2014 Preferred Drug List (2–Tier) Please bring this guide with you to your next doctor visit.
30690 (Ed. 09/13)
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Do you have questions?
Call Assurant Health Customer Service at the phone number
printed on your ID card.
Dear Member,
To help you know how drugs are covered by your plan, we are
pleased to provide you with a copy of our 2014 Preferred Drug List.
This document provides helpful information on the Assurant Preferred
Drug List and your pharmacy benefit plan. You may want to take this
guide with you when you see your doctor to talk about what is
covered under your plan.
Many commonly prescribed drugs are listed in this guide. Please
remember this is not a complete list of drugs covered under your
plan. Because thousands of drugs are included in your pharmacy
benefits plan, we only list the most commonly prescribed ones.
Please note that not all drugs listed in this guide are covered by all
pharmacy benefit programs. Check your benefit materials for the
specific covered drugs and your co-payment program.
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What is the Assurant Preferred Drug List?
Our Preferred Drug List is meant to give you a general view of drugs covered by your plan. Changes to the list are based on the latest medical findings as well as information from the Food and Drug Administration (FDA) and drug makers.
This list includes both brand-name and generic drugs and is updated regularly. Assurant will generally cover the drugs listed on our Preferred Drug List as long as they are medically necessary and plan rules are followed. Coverage is not limited to drugs on the Preferred Drug List.
The Preferred Drug List is subject to change. Drugs on the list are based on reliable medical data, safety and cost. When you talk to your doctor about what drug may be right for you, it is important to remember that you and your doctor are responsible for making the final decision on your drug therapy.
Why is the Preferred Drug List subject to change?
During the year, we may add or remove drugs from the Preferred Drug List. These changes happen for various reasons and may move a drug from one coverage tier to another.
As brand-name drugs lose their patents, generic versions may become available. When this happens, the generic drug may be added to the list and available at a lower copayment or coinsurance tier.
The FDA approves many new drugs throughout the year. Your plan generally covers new FDA-approved drugs; however, the new drug(s) also may be subject to precertification or step-therapy requirements.
Some drugs may also no longer require a prescription. If your drug becomes available over-the-counter (OTC), the drug will generally no longer be covered under your prescription plan.
If the FDA removes a drug from the market it will also no longer be covered under your prescription plan.
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Why do some drugs have quantity limits?
Your plan may limit the amount of a drug you can receive at one time. These limits help your doctor and pharmacist check that the drugs are used appropriately while promoting patient safety. We use medical guidelines, FDA approval and guidance from drug makers to set these coverage limits. The quantity limits program includes:
Dose Efficiency Edits – Limits coverage of prescriptions to one dose per day for drugs that are approved for once-daily dosing.
Maximum Daily Dose – A message is sent to the pharmacy if a prescription is higher than the maximum allowed dose.
Quantity Limits Over Time – Limits coverage of prescriptions to a specific number of units in a defined amount of time.
To get coverage for amounts over the allowed quantity, you, your doctor or the person you appoint to manage your care can request a coverage override by calling the phone number located on your ID Card. The quantity limit list is subject to change.
What is step-therapy?
With step-therapy you must try one or more alternate drugs before your plan will cover a step-therapy drug. These drugs are FDA-approved, treat the same condition(s) and, they may also be available to you at a lower copay or coinsurance tier.
If it is necessary for you to use a drug on the step therapy list, you, your doctor, or the person you appoint to manage your care can request a coverage override by calling the phone number located on your ID card.
What is the Prior Authorization program?
The Prior Authorization program encourages appropriate and cost-effective use of drugs by allowing coverage only when certain conditions are met.
• A physician, a patient, or a person appointed to manage the patient’s care must request prior authorization before drugs on the Prior Authorization List will be covered under a member’s pharmacy benefits plan. If the request is approved, the drug will then be covered at the applicable costs associated with the member’s plan.
• The Prior Authorization program is based upon current medical findings, FDA-approved manufacturer labeling information, and cost.
• To determine if a drug requires prior authorization, refer to the column titled Prior Authorization next to the list of drugs in this guide. You can also call the phone number on the back of the member identification card to obtain more information on the prior authorization review process.
• The list of drugs requiring prior authorization is subject to change.
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What are generic drugs?
Drug manufacturers develop and release new drugs under a brand name. When the patent expires, other manufacturers are then able to make duplicate versions of the same drug. Generic drugs are chemically the same as their branded counterparts. They are also the same in dosage, safety, strength, form and intended use. Plus, generics usually cost less than brand-name drugs.
Generic drugs are only available after the FDA approves them. When filling your prescription, your pharmacist generally can substitute a generic drug for a brand-name drug when the generic is rated by the FDA as equivalent and also where it is permitted by your doctor and state law.
Table of Contents – Preferred Drugs by Therapeutic Class
Therapeutic Class Page
Antineoplastic Agents 6 Blood Products – Modifiers – Volume Expanders 8 Cardiovascular System 9 Central Nervous System 18 Dermatological Agents 30 Endocrine System 35 Gastrointestinal System 44 Genitourinary System 48 Infections and Infestations 50 Musculoskeletal System 55 Ophthalmic Agents 58 Otic Agents 61 Respiratory Tract Agents 61 Miscellaneous 64
THERAPEUTIC CLASS LIST KEY (on following pages)
lower case - Generic medication
UPPERCASE – Brand-name medication
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Medication Name
2-Tier G = Generic
P = Preferred
Brand Prior
Authorization Quantity
Limit Step
Therapy
Antineoplastic Agents
Alkylating Agents
ALKERAN P
CEENU P
lomustine G
cyclophosphamide G
HEXALEN P
LEUKERAN P
MYLERAN P
TEMODAR capsule P √
temozolomide capsule G √
Antimetabolites
mercaptopurine G
methotrexate G
PURINETHOL P
TABLOID P
TREXALL P
XELODA P √
Antineoplastic – Enzyme Inhibitors
AFINITOR P √
BOSULIF P √
CAPRELSA P √
COMETRIQ P √
GILOTRIF P √
GLEEVEC P √
ICLUSIG P √
INLYTA P √
IRESSA P
JAKAFI P √
MEKINIST P √
NEXAVAR P √
POMALYST P √
SPRYCEL P √
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STIVARGA P √
SUTENT P √
TAFINLAR P √
TARCEVA P √
TASIGNA P √
TYKERB P √
VOTRIENT P √
XALKORI P √
ZELBORAF P √
ZOLINZA P √
Antineoplastic – Hormonal Agents
anastrozole G
ARIMIDEX P
AROMASIN P
bicalutamide G
CASODEX P
EMCYT P
exemestane G
FARESTON P
FEMARA P
flutamide G
letrozole G
LYSODREN P
MEGACE P
MEGACE ES P
megestrol G
NILANDRON P
tamoxifen G
XTANDI P √
ZYTIGA P √
Antineoplastics – Miscellaneous
ERIVEDGE P √
HYDREA P
hydroxyurea G
MATULANE P
TARGRETIN P
tretinoin 10 mg G √
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Chemotherapy Rescue/Antidote Agents
leucovorin calcium G
MESNEX P
Immunomodulators
REVLIMID P
THALOMID P
Topoisomerase I Inhibitors
HYCAMTIN P √
Blood Products – Modifiers – Volume Expanders
Anticoagulants – Coumarin
COUMADIN P
jantoven G
warfarin G
Anticoagulants – Direct Thrombin Inhibitors/Factor Xa Inhibitor
ELIQUIS P √ √
IPRIVASK P
PRADAXA P √
XARELTO P √
Anticoagulants – Heparins
ARIXTRA P
fondaparinux G
FRAGMIN P
heparin sodium G
LOVENOX P
enoxaparin G
Hemostatics – Systemic
AMICAR P
aminocaproic acid G
LYSTEDA P √
tranexamic acid G √
Platelet Aggregation Inhibitors
AGGRENOX P
AGRYLIN P
anagrelide G
BRILINTA P √
cilostazol G
clopidogrel G
dipyridamole G
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EFFIENT P √
PERSANTINE P
PLAVIX P
PLETAL P
ticlopidine G
Cardiovascular System
Alpha-Beta Blockers
carvedilol G
COREG P
COREG CR P
labetalol G
TRANDATE P
Anaphylaxis Therapy Agents
ADRENACLICK P
AUVI-Q P √
epinephrine G
EPIPEN P
EPIPEN-JR P
TWINJECT P
Angiotensin Converting Enzyme (ACE) Inhibitors and Combinations
ACCUPRIL P
ACCURETIC P
ACEON P
ALTACE P
benazepril G
benazepril/hydrochlorothiazide G
captopril G
captopril/hydrochlorothiazide G
enalapril G
enalapril/hydrochlorothiazide G
EPANED P √
fosinopril G
fosinopril/hydrochlorothiazide G
lisinopril G
lisinopril/hydrochlorothiazide G
moexipril G
moexipril/hydrochlorothiazide G
LOTENSIN P
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LOTENSIN HCT P
MAVIK P
perindopril G
PRINIVIL P
PRINZIDE P
quinapril G
quinapril/hydrochlorothiazide G
ramipril G
trandolapril G
UNIRETIC P
UNIVASC P
VASERETIC P
VASOTEC P
ZESTORETIC P
ZESTRIL P
Angiotensin II Receptor Antagonists and Combinations
ATACAND P √
candesartan G √
ATACAND HCT P √
candesartan/hydrochlorothiazide G √
AVALIDE P √
AVAPRO P √
AZOR P √ √
BENICAR P √ √
BENICAR HCT P √ √
COZAAR P √
DIOVAN P √ √
DIOVAN HCT P √ √
EDARBI P √ √
EDARBYCLOR P √ √
eprosartan G √
EXFORGE P √
EXFORGE HCT P √
HYZAAR P √
irbesartan G √
irbesartan/hydrochlorothiazide G √
losartan G √
losartan/hydrochlorothiazide G √
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MICARDIS P √
MICARDIS HCT P √
TEVETEN P √
TEVETEN HCT P
TRIBENZOR P √ √
TWYNSTA P √ √
valsartan/hydrochlorothiazide G √
Antiadrenergic Antihypertensives
CARDURA P
CATAPRES P
CATAPRES-TTS P
clonidine G
doxazosin G
guanabenz G
guanfacine G
methyldopa G
MINIPRESS P
NEXICLON P √
prazosin G
reserpine G
TENEX P
terazosin G
Antianginals – Nitrates
amyl nitrite G
DILATRATE SR P
IMDUR P
ISORDIL P
isosorbide dinitrate G
isosorbide mononitrate G
MONOKET P
NITRO-BID P
NITRO-DUR P
nitroglycerin G
nitroglycerin CR G
nitroglycerin SL G
NITROLINGUAL P
NITROMIST P
NITROSTAT P
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Antianginals – Other
RANEXA P √
Antiarrhythmics Type I-A
disopyramide G
NORPACE P
procainamide G
quinidine gluconate G
quinidine sulfate G
Antiarrhythmics Type I-B
mexiletine G
Antiarrhythmics Type I-C
flecainide G
propafenone G
RYTHMOL P
RYTHMOL SR P
TAMBOCOR P
Antiarrhythmics Type III
amiodarone G
CORDARONE P
MULTAQ P
PACERONE P
TIKOSYN P
Antihyperlipidemics – Bile Sequestrants
cholestyramine G
cholestyramine light G
COLESTID P
colestipol G
prevalite G
QUESTRAN P
QUESTRAN LITE P
WELCHOL P
Antihyperlipidemics – Fibric Acid Derivatives
ANTARA P √
fenofibrate G
fenofibrate choline G
fenofibrate micronized G
fenofibric acid G
FENOGLIDE P √
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FIBRICOR P √
gemfibrozil G
LOFIBRA P √
LOPID P √
LIPOFEN P √
TRICOR P √
TRIGLIDE P √
TRILIPIX P √
fenofibrate delayed-release G
Antihyperlipidemics – HMG CoA Reductase Inhibitors
ADVICOR P √
ALTOPREV P √ √
amlodipine/atorvastatin G √
atorvastatin G √
CADUET P √ √
CRESTOR P √
fluvastatin G √
LESCOL P √
LESCOL XL P √ √
LIPITOR P √ √
LIPTRUZET P √
LIVALO P √
lovastatin G √
MEVACOR P √
PRAVACHOL P √
pravastatin G √
SIMCOR P √
simvastatin G √
VYTORIN P √
ZOCOR P √
Antihyperlipidemics – Intestinal Cholesterol Absorption Inhibitors
ZETIA P √
Antihyperlipidemics – Miscellaneous
JUXTAPID P √ √
LOVAZA P
VASCEPA P
Antihyperlipidemics – Nicotinic Acid Derivatives
niacin ER tablet G
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NIASPAN P
Antihypertensives-Miscellaneous
VECAMYL P √ √
Beta Blockers Cardioselective and Combinations
acebutolol G
atenolol G
atenolol/chlorthalidone G
betaxolol G
bisoprolol G
bisoprolol/hydrochlorothiazide G
BYSTOLIC P
DUTOPROL P
KERLONE P
LOPRESS HCT P
LOPRESSOR P
metoprolol G
metoprolol ER G
metoprolol/hydrochlorothiazide G
SECTRAL P
TENORETIC P
TENORMIN P
TOPROL XL P
ZEBETA P
ZIAC P
Beta Blockers Non-Selective and Combinations
BETAPACE P
BETAPACE AF P
CORGARD P
CORZIDE P
INDERAL LA P
INNOPRAN XL P
LEVATOL P
nadolol G
nadolol/bendroflumethiazide G
pindolol G
propranolol G
propranolol SR G
propranolol/hydrochlorothiazide G
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sorine G
sotalol G
sotalol AF G
timolol G
Calcium Blockers
ADALAT CC P
afeditab G
amlodipine G
CALAN P
CALAN SR P
CARDENE SR P
CARDIZEM P
CARDIZEM CD P
CARDIZEM LA P
cartia XT G
COVERA-HS P
DILACOR XR P
dilt-CD G
dilt-XR G
diltiazem G
diltiazem CD/ER/CR/XT G
diltiazem SR extended release beads G
DYNACIRC CR P
felodipine G
ISOPTIN SR P
isradipine G
matzim LA G
nicardipine G
nifediac CC G
nifedical XL G
nifedipine G
nifedipine CR/ER/SR G
nimodipine G
nisoldipine G
NIMOTOP P
NORVASC P
NYMALIZE P √
PROCARDIA P
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PROCARDIA XL P
SULAR P
taztia XT G
TIAZAC P
verapamil G
verapamil CR/ER/SR G
VERELAN P
VERELAN PM P
VERELAN SR P
Cardiac Glycosides
digoxin G
LANOXIN P
Cardiovascular Combinations – Miscellaneous
amlodipine/benazepril G
BIDIL P
CLORPRES P
hydralazine/hydrochlorothiazide G
LOTREL P
methyldopa/hydrochlorothiazide G
rauwolfia/bendroflumethiazide G
TARKA P
Direct Renin Inhibitor and Combinations
AMTURNIDE P √
TEKAMLO P √
TEKTURNA P √
TEKTURNA HCT P √
Diuretics – Carbonic Anhydrase Inhibitors
acetazolamide G
DIAMOX P
methazolamide G
Diuretics – Loop
bumetanide G
DEMADEX P
EDECRIN P
furosemide G
LASIX P
torsemide G
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Diuretics – Potassium Sparing and Combinations
ALDACTAZIDE P
ALDACTONE P
amiloride G
amiloride/hydrochlorothiazide G
DYAZIDE P
DYRENIUM P
MAXZIDE P
MIDAMOR P
spironolactone G
spironolactone/hydrochlorothiazide G
triamterene/hydrochlorothiazide G
Diuretics – Selective Aldosterone Receptor Antagonists (SARAs)
eplerenone G
INSPRA P
Diuretics – Thiazide and Thiazide-Like
chlorothiazide G
chlorthalidone G
DIURIL P
hydrochlorothiazide G
indapamide G
methychlothiazide G
metolazone G
MICROZIDE P
THALITONE P
ZAROXOLYN P
Pheochromocytoma Agents
DEMSER P
DIBENZYLINE P
Pulmonary Hypertension Agents
ADCIRCA P √
LETAIRIS P
REVATIO P √
sildenafil G √
TRACLEER P
TYVASO P
VENTAVIS P
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Vasodilators
hydralazine G
isoxsuprine G
minoxidil G
papaverine ER G
Central Nervous System
ALS Agents
RILUTEK P
riluzole G
Alzheimer's Disease – Antidementia
ARICEPT 5 and 10 mg P
ARICEPT 23 mg P
ARICEPT ODT P
donepezil G
donepezil ODT G
EXELON capsule P
EXELON patch P
EXELON solution P
galantamine G
galantamine SR G
NAMENDA P
NAMENDA XR P
RAZADYNE P
RAZADYNE ER P
rivastigmine G
Antianxiety – Benzodiazepines
alprazolam G
alprazolam ER G
alprazolam ODT G
chlordiazepoxide G
clorazepate G
diazepam G
lorazepam G
NIRAVAM P
oxazepam G
XANAX XR P
Antianxiety – Miscellaneous
buspirone G
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hydroxyzine hydrochloride G
hydroxyzine pamoate G
meprobamate G
Anticonvulsants – Benzodiazepines
clonazepam G
clonazepam orally disintegrating tab G
DIASTAT P
diazepam rectal gel G
KLONOPIN P
ONFI P
Anticonvulsants – Carbamates
felbamate G
FELBATOL P
Anticonvulsants – GABA Modulators
GABITRIL P
SABRIL powder P
SABRIL tablet P
tiagabine G
Anticonvulsants – Hydantoins
DILANTIN P
phenytoin extended G
phenytoin sodium G
Anticonvulsants – Miscellaneous
BANZEL P
carbamazepine G
carbamazepine SR G
carbamazepine XR G
CARBATROL P
gabapentin G √
KEPPRA P
KEPPRA XR P
LAMICTAL P
LAMICTAL ODT P
LAMICTAL ER P
lamotrigine G
lamotrigine ER G
levetiracetam G
levetiracetam ER G
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LYRICA P √ √
NEURONTIN P √
oxcarbazepine G
OXTELLAR XR P
POTIGA P √
primidone G
TEGRETOL P
TEGRETOL XR P
TOPAMAX P
topiramate G
TRILEPTAL P
TROKENDI XR P √ √
VIMPAT P √
ZONEGRAN P
zonisamide G
Anticonvulsants – Succinimides
CELONTIN P
ethosuximide G
ZARONTIN P
Anticonvulsants – Valproic Acid
DEPAKENE P
DEPAKOTE P
DEPAKOTE ER P
DEPAKOTE SPRINKLE P
divalproex sodium delayed-release G
divalproex sodium sprinkle G
divalproex sodium SR G
STAVZOR P
valproic acid G
Antidepressants – Alpha-2 Receptor Antagonists
mirtazapine G √
mirtazapine ODT G √
REMERON P √
REMERON SOLUTAB P √
Antidepressants – MAO Inhibitors
EMSAM P √
MARPLAN P
NARDIL P
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PARNATE P
phenelzine G
tranylcypromine sulfate G
Antidepressants – Miscellaneous
APLENZIN P √ √
budeprion G √
budeprion XL G √
bupropion G √
bupropion SR G √
FORFIVO XL P √ √
maprotiline G √
WELLBUTRIN P √
WELLBUTRIN SR P √
WELLBUTRIN XL P √
Antidepressants – Modified Cyclics
nefazodone G
OLEPTRO P √ √
trazodone G
VIIBRYD P √ √
VIIBRYD KIT P √ √
Antidepressants – Serotonin-Norepinephrine Reuptake Inhibitors
CYMBALTA P √ √
DESVENLAFAXINE ER P √ √
EFFEXOR XR P √
PRISTIQ P √ √
venlafaxine G √
venlafaxine ER capsule G √
VENLAFAXINE ER tablet P √ √
VENLAFAXINE ER tablet G √
Antidepressants – Selective Serotonin Reuptake Inhibitors
CELEXA P √
citalopram G √
escitalopram G √
fluoxetine G √
FLUOXETINE 60 MG P √ √
fluoxetine delayed release G √
fluvoxamine G √
LEXAPRO P √
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LUVOX CR P √
paroxetine G √
paroxetine ER G √
PAXIL P √
PAXIL CR P √
PEXEVA P √ √
PROZAC P √
PROZAC WEEKLY P √
sertraline G √
ZOLOFT P √
Antidepressants – Tricyclic Agents
ANAFRANIL P
amitriptyline G
amoxapine G
clomipramine G
desipramine G
doxepin G
imipramine G
NORPRAMIN P
nortriptyline G
PAMELOR P
protriptyline G
SURMONTIL P
TOFRANIL P
TOFRANIL-PM P
trimipramine G
VIVACTIL P
Antiparkinsonian Adjuvants
LODOSYN P
Antiparkinsonian Anticholinergic
benztropine G
trihexyphenidyl G
Antiparkinsonian COMT Inhibitors
COMTAN P
entacapone G
TASMAR P
Antiparkinsonian Dopaminergic
amantadine G
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bromocriptine G
carbidopa/levodopa G
carbidopa/levodopa ODT G
carbidopa/levodopa SR G
carbidopa/levodopa/entacapone G
MIRAPEX P
MIRAPEX ER P √
NEUPRO P
PARCOPA P
PARLODEL P
pramipexole G
REQUIP P
REQUIP XL P
ropinirole G
ropinirole ER G
SINEMET P
SINEMET CR P
STALEVO P
Antiparkinsonian Monoamine Oxidase Inhibitor
AZILECT P
ELDEPRYL P
selegiline G
Antipsychotics – Atypical
ABILIFY P √
ABILIFY DISC P √
clozapine G √
CLOZARIL P √
FANAPT P √ √
FAZACLO P √
GEODON P √
INVEGA P √ √
LATUDA P √
olanzapine G √
olanzapine ODT G √
quetiapine G √
RISPERDAL P √
RISPERDAL M P √
risperidone G √
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risperidone ODT G √
SAPHRIS P √
SEROQUEL P √
SEROQUEL XR P √
ZYPREXA P √
ZYPREXA ZYDIS P √
ziprasidone G √
Antipsychotics – Combinations
chlordiazepoxide/amitriptyline G
olanzapine/fluoxetine G √
perphenazine/amitriptyline G
SYMBYAX P √
Antipsychotics – First Generation
chlorpromazine G
compro G
fluphenazine G
haloperidol G
loxapine G
perphenazine G
prochlorperazine G
thioridazine G
thiothixene G
trifluoperazine G
Antipsychotics – Miscellaneous
EQUETRO P
Attention Deficit Disorder
ADDERALL P √ √
ADDERALL XR P √ √
amphetamine/dextroamphetamine G √
amphetamine/dextroamphetamine SR G √
CONCERTA P √ √
DAYTRANA P √
DESOXYN P √ √
DEXEDRINE P √ √
DEXEDRINE CR P √ √
dexmethylphenidate G √
dextroamphetamine G √
dextroamphetamine CR G √
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dextroamphetamine sulfate solution G √
FOCALIN P √ √
FOCALIN XR P √ √
INTUNIV P √ √
KAPVAY P √ √
KAPVAY DOSE PACK P √ √
METADATE CD P √ √
metadate ER G √
methamphetamine G √
methylin G √
METHYLIN chew/soln P √ √
methylin ER G √
methylphenidate G √
methylphenidate SR G √
PROCENTRA P √ √
QUILLIVANT XR P √ √
RITALIN P √ √
RITALIN LA P √ √
RITALIN SR P √ √
STRATTERA P √
VYVANSE P √
ZENZEDI 2.5MG and 7.5MG P √ √
zenzedi 5MG and 10MG G √
Chemical Dependency
acampro cal G
ANTABUSE P
CAMPRAL P
naltrexone G
Fibromyalgia
CYMBALTA P √ √
LYRICA P √ √
SAVELLA P √
Huntington's Disease – Chorea
XENAZINE P √
Lithium
lithium carbonate G
lithium carbonate CR G
lithium citrate G
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LITHOBID P
Migraine Products
ALSUMA P √
AMERGE P √
AXERT P √ √
CAMBIA P √
dihydroergotamine nasal G √
FROVA P √ √
IMITREX P √
MAXALT P √
rizatriptan G √
MAXALT MLT P √
rizatriptan MLT G √
MIGRANAL P √
naratriptan G √
RELPAX P √ √
sumatriptan G √
SUMAVEL P √ √
TREXIMET P √ √
ZOMIG P √
zolmitriptan G √
ZOMIG ZMT P √
zolmitriptan ZMT G √
Multiple Sclerosis Agents
AMPYRA P √
AUBAGIO P √
GILENYA P √
TECFIDERA P √
Narcotic Agonists
ABSTRAL P √ √
ACTIQ P √ √
AVINZA P √
codeine phosphate G
codeine sulfate G
CONZIP P √
DEMEROL P
DILAUDID P
DURAGESIC P √
27
EXALGO P √ √
fentanyl lozenge G √ √
fentanyl patch G √
FENTORA P √ √
hydromorphone G
KADIAN P √
LAZANDA P √ √
levorphanol G
meperidine G
methadone G √
methadose G √
morphine sulfate G
morphine sulfate CR G √
MS CONTIN P √
NUCYNTA P √
NUCYNTA ER P √
ONSOLIS P √ √
OPANA P
OPANA ER P √
ORAMORPH SR P √
OXECTA P
oxycodone G
OXYCONTIN CR P √
oxymorphone ER G √
RYBIX ODT P
SUBSYS SPRAY P √ √
tramadol G
tramadol ER G √
ULTRAM P
ULTRAM ER P √
XOLOX P
Narcotic Combinations
acetaminophen/codeine G
butalbital/acetaminophen/caffeine/codeine G
butalbital/aspirin/caffeine/codeine G
BUPAP P
CAPITAL/CODEINE P
COCET P
28
COCET PLUS P
FIORICET/CODEINE P
FIORINAL/CODEINE P
hydrocodone/acetaminophen G
hydrocodone/ibuprofen G
IBUDONE P
LIQUICET P
LORCET P
LORCET PLUS P
LORTAB P
MAGNACET P
MAXIDONE P
NORCO P
oxycodone/acetaminophen G
oxycodone/aspirin G
oxycodone/ibuprofen G √
ORBIVAN P
ORBIVAN CF P
pentazocine/acetaminophen G
PERCOCET P
PERCODAN P
PHRENILIN P
REPREXAIN P
ROXICET P
stagesic G
STAFLEX P
SYNALGOS DC P
dihydrocodeine compound capsule G
TYLENOL/CODEINE P
TYLOX P
ULTRACET P
VICODIN P
VICODIN ES P
vicodin HP G
VICOPROFEN P
XODOL P
ZOLVIT P
ZYDONE P
29
Narcotic Partial Agonists
buprenorphine G √
butorphanol G √
buprenorphine/naloxone sublingual tablet G √
BUTRANS P √
pentazocine/naloxone G
SUBOXONE film P √ √
SUBOXONE sublingual tablet P √
SUBUTEX P √
ZUBSOLV P √ √
Postherpetic Neuralgia (PHN) Agent
GRALISE P √
Premenstrual Dysphoric Disorder
SARAFEM P √
fluoxetine (PMDD) G √
Psychotherapeutic and Neurological Agents
ergoloid mesylate G
ORAP P
modafinil G √
NUVIGIL P √
PROVIGIL P √
XYREM P √
Restless Leg Syndrome
HORIZANT P √
Sedative/Hypnotics – Barbiturate
BUTISOL SODIUM P
MEBARAL P
phenobarbital G
SECONAL P
Sedative/Hypnotics – Nonbarbiturates
AMBIEN P √
AMBIEN CR P √
chloral hydrate G
DORAL P
quazepam G
EDLUAR P √ √
estazolam G
flurazepam G
30
HALCION P
INTERMEZZO P √ √
LUNESTA P √
midazolam G
ROZEREM P √ √
SILENOR P √ √
SONATA P √ √
temazepam G
triazolam G
zaleplon G √
zolpidem G √
zolpidem ER G √
ZOLPIMIST P √ √
Miscellaneous
CUVPOSA P
NUEDEXTA P √
Dermatological Agents
Acne Products
ABSORICA P
ACANYA P √
ACZONE P
adapalene G
AKNE-MYCIN P
amnesteem G
ATRALIN P √
avita G
AZELEX P
BENZACLIN P √
BENZAMYCIN P √
BENZEFOAM P
BENZEFOAM ULTRA P √
BENZIQ P
BENZIQ LS P
BENZIQ wash P
benzoyl peroxide G
claravis G
CLARIFOAM EF P
clindamax G
31
clindamycin G
clindamycin/benzoyl peroxide G
DIFFERIN 0.1% cream/gel/lotion P √
DIFFERIN 0.3% gel P
DUAC P √
clindamycin/benzoyl peroxide 1.2-5% gel G
EPIDUO P
erythromycin G
erythromycin/benzoyl peroxide G
EVOCLIN P
FABIOR P √ √
isotretinoin G
KLARON P
lavoclen G
METROCREAM P
METROGEL 1% only P
metronidazole gel 1% G
METROLOTION P
metronidazole G
myorisan G
NEOBENZ P
NORITATE P
NUOX P
pacnex wash G
PACNEX HP P
PACNEX LP P
PACNEX MX P
PLEXION cloth P
PLEXION emulsion P
PLEXION SCT P
RETIN-A P √
RETIN-A MICRO P
RIAX P √
sodium sulfacetamide/sulfur G
SODIUM SULFA LIQ 10% WASH P
sotret G
SSS 10-4 P
SUMADAN WASH P
32
SUMAXIN P
SUMAXIN TS P
tretinoin G
TRETIN-X P √
TRIAZ P
VANOXIDE P
VELTIN P √
ZACARE P
Z-CLINZ P
ZIANA P
Antibiotics – Topical
ALTABAX P
BACTROBAN P
CENTANY P
gentamicin G
mupirocin G
Antifungals – Topical
ALOQUIN P
ciclopirox G
clotrimazole/betamethasone G
econazole G
ERTACZO P
EXELDERM P
HALOTIN P
hydrocortisone/iodoquinol G
ketoconazole G
LOPROX P
LOTRISONE P
NAFTIN P
nystatin G
nystatin/triamcinolone G
OXISTAT P
PENLAC P
VUSION P
XOLEGEL P
Antineoplastics and Keratolytics – Topical
CARAC P
EFUDEX P
33
FLUOROPLEX P
fluorouracil G
LEVULAN KERA P
METVIXIA P
PANRETIN P
PICATO P √
SOLARAZE P
TARGRETIN P
UTOPIC P
Antipruritics and Topical Anesthetics
cocaine hydrochloride G
lidocaine G
lidocaine pad G √
lidocaine/prilocaine G
LIDODERM P √
PLIAGLIS P
prudoxin G
QUTENZA P
SYNERA P
ZONALON P
Antipsoriatics
8-MOP P
acitretin G
calcipotriene G
CALCITRENE P
calcitriol G
DOVONEX P
DRITHO-SCALP P
OXSORALEN-UL P
SORIATANE P
SORILUX P
TACLONEX P
TAZORAC P
VECTICAL P
Antiseborrheic Products
EXTINA P
ketoconazole foam G
SCALACORT DK P
34
selenium sulfide G
SELRX P
sulfacetamide sodium G
Antiviral – Topical
acyclovir G
DENAVIR P
XERESE P
ZOVIRAX P
Corticosteroids – Topical
alclometasone G
amcinonide G
augmented betamethasone dipropionate G
betamethasone valerate G
clobetasol G
CLOBEX spray P
CLOBEX lotion/shampoo P
CLODERM P
CORDRAN P
CUTIVATE P
DERMATOP P
DESONATE P
desonide G
desoximetasone G
diflorasone G
DIPROLENE AF P
ELOCON P
fluocinolone acetonide G
fluocinonide G
fluticasone G
HALOG P
hydrocortisone G
hydrocortisone butyrate G
hydrocortisone valerate G
hydrocortisone/pramoxine G
lidocaine/hydrocortisone G
LOCOID P
LOCOID LIPOCREAM P
LUXIQ P
35
mometasone G
NUZON P
OLUX P
OLUX-E P
prednicarbate G
TACLONEX P
triamcinolone G
ULTRAVATE P
VANOS P
VERDESO P
VYTONE P
Keratolytic/Antimitotic Agents
CONDYLOX P
podofilox G
Immunomodulating Agents – Topical
ALDARA P √
ELIDEL P
imiquimod G √
PROTOPIC P
ZYCLARA P √
Rosacea Agents
FINACEA P
metronidazole G
MIRVASO P √
ORACEA P √
Scabicides & Pediculicides
EURAX P
lindane G
NATROBA P
permethrin G
SKLICE P
spinosad G
ULESFIA P
Sinecatechin
VEREGEN P
Endocrine System
Antidiuretic Agents
DDAVP P
36
desmopressin G
minirin G
STIMATE P
Contraceptives – Emergency-(Applies only to plans with contraceptive coverage)
ELLA P
next choice G
PLAN B P
levonorgesterol tablet 0.75 mg G
Contraceptives – Oral-(Applies only to plans with contraceptive coverage)
altavera G
amethia lo G
amethyst G
apri G
aranelle G
aviane G
BEYAZ P
BREVICON P
briellyn G
camrese G
camrese lo G
cesia G
cryselle G
CYCLESSA P
DESOGEN P
ELLA P
emoquette G
enpresse G
ESTROSTEP FE P
FEMCON P
GENERESS FE P
gianvi G
gildess FE G
jolessa G
junel 1.5/30 G
junel 1/20 G
junel FE 1.5/30 G
junel FE 1/20 G
kariva G
37
kelnor G
leena G
lessina G
levora G
LO LOESTRIN FE P
LO/OVRAL P
LOESTRIN 1.5/30 P
LOESTRIN 1/20 P
LOESTRIN FE P
LOESTRIN FE 1.5/30 P
LOESTRIN-24 P
LOMINISTRIN PAK FE P
loryna G
LOSEASONIQUE P
low-ogestrel G
lutera G
LYBREL P
microgestin 1.5/30 G
microgestin 1/20 G
microgestin FE 1.5/30 G
microgestin FE 1/20 G
MINASTRIN 24 FE P
MIRCETTE P
MODICON 0.5/35 P
mononessa G
NATAZIA P
necon 0.5/35 G
necon 1/35 G
necon 1/50 G
necon 10/11 G
necon 7/7/7 G
NORDETTE P
NORINYL 1+35 P
NORINYL 1+50 P
nortrel 0.5/35 G
nortrel 1/35 G
nortrel 7/7/7 G
ocella G
38
ogestrel G
ORTHO TRI-CYCLEN P
ORTHO TRI-CYCLEN LO P
ORTHO-CEPT P
ORTHO-CYCLEN P
ORTHO-NOVUM 1/35 P
ORTHO-NOVUM 7/7/7 P
OVCON 35 P
OVCON 50 P
portia G
previfem G
QUARTETTE P
quasense G
reclipsen G
SEASONALE P
SEASONIQUE P
amethia G
solia G
sprintec G
sronyx G
syedah G
trinessa G
TRI-NORINYL P
tri-previfem G
tri-sprintec G
trivora G
velivet G
YASMIN P
YAZ P
zarah G
zenchent FE G
zeosa G
zovia 1/35E G
zovia 1/50E G
Contraceptives – Oral Progestins-(Applies only to plans with contraceptive coverage)
camila G
errin G
jolivette G
39
nora-be G
NOR-QD P
ORTHO MICRONOR P
Contraceptives – Transdermal-(Applies only to plans with contraceptive coverage)
ORTHO EVRA P
Contraceptives – Vaginal-(Applies only to plans with contraceptive coverage)
NUVARING P
Diabetes – Alpha-Glucosidase Inhibitors
acarbose G
GLYSET P
PRECOSE P
Diabetes – Amylin Analogs
SYMLIN P
SYMLINPEN P
Diabetes – Biguanides and Combinations
FORTAMET P
glipizide/metformin G
GLUCOPHAGE P
GLUCOPHAGE XR P
GLUCOVANCE P
GLUMETZA P
glyburide/metformin G
METAGLIP P
metformin G
metformin ER G
RIOMET P
Diabetes – Dopamine Receptor Agonist
CYCLOSET P
Diabetes – DPP-IV Inhibitors and Combinations
JANUMET P
JANUMET XR P
JANUVIA P
JENTADUETO P
KOMBIGLYZE XR P
KAZANO P √ √
NESINA P √ √
ONGLYZA P
OSENI P √ √
40
TRADJENTA P
Diabetes – Glucocorticoid Receptor Antagonist
KORLYM P √
Diabetes – Incretin Mimetic Agents
BYDUREON P √
BYETTA P √
VICTOZA P √
Diabetes – Insulin
APIDRA P
HUMALOG products P
HUMULIN products P
LANTUS P
LANTUS SOLOSTAR P
LEVEMIR P
LEVEMIR FLEXPEN P
NOVOLIN products P √
NOVOLOG products P
RELION products P √
Diabetes – Meglitinides and Combinations
nateglinide G
PRANDIMET P
PRANDIN P
repaglinide G
STARLIX P
Diabetes - Sodium-glucose co-transporter 2 (SGLT2) inhibitor
INVOKANA P √ √
Diabetes – Sulfonylureas
AMARYL P
chlorpropamide G
DIABETA P
glimepiride G
glipizide G
glipizide ER G
glipizide XL G
GLUCOTROL P
GLUCOTROL XL P
glyburide G
glyburide micronized G
41
GLYNASE P
tolazamide G
tolbutamide G
Diabetic Supplies
BD insulin syringes P
BD lancets P
BD pen needles P
FREESTYLE glucose test strips P √
FREESTYLE LITE glucose test strips P √
FREESTYLE INSULINX P √
glucose test strips (any other brand name) P √ √
All Brand insulin syringes P
insulin syringes (any generic) G
All Brand lancets P
lancets (any generic) G
ONE TOUCH FAST TAKE glucose test strips P √
ONE TOUCH ULTRA glucose test strips P √
ONE TOUCH VERIO IQ glucose test strips P √
All Brand pen needles P
pen needles (any generic) G
PRECISION QID glucose test strips P √
PRECISION SOF-TACT glucose test strips P √
PRECISION XTRA glucose test strips P √
PRECISION XTRA ketone test strips P √
Diabetes – Thiazolidinediones (TZDs) and Combinations
ACTOPLUS MET P
pioglitazone/metformin G
ACTOPLUS MET XR P
ACTOS P
pioglitazone G
AVANDAMET P
AVANDARYL P
AVANDIA P
DUETACT P
pioglitazone/glimepiride G
JUVISYNC P
Gaucher Disease
ZAVESCA P
42
Glucose Elevating Agent
PROGLYCEM P
Gout Agents
allopurinol G
COLCRYS P
probenecid G
probenecid/colchicine G
ULORIC P √
ZYLOPRIM P
Hereditary Tyrosinemia
ORFADIN P
Homocystinuria
CYSTADANE P
Hormone Replacement – Androgens
ANDRODERM P √ √
ANDROGEL P √
AXIRON P √ √
danazol G
FORTESTA P √ √
STRIANT P √ √
TESTIM P √
Hormone Replacement – Estrogens
ALORA P √
CENESTIN P
CLIMARA P √
DIVIGEL P
ELESTRIN P
ENJUVIA P
ESTRACE P
ESTRADERM P √
estradiol patch G √
estradiol tablet G
ESTRASORB P
ESTROGEL P
estropipate G
EVAMIST P
MENEST P
MENOSTAR P √
43
MINIVELLE P √
ortho-est G
PREMARIN P
VIVELLE-DOT P √
Hormone Replacement – Estrogen Combinations
ACTIVELLA P
ANGELIQ P
CLIMARA PRO P √
COMBIPATCH P √
estradiol/norethindrone acetate G
FEMHRT P
FEMHRT LOW DOSE P
FEMTRACE P
jinteli G
PREFEST P
PREMPHASE P
PREMPRO P
Hormone Replacement – Progestins
medroxyprogesterone acetate G
norethindrone acetate G
progesterone micronized cap G
PROMETRIUM P
Hyperammonemia
RAVICTI P √
sodium phenylbutyrate G
Hyperparathyroidism
HECTOROL P
SENSIPAR P
ZEMPLAR P
LHRH/GnRH Agonist Analog Pituitary Suppressants
SYNAREL P
Metabolic Modifiers
CARNITOR P
SUCRAID P
Phenylketonuria
KUVAN P
Steroids – Glucocorticosteroids
budesonide SR G √
44
cortisone AC G
dexamethasone G
ENTOCORT EC P √
FLO-PRED P
hydrocortisone G
methylprednisolone G
MILLIPRED P
ORAPRED P
prednisolone G
prednisone G
RAYOS P √
VERIPRED P
Steroids – Mineralocorticoid
fludrocort G
Thyroid Hormones
ARMOUR THYROID P
CYTOMEL P
levothroid G
levothyroxine G
levoxyl G
liothyronine sodium G
SYNTHROID P
THYROLAR P
TIROSINT P
unithroid G
Thyroid – Antithyroid Agents
methimazole G
propylthiouracil G
TAPAZOLE P
Vasopressin Receptor Antagonist
SAMSCA P
Gastrointestinal System
Acid Suppressants – H-2 Antagonists
AXID P
cimetidine G
famotidine G
nizatidine G
PEPCID P
45
ranitidine G
ZANTAC P
Acid Suppressants – Proton Pump Inhibitors
ACIPHEX P √ √
DEXILANT P √
ESOMEPRAZOLE STRONTIUM P √ √
lansoprazole G √
lansoprazole ODT G √
NEXIUM P √
omeprazole G √
omeprazole/bicarbonate G √
pantoprazole G √
PREVACID P √ √
PREVACID SOLUTAB P √ √
PRILOSEC P √ √
PROTONIX P √ √
ZEGERID P √ √
Anal Fissure
RECTIVE P
HIV-Related Antidiarrheal
FULYZAQ P √
Antiemetics – 5-HT3 Receptor Antagonists
ANZEMET tablet P √
DICLEGIS P √
granisetron G √
GRANISOL P √
ondansetron G √
ondansetron ODT G √
SANCUSO PAD P √
ZOFRAN P √
ZOFRAN ODT P √
ZUPLENZ P √
Antiemetics – Anticholinergic
TRANSDERM-SCOP P
trimethobenzamide G
Antiemetics – Miscellaneous
CESAMET P √
dronabinol G
46
EMEND capsule P √
MARINOL P
Anti-Ulcer Drugs
misoprostol G
sucralfate G
Bowel Evacuants
COLYTE P
gavilyte-g G
GOLYTELY P
HALFLYTELY P
MOVIPREP P
NULYTELY P
OSMOPREP P
peg 3350 G
polyethylene glycol G
PREPOPIK P
trilyte G
SUCLEAR KIT P
SUPREP P
VISICOL P
Chronic Constipation Agents
AMITIZA P
LINZESS P √
Gallstone Solubilizing Agents
CHENODAL P
URSO 250 P
URSO FORTE P
ursodiol G
GI Antiallergy Agents
cromolyn sodium concentrate G
GASTROCROM P
GI Stimulants
metoclopramide G
METOZOLV ODT P
H. pylori Agents
HELIDAC P
lansoprazole/amoxicillin/clarithromycin P
OMECLAMOX-PAK P
47
PREVPAC P
PYLERA P
Inflammatory Bowel Agents
APRISO P √
ASACOL P √
ASACOL HD P √
AZULFIDINE P √
AZULFIDINE ENTABS P √
balsalazide G √
CANASA P √
COLAZAL P √
DELZICOL P √
DIPENTUM P √
GIAZO P √
LIALDA P √
mesalamine G
PENTASA P √
sulfasalazine G √
sulfasalazine ER G √
sulfazine G √
sulfazine EC G √
UCERIS P √
Irritable Bowel Syndrome (IBS) Agent
LOTRONEX P
Laxatives
KRISTALOSE P
lactulose G
Pancreatic Enzymes
CREON P
DIGEX P
PANCRELIPASE P
PANCREAZE P
PERTZYE P √
ULTRESA P √
VIOKACE P √
ZENPEP P
Rectal Steroids
colocort G
48
CORTIFOAM P
Genitourinary System
Cystinosis Agents
CYSTAGON P
PROCYSBI P √ √
Interstitial Cystitis Agent
ELMIRON P √
Phosphate Binders
calcium acetate G
ELIPHOS P
FOSRENOL P
PHOSLO P
PHOSLYRA P
RENAGEL P √
RENVELA P
Prostatic Hypertrophy Agents
alfuzosin G
AVODART P
CARDURA XL P
CIALIS 2.5 mg, 5 mg P √
finasteride G
FLOMAX P
JALYN P
PROSCAR P
RAPAFLO P
tamsulosin G
UROXATRAL P
Urinary Antispasmodics
bethanechol G
DETROL P √
DETROL LA P √
DITROPAN XL P √
ENABLEX P
flavoxate G
hyoscyamine G
oxybutynin G
oxybutynin ER G
GELNIQUE P
49
MYRBETRIQ P √
OXYTROL P √
SANCTURA P √
SANCTURA XR P √
tolterodine G
TOVIAZ P √
trospium G
URECHOLINE P
VESICARE P
Urinary Anti-infectives and Combinations
MACROBID P
methenamine hippurate G
methenamine mandelate G
MONUROL P
nitrofurantoin G
nitrofurantoin monohydrate macrocrystal G
UREX P
URIBEL P
URIMAR-T P
UTA P
Vaginal Anti-infectives
CLEOCIN VAGINAL P
clindamax G
METROGEL VAGINAL P
nystatin vaginal G
TERAZOL P
terconazole G
tioconazole G
vandazole G
zazole G
Vaginal Estrogens
ESTRACE VAGINAL P
ESTRING P
FEMRING P
PREMARIN VAGINAL P
VAGIFEM P
Vaginal Progestins
CRINONE P
50
ENDOMETRIN P
PROGESTERONE VAGINAL P
Infections and Infestations
Antibacterials – Aminoglycosides
neomycin G
paromomycin G
Antibacterials – Ampicillins and Combinations
amoxicillin G
amoxicillin/K clavulanate G
amoxicillin/K clavulanate SR G
ampicillin G
AUGMENTIN P
AUGMENTIN ES P
AUGMENTIN XR P
MOXATAG P
Antibacterials – Cephalosporins, 1st Generation
cefadroxil G
cephalexin G
Antibacterials – Cephalosporins, 2nd Generation
cefaclor G
cefaclor ER G
cefprozil G
CEFTIN P
cefuroxime G
Antibacterials – Cephalosporins, 3rd Generation
CEDAX P
cefdinir G
cefditoren G
cefpodoxime G
SPECTRACEF P
SUPRAX P
Antibacterials – Fluoroquinolones
AVELOX P
AVELOX ABC P
CIPRO P
ciprofloxacin G
ciprofloxacin ER G
FACTIVE P
51
LEVAQUIN P
levofloxacin G
NOROXIN P
ofloxacin G
Antibacterials – Ketolide
KETEK P
Antibacterials – Macrolides
azithromycin G
BIAXIN P
BIAXIN XL P
clarithromycin G
clarithromycin SR G
DIFICID P √
e.e.s. G
erythrocin G
erythromycin G
erythromycin delayed release particles G
erythromycin ethylsuccinate G
PCE P
ZITHROMAX P
ZMAX P
Antibacterials – Miscellaneous
clindamycin G
metronidazole G
NEBUPENT P
tinidazole G
TINDAMAX P
trimethoprim G
XIFAXAN P √
ZYVOX P
Antibacterials – Penicillins
dicloxacillin sodium G
penicillin VK G
Antibacterials – Sulfonamide
sulfadiazine G
Antibacterials – Tetracyclines
ADOXA P
avidoxy G
52
demeclocycline G
DORYX P
doxycycline hyclate G
doxycycline monohydrate G
DYNACIN P
MINOCIN P
minocycline G
MONODOX P
NUTRIDOX P
ORAXYL P
SOLODYN P
tetracycline G
VIBRAMYCIN P
Antifungals
ANCOBON P
BIO-STATIN P
clotrimazole troche G
DIFLUCAN (all other strengths) P
DIFLUCAN 150 mg P √
fluconazole (all other strengths) G
fluconazole 150 mg G √
flucytosine G
GRIFULVIN V P
GRIS-PEG P
itraconazole G
ketoconazole G
LAMISIL P
NOXAFIL P
nystatin G
ONMEL P
ORAVIG P √
SPORANOX P
terbinafine G
VFEND P
voriconazole G
Anti-infective Agents – Miscellaneous
colistimethate sodium G
COLY-MYCIN M P
53
Antimalarials and Combinations
ARALEN P √
atovaquone/proguanil G
chloroquine G √
COARTEM P
DARAPRIM P
hydroxychloroquine G √
MALARONE P
mefloquine G
PLAQUENIL P √
primaquine G
QUALAQUIN P √
quinine sulfate G √
Antimycobacterial Agents
dapsone G
ethambutol G
isonarif G
isoniazid G
MYAMBUTOL P
pyrazinamide G
RIFAMATE P
rifampin G
RIFATER P
Antiprotozoal Agents
ALINIA P
MEPRON P
Antiretrovirals – Chemokine Receptor Antagonist
SELZENTRY P
Antiretrovirals – Integrase Inhibitors
ISENTRESS P
TIVICAY P
Antiretrovirals – NRTI/NNRTI Combination
ATRIPLA P
Antiretrovirals – NRTI/NNRTI/HIV integrase Combination
STRIBILD P
Antiretrovirals – Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
EDURANT P
INTELENCE P
54
nevirapine G
RESCRIPTOR P
SUSTIVA P
VIRAMUNE P
VIRAMUNE XR P
Antiretrovirals – Nucleoside (NRTI) and Nucleotide (NtRTI) Analogs
abacavir G
COMBIVIR P
COMPLERA P
didanosine delayed-release G
EMTRIVA P
EPIVIR P
EPZICOM P
lamivudine G
lamivudine/zidovudine G
RETROVIR P
stavudine G
TRIZIVIR P
TRUVADA P
VIDEX P
VIDEX EC P
VIREAD P
ZERIT P
ZIAGEN P
zidovudine G
Antiretrovirals – Protease Inhibitors
APTIVUS P
CRIXIVAN P
INVIRASE P
KALETRA P
LEXIVA P
NORVIR P
PREZISTA P
REYATAZ P
VIRACEPT P
Antituberculin
SIRTURO P √
55
Antivirals – CMV Agent
VALCYTE P √
Antivirals – Hepatitis Agents
adefovir dipivoxil P
BARACLUDE P
COPEGUS P
EPIVIR HBV P
HEPSERA P
INCIVEK P √
REBETOL P
ribatab P
ribapak G
ribasphere G
ribavirin G
TYZEKA P
VICTRELIS P √
Antivirals – Herpes Agents
acyclovir G
FAMVIR P √
famciclovir G √
valacyclovir G
VALTREX P
ZOVIRAX P
Antivirals – Influenza Agents
FLUMADINE P
RELENZA P √
rimantadine G
TAMIFLU P √
Antivirals – Respiratory Syncytial Virus (RSV) Agent
VIRAZOLE P
Musculoskeletal System
Antimyasthenic Agents
MESTINON P
MESTINON TIMESPAN P
pyridostigmine G
Antirheumatic Agents
ARAVA P
leflunomide G
56
RHEUMATREX P
RIDAURA P
Muscle Relaxants and Combinations
AMRIX P √
baclofen G
carisoprodol G
carisoprodol/aspirin G
carisoprodol/aspirin/codeine G
chlorzoxazone G
cyclobenzaprine G
cyclobenzaprine ER G
DANTRIUM P
dantrolene G
FEXMID P √
LORZONE P
metaxalone G
methocarbamol G
orphenadrine ER G
orphenadrine/aspirin/caffeine G
SKELAXIN P
tizanidine G
ZANAFLEX P
NSAIDs
ARTHROTEC P
CELEBREX P √
DAYPRO P
DUEXIS P √ √
diclofenac G
diclofenac potassium G
diclofenac sodium XR G
etodolac G
etodolac ER G
fenoprofen G
FLECTOR patch P √
flurbiprofen G
ibuprofen G
indomethacin G
indomethacin ER G
57
ketoprofen G
ketoprofen ER G
ketorolac G √
meclofenamate sodium G
mefenamic acid G √
meloxicam G
MOBIC P
nabumetone G
NAPRELAN P
naproxen G
oxaprozin G
piroxicam G
PENNSAID P √ √
PONSTEL P √
SPRIX P √
sulindac G
tolmetin sodium G
VIMOVO P √ √
VOLTAREN P
VOLTAREN GEL P √ √
VOLTAREN XR P
ZIPSOR P
Osteoporosis/Bone Modifying Agents
ACTONEL P √
alendronate G √
ATELVIA P √
BINOSTO P √ √
BONIVA tablet P √ √
calcitonin salmon nasal G
DIDRONEL P
etidronate G
fortical G
FOSAMAX P √
FOSAMAX PLUS D P √ √
ibandronate tablet G √
MIACALCIN NASAL P
SKELID P
58
Rheumatoid Arthritis
XELJANZ P √
Selective Estrogen Receptor Modulator (SERM)
EVISTA P
Ophthalmic Agents
Glaucoma – Adrenergic Agents
ALPHAGAN P P
apraclonidine G
brimonidine G
IOPIDINE P
Glaucoma – Beta-blockers
betaxolol ophthalmic G
BETIMOL P
BETOPTIC-S P
carteolol G
ISTALOL P
levobunolol G
metipranolol G
OPTIPRANOLOL P
timolol ophthalmic G
Glaucoma – Carbonic Anhydrase Inhibitors
AZOPT P
dorzolamide G
dorzolamide/timolol G
COSOPT P
COSOPT PF P
COMBIGAN P
SIMBRINZA P
TRUSOPT P
Glaucoma – Miotics
ISO CARBACHOL P
ISOPTO CARPINE P
PHOSPHOLINE P
pilocarpine G
PILOPINE HS P
Glaucoma – Prostaglandins
latanoprost G
LUMIGAN 0.01% P
59
LUMIGAN 0.03% P
TRAVATAN Z P
XALATAN P
ZIOPTAN P √
Ophthalmic Miscellaneous
CYSTARAN P √
Ophthalmic Antihistamines and NSAIDs
ACULAR P
ACULAR LS P
ACUVAIL P
ALAMAST P
ALOCRIL P
ALOMIDE P
azelastine ophthalmic G
BEPREVE P
BROMDAY P
bromfenac G
cromolyn sodium ophthalmic G
diclofenac ophthalmic G
ELESTAT P
EMADINE P
epinastine G
flurbiprofen ophthalmic G
ILEVRO P
ketorolac tromethamine ophthalmic G
LASTACAFT P
NEVANAC P
OPTIVAR P
PATADAY P
PATANOL P √
PROLENSA P
VOLTAREN P
Ophthalmic Anti-infectives
AZASITE P
bacitracin G
bacitracin/neomycin/polymyxin G
bacitracin/polymyxin G
BESIVANCE P
60
ciprofloxacin G
erythromycin G
gentamicin G
IQUIX P
levofloxacin G
neomycin/polymyxin/gramicidin G
ofloxacin G
polymyxin B/trimethoprim G
QUIXIN P
sulfacetamide sodium G
tobramycin G
trifluridine G
triple antibiotic G
VIGAMOX P
ZIRGAN P
ZYMAXID P
Ophthalmic Immunomodulator
RESTASIS P
Ophthalmic Steroidal Anti-inflammatory Drugs
ALREX P
bacitracin/polymyxin/neomycin/ hydrocortisone
G
BLEPHAMIDE S.O.P. P
dexamethasone phosphate G
dexamethasone/neomycin/polymyxin G
DUREZOL P
fluorometholone G
fluor-op G
FML FORTE P
FML LIQUIFILM P
FML S.O.P. P
LOTEMAX OINT P
LOTEMAX SUS P
neomycin/polymyxin/hydrocortisone G
poly-dex G
PRED-G P
PRED-G S.O.P P
prednisolone G
61
sulfacetamide sodium/prednisolone G
tobramycin/dexamethasone G
TOBRADEX P
TOBRADEX ST P
VEXOL P
ZYLET P
Otic Agents
Otic Analgesic
PINNACAINE P
Otic Anti-infectives
ciprofloxacin otic G
ofloxacin otic G
Otic Combinations
acetic acid/antipyrine/benzocaine/polycosanol
G
antipyrine/benzocaine G
CETRAXAL P
CIPRO HC P
CIPRODEX P
COLY-MYCIN S P
cortomycin G
myoxin G
neomycin/polymyxin/hydrocortisone G
NEOTIC P
otozin G
TREAGAN P
TRIOXIN P
ZINOTIC P
ZINOTIC ES P
Respiratory Tract Agents
Antiasthmatics – Anticholinergics
ATROVENT HFA P
ipratropium inhaler G
SPIRIVA P
TUDORZA P
Anti-Inflammatory Agents (nebulizer)
cromolyn sodium nebulizer G
62
Bronchodilators – Sympathomimetics
ACCUNEB P
ADVAIR DISKUS P √
ADVAIR HFA P √
albuterol G
ARCAPTA P
BREO ELLIPTA P √ √
BROVANA P
COMBIVENT RESPIMAT P
COMBIVENT P
DULERA P
DUONEB P
FORADIL P
ipratropium/albuterol G
levalbuterol G
MAXAIR AUTOHALER P √
metaproterenol G
PERFOROMIST P
PROAIR HFA P
PROVENTIL HFA P
SEREVENT DISKUS P
SYMBICORT P
terbutaline G
VENTOLIN HFA P √
VOSPIRE ER P
XOPENEX P √
XOPENEX HFA P √
Bronchodilators – Xanthines
aminophylline G
THEO-24 P
theochron G
theophylline ER G
Cystic Fibrosis Agents
CAYSTON P
KALYDECO P √
PULMOZYME P
TOBI P
63
TOBI PODHALER P √
Inhaled Corticosteroids
ALVESCO P
ASMANEX P
budesonide inhalation susp G
FLOVENT DISKUS P
FLOVENT HFA P
PULMICORT FLEXHALER P
PULMICORT RESPULES P
QVAR P
Leukotriene Modulators
ACCOLATE P √
zafirlukast G √
SINGULAIR P √
montelukast G √
ZYFLO P √
ZYFLO CR P √
Mouth and Throat Products
cevimeline G
EVOXAC P
pilocarpine G
SALAGEN P
Nasal Antiallergy
ASTELIN NASAL P
ASTEPRO P
azelastine nasal G
DYMISTA P
PATANASE P
Nasal Anti-infective
BACTROBAN NASAL P
Nasal Anticholinergics
ATROVENT NASAL P
ipratropium nasal G
Nasal Steroids
BECONASE AQ P
FLONASE P
flunisolide G
64
fluticasone nasal G
NASACORT AQ P √
NASONEX P
QNASL P
OMNARIS P
RHINOCORT AQ P √
triamcinolone nasal G
VERAMYST P
ZETONNA P √
Non-Sedating Antihistamines and Combinations
CLARINEX P √
CLARINEX-D P √
CLARINEX REDITAB P √
desloratadine G √
desloratadine ODT G √
levocetirizine G √
XYZAL P √
Selective Phosphodiesterase 4 (PDE4) Inhibitor
DALIRESP P √
Upper Respiratory – Cough/Cold/Allergy Combinations
hydrocodone/chlorpheniramine polistirex G
SEMPREX-D P √
TUSSICAPS P
TUSSIONEX P
VITUZ P
Miscellaneous
Immunosuppressive Agents
ASTAGRAF XL P
AZASAN P
azathioprine G
CELLCEPT P
cyclosporine G
cyclosporine modified G
gengraf G
IMURAN P
MYFORTIC P
mycophenolate G
NEORAL P