2014 Preferred Drug List (2–Tier) Please bring this guide with you to your next doctor visit.

30690 (Ed. 09/13)

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Do you have questions?

Call Assurant Health Customer Service at the phone number

printed on your ID card.

Dear Member,

To help you know how drugs are covered by your plan, we are

pleased to provide you with a copy of our 2014 Preferred Drug List.

This document provides helpful information on the Assurant Preferred

Drug List and your pharmacy benefit plan. You may want to take this

guide with you when you see your doctor to talk about what is

covered under your plan.

Many commonly prescribed drugs are listed in this guide. Please

remember this is not a complete list of drugs covered under your

plan. Because thousands of drugs are included in your pharmacy

benefits plan, we only list the most commonly prescribed ones.

Please note that not all drugs listed in this guide are covered by all

pharmacy benefit programs. Check your benefit materials for the

specific covered drugs and your co-payment program.

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What is the Assurant Preferred Drug List?

Our Preferred Drug List is meant to give you a general view of drugs covered by your plan. Changes to the list are based on the latest medical findings as well as information from the Food and Drug Administration (FDA) and drug makers.

This list includes both brand-name and generic drugs and is updated regularly. Assurant will generally cover the drugs listed on our Preferred Drug List as long as they are medically necessary and plan rules are followed. Coverage is not limited to drugs on the Preferred Drug List.

The Preferred Drug List is subject to change. Drugs on the list are based on reliable medical data, safety and cost. When you talk to your doctor about what drug may be right for you, it is important to remember that you and your doctor are responsible for making the final decision on your drug therapy.

Why is the Preferred Drug List subject to change?

During the year, we may add or remove drugs from the Preferred Drug List. These changes happen for various reasons and may move a drug from one coverage tier to another.

As brand-name drugs lose their patents, generic versions may become available. When this happens, the generic drug may be added to the list and available at a lower copayment or coinsurance tier.

The FDA approves many new drugs throughout the year. Your plan generally covers new FDA-approved drugs; however, the new drug(s) also may be subject to precertification or step-therapy requirements.

Some drugs may also no longer require a prescription. If your drug becomes available over-the-counter (OTC), the drug will generally no longer be covered under your prescription plan.

If the FDA removes a drug from the market it will also no longer be covered under your prescription plan.

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Why do some drugs have quantity limits?

Your plan may limit the amount of a drug you can receive at one time. These limits help your doctor and pharmacist check that the drugs are used appropriately while promoting patient safety. We use medical guidelines, FDA approval and guidance from drug makers to set these coverage limits. The quantity limits program includes:

Dose Efficiency Edits – Limits coverage of prescriptions to one dose per day for drugs that are approved for once-daily dosing.

Maximum Daily Dose – A message is sent to the pharmacy if a prescription is higher than the maximum allowed dose.

Quantity Limits Over Time – Limits coverage of prescriptions to a specific number of units in a defined amount of time.

To get coverage for amounts over the allowed quantity, you, your doctor or the person you appoint to manage your care can request a coverage override by calling the phone number located on your ID Card. The quantity limit list is subject to change.

What is step-therapy?

With step-therapy you must try one or more alternate drugs before your plan will cover a step-therapy drug. These drugs are FDA-approved, treat the same condition(s) and, they may also be available to you at a lower copay or coinsurance tier.

If it is necessary for you to use a drug on the step therapy list, you, your doctor, or the person you appoint to manage your care can request a coverage override by calling the phone number located on your ID card.

What is the Prior Authorization program?

The Prior Authorization program encourages appropriate and cost-effective use of drugs by allowing coverage only when certain conditions are met.

• A physician, a patient, or a person appointed to manage the patient’s care must request prior authorization before drugs on the Prior Authorization List will be covered under a member’s pharmacy benefits plan. If the request is approved, the drug will then be covered at the applicable costs associated with the member’s plan.

• The Prior Authorization program is based upon current medical findings, FDA-approved manufacturer labeling information, and cost.

• To determine if a drug requires prior authorization, refer to the column titled Prior Authorization next to the list of drugs in this guide. You can also call the phone number on the back of the member identification card to obtain more information on the prior authorization review process.

• The list of drugs requiring prior authorization is subject to change.

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What are generic drugs?

Drug manufacturers develop and release new drugs under a brand name. When the patent expires, other manufacturers are then able to make duplicate versions of the same drug. Generic drugs are chemically the same as their branded counterparts. They are also the same in dosage, safety, strength, form and intended use. Plus, generics usually cost less than brand-name drugs.

Generic drugs are only available after the FDA approves them. When filling your prescription, your pharmacist generally can substitute a generic drug for a brand-name drug when the generic is rated by the FDA as equivalent and also where it is permitted by your doctor and state law.

Table of Contents – Preferred Drugs by Therapeutic Class

Therapeutic Class Page

Antineoplastic Agents 6 Blood Products – Modifiers – Volume Expanders 8 Cardiovascular System 9 Central Nervous System 18 Dermatological Agents 30 Endocrine System 35 Gastrointestinal System 44 Genitourinary System 48 Infections and Infestations 50 Musculoskeletal System 55 Ophthalmic Agents 58 Otic Agents 61 Respiratory Tract Agents 61 Miscellaneous 64

THERAPEUTIC CLASS LIST KEY (on following pages)

lower case - Generic medication

UPPERCASE – Brand-name medication

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Medication Name

2-Tier G = Generic

P = Preferred

Brand Prior

Authorization Quantity

Limit Step

Therapy

Antineoplastic Agents

Alkylating Agents

ALKERAN P

CEENU P

lomustine G

cyclophosphamide G

HEXALEN P

LEUKERAN P

MYLERAN P

TEMODAR capsule P √

temozolomide capsule G √

Antimetabolites

mercaptopurine G

methotrexate G

PURINETHOL P

TABLOID P

TREXALL P

XELODA P √

Antineoplastic – Enzyme Inhibitors

AFINITOR P √

BOSULIF P √

CAPRELSA P √

COMETRIQ P √

GILOTRIF P √

GLEEVEC P √

ICLUSIG P √

INLYTA P √

IRESSA P

JAKAFI P √

MEKINIST P √

NEXAVAR P √

POMALYST P √

SPRYCEL P √

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STIVARGA P √

SUTENT P √

TAFINLAR P √

TARCEVA P √

TASIGNA P √

TYKERB P √

VOTRIENT P √

XALKORI P √

ZELBORAF P √

ZOLINZA P √

Antineoplastic – Hormonal Agents

anastrozole G

ARIMIDEX P

AROMASIN P

bicalutamide G

CASODEX P

EMCYT P

exemestane G

FARESTON P

FEMARA P

flutamide G

letrozole G

LYSODREN P

MEGACE P

MEGACE ES P

megestrol G

NILANDRON P

tamoxifen G

XTANDI P √

ZYTIGA P √

Antineoplastics – Miscellaneous

ERIVEDGE P √

HYDREA P

hydroxyurea G

MATULANE P

TARGRETIN P

tretinoin 10 mg G √

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Chemotherapy Rescue/Antidote Agents

leucovorin calcium G

MESNEX P

Immunomodulators

REVLIMID P

THALOMID P

Topoisomerase I Inhibitors

HYCAMTIN P √

Blood Products – Modifiers – Volume Expanders

Anticoagulants – Coumarin

COUMADIN P

jantoven G

warfarin G

Anticoagulants – Direct Thrombin Inhibitors/Factor Xa Inhibitor

ELIQUIS P √ √

IPRIVASK P

PRADAXA P √

XARELTO P √

Anticoagulants – Heparins

ARIXTRA P

fondaparinux G

FRAGMIN P

heparin sodium G

LOVENOX P

enoxaparin G

Hemostatics – Systemic

AMICAR P

aminocaproic acid G

LYSTEDA P √

tranexamic acid G √

Platelet Aggregation Inhibitors

AGGRENOX P

AGRYLIN P

anagrelide G

BRILINTA P √

cilostazol G

clopidogrel G

dipyridamole G

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EFFIENT P √

PERSANTINE P

PLAVIX P

PLETAL P

ticlopidine G

Cardiovascular System

Alpha-Beta Blockers

carvedilol G

COREG P

COREG CR P

labetalol G

TRANDATE P

Anaphylaxis Therapy Agents

ADRENACLICK P

AUVI-Q P √

epinephrine G

EPIPEN P

EPIPEN-JR P

TWINJECT P

Angiotensin Converting Enzyme (ACE) Inhibitors and Combinations

ACCUPRIL P

ACCURETIC P

ACEON P

ALTACE P

benazepril G

benazepril/hydrochlorothiazide G

captopril G

captopril/hydrochlorothiazide G

enalapril G

enalapril/hydrochlorothiazide G

EPANED P √

fosinopril G

fosinopril/hydrochlorothiazide G

lisinopril G

lisinopril/hydrochlorothiazide G

moexipril G

moexipril/hydrochlorothiazide G

LOTENSIN P

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LOTENSIN HCT P

MAVIK P

perindopril G

PRINIVIL P

PRINZIDE P

quinapril G

quinapril/hydrochlorothiazide G

ramipril G

trandolapril G

UNIRETIC P

UNIVASC P

VASERETIC P

VASOTEC P

ZESTORETIC P

ZESTRIL P

Angiotensin II Receptor Antagonists and Combinations

ATACAND P √

candesartan G √

ATACAND HCT P √

candesartan/hydrochlorothiazide G √

AVALIDE P √

AVAPRO P √

AZOR P √ √

BENICAR P √ √

BENICAR HCT P √ √

COZAAR P √

DIOVAN P √ √

DIOVAN HCT P √ √

EDARBI P √ √

EDARBYCLOR P √ √

eprosartan G √

EXFORGE P √

EXFORGE HCT P √

HYZAAR P √

irbesartan G √

irbesartan/hydrochlorothiazide G √

losartan G √

losartan/hydrochlorothiazide G √

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MICARDIS P √

MICARDIS HCT P √

TEVETEN P √

TEVETEN HCT P

TRIBENZOR P √ √

TWYNSTA P √ √

valsartan/hydrochlorothiazide G √

Antiadrenergic Antihypertensives

CARDURA P

CATAPRES P

CATAPRES-TTS P

clonidine G

doxazosin G

guanabenz G

guanfacine G

methyldopa G

MINIPRESS P

NEXICLON P √

prazosin G

reserpine G

TENEX P

terazosin G

Antianginals – Nitrates

amyl nitrite G

DILATRATE SR P

IMDUR P

ISORDIL P

isosorbide dinitrate G

isosorbide mononitrate G

MONOKET P

NITRO-BID P

NITRO-DUR P

nitroglycerin G

nitroglycerin CR G

nitroglycerin SL G

NITROLINGUAL P

NITROMIST P

NITROSTAT P

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Antianginals – Other

RANEXA P √

Antiarrhythmics Type I-A

disopyramide G

NORPACE P

procainamide G

quinidine gluconate G

quinidine sulfate G

Antiarrhythmics Type I-B

mexiletine G

Antiarrhythmics Type I-C

flecainide G

propafenone G

RYTHMOL P

RYTHMOL SR P

TAMBOCOR P

Antiarrhythmics Type III

amiodarone G

CORDARONE P

MULTAQ P

PACERONE P

TIKOSYN P

Antihyperlipidemics – Bile Sequestrants

cholestyramine G

cholestyramine light G

COLESTID P

colestipol G

prevalite G

QUESTRAN P

QUESTRAN LITE P

WELCHOL P

Antihyperlipidemics – Fibric Acid Derivatives

ANTARA P √

fenofibrate G

fenofibrate choline G

fenofibrate micronized G

fenofibric acid G

FENOGLIDE P √

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FIBRICOR P √

gemfibrozil G

LOFIBRA P √

LOPID P √

LIPOFEN P √

TRICOR P √

TRIGLIDE P √

TRILIPIX P √

fenofibrate delayed-release G

Antihyperlipidemics – HMG CoA Reductase Inhibitors

ADVICOR P √

ALTOPREV P √ √

amlodipine/atorvastatin G √

atorvastatin G √

CADUET P √ √

CRESTOR P √

fluvastatin G √

LESCOL P √

LESCOL XL P √ √

LIPITOR P √ √

LIPTRUZET P √

LIVALO P √

lovastatin G √

MEVACOR P √

PRAVACHOL P √

pravastatin G √

SIMCOR P √

simvastatin G √

VYTORIN P √

ZOCOR P √

Antihyperlipidemics – Intestinal Cholesterol Absorption Inhibitors

ZETIA P √

Antihyperlipidemics – Miscellaneous

JUXTAPID P √ √

LOVAZA P

VASCEPA P

Antihyperlipidemics – Nicotinic Acid Derivatives

niacin ER tablet G

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NIASPAN P

Antihypertensives-Miscellaneous

VECAMYL P √ √

Beta Blockers Cardioselective and Combinations

acebutolol G

atenolol G

atenolol/chlorthalidone G

betaxolol G

bisoprolol G

bisoprolol/hydrochlorothiazide G

BYSTOLIC P

DUTOPROL P

KERLONE P

LOPRESS HCT P

LOPRESSOR P

metoprolol G

metoprolol ER G

metoprolol/hydrochlorothiazide G

SECTRAL P

TENORETIC P

TENORMIN P

TOPROL XL P

ZEBETA P

ZIAC P

Beta Blockers Non-Selective and Combinations

BETAPACE P

BETAPACE AF P

CORGARD P

CORZIDE P

INDERAL LA P

INNOPRAN XL P

LEVATOL P

nadolol G

nadolol/bendroflumethiazide G

pindolol G

propranolol G

propranolol SR G

propranolol/hydrochlorothiazide G

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sorine G

sotalol G

sotalol AF G

timolol G

Calcium Blockers

ADALAT CC P

afeditab G

amlodipine G

CALAN P

CALAN SR P

CARDENE SR P

CARDIZEM P

CARDIZEM CD P

CARDIZEM LA P

cartia XT G

COVERA-HS P

DILACOR XR P

dilt-CD G

dilt-XR G

diltiazem G

diltiazem CD/ER/CR/XT G

diltiazem SR extended release beads G

DYNACIRC CR P

felodipine G

ISOPTIN SR P

isradipine G

matzim LA G

nicardipine G

nifediac CC G

nifedical XL G

nifedipine G

nifedipine CR/ER/SR G

nimodipine G

nisoldipine G

NIMOTOP P

NORVASC P

NYMALIZE P √

PROCARDIA P

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PROCARDIA XL P

SULAR P

taztia XT G

TIAZAC P

verapamil G

verapamil CR/ER/SR G

VERELAN P

VERELAN PM P

VERELAN SR P

Cardiac Glycosides

digoxin G

LANOXIN P

Cardiovascular Combinations – Miscellaneous

amlodipine/benazepril G

BIDIL P

CLORPRES P

hydralazine/hydrochlorothiazide G

LOTREL P

methyldopa/hydrochlorothiazide G

rauwolfia/bendroflumethiazide G

TARKA P

Direct Renin Inhibitor and Combinations

AMTURNIDE P √

TEKAMLO P √

TEKTURNA P √

TEKTURNA HCT P √

Diuretics – Carbonic Anhydrase Inhibitors

acetazolamide G

DIAMOX P

methazolamide G

Diuretics – Loop

bumetanide G

DEMADEX P

EDECRIN P

furosemide G

LASIX P

torsemide G

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Diuretics – Potassium Sparing and Combinations

ALDACTAZIDE P

ALDACTONE P

amiloride G

amiloride/hydrochlorothiazide G

DYAZIDE P

DYRENIUM P

MAXZIDE P

MIDAMOR P

spironolactone G

spironolactone/hydrochlorothiazide G

triamterene/hydrochlorothiazide G

Diuretics – Selective Aldosterone Receptor Antagonists (SARAs)

eplerenone G

INSPRA P

Diuretics – Thiazide and Thiazide-Like

chlorothiazide G

chlorthalidone G

DIURIL P

hydrochlorothiazide G

indapamide G

methychlothiazide G

metolazone G

MICROZIDE P

THALITONE P

ZAROXOLYN P

Pheochromocytoma Agents

DEMSER P

DIBENZYLINE P

Pulmonary Hypertension Agents

ADCIRCA P √

LETAIRIS P

REVATIO P √

sildenafil G √

TRACLEER P

TYVASO P

VENTAVIS P

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Vasodilators

hydralazine G

isoxsuprine G

minoxidil G

papaverine ER G

Central Nervous System

ALS Agents

RILUTEK P

riluzole G

Alzheimer's Disease – Antidementia

ARICEPT 5 and 10 mg P

ARICEPT 23 mg P

ARICEPT ODT P

donepezil G

donepezil ODT G

EXELON capsule P

EXELON patch P

EXELON solution P

galantamine G

galantamine SR G

NAMENDA P

NAMENDA XR P

RAZADYNE P

RAZADYNE ER P

rivastigmine G

Antianxiety – Benzodiazepines

alprazolam G

alprazolam ER G

alprazolam ODT G

chlordiazepoxide G

clorazepate G

diazepam G

lorazepam G

NIRAVAM P

oxazepam G

XANAX XR P

Antianxiety – Miscellaneous

buspirone G

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hydroxyzine hydrochloride G

hydroxyzine pamoate G

meprobamate G

Anticonvulsants – Benzodiazepines

clonazepam G

clonazepam orally disintegrating tab G

DIASTAT P

diazepam rectal gel G

KLONOPIN P

ONFI P

Anticonvulsants – Carbamates

felbamate G

FELBATOL P

Anticonvulsants – GABA Modulators

GABITRIL P

SABRIL powder P

SABRIL tablet P

tiagabine G

Anticonvulsants – Hydantoins

DILANTIN P

phenytoin extended G

phenytoin sodium G

Anticonvulsants – Miscellaneous

BANZEL P

carbamazepine G

carbamazepine SR G

carbamazepine XR G

CARBATROL P

gabapentin G √

KEPPRA P

KEPPRA XR P

LAMICTAL P

LAMICTAL ODT P

LAMICTAL ER P

lamotrigine G

lamotrigine ER G

levetiracetam G

levetiracetam ER G

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LYRICA P √ √

NEURONTIN P √

oxcarbazepine G

OXTELLAR XR P

POTIGA P √

primidone G

TEGRETOL P

TEGRETOL XR P

TOPAMAX P

topiramate G

TRILEPTAL P

TROKENDI XR P √ √

VIMPAT P √

ZONEGRAN P

zonisamide G

Anticonvulsants – Succinimides

CELONTIN P

ethosuximide G

ZARONTIN P

Anticonvulsants – Valproic Acid

DEPAKENE P

DEPAKOTE P

DEPAKOTE ER P

DEPAKOTE SPRINKLE P

divalproex sodium delayed-release G

divalproex sodium sprinkle G

divalproex sodium SR G

STAVZOR P

valproic acid G

Antidepressants – Alpha-2 Receptor Antagonists

mirtazapine G √

mirtazapine ODT G √

REMERON P √

REMERON SOLUTAB P √

Antidepressants – MAO Inhibitors

EMSAM P √

MARPLAN P

NARDIL P

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PARNATE P

phenelzine G

tranylcypromine sulfate G

Antidepressants – Miscellaneous

APLENZIN P √ √

budeprion G √

budeprion XL G √

bupropion G √

bupropion SR G √

FORFIVO XL P √ √

maprotiline G √

WELLBUTRIN P √

WELLBUTRIN SR P √

WELLBUTRIN XL P √

Antidepressants – Modified Cyclics

nefazodone G

OLEPTRO P √ √

trazodone G

VIIBRYD P √ √

VIIBRYD KIT P √ √

Antidepressants – Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA P √ √

DESVENLAFAXINE ER P √ √

EFFEXOR XR P √

PRISTIQ P √ √

venlafaxine G √

venlafaxine ER capsule G √

VENLAFAXINE ER tablet P √ √

VENLAFAXINE ER tablet G √

Antidepressants – Selective Serotonin Reuptake Inhibitors

CELEXA P √

citalopram G √

escitalopram G √

fluoxetine G √

FLUOXETINE 60 MG P √ √

fluoxetine delayed release G √

fluvoxamine G √

LEXAPRO P √

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LUVOX CR P √

paroxetine G √

paroxetine ER G √

PAXIL P √

PAXIL CR P √

PEXEVA P √ √

PROZAC P √

PROZAC WEEKLY P √

sertraline G √

ZOLOFT P √

Antidepressants – Tricyclic Agents

ANAFRANIL P

amitriptyline G

amoxapine G

clomipramine G

desipramine G

doxepin G

imipramine G

NORPRAMIN P

nortriptyline G

PAMELOR P

protriptyline G

SURMONTIL P

TOFRANIL P

TOFRANIL-PM P

trimipramine G

VIVACTIL P

Antiparkinsonian Adjuvants

LODOSYN P

Antiparkinsonian Anticholinergic

benztropine G

trihexyphenidyl G

Antiparkinsonian COMT Inhibitors

COMTAN P

entacapone G

TASMAR P

Antiparkinsonian Dopaminergic

amantadine G

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bromocriptine G

carbidopa/levodopa G

carbidopa/levodopa ODT G

carbidopa/levodopa SR G

carbidopa/levodopa/entacapone G

MIRAPEX P

MIRAPEX ER P √

NEUPRO P

PARCOPA P

PARLODEL P

pramipexole G

REQUIP P

REQUIP XL P

ropinirole G

ropinirole ER G

SINEMET P

SINEMET CR P

STALEVO P

Antiparkinsonian Monoamine Oxidase Inhibitor

AZILECT P

ELDEPRYL P

selegiline G

Antipsychotics – Atypical

ABILIFY P √

ABILIFY DISC P √

clozapine G √

CLOZARIL P √

FANAPT P √ √

FAZACLO P √

GEODON P √

INVEGA P √ √

LATUDA P √

olanzapine G √

olanzapine ODT G √

quetiapine G √

RISPERDAL P √

RISPERDAL M P √

risperidone G √

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risperidone ODT G √

SAPHRIS P √

SEROQUEL P √

SEROQUEL XR P √

ZYPREXA P √

ZYPREXA ZYDIS P √

ziprasidone G √

Antipsychotics – Combinations

chlordiazepoxide/amitriptyline G

olanzapine/fluoxetine G √

perphenazine/amitriptyline G

SYMBYAX P √

Antipsychotics – First Generation

chlorpromazine G

compro G

fluphenazine G

haloperidol G

loxapine G

perphenazine G

prochlorperazine G

thioridazine G

thiothixene G

trifluoperazine G

Antipsychotics – Miscellaneous

EQUETRO P

Attention Deficit Disorder

ADDERALL P √ √

ADDERALL XR P √ √

amphetamine/dextroamphetamine G √

amphetamine/dextroamphetamine SR G √

CONCERTA P √ √

DAYTRANA P √

DESOXYN P √ √

DEXEDRINE P √ √

DEXEDRINE CR P √ √

dexmethylphenidate G √

dextroamphetamine G √

dextroamphetamine CR G √

25

dextroamphetamine sulfate solution G √

FOCALIN P √ √

FOCALIN XR P √ √

INTUNIV P √ √

KAPVAY P √ √

KAPVAY DOSE PACK P √ √

METADATE CD P √ √

metadate ER G √

methamphetamine G √

methylin G √

METHYLIN chew/soln P √ √

methylin ER G √

methylphenidate G √

methylphenidate SR G √

PROCENTRA P √ √

QUILLIVANT XR P √ √

RITALIN P √ √

RITALIN LA P √ √

RITALIN SR P √ √

STRATTERA P √

VYVANSE P √

ZENZEDI 2.5MG and 7.5MG P √ √

zenzedi 5MG and 10MG G √

Chemical Dependency

acampro cal G

ANTABUSE P

CAMPRAL P

naltrexone G

Fibromyalgia

CYMBALTA P √ √

LYRICA P √ √

SAVELLA P √

Huntington's Disease – Chorea

XENAZINE P √

Lithium

lithium carbonate G

lithium carbonate CR G

lithium citrate G

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LITHOBID P

Migraine Products

ALSUMA P √

AMERGE P √

AXERT P √ √

CAMBIA P √

dihydroergotamine nasal G √

FROVA P √ √

IMITREX P √

MAXALT P √

rizatriptan G √

MAXALT MLT P √

rizatriptan MLT G √

MIGRANAL P √

naratriptan G √

RELPAX P √ √

sumatriptan G √

SUMAVEL P √ √

TREXIMET P √ √

ZOMIG P √

zolmitriptan G √

ZOMIG ZMT P √

zolmitriptan ZMT G √

Multiple Sclerosis Agents

AMPYRA P √

AUBAGIO P √

GILENYA P √

TECFIDERA P √

Narcotic Agonists

ABSTRAL P √ √

ACTIQ P √ √

AVINZA P √

codeine phosphate G

codeine sulfate G

CONZIP P √

DEMEROL P

DILAUDID P

DURAGESIC P √

27

EXALGO P √ √

fentanyl lozenge G √ √

fentanyl patch G √

FENTORA P √ √

hydromorphone G

KADIAN P √

LAZANDA P √ √

levorphanol G

meperidine G

methadone G √

methadose G √

morphine sulfate G

morphine sulfate CR G √

MS CONTIN P √

NUCYNTA P √

NUCYNTA ER P √

ONSOLIS P √ √

OPANA P

OPANA ER P √

ORAMORPH SR P √

OXECTA P

oxycodone G

OXYCONTIN CR P √

oxymorphone ER G √

RYBIX ODT P

SUBSYS SPRAY P √ √

tramadol G

tramadol ER G √

ULTRAM P

ULTRAM ER P √

XOLOX P

Narcotic Combinations

acetaminophen/codeine G

butalbital/acetaminophen/caffeine/codeine G

butalbital/aspirin/caffeine/codeine G

BUPAP P

CAPITAL/CODEINE P

COCET P

28

COCET PLUS P

FIORICET/CODEINE P

FIORINAL/CODEINE P

hydrocodone/acetaminophen G

hydrocodone/ibuprofen G

IBUDONE P

LIQUICET P

LORCET P

LORCET PLUS P

LORTAB P

MAGNACET P

MAXIDONE P

NORCO P

oxycodone/acetaminophen G

oxycodone/aspirin G

oxycodone/ibuprofen G √

ORBIVAN P

ORBIVAN CF P

pentazocine/acetaminophen G

PERCOCET P

PERCODAN P

PHRENILIN P

REPREXAIN P

ROXICET P

stagesic G

STAFLEX P

SYNALGOS DC P

dihydrocodeine compound capsule G

TYLENOL/CODEINE P

TYLOX P

ULTRACET P

VICODIN P

VICODIN ES P

vicodin HP G

VICOPROFEN P

XODOL P

ZOLVIT P

ZYDONE P

29

Narcotic Partial Agonists

buprenorphine G √

butorphanol G √

buprenorphine/naloxone sublingual tablet G √

BUTRANS P √

pentazocine/naloxone G

SUBOXONE film P √ √

SUBOXONE sublingual tablet P √

SUBUTEX P √

ZUBSOLV P √ √

Postherpetic Neuralgia (PHN) Agent

GRALISE P √

Premenstrual Dysphoric Disorder

SARAFEM P √

fluoxetine (PMDD) G √

Psychotherapeutic and Neurological Agents

ergoloid mesylate G

ORAP P

modafinil G √

NUVIGIL P √

PROVIGIL P √

XYREM P √

Restless Leg Syndrome

HORIZANT P √

Sedative/Hypnotics – Barbiturate

BUTISOL SODIUM P

MEBARAL P

phenobarbital G

SECONAL P

Sedative/Hypnotics – Nonbarbiturates

AMBIEN P √

AMBIEN CR P √

chloral hydrate G

DORAL P

quazepam G

EDLUAR P √ √

estazolam G

flurazepam G

30

HALCION P

INTERMEZZO P √ √

LUNESTA P √

midazolam G

ROZEREM P √ √

SILENOR P √ √

SONATA P √ √

temazepam G

triazolam G

zaleplon G √

zolpidem G √

zolpidem ER G √

ZOLPIMIST P √ √

Miscellaneous

CUVPOSA P

NUEDEXTA P √

Dermatological Agents

Acne Products

ABSORICA P

ACANYA P √

ACZONE P

adapalene G

AKNE-MYCIN P

amnesteem G

ATRALIN P √

avita G

AZELEX P

BENZACLIN P √

BENZAMYCIN P √

BENZEFOAM P

BENZEFOAM ULTRA P √

BENZIQ P

BENZIQ LS P

BENZIQ wash P

benzoyl peroxide G

claravis G

CLARIFOAM EF P

clindamax G

31

clindamycin G

clindamycin/benzoyl peroxide G

DIFFERIN 0.1% cream/gel/lotion P √

DIFFERIN 0.3% gel P

DUAC P √

clindamycin/benzoyl peroxide 1.2-5% gel G

EPIDUO P

erythromycin G

erythromycin/benzoyl peroxide G

EVOCLIN P

FABIOR P √ √

isotretinoin G

KLARON P

lavoclen G

METROCREAM P

METROGEL 1% only P

metronidazole gel 1% G

METROLOTION P

metronidazole G

myorisan G

NEOBENZ P

NORITATE P

NUOX P

pacnex wash G

PACNEX HP P

PACNEX LP P

PACNEX MX P

PLEXION cloth P

PLEXION emulsion P

PLEXION SCT P

RETIN-A P √

RETIN-A MICRO P

RIAX P √

sodium sulfacetamide/sulfur G

SODIUM SULFA LIQ 10% WASH P

sotret G

SSS 10-4 P

SUMADAN WASH P

32

SUMAXIN P

SUMAXIN TS P

tretinoin G

TRETIN-X P √

TRIAZ P

VANOXIDE P

VELTIN P √

ZACARE P

Z-CLINZ P

ZIANA P

Antibiotics – Topical

ALTABAX P

BACTROBAN P

CENTANY P

gentamicin G

mupirocin G

Antifungals – Topical

ALOQUIN P

ciclopirox G

clotrimazole/betamethasone G

econazole G

ERTACZO P

EXELDERM P

HALOTIN P

hydrocortisone/iodoquinol G

ketoconazole G

LOPROX P

LOTRISONE P

NAFTIN P

nystatin G

nystatin/triamcinolone G

OXISTAT P

PENLAC P

VUSION P

XOLEGEL P

Antineoplastics and Keratolytics – Topical

CARAC P

EFUDEX P

33

FLUOROPLEX P

fluorouracil G

LEVULAN KERA P

METVIXIA P

PANRETIN P

PICATO P √

SOLARAZE P

TARGRETIN P

UTOPIC P

Antipruritics and Topical Anesthetics

cocaine hydrochloride G

lidocaine G

lidocaine pad G √

lidocaine/prilocaine G

LIDODERM P √

PLIAGLIS P

prudoxin G

QUTENZA P

SYNERA P

ZONALON P

Antipsoriatics

8-MOP P

acitretin G

calcipotriene G

CALCITRENE P

calcitriol G

DOVONEX P

DRITHO-SCALP P

OXSORALEN-UL P

SORIATANE P

SORILUX P

TACLONEX P

TAZORAC P

VECTICAL P

Antiseborrheic Products

EXTINA P

ketoconazole foam G

SCALACORT DK P

34

selenium sulfide G

SELRX P

sulfacetamide sodium G

Antiviral – Topical

acyclovir G

DENAVIR P

XERESE P

ZOVIRAX P

Corticosteroids – Topical

alclometasone G

amcinonide G

augmented betamethasone dipropionate G

betamethasone valerate G

clobetasol G

CLOBEX spray P

CLOBEX lotion/shampoo P

CLODERM P

CORDRAN P

CUTIVATE P

DERMATOP P

DESONATE P

desonide G

desoximetasone G

diflorasone G

DIPROLENE AF P

ELOCON P

fluocinolone acetonide G

fluocinonide G

fluticasone G

HALOG P

hydrocortisone G

hydrocortisone butyrate G

hydrocortisone valerate G

hydrocortisone/pramoxine G

lidocaine/hydrocortisone G

LOCOID P

LOCOID LIPOCREAM P

LUXIQ P

35

mometasone G

NUZON P

OLUX P

OLUX-E P

prednicarbate G

TACLONEX P

triamcinolone G

ULTRAVATE P

VANOS P

VERDESO P

VYTONE P

Keratolytic/Antimitotic Agents

CONDYLOX P

podofilox G

Immunomodulating Agents – Topical

ALDARA P √

ELIDEL P

imiquimod G √

PROTOPIC P

ZYCLARA P √

Rosacea Agents

FINACEA P

metronidazole G

MIRVASO P √

ORACEA P √

Scabicides & Pediculicides

EURAX P

lindane G

NATROBA P

permethrin G

SKLICE P

spinosad G

ULESFIA P

Sinecatechin

VEREGEN P

Endocrine System

Antidiuretic Agents

DDAVP P

36

desmopressin G

minirin G

STIMATE P

Contraceptives – Emergency-(Applies only to plans with contraceptive coverage)

ELLA P

next choice G

PLAN B P

levonorgesterol tablet 0.75 mg G

Contraceptives – Oral-(Applies only to plans with contraceptive coverage)

altavera G

amethia lo G

amethyst G

apri G

aranelle G

aviane G

BEYAZ P

BREVICON P

briellyn G

camrese G

camrese lo G

cesia G

cryselle G

CYCLESSA P

DESOGEN P

ELLA P

emoquette G

enpresse G

ESTROSTEP FE P

FEMCON P

GENERESS FE P

gianvi G

gildess FE G

jolessa G

junel 1.5/30 G

junel 1/20 G

junel FE 1.5/30 G

junel FE 1/20 G

kariva G

37

kelnor G

leena G

lessina G

levora G

LO LOESTRIN FE P

LO/OVRAL P

LOESTRIN 1.5/30 P

LOESTRIN 1/20 P

LOESTRIN FE P

LOESTRIN FE 1.5/30 P

LOESTRIN-24 P

LOMINISTRIN PAK FE P

loryna G

LOSEASONIQUE P

low-ogestrel G

lutera G

LYBREL P

microgestin 1.5/30 G

microgestin 1/20 G

microgestin FE 1.5/30 G

microgestin FE 1/20 G

MINASTRIN 24 FE P

MIRCETTE P

MODICON 0.5/35 P

mononessa G

NATAZIA P

necon 0.5/35 G

necon 1/35 G

necon 1/50 G

necon 10/11 G

necon 7/7/7 G

NORDETTE P

NORINYL 1+35 P

NORINYL 1+50 P

nortrel 0.5/35 G

nortrel 1/35 G

nortrel 7/7/7 G

ocella G

38

ogestrel G

ORTHO TRI-CYCLEN P

ORTHO TRI-CYCLEN LO P

ORTHO-CEPT P

ORTHO-CYCLEN P

ORTHO-NOVUM 1/35 P

ORTHO-NOVUM 7/7/7 P

OVCON 35 P

OVCON 50 P

portia G

previfem G

QUARTETTE P

quasense G

reclipsen G

SEASONALE P

SEASONIQUE P

amethia G

solia G

sprintec G

sronyx G

syedah G

trinessa G

TRI-NORINYL P

tri-previfem G

tri-sprintec G

trivora G

velivet G

YASMIN P

YAZ P

zarah G

zenchent FE G

zeosa G

zovia 1/35E G

zovia 1/50E G

Contraceptives – Oral Progestins-(Applies only to plans with contraceptive coverage)

camila G

errin G

jolivette G

39

nora-be G

NOR-QD P

ORTHO MICRONOR P

Contraceptives – Transdermal-(Applies only to plans with contraceptive coverage)

ORTHO EVRA P

Contraceptives – Vaginal-(Applies only to plans with contraceptive coverage)

NUVARING P

Diabetes – Alpha-Glucosidase Inhibitors

acarbose G

GLYSET P

PRECOSE P

Diabetes – Amylin Analogs

SYMLIN P

SYMLINPEN P

Diabetes – Biguanides and Combinations

FORTAMET P

glipizide/metformin G

GLUCOPHAGE P

GLUCOPHAGE XR P

GLUCOVANCE P

GLUMETZA P

glyburide/metformin G

METAGLIP P

metformin G

metformin ER G

RIOMET P

Diabetes – Dopamine Receptor Agonist

CYCLOSET P

Diabetes – DPP-IV Inhibitors and Combinations

JANUMET P

JANUMET XR P

JANUVIA P

JENTADUETO P

KOMBIGLYZE XR P

KAZANO P √ √

NESINA P √ √

ONGLYZA P

OSENI P √ √

40

TRADJENTA P

Diabetes – Glucocorticoid Receptor Antagonist

KORLYM P √

Diabetes – Incretin Mimetic Agents

BYDUREON P √

BYETTA P √

VICTOZA P √

Diabetes – Insulin

APIDRA P

HUMALOG products P

HUMULIN products P

LANTUS P

LANTUS SOLOSTAR P

LEVEMIR P

LEVEMIR FLEXPEN P

NOVOLIN products P √

NOVOLOG products P

RELION products P √

Diabetes – Meglitinides and Combinations

nateglinide G

PRANDIMET P

PRANDIN P

repaglinide G

STARLIX P

Diabetes - Sodium-glucose co-transporter 2 (SGLT2) inhibitor

INVOKANA P √ √

Diabetes – Sulfonylureas

AMARYL P

chlorpropamide G

DIABETA P

glimepiride G

glipizide G

glipizide ER G

glipizide XL G

GLUCOTROL P

GLUCOTROL XL P

glyburide G

glyburide micronized G

41

GLYNASE P

tolazamide G

tolbutamide G

Diabetic Supplies

BD insulin syringes P

BD lancets P

BD pen needles P

FREESTYLE glucose test strips P √

FREESTYLE LITE glucose test strips P √

FREESTYLE INSULINX P √

glucose test strips (any other brand name) P √ √

All Brand insulin syringes P

insulin syringes (any generic) G

All Brand lancets P

lancets (any generic) G

ONE TOUCH FAST TAKE glucose test strips P √

ONE TOUCH ULTRA glucose test strips P √

ONE TOUCH VERIO IQ glucose test strips P √

All Brand pen needles P

pen needles (any generic) G

PRECISION QID glucose test strips P √

PRECISION SOF-TACT glucose test strips P √

PRECISION XTRA glucose test strips P √

PRECISION XTRA ketone test strips P √

Diabetes – Thiazolidinediones (TZDs) and Combinations

ACTOPLUS MET P

pioglitazone/metformin G

ACTOPLUS MET XR P

ACTOS P

pioglitazone G

AVANDAMET P

AVANDARYL P

AVANDIA P

DUETACT P

pioglitazone/glimepiride G

JUVISYNC P

Gaucher Disease

ZAVESCA P

42

Glucose Elevating Agent

PROGLYCEM P

Gout Agents

allopurinol G

COLCRYS P

probenecid G

probenecid/colchicine G

ULORIC P √

ZYLOPRIM P

Hereditary Tyrosinemia

ORFADIN P

Homocystinuria

CYSTADANE P

Hormone Replacement – Androgens

ANDRODERM P √ √

ANDROGEL P √

AXIRON P √ √

danazol G

FORTESTA P √ √

STRIANT P √ √

TESTIM P √

Hormone Replacement – Estrogens

ALORA P √

CENESTIN P

CLIMARA P √

DIVIGEL P

ELESTRIN P

ENJUVIA P

ESTRACE P

ESTRADERM P √

estradiol patch G √

estradiol tablet G

ESTRASORB P

ESTROGEL P

estropipate G

EVAMIST P

MENEST P

MENOSTAR P √

43

MINIVELLE P √

ortho-est G

PREMARIN P

VIVELLE-DOT P √

Hormone Replacement – Estrogen Combinations

ACTIVELLA P

ANGELIQ P

CLIMARA PRO P √

COMBIPATCH P √

estradiol/norethindrone acetate G

FEMHRT P

FEMHRT LOW DOSE P

FEMTRACE P

jinteli G

PREFEST P

PREMPHASE P

PREMPRO P

Hormone Replacement – Progestins

medroxyprogesterone acetate G

norethindrone acetate G

progesterone micronized cap G

PROMETRIUM P

Hyperammonemia

RAVICTI P √

sodium phenylbutyrate G

Hyperparathyroidism

HECTOROL P

SENSIPAR P

ZEMPLAR P

LHRH/GnRH Agonist Analog Pituitary Suppressants

SYNAREL P

Metabolic Modifiers

CARNITOR P

SUCRAID P

Phenylketonuria

KUVAN P

Steroids – Glucocorticosteroids

budesonide SR G √

44

cortisone AC G

dexamethasone G

ENTOCORT EC P √

FLO-PRED P

hydrocortisone G

methylprednisolone G

MILLIPRED P

ORAPRED P

prednisolone G

prednisone G

RAYOS P √

VERIPRED P

Steroids – Mineralocorticoid

fludrocort G

Thyroid Hormones

ARMOUR THYROID P

CYTOMEL P

levothroid G

levothyroxine G

levoxyl G

liothyronine sodium G

SYNTHROID P

THYROLAR P

TIROSINT P

unithroid G

Thyroid – Antithyroid Agents

methimazole G

propylthiouracil G

TAPAZOLE P

Vasopressin Receptor Antagonist

SAMSCA P

Gastrointestinal System

Acid Suppressants – H-2 Antagonists

AXID P

cimetidine G

famotidine G

nizatidine G

PEPCID P

45

ranitidine G

ZANTAC P

Acid Suppressants – Proton Pump Inhibitors

ACIPHEX P √ √

DEXILANT P √

ESOMEPRAZOLE STRONTIUM P √ √

lansoprazole G √

lansoprazole ODT G √

NEXIUM P √

omeprazole G √

omeprazole/bicarbonate G √

pantoprazole G √

PREVACID P √ √

PREVACID SOLUTAB P √ √

PRILOSEC P √ √

PROTONIX P √ √

ZEGERID P √ √

Anal Fissure

RECTIVE P

HIV-Related Antidiarrheal

FULYZAQ P √

Antiemetics – 5-HT3 Receptor Antagonists

ANZEMET tablet P √

DICLEGIS P √

granisetron G √

GRANISOL P √

ondansetron G √

ondansetron ODT G √

SANCUSO PAD P √

ZOFRAN P √

ZOFRAN ODT P √

ZUPLENZ P √

Antiemetics – Anticholinergic

TRANSDERM-SCOP P

trimethobenzamide G

Antiemetics – Miscellaneous

CESAMET P √

dronabinol G

46

EMEND capsule P √

MARINOL P

Anti-Ulcer Drugs

misoprostol G

sucralfate G

Bowel Evacuants

COLYTE P

gavilyte-g G

GOLYTELY P

HALFLYTELY P

MOVIPREP P

NULYTELY P

OSMOPREP P

peg 3350 G

polyethylene glycol G

PREPOPIK P

trilyte G

SUCLEAR KIT P

SUPREP P

VISICOL P

Chronic Constipation Agents

AMITIZA P

LINZESS P √

Gallstone Solubilizing Agents

CHENODAL P

URSO 250 P

URSO FORTE P

ursodiol G

GI Antiallergy Agents

cromolyn sodium concentrate G

GASTROCROM P

GI Stimulants

metoclopramide G

METOZOLV ODT P

H. pylori Agents

HELIDAC P

lansoprazole/amoxicillin/clarithromycin P

OMECLAMOX-PAK P

47

PREVPAC P

PYLERA P

Inflammatory Bowel Agents

APRISO P √

ASACOL P √

ASACOL HD P √

AZULFIDINE P √

AZULFIDINE ENTABS P √

balsalazide G √

CANASA P √

COLAZAL P √

DELZICOL P √

DIPENTUM P √

GIAZO P √

LIALDA P √

mesalamine G

PENTASA P √

sulfasalazine G √

sulfasalazine ER G √

sulfazine G √

sulfazine EC G √

UCERIS P √

Irritable Bowel Syndrome (IBS) Agent

LOTRONEX P

Laxatives

KRISTALOSE P

lactulose G

Pancreatic Enzymes

CREON P

DIGEX P

PANCRELIPASE P

PANCREAZE P

PERTZYE P √

ULTRESA P √

VIOKACE P √

ZENPEP P

Rectal Steroids

colocort G

48

CORTIFOAM P

Genitourinary System

Cystinosis Agents

CYSTAGON P

PROCYSBI P √ √

Interstitial Cystitis Agent

ELMIRON P √

Phosphate Binders

calcium acetate G

ELIPHOS P

FOSRENOL P

PHOSLO P

PHOSLYRA P

RENAGEL P √

RENVELA P

Prostatic Hypertrophy Agents

alfuzosin G

AVODART P

CARDURA XL P

CIALIS 2.5 mg, 5 mg P √

finasteride G

FLOMAX P

JALYN P

PROSCAR P

RAPAFLO P

tamsulosin G

UROXATRAL P

Urinary Antispasmodics

bethanechol G

DETROL P √

DETROL LA P √

DITROPAN XL P √

ENABLEX P

flavoxate G

hyoscyamine G

oxybutynin G

oxybutynin ER G

GELNIQUE P

49

MYRBETRIQ P √

OXYTROL P √

SANCTURA P √

SANCTURA XR P √

tolterodine G

TOVIAZ P √

trospium G

URECHOLINE P

VESICARE P

Urinary Anti-infectives and Combinations

MACROBID P

methenamine hippurate G

methenamine mandelate G

MONUROL P

nitrofurantoin G

nitrofurantoin monohydrate macrocrystal G

UREX P

URIBEL P

URIMAR-T P

UTA P

Vaginal Anti-infectives

CLEOCIN VAGINAL P

clindamax G

METROGEL VAGINAL P

nystatin vaginal G

TERAZOL P

terconazole G

tioconazole G

vandazole G

zazole G

Vaginal Estrogens

ESTRACE VAGINAL P

ESTRING P

FEMRING P

PREMARIN VAGINAL P

VAGIFEM P

Vaginal Progestins

CRINONE P

50

ENDOMETRIN P

PROGESTERONE VAGINAL P

Infections and Infestations

Antibacterials – Aminoglycosides

neomycin G

paromomycin G

Antibacterials – Ampicillins and Combinations

amoxicillin G

amoxicillin/K clavulanate G

amoxicillin/K clavulanate SR G

ampicillin G

AUGMENTIN P

AUGMENTIN ES P

AUGMENTIN XR P

MOXATAG P

Antibacterials – Cephalosporins, 1st Generation

cefadroxil G

cephalexin G

Antibacterials – Cephalosporins, 2nd Generation

cefaclor G

cefaclor ER G

cefprozil G

CEFTIN P

cefuroxime G

Antibacterials – Cephalosporins, 3rd Generation

CEDAX P

cefdinir G

cefditoren G

cefpodoxime G

SPECTRACEF P

SUPRAX P

Antibacterials – Fluoroquinolones

AVELOX P

AVELOX ABC P

CIPRO P

ciprofloxacin G

ciprofloxacin ER G

FACTIVE P

51

LEVAQUIN P

levofloxacin G

NOROXIN P

ofloxacin G

Antibacterials – Ketolide

KETEK P

Antibacterials – Macrolides

azithromycin G

BIAXIN P

BIAXIN XL P

clarithromycin G

clarithromycin SR G

DIFICID P √

e.e.s. G

erythrocin G

erythromycin G

erythromycin delayed release particles G

erythromycin ethylsuccinate G

PCE P

ZITHROMAX P

ZMAX P

Antibacterials – Miscellaneous

clindamycin G

metronidazole G

NEBUPENT P

tinidazole G

TINDAMAX P

trimethoprim G

XIFAXAN P √

ZYVOX P

Antibacterials – Penicillins

dicloxacillin sodium G

penicillin VK G

Antibacterials – Sulfonamide

sulfadiazine G

Antibacterials – Tetracyclines

ADOXA P

avidoxy G

52

demeclocycline G

DORYX P

doxycycline hyclate G

doxycycline monohydrate G

DYNACIN P

MINOCIN P

minocycline G

MONODOX P

NUTRIDOX P

ORAXYL P

SOLODYN P

tetracycline G

VIBRAMYCIN P

Antifungals

ANCOBON P

BIO-STATIN P

clotrimazole troche G

DIFLUCAN (all other strengths) P

DIFLUCAN 150 mg P √

fluconazole (all other strengths) G

fluconazole 150 mg G √

flucytosine G

GRIFULVIN V P

GRIS-PEG P

itraconazole G

ketoconazole G

LAMISIL P

NOXAFIL P

nystatin G

ONMEL P

ORAVIG P √

SPORANOX P

terbinafine G

VFEND P

voriconazole G

Anti-infective Agents – Miscellaneous

colistimethate sodium G

COLY-MYCIN M P

53

Antimalarials and Combinations

ARALEN P √

atovaquone/proguanil G

chloroquine G √

COARTEM P

DARAPRIM P

hydroxychloroquine G √

MALARONE P

mefloquine G

PLAQUENIL P √

primaquine G

QUALAQUIN P √

quinine sulfate G √

Antimycobacterial Agents

dapsone G

ethambutol G

isonarif G

isoniazid G

MYAMBUTOL P

pyrazinamide G

RIFAMATE P

rifampin G

RIFATER P

Antiprotozoal Agents

ALINIA P

MEPRON P

Antiretrovirals – Chemokine Receptor Antagonist

SELZENTRY P

Antiretrovirals – Integrase Inhibitors

ISENTRESS P

TIVICAY P

Antiretrovirals – NRTI/NNRTI Combination

ATRIPLA P

Antiretrovirals – NRTI/NNRTI/HIV integrase Combination

STRIBILD P

Antiretrovirals – Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

EDURANT P

INTELENCE P

54

nevirapine G

RESCRIPTOR P

SUSTIVA P

VIRAMUNE P

VIRAMUNE XR P

Antiretrovirals – Nucleoside (NRTI) and Nucleotide (NtRTI) Analogs

abacavir G

COMBIVIR P

COMPLERA P

didanosine delayed-release G

EMTRIVA P

EPIVIR P

EPZICOM P

lamivudine G

lamivudine/zidovudine G

RETROVIR P

stavudine G

TRIZIVIR P

TRUVADA P

VIDEX P

VIDEX EC P

VIREAD P

ZERIT P

ZIAGEN P

zidovudine G

Antiretrovirals – Protease Inhibitors

APTIVUS P

CRIXIVAN P

INVIRASE P

KALETRA P

LEXIVA P

NORVIR P

PREZISTA P

REYATAZ P

VIRACEPT P

Antituberculin

SIRTURO P √

55

Antivirals – CMV Agent

VALCYTE P √

Antivirals – Hepatitis Agents

adefovir dipivoxil P

BARACLUDE P

COPEGUS P

EPIVIR HBV P

HEPSERA P

INCIVEK P √

REBETOL P

ribatab P

ribapak G

ribasphere G

ribavirin G

TYZEKA P

VICTRELIS P √

Antivirals – Herpes Agents

acyclovir G

FAMVIR P √

famciclovir G √

valacyclovir G

VALTREX P

ZOVIRAX P

Antivirals – Influenza Agents

FLUMADINE P

RELENZA P √

rimantadine G

TAMIFLU P √

Antivirals – Respiratory Syncytial Virus (RSV) Agent

VIRAZOLE P

Musculoskeletal System

Antimyasthenic Agents

MESTINON P

MESTINON TIMESPAN P

pyridostigmine G

Antirheumatic Agents

ARAVA P

leflunomide G

56

RHEUMATREX P

RIDAURA P

Muscle Relaxants and Combinations

AMRIX P √

baclofen G

carisoprodol G

carisoprodol/aspirin G

carisoprodol/aspirin/codeine G

chlorzoxazone G

cyclobenzaprine G

cyclobenzaprine ER G

DANTRIUM P

dantrolene G

FEXMID P √

LORZONE P

metaxalone G

methocarbamol G

orphenadrine ER G

orphenadrine/aspirin/caffeine G

SKELAXIN P

tizanidine G

ZANAFLEX P

NSAIDs

ARTHROTEC P

CELEBREX P √

DAYPRO P

DUEXIS P √ √

diclofenac G

diclofenac potassium G

diclofenac sodium XR G

etodolac G

etodolac ER G

fenoprofen G

FLECTOR patch P √

flurbiprofen G

ibuprofen G

indomethacin G

indomethacin ER G

57

ketoprofen G

ketoprofen ER G

ketorolac G √

meclofenamate sodium G

mefenamic acid G √

meloxicam G

MOBIC P

nabumetone G

NAPRELAN P

naproxen G

oxaprozin G

piroxicam G

PENNSAID P √ √

PONSTEL P √

SPRIX P √

sulindac G

tolmetin sodium G

VIMOVO P √ √

VOLTAREN P

VOLTAREN GEL P √ √

VOLTAREN XR P

ZIPSOR P

Osteoporosis/Bone Modifying Agents

ACTONEL P √

alendronate G √

ATELVIA P √

BINOSTO P √ √

BONIVA tablet P √ √

calcitonin salmon nasal G

DIDRONEL P

etidronate G

fortical G

FOSAMAX P √

FOSAMAX PLUS D P √ √

ibandronate tablet G √

MIACALCIN NASAL P

SKELID P

58

Rheumatoid Arthritis

XELJANZ P √

Selective Estrogen Receptor Modulator (SERM)

EVISTA P

Ophthalmic Agents

Glaucoma – Adrenergic Agents

ALPHAGAN P P

apraclonidine G

brimonidine G

IOPIDINE P

Glaucoma – Beta-blockers

betaxolol ophthalmic G

BETIMOL P

BETOPTIC-S P

carteolol G

ISTALOL P

levobunolol G

metipranolol G

OPTIPRANOLOL P

timolol ophthalmic G

Glaucoma – Carbonic Anhydrase Inhibitors

AZOPT P

dorzolamide G

dorzolamide/timolol G

COSOPT P

COSOPT PF P

COMBIGAN P

SIMBRINZA P

TRUSOPT P

Glaucoma – Miotics

ISO CARBACHOL P

ISOPTO CARPINE P

PHOSPHOLINE P

pilocarpine G

PILOPINE HS P

Glaucoma – Prostaglandins

latanoprost G

LUMIGAN 0.01% P

59

LUMIGAN 0.03% P

TRAVATAN Z P

XALATAN P

ZIOPTAN P √

Ophthalmic Miscellaneous

CYSTARAN P √

Ophthalmic Antihistamines and NSAIDs

ACULAR P

ACULAR LS P

ACUVAIL P

ALAMAST P

ALOCRIL P

ALOMIDE P

azelastine ophthalmic G

BEPREVE P

BROMDAY P

bromfenac G

cromolyn sodium ophthalmic G

diclofenac ophthalmic G

ELESTAT P

EMADINE P

epinastine G

flurbiprofen ophthalmic G

ILEVRO P

ketorolac tromethamine ophthalmic G

LASTACAFT P

NEVANAC P

OPTIVAR P

PATADAY P

PATANOL P √

PROLENSA P

VOLTAREN P

Ophthalmic Anti-infectives

AZASITE P

bacitracin G

bacitracin/neomycin/polymyxin G

bacitracin/polymyxin G

BESIVANCE P

60

ciprofloxacin G

erythromycin G

gentamicin G

IQUIX P

levofloxacin G

neomycin/polymyxin/gramicidin G

ofloxacin G

polymyxin B/trimethoprim G

QUIXIN P

sulfacetamide sodium G

tobramycin G

trifluridine G

triple antibiotic G

VIGAMOX P

ZIRGAN P

ZYMAXID P

Ophthalmic Immunomodulator

RESTASIS P

Ophthalmic Steroidal Anti-inflammatory Drugs

ALREX P

bacitracin/polymyxin/neomycin/ hydrocortisone

G

BLEPHAMIDE S.O.P. P

dexamethasone phosphate G

dexamethasone/neomycin/polymyxin G

DUREZOL P

fluorometholone G

fluor-op G

FML FORTE P

FML LIQUIFILM P

FML S.O.P. P

LOTEMAX OINT P

LOTEMAX SUS P

neomycin/polymyxin/hydrocortisone G

poly-dex G

PRED-G P

PRED-G S.O.P P

prednisolone G

61

sulfacetamide sodium/prednisolone G

tobramycin/dexamethasone G

TOBRADEX P

TOBRADEX ST P

VEXOL P

ZYLET P

Otic Agents

Otic Analgesic

PINNACAINE P

Otic Anti-infectives

ciprofloxacin otic G

ofloxacin otic G

Otic Combinations

acetic acid/antipyrine/benzocaine/polycosanol

G

antipyrine/benzocaine G

CETRAXAL P

CIPRO HC P

CIPRODEX P

COLY-MYCIN S P

cortomycin G

myoxin G

neomycin/polymyxin/hydrocortisone G

NEOTIC P

otozin G

TREAGAN P

TRIOXIN P

ZINOTIC P

ZINOTIC ES P

Respiratory Tract Agents

Antiasthmatics – Anticholinergics

ATROVENT HFA P

ipratropium inhaler G

SPIRIVA P

TUDORZA P

Anti-Inflammatory Agents (nebulizer)

cromolyn sodium nebulizer G

62

Bronchodilators – Sympathomimetics

ACCUNEB P

ADVAIR DISKUS P √

ADVAIR HFA P √

albuterol G

ARCAPTA P

BREO ELLIPTA P √ √

BROVANA P

COMBIVENT RESPIMAT P

COMBIVENT P

DULERA P

DUONEB P

FORADIL P

ipratropium/albuterol G

levalbuterol G

MAXAIR AUTOHALER P √

metaproterenol G

PERFOROMIST P

PROAIR HFA P

PROVENTIL HFA P

SEREVENT DISKUS P

SYMBICORT P

terbutaline G

VENTOLIN HFA P √

VOSPIRE ER P

XOPENEX P √

XOPENEX HFA P √

Bronchodilators – Xanthines

aminophylline G

THEO-24 P

theochron G

theophylline ER G

Cystic Fibrosis Agents

CAYSTON P

KALYDECO P √

PULMOZYME P

TOBI P

63

TOBI PODHALER P √

Inhaled Corticosteroids

ALVESCO P

ASMANEX P

budesonide inhalation susp G

FLOVENT DISKUS P

FLOVENT HFA P

PULMICORT FLEXHALER P

PULMICORT RESPULES P

QVAR P

Leukotriene Modulators

ACCOLATE P √

zafirlukast G √

SINGULAIR P √

montelukast G √

ZYFLO P √

ZYFLO CR P √

Mouth and Throat Products

cevimeline G

EVOXAC P

pilocarpine G

SALAGEN P

Nasal Antiallergy

ASTELIN NASAL P

ASTEPRO P

azelastine nasal G

DYMISTA P

PATANASE P

Nasal Anti-infective

BACTROBAN NASAL P

Nasal Anticholinergics

ATROVENT NASAL P

ipratropium nasal G

Nasal Steroids

BECONASE AQ P

FLONASE P

flunisolide G

64

fluticasone nasal G

NASACORT AQ P √

NASONEX P

QNASL P

OMNARIS P

RHINOCORT AQ P √

triamcinolone nasal G

VERAMYST P

ZETONNA P √

Non-Sedating Antihistamines and Combinations

CLARINEX P √

CLARINEX-D P √

CLARINEX REDITAB P √

desloratadine G √

desloratadine ODT G √

levocetirizine G √

XYZAL P √

Selective Phosphodiesterase 4 (PDE4) Inhibitor

DALIRESP P √

Upper Respiratory – Cough/Cold/Allergy Combinations

hydrocodone/chlorpheniramine polistirex G

SEMPREX-D P √

TUSSICAPS P

TUSSIONEX P

VITUZ P

Miscellaneous

Immunosuppressive Agents

ASTAGRAF XL P

AZASAN P

azathioprine G

CELLCEPT P

cyclosporine G

cyclosporine modified G

gengraf G

IMURAN P

MYFORTIC P

mycophenolate G

NEORAL P

65

PROGRAF P

RAPAMUNE P

SANDIMMUNE P

tacrolimus G

ZORTRESS P

Vasomotor Associated with Menopause

BRISDELLE P √ √

Wilson's Disease

DEPEN TITRATABS P

SYPRINE P

CUPRIMINE P