Early refills, vacation supplies, emergency supplies,
new member supply, reimbursement of medications
purchased out-of-pocket
unityhealth.com/pharmacy
To enroll in the RX90 Extended Supply program
UW Health Pharmacy
866-894-3784
Hometown Pharmacy (does not include Shopko)
888-846-1819
Mallatt’s Pharmacy and Costume
608-238-3106
The Medicine Shoppe Pharmacy of McFarland
888-247-5534
Ballweg Family Pharmacy
855-336-4714
Eannelli Pharmacy
800-717-3396
To enroll in the Unity Specialty Pharmaceuticals
Program
UW Health Pharmacy
866-894-3784
To inquire about the RX90 Extended Supply program unityhealth.com/pharmacy
or the Specialty Pharmaceuticals program
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7
FORMULARY
1 Tier (Generic)
2 Tier (Brand)
NONFORMULARY
3 Tier
CARDIOVASCULAR AGENTS (Blood Pressure, Heart Rhythm, Heart Medicine)
ACE-Inhibitors
benazepril*
benazepril/amlodipine
benazepril/HCTZ*
captopril*
captopril/HCTZ*
enalapril*
enalapril/HCTZ*
fosinopril*
fosinopril/HCTZ*
lisinopril*
lisinopril/HCTZ*
perindopril*
quinapril*
quinapril/HCTZ*
ramipril*
trandolapril
enalapril soln (Epaned)
moexipril
moexipril/HCTZ
trandolapril/verapamil (Tarka)
Angiotensin II Antagonists (ARBS)
candesartan*
candesartan/HCTZ*
irbesartan*
irbesartan/HCTZ*
losartan*
losartan/HCTZ*
valsartan
valsartan/HCTZ
PA
PA
amlodipine/olmesartan (Azor)
amlodipine/telmisartan
amlodipine/valsartan (Exforge)
amlodipine/valsartan/HCTZ (Exforge HCT)
amlodipine/olmesartan/HCTZ (Tribenzor)
azilsartan (Edarbi)
azilsartan/chlorthalidone (Edarbyclor)
eprosartan
eprosartan/HCTZ (Teveten HCT)
olmesartan (Benicar)
olmesartan/HCTZ (Benicar HCT)
telmisartan
telmisartan/HCTZ
Q
Q
Beta Blockers
acebutolol
atenolol*
atenolol/chlorthalidone*
bisoprolol
bisoprolol/HCTZ
carvedilol (reserve for CHF)*
labetalol
metoprolol/HCTZ
metoprolol succinate (XL)*
metoprolol tartrate*
nadolol
pindolol
propranolol
propranolol LA (Inderal LA equiv.)
propranolol soln (Generics)
propranolol/HCTZ
timolol
sotalol, sotalol AF
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propranolol LA (Innopran XL, Inderal XL)
betaxolol
carvedilol CR (Coreg CR)
metoprolol succinate/HCTZ (Dutoprol)
nadolol/bendroflumethizide
nebivolol (Bystolic)
propranolol soln (Hemangeol)
Q
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
8
Q
Q
PA
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
CARDIOVASCULAR AGENTS (Blood Pressure, Heart Rhythm, Heart Medicine)
Calcium Channel Blockers
amlodipine*
benazepril/amlodipine
diltiazem
diltiazem ER (12H)*
diltiazem ER (24H)*
diltiazem LA (Matzim LA, generics)*
felodipine
nifedipine
nifedipine ER*
nimodipine caps
verapamil
verapamil ER*
nimodipine soln (Nymalize)
aliskiren/amlodipine (Tekamlo)
amlodipine/atorvastatin
amlodipine/olmesartan (Azor)
amlodipine/telmisartan
amlodipine/valsartan (Exforge)
amlodipine/valsartan/hctz (Exforge HCT)
isradipine
nicardipine
nicardipine SR (Cardene SR)
nisoldipine
trandolapril/verapamil (Tarka)
triamterene (Dyrenium)
ethacrynic acid (Edecrin)
tolvaptan (Samsca)
Diuretics
amiloride
amiloride/HCTZ
bumetanide*
chlorthalidone*
chlorthiazide*
clonidine/chlorthalidone
eplerenone
furosemide*
hydralazine/HCTZ
hydrochlorothiazide (HCTZ)*
indapamide*
metolazone*
spironolactone*
spironolactone/HCTZ*
torsemide
triamterene/HCTZ*
PA
Adrenergics
clonidine
clonidine patch
doxazosin
guanabenz
guanfacine
methyldopa
methyldopa/HCTZ
prazosin
terazosin
doxazosin ER (Cardura XL)
Antiarrhythmics
amiodarone (generic, Pacerone)
digoxin (generic, Digitek)
disopyramide
flecainide
mexiletine
procainamide
propafenone
quinidine
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NTI
NTI
NTI
NTI
amiodarone (Cordarone)
digoxin (Lanoxin)
disopyramide (Norpace)
disopyramide ER (Norpace CR)
procainamide (Pronestyl)
quinidine (Quinidex)
NTI
NTI
NTI
NTI
NTI
NTI
dofetilide (Tikosyn)
dronedarone (Multaq)
propafenone SR
NTI
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
9
Q
Q
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
CARDIOVASCULAR AGENTS (Blood Pressure, Heart Rhythm, Heart Medicine)
Vasodilators/Nitrates/Miscellaneous Cardiovascular
hydralazine
hydralazine/HCTZ
hydralazine/reserpine
isosorbide dinitrate*
isosorbide mononitrate
midodrine
nitroglycerin patch
reserpine
sildenafil (Revatio equiv.)•
ambrisentan (Letairis)
bosentan (Tracleer)
nitroglycerin ointment (Nitro-bid)
nitroglycerin spray (Nitrolingual)
nitroglycerin tablets (Nitrostat)
ranolazine (Ranexa)
sildenafil susp (Revatio)•
treprostinil neb (Tyvaso)
PA
PA
PA
PA
aliskiren (Tekturna)
aliskiren/amlodipine (Tekamlo)
aliskiren/HCTZ (Tekturna HCT)
aliskiren/amlodipine/HCTZ (Amturnide)
droxidopa (Northera)
isosorbide dinitrate/hydralazine (BiDil)
iloprost (Ventavis)
macitentan (Opsumit)
mecamylamine (Vecamyl)
minoxidil
nitroglycerin spray (Nitromist equiv.)
phenoxybenzamine (Dibenzyline)
riociguat (Adempas)
tadalafil (Adcirca)
treprostinil diolamine (Orenitram ER)
Q
Q
Q
Q
PA
PA
PA Q
PA
PA Q
• Medications used for the treatment of erectile dysfunction are not a covered benefit
Blood Related (Antiplatelet, Clotting, Blood Building)
aminocaproic acid
anagrelide
cilostazol
clopidogrel*
dipyridamole
enoxaparin
pentoxifylline
ticlopidine
tranexamic acid
warfarin (Jantoven, generics)*
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NTI
dabigatran (Pradaxa)
Q
dalteparin (Fragmin)
darbepoetin for home use (Aranesp)
PA
erythropoeitin for home use (Procrit, Epogen) PA
filgrastim (Neupogen)
oprelvekin (Neumega)
PA SP Q
prasugrel (Effient)
PA
phytonadione (Mephyton)
rivaroxaban (Xarelto)
sargramostim (Leukine)
TBO-filgrastim (Granix)
ticagrelor (Brilinta)
warfarin (Coumadin)
NTI
apixaban (Eliquis)
aspirin/dipyridamole (Aggrenox)
deferiprone (Ferriprox)
desirudin (Iprivask)
eltrombopag (Promacta)
fondaparinux
pegfilgrastim (Neulasta)
tinzaparin (Innohep)
vorapaxar (Zontivity)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
PA SP Q
PA Q
PA Q
10
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
ENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)
Diabetes Medications – Sulfonylureas
chlorpropamide
glimepiride*
glipizide*
glipizide ER
glyburide*
tolazamide
tolbutamide
Diabetes Medications – Other Oral
acarbose
metformin*
metformin/glipizide
metformin/glyburide*
metformin ER* (Glucophage XR equiv.)
nateglinide
repaglinide
canagliflozin (Invokana)
canagliflozin/metformin (Invokamet)
metformin liquid (Riomet)
sitagliptin (Januvia)
sitagliptin/metformin (Janumet)
sitagliptin/metformin ER (Janumet XR)
sitagliptin/simvastatin (Juvisync)
PA Q
PA
Q
Q
alogliptin (Nesina)
alogliptin/metformin (Kazano)
alogliptin/pioglitazone (Oseni)
dapagliflozin (Farxiga)
empagliflozin (Jardiance)
linagliptin (Tradjenta)
linagliptin/metformin (Jentadueto)
metformin ER (Glumetza)
miglitol (Glyset)
repaglinide/metformin (Prandimet)
saxagliptin (Onglyza)
saxagliptin/metformin (Kombiglyze XR)
PA Q
PA
PA Q
PA Q
PA Q
PA Q
PA
PA Q
PA
Diabetes Medications – TZD
pioglitazone
pioglitazone/glimepiride
pioglitazone/metformin
alogliptin/pioglitazone (Oseni)
PA Q
pioglitazone/metformin XR (Actoplus Met XR)
rosiglitazone (Avandia)
rosiglitazone/glimepiride (Avandaryl)
rosiglitazone/metformin (Avandamet)
Diabetes Medications – Insulin and Other Injections
exenatide (Byetta)
exenatide weekly (Bydureon)
human insulin (Novolin R vial)*
human insulin-concentrated
(Humulin R U-500 vial)
insulin glargine (Lantus vial, Solostar pen)*
human insulin mix 70/30
(Novolin 70/30 vial and pen)*
human isophane (Novolin N vial and pen)*
insulin aspart (Novolog vial and pen)*
insulin aspart mix
(Novolog 70/30 vial and pen)*
insulin detemir (Levemir vial and pen)*
glucagon kit (GlucaGen)
ST
ST
Q
albiglutide (Tanzeum)
human insulin (Humulin R vial)
human insulin mix 70/30
(Humulin 70/30 vial)
human insulin mix 70/30
(Humulin 70/30 pen)
human isophane (Humulin N vial)
human isophane (Humulin N pen)
PA
PA
PA
insulin lispro (Humalog vial)
insulin lispro (Humalog pen)
insulin lispro mix (Humalog mix vial)
insulin lispro mix (Humalog mix pen)
insulin glulisine (Apidra vial)
insulin glulisine (Apidra Solostar pen)
liraglutide (Victoza)
pramlintide (Symlin)
Most insulin products (vials and pens) are limited to 30 ml/month; additional quantity requires PA
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PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
11
PA
PA
PA
PA
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
ENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)
Diabetes Medications – Test Strips and Other Supplies
insulin syringes*
Test strips-Abbott (Freestyle, Freestyle Lite,
Freestyle Insulinx, Precision Xtra)*
Test strips-Bayer (Contour, Contour Next,
Breeze 2, Ascensia)*
Test strips-Lifescan (One Touch Ultra
Blue-Animas pump use only)
lancets*
needles (for insulin syringes)*
Test strips-Lifescan (One Touch Verio IQ)
PA
Test strips-Roche (Accu-Chek, Aviva, Active) PA
PA
pen needles (for insulin pens)*
Abbott and Bayer glucometers are available at Unity Network Pharmacies for $0 copay (limit 1 meter/fill)
Test strips are limited to a quantity of 200/month; Additional quantity requires PA
Diabetes supplies (insulin syringes, needles, lancets, control solutions) are included in the value tier for RX Outcomes benefits*
Cholesterol Lowering Agents – Other
cholestyramine
cholestyramine light
colestipol
niacin extended release
colesevelam (Welchol)
colestipol (Colestid)
ezetimibe (Zetia)
omega-3 acid ethylesters (Lovaza)
ST Q
icosapent ethyl (Vascepa)
lomitapide (Juxtapid)
mipomersen (Kynamro)
niacin (Niacor)
ST Q
PA
PA
Cholesterol Lowering Agents - Fibrates
fenofibrate (Lofibra equiv.)
fenofibrate (Tricor equiv., Antara equiv.,
Triglide, Lipofen equiv., Fenoglide)
fenofibric acid
gemfibrozil*
ST
ST
Cholesterol Lowering Agents – Statins
atorvastatin*
lovastatin*
pravastatin*
simvastatin•*
Q
ezetimibe/simvastatin (Vytorin)•
lovastatin/niacin (Advicor)
rosuvastatin (Crestor) 20, 40 mg
simvastatin/niacin (Simcor)
sitagliptin/simvastatin (Juvisync)
Q
PA Q
Q
Q
amlodipine/atorvastatin
ezetimibe/atorvastatin (Liptruzet)
fluvastatin
fluvastatin XL (Lescol XL)
lovastatin (Altoprev)
pitavastatin (Livalo)
rosuvastatin (Crestor) 5, 10 mg
Q
PA Q
Q
Q
Q
PA Q
PA Q
• 80 mg doses require prior authorization (PA)
Calcium Metabolism/Osteoporosis – Miscellaneous
calcitriol oral
calcitonin nasal (Miacalcin Equiv.)
ergocalciferol
raloxifene•
calcitonin nasal (Fortical)
cinacalcet (Sensipar)
teriparatide (Forteo)
PA SP Q
conjugated estrogens/bazedoxifene (Duavee)
doxercalciferol
miglustat (Zavesca)
PA
paricalcitol
• covered at $0 cost share
Osteoporosis – Bisphosphonates
alendronate
etidronate
risedronate 150 mg
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risedronate 5, 30, 35 mg (Actonel, Atelvia)
Q
Q
alendronate/cholecalciferol (FosamaxD)
alendronate effervescent (Binosto)
ibandronate
tiludronate (Skelid)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
12
Q
Q
Q
FORMULARY
1 Tier (Generic)
2 Tier (Brand)
NONFORMULARY
3 Tier
ENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)
Electrolytes/Minerals/Supplements – Prescription Only
calcium acetate
fluoride drops, chew tab (generic, Epiflur)
folic acid
prenatal multivitamin*
potassium chloride (generic, Klor-Con)
sevelamer carbonate tab (Renvela equiv.)
sodium bicarbonate
sodium polystyrene sulfonate
calcium acetate soln (Phoslyra soln)
cyanocobalamin nasal (Nascobal)
fluoride (Fluoritab, Ludent, Flurabon)
fluoride paste, gel, cream, soln (Prevident)
lanthanum (Fosrenol)
levocarnitine (Carnitor)
prenatal multivitamin (NataChew, Natafort,
Vitafol+DHA, CitraNatal Assure)
sevelamer (Renagel)
sevelamer carbonate packet (Renvela)
citric acid/sodium citrate (Bicitra)
cyanocobalamin/folic acid/pyridoxine (Foltx)
deferasirox (Exjade)
fluoride tab (Flura-tab, Flura)
fluoride lozenge (FluraTab)
fluoride/xylitol (Fluor-A-Day)
potassium phosphate/sodium phosphate
(K-Phos)
prenatal multivitamin (Prenate, Crnatal,
Duet DHA Balanced)
sucroferric oxyhydroxide (Velphoro)
PA
Multi-Phasic Contraceptives (biphasic, triphasic, quadriphasic)
Desogestrel/Ethinyl estradiol:
Kariva, Azurette, Viorele, Pimtrea
Velivet, Caziant
Levonorgestrel/Ethinyl estradiol:
Trivora, Enpresse, Myzilra, Levonest
Norethindrone/Ethinyl estradiol:
Necon 10/11
Tri-Legest FE, Tilia Fe
Necon 777, Nortrel 777, Cyclafem 777,
Alyacen 777, Dasetta 777, Pirmella 777
Dienogest/Estradiol valerate:
Natazia
PA
Levonorgestrel/Ethinyl estradiol:
Amethia, Camrese, Daysee (3 copays)
Amethia Lo, Camrese Lo (3 copays)
Quartette
PA
PA
PA
Norethindrone/Ethinyl estradiol:
Aranelle, Leena
PA
Norgestimate/Ethinyl estradiol:
Ortho Tri-Cyclen Lo
PA
Norgestimate/Ethinyl estradiol:
Tri-Previfem, Trinessa, Tri-Sprintec, Tri-Linyah,
Tri-Estarylla
Contraceptives administered in a clinic are not covered as part of the pharmacy benefit;
some benefits allow 3 month supplies to be filled at retail pharmacies; approved claims will have a $0 cost share.
10-20-14
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
13
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
ENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)
Monophasic Contraceptives
Desogestrel/Ethinyl estradiol:
Reclipsen, Apri, Emoquette, Enskyce
Drospirenone/Ethinyl estradiol:
Beyaz, Gianvi, Loryna, Vestura
Ocella, Syeda, Zarah, Safyral
PA
PA
Ethynodiol diacetate/Ethinyl estradiol:
Zovia 1/35, Kelnor 1/35
Zovia 1/50
Levonorgestrel/Ethinyl estradiol:
Amethyst
PA
Levonorgestrel/Ethinyl estradiol:
Aviane, Aubra, Lessina, Lutera, Orsythia,
Sronyx, Falmina
Levora, Portia, Altavera, Marlissa, Kurvelo,
Chateal
Jolessa, Quasense, Introvale (3 copays)
Norethindrone/Ethinyl estradiol:
Generess FE
Lomedia 24 FE, Minastrin 24 FE
LoLoestrin FE, LoMinastrin FE
Balziva, Briellyn, Zeosa, Zenchent FE, Philith,
Gildagia
Norelgestromine/Ethinyl estradiol:
Xulane Patch
Norgestrel/Ethinyl estradiol:
Ogestrel
Q
PA
Norethindrone/Ethinyl estradiol:
Junel FE 1.5/30, Microgestin FE 1.5/30,
Gildess FE 1.5/30
Junel FE 1/20, Microgestin FE 1/20,
Gildess FE 1/20, Larin FE 1/20
Nortrel 0.5/35, Necon 0.5/35, Wera,
Brevicon
Necon 1/35, Nortrel 1/35, Cyclafem 1/35,
Alyacen 1/35, Dasetta 1/35,
Pirmella 1/35, Norinyl 1/35
Necon 1/50
Norgestimate/Ethinyl estradiol:
Sprintec, Mono-Linyah, Mononessa, Estarylla,
Previfem
Noregestrel/Ethinyl estradiol:
Cryselle, Low-Ogestrel, Elinest
Contraceptives administered in a clinic are not covered as part of the pharmacy benefit;
some benefits allow 3 month supplies to be filled at retail pharmacies; approved claims will have a $0 cost share.
Progestin-Only Contraceptives
Camila, Errin, Heather, Jolivette, NoraBe,
Jencycla
Contraceptives administered in a clinic are not covered as part of the pharmacy benefit;
some benefits allow 3 month supplies to be filled at retail pharmacies; approved claims will have a $0 cost share.
Other Contraceptives
levonorgestrel (Next Choice)
levonorgestrel (Next Choice One Dose,
My Way)
Xulane Patch
Q
Q
NuvaRing
ulipristal (Ella)
Q
Q
A prescription is required for Emergency Contraceptives to be covered on the pharmacy benefit
10-20-14
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
PA
PA
PA
PA
14
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
ENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)
Hormone Replacement – Oral Estrogen/Progestin
estropipate tab
conjugated estrogens tab (Cenestin, Premarin)
estradiol tab
conjugated estrogens/medroxyprogesterone tab
(Premphase, Prempro, PremproLo)
esterified estrogen tab (Menest)
esterified estrogen/methyltestosterone
(Covaryx, EEMT)
ethinyl estradiol/norethindrone tab (Jinteli)
esterified estrogen/methyltestosterone tab
(Syntest)
compounded hormones (estrogen,
progesterone)
conjugated estrogens tab (Enjuvia)
PA
conjugated estrogens/bazedoxifene (Duavee)
estradiol/norethindrone tab
estradiol acetate (Femtrace)
estradiol/norgestimate tab (Prefest)
estradiol/drospirenone (Angeliq)
Hormone Replacement – Transdermal Estrogen/Progestin
estradiol weekly patch (Climara equiv.)
Q
estradiol twice weekly patch (Vivelle-dot,
Alora, Minivelle)
estradiol/norethindrone twice weekly patch
(Combipatch)
Q
estradiol weekly patch (Menostar)
Q
Q
estradiol/levonorgestrel weekly patch
(ClimaraPro)
Q
Hormone Replacement – Topical Estrogen/Progestin
conjugated estrogen cream (Premarin cream)
estradiol vaginal tab (Vagifem)
estradiol vaginal cream (Estrace)
estradiol vaginal ring (Estring)
estradiol topical gel (Estrasorb, Estrogel,
Elestrin, Divigel)
estradiol vaginal ring (Femring)
estradiol spray (Evamist)
Q
Q
Hormone Replacement – Testosterone/Progesterone
fluoxymesterone (Androxy)
methyltestosterone (Testred, Methitest,
Android)
testosterone cypionate injection
(Depo-Testosterone)
testosterone topical packets (Androgel)
medroxyprogesterone
progesterone
testosterone enanthate injection
compounded hormones (progesterone,
testosterone)
norethindrone tab
PA
progesterone suppository (Endometrin,
PA
First Progesterone)
progesterone gel (Prochieve, Crinone)
PA
progesterone injection
PA
testosterone buccal (Striant)
testosterone topical (Fortestra equiv., Axiron)
testosterone topical (Androgel pump)
testosterone topical patches (Androderm)
Miscellaneous Hormones
bromocriptine
danazol
desmopressin (DDAVP)
levothyroxine (generics)
liothyronine
megestrol
cabergoline (Dostinex)
desmopressin nasal (Stimate)
thyroid pork (Armour Thyroid)
histrelin (Supprelin)
levothyroxine (Synthroid, Levothroid,
Levoxyl, Unithroid)
megestrol (Megace, ES)
methimazole
nafarelin (Synarel)
NTI
octreotide for home use
PA
oxandrolone
potassium iodide (SSKI)
propylthiouracil
thyroid pork (Westhroid, Nature-Throid)
PA
10-20-14
octreotide depot for home use
(Sandostatin LAR)
NTI
bromocriptine (Cycloset)
clomiphene - hypogonadism only
corticotropin gel (Acthar HP)
degarelix acetate for home use (Firmagon)
glycerol phenylbutyrate (Ravicti)
PA
human chorionic gonadotropin for home use- PA
hypogonadism only (Novarel, Pregnyl)
lanreotide for home use
PA SP
(Somatuline Depot)
leuprolide for home use (Lupron, generic)
PA
levothyroxine (Tirosint)
metreleptin (Myalept)
pasireotide (Signifor)
sapropterin (Kuvan)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
PA
PA
PA
PA
PA
PA
15
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
ENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)
Growth Hormones
somatropin (Tev-Tropin)
somatropin (Serostim) - AIDS wasting
PA SP
PA SP
mecasermin (Increlex, Iplex)
pegvisomant (Somavert)
somatropin (Genotropin, Humatrope,
Norditropin, Nutropin, Nutropin AQ,
PA SP
PA SP
PA SP
OPHTHALMIC/OTIC (Eyes/Ears – Allergies, Glaucoma, Inflammation,
Infection)
Omnitrope, Saizen,
Zorbtive)
Eye Allergy
azelastine
cromolyn
naphazoline
emedastine (Emadine)
lodoxamide (Alomide)
olopatadine (Patanol, Pataday)
alcaftadine (Lastacaft)
bepostastine (Bepreve)
epinastine
nedocromil (Alocril)
apraclonidine 1% (Iopidine)
betaxolol (Betoptic S)
brimonidine/timolol (Combigan)
brinzolamide (Azopt)
carbachol (Isopto Carbachol)
echothiophate (Phospholine)
timolol (Istalol)
travoprost (Travatan Z)
apraclonidine 0.5%
bimatoprost (Lumigan)
brimonidine 0.1% (Alphagan P)
brimonidine/brinzolamide (Simbrinza)
dorzolamide/timolol PF (Cosopt PF)
tafluprost (Zioptan)
unoprostone isopropyl (Rescula)
ketorolac PF (Acuvail)
nepafenac (Nevanac, Ilevro)
prednisolone/sulfacetamide (Blephamide)
prednisolone (Pred Forte)
NTI
tobramycin/dexamethasone ointment
(Tobradex ointment)
bromfenac (generics, Prolensa)
difluprednate (Durezol)
fluorometholone (FML Forte)
fluorometholone (FML SOP)
fluorometholone acetate (Flarex)
Glaucoma
brimonidine
carteolol
dorzolamide
dorzolamide/timolol
latanoprost
levobunolol
metipranolol
pilocarpine
timolol (Timoptic equiv.)
timolol XE
travoprost benzalkonium
Eye NSAIDS – Inflammation
diclofenac
fluorometholone
flurbiprofen
ketorolac (0.4%, 0.5%)
neomycin/bacitracin/polymyxin/hydrocortisone
ointment
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/hydrocortisone
prednisolone
prednisolone/sulfacetamide
loteprednol (Alrex, Lotemax)
rimexolone (Vexol)
tobramycin/lotepred (Zylet)
tobramycin/dexamethasone 0.3/0.05% drops
(Tobradex ST)
tobramycin/dexamethasone 0.3/0.1% drops
Eye Anti-infectives
bacitracin
bacitracin/polymyxin B
ciprofloxacin drops
erythromycin
gatifloxacin
gentamicin
neomycin/polymyxin/gramicidin
ofloxacin
polymyxin/trimethoprim
sulfacetamide ophthalmic
tobramycin
10-20-14
gentamicin/prednisolone (Pred-G)
moxifloxacin (Vigamox, Moxeza)
azithromycin (Azasite)
besifloxacin (Besivance)
ciprofloxacin ointment (Ciloxan)
doxycycline (Alodox kit)
ganciclovir (Zirgan)
levofloxacin (generics, Iquix)
natamycin (Natacyn)
sulfacetamide (Bleph-10)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
16
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
OPHTHALMIC/OTIC (Eyes/Ears – Allergies, Glaucoma, Inflammation, Infection)
Other Miscellaneous Eye Products
atropine
cyclopentolate
homatropine 5%
phenylephrine
proparacaine ophthalmic
homatropine 2% (Isopto Homatropine)
benoxinate/fluorescein (Altafluor, Flurox)
cyclosporine (Restasis)
cysteamine (Cystaran)
hydroxyamphetamine/tropicamide (Paremyd)
hydroxypropyl cellulose ophthalmic insert
(Lacrisert)
scopolamine (Isopto Hyoscine)
ciprofloxacin/hydrocortisone (Cipro HC)
ciprofloxacin/dexamethasone (Ciprodex)
antipyrine/benzocaine/zinc (Otozin)
chloroxylenol/benzoc/hydrocortisone (Trioxin)
fluocinolone otic (DermOtic)
tetracaine
trifluridine
tropicamide
Miscellaneous Ear Products
acetic acid
antipyrine/benzocaine
acetic acid/hydrocortisone
ciprofloxacin otic
ofloxacin otic
neomycin/polymyxin/hydrocortisone otic
INFECTIOUS DISEASE
Penicillins
amoxicillin
amoxicillin/clavulanate
amoxicillin/clavulanate ER
amoxicillin/clavulanate ES
ampicillin
dicloxacillin
penicillin VK (Veetids, PenVee K)
amoxicillin ER
Cephalosporins
cephalexin
cefpodoxime
cefdinir
cefaclor
cefadroxil
cefuroxime (Ceftin)
cefprozil (generics, Cefzil)
ceftibuten
cefditoren
cefixime (Suprax)
Quinolones
ciprofloxacin
levofloxacin oral
moxifloxacin
norfloxacin (Noroxin)
ciprofloxacin XR
gatifloxacin (Tequin)
gemifloxacin (Factive)
lomefloxacin (Maxaquin)
ofloxacin
Q
Macrolide/Ketolide
azithromycin
clarithromycin
clarithromycin ER
erythromycin
erythromycin ethyl succinate
erythromycin stearate (Erythrocin)
erythromycin/sulfisoxazole
10-20-14
clarithromycin (Biaxin suspension)
erythromycin (Erytab, Emycin)
azithromycin (Zmax)
erythromycin ethyl succinate (Eryped)
telithromycin (Ketek)
erythromycin ethyl succinate (EES)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
17
Q
PA Q
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
INFECTIOUS DISEASE
Sulfonamides/Tetracyclines
doxycycline hyclate tab 20, 100 mg
doxycyline hyclate cap 50, 100 mg
doxycycline monohydrate tab 50, 75, 100 mg
doxycycline suspension (Vibramycin susp)
sulfisoxazole (Gantrisin)
tetracycline tabs (Sumycin)
demeclocycline (Declomycin)
doxycycline monohydrate tab 150 mg
doxycycline monohydrate cap 75, 150 mg
(generics, Adoxa, Oracea)
doxycycline hyclate tab (Acticlate)
doxycycline hyclate DR cap 75, 100 mg
doxycycline hyclate DR tab 75, 100, 150 mg
doxycycline hyclate gel (Atridox)
clindamycin granules (Cleocin granules)
fidaxomicin (Dificid)
PA Q
interferon alfa-n3 (Alferon)
PA SP
interferon gamma (Actimmune)
PA SP
linezolid (Zyvox)
PA
methenamine (Mandelamine)
nitrofurantoin 25 mg (Macrodantin)
rifaximin (Xifaxan)
Q
clofazamine (Lamprene)
fosfomycin (Monurol)
methenamine/sodium salicylate (Cystex)
tedizolid (Sivextro)
albendazole (Albenza)
ivermectin (Stromectol)
pentamidine (Nebupent)
praziquantel (Biltricide)
nitazoxanide (Alinia)
tinidazole
doxycycline monohydrate cap 50, 100 mg
minocycline
sulfadiazine
sulfisoxazole
tetracycline capsule
trimethoprim/sulfa (TMP-Sulfa, Cotrim,
Sulfatrim)
Miscellaneous Anti-infectives
chlorhexidine
clindamycin capsules
methenamine (Urex)
metronidazole
neomycin
nitrofurantoin
trimethoprim
vancomycin oral
PA
Anti-Parasitics
paromomycin
Antimalarials
atovaquone
atovaquone/proquanil
chloroquine
hydroxychloroquine
mefloquine
quinine 260 mg
artemether/lumefantrine (Coartem)
primaquine
pyrimethamine (Daraprim)
quinine 324 mg
Antifungals
amphotericin
clotrimazole troche
fluconazole
griseofulvin
griseofulvin ultramicrosize
itraconazole (Sporanox equiv.)
ketoconazole
nystatin
terbinafine tablets
voriconazole
posaconazole susp (Noxafil)
terbinafine granules (Lamisil granules)
PA
flucytosine
itraconazole (Onmel)
miconazole (Oravig)
posaconazole tab (Noxafil)
PA
PA
PA
PA
Anti-TB
dapsone
ethambutol
isoniazid
pyrazinamide
rifabutin
rifampin
10-20-14
isoniazid/rifampin (Rifamate)
isoniazid/pyrazinamide (Rifater)
bedaquiline (Sirturo)
cycloserine (Seromycin)
ethionamide (Trecator)
rifapentine (Priftin)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
18
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
INFECTIOUS DISEASE
Antiviral – Hepatitis
adefovir
entecavir
boceprevir (Victrelis)
interferon alfa (Intron A)
lamivudine
1st line: pegylated interferon
(PegIntron)
2nd line: pegylated interferon
(Pegasys)
ribavirin solution (Rebetol)
sofosbuvir (Sovaldi)
telaprevir (Incivek)
ribavirin
PA SP
PA SP
PA SP Q
interferon alfacon (Infergen)
ribavirin (Ribapak, Moderiba,
Ribasphere 400 mg & 600 mg)
simeprevir (Olysio)
PA SP Q
telbivudine (Tyzeka)
PA SP
PA
PA SP Q
PA SP Q
PA SP
Antiviral – HIV
abacavir tablets*
abacavir/lamivudine/zidovudine*
didanosine*
lamivudine*
lamivudine/zidovudine
nevirapine*
nevirapine XR*
stavudine
zidovudine*
SP
SP
SP
SP
SP
SP
SP
SP
SP
abacavir suspension (Ziagen suspension)*
abacavir/dolutegravir/lamivudine (Triumeq)
abacavir/lamivudine (Epzicom)*
atazanavir (Reyataz)*
darunavir (Prezista)*
delavirdine (Rescriptor)*
dolutegravir (Tivicay)*
efavirenz (Sustiva)*
efavirenz/emtricitabine/tenofovir (Atripla)*
elvitegravir/cobicistat/emtricitabine/
tenofovir (Stribild)*
emtricitabine (Emtriva)*
emtricitabine/rilpivirine/tenofovir
(Complera)*
emtricitabine/tenofovir (Truvada)*
enfuvirtide (Fuzeon)*
etravirine (Intelence)*
fosamprenavir (Lexiva)*
indinavir (Crixivan)*
lopinavir/ritonavir (Kaletra)*
nelfinavir (Viracept)*
raltegravir (Isentress)*
rilpivirine (Edurant)*
ritonavir (Norvir)*
saquinivir (Invirase)*
tenofovir (Viread)*
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
maraviroc (Selzentry)
tipranavir (Aptivus)
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
The tier 4 (specialty) copay does not apply to HIV antivirals; copay will depend on the drug's formulary tier
Other Antiviral
acyclovir oral
amantadine
rimantadine
valacyclovir
10-20-14
oseltamivir (Tamiflu)
valganciclovir (Valcyte)
zanamivir (Relenza)
Q
Q
acyclovir buccal (Sitavig)
acyclovir topical
famciclovir
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
19
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
ONCOLOGY/IMMUNOLOGY
Anti-inflammatory/Immunology/Immunosuppressants
allopurinol
azathioprine (Imuran equiv.)
cyclosporine
cyclosporine modified (Gengraf)
dexamethasone
fludrocortisone
hydrocortisone
hydroxychloroquine
leflunomide
methylprednisolone
mycophenolate mofetil
mycophenolic acid
prednisolone soln (Generics)
prednisone
probenecid
sirolimus 0.5 mg
sulfasalazine
tacrolimus
NTI
NTI
auranofin (Ridaura)
colchicine (Colcrys)
cyclosporine (Sandimmune)
cyclosporine modified (Neoral)
febuxostat (Uloric)
penicillamine (Cuprimine, Depen)
prednisolone soln (Veripred)
prednisolone tab (Millipred)
sirolimus 1, 2 mg (Rapamune)
subcutaneous immune globulin (Hizentra)
triamcinolone (Aristocort)
NTI
NTI
PA
azathioprine (Azasan)
everolimus (Zortress)
icatibant (Firazyr)
pegylated interferon alfa 2b (Sylatron)
PA
prednisolone soln (Flo-Pred, Millipred)
prednisolone dispersible tab (Orapred ODT)
prednisone ER (Rayos)
ruxolitinib (Jakafi)
PA
tacrolimus ER (Astagraf XL)
PA
Oncology/Cancer
anastrozole
bicalutamide
capecitabine
cyclophosphamide
etoposide
exemestane
flutamide
hydroxyurea (Hydrea equiv.)
letrozole
leucovorin
busulfan (Myleran)
chlorambucil (Leukeran)
estramustine (Emcyt)
hydroxyurea (Droxia)
interferon alfa (Intron A)
lapatinib (Tykerb)
lenalidomide (Revlimid)
melphalan (Alkeran)
mesna (Mesnex)
mitotane (Lysodren)
levocarnitine
lomustine
mercaptopurine
methotrexate
tamoxifen•
temozolomide
procarbazine (Matulane)
thioguanine (Tabloid)
toremifene (Fareston)
vorinostat (Zolinza)
PA Q
PA SP
PA
PA Q
PA
abiraterone (Zytiga)
PA
afatinib (Gilotrif)
PA Q
bexarotene (Targretin)
cabozantinib (Cometriq)
PA
ceritinib (Zykadia)
PA
crizotinib (Xalkori)
PA
dabrafenib (Tafinlar)
PA
ibrutinib (Imbruvica)
PA
idelalisib (Zydelig)
PA Q
leuprolide for home use (generic, Lupron,
PA
Eligard)
mechlorethamine topical (Valchlor)
mercaptopurine susp (Purixan)
pomalidomide (Pomalyst)
PA
ponatinib (Iclusig)
PA
regorafenib (Stivarga)
PA
thalidomide (Thalomid)
topotecan (Hycamtin)
PA
trametinib (Mekinist)
PA
tretinoin capsules
vandetanib (Caprelsa)
PA
vismodegib (Erivedge)
PA
• covered at $0 cost share
10-20-14
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
20
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
ONCOLOGY/IMMUNOLOGY
Oncology–Oral Oncology Program Medications
dasatinib (Sprycel)
erlotinib (Tarceva)
imatinib (Gleevec)
sorafenib (Nexavar)
sunitinib (Sutent)
PA SP
PA SP Q
PA SP
PA SP
PA SP
axitinib (Inlyta)
PA SP
bosutinib (Bosulif)
PA SP
enzalutamide (Xtandi)
PA SP
everolimus (Afinitor)
PA SP
everolimus soluble tab (Afinitor Disperz) PA SP
nilotinib (Tasigna)
PA SP Q
pazopanib (Votrient)
PA SP
vemurafenib (Zelboraf)
PA SP
The tier 4 (specialty) copay does not apply to medications included in the oral oncology program;
copay will depend on the drug's formulary tier
Biologic Response Modifiers for Rheumatologic Disorders
methotrexate
1st line: adalimumab (Humira)
PA SP Q
2nd line: certolizumab pegol (Cimzia) PA SP Q
1st line: etanercept (Enbrel)
PA SP Q
abatacept SQ (Orencia)
anakinra (Kineret)
apremilast (Otezla)
golimumab (Simponi)
methotrexate (Otrexup, Rasuvo)
tocilizumab (Actemra)
tofacitinib (Xeljanz)
ustekinumab (Stelara)
PA SP Q
PA SP Q
PA Q
PA SP Q
PA
PA SP Q
PA SP
PA SP Q
methotrexate is first line before biologics
Multiple Sclerosis Medications
glatiramer 20 mg (Copaxone)
interferon beta-1a (Rebif)
interferon beta-1b (Extavia)
10-20-14
PA SP
PA SP
PA SP
dalfampridine (Ampyra)
dimethyl fumarate (Tecfidera)
fingolimod (Gilenya)
glatiramer 40 mg (Copaxone)
interferon beta-1a (Avonex)
interferon beta-1b (Betaseron)
teriflunomide (Aubagio)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
PA
PA Q
PA SP
PA SP
PA SP
PA SP
PA Q
21
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
CENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health, Sleep, etc.)
Antipsychotics
amitriptyline/perphenazine
chlorpromazine
clozapine
fluphenazine
haloperidol
lithium
lithium ER
loxapine
olanzapine
quetiapine
risperidone
thioridazine
thiothixene
trifluoroperazine
ziprasidone
NTI
NTI
NTI
aripiprazole (Abilify) 10, 20, 30 mg
aripiprazole (Abilify) 2, 5, 15 mg
clozapine (Clozaril)
Lithium (Eskalith)
lithium ER (Lithobid)
molindone (Moban)
pimozide (Orap)
PA Q H
PA Q
NTI
NTI
NTI
aripiprazole ODT (Abilify Discmelt)
asenapine (Saphris)
clozapine suspension (Versacloz)
clozapine ODT (FazaClo ODT)
fluoxetine/olanzapine
iloperidone (Fanapt)
lurasidone (Latuda)
olanzapine ODT
paliperidone (Invega)
quetiapine ER (Seroquel XR)
risperidone ODT
PA
NTI
Q
Alcohol/Drug Cessation
acamprosate
buprenorphine/naloxone sublingual film)
(Suboxone)
buprenorphine/naloxone sublingual tab
(Zubsolv)
buprenorphine/naloxone sublingual film
(Bunavail)
buprenorphine
buprenorphine/naloxone sublingual tab
disulfiram
methadone
naltrexone
Smoking Cessation ($0 cost share with a written prescription only)
bupropion SR (Zyban equiv. only)
nicotine patch (Nicoderm CQ, generics)
nicotine gum (Nicorette)
nicotine lozenge (Nicorette, Commit)
varenicline (Chantix)
Q
Q
nicotine inhaler (Nicotrol inhaler)
nicotine spray (Nicotrol NS)
PA
PA
Smoking cessation therapy is limited to two 90 day courses (180 days total) per calendar year
CNS Stimulants (ADD/ADHD)
amphetamine-dextroamphetamine combo
amphetamine-dextroamphetamine ER combo
dextroamphetamine (Dexedrine equiv.)
methamphetamine
methylphenidate
methylphenidate CD 30:70
(Metadate CD equiv.)
methylphenidate ER (Concerta equiv.)
methylphenidate SR (Metadate ER equiv.)
modafinil
PA Q
10-20-14
atomoxetine (Strattera)
methylphenidate patch (Daytrana)
Q
armodafinil (Nuvigil)
clonidine SR
dextroamphetamine (Zenzedi)
dexmethylphenidate
dexmethylphenidate XR
guanfacine ER (Intuniv)
PA Q
Q
lisdexamfetamine (Vyvanse)
Q
methylphenidate CD 50:50 (Ritalin LA equiv.)
methylphenidate ER oral susp. (Quillivant XR)
sodium oxybate (Xyrem)
PA
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
22
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
CENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health, Sleep, etc.)
Antidepressants – Tricyclic
amitriptyline
amoxapine
clomipramine
desipramine
doxepin
imipramine
nortriptyline
maprotiline
protriptyline
trimipramine
imipramine pamoate
Antidepressants – SSRI/SNRI
citalopram*
fluoxetine tab 10 mg (Sarafem)*
duloxetine
escitalopram*
fluoxetine cap*
fluoxetine tab 10, 60 mg (Prozac equiv.)*
fluoxetine tab 20 mg (Prozac equiv.)*
PA
fluvoxamine
paroxetine*
sertraline*
venlafaxine IR
venlafaxine ER tablets
venlafaxine SR capsules*
fluoxetine tab 20 mg (Sarafem)*
milnacipran (Savella)
PA
PA Q
desvenlafaxine (Pristiq,
Desvenlafaxine Fumarate ER)
fluoxetine weekly
fluvoxamine CR
levomilnacipran (Fetzima)
paroxetine mesylate (Pexeva)
paroxetine CR
vilazodone (Viibryd)
vortioxetine (Brintellix)
PA Q
Q
PA Q
PA Q
PA Q
Other Antidepressants
bupropion XL 150/300 mg*
bupropion*
bupropion SR*
nefazodone
mirtazapine*
phenelzine
tranylcypromine
trazodone*
Q
bupropion XL 450 mg (Forfivo XL)
bupropion hbr (Aplenzin)
isocarboxazid (Marplan)
selegiline patch (Emsam)
trazodone ER (Oleptro) ER)
Q
Q
Antianxiety
alprazolam
buspirone
chlordiazepoxide
clonazepam
clorazepate
diazepam
lorazepam
oxazepam
meprobamate
clorazepate ER
alprazolam ER
clonazepam ODT
midazolam syrup
Hypnotics (Sleeping)
estazolam
eszopiclone
flurazepam
temazepam
triazolam
zaleplon
zolpidem
10-20-14
ramelteon (Rozerem)
PA Q
Q
doxepin (Silenor)
quazepam
tasimelteon (Hetlioz)
zolpidem sublingual (Edluar, Intermezzo)
zolpidem CR
zolpidem spray (Zolpimist)
Q
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
23
PA Q
Q
Q
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
CENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health, Sleep, etc.)
Alzheimer's Disease/Other Neurological Disease
donepezil
galantamine
galantamine ER
pyridostigmine
riluzole
Q
memantine (Namenda)
memantine ERC (Namenda XR)
pyridostigmine SR (Mestinon SR)
PA
PA
dextromethorphan/quinidine (Nuedexta)
rivastigmine
rivastigmine patch (Exelon)
carbamazepine (Tegretol, Carbatrol)
carbamazepine SR (Tegretol XR)
divalproex sodium (Depakote)
divalproex sodium ER (Depakote ER)
methsuximide (Celontin)
phenytoin (Dilantin,Phenytek)
pregabalin (Lyrica)
primidone (Mysoline)
valproic acid (Depakene)
NTI
NTI
NTI
NTI
carbamazepine (Equetro)
NTI
clobazam (Onfi)
diazepam rectal
eslicarbazepine acetate (Aptiom)
ethotoin (Peganone)
ezogabine (Potiga)
felbamate
gabapentin soln (Fanatrex)
gabapentin ER (Horizant)
Q
gabapentin SR 300 mg (Gralise)
lacosamide (Vimpat)
Q
lamotrigine ODT (Lamictal ODT)
lamotrigine ER
Q
oxcarbazepine ER (Oxtellar XR)
perampanel (Fycompa)
rufinamide (Banzel)
tiagabine
topiramate ER (Trokendi XR, Qudexy XR equiv.)
valproic acid SA (Stavzor)
vigabatrin (Sabril)
Anticonvulsants (Seizures)
carbamazepine
carbamazepine SR
clonazepam
divalproex sodium
divalproex sodium ER
ethosuximide
gabapentin
lamotrigine
levetiracetam
levetiracetam ER
lorazepam
oxcarbazepine
phenytoin
phenobarbital
primidone
topiramate
valproic acid
zonisamide
NTI
NTI
NTI
NTI
NTI
NTI
NTI
NTI
PA Q
NTI
NTI
Migraine Products
acetaminophen/butalbital/caffeine/codeine
acetaminophen/butalbital/caffeine
acetaminophen/dichloralphenazone/
isometheptene
aspirin/butalbital/caffeine
butorphanol nasal spray
Q
dihydroergotamine nasal
(Prodrin)
methylergonovine
Q
ergotamine/caffeine (Cafergot)
acetaminophen/butalbital (Orbivan CF)
acetaminophen/butalbital/caffeine (Orbivan)
acetaminophen/dihydrocodeine/caffeine (Trezix)
aspirin/dihydrocodeine/caffeine
dihydroergotamine injection
for home use (DHE)
isometheptene/acetaminophen/caffeine
PA
Migraine Products – Triptans
naratriptan
rizatriptan
sumatriptan injection
sumatriptan tablets
sumatriptan nasal
10-20-14
Q
Q
Q
Q
Q
almotriptan (Axert)
eletriptan (Relpax)
frovatriptan (Frova)
sumatriptan (Sumavel Dosepro)
sumatriptan/naproxen (Treximet)
zolmitriptan
zolmitriptan nasal (Zomig)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
Q
Q
Q
Q
Q
Q
Q
24
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
CENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health, Sleep, etc.)
Muscle Relaxants/Muscle Spasm
baclofen
carisoprodol
carisoprodol/aspirin
chlorzoxazone 500 mg
cyclobenzaprine
metaxalone
methocarbamol
orphenadrine
orphenadrine/aspirin/caffeine
tizanidine tablets
chlorzoxazone 375, 750 mg (Lorzone)
cyclobenzaprine ER (Amrix)
dantrolene
tizanidine capsules
NSAIDS/Pain Relief/Pain medications
acetaminophen/phenyltolxamine
diclofenac sodium
diclofenac/misoprostol
diflunisal
etodolac
fenoprofen 600 mg
flurbiprofen
ibuprofen
indomethacin
ketoprofen
lidocaine 2% viscous
lidocaine 4%, 5% topical
lidocaine patch 5%
meclofenamate
meloxicam
nabumetone
naproxen
naproxen ER
naproxen sodium
oxaprozin
piroxicam
salsalate
sulindac
tolmetin
10-20-14
celecoxib (Celebrex)
fenoprofen 200, 400 mg (Nalfon)
PA Q
diclofenac gel (Voltaren gel, Solaraze equiv.)
diclofenac epolamine patch (Flector patch)
diclofenac potassium (Zipsor, Cambia)
diclofenac submicronized (Zorvolex)
diclofenac topical
hydrocortisone/lidocaine cream
ketorolac
Q
ketorolac injection for home use
ketorolac nasal (Sprix)
lidocaine 3% (LidoRX)
lidocaine patch 4% (Vexa)
mefenamic acid
naproxen sodium ER
naproxen sodium (Naprelan)
sumatriptan/naproxen (Treximet)
Q
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
25
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
CENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health, Sleep, etc.)
Narcotics
acetaminophen/codeine
acetaminophen/hydrocodone
acetaminophen/oxycodone
codeine
fentanyl patch
morphine
oxycodone (Oxecta)
oxycodone ER (Oxycontin)
Q
rasagiline (Azilect)
Q
PA Q
hydromorphone
levorphanol
methadone
morphine ER capsule (Kadian equiv.)
morphine ER tablet (MS Contin equiv.)
oxycodone
tramadol
tramadol/acetaminophen
PA
acetaminophen/hydrocodone (Vicodin, Hycet)
acetaminophen/oxycodone (Magnacet, Xolox)
acetaminophen/oxycodone ER
PA Q
(Xartemis XR)
buprenorphine patch (Butrans)
fentanyl oral (Abstral, Actiq, Fentora,
PA Q
generic)
fentanyl transmucosal film (Onsolis)
PA Q
fentanyl nasal (Lazanda)
PA Q
fentanyl sublingual spray (Subsys)
PA Q
hydrocodone ER (Zohydro ER)
PA Q
hydromorphone ER
ibuprofen/hydrocodone(Reprexain, Ibudone)
ibuprofen/oxycodone
morphine ER capsule (Avinza equiv.)
PA Q
morphine/naltrexone (Embeda)
Q
oxymorphone
PA
oxymorphone ER
PA Q
oxymorphone injection (Numorphan)
tapentadol (Nucynta)
Q
tapentadol ER (Nucynta ER)
Q
tramadol ER (Conzip, generics)
Q
tramadol ODT (Rybix ODT)
Parkinson's Disease
amantadine
benztropine
bromocriptine
carbidopa
carbidopa/levodopa
carbidopa/levodopa CR
pramipexole
ropinirole
selegiline
trihexyphenidyl
10-20-14
apomorphine (Apokyn)
carbidopa/levodopa/entacapone
entacapone
pramipexole ER (Mirapex ER)
ropinirole XL
rotigotine (Neupro)
tetrabenazine (Xenazine)
tolcapone (Tasmar)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
Q
26
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
DERMATOLOGIC AGENTS (Acne, Inflammation, Psoriasis, etc.)
Oral Acne
doxycycline hyclate tab 100 mg
doxycycline hyclate cap 50, 100 mg
doxycycline monohydrate tab 50, 75, 100 mg
doxycycline monohydrate cap 50, 100 mg
isotretinoin (Amnesteem, Claravis, Isotret,
Myorisan, Zenatane)
minocycline capsules
doxycycline hyclate DR tab 75, 100, 150 mg
doxycycline hyclate DR cap 75, 100 mg
doxycycline monohydrate tab 150 mg
doxycycline monohydrate cap 75, 150 mg
isotretinoin (Absorica)
minocycline tablets
minocycline ER
Topical Acne – Prescription Strength Only Covered
adapalene cream, gel
A<35
benzoyl peroxide
benzoyl peroxide/cleanser kit (Lavoclen-4,
Lavoclen-8)
benzoyl peroxide/erythromycin
clindamycin
clindamycin/benzoyl peroxide
erythromycin
metronidazole
sulfacetamide sodium wash, cleanser
sulfacetamide/sulfur 9%/4.5% cleanser
sulfacetamide/sulfur 10%/1% cleanser
sulfacetamide/sulfur 10%/5% cream,
cleanser, medicated pads, foam, lotion,
suspension
tretinoin
A<35
azelaic acid (Azelex, Finacea)
benzoyl peroxide (Brevoxyl, Desquam, Pacnex)
benzoyl peroxide/sulfur (Nuox)
adapalene lotion (Differin)
adapalene/benzoyl peroxide (Epiduo)
azelaic acid/ceramide (Finacea Plus)
clindamycin/benzoyl peroxide (Acanya)
benzoyl peroxide (Soluclenz RX,
NeoBenz Micro, Riax)
benzoyl peroxide/aloe vera
benzoyl peroxide/hydrocortisone (Bencort)
benzoyl peroxide/urea (ZoDerm)
clindamycin kit (Clindareach)
clindamycin/tretinoin (Ziana, Veltin)
clindamycin gel (Clindagel)
dapsone topical (Aczone)
erythromycin (Akne-mycin)
metronidazole (Noritate)
sulfacetamide/sulfur 10%/5% cleanser
(Rosanil)
tazarotene (Tazorac, Fabior)
tretinoin (Atralin)
PA
PA
PA
10-20-14
PA
salicylic acid solution (Durasal, Virasal, generic)
sulfacetamide sodium lotion (Ovace Plus)
sulfacetamide sodium shampoo, suspension
sulfacetamide/sulfur 8%/4% suspension
sulfacetamide/sulfur 9%/4% cleanser
sulfacetamide/sulfur 9.5%/5% medicated pads
(Avar)
sulfacetamide/sulfur 9.8%/4.8% cleanser,
cream, medicated pads, lotion (Plexion)
sulfacetamide/sulfur 10%/2% cream,
medicated pads (Avar LS)
sulfacetamide/sulfur 10%/4% foam,
medicated pads
tretinoin microsphere 0.04%, 0.1%
PA
tretinoin microsphere 0.8% (Retin A Micro) PA
tretinoin (Tretin-X)
PA
Topical Antibacterial (Rx Only)
clindamycin
gentamicin
mupirocin
silver sulfadiazine
PA
PA
mupirocin nasal ointment (Bactroban Nasal)
mafenide
retapamulin (Altabax)
sulfanilamide (AVC)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
27
FORMULARY
1 Tier (Generic)
2 Tier (Brand)
NONFORMULARY
3 Tier
DERMATOLOGIC AGENTS (Acne, Inflammation, Psoriasis, etc.)
Topical Antifungal (Rx Only)
butoconazole (Mycelex-3)
ciclopirox
butenafine (Mentax)
oxiconazole (Oxistat)
clotrimazole
clotrimazole/betamethasone cream
econazole cream
ketoconazole cream
nystatin topical
nystatin/triamcinolone
selenium sulfide suspension
sulconazole (Exederm)
ciclopirox nail lacquer
ciclopirox nail lacquer/nail lacquer
remover kit
clotrimazole/betamethasone lotion
econazole foam (Ecoza)
efinaconazole (Jublia)
ketoconazole foam
ketoconazole gel (Xolegel)
ketoconazole/pyrithione (Xolegel Duo)
luliconazole (Luzu)
miconazole/zinc oxide/petrolatum (Vusion)
naftifine (Naftin)
selenium sulfide foam, shampoo (Selrx,
Tersi Foam)
sertraconazole (Ertaczo)
tavaborole (Kerydin)
Antivirals, Antiparasitic and Other Topicals
calcipotriene ointment (generics, Calcitrene)
calcitriol topical
calcipotriene cream (Dovonex equiv.)
doxepin
fluorouracil
imiquimod (Aldara equiv.)
permethrin
podofilox
triamcinolone oropharyngeal
becaplermin (Regranex)
calcipotriene foam (Sorilux)
crotamiton (Eurax)
fluorouracil 0.5% cream (Carac)
pimecrolimus (Elidel)
podofilox gel (Condylox)
tacrolimus (Protopic)
acyclovir/hydrocortisone (Xerese)
acyclovir/lidocaine (Lidovir)
acyclovir topical
amlexanox (Aphthasol)
ammonium lactate 12%
anthralin (Zithranol-RR)
benzyl alcohol topical (Ulesfia)
betamethasone/calcipotriene
brimonidine gel (Mirvaso)
imiquimod (Zyclara)
ingenol (Picato)
ivermectin topical (Sklice)
lindane lotion/shampoo
lidocaine/tetracaine (Pliaglis)
malathion
neomycin sulfate/fluocinolone (Neo-Synalar)
penciclovir (Denavir)
podophyllin topical (Podocon 25)
salicylic acid/ceramides (Salex)
sinecatechins (Veregen)
spinosad
urea 47% (Keralac)
hydrocortisone/pramoxine lotion/ointment
(Pramosone)
desonide topical gel/lotion/foam (Tridesilon,
Desonate)
hydrocortisone soln (Texacort)
hydrocortisone/urea (U-Cort)
Corticosteroids – Low Potency
alclometasone
desonide topical cream/ointment
dexamethasone
hydrocortisone butyrate
hydrocortisone/pramoxine cream
hydrocortisone (Rx only)
10-20-14
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
28
PA
PA
PA
PA
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
DERMATOLOGIC AGENTS (Acne, Inflammation, Psoriasis, etc.)
Corticosteroids – Medium to High Potency
amcinonide
betamethasone valerate
betamethasone dipropionate
desoximetasone cream/gel/ointment
fluocinonide 0.05%
fluocinolone
fluticasone cream/ointment
mometasone topical
prednicarbate
triamcinolone topical
fluocinolone shampoo (Capex)
fluocinolone oil (Derma-Smoothe/FS)
flurandrenolide (Cordran, Cordran SP)
halcinonide (Halog)
betamethasone/calcipotriene
clocortolone
desoximetasone spray (Topicort)
diflorasone
fluocinonide 0.1%
fluticasone lotion
clobetasol spray (Clobex)
clobetasol foam
halobetasol/ammonium lactate
Corticosteroids – Very High Potency
augmented betamethasone diproprionate
clobetasol topical
halobetasol
Biologics & Others for Psoriasis
1st line: adalimumab (Humira)
1st line: entanercept (Enbrel)
PA SP Q
PA SP Q
acitretin
ustekinumab (Stelara)
PA SP Q
GASTROENTEROLOGY AGENTS (Ulcers, Heartburn, Nausea, Diarrhea, Constipation, etc.)
H2 Antagonists/Ulcer
cimetidine
famotidine
misoprostol
ranitidine
sucralfate
biskalcitrate/metronidazole/tetracycline (Pylera)
ibuprofen/famotidine (Duexis)
mepenzolate (Cantil)
nizatidine (generic, Axid)
Proton Pump Inhibitors
1st line: omeprazole, Prilosec OTC covered Q
with prescription
Q
1st line: pantoprazole
2nd line: lansoprazole
PA Q
lansoprazole soltab (Prevacid SoluTab - PA Q
age <18 only)
omeprazole powder (Prilosec suspension)
pantoprazole powder (Protonix suspension)
dexlansoprazole (Dexilant)
PA Q
esomeprazole (Nexium)
esomeprazole strontium
esomeprazole/naproxen (Vimovo)
lansoprazole compound kit
(First-lansoprazole)
lansoprazole/amoxicillin/clarithromycin
omeprazole/amoxacillin/clarithromycin
(Omeclamox-Pak)
omeprazole compound kit
omeprazole/sodium bicarbonate
rabeprazole tab
rabeprazole cap (Aciphex Sprinkles)
PA Q
PA Q
PA Q
PA Q
PA Q
PA Q
PA Q
PA Q
PA Q
Nausea/Vomiting
ondansetron
granisetron
promethazine
metoclopramide
prochlorperazine
trimethobenzamide
10-20-14
Q
Q
aprepitant (Emend)
prochlorperazine syrup (Compazine)
scopolamine patch (TransdermScop)
Q
Q
dolasetron (Anzemet)
doxylamine/pyridoxine (Diclegis)
dronabinol
granisetron patch (Sancuso)
metoclopramide ODT (Metozolv)
nabilone (Cesamet)
ondansetron film (Zuplenz)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
Q
Q
PA Q
29
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
GASTROENTEROLOGY AGENTS (Ulcers, Heartburn, Nausea, Diarrhea, Constipation, etc.)
Antispasmodic, Antidiarrheal
atropine/hyoscyamine/phenobarbital/
scopolamine
dicyclomine
diphenoxylate/atropine
hyoscyamine
phenazopyridine (Rx only)
propantheline
chlordiazepoxide/clindium (Librax)
alosetron (Lotronex)
PA Q
difenoxin/atropine (Motofen)
crofelemer (Fulyzaq)
hyoscyamine/phenyltoloxamine (Digex NF)
Constipation, Miscellaneous GI
balsalazide (Colazal equiv.)
budesonide oral (Entocort equiv.)
hydrocortisone rectal
Q
hydrocortisone/lidocaine rectal
(Peranex HC equiv.)
lactulose solution (Constulose, Enulose,
Generlac)
pancrealipase
PEG/electrolytes (generic, TriLyte)
PEG/electrolytes packets (Gavilyte-G)
sulfasalazine
ursodiol
budesonide oral (Uceris)
hydrocortisone rectal (Cortifoam)
linaclotide (Linzess)
mesalamine (Pentasa, Asacol HD, Delzicol)
balsalazide (Giazo)
chenodiol (Chenodal)
hydrocortisone/lidocaine rectal
(Rectagel HC equiv.)
laculose soln (Kristalose)
mesalamine rectal (Canasa)
lubiprostone (Amitiza)
nitroglycerin rectal ointment (Rectiv)
olsalazine (Dipentum)
pancrealipase (Creon, Ultrase, Pancreaze,
Pertzye, Ultresa, Viokace, Zenpep)
PEG/electrolytes packets (Colyte)
mesalamine (Lialda, Apriso)
methylnaltrexone (Relistor)
PA Q
PEG/electrolytes & bisacodyl (Halflytely Kit)
PEG/electrolytes/sodium ascorbate
(MoviPrep)
sodium phosphate (OsmoPrep)
Q
PA Q
Q
PA Q
PEG/electrolytes & sodium, potassium, and
magnesium sulfate (Suclear)
sodium, potassium and magnesium sulfate
(Suprep)
sodium picosulfate/magnesium oxide/citric acid
(Prepopik)
teduglutide (Gattex)
PA
Urinary Incontinence/BPH
alfuzosin
bethanechol
doxazosin
finasteride
flavoxate
oxybutynin
oxybutynin XL
prazosin
tamsulosin
terazosin
tolterodine
tolterodine ER
mirabegron (Myrbetriq)
ST Q
Q
darifenacin (Enablex)
dutasteride (Avodart)
dutasteride/tamsulosin (Jalyn)
fesoterodine fumarate (Toviaz)
oxybutynin patch (Oxytrol)∆
oxybutynin topical (Gelnique)
silodosin (Rapaflo)
solifenacin (Vesicare)
tadalafil (Cialis)•
trospium ER
trospium
Q
Q
Q
PA Q
PA Q
Q
• Medications used for the treatment of erectile dysfunction are not a covered benefit
∆ RX covered for men
Biologics for Inflammatory Bowel Disease (Crohns, Ulcerative Colitis)
1st line: adalimumab (Humira)
2nd line: certolizumab (Cimzia)
10-20-14
PA SP Q
PA SP Q
golimumab (Simponi)
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
PA SP Q
30
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
MISCELLANEOUS ORAL MEDICATIONS
acetazolamide
cevimeline
cromolyn sodium
glycopyrrolate (Robinul equiv.)
methazolamide
pilocarpine oral
ivacaftor (Kalydeco)
PA
carglumic acid (Carbaglu)
cysteamine bitartrate (Cystagon, Procysbi)
eliglustat (Cerdelga)
glycopyrrolate (Cuvposa, Glycate)
nitisinone (Orfadin)
paroxetine mesylate (Brisdelle)
pentosan (Elmiron)
sodium phenylbutyrate (Buphenyl)
sucralfate paste (Orafate)
PA
PA
RESPIRATORY AGENTS (Asthma, Allergies, etc.)
Allergy (Antihistamines, Cold Products, Miscellaneous Allergy Medications)
cyproheptadine
benzonatate
hydroxyzine
mixed grass pollen (Oralair)
short ragweed pollen (Ragwitek)
timothy grass pollen (Grastek)
PA Q
PA Q
PA Q
carbinoxamine
carbinoxamine ER susp (Karbinal ER)
desloratadine
PA
desloratadine/pseudoephedrine (Clarinex D) PA
doxylamine (Doxytex)
levocetirizine
PA
OTC antihistamines are not covered as part of the pharmacy benefit (fexofenadine, loratadine, cetirizine, diphenhydramine)
Cost of OTC products may be less than the applicable co-pay
Buy in bulk and buy generic to reduce the cost of therapy for OTC products
Nasal Corticosteroids/Antihistamine
azelastine nasal antihistamine spray
budesonide nasal
fluticasone nasal
ipratropium nasal
fluticasone furoate nasal (Veramyst)
azelastine/fluticasone nasal (Dymista)
PA
beclomethasone nasal (Beconase AQ, Qnasl)
ciclesonide nasal (Omnaris, Zetonna HFA)
flunisolide nasal
mometasone nasal (Nasonex)
olopatadine (Patanase)
triamcinolone nasal
fluticasone inhaler (Flovent)*
fluticasone-salmeterol inhaler (Advair)*
fluticasone furoate/vilanterol inhaler
(Breo Ellipta)
mometasone inhaler (Asmanex)*
mometasone-formoterol inhaler (Dulera)*
budesonide inhaler (Pulmicort)
budesonide-formoterol inhaler (Symbicort)
beclomethasone inhaler (QVAR)
PA
PA
PA
ciclesonide inhaled (Alvesco)
flunisolide inhaler (Aerospan)
PA
PA
albuterol HFA (Proventil HFA, Ventolin HFA)
albuterol-ipratropium inhaler (Combivent)
formoterol inhaler (Foradil)
formoterol nebulizer solution (Perforomist)
salmeterol inhaler (Serevent)
arformoterol inhaler (Brovana)
albuterol HFA (ProAir HFA)
indacaterol (Arcapta)
levalbuterol inhaler (Xopenex HFA)
levalbuterol nebulizer solution
olodaterol (Striverdi Respimat)
pirbuterol inhaler (Maxair)
PA
Inhaled Corticosteroids
budesonide nebulizer solution
Inhaled Beta Agonists
albuterol nebulizer solution
albuterol-ipratropium nebulizer solution
10-20-14
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
PA
31
FORMULARY
1 Tier (Generic)
NONFORMULARY
3 Tier
2 Tier (Brand)
RESPIRATORY AGENTS (Asthma, Allergies, etc.)
Other Inhaled Medications
cromolyn nebulizer solution
ipratropium
ipratropium HFA inhaler (Atrovent HFA)
tiotropium inhaler (Spiriva)
umeclidinium/vilanterol (Anoro Ellipta)
aclidinium bromide (Tudorza Pressair)
Inhaler assistance devices/spacers are included in the value tier of RX Outcomes benefits*
Oral Respiratory Medications
albuterol tabs
metaproterenol tabs
montelukast*
terbutaline tabs
theophylline
dyphylline (Lufyllin)
theophylline (Theo-24, Theocap)
NTI
roflumilast (Daliresp)
zafirlukast
zileuton (Zyflo)
NTI
Other Respiratory Medications
sodium chloride 3% for inh
sodium chloride 7% for inh
tobramycin inj for inh
tobramycin inhalation (TOBI equiv.)
aztreonam lysine (Cayston)
PA Q
colistimethate for inhalation (Coly-mycin)
dornase alfa (Pulmozyme)
Q
epinephrine injection (Epipen, Epipen Jr)
sodium chloride 6% for inh (Nebusal)
tobramycin inhalation (TOBI Podhaler,
PA
Bethkis)
acetylcysteine
epinephrine injection (Auvi-Q)
PREVENTIVE MEDICATIONS (Prescription required for OTC versions)
ferrous sulfate drops
ferrous sulfate oral suspension
aspirin 81 mg, 162 mg, 325 mg
aspirin 81 mg, 162 mg, 325 mg
cholecalciferol (vitamin D) 400 units
folic acid tablets 400 mcg, 800 mcg
fluoride drops and chewable tablets
age 6 to 12 months
age 6 to 12 months
females age 55 to 79 years, 1 tablet per day dosing, 100 days supply
males age 45 to 79 years, 1 tablet per day dosing, 100 days supply
members age ≥ 65 years, 1 tablet or capsule per day dosing, 100 days supply
females age 15 to 50 years, 1 tablet per day dosing, 100 days supply
age 6 months to 6 years
$0 copay, generics only when available
Buying OTC bottles in larger quantities without a prescription may be more convenient
10-20-14
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
32
FORMULARY
1 Tier (Generic)
2 Tier (Brand)
NONFORMULARY
3 Tier
MEDICAL BENEFIT MEDICATIONS
These medications are clinic administered and covered under the medical benefit but require a PA from the
Unity Pharmacy Program. Member costs for these medications is dependent on their medical benefit structure
(pharmacy benefit copays do not apply).
abobotulinum toxin (Dysport)
PA
abatacept (Orencia)
PA
alglucosidase alfa (Myozyme, Lumizyme)
PA
canakinumab (Ilaris)
PA
denosumab (Prolia, Xgeva)
PA
eculizumab (Soliris)
PA
human chorionic gonadotropin
(Novarel, Pregnyl)
human papillomavirus vaccine
A
(Gardasil, Cervarix)
hydroxyprogesterone caproate injection
PA
(Makena)
incobotulinum toxin (Xeomin)
PA
infliximab (Remicade)
PA
natalizumab (Tysabri)
PA
omalizumab (Xolair)
PA
onabotulinum toxin (Botox)
PA
palivizumab (Synagis)
PA
pegfilgrastim (Neulasta)
PA
rilonacept (Arcalyst)
PA
rimabotulinum toxin (Myobloc)
PA
rituximab (Rituxan) for rheumatology only
PA
(use for other diagnoses including oncology
do not require prior authorization at this time)
romiplostim (Nplate)
PA
tocilizumab (Actemra)
PA
ustekinumab (Stelara)
PA
vedolizumab (Entyvio)
PA
zoster vaccine (Zostavax)
A
not covered as a medical benefit, see PA criteria
covered for members ages 9 to 26
covered for members age 60 and older†
† Members whose Unity coverage is sponsored by the State of Wisconsin Employee Trust Fund (ETF) are covered from
age 60 to 64. Members age 65 or older have coverage through their Navitus pharmacy benefit
10-20-14
PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;
SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit
33
Appendix A: Medication Quantity Limit Information
Medication Name (Brand)
Dose(s)/Indication
Quantity Limit*
abatacept (Orencia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
acetaminophen/oxycodone ER (Xartemis XR) . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
afatinib (Gilotrif) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
adalimumab (Humira) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
alendronate (Binosto) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 mg . . . . . . . . . . . . . . . . . . . . . . . . . .4
alendronate/cholecalciferol (Fosamax Plus D) . . . . . . . . . . . .35 mg, 70 mg . . . . . . . . . . . . . . . . . . . .4
aliskiren (Tekturna) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
aliskiren/amlodipine (Tekamlo) . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
aliskiren/amlodipine/HCTZ (Amturnide) . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
aliskiren/hydrochlorothiazide (Tekturna HCT) . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
almotriptan (Axert) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
alogliptin (Nesina) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
alogliptin/pioglitazone (Oseni) . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
alosetron (Lotronex) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0.5 mg . . . . . . . . . . . . . . . . . . . . . . . . . .90
alosetron (Lotronex) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 mg . . . . . . . . . . . . . . . . . . . . . . . . . . .60
anakinra (Kineret) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
apremilast (Otezla) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
aprepitant (Emend) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 mg . . . . . . . . . . . . . . . . . . . . . . . . . .1
aprepitant (Emend) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 mg . . . . . . . . . . . . . . . . . . . . . . . . . .4
aprepitant (Emend) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125 mg . . . . . . . . . . . . . . . . . . . . . . . . .2
aprepitant (Emend) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Trifold Kit . . . . . . . . . . . . . . . . . . . . . . . .2 kits
aripiprazole (Abilify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
armodafinil (Nuvigil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
atorvastatin/amlodipine (Caduet) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
atorvastatin/ezetimibe (Liptruzet) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
azilsartan (Edarbi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
azilsartan/chlorthalidone (Edarbyclor) . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
azithromycin (Zmax) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 gm . . . . . . . . . . . . . . . . . . . . . . . . . . .60 ml/prescription
aztreonam inhalation solution (Cayston) . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
budesonide oral (Entocort EC) . . . . . . . . . . . . . . . . . . . . . . . .3mg . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
budesonide oral (Uceris) . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 mg . . . . . . . . . . . . . . . . . . . . . . . . . . .30
bupropion hydrobromide (Aplenzin) . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
bupropion XL (Budeprion XL, Wellbutrin XL) . . . . . . . . . . . . . .150 mg . . . . . . . . . . . . . . . . . . . . . . . . .30 or 90
bupropion XL (Budeprion XL, Wellbutrin XL) . . . . . . . . . . . . . .300 mg . . . . . . . . . . . . . . . . . . . . . . . . .30
butorphanol nasal spray (Stadol) . . . . . . . . . . . . . . . . . . . . . .10 mg/ml . . . . . . . . . . . . . . . . . . . . . . . .4 vials
canagliflozin (Invokana) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
carvedilol CR (Coreg CR) . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
celecoxib (Celebrex) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
certolizumab (Cimzia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
dabigatran (Pradaxa) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
dapagliflozin (Farxiga) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
darifenacin (Enablex) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
desvenlafaxine (Pristiq, Khedezla, Desvenlafaxine ER,
Desvenlafaxine Fumarate ER) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
dexlansoprazole (Dexilant) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
dihydroergotamine (Migranal) . . . . . . . . . . . . . . . . . . . . . . . .4 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . .16 ml
dimethyl fumarate (Tecfidera) . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
dolasetron (Anzemet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
dornase alfa (Pulmozyme) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
eletriptan (Relpax) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
eltrombopag olamine (Promacta) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
empagliflozin (Jardiance) . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
* Represents # of tablets, capsules, or doses allowed per 30 day period unless stated otherwise
10-20-14
34
Appendix A: Medication Quantity Limit Information
Medication Name (Brand)
Dose(s)/Indication
Quantity Limit*
erlotinib (Tarceva) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
esomeprazole ( esomeprazole strontium, Nexium) . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
estradiol vaginal ring (Estring/Femring) . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 ring/90 days
estradiol/(combo) bi-weekly transdermal patch
(Alora, Combipatch, Vivelle-dot, Minivelle) . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
estradiol/(combo) weekly transdermal patch
(Climara, ClimaraPro, Menostar) . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
eszopiclone (Lunesta) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
etanercept (Enbrel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 mg . . . . . . . . . . . . . . . . . . . . . . . . . .8
etanercept (Enbrel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 mg . . . . . . . . . . . . . . . . . . . . . . . . . .4
fentanyl immediate release (Fentora, Actiq lollipops,
Abstral, Onsolis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
fentanyl immediate release nasal (Lazanda) . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 ml
fentanyl sublingual spray (Subsys) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
fentanyl transdermal (Duragesic) . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
fesoterodine (Toviaz) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
fidaxomicin (Dificid) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20/prescription
fluvastatin (Lescol) fluvastatin XL (Lescol XL) . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
fluvoxamine CR (Luvox CR) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
frovatriptan (Frova) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
gabapentin (Gralise) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .300 mg . . . . . . . . . . . . . . . . . . . . . . . . .30
gabapentin (Gralise) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .600 mg . . . . . . . . . . . . . . . . . . . . . . . . .90
galantamine ER (Razadyne ER) . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
gemifloxacin (Factive) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7/prescription
golimumab (Simponi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
granisetron (Kytril) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
granisetron patch (Sancuso) . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 patch/prescription
guanfacine ER (Intuniv) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
hydrocodone ER (Zohydro ER) . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
human insulin-concentrated (Humulin R U500) . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 ml
ibandronate (Boniva) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150 mg . . . . . . . . . . . . . . . . . . . . . . . . .1
icosapent ethyl (Vascepa) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
idelalisib (Zydelig) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
ketorolac injection for home use . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 doses
lacosamide (Vimpat) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 mg . . . . . . . . . . . . . . . . . . . . . . . . . .140/30 days x 1 fill (for titration)
lacosamide (Vimpat) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 mg, 100 mg, 150 mg, 200 mg . . . . .60
lamotrigine ER (Lamictal XR) . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
lansoprazole (cap and soltab) (Prevacid) . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
lansoprazole compound kit (First-lansoprazole) . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
lansoprazole/amoxicillin/clarithromycin (PrevPac) . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
lenalidomide (Revlimid) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
levomilnacipran (Fetzima) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
levonorgestrel (Next Choice, Next Choice One Dose) . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 kit/prescription
linaclotide (Linzess) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
linagliptin (Tradjenta) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
lisdexamfetamine (Vyvanse) . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
lovastatin (Altoprev) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
lubiprostone (Amitiza) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
lurasidone (Latuda) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
memantine ER (Namenda XR) . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
methylnaltrexone (Relistor) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
methylphenidate transdermal patch (Daytrana) . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
* Represents # of tablets, capsules, or doses allowed per 30 day period unless stated otherwise
10-20-14
35
Appendix A: Medication Quantity Limit Information
Medication Name (Brand)
Dose(s)/Indication
Quantity Limit*
metoprolol succinate XL (Toprol XL) . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
metoprolol succinate/HCTZ (Dutoprol) . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
milnacipran (Savella) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
mirabegron (Myrbetriq) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
mixed grass pollen (Oralair) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
modafinil (Provigil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
morphine ER (Avinza) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
morphine/naltrexone (Embeda) . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
nabilone (Cesamet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14/cycle
naproxen/esomeprazole (Vimovo) . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
naratriptan (Amerge) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
nicotine gum (Nicorette) . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .600
nicotine lozenge (Nicorette, Commit) . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .600
nilotinib (Tasigna) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
Norelgestromin 6 mg/ethinyl estradiol 0.75 mg patch
(Xulane) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
omega-3 acid ethyl esters (Lovaza) . . . . . . . . . . . . . . . . . . . .Hypertriglyceremia . . . . . . . . . . . . . . . . . .120
omega-3 acid ethyl esters (Lovaza) . . . . . . . . . . . . . . . . . . . .Secondary prevention post-MI . . . . . . . . .30
omeprazole (Prilosec, Prilosec OTC) . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
omeprazole/amoxacillin/clarithromycin (Omeclamox-Pak) . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
omeprazole/sodium bicarb (Zegerid) . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
ondansetron (Zofran, Zofran ODT) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
oprelvekin (Neumega) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21/cycle
oseltamivir (Tamiflu) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10/prescription
oxybutynin transdermal patch (Oxytrol) . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
oxybutynin XL (Ditropan XL) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
oxycodone ER (Oxycontin) . . . . . . . . . . . . . . . . . . . . . . . . . . .10 mg, 15 mg, 20 mg, 30 mg, 40 mg . . .90
oxycodone ER (Oxycontin) . . . . . . . . . . . . . . . . . . . . . . . . . . .60 mg, 80 mg . . . . . . . . . . . . . . . . . . . .150
oxymorphone ER (Opana ER) . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
pantoprazole (Protonix) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
PEG/electrolytes/sodium ascorbate (MoviPrep) . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1/prescription
pegfilgrastim (Neulasta) . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 dose/prescription
pegylated interferon (Peg-Intron, Pegasys) . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 doses
pitavastatin (Livalo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
pramipexole (Mirapex ER) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
pregabalin (Lyrica) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
rabeprazole (Aciphex, Aciphex Sprinkles) . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
ramelteon (Rozerem) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
rasagiline (Azilect) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
rifaximin (Xifaxan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200 mg . . . . . . . . . . . . . . . . . . . . . . . . .5/day (course varies)
riociguat (Adempas) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
risedronate (Actonel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 mg . . . . . . . . . . . . . . . . . . . . . . . . . .4
risedronate (Actonel, Atelvia) . . . . . . . . . . . . . . . . . . . . . . . . .150 mg . . . . . . . . . . . . . . . . . . . . . . . . .1
rizatriptan (Maxalt, Maxalt MLT) . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
rosuvastatin (Crestor) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
saxagliptin (Onglyza) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
scopolamine patch (Transderm Scop) . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
selegiline patch (Emsam) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
short ragweed pollen (Ragwitek) . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
simeprevir (Olysio) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
simvastatin (Zocor) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 mg . . . . . . . . . . . . . . . . . . . . . . . . . .45
simvastatin (Zocor) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 mg . . . . . . . . . . . . . . . . . . . . . . . . . .30
* Represents # of tablets, capsules, or doses allowed per 30 day period unless stated otherwise
10-20-14
36
Appendix A: Medication Quantity Limit Information
Medication Name (Brand)
Dose(s)/Indication
Quantity Limit*
simvastatin/ezetimibe (Vytorin) . . . . . . . . . . . . . . . . . . . . . .40/10 mg, 80/10 mg . . . . . . . . . . . . . .30
simvastatin/niacin (Simcor) . . . . . . . . . . . . . . . . . . . . . . . . . .40/500 mg, 40/1000 mg . . . . . . . . . . .30
sitagliptan (Januvia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
sitagliptan/simvastatin (Juvisync) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
sofosbuvir (Sovaldi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
solifenacin (Vesicare) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
sumatriptan (Imitrex) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
sumatriptan injection (Imitrex, Sumavel DosePro) . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
sumatriptan nasal (Imitrex) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
sumatriptan/naproxen (Treximet) . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
tadalafil (Cialis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
tapentadol (Nucynta) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
tapentadol ER (Nucynta ER) . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
tasimelteon (Hetlioz) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
telithromycin (Ketek) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20/prescription
temozolomide (Temodar) . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30/prescription
teriflunomide (Aubagio) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
teriparatide (Forteo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 pen (3 ml)
timothy grass pollen (Grastek) . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
tocilizumab (Actemra) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
tolterodine LA (Detrol LA) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
tramadol ER (generics, Ryzolt ER, Ultram ER) . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
treprostinil diolamine (Orenitram ER) . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
ulipristal (Ella) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
ustekinumab (Stelara) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1/12 weeks
vilazodone HCl (Viibryd) . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
vorapaxar (Zontivity) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
vortioxetine (Brintellix) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
zanamivir (Relenza) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 inhaler/prescription
zolmitriptan (Zomig) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
zolmitriptan nasal (Zomig) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
zolpidem (Ambien, Edluar) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
zolpidem CR (Ambien CR) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
zolpidem sublingual (Intermezzo) . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
* Represents # of tablets, capsules, or doses allowed per 30 day period unless stated otherwise
10-20-14
37
INDEX
abacavir ......................................................................................19
abacavir/dolutegravir/lamivudine................................................19
abacavir/lamivudine ..................................................................19
abacavir/lamivudine/zidovudine ................................................19
abacavir suspension....................................................................19
abatacept ......................................................................21, 33, 34
Abilify ..................................................................................22, 34
Abilify Discmelt ..........................................................................22
abiraterone ................................................................................20
abobotulinum toxin ....................................................................33
Absorica......................................................................................27
Abstral ..................................................................................26, 35
acamprosate ..............................................................................22
Acanya ........................................................................................27
acarbose ....................................................................................11
Accolate see zafirlukast ..............................................................32
Accu-Chek ..................................................................................12
Accupril see quinapril....................................................................8
Accuretic see quinapril/HCTZ ........................................................8
Accutane see isotretinoin ............................................................27
acebutolol ....................................................................................8
Aceon see perindopril ..................................................................8
acetaminophen/butalbital ..........................................................24
acetaminophen/butalbital/caffeine ............................................24
acetaminophen/butalbital/caffeine/codeine ..............................24
acetaminophen/codeine ............................................................26
acetaminophen/dichloralphenazone/isometheptene ..................24
acetaminophen/dihydrocodeine/caffeine ....................................24
acetaminophen/hydrocodone......................................................26
acetaminophen/oxycodone ..................................................26, 34
acetaminophen/oxycodone ER..............................................26, 34
acetaminophen/phenyltolxamine ................................................25
acetazolamide ............................................................................31
acetic acid ..................................................................................17
acetic acid/hydrocortisone..........................................................17
acetylcysteine ............................................................................32
Achromycin see tetracycline..................................................18, 29
Aciphex see rabeprazole tab ......................................................29
Aciphex Sprinkles..................................................................29, 36
acitretin ......................................................................................29
aclidinium bromide ....................................................................32
Aclovate cream, ointment see alclometasone ..............................28
Actemra..........................................................................21, 33, 37
Acthar HP....................................................................................15
Acticlate......................................................................................18
Actigall see ursodiol ....................................................................30
Actimmune..................................................................................18
Actiq ....................................................................................26, 35
Activella see estradiol/norethindrone tab ....................................15
Actonel ................................................................................12, 36
Actoplus Met see pioglitazone/metformin ..................................11
Actoplus Met XR..........................................................................11
Actos see pioglitazone ..........................................................11, 34
10-20-14
Acular see ketorolac ......................................................16, 25, 35
Acular LS see ketorolac ..................................................16, 25, 35
AcuNeb see albuterol............................................................31, 32
Acuvail ........................................................................................16
acyclovir buccal ..........................................................................19
acyclovir oral ..............................................................................19
acyclovir topical ....................................................................19, 28
acyclovir/hydrocortisone ............................................................28
acyclovir/lidocaine ......................................................................28
Aczone ........................................................................................27
Adalat CC see nifedipine ER..........................................................9
adalimumab ............................................................21, 29, 30, 34
adapalene cream, gel..................................................................27
adapalene lotion ........................................................................27
adapalene/benzoyl peroxide ......................................................27
Adcirca........................................................................................10
Adderall see amphetamine-dextroamphetamine combo ..............22
Adderall XR see amphetamine-dextroamphetamine ER combo....22
adefovir ......................................................................................19
Adempas ..............................................................................10, 36
Adoxa see doxycycline monohydrate ....................................18, 27
Advair..........................................................................................31
Advicor........................................................................................12
Aerospan ....................................................................................31
afatinib ................................................................................20, 34
Afeditab see nifedipine ER ............................................................9
Afinitor ........................................................................................21
Afinitor Disperz............................................................................21
Aggrenox ....................................................................................10
Agrylin see anagrelide ................................................................10
AK-Con see naphazoline ............................................................16
Akne-mycin ................................................................................27
AK-Poly-Bac see bacitracin/polymyxin B ....................................16
albendazole ................................................................................18
Albenza ......................................................................................18
albiglutide ..................................................................................11
albuterol HFA ..............................................................................31
albuterol nebulizer solution ........................................................31
albuterol tabs..............................................................................32
albuterol-ipratropium inhaler ......................................................31
albuterol-ipratropium nebulizer solution ......................................31
alcaftadine..................................................................................16
Alcaine see proparacaine ophthalmic..........................................17
alclometasone ............................................................................28
Aldactazide see spironolactone/HCTZ............................................9
Aldactone see spironolactone ......................................................9
Aldara see imiquimod ................................................................28
alendronate ..........................................................................12, 34
alendronate/cholecalciferol ..................................................12, 34
alendronate effervescent ............................................................12
Alferon ........................................................................................18
alfuzosin ....................................................................................30
alglucosidase alfa ......................................................................33
38
INDEX
Alinia ..........................................................................................18
aliskiren............................................................................9, 10, 34
aliskiren/amlodipine ........................................................9, 10, 34
aliskiren/amlodipine/HCTZ ..................................................10, 34
aliskiren/HCTZ ............................................................................10
Alkeran........................................................................................20
allopurinol ..................................................................................20
almotriptan ..........................................................................24, 34
Alocril..........................................................................................16
Alodox kit....................................................................................16
alogliptin ..............................................................................11, 34
alogliptin/metformin ..................................................................11
alogliptin/pioglitazone ..........................................................11, 34
Alomide ......................................................................................16
Alora ....................................................................................15, 35
alosetron ..............................................................................30, 34
Alphagan see brimonidine ....................................................16, 28
Alphagan P see brimonidine ................................................16, 28
alprazolam ..................................................................................23
alprazolam ER ............................................................................23
Alrex............................................................................................16
Altabax........................................................................................27
Altace see ramipril ......................................................................8
Altafluor ......................................................................................17
Altavera ......................................................................................14
Altoprev ................................................................................12, 35
Alvesco ......................................................................................31
Alyacen 1/35..............................................................................14
Alyacen 777................................................................................13
amantadine ..........................................................................19, 26
Amaryl see glimepiride................................................................11
Ambien see zolpidem............................................................23, 37
Ambien CR see zolpidem CR ................................................23, 37
ambrisentan................................................................................10
amcinonide ................................................................................29
Amerge see naratriptan ........................................................24, 36
Amethia ......................................................................................13
Amethia Lo..................................................................................13
Amethyst ....................................................................................14
Amicar see aminocaproic acid ....................................................10
amiloride ......................................................................................9
amiloride/HCTZ ............................................................................9
aminocaproic acid ......................................................................10
amiodarone ..................................................................................9
Amitiza..................................................................................30, 35
amitriptyline..........................................................................22, 23
amitriptyline/perphenazine..........................................................22
amlexanox ..................................................................................28
amlodipine ..................................................................8-10, 12, 34
amlodipine/atorvastatin....................................................9, 12, 34
amlodipine/olmesartan ............................................................8, 9
amlodipine/olmesartan/HCTZ ......................................................8
amlodipine/telmisartan ............................................................8, 9
10-20-14
amlodipine/valsartan ................................................................8, 9
amlodipine/valsartan/HCTZ ......................................................8, 9
ammonium lactate 12%..............................................................28
Amnesteem ................................................................................27
amoxapine ..................................................................................23
amoxicillin ......................................................................17, 29, 35
amoxicillin ER..............................................................................17
amoxicillin/clavulanate ..............................................................17
amoxicillin/clavulanate ER ..........................................................17
amoxicillin/clavulanate ES ..........................................................17
amphetamine-dextroamphetamine combo ..................................22
amphetamine-dextroamphetamine ER combo ............................22
amphotericin ..............................................................................18
ampicillin ....................................................................................17
Ampyra ......................................................................................21
Amrix ..........................................................................................25
Amturnide ............................................................................10, 34
Anafranil see clomipramine ........................................................23
anagrelide ..................................................................................10
anakinra ..............................................................................21, 34
Anaprox see naproxen sodium ....................................................25
Anaprox DS see naproxen sodium ..............................................25
Anaspaz see hyoscyamine ..........................................................30
anastrozole ................................................................................20
Ancobon see flucytosine ............................................................18
Androderm ..................................................................................15
Androgel......................................................................................15
Androgel pump............................................................................15
Android ......................................................................................15
Androxy ......................................................................................15
Angeliq........................................................................................15
Anoro Ellipta ..............................................................................32
Ansaid see flurbiprofen ........................................................16, 25
Antabuse see disulfiram..............................................................22
Antara see fenofibrate ................................................................12
antipyrine/benzocaine ................................................................17
antipyrine/benzocaine/zinc ........................................................17
Anzemet................................................................................29, 34
Apexicon see diflorasone ............................................................29
Aphthasol....................................................................................28
Apidra vial ..................................................................................11
Apidra Solostar pen ....................................................................11
apixaban ....................................................................................10
Aplenzin................................................................................23, 34
Apokyn........................................................................................26
apomorphine ..............................................................................26
apraclonidine 0.5% ....................................................................16
apraclonidine 1% ........................................................................16
apremilast ............................................................................21, 34
aprepitant ............................................................................29, 34
Apresazide see hydralazine/HCTZ ............................................9, 10
Apresoline see hydralazine ......................................................9, 10
Apri ............................................................................................14
39
INDEX
Apriso ........................................................................................30
Aptiom ........................................................................................24
Aptivus........................................................................................19
Aralen see chloroquine................................................................18
Aranelle ......................................................................................13
Aranesp ......................................................................................10
Arava see leflunomide ................................................................20
Arcalyst ......................................................................................33
Arcapta ......................................................................................31
arformoterol inhaler ....................................................................31
Aricept see donepezil ..................................................................24
Arimidex see anastrozole ............................................................20
aripiprazole ..........................................................................22, 34
aripiprazole ODT..........................................................................22
Aristocort ....................................................................................20
Arixtra see fondaparinux..............................................................10
armodafinil ..........................................................................22, 34
Armour Thyroid ............................................................................15
Aromasin see exemestane ..........................................................20
Artane see trihexyphenidyl ..........................................................26
artemether/lumefantrine ............................................................18
Arthrotec see diclofenac/misoprostol ..........................................25
Asacol HD ..................................................................................30
Ascensia ....................................................................................12
Asendin see amoxapine ..............................................................23
Asmanex ....................................................................................31
aspirin/butalbital/caffeine ..........................................................24
aspirin/dihydrocodeine/caffeine ................................................24
aspirin/dipyridamole ..................................................................10
Astagraf XL ..................................................................................20
Astelin see azelastine nasal antihistamine spray ........................31
Astepro see azelastine nasal antihistamine spray........................31
Atacand see candesartan..............................................................8
Atacand HCT see candesartan/HCTZ ............................................8
Atarax see hydroxyzine ................................................................31
atazanavir ..................................................................................19
Atelvia ..................................................................................12, 36
atenolol ........................................................................................8
atenolol/chlorthalidone ................................................................8
Ativan see lorazepam............................................................23, 24
atomoxetine ................................................................................22
atorvastatin ......................................................................9, 12, 34
atovaquone ................................................................................18
atovaquone/proquanil ................................................................18
Atralin ........................................................................................27
Atridox ........................................................................................18
Atripla ........................................................................................19
atropine ................................................................................17, 30
atropine/hyoscyamine/phenobarbital/scopolamine ....................24
Atrovent HFA................................................................................32
Atrovent nasal see ipratropium..............................................31, 32
Aubagio ................................................................................21, 37
Aubra ..........................................................................................14
10-20-14
augmented betamethasone diproprionate ..................................29
Augmentin ES see amoxicillin/clavulanate ES ............................17
Augmentin XR see amoxicillin/clavulanate ER ............................17
Auralgan see antipyrine/benzocaine............................................17
auranofin ....................................................................................20
Auvi-Q ........................................................................................32
Avalide see irbesartan/HCTZ ........................................................8
Avandamet..................................................................................11
Avandaryl....................................................................................11
Avandia ......................................................................................11
Avapro see irbesartan....................................................................8
Avar ............................................................................................27
Avar LS ......................................................................................27
AVC ............................................................................................27
Avelox see moxifloxacin ........................................................16, 17
Aviane ........................................................................................14
Avinza see morphine ER capsule ................................................26
Aviva ..........................................................................................12
Avodart ......................................................................................30
Avonex ........................................................................................21
Axert ....................................................................................24, 34
Axid see nizatidine ......................................................................29
Axid ............................................................................................29
Axiron..........................................................................................15
axitinib ........................................................................................21
Aygestin see norethindrone tab ..................................................15
Azasan ........................................................................................20
Azasite ........................................................................................16
azathioprine ................................................................................20
azelaic acid ................................................................................27
azelaic acid/ceramide ................................................................27
azelastine ............................................................................16, 31
azelastine/fluticasone nasal........................................................31
azelastine nasal antihistamine spray ..........................................31
Azelex ........................................................................................27
Azilect ..................................................................................26, 36
azilsartan ..............................................................................8, 34
azilsartan/chlorthalidone ........................................................8, 34
azithromycin ..................................................................16, 17, 34
Azopt ..........................................................................................16
Azor ..........................................................................................8, 9
aztreonam lysine ........................................................................32
Azulfidine see sulfasalazine ..................................................20, 30
Azurette ......................................................................................13
bacitracin....................................................................................16
baclofen......................................................................................25
Bactrim see trimethoprim/sulfa ..................................................18
Bactroban see mupirocin ............................................................27
Bactroban Nasal ........................................................................27
balsalazide..................................................................................30
Balziva ........................................................................................14
Banzel ........................................................................................24
Baraclude see entecavir ..............................................................19
40
INDEX
beclomethasone inhaler ..............................................................31
beclomethasone nasal ................................................................31
Beconase AQ ..............................................................................31
bedaquiline ................................................................................18
benazepril ................................................................................8, 9
benazepril/amlodipine ..............................................................8, 9
benazepril/HCTZ............................................................................8
Bencort ......................................................................................27
Benicar ........................................................................................8
Benicar HCT ..................................................................................8
benoxinate/fluorescein................................................................17
Bentyl see dicyclomine................................................................30
Benzaclin see clindamycin/benzoyl peroxide ..............................27
Benzamycin see benzoyl peroxide/erythromycin ..........................27
Benziq see benzoyl peroxide/aloe vera........................................27
benzonatate ................................................................................31
benzyl alcohol topical..................................................................28
benzoyl peroxide ........................................................................27
benzoyl peroxide/aloe vera..........................................................27
benzoyl peroxide/cleanser kit ......................................................27
benzoyl peroxide/erythromycin....................................................27
benzoyl peroxide/hydrocortisone ................................................27
benzoyl peroxide/sulfur ..............................................................27
benzoyl peroxide/urea ................................................................27
benztropine ................................................................................26
bepostastine ..............................................................................16
Bepreve ......................................................................................16
besifloxacin ................................................................................16
Besivance ..................................................................................16
Betagan see levobunolol ............................................................16
betamethasone dipropionate ......................................................29
betamethasone valerate..............................................................29
betamethasone/calcipotriene ..............................................28, 29
Betapace see sotalol ....................................................................8
Betapace AF see sotalol AF ..........................................................8
Betaseron ..................................................................................21
betaxolol ................................................................................8, 16
bethanechol ................................................................................30
Bethkis........................................................................................32
Betimol see timolol ................................................................8, 16
Betoptic S ..................................................................................16
bexarotene ..................................................................................20
Beyaz ..........................................................................................14
Biaxin suspension ......................................................................17
Biaxin XL see clarithromycin ER ..................................................17
bicalutamide ..............................................................................20
Bicitra ........................................................................................13
BiDil............................................................................................10
Biltricide......................................................................................18
bimatoprost ................................................................................16
Binosto ................................................................................12, 34
biskalcitrate/metronidazole/tetracycline......................................29
bisoprolol ......................................................................................8
10-20-14
bisoprolol/HCTZ ............................................................................8
Bleph-10 see sulfacetamide ophthalmic ....................................16
Blephamide ................................................................................16
Blocadren see timolol ............................................................8, 16
boceprevir ..................................................................................19
Boniva see ibandronate ........................................................12, 35
bosentan ....................................................................................10
Bosulif ........................................................................................21
bosutinib ....................................................................................21
Botox ..........................................................................................33
Breeze 2 ....................................................................................12
Breo Ellipta ................................................................................31
Brethine see terbutaline ..............................................................32
Brevicon......................................................................................14
Brevoxyl ......................................................................................27
Briellyn........................................................................................14
Brilinta ........................................................................................10
brimonidine ..........................................................................16, 28
brimonidine 0.1% ......................................................................16
brimonidine gel ..........................................................................28
brimonidine/brinzolamide ..........................................................16
brimonidine/timolol ....................................................................16
Brintellix................................................................................23, 37
brinzolamide ..............................................................................16
Brisdelle......................................................................................31
Bromday see bromfenac ............................................................16
bromfenac ..................................................................................16
bromocriptine ......................................................................15, 26
Brovana ......................................................................................31
Budeprion XL see bupropion XL ............................................23, 34
budesonide nasal ......................................................................31
budesonide nebulizer solution ....................................................31
budesonide oral....................................................................30, 34
budesonide-formoterol inhaler ....................................................31
bumetanide ..................................................................................9
Bumex see bumetanide ................................................................9
Bunavail ......................................................................................22
Buphenyl ....................................................................................31
buprenorphine ......................................................................22, 26
buprenorphine patch ..................................................................26
buprenorphine/naloxone sublingual film ....................................22
buprenorphine/naloxone sublingual tab ......................................22
Buproban see bupropion ................................................22, 23, 34
bupropion ......................................................................22, 23, 34
bupropion hbr ............................................................................23
bupropion SR........................................................................22, 23
bupropion XL 150/300 mg ........................................................23
bupropion XL 450 mg ................................................................23
Buspar see buspirone ................................................................23
buspirone....................................................................................23
busulfan......................................................................................20
butenafine ..................................................................................28
butoconazole ............................................................................28
41
INDEX
butorphanol nasal spray........................................................24, 34
Butrans ......................................................................................26
Bydureon ....................................................................................11
Byetta ........................................................................................11
Bystolic ........................................................................................8
cabergoline ................................................................................15
cabozantinib ..............................................................................20
Caduet see amlodipine/atorvastatin ................................9, 12, 34
Cafergot ......................................................................................24
Calan see verapamil..................................................................8, 9
Calan SR see verapamil ............................................................8, 9
calcipotriene cream ....................................................................28
calcipotriene foam ......................................................................28
calcipotriene ointment ................................................................28
calcitonin nasal ..........................................................................12
Calcitrene....................................................................................28
calcitriol oral ..............................................................................12
calcitriol topical ..........................................................................28
calcium acetate ..........................................................................13
calcium acetate soln ..................................................................13
Cambia ......................................................................................25
Camila ........................................................................................14
Campral see acamprosate ..........................................................22
Camrese ....................................................................................13
Camrese Lo ................................................................................13
canagliflozin..........................................................................11, 34
canagliflozin/metformin ..............................................................11
canakinumab ..............................................................................33
Canasa ......................................................................................30
candesartan ..................................................................................8
candesartan/HCTZ ........................................................................8
Cantil ..........................................................................................29
capecitabine ..............................................................................20
Capex..........................................................................................29
Capoten see captopril ..................................................................8
Capozide see captopril/HCTZ ........................................................8
Caprelsa ....................................................................................20
captopril........................................................................................8
captopril/HCTZ ..............................................................................8
Carac ..........................................................................................28
Carafate see sucralfate ........................................................29, 31
carbachol....................................................................................16
Carbaglu ....................................................................................31
carbamazepine............................................................................24
carbamazepine SR ......................................................................24
Carbatrol ....................................................................................24
carbidopa ..................................................................................26
carbidopa/levodopa....................................................................26
carbidopa/levodopa CR ..............................................................26
carbidopa/levodopa/entacapone................................................26
carbinoxamine ............................................................................31
carbinoxamine ER susp ..............................................................31
Cardene see nicardipine................................................................9
10-20-14
Cardene SR ..................................................................................9
Cardizem see diltiazem..................................................................9
Cardizem CD see diltiazem ER (24H) ............................................9
Cardizem LA see diltiazem LA........................................................9
Cardizem SR see diltiazem ER (12H) ............................................9
Cardura see doxazosin ............................................................9, 30
Cardura XL ....................................................................................9
carglumic acid ..........................................................................31
carisoprodol ................................................................................25
carisoprodol/aspirin....................................................................25
Carnitor ......................................................................................13
carteolol......................................................................................16
carvedilol ................................................................................8, 34
carvedilol CR ..........................................................................8, 34
Casodex see bicalutamide ..........................................................20
Cataflam see diclofenac potassium ............................................25
Catapres see clonidine............................................................9, 22
Catapres TTS see clonidine patch ..................................................9
Cayston ................................................................................32, 34
Caziant........................................................................................13
Cedax see ceftibuten ..................................................................17
CeeNU see lomustine..................................................................20
cefaclor ......................................................................................17
cefadroxil ....................................................................................17
cefdinir........................................................................................17
cefditoren....................................................................................17
cefixime ......................................................................................17
cefpodoxime ..............................................................................17
cefprozil ......................................................................................17
ceftibuten....................................................................................17
Ceftin ..........................................................................................17
cefuroxime ..................................................................................17
Cefzil ..........................................................................................17
Celebrex................................................................................25, 34
celecoxib ..............................................................................25, 34
Celexa see citalopram ................................................................23
Cellcept see mycophenolate ......................................................20
Celontin ......................................................................................24
Cenestin..................................................................................3, 15
cephalexin ..................................................................................17
Cerdelga ....................................................................................31
ceritinib ......................................................................................20
certolizumab ..................................................................21, 30, 34
Cervarix ......................................................................................33
Cesamet ..............................................................................29, 36
Cetany see mupirocin..................................................................27
Cetraxal see ciprofloxacin otic ....................................................17
cevimeline ..................................................................................31
Chantix........................................................................................22
Chateal ......................................................................................14
Chenodal ....................................................................................30
chenodiol....................................................................................30
chlorambucil ..............................................................................20
42
INDEX
chlordiazepoxide ..................................................................23, 30
chlordiazepoxide/clindium ..........................................................30
chlorhexidine ..............................................................................18
chloroquine ................................................................................18
chloroxylenol/benzoc/hydrocortisone ........................................17
chlorpromazine............................................................................22
chlorpropamide ..........................................................................11
chlorthalidone ....................................................................8, 9, 34
chlorzoxazone..............................................................................25
cholestyramine............................................................................12
cholestyramine light ....................................................................12
Cialis ....................................................................................30, 37
ciclesonide inhaled ....................................................................31
ciclesonide nasal ........................................................................31
ciclopirox ....................................................................................28
ciclopirox nail lacquer ................................................................28
ciclopirox nail lacquer/nail lacquer remover kit ..........................28
cilostazol ....................................................................................10
Ciloxan........................................................................................16
Ciloxan see ciprofloxacin ......................................................16, 17
cimetidine ..................................................................................29
Cimzia ............................................................................21, 30, 34
cinacalcet ..................................................................................12
Cipro HC ....................................................................................17
Cipro XR see ciprofloxacin XR ......................................................17
Ciprodex......................................................................................17
ciprofloxacin ........................................................................16, 17
ciprofloxacin drops ......................................................................16
ciprofloxacin ointment ................................................................16
ciprofloxacin otic ........................................................................17
ciprofloxacin XR ..........................................................................17
ciprofloxacin/dexamethasone......................................................17
ciprofloxacin/hydrocortisone ......................................................17
citalopram ..................................................................................23
CitraNatal Assure ........................................................................13
citric acid/sodium citrate ............................................................13
Claravis see isotretinoin ..............................................................27
Claravis ......................................................................................27
Clarifoam see sulfacetamide/sulfur 10%/5% cream, cleanser,
medicated pads, foam, lotion, suspension............................27
Clarinex see desloratadine ..........................................................31
Clarinex D ..................................................................................31
clarithromycin ..........................................................17, 29, 35, 36
clarithromycin ER ........................................................................17
Cleocin see clindamycin ......................................................18, 27
Cleocin capsules see clindamycin capsules ................................18
Cleocin granules..........................................................................18
Climara see estradiol weekly patch ............................................15
ClimaraPro ............................................................................15, 35
Clindagel ....................................................................................27
Clindamax see clindamycin ..................................................18, 27
clindamycin ..........................................................................18, 27
clindamycin capsules ..................................................................18
10-20-14
clindamycin gel ..........................................................................27
clindamycin granules ..................................................................18
clindamycin kit............................................................................27
clindamycin/benzoyl peroxide ....................................................27
clindamycin/tretinoin ..................................................................27
Clindareach ................................................................................27
Clinoril see sulindac ....................................................................25
clobazam ....................................................................................24
clobetasol foam ..........................................................................29
clobetasol topical........................................................................29
clobetasol spray ..........................................................................29
Clobex see clobetasol topical......................................................29
clocortolone ................................................................................29
Cloderm see clocortolone............................................................29
clofazamine ................................................................................18
Clomid see clomiphene ..............................................................15
clomiphene ................................................................................15
clomipramine ..............................................................................23
clonazepam ..........................................................................23, 24
clonazepam ODT ........................................................................23
clonidine ................................................................................9, 22
clonidine patch ............................................................................9
clonidine SR................................................................................22
clonidine/chlorthalidone ..............................................................9
clopidogrel ..................................................................................10
clorazepate ................................................................................23
clorazepate ER ............................................................................23
Clorpres see clonidine/chlorthalidone ..........................................9
clotrimazole ..........................................................................18, 28
clotrimazole troche......................................................................18
clotrimazole/betamethasone cream ............................................28
clotrimazole/betamethasone lotion ............................................28
clozapine ....................................................................................22
clozapine ODT ............................................................................22
clozapine suspension ..................................................................22
Clozaril see clozapine..................................................................22
Clozaril........................................................................................22
CNL 8 see ciclopirox nail lacquer/nail lacquer remover kit ..........28
Coartem......................................................................................18
codeine ................................................................................24, 26
Cogentin see benztropine ............................................................26
Colazal see balsalazide ..............................................................30
colchicine....................................................................................20
Colcrys........................................................................................20
colesevelam ................................................................................12
Colestid see colestipol ................................................................12
Colestid ......................................................................................12
colestipol ....................................................................................12
colistimethate for inhalation........................................................32
Coly-mycin ..................................................................................32
Colyte ........................................................................................30
Combigan....................................................................................16
Combipatch ..........................................................................15, 35
43
INDEX
Combivent ..................................................................................31
Combivir see lamivudine/zidovudine ..........................................19
Combunox see ibuprofen/oxycodone ..........................................26
Cometriq ....................................................................................20
Commit ................................................................................22, 36
Compazine see prochlorperazine ................................................29
Compazine ..................................................................................29
Complera ....................................................................................19
compounded hormones ..............................................................15
Comtan see entacapone ............................................................26
Concerta see methylphenidate ER ..............................................22
Condylox ....................................................................................28
conjugated estrogen cream ........................................................15
conjugated estrogens/bazedoxifene ......................................12, 15
conjugated estrogens tab ............................................................15
conjugated estrogens/medroxyprogesterone tab..........................15
Constulose ..................................................................................30
Contour ......................................................................................12
Contour Next ..............................................................................12
Conzip ........................................................................................26
Copaxone....................................................................................21
Copegus see ribavirin ..................................................................19
Cordarone ....................................................................................9
Cordran ......................................................................................29
Cordran SP..................................................................................29
Coreg see carvedilol................................................................8, 34
Coreg CR ................................................................................8, 34
Corgard see nadolol ......................................................................8
Cortef see hydrocortisone ......................16, 17, 20, 25, 27, 28, 30
Cortenema see hydrocortisone rectal ..........................................30
corticotropin gel ..........................................................................15
Cortifoam ....................................................................................30
Cortisporin see neomycin/polymyxin/hydrocortisone ............16, 17
Cortisporin Otic see neomycin/polymyxin/hydrocortisone otic ....17
Cosopt see dorzolamide/timolol..................................................16
Cosopt PF ..................................................................................16
Cotrim ........................................................................................18
Coumadin ..................................................................................10
Covaryx ......................................................................................15
Cozaar see losartan ......................................................................8
Creon ..........................................................................................30
Crestor..................................................................................12, 36
Crinone ......................................................................................15
Crixivan ......................................................................................19
crizotinib ....................................................................................20
Crnatal........................................................................................13
crofelemer ..................................................................................30
cromolyn ........................................................................16, 31, 32
cromolyn nebulizer solution ........................................................32
crotamiton ..................................................................................28
Cryselle ......................................................................................14
Cuprimine ..................................................................................20
Cutivate cream and ointment see fluticasone........................29, 31
10-20-14
Cuvposa......................................................................................31
cyanocobalamin nasal ................................................................13
cyanocobalamin/folic acid/pyridoxine ........................................13
Cyclafem 1/35 ..........................................................................14
Cyclafem 777 ............................................................................13
Cyclessa see Velivet ....................................................................13
cyclobenzaprine ..........................................................................25
cyclobenzaprine ER ....................................................................25
Cyclogyl see cyclopentolate ........................................................17
cyclopentolate ............................................................................17
cyclophosphamide ......................................................................20
cycloserine ..................................................................................18
Cycloset ......................................................................................15
cyclosporine..........................................................................17, 20
cyclosporine modified ................................................................20
Cymbalta see duloxetine ............................................................23
cyproheptadine ..........................................................................31
Cystagon ....................................................................................31
Cystaran......................................................................................17
cysteamine ..........................................................................17, 31
cysteamine bitartrate ..................................................................31
Cystex ........................................................................................18
Cystospaz see hyoscyamine ........................................................30
Cytomel see liothyronine ............................................................15
Cytotec see misoprostol........................................................25, 29
Cytoxan see cyclophosphamide ..................................................20
dabigatran ..........................................................................10, 34
dabrafenib ..................................................................................20
dalfampridine..............................................................................21
Daliresp ......................................................................................32
Dalmane see flurazepam ............................................................23
dalteparin ..................................................................................10
danazol ......................................................................................15
Danocrine see danazol................................................................15
dantrolene ..................................................................................25
dapagliflozin ........................................................................11, 34
dapsone ..............................................................................18, 27
dapsone topical ..........................................................................27
Daraprim ....................................................................................18
darbepoetin ................................................................................10
darifenacin............................................................................30, 34
darunavir ....................................................................................19
dasatinib ....................................................................................21
Dasetta 1/35..............................................................................14
Dasetta 777 ..............................................................................13
Daypro see oxaprozin ..................................................................25
Daysee........................................................................................13
Daytrana ..............................................................................22, 35
DDAVP ........................................................................................15
Decadron see dexamethasone..................................16, 17, 20, 28
Declomycin ................................................................................18
deferasirox ..................................................................................13
deferiprone ................................................................................10
44
INDEX
degarelix acetate ........................................................................15
Delatestryl see testosterone enanthate injection ........................15
delavirdine ..................................................................................19
Delzicol ......................................................................................30
Demadex see torsemide................................................................9
demeclocycline ..........................................................................18
Demulen 1/35 see Zovia 1/35, Kelnor 1/35..............................14
Demulen 1/50 see Zovia 1/50 ..................................................14
Denavir ......................................................................................28
denosumab ................................................................................33
Depakene ..................................................................................24
Depakote ....................................................................................24
Depen ........................................................................................20
Depo-Testosterone ......................................................................15
Derma-Smoothe/FS ....................................................................29
Dermatop see prednicarbate ......................................................29
DermOtic ....................................................................................17
desipramine ................................................................................23
desloratadine ..............................................................................31
desloratadine/pseudoephedrine ................................................31
desmopressin..............................................................................15
desmopressin nasal ....................................................................15
Desogen see Apri ........................................................................14
Desonate ....................................................................................28
desonide topical cream/ointment ..............................................28
desonide topical gel/lotion/foam................................................28
Desowen cream and ointment see desonide topical....................28
desoximetasone cream/gel/ointment..........................................29
desoximetasone spray ................................................................29
Desoxyn see methamphetamine..................................................22
Desquam ....................................................................................27
desvenlafaxine ......................................................................23, 34
Desvenlafaxine ER see desvenlafaxine ..................................23, 34
Desvenlafaxine Fumarate ER ................................................23, 34
Desyrel see trazodone ................................................................23
Detrol see tolterodine ..........................................................30, 37
Detrol LA see tolterodine ER........................................................30
dexamethasone ........................................................16, 17, 20, 28
Dexedrine see dextroamphetamine..............................................22
dexlansoprazole ....................................................................29, 34
dexmethylphenidate ....................................................................22
dexmethylphenidate XR ..............................................................22
dextroamphetamine ....................................................................22
dextromethorphan/quinidine ......................................................24
DHE ............................................................................................24
Diabinase see chlorpropamide....................................................11
Diamox see acetazolamide..........................................................31
Diamox Sequels see acetazolamide ............................................31
Diastat see diazepam rectal ........................................................24
diazepam..............................................................................23, 24
diazepam rectal ..........................................................................24
Dibenzyline ................................................................................10
Diclegis ......................................................................................29
10-20-14
diclofenac ............................................................................16, 25
diclofenac epolamine patch ........................................................25
diclofenac gel..............................................................................25
diclofenac potassium ..................................................................25
diclofenac sodium ......................................................................25
diclofenac submicronized ............................................................25
diclofenac/misoprostol ..............................................................25
dicloxacillin ................................................................................17
dicyclomine ................................................................................30
didanosine ..................................................................................19
Didronel see etidronate ..............................................................12
difenoxin/atropine ......................................................................30
Differin see adapalene ................................................................27
Dificid ..................................................................................18, 35
diflorasone ..................................................................................29
Diflucan see fluconazole ............................................................18
diflunisal ....................................................................................25
difluprednate ..............................................................................16
Digex NF......................................................................................30
Digitek ..........................................................................................9
digoxin ..........................................................................................9
dihydroergotamine injection ........................................................24
dihydroergotamine nasal ............................................................24
Dilacor XR see diltiazem ER (24H) ................................................9
Dilantin ......................................................................................24
Dilaudid see hydromorphone ......................................................26
diltiazem ......................................................................................9
diltiazem ER (12H)........................................................................9
diltiazem ER (24H)........................................................................9
dimethyl fumarate ................................................................21, 34
Diovan see valsartan ................................................................8, 9
Diovan HCT see valsartan/HCTZ ................................................8, 9
Dipentum ....................................................................................30
diphenoxylate/atropine ..............................................................30
Diprolene see betamethasone ..............................................28, 29
Diprolene AF see augmented betamethasone..............................29
dipyridamole ..............................................................................10
Disalcid see salsalate ................................................................25
disopyramide ................................................................................9
disopyramide ER ..........................................................................9
disulfiram....................................................................................22
Ditropan see oxybutynin........................................................30, 36
Ditropan XL see oxybutynin XL ..............................................30, 36
Diuril see chlorthiazide ..................................................................9
divalproex sodium ......................................................................24
divalproex sodium ER..................................................................24
Divigel ........................................................................................15
dofetilide ......................................................................................9
dolasetron ............................................................................29, 34
Dolobid see diflunisal..................................................................25
Dolophine see methadone ....................................................22, 26
dolutegravir ................................................................................19
donepezil ....................................................................................24
45
INDEX
Donnatal see
atropine/hyoscyamine/phenobarbital/scopolamine..............24
Doral see quazepam ..................................................................23
dornase alfa ........................................................................32, 34
Doryx see doxycycline hyclate ..............................................18, 27
dorzolamide ................................................................................16
dorzolamide/timolol ....................................................................16
dorzolamide/timolol PF ..............................................................16
Dostinex see cabergoline ............................................................15
Dostinex......................................................................................15
Dovonex see calcipotriene cream ................................................28
doxazosin................................................................................9, 30
doxazosin ER ................................................................................9
doxepin ................................................................................23, 28
doxercalciferol ............................................................................12
doxycycline ....................................................................16, 18, 27
doxylamine ..........................................................................29, 31
doxylamine/pyridoxine ................................................................29
Doxytex ......................................................................................31
Drisdol see ergocalciferol ............................................................12
dronabinol ..................................................................................29
dronedarone..................................................................................9
Droxia ........................................................................................20
droxidopa....................................................................................10
Duac see clindamycin/benzoyl peroxide......................................27
Duavee ................................................................................12, 15
Duet DHA Balanced ....................................................................13
DuetAct see pioglitazone/glimepiride ..........................................11
Duexis ........................................................................................29
Dulera ........................................................................................31
duloxetine ..................................................................................23
Duragesic see fentanyl patch ......................................................26
Durasal ......................................................................................27
Durezol........................................................................................16
dutasteride..................................................................................30
dutasteride/tamsulosin ..............................................................30
Dutoprol..................................................................................8, 36
Dyazide see triamterene/HCTZ ......................................................9
Dymista ......................................................................................31
Dynacirc CR see isradipine............................................................9
Dynapen see dicloxacillin ............................................................17
dyphylline....................................................................................32
Dyrenium see triamterene ............................................................9
Dyrenium ......................................................................................9
Dysport ......................................................................................33
echothiophate ............................................................................16
EC-Naprosyn see naproxen ER ....................................................25
econazole cream ........................................................................28
econazole foam ..........................................................................28
Ecoza ..........................................................................................28
eculizumab..................................................................................33
Edarbi ....................................................................................8, 34
Edarbyclor ..............................................................................8, 34
10-20-14
Edecrin..........................................................................................9
Edluar ..................................................................................23, 37
Edurant ......................................................................................19
EEMT ..........................................................................................15
efavirenz......................................................................................19
efavirenz/emtricitabine/tenofovir ................................................19
Effexor see venlafaxine IR............................................................23
Effexor XR see venlafaxine SR capsules ......................................23
Effient ........................................................................................10
efinaconazole..............................................................................28
Efudex see fluorouracil ................................................................28
Elavil see amitriptyline ..........................................................22, 23
Eldepryl see selegiline ....................................................23, 26, 36
Elestat see epinastine ................................................................16
Elestrin........................................................................................15
eletriptan ..............................................................................24, 34
Elidel ..........................................................................................28
Eligard ........................................................................................20
eliglustat ....................................................................................31
Elimite see permethrin ................................................................28
Elinest ........................................................................................14
Eliquis ........................................................................................10
Ella 14, 37
Elmiron ......................................................................................31
Elocon see mometasone topical..................................................29
eltrombopag ........................................................................10, 34
elvitegravir/cobicistat/emtricitabine/tenofovir ............................19
Emadine ....................................................................................16
Embeline see clobetasol topical..................................................29
Emcyt..........................................................................................20
emedastine ................................................................................16
Emend ..................................................................................29, 34
Emend trifold kit..........................................................................34
Emoquette ..................................................................................14
empagliflozin ........................................................................11, 34
Emsam ................................................................................23, 36
emtricitabine ..............................................................................19
emtricitabine/rilpivirine/tenofovir ................................................19
emtricitabine/tenofovir ................................................................19
Emtriva........................................................................................19
Emycin ........................................................................................17
Enablex ................................................................................30, 34
enalapril........................................................................................8
enalapril soln ................................................................................8
enalapril/HCTZ ..............................................................................8
Enbrel ............................................................................21, 29, 35
Endometrin ................................................................................15
enfuvirtide ..................................................................................19
Enjuvia....................................................................................3, 15
enoxaparin ..................................................................................10
Enpresse ....................................................................................13
Enskyce ......................................................................................14
entacapone ................................................................................26
46
INDEX
entecavir ....................................................................................19
Entocort see budesonide oral ..............................................30, 34
Entyvio ........................................................................................33
Enulose ......................................................................................30
enzalutamide ..............................................................................21
Epaned ........................................................................................8
Epiduo ........................................................................................27
Epiflur ........................................................................................13
epinastine ..................................................................................16
epinephrine injection ..................................................................32
Epipen ........................................................................................32
Epipen Jr ....................................................................................32
Epivir see lamivudine ..................................................................19
Epivir HBV see lamivudine ..........................................................19
eplerenone....................................................................................9
Epogen........................................................................................10
eprosartan ....................................................................................8
eprosartan/HCTZ ..........................................................................8
Epzicom ......................................................................................19
Equetro ......................................................................................24
ergocalciferol ..............................................................................12
ergotamine/caffeine....................................................................24
Erivedge ......................................................................................20
erlotinib ................................................................................21, 35
Errin ............................................................................................14
Ertaczo........................................................................................28
Eryped ........................................................................................17
Erytab ........................................................................................17
Erythrocin....................................................................................17
erythromycin ..................................................................16, 17, 27
erythromycin ethyl succinate ......................................................17
erythromycin stearate..................................................................17
erythromycin/sulfisoxazole ..........................................................17
erythropoeitin..............................................................................10
escitalopram ..............................................................................23
Esgic see acetaminophen/butalbital/caffeine ............................24
Esgic-Plus see acetaminophen/butalbital/caffeine......................24
Eskalith ......................................................................................22
eslicarbazepine acetate ..............................................................24
esomeprazole ................................................................29, 35, 36
esomeprazole strontium ........................................................29, 35
esomeprazole/naproxen........................................................29, 36
Estarylla......................................................................................14
estazolam ..................................................................................23
esterified estrogen tab ................................................................15
esterified estrogen/methyltestosterone........................................15
Estrace........................................................................................15
estradiol acetate ........................................................................15
estradiol spray ............................................................................15
estradiol tab................................................................................15
estradiol topical gel ....................................................................15
estradiol twice weekly patch........................................................15
estradiol vaginal cream ..............................................................15
10-20-14
estradiol vaginal ring ............................................................15, 35
estradiol vaginal tab....................................................................15
estradiol weekly patch ................................................................15
estradiol/drospirenone..........................................................14, 15
estradiol/levonorgestrel weekly patch..........................................15
estradiol/norethindrone tab ........................................................15
estradiol/norethindrone twice weekly patch ................................15
estradiol/norgestimate tab ..........................................................15
estramustine ..............................................................................20
Estrasorb ....................................................................................15
Estratest see esterified estrogen/methyltestosterone ..................15
Estring ..................................................................................15, 35
Estrogel ......................................................................................15
estrogen/methyltestosterone tab ................................................15
estropipate tab ..........................................................................15
Estrostep 21 see Tri-Legest FE, Tilia FE ........................................13
Estrostep FE see Tri-Legest FE, Tilia FE ........................................13
eszopiclone ..........................................................................23, 35
etanercept ............................................................................21, 35
ethacrynic acid..............................................................................9
ethambutol ................................................................................18
ethinyl estradiol/norethindrone tab ............................................15
ethionamide................................................................................18
ethosuximide ..............................................................................24
ethotoin ......................................................................................24
etidronate ..................................................................................12
etodolac......................................................................................25
etoposide....................................................................................20
etravirine ....................................................................................19
Eulexin see flutamide ..................................................................20
Eurax ..........................................................................................28
Evamist ......................................................................................15
everolimus ............................................................................20, 21
everolimus soluble tab ................................................................21
Evista see raloxifene....................................................................12
Evoxac see cevimeline ................................................................31
Exalgo see hydromorphone ER ....................................................26
Exederm......................................................................................28
Exelon see rivastigmine ..............................................................24
Exelon patch ..............................................................................24
exemestane ................................................................................20
exenatide ....................................................................................11
exenatide weekly ........................................................................11
Exforge ......................................................................................8, 9
Exforge HCT ..............................................................................8, 9
Exjade ........................................................................................13
Extavia ........................................................................................21
Extina see ketoconazole foam ....................................................28
ezetimibe........................................................................12, 34, 37
ezetimibe/atorvastatin ..........................................................12, 34
ezetimibe/simvastatin ..........................................................12, 37
ezogabine ..................................................................................24
Fabior..........................................................................................27
47
INDEX
Factive ..................................................................................17, 35
Falmina ......................................................................................14
famciclovir ..................................................................................19
famotidine ..................................................................................29
Famvir see famciclovir ................................................................19
Fanapt ........................................................................................22
Fanatrex ......................................................................................24
Fareston......................................................................................20
Farxiga ..................................................................................11, 34
FazaClo ODT................................................................................22
febuxostat ..................................................................................20
felbamate ..................................................................................24
Felbatol see felbamate................................................................24
Feldene see piroxicam ................................................................25
felodipine......................................................................................9
Femara see letrozole ..................................................................20
Femcon FE see Zeosa ................................................................14
Femhrt see Jinteli........................................................................15
Femring ................................................................................15, 35
Femtrace ....................................................................................15
fenofibrate ..................................................................................12
fenofibric acid ............................................................................12
Fenoglide ....................................................................................12
fenoprofen ..................................................................................25
fentanyl nasal..............................................................................26
fentanyl oral ................................................................................26
fentanyl patch ............................................................................26
fentanyl sublingual spray ......................................................26, 35
fentanyl transmucosal film ..........................................................26
Fentora ................................................................................26, 35
Ferriprox......................................................................................10
fesoterodine fumarate ................................................................30
Fetzima ................................................................................23, 35
Fexmid see cyclobenzaprine ........................................................25
Fibricor see fenofibric acid ..........................................................12
fidaxomicin ..........................................................................18, 35
filgrastim ....................................................................................10
Finacea ......................................................................................27
Finacea Plus ..............................................................................27
finasteride ..................................................................................30
fingolimod ..................................................................................21
Fioricet see acetaminophen/butalbital/caffeine ..........................24
Fiorinal see aspirin/butalbital/caffeine ......................................24
Firazyr ........................................................................................20
Firmagon ....................................................................................15
First Progesterone ......................................................................15
First-lansoprazole..................................................................29, 35
First-omeprazole see omeprazole compound kit ..........................29
Flagyl see metronidazole ................................................18, 27, 29
Flarex ..........................................................................................16
flavoxate......................................................................................30
flecainide ......................................................................................9
Flector ........................................................................................25
10-20-14
Flexeril see cyclobenzaprine ........................................................25
Flomax see tamsulosin................................................................30
Flonase see fluticasone nasal ....................................................31
Flo-Pred ......................................................................................20
Florinef see fludrocortisone ........................................................20
Flovent ........................................................................................31
Floxin see ofloxacin ..............................................................16, 17
Floxin Otic see ofloxacin otic ......................................................17
fluconazole..................................................................................18
flucytosine ..................................................................................18
fludrocortisone ............................................................................20
Flumadine see rimantadine ........................................................19
flunisolide nasal..........................................................................31
flunisolide inhaler........................................................................31
fluocinolone....................................................................17, 28, 29
fluocinolone oil ..........................................................................29
fluocinolone otic ........................................................................17
fluocinolone shampoo ................................................................29
fluocinonide 0.05% ....................................................................29
fluocinonide 0.1% ......................................................................29
Fluor-A-Day ................................................................................13
fluoride ................................................................................13, 32
fluoride/xylitol ............................................................................13
Fluoritab......................................................................................13
fluorometholone ..........................................................................16
fluorometholone acetate ............................................................16
fluorouracil..................................................................................28
fluorouracil 0.5% cream ..............................................................28
fluoxetine cap ............................................................................23
fluoxetine tab ..............................................................................23
fluoxetine weekly ........................................................................23
fluoxetine/olanzapine..................................................................22
fluoxymesterone ..........................................................................15
fluphenazine ..............................................................................22
Flura ..........................................................................................13
flurandrenolide............................................................................29
Flura-tab ....................................................................................13
flurazepam ..................................................................................23
flurbiprofen ..........................................................................16, 25
Fluress see benoxinate/fluorescein ............................................17
Flurox ..........................................................................................17
flutamide ....................................................................................20
fluticasone cream/ointment ........................................................29
fluticasone lotion ........................................................................29
fluticasone furoate nasal ............................................................31
fluticasone furoate/vilanterol inhaler ..........................................31
fluticasone inhaler ......................................................................31
fluticasone nasal ........................................................................31
fluticasone-salmeterol inhaler ....................................................31
fluvastatin ............................................................................12, 35
fluvastatin XL ........................................................................12, 35
fluvoxamine ..........................................................................23, 35
fluvoxamine CR ....................................................................23, 35
48
INDEX
FML Forte....................................................................................16
FML Liquifilm see fluorometholone ..............................................16
FML SOP ....................................................................................16
Focalin see dexmethylphenidate..................................................22
Focalin XR see dexmethylphenidate XR ......................................22
folic acid ..............................................................................13, 32
Foltx............................................................................................13
fondaparinux ..............................................................................10
Foradil ........................................................................................31
Forfivo XL ....................................................................................23
formoterol inhaler........................................................................31
formoterol nebulizer solution ......................................................31
Fortamet see metformin ER ........................................................11
Forteo ..................................................................................12, 37
Fortestra see testosterone topical ..............................................15
Fortical........................................................................................12
Fosamax see alendronate ....................................................12, 34
FosamaxD ..................................................................................12
fosamprenavir ............................................................................19
fosfomycin ..................................................................................18
fosinopril ......................................................................................8
fosinopril/HCTZ ............................................................................8
Fosrenol ......................................................................................13
Fragmin ......................................................................................10
Freestyle ....................................................................................12
Freestyle Lite ..............................................................................12
Freestyle Insulinx ........................................................................12
Frova ....................................................................................24, 35
frovatriptan ..........................................................................24, 35
Fulyzaq........................................................................................30
Furadantin see nitrofurantoin ......................................................18
furosemide ....................................................................................9
Fuzeon ........................................................................................19
Fycompa ....................................................................................24
gabapentin ..........................................................................24, 35
gabapentin ER ..........................................................................24
gabapentin SR ............................................................................24
Gabitril see tiagabine ..................................................................24
galantamine..........................................................................24, 35
galantamine ER ....................................................................24, 35
ganciclovir ..................................................................................16
Gantrisin ....................................................................................18
Garamycin see gentamicin ....................................................16, 27
Gardasil ......................................................................................33
Garimide see sulfacetamide/sulfur 10%/5% cream, cleanser,
medicated pads, foam, lotion, suspension............................27
Gastrocrom see cromolyn sodium ..............................................31
gatifloxacin ..........................................................................16, 17
Gattex ........................................................................................30
Gavilyte-G ..................................................................................30
Gelnique ....................................................................................30
gemfibrozil ..................................................................................12
gemifloxacin..........................................................................17, 35
10-20-14
Generess FE................................................................................14
Generlac ....................................................................................30
Gengraf ......................................................................................20
Genotropin ..................................................................................16
gentamicin ............................................................................16, 27
Geodon see ziprasidone..............................................................22
Gianvi..........................................................................................14
Giazo ..........................................................................................30
Gildagia ......................................................................................14
Gildess FE 1.5/30 ......................................................................14
Gildess FE 1/20 ........................................................................14
Gilenya........................................................................................21
Gilotrif ..................................................................................20, 34
glatiramer 20 mg ........................................................................21
glatiramer 40 mg ........................................................................21
Gleevec ......................................................................................21
glimepiride ..................................................................................11
glipizide ......................................................................................11
glipizide ER ................................................................................11
GlucaGen ....................................................................................11
glucagon kit ................................................................................11
Glucotrol see glipizide ................................................................11
Glucotrol XL see glipizide ER ......................................................11
Glucovance see metformin/glyburide ..........................................11
Glumetza ....................................................................................11
glyburide ....................................................................................11
Glycate........................................................................................31
glycerol phenylbutyrate................................................................15
glycopyrrolate ............................................................................31
Glyset..........................................................................................11
golimumab ....................................................................21, 30, 35
Golytely packets see PEG/electrolytes packets............................30
Gralise ..................................................................................24, 35
granisetron............................................................................29, 35
granisetron patch ..................................................................29, 35
Granix ........................................................................................10
Grastek ................................................................................31, 37
griseofulvin..................................................................................18
griseofulvin ultramicrosize............................................................18
GrisPEG see griseofulvin ultramicrosize........................................18
guanabenz ....................................................................................9
guanfacine........................................................................9, 22, 35
Gynazole see butoconazole ........................................................28
halcinonide ................................................................................29
Halcion see triazolam..................................................................23
Haldol see haloperidol ................................................................22
Halflytely Kit ................................................................................30
halobetasol ................................................................................29
halobetasol/ammonium lactate ..................................................29
Halog ..........................................................................................29
Halonate PAC see halobetasol/ammonium lactate......................29
haloperidol..................................................................................22
HCTZ ..........................................................................8-10, 34, 36
49
INDEX
Hectorol see doxercalciferol ........................................................12
Hemangeol....................................................................................8
Hepsera see adefovir ..................................................................19
Hetlioz ..................................................................................23, 37
Hizentra ......................................................................................20
homatropine 2% ........................................................................17
homatropine 5% ........................................................................17
Horizant ......................................................................................24
Humalog ....................................................................................11
Humalog mix ..............................................................................11
human chorionic gonadotropin..............................................15, 33
human insulin ............................................................................11
human insulin-concentrated..................................................11, 35
human insulin mix ......................................................................11
human isophane ........................................................................11
human papillomavirus vaccine ....................................................33
Humatin see paromomycin..........................................................18
Humatrope ..................................................................................16
Humira ....................................................................21, 29, 30, 34
Humulin N ..................................................................................11
Humulin R ............................................................................11, 35
Humulin R U-500........................................................................11
Humulin 70/30 ..........................................................................11
Hycamtin ....................................................................................20
Hycet ..........................................................................................26
hydralazine..............................................................................9, 10
hydralazine/HCTZ ....................................................................9, 10
hydralazine/reserpine..................................................................10
hydrochlorothiazide ................................................................9, 34
hydrocodone ER....................................................................26, 35
hydrocortisone ......................................16, 17, 20, 25, 27, 28, 30
hydrocortisone rectal ..................................................................30
hydrocortisone soln ....................................................................28
hydrocortisone/lidocaine cream ..................................................25
hydrocortisone/lidocaine rectal ..................................................30
hydrocortisone/pramoxine cream ................................................28
hydrocortisone/pramoxine lotion/ointment..................................28
hydrocortisone/urea....................................................................28
hydromorphone ..........................................................................26
hydroxyamphetamine/tropicamide ..............................................17
hydroxychloroquine ..............................................................18, 20
hydroxyprogesterone caproate injection ......................................33
hydroxypropyl cellulose ophthalmic ............................................17
hydroxyurea ................................................................................20
hydroxyzine..................................................................................31
hyoscyamine................................................................................30
hyoscyamine/phenyltoloxamine ..................................................30
Hyper-Sal see sodium chloride 7% for inh ..................................32
Hytrin see terazosin ................................................................9, 30
Hyzaar see losartan/HCTZ ............................................................8
ibandronate ..........................................................................12, 35
ibrutinib ......................................................................................20
Ibudone ......................................................................................26
10-20-14
ibuprofen........................................................................25, 26, 29
ibuprofen/famotidine ..................................................................29
ibuprofen/hydrocodone ..............................................................26
ibuprofen/oxycodone ..................................................................26
icatibant......................................................................................20
Iclusig ........................................................................................20
Icosapent ethyl ....................................................................12, 35
idelalisib ..............................................................................20, 35
Ilaris............................................................................................33
Ilevro ..........................................................................................16
iloperidone..................................................................................22
iloprost........................................................................................10
imatinib ......................................................................................21
Imbruvica....................................................................................20
imipramine..................................................................................23
imipramine pamoate ..................................................................23
imiquimod ..................................................................................28
Imitrex injection see sumatriptan injection ............................24, 37
Imitrex nasal see sumatriptan nasal......................................24, 37
Imitrex tablets see sumatriptan tablets........................................24
Imuran see azathioprine..............................................................20
Incivek ........................................................................................19
incobotulinum toxin ....................................................................33
Increlex ......................................................................................16
indacaterol..................................................................................31
indapamide ..................................................................................9
Inderal LA see propranolol LA........................................................8
Inderal XL......................................................................................8
indinavir ......................................................................................19
Indocin see indomethacin ..........................................................25
indomethacin ..............................................................................25
Infergen ......................................................................................19
infliximab ....................................................................................33
ingenol........................................................................................28
Inlyta ..........................................................................................21
Innohep ......................................................................................10
Innopran XL ..................................................................................8
Inspra see eplerenone ..................................................................9
insulin aspart ..............................................................................11
insulin aspart mix........................................................................11
insulin detemir ............................................................................11
insulin glargine............................................................................11
insulin glulisine ..........................................................................11
insulin lispro ..............................................................................11
insulin lispro mix ........................................................................11
insulin syringes............................................................................12
Intelence ....................................................................................19
interferon alfa ......................................................................19, 20
interferon alfacon ........................................................................19
interferon alfa-n3 ........................................................................18
interferon beta-1a ......................................................................21
interferon beta-1b ......................................................................21
interferon gamma........................................................................18
50
INDEX
Intermezzo ............................................................................23, 37
Intron A ................................................................................19, 20
Introvale ......................................................................................14
Invega ........................................................................................22
Invirase ......................................................................................19
Invokamet ..................................................................................11
Invokana ..............................................................................11, 34
Iopidine ......................................................................................16
Iplex............................................................................................16
ipratropium ..........................................................................31, 32
ipratropium HFA inhaler ..............................................................32
ipratropium nasal........................................................................31
Iquix............................................................................................16
irbesartan......................................................................................8
irbesartan/HCTZ ............................................................................8
Isentress ....................................................................................19
isocarboxazid ..............................................................................23
isometheptene/acetaminophen/caffeine ....................................24
isoniazid......................................................................................18
isoniazid/pyrazinamide................................................................18
isoniazid/rifampin ......................................................................18
Isopto Atropine see atropine ................................................17, 30
Isopto Carbachol ........................................................................16
Isopto Carpine see pilocarpine..............................................16, 31
Isopto Homatropine ....................................................................17
Isopto Hyoscine ..........................................................................17
isosorbide dinitrate ....................................................................10
isosorbide dinitrate/hydralazine ..................................................10
isosorbide mononitrate................................................................10
Isotret ........................................................................................27
isotretinoin ..................................................................................27
isradipine ......................................................................................9
Istalol..........................................................................................16
itraconazole ................................................................................18
ivacaftor ......................................................................................31
ivermectin ............................................................................18, 28
ivermectin topical........................................................................28
Jakafi ..........................................................................................20
Jalyn ..........................................................................................30
Jantoven......................................................................................10
Janumet ......................................................................................11
Janumet XR ................................................................................11
Januvia ................................................................................11, 37
Jardiance ..............................................................................11, 34
Jencycla ......................................................................................14
Jentadueto ..................................................................................11
Jolessa........................................................................................14
Jolivette ......................................................................................14
Jublia ..........................................................................................28
Junel FE 1.5/30..........................................................................14
Junel FE 1/20 ............................................................................14
Juvisync ..........................................................................11, 12, 37
Juxtapid ......................................................................................12
10-20-14
Kadian see morphine ER capsule................................................26
Kaletra ........................................................................................19
Kalydeco ....................................................................................31
Kapidex see Dexilant ............................................................29, 34
Kapvay see clonidine SR ............................................................22
Karbinal ER ................................................................................31
Kariva..........................................................................................13
Kayexalate see sodium polystyrene sulfonate ..............................13
Kazano........................................................................................11
K-Dur see potassium chloride ....................................................13
Keflex see cephalexin..................................................................17
Kelnor 1/35................................................................................14
Kenalog see triamcinolone topical ..............................................29
Keppra see levetiracetam ............................................................24
Keppra XR see levetiracetam ER..................................................24
Keralac ......................................................................................28
Kerlone see betaxolol..............................................................8, 16
Kerydin ......................................................................................28
Ketek ....................................................................................17, 37
ketoconazole ........................................................................18, 28
ketoconazole cream ....................................................................28
ketoconazole foam ......................................................................28
ketoconazole gel ........................................................................28
ketoconazole/pyrithione ..............................................................28
ketoprofen ..................................................................................25
ketorolac ........................................................................16, 25, 35
ketorolac injection ................................................................25, 35
ketorolac nasal ..........................................................................25
ketorolac PF ................................................................................16
Khedezla see desvenlafaxine ................................................23, 34
Kineret ..................................................................................21, 34
Klaron see sulfacetamide sodium shampoo, suspension ............27
Klonopin see clonazepam ....................................................23, 24
Klor-Con......................................................................................13
Kombiglyze XR ............................................................................11
K-Phos ........................................................................................13
Kristalose ....................................................................................30
Kurvelo........................................................................................14
Kuvan..........................................................................................15
Kwell see lindane lotion/shampoo ..............................................28
Kynamro ....................................................................................12
Kytril see granisetron ............................................................29, 35
labetalol........................................................................................8
Lac-Hydrin see ammonium lactate 12%......................................28
lacosamide ..........................................................................24, 35
Lacrisert ......................................................................................17
lactulose solution........................................................................30
Lamictal see lamotrigine ......................................................24, 35
Lamictal ODT ..............................................................................24
Lamictal XR see lamotrigine ER ............................................24, 35
Lamisil see terbinafine ................................................................18
Lamisil granules ..........................................................................18
lamivudine ..................................................................................19
51
INDEX
lamivudine/zidovudine ................................................................19
lamotrigine............................................................................24, 35
lamotrigine ER ......................................................................24, 35
lamotrigine ODT ..........................................................................24
Lamprene....................................................................................18
lancets........................................................................................12
Lanoxin ........................................................................................9
lanreotide....................................................................................15
lansoprazole ........................................................................29, 35
lansoprazole compound kit ..................................................29, 35
lansoprazole soltab ....................................................................29
lansoprazole/amoxicillin/clarithromycin ................................29, 35
lanthanum ..................................................................................13
Lantus ........................................................................................11
Lantus Solostar Pen ....................................................................11
lapatinib ....................................................................................20
Lariam see mefloquine................................................................18
Larin FE 1/20 ............................................................................14
Lasix see furosemide ....................................................................9
Lastacaft ....................................................................................16
latanoprost..................................................................................16
Latuda ..................................................................................22, 35
Lavoclen-4 ..................................................................................27
Lavoclen-8 ..................................................................................27
Lazanda ................................................................................26, 35
Leena..........................................................................................13
leflunomide ................................................................................20
lenalidomide ........................................................................20, 35
Lescol see fluvastatin............................................................12, 35
Lescol XL ..............................................................................12, 35
Lessina ......................................................................................14
Letairis ........................................................................................10
letrozole ......................................................................................20
leucovorin ..................................................................................20
Leukeran ....................................................................................20
Leukine ......................................................................................10
leuprolide ............................................................................15, 20
levalbuterol inhaler......................................................................31
levalbuterol nebulizer solution ....................................................31
Levaquin see levofloxacin oral ....................................................17
Levbid see hyoscyamine ..............................................................30
Levemir ......................................................................................11
levetiracetam ..............................................................................24
levetiracetam ER ........................................................................24
levobunolol ................................................................................16
levocarnitine ........................................................................13, 20
levocetirizine ..............................................................................31
Levo-Dromoran see levorphanol ..................................................26
levofloxacin ..........................................................................16, 17
levofloxacin oral ..........................................................................17
levomilnacipran ....................................................................23, 35
Levonest......................................................................................13
levonorgestrel ..................................................................13-15, 35
10-20-14
Levora ........................................................................................14
levorphanol ................................................................................26
Levothroid ..................................................................................15
levothyroxine ..............................................................................15
Levoxyl ........................................................................................15
Levsin see hyoscyamine ..............................................................30
Lexapro see escitalopram............................................................23
Lexiva..........................................................................................19
Lialda..........................................................................................30
Librax ..........................................................................................30
Librium see chlordiazepoxide ................................................23, 30
Lidamantle HC see hydrocortisone/lidocaine cream ....................25
Lidex see fluocinonide ................................................................29
lidocaine 2% viscous ..................................................................25
lidocaine 3% ..............................................................................25
lidocaine 4%, 5% topical ............................................................25
lidocaine patch ..........................................................................25
lidocaine/tetracaine....................................................................28
Lidoderm see lidocaine patch ....................................................25
LidoRX ........................................................................................25
Lidovir ........................................................................................28
linaclotide ............................................................................30, 35
linagliptin ............................................................................11, 35
linagliptin/metformin ..................................................................11
lindane........................................................................................28
linezolid ......................................................................................18
Linzess..................................................................................30, 35
Lioresal see baclofen ..................................................................25
liothyronine ................................................................................15
Lipitor see atorvastatin ....................................................9, 12, 34
Lipofen see fenofibrate................................................................12
Liptruzet................................................................................12, 34
liraglutide....................................................................................11
lisdexamfetamine..................................................................22, 35
lisinopril ........................................................................................8
lisinopril/HCTZ ..............................................................................8
lithium ........................................................................................22
lithium ER ..................................................................................22
Lithobid ......................................................................................22
Livalo ..................................................................................12, 36
Locoid topical see hydrocortisone butyrate..................................28
Lodine see etodolac....................................................................25
Lodosyn see carbidopa ..............................................................26
lodoxamide ................................................................................16
Loestrin 24 FE see Lomedia 24 FE..............................................14
Loestrin FE 1.5/30 see Junel FE 1.5/30,
Microgestin FE 1.5/30 ........................................................14
Loestrin FE 1/20 see Junel FE 1/20, Microgestin FE 1/20 ........14
Lofibra see fenofibrate ................................................................12
LoLoestrin FE ..............................................................................14
Lomedia 24 FE............................................................................14
LoMinastrin FE ............................................................................14
lomefloxacin................................................................................17
52
INDEX
lomitapide ..................................................................................12
Lomotil see diphenoxylate/atropine ............................................30
lomustine ....................................................................................20
Lo-Ovral see Cryselle, Low-Ogestrel ............................................14
Lopid see gemfibrozil ..................................................................12
lopinavir/ritonavir ........................................................................19
Lopressor see metoprolol tartrate ..................................................8
Lopressor HCT see metoprolol/HCTZ..............................................8
Loprox see ciclopirox ..................................................................28
lorazepam ............................................................................23, 24
Lorcet see acetaminophen/hydrocodone ....................................26
Loryna ........................................................................................14
Lorzone ......................................................................................25
losartan ........................................................................................8
losartan/HCTZ ..............................................................................8
LoSeasonique see Amethia Lo, Camrese Lo ................................13
Lotemax ......................................................................................16
Lotensin see benazepril ............................................................8, 9
LotensinHCT see benazepril/HCTZ ................................................8
loteprednol..................................................................................16
Lotrel see benazepril/amlodipine ..............................................8, 9
Lotrimin see clotrimazole ......................................................18, 28
Lotrisone see clotrimazole/betamethasone ................................28
Lotronex................................................................................30, 34
lovastatin ..............................................................................12, 35
lovastatin/niacin ........................................................................12
Lovaza ..................................................................................12, 36
Lovenox see enoxaparin ..............................................................10
Low-Ogestrel ..............................................................................14
loxapine ......................................................................................22
Loxitane see loxapine..................................................................22
Lozol see indapamide ..................................................................9
lubiprostone..........................................................................30, 35
Ludent ........................................................................................13
Lufyllin ........................................................................................32
luliconazole ................................................................................28
Lumigan ......................................................................................16
Lumizyme....................................................................................33
Lunesta see eszopiclone ......................................................23, 35
Lupron ..................................................................................15, 20
lurasidone ............................................................................22, 35
Lutera ........................................................................................14
Luvox CR see fluvoxamine CR................................................23, 35
Luxiq see betamethasone valerate ..............................................29
Luzu ............................................................................................28
Lybrel see Amethyst ....................................................................14
Lyrica....................................................................................24, 36
Lysodren ....................................................................................20
Lysteda see tranexamic acid ......................................................10
macitentan..................................................................................10
MacroBID see nitrofurantoin........................................................18
Macrodantin................................................................................18
mafenide ....................................................................................27
10-20-14
Magnacet....................................................................................26
Makena ......................................................................................33
Malarone see atovaquone/proquanil ..........................................18
malathion....................................................................................28
Mandelamine ..............................................................................18
maprotiline..................................................................................23
maraviroc ....................................................................................19
Marinol see dronabinol ..............................................................29
Marlissa ......................................................................................14
Marplan ......................................................................................23
Matulane ....................................................................................20
Matzim LA ....................................................................................9
Mavik see trandolapril ..............................................................8, 9
Maxair ........................................................................................31
Maxalt see rizatriptan............................................................24, 36
Maxaquin ....................................................................................17
Maxiflor see diflorasone ..............................................................29
Maxitrol see neomycin/polymyxin/dexamethasone......................16
mecamylamine............................................................................10
mecasermin ................................................................................16
mechlorethamine topical ............................................................20
meclofenamate ..........................................................................25
Medrol see methylprednisolone ..................................................20
medroxyprogesterone ..................................................................15
mefenamic acid ..........................................................................25
mefloquine..................................................................................18
Megace see megestrol ................................................................15
Megace ......................................................................................15
megestrol ....................................................................................15
Mekinist ......................................................................................20
Mellaril see thioridazine ..............................................................22
meloxicam ..................................................................................25
melphalan ..................................................................................20
memantine ..........................................................................24, 35
memantine ERC ..........................................................................24
Menest........................................................................................15
Menostar ..............................................................................15, 35
Mentax........................................................................................28
mepenzolate ..............................................................................29
Mephyton see phytonadione........................................................10
Mephyton ....................................................................................10
meprobamate ............................................................................23
Mepron see atovaquone..............................................................18
mercaptopurine ..........................................................................20
mercaptopurine susp ..................................................................20
mesalamine ................................................................................30
mesalamine ................................................................................30
mesalamine rectal ......................................................................30
mesna ........................................................................................20
Mesnex ......................................................................................20
Mestinon see pyridostigmine ......................................................24
Mestinon SR ..............................................................................24
Metadate CD see methylphenidate CD 30:70 ............................22
53
INDEX
Metadate ER ..............................................................................22
Metaglip see metformin glipizide ................................................11
metaproterenol tabs....................................................................32
metaxalone ................................................................................25
metformin ..................................................................................11
metformin ER ..............................................................................11
metformin liquid..........................................................................11
metformin/glipizide ....................................................................11
metformin/glyburide....................................................................11
methadone ..........................................................................22, 26
Methadose see methadone ..................................................22, 26
methamphetamine ......................................................................22
methazolamide............................................................................31
methenamine..............................................................................18
methenamine/sodium salicylate ................................................18
Methergine see methylergonovine................................................24
methimazole ..............................................................................15
Methitest ....................................................................................15
methocarbamol ..........................................................................25
methotrexate ........................................................................20, 21
methsuximide..............................................................................24
methyldopa ..................................................................................9
methyldopa/HCTZ..........................................................................9
methylergonovine ........................................................................24
methylnaltrexone ..................................................................30, 35
methylphenidate ..................................................................22, 35
methylphenidate CD 30:70 ........................................................22
methylphenidate CD 50:50 ........................................................22
methylphenidate ER ....................................................................22
methylphenidate ER oral susp. ....................................................22
methylphenidate patch................................................................22
methylphenidate SR ....................................................................22
methylprednisolone ....................................................................20
methyltestosterone ......................................................................15
metipranolol................................................................................16
metoclopramide ..........................................................................29
metoclopramide ODT ..................................................................29
metolazone ..................................................................................9
metoprolol succinate (XL) ......................................................8, 36
metoprolol succinate/HCTZ ....................................................8, 36
metoprolol tartrate ........................................................................8
metoprolol/HCTZ ..........................................................................8
Metozolv ....................................................................................29
metreleptin..................................................................................15
Metrogel see metronidazole ............................................18, 27, 29
Metrolotion see metronidazole ........................................18, 27, 29
metronidazole ................................................................18, 27, 29
Mevacor see lovastatin..........................................................12, 35
mexiletine......................................................................................9
Mexitil see mexiletine ....................................................................9
Miacalcin see calcitonin..............................................................12
Micardis see telmisartan ..........................................................8, 9
Micardis HCT see telmisartan/HCTZ ..............................................8
10-20-14
miconazole ..........................................................................18, 28
miconazole/zinc oxide/petrolatum ..............................................28
Microgestin FE 1.5/30 ................................................................14
Microgestin FE 1/20 ..................................................................14
Micro-K see potassium chloride ..................................................13
Micronase see glyburide..............................................................11
Micronor see Camila, Errin, Heather, Jolivette, NoraBe ................14
midodrine ..................................................................................10
Midrin see acetaminophen/dichloralphenazone/isometheptene..24
miglitol........................................................................................11
miglustat ....................................................................................12
Migranal see dihydroergotamine nasal ........................................24
Millipred......................................................................................20
milnacipran ..........................................................................23, 36
Mimvey see estradiol/norethindrone tab ....................................15
Minastrin 24 FE ..........................................................................14
Minipress see prazosin............................................................9, 30
Minivelle ..............................................................................15, 35
Minocin see minocycline capsules ..............................................27
minocycline capsules ..................................................................27
minocycline ER............................................................................27
minocycline tablets ....................................................................27
minoxidil ....................................................................................10
mipomersen ................................................................................12
mirabegron ..........................................................................30, 36
Mirapex see pramipexole ......................................................26, 36
Mirapex ER ..........................................................................26, 36
Mircette see Kariva......................................................................13
mirtazapine ................................................................................23
Mirvaso ......................................................................................28
misoprostol ..........................................................................25, 29
mitotane ....................................................................................20
mixed grass pollen ..............................................................31, 36
Moban ........................................................................................22
modafinil ..............................................................................22, 36
Moderiba ....................................................................................19
Modicon see Nortrel 0.5/35, Necon 0.5/35, Wera, Brevicon ......14
Moduretic see amiloride/HCTZ ......................................................9
moexipril ......................................................................................8
moexipril/HCTZ..............................................................................8
molindone ..................................................................................22
mometasone inhaler ..................................................................31
mometasone nasal ....................................................................31
mometasone topical ..................................................................29
mometasone-formoterol inhaler ..................................................31
Monodox see doxycycline monohydrate ................................18, 27
Mono-Linyah ..............................................................................14
Mononessa ................................................................................14
Monopril see fosinopril ..................................................................8
Monopril-HCT see fosinopril/HCTZ ................................................8
montelukast ................................................................................32
Monurol ......................................................................................18
morphine ..............................................................................26, 36
54
INDEX
morphine ER capsule ..................................................................26
morphine ER tablet ....................................................................26
Motofen ......................................................................................30
Motrin see ibuprofen ......................................................25, 26, 29
MoviPrep ..............................................................................30, 36
Moxatag see amoxicillin ER ........................................................17
Moxeza ......................................................................................16
moxifloxacin..........................................................................16, 17
MS Contin see morphine ER tablet..............................................26
Mucomyst see acetylcysteine ......................................................32
Multaq ..........................................................................................9
mupirocin....................................................................................27
mupirocin nasal ointment............................................................27
My Way ......................................................................................14
Myalept ......................................................................................15
Myambutol see ethambutol ........................................................18
Mycelex see clotrimazole troche ..................................................18
Mycelex-3 ..................................................................................28
Mycobutin see rifabutin ..............................................................18
Mycolog II see nystatin/triamcinolone ........................................28
mycophenolate mofetil................................................................20
mycophenolic acid ......................................................................20
Mydriacyl see tropicamide ..........................................................17
Myfortic see mycophenolic acid ..................................................20
Myleran ......................................................................................20
Myobloc ......................................................................................33
Myorisan ....................................................................................27
Myozyme ....................................................................................33
Myrbetriq ..............................................................................30, 36
Mysoline ....................................................................................24
Myzilra ........................................................................................13
nabilone ..............................................................................29, 36
nabumetone................................................................................25
nadolol..........................................................................................8
nadolol/bendroflumethizide ..........................................................8
nafarelin......................................................................................15
naftifine ......................................................................................28
Naftin..........................................................................................28
Nalfon ........................................................................................25
naltrexone ......................................................................22, 26, 36
Namenda..............................................................................24, 35
Namenda XR ........................................................................24, 35
naphazoline ................................................................................16
Naprelan ....................................................................................25
Naprosyn see naproxen......................................24, 25, 29, 36, 37
naproxen ............................................................24, 25, 29, 36, 37
naproxen ER................................................................................25
naproxen sodium ........................................................................25
naproxen sodium ER ..................................................................25
naratriptan............................................................................24, 36
Nardil see phenelzine..................................................................23
Nasacort AQ see triamcinolone nasal ..........................................31
Nascobal ....................................................................................13
10-20-14
Nasonex......................................................................................31
NataChew ..................................................................................13
Natacyn ......................................................................................16
Natafort ......................................................................................13
natalizumab ................................................................................33
natamycin ..................................................................................16
Natazia ......................................................................................13
nateglinide ..................................................................................11
Natroba see spinosad ................................................................28
Nature-Throid ..............................................................................15
Navane see thiothixene ..............................................................22
Nebcin see tobramycin inj ..........................................................32
nebivolol ......................................................................................8
Nebupent....................................................................................18
Nebusal ......................................................................................32
Necon 0.5/35 ............................................................................14
Necon 1/35................................................................................14
Necon 1/50................................................................................14
Necon 10/11..............................................................................13
Necon 777..................................................................................13
nedocromil..................................................................................16
needles (for insulin syringes) ......................................................12
nefazodone ................................................................................23
nelfinavir ....................................................................................19
Neo-Synalar ................................................................................28
NeoBenz Micro............................................................................27
neomycin ........................................................................16-18, 28
neomycin sulfate/fluocinolone ....................................................28
neomycin/bacitracin/polymyxin/hydrocortisone ointment ..........16
neomycin/polymyxin/dexamethasone ........................................16
neomycin/polymyxin/gramicidin..................................................16
neomycin/polymyxin/hydrocortisone ....................................16, 17
neomycin/polymyxin/hydrocortisone otic ....................................17
Neoral ........................................................................................20
Neosporin see neomycin/polymyxin/gramicidin ..........................16
NeoSynephrine see phenylephrine ..............................................17
nepafenac ..................................................................................16
Neptazane see methazolamide....................................................31
Nesina ..................................................................................11, 34
Neulasta ........................................................................10, 33, 36
Neumega ..............................................................................10, 36
Neupogen ..................................................................................10
Neupro........................................................................................26
Neurontin see gabapentin ....................................................24, 35
Nevanac......................................................................................16
nevirapine ..................................................................................19
nevirapine XR ..............................................................................19
Nexavar ......................................................................................21
Nexium ................................................................................29, 35
Next Choice ..........................................................................14, 35
Next Choice One Dose ..........................................................14, 35
niacin ..................................................................................12, 37
niacin extended release ..............................................................12
55
INDEX
Niacor ........................................................................................12
Niaspan see niacin extended release ..........................................12
nicardipine ....................................................................................9
nicardipine SR ..............................................................................9
Nicoderm CQ see nicotine patch ................................................22
Nicorette ..............................................................................22, 36
nicotine gum ........................................................................22, 36
nicotine inhaler ..........................................................................22
nicotine lozenge ....................................................................22, 36
nicotine patch ............................................................................22
nicotine spray..............................................................................22
Nicotrol inhaler............................................................................22
Nicotrol NS ................................................................................22
Nifediac CC see nifedipine ER ......................................................9
Nifedical XL see nifedipine ER ......................................................9
nifedipine......................................................................................9
nifedipine ER ................................................................................9
nimodipine caps ..........................................................................9
nimodipine soln ............................................................................9
Nimotop see nimodipine caps ......................................................9
Niravam see alprazolam ..............................................................23
nisoldipine ....................................................................................9
nitazoxanide................................................................................18
nitisinone ....................................................................................31
Nitro-bid......................................................................................10
Nitrodur see nitroglycerin patch ..................................................10
nitrofurantoin ..............................................................................18
nitroglycerin ointment..................................................................10
nitroglycerin patch ......................................................................10
nitroglycerin rectal ointment ........................................................30
nitroglycerin spray ......................................................................10
nitroglycerin tablets ....................................................................10
Nitrolingual..................................................................................10
Nitromist see nitroglycerin spray..................................................10
Nitrostat ......................................................................................10
nizatidine ....................................................................................29
Nizoral see ketoconazole ......................................................18, 28
Nolvadex see tamoxifen ..............................................................20
NoraBe........................................................................................14
Nordette see Levora, Portia..........................................................14
Norditropin..................................................................................16
norethindrone tab ......................................................................15
Norflex see orphenadrine ............................................................25
norfloxacin ..................................................................................17
Norinyl 1/35 ..............................................................................14
Norinyl 1/50 see Necon 1/50 ....................................................14
Noritate ......................................................................................27
Normodyne see labetalol ..............................................................8
Noroxin ......................................................................................17
Norpace ........................................................................................9
Norpace CR ..................................................................................9
Norpramin see desipramine ........................................................23
NorQD see Camila, Errin, Heather, Jolivette, NoraBe ....................14
10-20-14
Northera......................................................................................10
Nortrel 0.5/35 ............................................................................14
Nortrel 1/35 ..............................................................................14
Nortrel 777 ................................................................................13
nortriptyline ................................................................................23
Norvasc see amlodipine ..............................................8-10, 12, 34
Norvir..........................................................................................19
Novarel ................................................................................15, 33
Novolin 70/30 ............................................................................11
Novolin N ....................................................................................11
Novolin R ....................................................................................11
Novolog ......................................................................................11
Novolog 70/30 ..........................................................................11
Noxafil ........................................................................................18
Nplate ........................................................................................33
Nucynta ................................................................................26, 37
Nucynta ER ..........................................................................26, 37
Nuedexta ....................................................................................24
Nulytely see PEG/electrolytes................................................30, 36
Numorphan ................................................................................26
Nuox ..........................................................................................27
Nutropin......................................................................................16
NuvaRing ....................................................................................14
Nuvigil ..................................................................................22, 34
Nyamyc see nystatin topical ........................................................28
Nymalize ......................................................................................9
nystatin ................................................................................18, 28
nystatin topical............................................................................28
nystatin/triamcinolone ................................................................28
Nystop see nystatin topical ........................................................28
Ocella ........................................................................................14
octreotide....................................................................................15
octreotide depot..........................................................................15
Ocufen see flurbiprofen ........................................................16, 25
Ocuflox see ofloxacin ............................................................16, 17
ofloxacin ..............................................................................16, 17
ofloxacin otic ..............................................................................17
Ogen see estropipate ..................................................................15
Ogestrel ......................................................................................14
olanzapine ..................................................................................22
olanzapine ODT ..........................................................................22
Oleptro ER ..................................................................................23
olmesartan................................................................................8, 9
olmesartan/HCTZ ..........................................................................8
olodaterol ..................................................................................31
olopatadine ..........................................................................16, 31
olsalazine....................................................................................30
Olux see clobetasol topical ........................................................29
Olux E see clobetasol foam ........................................................29
Olysio ..................................................................................19, 36
omalizumab ................................................................................33
Omeclamox-Pak ....................................................................29, 36
omega-3 acid ethylesters ............................................................12
56
INDEX
omeprazole ..........................................................................29, 36
omeprazole/amoxacillin/clarithromycin ................................29, 36
omeprazole compound kit ..........................................................29
omeprazole/sodium bicarbonate ................................................29
Omnaris ......................................................................................31
Omnicef see cefdinir ..................................................................17
Omnipred see prednisolone ..................................................16, 20
Omnitrope ..................................................................................16
onabotulinum toxin ....................................................................33
ondansetron ........................................................................29, 36
ondansetron film ........................................................................29
Onfi ............................................................................................24
Onglyza ................................................................................11, 36
Onmel ........................................................................................18
Onsolis ................................................................................26, 35
Opana see oxymorphone ......................................................26, 36
Opana ER see oxymorphone ER ............................................26, 36
oprelvekin ............................................................................10, 36
Opsumit ......................................................................................10
Optivar see azelastine ..........................................................16, 31
Oracea ........................................................................................18
Orafate........................................................................................31
Oralair ..................................................................................31, 36
Oralone see triamcinolone oropharyngeal....................................28
Oramorph SR see morphine ER ............................................26, 36
Orap............................................................................................22
Orapred see prednisolone ....................................................16, 20
Orapred ODT ..............................................................................20
Oravig ........................................................................................18
Orbivan ......................................................................................24
Orbivan CF ..................................................................................24
Orencia ..........................................................................21, 33, 34
Orenitram ER ........................................................................10, 37
Orfadin........................................................................................31
Orinase see tolbutamide ............................................................11
orphenadrine ..............................................................................25
orphenadrine/aspirin/caffeine ....................................................25
Orsythia ......................................................................................14
Ortho Cyclen see Mononessa, Previfem, Sprintec ........................14
Ortho Evra Patch see Xulane Patch ......................................14, 36
Ortho Novum 1/35 see Necon 1/35, Nortrel 1/35,
Cyclafem 1/35 ....................................................................14
Ortho Novum 1/50 see Necon 1/50 ..........................................14
Ortho Novum 10/11 see Necon 10/11 ......................................13
Ortho Novum 777 see Necon 777, Nortrel 777, Cyclafem 777 ..13
Ortho-Cept see Apri ....................................................................14
OrthoTri-Cyclen see Tri-Previfem, Trinessa, Tri-Sprintec ..................13
Orudis see ketoprofen ................................................................25
Oruvail see ketoprofen ................................................................25
Orvaten see midodrine ................................................................10
oseltamivir ............................................................................19, 36
Oseni ....................................................................................11, 34
OsmoPrep ..................................................................................30
10-20-14
Otozin ........................................................................................17
Otrexup ......................................................................................21
Otezla ..................................................................................21, 34
Ovace see sulfacetamide sodium ................................................27
Ovace Plus see sulfacetamide sodium ........................................27
Ovcon 35 see Balziva, Briellyn, Zeosa, Zenchent..........................14
Ovide see malathion ..................................................................28
Ovral see Ogestrel ......................................................................14
Oxandrin see oxandrolone ..........................................................15
oxandrolone ................................................................................15
oxaprozin ....................................................................................25
oxazepam....................................................................................23
oxcarbazepine ............................................................................24
oxcarbazepine ER........................................................................24
Oxecta ........................................................................................26
oxiconazole ................................................................................28
Oxistat ........................................................................................28
Oxtellar XR ..................................................................................24
oxybutynin ............................................................................30, 36
oxybutynin patch ........................................................................30
oxybutynin topical ......................................................................30
oxybutynin XL........................................................................30, 36
oxycodone ......................................................................26, 34, 36
oxycodone ER ................................................................26, 34, 36
Oxycontin..............................................................................26, 36
OxyFast see oxycodone ..................................................26, 34, 36
oxymorphone ........................................................................26, 36
oxymorphone ER ..................................................................26, 36
oxymorphone injection ................................................................26
Oxytrol ..................................................................................30, 36
Pacerone ......................................................................................9
Pacnex see benzoyl peroxide ......................................................27
paliperidone................................................................................22
palivizumab ................................................................................33
Pamelor see nortriptyline ............................................................23
pancrealipase ............................................................................30
pantoprazole ........................................................................29, 36
pantoprazole powder ..................................................................29
Parafon Forte DSC see chlorzoxazone..........................................25
Parcopa see carbidopa/levodopa................................................26
Paremyd......................................................................................17
paricalcitol ..................................................................................12
Parlodel see bromocriptine ..................................................15, 26
Parnate see tranylcypromine ......................................................23
paromomycin ..............................................................................18
paroxetine ............................................................................23, 31
paroxetine CR..............................................................................23
paroxetine mesylate ..............................................................23, 31
pasireotide..................................................................................15
Pataday ......................................................................................16
Patanase ....................................................................................31
Patanol ......................................................................................16
Paxil see paroxetine ..............................................................23, 31
57
INDEX
Paxil CR see paroxetine CR..........................................................23
pazopanib ..................................................................................21
Pediapred see prednisolone..................................................16, 20
Pediazole see erythromycin/sulfisoxazole ....................................17
Pedi-Dri see nystatin ............................................................18, 28
PEG/electrolytes ..................................................................30, 36
PEG/electrolytes & bisacodyl ......................................................30
PEG/electrolytes packets ............................................................30
PEG/electrolytes/sodium ascorbate......................................30, 36
PEG/electrolytes & sodium, potassium, and
magnesium sulfate ..............................................................30
Peganone ....................................................................................24
Pegasys ................................................................................19, 36
pegfilgrastim ..................................................................10, 33, 36
PegIntron ....................................................................................19
pegvisomant ..............................................................................16
pegylated interferon........................................................19, 20, 36
pegylated interferon alfa 2b ........................................................20
pen needles (for insulin pens) ....................................................12
penciclovir ..................................................................................28
penicillamine ..............................................................................20
penicillin VK ................................................................................17
PenLac see ciclopirox nail lacquer ..............................................28
Pennsaid see diclofenac topical ..................................................25
Pentam see pentamidine ............................................................18
pentamidine................................................................................18
Pentasa ......................................................................................30
pentosan ....................................................................................31
pentoxifylline ..............................................................................10
PenVee K ....................................................................................17
Pepcid see famotidine ................................................................29
perampanel ................................................................................24
Peranex HC see hydrocortisone/lidocaine rectal ..........................30
Percocet see acetaminophen/oxycodone ..............................26, 34
Perforomist..................................................................................31
Peridex see chlorhexidine ............................................................18
perindopril ....................................................................................8
Periostat see doxycycline monohydrate ................................18, 27
permethrin ..................................................................................28
perphenazine ..............................................................................22
Persantine see dipyridamole........................................................10
Pertzye ........................................................................................30
Pexeva ........................................................................................23
phenazopyridine ..........................................................................30
phenelzine ..................................................................................23
Phenergan see promethazine ......................................................29
phenobarbital ......................................................................24, 30
phenoxybenzamine......................................................................10
phenylephrine ............................................................................17
Phenytek ....................................................................................24
phenytoin ....................................................................................24
Philith ........................................................................................14
PhosLo see calcium acetate........................................................13
10-20-14
Phoslyra soln ..............................................................................13
Phospholine ................................................................................16
phytonadione ..............................................................................10
Picato ........................................................................................28
pilocarpine............................................................................16, 31
pilocarpine oral ..........................................................................31
Pilopine HS see pilocarpine ..................................................16, 31
pimecrolimus ..............................................................................28
pimozide ....................................................................................22
Pimtrea ......................................................................................13
pindolol ........................................................................................8
pioglitazone ..........................................................................11, 34
pioglitazone/glimepiride..............................................................11
pioglitazone/metformin ..............................................................11
pirbuterol inhaler ........................................................................31
Pirmella 1/35 ............................................................................14
Pirmella 777 ..............................................................................13
piroxicam ....................................................................................25
pitavastatin ..........................................................................12, 36
Plan B see Next Choice ........................................................14, 35
Plan B One-Step see Next Choice One Dose ........................14, 35
Plaquenil see hydroxychloroquine..........................................18, 20
Plavix see clopidogrel ..................................................................10
Plendil see felodipine ....................................................................9
Pletal see cilostazol ....................................................................10
Plexion ........................................................................................27
Pliaglis ........................................................................................28
Podocon 25 ................................................................................28
podofilox ....................................................................................28
podofilox gel ..............................................................................28
podophyllin topical......................................................................28
polymyxin/trimethoprim ..............................................................16
pomalidomide ............................................................................20
Pomalyst ....................................................................................20
ponatinib ....................................................................................20
Ponstel see mefenamic acid........................................................25
Portia ..........................................................................................14
posaconazole susp......................................................................18
posaconazole tab........................................................................18
potassium chloride......................................................................13
potassium iodide ........................................................................15
potassium phosphate/sodium ....................................................13
Potiga..........................................................................................24
Pradaxa ..............................................................................10, 34
pramipexole ..........................................................................26, 36
pramipexole ER ..........................................................................26
Pramosone..................................................................................28
Prandimet ..................................................................................11
Prandin see repaglinide ..............................................................11
prasugrel ....................................................................................10
pravastatin ................................................................................12
praziquantel ................................................................................18
prazosin ..................................................................................9, 30
58
INDEX
Precision Xtra ..............................................................................12
Precose see acarbose ................................................................11
Pred Forte ..................................................................................16
Pred-G ........................................................................................16
prednicarbate..............................................................................29
prednisolone soln........................................................................20
prednisolone tab ........................................................................20
prednisolone dispersible tab ......................................................20
prednisolone/sulfacetamide........................................................16
prednisone..................................................................................20
prednisone ER ............................................................................20
Prefest ........................................................................................15
pregabalin ............................................................................24, 36
Pregnyl..................................................................................15, 33
Prelone see prednisolone......................................................16, 20
Premarin ................................................................................3, 15
Premarin cream ..........................................................................15
Premphase..................................................................................15
Prempro ......................................................................................15
PremproLo ..................................................................................15
prenatal multivitamin ..................................................................13
Prenate ......................................................................................13
Prepopik ....................................................................................30
Prevacid see lansoprazole ....................................................29, 35
Prevacid SoluTab ........................................................................29
Prevident ....................................................................................13
Previfem......................................................................................14
PrevPac see lansoprazole/amoxicillin/clarithromycin ............29, 35
Prezista ......................................................................................19
Priftin ..........................................................................................18
Prilosec see omeprazole ......................................................29, 36
Prilosec OTC..........................................................................29, 36
primaquine..................................................................................18
primidone ..................................................................................24
Prinivil see lisinopril ......................................................................8
Prinzide see lisinopril/HCTZ ..........................................................8
Pristiq ..................................................................................23, 34
ProAir HFA ..................................................................................31
ProBanthine see propantheline ..................................................30
probenecid..................................................................................20
procainamide ................................................................................9
procarbazine ..............................................................................20
Procardia XL see nifedipine ER ......................................................9
Prochieve ....................................................................................15
prochlorperazine..........................................................................29
prochlorperazine syrup ................................................................29
Procrit ........................................................................................10
Procysbi ......................................................................................31
Prodrin ........................................................................................24
progesterone ..............................................................................15
progesterone gel ........................................................................15
progesterone injection ................................................................15
progesterone suppository ............................................................15
10-20-14
Prograf see tacrolimus ..........................................................20, 28
Prolensa......................................................................................16
Prolia ..........................................................................................33
Prolixin see fluphenazine ............................................................22
Promacta ..............................................................................10, 34
promethazine ..............................................................................29
Prometrium see progesterone......................................................15
Pronestyl ......................................................................................9
propafenone..................................................................................9
propantheline..............................................................................30
proparacaine ..............................................................................17
propranolol ..................................................................................8
propranolol LA ..............................................................................8
propranolol soln ............................................................................8
propranolol/HCTZ ..........................................................................8
propylthiouracil ..........................................................................15
Proscar see finasteride................................................................30
Prosom see estazolam ................................................................23
Protonix see pantoprazole ....................................................29, 36
Protonix suspension ....................................................................29
Protopic ......................................................................................28
protriptyline ................................................................................23
Proventil HFA ..............................................................................31
Provera see medroxyprogesterone ..............................................15
Provigil see modafinil ............................................................22, 36
Prozac see fluoxetine ............................................................22, 23
Prozac Weekly see fluoxetine weekly............................................23
Psorcon see diflorasone ..............................................................29
Pulmicort ....................................................................................31
Pulmozyme ..........................................................................32, 34
Purinethol see mercaptopurine....................................................20
Purixan........................................................................................20
Pylera..........................................................................................29
pyrazinamide ..............................................................................18
Pyridium see phenazopyridine ....................................................30
pyridostigmine ............................................................................24
pyridostigmine SR ......................................................................24
pyrimethamine ............................................................................18
Qnasl ..........................................................................................31
Qualaquin see quinine 324 mg ..................................................18
Quartette ....................................................................................13
Quasense....................................................................................14
quazepam ..................................................................................23
Qudexy XR see topiramate ER ....................................................24
Questran see cholestyramine ......................................................12
Questran Light see cholestyramine light ......................................12
quetiapine ..................................................................................22
quetiapine ER ............................................................................22
Quillivant XR................................................................................22
quinapril........................................................................................8
Quinidex........................................................................................9
quinidine ................................................................................9, 24
quinine 260 mg ..........................................................................18
59
INDEX
quinine 324 mg ..........................................................................18
Quixin see levofloxacin ..........................................................16, 17
QVAR ..........................................................................................31
rabeprazole cap ..........................................................................29
rabeprazole tab ..........................................................................29
Ragwitek ..............................................................................31, 36
raloxifene ....................................................................................12
raltegravir ....................................................................................19
ramelteon ............................................................................23, 36
ramipril ........................................................................................8
Ranexa........................................................................................10
ranitidine ....................................................................................29
ranolazine ..................................................................................10
Rapaflo ......................................................................................30
Rapamune ..................................................................................20
rasagiline ..............................................................................26, 36
Rasuvo........................................................................................21
Ravicti ........................................................................................15
Rayos ..........................................................................................20
Razadyne see galantamine....................................................24, 35
Razadyne ER see galantamine ER ........................................24, 35
Rebetol see ribavirin....................................................................19
Rebetol ......................................................................................19
Rebif ..........................................................................................21
Reclipsen ....................................................................................14
Rectagel HC see hydrocortisone/lidocaine rectal ........................30
Rectiv..........................................................................................30
Reglan see metoclopramide........................................................29
regorafenib..................................................................................20
Relafen see nabumetone ............................................................25
Relenza ................................................................................19, 37
Relistor ................................................................................30, 35
Relpax ..................................................................................24, 34
Remeron see mirtazapine............................................................23
Remicade....................................................................................33
Renagel ......................................................................................13
Renvela ......................................................................................13
repaglinide ..................................................................................11
repaglinide/metformin ................................................................11
Reprexain....................................................................................26
Requip see ropinirole ..................................................................26
Requip XL see ropinirole XL ........................................................26
Rescriptor....................................................................................19
Rescula ......................................................................................16
reserpine ....................................................................................10
Restasis ......................................................................................17
Restoril see temazepam ..............................................................23
retapamulin ................................................................................27
Retin A see tretinoin..............................................................20, 27
Retin A Micro ..............................................................................27
Retrovir see zidovudine................................................................19
Revatio........................................................................................10
ReVia see naltrexone ......................................................22, 26, 36
10-20-14
Revlimid................................................................................20, 35
Reyataz ......................................................................................19
Rheumatrex see methotrexate ..............................................20, 21
Rhinocort AQ see budesonide nasal ............................................31
Rhythmol SR see propafenone SR ................................................9
Riax 27
Ribapak ......................................................................................19
Ribasphere..................................................................................19
ribavirin ......................................................................................19
ribavirin solution..........................................................................19
Ridaura ......................................................................................20
rifabutin ......................................................................................18
Rifadin see rifampin ....................................................................18
Rifamate ....................................................................................18
rifampin ......................................................................................18
rifapentine ..................................................................................18
Rifater ........................................................................................18
rifaximin................................................................................18, 36
rilonacept....................................................................................33
rilpivirine ....................................................................................19
Rilutek see riluzole ......................................................................24
riluzole ........................................................................................24
rimabotulinum toxin ....................................................................33
Rimactone see rifampin ..............................................................18
rimantadine ................................................................................19
rimexolone ..................................................................................16
riociguat................................................................................10, 36
Riomet ........................................................................................11
risedronate ..........................................................................12, 36
Risperdal see risperidone............................................................22
Risperdal M-Tab see risperidone ODT ..........................................22
risperidone..................................................................................22
risperidone ODT ..........................................................................22
Ritalin see methylphenidate ..................................................22, 35
Ritalin LA see methylphenidate CD 50:50 ..................................22
ritonavir ......................................................................................19
Rituxan........................................................................................33
rituximab ....................................................................................33
rivaroxaban ................................................................................10
rivastigmine ................................................................................24
rizatriptan..............................................................................24, 36
Robaxin see methocarbamol ......................................................25
Robinul see glycopyrrolate ..........................................................31
Rocaltrol see calcitriol ..........................................................12, 28
roflumilast ..................................................................................32
romiplostim ................................................................................33
ropinirole ....................................................................................26
ropinirole XL ................................................................................26
Rosanil........................................................................................27
rosiglitazone................................................................................11
rosiglitazone/glimepiride ............................................................11
rosiglitazone/metformin ..............................................................11
rosuvastatin ..........................................................................12, 36
60
INDEX
rotigotine ....................................................................................26
Roxicet see acetaminophen/oxycodone ................................26, 34
Roxicodone see oxycodone ............................................26, 34, 36
Rozerem................................................................................23, 36
rufinamide ..................................................................................24
ruxolitinib ....................................................................................20
Rybix ODT....................................................................................26
Ryzolt ER see tramadol ER ....................................................26, 37
Safyral ........................................................................................14
Saizen ........................................................................................16
Salagen see pilocarpine oral ......................................................31
Salex ..........................................................................................28
salicylic acid solution ..................................................................27
salicylic acid/ceramides..............................................................28
salmeterol inhaler ......................................................................31
salsalate ....................................................................................25
Samsca ........................................................................................9
Sanctura see trospium ................................................................30
Sanctura XR see trospium ER......................................................30
Sancuso ..............................................................................29, 35
Sandimmune ..............................................................................20
Sandostatin see octreotide..........................................................15
Sandostatin LAR ........................................................................15
sapropterin..................................................................................15
saquinivir ....................................................................................19
Sarafem ......................................................................................23
sargramostim ..............................................................................10
Savella..................................................................................23, 36
saxagliptin ............................................................................11, 36
saxagliptin/metformin ................................................................11
scopolamine ............................................................17, 29, 30, 36
scopolamine patch ..............................................................29, 36
Seasonale see Jolessa, Quasense ..............................................14
Seasonique see Amethia, Camrese ............................................13
Sectral see acebutolol ..................................................................8
selegiline ........................................................................23, 26, 36
selegiline patch ....................................................................23, 36
selenium sulfide foam, shampoo ................................................28
selenium sulfide suspension ......................................................28
Selfemra see fluoxetine ........................................................22, 23
Selrx............................................................................................28
Selzentry ....................................................................................19
Sensipar ....................................................................................12
Septra see trimethoprim/sulfa ....................................................18
Serax see oxazepam ..................................................................23
Serevent......................................................................................31
Seromycin ..................................................................................18
Serophene see clomiphene ........................................................15
Seroquel see quetiapine ............................................................22
Seroquel XR ................................................................................22
Serostim ....................................................................................16
sertraconazole ............................................................................28
sertraline ....................................................................................23
10-20-14
Serzone see nefazodone ............................................................23
sevelamer....................................................................................13
sevelamer carbonate packet........................................................13
sevelamer carbonate tab ............................................................13
short ragweed pollen ............................................................31, 36
Signifor ......................................................................................15
sildenafil ....................................................................................10
Silenor ........................................................................................23
silodosin ....................................................................................30
Silvadene see silver sulfadiazine ................................................27
silver sulfadiazine........................................................................27
Simbrinza....................................................................................16
Simcor ..................................................................................12, 37
simeprevir ............................................................................19, 36
Simponi..........................................................................21, 30, 35
simvastatin ..............................................................11, 12, 36, 37
simvastatin/niacin ................................................................12, 37
sinecatechins ..............................................................................28
Sinemet see carbidopa/levodopa ..............................................26
Sinemet CR see carbidopa/levodopa CR ....................................26
Sinequan see doxepin ..........................................................23, 28
Singulair see montelukast ..........................................................32
sirolimus ....................................................................................20
Sirturo ........................................................................................18
sitagliptin..............................................................................11, 12
sitagliptin/metformin ..................................................................11
sitagliptin/metformin ER ............................................................11
sitagliptin/simvastatin ..........................................................11, 12
Sitavig ........................................................................................19
Sivextro ......................................................................................18
Skelaxin see metaxalone ............................................................25
Skelid..........................................................................................12
Sklice..........................................................................................28
sodium bicarbonate ..............................................................13, 29
sodium chloride 3% for inh ........................................................32
sodium chloride 6% for inh ........................................................32
sodium chloride 7% for inh ........................................................32
sodium oxybate ..........................................................................22
sodium phenylbutyrate ................................................................31
sodium phosphate ................................................................13, 30
sodium polystyrene sulfonate......................................................13
sodium, potassium and magnesium sulfate ..............................30
sodium picosulfate/magnesium oxide/citric acid ........................30
sofosbuvir ............................................................................19, 37
Solaraze see diclofenac gel ........................................................25
solifenacin ............................................................................30, 37
Soliris..........................................................................................33
Solodyn see minocycline ER........................................................27
Soluclenz RX ..............................................................................27
Soma see carisoprodol ..............................................................25
somatropin..................................................................................16
Somatuline depot........................................................................15
Somavert ....................................................................................16
61
INDEX
Sonata see zaleplon....................................................................23
sorafenib ....................................................................................21
Soriatane see acitretin ................................................................29
Sorilux ........................................................................................28
sotalol ..........................................................................................8
sotalol AF ......................................................................................8
Sotret see isotretinoin ................................................................27
Sovaldi..................................................................................19, 37
Spectracef see cefditoren............................................................17
Spectrazole see econazole ..........................................................28
spinosad ....................................................................................28
Spiriva ........................................................................................32
spironolactone ..............................................................................9
spironolactone/HCTZ ....................................................................9
Sporanox see itraconazole ..........................................................18
Sprintec ......................................................................................14
Sprix ..........................................................................................25
Sprycel ......................................................................................21
Sronyx ........................................................................................14
SSKI............................................................................................15
Stadol NS see butorphanol nasal spray ................................24, 34
Stalevo see carbidopa/levodopa/entacapone ............................26
Starlix see nateglinide ................................................................11
stavudine ....................................................................................19
Stavzor ........................................................................................24
Stelara ....................................................................21, 29, 33, 37
Stelazine see trifluoroperazine ....................................................22
Stimate ......................................................................................15
Stivarga ......................................................................................20
Strattera......................................................................................22
Striant ........................................................................................15
Stribild ........................................................................................19
Striverdi Respimat ......................................................................31
Stromectol ..................................................................................18
subcutaneous immune globulin ..................................................20
Suboxone....................................................................................22
Subsys..................................................................................26, 35
Subutex see buprenorphine ..................................................22, 26
Suclear ......................................................................................30
sucralfate..............................................................................29, 31
sucralfate paste ..........................................................................31
sucroferric oxyhydroxide ..............................................................13
Sular see nisoldipine ....................................................................9
sulconazole ................................................................................28
sulfacetamide ophthalmic ..........................................................16
sulfacetamide sodium lotion ......................................................27
sulfacetamide sodium shampoo, suspension ..............................27
sulfacetamide sodium wash, cleanser ........................................27
sulfacetamide/sulfur 8%/4% suspension....................................27
sulfacetamide/sulfur 9%/4% cleanser ........................................27
sulfacetamide/sulfur 9%/4.5% cleanser ....................................27
sulfacetamide/sulfur 9.5%/5% medicated pads ........................27
10-20-14
sulfacetamide/sulfur 9.8%/4.8% cleanser, cream,
medicated pads, lotion ........................................................27
sulfacetamide/sulfur 10%/1% cleanser ......................................27
sulfacetamide/sulfur 10%/2% cream, medicated pads ..............27
sulfacetamide/sulfur 10%/4% foam, medicated pads ................27
sulfacetamide/sulfur 10%/5% cream, cleanser,
medicated pads, foam, lotion, suspension............................27
sulfadiazine ..........................................................................18, 27
Sulfamylon see mafenide............................................................27
sulfanilamide ..............................................................................27
sulfasalazine ........................................................................20, 30
Sulfatrim ....................................................................................18
sulfisoxazole ........................................................................17, 18
sulindac ......................................................................................25
Sumadan see sulfacetamide/sulfur 9%/4.5% cleanser ..............27
sumatriptan injection ............................................................24, 37
sumatriptan nasal ................................................................24, 37
sumatriptan tablets ....................................................................24
sumatriptan/naproxen ....................................................24, 25, 37
Sumavel Dosepro..................................................................24, 37
Sumaxin see sulfacetamide/sulfur ..............................................27
Sumycin......................................................................................18
sunitinib......................................................................................21
Supprelin ....................................................................................15
Suprax ........................................................................................17
Suprep........................................................................................30
Surmontil see trimipramine ........................................................23
Sustiva........................................................................................19
Sutent ........................................................................................21
Syeda..........................................................................................14
Sylatron ......................................................................................20
Symbicort....................................................................................31
Symbyax see fluoxetine/olanzapine ............................................22
Symlin ........................................................................................11
Symmetrel see amantadine ..................................................19, 26
Synagis ......................................................................................33
Synalar see fluocinolone ................................................17, 28, 29
Synarel........................................................................................15
Syntest........................................................................................15
Synthroid ....................................................................................15
Tabloid ........................................................................................20
Taclonex see betamethasone/calcipotriene ..........................28, 29
tacrolimus ............................................................................20, 28
tacrolimus ER..............................................................................20
tadalafil ..........................................................................10, 30, 37
Tafinlar ........................................................................................20
tafluprost ....................................................................................16
Tagamet see cimetidine ..............................................................29
Tambocor see flecainide................................................................9
Tamiflu ..................................................................................19, 36
tamoxifen ....................................................................................20
tamsulosin ..................................................................................30
Tanzeum......................................................................................11
62
INDEX
Tapazole see methimazole ..........................................................15
tapentadol ............................................................................26, 37
tapentadol ER ......................................................................26, 37
Tarceva..................................................................................21, 35
Targretin ......................................................................................20
Tarka ........................................................................................8, 9
tasimelteon ..........................................................................23, 37
Tasmar ........................................................................................26
tavaborole ..................................................................................28
tazarotene ..................................................................................27
Tazorac........................................................................................27
TBO-filgrastim..............................................................................10
Tecfidera ..............................................................................21, 34
tedizolid ......................................................................................18
teduglutide..................................................................................30
Tegretol ......................................................................................24
Tegretol XR ..................................................................................24
Tekamlo ............................................................................9, 10, 34
Tekturna................................................................................10, 34
Tekturna HCT ........................................................................10, 34
telaprevir ....................................................................................19
telbivudine ................................................................................19
telithromycin ........................................................................17, 37
telmisartan................................................................................8, 9
telmisartan/HCTZ ..........................................................................8
temazepam ................................................................................23
Temodar see temozolomide ..................................................20, 37
Temovate see clobetasol topical..................................................29
temozolomide ......................................................................20, 37
Tenex see guanfacine........................................................9, 22, 35
tenofovir......................................................................................19
Tenoretic see atenolol/chlorthalidone............................................8
Tenormin see atenolol ..................................................................8
Tequin ........................................................................................17
terazosin ................................................................................9, 30
terbinafine ..................................................................................18
terbinafine granules ....................................................................18
terbutaline tabs ..........................................................................32
teriflunomide ........................................................................21, 37
teriparatide ..........................................................................12, 37
Tersi Foam ..................................................................................28
Tessalon see benzonatate ..........................................................31
Test strips-Abbott ........................................................................12
Test strips-Bayer ..........................................................................12
Test strips-Lifescan ......................................................................12
Test strips-Roche ........................................................................12
testosterone buccal ....................................................................15
testosterone cypionate injection..................................................15
testosterone enanthate injection ................................................15
testosterone topical ....................................................................15
testosterone topical packets........................................................15
testosterone topical patches ......................................................15
Testred ........................................................................................15
10-20-14
tetrabenazine ..............................................................................26
tetracaine ............................................................................17, 28
tetracycline capsule ....................................................................18
tetracycline tabs..........................................................................18
Teveten see eprosartan..................................................................8
Teveten HCT ..................................................................................8
Tev-Tropin ....................................................................................16
Texacort ......................................................................................28
thalidomide ................................................................................20
Thalomid ....................................................................................20
Theo-24 ......................................................................................32
Theocap ......................................................................................32
theophylline ................................................................................32
thioguanine ................................................................................20
thioridazine ................................................................................22
thiothixene ..................................................................................22
Thorazine see chlorpromazine......................................................22
thyroid pork ................................................................................15
thyroid pork (Westhroid, Nature-Throid)........................................15
tiagabine ....................................................................................24
Tiazac see diltiazem ER (24H) ......................................................9
ticagrelor ....................................................................................10
Ticlid see ticlopidine ..................................................................10
ticlopidine ..................................................................................10
Tigan see trimethobenzamide......................................................29
Tikosyn..........................................................................................9
Tilia FE ........................................................................................13
tiludronate ..................................................................................12
timolol ....................................................................................8, 16
timolol XE....................................................................................16
Timoptic see timolol................................................................8, 16
Timoptic XE see timolol XE ..........................................................16
timothy grass pollen..............................................................31, 37
Tindamax see tinidazole ..............................................................18
tinidazole ....................................................................................18
tinzaparin ....................................................................................10
tiotropium inhaler........................................................................32
tipranavir ....................................................................................19
Tivicay ........................................................................................19
tizanidine capsules......................................................................25
tizanidine tablets ........................................................................25
TMP-Sulfa ..................................................................................18
TOBI see tobramycin inhalation ..................................................32
TOBI Podhaler ............................................................................32
Tobradex drops see
tobramycin/dexamethasone 0.3/0.1% drops ......................16
Tobradex ointment ......................................................................16
Tobradex ST ................................................................................16
tobramycin............................................................................16, 32
tobramycin inhalation..................................................................32
tobramycin inj for inh ..................................................................32
tobramycin/dexamethasone 0.3/0.05% drops ..........................16
tobramycin/dexamethasone 0.3/0.1% drops..............................16
63
INDEX
tobramycin/dexamethasone ointment ........................................16
tobramycin/lotepred ..................................................................16
Tobrex see tobramycin ..........................................................16, 32
tocilizumab ....................................................................21, 33, 37
tofacitinib....................................................................................21
Tofranil see imipramine ..............................................................23
Tofranil-PM see imipramine pamoate ..........................................23
tolazamide ..................................................................................11
tolbutamide ................................................................................11
tolcapone....................................................................................26
Tolinase see tolazamide ..............................................................11
tolmetin ......................................................................................25
tolterodine ............................................................................30, 37
tolterodine ER ............................................................................30
tolvaptan ......................................................................................9
Topamax see topiramate ............................................................24
Topicort see desoximetasone ......................................................29
topiramate ..................................................................................24
topiramate ER ............................................................................24
topotecan ..................................................................................20
Toprol XL see metoprolol succinate (XL) ..................................8, 36
toremifene ..................................................................................20
torsemide......................................................................................9
Toviaz....................................................................................30, 35
Tracleer ......................................................................................10
Tradjenta ..............................................................................11, 35
tramadol ..............................................................................26, 37
tramadol ER..........................................................................26, 37
tramadol ODT..............................................................................26
tramadol/acetaminophen............................................................26
trametinib ..................................................................................20
Trandate see labetalol ..................................................................8
trandolapril ..............................................................................8, 9
trandolapril/verapamil ..............................................................8, 9
tranexamic acid ..........................................................................10
TransdermScop ..........................................................................29
Tranxene see clorazepate ............................................................23
Tranxene SD see clorazepate ER..................................................23
tranylcypromine ..........................................................................23
Travatan Z....................................................................................16
travoprost....................................................................................16
travoprost benzalkonium..............................................................16
trazodone....................................................................................23
trazodone ER ..............................................................................23
Trecator ......................................................................................18
Trental see pentoxifylline ............................................................10
treprostinil diolamine ............................................................10, 37
treprostinil neb............................................................................10
tretinoin ................................................................................20, 27
tretinoin microsphere 0.04%, 0.1% ............................................27
tretinoin microsphere 0.8% ........................................................27
tretinoin capsules........................................................................20
Tretin-X ........................................................................................27
10-20-14
Treximet ..........................................................................24, 25, 37
Trezix ..........................................................................................24
triamcinolone ..........................................................20, 28, 29, 31
triamcinolone oropharyngeal ......................................................28
triamcinolone nasal ....................................................................31
triamcinolone topical ..................................................................29
triamterene....................................................................................9
triamterene/HCTZ ..........................................................................9
triazolam ....................................................................................23
Tribenzor........................................................................................8
Tricor see fenofibrate ..................................................................12
Tridesilon ....................................................................................28
Tri-Estarylla..................................................................................13
trifluoroperazine ..........................................................................22
trifluridine....................................................................................17
Triglide ........................................................................................12
trihexyphenidyl ............................................................................26
Trilafon see perphenazine ............................................................22
Tri-Legest FE ................................................................................13
Trileptal see oxcarbazepine..........................................................24
Tri-Linyah ....................................................................................13
Trilipix see fenofibric acid ............................................................12
Trilyte ..........................................................................................30
trimethobenzamide......................................................................29
trimethoprim ........................................................................16, 18
trimethoprim/sulfa ......................................................................18
trimipramine................................................................................23
Trimox see amoxicillin ....................................................17, 29, 35
Trinessa ......................................................................................13
Tri-Norinyl see Aranelle, Leena ....................................................13
Trioxin..........................................................................................17
Triphasil see Trivora, Enpresse, Myzilra ........................................13
Tri-Previfem..................................................................................13
Triumeq ......................................................................................19
Tri-Sprintec ..................................................................................13
Trivora ........................................................................................13
Trizivir see abacavir/lamivudine/zidovudine ................................19
Trokendi XR ................................................................................24
tropicamide ................................................................................17
trospium ....................................................................................30
trospium ER ................................................................................30
Trusopt see dorzolamide..............................................................16
Truvada ......................................................................................19
Tudorza Pressair ..........................................................................32
Twynsta see amlodipine/telmisartan ........................................8, 9
Tykerb..........................................................................................20
Tylenol #3 see acetaminophen/codeine......................................26
Tysabri ........................................................................................33
Tyvaso ........................................................................................10
Tyzeka ........................................................................................19
Uceris ..................................................................................30, 34
U-Cort ........................................................................................28
Ulesfia ........................................................................................28
64
INDEX
ulipristal................................................................................14, 37
Uloric ..........................................................................................20
Ultracet see tramadol/acetaminophen ........................................26
Ultram see tramadol ............................................................26, 37
Ultram ER see tramadol ER ..................................................26, 37
Ultrase ........................................................................................30
Ultravate see halobetasol ............................................................29
Ultresa ........................................................................................30
umeclidinium/vilanterol ..............................................................32
Uniretic see moexipril/HCTZ ..........................................................8
Unithroid ....................................................................................15
Univasc see moexipril....................................................................8
unoprostone isopropyl ................................................................16
urea 47%....................................................................................28
Urecholine see bethanechol ........................................................30
Urex see methenamine................................................................18
Urex ............................................................................................18
Urispas see flavoxate ..................................................................30
Uroxatral see alfuzosin ................................................................30
URSO see ursodiol ......................................................................30
URSO Forte see ursodiol ............................................................30
ursodiol ......................................................................................30
ustekinumab ............................................................21, 29, 33, 37
Vagifem ......................................................................................15
valacyclovir..................................................................................19
Valchlor ......................................................................................20
Valcyte ........................................................................................19
valganciclovir ..............................................................................19
Valium see diazepam ............................................................23, 24
valproic acid ..............................................................................24
valproic acid SA ..........................................................................24
valsartan ..................................................................................8, 9
valsartan/HCTZ..........................................................................8, 9
Valtrex see valacyclovir ................................................................19
Vancocin see vancomycin oral ....................................................18
vancomycin oral ..........................................................................18
vandetanib ..................................................................................20
Vanos see fluocinonide 0.1% ......................................................29
Vantin see cefpodoxime ..............................................................17
varenicline ..................................................................................22
Vascepa................................................................................12, 35
Vaseretic see enalapril/HCTZ ........................................................8
Vasotec see enalapril ....................................................................8
Vecamyl ......................................................................................10
Vectical see calcitriol topical ......................................................28
vedolizumab................................................................................33
Veetids ........................................................................................17
Velivet ........................................................................................13
Velphoro......................................................................................13
Veltin ..........................................................................................27
vemurafenib ................................................................................21
venlafaxine ER tablets ................................................................23
venlafaxine IR..............................................................................23
10-20-14
venlafaxine SR capsules..............................................................23
Ventavis ......................................................................................10
Ventolin HFA................................................................................31
Veramyst ....................................................................................31
verapamil ..................................................................................8, 9
verapamil ER ................................................................................9
Veregen ......................................................................................28
Verelan PM see verapamil ER ........................................................9
Veripred ......................................................................................20
Versacloz ....................................................................................22
Vesanoid see tretinoin capsules ..................................................20
Vesicare ................................................................................30, 37
Vestura........................................................................................14
Vexa ............................................................................................25
Vexol ..........................................................................................16
Vfend see voriconazole................................................................18
Vibramycin see doxycycline monohydrate..............................18, 27
Vibramycin susp..........................................................................18
Vicodin see acetaminophen/hydrocodone ..................................26
Vicoprofen see ibuprofen/hydrocodone ......................................26
Victoza ........................................................................................11
Victrelis ......................................................................................19
Videx see didanosine ..................................................................19
Vigamox ......................................................................................16
Viibryd ..................................................................................23, 37
vilazodone ..........................................................................23, 37
Vimovo..................................................................................29, 36
Vimpat..................................................................................24, 35
Viokace ......................................................................................30
Viorele ........................................................................................13
Viracept ......................................................................................19
Viramune see nevirapine ............................................................19
Viramune XR see nevirapine XR ..................................................19
Virasal ........................................................................................27
Viread ........................................................................................19
Visken see pindolol ......................................................................8
vismodegib ................................................................................20
Vitafol+DHA ................................................................................13
Vivactil see protriptyline ..............................................................23
Vivelle-dot ............................................................................15, 35
Voltaren see diclofenac ........................................................16, 25
Voltaren gel ................................................................................25
vorapaxar..............................................................................10, 37
voriconazole ..............................................................................18
vortioxetine ..........................................................................23, 37
Votrient ......................................................................................21
Vusion ........................................................................................28
Vytorin ..................................................................................12, 37
Vyvanse ................................................................................22, 35
warfarin ......................................................................................10
Welchol ......................................................................................12
Wellbutrin see bupropion ................................................22, 23, 34
Wellbutrin XL see bupropion XL ............................................23, 34
65
INDEX
Wera ..........................................................................................14
Westhroid....................................................................................15
Xalatan see latanoprost ..............................................................16
Xalkori ........................................................................................20
Xanax see alprazolam ................................................................23
Xanax XR see alprazolam ER ......................................................23
Xarelto ......................................................................................10
Xartemis XR ..........................................................................26, 34
Xeljanz ........................................................................................21
Xeloda see capecitabine ............................................................20
Xenazine ....................................................................................26
Xeomin........................................................................................33
Xerese ........................................................................................28
Xgeva ..........................................................................................33
Xibrom see bromfenac ................................................................16
Xifaxan..................................................................................18, 36
Xodol see acetaminophen/hydrocodone ....................................26
Xolair ..........................................................................................33
Xolegel ........................................................................................28
Xolegel Duo ................................................................................28
Xolox ..........................................................................................26
Xopenex HFA ..............................................................................31
Xtandi ........................................................................................21
Xulane Patch ........................................................................14, 36
Xyrem..........................................................................................22
Xyzal see levocetirizine ................................................................31
Yasmin see Ocella, Syeda, Zarah ................................................14
Yaz see Gianvi, Loryna ................................................................14
zafirlukast ..................................................................................32
zaleplon ......................................................................................23
Zamicet see acetaminophen/hydrocodone..................................26
Zanaflex see tizanidine capsules ................................................25
zanamivir ..............................................................................19, 37
Zantac see ranitidine ..................................................................29
Zarah ..........................................................................................14
Zaroxolyn see metolazone ............................................................9
Zavesca ......................................................................................12
Zebeta see bisoprolol ....................................................................8
Zegerid see omeprazole/sodium bicarbonate ..............................29
Zelboraf ......................................................................................21
Zemplar see paricalcitol ..............................................................12
Zenatane ....................................................................................27
Zenchent ....................................................................................14
Zenpep........................................................................................30
Zenzedi ......................................................................................22
Zeosa..........................................................................................14
Zerit see stavudine ......................................................................19
Zestoretic see lisinopril/HCTZ ........................................................8
Zestril see lisinopril........................................................................8
Zetia ..........................................................................................12
Zetonna HFA................................................................................31
Ziac see bisoprolol/HCTZ ..............................................................8
Ziagen see abacavir tablets ........................................................19
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Ziagen suspension ......................................................................19
Ziana ..........................................................................................27
zidovudine ..................................................................................19
zileuton ......................................................................................32
Zioptan ......................................................................................16
ziprasidone ................................................................................22
Zipsor..........................................................................................25
Zithromax see azithromycin ............................................16, 17, 34
Zmax ....................................................................................17, 34
Zocor see simvastatin ..............................................11, 12, 36, 37
ZoDerm ......................................................................................27
Zofran see ondansetron ........................................................29, 36
Zohydro ER ..........................................................................26, 35
zolmitriptan ..........................................................................24, 37
zolmitriptan nasal ................................................................24, 37
Zoloft see sertraline ....................................................................23
zolpidem ..............................................................................23, 37
zolpidem CR ........................................................................23, 37
zolpidem spray ............................................................................23
zolpidem sublingual ..............................................................23, 37
Zolpimist ....................................................................................23
Zomig see zolmitriptan ..........................................................24, 37
zonisamide..................................................................................24
Zontivity ................................................................................10, 37
Zorbtive ......................................................................................16
Zortress ......................................................................................20
Zorvolex ......................................................................................25
Zovia 1/35..................................................................................14
Zovia 1/50..................................................................................14
Zovirax see acyclovir oral ............................................................19
Zovirax ointment see acyclovir topical ..................................19, 28
Zostavax ......................................................................................33
zoster vaccine ............................................................................33
Zubsolv ......................................................................................22
Zuplenz ......................................................................................29
Zyban see bupropion SR ......................................................22, 23
Zyclara ........................................................................................28
Zydelig ..................................................................................20, 35
Zyflo............................................................................................32
Zykadia ......................................................................................20
Zylet............................................................................................16
Zyloprim see allopurinol ..............................................................20
Zymaxid see gatifloxacin ......................................................16, 17
Zyprexa see olanzapine ..............................................................22
Zyprexa zydis see olanzapine ODT ..............................................22
Zytiga ..........................................................................................20
Zyvox ..........................................................................................18
66
Medication Prior Authorization Request Form
x
x
x
x
x
x
To view medication prior authorization criteria visit http://www.unityhealth.com/apps/medicationpriorauth/
Direct questions about medication prior authorization criteria to a Unity pharmacist at (888) 450-4884 or (608) 265-7397
To check the status of a PA request contact MedImpact Customer Service at (800) 788-2949
To appeal decisions contact Unity Customer Service at (800) 362-3310
Please complete the form entirely to ensure a prompt review
PRIOR AUTHORIZATION REQUESTS ARE ACCEPTED BY FAX OR MAIL ONLY
Please fax to:
(888) 450-4711
OR
Mail to:
Unity Pharmacy Program
University of Wisconsin Hospital and Clinics
600 Highland Ave. Mail code 9475
Madison, WI 53792
Step 1: Patient and Prescriber Information. (Please print clearly and complete entirely.)
Date:
Patient Name:
Prescriber Name:
Patient Date of Birth:
Prescriber Phone #:
Unity ID Number:
Prescriber Fax #:
Allergies:
Step 2: Diagnosis and Medication Information. (Please print clearly and complete entirely.)
Diagnosis:
Medication Name:
Dose:
Schedule:
Duration of Therapy:
Reason/Clinical Rationale for the Request (Include relevant past medical history and medication trials.)
Optional: Pharmacy Name
Optional: Pharmacy Phone
Optional: Pharmacy Fax
Step 3: For Clinic/Physician Administered Medications Only.
Administering Provider Name:
Provider Phone:
Provider Fax:
Providing Facility:
Facility Phone:
Facility Fax:
Procedure Code/Description:
**Prescribers will be notified by fax and patients will be notified by mail when a decision has been determined.**
CONFIDENTIALITY NOTICE: This document(s) comprising this facsimile and cover sheet are intended for use by the party to whom
it is addressed, may contain privileged, confidential, and/or trade secret information, and is protected from disclosure under
applicable law. If you are not the addressee, a person authorized to deliver the document to the addressee, or if you have received
this transmission in error, please notify the sender immediately. UH01080
10-20-14
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