Complete Drug List (Formulary) 2021 UnitedHealthcare® Group Medicare Advantage (PPO) Illinois Department of Central Management Services College Insurance Program (CIP) Important Notes: This document has information about the drugs covered by this plan. For more up-to-date information or if you have any questions, please call Customer Service at: Toll-free 1-888-223-1092, TTY 711 8 a.m. - 8 p.m. local time, Monday - Friday www.UHCRetiree.com/soi Formulary ID Number 00021068, Version 23 Y0066_052820_104500_C Last updated September 1, 2021
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Complete Drug List(Formulary) 2021
UnitedHealthcare® Group Medicare Advantage (PPO)
Illinois Department of Central Management Services College Insurance Program (CIP)
Important Notes: This document has information about the drugs covered by this plan. For more
up-to-date information or if you have any questions, please call Customer Service at:
Toll-free 1-888-223-1092, TTY 7118 a.m. - 8 p.m. local time, Monday - Friday
www.UHCRetiree.com/soi
Formulary ID Number 00021068, Version 23
Y0066_052820_104500_C Last updated September 1, 2021
Table Of Contents
What is a drug list?......................................................................................................................................3
Note to existing members:......................................................................................................................... 3
How do I use the drug list?.........................................................................................................................4
What are generic drugs?............................................................................................................................ 4
What is a compounded drug?....................................................................................................................4
Drug payment stage and drug tiers...........................................................................................................5
Getting Extra Help.......................................................................................................................................5
Are there any rules or limits on my drug coverage?................................................................................ 6
What if my drug is not on this list?.............................................................................................................8
How can I get an exception?......................................................................................................................8
Can I get my drug while I wait for an exception?......................................................................................9
Can the drug list change?........................................................................................................................ 10
Drugs with dosages other than a 1-month supply..................................................................................11
Covered drugs by name (Drug index)....................................................................................................12
Covered drugs by medical condition...................................................................................................... 40
Covered drugs with a quantity limit (QL).............................................................................................. 157
3What is a drug list?
A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team
of health care providers work together in selecting drugs that are needed for well-rounded care and
treatment.
Your plan will generally cover the drugs listed in our drug list as long as:
· The drug is used for a medically accepted indication,
· The prescription is filled at a network pharmacy and
· Other plan rules are followed.
For more information about your drug coverage, please review your Evidence of Coverage.
Note to existing members:
This complete list of prescription drugs covered by your plan is current as of September 1, 2021.
For an up-to-date list of covered drugs or if you have questions, please call Customer Service. Our
contact information is on the cover.
This drug list has changed since last year. Please review this document to make sure your
prescription drugs are still covered. In most cases, you must use network pharmacies to have your
prescriptions covered by the plan.
When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to
“plan,” “our plan,” or “your plan,” it means UnitedHealthcare Group Medicare Advantage.
4
How do I use the drug list?
There are 2 ways to find your prescription drugs in this drug list:
1. By name. Turn to section “Covered drugs by name (Drug index)” on pages 12–39 to see the
.......list of drug names in alphabetical order. Find the name of your drug. The page number where
.......you can find the drug will be next to it.
2. By medical condition. Turn to section “Covered drugs by medical condition” on pages
.......40–156 to look for drugs based on your medical conditions. For example, if you have a heart
.......condition, you should look in the category Cardiovascular Agents. This is where you will find
.......drugs that treat heart conditions.
What are generic drugs?
Generic drugs have the same active ingredients as brand name drugs. They usually cost less than
brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers
both brand name and generic drugs.
Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then
review the drug list to make sure you are getting the drug you need for the least amount of money.
The drug list shows brand name drugs in bold type (for example, Humalog) and generic drugs in
plain type (for example, Simvastatin).
What is a compounded drug?
A compounded drug is created by a pharmacist by combining or mixing ingredients to create a
prescription medication customized to the needs of an individual patient. Compounded drugs may
be Part D eligible. For more information about compounded drugs, please review your Evidence of
Coverage.
5
Drug payment stage and drug tiers
The amount you pay for a covered prescription drug will depend on:
· Your drug payment stage. Your plan has different stages of drug coverage. When you fill a
prescription, the amount you pay depends on the coverage stage you’re in.
· Your drug’s tier. Each covered drug is in 1 of 4 drug tiers. Each tier has a copay or coinsurance
amount. The chart below shows the differences between the tiers.
If you need help or have any questions about your drug costs, please review your Evidence of
Coverage or call Customer Service. Our contact information is on the cover.
Drug Tier Includes
Tier 1:
Preferred generic
Most generic drugs.
Tier 2:
Preferred brand
Many common brand name drugs, called preferred
brands and some higher-cost generic drugs.
Tier 3:
Non-preferred drug
Non-preferred generic and non-preferred brand name
drugs. In addition, Part D eligible compound medications
are covered in Tier 3.
Tier 4:
Specialty tier
Unique and/or very high-cost brand and generic drugs.
Getting Extra Help
If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may
be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for
People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about
your costs. You can also call Customer Service. Our contact information is on the cover.
6
Are there any rules or limits on my drug coverage?Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug
has any coverage rules or limits, there will be a code(s) in the “Coverage Rules or Limits on use”
column of the “Covered drugs by medical condition” chart starting on page 40. The codes and
what they mean are shown below and on the next page.
You can also get more information about the coverage rules and/or limits applied to specific
covered drugs by visiting our website. We have posted online documents that explain our prior
authorization and step therapy restrictions. If you would like a copy sent to you, please call
Customer Service. Our contact information is on the cover.
Coverage Rules and Limits
PA - Prior authorization
The plan requires you or your doctor to get prior approval for certain drugs. This means the plan
needs more information from your doctor to make sure the drug is being used and covered
correctly by Medicare for your medical condition. Certain drugs may be covered by either Medicare
Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs) depending on
how it is used. If you don’t get prior approval, the plan may not cover the drug.
QL - Quantity limits
The plan will cover only a certain amount of this drug for 1 copay/coinsurance or over a certain
number of days. These limits may be in place to ensure safe and effective use of the drug. If your
doctor prescribes more than this amount or thinks the limit is not right for your situation, you or
your doctor can ask the plan to cover the additional quantity.
ST - Step therapy
There may be effective, lower-cost drugs that treat the same medical condition as this drug. You
may be required to try 1 or more of these other drugs before the plan will cover your drug. If you
have already tried other drugs or your doctor thinks they are not right for you, you or your doctor
can ask the plan to cover this drug.
7
Other Special Coverage Rules
B/D - Medicare Part B or Part D
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and
outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide
the plan with more information about how this drug will be used to make sure it’s correctly
covered by Medicare.
HRM - High-risk medication
This drug is known as a high-risk medication (HRM) for patients 65 years and older. This drug
may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if
an alternative drug is available to treat your condition.
LA - Limited access
Drugs are considered “limited access” if the FDA says the drug can be given out only by certain
facilities or doctors. These drugs may require extra handling, provider coordination or patient
education that can’t be done at a network pharmacy.
MME - Morphine milligram equivalent
Additional quantity limits may apply across all drugs in the opioid class used for the treatment of
pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is
designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1
opioid drug for pain management. If your doctor prescribes more than this amount or thinks the
limit is not right for your situation, you or your doctor can ask the plan to cover the additional
quantity.
7D - 7-Day limit
An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members
with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For
members who are new to the plan and have a recent history of using opioids, the limit may be
overridden by having the pharmacy contact the plan.
DL - Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a 1-month supply per prescription.
You and your doctor may ask the plan for an exception to the coverage rules and/or limits for your
drug. See section “How can I get an exception?" on page 8 or see your Evidence of Coverage to
learn more.
If you don’t get approval from the plan before you fill a prescription for a drug with coverage rules
or limits, you may have to pay the full cost of the drug.
8
What if my drug is not on this list?
If your drug is not included in this drug list we may still cover it. Call Customer Service to ask if it’s
covered. Our contact information, along with the date we last updated the drug list is on the cover.
If you find out that your drug is not covered, you can do 1 of these things:
1. Ask Customer Service for a list of similar drugs that are covered by the plan. When you get
the list, show it to your doctor and ask him or her to prescribe a covered drug.
2. Ask the plan to make an exception and cover your drug. Review the next section for more
exception information.
How can I get an exception?
Sometimes you may need to ask for drug coverage that’s not normally provided by your plan. This
is called asking for an exception. When you do, the plan will review your request and give you a
coverage decision known as a coverage determination.
Types of exceptions you can ask for
· Drug list exception: Ask the plan to cover your drug even if it’s not on the drug list. If approved,
this drug will be covered at a pre-determined cost sharing level. You will not be able to ask us to
provide the drug at a lower cost sharing level.
· Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For
example, if your drug has a quantity limit, you can ask the plan to change the limit and cover
more.
· Tiering exception: Ask the plan to cover your drug on our list at a lower cost sharing level if this
drug is not on the specialty tier.
The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as
effective in treating your condition or would cause adverse medical effects.
Who can ask for an exception?
You, your authorized representative or your doctor can ask for an exception by calling Customer
Service. Your doctor must give us a supporting statement with the reason for the exception.
How long does it take to get an exception?
After we get the statement from your doctor supporting your request for an exception, we’ll give
you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor
believes that your health could be seriously harmed by waiting 72 hours. If your request for an
expedited review is approved, we’ll give you a decision within 24 hours after we get your doctor’s
supporting statement.
9
Can I get my drug while I wait for an exception?
As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s
not on our drug list or if it has rules or limits. For example, you may need a prior authorization from
us before you can fill your prescription. During the time when you are getting a temporary supply,
you should talk with your doctor to decide if there is a similar drug on the drug list you can take
instead. If you and your doctor decide this is the only drug that will work for you, you will need to
ask for an exception. We may cover your drug in certain cases during the first 90 days of your
membership.
The following chart shows how much of your drug we may cover while you ask for an exception.
If you... And you are… We may cover…
are a new member in the first 90 days of
your membership
OR
were a member last year and it’s the
first 90 days of your plan year
not in a nursing home or
long-term care facility
at least a 30-day
temporary supply
in a nursing home or long-
term care facility
at least a 31-day
temporary supply
have been in the plan for more than 90
days
in a nursing home or long-
term care facility and
need a supply right away
at least a 31-day
emergency supply
are going through a change in your level
of care, such as being transferred from
a hospital to a long-term care facility,
any time during the year
not in a nursing home or
long-term care facility
at least a 30-day
temporary supply
in a nursing home or long-
term care facility
at least a 31-day
temporary supply
The prescription must be filled at a network pharmacy. If your prescription is written for fewer days,
we’ll allow refills to provide at least the day supply listed in the chart above. (Please note that the
long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
We will not pay for more of your drug after you get this temporary or emergency supply unless you
receive authorization from the plan.
10
Can the drug list change?
Most changes in drug coverage happen on January 1. We may need to make changes during the
plan year for safety or other reasons that can affect you. We must follow the Medicare rules in
making these changes.
The drug list may change during the year if your plan:
· Adds new drugs, including generic drugs, as they become available.
· Removes a drug that has been found to be ineffective or unsafe.
· Changes the coverage rules or limits for a drug.
· Moves a drug into a different cost sharing tier.
If we add new generic drugs
We may immediately remove a brand name drug on our Drug List if we are replacing it with a new
generic drug that will appear on the same or lower cost sharing tier and with the same or fewer
restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug
on our Drug List, but immediately move it to a different cost sharing tier or add new restrictions. If
you are currently taking that brand name drug, we may not tell you in advance before we make that
change, but we will later provide you with information about the specific change(s) we have made.
If we make other changes
We may make other changes that affect members currently taking a drug. For instance, we may
add a generic drug that is not new to market to replace a brand name drug currently on the Drug
List; or add new restrictions to the brand name drug or move it to a different cost sharing tier or
both. Or we may make changes based on new clinical guidelines. If we remove drugs from our
Drug List, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move
a drug to a higher cost sharing tier, we must notify affected members of the change at least 30
days before the change becomes effective, or at the time the member requests a refill of the drug,
at which time the member will receive at least a 30 day supply of the drug.
If we add new generic drugs or make other changes, you or your prescriber can ask us to make
an exception and continue to cover the brand name drug for you. The notice we provide you will
also include information on how to request an exception, and you can also find information in the
section “How can I get an exception?” on page 8.
If we remove a drug from the list
If the Food and Drug Administration (FDA) says a drug you are taking is not effective or is unsafe,
we will let you know and take it off the drug list right away.
Changes that will not affect you if you are currently taking the drug
Usually, if you’re taking a drug on this drug list that was covered at the beginning of the year, we
will not remove or reduce coverage during the year except as described above. You will not get a
notice this year about changes that do not affect you. However, on January 1 of the next year these
changes will affect you, therefore it is important to check the Drug List for any changes to drugs for
the new plan year.
11
Drugs with dosages other than a 1-month supply
Drugs packaged in an extended day supply
Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When
you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription.
For more information, please call Customer Service. Our contact information is on the cover.
Daily cost sharing for oral medications filled for less than a 1-month supply
A daily cost sharing rate may apply when your doctor prescribes less than a full month’s supply of
certain drugs for you and you are required to pay a copayment. A daily cost sharing rate is the
copayment divided by the number of days in a month’s supply.
Daily cost sharing applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule)
when dispensed for a supply of less than 1-month under applicable law. The daily cost sharing
requirements do not apply to either of the following:
1. Solid oral doses of antibiotics.
2. Solid oral doses that are dispensed in their original container or are usually dispensed in their
original packaging to help patients comply with usage and dosage directions.
For more information
For more detailed information about your plan’s prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about your plan’s prescription drug coverage, please call Customer Service.
Our contact information, along with the date we last updated the drug list, is on the cover.
If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov
or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.
12
Covered drugs by name (Drug index)
A
Abacavir Sulfate..................... 83
Abacavir Sulfate-Lamivudine
.............................................. 83
Abacavir-Lamivudine-
Zidovudine........................... 83
Abelcet....................................64
Abilify...................................... 77
Abilify Maintena......................77
Abilify MyCite......................... 77
Abiraterone Acetate...............69
Absorica................................108
Absorica LD..........................108
Acamprosate Calcium........... 46
Acanya.................................. 108
Acarbose................................ 86
Accolate................................151
Accupril...................................95
Accuretic.................................98
Accutane.............................. 108
Acebutolol HCl....................... 96
Acetaminophen-Caffeine-
Dihydrocodeine................... 44
Acetaminophen-Codeine...... 44
Acetazolamide........................98
Acetazolamide ER..................98
Acetic Acid........................... 149
Acetylcysteine...................... 154
Aciphex.................................123
Acitretin................................ 108
Actemra................................ 138
Actemra ACTPen................. 138
Acthar................................... 127
ActHIB...................................141
Acticlate.................................. 54
Actimmune........................... 139
Actiq........................................44
Actonel..................................143
Actoplus Met.......................... 86
Actos....................................... 86
Acular....................................147
Acular LS.............................. 147
Acuvail.................................. 147
Acyclovir................................. 81
Acyclovir Sodium................... 81
Aczone..................................115
Adacel...................................141
Adapalene....................108, 109
Adapalene-Benzoyl Peroxide
............................................ 109
Adcirca..................................153
Adderall................................ 104
Adderall XR.......................... 104
Adefovir Dipivoxil................... 81
Adempas.............................. 153
Adlyxin.................................... 86
Adlyxin Starter Pack.............. 86
Admelog................................. 89
Admelog SoloStar..................89
Advair Diskus....................... 154
Advair HFA........................... 154
Adzenys ER.......................... 104
Adzenys XR-ODT................. 104
Aemcolo..................................48
Afinitor.....................................70
Afinitor Disperz.......................70
Afrezza.................................... 89
Agrylin.....................................92
Aimovig................................... 67
AirDuo Digihaler...................154
AirDuo RespiClick 113/14
............................................ 154
AirDuo RespiClick 232/14
............................................ 154
AirDuo RespiClick 55/14.... 154
Ajovy........................................67
Aklief..................................... 109
Ala Scalp...............................110
Ala-Cort.................................110
Albendazole............................74
Albenza................................... 74
Albuterol Sulfate.................. 151
Albuterol Sulfate HFA..........151
Alclometasone Dipropionate
............................................ 110
Alcohol Prep Pads............... 144
Aldactazide.............................99
Aldactone............................. 101
Aldara....................................114
Alecensa................................. 71
Alendronate Sodium............143
Alfuzosin HCl ER..................126
Alinia....................................... 74
Aliskiren Fumarate................. 99
Alkindi Sprinkle.................... 127
Allopurinol.............................. 66
Almotriptan Malate.................66
Alocril....................................146
Alogliptin Benzoate................86
Alogliptin-Metformin HCl....... 86
Alogliptin-Pioglitazone...........86
Alomide.................................146
13
Alora...................................... 130
Alosetron HCl........................121
Alphagan P........................... 148
Alprazolam.............................. 85
Alprazolam ER........................ 85
Alprazolam Intensol................85
Alprazolam ODT..................... 85
Alrex.......................................147
Altabax.................................. 115
Altace.......................................95
Altavera................................. 130
Altoprev................................. 102
Altreno...................................109
Alunbrig...................................71
Alvesco..................................150
Alyacen 1/35.........................130
Alyq........................................153
Amantadine HCl..................... 75
Amaryl..................................... 86
Ambien..................................155
AmBisome...............................64
Ambrisentan......................... 153
Amcinonide...........................110
Amerge....................................66
Amethia................................. 130
Amikacin Sulfate.....................47
Amiloride HCl........................101
Amiloride-Hydrochlorothiazide
...............................................99
Aminosyn II........................... 117
Aminosyn-PF.........................117
Amiodarone HCl..................... 95
Amitiza...................................120
Amitriptyline HCl.....................63
Amlodipine Besylate.............. 97
Amlodipine-Atorvastatin.........99
Amlodipine-Benazepril...........99
Amlodipine-Olmesartan......... 99
Amlodipine-Valsartan............. 99
Amlodipine-Valsartan-HCTZ
...............................................99
Ammonium Lactate..............110
Amnesteem...........................109
Amoxapine.............................. 63
Amoxicillin...............................51
Amoxicillin-Clarithromycin-
Lansoprazole......................121
Amoxicillin-Potassium
Clavulanate........................... 51
Amoxicillin-Potassium
Clavulanate ER..................... 51
Amphetamine ER................. 104
Amphetamine Sulfate.......... 104
Amphetamine-
Dextroamphetamine.......... 104
Amphetamine-
Dextroamphetamine ER.... 104
Amphotericin B.......................64
Ampicillin.................................51
Ampicillin Sodium.................. 51
Ampicillin-Sulbactam Sodium
...............................................51
Ampyra..................................107
Amzeeq................................. 115
Anafranil.................................. 63
Anagrelide HCl........................92
Anastrozole............................. 70
Ancobon..................................64
Androderm............................129
AndroGel...............................129
AndroGel Pump....................129
Annovera...............................130
Anoro Ellipta......................... 154
Antara....................................101
Anusol-HC............................. 143
ApexiCon E........................... 110
Apidra...................................... 89
Apidra SoloStar...................... 89
Aplenzin...................................61
Apokyn.................................... 75
Apraclonidine HCl................ 148
Aprepitant................................64
Apri........................................ 130
Apriso.................................... 142
Aptensio XR.......................... 105
Aptiom..................................... 59
Aptivus.....................................84
Aralast NP............................. 124
Aranelle................................. 130
Aranesp.............................92, 93
Arava..................................... 139
Arazlo.................................... 109
Arcalyst..................................138
Aricept..................................... 60
Arikayce...................................47
Arimidex.................................. 70
Aripiprazole.............................77
Aripiprazole ODT.................... 77
Aristada................................... 77
Aristada Initio.......................... 77
Arixtra...................................... 91
Armodafinil............................155
ArmonAir Digihaler...............150
Arnuity Ellipta........................150
14
Aromasin................................. 70
Arthrotec................................. 40
Asacol HD............................. 142
Asenapine Maleate.................77
Ashlyna..................................130
Asmanex............................... 150
Asmanex HFA.......................150
Aspirin-Dipyridamole ER........94
Astagraf XL........................... 139
Atacand................................... 95
Atacand HCT.......................... 99
Atazanavir Sulfate...................84
Atelvia....................................143
Atenolol................................... 96
Atenolol-Chlorthalidone......... 99
Ativan.......................................85
Atomoxetine HCl.................. 105
Atorvastatin Calcium............ 102
Atovaquone.............................74
Atovaquone-Proguanil HCl.... 74
Atralin.................................... 109
Atripla...................................... 82
Atropine Sulfate....................145
Atrovent HFA........................ 151
Aubagio.................................107
Aubra EQ...............................130
Auryxia...................................120
Austedo.................................106
Avalide.....................................99
Avapro..................................... 95
Aveed.................................... 129
Aviane....................................130
Avita.......................................109
Avodart..................................126
Avonex Pen...........................107
Avonex Prefilled....................107
Avycaz..................................... 50
Aygestin................................ 134
Ayvakit..................................... 71
Azactam.................................. 48
Azasan...................................139
Azasite...................................146
Azathioprine..........................139
Azelaic Acid.......................... 109
Azelastine HCl.............. 146, 149
Azelastine-Fluticasone......... 149
Azelex....................................109
Azilect...................................... 76
Azithromycin........................... 53
Azopt..................................... 148
Azor..........................................99
Aztreonam...............................48
Azulfidine.............................. 142
Azulfidine EN-tabs................ 142
B
Bacitracin.............................. 146
Bacitracin-Polymyxin B........ 146
Baclofen.................................. 80
Bactrim.................................... 54
Bactrim DS..............................54
Bafiertam...............................107
Balcoltra................................ 130
Balsalazide Disodium...........142
Balversa...................................71
Balziva................................... 130
Banzel......................................59
Baqsimi Two Pack..................88
Baraclude................................81
Basaglar KwikPen...................89
Baxdela....................................54
BCG Vaccine........................ 141
Beconase AQ........................150
Belbuca................................... 42
Belsomra...............................155
Benazepril HCl........................95
Benazepril-Hydrochlorothiazide
...............................................99
Benicar.................................... 95
Benicar HCT........................... 99
Benlysta.................................138
BenzaClin with Pump...........109
Benzamycin.......................... 109
Benznidazole.......................... 74
Benzoyl Peroxide-Erythromycin
.............................................109
Benztropine Mesylate............ 75
Bepotastine Besilate............ 146
Bepreve................................. 146
Berinert..................................137
Beser..................................... 110
Besivance..............................146
Betamethasone Dipropionate
.............................................110
Betamethasone Dipropionate
Aug......................................110
Betamethasone Valerate.... 110,
111
Betapace AF........................... 96
Betaseron..............................107
Betaxolol HCl..................96, 148
Bethanechol Chloride.......... 126
Bethkis.................................. 152
Betimol.................................. 148
15
Betoptic-S..............................148
Bevespi Aerosphere.............154
Bexarotene..............................73
Bexsero................................. 141
Beyaz.....................................130
Bicalutamide........................... 69
Bicillin C-R...............................52
Bicillin C-R 900/300............... 51
Bicillin L-A............................... 52
BiDil......................................... 99
Biktarvy....................................82
Biltricide.................................. 74
Bimatoprost.......................... 149
Bisoprolol Fumarate...............96
Bisoprolol-Hydrochlorothiazide
...............................................99
BIVIGAM................................137
Bleph-10................................ 146
Blephamide...........................145
Blephamide S.O.P................145
Blisovi 24 Fe..........................130
Blisovi Fe 1.5/30...................130
Boniva....................................143
Boostrix................................. 141
Bosentan...............................153
Bosulif......................................71
Braftovi.................................... 71
Breo Ellipta............................154
Breztri Aerosphere............... 154
Briellyn...................................130
Brilinta..................................... 94
Brimonidine Tartrate............ 148
Brinzolamide.........................148
BRIVIACT................................ 55
Bromfenac Sodium.............. 147
Bromocriptine Mesylate...75, 76
BromSite............................... 147
Bronchitol..............................154
Brovana................................. 151
Brukinsa.................................. 71
Bryhali................................... 111
Budesonide.................. 143, 150
Budesonide ER.....................143
Budesonide-Formoterol
Fumarate.............................154
Bumetanide.......................... 101
Buphenyl............................... 124
Buprenorphine........................42
Buprenorphine HCl................ 47
Buprenorphine HCl-Naloxone
HCl.........................................47
Bupropion HCl........................61
Bupropion HCl ER..................61
Bupropion HCl SR............47, 61
Bupropion HCl XL.................. 61
Buspirone HCl........................ 85
Butorphanol Tartrate..............44
Butrans.................................... 42
Bydureon BCise......................86
Byetta 10MCG Pen.................87
Byetta 5MCG Pen...................87
Bystolic....................................96
C
Cabergoline.......................... 136
Cablivi......................................94
Cabometyx..............................71
Caduet.....................................99
Cafergot...................................67
Calan SR................................. 97
Calcipotriene.........................114
Calcipotriene-Betamethasone
.............................................114
Calcitonin Salmon................ 143
Calcitriol........................114, 144
Calcium Acetate................... 120
Calquence...............................71
Cambia.................................... 40
Camila................................... 134
Camrese Lo.......................... 130
Canasa.................................. 142
Cancidas................................. 64
Candesartan Cilexetil............. 95
Candesartan Cilexetil-HCTZ
...............................................99
Capex.................................... 111
Caplyta.................................... 77
Caprelsa.................................. 71
Captopril..................................95
Carac..................................... 114
Carafate.................................123
Carbaglu................................117
Carbamazepine...................... 59
Carbamazepine ER................ 59
Carbatrol................................. 59
Carbidopa............................... 76
Carbidopa-Levodopa............. 76
Carbidopa-Levodopa ER....... 76
Carbidopa-Levodopa ODT.....76
Carbidopa-Levodopa-
Entacapone.......................... 75
Cardizem................................. 97
Cardizem CD...........................97
Cardizem LA........................... 97
Cardura................................... 94
16
Cardura XL............................126
Carnitor................................. 124
CaroSpir................................ 101
Carteolol HCl........................ 148
Cartia XT..................................97
Carvedilol................................ 96
Carvedilol Phosphate ER.......96
Casodex.................................. 69
Caspofungin Acetate............. 64
Catapres-TTS-1....................... 94
Catapres-TTS-2....................... 94
Catapres-TTS-3....................... 94
Cayston................................. 152
Caziant.................................. 130
Cefaclor...................................50
Cefaclor ER.............................50
Cefadroxil................................50
Cefazolin Sodium................... 50
Cefdinir....................................50
Cefepime HCl......................... 50
Cefixime.................................. 50
Cefotetan Disodium............... 50
Cefoxitin Sodium.................... 50
Cefpodoxime Proxetil.............50
Cefprozil.................................. 50
Ceftazidime............................. 50
Ceftriaxone Sodium................50
Cefuroxime Axetil................... 50
Cefuroxime Sodium............... 50
Celebrex.................................. 40
Celecoxib................................ 40
Celexa......................................62
Cellcept................................. 139
Celontin................................... 58
Cephalexin........................50, 51
Cequa....................................145
Cerdelga................................124
Cetirizine HCl........................149
Cetraxal................................. 149
Cevimeline HCl..................... 108
Chantix.................................... 47
Chantix Continuing Month Pak
...............................................47
Chantix Starting Month Pak...47
Chemet..................................119
Chenodal...............................121
Chlordiazepoxide HCl............ 85
Chlordiazepoxide-Clidinium
.............................................121
Chlorhexidine Gluconate.....108
Chloroquine Phosphate......... 74
Chlorpromazine HCl...............76
Chlorthalidone...................... 101
Chlorzoxazone......................155
Cholbam................................124
Cholestyramine.....................102
Cholestyramine Light........... 102
Cialis......................................126
Ciclopirox......................115, 116
Ciclopirox Olamine...............116
Cilostazol.................................94
Ciloxan.................................. 146
Cimduo....................................83
Cimetidine.............................122
Cimetidine HCl..................... 122
Cimzia....................................139
Cimzia Prefilled.....................139
Cinacalcet HCl......................144
Cinryze.................................. 137
Cipro........................................54
Cipro HC............................... 149
Ciprodex................................149
Ciprofloxacin HCl...54, 146, 149
Ciprofloxacin in D5W............. 54
Ciprofloxacin-Dexamethasone
.............................................149
Ciprofloxacin-Fluocinolone PF
.............................................149
Citalopram Hydrobromide..... 62
Claravis..................................109
Clarinex................................. 149
Clarinex-D 12 Hour............... 154
Clarithromycin.........................53
Clarithromycin ER...................53
Clenpiq..................................121
Cleocin.................................... 48
Cleocin Phosphate................. 48
Cleocin-T............................... 116
Climara Pro........................... 130
Clindacin-P............................116
Clindagel............................... 116
Clindamycin HCl.....................48
Clindamycin Palmitate HCl.... 48
Clindamycin Phosphate........48,
116
Clindamycin Phosphate in D5W
...............................................48
Clindamycin Phosphate-
Benzoyl Peroxide............... 109
Clindamycin-Tretinoin.......... 109
Clindesse.................................48
Clinimix E/Dextrose............. 117
Clinimix/Dextrose.................117
Clinisol SF............................. 117
17
Clobazam................................ 58
Clobetasol Propionate......... 111
Clobetasol Propionate
Emollient Base................... 111
Clobetasol Propionate
Emulsion............................. 111
Clobex................................... 111
Clobex Spray........................ 111
Clocortolone Pivalate........... 111
Clodan...................................111
Cloderm................................ 111
Clomipramine HCl.................. 63
Clonazepam............................85
Clonazepam ODT................... 85
Clonidine................................. 94
Clonidine HCl..........................94
Clonidine HCl ER..................105
Clopidogrel Bisulfate..............94
Clorazepate Dipotassium.......85
Clotrimazole....................64, 116
Clotrimazole-Betamethasone
.............................................114
Clovique................................ 119
Clozapine................................ 80
Clozapine ODT....................... 80
Clozaril.....................................80
Coartem...................................74
Codeine Sulfate...................... 44
Colazal...................................142
Colchicine............................... 66
Colcrys.....................................66
Colesevelam HCl.................. 102
Colestid................................. 102
Colestipol HCl.......................102
Colistimethate Sodium...........48
Combigan............................. 145
Combivent Respimat........... 154
Combivir.................................. 83
Cometriq................................. 71
Complera.................................82
Compro................................... 63
Comtan....................................75
Concerta................................105
Condylox............................... 114
Constulose............................120
ConZip.....................................42
Copaxone..............................107
Copiktra...................................71
Cordran................................. 111
Coreg.......................................96
Coreg CR................................ 96
Corgard................................... 96
Corlanor...................................99
Cortef.....................................127
Cosentyx............................... 138
Cosentyx Sensoready.......... 138
Cosopt...................................145
Cosopt PF............................. 145
Cotellic.....................................71
Cotempla XR-ODT................105
Cozaar..................................... 95
Creon.....................................124
Cresemba................................64
Crestor...................................102
Crinone..................................134
Cromolyn Sodium....... 124, 146,
153
Cryselle-28............................ 130
Cubicin.................................... 48
Cuprimine............................. 126
Cutivate................................. 111
Cuvposa................................ 121
Cyclafem 1/35...................... 130
Cyclafem 7/7/7.....................130
Cyclobenzaprine HCl........... 155
Cyclophosphamide..........68, 69
Cycloset...................................87
Cyclosporine.........................139
Cyclosporine Modified.........139
Cymbalta............................... 106
Cyproheptadine HCl............ 149
Cyred EQ...............................130
Cystadane............................. 124
Cystadrops............................145
Cystagon............................... 124
Cystaran................................ 145
Cytomel................................. 135
Cytotec.................................. 123
D
Dalfampridine ER................. 107
Daliresp................................. 153
Dalvance..................................48
Danazol................................. 129
Dantrium..................................80
Dantrolene Sodium................ 80
Dapsone..........................68, 116
Daptacel................................ 141
Daptomycin.............................48
DARAPRIM............................. 74
Darifenacin Hydrobromide ER
.............................................125
Daurismo.................................71
Daypro..................................... 40
18
Daytrana................................105
DayVigo.................................155
DDAVP.................................. 128
Deblitane...............................135
Deferasirox............................119
Deferasirox Granules........... 119
Deferiprone........................... 119
Delestrogen.......................... 130
Delstrigo.................................. 82
Delzicol..................................142
Demeclocycline HCl...............54
Demser.................................... 99
Denavir.................................... 81
Depakote.................................86
Depakote ER...........................86
Depakote Sprinkles................ 86
Depen Titratabs....................126
Depo-Estradiol...................... 130
Depo-Provera........................135
Depo-SubQ Provera 104......135
Depo-Testosterone...............129
Derma-Smoothe/FS Scalp...111
DermOtic...............................149
Descovy...................................83
Desipramine HCl.................... 63
Desloratadine........................150
Desloratadine ODT...............150
Desmopressin Acetate.........128
Desmopressin Acetate Spray
.............................................128
Desogestrel-Ethinyl Estradiol
.............................................130
Desonate...............................111
Desonide...............................111
DesOwen...............................111
Desoximetasone...................111
Desoxyn.................................104
Desvenlafaxine ER..................62
Desvenlafaxine Succinate ER
...............................................62
Detrol.....................................125
Detrol LA............................... 125
Dexabliss...............................127
Dexamethasone....................127
Dexamethasone Sodium
Phosphate.......................... 147
Dexedrine..............................104
Dexilant................................. 123
Dexmethylphenidate HCl.....105
Dexmethylphenidate HCl ER
.............................................105
Dextroamphetamine Sulfate
.................................... 104, 105
Dextroamphetamine Sulfate ER
.............................................104
Dextrose................................ 118
Dextrose-NaCl.......................118
Diacomit.................................. 58
Diastat AcuDial....................... 58
Diastat Pediatric......................58
Diazepam.......................... 58, 85
Diazepam Intensol..................85
Diazoxide.................................89
Dibenzyline..............................94
Diclofenac Epolamine............ 40
Diclofenac Potassium............ 40
Diclofenac Sodium........40, 114,
147
Diclofenac Sodium ER........... 40
Diclofenac-Misoprostol.......... 40
Dicloxacillin Sodium...............52
Dicyclomine HCl...................121
Differin...................................109
Dificid.......................................53
Diflorasone Diacetate...........112
Diflucan................................... 65
Diflunisal..................................40
Digitek..................................... 99
Digox....................................... 99
Digoxin.................................... 99
Dihydroergotamine Mesylate
...............................................67
Dilantin.................................... 59
Dilantin INFATABS................. 59
Dilaudid.............................44, 45
Dilt-XR......................................98
Diltiazem HCl.......................... 98
Diltiazem HCl ER.................... 98
Diltiazem HCl ER Beads........ 98
Diltiazem HCl ER Coated
Beads.................................... 98
Dimethyl Fumarate............... 107
Dimethyl Fumarate Starter Pack
.............................................107
Diovan......................................95
Diovan HCT.............................99
Dipentum...............................143
Diphenoxylate-Atropine....... 121
Diphtheria-Tetanus Toxoids DT
.............................................141
Diprolene...............................112
Disulfiram................................ 46
Ditropan XL........................... 125
Diuril...................................... 101
Divalproex Sodium................. 86
Divalproex Sodium ER........... 86
19
Dofetilide................................. 96
Dojolvi....................................144
Dolishale................................130
Donepezil HCl.........................60
Donepezil HCl ODT................ 60
Doptelet...................................94
Doryx....................................... 54
Doryx MPC.............................. 54
Dorzolamide HCl.................. 148
Dorzolamide HCl-Timolol
Maleate............................... 145
Dorzolamide HCl-Timolol
Maleate Preservative Free
.............................................145
Dotti....................................... 130
Dovato..................................... 82
Dovonex................................ 114
Doxazosin Mesylate............... 94
Doxepin HCl........... 63, 112, 155
Doxercalciferol......................144
Doxy 100................................. 54
Doxycycline Hyclate.........54, 55
Doxycycline Monohydrate..... 55
Drizalma Sprinkle................. 106
Dronabinol...............................64
Drospirenone-Ethinyl Estradiol
.............................................130
Drospirenone-Ethinyl Estradiol-
Levomefolate......................130
Droxia...................................... 69
Droxidopa................................94
Duaklir Pressair.................... 154
Duetact.................................... 87
Duexis......................................40
Dulera.................................... 154
Duloxetine HCl......................106
Duobrii...................................114
Duopa......................................76
Dupixent................................138
Durezol.................................. 147
Dutasteride............................126
Dutasteride-Tamsulosin HCl
.............................................126
DUTOPROL.............................99
Dyanavel XR..........................105
Dymista................................. 150
Dyrenium...............................101
E
E.E.S. Granules.......................53
Econazole Nitrate................. 116
Edarbi...................................... 95
Edarbyclor...............................99
Edecrin.................................. 101
Edurant....................................82
Efavirenz..................................82
Efavirenz-Emtricitabine-
Tenofovir...............................82
Efavirenz-Lamivudine-Tenofovir
...............................................82
Effexor XR............................... 62
Efudex................................... 114
Egrifta SV.............................. 128
Elestrin...................................130
Eletriptan Hydrobromide........66
Elidel......................................112
Eligard................................... 136
Eliquis...................................... 91
Eliquis Starter Pack................ 91
Elmiron.................................. 126
EluRyng.................................130
Emcyt.......................................69
Emend..................................... 64
Emend Tri-Pack...................... 64
Emflaza..................................127
Emgality............................ 67, 68
Emoquette.............................130
Emsam.....................................61
Emtricitabine...........................83
Emtricitabine-Tenofovir
Disoproxil Fumarate.............83
Emtriva.....................................83
Emverm................................... 74
Enalapril Maleate.................... 95
Enalapril-Hydrochlorothiazide
...............................................99
Enbrel............................139, 140
Enbrel Mini............................139
Enbrel SureClick...................140
Endari.................................... 118
Endocet................................... 45
Engerix-B...............................141
Enoxaparin Sodium................91
Enpresse-28.......................... 131
Enskyce.................................131
Enspryng............................... 140
Enstilar...................................114
Entacapone.............................75
Entecavir..................................81
Entocort EC...........................143
Entresto................................... 99
Enulose................................. 120
Envarsus XR..........................140
Epclusa....................................81
Epidiolex..................................55
Epiduo................................... 109
20
Epiduo Forte......................... 109
Epinastine HCl...................... 146
Epinephrine...........................152
EpiPen 2-Pak.........................152
EpiPen Jr 2-Pak.................... 152
Epitol........................................59
Epivir........................................83
Epivir HBV............................... 81
Eplerenone............................101
Epogen.................................... 93
Epzicom...................................83
Equetro....................................86
Eraxis....................................... 65
Ergotamine-Caffeine...............67
Erivedge.................................. 71
Erleada.................................... 69
Erlotinib HCl............................71
Errin....................................... 135
Ertaczo.................................. 116
Ertapenem Sodium................ 52
Ery..........................................116
Ery-Tab.................................... 53
Erygel.....................................116
EryPed 200..............................53
EryPed 400..............................53
Erythrocin Lactobionate.........53
Erythrocin Stearate.................53
Erythromycin................ 116, 146
Erythromycin Base................. 53
Erythromycin Ethylsuccinate
...............................................53
Esbriet................................... 153
Escitalopram Oxalate............. 62
Esomeprazole Magnesium
.............................................123
Estarylla.................................131
Estrace.................................. 131
Estradiol................................ 131
Estradiol Valerate................. 131
Estring................................... 131
Ethacrynic Acid.....................101
Ethambutol HCl...................... 68
Ethosuximide.......................... 58
Ethynodiol Diacetate-Ethinyl
Estradiol..............................131
Etodolac.................................. 40
Etodolac ER............................ 40
Etonogestrel-Ethinyl Estradiol
.............................................131
Eucrisa...................................112
Euthyrox................................ 135
Evekeo...................................105
Evekeo ODT..........................105
Evenity................................... 144
Everolimus...................... 71, 140
Evista..................................... 135
Evoclin...................................116
Evotaz...................................... 84
Evoxac...................................108
Evrysdi...................................124
Exelon......................................60
Exemestane............................ 70
Exforge.................................... 99
Exforge HCT........................... 99
Exjade....................................119
Extavia................................... 107
Extina.....................................116
Eysuvis.................................. 147
Ezallor Sprinkle.....................102
Ezetimibe.............................. 102
Ezetimibe-Simvastatin.......... 102
F
Fabior.................................... 109
Falmina..................................131
Famciclovir..............................81
Famotidine............................ 122
Fanapt............................... 77, 78
Fanapt Titration Pack............. 78
Fareston.................................. 69
Farxiga.....................................87
Farydak....................................71
Fasenra..................................154
Fasenra Pen..........................154
Fayosim.................................131
Febuxostat.............................. 66
Felbamate......................... 55, 56
Felbatol....................................56
Feldene....................................40
Felodipine ER......................... 97
Femara.................................... 70
Femring................................. 131
Femynor................................ 131
Fenofibrate............................101
Fenofibrate Micronized........101
Fenofibric Acid..................... 101
Fenoglide.............................. 102
Fenoprofen Calcium...............40
Fentanyl...................................42
Fentanyl Citrate.......................45
Fentora.................................... 45
Ferriprox................................119
Fetzima.................................... 62
Fetzima Titration..................... 62
Fexmid...................................155
21
Fiasp........................................ 89
Fiasp FlexTouch..................... 89
Fiasp PenFill............................89
Finacea..................................109
Finasteride............................ 126
Fintepla....................................56
Firazyr....................................137
Firdapse................................ 106
Firmagon...............................136
Firvanq.....................................48
Flac........................................ 149
Flagyl....................................... 48
Flarex.....................................147
Flavoxate HCl........................125
Flebogamma DIF..................137
Flecainide Acetate..................96
Flector......................................40
FloLipid................................. 102
Flomax...................................126
Flovent Diskus...................... 150
Flovent HFA.......................... 150
Fluconazole.............................65
Fluconazole in Sodium
Chloride................................ 65
Flucytosine..............................65
Fludrocortisone Acetate...... 127
Flunisolide.............................150
Fluocinolone Acetonide......112,
149
Fluocinolone Acetonide Scalp
.............................................112
Fluocinonide......................... 112
Fluocinonide Emulsified Base
.............................................112
Fluorometholone.................. 147
Fluoroplex............................. 114
Fluorouracil........................... 114
Fluoxetine HCl........................ 62
Fluphenazine Decanoate....... 76
Fluphenazine HCl................... 77
Flurandrenolide.................... 112
Flurbiprofen.............................40
Flurbiprofen Sodium............ 147
Flutamide................................ 69
Fluticasone Propionate.......112,
150
Fluticasone-Salmeterol........ 154
Fluvastatin Sodium...............102
Fluvastatin Sodium ER.........102
Fluvoxamine Maleate............. 62
Fluvoxamine Maleate ER....... 62
FML........................................147
FML Forte..............................147
FML Liquifilm........................ 147
Focalin...................................105
Focalin XR.............................105
Fondaparinux Sodium............91
Forfivo XL................................ 61
Fortamet.................................. 87
Forteo.................................... 144
Fortesta................................. 129
Fosamax................................144
Fosamax Plus D....................144
Fosamprenavir Calcium......... 84
Fosfomycin Tromethamine....48
Fosinopril Sodium.................. 95
Fosinopril Sodium-HCTZ....... 99
Fosrenol................................ 120
Fotivda.....................................69
Fragmin................................... 92
Frova........................................66
Frovatriptan Succinate........... 66
Fulphila....................................93
Furosemide...........................101
Fuzeon.....................................84
Fyavolv...................................131
Fycompa..................................56
G
Gabapentin............................. 58
Gabitril..................................... 58
Galafold.................................124
Galantamine Hydrobromide
...............................................60
Galantamine Hydrobromide ER
...............................................60
Gammagard..........................137
Gammagard S/D Less IgA
.............................................137
Gammaked........................... 137
Gammaplex...........................137
Gamunex-C........................... 137
Gardasil 9..............................141
Gastrocrom........................... 124
Gatifloxacin........................... 146
Gattex.................................... 121
Gauze.................................... 144
GaviLyte-C.............................121
GaviLyte-G.............................122
GaviLyte-N with Flavor Pack
.............................................122
Gavreto....................................71
Gelnique................................125
Gemfibrozil............................102
Gemmily................................ 131
22
Gemtesa................................125
Generess Fe..........................131
Generlac................................121
Gengraf................................. 140
Genotropin............................128
Genotropin MiniQuick..........128
Gentak...................................146
Gentamicin Sulfate........47, 116,
146
Gentamicin Sulfate-0.9%
Sodium Chloride.................. 47
Genvoya.................................. 82
Geodon....................................78
Gilenya.................................. 107
Gilotrif...................................... 71
Gimoti...................................... 63
Glassia...................................124
Glatiramer Acetate............... 107
Glatopa..................................107
Gleevec................................... 71
Glimepiride..............................87
Glipizide...................................87
Glipizide ER............................ 87
Glipizide-Metformin HCl.........87
Gloperba................................. 66
GlucaGen HypoKit..................89
Glucagon.................................89
Glucotrol XL............................ 87
Glumetza................................. 87
Glycopyrrolate...................... 121
Glyxambi................................. 87
Gocovri.................................... 75
GoLYTELY............................ 122
GoNitro..................................103
Gralise................................... 106
Granisetron HCl...................... 64
Granix...................................... 93
Grastek..................................138
Griseofulvin Microsize............65
Griseofulvin Ultramicrosize....65
Gvoke HypoPen 2-Pack......... 89
Gvoke PFS.............................. 89
Gynazole-1.............................. 65
H
Haegarda.............................. 137
Hailey 24 Fe.......................... 131
Halcinonide...........................112
Haldol...................................... 77
Haldol Decanoate...................77
Halobetasol Propionate....... 112
Halog..................................... 112
Haloperidol..............................77
Haloperidol Decanoate.......... 77
Haloperidol Lactate................ 77
Harvoni.................................... 81
Havrix.....................................141
Helidac Therapy................... 122
Hemady.................................127
Heparin Sodium......................92
HepatAmine.......................... 118
Hepsera...................................81
Hetlioz....................................155
Hetlioz LQ............................. 155
Hiberix................................... 141
Hiprex...................................... 48
Horizant.................................106
Humalog..................................89
Humalog Junior KwikPen...... 89
Humalog KwikPen.................. 89
Humalog Mix 50/50................89
Humalog Mix 50/50 KwikPen
...............................................89
Humalog Mix 75/25................89
Humalog Mix 75/25 KwikPen
...............................................89
Humatin...................................47
Humatrope............................ 128
Humira...................................140
Humira Pediatric Crohns Start
.............................................140
Humira Pen........................... 140
Humira Pen Crohns Disease
Starter................................. 140
Humira Pen Psoriasis Starter
.............................................140
Humira Pen-Pediatric UC Start
.............................................140
Humulin 70/30........................90
Humulin 70/30 KwikPen........ 89
Humulin N............................... 90
Humulin N KwikPen............... 90
Humulin R............................... 90
Humulin R U-500.................... 90
Humulin R U-500 KwikPen.....90
Hydralazine HCl....................103
Hydrea..................................... 69
Hydrochlorothiazide.............101
Hydrocodone Bitartrate ER... 42
Hydrocodone-Acetaminophen
...............................................45
Hydrocodone-Ibuprofen.........45
Hydrocortisone... 112, 113, 127,
143
Hydrocortisone Acetate-
Pramoxine...........................115
23
Hydrocortisone Butyrate......112
Hydrocortisone Valerate...... 113
Hydrocortisone-Acetic Acid
.............................................149
Hydromorphone HCl.............. 45
Hydromorphone HCl ER........ 42
Hydromorphone HCl
Preservative Free..................45
Hydroxychloroquine Sulfate
...............................................74
Hydroxyurea............................69
Hydroxyzine HCl..................... 85
Hydroxyzine Pamoate............ 85
Hysingla ER...................... 42, 43
Hyzaar......................................99
I
Ibandronate Sodium............ 144
Ibrance.................................... 71
Ibu............................................40
Ibuprofen.......................... 40, 41
Icatibant Acetate.................. 137
Iclevia.....................................131
Iclusig...................................... 71
Icosapent Ethyl..................... 103
IDHIFA..................................... 70
Ilevro...................................... 147
Ilumya.................................... 138
Imatinib Mesylate....................71
Imbruvica.................................71
Imipenem-Cilastatin................52
Imipramine HCl.......................63
Imipramine Pamoate.............. 63
Imiquimod............................. 115
Imitrex......................................66
Imitrex STATdose Refill......... 66
Imitrex STATdose System..... 66
Imovax Rabies...................... 141
Impavido..................................74
Impeklo..................................113
Imuran................................... 140
Imvexxy Maintenance Pack
.............................................131
Imvexxy Starter Pack............131
Inbrija.......................................76
Incassia................................. 135
Increlex..................................128
Incruse Ellipta....................... 151
Indapamide...........................101
Inderal LA................................96
Indocin.....................................41
Infanrix...................................142
Ingrezza.................................106
Inlyta........................................ 71
InnoPran XL............................ 96
Inqovi....................................... 71
Inrebic......................................71
Inspra.....................................101
Insulin Aspart.......................... 90
Insulin Aspart FlexPen........... 90
Insulin Aspart PenFill..............90
Insulin Aspart Prot & Aspart
...............................................90
Insulin Aspart Prot & Aspart
FlexPen................................. 90
Insulin Lispro...........................90
Insulin Lispro Junior KwikPen
...............................................90
Insulin Lispro Prot & Lispro... 90
Insulin Syringes, Needles.... 144
Intelence..................................82
Intralipid................................ 118
Intrarosa................................ 129
Intron A..................................139
Introvale.................................131
Invanz...................................... 52
Invega...................................... 78
Invega Sustenna..................... 78
Invega Trinza...........................78
Inveltys.................................. 147
Invirase.................................... 84
Invokamet................................87
Invokamet XR..........................87
Invokana.................................. 87
Iopidine................................. 148
IPOL.......................................142
Ipratropium Bromide............151
Ipratropium-Albuterol........... 154
Irbesartan................................ 95
Irbesartan-Hydrochlorothiazide
.............................................100
Iressa....................................... 71
Isentress.................................. 82
Isentress HD............................82
Isibloom.................................131
Isolyte-P in D5W....................118
Isolyte-S.................................118
Isoniazid.................................. 68
Isopto Carpine...................... 148
Isordil Titradose....................103
Isosorbide Dinitrate.............. 104
Isosorbide Mononitrate........104
Isosorbide Mononitrate ER
.............................................104
Isotretinoin............................ 109
Isradipine.................................97
24
Istalol..................................... 148
Isturisa................................... 136
Itraconazole.............................65
Ivermectin....................... 74, 115
Ixiaro......................................142
J
Jadenu...................................119
Jadenu Sprinkle....................120
Jakafi....................................... 71
Jalyn...................................... 126
Jantoven..................................92
Janumet...................................87
Janumet XR.............................87
Januvia.................................... 87
Jardiance.................................87
Jasmiel.................................. 131
Jatenzo..................................129
Jentadueto.............................. 87
Jentadueto XR........................ 87
Jinteli..................................... 131
Jornay PM............................. 105
Jublia..................................... 116
Juleber...................................131
Juluca...................................... 82
Junel 1.5/30..........................131
Junel 1/20.............................131
Junel Fe 1.5/30.....................131
Junel Fe 1/20........................131
Junel Fe 24........................... 131
Juxtapid.................................103
Jynarque............................... 120
K
K-Tab..................................... 118
Kaitlib Fe............................... 131
Kaletra..................................... 84
Kalydeco............................... 152
Kapvay...................................105
Kariva.....................................131
Katerzia....................................97
Kazano.....................................87
KCl in Dextrose-NaCl............118
KCl-Lactated Ringers-D5W
.............................................118
Kelnor 1/35........................... 131
Kelnor 1/50........................... 132
Kenalog................................. 113
Keppra.....................................56
Keppra XR...............................56
Kerydin.................................. 116
Kesimpta............................... 107
Ketoconazole..................65, 116
Ketodan.................................116
Ketoprofen.............................. 41
Ketoprofen ER........................ 41
Ketorolac Tromethamine...... 41,
147
Keveyis.................................. 124
Kevzara..................................138
Kineret................................... 138
Kinrix......................................142
Kisqali...................................... 72
Kisqali Femara........................ 72
Klaron.................................... 116
Klonopin.................................. 85
Klor-Con................................ 118
Klor-Con 10........................... 118
Klor-Con 8............................. 118
Klor-Con M10........................118
Klor-Con M15........................118
Klor-Con M20........................118
Kombiglyze XR....................... 87
Korlym................................... 129
Koselugo................................. 72
Krintafel................................... 74
Kristalose.............................. 121
Kurvelo.................................. 132
Kuvan.....................................124
Kynmobi.................................. 76
L
Labetalol HCl.......................... 96
Lacrisert................................ 145
Lactulose...............................121
Lamictal...................................56
Lamictal ODT.......................... 56
Lamictal Starter...................... 56
Lamictal XR.............................56
Lamivudine....................... 81, 83
Lamivudine-Zidovudine..........83
Lamotrigine............................. 56
Lamotrigine ER.......................56
Lamotrigine ODT.................... 56
Lamotrigine Starter Kit-Blue
...............................................56
Lamotrigine Starter Kit-Green
...............................................56
Lamotrigine Starter Kit-Orange
...............................................57
Lampit......................................74
Lanoxin..................................100
Lansoprazole........................ 123
Lansoprazole ODT............... 123
Lanthanum Carbonate.........120
Lantus......................................90
Lantus SoloStar...................... 90
25
Lapatinib Ditosylate................72
LARIN 1.5/30........................132
LARIN 1/20........................... 132
LARIN Fe 1.5/30...................132
LARIN Fe 1/20......................132
Larissia.................................. 132
Lasix...................................... 101
Lastacaft................................146
Latanoprost...........................149
Latuda......................................78
Layolis Fe.............................. 132
Lazanda...................................45
Ledipasvir-Sofosbuvir.............81
Leena.....................................132
Leflunomide..........................140
Lenvima 10MG Daily Dose.... 72
Lenvima 12MG Daily Dose.... 72
Lenvima 14MG Daily Dose.... 72
Lenvima 18MG Daily Dose.... 72
Lenvima 20MG Daily Dose.... 72
Lenvima 24MG Daily Dose.... 72
Lenvima 4MG Daily Dose...... 72
Lenvima 8MG Daily Dose...... 72
Lescol XL.............................. 102
Lessina.................................. 132
Letairis...................................153
Letrozole..................................70
Leucovorin Calcium............... 74
Leukeran................................. 69
Leukine....................................93
Leuprolide Acetate...............136
Levalbuterol HCl...................152
Levalbuterol Tartrate............152
Levemir....................................90
Levemir FlexTouch.................90
Levetiracetam......................... 57
Levetiracetam ER................... 57
Levo-T....................................135
Levobunolol HCl...................148
Levocarnitine........................ 124
Levocetirizine Dihydrochloride
.............................................150
Levofloxacin....................54, 146
Levofloxacin in D5W...............54
Levonest................................132
Levonorgestrel-Ethinyl Estradiol
.............................................132
Levonorgestrel-Ethinyl Estradiol
& Ethinyl Estradiol.............. 132
Levonorgestrel-Ethinyl Estradiol
91-Day................................. 132
Levora 0.15/30..................... 132
Levorphanol Tartrate..............43
Levothyroxine Sodium......... 135
Levoxyl.................................. 135
Lexapro................................... 62
Lexette...................................113
Lexiva.......................................84
Lialda.....................................143
Librax.....................................121
Licart........................................41
Lidocaine.................................46
Lidocaine HCl......................... 46
Lidocaine Viscous.................. 46
Lidocaine-Prilocaine...............46
Lidoderm.................................46
Lindane................................. 115
Linezolid.................................. 48
Linzess.................................. 121
Liothyronine Sodium............135
Lipitor.................................... 102
Lipofen.................................. 102
Lisinopril..................................95
Lisinopril-Hydrochlorothiazide
.............................................100
Lithium.....................................86
Lithium Carbonate..................86
Lithium Carbonate ER............86
Lithobid................................... 86
Lithostat................................ 127
Livalo..................................... 102
Lo Loestrin Fe.......................132
Locoid................................... 113
Locoid Lipocream................ 113
Lodine......................................41
Lodosyn...................................76
Loestrin 1.5/30..................... 132
Loestrin 1/20........................ 132
Loestrin Fe 1.5/30................ 132
Loestrin Fe 1/20................... 132
Lokelma.................................120
Lomotil.................................. 121
Lonhala Magnair...................151
Lonsurf.................................... 70
Loperamide HCl................... 121
Lopid..................................... 102
Lopinavir-Ritonavir..................84
Lopressor................................ 96
Loprox................................... 116
Lorazepam.............................. 85
Lorazepam Intensol................85
Lorbrena..................................72
Loryna................................... 132
26
Losartan Potassium................95
Losartan Potassium-HCTZ...100
LoSeasonique.......................132
Lotemax................................ 147
Lotemax SM..........................147
Lotensin...................................95
Loteprednol Etabonate........ 147
Lotrel..................................... 100
Lotronex................................ 121
Lovastatin..............................102
Lovaza................................... 103
Lovenox...................................92
Low-Ogestrel.........................132
Loxapine Succinate................77
Lubiprostone.........................121
Lucemyra................................ 47
Luliconazole..........................116
Lumigan................................ 149
Lupaneta Pack......................136
Lupkynis................................140
Lupron Depot........................136
Lutera.................................... 132
Luxiq......................................113
Luzu.......................................117
Lyleq......................................135
Lyllana................................... 132
Lynparza..................................72
Lyrica.............................106, 107
Lyrica CR...............................106
Lysodren............................... 136
Lysteda....................................94
Lyumjev................................... 90
Lyumjev KwikPen................... 90
Lyza....................................... 135
M
M-M-R II................................. 142
Macrobid................................. 48
Macrodantin............................48
Mafenide Acetate................. 117
Magnesium Sulfate.............. 118
Malarone................................. 74
Malathion.............................. 115
Marinol.....................................64
Marlissa................................. 132
Marplan................................... 61
Matulane..................................69
Matzim LA............................... 98
Mavenclad.............................107
Mavyret....................................81
Maxalt...................................... 66
Maxalt-MLT............................. 66
Maxidex.................................147
Maxitrol..................................145
Maxzide................................. 100
Maxzide-25............................100
Mayzent.................................107
Mayzent Starter Pack........... 107
Meclizine HCl..........................63
Meclofenamate Sodium.........41
Medrol................................... 127
Medroxyprogesterone Acetate
.............................................135
Mefenamic Acid......................41
Mefloquine HCl.......................74
Megestrol Acetate................ 135
Mekinist................................... 72
Mektovi....................................72
Meloxicam...............................41
Memantine HCl.......................61
Memantine HCl ER.................61
Memantine HCl Titration Pak
...............................................61
Menactra............................... 142
Menest...................................132
MenQuadfi............................ 142
Mentax...................................117
Menveo..................................142
Mepron.................................... 74
Mercaptopurine...................... 69
Meropenem...................... 52, 53
Merrem.................................... 53
Merzee...................................132
Mesalamine...........................143
Mesalamine ER.....................143
Mesnex.................................... 74
Mestinon..................................68
Metformin HCl.........................88
Metformin HCl ER...................87
Methadone HCl.......................43
Methamphetamine HCl........105
Methazolamide..................... 148
Methenamine Hippurate........ 48
Methimazole......................... 137
Methitest............................... 129
Methotrexate.........................140
Methotrexate Sodium...........140
Methoxsalen Rapid.............. 115
Methscopolamine Bromide
.............................................121
Methyldopa............................. 94
Methylin.................................105
Methylphenidate HCl........... 106
Methylphenidate HCl CD.....105
27
Methylphenidate HCl ER..... 105
Methylphenidate HCl ER
Osmotic Release................105
Methylphenidate HCl LA......105
Methylprednisolone............. 127
Methyltestosterone...............129
Metoclopramide HCl.............. 63
Metoclopramide HCl ODT..... 63
Metolazone........................... 101
Metoprolol Succinate ER.......97
Metoprolol Tartrate.................97
Metoprolol-Hydrochlorothiazide
.............................................100
MetroCream............................48
Metrogel.................................. 48
MetroLotion.............................48
Metronidazole...................48, 49
Metronidazole in NaCl 0.79%
...............................................49
Metyrosine............................ 100
Mexiletine HCl.........................96
Mibelas 24 Fe....................... 132
Micafungin Sodium................ 65
Micardis...................................95
Micardis HCT........................100
Miconazole 3...........................65
Microgestin 1.5/30...............132
Microgestin 1/20.................. 132
Microgestin Fe 1.5/30..........132
Microgestin Fe 1/20.............132
Midodrine HCl.........................94
Migergot.................................. 67
Miglitol.....................................88
Miglustat................................124
Migranal.................................. 67
Mili......................................... 132
Millipred................................ 127
Minastrin 24 Fe.....................132
Minipress.................................94
Minitran................................. 104
Minivelle................................ 133
Minocycline HCl......................55
Minocycline HCl ER................55
Minolira....................................55
Minoxidil................................103
Mirapex....................................76
Mirapex ER..............................76
Mirtazapine............................. 61
Mirtazapine ODT.....................61
Mirvaso..................................109
Misoprostol........................... 123
Mitigare................................... 66
Mobic.......................................41
Modafinil............................... 155
Moexipril HCl.......................... 95
Molindone HCl........................77
Mometasone Furoate..........113,
150
Mondoxyne NL....................... 55
Montelukast Sodium............ 151
Monurol................................... 49
Morphine Sulfate.................... 45
Morphine Sulfate ER.............. 43
Morphine Sulfate ER Beads
...............................................43
Motegrity............................... 121
Movantik................................121
MoviPrep...............................122
Moxeza..................................146
Moxifloxacin HCl............ 54, 146
Moxifloxacin HCl in NaCl....... 54
MS Contin............................... 43
Mulpleta...................................93
Multaq......................................96
Mupirocin.............................. 117
Mupirocin Calcium............... 117
Myalept..................................122
Myambutol.............................. 68
Mycamine................................65
Mycapssa..............................136
Mycobutin............................... 68
Mycophenolate Mofetil........ 140
Mycophenolate Sodium.......140
Mydayis................................. 105
Myfortic................................. 140
Myorisan................................109
Myrbetriq...............................125
Mysoline.................................. 58
Mytesi.................................... 121
N
Nabumetone........................... 41
Nadolol.................................... 97
Nafcillin Sodium..................... 52
Naftifine HCl..........................117
Naftin..................................... 117
Nalfon...................................... 41
Naloxone HCl..........................47
Naltrexone HCl....................... 47
Namenda.................................61
Namenda Titration Pak.......... 61
Namenda XR...........................61
Namzaric................................. 60
Naprelan..................................41
Naproxen.................................41
28
Naproxen DR.......................... 41
Naproxen Sodium.................. 41
Naproxen Sodium ER............ 41
Naproxen-Esomeprazole....... 41
Naratriptan HCl.......................66
Narcan..................................... 47
Nardil....................................... 61
Nasonex................................ 150
Natacyn................................. 146
Natazia...................................133
Nateglinide..............................88
Natesto.................................. 129
Natpara..................................144
Natroba................................. 115
Nayzilam..................................58
Nebupent................................ 74
Necon 0.5/35........................133
Nefazodone HCl..................... 62
Neo-Synalar...........................115
Neomycin Sulfate................... 47
Neomycin-Bacitracin-Polymyxin
.............................................146
Neomycin-Polymyxin-
Bacitracin-Hydrocortisone
.............................................145
Neomycin-Polymyxin-
Dexamethasone................. 145
Neomycin-Polymyxin-
Gramicidin.......................... 146
Neomycin-Polymyxin-HC.... 145,
149
Neoral....................................140
Nerlynx.................................... 72
Nesina......................................88
Neuac.................................... 109
Neulasta.................................. 93
Neupogen............................... 93
Neupro.....................................76
Neurontin................................ 58
Nevanac................................ 147
Nevirapine............................... 82
Nevirapine ER......................... 82
Nexavar................................... 72
Nexium.................................. 123
Nexletol................................. 103
Nexlizet..................................103
Nextstellis..............................133
Niacin ER.............................. 103
Niacor....................................103
Niaspan................................. 103
Nicardipine HCl...................... 97
Nicotrol....................................47
Nicotrol NS..............................47
Nifedipine ER..........................97
Nifedipine ER Osmotic Release
...............................................97
Nikki.......................................133
Nilandron.................................69
Nilutamide...............................69
Nimodipine..............................97
Ninlaro..................................... 70
Nisoldipine ER........................ 97
Nitazoxanide........................... 74
Nitisinone.............................. 124
Nitro-Bid................................ 104
Nitro-Dur................................104
Nitrofurantoin..........................49
Nitrofurantoin Macrocrystal...49
Nitrofurantoin Monohydrate
...............................................49
Nitroglycerin..........................104
Nitrolingual............................104
Nitrostat.................................104
Nityr....................................... 124
Nivestym..................................93
Nizatidine.............................. 122
Nocdurna.............................. 128
Nolix.......................................113
Nora-BE................................. 135
Norditropin FlexPro..............128
Norethindrone...................... 135
Norethindrone Acetate........ 135
Norethindrone Acetate-Ethinyl
Estradiol..............................133
Norethindrone Acetate-Ethinyl
Estradiol-Fe.........................133
Norgestimate-Ethinyl Estradiol
.............................................133
Norgestimate-Ethinyl Estradiol
Triphasic............................. 133
Noritate....................................49
Norpramin............................... 63
Northera.................................. 94
Nortrel 0.5/35....................... 133
Nortrel 1/35.......................... 133
Nortrel 7/7/7.........................133
Nortriptyline HCl..................... 63
Norvasc................................... 97
Norvir....................................... 84
Nourianz.................................. 75
Novolin 70/30......................... 91
Novolin 70/30 FlexPen...........90
Novolin N.................................91
Novolin N FlexPen.................. 91
Novolin R.................................91
Novolin R FlexPen.................. 91
29
NovoLog..................................91
NovoLog FlexPen................... 91
NovoLog Mix 70/30................91
NovoLog Mix 70/30 FlexPen
...............................................91
NovoLog PenFill..................... 91
Noxafil......................................65
Nubeqa....................................69
Nucala................................... 154
Nucynta................................... 45
Nucynta ER............................. 43
Nuedexta...............................106
NuLYTELY Lemon-Lime...... 122
Nuplazid.................................. 78
Nurtec ODT.............................66
Nutrilipid................................118
Nutropin AQ NuSpin 10.......128
Nutropin AQ NuSpin 20.......128
Nutropin AQ NuSpin 5......... 128
NuvaRing.............................. 133
Nuvigil....................................155
Nuzyra..................................... 55
Nyamyc................................. 117
Nylia 7/7/7............................ 133
Nymalize..................................97
Nymyo................................... 133
Nystatin........................... 65, 117
Nystatin-Triamcinolone........ 115
Nystop................................... 117
Nyvepria.................................. 93
O
Ocaliva...................................122
Ocella.................................... 133
Octagam................................137
Octreotide Acetate............... 136
Ocuflox.................................. 146
Odactra................................. 138
Odefsey................................... 83
Odomzo...................................72
Ofev....................................... 154
Ofloxacin................ 54, 146, 149
Olanzapine.............................. 78
Olanzapine ODT..................... 78
Olanzapine-Fluoxetine HCl.... 61
Olmesartan Medoxomil..........95
Olmesartan Medoxomil-HCTZ
.............................................100
Olmesartan-Amlodipine-HCTZ
.............................................100
Olopatadine HCl...........146, 150
Olumiant................................138
Olux....................................... 113
Olux-E.................................... 113
Omeclamox-Pak................... 122
Omega-3-Acid Ethyl Esters
.............................................103
Omeprazole.......................... 123
Omeprazole-Sodium
Bicarbonate........................ 123
Omnaris.................................150
Omnitrope.............................128
Ondansetron HCl....................64
Ondansetron ODT.................. 64
Onexton.................................109
Onfi.......................................... 58
Ongentys.................................75
Onglyza................................... 88
Onureg.................................... 69
Onzetra Xsail...........................66
Opsumit.................................153
Oracea.....................................55
Oralair 300IR.........................138
Orapred ODT........................ 127
Oravig...................................... 65
Orencia..................................138
Orencia ClickJect................. 138
Orenitram.............................. 153
Orfadin.................................. 124
Orgovyx................................. 136
Oriahnn..................................136
Orilissa...................................137
Orkambi................................ 152
Orladeyo................................137
Orsythia................................. 133
Ortikos...................................143
Oseltamivir Phosphate........... 84
Oseni....................................... 88
Osmolex ER............................ 75
OsmoPrep.............................122
Osphena................................135
Otezla.................................... 138
Otovel.................................... 149
Otrexup................................. 140
Ovide..................................... 115
Oxacillin Sodium.....................52
Oxacillin Sodium in Dextrose
...............................................52
Oxandrolone......................... 129
Oxaprozin................................41
Oxazepam............................... 85
Oxbryta.................................... 93
Oxcarbazepine........................59
Oxervate................................ 145
30
Oxiconazole Nitrate..............117
Oxistat................................... 117
Oxtellar XR.............................. 59
Oxybutynin Chloride............ 125
Oxybutynin Chloride ER...... 125
Oxycodone HCl................ 45, 46
Oxycodone HCl ER................ 43
Oxycodone-Acetaminophen
...............................................46
OxyContin............................... 44
Oxymorphone HCl..................46
Oxymorphone HCl ER............44
Oxytrol................................... 126
Ozempic.................................. 88
P
Pacerone................................. 96
Paliperidone ER......................78
Palynziq.................................124
Pamelor................................... 63
Pancreaze............................. 124
Pandel................................... 113
Pantoprazole Sodium...........123
Panzyga.................................137
Paricalcitol............................ 144
Parlodel................................... 76
Parnate.................................... 61
Paromomycin Sulfate.............47
Paroxetine HCl........................62
Paser........................................68
Patanase............................... 150
Paxil......................................... 62
Pediarix................................. 142
Pedvax HIB........................... 142
PEG-3350-Electrolytes......... 122
PEG-3350-NaCl-Na
Bicarbonate-KCl................. 122
PEG-KCl-NaCl-NaSulf-Na Asc-C
.............................................122
Pegasys.................................139
Pemazyre.................................70
Penicillamine.........................127
Penicillin G Potassium........... 52
Penicillin G Potassium in
Dextrose................................52
Penicillin G Procaine.............. 52
Penicillin G Sodium................52
Penicillin V Potassium............52
Pennsaid................................. 41
PENTAM 300.......................... 74
Pentamidine Isethionate........ 75
Pentasa................................. 143
Pentoxifylline ER...................100
Pepcid...........................122, 123
Percocet.................................. 46
Perforomist........................... 152
Perindopril Erbumine............. 95
Periogard.............................. 108
Permethrin............................ 115
Perphenazine..........................63
Perseris....................................78
Pertzye...................................125
Phenelzine Sulfate..................61
Phenobarbital......................... 58
Phenoxybenzamine HCl.........94
Phenytek................................. 60
Phenytoin................................ 60
Phenytoin Sodium Extended
...............................................60
Phoslyra................................ 120
Picato.................................... 115
Pifeltro..................................... 82
Pilocarpine HCl............ 108, 148
Pimecrolimus........................113
Pimozide..................................77
Pimtrea.................................. 133
Pindolol................................... 97
Pioglitazone HCl..................... 88
Pioglitazone HCl-Glimepiride
...............................................88
Pioglitazone HCl-Metformin HCl
...............................................88
Piperacillin-Tazobactam.........52
Piqray................................ 72, 73
Pirmella 1/35........................ 133
Piroxicam................................ 41
Plaquenil..................................75
Plasma-Lyte 148................... 118
Plasma-Lyte A....................... 118
Plavix....................................... 94
Plegridy................................. 107
Plenamine............................. 118
Plenvu....................................122
Pliaglis..................................... 46
Podofilox............................... 115
Polymyxin B Sulfate................49
Polymyxin B-Trimethoprim
.............................................146
Polytrim................................. 146
Pomalyst..................................69
Portia-28................................ 133
Posaconazole......................... 65
Potassium Chloride..............119
Potassium Chloride CR....... 118
Potassium Chloride ER........118
31
Potassium Chloride in Dextrose
.............................................118
Potassium Chloride in NaCl
.................................... 118, 119
Potassium Citrate ER........... 119
Pradaxa................................... 92
Praluent................................. 103
Pramipexole Dihydrochloride
...............................................76
Pramipexole Dihydrochloride
ER..........................................76
Prasugrel HCl..........................94
Pravastatin Sodium.............. 102
Praziquantel............................ 74
Prazosin HCl........................... 94
Pred Forte............................. 147
Pred Mild...............................148
Pred-G................................... 145
Pred-G S.O.P.........................145
Prednicarbate....................... 113
Prednisolone.........................127
Prednisolone Acetate...........148
Prednisolone Sodium
Phosphate.................. 127, 148
Prednisolone Sodium
Phosphate ODT..................127
Prednisone................... 127, 128
Prednisone Intensol............. 127
Pregabalin.............................107
Pregabalin ER.......................107
Premarin................................133
Premasol............................... 119
Pretomanid..............................68
Prevacid................................ 123
Prevacid SoluTab................. 123
Prevalite.................................103
Previfem................................ 133
Prevymis..................................80
Prezcobix................................ 84
Prezista....................................84
Priftin....................................... 68
Prilosec..................................123
Primaquine Phosphate...........75
Primaxin IV.............................. 53
Primidone................................58
Prinivil...................................... 95
Pristiq.......................................62
Privigen................................. 138
ProAir HFA............................ 152
ProAir RespiClick................. 152
Probenecid..............................66
Probenecid-Colchicine...........66
Procalamine..........................119
Procardia XL........................... 97
ProCentra..............................105
Prochlorperazine.................... 63
Prochlorperazine Maleate......63
Procrit...................................... 93
Procto-Med HC.....................143
Procto-Pak.............................143
Proctosol HC.........................143
Proctozone-HC..................... 143
Procysbi................................ 125
Progesterone........................ 135
Proglycem............................... 89
Prograf.......................... 140, 141
Prolastin-C.............................125
Prolate..................................... 46
Prolensa................................ 148
Prolia..................................... 144
Promacta.................................93
Promethazine HCl.................. 64
Prometrium........................... 135
Propafenone HCl....................96
Propafenone HCl ER..............96
Proparacaine HCl................. 145
Propranolol HCl...................... 97
Propranolol HCl ER................ 97
Propylthiouracil.....................137
ProQuad................................142
Proscar.................................. 126
Prosol.................................... 119
Protonix................................. 123
Protopic.................................113
Protriptyline HCl......................63
Proventil HFA........................152
Provera.................................. 135
Provigil...................................155
Prozac......................................62
PRUDOXIN............................113
Psorcon................................. 113
Pulmicort...............................150
Pulmicort Flexhaler.............. 150
Pulmozyme........................... 152
Purixan.................................... 70
Pylera.....................................122
Pyrazinamide.......................... 68
Pyridostigmine Bromide........ 68
Pyridostigmine Bromide ER
...............................................68
Pyrimethamine........................75
Q
Qbrelis..................................... 95
Qbrexza................................. 115
32
Qinlock.................................... 69
Qnasl..................................... 151
Qnasl Childrens.................... 150
Qtern........................................88
Quadracel............................. 142
Qualaquin................................75
Quartette............................... 133
Qudexy XR.............................. 57
Questran................................103
Questran Light...................... 103
Quetiapine Fumarate..............78
Quetiapine Fumarate ER........78
QuilliChew ER.......................106
Quillivant XR......................... 106
Quinapril HCl...........................95
Quinapril-Hydrochlorothiazide
.............................................100
Quinidine Gluconate ER........ 96
Quinidine Sulfate.................... 96
Quinine Sulfate....................... 75
QVAR RediHaler...................151
R
RabAvert............................... 142
Rabeprazole Sodium........... 123
Raloxifene HCl......................135
Ramelteon.............................155
Ramipril................................... 95
Ranexa.................................. 100
Ranolazine ER...................... 100
Rapaflo..................................126
Rapamune............................ 141
Rasagiline Mesylate............... 76
Rasuvo.................................. 141
RAVICTI.................................125
Rayaldee............................... 144
Rayos.....................................128
Razadyne ER.......................... 60
Rebif...................................... 108
Rebif Rebidose.....................108
Rebif Rebidose Titration Pack
.............................................108
Rebif Titration Pack..............108
Reclipsen.............................. 133
Recombivax HB....................142
Rectiv.....................................104
RediTrex................................141
Reglan..................................... 64
Regranex...............................115
Relafen DS.............................. 41
Relenza Diskhaler...................85
Relexxii..................................106
Relistor.................................. 121
Relpax......................................66
Reltone..................................122
Remeron..................................61
Remeron SolTab.................... 61
Renagel................................. 120
Renvela................................. 120
Repaglinide.............................88
Repatha.................................103
Repatha Pushtronex System
.............................................103
Repatha SureClick............... 103
Restasis Single-Use Vials.....145
Restoril.................................. 155
Retacrit.................................... 93
Retevmo.................................. 70
Retin-A...................................109
Retin-A Micro........................ 109
Retin-A Micro Pump.............110
Retrovir....................................83
Revatio.................................. 153
Revlimid...................................69
Rexulti......................................78
Reyataz....................................84
Reyvow.................................... 67
Rhofade.................................110
Rhopressa.............................148
Ribavirin.................................. 81
Ridaura..................................138
Rifabutin.................................. 68
Rifampin.................................. 68
Rilutek................................... 106
Riluzole..................................106
Rimantadine HCl.................... 85
Rinvoq................................... 138
Riomet..................................... 88
Risedronate Sodium............ 144
Risperdal................................. 79
Risperdal Consta....................78
Risperidone.............................79
Risperidone ODT....................79
Ritalin.....................................106
Ritalin LA...............................106
Ritonavir.................................. 84
Rivastigmine........................... 60
Rivastigmine Tartrate............. 60
Rivelsa................................... 133
Rizatriptan Benzoate..............67
Rizatriptan Benzoate ODT..... 67
Rocaltrol................................144
Rocklatan.............................. 145
Ropinirole HCl........................ 76
33
Ropinirole HCl ER.................. 76
Rosuvastatin Calcium.......... 102
Roszet................................... 103
Rotarix................................... 142
RotaTeq.................................142
Rowasa..................................143
Roweepra................................57
Roxicodone.............................46
Rozerem................................155
Rozlytrek................................. 73
Rubraca...................................73
Ruconest...............................137
Rufinamide..............................60
Rukobia................................... 84
Ruzurgi.................................. 106
Rybelsus..................................88
Rydapt..................................... 73
Rytary.......................................76
Rythmol SR............................. 96
S
Sabril........................................59
Safyral....................................133
Saizen....................................128
Saizenprep............................128
Salagen................................. 108
Samsca..................................120
Sancuso.................................. 64
Sandimmune........................ 141
Sandostatin...........................137
Santyl.....................................115
Saphris.................................... 79
Sapropterin Dihydrochloride
.............................................125
Savaysa................................... 92
Savella................................... 107
Savella Titration Pack...........107
Scopolamine...........................64
Seasonique........................... 133
Secuado.................................. 79
Segluromet..............................88
Selegiline HCl......................... 76
Selenium Sulfide.................. 113
Selzentry..................................84
Semglee.................................. 91
Sensipar................................ 144
Serevent Diskus....................152
Seroquel..................................79
Seroquel XR............................79
Serostim................................ 129
Sertraline HCl..........................62
Setlakin..................................133
Sevelamer Carbonate.......... 120
Sevelamer HCl......................120
Seysara....................................55
Sharobel................................135
Shingrix................................. 142
Signifor.................................. 137
Siklos....................................... 93
Sildenafil Citrate................... 153
Silenor................................... 155
Siliq........................................138
Silodosin............................... 126
Silvadene...............................115
Silver Sulfadiazine................ 115
Simbrinza.............................. 149
Simponi................................. 141
Simvastatin............................102
Sinemet................................... 76
Singulair................................ 151
Sirolimus............................... 141
Sirturo......................................68
Sitavig...................................... 81
Sivextro....................................49
Skyrizi.................................... 138
Skyrizi Pen............................ 138
Slynd......................................135
Sodium Chloride.................. 119
Sodium Fluoride................... 119
Sodium Phenylbutyrate........125
Sodium Polystyrene Sulfonate
.............................................120
Sofosbuvir-Velpatasvir............81
Solifenacin Succinate.......... 126
Soliqua.................................... 88
Solodyn................................... 55
Solosec....................................49
Soltamox................................. 69
Somavert............................... 137
Soolantra...............................115
Soriatane...............................110
Sorilux................................... 115
Sorine...................................... 96
Sotalol HCl.............................. 96
Sotalol HCl AF.........................96
Sotylize.................................... 96
Sovaldi.....................................81
Spinosad............................... 115
Spiriva HandiHaler............... 151
Spiriva Respimat.................. 151
Spironolactone..................... 101
Spironolactone-HCTZ.......... 100
Sporanox.................................65
34
Sprintec 28............................133
Spritam ODT........................... 57
Sprix.........................................41
Sprycel.....................................73
SPS........................................120
Sronyx................................... 133
SSD........................................115
Stalevo 100............................. 75
Stalevo 125............................. 75
Stalevo 150............................. 75
Stalevo 200............................. 75
Stalevo 50................................75
Stalevo 75................................75
Steglatro..................................88
Steglujan................................. 88
Stelara................................... 139
Stiolto Respimat................... 154
Stivarga....................................73
Strattera.................................106
Streptomycin Sulfate..............47
Stribild..................................... 82
Striverdi Respimat................152
Stromectol...............................74
Suboxone................................ 47
Subsys.....................................46
Sucraid.................................. 125
Sucralfate..............................123
Sular.........................................97
Sulfacetamide Sodium........117,
146, 147
Sulfacetamide-Prednisolone
.............................................145
Sulfadiazine.............................54
Sulfamethoxazole-
Trimethoprim........................54
Sulfamylon............................ 117
Sulfasalazine.........................143
Sulindac.................................. 41
Sumatriptan.............................67
Sumatriptan Succinate...........67
Sumatriptan Succinate Refill
...............................................67
Sumatriptan-Naproxen Sodium
...............................................67
Sunosi....................................155
Suprax..................................... 51
Suprep Bowel Prep Kit.........122
Sustiva..................................... 82
Sutab..................................... 122
Sutent...................................... 73
Syeda.....................................134
Symbicort..............................155
Symbyax..................................61
Symdeko............................... 152
Symfi........................................83
Symfi Lo.................................. 82
Symjepi..................................152
SymlinPen 120........................88
SymlinPen 60..........................88
Sympazan................................59
Symproic............................... 121
Symtuza...................................84
Synalar...................................113
Synarel.................................. 137
Syndros................................... 64
Synjardy...................................88
Synjardy XR.............................88
Synribo.................................... 70
Synthroid...............................136
Syprine.................................. 120
T
Tabloid.....................................70
Tabrecta.................................. 69
Taclonex................................115
Tacrolimus....................113, 141
Tadalafil........................ 126, 153
Tafinlar.....................................73
Tagrisso...................................73
Takhzyro................................137
Talicia.................................... 122
Taltz....................................... 139
Talzenna..................................73
Tamiflu.....................................85
Tamoxifen Citrate................... 69
Tamsulosin HCl.................... 126
Tapazole................................137
TaperDex 12-Day..................128
TaperDex 6-Day.................... 128
TaperDex 7-Day.................... 128
Tarceva....................................73
TARGADOX............................ 55
Targretin............................73, 74
Tarina 24 Fe..........................134
Tarina Fe 1/20 EQ................ 134
Tasigna....................................73
Tasmar.....................................75
Tavaborole............................ 117
Tavalisse..................................94
Tazarotene............................ 110
Tazicef..................................... 51
Tazorac..................................110
Taztia XT..................................98
Tazverik................................... 70
TDVAX................................... 142
35
Tecfidera............................... 108
Tecfidera Starter Pack......... 108
Teflaro..................................... 51
Tegretol................................... 60
Tegretol XR............................. 60
Tegsedi..................................125
Tekturna................................ 100
Tekturna HCT....................... 100
Telmisartan............................. 95
Telmisartan-Amlodipine.......100
Telmisartan-HCTZ................ 100
Temazepam.......................... 155
Temixys................................... 83
Temovate.............................. 113
Tenivac..................................142
Tenofovir Disoproxil Fumarate
...............................................83
Tenoretic 100........................100
Tenoretic 50..........................100
Tenormin................................. 97
Tepmetko................................ 73
Terazosin HCl....................... 126
Terbinafine HCl.......................65
Terbutaline Sulfate............... 152
Terconazole............................ 65
Teriparatide...........................144
Testim....................................129
Testosterone.........................129
Testosterone Cypionate.......129
Testosterone Enanthate.......129
Testosterone Pump..............129
Tetrabenazine.......................106
Tetracycline HCl..................... 55
Texacort................................ 113
Thalomid................................. 69
Theo-24................................. 153
Theophylline......................... 153
Theophylline ER................... 153
Thiola.....................................127
Thiola EC...............................127
Thioridazine HCl..................... 77
Thiothixene............................. 77
Thyquidity............................. 136
Tiadylt ER................................ 98
Tiagabine HCl......................... 59
Tiazac...................................... 98
Tibsovo....................................73
Tigecycline..............................49
Tiglutik...................................106
Tikosyn.................................... 96
Tilia Fe................................... 134
Timolol Maleate..............68, 148
Timolol Maleate Ophthalmic
Gel Forming........................148
Timolol Maleate PF.............. 148
Timoptic Ocudose................148
Timoptic-XE...........................148
Tinidazole................................49
Tiopronin...............................127
Tirosint.................................. 136
Tirosint-SOL.......................... 136
Tivicay......................................82
Tivicay PD............................... 82
Tizanidine HCl.........................80
TOBI...................................... 152
TOBI Podhaler...................... 152
TobraDex.............................. 145
TobraDex ST.........................145
Tobramycin...................147, 152
Tobramycin Sulfate................ 47
Tobramycin-Dexamethasone
.............................................145
Tobrex................................... 147
Tolcapone............................... 75
Tolsura.....................................65
Tolterodine Tartrate............. 126
Tolterodine Tartrate ER....... 126
Tolvaptan.............................. 120
Topamax................................. 57
Topamax Sprinkle.................. 57
Topicort.................................113
Topicort Spray...................... 113
Topiramate..............................57
Topiramate ER........................57
Toprol XL.................................97
Toremifene Citrate..................69
Torsemide.............................101
Tosymra...................................67
Toujeo Max SoloStar..............91
Toujeo SoloStar...................... 91
Tovet......................................113
Toviaz.................................... 126
TPN Electrolytes................... 119
Tracleer................................. 153
Tradjenta................................. 88
Tramadol HCl..........................46
Tramadol HCl ER....................44
Tramadol-Acetaminophen..... 46
Trandolapril.............................95
Trandolapril-Verapamil HCl ER
.............................................100
Tranexamic Acid.....................94
Transderm-Scop.....................64
36
Tranxene-T.............................. 85
Tranylcypromine Sulfate........ 61
Travasol.................................119
Travatan Z............................. 149
Travoprost.............................149
Trazodone HCl........................62
Trecator...................................68
Trelegy Ellipta....................... 155
Trelstar Mixject..................... 137
Tremfya................................. 139
Tresiba.....................................91
Tresiba FlexTouch..................91
Tretinoin..........................74, 110
Tretinoin Microsphere..........110
Trexall....................................141
Treximet.................................. 67
Trezix....................................... 46
Tri-Estarylla............................134
Tri-Legest Fe......................... 134
Tri-Lo-Estarylla...................... 134
Tri-Lo-Sprintec...................... 134
Tri-Mili....................................134
Tri-Nymyo..............................134
Tri-Previfem...........................134
Tri-Sprintec............................134
Tri-VyLibra.............................134
Tri-VyLibra Lo........................134
Triamcinolone Acetonide... 108,
113, 114
Triamterene...........................101
Triamterene-HCTZ................100
Trianex...................................114
Tribenzor...............................100
Tricor..................................... 102
Triderm..................................114
Trientine HCl.........................120
Trifluoperazine HCl.................77
Trifluridine.............................147
Trihexyphenidyl HCl............... 75
Trijardy XR...............................88
Trikafta.................................. 153
Trileptal....................................60
Trilipix....................................102
TriLyte....................................122
Trimethobenzamide HCl........64
Trimethoprim.......................... 49
Trimipramine Maleate............ 63
Trintellix................................... 63
Triumeq................................... 83
Trivora................................... 134
Trizivir...................................... 83
Trokendi XR............................ 57
TrophAmine.......................... 119
Trospium Chloride............... 126
Trospium Chloride ER......... 126
Trulance................................ 121
Trulicity....................................88
Trumenba..............................142
Trusopt.................................. 149
Truvada................................... 83
Tudorza Pressair.................. 151
Tukysa..................................... 70
Turalio......................................73
Twinrix................................... 142
Twynsta................................. 100
Tybost......................................84
Tydemy..................................134
Tygacil..................................... 49
Tykerb......................................73
Tymlos...................................144
Typhim Vi.............................. 142
U
Ubrelvy.................................... 67
Uceris.................................... 143
Udenyca.................................. 93
Ukoniq..................................... 73
Uloric....................................... 66
Ultracet.................................... 46
Ultram...................................... 46
Ultravate................................ 114
Unasyn.....................................52
Unithroid............................... 136
Uptravi................................... 153
Urocit-K 10............................ 119
Urocit-K 15............................ 119
Urocit-K 5.............................. 119
Uroxatral................................126
Urso 250................................122
Urso Forte............................. 122
Ursodiol.................................122
V
Vabomere................................53
Vagifem................................. 134
Valacyclovir HCl......................81
Valchlor................................... 69
Valcyte.....................................80
Valganciclovir HCl.................. 80
Valium......................................86
Valproic Acid...........................57
Valsartan..................................95
Valsartan-Hydrochlorothiazide
.............................................100
Valtoco 10 MG Dose.............. 59
37
Valtoco 15 MG Dose.............. 59
Valtoco 20 MG Dose.............. 59
Valtoco 5 MG Dose................ 59
Valtrex......................................81
Vancocin................................. 49
Vancocin HCl.......................... 49
Vancomycin HCl..................... 49
Vandazole................................49
Vanos.....................................114
VAQTA...................................142
Varivax...................................142
Varizig....................................138
Varubi...................................... 64
Vascepa................................ 103
Vaseretic............................... 100
Vasotec....................................95
Vecamyl.................................100
Vectical..................................115
Velivet.................................... 134
Velphoro................................120
Veltassa.................................120
Veltin......................................110
Vemlidy....................................81
Venclexta.................................73
Venclexta Starting Pack.........73
Venlafaxine HCl...................... 63
Venlafaxine HCl ER................ 63
Ventavis.................................153
Ventolin HFA.........................152
Verapamil HCl.........................98
Verapamil HCl ER...................98
Verdeso................................. 114
Veregen.................................115
Verelan.................................... 98
Verelan PM..............................98
Verquvo................................. 104
Versacloz.................................80
Verzenio.................................. 73
Vesicare.................................126
Vesicare LS...........................126
Vestura.................................. 134
Vfend....................................... 65
Vfend IV................................... 65
Viberzi....................................121
Vibramycin.............................. 55
Victoza.....................................88
Viekira Pak.............................. 81
Vienva....................................134
Vigabatrin................................ 59
Vigadrone................................59
Vigamox................................ 147
Viibryd......................................63
Viibryd Starter Pack................63
Vimovo.....................................41
Vimpat..................................... 60
Viokace..................................125
Viracept................................... 84
Viramune................................. 83
Viramune XR........................... 83
Viread...................................... 83
Vistaril...................................... 85
Vitrakvi.....................................73
Vivelle-Dot............................. 134
Vivitrol......................................47
Vivlodex................................... 41
Vizimpro.................................. 73
Vogelxo................................. 129
Vogelxo Pump...................... 129
Voriconazole.....................65, 66
Vosevi...................................... 81
Votrient.................................... 73
VP-PNV-DHA......................... 120
Vraylar......................................79
Vumerity................................ 108
Vyfemla..................................134
VyLibra.................................. 134
Vyndamax............................. 125
Vyndaqel............................... 125
Vytorin................................... 103
Vyvanse................................. 105
Vyzulta................................... 149
W
Wakix.....................................156
Warfarin Sodium.....................92
Welchol................................. 103
Wellbutrin SR.......................... 61
Wellbutrin XL...........................61
Wixela Inhub......................... 155
WYMZYA Fe..........................134
X
Xalatan...................................149
Xalkori......................................73
Xanax.......................................86
Xanax XR.................................86
Xarelto..................................... 92
Xarelto Starter Pack............... 92
Xatmep.................................. 141
Xcopri................................ 57, 58
Xeljanz................................... 139
Xeljanz XR............................. 139
Xelpros.................................. 149
Xenazine................................106
38
Xenleta.....................................49
Xepi........................................117
Xerese................................... 115
Xermelo................................. 121
Xgeva.....................................144
Xhance.................................. 151
Xifaxan.....................................49
Xigduo XR............................... 88
Xiidra..................................... 145
Xofluza.....................................85
Xolair......................................139
Xolegel...................................117
Xopenex................................ 152
Xopenex Concentrate.......... 152
Xopenex HFA........................152
Xospata................................... 73
Xpovio......................................70
Xtampza ER............................ 44
Xtandi.......................................69
Xulane....................................134
Xultophy.................................. 88
Xuriden.................................. 125
Xyosted................................. 130
Xyrem.................................... 156
Xywav.................................... 155
Y
Yasmin 28............................. 134
YAZ........................................134
YF-Vax....................................142
Yonsa.......................................69
Yupelri................................... 151
Yuvafem................................ 134
Z
Zafemy.................................. 134
Zafirlukast............................. 151
Zaleplon................................ 155
Zanaflex...................................80
Zarah..................................... 134
Zarontin................................... 58
Zarxio.......................................93
Zavesca................................. 125
Zegerid.................................. 123
Zejula.......................................73
Zelapar ODT........................... 76
Zelboraf................................... 73
Zemaira................................. 125
Zembrace SymTouch.............67
Zemdri..................................... 47
Zemplar................................. 144
Zenatane............................... 110
Zenpep..................................125
Zenzedi..................................105
Zepatier................................... 81
Zeposia..................................108
Zeposia 7-Day Starter Pack
.............................................108
Zeposia Starter Kit................108
Zerbaxa................................... 51
Zerviate..................................146
Zestoretic.............................. 100
Zestril.......................................95
Zetia.......................................103
Zetonna................................. 151
Ziac........................................100
Ziagen......................................83
Ziana......................................110
Zidovudine.............................. 83
Ziextenzo.................................94
Zileuton ER........................... 151
Zilxi........................................ 117
Zioptan.................................. 149
Ziprasidone HCl......................79
Ziprasidone Mesylate.............79
Zipsor...................................... 41
Zirgan...................................... 80
Zithromax................................ 53
Zithromax Tri-Pak................... 53
Zithromax Z-Pak..................... 53
Zocor..................................... 102
Zolinza..................................... 70
Zolmitriptan.............................67
Zolmitriptan ODT....................67
Zoloft....................................... 63
Zolpidem Tartrate.................155
Zomacton..............................129
Zomig...................................... 67
Zomig ZMT..............................67
Zonalon................................. 114
Zonegran.................................60
Zonisamide............................. 60
Zontivity................................... 92
Zorbtive................................. 129
Zortress................................. 141
Zorvolex...................................42
Zosyn.......................................52
Zovia 1/35E...........................134
Zovirax.....................................82
ZTlido...................................... 46
Zubsolv....................................47
Zuplenz....................................64
Zyclara Pump........................115
Zydelig.....................................73
39
Zyflo.......................................151
Zykadia....................................73
Zylet.......................................145
Zyloprim.................................. 66
Zymaxid.................................147
Zypitamag............................. 102
Zyprexa....................................79
Zyprexa Relprevv....................80
Zyprexa Zydis......................... 80
Zytiga.......................................69
Zyvox....................................... 49
40
Covered drugs by medical condition
The list below has information about the drugs covered by this plan. If you have trouble finding your
drug, turn to the “Covered drugs by name (Drug index)” on pages 12-39.
The first column lists the drug name, which may include the dosage form and strength. Brand
name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain
type (for example, Simvastatin). The information in the “Coverage Rules or limits on use” column
lists any special requirements for coverage of your drug. If quantity limits (QL) apply to a drug, the
restriction amounts are shown in the chart on pages 157-202.
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
A1
AnalgesicsB1
Nonsteroidal Anti-inflammatory DrugsC1
Arth
rote
c
Arthrotec (Oral Tablet Delayed Release) B 3
C1
Cam
bia
Cambia (Oral Packet) B 4
C1
Cele
brex
Celebrex (Oral Capsule) B 3 QL C1
Cele
coxi
b
Celecoxib (Oral Capsule) G 2 QL C1
Day
pro
Daypro (Oral Tablet) B 3
C1
Dicl
ofen
ac
Epol
ami
ne Diclofenac Epolamine (External Patch) G 3 PA; QL C1
Dicl
ofen
ac
Pota
ssiu
m Diclofenac Potassium (Oral Tablet) G 2
C1
Dicl
ofen
ac
Sodi
um
ER Diclofenac Sodium ER (Oral Tablet Extended Release 24
Hour)G 1
C1
Dicl
ofen
ac
Sodi
um Diclofenac Sodium (1% External Gel) G 2
C1
Dicl
ofen
ac
Sodi
um Diclofenac Sodium (External Solution) G 2 PA C1
Dicl
ofen
ac
Sodi
um Diclofenac Sodium (Oral Tablet Delayed Release) G 1
C1
Dicl
ofen
ac-
Mis
opr
osto
l Diclofenac-Misoprostol (Oral Tablet Delayed Release) G 3
C1
Diflu
nisal
Diflunisal (Oral Tablet) G 2
C1
Due
xis
Duexis (Oral Tablet) B 4 ST C1
Eto
dola
c
ER
Etodolac ER (Oral Tablet Extended Release 24 Hour) G 3
C1
Eto
dola
c
Etodolac (Oral Capsule) G 2
C1
Eto
dola
c
Etodolac (Oral Tablet Immediate Release) G 2
C1
Feld
ene
Feldene (Oral Capsule) B 3
C1
Fen
opr
ofen
Calc
ium Fenoprofen Calcium (400MG Oral Capsule) G 3
C1
Fen
opr
ofen
Calc
ium Fenoprofen Calcium (Oral Tablet) G 3
C1
Flec
tor
Flector (External Patch) B 3 PA; QL C1
Flur
bipr
ofen
Flurbiprofen (100MG Oral Tablet) G 2
C1
Ibu
Ibu (600MG Oral Tablet, 800MG Oral Tablet) G 1
C1
Ibup
rofe
n
Ibuprofen (Oral Suspension) G 1
You can find information on what the abbreviations in this table mean on pages 6 - 7.
41Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Ibup
rofe
n
Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet,
800MG Oral Tablet)G 1
C1
Indo
cin
Indocin (Rectal Suppository) G 4
C1
Ket
opr
ofen
ER
Ketoprofen ER (Oral Capsule Extended Release 24
Hour)G 3
C1
Ket
opr
ofen
Ketoprofen (Oral Capsule Immediate Release) G 2
C1
Ket
orol
ac
Tro
met
ham
ine Ketorolac Tromethamine (Nasal Solution) G 4 LA C1
Lica
rt
Licart (External Patch 24 Hour) B 3 PA; QL C1
Lodi
ne
Lodine (Oral Tablet) G 4
C1
Mec
lofe
nam
ate
Sodi
um Meclofenamate Sodium (Oral Capsule) G 3
C1
Mef
ena
mic
Acid
Mefenamic Acid (Oral Capsule) G 3
C1
Mel
oxic
am
Meloxicam (Oral Capsule) G 3 QL C1
Mel
oxic
am
Meloxicam (Oral Tablet) G 1
C1
Mob
ic
Mobic (Oral Tablet) B 3
C1
Nab
ume
tone
Nabumetone (Oral Tablet) G 2
C1
Nalf
on
Nalfon (Oral Capsule) B 3
C1
Nalf
on
Nalfon (Oral Tablet) G 3
C1
Nap
rela
n
Naprelan (Oral Tablet Extended Release 24 Hour) B 4
C1
Nap
roxe
n
Naproxen (Oral Suspension) G 4
C1
Nap
roxe
n
Naproxen (Oral Tablet Immediate Release) G 1
C1
Nap
roxe
n
DR
Naproxen DR (Oral Tablet Delayed Release) (Generic
EC-Naprosyn)G 1
C1
Nap
roxe
n
Sodi
um
ER Naproxen Sodium ER (375MG Oral Tablet Extended
Release 24 Hour) (Generic Naprelan)G 4
C1
Nap
roxe
n
Sodi
um
ER Naproxen Sodium ER (500MG Oral Tablet Extended
Release 24 Hour) (Generic Naprelan)G 3
C1
Nap
roxe
n
Sodi
um Naproxen Sodium (275MG Oral Tablet Immediate
Release, 550MG Oral Tablet Immediate Release)G 2
C1
Nap
roxe
n-
Eso
mep
razo
le Naproxen-Esomeprazole (Oral Tablet Delayed Release) G 4 ST C1