Medstar Family Choice - DC Healthy Families Prescribing Guide 2014

MedStar Family Choice - DC Healthy Families Prescribing Guide 2014

(10/01/2014)

INTRODUCTION ...... 5 PREFACE ...... 5 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...... 5 PRODUCT SELECTION CRITERIA ...... 6 GENERIC AVAILABILITY ...... 6 GENERIC SUBSTITUTION ...... 6 DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS ...... 7 MEDICAL EXCEPTION ...... 7 PRIOR AUTHORIZATION (PA) ...... 7 MANAGED DRUG LIMITATIONS (MDL) ...... 8 MANAGED DRUG LIMITATIONS (MDL): For members age 65 and older ...... 9 STEP THERAPY (ST) ...... 10 STEP THERAPY (ST): For members age 65 and older ...... 10 OVER-THE-COUNTER (OTC) DRUG COVERAGE ...... 10 EDITOR ...... 13 NOTICE ...... 13 LEGEND ...... 14 ANALGESICS ...... 15 NSAIDs ...... 15 NSAIDs, TOPICAL ...... 15 COX-2 INHIBITORS ...... 15 GOUT ...... 15 OPIOID ANALGESICS ...... 15 NON-OPIOID ANALGESICS ...... 16 VISCOSUPPLEMENTS...... 16 ANTI-INFECTIVES ...... 16 ANTIBACTERIALS ...... 16 ANTIFUNGALS ...... 17 ANTIMALARIALS ...... 17 ANTIRETROVIRAL AGENTS...... 18 ANTITUBERCULAR AGENTS ...... 18 ANTIVIRALS ...... 18 MISCELLANEOUS ...... 18 ANTINEOPLASTIC AGENTS ...... 19 ALKYLATING AGENTS ...... 19 ANTIMETABOLITES ...... 19 HORMONAL ANTINEOPLASTIC AGENTS ...... 19 KINASE INHIBITORS ...... 19 TOPOISOMERASE INHIBITORS ...... 20 MISCELLANEOUS ...... 20

1 CARDIOVASCULAR ...... 20 ACE INHIBITORS ...... 20 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS...... 20 ACE INHIBITOR/DIURETIC COMBINATIONS ...... 21 ADRENOLYTICS, CENTRAL ...... 21 ALDOSTERONE RECEPTOR ANTAGONISTS...... 21 ALPHA BLOCKERS ...... 21 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ...... 21 ANTIARRHYTHMICS ...... 21 ANTILIPEMICS ...... 21 BETA-BLOCKERS ...... 22 BETA-BLOCKER/DIURETIC COMBINATIONS ...... 22 CALCIUM CHANNEL BLOCKERS...... 23 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ...... 23 DIGITALIS GLYCOSIDES ...... 23 DIURETICS ...... 23 NITRATES ...... 24 PULMONARY ARTERIAL HYPERTENSION ...... 24 MISCELLANEOUS ...... 24 CENTRAL NERVOUS SYSTEM ...... 24 ANTIANXIETY ...... 24 ANTICONVULSANTS ...... 25 ANTIDEMENTIA ...... 25 ANTIDEPRESSANTS...... 26 ANTIPARKINSONIAN AGENTS ...... 26 ANTIPSYCHOTICS ...... 27 ATTENTION DEFICIT HYPERACTIVITY DISORDER ...... 27 FIBROMYALGIA ...... 27 HYPNOTICS ...... 28 MIGRAINE ...... 28 MOOD STABILIZERS ...... 28 MULTIPLE SCLEROSIS ...... 28 MUSCULOSKELETAL THERAPY AGENTS...... 28 MYASTHENIA GRAVIS...... 29 NARCOLEPSY/CATAPLEXY ...... 29 NEUROMUSCULAR BLOCKING AGENTS ...... 29 PSYCHOTHERAPEUTIC - MISCELLANEOUS ...... 29 ENDOCRINE AND METABOLIC ...... 29 ANDROGENS ...... 29 ANTIDIABETICS ...... 29 CALCIUM RECEPTOR ANTAGONISTS...... 31 CALCIUM REGULATORS...... 31 CONTRACEPTIVES...... 31 ESTROGENS ...... 33 ESTROGEN/PROGESTINS ...... 33 GLUCOCORTICOIDS ...... 33 GLUCOSE ELEVATING AGENTS ...... 33 HUMAN GROWTH HORMONES ...... 34 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS...... 34 PHOSPHATE BINDER AGENTS ...... 34 PROGESTINS ...... 34 SELECTIVE ESTROGEN RECEPTOR MODULATORS ...... 34 THYROID AGENTS...... 34 VASOPRESSINS ...... 34 MISCELLANEOUS ...... 34

2 GASTROINTESTINAL ...... 34 ANTACIDS ...... 34 ANTIDIARRHEALS ...... 34 ANTIEMETICS ...... 35 ANTISPASMODICS ...... 35 CHOLELITHOLYTICS ...... 35 H2 RECEPTOR ANTAGONISTS ...... 35 INFLAMMATORY BOWEL DISEASE ...... 35 LAXATIVES/STOOL SOFTENERS ...... 35 PANCREATIC ENZYMES ...... 36 PROSTAGLANDINS ...... 36 PROTON PUMP INHIBITORS ...... 36 STEROIDS, RECTAL ...... 36 ULCER THERAPY COMBINATIONS...... 36 MISCELLANEOUS ...... 36 GENITOURINARY ...... 36 BENIGN PROSTATIC HYPERPLASIA ...... 36 URINARY ANTISPASMODICS ...... 36 VAGINAL ANTI-INFECTIVES ...... 37 MISCELLANEOUS ...... 37 HEMATOLOGIC ...... 37 ANTICOAGULANTS...... 37 HEMATOPOIETIC GROWTH FACTORS ...... 37 HEREDITARY ANGIOEDEMA AGENTS ...... 37 PLATELET AGGREGATION INHIBITORS ...... 37 PLATELET SYNTHESIS INHIBITORS...... 38 IMMUNOLOGIC AGENTS ...... 38 ALLERGEN EXTRACTS ...... 38 BIOLOGIC DISEASE-MODIFYING AGENTS ...... 38 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ...... 38 IMMUNOMODULATORS ...... 38 IMMUNOSUPPRESSANTS ...... 38 NUTRITIONAL/SUPPLEMENTS ...... 38 ELECTROLYTES ...... 38 VITAMINS AND MINERALS...... 39 RESPIRATORY ...... 39 ANAPHYLAXIS TREATMENT AGENTS ...... 40 ANTICHOLINERGICS ...... 40 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ...... 40 ANTIHISTAMINES, LOW SEDATING ...... 40 ANTIHISTAMINES, NONSEDATING ...... 40 ANTIHISTAMINES, SEDATING ...... 40 ANTIHISTAMINE/DECONGESTANT COMBINATIONS ...... 40 ANTITUSSIVES ...... 40 ANTITUSSIVE COMBINATIONS ...... 40 BETA AGONISTS ...... 41 CYSTIC FIBROSIS ...... 41 DECONGESTANTS ...... 41 DECONGESTANT/EXPECTORANT COMBINATIONS ...... 41 EXPECTORANTS ...... 41 LEUKOTRIENE RECEPTOR ANTAGONISTS ...... 41 MAST CELL STABILIZERS...... 41 NASAL ANTIHISTAMINES...... 41 NASAL STEROIDS ...... 41 RESPIRATORY SYNCYTIAL VIRUS ...... 42 STEROID/BETA AGONIST COMBINATIONS ...... 42

3 STEROID INHALANTS ...... 42 XANTHINES ...... 42 MISCELLANEOUS ...... 42 TOPICAL ...... 42 DERMATOLOGY ...... 42 MOUTH/THROAT/DENTAL AGENTS...... 45 OPHTHALMIC ...... 45 OTIC ...... 46 WEBSITES ...... 48

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INTRODUCTION MedStar Family Choice is pleased to provide the 2014 MedStar Family Choice - DC Healthy Families Prescribing Guide for the District of Columbia to be used when prescribing for patients covered by the pharmacy plan offered by MedStar Family Choice - District of Columbia (MSFC-DC). This is a closed formulary and only those drugs listed in this formulary will be covered by MedStar Family Choice - District of Columbia for the Healthy Families Medicaid enrollees. For members in the Alliance program under MSFC, please refer to the Alliance Formulary and direct patients to Alliance/ADAP pharmacy locations during their business hours. Updated information on the Alliance Formulary and participating pharmacies can be found at: http://doh.dc.gov/node/236872 The drugs listed in the MedStar Family Choice - DC Healthy Families Prescribing Guide have been reviewed and approved by the MedStar Family Choice Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have drug benefits administered through MedStar Family Choice - District of Columbia. There may be occasions when an unlisted drug is desired for medical management of a specific patient. In those instances, the unlisted medication may be requested through the Medical Exception process. The information contained in this formulary and its appendices is provided solely for the convenience of medical providers. This formulary is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. MedStar Family Choice does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This 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. MedStar Family Choice does not assume 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. PREFACE The MedStar Family Choice - DC Healthy Families Prescribing Guide is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. All drugs listed were selected to be on this formulary. Products are listed by generic name. Brand-name products are included as a reference to assist in product recognition. Unless exceptions are noted, generally all dosage forms and strengths of the drug cited are covered. This formulary covers prescription and selected over-the-counter (OTC) products. You are encouraged to prescribe them when clinically appropriate. A prescription (written or telephoned) is also required for OTC medications and refills are permitted. Prescription medications for chronic conditions should be written as a one month supply with refills. Prescription and OTC medications can be refilled for a maximum of 12 months. For covered OTC products refer to the Over-The-Counter (OTC) Drug Coverage section that is located near the end of the introductory sections of this formulary. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The MedStar Family Choice P&T Committee includes physicians, pharmacists, and nurses. The Committee meets bimonthly to evaluate drugs for formulary inclusion and to develop policies concerning formulary and drug utilization management. Please visit the MedStar Family Choice website at www.medstarfamilychoice.com to view the decisions of the MedStar Family Choice P&T Committee and any applicable changes. The main features of the MedStar Family Choice P&T Policies are also on the website in the FAQs.

MedStar Family Choice - District of Columbia formulary information can also be found online through ePocrates. Registration is free and available at www.epocrates.com.

The DC Healthcare Alliance Formulary is a closed formulary that is managed by the DC Healthcare Alliance Formulary Pharmacy and Therapeutics Committee, not by the MSFC Pharmacy and Therapeutics Committee. DC Healthcare Alliance members should be prescribed medications on the Alliance formulary and should fill their prescriptions at one of the District of Columbia Healthcare Alliance ADAP Pharmacies.

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PRODUCT SELECTION CRITERIA The MedStar Family Choice Pharmacy and Therapeutics Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following: Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications/Warnings/Precautions Pharmacokinetics Patient administration/compliance considerations When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently on formulary. In addition, the entire MedStar Family Choice - DC Healthy Families Prescribing Guide is reviewed on an annual basis. All the information in the MedStar Family Choice - DC Healthy Families Prescribing Guide is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. GENERIC AVAILABILITY Boldface type of a generic drug name in this book indicates generic availability of that product. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In some cases, the brand name listed is a generic drug. Examples of the latter include Levoxyl and Trivora. GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand product. To gain FDA approval: 1. The generic drug must contain the same active ingredient(s), be the same strength and the same dosage form as the brand-name product. 2. The FDA has given the generic an "A" rating compared to the branded product indicating bioequivalence, and has determined the generic is therapeutically equivalent to the reference brand. The ratings of generic drugs are available by referring to the FDA reference, Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book). When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand-name product. In the District of Columbia, a retail pharmacist is required to substitute a generic medication if it is available at a lower cost. It is recommended that generic substitution not be exercised by the pharmacist with multisource products that appear in the Orange Book and carry a "B" rating, indicating that these products cannot be considered therapeutically equivalent to other products in the group.

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DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The 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. Some plans will not pay for DESI "less than fully effective" drug products. DESI drugs are excluded by MedStar Family Choice - DC. Exceptions: Anusol-HC suppositories, Donnatal and Midrin are covered. MEDICAL EXCEPTION If a non-covered drug is desired for medical management of a patient, a medication exception may be requested by calling MedStar Family Choice - DC at: 1-855-210-6203. PRIOR AUTHORIZATION (PA) The following drugs and generic versions, if available, require prior authorization. This list is subject to change. ABILIFY INTRON A QUARTETTE ACTEMRA INVEGA RAGWITEK ADCIRCA INVEGA SUSTENNA REBETOL ADEMPAS isotretinoin REMICADE ARAVA JAKAFI REMODULIN AVINZA JUXTAPID REVATIO BANZEL KALYDECO RISPERDAL CONSTA BENLYSTA KINERET SABRIL BEYAZ KORLYM SAFYRAL BOSULIF KRYSTEXXA SAPHRIS BOTOX LETAIRIS SENSIPAR CAMPRAL leuprolide acetate SEROQUEL XR CELEBREX LO LOESTRIN FE SEROSTIM CHANTIX LOVAZA SIRTURO COMETRIQ LUPRON DEPOT SOVALDI COPEGUS LYRICA STELARA CYMBALTA MEKINIST STIMATE DDAVP spray midazolam injection STIVARGA DIFICID MINASTRIN 24 FE SUPPRELIN LA DURAGESIC MS CONTIN SYNAGIS ELIGARD NAMENDA SYNRIBO ENBREL NATAZIA SYNVISC ERWINAZE NICOTROL INHALER SYNVISC-ONE FANAPT NICOTROL NS TAFINLAR FIRAZYR NORDITROPIN TARCEVA FLOLAN NOXAFIL TASIGNA FOSRENOL NUVIGIL TYKERB FULYZAQ OLYSIO TYVASO FUZEON ONFI VENTAVIS GAMMAGARD S/D OPSUMIT VIMPAT GENERESS FE ORALAIR XALKORI GILENYA ORENCIA XGEVA GRASTEK PEGASYS XOLAIR HERCEPTIN PEGINTRON XYREM HUMIRA POTIGA ZELBORAF HYCAMTIN CAPS PRADAXA ZEMAIRA ICLUSIG PROLIA ZOLADEX IMBRUVICA PROVIGIL ZONTIVITY INCIVEK PULMOZYME ZYDELIG

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If a medication on Prior Authorization is needed for a member, it can be requested by calling MedStar Family Choice - DC at: 1-855-210-6203 from 8 am to 5:30 pm. After hours, follow the instructions in the after-hours pharmacy message on the main telephone line. MANAGED DRUG LIMITATIONS (MDL) The Managed Drug Limitation program provides for a maximum quantity of drug product that a member may receive per prescription and/or over a specific period of time. Many drug products on the MedStar Family Choice - DC Healthy Families Prescribing Guide have quantity limits based upon the dosage described in product labeling. The following drugs are subject to MDL because they are typically not taken on a regular schedule and/or because of potential safety and utilization concerns. This list is subject to change. Contact MedStar Family Choice - DC at 1-855-210-6203 for an updated list. Drugs Limits alprazolam (XANAX) 90 tablets per 23 days amphetamine/dextroamphetamine mixed salts 5 mg, 7.5 mg, 10 mg, 12.5 mg 90 tablets per 23 days (ADDERALL) amphetamine/dextroamphetamine mixed salts 15 mg, 20 mg (ADDERALL) 60 tablets per 23 days amphetamine/dextroamphetamine mixed salts 30 mg (ADDERALL) 30 tablets per 23 days amphetamine/dextroamphetamine mixed salts ext-rel 5 mg, 10 mg 90 capsules per 23 days (ADDERALL XR) amphetamine/dextroamphetamine mixed salts ext-rel 15 mg, 20 mg, 25 mg, 30 capsules per 23 days 30 mg (ADDERALL XR) azelastine spray 3 inhalers per 23 days buprenorphine/naloxone sublingual tabs 24 mg buprenorphine per day butalbital/acetaminophen 30 units per 23 days butalbital/acetaminophen/caffeine (FIORICET) 30 units per 23 days butalbital/acetaminophen/caffeine/codeine (FIORICET w/CODEINE) 30 units per 23 days butalbital/aspirin/caffeine (FIORINAL) 30 units per 23 days butalbital/aspirin/caffeine/codeine (FIORINAL w/CODEINE) 30 units per 23 days CHANTIX 24 weeks per 12 months ciprofloxacin ext-rel 500 mg (CIPRO XR) 3 tablets per 23 days dexmethylphenidate 2.5 mg, 5 mg (FOCALIN) 120 tablets per 23 days dexmethylphenidate 10 mg (FOCALIN) 60 tablets per 23 days dextroamphetamine 120 tablets per 23 days dextroamphetamine ext-rel 5 mg, 10 mg (DEXEDRINE SPANSULE) 120 capsules per 23 days dextroamphetamine ext-rel 15 mg (DEXEDRINE SPANSULE) 60 capsules per 23 days diazepam Intensol soln 5 mg/mL (VALIUM) 240 mL per 23 days diazepam soln 5 mg/5 mL (VALIUM) 1200 mL per 23 days diazepam tabs (VALIUM) 120 tablets per 23 days dihydroergotamine spray (MIGRANAL) 8 mL per 23 days ELLA 3 fills per 365 days enoxaparin (LOVENOX) 28 prefilled syringes per 23 days esomeprazole magnesium delayed-rel (NEXIUM 24HR) 60 capsules per 23 days FLEET ENEMA 2 kits per 72 hours fluconazole 150 mg (DIFLUCAN) 3 tablets per 23 days granisetron 1 mg 10 tablets per 23 days ketorolac 20 tablets per 23 days lansoprazole (PREVACID) 30 units per 23 days levonorgestrel 0.75 mg 3 fills per 365 days levonorgestrel - Next Choice One Dose (PLAN B ONE-STEP) 3 fills per 365 days lorazepam (ATIVAN) 90 tablets per 23 days methylphenidate 5 mg, 10 mg (RITALIN) 180 tablets per 23 days methylphenidate ext-rel 10 mg 90 tablets per 23 days methylphenidate ext-rel 10 mg, 20 mg, 30 mg (METADATE CD) 60 capsules per 23 days methylphenidate ext-rel 10 mg, 20 mg, 30 mg (RITALIN LA) 60 capsules per 23 days methylphenidate ext-rel 18 mg, 27 mg, 36 mg (CONCERTA) 60 tablets per 23 days methylphenidate ext-rel 20 mg tabs - Metadate ER 90 tablets per 23 days methylphenidate ext-rel 40 mg, 50 mg (METADATE CD) 30 capsules per 23 days MedStar Family Choice - DC Healthy Families Program 8

Drugs Limits methylphenidate ext-rel 54 mg (CONCERTA) 30 tablets per 23 days methylphenidate oral soln 5 mg/5 mL (METHYLIN) 1800 mL per 23 days methylphenidate oral soln 10 mg/5 mL (METHYLIN) 900 mL per 23 days methylphenidate (METHYLIN) 180 tablets per 23 days naratriptan (AMERGE) 9 tablets per 23 days nicotine transdermal 90 day supply per calendar year omeprazole 40 mg (PRILOSEC) 60 capsules per 23 days omeprazole, except 40 mg (PRILOSEC) 30 capsules per 23 days oxazepam 120 units per 23 days pantoprazole 20 mg (PROTONIX) 30 tablets per 23 days pantoprazole 40 mg (PROTONIX) 60 tablets per 23 days PREVACID SOLUTAB 30 tablets per 23 days RELENZA 1 course of treatment per calendar year rizatriptan orally disintegrating tabs (MAXALT-MLT) 18 tablets per 23 days rizatriptan (MAXALT) 18 tablets per 23 days SEREVENT 1 inhaler per 23 days STRATTERA 10 mg, 18 mg, 25 mg 120 capsules per 23 days STRATTERA 40 mg 60 capsules per 23 days STRATTERA 60 mg, 80 mg, 100 mg 30 capsules per 23 days sumatriptan 25 mg, 50 mg, 100 mg (IMITREX) 9 tablets per 23 days sumatriptan inj (IMITREX) 6 vials (6 injections) per 23 days sumatriptan inj (IMITREX) 3 kits (6 injections) per 23 days sumatriptan nasal spray (IMITREX) 6 units (1 package) per 23 days TAMIFLU 1 course of treatment per calendar year temazepam (RESTORIL) 15 capsules per 23 days tramadol (ULTRAM) 120 tablets per 23 days ZANTAC 75 240 tablets per 23 days zolmitriptan 2.5 mg (ZOMIG) 12 tablets per 23 days zolmitriptan 5 mg (ZOMIG) 6 tablets per 23 days zolmitriptan orally disintegrating tabs 2.5 mg (ZOMIG-ZMT) 12 tablets per 23 days zolmitriptan orally disintegrating tabs 5 mg (ZOMIG-ZMT) 6 tablets per 23 days zolpidem (AMBIEN) 15 tablets per 23 days

MANAGED DRUG LIMITATIONS (MDL): For members age 65 and older Drugs Limits amitriptyline 10 mg 90 tablets per 23 days amitriptyline 25 mg, 50 mg 30 tablets per 23 days chlordiazepoxide 5 mg, 10 mg 60 capsules per 23 days desipramine 10 mg, 25 mg, 50 mg (NORPRAMIN) 90 tablets per 23 days desipramine 75 mg (NORPRAMIN) 60 tablets per 23 days desipramine 100 mg, 150 mg (NORPRAMIN) 30 tablets per 23 days doxepin 10 mg, 25 mg, 50 mg 90 tablets per 23 days doxepin 75 mg 60 tablets per 23 days doxepin 100 mg, 150 mg 30 tablets per 23 days doxepin oral concentrate 10 mg/mL 360 mL per 23 days imipramine caps, tabs (TOFRANIL) 60 units per 23 days nortriptyline 10 mg, 25 mg, 50 mg (PAMELOR) 60 tablets per 23 days nortriptyline 75 mg (PAMELOR) 30 tablets per 23 days nortriptyline soln 10 mg/5 mL (PAMELOR) 1500 mL per 23 days

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STEP THERAPY (ST) Drugs indicated with a "ST" require Step Therapy authorization for coverage. When using drugs within select drug classes, this program requires a certain order to be followed for the "ST" designated drugs to be covered by your benefit plan. Within the Step Therapy program, drug therapy is begun with the most cost-effective and safest drugs. If this initial therapy proves unsuccessful, treatment may move to other, more costly therapy. Step Therapy helps ensure that a plan member receives clinically appropriate, cost-effective medication. The following drugs are subject to Step Therapy: Drugs ADVAIR DISKUS ADVAIR HFA CARMOL 10, CARMOL 20 CRESTOR DULERA lansoprazole delayed-rel (PREVACID) methylphenidate ext-rel (CONCERTA) methylphenidate ext-rel (RITALIN LA) rizatriptan orally disintegrating tabs (MAXALT-MLT) rizatriptan (MAXALT) SKLICE STRATTERA SYMBICORT zolmitriptan orally disintegrating tabs (ZOMIG-ZMT) zolmitriptan tabs (ZOMIG)

STEP THERAPY (ST): For members age 65 and older Drugs chlordiazepoxide diazepam (VALIUM)

OVER-THE-COUNTER (OTC) DRUG COVERAGE In addition to prescription benefits, all over-the-counter medications on this list are covered by MedStar Family Choice-DC with a written or telephoned prescription. Refills are permitted. Prescriptions may be written for the State limited 12 month maximum. OTC products covered are restricted to generics when available. Brand names are provided as reference only. If both prescription and OTC products are available, you are encouraged to prescribe OTC products when clinically appropriate. Antacids aluminum hydroxide AlternaGEL aluminum hydroxide/magnesium hydroxide Alamag aluminum hydroxide/magnesium hydroxide/simethicone Maalox calcium carbonate Maalox

Antibacterial, Topical bacitracin bacitracin/polymyxin B Polysporin benzoyl peroxide Panoxyl neomycin/bacitracin/polymyxin B Neosporin

Antifungals, Topical butenafine Lotrimin Ultra clotrimazole Lotrimin AF miconazole Desenex terbinafine Lamisil AT tolnaftate Tinactin MedStar Family Choice - DC Healthy Families Program 10

Antifungals, Vaginal clotrimazole Gyne-Lotrimin miconazole Monistat

Antihistamines cetirizine Zyrtec chlorpheniramine Chlor-Trimeton clemastine Tavist-1 diphenhydramine Benadryl fexofenadine Allegra loratadine Claritin

Antihistamine/Decongestant Combinations cetirizine/pseudoephedrine ext-rel Zyrtec-D chlorpheniramine/phenylephrine tabs Cold & Allergy Relief loratadine/pseudoephedrine ext-rel Claritin-D

Anti-Inflammatories, Topical hydrocortisone crm, oint 0.5%, 1% Cortizone

Antilipemic Agents, Miscellaneous niacin

Contraceptives, Barrier condoms Trojan spermicide gel Gynol II

Contraceptives, Emergency levonorgestrel 0.75 mg levonorgestrel - Next Choice One Dose Plan B One-Step

Cough/Cold/Allergy (OTC products not covered for members under 4 years of age) dextromethorphan gelcaps, liquid Robitussin Long-Acting Cough dextromethorphan/chlorpheniramine liquid Robitussin Children's Cough & Cold, Long-Acting dextromethorphan/guaifenesin ext-rel Mucinex DM dextromethorphan/guaifenesin/pseudoephedrine liq 10 mg/100 mg/30 mg/5 mL dextromethorphan/guaifenesin syrup Robitussin Cough + Chest Congestion DM dextromethorphan/pyrilamine/phenylephrine Codituss DM guaifenesin ext-rel Mucinex guaifenesin liquid Diabetic Tussin guaifenesin liquid Mucinex for Kids guaifenesin/pseudoephedrine ext-rel Mucinex D oxymetazoline Afrin phenylephrine Neo-Synephrine phenylephrine drops PediaCare pseudoephedrine Sudafed sodium chloride solution Ocean sodium chloride solution Simply Saline triamcinolone acetonide spray Nasacort Allergy 24HR

Gastrointestinal famotidine Pepcid AC famotidine chewable tabs Pepcid AC lansoprazole delayed-rel Prevacid 24HR omeprazole magnesium delayed-rel Prilosec OTC omeprazole/sodium bicarbonate Zegerid OTC

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ranitidine 75 mg Zantac 75 ranitidine 150 mg Zantac 150

Gastrointestinal, Miscellaneous bismuth subsalicylate Pepto-Bismol dextrose/fructose/phosphoric acid Emetrol dimenhydrinate Dramamine docusate sodium caps Colace docusate sodium liquid loperamide liquid, tabs Anti-Diarrheal meclizine simethicone Mylicon

Laxatives bisacodyl Dulcolax glycerin rectal suppository, adult glycerin rectal suppository, pediatric magnesium citrate methylcellulose Citrucel mineral oil polyethylene glycol 3350 MiraLax psyllium/aspartame Natural Fiber sennosides 8.6 mg tablets Senokot sennosides 15 mg tablets Ex-Lax sennosides/docusate sodium Peri-Colace sodium phosphate/sodium biphosphate enema, adult Fleet Enema sodium phosphate/sodium biphosphate enema, pediatric Fleet Enema

Nutritional/Supplements calcium Tums cholecalciferol (D3) Vitamin D3 electrolyte rehydrating soln Pedialyte ergocalciferol (D2) drops Drisdol ferrous fumarate Ferrimin 150 ferrous gluconate Fergon ferrous sulfate Feosol ferrous sulfate delayed-rel Slow FE iron polysaccharides complex multivitamins drops multivitamins/iron drops omega-3 fatty acids Fish Oil omega-3 fatty acids/vitamin E Fish Oil omega-3 fatty acids/vitamins chewable Omega-3 Gummies prenatal vitamins/DHA/EPA/ferrous fumarate/folic acid One Daily Prenatal prenatal vitamins/folic acid pyridoxine 25 mg Vitamin B6

Pain & Fever acetaminophen Tylenol aspirin 81 mg (not chewable) Bayer enteric coated aspirin Ecotrin ibuprofen Advil naproxen sodium Aleve

Pediculocides permethrin 1% NIX Creme Rinse

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Sleep Aids doxylamine Unisom melatonin

Smoking Deterrents nicotine polacrilex gum, lozenge Nicorette nicotine transdermal

Miscellaneous, Topical ammonium lactate 12% Lac-Hydrin calamine lotion carbamide peroxide Debrox chlorhexidine Hibiclens coal tar shampoo Neutrogena docosanol Abreva eucalyptus/menthol/compound rub Vicks Vaporub ketotifen Zaditor oatmeal, colloidal oatmeal, colloidal/dimethicone Aveeno petrolatum/mineral oil Eucerin salicylic acid 17% gel salicylic acid 40% pad salicylic acid 17%/collodion Duofilm salicylic acid plaster 40% urea crm Carmol 20 urea lotion Carmol 10 zinc oxide Desitin

EDITOR Your comments and suggestions regarding the MedStar Family Choice - DC Healthy Families Prescribing Guide are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to: Medical Director MedStar Family Choice - District of Columbia 901 D Street, SW Suite 1050 Washington, DC 20024 Phone: 1-855-210-6203 or 202-243-5400 Fax: 202-243-5496 NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of MedStar Family Choice. ©2014. All rights reserved. This MedStar Family Choice - DC Healthy Families Prescribing Guide contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with MedStar Family Choice.

MedStar Family Choice does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by MedStar Family Choice.

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LEGEND DESI DESI drug; found by the FDA to be not effective HRM High Risk Medication; Use with caution in members age 65 and older MDL Managed Drug Limitation OTC Over the counter PA Prior Authorization required ST Step Therapy required 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: http://www.asahq.org

NSAIDs OTC ibuprofen ADVIL OTC naproxen sodium ALEVE choline magnesium trisalicylate diclofenac potassium CATAFLAM diclofenac sodium delayed-rel etodolac flurbiprofen ibuprofen indomethacin MDL ketorolac meloxicam MOBIC nabumetone naproxen NAPROSYN naproxen sodium ANAPROX oxaprozin DAYPRO sulindac CLINORIL

NSAIDs, TOPICAL diclofenac sodium gel VOLTAREN GEL

COX-2 INHIBITORS PA celecoxib CELEBREX

GOUT allopurinol ZYLOPRIM colchicine/probenecid probenecid colchicine COLCRYS PA pegloticase KRYSTEXXA

OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: http://www.asahq.org http://www.nccn.org

Opioid guidelines in the management of chronic non-malignant pain are available at: http://www.asipp.org/Guidelines.htm

MDL butalbital/acetaminophen/caffeine/codeine FIORICET w/CODEINE MDL butalbital/aspirin/caffeine/codeine FIORINAL w/CODEINE codeine sulfate codeine/acetaminophen TYLENOL w/CODEINE PA fentanyl transdermal DURAGESIC hydrocodone/acetaminophen 5/325 mg, 7.5/325 mg, 10/325 mg NORCO hydrocodone/acetaminophen soln 7.5/325 per 15 mL HYCET hydromorphone DILAUDID meperidine DEMEROL methadone DOLOPHINE morphine PA morphine ext-rel AVINZA PA morphine ext-rel MS CONTIN MedStar Family Choice - DC Healthy Families Program 15

morphine supp oxycodone caps, tabs 5 mg oxycodone concentrate 20 mg/mL oxycodone tabs 10 mg, 20 mg oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL ROXICODONE oxycodone/acetaminophen 5/325, 7.5/325 PERCOCET oxycodone/aspirin PERCODAN MDL tramadol ULTRAM

NON-OPIOID ANALGESICS MDL butalbital/acetaminophen MDL butalbital/acetaminophen/caffeine ESGIC MDL butalbital/aspirin/caffeine FIORINAL

VISCOSUPPLEMENTS PA hylan G-F 20 SYNVISC PA hylan G-F 20 SYNVISC-ONE

ANTI-INFECTIVES Hepatitis: CDC recommendations on the treatment of hepatitis are available at: http://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: http://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: http://www.aidsinfo.nih.gov

Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: http://www.myamericanheart.org

Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm

International Travel: CDC recommendations for international travel are available at: http://www.cdc.gov/travel

Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: http://www.cdc.gov/std/treatment/default.htm

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: http://www.cdc.gov/flu/

Practice Guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: http://www.idsociety.org

ANTIBACTERIALS Cephalosporins First Generation cefadroxil cephalexin KEFLEX

Second Generation cefaclor cefuroxime axetil CEFTIN

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Third Generation cefdinir cefpodoxime tablets ceftriaxone ROCEPHIN cefixime SUPRAX

Erythromycins/Macrolides azithromycin ZITHROMAX clarithromycin BIAXIN clarithromycin ext-rel BIAXIN XL erythromycin base erythromycin delayed-rel erythromycin ethylsuccinate E.E.S. erythromycin stearate erythromycin delayed-rel ERY-TAB PA fidaxomicin DIFICID

Fluoroquinolones ciprofloxacin CIPRO MDL ciprofloxacin ext-rel 500 mg ciprofloxacin ext-rel 1000 mg levofloxacin LEVAQUIN moxifloxacin AVELOX

Penicillins amoxicillin amoxicillin/clavulanate AUGMENTIN ampicillin dicloxacillin penicillin VK

Sulfonamides sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim DS sulfadiazine

Tetracyclines doxycycline hyclate VIBRAMYCIN minocycline MINOCIN tetracycline

ANTIFUNGALS clotrimazole troches MDL fluconazole DIFLUCAN griseofulvin microsize susp griseofulvin microsize tabs GRIFULVIN V griseofulvin ultramicrosize GRIS-PEG nystatin terbinafine tabs LAMISIL PA posaconazole NOXAFIL

MDL = 150 mg only (2 tabs/23 days)

ANTIMALARIALS atovaquone/proguanil MALARONE chloroquine ARALEN

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mefloquine primaquine

ANTIRETROVIRAL AGENTS Coverage for these medications will be provided by the District of Columbia through the ADAP Pharmacy Network. Prescribers and members can find the current listing of pharmacies participating in the ADAP Pharmacy Network at http://doh.dc.gov/node/236872.

ANTITUBERCULAR AGENTS ethambutol MYAMBUTOL isoniazid pyrazinamide rifampin RIFADIN PA bedaquiline SIRTURO

ANTIVIRALS Cytomegalovirus Agents foscarnet

Hepatitis Agents Hepatitis B lamivudine EPIVIR-HBV entecavir BARACLUDE telbivudine TYZEKA

Hepatitis C PA ribavirin caps REBETOL PA ribavirin tabs COPEGUS PA ribavirin oral soln REBETOL PA simeprevir OLYSIO PA sofosbuvir SOVALDI PA telaprevir INCIVEK

Herpes Agents acyclovir caps, susp, tabs ZOVIRAX famciclovir FAMVIR valacyclovir VALTREX

Influenza Agents amantadine caps, syrup rimantadine FLUMADINE MDL oseltamivir TAMIFLU MDL zanamivir RELENZA

MISCELLANEOUS OTC pyrantel PIN X atovaquone MEPRON clindamycin CLEOCIN dapsone metronidazole FLAGYL neomycin sulfate tabs HRM nitrofurantoin ext-rel MACROBID HRM nitrofurantoin macrocrystals MACRODANTIN HRM nitrofurantoin susp FURADANTIN paromomycin rifabutin MYCOBUTIN

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trimethoprim tabs vancomycin VANCOCIN pentamidine aerosol NEBUPENT

ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: http://www.asco.org http://www.nccn.org

ALKYLATING AGENTS cyclophosphamide tabs lomustine temozolomide TEMODAR altretamine HEXALEN busulfan MYLERAN chlorambucil LEUKERAN melphalan ALKERAN

ANTIMETABOLITES capecitabine XELODA mercaptopurine PURINETHOL

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide CASODEX flutamide

Antiestrogens tamoxifen fulvestrant FASLODEX toremifene FARESTON

Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA

Luteinizing Hormone-releasing Hormone (LHRH) Agonists PA leuprolide acetate PA goserelin acetate ZOLADEX PA leuprolide acetate ELIGARD PA leuprolide acetate LUPRON DEPOT

Progestins megestrol acetate MEGACE megestrol acetate susp MEGACE ES

KINASE INHIBITORS PA bosutinib BOSULIF PA cabozantinib COMETRIQ PA crizotinib XALKORI PA dabrafenib TAFINLAR PA erlotinib TARCEVA PA ibrutinib IMBRUVICA PA idelalisib ZYDELIG imatinib mesylate GLEEVEC MedStar Family Choice - DC Healthy Families Program 19

PA lapatinib TYKERB PA nilotinib TASIGNA PA ponatinib ICLUSIG PA regorafenib STIVARGA PA ruxolitinib JAKAFI PA trametinib MEKINIST PA vemurafenib ZELBORAF

TOPOISOMERASE INHIBITORS doxorubicin liposomal DOXIL PA topotecan caps HYCAMTIN CAPS

MISCELLANEOUS etoposide hydroxyurea HYDREA tretinoin caps PA asparaginase erwinia ERWINAZE bexarotene caps TARGRETIN caps hydroxyurea DROXIA mitotane LYSODREN PA omacetaxine mepesuccinate SYNRIBO procarbazine MATULANE PA trastuzumab HERCEPTIN

CARDIOVASCULAR The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: http://www.nhlbi.nih.gov/guidelines/hypertension

Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: http://www.acc.org http://www.heartfailureguideline.org http://www.myamericanheart.org

ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: http://professional.diabetes.org http://www.acc.org http://www.myamericanheart.org http://www.nhlbi.nih.gov/guidelines/hypertension

benazepril LOTENSIN captopril enalapril VASOTEC fosinopril lisinopril ZESTRIL moexipril UNIVASC quinapril ACCUPRIL ramipril ALTACE trandolapril MAVIK

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril LOTREL trandolapril/verapamil ext-rel TARKA

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ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide LOTENSIN HCT captopril/hydrochlorothiazide enalapril/hydrochlorothiazide VASERETIC fosinopril/hydrochlorothiazide lisinopril/hydrochlorothiazide ZESTORETIC moexipril/hydrochlorothiazide UNIRETIC quinapril/hydrochlorothiazide ACCURETIC

ADRENOLYTICS, CENTRAL clonidine CATAPRES clonidine transdermal CATAPRES-TTS guanfacine TENEX

ALDOSTERONE RECEPTOR ANTAGONISTS spironolactone ALDACTONE

ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: http://www.nhlbi.nih.gov/guidelines/hypertension

doxazosin CARDURA prazosin MINIPRESS terazosin

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: http://professional.diabetes.org http://www.nhlbi.nih.gov/guidelines/hypertension

irbesartan AVAPRO irbesartan/hydrochlorothiazide AVALIDE losartan COZAAR losartan/hydrochlorothiazide HYZAAR

ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: http://www.acc.org

amiodarone CORDARONE amiodarone PACERONE disopyramide NORPACE flecainide propafenone RYTHMOL quinidine gluconate ext-rel quinidine sulfate sotalol BETAPACE sotalol BETAPACE AF dofetilide TIKOSYN

ANTILIPEMICS The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) is available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

Bile Acid Resins cholestyramine QUESTRAN/QUESTRAN LIGHT MedStar Family Choice - DC Healthy Families Program 21

Cholesterol Absorption Inhibitors ezetimibe ZETIA

Fibrates fenofibrate, micronized LOFIBRA fenofibric acid FIBRICOR gemfibrozil LOPID

HMG-CoA Reductase Inhibitors atorvastatin LIPITOR lovastatin MEVACOR pravastatin PRAVACHOL simvastatin ZOCOR ST rosuvastatin CRESTOR

ST = Generic statin required first

Niacins OTC niacin niacin NIACOR niacin ext-rel NIASPAN

Miscellaneous OTC omega-3 fatty acids FISH OIL OTC omega-3 fatty acids/vitamin E FISH OIL OTC omega-3 fatty acids/vitamins chewable OMEGA-3 GUMMIES PA omega-3 acid ethyl esters LOVAZA PA lomitapide JUXTAPID

BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: http://www.acc.org http://www.nhlbi.nih.gov/guidelines/hypertension

atenolol TENORMIN bisoprolol ZEBETA carvedilol COREG labetalol TRANDATE metoprolol LOPRESSOR metoprolol ext-rel TOPROL-XL nadolol CORGARD pindolol propranolol propranolol ext-rel INDERAL LA timolol maleate tabs carvedilol phosphate ext-rel COREG CR

BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: http://www.acc.org http://www.nhlbi.nih.gov/guidelines/hypertension

atenolol/chlorthalidone TENORETIC bisoprolol/hydrochlorothiazide ZIAC

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CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine NORVASC felodipine ext-rel nicardipine nifedipine PROCARDIA nifedipine ext-rel ADALAT CC nifedipine ext-rel PROCARDIA XL nimodipine

Nondihydropyridines diltiazem CARDIZEM diltiazem ext-rel diltiazem ext-rel CARDIZEM CD diltiazem ext-rel TIAZAC verapamil CALAN verapamil ext-rel CALAN SR verapamil ext-rel VERELAN

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin CADUET

DIGITALIS GLYCOSIDES digoxin LANOXIN

DIURETICS Carbonic Anhydrase Inhibitors acetazolamide acetazolamide ext-rel DIAMOX SEQUELS methazolamide

Loop Diuretics bumetanide furosemide LASIX torsemide DEMADEX

Potassium-sparing Diuretics amiloride triamterene DYRENIUM

Thiazides and Thiazide-like Diuretics chlorothiazide chlorthalidone hydrochlorothiazide indapamide methyclothiazide metolazone ZAROXOLYN chlorothiazide susp DIURIL

Diuretic Combinations amiloride/hydrochlorothiazide spironolactone/hydrochlorothiazide ALDACTAZIDE triamterene/hydrochlorothiazide DYAZIDE triamterene/hydrochlorothiazide MAXZIDE

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NITRATES Oral isosorbide dinitrate ext-rel tabs isosorbide dinitrate oral ISORDIL isosorbide mononitrate isosorbide mononitrate ext-rel IMDUR

Sublingual isosorbide dinitrate sublingual nitroglycerin sublingual spray NITROLINGUAL nitroglycerin sublingual NITROSTAT

Transdermal nitroglycerin transdermal nitroglycerin transdermal NITRO-DUR nitroglycerin oint NITRO-BID

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA ambrisentan LETAIRIS PA macitentan OPSUMIT

Phosphodiesterase Inhibitors PA sildenafil REVATIO PA tadalafil ADCIRCA

Prostaglandin Vasodilators PA epoprostenol sodium FLOLAN PA iloprost VENTAVIS PA treprostinil REMODULIN PA treprostinil TYVASO

Soluble Guanylate Cyclase Stimulators PA riociguat ADEMPAS

MISCELLANEOUS hydralazine methyldopa methyldopa/hydrochlorothiazide midodrine minoxidil

CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: http://www.psych.org

ANTIANXIETY Benzodiazepines MDL alprazolam XANAX PA midazolam injection ST* chlordiazepoxide clonazepam tabs KLONOPIN

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ST* MDL diazepam VALIUM MDL lorazepam ATIVAN MDL oxazepam

ST* Only applies to members of age 65 and older; Short-acting benzodiazepine required first

Miscellaneous buspirone clomipramine ANAFRANIL fluvoxamine

ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: http://www.aan.com

carbamazepine TEGRETOL carbamazepine ext-rel CARBATROL carbamazepine ext-rel TEGRETOL-XR clonazepam KLONOPIN diazepam rectal gel DIASTAT divalproex sodium delayed-rel DEPAKOTE divalproex sodium ext-rel DEPAKOTE ER ethosuximide ZARONTIN felbamate FELBATOL gabapentin NEURONTIN lamotrigine LAMICTAL levetiracetam KEPPRA oxcarbazepine TRILEPTAL phenobarbital phenytoin DILANTIN INFATABS phenytoin sodium extended DILANTIN primidone MYSOLINE tiagabine GABITRIL topiramate TOPAMAX valproic acid DEPAKENE zonisamide ZONEGRAN PA clobazam ONFI PA ezogabine POTIGA PA lacosamide VIMPAT PA rufinamide BANZEL PA vigabatrin SABRIL

ANTIDEMENTIA Practice guidelines for the management of dementia are available at: http://www.aan.com

donepezil ARICEPT galantamine RAZADYNE rivastigmine EXELON PA memantine NAMENDA

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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: http://www.psych.org

Monoamine Oxidase Inhibitors (MAOIs) phenelzine NARDIL tranylcypromine PARNATE isocarboxazid MARPLAN

Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram CELEXA escitalopram LEXAPRO fluoxetine PROZAC paroxetine HCl PAXIL paroxetine HCl ext-rel PAXIL CR sertraline ZOLOFT paroxetine HCl susp PAXIL

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) PA duloxetine delayed-rel CYMBALTA venlafaxine venlafaxine ext-rel EFFEXOR XR

Tricyclic Antidepressants (TCAs) MDL * amitriptyline MDL * desipramine NORPRAMIN MDL * doxepin MDL * nortriptyline PAMELOR MDL * imipramine HCl TOFRANIL

MDL* Only applies to members of age 65 and older

Miscellaneous Agents bupropion WELLBUTRIN bupropion ext-rel WELLBUTRIN SR bupropion ext-rel WELLBUTRIN XL mirtazapine REMERON trazodone

ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: http://www.aan.com

amantadine caps, syrup benztropine bromocriptine PARLODEL carbidopa LODOSYN carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel SINEMET CR carbidopa/levodopa/entacapone STALEVO entacapone COMTAN pramipexole MIRAPEX ropinirole REQUIP selegiline caps ELDEPRYL MedStar Family Choice - DC Healthy Families Program 26

selegiline tabs trihexyphenidyl

ANTIPSYCHOTICS Atypicals clozapine CLOZARIL olanzapine ZYPREXA quetiapine SEROQUEL risperidone RISPERDAL ziprasidone GEODON PA aripiprazole ABILIFY PA iloperidone FANAPT PA paliperidone ext-rel INVEGA PA paliperidone palmitate INVEGA SUSTENNA PA quetiapine ext-rel SEROQUEL XR PA risperidone inj RISPERDAL CONSTA PA asenapine SAPHRIS

Miscellaneous chlorpromazine fluphenazine haloperidol perphenazine thiothixene trifluoperazine

ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: http://www.aacap.org http://www.aap.org

MDL amphetamine/dextroamphetamine mixed salts ADDERALL MDL amphetamine/dextroamphetamine mixed salts ext-rel ADDERALL XR MDL dexmethylphenidate FOCALIN MDL dextroamphetamine ext-rel DEXEDRINE SPANSULE MDL dextroamphetamine tabs 5 mg, 10 mg MDL methylphenidate RITALIN ST MDL methylphenidate ext-rel CONCERTA MDL methylphenidate ext-rel METADATE CD ST MDL methylphenidate ext-rel RITALIN LA MDL methylphenidate ext-rel 10 mg MDL methylphenidate ext-rel tabs 20 mg - Metadate ER MDL methylphenidate soln, tabs METHYLIN ST MDL atomoxetine STRATTERA

ST = Generic oral immediate-release formulary agent required first

FIBROMYALGIA milnacipran SAVELLA PA pregabalin LYRICA

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HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia are available at: http://www.aasmnet.org

Benzodiazepines MDL temazepam RESTORIL

Nonbenzodiazepines OTC doxylamine UNISOM MDL zolpidem AMBIEN

MIGRAINE Guidelines for prevention and management of migraine headaches are available at: http://www.aan.com

Ergotamine Derivatives MDL dihydroergotamine spray MIGRANAL ergotamine/caffeine CAFERGOT

Selective Serotonin Agonists MDL naratriptan AMERGE ST MDL rizatriptan MAXALT MDL sumatriptan IMITREX MDL sumatriptan inj IMITREX MDL sumatriptan nasal spray IMITREX ST MDL zolmitriptan tabs ZOMIG

ST = Generic sumatriptan required first

Miscellaneous DESI acetaminophen/dichloralphenazone/isometheptene MIDRIN amitriptyline

MOOD STABILIZERS lithium carbonate lithium carbonate ext-rel tabs 300 mg LITHOBID lithium carbonate ext-rel tabs 450 mg lithium citrate LITHIUM CITRATE

MULTIPLE SCLEROSIS Practice guidelines for multiple sclerosis are available at: http://www.aan.com

PA fingolimod GILENYA glatiramer COPAXONE interferon beta-1a AVONEX interferon beta-1b EXTAVIA

MUSCULOSKELETAL THERAPY AGENTS baclofen carisoprodol SOMA chlorzoxazone PARAFON FORTE DSC cyclobenzaprine 5 mg, 10 mg dantrolene DANTRIUM diazepam VALIUM methocarbamol ROBAXIN MedStar Family Choice - DC Healthy Families Program 28

orphenadrine ext-rel tizanidine tabs ZANAFLEX

MYASTHENIA GRAVIS pyridostigmine MESTINON pyridostigmine ext-rel MESTINON TIMESPAN

NARCOLEPSY/CATAPLEXY PA modafinil PROVIGIL PA armodafinil NUVIGIL PA sodium oxybate XYREM

NEUROMUSCULAR BLOCKING AGENTS PA onabotulinumtoxinA BOTOX

PSYCHOTHERAPEUTIC - MISCELLANEOUS Alcohol Deterrents PA acamprosate calcium CAMPRAL disulfiram ANTABUSE

Opioid Antagonists naltrexone REVIA

Partial Opioid Agonists * buprenorphine sublingual

* Concomitant opioid drug use will not be allowed 90 days after the initial buprenorphine or buprenorphine/naloxone prescription.

Partial Opioid Agonists/Opioid Antagonist Combinations * MDL buprenorphine/naloxone sublingual tabs

* Concomitant opioid drug use will not be allowed 90 days after the initial buprenorphine or buprenorphine/naloxone prescription.

Smoking Deterrents OTC nicotine polacrilex gum, lozenge NICORETTE OTC MDL nicotine transdermal PA nicotine inhaler NICOTROL INHALER PA nicotine nasal spray NICOTROL NS PA MDL varenicline CHANTIX

ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: http://www.aace.com

oxandrolone OXANDRIN testosterone enanthate inj DELATESTRYL testosterone gel FORTESTA testosterone soln AXIRON

ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: http://professional.diabetes.org

Alpha-glucosidase Inhibitors acarbose PRECOSE MedStar Family Choice - DC Healthy Families Program 29

Biguanides metformin GLUCOPHAGE * metformin ext-rel GLUCOPHAGE XR

* For extended-release metformin, use generic Glucophage XR; Fortamet and its generic equivalent are not covered. To achieve a 1000 mg dose, utilize 2 x 500 mg.

Biguanide/Sulfonylurea Combinations glipizide/metformin METAGLIP HRM glyburide/metformin GLUCOVANCE

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors linagliptin TRADJENTA sitagliptin phosphate JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations linagliptin/metformin JENTADUETO sitagliptin/metformin JANUMET sitagliptin/metformin ext-rel JANUMET XR

Incretin Mimetic Agents exenatide BYETTA exenatide ext-rel BYDUREON liraglutide VICTOZA

Insulins * OTC insulin human HUMULIN R * OTC insulin human NOVOLIN R * OTC insulin isophane human HUMULIN N * OTC insulin isophane human NOVOLIN N * OTC insulin isophane human 70%/regular 30% HUMULIN 70/30 * OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 * insulin aspart NOVOLOG * insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 * insulin glargine LANTUS * insulin lispro HUMALOG * insulin lispro protamine 50%/insulin lispro 50% HUMALOG MIX 50/50 * insulin lispro protamine 75%/insulin lispro 25% HUMALOG MIX 75/25

* Cartridges and pens are covered for participants 0-18 years of age

Insulin Sensitizers pioglitazone ACTOS

Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin ACTOPLUS MET

Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride DUETACT

Meglitinides nateglinide STARLIX repaglinide PRANDIN

Sulfonylureas glimepiride AMARYL

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glipizide GLUCOTROL glipizide ext-rel GLUCOTROL XL HRM glyburide HRM glyburide DIABETA HRM glyburide, micronized GLYNASE

Supplies * OTC blood glucose monitoring kits, test strips ACCU-CHEK KITS AND TEST STRIPS OTC glucose meter control solution ACCU-CHEK CONTROL SOLUTION OTC insulin syringes, needles OTC lancets, lancet devices OTC urine test strips CHEMSTRIP URINE TEST STRIPS OTC urine test strips KETOSTIX URINE TEST STRIPS

* Obtain a free Accu-Chek meter by calling 1-888-744-3671

CALCIUM RECEPTOR ANTAGONISTS PA cinacalcet SENSIPAR

CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: http://www.aace.com http://www.nof.org

Bisphosphonates alendronate tabs FOSAMAX alendronate/vitamin D3 FOSAMAX PLUS D

Calcitonins calcitonin-salmon MIACALCIN

RANK Ligand (RANKL) Inhibitors PA denosumab PROLIA PA denosumab XGEVA

CONTRACEPTIVES EE = ethinyl estradiol ME = mestranol

Monophasic 10 mcg Estrogen PA norethindrone acetate/EE 1/10 and EE 10 and iron LO LOESTRIN FE

20 mcg Estrogen drospirenone/EE 3/20 - Gianvi YAZ levonorgestrel/EE 0.09/20 - Amethyst levonorgestrel/EE 0.1/20 - Aviane norethindrone acetate/EE 1/20 LOESTRIN 1/20 norethindrone acetate/EE 1/20 and iron LOESTRIN FE 1/20 PA drospirenone/EE/levomefolate 3/20 and levomefolate BEYAZ PA norethindrone acetate/EE 1/20 and iron chewable MINASTRIN 24 FE

25 mcg Estrogen PA norethindrone/EE 0.8/25 chewable GENERESS FE MedStar Family Choice - DC Healthy Families Program 31

30 mcg Estrogen desogestrel/EE 0.15/30 ORTHO-CEPT drospirenone/EE 3/30 YASMIN levonorgestrel/EE 0.15/30 - Levora norethindrone acetate/EE 1.5/30 LOESTRIN 1.5/30 norethindrone acetate/EE 1.5/30 and iron LOESTRIN FE 1.5/30 norgestrel/EE 0.3/30 - Low-Ogestrel PA drospirenone/EE 3/30 SAFYRAL

35 mcg Estrogen ethynodiol diacetate/EE 1/35 - Zovia 1/35 norethindrone/EE 0.4/35 OVCON 35 norethindrone/EE 0.4/35 chewable FEMCON FE norethindrone/EE 0.5/35 MODICON norethindrone/EE 1/35 ORTHO-NOVUM 1/35 norgestimate/EE 0.25/35 ORTHO-CYCLEN

50 mcg Estrogen ethynodiol diacetate/EE 1/50 - Zovia 1/50 norethindrone/ME 1/50 NORINYL 1+50 norgestrel/EE 0.5/50 - Ogestrel

Biphasic desogestrel/EE MIRCETTE desogestrel/EE PIMTREA norethindrone/EE NECON 10/11

Triphasic desogestrel/EE CYCLESSA levonorgestrel/EE - Trivora norethindrone acetate/EE and iron ESTROSTEP FE norethindrone/EE ORTHO-NOVUM 7/7/7 norethindrone/EE TRI-NORINYL norgestimate/EE ORTHO TRI-CYCLEN norgestimate/EE ORTHO TRI-CYCLEN LO

Four Phase PA estradiol valerate and dienogest/estradiol valerate NATAZIA PA levonorgestrel/EE 0.15/20, 0.15/25, 0.15/30 and EE 10 QUARTETTE

Extended Cycle levonorgestrel/EE 0.1/20 and EE 10 LOSEASONIQUE levonorgestrel/EE 0.15/30 levonorgestrel/EE 0.15/30 and EE 10 SEASONIQUE

Progestin Only norethindrone ORTHO MICRONOR

Emergency Contraception MDL levonorgestrel 0.75 mg MDL levonorgestrel - Next Choice One Dose PLAN B ONE-STEP MDL ulipristal ELLA

Injectable medroxyprogesterone acetate 150 mg/mL DEPO-PROVERA

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Progestin Intrauterine Device levonorgestrel releasing IUD MIRENA levonorgestrel releasing IUD SKYLA

Transdermal norelgestromin/EE ORTHO EVRA

Miscellaneous OTC nonoxynol 9 gel GYNOL II diaphragm ORTHO-DIAPHRAGM etonogestrel/EE ring NUVARING intrauterine device PARAGARD T 380A

ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: http://www.menopause.org

Oral HRM estradiol ESTRACE estropipate estrogens, conjugated, synthetic A CENESTIN

Transdermal HRM estradiol CLIMARA estradiol ALORA estradiol VIVELLE-DOT

Vaginal estradiol vaginal cream ESTRACE estradiol vaginal ring FEMRING

ESTROGEN/PROGESTINS Oral EE/norethindrone acetate - Jinteli EE/norethindrone acetate FEMHRT estrogens, conjugated/medroxyprogesterone PREMPHASE estrogens, conjugated/medroxyprogesterone PREMPRO

Transdermal estradiol/levonorgestrel CLIMARA PRO estradiol/norethindrone acetate COMBIPATCH

GLUCOCORTICOIDS cortisone acetate dexamethasone fludrocortisone hydrocortisone CORTEF methylprednisolone MEDROL prednisolone sodium phosphate soln 5 mg/5 mL, 15 mg/5 mL, 25 mg/5 mL prednisolone syrup PRELONE prednisone

GLUCOSE ELEVATING AGENTS glucagon, human recombinant GLUCAGON EMERGENCY KIT

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HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: http://www.aace.com/publications/guidelines

PA somatropin NORDITROPIN PA somatropin SEROSTIM

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) ROCALTROL doxercalciferol HECTOROL

PHOSPHATE BINDER AGENTS calcium acetate PHOSLO PA lanthanum FOSRENOL

PROGESTINS medroxyprogesterone acetate PROVERA norethindrone acetate AYGESTIN

SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene EVISTA

THYROID AGENTS Antithyroid Agents methimazole TAPAZOLE propylthiouracil

Thyroid Supplements levothyroxine SYNTHROID levothyroxine - Levoxyl liothyronine CYTOMEL

VASOPRESSINS PA desmopressin spray DDAVP desmopressin tabs DDAVP PA desmopressin spray STIMATE

MISCELLANEOUS methylergonovine PA histrelin ac SUPPRELIN LA PA mifepristone KORLYM succimer CHEMET

GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: http://www.acg.gi.org http://www.gastro.org

ANTACIDS OTC aluminum hydroxide ALTERNAGEL OTC aluminum hydroxide/magnesium hydroxide ALAMAG OTC calcium carbonate MAALOX

ANTIDIARRHEALS OTC bismuth subsalicylate PEPTO-BISMOL OTC loperamide liquid, tabs ANTI-DIARRHEAL MedStar Family Choice - DC Healthy Families Program 34

HRM diphenoxylate/atropine LOMOTIL PA crofelemer FULYZAQ

ANTIEMETICS OTC dextrose/fructose/phosphoric acid EMETROL OTC dimenhydrinate DRAMAMINE OTC meclizine MDL granisetron meclizine ANTIVERT metoclopramide REGLAN ondansetron ZOFRAN prochlorperazine HRM promethazine trimethobenzamide TIGAN aprepitant EMEND

ANTISPASMODICS dicyclomine BENTYL glycopyrrolate hyoscyamine 0.15 mg tabs hyoscyamine sulfate 0.125 mg hyoscyamine sulfate 125 mcg/5 mL elixir hyoscyamine sulfate ext-rel 0.375 mg propantheline DESI atropine/hyoscyamine/scopolamine/phenobarbital 16.2 mg tabs DONNATAL 16.2 mg tabs DESI atropine/hyoscyamine/scopolamine/phenobarbital elixir DONNATAL elixir

CHOLELITHOLYTICS ursodiol ACTIGALL ursodiol URSO ursodiol URSO FORTE

H2 RECEPTOR ANTAGONISTS OTC famotidine PEPCID AC OTC MDL ranitidine 75 mg ZANTAC 75 OTC ranitidine 150 mg ZANTAC 150 OTC famotidine chewable tabs PEPCID AC cimetidine ranitidine ZANTAC

INFLAMMATORY BOWEL DISEASE Oral Agents budesonide delayed-rel caps ENTOCORT EC sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS mesalamine delayed-rel tabs ASACOL HD mesalamine ext-rel caps PENTASA

Rectal Agents hydrocortisone enema mesalamine rectal susp ROWASA hydrocortisone acetate foam CORTIFOAM mesalamine supp CANASA

LAXATIVES/STOOL SOFTENERS OTC docusate sodium caps COLACE

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OTC docusate sodium liquid OTC methylcellulose CITRUCEL OTC mineral oil OTC polyethylene glycol 3350 MIRALAX OTC psyllium/aspartame NATURAL FIBER OTC sennosides SENOKOT lactulose peg 3350/electrolytes GOLYTELY peg 3350/electrolytes NULYTELY

PANCREATIC ENZYMES pancrelipase delayed-rel CREON

PROSTAGLANDINS misoprostol CYTOTEC

PROTON PUMP INHIBITORS OTC lansoprazole delayed-rel PREVACID 24HR OTC omeprazole/sodium bicarbonate ZEGERID OTC OTC MDL esomeprazole magnesium delayed-rel NEXIUM 24HR OTC omeprazole magnesium delayed-rel PRILOSEC OTC ST MDL lansoprazole delayed-rel PREVACID MDL omeprazole delayed-rel caps PRILOSEC MDL pantoprazole delayed-rel PROTONIX * MDL lansoprazole delayed-rel orally-disintegrating 15 mg tabs PREVACID SOLUTAB

* Covered for members eight years of age and under ST = OTC PPI required first, contact 1-855-210-6203

STEROIDS, RECTAL hydrocortisone crm ANUSOL-HC 2.5% hydrocortisone rectal crm, oint DESI hydrocortisone supp ANUSOL-HC

ULCER THERAPY COMBINATIONS lansoprazole + amoxicillin + clarithromycin PREVPAC

MISCELLANEOUS OTC simethicone MYLICON sucralfate CARAFATE

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: http://www.auanet.org/guidelines

alfuzosin ext-rel UROXATRAL doxazosin CARDURA finasteride PROSCAR tamsulosin FLOMAX terazosin

URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel DITROPAN XL trospium SANCTURA MedStar Family Choice - DC Healthy Families Program 36

VAGINAL ANTI-INFECTIVES OTC clotrimazole GYNE-LOTRIMIN OTC miconazole MONISTAT clindamycin crm CLEOCIN metronidazole METROGEL-VAGINAL terconazole TERAZOL 3 terconazole TERAZOL 7

MISCELLANEOUS bethanechol URECHOLINE phenazopyridine PYRIDIUM potassium citrate ext-rel, except 15 mEq UROCIT-K potassium/sodium phosphates K-PHOS NEUTRAL sodium citrate/citric acid acetohydroxamic acid LITHOSTAT methenamine/hyoscyamine/methylene blue/benzoic acid/ PROSED/DS phenyl salicylate pentosan polysulfate sodium ELMIRON

HEMATOLOGIC Guidelines of treatment and management of hemophilia are available at: http://www.hemophilia.org

ANTICOAGULANTS Injectable MDL enoxaparin LOVENOX

Oral warfarin COUMADIN PA dabigatran etexilate PRADAXA rivaroxaban XARELTO

HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: http://www.asco.org

Guidelines for the management of anemia associated with chronic kidney disease are available at: http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm#guidelines

darbepoetin alfa ARANESP epoetin alfa EPOGEN epoetin alfa PROCRIT filgrastim NEUPOGEN pegfilgrastim NEULASTA sargramostim LEUKINE

HEREDITARY ANGIOEDEMA AGENTS ecallantide KALBITOR PA icatibant FIRAZYR

PLATELET AGGREGATION INHIBITORS clopidogrel PLAVIX dipyridamole PERSANTINE PA vorapaxar ZONTIVITY

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PLATELET SYNTHESIS INHIBITORS anagrelide AGRYLIN pentoxifylline ext-rel

IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: http://www.rheumatology.org

ALLERGEN EXTRACTS PA grass mixed pollen allergen extract ORALAIR PA ragweed pollen allergen extract RAGWITEK PA timothy grass pollen allergen extract GRASTEK

BIOLOGIC DISEASE-MODIFYING AGENTS PA adalimumab HUMIRA PA etanercept ENBREL PA infliximab REMICADE

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine PLAQUENIL PA leflunomide ARAVA methotrexate 2.5 mg

IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: http://www.cdc.gov/hepatitis/Resources/

Guidelines for the management of hepatitis are available at: http://www.aasld.org

Immune Globulins PA immune globulin, intravenous GAMMAGARD S/D

Interferons PA interferon alfa-2b INTRON A PA peginterferon alfa-2a PEGASYS PA peginterferon alfa-2b PEGINTRON

IMMUNOSUPPRESSANTS Antimetabolites azathioprine IMURAN mycophenolate mofetil CELLCEPT

Calcineurin Inhibitors cyclosporine SANDIMMUNE cyclosporine, modified NEORAL tacrolimus PROGRAF

Miscellaneous PA belimumab BENLYSTA

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride effervescent

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potassium chloride ext-rel potassium chloride liquid potassium chloride powder 20 mEq potassium chloride powder 25 mEq KLOR-CON/25

Potassium-Removing Agents sodium polystyrene sulfonate SPS

VITAMINS AND MINERALS Folic Acid Agents folic acid

Prenatal Vitamins OTC prenatal vitamins/folic acid OTC prenatal vitamins/DHA/EPA/ferrous fumarate/folic acid ONE DAILY PRENATAL prenatal vitamins/folic acid prenatal vitamins/folic acid PRENATABS RX prenatal vitamins/folic acid PRENATAL LOW IRON prenatal vitamins/DHA/docusate/folic acid CITRANATAL DHA

Miscellaneous OTC cholecalciferol (D3) VITAMIN D3 OTC ergocalciferol (D2) drops DRISDOL OTC ferrous gluconate FERGON OTC ferrous sulfate FEOSOL OTC ferrous sulfate delayed-rel SLOW FE OTC iron polysaccharides complex OTC melatonin OTC multivitamins drops OTC multivitamins/iron drops OTC pyridoxine 25 mg VITAMIN B6 OTC ferrous fumarate FERRIMIN 150 cyanocobalamin inj ergocalciferol (D2) caps DRISDOL fluoride drops LURIDE fluoride tabs LURIDE LOZI-TABS multivitamins/fluoride drops, tabs multivitamins/fluoride/iron drops, tabs multivitamins/iron TANDEM PLUS vitamin ADC/fluoride drops vitamin ADC/fluoride/iron drops vitamin B complex/vitamin C/folic acid NEPHRO-VITE RX phytonadione MEPHYTON zinc acetate GALZIN

RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: http://www.aaaai.org http://www.ginasthma.com http://www.goldcopd.com http://www.nhlbi.nih.gov

The Allergy Report and guidelines for allergy-related conditions are available at: http://www.aaaai.org

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ANAPHYLAXIS TREATMENT AGENTS epinephrine pen epinephrine pen EPIPEN epinephrine pen EPIPEN JR.

ANTICHOLINERGICS ipratropium soln aclidinium bromide TUDORZA tiotropium SPIRIVA

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ipratropium/albuterol soln ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT

ANTIHISTAMINES, LOW SEDATING OTC cetirizine ZYRTEC

ANTIHISTAMINES, NONSEDATING OTC fexofenadine ALLEGRA OTC loratadine CLARITIN

ANTIHISTAMINES, SEDATING OTC chlorpheniramine CHLOR-TRIMETON * OTC diphenhydramine clemastine cyproheptadine hydroxyzine HCl

* Both OTC and Rx products covered

ANTIHISTAMINE/DECONGESTANT COMBINATIONS OTC cetirizine/pseudoephedrine ext-rel ZYRTEC-D OTC chlorpheniramine/phenylephrine tabs COLD & ALLERGY RELIEF OTC loratadine/pseudoephedrine ext-rel CLARITIN-D

ANTITUSSIVES OTC dextromethorphan gelcaps, liquid ROBITUSSIN LONG-ACTING COUGH benzonatate TESSALON

ANTITUSSIVE COMBINATIONS Opioid codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin liquid codeine/guaifenesin/pseudoephedrine codeine/promethazine codeine/promethazine/phenylephrine hydrocodone/homatropine

Non-opioid OTC dextromethorphan/chlorpheniramine liquid ROBITUSSIN CHILDREN'S COUGH & COLD, LONG ACTING OTC dextromethorphan/guaifenesin ext-rel MUCINEX DM OTC dextromethorphan/guaifenesin syrup ROBITUSSIN COUGH + CHEST CONGESTION DM

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OTC dextromethorphan/guaifenesin/pseudoephedrine liq 10 mg/ 100 mg/30 mg/5 mL OTC dextromethorphan/pyrilamine/phenylephrine - Codituss DM dextromethorphan/brompheniramine/pseudoephedrine - Bromfed-DM dextromethorphan/promethazine

BETA AGONISTS Inhalants Short Acting albuterol inhalation solution albuterol sulfate, CFC-free aerosol PROAIR HFA albuterol sulfate, CFC-free aerosol VENTOLIN HFA

Long Acting formoterol inhalation caps FORADIL MDL salmeterol xinafoate SEREVENT

Oral Agents albuterol albuterol ext-rel VOSPIRE ER terbutaline

CYSTIC FIBROSIS tobramycin inhalation solution TOBI PA dornase alfa PULMOZYME PA ivacaftor KALYDECO

DECONGESTANTS OTC oxymetazoline AFRIN OTC phenylephrine NEO-SYNEPHRINE OTC pseudoephedrine SUDAFED

DECONGESTANT/EXPECTORANT COMBINATIONS OTC pseudoephedrine/guaifenesin ext-rel MUCINEX D phenylephrine/guaifenesin syrup

EXPECTORANTS OTC guaifenesin liquid DIABETIC TUSSIN OTC guaifenesin ext-rel MUCINEX OTC guaifenesin liquid MUCINEX FOR KIDS

LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast SINGULAIR zafirlukast ACCOLATE

MAST CELL STABILIZERS cromolyn soln for inhalation

NASAL ANTIHISTAMINES MDL azelastine spray

NASAL STEROIDS OTC triamcinolone acetonide spray NASACORT ALLERGY 24HR flunisolide spray fluticasone spray FLONASE

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triamcinolone acetonide spray NASACORT AQ

RESPIRATORY SYNCYTIAL VIRUS PA palivizumab SYNAGIS

STEROID/BETA AGONIST COMBINATIONS ST budesonide/formoterol SYMBICORT ST fluticasone/salmeterol ADVAIR DISKUS ST fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA ST mometasone/formoterol DULERA

ST = Inhaled corticosteroid required first

STEROID INHALANTS * budesonide susp PULMICORT RESPULES beclomethasone, CFC-free aerosol QVAR budesonide PULMICORT FLEXHALER fluticasone, CFC-free aerosol FLOVENT HFA mometasone ASMANEX

* Covered for individuals one through three years of age

XANTHINES aminophylline liquid, tabs theophylline ext-rel tabs theophylline liquid ELIXOPHYLLIN

MISCELLANEOUS OTC sodium chloride soln OCEAN OTC sodium chloride soln SIMPLY SALINE ipratropium nasal spray ATROVENT PA alpha-1 proteinase inhibitor ZEMAIRA PA omalizumab XOLAIR

TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: http://www.aad.org/education-and-quality-care/clinical-guidelines

Oral PA isotretinoin

Topical OTC benzoyl peroxide bar, gel 10% PANOXYL OTC benzoyl peroxide bar, gel, lotion 5% PANOXYL adapalene crm, gel 0.1%, 0.3% DIFFERIN benzoyl peroxide liquid 2.5% BENZAC AC clindamycin soln CLEOCIN T erythromycin gel 2% erythromycin soln sulfacetamide/sulfur cleanser, lotion tretinoin RETIN-A

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Actinic Keratosis fluorouracil EFUDEX fluorouracil FLUOROPLEX

Antibiotics OTC bacitracin OTC neomycin/polymyxin B crm OTC neomycin/polymyxin B/bacitracin/lidocaine oint OTC polymyxin B/bacitracin POLYSPORIN gentamicin crm, oint 0.1% mupirocin oint BACTROBAN silver sulfadiazine SILVADENE

Antifungals * OTC clotrimazole OTC clotrimazole LOTRIMIN AF OTC miconazole DESENEX OTC butenafine LOTRIMIN ULTRA OTC terbinafine LAMISIL AT ST ciclopirox crm, susp LOPROX clotrimazole/betamethasone LOTRISONE econazole ketoconazole nystatin nystatin/triamcinolone

* Both OTC and Rx products covered ST = Clotrimazole, clotrimazole/betamethasone, ketoconazole, nystatin or nystatin/triamcinolone required before ciclopirox

Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: http://www.aad.org

Injectable PA ustekinumab STELARA

Topical calcipotriene DOVONEX

Antiseborrheics OTC coal tar shampoo NEUTROGENA T/GEL ketoconazole shampoo 2% NIZORAL SHAMPOO selenium sulfide shampoo 2.5%

Corticosteroids Low Potency OTC hydrocortisone crm, oint 0.5%, 1% CORTIZONE desonide crm, lotion, oint 0.05% DESOWEN fluocinolone acetonide soln 0.01% hydrocortisone crm 2.5%

Medium Potency betamethasone valerate crm, lotion, oint 0.1% fluocinolone acetonide crm, oint 0.025% hydrocortisone valerate crm, oint 0.2% WESTCORT mometasone crm, oint, soln 0.1% ELOCON

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triamcinolone acetonide crm, lotion 0.025% triamcinolone acetonide crm, lotion, oint 0.1%

High Potency betamethasone dipropionate crm, lotion, oint 0.05% fluocinonide crm, gel, oint, soln 0.05% triamcinolone acetonide crm 0.5%

Very High Potency clobetasol propionate crm, gel, oint, soln 0.05% TEMOVATE

Immunomodulators Guidelines for the treatment of atopic dermatitis are available at: http://www.aad.org

pimecrolimus ELIDEL tacrolimus PROTOPIC

Local Anesthetics lidocaine oint lidocaine/prilocaine crm tetracaine soln 2% PONTOCAINE

Rosacea metronidazole crm 0.75% METROCREAM metronidazole gel 0.75% metronidazole lotion 0.75% METROLOTION metronidazole crm 1% NORITATE

Scabicides and Pediculicides OTC permethrin 1% NIX CREME RINSE malathion OVIDE permethrin 5% ST ivermectin SKLICE

ST= OTC permethrin 1% required before Sklice for members younger than age 6; malathion required before Sklice for members age 6 and older.

Miscellaneous Skin and Mucous Membrane OTC ammonium lactate 12% LAC-HYDRIN OTC calamine lotion OTC chlorhexidine HIBICLENS OTC oatmeal, colloidal OTC petrolatum/mineral oil EUCERIN OTC salicylic acid 17% gel OTC salicylic acid 40% pad OTC salicylic acid plaster 40% ST OTC urea crm CARMOL 20 ST OTC urea lotion CARMOL 10 OTC docosanol ABREVA OTC oatmeal, colloidal/dimethicone AVEENO imiquimod ALDARA podofilox CONDYLOX

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ST urea crm, gel 40% becaplermin REGRANEX collagenase SANTYL

ST = OTC Lac-Hydrin required first

MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous

Steroids - Mouth/Throat triamcinolone paste

Miscellaneous chlorhexidine gluconate PERIDEX

OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: http://one.aao.org

Antiallergics OTC ketotifen ZADITOR azelastine OPTIVAR cromolyn sodium

Anti-infectives bacitracin ciprofloxacin soln CILOXAN erythromycin gentamicin neomycin/polymyxin B/gramicidin NEOSPORIN ofloxacin OCUFLOX polymyxin B/bacitracin polymyxin B/trimethoprim POLYTRIM sulfacetamide soln 10% BLEPH-10 tobramycin soln TOBREX tobramycin oint TOBREX

Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone oint neomycin/polymyxin B/dexamethasone MAXITROL neomycin/polymyxin B/hydrocortisone susp sulfacetamide/prednisolone phosphate 10%/0.25% tobramycin/dexamethasone susp 0.3%/0.1% TOBRADEX gentamicin/prednisolone acetate PRED-G

Anti-inflammatories Nonsteroidal flurbiprofen OCUFEN ketorolac ACULAR

Steroidal dexamethasone sodium phosphate fluorometholone 0.1% FML prednisolone acetate 1% PRED FORTE prednisolone phosphate 1%

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fluorometholone 0.25% FML FORTE fluorometholone ointment FML S.O.P. loteprednol 0.5% LOTEMAX prednisolone acetate 0.12% PRED MILD rimexolone VEXOL

Antivirals trifluridine VIROPTIC

Beta-blockers Nonselective carteolol levobunolol BETAGAN metipranolol OPTIPRANOLOL timolol maleate TIMOPTIC timolol maleate gel TIMOPTIC-XE timolol hemihydrate BETIMOL

Selective betaxolol 0.5%

Carbonic Anhydrase Inhibitors Topical dorzolamide TRUSOPT brinzolamide AZOPT

Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate COSOPT

Local Anesthetic Combinations fluorescein/benoxinate 0.25%/0.4%

Mydriatics atropine homatropine ISOPTO HOMATROPINE tropicamide

Prostaglandins latanoprost XALATAN bimatoprost LUMIGAN

Sympathomimetics brimonidine 0.15% ALPHAGAN P brimonidine 0.2% brimonidine 0.1% ALPHAGAN P

Sympathomimetic/Beta-blocker Combinations brimonidine/timolol COMBIGAN

OTIC Clinical practice guidelines for the treatment of otitis media are available at: http://www.aap.org

Anti-infectives acetic acid acetic acid/aluminum acetate

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ofloxacin otic

Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/hydrocortisone

Miscellaneous OTC carbamide peroxide DEBROX hydrocortisone/pramoxine/chloroxylenol CORTANE-B

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WEBSITES American Congress of Obstetricians and Gynecologists Agency for Healthcare Research and Quality http://www.acog.org http://www.ahrq.gov American Diabetes Association Alzheimer's Association http://www.diabetes.org http://www.alz.org American Gastroenterological Association American Academy of Allergy, Asthma and http://www.gastro.org Immunology http://www.aaaai.org American Headache Society Committee for Headache Education American Academy of Child & Adolescent Psychiatry http://www.achenet.org http://www.aacap.org American Heart Association American Academy of Dermatology http://www.myamericanheart.org http://www.aad.org American Lung Association American Academy of Neurology http://www.lungusa.org http://www.aan.com American Medical Association American Academy of Ophthalmology http://www.ama-assn.org http://www.aao.org American Psychiatric Association American Academy of Pediatrics http://www.psych.org http://www.aap.org American Society of Anesthesiologists American Association for the Study of Liver Disease http://www.asahq.org http://www.aasld.org American Society of Clinical Oncology American Association of Clinical Endocrinologists http://www.asco.org http://www.aace.com American Society of Interventional Pain Physicians American Association of Diabetes Educators http://www.asipp.org http://www.diabeteseducator.org American Urological Association American Cancer Society http://www.auanet.org http://www.cancer.org Centers for Disease Control and Prevention American College of Allergy, Asthma and Immunology http://www.cdc.gov http://www.acaai.org Centers for Disease Control and Prevention American College of Cardiology Guideline topics: AIDS http://www.acc.org http://www.cdc.gov/hiv/resources/guidelines/index.htm

American College of Chest Physicians Centers for Disease Control and Prevention http://www.chestnet.org Guideline topics: Sexually Transmitted Diseases http://www.cdc.gov/std/treatment/default.htm American College of Gastroenterology http://www.acg.gi.org CVS/caremark http://www.caremark.com American College of Physicians http://www.acponline.org The Food and Drug Administration http://www.fda.gov American College of Rheumatology http://www.rheumatology.org

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Global Initiative for Asthma National Foundation for Infectious Diseases http://www.ginasthma.com http://www.nfid.org

Infectious Diseases Society of America National Guideline Clearinghouse http://www.idsociety.org http://www.guideline.gov

Institute for Safe Medication Practices National Heart, Lung and Blood Institute http://www.ismp.org http://www.nhlbi.nih.gov

Johns Hopkins AIDS Service National Institutes of Health http://www.thebody.com/content/art12096.html http://www.nih.gov

Juvenile Diabetes Research Foundation International National Kidney Foundation http://www.jdf.org http://www.kidney.org

MedWatch National Osteoporosis Foundation http://www.fda.gov/medwatch http://www.nof.org

National Agricultural Library North American Menopause Society http://www.nal.usda.gov http://www.menopause.org

National Cancer Institute United States Department of Health and Human http://www.cancer.gov/cancerinformation Services http://www.hhs.gov National Comprehensive Cancer Network http://www.nccn.org World Health Organization http://www.who.int

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A ambrisentan, 24 AMERGE, 9, 28 ABILIFY, 7, 27 amiloride, 23 ABREVA, 44 amiloride/hydrochlorothiazide, 23 acamprosate calcium, 29 aminophylline liquid, tabs, 42 acarbose, 29 amiodarone, 21 ACCOLATE, 41 amitriptyline, 26, 28 ACCU-CHEK CONTROL SOLUTION, 31 amitriptyline 10 mg, 9 ACCU-CHEK KITS AND TEST STRIPS, 31 amitriptyline 25 mg, 50 mg, 9 ACCUPRIL, 20 amlodipine, 23 ACCURETIC, 21 amlodipine/atorvastatin, 23 acetaminophen/dichloralphenazone/isometheptene, 28 amlodipine/benazepril, 20 acetazolamide, 23 ammonium lactate 12%, 44 acetazolamide ext-rel, 23 amoxicillin, 17 acetic acid, 46 amoxicillin/clavulanate, 17 acetic acid/aluminum acetate, 46 amphetamine/dextroamphetamine mixed salts, 27 acetohydroxamic acid, 37 amphetamine/dextroamphetamine mixed salts 15 mg, 20 mg, 8 aclidinium bromide, 40 amphetamine/dextroamphetamine mixed salts 30 mg, 8 ACTEMRA, 7 amphetamine/dextroamphetamine mixed salts 5 mg, 7.5 mg, ACTIGALL, 35 10 mg, 12.5 mg, 8 ACTOPLUS MET, 30 amphetamine/dextroamphetamine mixed salts ext-rel, 27 ACTOS, 30 amphetamine/dextroamphetamine mixed salts ext-rel 15 mg, ACULAR, 45 20 mg, 25 mg, 30 mg, 8 acyclovir caps, susp, tabs, 18 amphetamine/dextroamphetamine mixed salts ext-rel 5 mg, ADALAT CC, 23 10 mg, 8 adalimumab, 38 ampicillin, 17 adapalene crm, gel 0.1%, 0.3%, 42 ANAFRANIL, 25 ADCIRCA, 7, 24 anagrelide, 38 ADDERALL, 8, 27 ANAPROX, 15 ADDERALL XR, 8, 27 anastrozole, 19 ADEMPAS, 7, 24 ANTABUSE, 29 ADVAIR DISKUS, 10, 42 ANTI-DIARRHEAL, 34 ADVAIR HFA, 10, 42 ANTIVERT, 35 ADVIL, 15 ANUSOL-HC, 36 AFRIN, 41 ANUSOL-HC 2.5%, 36 AGRYLIN, 38 aprepitant, 35 ALAMAG, 34 ARALEN, 17 albuterol, 41 ARANESP, 37 albuterol ext-rel, 41 ARAVA, 7, 38 albuterol inhalation solution, 41 ARICEPT, 25 albuterol sulfate, CFC-free aerosol, 41 ARIMIDEX, 19 ALDACTAZIDE, 23 aripiprazole, 27 ALDACTONE, 21 armodafinil, 29 ALDARA, 44 AROMASIN, 19 alendronate tabs, 31 ASACOL HD, 35 alendronate/vitamin D3, 31 asenapine, 27 ALEVE, 15 ASMANEX, 42 alfuzosin ext-rel, 36 asparaginase erwinia, 20 ALKERAN, 19 atenolol, 22 ALLEGRA, 40 atenolol/chlorthalidone, 22 allopurinol, 15 ATIVAN, 8, 25 ALORA, 33 atomoxetine, 27 alpha-1 proteinase inhibitor, 42 atorvastatin, 22 ALPHAGAN P, 46 atovaquone, 18 alprazolam, 8, 24 atovaquone/proguanil, 17 ALTACE, 20 atropine, 46 ALTERNAGEL, 34 atropine/hyoscyamine/scopolamine/ altretamine, 19 phenobarbital 16.2 mg tabs, 35 aluminum hydroxide, 34 atropine/hyoscyamine/scopolamine/phenobarbital elixir, 35 aluminum hydroxide/magnesium hydroxide, 34 ATROVENT, 42 amantadine caps, syrup, 18, 26 AUGMENTIN, 17 AMARYL, 30 AVALIDE, 21 AMBIEN, 9, 28 AVAPRO, 21 MedStar Family Choice - DC Healthy Families Program 50

AVEENO, 44 budesonide susp, 42 AVELOX, 17 budesonide/formoterol, 42 AVINZA, 7, 15 bumetanide, 23 AVONEX, 28 buprenorphine sublingual, 29 AXIRON, 29 buprenorphine/naloxone sublingual tabs, 8, 29 AYGESTIN, 34 bupropion, 26 azathioprine, 38 bupropion ext-rel, 26 azelastine, 45 buspirone, 25 azelastine spray, 8, 41 busulfan, 19 azithromycin, 17 butalbital/acetaminophen, 8, 16 AZOPT, 46 butalbital/acetaminophen/caffeine, 8, 16 AZULFIDINE, 35 butalbital/acetaminophen/caffeine/codeine, 8, 15 AZULFIDINE EN-TABS, 35 butalbital/aspirin/caffeine, 8, 16 B butalbital/aspirin/caffeine/codeine, 8, 15 butenafine, 43 bacitracin, 43, 45 BYDUREON, 30 baclofen, 28 BYETTA, 30 BACTROBAN, 43 BANZEL, 7, 25 C BARACLUDE, 18 cabozantinib, 19 becaplermin, 45 CADUET, 23 beclomethasone, CFC-free aerosol, 42 CAFERGOT, 28 bedaquiline, 18 calamine lotion, 44 belimumab, 38 CALAN, 23 benazepril, 20 CALAN SR, 23 benazepril/hydrochlorothiazide, 21 calcipotriene, 43 BENLYSTA, 7, 38 calcitonin-salmon, 31 BENTYL, 35 calcitriol (1,25-D3), 34 BENZAC AC, 42 calcium acetate, 34 benzonatate, 40 calcium carbonate, 34 benzoyl peroxide bar, gel 10%, 42 CAMPRAL, 7, 29 benzoyl peroxide bar, gel, lotion 5%, 42 CANASA, 35 benzoyl peroxide liquid 2.5%, 42 capecitabine, 19 benztropine, 26 captopril, 20 BETAGAN, 46 captopril/hydrochlorothiazide, 21 betamethasone dipropionate crm, lotion, oint 0.05%, 44 CARAFATE, 36 betamethasone valerate crm, lotion, oint 0.1%, 43 carbamazepine, 25 BETAPACE, 21 carbamazepine ext-rel, 25 BETAPACE AF, 21 carbamide peroxide, 47 betaxolol 0.5%, 46 CARBATROL, 25 bethanechol, 37 carbidopa, 26 BETIMOL, 46 carbidopa/levodopa, 26 bexarotene caps, 20 carbidopa/levodopa ext-rel, 26 BEYAZ, 7, 31 carbidopa/levodopa/entacapone, 26 BIAXIN, 17 CARDIZEM, 23 BIAXIN XL, 17 CARDIZEM CD, 23 bicalutamide, 19 CARDURA, 21, 36 bimatoprost, 46 carisoprodol, 28 bismuth subsalicylate, 34 CARMOL 10, 10, 44 bisoprolol, 22 CARMOL 20, 10, 44 bisoprolol/hydrochlorothiazide, 22 carteolol, 46 BLEPH-10, 45 carvedilol, 22 blood glucose monitoring kits, test strips, 31 carvedilol phosphate ext-rel, 22 BOSULIF, 7, 19 CASODEX, 19 bosutinib, 19 CATAFLAM, 15 BOTOX, 7, 29 CATAPRES, 21 brimonidine 0.1%, 46 CATAPRES-TTS, 21 brimonidine 0.15%, 46 cefaclor, 16 brimonidine 0.2%, 46 cefadroxil, 16 brimonidine/timolol, 46 cefdinir, 17 brinzolamide, 46 cefixime, 17 bromocriptine, 26 cefpodoxime tablets, 17 budesonide, 42 CEFTIN, 16 budesonide delayed-rel caps, 35 ceftriaxone, 17

MedStar Family Choice - DC Healthy Families Program 51

cefuroxime axetil, 16 clotrimazole troches, 17 CELEBREX, 7, 15 clotrimazole/betamethasone, 43 celecoxib, 15 clozapine, 27 CELEXA, 26 CLOZARIL, 27 CELLCEPT, 38 coal tar shampoo, 43 CENESTIN, 33 codeine sulfate, 15 cephalexin, 16 codeine/acetaminophen, 15 cetirizine, 40 codeine/chlorpheniramine/pseudoephedrine, 40 cetirizine/pseudoephedrine ext-rel, 40 codeine/guaifenesin liquid, 40 CHANTIX, 7, 8, 29 codeine/guaifenesin/pseudoephedrine, 40 CHEMET, 34 codeine/promethazine, 40 CHEMSTRIP URINE TEST STRIPS, 31 codeine/promethazine/phenylephrine, 40 chlorambucil, 19 COLACE, 35 chlordiazepoxide, 10, 24 colchicine, 15 chlordiazepoxide 5 mg, 10 mg, 9 colchicine/probenecid, 15 chlorhexidine, 44 COLCRYS, 15 chlorhexidine gluconate, 45 COLD & ALLERGY RELIEF, 40 chloroquine, 17 collagenase, 45 chlorothiazide, 23 COMBIGAN, 46 chlorothiazide susp, 23 COMBIPATCH, 33 chlorpheniramine, 40 COMBIVENT RESPIMAT, 40 chlorpheniramine/phenylephrine tabs, 40 COMETRIQ, 7, 19 chlorpromazine, 27 COMTAN, 26 chlorthalidone, 23 CONCERTA, 8, 9, 10, 27 CHLOR-TRIMETON, 40 CONDYLOX, 44 chlorzoxazone, 28 COPAXONE, 28 cholecalciferol (D3), 39 COPEGUS, 7, 18 cholestyramine, 21 CORDARONE, 21 choline magnesium trisalicylate, 15 COREG, 22 ciclopirox crm, susp, 43 COREG CR, 22 CILOXAN, 45 CORGARD, 22 cimetidine, 35 CORTANE-B, 47 cinacalcet, 31 CORTEF, 33 CIPRO, 17 CORTIFOAM, 35 CIPRO XR, 8 cortisone acetate, 33 ciprofloxacin, 17 CORTIZONE, 43 ciprofloxacin ext-rel 1000 mg, 17 COSOPT, 46 ciprofloxacin ext-rel 500 mg, 8, 17 COUMADIN, 37 ciprofloxacin soln, 45 COZAAR, 21 citalopram, 26 CREON, 36 CITRANATAL DHA, 39 CRESTOR, 10, 22 CITRUCEL, 36 crizotinib, 19 clarithromycin, 17 crofelemer, 35 clarithromycin ext-rel, 17 cromolyn sodium, 45 CLARITIN, 40 cromolyn soln for inhalation, 41 CLARITIN-D, 40 cyanocobalamin inj, 39 clemastine, 40 CYCLESSA, 32 CLEOCIN, 18, 37 cyclobenzaprine 5 mg, 10 mg, 28 CLEOCIN T, 42 cyclophosphamide tabs, 19 CLIMARA, 33 cyclosporine, 38 CLIMARA PRO, 33 cyclosporine, modified, 38 clindamycin, 18 CYMBALTA, 7, 26 clindamycin crm, 37 cyproheptadine, 40 clindamycin soln, 42 CYTOMEL, 34 CLINORIL, 15 CYTOTEC, 36 clobazam, 25 D clobetasol propionate crm, gel, oint, soln 0.05%, 44 clomipramine, 25 dabigatran etexilate, 37 clonazepam, 25 dabrafenib, 19 clonazepam tabs, 24 DANTRIUM, 28 clonidine, 21 dantrolene, 28 clonidine transdermal, 21 dapsone, 18 clopidogrel, 37 darbepoetin alfa, 37 clotrimazole, 37, 43 DAYPRO, 15 MedStar Family Choice - DC Healthy Families Program 52

DDAVP, 34 dihydroergotamine spray, 8, 28 DDAVP spray, 7 DILANTIN, 25 DEBROX, 47 DILANTIN INFATABS, 25 DELATESTRYL, 29 DILAUDID, 15 DEMADEX, 23 diltiazem, 23 DEMEROL, 15 diltiazem ext-rel, 23 denosumab, 31 dimenhydrinate, 35 DEPAKENE, 25 diphenhydramine, 40 DEPAKOTE, 25 diphenoxylate/atropine, 35 DEPAKOTE ER, 25 dipyridamole, 37 DEPO-PROVERA, 32 disopyramide, 21 DESENEX, 43 disulfiram, 29 desipramine, 26 DITROPAN XL, 36 desipramine 10 mg, 25 mg, 50 mg, 9 DIURIL, 23 desipramine 100 mg, 150 mg, 9 divalproex sodium delayed-rel, 25 desipramine 75 mg, 9 divalproex sodium ext-rel, 25 desmopressin spray, 34 docosanol, 44 desmopressin tabs, 34 docusate sodium caps, 35 desogestrel/EE, 32 docusate sodium liquid, 36 desogestrel/EE 0.15/30, 32 dofetilide, 21 desonide crm, lotion, oint 0.05%, 43 DOLOPHINE, 15 DESOWEN, 43 donepezil, 25 dexamethasone, 33 DONNATAL 16.2 mg tabs, 35 dexamethasone sodium phosphate, 45 DONNATAL elixir, 35 DEXEDRINE SPANSULE, 8, 27 dornase alfa, 41 dexmethylphenidate, 27 dorzolamide, 46 dexmethylphenidate 10 mg, 8 dorzolamide/timolol maleate, 46 dexmethylphenidate 2.5 mg, 5 mg, 8 DOVONEX, 43 dextroamphetamine, 8 doxazosin, 21, 36 dextroamphetamine ext-rel, 27 doxepin, 26 dextroamphetamine ext-rel 15 mg, 8 doxepin 10 mg, 25 mg, 50 mg, 9 dextroamphetamine ext-rel 5 mg, 10 mg, 8 doxepin 100 mg, 150 mg, 9 dextroamphetamine tabs 5 mg, 10 mg, 27 doxepin 75 mg, 9 dextromethorphan gelcaps, liquid, 40 doxepin oral concentrate 10 mg/mL, 9 dextromethorphan/brompheniramine/pseudoephedrine - doxercalciferol, 34 Bromfed-DM, 41 DOXIL, 20 dextromethorphan/chlorpheniramine liquid, 40 doxorubicin liposomal, 20 dextromethorphan/guaifenesin ext-rel, 40 doxycycline hyclate, 17 dextromethorphan/guaifenesin syrup, 40 doxylamine, 28 dextromethorphan/guaifenesin/ DRAMAMINE, 35 pseudoephedrine liq 10 mg/100 mg/30 mg/5 mL, 41 DRISDOL, 39 dextromethorphan/promethazine, 41 drospirenone/EE 3/20 - Gianvi, 31 dextromethorphan/pyrilamine/phenylephrine - drospirenone/EE 3/30, 32 Codituss DM, 41 drospirenone/EE/levomefolate 3/20 and levomefolate, 31 dextrose/fructose/phosphoric acid, 35 DROXIA, 20 DIABETA, 31 DUETACT, 30 DIABETIC TUSSIN, 41 DULERA, 10, 42 DIAMOX SEQUELS, 23 duloxetine delayed-rel, 26 diaphragm, 33 DURAGESIC, 7, 15 DIASTAT, 25 DYAZIDE, 23 diazepam, 10, 25, 28 DYRENIUM, 23 diazepam Intensol soln 5 mg/mL, 8 E diazepam rectal gel, 25 diazepam soln 5 mg/5 mL, 8 E.E.S., 17 diazepam tabs, 8 ecallantide, 37 diclofenac potassium, 15 econazole, 43 diclofenac sodium delayed-rel, 15 EE/norethindrone acetate, 33 diclofenac sodium gel, 15 EE/norethindrone acetate - Jinteli, 33 dicloxacillin, 17 EFFEXOR XR, 26 dicyclomine, 35 EFUDEX, 43 DIFFERIN, 42 ELDEPRYL, 26 DIFICID, 7, 17 ELIDEL, 44 DIFLUCAN, 8, 17 ELIGARD, 7, 19 digoxin, 23 ELIXOPHYLLIN, 42 MedStar Family Choice - DC Healthy Families Program 53

ELLA, 8, 32 F ELMIRON, 37 famciclovir, 18 ELOCON, 43 famotidine, 35 EMEND, 35 famotidine chewable tabs, 35 EMETROL, 35 FAMVIR, 18 enalapril, 20 FANAPT, 7, 27 enalapril/hydrochlorothiazide, 21 FARESTON, 19 ENBREL, 7, 38 FASLODEX, 19 enoxaparin, 8, 37 felbamate, 25 entacapone, 26 FELBATOL, 25 entecavir, 18 felodipine ext-rel, 23 ENTOCORT EC, 35 FEMARA, 19 epinephrine pen, 40 FEMCON FE, 32 EPIPEN, 40 FEMHRT, 33 EPIPEN JR., 40 FEMRING, 33 EPIVIR-HBV, 18 fenofibrate, micronized, 22 epoetin alfa, 37 fenofibric acid, 22 EPOGEN, 37 fentanyl transdermal, 15 epoprostenol sodium, 24 FEOSOL, 39 ergocalciferol (D2) caps, 39 FERGON, 39 ergocalciferol (D2) drops, 39 FERRIMIN 150, 39 ergotamine/caffeine, 28 ferrous fumarate, 39 erlotinib, 19 ferrous gluconate, 39 ERWINAZE, 7, 20 ferrous sulfate, 39 ERY-TAB, 17 ferrous sulfate delayed-rel, 39 erythromycin, 45 fexofenadine, 40 erythromycin base, 17 FIBRICOR, 22 erythromycin delayed-rel, 17 fidaxomicin, 17 erythromycin ethylsuccinate, 17 filgrastim, 37 erythromycin gel 2%, 42 finasteride, 36 erythromycin soln, 42 fingolimod, 28 erythromycin stearate, 17 FIORICET, 8 escitalopram, 26 FIORICET w/CODEINE, 8, 15 ESGIC, 16 FIORINAL, 8, 16 esomeprazole magnesium delayed-rel, 8, 36 FIORINAL w/CODEINE, 8, 15 ESTRACE, 33 FIRAZYR, 7, 37 estradiol, 33 FISH OIL, 22 estradiol vaginal cream, 33 FLAGYL, 18 estradiol vaginal ring, 33 flecainide, 21 estradiol valerate and dienogest/estradiol valerate, 32 FLEET ENEMA, 8 estradiol/levonorgestrel, 33 FLOLAN, 7, 24 estradiol/norethindrone acetate, 33 FLOMAX, 36 estrogens, conjugated, synthetic A, 33 FLONASE, 41 estrogens, conjugated/medroxyprogesterone, 33 FLOVENT HFA, 42 estropipate, 33 fluconazole, 17 ESTROSTEP FE, 32 fluconazole 150 mg, 8 etanercept, 38 fludrocortisone, 33 ethambutol, 18 FLUMADINE, 18 ethosuximide, 25 flunisolide spray, 41 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 32 fluocinolone acetonide crm, oint 0.025%, 43 ethynodiol diacetate/EE 1/50 - Zovia 1/50, 32 fluocinolone acetonide soln 0.01%, 43 etodolac, 15 fluocinonide crm, gel, oint, soln 0.05%, 44 etonogestrel/EE ring, 33 fluorescein/benoxinate 0.25%/0.4%, 46 etoposide, 20 fluoride drops, 39 EUCERIN, 44 fluoride tabs, 39 EVISTA, 34 fluorometholone 0.1%, 45 EXELON, 25 fluorometholone 0.25%, 46 exemestane, 19 fluorometholone ointment, 46 exenatide, 30 FLUOROPLEX, 43 exenatide ext-rel, 30 fluorouracil, 43 EXTAVIA, 28 fluoxetine, 26 ezetimibe, 22 fluphenazine, 27 ezogabine, 25 flurbiprofen, 15, 45 flutamide, 19 MedStar Family Choice - DC Healthy Families Program 54

fluticasone spray, 41 griseofulvin microsize susp, 17 fluticasone, CFC-free aerosol, 42 griseofulvin microsize tabs, 17 fluticasone/salmeterol, 42 griseofulvin ultramicrosize, 17 fluticasone/salmeterol, CFC-free aerosol, 42 GRIS-PEG, 17 fluvoxamine, 25 guaifenesin ext-rel, 41 FML, 45 guaifenesin liquid, 41 FML FORTE, 46 guanfacine, 21 FML S.O.P., 46 GYNE-LOTRIMIN, 37 FOCALIN, 8, 27 GYNOL II, 33 folic acid, 39 H FORADIL, 41 formoterol inhalation caps, 41 haloperidol, 27 FORTESTA, 29 HECTOROL, 34 FOSAMAX, 31 HERCEPTIN, 7, 20 FOSAMAX PLUS D, 31 HEXALEN, 19 foscarnet, 18 HIBICLENS, 44 fosinopril, 20 histrelin ac, 34 fosinopril/hydrochlorothiazide, 21 homatropine, 46 FOSRENOL, 7, 34 HUMALOG, 30 fulvestrant, 19 HUMALOG MIX 50/50, 30 FULYZAQ, 7, 35 HUMALOG MIX 75/25, 30 FURADANTIN, 18 HUMIRA, 7, 38 furosemide, 23 HUMULIN 70/30, 30 FUZEON, 7 HUMULIN N, 30 HUMULIN R, 30 G HYCAMTIN CAPS, 7, 20 gabapentin, 25 HYCET, 15 GABITRIL, 25 hydralazine, 24 galantamine, 25 HYDREA, 20 GALZIN, 39 hydrochlorothiazide, 23 GAMMAGARD S/D, 7, 38 hydrocodone/acetaminophen 5/325 mg, 7.5/325 mg, gemfibrozil, 22 10/325 mg, 15 GENERESS FE, 7, 31 hydrocodone/acetaminophen soln 7.5/325 per 15 mL, 15 gentamicin, 45 hydrocodone/homatropine, 40 gentamicin crm, oint 0.1%, 43 hydrocortisone, 33 gentamicin/prednisolone acetate, 45 hydrocortisone acetate foam, 35 GEODON, 27 hydrocortisone crm, 36 GILENYA, 7, 28 hydrocortisone crm 2.5%, 43 glatiramer, 28 hydrocortisone crm, oint 0.5%, 1%, 43 GLEEVEC, 19 hydrocortisone enema, 35 glimepiride, 30 hydrocortisone rectal crm, oint, 36 glipizide, 31 hydrocortisone supp, 36 glipizide ext-rel, 31 hydrocortisone valerate crm, oint 0.2%, 43 glipizide/metformin, 30 hydrocortisone/pramoxine/chloroxylenol, 47 GLUCAGON EMERGENCY KIT, 33 hydromorphone, 15 glucagon, human recombinant, 33 hydroxychloroquine, 38 GLUCOPHAGE, 30 hydroxyurea, 20 GLUCOPHAGE XR, 30 hydroxyzine HCl, 40 glucose meter control solution, 31 hylan G-F 20, 16 GLUCOTROL, 31 hyoscyamine 0.15 mg tabs, 35 GLUCOTROL XL, 31 hyoscyamine sulfate 0.125 mg, 35 GLUCOVANCE, 30 hyoscyamine sulfate 125 mcg/5 mL elixir, 35 glyburide, 31 hyoscyamine sulfate ext-rel 0.375 mg, 35 glyburide, micronized, 31 HYZAAR, 21 glyburide/metformin, 30 I glycopyrrolate, 35 GLYNASE, 31 ibrutinib, 19 GOLYTELY, 36 ibuprofen, 15 goserelin acetate, 19 icatibant, 37 granisetron, 35 ICLUSIG, 7, 20 granisetron 1 mg, 8 idelalisib, 19 grass mixed pollen allergen extract, 38 iloperidone, 27 GRASTEK, 7, 38 iloprost, 24 GRIFULVIN V, 17 imatinib mesylate, 19 IMBRUVICA, 7, 19 MedStar Family Choice - DC Healthy Families Program 55

IMDUR, 24 KETOSTIX URINE TEST STRIPS, 31 imipramine caps, tabs, 9 ketotifen, 45 imipramine HCl, 26 KINERET, 7 imiquimod, 44 KLONOPIN, 24, 25 IMITREX, 9, 28 KLOR-CON/25, 39 immune globulin, intravenous, 38 KORLYM, 7, 34 IMURAN, 38 K-PHOS NEUTRAL, 37 INCIVEK, 7, 18 KRYSTEXXA, 7, 15 indapamide, 23 L INDERAL LA, 22 indomethacin, 15 labetalol, 22 infliximab, 38 LAC-HYDRIN, 44 insulin aspart, 30 lacosamide, 25 insulin aspart protamine 70%/insulin aspart 30%, 30 lactulose, 36 insulin glargine, 30 LAMICTAL, 25 insulin human, 30 LAMISIL, 17 insulin isophane human, 30 LAMISIL AT, 43 insulin isophane human 70%/regular 30%, 30 lamivudine, 18 insulin lispro, 30 lamotrigine, 25 insulin lispro protamine 50%/insulin lispro 50%, 30 lancets, lancet devices, 31 insulin lispro protamine 75%/insulin lispro 25%, 30 LANOXIN, 23 insulin syringes, needles, 31 lansoprazole, 8 interferon alfa-2b, 38 lansoprazole + amoxicillin + clarithromycin, 36 interferon beta-1a, 28 lansoprazole delayed-rel, 10, 36 interferon beta-1b, 28 lansoprazole delayed-rel orally-disintegrating 15 mg tabs, 36 intrauterine device, 33 lanthanum, 34 INTRON A, 7, 38 LANTUS, 30 INVEGA, 7, 27 lapatinib, 20 INVEGA SUSTENNA, 7, 27 LASIX, 23 ipratropium nasal spray, 42 latanoprost, 46 ipratropium soln, 40 leflunomide, 38 ipratropium/albuterol soln, 40 LETAIRIS, 7, 24 ipratropium/albuterol, CFC-free aerosol, 40 letrozole, 19 irbesartan, 21 LEUKERAN, 19 irbesartan/hydrochlorothiazide, 21 LEUKINE, 37 iron polysaccharides complex, 39 leuprolide acetate, 7, 19 isocarboxazid, 26 LEVAQUIN, 17 isoniazid, 18 levetiracetam, 25 ISOPTO HOMATROPINE, 46 levobunolol, 46 ISORDIL, 24 levofloxacin, 17 isosorbide dinitrate ext-rel tabs, 24 levonorgestrel - Next Choice One Dose, 8, 32 isosorbide dinitrate oral, 24 levonorgestrel 0.75 mg, 8, 32 isosorbide dinitrate sublingual, 24 levonorgestrel releasing IUD, 33 isosorbide mononitrate, 24 levonorgestrel/EE - Trivora, 32 isosorbide mononitrate ext-rel, 24 levonorgestrel/EE 0.09/20 - Amethyst, 31 isotretinoin, 7, 42 levonorgestrel/EE 0.1/20 - Aviane, 31 ivacaftor, 41 levonorgestrel/EE 0.1/20 and EE 10, 32 ivermectin, 44 levonorgestrel/EE 0.15/20, 0.15/25, 0.15/30 and EE 10, 32 levonorgestrel/EE 0.15/30, 32 J levonorgestrel/EE 0.15/30 - Levora, 32 JAKAFI, 7, 20 levonorgestrel/EE 0.15/30 and EE 10, 32 JANUMET, 30 levothyroxine, 34 JANUMET XR, 30 levothyroxine - Levoxyl, 34 JANUVIA, 30 LEXAPRO, 26 JENTADUETO, 30 lidocaine oint, 44 JUXTAPID, 7, 22 lidocaine viscous, 45 K lidocaine/prilocaine crm, 44 linagliptin, 30 KALBITOR, 37 linagliptin/metformin, 30 KALYDECO, 7, 41 liothyronine, 34 KEFLEX, 16 LIPITOR, 22 KEPPRA, 25 liraglutide, 30 ketoconazole, 43 lisinopril, 20 ketoconazole shampoo 2%, 43 lisinopril/hydrochlorothiazide, 21 ketorolac, 8, 15, 45 MedStar Family Choice - DC Healthy Families Program 56

lithium carbonate, 28 MEGACE, 19 lithium carbonate ext-rel tabs 300 mg, 28 MEGACE ES, 19 lithium carbonate ext-rel tabs 450 mg, 28 megestrol acetate, 19 lithium citrate, 28 megestrol acetate susp, 19 LITHIUM CITRATE, 28 MEKINIST, 7, 20 LITHOBID, 28 melatonin, 39 LITHOSTAT, 37 meloxicam, 15 LO LOESTRIN FE, 7, 31 melphalan, 19 LODOSYN, 26 memantine, 25 LOESTRIN 1.5/30, 32 meperidine, 15 LOESTRIN 1/20, 31 MEPHYTON, 39 LOESTRIN FE 1.5/30, 32 MEPRON, 18 LOESTRIN FE 1/20, 31 mercaptopurine, 19 LOFIBRA, 22 mesalamine delayed-rel tabs, 35 lomitapide, 22 mesalamine ext-rel caps, 35 LOMOTIL, 35 mesalamine rectal susp, 35 lomustine, 19 mesalamine supp, 35 loperamide liquid, tabs, 34 MESTINON, 29 LOPID, 22 MESTINON TIMESPAN, 29 LOPRESSOR, 22 METADATE CD, 8, 27 LOPROX, 43 METAGLIP, 30 loratadine, 40 metformin, 30 loratadine/pseudoephedrine ext-rel, 40 metformin ext-rel, 30 lorazepam, 8, 25 methadone, 15 losartan, 21 methazolamide, 23 losartan/hydrochlorothiazide, 21 methenamine/hyoscyamine/methylene blue/benzoic acid/ LOSEASONIQUE, 32 phenyl salicylate, 37 LOTEMAX, 46 methimazole, 34 LOTENSIN, 20 methocarbamol, 28 LOTENSIN HCT, 21 methotrexate 2.5 mg, 38 loteprednol 0.5%, 46 methyclothiazide, 23 LOTREL, 20 methylcellulose, 36 LOTRIMIN AF, 43 methyldopa, 24 LOTRIMIN ULTRA, 43 methyldopa/hydrochlorothiazide, 24 LOTRISONE, 43 methylergonovine, 34 lovastatin, 22 METHYLIN, 9, 27 LOVAZA, 7, 22 methylphenidate, 9, 27 LOVENOX, 8, 37 methylphenidate 5 mg, 10 mg, 8 LUMIGAN, 46 methylphenidate ext-rel, 10, 27 LUPRON DEPOT, 7, 19 methylphenidate ext-rel 10 mg, 8, 27 LURIDE, 39 methylphenidate ext-rel 10 mg, 20 mg, 30 mg, 8 LURIDE LOZI-TABS, 39 methylphenidate ext-rel 18 mg, 27 mg, 36 mg, 8 LYRICA, 7, 27 methylphenidate ext-rel 20 mg tabs - Metadate ER, 8 LYSODREN, 20 methylphenidate ext-rel 40 mg, 50 mg, 8 M methylphenidate ext-rel 54 mg, 9 methylphenidate ext-rel tabs 20 mg - Metadate ER, 27 MAALOX, 34 methylphenidate oral soln 10 mg/5 mL, 9 macitentan, 24 methylphenidate oral soln 5 mg/5 mL, 9 MACROBID, 18 methylphenidate soln, tabs, 27 MACRODANTIN, 18 methylprednisolone, 33 MALARONE, 17 metipranolol, 46 malathion, 44 metoclopramide, 35 MARPLAN, 26 metolazone, 23 MATULANE, 20 metoprolol, 22 MAVIK, 20 metoprolol ext-rel, 22 MAXALT, 9, 10, 28 METROCREAM, 44 MAXALT-MLT, 9, 10 METROGEL-VAGINAL, 37 MAXITROL, 45 METROLOTION, 44 MAXZIDE, 23 metronidazole, 18, 37 meclizine, 35 metronidazole crm 0.75%, 44 MEDROL, 33 metronidazole crm 1%, 44 medroxyprogesterone acetate, 34 metronidazole gel 0.75%, 44 medroxyprogesterone acetate 150 mg/mL, 32 metronidazole lotion 0.75%, 44 mefloquine, 18 MEVACOR, 22 MedStar Family Choice - DC Healthy Families Program 57

MIACALCIN, 31 NASACORT AQ, 42 miconazole, 37, 43 NATAZIA, 7, 32 midazolam injection, 7, 24 nateglinide, 30 midodrine, 24 NATURAL FIBER, 36 MIDRIN, 28 NEBUPENT, 19 mifepristone, 34 NECON 10/11, 32 MIGRANAL, 8, 28 neomycin sulfate tabs, 18 milnacipran, 27 neomycin/polymyxin B crm, 43 MINASTRIN 24 FE, 7, 31 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 45 mineral oil, 36 neomycin/polymyxin B/bacitracin/lidocaine oint, 43 MINIPRESS, 21 neomycin/polymyxin B/dexamethasone, 45 MINOCIN, 17 neomycin/polymyxin B/gramicidin, 45 minocycline, 17 neomycin/polymyxin B/hydrocortisone, 47 minoxidil, 24 neomycin/polymyxin B/hydrocortisone susp, 45 MIRALAX, 36 NEORAL, 38 MIRAPEX, 26 NEOSPORIN, 45 MIRCETTE, 32 NEO-SYNEPHRINE, 41 MIRENA, 33 NEPHRO-VITE RX, 39 mirtazapine, 26 NEULASTA, 37 misoprostol, 36 NEUPOGEN, 37 mitotane, 20 NEURONTIN, 25 MOBIC, 15 NEUTROGENA T/GEL, 43 modafinil, 29 NEXIUM 24HR, 8, 36 MODICON, 32 niacin, 22 moexipril, 20 niacin ext-rel, 22 moexipril/hydrochlorothiazide, 21 NIACOR, 22 mometasone, 42 NIASPAN, 22 mometasone crm, oint, soln 0.1%, 43 nicardipine, 23 mometasone/formoterol, 42 NICORETTE, 29 MONISTAT, 37 nicotine inhaler, 29 montelukast, 41 nicotine nasal spray, 29 morphine, 15 nicotine polacrilex gum, lozenge, 29 morphine ext-rel, 15 nicotine transdermal, 9, 29 morphine supp, 16 NICOTROL INHALER, 7, 29 moxifloxacin, 17 NICOTROL NS, 7, 29 MS CONTIN, 7, 15 nifedipine, 23 MUCINEX, 41 nifedipine ext-rel, 23 MUCINEX D, 41 nilotinib, 20 MUCINEX DM, 40 nimodipine, 23 MUCINEX FOR KIDS, 41 NITRO-BID, 24 multivitamins drops, 39 NITRO-DUR, 24 multivitamins/fluoride drops, tabs, 39 nitrofurantoin ext-rel, 18 multivitamins/fluoride/iron drops, tabs, 39 nitrofurantoin macrocrystals, 18 multivitamins/iron, 39 nitrofurantoin susp, 18 multivitamins/iron drops, 39 nitroglycerin oint, 24 mupirocin oint, 43 nitroglycerin sublingual, 24 MYAMBUTOL, 18 nitroglycerin sublingual spray, 24 MYCOBUTIN, 18 nitroglycerin transdermal, 24 mycophenolate mofetil, 38 NITROLINGUAL, 24 MYLERAN, 19 NITROSTAT, 24 MYLICON, 36 NIX CREME RINSE, 44 MYSOLINE, 25 NIZORAL SHAMPOO, 43 N nonoxynol 9 gel, 33 NORCO, 15 nabumetone, 15 NORDITROPIN, 7, 34 nadolol, 22 norelgestromin/EE, 33 naltrexone, 29 norethindrone, 32 NAMENDA, 7, 25 norethindrone acetate, 34 NAPROSYN, 15 norethindrone acetate/EE 1.5/30, 32 naproxen, 15 norethindrone acetate/EE 1.5/30 and iron, 32 naproxen sodium, 15 norethindrone acetate/EE 1/10 and EE 10 and iron, 31 naratriptan, 9, 28 norethindrone acetate/EE 1/20, 31 NARDIL, 26 norethindrone acetate/EE 1/20 and iron, 31 NASACORT ALLERGY 24HR, 41 norethindrone acetate/EE 1/20 and iron chewable, 31 MedStar Family Choice - DC Healthy Families Program 58

norethindrone acetate/EE and iron, 32 orphenadrine ext-rel, 29 norethindrone/EE, 32 ORTHO EVRA, 33 norethindrone/EE 0.4/35, 32 ORTHO MICRONOR, 32 norethindrone/EE 0.4/35 chewable, 32 ORTHO TRI-CYCLEN, 32 norethindrone/EE 0.5/35, 32 ORTHO TRI-CYCLEN LO, 32 norethindrone/EE 0.8/25 chewable, 31 ORTHO-CEPT, 32 norethindrone/EE 1/35, 32 ORTHO-CYCLEN, 32 norethindrone/ME 1/50, 32 ORTHO-DIAPHRAGM, 33 norgestimate/EE, 32 ORTHO-NOVUM 1/35, 32 norgestimate/EE 0.25/35, 32 ORTHO-NOVUM 7/7/7, 32 norgestrel/EE 0.3/30 - Low-Ogestrel, 32 oseltamivir, 18 norgestrel/EE 0.5/50 - Ogestrel, 32 OVCON 35, 32 NORINYL 1+50, 32 OVIDE, 44 NORITATE, 44 OXANDRIN, 29 NORPACE, 21 oxandrolone, 29 NORPRAMIN, 9, 26 oxaprozin, 15 nortriptyline, 26 oxazepam, 9, 25 nortriptyline 10 mg, 25 mg, 50 mg, 9 oxcarbazepine, 25 nortriptyline 75 mg, 9 oxybutynin, 36 nortriptyline soln 10 mg/5 mL, 9 oxybutynin ext-rel, 36 NORVASC, 23 oxycodone caps, tabs 5 mg, 16 NOVOLIN 70/30, 30 oxycodone concentrate 20 mg/mL, 16 NOVOLIN N, 30 oxycodone tabs 10 mg, 20 mg, 16 NOVOLIN R, 30 oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL, 16 NOVOLOG, 30 oxycodone/acetaminophen 5/325, 7.5/325, 16 NOVOLOG MIX 70/30, 30 oxycodone/aspirin, 16 NOXAFIL, 7, 17 oxymetazoline, 41 NULYTELY, 36 P NUVARING, 33 NUVIGIL, 7, 29 PACERONE, 21 nystatin, 17, 43 paliperidone ext-rel, 27 nystatin/triamcinolone, 43 paliperidone palmitate, 27 palivizumab, 42 O PAMELOR, 9, 26 oatmeal, colloidal, 44 pancrelipase delayed-rel, 36 oatmeal, colloidal/dimethicone, 44 PANOXYL, 42 OCEAN, 42 pantoprazole 20 mg, 9 OCUFEN, 45 pantoprazole 40 mg, 9 OCUFLOX, 45 pantoprazole delayed-rel, 36 ofloxacin, 45 PARAFON FORTE DSC, 28 ofloxacin otic, 47 PARAGARD T 380A, 33 olanzapine, 27 PARLODEL, 26 OLYSIO, 7, 18 PARNATE, 26 omacetaxine mepesuccinate, 20 paromomycin, 18 omalizumab, 42 paroxetine HCl, 26 omega-3 acid ethyl esters, 22 paroxetine HCl ext-rel, 26 omega-3 fatty acids, 22 paroxetine HCl susp, 26 omega-3 fatty acids/vitamin E, 22 PAXIL, 26 omega-3 fatty acids/vitamins chewable, 22 PAXIL CR, 26 OMEGA-3 GUMMIES, 22 peg 3350/electrolytes, 36 omeprazole 40 mg, 9 PEGASYS, 7, 38 omeprazole delayed-rel caps, 36 pegfilgrastim, 37 omeprazole magnesium delayed-rel, 36 peginterferon alfa-2a, 38 omeprazole, except 40 mg, 9 peginterferon alfa-2b, 38 omeprazole/sodium bicarbonate, 36 PEGINTRON, 7, 38 onabotulinumtoxinA, 29 pegloticase, 15 ondansetron, 35 penicillin VK, 17 ONE DAILY PRENATAL, 39 pentamidine aerosol, 19 ONFI, 7, 25 PENTASA, 35 OPSUMIT, 7, 24 pentosan polysulfate sodium, 37 OPTIPRANOLOL, 46 pentoxifylline ext-rel, 38 OPTIVAR, 45 PEPCID AC, 35 ORALAIR, 7, 38 PEPTO-BISMOL, 34 ORENCIA, 7 PERCOCET, 16

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PERCODAN, 16 PRENATABS RX, 39 PERIDEX, 45 PRENATAL LOW IRON, 39 permethrin 1%, 44 prenatal vitamins/DHA/docusate/folic acid, 39 permethrin 5%, 44 prenatal vitamins/DHA/EPA/ferrous fumarate/folic acid, 39 perphenazine, 27 prenatal vitamins/folic acid, 39 PERSANTINE, 37 PREVACID, 8, 10, 36 petrolatum/mineral oil, 44 PREVACID 24HR, 36 phenazopyridine, 37 PREVACID SOLUTAB, 9, 36 phenelzine, 26 PREVPAC, 36 phenobarbital, 25 PRILOSEC, 9, 36 phenylephrine, 41 PRILOSEC OTC, 36 phenylephrine/guaifenesin syrup, 41 primaquine, 18 phenytoin, 25 primidone, 25 phenytoin sodium extended, 25 PROAIR HFA, 41 PHOSLO, 34 probenecid, 15 phytonadione, 39 procarbazine, 20 pimecrolimus, 44 PROCARDIA, 23 PIMTREA, 32 PROCARDIA XL, 23 PIN X, 18 prochlorperazine, 35 pindolol, 22 PROCRIT, 37 pioglitazone, 30 PROGRAF, 38 pioglitazone/glimepiride, 30 PROLIA, 7, 31 pioglitazone/metformin, 30 promethazine, 35 PLAN B ONE-STEP, 8, 32 propafenone, 21 PLAQUENIL, 38 propantheline, 35 PLAVIX, 37 propranolol, 22 podofilox, 44 propranolol ext-rel, 22 polyethylene glycol 3350, 36 propylthiouracil, 34 polymyxin B/bacitracin, 43, 45 PROSCAR, 36 polymyxin B/trimethoprim, 45 PROSED/DS, 37 POLYSPORIN, 43 PROTONIX, 9, 36 POLYTRIM, 45 PROTOPIC, 44 ponatinib, 20 PROVERA, 34 PONTOCAINE, 44 PROVIGIL, 7, 29 posaconazole, 17 PROZAC, 26 potassium chloride effervescent, 38 pseudoephedrine, 41 potassium chloride ext-rel, 39 pseudoephedrine/guaifenesin ext-rel, 41 potassium chloride liquid, 39 psyllium/aspartame, 36 potassium chloride powder 20 mEq, 39 PULMICORT FLEXHALER, 42 potassium chloride powder 25 mEq, 39 PULMICORT RESPULES, 42 potassium citrate ext-rel, except 15 mEq, 37 PULMOZYME, 7, 41 potassium/sodium phosphates, 37 PURINETHOL, 19 POTIGA, 7, 25 pyrantel, 18 PRADAXA, 7, 37 pyrazinamide, 18 pramipexole, 26 PYRIDIUM, 37 PRANDIN, 30 pyridostigmine, 29 PRAVACHOL, 22 pyridostigmine ext-rel, 29 pravastatin, 22 pyridoxine 25 mg, 39 prazosin, 21 Q PRECOSE, 29 PRED FORTE, 45 QUARTETTE, 7, 32 PRED MILD, 46 QUESTRAN/QUESTRAN LIGHT, 21 PRED-G, 45 quetiapine, 27 prednisolone acetate 0.12%, 46 quetiapine ext-rel, 27 prednisolone acetate 1%, 45 quinapril, 20 prednisolone phosphate 1%, 45 quinapril/hydrochlorothiazide, 21 prednisolone sodium phosphate soln 5 mg/5 mL, quinidine gluconate ext-rel, 21 15 mg/5 mL, 25 mg/5 mL, 33 quinidine sulfate, 21 prednisolone syrup, 33 QVAR, 42 prednisone, 33 R pregabalin, 27 ragweed pollen allergen extract, 38 PRELONE, 33 RAGWITEK, 7, 38 PREMPHASE, 33 raloxifene, 34 PREMPRO, 33 ramipril, 20 MedStar Family Choice - DC Healthy Families Program 60

ranitidine, 35 SAVELLA, 27 ranitidine 150 mg, 35 SEASONIQUE, 32 ranitidine 75 mg, 35 selegiline caps, 26 RAZADYNE, 25 selegiline tabs, 27 REBETOL, 7, 18 selenium sulfide shampoo 2.5%, 43 REGLAN, 35 sennosides, 36 regorafenib, 20 SENOKOT, 36 REGRANEX, 45 SENSIPAR, 7, 31 RELENZA, 9, 18 SEREVENT, 9, 41 REMERON, 26 SEROQUEL, 27 REMICADE, 7, 38 SEROQUEL XR, 7, 27 REMODULIN, 7, 24 SEROSTIM, 7, 34 repaglinide, 30 sertraline, 26 REQUIP, 26 sildenafil, 24 RESTORIL, 9, 28 SILVADENE, 43 RETIN-A, 42 silver sulfadiazine, 43 REVATIO, 7, 24 simeprevir, 18 REVIA, 29 simethicone, 36 ribavirin caps, 18 SIMPLY SALINE, 42 ribavirin oral soln, 18 simvastatin, 22 ribavirin tabs, 18 SINEMET, 26 rifabutin, 18 SINEMET CR, 26 RIFADIN, 18 SINGULAIR, 41 rifampin, 18 SIRTURO, 7, 18 rimantadine, 18 sitagliptin phosphate, 30 rimexolone, 46 sitagliptin/metformin, 30 riociguat, 24 sitagliptin/metformin ext-rel, 30 RISPERDAL, 27 SKLICE, 10, 44 RISPERDAL CONSTA, 7, 27 SKYLA, 33 risperidone, 27 SLOW FE, 39 risperidone inj, 27 sodium chloride soln, 42 RITALIN, 8, 27 sodium citrate/citric acid, 37 RITALIN LA, 8, 10, 27 sodium oxybate, 29 rivaroxaban, 37 sodium polystyrene sulfonate, 39 rivastigmine, 25 sofosbuvir, 18 rizatriptan, 9, 10, 28 SOMA, 28 rizatriptan orally disintegrating tabs, 9, 10 somatropin, 34 ROBAXIN, 28 sotalol, 21 ROBITUSSIN CHILDREN'S COUGH & COLD, SOVALDI, 7, 18 LONG ACTING, 40 SPIRIVA, 40 ROBITUSSIN COUGH + CHEST CONGESTION DM, 40 spironolactone, 21 ROBITUSSIN LONG-ACTING COUGH, 40 spironolactone/hydrochlorothiazide, 23 ROCALTROL, 34 SPS, 39 ROCEPHIN, 17 STALEVO, 26 ropinirole, 26 STARLIX, 30 rosuvastatin, 22 STELARA, 7, 43 ROWASA, 35 STIMATE, 7, 34 ROXICODONE, 16 STIVARGA, 7, 20 rufinamide, 25 STRATTERA, 10, 27 ruxolitinib, 20 STRATTERA 10 mg, 18 mg, 25 mg, 9 RYTHMOL, 21 STRATTERA 40 mg, 9 S STRATTERA 60 mg, 80 mg, 100 mg, 9 succimer, 34 SABRIL, 7, 25 sucralfate, 36 SAFYRAL, 7, 32 SUDAFED, 41 salicylic acid 17% gel, 44 sulfacetamide soln 10%, 45 salicylic acid 40% pad, 44 sulfacetamide/prednisolone phosphate 10%/0.25%, 45 salicylic acid plaster 40%, 44 sulfacetamide/sulfur cleanser, lotion, 42 salmeterol xinafoate, 41 sulfadiazine, 17 SANCTURA, 36 sulfamethoxazole/trimethoprim, 17 SANDIMMUNE, 38 sulfamethoxazole/trimethoprim DS, 17 SANTYL, 45 sulfasalazine, 35 SAPHRIS, 7, 27 sulfasalazine delayed-rel, 35 sargramostim, 37 sulindac, 15 MedStar Family Choice - DC Healthy Families Program 61

sumatriptan, 28 tiotropium, 40 sumatriptan 25 mg, 50 mg, 100 mg, 9 tizanidine tabs, 29 sumatriptan inj, 9, 28 TOBI, 41 sumatriptan nasal spray, 9, 28 TOBRADEX, 45 SUPPRELIN LA, 7, 34 tobramycin inhalation solution, 41 SUPRAX, 17 tobramycin oint, 45 SYMBICORT, 10, 42 tobramycin soln, 45 SYNAGIS, 7, 42 tobramycin/dexamethasone susp 0.3%/0.1%, 45 SYNRIBO, 7, 20 TOBREX, 45 SYNTHROID, 34 TOFRANIL, 9, 26 SYNVISC, 7, 16 TOPAMAX, 25 SYNVISC-ONE, 7, 16 topiramate, 25 T topotecan caps, 20 TOPROL-XL, 22 tacrolimus, 38, 44 toremifene, 19 tadalafil, 24 torsemide, 23 TAFINLAR, 7, 19 TRADJENTA, 30 TAMIFLU, 9, 18 tramadol, 9, 16 tamoxifen, 19 trametinib, 20 tamsulosin, 36 TRANDATE, 22 TANDEM PLUS, 39 trandolapril, 20 TAPAZOLE, 34 trandolapril/verapamil ext-rel, 20 TARCEVA, 7, 19 tranylcypromine, 26 TARGRETIN caps, 20 trastuzumab, 20 TARKA, 20 trazodone, 26 TASIGNA, 7, 20 treprostinil, 24 TEGRETOL, 25 tretinoin, 42 TEGRETOL-XR, 25 tretinoin caps, 20 telaprevir, 18 triamcinolone acetonide crm 0.5%, 44 telbivudine, 18 triamcinolone acetonide crm, lotion 0.025%, 44 temazepam, 9, 28 triamcinolone acetonide crm, lotion, oint 0.1%, 44 TEMODAR, 19 triamcinolone acetonide spray, 41, 42 TEMOVATE, 44 triamcinolone paste, 45 temozolomide, 19 triamterene, 23 TENEX, 21 triamterene/hydrochlorothiazide, 23 TENORETIC, 22 trifluoperazine, 27 TENORMIN, 22 trifluridine, 46 TERAZOL 3, 37 trihexyphenidyl, 27 TERAZOL 7, 37 TRILEPTAL, 25 terazosin, 21, 36 trimethobenzamide, 35 terbinafine, 43 trimethoprim tabs, 19 terbinafine tabs, 17 TRI-NORINYL, 32 terbutaline, 41 tropicamide, 46 terconazole, 37 trospium, 36 TESSALON, 40 TRUSOPT, 46 testosterone enanthate inj, 29 TUDORZA, 40 testosterone gel, 29 TYKERB, 7, 20 testosterone soln, 29 TYLENOL w/CODEINE, 15 tetracaine soln 2%, 44 TYVASO, 7, 24 tetracycline, 17 TYZEKA, 18 theophylline ext-rel tabs, 42 theophylline liquid, 42 U thiothixene, 27 ulipristal, 32 tiagabine, 25 ULTRAM, 9, 16 TIAZAC, 23 UNIRETIC, 21 TIGAN, 35 UNISOM, 28 TIKOSYN, 21 UNIVASC, 20 timolol hemihydrate, 46 urea crm, 44 timolol maleate, 46 urea crm, gel 40%, 45 timolol maleate gel, 46 urea lotion, 44 timolol maleate tabs, 22 URECHOLINE, 37 TIMOPTIC, 46 urine test strips, 31 TIMOPTIC-XE, 46 UROCIT-K, 37 timothy grass pollen allergen extract, 38 UROXATRAL, 36

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URSO, 35 XGEVA, 7, 31 URSO FORTE, 35 XOLAIR, 7, 42 ursodiol, 35 XYREM, 7, 29 ustekinumab, 43 Y V YASMIN, 32 valacyclovir, 18 YAZ, 31 VALIUM, 8, 10, 25, 28 Z valproic acid, 25 VALTREX, 18 ZADITOR, 45 VANCOCIN, 19 zafirlukast, 41 vancomycin, 19 ZANAFLEX, 29 varenicline, 29 zanamivir, 18 VASERETIC, 21 ZANTAC, 35 VASOTEC, 20 ZANTAC 150, 35 vemurafenib, 20 ZANTAC 75, 9, 35 venlafaxine, 26 ZARONTIN, 25 venlafaxine ext-rel, 26 ZAROXOLYN, 23 VENTAVIS, 7, 24 ZEBETA, 22 VENTOLIN HFA, 41 ZEGERID OTC, 36 verapamil, 23 ZELBORAF, 7, 20 verapamil ext-rel, 23 ZEMAIRA, 7, 42 VERELAN, 23 ZESTORETIC, 21 VEXOL, 46 ZESTRIL, 20 VIBRAMYCIN, 17 ZETIA, 22 VICTOZA, 30 ZIAC, 22 vigabatrin, 25 zinc acetate, 39 VIMPAT, 7, 25 ziprasidone, 27 VIROPTIC, 46 ZITHROMAX, 17 vitamin ADC/fluoride drops, 39 ZOCOR, 22 vitamin ADC/fluoride/iron drops, 39 ZOFRAN, 35 vitamin B complex/vitamin C/folic acid, 39 ZOLADEX, 7, 19 VITAMIN B6, 39 zolmitriptan 2.5 mg, 9 VITAMIN D3, 39 zolmitriptan 5 mg, 9 VIVELLE-DOT, 33 zolmitriptan orally disintegrating tabs, 10 VOLTAREN GEL, 15 zolmitriptan orally disintegrating tabs 2.5 mg, 9 vorapaxar, 37 zolmitriptan orally disintegrating tabs 5 mg, 9 VOSPIRE ER, 41 zolmitriptan tabs, 10, 28 ZOLOFT, 26 W zolpidem, 9, 28 warfarin, 37 ZOMIG, 9, 10, 28 WELLBUTRIN, 26 ZOMIG-ZMT, 9, 10 WELLBUTRIN SR, 26 ZONEGRAN, 25 WELLBUTRIN XL, 26 zonisamide, 25 WESTCORT, 43 ZONTIVITY, 7, 37 X ZOVIRAX, 18 ZYDELIG, 7, 19 XALATAN, 46 ZYLOPRIM, 15 XALKORI, 7, 19 ZYPREXA, 27 XANAX, 8, 24 ZYRTEC, 40 XARELTO, 37 ZYRTEC-D, 40 XELODA, 19

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