A Reference Guide - Blue Cross Blue Shield of RI...A Reference Guide INTRODUCTION Below you’ll find the Blue Cross & Blue Shield of Rhode Island (BCBSRI) formulary, which is a list

BCBSRI Large Group 4‐Tier Formulary (Drug List)*

Effective April 1, 2016 to October 1, 2016

A Reference Guide

INTRODUCTION

Below you’ll find the Blue Cross & Blue Shield of Rhode Island (BCBSRI) formulary, which is a list of the prescription drugs covered under your health plan. Our formulary offers a wide range of medications from which to choose and is reviewed periodically by BCBSRI’s Pharmacy and Therapeutics Committee. This committee, which is made up of local, community‐based practicing physicians and pharmacists, evaluates the medications on the formulary for safety and effectiveness and helps to ensure that BCBSRI members have access to medications that support their health.

CONTROLLING COSTS

The BCBSRI formulary divides covered drugs into five “tiers.” Each tier has a corresponding copayment. This allows us to better manage the overall cost of providing prescription drug benefits to our members, while also helping you control what you pay out‐of‐pocket for your medications.

We realize that the BCBSRI formulary may not include every drug from every manufacturer. However, choosing medications from the BCBSRI formulary, when appropriate, can provide you with access to the medications you need—at the most affordable cost.

THE FIVE TIERS

First Tier: Includes generic prescription drugs that have the lowest copayment.

Second Tier: Includes generic prescription drugs that have a higher copayment than the first tier.

Third Tier: Includes high‐cost generic prescription drugs and preferred brand name prescription drugs, which have a higher copayment than the second tier.

Fourth Tier: Includes preferred specialty prescription drugs, which have a higher copayment than the third tier.

HOW TO USE THE FORMULARY REFERENCE GUIDE

This formulary reference guide lists generic drugs first in each drug category. The preferred brand name products are listed next, and non‐preferred brand products are listed last.

PLEASE NOTE: If a generic drug is listed in the “generics” section and its corresponding brand name product is not listed in the “preferred brand name” section, then only the generic drug is on the formulary. If a brand name product is listed in the “preferred brand name” section and its corresponding generic product is not listed in the “generics” section, then a generic version of the medication is not available.

CONSIDERING PREFERRED ALTERNATIVES This formulary reference guide lists possible preferred alternatives for commonly prescribed non‐ preferred medications. However, pharmacists cannot substitute a preferred brand name drug without the prescriber’s approval and will contact the prescriber to obtain authorization to dispense an alternative preferred product when a non‐preferred product has been prescribed.

SAVING ON OUT‐OF‐POCKET COSTS Your health plan’s prescription drug coverage encourages the use of generic and preferred brand name drugs. Choosing non‐preferred drugs may mean paying higher out‐of‐pocket expenses (such as coinsurance, copayments, and deductible amounts) or not receiving coverage at all. You will have lower copayments when you use generic drugs. If you use a brand name drug when there is a generic alternative available, you may be asked to pay the cost difference.

CONSULTING THE PRESCRIBER’S OFFICE WHEN APPROPRIATE BCBSRI’s formulary may provide coverage only for certain medications or for particular uses, time periods, doses, or quantities (for example, the formulary may exclude coverage for medications for unapproved, unproven, or cosmetic indications, as well as over‐the‐counter medications).

When prescription drug coverage is provided based on use or quantity, certain limits may apply. Your prescriber may request an exception based upon your individual circumstances. Contact BCBSRI for additional information to determine whether coverage is available under your plan. Members who are unsure whether these coverage rules apply for a particular medication can consult their BCBSRI subscriber agreement or contact a BCBSRI Customer Service representative to determine specific coverage requirements.

*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your health plan’s benefit design determines what is covered and the applicable copayment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of BCBSRI. The presence of a medication on this formulary list does not guarantee coverage. Certain therapeutic classes are routinely designated as formulary exclusions and are not eligible for coverage. These classes include but are not limited to: Weight Loss, Erectile Dysfunction, Smoking Cessation, OTC status products and drugs with OTC equivalents, Vaccines, products with DESI designations and experimental drugs. Most brand name drugs with generic equivalents are not covered. To see the most up‐to‐date formulary, please visit your member home page on bcbsri.com. You may also call Customer Service at the number listed on the back of your member ID card.

Table of Contents

ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

CEPHALOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

FIRST GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SECOND GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

THIRD GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

FOURTH GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

MACROLIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

QUINOLONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SULFONAMIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

AMEBICIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

MISC. ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ANTINEOPLASTICS, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ALKYLATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ANTIMETABOLITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

MITOTIC INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ENZYME INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

TOPOISOMERASE I INHIBITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTINEOPLASTICS MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CHEMOTHERAPY RESCUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTINEOPLASTIC COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CARDIOVASCULAR DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CARDIAC GLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTIANGINAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CALCIUM CHANNEL BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTIARRHYTHMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ACE INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ANGIOTENSIN RCPTR BLOCKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

DIRECT RENIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ANTIHYPERTENSIVES MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ANTIHYPERTENSIVE COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

DIURETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

CARDIOVASCULAR - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

DERMATOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ACNE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ROSACEA AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ANTIBIOTICS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ANTIFUNGALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ANTIVIRALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTI-INFLAMMATORY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTIPRURITICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTIPSORIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTISEBORRHEIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

CORTICOSTEROIDS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

IMMUNOMODULATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

DERMATOLOGICALS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

ENDOCRINE AND METABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

CORTICOSTEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

ESTROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

PROGESTINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

ANTIDIABETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

AMYLIN ANALOGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

INCRETIN MIMETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

SULFONYLUREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

BIGUANIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

MEGLITINIDE ANALOGUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

DIABETIC OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ALPHA-GLUCOSIDASE INHIBIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

DPP-4 INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

INSULIN SENSITIZING AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ANTIDIABETIC COMBINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

BISPHOSPHONATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

CALCITONINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

PARATHYROID HORMONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

RANK LIGAND INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

HORMONE RECEPTOR MDLTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

FERTILITY REGULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

LHRH/GNRH AGONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GNRH/LHRH ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GROWTH HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

SOMATOMEDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

SOMATOSTATIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GH RECEPTOR ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

POSTERIOR PITUITARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

CORTICOTROPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

PROLACTIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

VASOPRESSIN ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

PROGESTERONE ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

METABOLIC MODIFIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

THYROID AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GASTROINTESTINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANTACIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

GASTROINTESTINAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

GENITOURINARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

URINARY ANTISPASMODICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

VAGINAL PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

GENITOURINARY - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

HEMATOLOGICAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

HEMATOLOGICAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

MOUTH/THROAT/DENTAL AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

NEUROLOGY, CNS, PSYCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

ANTIANXIETY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

ADHD, NARCOLEPSY, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

ANTICONVULSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ANTIPARKINSON AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

NEUROLOGY, PSYCH - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

MUSCULOSKELETAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

OPHTHALMOLOGY AND OTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

ARTIFICIAL TEAR/LUBRICANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

BETA-BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

OPHTHALMIC STEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

PROSTAGLANDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

CYCLOPLEGIC MYDRIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

DECONGESTANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

MIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

ADRENERGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

LOCAL ANESTHETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

OPHTHALMICS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

ANALGESICS - NONNARCOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

ANALGESICS - OPIOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

ANTI-INFLAMMATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

LOCAL ANESTHETICS-INJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

RESPIRATORY, ALLERGY, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

NASAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

COUGH/COLD/ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

ANTIASTHMATIC/COPD AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

RESPIRATORY AGENTS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

MULTIVITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

MISCELLANEOUS AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

NON PREFERRED

Maxipime

MACROLIDES

April 2016

TIER 01 GENERIC

azithromycin

ANTI-INFECTIVES

clarithromycin

clarithromycin ER

PENICILLINS

erythromycin

TIER 01 GENERIC

erythromycin base

amoxicillin

erythromycin ethylsuccinate

amoxicillin ER

TIER 03 NON PREFERRED

amoxicillin/clavulanate potassium

DificidST

amoxicillin/clavulanate potassium ER

E.E.S. Granules

ampicillin

Ery-TAB

ampicillin sodium

Eryped 200

ampicillin-sulbactam

Eryped 400

dicloxacillin sodium

Erythrocin Stearate

nafcillin sodium

PCE

oxacillin sodium

Zmax

penicillin v potassium

penicillin G potassium

TETRACYCLINES

penicillin G procaine

TIER 01 GENERIC

penicillin G sodium

demeclocycline HCL


doxycycline

Augmentin

doxycycline hyclate

Bicillin C-R

doxycycline monohydrate

Bicillin L-A

minocycline HCL

Moxatag

tetracycline HCL

TIER 02 FORMULARY

CEPHALOSPORIN

doxycycline hyclate DR

FIRST GENERATION

minocycline HCL ER

TIER 01 GENERIC


cefadroxil

Ocudox

cefazolin sodium

Targadox

cephalexin

Vibramycin

SECOND GENERATION

TIER 01 GENERIC

QUINOLONES

cefaclor

TIER 01 GENERIC

cefaclor ER

ciprofloxacin

cefotetan

ciprofloxacin ER

cefoxitin sodium

ciprofloxacin HCL

cefprozil

levofloxacin

cefuroxime axetil

moxifloxacin HCL

cefuroxime sodium

ofloxacin



Cefotan

Factive

Ceftin

Noroxin

THIRD GENERATION

TIER 01 GENERIC

AMINOGLYCOSIDES

cefdinir

cefditoren pivoxil TIER 01 GENERIC

cefixime amikacin sulfate

cefotaxime sodium gentamicin sulfate

cefpodoxime proxetil gentamicin sulfate pediatric

ceftazidime neomycin sulfate

ceftibuten paromomycin sulfate

ceftriaxone sodium streptomycin sulfate

TIER 02 FORMULARY tobramycin sulfate

Suprax Cap Tab, Chew Tab, 500mg/5 Susp TIER 04 SPECIALTY

tobramycin

TIER 03 NON PREFERRED BethkisPA

Cedax Kitabis PAK

Fortaz Tobi PodhalerPA

Spectracef

FOURTH GENERATION SULFONAMIDES

TIER 01 GENERIC

TIER 01 GENERIC

cefepime

sulfadiazine

TIER 03

Effective April 1, 2016

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 1

ANTIMYCOBACTERIAL AGENTS

Norvir

TIER 01 GENERIC

Prezista

cycloserine

Rebetol

ethambutol HCL

Rescriptor

isoniazid

Reyataz

pyrazinamide

Ribasphere Ribapak

rifabutin

Rimantalist

rifampin

Selzentry

TIER 02 FORMULARY

Sustiva

Paser

Truvada

Priftin

Rifater

Viracept

Trecator

Viramune


Virazole

Capastat Sulfate

Viread

Rifamate

Sirturo


Atripla

ANTIFUNGALS

Baraclude

TIER 01 GENERIC

Complera

amphotericin b

Epzicom

fluconazole

Evotaz

flucytosine

Genvoya

griseofulvin microsize

Odefsey

griseofulvin ultramicrosize

Prezcobix

itraconazolePA

Relenza Diskhaler

ketoconazole

SitavigQL,PA

nystatin

Stribild

terbinafine HCL

Tamiflu QL

voriconazole

Tivicay


Triumeq

Cresemba

Tyzeka

LamisilPA

Videx Pediatric

Noxafil

Vitekta

SporanoxPA

Ziagen

Terbinex

TIER 04 SPECIALTY

DaklinzaPA

ANTIVIRALS

Fuzeon

TIER 01 GENERIC

HarvoniPA

abacavir

Peg-intronPA

abacavir sulfate/lamivudine/zidovudine

Peg-intron RedipenPA

acyclovir

Peg-intron Redipen PAK 4PA

adefovir dipivoxil

PegasysPA

didanosine

Pegasys ProclickPA

entecavir

PegintronPA

famciclovir

SovaldiPA

lamivudine

VictrelisQL,PA

lamivudine/zidovudine

nevirapine

ANTIMALARIALS

nevirapine ER

TIER 01 GENERIC

rimantadine HCL

atovaquone/proguanil HCL

stavudine

chloroquine phosphate

valacyclovir HCL

hydroxychloroquine sulfate

valganciclovir

mefloquine HCL

zidovudine

primaquine phosphate

TIER 02 FORMULARY

quinine sulfate

ribavirin

TIER 02 FORMULARY

Aptivus

Daraprim

Crixivan


Edurant

Coartem

Emtriva

Epivir HBV

AMEBICIDES

Intelence

TIER 02 FORMULARY

Invirase

Yodoxin

Isentress

Kaletra

ANTHELMINTICS

Lexiva

TIER 01 GENERIC

ivermectin



TIER 02 FORMULARY SPECIALTY

Albenza capecitabinePA

Biltricide

TIER 03 NON PREFERRED HORMONAL AGENTS

Emverm

TIER 01 GENERIC

anastrozole

MISC. ANTI-INFECTIVES

bicalutamide

TIER 01 GENERIC exemestane

atovaquone flutamide

aztreonam letrozole

bacitracin leuprolide acetate

clindamycin palmitate HCL megestrol acetate

clindamycin phosphate tamoxifen citrate

TIER 02 FORMULARY

clindamycin HCL Emcyt

colistimethate sodium Lysodren

dapsone Nilandron

lincomycin HCL Soltamox

lincomycin/lidocaine TIER 03 NON PREFERRED

linezolid Depo-provera

metronidazole Fareston

polymyxin b sulfate TIER 04 SPECIALTY

sulfamethoxazole/trimethoprim EligardPA

sulfamethoxazole/trimethoprim DS Firmagon

tinidazole Lupron DepotPA (7.5, 22.5, 30, 45mg only)

trimethoprim Trelstar

vancomycin HCL Trelstar Mixject

TIER 02 FORMULARY Vantas

Flagyl ER XtandiQL,PA

Nebupent Zoladex

Primsol ZytigaQL,PA


Alinia IMMUNOMODULATORS

Invanz

TIER 01 GENERIC

Ketek

azathioprine

Lincocin

cyclosporine

Pentam 300

cyclosporine modified

Sivextro

mycophenolate mofetil

XifaxanPA

mycophenolic acid DR

TIER 04 SPECIALTY

sirolimus

Cayston

tacrolimus

TIER 02 FORMULARY

ANTINEOPLASTICS, ETC.

Azasan


ALKYLATING AGENTS

Astagraf XL

TIER 01 GENERIC

Cellcept

cyclophosphamide

Imuran

lomustine

Neoral

TIER 02 FORMULARY

Prograf

Alkeran

Rapamune

Hexalen

Sandimmune

Leukeran

Zortress

Myleran

TIER 04 SPECIALTY


PomalystQL,PA

RevlimidQL,PA

TIER 04 SPECIALTY

ThalomidPA

temozolomidePA

ValchlorPA

MITOTIC INHIBITORS

TIER 01 GENERIC

ANTIMETABOLITES

etoposide

TIER 01 GENERIC

mercaptopurine

ENZYME INHIBITORS

methotrexate

TIER 04 SPECIALTY

methotrexate sodium

imatinib mesylatePA

TIER 02 FORMULARY

AfinitorPA

Purixan

Afinitor DisperzPA

Trexall

AlecensaPA


BosulifPA

Tabloid

CaprelsaQL,PA

TIER 04



CometriqPA ANTIANGINAL AGENTS

CotellicPA

TIER 01 GENERIC

FarydakPA

isosorbide dinitrate

GilotrifQL,PA

isosorbide dinitrate ER

GleevecPA

isosorbide mononitrate

IbrancePA

isosorbide mononitrate ER

IclusigPA

nitroglycerin lingual

ImbruvicaPA

nitroglycerin transdermal

InlytaPA

nitroglycerin ER

IressaPA

TIER 02 FORMULARY

JakafiPA

Dilatrate SR

Lenvima 10MG Daily DosePA

Nitro-Bid


Nitro-Dur


Nitrostat



LynparzaPA

Nitromist

MekinistPA

Ranexa

NexavarPA

NinlaroPA

BETA BLOCKERS

SprycelPA

TIER 01 GENERIC

StivargaPA

acebutolol HCL

SutentPA

atenolol

TafinlarPA

betaxolol HCL

TagrissoPA

bisoprolol fumarate

TarcevaPA

carvedilol

Tasigna

labetalol HCL

TykerbPA

metoprolol succinate ER

VotrientPA

metoprolol tartrate

XalkoriQL,PA

nadolol

ZelborafQL,PA

pindolol

ZolinzaPA

propranolol HCL

ZydeligPA

propranolol HCL ER

ZykadiaPA

sotalol HCL

sotalol HCL (AF)

TOPOISOMERASE I INHIBITOR

timolol maleate



Hycamtin

Bystolic

Coreg CR

ANTINEOPLASTICS MISC.

Hypertenevide-12.5

TIER 01 GENERIC Inderal XL

hydroxyurea Innopran XL

tretinoin Levatol

TIER 02 FORMULARY Sotylize

Matulane

TIER 04 SPECIALTY CALCIUM CHANNEL BLOCKERS

bexarotenePA

TIER 01 GENERIC

ActimmunePA

amlodipine besylate

Intron A

diltiazem CD

Intron A W/Diluent

diltiazem HCL

SylatronPA

diltiazem HCL ER

felodipine ER

CHEMOTHERAPY RESCUE

isradipine

TIER 01 GENERIC nicardipine HCL

leucovorin calcium nifedipine

TIER 02 FORMULARY nifedipine ER

Mesnex nimodipine

nisoldipine

ANTINEOPLASTIC COMBO nisoldipine ER

verapamil HCL

TIER 04 SPECIALTY

verapamil HCL ER

LonsurfPA

verapamil HCL SR

CARDIOVASCULAR DRUGS


CARDIAC GLYCOSIDES

Cardene SR

TIER 01 GENERIC

digoxin

Hypertenipine-2.5


Nymalize

lanoxin

Lanoxin

Lanoxin Pediatric



ANTIARRHYTHMICS TIER 03 NON PREFERRED

Vecamyl

TIER 01 GENERIC

amiodarone HCL

ANTIHYPERTENSIVE COMBO

disopyramide phosphate

flecainide acetate TIER 01 GENERIC

mexiletine HCL amlodipine besylate/benazepril hydrochloride

procainamide HCL amlodipine besylate/benazepril HCL

propafenone HCL amlodipine besylate/valsartan

propafenone HCL ER amlodipine/valsartan/hctz

quinidine gluconate atenolol/chlorthalidone

quinidine gluconate CR benazepril HCL/hydrochlorothiazide

quinidine gluconate ER bisoprolol fumarate/hydrochlorothiazide

quinidine sulfate candesartan cilexetil/hydrochlorothiazide

quinidine sulfate ER captopril/hydrochlorothiazide

TIER 02 FORMULARY enalapril maleate/hydrochlorothiazide

Norpace CR fosinopril sodium/hydrochlorothiazide

Tikosyn irbesartan/hydrochlorothiazideQL

TIER 03 NON PREFERRED lisinopril/hydrochlorothiazide

Multaq losartan potassium/hydrochlorothiazide

methyldopa/hydrochlorothiazide

ACE INHIBITORS metoprolol/hydrochlorothiazide

moexipril/hydrochlorothiazide

TIER 01 GENERIC

nadolol/bendroflumethiazide

benazepril HCL

propranolol/hydrochlorothiazide

captopril

quinapril/hydrochlorothiazide

enalapril maleate

telmisartan/amlodipine

fosinopril sodium

telmisartan/hydrochlorothiazideQL

lisinopril

trandolapril/verapamil HCL

moexipril HCL

trandolapril/verapamil HCL ER

perindopril erbumine

valsartan/hydrochlorothiazide

quinapril HCL

TIER 02 FORMULARY

ramipril

Benicar HCT

trandolapril



AmturnideQL

Epaned

Azor

Clorpres

ANGIOTENSIN RCPTR BLOCKER

Dutoprol

TIER 01 GENERIC

EdarbyclorST

candesartan cilexetilQL

Hypertensolol

eprosartan mesylate

irbesartanQL

losartan potassiumQL

TekamloQL

telmisartanQL

Tekturna HCTST

TIER 02 FORMULARY

Teveten HCTST

valsartanQL

TribenzorQL

BenicarQL


DIURETICS

EdarbiST

TIER 01 GENERIC

acetazolamide

DIRECT RENIN INHIBITORS

acetazolamide sodium


acetazolamide ER

TekturnaST

amiloride HCL

amiloride/hydrochlorothiazide

ANTIHYPERTENSIVES MISC.

bumetanide

TIER 01 GENERIC

chlorothiazide

clonidine HCL

chlorthalidone

doxazosin

furosemide

doxazosin mesylate

hydrochlorothiazide

eplerenone

indapamide

guanfacine HCL

methazolamide

hydralazine HCL

methyclothiazide

methyldopa

metolazone

minoxidil

spironolactone

phenoxybenzamine hydrochloride

spironolactone/hydrochlorothiazide

phentolamine mesylate

torsemide

prazosin HCL

triamterene/hydrochlorothiazide

reserpine

TIER 02 FORMULARY

terazosin HCL

Aldactazide

TIER 02 FORMULARY

Diuril

Demser



Edecrin

TIER 03 NON PREFERRED AdcircaQL,PA

Demadex AdempasPA

Dyrenium LetairisQL,PA

Opsumit

VASOPRESSORS OrenitramPA

RemodulinPA

TIER 01 GENERIC

TracleerQL,PA

ephedrine sulfate

TyvasoPA

epinephrine

Tyvaso RefillPA

midodrine HCL

Tyvaso StarterPA

phenylephrine HCL

VentavisPA

TIER 02 FORMULARY

Epipen 2-PAKQL

DERMATOLOGICALS

Epipen-JR 2-PAKQL


ACNE PRODUCTS

AdrenaclickQL

TIER 01 GENERIC

Adrenalin

clindamycin phosphate

TIER 04 SPECIALTY

erythromycin

NortheraPA

tretinoin

TIER 02 FORMULARY

ANTIHYPERLIPIDEMICS

adapalene

TIER 01 GENERIC

adapalene P.M.

atorvastatin calcium

benzoyl peroxide

cholestyramine

benzoyl peroxide SHORT contact

cholestyramine light

clindamycin/benzoyl peroxide

colestipol HCL

erythromycin/benzoyl peroxide

fenofibrate

sodium sulfacetamide

fenofibrate micronized

sodium sulfacetamide/sulfur

fenofibric acid DR

sodium sulfacetamide/sulfur cleanser

fluvastatin

sodium sulfacetamide/sulfur cleanser IN urea

fluvastatin sodium ER

sodium sulfacetamide/sulfur cleansing cloths

gemfibrozil

sodium sulfacetamide/sulfur green

lovastatin

sodium sulfacetamide/sulfur wash

omega-3-acid ethyl esters

sodium sulfacetamide/sulfur IN urea

pravastatin sodium

sulfacetamide sodium

simvastatin

sulfacetamide sodium/sulfur

TIER 02 FORMULARY

sulfacetamide sodium/sulfur cleanser

niacin ER

tretinoin microsphere

Crestor

tretinoin microsphere P.M.

Welchol


Zetia

Avar


Avar LS

Advicor

Clinoin

Altoprev

Epiduo Forte

Fenoglide

Fabior

Livalo

Tretin-X

Simcor

Vascepa

ROSACEA AGENTS

Vytorin

TIER 01 GENERIC

TIER 04 SPECIALTY

doxycycline

JuxtapidQL,PA

metronidazole

KynamroQL,PA


Finacea

CARDIOVASCULAR - MISC.

TIER 01 GENERIC

ANTIBIOTICS - TOPICAL

papaverine HCL

TIER 01 GENERIC

TIER 02 FORMULARY

gentamicin sulfate

amlodipine besylate/atorvastatin calcium

mupirocin

mupirocin calcium


TIER 02 FORMULARY

CialisRR

Cortisporin

CorlanorPA


EntrestoPA

centany

LevitraRR

Altabax

Muse RR

Centany AT

Staxyn RR

Neo-Synalar

ViagraRR

TIER 04 SPECIALTY

ANTIFUNGALS - TOPICAL

sildenafilQL,PA (for use in pulmonary hypertension only)

TIER 01


PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; RR = Rider Required 6

GENERIC Zithranol

ciclopirox Zithranol-RR

TIER 04 SPECIALTY

CosentyxPA

Cosentyx Sensoready PenPA

clotrimazole/betamethasone dipropionate StelaraQL,PA

econazole nitrate

ketoconazole ANTISEBORRHEIC AGENTS

naftifine hydrochloride

TIER 01 GENERIC

naftifine HCL

glycolic acid

nystatin

glycolic acid 70% high purity

nystatin/triamcinolone

selenium sulfide

oxiconazole nitrate


TIER 02 FORMULARY

sodium sulfacetamide wash

Exelderm


Halotin

Ovace Plus

Lamisil Spray

Promiseb

Oxistat

Promiseb Complete

Xolegel

Selrx


Tersi Foam

TL Triseb

Ecoza

CORTICOSTEROIDS - TOPICAL

Luzu

TIER 01 GENERIC

Mentax

alclometasone dipropionate

Naftin

amcinonide

augmented betamethasone dipropionate

Recura

betamethasone dipropionate

Vusion

betamethasone valerate

Xolegel Corepak

clobetasol propionate

Xolegel Duo/Head & Shoulders

clobetasol propionate emollient

Xolegel Duo/Xolex

clocortolone pivalate

clocortolone pivalate P.M.

ANTIVIRALS - TOPICAL

desonide

TIER 01 GENERIC

desoximetasone

acyclovir

diflorasone diacetate


fluocinolone acetonide

DenavirQL

fluocinonide

fluocinonide-e

ANTI-INFLAMMATORY AGENTS

fluticasone propionate

TIER 01 GENERIC halobetasol propionate

diclofenac sodium

TIER 02 FORMULARY hydrocortisone acetate/aloe

Voltaren hydrocortisone butyrate

TIER 03 NON PREFERRED hydrocortisone valerate

FlectorST hydrocortisone IN absorbase

PennsaidPA mometasone furoate

Xrylix prednicarbate

triamcinolone acetonide

ANTIPRURITICS TIER 02 FORMULARY

calcipotriene/betamethasone dipropionate

TIER 01 GENERIC

hydrocortisone butyrate (lipid)

doxepin hydrochloride

hydrocortisone butyrate (lipophilic)



Prudoxin

Capex

Zonalon

Cloderm

Cloderm P.M.

ANTIPSORIATICS

Cordran

TIER 01 GENERIC

Cordran Tape

acitretin

Dermasorb HC

calcipotriene

Dermasorb Ta

calcitriol

Desonate

methoxsalen

Desowen Cream/Cetaphil Lotion

TIER 02 FORMULARY

Desowen Lotion/Cetaphil Cream

8-mop

Desowen Ointment/Cetaphil Lotion


Enstilar

Sorilux

Epifoam

Taltz

Halog

Tazorac

Halonate

Vectical



Locoid Eurax

Pandel

Pediaderm HC

Pediaderm TA Gordofilm

Pramosone Gordons Urea

Scalacort DK Kerafoam

Kerafoam 42

Xerac AC

Synalar TS TIER 03 NON PREFERRED

Taclonex Susp

Texacort Alevicyn Antipruritic SG

Topicort Atopiclair

Trianex

Verdeso Avenova

IMMUNOMODULATING AGENTS Copasil

Eletone

TIER 01 GENERIC

tacrolimus

Elimite

TIER 02 FORMULARY

Emulsion SB

imiquimod

Epiceram

Elidel

Hylatopic


Hylatopic Plus

Zyclara

Zyclara P.M.

DERMATOLOGICALS - MISC.

TIER 01 GENERIC

arnica flower

Keralyt Scalp

benzoin compound tincture

benzoin tincture

Lycelle

boric acid

Mb Hydrogel

capsaicin

Medi-derm/L-RX

coal TAR

Megrix

cocaine HCL

Neosalus

ethyl chloride

Neosalus CP

ethyl chloride/fine pinpoint

Neuvaxin

ethyl chloride/fine stream

Nivatopic Plus

ethyl chloride/medium jet stream

Nuvail

ethyl chloride/medium stream

Pliaglis

ethyl chloride/mist

Pr Cream

lactic acid

Presera

lactic acid e

Pruclair

lactic acid w/vitamin e

Prumyx

lidocaine

Qutenza

lidocaine and tetracaine cream

Relyyt

lidocaine HCL

Salvax Duo Plus

lidocaine HCL jelly

Sinelee

lidocaine-prilocaine-cream base

Sklice

lidocaine/prilocaine

Solaice

lindane

Synera

malathion

Tetrix

permethrin

Tropazone

podofilox

Ulesfia

pyrogallic acid

salicylic acid

Umecta

salicylic acid cream

Umecta PD

salicylic acid lotion

Veregen

sodium hyaluronate

ENDOCRINE AND METABOLIC

spinosad

sulfurated lime CORTICOSTEROIDS

urea

TIER 01 GENERIC

urea topical

betamethasone sodium phosphate/betamethasone acetate

cortisone acetate

dexamethasone

TIER 02 FORMULARY

dexamethasone sodium phosphate

Anacaine

fludrocortisone acetate

Condylox



hydrocortisone tabs norethindrone acetate/ethinyl estradiol

methylprednisolone TIER 02 FORMULARY

methylprednisolone acetate Alora

methylprednisolone dose pack Cenestin

methylprednisolone sodiumsuccinate Climara Pro

methylprednisolone PF Combipatch

prednisolone Depo-estradiol

prednisolone sodium phosphate Enjuvia

prednisone Menest

triamcinolone Premarin

TIER 02 FORMULARY Premphase

budesonide Prempro

prednisolone sodium phosphate ODT TIER 03 NON PREFERRED

Dexamethasone Intensol Angeliq

Orapred ODT Delestrogen

Prednisone Intensol Divigel

TIER 03 NON PREFERRED Duavee

Elestrin

Estrasorb

Depo-medrol Estrogel

Dexpak 10 Day Evamist

Dexpak 13 Day Menostar

Dexpak 6 Day Minivelle

Dyural-l

FLO-pred

Medrol CONTRACEPTIVES

Millipred

TIER 01 GENERIC

Millipred DP

desogestrel/ethinyl estradiol

drospirenone/ethinyl estradiol

levonorgestrel

levonorgestrel and ethinyl estradiol

levonorgestrel/ethinyl estradiol

norethindrone

norethindrone & ethinyl estradiol ferrous fumarate

norethindrone acetate/ethinyl estradiol

norethindrone acetate/ethinyl estradiol/ferrous fumarate

Solu-medrol

norgestimate/ethinyl estradiol

Uceris


Veripred 20

Beyaz

Ella

ANDROGENS-ANABOLIC (PA required for use less than 40 yo)

Falessa

TIER 01 GENERIC LO Loestrin FE

danazolPA Minastrin 24 FE

methyltestosteronePA Natazia

oxandrolonePA Norinyl 1+50

testosteronePA Quartette

testosterone cypionatePA Safyral

testosterone enanthatePA

testosterone P.M. PA PROGESTINS

TIER 02 FORMULARY

TIER 01 GENERIC

AndrogelPA

medroxyprogesterone acetate

Androgel P.M. PA

medroxyprogesterone/lidocaine

AndroxyPA

megestrol acetate

AxironPA

norethindrone acetate


progesterone

Anadrol-50PA

TIER 04 SPECIALTY

AndrodermSTPA

MakenaPA

FortestaPA

StriantSTPA

ANTIDIABETIC AGENTS

TestimPA

INSULIN

VogelxoPA

TIER 02 FORMULARY (All Lilly Insulin preferred)

Vogelxo P.M. PA

Humalog

Humalog Kwikpen

ESTROGENS

Humalog Mix 50/50

TIER 01 GENERIC

Humalog Mix 50/50 Kwikpen

estradiol

Humalog Mix 75/25 and Kwikpen

estradiol valerate

Humulin N, Humulin R, Humulin 70/30

estradiol/norethindrone acetate

Humulin R U-500 (concentrated) Humulin R U-500 Kwikpen

estropipate

Lantus

Lantus Solostar



Levemir GENERIC

Levemir Flexpen alogliptin/metformin HCL

Levemir Flextouch alogliptin/pioglitazone

TIER 03 NON PREFERRED glipizide/metformin HCL

glyburide/metformin HCL

AMYLIN ANALOGS pioglitazone HCL/metformin HCL

TIER 03 NON PREFERRED repaglinide/metformin hydrochloride

Symlinpen 120 TIER 02 FORMULARY

Symlinpen 60 pioglitazone HCL-glimepiride

INCRETIN MIMETIC AGENTS Actoplus Met XR

TIER 02 FORMULARY Janumet

Byetta Janumet XR

Tanzeum Jentadueto

TIER 03 NON PREFERRED TIER 03 NON PREFERRED

BydureonPA

VictozaPA

Trulicity PA

SULFONYLUREAS Avandamet

TIER 01 GENERIC Avandaryl

chlorpropamide InvokametQL,ST

glimepiride KazanoST

glipizide Kombiglyze XRST

glipizide ER OseniST

glyburide Xigduo XRST

glyburide micronized

tolazamide BISPHOSPHONATES

tolbutamide

TIER 01 GENERIC


alendronate sodium

Diabeta

etidronate disodium

BIGUANIDES

ibandronate sodium

TIER 01 GENERIC

risedronate sodium

metformin HCL

risedronate sodium DR

metformin HCL ER



Binosto

Riomet

Fosamax Plus DST

MEGLITINIDE ANALOGUES

TIER 01 GENERIC

CALCITONINS

nateglinide

TIER 01 GENERIC

repaglinide

calcitonin salmon

DIABETIC OTHER

calcitonin-salmon

TIER 01 FORMULARY – LIFESCAN PRODUCTS PREFERRED


ONE Touch Test Strips – Ultra, Ultra Mini, UltraSmart,Verio IQ, Verios Sync

fortical


Miacalcin

FarxigaQL,ST

Glucagen Hypokit

PARATHYROID HORMONE

Glucagon Emergency Kit

TIER 04 SPECIALTY

InvokanaQL,ST

ForteoPA

JardianceQL,ST

TIER 04 SPECIALTY

RANK LIGAND INHIBITORS

KorlymPA

TIER 04 SPECIALTY

ALPHA-GLUCOSIDASE INHIBIT

ProliaPA

TIER 01 GENERIC

XgevaPA

acarbose

TIER 02 FORMULARY

HORMONE RECEPTOR MDLTR

Glyset

TIER 01 GENERIC

DPP-4 INHIBITORS

raloxifene hydrochloride

TIER 01 GENERIC


alogliptin

Osphena

TIER 02 FORMULARY

Januvia

FERTILITY REGULATORS

Tradjenta

TIER 01 GENERIC


clomiphene citrate

NesinaST

TIER 04 SPECIALTY

OnglyzaST

chorionic gonadotropin

INSULIN SENSITIZING AGENT

Bravelle PA

TIER 01 GENERIC

Follistim AQ

pioglitazone HCL

Gonal-fST


Gonal-f RFFST

Avandia

Gonal-f RFF PenPA

ANTIDIABETIC COMBINATIONS

Gonal-f RFF RedijectPA

TIER 01



Menopur GENERIC

Ovidrel cabergoline

Repronex

VASOPRESSIN ANTAGONISTS

LHRH/GNRH AGONIST


TIER 02 FORMULARY Samsca

Synarel

TIER 04 SPECIALTY PROGESTERONE ANTAGONISTS

Lupaneta Pack

TIER 02 FORMULARY

Lupron Depot-PED

Mifeprex

Supprelin LA

METABOLIC MODIFIERS

GNRH/LHRH ANTAGONISTS

TIER 01 GENERIC

TIER 04 SPECIALTY

calcitriol

ganirelix acetate

doxercalciferol

Cetrotide

levocarnitine

paricalcitol

GROWTH HORMONES

sodium phenylbutyrate

TIER 04 SPECIALTY TIER 02 FORMULARY

GenotropinPA Buphenyl

Genotropin MiniquickPA Orfadin

HumatropePA Sensipar

Humatrope Combo PackPA TIER 03 NON PREFERRED

Norditropin CartridgePA Cystadane

Norditropin FlexproPA Xuriden

Norditropin Nordiflex PenPA TIER 04 SPECIALTY

Nutropin AQ Nuspin 10PA CarbagluPA

Nutropin AQ Nuspin 20PA Kuvan

Nutropin AQ Nuspin 5PA RavictiPA

Nutropin AQ PenPA

OmnitropePA THYROID AGENTS

SaizenPA

TIER 01 GENERIC

Saizen Click.easyPA

levothyroxine sodium

SerostimPA

levothyroxine sodium TAB 0.075MG

Tev-tropinPA

liothyronine sodium

ZomactonPA

methimazole

ZorbtivePA

propylthiouracil

TIER 02 FORMULARY

SOMATOMEDINS

Thyrolar-1

TIER 04 SPECIALTY Thyrolar-1/2

IncrelexPA Thyrolar-1/4

Thyrolar-2

SOMATOSTATIC AGENTS Thyrolar-3


TIER 01 GENERIC

Armour Thyroid

octreotide acetate

Cytomel

TIER 04 SPECIALTY

Nature-throid

Sandostatin Lar Depot

Nature-throid NT-2.5

SigniforQL,PA

Synthroid

Signifor LarPA

Tirosint

Somatuline Depot

Westhroid

Wp Thyroid

GH RECEPTOR ANTAGONISTS

TIER 04 SPECIALTY

GASTROINTESTINAL

Somavert

LAXATIVES

POSTERIOR PITUITARY

TIER 01 GENERIC

TIER 01 GENERIC cascara sagrada

desmopressin acetate lactulose

vasopressin mineral oil heavy

TIER 02 FORMULARY peg 3350/electrolytes

Stimate peg-3350/electrolytes

peg-3350/NACL/NA bicarbonate/KCL

CORTICOTROPIN polyethylene glycol 3350

senna plus

TIER 04 SPECIALTY

TIER 02 FORMULARY

Golytely

Moviprep

PROLACTIN INHIBITORS

Osmoprep

TIER 01

Suclear




Colyte-flavor Packs Symax Duotab

Kristalose

Prepopik ANTIEMETICS

Suprep Bowel Prep

TIER 01 GENERIC

dimenhydrinate

ANTIDIARRHEALS

dronabinol

TIER 01 GENERIC granisetron HCLQL

diphenoxylate/atropine ondansetron ODT

paregoric ondansetron HCL

TIER 02 FORMULARY trimethobenzamide HCL

opium TIER 02 FORMULARY

opium tincture Transderm-scop

Motofen TIER 03 NON PREFERRED

VSL#3 DS Akynzeo

TIER 03 NON PREFERRED Anzemet

FulyzaqPA Cesamet

Restora RX Emend

Rezyst IM Granisol

Rezyst SB Sancuso

Zuplenz

ANTACIDS

DIGESTIVE AIDS

TIER 01 GENERIC

sodium bicarbonate TIER 01 GENERIC

pancrelipase

ULCER DRUGS TIER 02 FORMULARY

Creon

TIER 01 GENERIC

Pancreaze

atropine sulfate

Ultresa

belladonna & opium

Viokace

belladonna alkaloids & opium

Zenpep

chlordiazepoxide HCL/clidinium bromide


cimetidine

Pertzye

cimetidine HCL

TIER 04 SPECIALTY

dicyclomine hci

SucraidPA

dicyclomine HCL

famotidine

GASTROINTESTINAL - MISC.

glycopyrrolate

hyoscyamine sulfate TIER 01 GENERIC

hyoscyamine sulfate ODT alosetron hydrochloride

hyoscyamine sulfate ER balsalazide disodium

hyoscyamine sulfate SR calcium acetate

lansoprazole dexpanthenol

lansoprazole/amoxicillin/clarithromycin hydrocortisone tabs

methscopolamine bromide hydrocortisone acetate/lidocaine HCL

misoprostol hydrocortisone acetate/pramoxine

nizatidine lactulose

omeprazole lidocaine HCL-hydrocortisone acetate with aloe

omeprazole/sodium bicarbonate lidocaine HCL/hydrocortisone acetate

pantoprazole sodium mesalamine

propantheline bromide metoclopramide ODT

rabeprazole sodium metoclopramide HCL

ranitidine HCL sevelamer carbonate

scopolamine hydrobromide sulfasalazine

sucralfate ursodiol

TIER 02 FORMULARY

TIER 02 FORMULARY cromolyn sodium

Carafate Apriso

TIER 03 NON PREFERRED Asacol HD

Aciphex SprinklePA Canasa

Atropen Fosrenol

Cantil Lialda

Cuvposa Pentasa

Gabitidine Proctofoam HC

Levsin Renagel

Renvela

Pamine FQ TIER 03 NON PREFERRED

Prevacid SolutabPA auryxia

ProtonixPA Amitiza

Pylera




Chenodal AVC

Cortifoam Clindesse

Delzicol Crinone

Dipentum Endometrin

Entereg Estrace

Giazo Femring

Linzess Gynazole-1

MovantikQL,PA Relagard

Phoslyra

Procort GENITOURINARY - MISC.

Rectiv

TIER 01 GENERIC

Relistor

alfuzosin HCL ER

Sfrowasa

citric acid/sodium citrate

Uceris

dutasteride

Velphoro

dutasteride/tamsulosin hydrochloride

TIER 04 SPECIALTY

finasteride

CimziaQL,PA

phenazopyridine HCL

Cimzia Starter KitQL,PA

potassium citrate ER

GattexPA

potassium citrate-citric acid crystals

potassium citrate/citric acid

GENITOURINARY

potassium citrate/sodium citrate/citric acid

sodium citrate/citric acid

URINARY ANTI-INFECTIVES

tamsulosin HCL

TIER 01 GENERIC

tricitrates

methenamine hippurate

TIER 02 FORMULARY

methenamine mandelate

Cystagon

nitrofurantoin

Elmiron

nitrofurantoin macrocrystals

K-phos NO 2

nitrofurantoin monohydrate

Lithostat

nitrofurantoin monohydrate/macrocrystals

Oracit



Monurol

Cardura XL

Uretron D/S

Rapaflo

Uroqid #2

TIER 04 SPECIALTY

Procysbi

URINARY ANTISPASMODICS

ThiolaPA

TIER 01 GENERIC

bethanechol chloride

HEMATOLOGICAL AGENTS

darifenacin hydrobromide ER

HEMATOPOIETIC AGENTS

darifenacin ER

flavoxate HCL TIER 01 GENERIC

oxybutynin chloride

oxybutynin chloride ER cyanocobalamin

tolterodine tartrate folic acid

tolterodine tartrate ER hydroxocobalamin

trospium chloride TIER 02 FORMULARY

trospium chloride ER Droxia

TIER 02 FORMULARY TIER 03 NON PREFERRED

Vesicare Ciferex

TIER 03 NON PREFERRED Feriva 21/7

Gelnique Mozobil

Myrbetriq Nascobal

Toviaz Omontys

TIER 04 SPECIALTY

VAGINAL PRODUCTS Aranesp Albumin FreePA

Cerdelga

TIER 01 GENERIC

EpogenPA

clindamycin phosphate

Granix

metronidazole vaginal

Mircera

terconazole

NeulastaPA

TIER 02 FORMULARY

Cleocin

NeumegaPA

Estring

NeupogenPA,ST

NplatePA

ProcritPA

PromactaPA

ZavescaPA

Premarin

Vagifem



ANTICOAGULANTS Xyntha

TIER 01 GENERIC

MOUTH/THROAT/DENTAL AGENT

fondaparinux sodium

heparin sodium

heparin sodium dcu

TIER 01 GENERIC

heparin sodium/sodium chloride 0.9% premix

cevimeline HCL

heparin sodium/NACL 0.45%

chlorhexidine gluconate

heparin sodium/NACL 0.9%

chlorhexidine gluconate oral rinse

warfarin sodium

clotrimazole

TIER 02 FORMULARY

lidocaine viscous

enoxaparin sodium

lidocaine HCL

Xarelto

lidocaine HCL viscous


nystatin

Arixtra

pilocarpine hydrochloride

Eliquis

pilocarpine HCL

Fragmin

stannous fluoride oral rinse

Iprivask


Pradaxa

triamcinolone IN orabase

SavaysaQL

TIER 02 FORMULARY

Caphosol

HEMOSTATICS

Debacterol

TIER 01 GENERIC TIER 03 NON PREFERRED

aminocaproic acid Aquoral

tranexamic acid

TIER 02 FORMULARY Gelclair

Artiss Nafrinse Daily/Acidulated

Astringyn Nafrinse Daily/Neutral

Nafrinse Weekly

Neutrasal

Oravig

Salivamax

Thrombogen

TIER 03 NON PREFERRED NEUROLOGY, CNS, PSYCH

Evicel

ANTIANXIETY AGENTS

Evithrom

TIER 01 GENERIC

Recothrom

alprazolam

alprazolam ODT

Tisseel

alprazolam ER

Tisseel VH

buspirone HCL

chlordiazepoxide HCL

HEMATOLOGICAL - MISC.

clorazepate dipotassium

TIER 01 GENERIC

diazepam

anagrelide hydrochloride

droperidol

aspirin/dipyridamole

hydroxyzine pamoate

cilostazol

hydroxyzine HCL

clopidogrel

lorazepam

dipyridamole

meprobamate

pentoxifylline ER

oxazepam

ticlopidine HCL

TIER 02 FORMULARY

TIER 02 FORMULARY

Alprazolam Intensol

Aggrenox



Gabavale-5

Brilinta

Gabazolamine

Cathflo Activase

Gabazolamine-0.5

Effient

Kalbitor

Kinlytic

ANTIDEPRESSANTS

Kovaltry

TIER 01 GENERIC

Novoeight

amitriptyline HCL

Nuwiq

amoxapine

Xyntha Solofuse

bupropion HCL

TIER 04 SPECIALTY

bupropion HCL ER

Benefix

bupropion HCL SR

FirazyrPA

bupropion HCL XL

Helixate FS

citalopram hydrobromideQL

Ixinity

clomipramine HCL

Kogenate FS

desipramine HCL

Kogenate FS Bio-set

desvenlafaxine ER

Recombinate

doxepin HCL



escitalopram oxalateQL quetiapine fumarate

fluoxetine DR risperidone

fluoxetine HCL risperidone ODT

fluvoxamine maleate thioridazine HCL

fluvoxamine maleate ERPA thiothixene

imipramine pamoate trifluoperazine HCL

imipramine HCL ziprasidone HCL

maprotiline HCL

mirtazapine TIER 02 FORMULARY

mirtazapine ODT aripiprazolePA

nefazodone HCL lithium

nortriptyline HCL Equetro

paroxetine HCL Risperdal Consta

paroxetine HCL ERQL Seroquel XRST

phenelzine sulfate Zyprexa Relprevv

protriptyline HCL TIER 03 NON PREFERRED

sertraline HCLQL AbilifyPA

tranylcypromine sulfate Abilify DiscmeltPA

trazodone HCL Abilify Maintena

trimipramine maleate FanaptST

venlafaxine HCL

venlafaxine HCL ERQL FazacloST

TIER 02 FORMULARY Geodon

duloxetine HCLPA Invega Sustenna

Appbutamone Invega TrinzaPA

Gaboxetine LatudaST

Marplan SaphrisST

Sentroxatine VersaclozST

TIER 03 NON PREFERRED Vraylar

Emsam HYPNOTICS

FetzimaST

TIER 01 GENERIC

estazolam

Khedezla

eszopiclone

Oleptro

flurazepam HCL

Parnate

phenobarbital

PaxilPA

phenobarbital sodium

PexevaQL,ST

quazepam

PristiqST

temazepam

triazolam

zaleplon

zolpidem tartrate

Trazamine

TIER 02 FORMULARY

ViibrydST

zolpidem tartrate ER

Butisol Sodium


ANTIPSYCHOTICS

Amytal Sodium

TIER 01 GENERIC Doral

aripiprazole ODTPA Gabazolpidem-5

chlorpromazine HCL Nembutal Sodium

clozapine Rozerem

clozapine ODT

fluphenazine decanoate Strazepam

fluphenazine HCL Zolpimist

haloperidol

haloperidol decanoate ADHD, NARCOLEPSY, ETC.

haloperidol lactate

TIER 01 GENERIC

lithium carbonate

caffeine citrate

lithium carbonate ER

caffeine/sodium benzoate

loxapine

dexmethylphenidate HCL

loxapine succinate

dexmethylphenidate HCL ER

molindone hydrochloride

dextroamphetamine sulfate

olanzapine

guanfacine ER

olanzapine ODT

methamphetamine HCL

paliperidone ER

methylphenidate hydrochloride

perphenazine

methylphenidate HCL

prochlorperazine

TIER 02 FORMULARY

prochlorperazine edisylate

dextroamphetamine sulfate ER

prochlorperazine maleate

methylphenidate HCL CD



methylphenidate HCL ER Depakene

modafinil Depakote

Adderall XR Depakote ER

Concerta Depakote Sprinkles

NuvigilPA Dilantin

Dilantin Infatabs

Strattera Dilantin-125

Vyvanse Felbatol

TIER 03 NON PREFERRED Fycompa

amphetamine/dextroamphetamineST Keppra

methylphenidate HCL SRST Keppra XR

Adderall Lamictal

Lamictal Chewable Dispersible

Daytrana

Dexedrine

Dyanavel XR Lamictal XR

Focalin LyricaPA

Focalin XR Mysoline

Metadate CD OnfiST

Methylin Oxtellar XR

Procentra Peganone

Quillivant XR Phenytek

Ritalin Potiga

Ritalin LA Spritam

Tegretol

Zenzedi Topamax

Topamax Sprinkle

ANTICONVULSANTS Trileptal

Trokendi XR

TIER 01 GENERIC

Vimpat

carbamazepine

Zarontin

carbamazepine ER

TIER 04 SPECIALTY

clonazepam

SabrilPA

clonazepam ODT

diazepam

ANTIPARKINSON AGENTS

divalproex sodium

divalproex sodium DR TIER 01 GENERIC

divalproex sodium ER amantadine HCL

ethosuximide benztropine mesylate

felbamate bromocriptine mesylate

gabapentin carbidopa

lamotrigine carbidopa/levodopa

lamotrigine ODT carbidopa/levodopa ODT

lamotrigine titrationQL carbidopa/levodopa ER

lamotrigine ER carbidopa/levodopa/entacapone

levetiracetam entacapone

levetiracetam ER pramipexole dihydrochloride

oxcarbazepine pramipexole dihydrochloride ER

phenytoin ropinirole ER

phenytoin sodium ropinirole HCL

phenytoin sodium extended selegiline HCL

primidone tolcapone

tiagabine hydrochloride trihexyphenidyl HCL

topiramate TIER 03 NON PREFERRED

valproic acid Apokyn

zonisamide Azilect

TIER 02 FORMULARY Mirapex ER

Gabitril Neupro

Lamictal ODT Rytary

Stalevo 100

Stalevo 125

Stavzor

Stalevo 150

Tegretol-XR

Stalevo 200

Stalevo 50

Stalevo 75


Zelapar

Aptiom

Banzel

NEUROLOGY, PSYCH - MISC.

Carbatrol

TIER 01 GENERIC

Celontin

acamprosate calcium DR



chlordiazepoxide/amitriptyline FORMULARY

disulfiram metaxalone

donepezil HCL Prazolamine

ergoloid mesylates

fluoxetine

galantamine hydrobromide TIER 03 NON PREFERRED

memantine hydrochloride

memantine HCL

memantine HCL titration PAK Lorzone

olanzapine/fluoxetine

perphenazine/amitriptyline

pimozide

rivastigmine tartrate ANTIMYASTHENIC AGENTS

rivastigmine transdermal system

TIER 01 GENERIC

TIER 02 FORMULARY

guanidine HCL

Namenda XR

neostigmine methylsulfate

pyridostigmine bromide

TIER 02 FORMULARY



NamzaricPA

Enlon

Sarafem

SavellaPA

OPHTHALMOLOGY AND OTIC

ANTI-INFECTIVES

TIER 01 GENERIC

TIER 04 SPECIALTY

bacitracin

tetrabenazinePA

bacitracin/polymyxin b

AmpyraQL,PA

ciprofloxacin HCL

AubagioPA,ST

erythromycin

Avonex

gentamicin sulfate

Avonex Pen

levofloxacin

Betaseron

neomycin/bacitracin/polymyxin

Glatiramir acetate 20mg QL

neomycin/polymyxin/bacitracin zinc

ExtaviaPA,ST

neomycin/polymyxin/gramicidin

GilenyaST

ofloxacin

NuedextaPA

polymyxin b sulfate/trimethoprim sulfate

Plegridy


sulfacetamide sodium

RebifPA,ST

tobramycin sulfate

Rebif RebidosePA,ST

trifluridine

trimethoprim sulfate/polymyxin b sulfate

TIER 02 FORMULARY

TecfideraQL,ST

gatifloxacin

Betadine Ophthalmic Prep

XyremPA

Ciloxan

Natacyn

NEUROMUSCULAR AGENTS

Tobrex

TIER 01 GENERIC

Vigamox

riluzole



Azasite

Quelicin 1000

Besivance

TIER 04 SPECIALTY

Mitosol

BotoxPA

Moxeza

DysportPA

Zirgan

MyoblocPA

XeominPA

ARTIFICIAL TEAR/LUBRICANT


MUSCULOSKELETAL AGENTS

Lacrisert

TIER 01 GENERIC

baclofen

BETA-BLOCKERS

chlorzoxazone

TIER 01 GENERIC

cyclobenzaprine HCL

betaxolol HCL

dantrolene sodium

carteolol HCL

methocarbamol

dorzolamide HCL/timolol maleate

orphenadrine citrate

levobunolol HCL

orphenadrine citrate ER

timolol maleate

orphenadrine/asa/caffeine

timolol maleate ophthalmic gel forming

tizanidine HCL

TIER 02 FORMULARY

TIER 02

Betoptic-s



TIER 03 NON PREFERRED TIER 03 NON PREFERRED

metipranolol Isopto Carbachol

Betimol Phospholine Iodide

Combigan

Cosopt PF ADRENERGIC AGENTS

TIER 01 GENERIC

apraclonidine

OPHTHALMIC STEROIDS

brimonidine tartrate

TIER 01 GENERIC TIER 02 FORMULARY

dexamethasone sodium phosphate Iopidine

fluorometholone TIER 03 NON PREFERRED

neomycin/polymyxin/bacitracin/hydrocortisone

neomycin/polymyxin/dexamethasone Simbrinza

neomycin/polymyxin/hydrocortisone

prednisolone acetate LOCAL ANESTHETICS

prednisolone sodium phosphate

TIER 01 GENERIC

sulfacetamide sodium/prednisolone sodium phosphate

proparacaine HCL

tobramycin/dexamethasone

TIER 02 FORMULARY


Alrex

Akten

Blephamide

Blephamide S.o.p.

OPHTHALMICS - MISC.

FML

TIER 01 GENERIC

FML Forte

azelastine HCL

Lotemax

bromfenac

Maxidex

cromolyn sodium

Pred Mild

diclofenac sodium

Pred-G

dorzolamide HCL

Pred-G S.o.p.

epinastine HCL

Tobradex

flurbiprofen sodium


ketorolac tromethamine

Durezol

olopatadine HCL

Flarex

TIER 02 FORMULARY

Tobradex ST

Azopt

Vexol

Nevanac

Zylet


Acuvail

PROSTAGLANDINS

Alocril

TIER 01 GENERIC

Alomide

latanoprost

Bepreve

travoprost

Emadine

TIER 02 FORMULARY

Ilevro

Travatan Z

Lastacaft


Pataday

Lumigan

Prolensa

Rescula

TIER 04 SPECIALTY

Zioptan

CystaranQL,PA

CYCLOPLEGIC MYDRIATICS

OTIC AGENTS

TIER 01 GENERIC

TIER 01 GENERIC

atropine sulfate

acetic acid

cyclopentolate hydrochloride

acetic acid/aluminum acetate

cyclopentolate HCL

antipyrine/benzocaine

homatropine HBR

ciprofloxacin

TIER 02 FORMULARY

fluocinolone acetonide

Cyclomydril

fluocinolone acetonide ear drops

Isopto Homatropine

hydrocortisone/acetic acid

Isopto Hyoscine

neomycin/polymyxin/hydrocortisone


neomycin/polymyxin/HC

Cyclogyl

ofloxacin

TIER 02 FORMULARY

DECONGESTANTS

Ciprodex

TIER 01 GENERIC Coly-mycin S

naphazoline HCL TIER 03 NON PREFERRED

phenylephrine HCL Cetraxal

Cipro HC

MIOTICS Cortisporin-tc

Otiprio

TIER 01 GENERIC

pilocarpine HCL



OXYTOCICS fentanyl citrate oral transmucosalQL,PA

Capital/Codeine

Suboxone Film QL,PA

TIER 01 GENERIC


methylergonovine maleate

AbstralPA

oxytocin

Conzip

TIER 02 FORMULARY

Dilaudid-HP

Cervidil

Embeda

Prostin E2

ExalgoPA


FentoraPA

Hemabate

Prepidil

LazandaPA

Lortab

PAIN MANAGEMENT

Morphine Sulfate Powder

ANALGESICS - NONNARCOTIC

Nucynta

TIER 01 GENERIC

Nucynta ERPA

butalbital/acetaminophen

Opana ER (crush Resistant)PA

butalbital/acetaminophen/caffeine

Oxaydo

butalbital/aspirin/caffeine

Oxecta

choline magnesium trisalicylate

OxycontinQL,PA

diflunisal

Primlev

salsalate

Roxicet


SubsysPA

Allzital

Synalgos-DC

Bupap

Trezix

Equagesic

Zamicet

Levacet

ANTI-INFLAMMATORY

ANALGESICS – OPIOID (PA may be required for new starts)

TIER 01 GENERIC

TIER 01 GENERIC

diclofenac potassium

acetaminophen/caffeine/dihydrocodeine

diclofenac sodium DR

acetaminophen/codeine

diclofenac sodium ER

acetaminophen/codeine #2

diclofenac sodium/misoprostol


etodolac


etodolac ER

acetaminophen/codeine phosphate

fenoprofen calcium

alfentanil

flurbiprofen

aspirin-caffeine-dihydrocodeine

ibuprofen

buprenorphine HCLPA

indomethacin

buprenorphine HCL/naloxone HCLQL

indomethacin ER

butalbital/acetaminophen/caffeine/codeine

ketoprofen

butalbital/aspirin/caffeine/codeine

ketoprofen ER

butorphanol tartrate

ketorolac tromethamine

codeine sulfate

leflunomide

hydrocodone bitartrate/acetaminophen

meclofenamate sodium

hydrocodone/acetaminophen

mefenamic acid

hydrocodone/ibuprofen

meloxicam

hydromorphone HCL

nabumetone

hydromorphone HCL dosette

naproxen

hydromorphone HCL ERPA

naproxen sodium

levorphanol tartrate

oxaprozin

meperidine HCL

piroxicam

methadone HCLPA

sulindac

morphine sulfate

tolmetin sodium

morphine sulfate ERQL,PA

TIER 02 FORMULARY

nalbuphine HCL

celecoxib

oxycodone HCL

naproxen sodium ER

oxycodone HCL ERQL,PA

Indocin

oxycodone/acetaminophen

Ridaura

oxycodone/aspirin


oxycodone/ibuprofen

oxymorphone hydrochloride

oxymorphone hydrochloride ERPA

pentazocine/naloxone HCL

tramadol hydrochloride/acetaminophen

IC 400

tramadol HCL

IC 800

tramadol HCL ER

Mobic

TIER 02 FORMULARY

Nalfon

fentanylPA




Mitigare

Rasuvo Uloric

Rheumatrex

SprixPA

TIER 04 SPECIALTY

ActemraPA

Arcalyst

EnbrelPA

Enbrel SureclickPA

HumiraQL,PA

Humira Pediatric Crohns Disease Starter Pack

Humira PenQL,PA

Humira Pen-crohns DiseasestarterQL,PA

Humira Pen-psoriasis StarterQL,PA

Ilaris

KineretPA

OrenciaQL,PA

OtezlaQL,PA

SimponiPA

XeljanzQL,PA

Xeljanz XR

MIGRAINE PRODUCTS

TIER 01 GENERIC

almotriptan malate

dihydroergotamine mesylate

RESPIRATORY, ALLERGY, ETC

frovatriptan succinate

ANTIHISTAMINES

naratriptan HCL

TIER 01 GENERIC

rizatriptan benzoate

brompheniramine

sumatriptan

brompheniramine tannate

sumatriptan succinate

carbinoxamine maleate

sumatriptan succinate refill

cetirizine HCL

zolmitriptan

clemastine fumarate

TIER 02 FORMULARY

cyproheptadine HCL

rizatriptan benzoate ODT

desloratadine

zolmitriptan ODT

desloratadine ODT

Migral

dexchlorpheniramine maleate

Relpax

diphenhydramine HCL


levocetirizine dihydrochloride

AlsumaST

promethazine HCL

Cafergot

promethazine HCL plain

Ergomar


FrovaST

Karbinal ER

Imitrex

Phenergan Fortis

Migergot

Sumavel DoseproST

NASAL AGENTS

TreximetST

TIER 01 GENERIC

Zomig azelastine HCL

Zomig Nasal Spray budesonide

flunisolide

GOUT AGENTS fluticasone propionate

ipratropium bromide

TIER 01 GENERIC

mometasone furoate

allopurinol

olopatadine HCL

colchicine


probenecid

TIER 02 FORMULARY

probenecid/colchicine

Adrenalin

TIER 02 FORMULARY

Bactroban Nasal

Colcrys



Nasonex theophylline CR

Tyzine theophylline ER

Tyzine Pediatric Nasal Drops zafirlukast

TIER 03 NON PREFERRED TIER 02 FORMULARY

Beconase AQ budesonide

Dymista Asmanex HFA

Omnaris Asmanex Twisthaler 120 Metered Doses

Qnasl Asmanex Twisthaler 14 Metered Doses

Qnasl Childrens Asmanex Twisthaler 30 Metered Doses

Veramyst Asmanex Twisthaler 60 Metered Doses

Zetonna Asmanex Twisthaler 7 Metered Doses

Atrovent HFA

COUGH/COLD/ALLERGY Combivent Respimat

Dulera

TIER 01 GENERIC

Elixophyllin

acetylcysteine

Foradil Aerolizer

benzonatate

Incruse Ellipta

bromphen/pseudoephedrine HCL/dextromethorphan HBR

Lufyllin

dextromethorphan HBR/chlorpheniramine/phenylephrine HCL

Proair HFA

hydrocodone bitartrate/chlorpheniramine maleate/PSE

Qvar

hydrocodone bitartrate/homatropine methylbromide

Serevent Diskus

hydrocodone polistirex/chlorpheniramine polistirex

Spiriva Handihaler

hydrocodone/homatropine

Symbicort

phenylephrine/guaifenesin

Theo-24

promethazine-DM

Ventolin HFA

promethazine/codeine


promethazine/dextromethorphan

Advair DiskusST

promethazine/phenylephrine

Advair HFAST

promethazine/phenylephrine/codeine

Alvesco

sodium chloride

Anoro Ellipta

TIER 02 FORMULARY

Arcapta Neohaler

Vituz

Arnuity ElliptaST


Breo ElliptaQL,ST

Carbaphen 12

Brovana

Carbaphen 12 PED

DalirespPA

Codar AR

Flovent DiskusST

Cpb Wc

Flovent HFAST

Decon-a

Isuprel

Gilphex TR

Perforomist

Giltuss PED-c

Proair Respiclick

Giltuss TR

Proventil HFAST

Hypersal

Pulmicort FlexhalerST

Nebusal

Pulmophylline

Neotuss Plus

Spiriva Respimat

Panatuss Dxp

Stiolto Respimat

Pediatex TDM

Tudorza Pressair

Relhist

Xopenex

Rescon-JR

Xopenex HFAST

Rescon-MX

Zyflo

Rezira

Zyflo CR

Semprex-D

TIER 04 SPECIALTY

XolairPA

Tuzistra XR

RESPIRATORY AGENTS - MISC

ANTIASTHMATIC/COPD AGENTS


TIER 01 GENERIC

Curosurf

albuterol

Infasurf

albuterol sulfate

Survanta Intratracheal

albuterol sulfate ER

TIER 04 SPECIALTY

cromolyn sodium

EsbrietPA

epinephrine HCL

KalydecoQL,PA

ipratropium bromide

OfevPA

ipratropium bromide/albuterol sulfate

OrkambiPA

levalbuterol

Pulmozyme

levalbuterol HCL

metaproterenol sulfate

VITAMINS

montelukast sodium

MULTIVITAMINS

terbutaline sulfate

TIER 01 GENERIC

theophylline

b-complex 100



TIER 02 FORMULARY Prenate Pixie

Mykidz Iron Fl Prenate Restore

TIER 03 NON PREFERRED Prenate Star

Atabex EC Preque 10

Bal-care DHA Provida OB

Citranatal Assure R-natal OB

Citranatal B-calm Select-ob+dha

Citranatal DHA Select-OB

Citranatal Harmony Taron-bc

Citranatal RX Taron-c DHA

Citranatal 90 DHA Texavite LQ

Concept DHA Tri-VI-flor

Concept OB Tricare Prenatal Compleat

Crnatal Tricare Prenatal DHA One

Duet DHA Balanced Triveen-duo DHA

Duet DHA 400 Triveen-prx RNF

Duet DHA 400EC Vemavite-prx 2

Duet DHA 430 Vinacal B

Duet DHA 430EC Vinate AZ Extra

Escavite Vinate Calcium

Escavite D Vinate DHA RF

Floriva Vita-pren

Focalgin CA Vitafol Ultra

Focalgin 90 DHA Vitafol-nano

Folcaps Omega 3 Vitafol-ob+dha

Folet DHA Vitafol-one

Folivane-prx DHA NF Vitamedmd One RX/Quatrefolic

Folivane-OB Vitamedmd Plus RX/Quatre Folic

Gesticare DHA Vitamedmd Redichew RX

Marnatal-f Vitamedmd Redichew RX/Quatrefolic

Mynatal Vitapearl

Natachew Viva DHA

Natalvirt CA Zatean-pn

Natalvirt 90 DHA Zatean-pn DHA

Natalvit Zatean-pn Plus

Natelle One Zatean-CH

Neevo DHA

Nestabs MISCELLANEOUS AGENTS

Nestabs Abc

Nestabs DHA

TIER 01 GENERIC

Newgen

pentetate calcium trisodium

Nexa Plus

pentetate zinc trisodium

Nicomide


Niva-plus

Chemet

O-CAL Fa

TIER 04 SPECIALTY

O-CAL Prenatal

Exjade

Obstetrix DHA

FerriproxPA

Ocuvel

OB Complete

OB Complete One

OB Complete Petite

OB Complete Premier

OB Complete 400

OB Complete/DHA

Paire OB

Poly-VI-flor

Poly-VI-flor/Iron

Prefera OB

Prefera OB + DHA

Preferaob +dha

Preferaob One

Prefol-DHA

Prenata

Prenate

Prenate AM

Prenate DHA

Prenate Elite

Prenate Enhance

Prenate Essential

Prenate Mini



Index

A

almotriptan malate, 20

Alocril, 18

abacavir, 2

alogliptin, 10 apraclonidine, 18

abacavir sulfate/lamivudine/zidovudine, 2

alogliptin/metformin HCL, 10 Apriso, 12

Abilify, 15

alogliptin/pioglitazone, 10 Aptiom, 16

Abilify Discmelt, 15

Alomide, 18 Aptivus, 2

Abilify Maintena, 15

Alora, 9 Aquoral, 14

Abstral, 19

alosetron hydrochloride, 12 Aranesp Albumin Free, 13

acamprosate calcium DR, 16

Arcalyst, 20

acarbose, 10

alprazolam, 14 Arcapta Neohaler, 21

acebutolol HCL, 4

alprazolam ER, 14 aripiprazole, 15

acetaminophen/caffeine/dihydrocodeine, 19

Alprazolam Intensol, 14 aripiprazole ODT, 15

alprazolam ODT, 14

acetaminophen/codeine, 19

Alrex, 18

acetaminophen/codeine #2, 19

Alsuma, 20 Arixtra, 14


Altabax, 6 Armour Thyroid, 11


Altoprev, 6 arnica flower, 8

acetaminophen/codeine phosphate, 19

Alvesco, 21 Arnuity Ellipta, 21

acetazolamide, 5

amantadine HCL, 16 Artiss, 14

acetazolamide ER, 5

amcinonide, 7 Asacol HD, 12

acetazolamide sodium, 5

amikacin sulfate, 1 Asmanex HFA, 21

acetic acid, 18

amiloride HCL, 5 Asmanex Twisthaler 120 Metered Doses, 21

acetic acid/aluminum acetate, 18

amiloride/hydrochlorothiazide, 5

acetylcysteine, 21

aminocaproic acid, 14 Asmanex Twisthaler 14 Metered Doses, 21

Aciphex Sprinkle, 12

amiodarone HCL, 5

acitretin, 7

Amitiza, 12 Asmanex Twisthaler 30 Metered Doses, 21

Actemra, 20

amitriptyline HCL, 14

Actimmune, 4

amlodipine besylate, 4 Asmanex Twisthaler 60 Metered Doses, 21

Actoplus Met XR, 10

amlodipine besylate/atorvastatin calcium, 6

Asmanex Twisthaler 7 Metered Doses, 21

amlodipine besylate/benazepril HCL, 5

Acuvail, 18

amlodipine besylate/benazepril hydrochloride, 5

aspirin-caffeine-dihydrocodeine, 19

acyclovir, 2, 7

aspirin/dipyridamole, 14

adapalene, 6

amlodipine besylate/valsartan, 5 Astagraf XL, 3

adapalene P.M., 6

amlodipine/valsartan/hctz, 5 Astringyn, 14

Adcirca, 6

amoxapine, 14 Atabex EC, 22

Adderall, 16

amoxicillin, 1 atenolol, 4

Adderall XR, 16

amoxicillin ER, 1 atenolol/chlorthalidone, 5

adefovir dipivoxil, 2

amoxicillin/clavulanate potassium, 1 Atopiclair, 8

Adempas, 6

amoxicillin/clavulanate potassium ER, 1 atorvastatin calcium, 6

Adrenaclick, 6

amphetamine/dextroamphetamine, 16 atovaquone, 3

Adrenalin, 6, 20

amphotericin b, 2 atovaquone/proguanil HCL, 2

Advair Diskus, 21

ampicillin, 1 Atripla, 2

Advair HFA, 21

ampicillin sodium, 1 Atropen, 12

Advicor, 6

ampicillin-sulbactam, 1 atropine sulfate, 12, 18

Ampyra, 17 Atrovent HFA, 21

Afinitor, 3

Amturnide, 5 Aubagio, 17

Afinitor Disperz, 3

Amytal Sodium, 15 augmented betamethasone dipropionate, 7

Aggrenox, 14

Anacaine, 8

Akten, 18

Anadrol-50, 9 Augmentin, 1

Akynzeo, 12

anagrelide hydrochloride, 14

Albenza, 3

albuterol, 21

auryxia, 12

albuterol sulfate, 21

anastrozole, 3 Avandamet, 10

albuterol sulfate ER, 21

Androderm, 9 Avandaryl, 10

alclometasone dipropionate, 7

Androgel, 9 Avandia, 10

Aldactazide, 5

Androgel P.M., 9 Avar, 6

Alecensa, 3

Androxy, 9 Avar LS, 6

alendronate sodium, 10

Angeliq, 9 Avc, 13

Alevicyn Antipruritic SG, 8

Anoro Ellipta, 21 Avenova, 8

alfentanil, 19

antipyrine/benzocaine, 18 Avonex, 17

alfuzosin HCL ER, 13

Anzemet, 12 Avonex Pen, 17

Alinia, 3

Axiron, 9

Alkeran, 3

Apokyn, 16 Azasan, 3

allopurinol, 20

Appbutamone, 15 Azasite, 17

Allzital, 19

azathioprine, 3

HCL/dextromethorphan HBR, 21

azelastine HCL, 18, 20

brompheniramine, 20 Cardura XL, 13

Azilect, 16

brompheniramine tannate, 20 carteolol HCL, 17

azithromycin, 1

Brovana, 21 carvedilol, 4

Azopt, 18

budesonide, 9, 20, 21 cascara sagrada, 11

Azor, 5

bumetanide, 5 Cathflo Activase, 14

aztreonam, 3

Bupap, 19 Cayston, 3

B

Buphenyl, 11 Cedax, 1

cefaclor, 1

cefaclor ER, 1

b-complex 100, 21

buprenorphine HCL, 19 cefadroxil, 1

bacitracin, 3, 17

buprenorphine HCL/naloxone HCL, 19 cefazolin sodium, 1

bacitracin/polymyxin b, 17

bupropion HCL, 14 cefdinir, 1

baclofen, 17

bupropion HCL ER, 14 cefditoren pivoxil, 1

Bactroban Nasal, 20

bupropion HCL SR, 14 cefepime, 1

Bal-care DHA, 22

bupropion HCL XL, 14 cefixime, 1

balsalazide disodium, 12

buspirone HCL, 14 Cefotan, 1

Banzel, 16

butalbital/acetaminophen, 19 cefotaxime sodium, 1

Baraclude, 2

butalbital/acetaminophen/caffeine, 19 cefotetan, 1

Beconase AQ, 21

butalbital/acetaminophen/caffeine/codeine, 19

cefoxitin sodium, 1

belladonna & opium, 12

cefpodoxime proxetil, 1

belladonna alkaloids & opium, 12

butalbital/aspirin/caffeine, 19 cefprozil, 1

benazepril HCL, 5

butalbital/aspirin/caffeine/codeine, 19 ceftazidime, 1

benazepril HCL/hydrochlorothiazide, 5

Butisol Sodium, 15 ceftibuten, 1

Benefix, 14

butorphanol tartrate, 19 Ceftin, 1

Benicar, 5

Bydureon, 10 ceftriaxone sodium, 1

Benicar HCT, 5

Byetta, 10 cefuroxime axetil, 1

benzoin compound tincture, 8

Bystolic, 4 cefuroxime sodium, 1

benzoin tincture, 8

C celecoxib, 19

benzonatate, 21

Cellcept, 3

benzoyl peroxide, 6

cabergoline, 11

Celontin, 16

benzoyl peroxide SHORT contact, 6

Cafergot, 20

Cenestin, 9

benztropine mesylate, 16

caffeine citrate, 15

centany, 6

Bepreve, 18

caffeine/sodium benzoate, 15

Centany AT, 6

Besivance, 17

calcipotriene, 7

cephalexin, 1

Betadine Ophthalmic Prep, 17

calcipotriene/betamethasone dipropionate, 7

Cerdelga, 13

betamethasone dipropionate, 7

Cervidil, 19

betamethasone sodium phosphate/betamethasone acetate, 8

calcitonin salmon, 10

Cesamet, 12

calcitonin-salmon, 10

cetirizine HCL, 20

betamethasone valerate, 7

calcitriol, 7, 11

Cetraxal, 18

Betaseron, 17

calcium acetate, 12

Cetrotide, 11

betaxolol HCL, 4, 17

Canasa, 12

cevimeline HCL, 14

bethanechol chloride, 13

candesartan cilexetil, 5

Chemet, 22

Bethkis, 1

candesartan cilexetil/hydrochlorothiazide, 5

Chenodal, 13

Betimol, 18

chlordiazepoxide HCL, 14

Betoptic-s, 17

Cantil, 12

chlordiazepoxide HCL/clidinium bromide, 12

bexarotene, 4

Capastat Sulfate, 2

Beyaz, 9

capecitabine, 3

chlordiazepoxide/amitriptyline, 17

bicalutamide, 3

Capex, 7

chlorhexidine gluconate, 14

Bicillin C-R, 1

Caphosol, 14

chlorhexidine gluconate oral rinse, 14

Bicillin L-A, 1

Capital/Codeine, 19

Bidil, 6

Caprelsa, 3

chloroquine phosphate, 2

Biltricide, 3

capsaicin, 8

chlorothiazide, 5

Binosto, 10

captopril, 5

chlorpromazine HCL, 15

bisoprolol fumarate, 4

captopril/hydrochlorothiazide, 5

chlorpropamide, 10

bisoprolol fumarate/hydrochlorothiazide, 5

Carafate, 12

chlorthalidone, 5

Carbaglu, 11

chlorzoxazone, 17

Blephamide, 18

carbamazepine, 16

cholestyramine, 6

Blephamide S.o.p., 18

carbamazepine ER, 16

cholestyramine light, 6

boric acid, 8

Carbaphen 12, 21

choline magnesium trisalicylate, 19

Bosulif, 3

Carbaphen 12 PED, 21

chorionic gonadotropin, 10

Botox, 17

Carbatrol, 16

Cialis, 6

Bravelle, 10

carbidopa, 16

Breo Ellipta, 21

carbidopa/levodopa, 16

ciclopirox, 7

Brilinta, 14

carbidopa/levodopa ER, 16

brimonidine tartrate, 18

carbidopa/levodopa ODT, 16

bromfenac, 18

carbidopa/levodopa/entacapone, 16

bromocriptine mesylate, 16

carbinoxamine maleate, 20

Ciferex, 13

bromphen/pseudoephedrine

Cardene SR, 4

cilostazol, 14

Cometriq, 4 Depakote ER, 16

Ciloxan, 17

Complera, 2 Depakote Sprinkles, 16

cimetidine, 12

Concept DHA, 22 Depo-estradiol, 9

cimetidine HCL, 12

Concept OB, 22 Depo-medrol, 9

Cimzia, 13

Concerta, 16 Depo-provera, 3

Cimzia Starter Kit, 13

Condylox, 8

Cipro HC, 18

Ciprodex, 18

Conzip, 19 Dermasorb HC, 7

ciprofloxacin, 1, 18

Copasil, 8 Dermasorb Ta, 7

ciprofloxacin ER, 1

desipramine HCL, 14

ciprofloxacin HCL, 1, 17

Cordran, 7 desloratadine, 20

citalopram hydrobromide, 14

Cordran Tape, 7 desloratadine ODT, 20

Coreg CR, 4 desmopressin acetate, 11

Corlanor, 6 desogestrel/ethinyl estradiol, 9

Citranatal 90 DHA, 22

Cortifoam, 13 Desonate, 7

Citranatal Assure, 22

cortisone acetate, 8 desonide, 7

Citranatal B-calm, 22

Cortisporin, 6 Desowen Cream/Cetaphil Lotion, 7

Citranatal DHA, 22

Cortisporin-tc, 18 Desowen Lotion/Cetaphil Cream, 7

Citranatal Harmony, 22

Cosentyx, 7 Desowen Ointment/Cetaphil Lotion, 7

Citranatal RX, 22

Cosentyx Sensoready Pen, 7 desoximetasone, 7

citric acid/sodium citrate, 13

Cosopt PF, 18 desvenlafaxine ER, 14

clarithromycin, 1

Cotellic, 4 dexamethasone, 8

clarithromycin ER, 1

Cpb Wc, 21 Dexamethasone Intensol, 9

clemastine fumarate, 20

Creon, 12 dexamethasone sodium phosphate, 8, 18

Cleocin, 13

Cresemba, 2

Crestor, 6 dexchlorpheniramine maleate, 20

Climara Pro, 9

Crinone, 13 Dexedrine, 16

clindamycin HCL, 3

Crixivan, 2 dexmethylphenidate HCL, 15

clindamycin palmitate HCL, 3

Crnatal, 22 dexmethylphenidate HCL ER, 15

clindamycin phosphate, 3, 6, 13

cromolyn sodium, 12, 18, 21 Dexpak 10 Day, 9

Curosurf, 21 Dexpak 13 Day, 9

Cuvposa, 12 Dexpak 6 Day, 9

clindamycin/benzoyl peroxide, 6

cyanocobalamin, 13 dexpanthenol, 12

Clindesse, 13

dextroamphetamine sulfate, 15

Clinoin, 6

cyclobenzaprine HCL, 17 dextroamphetamine sulfate ER, 15

clobetasol propionate, 7

Cyclogyl, 18 dextromethorphan HBR/chlorpheniramine/phenylephrine HCL, 21

clobetasol propionate emollient, 7

Cyclomydril, 18

clocortolone pivalate, 7

cyclopentolate HCL, 18

clocortolone pivalate P.M., 7

cyclopentolate hydrochloride, 18

Diabeta, 10

Cloderm, 7

cyclophosphamide, 3

diazepam, 14, 16

Cloderm P.M., 7

cycloserine, 2

diclofenac potassium, 19

clomiphene citrate, 10

cyclosporine, 3

diclofenac sodium, 7, 18

clomipramine HCL, 14

cyclosporine modified, 3

diclofenac sodium DR, 19

clonazepam, 16

cyproheptadine HCL, 20

diclofenac sodium ER, 19

clonazepam ODT, 16

Cystadane, 11

diclofenac sodium/misoprostol, 19

clonidine HCL, 5

Cystagon, 13

dicloxacillin sodium, 1

clopidogrel, 14

Cystaran, 18

dicyclomine hci, 12

clorazepate dipotassium, 14

Cytomel, 11

dicyclomine HCL, 12

Clorpres, 5

D

didanosine, 2

clotrimazole, 14

Dificid, 1

Daklinza, 2

clotrimazole/betamethasone dipropionate, 7

diflorasone diacetate, 7

Daliresp, 21

diflunisal, 19

danazol, 9

clozapine, 15

digoxin, 4

dantrolene sodium, 17

clozapine ODT, 15

dihydroergotamine mesylate, 20

dapsone, 3

coal TAR, 8

Dilantin, 16

Daraprim, 2

Coartem, 2

Dilantin Infatabs, 16

darifenacin ER, 13

cocaine HCL, 8

Dilantin-125, 16

darifenacin hydrobromide ER, 13

Codar AR, 21

Dilatrate SR, 4

Daytrana, 16

codeine sulfate, 19

Dilaudid-HP, 19

Debacterol, 14

colchicine, 20

diltiazem CD, 4

Decon-a, 21

Colcrys, 20

diltiazem HCL, 4

Delestrogen, 9

colestipol HCL, 6

diltiazem HCL ER, 4

Delzicol, 13

colistimethate sodium, 3

dimenhydrinate, 12

Demadex, 6

Coly-mycin S, 18

Dipentum, 13

demeclocycline HCL, 1

Colyte-flavor Packs, 12

diphenhydramine HCL, 20

Demser, 5

Combigan, 18

diphenoxylate/atropine, 12

Denavir, 7

Combipatch, 9

dipyridamole, 14

Depakene, 16

Combivent Respimat, 21

disopyramide phosphate, 5

Depakote, 16

disulfiram, 17

Embeda, 19 ethyl chloride/mist, 8

Diuril, 5

Emcyt, 3 etidronate disodium, 10

divalproex sodium, 16

Emend, 12 etodolac, 19

divalproex sodium DR, 16

Emsam, 15 etodolac ER, 19

divalproex sodium ER, 16

Emtriva, 2 etoposide, 3

Divigel, 9

Emulsion SB, 8 Eurax, 8

donepezil HCL, 17

Emverm, 3 Evamist, 9

Doral, 15

enalapril maleate, 5 Evicel, 14

dorzolamide HCL, 18

enalapril maleate/hydrochlorothiazide, 5 Evithrom, 14

dorzolamide HCL/timolol maleate, 17

Enbrel, 20 Evotaz, 2

doxazosin, 5

Enbrel Sureclick, 20 Exalgo, 19

doxazosin mesylate, 5

Endometrin, 13 Exelderm, 7

doxepin HCL, 14

Enjuvia, 9 exemestane, 3

doxepin hydrochloride, 7

Enlon, 17 Exjade, 22

doxercalciferol, 11

enoxaparin sodium, 14

doxycycline, 1, 6

Enstilar, 7 Extavia, 17

doxycycline hyclate, 1

entacapone, 16 F

doxycycline hyclate DR, 1

entecavir, 2

Fabior, 6

doxycycline monohydrate, 1

Entereg, 13

Factive, 1

dronabinol, 12

Entresto, 6

Falessa, 9

droperidol, 14

Epaned, 5

famciclovir, 2

drospirenone/ethinyl estradiol, 9

ephedrine sulfate, 6

famotidine, 12

Droxia, 13

Epiceram, 8

Fanapt, 15

Duavee, 9

Epiduo Forte, 6

Duet DHA 400, 22

Epifoam, 7

Fareston, 3

Duet DHA 400EC, 22

epinastine HCL, 18

Farxiga, 10

Duet DHA 430, 22

epinephrine, 6

Farydak, 4

Duet DHA 430EC, 22

epinephrine HCL, 21

Fazaclo, 15

Duet DHA Balanced, 22

Epipen 2-PAK, 6

felbamate, 16

Dulera, 21

Epipen-JR 2-PAK, 6

Felbatol, 16

duloxetine HCL, 15

Epivir HBV, 2

felodipine ER, 4

eplerenone, 5

Femring, 13

Epogen, 13

fenofibrate, 6

eprosartan mesylate, 5

fenofibrate micronized, 6

Epzicom, 2

fenofibric acid DR, 6

Equagesic, 19

Fenoglide, 6

Equetro, 15

fenoprofen calcium, 19

ergoloid mesylates, 17

fentanyl, 19

Ergomar, 20

fentanyl citrate oral transmucosal, 19

Durezol, 18

Ery-TAB, 1

Fentora, 19

dutasteride, 13

Eryped 200, 1

Feriva 21/7, 13

dutasteride/tamsulosin hydrochloride, 13

Eryped 400, 1

Ferriprox, 22

Dutoprol, 5

Erythrocin Stearate, 1

Fetzima, 15

Dyanavel XR, 16

erythromycin, 1, 6, 17

Finacea, 6

Dymista, 21

erythromycin base, 1

finasteride, 13

Dyrenium, 6

erythromycin ethylsuccinate, 1

Firazyr, 14

Dysport, 17

erythromycin/benzoyl peroxide, 6

Firmagon, 3

Dyural-l, 9

Esbriet, 21

E

Escavite, 22

Escavite D, 22

E.e.s. Granules, 1

escitalopram oxalate, 15

econazole nitrate, 7

estazolam, 15

Ecoza, 7

Estrace, 13

Edarbi, 5

estradiol, 9

Edarbyclor, 5

estradiol valerate, 9

Edecrin, 6

estradiol/norethindrone acetate, 9

Edurant, 2

Estrasorb, 9

Effient, 14

Estring, 13

Elestrin, 9

Estrogel, 9

Eletone, 8

Flagyl ER, 3

estropipate, 9

eszopiclone, 15

Elidel, 8

Flarex, 18

ethambutol HCL, 2

Eligard, 3

flavoxate HCL, 13

ethosuximide, 16

Elimite, 8

flecainide acetate, 5

ethyl chloride, 8

Eliquis, 14

Flector, 7

ethyl chloride/fine pinpoint, 8

Elixophyllin, 21

FLO-pred, 9

ethyl chloride/fine stream, 8

Ella, 9

Floriva, 22

ethyl chloride/medium jet stream, 8

Elmiron, 13

Flovent Diskus, 21

ethyl chloride/medium stream, 8

Emadine, 18

Flovent HFA, 21

fluconazole, 2

Gelclair, 14

flucytosine, 2

Gelnique, 13

fludrocortisone acetate, 8

gemfibrozil, 6

flunisolide, 20

Genotropin, 11 Humalog, 9

fluocinolone acetonide, 7, 18

Genotropin Miniquick, 11 Humalog Kwikpen, 9

fluocinolone acetonide ear drops, 18

gentamicin sulfate, 1, 6, 17 Humalog Mix 50/50, 9

fluocinonide, 7

gentamicin sulfate pediatric, 1 Humalog Mix 50/50 Kwikpen, 9

fluocinonide-e, 7

Genvoya, 2 Humalog Mix 75/25, 9

fluorometholone, 18

Geodon, 15 Humalog Mix 75/25 Kwikpen, 9

fluoxetine, 17

Gesticare DHA, 22 Humatrope, 11

fluoxetine DR, 15

Giazo, 13 Humatrope Combo Pack, 11

fluoxetine HCL, 15

Gilenya, 17 Humira, 20

fluphenazine decanoate, 15

Gilotrif, 4 Humira Pediatric Crohns Disease Starter Pack, 20

fluphenazine HCL, 15

Gilphex TR, 21

flurazepam HCL, 15

Giltuss PED-c, 21 Humira Pen, 20

flurbiprofen, 19

Giltuss TR, 21 Humira Pen-crohns Diseasestarter, 20

flurbiprofen sodium, 18

Gleevec, 4 Humira Pen-psoriasis Starter, 20

flutamide, 3

Glatiramer acetate , 17 Humulin R U-500 (concentrated), 9

fluticasone propionate, 7, 20

glimepiride, 10 Humulin R U-500 Kwikpen, 9

fluvastatin, 6

glipizide, 10 Hycamtin, 4

fluvastatin sodium ER, 6

glipizide ER, 10 hydralazine HCL, 5

fluvoxamine maleate, 15

glipizide/metformin HCL, 10 hydrochlorothiazide, 5

fluvoxamine maleate ER, 15

Glucagen Hypokit, 10 hydrocodone bitartrate/acetaminophen, 19

FML, 18

Glucagon Emergency Kit, 10

FML Forte, 18

glyburide, 10 hydrocodone bitartrate/chlorpheniramine maleate/PSE, 21

Focalgin 90 DHA, 22

glyburide micronized, 10

Focalgin CA, 22

glyburide/metformin HCL, 10 hydrocodone bitartrate/homatropine methylbromide, 21

Focalin, 16

glycolic acid, 7

Focalin XR, 16

glycolic acid 70% high purity, 7 hydrocodone polistirex/chlorpheniramine polistirex, 21

Folcaps Omega 3, 22

glycopyrrolate, 12

Folet DHA, 22

Glyset, 10 hydrocodone/acetaminophen, 19

folic acid, 13

Golytely, 11 hydrocodone/homatropine, 21

Folivane-OB, 22

Gonal-f, 10 hydrocodone/ibuprofen, 19

Folivane-prx DHA NF, 22

Gonal-f RFF, 10 hydrocortisone, 9, 12

Follistim AQ, 10

Gonal-f RFF Pen, 10 hydrocortisone acetate/aloe, 7

fondaparinux sodium, 14

Gonal-f RFF Rediject, 10 hydrocortisone acetate/lidocaine HCL,

Foradil Aerolizer, 21

Gordofilm, 8 hydrocortisone acetate/pramoxine, 12

Gordons Urea, 8 hydrocortisone butyrate, 7

Fortaz, 1

granisetron HCL, 12 hydrocortisone butyrate (lipid), 7

Forteo, 10

Granisol, 12 hydrocortisone butyrate (lipophilic), 7

Fortesta, 9

Granix, 13 hydrocortisone IN absorbase, 7

fortical, 10

griseofulvin microsize, 2 hydrocortisone valerate, 7

Fosamax Plus D, 10

griseofulvin ultramicrosize, 2 hydrocortisone/acetic acid, 18

fosinopril sodium, 5

guanfacine ER, 15 hydromorphone HCL, 19

fosinopril sodium/hydrochlorothiazide, 5

guanfacine HCL, 5 hydromorphone HCL dosette, 19

Fosrenol, 12

guanidine HCL, 17 hydromorphone HCL ER, 19

Fragmin, 14

Gynazole-1, 13 hydroxocobalamin, 13

Frova, 20

H hydroxychloroquine sulfate, 2

frovatriptan succinate, 20

hydroxyurea, 4

Fulyzaq, 12

hydroxyzine HCL, 14

halobetasol propionate, 7

furosemide, 5

hydroxyzine pamoate, 14

Halog, 7

Fuzeon, 2

Hylatopic, 8

Halonate, 7

Fycompa, 16

Hylatopic Plus, 8

haloperidol, 15

G

hyoscyamine sulfate, 12

haloperidol decanoate, 15

hyoscyamine sulfate ER, 12

gabapentin, 16

haloperidol lactate, 15

hyoscyamine sulfate ODT, 12

Gabavale-5, 14

Halotin, 7

hyoscyamine sulfate SR, 12

Gabazolamine, 14

Harvoni, 2

Hypersal, 21

Gabazolamine-0.5, 14

Helixate FS, 14

Hypertenevide-12.5, 4

Gabazolpidem-5, 15

Hemabate, 19

Hypertenipine-2.5, 4

Gabitidine, 12

heparin sodium, 14

Hypertensolol, 5

Gabitril, 16

heparin sodium dcu, 14

I

Gaboxetine, 15

heparin sodium/NACL 0.45%, 14

galantamine hydrobromide, 17

heparin sodium/NACL 0.9%, 14 ibandronate sodium, 10

ganirelix acetate, 11

heparin sodium/sodium chloride 0.9% premix, 14

Ibrance, 4

gatifloxacin, 17

ibuprofen, 19

Gattex, 13

Hexalen, 3

homatropine HBR, 18 IC 400, 19

IC 800, 19

Iclusig, 4

Keppra, 16 Leukeran, 3

Ilaris, 20

Keppra XR, 16 leuprolide acetate, 3

Ilevro, 18

Kerafoam, 8 Levacet, 19

imatinib mesylate, 3

Kerafoam 42, 8 levalbuterol, 21

Imbruvica, 4

Keralyt Scalp, 8 levalbuterol HCL, 21

imipramine HCL, 15

Ketek, 3 Levatol, 4

imipramine pamoate, 15

ketoconazole, 2, 7 Levemir, 10

imiquimod, 8

Levemir Flexpen, 10

Imitrex, 20

ketoprofen, 19 Levemir Flextouch, 10

Imuran, 3

ketoprofen ER, 19 levetiracetam, 16

Increlex, 11

ketorolac tromethamine, 18, 19 levetiracetam ER, 16

Incruse Ellipta, 21

Khedezla, 15 Levitra, 6

indapamide, 5

Kineret, 20 levobunolol HCL, 17

Inderal XL, 4

Kinlytic, 14 levocarnitine, 11

Indocin, 19

Kitabis PAK, 1 levocetirizine dihydrochloride, 20

indomethacin, 19

Kogenate FS, 14 levofloxacin, 1, 17

indomethacin ER, 19

Kogenate FS Bio-set, 14 levonorgestrel, 9

Infasurf, 21

Kombiglyze XR, 10 levonorgestrel and ethinyl estradiol, 9

Inlyta, 4

Korlym, 10 levonorgestrel/ethinyl estradiol, 9

Innopran XL, 4

Kovaltry, 14 levorphanol tartrate, 19

Intelence, 2

Kristalose, 12 levothyroxine sodium, 11

Intron A, 4

Kuvan, 11 levothyroxine sodium TAB 0.075MG, 11

Intron A W/Diluent, 4

Kynamro, 6 Levsin, 12

Invanz, 3

L Lexiva, 2

Invega Sustenna, 15

Lialda, 12

labetalol HCL, 4

Invega Trinza, 15

Lido-RX 4.1, 8

Lacrisert, 17

Invirase, 2

lidocaine, 8

lactic acid, 8

Invokamet, 10

lidocaine and tetracaine cream, 8

lactic acid e, 8

Invokana, 10

lidocaine HCL, 8, 14,

lactic acid w/vitamin e, 8

Iopidine, 18

lidocaine HCL jelly, 8

lactulose, 11, 12

ipratropium bromide, 20, 21

lidocaine HCL viscous, 14

Lamictal, 16

ipratropium bromide/albuterol sulfate, 21

lidocaine HCL-hydrocortisone acetate with aloe, 12

Lamictal Chewable Dispersible, 16

Iprivask, 14

Lamictal ODT, 16

irbesartan, 5

lidocaine HCL/hydrocortisone acetate,

irbesartan/hydrochlorothiazide, 5

lidocaine viscous, 14

Iressa, 4

lidocaine-prilocaine-cream base, 8

Isentress, 2

isoniazid, 2

lidocaine/prilocaine, 8

Isopto Carbachol, 18

Lincocin, 3

Isopto Homatropine, 18

lincomycin HCL, 3

Lamictal XR, 16

Isopto Hyoscine, 18

lincomycin/lidocaine, 3

Lamisil, 2

isosorbide dinitrate, 4

lindane, 8

Lamisil Spray, 7

isosorbide dinitrate ER, 4

linezolid, 3

lamivudine, 2

isosorbide mononitrate, 4

Linzess, 13

lamivudine/zidovudine, 2

isosorbide mononitrate ER, 4

liothyronine sodium, 11

lamotrigine, 16

isradipine, 4

lisinopril, 5

lamotrigine ER, 16

Isuprel, 21

lisinopril/hydrochlorothiazide, 5

lamotrigine ODT, 16

itraconazole, 2

lithium, 15

lamotrigine titration, 16

lithium carbonate, 15

lanoxin, 4

ivermectin, 2

lithium carbonate ER, 15

Lanoxin, 4

Ixinity, 14

Lithostat, 13

Lanoxin Pediatric, 4

J

Livalo, 6

lansoprazole, 12

LO Loestrin FE, 9

Jakafi, 4

lansoprazole/amoxicillin/clarithromycin, 12

Locoid, 8

Janumet, 10

lomustine, 3

Janumet XR, 10

Lantus, 9

Lonsurf, 4

Januvia, 10

Lantus Solostar, 9

lorazepam, 14

Jardiance, 10

Lastacaft, 18

Lortab, 19

Jentadueto, 10

latanoprost, 18

Juxtapid, 6

Latuda, 15

Lorzone, 17

K

Lazanda, 19

losartan potassium, 5

leflunomide, 19

losartan potassium/hydrochlorothiazide, 5

K-phos NO 2, 13

Lenvima 10MG Daily Dose, 4


Lotemax, 18

Kalbitor, 14


lovastatin, 6

Kaletra, 2


loxapine, 15

Kalydeco, 21

Letairis, 6

loxapine succinate, 15

Karbinal ER, 20

letrozole, 3

Lufyllin, 21

Kazano, 10

leucovorin calcium, 4

Lumigan, 18

methylphenidate HCL CD, 15 moxifloxacin HCL, 1

Lupaneta Pack, 11

methylphenidate HCL ER, 16 Mozobil, 13

Lupron Depot, 3

methylphenidate HCL SR, 16 Multaq, 5

Lupron Depot-PED, 11

methylphenidate hydrochloride, 15 mupirocin, 6

Luzu, 7

methylprednisolone, 9 mupirocin calcium, 6

Lycelle, 8

methylprednisolone acetate, 9 Muse, 6

Lynparza, 4

methylprednisolone dose pack, 9 mycophenolate mofetil, 3

Lyrica, 16

methylprednisolone PF, 9 mycophenolic acid DR, 3

Lysodren, 3

methylprednisolone sodiumsuccinate, 9 Mykidz Iron Fl, 22

methyltestosterone, 9 Myleran, 3

metipranolol, 18 Mynatal, 22

M

metoclopramide HCL, 12 Myobloc, 17

metoclopramide ODT, 12 Myrbetriq, 13

Makena, 9

metolazone, 5 Mysoline, 16

malathion, 8

metoprolol succinate ER, 4 N

maprotiline HCL, 15

metoprolol tartrate, 4

Marnatal-f, 22

nabumetone, 19

metoprolol/hydrochlorothiazide, 5

Marplan, 15

nadolol, 4

metronidazole, 3, 6

Matulane, 4

nadolol/bendroflumethiazide, 5

metronidazole vaginal, 13

Maxidex, 18

nafcillin sodium, 1

mexiletine HCL, 5

Maxipime, 1

Nafrinse Daily/Acidulated, 14

Miacalcin, 10

Mb Hydrogel, 8

Nafrinse Daily/Neutral, 14

midodrine HCL, 6

meclofenamate sodium, 19

Nafrinse Weekly, 14

Mifeprex, 11

Medi-derm/L-RX, 8

naftifine HCL, 7

Migergot, 20

Medrol, 9

naftifine hydrochloride, 7

Migral, 20

medroxyprogesterone acetate, 9

Naftin, 7

Millipred, 9

medroxyprogesterone/lidocaine, 9

nalbuphine HCL, 19

Millipred DP, 9

mefenamic acid, 19

Nalfon, 19

Minastrin 24 FE, 9

mefloquine HCL, 2

Namenda XR, 17

mineral oil heavy, 11

megestrol acetate, 3, 9

Minivelle, 9

Megrix, 8

Namzaric, 17

minocycline HCL, 1

Mekinist, 4

naphazoline HCL, 18

minocycline HCL ER, 1

meloxicam, 19

naproxen, 19

minoxidil, 5

Mirapex ER, 16

memantine HCL, 17

naproxen sodium, 19

Mircera, 13

memantine HCL titration PAK, 17

naproxen sodium ER, 19

mirtazapine, 15

memantine hydrochloride, 17

naratriptan HCL, 20

mirtazapine ODT, 15

Menest, 9

Nascobal, 13

misoprostol, 12

Menopur, 11

Nasonex, 21

Mitigare, 20

Menostar, 9

Natachew, 22

Mitosol, 17

Mentax, 7

Natacyn, 17

meperidine HCL, 19

Natalvirt 90 DHA, 22

Mobic, 19

meprobamate, 14

Natalvirt CA, 22

modafinil, 16

mercaptopurine, 3

Natalvit, 22

Moderiba, 2

mesalamine, 12

Natazia, 9

Mesnex, 4

nateglinide, 10

Natelle One, 22

moexipril HCL, 5

Metadate CD, 16

Nature-throid, 11

moexipril/hydrochlorothiazide, 5

metaproterenol sulfate, 21

Nature-throid Nt-2.5, 11

molindone hydrochloride, 15

metaxalone, 17

Nebupent, 3

mometasone furoate, 7, 20

metformin HCL, 10

Nebusal, 21

metformin HCL ER, 10

Neevo DHA, 22

methadone HCL, 19

nefazodone HCL, 15

methamphetamine HCL, 15

Nembutal Sodium, 15

methazolamide, 5

Neo-synalar, 6

methenamine hippurate, 13

neomycin sulfate, 1

methenamine mandelate, 13

neomycin/bacitracin/polymyxin, 17

methimazole, 11

neomycin/polymyxin/bacitracin zinc, 17

methocarbamol, 17

neomycin/polymyxin/bacitracin/hydrocortisone, 18

montelukast sodium, 21

methotrexate, 3

Monurol, 13

methotrexate sodium, 3

neomycin/polymyxin/dexamethasone, 18

morphine sulfate, 19

methoxsalen, 7

neomycin/polymyxin/gramicidin, 17

morphine sulfate ER, 19

methscopolamine bromide, 12

neomycin/polymyxin/HC, 18

Morphine Sulfate Powder, 19

methyclothiazide, 5

neomycin/polymyxin/hydrocortisone, 18(2)

Motofen, 12

methyldopa, 5

Movantik, 13

methyldopa/hydrochlorothiazide, 5

Neoral, 3

Moviprep, 11

methylergonovine maleate, 19

Neosalus, 8

Moxatag, 1

Methylin, 16

Neosalus CP, 8

Moxeza, 17

methylphenidate HCL, 15

neostigmine methylsulfate, 17

Neotuss Plus, 21

Nutropin AQ Nuspin 10, 11 oxcarbazepine, 16

Nutropin AQ Nuspin 20, 11 Oxecta, 19

Nesina, 10

Nutropin AQ Nuspin 5, 11 oxiconazole nitrate, 7

Nestabs, 22

Nutropin AQ Pen, 11 Oxistat, 7

Nestabs Abc, 22

Nuvail, 8 Oxtellar XR, 16

Nestabs DHA, 22

Nuvigil, 16 oxybutynin chloride, 13

Neulasta, 13

Nuwiq, 14 oxybutynin chloride ER, 13

Nymalize, 4 oxycodone HCL, 19

Neumega, 13

nystatin, 2, 7, 14 oxycodone HCL ER, 19

Neupogen, 13

nystatin/triamcinolone, 7 oxycodone/acetaminophen, 19

Neupro, 16

O oxycodone/aspirin, 19

Neutrasal, 14

oxycodone/ibuprofen, 19

O-CAL Fa, 22

Neuvaxin, 8

Oxycontin, 19

O-CAL Prenatal, 22

Nevanac, 18

oxymorphone hydrochloride, 19

OB Complete, 22

nevirapine, 2

oxymorphone hydrochloride ER, 19

OB Complete 400, 22

nevirapine ER, 2

oxytocin, 19

OB Complete One, 22

Newgen, 22

P

OB Complete Petite, 22

Nexa Plus, 22

OB Complete Premier, 22 Paire OB, 22

Nexavar, 4

OB Complete/DHA, 22 paliperidone ER, 15

niacin ER, 6

Obstetrix DHA, 22 Pamine FQ, 12

nicardipine HCL, 4

octreotide acetate, 11 Panatuss Dxp, 21

Nicomide, 22

Ocudox, 1 Pancreaze, 12

nifedipine, 4

Ocuvel, 22 pancrelipase, 12

nifedipine ER, 4

Odefsey, 2 Pandel, 8

Nilandron, 3

Ofev, 21 pantoprazole sodium, 12

nimodipine, 4

ofloxacin, 1, 17, 18 papaverine HCL, 6

Ninlaro, 4

olanzapine, 15 paregoric, 12

nisoldipine, 4

olanzapine ODT, 15 paricalcitol, 11

nisoldipine ER, 4

olanzapine/fluoxetine, 17 Parnate, 15

Nitro-bid, 4

Oleptro, 15 paromomycin sulfate, 1

Nitro-dur, 4

olopatadine HCL, 18, 20 paroxetine HCL, 15

nitrofurantoin, 13

One Touch Test Strips 10 paroxetine HCL ER, 15

nitrofurantoin macrocrystals, 13

omega-3-acid ethyl esters, 6 Paser, 2

nitrofurantoin monohydrate, 13

omeprazole, 12 Pataday, 18

nitrofurantoin monohydrate/macrocrystals, 13

omeprazole/sodium bicarbonate, 12 Paxil, 15

Omnaris, 21 PCE, 1

nitroglycerin ER, 4

Omnitrope, 11

nitroglycerin lingual, 4

Omontys, 13 Pediaderm HC, 8

nitroglycerin transdermal, 4

ondansetron HCL, 12 Pediaderm Ta, 8

Nitromist, 4

ondansetron ODT, 12 Pediatex TDM, 21

Nitrostat, 4

Onfi, 16 peg 3350/electrolytes, 11

Niva-plus, 22

Onglyza, 10 peg-3350/electrolytes, 11

Nivatopic Plus, 8

Opana ER (crush Resistant), 19 peg-3350/NACL/NA bicarbonate/KCL,

nizatidine, 12

opium, 12 Peg-intron, 2

Norditropin Cartridge, 11

opium tincture, 12 Peg-intron Redipen, 2

Norditropin Flexpro, 11

Opsumit, 6 Peg-intron Redipen PAK 4, 2

Norditropin Nordiflex Pen, 11

Oracit, 13 Peganone, 16

norethindrone, 9

Orapred ODT, 9 Pegasys, 2

norethindrone & ethinyl estradiol ferrous fumarate, 9

Oravig, 14 Pegasys Proclick, 2

Orencia, 20 Pegintron, 2

norethindrone acetate, 9

Orenitram, 6 penicillin G potassium, 1

norethindrone acetate/ethinyl estradiol, 9(2)

Orfadin, 11 penicillin G procaine, 1

Orkambi, 21 penicillin G sodium, 1

norethindrone acetate/ethinyl estradiol/ferrous fumarate, 9

orphenadrine citrate, 17 penicillin v potassium, 1

orphenadrine citrate ER, 17 Pennsaid, 7

norgestimate/ethinyl estradiol, 9

orphenadrine/asa/caffeine, 17 Pentam 300, 3

Norinyl 1+50, 9

Oseni, 10 Pentasa, 12

Noroxin, 1

Osmoprep, 11 pentazocine/naloxone HCL, 19

Norpace CR, 5

Osphena, 10 pentetate calcium trisodium, 22

Northera, 6

Otezla, 20 pentetate zinc trisodium, 22

nortriptyline HCL, 15

Otiprio, 18 pentoxifylline ER, 14

Norvir, 2

Ovace Plus, 7 Perforomist, 21

Novoeight, 14

Ovidrel, 11 perindopril erbumine, 5

Noxafil, 2

oxacillin sodium, 1 permethrin, 8

Nplate, 13

oxandrolone, 9 perphenazine, 15

Nucynta, 19

oxaprozin, 19 perphenazine/amitriptyline, 17

Nucynta ER, 19

Oxaydo, 19 Pertzye, 12

Nuedexta, 17

oxazepam, 14 Pexeva, 15

phenazopyridine HCL, 13

Prenate, 22 Provida OB, 22

phenelzine sulfate, 15

Prenate AM, 22 Pruclair, 8

Phenergan Fortis, 20

Prenate DHA, 22 Prudoxin, 7

phenobarbital, 15

Prenate Elite, 22 Prumyx, 8

phenobarbital sodium, 15

Prenate Enhance, 22 Pulmicort Flexhaler, 21

phenoxybenzamine hydrochloride, 5

Prenate Essential, 22 Pulmophylline, 21

phentolamine mesylate, 5

Prenate Mini, 22 Pulmozyme, 21

phenylephrine HCL, 6, 18

Prenate Pixie, 22 Purixan, 3

phenylephrine/guaifenesin, 21

Prenate Restore, 22 Pylera, 12

Phenytek, 16

Prenate Star, 22 pyrazinamide, 2

phenytoin, 16

Prepidil, 19 pyridostigmine bromide, 17

phenytoin sodium, 16

Prepopik, 12 pyrogallic acid, 8

phenytoin sodium extended, 16

Preque 10, 22 Q

Phoslyra, 13

Presera, 8

Qnasl, 21

Phospholine Iodide, 18

Prevacid Solutab, 12

Qnasl Childrens, 21

pilocarpine HCL, 14, 18

Quartette, 9

pilocarpine hydrochloride, 14

Prezcobix, 2

quazepam, 15

pimozide, 17

Prezista, 2

Quelicin 1000, 17

pindolol, 4

Priftin, 2

quetiapine fumarate, 15

pioglitazone HCL, 10

primaquine phosphate, 2

Quillivant XR, 16

pioglitazone HCL-glimepiride, 10

primidone, 16

quinapril HCL, 5

pioglitazone HCL/metformin HCL, 10

Primlev, 19

quinapril/hydrochlorothiazide, 5

piroxicam, 19

Primsol, 3

quinidine gluconate, 5

Plegridy, 17

Pristiq, 15

quinidine gluconate CR, 5

quinidine gluconate ER, 5

Pliaglis, 8

quinidine sulfate, 5

podofilox, 8

quinidine sulfate ER, 5

Poly-VI-flor, 22

quinine sulfate, 2

Poly-VI-flor/Iron, 22

Proair HFA, 21

Qutenza, 8

polyethylene glycol 3350, 11

Proair Respiclick, 21

Qvar, 21

polymyxin b sulfate, 3

probenecid, 20

R

polymyxin b sulfate/trimethoprim sulfate, 17

probenecid/colchicine, 20

procainamide HCL, 5

R-natal OB, 22

Pomalyst, 3

Procentra, 16

rabeprazole sodium, 12

potassium citrate ER, 13

prochlorperazine, 15

raloxifene hydrochloride, 10

potassium citrate-citric acid crystals, 13

prochlorperazine edisylate, 15

ramipril, 5

potassium citrate/citric acid, 13

prochlorperazine maleate, 15

Ranexa, 4

potassium citrate/sodium citrate/citric acid, 13

Procort, 13

ranitidine HCL, 12

Procrit, 13

Rapaflo, 13

Potiga, 16

Proctofoam HC, 12

Rapamune, 3

Pr Cream, 8

Procysbi, 13

Rasuvo, 20

Pradaxa, 14

progesterone, 9

Ravicti, 11

pramipexole dihydrochloride, 16

pramipexole dihydrochloride ER, 16

Prograf, 3

Pramosone, 8

Prolensa, 18

pravastatin sodium, 6

Prolia, 10

Prazolamine, 17

Promacta, 13

Rebetol, 2

prazosin HCL, 5

promethazine HCL, 20

Rebif, 17

Pred Mild, 18

promethazine HCL plain, 20

Rebif Rebidose, 17

Pred-G, 18

promethazine-DM, 21

Pred-G S.o.p., 18

promethazine/codeine, 21

prednicarbate, 7

promethazine/dextromethorphan, 21

Recombinate, 14

prednisolone, 9

promethazine/phenylephrine, 21

Recothrom, 14

prednisolone acetate, 18

promethazine/phenylephrine/codeine, 21

prednisolone sodium phosphate, 9, 18

Promiseb, 7

Rectiv, 13

prednisolone sodium phosphate ODT, 9

Promiseb Complete, 7

Recura, 7

prednisone, 9

propafenone HCL, 5

Relagard, 13

Prednisone Intensol, 9

propafenone HCL ER, 5

Relenza Diskhaler, 2

Prefera OB, 22

propantheline bromide, 12

Relhist, 21

Prefera OB + DHA, 22

proparacaine HCL, 18

Relistor, 13

Preferaob +dha, 22

propranolol HCL, 4

Relpax, 20

Preferaob One, 22

propranolol HCL ER, 4

Relyyt, 8

propranolol/hydrochlorothiazide, 5

Remodulin, 6

Prefol-DHA, 22

propylthiouracil, 11

Renagel, 12

Premarin, 9, 13

Prostin E2, 19

Renvela, 12

Premphase, 9

Protonix, 12

repaglinide, 10

Prempro, 9

protriptyline HCL, 15

repaglinide/metformin hydrochloride, 10

Prenata, 22

Proventil HFA, 21

Repronex, 11

Rescon-JR, 21

Selrx, 7 Spritam, 16

Rescon-MX, 21

Selzentry, 2 Sprix, 20

Rescriptor, 2

Semprex-d, 21 Sprycel, 4

Rescula, 18

senna plus, 11 Stalevo 100, 16

reserpine, 5

Sensipar, 11 Stalevo 125, 16

Restora RX, 12

Stalevo 150, 16

Revlimid, 3

Stalevo 200, 16

Reyataz, 2

Stalevo 50, 16

Rezira, 21

Stalevo 75, 16

Rezyst IM, 12

stannous fluoride oral rinse, 14

Rezyst SB, 12

stavudine, 2

Rheumatrex, 20

Stavzor, 16

Ribasphere Ribapak, 2

Staxyn, 6

ribavirin, 2

Sentroxatine, 15 Stelara, 7

Ridaura, 19

Serevent Diskus, 21 Stimate, 11

rifabutin, 2

Seroquel XR, 15 Stiolto Respimat, 21

Rifamate, 2

Serostim, 11 Stivarga, 4

rifampin, 2

sertraline HCL, 15 Strattera, 16

Rifater, 2

sevelamer carbonate, 12 Strazepam, 15

riluzole, 17

Sfrowasa, 13 streptomycin sulfate, 1

rimantadine HCL, 2

Signifor, 11 Striant, 9

Rimantalist, 2

Signifor Lar, 11 Stribild, 2

Riomet, 10

sildenafil, 6 Suboxone, 19

risedronate sodium, 10

sildenafil citrate, 6 Subsys, 19

risedronate sodium DR, 10

Simbrinza, 18 Suclear, 11

Risperdal Consta, 15

Simcor, 6 Sucraid, 12

risperidone, 15

Simponi, 20 sucralfate, 12

risperidone ODT, 15

simvastatin, 6 sulfacetamide sodium, 6, 17

Ritalin, 16

Sinelee, 8 sulfacetamide sodium/prednisolone sodium phosphate, 18

Ritalin LA, 16

sirolimus, 3

Sirturo, 2 sulfacetamide sodium/sulfur, 6

rivastigmine tartrate, 17

Sitavig, 2 sulfacetamide sodium/sulfur cleanser, 6

rivastigmine transdermal system, 17

Sivextro, 3 sulfadiazine, 1

rizatriptan benzoate, 20

Sklice, 8 sulfamethoxazole/trimethoprim, 3

rizatriptan benzoate ODT, 20

sulfamethoxazole/trimethoprim DS, 3

ropinirole ER, 16

sodium bicarbonate, 12 sulfasalazine, 12

ropinirole HCL, 16

sodium chloride, 21 sulfurated lime, 8

Roxicet, 19

sodium citrate/citric acid, 13 sulindac, 19

Rozerem, 15

sodium hyaluronate, 8 sumatriptan, 20

Rytary, 16

sodium phenylbutyrate, 11 sumatriptan succinate, 20

S

sodium sulfacetamide, 6, 7, 17 sumatriptan succinate refill, 20

sodium sulfacetamide wash, 7 Sumavel Dosepro, 20

Sabril, 16

sodium sulfacetamide/sulfur, 6 Supprelin LA, 11

Safyral, 9

sodium sulfacetamide/sulfur cleanser, 6 Suprax, 1

Saizen, 11

sodium sulfacetamide/sulfur cleanser IN urea, 6

Suprep Bowel Prep, 12

Saizen Click.easy, 11

Survanta Intratracheal, 21

salicylic acid, 8

sodium sulfacetamide/sulfur cleansing cloths, 6

Sustiva, 2

salicylic acid cream, 8

Sutent, 4

sodium sulfacetamide/sulfur green, 6 Sylatron, 4

sodium sulfacetamide/sulfur IN urea, 6 Symax Duotab, 12

salicylic acid lotion, 8

sodium sulfacetamide/sulfur wash, 6 Symbicort, 21

Salivamax, 14

Solaice, 8 Symlinpen 120, 10

salsalate, 19

Soltamox, 3 Symlinpen 60, 10

Salvax Duo Plus, 8

Solu-medrol, 9

Samsca, 11

Somatuline Depot, 11

Sancuso, 12

Somavert, 11 Synalar TS, 8

Sandimmune, 3

Sorilux, 7 Synalgos-DC, 19

Sandostatin Lar Depot, 11

sotalol HCL, 4 Synarel, 11

Saphris, 15

sotalol HCL (AF), 4 Synera, 8

Sarafem, 17

Sotylize, 4 Synthroid, 11

Savaysa, 14

Sovaldi, 2 T

Savella, 17

Spectracef, 1

Tabloid, 3

spinosad, 8

Scalacort DK, 8

Taclonex, 8

Spiriva Handihaler, 21

scopolamine hydrobromide, 12

tacrolimus, 3, 8

Spiriva Respimat, 21

Select-OB, 22

Tafinlar, 4

spironolactone, 5

Select-ob+dha, 22

Tagrisso, 4

spironolactone/hydrochlorothiazide, 5

selegiline HCL, 16

Taltz, 7

Sporanox, 2

selenium sulfide, 7

Tamiflu, 2

tamoxifen citrate, 3

Thyrolar-1/4, 11 triamcinolone IN orabase, 14

tamsulosin HCL, 13

Thyrolar-2, 11 triamterene/hydrochlorothiazide, 5

Tanzeum, 10

Thyrolar-3, 11 Trianex, 8

Tarceva, 4

tiagabine hydrochloride, 16 triazolam, 15

Targadox, 1

ticlopidine HCL, 14 Tribenzor, 5

Taron-bc, 22

Tikosyn, 5 Tricare Prenatal Compleat, 22

Taron-c DHA, 22

timolol maleate, 4, 17 Tricare Prenatal DHA One, 22

Tasigna, 4

timolol maleate ophthalmic gel forming, 17

tricitrates, 13

Tazorac, 7

trifluoperazine HCL, 15

Tecfidera, 17

trifluridine, 17

tinidazole, 3 trihexyphenidyl HCL, 16

Tegretol, 16

Tirosint, 11 Trileptal, 16

Tegretol-XR, 16

Tisseel, 14 trimethobenzamide HCL, 12

Tekamlo, 5

Tisseel VH, 14 trimethoprim, 3

Tekturna, 5

Tivicay, 2 trimethoprim sulfate/polymyxin b sulfate, 17

Tekturna HCT, 5

telmisartan, 5

tizanidine HCL, 17 trimipramine maleate, 15

telmisartan/amlodipine, 5

TL Triseb, 7 Triumeq, 2

telmisartan/hydrochlorothiazide, 5

Tobi Podhaler, 1 Triveen-duo DHA, 22

temazepam, 15

Tobradex, 18 Triveen-prx RNF, 22

temozolomide, 3

Tobradex ST, 18 Trokendi XR, 16

terazosin HCL, 5

tobramycin, 1 Tropazone, 8

terbinafine HCL, 2

tobramycin sulfate, 1, 17 trospium chloride, 13

Terbinex, 2

tobramycin/dexamethasone, 18 trospium chloride ER, 13

terbutaline sulfate, 21

Tobrex, 17 Truvada, 2

terconazole, 13

tolazamide, 10 Tudorza Pressair, 21

Tersi Foam, 7

tolbutamide, 10

Testim, 9

tolcapone, 16

testosterone, 9

tolmetin sodium, 19

testosterone cypionate, 9

tolterodine tartrate, 13 Tuzistra XR, 21

testosterone enanthate, 9

tolterodine tartrate ER, 13 Tykerb, 4

testosterone P.M., 9

Topamax, 16 Tyvaso, 6

tetrabenazine, 17

Topamax Sprinkle, 16 Tyvaso Refill, 6

Topicort, 8 Tyvaso Starter, 6

tetracycline HCL, 1

topiramate, 16 Tyzeka, 2

Tetrix, 8

torsemide, 5 Tyzine, 21

Tev-tropin, 11

Toviaz, 13 Tyzine Pediatric Nasal Drops, 21

Teveten HCT, 5

Tracleer, 6 U

Texacort, 8

Tradjenta, 10

Uceris, 9, 13

Texavite LQ, 22

tramadol HCL, 19

Ulesfia, 8

Thalomid, 3

tramadol HCL ER, 19

Uloric, 20

Theo-24, 21

tramadol hydrochloride/acetaminophen, 19

theophylline, 21

theophylline CR, 21

trandolapril, 5

Ultresa, 12

theophylline ER, 21

trandolapril/verapamil HCL, 5

Umecta, 8

trandolapril/verapamil HCL ER, 5

Umecta PD, 8

tranexamic acid, 14

urea, 8

Transderm-scop, 12

tranylcypromine sulfate, 15

Travatan Z, 18

travoprost, 18

urea topical, 8

Trazamine, 15

Uretron D/S, 13

trazodone HCL, 15

Uroqid #2, 13

Trecator, 2

ursodiol, 12

Trelstar, 3

V

Trelstar Mixject, 3

Vagifem, 13

Thiola, 13

valacyclovir HCL, 2

thioridazine HCL, 15

Tretin-X, 6

Valchlor, 3

thiothixene, 15

tretinoin, 4, 6

tretinoin microsphere, 6

valganciclovir, 2

tretinoin microsphere P.M., 6

valproic acid, 16

Trexall, 3

valsartan, 5

Treximet, 20

valsartan/hydrochlorothiazide, 5

Trezix, 19

vancomycin HCL, 3

Thrombogen, 14

Tri-VI-flor, 22

Vantas, 3

Thyrolar-1, 11

triamcinolone, 9

Vascepa, 6

Thyrolar-1/2, 11

triamcinolone acetonide, 7, 14, 20

vasopressin, 11

Vecamyl, 5

Xeljanz, 20 Zyflo CR, 21

Vectical, 7

Xeljanz XR, 20 Zykadia, 4

Velphoro, 13

Xeomin, 17 Zylet, 18

Vemavite-prx 2, 22

Xerac Ac, 8 Zyprexa Relprevv, 15

venlafaxine HCL, 15

Xgeva, 10 Zytiga, 3

venlafaxine HCL ER, 15

Xifaxan, 3 8

Ventavis, 6

Xigduo XR, 10

8-mop, 7

Ventolin HFA, 21

Xolair, 21

Veramyst, 21

Xolegel, 7

verapamil HCL, 4

Xolegel Corepak, 7

verapamil HCL ER, 4

Xolegel Duo/Head & Shoulders, 7

verapamil HCL SR, 4

Xolegel Duo/Xolex, 7

Verdeso, 8

Xopenex, 21

Veregen, 8

Xopenex HFA, 21

Veripred 20, 9

Xrylix, 7

Versacloz, 15

Xtandi, 3

Vesicare, 13

Xuriden, 11

Vexol, 18

Viagra, 6

Xyntha, 14

Vibramycin, 1

Xyntha Solofuse, 14

Victoza, 10

Xyrem, 17

Victrelis, 2

Y

Videx Pediatric, 2

Yodoxin, 2

Vigamox, 17

Z

Viibryd, 15

zafirlukast, 21

Vimpat, 16

zaleplon, 15

Vinacal B, 22

Zamicet, 19

Vinate AZ Extra, 22

Zarontin, 16

Vinate Calcium, 22

Zatean-CH, 22

Vinate DHA RF, 22

Zatean-pn, 22

Viokace, 12

Zatean-pn DHA, 22

Viracept, 2

Zatean-pn Plus, 22

Viramune, 2

Zavesca, 13

Virazole, 2

Zelapar, 16

Viread, 2

Zelboraf, 4

Vita-pren, 22

Vitafol Ultra, 22

Zenpep, 12

Vitafol-nano, 22

Zenzedi, 16

Vitafol-ob+dha, 22

Zetia, 6

Vitafol-one, 22

Zetonna, 21

Vitamedmd One RX/Quatrefolic, 22

Ziagen, 2

Vitamedmd Plus RX/Quatre Folic, 22

zidovudine, 2

Vitamedmd Redichew RX, 22

Zioptan, 18

Vitamedmd Redichew RX/Quatrefolic, 22

ziprasidone HCL, 15

Vitapearl, 22

Zirgan, 17

Vitekta, 2

Zithranol, 7

Vituz, 21

Zithranol-rr, 7

Viva DHA, 22

Zmax, 1

Vogelxo, 9

Zoladex, 3

Vogelxo P.M., 9

Zolinza, 4

Voltaren, 7

zolmitriptan, 20

voriconazole, 2

zolmitriptan ODT, 20

Votrient, 4

zolpidem tartrate, 15

Vraylar, 15

zolpidem tartrate ER, 15

Vsl#3 DS, 12

Zolpimist, 15

Vusion, 7

Zomacton, 11

Vytorin, 6

Zomig, 20

Vyvanse, 16

Zomig Nasal Spray, 20

W

Zonalon, 7

zonisamide, 16

warfarin sodium, 14

Zorbtive, 11

Welchol, 6

Zortress, 3

Westhroid, 11

Zuplenz, 12

Wp Thyroid, 11

Zyclara, 8

X

Zyclara P.M., 8

Xalkori, 4

Zydelig, 4

Xarelto, 14

Zyflo, 21 RX-61479 Revised 04/01/2016

Documents

A Reference Guide - Blue Cross Blue Shield of RI...A Reference Guide INTRODUCTION Below you’ll find the Blue Cross & Blue Shield of Rhode Island (BCBSRI) formulary, which is a list