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MEDICAID DRUG FORMULARY
EFFECTIVE JANUARY 1, 2015
LAST UPDATED May 20, 2015
INTRODUCTION
The Health Alliance Medicaid Drug Formulary is the list of drugs we cover at retail pharmacies. Members
should show this list to their doctors and pharmacists. We encourage doctors to use this list when considering
treatment options, but final treatment decisions are between the doctor and patient.
The formulary could change at any time. Members can see the most up-to-date list on the “For Members”
section of HealthAllianceConnect.org. Also, log in to CatamaranRx.com to learn more about drug coverage and
prices.
This formulary is not for members who have both Medicare and Medicaid.
HOW TO USE THIS LIST
This drug list is broken into groups of similar drugs used to treat the same condition or sickness. Each group
has subsections in it to help locate drugs. All the drugs listed, whether generic or brand-name, are covered.
To find a drug in this PDF, choose the search function, type in a drug name and click “Search” or “Find.” You
can also use the index, which lists drugs in alphabetical order.
Generics
Like brand-name drugs, generic drugs go through an approval process by the Food and Drug Administration
(FDA). Generics are safe and have about the same results as brand-name drugs. They also cost a lot less.
As a patient, you can tell your pharmacist you want a generic. In most cases, your pharmacist can give you a
generic without a new prescription from your doctor.
To learn more about generics, go to AskForGenerics.org.
Drugs to Treat Multiple Conditions
Some drugs can treat more than one medical condition. In this document, each drug is listed by its first FDAapproved use. Check the index if you do not find your drug listed under your condition.
COVERAGE AND LIMITATIONS
Drug Costs
Drugs on this formulary do not cost you anything. A generic must be used when available.
Utilization Management
Some drugs on this list require utilization management (UM), like preauthorization, quantity limits and/or steptherapy. If a drug needs UM, it has one of these symbols after its name:
•
•
QL–Quantity Limits
PA–Preauthorization
•
ST–Step-Therapy
Preauthorization request forms are on the “For Providers” section of HealthAllianceConnect.org.
Quantity Limits (QL)
For safety reasons, some drugs have a limit on the amount we will cover. For example, we cover 60 pills in 30
days for some drugs.
Preauthorization (PA)
Some drugs need preauthorization (approval) from Health Alliance, which means certain criteria have to be met
before a member can get the drug. If it is not approved, we will not cover the drug.
Step-Therapy (ST)
Sometimes, one or more (pre-requisite) drugs have to be tried before others (called step-therapy drugs) will be
covered. These first drugs and their step-therapy counterparts treat the same conditions.
Specialty Drugs
Specialty drugs need special handling and/or administration (how it is given). These drugs are available from
Health Alliance’s preferred specialty pharmacy vendor, CVS Caremark. Preauthorization might be needed
before getting these drugs.
Sign-up forms for CVS Caremark and a list of covered specialty drugs are on the “For Members” section of
HealthAllianceConnect.org.
Dispensing Limits
Up to a 30-day supply for each new prescription or refill can be given at once. Members can’t get refills before
75 percent of the last amount has been taken as directed.
Some drugs have limits set by the FDA. These limits are to make sure drugs are taken safely.
Dosage Forms
Some medications come in more than one dosage form, such as tablets, liquid, or patches. Health Alliance may
not cover every dosage form that is available.
Medical Exception
A Medical Exception is a process for reviewing coverage for drugs not on our formulary. Members may get a
Medical Exception if they meet one of these requirements.
A. Documented failure of all formulary drugs in the same group/class.
B. Documented allergy to a formulary drug, with no other formulary choices.
C. A certain drug is working for his or her condition, and switching may cause a health risk.
o Immunosuppressants
o HIV/AIDS medications
o Oncology medications
o Antiarrhythmics
o Seizure medications
o Antipsychotics
o Antidepressants
Physicians—Requesting a Medical Exception
For more information or to request a Medical Exception for a member, call the Health Alliance Pharmacy
Department at 1-800-851-3379, option 4, or fax the Preauthorization/Medical Exception form to 217-255-4598.
Please give the following information when requesting a Medical Exception:
•
•
•
•
•
Patient name and Health Alliance ID number
Doctor name, address and phone number
Drug name and strength
Patient diagnosis
Chart documentation/documentation of previous medical history related to the requested drug
General Exclusions
A.
B.
C.
D.
E.
F.
G.
H.
I.
Over-the-counter (OTC) drugs and their equivalents (unless they are on the Covered OTC Drug List).
Drugs for erectile dysfunction.
Drugs for anorexia, weight loss or weight gain.
Drugs for cosmetic (not medical) purposes.
Fertility-enhancing drugs.
Immunizations and vaccines (except flu vaccine).
Experimental drugs, or any drug used in an experimental way.
Replacement of lost or stolen drugs.
Non-self-administered injectable drugs, unless otherwise noted, are not covered through the pharmacy
benefit. Review your description of coverage materials to learn more.
J. Foreign drugs and drugs not approved by the FDA.
Over-the-Counter Drugs
Health Alliance covers some over-the-counter (OTC) drugs at no cost to you with a prescription from your
doctor. A list of covered OTC drugs is on the “For Members” section of HealthAllianceConnect.org.
Mail-Order Program
Health Alliance offers a 90-day supply of some maintenance drugs through our mail-order pharmacy program.
These drugs are for long-term conditions or sicknesses. A list of covered maintenance drugs are on the “For
Members” section of HealthAllianceConnect.org.
To sign up for our mail order program, please call Catamaran, our pharmacy benefits manager, at 1-866-8147105. Or sign up at YourHealthAlliance.org.
CONTACT US
Health Alliance Pharmacy Department
301 S. Vine St.
Urbana, IL 61801-3347
1-800-851-3379, option 4
HealthAllianceConnect.org
Table of Contents
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
CEPHALOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
FIRST GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
SECOND GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
THIRD GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
MACROLIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
QUINOLONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
SULFONAMIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
AMEBICIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
MISC. ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ANTINEOPLASTICS, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ALKYLATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ANTIMETABOLITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ENZYME INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ANTINEOPLASTICS MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
CHEMOTHERAPY RESCUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
CHEMOTHERAPY ADJUNCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
CARDIOVASCULAR DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
CARDIAC GLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ANTIANGINAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
CALCIUM CHANNEL BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ANTIARRHYTHMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ACE INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ANGIOTENSIN RCPTR BLOCKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ANTIHYPERTENSIVES MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ANTIHYPERTENSIVE COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
DIURETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
CARDIOVASCULAR - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
DERMATOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ACNE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ROSACEA AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANTIBIOTICS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANTIFUNGALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANTIVIRALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANTI-INFLAMMATORY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANTIPRURITICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANTIPSORIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANTISEBORRHEIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
CORTICOSTEROIDS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
IMMUNOMODULATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
DERMATOLOGICALS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ENDOCRINE AND METABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
CORTICOSTEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ESTROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
PROGESTINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
ANTIDIABETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
AMYLIN ANALOGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
INCRETIN MIMETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
SULFONYLUREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
BIGUANIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
MEGLITINIDE ANALOGUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
DIABETIC OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
ALPHA-GLUCOSIDASE INHIBIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
DPP-4 INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
INSULIN SENSITIZING AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
ANTIDIABETIC COMBINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
BISPHOSPHONATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
CALCITONINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
PARATHYROID HORMONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
HORMONE RECEPTOR MDLTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
FERTILITY REGULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
LHRH/GNRH AGONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
GROWTH HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
SOMATOMEDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
SOMATOSTATIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
GH RECEPTOR ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
POSTERIOR PITUITARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
PROLACTIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
VASOPRESSIN ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
PROGESTERONE ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
METABOLIC MODIFIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
THYROID AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
GASTROINTESTINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
GASTROINTESTINAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
GENITOURINARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
URINARY ANTISPASMODICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
VAGINAL PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
GENITOURINARY - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
HEMATOLOGICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
HEMATOLOGICAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
MOUTH/THROAT/DENTAL AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
NEUROLOGY, CNS, PSYCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTIANXIETY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ADHD, NARCOLEPSY, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTICONVULSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTIPARKINSON AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
NEUROLOGY, PSYCH - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
MUSCULOSKELETAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
OPHTHALMOLOGY AND OTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
BETA-BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
OPHTHALMIC STEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
PROSTAGLANDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
CYCLOPLEGIC MYDRIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
DECONGESTANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
MIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
ADRENERGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
LOCAL ANESTHETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
OPHTHALMICS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
ANALGESICS - NONNARCOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
ANALGESICS - OPIOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
ANTI-INFLAMMATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
RESPIRATORY, ALLERGY, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
NASAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
COUGH/COLD/ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
ANTIASTHMATIC/COPD AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
RESPIRATORY AGENTS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
TOXOIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
MULTIVITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
MEDICAL DEVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
DIABETIC SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
MEDICAL DEVICES - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
MISCELLANEOUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
May 2015
HEALTH ALLIANCE CONNECT MEDICAID
PREFERRED DRUG LIST
ANTI-INFECTIVES
doxycycline hyclate DR
doxycycline monohydrate
minocycline HCL
minocycline HCL ER
morgidox 1X100MG
morgidox 2X100MG
Tetracycline HCL
Vibramycin
PENICILLINS
QUINOLONES
COVERED
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium ER
ampicillin
dicloxacillin sodium
penicillin v potassium
Amoxicillin ER
Augmentin
Moxatag
AMINOGLYCOSIDES
CEPHALOSPORIN
FIRST GENERATION
COVERED
cefadroxil
cephalexin
SECOND GENERATION
COVERED
cefaclor
cefprozil
cefuroxime axetil
Cefaclor ER
Ceftin
THIRD GENERATION
COVERED
cefdinir
cefixime
cefpodoxime proxetil
Cedax
Cefditoren Pivoxil
Ceftibuten
Spectracef
Suprax
MACROLIDES
COVERED
azithromycin
clarithromycin
clarithromycin ER
erythromycin
DificidST
E.e.s. Granules
E.e.s. 400
Ery-TAB
Eryped 200
Eryped 400
Erythrocin Stearate
Erythromycin Base
Erythromycin Ethylsuccinate
PCE
Zmax
COVERED
ciprofloxacin
ciprofloxacin ER
ciprofloxacin HCL
levofloxacin
ofloxacin
Factive
Noroxin
COVERED
neomycin sulfate
paromomycin sulfate
tobramycinPA
Kitabis PAKPA
Tobi PodhalerPA
SULFONAMIDES
COVERED
Sulfadiazine
ANTIMYCOBACTERIAL AGENTS
COVERED
ethambutol HCL
isoniazid
pyrazinamide
rifabutin
rifampin
Cycloserine
Isoniazid
Paser
Priftin
Rifamate
Rifater
Trecator
ANTIFUNGALS
COVERED
fluconazole
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
ketoconazole
nystatin
terbinafine HCL
voriconazolePA
Lamisil
NoxafilPA
OnmelPA
Sporanox
TETRACYCLINES
ANTIVIRALS
COVERED
avidoxy
demeclocycline HCL
doxycycline
doxycycline hyclate
COVERED
abacavir
abacavir sulfate/lamivudine/zidovudine
acyclovir
adefovir dipivoxilPA
didanosine
entecavirPA
famciclovir
lamivudine
lamivudine/zidovudine
moderiba
nevirapine
nevirapine ER
ribasphere
ribavirin
rimantadine HCL
stavudine
valacyclovir HCL
valganciclovir
zidovudine
Aptivus
Atripla
BaracludePA
Complera
Crixivan
Edurant
Emtriva
Epivir HBV
Epzicom
Evotaz
HarvoniPA
IncivekPA,QL
InfergenPA
Intelence
Invirase
Isentress
Kaletra
Lexiva
Moderiba
Moderiba 1200 Dose Pack
Moderiba 800 Dose Pack
Nevirapine
Norvir
OlysioPA
Peg-intronPA
Peg-intron RedipenPA
Peg-intron Redipen PAK 4PA
PegasysPA
Pegasys ProclickPA
PegintronPA
Prezcobix
Prezista
Rebetol
Relenza DiskhalerQL
Rescriptor
Reyataz
Ribasphere
Ribasphere Ribapak
Ribatab
Selzentry
SovaldiPA
Stribild
Sustiva
TamifluQL
Tivicay
Triumeq
Truvada
TybostST
TyzekaPA
Valcyte
VictrelisPA,QL
Videx Pediatric
Viekira PAKPA,QL
Viracept
Viramune
Viramune XR
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
1
Virazole
Viread
Vitekta
Ziagen
HORMONAL AGENTS
AMEBICIDES
COVERED
anastrozole
bicalutamide
exemestane
flutamide
letrozole
leuprolide acetatePA
megestrol acetate
tamoxifen citrate
Emcyt
Fareston
Lysodren
Nilandron
XtandiPA
Zoladex
ZytigaPA
COVERED
Yodoxin
IMMUNOMODULATORS
ANTIMALARIALS
COVERED
atovaquone/proguanil HCL
chloroquine phosphate
hydroxychloroquine sulfate
mefloquine HCL
quinine sulfatePA
Coartem
Daraprim
Primaquine Phosphate
ANTHELMINTICS
COVERED
ivermectin
Albenza
Biltricide
MISC. ANTI-INFECTIVES
COVERED
atovaquone
clindamycin palmitate HCL
clindamycin HCL
e.s.p.
metronidazole
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim DS
sulfatrim pediatric
tinidazole
trimethoprim
vancomycin HCL
Alinia
CaystonPA
Dapsone
First-vancomycin 25
First-vancomycin 50
Flagyl ER
Ketek
Nebupent
Primsol
SivextroPA,QL
XifaxanPA
ZyvoxPA,QL
ANTINEOPLASTICS, ETC
ALKYLATING AGENTS
COVERED
Cyclophosphamide
Hexalen
Leukeran
ANTIMETABOLITES
COVERED
capecitabinePA
mercaptopurine
methotrexate
methotrexate sodium
Tabloid
Trexall
COVERED
azathioprine
cyclosporine
cyclosporine modified
gengraf
hecoria
mycophenolate mofetil
mycophenolic acid DR
sirolimus
tacrolimus
Astagraf XL
Azasan
Cellcept
Cyclosporine Modified
Neoral
PomalystPA
Rapamune
RevlimidPA
Sandimmune
ThalomidPA
Zortress
ENZYME INHIBITORS
COVERED
AfinitorPA
Afinitor DisperzPA
BosulifPA,QL
Caprelsa
CometriqPA
FarydakPA
GilotrifPA
GleevecPA,QL
IbrancePA
IclusigPA,QL
ImbruvicaPA
InlytaPA
JakafiPA
Lenvima 10MG Daily DosePA
Lenvima 14MG Daily DosePA
Lenvima 20MG Daily DosePA
Lenvima 24MG Daily DosePA
LynparzaPA
MekinistPA
NexavarPA
SprycelPA
StivargaPA
SutentPA
TafinlarPA
TarcevaPA
TasignaPA
TykerbPA
VotrientPA
XalkoriPA
ZelborafPA
ZolinzaPA
ZydeligPA
ZykadiaPA
ANTINEOPLASTICS MISC.
COVERED
hydroxyurea
tretinoin
ActimmunePA
Intron A
Intron-a W/Diluent
Matulane
SylatronPA
Synribo
Targretin
CHEMOTHERAPY RESCUE
COVERED
leucovorin calcium
Mesnex
CHEMOTHERAPY ADJUNCTS
COVERED
Kepivance
CARDIOVASCULAR DRUGS
CARDIAC GLYCOSIDES
COVERED
digitek
digox
digoxin
LanoxinPA
ANTIANGINAL AGENTS
COVERED
isoditrate ER
isosorbide dinitrate
isosorbide dinitrate ER
isosorbide mononitrate
isosorbide mononitrate ER
minitran
nitroglycerin
nitroglycerin lingual
nitroglycerin transdermal
Dilatrate SR
Isordil Titradose
Isosorbide Dinitrate
Nitro-bid
Nitro-dur
Nitrostat
Ranexa
BETA BLOCKERS
COVERED
acebutolol HCL
atenolol
betaxolol HCL
bisoprolol fumarate
carvedilol
labetalol HCL
metoprolol succinate ER
metoprolol tartrate
nadolol
pindolol
propranolol HCL
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
2
propranolol HCL ER
sorine
sotalol HCL
Bystolic
Hemangeol
Inderal XL
Innopran XL
Levatol
Sotylize
Timolol Maleate
CALCIUM CHANNEL BLOCKERS
COVERED
afeditab CR
amlodipine besylate
cartia XT
dilt-CD
dilt-XR
diltiazem CD
diltiazem HCL
diltiazem HCL ER
diltzac
isradipine
matzim LA
nicardipine HCL
nifediac CC
nifedical XL
nifedipinePA
nifedipine ER
nimodipine
taztia XT
verapamil HCL
verapamil HCL ER
verapamil HCL SR
Cardene SR
Nymalize
ANTIARRHYTHMICS
COVERED
amiodarone HCL
disopyramide phosphatePA
flecainide acetate
mexiletine HCL
pacerone
propafenone HCL
propafenone HCL ER
quinidine gluconate CR
quinidine gluconate ER
quinidine sulfate
Multaq
Nexterone
Quinidine Sulfate ER
Tikosyn
ACE INHIBITORS
COVERED
benazepril HCL
captopril
enalapril maleate
fosinopril sodium
lisinopril
moexipril HCL
perindopril erbumine
quinapril HCL
ramipril
trandolapril
Epaned
ANGIOTENSIN RCPTR BLOCKER
COVERED
candesartan cilexetil
eprosartan mesylate
irbesartan
losartan potassium
valsartan
Edarbi
ANTIHYPERTENSIVES MISC.
COVERED
clonidine HCL
doxazosin
doxazosin mesylate
eplerenone
guanfacine HCLPA
hydralazine HCL
methyldopaPA
minoxidil
prazosin HCL
terazosin HCL
Demser
Dibenzyline
ANTIHYPERTENSIVE COMBO
COVERED
amlodipine besylate/benazepril hydrochloride
amlodipine besylate/benazepril HCL
atenolol/chlorthalidone
benazepril HCL/hydrochlorothiazide
bisoprolol fumarate/hydrochlorothiazide
candesartan cilexetil/hydrochlorothiazide
enalapril maleate/hydrochlorothiazide
fosinopril sodium/hydrochlorothiazide
irbesartan/hydrochlorothiazide
lisinopril/hydrochlorothiazide
losartan potassium/hydrochlorothiazide
metoprolol/hydrochlorothiazide
moexipril/hydrochlorothiazide
nadolol/bendroflumethiazide
quinapril/hydrochlorothiazide
trandolapril/verapamil HCL
trandolapril/verapamil HCL ER
valsartan/hydrochlorothiazide
Azor
Captopril/Hydrochlorothiazide
Clorpres
Dutoprol
Edarbyclor
Propranolol/Hydrochlorothiazide
Teveten HCT
Acetazolamide
Chlorthalidone
Diuril
Dyrenium
Edecrin
Methyclothiazide
VASOPRESSORS
COVERED
midodrine HCL
Adrenaclick
Auvi-q
Epinephrine
Epipen 2-PAK
Epipen-JR 2-PAK
ANTIHYPERLIPIDEMICS
COVERED
atorvastatin calcium
cholestyramine
cholestyramine light
colestipol HCL
colestipol HCL for oral suspension
fenofibrate
fenofibrate micronized
fluvastatin
gemfibrozil
lovastatin
micronized colestipol HCL
pravastatin sodium
prevalite
simvastatin
Fenofibrate
Lipofen
Niacor
Triglide
ZetiaST
CARDIOVASCULAR - MISC.
COVERED
amlodipine besylate/atorvastatin calcium
sildenafilPA
sildenafil citratePA
AdcircaPA
Adempas
Bidil
LetairisPA
Opsumit
RevatioPA
TracleerPA
Veletri
VentavisPA
DIURETICS
COVERED
acetazolamide
acetazolamide ER
amiloride HCL
amiloride/hydrochlorothiazide
bumetanide
chlorothiazide
furosemide
hydrochlorothiazide
indapamide
methazolamide
metolazone
spironolactone
spironolactone/hydrochlorothiazide
torsemide
triamterene/hydrochlorothiazide
DERMATOLOGICALS
ACNE PRODUCTS
COVERED
adapalene
avita
clindacin etz pledgets
clindacin-p
clindamax
clindamycin phosphate
erythromycin
sodium sulfacetamide
sulfacetamide sodium
tretinoin
Azelex
Clindagel
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
3
COVERED
ciclodan
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine
clotrimazole
clotrimazole/betamethasone dipropionate
econazole nitrate
ketoconazole
ketodan
nyamyc
nystatin
nystatin/triamcinolone
nystop
pedi-dri
MentaxST
NaftinST
OxistatST
Vusion
Xolegel
COVERED
ala cort
alclometasone dipropionate
alphatrex
augmented betamethasone dipropionate
betamethasone dipropionate
betamethasone valerate
clobetasol propionate
clobetasol propionate e
clobetasol propionate emollient
cormax scalp application
desonide
desoximetasone
fluocinolone acetonide
fluocinolone acetonide body
fluocinolone acetonide scalp
fluocinonide
fluticasone propionate
halobetasol propionate
hydrocortisone
hydrocortisone acetate/aloe
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone IN absorbase
lokara
mometasone furoate
prednicarbate
triamcinolone acetonide
triderm
Amcinonide
Cordran Tape
Texacort
Triamcinolone Acetonide
ANTIVIRALS - TOPICAL
IMMUNOMODULATING AGENTS
ROSACEA AGENTS
COVERED
metronidazole
rosadan
FinaceaPA
ANTIBIOTICS - TOPICAL
COVERED
mupirocin
mupirocin calcium
Gentamicin Sulfate
ANTIFUNGALS - TOPICAL
Veregen
ENDOCRINE AND METABOLIC
CORTICOSTEROIDS
COVERED
baycadron
budesonide
dexamethasone
fludrocortisone acetate
hydrocortisone
methylprednisolone
methylprednisolone dose pack
prednisolone
prednisolone sodium phosphate
prednisolone sodium phosphate odt
prednisone
Celestone
Cortisone Acetate
Dexamethasone
Dexamethasone Intensol
Dexpak 10 Day
Dexpak 13 Day
Dexpak 6 Day
FLO-pred
Medrol
Millipred
Millipred DP
Orapred Odt
Rayos
UcerisPA
Veripred 20
ANDROGENS-ANABOLIC
COVERED
acyclovir
DenavirST
Zovirax
COVERED
imiquimod
tacrolimus
Elidel
COVERED
danazolQL
oxandroloneQL
testosterone cypionateQL
testosterone enanthate
AndroxyPA,QL
ANTI-INFLAMMATORY AGENTS
DERMATOLOGICALS - MISC.
ESTROGENS
COVERED
Voltaren
ANTIPRURITICS
COVERED
Prudoxin
Zonalon
ANTIPSORIATICS
COVERED
acitretin
calcipotriene
calcitrene
methoxsalen
CalcitriolST
Cosentyx Sensoready PenPA
Dritho-creme HP
TazoracPA
VecticalST
8-mop
ANTISEBORRHEIC AGENTS
COVERED
selenium sulfide
Tersi Foam
CORTICOSTEROIDS - TOPICAL
COVERED
acticin
ammonium lactate
glydo
hypercare
laclotion
lidocaine
lidocaine HCL
lidocaine HCL jelly
lidocaine/prilocaine
lindane
malathion
permethrin
podofilox
Anacaine
Cocaine HCL
Eurax
Hylira
Lidocaine And Tetracaine Cream
Natroba
Oxsoralen
Pliaglis
Podocon 25 IN Benzoin Tincture
Pyrogallic Acid
SklicePA
Spinosad
Synera
Ulesfia
COVERED
estradiolPA
estradiol valeratePA
estropipatePA
jinteli
norethindrone acetate/ethinyl estradiol
ortho-estPA
DelestrogenPA
Depo-estradiol
Estrasorb
Estrogel
CONTRACEPTIVES
COVERED
aftera
altavera
alyacen 1/35
alyacen 7/7/7
amethia
amethia LO
apri
aranelle
ashlyna
aubra
aviane
azurette
balziva
briellyn
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
4
camila
camrese
camrese LO
caziant
cesia
chateal
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
dasetta 1/35
dasetta 7/7/7
daysee
deblitane
delyla
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
econtra EZ
elinest
emoquette
enpresse-28
enskyce
errin
estarylla
fallback solo
falmina
gianvi
gildagia
gildess FE 1.5/30
gildess FE 1/20
gildess 1.5/30
gildess 1/20
heather
introvale
jencycla
jolessa
jolivette
junel FE 1.5/30
junel FE 1/20
junel 1.5/30
junel 1/20
kariva
kelnor 1/35
kurvelo
larin FE 1.5/30
larin FE 1/20
larin 1.5/30
larin 1/20
leena
lessina
levonest
levonorgestrel
levonorgestrel and ethinyl estradiol
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
loryna
low-ogestrel
lutera
lyza
marlissa
medroxyprogesterone acetate
microgestin FE
microgestin FE 1.5/30
microgestin 1.5/30
microgestin 1/20
mono-linyah
mononessa
my way
myzilra
necon 0.5/35-28
necon 1/35
necon 7/7/7
next choice one dose
nikki
nora-be
norethindrone
norethindrone acetate/ethinyl estradiol
norethindrone acetate/ethinyl estradiol/ferrous
fumarate
norgestimate/ethinyl estradiol
norlyroc
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ocella
opcicon one-step
orsythia
philith
pimtrea
pirmella 1/35
pirmella 7/7/7
portia-28
previfem
quasense
reclipsen
sharobel
solia
sprintec 28
sronyx
syeda
take action
tarina FE 1/20
tilia FE
tri-estarylla
tri-legest FE
tri-linyah
tri-previfem
tri-sprintec
trinessa
trivora-28
velivet
vestura
viorele
vyfemla
wera
wymzya FE
xulane
zarah
zenchent
zenchent FE
zovia 1/35e
Depo-subq Provera 104
Ella
Falessa
LO Minastrin FE
Necon 1/50-28
Necon 10/11-28
Norinyl 1+50
Nuvaring
Ogestrel
Quartette
Zovia 1/50e
PROGESTINS
COVERED
medroxyprogesterone acetate
norethindrone acetate
progesterone
Megace ES
ANTIDIABETIC AGENTS
INSULIN
COVERED
ApidraQL
Apidra SolostarQL
HumalogQL
Humalog KwikpenQL
Humalog Mix 50/50QL
Humalog Mix 50/50 KwikpenQL
Humalog Mix 75/25QL
Humalog Mix 75/25 KwikpenQL
Humulin NQL
Humulin N KwikpenQL
Humulin N U-100 PenQL
Humulin RQL
Humulin R U-500 (concentrated)QL
Humulin 70/30QL
Humulin 70/30 KwikpenQL
Humulin 70/30 PenQL
LantusQL
Lantus SolostarQL
LevemirQL
AMYLIN ANALOGS
COVERED
Symlinpen 120ST
Symlinpen 60ST
INCRETIN MIMETIC AGENTS
COVERED
BydureonST
ByettaST
VictozaST
SULFONYLUREAS
COVERED
glimepiride
glipizide
glipizide ER
glipizide XL
glyburide
tolazamide
Glyburide
Tolazamide
Tolbutamide
BIGUANIDES
COVERED
metformin HCL
metformin HCL ER
Glumetza
Riomet
MEGLITINIDE ANALOGUES
COVERED
nateglinide
repaglinide
DIABETIC OTHER
COVERED
Glucagon Emergency Kit
KorlymPA
Proglycem
ALPHA-GLUCOSIDASE INHIBIT
COVERED
acarbose
Glyset
DPP-4 INHIBITORS
COVERED
TradjentaST
INSULIN SENSITIZING AGENT
COVERED
pioglitazone HCLST
Avandia
ANTIDIABETIC COMBINATIONS
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
5
COVERED
glipizide/metformin HCL
pioglitazone HCL-glimepirideST
pioglitazone HCL/metformin HCLST
InvokametST
JentaduetoST,QL
Prandimet
COVERED
cabergoline
peg-3350/electrolytes
peg-3350/NACL/NA bicarbonate/KCL
pegylax
polyethylene glycol 3350
trilyte
Golytely
Kristalose
Moviprep
Osmoprep
Prepopik
Suclear
Suprep Bowel Prep
VASOPRESSIN ANTAGONISTS
ANTIDIARRHEALS
GH RECEPTOR ANTAGONISTS
COVERED
SomavertPA
POSTERIOR PITUITARY
COVERED
desmopressin acetate
Stimate
BISPHOSPHONATES
COVERED
alendronate sodium
ibandronate sodium
Etidronate Disodium
CALCITONINS
COVERED
calcitonin salmon
calcitonin-salmon
Fortical
PARATHYROID HORMONE
COVERED
ForteoPA
NatparaPA
PROLACTIN INHIBITORS
COVERED
SamscaPA
PROGESTERONE ANTAGONISTS
COVERED
Mifeprex
METABOLIC MODIFIERS
COVERED
Synarel
COVERED
calcitriol
doxercalciferol
levocarnitine
paricalcitol
sodium phenylbutyrate
Buphenyl
Carbaglu
Cystadane
KuvanPA
Lumizyme
MyaleptPA
Myozyme
OrfadinPA
SensiparPA
VimizimPA
GROWTH HORMONES
THYROID AGENTS
COVERED
GenotropinPA
Genotropin MiniquickPA
HumatropePA
Humatrope Combo PackPA
Norditropin CartridgePA
Norditropin FlexproPA
Norditropin Nordiflex PenPA
NutropinPA
Nutropin AQ Nuspin 10PA
Nutropin AQ Nuspin 20PA
Nutropin AQ Nuspin 5PA
Nutropin AQ PenPA
OmnitropePA
Saizen
Saizen Click.easy
Serostim
Tev-tropinPA
ZomactonPA
Zorbtive
COVERED
levothyroxine sodium
levoxyl
liothyronine sodium
methimazole
propylthiouracil
unithroid
unithroid direct
Armour Thyroid
Synthroid
Thyrolar-1
Thyrolar-1/2
Thyrolar-1/4
Thyrolar-2
Thyrolar-3
Tirosint
HORMONE RECEPTOR MDLTR
COVERED
raloxifene hydrochloride
FERTILITY REGULATORS
COVERED
chorionic gonadotropinPA
novarelPA
pregnyl w/diluent benzyl alcohol/NACLPA
LHRH/GNRH AGONIST
SOMATOMEDINS
COVERED
IncrelexPA
SOMATOSTATIC AGENTS
COVERED
octreotide acetatePA
GASTROINTESTINAL
LAXATIVES
COVERED
constulose
gavilyte-c
gavilyte-h
gavilyte-n/flavor pack
gavilyte-G
lactulose
peg 3350/electrolytes
peg-prep
COVERED
diphenoxylate/atropine
lofene
lonox
loperamide HCL
Diphenoxylate/Atropine
Motofen
Opium Tincture (paregoric)
ULCER DRUGS
COVERED
cimetidine
cimetidine HCL
dicyclomine HCL
ed-spaz
eq lansoprazoleST,QL
famotidine
glycopyrrolate
gnp lansoprazoleST,QL
heartburn relief 24 HOURST,QL
heartburn treatment 24 HOURST,QL
hyomax-SL
hyoscyamine sulfate
hyoscyamine sulfate odt
hyoscyamine sulfate ERPA
hyoscyamine sulfate SRPA
hyosyne
kls lansoprazoleST,QL
lansoprazoleST,QL
methscopolamine bromide
misoprostol
nizatidine
nulev
omeprazole
omeprazole/sodium bicarbonate
oscimin
oscimin SRPA
pantoprazole sodium
ra lansoprazoleST,QL
ranitidine HCL
sm lansoprazoleST,QL
sucralfate
symax fastabs
symax-SL
symax-SRPA
Cantil
Carafate
Cuvposa
CVS lansoprazoleST,QL
Helidac
HM lansoprazoleST,QL
Propantheline Bromide
Pylera
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
6
ANTIEMETICS
COVERED
dronabinolQL
granisetron HCL
meclizine HCL
ondansetron odt
ondansetron HCL
trimethobenzamide HCLPA
Cesamet
Granisol
SancusoQL
Transderm-scop
Monurol
URINARY ANTISPASMODICS
COVERED
bethanechol chloride
flavoxate HCL
oxybutynin chloride
oxybutynin chloride ER
tolterodine tartrate
trospium chloride
trospium chloride ER
Gelnique
Toviaz
DIGESTIVE AIDS
VAGINAL PRODUCTS
COVERED
Creon
Pancrelipase
Sucraid
Zenpep
GASTROINTESTINAL - MISC.
COVERED
balsalazide disodium
calcium acetate
colocort
cromolyn sodium
enulose
generlac
hydrocort ene 100MG
hydrocortisone
lactulose
mesalamine
metoclopramide odt
metoclopramide HCL
procto-PAK
proctosol HC
proctozone-HC
sulfasalazine
sulfazine
sulfazine EC
ursodiol
AmitizaPA,QL
Apriso
Asacol HD
Chenodal
CholbamPA
CimziaPA
Cimzia Starter KitPA
Cortifoam
Delzicol
Dipentum
Fosrenol
GattexPA
LotronexPA
Phoslyra
Rectiv
RelistorPA
Renagel
Renvela
Sevelamer Carbonate
GENITOURINARY
URINARY ANTI-INFECTIVES
COVERED
methenamine mandelate
nitrofurantoinPA
nitrofurantoin macrocrystalsPA
nitrofurantoin monohydratePA
nitrofurantoin monohydrate/macrocrystalsPA
COVERED
clindamycin phosphate
metronidazole vaginal
terconazole
vandazole
zazole
Avc
Cleocin
Crinone
Estrace
Estring
Femring
Miconazole 3
Premarin
Vagifem
GENITOURINARY - MISC.
COVERED
alfuzosin HCL ER
argyle sterile saline 100ML
citric acid/sodium citrate
curity sterile saline
cytra k crystals
cytra-k
cytra-2
finasteride
phenazo
phenazopyridine HCL
potassium citrate ER
potassium citrate-citric acid crystals
potassium citrate/citric acid
potassium citrate/sodium citrate/citric acid
sodium chloride
sodium chloride 0.9%
sodium citrate/citric acid
tamsulosin HCL
taron-crystals
tricitrates
virtrate-k
virtrate-2
virtrate-3
Cystagon
Cytra-3
Elmiron
K-phos NO 2
Lithostat
Oracit
ProcysbiPA
ThiolaPA
HEMATOLOGICAL
HEMATOPOIETIC AGENTS
COVERED
cyanocobalamin
folic acid
Aranesp Albumin Free
CerdelgaPA
Droxia
Epogen
Granix
Leukine
MirceraPA
Neulasta
Neulasta Delivery Kit
NeumegaPA
Neupogen
Procrit
PromactaPA
Vpriv
ZavescaPA
ANTICOAGULANTS
COVERED
enoxaparin sodium
fondaparinux sodium
jantoven
warfarin sodium
Coumadin
Fragmin
PradaxaST
XareltoST
HEMOSTATICS
COVERED
aminocaproic acid
tranexamic acid
HEMATOLOGICAL - MISC.
COVERED
anagrelide hydrochloride
cilostazol
clopidogrel
dipyridamolePA
pentoxifylline ER
ticlopidine HCLPA
Aggrenox
FirazyrPA,QL
Thrombate Iii W/20 ML Sterile WaterPA
MOUTH/THROAT/DENTAL AGENT
COVERED
cavarest
cavirinse
cevimeline HCL
chlorhexidine gluconate
chlorhexidine gluconate oral rinse
clotrimazole
controlrx
denta 5000 plus
dentagel
fluoridex daily defense
fluoridex daily defense enhanced whitening
karigel
karigel-n
lidocaine viscous
lidocaine HCL
lidocaine HCL viscous
neutragard advanced
neutral sodium fluoride
nystatin
oralone
paroex
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
7
periogard
phos-flur
pilocarpine hydrochloride
pilocarpine HCL
stannous fluoride oral rinse
triamcinolone acetonide
triamcinolone IN orabase
Arestin
Oravig
SF
SF 5000 plus
NEUROLOGY, CNS, PSYCH
ANTIANXIETY AGENTS
COVERED
alprazolamQL
alprazolam odtST,QL
alprazolam ERQL
alprazolam XRQL
buspirone HCLQL
chlordiazepoxide HCLQL
clorazepate dipotassiumQL
diazepamQL
diazepam intensol
gene-xene TAB 15MGQL
gene-xene TAB 3.75MGQL
gene-xene TAB 7.5MGQL
hydroxyzine pamoatePA
hydroxyzine HCLPA
lorazepamQL
oxazepamQL
ANTIDEPRESSANTS
COVERED
amitriptyline HCL
budeprion SR
bupropion HCL
bupropion HCL ER
bupropion HCL SR
bupropion HCL XL
citalopram hydrobromide
clomipramine HCL
desipramine HCL
doxepin HCL
duloxetine HCLQL
escitalopram oxalate
fluoxetine DR
fluoxetine HCL
fluvoxamine maleate
fluvoxamine maleate ER
imipramine pamoate
imipramine HCL
mirtazapine
mirtazapine odt
nefazodone HCL
nortriptyline HCL
paroxetine HCL
paroxetine HCL ER
phenelzine sulfate
protriptyline HCL
sertraline HCL
tranylcypromine sulfate
trazodone HCL
venlafaxine HCL
venlafaxine HCL ER
Amoxapine
AplenzinPA,QL
Desvenlafaxine ER
Emsam
Forfivo XL
Khedezla
Maprotiline HCL
Marplan
Paxil
PexevaST
PristiqPA
Surmontil
ViibrydPA
ANTIPSYCHOTICS
COVERED
aripiprazole
chlorpromazine HCL
clozapine
compazine
compro
fluphenazine decanoate
fluphenazine HCL
haloperidol
haloperidol decanoate
haloperidol lactate
lithium carbonate
lithium carbonate ER
loxapine
loxapine succinate
olanzapine
olanzapine odt
perphenazine
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
quetiapine fumarate
risperidone
risperidone odt
risperidone M-TAB
thioridazine HCL
thiothixene
trifluoperazine HCL
ziprasidone HCL
Abilify
Abilify Discmelt
Abilify Maintena
Chlorpromazine HCL
Clozapine Odt
Equetro
FanaptST
Fanapt Titration PackST
Fazaclo
Fluphenazine HCL
Geodon
InvegaST
Invega Sustenna
LatudaST
Lithium
Lithobid
Risperdal Consta
SaphrisST
Seroquel XRST
Zyprexa Relprevv
HYPNOTICS
COVERED
estazolamQL
flurazepam HCLQL
midazolam HCL
phenobarbital
temazepamQL
triazolamQL
zaleplonPA
zolpidem tartrate
RozeremQL
ADHD, NARCOLEPSY, ETC.
COVERED
amphetamine/dextroamphetamine
caffeine citrate
clonidine HCL ER
dexedrine
dexmethylphenidate HCL
dexmethylphenidate HCL ER
dextroamphetamine sulfate
dextroamphetamine sulfate ER
metadate ER
methamphetamine HCL
methylphenidate hydrochloride
methylphenidate HCL
methylphenidate HCL CD
methylphenidate HCL ER
methylphenidate HCL SR
zenzedi
DaytranaPA
Focalin XRPA
Kapvay Dose Pack
NuvigilPA
Ritalin LAPA
ANTICONVULSANTS
COVERED
carbamazepine
carbamazepine ER
clonazepamQL
clonazepam odtQL
divalproex sodium
divalproex sodium DR
divalproex sodium ER
epitol
ethosuximide
felbamate
gabapentin
lamotrigine
lamotrigine ER
levetiracetam
levetiracetam ER
oxcarbazepine
phenytoin
phenytoin infatabs
phenytoin sodium extended
primidone
tiagabine hydrochloride
topiragen
topiramate
valproic acid
zonisamide
AptiomST
Banzel
Celontin
Dilantin
Dilantin Infatabs
Fycompa
Gabitril
Lamictal Starter/Taking Valproate
LyricaST
Onfi
Oxtellar XR
Peganone
Phenytek
PotigaPA
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
8
SabrilPA
Stavzor
Trokendi XR
Vimpat
SavellaPA
Savella Titration PackPA
XenazinePA
XyremPA
ANTIPARKINSON AGENTS
NEUROMUSCULAR AGENTS
COVERED
amantadine HCL
benztropine mesylate
bromocriptine mesylate
carbidopa
carbidopa/levodopa
carbidopa/levodopa odt
carbidopa/levodopa ER
entacapone
pramipexole dihydrochloride
pramipexole dihydrochloride ER
ropinirole ER
ropinirole HCL
selegiline HCL
tolcapone
trihexyphenidyl HCLPA
Azilect
Carbidopa/Levodopa/Entacapone
Mirapex ER
Neupro
Stalevo 100
Stalevo 125
Stalevo 150
Stalevo 200
Stalevo 50
Stalevo 75
Zelapar
COVERED
riluzolePA
MyoblocPA
NEUROLOGY, PSYCH - MISC.
COVERED
acamprosate calcium DR
buproban
bupropion HCL SR
disulfiram
donepezil HCL
galantamine
galantamine hydrobromide
olanzapine/fluoxetineST
rivastigmine tartrate
AmpyraPA
AubagioPA
AvonexPA
Avonex PenPA
BetaseronPA
Chantix
Chantix Continuing Month PAK
Chantix Starting Month PAK
CopaxonePA
ExtaviaPA
GraliseST
Gralise StarterST
Namenda
Namenda Titration PAK
Nicotrol Inhaler
Nicotrol Ns
Nuedexta
Orap
PlegridyPA
Plegridy Starter PackPA
RebifPA
Rebif RebidosePA
Rebif Rebidose Titration PackPA
Rebif Titration PackPA
MUSCULOSKELETAL AGENTS
COVERED
baclofen
chlorzoxazonePA
cyclobenzaprine HCLPA
dantrolene sodium
metaxalonePA
methocarbamolPA
orphenadrine citrate ERPA
tizanidine HCL
ANTIMYASTHENIC AGENTS
COVERED
pyridostigmine bromide
Guanidine HCL
Mestinon
Mestinon Timespan
Prostigmin
OPHTHALMOLOGY AND OTIC
ANTI-INFECTIVES
COVERED
ak-poly-bac
bacitracin/polymyxin b
ciprofloxacin HCL
erythromycin
garamycin
gentak
gentamicin sulfate
ilotycin
levofloxacin
neo-polycin
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin zinc
neomycin/polymyxin/gramicidin
ofloxacin
polycin
polycin b
polymyxin b sulfate/trimethoprim sulfate
romycin
sodium sulfacetamide
sulfacetamide sodium
tobramycin sulfate
trifluridine
trimethoprim sulfate/polymyxin b sulfate
Bacitracin
fluorometholone
neo-polycin HC
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/dexamethasone
poly-dex
prednisolone acetate
sulfacetamide sodium/prednisolone sodium
phosphate
tobramycin/dexamethasone
Neomycin/Polymyxin/Hydrocortisone
Prednisolone Sodium Phosphate
PROSTAGLANDINS
COVERED
latanoprost
Travatan Z
Travoprost
CYCLOPLEGIC MYDRIATICS
COVERED
atropine sulfate
atropine-care
cyclopentolate HCL
homatropaire
homatropine HBR
mydral
tropicamide
DECONGESTANTS
COVERED
altafrin
neofrin
phenylephrine HCL
Naphazoline HCL
MIOTICS
COVERED
pilocarpine HCL
Phospholine Iodide
ADRENERGIC AGENTS
COVERED
apraclonidine
brimonidine tartrate
LOCAL ANESTHETICS
COVERED
altacaine
parcaine
proparacaine HCL
tetcaine
tetracaine HCL
tetravisc
tetravisc forte
Akten
OPHTHALMICS - MISC.
BETA-BLOCKERS
COVERED
betaxolol HCL
carteolol HCL
dorzolamide HCL/timolol maleate
levobunolol HCL
timolol maleate
timolol maleate ophthalmic gel forming
OPHTHALMIC STEROIDS
COVERED
dexamethasone sodium phosphate
COVERED
azelastine HCL
bromfenac
cromolyn sodium
diclofenac sodium
dorzolamide HCL
epinastine HCL
flucaine
fluorescein/proparacaine
flurbiprofen sodium
ketorolac tromethamine
Alocril
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
9
OTIC AGENTS
COVERED
acetasol HC
acetic acid
antipyrine/benzocaine
aurodex
fluocinolone acetonide
fluocinolone acetonide ear drops
hydrocortisone/acetic acid
neomycin/polymyxin/hydrocortisone
neomycin/polymyxin/HC
ofloxacin
otic care
Cetraxal
Ciprofloxacin
Cresylate
OXYTOCICS
COVERED
methylergonovine maleate
Prostin E2
PAIN MANAGEMENT
ANALGESICS - NONNARCOTIC
COVERED
adult aspirin EC low strength
ali-flex
aspir-low
aspir-81
aspirin
aspirin adult low dose
aspirin adult low strength
aspirin childrens
aspirin enteric coated adult low strength
aspirin low dose
aspirin low strength
aspirin EC
aspirin EC low dose
aspirin EC LO-dose
aspirin 81
aspirin 81 low dose
aspirtab
aspirtab maximum strength
bayer advanced aspirin extra strength
bayer advanced aspirin regular strength
bayer aspirin
bayer aspirin extra strength
bayer aspirin regimen
bayer aspirin EC low dose
bayer chewable low dose
bayer low dose
butalbital/acetaminophen/caffeine
butalbital/apap/caffeine
butalbital/aspirin/caffeine
capacet
childrens aspirin
childrens aspirin low strength
choline magnesium trisalicylate
coated aspirin
diflunisal
dolorex
duraxin
ecotrin low strength
ecpirin
ed-flex
enteric coated aspirin
eq adult aspirin low strength
eq aspirin
eq aspirin adult low dose
eq aspirin low dose
eq aspirin EC
eq childrens aspirin
eql adult aspirin low strength
eql aspirin
eql aspirin low dose
eql aspirin EC
eql childrens aspirin
esgic
gnp adult aspirin low strength
gnp aspirin
gnp aspirin low dose
goodsense aspirin low dose
kls aspirin low dose
kls aspirin EC
kp aspirin
margesic
meijer aspirin EC
miniprin low dose
norwich aspirin
px aspirin
px enteric aspirin
qc aspirin
qc aspirin low dose
qc childrens aspirin
ra aspirin
ra aspirin adult low dose
ra aspirin adult low strength
ra aspirin childrens
ra aspirin EC
ra aspirin EC adult low strength
ra childrens aspirin
salsalate
sm aspirin
sm aspirin adult low strength
sm aspirin enteric coated
sm aspirin low dose
sm aspirin EC low strength
sm childrens aspirin
st joseph aspirin
tgt aspirin
tgt aspirin low dose
tgt childrens aspirin
tgt enteric-coated aspirin
th aspirin
th aspirin low dose
th enteric aspirin
zebutal
Bioregesic
Butalbital/Aspirin/Caffeine
CVS aspirin
CVS aspirin adult low dose
CVS aspirin adult low strength
CVS aspirin child
CVS aspirin low dose
CVS aspirin low strength
CVS aspirin EC
CVS childrens aspirin
CVS enteric aspirin
Dolgic Plus
EC-81 aspirin
HM aspirin
HM aspirin EC
HM aspirin EC low dose
MM aspirin
Relagesic
Rhinoflex-650
SB aspirin
SB aspirin EC
SB childrens aspirin
SB low dose asa EC
Zgesic
ANALGESICS - OPIOID
COVERED
acetaminophen/codeine
acetaminophen/codeine #2
acetaminophen/codeine #3
acetaminophen/codeine #4
acetaminophen/codeine phosphate
buprenorphine HCLQL
buprenorphine HCL/naloxone HCL
butorphanol tartrate
codeine sulfate
endocet
endodan
fentanylQL
fentanyl citrate oral transmucosalPA
hydrocodone bitartrate/acetaminophen
hydrocodone/acetaminophen
hydrocodone/ibuprofen
hydrogesic
hydromorphone HCL
ibudone
lorcet
lorcet plus
lorcet HD
lortab
methadone HCL
methadone HCL intensol
methadose
morphine sulfate
morphine sulfate ERST,QL
oxycodone HCL
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
oxymorphone hydrochloride
oxymorphone hydrochloride ER
reprexain
roxicet
stagesic
tramadol hydrochloride/acetaminophen
tramadol HCL
tramadol HCL ER
verdrocet
vicodin
vicodin ES
vicodin HP
xylon
zamicet
Acetaminophen/Caffeine/Dihydrocodeine Bitartrate
Aspirin-caffeine-dihydrocodeine
Capital/Codeine
Levorphanol Tartrate
Lortab
Morphine Sulfate
Roxicet
Synalgos-dc
Trezix
ANTI-INFLAMMATORY
COVERED
diclofenac potassium
diclofenac sodium DR
diclofenac sodium ER
diclofenac sodium/misoprostol
etodolac
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
10
etodolac ER
flurbiprofen
ibuprofen
indomethacinPA
indomethacin ERPA
ketoprofen
ketorolac tromethamineQL
leflunomide
mefenamic acid
meloxicam
nabumetone
naproxen
naproxen kit
naproxen sodium
naproxen DR
oxaprozin
piroxicam
sulindac
tolmetin sodium
EnbrelPA
Enbrel SureclickPA
Fenoprofen Calcium
HumiraPA
Humira Pediatric Crohns Disease Starter PackPA
Humira PenPA
Humira Pen-crohns DiseasestarterPA
Humira Pen-psoriasis StarterPA
Ketoprofen ER
Meclofenamate Sodium
OtezlaPA
Ridaura
MIGRAINE PRODUCTS
COVERED
naratriptan HCLQL
rizatriptan benzoateQL
rizatriptan benzoate odtQL
sumatriptan succinateQL
sumatriptan succinate refillQL
AlsumaQL
Cafergot
Dihydroergotamine MesylateQL
Ergomar
Migergot
MigranalQL
Sumatriptan SuccinateQL
GOUT AGENTS
COVERED
allopurinol
probenecid
probenecid/colchicine
Colchicine
Colcrys
Uloric
RESPIRATORY, ALLERGY, ETC
ANTIHISTAMINES
COVERED
cetirizine HCL
cyproheptadine HCL
phenadozPA
phenerganPA
promethazine HCLPA
promethazine HCL plainPA
prometheganPA
NASAL AGENTS
COVERED
azelastine HCL
flunisolide
fluticasone propionate
ipratropium bromide
triamcinolone acetonide
Bactroban Nasal
Tyzine
Tyzine Pediatric Nasal Drops
COUGH/COLD/ALLERGY
COVERED
acetylcysteine
benzonatate
nebusal
pulmosal
sodium chloride
ANTIASTHMATIC/COPD AGENTS
COVERED
albuterol sulfate
albuterol sulfate ER
albuterol TAB 4MG
budesonidePA
ipratropium bromide
ipratropium bromide/albuterol sulfate
levalbuterolPA
levalbuterol HCLPA
montelukast sodium
terbutaline sulfate
theochron
theophylline CR
theophylline ER
zafirlukast
Aerospan
Anoro ElliptaST
Atrovent HFA
Brovana
Combivent
Combivent Respimat
DalirespST
Dulera
Elixophyllin
Lufyllin
Maxair Autohaler
Metaproterenol Sulfate
PulmicortPA
Pulmicort Flexhaler
QvarQL
Serevent Diskus
Symbicort
Theo-24
Tudorza Pressair
Ventolin HFAQL
Zyflo
Zyflo CR
RESPIRATORY AGENTS - MISC
COVERED
EsbrietPA
KalydecoPA
OfevPA
PulmozymePA
TOXOIDS
COVERED
Adacel
Boostrix
Tetanus/Diphtheria Toxoids-adsorbed Adult
VITAMINS
VITAMINS
COVERED
aqueous vitamin d infants
bio-d-mulsion
bio-d-mulsion forte
bprotected pedia d-vite
calcidol
calciferol
d 1000
d 10000
d 2000
d 400
d 5000
d-vita
d-1000
d-1000 extra strength
d-2000 maximum strength
d-3-5
d-400
d-5000
d-5000 maximum strength
decara
delta d3
dialyvite vitamin d 5000
d2000 ultra strength
d3
d3 adult
d3 adult gummy
d3 high potency
d3 kids
d3 maximum strength
d3 super strength
d3 ultra strength
d3-1000
d3-50
eql childrens vitamin d gummies
eql vitamin d-3
eql vitamin d3
ergocalciferol
gnp vitamin d
gnp vitamin d maximum strength
gnp vitamin d super strength
gnp vitamin d3 extra strength
healthy kids vitamin d3
just d
kp vitamin d
maximum d3
nat-rul vitamin d
optimal-d
optimal-d pack
opurity vitamin d
pronutrients vitamin d3
ra vitamin d-3
sm vitamin d
sm vitamin d3
th vitamin d3
thera-d rapid repletion
thera-d sport
thera-d 2000
vitamin d
vitamin d high potency
vitamin d 400
vitamin d-1000
vitamin d-1000 maximum strength
vitamin d-3
vitamin d-400
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
11
vitamin d3
vitamin d3 adult gummies
vitamin d3 high potency
vitamin d3 maximum strength
vitamin d3 super strength
CVS childrens vitamin d for bone health
CVS d3
CVS vitamin d
CVS vitamin d infants
CVS vitamin d 5000 high-potency
CVS vitamin d3
HM vitamin d
HM vitamin d3
PA vitamin d-3
PA vitamin d-3 gummy
MULTIVITAMINS
COVERED
multi-vit/fluoride
multi-vitamin/fluoride
M-vit
Niva-plus
O-CAL Fa
Prenaplus
Prenatal
Prenatal Low Iron
Prenatal Plus
Prenatal Vitamins Plus
Preplus
PNV Folic Acid + Iron Multivitamin
PNV Prenatal Plus Multivitamin
Tri-vit/Fluoride/Iron
Tricare
Vinate II
Vol-plus
MEDICAL DEVICES
DIABETIC SUPPLIES
COVERED
Freestyle Freedom Lite
Freestyle Insulinx Blood Glucose Monitoring
System
Freestyle Insulinx Blood Glucose TestQL
Freestyle Insulinx Blood Glucose Test StripsQL
Freestyle Lite Blood Glucose Monitoring System
Freestyle Lite Test StripsQL
Freestyle Test StripsQL
Precision XTRA
Precision XTRA Blood Glucose Test StripsQL
QL
MEDICAL DEVICES - MISC
COVERED
Aerochamber Mini Aerosol Chamber
Aerochamber MV
Aerochamber Plus Flow VU
Aerochamber Plus Flow-VU
Aerochamber Plus Flow-VU/Large Mask
Aerochamber Plus Flow-VU/Mask
Aerochamber Plus Flow-VU/Medium Mask
Aerochamber Plus Flow-VU/Small Mask
Aerochamber Z-stat Plus Valved Holding Chamber
W/Flow VU
Aerochamber Z-stat Plus/Flowsignal
Aerochamber Z-stat Plus/Large Mask
Aerochamber Z-stat Plus/Medium Mask
Aerochamber Z-stat Plus/Small Mask
Aerochamber/Flowsignal
Aerovent Plus Holding Chamber/Collapsible
Breatherite
Breatherite Collapsible Adult Spacer W/Mask
Breatherite Collapsible Child Spacer W/Mask
Breatherite Collapsible Infant Spacer W/Mask
Breatherite Collapsible Small Child Spacer
W/Mask
Breatherite Collapsible Spacer W/ Neonate Mask
Breatherite Rigid Spacer W/Mask
Breatherite W/Large Mask
Breatherite W/Medium Mask
Breatherite W/Small Mask
E-z Spacer
E-z Spacer The Body Guards Pack
Easivent
Easivent/Mask-large
Easivent/Mask-medium
Easivent/Mask-small
Inspirachamber/Anti-static Valved/Mouthpiece
Inspirachamber/Soothermask/Inspiramask/Medium
Inspirachamber/Soothermask/Inspiramask/Small
Inspirease Bags
Inspirease Drug Delivery System
Inspirease Mouthpiece
Inspirease Reservoir Bags
Liteaire
Microchamber
Microspacer
Optichamber Advantage
Optichamber Diamond
Optichamber Diamond/Largeface Mask
Optichamber Diamond/Medium Face Mask
Optichamber Diamond/Smallface Mask
Optihaler
Optihaler MDI Drug Delivery System
Pocket Chamber
Pocket Spacer
Riteflo
Valved Holding Chamber
Vortex Valved Holding Chamber
Watchhaler
MISCELLANEOUS
COVERED
ExjadePA
FerriproxPA
JadenuPA
Formulary Disclaimer: Coverage for some drugs
may be limited to specific dosage forms and/or
strengths. The benefit design determines what is
covered and the applicable co-payment. The
medications listed on this formulary are subject to
change pursuant to the formulary management
activities of Catamaran. The presence of a
medication on this formulary list does not guarantee
coverage.
Effective May 20, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
12
Index
A
abacavir, 1
abacavir sulfate/lamivudine/zidovudine, 1
Abilify, 8
Abilify Discmelt, 8
Abilify Maintena, 8
acamprosate calcium DR, 9
acarbose, 5
acebutolol HCL, 2
Acetaminophen/Caffeine/Dihydrocodeine
Bitartrate, 10
acetaminophen/codeine, 10
acetaminophen/codeine #2, 10
acetaminophen/codeine #3, 10
acetaminophen/codeine #4, 10
acetaminophen/codeine phosphate, 10
acetasol HC, 10
acetazolamide, 3
Acetazolamide, 3
acetazolamide ER, 3
acetic acid, 10
acetylcysteine, 11
acitretin, 4
acticin, 4
Actimmune, 2
acyclovir, 1, 4
Adacel, 11
adapalene, 3
Adcirca, 3
adefovir dipivoxil, 1
Adempas, 3
Adrenaclick, 3
adult aspirin EC low strength, 10
Aerochamber Mini Aerosol Chamber, 12
Aerochamber MV, 12
Aerochamber Plus Flow VU, 12
Aerochamber Plus Flow-VU, 12
Aerochamber Plus Flow-VU/Large Mask,
12
Aerochamber Plus Flow-VU/Mask, 12
Aerochamber Plus Flow-VU/Medium
Mask, 12
Aerochamber Plus Flow-VU/Small Mask,
12
Aerochamber Z-stat Plus Valved Holding
Chamber W/Flow VU, 12
Aerochamber Z-stat Plus/Flowsignal, 12
Aerochamber Z-stat Plus/Large Mask, 12
Aerochamber Z-stat Plus/Medium Mask,
12
Aerochamber Z-stat Plus/Small Mask, 12
Aerochamber/Flowsignal, 12
Aerospan, 11
Aerovent Plus Holding
Chamber/Collapsible, 12
afeditab CR, 3
Afinitor, 2
Afinitor Disperz, 2
aftera, 4
Aggrenox, 7
ak-poly-bac, 9
Akten, 9
ala cort, 4
Albenza, 2
albuterol sulfate, 11
albuterol sulfate ER, 11
albuterol TAB 4MG, 11
alclometasone dipropionate, 4
alendronate sodium, 6
alfuzosin HCL ER, 7
ali-flex, 10
Alinia, 2
allopurinol, 11
Alocril, 9
alphatrex, 4
alprazolam, 8
alprazolam ER, 8
alprazolam odt, 8
alprazolam XR, 8
Alsuma, 11
altacaine, 9
altafrin, 9
altavera, 4
alyacen 1/35, 4
alyacen 7/7/7, 4
amantadine HCL, 9
Amcinonide, 4
amethia, 4
amethia LO, 4
amiloride HCL, 3
amiloride/hydrochlorothiazide, 3
aminocaproic acid, 7
amiodarone HCL, 3
Amitiza, 7
amitriptyline HCL, 8
amlodipine besylate, 3
amlodipine besylate/atorvastatin calcium,
3
amlodipine besylate/benazepril HCL, 3
amlodipine besylate/benazepril
hydrochloride, 3
ammonium lactate, 4
Amoxapine, 8
amoxicillin, 1
Amoxicillin ER, 1
amoxicillin/clavulanate potassium, 1
amoxicillin/clavulanate potassium ER, 1
amphetamine/dextroamphetamine, 8
ampicillin, 1
Ampyra, 9
Anacaine, 4
anagrelide hydrochloride, 7
anastrozole, 2
Androxy, 4
Anoro Ellipta, 11
antipyrine/benzocaine, 10
Apidra, 5
Apidra Solostar, 5
Aplenzin, 8
apraclonidine, 9
apri, 4
Apriso, 7
Aptiom, 8
Aptivus, 1
aqueous vitamin d infants, 11
aranelle, 4
Aranesp Albumin Free, 7
Arestin, 8
argyle sterile saline 100ML, 7
aripiprazole, 8
Armour Thyroid, 6
Asacol HD, 7
ashlyna, 4
aspir-81, 10
aspir-low, 10
aspirin, 10
aspirin 81, 10
aspirin 81 low dose, 10
aspirin adult low dose, 10
aspirin adult low strength, 10
aspirin childrens, 10
aspirin EC, 10
aspirin EC LO-dose, 10
aspirin EC low dose, 10
aspirin enteric coated adult low strength,
10
aspirin low dose, 10
aspirin low strength, 10
Aspirin-caffeine-dihydrocodeine, 10
aspirtab, 10
aspirtab maximum strength, 10
Astagraf XL, 2
atenolol, 2
atenolol/chlorthalidone, 3
atorvastatin calcium, 3
atovaquone, 2
atovaquone/proguanil HCL, 2
Atripla, 1
atropine sulfate, 9
atropine-care, 9
Atrovent HFA, 11
Aubagio, 9
aubra, 4
augmented betamethasone dipropionate,
4
Augmentin, 1
aurodex, 10
Auvi-q, 3
Avandia, 5
Avc, 7
aviane, 4
avidoxy, 1
avita, 3
Avonex, 9
Avonex Pen, 9
Azasan, 2
azathioprine, 2
azelastine HCL, 9, 11
Azelex, 3
Azilect, 9
azithromycin, 1
Azor, 3
azurette, 4
B
Bacitracin, 9
bacitracin/polymyxin b, 9
baclofen, 9
Bactroban Nasal, 11
balsalazide disodium, 7
balziva, 4
Banzel, 8
Baraclude, 1
baycadron, 4
bayer advanced aspirin extra strength,
10
bayer advanced aspirin regular strength,
10
bayer aspirin, 10
bayer aspirin EC low dose, 10
bayer aspirin extra strength, 10
bayer aspirin regimen, 10
bayer chewable low dose, 10
bayer low dose, 10
benazepril HCL, 3
benazepril HCL/hydrochlorothiazide, 3
benzonatate, 11
benztropine mesylate, 9
betamethasone dipropionate, 4
betamethasone valerate, 4
Betaseron, 9
betaxolol HCL, 2, 9
bethanechol chloride, 7
bicalutamide, 2
Bidil, 3
Biltricide, 2
bio-d-mulsion, 11
bio-d-mulsion forte, 11
Bioregesic, 10
bisoprolol fumarate, 2
bisoprolol fumarate/hydrochlorothiazide,
3
Boostrix, 11
Bosulif, 2
bprotected pedia d-vite, 11
Breatherite, 12
Breatherite Collapsible Adult Spacer
W/Mask, 12
Breatherite Collapsible Child Spacer
W/Mask, 12
Breatherite Collapsible Infant Spacer
W/Mask, 12
Breatherite Collapsible Small Child
Spacer W/Mask, 12
Breatherite Collapsible Spacer W/
Neonate Mask, 12
Breatherite Rigid Spacer W/Mask, 12
Breatherite W/Large Mask, 12
Breatherite W/Medium Mask, 12
Breatherite W/Small Mask, 12
briellyn, 4
brimonidine tartrate, 9
bromfenac, 9
bromocriptine mesylate, 9
Brovana, 11
budeprion SR, 8
budesonide, 4, 11
bumetanide, 3
Buphenyl, 6
buprenorphine HCL, 10
buprenorphine HCL/naloxone HCL, 10
buproban, 9
bupropion HCL, 8
bupropion HCL ER, 8
bupropion HCL SR, 8, 9
bupropion HCL XL, 8
buspirone HCL, 8
butalbital/acetaminophen/caffeine, 10
butalbital/apap/caffeine, 10
butalbital/aspirin/caffeine, 10
Butalbital/Aspirin/Caffeine, 10
butorphanol tartrate, 10
Bydureon, 5
Byetta, 5
Bystolic, 3
C
cabergoline, 6
Cafergot, 11
caffeine citrate, 8
calcidol, 11
calciferol, 11
calcipotriene, 4
calcitonin salmon, 6
calcitonin-salmon, 6
calcitrene, 4
Calcitriol, 4
calcitriol, 6
calcium acetate, 7
camila, 5
camrese, 5
camrese LO, 5
candesartan cilexetil, 3
candesartan cilexetil/hydrochlorothiazide,
3
Cantil, 6
capacet, 10
capecitabine, 2
Capital/Codeine, 10
Caprelsa, 2
captopril, 3
Captopril/Hydrochlorothiazide, 3
Carafate, 6
Carbaglu, 6
carbamazepine, 8
carbamazepine ER, 8
carbidopa, 9
carbidopa/levodopa, 9
carbidopa/levodopa ER, 9
carbidopa/levodopa odt, 9
Carbidopa/Levodopa/Entacapone, 9
Cardene SR, 3
carteolol HCL, 9
cartia XT, 3
carvedilol, 2
cavarest, 7
cavirinse, 7
Cayston, 2
caziant, 5
Cedax, 1
cefaclor, 1
Cefaclor ER, 1
cefadroxil, 1
cefdinir, 1
Cefditoren Pivoxil, 1
cefixime, 1
cefpodoxime proxetil, 1
cefprozil, 1
Ceftibuten, 1
Ceftin, 1
cefuroxime axetil, 1
Celestone, 4
Cellcept, 2
Celontin, 8
cephalexin, 1
Cerdelga, 7
Cesamet, 7
cesia, 5
cetirizine HCL, 11
Cetraxal, 10
cevimeline HCL, 7
Chantix, 9
Chantix Continuing Month PAK, 9
Chantix Starting Month PAK, 9
chateal, 5
Chenodal, 7
childrens aspirin, 10
childrens aspirin low strength, 10
chlordiazepoxide HCL, 8
chlorhexidine gluconate, 7
chlorhexidine gluconate oral rinse, 7
chloroquine phosphate, 2
chlorothiazide, 3
chlorpromazine HCL, 8
Chlorpromazine HCL, 8
Chlorthalidone, 3
chlorzoxazone, 9
Cholbam, 7
cholestyramine, 3
cholestyramine light, 3
choline magnesium trisalicylate, 10
chorionic gonadotropin, 6
ciclodan, 4
ciclopirox, 4
ciclopirox nail lacquer, 4
ciclopirox olamine, 4
cilostazol, 7
cimetidine, 6
cimetidine HCL, 6
Cimzia, 7
Cimzia Starter Kit, 7
ciprofloxacin, 1
Ciprofloxacin, 10
ciprofloxacin ER, 1
ciprofloxacin HCL, 1, 9
citalopram hydrobromide, 8
citric acid/sodium citrate, 7
clarithromycin, 1
clarithromycin ER, 1
Cleocin, 7
clindacin etz pledgets, 3
clindacin-p, 3
Clindagel, 3
clindamax, 3
clindamycin HCL, 2
clindamycin palmitate HCL, 2
clindamycin phosphate, 3, 7
clobetasol propionate, 4
clobetasol propionate e, 4
clobetasol propionate emollient, 4
clomipramine HCL, 8
clonazepam, 8
clonazepam odt, 8
clonidine HCL, 3
clonidine HCL ER, 8
clopidogrel, 7
clorazepate dipotassium, 8
Clorpres, 3
clotrimazole, 4, 7
clotrimazole/betamethasone dipropionate,
4
clozapine, 8
Clozapine Odt, 8
Coartem, 2
coated aspirin, 10
Cocaine HCL, 4
codeine sulfate, 10
Colchicine, 11
Colcrys, 11
colestipol HCL, 3
colestipol HCL for oral suspension, 3
colocort, 7
Combivent, 11
Combivent Respimat, 11
Cometriq, 2
compazine, 8
Complera, 1
compro, 8
constulose, 6
controlrx, 7
Copaxone, 9
Cordran Tape, 4
cormax scalp application, 4
Cortifoam, 7
Cortisone Acetate, 4
Cosentyx Sensoready Pen, 4
Coumadin, 7
Creon, 7
Cresylate, 10
Crinone, 7
Crixivan, 1
cromolyn sodium, 7, 9
cryselle-28, 5
curity sterile saline, 7
Cuvposa, 6
CVS aspirin, 10
CVS aspirin adult low dose, 10
CVS aspirin adult low strength, 10
CVS aspirin child, 10
CVS aspirin EC, 10
CVS aspirin low dose, 10
CVS aspirin low strength, 10
CVS childrens aspirin, 10
CVS childrens vitamin d for bone health,
12
CVS d3, 12
CVS enteric aspirin, 10
CVS lansoprazole, 6
CVS vitamin d, 12
CVS vitamin d 5000 high-potency, 12
CVS vitamin d infants, 12
CVS vitamin d3, 12
cyanocobalamin, 7
cyclafem 1/35, 5
cyclafem 7/7/7, 5
cyclobenzaprine HCL, 9
cyclopentolate HCL, 9
Cyclophosphamide, 2
Cycloserine, 1
cyclosporine, 2
cyclosporine modified, 2
Cyclosporine Modified, 2
cyproheptadine HCL, 11
Cystadane, 6
Cystagon, 7
cytra k crystals, 7
cytra-2, 7
Cytra-3, 7
cytra-k, 7
D
d 1000, 11
d 10000, 11
d 2000, 11
d 400, 11
d 5000, 11
d-1000, 11
d-1000 extra strength, 11
d-2000 maximum strength, 11
d-3-5, 11
d-400, 11
d-5000, 11
d-5000 maximum strength, 11
d-vita, 11
d2000 ultra strength, 11
d3, 11
d3 adult, 11
d3 adult gummy, 11
d3 high potency, 11
d3 kids, 11
d3 maximum strength, 11
d3 super strength, 11
d3 ultra strength, 11
d3-1000, 11
d3-50, 11
Daliresp, 11
danazol, 4
dantrolene sodium, 9
Dapsone, 2
Daraprim, 2
dasetta 1/35, 5
dasetta 7/7/7, 5
daysee, 5
Daytrana, 8
deblitane, 5
decara, 11
Delestrogen, 4
delta d3, 11
delyla, 5
Delzicol, 7
demeclocycline HCL, 1
Demser, 3
Denavir, 4
denta 5000 plus, 7
dentagel, 7
Depo-estradiol, 4
Depo-subq Provera 104, 5
desipramine HCL, 8
desmopressin acetate, 6
desogestrel/ethinyl estradiol, 5
desonide, 4
desoximetasone, 4
Desvenlafaxine ER, 8
dexamethasone, 4
Dexamethasone, 4
Dexamethasone Intensol, 4
dexamethasone sodium phosphate, 9
dexedrine, 8
dexmethylphenidate HCL, 8
dexmethylphenidate HCL ER, 8
Dexpak 10 Day, 4
Dexpak 13 Day, 4
Dexpak 6 Day, 4
dextroamphetamine sulfate, 8
dextroamphetamine sulfate ER, 8
dialyvite vitamin d 5000, 11
diazepam, 8
diazepam intensol, 8
Dibenzyline, 3
diclofenac potassium, 10
diclofenac sodium, 9
diclofenac sodium DR, 10
diclofenac sodium ER, 10
diclofenac sodium/misoprostol, 10
dicloxacillin sodium, 1
dicyclomine HCL, 6
didanosine, 1
Dificid, 1
diflunisal, 10
digitek, 2
digox, 2
digoxin, 2
Dihydroergotamine Mesylate, 11
Dilantin, 8
Dilantin Infatabs, 8
Dilatrate SR, 2
dilt-CD, 3
dilt-XR, 3
diltiazem CD, 3
diltiazem HCL, 3
diltiazem HCL ER, 3
diltzac, 3
Dipentum, 7
diphenoxylate/atropine, 6
Diphenoxylate/Atropine, 6
dipyridamole, 7
disopyramide phosphate, 3
disulfiram, 9
Diuril, 3
divalproex sodium, 8
divalproex sodium DR, 8
divalproex sodium ER, 8
Dolgic Plus, 10
dolorex, 10
donepezil HCL, 9
dorzolamide HCL, 9
dorzolamide HCL/timolol maleate, 9
doxazosin, 3
doxazosin mesylate, 3
doxepin HCL, 8
doxercalciferol, 6
doxycycline, 1
doxycycline hyclate, 1
doxycycline hyclate DR, 1
doxycycline monohydrate, 1
Dritho-creme HP, 4
dronabinol, 7
drospirenone/ethinyl estradiol, 5
Droxia, 7
Dulera, 11
duloxetine HCL, 8
duraxin, 10
Dutoprol, 3
Dyrenium, 3
E
E-z Spacer, 12
E-z Spacer The Body Guards Pack, 12
E.e.s. 400, 1
E.e.s. Granules, 1
e.s.p., 2
Easivent, 12
Easivent/Mask-large, 12
Easivent/Mask-medium, 12
Easivent/Mask-small, 12
EC-81 aspirin, 10
econazole nitrate, 4
econtra EZ, 5
ecotrin low strength, 10
ecpirin, 10
ed-flex, 10
ed-spaz, 6
Edarbi, 3
Edarbyclor, 3
Edecrin, 3
Edurant, 1
Elidel, 4
elinest, 5
Elixophyllin, 11
Ella, 5
Elmiron, 7
Emcyt, 2
emoquette, 5
Emsam, 8
Emtriva, 1
enalapril maleate, 3
enalapril maleate/hydrochlorothiazide, 3
Enbrel, 11
Enbrel Sureclick, 11
endocet, 10
endodan, 10
enoxaparin sodium, 7
enpresse-28, 5
enskyce, 5
entacapone, 9
entecavir, 1
enteric coated aspirin, 10
enulose, 7
Epaned, 3
epinastine HCL, 9
Epinephrine, 3
Epipen 2-PAK, 3
Epipen-JR 2-PAK, 3
epitol, 8
Epivir HBV, 1
eplerenone, 3
Epogen, 7
eprosartan mesylate, 3
Epzicom, 1
eq adult aspirin low strength, 10
eq aspirin, 10
eq aspirin adult low dose, 10
eq aspirin EC, 10
eq aspirin low dose, 10
eq childrens aspirin, 10
eq lansoprazole, 6
eql adult aspirin low strength, 10
eql aspirin, 10
eql aspirin EC, 10
eql aspirin low dose, 10
eql childrens aspirin, 10
eql childrens vitamin d gummies, 11
eql vitamin d-3, 11
eql vitamin d3, 11
Equetro, 8
ergocalciferol, 11
Ergomar, 11
errin, 5
Ery-TAB, 1
Eryped 200, 1
Eryped 400, 1
Erythrocin Stearate, 1
erythromycin, 1, 3, 9
Erythromycin Base, 1
Erythromycin Ethylsuccinate, 1
Esbriet, 11
escitalopram oxalate, 8
esgic, 10
estarylla, 5
estazolam, 8
Estrace, 7
estradiol, 4
estradiol valerate, 4
Estrasorb, 4
Estring, 7
Estrogel, 4
estropipate, 4
ethambutol HCL, 1
ethosuximide, 8
Etidronate Disodium, 6
etodolac, 10
etodolac ER, 11
Eurax, 4
Evotaz, 1
exemestane, 2
Exjade, 12
Extavia, 9
F
Factive, 1
Falessa, 5
fallback solo, 5
falmina, 5
famciclovir, 1
famotidine, 6
Fanapt, 8
Fanapt Titration Pack, 8
Fareston, 2
Farydak, 2
Fazaclo, 8
felbamate, 8
Femring, 7
fenofibrate, 3
Fenofibrate, 3
fenofibrate micronized, 3
Fenoprofen Calcium, 11
fentanyl, 10
fentanyl citrate oral transmucosal, 10
Ferriprox, 12
Finacea, 4
finasteride, 7
Firazyr, 7
First-vancomycin 25, 2
First-vancomycin 50, 2
Flagyl ER, 2
flavoxate HCL, 7
flecainide acetate, 3
FLO-pred, 4
flucaine, 9
fluconazole, 1
flucytosine, 1
fludrocortisone acetate, 4
flunisolide, 11
fluocinolone acetonide, 4, 10
fluocinolone acetonide body, 4
fluocinolone acetonide ear drops, 10
fluocinolone acetonide scalp, 4
fluocinonide, 4
fluorescein/proparacaine, 9
fluoridex daily defense, 7
fluoridex daily defense enhanced
whitening, 7
fluorometholone, 9
fluoxetine DR, 8
fluoxetine HCL, 8
fluphenazine decanoate, 8
fluphenazine HCL, 8
Fluphenazine HCL, 8
flurazepam HCL, 8
flurbiprofen, 11
flurbiprofen sodium, 9
flutamide, 2
fluticasone propionate, 4, 11
fluvastatin, 3
fluvoxamine maleate, 8
fluvoxamine maleate ER, 8
Focalin XR, 8
folic acid, 7
fondaparinux sodium, 7
Forfivo XL, 8
Forteo, 6
Fortical, 6
fosinopril sodium, 3
fosinopril sodium/hydrochlorothiazide, 3
Fosrenol, 7
Fragmin, 7
Freestyle Freedom Lite, 12
Freestyle Insulinx Blood Glucose
Monitoring System, 12
Freestyle Insulinx Blood Glucose Test,
12
Freestyle Insulinx Blood Glucose Test
Strips, 12
Freestyle Lite Blood Glucose Monitoring
System, 12
Freestyle Lite Test Strips, 12
Freestyle Test Strips, 12
furosemide, 3
Fycompa, 8
G
gabapentin, 8
Gabitril, 8
galantamine, 9
galantamine hydrobromide, 9
garamycin, 9
Gattex, 7
gavilyte-c, 6
gavilyte-G, 6
gavilyte-h, 6
gavilyte-n/flavor pack, 6
Gelnique, 7
gemfibrozil, 3
gene-xene TAB 15MG, 8
gene-xene TAB 3.75MG, 8
gene-xene TAB 7.5MG, 8
generlac, 7
gengraf, 2
Genotropin, 6
Genotropin Miniquick, 6
gentak, 9
Gentamicin Sulfate, 4
gentamicin sulfate, 9
Geodon, 8
gianvi, 5
gildagia, 5
gildess 1.5/30, 5
gildess 1/20, 5
gildess FE 1.5/30, 5
gildess FE 1/20, 5
Gilotrif, 2
Gleevec, 2
glimepiride, 5
glipizide, 5
glipizide ER, 5
glipizide XL, 5
glipizide/metformin HCL, 6
Glucagon Emergency Kit, 5
Glumetza, 5
glyburide, 5
Glyburide, 5
glycopyrrolate, 6
glydo, 4
Glyset, 5
gnp adult aspirin low strength, 10
gnp aspirin, 10
gnp aspirin low dose, 10
gnp lansoprazole, 6
gnp vitamin d, 11
gnp vitamin d maximum strength, 11
gnp vitamin d super strength, 11
gnp vitamin d3 extra strength, 11
Golytely, 6
goodsense aspirin low dose, 10
Gralise, 9
Gralise Starter, 9
granisetron HCL, 7
Granisol, 7
Granix, 7
griseofulvin microsize, 1
griseofulvin ultramicrosize, 1
guanfacine HCL, 3
Guanidine HCL, 9
H
halobetasol propionate, 4
haloperidol, 8
haloperidol decanoate, 8
haloperidol lactate, 8
Harvoni, 1
healthy kids vitamin d3, 11
heartburn relief 24 HOUR, 6
heartburn treatment 24 HOUR, 6
heather, 5
hecoria, 2
Helidac, 6
Hemangeol, 3
Hexalen, 2
HM aspirin, 10
HM aspirin EC, 10
HM aspirin EC low dose, 10
HM lansoprazole, 6
HM vitamin d, 12
HM vitamin d3, 12
homatropaire, 9
homatropine HBR, 9
Humalog, 5
Humalog Kwikpen, 5
Humalog Mix 50/50, 5
Humalog Mix 50/50 Kwikpen, 5
Humalog Mix 75/25, 5
Humalog Mix 75/25 Kwikpen, 5
Humatrope, 6
Humatrope Combo Pack, 6
Humira, 11
Humira Pediatric Crohns Disease Starter
Pack, 11
Humira Pen, 11
Humira Pen-crohns Diseasestarter, 11
Humira Pen-psoriasis Starter, 11
Humulin 70/30, 5
Humulin 70/30 Kwikpen, 5
Humulin 70/30 Pen, 5
Humulin N, 5
Humulin N Kwikpen, 5
Humulin N U-100 Pen, 5
Humulin R, 5
Humulin R U-500 (concentrated), 5
hydralazine HCL, 3
hydrochlorothiazide, 3
hydrocodone bitartrate/acetaminophen,
10
hydrocodone/acetaminophen, 10
hydrocodone/ibuprofen, 10
hydrocort ene 100MG, 7
hydrocortisone, 4(2), 7
hydrocortisone acetate/aloe, 4
hydrocortisone butyrate, 4
hydrocortisone IN absorbase, 4
hydrocortisone valerate, 4
hydrocortisone/acetic acid, 10
hydrogesic, 10
hydromorphone HCL, 10
hydroxychloroquine sulfate, 2
hydroxyurea, 2
hydroxyzine HCL, 8
hydroxyzine pamoate, 8
Hylira, 4
hyomax-SL, 6
hyoscyamine sulfate, 6
hyoscyamine sulfate ER, 6
hyoscyamine sulfate odt, 6
hyoscyamine sulfate SR, 6
hyosyne, 6
hypercare, 4
I
ibandronate sodium, 6
Ibrance, 2
ibudone, 10
ibuprofen, 11
Iclusig, 2
ilotycin, 9
Imbruvica, 2
imipramine HCL, 8
imipramine pamoate, 8
imiquimod, 4
Incivek, 1
Increlex, 6
indapamide, 3
Inderal XL, 3
indomethacin, 11
indomethacin ER, 11
Infergen, 1
Inlyta, 2
Innopran XL, 3
Inspirachamber/Anti-static
Valved/Mouthpiece, 12
Inspirachamber/Soothermask/Inspiramas
k/Medium, 12
Inspirachamber/Soothermask/Inspiramas
k/Small, 12
Inspirease Bags, 12
Inspirease Drug Delivery System, 12
Inspirease Mouthpiece, 12
Inspirease Reservoir Bags, 12
Intelence, 1
Intron A, 2
Intron-a W/Diluent, 2
introvale, 5
Invega, 8
Invega Sustenna, 8
Invirase, 1
Invokamet, 6
ipratropium bromide, 11(2)
ipratropium bromide/albuterol sulfate, 11
irbesartan, 3
irbesartan/hydrochlorothiazide, 3
Isentress, 1
isoditrate ER, 2
isoniazid, 1
Isoniazid, 1
Isordil Titradose, 2
isosorbide dinitrate, 2
Isosorbide Dinitrate, 2
isosorbide dinitrate ER, 2
isosorbide mononitrate, 2
isosorbide mononitrate ER, 2
isradipine, 3
itraconazole, 1
ivermectin, 2
J
Jadenu, 12
Jakafi, 2
jantoven, 7
jencycla, 5
Jentadueto, 6
jinteli, 4
jolessa, 5
jolivette, 5
junel 1.5/30, 5
junel 1/20, 5
junel FE 1.5/30, 5
junel FE 1/20, 5
just d, 11
K
K-phos NO 2, 7
Kaletra, 1
Kalydeco, 11
Kapvay Dose Pack, 8
karigel, 7
karigel-n, 7
kariva, 5
kelnor 1/35, 5
Kepivance, 2
Ketek, 2
ketoconazole, 1, 4
ketodan, 4
ketoprofen, 11
Ketoprofen ER, 11
ketorolac tromethamine, 9, 11
Khedezla, 8
Kitabis PAK, 1
kls aspirin EC, 10
kls aspirin low dose, 10
kls lansoprazole, 6
Korlym, 5
kp aspirin, 10
kp vitamin d, 11
Kristalose, 6
kurvelo, 5
Kuvan, 6
L
labetalol HCL, 2
laclotion, 4
lactulose, 6, 7
Lamictal Starter/Taking Valproate, 8
Lamisil, 1
lamivudine, 1
lamivudine/zidovudine, 1
lamotrigine, 8
lamotrigine ER, 8
Lanoxin, 2
lansoprazole, 6
Lantus, 5
Lantus Solostar, 5
larin 1.5/30, 5
larin 1/20, 5
larin FE 1.5/30, 5
larin FE 1/20, 5
latanoprost, 9
Latuda, 8
leena, 5
leflunomide, 11
Lenvima 10MG Daily Dose, 2
Lenvima 14MG Daily Dose, 2
Lenvima 20MG Daily Dose, 2
Lenvima 24MG Daily Dose, 2
lessina, 5
Letairis, 3
letrozole, 2
leucovorin calcium, 2
Leukeran, 2
Leukine, 7
leuprolide acetate, 2
levalbuterol, 11
levalbuterol HCL, 11
Levatol, 3
Levemir, 5
levetiracetam, 8
levetiracetam ER, 8
levobunolol HCL, 9
levocarnitine, 6
levofloxacin, 1, 9
levonest, 5
levonorgestrel, 5
levonorgestrel and ethinyl estradiol, 5
levonorgestrel/ethinyl estradiol, 5
levora 0.15/30-28, 5
Levorphanol Tartrate, 10
levothyroxine sodium, 6
levoxyl, 6
Lexiva, 1
lidocaine, 4
Lidocaine And Tetracaine Cream, 4
lidocaine HCL, 4, 7
lidocaine HCL jelly, 4
lidocaine HCL viscous, 7
lidocaine viscous, 7
lidocaine/prilocaine, 4
lindane, 4
liothyronine sodium, 6
Lipofen, 3
lisinopril, 3
lisinopril/hydrochlorothiazide, 3
Liteaire, 12
Lithium, 8
lithium carbonate, 8
lithium carbonate ER, 8
Lithobid, 8
Lithostat, 7
LO Minastrin FE, 5
lofene, 6
lokara, 4
lonox, 6
loperamide HCL, 6
lorazepam, 8
lorcet, 10
lorcet HD, 10
lorcet plus, 10
lortab, 10
Lortab, 10
loryna, 5
losartan potassium, 3
losartan potassium/hydrochlorothiazide,
3
Lotronex, 7
lovastatin, 3
low-ogestrel, 5
loxapine, 8
loxapine succinate, 8
Lufyllin, 11
Lumizyme, 6
lutera, 5
Lynparza, 2
Lyrica, 8
Lysodren, 2
lyza, 5
M
M-vit, 12
malathion, 4
Maprotiline HCL, 8
margesic, 10
marlissa, 5
Marplan, 8
Matulane, 2
matzim LA, 3
Maxair Autohaler, 11
maximum d3, 11
meclizine HCL, 7
Meclofenamate Sodium, 11
Medrol, 4
medroxyprogesterone acetate, 5(2)
mefenamic acid, 11
mefloquine HCL, 2
Megace ES, 5
megestrol acetate, 2
meijer aspirin EC, 10
Mekinist, 2
meloxicam, 11
Mentax, 4
mercaptopurine, 2
mesalamine, 7
Mesnex, 2
Mestinon, 9
Mestinon Timespan, 9
metadate ER, 8
Metaproterenol Sulfate, 11
metaxalone, 9
metformin HCL, 5
metformin HCL ER, 5
methadone HCL, 10
methadone HCL intensol, 10
methadose, 10
methamphetamine HCL, 8
methazolamide, 3
methenamine mandelate, 7
methimazole, 6
methocarbamol, 9
methotrexate, 2
methotrexate sodium, 2
methoxsalen, 4
methscopolamine bromide, 6
Methyclothiazide, 3
methyldopa, 3
methylergonovine maleate, 10
methylphenidate HCL, 8
methylphenidate HCL CD, 8
methylphenidate HCL ER, 8
methylphenidate HCL SR, 8
methylphenidate hydrochloride, 8
methylprednisolone, 4
methylprednisolone dose pack, 4
metoclopramide HCL, 7
metoclopramide odt, 7
metolazone, 3
metoprolol succinate ER, 2
metoprolol tartrate, 2
metoprolol/hydrochlorothiazide, 3
metronidazole, 2, 4
metronidazole vaginal, 7
mexiletine HCL, 3
Miconazole 3, 7
Microchamber, 12
microgestin 1.5/30, 5
microgestin 1/20, 5
microgestin FE, 5
microgestin FE 1.5/30, 5
micronized colestipol HCL, 3
Microspacer, 12
midazolam HCL, 8
midodrine HCL, 3
Mifeprex, 6
Migergot, 11
Migranal, 11
Millipred, 4
Millipred DP, 4
miniprin low dose, 10
minitran, 2
minocycline HCL, 1
minocycline HCL ER, 1
minoxidil, 3
Mirapex ER, 9
Mircera, 7
mirtazapine, 8
mirtazapine odt, 8
misoprostol, 6
MM aspirin, 10
moderiba, 1
Moderiba, 1
Moderiba 1200 Dose Pack, 1
Moderiba 800 Dose Pack, 1
moexipril HCL, 3
moexipril/hydrochlorothiazide, 3
mometasone furoate, 4
mono-linyah, 5
mononessa, 5
montelukast sodium, 11
Monurol, 7
morgidox 1X100MG, 1
morgidox 2X100MG, 1
morphine sulfate, 10
Morphine Sulfate, 10
morphine sulfate ER, 10
Motofen, 6
Moviprep, 6
Moxatag, 1
Multaq, 3
multi-vit/fluoride, 12
multi-vitamin/fluoride, 12
mupirocin, 4
mupirocin calcium, 4
my way, 5
Myalept, 6
mycophenolate mofetil, 2
mycophenolic acid DR, 2
mydral, 9
Myobloc, 9
Myozyme, 6
myzilra, 5
N
nabumetone, 11
nadolol, 2
nadolol/bendroflumethiazide, 3
Naftin, 4
Namenda, 9
Namenda Titration PAK, 9
Naphazoline HCL, 9
naproxen, 11
naproxen DR, 11
naproxen kit, 11
naproxen sodium, 11
naratriptan HCL, 11
nat-rul vitamin d, 11
nateglinide, 5
Natpara, 6
Natroba, 4
Nebupent, 2
nebusal, 11
necon 0.5/35-28, 5
necon 1/35, 5
Necon 1/50-28, 5
Necon 10/11-28, 5
necon 7/7/7, 5
nefazodone HCL, 8
neo-polycin, 9
neo-polycin HC, 9
neofrin, 9
neomycin sulfate, 1
neomycin/bacitracin/polymyxin, 9
neomycin/polymyxin/bacitracin zinc, 9
neomycin/polymyxin/bacitracin/hydrocorti
sone, 9
neomycin/polymyxin/dexamethasone, 9
neomycin/polymyxin/gramicidin, 9
neomycin/polymyxin/HC, 10
Neomycin/Polymyxin/Hydrocortisone, 9
neomycin/polymyxin/hydrocortisone, 10
Neoral, 2
Neulasta, 7
Neulasta Delivery Kit, 7
Neumega, 7
Neupogen, 7
Neupro, 9
neutragard advanced, 7
neutral sodium fluoride, 7
nevirapine, 1
Nevirapine, 1
nevirapine ER, 1
Nexavar, 2
next choice one dose, 5
Nexterone, 3
Niacor, 3
nicardipine HCL, 3
Nicotrol Inhaler, 9
Nicotrol Ns, 9
nifediac CC, 3
nifedical XL, 3
nifedipine, 3
nifedipine ER, 3
nikki, 5
Nilandron, 2
nimodipine, 3
Nitro-bid, 2
Nitro-dur, 2
nitrofurantoin, 7
nitrofurantoin macrocrystals, 7
nitrofurantoin monohydrate, 7
nitrofurantoin
monohydrate/macrocrystals, 7
nitroglycerin, 2
nitroglycerin lingual, 2
nitroglycerin transdermal, 2
Nitrostat, 2
Niva-plus, 12
nizatidine, 6
nora-be, 5
Norditropin Cartridge, 6
Norditropin Flexpro, 6
Norditropin Nordiflex Pen, 6
norethindrone, 5
norethindrone acetate, 5
norethindrone acetate/ethinyl estradiol,
4, 5
norethindrone acetate/ethinyl
estradiol/ferrous fumarate, 5
norgestimate/ethinyl estradiol, 5
Norinyl 1+50, 5
norlyroc, 5
Noroxin, 1
nortrel 0.5/35 (28), 5
nortrel 1/35, 5
nortrel 7/7/7, 5
nortriptyline HCL, 8
Norvir, 1
norwich aspirin, 10
novarel, 6
Noxafil, 1
Nuedexta, 9
nulev, 6
Nutropin, 6
Nutropin AQ Nuspin 10, 6
Nutropin AQ Nuspin 20, 6
Nutropin AQ Nuspin 5, 6
Nutropin AQ Pen, 6
Nuvaring, 5
Nuvigil, 8
nyamyc, 4
Nymalize, 3
nystatin, 1, 4, 7
nystatin/triamcinolone, 4
nystop, 4
O
O-CAL Fa, 12
ocella, 5
octreotide acetate, 6
Ofev, 11
ofloxacin, 1, 9, 10
Ogestrel, 5
olanzapine, 8
olanzapine odt, 8
olanzapine/fluoxetine, 9
Olysio, 1
omeprazole, 6
omeprazole/sodium bicarbonate, 6
Omnitrope, 6
ondansetron HCL, 7
ondansetron odt, 7
Onfi, 8
Onmel, 1
opcicon one-step, 5
Opium Tincture (paregoric), 6
Opsumit, 3
Optichamber Advantage, 12
Optichamber Diamond, 12
Optichamber Diamond/Largeface Mask,
12
Optichamber Diamond/Medium Face
Mask, 12
Optichamber Diamond/Smallface Mask,
12
Optihaler, 12
Optihaler MDI Drug Delivery System, 12
optimal-d, 11
optimal-d pack, 11
opurity vitamin d, 11
Oracit, 7
oralone, 7
Orap, 9
Orapred Odt, 4
Oravig, 8
Orfadin, 6
orphenadrine citrate ER, 9
orsythia, 5
ortho-est, 4
oscimin, 6
oscimin SR, 6
Osmoprep, 6
Otezla, 11
otic care, 10
oxandrolone, 4
oxaprozin, 11
oxazepam, 8
oxcarbazepine, 8
Oxistat, 4
Oxsoralen, 4
Oxtellar XR, 8
oxybutynin chloride, 7
oxybutynin chloride ER, 7
oxycodone HCL, 10
oxycodone/acetaminophen, 10
oxycodone/aspirin, 10
oxycodone/ibuprofen, 10
oxymorphone hydrochloride, 10
oxymorphone hydrochloride ER, 10
P
PA vitamin d-3, 12
PA vitamin d-3 gummy, 12
pacerone, 3
Pancrelipase, 7
pantoprazole sodium, 6
parcaine, 9
paricalcitol, 6
paroex, 7
paromomycin sulfate, 1
paroxetine HCL, 8
paroxetine HCL ER, 8
Paser, 1
Paxil, 8
PCE, 1
pedi-dri, 4
peg 3350/electrolytes, 6
peg-3350/electrolytes, 6
peg-3350/NACL/NA bicarbonate/KCL, 6
Peg-intron, 1
Peg-intron Redipen, 1
Peg-intron Redipen PAK 4, 1
peg-prep, 6
Peganone, 8
Pegasys, 1
Pegasys Proclick, 1
Pegintron, 1
pegylax, 6
penicillin v potassium, 1
pentoxifylline ER, 7
perindopril erbumine, 3
periogard, 8
permethrin, 4
perphenazine, 8
Pexeva, 8
phenadoz, 11
phenazo, 7
phenazopyridine HCL, 7
phenelzine sulfate, 8
phenergan, 11
phenobarbital, 8
phenylephrine HCL, 9
Phenytek, 8
phenytoin, 8
phenytoin infatabs, 8
phenytoin sodium extended, 8
philith, 5
phos-flur, 8
Phoslyra, 7
Phospholine Iodide, 9
pilocarpine HCL, 8, 9
pilocarpine hydrochloride, 8
pimtrea, 5
pindolol, 2
pioglitazone HCL, 5
pioglitazone HCL-glimepiride, 6
pioglitazone HCL/metformin HCL, 6
pirmella 1/35, 5
pirmella 7/7/7, 5
piroxicam, 11
Plegridy, 9
Plegridy Starter Pack, 9
Pliaglis, 4
PNV Folic Acid + Iron Multivitamin, 12
PNV Prenatal Plus Multivitamin, 12
Pocket Chamber, 12
Pocket Spacer, 12
Podocon 25 IN Benzoin Tincture, 4
podofilox, 4
poly-dex, 9
polycin, 9
polycin b, 9
polyethylene glycol 3350, 6
polymyxin b sulfate/trimethoprim sulfate,
9
Pomalyst, 2
portia-28, 5
potassium citrate ER, 7
potassium citrate-citric acid crystals, 7
potassium citrate/citric acid, 7
potassium citrate/sodium citrate/citric
acid, 7
Potiga, 8
Pradaxa, 7
pramipexole dihydrochloride, 9
pramipexole dihydrochloride ER, 9
Prandimet, 6
pravastatin sodium, 3
prazosin HCL, 3
Precision XTRA, 12
Precision XTRA Blood Glucose Test
Strips, 12
prednicarbate, 4
prednisolone, 4
prednisolone acetate, 9
prednisolone sodium phosphate, 4
Prednisolone Sodium Phosphate, 9
prednisolone sodium phosphate odt, 4
prednisone, 4
pregnyl w/diluent benzyl alcohol/NACL, 6
Premarin, 7
Prenaplus, 12
Prenatal, 12
Prenatal Low Iron, 12
Prenatal Plus, 12
Prenatal Vitamins Plus, 12
Preplus, 12
Prepopik, 6
prevalite, 3
previfem, 5
Prezcobix, 1
Prezista, 1
Priftin, 1
Primaquine Phosphate, 2
primidone, 8
Primsol, 2
Pristiq, 8
probenecid, 11
probenecid/colchicine, 11
prochlorperazine, 8
prochlorperazine edisylate, 8
prochlorperazine maleate, 8
Procrit, 7
procto-PAK, 7
proctosol HC, 7
proctozone-HC, 7
Procysbi, 7
progesterone, 5
Proglycem, 5
Promacta, 7
promethazine HCL, 11
promethazine HCL plain, 11
promethegan, 11
pronutrients vitamin d3, 11
propafenone HCL, 3
propafenone HCL ER, 3
Propantheline Bromide, 6
proparacaine HCL, 9
propranolol HCL, 2
propranolol HCL ER, 3
Propranolol/Hydrochlorothiazide, 3
propylthiouracil, 6
Prostigmin, 9
Prostin E2, 10
protriptyline HCL, 8
Prudoxin, 4
Pulmicort, 11
Pulmicort Flexhaler, 11
pulmosal, 11
Pulmozyme, 11
px aspirin, 10
px enteric aspirin, 10
Pylera, 6
pyrazinamide, 1
pyridostigmine bromide, 9
Pyrogallic Acid, 4
Q
qc aspirin, 10
qc aspirin low dose, 10
qc childrens aspirin, 10
Quartette, 5
quasense, 5
quetiapine fumarate, 8
quinapril HCL, 3
quinapril/hydrochlorothiazide, 3
quinidine gluconate CR, 3
quinidine gluconate ER, 3
quinidine sulfate, 3
Quinidine Sulfate ER, 3
quinine sulfate, 2
Qvar, 11
R
ra aspirin, 10
ra aspirin adult low dose, 10
ra aspirin adult low strength, 10
ra aspirin childrens, 10
ra aspirin EC, 10
ra aspirin EC adult low strength, 10
ra childrens aspirin, 10
ra lansoprazole, 6
ra vitamin d-3, 11
raloxifene hydrochloride, 6
ramipril, 3
Ranexa, 2
ranitidine HCL, 6
Rapamune, 2
Rayos, 4
Rebetol, 1
Rebif, 9
Rebif Rebidose, 9
Rebif Rebidose Titration Pack, 9
Rebif Titration Pack, 9
reclipsen, 5
Rectiv, 7
Relagesic, 10
Relenza Diskhaler, 1
Relistor, 7
Renagel, 7
Renvela, 7
repaglinide, 5
reprexain, 10
Rescriptor, 1
Revatio, 3
Revlimid, 2
Reyataz, 1
Rhinoflex-650, 10
ribasphere, 1
Ribasphere, 1
Ribasphere Ribapak, 1
Ribatab, 1
ribavirin, 1
Ridaura, 11
rifabutin, 1
Rifamate, 1
rifampin, 1
Rifater, 1
riluzole, 9
rimantadine HCL, 1
Riomet, 5
Risperdal Consta, 8
risperidone, 8
risperidone M-TAB, 8
risperidone odt, 8
Ritalin LA, 8
Riteflo, 12
rivastigmine tartrate, 9
rizatriptan benzoate, 11
rizatriptan benzoate odt, 11
romycin, 9
ropinirole ER, 9
ropinirole HCL, 9
rosadan, 4
roxicet, 10
Roxicet, 10
Rozerem, 8
S
Sabril, 9
Saizen, 6
Saizen Click.easy, 6
salsalate, 10
Samsca, 6
Sancuso, 7
Sandimmune, 2
Saphris, 8
Savella, 9
Savella Titration Pack, 9
SB aspirin, 10
SB aspirin EC, 10
SB childrens aspirin, 10
SB low dose asa EC, 10
selegiline HCL, 9
selenium sulfide, 4
Selzentry, 1
Sensipar, 6
Serevent Diskus, 11
Seroquel XR, 8
Serostim, 6
sertraline HCL, 8
Sevelamer Carbonate, 7
SF, 8
SF 5000 plus, 8
sharobel, 5
sildenafil, 3
sildenafil citrate, 3
simvastatin, 3
sirolimus, 2
Sivextro, 2
Sklice, 4
sm aspirin, 10
sm aspirin adult low strength, 10
sm aspirin EC low strength, 10
sm aspirin enteric coated, 10
sm aspirin low dose, 10
sm childrens aspirin, 10
sm lansoprazole, 6
sm vitamin d, 11
sm vitamin d3, 11
sodium chloride, 7, 11
sodium chloride 0.9%, 7
sodium citrate/citric acid, 7
sodium phenylbutyrate, 6
sodium sulfacetamide, 3, 9
solia, 5
Somavert, 6
sorine, 3
sotalol HCL, 3
Sotylize, 3
Sovaldi, 1
Spectracef, 1
Spinosad, 4
spironolactone, 3
spironolactone/hydrochlorothiazide, 3
Sporanox, 1
sprintec 28, 5
Sprycel, 2
sronyx, 5
st joseph aspirin, 10
stagesic, 10
Stalevo 100, 9
Stalevo 125, 9
Stalevo 150, 9
Stalevo 200, 9
Stalevo 50, 9
Stalevo 75, 9
stannous fluoride oral rinse, 8
stavudine, 1
Stavzor, 9
Stimate, 6
Stivarga, 2
Stribild, 1
Suclear, 6
Sucraid, 7
sucralfate, 6
sulfacetamide sodium, 3, 9
sulfacetamide sodium/prednisolone
sodium phosphate, 9
Sulfadiazine, 1
sulfamethoxazole/trimethoprim, 2
sulfamethoxazole/trimethoprim DS, 2
sulfasalazine, 7
sulfatrim pediatric, 2
sulfazine, 7
sulfazine EC, 7
sulindac, 11
sumatriptan succinate, 11
Sumatriptan Succinate, 11
sumatriptan succinate refill, 11
Suprax, 1
Suprep Bowel Prep, 6
Surmontil, 8
Sustiva, 1
Sutent, 2
syeda, 5
Sylatron, 2
symax fastabs, 6
symax-SL, 6
symax-SR, 6
Symbicort, 11
Symlinpen 120, 5
Symlinpen 60, 5
Synalgos-dc, 10
Synarel, 6
Synera, 4
Synribo, 2
Synthroid, 6
T
Tabloid, 2
tacrolimus, 2, 4
Tafinlar, 2
take action, 5
Tamiflu, 1
tamoxifen citrate, 2
tamsulosin HCL, 7
Tarceva, 2
Targretin, 2
tarina FE 1/20, 5
taron-crystals, 7
Tasigna, 2
Tazorac, 4
taztia XT, 3
temazepam, 8
terazosin HCL, 3
terbinafine HCL, 1
terbutaline sulfate, 11
terconazole, 7
Tersi Foam, 4
testosterone cypionate, 4
testosterone enanthate, 4
Tetanus/Diphtheria Toxoids-adsorbed
Adult, 11
tetcaine, 9
tetracaine HCL, 9
Tetracycline HCL, 1
tetravisc, 9
tetravisc forte, 9
Tev-tropin, 6
Teveten HCT, 3
Texacort, 4
tgt aspirin, 10
tgt aspirin low dose, 10
tgt childrens aspirin, 10
tgt enteric-coated aspirin, 10
th aspirin, 10
th aspirin low dose, 10
th enteric aspirin, 10
th vitamin d3, 11
Thalomid, 2
Theo-24, 11
theochron, 11
theophylline CR, 11
theophylline ER, 11
thera-d 2000, 11
thera-d rapid repletion, 11
thera-d sport, 11
Thiola, 7
thioridazine HCL, 8
thiothixene, 8
Thrombate Iii W/20 ML Sterile Water, 7
Thyrolar-1, 6
Thyrolar-1/2, 6
Thyrolar-1/4, 6
Thyrolar-2, 6
Thyrolar-3, 6
tiagabine hydrochloride, 8
ticlopidine HCL, 7
Tikosyn, 3
tilia FE, 5
Timolol Maleate, 3
timolol maleate, 9
timolol maleate ophthalmic gel forming, 9
tinidazole, 2
Tirosint, 6
Tivicay, 1
tizanidine HCL, 9
Tobi Podhaler, 1
tobramycin, 1
tobramycin sulfate, 9
tobramycin/dexamethasone, 9
tolazamide, 5
Tolazamide, 5
Tolbutamide, 5
tolcapone, 9
tolmetin sodium, 11
tolterodine tartrate, 7
topiragen, 8
topiramate, 8
torsemide, 3
Toviaz, 7
Tracleer, 3
Tradjenta, 5
tramadol HCL, 10
tramadol HCL ER, 10
tramadol hydrochloride/acetaminophen,
10
trandolapril, 3
trandolapril/verapamil HCL, 3
trandolapril/verapamil HCL ER, 3
tranexamic acid, 7
Transderm-scop, 7
tranylcypromine sulfate, 8
Travatan Z, 9
Travoprost, 9
trazodone HCL, 8
Trecator, 1
tretinoin, 2, 3
Trexall, 2
Trezix, 10
tri-estarylla, 5
tri-legest FE, 5
tri-linyah, 5
tri-previfem, 5
tri-sprintec, 5
Tri-vit/Fluoride/Iron, 12
triamcinolone acetonide, 4, 8, 11
Triamcinolone Acetonide, 4
triamcinolone IN orabase, 8
triamterene/hydrochlorothiazide, 3
triazolam, 8
Tricare, 12
tricitrates, 7
triderm, 4
trifluoperazine HCL, 8
trifluridine, 9
Triglide, 3
trihexyphenidyl HCL, 9
trilyte, 6
trimethobenzamide HCL, 7
trimethoprim, 2
trimethoprim sulfate/polymyxin b sulfate,
9
trinessa, 5
Triumeq, 1
trivora-28, 5
Trokendi XR, 9
tropicamide, 9
trospium chloride, 7
trospium chloride ER, 7
Truvada, 1
Tudorza Pressair, 11
Tybost, 1
Tykerb, 2
Tyzeka, 1
Tyzine, 11
Tyzine Pediatric Nasal Drops, 11
U
Uceris, 4
Ulesfia, 4
Uloric, 11
unithroid, 6
unithroid direct, 6
ursodiol, 7
V
Vagifem, 7
valacyclovir HCL, 1
Valcyte, 1
valganciclovir, 1
valproic acid, 8
valsartan, 3
valsartan/hydrochlorothiazide, 3
Valved Holding Chamber, 12
vancomycin HCL, 2
vandazole, 7
Vectical, 4
Veletri, 3
velivet, 5
venlafaxine HCL, 8
venlafaxine HCL ER, 8
Ventavis, 3
Ventolin HFA, 11
verapamil HCL, 3
verapamil HCL ER, 3
verapamil HCL SR, 3
verdrocet, 10
Veregen, 4
Veripred 20, 4
vestura, 5
Vibramycin, 1
vicodin, 10
vicodin ES, 10
vicodin HP, 10
Victoza, 5
Victrelis, 1
Videx Pediatric, 1
Viekira PAK, 1
Viibryd, 8
Vimizim, 6
Vimpat, 9
Vinate II, 12
viorele, 5
Viracept, 1
Viramune, 1
Viramune XR, 1
Virazole, 2
Viread, 2
virtrate-2, 7
virtrate-3, 7
virtrate-k, 7
vitamin d, 11
vitamin d 400, 11
vitamin d high potency, 11
vitamin d-1000, 11
vitamin d-1000 maximum strength, 11
vitamin d-3, 11
vitamin d-400, 11
vitamin d3, 12
vitamin d3 adult gummies, 12
vitamin d3 high potency, 12
vitamin d3 maximum strength, 12
vitamin d3 super strength, 12
Vitekta, 2
Vol-plus, 12
Voltaren, 4
voriconazole, 1
Vortex Valved Holding Chamber, 12
Votrient, 2
Vpriv, 7
Vusion, 4
vyfemla, 5
W
warfarin sodium, 7
Watchhaler, 12
wera, 5
wymzya FE, 5
X
Xalkori, 2
Xarelto, 7
Xenazine, 9
Xifaxan, 2
Xolegel, 4
Xtandi, 2
xulane, 5
xylon, 10
Xyrem, 9
Y
Yodoxin, 2
Z
zafirlukast, 11
zaleplon, 8
zamicet, 10
zarah, 5
Zavesca, 7
zazole, 7
zebutal, 10
Zelapar, 9
Zelboraf, 2
zenchent, 5
zenchent FE, 5
Zenpep, 7
zenzedi, 8
Zetia, 3
Zgesic, 10
Ziagen, 2
zidovudine, 1
ziprasidone HCL, 8
Zmax, 1
Zoladex, 2
Zolinza, 2
zolpidem tartrate, 8
Zomacton, 6
Zonalon, 4
zonisamide, 8
Zorbtive, 6
Zortress, 2
zovia 1/35e, 5
Zovia 1/50e, 5
Zovirax, 4
Zydelig, 2
Zyflo, 11
Zyflo CR, 11
Zykadia, 2
Zyprexa Relprevv, 8
Zytiga, 2
Zyvox, 2
8
8-mop, 4