Providence Health Plan - Oregon Health Plan Formulary Drug Name Status* Requirements/Limits
Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Analgesics acetaminophen (80mg/0.8ml drops susp, 100 mg/ml drops, 160 mg/5ml oral susp, 325 mg supp.rect, 325 mg tablet, 325/10.15 oral susp, 500 mg tablet, 650 mg supp.rect, 650 mg tablet er) OTC ACETAMINOPHEN PM OTC acetaminophen/diphenhydramine hcl OTC alagesic lq Generic ARTHRITIS PAIN RELIEF (KRO ARTHRIT RLF ER 650 MG, SB ARTHRITIS ER 650 MG, SB ARTHRITIS RLF 8-HR 650) OTC aspirin (81 mg tab chew, 81 mg tablet dr, 325 mg tablet, 325 mg tablet dr) OTC butalbital/acetaminophen Generic butalbital/acetaminophen/caffeine (50325-40 capsule, 50-325-40 tablet, 50500-40 tablet) Generic butalbital/aspirin/caffeine Generic capacet Generic CHILD TRIAMINIC FEVER REDUCER OTC CHILD'S ACCUDIAL ACETAMINOPHEN OTC CHILDREN'S PAIN & FEVER OTC CHILDREN'S PAIN RELIEF OTC CHILDREN'S PAIN RELIEVER OTC EXTRA STRENGTH NON-ASPIRIN OTC FEVERALL (120 MG, 325 MG, 650 MG) OTC fioricet 50-325-40 mg tablet Generic HALFPRIN OTC INFANT TRIAMINIC FEVER REDUCER OTC INFANT'S NON-ASPIRIN OTC *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 1 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* INFANT'S PAIN RELIEF OTC INFANTS' MAPAP OTC INFANTS' NON-ASPIRIN OTC INFANTS' PAIN & FEVER OTC INFANTS' PAIN RELIEVER OTC MAPAP (160 MG/5 ML SUSPENSION, 500 MG GELCAP) OTC MAPAP INFANT OTC MINIPRIN OTC NON-ASPIRIN OTC NON-ASPIRIN EXTRA STRENGTH OTC PAIN RELIEF PM OTC PAIN RELIEVER OTC PAIN RELIEVER PM OTC PV PAIN RELIEF 500 MG TABLET OTC tencon 50-325 mg tablet Generic tramadol hcl/acetaminophen Generic TYLENOL PM EXTRA STRENGTH OTC TYLENOL X-STR 500 MG/15 ML LIQ OTC zebutal capsule Generic Requirements/Limits QL (240 PER 30 DAYS) Nonsteroidal Anti-inflammatory Drugs ALL DAY PAIN RELIEF OTC ALL DAY RELIEF OTC aspirin 975 mg tablet dr Generic CELEBREX (50 MG, 100 MG, 200 MG) Brand PA, QL (60 PER 30 DAYS) CELEBREX 400 MG CAPSULE Brand PA, QL (30 PER 30 DAYS) CHILD IBUPROFEN OTC diclofenac potassium Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 2 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* diflunisal Generic etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet, 600 mg tab er 24h) Generic fenoprofen calcium 600 mg tablet Generic flurbiprofen (50 mg, 100 mg) Generic ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) Generic ibuprofen (50 mg/1.25 drops susp, 200 mg capsule, 200 mg tablet) OTC INDOCIN 25 MG/5 ML SUSPENSION Brand indomethacin (25 mg, 50 mg, 75 mg er) Generic ketoprofen (50 mg capsule, 75 mg capsule, 200 mg cap24h pel) Generic ketorolac tromethamine 10 mg tablet Generic meclofenamate sodium (50 mg, 100 mg) Generic meloxicam (7.5 mg, 15 mg) Generic MOTRIN IB OTC MOTRIN JR STR 100 MG TAB CHEW OTC nabumetone (500 mg, 750 mg) Generic NAPRELAN CR 500 MG TABLET Brand naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet, 500 mg tablet dr) Generic naproxen sodium (275 mg, 550 mg) Generic naproxen sodium 220 mg tablet OTC oxaprozin Generic piroxicam (10 mg, 20 mg) Generic sulindac (150 mg, 200 mg) Generic Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 3 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* tolmetin sodium Generic WAL-PROFEN OTC Requirements/Limits Opioid Analgesics, Long-acting fentanyl (12 mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100 mcg/hr) Generic QL (15 PER 30 DAYS) KADIAN ER 200 MG CAPSULE Brand methadone hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/5 ml solution, 10 mg/ml oral conc, 40 mg tablet sol) Generic methadone intensol Generic methadose 40 mg tablet dispr Generic morphine sulfate (30 mg, 60 mg) Generic morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 15 mg tablet er, 20 mg supp.rect, 30 mg cap er pel, 30 mg supp.rect, 30 mg tablet er, 50 mg cap er pel, 60 mg cap er pel, 60 mg tablet er, 80 mg cap er pel, 100 mg cap er pel, 100 mg tablet er, 200 mg tablet er) Generic oxycodone hcl (10 mg er, 20 mg er, 40 mg er, 80 mg er) Generic PA, QL (90 PER 30 DAYS) OXYCONTIN (15 MG, 30 MG, 60 MG) Brand PA, QL (90 PER 30 DAYS) tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mg tab er 24h, 200 mg tbmp 24hr, 300 mg tab er 24h, 300 mg tbmp 24hr) Generic PA Opioid Analgesics, Short-acting acetaminophen with codeine phosphate (120-12mg/5 solution, 240-24/10 solution, 300mg-15mg tablet, 300mg30mg tablet, 300mg-60mg tablet, 300mg/12.5 solution, 360-36/15 solution) Generic ascomp with codeine Generic butalbit/acetamin/caff/codeine 50-32530 capsule Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 4 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits butorphanol tartrate (1 mg/ml, 2 mg/ml) Generic PA butorphanol tartrate 10 mg/ml spray Generic co-gesic Generic codeine phosphate/butalbital/aspirin/caffeine Generic codeine phosphate/carisoprodol/aspirin Generic codeine sulfate (15 mg, 30 mg, 60 mg) Generic endocet Generic endodan Generic hydrocodone bit/acetaminophen Generic hydrocodone bitartrate/acetaminophen (2.5-167/5 solution, 2.5-500 mg tablet, 5 mg-500mg tablet, 5-334mg/10 solution, 5mg-325mg tablet, 7.5-325/15 solution, 7.5-325mg tablet, 7.5-500/15 solution, 7.5-500mg tablet, 7.5-650 mg tablet, 7.5-750mg tablet, 10-660mg tablet, 10mg-325mg tablet, 10mg500mg tablet, 10mg-650mg tablet) Generic hydrocodone/ibuprofen Generic hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mg supp.rect, 4 mg tablet, 8 mg tablet) Generic ibudone 5-200 mg tablet Generic lorcet Generic lorcet hd Generic lorcet plus 7.5-325 mg tablet Generic lortab (5-325 mg, 5-500, 7.5-325 mg, 10-325 mg) Generic meperidine hcl (50 mg tablet, 50 mg/5 ml solution, 100 mg tablet) Generic meperitab Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 5 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* morphine sulfate (10 mg/5 ml solution, 15 mg tablet, 20 mg/5 ml solution, 30 mg tablet, 100 mg/5ml solution) Generic MYLERAN Brand oxycodone hcl (5 mg capsule, 5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 15 mg tablet, 20 mg tablet, 20 mg/ml oral conc, 30 mg tablet) Generic oxycodone hcl/acetaminophen Generic oxycodone hcl/aspirin Generic oxymorphone hcl (5 mg, 10 mg) Generic pentazocine hcl/acetaminophen Generic pentazocine hcl/naloxone hcl Generic reprexain 10-200 mg tablet Generic ROXICET 5-325 ORAL SOLUTION Brand roxicet 5-325 tablet Generic stagesic Generic tramadol hcl 50 mg tablet Generic xylon 10 Generic Requirements/Limits PA Anesthetics Local Anesthetics glydo Generic lidocaine 5 % oint. (g) Generic lidocaine 5%(700mg) adh. patch Generic lidocaine hcl (2 % jel (ml), 2 % jel/pf app, 2 % solution, 4 % solution, 40 mg/ml solution) Generic lidocaine/prilocaine (2.5 cream (g), 2.5 kit) Generic NAROPIN (0.2% 400 MG/200 ML, 2 MG/ML INFUSION, 5 MG/ML INFUSION, 200 MG/100 ML INF) Brand PA, QL (90 PER 30 DAYS) *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 6 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium Generic disulfiram (250 mg, 500 mg) Generic buprenorphine hcl/naloxone hcl Generic Opioid Antagonists depade Generic naltrexone hcl 50 mg tablet Generic revia Generic Smoking Cessation Agents buproban Generic CHANTIX Brand nicotine (14mg/24hr, 21 mg/24hr) OTC Anti-inflammatory Agents Glucocorticoids alclometasone dipropionate Generic amcinonide 0.1 % cream (g) Generic ANALPRAM HC 2.5% LOTION Brand apexicon e Generic betamethasone dipropionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 % lotion, 0.05 % oint. (g)) Generic betamethasone dipropionate/propylene glycol (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) Generic betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 7 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* clobetasol propionate (0.05 % cream (g), 0.05 % foam, 0.05 % gel (gram), 0.05 % oint. (g), 0.05 % shampoo, 0.05 % solution) Generic clobetasol propionate/emollient base Generic clodan 0.05% shampoo Generic cormax Generic CORTISONE OTC desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) Generic desoximetasone Generic fludrocortisone acetate 0.1 mg tablet Generic fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, 0.025 % cream (g), 0.025 % oint. (g)) Generic fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 % solution) Generic fluocinonide/emollient base Generic fluticasone propionate (0.05 % cream (g), 0.05 % lotion) Generic halobetasol propionate Generic hydrocortisone (1 % lotion, 1 % packet) OTC hydrocortisone (2.5 % cream (g), 2.5 % lotion, 2.5 % oint. (g)) Generic hydrocortisone butyrate 0.1 % cream (g) Generic hydrocortisone/aloe vera 1 % cream (g) OTC millipred 5 mg tablet Generic millipred dp Generic nystatin/triamcinolone acetonide Generic oralone Generic ORAPRED ODT Brand Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 8 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* prednisolone 15 mg/5 ml solution Generic prednisolone sod phosphate (5 ml, 15 ml) Generic prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab ds pk, 10 mg tablet, 20 mg tablet, 50 mg tablet) Generic prednisone intensol Generic triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g), 0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.1 % paste (g), 0.5 % cream (g), 0.5 % oint. (g)) Generic triderm Generic Requirements/Limits Nonsteroidal Anti-inflammatory Drugs choline sal/mag salicylate 500 mg/5ml liquid Generic INDOCIN 50 MG SUPPOSITORY Brand Antibacterials Aminoglycosides garamycin 0.3% eye drops Generic gentak (0.3 % ointment, 3 mg/ml drops) Generic gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 0.3 % drops, 0.3 % oint. (g)) Generic neomycin sulfate 500 mg tablet Generic TOBI PODHALER Specialty tobramycin 0.3 % drops Generic tobramycin in 0.225 % sodium chloride Generic LA Antibacterials, Other acetasol hc Generic acetic acid 2 % solution Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 9 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* acetic acid/aluminum acetate Generic acetic acid/hydrocortisone Generic bacitracin 500 unit/g oint. (g) OTC bacitracin zinc (500 oint. (g), 500 oint.(ea)) OTC chlorhexidine gluconate 0.12 % mouthwash Generic clinda-derm Generic clindacin etz 1% pledget Generic clindacin p Generic clindamycin hcl (75 mg, 150 mg, 300 mg) Generic clindamycin palmitate hcl Generic clindamycin phosphate (1 % foam, 1 % gel (gram), 1 % lotion, 1 % med. swab, 1 % solution, 2 % cream/appl) Generic cycloserine 250 mg capsule Generic FLAGYL ER Brand MACRODANTIN 25 MG CAPSULE Brand methenamine hippurate Generic metronidazole (0.75 % gel (gram), 0.75 % gel w/appl, 0.75 % lotion, 250 mg tablet, 375 mg capsule, 500 mg tablet) Generic MONUROL Brand mupirocin 2 % oint. (g) Generic nitrofurantoin (25 mg/5 ml oral susp, 50 mg capsule) Generic nitrofurantoin macrocrystal (50 mg, 100 mg) Generic nitrofurantoin monohydrate/macrocrystals Generic paroex Generic Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 10 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits periogard Generic rosadan 0.75% gel Generic trimethoprim 100 mg tablet Generic TRIPLE ANTIBIOTIC OTC TRIPLE ANTIBIOTIC-PAIN RELIEF OTC vancomycin hcl (125 mg, 250 mg) Generic vandazole Generic XIFAXAN 200 MG TABLET Brand PA, QL (90 PER 30 DAYS) XIFAXAN 550 MG TABLET Brand PA, QL (60 PER 30 DAYS) ZYVOX (100 MG/5 ML SUSPENSION, 600 MG TABLET) Brand PA Beta-lactam, Cephalosporins CEDAX 90 MG/5 ML SUSPENSION Brand cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375 mg/5ml susp recon, 500 mg capsule, 500 mg tab er 12h) Generic cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule) Generic cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) Generic cefpodoxime proxetil (100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet) Generic cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) Generic ceftibuten dihydrate (180 mg/5ml susp recon, 400 mg capsule) Generic CEFTIN (125 ML, 250 ML) Brand cefuroxime axetil Generic cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg tablet) Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 11 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Beta-lactam, Penicillins amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg tab chew, 400 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 875 mg tablet) Generic amoxicillin/potassium clavulanate (20028.5/5 susp recon, 200-28.5mg tab chew, 250-125 mg tablet, 250-62.5/5 susp recon, 400-57mg tab chew, 40057mg/5 susp recon, 500-125 mg tablet, 600-42.9/5 susp recon, 875-125 mg tablet, 1000-62.5 tab er 12h) Generic ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule) Generic AUGMENTIN 125-31.25 MG/5 ML Brand dicloxacillin sodium Generic penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) Generic Macrolides AKNE-MYCIN Brand azithromycin (100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet) Generic clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tab er 24h, 500 mg tablet) Generic E.E.S. 200 Brand ery Generic ERY-TAB Brand erygel Generic ERYPED 200 Brand *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 12 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* ERYPED 400 Brand ERYTHROCIN STEARATE Brand erythromycin base (5 mg/g oint. (g), 5mg/g oint. (g), 250 mg capsule dr, 250 mg tablet, 500 mg tablet) Generic erythromycin base/ethyl alcohol (2 % gel (gram), 2 % med. swab, 2 % solution) Generic erythromycin ethylsuccinate 400 mg tablet Generic erythromycin ethylsuccinate/sulfisoxazole acetyl Generic Requirements/Limits Quinolones ciprofloxacin Generic ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) Generic ciprofloxacin/ciprofloxacin hcl Generic levofloxacin (0.5 % drops, 250 mg tablet, 250mg/10ml solution, 500 mg tablet, 750 mg tablet) Generic moxifloxacin hcl 400 mg tablet Generic ofloxacin (0.3 % drops, 200 mg tablet, 300 mg tablet, 400 mg tablet) Generic Sulfonamides bleph-10 Generic silver sulfadiazine 1 % cream (g) Generic sulfacetamide sodium 10 % drops Generic sulfamethoxazole/trimethoprim (20040mg/5 oral susp, 400mg-80mg tablet, 800-160 mg tablet, 800-160/20 oral susp) Generic sulfamide Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 13 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Tetracyclines avidoxy Generic demeclocycline hcl (150 mg, 300 mg) Generic doxycycline hyclate (50 mg capsule, 100 mg capsule, 100 mg tablet) Generic doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mg tablet, 75 mg tablet, 100 mg capsule, 100 mg tablet) Generic dynacin (50 mg, 100 mg) Generic minocycline hcl (50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet) Generic morgidox 100 mg capsule Generic OCUDOX Brand tetracycline hcl (250 mg, 500 mg) Generic VIBRAMYCIN 50 MG/5 ML SYRUP Brand Anticonvulsants Anticonvulsants, Other acetazolamide (125 mg, 250 mg) Generic levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet, 500 mg/5ml solution, 750 mg tab er 24h, 750 mg tablet, 1000 mg tablet) Generic primidone (50 mg, 250 mg) Generic Calcium Channel Modifying Agents CELONTIN Brand ethosuximide (250 mg capsule, 250 mg/5ml solution) Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 14 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits LYRICA (20 MG/ML ORAL SOLUTION, 25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE) Brand PA zonisamide Generic Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT Brand diazepam (5-7.5-10mg, 12.5-15-20) Generic diazepam 2.5 mg kit Brand gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet) Generic GABITRIL (12 MG, 16 MG) Brand ONFI (5 MG, 10 MG, 20 MG) Brand PA, QL (60 PER 30 DAYS) ONFI 2.5 MG/ML SUSPENSION Brand PA phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet) Generic SABRIL Brand tiagabine hcl Generic LA Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) Generic QUDEXY XR 200 MG CAPSULE Brand topiragen Generic topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) Generic topiramate (25 mg 24, 50 mg 24, 100 mg 24, 150 mg 24) Generic PA topiramate 200 mg cap spr 24 Brand PA PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 15 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits APTIOM Brand PA BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) Brand PA carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300 mg cpmp 12hr, 400 mg tab er 12h) Generic DILANTIN 30 MG CAPSULE Brand epitol Generic oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) Generic PEGANONE Brand PHENYTEK 300 MG CAPSULE Brand phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) Generic phenytoin sodium extended (100 mg, 200 mg) Generic phenytoin sodium extended 300 mg capsule Brand TEGRETOL XR 100 MG TABLET Brand VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET) Brand Sodium Channel Agents PA Antidementia Agents Cholinesterase Inhibitors donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tab rapdis, 10 mg tablet) Generic EXELON (2 MG/ML ORAL SOLUTION, 4.6 MG/24HR PATCH, 9.5 MG/24HR PATCH, 13.3 MG/24HR PATCH) Brand *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 16 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg tablet, 12 mg tablet) Generic rivastigmine tartrate Generic Requirements/Limits N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA (5 MG TABLET, 5-10 MG TITRATION PK, 10 MG TABLET) Brand PA, QL (60 PER 30 DAYS) NAMENDA 10 MG/5 ML SOLUTION Brand PA, QL (360 ML PER 30 DAYS) Antidepressants Antidepressants, Other budeprion sr 150 mg tablet Generic bupropion hcl 150 mg tablet er Generic Antiemetics Antiemetics, Other compro Generic DICLEGIS Brand hydroxyzine hcl (10 mg tablet, 10 mg/5 ml syrup, 25 mg tablet, 50 mg tablet) Generic hydroxyzine pamoate (25 mg, 50 mg, 100 mg) Generic meclizine hcl (12.5 mg, 25 mg) Generic metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10ml solution) Generic MOTION SICKNESS OTC MOTION SICKNESS II OTC MOTION SICKNESS RELIEF OTC MOTION-TIME OTC phenadoz Generic phenergan 25 mg/ml vial Generic QL (60 PER 30 DAYS) *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 17 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* prochlorperazine maleate (5 mg tablet, 10 mg tablet, 25 mg supp.rect) Generic promethazine hcl (6.25mg/5ml syrup, 12.5 mg supp.rect, 12.5 mg tablet, 25 mg supp.rect, 25 mg tablet, 25 mg/ml vial, 50 mg supp.rect, 50 mg tablet) Generic promethegan Generic TRAVEL SICKNESS 50 MG TABLET OTC trimethobenzamide hcl 300 mg capsule Generic Requirements/Limits Emetogenic Therapy Adjuncts EMEND (80 MG CAPSULE, 125 MG CAPSULE, TRIFOLD PACK) Brand ondansetron Generic ondansetron hcl (4 mg tablet, 4 mg/5 ml solution, 8 mg tablet, 24 mg tablet) Generic QL (4 PER 30 DAYS) Antifungals ANTIFUNGAL CREAM OTC ciclodan 0.77% cream Generic ciclopirox (0.77 % gel (gram), 1 % shampoo) Generic ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) Generic clotrimazole (1 % cream (g), 1 % solution, 10 mg troche) Generic clotrimazole 2 % cream/appl OTC clotrimazole/betamethasone dipropionate (1 % cream (g), 1 % lotion) Generic DESENEX OTC econazole nitrate 1 % cream (g) Generic fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet) Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 18 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* flucytosine (250 mg, 500 mg) Generic griseofulvin ultramicrosize Generic griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) Generic GYNE-LOTRIMIN OTC itraconazole 100 mg capsule Generic JOCK ITCH OTC ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo) Generic ketodan 2% foam Generic LOTRIMIN AF 2% SPRAY POWDER OTC miconazole nitrate (2 % cream (g), 2 % cream/appl, 200 mg-2 % cmb pf crm, 200 mg-2 % kit) OTC miconazole nitrate 200 mg supp.vag Generic MIRANEL AF OTC MITRAZOL OTC MONISTAT 7 Brand NOXAFIL DR 100 MG TABLET Brand nyamyc Generic nystatin (50mm unit powder(ea), 100k unit tablet, 150mm unit powder(ea), 500k unit tablet, 500mm unit powder(ea), 100000/g cream (g), 100000/g oint. (g), 100000/g powder, 100000/ml oral susp) Generic nystop Generic OXISTAT (CREAM, LOTION) Brand pedi-dri Generic SPORANOX 10 MG/ML SOLUTION Brand terbinafine hcl 250 mg tablet Generic terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) Generic Requirements/Limits PA PA PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 19 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* voriconazole (200 mg tablet, 200 mg/5ml susp recon) Generic Requirements/Limits Antigout Agents allopurinol (100 mg, 300 mg) Generic colchicine/probenecid Generic COLCRYS Brand probenecid Generic QL (60 PER 30 DAYS) Antimigraine Agents Ergot Alkaloids cafergot Generic dihydroergotamine mesylate 0.5mg/spry spray/pump Brand ergotamine tartrate/caffeine Generic migergot Generic MIGRANAL Brand QL (3.5 ML PER 30 DAYS) QL (3.5 ML PER 30 DAYS) Prophylactic timolol maleate (5 mg, 10 mg, 20 mg) Generic Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl Generic QL (18 PER 30 DAYS) rizatriptan benzoate Generic QL (24 PER 30 DAYS) sumatriptan (5 mg, 20 mg) Generic QL (6 PER 30 DAYS) sumatriptan succinate (25 mg, 50 mg, 100 mg) Generic QL (18 PER 30 DAYS) sumatriptan succinate (4 cartridge, 4 pen injctr, 6 cartridge, 6 pen injctr, 6 syringe, 6 vial) Generic QL (2 ML PER 30 DAYS) zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet) Generic QL (12 PER 30 DAYS) ZOMIG (2.5 MG, 5 MG) Brand QL (12 PER 30 DAYS) *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 20 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Antimyasthenic Agents Parasympathomimetics MESTINON (60 MG/5 ML SYRUP, 180 MG TIMESPAN) Brand pyridostigmine bromide 60 mg tablet Generic Antimycobacterials Antimycobacterials, Other dapsone (25 mg, 100 mg) Generic rifabutin Generic Antituberculars ethambutol hcl Generic isonarif Generic isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) Generic pyrazinamide Generic rifampin (150 mg, 300 mg) Generic SIRTURO Specialty LA ALKERAN 2 MG TABLET Brand PA CEENU Brand cyclophosphamide capsules Generic cyclophosphamide tablets Generic LEUKERAN Brand lomustine Brand MATULANE Specialty Antineoplastics Alkylating Agents *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 21 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits REVLIMID Specialty PA, LA THALOMID Specialty Antiangiogenic Agents Antiestrogens/Modifiers EMCYT Specialty FARESTON Brand FASLODEX Brand SOLTAMOX Brand tamoxifen citrate (10 mg, 20 mg) Generic PA Antimetabolites capecitabine Generic DROXIA Brand hydroxyurea 500 mg capsule Generic mercaptopurine 50 mg tablet Generic methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) Generic methotrexate sodium/pf (1 g, 25 mg/ml) Generic RHEUMATREX Brand TABLOID Brand TREXALL Brand Antineoplastics, Other flutamide Generic HEXALEN Specialty imiquimod 5 % cream pack Generic leucovorin calcium 5 mg tablet Generic temozolomide Specialty PA VALCHLOR Specialty PA, LA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 22 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits ZOLADEX 3.6 MG IMPLANT SYRN Brand PA Aromatase Inhibitors, 3rd Generation anastrozole 1 mg tablet Generic exemestane Generic letrozole 2.5 mg tablet Generic Enzyme Inhibitors etoposide 50 mg capsule Generic GILOTRIF Specialty PA, LA JAKAFI Specialty PA, LA MEKINIST Specialty PA TAFINLAR Specialty PA VOTRIENT Specialty PA ZYTIGA Specialty PA AFINITOR (2.5 MG, 5 MG, 10 MG) Specialty PA, QL (30 PER 30 DAYS) AFINITOR 7.5 MG TABLET Brand PA, QL (30 PER 30 DAYS) AFINITOR DISPERZ Specialty QL (30 PER 30 DAYS) CAPRELSA 100 MG TABLET Specialty PA COMETRIQ Specialty PA, LA ERIVEDGE Specialty PA, LA GLEEVEC Specialty PA ICLUSIG Specialty PA, LA IMBRUVICA Specialty PA, LA INLYTA Specialty PA, LA NEXAVAR Specialty PA SPRYCEL Specialty PA STIVARGA Specialty PA SUTENT Specialty PA Molecular Target Inhibitors *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 23 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits TARCEVA Specialty PA TASIGNA Specialty PA TYKERB Specialty PA vandetanib Specialty PA ZELBORAF Specialty PA ZOLINZA Specialty PA ZYKADIA Specialty PA TARGRETIN (1% GEL, 75 MG CAPSULE, 75 MG SOFTGEL) Specialty PA tretinoin 10 mg capsule Specialty PA Retinoids Antiparasitics Anthelmintics ALBENZA Brand STROMECTOL Brand Antiprotozoals atovaquone Generic PA atovaquone/proguanil hcl Generic PA chloroquine phosphate (250 mg, 500 mg) Generic PA DARAPRIM Brand PA hydroxychloroquine sulfate 200 mg tablet Generic NEBUPENT Brand primaquine phosphate Generic PA tinidazole (250 mg, 500 mg) Generic PA Pediculicides/Scabicides elimite Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 24 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* lindane Generic permethrin 5 % cream (g) Generic ULESFIA Brand Requirements/Limits Antiparkinson Agents Anticholinergics benztropine mesylate (0.5 mg, 1 mg, 2 mg) Generic trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg tablet) Generic Antiparkinson Agents, Other amantadine hcl (50 mg/5 ml syrup, 100 mg capsule, 100 mg tablet) Generic carbidopa/levodopa/entacapone Generic entacapone Generic Dopamine Agonists bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) Generic pramipexole di-hcl Generic ropinirole hcl (0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg) Generic Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa 25 mg tablet Generic carbidopa/levodopa (10mg-100mg, 25mg-100mg, 25mg-100mg er, 25mg250mg, 50mg-200mg er) Generic Monoamine Oxidase B (MAO-B) Inhibitors AZILECT Brand selegiline hcl (5 mg capsule, 5 mg tablet) Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 25 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Antispasticity Agents baclofen (10 mg, 20 mg) Generic dantrolene sodium (25 mg, 50 mg, 100 mg) Generic tizanidine hcl (2 mg, 4 mg) Generic Antivirals Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors EDURANT Brand INTELENCE Brand nevirapine (50 mg/5 ml oral susp, 200 mg tablet, 400 mg tab er 24h) Generic RESCRIPTOR 100 MG TABLET Brand SUSTIVA Brand VIRAMUNE XR 100 MG TABLET Brand Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate Generic abacavir sulfate/lamivudine/zidovudine Generic didanosine Generic EMTRIVA 200 MG CAPSULE Brand EPIVIR 10 MG/ML ORAL SOLN Brand EPZICOM Brand lamivudine (150 mg, 300 mg) Generic lamivudine/zidovudine Generic stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) Generic TRUVADA Brand VIDEX Brand *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 26 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER) Brand ZIAGEN 20 MG/ML SOLUTION Brand zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) Generic Requirements/Limits Anti-HIV Agents, Other ATRIPLA Brand COMPLERA Brand FUZEON Brand ISENTRESS (100 MG POWDER PACKET, 400 MG TABLET) Brand SELZENTRY Brand STRIBILD Brand TIVICAY Brand Anti-HIV Agents, Protease Inhibitors APTIVUS 250 MG CAPSULE Brand CRIXIVAN Brand INVIRASE Brand KALETRA (100-25 MG TABLET, 200-50 MG TABLET, 400-100/5 ML ORAL SOLU) Brand LEXIVA 700 MG TABLET Brand NORVIR (80 MG/ML SOLUTION, 100 MG SOFTGEL CAP, 100 MG TABLET) Brand PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) Brand REYATAZ Brand VIRACEPT Brand *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 27 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits VALCYTE 450 MG TABLET Brand QL (60 PER 30 DAYS) VALCYTE 50 MG/ML SOLUTION Brand ZIRGAN Brand Anti-cytomegalovirus (CMV) Agents Anti-influenza Agents RELENZA Brand rimantadine hcl Generic TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE) Brand Antihepatitis Agents adefovir dipivoxil Specialty BARACLUDE 0.05 MG/ML SOLUTION Specialty PA entecavir Specialty PA EPIVIR HBV 25 MG/5 ML SOLN Brand INCIVEK Specialty INFERGEN Specialty INTRON A (6 MILLION UNIT/ML VL, 10 MILLION UNIT/ML, 10 MILLION UNITS VIL, 18 MILLION UNITS VIL, 50 MILLION UNITS VIL) Specialty lamivudine 100 mg tablet Generic MODERIBA Specialty PA OLYSIO Specialty PA PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) Specialty PA PEGASYS PROCLICK Specialty PA PEGINTRON Specialty PA PEGINTRON REDIPEN Specialty PA REBETOL 40 MG/ML SOLUTION Specialty PA PA PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 28 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits RIBAPAK Specialty PA RIBASPHERE Specialty PA RIBATAB Specialty PA ribavirin (200 mg capsule, 200 mg tablet, 400 mg tablet, 600 mg tablet) Specialty PA SOVALDI Specialty PA SYLATRON Specialty PA, QL (1 PER 28 DAYS) SYLATRON 4-PACK Specialty PA, QL (1 PER 28 DAYS) VICTRELIS Specialty PA Antiherpetic Agents acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) Generic DENAVIR Brand famciclovir Generic trifluridine 1 % drops Generic valacyclovir hcl (500 mg, 1000 mg) Generic PA Blood Glucose Regulators Antidiabetic Agents acarbose Generic ACTOPLUS MET XR Brand BYDUREON Brand PA BYDUREON PEN Brand PA BYETTA Brand PA chlorpropamide Generic FARXIGA Brand glimepiride Generic glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10 mg tab er 24, 10 mg tablet) Generic PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 29 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits glipizide/metformin hcl Generic glyburide Generic glyburide,micronized Generic glyburide/metformin hcl Generic INVOKANA Brand PA JANUMET Brand PA JANUMET XR Brand PA JANUVIA Brand PA JENTADUETO Brand PA JUVISYNC (50-20 MG, 50-40 MG) Brand PA KAZANO Brand PA KOMBIGLYZE XR Brand PA metformin hcl (500 mg tab er 24h, 500 mg tablet, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet) Generic NESINA Brand PA ONGLYZA Brand PA OSENI Brand PA pioglitazone hcl Generic pioglitazone hcl/glimepiride Generic pioglitazone hcl/metformin hcl Generic RIOMET Brand SYMLINPEN 120 Brand PA SYMLINPEN 60 Brand PA tolazamide Generic TRADJENTA Brand PA VICTOZA 2-PAK Brand PA VICTOZA 3-PAK Brand PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 30 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Glycemic Agents GLUCAGEN Brand GLUCAGON EMERGENCY KIT Brand Insulins APIDRA Brand APIDRA SOLOSTAR Brand HUMALOG Brand HUMALOG MIX 50-50 Brand HUMALOG MIX 75-25 Brand HUMULIN 70-30 (, RELION) OTC HUMULIN N (HUMULI100 UITS/ML VIAL, RELIOHUMULI100 UIT/ML) OTC HUMULIN R (100 UNITS/ML VIAL, ELION 100 UNIT/ML) OTC LANTUS Brand LEVEMIR Brand LEVEMIR FLEXPEN Brand LEVEMIR FLEXTOUCH Brand NOVOLIN 70-30 OTC NOVOLIN N OTC NOVOLIN R OTC NOVOLOG Brand NOVOLOG FLEXPEN Brand NOVOLOG MIX 70-30 Brand NOVOLOG MIX 70-30 FLEXPEN Brand Blood Products/Modifiers/ Volume Expanders Anticoagulants ELIQUIS Brand *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 31 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* enoxaparin sodium Generic fondaparinux sodium Generic FRAGMIN Specialty heparin 50 units/5 ml (10/ml) Generic heparin sodium,porcine (10 unit/ml syringe, 10 unit/ml vial, 100/ml (1) syringe, 100/ml vial, 500/5 ml syringe, 1000/ml vial, 5000/ml vial, 10000/ml vial, 20000/ml vial) Generic heparin sodium,porcine/pf (10 unit/ml syringe, 10 unit/ml vial, 100/ml (1) vial, 500/5 ml syringe, 1000/10 ml syringe, 1000/ml vial) Generic jantoven Generic monoject prefill advanced (1,000 unit/10 (100/ml), 30 units/3 ml (10/ml), 100 unit/10 ml (10/ml), 500 unit/5 ml (100/ml)) Generic PRADAXA Brand warfarin sodium (1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg, 10 mg) Generic XARELTO Brand Requirements/Limits Blood Formation Modifiers anagrelide hcl Generic ARANESP Specialty PA EPOGEN Specialty PA GRANIX Brand LEUKINE (250 MCG, 500 MCG/ML) Specialty NEULASTA Specialty NEUMEGA Specialty NEUPOGEN Specialty PROCRIT Specialty PA PROMACTA (12.5 MG, 25 MG, 50 MG) Specialty PA PA PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 32 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Coagulants MEPHYTON Brand tranexamic acid 650 mg tablet Generic Platelet Modifying Agents AGGRENOX Brand BRILINTA Brand cilostazol Generic clopidogrel bisulfate 75 mg tablet Generic dipyridamole (25 mg, 50 mg, 75 mg) Generic EFFIENT Brand ticlopidine hcl Generic Cardiovascular Agents Alpha-adrenergic Agonists clonidine Generic clonidine hcl (0.1 mg, 0.2 mg, 0.3 mg) Generic clorpres Generic guanfacine hcl Generic methyldopa Generic methyldopa/hydrochlorothiazide Generic midodrine hcl (2.5 mg, 5 mg) Generic Alpha-adrenergic Blocking Agents doxazosin mesylate Generic prazosin hcl (1 mg, 2 mg, 5 mg) Generic terazosin hcl Generic Angiotensin II Receptor Antagonists candesartan cilexetil Generic eprosartan mesylate Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 33 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* irbesartan Generic irbesartan/hydrochlorothiazide Generic losartan potassium Generic losartan potassium/hydrochlorothiazide Generic valsartan Generic valsartan/hydrochlorothiazide Generic Requirements/Limits Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl (5 mg, 10 mg, 20 mg, 40 mg) Generic benazepril hcl/hydrochlorothiazide Generic captopril (12.5 mg, 25 mg, 50 mg, 100 mg) Generic captopril/hydrochlorothiazide Generic enalapril maleate (2.5 mg, 5 mg, 10 mg, 20 mg) Generic enalapril maleate/hydrochlorothiazide Generic EPANED Brand fosinopril sodium Generic fosinopril sodium/hydrochlorothiazide Generic lisinopril (2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40 mg) Generic lisinopril/hydrochlorothiazide Generic moexipril hcl Generic perindopril erbumine Generic quinapril hcl Generic quinapril hcl/hydrochlorothiazide Generic trandolapril 1 mg tablet Generic Antiarrhythmics amiodarone hcl (100 mg, 200 mg, 400 mg) Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 34 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* disopyramide phosphate Generic flecainide acetate Generic mexiletine hcl (150 mg, 200 mg, 250 mg) Generic MULTAQ Brand NORPACE CR Brand pacerone 200 mg tablet Generic propafenone hcl (150 mg, 225 mg, 300 mg) Generic quinidine gluconate 324 mg tablet er Generic quinidine sulfate (200 mg, 300 mg, 300 mg er) Generic sorine Generic sotalol hcl (80 mg, 120 mg, 160 mg, 240 mg) Generic verapamil hcl (40 mg, 80 mg, 120 mg) Generic Requirements/Limits Beta-adrenergic Blocking Agents acebutolol hcl (200 mg, 400 mg) Generic atenolol (25 mg, 50 mg, 100 mg) Generic atenolol/chlorthalidone Generic betaxolol hcl (10 mg, 20 mg) Generic bisoprolol fumarate Generic bisoprolol fumarate/hydrochlorothiazide Generic carvedilol Generic COREG CR Brand esmolol hcl Generic INDERAL XL Brand INNOPRAN XL Brand labetalol hcl (100 mg, 200 mg, 300 mg) Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 35 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* LEVATOL Brand metoprolol succinate Generic metoprolol tartrate (25 mg, 50 mg, 100 mg) Generic metoprolol tartrate/hydrochlorothiazide Generic nadolol (20 mg, 40 mg, 80 mg) Generic pindolol Generic propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mg tablet, 120 mg cap sa 24h, 160 mg cap sa 24h) Generic propranolol hcl/hydrochlorothiazide Generic Requirements/Limits Calcium Channel Blocking Agents afeditab cr Generic amlodipine besylate (2.5 mg, 5 mg, 10 mg) Generic amlodipine besylate/benazepril hcl (5 mg-40 mg, 10 mg-40mg) Generic CARDENE SR Brand cartia xt Generic dilt-cd Generic dilt-xr Generic diltia xt Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 36 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120 mg capsule er, 120 mg tablet, 180 mg cap er 24h, 180 mg cap er deg, 180 mg capsule er, 180 mg tab er 24h, 240 mg cap er 24h, 240 mg cap er deg, 240 mg capsule er, 240 mg tab er 24h, 300 mg cap er 24h, 300 mg capsule er, 360 mg cap er 24h, 360 mg capsule er, 360 mg tab er 24h, 420mg capsule er, 420mg tab er 24h) Generic diltiazem hcl 300 mg tab er 24h Generic diltzac er Generic felodipine Generic matzim la (180 mg, 240 mg, 360 mg, 420 mg) Generic matzim la 300 mg tablet Generic nicardipine hcl (20 mg, 30 mg) Generic nifediac cc Generic nifedical xl Generic nifedipine (10 mg capsule, 20 mg capsule, 30 mg tab er 24, 30 mg tablet er, 60 mg tab er 24, 60 mg tablet er, 90 mg tab er 24, 90 mg tablet er) Generic nimodipine 30 mg capsule Generic nisoldipine (8.5mg er, 17 mg er, 25.5 mg er, 34 mg er) Generic taztia xt Generic verapamil hcl (100 mg cap24h pct, 120 mg cap24h pel, 120 mg tablet er, 180 mg cap24h pel, 180 mg tablet er, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360 mg cap24h pel) Generic Requirements/Limits PA PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 37 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Cardiovascular Agents, Other amlodipine besylate/atorvastatin calcium Generic digox Generic digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) Generic LANOXIN (62.5 MCG, 187.5 MCG) Brand omega-3 fatty acids/fish oil (3001000mg, 340-1000mg) OTC omega-3 fatty acids/vitamin e OTC omega-3/dha/epa/fish oil 500-1000mg capsule OTC pentoxifylline 400 mg tablet er Generic reserpine (0.1 mg, 0.25 mg) Generic Diuretics, Carbonic Anhydrase Inhibitors acetazolamide 500 mg capsule er Generic methazolamide (25 mg, 50 mg) Generic Diuretics, Loop bumetanide (0.5 mg, 1 mg, 2 mg) Generic EDECRIN Brand furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 80 mg tablet) Generic SODIUM EDECRIN Brand torsemide (5 mg, 10 mg, 20 mg, 100 mg) Generic Diuretics, Potassium-sparing amiloride hcl 5 mg tablet Generic amiloride hcl/hydrochlorothiazide Generic eplerenone 25 mg tablet Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 38 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* spironolactone (25 mg, 50 mg, 100 mg) Generic spironolactone/hydrochlorothiazide Generic triamterene/hydrochlorothiazide Generic Requirements/Limits Diuretics, Thiazide chlorothiazide Generic chlorthalidone Generic hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25 mg tablet, 50 mg tablet) Generic indapamide Generic methyclothiazide Generic metolazone Generic Dyslipidemics, Fibric Acid Derivatives fenofibrate (54 mg, 160 mg) Generic fenofibrate nanocrystallized Generic fenofibrate,micronized (67 mg, 134mg, 200 mg) Generic fenofibric acid Generic fenofibric acid (choline) Generic gemfibrozil 600 mg tablet Generic lofibra Generic TRIGLIDE 160 MG TABLET Brand Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium Generic fluvastatin sodium Generic lovastatin Generic pravastatin sodium Generic simvastatin (5 mg, 10 mg, 20 mg, 40 mg) Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 39 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Dyslipidemics, Other cholestyramine (with sugar) (suar) 4 powd pack, suar) 4 powder) Generic cholestyramine/aspartame 4 g powd pack Generic COLESTID FLAVORED GRANULES Brand colestid granules Generic colestipol hcl (1 tablet, 5 packet, 5 ranules) Generic JUXTAPID Specialty PA, LA KYNAMRO Specialty PA, LA niacin (500 mg er, 750 mg er, 1000 mg er) Generic PA niacin (500 mg, 500 mg er) OTC omega-3 acid ethyl esters Generic prevalite packet Generic ZETIA Brand PA PA Vasodilators, Direct-acting Arterial hydralazine hcl (10 mg, 25 mg, 50 mg, 100 mg) Generic minoxidil (2.5 mg, 10 mg) Generic Vasodilators, Direct-acting Arterial/Venous isochron Generic isosorbide dinitrate Generic isosorbide mononitrate Generic minitran Generic NITRO-BID Brand NITRO-DUR (0.3, 0.8) Brand nitro-time Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 40 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er) Generic NITROSTAT Brand Requirements/Limits Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine sulfsaccharate/amphetamine sulfaspartate Generic dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet, 10 mg capsule er, 10 mg tablet, 15 mg capsule er) Generic VYVANSE Brand zenzedi (5 mg, 10 mg) Generic Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines DAYTRANA Brand dexmethylphenidate hcl (5 mg, 10 mg) Generic metadate er Generic methylphenidate hcl (5 mg tablet, 10 mg cpbp 30-70, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 18 mg tab er 24, 20 mg cpbp 30-70, 20 mg cpbp 50-50, 20 mg tablet, 20 mg tablet er, 27 mg tab er 24, 30 mg cpbp 30-70, 30 mg cpbp 50-50, 36 mg tab er 24, 40 mg cpbp 30-70, 40 mg cpbp 50-50, 50 mg cpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70) Generic RITALIN LA 10 MG CAPSULE Brand PA, QL (30 PER 30 DAYS) Central Nervous System Agents, Other NUEDEXTA Brand riluzole Generic PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 41 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits XENAZINE Specialty PA Brand PA, QL (60 PER 30 DAYS) AMPYRA Specialty PA, LA, QL (60 PER 30 DAYS) AUBAGIO Specialty PA, LA, QL (30 PER 30 DAYS) AVONEX (30 MCG, 30 MCG KT) Specialty AVONEX ADMINISTRATION PACK Specialty AVONEX PEN Specialty BETASERON 0.3 MG KIT Specialty PA, QL (14 PER 30 DAYS) BETASERON 0.3 MG VIAL Specialty PA, QL (15 PER 30 DAYS) COPAXONE 20 MG/ML SYRINGE Specialty QL (30 ML PER 30 DAYS) COPAXONE 40 MG/ML SYRINGE Specialty QL (12 ML PER 28 DAYS) EXTAVIA 0.3 MG KIT Specialty PA, QL (14 PER 30 DAYS) EXTAVIA 0.3 MG VIAL Specialty PA, QL (15 PER 30 DAYS) FIRAZYR Specialty PA, QL (9 ML PER 30 DAYS) GILENYA Specialty PA, QL (30 PER 30 DAYS) PLEGRIDY Specialty QL (1 ML PER 28 DAYS) PLEGRIDY PEN Specialty QL (1 ML PER 28 DAYS) REBIF (22 ML, 44 ML) Specialty QL (6 ML PER 30 DAYS) REBIF REBIDOSE (22 ML, 44 ML) Specialty QL (6 ML PER 30 DAYS) REBIF REBIDOSE TITRATION PACK Specialty QL (4.2 ML PER 30 DAYS) TECFIDERA Specialty QL (60 PER 30 DAYS) Fibromyalgia Agents SAVELLA 50 MG TABLET Multiple Sclerosis Agents Dental and Oral Agents pilocarpine hcl (5 mg, 7.5 mg) Generic Dermatological Agents acitretin Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 42 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits ANTI-ITCH OTC calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 % solution) Generic calcitrene Generic CONDYLOX 0.5% GEL Brand CORTAID 1% CREAM OTC CORTIZONE-10 OTC DRITHOCREME HP Brand ELIDEL Brand EPIFOAM Brand gengraf 100 mg capsule Generic HC-1% HEMORRHOID OTC hydrocortisone (1 % cream, 1 % oint.) Generic hydrocortisone 0.5 % cream (g) OTC HYDROCORTISONE PLUS 12 OTC ITCH RELIEF OTC ITCH-X HC OTC mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) Generic PICATO Brand podofilox 0.5 % solution Generic PROTOPIC Brand PA REGRANEX Brand PA selenium sulfide (2.25 % shampoo, 2.5 % suspension) Generic trianex Generic VOLTAREN Brand WAL-DRYL 2%-0.1% CREAM OTC PA PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 43 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits BUPHENYL 500 MG TABLET Specialty PA CARBAGLU Brand CREON Brand ELELYSO Specialty KUVAN Specialty ORFADIN 2 MG CAPSULE Specialty pancrelipase 5,000 Generic RAVICTI Specialty LA sodium phenylbutyrate 0.94 g/g powder Specialty PA ZENPEP (3,000, 10,000, 15,000, 20,000, 25,000) Brand Enzyme Replacement/ Modifiers PA, LA Gastrointestinal Agents Antispasmodics, Gastrointestinal CUVPOSA Brand dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet) Generic PA Gastrointestinal Agents, Other aluminum hydroxide 320 mg/5ml oral susp OTC *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 44 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* ANTACID (500 MG CHEW TABLET, 500 MG CHEWABLE TABLET, CVS 500 MG CHEW TABLET, CVS 500 MG TABLET CHEW, EQ 500 MG CHEW TABLET, EQL 500 MG CHEW TABLET, GNP 500 MG CHEW TABLET, KRO 500 MG CHEW TABLET, LIQUID, PUB 500 MG CHEW TABLET, QC 500 MG CHEW TABLET, RA 500 MG CHEW TABLET, RA LIQUID SUSPENSION, SB 500 MG CHEW TABLET, SM 500 MG CHEW TABLET, SUSPENSION) OTC ANTACID EXTRA STRENGTH OTC ANTACID PLUS EXTRA STRENGTH OTC ANTACID ULTRA STRENGTH OTC ANTI-DIARRHEAL (1 MG/5 ML SOLN, 2 MG CAPLET, CVS 2 MG SFTGEL, RA 2 MG CAPLET) OTC APRISO Brand ASACOL Brand ASACOL HD Brand BAN-ACID OTC CAL-GEST OTC CALCIUM ANTACID OTC calcium carbonate (200(500)mg tab chew, 600 mg tablet) OTC CANASA Brand DELZICOL Brand diphenoxylate hcl/atropine sulfate (2.5.025/5 liquid, 2.5-.025mg tablet) Generic ENEMA OTC EQUALIZER GAS RELIEF OTC FOAMING ANTACID OTC FULYZAQ Brand Requirements/Limits PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 45 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* GAS RELIEF (80 MG TABLET CHEW, 125 MG CHEW TABLET, 125 MG SOFTGEL, 125 TABLET CHEW, 180 MG SOFTGEL, CVS 125 MG SOFTGEL, CVS 80 MG TAB CHEW, DROPS, GNP 125 TAB CHEW, PV 180 MG SOFTGEL, RA 125 MG SOFTGEL, RA 125 MG TAB CHEW, RA INFANT DROPS) OTC GAS-X EXTRA STRENGTH SOFTGEL OTC GATTEX Specialty gavilyte-c Generic gavilyte-g Generic gavilyte-n Generic INFANTS' GAS RELIEF OTC ipecac Generic LIALDA Brand LIQUID ANTACID OTC loperamide hcl 2 mg capsule Generic MAALOX MAXIMUM STRENGTH OTC magnesium hydroxide 400 mg/5ml oral susp OTC mesalamine 4 g/60 ml enema Generic MILANTEX OTC MYLANTEX DOUBLE-STRENGTH OTC nulytely with flavor packs Generic OYST-CAL-500 OTC peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl Generic PENTASA Brand PEP-T-MED OTC PEPTIC RELIEF 262 MG CHEW TAB OTC PHOSPHATE LAXATIVE OTC Requirements/Limits PA, LA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 46 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* propantheline bromide 15 mg tablet Generic PYLERA Brand RELISTOR 8 MG/0.4 ML SYRINGE Brand simethicone 125 mg tab chew OTC sodium chloride/sodium bicarbonate/potassium chloride/peg Generic SOOTHE OTC sulfasalazine (500 mg, 500 mg dr) Generic sulfazine Generic sulfazine ec Generic trilyte with flavor packets Generic ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) Generic WAL-PHOSPHATE OTC Requirements/Limits Histamine2 (H2) Receptor Antagonists ACID CONTROLLER OTC ACID REDUCER OTC cimetidine (200 mg, 300 mg, 400 mg, 800 mg) Generic cimetidine hcl Generic famotidine (20 mg, 40 mg) Generic nizatidine (150 mg, 300 mg) Generic PEPCID AC 20 MG TABLET OTC ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet, 300 mg capsule, 300 mg tablet) Generic ranitidine hcl 75 mg tablet OTC WAL-ZAN 150 OTC WAL-ZAN 75 OTC *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 47 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Brand PA Irritable Bowel Syndrome Agents LOTRONEX Laxatives bisacodyl (5 mg tablet dr, 10 mg supp.rect) OTC castor oil OTC COLACE OTC constulose Generic DIOCTO OTC docusate sodium (50 mg/5 ml liquid, 100 mg capsule) OTC DULCOLAX OTC enulose Generic FIBER LAXATIVE OTC FIBER SUPPLEMENT OTC FIBERTAB OTC generlac Generic GENTLE LAXATIVE OTC GENTLELAX OTC glycerin (adult, pediatric) OTC KAO-TIN OTC KONSYL FIBER OTC KONSYL PSYLLIUM FIBER POWDER OTC KONSYL-D OTC KRISTALOSE Brand lactulose Generic LAXATIVE PEG 3350 OTC magnesium sulfate 100 % crystals OTC MG-PLUS-PROTEIN OTC *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 48 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* mineral oil enema OTC MOVIPREP Brand PHILLIPS' MILK OF MAGNESIA OTC polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder) Generic POWDERLAX OTC PURELAX OTC SENEXON OTC SENNA OTC SENNA PLUS OTC SENNA S OTC SENNA-GEN OTC sennosides/docusate sodium OTC sorbitol solution 70 % solution OTC STOOL SOFTENER (100 MG SOFTGEL, HM 100 MG SFTGL, SM 100 MG SFTGL) OTC SUPREP Brand WOMEN'S GENTLE LAXATIVE OTC Requirements/Limits Protectants misoprostol (100 mcg, 200 mcg) Generic sucralfate (1 g tablet, 1 g/10 ml oral susp) Generic Proton Pump Inhibitors FIRST-LANSOPRAZOLE Brand FIRST-OMEPRAZOLE Brand HEARTBURN RELIEF 24 HOUR OTC HEARTBURN TREATMENT 24 HOUR OTC lansoprazole (15 mg, 30 mg) Generic lansoprazole/amoxicillin trihydrate/clarithromycin Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 49 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* omeprazole (10 mg, 20 mg, 40 mg) Generic omeprazole 20 mg tablet dr OTC omeprazole magnesium OTC OMEPRAZOLE+SYRSPEND SF ALKA Brand pantoprazole sodium (20 mg, 40 mg) Generic PREVACID 30 MG SOLUTAB Brand PROTONIX 40 MG SUSPENSION Brand rabeprazole sodium Generic Requirements/Limits Genitourinary Agents Antispasmodics, Urinary flavoxate hcl Generic oxybutynin chloride (5 mg tab er 24, 5 mg tablet, 5 mg/5 ml syrup, 10 mg tab er 24, 15 mg tab er 24) Generic OXYTROL Brand tolterodine tartrate Generic trospium chloride 20 mg tablet Generic Benign Prostatic Hypertrophy Agents alfuzosin hcl Generic finasteride 5 mg tablet Generic tamsulosin hcl Generic Genitourinary Agents, Other bethanechol chloride (5 mg, 10 mg, 25 mg, 50 mg) Generic cytra-k oral solution Generic ELMIRON Brand methylergonovine maleate 0.2 mg tablet Generic potassium citrate/citric acid 1100-334/5 solution Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 50 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits PROCYSBI Brand PA, LA RE-AZO OTC URINARY PAIN RELIEF (KRO 95 MG, PV 95 MG) OTC Phosphate Binders calcium acetate Generic eliphos Generic RENAGEL Brand PA RENVELA Brand PA sevelamer carbonate Brand PA Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Glucocorticoids/Mineralocorticoids budesonide 3 mg capdr - er Generic dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet) Generic dexamethasone intensol Generic DEXPAK 13 DAY 1.5 MG TABLET Brand FLOVENT DISKUS Brand FLOVENT HFA Brand fluocinolone acetonide oil Generic fluorometholone 0.1 % drops susp Generic fluticasone propionate 50 mcg spray susp Generic FML FORTE Brand FML S.O.P. Brand hydrocortisone (5 mg, 10 mg, 20 mg) Generic hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution) Generic PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 51 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* hydrocortisone valerate Generic MEDROL 2 MG TABLET Brand methylprednisolone Generic UCERIS Brand Requirements/Limits PA Hormonal Agents, Stimulant/Replacement/Modifying (Other) MYALEPT Brand PA, LA Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet, 10/spray spray/pump) Generic PA desmopressin acetate (nonrefrigerated) Generic PA EGRIFTA Specialty PA GENOTROPIN Specialty PA NUTROPIN 5 MG VIAL Specialty PA NUTROPIN AQ 20 MG/2ML PEN CART Specialty NUTROPIN AQ 5 MG/ML VIAL Specialty NUTROPIN AQ NUSPIN 20 PEN CART Specialty SAIZEN Specialty PA SEROSTIM (5 MG, 8.8 MG) Specialty PA STIMATE Brand TEV-TROPIN Specialty PA ZORBTIVE Specialty PA PA Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Estrogens ALORA (0.05 MG, 0.075 MG, 0.1 MG) Brand altavera Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 52 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* alyacen Generic amethia Generic amethia lo Generic amethyst Generic apri Generic aranelle Generic aubra Generic aviane Generic balziva Generic briellyn Generic camrese Generic camrese lo Generic caziant Generic chateal Generic cryselle Generic cyclafem Generic dasetta Generic daysee Generic delyla Generic desogestrel-ethinyl estradiol Generic DUAVEE Brand elinest Generic emoquette Generic enpresse Generic enskyce Generic ESTRACE 0.01% CREAM Brand Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 53 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* estradiol (.025mg/24h patch tdwk, .0375mg/24 patch tdwk, 0.05mg/24h patch tdwk, 0.06mg/24h patch tdwk, .075mg/24h patch tdwk, 0.1mg/24hr patch tdwk, 0.5 mg tablet, 1 mg tablet, 2 mg tablet) Generic estradiol/norethindrone acetate Generic ESTRING Brand estropipate (0.75 mg, 1.5 mg, 3 mg) Generic ethinyl estradiol/drospirenone Generic falmina Generic gianvi Generic gildagia Generic gildess Generic gildess fe Generic introvale Generic jolessa Generic junel Generic junel fe Generic kelnor 1-35 Generic kurvelo Generic larin Generic larin fe Generic leena Generic lessina Generic levonest Generic levonorgestrel-eth estra/ethinyl estradiol Generic levonorgestrel-ethinyl estradiol Generic levora-28 Generic lomedia 24 fe Generic Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 54 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* loryna Generic low-ogestrel Generic lutera Generic marlissa Generic microgestin Generic microgestin fe Generic mimvey Generic mimvey lo Generic MINIVELLE Brand myzilra Generic necon (1-35-28, 1-50-28, 7-7-7-28, 1011-28) Generic nikki Generic norethindrone acetate-ethinyl estradiol Generic norethindrone acetate-ethinyl estradiol/ferrous fumarate Generic norgestimate-ethinyl estradiol 7daysx3 28 tablet Generic nortrel (1-35, 7-7-7-28) Generic NUVARING Brand ocella Generic ogestrel Generic orsythia Generic philith Generic pirmella Generic portia Generic PREFEST Brand PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET, VAGINAL CREAM-APPL) Brand Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 55 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* PREMPHASE Brand PREMPRO Brand quasense Generic reclipsen Generic sronyx Generic syeda Generic tarina fe Generic tri-estarylla Generic tri-linyah Generic tri-previfem Generic tri-sprintec Generic trinessa Generic trivora-28 Generic VAGIFEM Brand velivet Generic vestura Generic VIVELLE-DOT (0.0375 MG, 0.05 MG, 0.075 MG, 0.1 MG) Brand vyfemla Generic xulane Generic zarah Generic zenchent Generic zovia 1-35e Generic zovia 1-50e Generic Requirements/Limits Progestins camila Generic deblitane Generic DEPO-SUBQ PROVERA 104 Brand errin Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 56 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* FALLBACK SOLO OTC heather Generic jencycla Generic jolivette Generic levonorgestrel Generic lyza Generic medroxyprogesterone acetate (2.5 mg, 5 mg, 10 mg) Generic megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/10ml oral susp) Generic my way Generic next choice Generic next choice one dose Generic nora-be Generic norethindrone 0.35 mg tablet Generic norethindrone acetate 5 mg tablet Generic norlyroc Generic progesterone,micronized (100 mg, 200 mg) Generic sharobel Generic Requirements/Limits Selective Estrogen Receptor Modifying Agents raloxifene hcl Generic Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothroid Generic levothyroxine sodium (25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175mcg, 200 mcg, 300 mcg) Generic levoxyl Generic liothyronine sodium (5 mcg, 25 mcg, 50 mcg) Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 57 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* THYROLAR-1 Brand THYROLAR-1/2 Brand THYROLAR-1/4 Brand THYROLAR-2 Brand THYROLAR-3 Brand unithroid (25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg) Generic Requirements/Limits Hormonal Agents, Suppressant (Adrenal) LYSODREN Brand SIGNIFOR Specialty PA, LA Hormonal Agents, Suppressant (Parathyroid) calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) Generic paricalcitol Generic ST SENSIPAR (30 MG, 60 MG) Specialty QL (60 PER 30 DAYS) SENSIPAR 90 MG TABLET Specialty ZEMPLAR (2 MCG/ML, 5 MCG/ML, 10 MCG/2 ML) Brand ST Hormonal Agents, Suppressant (Pituitary) ELIGARD Brand PA ganirelix acetate Brand PA leuprolide acetate 1 mg/0.2ml kit Generic PA SOMAVERT Specialty PA, LA Hormonal Agents, Suppressant (Sex Hormones/Modifiers) Antiandrogens bicalutamide Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 58 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* NILANDRON Brand XTANDI Specialty Requirements/Limits PA Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole (5 mg, 10 mg) Generic propylthiouracil 50 mg tablet Generic Immunological Agents Angioedema (HAE) Agents BERINERT 500 UNIT KIT Specialty PA, QL (3 PER 30 DAYS) Immune Suppressants ASTAGRAF XL Brand azathioprine 50 mg tablet Generic CELLCEPT 200 MG/ML ORAL SUSP Brand cyclosporine (25 mg, 100 mg) Generic cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg capsule, 100 mg/ml solution) Generic ENBREL (25 MG/0.5 ML SYRINGE, 50 MG/ML SURECLICK SYR, 50 MG/ML SYRINGE) Specialty QL (4 ML PER 28 DAYS) ENBREL 25 MG KIT Specialty QL (8 PER 28 DAYS) gengraf (25 mg capsule, 100 mg/ml solution) Generic GRASTEK Brand hecoria Generic HUMIRA Specialty HUMIRA PEDIATRIC Specialty mycophenolate mofetil Generic PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 59 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits mycophenolate sodium Generic ORALAIR Specialty PA, LA RAGWITEK Brand PA RAPAMUNE 1 MG/ML ORAL SOLN Brand RESTASIS Brand sirolimus (0.5 mg, 1 mg, 2 mg) Generic tacrolimus (0.5 mg, 1 mg, 5 mg) Generic ZORTRESS Specialty PA, QL (60 PER 30 DAYS) Immunizing Agents, Passive GAMMAKED Specialty PA GAMUNEX-C Specialty PA ACTIMMUNE Specialty PA ALFERON N Specialty PA leflunomide Generic Immunomodulators Inflammatory Bowel Disease Agents Aminosalicylates balsalazide disodium Generic DIPENTUM Brand Glucocorticoids anusol-hc 2.5% cream Generic colocort Generic hydrocortisone 100mg/60ml enema Generic proctocream-hc Generic PROCTOFOAM-HC Brand proctosol-hc Generic proctozone-hc Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 60 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits ACTONEL (5 MG, 30 MG, 35 MG) Brand PA alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70 mg tablet, 70 mg/75ml solution) Generic calcitonin,salmon,synthetic Generic doxercalciferol (0.5 mcg, 1 mcg, 2.5 mcg) Generic doxercalciferol 4mcg/2ml vial Generic etidronate disodium Generic ibandronate sodium 150 mg tablet Generic Metabolic Bone Disease Agents ST Miscellaneous Glucose Testing ACCU-CHECK (METERS & TEST STRIPS) DME Benefit lancets (, 25 gauge, 30 gauge) OTC LIFESCAN (METERS & TEST STRIPS) DME Benefit urine glucose test,strip OTC QL QL Miscellaneous, Other lancets (28, 33) OTC petrolatum,white oint pack OTC urine acetone test,strips OTC urine gluc-acet comb.tst,strip OTC vaseline white petroleum Generic Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs latanoprost Generic LUMIGAN 0.01% EYE DROPS Brand ST *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 61 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits LUMIGAN 0.03% EYE DROPS Brand Step Therapy TRAVATAN Z Brand Ophthalmic Agents, Other altafrin (2.5%, 10%) Generic BLEPHAMIDE Brand BLEPHAMIDE S.O.P. Brand CYSTARAN Brand EYE LUBRICANT OTC gatifloxacin Generic LUBRICANT EYE DROPS OTC MOISTURIZING LUBRICANT OTC mydfrin Generic naphazoline hcl 0.1 % drops Generic neo-polycin Generic neo-polycin hc Generic neofrin Generic neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone Generic neomycin sulfate/bacitracin/polymyxin b Generic neomycin sulfate/polymyxin b sulfate/gramicidin d Generic neomycin/polymyxin b sulf/hc 3.5-10k10 drops susp Generic neomycin/polymyxin b sulfate/dexamethasone (0.1 % drops susp, 3.5-10k-.1 oint. (g)) Generic neosporin eye drops Generic NU-TEARS OTC phenylephrine hcl (2.5 %, 10 %) Generic polymyxin b sulfate/trimethoprim Generic PA, LA, QL (60 ML PER 30 DAYS) *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 62 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* RETAINE CMC OTC sulfacetamide sodium 10 % oint. (g) Generic sulfacetamide sodium/prednisolone sodium phosphate Generic TOBRADEX EYE OINTMENT Brand TOBRADEX ST Brand tobramycin/dexamethasone Generic ZYLET Brand Requirements/Limits Ophthalmic Anti-allergy Agents ALOMIDE Brand azelastine hcl 0.05 % drops Generic Ophthalmic Anti-inflammatories dexamethasone sod phosphate 0.1 % drops Generic diclofenac sodium 0.1 % drops Generic flurbiprofen sodium Generic LOTEMAX (EYE DROPS, EYE OINTMENT, OPHTHALMIC GEL) Brand PRED MILD Brand prednisolone acetate 1 % drops susp Generic prednisolone sod phosphate 1 % drops Generic VEXOL Brand Ophthalmic Antiglaucoma Agents AZOPT Brand betaxolol hcl 0.5 % drops Generic BETIMOL Brand BETOPTIC S Brand brimonidine tartrate (0.15 %, 0.2 %) Generic carteolol hcl Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 63 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* dorzolamide hcl/timolol maleate Generic levobunolol hcl Generic pilocarpine hcl (1 %, 2 %, 4 %) Generic timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drops, 0.5 % sol-gel) Generic Requirements/Limits Otic Agents carbamide peroxide 6.5 % drops OTC CIPRODEX Brand ciprofloxacin hcl 0.2 % droperette Generic COLY-MYCIN S Brand CORTISPORIN-TC Brand EAR DROPS OTC neomycin sulfate/polymyxin b sulfate/hydrocortisone (drops susp, solution) Generic Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids ADVAIR DISKUS Brand ADVAIR HFA Brand AEROSPAN Brand ALVESCO Brand ASMANEX Brand BREO ELLIPTA Brand budesonide (0.25mg/2ml, 0.5 mg/2ml) Generic flunisolide 29mcg spray Generic PULMICORT 1 MG/2 ML RESPULE Brand PULMICORT FLEXHALER Brand QVAR Brand PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 64 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits ALL DAY ALLERGY 10 MG TABLET OTC PA ALLER-CHLOR 2 MG/5 ML SYRUP OTC ALLER-FEX OTC ALLER-G-TIME OTC ALLERGY OTC ALLERGY & CONGESTION RELIEF OTC ALLERGY MEDICINE OTC ALLERGY RELIEF (10 MG ODT, CVS 10 MG TAB, CVS 180 MG TAB, CVS 5 MG/5 ML, KRO 10 MG TAB, KRO 60 MG TAB, QC 5 MG/5 ML) OTC PA ALLERGY RELIEF D OTC PA ALLERGY RELIEF-NASAL DECONGEST OTC PA ALLERGY-CONGESTION RELIEF OTC BANOPHEN OTC BENADRYL ALLERGY OTC cetirizine hcl (5 mg, 10 mg) OTC PA cetirizine hcl 1 mg/ml solution Generic PA CHILD'S WAL-DRYL 12.5 MG/5 ML OTC CHILDREN'S ALL DAY ALLERGY OTC CHILDREN'S ALLERGY OTC CHILDREN'S ALLERGY RELIEF (CVS 10 MG CHW TB, CVS 5 MG/5 ML, CVS RELF 1 MG/ML, CVS RLF 1 MG/ML, QC RLF 1 MG/1 ML) OTC PA CHILDREN'S WAL-ZYR OTC PA CHLD ALLEGRA ALLERGY 30 MG ODT OTC PA chlorpheniramine maleate 4 mg tablet OTC CLARITIN OTC clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet) Generic Antihistamines PA PA PA PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 65 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits COMPLETE ALLERGY OTC CVS ALLERGY RELIEF 4 MG TABLET OTC cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet) Generic dexchlorpheniramine maleate 2 mg/5 ml syrup Generic diphenhydramine hcl (12.5mg/5ml elixir, 50 mg capsule) Generic fexofenadine hcl (60 mg, 180 mg) OTC PA fexofenadine hcl 30 mg tablet Generic PA fexofenadine hcl/pseudoephedrine hcl Generic PA levocetirizine dihydrochloride (2.5 mg/5ml solution, 5 mg tablet) Generic PA loratadine (5 mg/5 ml solution, 10 mg tablet) OTC PA LORATADINE-D OTC PA MUCINEX ALLERGY OTC PA promethazine hcl/codeine Generic promethazine/phenylephrine hcl/codeine Generic TAVIST-1 OTC VICKS QLEARQUIL ALLERGY OTC VICKS QLEARQUIL NIGHT 25 MG OTC WAL-DRYL (25 MG CAPSULE, 25 MG MINITAB) OTC WAL-FEX ALLERGY OTC PA WAL-ITIN OTC PA WAL-ITIN D OTC PA WAL-ITIN D 12 HOUR OTC PA WAL-ZYR 10 MG TABLET OTC PA PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 66 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mg tablet) Generic PA zafirlukast Generic QL (60 PER 30 DAYS) Antileukotrienes Bronchodilators, Anticholinergic ATROVENT HFA Brand COMBIVENT Brand QL (14.7 GM PER 30 DAYS) COMBIVENT RESPIMAT Brand QL (4 GM PER 30 DAYS) hydrocodone bitartrate/homatropine methylbromide (5 mg-1.5mg tablet, 51.5 mg/5 syrup) Generic hydromet Generic ipratropium bromide 0.2 mg/ml solution Generic ipratropium bromide/albuterol sulfate Generic SPIRIVA Brand tussigon Generic Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) ELIXOPHYLLIN Brand THEO-24 ER 300 MG CAPSULE Brand theochron Generic theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution, 100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 450 mg tab er 12h) Generic Bronchodilators, Sympathomimetic albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg tablet, 2 mg/5 ml syrup, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 4 mg tab er 12h, 4 mg tablet, 5 mg/ml solution, 8 mg tab er 12h) Generic *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 67 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* EPIPEN 2-PAK Brand EPIPEN JR 2-PAK Brand metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet) Generic proair hfa Generic SEREVENT DISKUS Brand terbutaline sulfate (2.5 mg, 5 mg) Generic ventolin hfa Generic XOPENEX HFA Brand Requirements/Limits QL (17 GM PER 30 DAYS) QL (36 GM PER 30 DAYS) Mast Cell Stabilizers cromolyn sodium 20 mg/2 ml ampulneb Generic Pulmonary Antihypertensives ADCIRCA Specialty PA ADEMPAS Specialty PA epoprostenol sodium (glycine) Generic PA LETAIRIS Specialty PA OPSUMIT Specialty PA, LA REMODULIN Brand PA sildenafil citrate 20 mg tablet Generic PA, QL (90 PER 30 DAYS) TRACLEER Specialty PA, LA VELETRI Specialty PA VENTAVIS Specialty PA Respiratory Tract Agents, Other 12 HOUR DECONGESTANT OTC ANORO ELLIPTA Brand benzonatate Generic bromfed dm Generic BRONCOTRON OTC *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 68 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* CHILD MUCINEX CHEST CONGESTION OTC CHILD'S MUCINEX 100 MG/5 ML LQ OTC CHILDREN'S SALINE NASAL SPRAY OTC COUGH CONTROL CF OTC CREO-TERPIN OTC d-methorphan hb/p-epd hcl/bpm 10-302/5 syrup Generic DESGEN OTC dextromethorphan hbr/promethazine hcl Generic guaifenesin (200 mg, 600 mg er) OTC guaifenesin/codeine phosphate OTC HYPER-SAL 3.5% VIAL Brand KALYDECO Specialty LORTUSS EX OTC MUCINEX DM ER 600-30 MG TABLET OTC MUCINEX ER 600 MG TABLET OTC MUCUS ER OTC MYTUSSIN DAC OTC NASAL DECONGESTANT OTC ORGAN-I NR OTC phenylephrine hcl/promethazine hcl Generic pseudoephedrine hcl 120 mg tablet er OTC pulmosal Generic PULMOZYME Specialty ROBAFEN OTC ROBAFEN-DM CLEAR OTC SB MUCUS RELIEF 200 MG TABLET OTC sodium chloride 0.65 % spray OTC Requirements/Limits PA, LA, QL (60 PER 30 DAYS) *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 69 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* sodium chloride for inhalation 7 % vialneb Generic SORBUGEN NR OTC SUDOGEST OTC SYMBICORT Brand TUSSIN OTC TUSSIN DM OTC TYLENOL COLD SEVERE CONGESTION OTC VIRTUSSIN AC OTC Requirements/Limits Skeletal Muscle Relaxants carisoprodol (250 mg, 350 mg) Generic carisoprodol/aspirin Generic chlorzoxazone Generic cyclobenzaprine hcl (5 mg, 7.5 mg, 10 mg) Generic metaxalone Generic methocarbamol (500 mg, 750 mg) Generic orphenadrine citrate 100 mg tablet er Generic orphenadrine/aspirin/caffeine 50-77060 tablet Generic Sleep Disorder Agents GABA Receptor Modulators flurazepam hcl Generic temazepam (7.5 mg, 15 mg, 30 mg) Generic triazolam Generic Sleep Disorders, Other NIGHTTIME SLEEP AID OTC ROZEREM Brand PA, QL (30 PER 30 DAYS) *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 70 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* SIMPLY SLEEP OTC SLEEP II OTC XYREM Specialty Requirements/Limits PA, LA, QL (540 ML PER 30 DAYS) Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Modifiers EXJADE Specialty kionex powder Generic marlexate Generic sodium polystyrene sulfonate (50g/200ml enema, powder) Generic Electrolyte/Mineral Replacement A THRU Z ADVANCED FORMULA OTC A THRU Z HIGH POTENCY CAPLET OTC A THRU Z SELECT CAPLET OTC A-G PRO OTC ANTICAVITY FLUORIDE OTC ANTIOXIDANT ULTRA FORMULA OTC ascorbate calcium 500 mg tablet OTC ascorbic acid (250 mg tablet, 500 mg tab chew, 500 mg tablet, 500 mg tablet er) OTC b complex with vitamin c OTC B-50 OTC b-plex Generic b-plex plus Generic CALCARB 600 WITH VITAMIN D OTC calcium carbonate 500(1250) tab chew OTC calcium carbonate/cholecalciferol (vitamin d3) OTC PA *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 71 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* calcium citrate 200(950)mg tablet OTC CARNITOR SF Brand CENTURY VITAMIN OTC CHEWABLE MULTIVITAMIN W-IRON OTC CHILDREN VITAMIN OTC cholecalciferol (vitamin d3) (400 capsule, 400 tablet, 1000 capsule, 1000 tablet, 2000 capsule, 2000 tablet, 5000 capsule, 5000 tablet) OTC CLUSIMAR OTC COMPLETE MULTIVITAMIN OTC completenate Generic cyanocobalamin (vitamin b-12) 1000 mcg tablet OTC cyanocobalamin (vitamin b-12) 1000mcg/ml vial Generic DAILY DIET SUPPORT OTC DAILY MULTIPLE VITAMIN OTC DAILY MULTIVITAMIN-IRON OTC denta 5000 plus Generic dentagel Generic dialyvite Generic DIALYVITE ZINC Brand ELDERCAPS Brand ENFALYTE OTC ergocalciferol (vitamin d2) 50000 unit capsule Generic FERATE OTC ferrex 150 forte plus Generic ferrous sulfate (143(45) mg tablet er, 220(44)/5 solution, 220mg/5ml elixir, 325(65) mg tablet) OTC Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 72 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* FERUS OTC FLUOR-A-DAY (0.25 MG TAB, 0.5 MG TAB, 1 MG TABLET) Brand fluoride/iron/vitamins a,c,and d Generic fluoridex daily defense Generic fluoritab (0.125 mg/drp drops, 0.5 mg tablet chew) Generic flura-drops Generic folbee plus Generic folic acid (0.4 mg, 0.8 mg) OTC folic acid 1 mg tablet Generic FORMULA E OTC FRUITY CHEWS OTC HEALTHY EYES OTC iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid Generic KID'S VITAMINS + IRON OTC klor-con 10 Generic klor-con 8 Generic klor-con m10 Generic klor-con m15 Generic klor-con m20 Generic levocarnitine (with sugar) Generic levocarnitine 330 mg tablet Generic ludent fluoride Generic magnesium oxide 400 mg tablet OTC maternity Generic MEN'S MULTIVITAMIN OTC MULTIVITAL OTC MULTIVITAL PLATINUM OTC Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 73 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* multivitamin with minerals OTC multivitamins with fluoride Generic multivitamins with iron (drops, tablet) OTC mynephrocaps Generic natal-v rx Generic niacin 100 mg tablet OTC ONE DAILY MULTIVITAMIN-IRON OTC OYST-CAL-D 500 OTC pediatric multivitamin combination no.2/sodium fluoride Generic pediatric multivitamins a,c,& d3 no.21 OTC pediatric multivitamins a,c,& d3 no.21 with sodium fluoride Generic pediatric multivitamins no.16 with sodium fluoride Generic pediatric multivitamins no.17 with sodium fluoride Generic pediatric multivitamins no.82 with sodium fluoride Generic phos-flur 1.1% gel Generic PHOS-FLUR ORAL RINSE OTC pnv 29-1 Generic POLYSACCHARIDE IRON OTC potassium chloride (8 tablet er, 10 capsule er, 10 tab er prt, 10 tablet er, 20 tab er prt, 20 tablet er) Generic potassium chloride/potassium bicarbonate/citric acid Generic potassium citrate (5 er, 10 er) Generic prenaplus Generic prenatal vitamins comb no.115/iron fumarate/folic acid Generic Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 74 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* prenatal vitamins comb no.115/iron fumarate/folic acid/dss Generic prenatal vitamins combo no.60/ferrous fumarate/folic acid Generic prenatal vitamins with calcium/ferrous fumarate/folic acid OTC prenatal vitamins/ferrous fumarate/folic acid OTC prenatal vitamins/ferrous sulfate/folic acid OTC prenatal vits w-ca,fe,fa(<1mg) OTC prenatal vits with calcium #72/ferrous fumarate/folic acid Generic prenatal vits with calcium #72/iron,carbonyl/folic acid Generic preplus Generic prevident 1.1% gel Generic PV HAIR, SKIN & NAILS TABLET OTC pyridoxine hcl 50 mg tablet OTC QUFLORA (0.25 MG/ML, 0.5 MG/ML) Brand rena-vite rx Generic renal caps Generic reno caps Generic se-natal 19 Generic SENIOR VITAMIN OTC SENTRY PERFORM OTC sf Generic sf 5000 plus Generic sodium fluoride (0.2 % solution, 0.25(0.55) tab chew, 0.5 mg/ml drops, 0.5(1.1)mg tab chew, 1mg(2.2mg) tab chew, 1mg(2.2mg) tablet) Generic Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 75 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* STRESS FORMULA WITH ZINC OTC SUPER VIKAPS OTC THERAMILL FORTE OTC therapeutic hematinic Generic therapeutic vitamin w-minerals Generic THERAPEUTIC-M OTC THERIN-M MULTIVIT-MINERAL OTC thiamine hcl 100 mg tablet OTC tl-fluorivite Generic TRICARE Brand trinatal rx 1 Generic triphrocaps Generic v-c forte Generic vic-forte Generic VIMAR OTC vinate calcium Generic vinate one Generic vinate pn care Generic vinate-m Generic virt nate Generic virt-caps Generic vitamin a 10000 unit capsule OTC vitamin a palmitate 10000 unit capsule OTC vitamin e (dl,tocopheryl acet) 400 unit capsule OTC vitamin e 400 unit capsule OTC vitamin e acetate 400 unit capsule OTC vitamin e acid succinate 200 unit tablet OTC vitamin e mixed (mixd 200 tablt, mixd 400 capsul) OTC Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 76 Providence Health Plan - Oregon Health Plan Formulary To help find a drug see the back of the document for an alphabetical listing Drug Name Status* vol-care rx Generic vol-nate Generic vol-plus Generic vol-tab rx Generic Requirements/Limits *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 77 Alphabetical Listing 1 12 HOUR DECONGESTANT 68 alagesic lq 1 ALBENZA 24 albuterol sulfate 67 alclometasone dipropionate A 7 alendronate sodium 61 A THRU Z 71 ALFERON N 60 A THRU Z ADVANCED FORMULA 71 alfuzosin hcl 50 A THRU Z SELECT 71 ALKERAN 21 A-G PRO 71 ALL DAY ALLERGY 65 abacavir sulfate 26 ALL DAY PAIN RELIEF 2 abacavir sulfate/lamivudine/zidovudine 26 ALL DAY RELIEF 2 acamprosate calcium 7 ALLER-CHLOR 65 acarbose 29 ALLER-FEX 65 acebutolol hcl 35 ALLER-G-TIME 65 acetaminophen 1 ALLERGY 65 ACETAMINOPHEN PM 1 ALLERGY & CONGESTION RELIEF 65 acetaminophen with codeine phosphate 4 ALLERGY MEDICINE 65 acetaminophen/diphenhydramine hcl 1 ALLERGY RELIEF acetasol hc 9 ALLERGY RELIEF D 65 ALLERGY RELIEF-NASAL DECONGEST 65 ALLERGY-CONGESTION RELIEF 65 acetazolamide acetic acid 14,38 9 65,66 acetic acid/aluminum acetate 10 allopurinol 20 acetic acid/hydrocortisone 10 ALOMIDE 63 ACID CONTROLLER 47 ALORA 52 ACID REDUCER 47 altafrin 62 acitretin 42 altavera 52 ACTIMMUNE 60 aluminum hydroxide 44 ACTONEL 61 ALVESCO 64 ACTOPLUS MET XR 29 alyacen 53 acyclovir 29 amantadine hcl 25 ADCIRCA 68 amcinonide adefovir dipivoxil 28 amethia 53 ADEMPAS 68 amethia lo 53 ADVAIR DISKUS 64 amethyst 53 ADVAIR HFA 64 amiloride hcl 38 AEROSPAN 64 amiloride hcl/hydrochlorothiazide 38 afeditab cr 36 amiodarone hcl 34 AFINITOR 23 amlodipine besylate 36 AFINITOR DISPERZ 23 amlodipine besylate/atorvastatin calcium 38 AGGRENOX 33 amlodipine besylate/benazepril hcl 36 AKNE-MYCIN 12 amoxicillin 12 78 7 amoxicillin/potassium clavulanate 12 ATROVENT HFA 67 ampicillin trihydrate 12 AUBAGIO 42 AMPYRA 42 aubra 53 anagrelide hcl 32 AUGMENTIN 12 7 aviane 53 anastrozole 23 avidoxy 14 ANORO ELLIPTA 68 AVONEX 42 ANTACID 45 AVONEX ADMINISTRATION PACK 42 ANTACID EXTRA STRENGTH 45 AVONEX PEN 42 ANTACID PLUS EXTRA STRENGTH 45 azathioprine 59 ANTACID ULTRA STRENGTH 45 azelastine hcl 63 ANTI-DIARRHEAL 45 AZILECT 25 ANTI-ITCH 43 azithromycin 12 ANTICAVITY FLUORIDE 71 AZOPT 63 ANTIFUNGAL CREAM 18 ANTIOXIDANT ULTRA FORMULA 71 B anusol-hc 60 b complex with vitamin c 71 apexicon e 7 B-50 71 ANALPRAM HC APIDRA 31 b-plex 71 APIDRA SOLOSTAR 31 b-plex plus 71 apri 53 bacitracin 10 APRISO 45 bacitracin zinc 10 APTIOM 16 baclofen 26 APTIVUS 27 balsalazide disodium 60 aranelle 53 balziva 53 ARANESP 32 BAN-ACID 45 BANOPHEN 65 ARTHRITIS PAIN RELIEF 1 ASACOL 45 BANZEL 16 ASACOL HD 45 BARACLUDE 28 BENADRYL ALLERGY 65 ascomp with codeine 4 ascorbate calcium 71 benazepril hcl 34 ascorbic acid 71 benazepril hcl/hydrochlorothiazide 34 ASMANEX 64 benzonatate 68 aspirin 1,2 benztropine mesylate 25 ASTAGRAF XL 59 BERINERT 59 atenolol 35 betamethasone dipropionate 7 atenolol/chlorthalidone 35 betamethasone dipropionate/propylene glycol 7 atorvastatin calcium 39 betamethasone valerate 7 atovaquone 24 BETASERON atovaquone/proguanil hcl 24 betaxolol hcl ATRIPLA 27 bethanechol chloride 79 42 35,63 50 BETIMOL 63 calcium acetate 51 BETOPTIC S 63 CALCIUM ANTACID 45 bicalutamide 58 calcium carbonate bisacodyl 48 calcium carbonate/cholecalciferol (vitamin d3) 71 bisoprolol fumarate 35 calcium citrate 72 bisoprolol fumarate/hydrochlorothiazide 35 camila 56 bleph-10 13 camrese 53 BLEPHAMIDE 62 camrese lo 53 BLEPHAMIDE S.O.P. 62 CANASA 45 blood sugar diagnostic 61 candesartan cilexetil 33 BREO ELLIPTA 64 capacet briellyn 53 capecitabine 22 BRILINTA 33 CAPRELSA 23 brimonidine tartrate 63 captopril 34 bromfed dm 68 captopril/hydrochlorothiazide 34 bromocriptine mesylate 25 CARBAGLU 44 BRONCOTRON 68 carbamazepine 16 budeprion sr 17 carbamide peroxide 64 carbidopa 25 45,71 1 budesonide 51,64 bumetanide 38 carbidopa/levodopa 25 BUPHENYL 44 carbidopa/levodopa/entacapone 25 buprenorphine hcl/naloxone hcl 7 CARDENE SR 36 buproban 7 carisoprodol 70 carisoprodol/aspirin 70 bupropion hcl 17 butalbital/acetaminophen 1 CARNITOR SF 72 butalbital/acetaminophen/caffeine 1 carteolol hcl 63 butalbital/acetaminophen/caffeine/codeine phosphate 4 cartia xt 36 butalbital/aspirin/caffeine 1 carvedilol 35 butorphanol tartrate 5 castor oil 48 BYDUREON 29 caziant 53 BYDUREON PEN 29 CEDAX 11 BYETTA 29 CEENU 21 cefaclor 11 cefadroxil 11 C cafergot 20 cefdinir 11 CAL-GEST 45 cefpodoxime proxetil 11 CALCARB 600 WITH VITAMIN D 71 cefprozil 11 calcipotriene 43 ceftibuten dihydrate 11 calcitonin,salmon,synthetic 61 CEFTIN 11 calcitrene 43 cefuroxime axetil 11 calcitriol 58 CELEBREX 80 2 CELLCEPT 59 CIPRODEX 64 CELONTIN 14 ciprofloxacin 13 CENTURY VITAMIN 72 ciprofloxacin hcl cephalexin 11 ciprofloxacin/ciprofloxacin hcl 13 cetirizine hcl 65 clarithromycin 12 CLARITIN 65 CHANTIX 7 13,64 chateal 53 clemastine fumarate 65 CHEWABLE MULTIVITAMIN W-IRON 72 clinda-derm 10 2 clindacin etz 10 clindacin p 10 CHILD IBUPROFEN CHILD MUCINEX CHEST CONGESTION 69 CHILD TRIAMINIC FEVER REDUCER 1 clindamycin hcl 10 CHILD'S ACCUDIAL ACETAMINOPHEN 1 clindamycin palmitate hcl 10 10 CHILDREN VITAMIN 72 clindamycin phosphate CHILDREN'S ALL DAY ALLERGY 65 clobetasol propionate 8 CHILDREN'S ALLEGRA ALLERGY 65 clobetasol propionate/emollient base 8 CHILDREN'S ALLERGY 65 clodan 8 CHILDREN'S ALLERGY RELIEF 65 clonidine 33 CHILDREN'S MUCINEX 69 clonidine hcl 33 CHILDREN'S PAIN & FEVER 1 clopidogrel bisulfate 33 CHILDREN'S PAIN RELIEF 1 clorpres 33 CHILDREN'S PAIN RELIEVER 1 clotrimazole 18 CHILDREN'S SALINE NASAL SPRAY 69 clotrimazole/betamethasone dipropionate 18 CHILDREN'S WAL-DRYL ALLERGY 65 CLUSIMAR 72 CHILDREN'S WAL-ZYR 65 co-gesic 5 chlorhexidine gluconate 10 codeine phosphate/butalbital/aspirin/caffeine 5 chloroquine phosphate 24 codeine phosphate/carisoprodol/aspirin 5 chlorothiazide 39 codeine sulfate 5 chlorpheniramine maleate 65 COLACE 48 chlorpropamide 29 colchicine/probenecid 20 chlorthalidone 39 COLCRYS 20 chlorzoxazone 70 COLESTID 40 cholecalciferol (vitamin d3) 72 colestid 40 cholestyramine (with sugar) 40 colestipol hcl 40 cholestyramine/aspartame 40 colocort 60 COLY-MYCIN S 64 choline salicylate/magnesium salicylate 9 ciclodan 18 COMBIVENT 67 ciclopirox 18 COMBIVENT RESPIMAT 67 ciclopirox olamine 18 COMETRIQ 23 cilostazol 33 COMPLERA 27 cimetidine 47 COMPLETE ALLERGY 66 cimetidine hcl 47 COMPLETE MULTIVITAMIN 72 81 completenate 72 delyla 53 compro 17 DELZICOL 45 CONDYLOX 43 demeclocycline hcl 14 constulose 48 DENAVIR 29 COPAXONE 42 denta 5000 plus 72 COREG CR 35 dentagel 72 8 depade 7 cormax CORTAID DEPO-SUBQ PROVERA 104 56 8 DESENEX 18 CORTISPORIN-TC 64 DESGEN 69 CORTIZONE-10 43 desmopressin acetate 52 COUGH CONTROL CF 69 desmopressin acetate (non-refrigerated) 52 CREO-TERPIN 69 desogestrel-ethinyl estradiol 53 CREON 44 desonide 8 CRIXIVAN 27 desoximetasone 8 cromolyn sodium 68 dexamethasone 51 cryselle 53 dexamethasone intensol 51 CUVPOSA 44 dexamethasone sod phosphate 63 cyanocobalamin (vitamin b-12) 72 dexchlorpheniramine maleate 66 cyclafem 53 dexmethylphenidate hcl 41 cyclobenzaprine hcl 70 DEXPAK 51 cyclophosphamide capsules 21 dextroamphetamine sulf-saccharate/amphetamine sulf- cyclophosphamide tablets 21 aspartate 41 cycloserine 10 dextroamphetamine sulfate 41 cyclosporine 59 dextromethorphan hbr/promethazine hcl 69 cyclosporine, modified 59 dextromethorphan hbr/pseudoephedrine cyproheptadine hcl 66 hcl/brompheniramine 69 CYSTARAN 62 dialyvite 72 cytra-k 50 DIALYVITE ZINC 72 DIASTAT 15 diazepam 15 17 CORTISONE 43 D DAILY DIET SUPPORT 72 DICLEGIS DAILY MULTIPLE VITAMIN 72 diclofenac potassium DAILY MULTIVITAMIN-IRON 72 diclofenac sodium dantrolene sodium 26 dicloxacillin sodium 12 dapsone 21 dicyclomine hcl 44 DARAPRIM 24 didanosine 26 dasetta 53 diflunisal daysee 53 digox 38 DAYTRANA 41 digoxin 38 deblitane 56 dihydroergotamine mesylate 20 82 2 3,63 3 DILANTIN 16 ELIQUIS 31 dilt-cd 36 ELIXOPHYLLIN 67 dilt-xr 36 ELMIRON 50 diltia xt 36 EMCYT 22 diltiazem hcl 37 EMEND 18 diltzac er 37 emoquette 53 DIOCTO 48 EMTRIVA 26 DIPENTUM 60 enalapril maleate 34 diphenhydramine hcl 66 enalapril maleate/hydrochlorothiazide 34 diphenoxylate hcl/atropine sulfate 45 ENBREL 59 dipyridamole 33 endocet 5 disopyramide phosphate 35 endodan 5 7 ENEMA 45 disulfiram docusate sodium 48 ENFALYTE 72 donepezil hcl 16 enoxaparin sodium 32 dorzolamide hcl/timolol maleate 64 enpresse 53 doxazosin mesylate 33 enskyce 53 doxercalciferol 61 entacapone 25 doxycycline hyclate 14 entecavir 28 doxycycline monohydrate 14 enulose 48 DRITHOCREME HP 43 EPANED 34 DROXIA 22 EPIFOAM 43 DUAVEE 53 EPIPEN 2-PAK 68 DULCOLAX 48 EPIPEN JR 2-PAK 68 dynacin 14 epitol 16 EPIVIR 26 EPIVIR HBV 28 E E.E.S. 200 12 eplerenone 38 EAR DROPS 64 EPOGEN 32 econazole nitrate 18 epoprostenol sodium (glycine) 68 EDECRIN 38 eprosartan mesylate 33 EDURANT 26 EPZICOM 26 EFFIENT 33 EQUALIZER GAS RELIEF 45 EGRIFTA 52 ergocalciferol (vitamin d2) 72 ELDERCAPS 72 ergotamine tartrate/caffeine 20 ELELYSO 44 ERIVEDGE 23 ELIDEL 43 errin 56 ELIGARD 58 ery 12 elimite 24 ERY-TAB 12 elinest 53 erygel 12 eliphos 51 ERYPED 200 12 83 ERYPED 400 13 fentanyl 4 ERYTHROCIN STEARATE 13 FERATE 72 erythromycin base 13 ferrex 150 forte plus 72 erythromycin base/ethyl alcohol 13 ferrous sulfate 72 erythromycin ethylsuccinate 13 FERUS 73 erythromycin ethylsuccinate/sulfisoxazole acetyl 13 FEVERALL esmolol hcl 35 fexofenadine hcl 66 ESTRACE 53 fexofenadine hcl/pseudoephedrine hcl 66 estradiol 54 FIBER LAXATIVE 48 estradiol/norethindrone acetate 54 FIBER SUPPLEMENT 48 ESTRING 54 FIBERTAB 48 estropipate 54 finasteride 50 ethambutol hcl 21 fioricet ethinyl estradiol/drospirenone 54 FIRAZYR 42 ethosuximide 14 FIRST-LANSOPRAZOLE 49 etidronate disodium 61 FIRST-OMEPRAZOLE 49 1 1 etodolac 3 FLAGYL ER 10 etoposide 23 flavoxate hcl 50 EXELON 16 flecainide acetate 35 exemestane 23 FLOVENT DISKUS 51 EXJADE 71 FLOVENT HFA 51 EXTAVIA 42 fluconazole 18 1 flucytosine 19 EXTRA STRENGTH NON-ASPIRIN EYE LUBRICANT 62 fludrocortisone acetate flunisolide F fluocinolone acetonide 8 64 8 FALLBACK SOLO 57 fluocinolone acetonide oil falmina 54 fluocinonide 8 famciclovir 29 fluocinonide/emollient base 8 famotidine 47 FLUOR-A-DAY 73 FARESTON 22 fluoride/iron/vitamins a,c,and d 73 FARXIGA 29 fluoridex daily defense 73 FASLODEX 22 fluoritab 73 felbamate 15 fluorometholone 51 felodipine 37 flura-drops 73 fenofibrate 39 flurazepam hcl 70 fenofibrate nanocrystallized 39 flurbiprofen fenofibrate,micronized 39 flurbiprofen sodium 63 fenofibric acid 39 flutamide 22 fenofibric acid (choline) 39 fluticasone propionate fenoprofen calcium 3 84 fluvastatin sodium 51 3 8,51 39 FML FORTE 51 gildess fe 54 FML S.O.P. 51 GILENYA 42 FOAMING ANTACID 45 GILOTRIF 23 folbee plus 73 GLEEVEC 23 folic acid 73 glimepiride 29 fondaparinux sodium 32 glipizide 29 FORMULA E 73 glipizide/metformin hcl 30 fosinopril sodium 34 GLUCAGEN 31 fosinopril sodium/hydrochlorothiazide 34 GLUCAGON EMERGENCY KIT 31 FRAGMIN 32 glyburide 30 FRUITY CHEWS 73 glyburide,micronized 30 FULYZAQ 45 glyburide/metformin hcl 30 furosemide 38 glycerin 48 FUZEON 27 glydo G 6 GRANIX 32 GRASTEK 59 gabapentin 15 griseofulvin ultramicrosize 19 GABITRIL 15 griseofulvin, microsize 19 galantamine hbr 17 guaifenesin 69 GAMMAKED 60 guaifenesin/codeine phosphate 69 GAMUNEX-C 60 guanfacine hcl 33 ganirelix acetate 58 GYNE-LOTRIMIN 19 garamycin 9 GAS RELIEF 46 H GAS-X 46 HAIR, SKIN & NAILS gatifloxacin 62 HALFPRIN 1 GATTEX 46 halobetasol propionate 8 gavilyte-c 46 HC-1% HEMORRHOID 43 gavilyte-g 46 HEALTHY EYES 73 gavilyte-n 46 HEARTBURN RELIEF 24 HOUR 49 gemfibrozil 39 HEARTBURN TREATMENT 24 HOUR 49 generlac 48 heather 57 43,59 hecoria 59 heparin sodium,porcine 32 gengraf GENOTROPIN 52 75 gentak 9 heparin sodium,porcine/pf 32 gentamicin sulfate 9 HEXALEN 22 GENTLE LAXATIVE 48 HUMALOG 31 GENTLELAX 48 HUMALOG MIX 50-50 31 gianvi 54 HUMALOG MIX 75-25 31 gildagia 54 HUMIRA 59 gildess 54 HUMIRA PEDIATRIC 59 85 HUMULIN 70-30 31 INFANTS' PAIN RELIEVER 2 HUMULIN N 31 INFERGEN 28 HUMULIN R 31 INLYTA 23 hydralazine hcl 40 INNOPRAN XL 35 hydrochlorothiazide 39 INTELENCE 26 hydrocodone bit/acetaminophen 5 INTRON A 28 hydrocodone bitartrate/acetaminophen 5 introvale 54 hydrocodone bitartrate/homatropine methylbromide 67 INVIRASE 27 hydrocodone/ibuprofen INVOKANA 30 ipecac 46 ipratropium bromide 67 hydrocortisone hydrocortisone butyrate 5 8,43,51,60 8,51 HYDROCORTISONE PLUS 12 43 ipratropium bromide/albuterol sulfate 67 hydrocortisone valerate 52 irbesartan 34 hydrocortisone/aloe vera 8 irbesartan/hydrochlorothiazide 34 hydromet hydromorphone hcl 67 iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca- 5 thr/succ.acid 73 hydroxychloroquine sulfate 24 ISENTRESS 27 hydroxyurea 22 isochron 40 hydroxyzine hcl 17 isonarif 21 hydroxyzine pamoate 17 isoniazid 21 HYPER-SAL 69 isosorbide dinitrate 40 isosorbide mononitrate 40 ITCH RELIEF 43 61 ITCH-X HC 43 ibudone 5 itraconazole 19 ibuprofen 3 ICLUSIG 23 J IMBRUVICA 23 JAKAFI 23 imiquimod 22 jantoven 32 INCIVEK 28 JANUMET 30 indapamide 39 JANUMET XR 30 INDERAL XL 35 JANUVIA 30 INDOCIN 3,9 jencycla 57 I ibandronate sodium indomethacin 3 JENTADUETO 30 INFANT TRIAMINIC FEVER REDUCER 1 JOCK ITCH 19 INFANT'S NON-ASPIRIN 1 jolessa 54 INFANT'S PAIN RELIEF 2 jolivette 57 INFANTS' GAS RELIEF 46 junel 54 INFANTS' MAPAP 2 junel fe 54 INFANTS' NON-ASPIRIN 2 JUVISYNC 30 INFANTS' PAIN & FEVER 2 JUXTAPID 40 86 K KADIAN 4 LAXATIVE PEG 3350 48 leena 54 leflunomide 60 KALETRA 27 lessina 54 KALYDECO 69 LETAIRIS 68 KAO-TIN 48 letrozole 23 KAZANO 30 leucovorin calcium 22 kelnor 1-35 54 LEUKERAN 21 ketoconazole 19 LEUKINE 32 ketodan 19 leuprolide acetate 58 ketoprofen 3 LEVATOL 36 ketorolac tromethamine 3 LEVEMIR 31 KID'S VITAMINS + IRON 73 LEVEMIR FLEXPEN 31 kionex 71 LEVEMIR FLEXTOUCH 31 klor-con 10 73 levetiracetam 14 klor-con 8 73 levobunolol hcl 64 klor-con m10 73 levocarnitine 73 klor-con m15 73 levocarnitine (with sugar) 73 klor-con m20 73 levocetirizine dihydrochloride 66 KOMBIGLYZE XR 30 levofloxacin 13 KONSYL 48 levonest 54 KONSYL FIBER 48 levonorgestrel 57 KONSYL-D 48 levonorgestrel-eth estra/ethinyl estradiol 54 KRISTALOSE 48 levonorgestrel-ethinyl estradiol 54 kurvelo 54 levora-28 54 KUVAN 44 levothroid 57 KYNAMRO 40 levothyroxine sodium 57 levoxyl 57 LEXIVA 27 L labetalol hcl 35 LIALDA 46 lactulose 48 lidocaine 6 lidocaine hcl 6 6 lamivudine 26,28 lamivudine/zidovudine 26 lidocaine/prilocaine lancets 61 lindane 25 LANOXIN 38 liothyronine sodium 57 lansoprazole 49 LIQUID ANTACID 46 lansoprazole/amoxicillin trihydrate/clarithromycin 49 lisinopril 34 LANTUS 31 lisinopril/hydrochlorothiazide 34 larin 54 lofibra 39 larin fe 54 lomedia 24 fe 54 latanoprost 61 lomustine 21 87 loperamide hcl 46 megestrol acetate 57 loratadine 66 MEKINIST 23 LORATADINE-D 66 meloxicam 3 lorcet 5 MEN'S MULTIVITAMIN 73 lorcet hd 5 meperidine hcl 5 lorcet plus 5 meperitab 5 lortab 5 MEPHYTON 33 LORTUSS EX 69 mercaptopurine 22 loryna 55 mesalamine 46 losartan potassium 34 MESTINON 21 losartan potassium/hydrochlorothiazide 34 metadate er 41 LOTEMAX 63 metaproterenol sulfate 68 LOTRIMIN AF 19 metaxalone 70 LOTRONEX 48 metformin hcl 30 lovastatin 39 methadone hcl 4 low-ogestrel 55 methadone intensol 4 LUBRICANT EYE DROPS 62 methadose 4 ludent fluoride 73 methazolamide 38 methenamine hippurate 10 LUMIGAN 61,62 lutera 55 methimazole 59 LYRICA 15 methocarbamol 70 LYSODREN 58 methotrexate sodium 22 lyza 57 methotrexate sodium/pf 22 methyclothiazide 39 methyldopa 33 M MAALOX MAXIMUM STRENGTH 46 methyldopa/hydrochlorothiazide 33 MACRODANTIN 10 methylergonovine maleate 50 magnesium hydroxide 46 methylphenidate hcl 41 magnesium oxide 73 methylprednisolone 52 magnesium sulfate 48 metoclopramide hcl 17 MAPAP 2 metolazone 39 MAPAP INFANT 2 metoprolol succinate 36 marlexate 71 metoprolol tartrate 36 marlissa 55 metoprolol tartrate/hydrochlorothiazide 36 maternity 73 metronidazole 10 MATULANE 21 mexiletine hcl 35 matzim la 37 MG-PLUS-PROTEIN 48 meclizine hcl 17 miconazole nitrate 19 microgestin 55 meclofenamate sodium 3 MEDROL 52 microgestin fe 55 medroxyprogesterone acetate 57 midodrine hcl 33 88 migergot 20 MULTIVITAL 73 MIGRANAL 20 MULTIVITAL PLATINUM 73 MILANTEX 46 multivitamin with minerals 74 millipred 8 multivitamins with fluoride 74 millipred dp 8 multivitamins with iron 74 mimvey 55 mupirocin 10 mimvey lo 55 my way 57 mineral oil 49 MYALEPT 52 MINIPRIN 2 mycophenolate mofetil 59 minitran 40 mycophenolate sodium 60 MINIVELLE 55 mydfrin 62 minocycline hcl 14 MYLANTEX DOUBLE-STRENGTH 46 minoxidil 40 MYLERAN MIRANEL AF 19 mynephrocaps 74 misoprostol 49 MYTUSSIN DAC 69 MITRAZOL 19 myzilra 55 MODERIBA 28 moexipril hcl 34 N MOISTURIZING LUBRICANT 62 nabumetone mometasone furoate 43 nadolol MONISTAT 7 19 naltrexone hcl monoject prefill 32 NAMENDA 17 monoject prefill advanced 32 naphazoline hcl 62 montelukast sodium 67 NAPRELAN 3 MONUROL 10 naproxen 3 morgidox 14 naproxen sodium 3 morphine sulfate 4,6 naratriptan hcl MOTION SICKNESS 17 NAROPIN MOTION SICKNESS II 17 NASAL DECONGESTANT 69 MOTION SICKNESS RELIEF 17 natal-v rx 74 MOTION-TIME 17 NEBUPENT 24 6 3 36 7 20 6 MOTRIN 3 necon 55 MOTRIN IB 3 neo-polycin 62 MOVIPREP 49 neo-polycin hc 62 moxifloxacin hcl 13 neofrin 62 MUCINEX 69 neomycin sulfate MUCINEX ALLERGY 66 neomycin sulfate/bacitracin zinc/polymyxin MUCINEX DM 69 b/hydrocortisone 62 MUCUS ER 69 neomycin sulfate/bacitracin/polymyxin b 62 MUCUS RELIEF 69 neomycin sulfate/polymyxin b sulfate/gramicidin d 62 MULTAQ 35 89 9 neomycin sulfate/polymyxin b sulfate/hydrocortisone 62,64 norlyroc 57 NORPACE CR 35 neomycin/polymyxin b sulfate/dexamethasone 62 nortrel 55 neosporin 62 NORVIR 27 NESINA 30 NOVOLIN 70-30 31 NEULASTA 32 NOVOLIN N 31 NEUMEGA 32 NOVOLIN R 31 NEUPOGEN 32 NOVOLOG 31 nevirapine 26 NOVOLOG FLEXPEN 31 NEXAVAR 23 NOVOLOG MIX 70-30 31 next choice 57 NOVOLOG MIX 70-30 FLEXPEN 31 next choice one dose 57 NOXAFIL 19 NU-TEARS 62 NUEDEXTA 41 nulytely with flavor packs 46 niacin nicardipine hcl nicotine 40,74 37 7 nifediac cc 37 NUTROPIN 52 nifedical xl 37 NUTROPIN AQ 52 nifedipine 37 NUTROPIN AQ NUSPIN 52 NIGHTTIME SLEEP AID 70 NUVARING 55 nikki 55 nyamyc 19 NILANDRON 59 nystatin 19 nimodipine 37 nystatin/triamcinolone acetonide nisoldipine 37 nystop NITRO-BID 40 NITRO-DUR 40 O nitro-time 40 ocella 55 nitrofurantoin 10 OCUDOX 14 nitrofurantoin macrocrystal 10 ofloxacin 13 nitrofurantoin monohydrate/macrocrystals 10 ogestrel 55 nitroglycerin 41 OLYSIO 28 NITROSTAT 41 omega-3 acid ethyl esters 40 nizatidine 47 omega-3 fatty acids/docosahexanoic acid/epa/fish 8 19 NON-ASPIRIN 2 oil 38 NON-ASPIRIN EXTRA STRENGTH 2 omega-3 fatty acids/fish oil 38 nora-be 57 omega-3 fatty acids/vitamin e 38 norethindrone 57 omeprazole 50 norethindrone acetate 57 omeprazole magnesium 50 norethindrone acetate-ethinyl estradiol 55 OMEPRAZOLE+SYRSPEND SF ALKA 50 ondansetron 18 norethindrone acetate-ethinyl estradiol/ferrous fumarate 55 ondansetron hcl 18 norgestimate-ethinyl estradiol 55 ONE DAILY MULTIVITAMIN-IRON 74 90 ONFI 15 pediatric multivitamins no.16 with sodium fluoride 74 ONGLYZA 30 pediatric multivitamins no.17 with sodium fluoride 74 OPSUMIT 68 pediatric multivitamins no.82 with sodium fluoride 74 ORALAIR 60 peg 3350/sod sulf/sod bicarbonate/sod oralone 8 chloride/potassium chl 46 ORAPRED ODT 8 PEGANONE 16 ORFADIN 44 PEGASYS 28 ORGAN-I NR 69 PEGASYS PROCLICK 28 orphenadrine citrate 70 PEGINTRON 28 orphenadrine citrate/aspirin/caffeine 70 PEGINTRON REDIPEN 28 orsythia 55 penicillin v potassium 12 OSENI 30 PENTASA 46 oxaprozin 3 pentazocine hcl/acetaminophen 6 6 oxcarbazepine 16 pentazocine hcl/naloxone hcl OXISTAT 19 pentoxifylline 38 oxybutynin chloride 50 PEP-T-MED 46 oxycodone hcl 4,6 PEPCID AC 47 oxycodone hcl/acetaminophen 6 PEPTIC RELIEF 46 oxycodone hcl/aspirin 6 perindopril erbumine 34 OXYCONTIN 4 periogard 11 oxymorphone hcl 6 permethrin 25 OXYTROL 50 petrolatum,white 61 OYST-CAL-500 46 phenadoz 17 OYST-CAL-D 500 74 phenergan 17 phenobarbital 15 phenylephrine hcl 62 phenylephrine hcl/promethazine hcl 69 P pacerone 35 PAIN RELIEF 2 PHENYTEK 16 PAIN RELIEF PM 2 phenytoin 16 PAIN RELIEVER 2 phenytoin sodium extended 16 PAIN RELIEVER PM 2 philith 55 pancrelipase 5,000 44 PHILLIPS' MILK OF MAGNESIA 49 pantoprazole sodium 50 phos-flur 74 paricalcitol 58 PHOS-FLUR 74 paroex 10 PHOSPHATE LAXATIVE 46 pedi-dri 19 PICATO 43 pediatric multivitamin combination no.2/sodium pilocarpine hcl 42,64 fluoride 74 pindolol 36 pediatric multivitamins a,c,& d3 no.21 74 pioglitazone hcl 30 pioglitazone hcl/glimepiride 30 pioglitazone hcl/metformin hcl 30 pediatric multivitamins a,c,& d3 no.21 with sodium fluoride 74 91 pirmella 55 piroxicam 3 prenatal vits with calcium #72/ferrous fumarate/folic acid 75 PLEGRIDY 42 prenatal vits with calcium #72/iron,carbonyl/folic acid 75 PLEGRIDY PEN 42 preplus 75 pnv 29-1 74 PREVACID 50 podofilox 43 prevalite 40 polyethylene glycol 3350 49 prevident 75 polymyxin b sulfate/trimethoprim 62 PREZISTA 27 POLYSACCHARIDE IRON 74 primaquine phosphate 24 portia 55 primidone 14 potassium chloride 74 proair hfa 68 potassium chloride/potassium bicarbonate/citric acid 74 probenecid 20 potassium citrate 74 prochlorperazine maleate 18 potassium citrate/citric acid 50 PROCRIT 32 POWDERLAX 49 proctocream-hc 60 PRADAXA 32 PROCTOFOAM-HC 60 pramipexole di-hcl 25 proctosol-hc 60 pravastatin sodium 39 proctozone-hc 60 prazosin hcl 33 PROCYSBI 51 PRED MILD 63 progesterone,micronized 57 prednisolone 9 PROMACTA 32 promethazine hcl 18 promethazine hcl/codeine 66 prednisolone acetate prednisolone sod phosphate 63 9,63 prednisone 9 promethazine/phenylephrine hcl/codeine 66 prednisone intensol 9 promethegan 18 PREFEST 55 propafenone hcl 35 PREMARIN 55 propantheline bromide 47 PREMPHASE 56 propranolol hcl 36 PREMPRO 56 propranolol hcl/hydrochlorothiazide 36 prenaplus 74 propylthiouracil 59 PROTONIX 50 PROTOPIC 43 pseudoephedrine hcl 69 PULMICORT 64 PULMICORT FLEXHALER 64 pulmosal 69 PULMOZYME 69 prenatal vitamins comb no.115/iron fumarate/folic acid 74 prenatal vitamins comb no.115/iron fumarate/folic acid/dss 75 prenatal vitamins combo no.60/ferrous fumarate/folic acid 75 prenatal vitamins with calcium/ferrous fumarate/folic acid 75 PURELAX 49 prenatal vitamins/ferrous fumarate/folic acid 75 PYLERA 47 prenatal vitamins/ferrous sulfate/folic acid 75 pyrazinamide 21 prenatal vits w-ca,fe,fa(<1mg) 75 pyridostigmine bromide 21 92 pyridoxine hcl 75 Q RHEUMATREX 22 RIBAPAK 29 RIBASPHERE 29 quasense 56 RIBATAB 29 QUDEXY XR 15 ribavirin 29 QUFLORA 75 rifabutin 21 quinapril hcl 34 rifampin 21 quinapril hcl/hydrochlorothiazide 34 riluzole 41 quinidine gluconate 35 rimantadine hcl 28 quinidine sulfate 35 RIOMET 30 QVAR 64 RITALIN LA 41 rivastigmine tartrate 17 rizatriptan benzoate 20 R rabeprazole sodium 50 ROBAFEN 69 RAGWITEK 60 ROBAFEN-DM CLEAR 69 raloxifene hcl 57 ropinirole hcl 25 ranitidine hcl 47 rosadan 11 RAPAMUNE 60 ROXICET 6 RAVICTI 44 roxicet 6 RE-AZO 51 ROZEREM REBETOL 28 REBIF 42 S REBIF REBIDOSE 42 SABRIL 15 reclipsen 56 SAIZEN 52 REGRANEX 43 SAVELLA 42 RELENZA 28 se-natal 19 75 RELISTOR 47 selegiline hcl 25 REMODULIN 68 selenium sulfide 43 rena-vite rx 75 SELZENTRY 27 RENAGEL 51 SENEXON 49 renal caps 75 SENIOR VITAMIN 75 reno caps 75 SENNA 49 RENVELA 51 SENNA PLUS 49 reprexain 6 SENNA S 49 70 RESCRIPTOR 26 SENNA-GEN 49 reserpine 38 sennosides/docusate sodium 49 RESTASIS 60 SENSIPAR 58 RETAINE CMC 63 SENTRY PERFORM 75 7 SEREVENT DISKUS 68 revia REVLIMID 22 SEROSTIM 52 REYATAZ 27 sevelamer carbonate 51 93 sf 75 STROMECTOL 24 sf 5000 plus 75 sucralfate 49 sharobel 57 SUDOGEST 70 SIGNIFOR 58 sulfacetamide sodium sildenafil citrate 68 sulfacetamide sodium/prednisolone sodium silver sulfadiazine 13 phosphate 63 simethicone 47 sulfamethoxazole/trimethoprim 13 SIMPLY SLEEP 71 sulfamide 13 simvastatin 39 sulfasalazine 47 sirolimus 60 sulfazine 47 SIRTURO 21 sulfazine ec 47 SLEEP II 71 sulindac sodium chloride 69 sumatriptan 20 sodium chloride for inhalation 70 sumatriptan succinate 20 SUPER VIKAPS 76 sodium chloride/sodium bicarbonate/potassium 13,63 3 chloride/peg 47 SUPREP 49 SODIUM EDECRIN 38 SUSTIVA 26 sodium fluoride 75 SUTENT 23 sodium phenylbutyrate 44 syeda 56 sodium polystyrene sulfonate 71 SYLATRON 29 SOLTAMOX 22 SYLATRON 4-PACK 29 SOMAVERT 58 SYMBICORT 70 SOOTHE 47 SYMLINPEN 120 30 sorbitol solution 49 SYMLINPEN 60 30 SORBUGEN NR 70 sorine 35 T sotalol hcl 35 TABLOID 22 SOVALDI 29 tacrolimus 60 SPIRIVA 67 TAFINLAR 23 spironolactone 39 TAMIFLU 28 spironolactone/hydrochlorothiazide 39 tamoxifen citrate 22 SPORANOX 19 tamsulosin hcl 50 SPRYCEL 23 TARCEVA 24 sronyx 56 TARGRETIN 24 tarina fe 56 stagesic 6 stavudine 26 TASIGNA 24 STIMATE 52 TAVIST-1 66 STIVARGA 23 taztia xt 37 STOOL SOFTENER 49 TECFIDERA 42 STRESS FORMULA WITH ZINC 76 TEGRETOL XR 16 STRIBILD 27 temazepam 70 94 temozolomide torsemide 38 2 TRACLEER 68 terazosin hcl 33 TRADJENTA 30 terbinafine hcl 19 tramadol hcl 4,6 terbutaline sulfate 68 tramadol hcl/acetaminophen terconazole 19 trandolapril 34 tetracycline hcl 14 tranexamic acid 33 TEV-TROPIN 52 TRAVATAN Z 62 THALOMID 22 TRAVEL SICKNESS 18 THEO-24 67 tretinoin 24 theochron 67 TREXALL 22 theophylline anhydrous 67 tri-estarylla 56 THERAMILL FORTE 76 tri-linyah 56 therapeutic hematinic 76 tri-previfem 56 therapeutic vitamin w-minerals 76 tri-sprintec 56 THERAPEUTIC-M 76 triamcinolone acetonide THERIN-M MULTIVIT-MINERAL 76 triamterene/hydrochlorothiazide 39 thiamine hcl 76 trianex 43 THYROLAR-1 58 triazolam 70 THYROLAR-1/2 58 TRICARE 76 THYROLAR-1/4 58 triderm THYROLAR-2 58 trifluridine 29 THYROLAR-3 58 TRIGLIDE 39 tiagabine hcl 15 trihexyphenidyl hcl 25 ticlopidine hcl 33 trilyte with flavor packets 47 trimethobenzamide hcl 18 tencon timolol maleate 22 20,64 2 9 9 tinidazole 24 trimethoprim 11 TIVICAY 27 trinatal rx 1 76 tizanidine hcl 26 trinessa 56 tl-fluorivite 76 triphrocaps 76 TRIPLE ANTIBIOTIC 11 TOBI PODHALER 9 TOBRADEX 63 TRIPLE ANTIBIOTIC-PAIN RELIEF 11 TOBRADEX ST 63 trivora-28 56 tobramycin 9 trospium chloride 50 tobramycin in 0.225 % sodium chloride 9 TRUVADA 26 tobramycin/dexamethasone 63 tussigon 67 tolazamide 30 TUSSIN 70 TUSSIN DM 70 tolmetin sodium 4 tolterodine tartrate 50 TYKERB 24 topiragen 15 TYLENOL COLD SEVERE CONGESTION 70 topiramate 15 TYLENOL EXTRA STRENGTH 95 2 TYLENOL PM EXTRA STRENGTH 2 U vinate calcium 76 vinate one 76 vinate pn care 76 UCERIS 52 vinate-m 76 ULESFIA 25 VIRACEPT 27 unithroid 58 VIRAMUNE XR 26 URINARY PAIN RELIEF 51 VIREAD 27 urine acetone test,strips 61 virt nate 76 urine gluc-acet comb.tst,strip 61 virt-caps 76 urine glucose test,strip 61 VIRTUSSIN AC 70 ursodiol 47 vitamin a 76 vitamin a palmitate 76 vitamin e 76 V v-c forte 76 vitamin e (dl-alpha tocopheryl acetate) 76 VAGIFEM 56 vitamin e acetate 76 valacyclovir hcl 29 vitamin e acid succinate 76 VALCHLOR 22 vitamin e mixed 76 VALCYTE 28 VIVELLE-DOT 56 valsartan 34 vol-care rx 77 valsartan/hydrochlorothiazide 34 vol-nate 77 vancomycin hcl 11 vol-plus 77 vandazole 11 vol-tab rx 77 vandetanib 24 VOLTAREN 43 vaseline white petroleum 61 voriconazole 20 VELETRI 68 VOTRIENT 23 velivet 56 vyfemla 56 VENTAVIS 68 VYVANSE 41 ventolin hfa 68 verapamil hcl 35,37 W vestura 56 WAL-DRYL VEXOL 63 WAL-FEX ALLERGY 66 VIBRAMYCIN 14 WAL-ITIN 66 vic-forte 76 WAL-ITIN D 66 VICKS QLEARQUIL ALLERGY 66 WAL-ITIN D 12 HOUR 66 VICKS QLEARQUIL NIGHTTIME 66 WAL-PHOSPHATE 47 VICTOZA 2-PAK 30 WAL-PROFEN 4 VICTOZA 3-PAK 30 WAL-ZAN 150 47 VICTRELIS 29 WAL-ZAN 75 47 VIDEX 26 WAL-ZYR 66 VIMAR 76 warfarin sodium 32 VIMPAT 16 WOMEN'S GENTLE LAXATIVE 49 96 43,66 X XARELTO 32 XENAZINE 42 XIFAXAN 11 XOPENEX HFA 68 XTANDI 59 xulane 56 xylon 10 6 XYREM 71 Z zafirlukast 67 zarah 56 zebutal 2 ZELBORAF 24 ZEMPLAR 58 zenchent 56 ZENPEP 44 zenzedi 41 ZETIA 40 ZIAGEN 27 zidovudine 27 ZIRGAN 28 ZOLADEX 23 ZOLINZA 24 zolmitriptan 20 ZOMIG 20 zonisamide 15 ZORBTIVE 52 ZORTRESS 60 zovia 1-35e 56 zovia 1-50e 56 ZYKADIA 24 ZYLET 63 ZYTIGA 23 ZYVOX 11 97 Category Listing Analgesics Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Anti-inflammatory Agents Antibacterials Anticonvulsants Antidementia Agents Antidepressants Antiemetics Antifungals Antigout Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics Antiparasitics Antiparkinson Agents Antispasticity Agents Antivirals Blood Glucose Regulators Blood Products/Modifiers/ Volume Expanders Cardiovascular Agents Central Nervous System Agents Dental and Oral Agents Dermatological Agents Enzyme Replacement/ Modifiers Gastrointestinal Agents Genitourinary Agents Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Other) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Sex Hormones/Modifiers) Hormonal Agents, Suppressant (Thyroid) Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Miscellaneous 98 1 6 7 7 9 14 16 17 17 18 20 20 21 21 21 24 25 26 26 29 31 33 41 42 42 44 44 50 51 52 52 52 57 58 58 58 58 59 59 60 61 61 Ophthalmic Agents Otic Agents Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Therapeutic Nutrients/ Minerals/ Electrolytes 61 64 64 70 70 71 99 Last Update November 2014
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