CareFirst Formulary 1 (Non
CareFirst Formulary 1 (Non-ACA Plans) 2015 Note: The self-administered injectables drug tier may differ based on your prescription benefit plan. All self-administered injectables are noted with SI. If you have a 4-tier prescription drug plan then the self-injectable will fall under Tier 4 (excluding insulin). If you have a 3-tier prescription drug plan, the self-injectable will fall under Tier 3. PLEASE READ: This document contains information about the drugs we cover in this plan. This formulary is for members of an employer group with 51 or more employees OR individuals or families who have a “grandfathered” plan (purchased before the March 23, 2010 Affordable Care Act date) This formulary was updated 01/01/2015. For more recent information or other questions, please contact CareFirst Pharmacy Services at 800-241-3371 or visit www.carefirst.com/rx. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc. LAST UPDATED 01/01/2014 LAST UPDATED 01/01/2015 CareFirst Formulary 1 (Non-ACA Drug List) (01/01/2015) WHAT IS THE CAREFIRST FORMULARY 1?........................................................................................................................................................ 4 HOW DO I USE THE CAREFIRST FORMULARY 1? ............................................................................................................................................. 4 DRUG LIST PRODUCT DESCRIPTIONS (FOR HEALTH CARE PROVIDERS) ................................................................................................... 5 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 6 LEGEND ................................................................................................................................................................................................................... 6 NOTICES .................................................................................................................................................................................................................. 6 ANALGESICS........................................................................................................................................................................................................... 8 NSAIDs ........................................................................................................................................................................................................... 8 NSAIDs, COMBINATIONS ............................................................................................................................................................................. 8 NSAIDs, TOPICAL ......................................................................................................................................................................................... 8 COX-2 INHIBITORS ....................................................................................................................................................................................... 8 GOUT ............................................................................................................................................................................................................. 8 OPIOID ANALGESICS ................................................................................................................................................................................... 8 NON-OPIOID ANALGESICS.......................................................................................................................................................................... 9 VISCOSUPPLEMENTS ................................................................................................................................................................................. 9 ANTI-INFECTIVES ................................................................................................................................................................................................... 9 ANTIBACTERIALS ......................................................................................................................................................................................... 9 ANTIFUNGALS ............................................................................................................................................................................................ 10 ANTIMALARIALS ......................................................................................................................................................................................... 10 ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 10 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 11 ANTIVIRALS................................................................................................................................................................................................. 11 MISCELLANEOUS ....................................................................................................................................................................................... 12 ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 12 ALKYLATING AGENTS ............................................................................................................................................................................... 12 ANTIMETABOLITES .................................................................................................................................................................................... 12 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 12 IMMUNOMODULATORS ............................................................................................................................................................................. 13 KINASE INHIBITORS................................................................................................................................................................................... 13 TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 13 MISCELLANEOUS ....................................................................................................................................................................................... 13 CARDIOVASCULAR .............................................................................................................................................................................................. 13 ACE INHIBITORS ........................................................................................................................................................................................ 13 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 14 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 14 ADRENOLYTICS, CENTRAL....................................................................................................................................................................... 14 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 14 ALPHA BLOCKERS ..................................................................................................................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 15 ANTIARRHYTHMICS ................................................................................................................................................................................... 15 ANTILIPEMICS............................................................................................................................................................................................. 15 BETA-BLOCKERS ....................................................................................................................................................................................... 16 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 16 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 16 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 16 DIGITALIS GLYCOSIDES............................................................................................................................................................................ 16 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 16 DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...................................................................................... 16 DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS .................................................................... 16 DIURETICS .................................................................................................................................................................................................. 17 NITRATES .................................................................................................................................................................................................... 17 NITRATE/VASODILATOR COMBINATIONS .............................................................................................................................................. 17 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 17 MISCELLANEOUS ....................................................................................................................................................................................... 18 1 CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 18 ANTIANXIETY .............................................................................................................................................................................................. 18 ANTICONVULSANTS .................................................................................................................................................................................. 18 ANTIDEMENTIA ........................................................................................................................................................................................... 18 ANTIDEPRESSANTS .................................................................................................................................................................................. 19 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 19 ANTIPSYCHOTICS ...................................................................................................................................................................................... 20 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 20 FIBROMYALGIA .......................................................................................................................................................................................... 20 HUNTINGTON'S DISEASE AGENTS .......................................................................................................................................................... 21 HYPNOTICS................................................................................................................................................................................................. 21 MIGRAINE .................................................................................................................................................................................................... 21 MOOD STABILIZERS .................................................................................................................................................................................. 21 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 21 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 22 MYASTHENIA GRAVIS ............................................................................................................................................................................... 22 NARCOLEPSY/CATAPLEXY....................................................................................................................................................................... 22 POSTHERPETIC NEURALGIA (PHN)......................................................................................................................................................... 22 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 22 ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 22 ANDROGENS .............................................................................................................................................................................................. 22 ANTIDIABETICS .......................................................................................................................................................................................... 22 ANTIOBESITY * ........................................................................................................................................................................................... 24 CALCIUM REGULATORS ........................................................................................................................................................................... 24 CONTRACEPTIVES * .................................................................................................................................................................................. 24 ENDOMETRIOSIS ....................................................................................................................................................................................... 25 ESTROGENS ............................................................................................................................................................................................... 26 ESTROGEN/PROGESTINS......................................................................................................................................................................... 26 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................. 26 FERTILITY REGULATORS.......................................................................................................................................................................... 26 GLUCOCORTICOIDS .................................................................................................................................................................................. 26 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 26 HUMAN GROWTH HORMONES................................................................................................................................................................. 27 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 27 PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 27 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 27 PROGESTINS .............................................................................................................................................................................................. 27 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 27 THYROID AGENTS ..................................................................................................................................................................................... 27 VASOPRESSINS ......................................................................................................................................................................................... 27 MISCELLANEOUS ....................................................................................................................................................................................... 27 GASTROINTESTINAL ........................................................................................................................................................................................... 28 ANTIDIARRHEALS ...................................................................................................................................................................................... 28 ANTIEMETICS ............................................................................................................................................................................................. 28 ANTISPASMODICS ..................................................................................................................................................................................... 28 CHOLELITHOLYTICS .................................................................................................................................................................................. 28 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 28 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 28 IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 29 LAXATIVES .................................................................................................................................................................................................. 29 PANCREATIC ENZYMES ............................................................................................................................................................................ 29 PROSTAGLANDINS .................................................................................................................................................................................... 29 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 29 SALIVA STIMULANTS ................................................................................................................................................................................. 29 STEROIDS, RECTAL ................................................................................................................................................................................... 29 ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 29 MISCELLANEOUS ....................................................................................................................................................................................... 29 GENITOURINARY .................................................................................................................................................................................................. 30 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 30 ERECTILE DYSFUNCTION ......................................................................................................................................................................... 30 URINARY ANTISPASMODICS .................................................................................................................................................................... 30 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 30 MISCELLANEOUS ....................................................................................................................................................................................... 30 2 HEMATOLOGIC ..................................................................................................................................................................................................... 30 ANTICOAGULANTS .................................................................................................................................................................................... 30 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 31 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 31 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 31 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 31 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 31 STEM CELL MOBILIZERS........................................................................................................................................................................... 31 MISCELLANEOUS ....................................................................................................................................................................................... 31 IMMUNOLOGIC AGENTS...................................................................................................................................................................................... 31 BIOLOGIC DISEASE-MODIFYING AGENTS .............................................................................................................................................. 31 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 31 IMMUNOMODULATORS ............................................................................................................................................................................. 32 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 32 NUTRITIONAL/SUPPLEMENTS............................................................................................................................................................................ 32 ELECTROLYTES ......................................................................................................................................................................................... 32 VITAMINS AND MINERALS ........................................................................................................................................................................ 32 RESPIRATORY ...................................................................................................................................................................................................... 33 ANAPHYLAXIS TREATMENT AGENTS...................................................................................................................................................... 33 ANTICHOLINERGICS .................................................................................................................................................................................. 33 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS............................................................................................................................ 33 ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 33 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 33 ANTITUSSIVES............................................................................................................................................................................................ 33 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 33 BETA AGONISTS ........................................................................................................................................................................................ 34 CYSTIC FIBROSIS ...................................................................................................................................................................................... 34 LEUKOTRIENE RECEPTOR ANTAGONISTS ............................................................................................................................................ 34 MAST CELL STABILIZERS ......................................................................................................................................................................... 34 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 34 NASAL STEROIDS ...................................................................................................................................................................................... 34 PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 34 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 34 STEROID INHALANTS ................................................................................................................................................................................ 34 XANTHINES ................................................................................................................................................................................................. 35 MISCELLANEOUS ....................................................................................................................................................................................... 35 TOPICAL ................................................................................................................................................................................................................ 35 DERMATOLOGY ......................................................................................................................................................................................... 35 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 37 OPHTHALMIC .............................................................................................................................................................................................. 38 OTIC ............................................................................................................................................................................................................. 39 WEBSITES ............................................................................................................................................................................................................. 40 INDEX ..................................................................................................................................................................................................................... 42 3 What is the CareFirst Formulary 1? The CareFirst Formulary 1 (drug list) is a list of covered drugs and can be used as a reference and informational tool. It includes safe and clinically effective drug therapies reflecting current medical practices. The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) committee and are approved for inclusion by CareFirst. The P&T committee consists of physicians, pharmacists, and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding pharmacy drugs. Your prescription benefit plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a participating pharmacy in the CareFirst network, and other plan rules are followed. Please note this is not an all-inclusive list and is subject to change. A Preferred Drug List which represents those preferred drugs that have been identified as the lowest cost, therapeutic alternatives can be found at www.carefirst.com/rx. The Preferred Drug List can be printed out and taken to your physician to assist in prescribing a safe and cost effective medication. How do I use the CareFirst Formulary 1? The CareFirst formulary was designed for members and health care providers. The formulary is organized by sections. Each section is divided into therapeutic drug classes such as: analgesics, anti-infectives, antineoplastic agents, cardiovascular, central nervous system, endocrine and metabolic, gastrointestinal, genitourinary, hematologic, immunologic agents, nutritional/supplements, respiratory and topical. Note: references for your physician on practice guidelines and recommendations for treatment are provided for each therapeutic drug class. Drugs listed in the formulary are ranked into tiers or categories and the cost you pay for your drug varies depending on your prescription benefit plan. Our plan covers both generic and brand-name drugs. Generic drugs are approved by the Food and Drug Administration (FDA) and have the same active ingredients as their brand-name counterpart. Generic drugs are typically available at the lowest cost-share. Refer to the Summary of Benefits or Plan Summary for cost-sharing information. Tier 0: $0 copay drugs include oral chemotherapy drugs, selected diabetic supplies, and drugs classified as preventative drugs by the Affordable Care Act. Tier 1: Generic drugs work the same as brand-name drugs, but cost much less. So you’ll pay less to use them. You should ask your doctor to prescribe a generic drug or choose a generic version of the prescribed brand-name drug if one is available. Tier 2: Preferred brand drugs are brand-name drugs that are not yet available in generic form, but are chosen for their effectiveness and affordability compared to alternatives. They cost more than generics but less than non-preferred brand drugs. If a generic drug becomes available, the preferred brand drug will be moved to the non-preferred brand tier or category. Tier 3: Non-preferred brand drugs are often available in less-expensive forms, either as generic or preferred brand drugs. You will pay more for drugs in this tier. Tier 4: Self-administered injectables (excluding insulin) often have the highest out-of-pocket cost. In most cases, these are high-cost prescription drugs that may require special handling, administration or monitoring. Note: The self-administered injectables drug tier may differ based on your prescription benefit plan. All self-administered injectables are noted with SI. If you have a 4-tier prescription drug plan then the self-injectable will fall under Tier 4 (excluding insulin). If you have a 3-tier prescription drug plan, the self-injectable will fall under Tier 3. 4 Products on the CareFirst Formulary 1 are listed by generic name with the brand-name listed for reference only. Generic drugs are listed in lower case. When a generic drug is available, the brand-name drug and tier will be listed next to the generic form of the drug. When a generic drug is available for dispensing to replace the brand-name drug, the generic will be listed in boldface type. For example, under the cardiovascular section, LOTENSIN is listed as a Tier 3 drug with “benazepril” indicated as the generic form of that drug which can be dispensed in place of the highercost brand-name drug. Note: all strengths or dosage forms may not be available in generic form. Generics should be considered the first line of prescribing. Unless exceptions are noted, all applicable dosage forms and strengths of the drug listed are generally included in this list. Individual pharmacy benefit plans may have additional care management criteria, while some products may not be covered at all. These criteria may include: • Prior authorization – Certain medications require advance approval (prior authorization) by your doctor before they can be filled. Without prior approval, your drugs may not be covered. • Step therapy ensures lower costs – When similar medications are available in multiple forms, step therapy guides your doctor to prescribe the lower-cost option first. You may then move up the cost levels until you find the prescription drug that works best for you. Higher step prescription drugs will require advance approval (prior authorization) by your doctor before they can be filled. • Quantity limits – Limits have been placed on the use of selected drugs for quality, safety or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are usually, not included in the pharmacy benefit. Pharmacy law requires a valid prescription for the purchase of needles and syringes in certain states. Drug list product descriptions (for health care providers) Examples are noted below to assist in understanding which specific strengths and dosage forms are on CareFirst Formulary 1. The general principles shown in the examples can usually be extended to other entries in the list. Any exceptions are noted. Products on the drug list include all strengths and dosage forms of the cited brand-name product. aripiprazole Abilify Oral tablets, oral disintegrating tablets, solution and all strengths of Abilify would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is on the drug list. Other strengths/dosage forms of the reference product are not listed. acyclovir caps, tabs Zovirax The capsules and tablets of Zovirax are on the drug list. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry. Extended-release and delayed-release products require their own entry. sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR. sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms the extended-release product is on the drug list. Dosage forms on the drug list will be consistent with the category and use where listed. neomycin/polymyxin B/hydrocortisone Cortisporin Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the drug list. 5 Generic substitution Generic substitution is a pharmacy action where a generic version is dispensed rather than a prescribed brand-name product. One way to reduce out-of-pocket costs is by requesting a generic drug. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are: Approved by the FDA for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. Manufactured in the same strength and dosage form as the brand-name drugs. When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug. Brand-name drugs having a generic available may: Incur higher copay/coinsurance (tier 3) Require payment of the difference in price between generic and brand, in addition to copay/coinsurance Require mandatory generic substitution Legend # OTC QL PA SI SP boldface delayed-rel ext-rel Covered under the medical benefit. Over-the-counter Quantity limits Prior authorization Self-injectable product; These products may have a higher member copay/coinsurance. 4th tier benefit may apply. Specialty product Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification Extended-release (also known as sustained-release), refer to the reference brand listed for clarification Notices CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (CareFirst) are both independent licensees of the Blue Cross and Blue Shield Association. The information contained in this document is proprietary and may not be copied in whole or in part without written permission. ©2014. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CareFirst. CareFirst does not operate the websites/organizations listed here, nor are they responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CareFirst. 6 National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov, on the websites listed under each therapeutic class and on the sites listed in the websites section of this publication. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This list is not intended to be a substitute for the knowledge, expertise, skill and judgment of the health care provider in his or her choice of prescription drugs. All the information in this list is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. This document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information. When viewing the CareFirst Formulary 1 (drug list) via the Internet, please be advised that this list is updated periodically and changes may appear prior to their effective date to allow for client notification. 7 ANALGESICS Practice guidelines of pain management are available at: http://www.asahq.org NSAIDs diclofenac sodium delayed-rel diflunisal etodolac ibuprofen nabumetone meloxicam naproxen naproxen sodium oxaprozin sulindac Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/misoprostol Tier 1 NSAIDs, TOPICAL diclofenac sodium soln diclofenac sodium gel Tier 1 Tier 2 VOLTAREN GEL COX-2 INHIBITORS celecoxib Tier 2 CELEBREX MOBIC NAPROSYN ANAPROX DAYPRO CLINORIL GOUT probenecid colchicine febuxostat allopurinol Tier 1 Tier 2 COLCRYS Tier 2 ULORIC Tier 3 ZYLOPRIM OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: http://www.asahq.org http://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: http://www.asipp.org/Guidelines.htm PA PA QL fentanyl transmucosal lozenge methadone morphine morphine supp oxycodone caps, tabs 5 mg oxycodone concentrate 20 mg/mL tramadol ext-rel buprenorphine transdermal fentanyl citrate buccal fentanyl citrate nasal spray oxycodone ext-rel oxymorphone ext-rel tapentadol tapentadol ext-rel codeine/acetaminophen fentanyl transdermal hydrocodone/acetaminophen hydromorphone Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 BUTRANS FENTORA LAZANDA OXYCONTIN OPANA ER NUCYNTA NUCYNTA ER TYLENOL w/CODEINE DURAGESIC NORCO DILAUDID 8 hydromorphone ext-rel morphine ext-rel morphine ext-rel morphine ext-rel oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL oxycodone/acetaminophen 5/325 tramadol Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 EXALGO AVINZA KADIAN MS CONTIN ROXICODONE PERCOCET ULTRAM NON-OPIOID ANALGESICS butalbital/acetaminophen/caffeine tabs butalbital/aspirin/caffeine Tier 2 ESGIC Tier 2 FIORINAL VISCOSUPPLEMENTS # sodium hyaluronate # sodium hyaluronate # sodium hyaluronate Tier 2 GEL-ONE Tier 2 HYALGAN Tier 2 SUPARTZ ANTI-INFECTIVES Hepatitis: CDC recommendations on the treatment of hepatitis are available at: http://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: http://www.aasld.org HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: http://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: http://www.myamericanheart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm International Travel: CDC recommendations for international travel are available at: http://www.cdc.gov/travel Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: http://www.cdc.gov/std/treatment/default.htm Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: http://www.cdc.gov/flu/ Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: http://www.idsociety.org ANTIBACTERIALS Cephalosporins First Generation cefadroxil cephalexin Tier 1 Tier 3 KEFLEX Second Generation cefprozil cefuroxime axetil Tier 1 Tier 3 CEFTIN 9 Third Generation cefdinir cefixime Tier 1 Tier 2 SUPRAX Erythromycins/Macrolides erythromycin delayed-rel erythromycin stearate erythromycin/sulfisoxazole fidaxomicin azithromycin clarithromycin clarithromycin ext-rel erythromycin ethylsuccinate Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Fluoroquinolones ciprofloxacin ext-rel ciprofloxacin levofloxacin moxifloxacin Tier 1 Tier 3 CIPRO Tier 3 LEVAQUIN Tier 3 AVELOX DIFICID ZITHROMAX BIAXIN BIAXIN XL E.E.S. Penicillins amoxicillin amoxicillin/clavulanate ext-rel ampicillin dicloxacillin penicillin VK amoxicillin/clavulanate Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 AUGMENTIN Tetracyclines doxycycline hyclate 20 mg tetracycline doxycycline hyclate minocycline Tier 1 Tier 1 Tier 3 VIBRAMYCIN Tier 3 MINOCIN ANTIFUNGALS clotrimazole troches ketoconazole nystatin griseofulvin ultramicrosize voriconazole fluconazole itraconazole terbinafine tabs Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 ANTIMALARIALS mefloquine artemether/lumefantrine atovaquone/proguanil chloroquine Tier 1 Tier 2 COARTEM Tier 2 MALARONE Tier 2 ARALEN ANTIRETROVIRAL AGENTS Antiretroviral Combinations efavirenz/emtricitabine/tenofovir elvitegravir/cobicistat/emtricitabine/tenofovir emtricitabine/tenofovir lamivudine/zidovudine Tier 2 Tier 2 Tier 2 Tier 2 GRIS-PEG VFEND DIFLUCAN SPORANOX LAMISIL ATRIPLA STRIBILD TRUVADA COMBIVIR 10 Fusion Inhibitors PA, SP, SI enfuvirtide Tier 4 FUZEON Integrase Inhibitors raltegravir Tier 2 ISENTRESS Non-nucleoside Reverse Transcriptase Inhibitors delavirdine efavirenz etravirine nevirapine nevirapine ext-rel rilpivirine Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 RESCRIPTOR SUSTIVA INTELENCE VIRAMUNE VIRAMUNE XR EDURANT Nucleoside Reverse Transcriptase Inhibitors abacavir tabs didanosine delayed-rel emtricitabine lamivudine stavudine zidovudine Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 ZIAGEN tabs VIDEX EC EMTRIVA EPIVIR ZERIT RETROVIR Nucleotide Reverse Transcriptase Inhibitors tenofovir Tier 2 VIREAD Protease Inhibitors atazanavir darunavir lopinavir/ritonavir ritonavir Tier 2 Tier 2 Tier 2 Tier 2 ANTITUBERCULAR AGENTS isoniazid pyrazinamide ethambutol rifampin Tier 1 Tier 1 Tier 2 MYAMBUTOL Tier 2 RIFADIN ANTIVIRALS Cytomegalovirus Agents valganciclovir Tier 2 VALCYTE Hepatitis Agents Hepatitis B entecavir lamivudine Tier 2 BARACLUDE Tier 2 EPIVIR-HBV Hepatitis C PA, SP PA, SP PA, SP PA, SP PA, SP Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 boceprevir ribavirin caps ribavirin oral soln ribavirin tabs sofosbuvir Herpes Agents valacyclovir acyclovir caps, tabs famciclovir REYATAZ PREZISTA KALETRA NORVIR VICTRELIS REBETOL REBETOL COPEGUS SOVALDI Tier 1 Tier 3 ZOVIRAX Tier 3 FAMVIR 11 Influenza Agents amantadine QL oseltamivir QL zanamivir rimantadine Tier 1 Tier 2 TAMIFLU Tier 2 RELENZA Tier 3 FLUMADINE MISCELLANEOUS dapsone sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim DS trimethoprim clindamycin linezolid nitazoxanide nitrofurantoin ext-rel nitrofurantoin macrocrystals nitrofurantoin susp PA rifaximin tinidazole vancomycin metronidazole Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 CLEOCIN ZYVOX ALINIA MACROBID MACRODANTIN FURADANTIN XIFAXAN 550 mg TINDAMAX VANCOCIN FLAGYL ALKYLATING AGENTS cyclophosphamide altretamine busulfan chlorambucil lomustine melphalan PA, SP temozolomide Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 HEXALEN MYLERAN LEUKERAN CEENU ALKERAN TEMODAR ANTIMETABOLITES PA, SP capecitabine mercaptopurine methotrexate thioguanine Tier 0 Tier 0 Tier 0 Tier 0 XELODA PURINETHOL TREXALL TABLOID HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens flutamide bicalutamide Tier 0 Tier 0 CASODEX Antiestrogens tamoxifen toremifene # fulvestrant Tier 0 Tier 0 FARESTON Tier 2 FASLODEX Aromatase Inhibitors anastrozole exemestane letrozole Tier 0 ARIMIDEX Tier 0 AROMASIN Tier 0 FEMARA ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: http://www.asco.org http://www.nccn.org 12 Luteinizing Hormone-releasing Hormone (LHRH) Agonists # goserelin acetate # leuprolide acetate # triptorelin pamoate PA, SP, SI leuprolide acetate Tier 2 ZOLADEX Tier 2 LUPRON DEPOT Tier 2 TRELSTAR Tier 4 Progestins megestrol acetate Tier 0 MEGACE IMMUNOMODULATORS PA, SP lenalidomide PA, SP pomalidomide PA, SP thalidomide Tier 0 REVLIMID Tier 0 POMALYST Tier 0 THALOMID KINASE INHIBITORS PA, SP bosutinib PA, SP dasatinib PA, SP erlotinib PA, SP everolimus PA, SP imatinib mesylate PA, SP lapatinib PA, SP pazopanib PA, SP ponatinib PA, SP sorafenib PA, SP sunitinib Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 TOPOISOMERASE INHIBITORS PA, SP topotecan caps Tier 0 HYCAMTIN caps MISCELLANEOUS PA, SP bexarotene caps etoposide hydroxyurea mitotane procarbazine tretinoin caps PA, SP vorinostat Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 BOSULIF SPRYCEL TARCEVA AFINITOR GLEEVEC TYKERB VOTRIENT ICLUSIG NEXAVAR SUTENT TARGRETIN caps HYDREA LYSODREN MATULANE ZOLINZA CARDIOVASCULAR The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: http://www.nhlbi.nih.gov/guidelines/hypertension Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: http://www.acc.org http://www.heartfailureguideline.org http://www.myamericanheart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: http://professional.diabetes.org http://www.acc.org http://www.myamericanheart.org http://www.nhlbi.nih.gov/guidelines/hypertension captopril fosinopril benazepril Tier 1 Tier 1 Tier 3 LOTENSIN 13 enalapril lisinopril perindopril quinapril ramipril trandolapril Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 VASOTEC ZESTRIL ACEON ACCUPRIL ALTACE MAVIK ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril trandolapril/verapamil ext-rel Tier 2 LOTREL Tier 2 TARKA ACE INHIBITOR/DIURETIC COMBINATIONS captopril/hydrochlorothiazide fosinopril/hydrochlorothiazide benazepril/hydrochlorothiazide enalapril/hydrochlorothiazide lisinopril/hydrochlorothiazide quinapril/hydrochlorothiazide Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 ADRENOLYTICS, CENTRAL clonidine clonidine transdermal guanfacine Tier 2 CATAPRES Tier 2 CATAPRES-TTS Tier 2 TENEX ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone spironolactone Tier 2 INSPRA Tier 2 ALDACTONE LOTENSIN HCT VASERETIC ZESTORETIC ACCURETIC ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: http://www.nhlbi.nih.gov/guidelines/hypertension terazosin doxazosin Tier 1 Tier 3 CARDURA ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: http://professional.diabetes.org http://www.nhlbi.nih.gov/guidelines/hypertension candesartan candesartan/hydrochlorothiazide eprosartan irbesartan irbesartan/hydrochlorothiazide valsartan/hydrochlorothiazide olmesartan olmesartan/hydrochlorothiazide losartan losartan/hydrochlorothiazide telmisartan telmisartan/hydrochlorothiazide valsartan Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 BENICAR BENICAR HCT COZAAR HYZAAR MICARDIS MICARDIS HCT DIOVAN ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/olmesartan Tier 2 AZOR amlodipine/valsartan Tier 2 EXFORGE 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide Tier 2 EXFORGE HCT olmesartan/amlodipine/hydrochlorothiazide Tier 2 TRIBENZOR ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: http://www.acc.org PA, SP amiodarone disopyramide disopyramide ext-rel dofetilide flecainide propafenone propafenone ext-rel sotalol sotalol Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 CORDARONE NORPACE NORPACE CR TIKOSYN TAMBOCOR RYTHMOL RYTHMOL SR BETAPACE BETAPACE AF ANTILIPEMICS The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) is available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm Bile Acid Resins colesevelam cholestyramine colestipol Tier 2 WELCHOL Tier 3 QUESTRAN/QUESTRAN LIGHT Tier 3 COLESTID Cholesterol Absorption Inhibitors ezetimibe Tier 2 ZETIA Fibrates fenofibrate fenofibrate fenofibrate fenofibrate fenofibric acid delayed-rel gemfibrozil Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 ANTARA LIPOFEN LOFIBRA TRILIPIX LOPID HMG-CoA Reductase Inhibitors/Combinations atorvastatin fluvastatin ezetimibe/simvastatin rosuvastatin lovastatin pravastatin simvastatin Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 VYTORIN CRESTOR MEVACOR PRAVACHOL ZOCOR Niacins/Combinations niacin ext-rel/simvastatin niacin ext-rel Tier 2 SIMCOR Tier 3 NIASPAN Omega-3 Fatty Acids PA omega-3 acid ethyl esters Tier 2 LOVAZA 15 BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: http://www.acc.org http://www.nhlbi.nih.gov/guidelines/hypertension labetalol pindolol propranolol carvedilol phosphate ext-rel nebivolol atenolol bisoprolol carvedilol metoprolol succinate ext-rel metoprolol tartrate nadolol propranolol ext-rel Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 COREG CR BYSTOLIC TENORMIN ZEBETA COREG TOPROL-XL LOPRESSOR CORGARD INDERAL LA BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: http://www.acc.org http://www.nhlbi.nih.gov/guidelines/hypertension atenolol/chlorthalidone bisoprolol/hydrochlorothiazide metoprolol/hydrochlorothiazide Tier 2 TENORETIC Tier 2 ZIAC Tier 2 LOPRESSOR HCT CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine felodipine ext-rel nifedipine ext-rel nifedipine ext-rel Tier 1 Tier 1 Tier 3 ADALAT CC Tier 3 PROCARDIA XL Nondihydropyridines diltiazem ext-rel diltiazem ext-rel diltiazem ext-rel verapamil ext-rel Tier 3 Tier 3 Tier 3 Tier 3 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin Tier 3 CADUET DIGITALIS GLYCOSIDES digoxin ped elixir digoxin Tier 1 Tier 2 LANOXIN DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS aliskiren aliskiren/hydrochlorothiazide Tier 2 TEKTURNA Tier 2 TEKTURNA HCT CARDIZEM CD CARDIZEM LA TIAZAC CALAN SR DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS aliskiren/amlodipine Tier 2 TEKAMLO DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS aliskiren/amlodipine/hydrochlorothiazide Tier 2 AMTURNIDE 16 DIURETICS Carbonic Anhydrase Inhibitors acetazolamide methazolamide acetazolamide ext-rel Tier 1 Tier 1 Tier 2 DIAMOX SEQUELS Loop Diuretics bumetanide furosemide torsemide Tier 1 Tier 3 LASIX Tier 3 DEMADEX Potassium-sparing Diuretics amiloride Tier 1 Thiazides and Thiazide-like Diuretics chlorthalidone hydrochlorothiazide indapamide metolazone Tier 1 Tier 1 Tier 1 Tier 3 ZAROXOLYN Diuretic Combinations amiloride/hydrochlorothiazide spironolactone-hydrochlorothiazide triamterene-hydrochlorothiazide triamterene-hydrochlorothiazide Tier 1 Tier 3 ALDACTAZIDE Tier 3 DYAZIDE Tier 3 MAXZIDE NITRATES Oral isosorbide dinitrate ext-rel tabs isosorbide mononitrate isosorbide dinitrate oral isosorbide mononitrate ext-rel Tier 1 Tier 1 Tier 2 ISORDIL Tier 2 IMDUR nitroglycerin sublingual nitroglycerin sublingual spray Tier 2 NITROSTAT Tier 2 NITROLINGUAL Sublingual Transdermal nitroglycerin transdermal nitroglycerin transdermal Tier 1 Tier 2 NITRO-DUR NITRATE/VASODILATOR COMBINATIONS isosorbide dinitrate/hydralazine Tier 2 BIDIL PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA, SP ambrisentan PA, SP bosentan Tier 2 LETAIRIS Tier 2 TRACLEER Phosphodiesterase Inhibitors PA, SP tadalafil PA, SP sildenafil Tier 2 ADCIRCA Tier 3 REVATIO Prostaglandin Vasodilators # epoprostenol sodium PA, SP iloprost # treprostinil PA, SP treprostinil Tier 2 Tier 2 Tier 2 Tier 2 FLOLAN VENTAVIS REMODULIN TYVASO 17 MISCELLANEOUS hydralazine methyldopa midodrine ranolazine ext-rel Tier 1 Tier 1 Tier 1 Tier 2 RANEXA CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: http://www.psych.org ANTIANXIETY Benzodiazepines oxazepam alprazolam clonazepam tabs diazepam lorazepam Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Miscellaneous buspirone fluvoxamine clomipramine Tier 1 Tier 1 Tier 2 ANAFRANIL XANAX KLONOPIN VALIUM ATIVAN ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: http://www.aan.com phenobarbital lacosamide lamotrigine ext-rel lamotrigine orally disintegrating tabs tiagabine carbamazepine carbamazepine ext-rel carbamazepine ext-rel diazepam rectal gel divalproex sodium delayed-rel divalproex sodium ext-rel ethosuximide gabapentin lamotrigine levetiracetam levetiracetam ext-rel oxcarbazepine phenytoin phenytoin sodium extended primidone topiramate valproic acid zonisamide Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 VIMPAT LAMICTAL XR LAMICTAL ODT GABITRIL TEGRETOL CARBATROL TEGRETOL-XR DIASTAT DEPAKOTE DEPAKOTE ER ZARONTIN NEURONTIN LAMICTAL KEPPRA KEPPRA XR TRILEPTAL DILANTIN INFATABS DILANTIN MYSOLINE TOPAMAX DEPAKENE ZONEGRAN ANTIDEMENTIA Practice guidelines for the management of dementia are available at: http://www.aan.com memantine memantine ext-rel rivastigmine transdermal Tier 2 NAMENDA Tier 2 NAMENDA XR Tier 2 EXELON PATCH 18 donepezil galantamine galantamine ext-rel rivastigmine Tier 3 Tier 3 Tier 3 Tier 3 ARICEPT RAZADYNE RAZADYNE ER EXELON ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder. Guidelines for the evaluation and management of bipolar and depressive disorders are available at: http://www.psych.org Monoamine Oxidase Inhibitors (MAOIs) isocarboxazid phenelzine tranylcypromine Tier 2 MARPLAN Tier 2 NARDIL Tier 2 PARNATE Selective Serotonin Reuptake Inhibitors (SSRIs) fluoxetine vilazodone citalopram escitalopram fluoxetine paroxetine HCl paroxetine HCl ext-rel sertraline Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) venlafaxine desvenlafaxine ext-rel duloxetine delayed-rel venlafaxine ext-rel Tier 1 Tier 2 PRISTIQ Tier 3 CYMBALTA Tier 3 EFFEXOR XR Tricyclic Antidepressants (TCAs) amitriptyline doxepin desipramine imipramine HCl nortriptyline Tier 1 Tier 1 Tier 2 NORPRAMIN Tier 2 TOFRANIL Tier 2 PAMELOR Miscellaneous Agents trazodone bupropion bupropion ext-rel bupropion ext-rel mirtazapine Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 FLUOXETINE 60 mg VIIBRYD CELEXA LEXAPRO PROZAC PAXIL PAXIL CR ZOLOFT WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL REMERON ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: http://www.aan.com amantadine benztropine selegiline trihexyphenidyl bromocriptine pramipexole ext-rel rasagiline mesylate Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 PARLODEL Tier 2 MIRAPEX ER Tier 2 AZILECT 19 rotigotine transdermal selegiline orally disintegrating tabs carbidopa/levodopa carbidopa/levodopa ext-rel carbidopa/levodopa orally disintegrating tabs carbidopa/levodopa/entacapone entacapone pramipexole ropinirole ropinirole ext-rel Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 NEUPRO ZELAPAR SINEMET SINEMET CR PARCOPA STALEVO COMTAN MIRAPEX REQUIP REQUIP XL ANTIPSYCHOTICS Atypicals aripiprazole # aripiprazole inj lurasidone quetiapine ext-rel # risperidone long-acting injection clozapine olanzapine quetiapine risperidone ziprasidone Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 ABILIFY ABILIFY injection LATUDA SEROQUEL XR RISPERDAL CONSTA CLOZARIL ZYPREXA SEROQUEL RISPERDAL GEODON Miscellaneous chlorpromazine fluphenazine haloperidol perphenazine thiothixene trifluoperazine Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: http://www.aacap.org http://www.aap.org amphetamine/dextroamphetamine mixed salts amphetamine/dextroamphetamine mixed salts ext-rel dextroamphetamine methylphenidate ext-rel 10 mg atomoxetine guanfacine ext-rel lisdexamfetamine methylphenidate ext-rel susp methylphenidate transdermal dexmethylphenidate dexmethylphenidate ext-rel dextroamphetamine ext-rel methylphenidate methylphenidate methylphenidate ext-rel methylphenidate ext-rel FIBROMYALGIA milnacipran pregabalin Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 STRATTERA INTUNIV VYVANSE QUILLIVANT XR DAYTRANA FOCALIN FOCALIN XR DEXEDRINE SPANSULE METHYLIN RITALIN CONCERTA RITALIN LA Tier 2 SAVELLA Tier 2 LYRICA 20 HUNTINGTON'S DISEASE AGENTS PA, SP tetrabenazine Tier 2 XENAZINE HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: http://www.aasmnet.org Benzodiazepines temazepam Tier 3 RESTORIL Nonbenzodiazepines eszopiclone zolpidem zolpidem ext-rel Tier 1 Tier 3 AMBIEN Tier 3 AMBIEN CR Tricyclics doxepin Tier 2 SILENOR MIGRAINE Guidelines for prevention and management of migraine headaches are available at: http://www.aan.com Ergotamine Derivatives dihydroergotamine spray ergotamine/caffeine SI dihydroergotamine inj Tier 2 MIGRANAL Tier 2 CAFERGOT Tier 4 D.H.E. 45 Selective Serotonin Agonists QL naratriptan QL eletriptan QL zolmitriptan nasal spray QL rizatriptan QL sumatriptan QL sumatriptan nasal spray QL zolmitriptan QL, SI sumatriptan inj QL, SI sumatriptan inj Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 RELPAX ZOMIG MAXALT IMITREX IMITREX ZOMIG IMITREX SUMAVEL DOSEPRO Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations QL sumatriptan/naproxen sodium Tier 2 TREXIMET MOOD STABILIZERS lithium carbonate lithium carbonate ext-rel tabs 450 mg lithium carbonate ext-rel tabs 300 mg Tier 1 Tier 1 Tier 2 LITHOBID MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: http://www.aan.com PA, SP PA, SP PA, SP, SI PA, SP, SI PA, SP, SI dimethyl fumarate delayed-rel fingolimod glatiramer interferon beta-1a interferon beta-1b Tier 2 Tier 2 Tier 4 Tier 4 Tier 4 TECFIDERA GILENYA COPAXONE AVONEX EXTAVIA 21 MUSCULOSKELETAL THERAPY AGENTS baclofen carisoprodol cyclobenzaprine orphenadrine/aspirin/caffeine chlorzoxazone dantrolene metaxalone methocarbamol tizanidine Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 MYASTHENIA GRAVIS pyridostigmine pyridostigmine ext-rel Tier 2 MESTINON Tier 2 MESTINON TIMESPAN NARCOLEPSY/CATAPLEXY armodafinil sodium oxybate Tier 2 NUVIGIL Tier 2 XYREM POSTHERPETIC NEURALGIA (PHN) gabapentin ext-rel Tier 2 GRALISE PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium disulfiram Tier 2 CAMPRAL Tier 2 ANTABUSE Opioid Antagonists naltrexone Tier 2 REVIA Partial Opioid Agonist/Opioid Antagonist Combinations buprenorphine/naloxone sublingual tabs buprenorphine/naloxone sublingual tabs Tier 1 Tier 2 ZUBSOLV Smoking Deterrents * bupropion ext-rel varenicline Tier 0 ZYBAN Tier 0 CHANTIX PARAFON FORTE DSC DANTRIUM SKELAXIN ROBAXIN ZANAFLEX tabs * Brands are not covered when the generic alternative is available. ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: http://www.aace.com # # testosterone cypionate testosterone enanthate testosterone gel testosterone soln testosterone transdermal Tier 1 Tier 1 Tier 2 FORTESTA Tier 2 AXIRON Tier 2 ANDRODERM ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: http://professional.diabetes.org Alpha-glucosidase Inhibitors acarbose Tier 2 PRECOSE 22 Amylin Analogs SI pramlintide Tier 4 SYMLINPEN Biguanides metformin metformin ext-rel Tier 3 GLUCOPHAGE Tier 3 GLUCOPHAGE XR Biguanide/Sulfonylurea Combinations glipizide/metformin Tier 3 METAGLIP Dipeptidyl Peptidase-4 (DPP-4) Inhibitors linagliptin sitagliptin phosphate Tier 2 TRADJENTA Tier 2 JANUVIA Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations linagliptin/metformin sitagliptin/metformin sitagliptin/metformin ext-rel Tier 2 JENTADUETO Tier 2 JANUMET Tier 2 JANUMET XR Incretin Mimetic Agents SI exenatide ext-rel SI liraglutide Tier 4 BYDUREON Tier 4 VICTOZA Insulins OTC OTC OTC insulin aspart insulin aspart protamine 70%/insulin aspart 30% insulin detemir insulin glargine insulin human insulin human insulin isophane human insulin isophane human 70%/regular 30% Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 NOVOLOG NOVOLOG MIX 70/30 LEVEMIR LANTUS HUMULIN R U-500 NOVOLIN R NOVOLIN N NOVOLIN 70/30 Insulin Sensitizers pioglitazone Tier 1 Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 3 ACTOPLUS MET Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride Tier 3 DUETACT Meglitinides nateglinide repaglinide Tier 1 Tier 3 PRANDIN Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors canagliflozin Tier 2 INVOKANA Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor/Biguanide Combinations canagliflozin/metformin Tier 2 INVOKAMET Sulfonylureas glyburide glimepiride glipizide glipizide ext-rel Tier 1 Tier 3 AMARYL Tier 3 GLUCOTROL Tier 3 GLUCOTROL XL 23 Supplies * * blood glucose continuous monitoring receivers, sensors, transmitters OTC, * blood glucose monitoring kits, test strips OTC insulin syringes, needles OTC lancets Tier 0 DEXCOM G4 Tier 0 ONETOUCH kits and test strips Tier 0 BD insulin syringes and needles Tier 0 LANCETS * Blood glucose monitoring kits are covered under the medical benefit. ANTIOBESITY * Guidelines of treatment and management of obesity are available at: http://www.aace.com http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm Anorexiant Combinations phentermine/topiramate ext-rel Tier 2 QSYMIA * Coverage for weight loss medications may vary depending on the member's benefit plan. CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: http://www.aace.com http://www.nof.org Bisphosphonates risedronate risedronate delayed-rel alendronate ibandronate Tier 2 Tier 2 Tier 3 Tier 3 Calcitonins SI calcitonin-salmon Tier 4 MIACALCIN Parathyroid Hormones PA, SP, SI teriparatide Tier 4 FORTEO ACTONEL ATELVIA FOSAMAX BONIVA CONTRACEPTIVES * * Brand drugs will not be covered when the generic alternative is available. EE = ethinyl estradiol ME = mestranol Monophasic 10 mcg Estrogen norethindrone acetate/EE 1/10 and EE 10 and iron Tier 0 LO LOESTRIN FE 20 mcg Estrogen drospirenone/EE 3/20 drospirenone/EE/levomefolate 3/20 and levomefolate levonorgestrel/EE 0.1/20 - Lessina norethindrone acetate/EE 1/20 norethindrone acetate/EE 1/20 and iron norethindrone acetate/EE 1/20 and iron - Lomedia 24 Fe norethindrone acetate/EE 1/20 and iron chewable Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 30 mcg Estrogen desogestrel/EE 0.15/30 drospirenone/EE 3/30 Tier 0 ORTHO-CEPT Tier 0 YASMIN YAZ BEYAZ LOESTRIN 1/20 LOESTRIN FE 1/20 MINASTRIN 24 FE 24 levonorgestrel/EE 0.15/30 - Levora norethindrone acetate/EE 1.5/30 norethindrone acetate/EE 1.5/30 and iron norgestrel/EE 0.3/30 - Low-Ogestrel Tier 0 Tier 0 LOESTRIN 1.5/30 Tier 0 LOESTRIN FE 1.5/30 Tier 0 35 mcg Estrogen ethynodiol diacetate/EE 1/35 - Zovia 1/35 norethindrone/EE 0.5/35 norethindrone/EE 0.5/35 norethindrone/EE 1/35 norethindrone/EE 1/35 norgestimate/EE 0.25/35 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 50 mcg Estrogen ethynodiol diacetate/EE 1/50 - Zovia 1/50 norethindrone/ME 1/50 Tier 0 Tier 0 NORINYL 1+50 BREVICON MODICON NORINYL 1+35 ORTHO-NOVUM 1/35 ORTHO-CYCLEN Biphasic desogestrel/EE Tier 0 MIRCETTE desogestrel/EE levonorgestrel/EE - Trivora norethindrone/EE norethindrone/EE norgestimate/EE norgestimate/EE Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 Tier 0 estradiol valerate and dienogest/estradiol valerate Tier 0 NATAZIA Triphasic CYCLESSA ORTHO-NOVUM 7/7/7 TRI-NORINYL ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO Four Phase Extended Cycle levonorgestrel/EE 0.1/20 and EE 10 levonorgestrel/EE 0.15/30 levonorgestrel/EE 0.15/30 and EE 10 Tier 0 LOSEASONIQUE Tier 0 Tier 0 SEASONIQUE Progestin Only norethindrone norethindrone Tier 0 NOR-QD Tier 0 ORTHO MICRONOR Injectable SI medroxyprogesterone acetate 150 mg/mL Tier 0 DEPO-PROVERA Progestin Intrauterine Device levonorgestrel releasing IUD Tier 0 MIRENA Transdermal norelgestromin/EE Tier 0 ORTHO EVRA Vaginal etonogestrel/EE ring ENDOMETRIOSIS danazol nafarelin Tier 0 NUVARING Tier 1 Tier 2 SYNAREL 25 ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: http://www.menopause.org Oral estropipate estrogens, conjugated estradiol Transdermal estradiol estradiol estradiol estradiol estradiol Tier 1 Tier 2 PREMARIN Tier 3 ESTRACE Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 DIVIGEL EVAMIST MINIVELLE VIVELLE-DOT CLIMARA Vaginal estradiol vaginal crm estradiol vaginal tabs estrogens, conjugated crm ESTROGEN/PROGESTINS Oral EE/norethindrone acetate - Jinteli estradiol/norethindrone estrogens, conjugated/medroxyprogesterone estrogens, conjugated/medroxyprogesterone EE/norethindrone acetate Tier 2 ESTRACE Tier 2 VAGIFEM Tier 2 PREMARIN crm Tier 1 Tier 1 Tier 2 PREMPHASE Tier 2 PREMPRO Tier 3 FEMHRT ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS conjugated estrogens/bazedoxifene Tier 2 DUAVEE FERTILITY REGULATORS GNRH/LHRH Antagonists SI cetrorelix SI ganirelix Tier 4 CETROTIDE Tier 4 Ovulation Stimulants, Gonadotropins SI choriogonadotropin alfa SI chorionic gonadotropin - Novarel SI follitropin beta Tier 4 OVIDREL Tier 4 Tier 4 FOLLISTIM AQ Ovulation Stimulants, Synthetic clomiphene Tier 2 CLOMID GLUCOCORTICOIDS dexamethasone fludrocortisone prednisolone sodium phosphate 5 mg/5 mL prednisone hydrocortisone methylprednisolone prednisolone sodium phosphate prednisolone syrup Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 GLUCOSE ELEVATING AGENTS SI glucagon, human recombinant SI glucagon, human recombinant Tier 4 GLUCAGEN HYPOKIT Tier 4 GLUCAGON EMERGENCY KIT CORTEF MEDROL ORAPRED PRELONE 26 HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: http://www.aace.com/publications/guidelines PA, SP, SI somatropin PA, SP, SI somatropin Tier 4 HUMATROPE Tier 4 NORDITROPIN HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) doxercalciferol paricalcitol Tier 2 ROCALTROL Tier 2 HECTOROL Tier 2 ZEMPLAR PHENYLKETONURIA TREATMENT AGENTS PA, SP sapropterin Tier 2 KUVAN PHOSPHATE BINDER AGENTS calcium acetate tabs calcium acetate sevelamer carbonate sucroferric oxyhydroxide calcium acetate Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 PHOSLYRA RENVELA VELPHORO PHOSLO PROGESTINS Oral megestrol acetate susp medroxyprogesterone acetate norethindrone acetate progesterone, micronized Tier 2 Tier 3 Tier 3 Tier 3 MEGACE ES PROVERA AYGESTIN PROMETRIUM Vaginal progesterone gel Tier 2 CRINONE SELECTIVE ESTROGEN RECEPTOR MODULATORS ospemifene raloxifene Tier 2 OSPHENA Tier 3 EVISTA THYROID AGENTS Antithyroid Agents propylthiouracil methimazole Tier 1 Tier 2 TAPAZOLE Thyroid Supplements levothyroxine levothyroxine - Levoxyl levothyroxine liothyronine Tier 1 Tier 1 Tier 2 SYNTHROID Tier 2 CYTOMEL VASOPRESSINS desmopressin spray, tabs Tier 2 DDAVP MISCELLANEOUS cabergoline levocarnitine Tier 1 Tier 2 CARNITOR 27 GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: http://www.acg.gi.org http://www.gastro.org ANTIDIARRHEALS loperamide diphenoxylate/atropine Tier 1 Tier 2 LOMOTIL ANTIEMETICS granisetron prochlorperazine promethazine doxylamine/pyridoxine delayed-rel granisetron transdermal scopolamine dronabinol meclizine metoclopramide ondansetron trimethobenzamide Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 ANTISPASMODICS chlordiazepoxide/clidinium hyoscyamine sulfate ext-rel caps hyoscyamine sulfate orally disintegrating tabs dicyclomine hyoscyamine sulfate hyoscyamine sulfate ext-rel Tier 1 Tier 1 Tier 1 Tier 2 BENTYL Tier 2 LEVSIN Tier 2 LEVBID CHOLELITHOLYTICS ursodiol ursodiol Tier 2 ACTIGALL Tier 2 URSO H2 RECEPTOR ANTAGONISTS cimetidine famotidine ranitidine Tier 1 Tier 3 PEPCID Tier 3 ZANTAC INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide budesonide delayed-rel caps budesonide ext-rel mesalamine delayed-rel tabs mesalamine ext-rel caps mesalamine ext-rel caps olsalazine sulfasalazine sulfasalazine delayed-rel Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 UCERIS LIALDA APRISO PENTASA DIPENTUM AZULFIDINE AZULFIDINE EN-TABS Rectal Agents hydrocortisone enema hydrocortisone acetate foam mesalamine rectal susp mesalamine supp mesalamine rectal susp Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 CORTIFOAM SFROWASA CANASA ROWASA DICLEGIS SANCUSO TRANSDERM SCOP MARINOL ANTIVERT REGLAN ZOFRAN TIGAN 28 IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation linaclotide lubiprostone Tier 2 LINZESS Tier 2 AMITIZA Irritable Bowel Syndrome with Diarrhea * alosetron Tier 2 LOTRONEX * For safety reasons, to prescribe Lotronex, the physician must be enrolled in the Prescribing Program for Lotronex. Physicians must understand the benefits and risks of treatment with Lotronex for severe diarrhea-predominant IBS, including the information in the Prescribing Information, Medication Guide and Patient-Physician Agreement for Lotronex. To enroll or for more information on the Prescribing Program for Lotronex, call toll-free: 1-888-423-5227 or visit www.lotronex.com to complete the Physician Enrollment Form. LAXATIVES Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 MOVIPREP SUCLEAR MIRALAX SUPREP GOLYTELY NULYTELY PANCREATIC ENZYMES pancrelipase pancrelipase delayed-rel pancrelipase delayed-rel pancrelipase delayed-rel Tier 2 Tier 2 Tier 2 Tier 2 VIOKACE CREON ULTRESA ZENPEP PROSTAGLANDINS misoprostol Tier 2 CYTOTEC PROTON PUMP INHIBITORS lansoprazole delayed-rel omeprazole/sodium bicarbonate caps pantoprazole delayed-rel dexlansoprazole delayed-rel esomeprazole delayed-rel omeprazole delayed-rel Tier 1 Tier 1 Tier 1 Tier 2 DEXILANT Tier 2 NEXIUM Tier 3 PRILOSEC SALIVA STIMULANTS cevimeline pilocarpine tabs Tier 2 EVOXAC Tier 2 SALAGEN STEROIDS, RECTAL hydrocortisone acetate/pramoxine foam hydrocortisone crm Tier 2 PROCTOFOAM-HC Tier 2 ANUSOL-HC ULCER THERAPY COMBINATIONS bismuth/metronidazole/tetracycline lansoprazole + amoxicillin + clarithromycin Tier 2 PYLERA Tier 2 PREVPAC MISCELLANEOUS sucralfate SI methylnaltrexone Tier 2 CARAFATE Tier 4 RELISTOR * * * lactulose peg 3350/electrolytes peg 3350/electrolytes polyethylene glycol 3350 sodium sulfate/potassium sulfate/magnesium sulfate peg 3350/electrolytes peg 3350/electrolytes * Covered at $0 copay for age 50 to 74 years 29 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: http://www.auanet.org/guidelines alfuzosin ext-rel dutasteride silodosin finasteride tamsulosin Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 AVODART RAPAFLO PROSCAR FLOMAX ERECTILE DYSFUNCTION Guidelines for the management of erectile dysfunction are available at: http://www.auanet.org/guidelines Alprostadil Agents QL alprostadil supp QL, SI alprostadil inj Tier 2 MUSE Tier 4 EDEX Phosphodiesterase Inhibitors QL sildenafil QL tadalafil Tier 2 VIAGRA Tier 2 CIALIS URINARY ANTISPASMODICS oxybutynin tolterodine ext-rel trospium trospium ext-rel mirabegron ext-rel oxybutynin gel solifenacin succinate oxybutynin ext-rel tolterodine Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 MYRBETRIQ GELNIQUE VESICARE DITROPAN XL DETROL VAGINAL ANTI-INFECTIVES clindamycin crm clindamycin supp metronidazole terconazole terconazole Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 CLEOCIN CLEOCIN METROGEL-VAGINAL TERAZOL 3 TERAZOL 7 MISCELLANEOUS bethanechol pentosan polysulfate sodium phenazopyridine potassium citrate ext-rel Tier 2 Tier 2 Tier 2 Tier 2 URECHOLINE ELMIRON PYRIDIUM UROCIT-K HEMATOLOGIC Guidelines of treatment and management of hemophilia are available at: http://www.hemophilia.org ANTICOAGULANTS Injectable SI dalteparin SI enoxaparin Tier 4 FRAGMIN Tier 4 LOVENOX 30 Oral apixaban dabigatran etexilate rivaroxaban warfarin Synthetic Heparinoid-like Agents SI fondaparinux Tier 2 Tier 2 Tier 2 Tier 3 ELIQUIS PRADAXA XARELTO COUMADIN Tier 4 ARIXTRA HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: http://www.asco.org Guidelines for the management of anemia associated with chronic kidney disease are available at: http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm#guidelines PA, SP, SI PA, SP, SI PA, SP, SI PA, SP, SI darbepoetin alfa epoetin alfa filgrastim pegfilgrastim Tier 4 Tier 4 Tier 4 Tier 4 ARANESP PROCRIT NEUPOGEN NEULASTA IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PA, SP eltrombopag Tier 2 PROMACTA PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS # eculizumab Tier 2 SOLIRIS PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole dipyridamole ext-rel/aspirin prasugrel ticagrelor Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 PLATELET SYNTHESIS INHIBITORS anagrelide Tier 2 AGRYLIN STEM CELL MOBILIZERS # plerixafor Tier 2 MOZOBIL MISCELLANEOUS cilostazol Tier 2 PLETAL PERSANTINE AGGRENOX EFFIENT BRILINTA IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: http://www.rheumatology.org BIOLOGIC DISEASE-MODIFYING AGENTS PA, SP, SI adalimumab PA, SP, SI anakinra PA, SP, SI certolizumab pegol PA, SP, SI etanercept PA, SP, SI golimumab Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) methotrexate hydroxychloroquine leflunomide Tier 1 Tier 2 PLAQUENIL Tier 2 ARAVA HUMIRA KINERET CIMZIA ENBREL SIMPONI 31 methotrexate Tier 2 RHEUMATREX IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: http://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of hepatitis are available at: http://www.aasld.org Interferons PA, SP, SI PA, SP, SI PA, SP, SI PA, SP, SI interferon alfa-2b peginterferon alfa-2a peginterferon alfa-2b peginterferon alfa-2b Tier 4 Tier 4 Tier 4 Tier 4 INTRON A PEGASYS PEGINTRON SYLATRON Miscellaneous # canakinumab Tier 2 ILARIS IMMUNOSUPPRESSANTS Antimetabolites azathioprine azathioprine mycophenolate mofetil mycophenolate sodium delayed-rel Tier 2 Tier 2 Tier 2 Tier 2 Calcineurin Inhibitors cyclosporine cyclosporine, modified tacrolimus Tier 2 SANDIMMUNE Tier 2 NEORAL Tier 2 PROGRAF Rapamycin Derivatives sirolimus Tier 2 RAPAMUNE AZASAN IMURAN CELLCEPT MYFORTIC NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel potassium chloride liquid Tier 1 Tier 1 VITAMINS AND MINERALS Folic Acid/Combinations * folic acid folic acid/vitamin B6/vitamin B12 Tier 1 Tier 1 * Covered at $0 for females, ages 55 years and under Prenatal Vitamins prenatal vitamins prenatal vitamins/DHA/docusate/folic acid prenatal vitamins/DHA/docusate/folic acid prenatal vitamins/DHA/docusate/folic acid prenatal vitamins/docusate/folic acid prenatal vitamins/docusate/folic acid + DHA prenatal vitamins/folic acid + pyridoxine Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Miscellaneous cyanocobalamin inj multivitamins/fluoride drops, tabs Tier 1 Tier 1 CITRANATAL 90 DHA CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX CITRANATAL ASSURE CITRANATAL B-CALM 32 * ** ** multivitamins/fluoride/iron drops, tabs vitamin ADC/fluoride drops vitamin ADC/fluoride/iron drops ergocalciferol (D2) fluoride drops fluoride tabs phytonadione Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 DRISDOL LURIDE LURIDE LOZI-TABS MEPHYTON * Covered at $0 for ages 65 years and older. ** Covered at $0 for ages 6 years and under. RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: http://www.aaaai.org http://www.ginasthma.com http://www.goldcopd.com http://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: http://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS SI epinephrine SI epinephrine SI epinephrine Tier 4 AUVI-Q Tier 4 EPIPEN Tier 4 EPIPEN JR. ANTICHOLINERGICS ipratropium soln tiotropium Tier 1 Tier 2 SPIRIVA ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ipratropium/albuterol, CFC-free aerosol umeclidinium/vilanterol ipratropium/albuterol soln Tier 2 COMBIVENT RESPIMAT Tier 2 ANORO ELLIPTA Tier 3 DUONEB ANTIHISTAMINES, LOW SEDATING levocetirizine Tier 2 XYZAL ANTIHISTAMINES, SEDATING clemastine 2.68 mg cyproheptadine hydroxyzine HCl Tier 1 Tier 1 Tier 1 ANTITUSSIVES benzonatate Tier 2 TESSALON ANTITUSSIVE COMBINATIONS Opioid codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin liquid codeine/guaifenesin/pseudoephedrine codeine/promethazine codeine/promethazine/phenylephrine hydrocodone/homatropine Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Non-opioid dextromethorphan/brompheniramine/pseudoephedrine dextromethorphan/promethazine Tier 1 Tier 1 33 BETA AGONISTS Inhalants Short Acting albuterol soln albuterol sulfate, CFC-free aerosol Tier 1 Tier 2 PROAIR HFA Long Acting formoterol inhalation caps formoterol inhalation soln indacaterol salmeterol xinafoate Tier 2 Tier 2 Tier 2 Tier 2 FORADIL PERFOROMIST ARCAPTA NEOHALER SEREVENT albuterol terbutaline albuterol ext-rel Tier 1 Tier 1 Tier 2 VOSPIRE ER CYSTIC FIBROSIS PA, SP dornase alfa PA, SP tobramycin inhalation soln Tier 2 PULMOZYME Tier 2 TOBI LEUKOTRIENE RECEPTOR ANTAGONISTS zafirlukast montelukast Tier 1 Tier 3 SINGULAIR MAST CELL STABILIZERS cromolyn soln Tier 1 NASAL ANTIHISTAMINES azelastine spray olopatadine spray azelastine spray Tier 1 Tier 2 PATANASE Tier 3 ASTEPRO NASAL STEROIDS flunisolide spray mometasone spray fluticasone spray triamcinolone acetonide spray Tier 1 Tier 2 NASONEX Tier 3 FLONASE Tier 3 NASACORT AQ PHOSPHODIESTERASE-4 INHIBITORS roflumilast Tier 2 DALIRESP STEROID/BETA AGONIST COMBINATIONS fluticasone/salmeterol fluticasone/salmeterol, CFC-free aerosol mometasone/formoterol fluticasone/vilanterol Tier 2 Tier 2 Tier 2 Tier 3 ADVAIR ADVAIR HFA DULERA BREO ELLIPTA STEROID INHALANTS beclomethasone, CFC-free aerosol budesonide fluticasone fluticasone, CFC-free aerosol mometasone budesonide inh susp Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 QVAR PULMICORT FLEXHALER FLOVENT DISKUS FLOVENT HFA ASMANEX PULMICORT RESPULES Oral Agents 34 XANTHINES theophylline ext-rel tabs theophylline ext-rel caps theophylline liquid Tier 1 Tier 2 THEO-24 Tier 2 ELIXOPHYLLIN MISCELLANEOUS ipratropium spray omalizumab Tier 2 ATROVENT spray Tier 2 XOLAIR TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: http://www.aad.org/education-and-quality-care/clinical-guidelines Oral isotretinoin Tier 1 erythromycin gel 2% erythromycin soln sulfacetamide/sulfur crm, gel, lotion, pads tretinoin adapalene adapalene/benzoyl peroxide clindamycin/benzoyl peroxide clindamycin/benzoyl peroxide tazarotene tretinoin tretinoin gel microsphere benzoyl peroxide clindamycin gel, lotion, soln clindamycin/benzoyl peroxide erythromycin/benzoyl peroxide sulfacetamide lotion 10% tretinoin Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Topical PA PA PA PA PA Actinic Keratosis fluorouracil crm, soln 5%, soln 2% fluorouracil imiquimod ingenol mebutate AVITA DIFFERIN EPIDUO ACANYA BENZACLIN TAZORAC ATRALIN RETIN-A MICRO BENZAC AC CLEOCIN T DUAC BENZAMYCIN KLARON RETIN-A Tier 1 Tier 2 CARAC Tier 2 ZYCLARA Tier 2 PICATO Antibiotics gentamicin mupirocin silver sulfadiazine Tier 1 Tier 2 BACTROBAN Tier 2 SILVADENE clotrimazole econazole ketoconazole nystatin butenafine ciclopirox Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 MENTAX Tier 3 LOPROX Antifungals 35 Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: http://www.aad.org Injectable PA, SP, SI ustekinumab Tier 4 STELARA Oral acitretin methoxsalen oral Tier 3 SORIATANE Tier 3 OXSORALEN-ULTRA calcipotriene calcipotriene Tier 2 SORILUX Tier 3 DOVONEX Topical Antiseborrheics ketoconazole shampoo 2% selenium sulfide shampoo 2.5% Tier 2 NIZORAL SHAMPOO Tier 2 SELSUN Corticosteroids Low Potency fluocinolone acetonide soln 0.01% hydrocortisone crm 2.5% hydrocortisone lotion 1% alclometasone crm, oint 0.05% desonide crm, lotion, oint 0.05% Tier 1 Tier 1 Tier 1 Tier 2 ACLOVATE Tier 2 DESOWEN Medium Potency betamethasone valerate crm, lotion, oint 0.1% fluocinolone acetonide crm, oint 0.025% triamcinolone acetonide crm, lotion 0.025% triamcinolone acetonide crm, lotion, oint 0.1% clocortolone crm 0.1% desoximetasone oint 0.05% fluticasone propionate oint 0.005% hydrocortisone butyrate crm 0.1% hydrocortisone butyrate lotion 0.1% hydrocortisone butyrate oint, soln 0.1% hydrocortisone valerate oint 0.2% mometasone oint 0.1% desoximetasone crm 0.05% fluticasone propionate crm, lotion 0.05% hydrocortisone butyrate crm 0.1% hydrocortisone valerate crm 0.2% mometasone crm, lotion 0.1% Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 CLODERM TOPICORT LP CUTIVATE LOCOID LIPOCREAM LOCOID LOCOID WESTCORT ELOCON TOPICORT LP CUTIVATE LOCOID WESTCORT ELOCON High Potency betamethasone dipropionate crm, lotion, oint 0.05% diflorasone diacetate crm 0.05% fluocinonide crm, gel, oint, soln 0.05% triamcinolone acetonide crm 0.5% desoximetasone oint 0.25%, gel 0.05% betamethasone dipropionate augmented crm 0.05% betamethasone dipropionate augmented lotion 0.05% desoximetasone crm 0.25% Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 TOPICORT DIPROLENE AF DIPROLENE TOPICORT 36 Very High Potency clobetasol propionate foam 0.05% diflorasone diacetate oint 0.05% betamethasone dipropionate augmented gel, oint 0.05% clobetasol propionate crm, gel, oint 0.05% clobetasol propionate lotion, shampoo 0.05% clobetasol propionate spray 0.05% halobetasol propionate crm, oint 0.05% clobetasol propionate soln 0.05% Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 DIPROLENE TEMOVATE CLOBEX CLOBEX ULTRAVATE TEMOVATE Emollients ammonium lactate 12% Tier 2 LAC-HYDRIN Immunomodulators Guidelines for the treatment of atopic dermatitis are available at: http://www.aad.org pimecrolimus tacrolimus Tier 2 ELIDEL Tier 2 PROTOPIC Local Analgesics lidocaine patch Tier 2 LIDODERM Local Anesthetics lidocaine/prilocaine Tier 1 Rosacea metronidazole gel 0.75% sulfacetamide/sulfur azelaic acid gel doxycycline monohydrate metronidazole crm 0.75% metronidazole gel 1% metronidazole lotion 0.75% Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 FINACEA ORACEA METROCREAM METROGEL METROLOTION Scabicides and Pediculicides permethrin 5% malathion Tier 1 Tier 2 OVIDE Miscellaneous Skin and Mucous Membrane imiquimod podofilox Tier 2 ALDARA Tier 2 CONDYLOX MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Tier 1 Protectants - Mouth/Throat PA, SP benzyl alcohol/carbomer 941/glycerin soy phospholipid/glycerol dioleate Tier 2 MUGARD Tier 2 EPISIL Steroids - Mouth/Throat triamcinolone paste Tier 1 37 OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: http://one.aao.org Antiallergics cromolyn sodium olopatadine olopatadine azelastine Tier 1 Tier 2 PATADAY Tier 2 PATANOL Tier 3 OPTIVAR Antifungals natamycin Tier 2 NATACYN Anti-infectives bacitracin erythromycin gentamicin levofloxacin polymyxin B/bacitracin sulfacetamide oint 10% besifloxacin moxifloxacin moxifloxacin ciprofloxacin neomycin/polymyxin B/gramicidin ofloxacin polymyxin B/trimethoprim sulfacetamide soln 10% tobramycin Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 BESIVANCE MOXEZA VIGAMOX CILOXAN NEOSPORIN OCUFLOX POLYTRIM BLEPH-10 TOBREX Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone oint neomycin/polymyxin B/hydrocortisone susp sulfacetamide/prednisolone phosphate 10%/0.25% tobramycin/dexamethasone oint 0.3%/0.1% tobramycin/dexamethasone susp 0.3%/0.05% tobramycin/loteprednol neomycin/polymyxin B/dexamethasone tobramycin/dexamethasone susp 0.3%/0.1% Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 TOBRADEX OINTMENT TOBRADEX ST ZYLET MAXITROL TOBRADEX SUSPENSION Anti-inflammatories Nonsteroidal bromfenac sodium diclofenac sodium ketorolac Tier 1 Tier 1 Tier 3 ACULAR Steroidal dexamethasone sodium phosphate difluprednate loteprednol 0.2% loteprednol 0.5% fluorometholone prednisolone acetate 1% prednisolone phosphate 1% Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 trifluridine Tier 2 VIROPTIC DUREZOL ALREX LOTEMAX FML PRED FORTE Antivirals 38 Beta-blockers Nonselective timolol hemihydrate levobunolol metipranolol timolol maleate timolol maleate gel Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 BETIMOL BETAGAN OPTIPRANOLOL TIMOPTIC TIMOPTIC-XE Selective betaxolol Tier 2 BETOPTIC S Carbonic Anhydrase Inhibitors Topical brinzolamide dorzolamide Tier 2 AZOPT Tier 3 TRUSOPT Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate/preservative-free dorzolamide/timolol maleate Tier 2 COSOPT PF Tier 3 COSOPT Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations brinzolamide/brimonidine Tier 2 SIMBRINZA Immunomodulators cyclosporine, emulsion Tier 2 RESTASIS Prostaglandins travoprost tafluprost travoprost latanoprost Tier 1 Tier 2 ZIOPTAN Tier 2 TRAVATAN Z Tier 3 XALATAN Sympathomimetics brimonidine 0.2% brimonidine 0.1% brimonidine 0.15% Tier 1 Tier 2 ALPHAGAN P Tier 2 ALPHAGAN P Sympathomimetic/Beta-blocker Combinations brimonidine/timolol Tier 2 COMBIGAN OTIC Clinical practice guidelines for the treatment of otitis media are available at: http://www.aap.org Anti-infectives acetic acid acetic acid/aluminum acetate ofloxacin otic Tier 1 Tier 1 Tier 1 Anti-infective/Anti-inflammatory Combinations ciprofloxacin/dexamethasone neomycin/polymyxin B/hydrocortisone Tier 2 CIPRODEX Tier 2 CORTISPORIN OTIC 39 WEBSITES Agency for Healthcare Research and Quality http://www.ahrq.gov Alzheimer's Association http://www.alz.org American Academy of Allergy, Asthma and Immunology http://www.aaaai.org American Academy of Child & Adolescent Psychiatry http://www.aacap.org American Academy of Dermatology http://www.aad.org American Academy of Neurology http://www.aan.com American Academy of Ophthalmology http://www.aao.org American Academy of Pediatrics http://www.aap.org American Association for the Study of Liver Disease http://www.aasld.org American Association of Clinical Endocrinologists http://www.aace.com American Association of Diabetes Educators http://www.diabeteseducator.org American Cancer Society http://www.cancer.org American College of Allergy, Asthma and Immunology http://www.acaai.org American College of Cardiology http://www.acc.org American College of Chest Physicians http://www.chestnet.org American Congress of Obstetricians and Gynecologists http://www.acog.org American Diabetes Association http://www.diabetes.org American Gastroenterological Association http://www.gastro.org American Headache Society Committee for Headache Education http://www.achenet.org American Heart Association http://www.myamericanheart.org American Lung Association http://www.lungusa.org American Medical Association http://www.ama-assn.org American Psychiatric Association http://www.psych.org American Society of Anesthesiologists http://www.asahq.org American Society of Clinical Oncology http://www.asco.org American Society of Interventional Pain Physicians http://www.asipp.org American Urological Association http://www.auanet.org Centers for Disease Control and Prevention http://www.cdc.gov Centers for Disease Control and Prevention Guideline topics: AIDS http://www.cdc.gov/hiv/resources/guidelines/index.htm American College of Gastroenterology http://www.acg.gi.org Centers for Disease Control and Prevention Guideline topics: Sexually Transmitted Diseases http://www.cdc.gov/std/treatment/default.htm American College of Physicians http://www.acponline.org CVS/caremark http://www.caremark.com American College of Rheumatology http://www.rheumatology.org The Food and Drug Administration http://www.fda.gov 40 Global Initiative for Asthma http://www.ginasthma.com National Foundation for Infectious Diseases http://www.nfid.org Infectious Diseases Society of America http://www.idsociety.org National Guideline Clearinghouse http://www.guideline.gov Institute for Safe Medication Practices http://www.ismp.org National Heart, Lung and Blood Institute http://www.nhlbi.nih.gov Johns Hopkins AIDS Service http://www.thebody.com/content/art12096.html National Institutes of Health http://www.nih.gov Juvenile Diabetes Research Foundation International http://www.jdf.org National Kidney Foundation http://www.kidney.org MedWatch http://www.fda.gov/medwatch National Osteoporosis Foundation http://www.nof.org National Agricultural Library http://www.nal.usda.gov North American Menopause Society http://www.menopause.org National Cancer Institute http://www.cancer.gov/cancerinformation United States Department of Health and Human Services http://www.hhs.gov National Comprehensive Cancer Network http://www.nccn.org World Health Organization http://www.who.int 41 INDEX A abacavir tabs, 11 ABILIFY, 20 ABILIFY injection, 20 acamprosate calcium, 22 ACANYA, 35 acarbose, 22 ACCUPRIL, 14 ACCURETIC, 14 ACEON, 14 acetazolamide, 17 acetazolamide ext-rel, 17 acetic acid, 39 acetic acid/aluminum acetate, 39 acitretin, 36 ACLOVATE, 36 ACTIGALL, 28 ACTONEL, 24 ACTOPLUS MET, 23 ACULAR, 38 acyclovir caps, tabs, 11 ADALAT CC, 16 adalimumab, 31 adapalene, 35 adapalene/benzoyl peroxide, 35 ADCIRCA, 17 ADVAIR, 34 ADVAIR HFA, 34 AFINITOR, 13 AGGRENOX, 31 AGRYLIN, 31 albuterol, 34 albuterol ext-rel, 34 albuterol soln, 34 albuterol sulfate, CFC-free aerosol, 34 alclometasone crm, oint 0.05%, 36 ALDACTAZIDE, 17 ALDACTONE, 14 ALDARA, 37 alendronate, 24 alfuzosin ext-rel, 30 ALINIA, 12 aliskiren, 16 aliskiren/amlodipine, 16 aliskiren/amlodipine/hydrochlorothiazide, 16 aliskiren/hydrochlorothiazide, 16 ALKERAN, 12 allopurinol, 8 alosetron, 29 ALPHAGAN P, 39 alprazolam, 18 alprostadil inj, 30 alprostadil supp, 30 ALREX, 38 ALTACE, 14 altretamine, 12 amantadine, 12, 19 AMARYL, 23 AMBIEN, 21 AMBIEN CR, 21 ambrisentan, 17 amiloride, 17 amiloride/hydrochlorothiazide, 17 amiodarone, 15 AMITIZA, 29 amitriptyline, 19 amlodipine, 16 amlodipine/atorvastatin, 16 amlodipine/benazepril, 14 amlodipine/olmesartan, 14 amlodipine/valsartan, 14 amlodipine/valsartan/hydrochlorothiazide, 15 ammonium lactate 12%, 37 amoxicillin, 10 amoxicillin/clavulanate, 10 amoxicillin/clavulanate ext-rel, 10 amphetamine/dextroamphetamine mixed salts, 20 amphetamine/dextroamphetamine mixed salts ext-rel, 20 ampicillin, 10 AMTURNIDE, 16 ANAFRANIL, 18 anagrelide, 31 anakinra, 31 ANAPROX, 8 anastrozole, 12 ANDRODERM, 22 ANORO ELLIPTA, 33 ANTABUSE, 22 ANTARA, 15 ANTIVERT, 28 ANUSOL-HC, 29 apixaban, 31 APRISO, 28 ARALEN, 10 ARANESP, 31 ARAVA, 31 ARCAPTA NEOHALER, 34 ARICEPT, 19 ARIMIDEX, 12 aripiprazole, 20 aripiprazole inj, 20 ARIXTRA, 31 armodafinil, 22 AROMASIN, 12 artemether/lumefantrine, 10 ASMANEX, 34 ASTEPRO, 34 atazanavir, 11 ATELVIA, 24 atenolol, 16 atenolol/chlorthalidone, 16 ATIVAN, 18 atomoxetine, 20 atorvastatin, 15 atovaquone/proguanil, 10 ATRALIN, 35 ATRIPLA, 10 ATROVENT spray, 35 AUGMENTIN, 10 AUVI-Q, 33 AVELOX, 10 AVINZA, 9 AVITA, 35 AVODART, 30 AVONEX, 21 42 AXIRON, 22 AYGESTIN, 27 AZASAN, 32 azathioprine, 32 azelaic acid gel, 37 azelastine, 38 azelastine spray, 34 AZILECT, 19 azithromycin, 10 AZOPT, 39 AZOR, 14 AZULFIDINE, 28 AZULFIDINE EN-TABS, 28 B bacitracin, 38 baclofen, 22 BACTROBAN, 35 balsalazide, 28 BARACLUDE, 11 BD insulin syringes and needles, 24 beclomethasone, CFC-free aerosol, 34 benazepril, 13 benazepril/hydrochlorothiazide, 14 BENICAR, 14 BENICAR HCT, 14 BENTYL, 28 BENZAC AC, 35 BENZACLIN, 35 BENZAMYCIN, 35 benzonatate, 33 benzoyl peroxide, 35 benztropine, 19 benzyl alcohol/carbomer 941/glycerin, 37 besifloxacin, 38 BESIVANCE, 38 BETAGAN, 39 betamethasone dipropionate augmented crm 0.05%, 36 betamethasone dipropionate augmented gel, oint 0.05%, 37 betamethasone dipropionate augmented lotion 0.05%, 36 betamethasone dipropionate crm, lotion, oint 0.05%, 36 betamethasone valerate crm, lotion, oint 0.1%, 36 BETAPACE, 15 BETAPACE AF, 15 betaxolol, 39 bethanechol, 30 BETIMOL, 39 BETOPTIC S, 39 bexarotene caps, 13 BEYAZ, 24 BIAXIN, 10 BIAXIN XL, 10 bicalutamide, 12 BIDIL, 17 bismuth/metronidazole/tetracycline, 29 bisoprolol, 16 bisoprolol/hydrochlorothiazide, 16 BLEPH-10, 38 blood glucose continuous monitoring receivers, sensors, transmitters, 24 blood glucose monitoring kits, test strips, 24 boceprevir, 11 BONIVA, 24 bosentan, 17 BOSULIF, 13 bosutinib, 13 BREO ELLIPTA, 34 BREVICON, 25 BRILINTA, 31 brimonidine 0.1%, 39 brimonidine 0.15%, 39 brimonidine 0.2%, 39 brimonidine/timolol, 39 brinzolamide, 39 brinzolamide/brimonidine, 39 bromfenac sodium, 38 bromocriptine, 19 budesonide, 34 budesonide delayed-rel caps, 28 budesonide ext-rel, 28 budesonide inh susp, 34 bumetanide, 17 buprenorphine transdermal, 8 buprenorphine/naloxone sublingual tabs, 22 bupropion, 19 bupropion ext-rel, 19, 22 buspirone, 18 busulfan, 12 butalbital/acetaminophen/caffeine tabs, 9 butalbital/aspirin/caffeine, 9 butenafine, 35 BUTRANS, 8 BYDUREON, 23 BYSTOLIC, 16 C cabergoline, 27 CADUET, 16 CAFERGOT, 21 CALAN SR, 16 calcipotriene, 36 calcitonin-salmon, 24 calcitriol (1,25-D3), 27 calcium acetate, 27 calcium acetate tabs, 27 CAMPRAL, 22 canagliflozin, 23 canagliflozin/metformin, 23 canakinumab, 32 CANASA, 28 candesartan, 14 candesartan/hydrochlorothiazide, 14 capecitabine, 12 captopril, 13 captopril/hydrochlorothiazide, 14 CARAC, 35 CARAFATE, 29 carbamazepine, 18 carbamazepine ext-rel, 18 CARBATROL, 18 carbidopa/levodopa, 20 carbidopa/levodopa ext-rel, 20 carbidopa/levodopa orally disintegrating tabs, 20 carbidopa/levodopa/entacapone, 20 CARDIZEM CD, 16 CARDIZEM LA, 16 CARDURA, 14 carisoprodol, 22 CARNITOR, 27 carvedilol, 16 carvedilol phosphate ext-rel, 16 CASODEX, 12 43 CATAPRES, 14 CATAPRES-TTS, 14 CEENU, 12 cefadroxil, 9 cefdinir, 10 cefixime, 10 cefprozil, 9 CEFTIN, 9 cefuroxime axetil, 9 CELEBREX, 8 celecoxib, 8 CELEXA, 19 CELLCEPT, 32 cephalexin, 9 certolizumab pegol, 31 cetrorelix, 26 CETROTIDE, 26 cevimeline, 29 CHANTIX, 22 chlorambucil, 12 chlordiazepoxide/clidinium, 28 chloroquine, 10 chlorpromazine, 20 chlorthalidone, 17 chlorzoxazone, 22 cholestyramine, 15 choriogonadotropin alfa, 26 chorionic gonadotropin - Novarel, 26 CIALIS, 30 ciclopirox, 35 cilostazol, 31 CILOXAN, 38 cimetidine, 28 CIMZIA, 31 CIPRO, 10 CIPRODEX, 39 ciprofloxacin, 10, 38 ciprofloxacin ext-rel, 10 ciprofloxacin/dexamethasone, 39 citalopram, 19 CITRANATAL 90 DHA, 32 CITRANATAL ASSURE, 32 CITRANATAL B-CALM, 32 CITRANATAL DHA, 32 CITRANATAL HARMONY, 32 CITRANATAL RX, 32 clarithromycin, 10 clarithromycin ext-rel, 10 clemastine 2.68 mg, 33 CLEOCIN, 12, 30 CLEOCIN T, 35 CLIMARA, 26 clindamycin, 12 clindamycin crm, 30 clindamycin gel, lotion, soln, 35 clindamycin supp, 30 clindamycin/benzoyl peroxide, 35 CLINORIL, 8 clobetasol propionate crm, gel, oint 0.05%, 37 clobetasol propionate foam 0.05%, 37 clobetasol propionate lotion, shampoo 0.05%, 37 clobetasol propionate soln 0.05%, 37 clobetasol propionate spray 0.05%, 37 CLOBEX, 37 clocortolone crm 0.1%, 36 CLODERM, 36 CLOMID, 26 clomiphene, 26 clomipramine, 18 clonazepam tabs, 18 clonidine, 14 clonidine transdermal, 14 clopidogrel, 31 clotrimazole, 35 clotrimazole troches, 10 clozapine, 20 CLOZARIL, 20 COARTEM, 10 codeine/acetaminophen, 8 codeine/chlorpheniramine/pseudoephedrine, 33 codeine/guaifenesin liquid, 33 codeine/guaifenesin/pseudoephedrine, 33 codeine/promethazine, 33 codeine/promethazine/phenylephrine, 33 colchicine, 8 COLCRYS, 8 colesevelam, 15 COLESTID, 15 colestipol, 15 COMBIGAN, 39 COMBIVENT RESPIMAT, 33 COMBIVIR, 10 COMTAN, 20 CONCERTA, 20 CONDYLOX, 37 conjugated estrogens/bazedoxifene, 26 COPAXONE, 21 COPEGUS, 11 CORDARONE, 15 COREG, 16 COREG CR, 16 CORGARD, 16 CORTEF, 26 CORTIFOAM, 28 CORTISPORIN OTIC, 39 COSOPT, 39 COSOPT PF, 39 COUMADIN, 31 COZAAR, 14 CREON, 29 CRESTOR, 15 CRINONE, 27 cromolyn sodium, 38 cromolyn soln, 34 CUTIVATE, 36 cyanocobalamin inj, 32 CYCLESSA, 25 cyclobenzaprine, 22 cyclophosphamide, 12 cyclosporine, 32 cyclosporine, emulsion, 39 cyclosporine, modified, 32 CYMBALTA, 19 cyproheptadine, 33 CYTOMEL, 27 CYTOTEC, 29 D D.H.E. 45, 21 dabigatran etexilate, 31 DALIRESP, 34 dalteparin, 30 44 danazol, 25 DANTRIUM, 22 dantrolene, 22 dapsone, 12 darbepoetin alfa, 31 darunavir, 11 dasatinib, 13 DAYPRO, 8 DAYTRANA, 20 DDAVP, 27 delavirdine, 11 DEMADEX, 17 DEPAKENE, 18 DEPAKOTE, 18 DEPAKOTE ER, 18 DEPO-PROVERA, 25 desipramine, 19 desmopressin spray, tabs, 27 desogestrel/EE, 25 desogestrel/EE 0.15/30, 24 desonide crm, lotion, oint 0.05%, 36 DESOWEN, 36 desoximetasone crm 0.05%, 36 desoximetasone crm 0.25%, 36 desoximetasone oint 0.05%, 36 desoximetasone oint 0.25%, gel 0.05%, 36 desvenlafaxine ext-rel, 19 DETROL, 30 dexamethasone, 26 dexamethasone sodium phosphate, 38 DEXCOM G4, 24 DEXEDRINE SPANSULE, 20 DEXILANT, 29 dexlansoprazole delayed-rel, 29 dexmethylphenidate, 20 dexmethylphenidate ext-rel, 20 dextroamphetamine, 20 dextroamphetamine ext-rel, 20 dextromethorphan/brompheniramine/pseudoephedrine, 33 dextromethorphan/promethazine, 33 DIAMOX SEQUELS, 17 DIASTAT, 18 diazepam, 18 diazepam rectal gel, 18 DICLEGIS, 28 diclofenac sodium, 38 diclofenac sodium delayed-rel, 8 diclofenac sodium delayed-rel/misoprostol, 8 diclofenac sodium gel, 8 diclofenac sodium soln, 8 dicloxacillin, 10 dicyclomine, 28 didanosine delayed-rel, 11 DIFFERIN, 35 DIFICID, 10 diflorasone diacetate crm 0.05%, 36 diflorasone diacetate oint 0.05%, 37 DIFLUCAN, 10 diflunisal, 8 difluprednate, 38 digoxin, 16 digoxin ped elixir, 16 dihydroergotamine inj, 21 dihydroergotamine spray, 21 DILANTIN, 18 DILANTIN INFATABS, 18 DILAUDID, 8 diltiazem ext-rel, 16 dimethyl fumarate delayed-rel, 21 DIOVAN, 14 DIPENTUM, 28 diphenoxylate/atropine, 28 DIPROLENE, 36, 37 DIPROLENE AF, 36 dipyridamole, 31 dipyridamole ext-rel/aspirin, 31 disopyramide, 15 disopyramide ext-rel, 15 disulfiram, 22 DITROPAN XL, 30 divalproex sodium delayed-rel, 18 divalproex sodium ext-rel, 18 DIVIGEL, 26 dofetilide, 15 donepezil, 19 dornase alfa, 34 dorzolamide, 39 dorzolamide/timolol maleate, 39 dorzolamide/timolol maleate/preservative-free, 39 DOVONEX, 36 doxazosin, 14 doxepin, 19, 21 doxercalciferol, 27 doxycycline hyclate, 10 doxycycline hyclate 20 mg, 10 doxycycline monohydrate, 37 doxylamine/pyridoxine delayed-rel, 28 DRISDOL, 33 dronabinol, 28 drospirenone/EE 3/20, 24 drospirenone/EE 3/30, 24 drospirenone/EE/levomefolate 3/20 and levomefolate, 24 DUAC, 35 DUAVEE, 26 DUETACT, 23 DULERA, 34 duloxetine delayed-rel, 19 DUONEB, 33 DURAGESIC, 8 DUREZOL, 38 dutasteride, 30 DYAZIDE, 17 E E.E.S., 10 econazole, 35 eculizumab, 31 EDEX, 30 EDURANT, 11 EE/norethindrone acetate, 26 EE/norethindrone acetate - Jinteli, 26 efavirenz, 11 efavirenz/emtricitabine/tenofovir, 10 EFFEXOR XR, 19 EFFIENT, 31 eletriptan, 21 ELIDEL, 37 ELIQUIS, 31 ELIXOPHYLLIN, 35 ELMIRON, 30 ELOCON, 36 eltrombopag, 31 45 elvitegravir/cobicistat/emtricitabine/tenofovir, 10 emtricitabine, 11 emtricitabine/tenofovir, 10 EMTRIVA, 11 enalapril, 14 enalapril/hydrochlorothiazide, 14 ENBREL, 31 enfuvirtide, 11 enoxaparin, 30 entacapone, 20 entecavir, 11 EPIDUO, 35 epinephrine, 33 EPIPEN, 33 EPIPEN JR., 33 EPISIL, 37 EPIVIR, 11 EPIVIR-HBV, 11 eplerenone, 14 epoetin alfa, 31 epoprostenol sodium, 17 eprosartan, 14 ergocalciferol (D2), 33 ergotamine/caffeine, 21 erlotinib, 13 erythromycin, 38 erythromycin delayed-rel, 10 erythromycin ethylsuccinate, 10 erythromycin gel 2%, 35 erythromycin soln, 35 erythromycin stearate, 10 erythromycin/benzoyl peroxide, 35 erythromycin/sulfisoxazole, 10 escitalopram, 19 ESGIC, 9 esomeprazole delayed-rel, 29 ESTRACE, 26 estradiol, 26 estradiol vaginal crm, 26 estradiol vaginal tabs, 26 estradiol valerate and dienogest/estradiol valerate, 25 estradiol/norethindrone, 26 estrogens, conjugated, 26 estrogens, conjugated crm, 26 estrogens, conjugated/medroxyprogesterone, 26 estropipate, 26 eszopiclone, 21 etanercept, 31 ethambutol, 11 ethosuximide, 18 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 25 ethynodiol diacetate/EE 1/50 - Zovia 1/50, 25 etodolac, 8 etonogestrel/EE ring, 25 etoposide, 13 etravirine, 11 EVAMIST, 26 everolimus, 13 EVISTA, 27 EVOXAC, 29 EXALGO, 9 EXELON, 19 EXELON PATCH, 18 exemestane, 12 exenatide ext-rel, 23 EXFORGE, 14 EXFORGE HCT, 15 EXTAVIA, 21 ezetimibe, 15 ezetimibe/simvastatin, 15 F famciclovir, 11 famotidine, 28 FAMVIR, 11 FARESTON, 12 FASLODEX, 12 febuxostat, 8 felodipine ext-rel, 16 FEMARA, 12 FEMHRT, 26 fenofibrate, 15 fenofibric acid delayed-rel, 15 fentanyl citrate buccal, 8 fentanyl citrate nasal spray, 8 fentanyl transdermal, 8 fentanyl transmucosal lozenge, 8 FENTORA, 8 fidaxomicin, 10 filgrastim, 31 FINACEA, 37 finasteride, 30 fingolimod, 21 FIORINAL, 9 FLAGYL, 12 flecainide, 15 FLOLAN, 17 FLOMAX, 30 FLONASE, 34 FLOVENT DISKUS, 34 FLOVENT HFA, 34 fluconazole, 10 fludrocortisone, 26 FLUMADINE, 12 flunisolide spray, 34 fluocinolone acetonide crm, oint 0.025%, 36 fluocinolone acetonide soln 0.01%, 36 fluocinonide crm, gel, oint, soln 0.05%, 36 fluoride drops, 33 fluoride tabs, 33 fluorometholone, 38 fluorouracil, 35 fluorouracil crm, soln 5%, soln 2%, 35 fluoxetine, 19 FLUOXETINE 60 mg, 19 fluphenazine, 20 flutamide, 12 fluticasone, 34 fluticasone propionate crm, lotion 0.05%, 36 fluticasone propionate oint 0.005%, 36 fluticasone spray, 34 fluticasone, CFC-free aerosol, 34 fluticasone/salmeterol, 34 fluticasone/salmeterol, CFC-free aerosol, 34 fluticasone/vilanterol, 34 fluvastatin, 15 fluvoxamine, 18 FML, 38 FOCALIN, 20 FOCALIN XR, 20 folic acid, 32 folic acid/vitamin B6/vitamin B12, 32 46 FOLLISTIM AQ, 26 follitropin beta, 26 fondaparinux, 31 FORADIL, 34 formoterol inhalation caps, 34 formoterol inhalation soln, 34 FORTEO, 24 FORTESTA, 22 FOSAMAX, 24 fosinopril, 13 fosinopril/hydrochlorothiazide, 14 FRAGMIN, 30 fulvestrant, 12 FURADANTIN, 12 furosemide, 17 FUZEON, 11 G gabapentin, 18 gabapentin ext-rel, 22 GABITRIL, 18 galantamine, 19 galantamine ext-rel, 19 ganirelix, 26 GELNIQUE, 30 GEL-ONE, 9 gemfibrozil, 15 gentamicin, 35, 38 GEODON, 20 GILENYA, 21 glatiramer, 21 GLEEVEC, 13 glimepiride, 23 glipizide, 23 glipizide ext-rel, 23 glipizide/metformin, 23 GLUCAGEN HYPOKIT, 26 GLUCAGON EMERGENCY KIT, 26 glucagon, human recombinant, 26 GLUCOPHAGE, 23 GLUCOPHAGE XR, 23 GLUCOTROL, 23 GLUCOTROL XL, 23 glyburide, 23 golimumab, 31 GOLYTELY, 29 goserelin acetate, 13 GRALISE, 22 granisetron, 28 granisetron transdermal, 28 griseofulvin ultramicrosize, 10 GRIS-PEG, 10 guanfacine, 14 guanfacine ext-rel, 20 H halobetasol propionate crm, oint 0.05%, 37 haloperidol, 20 HECTOROL, 27 HEXALEN, 12 HUMATROPE, 27 HUMIRA, 31 HUMULIN R U-500, 23 HYALGAN, 9 HYCAMTIN caps, 13 hydralazine, 18 HYDREA, 13 hydrochlorothiazide, 17 hydrocodone/acetaminophen, 8 hydrocodone/homatropine, 33 hydrocortisone, 26 hydrocortisone acetate foam, 28 hydrocortisone acetate/pramoxine foam, 29 hydrocortisone butyrate crm 0.1%, 36 hydrocortisone butyrate lotion 0.1%, 36 hydrocortisone butyrate oint, soln 0.1%, 36 hydrocortisone crm, 29 hydrocortisone crm 2.5%, 36 hydrocortisone enema, 28 hydrocortisone lotion 1%, 36 hydrocortisone valerate crm 0.2%, 36 hydrocortisone valerate oint 0.2%, 36 hydromorphone, 8 hydromorphone ext-rel, 9 hydroxychloroquine, 31 hydroxyurea, 13 hydroxyzine HCl, 33 hyoscyamine sulfate, 28 hyoscyamine sulfate ext-rel, 28 hyoscyamine sulfate ext-rel caps, 28 hyoscyamine sulfate orally disintegrating tabs, 28 HYZAAR, 14 I ibandronate, 24 ibuprofen, 8 ICLUSIG, 13 ILARIS, 32 iloprost, 17 imatinib mesylate, 13 IMDUR, 17 imipramine HCl, 19 imiquimod, 35, 37 IMITREX, 21 IMURAN, 32 indacaterol, 34 indapamide, 17 INDERAL LA, 16 ingenol mebutate, 35 INSPRA, 14 insulin aspart, 23 insulin aspart protamine 70%/insulin aspart 30%, 23 insulin detemir, 23 insulin glargine, 23 insulin human, 23 insulin isophane human, 23 insulin isophane human 70%/regular 30%, 23 insulin syringes, needles, 24 INTELENCE, 11 interferon alfa-2b, 32 interferon beta-1a, 21 interferon beta-1b, 21 INTRON A, 32 INTUNIV, 20 INVOKAMET, 23 INVOKANA, 23 ipratropium soln, 33 ipratropium spray, 35 ipratropium/albuterol soln, 33 ipratropium/albuterol, CFC-free aerosol, 33 irbesartan, 14 irbesartan/hydrochlorothiazide, 14 ISENTRESS, 11 47 isocarboxazid, 19 isoniazid, 11 ISORDIL, 17 isosorbide dinitrate ext-rel tabs, 17 isosorbide dinitrate oral, 17 isosorbide dinitrate/hydralazine, 17 isosorbide mononitrate, 17 isosorbide mononitrate ext-rel, 17 isotretinoin, 35 itraconazole, 10 J JANUMET, 23 JANUMET XR, 23 JANUVIA, 23 JENTADUETO, 23 K KADIAN, 9 KALETRA, 11 KEFLEX, 9 KEPPRA, 18 KEPPRA XR, 18 ketoconazole, 10, 35 ketoconazole shampoo 2%, 36 ketorolac, 38 KINERET, 31 KLARON, 35 KLONOPIN, 18 KUVAN, 27 L labetalol, 16 LAC-HYDRIN, 37 lacosamide, 18 lactulose, 29 LAMICTAL, 18 LAMICTAL ODT, 18 LAMICTAL XR, 18 LAMISIL, 10 lamivudine, 11 lamivudine/zidovudine, 10 lamotrigine, 18 lamotrigine ext-rel, 18 lamotrigine orally disintegrating tabs, 18 lancets, 24 LANCETS, 24 LANOXIN, 16 lansoprazole + amoxicillin + clarithromycin, 29 lansoprazole delayed-rel, 29 LANTUS, 23 lapatinib, 13 LASIX, 17 latanoprost, 39 LATUDA, 20 LAZANDA, 8 leflunomide, 31 lenalidomide, 13 LETAIRIS, 17 letrozole, 12 LEUKERAN, 12 leuprolide acetate, 13 LEVAQUIN, 10 LEVBID, 28 LEVEMIR, 23 levetiracetam, 18 levetiracetam ext-rel, 18 levobunolol, 39 levocarnitine, 27 levocetirizine, 33 levofloxacin, 10, 38 levonorgestrel releasing IUD, 25 levonorgestrel/EE - Trivora, 25 levonorgestrel/EE 0.1/20 - Lessina, 24 levonorgestrel/EE 0.1/20 and EE 10, 25 levonorgestrel/EE 0.15/30, 25 levonorgestrel/EE 0.15/30 - Levora, 25 levonorgestrel/EE 0.15/30 and EE 10, 25 levothyroxine, 27 levothyroxine - Levoxyl, 27 LEVSIN, 28 LEXAPRO, 19 LIALDA, 28 lidocaine patch, 37 lidocaine viscous, 37 lidocaine/prilocaine, 37 LIDODERM, 37 linaclotide, 29 linagliptin, 23 linagliptin/metformin, 23 linezolid, 12 LINZESS, 29 liothyronine, 27 LIPOFEN, 15 liraglutide, 23 lisdexamfetamine, 20 lisinopril, 14 lisinopril/hydrochlorothiazide, 14 lithium carbonate, 21 lithium carbonate ext-rel tabs 300 mg, 21 lithium carbonate ext-rel tabs 450 mg, 21 LITHOBID, 21 LO LOESTRIN FE, 24 LOCOID, 36 LOCOID LIPOCREAM, 36 LOESTRIN 1.5/30, 25 LOESTRIN 1/20, 24 LOESTRIN FE 1.5/30, 25 LOESTRIN FE 1/20, 24 LOFIBRA, 15 LOMOTIL, 28 lomustine, 12 loperamide, 28 LOPID, 15 lopinavir/ritonavir, 11 LOPRESSOR, 16 LOPRESSOR HCT, 16 LOPROX, 35 lorazepam, 18 losartan, 14 losartan/hydrochlorothiazide, 14 LOSEASONIQUE, 25 LOTEMAX, 38 LOTENSIN, 13 LOTENSIN HCT, 14 loteprednol 0.2%, 38 loteprednol 0.5%, 38 LOTREL, 14 LOTRONEX, 29 lovastatin, 15 LOVAZA, 15 LOVENOX, 30 lubiprostone, 29 48 LUPRON DEPOT, 13 lurasidone, 20 LURIDE, 33 LURIDE LOZI-TABS, 33 LYRICA, 20 LYSODREN, 13 M MACROBID, 12 MACRODANTIN, 12 MALARONE, 10 malathion, 37 MARINOL, 28 MARPLAN, 19 MATULANE, 13 MAVIK, 14 MAXALT, 21 MAXITROL, 38 MAXZIDE, 17 meclizine, 28 MEDROL, 26 medroxyprogesterone acetate, 27 medroxyprogesterone acetate 150 mg/mL, 25 mefloquine, 10 MEGACE, 13 MEGACE ES, 27 megestrol acetate, 13 megestrol acetate susp, 27 meloxicam, 8 melphalan, 12 memantine, 18 memantine ext-rel, 18 MENTAX, 35 MEPHYTON, 33 mercaptopurine, 12 mesalamine delayed-rel tabs, 28 mesalamine ext-rel caps, 28 mesalamine rectal susp, 28 mesalamine supp, 28 MESTINON, 22 MESTINON TIMESPAN, 22 METAGLIP, 23 metaxalone, 22 metformin, 23 metformin ext-rel, 23 methadone, 8 methazolamide, 17 methimazole, 27 methocarbamol, 22 methotrexate, 12, 31, 32 methoxsalen oral, 36 methyldopa, 18 METHYLIN, 20 methylnaltrexone, 29 methylphenidate, 20 methylphenidate ext-rel, 20 methylphenidate ext-rel 10 mg, 20 methylphenidate ext-rel susp, 20 methylphenidate transdermal, 20 methylprednisolone, 26 metipranolol, 39 metoclopramide, 28 metolazone, 17 metoprolol succinate ext-rel, 16 metoprolol tartrate, 16 metoprolol/hydrochlorothiazide, 16 METROCREAM, 37 METROGEL, 37 METROGEL-VAGINAL, 30 METROLOTION, 37 metronidazole, 12, 30 metronidazole crm 0.75%, 37 metronidazole gel 0.75%, 37 metronidazole gel 1%, 37 metronidazole lotion 0.75%, 37 MEVACOR, 15 MIACALCIN, 24 MICARDIS, 14 MICARDIS HCT, 14 midodrine, 18 MIGRANAL, 21 milnacipran, 20 MINASTRIN 24 FE, 24 MINIVELLE, 26 MINOCIN, 10 minocycline, 10 mirabegron ext-rel, 30 MIRALAX, 29 MIRAPEX, 20 MIRAPEX ER, 19 MIRCETTE, 25 MIRENA, 25 mirtazapine, 19 misoprostol, 29 mitotane, 13 MOBIC, 8 MODICON, 25 mometasone, 34 mometasone crm, lotion 0.1%, 36 mometasone oint 0.1%, 36 mometasone spray, 34 mometasone/formoterol, 34 montelukast, 34 morphine, 8 morphine ext-rel, 9 morphine supp, 8 MOVIPREP, 29 MOXEZA, 38 moxifloxacin, 10, 38 MOZOBIL, 31 MS CONTIN, 9 MUGARD, 37 multivitamins/fluoride drops, tabs, 32 multivitamins/fluoride/iron drops, tabs, 33 mupirocin, 35 MUSE, 30 MYAMBUTOL, 11 mycophenolate mofetil, 32 mycophenolate sodium delayed-rel, 32 MYFORTIC, 32 MYLERAN, 12 MYRBETRIQ, 30 MYSOLINE, 18 N nabumetone, 8 nadolol, 16 nafarelin, 25 naltrexone, 22 NAMENDA, 18 NAMENDA XR, 18 NAPROSYN, 8 49 naproxen, 8 naproxen sodium, 8 naratriptan, 21 NARDIL, 19 NASACORT AQ, 34 NASONEX, 34 NATACYN, 38 natamycin, 38 NATAZIA, 25 nateglinide, 23 nebivolol, 16 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 38 neomycin/polymyxin B/dexamethasone, 38 neomycin/polymyxin B/gramicidin, 38 neomycin/polymyxin B/hydrocortisone, 39 neomycin/polymyxin B/hydrocortisone susp, 38 NEORAL, 32 NEOSPORIN, 38 NEULASTA, 31 NEUPOGEN, 31 NEUPRO, 20 NEURONTIN, 18 nevirapine, 11 nevirapine ext-rel, 11 NEXAVAR, 13 NEXIUM, 29 niacin ext-rel, 15 niacin ext-rel/simvastatin, 15 NIASPAN, 15 nifedipine ext-rel, 16 nitazoxanide, 12 NITRO-DUR, 17 nitrofurantoin ext-rel, 12 nitrofurantoin macrocrystals, 12 nitrofurantoin susp, 12 nitroglycerin sublingual, 17 nitroglycerin sublingual spray, 17 nitroglycerin transdermal, 17 NITROLINGUAL, 17 NITROSTAT, 17 NIZORAL SHAMPOO, 36 NORCO, 8 NORDITROPIN, 27 norelgestromin/EE, 25 norethindrone, 25 norethindrone acetate, 27 norethindrone acetate/EE 1.5/30, 25 norethindrone acetate/EE 1.5/30 and iron, 25 norethindrone acetate/EE 1/10 and EE 10 and iron, 24 norethindrone acetate/EE 1/20, 24 norethindrone acetate/EE 1/20 and iron, 24 norethindrone acetate/EE 1/20 and iron - Lomedia 24 Fe, 24 norethindrone acetate/EE 1/20 and iron chewable, 24 norethindrone/EE, 25 norethindrone/EE 0.5/35, 25 norethindrone/EE 1/35, 25 norethindrone/ME 1/50, 25 norgestimate/EE, 25 norgestimate/EE 0.25/35, 25 norgestrel/EE 0.3/30 - Low-Ogestrel, 25 NORINYL 1+35, 25 NORINYL 1+50, 25 NORPACE, 15 NORPACE CR, 15 NORPRAMIN, 19 NOR-QD, 25 nortriptyline, 19 NORVIR, 11 NOVOLIN 70/30, 23 NOVOLIN N, 23 NOVOLIN R, 23 NOVOLOG, 23 NOVOLOG MIX 70/30, 23 NUCYNTA, 8 NUCYNTA ER, 8 NULYTELY, 29 NUVARING, 25 NUVIGIL, 22 nystatin, 10, 35 O OCUFLOX, 38 ofloxacin, 38 ofloxacin otic, 39 olanzapine, 20 olmesartan, 14 olmesartan/amlodipine/hydrochlorothiazide, 15 olmesartan/hydrochlorothiazide, 14 olopatadine, 38 olopatadine spray, 34 olsalazine, 28 omalizumab, 35 omega-3 acid ethyl esters, 15 omeprazole delayed-rel, 29 omeprazole/sodium bicarbonate caps, 29 ondansetron, 28 ONETOUCH kits and test strips, 24 OPANA ER, 8 OPTIPRANOLOL, 39 OPTIVAR, 38 ORACEA, 37 ORAPRED, 26 orphenadrine/aspirin/caffeine, 22 ORTHO EVRA, 25 ORTHO MICRONOR, 25 ORTHO TRI-CYCLEN, 25 ORTHO TRI-CYCLEN LO, 25 ORTHO-CEPT, 24 ORTHO-CYCLEN, 25 ORTHO-NOVUM 1/35, 25 ORTHO-NOVUM 7/7/7, 25 oseltamivir, 12 ospemifene, 27 OSPHENA, 27 OVIDE, 37 OVIDREL, 26 oxaprozin, 8 oxazepam, 18 oxcarbazepine, 18 OXSORALEN-ULTRA, 36 oxybutynin, 30 oxybutynin ext-rel, 30 oxybutynin gel, 30 oxycodone caps, tabs 5 mg, 8 oxycodone concentrate 20 mg/mL, 8 oxycodone ext-rel, 8 oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL, 9 oxycodone/acetaminophen 5/325, 9 OXYCONTIN, 8 oxymorphone ext-rel, 8 P PAMELOR, 19 50 pancrelipase, 29 pancrelipase delayed-rel, 29 pantoprazole delayed-rel, 29 PARAFON FORTE DSC, 22 PARCOPA, 20 paricalcitol, 27 PARLODEL, 19 PARNATE, 19 paroxetine HCl, 19 paroxetine HCl ext-rel, 19 PATADAY, 38 PATANASE, 34 PATANOL, 38 PAXIL, 19 PAXIL CR, 19 pazopanib, 13 peg 3350/electrolytes, 29 PEGASYS, 32 pegfilgrastim, 31 peginterferon alfa-2a, 32 peginterferon alfa-2b, 32 PEGINTRON, 32 penicillin VK, 10 PENTASA, 28 pentosan polysulfate sodium, 30 PEPCID, 28 PERCOCET, 9 PERFOROMIST, 34 perindopril, 14 permethrin 5%, 37 perphenazine, 20 PERSANTINE, 31 phenazopyridine, 30 phenelzine, 19 phenobarbital, 18 phentermine/topiramate ext-rel, 24 phenytoin, 18 phenytoin sodium extended, 18 PHOSLO, 27 PHOSLYRA, 27 phytonadione, 33 PICATO, 35 pilocarpine tabs, 29 pimecrolimus, 37 pindolol, 16 pioglitazone, 23 pioglitazone/glimepiride, 23 pioglitazone/metformin, 23 PLAQUENIL, 31 plerixafor, 31 PLETAL, 31 podofilox, 37 polyethylene glycol 3350, 29 polymyxin B/bacitracin, 38 polymyxin B/trimethoprim, 38 POLYTRIM, 38 pomalidomide, 13 POMALYST, 13 ponatinib, 13 potassium chloride ext-rel, 32 potassium chloride liquid, 32 potassium citrate ext-rel, 30 PRADAXA, 31 pramipexole, 20 pramipexole ext-rel, 19 pramlintide, 23 PRANDIN, 23 prasugrel, 31 PRAVACHOL, 15 pravastatin, 15 PRECOSE, 22 PRED FORTE, 38 prednisolone acetate 1%, 38 prednisolone phosphate 1%, 38 prednisolone sodium phosphate, 26 prednisolone sodium phosphate 5 mg/5 mL, 26 prednisolone syrup, 26 prednisone, 26 pregabalin, 20 PRELONE, 26 PREMARIN, 26 PREMARIN crm, 26 PREMPHASE, 26 PREMPRO, 26 prenatal vitamins, 32 prenatal vitamins/DHA/docusate/folic acid, 32 prenatal vitamins/docusate/folic acid, 32 prenatal vitamins/docusate/folic acid + DHA, 32 prenatal vitamins/folic acid + pyridoxine, 32 PREVPAC, 29 PREZISTA, 11 PRILOSEC, 29 primidone, 18 PRISTIQ, 19 PROAIR HFA, 34 probenecid, 8 procarbazine, 13 PROCARDIA XL, 16 prochlorperazine, 28 PROCRIT, 31 PROCTOFOAM-HC, 29 progesterone gel, 27 progesterone, micronized, 27 PROGRAF, 32 PROMACTA, 31 promethazine, 28 PROMETRIUM, 27 propafenone, 15 propafenone ext-rel, 15 propranolol, 16 propranolol ext-rel, 16 propylthiouracil, 27 PROSCAR, 30 PROTOPIC, 37 PROVERA, 27 PROZAC, 19 PULMICORT FLEXHALER, 34 PULMICORT RESPULES, 34 PULMOZYME, 34 PURINETHOL, 12 PYLERA, 29 pyrazinamide, 11 PYRIDIUM, 30 pyridostigmine, 22 pyridostigmine ext-rel, 22 Q QSYMIA, 24 QUESTRAN/QUESTRAN LIGHT, 15 quetiapine, 20 quetiapine ext-rel, 20 QUILLIVANT XR, 20 51 quinapril, 14 quinapril/hydrochlorothiazide, 14 QVAR, 34 R raloxifene, 27 raltegravir, 11 ramipril, 14 RANEXA, 18 ranitidine, 28 ranolazine ext-rel, 18 RAPAFLO, 30 RAPAMUNE, 32 rasagiline mesylate, 19 RAZADYNE, 19 RAZADYNE ER, 19 REBETOL, 11 REGLAN, 28 RELENZA, 12 RELISTOR, 29 RELPAX, 21 REMERON, 19 REMODULIN, 17 RENVELA, 27 repaglinide, 23 REQUIP, 20 REQUIP XL, 20 RESCRIPTOR, 11 RESTASIS, 39 RESTORIL, 21 RETIN-A, 35 RETIN-A MICRO, 35 RETROVIR, 11 REVATIO, 17 REVIA, 22 REVLIMID, 13 REYATAZ, 11 RHEUMATREX, 32 ribavirin caps, 11 ribavirin oral soln, 11 ribavirin tabs, 11 RIFADIN, 11 rifampin, 11 rifaximin, 12 rilpivirine, 11 rimantadine, 12 risedronate, 24 risedronate delayed-rel, 24 RISPERDAL, 20 RISPERDAL CONSTA, 20 risperidone, 20 risperidone long-acting injection, 20 RITALIN, 20 RITALIN LA, 20 ritonavir, 11 rivaroxaban, 31 rivastigmine, 19 rivastigmine transdermal, 18 rizatriptan, 21 ROBAXIN, 22 ROCALTROL, 27 roflumilast, 34 ropinirole, 20 ropinirole ext-rel, 20 rosuvastatin, 15 rotigotine transdermal, 20 ROWASA, 28 ROXICODONE, 9 RYTHMOL, 15 RYTHMOL SR, 15 S SALAGEN, 29 salmeterol xinafoate, 34 SANCUSO, 28 SANDIMMUNE, 32 sapropterin, 27 SAVELLA, 20 scopolamine, 28 SEASONIQUE, 25 selegiline, 19 selegiline orally disintegrating tabs, 20 selenium sulfide shampoo 2.5%, 36 SELSUN, 36 SEREVENT, 34 SEROQUEL, 20 SEROQUEL XR, 20 sertraline, 19 sevelamer carbonate, 27 SFROWASA, 28 sildenafil, 17, 30 SILENOR, 21 silodosin, 30 SILVADENE, 35 silver sulfadiazine, 35 SIMBRINZA, 39 SIMCOR, 15 SIMPONI, 31 simvastatin, 15 SINEMET, 20 SINEMET CR, 20 SINGULAIR, 34 sirolimus, 32 sitagliptin phosphate, 23 sitagliptin/metformin, 23 sitagliptin/metformin ext-rel, 23 SKELAXIN, 22 sodium hyaluronate, 9 sodium oxybate, 22 sodium sulfate/potassium sulfate/magnesium sulfate, 29 sofosbuvir, 11 solifenacin succinate, 30 SOLIRIS, 31 somatropin, 27 sorafenib, 13 SORIATANE, 36 SORILUX, 36 sotalol, 15 SOVALDI, 11 soy phospholipid/glycerol dioleate, 37 SPIRIVA, 33 spironolactone, 14 spironolactone-hydrochlorothiazide, 17 SPORANOX, 10 SPRYCEL, 13 STALEVO, 20 stavudine, 11 STELARA, 36 STRATTERA, 20 STRIBILD, 10 SUCLEAR, 29 sucralfate, 29 52 sucroferric oxyhydroxide, 27 sulfacetamide lotion 10%, 35 sulfacetamide oint 10%, 38 sulfacetamide soln 10%, 38 sulfacetamide/prednisolone phosphate 10%/0.25%, 38 sulfacetamide/sulfur, 37 sulfacetamide/sulfur crm, gel, lotion, pads, 35 sulfamethoxazole/trimethoprim, 12 sulfamethoxazole/trimethoprim DS, 12 sulfasalazine, 28 sulfasalazine delayed-rel, 28 sulindac, 8 sumatriptan, 21 sumatriptan inj, 21 sumatriptan nasal spray, 21 sumatriptan/naproxen sodium, 21 SUMAVEL DOSEPRO, 21 sunitinib, 13 SUPARTZ, 9 SUPRAX, 10 SUPREP, 29 SUSTIVA, 11 SUTENT, 13 SYLATRON, 32 SYMLINPEN, 23 SYNAREL, 25 SYNTHROID, 27 T TABLOID, 12 tacrolimus, 32, 37 tadalafil, 17, 30 tafluprost, 39 TAMBOCOR, 15 TAMIFLU, 12 tamoxifen, 12 tamsulosin, 30 TAPAZOLE, 27 tapentadol, 8 tapentadol ext-rel, 8 TARCEVA, 13 TARGRETIN caps, 13 TARKA, 14 tazarotene, 35 TAZORAC, 35 TECFIDERA, 21 TEGRETOL, 18 TEGRETOL-XR, 18 TEKAMLO, 16 TEKTURNA, 16 TEKTURNA HCT, 16 telmisartan, 14 telmisartan/hydrochlorothiazide, 14 temazepam, 21 TEMODAR, 12 TEMOVATE, 37 temozolomide, 12 TENEX, 14 tenofovir, 11 TENORETIC, 16 TENORMIN, 16 TERAZOL 3, 30 TERAZOL 7, 30 terazosin, 14 terbinafine tabs, 10 terbutaline, 34 terconazole, 30 teriparatide, 24 TESSALON, 33 testosterone cypionate, 22 testosterone enanthate, 22 testosterone gel, 22 testosterone soln, 22 testosterone transdermal, 22 tetrabenazine, 21 tetracycline, 10 thalidomide, 13 THALOMID, 13 THEO-24, 35 theophylline ext-rel caps, 35 theophylline ext-rel tabs, 35 theophylline liquid, 35 thioguanine, 12 thiothixene, 20 tiagabine, 18 TIAZAC, 16 ticagrelor, 31 TIGAN, 28 TIKOSYN, 15 timolol hemihydrate, 39 timolol maleate, 39 timolol maleate gel, 39 TIMOPTIC, 39 TIMOPTIC-XE, 39 TINDAMAX, 12 tinidazole, 12 tiotropium, 33 tizanidine, 22 TOBI, 34 TOBRADEX OINTMENT, 38 TOBRADEX ST, 38 TOBRADEX SUSPENSION, 38 tobramycin, 38 tobramycin inhalation soln, 34 tobramycin/dexamethasone oint 0.3%/0.1%, 38 tobramycin/dexamethasone susp 0.3%/0.05%, 38 tobramycin/dexamethasone susp 0.3%/0.1%, 38 tobramycin/loteprednol, 38 TOBREX, 38 TOFRANIL, 19 tolterodine, 30 tolterodine ext-rel, 30 TOPAMAX, 18 TOPICORT, 36 TOPICORT LP, 36 topiramate, 18 topotecan caps, 13 TOPROL-XL, 16 toremifene, 12 torsemide, 17 TRACLEER, 17 TRADJENTA, 23 tramadol, 9 tramadol ext-rel, 8 trandolapril, 14 trandolapril/verapamil ext-rel, 14 TRANSDERM SCOP, 28 tranylcypromine, 19 TRAVATAN Z, 39 travoprost, 39 trazodone, 19 TRELSTAR, 13 53 treprostinil, 17 tretinoin, 35 tretinoin caps, 13 tretinoin gel microsphere, 35 TREXALL, 12 TREXIMET, 21 triamcinolone acetonide crm 0.5%, 36 triamcinolone acetonide crm, lotion 0.025%, 36 triamcinolone acetonide crm, lotion, oint 0.1%, 36 triamcinolone acetonide spray, 34 triamcinolone paste, 37 triamterene-hydrochlorothiazide, 17 TRIBENZOR, 15 trifluoperazine, 20 trifluridine, 38 trihexyphenidyl, 19 TRILEPTAL, 18 TRILIPIX, 15 trimethobenzamide, 28 trimethoprim, 12 TRI-NORINYL, 25 triptorelin pamoate, 13 trospium, 30 trospium ext-rel, 30 TRUSOPT, 39 TRUVADA, 10 TYKERB, 13 TYLENOL w/CODEINE, 8 TYVASO, 17 U UCERIS, 28 ULORIC, 8 ULTRAM, 9 ULTRAVATE, 37 ULTRESA, 29 umeclidinium/vilanterol, 33 URECHOLINE, 30 UROCIT-K, 30 URSO, 28 ursodiol, 28 ustekinumab, 36 V VAGIFEM, 26 valacyclovir, 11 VALCYTE, 11 valganciclovir, 11 VALIUM, 18 valproic acid, 18 valsartan, 14 valsartan/hydrochlorothiazide, 14 VANCOCIN, 12 vancomycin, 12 varenicline, 22 VASERETIC, 14 VASOTEC, 14 VELPHORO, 27 venlafaxine, 19 venlafaxine ext-rel, 19 VENTAVIS, 17 verapamil ext-rel, 16 VESICARE, 30 VFEND, 10 VIAGRA, 30 VIBRAMYCIN, 10 VICTOZA, 23 VICTRELIS, 11 VIDEX EC, 11 VIGAMOX, 38 VIIBRYD, 19 vilazodone, 19 VIMPAT, 18 VIOKACE, 29 VIRAMUNE, 11 VIRAMUNE XR, 11 VIREAD, 11 VIROPTIC, 38 vitamin ADC/fluoride drops, 33 vitamin ADC/fluoride/iron drops, 33 VIVELLE-DOT, 26 VOLTAREN GEL, 8 voriconazole, 10 vorinostat, 13 VOSPIRE ER, 34 VOTRIENT, 13 VYTORIN, 15 VYVANSE, 20 W warfarin, 31 WELCHOL, 15 WELLBUTRIN, 19 WELLBUTRIN SR, 19 WELLBUTRIN XL, 19 WESTCORT, 36 X XALATAN, 39 XANAX, 18 XARELTO, 31 XELODA, 12 XENAZINE, 21 XIFAXAN 550 mg, 12 XOLAIR, 35 XYREM, 22 XYZAL, 33 Y YASMIN, 24 YAZ, 24 Z zafirlukast, 34 ZANAFLEX tabs, 22 zanamivir, 12 ZANTAC, 28 ZARONTIN, 18 ZAROXOLYN, 17 ZEBETA, 16 ZELAPAR, 20 ZEMPLAR, 27 ZENPEP, 29 ZERIT, 11 ZESTORETIC, 14 ZESTRIL, 14 ZETIA, 15 ZIAC, 16 ZIAGEN tabs, 11 zidovudine, 11 ZIOPTAN, 39 ziprasidone, 20 ZITHROMAX, 10 ZOCOR, 15 ZOFRAN, 28 54 ZOLADEX, 13 ZOLINZA, 13 zolmitriptan, 21 zolmitriptan nasal spray, 21 ZOLOFT, 19 zolpidem, 21 zolpidem ext-rel, 21 ZOMIG, 21 ZONEGRAN, 18 zonisamide, 18 ZOVIRAX, 11 ZUBSOLV, 22 ZYBAN, 22 ZYCLARA, 35 ZYLET, 38 ZYLOPRIM, 8 ZYPREXA, 20 ZYVOX, 12 55 This formulary was updated 01/01/2015. For more recent information or other questions, please contact CareFirst Pharmacy Services at 800-241-3371 or visit www.carefirst.com/rx. The CareFirst BlueCross BlueShield family of health care plans 10455 Mill Run Circle Owings Mills, MD 21117 www.carefirst.com/rx CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc. SUM2358-1S (9/14)
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