FEP 5 Tier Rx Drug Formulary (607) Standard Option
FEP 5 Tier Rx Drug Formulary (607) Standard Option
Effective July 1, 2021
The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs. Also included in the formulary are Tier 3, non-preferred brand-name drugs, Tier 4, preferred specialty drugs and Tier 5, non-preferred specialty drugs.
Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your physician to prescribe a preferred brand-name drug.
The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and cost-effective.
Click on the category name in the Table of Contents below to go directly to that page
INTRODUCTION ...... 5 PREFACE ...... 5 EXCLUDED DRUGS ...... 6 PRIOR APPROVAL ...... 6 QUANTITY LIMITATIONS ...... 6 PHARMACY AND MEDICAL POLICY COMMITTEE ...... 6 PRODUCT SELECTION CRITERIA ...... 6 FORMULARY PRODUCT DESCRIPTIONS ...... 7 GENERIC SUBSTITUTION ...... 7 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS ...... 8 EDITOR ...... 8 NOTICE ...... 8 LEGEND ...... 8 ANALGESICS ...... 10 ANALGESICS, OTHER ...... 10 NSAIDs ...... 10 NSAIDs, COMBINATIONS ...... 10 NSAIDs, TOPICAL ...... 10 COX-2 INHIBITORS ...... 10 GOUT ...... 10 OPIOID ANALGESICS ...... 10 NON-OPIOID ANALGESICS ...... 11 VISCOSUPPLEMENTS ...... 11 ANTI-INFECTIVES ...... 12 ANTIBACTERIALS ...... 12 ANTIFUNGALS ...... 13 ANTIMALARIALS ...... 14 ANTIRETROVIRAL AGENTS ...... 14 ANTITUBERCULAR AGENTS ...... 15 ANTIVIRALS ...... 15 MISCELLANEOUS ...... 16 ANTINEOPLASTIC AGENTS ...... 17 ALKYLATING AGENTS ...... 17 ANTIMETABOLITES ...... 17 HORMONAL ANTINEOPLASTIC AGENTS ...... 18 IMMUNOMODULATORS ...... 18 KINASE INHIBITORS ...... 18 MULTIPLE MYELOMA ...... 20 TOPOISOMERASE INHIBITORS ...... 20 MISCELLANEOUS ...... 20 CARDIOVASCULAR ...... 22 ACE INHIBITORS ...... 22 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 23 ACE INHIBITOR/DIURETIC COMBINATIONS ...... 23
1 ADRENOLYTICS, CENTRAL ...... 23 ALDOSTERONE RECEPTOR ANTAGONISTS ...... 23 ALPHA BLOCKERS ...... 23 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ...... 23 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 23 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ...... 23 ANTIARRHYTHMICS ...... 24 ANTILIPEMICS ...... 24 BETA-BLOCKERS ...... 25 BETA-BLOCKER/DIURETIC COMBINATIONS ...... 25 CALCIUM CHANNEL BLOCKERS ...... 25 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ...... 26 DIGITALIS GLYCOSIDES ...... 26 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ...... 26 DIURETICS ...... 26 HEART FAILURE ...... 26 NITRATES ...... 27 PULMONARY ARTERIAL HYPERTENSION ...... 27 MISCELLANEOUS ...... 27 CENTRAL NERVOUS SYSTEM ...... 27 ANTIANXIETY ...... 28 ANTICONVULSANTS ...... 28 ANTIDEMENTIA...... 29 ANTIDEPRESSANTS ...... 29 ANTIPARKINSONIAN AGENTS ...... 30 ANTIPSYCHOTICS ...... 31 ATTENTION DEFICIT HYPERACTIVITY DISORDER ...... 31 FIBROMYALGIA ...... 32 HYPNOTICS ...... 32 MIGRAINE ...... 33 MOOD STABILIZERS ...... 33 MOVEMENT DISORDERS ...... 33 MULTIPLE SCLEROSIS ...... 33 MUSCULOSKELETAL THERAPY AGENTS ...... 34 MYASTHENIA GRAVIS ...... 34 NARCOLEPSY/CATAPLEXY ...... 34 PSYCHOTHERAPEUTIC-MISCELLANEOUS ...... 34 MISCELLANEOUS ...... 35 ENDOCRINE AND METABOLIC ...... 35 ANDROGENS ...... 35 ANTIDIABETICS ...... 36 CALCIUM RECEPTOR ANTAGONISTS ...... 38 CALCIUM REGULATORS ...... 38 CARNITINE DEFICIENCY AGENTS ...... 39 CONTRACEPTIVES ...... 39 ENDOMETRIOSIS ...... 40 ESTROGENS ...... 41 ESTROGEN/PROGESTINS ...... 41 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ...... 41 FERTILITY REGULATORS ...... 41 GAUCHER DISEASE ...... 42 GLUCOCORTICOIDS ...... 42 GLUCOSE ELEVATING AGENTS ...... 42 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ...... 42 HUMAN GROWTH HORMONES ...... 42 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ...... 43 INSULIN-LIKE GROWTH FACTOR-1 AGENTS ...... 43 PHENYLKETONURIA TREATMENT AGENTS ...... 43 PHOSPHATE BINDER AGENTS ...... 43 POTASSIUM-REMOVING AGENTS ...... 43 PROGESTINS ...... 43 SELECTIVE ESTROGEN RECEPTOR MODULATORS ...... 43 THYROID AGENTS ...... 43 UREA CYCLE DISORDERS ...... 44 UTERINE FIBROIDS ...... 44
2 VASOPRESSINS ...... 44 MISCELLANEOUS ...... 44 GASTROINTESTINAL ...... 45 ANTIDIARRHEALS ...... 45 ANTIEMETICS ...... 45 ANTISPASMODICS ...... 45 CHOLELITHOLYTICS ...... 45 H2 RECEPTOR ANTAGONISTS ...... 45 INFLAMMATORY BOWEL DISEASE ...... 46 IRRITABLE BOWEL SYNDROME ...... 46 LAXATIVES ...... 46 OPIOID-INDUCED CONSTIPATION ...... 46 PANCREATIC ENZYMES ...... 46 PROSTAGLANDINS ...... 47 PROTON PUMP INHIBITORS ...... 47 SALIVA STIMULANTS ...... 47 STEROIDS, RECTAL ...... 47 ULCER THERAPY COMBINATIONS ...... 47 MISCELLANEOUS ...... 47 GENITOURINARY ...... 47 BENIGN PROSTATIC HYPERPLASIA ...... 47 URINARY ANTISPASMODICS ...... 48 VAGINAL ANTI-INFECTIVES ...... 48 MISCELLANEOUS ...... 48 HEMATOLOGIC ...... 48 ANTICOAGULANTS ...... 48 HEMATOPOIETIC GROWTH FACTORS ...... 48 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS ...... 49 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...... 50 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ...... 50 PLATELET AGGREGATION INHIBITORS ...... 50 PLATELET SYNTHESIS INHIBITORS ...... 50 SICKLE CELL DISEASE ...... 50 STEM CELL MOBILIZERS ...... 50 THROMBOCYTOPENIA AGENTS ...... 50 MISCELLANEOUS ...... 50 IMMUNOLOGIC AGENTS ...... 51 ALLERGENIC EXTRACTS ...... 51 AUTOIMMUNE AGENTS ...... 51 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ...... 51 HEREDITARY ANGIOEDEMA AGENTS ...... 51 IMMUNE GLOBULINS ...... 52 IMMUNOMODULATORS ...... 52 IMMUNOSUPPRESSANTS ...... 52 NUTRITIONAL/SUPPLEMENTS ...... 53 ELECTROLYTES ...... 53 VITAMINS AND MINERALS ...... 53 MISCELLANEOUS ...... 53 RESPIRATORY ...... 53 ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS ...... 54 ANAPHYLAXIS TREATMENT AGENTS ...... 54 ANTICHOLINERGICS ...... 54 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ...... 54 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ...... 54 ANTIHISTAMINES, LOW SEDATING ...... 54 ANTIHISTAMINES, NONSEDATING ...... 54 ANTIHISTAMINES, SEDATING ...... 54 ANTIHISTAMINE/DECONGESTANT COMBINATIONS ...... 55 ANTITUSSIVES ...... 55 ANTITUSSIVE COMBINATIONS ...... 55 BETA AGONISTS ...... 55 CYSTIC FIBROSIS ...... 55 LEUKOTRIENE MODULATORS ...... 56 MAST CELL STABILIZERS ...... 56
3 NASAL ANTIHISTAMINES ...... 56 NASAL STEROIDS/COMBINATIONS ...... 56 PHOSPHODIESTERASE-4 INHIBITORS...... 56 PULMONARY FIBROSIS AGENTS ...... 56 SEVERE ASTHMA AGENTS ...... 56 STEROID/BETA AGONIST COMBINATIONS ...... 56 STEROID INHALANTS ...... 56 XANTHINES ...... 57 MISCELLANEOUS ...... 57 TOPICAL ...... 57 DERMATOLOGY ...... 57 MOUTH/THROAT/DENTAL AGENTS ...... 61 OPHTHALMIC ...... 61 OTIC ...... 64 WEBSITES ...... 65 2021 FEP EXCLUDED DRUG LIST STANDARD OPTION CHART ...... 67 INDEX ...... 72
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The Retail and Mail Service Prescription Drug Program cannot refill a controlled substance until 80% of the prescription has been used. Call us at 1-800-624-5060 or visit our website www.fepblue.org if you have any questions about dispensing limits.
INTRODUCTION FEP is pleased to provide the 2021 FEP 5 Tier Rx Drug Formulary as a useful reference for drug product selection. The drugs on the FEP 5 Tier Rx Drug Formulary have been reviewed by the FEP Pharmacy and Medical Policy Committee and FEP physicians and pharmacists and found appropriate for preferred status.
All the information in the FEP 5 Tier Rx Drug Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.
National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/, on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication. PREFACE The formulary is organized by sections, which refer to either a drug class or disease state. Unless exceptions are noted, all dosage forms and strengths of the drug cited are included in the formulary.
The FEP 5 Tier Rx Drug Formulary is an open formulary, but FEP may impose restrictions or not reimburse for specific drug products or types of products. For example, drugs and supplies for weight loss are excluded from the pharmacy benefit. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are generally not included in the pharmacy benefit. Some OTC products are listed in the formulary for informational purposes only.
The formulary is separated by Tiers in the following manner:
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 generic drugs preferred brand- non-preferred brand- preferred specialty non-preferred name drugs name drugs and all drugs specialty drugs compounded medications Standard Option $7.50 copayment 30% coinsurance 50% coinsurance 30% coinsurance 30% coinsurance Preferred Retail for a 0 to 30-day Limit*: one 30-day Limit*: one 30-day Pharmacy supply supply fill at retail supply fill at retail ($22.50 copayment for a 31 to 90-day supply)
Medicare Part B $5 copayment for a Primary 0 to 30-day supply ($15 copayment for a 31 to 90-day supply) Standard Option 45% of average wholesale price plus any difference between our allowance and the billed amount Non-Preferred Retail Pharmacy Standard Option $15 copay $90 copay $125 copay Mail Pharmacy
Medicare Part B $10 copay Standard Option $65 for a 0 to 30- $85 for a 0 to 30- Specialty Drug day supply day supply Pharmacy Program $185 for 31 to 90- $240 for 31 to 90- day supply day supply
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* First fill of specialty medications is limited to a 30-day supply at retail. All subsequent fills must be through the Specialty Drug Pharmacy Program. A 90-day supply fill of a specialty medication may only be obtained through the Specialty Drug Pharmacy Program once a member has received three 30-day supply fills of that medication.
Drug products shown in boldface type indicate generic availability.
All drugs that are preferred are noted in their respective tiers of the drug lists throughout this formulary. Drugs may be reviewed by the FEP Pharmacy and Medical Policy Committee and designated non-preferred. FEP may designate certain drugs as non- preferred, typically if the cost-effectiveness is less than other similar drugs. EXCLUDED DRUGS Effective January 1, 2021, selected medications will no longer be covered on the Standard Option drug benefit plan. These excluded medications have available covered options in the same therapeutic class. For a full listing of these excluded medications please see the EXCLUDED DRUG LIST STANDARD OPTION CHART located on page 67 before the INDEX in this document.
Patients taking an excluded medication on or after January 1, 2021 should expect to pay the full cost of the prescription. PRIOR APPROVAL Prior approval (PA) is required for certain drugs before FEP will cover them. The prescribing physician may request PA by calling toll-free 1-877-727-3784. The list of prior approval medications is subject to change. For a current list of medications that require prior approval please see our Prior Approval web page. QUANTITY LIMITATIONS Quantity limitations (QL) have been established for some of the medications covered by FEP. Requests for quantities greater than allowed can be submitted to the Prior Approval program by the prescribing physician by calling toll-free 1-877-727-3784. The list of medications that have quantity limitations is subject to change. For a current list of medications with quantity limitations please see our Prior Approval web page. PHARMACY AND MEDICAL POLICY COMMITTEE The role of the FEP Pharmacy and Medical Policy Committee includes evaluating new medications, and making recommendations for the designation of preferred or non-preferred status on the FEP 5 Tier Rx Drug Formulary. The FEP Pharmacy and Medical Policy Committee is made up of physicians and pharmacists who are not employees or agents of, nor have financial interest in FEP. PRODUCT SELECTION CRITERIA The FEP Pharmacy and Medical Policy Committee will consider U.S. Food and Drug Administration (FDA) approved drugs for preferred status designation. The evaluation includes a literature review; expert opinion may also be sought. Formal reviews are prepared that typically address the following information:
• Safety • Efficacy • Comparison studies • Drug interactions • Approved indications • Formulation and administration • Adverse effects • Contraindications • Pharmacokinetics • Patient compliance considerations • Medical outcome and pharmacoeconomic studies
When a new drug is considered for preferred status, an attempt will be made to examine the drug relative to similar drugs currently preferred. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a
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designation of non-preferred status to drug(s) in a particular therapeutic class, in an effort to continually promote the most clinically useful and cost-effective agents.
Drugs evaluated by the Pharmacy and Medical Policy Committee and not classified as preferred receive a non-preferred designation in the FEP 5 Tier Rx Drug Formulary. This designation indicates the Pharmacy and Medical Policy Committee's belief that the drug offers no important clinical or cost advantage over comparable preferred drugs, or that there is currently insufficient information to determine its appropriate clinical role, or that questions remain regarding safety and effectiveness. In an open formulary environment, non-preferred drugs are covered under FEP's pharmacy benefit. However, there may be additional costs incurred by the patient to receive a non-preferred medication. Physicians are encouraged to prescribe preferred drugs.
All the information in the FEP 5 Tier Rx Drug Formulary is provided as a reference for drug therapy selection. The final choice of a specific drug selection for an individual patient rests solely with the prescriber. FORMULARY PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are preferred, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted.
Preferred products include all strengths and dosage forms of the cited brand-name product. sevelamer carbonate Renvela Oral powder packets, tabs and all strengths of Renvela would be included in this listing.
When a strength or dosage form is specified, only the specified strength and dosage form is preferred. Other strengths/dosage forms of the reference product are not. acyclovir caps, susp, tabs Zovirax The capsules, suspension and tablets of Zovirax are preferred. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry.
Extended-release and delayed-release products require their own entry. sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR.
sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the formulary.
Dosage forms will be consistent with the category and use where listed. nystatin The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI- INFECTIVES section of the formulary.
GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.
One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand- name equivalents. Prescription generic drugs are:
• Approved by the FDA for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. • Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and to the same extent as the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. • Manufactured in the same strength and dosage form as the brand-name drugs.
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When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug. DRUG EFFICACY STUDY IMPLEMENTATION DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Since 1962, all new drugs are required to be both safe and effective before they can be marketed. The legislation that resulted in this change also applies retroactively to all drugs approved as safe from 1938-1962. The Drug Efficacy Study Implementation (DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also classified as DESI are many products listed as identical, similar, or related to actual DESI products. EDITOR Your comments and suggestions regarding this FEP 5 Tier Rx Drug Formulary are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to:
FEP Rx Drug Formulary - MC 145 P.O. Box 52115 Phoenix, AZ 85072-2115 NOTICE The information contained in this FEP 5 Tier Rx Drug Formulary and its appendices is provided by FEP, solely for the convenience of medical providers. FEP does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The FEP 5 Tier Rx Drug Formulary is not a complete list of all covered medications. This FEP 5 Tier Rx Drug Formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. FEP assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.
The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of FEP. ©2021. All rights reserved.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with FEP.
If viewing this formulary via Internet, please be advised that the formulary is updated periodically and changes may appear prior to their effective date. LEGEND † Generic contraceptives are covered at no charge to qualifying members ‡ Medication is covered at no charge to the member d DESI drug OTC Over the counter PA Prior Approval PA/ST Prior Approval with Step Therapy QL Quantity Limitations - quantity allowed before prior approval is required. Quantity limits apply for both brands and generics ST Step Therapy - indicates the requirement for previous use of one or more drugs before coverage is provided for the targeted drug boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for clarification
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ANALGESICS Practice guidelines of pain management are available at: https://www.asahq.org
ANALGESICS, OTHER Treatment recommendations for osteoarthritis are available at: https://www.rheumatology.org
acetaminophen inj Tier 1 OFIRMEV Tier 3
NSAIDs diclofenac sodium delayed-rel Tier 1 diclofenac sodium ext-rel Tier 1 diflunisal Tier 1 etodolac Tier 1 etodolac ext-rel Tier 1 flurbiprofen Tier 1 ibuprofen Tier 1 indomethacin (except caps 20 mg, 40 mg) Tier 1 indomethacin ext-rel Tier 1 ketoprofen Tier 1 ketoprofen ext-rel Tier 1 ketorolac Tier 1 meloxicam tabs Tier 1 MOBIC Tier 3 nabumetone Tier 1 naproxen Tier 1 NAPROSYN Tier 3 naproxen sodium Tier 1 oxaprozin Tier 1 DAYPRO Tier 3 piroxicam Tier 1 FELDENE Tier 3 sulindac Tier 1 ibuprofen inj CALDOLOR Tier 2 indomethacin susp INDOCIN susp Tier 2 PA ketorolac tromethamine nasal spray SPRIX Tier 3
NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/misoprostol Tier 1 ARTHROTEC Tier 3
NSAIDs, TOPICAL QL diclofenac sodium gel 1% Tier 1 diclofenac sodium soln Tier 1
COX-2 INHIBITORS QL celecoxib Tier 1 CELEBREX Tier 3
GOUT allopurinol Tier 1 ZYLOPRIM Tier 3 colchicine Tier 1 COLCRYS Tier 3 colchicine Tier 1 MITIGARE Tier 3 PA febuxostat Tier 1 ULORIC Tier 3 probenecid Tier 1 PA pegloticase KRYSTEXXA Tier 5
OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org
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Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html
QL buprenorphine transdermal Tier 1 BUTRANS Tier 3 QL butalbital/acetaminophen/caffeine/codeine Tier 1 FIORICET w/CODEINE Tier 3 QL butalbital/aspirin/caffeine/codeine Tier 1 QL butorphanol nasal spray Tier 1 QL codeine/acetaminophen Tier 1 PA fentanyl citrate buccal Tier 1 FENTORA Tier 3 QL fentanyl transdermal Tier 1 DURAGESIC Tier 3 PA fentanyl transmucosal lozenge Tier 1 ACTIQ Tier 3 PA hydrocodone ext-rel caps Tier 1 ZOHYDRO ER Tier 3 QL hydrocodone/acetaminophen Tier 1 QL hydromorphone Tier 1 DILAUDID Tier 3 QL hydromorphone ext-rel Tier 1 QL methadone Tier 1 QL morphine Tier 1 QL morphine ext-rel Tier 1 QL morphine ext-rel Tier 1 MS CONTIN Tier 3 QL morphine supp Tier 1 QL oxycodone Tier 1 ROXICODONE Tier 3 QL oxycodone concentrate 20 mg/mL Tier 1 QL oxycodone soln Tier 1 QL oxycodone/acetaminophen 5/325 Tier 1 PERCOCET Tier 3 QL oxymorphone Tier 1 OPANA Tier 3 QL tramadol (except 100 mg tabs) Tier 1 ULTRAM Tier 3 QL tramadol ext-rel Tier 1 ULTRAM ER Tier 3 QL tramadol/acetaminophen Tier 1 QL morphine/naltrexone ext-rel EMBEDA Tier 2 QL oxycodone ext-rel XTAMPZA ER Tier 2 QL tapentadol NUCYNTA Tier 2 QL tapentadol ext-rel NUCYNTA ER Tier 2 QL buprenorphine BELBUCA Tier 3 PA fentanyl sublingual spray SUBSYS Tier 3 PA hydrocodone ext-rel tabs HYSINGLA ER Tier 3 QL morphine ext-rel MORPHABOND Tier 3 QL oxycodone ext-rel OXYCONTIN Tier 3 QL tramadol oral solution QDOLO Tier 3
NON-OPIOID ANALGESICS QL butalbital/acetaminophen Tier 1 QL butalbital/acetaminophen/caffeine Tier 1 FIORICET Tier 3 QL butalbital/aspirin/caffeine Tier 1 FIORINAL Tier 3 ziconotide PRIALT Tier 4
VISCOSUPPLEMENTS PA sodium hyaluronate GEL-ONE Tier 4 PA sodium hyaluronate GELSYN-3 Tier 4 PA sodium hyaluronate HYALGAN Tier 4 PA sodium hyaluronate SUPARTZ FX Tier 4 PA high molecular weight hyaluronan HYMOVIS Tier 5 PA high molecular weight hyaluronan ORTHOVISC Tier 5 PA hyaluronate sodium TRIVISC Tier 5 PA hylan G-F 20 SYNVISC Tier 5 PA hylan G-F 20 SYNVISC-ONE Tier 5
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PA sodium hyaluronate DUROLANE Tier 5 PA sodium hyaluronate EUFLEXXA Tier 5 PA sodium hyaluronate MONOVISC Tier 5
ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org
Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/
Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org
HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov
Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org
Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html
International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel
Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html
Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm
ANTIBACTERIALS Cephalosporins First Generation cephalexin Tier 1 KEFLEX Tier 3
Second Generation cefaclor Tier 1 cefoxitin Tier 1 cefprozil Tier 1 cefuroxime axetil Tier 1
Third Generation cefdinir Tier 1 cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL Tier 1 SUPRAX Tier 2 QL cefotaxime Tier 1 cefpodoxime Tier 1 ceftazidime Tier 1 QL ceftriaxone Tier 1 ROCEPHIN Tier 3
Fourth Generation cefepime Tier 1
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Fifth Generation ceftaroline fosamil TEFLARO Tier 2
Erythromycins/Macrolides azithromycin Tier 1 ZITHROMAX Tier 3 clarithromycin Tier 1 clarithromycin ext-rel Tier 1 erythromycin delayed-rel Tier 1 erythromycin delayed-rel - Ery-tab Tier 1 erythromycin ethylsuccinate Tier 1 E.E.S. Tier 3 erythromycin ethylsuccinate Tier 1 ERYPED Tier 3 erythromycin stearate Tier 1 fidaxomicin DIFICID Tier 2
Fluoroquinolones ciprofloxacin Tier 1 CIPRO Tier 3 levofloxacin Tier 1 LEVAQUIN Tier 3 ofloxacin Tier 1
Penicillins amoxicillin, except film-coated tabs Tier 1 amoxicillin/clavulanate Tier 1 AUGMENTIN Tier 3 amoxicillin/clavulanate ext-rel Tier 1 amoxicillin/clavulanate susp 600 mg Tier 1 ampicillin Tier 1 ampicillin sodium/sulbactam sodium Tier 1 UNASYN Tier 3 dicloxacillin Tier 1 penicillin VK Tier 1 piperacillin/tazobactam Tier 1 ZOSYN Tier 3
Tetracyclines doxycycline hyclate Tier 1 VIBRAMYCIN Tier 3 doxycycline hyclate delayed-rel tabs Tier 1 DORYX/MPC Tier 3 doxycycline monohydrate Tier 1 minocycline Tier 1 MINOCIN Tier 3 minocycline ext-rel Tier 1 SOLODYN Tier 3 tetracycline Tier 1 QL omadacycline NUZYRA Tier 3 sarecycline SEYSARA Tier 3
Miscellaneous QL lefamulin XENLETA Tier 3 QL rifamycin delayed-rel AEMCOLO Tier 3
ANTIFUNGALS clotrimazole troches Tier 1 fluconazole Tier 1 DIFLUCAN Tier 3 griseofulvin microsize Tier 1 griseofulvin ultramicrosize Tier 1 PA itraconazole Tier 1 SPORANOX Tier 3 PA ketoconazole tabs Tier 1 micafungin Tier 1 MYCAMINE Tier 3 nystatin Tier 1 PA posaconazole delayed-rel tabs Tier 1 NOXAFIL tabs Tier 3 terbinafine tabs Tier 1 QL voriconazole Tier 1 VFEND Tier 3
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amphotericin B lipid complex inj ABELCET Tier 2 amphotericin B liposome inj AMBISOME Tier 2 anidulafungin ERAXIS Tier 2 PA posaconazole susp NOXAFIL susp Tier 2 PA isavuconazonium CRESEMBA Tier 3
ANTIMALARIALS atovaquone/proguanil Tier 1 MALARONE Tier 3 chloroquine Tier 1 mefloquine Tier 1 primaquine Tier 1 PA pyrimethamine Tier 1 DARAPRIM Tier 3 artemether/lumefantrine COARTEM Tier 2 tafenoquine ARAKODA Tier 3 tafenoquine KRINTAFEL Tier 3
ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants cobicistat TYBOST Tier 2
Antiretroviral Combinations abacavir/lamivudine Tier 1 EPZICOM Tier 3 abacavir/lamivudine/zidovudine Tier 1 TRIZIVIR Tier 3 efavirenz/emtricitabine/tenofovir disoproxil fumarate Tier 1 ATRIPLA Tier 3 efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 1 SYMFI Tier 3 efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 1 SYMFI LO Tier 3 emtricitabine/tenofovir disoproxil fumarate Tier 1 TRUVADA Tier 3 lamivudine/zidovudine Tier 1 COMBIVIR Tier 3 abacavir/dolutegravir/lamivudine TRIUMEQ Tier 2 atazanavir/cobicistat EVOTAZ Tier 2 bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY Tier 2 darunavir/cobicistat PREZCOBIX Tier 2 darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA Tier 2 dolutegravir/lamivudine DOVATO Tier 2 doravirine/lamivudine/tenofovir disoproxil fumarate DELSTRIGO Tier 2 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA Tier 2 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD Tier 2 emtricitabine/rilpivirine/tenofovir alafenamide ODEFSEY Tier 2 emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA Tier 2 emtricitabine/tenofovir alafenamide DESCOVY Tier 2 dolutegravir/rilpivirine JULUCA Tier 3 lamivudine/tenofovir disoproxil fumarate CIMDUO Tier 3 lamivudine/tenofovir disoproxil fumarate TEMIXYS Tier 3
Chemokine Receptor Antagonists maraviroc SELZENTRY Tier 2
Fusion Inhibitors enfuvirtide FUZEON Tier 4
Gp120-Directed Attachment Inhibitors fostemsavir ext-rel RUKOBIA Tier 2
Integrase Inhibitors dolutegravir TIVICAY Tier 2 raltegravir ISENTRESS Tier 2
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Monoclonal Antibody PA ibalizumab-uiyk TROGARZO Tier 4
Non-nucleoside Reverse Transcriptase Inhibitors efavirenz Tier 1 SUSTIVA Tier 3 nevirapine Tier 1 VIRAMUNE Tier 3 nevirapine ext-rel Tier 1 VIRAMUNE XR Tier 3 etravirine INTELENCE Tier 2 rilpivirine EDURANT Tier 2 doravirine PIFELTRO Tier 3
Nucleoside Reverse Transcriptase Inhibitors abacavir Tier 1 ZIAGEN Tier 3 abacavir soln Tier 1 ZIAGEN soln Tier 3 emtricitabine caps Tier 1 EMTRIVA Tier 2 lamivudine Tier 1 EPIVIR Tier 3 stavudine Tier 1 zidovudine Tier 1 RETROVIR Tier 3
Nucleotide Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate tabs 300 mg Tier 1 VIREAD Tier 2
Protease Inhibitors atazanavir caps Tier 1 REYATAZ Tier 3 fosamprenavir Tier 1 LEXIVA Tier 3 ritonavir tabs Tier 1 NORVIR Tier 2 darunavir PREZISTA Tier 2 indinavir CRIXIVAN Tier 2 lopinavir/ritonavir KALETRA Tier 2 nelfinavir VIRACEPT Tier 2 saquinavir mesylate INVIRASE Tier 2 tipranavir APTIVUS Tier 2
ANTITUBERCULAR AGENTS ethambutol Tier 1 MYAMBUTOL Tier 3 isoniazid Tier 1 pyrazinamide Tier 1 rifampin Tier 1 RIFADIN Tier 3 pretomanid tabs PRETOMANID Tier 2 rifampin/isoniazid/pyrazinamide RIFATER Tier 2 rifapentine PRIFTIN Tier 2 bedaquiline SIRTURO Tier 3
ANTIVIRALS Cytomegalovirus Agents cidofovir Tier 1 VISTIDE Tier 3 PA valganciclovir Tier 1 VALCYTE Tier 3 ganciclovir inj Tier 4 cytomegalovirus immune globulin CYTOGAM Tier 4 PA letermovir PREVYMIS Tier 4
Hepatitis Agents Hepatitis B lamivudine Tier 1 EPIVIR-HBV Tier 3 PA, * adefovir dipivoxil Tier 4 HEPSERA Tier 5
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PA, * entecavir tabs Tier 4 BARACLUDE Tier 5 entecavir soln BARACLUDE soln Tier 4 telbivudine TYZEKA Tier 4 tenofovir alafenamide VEMLIDY Tier 4
* Brand requires prior approval
Hepatitis C PA ledipasvir/sofosbuvir Tier 4 HARVONI Tier 4 PA ribavirin caps Tier 4 PA ribavirin caps - Ribasphere Tier 4 PA ribavirin tabs Tier 4 PA sofosbuvir/velpatasvir Tier 4 EPCLUSA Tier 4 PA glecaprevir/pibrentasvir MAVYRET Tier 4 PA sofosbuvir SOVALDI Tier 4 PA sofosbuvir/velpatasvir/voxilaprevir VOSEVI Tier 4 PA elbasvir/grazoprevir ZEPATIER Tier 5
Herpes Agents acyclovir caps, susp, tabs Tier 1 ZOVIRAX Tier 3 famciclovir Tier 1 valacyclovir Tier 1 VALTREX Tier 3
Influenza Agents QL oseltamivir Tier 1 TAMIFLU Tier 3 rimantadine Tier 1 QL zanamivir RELENZA Tier 2 QL baloxavir XOFLUZA Tier 3
Respiratory Syncytial Virus Agents PA palivizumab SYNAGIS Tier 4
MISCELLANEOUS PA albendazole Tier 1 ALBENZA Tier 3 atovaquone Tier 1 MEPRON Tier 3 aztreonam Tier 1 AZACTAM Tier 3 clindamycin Tier 1 CLEOCIN Tier 3 QL dapsone Tier 1 ACZONE Tier 3 daptomycin 500 mg Tier 1 CUBICIN Tier 3 ertapenem Tier 1 INVANZ Tier 3 imipenem/cilastatin Tier 1 PRIMAXIN Tier 3 QL linezolid Tier 1 ZYVOX Tier 3 meropenem Tier 1 methenamine hippurate, prophylaxis Tier 1 HIPREX Tier 3 metronidazole tabs Tier 1 FLAGYL Tier 3 nitazoxanide tabs Tier 1 ALINIA Tier 2 nitrofurantoin ext-rel Tier 1 MACROBID Tier 3 nitrofurantoin macrocrystals Tier 1 MACRODANTIN Tier 3 rifabutin Tier 1 MYCOBUTIN Tier 3 sulfamethoxazole/trimethoprim Tier 1 sulfamethoxazole/trimethoprim DS Tier 1 tigecycline Tier 1 TYGACIL Tier 3 tinidazole Tier 1 trimethoprim Tier 1 vancomycin caps Tier 1 VANCOCIN Tier 3
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PA mebendazole EMVERM Tier 2 miltefosine IMPAVIDO Tier 2 QL rifaximin XIFAXAN Tier 2 vancomycin oral soln FIRVANQ Tier 2 nifurtimox LAMPIT Tier 3 secnidazole SOLOSEC Tier 3 QL tedizolid SIVEXTRO Tier 3 telavancin VIBATIV Tier 3
ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org
ALKYLATING AGENTS busulfan Tier 1 BUSULFEX Tier 2 ifosfamide/mesna Tier 1 carmustine Tier 4 BICNU Tier 5 cyclophosphamide caps Tier 4 CYCLOPHOSPHAMIDE Tier 4 CAPSULES cyclophosphamide inj Tier 4 dacarbazine Tier 4 melphalan inj Tier 4 ALKERAN inj Tier 5 melphalan tabs Tier 4 ALKERAN tabs Tier 5 PA, * temozolomide caps Tier 4 TEMODAR caps Tier 5 thiotepa Tier 4 TEPADINA Tier 5 busulfan MYLERAN Tier 2 chlorambucil LEUKERAN Tier 2 lomustine GLEOSTINE Tier 2 PA mechlorethamine gel VALCHLOR Tier 4 streptozocin ZANOSAR Tier 4 PA trabectedin YONDELIS Tier 4 PA bendamustine BELRAPZO Tier 5 PA bendamustine TREANDA Tier 5 PA lurbinectedin ZEPZELCA Tier 5 temozolomide inj TEMODAR inj Tier 5
* Brand TEMODAR caps requires prior approval
ANTIMETABOLITES mercaptopurine Tier 1 PA, * capecitabine Tier 4 XELODA Tier 5 cladribine Tier 4 clofarabine Tier 4 CLOLAR Tier 5 cytarabine Tier 4 floxuridine Tier 4 fludarabine Tier 4 fluorouracil inj Tier 4 gemcitabine inj Tier 4 GEMCITABINE Tier 4 thioguanine TABLOID Tier 2 pemetrexed ALIMTA Tier 4 pentostatin NIPENT Tier 4 pralatrexate FOLOTYN Tier 4 rasburicase ELITEK Tier 4 PA azacitidine ONUREG Tier 5
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mercaptopurine susp PURIXAN Tier 5
* Brand XELODA requires prior approval
HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide Tier 1 CASODEX Tier 3 flutamide Tier 1 PA nilutamide Tier 1 NILANDRON Tier 3 PA abiraterone Tier 4 ZYTIGA Tier 5 PA enzalutamide XTANDI Tier 4 PA abiraterone YONSA Tier 5 PA apalutamide ERLEADA Tier 5 PA darolutamide NUBEQA Tier 5
Antiestrogens tamoxifen Tier 1 toremifene Tier 1 FARESTON Tier 3 PA, * fulvestrant Tier 4 FASLODEX Tier 5
*Brand FASLODEX requires prior approval
Aromatase Inhibitors anastrozole Tier 1 ARIMIDEX Tier 3 exemestane Tier 1 AROMASIN Tier 3 letrozole Tier 1 FEMARA Tier 3
Gonadotropin-Releasing Hormone (GnRH) Antagonists PA degarelix acetate FIRMAGON Tier 4 PA relugolix ORGOVYX Tier 5
Luteinizing Hormone-Releasing Hormone (LHRH) Agonists PA leuprolide acetate Tier 4 PA goserelin acetate ZOLADEX Tier 4 PA histrelin acetate VANTAS Tier 4 PA leuprolide acetate ELIGARD Tier 4 PA leuprolide acetate LUPRON DEPOT Tier 4 PA triptorelin pamoate TRELSTAR Tier 4 PA triptorelin pamoate TRELSTAR DEPOT Tier 4 PA triptorelin pamoate TRELSTAR LA Tier 4 PA leuprolide acetate FENSOLVI Tier 5
Progestins megestrol acetate Tier 1
IMMUNOMODULATORS PA pembrolizumab KEYTRUDA Tier 4 PA pomalidomide POMALYST Tier 5
KINASE INHIBITORS PA erlotinib Tier 4 PA everolimus 2.5 mg, 5 mg, 7.5 mg Tier 4 AFINITOR 2.5 mg, 5 mg, 7.5 mg Tier 5 PA imatinib mesylate Tier 4 GLEEVEC Tier 5 PA lapatinib Tier 4 TYKERB Tier 5 temsirolimus Tier 4 TORISEL Tier 5 PA abemaciclib VERZENIO Tier 4
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PA acalabrutinib CALQUENCE Tier 4 PA afatinib GILOTRIF Tier 4 PA alpelisib PIQRAY Tier 4 PA axitinib INLYTA Tier 4 PA bosutinib BOSULIF Tier 4 PA cabozantinib CABOMETYX Tier 4 PA cabozantinib COMETRIQ Tier 4 PA ceritinib ZYKADIA Tier 4 PA cobimetinib COTELLIC Tier 4 PA crizotinib XALKORI Tier 4 PA dabrafenib TAFINLAR Tier 4 PA dasatinib SPRYCEL Tier 4 PA entrectinib ROZLYTREK Tier 4 PA erdafitinib BALVERSA Tier 4 PA everolimus 10 mg AFINITOR 10 mg Tier 4 PA everolimus tabs for oral suspension AFINITOR DISPERZ Tier 4 PA ibrutinib IMBRUVICA Tier 4 PA idelalisib ZYDELIG Tier 4 PA larotrectinib VITRAKVI Tier 4 PA lenvatinib LENVIMA Tier 4 PA midostaurin RYDAPT Tier 4 PA palbociclib IBRANCE Tier 4 PA pazopanib VOTRIENT Tier 4 PA pexidartinib TURALIO Tier 4 PA ponatinib ICLUSIG Tier 4 PA regorafenib STIVARGA Tier 4 PA ribociclib KISQALI Tier 4 PA ribociclib + letrozole KISQALI FEMARA CO-PACK Tier 4 PA ruxolitinib JAKAFI Tier 4 PA selpercatinib RETEVMO Tier 4 PA selumetinib KOSELUGO Tier 4 PA sorafenib NEXAVAR Tier 4 PA sunitinib SUTENT Tier 4 PA trametinib MEKINIST Tier 4 PA vandetanib CAPRELSA Tier 4 PA vemurafenib ZELBORAF Tier 4 PA alectinib ALECENSA Tier 5 PA avapritinib AYVAKIT Tier 5 PA binimetinib MEKTOVI Tier 5 PA brigatinib ALUNBRIG Tier 5 PA capmatinib TABRECTA Tier 5 PA dacomitinib VIZIMPRO Tier 5 PA duvelisib COPIKTRA Tier 5 PA encorafenib BRAFTOVI Tier 5 PA fedratinib INREBIC Tier 5 PA gefitinib IRESSA Tier 5 PA gilteritinib XOSPATA Tier 5 PA lorlatinib LORBRENA Tier 5 PA neratinib NERLYNX Tier 5 PA nilotinib TASIGNA Tier 5 PA osimertinib TAGRISSO Tier 5 PA pemigatinib PEMAZYRE Tier 5 PA pralsetinib GAVRETO Tier 5 PA ripretinib QINLOCK Tier 5 PA tazemetostat TAZVERIK Tier 5 PA tucatinib TUKYSA Tier 5
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PA zanubrutinib BRUKINSA Tier 5
MULTIPLE MYELOMA Immunomodulators PA lenalidomide REVLIMID Tier 4 thalidomide THALOMID Tier 4 PA isatuximab-irfc SARCLISA Tier 5
Proteasome Inhibitors PA ixazomib NINLARO Tier 4 PA bortezomib VELCADE Tier 5
TOPOISOMERASE INHIBITORS topotecan inj Tier 4 HYCAMTIN inj Tier 5 topotecan HYCAMTIN Tier 4 PA irinotecan liposome inj ONIVYDE Tier 5
MISCELLANEOUS hydroxyurea Tier 1 HYDREA Tier 3 leucovorin calcium Tier 1 amifostine Tier 4 ETHYOL Tier 5 arsenic trioxide Tier 4 TRISENOX Tier 5 azacitidine Tier 4 VIDAZA Tier 5 PA bexarotene caps Tier 4 TARGRETIN caps Tier 5 bleomycin sulfate Tier 4 carboplatin Tier 4 cisplatin Tier 4 dactinomycin Tier 4 COSMEGEN Tier 5 daunorubicin Tier 4 decitabine Tier 4 DACOGEN Tier 5 dexrazoxane Tier 4 dexrazoxane Tier 4 TOTECT Tier 5 docetaxel Tier 4 doxorubicin Tier 4 doxorubicin liposomal Tier 4 DOXIL Tier 5 epirubicin Tier 4 epirubicin Tier 4 ELLENCE Tier 5 etoposide Tier 4 idarubicin Tier 4 IDAMYCIN PFS Tier 5 ifosfamide Tier 4 IFEX Tier 5 irinotecan Tier 4 CAMPTOSAR Tier 5 levoleucovorin calcium Tier 4 mesna inj Tier 4 MESNEX inj Tier 5 mitomycin Tier 4 mitoxantrone Tier 4 oxaliplatin Tier 4 paclitaxel Tier 4 PA romidepsin Tier 4 ISTODAX Tier 5 teniposide Tier 4 valrubicin Tier 4 VALSTAR Tier 5 vinblastine Tier 4 vincristine Tier 4 vinorelbine Tier 4 NAVELBINE Tier 5 PA mitotane LYSODREN Tier 2 PA ado-trastuzumab emtansine KADCYLA Tier 4 aldesleukin PROLEUKIN Tier 4
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asparaginase ELSPAR Tier 4 PA asparaginase Erwinia chrysanthemi ERWINAZE Tier 4 PA atezolizumab TECENTRIQ Tier 4 BCG live vaccine TICE BCG Tier 4 PA belinostat BELEODAQ Tier 4 PA bendamustine BENDEKA Tier 4 PA bevacizumab-awwb MVASI Tier 4 PA bevacizumab-bvzr ZIRABEV Tier 4 PA bexarotene gel TARGRETIN gel Tier 4 PA blinatumomab BLINCYTO Tier 4 PA brentuximab vedotin ADCETRIS Tier 4 PA cabazitaxel JEVTANA Tier 4 PA cetuximab ERBITUX Tier 4 PA daratumumab DARZALEX Tier 4 PA decitabine-cedazuridine INQOVI Tier 4 doxorubicin ADRIAMYCIN Tier 4 PA elotuzumab EMPLICITI Tier 4 PA eribulin HALAVEN Tier 4 etoposide phosphate ETOPOPHOS Tier 4 glucarpidase VORAXAZE Tier 4 PA ipilimumab YERVOY Tier 4 ixabepilone IXEMPRA Tier 4 mesna tabs 400 mg MESNEX Tier 4 PA necitumumab PORTRAZZA Tier 4 nelarabine ARRANON Tier 4 PA niraparib ZEJULA Tier 4 PA nivolumab OPDIVO Tier 4 PA obinutuzumab GAZYVA Tier 4 PA ofatumumab ARZERRA Tier 4 PA olaparib LYNPARZA Tier 4 PA omacetaxine mepesuccinate SYNRIBO Tier 4 paclitaxel protein-bound particles ABRAXANE Tier 4 PA panitumumab VECTIBIX Tier 4 PA pegaspargase ONCASPAR Tier 4 PA pertuzumab PERJETA Tier 4 PA pertuzumab/trastuzumab/hyaluronidase-zzxf PHESGO Tier 4 procarbazine MATULANE Tier 4 PA rituximab-abbs TRUXIMA Tier 4 PA rituximab-arrx RIABNI Tier 4 PA rituximab-pvvr RUXIENCE Tier 4 PA rucaparib RUBRACA Tier 4 PA talazoparib TALZENNA Tier 4 PA talimogene laherparepvec IMLYGIC Tier 4 PA trastuzumab-anns KANJINTI Tier 4 PA trastuzumab-dkst OGIVRI Tier 4 PA trastuzumab-dttb ONTRUZANT Tier 4 PA trastuzumab-pkrb HERZUMA Tier 4 PA trastuzumab-qyyp TRAZIMERA Tier 4 PA venetoclax VENCLEXTA Tier 4 PA vincristine sulfate liposomal MARQIBO Tier 4 PA vismodegib ERIVEDGE Tier 4 PA vorinostat ZOLINZA Tier 4 PA ziv-aflibercept ZALTRAP Tier 4 PA avelumab BAVENCIO Tier 5 PA belantamab mafodotin-blmf BLENREP Tier 5 PA bevacizumab AVASTIN Tier 5
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PA calaspargase pegol-mknl ASPARLAS Tier 5 PA carfilzomib KYPROLIS Tier 5 PA daratumumab/hyaluronidase-fihj DARZALEX FASPRO Tier 5 PA durvalumab IMFINZI Tier 5 PA enasidenib IDHIFA Tier 5 PA enfortumab vedotin-ejfv PADCEV Tier 5 PA fam-trastuzumab deruxtecan-nxki ENHERTU Tier 5 PA gemtuzumab ozogamicin MYLOTARG Tier 5 PA glasdegib DAURISMO Tier 5 PA hydroxyurea SIKLOS Tier 5 PA inotuzumab ozogamicin BESPONSA Tier 5 PA ivosidenib TIBSOVO Tier 5 levoleucovorin KHAPZORY Tier 5 PA melphalan EVOMELA Tier 5 PA mogamulizumab-kpkc POTELIGEO Tier 5 PA moxetumomab pasudotox-tdfk LUMOXITI Tier 5 PA panobinostat FARYDAK Tier 5 PA polatuzumab vedotin-piiq POLIVY Tier 5 PA ramucirumab CYRAMZA Tier 5 PA rituximab RITUXAN Tier 5 PA rituximab/hyaluronidase human RITUXAN HYCELA Tier 5 PA sacituzumab govitecan-hziy TRODELVY Tier 5 PA selinexor XPOVIO Tier 5 PA sonidegib ODOMZO Tier 5 PA trastuzumab HERCEPTIN Tier 5 PA trastuzumab/hyaluronidase-oysk HERCEPTIN HYLECTA Tier 5 PA trifluridine/tipiracil LONSURF Tier 5
CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497
Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org
ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org
benazepril Tier 1 LOTENSIN Tier 3 enalapril Tier 1 VASOTEC Tier 3 fosinopril Tier 1 lisinopril Tier 1 PRINIVIL Tier 3 lisinopril Tier 1 ZESTRIL Tier 3 perindopril Tier 1 quinapril Tier 1 ACCUPRIL Tier 3 ramipril Tier 1 ALTACE Tier 3 trandolapril Tier 1 enalapril oral soln EPANED Tier 3 lisinopril oral soln QBRELIS Tier 3
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ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS benazepril/amlodipine Tier 1 LOTREL Tier 3 trandolapril/verapamil ext-rel Tier 1 TARKA Tier 3 perindopril arginine/amlodipine PRESTALIA Tier 3
ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide Tier 1 LOTENSIN HCT Tier 3 captopril/hydrochlorothiazide Tier 1 enalapril/hydrochlorothiazide Tier 1 VASERETIC Tier 3 fosinopril/hydrochlorothiazide Tier 1 lisinopril/hydrochlorothiazide Tier 1 ZESTORETIC Tier 3 quinapril/hydrochlorothiazide Tier 1 ACCURETIC Tier 3
ADRENOLYTICS, CENTRAL clonidine Tier 1 CATAPRES Tier 3 clonidine transdermal Tier 1 CATAPRES-TTS Tier 3
ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone Tier 1 INSPRA Tier 3 spironolactone Tier 1 ALDACTONE Tier 3
ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497
doxazosin Tier 1 CARDURA Tier 3 prazosin Tier 1 MINIPRESS Tier 3 terazosin Tier 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org
candesartan Tier 1 ATACAND Tier 3 candesartan/hydrochlorothiazide Tier 1 ATACAND HCT Tier 3 irbesartan Tier 1 AVAPRO Tier 3 irbesartan/hydrochlorothiazide Tier 1 AVALIDE Tier 3 losartan Tier 1 COZAAR Tier 3 losartan/hydrochlorothiazide Tier 1 HYZAAR Tier 3 olmesartan Tier 1 BENICAR Tier 3 olmesartan/hydrochlorothiazide Tier 1 BENICAR HCT Tier 3 telmisartan Tier 1 MICARDIS Tier 3 telmisartan/hydrochlorothiazide Tier 1 MICARDIS HCT Tier 3 valsartan Tier 1 DIOVAN Tier 3 valsartan/hydrochlorothiazide Tier 1 DIOVAN HCT Tier 3 azilsartan EDARBI Tier 3 azilsartan/chlorthalidone EDARBYCLOR Tier 3
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/olmesartan Tier 1 AZOR Tier 3 amlodipine/telmisartan Tier 1 TWYNSTA Tier 3 amlodipine/valsartan Tier 1 EXFORGE Tier 3
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide Tier 1 EXFORGE HCT Tier 3
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olmesartan/amlodipine/hydrochlorothiazide Tier 1 TRIBENZOR Tier 3
ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org
amiodarone Tier 1 disopyramide Tier 1 NORPACE Tier 3 flecainide Tier 1 mexiletine Tier 1 propafenone ext-rel Tier 1 RYTHMOL SR Tier 3 quinidine gluconate ext-rel Tier 1 sotalol Tier 1 sotalol AF Tier 1 PA, * dofetilide Tier 4 TIKOSYN Tier 5 disopyramide ext-rel NORPACE CR Tier 2 dronedarone MULTAQ Tier 2
* Brand TIKOSYN requires prior approval
ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625 ACL Inhibitor/Combinations PA bempedoic acid NEXLETOL Tier 3 PA bempedoic acid/ezetimibe NEXLIZET Tier 3
Bile Acid Resins cholestyramine pkt Tier 1 QUESTRAN/QUESTRAN LIGHT Tier 3 colesevelam Tier 1 WELCHOL Tier 3 colestipol Tier 1 COLESTID Tier 3
Cholesterol Absorption Inhibitors ezetimibe Tier 1 ZETIA Tier 3
Fibrates fenofibrate Tier 1 LIPOFEN Tier 3 fenofibrate Tier 1 TRICOR Tier 3 fenofibric acid delayed-rel Tier 1 TRILIPIX Tier 3 gemfibrozil Tier 1 LOPID Tier 3 fenofibrate ANTARA Tier 3
HMG-CoA Reductase Inhibitors/Combinations ‡, * atorvastatin Tier 1 LIPITOR Tier 3 ezetimibe/simvastatin Tier 1 VYTORIN Tier 3 ‡, * fluvastatin Tier 1 ‡, * fluvastatin ext-rel Tier 1 LESCOL XL Tier 3 ‡, * lovastatin Tier 1 ‡, * pravastatin Tier 1 PRAVACHOL Tier 3 ‡, * rosuvastatin Tier 1 CRESTOR Tier 3 ‡, * simvastatin Tier 1 ZOCOR Tier 3 pitavastatin LIVALO Tier 3 rosuvastatin capsules EZALLOR SPRINKLE Tier 3
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* Generic cholesterol-lowering statin drugs are covered at no charge to the member at a preferred retail pharmacy or for Standard Option members and for Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program.
Microsomal Triglyceride Transfer Protein Inhibitors PA lomitapide JUXTAPID Tier 4
Niacins niacin ext-rel Tier 1 NIASPAN Tier 3
Omega-3 Fatty Acids icosapent ethyl caps 1 gm Tier 1 VASCEPA Tier 2 omega-3 acid ethyl esters Tier 1 LOVAZA Tier 3
PCSK9 Inhibitors PA evolocumab REPATHA Tier 4 PA alirocumab PRALUENT Tier 5
BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org
acebutolol Tier 1 atenolol Tier 1 TENORMIN Tier 3 carvedilol Tier 1 COREG Tier 3 carvedilol phosphate ext-rel Tier 1 COREG CR Tier 3 esmolol Tier 1 BREVIBLOC Tier 3 metoprolol succinate ext-rel Tier 1 TOPROL-XL Tier 3 metoprolol tartrate Tier 1 LOPRESSOR Tier 3 pindolol Tier 1 propranolol Tier 1 propranolol ext-rel Tier 1 INDERAL LA Tier 3 nebivolol BYSTOLIC Tier 2 metoprolol succinate ext-rel KAPSPARGO Tier 3 penbutolol LEVATOL Tier 3 propranolol ext-rel INNOPRAN XL Tier 3
BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org
atenolol/chlorthalidone Tier 1 bisoprolol/hydrochlorothiazide Tier 1 ZIAC Tier 3 metoprolol/hydrochlorothiazide Tier 1
CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine tabs Tier 1 NORVASC Tier 3 felodipine ext-rel Tier 1 nicardipine Tier 1 nifedipine ext-rel Tier 1 nifedipine ext-rel Tier 1 PROCARDIA XL Tier 3 nimodipine Tier 1 NIMOTOP Tier 3 nisoldipine ext-rel Tier 1 SULAR Tier 3 levamlodipine maleate CONJUPRI Tier 3
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Nondihydropyridines diltiazem Tier 1 CARDIZEM Tier 3 diltiazem ext-rel Tier 1 CARDIZEM CD Tier 3 diltiazem ext-rel Tier 1 TIAZAC Tier 3 verapamil Tier 1 verapamil ext-rel Tier 1 CALAN SR Tier 3
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin Tier 1 CADUET Tier 3
DIGITALIS GLYCOSIDES digoxin Tier 1 LANOXIN Tier 2
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS aliskiren Tier 1 TEKTURNA Tier 3 aliskiren/hydrochlorothiazide TEKTURNA HCT Tier 2
DIURETICS Carbonic Anhydrase Inhibitors acetazolamide Tier 1 acetazolamide ext-rel Tier 1 methazolamide Tier 1 PA dichlorphenamide KEVEYIS Tier 3
Loop Diuretics bumetanide Tier 1 ethacrynic acid Tier 1 EDECRIN Tier 3 furosemide Tier 1 LASIX Tier 3 torsemide Tier 1
Potassium-sparing Diuretics amiloride Tier 1
Thiazides and Thiazide-like Diuretics chlorthalidone Tier 1 hydrochlorothiazide Tier 1 indapamide Tier 1 metolazone Tier 1
Diuretic Combinations amiloride/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 1 ALDACTAZIDE Tier 3 triamterene/hydrochlorothiazide Tier 1 DYAZIDE Tier 3 triamterene/hydrochlorothiazide Tier 1 MAXZIDE Tier 3 triamterene/hydrochlorothiazide 37.5/25 Tier 1 MAXZIDE-25 Tier 3 triamterene/hydrochlorothiazide 50/25 Tier 1
HEART FAILURE isosorbide dinitrate/hydralazine BIDIL Tier 2 PA ivabradine CORLANOR Tier 3 PA sacubitril/valsartan ENTRESTO Tier 3 PA tafamidis VYNDAMAX Tier 4 PA tafamidis meglumine VYNDAQEL Tier 4
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NITRATES Oral isosorbide dinitrate oral Tier 1 ISORDIL Tier 3 isosorbide mononitrate Tier 1 isosorbide mononitrate ext-rel Tier 1
Sublingual/Translingual nitroglycerin lingual spray Tier 1 NITROLINGUAL Tier 3 nitroglycerin sublingual Tier 1 NITROSTAT Tier 3 nitroglycerin sublingual aerosol NITROMIST Tier 3 nitroglycerin sublingual powder GONITRO Tier 3
Transdermal nitroglycerin transdermal Tier 1 nitroglycerin transdermal Tier 1 NITRO-DUR Tier 3 nitroglycerin ointment NITRO-BID Tier 3
PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA ambrisentan Tier 4 LETAIRIS Tier 5 PA bosentan Tier 4 TRACLEER Tier 5 PA macitentan OPSUMIT Tier 4
Phosphodiesterase Inhibitors PA sildenafil Tier 4 REVATIO Tier 5 PA tadalafil tabs 20 mg Tier 4 ADCIRCA Tier 5 PA tadalafil tabs 20 mg - Alyq Tier 4
Prostacyclin Receptor Agonists PA selexipag UPTRAVI Tier 5
Prostaglandin Vasodilators PA epoprostenol Tier 4 VELETRI Tier 5 PA epoprostenol sodium Tier 4 FLOLAN Tier 5 PA treprostinil Tier 4 REMODULIN Tier 5 PA iloprost VENTAVIS Tier 4 PA treprostinil ext-rel ORENITRAM Tier 4 PA treprostinil TYVASO Tier 5
Soluble Guanylate Cyclase Stimulators PA riociguat ADEMPAS Tier 5
MISCELLANEOUS hydralazine Tier 1 midodrine Tier 1 minoxidil tabs Tier 1 ranolazine ext-rel Tier 1 RANEXA Tier 3 PA droxidopa Tier 4 NORTHERA Tier 5 mecamylamine VECAMYL Tier 3
CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org
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ANTIANXIETY Benzodiazepines alprazolam Tier 1 XANAX Tier 3 alprazolam ext-rel Tier 1 XANAX XR Tier 3 chlordiazepoxide Tier 1 clonazepam Tier 1 KLONOPIN Tier 3 clorazepate Tier 1 TRANXENE T-TAB Tier 3 diazepam Tier 1 VALIUM Tier 3 lorazepam Tier 1 ATIVAN Tier 3 oxazepam Tier 1
Miscellaneous buspirone Tier 1 clomipramine Tier 1 ANAFRANIL Tier 3 fluvoxamine Tier 1 fluvoxamine ext-rel Tier 1 hydroxyzine HCl Tier 1 hydroxyzine pamoate Tier 1 VISTARIL Tier 3
ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com
carbamazepine Tier 1 TEGRETOL Tier 3 carbamazepine ext-rel Tier 1 CARBATROL Tier 3 carbamazepine ext-rel Tier 1 TEGRETOL-XR Tier 3 clobazam Tier 1 ONFI Tier 3 diazepam rectal gel Tier 1 DIASTAT Tier 3 divalproex sodium delayed-rel Tier 1 DEPAKOTE Tier 3 divalproex sodium ext-rel Tier 1 DEPAKOTE ER Tier 3 divalproex sodium sprinkle caps Tier 1 DEPAKOTE SPRINKLE Tier 3 ethosuximide Tier 1 ZARONTIN Tier 3 felbamate Tier 1 FELBATOL Tier 3 QL gabapentin Tier 1 NEURONTIN Tier 3 lamotrigine Tier 1 LAMICTAL Tier 3 lamotrigine ext-rel Tier 1 LAMICTAL XR Tier 3 lamotrigine orally disintegrating tabs Tier 1 LAMICTAL ODT Tier 3 levetiracetam Tier 1 KEPPRA Tier 3 levetiracetam ext-rel Tier 1 KEPPRA XR Tier 3 oxcarbazepine Tier 1 TRILEPTAL Tier 3 phenobarbital Tier 1 phenytoin Tier 1 DILANTIN INFATABS Tier 3 phenytoin sodium extended Tier 1 DILANTIN Tier 3 primidone Tier 1 MYSOLINE Tier 3 rufinamide Tier 1 BANZEL Tier 3 tiagabine Tier 1 GABITRIL Tier 3 topiramate Tier 1 TOPAMAX Tier 3 topiramate ext-rel Tier 1 QUDEXY XR Tier 3 valproic acid Tier 1 zonisamide Tier 1 ZONEGRAN Tier 3 PA vigabatrin Tier 4 SABRIL Tier 5 PA vigabatrin powder - Vigadrone Tier 4 lacosamide VIMPAT Tier 2 brivaracetam BRIVIACT Tier 3 PA cenobamate XCOPRI Tier 3 PA diazepam nasal spray VALTOCO Tier 3
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eslicarbazepine APTIOM Tier 3 PA midazolam nasal spray NAYZILAM Tier 3 oxcarbazepine ext-rel OXTELLAR XR Tier 3 perampanel FYCOMPA Tier 3 topiramate ext-rel TROKENDI XR Tier 3 PA cannabidiol EPIDIOLEX Tier 5 PA fenfluramine FINTEPLA Tier 5 PA stiripentol DIACOMIT Tier 5
ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com
donepezil Tier 1 ARICEPT Tier 3 donepezil orally disintegrating tabs Tier 1 galantamine Tier 1 galantamine ext-rel Tier 1 RAZADYNE ER Tier 3 memantine soln Tier 1 memantine tabs Tier 1 NAMENDA tabs Tier 3 rivastigmine Tier 1 rivastigmine transdermal Tier 1 EXELON PATCH Tier 3
ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder.
Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org
Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 1 NARDIL Tier 3 tranylcypromine Tier 1 PARNATE Tier 3 isocarboxazid MARPLAN Tier 3 selegiline transdermal EMSAM Tier 3
Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram Tier 1 CELEXA Tier 3 escitalopram Tier 1 LEXAPRO Tier 3 fluoxetine Tier 1 fluoxetine Tier 1 PROZAC Tier 3 fluoxetine delayed-rel Tier 1 paroxetine HCl Tier 1 PAXIL Tier 3 paroxetine HCl ext-rel Tier 1 PAXIL CR Tier 3 sertraline Tier 1 ZOLOFT Tier 3 duloxetine delayed-release sprinkle capsule DRIZALMA SPRINKLE Tier 3 paroxetine mesylate PEXEVA Tier 3 vilazodone VIIBRYD Tier 3 vortioxetine TRINTELLIX Tier 3
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine ext-rel Tier 1 PRISTIQ Tier 3 duloxetine delayed-rel Tier 1 CYMBALTA Tier 3 venlafaxine Tier 1 venlafaxine ext-rel Tier 1 EFFEXOR XR Tier 3 venlafaxine ext-rel tabs Tier 1 levomilnacipran ext-rel FETZIMA Tier 3
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Tricyclic Antidepressants (TCAs) amitriptyline Tier 1 desipramine Tier 1 NORPRAMIN Tier 3 doxepin Tier 1 imipramine HCl Tier 1 imipramine pamoate Tier 1 nortriptyline Tier 1 PAMELOR Tier 3 protriptyline Tier 1
Miscellaneous Agents amitriptyline/perphenazine Tier 1 bupropion Tier 1 bupropion ext-rel Tier 1 FORFIVO XL Tier 3 bupropion ext-rel Tier 1 WELLBUTRIN SR Tier 3 bupropion ext-rel Tier 1 WELLBUTRIN XL Tier 3 mirtazapine Tier 1 REMERON Tier 3 nefazodone Tier 1 trazodone Tier 1 bupropion ext-rel APLENZIN Tier 3 PA esketamine nasal solution SPRAVATO Tier 3
ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com
amantadine, except tabs Tier 1 benztropine Tier 1 bromocriptine Tier 1 PARLODEL Tier 3 carbidopa/levodopa Tier 1 SINEMET Tier 3 carbidopa/levodopa ext-rel Tier 1 carbidopa/levodopa orally disintegrating tabs Tier 1 carbidopa/levodopa/entacapone Tier 1 STALEVO Tier 3 diphenhydramine Tier 1 entacapone Tier 1 COMTAN Tier 3 pramipexole Tier 1 MIRAPEX Tier 3 pramipexole ext-rel Tier 1 MIRAPEX ER Tier 3 rasagiline Tier 1 AZILECT Tier 3 ropinirole Tier 1 ropinirole ext-rel Tier 1 selegiline caps Tier 1 tolcapone Tier 1 trihexyphenidyl Tier 1 rotigotine transdermal NEUPRO Tier 2 selegiline orally disintegrating tabs ZELAPAR Tier 2 PA amantadine ext-rel GOCOVRI Tier 3 PA amantadine ext-rel OSMOLEX ER Tier 3 PA apomorphine KYNMOBI Tier 3 carbidopa/levodopa enteral susp DUOPA Tier 3 carbidopa/levodopa ext-rel RYTARY Tier 3 opicapone ONGENTYS Tier 3 safinamide XADAGO Tier 3 PA apomorphine APOKYN Tier 4 PA istradefylline NOURIANZ Tier 5 PA levodopa inhalation powder INBRIJA Tier 5
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ANTIPSYCHOTICS Atypicals aripiprazole Tier 1 ABILIFY Tier 3 aripiprazole orally disintegrating tabs Tier 1 asenapine Tier 1 SAPHRIS Tier 3 clozapine Tier 1 CLOZARIL Tier 3 clozapine orally disintegrating tabs Tier 1 olanzapine Tier 1 ZYPREXA/ZYPREXA ZYDIS Tier 3 olanzapine/fluoxetine Tier 1 paliperidone ext-rel Tier 1 INVEGA Tier 3 quetiapine Tier 1 SEROQUEL Tier 3 quetiapine ext-rel Tier 1 SEROQUEL XR Tier 3 risperidone Tier 1 RISPERDAL Tier 3 risperidone orally disintegrating tabs Tier 1 RISPERDAL M-TABS Tier 3 ziprasidone Tier 1 GEODON Tier 3 paliperidone palmitate ext-rel inj INVEGA SUSTENNA Tier 2 risperidone long-acting inj RISPERDAL CONSTA Tier 2 aripiprazole ext-rel inj ABILIFY MAINTENA Tier 3 aripiprazole lauroxil ext-rel inj ARISTADA Tier 3 PA aripiprazole tab with sensor ABILIFY MYCITE Tier 3 brexpiprazole REXULTI Tier 3 cariprazine VRAYLAR Tier 3 iloperidone FANAPT Tier 3 lumateperone CAPLYTA Tier 3 lurasidone LATUDA Tier 3 PA olanzapine pamoate ext-rel inj ZYPREXA RELPREVV Tier 3 paliperidone palmitate ext-rel inj INVEGA TRINZA Tier 3 risperidone ext-rel inj PERSERIS Tier 3
Miscellaneous fluphenazine Tier 1 haloperidol Tier 1 haloperidol decanoate inj Tier 1 HALDOL DECANOATE 100 Tier 3 haloperidol lactate inj Tier 1 HALDOL Tier 3 loxapine Tier 1 perphenazine Tier 1 thioridazine Tier 1 thiothixene Tier 1 trifluoperazine Tier 1 PA pimavanserin NUPLAZID Tier 5
ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org
PA amphetamine ext-rel susp Tier 1 ADZENYS ER SUSP Tier 3 PA amphetamine sulfate Tier 1 EVEKEO Tier 3 PA amphetamine/dextroamphetamine mixed salts Tier 1 ADDERALL Tier 3 PA amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 ADDERALL XR Tier 3 atomoxetine Tier 1 STRATTERA Tier 3 clonidine ext-rel Tier 1 KAPVAY Tier 3 PA dexmethylphenidate Tier 1 FOCALIN Tier 3 PA dexmethylphenidate ext-rel Tier 1 FOCALIN XR Tier 3 PA dextroamphetamine Tier 1 PA dextroamphetamine Tier 1 ZENZEDI Tier 3
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PA dextroamphetamine ext-rel Tier 1 DEXEDRINE SPANSULE Tier 3 PA dextroamphetamine soln - Procentra Tier 1 guanfacine ext-rel Tier 1 INTUNIV Tier 3 PA methamphetamine Tier 1 PA methylphenidate Tier 1 METHYLIN Tier 3 PA methylphenidate Tier 1 RITALIN Tier 3 PA methylphenidate ext-rel Tier 1 CONCERTA Tier 3 PA methylphenidate ext-rel Tier 1 RITALIN LA Tier 3 PA methylphenidate ext-rel (except methylphenidate tab ER Tier 1 osmotic release 72 mg) PA methylphenidate ext-rel caps Tier 1 APTENSIO XR Tier 3 PA lisdexamfetamine VYVANSE Tier 2 PA amphetamine ext-rel orally disintegrating tabs ADZENYS XR-ODT Tier 3 PA amphetamine ext-rel suspension DYANAVEL XR Tier 3 PA amphetamine sulfate orally disintegrating tablet EVEKEO ODT Tier 3 PA amphetamine/dextroamphetamine mixed salts ext-rel MYDAYIS Tier 3 PA methylphenidate ext-rel caps ADHANSIA XR Tier 3 PA methylphenidate ext-rel chewable tabs QUILLICHEW ER Tier 3 PA methylphenidate ext-rel orally disintegrating tablets COTEMPLA XR-ODT Tier 3 PA methylphenidate ext-rel susp QUILLIVANT XR Tier 3 PA methylphenidate transdermal DAYTRANA Tier 3
FIBROMYALGIA QL pregabalin Tier 1 LYRICA Tier 3 QL milnacipran SAVELLA Tier 3
HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: https://aasm.org
Benzodiazepines QL estazolam Tier 1 QL flurazepam Tier 1 quazepam Tier 1 DORAL Tier 3 QL temazepam Tier 1 RESTORIL Tier 3
Nonbenzodiazepines QL eszopiclone Tier 1 LUNESTA Tier 3 QL ramelteon Tier 1 ROZEREM Tier 3 QL zaleplon Tier 1 QL zolpidem Tier 1 AMBIEN Tier 3 QL zolpidem ext-rel Tier 1 AMBIEN CR Tier 3 QL zolpidem sublingual Tier 1 QL lemborexant DAYVIGO Tier 3 QL suvorexant BELSOMRA Tier 3 QL zolpidem spray ZOLPIMIST Tier 3 QL zolpidem sublingual EDLUAR Tier 3 PA tasimelteon HETLIOZ Tier 4
Tricyclics doxepin Tier 1 SILENOR Tier 3
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MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com
Calcitonin Gene-Related Peptide Receptor Antagonist PA rimegepant NURTEC ODT Tier 3
Ergotamine Derivatives dihydroergotamine inj Tier 1 D.H.E. 45 Tier 3 PA dihydroergotamine spray Tier 1 MIGRANAL Tier 3 ergotamine/caffeine supp Tier 1 MIGERGOT Tier 1 ergotamine/caffeine tabs Tier 1 CAFERGOT Tier 3
Monoclonal Antibodies PA erenumab-aooe AIMOVIG Tier 2 PA galcanezumab-gnlm 100 mg/mL EMGALITY 100 mg/mL Tier 2 PA galcanezumab-gnlm 120 mg/mL EMGALITY 120 mg/mL Tier 2 PA eptinezumab-jjmr VYEPTI Tier 5
Selective Serotonin Agonists QL almotriptan Tier 1 QL eletriptan Tier 1 RELPAX Tier 3 QL frovatriptan Tier 1 FROVA Tier 3 QL naratriptan Tier 1 AMERGE Tier 3 QL rizatriptan Tier 1 MAXALT/MAXALT-MLT Tier 3 QL sumatriptan Tier 1 IMITREX Tier 3 QL zolmitriptan Tier 1 ZOMIG/ZOMIG-ZMT Tier 3 QL zolmitriptan nasal spray Tier 1 ZOMIG Tier 3 QL sumatriptan nasal powder ONZETRA XSAIL Tier 3 QL sumatriptan nasal spray TOSYMRA Tier 3
Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations QL sumatriptan/naproxen sodium TREXIMET Tier 3
MOOD STABILIZERS lithium carbonate Tier 1 lithium carbonate ext-rel tabs 300 mg Tier 1 LITHOBID Tier 3 lithium carbonate ext-rel tabs 450 mg Tier 1 carbamazepine EQUETRO Tier 3
MOVEMENT DISORDERS PA tetrabenazine Tier 4 XENAZINE Tier 5 PA deutetrabenazine AUSTEDO Tier 5
MULTIPLE SCLEROSIS Practice guidelines for multiple sclerosis are available at: https://www.aan.com
PA dalfampridine ext-rel Tier 4 PA dimethyl fumarate delayed-rel Tier 4 TECFIDERA Tier 5 PA glatiramer Tier 4 COPAXONE Tier 5 PA glatiramer - Glatopa Tier 4 PA fingolimod GILENYA Tier 4 PA interferon beta-1a AVONEX Tier 4 PA interferon beta-1a REBIF Tier 4 PA interferon beta-1a REBIF REBIDOSE Tier 4
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PA interferon beta-1b BETASERON Tier 4 PA natalizumab TYSABRI Tier 4 PA ocrelizumab OCREVUS Tier 4 PA ozanimod ZEPOSIA Tier 4 PA peginterferon beta-1a PLEGRIDY Tier 4 PA peginterferon beta-1a PLEGRIDY PEN Tier 4 PA siponimod MAYZENT Tier 4 PA teriflunomide AUBAGIO Tier 4 PA alemtuzumab LEMTRADA Tier 5 PA cladribine MAVENCLAD Tier 5 PA diroximel fumarate delayed-rel VUMERITY Tier 5 PA interferon beta-1b EXTAVIA Tier 5 PA monomethyl fumarate BAFIERTAM Tier 5 PA ofatumumab KESIMPTA Tier 5
MUSCULOSKELETAL THERAPY AGENTS baclofen Tier 1 baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL) Tier 1 LIORESAL INTRATHECAL Tier 2 cyclobenzaprine Tier 1 dantrolene Tier 1 DANTRIUM Tier 3
MYASTHENIA GRAVIS pyridostigmine Tier 1 MESTINON Tier 3 pyridostigmine ext-rel tabs 180 mg Tier 1 MESTINON TIMESPAN Tier 3
NARCOLEPSY/CATAPLEXY PA armodafinil Tier 1 NUVIGIL Tier 3 PA modafinil Tier 1 PROVIGIL Tier 3 PA sodium oxybate XYREM Tier 2 PA calcium, magnesium, potassium, and sodium oxybates XYWAV Tier 3 PA solriamfetol SUNOSI Tier 3 PA pitolisant WAKIX Tier 5
PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium Tier 1 disulfiram Tier 1 naltrexone Tier 1 naltrexone microspheres VIVITROL Tier 4
Opioid Antagonists PA, * naloxone auto-injector Tier 1 EVZIO Tier 3 naloxone inj Tier 1 naloxone nasal spray NARCAN Tier 1
* Brand EVZIO requires prior approval
Partial Opioid Agonists QL buprenorphine Tier 1 PA buprenorphine ext-rel inj SUBLOCADE Tier 5
Partial Opioid Agonist/Opioid Antagonist Combinations QL buprenorphine/naloxone sublingual film Tier 1 SUBOXONE FILM Tier 3 QL buprenorphine/naloxone sublingual tabs Tier 1 QL buprenorphine/naloxone sublingual tabs ZUBSOLV Tier 2
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Pseudobulbar Affect PA dextromethorphan/quinidine NUEDEXTA Tier 2
Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html
bupropion ext-rel Tier 1 varenicline CHANTIX Tier 2
MISCELLANEOUS Amyotrophic Lateral Sclerosis riluzole Tier 1 RILUTEK Tier 3 riluzole TIGLUTIK Tier 3 PA edaravone RADICAVA Tier 5
Botulinum Toxins PA abobotulinumtoxinA DYSPORT Tier 4 PA incobotulinumtoxinA XEOMIN Tier 4 PA onabotulinumtoxinA BOTOX Tier 4 PA rimabotulinumtoxinB MYOBLOC Tier 4
Duchenne Muscular Dystrophy PA deflazacort EMFLAZA Tier 5 PA eteplirsen EXONDYS 51 Tier 5 PA golodirsen VYONDYS 53 Tier 5 PA viltolarsen VILTEPSO Tier 5
Lambert-Eaton Myasthenic Syndrome PA amifampridine FIRDAPSE Tier 4 PA amifampridine RUZURGI Tier 5
Spinal Muscular Atrophy PA risdiplam EVRYSDI Tier 5
Tardive Dyskinesia PA valbenazine INGREZZA Tier 5
ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com
PA testosterone cypionate Tier 1 PA testosterone enanthate Tier 1 PA testosterone gel Tier 1 ANDROGEL Tier 3 PA testosterone gel Tier 1 FORTESTA Tier 3 PA testosterone gel Tier 1 TESTIM Tier 3 PA testosterone gel Tier 1 VOGELXO Tier 3 PA testosterone soln Tier 1 PA testosterone transdermal ANDRODERM Tier 2 PA testosterone buccal STRIANT Tier 3 PA testosterone enanthate auto-injector XYOSTED Tier 3 PA testosterone undecanoate inj AVEED Tier 4 PA testosterone pellets TESTOPEL Tier 5
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ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org
Alpha-glucosidase Inhibitors acarbose Tier 1 PRECOSE Tier 3 miglitol Tier 1
Amylin Analogs pramlintide SYMLINPEN Tier 2
Biguanides metformin Tier 1 * metformin ext-rel Tier 1 PA metformin ext-rel Tier 1 FORTAMET Tier 3 PA metformin oral soln Tier 1 RIOMET IR Tier 3
* Generic version of GLUMETZA (metformin ext-rel tabs) requires PA
Biguanide/Sulfonylurea Combinations glipizide/metformin Tier 1 glyburide/metformin Tier 1
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors alogliptin Tier 1 sitagliptin phosphate JANUVIA Tier 2
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations alogliptin/metformin Tier 1 sitagliptin/metformin JANUMET Tier 2 sitagliptin/metformin ext-rel JANUMET XR Tier 2
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations alogliptin/pioglitazone Tier 1
Incretin Mimetic Agents dulaglutide TRULICITY Tier 2 liraglutide VICTOZA Tier 2 semaglutide OZEMPIC Tier 2 exenatide BYETTA Tier 3 exenatide ext-rel BYDUREON Tier 3 exenatide ext-rel BYDUREON BCISE Tier 3 lixisenatide ADLYXIN Tier 3 semaglutide RYBELSUS Tier 3
Incretin Mimetic Agent/Insulin Combinations PA liraglutide/insulin degludec XULTOPHY Tier 3 PA lixisenatide/insulin glargine SOLIQUA Tier 3
Insulins insulin aspart FIASP Tier 2 insulin aspart FIASP FLEXTOUCH Tier 2 insulin aspart INSULIN ASPART Tier 2 insulin aspart NOVOLOG Tier 2 insulin aspart protamine 70%/insulin aspart 30% INSULIN ASPART PROTAMINE Tier 2 70%/INSULIN ASPART 30%
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insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 Tier 2 insulin degludec TRESIBA Tier 2 insulin detemir LEVEMIR Tier 2 insulin glargine BASAGLAR Tier 2 insulin glargine LANTUS Tier 2 insulin glargine TOUJEO Tier 2 OTC insulin human HUMULIN R Tier 2 insulin human HUMULIN R U-500 Tier 2 OTC insulin human NOVOLIN R Tier 2 OTC insulin isophane human HUMULIN N Tier 2 OTC insulin isophane human NOVOLIN N Tier 2 OTC insulin isophane human 70%/regular 30% HUMULIN 70/30 Tier 2 OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 Tier 2 insulin lispro HUMALOG Tier 2 insulin lispro INSULIN LISPRO Tier 2 insulin lispro protamine/insulin lispro HUMALOG MIX Tier 2 insulin lispro protamine/insulin lispro INSULIN LISPRO Tier 2 PROTAMINE/INSULIN LISPRO insulin glulisine APIDRA Tier 3 PA insulin human inhalation powder AFREZZA Tier 3 insulin lispro ADMELOG Tier 3 insulin lispro ADMELOG SOLOSTAR Tier 3 insulin lispro-aabc LYUMJEV/KWIKPEN Tier 3
Insulin Sensitizers pioglitazone Tier 1 ACTOS Tier 3 rosiglitazone AVANDIA Tier 3
Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 1 ACTOPLUS MET Tier 3 pioglitazone/metformin ext-rel ACTOPLUS MET XR Tier 3
Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride Tier 1 DUETACT Tier 3
Meglitinides nateglinide Tier 1 STARLIX Tier 3 repaglinide Tier 1
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors ST dapagliflozin FARXIGA Tier 2 ST empagliflozin JARDIANCE Tier 2 PA/ST canagliflozin INVOKANA Tier 3 PA/ST ertugliflozin STEGLATRO Tier 3
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations ST dapagliflozin/metformin ext-rel XIGDUO XR Tier 2 ST empagliflozin/metformin SYNJARDY Tier 2 ST empagliflozin/metformin ext-rel SYNJARDY XR Tier 2 PA/ST canagliflozin/metformin INVOKAMET Tier 3 PA/ST canagliflozin/metformin ext-rel INVOKAMET XR Tier 3 PA/ST ertugliflozin/metformin SEGLUROMET Tier 3
Sodium-Glucose Co-Transporter 2 Inhibitor/Dipeptidyl Peptidase-4 Inhibitor Combinations ST dapagliflozin/saxagliptin QTERN Tier 2 ST empagliflozin/linagliptin GLYXAMBI Tier 2
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PA/ST ertugliflozin/sitagliptin STEGLUJAN Tier 3
Sodium Glucose Co-Transporter 2 Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations PA/ST empagliflozin/linagliptin/metformin extended-release TRIJARDY XR Tier 3
Sulfonylureas glimepiride Tier 1 AMARYL Tier 3 glipizide Tier 1 GLUCOTROL Tier 3 glipizide ext-rel Tier 1 GLUCOTROL XL Tier 3 glyburide Tier 1 glyburide, micronized Tier 1 GLYNASE Tier 3
Supplies PA blood glucose continuous monitoring receivers, sensors, FREESTYLE LIBRE / Tier 2 transmitters FREESTYLE LIBRE 2 CONTINUOUS GLUCOSE MONITORING SYST OTC blood glucose meters and kits ACCU-CHEK METERS AND KITS Tier 2 OTC blood glucose meters and kits ONETOUCH METERS AND KITS Tier 2 OTC blood glucose test strips ACCU-CHEK TEST STRIPS Tier 2 OTC blood glucose test strips ONETOUCH TEST STRIPS Tier 2 OTC insulin pen needles NOVOFINE PEN NEEDLES Tier 2 OTC insulin syringes, needles BD INSULIN SYRINGES AND Tier 2 NEEDLES OTC lancet device ACCU-CHEK FASTCLIX LANCET Tier 2 DEVICE OTC lancet device SOFTCLIX LANCET DEVICE Tier 2 OTC lancet device SOFTTOUCH LANCET DEVICE Tier 2 OTC lancets ACCU-CHEK FASTCLIX Tier 2 LANCETS OTC lancets ONETOUCH LANCETS Tier 2 OTC lancets SOFTCLIX LANCETS Tier 2 OTC lancets SOFTTOUCH LANCETS Tier 2 OTC urine test strips CHEMSTRIP K URINE KETONE Tier 2 STRIPS OTC urine test strips CHEMSTRIP UGK URINE Tier 2 GLUCOSE/KETONE STRIPS OTC urine test strips CHEMSTRIP UG URINE Tier 2 GLUCOSE STRIPS PA blood glucose continuous monitoring receivers, sensors, DEXCOM CONTINUOUS Tier 3 transmitters GLUCOSE MONITORING SYSTEM
CALCIUM RECEPTOR ANTAGONISTS PA cinacalcet Tier 4 SENSIPAR Tier 5 PA etelcalcetide PARSABIV Tier 5
CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org
Bisphosphonates alendronate Tier 1 FOSAMAX Tier 3 ibandronate Tier 1 BONIVA Tier 3 risedronate Tier 1 ACTONEL Tier 3
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risedronate delayed-rel Tier 1 ATELVIA Tier 3 pamidronate Tier 4 zoledronic acid 4 mg/100 mL Tier 4 PA, * zoledronic acid 5 mg/100 mL Tier 4 RECLAST Tier 5 alendronate/vitamin D3 FOSAMAX PLUS D Tier 3
* Brand RECLAST requires prior approval
Calcitonins calcitonin-salmon spray Tier 1 MIACALCIN Tier 3 calcitonin-salmon inj MIACALCIN inj Tier 3
Parathyroid Hormones PA teriparatide FORTEO Tier 4 PA abaloparatide TYMLOS Tier 5 PA parathyroid hormone (recombinant) NATPARA Tier 5
Miscellaneous PA denosumab PROLIA Tier 4 PA denosumab XGEVA Tier 4 PA romosozumab-aqqg EVENITY Tier 5
CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1 CARNITOR Tier 3
CONTRACEPTIVES EE = ethinyl estradiol
Monophasic 20 mcg Estrogen † drospirenone/EE 3/20 Tier 1 YAZ Tier 3 † levonorgestrel/EE 0.1/20 Tier 1 † norethindrone acetate/EE 1/20 Tier 1 † norethindrone acetate/EE 1/20 and iron Tier 1 † norethindrone acetate/EE 1/20 and iron Tier 1 TAYTULLA Tier 3
30 mcg Estrogen † desogestrel/EE 0.15/30 Tier 1 † drospirenone/EE 3/30 Tier 1 YASMIN Tier 3 † drospirenone/EE/levomefolate 3/30 and levomefolate Tier 1 SAFYRAL Tier 3 † levonorgestrel/EE 0.15/30 Tier 1 † levonorgestrel/EE 0.15/30 - Levora Tier 1 † norethindrone acetate/EE 1.5/30 Tier 1 † norethindrone acetate/EE 1.5/30 and iron Tier 1 † norgestrel/EE 0.3/30 - Cryselle Tier 1 † norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1
35 mcg Estrogen † ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1 † norethindrone/EE 0.4/35 Tier 1 † norethindrone/EE 0.5/35 Tier 1 † norethindrone/EE 1/35 Tier 1 † norgestimate/EE 0.25/35 Tier 1
50 mcg Estrogen † ethynodiol diacetate/EE 1/50 Tier 1
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† norgestrel/EE 0.5/50 Tier 1
Biphasic † desogestrel/EE Tier 1 MIRCETTE Tier 3 norethindrone acetate/EE 1/10 and EE 10 and iron LO LOESTRIN FE Tier 3
Triphasic † desogestrel/EE Tier 1 † levonorgestrel/EE - Trivora Tier 1 † norethindrone acetate/EE and iron Tier 1 ESTROSTEP FE Tier 3 † norethindrone/EE Tier 1 † norgestimate/EE Tier 1
Four Phase estradiol valerate and dienogest/estradiol valerate NATAZIA Tier 3
Extended Cycle † levonorgestrel/EE 0.1/20 and EE 10 Tier 1 LOSEASONIQUE Tier 3 † levonorgestrel/EE 0.15/30 - Jolessa Tier 1 † levonorgestrel/EE 0.15/30 and EE 10 Tier 1 SEASONIQUE Tier 3
Continuous † levonorgestrel/EE 0.09/20 - Amethyst Tier 1
Progestin Only † norethindrone Tier 1 ORTHO MICRONOR Tier 3 drospirenone SLYND Tier 3
Implant ‡ etonogestrel implant NEXPLANON Tier 4
Injectable † medroxyprogesterone acetate 150 mg/mL Tier 1 DEPO-PROVERA Tier 3
Intrauterine Devices ‡ intrauterine copper contraceptive PARAGARD T 380A Tier 2 ‡ levonorgestrel-releasing IUD KYLEENA Tier 4 ‡ levonorgestrel-releasing IUD MIRENA Tier 4 ‡ levonorgestrel-releasing IUD SKYLA Tier 4 levonorgestrel-releasing IUD LILETTA Tier 5
Transdermal † norelgestromin/EE Tier 1 ethinyl estradiol/levonorgestrel TWIRLA Tier 3
Vaginal †, * etonogestrel/EE - EluRyng Tier 1 NUVARING Tier 3 lactic acid/citric acid/potassium bitartrate gel PHEXXI Tier 3 segesterone acetate/EE ring ANNOVERA Tier 3
* Generic versions are covered at no charge to qualifying members
ENDOMETRIOSIS danazol Tier 1 PA nafarelin SYNAREL Tier 2 PA elagolix ORILISSA Tier 3
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leuprolide acetate/norethindrone acetate LUPANETA PACK Tier 4
ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf
Injectable estradiol valerate Tier 1 DELESTROGEN Tier 2
Oral estradiol Tier 1 ESTRACE Tier 3 estrogens, esterified/methyltestosterone Tier 1 estrogens, conjugated PREMARIN Tier 2
Transdermal estradiol Tier 1 CLIMARA Tier 3 estradiol Tier 1 MINIVELLE Tier 3 estradiol Tier 1 VIVELLE-DOT Tier 3 estradiol transdermal spray EVAMIST Tier 2 estradiol ALORA Tier 3 estradiol transdermal gel ESTROGEL Tier 3
Vaginal estradiol vaginal crm Tier 1 ESTRACE Tier 3 estradiol vaginal tabs Tier 1 VAGIFEM Tier 3 estradiol vaginal ring ESTRING Tier 2 estrogens, conjugated crm PREMARIN crm Tier 2 estradiol vaginal inserts IMVEXXY Tier 3 estradiol vaginal ring FEMRING Tier 3
ESTROGEN/PROGESTINS Oral EE/norethindrone acetate Tier 1 FEMHRT Tier 3 EE/norethindrone acetate - Jinteli Tier 1 estradiol/norethindrone acetate Tier 1 ACTIVELLA Tier 3 estrogens, conjugated/medroxyprogesterone PREMPHASE Tier 2 estrogens, conjugated/medroxyprogesterone PREMPRO Tier 2 drospirenone/estradiol ANGELIQ Tier 3 estradiol/norgestimate PREFEST Tier 3 estradiol/progesterone BIJUVA Tier 3
Transdermal estradiol/levonorgestrel CLIMARA PRO Tier 2 estradiol/norethindrone acetate COMBIPATCH Tier 3
ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS conjugated estrogens/bazedoxifene DUAVEE Tier 3
FERTILITY REGULATORS PA clomiphene Tier 1 PA chorionic gonadotropin Tier 4 PA ganirelix acetate inj Tier 4 GANIRELIX ACETATE Tier 4 PA gonadorelin LUTREPULSE Tier 2 PA cetrorelix CETROTIDE Tier 4 PA choriogonadotropin alfa OVIDREL Tier 4
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PA chorionic gonadotropin NOVAREL Tier 4 PA chorionic gonadotropin PREGNYL Tier 4 PA follitropin beta FOLLISTIM AQ Tier 4 PA menotropins MENOPUR Tier 4 PA follitropin alfa GONAL-F Tier 5 PA follitropin alfa GONAL-F RFF Tier 5
GAUCHER DISEASE PA eliglustat CERDELGA Tier 4 PA imiglucerase CEREZYME Tier 4
GLUCOCORTICOIDS cortisone acetate Tier 1 dexamethasone Tier 1 fludrocortisone Tier 1 hydrocortisone Tier 1 CORTEF Tier 3 methylprednisolone Tier 1 MEDROL Tier 3 prednisolone Tier 1 prednisolone sodium phosphate Tier 1 prednisolone sodium phosphate orally disintegrating tabs Tier 1 ORAPRED ODT Tier 3 prednisolone syrup Tier 1 prednisone Tier 1 PA dexamethasone HEMADY Tier 3 hydrocortisone ALKINDI SPRINKLE CAPS Tier 3 PA prednisone delayed-rel RAYOS Tier 3
GLUCOSE ELEVATING AGENTS diazoxide Tier 1 PROGLYCEM Tier 3 glucagon, human recombinant (KIT) Tier 1 GLUCAGON EMERGENCY KIT Tier 3 glucagon nasal powder BAQSIMI Tier 2 glucagon subcutaneous soln GVOKE Tier 2 glucagon, human recombinant GLUCAGEN Tier 2
HEREDITARY TYROSINEMIA TYPE 1 AGENTS nitisinone Tier 4 ORFADIN Tier 4 nitisinone NITYR Tier 5
HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines
PA somatropin NORDITROPIN Tier 4 PA, * somatropin SEROSTIM Tier 4 PA, ** somatropin ZORBTIVE Tier 4 PA somatropin GENOTROPIN Tier 5 PA somatropin HUMATROPE Tier 5 PA somatropin NUTROPIN AQ Tier 5 PA somatropin NUTROPIN AQ NUSPIN Tier 5 PA somatropin OMNITROPE Tier 5 PA somatropin SAIZEN Tier 5 PA somatropin ZOMACTON Tier 5
* Indicated for AIDS wasting only ** Indicated only for the treatment of Short Bowel Syndrome in patients receiving specialized nutritional support
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HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) Tier 1 ROCALTROL Tier 3 doxercalciferol Tier 1 HECTOROL Tier 3 paricalcitol Tier 1 ZEMPLAR Tier 3 calcifediol ext-rel RAYALDEE Tier 3
INSULIN-LIKE GROWTH FACTOR-1 AGENTS PA mecasermin INCRELEX Tier 4
PHENYLKETONURIA TREATMENT AGENTS PA sapropterin Tier 4 KUVAN Tier 5 PA pegvaliase-pqpz PALYNZIQ Tier 5
PHOSPHATE BINDER AGENTS calcium acetate Tier 1 lanthanum carbonate chew tabs Tier 1 FOSRENOL CHEWABLE Tier 3 TABLETS sevelamer carbonate Tier 1 RENVELA Tier 3 sevelamer HCl Tier 1 RENAGEL Tier 3 lanthanum oral powder FOSRENOL ORAL POWDER Tier 2 ferric citrate AURYXIA Tier 3 sucroferric oxyhydroxide VELPHORO Tier 3
POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate Tier 1 PA patiromer VELTASSA Tier 3 PA sodium zirconium cyclosilicate LOKELMA Tier 3
PROGESTINS Injectable hydroxyprogesterone caproate Tier 4 MAKENA Tier 5
Oral medroxyprogesterone acetate Tier 1 PROVERA Tier 3 megestrol acetate susp Tier 1 norethindrone acetate Tier 1 AYGESTIN Tier 3 PA progesterone, micronized Tier 1 PROMETRIUM Tier 3
Vaginal PA progesterone vaginal inserts ENDOMETRIN Tier 2
SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene Tier 1 EVISTA Tier 3 ospemifene OSPHENA Tier 3
THYROID AGENTS Antithyroid Agents methimazole Tier 1 TAPAZOLE Tier 3 propylthiouracil Tier 1
Thyroid Supplements levothyroxine Tier 1 SYNTHROID Tier 2 levothyroxine Tier 1 TIROSINT Tier 3 levothyroxine - Levoxyl Tier 1 liothyronine Tier 1 CYTOMEL Tier 3 thyroid ARMOUR THYROID Tier 3
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UREA CYCLE DISORDERS PA sodium phenylbutyrate Tier 4 BUPHENYL Tier 5
UTERINE FIBROIDS PA elagolix sodium/estradiol/norethindrone acetate ORIAHNN Tier 3
VASOPRESSINS desmopressin spray, tabs Tier 1 DDAVP Tier 3
MISCELLANEOUS acetylcysteine Tier 1 ACETADOTE Tier 3 methylergonovine Tier 1 trientine Tier 1 SYPRINE Tier 3 corticotropin powder Tier 4 PA miglustat Tier 4 ZAVESCA Tier 5 PA, * octreotide acetate Tier 4 SANDOSTATIN Tier 5 PA tolvaptan Tier 4 SAMSCA Tier 5 hydroxocobalamin CYANOKIT Tier 2 prasterone vaginal inserts INTRAROSA Tier 3 PA uridine triacetate XURIDEN Tier 3 PA agalsidase beta FABRAZYME Tier 4 PA alglucosidase alfa LUMIZYME Tier 4 PA asfotase alfa STRENSIQ Tier 4 betaine anhydrous CYSTADANE Tier 4 PA burosumab-twza CRYSVITA Tier 4 PA carglumic acid CARBAGLU Tier 4 cysteamine CYSTAGON Tier 4 PA cysteamine delayed-rel PROCYSBI Tier 4 PA elosulfase alfa VIMIZIM Tier 4 PA galsulfase NAGLAZYME Tier 4 PA glycerol phenylbutyrate RAVICTI Tier 4 PA histrelin acetate SUPPRELIN LA Tier 4 PA idursulfase ELAPRASE Tier 4 PA lanreotide acetate SOMATULINE DEPOT Tier 4 PA laronidase ALDURAZYME Tier 4 PA leuprolide acetate LUPRON DEPOT-PED Tier 4 PA lonafarnib ZOKINVY Tier 4 PA mifepristone KORLYM Tier 4 PA octreotide acetate SANDOSTATIN LAR Tier 4 PA pasireotide SIGNIFOR Tier 4 pegvisomant SOMAVERT Tier 4 PA sebelipase alfa KANUMA Tier 4 PA taliglucerase alfa ELELYSO Tier 4 PA tesamorelin EGRIFTA Tier 4 thyrotropin alfa THYROGEN Tier 4 PA tolvaptan JYNARQUE Tier 4 PA velaglucerase alfa VPRIV Tier 4 PA vestronidase alfa-vjbk MEPSEVII Tier 4 PA corticotropin ACTHAR Tier 5 PA elapegademase-lvlr REVCOVI Tier 5 PA inotersen TEGSEDI Tier 5 PA metreleptin MYALEPT Tier 5 PA migalastat GALAFOLD Tier 5 PA octreotide MYCAPSSA Tier 5 PA octreotide acetate BYNFEZIA Tier 5
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PA osilodrostat phosphate ISTURISA Tier 5 PA triptorelin pamoate TRIPTODUR Tier 5
* Brand SANDOSTATIN requires prior approval
GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org
ANTIDIARRHEALS diphenoxylate/atropine Tier 1 LOMOTIL Tier 3 loperamide Tier 1 crofelemer delayed-rel MYTESI Tier 3
ANTIEMETICS QL aprepitant caps Tier 1 EMEND Tier 3 PA doxylamine/pyridoxine delayed-rel Tier 1 DICLEGIS Tier 3 QL dronabinol Tier 1 MARINOL Tier 3 granisetron Tier 1 meclizine Tier 1 metoclopramide Tier 1 REGLAN Tier 3 QL ondansetron Tier 1 ZOFRAN Tier 3 QL ondansetron orally disintegrating tabs Tier 1 PA palonosetron Tier 1 ALOXI Tier 3 prochlorperazine Tier 1 promethazine Tier 1 scopolamine transdermal Tier 1 TRANSDERM SCOP Tier 3 trimethobenzamide Tier 1 TIGAN Tier 3 QL granisetron transdermal SANCUSO Tier 2 QL rolapitant VARUBI Tier 2 QL aprepitant CINVANTI Tier 3 QL aprepitant susp EMEND Tier 3 PA doxylamine/pyridoxine ext-rel BONJESTA Tier 3 PA granisetron ext-rel inj SUSTOL Tier 3 metoclopramide nasal spray GIMOTI Tier 3 QL netupitant/palonosetron AKYNZEO Tier 3
ANTISPASMODICS d atropine/hyoscyamine/scopolamine/phenobarbital Tier 1 chlordiazepoxide/clidinium Tier 1 dicyclomine Tier 1 d hyoscyamine sulfate Tier 1 LEVSIN Tier 3 d hyoscyamine sulfate ext-rel Tier 1 LEVBID Tier 3 propantheline 15 mg Tier 1
CHOLELITHOLYTICS ursodiol Tier 1 ACTIGALL Tier 3 ursodiol Tier 1 URSO Tier 3 ursodiol Tier 1 URSO FORTE Tier 3
H2 RECEPTOR ANTAGONISTS cimetidine Tier 1 * famotidine Tier 1 nizatidine Tier 1
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* Except OTC available versions like 10 mg and 20 mg
INFLAMMATORY BOWEL DISEASE Injectable Agents PA vedolizumab ENTYVIO Tier 5
Oral Agents balsalazide Tier 1 budesonide delayed-rel caps Tier 1 ENTOCORT EC Tier 3 mesalamine delayed-rel caps Tier 1 DELZICOL Tier 3 mesalamine delayed-rel tabs Tier 1 ASACOL HD Tier 3 mesalamine delayed-rel tabs Tier 1 LIALDA Tier 3 mesalamine ext-rel caps Tier 1 APRISO Tier 3 sulfasalazine Tier 1 AZULFIDINE Tier 3 sulfasalazine delayed-rel Tier 1 AZULFIDINE EN-TABS Tier 3 mesalamine ext-rel caps PENTASA Tier 2 budesonide ext-rel caps ORTIKOS Tier 3 olsalazine DIPENTUM Tier 3
Rectal Agents hydrocortisone enema Tier 1 mesalamine rectal susp Tier 1 ROWASA Tier 3 mesalamine supp Tier 1 CANASA Tier 3 hydrocortisone acetate foam CORTIFOAM Tier 2
IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation PA lubiprostone Tier 1 AMITIZA Tier 3 PA linaclotide LINZESS Tier 2 PA tegaserod maleate ZELNORM Tier 3
Irritable Bowel Syndrome with Diarrhea alosetron Tier 1 LOTRONEX Tier 3 PA eluxadoline VIBERZI Tier 3
LAXATIVES lactulose soln Tier 1 peg 3350/electrolytes Tier 1 GOLYTELY Tier 3 peg 3350/electrolytes Tier 1 MOVIPREP Tier 3 peg 3350/electrolytes Tier 1 NULYTELY Tier 3 sodium sulfate/potassium sulfate/magnesium sulfate SUPREP Tier 2 lactulose KRISTALOSE pak Tier 3 peg 3350/electrolytes PLENVU Tier 3 sodium phosphates OSMOPREP Tier 3 sodium picosulfate/magnesium oxide/citric acid CLENPIQ Tier 3 sodium picosulfate/magnesium oxide/citric acid PREPOPIK Tier 3 sodium sulfate/magnesium sulfate/potassium chloride SUTAB Tier 3
OPIOID-INDUCED CONSTIPATION PA naloxegol MOVANTIK Tier 2 PA methylnaltrexone RELISTOR Tier 3
PANCREATIC ENZYMES pancrelipase VIOKACE Tier 2 pancrelipase delayed-rel CREON Tier 2 pancrelipase delayed-rel ZENPEP Tier 2
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pancrelipase delayed-rel PANCREAZE Tier 3
PROSTAGLANDINS misoprostol Tier 1 CYTOTEC Tier 3
PROTON PUMP INHIBITORS QL esomeprazole magnesium delayed-rel Tier 1 QL lansoprazole delayed-rel Tier 1 omeprazole delayed-rel Tier 1 QL omeprazole/sodium bicarbonate Tier 1 QL pantoprazole delayed-rel Tier 1 QL rabeprazole delayed-rel (except rabeprazole capsule sprinkle Tier 1 delayed-rel) QL dexlansoprazole delayed-rel DEXILANT Tier 3
SALIVA STIMULANTS cevimeline Tier 1 EVOXAC Tier 3 pilocarpine tabs Tier 1 SALAGEN Tier 3
STEROIDS, RECTAL d hydrocortisone acetate/pramoxine foam EPIFOAM Tier 2 d hydrocortisone acetate/pramoxine foam PROCTOFOAM-HC Tier 2
ULCER THERAPY COMBINATIONS QL lansoprazole + amoxicillin + clarithromycin Tier 1 QL bismuth subsalicylate + metronidazole + tetracycline PYLERA Tier 2 QL amoxicillin/rifabutin/omeprazole TALICIA Tier 3
MISCELLANEOUS alvimopan Tier 1 ENTEREG Tier 3 cromolyn sodium Tier 1 GASTROCROM Tier 3 sucralfate Tier 1 QL dronabinol solution SYNDROS Tier 3 glycopyrrolate CUVPOSA Tier 3 nitroglycerin rectal oint 0.4% RECTIV Tier 3 PA plecanatide TRULANCE Tier 3 dextranomer/sodium hyaluronate SOLESTA Tier 4 PA palifermin KEPIVANCE Tier 4 PA teduglutide GATTEX Tier 4 PA cholic acid CHOLBAM Tier 5 PA givosiran GIVLAARI Tier 5 PA obeticholic acid OCALIVA Tier 5 PA telotristat XERMELO Tier 5
GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines
alfuzosin ext-rel Tier 1 dutasteride Tier 1 AVODART Tier 3 dutasteride/tamsulosin Tier 1 JALYN Tier 3 finasteride Tier 1 PROSCAR Tier 3 silodosin Tier 1 RAPAFLO Tier 3 PA tadalafil 2.5 mg, 5 mg Tier 1 CIALIS Tier 3 tamsulosin Tier 1 FLOMAX Tier 3
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URINARY ANTISPASMODICS darifenacin ext-rel Tier 1 oxybutynin Tier 1 oxybutynin ext-rel Tier 1 DITROPAN XL Tier 3 solifenacin Tier 1 tolterodine Tier 1 tolterodine ext-rel Tier 1 trospium Tier 1 trospium ext-rel Tier 1 fesoterodine ext-rel TOVIAZ Tier 2 mirabegron ext-rel MYRBETRIQ Tier 2 oxybutynin gel GELNIQUE Tier 3 solifenacin VESICARE LS Tier 3
VAGINAL ANTI-INFECTIVES metronidazole vaginal Tier 1 terconazole crm Tier 1 terconazole supp 80 mg Tier 1 clindamycin supp CLEOCIN vaginal supp Tier 2 clindamycin vaginal cream CLINDESSE Tier 2
MISCELLANEOUS bethanechol Tier 1 phenazopyridine Tier 1 PYRIDIUM Tier 3 potassium citrate ext-rel Tier 1 UROCIT-K Tier 3 PA tiopronin Tier 1 THIOLA Tier 3 pentosan polysulfate sodium ELMIRON Tier 2 PA tiopronin delayed-rel THIOLA EC Tier 3
HEMATOLOGIC ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular
Injectable enoxaparin Tier 1 LOVENOX Tier 3 dalteparin FRAGMIN Tier 2
Oral warfarin Tier 1 apixaban ELIQUIS Tier 2 rivaroxaban XARELTO Tier 2 dabigatran etexilate PRADAXA Tier 3
Synthetic Heparinoid-like Agents fondaparinux Tier 1 ARIXTRA Tier 3
HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org
Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines
PA darbepoetin alfa ARANESP Tier 4
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PA epoetin alfa-epbx RETACRIT Tier 4 PA filgrastim-aafi NIVESTYM Tier 4 PA filgrastim-sndz ZARXIO Tier 4 PA pegfilgrastim-apgf NYVEPRIA Tier 4 PA pegfilgrastim-bmez ZIEXTENZO Tier 4 PA pegfilgrastim-cbqv UDENYCA Tier 4 PA pegfilgrastim-jmdb FULPHILA Tier 4 PA tbo-filgrastim GRANIX Tier 4 PA epoetin alfa EPOGEN Tier 5 PA epoetin alfa PROCRIT Tier 5 PA filgrastim NEUPOGEN Tier 5 PA methoxy polyethylene glycol/epoetin beta MIRCERA Tier 5 PA pegfilgrastim NEULASTA Tier 5 PA sargramostim LEUKINE Tier 5
HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org
AHF, human/VWF, human HUMATE-P Tier 4 antihemophilic factor ALPHANATE Tier 4 antihemophilic factor HEMOFIL M Tier 4 antihemophilic factor KOATE-DVI Tier 4 antihemophilic factor recombinant, Fc fusion protein ELOCTATE Tier 4 antihemophilic factor, recombinant ADVATE Tier 4 antihemophilic factor, recombinant AFSTYLA Tier 4 antihemophilic factor, recombinant KOGENATE FS Tier 4 antihemophilic factor, recombinant KOVALTRY Tier 4 antihemophilic factor, recombinant NOVOEIGHT Tier 4 antihemophilic factor, recombinant RECOMBINATE Tier 4 antihemophilic factor, recombinant XYNTHA Tier 4 antihemophilic factor, recombinant XYNTHA SOLOFUSE Tier 4 anti-inhibitor coagulant complex FEIBA VH IMMUNO Tier 4 coagulation factor IX (recombinant), glycopegylated REBINYN Tier 4 coagulation factor IX, recombinant IDELVION Tier 4 coagulation factor IX, recombinant IXINITY Tier 4 coagulation factor VIIa NOVOSEVEN RT Tier 4 coagulation factor X, human COAGADEX Tier 4 desmopressin spray STIMATE Tier 4 emicizumab-kxwh HEMLIBRA Tier 4 factor IX concentrate ALPHANINE SD Tier 4 factor IX concentrate BENEFIX Tier 4 factor IX concentrate MONONINE Tier 4 factor IX concentrate PROFILNINE Tier 4 factor IX concentrate RIXUBIS Tier 4 factor IX recombinant, Fc fusion protein ALPROLIX Tier 4 factor XIII A-subunit recombinant TRETTEN Tier 4 factor XIII concentrate CORIFACT Tier 4 fibrinogen RIASTAP Tier 4 human coagulation factor VIII (rDNA) simoctocog alfa NUWIQ Tier 4 von Willebrand factor, recombinant VONVENDI Tier 4 VWF, human/factor VIII complex WILATE Tier 4 antihemophilic factor (recombinant) pegylated ADYNOVATE Tier 5 antihemophilic factor (recombinant) pegylated-aucl JIVI Tier 5 antihemophilic factor (recombinant) porcine sequence OBIZUR Tier 5 antihemophilic factor (recombinant), glycopegylated-exei ESPEROCT Tier 5
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coagulation factor VIIa-jncw SEVENFACT Tier 5 fibrinogen FIBRYGA Tier 5
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PA eltrombopag PROMACTA Tier 4 PA romiplostim NPLATE Tier 4 PA fostamatinib TAVALISSE Tier 5
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS PA eculizumab SOLIRIS Tier 4 PA ravulizumab-cwvz ULTOMIRIS Tier 5
PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1 PLAVIX Tier 3 dipyridamole Tier 1 dipyridamole ext-rel/aspirin Tier 1 AGGRENOX Tier 3 prasugrel Tier 1 EFFIENT Tier 3 PA aspirin ext-rel DURLAZA Tier 3 cangrelor KENGREAL Tier 3 eptifibatide INTEGRILIN Tier 3 ticagrelor BRILINTA Tier 3 tirofiban inj AGGRASTAT Tier 3 vorapaxar ZONTIVITY Tier 3
PLATELET SYNTHESIS INHIBITORS anagrelide Tier 1 AGRYLIN Tier 3
SICKLE CELL DISEASE PA crizanlizumab-tmca ADAKVEO Tier 4 PA voxelotor OXBRYTA Tier 4
STEM CELL MOBILIZERS PA plerixafor MOZOBIL Tier 4
THROMBOCYTOPENIA AGENTS QL lusutrombopag MULPLETA Tier 5
MISCELLANEOUS aminocaproic acid Tier 1 AMICAR Tier 3 cilostazol Tier 1 pentoxifylline ext-rel Tier 1 tranexamic acid Tier 1 CYKLOKAPRON inj Tier 3 tranexamic acid Tier 1 LYSTEDA Tier 3 PA deferasirox Tier 4 EXJADE Tier 5 PA deferasirox Tier 4 JADENU Tier 5 PA deferiprone Tier 4 FERRIPROX Tier 4 deferoxamine Tier 4 DESFERAL Tier 5 alteplase CATHFLO ACTIVASE Tier 2 PA luspatercept-aamt REBLOZYL Tier 4 PA protein C concentrate, human CEPROTIN Tier 4 PA avatrombopag DOPTELET Tier 5 PA L-glutamine oral powder ENDARI Tier 5
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IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org
ALLERGENIC EXTRACTS PA grass mixed pollen allergen extract ORALAIR Tier 5 PA peanut allergen-dfnp PALFORZIA Tier 5
AUTOIMMUNE AGENTS PA adalimumab HUMIRA Tier 4 PA apremilast OTEZLA Tier 4 PA etanercept ENBREL Tier 4 PA etanercept ENBREL SURECLICK Tier 4 PA golimumab SIMPONI 100 mg Tier 4 PA ixekizumab TALTZ Tier 4 PA risankizumab-rzaa SKYRIZI Tier 4 PA tocilizumab ACTEMRA Tier 4 PA tofacitinib XELJANZ Tier 4 PA tofacitinib ext-rel XELJANZ XR Tier 4 PA upadacitinib RINVOQ ER Tier 4 PA ustekinumab STELARA SUBCUTANEOUS Tier 4 PA abatacept ORENCIA Tier 5 PA anakinra KINERET Tier 5 PA baricitinib OLUMIANT Tier 5 PA brodalumab SILIQ Tier 5 PA certolizumab pegol CIMZIA Tier 5 PA golimumab SIMPONI 50 mg Tier 5 PA, * infliximab REMICADE PA, * infliximab-abda RENFLEXIS PA, * infliximab-dyyb INFLECTRA PA sarilumab KEVZARA Tier 5 PA satralizumab-mwge ENSPRYNG Tier 5 PA tildrakizumab-asmn ILUMYA Tier 5
* Medical Benefit only drug
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine Tier 1 PLAQUENIL Tier 3 leflunomide Tier 1 ARAVA Tier 3 methotrexate inj Tier 1 methotrexate oral Tier 1 penicillamine tabs Tier 1 DEPEN Tier 3 auranofin RIDAURA Tier 3 PA methotrexate auto-injector RASUVO Tier 3 PA methotrexate inj OTREXUP Tier 3
HEREDITARY ANGIOEDEMA AGENTS PA icatibant Tier 4 FIRAZYR Tier 5 PA C1 esterase inhibitor BERINERT Tier 4 PA C1 esterase inhibitor CINRYZE Tier 4 PA ecallantide KALBITOR Tier 4 PA berotralstat ORLADEYO Tier 5 PA C1 esterase inhibitor HAEGARDA Tier 5 PA C1 esterase inhibitor, recombinant RUCONEST Tier 5
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PA lanadelumab-flyo TAKHZYRO Tier 5
IMMUNE GLOBULINS hepatitis B immune globulin HEPAGAM B Tier 4 hepatitis B immune globulin HYPERHEP B S-D Tier 4 hepatitis B immune globulin NABI-HB Tier 4 PA immune globulin (human)-ifas PANZYGA Tier 4 PA immune globulin, gamma GAMASTAN Tier 4 PA immune globulin, gamma GAMASTAN S-D Tier 4 PA immune globulin, gamma GAMUNEX-C Tier 4 PA immune globulin, gamma (IGG) GAMMAKED Tier 4 PA immune globulin, gamma (IGG) GAMMAPLEX Tier 4 PA immune globulin, intravenous BIVIGAM Tier 4 PA immune globulin, intravenous FLEBOGAMMA Tier 4 PA immune globulin, intravenous GAMMAGARD LIQUID Tier 4 PA immune globulin, intravenous GAMMAGARD S-D Tier 4 PA immune globulin, intravenous OCTAGAM Tier 4 PA immune globulin, intravenous PRIVIGEN Tier 4 PA immune globulin, subcutaneous HIZENTRA Tier 4 PA immune globulin/hyaluronidase HYQVIA Tier 4 Rho (D) immune globulin HYPERRHO S-D Tier 4 Rho (D) immune globulin MICRHOGAM Tier 4 Rho (D) immune globulin MICRHOGAM PLUS Tier 4 Rho (D) immune globulin RHOGAM Tier 4 Rho (D) immune globulin RHOGAM PLUS Tier 4 Rho (D) immune globulin RHOPHYLAC Tier 4 Rho (D) immune globulin WINRHO SDF Tier 4 varicella zoster immune globulin VARIZIG Tier 4 PA immune globulin (human)-klhw XEMBIFY Tier 5 PA immune globulin (human)-slra ASCENIV Tier 5 PA immune globulin, subcutaneous CUVITRU Tier 5 PA immune globulin-hipp CUTAQUIG Tier 5
IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/
Guidelines for the management of hepatitis are available at: https://www.aasld.org
Interferons PA interferon alfa-2b INTRON A Tier 4 PA interferon gamma-1b, recombinant ACTIMMUNE Tier 4 PA peginterferon alfa-2a PEGASYS Tier 4 PA peginterferon alfa-2b PEGINTRON Tier 4
Miscellaneous bezlotoxumab ZINPLAVA Tier 3 PA canakinumab ILARIS Tier 4 PA rilonacept ARCALYST Tier 4
IMMUNOSUPPRESSANTS Antimetabolites azathioprine Tier 1 IMURAN Tier 3 mycophenolate mofetil Tier 1 CELLCEPT Tier 3 mycophenolate sodium delayed-rel Tier 1 MYFORTIC Tier 3
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Calcineurin Inhibitors cyclosporine Tier 1 SANDIMMUNE Tier 3 cyclosporine, modified Tier 1 NEORAL Tier 3 tacrolimus Tier 1 PROGRAF Tier 3 tacrolimus ext-rel ASTAGRAF XL Tier 2 tacrolimus ext-rel ENVARSUS XR Tier 3 PA voclosporin LUPKYNIS Tier 5
Rapamycin Derivatives sirolimus Tier 1 RAPAMUNE Tier 3 everolimus 0.25 mg, 0.5 mg, 0.75 mg Tier 4 ZORTRESS 0.25 mg, 0.5 mg, 0.75 Tier 5 mg everolimus 1 mg ZORTRESS 1 mg Tier 4
Miscellaneous belatacept NULOJIX Tier 4 PA belimumab BENLYSTA Tier 4
NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel Tier 1 potassium chloride liquid Tier 1 potassium chloride powder Tier 1
VITAMINS AND MINERALS Folic Acid Agents folic acid Tier 1
Prenatal Vitamins prenatal vitamins/folic acid DUET DHA Tier 2 prenatal vitamins/folic acid PRENATE ELITE Tier 2 prenatal vitamins/docusate/folic acid CITRANATAL RX Tier 3 prenatal vitamins/folic acid VITAFOL-OB Tier 3
Miscellaneous cyanocobalamin inj Tier 1 ergocalciferol (D2) Tier 1 phytonadione Tier 1 MEPHYTON Tier 3 sodium ferric gluconate inj Tier 1 FERRLECIT Tier 3 cyanocobalamin spray NASCOBAL Tier 2 iron sucrose inj VENOFER Tier 2 zinc acetate GALZIN Tier 2 ferric carboxymaltose inj INJECTAFER Tier 3 ferric derisomaltose inj MONOFERRIC Tier 3 ferumoxytol inj FERAHEME Tier 3
MISCELLANEOUS PA triheptanoin DOJOLVI Tier 5
RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org
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https://goldcopd.org https://www.nhlbi.nih.gov
The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org
ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS PA alpha-1 proteinase inhibitor ARALAST NP Tier 4 PA alpha-1 proteinase inhibitor GLASSIA Tier 4 PA alpha-1 proteinase inhibitor PROLASTIN-C Tier 4 PA alpha-1 proteinase inhibitor ZEMAIRA Tier 4
ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector 0.15 mg Tier 1 EPIPEN JR. Tier 3 epinephrine auto-injector 0.30 mg Tier 1 EPIPEN Tier 3 epinephrine inj (0.15 mg and 0.30 mg) SYMJEPI Tier 2
ANTICHOLINERGICS ipratropium soln Tier 1 ipratropium, CFC-free aerosol ATROVENT HFA Tier 2 tiotropium SPIRIVA Tier 2 tiotropium SPIRIVA RESPIMAT Tier 2 aclidinium bromide TUDORZA PRESSAIR Tier 3 glycopyrrolate inhalation powder SEEBRI NEOHALER Tier 3 glycopyrrolate inhalation solution LONHALA MAGNAIR Tier 3 revefenacin inhalation solution YUPELRI Tier 3 umeclidinium bromide INCRUSE ELLIPTA Tier 3
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol soln Tier 1 ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT Tier 3
Long Acting tiotropium/olodaterol STIOLTO RESPIMAT Tier 2 umeclidinium/vilanterol ANORO ELLIPTA Tier 2 aclidinium bromide/formoterol fumarate DUAKLIR PRESSAIR Tier 3 glycopyrrolate/formoterol BEVESPI AEROSPHERE Tier 3 indacaterol/glycopyrrolate inhalation powder UTIBRON NEOHALER Tier 3
ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS fluticasone/umeclidinium/vilanterol TRELEGY ELLIPTA Tier 2 budesonide/glycopyrrolate/formoterol BREZTRI AEROSPHERE Tier 3
ANTIHISTAMINES, LOW SEDATING levocetirizine Tier 1
ANTIHISTAMINES, NONSEDATING desloratadine Tier 1 CLARINEX Tier 3
ANTIHISTAMINES, SEDATING cyproheptadine Tier 1 diphenhydramine Tier 1 hydroxyzine HCl Tier 1 hydroxyzine pamoate Tier 1 VISTARIL Tier 3 promethazine Tier 1
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ANTIHISTAMINE/DECONGESTANT COMBINATIONS desloratadine/pseudoephedrine ext-rel CLARINEX-D Tier 3
ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf
benzonatate Tier 1 TESSALON Tier 3
ANTITUSSIVE COMBINATIONS Opioid QL codeine/promethazine Tier 1 QL codeine/promethazine/phenylephrine Tier 1 QL hydrocodone/homatropine Tier 1
BETA AGONISTS Inhalants Short Acting albuterol soln Tier 1 albuterol sulfate, CFC-free aerosol Tier 1 PROAIR HFA Tier 2 albuterol sulfate, CFC-free aerosol Tier 1 PROVENTIL HFA Tier 2 albuterol sulfate, CFC-free aerosol Tier 1 VENTOLIN HFA Tier 2 levalbuterol inhalation soln Tier 1 XOPENEX SOLUTION Tier 3 levalbuterol nebulizer soln concentrate Tier 1 XOPENEX CONCENTRATE Tier 3 levalbuterol tartrate, CFC-free aerosol Tier 1 XOPENEX HFA Tier 3 albuterol sulfate aerosol powder breath-activated PROAIR RESPICLICK Tier 2 albuterol sulfate aerosol powder 108mcg/actuation with sensor PROAIR DIGIHALER Tier 3
Long Acting Hand-held Active Inhalation salmeterol xinafoate SEREVENT DISKUS Tier 2 formoterol inhalation caps FORADIL Tier 3 olodaterol, CFC-free aerosol STRIVERDI RESPIMAT Tier 3
Nebulized Passive Inhalation arformoterol soln BROVANA Tier 3 formoterol inhalation soln PERFOROMIST Tier 3
Oral Agents albuterol Tier 1 albuterol ext-rel Tier 1 terbutaline Tier 1
CYSTIC FIBROSIS tobramycin inhalation soln Tier 4 BETHKIS Tier 5 tobramycin inhalation soln Tier 4 KITABIS PAK Tier 5 tobramycin inhalation soln Tier 4 TOBI Tier 5 aztreonam lysine inhalation soln CAYSTON Tier 4 PA dornase alfa PULMOZYME Tier 4 PA elexacaftor/tezacaftor/ivacaftor + ivacaftor TRIKAFTA Tier 4 PA ivacaftor KALYDECO Tier 4 PA lumacaftor/ivacaftor ORKAMBI Tier 4 PA tezacaftor/ivacaftor + ivacaftor SYMDEKO Tier 4 tobramycin inhalation powder TOBI PODHALER Tier 4 PA amikacin liposome inhalation susp ARIKAYCE Tier 5
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PA mannitol inhalation powder BRONCHITOL Tier 5
LEUKOTRIENE MODULATORS montelukast Tier 1 SINGULAIR Tier 3 zafirlukast Tier 1 ACCOLATE Tier 3
MAST CELL STABILIZERS cromolyn soln Tier 1
NASAL ANTIHISTAMINES azelastine spray Tier 1 olopatadine spray Tier 1 PATANASE Tier 3
NASAL STEROIDS/COMBINATIONS azelastine/fluticasone nasal spray Tier 1 DYMISTA Tier 3 flunisolide spray Tier 1 fluticasone spray Tier 1 mometasone spray Tier 1 NASONEX Tier 3 ciclesonide spray OMNARIS Tier 2 fluticasone furoate spray VERAMYST Tier 2 beclomethasone spray BECONASE AQ Tier 3 PA fluticasone propionate XHANCE Tier 3
PHOSPHODIESTERASE-4 INHIBITORS roflumilast DALIRESP Tier 3
PULMONARY FIBROSIS AGENTS PA nintedanib OFEV Tier 4 PA pirfenidone ESBRIET Tier 4
SEVERE ASTHMA AGENTS PA omalizumab XOLAIR Tier 4 PA mepolizumab NUCALA Tier 5
STEROID/BETA AGONIST COMBINATIONS budesonide/formoterol Tier 1 SYMBICORT Tier 2 fluticasone/salmeterol Tier 1 ADVAIR Tier 3 fluticasone/salmeterol Tier 1 AIRDUO RESPICLICK Tier 3 fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA Tier 2 fluticasone/vilanterol BREO ELLIPTA Tier 2 mometasone/formoterol DULERA Tier 2 fluticasone/salmeterol AIRDUO DIGIHALER Tier 3
STEROID INHALANTS budesonide inhalation suspension Tier 1 PULMICORT RESPULES Tier 3 beclomethasone breath-activated aerosol QVAR REDIHALER Tier 2 beclomethasone, CFC-free aerosol QVAR Tier 2 budesonide PULMICORT FLEXHALER Tier 2 fluticasone ARNUITY ELLIPTA Tier 2 fluticasone FLOVENT Tier 2 fluticasone, CFC-free aerosol FLOVENT HFA Tier 2 ciclesonide ALVESCO Tier 3 fluticasone propionate ARMONAIR DIGIHALER Tier 3 mometasone ASMANEX Tier 3 mometasone, CFC-free aerosol ASMANEX HFA Tier 3
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XANTHINES caffeine citrate Tier 1 CAFCIT Tier 3 theophylline ext-rel tabs Tier 1 theophylline ext-rel caps THEO-24 Tier 2 theophylline liquid ELIXOPHYLLIN Tier 2
MISCELLANEOUS ipratropium nasal spray Tier 1 PA benralizumab FASENRA Tier 5 PA reslizumab inj CINQAIR Tier 5
TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines
Oral isotretinoin Tier 1 PA, * isotretinoin Tier 1 ABSORICA Tier 3 minocycline ext-rel caps Tier 1 XIMINO Tier 3
* Brand ABSORICA requires PA
Topical PA adapalene crm, gel Tier 1 DIFFERIN Tier 3 PA adapalene/benzoyl peroxide Tier 1 EPIDUO Tier 3 benzoyl peroxide Tier 1 BENZAC AC Tier 3 QL clindamycin gel, lotion, soln Tier 1 CLEOCIN T Tier 3 clindamycin swabs Tier 1 clindamycin/benzoyl peroxide Tier 1 clindamycin/benzoyl peroxide Tier 1 ACANYA Tier 3 clindamycin/benzoyl peroxide Tier 1 BENZACLIN Tier 3 PA clindamycin/tretinoin Tier 1 VELTIN Tier 3 PA clindamycin/tretinoin Tier 1 ZIANA Tier 3 QL erythromycin gel 2% Tier 1 ERYGEL Tier 3 QL erythromycin soln Tier 1 erythromycin/benzoyl peroxide Tier 1 BENZAMYCIN Tier 3 QL, * sulfacetamide sodium Tier 1 PA tazarotene crm 0.1% Tier 1 TAZORAC Tier 3 PA tretinoin Tier 1 ATRALIN Tier 3 PA tretinoin Tier 1 RETIN-A Tier 3 PA tretinoin gel microsphere Tier 1 RETIN-A MICRO Tier 3 PA adapalene/benzoyl peroxide EPIDUO FORTE Tier 3 azelaic acid AZELEX Tier 3 clindamycin/benzoyl peroxide ONEXTON Tier 3 QL minocycline hcl micronized foam AMZEEQ Tier 3 PA tazarotene crm 0.05%, gel 0.05%, 0.1% TAZORAC Tier 3 PA tazarotene foam 0.1% FABIOR Tier 3 PA tazarotene lotion 0.045% ARAZLO Tier 3 PA trifarotene cream 0.005% AKLIEF Tier 3
* generic for OVACE and OVACE PLUS
Actinic Keratosis PA diclofenac sodium 3% gel Tier 1
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fluorouracil Tier 1 CARAC Tier 3 fluorouracil Tier 1 EFUDEX Tier 3 PA aminolevulinic acid gel 10% AMELUZ Tier 3 PA aminolevulinic acid soln LEVULAN KERASTICK Tier 3 fluorouracil FLUOROPLEX Tier 3 fluorouracil crm 4% TOLAK Tier 3 PA tirbanibulin KLISYRI Tier 3
Antibiotics QL gentamicin crm Tier 1 mafenide acetate packets 5% Tier 1 SULFAMYLON Tier 3 QL mupirocin Tier 1 silver sulfadiazine Tier 1 SILVADENE Tier 3 retapamulin ALTABAX Tier 2 PA ozenoxacin XEPI Tier 3
Antifungals QL ciclopirox Tier 1 LOPROX Tier 3 QL clotrimazole Tier 1 QL clotrimazole/betamethasone Tier 1 QL econazole Tier 1 QL ketoconazole Tier 1 PA luliconazole Tier 1 LUZU Tier 3 QL miconazole nitrate/zinc oxide Tier 1 VUSION Tier 3 QL naftifine Tier 1 NAFTIN (EXCEPT 2% GEL) Tier 3 QL nystatin Tier 1 PA oxiconazole crm Tier 1 OXISTAT Tier 3 PA sulconazole Tier 1 EXELDERM Tier 3 PA tavaborole sol 5% Tier 1 KERYDIN Tier 3 QL naftifine gel 2% NAFTIN GEL 2% Tier 2 butenafine MENTAX Tier 3 PA econazole foam ECOZA Tier 3 PA efinaconazole JUBLIA Tier 3 PA sertaconazole ERTACZO Tier 3
Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org
Injectable PA guselkumab TREMFYA Tier 4 PA ustekinumab STELARA Tier 4 PA secukinumab COSENTYX Tier 5
Oral acitretin Tier 1 methoxsalen oral Tier 1 OXSORALEN-ULTRA Tier 3
Topical QL betamethasone dipropionate/calcipotriene oint, susp Tier 1 QL calcipotriene Tier 1 DOVONEX Tier 3 QL, * calcipotriene foam Tier 1 SORILUX Tier 3 calcitriol oint Tier 1 VECTICAL Tier 3 PA calcipotriene/betamethasone dipropionate cream WYNZORA Tier 3 QL calcipotriene/betamethasone foam ENSTILAR Tier 3
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* Does not include NDC 73308-0357-60
Antiseborrheics QL ketoconazole shampoo 2% Tier 1 NIZORAL SHAMPOO Tier 3
Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines
Injectable PA dupilumab DUPIXENT Tier 5
Topical pimecrolimus Tier 1 ELIDEL Tier 3 tacrolimus Tier 1 PROTOPIC Tier 3 PA crisaborole oint EUCRISA Tier 3
Corticosteroids Low Potency QL alclometasone crm, oint 0.05% Tier 1 QL desonide crm 0.05% Tier 1 DESOWEN Tier 3 QL desonide gel 0.05% Tier 1 DESONATE Tier 3 QL desonide lotion, oint 0.05% Tier 1 QL fluocinolone acetonide soln 0.01% Tier 1 QL hydrocortisone crm 2.5% Tier 1 QL desonide foam 0.05% VERDESO Tier 2 QL fluocinolone shampoo 0.01% CAPEX Tier 3 pramoxine/hydrocortisone PRAMOSONE Tier 3
Medium Potency QL betamethasone valerate crm, lotion, oint 0.1% Tier 1 QL clocortolone pivalate crm 0.1% Tier 1 CLODERM Tier 3 QL desoximetasone crm, oint 0.05% Tier 1 QL fluocinolone acetonide crm, oint 0.025% Tier 1 SYNALAR Tier 3 QL fluocinolone acetonide oil 0.01% Tier 1 DERMA-SMOOTHE/FS Tier 3 QL flurandrenolide crm, lotion, oint 0.05% Tier 1 CORDRAN crm, lotion, oint Tier 3 QL fluticasone propionate crm 0.05%, oint 0.005% Tier 1 QL fluticasone propionate lotion 0.005% Tier 1 CUTIVATE Tier 3 QL hydrocortisone butyrate crm 0.1% Tier 1 LOCOID LIPOCREAM Tier 3 QL hydrocortisone butyrate crm, lotion, oint, soln 0.1% Tier 1 LOCOID Tier 3 QL hydrocortisone valerate crm, oint 0.2% Tier 1 QL mometasone crm, lotion, oint 0.1% Tier 1 QL triamcinolone acetonide crm, lotion 0.025% Tier 1 QL triamcinolone acetonide crm, lotion, oint 0.1% Tier 1 QL flurandrenolide tape CORDRAN TAPE Tier 2 QL hydrocortisone probutate crm 0.1% PANDEL Tier 3
High Potency QL amcinonide crm, lotion, oint 0.1% Tier 1 QL betamethasone dipropionate augmented crm 0.05% Tier 1 DIPROLENE AF Tier 3 QL betamethasone dipropionate augmented gel, lot 0.05% Tier 1 QL betamethasone dipropionate augmented oint 0.05% Tier 1 DIPROLENE Tier 3 QL betamethasone dipropionate crm, lotion, oint 0.05% Tier 1 QL desoximetasone crm, oint, spray 0.25%, gel 0.05% Tier 1 TOPICORT Tier 3 QL diflorasone diacetate crm 0.05% Tier 1 QL fluocinonide crm, gel, oint, soln 0.05% Tier 1
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QL triamcinolone acetonide crm 0.5% Tier 1 QL triamcinolone acetonide topical spray Tier 1 KENALOG SPRAY Tier 3 QL betamethasone dipropionate spray 0.05% SERNIVO Tier 3 QL diflorasone diacetate emollient crm 0.05% APEXICON E Tier 3 QL halcinonide crm, oint, soln 0.1% HALOG Tier 3
Very High Potency QL betamethasone dipropionate augmented gel, oint 0.05% Tier 1 DIPROLENE Tier 3 QL clobetasol propionate crm, gel, oint, soln 0.05% Tier 1 TEMOVATE Tier 3 QL clobetasol propionate lotion, shampoo, spray 0.05% Tier 1 CLOBEX Tier 3 QL diflorasone diacetate oint 0.05% Tier 1 QL fluocinonide crm 0.1% Tier 1 QL halobetasol propionate crm, oint 0.05% Tier 1 ULTRAVATE Tier 3 QL clobetasol propionate lotion IMPEKLO Tier 3
Emollients ammonium lactate 12% Tier 1
Local Analgesics QL lidocaine patch Tier 1 LIDODERM Tier 3 PA capsaicin 8% patch QUTENZA Tier 3
Local Anesthetics QL lidocaine Tier 1 XYLOCAINE Tier 3 QL lidocaine/prilocaine Tier 1
Rosacea PA azelaic acid gel Tier 1 FINACEA Tier 3 doxycycline monohydrate delayed-rel caps Tier 1 ORACEA Tier 3 PA ivermectin crm 1% Tier 1 SOOLANTRA Tier 3 QL metronidazole crm 0.75% Tier 1 METROCREAM Tier 3 QL metronidazole gel 0.75% Tier 1 metronidazole gel 1% Tier 1 METROGEL Tier 3 metronidazole lotion 0.75% Tier 1 METROLOTION Tier 3 PA brimonidine topical gel MIRVASO Tier 3 PA metronidazole crm NORITATE Tier 3 QL minocycline foam ZILXI Tier 3 PA oxymetazoline crm 1% RHOFADE Tier 3
Scabicides and Pediculicides crotamiton lotion Tier 1 EURAX lotion Tier 2 ivermectin Tier 1 lindane Tier 1 permethrin 5% Tier 1 spinosad Tier 1 NATROBA Tier 3 crotamiton crm EURAX crm Tier 2
Miscellaneous Skin and Mucous Membrane acyclovir Tier 1 ZOVIRAX Tier 3 QL doxepin crm Tier 1 ZONALON Tier 3 d, PA hydrocortisone/aloe polysaccharide/iodoquinol Tier 1 d, PA hydrocortisone/iodoquinol Tier 1 PA imiquimod Tier 1 ALDARA Tier 3 PA imiquimod crm 3.75% Tier 1 ZYCLARA Tier 2 podofilox Tier 1 CONDYLOX Tier 3 alitretinoin PANRETIN Tier 2
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PA becaplermin REGRANEX Tier 2 absorbable fibrin sealant TACHOSIL Tier 3 penciclovir DENAVIR Tier 3 PA collagenase clostridium histolyticum XIAFLEX Tier 4 PA interferon alfa-n3 ALFERON N Tier 4
MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Tier 1
Steroids - Mouth/Throat triamcinolone paste Tier 1
Miscellaneous sodium fluoride Tier 1 PREVIDENT Tier 3
OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org
Antiallergics bepotastine Tier 1 BEPREVE Tier 3 cromolyn sodium Tier 1 epinastine Tier 1 olopatadine Tier 1 phenylephrine Tier 1 alcaftadine LASTACAFT Tier 3 lodoxamide ALOMIDE Tier 3 olopatadine PAZEO Tier 3
Antifungals natamycin NATACYN Tier 2
Anti-infectives bacitracin Tier 1 ciprofloxacin Tier 1 CILOXAN Tier 3 erythromycin Tier 1 levofloxacin Tier 1 moxifloxacin Tier 1 MOXEZA Tier 3 moxifloxacin Tier 1 VIGAMOX Tier 3 neomycin/polymyxin B/gramicidin Tier 1 ofloxacin Tier 1 OCUFLOX Tier 3 polymyxin B/bacitracin Tier 1 polymyxin B/trimethoprim Tier 1 POLYTRIM Tier 3 sulfacetamide soln 10% Tier 1 BLEPH-10 Tier 3 tobramycin Tier 1 TOBREX Tier 3 azithromycin AZASITE Tier 2 besifloxacin BESIVANCE Tier 2
Anti-infective/Anti-inflammatory Combinations neomycin/dexamethasone Tier 1 neomycin/polymyxin B/dexamethasone Tier 1 MAXITROL Tier 3 neomycin/polymyxin B/hydrocortisone susp Tier 1 sulfacetamide/prednisolone phosphate 10%/0.25% Tier 1 tobramycin/dexamethasone susp 0.3%/0.1% Tier 1 TOBRADEX SUSPENSION Tier 3 tobramycin/dexamethasone oint 0.3%/0.1% TOBRADEX OINTMENT Tier 2
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tobramycin/loteprednol ZYLET Tier 2 gentamicin/prednisolone acetate PRED-G Tier 3 sulfacetamide/prednisolone acetate oint 10%/0.2% BLEPHAMIDE SOP Tier 3
Anti-inflammatories Nonsteroidal bromfenac sodium Tier 1 diclofenac sodium Tier 1 flurbiprofen Tier 1 ketorolac 0.5% Tier 1 ACULAR Tier 3 bromfenac 0.075% BROMSITE Tier 3 bromfenac sodium 0.07% PROLENSA Tier 3 ketorolac 0.45% ACUVAIL Tier 3 nepafenac NEVANAC Tier 3 nepafenac 0.3% ILEVRO Tier 3
Steroidal dexamethasone sodium phosphate Tier 1 fluorometholone Tier 1 FML Tier 3 loteprednol 0.5% gel, susp Tier 1 LOTEMAX Gel, Susp Tier 3 prednisolone acetate 1% Tier 1 PRED FORTE Tier 3 prednisolone phosphate 1% Tier 1 difluprednate DUREZOL Tier 2 loteprednol LOTEMAX SM Tier 2 loteprednol 0.2% ALREX Tier 2 loteprednol oint LOTEMAX Oint Tier 2 prednisolone acetate 0.12% PRED MILD Tier 2 rimexolone VEXOL Tier 2 dexamethasone MAXIDEX Tier 3 fluorometholone acetate FLAREX Tier 3 loteprednol 1.0% INVELTYS Tier 3
Antivirals trifluridine Tier 1 ganciclovir ZIRGAN Tier 2
Beta-blockers Nonselective carteolol Tier 1 levobunolol Tier 1 timolol maleate Tier 1 ISTALOL Tier 3 timolol maleate Tier 1 TIMOPTIC Tier 3 timolol maleate gel Tier 1 TIMOPTIC-XE Tier 3 timolol hemihydrate BETIMOL Tier 3
Selective betaxolol BETOPTIC S Tier 3
Carbonic Anhydrase Inhibitors Topical brinzolamide Tier 1 AZOPT Tier 3 dorzolamide Tier 1 TRUSOPT Tier 3
Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate Tier 1 COSOPT Tier 3
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Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations brinzolamide/brimonidine SIMBRINZA Tier 2
Dry Eye Disease PA cyclosporine, emulsion RESTASIS Tier 2 PA lifitegrast XIIDRA Tier 2 PA cyclosporine eye solution CEQUA Tier 3 PA loteprednol etabonate EYSUVIS Tier 3
Mydriatics atropine sulfate soln Tier 1 cyclopentolate Tier 1 CYCLOGYL Tier 3 scopolamine ISOPTO HYOSCINE Tier 2
Neurotrophic Keratitis PA cenegermin-bkbj OXERVATE Tier 4
Parasympathomimetics pilocarpine PILOPINE HS GEL Tier 3
Prostaglandins latanoprost Tier 1 XALATAN Tier 3 travoprost Tier 1 TRAVATAN Z Tier 3 bimatoprost 0.01% LUMIGAN Tier 2 latanoprost ophthalmic emulsion XELPROS Tier 3 latanoprostene bunod VYZULTA Tier 3 tafluprost ZIOPTAN Tier 3
Retinal Disorders PA aflibercept EYLEA Tier 4 PA ranibizumab LUCENTIS Tier 4 PA brolucizumab-dbll BEOVU Tier 5
Rho Kinase Inhibitors netarsudil RHOPRESSA Tier 3
Rho Kinase Inhibitor/Prostaglandin Combinations netarsudil/latanoprost ROCKLATAN Tier 3
Sympathomimetics brimonidine 0.15% Tier 1 ALPHAGAN P 0.15% Tier 3 brimonidine 0.2% Tier 1 brimonidine 0.1% ALPHAGAN P 0.1% Tier 2
Sympathomimetic/Beta-blocker Combinations brimonidine/timolol COMBIGAN Tier 2
Miscellaneous naphazoline Tier 1 PA oxymetazoline opth soln UPNEEQ Tier 3 cysteamine CYSTARAN Tier 4 verteporfin VISUDYNE Tier 4 cysteamine CYSTADROPS Tier 5 PA teprotumumab-trbw for IV soln TEPEZZA Tier 5
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OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org
Anti-infectives acetic acid Tier 1 ciprofloxacin otic Tier 1 CETRAXAL Tier 3 ofloxacin otic Tier 1
Anti-infective/Anti-inflammatory Combinations acetic acid/hydrocortisone Tier 1 ciprofloxacin/dexamethasone Tier 1 CIPRODEX Tier 3 neomycin/polymyxin B/hydrocortisone Tier 1 ciprofloxacin/hydrocortisone CIPRO HC OTIC Tier 2
Miscellaneous fluocinolone acetonide Tier 1 DERMOTIC Tier 3 triethanolamine polypeptide oleate CERUMENEX Tier 3
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WEBSITES Agency for Healthcare Research and Quality American Congress of Obstetricians and https://www.ahrq.gov Gynecologists https://www.acog.org Alzheimer's Association https://www.alz.org American Diabetes Association http://www.diabetes.org American Academy of Allergy, Asthma and Immunology American Gastroenterological Association https://www.aaaai.org https://www.gastro.org
American Academy of Child & Adolescent Psychiatry American Headache Society Committee for Headache https://www.aacap.org Education https://americanheadachesociety.org American Academy of Dermatology https://www.aad.org American Heart Association https://professional.heart.org American Academy of Neurology https://www.aan.com American Lung Association https://www.lung.org American Academy of Ophthalmology https://www.aao.org American Medical Association https://www.ama-assn.org American Academy of Pediatrics https://www.aap.org American Psychiatric Association https://www.psychiatry.org American Association for the Study of Liver Disease https://www.aasld.org American Society of Anesthesiologists https://www.asahq.org American Association of Clinical Endocrinologists https://www.aace.com American Society of Clinical Oncology https://www.asco.org American Association of Diabetes Educators https://www.diabeteseducator.org American Society of Interventional Pain Physicians https://www.asipp.org American Cancer Society https://www.cancer.org American Urological Association https://www.auanet.org American College of Allergy, Asthma and Immunology https://www.acaai.org Centers for Disease Control and Prevention https://www.cdc.gov American College of Cardiology https://www.acc.org Centers for Disease Control and Prevention Guideline topics: AIDS American College of Chest Physicians https://www.cdc.gov/hiv/default.html https://www.chestnet.org Centers for Disease Control and Prevention American College of Gastroenterology Guideline topics: Sexually Transmitted Diseases https://gi.org https://www.cdc.gov/std/treatment/default.htm
American College of Physicians CVS Caremark https://www.acponline.org https://www.caremark.com
American College of Rheumatology The Food and Drug Administration https://www.rheumatology.org https://www.fda.gov
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Global Initiative for Asthma http://www.nfid.org https://ginasthma.org National Guideline Clearinghouse Infectious Diseases Society of America https://www.ahrq.gov https://www.idsociety.org National Heart, Lung and Blood Institute Institute for Safe Medication Practices https://www.nhlbi.nih.gov https://www.ismp.org National Institutes of Health Johns Hopkins AIDS Service https://www.nih.gov https://www.thebody.com/content/art12096.html National Kidney Foundation Juvenile Diabetes Research Foundation International https://www.kidney.org https://www.jdrf.org National Osteoporosis Foundation MedWatch https://www.nof.org https://www.fda.gov/Safety/MedWatch/default.htm North American Menopause Society National Agricultural Library https://www.menopause.org https://www.nal.usda.gov United States Department of Health and Human National Cancer Institute Services https://www.cancer.gov/about-cancer https://www.hhs.gov
National Comprehensive Cancer Network World Health Organization https://www.nccn.org https://www.who.int
National Foundation for Infectious Diseases
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2021 FEP EXCLUDED DRUG LIST STANDARD OPTION CHART These listed drugs are not covered under Standard Option. If you use any of these Excluded Drugs, you will need to pay the full cost of the drug(s).
If you are using one of these non-covered drugs, ask your doctor for one of the covered generic or brand name options.
CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS* 2021 FOR STANDARD OPTION ACNE MINOLIRA azithromycin, doxycycline (except 20 mg), ORAL ANTIBIOTICS minocycline, minocycline ext-rel, sulfamethoxazole/trimethoprim, MINOCIN, SOLODYN, VIBRAMYCIN, ZITHROMAX ACNE adapalene pad, adapalene soln 0.1% adapalene crm, adapalene gel, DIFFERIN TOPICAL ABSORICA LD isotretinoin, ABSORICA
ALLERGIES carbinoxamine 6 mg, RYVENT desloratadine, levocetirizine (Rx), montelukast, ANTIHISTAMINES zafirlukast, ACCOLATE, CLARINEX, CLARINEX- D, SINGULAIR ANAPHYLAXIS TREATMENT AUVI-Q epinephrine injection/auto-injector (0.15 mg, 0.30 mg), EPIPEN, EPIPEN JR., SYMJEPI ANTIDIARRHEALS opium tincture diphenoxylate/atropine, loperamide ANTIFUNGALS TOLSURA fluconazole, itraconazole, ketoconazole, posaconazole delayed-rel tabs, voriconazole, DIFLUCAN, NOXAFIL susp, NOXAFIL tabs, SPORANOX, VFEND ANTI-INFLAMMATORIES fenoprofen cap 200 mg, diclofenac DR/ER, diclofenac gel/soln, NONSTEROIDAL ANTI-INFLAMMATORIES indomethacin caps (20 mg, 40 mg), etodolac/ER, flurbiprofen, ibuprofen, (NSAIDs) meloxicam caps (5 mg, 10 indomethacin/ER (except indomethacin caps 20 mg), naproxen sodium ext-rel mg, 40 mg), ketoprofen/ER, meloxicam tabs, tablets, CAMBIA, FENORTHO, nabumetone, naproxen, oxaprozin, piroxicam, NAPRELAN, PENNSAID 2%, QMIIZ, sulindac RELAFEN DS, TIVORBEX, VIVLODEX, ZIPSOR, ZORVOLEX ANTI-INFLAMMATORIES naproxen/esomeprazole magnesium diclofenac/misoprostol, esomeprazole NONSTEROIDAL ANTI-INFLAMMATORIES tabs DR, DUEXIS, VIMOVO magnesium delayed-rel, famotidine, ibuprofen, (NSAIDs) COMBINATIONS naproxen CONSENSI celecoxib, CELEBREX, AND amlodipine tabs, NORVASC
ANTIRHEUMATICS penicillamine caps, CUPRIMINE azathioprine, hydroxychloroquine, leflunomide, methotrexate, penicillamine tabs, DEPEN ANTISPASMODICS LIBRAX clidinium/chlordiazepoxide, dicyclomine, hyoscyamine DONNATAL atropine/hyoscyamine/scopolamine/phenobarbital
ASTHMA zileuton ext-rel, ZYFLO CR montelukast, zafirlukast, ACCOLATE, LEUKOTRIENE MODULATORS SINGULAIR
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BENIGN PROSTATIC HYPERPLASIA (BPH) UROXATRAL alfuzosin ext-rel, dutasteride, dutasteride/tamsulosin, finasteride, silodosin, tadalafil (2.5mg, 5mg), tamsulosin, AVODART, CIALIS (2.5mg, 5mg), JALYN, PROSCAR, RAPAFLO, FLOMAX BLADDER AGENTS DETROL, DETROL LA, ENABLEX, darifenacin ext-rel, oxybutynin, oxybutynin ext-rel, OXYTROL, VESICARE solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, DITROPAN XL, GELNIQUE, MYRBETRIQ, TOVIAZ, VESICARE LS CARDIOVASCULAR BETAPACE, BETAPACE AF sotalol, sotalol AF ANTIARRHYTHMICS CARDIOVASCULAR aspirin/omeprazole delayed-rel tabs, aspirin*** and esomeprazole magnesium HEART YOSPRALA delayed-rel, lansoprazole, omeprazole, pantoprazole, rabeprazole CENTRAL NERVOUS SYSTEM SYMBYAX olanzapine/fluoxetine ANTIDEPRESSANT COMBINATIONS CENTRAL NERVOUS SYSTEM methylphenidate tab ER osmotic amphetamine/dextroamphetamine mixed MISCELLANEOUS release 72 mg, DESOXYN, JORNAY salts/ER, amphetamine ext-rel susp, PM, RELEXXII amphetamine sulfate, dexmethylphenidate/ER, dextroamphetamine/ER, methylphenidate/ER (except methylphenidate tab ER osmotic release 72 mg), ADDERALL, ADDERALL XR, ADHANSIA XR, ADZENYS ER SUSP, ADZENYS XR-ODT, APTENSIO XR, CONCERTA, COTEMPLA XR-ODT, DAYTRANA, DEXEDRINE, DYANAVEL XR, EVEKEO, EVEKEO ODT, FOCALIN, FOCALIN XR, METHYLIN, MYDAYIS, PROCENTRA, QULLICHEW ER, QUILLIVANT XR, RITALIN, RITALIN LA, VYVANSE, ZENZEDI COTRICOSTEROIDS DEXABLISS, DXEVO 11-DAY, cortisone acetate, dexamethasone, ORAL MILLIPRED fludrocortisone, hydrocortisone, methylprednisolone, prednisolone, prednisone, CORTEF, MEDROL, ORAPRED ODT, RAYOS DERMATOLOGY ALCORTIN-A, XOLEGEL ciclopirox, clotrimazole, ANTIFUNGAL hydrocortisone/iodoquinol, hydrocortisone/iodoquinol/aloe, ketoconazole 2% cream, naftifine, nystatin, terbinafine, ECOZA, NAFTIN DERMATOLOGY halobetasol propionate topical foam, betamethasone dipropionate (crm, lotion, oint), CORTICOSTEROIDS triamcinolone oint 0.05%, BRYHALI, betamethasone dipropionate augmented (crm, LEXETTE, NOVACORT, lotion, gel, oint), clobetasol propionate, OLUX/OLUX-E, PSORCON, diflorasone diacetate, fluocinonide (crm, gel, oint, TRIANEX, VANOS soln), halobetasol propionate crm, triamcinolone acetonide (except triamcinolone oint 0.05%), APEXICON E, CLOBEX, DIPROLENE, DIPROLENE AF, HALOG, KENALOG SPRAY, SERNIVO, TEMOVATE, TOPICORT, ULTRAVATE DERMATOLOGY XERESE acyclovir, hydrocortisone MISCELLANEOUS
68
VEREGEN imiquimod, ALDARA, ZYCLARA
EXTINA ketoconazole foam 2%
OVACE, OVACE PLUS sulfacetamide sodium
DERMATOLOGY SORIATANE, TACLONEX acitretin, betamethasone PSORIASIS dipropionate/calcipotriene (oint, susp), calcitriol, methoxsalen, DOVONEX, OXSORALEN ULTRA, SORILUX DIABETES JENTADUETO, JENTADUETO XR, alogliptin, alogliptin/metformin, DIPEPTIDYL PEPTIDASE-4 (DPP-4) KAZANO, KOMBIGLYZE XR, alogliptin/pioglitazone, JANUMET, JANUMET INHIBITORS/COMBINATIONS NESINA, ONGLYZA, OSENI, XR, JANUVIA TRADJENTA DIABETES SEMGLEE BASAGLAR, LANTUS, LEVEMIR, TOUJEO, INSULINS TRESIBA DIABETES GLUMETZA, RIOMET ER metformin ext-rel, metformin oral soln, METFORMIN FORTAMET, RIOMET IR DIABETES CYCLOSET alogliptin, alogliptin/metformin, OTHER alogliptin/pioglitazone, bromocriptine mesylate, glimepiride, glipizide, glyburide, glyburide/metformin, pioglitazone, repaglinide H2 RECEPTOR ANTAGONISTS PEPCID cimetidine, famotidine 40mg, nizatidine HIGH BLOOD PRESSURE DUTOPROL metoprolol succinate ext-rel, hydrochlorothiazide BETA-BLOCKERS/COMBINATIONS HIGH CHOLESTEROL FENOGLIDE fenofibrate, fenofibric acid del-rel, gemfibrozil, FIBRATES ANTARA, LIPOFEN, LOPID, TRICOR, TRIPLEX HIGH CHOLESTEROL simvastatin susp, ALTOPREV, atorvastatin, ezetimibe/simvastatin, fluvastatin, STATINS FLOLIPID, ZYPITAMAG fluvastatin ext-rel, lovastatin, pravastatin, rosuvastatin, simvastatin, CRESTOR, EZALLOR SPRINKLE, LESCOL XL, LIPITOR, LIVALO, PRAVACHOL, VYTORIN, ZOCOR INFLUENZA AGENTS FLUMADINE oseltamivir, rimantadine, RELENZA, TAMIFLU, XOFLUZA LAXATIVES LACTULOSE PAK 10MG, PCP 100 lactulose solution, PEG 3350/electrolytes, CLENPIQ, GOLYTELY, KRISTALOSE, MOVIPREP, NULYTELY, OSMOPREP, PLENVU, PREPOPIK, SUPREP MIGRAINE AGENTS AJOVY AIMOVIG, EMGALITY 120 mg/mL, VYEPTI CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS UBRELVY NURTEC ODT
MIGRAINE AGENTS REYVOW almotriptan, eletriptan, frovatriptan, naratriptan, SELECTIVE SEROTONIN AGONISTS rizatriptan, sumatriptan, zolmitriptan, AMERGE, FROVA, IMITREX, MAXALT, MAXALT-MLT, ONZETRA XSAIL, RELPAX, TOSYMRA,
69
ZOMIG, ZOMIG-ZMT MOVEMENT DISORDERS TASMAR amantadine, benztropine, bromocriptine, carbidopa/levodopa, entacapone, pramipexole, rasagiline, ropinirole/ER, selegiline, tolcapone, APOKYN, AZILECT, COMTAN, DUOPA, GOCOVRI, KYNMOBI, MIRAPEX, MIRAPEX XR, NEUPRO, OSMOLEX ER, PARLODEL, RYTARY, SINEMET, STALEVO, XADAGO, ZELAPAR MULTIPLE SCLEROSIS AMPYRA dalfampridine ER MUSCLE RELAXANT cyclobenzaprine ext-rel, AMRIX baclofen, cyclobenzaprine MUSCULOSKELETAL AGENTS chlorzoxazone tab (250mg, 375mg, chlorzoxazone tab 500mg MISCELLANEOUS 750mg), LORZONE NAUSEA AND VOMITING THERAPY ANZEMET, ZUPLENZ granisetron, ondansetron, palonosetron, (5HT-3 BLOCKER) promethazine, ALOXI, SANCUSO, ZOFRAN OPHTHALMOLOGY BACIGUENT bacitracin ophthalmic ANTI-INFECTIVES OPHTHALMOLOGY atropine sulfate eye ointment atropine ophthalmic solution, cyclopentolate MISCELLANEOUS ophthalmic solution PAIN MEDICATIONS pregabalin ext-rel tabs, GRALISE, gabapentin, pregabalin (does not include ext-rel NEUROPATHIC PAIN HORIZANT, LYRICA CR tabs), LYRICA, NEURONTIN PAIN MEDICATIONS benzhydrocodone/acetaminophen, codeine/acetaminophen, OPIOIDS hydrocodone-acetaminophen sol 10- hydrocodone/acetaminophen, 325 mg/15 mL, oxycodone/acetaminophen (except 2.5 mg - 300, oxycodone/acetaminophen tab (2.5 5 mg - 300 mg, 10 mg - 300 mg tabs), mg - 300 mg, 5 mg - 300 mg, 10 mg tramadol/acetaminophen, ENDOCET, LORTAB, - 300 mg), APADAZ, NALOCET, PERCOCET PRIMLEV, PROLATE LAZANDA fentanyl buccal, fentanyl sublingual, fentanyl transmucosal, ACTIQ, FENTORA, SUBSYS
levorphanol hydromorphone, morphine, oxycodone, tramadol (except 100mg tab), DILAUDID, NUCYNTA, OPANA, ROXICODONE
tramadol 100 mg tabs, CONZIP tramadol (except 100 mg tabs), tramadol ext-rel, tramadol/acetaminophen, ULTRAM, ULTRAM ER PAIN MEDICATIONS ZTLIDO lidocaine cream, lidocaine gel, lidocaine lotion, TOPICAL lidocaine ointment, lidocaine patch 5%, LIDODERM PATCH, QUTENZA PATCH, XYLOCAINE PROTON PUMP INHIBITORS esomeprazole strontium, rabeprazole esomeprazole magnesium delayed-rel, capsule sprinkle delayed-rel, lansoprazole delayed-rel, omeprazole delayed- ACIPHEX, FIRST-LANSOPRAZOLE, rel, omeprazole/sodium bicarbonate, FIRST-OMEPRAZOLE, NEXIUM, pantoprazole delayed-rel, rabeprazole (except PREVACID, PREVACID SOLUTAB, rabeprazole capsule sprinkle delayed-rel), PRILOSEC, PROTONIX, ZEGERID DEXILANT SLEEP AGENTS SECONAL estazolam, eszopiclone, flurazepam, ramelteon,
70
temazepam, triazolam, zaleplon, zolpidem/ER, AMBIEN, AMBIEN CR, BELSOMRA, EDLUAR, LUNESTA, ROZEREM, ZOLPIMIST ULCERATIVE COLITIS COLAZAL balsalazide, mesalamine delayed-rel (caps, tabs), mesalamine ext-rel caps, sulfasalazine, sulfasalazine delayed, rel, ASACOL HD, APRISO, AZULFIDINE, DELZICOL, DIPENTIUM, LIALDA, PENTASA ULCER THERAPY CARAFATE sucralfate MISCELLANEOUS
*This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.
**For more covered options, consult 2021 Standard Option formulary.
***Low dose aspirin (81 mg) is covered for men age 45 through 79 and women age 12 through 79 and for pregnant women at risk of preeclampsia.
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INDEX
A ADCIRCA, 27 ADDERALL, 31 abacavir, 15 ADDERALL XR, 31 abacavir soln, 15 adefovir dipivoxil, 15 abacavir/dolutegravir/lamivudine, 14 ADEMPAS, 27 abacavir/lamivudine, 14 ADHANSIA XR, 32 abacavir/lamivudine/zidovudine, 14 ADLYXIN, 36 abaloparatide, 39 ADMELOG, 37 abatacept, 51 ADMELOG SOLOSTAR, 37 ABELCET, 14 ado-trastuzumab emtansine, 20 abemaciclib, 18 ADRIAMYCIN, 21 ABILIFY, 31 ADVAIR, 56 ABILIFY MAINTENA, 31 ADVAIR HFA, 56 ABILIFY MYCITE, 31 ADVATE, 49 abiraterone, 18 ADYNOVATE, 49 abobotulinumtoxinA, 35 ADZENYS ER SUSP, 31 ABRAXANE, 21 ADZENYS XR-ODT, 32 absorbable fibrin sealant, 61 AEMCOLO, 13 ABSORICA, 57 afatinib, 19 acalabrutinib, 19 AFINITOR 10 mg, 19 acamprosate calcium, 34 AFINITOR 2.5 mg, 5 mg, 7.5 mg, 18 ACANYA, 57 AFINITOR DISPERZ, 19 acarbose, 36 aflibercept, 63 ACCOLATE, 56 AFREZZA, 37 ACCU-CHEK FASTCLIX LANCET DEVICE, 38 AFSTYLA, 49 ACCU-CHEK FASTCLIX LANCETS, 38 agalsidase beta, 44 ACCU-CHEK METERS AND KITS, 38 AGGRASTAT, 50 ACCU-CHEK TEST STRIPS, 38 AGGRENOX, 50 ACCUPRIL, 22 AGRYLIN, 50 ACCURETIC, 23 AHF, human/VWF, human, 49 acebutolol, 25 AIMOVIG, 33 ACETADOTE, 44 AIRDUO DIGIHALER, 56 acetaminophen inj, 10 AIRDUO RESPICLICK, 56 acetazolamide, 26 AKLIEF, 57 acetazolamide ext-rel, 26 AKYNZEO, 45 acetic acid, 64 albendazole, 16 acetic acid/hydrocortisone, 64 ALBENZA, 16 acetylcysteine, 44 albuterol, 55 acitretin, 58 albuterol ext-rel, 55 aclidinium bromide, 54 albuterol soln, 55 aclidinium bromide/formoterol fumarate, 54 albuterol sulfate aerosol powder 108mcg/actuation with sensor, 55 ACTEMRA, 51 albuterol sulfate aerosol powder breath-activated, 55 ACTHAR, 44 albuterol sulfate, CFC-free aerosol, 55 ACTIGALL, 45 alcaftadine, 61 ACTIMMUNE, 52 alclometasone crm, oint 0.05%, 59 ACTIQ, 11 ALDACTAZIDE, 26 ACTIVELLA, 41 ALDACTONE, 23 ACTONEL, 38 ALDARA, 60 ACTOPLUS MET, 37 aldesleukin, 20 ACTOPLUS MET XR, 37 ALDURAZYME, 44 ACTOS, 37 ALECENSA, 19 ACULAR, 62 alectinib, 19 ACUVAIL, 62 alemtuzumab, 34 acyclovir, 60 alendronate, 38 acyclovir caps, susp, tabs, 16 alendronate/vitamin D3, 39 ACZONE, 16 ALFERON N, 61 ADAKVEO, 50 alfuzosin ext-rel, 47 adalimumab, 51 alglucosidase alfa, 44 adapalene crm, gel, 57 ALIMTA, 17 adapalene/benzoyl peroxide, 57 ALINIA, 16 ADCETRIS, 21 alirocumab, 25
72
aliskiren, 26 amoxicillin/clavulanate susp 600 mg, 13 aliskiren/hydrochlorothiazide, 26 amoxicillin/rifabutin/omeprazole, 47 alitretinoin, 60 amphetamine ext-rel orally disintegrating tabs, 32 ALKERAN inj, 17 amphetamine ext-rel susp, 31 ALKERAN tabs, 17 amphetamine ext-rel suspension, 32 ALKINDI SPRINKLE CAPS, 42 amphetamine sulfate, 31 allopurinol, 10 amphetamine sulfate orally disintegrating tablet, 32 almotriptan, 33 amphetamine/dextroamphetamine mixed salts, 31 alogliptin, 36 amphetamine/dextroamphetamine mixed salts ext-rel, 31, 32 alogliptin/metformin, 36 amphotericin B lipid complex inj, 14 alogliptin/pioglitazone, 36 amphotericin B liposome inj, 14 ALOMIDE, 61 ampicillin, 13 ALORA, 41 ampicillin sodium/sulbactam sodium, 13 alosetron, 46 AMZEEQ, 57 ALOXI, 45 ANAFRANIL, 28 alpelisib, 19 anagrelide, 50 alpha-1 proteinase inhibitor, 54 anakinra, 51 ALPHAGAN P 0.1%, 63 anastrozole, 18 ALPHAGAN P 0.15%, 63 ANDRODERM, 35 ALPHANATE, 49 ANDROGEL, 35 ALPHANINE SD, 49 ANGELIQ, 41 alprazolam, 28 anidulafungin, 14 alprazolam ext-rel, 28 ANNOVERA, 40 ALPROLIX, 49 ANORO ELLIPTA, 54 ALREX, 62 ANTARA, 24 ALTABAX, 58 antihemophilic factor, 49 ALTACE, 22 antihemophilic factor (recombinant) pegylated, 49 alteplase, 50 antihemophilic factor (recombinant) pegylated-aucl, 49 ALUNBRIG, 19 antihemophilic factor (recombinant) porcine sequence, 49 ALVESCO, 56 antihemophilic factor (recombinant), glycopegylated-exei, 49 alvimopan, 47 antihemophilic factor recombinant, Fc fusion protein, 49 amantadine ext-rel, 30 antihemophilic factor, recombinant, 49 amantadine, except tabs, 30 anti-inhibitor coagulant complex, 49 AMARYL, 38 apalutamide, 18 AMBIEN, 32 APEXICON E, 60 AMBIEN CR, 32 APIDRA, 37 AMBISOME, 14 apixaban, 48 ambrisentan, 27 APLENZIN, 30 amcinonide crm, lotion, oint 0.1%, 59 APOKYN, 30 AMELUZ, 58 apomorphine, 30 AMERGE, 33 apremilast, 51 AMICAR, 50 aprepitant, 45 amifampridine, 35 aprepitant caps, 45 amifostine, 20 aprepitant susp, 45 amikacin liposome inhalation susp, 55 APRISO, 46 amiloride, 26 APTENSIO XR, 32 amiloride/hydrochlorothiazide, 26 APTIOM, 29 aminocaproic acid, 50 APTIVUS, 15 aminolevulinic acid gel 10%, 58 ARAKODA, 14 aminolevulinic acid soln, 58 ARALAST NP, 54 amiodarone, 24 ARANESP, 48 AMITIZA, 46 ARAVA, 51 amitriptyline, 30 ARAZLO, 57 amitriptyline/perphenazine, 30 ARCALYST, 52 amlodipine tabs, 25 arformoterol soln, 55 amlodipine/atorvastatin, 26 ARICEPT, 29 amlodipine/olmesartan, 23 ARIKAYCE, 55 amlodipine/telmisartan, 23 ARIMIDEX, 18 amlodipine/valsartan, 23 aripiprazole, 31 amlodipine/valsartan/hydrochlorothiazide, 23 aripiprazole ext-rel inj, 31 ammonium lactate 12%, 60 aripiprazole lauroxil ext-rel inj, 31 amoxicillin, except film-coated tabs, 13 aripiprazole orally disintegrating tabs, 31 amoxicillin/clavulanate, 13 aripiprazole tab with sensor, 31 amoxicillin/clavulanate ext-rel, 13 ARISTADA, 31
73
ARIXTRA, 48 azelastine spray, 56 armodafinil, 34 azelastine/fluticasone nasal spray, 56 ARMONAIR DIGIHALER, 56 AZELEX, 57 ARMOUR THYROID, 43 AZILECT, 30 ARNUITY ELLIPTA, 56 azilsartan, 23 AROMASIN, 18 azilsartan/chlorthalidone, 23 ARRANON, 21 azithromycin, 13, 61 arsenic trioxide, 20 AZOPT, 62 artemether/lumefantrine, 14 AZOR, 23 ARTHROTEC, 10 aztreonam, 16 ARZERRA, 21 aztreonam lysine inhalation soln, 55 ASACOL HD, 46 AZULFIDINE, 46 ASCENIV, 52 AZULFIDINE EN-TABS, 46 asenapine, 31 B asfotase alfa, 44 bacitracin, 61 ASMANEX, 56 baclofen, 34 ASMANEX HFA, 56 baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL), 34 asparaginase, 21 BAFIERTAM, 34 asparaginase Erwinia chrysanthemi, 21 baloxavir, 16 ASPARLAS, 22 balsalazide, 46 aspirin ext-rel, 50 BALVERSA, 19 ASTAGRAF XL, 53 BANZEL, 28 ATACAND, 23 BAQSIMI, 42 ATACAND HCT, 23 BARACLUDE, 16 atazanavir caps, 15 BARACLUDE soln, 16 atazanavir/cobicistat, 14 baricitinib, 51 ATELVIA, 39 BASAGLAR, 37 atenolol, 25 BAVENCIO, 21 atenolol/chlorthalidone, 25 BCG live vaccine, 21 atezolizumab, 21 BD INSULIN SYRINGES AND NEEDLES, 38 ATIVAN, 28 becaplermin, 61 atomoxetine, 31 beclomethasone breath-activated aerosol, 56 atorvastatin, 24 beclomethasone spray, 56 atovaquone, 16 beclomethasone, CFC-free aerosol, 56 atovaquone/proguanil, 14 BECONASE AQ, 56 ATRALIN, 57 bedaquiline, 15 ATRIPLA, 14 belantamab mafodotin-blmf, 21 atropine sulfate soln, 63 belatacept, 53 atropine/hyoscyamine/scopolamine/phenobarbital, 45 BELBUCA, 11 ATROVENT HFA, 54 BELEODAQ, 21 AUBAGIO, 34 belimumab, 53 AUGMENTIN, 13 belinostat, 21 auranofin, 51 BELRAPZO, 17 AURYXIA, 43 BELSOMRA, 32 AUSTEDO, 33 bempedoic acid, 24 AVALIDE, 23 bempedoic acid/ezetimibe, 24 AVANDIA, 37 benazepril, 22 avapritinib, 19 benazepril/amlodipine, 23 AVAPRO, 23 benazepril/hydrochlorothiazide, 23 AVASTIN, 21 bendamustine, 17, 21 avatrombopag, 50 BENDEKA, 21 AVEED, 35 BENEFIX, 49 avelumab, 21 BENICAR, 23 AVODART, 47 BENICAR HCT, 23 AVONEX, 33 BENLYSTA, 53 axitinib, 19 benralizumab, 57 AYGESTIN, 43 BENZAC AC, 57 AYVAKIT, 19 BENZACLIN, 57 azacitidine, 17, 20 BENZAMYCIN, 57 AZACTAM, 16 benzonatate, 55 AZASITE, 61 benzoyl peroxide, 57 azathioprine, 52 benztropine, 30 azelaic acid, 57 BEOVU, 63 azelaic acid gel, 60
74
bepotastine, 61 BRILINTA, 50 BEPREVE, 61 brimonidine 0.1%, 63 BERINERT, 51 brimonidine 0.15%, 63 berotralstat, 51 brimonidine 0.2%, 63 besifloxacin, 61 brimonidine topical gel, 60 BESIVANCE, 61 brimonidine/timolol, 63 BESPONSA, 22 brinzolamide, 62 betaine anhydrous, 44 brinzolamide/brimonidine, 63 betamethasone dipropionate augmented crm 0.05%, 59 brivaracetam, 28 betamethasone dipropionate augmented gel, lot 0.05%, 59 BRIVIACT, 28 betamethasone dipropionate augmented gel, oint 0.05%, 60 brodalumab, 51 betamethasone dipropionate augmented oint 0.05%, 59 brolucizumab-dbll, 63 betamethasone dipropionate crm, lotion, oint 0.05%, 59 bromfenac 0.075%, 62 betamethasone dipropionate spray 0.05%, 60 bromfenac sodium, 62 betamethasone dipropionate/calcipotriene oint, susp, 58 bromfenac sodium 0.07%, 62 betamethasone valerate crm, lotion, oint 0.1%, 59 bromocriptine, 30 BETASERON, 34 BROMSITE, 62 betaxolol, 62 BRONCHITOL, 56 bethanechol, 48 BROVANA, 55 BETHKIS, 55 BRUKINSA, 20 BETIMOL, 62 budesonide, 56 BETOPTIC S, 62 budesonide delayed-rel caps, 46 bevacizumab, 21 budesonide ext-rel caps, 46 bevacizumab-awwb, 21 budesonide inhalation suspension, 56 bevacizumab-bvzr, 21 budesonide/formoterol, 56 BEVESPI AEROSPHERE, 54 budesonide/glycopyrrolate/formoterol, 54 bexarotene caps, 20 bumetanide, 26 bexarotene gel, 21 BUPHENYL, 44 bezlotoxumab, 52 buprenorphine, 11, 34 bicalutamide, 18 buprenorphine ext-rel inj, 34 BICNU, 17 buprenorphine transdermal, 11 bictegravir/emtricitabine/tenofovir alafenamide, 14 buprenorphine/naloxone sublingual film, 34 BIDIL, 26 buprenorphine/naloxone sublingual tabs, 34 BIJUVA, 41 bupropion, 30 BIKTARVY, 14 bupropion ext-rel, 30, 35 bimatoprost 0.01%, 63 burosumab-twza, 44 binimetinib, 19 buspirone, 28 bismuth subsalicylate + metronidazole + tetracycline, 47 busulfan, 17 bisoprolol/hydrochlorothiazide, 25 BUSULFEX, 17 BIVIGAM, 52 butalbital/acetaminophen, 11 BLENREP, 21 butalbital/acetaminophen/caffeine, 11 bleomycin sulfate, 20 butalbital/acetaminophen/caffeine/codeine, 11 BLEPH-10, 61 butalbital/aspirin/caffeine, 11 BLEPHAMIDE SOP, 62 butalbital/aspirin/caffeine/codeine, 11 blinatumomab, 21 butenafine, 58 BLINCYTO, 21 butorphanol nasal spray, 11 blood glucose continuous monitoring receivers, sensors, transmitters, BUTRANS, 11 38 BYDUREON, 36 blood glucose meters and kits, 38 BYDUREON BCISE, 36 blood glucose test strips, 38 BYETTA, 36 BONIVA, 38 BYNFEZIA, 44 BONJESTA, 45 BYSTOLIC, 25 bortezomib, 20 C bosentan, 27 C1 esterase inhibitor, 51 BOSULIF, 19 C1 esterase inhibitor, recombinant, 51 bosutinib, 19 cabazitaxel, 21 BOTOX, 35 CABOMETYX, 19 BRAFTOVI, 19 cabozantinib, 19 brentuximab vedotin, 21 CADUET, 26 BREO ELLIPTA, 56 CAFCIT, 57 BREVIBLOC, 25 CAFERGOT, 33 brexpiprazole, 31 caffeine citrate, 57 BREZTRI AEROSPHERE, 54 CALAN SR, 26 brigatinib, 19
75
calaspargase pegol-mknl, 22 cefpodoxime, 12 calcifediol ext-rel, 43 cefprozil, 12 calcipotriene, 58 ceftaroline fosamil, 13 calcipotriene foam, 58 ceftazidime, 12 calcipotriene/betamethasone dipropionate cream, 58 ceftriaxone, 12 calcipotriene/betamethasone foam, 58 cefuroxime axetil, 12 calcitonin-salmon inj, 39 CELEBREX, 10 calcitonin-salmon spray, 39 celecoxib, 10 calcitriol (1,25-D3), 43 CELEXA, 29 calcitriol oint, 58 CELLCEPT, 52 calcium acetate, 43 cenegermin-bkbj, 63 calcium, magnesium, potassium, and sodium oxybates, 34 cenobamate, 28 CALDOLOR, 10 cephalexin, 12 CALQUENCE, 19 CEPROTIN, 50 CAMPTOSAR, 20 CEQUA, 63 canagliflozin, 37 CERDELGA, 42 canagliflozin/metformin, 37 CEREZYME, 42 canagliflozin/metformin ext-rel, 37 ceritinib, 19 canakinumab, 52 certolizumab pegol, 51 CANASA, 46 CERUMENEX, 64 candesartan, 23 CETRAXAL, 64 candesartan/hydrochlorothiazide, 23 cetrorelix, 41 cangrelor, 50 CETROTIDE, 41 cannabidiol, 29 cetuximab, 21 capecitabine, 17 cevimeline, 47 CAPEX, 59 CHANTIX, 35 CAPLYTA, 31 CHEMSTRIP K URINE KETONE STRIPS, 38 capmatinib, 19 CHEMSTRIP UG URINE GLUCOSE STRIPS, 38 CAPRELSA, 19 CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS, 38 capsaicin 8% patch, 60 chlorambucil, 17 captopril/hydrochlorothiazide, 23 chlordiazepoxide, 28 CARAC, 58 chlordiazepoxide/clidinium, 45 CARBAGLU, 44 chloroquine, 14 carbamazepine, 28, 33 chlorthalidone, 26 carbamazepine ext-rel, 28 CHOLBAM, 47 CARBATROL, 28 cholestyramine pkt, 24 carbidopa/levodopa, 30 cholic acid, 47 carbidopa/levodopa enteral susp, 30 choriogonadotropin alfa, 41 carbidopa/levodopa ext-rel, 30 chorionic gonadotropin, 41, 42 carbidopa/levodopa orally disintegrating tabs, 30 CIALIS, 47 carbidopa/levodopa/entacapone, 30 ciclesonide, 56 carboplatin, 20 ciclesonide spray, 56 CARDIZEM, 26 ciclopirox, 58 CARDIZEM CD, 26 cidofovir, 15 CARDURA, 23 cilostazol, 50 carfilzomib, 22 CILOXAN, 61 carglumic acid, 44 CIMDUO, 14 cariprazine, 31 cimetidine, 45 carmustine, 17 CIMZIA, 51 CARNITOR, 39 cinacalcet, 38 carteolol, 62 CINQAIR, 57 carvedilol, 25 CINRYZE, 51 carvedilol phosphate ext-rel, 25 CINVANTI, 45 CASODEX, 18 CIPRO, 13 CATAPRES, 23 CIPRO HC OTIC, 64 CATAPRES-TTS, 23 CIPRODEX, 64 CATHFLO ACTIVASE, 50 ciprofloxacin, 13, 61 CAYSTON, 55 ciprofloxacin otic, 64 cefaclor, 12 ciprofloxacin/dexamethasone, 64 cefdinir, 12 ciprofloxacin/hydrocortisone, 64 cefepime, 12 cisplatin, 20 cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL, 12 citalopram, 29 cefotaxime, 12 CITRANATAL RX, 53 cefoxitin, 12 cladribine, 17, 34
76
CLARINEX, 54 COMPLERA, 14 CLARINEX-D, 55 COMTAN, 30 clarithromycin, 13 CONCERTA, 32 clarithromycin ext-rel, 13 CONDYLOX, 60 CLENPIQ, 46 conjugated estrogens/bazedoxifene, 41 CLEOCIN, 16 CONJUPRI, 25 CLEOCIN T, 57 COPAXONE, 33 CLEOCIN vaginal supp, 48 COPIKTRA, 19 CLIMARA, 41 CORDRAN crm, lotion, oint, 59 CLIMARA PRO, 41 CORDRAN TAPE, 59 clindamycin, 16 COREG, 25 clindamycin gel, lotion, soln, 57 COREG CR, 25 clindamycin supp, 48 CORIFACT, 49 clindamycin swabs, 57 CORLANOR, 26 clindamycin vaginal cream, 48 CORTEF, 42 clindamycin/benzoyl peroxide, 57 corticotropin, 44 clindamycin/tretinoin, 57 corticotropin powder, 44 CLINDESSE, 48 CORTIFOAM, 46 clobazam, 28 cortisone acetate, 42 clobetasol propionate crm, gel, oint, soln 0.05%, 60 COSENTYX, 58 clobetasol propionate lotion, 60 COSMEGEN, 20 clobetasol propionate lotion, shampoo, spray 0.05%, 60 COSOPT, 62 CLOBEX, 60 COTELLIC, 19 clocortolone pivalate crm 0.1%, 59 COTEMPLA XR-ODT, 32 CLODERM, 59 COZAAR, 23 clofarabine, 17 CREON, 46 CLOLAR, 17 CRESEMBA, 14 clomiphene, 41 CRESTOR, 24 clomipramine, 28 crisaborole oint, 59 clonazepam, 28 CRIXIVAN, 15 clonidine, 23 crizanlizumab-tmca, 50 clonidine ext-rel, 31 crizotinib, 19 clonidine transdermal, 23 crofelemer delayed-rel, 45 clopidogrel, 50 cromolyn sodium, 47, 61 clorazepate, 28 cromolyn soln, 56 clotrimazole, 58 crotamiton crm, 60 clotrimazole troches, 13 crotamiton lotion, 60 clotrimazole/betamethasone, 58 CRYSVITA, 44 clozapine, 31 CUBICIN, 16 clozapine orally disintegrating tabs, 31 CUTAQUIG, 52 CLOZARIL, 31 CUTIVATE, 59 COAGADEX, 49 CUVITRU, 52 coagulation factor IX (recombinant), glycopegylated, 49 CUVPOSA, 47 coagulation factor IX, recombinant, 49 cyanocobalamin inj, 53 coagulation factor VIIa, 49 cyanocobalamin spray, 53 coagulation factor VIIa-jncw, 50 CYANOKIT, 44 coagulation factor X, human, 49 cyclobenzaprine, 34 COARTEM, 14 CYCLOGYL, 63 cobicistat, 14 cyclopentolate, 63 cobimetinib, 19 cyclophosphamide caps, 17 codeine/acetaminophen, 11 CYCLOPHOSPHAMIDE CAPSULES, 17 codeine/promethazine, 55 cyclophosphamide inj, 17 codeine/promethazine/phenylephrine, 55 cyclosporine, 53 colchicine, 10 cyclosporine eye solution, 63 COLCRYS, 10 cyclosporine, emulsion, 63 colesevelam, 24 cyclosporine, modified, 53 COLESTID, 24 CYKLOKAPRON inj, 50 colestipol, 24 CYMBALTA, 29 collagenase clostridium histolyticum, 61 cyproheptadine, 54 COMBIGAN, 63 CYRAMZA, 22 COMBIPATCH, 41 CYSTADANE, 44 COMBIVENT RESPIMAT, 54 CYSTADROPS, 63 COMBIVIR, 14 CYSTAGON, 44 COMETRIQ, 19 CYSTARAN, 63
77
cysteamine, 44, 63 DESCOVY, 14 cysteamine delayed-rel, 44 DESFERAL, 50 cytarabine, 17 desipramine, 30 CYTOGAM, 15 desloratadine, 54 cytomegalovirus immune globulin, 15 desloratadine/pseudoephedrine ext-rel, 55 CYTOMEL, 43 desmopressin spray, 49 CYTOTEC, 47 desmopressin spray, tabs, 44 D desogestrel/EE, 40 desogestrel/EE 0.15/30, 39 D.H.E. 45, 33 DESONATE, 59 dabigatran etexilate, 48 desonide crm 0.05%, 59 dabrafenib, 19 desonide foam 0.05%, 59 dacarbazine, 17 desonide gel 0.05%, 59 DACOGEN, 20 desonide lotion, oint 0.05%, 59 dacomitinib, 19 DESOWEN, 59 dactinomycin, 20 desoximetasone crm, oint 0.05%, 59 dalfampridine ext-rel, 33 desoximetasone crm, oint, spray 0.25%, gel 0.05%, 59 DALIRESP, 56 desvenlafaxine ext-rel, 29 dalteparin, 48 deutetrabenazine, 33 danazol, 40 dexamethasone, 42, 62 DANTRIUM, 34 dexamethasone sodium phosphate, 62 dantrolene, 34 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM, 38 dapagliflozin, 37 DEXEDRINE SPANSULE, 32 dapagliflozin/metformin ext-rel, 37 DEXILANT, 47 dapagliflozin/saxagliptin, 37 dexlansoprazole delayed-rel, 47 dapsone, 16 dexmethylphenidate, 31 daptomycin 500 mg, 16 dexmethylphenidate ext-rel, 31 DARAPRIM, 14 dexrazoxane, 20 daratumumab, 21 dextranomer/sodium hyaluronate, 47 daratumumab/hyaluronidase-fihj, 22 dextroamphetamine, 31 darbepoetin alfa, 48 dextroamphetamine ext-rel, 32 darifenacin ext-rel, 48 dextroamphetamine soln - Procentra, 32 darolutamide, 18 dextromethorphan/quinidine, 35 darunavir, 15 DIACOMIT, 29 darunavir/cobicistat, 14 DIASTAT, 28 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 14 diazepam, 28 DARZALEX, 21 diazepam nasal spray, 28 DARZALEX FASPRO, 22 diazepam rectal gel, 28 dasatinib, 19 diazoxide, 42 daunorubicin, 20 dichlorphenamide, 26 DAURISMO, 22 DICLEGIS, 45 DAYPRO, 10 diclofenac sodium, 62 DAYTRANA, 32 diclofenac sodium 3% gel, 57 DAYVIGO, 32 diclofenac sodium delayed-rel, 10 DDAVP, 44 diclofenac sodium delayed-rel/misoprostol, 10 decitabine, 20 diclofenac sodium ext-rel, 10 decitabine-cedazuridine, 21 diclofenac sodium gel 1%, 10 deferasirox, 50 diclofenac sodium soln, 10 deferiprone, 50 dicloxacillin, 13 deferoxamine, 50 dicyclomine, 45 deflazacort, 35 DIFFERIN, 57 degarelix acetate, 18 DIFICID, 13 DELESTROGEN, 41 diflorasone diacetate crm 0.05%, 59 DELSTRIGO, 14 diflorasone diacetate emollient crm 0.05%, 60 DELZICOL, 46 diflorasone diacetate oint 0.05%, 60 DENAVIR, 61 DIFLUCAN, 13 denosumab, 39 diflunisal, 10 DEPAKOTE, 28 difluprednate, 62 DEPAKOTE ER, 28 digoxin, 26 DEPAKOTE SPRINKLE, 28 dihydroergotamine inj, 33 DEPEN, 51 dihydroergotamine spray, 33 DEPO-PROVERA, 40 DILANTIN, 28 DERMA-SMOOTHE/FS, 59 DILANTIN INFATABS, 28 DERMOTIC, 64 DILAUDID, 11
78
diltiazem, 26 DUETACT, 37 diltiazem ext-rel, 26 dulaglutide, 36 dimethyl fumarate delayed-rel, 33 DULERA, 56 DIOVAN, 23 duloxetine delayed-rel, 29 DIOVAN HCT, 23 duloxetine delayed-release sprinkle capsule, 29 DIPENTUM, 46 DUOPA, 30 diphenhydramine, 30, 54 dupilumab, 59 diphenoxylate/atropine, 45 DUPIXENT, 59 DIPROLENE, 59, 60 DURAGESIC, 11 DIPROLENE AF, 59 DUREZOL, 62 dipyridamole, 50 DURLAZA, 50 dipyridamole ext-rel/aspirin, 50 DUROLANE, 12 diroximel fumarate delayed-rel, 34 durvalumab, 22 disopyramide, 24 dutasteride, 47 disopyramide ext-rel, 24 dutasteride/tamsulosin, 47 disulfiram, 34 duvelisib, 19 DITROPAN XL, 48 DYANAVEL XR, 32 divalproex sodium delayed-rel, 28 DYAZIDE, 26 divalproex sodium ext-rel, 28 DYMISTA, 56 divalproex sodium sprinkle caps, 28 DYSPORT, 35 docetaxel, 20 E dofetilide, 24 E.E.S., 13 DOJOLVI, 53 ecallantide, 51 dolutegravir, 14 econazole, 58 dolutegravir/lamivudine, 14 econazole foam, 58 dolutegravir/rilpivirine, 14 ECOZA, 58 donepezil, 29 eculizumab, 50 donepezil orally disintegrating tabs, 29 edaravone, 35 DOPTELET, 50 EDARBI, 23 DORAL, 32 EDARBYCLOR, 23 doravirine, 15 EDECRIN, 26 doravirine/lamivudine/tenofovir disoproxil fumarate, 14 EDLUAR, 32 dornase alfa, 55 EDURANT, 15 DORYX/MPC, 13 EE/norethindrone acetate, 41 dorzolamide, 62 EE/norethindrone acetate - Jinteli, 41 dorzolamide/timolol maleate, 62 efavirenz, 15 DOVATO, 14 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 14 DOVONEX, 58 efavirenz/lamivudine/tenofovir disoproxil fumarate, 14 doxazosin, 23 EFFEXOR XR, 29 doxepin, 30, 32 EFFIENT, 50 doxepin crm, 60 efinaconazole, 58 doxercalciferol, 43 EFUDEX, 58 DOXIL, 20 EGRIFTA, 44 doxorubicin, 20, 21 elagolix, 40 doxorubicin liposomal, 20 elagolix sodium/estradiol/norethindrone acetate, 44 doxycycline hyclate, 13 elapegademase-lvlr, 44 doxycycline hyclate delayed-rel tabs, 13 ELAPRASE, 44 doxycycline monohydrate, 13 elbasvir/grazoprevir, 16 doxycycline monohydrate delayed-rel caps, 60 ELELYSO, 44 doxylamine/pyridoxine delayed-rel, 45 eletriptan, 33 doxylamine/pyridoxine ext-rel, 45 elexacaftor/tezacaftor/ivacaftor + ivacaftor, 55 DRIZALMA SPRINKLE, 29 ELIDEL, 59 dronabinol, 45 ELIGARD, 18 dronabinol solution, 47 eliglustat, 42 dronedarone, 24 ELIQUIS, 48 drospirenone, 40 ELITEK, 17 drospirenone/EE 3/20, 39 ELIXOPHYLLIN, 57 drospirenone/EE 3/30, 39 ELLENCE, 20 drospirenone/EE/levomefolate 3/30 and levomefolate, 39 ELMIRON, 48 drospirenone/estradiol, 41 ELOCTATE, 49 droxidopa, 27 elosulfase alfa, 44 DUAKLIR PRESSAIR, 54 elotuzumab, 21 DUAVEE, 41 ELSPAR, 21 DUET DHA, 53
79
eltrombopag, 50 eplerenone, 23 eluxadoline, 46 epoetin alfa, 49 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 14 epoetin alfa-epbx, 49 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate, 14 EPOGEN, 49 EMBEDA, 11 epoprostenol, 27 EMEND, 45 epoprostenol sodium, 27 EMFLAZA, 35 eptifibatide, 50 EMGALITY 100 mg/mL, 33 eptinezumab-jjmr, 33 EMGALITY 120 mg/mL, 33 EPZICOM, 14 emicizumab-kxwh, 49 EQUETRO, 33 empagliflozin, 37 ERAXIS, 14 empagliflozin/linagliptin, 37 ERBITUX, 21 empagliflozin/linagliptin/metformin extended-release, 38 erdafitinib, 19 empagliflozin/metformin, 37 erenumab-aooe, 33 empagliflozin/metformin ext-rel, 37 ergocalciferol (D2), 53 EMPLICITI, 21 ergotamine/caffeine supp, 33 EMSAM, 29 ergotamine/caffeine tabs, 33 emtricitabine caps, 15 eribulin, 21 emtricitabine/rilpivirine/tenofovir alafenamide, 14 ERIVEDGE, 21 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 14 ERLEADA, 18 emtricitabine/tenofovir alafenamide, 14 erlotinib, 18 emtricitabine/tenofovir disoproxil fumarate, 14 ERTACZO, 58 EMTRIVA, 15 ertapenem, 16 EMVERM, 17 ertugliflozin, 37 enalapril, 22 ertugliflozin/metformin, 37 enalapril oral soln, 22 ertugliflozin/sitagliptin, 38 enalapril/hydrochlorothiazide, 23 ERWINAZE, 21 enasidenib, 22 ERYGEL, 57 ENBREL, 51 ERYPED, 13 ENBREL SURECLICK, 51 erythromycin, 61 encorafenib, 19 erythromycin delayed-rel, 13 ENDARI, 50 erythromycin delayed-rel - Ery-tab, 13 ENDOMETRIN, 43 erythromycin ethylsuccinate, 13 enfortumab vedotin-ejfv, 22 erythromycin gel 2%, 57 enfuvirtide, 14 erythromycin soln, 57 ENHERTU, 22 erythromycin stearate, 13 enoxaparin, 48 erythromycin/benzoyl peroxide, 57 ENSPRYNG, 51 ESBRIET, 56 ENSTILAR, 58 escitalopram, 29 entacapone, 30 esketamine nasal solution, 30 entecavir soln, 16 eslicarbazepine, 29 entecavir tabs, 16 esmolol, 25 ENTEREG, 47 esomeprazole magnesium delayed-rel, 47 ENTOCORT EC, 46 ESPEROCT, 49 entrectinib, 19 estazolam, 32 ENTRESTO, 26 ESTRACE, 41 ENTYVIO, 46 estradiol, 41 ENVARSUS XR, 53 estradiol transdermal gel, 41 enzalutamide, 18 estradiol transdermal spray, 41 EPANED, 22 estradiol vaginal crm, 41 EPCLUSA, 16 estradiol vaginal inserts, 41 EPIDIOLEX, 29 estradiol vaginal ring, 41 EPIDUO, 57 estradiol vaginal tabs, 41 EPIDUO FORTE, 57 estradiol valerate, 41 EPIFOAM, 47 estradiol valerate and dienogest/estradiol valerate, 40 epinastine, 61 estradiol/levonorgestrel, 41 epinephrine auto-injector 0.15 mg, 54 estradiol/norethindrone acetate, 41 epinephrine auto-injector 0.30 mg, 54 estradiol/norgestimate, 41 epinephrine inj (0.15 mg and 0.30 mg), 54 estradiol/progesterone, 41 EPIPEN, 54 ESTRING, 41 EPIPEN JR., 54 ESTROGEL, 41 epirubicin, 20 estrogens, conjugated, 41 EPIVIR, 15 estrogens, conjugated crm, 41 EPIVIR-HBV, 15 estrogens, conjugated/medroxyprogesterone, 41
80
estrogens, esterified/methyltestosterone, 41 famciclovir, 16 ESTROSTEP FE, 40 famotidine, 45 eszopiclone, 32 fam-trastuzumab deruxtecan-nxki, 22 etanercept, 51 FANAPT, 31 etelcalcetide, 38 FARESTON, 18 eteplirsen, 35 FARXIGA, 37 ethacrynic acid, 26 FARYDAK, 22 ethambutol, 15 FASENRA, 57 ethinyl estradiol/levonorgestrel, 40 FASLODEX, 18 ethosuximide, 28 febuxostat, 10 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 39 fedratinib, 19 ethynodiol diacetate/EE 1/50, 39 FEIBA VH IMMUNO, 49 ETHYOL, 20 felbamate, 28 etodolac, 10 FELBATOL, 28 etodolac ext-rel, 10 FELDENE, 10 etonogestrel implant, 40 felodipine ext-rel, 25 etonogestrel/EE - EluRyng, 40 FEMARA, 18 ETOPOPHOS, 21 FEMHRT, 41 etoposide, 20 FEMRING, 41 etoposide phosphate, 21 fenfluramine, 29 etravirine, 15 fenofibrate, 24 EUCRISA, 59 fenofibric acid delayed-rel, 24 EUFLEXXA, 12 FENSOLVI, 18 EURAX crm, 60 fentanyl citrate buccal, 11 EURAX lotion, 60 fentanyl sublingual spray, 11 EVAMIST, 41 fentanyl transdermal, 11 EVEKEO, 31 fentanyl transmucosal lozenge, 11 EVEKEO ODT, 32 FENTORA, 11 EVENITY, 39 FERAHEME, 53 everolimus 0.25 mg, 0.5 mg, 0.75 mg, 53 ferric carboxymaltose inj, 53 everolimus 1 mg, 53 ferric citrate, 43 everolimus 10 mg, 19 ferric derisomaltose inj, 53 everolimus 2.5 mg, 5 mg, 7.5 mg, 18 FERRIPROX, 50 everolimus tabs for oral suspension, 19 FERRLECIT, 53 EVISTA, 43 ferumoxytol inj, 53 evolocumab, 25 fesoterodine ext-rel, 48 EVOMELA, 22 FETZIMA, 29 EVOTAZ, 14 FIASP, 36 EVOXAC, 47 FIASP FLEXTOUCH, 36 EVRYSDI, 35 fibrinogen, 49, 50 EVZIO, 34 FIBRYGA, 50 EXELDERM, 58 fidaxomicin, 13 EXELON PATCH, 29 filgrastim, 49 exemestane, 18 filgrastim-aafi, 49 exenatide, 36 filgrastim-sndz, 49 exenatide ext-rel, 36 FINACEA, 60 EXFORGE, 23 finasteride, 47 EXFORGE HCT, 23 fingolimod, 33 EXJADE, 50 FINTEPLA, 29 EXONDYS 51, 35 FIORICET, 11 EXTAVIA, 34 FIORICET w/CODEINE, 11 EYLEA, 63 FIORINAL, 11 EYSUVIS, 63 FIRAZYR, 51 EZALLOR SPRINKLE, 24 FIRDAPSE, 35 ezetimibe, 24 FIRMAGON, 18 ezetimibe/simvastatin, 24 FIRVANQ, 17 F FLAGYL, 16 FLAREX, 62 FABIOR, 57 FLEBOGAMMA, 52 FABRAZYME, 44 flecainide, 24 factor IX concentrate, 49 FLOLAN, 27 factor IX recombinant, Fc fusion protein, 49 FLOMAX, 47 factor XIII A-subunit recombinant, 49 FLOVENT, 56 factor XIII concentrate, 49 FLOVENT HFA, 56
81
floxuridine, 17 fostamatinib, 50 fluconazole, 13 fostemsavir ext-rel, 14 fludarabine, 17 FRAGMIN, 48 fludrocortisone, 42 FREESTYLE LIBRE / FREESTYLE LIBRE 2 CONTINUOUS flunisolide spray, 56 GLUCOSE MONITORING SYST, 38 fluocinolone acetonide, 64 FROVA, 33 fluocinolone acetonide crm, oint 0.025%, 59 frovatriptan, 33 fluocinolone acetonide oil 0.01%, 59 FULPHILA, 49 fluocinolone acetonide soln 0.01%, 59 fulvestrant, 18 fluocinolone shampoo 0.01%, 59 furosemide, 26 fluocinonide crm 0.1%, 60 FUZEON, 14 fluocinonide crm, gel, oint, soln 0.05%, 59 FYCOMPA, 29 fluorometholone, 62 G fluorometholone acetate, 62 gabapentin, 28 FLUOROPLEX, 58 GABITRIL, 28 fluorouracil, 58 GALAFOLD, 44 fluorouracil crm 4%, 58 galantamine, 29 fluorouracil inj, 17 galantamine ext-rel, 29 fluoxetine, 29 galcanezumab-gnlm 100 mg/mL, 33 fluoxetine delayed-rel, 29 galcanezumab-gnlm 120 mg/mL, 33 fluphenazine, 31 galsulfase, 44 flurandrenolide crm, lotion, oint 0.05%, 59 GALZIN, 53 flurandrenolide tape, 59 GAMASTAN, 52 flurazepam, 32 GAMASTAN S-D, 52 flurbiprofen, 10, 62 GAMMAGARD LIQUID, 52 flutamide, 18 GAMMAGARD S-D, 52 fluticasone, 56 GAMMAKED, 52 fluticasone furoate spray, 56 GAMMAPLEX, 52 fluticasone propionate, 56 GAMUNEX-C, 52 fluticasone propionate crm 0.05%, oint 0.005%, 59 ganciclovir, 62 fluticasone propionate lotion 0.005%, 59 ganciclovir inj, 15 fluticasone spray, 56 GANIRELIX ACETATE, 41 fluticasone, CFC-free aerosol, 56 ganirelix acetate inj, 41 fluticasone/salmeterol, 56 GASTROCROM, 47 fluticasone/salmeterol, CFC-free aerosol, 56 GATTEX, 47 fluticasone/umeclidinium/vilanterol, 54 GAVRETO, 19 fluticasone/vilanterol, 56 GAZYVA, 21 fluvastatin, 24 gefitinib, 19 fluvastatin ext-rel, 24 GELNIQUE, 48 fluvoxamine, 28 GEL-ONE, 11 fluvoxamine ext-rel, 28 GELSYN-3, 11 FML, 62 GEMCITABINE, 17 FOCALIN, 31 gemcitabine inj, 17 FOCALIN XR, 31 gemfibrozil, 24 folic acid, 53 gemtuzumab ozogamicin, 22 FOLLISTIM AQ, 42 GENOTROPIN, 42 follitropin alfa, 42 gentamicin crm, 58 follitropin beta, 42 gentamicin/prednisolone acetate, 62 FOLOTYN, 17 GENVOYA, 14 fondaparinux, 48 GEODON, 31 FORADIL, 55 GILENYA, 33 FORFIVO XL, 30 GILOTRIF, 19 formoterol inhalation caps, 55 gilteritinib, 19 formoterol inhalation soln, 55 GIMOTI, 45 FORTAMET, 36 GIVLAARI, 47 FORTEO, 39 givosiran, 47 FORTESTA, 35 glasdegib, 22 FOSAMAX, 38 GLASSIA, 54 FOSAMAX PLUS D, 39 glatiramer, 33 fosamprenavir, 15 glatiramer - Glatopa, 33 fosinopril, 22 glecaprevir/pibrentasvir, 16 fosinopril/hydrochlorothiazide, 23 GLEEVEC, 18 FOSRENOL CHEWABLE TABLETS, 43 GLEOSTINE, 17 FOSRENOL ORAL POWDER, 43
82
glimepiride, 38 HERZUMA, 21 glipizide, 38 HETLIOZ, 32 glipizide ext-rel, 38 high molecular weight hyaluronan, 11 glipizide/metformin, 36 HIPREX, 16 GLUCAGEN, 42 histrelin acetate, 18, 44 GLUCAGON EMERGENCY KIT, 42 HIZENTRA, 52 glucagon nasal powder, 42 HUMALOG, 37 glucagon subcutaneous soln, 42 HUMALOG MIX, 37 glucagon, human recombinant, 42 human coagulation factor VIII (rDNA) simoctocog alfa, 49 glucagon, human recombinant (KIT), 42 HUMATE-P, 49 glucarpidase, 21 HUMATROPE, 42 GLUCOTROL, 38 HUMIRA, 51 GLUCOTROL XL, 38 HUMULIN 70/30, 37 glyburide, 38 HUMULIN N, 37 glyburide, micronized, 38 HUMULIN R, 37 glyburide/metformin, 36 HUMULIN R U-500, 37 glycerol phenylbutyrate, 44 HYALGAN, 11 glycopyrrolate, 47 hyaluronate sodium, 11 glycopyrrolate inhalation powder, 54 HYCAMTIN, 20 glycopyrrolate inhalation solution, 54 HYCAMTIN inj, 20 glycopyrrolate/formoterol, 54 hydralazine, 27 GLYNASE, 38 HYDREA, 20 GLYXAMBI, 37 hydrochlorothiazide, 26 GOCOVRI, 30 hydrocodone ext-rel caps, 11 golimumab, 51 hydrocodone ext-rel tabs, 11 golodirsen, 35 hydrocodone/acetaminophen, 11 GOLYTELY, 46 hydrocodone/homatropine, 55 gonadorelin, 41 hydrocortisone, 42 GONAL-F, 42 hydrocortisone acetate foam, 46 GONAL-F RFF, 42 hydrocortisone acetate/pramoxine foam, 47 GONITRO, 27 hydrocortisone butyrate crm 0.1%, 59 goserelin acetate, 18 hydrocortisone butyrate crm, lotion, oint, soln 0.1%, 59 granisetron, 45 hydrocortisone crm 2.5%, 59 granisetron ext-rel inj, 45 hydrocortisone enema, 46 granisetron transdermal, 45 hydrocortisone probutate crm 0.1%, 59 GRANIX, 49 hydrocortisone valerate crm, oint 0.2%, 59 grass mixed pollen allergen extract, 51 hydrocortisone/aloe polysaccharide/iodoquinol, 60 griseofulvin microsize, 13 hydrocortisone/iodoquinol, 60 griseofulvin ultramicrosize, 13 hydromorphone, 11 guanfacine ext-rel, 32 hydromorphone ext-rel, 11 guselkumab, 58 hydroxocobalamin, 44 GVOKE, 42 hydroxychloroquine, 51 H hydroxyprogesterone caproate, 43 hydroxyurea, 20, 22 HAEGARDA, 51 hydroxyzine HCl, 28, 54 HALAVEN, 21 hydroxyzine pamoate, 28, 54 halcinonide crm, oint, soln 0.1%, 60 hylan G-F 20, 11 HALDOL, 31 HYMOVIS, 11 HALDOL DECANOATE 100, 31 hyoscyamine sulfate, 45 halobetasol propionate crm, oint 0.05%, 60 hyoscyamine sulfate ext-rel, 45 HALOG, 60 HYPERHEP B S-D, 52 haloperidol, 31 HYPERRHO S-D, 52 haloperidol decanoate inj, 31 HYQVIA, 52 haloperidol lactate inj, 31 HYSINGLA ER, 11 HARVONI, 16 HYZAAR, 23 HECTOROL, 43 HEMADY, 42 I HEMLIBRA, 49 ibalizumab-uiyk, 15 HEMOFIL M, 49 ibandronate, 38 HEPAGAM B, 52 IBRANCE, 19 hepatitis B immune globulin, 52 ibrutinib, 19 HEPSERA, 15 ibuprofen, 10 HERCEPTIN, 22 ibuprofen inj, 10 HERCEPTIN HYLECTA, 22 icatibant, 51
83
ICLUSIG, 19 INSPRA, 23 icosapent ethyl caps 1 gm, 25 insulin aspart, 36 IDAMYCIN PFS, 20 INSULIN ASPART, 36 idarubicin, 20 insulin aspart protamine 70%/insulin aspart 30%, 36, 37 idelalisib, 19 INSULIN ASPART PROTAMINE 70%/INSULIN ASPART 30%, 36 IDELVION, 49 insulin degludec, 37 IDHIFA, 22 insulin detemir, 37 idursulfase, 44 insulin glargine, 37 IFEX, 20 insulin glulisine, 37 ifosfamide, 20 insulin human, 37 ifosfamide/mesna, 17 insulin human inhalation powder, 37 ILARIS, 52 insulin isophane human, 37 ILEVRO, 62 insulin isophane human 70%/regular 30%, 37 iloperidone, 31 insulin lispro, 37 iloprost, 27 INSULIN LISPRO, 37 ILUMYA, 51 insulin lispro protamine/insulin lispro, 37 imatinib mesylate, 18 INSULIN LISPRO PROTAMINE/INSULIN LISPRO, 37 IMBRUVICA, 19 insulin lispro-aabc, 37 IMFINZI, 22 insulin pen needles, 38 imiglucerase, 42 insulin syringes, needles, 38 imipenem/cilastatin, 16 INTEGRILIN, 50 imipramine HCl, 30 INTELENCE, 15 imipramine pamoate, 30 interferon alfa-2b, 52 imiquimod, 60 interferon alfa-n3, 61 imiquimod crm 3.75%, 60 interferon beta-1a, 33 IMITREX, 33 interferon beta-1b, 34 IMLYGIC, 21 interferon gamma-1b, recombinant, 52 immune globulin (human)-ifas, 52 INTRAROSA, 44 immune globulin (human)-klhw, 52 intrauterine copper contraceptive, 40 immune globulin (human)-slra, 52 INTRON A, 52 immune globulin, gamma, 52 INTUNIV, 32 immune globulin, gamma (IGG), 52 INVANZ, 16 immune globulin, intravenous, 52 INVEGA, 31 immune globulin, subcutaneous, 52 INVEGA SUSTENNA, 31 immune globulin/hyaluronidase, 52 INVEGA TRINZA, 31 immune globulin-hipp, 52 INVELTYS, 62 IMPAVIDO, 17 INVIRASE, 15 IMPEKLO, 60 INVOKAMET, 37 IMURAN, 52 INVOKAMET XR, 37 IMVEXXY, 41 INVOKANA, 37 INBRIJA, 30 ipilimumab, 21 incobotulinumtoxinA, 35 ipratropium nasal spray, 57 INCRELEX, 43 ipratropium soln, 54 INCRUSE ELLIPTA, 54 ipratropium, CFC-free aerosol, 54 indacaterol/glycopyrrolate inhalation powder, 54 ipratropium/albuterol soln, 54 indapamide, 26 ipratropium/albuterol, CFC-free aerosol, 54 INDERAL LA, 25 irbesartan, 23 indinavir, 15 irbesartan/hydrochlorothiazide, 23 INDOCIN susp, 10 IRESSA, 19 indomethacin (except caps 20 mg, 40 mg), 10 irinotecan, 20 indomethacin ext-rel, 10 irinotecan liposome inj, 20 indomethacin susp, 10 iron sucrose inj, 53 INFLECTRA, 51 isatuximab-irfc, 20 infliximab, 51 isavuconazonium, 14 infliximab-abda, 51 ISENTRESS, 14 infliximab-dyyb, 51 isocarboxazid, 29 INGREZZA, 35 isoniazid, 15 INJECTAFER, 53 ISOPTO HYOSCINE, 63 INLYTA, 19 ISORDIL, 27 INNOPRAN XL, 25 isosorbide dinitrate oral, 27 inotersen, 44 isosorbide dinitrate/hydralazine, 26 inotuzumab ozogamicin, 22 isosorbide mononitrate, 27 INQOVI, 21 isosorbide mononitrate ext-rel, 27 INREBIC, 19 isotretinoin, 57
84
ISTALOL, 62 KITABIS PAK, 55 ISTODAX, 20 KLISYRI, 58 istradefylline, 30 KLONOPIN, 28 ISTURISA, 45 KOATE-DVI, 49 itraconazole, 13 KOGENATE FS, 49 ivabradine, 26 KORLYM, 44 ivacaftor, 55 KOSELUGO, 19 ivermectin, 60 KOVALTRY, 49 ivermectin crm 1%, 60 KRINTAFEL, 14 ivosidenib, 22 KRISTALOSE pak, 46 ixabepilone, 21 KRYSTEXXA, 10 ixazomib, 20 KUVAN, 43 ixekizumab, 51 KYLEENA, 40 IXEMPRA, 21 KYNMOBI, 30 IXINITY, 49 KYPROLIS, 22 J L JADENU, 50 lacosamide, 28 JAKAFI, 19 lactic acid/citric acid/potassium bitartrate gel, 40 JALYN, 47 lactulose, 46 JANUMET, 36 lactulose soln, 46 JANUMET XR, 36 LAMICTAL, 28 JANUVIA, 36 LAMICTAL ODT, 28 JARDIANCE, 37 LAMICTAL XR, 28 JEVTANA, 21 lamivudine, 15 JIVI, 49 lamivudine/tenofovir disoproxil fumarate, 14 JUBLIA, 58 lamivudine/zidovudine, 14 JULUCA, 14 lamotrigine, 28 JUXTAPID, 25 lamotrigine ext-rel, 28 JYNARQUE, 44 lamotrigine orally disintegrating tabs, 28 K LAMPIT, 17 lanadelumab-flyo, 52 KADCYLA, 20 lancet device, 38 KALBITOR, 51 lancets, 38 KALETRA, 15 LANOXIN, 26 KALYDECO, 55 lanreotide acetate, 44 KANJINTI, 21 lansoprazole + amoxicillin + clarithromycin, 47 KANUMA, 44 lansoprazole delayed-rel, 47 KAPSPARGO, 25 lanthanum carbonate chew tabs, 43 KAPVAY, 31 lanthanum oral powder, 43 KEFLEX, 12 LANTUS, 37 KENALOG SPRAY, 60 lapatinib, 18 KENGREAL, 50 laronidase, 44 KEPIVANCE, 47 larotrectinib, 19 KEPPRA, 28 LASIX, 26 KEPPRA XR, 28 LASTACAFT, 61 KERYDIN, 58 latanoprost, 63 KESIMPTA, 34 latanoprost ophthalmic emulsion, 63 ketoconazole, 58 latanoprostene bunod, 63 ketoconazole shampoo 2%, 59 LATUDA, 31 ketoconazole tabs, 13 ledipasvir/sofosbuvir, 16 ketoprofen, 10 lefamulin, 13 ketoprofen ext-rel, 10 leflunomide, 51 ketorolac, 10 lemborexant, 32 ketorolac 0.45%, 62 LEMTRADA, 34 ketorolac 0.5%, 62 lenalidomide, 20 ketorolac tromethamine nasal spray, 10 lenvatinib, 19 KEVEYIS, 26 LENVIMA, 19 KEVZARA, 51 LESCOL XL, 24 KEYTRUDA, 18 LETAIRIS, 27 KHAPZORY, 22 letermovir, 15 KINERET, 51 letrozole, 18 KISQALI, 19 leucovorin calcium, 20 KISQALI FEMARA CO-PACK, 19 LEUKERAN, 17
85
LEUKINE, 49 lixisenatide, 36 leuprolide acetate, 18, 44 lixisenatide/insulin glargine, 36 leuprolide acetate/norethindrone acetate, 41 LO LOESTRIN FE, 40 levalbuterol inhalation soln, 55 LOCOID, 59 levalbuterol nebulizer soln concentrate, 55 LOCOID LIPOCREAM, 59 levalbuterol tartrate, CFC-free aerosol, 55 lodoxamide, 61 levamlodipine maleate, 25 LOKELMA, 43 LEVAQUIN, 13 lomitapide, 25 LEVATOL, 25 LOMOTIL, 45 LEVBID, 45 lomustine, 17 LEVEMIR, 37 lonafarnib, 44 levetiracetam, 28 LONHALA MAGNAIR, 54 levetiracetam ext-rel, 28 LONSURF, 22 levobunolol, 62 loperamide, 45 levocarnitine, 39 LOPID, 24 levocetirizine, 54 lopinavir/ritonavir, 15 levodopa inhalation powder, 30 LOPRESSOR, 25 levofloxacin, 13, 61 LOPROX, 58 levoleucovorin, 22 lorazepam, 28 levoleucovorin calcium, 20 LORBRENA, 19 levomilnacipran ext-rel, 29 lorlatinib, 19 levonorgestrel/EE - Trivora, 40 losartan, 23 levonorgestrel/EE 0.09/20 - Amethyst, 40 losartan/hydrochlorothiazide, 23 levonorgestrel/EE 0.1/20, 39 LOSEASONIQUE, 40 levonorgestrel/EE 0.1/20 and EE 10, 40 LOTEMAX Gel, Susp, 62 levonorgestrel/EE 0.15/30, 39 LOTEMAX Oint, 62 levonorgestrel/EE 0.15/30 - Jolessa, 40 LOTEMAX SM, 62 levonorgestrel/EE 0.15/30 - Levora, 39 LOTENSIN, 22 levonorgestrel/EE 0.15/30 and EE 10, 40 LOTENSIN HCT, 23 levonorgestrel-releasing IUD, 40 loteprednol, 62 levothyroxine, 43 loteprednol 0.2%, 62 levothyroxine - Levoxyl, 43 loteprednol 0.5% gel, susp, 62 LEVSIN, 45 loteprednol 1.0%, 62 LEVULAN KERASTICK, 58 loteprednol etabonate, 63 LEXAPRO, 29 loteprednol oint, 62 LEXIVA, 15 LOTREL, 23 L-glutamine oral powder, 50 LOTRONEX, 46 LIALDA, 46 lovastatin, 24 lidocaine, 60 LOVAZA, 25 lidocaine patch, 60 LOVENOX, 48 lidocaine viscous, 61 loxapine, 31 lidocaine/prilocaine, 60 lubiprostone, 46 LIDODERM, 60 LUCENTIS, 63 lifitegrast, 63 luliconazole, 58 LILETTA, 40 lumacaftor/ivacaftor, 55 linaclotide, 46 lumateperone, 31 lindane, 60 LUMIGAN, 63 linezolid, 16 LUMIZYME, 44 LINZESS, 46 LUMOXITI, 22 LIORESAL INTRATHECAL, 34 LUNESTA, 32 liothyronine, 43 LUPANETA PACK, 41 LIPITOR, 24 LUPKYNIS, 53 LIPOFEN, 24 LUPRON DEPOT, 18 liraglutide, 36 LUPRON DEPOT-PED, 44 liraglutide/insulin degludec, 36 lurasidone, 31 lisdexamfetamine, 32 lurbinectedin, 17 lisinopril, 22 luspatercept-aamt, 50 lisinopril oral soln, 22 lusutrombopag, 50 lisinopril/hydrochlorothiazide, 23 LUTREPULSE, 41 lithium carbonate, 33 LUZU, 58 lithium carbonate ext-rel tabs 300 mg, 33 LYNPARZA, 21 lithium carbonate ext-rel tabs 450 mg, 33 LYRICA, 32 LITHOBID, 33 LYSODREN, 20 LIVALO, 24 LYSTEDA, 50
86
LYUMJEV/KWIKPEN, 37 metformin ext-rel, 36 M metformin oral soln, 36 methadone, 11 macitentan, 27 methamphetamine, 32 MACROBID, 16 methazolamide, 26 MACRODANTIN, 16 methenamine hippurate, prophylaxis, 16 mafenide acetate packets 5%, 58 methimazole, 43 MAKENA, 43 methotrexate auto-injector, 51 MALARONE, 14 methotrexate inj, 51 mannitol inhalation powder, 56 methotrexate oral, 51 maraviroc, 14 methoxsalen oral, 58 MARINOL, 45 methoxy polyethylene glycol/epoetin beta, 49 MARPLAN, 29 methylergonovine, 44 MARQIBO, 21 METHYLIN, 32 MATULANE, 21 methylnaltrexone, 46 MAVENCLAD, 34 methylphenidate, 32 MAVYRET, 16 methylphenidate ext-rel, 32 MAXALT/MAXALT-MLT, 33 methylphenidate ext-rel (except methylphenidate tab ER osmotic MAXIDEX, 62 release 72 mg), 32 MAXITROL, 61 methylphenidate ext-rel caps, 32 MAXZIDE, 26 methylphenidate ext-rel chewable tabs, 32 MAXZIDE-25, 26 methylphenidate ext-rel orally disintegrating tablets, 32 MAYZENT, 34 methylphenidate ext-rel susp, 32 mebendazole, 17 methylphenidate transdermal, 32 mecamylamine, 27 methylprednisolone, 42 mecasermin, 43 metoclopramide, 45 mechlorethamine gel, 17 metoclopramide nasal spray, 45 meclizine, 45 metolazone, 26 MEDROL, 42 metoprolol succinate ext-rel, 25 medroxyprogesterone acetate, 43 metoprolol tartrate, 25 medroxyprogesterone acetate 150 mg/mL, 40 metoprolol/hydrochlorothiazide, 25 mefloquine, 14 metreleptin, 44 megestrol acetate, 18 METROCREAM, 60 megestrol acetate susp, 43 METROGEL, 60 MEKINIST, 19 METROLOTION, 60 MEKTOVI, 19 metronidazole crm, 60 meloxicam tabs, 10 metronidazole crm 0.75%, 60 melphalan, 22 metronidazole gel 0.75%, 60 melphalan inj, 17 metronidazole gel 1%, 60 melphalan tabs, 17 metronidazole lotion 0.75%, 60 memantine soln, 29 metronidazole tabs, 16 memantine tabs, 29 metronidazole vaginal, 48 MENOPUR, 42 mexiletine, 24 menotropins, 42 MIACALCIN, 39 MENTAX, 58 MIACALCIN inj, 39 MEPHYTON, 53 micafungin, 13 mepolizumab, 56 MICARDIS, 23 MEPRON, 16 MICARDIS HCT, 23 MEPSEVII, 44 miconazole nitrate/zinc oxide, 58 mercaptopurine, 17 MICRHOGAM, 52 mercaptopurine susp, 18 MICRHOGAM PLUS, 52 meropenem, 16 midazolam nasal spray, 29 mesalamine delayed-rel caps, 46 midodrine, 27 mesalamine delayed-rel tabs, 46 midostaurin, 19 mesalamine ext-rel caps, 46 mifepristone, 44 mesalamine rectal susp, 46 migalastat, 44 mesalamine supp, 46 MIGERGOT, 33 mesna inj, 20 miglitol, 36 mesna tabs 400 mg, 21 miglustat, 44 MESNEX, 21 MIGRANAL, 33 MESNEX inj, 20 milnacipran, 32 MESTINON, 34 miltefosine, 17 MESTINON TIMESPAN, 34 MINIPRESS, 23 metformin, 36 MINIVELLE, 41
87
MINOCIN, 13 N minocycline, 13 NABI-HB, 52 minocycline ext-rel, 13 nabumetone, 10 minocycline ext-rel caps, 57 nafarelin, 40 minocycline foam, 60 naftifine, 58 minocycline hcl micronized foam, 57 naftifine gel 2%, 58 minoxidil tabs, 27 NAFTIN (EXCEPT 2% GEL), 58 mirabegron ext-rel, 48 NAFTIN GEL 2%, 58 MIRAPEX, 30 NAGLAZYME, 44 MIRAPEX ER, 30 naloxegol, 46 MIRCERA, 49 naloxone auto-injector, 34 MIRCETTE, 40 naloxone inj, 34 MIRENA, 40 naloxone nasal spray, 34 mirtazapine, 30 naltrexone, 34 MIRVASO, 60 naltrexone microspheres, 34 misoprostol, 47 NAMENDA tabs, 29 MITIGARE, 10 naphazoline, 63 mitomycin, 20 NAPROSYN, 10 mitotane, 20 naproxen, 10 mitoxantrone, 20 naproxen sodium, 10 MOBIC, 10 naratriptan, 33 modafinil, 34 NARCAN, 34 mogamulizumab-kpkc, 22 NARDIL, 29 mometasone, 56 NASCOBAL, 53 mometasone crm, lotion, oint 0.1%, 59 NASONEX, 56 mometasone spray, 56 NATACYN, 61 mometasone, CFC-free aerosol, 56 natalizumab, 34 mometasone/formoterol, 56 natamycin, 61 MONOFERRIC, 53 NATAZIA, 40 monomethyl fumarate, 34 nateglinide, 37 MONONINE, 49 NATPARA, 39 MONOVISC, 12 NATROBA, 60 montelukast, 56 NAVELBINE, 20 MORPHABOND, 11 NAYZILAM, 29 morphine, 11 nebivolol, 25 morphine ext-rel, 11 necitumumab, 21 morphine supp, 11 nefazodone, 30 morphine/naltrexone ext-rel, 11 nelarabine, 21 MOVANTIK, 46 nelfinavir, 15 MOVIPREP, 46 neomycin/dexamethasone, 61 moxetumomab pasudotox-tdfk, 22 neomycin/polymyxin B/dexamethasone, 61 MOXEZA, 61 neomycin/polymyxin B/gramicidin, 61 moxifloxacin, 61 neomycin/polymyxin B/hydrocortisone, 64 MOZOBIL, 50 neomycin/polymyxin B/hydrocortisone susp, 61 MS CONTIN, 11 NEORAL, 53 MULPLETA, 50 nepafenac, 62 MULTAQ, 24 nepafenac 0.3%, 62 mupirocin, 58 neratinib, 19 MVASI, 21 NERLYNX, 19 MYALEPT, 44 netarsudil, 63 MYAMBUTOL, 15 netarsudil/latanoprost, 63 MYCAMINE, 13 netupitant/palonosetron, 45 MYCAPSSA, 44 NEULASTA, 49 MYCOBUTIN, 16 NEUPOGEN, 49 mycophenolate mofetil, 52 NEUPRO, 30 mycophenolate sodium delayed-rel, 52 NEURONTIN, 28 MYDAYIS, 32 NEVANAC, 62 MYFORTIC, 52 nevirapine, 15 MYLERAN, 17 nevirapine ext-rel, 15 MYLOTARG, 22 NEXAVAR, 19 MYOBLOC, 35 NEXLETOL, 24 MYRBETRIQ, 48 NEXLIZET, 24 MYSOLINE, 28 NEXPLANON, 40 MYTESI, 45
88
niacin ext-rel, 25 NOVAREL, 42 NIASPAN, 25 NOVOEIGHT, 49 nicardipine, 25 NOVOFINE PEN NEEDLES, 38 nifedipine ext-rel, 25 NOVOLIN 70/30, 37 nifurtimox, 17 NOVOLIN N, 37 NILANDRON, 18 NOVOLIN R, 37 nilotinib, 19 NOVOLOG, 36 nilutamide, 18 NOVOLOG MIX 70/30, 37 nimodipine, 25 NOVOSEVEN RT, 49 NIMOTOP, 25 NOXAFIL susp, 14 NINLARO, 20 NOXAFIL tabs, 13 nintedanib, 56 NPLATE, 50 NIPENT, 17 NUBEQA, 18 niraparib, 21 NUCALA, 56 nisoldipine ext-rel, 25 NUCYNTA, 11 nitazoxanide tabs, 16 NUCYNTA ER, 11 nitisinone, 42 NUEDEXTA, 35 NITRO-BID, 27 NULOJIX, 53 NITRO-DUR, 27 NULYTELY, 46 nitrofurantoin ext-rel, 16 NUPLAZID, 31 nitrofurantoin macrocrystals, 16 NURTEC ODT, 33 nitroglycerin lingual spray, 27 NUTROPIN AQ, 42 nitroglycerin ointment, 27 NUTROPIN AQ NUSPIN, 42 nitroglycerin rectal oint 0.4%, 47 NUVARING, 40 nitroglycerin sublingual, 27 NUVIGIL, 34 nitroglycerin sublingual aerosol, 27 NUWIQ, 49 nitroglycerin sublingual powder, 27 NUZYRA, 13 nitroglycerin transdermal, 27 nystatin, 13, 58 NITROLINGUAL, 27 NYVEPRIA, 49 NITROMIST, 27 O NITROSTAT, 27 obeticholic acid, 47 NITYR, 42 obinutuzumab, 21 NIVESTYM, 49 OBIZUR, 49 nivolumab, 21 OCALIVA, 47 nizatidine, 45 ocrelizumab, 34 NIZORAL SHAMPOO, 59 OCREVUS, 34 NORDITROPIN, 42 OCTAGAM, 52 norelgestromin/EE, 40 octreotide, 44 norethindrone, 40 octreotide acetate, 44 norethindrone acetate, 43 OCUFLOX, 61 norethindrone acetate/EE 1.5/30, 39 ODEFSEY, 14 norethindrone acetate/EE 1.5/30 and iron, 39 ODOMZO, 22 norethindrone acetate/EE 1/10 and EE 10 and iron, 40 ofatumumab, 21, 34 norethindrone acetate/EE 1/20, 39 OFEV, 56 norethindrone acetate/EE 1/20 and iron, 39 OFIRMEV, 10 norethindrone acetate/EE and iron, 40 ofloxacin, 13, 61 norethindrone/EE, 40 ofloxacin otic, 64 norethindrone/EE 0.4/35, 39 OGIVRI, 21 norethindrone/EE 0.5/35, 39 olanzapine, 31 norethindrone/EE 1/35, 39 olanzapine pamoate ext-rel inj, 31 norgestimate/EE, 40 olanzapine/fluoxetine, 31 norgestimate/EE 0.25/35, 39 olaparib, 21 norgestrel/EE 0.3/30 - Cryselle, 39 olmesartan, 23 norgestrel/EE 0.3/30 - Low-Ogestrel, 39 olmesartan/amlodipine/hydrochlorothiazide, 24 norgestrel/EE 0.5/50, 40 olmesartan/hydrochlorothiazide, 23 NORITATE, 60 olodaterol, CFC-free aerosol, 55 NORPACE, 24 olopatadine, 61 NORPACE CR, 24 olopatadine spray, 56 NORPRAMIN, 30 olsalazine, 46 NORTHERA, 27 OLUMIANT, 51 nortriptyline, 30 omacetaxine mepesuccinate, 21 NORVASC, 25 omadacycline, 13 NORVIR, 15 omalizumab, 56 NOURIANZ, 30
89
omega-3 acid ethyl esters, 25 oxycodone soln, 11 omeprazole delayed-rel, 47 oxycodone/acetaminophen 5/325, 11 omeprazole/sodium bicarbonate, 47 OXYCONTIN, 11 OMNARIS, 56 oxymetazoline crm 1%, 60 OMNITROPE, 42 oxymetazoline opth soln, 63 onabotulinumtoxinA, 35 oxymorphone, 11 ONCASPAR, 21 ozanimod, 34 ondansetron, 45 OZEMPIC, 36 ondansetron orally disintegrating tabs, 45 ozenoxacin, 58 ONETOUCH LANCETS, 38 P ONETOUCH METERS AND KITS, 38 paclitaxel, 20 ONETOUCH TEST STRIPS, 38 paclitaxel protein-bound particles, 21 ONEXTON, 57 PADCEV, 22 ONFI, 28 palbociclib, 19 ONGENTYS, 30 PALFORZIA, 51 ONIVYDE, 20 palifermin, 47 ONTRUZANT, 21 paliperidone ext-rel, 31 ONUREG, 17 paliperidone palmitate ext-rel inj, 31 ONZETRA XSAIL, 33 palivizumab, 16 OPANA, 11 palonosetron, 45 OPDIVO, 21 PALYNZIQ, 43 opicapone, 30 PAMELOR, 30 OPSUMIT, 27 pamidronate, 39 ORACEA, 60 PANCREAZE, 47 ORALAIR, 51 pancrelipase, 46 ORAPRED ODT, 42 pancrelipase delayed-rel, 46, 47 ORENCIA, 51 PANDEL, 59 ORENITRAM, 27 panitumumab, 21 ORFADIN, 42 panobinostat, 22 ORGOVYX, 18 PANRETIN, 60 ORIAHNN, 44 pantoprazole delayed-rel, 47 ORILISSA, 40 PANZYGA, 52 ORKAMBI, 55 PARAGARD T 380A, 40 ORLADEYO, 51 parathyroid hormone (recombinant), 39 ORTHO MICRONOR, 40 paricalcitol, 43 ORTHOVISC, 11 PARLODEL, 30 ORTIKOS, 46 PARNATE, 29 oseltamivir, 16 paroxetine HCl, 29 osilodrostat phosphate, 45 paroxetine HCl ext-rel, 29 osimertinib, 19 paroxetine mesylate, 29 OSMOLEX ER, 30 PARSABIV, 38 OSMOPREP, 46 pasireotide, 44 ospemifene, 43 PATANASE, 56 OSPHENA, 43 patiromer, 43 OTEZLA, 51 PAXIL, 29 OTREXUP, 51 PAXIL CR, 29 OVIDREL, 41 PAZEO, 61 oxaliplatin, 20 pazopanib, 19 oxaprozin, 10 peanut allergen-dfnp, 51 oxazepam, 28 peg 3350/electrolytes, 46 OXBRYTA, 50 pegaspargase, 21 oxcarbazepine, 28 PEGASYS, 52 oxcarbazepine ext-rel, 29 pegfilgrastim, 49 OXERVATE, 63 pegfilgrastim-apgf, 49 oxiconazole crm, 58 pegfilgrastim-bmez, 49 OXISTAT, 58 pegfilgrastim-cbqv, 49 OXSORALEN-ULTRA, 58 pegfilgrastim-jmdb, 49 OXTELLAR XR, 29 peginterferon alfa-2a, 52 oxybutynin, 48 peginterferon alfa-2b, 52 oxybutynin ext-rel, 48 peginterferon beta-1a, 34 oxybutynin gel, 48 PEGINTRON, 52 oxycodone, 11 pegloticase, 10 oxycodone concentrate 20 mg/mL, 11 pegvaliase-pqpz, 43 oxycodone ext-rel, 11
90
pegvisomant, 44 POLYTRIM, 61 PEMAZYRE, 19 pomalidomide, 18 pembrolizumab, 18 POMALYST, 18 pemetrexed, 17 ponatinib, 19 pemigatinib, 19 PORTRAZZA, 21 penbutolol, 25 posaconazole delayed-rel tabs, 13 penciclovir, 61 posaconazole susp, 14 penicillamine tabs, 51 potassium chloride ext-rel, 53 penicillin VK, 13 potassium chloride liquid, 53 PENTASA, 46 potassium chloride powder, 53 pentosan polysulfate sodium, 48 potassium citrate ext-rel, 48 pentostatin, 17 POTELIGEO, 22 pentoxifylline ext-rel, 50 PRADAXA, 48 perampanel, 29 pralatrexate, 17 PERCOCET, 11 pralsetinib, 19 PERFOROMIST, 55 PRALUENT, 25 perindopril, 22 pramipexole, 30 perindopril arginine/amlodipine, 23 pramipexole ext-rel, 30 PERJETA, 21 pramlintide, 36 permethrin 5%, 60 PRAMOSONE, 59 perphenazine, 31 pramoxine/hydrocortisone, 59 PERSERIS, 31 prasterone vaginal inserts, 44 pertuzumab, 21 prasugrel, 50 pertuzumab/trastuzumab/hyaluronidase-zzxf, 21 PRAVACHOL, 24 PEXEVA, 29 pravastatin, 24 pexidartinib, 19 prazosin, 23 phenazopyridine, 48 PRECOSE, 36 phenelzine, 29 PRED FORTE, 62 phenobarbital, 28 PRED MILD, 62 phenylephrine, 61 PRED-G, 62 phenytoin, 28 prednisolone, 42 phenytoin sodium extended, 28 prednisolone acetate 0.12%, 62 PHESGO, 21 prednisolone acetate 1%, 62 PHEXXI, 40 prednisolone phosphate 1%, 62 phytonadione, 53 prednisolone sodium phosphate, 42 PIFELTRO, 15 prednisolone sodium phosphate orally disintegrating tabs, 42 pilocarpine, 63 prednisolone syrup, 42 pilocarpine tabs, 47 prednisone, 42 PILOPINE HS GEL, 63 prednisone delayed-rel, 42 pimavanserin, 31 PREFEST, 41 pimecrolimus, 59 pregabalin, 32 pindolol, 25 PREGNYL, 42 pioglitazone, 37 PREMARIN, 41 pioglitazone/glimepiride, 37 PREMARIN crm, 41 pioglitazone/metformin, 37 PREMPHASE, 41 pioglitazone/metformin ext-rel, 37 PREMPRO, 41 piperacillin/tazobactam, 13 prenatal vitamins/docusate/folic acid, 53 PIQRAY, 19 prenatal vitamins/folic acid, 53 pirfenidone, 56 PRENATE ELITE, 53 piroxicam, 10 PREPOPIK, 46 pitavastatin, 24 PRESTALIA, 23 pitolisant, 34 PRETOMANID, 15 PLAQUENIL, 51 pretomanid tabs, 15 PLAVIX, 50 PREVIDENT, 61 plecanatide, 47 PREVYMIS, 15 PLEGRIDY, 34 PREZCOBIX, 14 PLEGRIDY PEN, 34 PREZISTA, 15 PLENVU, 46 PRIALT, 11 plerixafor, 50 PRIFTIN, 15 podofilox, 60 primaquine, 14 polatuzumab vedotin-piiq, 22 PRIMAXIN, 16 POLIVY, 22 primidone, 28 polymyxin B/bacitracin, 61 PRINIVIL, 22 polymyxin B/trimethoprim, 61 PRISTIQ, 29
91
PRIVIGEN, 52 QVAR REDIHALER, 56 PROAIR DIGIHALER, 55 R PROAIR HFA, 55 rabeprazole delayed-rel (except rabeprazole capsule sprinkle delayed- PROAIR RESPICLICK, 55 rel), 47 probenecid, 10 RADICAVA, 35 procarbazine, 21 raloxifene, 43 PROCARDIA XL, 25 raltegravir, 14 prochlorperazine, 45 ramelteon, 32 PROCRIT, 49 ramipril, 22 PROCTOFOAM-HC, 47 ramucirumab, 22 PROCYSBI, 44 RANEXA, 27 PROFILNINE, 49 ranibizumab, 63 progesterone vaginal inserts, 43 ranolazine ext-rel, 27 progesterone, micronized, 43 RAPAFLO, 47 PROGLYCEM, 42 RAPAMUNE, 53 PROGRAF, 53 rasagiline, 30 PROLASTIN-C, 54 rasburicase, 17 PROLENSA, 62 RASUVO, 51 PROLEUKIN, 20 RAVICTI, 44 PROLIA, 39 ravulizumab-cwvz, 50 PROMACTA, 50 RAYALDEE, 43 promethazine, 45, 54 RAYOS, 42 PROMETRIUM, 43 RAZADYNE ER, 29 propafenone ext-rel, 24 REBIF, 33 propantheline 15 mg, 45 REBIF REBIDOSE, 33 propranolol, 25 REBINYN, 49 propranolol ext-rel, 25 REBLOZYL, 50 propylthiouracil, 43 RECLAST, 39 PROSCAR, 47 RECOMBINATE, 49 protein C concentrate, human, 50 RECTIV, 47 PROTOPIC, 59 REGLAN, 45 protriptyline, 30 regorafenib, 19 PROVENTIL HFA, 55 REGRANEX, 61 PROVERA, 43 RELENZA, 16 PROVIGIL, 34 RELISTOR, 46 PROZAC, 29 RELPAX, 33 PULMICORT FLEXHALER, 56 relugolix, 18 PULMICORT RESPULES, 56 REMERON, 30 PULMOZYME, 55 REMICADE, 51 PURIXAN, 18 REMODULIN, 27 PYLERA, 47 RENAGEL, 43 pyrazinamide, 15 RENFLEXIS, 51 PYRIDIUM, 48 RENVELA, 43 pyridostigmine, 34 repaglinide, 37 pyridostigmine ext-rel tabs 180 mg, 34 REPATHA, 25 pyrimethamine, 14 reslizumab inj, 57 Q RESTASIS, 63 QBRELIS, 22 RESTORIL, 32 QDOLO, 11 RETACRIT, 49 QINLOCK, 19 retapamulin, 58 QTERN, 37 RETEVMO, 19 quazepam, 32 RETIN-A, 57 QUDEXY XR, 28 RETIN-A MICRO, 57 QUESTRAN/QUESTRAN LIGHT, 24 RETROVIR, 15 quetiapine, 31 REVATIO, 27 quetiapine ext-rel, 31 REVCOVI, 44 QUILLICHEW ER, 32 revefenacin inhalation solution, 54 QUILLIVANT XR, 32 REVLIMID, 20 quinapril, 22 REXULTI, 31 quinapril/hydrochlorothiazide, 23 REYATAZ, 15 quinidine gluconate ext-rel, 24 Rho (D) immune globulin, 52 QUTENZA, 60 RHOFADE, 60 QVAR, 56 RHOGAM, 52
92
RHOGAM PLUS, 52 romosozumab-aqqg, 39 RHOPHYLAC, 52 ropinirole, 30 RHOPRESSA, 63 ropinirole ext-rel, 30 RIABNI, 21 rosiglitazone, 37 RIASTAP, 49 rosuvastatin, 24 ribavirin caps, 16 rosuvastatin capsules, 24 ribavirin caps - Ribasphere, 16 rotigotine transdermal, 30 ribavirin tabs, 16 ROWASA, 46 ribociclib, 19 ROXICODONE, 11 ribociclib + letrozole, 19 ROZEREM, 32 RIDAURA, 51 ROZLYTREK, 19 rifabutin, 16 RUBRACA, 21 RIFADIN, 15 rucaparib, 21 rifampin, 15 RUCONEST, 51 rifampin/isoniazid/pyrazinamide, 15 rufinamide, 28 rifamycin delayed-rel, 13 RUKOBIA, 14 rifapentine, 15 RUXIENCE, 21 RIFATER, 15 ruxolitinib, 19 rifaximin, 17 RUZURGI, 35 rilonacept, 52 RYBELSUS, 36 rilpivirine, 15 RYDAPT, 19 RILUTEK, 35 RYTARY, 30 riluzole, 35 RYTHMOL SR, 24 rimabotulinumtoxinB, 35 S rimantadine, 16 SABRIL, 28 rimegepant, 33 sacituzumab govitecan-hziy, 22 rimexolone, 62 sacubitril/valsartan, 26 RINVOQ ER, 51 safinamide, 30 riociguat, 27 SAFYRAL, 39 RIOMET IR, 36 SAIZEN, 42 ripretinib, 19 SALAGEN, 47 risankizumab-rzaa, 51 salmeterol xinafoate, 55 risdiplam, 35 SAMSCA, 44 risedronate, 38 SANCUSO, 45 risedronate delayed-rel, 39 SANDIMMUNE, 53 RISPERDAL, 31 SANDOSTATIN, 44 RISPERDAL CONSTA, 31 SANDOSTATIN LAR, 44 RISPERDAL M-TABS, 31 SAPHRIS, 31 risperidone, 31 sapropterin, 43 risperidone ext-rel inj, 31 saquinavir mesylate, 15 risperidone long-acting inj, 31 SARCLISA, 20 risperidone orally disintegrating tabs, 31 sarecycline, 13 RITALIN, 32 sargramostim, 49 RITALIN LA, 32 sarilumab, 51 ritonavir tabs, 15 satralizumab-mwge, 51 RITUXAN, 22 SAVELLA, 32 RITUXAN HYCELA, 22 scopolamine, 63 rituximab, 22 scopolamine transdermal, 45 rituximab/hyaluronidase human, 22 SEASONIQUE, 40 rituximab-abbs, 21 sebelipase alfa, 44 rituximab-arrx, 21 secnidazole, 17 rituximab-pvvr, 21 secukinumab, 58 rivaroxaban, 48 SEEBRI NEOHALER, 54 rivastigmine, 29 segesterone acetate/EE ring, 40 rivastigmine transdermal, 29 SEGLUROMET, 37 RIXUBIS, 49 selegiline caps, 30 rizatriptan, 33 selegiline orally disintegrating tabs, 30 ROCALTROL, 43 selegiline transdermal, 29 ROCEPHIN, 12 selexipag, 27 ROCKLATAN, 63 selinexor, 22 roflumilast, 56 selpercatinib, 19 rolapitant, 45 selumetinib, 19 romidepsin, 20 SELZENTRY, 14 romiplostim, 50
93
semaglutide, 36 SOMAVERT, 44 SENSIPAR, 38 sonidegib, 22 SEREVENT DISKUS, 55 SOOLANTRA, 60 SERNIVO, 60 sorafenib, 19 SEROQUEL, 31 SORILUX, 58 SEROQUEL XR, 31 sotalol, 24 SEROSTIM, 42 sotalol AF, 24 sertaconazole, 58 SOVALDI, 16 sertraline, 29 spinosad, 60 sevelamer carbonate, 43 SPIRIVA, 54 sevelamer HCl, 43 SPIRIVA RESPIMAT, 54 SEVENFACT, 50 spironolactone, 23 SEYSARA, 13 spironolactone/hydrochlorothiazide, 26 SIGNIFOR, 44 SPORANOX, 13 SIKLOS, 22 SPRAVATO, 30 sildenafil, 27 SPRIX, 10 SILENOR, 32 SPRYCEL, 19 SILIQ, 51 STALEVO, 30 silodosin, 47 STARLIX, 37 SILVADENE, 58 stavudine, 15 silver sulfadiazine, 58 STEGLATRO, 37 SIMBRINZA, 63 STEGLUJAN, 38 SIMPONI 100 mg, 51 STELARA, 58 SIMPONI 50 mg, 51 STELARA SUBCUTANEOUS, 51 simvastatin, 24 STIMATE, 49 SINEMET, 30 STIOLTO RESPIMAT, 54 SINGULAIR, 56 stiripentol, 29 siponimod, 34 STIVARGA, 19 sirolimus, 53 STRATTERA, 31 SIRTURO, 15 STRENSIQ, 44 sitagliptin phosphate, 36 streptozocin, 17 sitagliptin/metformin, 36 STRIANT, 35 sitagliptin/metformin ext-rel, 36 STRIBILD, 14 SIVEXTRO, 17 STRIVERDI RESPIMAT, 55 SKYLA, 40 SUBLOCADE, 34 SKYRIZI, 51 SUBOXONE FILM, 34 SLYND, 40 SUBSYS, 11 sodium ferric gluconate inj, 53 sucralfate, 47 sodium fluoride, 61 sucroferric oxyhydroxide, 43 sodium hyaluronate, 11, 12 SULAR, 25 sodium oxybate, 34 sulconazole, 58 sodium phenylbutyrate, 44 sulfacetamide sodium, 57 sodium phosphates, 46 sulfacetamide soln 10%, 61 sodium picosulfate/magnesium oxide/citric acid, 46 sulfacetamide/prednisolone acetate oint 10%/0.2%, 62 sodium polystyrene sulfonate, 43 sulfacetamide/prednisolone phosphate 10%/0.25%, 61 sodium sulfate/magnesium sulfate/potassium chloride, 46 sulfamethoxazole/trimethoprim, 16 sodium sulfate/potassium sulfate/magnesium sulfate, 46 sulfamethoxazole/trimethoprim DS, 16 sodium zirconium cyclosilicate, 43 SULFAMYLON, 58 sofosbuvir, 16 sulfasalazine, 46 sofosbuvir/velpatasvir, 16 sulfasalazine delayed-rel, 46 sofosbuvir/velpatasvir/voxilaprevir, 16 sulindac, 10 SOFTCLIX LANCET DEVICE, 38 sumatriptan, 33 SOFTCLIX LANCETS, 38 sumatriptan nasal powder, 33 SOFTTOUCH LANCET DEVICE, 38 sumatriptan nasal spray, 33 SOFTTOUCH LANCETS, 38 sumatriptan/naproxen sodium, 33 SOLESTA, 47 sunitinib, 19 solifenacin, 48 SUNOSI, 34 SOLIQUA, 36 SUPARTZ FX, 11 SOLIRIS, 50 SUPPRELIN LA, 44 SOLODYN, 13 SUPRAX, 12 SOLOSEC, 17 SUPREP, 46 solriamfetol, 34 SUSTIVA, 15 somatropin, 42 SUSTOL, 45 SOMATULINE DEPOT, 44 SUTAB, 46
94
SUTENT, 19 tbo-filgrastim, 49 suvorexant, 32 TECENTRIQ, 21 SYMBICORT, 56 TECFIDERA, 33 SYMDEKO, 55 tedizolid, 17 SYMFI, 14 teduglutide, 47 SYMFI LO, 14 TEFLARO, 13 SYMJEPI, 54 tegaserod maleate, 46 SYMLINPEN, 36 TEGRETOL, 28 SYMTUZA, 14 TEGRETOL-XR, 28 SYNAGIS, 16 TEGSEDI, 44 SYNALAR, 59 TEKTURNA, 26 SYNAREL, 40 TEKTURNA HCT, 26 SYNDROS, 47 telavancin, 17 SYNJARDY, 37 telbivudine, 16 SYNJARDY XR, 37 telmisartan, 23 SYNRIBO, 21 telmisartan/hydrochlorothiazide, 23 SYNTHROID, 43 telotristat, 47 SYNVISC, 11 temazepam, 32 SYNVISC-ONE, 11 TEMIXYS, 14 SYPRINE, 44 TEMODAR caps, 17 T TEMODAR inj, 17 TEMOVATE, 60 TABLOID, 17 temozolomide caps, 17 TABRECTA, 19 temozolomide inj, 17 TACHOSIL, 61 temsirolimus, 18 tacrolimus, 53, 59 teniposide, 20 tacrolimus ext-rel, 53 tenofovir alafenamide, 16 tadalafil 2.5 mg, 5 mg, 47 tenofovir disoproxil fumarate tabs 300 mg, 15 tadalafil tabs 20 mg, 27 TENORMIN, 25 tadalafil tabs 20 mg - Alyq, 27 TEPADINA, 17 tafamidis, 26 TEPEZZA, 63 tafamidis meglumine, 26 teprotumumab-trbw for IV soln, 63 tafenoquine, 14 terazosin, 23 TAFINLAR, 19 terbinafine tabs, 13 tafluprost, 63 terbutaline, 55 TAGRISSO, 19 terconazole crm, 48 TAKHZYRO, 52 terconazole supp 80 mg, 48 talazoparib, 21 teriflunomide, 34 TALICIA, 47 teriparatide, 39 taliglucerase alfa, 44 tesamorelin, 44 talimogene laherparepvec, 21 TESSALON, 55 TALTZ, 51 TESTIM, 35 TALZENNA, 21 TESTOPEL, 35 TAMIFLU, 16 testosterone buccal, 35 tamoxifen, 18 testosterone cypionate, 35 tamsulosin, 47 testosterone enanthate, 35 TAPAZOLE, 43 testosterone enanthate auto-injector, 35 tapentadol, 11 testosterone gel, 35 tapentadol ext-rel, 11 testosterone pellets, 35 TARGRETIN caps, 20 testosterone soln, 35 TARGRETIN gel, 21 testosterone transdermal, 35 TARKA, 23 testosterone undecanoate inj, 35 TASIGNA, 19 tetrabenazine, 33 tasimelteon, 32 tetracycline, 13 tavaborole sol 5%, 58 tezacaftor/ivacaftor + ivacaftor, 55 TAVALISSE, 50 thalidomide, 20 TAYTULLA, 39 THALOMID, 20 tazarotene crm 0.05%, gel 0.05%, 0.1%, 57 THEO-24, 57 tazarotene crm 0.1%, 57 theophylline ext-rel caps, 57 tazarotene foam 0.1%, 57 theophylline ext-rel tabs, 57 tazarotene lotion 0.045%, 57 theophylline liquid, 57 tazemetostat, 19 thioguanine, 17 TAZORAC, 57 THIOLA, 48 TAZVERIK, 19 THIOLA EC, 48
95
thioridazine, 31 trabectedin, 17 thiotepa, 17 TRACLEER, 27 thiothixene, 31 tramadol (except 100 mg tabs), 11 THYROGEN, 44 tramadol ext-rel, 11 thyroid, 43 tramadol oral solution, 11 thyrotropin alfa, 44 tramadol/acetaminophen, 11 tiagabine, 28 trametinib, 19 TIAZAC, 26 trandolapril, 22 TIBSOVO, 22 trandolapril/verapamil ext-rel, 23 ticagrelor, 50 tranexamic acid, 50 TICE BCG, 21 TRANSDERM SCOP, 45 TIGAN, 45 TRANXENE T-TAB, 28 tigecycline, 16 tranylcypromine, 29 TIGLUTIK, 35 trastuzumab, 22 TIKOSYN, 24 trastuzumab/hyaluronidase-oysk, 22 tildrakizumab-asmn, 51 trastuzumab-anns, 21 timolol hemihydrate, 62 trastuzumab-dkst, 21 timolol maleate, 62 trastuzumab-dttb, 21 timolol maleate gel, 62 trastuzumab-pkrb, 21 TIMOPTIC, 62 trastuzumab-qyyp, 21 TIMOPTIC-XE, 62 TRAVATAN Z, 63 tinidazole, 16 travoprost, 63 tiopronin, 48 TRAZIMERA, 21 tiopronin delayed-rel, 48 trazodone, 30 tiotropium, 54 TREANDA, 17 tiotropium/olodaterol, 54 TRELEGY ELLIPTA, 54 tipranavir, 15 TRELSTAR, 18 tirbanibulin, 58 TRELSTAR DEPOT, 18 tirofiban inj, 50 TRELSTAR LA, 18 TIROSINT, 43 TREMFYA, 58 TIVICAY, 14 treprostinil, 27 TOBI, 55 treprostinil ext-rel, 27 TOBI PODHALER, 55 TRESIBA, 37 TOBRADEX OINTMENT, 61 tretinoin, 57 TOBRADEX SUSPENSION, 61 tretinoin gel microsphere, 57 tobramycin, 61 TRETTEN, 49 tobramycin inhalation powder, 55 TREXIMET, 33 tobramycin inhalation soln, 55 triamcinolone acetonide crm 0.5%, 60 tobramycin/dexamethasone oint 0.3%/0.1%, 61 triamcinolone acetonide crm, lotion 0.025%, 59 tobramycin/dexamethasone susp 0.3%/0.1%, 61 triamcinolone acetonide crm, lotion, oint 0.1%, 59 tobramycin/loteprednol, 62 triamcinolone acetonide topical spray, 60 TOBREX, 61 triamcinolone paste, 61 tocilizumab, 51 triamterene/hydrochlorothiazide, 26 tofacitinib, 51 triamterene/hydrochlorothiazide 37.5/25, 26 tofacitinib ext-rel, 51 triamterene/hydrochlorothiazide 50/25, 26 TOLAK, 58 TRIBENZOR, 24 tolcapone, 30 TRICOR, 24 tolterodine, 48 trientine, 44 tolterodine ext-rel, 48 triethanolamine polypeptide oleate, 64 tolvaptan, 44 trifarotene cream 0.005%, 57 TOPAMAX, 28 trifluoperazine, 31 TOPICORT, 59 trifluridine, 62 topiramate, 28 trifluridine/tipiracil, 22 topiramate ext-rel, 28, 29 triheptanoin, 53 topotecan, 20 trihexyphenidyl, 30 topotecan inj, 20 TRIJARDY XR, 38 TOPROL-XL, 25 TRIKAFTA, 55 toremifene, 18 TRILEPTAL, 28 TORISEL, 18 TRILIPIX, 24 torsemide, 26 trimethobenzamide, 45 TOSYMRA, 33 trimethoprim, 16 TOTECT, 20 TRINTELLIX, 29 TOUJEO, 37 TRIPTODUR, 45 TOVIAZ, 48 triptorelin pamoate, 18, 45
96
TRISENOX, 20 VALTREX, 16 TRIUMEQ, 14 VANCOCIN, 16 TRIVISC, 11 vancomycin caps, 16 TRIZIVIR, 14 vancomycin oral soln, 17 TRODELVY, 22 vandetanib, 19 TROGARZO, 15 VANTAS, 18 TROKENDI XR, 29 varenicline, 35 trospium, 48 varicella zoster immune globulin, 52 trospium ext-rel, 48 VARIZIG, 52 TRULANCE, 47 VARUBI, 45 TRULICITY, 36 VASCEPA, 25 TRUSOPT, 62 VASERETIC, 23 TRUVADA, 14 VASOTEC, 22 TRUXIMA, 21 VECAMYL, 27 tucatinib, 19 VECTIBIX, 21 TUDORZA PRESSAIR, 54 VECTICAL, 58 TUKYSA, 19 vedolizumab, 46 TURALIO, 19 velaglucerase alfa, 44 TWIRLA, 40 VELCADE, 20 TWYNSTA, 23 VELETRI, 27 TYBOST, 14 VELPHORO, 43 TYGACIL, 16 VELTASSA, 43 TYKERB, 18 VELTIN, 57 TYMLOS, 39 VEMLIDY, 16 TYSABRI, 34 vemurafenib, 19 TYVASO, 27 VENCLEXTA, 21 TYZEKA, 16 venetoclax, 21 U venlafaxine, 29 venlafaxine ext-rel, 29 UDENYCA, 49 venlafaxine ext-rel tabs, 29 ULORIC, 10 VENOFER, 53 ULTOMIRIS, 50 VENTAVIS, 27 ULTRAM, 11 VENTOLIN HFA, 55 ULTRAM ER, 11 VERAMYST, 56 ULTRAVATE, 60 verapamil, 26 umeclidinium bromide, 54 verapamil ext-rel, 26 umeclidinium/vilanterol, 54 VERDESO, 59 UNASYN, 13 verteporfin, 63 upadacitinib, 51 VERZENIO, 18 UPNEEQ, 63 VESICARE LS, 48 UPTRAVI, 27 vestronidase alfa-vjbk, 44 uridine triacetate, 44 VEXOL, 62 urine test strips, 38 VFEND, 13 UROCIT-K, 48 VIBATIV, 17 URSO, 45 VIBERZI, 46 URSO FORTE, 45 VIBRAMYCIN, 13 ursodiol, 45 VICTOZA, 36 ustekinumab, 51, 58 VIDAZA, 20 UTIBRON NEOHALER, 54 vigabatrin, 28 V vigabatrin powder - Vigadrone, 28 VAGIFEM, 41 VIGAMOX, 61 valacyclovir, 16 VIIBRYD, 29 valbenazine, 35 vilazodone, 29 VALCHLOR, 17 VILTEPSO, 35 VALCYTE, 15 viltolarsen, 35 valganciclovir, 15 VIMIZIM, 44 VALIUM, 28 VIMPAT, 28 valproic acid, 28 vinblastine, 20 valrubicin, 20 vincristine, 20 valsartan, 23 vincristine sulfate liposomal, 21 valsartan/hydrochlorothiazide, 23 vinorelbine, 20 VALSTAR, 20 VIOKACE, 46 VALTOCO, 28 VIRACEPT, 15 VIRAMUNE, 15
97
VIRAMUNE XR, 15 XGEVA, 39 VIREAD, 15 XHANCE, 56 vismodegib, 21 XIAFLEX, 61 VISTARIL, 28, 54 XIFAXAN, 17 VISTIDE, 15 XIGDUO XR, 37 VISUDYNE, 63 XIIDRA, 63 VITAFOL-OB, 53 XIMINO, 57 VITRAKVI, 19 XOFLUZA, 16 VIVELLE-DOT, 41 XOLAIR, 56 VIVITROL, 34 XOPENEX CONCENTRATE, 55 VIZIMPRO, 19 XOPENEX HFA, 55 voclosporin, 53 XOPENEX SOLUTION, 55 VOGELXO, 35 XOSPATA, 19 von Willebrand factor, recombinant, 49 XPOVIO, 22 VONVENDI, 49 XTAMPZA ER, 11 vorapaxar, 50 XTANDI, 18 VORAXAZE, 21 XULTOPHY, 36 voriconazole, 13 XURIDEN, 44 vorinostat, 21 XYLOCAINE, 60 vortioxetine, 29 XYNTHA, 49 VOSEVI, 16 XYNTHA SOLOFUSE, 49 VOTRIENT, 19 XYOSTED, 35 voxelotor, 50 XYREM, 34 VPRIV, 44 XYWAV, 34 VRAYLAR, 31 Y VUMERITY, 34 YASMIN, 39 VUSION, 58 YAZ, 39 VWF, human/factor VIII complex, 49 YERVOY, 21 VYEPTI, 33 YONDELIS, 17 VYNDAMAX, 26 YONSA, 18 VYNDAQEL, 26 YUPELRI, 54 VYONDYS 53, 35 VYTORIN, 24 Z VYVANSE, 32 zafirlukast, 56 VYZULTA, 63 zaleplon, 32 W ZALTRAP, 21 zanamivir, 16 WAKIX, 34 ZANOSAR, 17 warfarin, 48 zanubrutinib, 20 WELCHOL, 24 ZARONTIN, 28 WELLBUTRIN SR, 30 ZARXIO, 49 WELLBUTRIN XL, 30 ZAVESCA, 44 WILATE, 49 ZEJULA, 21 WINRHO SDF, 52 ZELAPAR, 30 WYNZORA, 58 ZELBORAF, 19 X ZELNORM, 46 XADAGO, 30 ZEMAIRA, 54 XALATAN, 63 ZEMPLAR, 43 XALKORI, 19 ZENPEP, 46 XANAX, 28 ZENZEDI, 31 XANAX XR, 28 ZEPATIER, 16 XARELTO, 48 ZEPOSIA, 34 XCOPRI, 28 ZEPZELCA, 17 XELJANZ, 51 ZESTORETIC, 23 XELJANZ XR, 51 ZESTRIL, 22 XELODA, 17 ZETIA, 24 XELPROS, 63 ZIAC, 25 XEMBIFY, 52 ZIAGEN, 15 XENAZINE, 33 ZIAGEN soln, 15 XENLETA, 13 ZIANA, 57 XEOMIN, 35 ziconotide, 11 XEPI, 58 zidovudine, 15 XERMELO, 47 ZIEXTENZO, 49
98
ZILXI, 60 ZOLPIMIST, 32 zinc acetate, 53 ZOMACTON, 42 ZINPLAVA, 52 ZOMIG, 33 ZIOPTAN, 63 ZOMIG/ZOMIG-ZMT, 33 ziprasidone, 31 ZONALON, 60 ZIRABEV, 21 ZONEGRAN, 28 ZIRGAN, 62 zonisamide, 28 ZITHROMAX, 13 ZONTIVITY, 50 ziv-aflibercept, 21 ZORBTIVE, 42 ZOCOR, 24 ZORTRESS 0.25 mg, 0.5 mg, 0.75 mg, 53 ZOFRAN, 45 ZORTRESS 1 mg, 53 ZOHYDRO ER, 11 ZOSYN, 13 ZOKINVY, 44 ZOVIRAX, 16, 60 ZOLADEX, 18 ZUBSOLV, 34 zoledronic acid 4 mg/100 mL, 39 ZYCLARA, 60 zoledronic acid 5 mg/100 mL, 39 ZYDELIG, 19 ZOLINZA, 21 ZYKADIA, 19 zolmitriptan, 33 ZYLET, 62 zolmitriptan nasal spray, 33 ZYLOPRIM, 10 ZOLOFT, 29 ZYPREXA RELPREVV, 31 zolpidem, 32 ZYPREXA/ZYPREXA ZYDIS, 31 zolpidem ext-rel, 32 ZYTIGA, 18 zolpidem spray, 32 ZYVOX, 16 zolpidem sublingual, 32
99