Preferred Drug List (PDL) Arizona Effective Date: 1/1/2013

Introduction UnitedHealthcare Community Plan assumes no responsibility for the actions or omissions of any UnitedHealthcare Community Plan is pleased to medical provider based upon reliance, in whole provide this Preferred Drug List (PDL) to be used or in part, on the information contained herein . when prescribing for patients covered by the The medical provider should consult the drug pharmacy benefit plan offered by UnitedHealthcare manufacturer’s product literature or standard Community Plan . The drugs listed in this PDL references for more detailed information . are intended to provide sufficient options to treat patients who require treatment with a drug from National guidelines can be found on the Web that pharmacologic or therapeutic class . The drugs sites listed in the Web site section or go to listed in the UnitedHealthcare Community Plan the National Guideline Clearinghouse site at PDL have been reviewed and approved by the http://www.guideline.gov. Pharmacy and Therapeutics Committee . The drugs have been selected to provide the most clinically Preface appropriate and cost-effective medications for patients who have their drug benefit administered The UnitedHealthcare Community Plan PDL is through UnitedHealthcare Community Plan . It is organized by sections . Each section includes also recognized there may be occasions where therapeutic groups identified by either a drug class an unlisted drug is desired for proper medical or disease state . management of a specific patient . In those Products are listed by generic name . Brand names infrequent instances, the unlisted medication may be are included as a reference to assist in product requested through the prior authorization process . recognition . Unless exceptions are noted, generally The drugs represented have been reviewed by the all applicable dosage forms and strengths of the Pharmacy and Therapeutics (P&T) Committee and drug cited are included in the PDL . Generics are approved for inclusion . The PDL is reflective of should be considered the first line of prescribing . current medical practice as of the date of review . The UnitedHealthcare Community Plan PDL covers This edition incorporates drugs added to the PDL selected over-the-counter (OTC) products . You are since the last edition as well as numerous revisions encouraged to prescribe OTC medications when to the prescribing information based on changes clinically appropriate . in pharmacotherapy . Comments and suggestions from practicing physicians have also been Pharmacy and Therapeutics incorporated to ensure that the UnitedHealthcare (P&T) Committee Community Plan PDL is reflective of current The P&T Committee includes physicians and medical practice . pharmacists who are not employees or agents of UnitedHealthcare Community Plan or its Notice affiliates . They must adhere to the Ethics Policy The information contained in this PDL and its standards of the P&T Committee . UnitedHealthcare appendices is provided by UnitedHealthcare Community Plan medical directors and pharmacists Community Plan, solely for the convenience of also participate in the P&T Committee . The P&T medical providers . UnitedHealthcare Community Committee meets quarterly to discuss a variety of Plan does not warrant or assure accuracy of such issues . Those issues pertaining to pharmaceutical information nor is it intended to be comprehensive selection and pharmacy program management in nature . are communicated quarterly . This newsletter is distributed to all participating physicians who This PDL is not intended to be a substitute for the have received the PDL . PDL decisions are also knowledge, expertise, skill and judgment of the communicated quarterly on the UnitedHealthcare medical provider in their choice of prescription drugs . Community Plan internet site . ii Outpatient Prescription Drug PDL Product Descriptions Benefit-Covered Medications To assist in understanding which specific Medically necessary outpatient prescription strengths and dosage forms are covered on the drugs are covered when prescribed by a provider PDL, examples are noted below . The general licensed to prescribe federal legend drugs or principles shown in the examples can then usually medicines . Some items are covered only with prior be extended to other entries in the book . Any authorization . Eligibility for Outpatient Prescription exceptions are noted in the drug list . There may Drug Benefits and copays are based on the also be a statement associated with a drug list that individual member’s benefit plan . gives additional information about which specific products or dosage forms are covered .

Product Selection Criteria Products covered include all strengths The P&T Committee considers clinical information associated with the dosage form of the on new-to-market drugs that are typically included cited brand name product. in an outpatient pharmacy benefit . The evaluation carvedilol Coreg includes all or part of the following: All strengths of Coreg would be covered by • Safety this listing . • Efficacy Extended-release and delayed-release • Comparison studies products require their own entry. • Approved indications diltiazem sustained release Cardizem SR • Adverse effects Dosage forms covered will be consistent with • Contraindications/Warnings/Precautions the category and use where listed. • Pharmacokinetics Neomycin/polymixin B/ Cortisporin • Patient administration/compliance Hydrocortisone considerations As listed in the OTIC section, this is limited to • Medical outcome and pharmacoeconomic the otic solution and suspension . From this entry, studies the ophthalmic solution and ointment, and the topical cream, cannot be assumed to be on the list When a new drug is considered for PDL inclusion, unless there are entries for these products in the it will be reviewed relative to similar drugs currently OPHTHALMIC and DERMATOLOGY sections of included in the UnitedHealthcare Community Plan the PDL . PDL . This review process may result in deletion of drug(s) in a particular therapeutic class in an effort When a strength or dosage form is specified, to continually promote the most clinically useful only the specified strength and dosage form and cost-effective agents . is on the PDL. Other strengths/dosage forms of the reference product are not. All the information in the PDL is provided as a citalopram 40mg tabs Celexa tabs reference for drug therapy selection . Specific drug selection for an individual patient rests solely with the prescriber .

iii Generic Availability bioequivalence between the generic versions and the reference brand product . To gain Drug names in bold type indicate generic FDA approval: availability of that product . However, not all strengths or dosage forms of the generic name in 1 . The generic drug must contain the same active boldface type may be generically available . In some ingredient(s), be the same strength and the cases, the brand name listed is a generic drug . same dosage form as the brand name product . Generic Substitution 2 . The FDA has given the generic an “A” rating compared to the branded product indicating The UnitedHealthcare Community Plan PDL bioequivalence, and has determined the requires generic substitution on the majority of generic is therapeutically equivalent to the products when a generic equivalent is available . reference brand . The ratings of generic drugs are available by referring to the FDA reference, Generic substitution is a pharmacy action whereby Approved Drug Products with Therapeutic a generic equivalent is dispensed rather than Equivalence Evaluations the brand name product . Products designated (Orange Book) . in the PDL drug lists by boldface type have generic availability . When the above two criteria are met, a generic can be substituted with the full expectation that the Products with a narrow therapeutic index (NTI) substituted product will produce the same clinical as defined by the UnitedHealthcare Community effect and safety profile as the prescribed product . Plan P&T committee are exempt from generic Drug products that have a narrow therapeutic substitution requirements . Current exempt agents index (NTI) can also be guided by these principles . include: It is not necessary for the health care provider • Tegretol (carbamezapine) to approach any one therapeutic class of drug products (e .g ., NTI drugs) differently from any other • Synthroid (levothyroxine) class, when there has been a determination of • Coumadin (warfarin sodium) therapeutic equivalence by the FDA for the drug • Lanoxin (digoxin) products under consideration . Also, additional clinical tests or examinations by the physician • Dilantin (phenytoin) are not needed when a therapeutically equivalent generic drug product is substituted for the brand If a brand name drug from another category name product . is medically necessary, please submit a prior authorization request . There are now many brand name products that are repackaged or distributed under a generic The UnitedHealthcare Community Plan MAC label . The generic label version should always list sets a ceiling price for the reimbursement of be considered therapeutically equivalent and certain multisource prescription drugs . This price substitutable for the source branded product . will typically cover the acquisition of most generics but not branded versions of the same drug . The products selected for inclusion on the MAC list Drug Efficacy Study Implementation are commonly prescribed and dispensed and (DESI) Drugs have usually gone through the FDA’s review and Drugs first marketed between 1938 and 1962 approval process . were approved as safe but required no showing of effectiveness for FDA approval . Beginning in An important consideration for generic substitution 1962, all new drugs were required to be both is the knowledge that all approvals of generic safe and effective before they could be marketed . drugs by the FDA since 1984, and many generic This legislation also applied retroactively to all approvals prior to 1984, have a showing of iv drugs approved as safe from 1938-1962 . The Days Supply Dispensing Limitations DESI program was established by the FDA to UnitedHealthcare Community Plan members may review the effectiveness of these pre-1962 drugs receive up to a one- month supply of a specific for their labeled indications, and a determination medication per prescription order or prescription of “fully effective” was made for most of these refill . A medication may be reordered or refilled products and they remain in the marketplace . A when seventy-five percent (75%) of the medication few DESI products remain classified as “less than has been utilized . If a claim is submitted before fully effective” while awaiting final administrative 75% of the medication has been used, based on disposition . Also, classified as DESI are many the original day supply submitted on the claim, the products listed as identical, similar, or related claim will reject with a “refill too soon” message . to actual DESI products . UnitedHealthcare Community Plan’s PDL does not cover DESI “less than fully effective” drug products . Mandatory Generic Substitution The UnitedHealthcare Community Plan PDL Plan Exclusions requires mandatory generic substitution on the vast majority of products when a generic equivalent The following drug categories are excluded is available; however, brand name drugs may be from coverage under the outpatient pharmacy covered in certain situations by requesting a prior benefit and are not part of the UnitedHealthcare authorization . The UnitedHealthcare Community Community Plan PDL . Plan PDL prior authorization (PA) list does not • DESI drugs include branded items where a generic equivalent • Antiobesity agents is covered . • Experimental / research drugs Prior Authorization of • Cosmetic drugs Non-PDL Medications • Immunization agents The drugs in the UnitedHealthcare Community • Nutritional / diet supplements Plan PDL have been selected to provide the most clinically appropriate and cost-effective • Blood and blood plasma products medications for patients who have their drug • Agents used to promote fertility benefit administered through UnitedHealthcare • Agents used for erectile dysfunction Community Plan . It is also recognized that there may be occasions where an unlisted drug is • Agents used for cosmetic hair growth desired for the proper medical management of a • Drugs from manufacturers that do not specific patient . In those infrequent instances, the participate in the FFS Medicaid Drug prior authorization process reviews requests for Rebate Program unlisted medications the physician may consider medically necessary for patient management . • Diagnostic products • Medical supplies and DME except as listed: Requests for these exceptions should be either syringes, needles, lancets, alcohol swabs, made in writing by the physician and faxed or Easivent MDI spacer, preferred diabetes test called in to: strips, peak flow meters (Astech, Assess, Peak Air brands, max two per year), vaporizer UnitedHealthcare Community Plan (limit of one per three years), humidifier (limit Pharmacy Services Department of one per three years) Fax 1-866-940-7328 Phone 1-800-310-6826 • Mirena

v A prior authorization request form is available in the UnitedHealthcare Community Plan at UnitedHealthcare Community Plan provider manual 1-866-940-7328 . and should be used for all prior authorization requests if possible . Appropriate documentation Quantity Limitations (QL) must be provided to support the medical necessity Prescriptions for monthly quantities greater of the non-PDL request . All requests will be than the indicated limit require a prior responded to within 24 hours of receipt . authorization request .

Physicians are requested to adhere to this PDL Quantity Limits Based on Efficient when prescribing for patients covered by their Medication Dosing pharmacy benefit plan offered by UnitedHealthcare Community Plan . If a pharmacist receives a The Efficient Medication Dosing Program is prescription for a non-PDL drug, the pharmacist designed to consolidate medication dosage to the should contact the prescribing physician and most efficient daily quantity to increase adherence request that the prescription be changed to to therapy and also promote the efficient use of a medication included in this PDL . If a PDL health care dollars . alternative is not appropriate, the physician The limits for the program are established based should then be instructed to contact the Plan on FDA approval for dosing and the availability for a prior authorization . of the total daily dose in the least amount of Please contact the UnitedHealthcare Community tablets or capsules daily . Quantity Limits in Plan Pharmacy Prior Notification Service at the prescription claims processing system will 1-800-310-6826 with questions concerning limit the dispensing to consolidate dosing . The the prior authorization process . pharmacy claims processing system will prompt the pharmacist to request a new prescription order Non-PDL Drugs Five-Day from the physician . Temporary Supply Overrides Additions to the QL program drug list will be To ensure the use of PDL drugs, all non-PDL made from time to time and providers notified drugs should be discussed with the prescribing accordingly . As always, we recognize that a physician . If you cannot speak to the physician number of patient-specific variables must be taken immediately, and there is an immediate need into consideration when drug therapy is prescribed for the medication, the claim processing and therefore overrides will be available through system will accept an override to permit a the medical exception (prior authorization) process . one-time dispensing of a five-day supply Please contact the UnitedHealthcare Community of the newly prescribed non-PDL drug. The Plan Pharmacy Prior Notification Service at pharmacy should submit a claim for a five day 1-800-310-6826 with questions . supply, with a PA Type of 8 and Prior Authorization Controlled Substances number of “00000000120” . Please note that non-preferred drugs are available for a five-day You may fill any FOUR medications from the supply, however, availability is subject to the benefit following classes in a 30-day period: design . For assistance, pharmacies may call • opiate analgesics 1-800-310-6826 . • benzodiazepines The pharmacy should contact the physician • sedative hypnotic agents to discuss a PDL drug or if a prior authorization • barbiturates request is warranted . If the prescribing physician feels a drug is medically necessary, the physician • select muscle relaxants may fax a request for prior authorization to vi Additional fills will require prior authorization . Hepatitis C Therapy (Peg-Intron, Pegasys, Pegasys Medications in these classes may also be subject Proclick, Infergen, Ribavirin, Incivek) to individual quantity limits . Hereditary Angioedema (Firazyr, Berinert) Specialty Pharmaceutical Ilaris Management Program Increlex UnitedHealthcare Community Plan is continuously looking for ways to provide high-quality cost- Interferons (Intron A, Pegasys, Sylatron) effective care for Plan members . The Specialty Korlym Pharmaceutical Management Program helps UnitedHealthcare Community Plan to achieve Kuvan these goals . Injectable medications that are Lovenox (*Specialty for quantities greater than part of this program require plan authorization 14 days) and are not available through the retail pharmacy network . Lupron

To obtain authorization, the provider must Mozobil submit the appropriate Prior Authorization form Multiple Sclerosis Agents (Avonex, Avonex Pen, to the UnitedHealthcare Community Plan Pharmacy Copaxone, Rebif) Department via fax at 1-866-940-7328 . Neumega The UnitedHealthcare Community Plan Oral Chemotherapy (Oforta, Xeloda, Zolinza, Pharmacy Department will review all requests Afinitor, Gleevec, Nexavar, Sprycel, Sutent, within 24 hours, and if authorized for payment, Tarceva, Tasigna, Tykerb, Vandetanib, Votrient, UnitedHealthcare Community Plan will coordinate Temodar, Xalkori, Zelboraf, Zytiga, Erivedge, the delivery of the product to the member or Jakafi, Inlyta) provider . PAH (Adcirca, Revatio, Letairis, Tracleer) The following drugs or drug classes are included in the program: Promacta Revlimid Specialty Pharmaceutical Program Drug List Arcalyst Rheumatoid Arthritis Agents (Enbrel, Humira, Cimzia) Colony Stimulating Factors (Neulasta, Neupogen, Leukine) Sabril Cystic Fibrosis Agents (Pulmozyme, Xenazine TOBI, Kalydeco) Xolair Erythropoiesis Stimulating Agents (Aranesp, Drugs that are part of this program and are on Epogen, Procrit) the PDL are identified in this booklet by the Exjade designation “SP” .

Forteo Prior Authorization request forms can be requested Fuzeon by calling the UnitedHealthcare Community Plan Pharmacy Department at 1-800-310-6826 . Growth Hormone Products (Tev-Tropin, Omnitrope)

vii Step Therapy (ST) STEP Drug First-Line Agent(s) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line Dulera 30-day trial of inhaled agent has been adequately tried and failed . These corticosteroid . medications may also be requested through the Elidel Trial of two different topical Prior authorization process . corticosteroids . Step therapy only applies to members 12 While lower cost PDL alternatives may be years of age and older . appropriate in many instances, other non-PDL alternatives are available with prior authorization (PA) . fenofibrate Fill of a statin or 90 days of gemfibrozil within the previous STEP Drug First-Line Agent(s) 180 days .

Abilify 30 day trial of one of the fentanyl 30-day trial of at least 200mg following: risperidone, quetiapine, patches per day of morphine sulfate ER . ziprasidone, olanzapine Gabitril 30-day trial of two of the Advair 30-day trial of inhaled following: lamotrigine, corticosteroid or-60 day trial of topiramate, carbamazepine, a long acting beta agonist with divalproex, or phenytoin . Step an anticholinergic . therapy only applies to members 12 years of age and older . Amerge Trial at a minimum dose of Members less than 12 require 50mg of sumatriptan tablets . prior authorization . Aricept 23mg 90-day trial of Aricept 10mg daily . Intuniv 30-day trial of one of the atorvastatin 90 day trial of simvastatin following: methylphenidate, 40mg within previous methylphenidate SR, Concerta, 180 days is required first . amphetamine salts, Adderall XR, dextroamphetamine, or Banzel 30-day trial of two of the dextroamphetamine SA . following: lamotrigine, lansoprazole/ 30-day trial of omeprazole divalproex, or topiramate . Prevacid OTC 40mg and pantoprazole 40mg Cymbalta Minimum 2-month trial of 2 within previous 180 days is PDL generic antidepressants required first . in the preceding 6 months . levocetirizine 30 day trial of loratadine Ditropan XL 30-day trial of oxybutynin and cetirizine immediate release . Step Therapy Maxalt/MLT Trial at a minimum dose of only applies to members less 50mg of sumatriptan tablets . than 65 years of age . Nucynta ER 30 day trial of at least 200mg DPP4 At least a 90-day trial of per day of morphine sulfate ER . Inhibitors 1500mg/day of metformin . (Januvia, Onfi 30 day trial of two of the Janumet, following: lamotrigine, Janumet XR) divalproex, or topiramate . viii STEP Drug First-Line Agent(s) STEP Drug First-Line Agent(s) Opana ER 30-day trial of at least Symbicort 30-day trial of inhaled 200mg per day of morphine corticosteroid or-60 day trial sulfate ER . of a long acting beta agonist with an anticholinergic . Potiga 30-day trial of two of the following: lamotrigine, tolterodine 30 day trial of oxybutynin topiramate, carbamazepine, immediate release . divalproex, or phenytoin . Step Step Therapy only applies therapy only applies to members to members less than 18 years of age and older . 65 years of age . Members less than 18 require prior authorization . trospium 30 day trial of oxybutynin immediate release . Pristiq 60-day trial of preferred SSRI, Step Therapy only applies venlafaxine, mirtazapine, to members less than bupropion, or bupropion SR . 65 years of age .

Protopic 0.03% Trial of two different topical TZD’s (Actos, At least a 90-day trial of corticosteroids . Step therapy ActosPlusMet, 1500mg/day of metformin . only applies to members ActoPlusMet 12 years of age and older . XR, Duetact) Protopic 0.1% Minimum age of 16 . Trial of two different topical corticosteroids . Uloric 8-week trial of up to 600mg of allopurinol required first . Ranexa Trial of one drug from the Vancocin One fill of metronidazole tabs following classes: beta blockers, or caps . calcium channel blockers, long acting nitrates . Vimpat 30-day trial of two of the following: lamotrigine, Renvela 8-week trial of calcium acetate topiramate, carbamazepine, divalproex, or phenytoin . Step Singulair 60-day trial of preferred inhaled therapy only applies to members corticosteroid or 30-day trial 17 years of age and older . of either loratadine or cetirizine Members less than 17 require with a preferred intranasal prior authorization . steroid . Vytorin 90-day trial of simvastatin 80mg Strattera 30-day trial of one of the within previous 180 days is following: methylphenidate, required first . methylphenidate SR, Concerta, amphetamine salts, Adderall Xopenex 30-day trial of Albuterol .083% XR, dextroamphetamine, or Respules or .5% respules . dextroamphetamine SA .

ix PDL Suggestions Legend Providers who wish to propose PDL suggestions # Only the dosage forms/strengths should forward the information to the of the brand name products noted UnitedHealthcare Community Plan Director of are on the PDL Pharmacy Services by either mail or fax . OTC over-the-counter Attn: Director of Pharmacy Services boldface indicates generic availability; UnitedHealthcare Community Plan boldface may not apply to every 1001 Brinton Road strength or dosage form under Pittsburgh, PA 15221 the listed generic name Fax: 1-866-940-7328 delayed-rel delayed-release (also known as Providers should furnish adequate documentation, enteric coated) such as clinical studies from the medical literature, EC enteric-coated in order for the request to be considered for PDL addition . This literature should include information ext-rel extended-release (also known as documenting clinical necessity as well as sustained-release) therapeutic advantages over current PDL products . Suggestions received by UnitedHealthcare PA Prior Authorization required Community Plan will be reviewed by the Pharmacy QL Quantity Limits apply and Therapeutics Committee at the subsequent P&T Committee meeting . ST Step Therapy, see pages viii - ix for details Editor SP Specialty Pharmaceuticals; see Your comments and suggestions regarding the page vii for details UnitedHealthcare Community Plan PDL are encouraged . Your input is vital to this PDL’s continued success . All responses will be reviewed Notice and considered . Please send your comments to: The information contained in this document is proprietary information . The information may not UnitedHealthcare Community Plan be copied in whole or in part without the written 1001 Brinton Road permission of UnitedHealthcare Community Plan . Pittsburgh, PA 15221 All rights reserved . Fax: 1-866-940-7328 The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare Community Plan . These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare Community Plan and such third-party pharmaceutical companies .

If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification . x Introducción Community Plan, exclusivamente para la comodidad de los proveedores médicos . UnitedHealthcare Community Plan se complace UnitedHealthcare Community Plan no garantiza en ofrecer esta Lista de medicamentos preferidos ni asegura la precisión de dicha información ni (Preferred Drug List, PDL) que se utilizará al pretende ser integral por naturaleza . realizar recetas para los pacientes que tienen cobertura del plan de beneficios de farmacia Esta PDL no tiene la finalidad de sustituir el ofrecido por UnitedHealthcare Community Plan . conocimiento, la pericia, las habilidades ni el Los medicamentos incluidos en esta PDL tienen criterio del proveedor médico en su elección como finalidad ofrecer opciones suficientes para de medicamentos recetados . tratar a los pacientes que necesitan tratamiento con un medicamento de dicha clase farmacológica UnitedHealthcare Community Plan no asume o terapéutica . Los medicamentos incluidos en la ninguna responsabilidad por las acciones u PDL de UnitedHealthcare Community Plan han omisiones de los proveedores médicos sobre sido revisados y aprobados por el Comité de la base de la confianza, total o parcial, de la Farmacia y Terapéutica . Los medicamentos se información incluida aquí . El proveedor médico han seleccionado para ofrecer los medicamentos debe consultar la información del producto del más apropiados desde el punto de vista clínico y fabricante del medicamento o las referencias más asequibles para los pacientes que tienen su estándar para obtener información detallada . beneficio de medicamentos administrado a través de UnitedHealthcare Community Plan . También Las pautas nacionales pueden encontrarse en se reconoce que puede haber ocasiones en que los sitios web que se enumeran en la sección un medicamento no incluido en la lista se requiere del sitio web, o bien, visite el sitio del Centro de para el control médico adecuado de un paciente Intercambio de Información de Pautas Nacionales específico . En estas instancias poco frecuentes, en http://www.guideline.gov. los medicamentos que no estén incluidos pueden ser requeridos a través del proceso Prólogo de autorización previa . La PDL de UnitedHealthcare Community Plan está organizada por secciones . Cada sección incluye Los medicamentos representados han sido grupos terapéuticos identificados por una clase de revisados por el Comité de Farmacia y Terapéutica medicamento o estado de la enfermedad . (Pharmacy and Therapeutics, P&T) y están aprobados para su inclusión . La PDL refleja Los productos están enumerados por nombre la práctica médica actual desde la fecha de genérico . Las marcas están incluidas como la revisión . una referencia para ayudarlo a reconocer el producto . A menos que se incluyan excepciones, Esta edición incorpora medicamentos agregados por lo general todas las formas de dosificación a la PDL desde la última edición así como y concentraciones aplicables del medicamento numerosas revisiones para la información de citado están incluidas en la PDL . Los prescripción basada en los cambios en la medicamentos genéricos deben ser considerados farmacoterapia . También se han incorporado como medicamentos recetados de primera línea . comentarios y sugerencias de médicos practicantes para garantizar que la PDL de La PDL de UnitedHealthcare Community UnitedHealthcare Community Plan refleje la Plan cubre algunos productos de venta libre práctica médica actual . (over-the-counter, OTC) . Lo alentamos a que recete medicamento OTC cuando sea Aviso clínicamente apropiado . La información incluida en esta PDL y sus apéndices es provista por UnitedHealthcare

xi Comité de Farmacia y • Estudios de comparación Terapéutica (P&T) • Indicaciones aprobadas El Comité de P&T incluye médicos y farmacéuticos • Efectos adversos que no son empleados ni agentes de • Contraindicaciones/Advertencias/ UnitedHealthcare Community Plan o sus afiliadas . Precauciones Deben respetar los estándares de la Política sobre ética del Comité de P&T . Los directores • Farmacocinética médicos de UnitedHealthcare Community Plan • Administración de pacientes/consideraciones y los farmacéuticos también participan en el de cumplimiento Comité de P&T . El Comité de P&T se reúne trimestralmente para analizar diversos temas . Los • Resultados médicos y estudios temas pertinentes a la selección farmacéutica y la farmacoeconómicos administración del programa de farmacia Cuando un medicamento nuevo se considera para se comunican trimestralmente . Este boletín su inclusión en la PDL, se revisará en relación informativo se distribuye a todos los médicos a los medicamentos similares que se incluyen participantes que hayan recibido la PDL . Las actualmente en la PDL de UnitedHealthcare decisiones de PDL también son comunicadas Community Plan . Este proceso de revisión trimestralmente en el sitio de Internet de puede derivar en la supresión de medicamentos UnitedHealthcare Community Plan . en una clase terapéutica en particular con el fin de promover continuamente los agentes Beneficio de Medicamentos más económicos y útiles desde el punto de Recetados Para Pacientes vista clínico . Ambulatorios - Medicamentos Toda la información que se incluye en la PDL se Cubiertos proporciona como referencia para la selección de tratamientos con medicamentos . La selección Los medicamentos recetados para pacientes de medicamentos específicos para un paciente ambulatorios médicamente necesarios están individual la realiza exclusivamente el profesional cubiertos cuando son recetados por un proveedor autorizado para recetar medicamentos . autorizado para recetar medicamentos o fármacos con leyenda federales . Algunos artículos solo se Descripciones de los Productos cubren con autorización previa . La elegibilidad para los beneficios de medicamentos recetados Incluidos en la PDL para pacientes ambulatorios y los copagos A fin de brindar ayuda para entender qué están basados en el plan de beneficios del concentraciones específicas y formas de miembro individual . dosificación están cubiertas en la PDL, a continuación se incluyen ejemplos: Los principios Criterios de Selección de Productos generales que se muestran en los ejemplos El Comité de P&T considera la información clínica generalmente luego pueden extenderse a otras en los medicamentos nuevos para el mercado entradas del libro . Las excepciones se indican en que por lo general se incluyen en el beneficio la lista de medicamentos . También puede haber de farmacia para pacientes ambulatorios . La una declaración relacionada con una lista de evaluación incluye todo o parte de lo siguiente: medicamentos que ofrece información adicional acerca de cuáles son los productos específicos o • Seguridad formas de dosificación que se cubren . • Eficacia

xii Los productos cubiertos incluyen todas las Disponibilidad de concentraciones asociadas con la forma de dosificación del producto de marca citado. Medicamentos Genéricos Los nombres de medicamentos que aparecen carvedilol Coreg en negrita indican la disponibilidad de Todas las concentraciones de Coreg estarían medicamentos genéricos de dicho producto . cubiertas según esta lista . No obstante, no todas las concentraciones o formas de dosificación del nombre genérico que Los productos de liberación prolongada aparece en negrita pueden estar disponibles y de liberación retardada requieren su en forma genérica . En algunos casos, la marca propia entrada. incluida en la lista es un medicamento genérico . diltiazem de liberación Cardizem SR

Las formas de dosificación cubiertas serán Sustitución por Genéricos consistentes con la categoría y el uso en los La PDL de UnitedHealthcare Community Plan casos que se incluyan en la lista. requiere la sustitución por genéricos en la mayoría de los productos cuando se encuentra disponible Neomicina/polimixina B/ Cortisporin un equivalente del medicamento genérico . Hidrocortisona Según lo enumerado en la sección de productos La sustitución por genéricos es una medida ÓTICOS, se limita a la solución y suspensión que toma la farmacia en los casos en que un ótica . En esta entrada, no puede suponerse que la equivalente de genérico se dispense en lugar del solución oftálmica, el ungüento y la crema tópica producto de marca . Los productos designados estén incluidos en la lista a menos que existan en negrita en las listas de medicamentos están entradas para estos productos en las secciones de disponibles en forma genérica . productos OFTÁLMICOS y DERMATOLÓGICOS de la PDL . Los productos con un índice terapéutico estrecho (narrow therapeutic index, NTI) según lo definido En los casos en que se especifique la por el Comité de P&T de UnitedHealthcare concentración y la forma de dosificación, Community Plan están exentos de los requisitos solo la concentración especificada y la forma de sustitución por genéricos . Los agentes exentos de dosificación se encuentran incluidas en actuales incluyen: la PDL. Otras concentraciones o formas de dosificación del producto de referencia • Tegretol (carbamezepina) no son. • Synthroid (levotiroxina) los comprimidos de Celexa tabs • Coumadin (warfarina sódica) citalopram 40 mg • Lanoxin (digoxina) • Dilantin (fenitoína) Si un medicamento de marca de otra categoría es médicamente necesario, envíe una solicitud de autorización previa .

La lista del Consejo de Apelaciones de Medicare (Medicare Appeals Council, MAC) de UnitedHealthcare Community Plan establece un precio máximo para el reembolso de ciertos medicamentos recetados de múltiples fuentes .

xiii Este precio por lo general cubrirá la adquisición de la de cualquier otra clase, cuando la FDA ha la mayoría de los medicamentos genéricos pero no determinado la equivalencia terapéutica de los las versiones de marca del mismo medicamento . productos farmacéuticos en cuestión . Además, no Los productos seleccionados para su inclusión es necesario que los médicos realicen pruebas en la lista del MAC son recetados y dispensados clínicas o exámenes adicionales cuando un comúnmente, y por lo general han pasado producto farmacológico genérico equivalente por el proceso de revisión y aprobación de la desde el punto de vista terapéutico se sustituye Administración de Alimentos y Medicamentos (FDA) . por el producto de marca .

Una consideración importante para la sustitución Actualmente, hay muchos productos de marca que por genéricos es el conocimiento de que todas cuentan con un envase nuevo o son distribuidos las aprobaciones de medicamentos genéricos por con etiquetas de medicamento genérico . La parte de la FDA desde el año 1984, y muchas versión con etiqueta de medicamento genérico aprobaciones de medicamentos genéricos siempre debe considerarse como un equivalente antes de este año, demuestran una equivalencia desde el punto de vista terapéutico y sustituible biológica entre las versiones genéricas y el por el producto de marca original . producto de marca de referencia . Para obtener la aprobación de la FDA: Medicamentos del Programa 1 . El medicamento genérico debe incluir los Implementación del Estudio Sobre mismos ingredientes activos y tener la misma Eficacia de Medicamentos (DESI) concentración y forma de dosificación que el Los medicamentos que se comercializaron por producto de marca . primera vez entre 1938 y 1962 fueron aprobados 2 . La FDA ha otorgado a los medicamentos por ser seguros pero no requerían demostración genéricos la calificación “A” en comparación de eficacia para la aprobación de la FDA . A con los productos de marca que indican partir de 1962, todos los medicamentos nuevos la equivalencia biológica; además, ha debían ser seguros y eficaces antes de que determinado que, desde el punto de vista pudieran ser comercializados . Esta legislación terapéutico, el medicamento genérico es también se aplicó de forma retroactiva a todos equivalente al medicamento de marca . Las los medicamentos aprobados por su seguridad calificaciones de los medicamentos genéricos entre los años 1938 y 1962 . El programa DESI están disponibles al consultar la referencia de fue establecido por la FDA para revisar la eficacia la FDA, Productos farmacéuticos aprobados de estos medicamentos anteriores a 1962 para con evaluaciones de equivalencia terapéutica las indicaciones de sus etiquetas, y se realizó (Libro naranja) una determinación de eficacia total para la mayoría de estos productos, y permanecen en el En los casos en que se cumpla con los dos mercado . Unos pocos productos del programa criterios mencionados, un medicamento genérico DESI permanecen clasificados como “menos puede sustituirse con la total expectativa de que que totalmente eficaces” mientras se espera la el producto sustituido producirá el mismo efecto disposición administrativa final . Además, muchos clínico y tendrá el mismo perfil de seguridad que el productos incluidos como idénticos, similares o producto recetado . Los productos farmacéuticos relacionados con los productos verdaderos del que tengan un índice terapéutico estrecho (NTI) programa DESI están clasificados como DESI . también pueden ser guiados por estos principios . La PDL de UnitedHealthcare Community Plan no No es necesario que el proveedor de atención cubre los productos farmacéuticos “menos que médica se aproxime a cualquier clase terapéutica totalmente eficaces” de DESI . de los productos farmacéuticos (por ejemplo, medicamentos con NTI) de forma diferente a

xiv Exclusiones del Plan receta o reposición de medicamentos recetados . Un medicamento puede volver a pedirse o Las siguientes categorías de medicamentos están reponerse cuando se ha utilizado el setenta y cinco excluidas de la cobertura conforme al beneficio por ciento (75%) del medicamento . Si se presenta de farmacia para pacientes ambulatorios y una reclamación antes de haberse utilizado no son parte de la PDL de UnitedHealthcare el 75% del medicamento, según los días de Community Plan . suministro original presentado en la reclamación, • Medicamentos del programa DESI esta será rechazada con un mensaje de • Agentes contra la obesidad “reposición prematura” . • Medicamentos experimentales o en Sustitución por Genéricos investigación Obligatoria • Medicamentos usados para fines cosméticos La PDL de UnitedHealthcare Community Plan • Agentes de vacunación PDL requiere de la sustitución por genéricos • Suplementos nutricionales/dietéticos obligatoria en gran parte de los productos cuando se encuentra disponible un equivalente • Productos de sangre o plasma sanguíneo genérico; no obstante, los medicamentos de • Medicamentos usados para promover marca pueden estar cubiertos en determinadas la fertilidad situaciones al solicitar una autorización previa . La lista de autorización previa (PA) de la PDL de • Agentes usados para la disfunción eréctil UnitedHealthcare Community Plan no incluye • Agentes usados con fines cosméticos para el artículos de marca en los casos en que el crecimiento del cabello equivalente genérico está cubierto . • Medicamentos de fabricantes que no participan en el Programa de descuentos en Autorización Previa de medicamentos de Medicaid de FFS Medicamentos No Incluidos • Productos de diagnóstico en la PDL • Suministros médicos y equipo médico Los medicamentos incluidos en la PDL de duradero (durable medical equipment, DME) UnitedHealthcare Community Plan PDL han sido excepto según se menciona: jeringas, agujas, seleccionados para ofrecer los medicamentos lancetas, toallitas con alcohol, espaciador de más apropiados desde el punto de vista clínico MDI Easivent, tiras reactivas para medir la y más asequibles para los pacientes que tienen glucosa, medidores de flujo máximo (marcas su beneficio de medicamentos administrado a Astech, Assess, Peak Air, máx . dos por año), través de UnitedHealthcare Community Plan . vaporizador (límite de 1 por cada 3 años), También se reconoce que puede haber ocasiones humidificador (límite de 1 por cada 3 años) en que un medicamento no incluido en la lista • Mirena se requiere para el control médico adecuado de un paciente específico . En estos casos poco frecuentes, el proceso de autorización previa Limitaciones en la Provisión de revisa las solicitudes para los medicamentos Suministros de Días no incluidos en la lista que el médico puede Los miembros de UnitedHealthcare Community considerar médicamente necesario para el control Plan pueden recibir hasta un suministro de un del paciente . mes de un medicamento específico por pedido de

xv El médico debe realizar las solicitudes de estas medicamento de forma urgente, el sistema excepciones por escrito y enviarlas por fax, o bien, de procesamiento de reclamaciones aceptará debe llamar a: una sustitución para permitir una provisión por única vez de un suministro de 5 días UnitedHealthcare Community Plan del medicamento recientemente recetado Pharmacy Services Department que no está incluido en la PDL. La farmacia Fax 1-866-940-7328 debe enviar una reclamación para un suministro Teléfono 1-800-310-6826 de 5 días, con el tipo 8 de PA y el número de autorización previa “00000000120” . Tenga en En el manual de proveedores de UnitedHealthcare cuenta que los medicamentos no preferidos están Community Plan se encuentra disponible disponibles para un suministro de 5 días, no un formulario de solicitud de autorización obstante, la disponibilidad está sujeta al esquema previa y, si es posible, debe utilizarse para de beneficios . Para obtener ayuda, las farmacias todas las solicitudes de autorización previa . pueden llamar al 1-800-310-6826 . La documentación correspondiente debe proporcionarse para respaldar la necesidad médica La farmacia debe comunicarse con el médico de la solicitud de medicamentos no incluidos en para analizar el medicamento de la PDL o si la PDL . Todas las solicitudes serán respondidas se justifica la solicitud de una autorización previa . dentro de las 24 horas de la recepción . Si el médico que realiza la receta considera que un medicamento es médicamente necesario, el Los médicos deben respetar esta PDL al realizar médico puede enviar por fax una solicitud de recetas para los pacientes que tienen cobertura autorización previa a UnitedHealthcare Community mediante su plan de beneficios de farmacia Plan al 1-866-940-7328 . ofrecido por UnitedHealthcare Community Plan . Si un farmacéutico recibe una receta para un medicamento que no está incluido en la PDL, debe Limitaciones de Cantidad (QL) comunicarse con el médico que realizó la receta Las recetas para cantidades mensuales que y solicitarle que cambie el medicamento por uno superen el límite indicado requieren de una que esté incluido en la PDL . Si una alternativa de solicitud de autorización previa . la PDL no es adecuada, debe indicarse al médico que se comunique con el plan para solicitar una Límites de cantidad basados en la autorización previa . dosificación de medicamentos eficaces El Programa de dosificación de medicamentos Comuníquese con el Servicio de Notificación eficaces está diseñado para consolidar la Previa de Farmacia de UnitedHealthcare dosificación del medicamento a la cantidad diaria Community Plan al 1-800-310-6826 si tiene más eficaz, para aumentar el seguimiento del preguntas relacionadas con el proceso de tratamiento y también promover el uso eficaz del autorización previa . dinero invertido en la atención médica . Sustituciones de Suministros Los límites del programa se establecen conforme a la aprobación de la FDA en cuanto a la Temporales de 5 Días de dosificación y la disponibilidad de la dosis diaria Medicamentos Que No Están total con la menor cantidad de comprimidos o Incluidos en la PDL cápsulas diarias . Los límites de cantidad en el sistema de procesamiento de reclamaciones de Para garantizar el uso de medicamentos incluidos recetas limitará la provisión para consolidar la en la PDL, debe consultar al médico que realiza la dosificación . El sistema de procesamiento de receta acerca de todos los medicamentos que no reclamaciones de farmacia indicará al farmacéutico están incluidos en la PDL . Si no puede hablar que solicite un nuevo pedido de receta del médico . con el médico de inmediato y necesita el xvi Las adiciones a la lista de medicamentos del todas las solicitudes dentro de las 24 horas y, si programa de nivel de cantidad (QL) se realizarán se autoriza el pago, UnitedHealthcare Community de vez en cuando y se notificará a los proveedores Plan coordinará la entrega del producto al miembro al respecto . Como siempre, reconocemos que o proveedor . deben tenerse en cuenta diversas variables específicas del paciente cuando se indica un Los siguientes medicamentos o clases de tratamiento con medicamentos y, por consiguiente, medicamentos están incluidos en el programa: las sustituciones estarán disponibles a través del Lista de medicamentos del Programa de proceso de excepción médica (PA) . Comuníquese productos farmacéuticos especiales con el Servicio de Notificación Previa de Farmacia de UnitedHealthcare Community Plan Arcalyst al 1-800-310-6826 si tiene preguntas . Factores estimulantes de colonias (Neulasta, Neupogen, Leukine) Sustancias controladas Agentes para la fibrosis quística (Pulmozyme, Puede surtirse con cualquiera de los CUATRO TOBI, Kalydeco) medicamentos de las siguientes clases en un Agentes estimulantes de la eritrocitopoyesis período de 30 días: (Aranesp, Epogen, Procrit) Exjade • analgésicos opioides Forteo • benzodiazepinas Fuzeon • agentes sedantes hipnóticos Hormonas de crecimiento (Tev-Tropin, Omnitrope) Angioedema heredetario (Firazyr, Berinert) • barbitúricos Tratamiento para la hepatitis C (Peg-Intron, Pegasys, • algunos relajantes musculares . Pegasys Proclick, Infergen, Ribavirin, Incivek) Los surtidos adicionales requieren de autorización Ilaris previa . Los medicamentos de estas clases Increlex también pueden estar sujetos a los límites Interferones (Intron A, Pegasys, Sylatron) de cantidad individuales . Korlym Kuvan Programa de administración de productos Lovenox (*Medicamento especializado para farmacéuticos especiales cantidades superiores a los 14 días) UnitedHealthcare Community Plan busca Lupron continuamente formas de ofrecer una atención Mozobil asequible de alta calidad para los miembros Agentes para la esclerosis múltiple (Avonex, del plan . El Programa de administración de Avonex Pen, Copaxone, Rebif) productos farmacéuticos especiales ayuda a Neumega UnitedHealthcare Community Plan a lograr estos Quimoterapia oral (Oforta, Xeloda, Zolinza, objetivos . Los medicamentos inyectables que Afinitor, Gleevec, Nexavar, Sprycel, Sutent, forman parte de este programa requieren de la Tarceva, Tasigna, Tykerb, Vandetanib, Votrient, autorización del plan y no están disponibles a Temodar, Xalkori, Zelboraf, Zytiga, Erivedge, través de la red de farmacias minoristas . Para Jakafi, Inlyta) obtener la autorización, el proveedor debe Hipertensión arterial pulmonar (Adcirca, Revatio, enviar por fax el formulario de autorización Letairis, Tracleer) previa correspondiente al Departamento de Promacta Farmacia de UnitedHealthcare Community Plan al Revlimid 1-866-940-7328 . El Departamento de Farmacia Agentes para la artritis reumatoide de UnitedHealthcare Community Plan revisará (Enbrel, Humira, Cimzia)

xvii Sabril Medicamento Agentes de primera línea Xenazine para TERAPIA Xolair ESCALONADA Los medicamentos que forman parte de este Amerge Estudio con dosis mínima programa y están incluidos en la PDL están de 50 mg de comprimidos identificados en este folleto mediante la de sumatriptán . designación “SP” . Aricept 23mg Estudio de 90 días de Los formularios de solicitud de autorización previa Aricept de 10 mg diario pueden solicitarse llamando al Departamento de Farmacia de UnitedHealthcare Community Plan al atorvastatin Se requiere primero un 1-800-310-6826 . estudio de 90 días de simvastatin 40mg dentro Terapia Escalonada de los 180 días anteriores . (Step Therapy, ST) Banzel Estudio de 30 días de Los siguientes medicamentos de la PDL se dos de los siguientes cubren rutinariamente solo después de un medicamentos: lamotrigina, estudio suficiente de un agente de primera línea divalproex o topiramato . indicado que se haya estudiado adecuadamente Cymbalta Estudio de dos meses y se haya desaprobado . Estos medicamentos como mínimo de dos también pueden solicitarse a través del proceso de antidepresivos genéricos autorización previa . de la PDL en los 6 meses Si bien las alternativas de menor costo que se previos . incluyen en la PDL pueden ser apropiadas en muchos casos, otras alternativas que no se Ditropan XL Estudio de 30 días de incluyen en la PDL se encuentran disponibles oxibutinina de liberación con autorización previa (prior authorization, PA) . inmediata . La terapia escalonada solo se aplica a los miembros menores Medicamento Agentes de primera línea de 65 años . para TERAPIA ESCALONADA Inhibidores de Estudio de al menos Abilify Estudio de 30 días de DPP4 (Januvia, 90 días de 1500 mg/día uno de los siguientes Janumet, de metformina . medicamentos: risperidone, Janumet XR) quetiapine, ziprasidone, olanzapine . Dulera Estudio de 30 días de corticosteroide inhalado . Advair Estudio de 30 días de corticosteroide inhalado o Elidel Estudio de dos estudio de 60 días corticosteroides tópicos de un betaagonista de diferentes . La terapia efecto prolongado con escalonada solo se aplica un anticolinérgico . a los miembros mayores de 12 años .

xviii Medicamento Agentes de primera línea Medicamento Agentes de primera línea para TERAPIA para TERAPIA ESCALONADA ESCALONADA Fenofibrato Surtido de una estatina o 90 Nucynta ER Estudio de 30 días de por días de Gemfibrozil dentro lo menos 200mg diario de de los 180 días previos . sulfato de morfina ER . Parches de Estudio de 30 días de al fentanilo menos 200 mg por día de Onfi Periodo de aprobación sulfato de morfina ER . de 30 días para dos de los siguientes medicamentos: Gabitril Periodo de aprobación de lamotrigine, divalproex 30 días para dos de los o topiramate . siguientes medicamentos: lamotrigine, topiramate, Opana ER Estudio de 30 días de al carbamazepine, divalproex menos 200 mg por día de o phenytoin . La terapia sulfato de morfina ER . escalonada normalmente se aplica solamente para los miembros mayores de 12 Potiga Periodo de aprobación de años . Se requiere de previa 30 días para dos de los autorización cuando esta siguientes medicamentos: terapia es para miembros lamotrigine, topiramate, menores de 12 años . carbamazepine, divalproex o phenytoin . La terapia Intuniv Estudio de 30 días de escalonada normalmente se uno de los siguientes aplica solamente para los medicamentos: miembros mayores de 18 metilfenidato, metilfenidato años . Se requiere de previa SR, Concerta, sales de autorización cuando esta anfetamina, Adderall terapia es para miembros XR, dextroanfetamina o menores de 18 años . dextroanfetamina SA . Pristiq Estudio de 60 días de SSRI, Lansoprazol/ Primero se requiere venlafaxina, mirtazapina, Prevacid OTC un estudio de 30 días bupropiona o bupropiona SR . de omeprazol 40 mg y pantoprazole 40 mg dentro Protopic 0.03% Estudio de dos de los 180 días previos . corticosteroides tópicos diferentes . La terapia levocetirizine Estudio de 30 días de escalonada solo se aplica loratadine y cetirizine . a los miembros de 12 años o mayor . Maxalt/MLT Estudio con dosis mínima Protopic 0.1% Edad mínimo de 16 . Estudio de 50 mg de comprimidos de dos corticosteroides de sumatriptán . tópicos diferentes .

xix Medicamento Agentes de primera línea Medicamento Agentes de primera línea para TERAPIA para TERAPIA ESCALONADA ESCALONADA Ranexa Estudio de un medicamento Tiazolidinedionas Estudio de al menos de las siguientes (Actos, 90 días de 1500 mg/día categorías: bloqueadores ActosPlusMet, de metformina . beta, antagonistas del ActoPlusMet XR calcio, nitratos de acción Duetact) prolongada . Uloric Primero se requiere un Renvela Estudio de 8 semanas de estudio de 8 semanas de acetato de calcio . hasta 600 mg de alopurinol . Singulair Estudio de 60 días de Vancocin Un surtido de comprimidos corticosteroide inhalado o cápsulas de metronidazol . preferido o estudio de 30 días de loratadina o Vimpat Periodo de aprobación de cetirizina con un esteroide 30 días para dos de los intranasal preferido . siguientes medicamentos: lamotrigine, topiramate, Strattera Estudio de 30 días de carbamazepine, divalproex uno de los siguientes o phenytoin . La terapia medicamentos: escalonada normalmente se metilfenidato, metilfenidato aplica solamente para los SR, Concerta, sales de miembros mayores de 17 anfetamina, Adderall años . Se requiere de previa XR, dextroanfetamina o autorización cuando esta dextroanfetamina SA . terapia es para miembros menores de 17 años . Symbicort Estudio de 30 días de corticosteroide inhalado Vytorin Primero se requiere un o estudio de 60 días estudio de 90 días de de un beta-agonista de simvastatina 80 mg acción prolongada con un dentro de los 180 anticolinérgico . días previos . tolterodine Estudio de 30 días de Xopenex Estudio de 30 días de oxibutinina de liberación Respules Albuterol 0 .83% o 0 .5% inmediata . La terapia de Respules . escalonada solo se aplica a los miembros menores de 65 años . trospium Estudio de 30 días de oxibutinina de liberación inmediata . La terapia escalonada solo se aplica a los miembros menores de 65 años . xx Sugerencias Sobre la PDL Leyenda Los proveedores que deseen hacer sugerencias # Solo las concentraciones o sobre la PDL deben enviar la información por formas de dosificación de los correo o fax al Director de Servicios de Farmacia productos de marca indicados de UnitedHealthcare Community Plan . están incluidas en la PDL . Attn: Director of Pharmacy Services OTC de venta libre UnitedHealthcare Community Plan 1001 Brinton Road negrita indica la disponibilidad de Pittsburgh, PA 15221 medicamentos genéricos; es Fax: 1-866-940-7328 posible que la letra en negrita no se aplique a cada concentración Los proveedores deben proporcionar la o forma de dosificación según el documentación adecuada, como los estudios nombre genérico incluido . clínicos de la literatura médica, para que la solicitud sea considerada para la inclusión en la PDL . Esta delayed-rel liberación ret liberación retardada literatura debe incluir información que documente la (también conocido como necesidad clínica así como las ventajas terapéuticas recubrimiento entérico) por sobre los productos actuales incluidos en la PDL . EC recubrimiento entérico Las sugerencias recibidas por UnitedHealthcare Community Plan serán revisadas por el Comité de ext-rel liberación prolongada Farmacia y Terapéutica en la reunión subsiguiente del (también conocida como comité . liberación sostenida) Editor PA Autorización previa requerida Se alienta a que realice sus comentarios QL Se aplican límites de cantidad y sugerencias relacionados con la PDL de UnitedHealthcare Community Plan . Su comentario ST Terapia escalonada, ver páginas es muy importante para el éxito continuo de la xviii - xx para obtener detalles PDL . Todas las respuestas serán revisadas y SP Productos farmacéuticos tomadas en cuenta . Envíe sus comentarios a: especiales, ver página xvii para UnitedHealthcare Community Plan obtener detalles 1001 Brinton Road Pittsburgh, PA 15221 Fax: 1-866-940-7328

xxi Aviso La información incluida en este documento es privada . La información no puede ser copiada total o parcialmente sin el permiso escrito de UnitedHealthcare Community Plan . Todos los derechos reservados .

Los nombres de los medicamentos incluidos aquí son marcas comerciales registradas y no registradas de compañías farmacéuticas de terceros no relacionadas ni afiliadas a UnitedHealthcare Community Plan . Estas marcas comerciales registradas se incluyen aquí con fines informativos solamente y no tienen la finalidad de denotar ni sugerir afiliación entre Evercare y dichas compañías farmacéuticas de terceros .

Si ve esta PDL por Internet, tenga en cuenta que la misma se actualiza periódicamente y es posible que se incluyan cambios antes de la fecha de vigencia para permitir su notificación .

xxii Table of Contents

ANTINEOPLASTICS & IMMUNOSUPPRESSANTS ...... 1 HORMONAL ANTINEOPLASTIC AGENTS ...... 1 ORAL AGENTS ...... 1. . . . . IMMUNOSUPPRESSANTS ...... 2. . . . IMMUNOMODULATORS ...... 3 . . . . MISCELLANEOUS ...... 3. . . . . BLOOD MODIFIERS 3 ORAL ...... 3 . . . . . BLOOD CELL FORMATION ...... 3. . . . PLATELET SYNTHESIS INHIBITOR ...... 3 MISCELLANEOUS ...... 4. . . . . PLATELET AGGREGATION INHIBITORS ...... 4 . . . CARDIOVASCULAR AGENTS ...... 4 ACE INHIBITORS ...... 4 ACE INHIBITOR/DIURETIC COMBINATIONS ...... 4 ADRENOLYTICS, CENTRAL ...... 5. . . . ALPHA BLOCKERS ...... 5 . . . . ANGIOTENSIN II RECEPTOR BLOCKERS (ANTAGONISTS) ...... 5 . . . ANGIOTENSIN II RECEPTOR BLOCKER COMBINATIONS ...... 5 ANTIARRHYTHMICS AND CARDIAC GLYCOSIDES ...... 5. . . BETA BLOCKERS AND BETA BLOCKER/DIURETIC COMBINATIONS ...... 6. . . CALCIUM CHANNEL BLOCKERS ...... 6 . . . . DIURETICS ...... 7 . . . . HEART FAILURE ...... 7 . . . . NITRATES ...... 7. . . . . LIPID LOWERING AGENTS ...... 8 MISCELLANEOUS ...... 8. . . . . CENTRAL NERVOUS SYSTEM ...... 9 ALZHEIMER’S DISEASE ...... 9 . . . . ANALGESICS ...... 9 . . . . . MIGRAINE ...... 10 ABORTIVE THERAPY ...... 11 PROPHYLACTIC THERAPY ...... 11 MULTIPLE SCLEROSIS ...... 11 . . . . MYASTHENIA GRAVIS ...... 11 . . . . PARKINSON’S DISEASE ...... 11 SEIZURES ...... 12 . . . . . MISCELLANEOUS ...... 12 . . . . DERMATOLOGY ...... 13 ACNE VULGARIS ...... 13 BACTERIAL INFECTIONS ...... 13. . . . . CORTICOSTEROIDS ...... 13 . . . . FUNGAL INFECTIONS ...... 14 . . . . PSORIASIS ...... 15. . . . . ROSACEA ...... 15 . . . . . SCABIES AND PEDICULOSIS ...... 15 . . . . VIRAL INFECTIONS ...... 15 MISCELLANEOUS ...... 15 . . . . EAR, NOSE & THROAT 16 EAR ...... 16. . . . . NOSE ...... 16 . . . . . MISCELLANEOUS NASAL ...... 17 THROAT AND MOUTH ...... 17 . . . . ENDOCRINOLOGY 17 ADRENAL CORTICOSTEROIDS ...... 17. . . . ANDROGENS ...... 18 . . . . DIABETES MELLITUS ...... 18 . . . . GROWTH STIMULATING AGENTS ...... 19 OSTEOPOROSIS ...... 19 . . . . THYROID DISEASE ...... 20 MISCELLANEOUS ...... 20 . . . . GASTROINTESTINAL ...... 20 DIARRHEA ...... 20 EMESIS ...... 20 GASTROESOPHAGEAL REFLUX DISEASE (GERD)/ PEPTIC ULCERS ...... 21 GASTROINTESTINAL SPASM ...... 21. . . . INFLAMMATORY BOWEL DISEASE ...... 21 . . . . PANCREATIC ENZYMES ...... 22 LAXATIVES ...... 22 PROBIOTIC SUPPLEMENTATION ...... 22. . . . MISCELLANEOUS ...... 22 . . . . INFECTIOUS DISEASES ...... 23 ANTIBACTERIALS ...... 23 ANTIFUNGALS ...... 24 . . . . . ANTIVIRALS ...... 24. . . . . MISCELLANEOUS ...... 26 . . . . MUSCULOSKELETAL ...... 27 ARTHRITIS ...... 27 GOUT ...... 27 SKELETAL MUSCLE RELAXANTS ...... 28 OB-GYN ...... 28 CONTRACEPTIVES ...... 28 ENDOMETRIOSIS ...... 29 . . . . HORMONE THERAPY/MENOPAUSE ...... 30. . . . VAGINAL INFECTIONS ...... 30 MISCELLANEOUS ...... 31 . . . . OPHTHALMIC 31 ALLERGY ...... 31 ANTI-INFLAMMATORIES ...... 31 GLAUCOMA ...... 32. . . . . INFECTIONS ...... 33 MISCELLANEOUS OPHTHALMICS ...... 33 . . . . PSYCHIATRIC 33 ALCOHOL DETERRENTS ...... 33. . . . . ANXIETY ...... 33. . . . . MISCELLANEOUS ...... 34 . . . . ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) ...... 34. . . BIPOLAR DISORDER ...... 34 . . . . DEPRESSION ...... 34 INSOMNIA ...... 35 . . . . . NARCOTIC ANTAGONISTS ...... 36 . . . . SMOKING CESSATION ...... 36 . . . . PSYCHOSES ...... 36 . . . . MISCELLANEOUS ...... 36 . . . . RESPIRATORY DRUGS ...... 37 ANTITUSSIVES, DECONGESTANTS, EXPECTORANTS AND COMBINATIONS ...... 37 . . ASTHMA/COPD ...... 40. . . . . SUPPLEMENTS ...... 41 POTASSIUM ...... 41. . . . . POTASSIUM-REMOVING AGENTS ...... 41 VITAMINS AND MINERALS ...... 41 . . . . UROLOGICAL 43 SYMPTOMATIC BENIGN PROSTATIC HYPERTROPHY ...... 43. . . MISCELLANEOUS ...... 43 . . . . HOME INFUSION DRUGS ...... 43 ANALGESICS - NSAIDS ...... 43 . . . . ANALGESICS - OPIOD ...... 44 ANTIBIOTICS ...... 44 . . . . ANTIHISTAMINES ...... 44 DIURETICS ...... 44 ELECTROLYTE MIXTURES ...... 44 GENITOURINARY IRRIGANTS ...... 45 . . . . MINERALS & ELECTROLYTES ...... 45 NUTRIENTS ...... 45. . . . . VITAMINS ...... 45 MISCELLANEOUS ...... 45 ANAPHYLAXIS ...... 45 . . . . . CYSTIC FIBROSIS ...... 45 . . . . HEREDITARY ANGIOEDEMA ...... 45. . . . HYPERPHOSPHATEMIA ...... 46 IMMUNE THROMBOCYTOPENIC PURPURA ...... 46 MEDICAL DEVICES ...... 46. . . . . OTC MEDICATIONS ...... 47 WEBSITES ...... 51 INDEX 53 ANTINEOPLASTICS & IMMUNOSUPPRESSANTS Many oral antineoplastics and oral immunosuppressants are on the PDL . The most common products are listed below . Additional agents may also be covered, please check with the plan .

HORMONAL ANTINEOPLASTIC AGENTS

Androgen Biosynthesis Inhibitors

abiraterone PA SP ZYTIGA

Antiandrogens

bicalutamide CASODEX flutamide EULEXIN

Antiestrogens

tamoxifen NOLVADEX toremifene FARESTON

Aromatase Inhibitors

anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA

Progestin

megestrol acetate MEGACE

ORAL AGENTS

Alkylating Agents

busulfan MYLERAN chlorambucil LUEKERAN cyclophosphamide CYTOXAN estramustine phosphate sodium EMCYT lomustine CEENU melphalan ALKERAN temozolomide PA SP TEMODAR

Antimetabolites

capecitabine PA SP XELODA fludarabine PA SP OFORTA mercaptopurine PURINETHOL thioguanine THIOGUANINE

1 Tyrosine Kinase Inhibitor

axitinib PA SP INLYTA crizotinib PA SP XALKORI dasatanib PA SP SPRYCEL erlotinib PA SP TARCEVA imatinib mesylate PA QL SP GLEEVEC lapatinib ditosylate PA SP TYKERB nilotinib PA SP TASIGNA pazopanib PA SP VOTRIENT ruxolitinib PA SP JAKAFI sorafenib PA SP NEXAVAR sunitinib PA SP SUTENT vandetanib PA SP VANDETANIB vemurafenib PA SP ZELBORAF

Miscellaneous

altretamine HEXALEN bexarotene TARGRETIN etoposide VEPESID everolimus PA SP AFINITOR hydroxyurea DROXIA HYDREA mitotane LYSODREN octreotide SANDOSTATIN procarbazine MATULANE tretinoin caps VESANOID vismodegib PA SP ERIVEDGE vorinostat PA SP ZOLINZA

IMMUNOSUPPRESSANTS

Antimetabolites

azathioprine IMURAN mycophenolate mofetil CELLCEPT mycophenolate sodium MYFORTIC

Calcineurin Inhibitors

cyclosporine SANDIMMUNE cyclosporine, modified NEORAL GENGRAF tacrolimus HECORIA PROGRAF

2 Other

everolimus ZORTRESS

Rapamycin Derivative

sirolimus RAPAMUNE

IMMUNOMODULATORS

Interferons

interferon alfa-2a PA SP interferon alfa-2b PA SP INTRON A

Other

lenalidomide PA SP REVLIMID

MISCELLANEOUS

leuprolide PA SP LUPRON LUPRON DEPOT LUPRON DEPOT 6-MONTH LUPRON DEPOT-PED

BLOOD MODIFIERS ANTICOAGULANTS

ORAL

warfarin COUMADIN

BLOOD CELL FORMATION

darbepoetin alfa PA SP ARANESP epoetin alfa PA SP EPOGEN PROCRIT filgrastimPA SP NEUPOGEN oprelvekin SP NEUMEGA pegfilgrastimPA SP NEULASTA sargramostim PA SP LEUKINE

PLATELET SYNTHESIS INHIBITOR

anagrelide AGRYLIN

3 MISCELLANEOUS

aminocaproic acid (500 mg tabs only) AMICAR cilostazol PLETAL deferasirox PA SP EXJADE enoxaparin* QL PA SP LOVENOX heparin HEPARIN pentoxifylline ext-rel TRENTAL plerixafor PA SP MOZOBIL rivaroxaban PA XARELTO

*SP and PA only applies for quantities greater than 14 days

PLATELET AGGREGATION INHIBITORS — www.chestjournal.org

The American College of Cardiology and American Heart Association guidelines recommend that in an evolving MI, aspirin, at a dose of at least 162 mg, should be taken to achieve an immediate clinical antithrombotic effect .

aspirin OTC BAYER ECOTRIN clopidogrel QL (applies to 300 mg tab only) PLAVIX dipyridamole PERSANTINE

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

ACE INHIBITORS

Guidelines for the use of ACE inhibitors are available at: www.acc.org, www.americanheart.org, www.diabetes.org, www.nhlbi.nih.gov and www.nhlbi.nih.gov/guidelines/hypertension/index.htm

Potassium supplements and salt substitutes should be given cautiously, if at all, with ACE inhibitors . The antihypertensive effect of ACE inhibitors may be diminished when given in combination with a NSAID .

benazepril LOTENSIN captopril CAPOTEN enalapril VASOTEC fosinopril QL MONOPRIL lisinopril QL ZESTRIL quinapril QL ACCUPRIL

ACE INHIBITOR/DIURETIC COMBINATIONS

benazepril/hydrochlorothiazide LOTENSIN HCT captopril/hydrochlorothiazide CAPOZIDE enalapril/hydrochlorothiazide VASERETIC

4 fosinopril/hydrochlorothiazide QL MONOPRIL-HCT lisinopril/hydrochlorothiazide QL ZESTORETIC quinapril/hydrochlorothiazide QL ACCURETIC

ADRENOLYTICS, CENTRAL

clonidine CATAPRES clonidine transdermal CATAPRES-TTS guanfacine TENEX

ALPHA BLOCKERS

Guidelines for the use of alpha blockers in various populations are available at: www.nhlbi.nih.gov/guidelines/hypertension/index.htm.

The National Heart, Lung and Blood Institute recommends that alpha-1 blockers not be used as initial therapy in the management of hypertension, based upon the result of the ALLHAT study .

doxazosin CARDURA prazosin MINIPRESS terazosin HYTRIN

ANGIOTENSIN II RECEPTOR BLOCKERS (ANTAGONISTS)

Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: www.diabetes.org, www.nhlbi.nih.gov and www.nhlbi.nih.gov/guidelines/hypertension/index.htm

losartan QL COZAAR

ANGIOTENSIN II RECEPTOR BLOCKER COMBINATIONS

losartan/HCTZ QL HYZAAR

ANTIARRHYTHMICS AND CARDIAC GLYCOSIDES

Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: www.acc.org/clinical/topic/topic.htm#guidelines, www.acc.org/clinical/guidelines/atrial_fib/af_index.htm and www.aafp.org/x25474.xml

Proarrhythmic effects can be dose-dependent or idiosyncratic . Therapeutic drug monitoring should be performed for patients treated with digoxin in order to minimize the risk of dose-dependent toxicity .

Patients receiving digoxin should be monitored due to potential drug interactions (e .g ., quinidine, verapamil, or erythromycin) as well as in numerous clinical situations (e g. ., renal dysfunction or electrolyte abnormalities) in older adults .

amiodarone CORDARONE digoxin LANOXIN digoxin LANOXICAPS

5 disopyramide NORPACE disopyramide ext-rel NORPACE CR dofetilide TIKOSYN flecainide TAMBOCOR mexiletine MEXITIL moricizine ETHMOZINE procainamide PRONESTYL procainamide ext-rel PROCANBID procainamide ext-rel PROCAINAMIDE EXT-REL propafenone (IR only) RYTHMOL quinidine gluconate ext-rel QUINIDINE GLUCONATE EXT-REL quinidine sulfate QUINIDINE SULFATE quinidine sulfate ext-rel QUINIDINE SULFATE EXT-REL sotalol BETAPACE

BETA BLOCKERS AND BETA BLOCKER/DIURETIC COMBINATIONS

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

All beta blockers may increase bronchial airway resistance, although this effect is less with cardioselective beta blockers .

When discontinuation of a beta blocker is planned, it is recommended that the dosage of the beta blocker be tapered over 7-14 days .

acebutalol SECTRAL atenolol TENORMIN atenolol/chlorthalidone TENORETIC bisoprolol ZEBETA bisoprolol/hydrochlorothiazide ZIAC carvedilol QL COREG labetalol TRANDATE metoprolol 50 mg and 100 mg only LOPRESSOR metoprolol succinate TOPROL XL nadolol CORGARD pindolol PINDOLOL propranolol (IR only) INDERAL propranolol/HCTZ INDERIDE timolol maleate tablets

CALCIUM CHANNEL BLOCKERS

Dihydropyridines

amlodipine QL NORVASC felodipine ext-rel QL PLENDIL nicardipine CARDENE nifedipine PROCARDIA

6 nifedipine ext-rel QL ADALAT CC PROCARDIA XL nimodipine QL NIMOTOP

Nondihydropyridines

diltiazem CARDIZEM diltiazem ext release QL CARDIZEM CD diltiazem sustained release QL CARDIZEM SR diltiazem ext-rel QL DILACOR XR TIAZAC verapamil CALAN verapamil ext-rel QL (applies to 120 mg only) CALAN SR

DIURETICS — www.acc.org and www.nhlbi.nih.gov

amiloride MIDAMOR amiloride/hydrochlorothiazide MODURETIC bumetanide BUMEX chlorothiazide DIURIL chlorthalidone CHLORTHALIDONE furosemide LASIX hydrochlorothiazide 12 .5 mg caps MICROZIDE hydrochlorothiazide soln, tabs HYDROCHLOROTHIAZIDE indapamide LOZOL metolazone ZAROXOLYN spironolactone ALDACTONE spironolactone/hydrochlorothiazide ALDACTAZIDE triamterene/hydrochlorothiazide 37 .5/25 DYAZIDE triamterene/hydrochlorothiazide 37 .5/25 MAXZIDE-25 triamterene/hydrochlorothiazide 50/25 DYAZIDE triamterene/hydrochlorothiazide 75/50 MAXZIDE

HEART FAILURE

Guidelines for the evaluation and management of chronic heart failure in adults are available at: www.acc.org, www.americanheart.org and www.hfsa.org

NITRATES

Oral

isosorbide dinitrate ext-rel ISOSORBIDE DINITRATE ER isosorbide dinitrate ISORDIL isosorbide mononitrate ISMO isosorbide mononitrate ext-rel IMDUR nitroglycerin ext-rel

7 Sublingual

isosorbide dinitrate ISORDIL S .L . nitroglycerin NITROSTAT nitroglycerin NITROLINGUAL

Transdermal

nitroglycerin oint NITRO-BID nitroglycerin transdermal QL NITREK NITRO-DUR niacin NIACOR niacin ext-rel NIASPAN

LIPID LOWERING AGENTS

Guidelines for the use of lipid lowering agents in various patient populations are available at: www.nhlbi.nih.gov

Bile Acid Resin

cholestyramine* QUESTRAN QUESTRAN-LIGHT

Fibrates

fenofibrateST LOFIBRA gemfibrozil LOPID

HMG-CoA Reductase Inhibitors and Combinations

atorvastatin ST LIPITOR ezetimibe/simvastatin ST VYTORIN lovastatin QL MEVACOR pravastatin QL PRAVACHOL simvastatin QL ZOCOR simvastatin/niacin ER SIMCOR

*Only the bulk products are covered (cans). Individual packets are not covered.

MISCELLANEOUS

ambrisentan PA SP LETAIRIS bosentan PA SP TRACLEER guanabenz WYTENSIN hydralazine APRESOLINE methyldopa ALDOMET methyldopa/HCTZ ALDORIL midodrine PROAMATINE minoxidil LONITEN

8 ranolazine ST RANEXA sildenafilPA REVATIO tadalafilPA SP ADCIRCA

CENTRAL NERVOUS SYSTEM

ALZHEIMER’S DISEASE

donepezil 5mg and 10mg QL ARICEPT donepezil 23mg ST ARICEPT galantamine QL RAZADYNE memantine QL NAMENDA rivastigmine QL EXELON

ANALGESICS

Practice guidelines of pain management are available at: www.asahq.org

Analgesic, Other

acetaminophen OTC TYLENOL aspirin/acetaminophen/caffeine 250-250-65 mg OTC EXCEDRIN MIGRAINE tramadol QL ULTRAM

Miscellaneous Non-Narcotic analgesics

butalbital/acetaminophen QL PHRENILIN butalbital/acetaminophen QL SEDAPAP butalbital/acetaminophen/caffeine QL FIORICET butalbital/aspirin/caffeine QL FIORINAL

NSAIDS

choline magnesium trisalicylate TRILISATE diclofenac sodium delayed release VOLTAREN etodolac (IR Only) LODINE fenoprofen 600 mg NALFON ibuprofen* OTC ADVIL ibuprofen* MOTRIN indomethacin INDOCIN ketoprofen (IR only) ORUDIS ketorolac tromethamine QL TORADOL meloxicam QL MOBIC naproxen (Not EC) NAPROSYN naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL *tabs, chew tabs and susp

9 Opioids — Narcotic analgesics Practice guidelines for cancer pain management (includes WHO analgesic ladder) are available at: www.asahq.org

The total dose of acetaminophen should not exceed 4 g per day in adults . Patients should be monitored for use of concomitant non-prescription pain/fever products containing acetaminophen .

butalbital/apap/caff/cod QL FIORICET W/CODEINE butalbital/asa/caff/cod QL FIORINAL W/CODEINE butorphanol nasal spray QL STADOL codeine sulfate QL codeine/acetaminophen QL TYLENOL W/CODEINE fentanyl transdermal QL ST DURAGESIC hydrocodone/acetaminophen NORCO 5/325, 7 .5/325, 10/325 QL hydrocodone/acetaminophen QL LORTAB ELIXIR hydrocodone/acetaminophen 2 .5/500 QL LORTAB 2 .5/500 hydrocodone/acetaminophen 5/500 QL LORTAB 5/500 BANCAP HC, VICODIN 5/500 hydrocodone/acetaminophen 7 .5/500 QL LORTAB 7 .5/500 hydrocodone/acetaminophen 7 .5/650 QL LORCET PLUS hydrocodone/acetaminophen 7 .5/750 QL VICODIN ES hydrocodone/acetaminophen 10/500 QL LORTAB 10/500 hydrocodone/acetaminophen 10/650 QL LORCET 10/650 hydromorphone QL DILAUDID meperidine QL DEMEROL methadone tablets PA QL morphine QL MSIR morphine QL RMS morphine ext-rel QL MS CONTIN oxycodone QL (5 mg, 15 mg and 30 mg) OXY IR oxycodone QL ROXICODONE oxycodone ER QL ST OXYCONTIN oxycodone/acetaminophen 5/325 QL PERCOCET oxycodone/acetaminophen 5/500 QL TYLOX oxycodone/aspirin QL PERCODAN oxycodone soln QL OXYFAST oxymorphone QL ST OPANA ER pentazocine/naloxone QL TALWI N NX tapentadol ER ST NUCYNTA ER

MIGRAINE

Guidelines for prevention of migraine headaches are available at: www.achenet.org, www.headaches.org/professional/ linksindex.html and www.aan.com/professionals/practice/index.cmf

10 ABORTIVE THERAPY

Ergotamine Derivatives

dihydroergotamine inj QL D .H .E . 45 dihydroergotamine MIGRANAL ergotamine/caffeine CAFERGOT

Selective Serotonin Agonists

naratriptan ST AMERGE rizatriptan QL ST MAXALT/MAXALT MLT sumatriptan QL IMITREX

PROPHYLACTIC THERAPY

amitriptyline ELAVIL divalproex sodium delayed-rel (Minimum age 2) DEPAKOTE divalproex sodium ext-rel QL DEPAKOTE ER propranolol (IR only) INDERAL verapamil CALAN

MULTIPLE SCLEROSIS

glatiramer acetate PA QL SP COPAXONE interferon beta-1a PA QL SP AVONEX/AVONEX PEN interferon beta-1a PA QL SP REBIF

MYASTHENIA GRAVIS

pyridostigmine MESTINON pyridostigmine ext-rel MESTINON TIMESPAN

PARKINSON’S DISEASE

amantadine (except tabs) SYMMETREL benztropine COGENTIN biperiden AKINETON bromocriptine PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel SINEMET CR entacapone COMTAN pramipexole MIRAPEX ropinirole REQUIP rotigotine NEUPRO

11 selegiline tabs ELDEPRYL tolcapone TASMAR trihexyphenidyl ARTANE

SEIZURES

carbamazepine TEGRETOL carbamazepine ext-rel CARBATROL TEGRETOL-XR clobazam ST ONFI clonazepam tabs KLONOPIN diazepam rectal gel QL DIASTAT ACUDIAL divalproex sodium delayed-rel (Minimum age 2) DEPAKOTE divalproex sodium ext-rel QL DEPAKOTE ER ethosuximide ZARONTIN exogabine* ST POTIGA gabapentin (caps and tabs only) NEURONTIN lacosamide* ST VIMPAT lamotrigine QL LAMICTAL levetiracetam QL (Maximum age of 9 for solution) KEPPRA oxcarbazepine QL (Maximum age of 9 for solution) TRILEPTAL phenobarbital PHENOBARBITAL phenytoin DILANTIN INFATABS phenytoin sodium extended DILANTIN PHENYTEK pregabalin PA LY R I CA primidone MYSOLINE rufinamide(tablets only) QL ST BANZEL tiagabine* ST GABITRIL topiramate QL TOPAMAX valproic acid DEPAKENE vigabatrin PA SP SABRIL zonisamide QL ZONEGRAN

*Age Limits Apply

MISCELLANEOUS

tetrabenazine PA SP XENAZINE

12 DERMATOLOGY

ACNE VULGARIS

Guidelines for the care and treatment of acne vulgaris are available at: www.aadassociation.org

Oral

isotretinoin PA ACCUTANE

Topical

azelaic acid FINACEA benzoyl peroxide BENZAC AC clindamycin gel CLEOCIN T clindamycin lotion CLEOCIN T clindamycin soln CLEOCIN T erythromycin/benzoyl peroxide BENZAMYCIN erythromycin gel 2% ERYGEL erythromycin soln T-STAT sulfacetamide SULFACET-R sulfacetamide/sulfur PLEXION tretinoin* AVITA RETIN-A

*Max age 20

BACTERIAL INFECTIONS

bacitracin OTC BACITRACIN gentamicin GENTAK mupirocin ointment* BACTROBAN neomycin/polymyxin B/bacitracin OTC NEOSPORIN silver sulfadiazine SILVADENE

*22 gram tube only

CORTICOSTEROIDS

Guidelines of care for the use of topical corticosteroids are available at: www.aadassociation.org

Low Potency

alclometasone .05% crm/oint ACLOVATE desonide .05% crm/oint DESOWEN fluocinolone acetonide oil 0 .01% DERMA-SMOOTHE OIL/FS fluocinolone acetonidesoln/crm 0 .01% SYNALAR hydrocortisone crm 2 .5% HYTONE hydrocortisone 1% lotion HYTONE hydrocortisone crm, oint, lot OTC CORTIZONE

13 Medium Potency

betamethasone val. crm/oint/lotion 0 .1% BETA-VAL fluocinolone acetonidecrm, oint 0 .025% SYNALAR flurandrenolidelotion 0 .05% CORDRAN flurandrenolidetape CORDRAN fluticasone propionate crm 0 .05%, oint 0 .005% CUTIVATE hydrocortisone butyrate crm/oint/soln 0 .1% LOCOID mometasone furoate crm 0 .1% ELOCON mometasone furoate oint 0 .1% ELOCON prednicarbate crm/oint 0 .1% DERMATOP triamcinolone acetonide crm/lot/oint 0 .025% KENALOG triamcinolone acetonide crm/oint/lotion 0 .1% KENALOG

High Potency

betamethasone augmented dip crm 0 .05% DIPROLENE AF betamethasone augmented dip lotion 0 .05% DIPROLENE betamethasone dipropionate crm/lotion/oint 0 .05% fluocinonidecrm/oint/gel 0 .05% LIDEX fluocinonide emulsified basecrm 0 .05% LIDEX E triamcinolone acetonide crm 0 .5% KENALOG

Very High Potency

betamethasone dip augmented gel 0 .05% DIPROLENE betamethasone dip augmented oint 0 .05% DIPROLENE clobetasol propionate crm/gel/oint/soln 0 .05% TEMOVATE halobetasol propionate crm/oint 0 .05% ULTRAVATE

FUNGAL INFECTIONS

ciclopirox PENLAC SOLUTION 8% clotrimazole MYCELEX clotrimazole OTC LOTRIMIN AF clotrimazole with betamethasone LOTRISONE econazole SPECTAZOLE ketoconazole NIZORAL miconazole OTC MICATIN miconazole MONISTAT-DERM miconazole powder DESENEX POWDER 2% nystatin MYCOSTATIN nystatin/triamcinolone MYCOLOG-II terbinafine OTC LAMISIL AT tolnaftate OTC TINACTIN

14 PSORIASIS

Guidelines for the care of psoriasis are available at: www.aad.org

acitretin oral caps PA SORIATANE calcipotriene DOVONEX calcitriol VECTICAL methoxsalen OXSORALEN-ULTRA

ROSACEA

metronidazole METROCREAM METROGEL METROLOTION

SCABIES AND PEDICULOSIS

Information about the treatment of scabies and pediculosis is available at: www.cdc.gov

crotamiton EURAX malathion QL OVIDE permethrin 1% OTC NIX CREME RINSE permethrin 5% QL ELIMITE pyrethrins/piperonyl but. 4% OTC RID SHAMPOO/BUTOXIDE SHAMPOO

VIRAL INFECTIONS

podofilox sol CONDYLOX SOL salicylic acid 17%/collodion OTC DUOFILM

MISCELLANEOUS

aluminum acetate soln/cream OTC aluminum chloride hexahydrate HYPERCARE 20% ammonium lactate 12% LAC-HYDRIN calamine lotion/ointment OTC chloroxine CAPITROL fluorouracil EFUDEX fluorouracil0 .5% cream CARAC fluorouracil1% cream FLUOROPLEX hexachlorophene PHISOHEX hydrocortisone crm PROCTOCREAM-HC 2 .5% hydrocortisone crm 1% PROCTOCORT ketoconazole shampoo 2% NIZORAL SHAMPOO lidocaine 3% cream LIDAMANTEL lidocaine jelly 2% XYLOCAINE

15 lidocaine oint 5% XYLOCAINE lidocaine 4% cream (15 gm tubes) QL LMX-4 lidocaine/prilocaine 2 .5% cream EMLA pimecrolimus cream QL ST* ELIDEL selenium sulfideshampoo 2 .5% SELSUN tacrolimus ointment 0 .03% ST* PROTOPIC 0 .03% tacrolimus ointment 0 .1% ST (minimum age 16) PROTOPIC 0 .1% urea 40% cream and lotion UREA 40% CREAM AND LOTION

*Step therapy is not required for members ages 2-11; not covered for members less than 2 years of age EAR, NOSE & THROAT

EAR

acetic acid otic VOSOL OTIC acetic acid/aluminum acetate DOMEBORO OTIC acetic acid/hydrocortisone VOSOL HC OTIC benzocaine/antipyrine BENZOTIC carbamide peroxide 6 .5% OTC DEBROX ciprofloxacin/dexamethasonePA CIPRODEX neomycin/polymyxin B/hydrocortisone otic CORTISPORIN OTIC ofloxacin FLOXIN OTIC

NOSE — www.aaaai.org

Antihistamines First Generation, Sedating

chlorpheniramine OTC CHLOR-TRIMETON ALLERGY chlorpheniramine ext-rel OTC CHLOR-TRIMETON ALLERGY clemastine CLEMASTINE cyproheptadine CYPROHEPTADINE diphenhydramine OTC BENADRYL diphenhydramine hydroxyzine HCL ATARAX hydroxyzine pamoate VISTARIL

Second Generation, Nonsedating cetirizine OTC ZYRTEC levocetirizine tabs ST XYZAL loratadine OTC ALAVERT CLARITIN

Others

azelastine spray ASTELIN

16 Antihistamine/Decongestant Combinations First Generation chlorpheniramine/phenylephrine/ TRIOTANN pyrilamine chlorpheniramine/pseudoephedrine ext-rel DECONAMINE SR triprolidine/pseudoephedrine OTC ACTIFED

Second Generation cetirizine hydrochloride/pseudoephedrine ZYRTEC-D hydrochloride 12 hours extended -release 5 mg-120 mg tablet loratadine/pseudoephedrine ext-rel OTC ALAVERT-D ALAVERT ALRG TAB/SINUS ALLERY/CONG

Nasal Steroids

flunisolide fluticasone FLONASE

Miscellaneous Nasal Decongestants

oxymetazoline OTC AFRIN phenylephrine OTC NEO-SYNEPHRINE DIMEATAPP DRO DECONGES

MISCELLANEOUS NASAL

cromolyn sodium OTC NASALCROM saline nasal spray 0.65% OTC OCEAN NASAL SPRAY

THROAT AND MOUTH

artificial saliva OTC chlorhexidine gluconate PERIDEX lidocaine viscous XYLOCAINE pilocarpine SALAGEN triamcinolone paste KENALOG IN ORABASE

ENDOCRINOLOGY

ADRENAL CORTICOSTEROIDS

cortisone acetate dexamethasone DECADRON fludrocortisone FLORINEF hydrocortisone CORTEF

17 methylprednisolone MEDROL prednisolone prednisolone sodium phosphate ORAPRED PEDIAPRED prednisolone syrup PRELONE prednisone DELTASONE

ANDROGENS

testosterone cypionate DEPO-TESTOSTERONE testosterone gel PA ANDROGEL 1 .62% testosterone enanthate* DELATESTRYL testosterone patch 2 mg and 4 mg PA ANDRODERM

*Vials only. Disposable syringes not covered.

DIABETES MELLITUS

Guidelines of the treatment and management of diabetes are available at: www.diabetes.org

Glucose Elevating Agents

glucagon, human recombinant QL GLUCAGON

Insulins Insulin preparations covered include the specific brands of human insulins noted in the list . Only the vials are covered. The PDL also includes all syringes and needles .

insulin aspart QL NOVOLOG insulin aspart protamine 70%/insulin aspart 30% QL NOVOLOG MIX 70/30 insulin detemir QL LEVEMIR insulin glargine QL LANTUS insulin human OTC QL NOVOLIN R insulin human OTC QL RELION R insulin isophane human OTC QL NOVOLIN N insulin isophane human OTC QL RELION N insulin isophane human 70%/regular 30% OTC QL NOVOLIN 70/30 insulin isophane human 70%/regular 30% OTC QL RELION 70/30

Monitoring- Strips and Kits/Diabetic Supplies

ACCU-CHEK TEST STRIPS (ACTIVE, AVIVA, AVIVA PLUS, COMFORT CURVE, COMPACT, SMARTVIEW) QL# ACCU-CHEK CARE KIT (ACTIVE, AVIVA, COMPACT PLUS, NANO SMARTVIEW)* QL ONE TOUCH TEST STRIPS (BASIC/PROFILE, SURESTEP, ULTRA) QL# ONE TOUCH SYSTEMS (ULTRA, ULTRASMART, ULTRA2, ULTRAMINI)** QL *Direct from manufacturer, call 877-411-9833 **Direct from manufacturer, call 800-285-9814, Order Code: 596UHC100 #QL for non-insulin dependent members: allow once daily testing QL for insulin dependent or pregnant members: allow testing up to 6 times per day

18 Oral Agents

acarbose PRECOSE chlorpropamide DIABINESE glimepiride AMARYL glipizide GLUCOTROL glipizide ext-rel GLUCOTROL XL glyburide MICRONASE glyburide, micronized GLYNASE metformin GLUCOPHAGE metformin ER GLUCOPHAGE ER metformin/glyburide GLUCOVANCE nateglinide STARLIX pioglitazone QL ST ACTOS pioglitazone/metformin ER ST ACTOPLUS MET XR pioglitazone/metformin QL ST ACTOPLUSMET pioglitazone/glimiperide ST DUETACT repaglinide PRANDIN sitagliptan QL ST JANUVIA sitagliptan/metformin QL ST JANUMET sitagliptan/metformin ER QL ST JANUMET XR tolazamide TOLINASE tolbutamide TOLBUTAMIDE

Miscellaneous Antidiabetic Agents

exenatide PA BYETTA liraglutide PA VICTOZA pramlintide PA SYMLIN

GROWTH STIMULATING AGENTS

Guidelines for use of growth hormones are available at: www.aace.com

mecasermin PA SP INCRELEX somatropin PA SP OMNITROPE TEV-TROPIN

OSTEOPOROSIS

Guidelines of treatment and management of osteoporosis are available at: www.aace.org and www.nof.org

alendronate QL FOSAMAX calcitonin-salmon inj MIACALCIN calcitonin-salmon nasal spray QL MIACALCIN FORTICAL

19 etidronate DIDRONEL raloxifene EVISTA teriparatide inj PA SP FORTEO

THYROID DISEASE

levothyroxine LEVOXYL levothyroxine SYNTHROID liothyronine CYTOMEL liotrix THYROLAR methimazole TAPAZOLE propylthiouracil PROPYLTHIOURACIL thyroid ARMOUR THYROID

MISCELLANEOUS

bromocriptine PARLODEL desmopressin QL DDAVP methylergonovine METHERGINE mifeprstone PA SP KO R LY M sapropterin PA SP KUVAN

GASTROINTESTINAL

DIARRHEA

diphenoxylate/atropine LOMOTIL loperamide LOPERAMIDE loperamide OTC IMODIUM A-D

EMESIS

aprepitant (QL applies to 40mg, 80mg and 80-125mg) EMEND meclizine ANTIVERT metoclopramide REGLAN ondansetron QL ZOFRAN ZOFRAN ODT prochlorperazine COMPAZINE promethazine PHENERGAN thiethylperazine TORECAN trimethobenzamide 300 mg caps TIGAN

20 GASTROESOPHAGEAL REFLUX DISEASE (GERD)/ PEPTIC ULCERS

Guidelines of treatment and management of GERD and heartburn are available at: www.acg.gi.org and www.gastro.org Guidelines of treatment and management of gastrointestinal spasms and ulcers are available at: www.acg.gi.org

alginic acid/sodium bicarbonate OTC alumina/magnesia OTC MAALOX alumina/magnesia/simethicone OTC MYLANTA cimetidine TAGAMET famotidine# PEPCID PEPCID AC lansoprazole+amoxicillin+clarithromycin PREVPAC lansoprazole ST PREVACID lansoprazole del-rel orally disintegrating tabs* QL PREVACID SOLUTAB omeprazole delayed-rel (QL for 20 mg only) PRILOSEC pantoprazole PROTONIX ranitidine ZANTAC sucralfate CARAFATE sulcralfate suspension ** CARAFATE SUSPENSION

*Members ≥ 10 years of age will require prior authorization. ** Members 10 years of age up to 65 years of age will require prior authorization. #OTC Pepcid AC 10 mg and 20 mg also covered/encouraged with written prescription.

GASTROINTESTINAL SPASM

dicyclomine BENTYL glycopyrrolate ROBINUL hyoscyamine sulfate LEVSIN hyoscyamine sulfate ext-rel LEVSINEX

INFLAMMATORY BOWEL DISEASE

balsalazide COLAZAL hydrocortisone enema COLOCORT mesalamine delayed-rel ASACOL mesalamine ext-rel PENTASA mesalamine (enema only) ROWASA mesalamine supp CANASA olsalazine sodium DIPENTUM sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS

21 PANCREATIC ENZYMES

Only the enzyme products listed below are on the PDL .

pancrelipase CREON CREON 3000 UNIT PANCREAZE ZENPEP

LAXATIVES

casanthranol-docusate sodium OTC docusate calcium plus OTC docusate potasssium OTC glycerin suppository OTC GLYCERIN SUPPOSITORY lactulose ENULOSE peg 3350/electrolytes COLYTE peg 3350/sodium bicarbonate/ NULYTELY sodium chloride/potassium chloride peg 3350/sodium bicarbonate/sodium chloride TRILYTE polyethylene glycol 3350 MIRALAX sennosides 8 .6 mg tab OTC SENOKOT

PROBIOTIC SUPPLEMENTATION

acidophilus caps and tabs OTC ACIDOPHILUS acidophilus OTC ACIDOPHILUS XTRA acidophilus/bifidusOTC ACIDOPHILUS/BIFIDUS WAFER acidophilus/citrus pectin tabs OTC ACIDOPHILUS/ CITRUS PECTIN acidophilus/pectin caps OTC ACIDOPHILUS/PECTIN lactobacillus chewable tablets OTC FLORANEX probiotic product caps OTC PROBIOTIC FORMULA

MISCELLANEOUS

atropine sulfate SAL-TROPINE bismuth subsalicylate+metronidazole+tetracycline HELIDAC methylnaltrexone PA RELISTOR misoprostol CYTOTEC ursodiol URSO URSO FORTE ACTIGALL

22 INFECTIOUS DISEASES www.cdc.gov

Antibacterial resistance represents a serious and growing public health problem in the United States and worldwide . Judicious prescribing of antimicrobial agents and proper antibiotic usage by patients play an important role in diminishing resistance to antibiotics .

ANTIBACTERIALS

Cephalosporins First Generation cefadroxil DURICEF cephalexin* KEFLEX

*Tabs are not covered. Second Generation cefaclor CECLOR cefprozil CEFZIL cefuroxime axetil CEFTIN

Third Generation cefdinir OMNICEF cefixime (400 mg tabs only) QL SUPRAX

Fluoroquinolones

ciprofloxacin CIPRO levofloxacin (tablets only) LEVAQUIN ofloxacin tabs FLOXIN

Macrolides

azithromycin QL ZITHROMAX clarithromycin BIAXIN erythromycin ethylsuccinate E .E .S . erythromycin delayed-rel ERYC erythromycin delayed-rel E RY-TAB erythromycin stearate ERYTHROCIN erythromycin/sulfisoxazole PEDIAZOLE

Penicillins

amoxicillin* AMOXICILLIN CAPSULES AND CHEWABLES amoxicillin/clavulanate AUGMENTIN amoxicillin/clavulanate AUGMENTIN ES-600 amoxicillin suspension AMOXIL SUSP

23 ampicillin PRINCIPEN dicloxacillin DICLOXACILLIN penicillin VK VEETIDS *Except 500 mg and 875 mg film-coated tabs. Sulfonamides sulfisoxazole sulfamethoxazole/trimethoprim, DS BACTRIM BACTRIM DS

Tetracyclines

doxycycline hyclate VIBRAMYCIN minocycline capsules, except 75 mg MINOCIN tetracycline SUMYCIN

Miscellaneous

vancomycin HCl cap ST VANCOCIN HCL

ANTIFUNGALS

clotrimazole troches MYCELEX fluconazole QL DIFLUCAN griseofulvin ultramicrosize GRIS-PEG griseofulvin microsize GRIFULVIN V itraconazole PA QL SPORANOX ketoconazole NIZORAL nystatin MYCOSTATIN terbinafineQL LAMISIL

ANTIVIRALS

Cytomegalovirus Treatment

ganciclovir CYTOVENE valganciclovir VALCYTE

Entry/Fusion Inhibitors

enfuvirtide SP FUZEON KIT

Hepatitis Treatment

adefovir HEPSERA entecavir BARACLUDE interferon alfa-2b PA SP INTRON A interferon alfacon-1 PA SP INFERGEN lamivudine EPIVIR HBV peginterferon alfa-2a PA SP PEGASYS

24 peginterferon alfa-2a PA SP PEGASYS PROCLICK peginterferon alfa-2b PA SP SYLATRON ribavirin PA SP REBETOL/COPEGUS telaprevir PA SP INCIVEK

Herpes Treatment

acyclovir ZOVIRAX valacyclovir VALTREX

Influenza Treatment

amantadine (except tabs) SYMMETREL oseltamivir QL TAMIFLU rimantadine FLUMADINE zanamivir QL RELENZA

Non-Nucleoside Reverse Transcriptase Inhibitors

delavirdine RESCRIPTOR efavirenz SUSTIVA nevirapine VIRAMUNE nevirapine ER VIRAMUNE XR rilpivirine EDURANT

Nucleoside Analogues Nucleoside Reverse-Transcriptase Inhibitors/and Combinations

abacavir ZIAGEN abacavir/lamivudine EPZICOM abacavir/lamivudine/zidovudine TRIZIVIR didanosine VIDEX didanosine delayed-rel VIDEX EC emtricitabine EMTRIVA emtricitabine/rilpivirine/tenofovir COMPLERA lamivudine EPIVIR lamivudine/zidovudine COMBIVIR stavudine ZERIT zalcitabine HIVID zidovudine RETROVIR

Nucleoside/Nucleotide Reverse-Transcriptase Inhibitor Combination

efavirenz/emtricitabine/tenofovir ATRIPLA emtricitabine/tenofovir TRUVADA

Nucleotide Analogues Nucleotide Reverse-Transcriptase Inhibitor

tenofovir VIREAD

25 Protease Inhibitors

amprenavir AGENERASE atazanavir R EYATAZ darunavir PREZISTA fosamprenavir LEXIVA indinavir CRIXIVAN lopinavir/ritonavir KALETRA nelfinavir VIRACEPT ritonavir NORVIR saquinavir FORTOVASE saquinavir mesylate INVIRASE tipranavir APTIVUS

MISCELLANEOUS

atovaquone PA MEPRON chloroquine phosphate ARALEN clindamycin (150 mg and 300 mg only) CLEOCIN dapsone DAPSONE ethambutol MYAMBUTOL etravirine INTELENCE hydroxychloroquine PLAQUENIL isoniazid ISONIAZID linezolid PA ZYVOX maraviroc SELZENTRY mebendazole VERMOX mefloquine LARIAM metronidazole (tabs only) FLAGYL neomycin sulfate nitrofurantoin ext-rel MACROBID nitrofurantoin macrocrystals MACRODANTIN nitrofurantoin macrocrystals MACRODANTIN 25 MG palivizumab PA SYNAGIS paromomycin HUMATIN povidone-iodine OTC primaquine pyrimethamine DARAPRIM pyrazinamide PYRAZINAMIDE raltegravir ISENTRESS rifabutin MYCOBUTIN rifampin RIFADIN tobramycin SP TOBI trimethoprim (tabs only) TRIMETHOPRIM vancomycin ST VANCOCIN

26 MUSCULOSKELETAL

ARTHRITIS — www.rheumatology.org

Disease Modifying Anti-Rheumatic Drugs

adalimumab PA SP HUMIRA auranofin RIDAURA azathioprine IMURAN certolizumab pegol PA SP CIMZIA etanercept PA SP ENBREL hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate RHEUMATREX penicillamine CUPRIMINE sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS

NSAIDs and Other Analgesics

acetaminophen OTC TYLENOL aspirin OTC BAYER ECOTRIN capsaicin OTC celecoxib PA QL CELEBREX choline magnesium trisalicylate TRILISATE diclofenac sodium delayed release VOLTAREN etodolac (IR only) LODINE fenoprofen 600 mg NALFON ibuprofen* OTC ADVIL ibuprofen* MOTRIN indomethacin INDOCIN ketoprofen (IR only) ORUDIS meloxicam QL MOBIC naproxen (not EC) NAPROSYN naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL *tabs, chew tabs and susp

GOUT

allopurinol ZYLOPRIM colchicine COLCRYS

27 febuxostat ST ULORIC probenecid PROBENECID

SKELETAL MUSCLE RELAXANTS

Guidelines for the evaluation and management of musculoskeletal/arthritis condition are available at: www.rheumatology.org

Muscle Spasm

chlorzoxazone PARAFON FORTE DSC cyclobenzaprine QL FLEXERIL methocarbamol ROBAXIN orphenadrine ext-rel NORFLEX

Spasticity

baclofen BACLOFEN dantrolene DANTRIUM diazepam QL VALIUM tizanidine QL (tabs only) ZANAFLEX

OB-GYN

EE = ethinyl estradiol ME = mestranol

Gender edits apply: for female patients only.

CONTRACEPTIVES

Biphasic

desogestrel/EE QL MIRCETTE norethindrone/EE QL ORTHO-NOVUM 10/11

Emergency Contraception

levonorgestrel QL PLAN B levonorgestrel 1 .5mg tab PLAN B ONE STEP

Injectable

medroxyprogesterone acetate QL DEPO-PROVERA

Intravaginal

etonogestrel/EE ring QL NUVARING ortho diaphragm QL ORTHO COIL ORTHO FLAT ORTHO FLEX

28 Monophasic 20 mcg estrogen levonorgestrel/EE 0 .1/20 QL ALESSE norethindrone acetate/EE 1/20 QL LOESTRIN 1/20 norethindrone acetate/EE/iron 1/20 QL LOESTRIN FE 1/20

30 mcg estrogen desogestrel/EE 0 .15/30 QL ORTHO-CEPT levonorgestrel/EE 0 .15/30 QL NORDETTE norethindrone acetate/EE/iron 1 .5/30 QL LOESTRIN FE 1 .5/30 norethindrone acetate/EE 1 .5/30 QL LOESTRIN 1 .5/30 norgestrel/EE 0 .3/30 QL LO/OVRAL

35 mcg estrogen ethynodiol diacetate/EE 1/35 QL ZOVIA 1/35 norethindrone/EE 0 .4/35 QL BALZIVA norethindrone/EE 0 .5/35 QL MODICON norethindrone/EE 1/35 QL ORTHO-NOVUM 1/35 norgestimate/EE 0 .25/35 QL ORTHO-CYCLEN

50 mcg estrogen ethynodiol diacetate/EE 1/50 QL ZOVIA 1/50 norethindrone/EE 1/50 QL OVCON 50 norethindrone/ME 1/50 QL ORTHO-NOVUM 1/50 norgestrel/EE 0 .5/50 QL OVRAL

Progestin

norethindrone ORTHO MICRONOR norgestrel OVRETTE

Transdermal

norelgestromin/EE ORTHO EVRA

Triphasic

levonorgestrel/EE QL TRIVORA norethindrone acetate/EE/iron QL ESTROSTEP FE norethindrone/EE QL TRI-NORINYL norethindrone/EE QL ORTHO-NOVUM 7/7/7 norgestimate/EE QL ORTHO TRI-CYCLEN

ENDOMETRIOSIS

danazol* DANOCRINE

*Gender edits apply: for female patients only.

29 HORMONE THERAPY/MENOPAUSE

Gender edits apply: for female patients only . Guidelines of treatment and management of hormone therapy and menopause are available at: www.acog.com, www.menopause.org and www.nhlbi.nih.gov

Estrogens Intravaginal

estradiol ESTRACE CRM estrogens, conjugated crm PREMARIN

Oral estradiol ESTRACE estrogens, conjugated, synthetic A CENESTIN estrogens, conjugated, synthetic B ENJUVIA estrogens, conjugated PREMARIN estropipate OGEN

Transdermal estradiol QL CLIMARA

Estrogen/Progestin

estrogens, conjugated/medroxyprogesterone PREMPHASE PREMPRO

Progestins

medroxyprogesterone acetate PROVERA norethindrone acetate AYGESTIN

VAGINAL INFECTIONS

Oral

fluconazoleQL DIFLUCAN metronidazole tabs FLAGYL

Vaginal

clotrimazole OTC GYNE-LOTRIMIN clindamycin crm CLEOCIN clindamycin supp CLEOCIN metronidazole METROGEL-VAGINAL METROGEL 1% miconazole OTC MONISTAT miconazole MONISTAT 3 terconazole TERAZOL 3/7

30 MISCELLANEOUS

methylergonovine METHERGINE tranexamic acid PA LYSTEDA

OPHTHALMIC

ALLERGY

azelastine ST OPTIVAR cromolyn sodium QL CROLOM ketotifen ALAWAY OTC naphazoline HCL soln 0 .02% VASOCLEAR naphazoline/antazoline naphazoline/glycerin CLEAR EYES REDNESS RELIEF naphazoline/zinc sulfate VASOCLEAR A tetrahydrozoline/zinc sulfate VISINE-AC

ANTI-INFLAMMATORIES

Nonsteroidal

diclofenac sodium VOLTAREN flurbiprofen OCUFEN ketorolac ACULAR/ACULAR LS

Steroidal

dexamethasone sodium phosphate soln 0 .1% DEXASOL fluorometholone0 .1% FML FML SOP fluorometholonesusp 0 .25% FML FORTE fluorometholone acetate FLAREX prednisolone acetate 0 .12% PRED MILD prednisolone acetate 1% PRED FORTE prednisolone phosphate 1% INFLAMASE FORTE rimexolone VEXOL

Anti-Infective/Anti-Inflammatory Combinations

gentamicin/prednisolone acetate PRED-G neomycin/polymyxin B/dexamethasone MAXITROL neomycin/polymyxin B/hydrocortisone CORTISPORIN sulfacetamide/pred. phos. 10%/0 .25% VASOCIDIN tobramycin/dexamethasone TOBRADEX

31 GLAUCOMA

Oral

acetazolamide ACETAZOLAMIDE acetazolamide ext-rel DIAMOX SEQUELS methazolamide NEPTAZANE

Topical Sympathomimetics

brimonidine ALPHAGAN P brimonidine 0 .2% BRIMONIDINE

Parasympathomimetics

pilocarpine PILOPINE HS GEL pilocarpine ISOPTO CARPINE

Beta-blockers carteolol levobunolol ophthalmic solution BETAGAN metipranolol 0 .3% ophthalmic solution OPTIPRANOLOL timolol gel forming solution TIMOPTIC XE timolol hemihydrate BETIMOL timolol maleate TIMOPTIC

Prostaglandins

latanoprost QL XALATAN

Carbonic Anhydrase Inhibitors

dorzolamide TRUSOPT

Carbonic Anhydrase Inhibitor/Beta-blocker Combination

dorzolamide/timolol maleate COSOPT

Cholinesterase Inhibitor

ecothiophate PHOSPHOLINE IODINE

Mydriatics

atropine ISOPTO ATROPINE cyclopentolate CYCLOGYL homatropine ISOPTO HOMATROPINE scopolamine ISOPTO HYOSCINE tropicamide ophthalmic solution MYDRIACYL

32 INFECTIONS

Bacterial bacitracin ciprofloxacin CILOXAN erythromycin ERYTHROMYCIN gatifloxin PA ZYMAR gentamicin GENTAK neomycin/polymyxin B/gramicidin NEOSPORIN ofloxacin OCUFLOX polymyxin B/bacitracin POLYSPORIN polymyxin B/trimethoprim POLYTRIM sulfacetamide/phenylephrine VASOSULF sulfacetamide oint/soln BLEPH-10 tobramycin TOBREX

Viral

trifluridine VIROPTIC

MISCELLANEOUS OPHTHALMICS

sodium chloride hypertonic soln 5% MURO 128

PSYCHIATRIC

ALCOHOL DETERRENTS

acamprosate CAMPRAL disulfiram ANTABUSE naltrexone REVIA

ANXIETY

Benzodiazepines

alprazolam QL (IR only) XANAX chlordiazepoxide LIBRIUM clonazepam (not wafers) KLONOPIN clorazepate TRANXENE diazepam QL VALIUM lorazepam QL ATIVAN oxazepam QL SERAX

33 MISCELLANEOUS

buspirone BUSPAR clomipramine ANAFRANIL fluvoxamine LUVOX

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

Guidelines for the evaluation and management of ADHD are available at: www.aap.org and www.psych.org

amphetamine/dextroamphetamine mixed salts* QL ADDERALL amphetamine/dextroamphetamine ADDERALL XR mixed salts ext-rel* QL (BRAND ADDERALL XR IS PREFERED) atomoxetine* QL ST STRATTERA dextroamphetamine* QL DEXEDRINE dextroamphetamine* QL DEXTROSTAT dextroamphetamine ext-rel* QL DEXEDRINE SPANSULE guanfacine* ST INTUNIV lisdexamfetamine* QL VYVANSE methylphenidate* QL (tabs only) RITALIN methylphenidate ext-rel* QL CONCERTA methylphenidate ext-rel* QL METADATE ER RITALIN-SR

*Age Limits Apply

BIPOLAR DISORDER

Guidelines from the American Psychiatric Association for the treatment of bipolar disorder are available at: www.psych.org.

divalproex sodium delayed-rel (Minimum age 2) DEPAKOTE divalproex sodium ext-rel QL DEPAKOTE ER lithium carbonate LITHIUM CARBONATE lithium carbonate ext-rel ESKALITH CR LITHOBID

DEPRESSION

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: www.psych.org

Monoamine Oxidase Inhibitor (MAOI)

tranylcypromine PARNATE

34 Selective Serotonin Reuptake Inhibitor (SSRIs)

citalopram QL CELEXA fluoxetine(10 mg and 20 mg caps and 20 mg soln only) PROZAC paroxetine tablets PAXIL sertraline tablets QL ZOLOFT

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

desvenlafaxine ST PRISTIQ duloxetine QL ST CYMBALTA venlafaxine QL EFFEXOR venlafaxine XR QL EFFEXOR XR

Tricyclic Antidepressants (TCAs)

amitriptyline tablets ELAVIL amoxapine desipramine NORPRAMIN doxepin SINEQUAN imipramine HCL tablets TOFRANIL nortriptyline PAMELOR

Tricyclic Antidepressant/Phenothiazine combination

amitriptyline/perphenazine TRIAVIL

Miscellaneous Agents

bupropion WELLBUTRIN bupropion ext-rel QL WELLBUTRIN SR bupropion ext-rel 150 mg and 300 mg WELLBUTRIN XL maprotiline LUDIOMIL mirtazapine tabs (not soltabs) REMERON trazodone DESYREL

INSOMNIA

Short-term insomnia may last for a few weeks and may recur . A sedative/hypnotic can be useful but should preferably not be given for more than 7-10 days .

Information about sleep disorders is available at: www.aasmnet.org

Benzodiazepines

flurazepamQL DALMANE temazepam QL (15 mg and 30 mg only) RESTORIL triazolam QL HALCION

35 Non-benzodiazepines

chloral hydrate CHLORAL HYDRATE diphenhydramine OTC NYTOL QUICK CAPS zaleplon QL SONATA zolpidem QL AMBIEN

NARCOTIC ANTAGONISTS

buprenorphine PA QL SUBUTEX buprenorphine/naloxone PA QL (film only) SUBOXONE naltrexone REVIA

SMOKING CESSATION

nicotine patches QL NICODERM CQ nicotine QL NICOTROL INHALER NICOTROL NS nicotine polacrilex gum QL NICORETTE OTC nicotine polacrilex lozenge QL COMMITT OTC varenicline QL CHANTIX

PSYCHOSES

Atypicals

aripiprazole tablets QL ST* ABILIFY TABLETS clozapine* CLOZARIL olanzapine tablets QL* ZYPREXA paliperidone QL* INVEGA SUSTENNA quetiapine QL* SEROQUEL risperidone QL* RISPERDAL CONSTA risperidone QL (Not M-Tabs)* RISPERDAL ziprasidone QL* GEODON

*Age Limit Applies.

MISCELLANEOUS

chlorpromazine THORAZINE dextromethorphan/quinidine PA NUEDEXTA fluphenazine PROLIXIN fluphenazine decanoate PROLIXIN DECANOATE haloperidol HALDOL haloperidol decanoate HALDOL DECANOATE loxapine LOXITANE perphenazine TRILAFON

36 pimozide ORAP thioridazine MELLARIL thiothixene NAVANE trifluoperazine STELAZINE

RESPIRATORY DRUGS

ANTITUSSIVES, DECONGESTANTS, EXPECTORANTS AND COMBINATIONS

benzonatate TESSALON brompheniramine & phenylephrine DIMETAPP CLD ELX/ALLERGY brompheniramine/pseudoephedrine BROMFENEX PD CAP DIMETAPP ELX CLD/ALLE UNI-HIST DRO CARDEC SYP brompheniramine/pseudoephedrine BROMALINE DM /dextromethorphan elixir brompheniramine/pseudoephedrine BROMFED DM /dextromethorphan syrup DALLERGY DM CARBOFED NEO DM ANAPLEX DM brompheniramine/pseudoephedrine/ HISTACOL DM dextromethorphan/guaifenesin syrup brompheniramine/pseudoephedrine liquid ACCUHIST DROPS RESPERAL-DM brompheniramine/pseudoephedrine/ ACCUHIST PDX DROPS dextromethorphan liquid brompheniramine/pseudoephedrine syrup RONDEC SYRUP carbetapentane/chlorpheniramine/ RYNATUSS ephedrine/phenylephrine carbinoxamine/pseudoephedrine liquid RONDEC DROPS chlorphen-PE-methscopolamine syrup DURADRYL QV-ALLERGY chlorpheniramine/dextromethorphan ROBITUSSIN PED LIQ CGH/COLD ROBITUSSIN LIQ CGH/CLD DIMETAPP SYP CGH/CLD CORICIDIN TAB CGH/CLD chlorpheniramine/pseudoephedrine HISTEX CPM/PSE chlorpheniramine/phenylephrine liquid RONDEC DROPS CARDEC DRO chlorpheniramine/phenylephrine syrup RONDEC SYRUP CARDEC SYP

37 chlorpheniramine maleate phenylephrine HCL ED A-HIST TABLETS AND LIQUID chlorpheniramine tan/ RYNATAN PEDIATRIC SUSP phenylephrine tan susp chlorphen tan/pseudoeph tan susp TANAFED chlorphen tan/pyrilamine tan/ TRIOTANN PEDIATRIC SUSP PE tan susp R-TANNAMINE chlorphen tan/carbetapentane tan susp TUSSI-12 S codeine/chlorpheniramine/pseudoephedrine DIHISTINE DH PHENYLHIST LIQ DH codeine/guaifenesin QL GUIATUSS AC GG/CODEINE M-CLEAR WC codeine/guaifenesin/pseudoephedrine GUIATUSS DAC codeine/promethazine QL PROMETHAZINE W/CODEINE codeine/promethazine/phenylephrine QL PROMETHAZINE VC W/CODEINE dextromethorphan-guaifenesin liq 10-200 mg/ 5 ml ROBITUSSIN LIQ CGH/CONG dextromethorphan-guaifenesin soln 25-225 mg/5 ml DURATUSS DM ELX dextromethorphan polistirex ext rel OTC DELSYM dextromethorphan/guaifenesin OTC GG/DM CR MUCINEX DM ROBITUSSIN DM TUSSIN DM dextromethorphan hbr syrup ROBITUSSIN SYP MAX-ST ROBITUSSIN PED SYP dextromethorphan/brompheniramine/ BROMETANE DX pseudoephedrine dextromethorphan/carbinoxamine/ CARDEC-DM pseudoephedrine drops dextromethorphan/promethazine PHENERGAN DM PROMETHAZINE SYP DM guaifenesin OTC ROBITUSSIN guaifenesin ext-rel OTC MUCINEX guaifenesin syrup 100 mg/5 ml ROBITUSSIN SYP CHST CNG guaifenesin/pseudoephedrine ext rel GUAIFED guaifenesin/pseudoephedrine syrup OTC ROBITUSSIN PE PSE/GG guaifenesin/pseudoephedrine ext rel OTC GUAIFEN PSE MUCINEX D GG/PSE CR guaifenesin/pseudoephedrine/dextromethorphan ROBITUSSIN CF hydrocodone/chlorpheniramine/phenylephrine HISTUSSIN HC hydrocodone/guaifenesin VITUSSIN HYDROCODO/GG SYP

38 hydrocodone/homatropine HYCODAN HYDROMET SYP HYDROCODONE/TAB HOMATROP loratadine & pseudoephedrine SR 24hr tab 10-240 mg ALLERGY/CONG TAB RELIEF phenyleph/bromphen/dextromethorphan/guaifenesin ALLANHIST SYP PDX phenylephrine/brompheniramine/ dextromethorphan OTC phenylephrine/chlorpheniramine QUAL-TUSSIN SYP DC phenylephrine/chlorpheniramine/ ATUSS DR dextromethorphan syrup phenylephrine/chlorpheniramine/ DE-CHLOR DM dextromethorphan syrup phenylephrine/chlorpheniramine/ RONDEC DM DROPS dextromethorphan liquid CARDEC DM DRO ROBITUSSIN LIQ CGH/ALRG phenylephrine/chlorpheniramine/ RONDEC DM dextromethorphan syrup STATUSS DM SYP CARDEC DM SYP MINUTUSS DR SYP phenylephrine/chlorpheniramine/dihydrocodeine DIHYDRO-PE SYP phenylephrine/dextromethorphan DIMETAPP DRO DCON/CGH phenylephrine/dextromethorphan/guaifenesin ROBITUSSIN LIQ CGH/CLD phenylephrine/ephed/CPM w/ RYNATUSS PEDIATRIC SUSP carbetapentane susp phenylephrine/guaifenesin ROBITUSSIN LIQ HD/CHST phenylephrine/hydrocodone/guaifenesin QUAL-TUSSIN SYP DC phenylephrine/pyrilamine/dextromethorphan CODAL-DM phenylephrine/pyrilamine w/ CODIMAL DH hydrocodone syrup phenylephrine tan/pyrilamine tan/ TUSSI 12D S carbeta tan susp promethazine & phenylephrine syrup 6 .25-5 mg/ 5mg PROMETH VC SYP 6 .25-5/5 pseudoephedrine/acetaminophen/dextromethorphan MAPAP COLD TAB pseudoephedrine/chlorpheniramine/ PEDIACARE LIQ MULTI-SY dextromethorphan ROBITUSSIN LIQ PED NGHT pseudoephedrine/dextromethorphan/guaifenesin MULTI SYMPTOM TAB COLD RLF pseudoephedrine/iburprofen CHILD IBUPRO SUS COLD IBUOROFEN TAB COLD/SIN pseudoephedrine tan/ dexchlorphen tan/ TANAFED DMX SUSPENSION DM tan susp TRI-FED X pyrilamine tan/phenyleph tan susp RYNA-12 S tripolidine/pseudoephedrine TRIPROL/PSE SYP APHEDRID TAB

Coverage of these medications will be determined by the member’s individual benefits. Please refer to plan documents for coverage.

39 ASTHMA/COPD

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

The allergy report is available at: www.aaaai.org

Inhalers Beta Agonists

albuterol sulfate QL VENTOLIN HFA formoterol inhalation caps FORADIL AEROLIZER salmeterol xinafoate QL SEREVENT DISKUS

Corticosteroids

beclomethasone QL QVAR budesonide PULMICORT FLEXHALER flunisolidenasal solution fluticasone HFA QL FLOVENT HFA fluticasone propionateQL FLOVENT DISKUS mometasone QL ASMANEX TWISTHALER

Others

cromolyn QL INTAL budesonide/formoterol ST SYMBICORT fluticasone/salmeterolQL ST ADVAIR DISKUS ADVAIR HFA ADVAIR INHAL AEROSOL ipratropium HFA ATROVENT HFA ipratropium/albuterol QL COMBIVENT ipratropium/albuterol inhaler COMBIVENT RESPIMAT mometasone/formoterol ST DULERA nedocromil TILADE omalizumab PA SP XOLAIR tiotropium SPIRIVA

Inhalers for Nebulization albuterol soln 0 .083%, 0 .5% PROVENTIL budesonide susp** QL PULMICORT RESPULES cromolyn soln QL INTAL ipratropium soln QL ATROVENT ipratropium/albuterol soln DUONEB levalbuterol HCl QL ST XOPENEX RESPULES

**Covered for members less than 8 years of age. Members ≥ 8 years of age will require prior authorization.

40 Oral Agents Beta Agonists albuterol ALBUTEROL metaproterenol METAPROTERENOL SYRUP terbutaline BRETHINE

Leukotriene Modifiers

montelukast QL ST SINGULAIR

Theophylline theophylline ext-rel caps (12 hr) THEOPHYLLINE EXT-REL theophylline ext-rel tabs THEOCHRON theophylline liquid THEOPHYLLINE theophylline ext-rel caps THEO-24 theophylline ext-rel tabs UNIPHYL

SUPPLEMENTS

Guidelines for recommended dietary intakes for vitamins and minerals are available at: www.nal.usda.gov/fnic/dga/rda.html

POTASSIUM

phosphorus tabs K-PHOS NEUTRAL potassium acid phosphate K-PHOS ORIGINAL potassium bicarbonate/potassium citrate K-LYTE effervescent tabs potassium chloride ext-rel caps MICRO-K 10 potassium chloride ext-rel tabs K-D U R 10 K-DUR 20 KLOR-CON 8 KLOR-CON 10 potassium chloride liquid POTASSIUM CHLORIDE potassium chloride powder K-LOR potassium iodide PIMA

POTASSIUM-REMOVING AGENTS

sodium polysterene sulfonate susp (susp only) KAYEXALATE

VITAMINS AND MINERALS

calcitriol ROCALTROL calcium OTC OS-CAL cholecalciferol tab 400 unit OTC VITAMIN D TAB 400 UNIT

41 cholecalciferol tab 1000 unit OTC VITAMIN D TAB 1000 UNIT cholecalciferol tab 2000 unit OTC VITAMIN D TAB 2000 UNIT cholecalciferol cap 400 unit OTC VITAMIN D CAP 400 UNIT cholecalciferol cap 2000 unit OTC VITAMIN D CAP 2000 UNIT cholecalciferol cap 50000 unit OTC D3-50 CAP cholecalciferol drops 400 unit/0.03ml OTC BIO-D DRO -MULSION cholecalciferol drops 2000 unit/0.03ml OTC BIO-D-MULSIO DRO FORTE cyanocobalamin inj* VITAMIN B-12 electrolyte soln, oral OTC PEDIALYTE ergocalciferol (D2)* DRISDOL ferrous bisglycinate/polysaccarides iron caps OTC NIFEREX ferrous sulfate OTC FEOSOL fluoride* GEL-KAM LURIDE LURIDE LOZI-TABS PREVIDENT PHOS-FLUR folic acid FOLIC ACID magnesium oxide OTC* MAG-OX multivitamins/fluoride/±iron* POLY-VI-FLOR multivitamins/minerals OTC* CENTRUM phytonadione MEPHYTON polysaccharide iron complex elixir OTC NIFEREX prenat w/o A w/fecbn-fegl-DSS-FA & DHA FOLTABS PAK PLUS DHA RE OB + DHA PAK prenatal vit w/ FE bisglyc-FE prot succ-FA VINATE III prenatal vit w/ FE bisglycinate chelate-FA VITAPHIL prenatal vit w/ FE bisglycinate chelate-FA GENTEX ADE 28-1MG prenatal vit w/ FE bisglycinate chelate-FA VINATE AZ EX prenatal vit w/ FE polysac cmplx-FA EDGE OB CHW prenatal vit w/ iron carbonyl-FA ATABEX PRENATAL prenatal vitamins w/folic acid QL PRENATAL VITAMINS W/ FOLIC ACID CENOGEN OB/ULTRA MATERNA NATACHEW NATALCARE NESTABSCBF/FA/RX NIFEREX-PN FORTE prenatal w/o A w/ FE carbonyl-FE gluc-DSS-FA FOLTABS PRENATAL TRI RX prenat-FE Bis-FE prot succ-FA-CA & omega 3 COMPLETE NATALCARE PAK DHA prenat-FE bis-FE prot succ-FA-CA & omega 3 TRUST NATALCARE PAK DHA prenat-FE bis-FE prot succ-FA-CA & omega 3 PRUET DHA PAK SETONET PAK renat-FE bis-FE prot succ-FA-CA & omega DR PRUET DHAEC PAK

42 vitamin A OTC vitamin ADC/fluoride/±iron drops* TRI-VI-FLOR vitamin B complex/vitamin C/folic acid* NEPHROCAPS vitamin B-1 OTC vitamin C OTC vitamin B-6 OTC vitamins pediatric members <3 years old OTC* TRI-VI-SOL zinc OTC

*Coverage for these medications will be determined by the member’s individual benefits. Please refer to individual plan documents for coverage information. UROLOGICAL

SYMPTOMATIC BENIGN PROSTATIC HYPERTROPHY

alfuzosin ER UROXATRAL doxazosin CARDURA finasteride PROSCAR tamsulosin FLOMAX terazosin HYTRIN

MISCELLANEOUS

bethanechol URECHOLINE hyoscyamine, methenamine, phenyl salicylate, sodium UTIRA C phosphate monobasic, methylene blue methenamine hippurate HIPREX UREX oxybutynin IR DITROPAN oxybutynin chloride QL ST DITROPAN XL potassium citrate UROCIT-K propantheline phenazopyridine PYRIDIUM sodium citrate/citric acid BICITRA tolterodine ST DETROL trospium ST SANCTURA

HOME INFUSION DRUGS

ANALGESICS - NSAIDS

ketorolac tromethamine im inj 30 mg/ml* KETOROLAC INJ ketorolac tromethamine inj 30 mg/ml* KETOROLAC INJ

43 ANALGESICS - OPIOD

fentanyl citrate inj 0.05 mg/ml* FENTANYL CIT INJ morphine sulfate inj 10 mg/ml* DURAMORPH INJ morphine sulfate inj 15 mg/ml* MORPHINE SUL INJ morphine sulfate inj 2 mg/ml* MORPHINE SUL INJ morphine sulfate inj 4 mg/ml* ASTRAMOR INJ morphine sulfate iv soln 50 mg/ml* MORPHINE SUL INJ

ANTIBIOTICS

amikacin sulfate inj 250 mg/ml* AMIKACIN INJ cefazolin sodium for inj 1 gm* ANCEF INJ ceftriaxone sodium for inj 1 gm* CEFTRIAXONE INJ ceftriaxone sodium for inj 2 gm* CEFTRIAXONE INJ ceftriaxone sodium for inj 500 mg* CEFTRIAXONE INJ ceftriaxone sodium for iv soln 1 gm and dextrose 3.74%* CEFTRIAX/DEX INJ ceftriaxone sodium in dextrose inj 20 mg/ml* CEFTRIAXONE/ INJ DEX ciprofloxacin 0.2% in d5w* CIPRO I .V . SOL ciprofloxacin iv soln 1%* CIPRO I V. . INJ clindamycin phosphate inj 150 mg/ml* CLEOCIN PHOS INJ imipenem-cilastatin intravenous for soln 500 mg* IMIPENEM/CIL INJ levofloxacin in d5w iv soln 5 mg/ml* levofloxacin iv soln 25 mg/ml* LEVAQUIN INJ piperacillin sodium-tazobactam sodium for inj 3-0.375 gm* PIPER/TAZOBA INJ piperacillin sodium-tazobactam sodium for inj 4-0.5 gm* PIPER/TAZOBA INJ piperacillin sod-tazobactam sod in dex iv sol ZOSYN SOL 3-0.375 gm/50 ml* vancomycin hcl for inj 1000 mg* VANCOCIN HCL INJ vancomycin hcl for inj 500 mg* VANCOCIN HCL INJ vancomycin hcl in dextrose inj 500 mg/100 ml* VANCOCIN/DEX INJ

ANTIHISTAMINES

diphenhydramine hcl inj 50 mg/ml* BENA-D-50 INJ promethazine hcl inj 25 mg/ml* ANERGAN 25 INJ

DIURETICS

furosemide inj 10 mg/ml* DIAQUA-2 INJ

ELECTROLYTE MIXTURES

dextrose 5% w/ sodium chloride 0.45%* D5W/NACL INJ

44 GENITOURINARY IRRIGANTS

sodium chloride irrigation soln 0.9%*

MINERALS & ELECTROLYTES

sodium chloride inj 0.45%* SOD CHLORIDE INJ sodium chloride inj 0.9%* BD POSIFLUSH INJ sodium chloride iv soln 0.9%* SOD CHLORIDE INJ

NUTRIENTS

dextrose inj 5%* DEXTROSE INJ dextrose inj 50%* DEXTROSE INJ

VITAMINS

phytonadione inj 10 mg/ml* AQUA-MEPHYTO INJ

*Limited to 14 days supply every 30 days MISCELLANEOUS

ANAPHYLAXIS

epinephrine QL ADRENACLICK epinephrine QL EPIPEN EPIPEN JR . TWINJECT

Cryopyrin — Associated Periodic Syndromes (CAPS)

canakinumab PA SP ILARIS rilonacept PA SP ARCALYST

CYSTIC FIBROSIS

acetylcysteine MUCOMYST dornase alfa SP PULMOZYME ivacaftor PA SP KALYDECO

HEREDITARY ANGIOEDEMA

C1 Inhibitor, Human SP BERINERT icatibant SP FIRAZYR

45 HYPERPHOSPHATEMIA

calcium acetate PHOSLO cinacalcet PA SENSIPAR sevelamer ST RENVELA

IMMUNE THROMBOCYTOPENIC PURPURA

eltromobpag PA SP PROMACTA

MEDICAL DEVICES

EasiVent Mask QL EASIVENT MASK EasiVent valved holding chamber QL EASIVENT CHAMBER Inspirease INSPIREASE

46 OTC MEDICATIONS The following is a list of OTC products on the PDL . Some OTC products are listed on the drug list . OTC products covered are restricted to generics when available . Brand names are provided as reference only .

CATEGORY/GENERIC NAME/DOSAGE FORM BRAND NAME EXAMPLES Acne benzoyl peroxide CLEARASIL —crm, gel, lotion

Antifungals clotrimazole MICATIN miconazole LOTRIMIN AF —crm, soln tolnaftate TINACTIN vaginal products MONISTAT GYNE-LOTRIMIN

Asthma saline for nebulization BRONCHO SALINE

Cough/Cold Allergy antihistamines CHLOR-TRIMETON BENADRYL CLARITIN OTC ALAVERT OTC ZYRTEC OTC antihistamine/decongestant combinations ACTIFED DIMETAPP ALAVERT D OTC cetirizine/pesudoephedrine OTC ZYRTEC D loratadine/pseudoephedrine ALAVERT ALRG TAB/SINUS ALLERGY/CONG cough/cold* ROBITUSSIN ROBITUSSIN DM ROBITUSSIN PE ROBITUSSIN CF DELSYM *Age edit applied. Not covered for members under the age 2. nasal sprays NEO-SYNEPHRINE AFRIN DIMETAPP DRO DECONGES

47 Atopic Dermatitis emollients BETACARE CREAM AND LOTION CETAPHIL CREAM AND LOTION DERMAPHOR OINTMENT E-OINTMENT GLYCERIN TOPICAL

Diabetes alcohol swabs CURITY ALCOHOL PADS glucose oral tablets insulin (vials only) NOVOLIN

Earwax Removal Products carbamide peroxide DEBROX

Family Planning condoms TROJAN contraceptive foam DELFEN contraceptive gel GYNOL II

First Aid Burow’s soln, wet dressings DOMEBORO dermatological baths COLLOIDAL OATMEAL BATHS hydrocortisone CORTAID —crm, oint topical antibacterials NEOSPORIN MYCITRACIN BACITRACIN

Gastrointestinal antacids MYLANTA LIQUID —liquids, chew tabs MAALOX LIQUID TUMS antidiarrheals IMODIUM A-D KAOPECTATE electrolyte rehydrating soln PEDIALYTE famotidine PEPCID AC laxative enemas FLEET ENEMA laxatives DULCOLAX FLEET PHOSPHO-SODA psyllium METAMUCIL rectal PREPARATION H —crm, suppositories simethicone MYLICON

48 stool softeners COLACE sugar+orthophosphoric acid EMETROL

Lice Products permethrin NIX piperonyl butoxide PIPERONYL BUTOXIDE —gel, liquid shampoo

Motion Sickness dimenhydrinate DRAMAMINE meclizine BONINE

Ophthalmics allergic conjunctivitis ALAWAY artificial tears HYPOTEARS decongestants VISINE MURINE NAPHCON A

Pain acetaminophen TYLENOL —tabs, liquid, drops, suppositories aspirin BAYER —tabs, EC . tabs ECOTRIN aspirin with buffers —tabs ibuprofen ADVIL —tabs, chew tabs and susp MOTRIN IB

Smoking Cessation Products nicotine COMMIT LOZENGES QL NICODERM CQ QL NICOTINE GUM QL NICOTROL QL

Vitamins/Minerals calcium OS-CAL CALTRATE TUMS iron FERGON —ferrous fumarate, ferrous, gluconate, FEOSOL errous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps

49 iron polysaccharides NIFEREX magnesium oxide MAG-OX vitamin D 400 IU Vitamin D 400 IU (OTC only) vitamins pediatric VI-DAYLIN —members <3 years old POLY-VI-SOL TRI-VI-SOL vitamins prenatal STUART PRENATAL

Warts salicylic acid 17%/collodion DUOFILM

Miscellaneous fluoride dental rinse PHOS-FLUR

50 Websites

Agency for Healthcare Research and Quality American Council for Headache Education www.ahrq.gov/ www.achenet.org/

Alzheimer’s Association American Diabetes Association www.druglist.com/2004/f500.htm# www.diabetes.org/

American Academy of Allergy, American Gastroenteurology Association Asthma and Immunology www.gastro.org/ www.aaaai.org/ American Heart Association American Academy of Dermatology www.americanheart.org/ www.aad.org/ American Lung Association American Academy of Dermatology Association www.lungusa.org/ www.aadassociation.org/ American Medical Association American Academy of Pediatrics www.ama-assn.org/ www.aap.org/ American Psychiatric Association American Association of Clinical Endocrinologists www.psych.org/ www.aace.com/ American Society of Anesthesiologists American Association of Diabetes Educators www.asahg.org/ www.aadenet.org/ Centers for Disease Control and Prevention American Cancer Society www.cdc.gov/ www.cancer.org/ Centers for Disease Control and Prevention American College of Allergy, Asthma and Guideline topics: AIDS Immunology www.cdc.gov/hiv/pubs/guidelines.htm#treatment www.acaai.org/ Centers for Disease Control and Prevention American College of Cardiology Guideline topics: Sexually Transmitted Diseases www.acc.org/ www.cdc.gov/mmwr/preview/mmwrhtml/rr5106a1.htm

American College of Chest Physicians Crohn’s and Colitis Foundation of America www.chestjournal.org/ www.ccfa.org/

American College of Gastroenterology The Food and Drug Administration www.acg.gi.org/ www.fda.gov/

American College of Obstetricians and Infectious Disease Society of America Gynecologists www.journals.uchicago.edu/IDSA/guidelines www.acog.org/ Institute of Safe Medication Practices American College of Physicians www.ismp.org/ www.acp.org/ Johns Hopkins AIDS Service American College of Rheumatology www.hopkins-aids.edu/ www.rheumatology.org/ Juvenile Diabetes Foundation International www.jdf.org/

51 MedWatch National Institutes of Health - Ulcerative Colitis www.fda.gov/medwatch/safety.htm www.nlm.nih.gov/medlineplus/ulcerativecolitis.html

National Academy of Sciences National Osteoporosis Foundation www.nal.usda.gov/fnic/dga/rda.html www.nof.org/

National Cancer Institute North American Menopause Society www.cancer.gov/cancerinformation www.menopause.org/

National Foundation for Infectious Diseases United States Department of www.nfid.org/ Health and Human Resources www.os.dhhs.gov/ National Guideline Clearinghouse www.guideline.gov/ University of Pennsylvania Cancer Center www.oncolink.upenn.edu/ National Heart, Lung and Blood Institute www.nhlbi.nih.gov/ U.S. Department of Health and Human Services www.os.dhhs.gov/ National Institutes of Health www.nih.gov/ World Health Organization www.who.int/

A World of Information on Pain www.pain.com/

52 Index

A ACULAR/ACULAR LS . . . 31 . alprazolam ...... 33 ANTIVERT ...... 20 . acyclovir ...... 25 altretamine 2 APHEDRID TAB . . . . .39 . abacavir ...... 25 ADALAT CC ...... 7 alumina/magnesia OTC 21 aprepitant ...... 20 abacavir/lamivudine ...... 25 adalimumab ...... 27 alumina/magnesia/ APRESOLINE ...... 8 abacavir/lamivudine/zidovudine 25 simethicone OTC . . . 21 ADCIRCA ...... 9 . APTIVUS ...... 26 ABILIFY TABLETS . . . . 36. aluminum acetate ADDERALL ...... 34 AQUA-MEPHYTO INJ . . . . 45. abiraterone 1 soln/cream OTC 15 ADDERALL XR . . . . . 34. . ARALEN ...... 26. . acamprosate 33 aluminum chloride hexahydrate 15 adefovir ...... 24 ARANESP ...... 3 acarbose 19 amantadine ...... 11, 25 ADRENACLICK . . . . .45 . ARAVA ...... 27 . . ACCU-CHEK CARE KIT AMARYL ...... 19. . (ACTIVE, AVIVA, ADVAIR DISKUS . . . . .40 . ARCALYST ...... 45 . AMBIEN ...... 36 COMPACT PLUS, NANO ADVAIR HFA ...... 40 . ARICEPT ...... 9 . SMARTVIEW) ...... 18 ambrisentan ...... 8 ADVAIR INHAL AEROSOL . 40 ARIMIDEX ...... 1 ACCU-CHEK TEST STRIPS AMERGE ...... 11. . (ACTIVE, AVIVA, ADVIL ...... 9,. . 27, 49 aripiprazole tablets . . . . 36 AMICAR ...... 4 AVIVA PLUS, COMFORT AFINITOR ...... 2 . ARMOUR THYROID . . . 20 . CURVE, COMPACT, AMIKACIN INJ . . . . . 44. . AFRIN ...... 17,. . 47 AROMASIN ...... 1 . . SMARTVIEW) . . . .18 . amikacin sulfate inj . . . . 44 AGENERASE . . . . . 26. . ARTANE ...... 12 ACCUHIST DROPS . . . .37 . amiloride ...... 7 AGRYLIN ...... 3 . artificial saliva OTC . . . . .17 ACCUHIST PDX DROPS . .37 . amiloride/hydrochlorothiazide 7 AKINETON ...... 11 . ASACOL ...... 21. . ACCUPRIL ...... 4 . . aminocaproic acid 4 ALAVERT ...... 16. . ASMANEX TWISTHALER . . . 40 ACCURETIC ...... 5. . amiodarone ...... 5 ALAVERT ALRG aspirin ...... 49 ACCUTANE ...... 13 . . amitriptyline ...... 11 TAB/SINUS . . . .17, . 47 aspirin/acetaminophen/caffeine 9 acebutalol ...... 6 amitriptyline/perphenazine . . 35 ALAVERT-D ...... 17 . aspirin OTC ...... 4, 27 acetaminophen ...... 49 amitriptyline tablets . . . . 35 ALAVERT D OTC . . . . .47 . aspirin with buffers . . . . 49 acetaminophen OTC . . . 9, 27 amlodipine 6 ALAVERT OTC . . . . . 47. . ASTRAMOR INJ . . . . .44 . acetazolamide ...... 32 ammonium lactate 15 ALAWAY ...... 49 ATABEX PRENATAL . . . .42 . ACETAZOLAMIDE ...... 32 amoxapine ...... 35 ALAWAY OTC ...... 31 ATARAX ...... 16 acetazolamide ext-rel . . . . 32 amoxicillin ...... 23 albuterol ...... 41 atazanavir ...... 26 acetylcysteine ...... 45 AMOXICILLIN CAPSULES ALBUTEROL ...... 41 ACIDOPHILUS ...... 22 AND CHEWABLES . .23 . atenolol ...... 6 albuterol soln ...... 40 acidophilus/bifidus OTC . . .22 amoxicillin/clavulanate . . . 23 atenolol/chlorthalidone . . . .6 albuterol sulfate ...... 40 ACIDOPHILUS/BIFIDUS amoxicillin suspension . . . 23 ATIVAN ...... 33 . . alclometasone ...... 13 WAFER ...... 22 . . AMOXIL SUSP ...... 23 atomoxetine ...... 34 ALDACTAZIDE ...... 7 acidophilus caps and amphetamine/dextroamphetamine atorvastatin 8 tabs OTC ...... 22 ALDACTONE ...... 7 mixed salts ext-rel . . . 34 atovaquone ...... 26 ACIDOPHILUS/ CITRUS ALDOMET ...... 8 amphetamine/dextroamphetamine PECTIN ...... 22 . . ATRIPLA ...... 25 ALDORIL ...... 8 . mixed salts 34 acidophilus/citrus atropine ...... 32 alendronate ...... 19 ampicillin 24 pectin tabs OTC . . . . 22 atropine sulfate ...... 22 ALESSE ...... 29 amprenavir 26 acidophilus OTC 22 ATROVENT ...... 40 . alfuzosin ER ...... 43 ANAFRANIL ...... 34 ACIDOPHILUS/PECTIN . . . . 22 ATROVENT HFA . . . . .40 . alginic acid/sodium anagrelide ...... 3 acidophilus/pectin caps OTC 22 ATUSS DR ...... 39 . bicarbonate OTC . . . 21 ANAPLEX DM ...... 37 ACIDOPHILUS XTRA . . . 22 . AUGMENTIN ...... 23 ALKERAN ...... 1 . ANAPROX ...... 9, . 27 acitretin oral caps . . . . . 15 auranofin 27 ALLANHIST SYP PDX . . . 39 . anastrozole 1 ACLOVATE ...... 13 . AVITA ...... 13. . ALLERGY/CONG . . . . 47. . ANCEF INJ ...... 44 . ACTIFED ...... 17,. . 47 AVONEX/AVONEX PEN . . . . 11 ALLERGY/CONG ANDRODERM . . . . . 18. . ACTIGALL ...... 22 TAB RELIEF ...... 39 axitinib ...... 2 ANDROGEL ...... 18 . . ACTOPLUSMET . . . . .19 . ALLERY/CONG ...... 17 AYGESTIN ...... 30 . ANERGAN ...... 44 . ACTOPLUS MET XR . . . . . 19 allopurinol ...... 27 azathioprine ...... 2, 27 ANTABUSE ...... 33 . ACTOS ...... 19 . . ALPHAGAN P . . . . . 32. . azelaic acid ...... 13

53 azelastine spray ...... 16 BICITRA ...... 43 butalbital/acetaminophen/ CARDEC SYP . . . . . 37. . caffeine 9 azelastine ...... 31 BIO-D DRO -MULSION . . 42. . CARDENE ...... 6 . . butalbital/acetaminophen . . . 9 azithromycin ...... 23 BIO-D-MULSIO DRO FORTE 42 CARDIZEM ...... 7 butalbital/apap/caff/cod 10 AZULFIDINE . . . . .21, . 27 biperiden 11 CARDIZEM CD ...... 7 butalbital/asa/caff/cod 10 AZULFIDINE EN-TABS . 21, 27 bismuth subsalicylate+metronidaz CARDIZEM SR ...... 7 ole+tetracycline . . . . 22 butalbital/aspirin/caffeine . . . 9 CARDURA ...... 5 . . bisoprolol ...... 6 butorphanol nasal spray 10 B CARDURA ...... 43 . bisoprolol/hydrochlorothiazide . 6 BYETTA ...... 19 . . carteolol ...... 32 bacitracin ...... 33 BLEPH-10 ...... 33 carvedilol 6 BACITRACIN . . . . .13, . 48 BONINE ...... 49 C casanthranol-docusate bacitracin OTC ...... 13 bosentan 8 sodium OTC . . . . . 22 C1 Inhibitor, Human 45 baclofen ...... 28 BRETHINE ...... 41 . CASODEX ...... 1 . . CAFERGOT ...... 11 . . BACLOFEN ...... 28 . . brimonidine ...... 32 CATAPRES ...... 5 calamine lotion/ointment OTC 15 BACTRIM ...... 24. . BRIMONIDINE ...... 32 CATAPRES-TTS . . . . . 5. . CALAN ...... 7, 11 BACTRIM DS ...... 24 brimonidine ...... 32 CECLOR ...... 23. . CALAN SR ...... 7 . . BACTROBAN . . . . . 13. . BROMALINE DM ...... 37 CEENU ...... 1. . calcipotriene 15 balsalazide 21 BROMETANE DX ...... 38 cefaclor ...... 23 calcitonin-salmon inj . . . . 19 BALZIVA ...... 29 BROMFED DM ...... 37 cefadroxil 23 calcitonin-salmon nasal spray 19 BANCAP HC, BROMFENEX PD CAP . . 37. . cefazolin sodium for inj . . . 44 VICODIN 5/500 . . . . . 10 calcitriol ...... 15, 41 bromocriptine . . . . . 11, 20 cefdinir 23 BANZEL ...... 12 calcium acetate ...... 46 brompheniramine & cefixime ...... 23 BARACLUDE ...... 24 . . phenylephrine . . . . .37 calcium OTC 41 cefprozil ...... 23 BAYER ...... 4, 27, 49 brompheniramine/ CALTRATE ...... 49 CEFTIN ...... 23 . . BD POSIFLUSH INJ . . . .45 . pseudoephedrine . . . 37 CAMPRAL ...... 33 CEFTRIAX/DEX INJ . . . .44 . beclomethasone 40 brompheniramine/ canakinumab ...... 45 pseudoephedrine CEFTRIAXONE INJ . . . .44 . BENA-D-50 INJ ...... 44 CANASA ...... 21 /dextromethorphan elixir 37 CEFTRIAXONE/ INJ DEX . . 44 BENADRYL . . . . . 16,. . 47 capecitabine 1 brompheniramine/ ceftriaxone sodium for inj 44 benazepril ...... 4 pseudoephedrine/ CAPITROL ...... 15 . dextromethorphan/ ceftriaxone sodium for iv soln 1 CAPOTEN ...... 4 benazepril/hydrochlorothiazide . 4 guaifenesin syrup . . . 37 gm and dextrose . . . 44 BENTYL ...... 21. CAPOZIDE ...... 4 brompheniramine/ ceftriaxone sodium in BENZAC AC ...... 13 . . pseudoephedrine/ capsaicin OTC 27 dextrose inj . . . . . 44 dextromethorphan liquid .37 BENZAMYCIN . . . . . 13. . captopril ...... 4 cefuroxime axetil 23 brompheniramine/ benzonatate ...... 37 captopril/hydrochlorothiazide 4 CEFZIL ...... 23 . . pseudoephedrine benzoyl peroxide 13, 47 /dextromethorphan syrup .37 CARAC ...... 15 . . CELEBREX ...... 27 benztropine ...... 11 brompheniramine/ CARAFATE ...... 21 . celecoxib 27 BERINERT ...... 45 . pseudoephedrine . . . 37 CARAFATE SUSPENSION . 21. CELEXA ...... 35 BRONCHO SALINE . . . .47 . BETACARE CREAM AND carbamazepine ...... 12 CELLCEPT ...... 2 . . LOTION ...... 48 . budesonide ...... 40 carbamazepine ext-rel 12 CENESTIN ...... 30 . BETAGAN ...... 32 budesonide/formoterol . . . 40 carbamide peroxide . . . . 48 CENOGEN OB/ULTRA . . 42. . betamethasone augmented dip 14 budesonide susp . . . . . 40 CARBATROL ...... 12 CENTRUM ...... 42 . betamethasone dipropionate crm/ bumetanide ...... 7 carbetapentane/chlorpheniramine/ cephalexin ...... 23 lotion/oint ...... 14 BUMEX ...... 7 ephedrine/phenylephrine .37 certolizumab pegol . . . . .27 betamethasone val. buprenorphine/naloxone . . 36 carbidopa/levodopa . . . . .11 crm/oint/lotion . . . . .14 CETAPHIL CREAM AND buprenorphine 36 carbidopa/levodopa ext-rel . . 11 LOTION ...... 48 . BETAPACE ...... 6 . . bupropion ...... 35 carbinoxamine/pseudoephedrine cetirizine hydrochloride/ BETA-VAL ...... 14 liquid ...... 37 pseudoephedrine bupropion ext-rel . . . . . 35 bethanechol ...... 43 hydrochloride 12 hours CARBOFED ...... 37 . . BUSPAR ...... 34 extended -release . . . 17 BETIMOL ...... 32. . CARDEC-DM ...... 38 buspirone ...... 34 cetirizine OTC ...... 16 bexarotene 2 CARDEC DM DRO . . . . . 39 busulfan ...... 1 CHANTIX ...... 36. . BIAXIN ...... 23 CARDEC DM SYP . . . . 39. CHILD IBUPRO SUS COLD 39 bicalutamide 1 CARDEC DRO . . . . . 37. . 54 chloral hydrate 36 ciprofloxacin ...... 23, 33 CODIMAL DH . . . . . 39. . cyclopentolate 32 CHLORAL HYDRATE . . . 36 . ciprofloxacin 0.2% in d5w . . 44 COGENTIN ...... 11 . . cyclophosphamide . . . . . 1 chlorambucil 1 ciprofloxacin/dexamethasone 16 COLACE ...... 49. . cyclosporine 2 chlordiazepoxide 33 ciprofloxacin iv soln 44 COLAZAL ...... 21 cyclosporine, modified . . . .2 chlorhexidine gluconate 17 CIPRO I V. . INJ ...... 44 colchicine ...... 27 cyproheptadine ...... 16 chloroquine phosphate . . . 26 CIPRO I .V . SOL ...... 44 COLCRYS ...... 27 CYPROHEPTADINE . . . . . 16 chlorothiazide ...... 7 citalopram ...... 35 COLLOIDAL OATMEAL CYTOMEL ...... 20 BATHS ...... 48 chloroxine ...... 15 clarithromycin ...... 23 CYTOTEC ...... 22 . COLOCORT ...... 21 . . chlorpheniramine/ CLARITIN ...... 16 CYTOVENE ...... 24 dextromethorphan . . . . .37 COLYTE ...... 22 . . CLARITIN OTC . . . . . 47. . CYTOXAN ...... 1 chlorpheniramine ext-rel OTC 16 COMBIVENT . . . . . 40. . CLEARASIL ...... 47 chlorpheniramine maleate COMBIVENT RESPIMAT . .40 CLEAR EYES REDNESS phenylephrine HCL . . 38 D RELIEF ...... 31 COMBIVIR ...... 25 . chlorpheniramine OTC . . . 16 clemastine ...... 16 COMMIT LOZENGES . . . 49 . D3-50 CAP ...... 42 . chlorpheniramine/ CLEMASTINE . . . . . 16. . COMMITT OTC ...... 36 D5W/NACL INJ . . . . .44 . phenylephrine liquid 37 CLEOCIN ...... 26, 30 COMPAZINE ...... 20 DALLERGY DM ...... 37 chlorpheniramine/phenylephrine/ pyrilamine ...... 17 CLEOCIN PHOS INJ . . . . 44 COMPLERA ...... 25 . . DALMANE ...... 35 chlorpheniramine/ CLEOCIN T ...... 13 . . COMPLETE NATALCARE danazol 29 PAK DHA . . . . . 42. . phenylephrine syrup 37 CLIMARA ...... 30 DANOCRINE ...... 29 . . COMTAN ...... 11. . chlorpheniramine/ clindamycin . . . . 13, 26, 30 DANTRIUM ...... 28 pseudoephedrine . . . 37 CONCERTA ...... 34 clindamycin phosphate inj . . 44 dantrolene 28 chlorpheniramine/ COPAXONE ...... 11 . . pseudoephedrine ext-rel .17 clindamycin soln 13 dapsone ...... 26 CORDARONE ...... 5 . DAPSONE ...... 26 . chlorpheniramine tan/ clindamycin supp . . . . . 30 CORDRAN ...... 14 phenylephrine tan susp . 38 CLINORIL ...... 9, 27 DARAPRIM ...... 26 . COREG ...... 6. . chlorphen-PE-methscopolamine clobazam 12 darbepoetin alfa ...... 3 syrup ...... 37 CORGARD ...... 6 clobetasol propionate crm/gel/ darunavir 26 chlorphen tan/carbetapentane oint/soln ...... 14 CORICIDIN TAB CGH/CLD .37 dasatanib ...... 2 tan susp ...... 38 clomipramine ...... 34 CORTAID ...... 48. . DAYPRO ...... 9, 27 chlorphen tan/pseudoeph tan susp ...... 38 clonazepam ...... 12, 33 CORTEF ...... 17. . DDAVP ...... 20 . . chlorphen tan/pyrilamine clonidine 5 cortisone acetate . . . . . 17 DEBROX ...... 48. . tan/PE tan susp . . . . 38 clonidine transdermal . . . . 5 CORTISPORIN . . . . .31 . DECADRON ...... 17 . . chlorpromazine ...... 36 clopidogrel 4 CORTIZONE ...... 13 . . DE-CHLOR DM ...... 39 chlorpropamide ...... 19 clorazepate 33 COSOPT ...... 32 DECONAMINE SR ...... 17 chlorthalidone 7 clotrimazole ...... 14, 47 COUMADIN ...... 3 deferasirox 4 CHLORTHALIDONE . . . .7 . clotrimazole OTC . . . .14, 30 COZAAR ...... 5 . DELATESTRYL . . . . . 18. . CHLOR-TRIMETON . . . .47 . clotrimazole troches 24 CPM/PSE ...... 37 delavirdine 25 CHLOR-TRIMETON clotrimazole with CREON ...... 22 . . DELFEN ...... 48 ALLERGY . . . . . 16. . betamethasone . . . . 14 CRIXIVAN ...... 26 . DELSYM ...... 38, 47 chlorzoxazone ...... 28 clozapine 36 crizotinib 2 DELTASONE ...... 18 . . cholecalciferol OTC . . . 41, 42 CLOZARIL ...... 36 . CROLOM ...... 31. . DEMEROL ...... 10 . cholestyramine 8 CODAL-DM ...... 39 cromolyn 40 DEPAKENE ...... 12 choline magnesium codeine/acetaminophen 10 trisalicylate 9, 27 cromolyn sodium OTC . . . 17 DEPAKOTE . . . . . 11, 12, 34 codeine/chlorpheniramine/ cromolyn sodium . . . . . 31 ciclopirox 14 pseudoephedrine . . . 38 DEPAKOTE ER . . .11, . 12, 34 crotamiton ...... 15 cilostazol 4 codeine/guaifenesin/ DEPO-PROVERA . . . . 28. . CILOXAN ...... 33. pseudoephedrine . . . 38 CUPRIMINE ...... 27 . . DEPO-TESTOSTERONE . .18 . CURITY ALCOHOL PADS . . 48 cimetidine ...... 21 codeine/guaifenesin 38 DERMAPHOR OINTMENT . 48 CIMZIA ...... 27 . . codeine/promethazine/ CUTIVATE ...... 14. DERMA-SMOOTHE OIL/FS .13 phenylephrine . . . . 38 cinacalcet ...... 46 cyanocobalamin inj . . . . .42 DERMATOP ...... 14 codeine/promethazine 38 CIPRO ...... 23 . . cyclobenzaprine 28 DESENEX POWDER . . . 14 . codeine sulfate ...... 10 CYCLOGYL ...... 32 desipramine ...... 35

55 desmopressin ...... 20 DIDRONEL ...... 20 . DOVONEX ...... 15 . emtricitabine/rilpivirine/ tenofovir ...... 25 desogestrel/EE ...... 29 DIFLUCAN . . . . . 24,. . 30 doxazosin ...... 5, 43 emtricitabine/tenofovir 25 desogestrel/EE ...... 28 digoxin ...... 5 doxepin 35 EMTRIVA ...... 25. . desonide ...... 13 DIHISTINE DH ...... 38 doxycycline hyclate . . . . .24 enalapril ...... 4 DESOWEN ...... 13 . dihydroergotamine 11 DRAMAMINE ...... 49 . enalapril/hydrochlorothiazide . . 4 desvenlafaxine 35 dihydroergotamine inj ...... 11 DRISDOL ...... 42. . ENBREL ...... 27 DESYREL ...... 35 DIHYDRO-PE SYP . . . . . 39 DROXIA ...... 2. . enfuvirtide ...... 24 DETROL ...... 43 DILACOR XR ...... 7 DUETACT ...... 19 ENJUVIA ...... 30 dexamethasone ...... 17 DILANTIN ...... 12. . DULCOLAX ...... 48 enoxaparin 4 dexamethasone sodium DILAUDID ...... 10 . DULERA ...... 40. . phosphate soln . . . . 31 entacapone ...... 11 diltiazem ...... 7 duloxetine ...... 35 DEXASOL ...... 31 entecavir ...... 24 diltiazem ext-rel ...... 7 DUOFILM ...... 50. . DEXEDRINE ...... 34 . ENULOSE ...... 22 diltiazem sustained release . . 7 DUONEB ...... 40. . DEXEDRINE SPANSULE . . 34 E-OINTMENT ...... 48 DIMEATAPP DRO DURADRYL ...... 37 dextroamphetamine ext-rel . . 34 DECONGES . . . . 17. . epinephrine QL ...... 45 DURAGESIC ...... 10. . dextroamphetamine . . . . 34 dimenhydrinate ...... 49 EPIPEN ...... 45 DURAMORPH INJ . . . . 44. dextromethorphan/ DIMETAPP ...... 47 . EPIPEN JR ...... 45 . DURATUSS DM ELX . . . 38 . brompheniramine/ DIMETAPP CLD EPIVIR ...... 25 pseudoephedrine . . . 38 DURICEF ...... 23. . ELX/ALLERGY . . . .37 . EPIVIR HBV ...... 24 dextromethorphan/carbinoxamine/ DYAZIDE ...... 7 . DIMETAPP DRO pseudoephedrine drops 38 epoetin alfa ...... 3 DCON/CGH . . . . 39. dextromethorphan- EPOGEN ...... 3 . DIMETAPP DRO guaifenesin liq . . . . 38 E DECONGES . . . . 47. . EPZICOM ...... 25 dextromethorphan/ DIMETAPP ELX CLD/ALLE . 37. EASIVENT CHAMBER . . . . 46 ergocalciferol ...... 42 guaifenesin OTC 38 DIMETAPP SYP CGH/CLD . 37 . EASIVENT MASK ...... 46 ergotamine/caffeine . . . . .11 dextromethorphan-guaifenesin soln 38 DIPENTUM ...... 21 EasiVent Mask 46 ERIVEDGE ...... 2 . . dextromethorphan hbr syrup . 38 diphenhydramine . . . . . 16 EasiVent valved holding erlotinib ...... 2 chamber ...... 46 dextromethorphan polistirex diphenhydramine hcl inj 44 ERYC ...... 23. . econazole ...... 14 ext rel OTC 38 diphenhydramine OTC . .16, 36 ERYGEL ...... 13. . ecothiophate 32 dextromethorphan/ diphenoxylate/atropine . . . 20 E RY-TAB ...... 23. . promethazine . . . . 38 ECOTRIN . . . . . 4,. 27, 49 DIPROLENE ...... 14 . . ERYTHROCIN . . . . . 23. . dextromethorphan/quinidine . 36 ED A-HIST TABLETS AND DIPROLENE AF . . . . .14 . LIQUID ...... 38 erythromycin 33 dextrose 5% w/ sodium chloride 0.45% . . . . 44 dipyridamole 4 EDGE OB CHW . . . . .42 . ERYTHROMYCIN . . . . 33. . DEXTROSE INJ ...... 45 disopyramide ...... 6 EDURANT ...... 25 erythromycin/benzoyl peroxide 13 dextrose inj ...... 45 disopyramide ext-rel 6 E .E .S ...... 23. . erythromycin delayed-rel . . .23 DEXTROSTAT . . . . . 34. . disulfiram ...... 33 efavirenz ...... 25 erythromycin ethylsuccinate . 23 D .H .E . 45 ...... 11. . DITROPAN ...... 43 . efavirenz/emtricitabine/ erythromycin gel 2% . . . . 13 DIABINESE ...... 19. DITROPAN XL . . . . . 43. . tenofovir ...... 25 erythromycin soln . . . . . 13 DIAMOX SEQUELS . . . .32 . DIURIL ...... 7 EFUDEX ...... 15. . erythromycin stearate . . . . 23 DIAQUA-2 INJ . . . . . 44. . divalproex sodium ELAVIL ...... 11, . 35 erythromycin/sulfisoxazole . . 23 delayed-rel 11, 12, 34 DIASTAT ACUDIAL . . . .12 . ELDEPRYL ...... 12 . ESKALITH CR . . . . . 34. . divalproex sodium electrolyte soln, oral OTC 42 ESTRACE ...... 30 diazepam 28, 33 ext-rel . . . . 11, 12, 34 ELIDEL ...... 16 . . ESTRACE CRM . . . . .30 . diazepam rectal gel . . . . 12 docusate calcium plus OTC . 22 ELIMITE ...... 15 estradiol ...... 30 diclofenac sodium 31 docusate potasssium OTC . . 22 ELOCON ...... 14. . estradiol ...... 30 diclofenac sodium delayed dofetilide 6 release ...... 9, 27 eltromobpag ...... 46 estramustine phosphate sodium 1 DOMEBORO ...... 48 dicloxacillin ...... 24 EMCYT ...... 1. . estrogens, conjugated 30 donepezil ...... 9 DICLOXACILLIN ...... 24 EMEND ...... 20 . . estrogens, conjugated crm . . 30 dornase alfa ...... 45 dicyclomine ...... 21 EMETROL ...... 49 estrogens, conjugated/ dorzolamide ...... 32 didanosine 25 EMLA ...... 16. . medroxyprogesterone . . 30 dorzolamide/timolol maleate . 32 didanosine delayed-rel . . . 25 emtricitabine 25 56 estrogens, conjugated, FIORICET W/CODEINE . . . . 10 FOLTABS PAK PLUS DHA RE GLYCERIN SUPPOSITORY . 22. synthetic A 30 OB + DHA PAK . . . . . 42 FIORINAL ...... 9 glycerin suppository OTC 22 estrogens, conjugated, FOLTABS PRENATAL . . . 42 . FIORINAL W/CODEINE . . . . 10 GLYCERIN TOPICAL . . . . 48 synthetic B 30 FORADIL AEROLIZER . . 40. FIRAZYR ...... 45. . glycopyrrolate ...... 21 estropipate 30 formoterol inhalation caps 40 FLAGYL ...... 26, 30 GLYNASE ...... 19 ESTROSTEP FE . . . . .29 . FORTEO ...... 20 FLAREX ...... 31 . . GRIFULVIN V ...... 24 . . etanercept ...... 27 FORTICAL ...... 19 flecainide 6 griseofulvin microsize . . . . 24 ethambutol 26 FORTOVASE ...... 26 FLEET ENEMA . . . . . 48. . griseofulvin ultramicrosize . . 24 ETHMOZINE ...... 6 FOSAMAX ...... 19 FLEET PHOSPHO-SODA . . 48 GRIS-PEG ...... 24 . ethosuximide 12 fosamprenavir ...... 26 FLEXERIL ...... 28 GUAIFED ...... 38. . ethynodiol diacetate/EE 29 fosinopril/hydrochlorothiazide 5 FLOMAX ...... 43 guaifenesin ext-rel OTC 38 etidronate ...... 20 fosinopril 4 FLONASE ...... 17 guaifenesin OTC 38 etodolac ...... 9, 27 furosemide ...... 7 FLORANEX ...... 22 . guaifenesin/pseudoephedrine/ etonogestrel/EE ring . . . . 28 furosemide inj 44 dextromethorphan . . . . 38 FLORINEF ...... 17 . etoposide ...... 2 FUZEON KIT ...... 24 . . guaifenesin/pseudoephedrine FLOVENT DISKUS . . . . 40. etravirine 26 ext rel 38 FLOVENT HFA . . . . . 40. . EULEXIN ...... 1 . guaifenesin/pseudoephedrine FLOXIN ...... 23 . . G ext rel OTC 38 EURAX ...... 15 . . fluconazole 24, 30 guaifenesin/pseudoephedrine everolimus ...... 2, 3 gabapentin ...... 12 fludarabine 1 syrup OTC ...... 38 EVISTA ...... 20 GABITRIL ...... 12 fludrocortisone 17 guaifenesin syrup . . . . . 38 EXCEDRIN MIGRAINE . . . 9 . galantamine ...... 9 FLUMADINE ...... 25 . . GUAIFEN PSE . . . . . 38. . EXELON ...... 9 . ganciclovir ...... 24 flunisolide ...... 17 guanabenz 8 exemestane ...... 1 gatifloxin ...... 33 flunisolide nasal solution . . 40 guanfacine 5, 34 exenatide 19 GEL-KAM ...... 42. . fluocinolone acetonide . .13, 14 GUIATUSS AC ...... 38 EXJADE ...... 4. . gemfibrozil ...... 8 fluocinonide emulsified base 14 GUIATUSS DAC ...... 38 exogabine ...... 12 GENGRAF ...... 2 . . fluoride 42 GYNE-LOTRIMIN . . . . 30, 47 ezetimibe/simvastatin . . . . 8 GENTAK ...... 13, . 33 GYNOL II ...... 48. . fluorometholone ...... 31 gentamicin 13, 33 fluorometholone acetate 31 gentamicin/ F fluorometholone susp ...... 31 prednisolone acetate . . 31 H famotidine ...... 21 FLUOROPLEX ...... 15 GENTEX ADE ...... 42 HALCION ...... 35 FARESTON ...... 1 . . fluorouracil 15 GEODON ...... 36 HALDOL ...... 36. . febuxostat ...... 28 fluoxetine 35 GG/CODEINE ...... 38 HALDOL DECANOATE . . 36. FELDENE ...... 9,. . 27 fluphenazine 36 GG/DM CR ...... 38 halobetasol propionate . . . 14 felodipine ext-rel 6 fluphenazine decanoate 36 GG/PSE CR ...... 38 . haloperidol 36 FEMARA ...... 1 flurandrenolide 14 glatiramer acetate . . . . . 11 haloperidol decanoate 36 fenofibrate ...... 8 flurazepam 35 GLEEVEC ...... 2 HECORIA ...... 2 . . fenoprofen ...... 9, 27 flurbiprofen 31 glimepiride 19 HELIDAC ...... 22. . FENTANYL CIT INJ . . . .44 . flutamide 1 glipizide ...... 19 heparin 4 fentanyl citrate inj 44 fluticasone ...... 17 glipizide ext-rel ...... 19 HEPARIN ...... 4 . fentanyl transdermal 10 fluticasone HFA ...... 40 GLUCAGON ...... 18 HEPSERA ...... 24 FEOSOL ...... 42, . 49 fluticasone propionate 14, 40 glucagon, human recombinant 18 hexachlorophene . . . . . 15 FERGON ...... 49. . fluticasone/salmeterol 40 GLUCOPHAGE . . . . .19 . HEXALEN ...... 2 ferrous bisglycinate/ fluvoxamine ...... 34 GLUCOPHAGE ER . . . .19 . HIPREX ...... 43 . . polysaccarides iron caps FML ...... 31 . . glucose oral tablets . . . . 48 OTC ...... 42 HISTACOL DM . . . . . 37. . FML FORTE ...... 31 GLUCOTROL . . . . . 19. . ferrous sulfate OTC . . . . .42 HISTEX ...... 37 . . FML SOP ...... 31. . GLUCOTROL XL ...... 19 filgrastim ...... 3 HISTUSSIN HC ...... 38 folic acid ...... 42 GLUCOVANCE ...... 19 FINACEA ...... 13. . HIVID ...... 25. . FOLIC ACID ...... 42 . . glyburide 19 finasteride ...... 43 homatropine ...... 32 glyburide, micronized . . . . 19 FIORICET ...... 9 . . HUMATIN ...... 26. .

57 HUMIRA ...... 27 IMODIUM A-D . . . . 20,. 48 isosorbide dinitrate . . . . . 8 lactulose ...... 22 HYCODAN ...... 39 . IMURAN ...... 2, 27 ISOSORBIDE DINITRATE ER 7 LAMICTAL ...... 12 . hydralazine 8 INCIVEK ...... 25 isosorbide dinitrate ext-rel . . 7 LAMISIL ...... 24 HYDREA ...... 2 INCRELEX ...... 19 . isosorbide mononitrate . . . .7 LAMISIL AT ...... 14 . HYDROCHLOROTHIAZIDE . 7 indapamide ...... 7 isosorbide mononitrate ext-rel . 7 lamivudine ...... 24 hydrochlorothiazide . . . . . 7 INDERAL ...... 6,. . 11 isotretinoin 13 lamivudine ...... 25 HYDROCODO/GG SYP . .38 INDERIDE ...... 6 itraconazole ...... 24 lamivudine/zidovudine . . . 25 hydrocodone/acetaminophen 10 indinavir ...... 26 ivacaftor ...... 45 lamotrigine 12 hydrocodone/chlorpheniramine/ INDOCIN ...... 9,. . 27 LANOXICAPS ...... 5 phenylephrine . . . . 38 indomethacin . . . . . 9, 27 J LANOXIN ...... 5 hydrocodone/guaifenesin 38 INFERGEN ...... 24 . lansoprazole+amoxicillin+ hydrocodone/homatropine . . 39 JAKAFI ...... 2 clarithromycin . . . . .21 INFLAMASE FORTE . . . .31 . HYDROCODONE/TAB JANUMET ...... 19. . lansoprazole del-rel . . . . .21 INLYTA ...... 2 HOMATROP . . . . 39. JANUMET XR ...... 19 lansoprazole ...... 21 Inspirease ...... 46 hydrocortisone 13, 17, 48 JANUVIA ...... 19 LANTUS ...... 18. . INSPIREASE ...... 46 . hydrocortisone butyrate lapatinib ditosylate 2 crm/oint/soln 14 insulin aspart protamine 70%/ insulin aspart 30% . . 18 K LARIAM ...... 26 hydrocortisone crm . . . 13, 15 insulin aspart ...... 18 LASIX ...... 7 . . hydrocortisone crm, oint, KALETRA ...... 26. . lot OTC 13 insulin detemir 18 latanoprost 32 KALYDECO ...... 45 . hydrocortisone enema 21 insulin glargine ...... 18 leflunomide ...... 27 KAOPECTATE ...... 48 HYDROMET SYP ...... 39 insulin human OTC . . . . 18 lenalidomide 3 KAYEXALATE ...... 41 . . hydromorphone ...... 10 insulin isophane human 70%/ LETAIRIS ...... 8 . K-DUR ...... 41 regular 30% OTC . . . 18 hydroxychloroquine . . . 26, 27 letrozole ...... 1 KEFLEX ...... 23 insulin isophane human OTC 18 hydroxyurea ...... 2 LEUKINE ...... 3 . INTAL ...... 40. . KENALOG ...... 14 . hydroxyzine HCL . . . . . 16 leuprolide ...... 3 INTELENCE ...... 26 KENALOG IN ORABASE . .17 . hydroxyzine pamoate . . . . 16 levalbuterol HCl 40 KEPPRA ...... 12 interferon alfa-2a ...... 3 hyoscyamine, methenamine, LEVAQUIN ...... 23 . interferon alfa-2b . . . . 3, 24 ketoconazole 14, 24 phenyl salicylate, sodium LEVAQUIN INJ . . . . . 44. . phosphate monobasic, interferon alfacon-1 . . . . .24 ketoconazole shampoo . . . 15 methylene blue . . . . 43 LEVEMIR ...... 18. . interferon beta-1a . . . . . 11 ketoprofen ...... 9, 27 hyoscyamine sulfate 21 levetiracetam 12 INTRON A ...... 3, 24 ketorolac 31 hyoscyamine sulfate ext-rel 21 levobunolol ophthalmic solution 32 INTUNIV ...... 34 KETOROLAC INJ ...... 43 HYPERCARE ...... 15 . . levocetirizine tabs . . . . . 16 INVEGA SUSTENNA . . . . 36 ketorolac tromethamine im inj 43 HYPOTEARS ...... 49 . levofloxacin in d5w iv soln . . 44 INVIRASE ...... 26 ketorolac tromethamine inj . . 43 HYTONE ...... 13. . levofloxacin iv soln . . . . 44 ipratropium/albuterol inhaler . 40 ketorolac tromethamine . . . .9 HYTRIN ...... 5, . 43 levofloxacin ...... 23 ipratropium/albuterol . . . . 40 ketotifen ...... 31 levonorgestrel ...... 28 KLONOPIN ...... 12, 33 ipratropium/albuterol soln 40 levonorgestrel/EE . . . . . 29 I K-LOR ...... 41. . ipratropium HFA 40 levothyroxine 20 KLOR-CON ...... 41. IBUOROFEN TAB COLD/SIN 39 ipratropium soln ...... 40 LEVOXYL ...... 20. . K-LYTE ...... 41 ibuprofen 9, 27, 49 ISENTRESS ...... 26 LEVSIN ...... 21 . . KO R LY M ...... 20 ibuprofen OTC 9, 27 ISMO ...... 7 . . LEVSINEX ...... 21 . K-PHOS ...... 41 icatibant ...... 45 isoniazid ...... 26 LEXIVA ...... 26 ILARIS ...... 45 ISONIAZID ...... 26 KUVAN ...... 20 LIBRIUM ...... 33. . imatinib mesylate ...... 2 ISOPTO ATROPINE . . . .32 . LIDAMANTEL ...... 15 . . IMDUR ...... 7 ISOPTO CARPINE ...... 32 L LIDEX ...... 14 imipenem-cilastatin intravenous ISOPTO HOMATROPINE . .32 . labetalol ...... 6 LIDEX E ...... 14 . . for soln 44 ISOPTO HYOSCINE . . . . . 32 LAC-HYDRIN ...... 15 lidocaine ...... 15, 16 IMIPENEM/CIL INJ . . . . . 44 ISORDIL ...... 7 . lacosamide 12 lidocaine/prilocaine imipramine HCL tablets 35 ISORDIL S .L ...... 8. . lactobacillus chewable 2.5% cream . . . . . 16 IMITREX ...... 11 isosorbide dinitrate . . . . . 7 tablets OTC . . . . . 22 lidocaine viscous . . . . . 17

58 linezolid ...... 26 LUEKERAN ...... 1 . . mesalamine supp . . . . . 21 mifeprstone ...... 20 liothyronine ...... 20 LUPRON ...... 3 . MESTINON ...... 11 MIGRANAL ...... 11 liotrix ...... 20 LUPRON DEPOT ...... 3 MESTINON TIMESPAN . . 11. . MINIPRESS ...... 5 LIPITOR ...... 8. . LUPRON DEPOT-PED . . . . 3 METADATE ER . . . . . 34. . MINOCIN ...... 24 liraglutide ...... 19 LURIDE ...... 42 METAMUCIL ...... 48 . minocycline capsules . . . . 24 lisdexamfetamine . . . . . 34 LUVOX ...... 34 metaproterenol 41 minoxidil ...... 8 lisinopril/hydrochlorothiazide . . 5 LY R I CA ...... 12 . . METAPROTERENOL SYRUP 41 MINUTUSS DR SYP . . . .39 . lisinopril ...... 4 LYSODREN ...... 2 . . metformin ...... 19 MIRALAX ...... 22. . lithium carbonate . . . . . 34 LYSTEDA ...... 31. . metformin ER ...... 19 MIRAPEX ...... 11 LITHIUM CARBONATE . . 34. metformin/glyburide 19 MIRCETTE ...... 28 . lithium carbonate ext-rel . . 34 M methadone tablets 10 mirtazapine tabs 35 LITHOBID ...... 34 methazolamide ...... 32 misoprostol ...... 22 MAALOX ...... 21 LMX-4 ...... 16. . methenamine hippurate 43 mitotane ...... 2 MAALOX LIQUID ...... 48 LOCOID ...... 14 METHERGINE . . . . 20,. 31 MOBIC ...... 9, . 27 MACROBID ...... 26 . . LODINE ...... 9, 27 methimazole ...... 20 MODICON ...... 29 . MACRODANTIN . . . . .26 . LOESTRIN ...... 29 methocarbamol ...... 28 MODURETIC ...... 7 magnesium oxide OTC . . . 42 LOESTRIN FE ...... 29 methotrexate 27 mometasone/formoterol 40 MAG-OX ...... 42, 50 LOFIBRA ...... 8 . methoxsalen ...... 15 mometasone furoate 14 malathion ...... 15 LOMOTIL ...... 20. . methyldopa ...... 8 mometasone 40 MAPAP COLD TAB . . . . . 39 lomustine ...... 1 methyldopa/HCTZ 8 MONISTAT . . . . . 30,. . 47 maprotiline 35 LONITEN ...... 8 . methylergonovine . . . .20, 31 MONISTAT 3 ...... 30 . maraviroc ...... 26 LO/OVRAL ...... 29 . methylnaltrexone . . . . . 22 MONISTAT-DERM . . . . 14. . MATERNA ...... 42 loperamide 20 methylphenidate ext-rel . . . 34 MONOPRIL ...... 4 MATULANE ...... 2 . . LOPERAMIDE . . . . . 20. . methylphenidate 34 MONOPRIL-HCT . . . . .5 . MAXALT/MAXALT MLT . . . 11 . loperamide OTC 20 methylprednisolone . . . . 18 montelukast ...... 41 MAXITROL ...... 31 . LOPID ...... 8 metipranolol 0.3% ophthalmic moricizine ...... 6 MAXZIDE ...... 7 solution 32 lopinavir/ritonavir . . . . . 26 morphine ext-rel 10 MAXZIDE-25 ...... 7 metoclopramide ...... 20 LOPRESSOR ...... 6 . morphine 10 M-CLEAR WC . . . . . 38. . metolazone ...... 7 loratadine OTC ...... 16 morphine sulfate inj 44 mebendazole ...... 26 metoprolol 6 loratadine/pseudoephedrine morphine sulfate iv soln . . 44 ext-rel OTC . . . . . 17 mecasermin ...... 19 metoprolol succinate . . . . 6 MORPHINE SUL INJ . . . . 44 loratadine & pseudoephedrine meclizine 20 METROCREAM ...... 15 MOTRIN ...... 9,. . 27 SR ...... 39 meclizine 49 METROGEL ...... 15, 30 MOTRIN IB ...... 49 . lorazepam ...... 33 MEDROL ...... 18. METROGEL-VAGINAL . . 30. MOZOBIL ...... 4 LORCET ...... 10 medroxyprogesterone METROLOTION . . . . .15 . MS CONTIN ...... 10. . LORCET PLUS ...... 10 . acetate ...... 28, 30 metronidazole . . . 15, 26, 30 MSIR ...... 10 . LORTAB ...... 10 . . mefloquine 26 MEVACOR ...... 8 . . MUCINEX ...... 38 LORTAB ELIXIR . . . . . 10 . MEGACE ...... 1 . mexiletine ...... 6 MUCINEX D ...... 38 . losartan/HCTZ 5 megestrol acetate ...... 1 MEXITIL ...... 6 MUCINEX DM . . . . . 38. . losartan ...... 5 MELLARIL ...... 37 MIACALCIN ...... 19 . . MUCOMYST ...... 45 . . LOTENSIN ...... 4 . . meloxicam ...... 9, 27 MICATIN ...... 14, 47 MULTI SYMPTOM TAB COLD LOTENSIN HCT . . . . . 4. . melphalan ...... 1 miconazole 14, 30, 47 RLF ...... 39 LOTRIMIN AF ...... 14, 47 memantine 9 miconazole OTC 14, 30 multivitamins/fluoride/±iron 42 LOTRISONE ...... 14 . . meperidine 10 miconazole powder . . . . .14 multivitamins/minerals OTC 42 lovastatin 8 MEPHYTON ...... 42 . . MICRO-K 10 ...... 41 . . mupirocin ointment . . . . 13 LOVENOX ...... 4 MEPRON ...... 26 MICRONASE ...... 19 MURINE ...... 49 loxapine ...... 36 mercaptopurine ...... 1 MICROZIDE ...... 7. . MURO 128 ...... 33 . LOXITANE ...... 36 mesalamine delayed-rel 21 MIDAMOR ...... 7 . . MYAMBUTOL . . . . . 26. . LOZOL ...... 7. . mesalamine ...... 21 midodrine ...... 8 MYCELEX ...... 14 LUDIOMIL ...... 35 mesalamine ext-rel . . . . .21

59 MYCELEX ...... 24 . NEPTAZANE ...... 32 . . NORDETTE ...... 29. ONE TOUCH TEST STRIPS (BASIC/PROFILE, MYCITRACIN ...... 48 . NESTABSCBF/FA/RX . . . 42 . norethindrone ...... 29 SURESTEP, ULTRA) . .18 . MYCOBUTIN ...... 26 . . NEULASTA ...... 3 . . norethindrone acetate 30 ONFI ...... 12 MYCOLOG-II ...... 14 . . NEUMEGA ...... 3 . . norethindrone acetate/EE . . 29 OPANA ER ...... 10 . mycophenolate mofetil . . . .2 NEUPOGEN ...... 3. . norethindrone acetate/EE/iron 29 oprelvekin ...... 3 mycophenolate sodium . . . .2 NEUPRO ...... 11. . norethindrone/EE . . . .28, 29 OPTIPRANOLOL ...... 32 MYCOSTATIN . . . . 14,. 24 NEURONTIN ...... 12 norethindrone/ME 29 OPTIVAR ...... 31. . MYDRIACYL ...... 32 . . nevirapine ...... 25 NORFLEX ...... 28 . ORAP ...... 37. . MYFORTIC ...... 2 . . nevirapine ER ...... 25 norgestimate/EE 29 ORAPRED ...... 18 . MYLANTA ...... 21. . NEXAVAR ...... 2 . norgestrel ...... 29 orphenadrine ext-rel 28 MYLANTA LIQUID . . . . 48. niacin 8 norgestrel/EE ...... 29 ORTHO-CEPT ...... 29 MYLERAN ...... 1 niacin ext-rel 8 NORPACE ...... 6 . . ORTHO COIL ...... 28 MYLICON ...... 48 NIACOR ...... 8 NORPACE CR ...... 6 ORTHO-CYCLEN . . . . 29. . MYSOLINE ...... 12 NIASPAN ...... 8 . NORPRAMIN . . . . . 35. . ortho diaphragm 28 nicardipine 6 nortriptyline ...... 35 ORTHO EVRA . . . . . 29. . NICODERM CQ . . . 36, . 49 NORVASC ...... 6 . . N ORTHO FLAT ...... 28 NICORETTE OTC . . . . 36. NORVIR ...... 26 nadolol 6 ORTHO FLEX ...... 28 NICOTINE GUM . . . . .49 . NOVOLIN ...... 18, . 48 NALFON ...... 9, 27 ORTHO MICRONOR . . . 29 . nicotine patches 36 NOVOLIN N ...... 18 naltrexone ...... 33, 36 ORTHO-NOVUM . . . . 28, 29 nicotine polacrilex gum . . . 36 NOVOLIN R ...... 18 NAMENDA ...... 9 . . ORTHO TRI-CYCLEN . . . . . 29 nicotine polacrilex lozenge . . 36 NOVOLOG ...... 18 naphazoline/antazoline . . . 31 ORUDIS ...... 9, 27 nicotine ...... 36 NOVOLOG MIX ...... 18 naphazoline/glycerin . . . . 31 OS-CAL ...... 41, . 49 NICOTROL INHALER . . . 36 . NUCYNTA ER ...... 10 naphazoline HCL soln . . . 31 oseltamivir ...... 25 NICOTROL NS ...... 36 NUEDEXTA ...... 36 . naphazoline/zinc sulfate 31 OVCON 50 ...... 29 NICOTROL ...... 49 . NULYTELY ...... 22 NAPHCON A ...... 49 . OVIDE ...... 15. . nifedipine ...... 6 NUVARING ...... 28 NAPROSYN . . . . . 9,. 27 OVRAL ...... 29 nifedipine ext-rel 7 nystatin 14, 24 naproxen 9, 27 OVRETTE ...... 29. . NIFEREX ...... 42, . 50 nystatin/triamcinolone 14 naproxen sodium . . . . 9, 27 oxaprozin 9, 27 NIFEREX-PN FORTE . . . . . 42 NYTOL QUICK CAPS . . . 36 . naratriptan ...... 11 oxazepam ...... 33 nilotinib ...... 2 NASALCROM ...... 17 oxcarbazepine ...... 12 nimodipine 7 O NATACHEW ...... 42 OXSORALEN-ULTRA . . . 15 . NIMOTOP ...... 7 NATALCARE ...... 42 OCEAN NASAL SPRAY . . 17. . oxybutynin chloride . . . . .43 NITREK ...... 8 nateglinide 19 octreotide ...... 2 oxybutynin IR ...... 43 NITRO-BID ...... 8 . . NAVANE ...... 37. . OCUFEN ...... 31. . oxycodone/acetaminophen 10 NITRO-DUR ...... 8 nedocromil 40 OCUFLOX ...... 33 . oxycodone/aspirin 10 nitrofurantoin ext-rel 26 nelfinavir ...... 26 ofloxacin ...... 33 oxycodone ER 10 nitrofurantoin macrocrystals 26 NEO DM ...... 37 ofloxacin tabs ...... 23 oxycodone 10 nitroglycerin ...... 8 neomycin/polymyxin B/ OFORTA ...... 1 OXYCONTIN ...... 10. . bacitracin OTC 13 nitroglycerin ext-rel . . . . . 7 OGEN ...... 30 OXYFAST ...... 10. . neomycin/polymyxin B/ nitroglycerin oint 8 olanzapine tablets 36 OXY IR ...... 10 . . dexamethasone . . . . 31 nitroglycerin transdermal . . . 8 olsalazine sodium . . . . . 21 oxymetazoline OTC . . . . .17 neomycin/polymyxin B/ NITROLINGUAL . . . . . 8. . gramicidin ...... 33 omalizumab ...... 40 oxymorphone ...... 10 NITROSTAT ...... 8 neomycin/polymyxin B/ omeprazole delayed-rel . . . 21 NIX ...... 49 . . hydrocortisone 31 OMNICEF ...... 23 . P NIX CREME RINSE . . . .15 . neomycin sulfate . . . . . 26 OMNITROPE ...... 19 . . NIZORAL ...... 14, 24 paliperidone 36 NEORAL ...... 2 ondansetron ...... 20 NIZORAL SHAMPOO . . . 15 . palivizumab ...... 26 NEOSPORIN . . . . 13, 33, 48 ONE TOUCH SYSTEMS NOLVADEX ...... 1 . . PAMELOR ...... 35 . NEO-SYNEPHRINE . . .17, . 47 (ULTRA, ULTRASMART, NORCO ...... 10. . ULTRA2, ULTRAMINI) . 18. PANCREAZE ...... 22 . . NEPHROCAPS ...... 43

60 pancrelipase 22 phenylephrine/ PIPER/TAZOBA INJ . . . .44 . PREMPRO ...... 30 . chlorpheniramine . . . 39 pantoprazole 21 piroxicam 9, 27 PRENATAL VITAMINS phenylephrine/chlorpheniramine/ W/ FOLIC ACID . . . 42 . PARAFON FORTE DSC . . 28. . PLAN B ...... 28 dextromethorphan liquid 39 prenatal vitamins w/folic acid 42 PARLODEL ...... 11, 20 PLAQUENIL . . . . .26, . 27 phenylephrine/chlorpheniramine/ prenatal vit w/ FE bisglyc-FE PARNATE ...... 34. . dextromethorphan syrup 39 PLAVIX ...... 4 prot succ-FA 42 paromomycin ...... 26 phenylephrine/chlorpheniramine/ PLENDIL ...... 6 . prenatal vit w/ FE bisglycinate dihydrocodeine . . . . 39 paroxetine ...... 35 plerixafor 4 chelate-FA ...... 42 phenylephrine/ PAXIL ...... 35. . PLETAL ...... 4. . prenatal vit w/ FE polysac dextromethorphan . . . . 39 pazopanib ...... 2 PLEXION ...... 13. . cmplx-FA 42 phenylephrine/dextromethorphan/ prenatal vit w/ iron carbonyl-FA 42 PEDIACARE LIQ MULTI-SY . 39 guaifenesin 39 polyethylene glycol 3350 22 prenatal w/o A w/ FE carbonyl-FE PEDIALYTE . . . . . 42,. . 48 phenylephrine/ephed/CPM w/ polymyxin B/bacitracin . . . 33 gluc-DSS-FA . . . . .42 PEDIAPRED ...... 18 . . carbetapentane susp . . 39 polymyxin B/trimethoprim 33 prenat-FE bis-FE prot succ-FA- phenylephrine/guaifenesin . . 39 PEDIAZOLE ...... 23 . . polysaccharide iron complex elixir CA & omega 3 42 phenylephrine/hydrocodone/ OTC ...... 42 peg 3350/electrolytes 22 prenat w/o A w/fecbn-fegl-DSS- guaifenesin . . . . . 39 POLYSPORIN . . . . . 33. . peg 3350/sodium bicarbonate/ FA & DHA ...... 42 phenylephrine OTC . . . . .17 sodium chloride . . . . 22 POLYTRIM ...... 33 . PREPARATION H ...... 48 phenylephrine/pyrilamine/ peg 3350/sodium bicarbonate/ POLY-VI-FLOR . . . . . 42. . PREVACID ...... 21 . sodium chloride/potassium dextromethorphan . . . . 39 POLY-VI-SOL ...... 50 . PREVIDENT ...... 42 chloride 22 phenylephrine/pyrilamine w/ potassium acid phosphate . . 41 PEGASYS ...... 24 hydrocodone syrup . . 39 PREVPAC ...... 21. . potassium bicarbonate/potassium PEGASYS PROCLICK . . . . . 25 phenylephrine tan/pyrilamine tan/ PREZISTA ...... 26 carbeta tan susp 39 citrate effervescent tabs 41 pegfilgrastim 3 PRILOSEC ...... 21 . PHENYLHIST LIQ DH . . . 38 . POTASSIUM CHLORIDE . . . 41 peginterferon alfa-2a . . 24, 25 primaquine 26 PHENYTEK ...... 12 . potassium chloride ext-rel 41 peginterferon alfa-2b . . . . 25 primidone ...... 12 phenytoin ...... 12 potassium chloride . . . . .41 penicillamine 27 PRINCIPEN ...... 24 . . phenytoin sodium extended . 12 potassium citrate . . . . . 43 penicillin VK ...... 24 PRISTIQ ...... 35 PHISOHEX ...... 15 . potassium iodide . . . . . 41 PENLAC SOLUTION . . . . . 14 PROAMATINE ...... 8 . PHOS-FLUR ...... 50 . POTIGA ...... 12 . . PENTASA ...... 21 probenecid 28 PHOS-FLUR ...... 42 . . povidone-iodine OTC . . . . 26 pentazocine/naloxone 10 PROBENECID ...... 28 PHOSLO ...... 46. . pramipexole ...... 11 pentoxifylline ext-rel 4 PROBIOTIC FORMULA . . . 22. PHOSPHOLINE IODINE . .32 . pramlintide 19 PEPCID ...... 21 . . probiotic product caps OTC . 22 phosphorus tabs 41 PRANDIN ...... 19 PEPCID AC ...... 21, 48 procainamide ...... 6 PHRENILIN ...... 9 PRAVACHOL ...... 8. . PERCOCET ...... 10. . procainamide ext-rel 6 phytonadione . . . . . 42, 45 pravastatin ...... 8 PERCODAN ...... 10. . PROCAINAMIDE EXT-REL . . 6 pilocarpine 17, 32 prazosin ...... 5 PERIDEX ...... 17. . PROCANBID ...... 6 PILOPINE HS GEL ...... 32 PRECOSE ...... 19 . permethrin ...... 49 procarbazine 2 PIMA ...... 41 PRED FORTE ...... 31 permethrin 1% OTC 15 PROCARDIA ...... 6. . pimecrolimus cream . . . . 16 PRED-G ...... 31 permethrin 5% 15 PROCARDIA XL . . . . . 7. . pimozide 37 PRED MILD ...... 31 . . perphenazine ...... 36 prochlorperazine 20 pindolol ...... 6 prednicarbate crm/oint . . . 14 PERSANTINE ...... 4 PROCRIT ...... 3 . PINDOLOL ...... 6 prednisolone ...... 18 phenazopyridine 43 PROCTOCORT ...... 15 pioglitazone/glimiperide 19 prednisolone acetate . . . . 31 PHENERGAN . . . . . 20. . PROCTOCREAM-HC . . . . . 15 pioglitazone/metformin ER 19 prednisolone phosphate . . .31 PHENERGAN DM . . . . 38. PROGRAF ...... 2 . . pioglitazone/metformin . . . 19 prednisolone sodium phenobarbital ...... 12 phosphate ...... 18 PROLIXIN ...... 36 . pioglitazone ...... 19 PHENOBARBITAL ...... 12 prednisolone syrup . . . . 18 PROLIXIN DECANOATE . . . 36 piperacillin sodium-tazobactam PROMACTA ...... 46 phenyleph/bromphen/ sodium for inj . . . . 44 prednisone 18 dextromethorphan/ pregabalin ...... 12 promethazine ...... 20 guaifenesin 39 piperacillin sod-tazobactam sod in dex iv sol 44 PRELONE ...... 18 . promethazine hcl inj . . . . 44 phenylephrine/brompheniramine/ promethazine & phenylephrine dextromethorphan OTC . 39 piperonyl butoxide 49 PREMARIN ...... 30 syrup ...... 39 PIPERONYL BUTOXIDE . . . 49 PREMPHASE ...... 30 PROMETHAZINE SYP DM . 38

61 PROMETHAZINE VC W/ Q ribavirin ...... 25 rufinamide ...... 12 CODEINE . . . . .38 . RIDAURA ...... 27 ruxolitinib 2 QUAL-TUSSIN SYP DC . . 39. PROMETHAZINE RID SHAMPOO/BUTOXIDE RYNA-12 S ...... 39 . W/CODEINE . . . . . 38 QUESTRAN ...... 8 SHAMPOO . . . . .15 . RYNATAN PEDIATRIC SUSP 38 PROMETH VC SYP . . . .39 . QUESTRAN-LIGHT . . . . 8. rifabutin ...... 26 RYNATUSS ...... 37 . PRONESTYL ...... 6. . quetiapine 36 RIFADIN ...... 26. . RYNATUSS PEDIATRIC propafenone 6 quinapril/hydrochlorothiazide 5 rifampin ...... 26 SUSP ...... 39 . propantheline ...... 43 quinapril ...... 4 rilonacept ...... 45 RYTHMOL ...... 6 . . propranolol/HCTZ 6 quinidine gluconate ext-rel . . 6 rilpivirine ...... 25 propranolol 6, 11 QUINIDINE GLUCONATE rimantadine ...... 25 EXT-REL ...... 6 . S propylthiouracil ...... 20 rimexolone 31 quinidine sulfate 6 PROPYLTHIOURACIL . . . . . 20 SABRIL ...... 12 . . RISPERDAL ...... 36 . QUINIDINE SULFATE . . . . 6 PROSCAR ...... 43 . SALAGEN ...... 17 . RISPERDAL CONSTA . . . . 36 quinidine sulfate ext-rel . . . .6 PROTONIX ...... 21 . saline for nebulization 47 risperidone 36 QUINIDINE SULFATE EXT-REL 6 PROTOPIC ...... 16 . saline nasal spray 0.65% OTC .17 RITALIN ...... 34 QV-ALLERGY ...... 37 PROVENTIL ...... 40 . salmeterol xinafoate ...... 40 RITALIN-SR ...... 34 . QVAR ...... 40. . PROVERA ...... 30 . SAL-TROPINE . . . . . 22. . ritonavir ...... 26 PROZAC ...... 35. . SANCTURA ...... 43 rivaroxaban 4 PRUET DHAEC PAK . . . . . 42 R SANDIMMUNE ...... 2 rivastigmine ...... 9 PRUET DHA PAK SANDOSTATIN ...... 2 raloxifene 20 rizatriptan ...... 11 SETONET PAK . . . .42 . sapropterin 20 raltegravir ...... 26 RMS ...... 10 PSE/GG ...... 38 saquinavir ...... 26 RANEXA ...... 9 ROBAXIN ...... 28 pseudoephedrine/acetaminophen/ saquinavir mesylate . . . . 26 dextromethorphan . . . . 39 ranitidine 21 ROBINUL ...... 21 sargramostim ...... 3 pseudoephedrine/ ranolazine ...... 9 ROBITUSSIN ...... 38, 47 scopolamine 32 chlorpheniramine/ RAPAMUNE ...... 3 ROBITUSSIN CF . . . . 38, 47 dextromethorphan 39 SECTRAL ...... 6 . RAZADYNE ...... 9 . . ROBITUSSIN DM . . . 38, . 47 pseudoephedrine/ SEDAPAP ...... 9 REBETOL/COPEGUS . . 25. . dextromethorphan/ ROBITUSSIN LIQ selegiline 12 guaifenesin 39 REBIF ...... 11. . CGH/ALRG ...... 39 selenium sulfide shampoo . . 16 pseudoephedrine/iburprofen . 39 REGLAN ...... 20. . ROBITUSSIN LIQ CGH/CLD 37 SELSUN ...... 16. . pseudoephedrine tan/ RELENZA ...... 25 ROBITUSSIN LIQ CGH/CLD 39 dexchlorphen tan/ SELZENTRY ...... 26 . . RELION ...... 18 ROBITUSSIN LIQ DM tan susp . . . . . 39 CGH/CONG . . . . . 38 sennosides OTC 22 RELION N ...... 18 psyllium ...... 48 ROBITUSSIN LIQ HD/CHST 39 SENOKOT ...... 22 . RELION R ...... 18 PULMICORT FLEXHALER . 40 ROBITUSSIN LIQ SENSIPAR ...... 46 . RELISTOR ...... 22 PULMICORT RESPULES . . . 40 PED NGHT . . . . .39 . SERAX ...... 33 . . REMERON ...... 35 PULMOZYME ...... 45 ROBITUSSIN PE . . . . 38, 47 SEREVENT DISKUS . . . . 40 renat-FE bis-FE prot succ-FA- PURINETHOL ...... 1 . ROBITUSSIN PED LIQ CA & omega DR 42 CGH/COLD ...... 37 SEROQUEL ...... 36 . pyrazinamide 26 RENVELA ...... 46. . ROBITUSSIN PED SYP . . 38. sertraline tablets 35 PYRAZINAMIDE ...... 26 repaglinide 19 ROBITUSSIN SYP sevelamer ...... 46 pyrethrins/piperonyl but. REQUIP ...... 11 CHST CNG . . . . .38 . sildenafil ...... 9 4% OTC ...... 15 RESCRIPTOR . . . . . 25. . ROBITUSSIN SYP MAX-ST . 38 SILVADENE ...... 13 . . PYRIDIUM ...... 43 . RESPERAL-DM ...... 37 ROCALTROL ...... 41 silver sulfadiazine . . . . . 13 pyridostigmine 11 RESTORIL ...... 35 RONDEC DM ...... 39 SIMCOR ...... 8 . pyridostigmine ext-rel . . . . 11 RETIN-A ...... 13 RONDEC DROPS . . . . 37. . simethicone ...... 48 pyrilamine tan/phenyleph tan susp ...... 39 RETROVIR ...... 25 . RONDEC SYRUP . . . . 37. . simvastatin/niacin ER . . . . 8 pyrimethamine 26 REVATIO ...... 9 . ropinirole 11 simvastatin 8 REVIA ...... 33,. . 36 rotigotine 11 SINEMET ...... 11 REVLIMID ...... 3 ROWASA ...... 21 SINEMET CR ...... 11 R EYATAZ ...... 26. . ROXICODONE . . . . . 10 . SINEQUAN ...... 35 RHEUMATREX ...... 27 R-TANNAMINE . . . . . 38. . SINGULAIR ...... 41

62 sirolimus ...... 3 sumatriptan ...... 11 terbinafine OTC ...... 14 TOFRANIL ...... 35 . sitagliptan/metformin ER . . 19 SUMYCIN ...... 24 . terbinafine ...... 24 tolazamide ...... 19 sitagliptan/metformin . . . . 19 sunitinib ...... 2 terbutaline ...... 41 tolbutamide ...... 19 sitagliptan ...... 19 SUPRAX ...... 23 terconazole ...... 30 TOLBUTAMIDE ...... 19 SOD CHLORIDE INJ . . . 45 . SUSTIVA ...... 25. . teriparatide inj ...... 20 tolcapone ...... 12 sodium chloride hypertonic SUTENT ...... 2 TESSALON ...... 37 TOLINASE ...... 19 soln 33 SYLATRON ...... 25 . testosterone cypionate . . . 18 tolnaftate OTC 14 sodium chloride inj . . . . 45 SYMBICORT ...... 40 . testosterone enanthate . . . 18 tolterodine ...... 43 sodium chloride irrigation soln 45 SYMLIN ...... 19 . . testosterone gel ...... 18 TOPAMAX ...... 12 . sodium chloride iv soln . . . 45 SYMMETREL ...... 11, 25 testosterone patch 18 topiramate ...... 12 sodium citrate/citric acid . . .43 SYNAGIS ...... 26. . tetrabenazine ...... 12 TOPROL XL ...... 6 sodium polysterene sulfonate SYNALAR ...... 13, . 14 tetracycline 24 TORADOL ...... 9 susp ...... 41 SYNTHROID ...... 20 . . tetrahydrozoline/zinc sulfate . 31 TORECAN ...... 20 somatropin 19 TEV-TROPIN ...... 19 . . toremifene ...... 1 SONATA ...... 36 THEO-24 ...... 41. . TRACLEER ...... 8 . . sorafenib 2 T THEOCHRON ...... 41 tramadol ...... 9 SORIATANE ...... 15 tacrolimus ...... 2 THEOPHYLLINE ...... 41 TRANDATE ...... 6 . . sotalol ...... 6 tacrolimus ointment . . . . 16 THEOPHYLLINE EXT-REL . 41. tranexamic acid ...... 31 SPECTAZOLE . . . . . 14. . tadalafil 9 theophylline ext-rel . . . . .41 TRANXENE ...... 33 . SPIRIVA ...... 40 . TAGAMET ...... 21 theophylline liquid 41 tranylcypromine ...... 34 spironolactone ...... 7 TALWI N NX ...... 10 . thiethylperazine ...... 20 trazodone ...... 35 spironolactone/ TAMBOCOR ...... 6. . hydrochlorothiazide . . . 7 thioguanine ...... 1 TRENTAL ...... 4 . TAMIFLU ...... 25 SPORANOX ...... 24 . . THIOGUANINE ...... 1 tretinoin ...... 2, 13 tamoxifen 1 SPRYCEL ...... 2 . thioridazine ...... 37 triamcinolone acetonide . . .14 tamsulosin ...... 43 STADOL ...... 10 thiothixene 37 triamcinolone paste . . . . .17 TANAFED ...... 38. . STARLIX ...... 19 THORAZINE ...... 36 . triamterene/hydrochlorothiazide 7 TANAFED DMX STATUSS DM SYP . . . . 39. SUSPENSION . . . .39 . thyroid ...... 20 TRIAVIL ...... 35 . . stavudine 25 TAPAZOLE ...... 20 . THYROLAR ...... 20 . triazolam ...... 35 STELAZINE ...... 37 tapentadol ER ...... 10 tiagabine 12 TRI-FED X ...... 39 STRATTERA ...... 34 . TARCEVA ...... 2 . TIAZAC ...... 7. . trifluoperazine ...... 37 STUART PRENATAL . . . .50 . TARGRETIN ...... 2 TIGAN ...... 20. . trifluridine ...... 33 SUBOXONE ...... 36 . TASIGNA ...... 2 . TIKOSYN ...... 6 . trihexyphenidyl 12 SUBUTEX ...... 36 TASMAR ...... 12 TILADE ...... 40 . TRILAFON ...... 36 sucralfate 21 TEGRETOL ...... 12 timolol gel forming solution . . 32 TRILEPTAL ...... 12 . sulcralfate suspension 21 TEGRETOL-XR . . . . . 12. . timolol hemihydrate . . . . .32 TRILISATE ...... 9, 27 sulfacetamide 13 telaprevir 25 timolol maleate 6, 32 TRILYTE ...... 22 . . sulfacetamide oint/soln . . . 33 temazepam 35 TIMOPTIC ...... 32 . trimethobenzamide . . . . 20 sulfacetamide/phenylephrine . .33 TEMODAR ...... 1 . . TIMOPTIC XE ...... 32 TRIMETHOPRIM ...... 26 sulfacetamide/pred. phos . . .31 TEMOVATE ...... 14 TINACTIN ...... 14, 47 trimethoprim ...... 26 sulfacetamide/sulfur . . . . 13 temozolomide ...... 1 tiotropium ...... 40 TRI-NORINYL . . . . . 29. . SULFACET-R ...... 13 . . TENEX ...... 5 tipranavir 26 TRIOTANN ...... 17 . sulfamethoxazole/ tenofovir ...... 25 tizanidine 28 TRIOTANN PEDIATRIC SUSP 38 trimethoprim, DS 24 TENORETIC ...... 6. . TOBI ...... 26 tripolidine/pseudoephedrine . 39 sulfasalazine 21, 27 TENORMIN ...... 6 TOBRADEX ...... 31 . . triprolidine/ sulfasalazine delayed-rel . 21, 27 pseudoephedrine OTC . 17 TERAZOL 3/7 ...... 30 tobramycin 26, 33 sulfisoxazole 24 TRIPROL/PSE SYP . . . .39 . terazosin 5, 43 tobramycin/dexamethasone . 31 TRI RX ...... 42 sulindac ...... 9, 27 TOBREX ...... 33. .

63 TRI-VI-FLOR ...... 43 . . valganciclovir ...... 24 VIRAMUNE XR . . . . . 25. . Z TRI-VI-SOL . . . . . 43,. . 50 VALIUM ...... 28, 33 VIREAD ...... 25 zalcitabine ...... 25 TRIVORA ...... 29. . valproic acid ...... 12 VIROPTIC ...... 33 . zaleplon ...... 36 TRIZIVIR ...... 25. . VALTREX ...... 25. . VISINE ...... 49 ZANAFLEX ...... 28 . TROJAN ...... 48 . VANCOCIN ...... 26 . . VISINE-AC ...... 31 . zanamivir 25 tropicamide ophthalmic VANCOCIN/DEX INJ . . . 44 . vismodegib ...... 2 ZANTAC ...... 21. . solution 32 VANCOCIN HCL ...... 24 VISTARIL ...... 16. . ZARONTIN ...... 12 trospium ...... 43 VANCOCIN HCL INJ . . . . 44 vitamin ADC/fluoride/ ZAROXOLYN ...... 7 TRUSOPT ...... 32 . vancomycin HCl cap . . . . 24 ±iron drops . . . . . 43 ZEBETA ...... 6. . TRUST NATALCARE vancomycin hcl for inj . . . 44 vitamin A OTC 43 PAK DHA . . . . . 42. . ZELBORAF ...... 2 . . vancomycin hcl in dextrose inj 44 vitamin B-1 OTC . . . . . 43 TRUVADA ...... 25 ZENPEP ...... 22 vancomycin ...... 26 vitamin B-6 OTC . . . . . 43 T-STAT ...... 13 ZERIT ...... 25 VANDETANIB ...... 2 VITAMIN B-12 . . . . . 42. . TUMS ...... 48,. . 49 ZESTORETIC ...... 5 . vandetanib 2 vitamin B complex/vitamin C/ TUSSI 12D S ...... 39 . folic acid ...... 43 ZESTRIL ...... 4 . varenicline ...... 36 TUSSI-12 S ...... 38 vitamin C OTC 43 ZIAC ...... 6 VASERETIC ...... 4. . TUSSIN DM ...... 38 . VITAMIN D ...... 41, 42 ZIAGEN ...... 25 VASOCIDIN ...... 31 . . TWINJECT ...... 45 . vitamins pediatric members <3 zidovudine ...... 25 VASOCLEAR ...... 31 . . TYKERB ...... 2 years old OTC . . . . .43 zinc OTC 43 VASOCLEAR A ...... 31 TYLENOL . . . . . 9,. 27, 49 VITAPHIL ...... 42. . ziprasidone ...... 36 VASOSULF ...... 33 . TYLENOL W/CODEINE . . . . 10 VITUSSIN ...... 38. . ZITHROMAX ...... 23 VASOTEC ...... 4 TYLOX ...... 10 VOLTAREN . . . . .9, . 27, 31 ZOCOR ...... 8 VECTICAL ...... 15 vorinostat ...... 2 ZOFRAN ...... 20 VEETIDS ...... 24. . VOTRIENT ...... 2 ZOFRAN ODT . . . . . 20. . U vemurafenib ...... 2 VYTORIN ...... 8 . ZOLINZA ...... 2 . ULORIC ...... 28 . . venlafaxine 35 VYVANSE ...... 34. . ZOLOFT ...... 35 ULTRAM ...... 9 venlafaxine XR 35 zolpidem 36 ULTRAVATE ...... 14 VENTOLIN HFA ...... 40 W ZONEGRAN ...... 12 . . UNI-HIST DRO ...... 37 VEPESID ...... 2 . zonisamide 12 warfarin ...... 3 UNIPHYL ...... 41 verapamil 7, 11 ZORTRESS ...... 3 WELLBUTRIN . . . . . 35. . urea 40% cream and lotion 16 verapamil ext-rel 7 ZOSYN SOL ...... 44 . WELLBUTRIN SR . . . . 35. . UREA 40% CREAM AND VERMOX ...... 26. . ZOVIA ...... 29. . LOTION ...... 16 . . WELLBUTRIN XL ...... 35 VESANOID ...... 2 . . ZOVIRAX ...... 25. . URECHOLINE ...... 43 WYTENSIN ...... 8 . . VEXOL ...... 31 ZYLOPRIM ...... 27 . UREX ...... 43. . VIBRAMYCIN . . . . . 24. . ZYMAR ...... 33 . . UROCIT-K ...... 43 VICODIN ES ...... 10. . X ZYPREXA ...... 36 UROXATRAL ...... 43 . . VICTOZA ...... 19. . XALATAN ...... 32. . ZYRTEC ...... 16 URSO ...... 22 VI-DAYLIN ...... 50 XALKORI ...... 2 . ZYRTEC D ...... 17, 47 ursodiol ...... 22 VIDEX ...... 25 XANAX ...... 33 ZYRTEC OTC ...... 47 URSO FORTE . . . . . 22. . VIDEX EC ...... 25. . XARELTO ...... 4 . ZYTIGA ...... 1. . UTIRA C ...... 43 vigabatrin ...... 12 XELODA ...... 1 ZYVOX ...... 26 . . VIMPAT ...... 12 . . XENAZINE ...... 12 . V VINATE AZ EX . . . . . 42. . XOLAIR ...... 40 . vaginal products 47 VINATE III ...... 42. . XOPENEX RESPULES . . 40. valacyclovir ...... 25 VIRACEPT ...... 26 . XYLOCAINE . . . .15, . 16, 17 VALCYTE ...... 24. . VIRAMUNE ...... 25 XYZAL ...... 16. .

64