DRUG FORMULARY

EFFECTIVE JANUARY 1, 2013

LAST UPDATED SEPTEMBER 16, 2013

TABLE OF CONTENTS

INTRODUCTION................................................................................................................................................................. 2
HOW TO USE THIS LIST .................................................................................................................................................. 2
COVERAGE AND LIMITATIONS ................................................................................................................................... 3
PHARMACY SAVINGS PROGRAMS .............................................................................................................................. 4
CONTACT US ...................................................................................................................................................................... 5
DRUG FORMULARY LIST ............................................................................................................................................... 6
ANTI-INFECTIVE DRUGS ................................................................................................................................................ 6
AUTOIMMUNE INFLAMMATORY DISORDERS ........................................................................................................ 8
BLOOD MODIFYING DRUGS .......................................................................................................................................... 8
CANCER DRUGS ................................................................................................................................................................ 9
CENTRAL NERVOUS SYSTEM ....................................................................................................................................... 9
GASTROINTESTINAL DRUGS ...................................................................................................................................... 12
GENITOURINARY DRUGS ............................................................................................................................................. 13
HEART AND CIRCULATORY DRUGS......................................................................................................................... 14
HORMONES, DIABETES, TEST SUPPLIES, AND RELATED DRUGS................................................................... 17
MISCELLANEOUS CATEGORIES (INCLUDES SUPPLIES AND DEVICES) ....................................................... 20
MULTIPLE SCLEROSIS .................................................................................................................................................. 20
NEUROMUSCULAR DRUGS .......................................................................................................................................... 20
PAIN-RELIEF DRUGS...................................................................................................................................................... 22
RESPIRATORY AGENTS ................................................................................................................................................ 24
SUPPLEMENTS ................................................................................................................................................................. 25
TOPICAL DRUGS ............................................................................................................................................................. 25
MANAGED DOSE LIMITATIONS (MDL) .................................................................................................................... 30
PREAUTHORIZATION (PA) ........................................................................................................................................... 32
STEP-THERAPY (ST) ....................................................................................................................................................... 34
SPECIALTY DRUG LIST ................................................................................................................................................. 36
INDEX .................................................................................................................................................................................. 38

ph-comform-0913

INTRODUCTION
This is the 2013 Health Alliance Drug
Formulary. In order to assist members and providers
in choosing covered prescription drugs for
treatment, we encourage members to show this list
to their physicians and pharmacists. In addition, we
encourage prescribers to use this list when
considering treatment options. Final decisions
regarding treatment options are made between the
physician and patient.
The formulary is subject to change at any time.
Members can access the most up-to-date version of
this list by visiting the Pharmacy section of
HealthAlliance.org. In addition, members can login
to CatamaranRx.com to access specific drug
coverage and pricing information.
The formulary does not provide information
about an individuals specific coverage. Please refer
to your plan documents for complete coverage
details.

HOW TO USE THIS LIST

This drug list is organized in sections by drug
class or medical condition. Within each section are
subsections to help locate medications. Most drugs
listed, whether generic or brand, are formulary
drugs. There are a few nonformulary drugs listed
and designated as Tier 3.
To search within the PDF, choose the search
function, enter a drug name and click search or
find. You can also search using the index, which
lists drugs alphabetically.
The list is organized first by therapeutic class.

THERAPEUTIC CLASS
Then by sub-type (if applicable).

SUB-TYPE
And last by additional sub-type (if applicable).
ADDITIONAL SUB-TYPE
Covered brand-name drugs are listed in all
CAPITAL letters, followed by the generic name.

Covered generic drugs appear in lowercase bold

type, followed by their reference brand drug in
parentheses.
Example: atenolol (Tenormin)

Generics
Like brand drugs, generic drugs go through an
approval process by the Food and Drug
Administration (FDA) and must meet similar
standards of effectiveness and chemical make-up as
branded drugs.
The main difference between the reference brand
drug and its generic equivalent is that the generic
often costs much less.
As a general rule, generic drugs have the lowest
member copayment. Typically, when a generic
enters the market the brand drug moves to Tier 3.
Members who choose the brand name after the
release of a generic version may pay the copayment
plus the difference in cost between the brand and
generic drug. Generic drugs can help members save
on out-of-pocket medication costs.
Generic Equivalent vs. Generic Alternative
Generic equivalents are medications that contain
the same active ingredient, with the same strength
and dosage form as the brand medication. Generic
equivalents are as safe and effective and produce
the same results as the brand counterpart.
Generic alternatives can produce the same
intended effect on the body as the comparable
brand. Generic alternatives are medications that
work like a particular brand drug and are used to
treat the same condition. However, the active
ingredient in a generic alternative is different from
the brand medication.
Talk to Your Doctor
If your doctor writes a prescription for a brand
drug that does not have a generic equivalent,
consider asking if an appropriate generic alternative
is available.
As a patient, you can tell your pharmacist you
are interested in generics. In most situations, your
pharmacist can substitute a generic equivalent for
its brand counterpart without a new prescription
from your doctor.
For more information on generics, visit
AskForGenerics.org.

Example: VESICARE - solefenacin

2

Drugs to Treat Multiple Conditions

Doctors use some drugs to treat more than one
medical condition. Within this document, each drug
is listed according to its first FDA-approved use.
Please check the index if you do not find your
medication in the therapeutic class that corresponds
to your condition.

COVERAGE AND LIMITATIONS

Tier Information
A drugs copayment tier indicates what you will
pay for the medication with each fill.

The majority of generics are Tier 1. These

are your least expensive prescription drugs.
Formulary brands listed in this document are
available at the lowest brand tier, unless
otherwise noted.
Specialty drugs in this list may have a
different copayment. For a complete listing
of specialty drugs, please refer to page 36.

Depending on your plan, you may have a threetier or a six-tier copayment structure. Refer to your
description of coverage documents for details. Your
pharmacy benefit includes coverage for the majority
of prescription drugs, though some exclusions may
apply.

Utilization Management
Some drugs on this list require utilization
management (UM), i.e. preauthorization, managed
dose limitations and step-therapy. If UM applies to
a drug, it is indicated with one of the following
symbols in the column next to the drug name.

MDL- Managed Dose Limitations

PA- Preauthorization
ST- Step-Therapy

Medical Exception (varies by plan design)

Medical exception is a process for reviewing
coverage for drugs not on our formulary. Members
may qualify for a medical exception if they meet
one of these:
A. Documented failure of all formulary drugs
within the same therapeutic class
B. Documented allergy to a formulary drug,
with no other formulary choices

C. Successfully maintained condition on a

specific drug where switching to an
alternative drug may cause a health risk:
o Antiarrhythmics
o Theophylline products
o Seizure medications
o Antipsychotics
o Antidepressants
PhysiciansRequesting a Medical
Exception
To request a Medical Exception for a
medication on behalf of a member, or to request
further information, please call the Health Alliance
Pharmacy department at 1-800-851-3379, option 4,
or fax the Preauthorization/Medical Exception form
to 217-255-4598. Please provide the following
information when requesting a Medical Exception:

Patient name and Health Alliance

identification number
Physician name, address and phone number
Drug name and strength
Patient diagnosis
Chart documentation/documentation of
previous medical history pertaining to the
requested drug

Contraceptive Coverage Under

Preventive Health Wellness Benefit
A female member age 1050 years old has
coverage of some FDA-approved contraceptives for
no out-of-pocket cost.
Free contraceptives are listed below:
Tier 1 oral contraceptives
Limit of three units on condoms (male or
female)
Limit of 2.7 units of spermicidal product
Only one Tier 1 prescription drug (like a generic
oral contraceptive) or one over-the-counter (OTC)
product (like male and female condoms or
spermicides) is covered per 30-day period for no
cost to the member.
Brand-name contraceptives that are Tier 2 or
higher are covered with the appropriate member
cost share/quantity restrictions according to the
members plan.
3

Emergency contraception is covered at Tier 1

using generic levonorgestrel/ethinyl estradiolcontaining products. Brand-name emergency
contraception is covered according to the members
plan.
Quantities above a 30-day supply, including
vacation overrides and commercially available
extended-cycle contraceptives (like Seasonale), are
subject to appropriate member cost-sharing
according to the members plan.

Rxtra

Health Alliance members with prescription

coverage can save money based on where they have
their 30-day-supply of prescriptions filled.
The Rxtra program is simple.

General Exclusions
A. Over-the-counter (OTC) medications and
their equivalents are not covered, unless
otherwise specified within the Formulary.
Nicotine smoking-cessation products (e.g.,
transdermal nicotine, nicotine gum, nicotine
inhaler) coverage is based on specific
member benefits.
B. Any drugs used for cosmetic purposes are
not covered.
C. Experimental drugs, or any drug product
used in an experimental manner, are not
covered.
D. Replacement of lost or stolen medication is
not covered.
E. Non-self-administered injectable drugs,
unless otherwise noted, are not covered
through the pharmacy benefit. Refer to your
description of coverage materials for details.
F. Foreign drugs and drugs not approved by the
FDA are not covered.

PreferredAt Preferred pharmacies,

members can get hundreds of common
prescriptions FREE.
Preferred PlusAt Preferred Plus
pharmacies, members have the same
benefits as the Preferred pharmacies
mentioned above. In addition, simvastatin,
pravastatin and Ventolin HFA are FREE.

For a list of participating pharmacies and

available drugs in the Rxtra program, visit the
pharmacy section of HealthAlliance.org.

Split the Pill, Split the Bill

For members willing to split their pills in half,
we offer a designated list of maintenance
medications for half the copayment.
For Example:

Benicar 20mg taken once daily for a 30 day

supply Tier 2 copayment
Benicar 40mg split in half to dose at 20mg
once daily of Tier 2 copayment

Members can receive a FREE pill splitter with a

prescription from their doctor.

PHARMACY SAVINGS PROGRAMS

Retail 90

Health Alliance offers members several

programs to lower the drug costs and to help
members take their medications safely and
correctly.

The Retail 90 program allows members to

purchase a 90-day supply of maintenance
medication at a discounted copayment from
participating retail pharmacies. Because this is a
voluntary program designed to increase flexibility,
members who prefer may continue purchasing the
traditional 30-day supply from their pharmacy with
their regular copayment.

Value-Based Benefit

Blood Glucose Monitors FREE By Mail

The value-based benefit is designed so that

member copayments are aligned with the value the
drug has for keeping members healthy.
Medications listed below are used to treat
common conditions like asthma, high cholesterol,
high blood pressure and diabetes and are available
to members at a lower cost than other similar
medications.

Members with diabetes are eligible to receive a

FREE blood glucose meter if they choose one of the
preferred meters listed below and obtain the meter
by mail. If a member picks up a blood glucose
meter at their local pharmacy, the members Tier 2
copayment will apply when obtained with a
prescription. Free meters are limited to one meter
per member per year. The FreeStyle InsuLinx
System is limited to one meter every three years.

Value-Based Benefit
Drug Class
Diabetes

Asthma
Hypertension
High
Cholesterol

Drug Name
All generics
Vials, pens and
cartridges for
Lilly insulin
All generics,
Ventolin HFA
QVAR
All generics
All generics

Formulary
Status
Tier 1
$20 copayment
Tier 1
$20 copayment
Tier 1
Tier 1

ACCU-CHEK
ACCU-CHEK Aviva System
ACCU-CHEK Nano System
ACCU-CHEK Compact Plus System
To get an ACCU-CHEK product, call
1-888-605-9872
Or visit meters.accu-chek.com
Freestyle Lite and Freestyle InsuLinx
FreeStyle Lite System
FreeStyle Freedom Lite System
FreeStyle InsuLinx System
To get an Abbott product, call
1-866-224-8892 and mention Health Alliance
Or visit www.myfreestyle.com/meterprogram
*InsuLinx systems are limited to one free product per
member every three years.

Not all benefit plans include each of the programs

listed above. Please refer to your description of
coverage documents for more detail or contact the
Pharmacy department at 1-800-851-3379, option 4.

CONTACT US
Health Alliance Pharmacy Department
301 S. Vine St.
Urbana, IL 61801-3347
1-800-851-3379, option 4
HealthAlliance.org

DRUG FORMULARY LIST

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

PA

Specialty

ANTI-INFECTIVE DRUGS
CEPHALOSPORINS
cefdinir (Omnicef)
cefpodoxime (Vantin)
cefprozil (Cefzil)
cefuroxime (Ceftin)

FLUOROQUINOLONES
ciprofloxacin (Cipro)
CIPRO SUSPENSIONciprofloxacin suspension
levofloxacin (Levaquin)

FUNGAL INFECTIONS
fluconazole (Diflucan)
flucytosine (Ancoban)
griseofulvin microsize (Fulvicin, Grisfulvin)
GRIFULVIN Vgriseofulvin
GRIS-PEGgriseofulvin
itraconazole (Sporanox)
ketoconazole tablets (Nizoral)
nystatin oral (Mycostatin)
terbinafine (Lamisil)
voriconazole (Vfend)

HEPATITIS
EPIVIR HBVlamivudine

MACROLIDES
azithromycin (Zithromax)
clarithromycin (Biaxin)
clarithromycin ER (Biaxin XL)
E.E.S. GRANULESerythromycin ethylsuccinate

OTHER ANTI-INFECTIVES
erythromycin/sulfisoxazole (Pediazole)
MEPRONatovaquone suspension
metronidazole (Flagyl)
sulfamethoxazole/trimethoprim (Bactrim)
trimethoprim
TINDAMAXtinidazole
6

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

PA
PA

Specialty
Specialty

vancomycin (Vancocin)

PENICILLINS
amoxicillin/potassium clavulanate (Augmentin)
amoxicillin/potassium clavulanate ER (Augmentin XR)
amoxicillin (Amoxil)
dicloxacillin (Dicloxacillin)
penicillin v potassium (Veetids)

TETRACYCLINES
VIBRAMYCIN SYRUPdoxycycline syrup
minocycline (Minocin)
doxycycline hyclate (Vibramycin)

TUBERCULOSIS
ethambutol (Myambutol)
isoniazid (Laniazid, Nydrazid)
isoniazid/rifampin (Rifamate)
MYCOBUTINrifabutin
pyrazinamide
rifampin (Rifadin)

VIRAL INFECTIONS
HEPATITIS C
PEGASYSpeginterferon alfa-2a
PEG INTRONpeginterferon-2a
HERPES
acyclovir (Zovirax)
famciclovir (Famvir)
valacyclovir (Valtrex)
HIV/AIDS
APTIVUStipranavir
ATRIPLAefavirenz-emtricitabine-tenofovir
CRIXIVANindinavir
didanosine DR (Videc EC)
EMTRIVAemtricitabine
EPZICOMabacavir-lamivudine
INVIRASEsaquinavir
ISENTRESSraltegravir
KALETRAlopinavir-ritonavir
lamivudine (Epivir)

UTILIZATION
MANAGEMENT

lamivudine/zidovudine (Combivir)
NORVIR SOLUTIONritonavir
stavudine (Zerit)
RESCRIPTORdelavirdine
REYATAZatazanavir
SELZENTRYmaraviroc
SUSTIVAefavirenz
TRIZIVIRabacavir sulfate-lamivudine-zidovudine
TRUVADAemtricitabine-tenofovir disoproxil fumarate
VIDEX PEDIATRICdidanosine solution
VIRAMUNEnevirapine
VIRAMUNE XRnevirapine
VIREADtenofovir
ZIAGENabacavir
zidovudine (Retrovir)

OTHER COVERAGE
NOTES

PA

MALARIA
atovaquone/proguanil 250-100 mg (Malarone)
chloroquine phosphate (Aralen)
COARTEMartemether-lumefantrine
hydroxychloroquine (Plaquenil)
mefloquine (Larium)
primaquine

AUTOIMMUNE INFLAMMATORY DISORDERS

ENBRELetanercept
HUMIRAadalimumab
REMICADEinfliximab

PA
PA
PA

Specialty
Specialty
Specialty

BLOOD MODIFYING DRUGS

anagrelide (Agrylin)
cilostazol (Pletal)
clopidogrel (Plavix)
COUMADINwarfarin sodium
cyanocobalamin injection
dipyridamole (Persantine)
DROXIAhydroxyurea
enoxaparin (Lovenox)
folic acid tablets
FRAGMINdalteparin sodium, injection
8

LOVENOXenoxaparin sodium, injection

LYSTEDAtranexamic acid
pentoxifylline ER (Trental)
PROMACTAeltrombopag
warfarin (Coumadin)

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

PA

Specialty

CANCER DRUGS
ALKERANmelphalan
anastrozole (Arimidex)
bicalutamide (Casodex)
CEENUlomustine
EMCYT estramustine
exemestane (Aromasin)
flutamide (Eulexin)
FARESTONtoremifene
HEXALEN altretamine
hydroxyurea (Hydrea)
letrozole (Femara)
leucovorin calcium tablets (Folinic acid)
LEUKERAN chlorambucil
LYSODRENmitotane
MATULANE procarbazine
megestrol (Megace)
mercaptopurine (Purinethol)
MESNEXmesna
methotrexate (Trexall)
MYLERANbusulfan
NILANDRONnilutamide
TABLOIDthioguanine
tamoxifen (Nolvadex)
TARGRETINbexarotene
TREXALLmethotrexate

CENTRAL NERVOUS SYSTEM

ANXIETY
amitriptyline (Elavil)
bupropion (Wellbutrin)
alprazolam (Xanax)
buspirone (Buspar)
9

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

diazepam (Valium)
hydroxyzine (Atarax, Vistaril)
lorazepam (Ativan)

DEPRESSION
bupropion ext-release (Wellbutrin SR, Wellbutrin XL)
citalopram (Celexa)
clomipramine (Anafranil)
desipramine (Norpramin)
doxepin (Sinequan)
escitalopram (Lexapro)
fluoxetine (Prozac)
imipramine hcl (Tofranil)
mirtazapine (Remeron, Remeron SolTab)
nortriptyline (Pamelor)
paroxetine hcl (Paxil)
paroxetine hcl ER (Paxil CR)
PAXILparoxetine HCL, oral suspension
phenelzine (Nardil)
sertraline (Zoloft)
tranylcypromine (Parnate)
trazodone (Desyrel)
venlafaxine (Effexor)
venlafaxine ER (Effexor XR)

MDL

MDL

HYPERACTIVITY/NARCOLEPSY
amphetamine/detroamphetamine (Adderall)
dextroamphetamine
dextroamphetamine ER (Dexedrine Spansule)
METADATE CDmethylphenidate HCL
METHYLINmethylphenidate HCL
methylphenidate ER capsules, tablets (Ritalin LA, Ritalin SR)
methylphenidate tablets (Ritalin)

OTHER CENTRAL NERVOUS SYSTEM DRUGS

ARICEPTdonepezil hydrochloride
bupropion ER (Zyban)
CHANTIXvarenicline tartrate
disulfiram (Antabuse)
donepezil (Aricept, Aricept ODT)
EMSAMselegiline

MDL

10

UTILIZATION
MANAGEMENT

EXELONrivastigmine
galantamine (Razadyne)
galantamine ER (Razadyne ER)
naltrexone (ReVia)
NAMENDAmemantine
NICOTROL INHALERnicotine inhaler system
NICOTROL NSnicotine, nasal spray
SARAFEMfluoxetine

OTHER COVERAGE
NOTES

MDL
MDL
ST

PSYCHOTIC AND BIPOLAR DISORDER

chlorpromazine (Thorazine)
clozapine (Clozaril)
EQUETROcarbamazepine
FAZACLOclozapine
fluphenazine (Prolixin)
haloperidol (Haldol)
LATUDAlurasidone
LITHOBIDlithium carbonate
lithium carbonate
lithium carbonate ER (Lithobid, Eskalith CR)
loxapine (Loxitane)
olanzapine (Zyprexa, Zyprexa Zydis)
perphenazine (Trilafon)
prochlorperazine (Compazine)
quetiapine (Seroquel)
risperidone (Risperdal, Risperdal-M tablets)
SEROQUEL XRquetiapine fumarate
thiothixene (Navane)
trifluoperazine (Stelazine)
ziprasidone (Geodon)

ST

Tier 3

ST

SLEEP AIDS
estazolam (Prosom)
phenobarbital
temazepam (Restoril)
zaleplon (Sonata)
zolpidem (Ambien)
zolpidem ER (Ambien CR)

11

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

GASTROINTESTINAL DRUGS
DIGESTIVE ENZYMES
CREONpancrelipase
ZENPEPpancrelipase

NAUSEA AND VOMITING

ANZEMETdolasetron desylate
EMENDaprepitant
granisetron (Kytril)
meclizine (Antivert)
ondansetron (Zofran, Zofran ODT)
SANCUSOgranisetron
trimethobenzamide (Tigan)

MDL

MDL

OTHER GASTROINTESTINAL DRUGS

5-AMINOSALICYLIC ACIDmesalamine powder
APRISOmesalamine
ASACOLmesalamine
balsalazide (Colazal)
CANASAmesalamine
DELZICOLmesalamine
DIPENTUMolsalazine sodium
diphenoxylate/atropine tablets (Lomotil)
lactulose (Enulose)
LIALDAmesalamine
mesalamine (Asacol)
mesalamine powder (5-aminosalicylic acid)
metoclopramide (Reglan)
PENTASAmesalamine
RELISTORmethylnaltrexone bromide, injection
ROWASAmesalamine
sulfasalazine (Azulfidine)
sulfasalazine DR (Azulfidine EN-Tabs)
ursodiol (Actigall, Urso 250, Urso Forte)

PA

ULCER/REFLUX
CARAFATE SUSPENSIONsucralfate
cimetidine (Tagamet)
dicyclomine (Bentyl)
12

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

famotidine (Pepcid)
glycopyrrolate (Robinul)
hyoscyamine (Anaspaz, Levsin/SL)
hyoscyamine ER (Levbid, Symax Duotab)
lansoprazole DR (Prevacid)
methscopolamine (Pamine, Pamine Forte)
misoprostol (Cytotec)
omeprazole DR (Prilosec)
pantoprazole DR (Protonix)
ranitidine (Zantac)
sucralfate tablets (Carafate)

GENITOURINARY DRUGS
alfuzosin (Uroxatral)
AVODARTdutasteride
CARDURA XL-doxazosin mesylate
finasteride (Proscar)
JALYNdutasteride-tamsulosin
tamsulosin (Flomax)

OTHER GENITOURINARY DRUGS

ORACITsodium citrate and citric acid
potassium citrate ER (Urocit-K)
potassium citrate/citric acid (Polycitra-K)
sodium citrate/citric acid (Shohls)
UROCIT-K 15potassium citrate

URINARY TRACT INFECTIONS

MACRODANTINnitrofurantoin macrocrystalline
nitrofurantoin (Furadantin)
nitrofurantoin macrocrystalline (Macrodantin)
nitrofurantoin monohydrate/macrocrystalline (Macrobid)

URINARY TRACT SPASMS

VESICARE solifenacin succinate
oxybutynin (Ditropan)
oxybutynin ER (Ditropan XL)

VAGINAL PRODUCTS
CLEOCINclindamycin phosphate
clindamycin vaginal cream (Cleocin)
ENDOMETRINprogesterone
13

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

ESTRACEestradiol
ESTRINGestradiol
metronidazole (MetroGel-Vaginal)
terconazole (Terazol)

HEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS
benazepril (Lotensin)
benazepril/hydrochlorothiazide (Lotensin HCT)
captopril (Capoten)
captopril/hydrochlorothiazide (Capozide)
enalapril (Vasotec)
enalapril/hydrochlorothiazide (Vaseretic)
fosinopril (Monopril)
fosinopril/hydrochlorothiazide (Monopril HCT)
lisinopril (Prinivil)
lisinopril/hydrochlorothiazide (Prinizide)
moexipril (Univasc)
moexipril/hydrochlorothiazide (Uniretic)
perindopril (Aceon)
quinapril (Accupril)
quinapril/hydrochlorothiazide (Accuretic)
ramipril (Altace)
trandolapril (Mavik)

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS

AZORamlodipine-olmesartan
BENICARolmesartan-hydrochlorothiazide
DIOVANvalsartan
DIOVAN HCTvalsartan-hydrochlorothiazide
EXFORGE-amlodipine-valsartan
EXFORGE HCTamlodipine-valsartan-hydrochlorothiazide
irbesartan (Avapro)
irbesartan/hydrochlorothiazide (Avalide)
losartan (Cozaar)
losartan/hydrochlorothiazide (Hyzaar)
TRIBENZORolmesartan-amlodipine-hydrochlorothiazide

BETA BLOCKERS AND COMBINATION AGENTS

acebutolol (Sectral)
14

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

atenolol (Tenormin)
atenolol/chlorthalidone (Tenoretic)
bisoprolol (Zebeta)
bisoprolol/hydrochlorothiazide (Ziac)
carvedilol (Coreg)
COREG CRcarvedilol
labetalol (Trandate)
metoprolol succinate ER (Toprol XL)
metoprolol tartrate (Lopressor)
nadolol (Corgard)
propranolol ER (Inderal LA)
propranolol tablets (Inderal)

CALCIUM CHANNEL BLOCKERS AND COMBINATIONS

amlodipine (Norvasc)
amlodipine/benazepril (Lotrel)
diltiazem ER (Cardizem CD, Cardizem LA, Dilacor XR, Tiazac)
diltiazem (Cardizem)
felodipine ER (Plendil)
nifedipine ER (Adalat CC, Procardia XL)
verapamil (Calan)
verapamil ER (Calan SR, Isoptin SR, Verelan, Verelan PM)

CHEST PAIN
DILATRATE SRisosorbide dinitrate CR
isosorbide dinitrate (Isordil)
isosorbide mononitrate (Monoket)
isosorbide mononitrate ER (Imdur)
ISORDIL TITRADOSEisosorbide dinitrate
NITRO-BIDnitroglycerin
NITRO-DURnitroglycerin patch
nitroglycerin (Nitro-Dur)
NITROMISTnitroglycerin lingual
NITROSTATnitroglycerin SL

CHOLESTEROL LOWERING
ADVICORniacin-lovastatin
atorvastatin (Lipitor)
cholestyramine (Questran, Questran Light)
colestipol (Colestid)
CRESTORrosuvastatin

ST

ST
15

UTILIZATION
MANAGEMENT

fenofibrate, micronized (Lofibra)

gemfibrozil (Lopid)
LOVAZAomega-3-acid ethyl esters
lovastatin (Mevacor)
NIASPANniacin tablet CR
pravastatin (Pravachol)
SIMCORniacin-simvastatin SR 24-hour
simvastatin (Zocor)
WELCHOLolesevelam

OTHER COVERAGE
NOTES

ST

ERECTILE DYSFUNCTION
CAVERJECTalprostadil for injection
CIALIStadalafil
EDEXalprostadil for injection kit
MUSEalprostadil urethral pellet

ST

Tier 3

FLUID RETENTION
acetazolamide (Diamox)
acetazolamide ER (Diamox Sequels)
amiloride (Midamor)
amiloride/hydrochlorothiazide (Moduretic)
bumetanide (Bumex)
chlorthalidone (Thalitone)
furosemide (Lasix)
hydrochlorothiazide (Microzide, Hydrodiuril)
indapamide (Lozol)
methazolamide (Neprazane)
metolazone (Zaroxolyn)
spironolactone (Aldactone)
spironolactone/hydrochlorothiazide (Aldactazide)
THALITONEchlorthalidone
torsemide (Demadex)

HEART RHYTHM
amiodarone (Cordarone, Pacerone)
clonidine (Catapres, Catapres-TTS)
disopyramide (Norpace)
flecainide (Tambocor)
MULTAQdronedarone
NORPACE CRdisopyramide
propafenone (Rythmol)
16

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

propafenone ER (Rythmol SR)

quinidine gluconate ER (Quinaglute)
quinidine sulfate (Quinidex)
sotalol (Betapace, Betapace AF)

OTHER RELATED DRUGS

digoxin (Lanoxin)
doxazosin (Cardura)
eplerenone (Inspra)
guanfacine (Tenex)
hydralazine (Apresolutionine)
LANOXINdigoxin
methyldopa (Aldomet)
minoxidil (Loniten)
prazosin (Minipress)
terazosin (Hytrin)

RENIN INHIBITORS AND COMBINATIONS

AMTURNIDEaliskiren-amlodipine-hydrochlorothiazide
TEKAMLOaliskiren-amlodipine
TEKTURNAaliskiren
TEKTURNA HCTaliskiren-hydrochlorothiazide

HORMONES, DIABETES, TEST SUPPLIES, AND RELATED DRUGS

BIRTH CONTROL
levonorgestrel (Plan B)
oral contraceptives - all generics

CORTICOSTEROIDS
budesonide ER (Entocort EC)
dexamethasone
DEXAMETHASONE INTENSOLdexamethasone
fludrocortisones (Florinef)
hydrocortisone (Cortef)
methylprednisolone (Medrol)
MILLIPRED prednisolone
PREDNISONE INTENSOLprednisone
prednisolone (Prelone)
prednisolone sodium phosphate (Orapred, Pediapred)
prednisone tablets
17

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

DIABETES
acarbose (Precose)
DUETACTpioglitazone -glimepiride
glimepiride (Amaryl)
glipizide (Glucotrol)
glipizide ER (Glucotrol XL)
GLUCAGENglucagon
GLUCAGON EMERGENCY KITglucagon
glyburide (Micronase)
glyburide micronized (Glynase)
glyburide/metformin (Glucovance)
JENTADUETOlinagliptin/metformin
metformin (Glucophage)
metformin ER (Glucophage XR, Fortamet)
nateglinide (Starlix)
pioglitazone (Actos)
pioglitazone-metformin (Actoplus met)
pioglitazone-metformin SR (Actoplus met XR)
TRADJENTAlinagliptin
VICTOZAliraglutide

PA

ST
ST
ST
ST
ST

DIABETES-INSULINS
BASAL INSULIN
LANTUSinsulin glargine
LANTUS SOLOSTARinsulin glargine
RAPID ACTING INSULIN
APIDRAinsulin glulisine
APIDRA SOLOSTARinsulin glulisine
HUMALOGinsulin lispro
SHORT ACTING INSULIN
HUMULINinsulin human nph, reg

MDL
MDL
MDL
MDL
MDL
MDL

DIABETESTESTING SUPPLIES
ACCU-CHEK NANO METER (Free by mail)
ACCU-CHEK AVIVA METER (Free by mail)
ACCU-CHEK COMPACT PLUS METER (Free by mail)
ACCU-CHEK COMPACT TEST STRIPS
ACCU-CHEK SMART VIEW TEST STRIPS
ACCU-CHEK AVIVA PLUS TESTS STRIPS
ACCU-CHEK COMFORT CURVE TEST STRIPS

MDL
MDL
MDL
MDL
MDL
MDL
MDL
18

UTILIZATION
MANAGEMENT

ACCU-CHEK ACTIVE TEST STRIPS

MDL

FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM

(Free by mail)
FREESTYLE FREEDOM LITE BLOOD GLUCOSE SYSTEM
(Free by mail)
FREESTYLE LITE TEST STRIPS
FREESTYLE INSULINX BLOOD GLUCOSE SYSTEM (Free by
mail)
FREESTYLE INSULINX TEST STRIPS
PRECISION XTRA BLOOD GLUCOSE SYSTEM (Free by mail)

MDL

OTHER COVERAGE
NOTES

MDL
MDL
MDL
MDL
MDL

ESTROGENS
ALORAestradiol
estradiol (Climara, Estrace)
estradiol/norethindrone acetate (Activella)
estropiopate (Ogen, Ortho-Est)
FEMHRT LOW DOSEnorethindrone acetate-ethinyl estradiol
MENESTesterified estrogens
MENOSTARestradiol
norethindrone acetate/ethinyl estradiol
VIVELLE-DOTestradiol

INFERTILITY
clomiphene (Clomid)
FOLLISTIM AQfollitropin

PA
PA

Specialty

PA

Specialty

MALE HORMONES
ANDROGELtestosterone gel
danazol (Danocrine)

OTHER HORMONES
alendronate tablets (Fosamax)
cabergoline (Dostinex)
calcitonin-salmon (Miacalcin)
calcitriol (Rocaltrol)
desmopressin (DDVAP)
etidronate (Didronal)
EVISTAraloxifene
ibandronate oral (Boniva)
propylthiouracil
RECLASTzoledronic acid
STIMATEdesmopressin

19

SYNARELnafarelin
TEV TROPINsomatropin

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

PA

Specialty

PROGESTINS
medroxyprogesterone acetate (Provera)
norethindrone acetate (Aygestin)
progesterone micronized (Prometrium)

THYROID REGULATION
ARMOUR THYROIDthyroid
levothyroxine (Synthroid, Levoxyl)
liothyronine (Cytomel)
methimazole (Tapazole)
SYNTHROIDlevothyroxine
THYROLARliotrix (T3-T4)

MISCELLANEOUS CATEGORIES (INCLUDES SUPPLIES AND DEVICES)

MISCELLANEOUS DRUGS
azathioprine (Imuran)
CELLCEPTmycophenolate mofetil
cyclosporine (Sandimmune)
cyclosporine modified capsules
mycophenolate mofetil (Cellcept)
NEORALcyclosporine modified
PROGRAFtacrolimus
RAPAMUNEsirolimust
SANDIMMUNEcyclosporine
sodium polystyrene sulfonate
tacrolimus (Prograf)

MULTIPLE SCLEROSIS
AVONEXinterferon beta-1a
BETASERONinterferon beta-1b
COPAXONEglaitamer

PA
PA
PA

Specialty
Specialty
Specialty

NEUROMUSCULAR DRUGS
MUSCLE RELAXANTS
baclofen (Lioresal)
chlorzoxazone (Parafon)
cyclobenzaprine (Flexeril, Fexmid)
20

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

dantrolene (Dantrium)
metaxalone (Skelaxin)
methocarbamol (Robaxin)
orphenadrine citrate ER (Norflex)
orphenadrine/aspirin/caffeine (Norgesic)
tizanidine (Zanaflex)

OTHER NEUROMUSCULAR DRUGS

MESTINONpyridostigmine bromide
MESTINON TIMESPANpyridostigmine bromide
POTABA potassium aminobenzoate
POTASSIUM P-AMINOBENZOATEpotassium aminobenzoate
powder
pyridostigmine (Mestinon)

PARKINSON'S DISEASE
amantadine (Symmetrel)
benztropine (Cogentin)
bromocriptine (Parlodel)
carbidopa/levodopa (Parcopa, Sinemet)
carbidopa/levodopa ER (Sinemet CR)
pramipexole (Mirapex)
REQUIP XLropinirole hydrochloride
ropinirole (Requip)
selegiline (Eldepryl)
trihexyphenidyl (Artane)

SEIZURES
BANZEL rufinamide
carbamazepine (Tegretol)
carbamazepine ER (Carbatrol, Tegretol-XR)
CARBATROLcarbamazepine
clonazepam (Klonopin)
DEPAKENEvalproic acid
DEPAKOTEdivalproex sodium
DEPAKOTE SPRINKLESdivalproex sodium
DILANTINphenytoin sodium extended
divalproex DR (Depakote Sprinkles, Depakote)
divalproex ER (Depakote ER)
ethosuximide (Zarontin)
FELBATOL felbamate
gabapentin (Neurontin)
21

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

GABITRILtiagabine HCL
KLONOPINclonazepam
LAMICTALlamotrigine
LAMICTAL XRlamotrigine
lamotrigine (Lamictal)
levetiracetam (Keppra)
MYSOLINEprimidone
NEURONTINgabapentin
oxcarbazepine (Trileptal)
phenytoin sodium ER (Dilantin, Phenytek)
phenytoin suspenion (Dilantin)
primidone (Mysolutionine)
TEGRETOLcarbamazepine
TEGRETOL-XRcarbamazepine
topiramate (Topamax Sprinkle, Topamax)
TOPAMAXtopiramate
valproic acide (Depakene)
ZARONTINethosuximide
ZONEGRANzonisamide
zonisamide (Zonegran)

PAIN-RELIEF DRUGS
GOUT
allopurinol (Zyloprim)
COLCRYS colchicine
probenecid (Benemid)
ULORIC--febuxostat

Tier 3

MIGRAINE HEADACHES
acetaminophen/isometheptene/dichloralphenazone (Midrin)
naratriptan (Amerge)
MIGRANALdihydroergotamine mesylate
sumatriptan injection, tablets (Imitrex)
TREXIMETsumatriptan-naproxen sodium

MDL
MDL
MDL

NARCOTIC DRUGS
acetaminophen/codeine (Tylenol w/Codeine)
buprenorphine (Subutex)
22

UTILIZATION
MANAGEMENT

butalbital/aspirin/caffeine/codeine (Fiorinal w/Codeine)

DILAUDID-5hydromorphone HCL
fentanyl oral lozenge (Actiq)
fentanyl patch (Duragesic)
hydrocodone/acetaminophen (Vicodin, Lorcet, Lortab, Norco)
hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen)
hydromorphone tablets (Dilaudid)
methadone solution
methadone tablets (Dolophine)
morphine sulfate ER (MS Contin)
OPANA ER (CRUSH RESISTANT) oxymorphone HCL
oxycodone (Roxicodone)
oxycodone/acetaminophen (Percocet, Tylox)
oxycodone/aspirin (Percodan)
tramadol (Ultram)
tramadol/acetaminophen (Ultracet)

OTHER COVERAGE
NOTES

PA
MDL

MDL

NON-NARCOTIC DRUGS
butalbital/acetaminophen (Sedapap)
butalbital/acetaminophen/caffeine (Esgic, Esgic Plus, Fioricet)
butalbital/aspirin/caffeine (Fiorinal)
PHRENILIN FORTEbutalbital-acetaminophen
salsalate (Disalcid)

RHEUMATOID AND OSTEOARTHRITIS

diclofenac potassium (Cataflam)
diclofenac sodium DR (Voltaren)
diclofenac sodium ER (Voltaren-XR)
etodolac (Lodine)
ibuprofen (Motrin)
indomethacin (Indocin)
ketoprofen (Oruvail)
leflunomide (Arava)
meloxicam (Mobic)
NALFONfenoprofen
naproxen (Naprosyn)
naproxen DR (EC-Naprosyn)
naproxen sodium (Anaprox)
oxaprozin (Daypro)
piroxicam (Feldene)
RIDAURAauranofin
23

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

sulindac (Clinoril)

RESPIRATORY AGENTS
ASTHMA/COPD
ADVAIRfluticasone-salmeterol
albuterol 0.63 mg/3 mL, 1.25 mg/3 ml (Accuneb)
albuterol inhaler solution, 0.0835, 0.5% (Ventolin)
albuterol syrup, tablets (Ventolin)
ATROVENT HFAipratropium bromide HFA
budesonide ER (Pulmicort Respules)
COMBIVENT RESPIMATipratropium-albuterol
cromolym sodium inhal solution (Intal)
ELIXOPHYLLINtheophylline
FLOVENTfluticasone propionate
FORADIL AEROLIZERformoterol fumarate
ipratropium inhalersolution (Atrovent, Aerovent)
ipratropium/albuterol (Duoneb)
MAXAIR AUTOHALERpirbuterol acetate
montelukast sodium (Singulair)
PULMICORT FLEXHALERbudesonide
QVARbeclomethasone dipropionate
SEREVENT DISKUSsalmeterol xinafoate
SPIRIVAtiotropium bromide
SPIRIVA HANDIHALERtiotropium
SYMBICORTbudesonide-formoterol
terbutaline (Brethine)
THEO-24theophylline
theophylline ER (Theo-Dur)
TUDORZA aclidinium bromide
VENTOLIN HFAalbuterol HFA
zafirlukast (Accolate)

MDL

MDL

BEE STING KITS

EPINEPHRINE
EPIPENepinephrine
EPIPEN-JR 2-PAKepinephrine

NASAL ANTIHISTAMINE
ASTEPROazelastine HCL nasal
azelastine (Astelin)
24

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

NASAL ANTI-INFLAMMATORY STEROIDS

fluticasone (Flonase)
triamcinolone (Nasacort AQ)

SUPPLEMENTS
VITAMINS
ergocalciferol (Drisdol)
GALZINzinc acetate
MEPHYTONphytonadione
NASCOBALcyanocobalamin

MINERALS AND ELECTROLYTES

potassium bicarbonate/chloride effervescent tablets
potassium chloride
potassium chloride ER
potassium phosphate/sodium phosphates (K-Phos Neutral)
sodium fluoride

MULTIVITAMINS
prenatal vitamin/folic acid - all generics

TOPICAL DRUGS
ANORECTAL AGENTS
ANALPRAM EHC-pramoxine
CORTIFOAMhydrocortisone acetate rectal foam
hydrocortisone acetate rectal cream, suppository
(Anusolution-HC, Proctocort)
hydrocortisone enema (Cortenema)

EAR
acetic acid ear solution
benzocaine/antipyrine ear solution
hydrocortisone/acetic acid ear solution
neomycin/polymyxin B/hydrocortisone ear solution,
suspension (Cortisporin)
ofloxacin ear solution (Floxin otic)

EYE
ANTI-INFECTIVE
bacitracin/polymyxin B eye ointment
ciprofloxacin eye solution (Ciloxan)
erythromycin eye ointment
25

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

gentamicin eye ointment, solution (Garamycin)

neomycin/polymyxin B/gramicidin eye solution (Neosporin)
neomycin/polymyxin/bacitracin eye ointment
ofloxacin eye solution (Ocuflox)
polymyxin B/trimethoprim eye solution (Polytrim)
sulfacetamide sodium eye solution (Bleph-10)
tobramycin eye solution (Tobrex)
trifluridine eye solution (Viroptic)
TOBREXtobramycin sulfate, ophthalmic ointment 0.3%
ZYMAXIDgatifloxacin
GLAUCOMA
BETOPTIC-Sbetaxolol HCL, ophthalmic suspension 0.25%
brimonidine eye solution, 0.15% (Alphagan P)
brimonidine eye solution, 0.2%
carteolol eye solution (Ocupress)
dorzolamide eye solution (Trusopt)
dorzolamide/timolol maleate eye solution (Cosopt)
lantanoprost eye solution (Xalatan)
levobunolol eye solution, 0.5% (Betagan)
LUMIGANbimatoprost, ophthalmic solution
metipranolol eye solution (Optipranolol)
pilocarpine eye solution, 1%, 2%, 4% (Isopto Carpine)
timolol maleate eye solution (Timoptic, Timoptic XE)
TIMOPTIC OCUDOSEtimolol maleate, ophthalmic solution
0.25%
TRAVATANtravopost
OTHER EYE PRODUCTS
ALOMIDElodoxamide tromethamine
ALPHAGAN Pbrimonidine tartrate
atropine sulfate eye ointment, solution (Isopto Atropine)
azelastine eye solution (Optivar)
cromolyn sodium eye solution (Opticrom)
CYCLOGYLcyclopentolate HCL
CYCLOMYDRILcyclopentolate wtih phenylephrine
cyclopentolate eye solution (Cyclogyl)
diclofenac eye solution (Voltaren)
flurbiprofen eye solution (Ocufen)
homatropine eye solution (Isopto Homatropine)
ISOPTO CARBACHOLcarbachol
ISOPTO HOMATROPINEhomatropine

Tier 3

26

UTILIZATION
MANAGEMENT

OTHER COVERAGE
NOTES

ketorolac eye solution (Acular, Acular LS)

LASTACAFTalcaftadine

Tier 3

PHOSPHOLINE IODIDEechothiophate iodide

PILOPINE HSpilocarpine HCL
tropicamide eye solution (Mydriacyl)
STEROIDS AND COMBINATION PRODUCTS
BLEPHAMIDE S.O.P. sulfacetamide sodium-prednisolone
dexamethasone sodium phosphate eye solution
FLAREXfluorometholone acetate
FML FORTEfluorometholone
fluorometholone eye suspension, 0.1% (FML Liquifilm)
neomycin/polymyxin B/bacitracin/hydrocortisone eye
ointment
neomycin/polymyxin B/dexamethasone eye ointment,
suspenion (Maxitrol)
PRED MILDprednisolone acetate
PRED-Ggentamicin-prednisolone
PRED-G S.O.P.gentamicin-prednisolone
prednisolone acetate eye suspenion (Pred Forte)
sulfacetamide sodium/prednisolone eye solution
TOBRADEXtobramycin-dexamethasone
TOBRADEX STtobramycin-dexamethasone
tobramycin/dexamethasone eye suspenion (Tobradex)
VEXOLrimexolone, ophthalmic suspension 1%

MOUTH AND THROATLOCAL

chlorhexidine oral rinse (Peridex)
clotrimazole troche (Mycelex Troche)
lidocaine viscous
nystatin suspension
pilocarpine (Salagen)
sodium fluoride (Prevident)
triamcinolone dental paste (Kenalog in Orabase)

SKIN CONDITIONS/PRODUCTS
ACNE
adapalene (Differin)
clindamycin (Cleocin-T)
erythromycin gel, pads, solution
metronidazole (Metrocream, Metrolotion)
27

UTILIZATION
MANAGEMENT

metronidazole topical gel (Metrogel)

sulfacetamide sodium/sulfur cloth, cream, emulsion, lotion
tretinoin (Retin-A)

OTHER COVERAGE
NOTES

PA

ANTI-INFECTIVES
ciclopirox gel, shampoo (Loprox)
ciclopirox solution (Penlac)
econazole (Spectazole)
ketoconazole (Nizoral)
mupirocin ointment (Bactroban)
nystatatin topical
silver sulfadiazine (Silvadene)
CORTICOSTEROIDS
alclometasone (Aclovate)
amcinonide cream (Cyclocort)
betamethasone dipropionate (Diprosone)
betamethasone dipropionate, augmented (Diprolene)
betamethasone valerate cream, lotion
clobetasol (Olux, Temovate)
desonide (Desowen)
desoximetasone cream, 0.25%; gel; ointment 0.25% (Topicort)
diflorasone ointment
fluocinolone acetonide oil (Derma-Smoothe/FS)
fluocinonide
fluticasone propionate (Cutivate)
halobetasol (Ultravate)
hydrcortisone valerate (Westcort)
hydrocortisone topical
mometasone (Elocon)
triamcinolone cream; lotion; ointment, 0.025%, 0.1%
OTHER SKIN PRODUCTS
8-MOPmethoxsalen, capsule 10 mg
aluminum chloride (Drysol)
calcipotriene solution (Dovonex)
fluorouracil (Efudex)
imiquimod (Aldara)
lidocaine topical (Xylocaine)
lindane
OXSORALEN ULTRAmethoxsalen
permethrin
podofilox (Condylox)
PROTOPICtacrolimus

28

UTILIZATION
MANAGEMENT

selenium sulfide (Selsun)

SORIATANEacitretin, capsule 10 mg
VOLTAREN GELdiclofenac

OTHER COVERAGE
NOTES

MDL
Tier 3

29

DRUGS WITH MANAGED

DOSE LIMITATIONS (MDL)
The table below contains the list of drugs with managed dose limitations. Certain products are
subject to managed drug limitations based on FDA-approved dosage recommendations and the
drug manufacturers package size. The pupose of these limitations is to encourage safe and costeective use of drug therapies. MDL quantities may vary depending on plan design.

Drug Class
ACNE
ASTHMA

BEHAVIORAL
HEALTH:
ADHD
BEHAVIORAL
HEALTH:
Depression

Drug Name
isotretinoin oral (Claravis and
Amnesteem)
Arcapta Neohaler
Asmanex
Flovent HFA
QVAR
Ventolin HFA
Quillivant XRTM

citalopram
Cymbalta, 30mg or 60mg
Cymbalta, 20mg
sertraline
ENDOCRINE:
blood glucose test strips
Diabetes
insulin vials
insulin pens
Januvia, JuvisyncTM, Janumet XR,
OnglyzaTM, KobmiglyzeTM XR,
Tradjenta
Janumet, Jentadueto
ENDOCRINE:
Caverject/Edex/Muse
Impotency
Cialis
Levitra
StaxynTM
Viagra
GASTROINTESTINAL: Emend
Emesis
Sancuso
HEMATOLOGICAL
Xarelto 10 mg
DISORDERS
INFECTIOUS
Incivek
DISEASE:
Victrelis
Hepatitis C
INFECTIOUS
Relenza
DISEASE:
Influenza
Tamiflu
LOWER GI
DISORDERS: Irritable
Bowel Syndrome

Amitiza
LinzessTM

30 caps
1 inhaler
24gm (2 inhalers)
2 inhalers
3 inhalers
180ml

90-Day Supply
(Mail Order)*
*maximum of 6
months of treatment
90 caps
3 inhalers
72gm (6 inhalers)
6 inhalers
9 inhalers
N/A

30 tablets
30 capsules
60 capsules
60 tablets
150 test strips
60ml (6 vials)
4 boxes
30 tablets

90 tablets
90 capsules
180 capsules
180 tablets
450 test strips
180ml (18 vials)
12 boxes
90 tablets

60 tablets
6 units
4 tablets1
4 tablets1
4 tablets1
4 tablets1
6 tablets
1 patch
35 tablets/6 months

180 tablets
18 units
12 tablets1
12 tablets1
12 tablets1
12 tablets1
18 tablets
3 patches
N/A

180 tablets
360 tablets

N/A
N/A

1 rx/6 months, max

quant 20 doses
1 rx/6 months, max
quant 10 caps
60 capsules
30 capsules

N/A

30-Day Supply
N/A

N/A
180 capsules
90 capsules

continued on next page

Drug Class
NEUROLOGY:
Migraine

NEUROLOGY:
Narcolepsy
PAIN
MANAGEMENT

SMOKING
CESSATION

Drug Name
Axert
Amerge (naratriptan)
Frova
Imitrex/Sumavel (sumatriptan) injectable
Imitrex (sumatriptan) - nasal

30-Day Supply
9 tablets
9 tablets
9 tablets
2 kits
(4 injections)
6 nasal spray devices

Imitrex (sumatriptan) - tablets

Maxalt, Maxalt-MLT
Migranal
Relpax
Treximet
Zomig
Nuvigil
Provigil
Avinza
Embeda
Exalgo
fentanyl patch
Kadian
Nucynta ER
Nucynta
Oxycontin
Toradol (ketorolac)
tramadol ER
Sprix (ketorolac) nasal spray
nicotine replacement therapy2
Zyban (bupropion)2

9 tablets
12 tablets
8 units
9 tablets
9 tablets
9 tablets
30 tablets
30 tablets
60 tablets
60 tablets
60 tablets
15 patches
60 tablets
60 tablets
120 tablets
60 tablets
20 tablets
60 tablets
5 nasal spray units
30 units
60 tablets

90-Day Supply
(Mail Order)*
27 tablets
27 tablets
27 tablets
6 kits
(12 injections)
18 nasal spray
devices
27 tablets
36 tablets
24 units
27 tablets
27 tablets
27 tablets
90 tablets
90 tablets
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
180 tabs/0 refill

Please Note: This applies to most Health Alliance plans. If you have questions, please
contact the Pharmacy Department at 1-800-851-3379, option 4.
1

Quantity may vary depending on plan setup

Iowa State = 6/12
Horizon = 6/12
Federal = 6/12

3 months per year for most plans

9 months per lifetime for most plans

ph-MDLdrugs-0613

DRUGS REQUIRING
PREAUTHORIZATION
The table below outlines the medications requiring a review by the Clinical Pharmacist, and
if necessary, a Health Alliance Medical Director. If a provider wished for coverage of a drug
designated as preauthorization required (PA), they must provide documentation to meet criteria
for that particular medication. Provider must request prior authorization from Health Alliance for
drugs on the following list:
Drug Class

Drug Name

Comments

ASTHMA

Advair (fluticasone-salmeterol)
500/50mcg only

Documentation of asthma diagnosis

BEHAVIORAL
HEALTH:
ADHD

Quillivant XR (methylphenidate
suspension)

Preauthorization required for age 13

years and older.

BEHAVIORAL
HEALTH:
Antidepressants

Pristiq (desvenlafaxine)
Viibryd (vilazodone)

See behavioral health policy;

Two SSRI and venlafaxine, or
venlafaxine SR and buproprion,
buproprion XL or buproprion SR

Cymbalta (duloxetine)

See Cymbalta policy

BEHAVIORAL
HEALTH:
Narcolepsy

Provigil (modafinil)
Nuvigil (armodafinil)

See Provigil and Nuvigil policy, only

medically necessary FDA label diagnosis
covered

CARDIOVASCULAR:
Lipotropics

Vytorin (simvastatin/ezetimibe)
Zetia (ezetimibe)

See Zetia and Vytorin policy;

LDL goal not met with maximum
tolerated statin OR intolerance/
contraindication to statins

DERMATOLOGY

tretinoin
Finacea (azelaic acid)
Picato (ingenol mebutate)
Tazorac (tazarotene)
Aczone (dapsone)

Documentation of a non-cosmetic
diagnosis (acne, actinic keratosis, ect).
Trial of a Tier 1 agent.

DIABETES:
DPP4 Inhibitors

Januvia (sitagliptin)
Janumet (sitagliptin-metformin)
Janumet XR (sitagliptin-metformin ER)
Juvisync (sitagliptin-simvastatin)
Onglyza (saxagliptin)
Kombiglyze (saxagliptin-metformin)
Kombiglyze XR (saxagliptin-metformin
ER)

See diabetes drug therapy policy;

Type 2 DM; metformin or a sulfonylurea;
HBA1c greater than 6.5% and less than
9%; trial of Tradjenta required on new
starts and existing members not at goal
on non-preferred DPP4

DIABETES:
GLP1

Byetta (exenatide)
Bydureon (exenatide ER)

See diabetes drug therapy policy;

Type 2 DM; metformin or a sulfonylurea;
HBA1c greater than 6.5% and less than
9%; trial of Victoza on new starts and
existing members not at goal on current
non-preferred GLP1

DIABETES, MISC.

Becaplermin (Regranex)

Diagnosis of diabetic ulcers with failure

on conventional (dressings, soaks,
debridement, etc.).
continued on next page

Drug Class

Drug Name

Comments

INFECTIOUS
DISEASE:
Antibacterial, Misc

Xifaxan 550mg (rifaximin)

See separate policy on Xifaxan550 in

hepatic encephalopathy

INFLAMMATORY
DISEASE:
NSAIDs

Celebrex (celecoxib)

See COX-2 inhibitor policy, age greater

than 65 exempt. Trial of three NSAID
classes or a qualifying risk factor (see
policy)

LOWER GI
DISORDERS:
Irritable Bowel
Syndrome

Amitiza (lubiprostone)
Linzess (linaclotide)
Lotronex (alosetron)

See Amitiza and Linzess for chronic

constipation policy; 12 week initial
therapy

LOWER GI
DISORDERS:
Narcotic antagonists

Relistor (methylnaltrexone)

See Relistor policy for opioid induced

constipation

NASAL AGENTS

Dymista (azelastine/fluticasone)

See Dymista policy

NEUROLOGICAL
DISEASE: GABA
analogs

Lyrica (Pregabalin)
Gratise (Gabapentin ER)
Horizant (Gabapentin ER)

See Gabapentin Coverage Requirement

Policy; FDA label diagnosis specific to
product, and trial of Gabapentin

NEUROLOGICAL
DISEASE: Botulinum
toxins

Botox (onabotulinumtoxinA)
Xeomin (incoboluminumtoxinA)
Myobloc (rimabotulinumtoxinB)

Medical benefit see botulinum toxins

policy

NEUROLOGICAL
DISEASE:
Fibromyalgia agents

Savella (milnacipran)

Trial of TCA, muscle relaxant,

gabapentin and non-pharmacologic
therapy

PAIN
MANAGEMENT:
Analgesics, Narcotics

Actiq (fentanyl citrate)

Fentora (fentanyl citrate)
Onsolis (fentalyl buccal film)
Abstral (fentanyl sublingual tablet)
Subsys (fentanyl sublingual spray)

See Fentanyl oral dosage formulation

policy; limited to cancer diagnosis and
inability to swallow and concurrent long
acting agent requiring breakthrough
agent

Butrans (buprenorphine)

See Butrans policy

UPPER GI
Aciphex (rabeprazole);
Dexilant (dexlansoprazole);
DISORDERS;
Anti-ulcer preparations Nexium (esomeprazole);
Zegerid (omeprazole/sod bicarb)

See PPI policy; trial of three generic PPI

(at least 14 day in duration) in addition
to qualifying diagnosis

Note: This is an incomplete list. Products with one year or less from the date of product launch
are excluded from coverage.
Please Note: This applies to most Health Alliance plans. If you have questions,
please contact the Pharmacy Department at 1-800-851-3379, option 4.

ph-preauthdrugs-0613

DRUGS REQUIRING
STEP-THERAPY
Step-Therapy (ST)
If a drug is covered as a step-therapy medication, one or more prerequisite medications must
be tried rst before the step-therapy medication will be covered under the pharmacy benet.
Prerequisite medications and their corresponding step-therapy medications are used to treat the
same conditions. If it is medically necessary, a step-therapy medication can be obtained without
trying a prerequisite medication rst. In this case, the members physician must request coverage
for a step-therapy medication as a medical exception.

Drug Class

Step-Therapy (ST)
Medication

ASTHMA
Bronchodilating

ProAir HFA (albuterol)

Proventil HFA (albuterol)

Ventolin HFA

BEHAVIORAL HEALTH
Anti-anxiety

Niravam (alprazolam)

alprazolam

BEHAVIORAL HEALTH
Atypical antipsychotic

Symbyax
(olanzapine and fluoxetine)

olanzapine and fluoxetine

Abilify (aripiprazole)
Invega (paliperidone)
Seroquel XR (quetiapine)
Fanapt (iloperidone)
Latuda (lurasidone)
Saphris (asenapine)

risperidone, olanzapine,
quetiapine or ziprasidone

BEHAVIORAL HEALTH
Antidepressants NDRI

Aplenzin (bupropion)

bupropion

BEHAVIORAL HEALTH
Antidepressants SARI

Oleptro (trazodone)

trazodone

BEHAVIORAL HEALTH
Opioid dependence

Suboxone Film (buprenorphine

and naloxone)

generic buprenorphine/naloxone
tablets

CARDIOVASCULAR
Statins

Advicor (lovastatin/niacin)
Altoprev (lovastatin ER)
Crestor (rosuvastatin)
Caduet (atorvastatin/
amlodipine)
Livalo (pitavastatin)
Lescol XL (fluvastatin)

atorvastatin

COPD (Chronic Obstructive

Pulmonary Disease)

Daliresp (roflumilast)

ICS (inhaled corticosteroid) or

ICS combo, Asmanex, Flovent,
QVar, Aerobid, Aerobid-M,
Alvesco, Azmacort, Pulmicort,
Advair, Symbicort or Dulera

DERMATOLOGY
Topical anti-infective

Denavir (penciclovir)

acyclovir

Prerequisite Medication

All brand name topical anti-fungal Tier 1 generic topical antifungal

DERMATOLOGY
Local anesthetic

Lidoderm (lidocaine)

gabapentin

DERMATOLOGY
Topical anti-inflammatory

Flector patch (diclofenac)

Pennsaid (diclofenac)

Voltaren gel

continued on next page

Drug Class

Step-Therapy (ST)
Medication

Prerequisite Medication

DIABETES
TZDs (Thiazolidinedione)

Actos (pioglitazone)
Actoplus Met
Actoplus Met XR
Duetact
Avandia (rosiglitazone)
Avandaryl
Avandamet

metformin or a sulfonylurea
(glimepiride, chlorpropamide,
glipizide, glyburide, tolbutamide,
tolazamide)

DIABETES
DPP4 (Dipeptidyl/Peptidase IV)

Tradjenta (linagliptin)
Jentadueto (linagliptin/
metformin)

metformin or a sulfonylurea

DIABETES
GLP-1 (Glucagon-like peptide-1)

Victoza (liraglutide)

metformin or a sulfonylurea

ENDOCRINE
Bone

Actonel (risedronate)
Atelvia (risedronate)
Binosto (alendronate)

alendronate or ibandronate

ENDOCRINE
Testosterone replacement

Androderm (testosterone
transdermal)
Axiron (testosterone topical)
Fortesta (testosterone gel)
Testim (testosterone gel)
Striant (testosterone buccal)

Androgel (testosterone gel)

HEMATOLOGICAL DISORDER
Anti-Platelet

Brilinta (ticagrelor)
Effient (prasugrel)

New start prescriptions are

restricted to cardiologists

Plavix (clopidogrel)

clopidogrel

HEMATOLOGICAL DISORDER
Thrombin Inhibitors

Eliquis (apixaban)
Pradaxa (dabigatran)
Xarelto (rivaroxaban)

warfarin

HYPERPARATHYROID AGENT

Zemplar (paricalcitol)

calcitriol or Vitamin D

INFECTIOUS DISEASE
Antibiotic

Dificid (fidaxomicin)

metronidazole or vancomycin

INFLAMMATORY DISEASE

Vimovo (esomeprazole/
naproxen)

naproxen and Nexium

PAIN MANAGEMENT
Long Acting Opioid

Avinza (morphine ER)

Embeda (morphine-naltrexone)
Exalgo (hydromorphone ER)
Kadian (morphine ER)
Nucynta ER (tapentadol ER)
Oxycontin (oxycodone)

morphine sulfate ER, fentanyl

and Opana ER

PAIN MANAGEMENT
Short Acting Opioid

Nucynta (tapentadol)

Tier 1 opioid

Ryzolt (tramadol)
tramadol ER

tramadol IR

SEDATIVE-HYPNOTICS

Lunesta (eszopiclone)
ZolpiMist (zolpidem)
Silenor (doxepin)

zolpidem/zolpidem ER and
zaleplon

SKELETAL MUSCLE DISORDER

Fexmid (cyclobenzaprine)

URINARY TRACT
Cialis (tadalafil) once daily
BPH (Benign Prostatic Hypertrophy)

ph-stdruglistMEMB-0413

cyclobenzaprine
tamsulosin, alfuzosin, Rapaflo,
finasteride, Avodart or Jalyn
(dutasteride/tamsulosin)

SPECIALTY DRUG LIST

Specialty medications are usually prescribed for complex, ongoing conditions. To be eective, they often
have special instructions or need to be administered by a health care professional. The medications Health
Alliance classies as specialty are listed below.
Age-Related Macular Edema
Eylea (M)*
Lucentis (M)*
Macugen (M)*
Visudyne (M)*
Antiemetic Intravenous
Aloxi (M)
Anzemet (M)
Emend (M)
granisetron (M)
Kytril (M)
Autoimmune Inammatory Disorders
Actemra (M)*
Amevive (M)*
Arcalyst (M)*
Benlysta (M)*(NF)
Cimzia*
Enbrel*
Humira*
Ilaris (M)*
Kineret*
Orencia (M)*
Orencia Sub Q*
Remicade (M)*
Simponi*
Stelara* (M)
Blood Modiers
Aranesp*
Epogen*
Leukine*
Neulasta*
Neumega*
Neupogen*
Nplate (M)*
Procrit*
Promacta*
Bone Resorption
Aredia (M)*
Boniva IV (M)*
Forteo*
Prolia (M)*
Xgeva (M)*
zoledronic acid (M)*
Clotting Disorders
Advate (M)*
Alphanate/VWF (M)*
Alphanine SD (M)*
Bebulin VH (M)*
BeneFIX (M)*
Feiba NF (M)*
Feiba VH (M)*
Helixate FS (M)*
Hemofil M (M)*
Humate-P (M)*
Koate-DVI (M)*

Kogenate FS (M)*
Monoclate-P (M)*
Mononine (M)*
NovoSeven RT (M)*
Profilnine SD (M)*
Recombinate (M)*
Wilate (M)*
Xyntha (M)*
Cystic Fibrosis
Cayston*
Kalydeco*
Pulmozyme*
TOBI*
Enzyme Deciencies
Aldurazyme (M)*
Carbaglu* (NF)
Ceredase (M)*(NF)
Cerezyme (M)*(NF)
Cinryze (M)*(NF)
Elaprase (M)*(NF)
Fabrazyme (M)*(NF)
Kuvan* (NF)
Lumizyme (M)*(NF)
Myozyme (M)*(NF)
Naglazyme (M)*(NF)
Orfadin* (NF)
Sucraid* (NF)
Vpriv (M)*(NF)
Zavesca*(NF)
Growth Hormone
Genotropin*
Humatrope*
Increlex*
Norditropin*
Nutropin AQ*
Omnitrope*
Protropin*
Saizen*
Serostim*
Tev-Tropin*
Zorbtive*
Hepatitis C
Copegus*
Incivek*
Infergen*
Pegasys*
Peg-Intron*
Rebetrol*
Rebetron*
Ribapak*
Ribasphere*
RibaTab*
ribavirin*
Roferon-A*
Sylatron injection (M)
Victrelis*

Hereditary Angioedema
Berinert (M)*(NF)
Kalbitor (M)*(NF)
Firazyr*(NF)
HIV
Atripla
Complera
Fuzeon
Selzentry
Stribild
Trizivir
Truvada
HIV Lipodystrophy
Egrifta* (NF)
Immune Globulin
Carimune NF (M)*
CytoGam (M)*
Flebogamma DIF (M)*
Gamastan S/D (M)*
Gammagard (M)*
Gammaplex (M)*
Gamunex (M)*
Gamunex-C (M)*
Hizentra*
Hyperrho S/D (M)*
Nabi-HB (M)*
Octagam (M)*
Privigen (M)*
RhoGAM Plus (M)
Rhophylac (M)
WinRho SDF (M)
Infertility
Bravelle*
Cetrotide*
chorionic gonadotropin*
Delestrogen*
Follistim AQ*
ganirelix*
Gonal-F*
Lupron subQ*
Luveris*
Menopur*
Novarel*
Ovidrel*
Pregnyl*
progesterone in oil*
Repronex*

Key
(M) Medical Benet
* Requires Preauthorization
Bolded items are preferred agents
(NF) Non-Formulary drugs

Lung Disorders
Actimmune*
Aralast (M)*(NF)
Aralast NP (M)*(NF)
Glassia (M)*(NF)
Prolastin C (M)*(NF)
Synagis (M)*
Xolair (M)*
Zemaira (M)*(NF)
Multiple Sclerosis
Ampyra* (NF)
Avonex*
Betaseron*
Copaxone*
Extavia*
Gilenya*
Rebif*
Tysabri (M)*
Oncology
Abraxane (M)
Adcetris (M)
Adriamycin (M)
Adrucil (M)
Afinitor*
Alferon N (M)*
Alimta (M)
Alkeran (M)
Ara-C (M)
Arranon (M)
Arzerra (M)
Avastin (M)*
Bexxar (M)
BiCNU (M)
Blenoxane (M)
Busulfex (M)
calcium folinate (M)
Campath (M)
Camptosar (M)
CARBOplatin (M)
Cerubidine (M)
cisplatin (M)
Clolar (M)
Cosmegen (M)
Cytoxan (M)
Dacogen (M)
Daunoxome (M)
DepoCyt (M)
Doxil (M)
DTIC-Dome (M)
Efudex (M)
Eligard (M)*
Elitek (M)*
Ellence (M)
Eloxatin (M)
Elspar (M)
Erbitux (M)*
Erivedge*
Erwinaze (M)
Etopophos (M)
Faslodex (M)
Firmagon (M)
Fludara injectable (M)
Fludara oral*
Folotyn (M)
FUDR (M)
Fusilev (M)
Gemzar (M)
Gleevec*
ph-memspeclist-0713

Halaven (M)
Herceptin (M)*
Hycamtin (M)
Idamycin PFS (M)
Ifex (M)
Inlyta*
Intron A (M)
Istodax (M)
Ixempra (M)
Jakafi*
Jevtana (M)
Kepivance (M)
Leustatin (M)
Mekinist* (NF)
methotrexate (M)
Mitomycin (M)
Mozobil (M)*
Mustargen (M)
Mylotarg (M)
Navelbine (M)
Nexavar*
Nipent (M)
Oncaspar (M)
Ontak (M)
Onxol (M)
Orthoclone OKT 3 (M)
Paraplatin (M)
Perjeta (M)*
Platinol-AQ (M)
Proleukin (M)
Provenge (M)*(NF)
Revlimid*
Rituxan (M)*
Sprycel*
Sutent*
Tafinlar* (NF)
Tarceva*
Targretin*
Tasigna*
Taxol (M)
Taxotere (M)
Temodar*
Tespa (M)
Thalomid*
Thioplex (M)
Torisel (M)
Treanda (M)
Trelstar Depot (M)*
Trisenox (M)
Tykerb*
Valstar (M)
Vectibix (M)*
Velban (M)
Velcade (M)
VePesid (M)
Vidaza (M)
Vincasar (M)
Votrient*
Vumon (M)
Xalkori*
Xeloda*
Yervoy (M)
Zanosar (M)
Zelboraf*
Zevalin (M)
Zoladex (M)*
Zolinza*
Zostress*
Zytiga*

Oncology Adjuvant
amifostine (M)
Duraclon (M)
Ethyol (M)
Ganite (M)
Kepivance (M)
pamidronate (M)
Other
Acthar HP*(NF)
Adagen (M)*
Apokyn*
chenodiol*
Exjade*
Ferriprox*
Jetrea (M)*(NF)
Korlym*
Krystexxa (M)*
Lupron Depot (M)*
Novantrone (M)
octreotide*
Procysbi* (NF)
Rilutek
Sabril*
Samsca*
Sandostatin*
Sandostatin LAR depot (M)*
Sensipar*
Sirturo* (NF)
Soliris (M)*
Somatuline Depot (M)*
Somavert* (NF)
Supprelin LA (M)*(NF)
Vantas (M)
Vivitrol (M)
voriconazole*
Xenazine* (NF)
Xiaflex (M)*(NF)
Xyrem* (NF)
Pregnancy Support
Makena* (NF)
Pulmonary Hypertension
Adcirca*
epoprostenol sodium (M)*
Flolan (M)*
Letairis*
Remodulin (M)*
sildenafil*
Tracleer*
Tyvaso*
Veletri (M)*
Ventavis*
Viscosupplementation
Euflexxa (M)
Hyalgan (M)
OrthoVisc (M)
Supartz (M)
Synvisc (M)
Synvisc One (NF)

Please contact CVS Caremark at

1-800-237-2767 or the Health Alliance
Pharmacy department at 1-800-851-3379,
option 4 for more information.

INDEX
#
5-AMINOSALICYLIC ACID .........................................................12
8-MOP .............................................................................................28

A
acarbose (Precose) .......................................................................18
ACCU-CHEK ACTIVE TEST STRIPS ........................................19
ACCU-CHEK AVIVA METER .......................................................18
ACCU-CHEK AVIVA PLUS TESTS STRIPS .............................18
ACCU-CHEK COMFORT CURVE TEST STRIPS ....................18
ACCU-CHEK COMPACT PLUS METER ...................................18
ACCU-CHEK COMPACT TEST STRIPS ...................................18
ACCU-CHEK NANO METER .......................................................18
ACCU-CHEK SMART VIEW TEST STRIPS ..............................18
acebutolol (Sectral) ........................................................................14
acetaminophen (Ultracet) ............................................................23
acetaminophen/codeine ................................................................22
acetaminophen/isometheptene/dichloralphenazone (Midrin) .22
acetazolamide (Diamox) ...............................................................16
acetazolamide ER (Diamox Sequels) .........................................16
acetic acid ear solution..................................................................25
acyclovir (Zovirax)...........................................................................7
ADVAIR...........................................................................................24
ADVICOR........................................................................................15
ainocycline (Minocin) .......................................................................7
albuterol...........................................................................................24
albuterol inhaler solution ...............................................................24
albuterol syrup, tablets ..................................................................24
alclometasone (Aclovate) .............................................................28
alendronate tablets (Fosamax) ....................................................19
alfuzosin (Uroxatral) .....................................................................13
ALKERAN ........................................................................................9
allopurinol (Zyloprim) .....................................................................22
ALOMIDE........................................................................................26
ALORA ............................................................................................19
ALPHAGAN P ................................................................................26
alprazolam (Xanax)..........................................................................9
amantadine (Symmetrel)...............................................................21
amiloride (Midamor).......................................................................16
amiloride/hydrochlorothiazide (Moduretic) ................................16
amiodarone (Cordarone, Pacerone) .........................................16
amitriptyline .......................................................................................9
amlodipine (Norvasc) ....................................................................15
amlodipine/benazepril (Lotrel) ......................................................15
amoxicillin (Amoxil).........................................................................7
amoxicillin/potassium clavulanate (Augmentin) ...........................7
amoxicillin/potassium clavulanate ER (Augmentin XR)..............7
amphetamine/detroamphetamine (Adderall)..............................10
AMTURNIDE ..................................................................................17

anagrelide (Agrylin) ......................................................................... 8

ANALPRAM E ............................................................................... 25
anastrozole (Arimidex) .................................................................... 9
ANDROGEL ................................................................................... 19
ANZEMET ...................................................................................... 12
APIDRA .......................................................................................... 18
APIDRA SOLOSTAR ................................................................... 18
APRISO .......................................................................................... 12
APTIVUS .......................................................................................... 7
ARICEPT ........................................................................................ 10
ARMOUR THYROID ..................................................................... 20
ASACOL ......................................................................................... 12
ASTEPRO ...................................................................................... 24
atenolol (Tenormin) ....................................................................... 15
atenolol/chlorthalidone (Tenoretic) .............................................. 15
atorvastatin (Lipitor)....................................................................... 15
atovaquone/proguanil 250-100 mg (Malarone) .......................... 8
ATRIPLA .......................................................................................... 7
atropine sulfate eye ointment, solution (Isopto Atropine)......... 26
ATROVENT HFA .......................................................................... 24
AVODART ...................................................................................... 13
AVONEX ......................................................................................... 20
azathioprine (Imuran) .................................................................... 20
azelastine (Astelin) ....................................................................... 24
azelastine eye solution (Optivar) ................................................. 26
azithromycin (Zithromax) ............................................................ 6
AZOR .............................................................................................. 14

B
baclofen (Lioresal) ......................................................................... 20
balsalazide (Colazal) ..................................................................... 12
BANZEL ......................................................................................... 21
benazepril (Lotensin)..................................................................... 14
benazepril/hydrochlorothiazide (Lotensin HCT) ........................ 14
BENICAR ....................................................................................... 14
benztropine (Cogentin) ................................................................. 21
betamethasone dipropionate (Diprosone).................................. 28
betamethasone dipropionate, augmented (Diprolene) ............. 28
betamethasone valerate cream, lotion ....................................... 28
BETASERON ................................................................................. 20
BETOPTIC-S.................................................................................. 26
bicalutamide (Casodex) .................................................................. 9
bisoprolol (Zebeta)......................................................................... 15
bisoprolol/hydrochlorothiazide (Ziac) .......................................... 15
BLEPHAMIDE S.O.P.................................................................... 27
brimonidine eye solution, 0.2%.................................................... 26
bromocriptine (Parlodel) ............................................................... 21
budesonide ER (Entocort EC) ..................................................... 17
budesonide ER (Pulmicort Respules) ......................................... 24
bumetanide (Bumex) ..................................................................... 16

38

buprenorphine (Subutex) ..............................................................22

bupropion (Wellbutrin) ...................................................................9
bupropion ER (Zyban) ..................................................................10
bupropion ext-release (Wellbutrin SR, Wellbutrin XL) ..........10
buspar (Valium) ..............................................................................10
buspirone (Buspar) ..........................................................................9
butalbital/acetaminophen ..............................................................23
butalbital/acetaminophen/caffeine (Esgic, Esgic Plus,
Fioricet) .....................................................................................23
butalbital/aspirin/caffeine (Fiorinal)..............................................23
butalbital/aspirin/caffeine/codeine ...............................................23

C
cabergoline (Dostinex) ..................................................................19
calcipotriene solution (Dovonex) ..................................................28
calcitonin-salmon (Miacalcin) .......................................................19
calcitriol (Rocaltrol) ........................................................................19
CANASA .........................................................................................12
captopril (Capoten) ........................................................................14
captopril/hydrochlorothiazide (Capozide) ...................................14
CARAFATE SUSPENSION .........................................................12
carbamazepine (Tegretol).............................................................21
carbamazepine ER (Carbatrol, Tegretol-XR) .............................21
CARBATROL .................................................................................21
carbidopa/levodopa (Parcopa, Sinemet) ....................................21
carbidopa/levodopa ER (Sinemet CR) ........................................21
CARDURA XL ................................................................................13
carteolol eye solution (Ocupress) ................................................26
carvedilol (Coreg)...........................................................................15
CAVERJECT ..................................................................................16
CEENU ..............................................................................................9
cefdinir (Omnicef) ..........................................................................6
cefpodoxime (Vantin)....................................................................6
cefprozil (Cefzil) .............................................................................6
cefuroxime (Ceftin) ........................................................................6
CELLCEPT .....................................................................................20
CHANTIX ........................................................................................10
chlorhexidine oral rinse (Peridex) ................................................27
chloroquine phosphate (Aralen) ....................................................8
chlorpromazine (Thorazaine) .......................................................11
chlorthalidone 25 mg, 50 mg (Thalitone) ....................................16
chlorzoxazone (Parafon) ..............................................................20
cholestyramine (Questran, Questran Light) ...............................15
CIALIS .............................................................................................16
ciclopirox gel, shampoo (Loprox) .................................................28
cilostazol (Pletal) ..............................................................................8
cimetidine (cimetidine) ..................................................................12
CIPRO SUSPENSION ....................................................................6
ciprofloxacin (Cipro) .....................................................................6
citalopram (Celexa)........................................................................10
clarithromycin (Biaxin) .................................................................6
clarithromycin ER (Biaxin XL) ....................................................6
CLEOCIN ........................................................................................13

clindamycin vaginal cream (Cleocin) .......................................... 13

clobetasolution (Olux, Temovate) ............................................... 28
clomiphene (Clomid) ..................................................................... 19
clomipramine (Anafranil)............................................................... 10
clonazepam (Klonopin) ................................................................. 21
clonidine (Catapres, Catapres-TTS) ........................................... 16
clopidogrel (Plavix) .......................................................................... 8
clozapine (Clozaril) ........................................................................ 11
COARTEM ....................................................................................... 8
COLCRYS ...................................................................................... 22
colestipol (Colestid) ....................................................................... 15
COMBIVENT .................................................................................. 24
COPAXONE ................................................................................... 20
COREG CRcarvedilol .............................................................. 15
CORTIFOAM.................................................................................. 25
COUMADIN ...................................................................................... 8
CREON ........................................................................................... 12
CRESTOR ...................................................................................... 15
CRIXIVAN......................................................................................... 7
cromolym sodium inhal solution (Intal) ....................................... 24
cyanocobalmin injection.................................................................. 8
cyclobenzaprine (Flexeril, Fexmid) ........................................... 20
CYCLOGYL ................................................................................... 26
CYCLOMYDRIL ............................................................................ 26
cyclopentolate eye solution (Cyclogyl) ....................................... 26
cyclosporine (Sandimmune) ........................................................ 20
cyclosporine modified capsules ................................................... 20

D
danazol (Danocrine) ...................................................................... 19
dantrolene (Dantrium) ................................................................... 21
DELZICOL ...................................................................................... 12
DEPAKENE ................................................................................... 21
DEPAKOTE ................................................................................... 21
DEPAKOTE SPRINKLES ............................................................ 21
desipramine (Norpramin) .............................................................. 10
desmopressin (DDVAP)................................................................ 19
desonide (Desowen) ..................................................................... 28
desoximetasone cream, 0.25%; gel; ointment 0.25% (Topicort)
.................................................................................................... 28
DEXAMETHASONE INTENSOL ................................................ 17
dextroamphetamine....................................................................... 10
dextroamphetamine ER (Dexedrine Spansule) ......................... 10
diclofenac eye solution (Voltaren) ............................................... 26
diclofenac potassium..................................................................... 23
diclofenac sodium DR (Voltaren) ............................................... 23
diclofenac sodium ER ................................................................... 23
dicloxacillin (Dicloxacillin)............................................................. 7
dicyclomine (Bentyl) ...................................................................... 12
didanosine DR (Videc EC) ............................................................. 7
diflorasone ointment ...................................................................... 28
digoxin (Lanoxin) ........................................................................... 17
DILANTIN ....................................................................................... 21

39

DILATRATE SR .............................................................................15
DILAUDID-5 ...................................................................................23
diltiazem ER....................................................................................15
diltizaem (Cardizem)......................................................................15
DIOVAN ..........................................................................................14
DIOVAN HCT .................................................................................14
DIPENTUM .....................................................................................12
diphenoxylate/atropine tablets (Lomotil) .....................................12
dipyridamole (Persantine) ...............................................................8
disopyramide (Norpace)................................................................16
disulfiram (Antabuse) ....................................................................10
divalproex DR (Depakote Sprinkles, Depakote) ........................21
divalproex ER (Depakote ER) ......................................................21
donepezil (Aricept, Aricept ODT) .................................................10
dorzolamide eye solution (Trusopt) .............................................26
dorzolamide/timolol maleate eye solution (Cosopt) ..................26
doxazosin (Cardura) ......................................................................17
doxepin (Sinequan) ......................................................................10
doxycycline hyclate (Vibramycin) .................................................7
DROXIA ............................................................................................8
DUETACT .......................................................................................18

E
E.E.S. GRANULES .........................................................................6
econazole (Spectazole) ................................................................28
EDEX ...............................................................................................16
ELIXOPHYLLIN .............................................................................24
EMCYT ..............................................................................................9
EMEND ...........................................................................................12
EMSAM ...........................................................................................10
EMTRIVA ..........................................................................................7
enalapril (Vasotec) .........................................................................14
enalapril/hydrochlorothiazide (Vaseretic) ...................................14
ENBREL ............................................................................................8
ENDOMETRIN ...............................................................................13
enoxaparin (Lovenox)......................................................................8
EPIPEN ...........................................................................................24
EPIPEN-JR 2-PAK ........................................................................24
EPIVIR HBV .....................................................................................6
eplerenone (Inspra) .......................................................................17
EPZICOM ..........................................................................................7
EQUETRO ......................................................................................11
erythromycin eye ointment ...........................................................25
erythromycin gel, pads, solution ..................................................27
erythromycin/sulfisoxazole (Pediazole) ...................................6
escitalopram (Lexapro) .................................................................10
estazolam (Prosom) ......................................................................11
ESTRACE .......................................................................................14
estradiol (Climara, Estrace) ..........................................................19
estradiol/norethindrone acetate (Activella) ...............................19
ESTRING ........................................................................................14
estropiopate (Ogen, Ortho-Est)....................................................19

ethambutol (Myambutol) ................................................................. 7

ethosuximide (Zarontin) ................................................................ 21
etidronate (Didronal) ..................................................................... 19
etodolac (Lodine) .......................................................................... 23
EVISTA ........................................................................................... 19
EVISTAraloxifene..................................................................... 19
EXELON ......................................................................................... 11
exemestane (Aromasin).................................................................. 9
EXFORGE ...................................................................................... 14
EXFORGE HCT ............................................................................. 14

F
famciclovir (Famvir) ......................................................................... 7
famotidine (Pepcid) ....................................................................... 13
FARESTON ...................................................................................... 9
FAZACLO....................................................................................... 11
FELBATOL .................................................................................... 21
felodipine ER (Plendil) .................................................................. 15
FEMHRT LOW DOSE .................................................................. 19
fenofibrate, micronized (Liofibra) ................................................. 16
fentanyl oral lozenge (Actiq) ....................................................... 23
fentanyl patch (Duragesic) .......................................................... 23
finasteride (Proscar) ................................................................... 13
FLAREX .......................................................................................... 27
flecainide (Tambocor) ................................................................... 16
FLOVENT ....................................................................................... 24
fluconazole (Diflucan) .................................................................. 6
flucytosine (Ancoban) .................................................................. 6
fludrocortisones (Florinef)............................................................. 17
fluocinonide .................................................................................... 28
fluorometholone eye suspenion, 0.1% (FML Liquifilm) ............ 27
FLUOROQUINOLONES ................................................................. 6
fluorouracil (Efudex) ...................................................................... 28
fluoxetine (Prozac)......................................................................... 10
fluphenazine hcl tablets (Prolixin)................................................ 11
flurbiprofen eye solution (Ocufen) ............................................... 26
flutamide (Eulexin) ........................................................................... 9
fluticasone propionate (Cutivate)................................................. 28
FML FORTE ................................................................................... 27
folic acid tablets, 1 mg .................................................................... 8
FOLLISTIM AQ .............................................................................. 19
FORADIL AEROLIZER ................................................................ 24
fosinopril (Monopril) ....................................................................... 14
FRAGMIN ......................................................................................... 8
FREESTYLE FREEDOM LITE BLOOD GLUCOSE SYSTEM 19
FREESTYLE INSULINX BLOOD GLUCOSE SYST ............... 19
FREESTYLE INSULINX TEST STRIPS..................................... 19
FREESTYLE LITE BLOOD GLUCOSE MONITORING
SYSTEM .................................................................................... 19
FREESTYLE LITE TEST STRIPS .............................................. 19
furosemide (Lasix) ......................................................................... 16

40

G
gabapentin (Neurontin) .................................................................21
GABITRIL .......................................................................................22
galantamine (Razadyne) ...............................................................11
galantamine ER (Razadyne ER)..................................................11
GALZIN ...........................................................................................25
gemfibrozil (Lopid) ........................................................................16
gentamicin eye ointment, solution (Garamycin) ........................26
glimepiride (Amaryl).......................................................................18
glipizde (Glucotrol) .........................................................................18
glipizde ER (Glucotrol XL) ............................................................18
GLUCAGEN ...................................................................................18
GLUCAGON EMERGENCY KIT .................................................18
glyburide (Micronase) ....................................................................18
glyburide micronized (Glynase) ...................................................18
glyburide/metformin (Glucovance)...............................................18
granisetron (Kytril) .........................................................................12
GRIFULVIN V ...................................................................................6
griseofulvin microsize (Fulvicin, Grisfulvin) ...........................6
GRIS-PEG ........................................................................................6
guanfacine (Tenex) ........................................................................17

ibuprofen (Motrin) ......................................................................... 23

imipramine hcl (Tofranil) ............................................................... 10
imiquimod (Aldara) ........................................................................ 28
indapamide (Lozol) ........................................................................ 16
INVIRASE ......................................................................................... 7
ipratropium inhale rsolution (Atrovent, Aerovent)...................... 24
ipratropium/albuterol (Duoneb) .................................................... 24
irbesartan (Avapro)........................................................................ 14
irbesartan/hydrochlorothiazide (Avalide) .................................... 14
ISENTRESS ..................................................................................... 7
isoniazid (Laniazid, Nydrazid) ........................................................ 7
isoniazid/rifampin (Rifamate) ......................................................... 7
ISOPTO CARBACHOL ................................................................ 26
ISOPTO HOMATROPINE ............................................................ 26
ISORDIL TITRADOSEisosorbide dinitrate ......................... 15
isosorbide dinitrate (Isordil) .......................................................... 15
isosorbide mononitrate (Monoket)............................................... 15
isosorbide mononitrate ER (Imdur) ............................................. 15
itraconazole (Sporonox) .............................................................. 6

J
JALYN ............................................................................................ 13

H
halobetasolution (Ultravate) .........................................................28
haloperidol (Haldol)........................................................................11
HEXALEN .........................................................................................9
hlycopyrrolate (Robinul) ................................................................13
homatropine eye solution (Isopto Homatropine) .......................26
HUMALOG .....................................................................................18
HUMIRA ............................................................................................8
HUMULIN........................................................................................18
hydralazine (Apresolutionine).......................................................17
hydrcortisone valerate (Westcort)................................................28
hydrochlorothiazide (Microzide, Hydrodiuril) ..........................16
hydrocodone/acetaminophen (Vicodin, Lorcet, Lortab,
Norco) ........................................................................................23
hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen) ..23
hydrocortisone (Cortef) ................................................................17
hydrocortisone acetate ..................................................................25
hydrocortisone enema (Cortenema) ...........................................25
hydrocortisone topical ...................................................................28
hydrocortisone/acetic acid ear solution.......................................25
hydromorphone tablets .................................................................23
hydroxychloroquine..........................................................................8
hydroxyurea (Hydrea)......................................................................9
hydroxyzine (Atarax, Vistaril) .......................................................10
hyoscyamine (Anaspaz, Levsin/SL) ............................................13
hyoscyamine ER (Levbid, Symax Duotab) .................................13

I
ibandronate oral (Boniva) .............................................................19

K
KALETRA......................................................................................... 7
ketoconazole (Nizoral) .................................................................. 28
ketoconazole tablets (Nizoral) .................................................... 6
ketoprofen (Oruvail) ..................................................................... 23
ketorolac eye solution (Acular, Acular LS) ................................. 27
KLONOPIN ................................................................................. 22

L
labetalol (Trandate) ....................................................................... 15
lactulose (Enulose) ....................................................................... 12
LAMICTAL ..................................................................................... 22
LAMICTAL XR ............................................................................... 22
lamivudine (Epivir) ........................................................................... 7
lamivudine/zidovudine (Combivir) ................................................ 8
lamotrigine (Lamictal).................................................................... 22
LANOXIN ........................................................................................ 17
lansoprazole DR ............................................................................ 13
lantanoprost eye solution (Xalatan) ............................................ 26
LANTUS ......................................................................................... 18
LANTUS SOLOSTAR .................................................................. 18
LASTACAFT alcaftadine ........................................................ 27
LATUDAlurasidone ................................................................. 11
leflunomide (Arava)....................................................................... 23
letrozole (Femara) ........................................................................... 9
leucovorin calcium tablets .............................................................. 9
LEUKERAN ..................................................................................... 9
levetiracetam (Keppra) ................................................................. 22

41

levobunolol eye solution, 0.5% (Betagan) ..................................26

levofloxacin (Levaquin) ................................................................6
levonorgestrel (Plan B)..................................................................17
levothyroxine (Synthroid, Levoxyl) ...........................................20
LIALDA ...........................................................................................12
lidocaine topical (Xylocaine) .........................................................28
lidocaine viscous ............................................................................27
lindane .............................................................................................28
liothyronine (Cytomel) ...................................................................20
lisinopril ...........................................................................................14
lisinopril/hydrochlorothiazide (Prinizide) .....................................14
lithium carbonate ............................................................................11
lithium carbonate ER (Lithobid, Eskalith CR) .............................11
LITHOBID .......................................................................................11
lorazepam (Ativan).........................................................................10
losartan (Cozaar) ...........................................................................14
losartan/hydrochlorothiazide (Hyzaar) ........................................14
lovastatin (Mevacor) ......................................................................16
LOVAZA..........................................................................................16
LOVENOX ........................................................................................9
loxapine (Loxitane) ........................................................................11
LUMIGANbimatoprost, ophthalmic solution 0.03% ...............26
LYSODREN ......................................................................................9
LYSTEDA .........................................................................................9

M
MACRODANTIN ............................................................................13
MATULANE......................................................................................9
MAXAIR AUTOHALER ................................................................24
meclizine (Antivert) .......................................................................12
medroxyprogesterone acetate (Provera) ...................................20
mefloquine (Larium)........................................................................8
megestrol (Megace).........................................................................9
meloxicam (Mobic) ........................................................................23
MENEST .........................................................................................19
MENOSTAR ...................................................................................19
MEPHYTON ...................................................................................25
MEPRONatovaquone suspension .........................................6
mercaptopurine (Purinethol) ...........................................................9
mesalamine (Asacol) .....................................................................12
mesalamine powder (5-aminosalicylic acid) .........................12
MESNEX ...........................................................................................9
MESTINON .....................................................................................21
MESTINON TIMESPAN ...............................................................21
METADATE CD .............................................................................10
metaxalone (Skelaxin) ...................................................................21
metformin (Glucophage) ...............................................................18
metformin ER (Glucophage XR) ..................................................18
methadone solution .......................................................................23
methadone tablets .........................................................................23
methazolamide (Neprazane) ........................................................16
methimazole (Tapaxzole) .............................................................20

methocarbamol (Robaxin) ............................................................ 21

methotrexate (Trexall) ..................................................................... 9
methyldopa (Aldomet) ................................................................... 17
METHYLIN ..................................................................................... 10
methylphenidate ER capsules, tablets (Ritalin LA, Ritalin SR)10
methylphenidate tablets (Ritalin) ................................................. 10
methylprednisolone (Medrol)....................................................... 17
metipranolol eye solution (Optipranolol) ..................................... 26
metoclopramide (Reglan) ............................................................. 12
metolazone (Zaroxolyn) ................................................................ 16
metoprolol succinate ER............................................................... 15
metoprolol tartrate (Lopressor) .................................................... 15
metronidazole (Flagyl).................................................................. 6
metronidazole (Metrocream, Metrolotion) .................................. 27
metronidazole (MetroGel-Vaginal) .............................................. 14
metronidazole topical gel (Metrogel)........................................... 28
MIGRANAL .................................................................................... 22
MILLIPRED .................................................................................... 17
minoxidil (Loniten) ......................................................................... 17
mirtazapine (Remeron, Remeron SolTab) ................................. 10
misoprostol (Cytotec) .................................................................... 13
moexipril (Univasc) ........................................................................ 14
moexipril/hydrochlorothiazide (Uniretic) ..................................... 14
mometasone................................................................................... 28
montelukast sodium ...................................................................... 24
MOP ................................................................................................ 28
morphine sulfate ER (MS Contin) .............................................. 23
MULTAQ......................................................................................... 16
mupirocin ointment (Bactroban) .................................................. 28
MUSE .............................................................................................. 16
MYCOBUTIN.................................................................................... 7
mycophenolate mofetil (Cellcept) ................................................ 20
MYLERAN ........................................................................................ 9
MYSOLINE ..................................................................................... 22

N
nadolol (Corgard) ........................................................................... 15
NALFON ......................................................................................... 23
naltrexone (ReVia)......................................................................... 11
NAMENDA ..................................................................................... 11
naproxen (Naprosyn) ................................................................... 23
naproxen DR (EC-Naprosyn) ..................................................... 23
naproxen sodium (Anaprox) ....................................................... 23
naratriptan (Amerge) ..................................................................... 22
NASCOBAL ................................................................................... 25
nateglinide (Starlix)........................................................................ 18
neomycin/polymyxin B/bacitracin/hydrocortisone eye ointment
.................................................................................................... 27
neomycin/polymyxin B/dexamethasone eye ointment,
suspenion (Maxitrolo) .............................................................. 27
neomycin/polymyxin B/gramicidin eye solution (Neosporin) ... 26
neomycin/polymyxin B/hydrocortisone ear solution, suspension
(Cortisporin) .............................................................................. 25

42

neomycin/polymyxin/bacitracin eye ointment.............................26

NEORAL .........................................................................................20
NEURONTIN ..................................................................................22
NIASPAN ........................................................................................16
NICOTROL INHALER ..................................................................11
NICOTROL NS...............................................................................11
nifedipine ER (Adalat CC, Procardia XL)....................................15
NILANDRON ....................................................................................9
NITRO-BIDnitroglycerin .........................................................15
NITRO-DURnitroglycerin patch ............................................15
nitrofurantoin (Furadantin) ............................................................13
nitrofurantoin macrocrystalline (Macrodantin) ..........................13
nitrofurantoin monohydrate/macrocrystalline (Macrobid) .........13
nitroglycerin (Nitro-Dur) .................................................................15
NITROMIST ....................................................................................15
NITROSTATnitroglycerin SL .................................................15
norethindrone acetate (Aygestin) ................................................20
norethindrone acetate/ethinyl estradiol .......................................19
NORPACE CR ...........................................................................16
nortriptyline (Pamelor) ...................................................................10
NORVIR SOLUTION .......................................................................8
nystatatin topical ............................................................................28
nystatin oral (Mycostatin) ............................................................6
nystatin suspenion .........................................................................27

O
ofloxacin ear solution (Floxin otic) ...............................................25
ofloxacin eye solution (Ocuflox) ...................................................26
triamcinolone cream; lotion...........................................................28
olanzapine (Zyprexa, Zyprexa Zydis)..........................................11
omeprazole DR (Prilosec).............................................................13
ondansetron (Zofran, Zofran ODT) ..............................................12
OPANA ER .....................................................................................23
ORACIT...........................................................................................13
oral contraceptives......................................................................17
orphenadrine citrate ER (Norflex) ................................................21
orphenadrine/aspirin/caffeine (Norgesic)....................................21
oxaprozin (Daypro) .......................................................................23
oxcarbazepine (Trileptal) ..............................................................22
OXSORALEN ULTR .....................................................................28
oxybutynin (Ditropan) ....................................................................13
oxybutynin ER (Ditropan XL) ......................................................13
oxycodone (Roxicodone) ............................................................23
oxycodone/acetaminophen...........................................................23
oxycodone/aspirin (Percodan) .....................................................23

P
pantoprazole DR (Protonix) ..........................................................13
paroxetine hcl (Paxil) .....................................................................10
paroxetine hcl ER (Paxil CR) .......................................................10
PAXIL ..............................................................................................10
PEG INTRON ...................................................................................7

PEGASYS......................................................................................... 7
penicillin v potassium (Veetids) .................................................... 7
PENTASA....................................................................................... 12
pentoxifylline ER (Trental) .............................................................. 9
perindopril (Aceon) ........................................................................ 14
permethrin....................................................................................... 28
perphenazine (Trilafon)................................................................. 11
phenelzine (Nardil) ....................................................................... 10
phenobarbital ................................................................................. 11
phenytoin sodium ER (Dilantin, Phenytek) ................................ 22
phenytoin suspenion (Dilantin) .................................................... 22
PHOSPHOLINE IODIDE .............................................................. 27
PHRENILIN FORTE ...................................................................... 23
pilocarpine (Salagen) .................................................................... 27
pilocarpine eye solution, 1%, 2%, 4% (Isopto Carpine) ........... 26
PILOPINE HS ................................................................................ 27
pioglitazone (Actos)...................................................................... 18
pioglitazone-metformin (Actoplus met) ..................................... 18
pioglitazone-metformin SR ........................................................... 18
piroxicam (Feldene) ...................................................................... 23
podofilox (Condylox) ..................................................................... 28
polymyxin B/trimethoprim eye solution (Polytrim) ..................... 26
POTABA ......................................................................................... 21
potassium chloride ER .................................................................. 25
potassium citrate ER (Urocit-K) ............................................... 13
potassium citrate/citric acid .......................................................... 13
potassium citrate/citric acid (Polycitra-K) ................................... 13
POTASSIUM P-AMINOBENZOATE .......................................... 21
potassium phosphate/sodium phosphates (K-Phos Neutral) .. 25
pramipexole (Mirapex) .................................................................. 21
pravastatin (Pravachol) ................................................................. 16
prazosin (Minipress) ...................................................................... 17
PRECISION XTRA BLOOD GLUCOSE SYSTEM ................... 19
PRED MILD .................................................................................... 27
PRED-G .......................................................................................... 27
PRED-G S.O.P. ............................................................................. 27
prednisolone (Prelone)................................................................. 17
prednisolutionone acetate eye suspenion (Pred Forte) ........... 27
prednisolutionone sodium phosphate (Orapred, Pediapred) .. 17
PREDNISONE INTENSOL .......................................................... 17
prednisone tablets ......................................................................... 17
prenatal vitamin/folic acid - all generics...................................... 25
primaquine ........................................................................................ 8
primidone (Mysolutionine) ............................................................ 22
probenecid (Benemid)................................................................... 22
prochlorperazine (Compazine) .................................................... 11
progesterone micronized (Prometrium) .................................... 20
PROGRAF ...................................................................................... 20
PROMACTA ..................................................................................... 9
propafenone (Rythmol) ................................................................. 16
propafenone ER (Rythmol SR) .................................................... 17
propranolol ER (Inderal LA) ......................................................... 15
propranolol tablets (Inderal) ......................................................... 15

43

propylthiouracil ...............................................................................19
PULMICORT FLEXHALER .........................................................24
pyrazinamide ....................................................................................7
pyridostigmine (Mestinon).............................................................21

Q
quetiapine (Seroquel) ....................................................................11
quinapril (Accupril) .........................................................................14
quinapril/hydrochlorothiazide (Accuretic)....................................14
quinidine gluconate ER (Quinaglute) ..........................................17
quinidine sulfate (Quinidex).........................................................17
QVAR ..............................................................................................24

R
ramipril (Altace) ..............................................................................14
ranitidine (Zantac) ..........................................................................13
RAPAMUNE ...................................................................................20
RECLAST .......................................................................................19
RELISTOR ......................................................................................12
REMICADE .......................................................................................8
REQUIP XL ....................................................................................21
RESCRIPTOR ..................................................................................8
REYATAZ .........................................................................................8
RIDAURA........................................................................................23
rifampin (Rifadin) ..............................................................................7
risperidone (Risperdal, Risperdal-M tablets)..............................11
ropinirole (Requip) .........................................................................21

S
salsalate (Disalcid) .......................................................................23
SANCUSO ......................................................................................12
SANDIMMUNE...............................................................................20
SARAFEM ......................................................................................11
selegiline (Eldepryl) .......................................................................21
selenium sulfide (Selsun)..............................................................29
SELZENTRY ....................................................................................8
SEREVENT DISKUS ....................................................................24
SEROQUEL XR .............................................................................11
sertraline (Zoloft) ............................................................................10
SFROWASA ...................................................................................12
silver sulfadiazine (Silvadene)......................................................28
SIMCOR ..........................................................................................16
simvastatin (Zocor) ........................................................................16
sodium citrate/citric acid................................................................13
sodium citrate/citric acid (Shohls) ..........................................13
sodium fluoride ...............................................................................25
sodium fluoride (Prevident)...........................................................27
sodium polystyrene sulfonate.......................................................20
SORIATANE ..................................................................................29
sotalol (Betapace, Betapace AF) .................................................17
SPIRIVA ..........................................................................................24

SPIRIVA HANDIHALER .............................................................. 24

spironolactone (Aldactone) .......................................................... 16
spironolactone/hydrochlorothiazide ............................................ 16
stavudine (Zerit) ............................................................................... 8
STIMATE ........................................................................................ 19
sucralfate (Carafate) ..................................................................... 13
sulfacetamide sodium eye solution (Bleph-10).......................... 26
sulfacetamide sodium/prednisolutionone eye solution ............. 27
sulfacetamide sodium/sulfur cloth, cream, emulsion, lotion ... 28
sulfamethoxazole/trimethoprim (Bactrim) .............................. 6
sulfasalazine (Azulfidine) .............................................................. 12
sulfasalazine DR (Azulfidine EN-Tabs) ...................................... 12
sulindac (Clinoril).......................................................................... 24
sumatriptan injection, tablets (Imitrex) ....................................... 22
SUSTIVA .......................................................................................... 8
SUSTIVAefavirenz ..................................................................... 8
SYMBICORT .................................................................................. 24
SYNAREL....................................................................................... 20
SYNTHROID .................................................................................. 20

T
TABLOID .......................................................................................... 9
tacrolimus (Prograf) ....................................................................... 20
tamoxifen (Nolvadex) ...................................................................... 9
tamsulosin (Flomax) ...................................................................... 13
TARGRETIN .................................................................................... 9
TEGRETOL .................................................................................... 22
TEGRETOL-XR ............................................................................. 22
TEKAMLO ...................................................................................... 17
TEKTURNA .................................................................................... 17
TEKTURNA HCT........................................................................... 17
temazepam (Restoril).................................................................... 11
terazosin (Hytrin) ........................................................................... 17
terbinafine (Lamisil) ...................................................................... 6
terbutaline (Brethine)..................................................................... 24
terconazole (Terazol) .................................................................... 14
TEV TROPIN .................................................................................. 20
THALITONE ................................................................................... 16
THEO-24 ......................................................................................... 24
theophylline ER (Theo-Dur) ......................................................... 24
thiothixene (Navane) ..................................................................... 11
THYROLAR ................................................................................... 20
timolol maleate eye solution (Timoptic, Timoptic XE) ............... 26
TIMOPTIC OCUDOSE.................................................................. 26
TINDAMAX....................................................................................... 6
tizanidine (Zanaflex) ...................................................................... 21
TOBRADEX ................................................................................... 27
TOBRADEX ST ............................................................................. 27
tobramycin eye solution (Tobrex) ................................................ 26
tobramycin/dexamethasone eye suspenion (Tobradex) .......... 27
TOBREX ......................................................................................... 26
TOPAMAX ...................................................................................... 22

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topiramate (Topamax Sprinkle, Topamax) .................................22

torsemide (Demadex) ....................................................................16
TRADJENTA ..................................................................................18
tramadol (Ultram) ..........................................................................23
trandolapril (Mavik) ........................................................................14
tranylcypromine (Parnate) ............................................................10
TRAVATAN .....................................................................................26
trazodone (Desyrel) .......................................................................10
tretinoin (Retin-A) ...........................................................................28
TREXALL..........................................................................................9
TREXIMET ......................................................................................22
triamcinolone (Nasacort AQ) ........................................................25
triamcinolone dental paste (Kenalog in Orabase) .....................27
TRIBENZOR ...................................................................................14
trifluoperazine (Stelazine) .............................................................11
trifluridine eye solution (Viroptic)..................................................26
trihexyphenidyl (Artane) ................................................................21
trimethobenzamide (Tigan)...........................................................12
trimethoprim ......................................................................................6
TRIZIVIR ...........................................................................................8
tropicamide eye solution (Mydriacyl) ...........................................27
TRUVADA ........................................................................................8
TUDORZA ......................................................................................24

U
ULORIC...........................................................................................22
UROCIT-K 15 .............................................................................13
urosdiol (Actigall, Urso 250, Urso Forte) ....................................12

V
valacyclovir (Valtrex) ......................................................................7
valproic acide (Depakene) ............................................................22
vancomycin (Vancocin)................................................................7
venlafaxine (Effexor)......................................................................10

venlafaxine ER (Effexor XR) ........................................................ 10

VENTOLIN HFA ............................................................................ 24
verapamil (Calan) .......................................................................... 15
verapamil ER (Calan SR, Isoptin SR, Verelan, Verelan PM) .. 15
VESICARE ..................................................................................... 13
VEXOL ............................................................................................ 27
VIBRAMYCIN SYRUP .................................................................... 7
VICTOZA ........................................................................................ 18
VIDEX PEDIATRIC ......................................................................... 8
VIRAMUNE ...................................................................................... 8
VIRAMUNE XR ................................................................................ 8
VIREAD............................................................................................. 8
VIVELLE-DOT ............................................................................... 19
VOLTAREN GEL .......................................................................... 29
voriconazole (Vfend)..................................................................... 6

W
warfarin (Coumadin)........................................................................ 9
WELCHOL ..................................................................................... 16

Z
zafirlukast (Accolate ..................................................................... 24
zaleplon (Sonata) .......................................................................... 11
ZARONTIN ..................................................................................... 22
ZENPEP.......................................................................................... 12
ZIAGEN............................................................................................. 8
zidovudine (Retrovir) ....................................................................... 8
ziprasidone (Geodon) ................................................................... 11
zolpidem (Ambien)......................................................................... 11
zolpidem ER(Ambien CR) ............................................................ 11
ZONEGRAN ................................................................................... 22
zonisamide (Zonegran) ................................................................. 22
ZYMAXID gatifloxacin............................................................. 26

45