Department of Human Services
v Department of Human Services IOWA Medicaid Program PDL Effective Date January 23, 2015 (Two Drug Columns) Highlighted categories denote new changes to the PDL since previous update Column Header Explanations: B, G or O: B = Brand G = Generic O = OTC ND = Non Drug Comment Num 3 6 11 13 16 17 19 21 22 23 24 25 28 29 34 36 37 39 43 44 46 47 48 50 52 57 58 59 62 63 64 65 67 68 69 70 72 P, NP, R, or NR: P = Preferred N = Non-Preferred R = Recommended NR = Non-Recommended Key to Color Highlights: Blue = Changes in PDL Status/PA Criteria Pink = New Drugs Blue Underline = Click hyperlink for PA Form Hover to the left of Comment Number for comment text Comment BUSPIRONE 30mg - Use 2 BUSPIRONE 15mg tablets FLUOXETINE HCL 20mg TABS - Use FLUOXETINE HCL 20mg CAPS instead PA Required PA Required > 90 days Grandfathered for Existing Users with previous Actos use or CHF diagnosis PA Required> 12 Units/30 Days supply Preferred < 8yo PROZAC,FLUOXETINE HCL 40mg CAPS - Use two FLUOXETINE HCL 20mg CAPS instead RHEUMATREX - Write METHOTREXATE instead ULTRACET - Use Tramadol & Acetaminophen separately PA Required >= 21 yo. PA Required: > 14 Units/30Days Supply PA required for quantities exceeding 12-4mg tabs, 12-8mg tabs, 4-24mg tabs, 4-20ml vials, and 8-2ml vials. PA required for quantities exceeding 12-4mg tabs, 12-8mg tabs. PA required, Limit of 144 for initial fill Payable for members who are 12 years of age and older. Quantity limitations of 12 packets/4 weeks (28 days) or a total of 48 packets/16 weeks ( 112 days). Restricted to persons 40 years of age and older. Grandfather Existing Users PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. PA required if ACE-I not previously filled. Grandfather for seizure disorder. Preferred with Conditions and allow a one time fill. Those 0-18 should be referred to the Vaccines for Children Program. Requires a Selected Brand Name Drug PA Imipramine Pamoate - Use Imipramine HCL Duplicate therapy with other antipsychotics will be allowed for a maximum of 30 days. PA required limited to package size of #14 for initial fill PA required limited to package size of #110 for initial fill 3 tablets per 60 days allowed. PA required for quantities exceeding this limit Initial fill limited to 15 day supply. Use Multiples of Phenytoin Sodium 100mg Capsules. PA required. Preferred for post surgery DVT prophylaxis only. PA required limited to package size 168 for intial fill PA required limited to package size 40ml for initial fill Payable for members who are 18 years of age and older. Quantity limitations of 15 grams/4 weeks (28 days) or a total of 60 grams/16 weeks (112 days) Payable for members 50 years of age and older without prior authorization Preferred < 2 years of age 73 74 76 77 78 79 80 81 83 84 85 87 88 89 90 No manual PA required if one course of treatment of a preferred permethrin product is in the member's pharmacy claims history in past 30 days. Trial of Natroba or Ulesfia is required prior to consideration of any non-preferred agent. PA Required < 4 years of age PA Required < 15 years of age PA Required < 6 years of age PA Required < 9 years of age PA Required > 15 units / 30 days. Initial fill limited to 14 day supply. PA Required < 18 years of age Norvir tablets - Use Norvir capsules instead PA Required > 12 years of age PA Required < 5 years of age Preferred product is authorized generic distributed by Watson. PA Required >= 21 yo. No manual PA required if HMG-CoA reductase inhibitor found in member’s pharmacy claims history in past 12 months. No manual PA required if a preferred agent of a different chemical entity is found in member’s pharmacy claims history in past 12 months PA Required < 7 years of age No manual PA required if a preferred injectable MS agent is found in member’s pharmacy claims history in past 12 months Iowa Medicaid Preferred Drug List (PDL) New Drug Process New Drug Entities New drug entities (including new generics and new drug product dosage forms of existing drug entities) will be identified weekly and immediately be coded as "Non-preferred-Prior Authorization required" until presented at the next quarterly scheduled P&T [pharmaceutical and therapeutics] Committee meeting. If the drug category requires step therapy, the step therapy requirements must also be met, treating the new drug as a non-preferred, step 3 drug. These prior authorization and step therapy restrictions will continue through the review process, including while committee recommendations are being made, and lasting until DHS makes a final determination. Exceptions to the Non-preferred default policy for new PDL drugs There are two major potential exceptions to the non-preferred default policy for new PDL drugs: A). If a new medication is classified as a priority drug by the FDA, the State may indicate that such a drug is preferred, until the drug is reviewed by the P&T Committee at the nearest scheduled meeting. B). The State may decide to designate a new drug as "draft preferred" and provide immediate access and increased therapeutic choice to physicians until the drug is reviewed by the P&T Committee at the nearest scheduled meeting if: - a new drug is therapeutically equivalent or superior to existing preferred or non-preferred choices, and - is as safe or safer than existing preferred or non-preferred choices, and - the net cost, adjusted for all rebates, is less expensive than all existing preferred choices. Existing PDL Drugs Although the State discourages supplemental rebate offers on existing PDL drugs between annual bidding periods, it may entertain such bids and may accept them if they are determined to represent significant additional savings or if they would replace a delinquent manufacturer's product or a preferred drug pulled from the marketplace or significantly restricted by the FDA. This interim preferred status will remain in effect until the drug is reviewed by the P&T Committee at the next scheduled meeting. Supplemental rebates will only be invoiced for approved drugs under contract. Draft preferred drugs with supplemental rebates will not be invoiced until approved by the Committee and accepted by the State. At that time, the supplemental rebates will be invoiced back to the effective date of the agreement, which is the date the drug began to benefit from preferred status. B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ACE AND THIAZIDE COMBO'S G P benazepril & hydrochlorothiazide B N LOTENSIN HCT G P captopril & hydrochlorothiazide G P enalapril maleate & hydrochlorothiazide B N VASERETIC G N fosinopril sodium & hydrochlorothiazide G P lisinopril & hydrochlorothiazide B N ZESTORETIC G N moexipril-hydrochlorothiazide B P UNIRETIC B N ACCURETIC G N quinapril-hydrochlorothiazide ACE INHIBITORS G P benazepril hcl B N LOTENSIN G P captopril G P enalapril maleate B P EPANED B 19 N VASOTEC G N enalaprilat G P fosinopril sodium G P lisinopril B N PRINIVIL B N ZESTRIL G N moexipril hcl B N UNIVASC G N perindopril erbumine B N ACCUPRIL G P quinapril hcl B N ALTACE G P ramipril B N MAVIK G P trandolapril ACE INHIBITORS AND CALCIUM CHANNEL BLOCKERS G N amlodipine besylate-benazepril hcl B P LOTREL B P TARKA ACNE PRODUCTS: ISOTRETINOIN B 11 P ABSORICA G 11 P isotretinoin AGENTS FOR FABRYS DISEASE B P FABRAZYME AGENTS FOR GAUCHER DISEASE B N CERDELGA B N CEREZYME B N ZAVESCA B N ELELYSO B N VPRIV RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category AGENTS FOR PHEOCHROMOCYTOMA G P phentolamine mesylate B N DEMSER ALCOHOL DETERRENTS G N acamprosate calcium B P CAMPRAL B P ANTABUSE ALLERGENIC EXTRACTS B 11 N GRASTEK B 11 N RAGWITEK ALPHA-PROTEINASE INHIBITOR B 11 N ARALAST B 11 N GLASSIA B 11 N PROLASTIN B 11 P PROLASTIN SOLR 1000MG B 11 N ZEMAIRA ALS DRUG B 11 P RILUTEK G 11 N riluzole ALZHEIMER - CHOLINOMIMETICS B 37 N ARICEPT B 37 N ARICEPT ODT G 37 P donepezil hydrochloride G 37 N galantamine hydrobromide B 37 N RAZADYNE B 37 P EXELON G 37 N rivastigmine tartrate B 37 P NAMENDA B 37 P NAMENDA XR B 37 N NAMENDA XR TITRATION PACK AMINO GLYCOSIDES G P amikacin sulfate G P gentamicin sulfate G P gentamicin in saline G P neomycin sulfate G P paromomycin sulfate G P streptomycin sulfate B P BETHKIS B P TOBI B N TOBI PODHALER G N tobramycin neb solution G P tobramycin sulfate ANALGESICS - MISC. O P Aspirin G P diflunisal G P salsalate O P Aspirin Buffered O P Acetaminophen G P butalbital-acetaminophen tab 50-325 mg B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANALGESICS - MISC. G P butalbital-acetaminophen-caffeine cap 50-325-40 mg G P butalbital-acetaminophen-caffeine tab 50-325-40 mg G P butalbital-aspirin-caffeine ANAPHYLAXIS THERAPY B N ADRENACLICK B N ADRENALIN B N AUVI-Q G N epinephrine B P EPIPEN ANDROGENS - ANABOLICS G N danazol B P ANDROXY B 11 P ANDROID B 11 N METHITEST B 11 P TESTRED B 11 N DEPO-TESTOSTERONE G 11 P testosterone cypionate B 11 N DELATESTRYL G 11 P testosterone enanthate B 11 N AVEED N oxandrolone G ANDROGENS -TOPICAL B 11 P ANDRODERM B 11 N ANDROGEL B 11 N AXIRON B 11 N FORTESTA B 11 N STRIANT B 11 P TESTIM G 11 N testosterone gel B 11 N VOGELXO ANORECTAL - MISC. B N ANUSOL-HC G P hydrocortisone (rectal) B N CORTENEMA G P hydrocortisone (intrarectal) B N CORTIFOAM B N RECTIV G N lidocaine-hydrocortisone acetate (rectal) G N hydrocortisone acetate w/ pramoxine B N PROCTOFOAM HC ANTHELMINTICS B P ALBENZA B P STROMECTOL B P BILTRICIDE ANTI INFECTIVE COMBO'S - MISC. B N BACTRIM G P sulfamethoxazole-trimethoprim RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category ANTIANGINALS - Contd - B N RANEXA ANTIANGINALS--ISOSORBIDE NITRATE B N DILATRATE SR B N ISORDIL TITRADOSE G P isosorbide dinitrate B N IMDUR G P isosorbide mononitrate B N BIDIL ANTIARRHYTHMICS G P disopyramide phosphate B N NORPACE G P procainamide hcl G P quinidine gluconate G P quinidine sulfate G N quinidine sulfate tablet er G N lidocaine hcl (cardiac) B N XYLOCAINE G P mexiletine hcl G P flecainide acetate G P propafenone hcl N RYTHMOL SR B N RYTHMOL TABS G P amiodarone hcl tab 200 mg G N amiodarone hcl tabs 400mg B N CORDARONE B P TIKOSYN B P MULTAQ B 11 ANTIASTHMATIC - 5-LIPOXYGENASE INHIBITORS B N ZYFLO ANTIASTHMATIC - ADRENERGIC COMBOS B P COMBIVENT RESPIMAT G P ipratropium-albuterol B P SYMBICORT B P ADVAIR B P ADVAIR HFA B N BREO ELLIPTA B P DULERA B N ANORO ELLIPTA ANTIASTHMATIC - ANTI-CHOLINERGICS B N TUDORZA PRESSAIR G P ipratropium bromide B P ATROVENT HFA B P SPIRIVA HANDIHALER ANTIASTHMATIC - ANTIINFLAMMATORY AGENTS G B 11 P cromolyn sodium N XOLAIR ANTIASTHMATIC - BETA - ADRENERGICS G 72 P albuterol sulfate nebu 0.63mg/3 B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTIASTHMATIC - BETA - ADRENERGICS G P albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) G P albuterol sulfate soln nebu 0.5% (5 mg/ml) G N albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) G P albuterol sulfate syrup 2 mg/5ml G N albuterol sulfate tab 2 mg G N albuterol sulfate tab 4 mg G P albuterol sulfate tab sr 12hr 4 mg G P albuterol sulfate tab sr 12hr 8 mg B P PROAIR HFA B P PROVENTIL HFA B P VENTOLIN HFA B N VOSPIRE ER B N BROVANA P FORADIL AEROLIZER B N PERFOROMIST B N ARCAPTA NEOHALER N XOPENEX G N metaproterenol sulfate B N STRIVERDI RESPIMAT P SEREVENT DISKUS G N terbutaline sulfate inj 1 mg/ml G P terbutaline sulfate tab 2.5 mg G P terbutaline sulfate tab 5 mg B B B 84 11 74 ANTIASTHMATIC - LEUKOTRIENE RECEPTOR ANTAGONISTS G P montelukast sodium chew tab 4 mg (base equiv) G P montelukast sodium chew tab 5 mg (base equiv) G P montelukast sodium tab 10 mg (base equiv) B N SINGULAIR CHW 4MG B N SINGULAIR CHW 5MG B N SINGULAIR TAB 10MG P SINGULAIR PACK B N ACCOLATE G N zafirlukast B 72 ANTIASTHMATIC - MISC. RESPIRATORY INHALANTS ND P sodium chloride soln nebu 0.9% G P sodium chloride soln nebu 10% G P sodium chloride soln nebu 3% ANTIASTHMATIC - MIXED ADRENERGICS G P epinephrine hcl ANTIASTHMATIC - MUCOLYTICS G P acetylcysteine ANTIASTHMATIC - NASAL MISC. B N ATROVENT B N ATROVENT NAS SOL 0.06% G P ipratropium bromide (nasal) soln 0.03% G N ipratropium bromide nasal soln 0.06% (42 mcg/spray) ANTIASTHMATIC - STEROID INHALANTS B RT45620 P QVAR B, G, or O COM P , N, R, or NR Therapeutic Category G N budesonide (inhalation) B P PULMICORT INHALER P PULMICORT SUS B N PULMICORT SUS SUSP 1MG/2ML B N ALVESCO B P AEROSPAN B P FLOVENT B P ASMANEX 120 AER 220MCG B P ASMANEX 14 AER 220MCG P ASMANEX 30 AER 110MCG B P ASMANEX 30 AER 220MCG B P ASMANEX 60 AER 220MCG B N ASMANEX 7 AER 110MCG - Contd - B B 19 83 ANTIASTHMATIC - XANTHINES G P aminophylline B P ELIXOPHYLLIN B P THEO-24 G P theophylline ANTIBIOTICS - MISC. G P sulfadiazine B P AZACTAM G N aztreonam B N AZACTAM IN DEXTROSE P CAYSTON G N colistimethate sodium B P COLY-MYCIN-M B N FLAGYL N FLAGYL ER G N metronidazole caps G P metronidazole tab 250 mg G P metronidazole tab 500 mg B P METRO IV G P metronidazole in nacl B P NEBUPENT B P PENTAM 300 B N XIFAXAN B N VIBATIV G P trimethoprim B P VANCOCIN HCL G P vancomycin hcl G N vancomycin hcl caps G P vancomycin hcl in dextrose G N polymyxin b sulfate B P TYGACIL B B 89 11 ANTI-CATAPLECTIC AGENTS B 11 N XYREM ANTICOAGULANTS G P heparin sodium (porcine) G P heparin (porcine) in sodium chloride B P FRAGMIN G P enoxaparin sodium syringes G N enoxaparin sodium vials B N LOVENOX SYRINGES B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTICOAGULANTS B P LOVENOX VIALS B N ARIXTRA G N fondaparinux sodium B P COUMADIN B N COUMADIN SOLR G P warfarin sodium B 11 N PRADAXA B 11 N ELIQUIS B 65 P XARELTO ANTICONVULSANTS B N EQUETRO B 11 N GRALISE B 11 N ONFI P clonazepam G G 11 N clonazepam tablet disperse B 11 N KLONOPIN B P DIASTAT G N diazepam (anticonvulsant) gel N felbamate B P FELBATOL B P GABITRIL B N PEGANONE G N fosphenytoin sodium B P DILANTIN INFATABS B P DILANTIN SUSP G N phenytoin G P phenytoin sodium N DILANTIN P DILANTIN CAPS 30MG N PHENYTEK P phenytoin sodium extended cap 100 mg G B 46 46 B B 39 G G 64 N phenytoin sodium extended caps 200mg G 64 N phenytoin sodium extended caps 300mg G N ethosuximide caps G P ethosuximide soln 250 mg/5ml B P ZARONTIN B N ZARONTIN SOLN B N DEPAKOTE B P DEPAKOTE ER B P DEPAKOTE SPRINKLES G P divalproex sodium G N divalproex sodium cap sprinkle N divalproex sodium tablet er 24hr B N DEPACON B N DEPAKENE G P valproate sodium B N DEPAKENE B N STAVZOR G P valproic acid B N FYCOMPA G P carbamazepine G N carbamazepine capsule er 12hr N carbamazepine susp G G 46 46 RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G N carbamazepine tablet er 12hr B P CARBATROL P TEGRETOL B P TEGRETOL SUSP B P TEGRETOL XR B N APTIOM B N POTIGA G P gabapentin cap 100 mg G P gabapentin cap 300 mg G P gabapentin cap 400 mg G P gabapentin oral soln 250 mg/5ml G P gabapentin tab 600 mg G P gabapentin tab 800 mg B N NEURONTIN - Contd - B B 46 N NEURONTIN SOLN B 88 P VIMPAT B 46 N LAMICTAL B 11 N LAMICTAL XR P lamotrigine G G 11 N lamotrigine tablet er 24hr B 46 N KEPPRA B 46 N KEPPRA XR P levetiracetam G G 11 N levetiracetam tablet er 24hr G 46 N oxcarbazepine susp G P oxcarbazepine tab 150 mg G P oxcarbazepine tab 300 mg G P oxcarbazepine tab 600 mg N OXTELLAR XR B N TRILEPTAL B P TRILEPTAL SUSP B 11 B 11 N LYRICA B 39 N MYSOLINE G P primidone B N BANZEL N QUDEXY XR B N TOPAMAX G P topiramate B 11 G 11 N topiramate cs24 B 11 N TROKENDI XR B 46 N ZONEGRAN P zonisamide G ANTIDEPRESSANTS - MAO INHIBITORS B N NARDIL G P phenelzine sulfate N EMSAM B P PARNATE G P tranylcypromine sulfate B 39 ANTIDEPRESSANTS - SELECTED SSRI'S G G 11 B P mirtazapine N mirtazapine tablet disperse N REMERON B 11 N REMERON SOLTAB G 63 P nefazodone hcl B 11 N OLEPTRO B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTIDEPRESSANTS - SELECTED SSRI'S G P trazodone hcl G N trazodone hcl tabs 300mg B 11 N VIIBRYD B 11 N BRINTELLIX B N CELEXA G P citalopram hydrobromide G P escitalopram oxalate B N LEXAPRO G P fluoxetine hcl G 21 N fluoxetine hcl caps 40mg G 11 N fluoxetine hcl capsule delayed release G 6 N fluoxetine hcl tabs 20mg N PROZAC N PROZAC WEEKLY P fluvoxamine maleate B B 11 G B N LUVOX CR G P paroxetine hcl G P paroxetine hcl er B N PAXIL N PAXIL CR P PAXIL SUSP N PEXEVA G P sertraline hcl B N ZOLOFT B 11 39 B B 63 G 11 N desvenlafaxine B 11 N KHEDEZLA B 11 N PRISTIQ B 11 N CYMBALTA G 11 P duloxetine hcl B 11 N FETZIMA B N EFFEXOR XR G P venlafaxine hcl G P venlafaxine hcl cap sr 24hr 150 mg (base equivalent) G P venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) G P venlafaxine hcl cap sr 24hr 75 mg (base equivalent) G N venlafaxine hcl tablet er 24hr G P maprotiline hcl G P bupropion hcl tab 100 mg G P bupropion hcl tab 75 mg G P bupropion hcl tab sr 12hr 100 mg G P bupropion hcl tab sr 12hr 150 mg G P bupropion hcl tab sr 12hr 200 mg G P bupropion hcl tab sr 24hr 150 mg G P bupropion hcl tab sr 24hr 300 mg N FORFIVO XL B P WELLBUTRIN B N WELLBUTRIN XL B 63 63 B 11 N APLENZIN G 63 N fluoxetine hcl (pmdd) B 63 N SARAFEM N BRISDELLE N SAVELLA B B 11 ANTIDEPRESSANTS - TRI-CYCLICS RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G P amitriptyline hcl G P amoxapine P ANAFRANIL N clomipramine hcl N desipramine hcl B N NORPRAMIN G P doxepin hcl G P imipramine hcl B N TOFRANIL - Contd - B 63 G G 39 G 52 N imipramine pamoate B 52 N TOFRANIL-PM G P nortriptyline hcl B N PAMELOR G N protriptyline hcl B N VIVACTIL B P SURMONTIL B N SILENOR ANTIDOTES G P deferoxamine mesylate B N DESFERAL B N FERRIPROX ANTIDOTES - CHELATING AGENTS B N EXJADE B P CHEMET ANTIEMETIC - 5-HT3 RECEPTOR ANTAGONISTS/ SUBSTANCE P NEUROKININ B 11 N ANZEMET B 11 N SANCUSO G 11 N granisetron hcl G 29 P ondansetron odt B 11 N ZOFRAN ODT G 28 P ondansetron hcl G 11 N ondansetron hcl oral soln 4 mg/5ml B 11 N ZOFRAN B 11 N ALOXI B 11 N EMEND ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC B N PHENERGAN G N promethazine hcl inj 25 mg/ml G N promethazine hcl inj 50 mg/ml G P promethazine hcl suppos 12.5 mg G P promethazine hcl suppos 25 mg G P promethazine hcl syrup 6.25 mg/5ml G N promethazine hcl tab 12.5 mg G P promethazine hcl tab 25 mg G P promethazine hcl tab 50 mg O P Meclizine HCl B P TRANSDERM-SCOP B N TIGAN G P trimethobenzamide hcl N DICLEGIS B 63 ANTIEMETIC - TETRAHYDROCANNABINOL (THC) DERIVATIVES G N dronabinol B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTIEMETIC - TETRAHYDROCANNABINOL (THC) DERIVATIVES B N MARINOL B N CESAMET ANTIFUNGALS - ASSORTED B 13 P AMBISOME B 13 P ANCOBON G 11 N flucytosine G 11 N griseofulvin microsize tabs G 13 P griseofulvin sus B 13 P GRIS-PEG G 11 N griseofulvin ultramicrosize G P nystatin B 11 N LAMISIL G 13 P terbinafine hcl G 11 N ketoconazole B 11 N DIFLUCAN G 13 P fluconazole G 13 P fluconazole in nacl G 13 P fluconazole in dextrose G 11 N itraconazole B 11 N ONMEL B 11 N SPORANOX B 11 N NOXAFIL B 11 N VFEND B 13 P VFEND IV B 13 P VFEND SUSR G 13 P voriconazole G 11 N voriconazole solr B 13 P CANCIDAS P MYCAMINE P clotrimazole troche B G 13 ANTIHISTAMINES - NON-SEDATING O P Cetirizine HCl Oral Soln 1 MG/ML (5 MG/5ML) O P Cetirizine HCl Tab 10 MG O P Cetirizine HCl Tab 5 MG B 11 N CLARINEX G 11 N desloratadine G 11 N levocetirizine dihydrochloride B 11 N XYZAL O P Loratadine Syrup 5 MG/5ML O P Loratadine Tab 10 MG B 11 N ASTEPRO G 11 N azelastine hcl P PATANASE B ANTIHISTAMINES - NON-SEDATING / DECONGESTANTS B 11 N CLARINEX-D ANTIHISTAMINES - OTHER O P Chlorpheniramine Maleate G 11 N carbinoxamine maleate G 11 N clemastine fumarate P diphenhydramine hcl G RT45620 B, G, or O COM P , N, R, or NR O Therapeutic Category P Diphenhydramine HCl N cyproheptadine hcl P hydroxyzine hcl soln G P hydroxyzine hcl syrp G N hydroxyzine hcl tab 25 mg G N hydroxyzine hcl tab 50 mg G P hydroxyzine hcl tabs 10mg G P hydroxyzine pamoate G - Contd - G 11 G 11 N hydroxyzine pamoate caps 100mg B 11 N VISTARIL G P prochlorperazine supp G P prochlorperazine maleate G P prochlorperazine edisylate ANTIHISTAMINES/DECONGESTANTS B N SEMPREX-D ANTIHYPERLIPIDEMICS B N JUXTAPID B N KYNAMRO ANTIHYPERTENSIVE COMBOS B N CLORPRES G P methyldopa & hydrochlorothiazide B N AMTURNIDE ANTIHYPERTENSIVES - CENTRAL B N CATAPRES B P CATAPRES-TTS G N clonidine hcl patch weekly G P clonidine hcl tab 0.1 mg G P clonidine hcl tab 0.2 mg G P clonidine hcl tab 0.3 mg G P guanfacine hcl B N TENEX G P methyldopa G N methyldopate hcl B N MINIPRESS G P prazosin hcl G P reserpine G P hydralazine hcl G P minoxidil ANTILEPROTIC B P THALOMID ANTIMALARIAL AGENTS G P chloroquine phosphate G P hydroxychloroquine sulfate B N PLAQUENIL G P mefloquine hcl B N DARAPRIM B P MALARONE ANTIMYCOBACTERIALS / ANTITUBERCULOSIS B N SIRTURO G N cycloserine B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTIMYCOBACTERIALS / ANTITUBERCULOSIS G P ethambutol hcl B P MYAMBUTOL B P TRECATOR G P isoniazid G P pyrazinamide B N MYCOBUTIN B N RIFADIN G P rifampin ANTI-PARKINSONIAN DRUGS G P amantadine hcl cap 100 mg G P amantadine hcl syrup 50 mg/5ml G N amantadine hcl tab 100 mg G N bromocriptine mesylate B P PARLODEL G P carbidopa-levodopa B N SINEMET G P carbidopa-levodopa-entacapone B N STALEVO B N AZILECT B N ELDEPRYL G P selegiline hcl B N ZELAPAR B N LODOSYN G N atracurium besylate ANTIPROTOZOAL AGENTS B N TINDAMAX G N tinidazole G N atovaquone B P MEPRON B P ALINIA ANTI-PSORIATICS - NON-BIOLOGICALS G P calcipotriene B N DOVONEX B N SORILUX B N VECTICAL P TAZORAC G B 11 N acitretin B N SORIATANE G N methoxsalen rapid B P OXSORALEN ULTRA ANTIPSYCHOTICS - ATYPICALS Step therapy required. See step therapy in PA criteria chart located at www.iowamedicaidpdl.com under the Prior Authorization Criteria link. Step 1: Preferred generic - no PA required. Step 2: Preferred brand - no PA required with Step 1 history in past 12 months. Step 3: Non-preferred - PA required with prior trials of Step 1 & Step 2 drugs. B P Step 2 - FANAPT B N Step 3 - FANAPT TITRATION PACK B 11 N Step 3 - INVEGA B 43 P Step 2 - INVEGA SUSTENNA B 43 N Step 3 - RISPERDAL B 11 N Step 3 - RISPERDAL M-TAB RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G 43 P Step 1 - risperidone G 11 N Step 3 - risperidone tablet disperse 43 P Step 2 - RISPERDAL CONSTA G P Step 1 - quetiapine fumarate B N Step 3 - SEROQUEL - Contd - B B 11 N Step 3 - SEROQUEL XR B 57 P Step 2 - SAPHRIS P Step 1 - olanzapine N Step 3 - olanzapine tablet disperse N Step 3 - ZYPREXA G G 11 B B 11 N Step 3 - ZYPREXA ZYDIS B 79 P Step 2 - ABILIFY B 11 N Step 3 - ABILIFY DISCMELT B 11 N Step 3 - ABILIFY MAINTENA B P Step 2 - LATUDA B N Step 3 - GEODON G P Step 1 - ziprasidone hcl ANTIPSYCHOTICS - SPECIAL ATYPICALS G P clozapine B N CLOZARIL B 39 N FAZACLO B 11 N VERSACLOZ ANTIPSYCHOTICS - TYPICAL G 43 P haloperidol B 43 N HALDOL G 43 P haloperidol lactate B 43 N HALDOL DECANOATE 100 B 43 N HALDOL DECANOATE 50 G 43 P haloperidol decanoate G P loxapine succinate B N LOXITANE G P chlorpromazine hcl G 43 P fluphenazine hcl G 43 P fluphenazine decanoate G P perphenazine G P thioridazine hcl G P trifluoperazine hcl G P thiothixene ANTISPASMODICS G P oxybutynin syp 5mg/5ml G P oxybutynin tab 5mg N DETROL N tolterodine tartrate B 63 G G 63 N trospium chloride G 63 P flavoxate hcl ANTISPASMODICS - LONG ACTING B N ENABLEX B P TOVIAZ B N DITROPAN XL N GELNIQUE P oxybutynin chloride er B 63 63 G B 63 P VESICARE B 63 N DETROL LA B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTISPASMODICS - LONG ACTING G 63 N tolterodine tartrate B 63 N MYRBETRIQ ANTITHYROID THERAPIES G P methimazole B N TAPAZOLE G P propylthiouracil ANXIOLYTICS - BENZODIAZEPINES G P alprazolam B P ALPRAZOLAM INTENSOL G 11 N alprazolam tablet disperse B 11 N NIRAVAM B 11 N XANAX P chlordiazepoxide hcl G G 78 P clorazepate dipotassium B 11 N TRANXENE G P diazepam B P DIAZEPAM INTENSOL N ATIVAN P lorazepam B 11 G B 11 N LORAZEPAM INTENSOL G 77 P oxazepam ANXIOLYTICS - LONG ACTING G 11 N alprazolam tab sr 24hr 0.5 mg G 11 N alprazolam tab sr 24hr 1 mg G 11 N alprazolam tab sr 24hr 2 mg G 11 N alprazolam tab sr 24hr 3 mg B 11 N XANAX XR ANXIOLYTICS - MISC. G P buspirone hcl tab 10 mg G P buspirone hcl tab 15 mg G P buspirone hcl tab 5 mg P buspirone hcl tab 7.5 mg N buspirone hcl tabs 30mg G P droperidol G P meprobamate G G 3 ARB/CCB B 11 N AZOR B 44 P EXFORGE G 11 N telmisartan-amlodipine B 11 N TWYNSTA ARB/CCB PLUS DIURETICS B 44 P EXFORGE HCT B 11 N TRIBENZOR ARB'S B 11 N EDARBI B 11 N ATACAND G 11 N candesartan cilexetil RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G 11 N eprosartan mesylate B 11 N TEVETEN 11 N AVAPRO G 44 P irbesartan B 11 N COZAAR G 44 P losartan potassium B 11 N BENICAR B 44 P MICARDIS G 11 N telmisartan B 44 P DIOVAN G 11 N valsartan - Contd - B ARB'S AND DIURETICS B 11 N EDARBYCLOR B 11 N ATACAND HCT G 11 N candesartan cilexetil-hydrochlorothiazide B 11 N TEVETEN HCT B 11 N AVALIDE G 44 P irbesartan-hydrochlorothiazide B 11 N HYZAAR G 44 P losartan potassium & hydrochlorothiazide B 11 N BENICAR HCT B 44 P MICARDIS HCT G 11 N telmisartan-hydrochlorothiazide B 11 N DIOVAN HCT G 44 P valsartan-hydrochlorothiazide ARTHRITIS - MISC. B P RIDAURA B 11 N OTREXUP B 22 N RHEUMATREX ARTIFICIAL SALIVA/STIMULANTS G N cevimeline hcl B N EVOXAC G P pilocarpine hcl (oral) B N SALAGEN BETA BLOCKERS - ALPHA / BETA G P carvedilol B N COREG TABS N COREG CR G P labetalol hcl B N TRANDATE B 11 BETA BLOCKERS - CARDIO SELECTIVE G P acebutolol hcl B N SECTRAL G P atenolol B N TENORMIN G N betaxolol hcl G P bisoprolol fumarate B N ZEBETA G N metoprolol succinate B P TOPROL XL B N LOPRESSOR G P metoprolol tartrate B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories BETA BLOCKERS - CARDIO SELECTIVE B 11 N BYSTOLIC BETA BLOCKERS - NON SELECTIVE B N CORGARD G P nadolol B P LEVATOL G P pindolol B N HEMANGEOL B N INDERAL LA G P propranolol hcl B N INNOPRAN XL B N BETAPACE G P sotalol hcl B N BETAPACE AF G P sotalol hcl (afib/afl) G P timolol maleate BETA BLOCKERS AND DIURETIC COMBO'S G P atenolol & chlorthalidone B N TENORETIC G P bisoprolol & hydrochlorothiazide B N ZIAC B N DUTOPROL B N LOPRESSOR HCT G N metoprolol & hydrochlorothiazide B N CORZIDE G N nadolol & bendroflumethiazide G P propranolol & hydrochlorothiazide BETA-LACTAMS / CLAVULANATE COMBO'S G P penicillin g potassium B P PFIZERPEN-G G P penicillin g pot in dextrose B P BICILLIN G P penicillin v potassium G P amoxicillin (trihydrate) cap 250 mg G P amoxicillin (trihydrate) chew tab 125 mg G P amoxicillin (trihydrate) chew tab 250 mg G P amoxicillin (trihydrate) for susp 125 mg/5ml G P amoxicillin (trihydrate) for susp 200 mg/5ml G P amoxicillin (trihydrate) for susp 250 mg/5ml G P amoxicillin (trihydrate) for susp 400 mg/5ml G P amoxicillin (trihydrate) tab 500 mg G P amoxicillin (trihydrate) tab 875 mg G N amoxicillin (trihydrate) tab sr 24hr 775 mg N MOXATAG G P ampicillin G P dicloxacillin sodium G P nafcillin sodium G P oxacillin sodium B P BACTOCILL IN DEXTROSE B P BICILLIN G N amoxicillin & k clavulanate chew tab 200-28.5 mg G P amoxicillin & k clavulanate chew tab 400-57 mg B 11 RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G P amoxicillin & k clavulanate for susp 200-28.5 mg/5ml G N amoxicillin & k clavulanate for susp 250-62.5 mg/5ml P amoxicillin & k clavulanate for susp 400-57 mg/5ml G P amoxicillin & k clavulanate for susp 600-42.9 mg/5ml G N amoxicillin & k clavulanate tab 250-125 mg G P amoxicillin & k clavulanate tab 500-125 mg G P amoxicillin & k clavulanate tab 875-125 mg N amoxicillin & pot clavulanate tablet er 12hr B N AUGMENTIN SUS 125/5ML B N AUGMENTIN SUS 250/5ML B N AUGMENTIN SUS ES-600 B N AUGMENTIN TAB 500MG B N AUGMENTIN TAB 875MG N AUGMENTIN XR G N ampicillin & sulbactam sodium B P UNASYN B P TIMENTIN G N piperacillin sodium-tazobactam sodium B P ZOSYN - Contd - G G B 11 11 BIOLOGIC IMMUNOMODULATORS B 11 N CIMZIA B 11 N REMICADE B 11 N KINERET B 11 P HUMIRA B 11 P HUMIRA PEN B 47 P HUMIRA PEN-CROHNS DISEASESTARTER B 47 P HUMIRA PEN-PSORIASIS STARTER B 11 N SIMPONI B 11 P ENBREL B 11 N ORENCIA B 11 N ACTEMRA B 11 N XELJANZ B 11 N OTEZLA B 11 N STELARA B N CARDURA G P doxazosin mesylate G P terazosin hcl N AVODART G P finasteride B N PROSCAR G P alfuzosin hcl B N UROXATRAL N CARDURA XL B N RAPAFLO B N FLOMAX G P tamsulosin hcl B N JALYN G P finasteride (alopecia) BPH B B 39 11 CALCIUM CHANNEL BLOCKERS--AMLODIPINES G P amlodipine besylate B N NORVASC CALCIUM CHANNEL BLOCKERS--DILTIAZEMS B, G, or O COM P, N, Therapeutic Category R, or NR B, G, or O G PDL Categories CALCIUM CHANNEL BLOCKERS--DILTIAZEMS B N CARDIZEM B N DILACOR XR G P diltiazem hcl G N diltiazem hcl extended release beads B P TIAZAC B N CARDIZEM CD B N CARDIZEM LA G N diltiazem hcl coated beads N felodipine CALCIUM CHANNEL BLOCKERS--ISRADIPINES G N isradipine CALCIUM CHANNEL BLOCKERS--NIFEDIPINES B N ADALAT CC G P nifedipine G P nifedipine tab sr 24hr 30 mg G P nifedipine tab sr 24hr 60 mg G P nifedipine tab sr 24hr 90 mg B N PROCARDIA B N PROCARDIA XL B N NYMALIZE CALCIUM CHANNEL BLOCKERS--NISOLDIPINE G N nisoldipine B N SULAR CALCIUM CHANNEL BLOCKERS--VERAPAMILS B N CALAN G P verapamil hcl G N verapamil hcl soln B N VERELAN CARBAPENEMS B P INVANZ G P meropenem B N MERREM G N imipenem-cilastatin B N PRIMAXIN CARDIAC GLYCOSIDES G P digoxin G N digoxin ij N LANOXIN B 39 CARNITINE REPLENISHER - AGENTS B N CARNITOR INJ 1GM/5ML B P CARNITOR SOL 1GM/10ML B P CARNITOR TAB 330MG B P CARNITOR SF SOL 1GM/10ML G P levocarnitine inj 200 mg/ml G N levocarnitine oral soln 1 gm/10ml (10%) RT45620 N Therapeutic Category levocarnitine tab 330 mg CCB / LIPID G N amlodipine besylate-atorvastatin calcium B N CADUET CENTRAL PRECOCIOUS PUBERTY AGENTS CALCIUM CHANNEL BLOCKERS--FELODIPINES G - Contd - COM P , N, R, or NR B P LUPR DEP-PED INJ 11.25MG B P LUPR DEP-PED INJ 15MG B P LUPR DEP-PED INJ 7.5MG B P LUPRON DEPOT-PED KIT 11.25MG B P LUPRON DEPOT-PED KIT 30MG CEPHALOSPORINS G P cefadroxil cap 500 mg G P cefadroxil for susp 250 mg/5ml G P cefadroxil for susp 500 mg/5ml G N cefadroxil tab 1 gm G P cefazolin sodium G P cefazolin in d5w G P cephalexin G P cephalexin caps 750mg G N cephalexin tabs B N KEFLEX G N cefaclor cap 250 mg G N cefaclor cap 500 mg G N cefaclor for susp 125 mg/5ml G N cefaclor for susp 250 mg/5ml G N cefaclor for susp 375 mg/5ml G N cefaclor monohydrate tab sr 12hr 500 mg G P cefprozil B N CEFTIN G P cefuroxime axetil tab 250 mg G P cefuroxime axetil tab 500 mg G P cefuroxime sodium B N ZINACEF G P cefdinir G N cefditoren pivoxil B N SPECTRACEF B N SUPRAX B P SUPRAX SUSR 100/5ML B P SUPRAX SUSR 200/5ML G N cefpodoxime proxetil G N cefotaxime sodium B P CLAFORAN G P ceftazidime B N FORTAZ B N CEDAX G P ceftriaxone sodium B N ROCEPHIN G P ceftriaxone sodium in dextrose G P cefepime hcl G N cefepime hcl and dextrose CHELATING AGENTS B P SYPRINE B N CUPRIMINE INJ 1GM B, G, or O COM P, N, Therapeutic Category R, or NR B, G, or O G PDL Categories CHELATING AGENTS B P DEPEN TITRATABS CHOLESTEROL - BILE SEQUESTRANTS G P cholestyramine B N QUESTRAN G P cholestyramine light B N WELCHOL B N COLESTID G P colestipol hcl CHOLESTEROL - FIBRIC ACID DERIVATIVES N TRILIPIX G B N fenofibrate caps G P fenofibrate tabs B N LIPOFEN B N LOFIBRA B N TRICOR B N TRIGLIDE B N ANTARA G N fenofibrate micronized G P gemfibrozil B N LOPID G N niacin (antihyperlipidemic) N NIASPAN B 11 39 CHOLESTEROL - HMG COA + ABSORB INHIBITORS B N LIVALO N SIMCOR B N VASCEPA B N LIPTRUZET B 39 CHOLESTEROL - HMG COA + ABSORB INHIBITORS: HIGH POTENCY DRUGS/COMBINATIONS G P atorvastatin calcium B N LIPITOR B P CRESTOR G P simvastatin tab 10 mg G P simvastatin tab 20 mg G P simvastatin tab 40 mg G P simvastatin tab 5 mg N simvastatin tabs 80mg B N ZOCOR B P VYTORIN G 39 CHOLESTEROL - HMG COA + ABSORB INHIBITORS: LOW POTENCY DRUGS/COMBINATIONS B 87 P ZETIA G N fluvastatin sodium B P LESCOL B P LESCOL XL B N ALTOPREV G P lovastatin B N PRAVACHOL G P pravastatin sodium B N ADVICOR B N LOVAZA RT45620 - Contd - COM P , N, R, or NR N Therapeutic Category omega-3-acid ethyl esters CHOLINERGIC G P bethanechol chloride B N URECHOLINE COMPOUNDING MATERIALS ND P sterile dilu sol flolan ND P water for inject, bacteriostatic parabens ND P saline, bacteriostatic CONTRACEPTIVES - BI-PHASIC COMBINATIONS B N NECON 10/11-28 CONTRACEPTIVES - EMERGENCY CONTRACEPTIVE G P levonorgestrel (emergency oc) B P ELLA CONTRACEPTIVES - INJECTABLE B N DEPO-PROVERA G P medroxyprogesterone acetate (contraceptive) CONTRACEPTIVES - MONOPHASIC COMBINATION O/C'S B P DESOGEN G P desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg B N ORTHO-CEPT G N drospirenone-ethinyl estradiol tab 3-0.02 mg G N drospirenone-ethinyl estradiol tab 3-0.03 mg B P YASMIN 28 B P YAZ G P ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg B P ZOVIA 1/50E G P levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg G P levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg B N BREVICON-28 B P MODICON G P norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg G P norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg G P norethindrone & ethinyl estradiol tab 1 mg-35 mcg B N NORINYL B N ORTHO-NOVUM TAB 1/35 B N OVCON-35 B N LOESTRIN G N norethindrone acet & eth estra B P NECON 1/50-28 B P NORINYL G P norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg B N OGESTREL B N BEYAZ B P FEMCON FE G N norethindrone & ethinyl estradiol-fe B N LOESTRIN 24 FE B N LOESTRIN FE 1.5/30 B N LOESTRIN FE 1/20 G P norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg G P norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg G N desogestrel-ethinyl estradiol (biphasic) TAB 1/35 TAB 1+50-28 B, G, or O COM P, N, Therapeutic Category R, or NR B, G, or O B PDL Categories CONTRACEPTIVES - MONOPHASIC COMBINATION O/C'S B P MIRCETTE B N LO LOESTRIN FE G N levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) G P levonorgestrel-ethinyl estradiol (91-day) tabs B N LOSEASONIQUE B N QUARTETTE B P SEASONIQUE B N AMETHYST CONTRACEPTIVES - MULTI-PHASIC COMBINATIONS B N NATAZIA CONTRACEPTIVES - PATCHES/ VAGINAL PRODUCTS B P ORTHO EVRA G N xulane B P NUVARING CONTRACEPTIVES - PROGESTIN ONLY B N NOR-QD G P norethindrone (contraceptive) B P ORTHO MICRONOR CONTRACEPTIVES - TRI-PHASIC COMBINATIONS B P CYCLESSA G N desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg G P levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg G P norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg G N norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg B N ORTHO-NOVUM 7/7/7 B P TRI-NORINYL 28 G P norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg B P ORTHO TRI-CYCLEN B N ORTHO TRI-CYCLEN LO B P ESTROSTEP FE G N norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg COUGH/COLD - ANTITUSSIVE-EXPECTORANT O P Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML COUGH/COLD - SYSTEMIC DECONGESTANTS O P Pseudoephedrine HCl Tab 30 MG O P Pseudoephedrine HCl Tab 60 MG COX 2 INHIBITORS - SELECTIVE G 11 N ketorolac tromethamine G 11 N ketorolac tromethamine soln 60mg/2ml B 11 N SPRIX P meloxicam N MOBIC P nabumetone N CELEBREX G B 11 G B 11 CYSTIC FIBROSIS AGENTS B 11 RT45620 N KALYDECO - Contd - COM P , N, R, or NR 11 P Therapeutic Category PULMOZYME CYTO-MEGALOVIRUS AGENTS B P VISTIDE B N CYTOVENE G N ganciclovir sodium B P VALCYTE DENTAL PRODUCTS G P sodium fluoride (dental) G P stannous fluoride DIABETIC - ALPHAGLUCOSIDASE G N acarbose B N PRECOSE B P GLYSET DIABETIC - INSULIN B P NOVOLOG B P LANTUS B N APIDRA B P HUMALOG B P LEVEMIR B P HUMULIN R O P HUMULIN R O P NOVOLIN R O P NOVOLIN R RELION O P HUMULIN N O P NOVOLIN N O P NOVOLIN N RELION B P NOVOLOG MIX 70/30 B P HUMALOG MIX 50/50 B P HUMALOG MIX 75/25 O P HUMULIN 70/30 O P NOVOLIN 70/30 O P NOVOLIN 70/30 RELION INJ 100/ML DIABETIC - INSULIN PENFILLS B 11 P NOVOLOG B 11 P LANTUS SOLOSTAR B 11 N APIDRA B 11 N HUMALOG B 11 P LEVEMIR O 11 N HUMULIN N U-100 PEN B 11 N HUMALOG MIX 50/50 B 11 N HUMALOG MIX 75/25 O 11 N HUMULIN 70/30 PEN DIABETIC - MEGLITINIDES G P nateglinide B N STARLIX B N PRANDIN G N repaglinide DIABETIC - NON-INSULIN INJECTABLES B 11 N TANZEUM B 11 N BYDUREON B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories DIABETIC - NON-INSULIN INJECTABLES B 11 P BYETTA B 11 N VICTOZA DIABETIC - ORAL BIGUANIDES B N FORTAMET B N GLUCOPHAGE G P metformin hcl N metformin hcl tablet er 24hr 500mg er N RIOMET G 11 B DIABETIC - ORAL SULFONYLUREAS G P chlorpropamide B N AMARYL G P glimepiride G P glipizide B N GLUCOTROL N GLUCOTROL XL B P DIABETA G P glyburide G P glyburide micronized B N GLYNASE G P tolazamide G N tolbutamide B 11 DIABETIC - OTHER B 11 N SYMLINPEN 120 B 11 N SYMLINPEN 60 B N GLUCAGON EMERGENCY KIT B P GLUCAGEN B P PROGLYCEM B N KORLYM B 11 N NESINA B 11 N TRADJENTA B 11 P ONGLYZA B 11 P JANUVIA B 11 N INVOKANA B 11 N FARXIGA B 11 N JARDIANCE B 11 N KAZANO B 11 N JENTADUETO B 11 P KOMBIGLYZE XR B 11 P JANUMET B 11 N JANUMET XR B 11 N OSENI N PRANDIMET N INVOKAMET B B 11 DIABETIC - SULFONYLUREA / BIGUANIDE G P glipizide-metformin hcl B N GLUCOVANCE G P glyburide-metformin N AVANDARYL B 16 DIABETIC - THIAZOL RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category B N ACTOS G P pioglitazone hcl - Contd - B 16 N AVANDIA B 16 N DUETACT N pioglitazone hcl-glimepiride G DIABETIC - THIAZOL / BIGUANIDE COMBO B N ACTOPLUS MET B N ACTOPLUS MET XR G N pioglitazone hcl-metformin hcl N AVANDAMET B 16 DIAGNOSTIC BIOLOGICALS B P APLISOL DIAGNOSTIC DRUGS B N CORTROSYN G N cosyntropin B N THYROGEN DIRECT RENIN INHIBITORS B N TEKTURNA B N TEKTURNA HCT B N TEKAMLO DIURETICS G 11 P eplerenone B 11 N INSPRA G P acetazolamide B N DIAMOX G P methazolamide B P NEPTAZANE G P bumetanide B P EDECRIN G P furosemide B N LASIX B N DEMADEX G P torsemide G P amiloride hcl B N ALDACTONE G P spironolactone G P chlorothiazide tab B N DIURIL G N chlorothiazide sodium G P chlorthalidone G P hydrochlorothiazide B N MICROZIDE G P indapamide G P methyclothiazide G P metolazone B P ZAROXOLYN G P amiloride & hydrochlorothiazide B N ALDACTAZIDE TAB 25/25 B P ALDACTAZIDE TABS 50/50 G P spironolactone & hydrochlorothiazide B N DYAZIDE B N MAXZIDE B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories P triamterene & hydrochlorothiazide DOPAMINE RECEPTOR AGONISTS G P cabergoline EAR G P ofloxacin (otic) B N PINNACAINE OTIC B N DERMOTIC G P fluocinolone acetonide (otic) G N vosol hc G P acetic acid (otic) G N acetic acid-aluminum acetate P CIPRODEX B P CIPRO HC B N CORTISPORIN G P neomycin-polymyxin-hc (otic) B N COLY-MYCIN S B N CORTISPORIN-TC G P antipyrine-benzocaine B 19 ELECTROLYTES/ NUTRITIONALS ND P *oral electrolyte solution*** G N parenteral electrolytes G P lactated ringer's G P potassium chloride in nacl G P potassium chloride in dextrose G P dextrose w/ sodium chloride G P dextrose in lactated ringers G P potassium chloride in dextrose & sodium chloride G P dextrose B N INTRALIPID B P LIPOSYN G N amino acid infusion G P amino acid infusion soln 6% B P AMINOSYN B P AMINOSYN II B N AMINOSYN-HBC B N AMINOSYN-PF B N FREAMINE III B P PREMASOL B P TRAVASOL B N TROPHAMINE G P amino acid electrolyte infusion B N PROCALAMINE G N albumin, human ERYTHROPOEISIS STIMULATING AGENTS B 11 N ARANESP ALBUMIN FREE B 11 N EPOGEN B 11 P PROCRIT ESTROGEN COMBOS B RT45620 P PREMPHASE COM P , N, R, or NR Therapeutic Category B P PREMPRO B N ACTIVELLA N COMBIPATCH G N estradiol & norethindrone acetate B N FEMHRT B N JINTELI B N ANGELIQ B N CLIMARA PRO B N PREFEST - Contd - B DIURETICS G B, G, or O ESTROGENS - PATCHES B P ALORA B P CLIMARA B N DIVIGEL B N ELESTRIN G N estradiol B N EVAMIST B N MENOSTAR B N MINIVELLE B P VIVELLE ESTROGENS - TABS B P PREMARIN B P CENESTIN B N ENJUVIA B P MENEST B N ESTRACE G P estradiol B P DEPO-ESTRADIOL B N DELESTROGEN G N estradiol valerate G P estropipate FLUOROQUINOLONES B N CIPRO (10%) SUS 500MG/5 B N CIPRO (5%) SUS 250MG/5 G P ciprofloxacin iv soln 200 mg/20ml (1%) G P ciprofloxacin iv soln 400 mg/40ml (1%) G P ciprofloxacin-ciprofloxacin hcl B N CIPRO TABS G P ciprofloxacin hcl tab 100 mg (base equiv) G P ciprofloxacin hcl tab 250 mg (base equiv) G P ciprofloxacin hcl tab 500 mg (base equiv) G P ciprofloxacin hcl tab 750 mg (base equiv) B N LEVAQUIN B P LEVAQUIN SOLN G P levofloxacin G N levofloxacin soln 25mg/ml G P levofloxacin in d5w G N moxifloxacin hcl G N ofloxacin B N FACTIVE GI - ANTI - FLATULENTS / GI STIMULANTS B N OSMOPREP O P Senna Tab 187 MG O P Sennosides Tab 8.6 MG B, G, or O COM P, N, Therapeutic Category R, or NR B, G, or O PDL Categories GI - ANTI - FLATULENTS / GI STIMULANTS B N KRISTALOSE G P lactulose G P polyethylene glycol 3350 O P polyethylene glycol 3350 B P NULYTELY G P peg 3350-potassium chloride-sod bicarbonate-sod chloride B P COLYTE B P GOLYTELY G P peg 3350-kcl-sod bicarb-sod chloride-sod sulfate G P cromolyn sodium (mastocytosis) B P GASTROCROM G P metoclopramide hcl N METOZOLV ODT B N REGLAN G P lactulose (encephalopathy) N AMITIZA B B 11 11 GI - ANTIDIARRHEAL / ANTACID - MISC. B N FULYZAQ ND 11 P sodium bicarbonate (antacid) tabs ND 11 P magnesium oxide tab 400 mg G P atropine sulfate B P ANASPAZ G P hyoscyamine sulfate B N LEVSIN B N CUVPOSA G N glycopyrrolate injection G P glycopyrrolate tabs B N ROBINUL G P methscopolamine bromide B N PAMINE G P propantheline bromide B N BENTYL CAP 10MG B N BENTYL INJ 10MG/ML B N BENTYL TAB 20MG G P dicyclomine hcl GI - ANTIPERISTALTIC AGENTS G P diphenoxylate w/ atropine B N LOMOTIL B N MOTOFEN G P loperamide hcl cap 2 mg O P Loperamide HCl Liq 1 MG/5ML (0.2 MG/ML) O P Loperamide HCl Tab 2 MG G N opium tincture G N paregoric B N GATTEX GI - DIGESTIVE ENZYMES B P CREON B N PANCREAZE G P pancrelipase (lipase-protease-amylase) B N PERTZYE B N ULTRESA RT45620 - Contd - COM P , N, R, or NR Therapeutic Category B N VIOKACE B P ZENPEP GI - H2-ANTAGONISTS G P cimetidine G N ranitidine hcl cap 150 mg G N ranitidine hcl cap 300 mg G P ranitidine hcl inj 150 mg/6ml (25 mg/ml) G P ranitidine hcl inj 50 mg/2ml (25 mg/ml) G P ranitidine hcl syrup 15 mg/ml (75 mg/5ml) G P ranitidine hcl tab 150 mg G P ranitidine hcl tab 300 mg B N ZANTAC G N famotidine for susp 40 mg/5ml G P famotidine tab 20 mg G P famotidine tab 40 mg B N PEPCID B N AXID G N nizatidine GI - INFLAMMATORY BOWEL AGENTS G P balsalazide disodium B N COLAZAL B N GIAZO B P APRISO B N ASACOL HD TAB 800MG B N CANASA B N DELZICOL B N LIALDA G P mesalamine B P PENTASA CAP 250MG CR B N PENTASA CAP 500MG CR B N SFROWASA B P DIPENTUM B N AZULFIDINE G P sulfasalazine CAP 0.375GM SUP 1000MG CAP 400MG TAB 1.2GM ENE 4GM GI - IRRITABLE BOWEL SYNDROME AGENTS B N LOTRONEX N LINZESS O P Magnesium Hydroxide Susp 400 MG/5ML O P Sennosides Syrup 8.8 MG/5ML O P Sennosides-Docusate Sodium Tab 8.6-50 MG B N MOVIPREP B N ACTIGALL B N URSO G P ursodiol B N RELISTOR B 11 GI - MISC. GI - MISC. ANTI-ULCER B N CARAFATE SUS 1GM/10ML B N CARAFATE TAB 1GM G N sucralfate susp 1 gm/10ml G P sucralfate tab 1 gm B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories GI - PROSTAGLANDINS B N CYTOTEC G P misoprostol GI - PROTON PUMP INHIBITOR B P DEXILANT B 11 N NEXIUM G 11 N esomeprazole strontium G 11 N lansoprazole B 11 N PREVACID B 11 N PREVACID SOLUTAB P omeprazole N PRILOSEC P pantoprazole sodium G B 11 G B 11 N PROTONIX B 11 N ACIPHEX G 11 N rabeprazole sodium G 11 N omeprazole-sodium bicarbonate GI - PROTON PUMP INHIBITOR/NSAID COMBO B 11 N VIMOVO GI - ULCER ANTI-INFECTIVE B P PYLERA B N HELIDAC G N amoxicillin-clarithromycin w/ lansoprazole B N PREVPAC B N OMECLAMOX-PAK GLUCOCORTICOIDS - CORTICOTROPIN B 11 N H.P. ACTHAR GLUCOCORTICOIDS - MINERALOCORTICOIDS G P budesonide B N ENTOCORT EC G P cortisone acetate G P dexamethasone B P DEXAMETHASONE INTENSOL B N DEXPAK G P dexamethasone sodium phosphate B P CORTEF G P hydrocortisone B P A-HYDROCORT B P SOLU-CORTEF B P MEDROL PAK 4MG B N MEDROL TAB 16MG B N MEDROL TAB 2MG B N MEDROL TAB 32MG B P MEDROL TAB 4MG B N MEDROL TAB 8MG G N methylprednisolone tab 16 mg G N methylprednisolone tab 32 mg G P methylprednisolone tab 4 mg G N methylprednisolone tab 8 mg B P DEPO-MEDROL RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G N methylprednisolone acetate G N methylprednisolone sod succ B P SOLU-MEDROL B N MILLIPRED TABS G P prednisolone B N MILLIPRED SOL 10MG/5ML B N ORAPRED B N PEDIAPRED G P prednisolone sodium phosphate B N VERIPRED 20 G P prednisone B N PREDNISONE INTENSOL N RAYOS B P KENALOG B N CELESTONE-SOLUSPAN G P fludrocortisone acetate G P allopurinol B N ZYLOPRIM B 11 GOUT B 62 N COLCRYS B 11 N ULORIC G P probenecid G P colchicine w/ probenecid GRANULOCYTE CSF B 11 P NEUPOGEN B 11 N GRANIX B 11 N NEULASTA B 11 N LEUKINE B 11 N NEUMEGA GROWTH HORMONE B 11 N GENOTROPIN B 11 N HUMATROPE B 11 P NORDITROPIN B 11 P NUTROPIN AQ B 11 N OMNITROPE B 11 N TEV-TROPIN B 11 N SAIZEN B 11 N SEROSTIM B 11 N ZORBTIVE B 11 N INCRELEX HEMOSTATIC G P aminocaproic acid B N LYSTEDA HEPATITIS B ONLY G N adefovir dipivoxil B P HEPSERA B P BARACLUDE G N entecavir B N TYZEKA HEPATITIS C AGENTS B 11 P VICTRELIS B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories B N INFERGEN B P PEGASYS B P PEGASYS PROCLICK B P PEG-INTRON B N COPEGUS B N REBETOL B N RIBASPHERE B N RIBASPHERE RIBAPAK G P ribavirin cap 200 mg G P ribavirin tab 200 mg 11 N OLYSIO B 11 P SOVALDI B 11 N HARVONI HEREDITARY ANGIOEDEMA AGENTS B N FIRAZYR HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS B P ORFADIN HERPES AGENTS G P acyclovir G N acyclovir susp N SITAVIG B N ZOVIRAX CAP 200MG B P ZOVIRAX SUS 200/5ML B N ZOVIRAX TAB 400MG B N ZOVIRAX TAB 800MG G P acyclovir sodium G P valacyclovir hcl B N VALTREX G N famciclovir B N FAMVIR B 11 HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS G P calcitriol G N doxercalciferol N HECTOROL B 39 HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS AND CALCIMIMETICS G B 39 B N paricalcitol N ZEMPLAR N SENSIPAR IMMUNE SERUMS B N CYTOGAM B N HEPAGAM B B N HYPERHEP B S/D B P HYPERHEP B S/D SOLN B P NABI-HB B N GAMASTAN S/D B P BIVIGAM B P CARIMUNE NANOFILTERED B P FLEBOGAMMA RT45620 COM P , N, R, or NR Therapeutic Category B P GAMMAGARD B N GAMMAPLEX N OCTAGAM B N PRIVIGEN B N HIZENTRA B N GAMMAKED B P GAMUNEX-C B P HYPERRHO S/D B P MICRHOGAM ULTRA-FILTEREDPLUS B P RHOGAM ULTRA-FILTERED PLUS B P RHOPHYLAC B P WINRHO SDF B P HYPERTET S/D - Contd - B HEPATITIS C AGENTS B B, G, or O IMMUNOSUPPRESSANTS G P cyclosporine B P SANDIMMUNE G P cyclosporine modified (for microemulsion) G P gengraf B N NEORAL B N CELLCEPT B P CELLCEPT SUSR G P mycophenolate mofetil G N mycophenolate sodium B P MYFORTIC B N ZORTRESS B P RAPAMUNE G P sirolimus N ASTAGRAF XL B N PROGRAF G P tacrolimus B 11 INFLUENZA AGENTS B N FLUMADINE G P rimantadine hydrochloride P TAMIFLU P RELENZA DISKHALER B 25 B B 48 P FLULAVAL B 48 P FLUZONE SPLT INJ 2014-15 INJ 2014-15 B 48 P AFLURIA B 48 P FLUARIX PF INJ 2014-15 B 48 P FLUZONE B 48 P FLUARIX QUAD INJ 2014-15 B 48 P FLUVIRIN B 48 P FLUVIRIN PF INJ 2014-15 INJ PF 14-15 INJ PF 14-15 INJ 2014-15 K REMOVING RESINS G P sodium polystyrene sulfonate B N SPS LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS B N LUPANETA PACK LINCOSAMIDES / OXAZOLIDINONES / LEPROSTATICS G N chloramphenicol sodium succinate B N LINCOCIN B N CLEOCIN CAP 150MG B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories LINCOSAMIDES / OXAZOLIDINONES / LEPROSTATICS B N CLEOCIN CAP 300MG B N CLEOCIN CAP 75MG G P clindamycin hcl cap 150 mg G N clindamycin hcl cap 300 mg B P CLEOCIN PED SOL 75MG/5ML G N clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) B P CLEOCIN IN D5W P ZYVOX B B 11 N SIVEXTRO B N CUBICIN G P dapsone N MYALEPT LITHIUM G P lithium carbonate cap 150 mg G P lithium carbonate cap 300 mg G N lithium carbonate cap 600 mg G P lithium carbonate tab 300 mg G P lithium carbonate tab cr 300 mg G P lithium carbonate tab cr 450 mg N LITHOBID B 39 MACROLIDES / ERYTHROMYCIN'S / KETOLIDES B N ERY-TAB G N erythromycin base B N PCE B N E.E.S. GRANULES B N ERYPED G N erythromycin ethylsuccinate G P azithromycin for susp 100 mg/5ml G P azithromycin for susp 200 mg/5ml G N azithromycin iv for soln 500 mg G P azithromycin powd pack for susp 1 gm G P azithromycin tab 250 mg G P azithromycin tab 500 mg G P azithromycin tab 600 mg B N ZITHROMAX INJ 500MG B N ZITHROMAX POW 1GM PAK B N ZITHROMAX SUS 100/5ML B N ZITHROMAX SUS 200/5ML B N ZITHROMAX TAB 250MG B N ZITHROMAX TAB 500MG B N ZITHROMAX TAB 600MG B N ZITHROMAX TAB TRI-PAK B N ZITHROMAX TAB Z-PAK B N ZMAX SUS 2GM B N BIAXIN SUS 250/5ML B N BIAXIN TAB 250MG B N BIAXIN TAB 500MG B N BIAXIN XL TAB 500MG B N BIAXIN XL TAB PAC 500 G P clarithromycin for susp 125 mg/5ml RT45620 COM P , N, R, or NR Therapeutic Category G P clarithromycin for susp 250 mg/5ml G P clarithromycin tab 250 mg P clarithromycin tab 500 mg G N clarithromycin tab sr 24hr 500 mg B N DIFICID B N KETEK - Contd - G METABOLIC MODIFIERS - LYSOSOMAL STORAGE DISORDER TREATMENTS B N NAGLAZYME MIGRAINE - ERGOT COMBINATIONS B N CAFERGOT B P MIGERGOT MIGRAINE - ERGOTAMINE DERIVATIVES LIPODYSTROPHY AGENTS B B, G, or O B N D.H.E. 45 G N dihydroergotamine mesylate B P MIGRANAL MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)--INJECTABLES B 17 P IMITREX G 11 N sumatriptan spray B 17 P IMITREX STATDOSE REFILL B 17 P IMITREX STATDOSE SYSTEM G 11 N sumatriptan succinate B 11 N SUMAVEL DOSEPRO B 11 N ZOMIG NASAL SPRAY MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)--TABS B 11 N AXERT B 17 P RELPAX B 11 N FROVA B 11 N AMERGE G 11 N naratriptan hcl B 11 N MAXALT B 11 N MAXALT-MLT G 17 P rizatriptan benzoate G 11 N rizatriptan benzoate tablet disperse B 11 N IMITREX G 17 P sumatriptan succinate G 11 N zolmitriptan B 11 N ZOMIG B 11 N ZOMIG ZMT MIGRAINE - SELECTIVE SEROTONIN AGONISTS-5HT COMBINATIONS B 11 N TREXIMET MINERALS ND P calcium carbonate (antacid) G 11 P sodium acetate inj 2 meq/ml G P sodium bicarbonate inj 4.2% G P sodium bicarbonate inj 7.5% G P sodium bicarbonate inj 8.4% ND 11 P calcium carbonate ND 11 P calcium carbonate tab 600 mg ND 11 P calcium carbonate-vitamin d tab 500 mg-200 unit N calcium & phosphorus w/ vitamin d tab 105 mg-81 mg-120 unit ND B, G, or O COM P, N, Therapeutic Category R, or NR B, G, or O B PDL Categories - Contd - MINERALS G P sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) G P sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) G P sodium fluoride chew tab 1 mg f (from 2.2 mg naf) G P sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) G P sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) B P SSKI G P magnesium sulfate inj 4% G P magnesium sulfate inj 50% P magnesium sulfate inj 8% P MAGNEBIND 400 G P potassium phosphate dibasic inj 3 mmole/ml G P sodium phosphate inj 3 mmole/ml G P pot phosphate monobasic w/ sod phosphate dibasic & monobasic G P potassium acetate inj 2 meq/ml G P potassium acetate inj 4 meq/ml G P potassium bicarbonate effer tab 25 meq B P MICRO-K G P potassium chloride inj 10 meq/100 ml G P potassium chloride inj 10 meq/50 ml G P potassium chloride inj 2 meq/ml G P potassium chloride oral liq 10% (20 meq/15ml) G P potassium chloride oral liq 20% (40 meq/15ml) G P potassium chloride tab cr 10 meq G P potassium chloride tab cr 8 meq (600 mg) G P potassium chloride tablet er 20meq er G P sodium chloride inj 0.45% ND P sodium chloride inj 0.9% G P sodium chloride inj 3% ND P sodium chloride iv soln 0.9% G P trace minerals (cr-cu-mn-se-zn) ND P ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ND P ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) ND P ferrous sulfate tab 325 mg (65 mg elemental fe) ND P ferrous gluconate tab 324 mg (38 mg elemental iron) ND P ferrous fumarate tab 325 mg (106 mg elemental fe) G P iron dextran ND P saline w/ benzyl alcohol G B 11 MOUTH - ANESTHETICS TOPICAL ORAL G P lidocaine hcl viscous soln 2% MOUTH - STEROIDS G P triamcinolone acetonide dental paste 0.1% MOUTH ANTI-INFECTIVES G P nystatin susp 100000 unit/ml MOUTH ANTISEPTICS G P chlorhexidine gluconate soln 0.12% MUCOPOLYSACCHARIDOSIS B P ALDURAZYME MULTIPLE SCLEROSIS AGENTS RT45620 COM P , N, R, or NR 11 N Therapeutic Category TECFIDERA MULTIPLE SCLEROSIS AGENTS – INTERFERONS B P AVONEX B P AVONEX PEN B 39 N REBIF B 39 N REBIF REBIDOSE B 39 N REBIF REBIDOSE TITRATIONPACK B N BETASERON B P EXTAVIA MULTIPLE SCLEROSIS AGENTS – NON-INTERFERONS B P COPAXONE B N COPAXONE 11 N AUBAGIO B 11 N AMPYRA B 90 P GILENYA B INJ 40MG/ML MUSCLE RELAXANT -COMBINATIONS G 11 N carisoprodol w/ aspirin G 11 N carisoprodol w/ aspirin & codeine MUSCLE RELAXANTS G P baclofen B P GABLOFEN B P LIORESAL INTRATHECAL G 11 N carisoprodol B 11 N SOMA P chlorzoxazone G B 11 N PARAFON FORTE DSC B 11 N AMRIX P cyclobenzaprine hcl G B 11 N FEXMID G 11 N metaxalone B 11 N SKELAXIN P methocarbamol N ROBAXIN G P orphenadrine citrate G P tizanidine hcl G B 11 B 11 N ZANAFLEX B 11 N DANTRIUM G 11 N dantrolene sodium NARCOTIC - ANTAGONISTS G P naloxone hcl B N VIVITROL G P naltrexone hcl B N REVIA NARCOTICS - MISC. G P codeine sulfate B 11 N SUBSYS B 11 N ABSTRAL B 11 N ACTIQ G 11 N fentanyl citrate P fentanyl citrate soln N FENTORA G B 11 B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories NARCOTICS - MISC. B 11 N SUBLIMAZE B 11 N DILAUDID G 11 N hydromorphone hcl inj G P hydromorphone hcl tab 2 mg G P hydromorphone hcl tab 4 mg G P hydromorphone hcl tab 8 mg B 11 N DEMEROL G 11 N meperidine hcl soln G P meperidine hcl tab 100 mg G P meperidine hcl tab 50 mg G P morphine sulfate N OXECTA P oxycodone hcl B 11 G B 11 N ROXICODONE B 11 N OPANA N oxymorphone hcl G B 11 N NUCYNTA B 11 N BUTRANS G 11 N buprenorphine hcl G 11 N buprenorphine hcl-naloxone hcl dihydrate B 11 P SUBOXONE B 11 N ZUBSOLV G 11 N pentazocine w/ naloxone G 11 N oxycodone w/ acetaminophen tab 10-325 mg G P oxycodone w/ acetaminophen tab 5-325 mg G P oxycodone w/ acetaminophen tabs 2.5-325 N oxycodone w/ acetaminophen tabs 7.5-325 G P oxycodone-aspirin B P PERCODAN N oxycodone-ibuprofen P acetaminophen w/ codeine G G 11 11 G B 11 N CAPITAL/CODEINE B 11 N TYLENOL/CODEINE G 11 N butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg P butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg G B 11 N FIORICET/CODEINE G 11 N butalbital-aspirin-caffeine w/cod B 11 N FIORINAL/CODEINE #3 B 11 N SYNALGOS-DC B 11 N HYCET P hydrocodone-acetaminophen G G 11 N hydrocodone-acetaminophen tabs 10-300mg G 11 N hydrocodone-acetaminophen tabs 5-300mg G 11 N hydrocodone-acetaminophen tabs 7.5-300 B 11 N NORCO B 11 N XODOL B 11 N ZOLVIT G 11 N hydrocodone-ibuprofen B 11 N IBUDONE B 11 N VICOPROFEN NARCOTICS - SELECTED B 11 B RT45620 N CONZIP N RYBIX ODT B, G, or O COM P , N, R, or NR Therapeutic Category G P tramadol hcl G N tramadol hcl tab sr 24hr biphasic release 100 mg N tramadol hcl tab sr 24hr biphasic release 200 mg N tramadol hcl tab sr 24hr biphasic release 300 mg - Contd - G G G 11 N tramadol hcl tablet er 24hr B 11 N ULTRAM B 11 N BUPRENEX G 11 N buprenorphine hcl G 11 P butorphanol tartrate P nalbuphine hcl G B 11 N MAGNACET G 23 N tramadol-acetaminophen B 23 N ULTRACET NARCOTICS -LONG ACTING B 11 N DURAGESIC G 11 N fentanyl B 11 N ZOHYDRO ER B 11 N EXALGO B 11 N DOLOPHINE G P methadone hcl conc G P methadone hcl soln G P methadone hcl tab 10 mg G P methadone hcl tab 5 mg G P methadone hcl tab for oral susp 40 mg B P METHADOSE CON 10MG/ML B P METHADOSE SF CON 10MG/ML B P KADIAN N morphine sul cap er G P morphine sul tab er G P morphine sulfate B P MS CONTIN G 11 B 11 N AVINZA B 11 N OXYCONTIN B 11 N OPANA ER G 11 N oxymorphone hcl B 11 N NUCYNTA ER B 11 N XARTEMIS XR NASAL STEROID/ANTIHISTAMINE COMBOS B N DYMISTA NASAL STEROIDS B N QNASL B N BECONASE AQ G N budesonide (nasal) B N RHINOCORT AQUA B N OMNARIS B N ZETONNA G N flunisolide (nasal) B N VERAMYST B N FLONASE G P fluticasone propionate (nasal) B P NASONEX B N NASACORT AQ G N triamcinolone acetonide (nasal) B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories NEUROLOGICS - MISC. P ergoloid mesylates B P ORAP B N NUEDEXTA B P PROSTIGMIN B P MESTINON B N MESTINON TABS B P MESTINON TIMESPAN G P pyridostigmine bromide B P REGONOL SYP 60MG/5ML NEUROMUSCULAR BLOCKING AGENTS N DYSPORT B N BOTOX B N MYOBLOC B N XEOMIN NICARDIPINES G N nicardipine hcl NICOTINE REPLACEMENT THERAPY O 58 N NICODERM CQ O 58 P Nicotine TD Patch 24HR 14 MG/24HR O 58 P Nicotine TD Patch 24HR 21 MG/24HR O 58 P Nicotine TD Patch 24HR 7 MG/24HR B 67 N NICOTROL B 68 N NICOTROL SOLN O 59 N NICORETTE O 34 N NICORETTE LOZG O 34 N NICORETTE MINI O 59 N NICORETTE STARTER KIT O 59 P Nicotine Polacrilex O 34 P Nicotine Polacrilex LOZG NITRO - OINTMENT/CAP/CR B P NITRO-BID G P nitroglycerin G N nitroglycerin in d5w NITRO - PATCHES B N NITRO-DUR DIS 0.1MG/HR B N NITRO-DUR DIS 0.2MG/HR B N NITRO-DUR DIS 0.3MG/HR B N NITRO-DUR DIS 0.4MG/HR B N NITRO-DUR DIS 0.6MG/HR B P NITRO-DUR DIS 0.8MG/HR G P nitroglycerin NITRO - SUBLINGUAL/ SPRAY G N nitroglycerin soln B N NITROLINGUAL B N NITROMIST B P NITROSTAT NSAIDS RT45620 COM P , N, R, or NR Therapeutic Category B 11 N ZORVOLEX B 11 N CATAFLAM P diclofenac potassium N ZIPSOR P diclofenac sodium G G B B, G, or O B 11 G G 11 N diclofenac sodium tablet er 24hr B 11 N VOLTAREN-XR G 11 N etodolac caps G P etodolac tab 400 mg G P etodolac tab 500 mg G 11 N etodolac tab sr 24hr 400 mg G 11 N etodolac tab sr 24hr 500 mg G 11 N etodolac tab sr 24hr 600 mg G 11 N fenoprofen calcium B 11 N NALFON P flurbiprofen N CALDOLOR G N ibuprofen susp 100 mg/5ml O P Ibuprofen Susp 100 MG/5ML O P Ibuprofen Tab 200 MG G P ibuprofen tab 400 mg G P ibuprofen tab 600 mg G P ibuprofen tab 800 mg N INDOCIN P indomethacin N indomethacin cpcr P ketoprofen G B B 11 11 G G 11 G G 11 N ketoprofen capsule er 24hr G 11 N meclofenamate sodium G 11 N mefenamic acid B 11 N PONSTEL B 11 N EC-NAPROSYN B 11 N NAPROSYN B P NAPROSYN SUSP G P naproxen B 11 N ANAPROX B 11 N NAPRELAN P naproxen sodium tab 550 mg G G 11 N naproxen sodium tabs 275mg B 11 N DAYPRO G 11 N oxaprozin B 11 N FELDENE G 11 N piroxicam P sulindac G G 11 N tolmetin sodium B 11 N ARTHROTEC G 11 N diclofenac w/ misoprostol B 11 N DUEXIS B 11 N FLECTOR G 11 N diclofenac sodium (topical) B 11 N PENNSAID B 11 N VOLTAREN GEL OP. ANTIALLERGICS - ANTIHISTAMINES B N LASTACAFT G N azelastine hcl (ophth) B N OPTIVAR B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories OP. ANTIALLERGICS - ANTIHISTAMINES B N BEPREVE B N EMADINE B N ELESTAT G N epinastine hcl (ophth) B P PATADAY B P PATANOL OP. ANTIALLERGICS - MAST CELL STABILIZERS G P cromolyn sodium (ophth) B N ALOMIDE B N ALOCRIL OP. ANTIBIOTICS B N AZASITE G N bacitracin (ophthalmic) G P erythromycin (ophth) G P gentamicin sulfate (ophth) G P tobramycin (ophth) B N TOBREX B N BLEPH-10 G P sulfacetamide sodium (ophth) B N ZIRGAN G P trifluridine B N VIROPTIC G P bacitracin-polymyxin b (ophth) G P polymyxin b-trimethoprim B N POLYTRIM G N neomycin-bacitracin zn-polymyxin G N neomycin-polymyxin-gramicidin B N NEOSPORIN OP. ANTIINFLAMMATORY / STEROIDS OPHTH. B P MAXIDEX G P dexamethasone sodium phosphate (ophth) B P DUREZOL G N fluorometholone (ophth) B P FML B N FML LIQUIFILM B P FLAREX B P ALREX B N LOTEMAX B N OMNIPRED B N PRED FORTE B P PRED MILD G N prednisolone acetate (ophth) G P prednisolone sodium phosphate (ophth) B P VEXOL B P PRED-G B P ZYLET B P BLEPHAMIDE B P BLEPHAMIDE S.O.P. G N sulfacetamide sod-prednisolone B P TOBRADEX B N TOBRADEX ST RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G N tobramycin-dexamethasone B P MAXITROL P neomycin-polymy-dexameth G N neomycin-polymyxin-hc (ophth) G N bacitracin-poly-neomycin-hc - Contd - G OP. BETA - BLOCKERS G N betaxolol hcl (ophth) B P BETOPTIC-S G P carteolol hcl (ophth) G P metipranolol B N BETAGAN G P levobunolol hcl B N BETIMOL B N ISTALOL G P timolol maleate ophth gel forming soln 0.25% G P timolol maleate ophth gel forming soln 0.5% G P timolol maleate ophth soln 0.25% G P timolol maleate ophth soln 0.5% B N TIMOPTIC B N TIMOPTIC-XE OP. CARBONIC ANHYDRASE INHIBITORS/COMBO B P COMBIGAN B N COSOPT B N COSOPT PF G P dorzolamide hcl-timolol maleate B P AZOPT G P dorzolamide hcl B N TRUSOPT OP. CYCLOPLEGICS G P atropine sulfate (ophthalmic) B N ISOPTO ATROPINE B N CYCLOGYL G P cyclopentolate hcl B P ISOPTO HYOSCINE B N MYDRIACYL G P tropicamide B N CYCLOMYDRIL OP. MIOTICS - DIRECT ACTING B N ISOPTO CARPINE G P pilocarpine hcl B P PILOPINE HS B P PHOSPHOLINE IODIDE O P Artificial Tear Solution O P Artificial Tear Ointment G P naphazoline hcl B P MYDFRIN G P phenylephrine hcl (ophth) B N RESTASIS B N ALCAINE G P proparacaine hcl G P tetracaine hcl (ophth) OP. MISC B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories O P Sodium Chloride Hypertonic Ophth Oint 5% O P Sodium Chloride Hypertonic Ophth Soln 5% B N CYSTARAN OP. NSAID'S G N bromfenac sodium (ophth) B N PROLENSA G P diclofenac sodium (ophth) G P flurbiprofen sodium B N OCUFEN B N ACULAR B N ACUVAIL G P ketorolac tromethamine (ophth) B P ILEVRO B P NEVANAC B N LUMIGAN G P latanoprost B N XALATAN B N ZIOPTAN B P TRAVATAN Z G N travoprost B N RESCULA N etidronate disodium B N BONIVA N ibandronate sodium G N pamidronate disodium B N ACTONEL B N ATELVIA B N ZOMETA G N calcitonin (salmon) B N FORTICAL B N MIACALCIN INJ 200/ML B P MIACALCIN SPR 200/ACT B N FORTEO B N EVISTA G N raloxifene hcl SPR 200/ACT G P methylergonovine maleate G N benztropine mesylate inj 1 mg/ml G P benztropine mesylate tab 0.5 mg G P benztropine mesylate tab 1 mg G P benztropine mesylate tab 2 mg G P trihexyphenidyl hcl PARKINSONS - COMT INHIBITORS B N TASMAR B P COMTAN G N entacapone PARKINSONS - SELECTED DOPAMIN AGONISTS B N BESIVANCE B P CILOXAN OIN 0.3% OP B N CILOXAN SOL 0.3% OP G P ciprofloxacin hcl (ophth) G N levofloxacin ophth soln 0.5% B N OCUFLOX G P ofloxacin (ophth) OP. QUINOLONES FOURTH GENERATION G N gatifloxacin (ophth) B N ZYMAXID B P MOXEZA B P VIGAMOX B P APOKYN B N MIRAPEX N MIRAPEX ER B N MIRAPEX ER TABLET ER 24HR 2.25MG B N MIRAPEX ER TABLET ER 24HR 3.75MG G P pramipexole dihydrochloride B N REQUIP N REQUIP XL P ropinirole hydrochloride N ropinirole hydrochloride tablet er 24hr N NEUPRO B B B G N apraclonidine hcl B N IOPIDINE B N ALPHAGAN P SOL 0.1% B P ALPHAGAN P SOLN 0.15% G P brimonidine tartrate ophth soln 0.2% G N brimonidine tartrate soln 0.15% B P SIMBRINZA OSTEOPOROSIS G P alendronate sodium G N alendronate sodium soln N BINOSTO N FOSAMAX TAB 70MG 11 11 G G OP. SELECTIVE ALPHA ADRENERGIC AGONISTS RT45620 G PARKINSONS - ANTICHOLINERGICS OP. QUINOLONES B Therapeutic Category OXYTOCICS OP. PROSTAGLANDINS 11 COM P , N, R, or NR - Contd - G OP. MISC B B, G, or O 11 PERIPHERAL VASODILATORS G P papaverine hcl PHENYLKETONURIA B N KUVAN PHOSPHATE BINDERS G P calcium acetate (phosphate binder) B P ELIPHOS B N PHOSLO B P PHOSLYRA B N FOSRENOL B N RENVELA G N sevelamer carbonate B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories B P RENAGEL TAB 400MG B P RENAGEL TAB 800MG B N VELPHORO PHOSPHODIESTERASE INHIBITORS G N milrinone lactate G N milrinone in dextrose B N DALIRESP PLATELET AGGR. INHIBITORS / COMBO'S - MISC. P cilostazol N PLETAL N ZONTIVITY B N AGRYLIN G P anagrelide hcl B P AGGRENOX G P pentoxifylline B B 11 PLATELET AGGREGATION INHIBITORS G P dipyridamole B N PERSANTINE G P clopidogrel bisulfate G N clopidogrel bisulfate tabs 300mg B N PLAVIX B N EFFIENT G N ticlopidine hcl B N BRILINTA POWDERS P progesterone powder ND P progesterone micronized powder ND P metronidazole powder PRESSORS G N ephedrine sulfate (pressors) G P midodrine hcl PROGESTINS P medroxyprogesterone acetate B N PROVERA B N MEGACE ES B N AYGESTIN G P norethindrone acetate tab 5 mg G N progesterone im in oil 50 mg/ml G N progesterone micronized capsule B N PROMETRIUM PSYCHOTHERAPEUTIC COMBINATION G P chlordiazepoxide-amitriptyline G P perphenazine-amitriptyline G 39 N olanzapine-fluoxetine hcl B 39 N SYMBYAX PULMONARY ANTI-HYPERTENSIVES RT45620 11 N ADEMPAS 39 N REVATIO 11 N REVATIO SUSR G 11 P sildenafil citrate (pulmonary hypertension) B 39 N ADCIRCA B 11 N OPSUMIT G 11 P epoprostenol sodium B 11 N FLOLAN B 11 N VELETRI B 11 P VENTAVIS B 11 N TYVASO B 11 N ORENITRAM B 11 N REMODULIN PULMONARY ANTI-HYPERTENSIVES-ENDOTHELIN RECEPTOR ANTAGONIST B 11 P LETAIRIS B 11 P TRACLEER PURINE ANALOG B P AZASAN G P azathioprine B N IMURAN RESTLESS LEG SYNDROME AGENTS B 11 N HORIZANT RHEUMATOID ARTHRITIS - NON-BIOLOGICALS B N ARAVA G P leflunomide RSV PROPHYLAXIS 11 P SYNAGIS SEDATIVE/HYPNOTICS - BARBITURATE B N BUTISOL SODIUM G P phenobarbital G N phenobarbital sodium B N SECONAL SEDATIVE/HYPNOTICS - BENZODIAZEPINES G G Therapeutic Category B B ND COM P , N, R, or NR B - Contd - B PHOSPHATE BINDERS G B, G, or O P estazolam G 76 P flurazepam hcl G 11 N midazolam hcl G P midazolam hcl syrp B P DORAL N RESTORIL G P temazepam cap 15 mg G P temazepam cap 30 mg B 11 G 11 N temazepam caps 22.5mg G 11 N temazepam caps 7.5mg B 11 N HALCION G 11 N triazolam SEDATIVE/HYPNOTICS - NON-BENZODIAZEPINES G 11 N eszopiclone B 11 N LUNESTA B 11 N SONATA B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories SEDATIVE/HYPNOTICS - NON-BENZODIAZEPINES G 11 N zaleplon B 11 N AMBIEN B 11 N AMBIEN CR B 11 N EDLUAR B 11 N INTERMEZZO P zolpidem tartrate G G 11 N zolpidem tartrate tablet er B 11 N ZOLPIMIST B 11 N ROZEREM B 11 N HETLIOZ SMOKING CESSATION (ORAL) G 11 P bupropion hcl (smoking deterrent) B 11 P CHANTIX B 11 P CHANTIX CONTINUING MONTHPAK B 11 P CHANTIX STARTING MONTH PAK SOMATOSTATIC AGENTS G N octreotide acetate B P SANDOSTATIN B N SIGNIFOR B N SOMAVERT STIMULANTS 11 N PROCENTRA B 11 N DESOXYN G 11 N methamphetamine hcl STIMULANTS - AMPHETAMINES - LONG ACTING B 11 N DEXEDRINE G 11 N dextroamphetamine sulfate B 24 P VYVANSE B 39 N ADDERALL XR G 11 N amphetamine-dextroamphetamine er STIMULANTS - AMPHETAMINES - SHORT ACTING G 11 N dextroamphetamine sulfate B 11 N ADDERALL G 24 P amphetamine-dextroamphetamine STIMULANTS - METHYLPHENIDATE N dexmethylphenidate hcl B 24 P FOCALIN G 24 P methylphenidate hcl B 11 N RITALIN STIMULANTS - METHYLPHENIDATE - LONG ACTING G 11 N dexmethylphenidate hcl B 24 P FOCALIN XR B 24 P DAYTRANA B 11 N CONCERTA B 24 P METADATE G 11 N methylphenidate hcl capsule er 24hr G 85 P methylphenidate hcl tab sa osm 18 mg RT45620 COM P , N, R, or NR Therapeutic Category G 85 P methylphenidate hcl tab sa osm 27 mg G 85 P methylphenidate hcl tab sa osm 36 mg 85 P methylphenidate hcl tab sa osm 54 mg G 24 P methylphenidate hcl tablet er 10mg er G 24 P methylphenidate tab 20mg cr B 24 P QUILLIVANT XR B 11 N RITALIN LA B 11 N RITALIN SR - Contd - G STIMULANTS - OTHER STIMULANTS / LIKE STIMULANTS G 11 N clonidine hcl (adhd) B 11 N KAPVAY B 11 N INTUNIV B 24 P STRATTERA B 11 N NUVIGIL G 11 N modafinil B 24 P PROVIGIL TETRACYCLINES G N demeclocycline hcl N ADOXA G N doxycycline (monohydrate) G P doxycycline (monohydrate) caps 100mg G P doxycycline (monohydrate) caps 50mg B N VIBRAMYCIN SUSR N DORYX N doxycycline hyclate N doxycycline hyclate tbec B N VIBRAMYCIN CAP 100MG B P VIBRAMYCIN SYRP G P minocycline hcl cap 100 mg G P minocycline hcl cap 50 mg G P minocycline hcl cap 75 mg G N minocycline hcl tab 100 mg G N minocycline hcl tab 50 mg G N minocycline hcl tab 75 mg B B 11 11 G B G B, G, or O G 11 G 11 N minocycline hcl tablet er 24hr B 11 N SOLODYN G N tetracycline hcl B N ORACEA THROMBOPOEITIN RECEPTOR AGONISTS B 11 P PROMACTA B 11 N NPLATE THYROID HORMONES G N levothyroxine sodium for iv inj 500 mcg G P levothyroxine sodium tab 100 mcg G P levothyroxine sodium tab 112 mcg G P levothyroxine sodium tab 125 mcg G P levothyroxine sodium tab 137 mcg G P levothyroxine sodium tab 150 mcg G P levothyroxine sodium tab 175 mcg G P levothyroxine sodium tab 200 mcg G P levothyroxine sodium tab 25 mcg G P levothyroxine sodium tab 300 mcg G P levothyroxine sodium tab 50 mcg B, G, or O COM P, N, Therapeutic Category R, or NR THYROID HORMONES G P levothyroxine sodium tab 75 mcg G P levothyroxine sodium tab 88 mcg B N SYNTHROID B N TIROSINT B P CYTOMEL G N liothyronine sodium B P TRIOSTAT B P THYROLAR N ARMOUR THYROID 39 TISSUE PLASMINOGEN ACTIVATOR B P ACTIVASE B P CATHFLO ACTIVASE TOPICAL - ACNE PREPARATIONS G 11 N adapalene B 11 P DIFFERIN CRE 0.1% B 11 P DIFFERIN GEL 0.1% B 11 P DIFFERIN GEL 0.3% B 11 N DIFFERIN LOTN B 11 P AZELEX P Benzoyl Peroxide O G 11 N benzoyl peroxide liq 7% B 11 N CLEOCIN-T B 11 N CLINDAGEL G 11 P clindamycin phosphate (topical) B 11 N EVOCLIN B 11 N AKNE-MYCIN G 11 P erythromycin (acne aid) B 11 N KLARON G 11 N sulfacetamide sodium (acne) B 11 N EPIDUO B 11 N BENZAMYCIN B 11 N BENZAMYCIN GEL PAK G 11 P benzoyl peroxide-erythromycin B 11 N ACANYA B 11 P BENZACLIN GEL 1-5%PUMP B 11 N BENZACLIN GEL 1-5% G 11 N clindamycin phosphate-benzoyl peroxide B 11 P DUAC B 11 N VELTIN B 11 N ZIANA G 11 N sulfacetamide sodium w/ sulfur B 11 N SUMAXIN B 11 N SUMAXIN TS B 11 N FINACEA B 11 P METROCREAM B 11 P METROGEL B 11 P METROLOTION G 11 N metronidazole (topical) lotn G 11 N metronidazole cream 0.75% G 11 N metronidazole gel 0.75% B 11 N NORITATE RT45620 COM P , N, R, or NR Therapeutic Category TOPICAL - ANTIBIOTIC PDL Categories B B, G, or O - Contd - O P Bacitracin (Topical) G P gentamicin sulfate (topical) B N BACTROBAN OINT B N CENTANY AT G P mupirocin oint B N BACTROBAN CRE 2% G N mupirocin calcium cream 2% B N ALTABAX O P Neomycin-Bacitracin-Polymyxin B N CORTISPORIN TOPICAL - ANTIFUNGALS B N MENTAX G N ciclopirox gel 0.77% G N ciclopirox shampoo 1% G P ciclopirox solution 8% B N LOPROX SHAMPOO B N PENLAC NAIL LACQUER G P ciclopirox olamine B N NAFTIN G N nystatin cream 100000 unit/gm G P nystatin oint 100000 unit/gm O P Tolnaftate G P clotrimazole (topical) G N econazole nitrate B N JUBLIA B N EXTINA G P ketoconazole (topical) G N ketoconazole (topical) foam B N NIZORAL SHAMPOO O P Miconazole Nitrate Cream 2% B N OXISTAT B N ERTACZO B N EXELDERM G P clotrimazole w/ betamethasone B N LOTRISONE G N nystatin-triamcinolone N VUSION B 11 TOPICAL - ANTINEOPLASTICS B N CARAC B P EFUDEX G N fluorouracil cream 5% G P fluorouracil soln 2% G P fluorouracil soln 5% G N diclofenac sodium (actinic keratoses) B N SOLARAZE B N PICATO TOPICAL - ANTIPRURITICS B N PRUDOXIN B P ZONALON TOPICAL - ANTISEBORRHEICS G P selenium sulfide B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories TOPICAL - ANTISEBORRHEICS G P sulfacetamide sodium liquid 10% G P selenium sulfide-pyrithione zinc in urea vehicle TOPICAL - ANTIVIRALS G N acyclovir topical B N ZOVIRAX CRE 5% B P ZOVIRAX OIN 5% B N DENAVIR B N XERESE TOPICAL - ASTRINGENTS / PROTECTANTS G P hypercare sol 20% O P XERAC AC TOPICAL - BURN PRODUCTS B N SULFAMYLON B N SILVADENE G P silver sulfadiazine TOPICAL - CAUTERIZING AGENTS G P silver nitrate TOPICAL - CORTICOSTEROIDS G N alclometasone dipropionate G N amcinonide cream 0.1% G N amcinonide lotn G N amcinonide oint G P betamethasone dipropionate (topical) lotn G P betamethasone dipropionate (topical) oint G P betamethasone dipropionate cream 0.05% G P betamethasone dipropionate augmented cream 0.05% G N betamethasone dipropionate augmented gel 0.05% G N betamethasone dipropionate augmented lotion 0.05% G N betamethasone dipropionate augmented oint 0.05% B P DIPROLENE B N DIPROLENE AF CRE 0.05% B N DIPROLENE OINT G P betamethasone valerate G N betamethasone valerate foam B N LUXIQ G N clobetasol propionate G P clobetasol propionate soln B P CLOBEX B N CLOBEX LIQD B P OLUX B P TEMOVATE G P clobetasol propionate emollient base G N clobetasol propionate emulsion foam B P OLUX-E B N CLODERM B N DESONATE G N desonide B N DESOWEN G N desoximetasone RT45620 LOT 0.05% B, G, or O COM P , N, R, or NR Therapeutic Category B N TOPICORT G N diflorasone diacetate cream 0.05% N diflorasone diacetate oint 0.05% B P CAPEX B N DERMA-SMOOTHE/FS BODY B N DERMA-SMOOTHE/FS SCALP G P fluocinolone acetonide G N fluocinolone acetonide oil 0.01% (body oil) G N fluocinolone acetonide oil 0.01% (scalp oil) G P fluocinonide cream 0.05% G N fluocinonide cream 0.1% G P fluocinonide gel 0.05% G P fluocinonide oint 0.05% G P fluocinonide soln 0.05% B N VANOS G P fluocinonide emulsified base B N CORDRAN B N CUTIVATE G N fluticasone propionate G P fluticasone propionate lotn B N HALOG G N halobetasol propionate B P ULTRAVATE G P hydrocortisone cream 1% G P hydrocortisone cream 2.5% G P hydrocortisone lotion 2.5% G P hydrocortisone oint 1% G P hydrocortisone oint 2.5% B N TEXACORT G N hydrocortisone valerate B N PANDEL G N hydrocortisone butyrate B N ELOCON CRE 0.1% B N ELOCON LOT 0.1% B N ELOCON OIN 0.1% G P mometasone furoate B N DERMATOP G N prednicarbate B N KENALOG G P triamcinolone acetonide (topical) G N triamcinolone acetonide (topical) lotn - Contd - G TOPICAL - EMOLLIENTS G N lactic acid (ammonium lactate) cream 12% ND P lactic acid (ammonium lactate) lotion 12% B N UMECTA B N UMECTA NAIL FILM B N URAMAXIN G N urea cream 50% G N urea foam 40% G N urea gel 40% G N urea gel 45% G P urea lotion 40% G N urea lotion 45% G P x-viate cre 40% TOPICAL - ENZYMES / KERATOLYTICS / UREA B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories TOPICAL - ENZYMES / KERATOLYTICS / UREA B P SANTYL B N PODOCON 25 B N SALEX G P salicylic acid cream 6% G P salicylic acid lotion 6% G P salicylic acid shampoo 6% G P salicylic acid soln 26% TOPICAL - GENITAL WARTS B N CONDYLOX G N podofilox B 69 P VEREGEN B 36 N ALDARA G 36 P imiquimod B N ZYCLARA B N ZYCLARA PUMP TOPICAL - IMMUNOMODULATORS B 11 N ELIDEL B 11 N PROTOPIC TOPICAL - LOCAL ANESTHETICS B P MARCAINE B P MARCAINE W/O EPI G N bupivacaine in dextrose G P lidocaine hcl local inj 1% G P lidocaine hcl local inj 1.5% G P lidocaine hcl local inj 2% G P lidocaine hcl local inj 4% G P lidocaine hcl local preservative free (pf) inj 0.5% G P lidocaine hcl local preservative free (pf) inj 1% G P lidocaine hcl local preservative free (pf) inj 2% B N XYLOCAINE-MPF B N CARBOCAINE G N mepivacaine hcl G P lidocaine w/ epinephrine B P XYLOCAINE/EPINEPHRINE G P lidocaine oint 5% N LIDODERM G P lidocaine hcl cream 3% G P lidocaine hcl gel 2% G P lidocaine hcl lotion 3% G P lidocaine hcl soln 4% B N SYNERA G P lidocaine-prilocaine B 11 TOPICAL - NASAL ANTIBIOTICS B P BACTROBAN NASAL TOPICAL - SCABICIDES AND PEDICULICIDES B 73 P ULESFIA B P EURAX B N SKLICE G N lindane RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G N malathion B N OVIDE N ELIMITE G N permethrin cream 5% O P Permethrin Lotion 1% P NATROBA G N spinosad O P Pyrethrins-Piperonyl Butoxide - Contd - B B 73 TOPICAL - STEROID COMBINATIONS G N calcipotriene-betamethasone dipropionate B N TACLONEX B N U-CORT TOPICAL - STEROID LOCAL ANESTHETICS G P lidocaine-hydrocortisone acetate (rectal) B N EPIFOAM TOPICAL - TRETINOIDS B 11 N FABIOR B 11 P ATRALIN B 11 P RETIN-A G 11 P tretinoin B 11 N RETIN-A MICRO B 11 N RETIN-A MICRO PUMP G 11 N tretinoin microsphere TOPICAL - WOUND / DECUBITUS CARE B 11 N REGRANEX UREA CYCLE DISORDER - AGENTS B N RAVICTI B N AMMONUL B N BUPHENYL UROLOGICAL - MISC. B P MONUROL G P methenamine mandelate B N HIPREX G N methenamine hippurate B N FURADANTIN G P nitrofurantoin suspension B N MACRODANTIN G P nitrofurantoin macrocrystal B N MACROBID G N nitrofurantoin monohyd macro G N methenamine-hyosc-methylene blue-sod phos-phenyl sal B P K-PHOS G P potassium citrate (alkalinizer) B P UROCIT B P ORACIT G P sodium citrate & citric acid G N potassium citrate & citric acid powder pack 3300-1002 mg G P pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml G P phenazopyridine hcl B N CYSTAGON B N PROCYSBI TAB NO 2 B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories B N ELMIRON B N LITHOSTAT B N THIOLA B P RENACIDIN G P acetic acid G P sodium chloride (gu irrigant) G P neomycin/polymyxin b gu B P NEOSPORIN GU IRRIGANT P ZOSTAVAX INJ VAGINAL - ANTI FUNGALS B N CLINDESSE O P Miconazole Nitrate Vaginal Cream 2% O P Miconazole Nitrate Vaginal Suppos 100 MG B N TERAZOL G P terconazole vaginal cream 0.4% G P terconazole vaginal cream 0.8% G N terconazole vaginal suppos 80 mg VAGINAL - ANTIBACTERIALS Therapeutic Category 11 N niacin tab 500 mg ND 11 N ergocalciferol soln 8000 unit/ml P MEPHYTON G P phytonadione G P cyanocobalamin inj 1000 mcg/ml ND 11 N cyanocobalamin tab 1000 mcg ND 11 N cyanocobalamin tab cr 1000 mcg P folic acid tab 1 mg G VACCINES 70 COM P , N, R, or NR ND - Contd - B UROLOGICAL - MISC. B B, G, or O VITAMINS - MISC. ND 11 P *B-Complex w/ C & Folic Acid Tab 1 MG*** ND 11 P B-Complex w/ C & Folic Acid B 11 P DIALYVITE/ TAB ZINC B 11 P NEPHPLEX RX ND 11 P AQUADEKS ND 11 P Pediatric Multiple Vitamin w/ Minerals & C B P PNV FOLIC AC TAB + IRON B P PRENATAL VIT TAB PLUS B P TRINATAL RX 1 B P VOL-NATE B P VOL-PLUS B P TRINATAL GT B P PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID B P SE-NATAL 19 CHEW TABLET P ferrous fumarate w/ b12-vit c-fa-ifc G 11 TAB RDL Categories B N CLEOCIN CRE 2% VAG B P CLEOCIN SUP 100MG G P clindamycin phosphate vaginal B P METROGEL-VAGINAL B R HEMOFIL M G N metronidazole vaginal B R KOATE-DVI B R MONOCLATE-P B R HELIXATE FS VAGINAL - ESTROGENS ANTIHEMOPHILIC AGENTS B N ESTRACE B NR KOGENATE FS B N ESTRING B NR KOGENATE FS BIO-SET B N VAGIFEM B R RECOMBINATE B N FEMRING B R ADVATE B P PREMARIN B NR ELOCTATE B R ALPHANATE B R HUMATE-P B R WILATE VASOPRESSINS B 11 N DDAVP INJ 4MCG/ML B 11 N DDAVP TABS B NR FEIBA G 11 P desmopressin acetate B R NOVOSEVEN B 11 P STIMATE B R ALPHANINE SD B 11 N DDAVP B R MONONINE G 11 P desmopressin acetate refrigerated B R BENEFIX G 11 P desmopressin acetate spray refrigerated B NR RIXUBIS B 11 N DDAVP B NR ALPROLIX G 11 P desmopressin acetate spray B R BEBULIN B N PITRESSIN SYNTHETIC B R PROFILNINE SD G N vasopressin inj 20 unit/ml ANTINEOPLASTICS - ALKYLATING AGENTS B N SAMSCA SOL 0.01% SPR 0.01% VITAMINS G B R BUSULFEX B R MYLERAN R cisplatin P Thiamine Injection G ND 11 N niacin tab 100 mg ND 11 N niacin tab 250 mg ANTINEOPLASTICS - ANDROGEN BIOSYNTHESIS INHIBITOR. ND 11 N niacin tab 50 mg B RT45620 80 NR ZYTIGA B, G, or O COM P, N, Therapeutic Category R, or NR RDL Categories ANTINEOPLASTICS - ANTIADRENALS B R LYSODREN ANTINEOPLASTICS - ANTIANDROGENS G R bicalutamide B 50 NR CASODEX B 63 NR XTANDI G NR flutamide B R NILANDRON ANTINEOPLASTICS - ANTIBIOTICS G R bleomycin sulfate G R doxorubicin hcl B R DOXIL ANTINEOPLASTICS - ANTIESTROGENS B NR SOLTAMOX G R tamoxifen citrate B R FARESTON ANTINEOPLASTICS - ANTIMETABOLITES B R VIDAZA G NR capecitabine B R XELODA G NR cytarabine B NR DEPOCYT G R fluorouracil G NR gemcitabine hcl B R GEMZAR G R mercaptopurine B NR PURINETHOL G R methotrexate sodium B R TREXALL B R ARRANON B R ALIMTA B R FOLOTYN B R TABLOID B R AVASTIN B R ERBITUX B R HERCEPTIN NR ERIVEDGE B 80 ANTINEOPLASTICS - AROMATASE INHIBITORS G R anastrozole B NR ARIMIDEX B R AROMASIN G NR exemestane B 70 NR FEMARA G 70 R letrozole ANTINEOPLASTICS - CARDIAC PROTECTIVE AGENTS G R dexrazoxane B R ZINECARD ANTINEOPLASTICS - COMBINATIONS RT45620 B, G, or O COM P , N, R, or NR G R Therapeutic Category ifosfamide & mesna ANTINEOPLASTICS - ESTROGEN RECEPTOR ANTAGONIST B R FASLODEX ANTINEOPLASTICS - ESTROGENS B R EMCYT ANTINEOPLASTICS - FOLIC ACID ANTAGONISTS RESCUE AGENTS G R leucovorin calcium ANTINEOPLASTICS - IMIDAZOTETRAZINES B R TEMODAR G NR temozolomide ANTINEOPLASTICS - INTERLEUKINS B R PROLEUKIN ANTINEOPLASTICS - LHRH ANALOGS B R ZOLADEX R ELIGARD G NR leuprolide acetate B R LUPRON DEPOT B R TRELSTAR B 80 ANTINEOPLASTICS - MISC. B NR POMALYST B NR ICLUSIG B NR HYDREA G R hydroxyurea B R MATULANE B NR INTRON-A B NR ACTIMMUNE B NR SYLATRON B NR DROXIA NR REVLIMID B 80 ANTINEOPLASTICS - MITOTIC INHIBITORS B R TAXOTERE G NR etoposide G NR paclitaxel B R ABRAXANE G R vincristine sulfate G R vinblastine sulfate B R NAVELBINE G R vinorelbine tartrate ANTINEOPLASTICS - NITROGEN MUSTARDS B R LEUKERAN G NR cyclophosphamide B R ALKERAN G NR melphalan hcl ANTINEOPLASTICS - NITROSOUREAS B R GLIADEL WAFER G NR lomustine B, G, or O COM P, N, Therapeutic Category R, or NR ANTINEOPLASTICS - PROGESTINS B 50 G R DEPO-PROVERA NR MEGACE ORAL R megestrol acetate ANTINEOPLASTICS - PROTEIN-TYROSINE KINASE INHIBITORS B 63 NR ZOLINZA B 11 NR TAFINLAR B 11 NR ZELBORAF B 63 R AFINITOR NR STIVARGA B B 63 NR NEXAVAR B 63 R SUTENT B 11 NR MEKINIST NR GILOTRIF B B 80 NR INLYTA B 63 NR BOSULIF NR COMETRIQ NR ZYKADIA B B 63 B 11 NR XALKORI B 63 NR SPRYCEL B 63 R TARCEVA NR IMBRUVICA R GLEEVEC NR TYKERB B B 63 B B 63 R VOTRIENT B 63 R CAPRELSA R VELCADE R JAKAFI NR ZYDELIG B B 80 B 63 R CAMPTOSAR G R irinotecan hcl B R HYCAMTIN NR amifostine crystalline NR mesna B R MESNEX ANTIRETROVIRALS SELZENTRY NR TIVICAY KALETRA B NR TRIUMEQ G NR abacavir sulfate-lamivudine-zidovudine B R TRIZIVIR B 80 NR COMPLERA B 80 NR STRIBILD R FUZEON B R REYATAZ B R LEXIVA B R CRIXIVAN B R VIRACEPT B R NORVIR CAP 100MG B R NORVIR SOL 80MG/ML NR NORVIR TABS B R INVIRASE B R APTIVUS 81 B R RESCRIPTOR B R SUSTIVA B NR INTELENCE G R nevirapine G NR nevirapine susp NR VIRAMUNE B R VIRAMUNE SUSP B R VIRAMUNE XR NR EDURANT B 50 80 ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES G NR abacavir sulfate B R ZIAGEN G R didanosine B R VIDEX ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINES B R EMTRIVA B R EPIVIR G NR lamivudine ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINES G B 83 R ISENTRESS CHW 100MG B 83 R ISENTRESS CHW 25MG B R ISENTRESS TABS B R PREZISTA B R EPZICOM B R TRUVADA B R ATRIPLA RT45620 R B G NR lamivudine-zidovudine B ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES G B COMBIVIR NR B ANTINEOPLASTICS - URINARY TRACT PROTECTIVE AGENTS B R G ANTIRETROVIRALS - PROTEASE INHIBITORS ANTINEOPLASTICS - TOPOISOMERASE I INHIBITORS R B B TARGRETIN B Therapeutic Category ANTIRETROVIRALS - FUSION INHIBITORS ANTINEOPLASTICS - SELECTIVE RETINOID X RECEPTOR AGONISTS B COM P , N, R, or NR ANTIRETROVIRALS - COMBINATIONS RDL Categories B B, G, or O R stavudine B 50 NR ZERIT B 50 NR RETROVIR R zidovudine G ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES B R VIREAD
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