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MetroPlus Health Plan (10/01/2020) INTRODUCTION
.....................................................................................................................................................................................................
4PREFACE
...............................................................................................................................................................................................................
4DRUG LIST PRODUCT DESCRIPTIONS
..............................................................................................................................................................
4GENERIC SUBSTITUTION
.....................................................................................................................................................................................
5NON-COVERED MEDICATIONS
...........................................................................................................................................................................
5OVER-THE-COUNTER DRUG COVERAGE
..........................................................................................................................................................
5SPECIALTY PLAN DESIGN
...................................................................................................................................................................................
5PLAN DESIGN
........................................................................................................................................................................................................
6LEGEND
..................................................................................................................................................................................................................
6NOTICE
...................................................................................................................................................................................................................
6ANALGESICS
.........................................................................................................................................................................................................
7
NSAIDs
.........................................................................................................................................................................................................
7COX-2 INHIBITORS
.....................................................................................................................................................................................
7GOUT
............................................................................................................................................................................................................
7OPIOID ANALGESICS
.................................................................................................................................................................................
7NON-OPIOID ANALGESICS
........................................................................................................................................................................
8
ANTI-INFECTIVES
..................................................................................................................................................................................................
8ANTIBACTERIALS
.......................................................................................................................................................................................
8ANTIFUNGALS
.............................................................................................................................................................................................
9ANTIMALARIALS
..........................................................................................................................................................................................
9ANTIRETROVIRAL AGENTS
.......................................................................................................................................................................
9ANTITUBERCULAR AGENTS
....................................................................................................................................................................
10ANTIVIRALS
...............................................................................................................................................................................................
11MISCELLANEOUS
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11
ANTINEOPLASTIC AGENTS
...............................................................................................................................................................................
11ALKYLATING AGENTS
..............................................................................................................................................................................
11ANTIMETABOLITES
...................................................................................................................................................................................
11HORMONAL ANTINEOPLASTIC AGENTS
...............................................................................................................................................
12IMMUNOMODULATORS
............................................................................................................................................................................
12KINASE INHIBITORS
.................................................................................................................................................................................
12MISCELLANEOUS
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13
CARDIOVASCULAR
............................................................................................................................................................................................
13ACE INHIBITORS
.......................................................................................................................................................................................
13ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS
.......................................................................................................
13ACE INHIBITOR/DIURETIC COMBINATIONS
...........................................................................................................................................
13ADRENOLYTICS, CENTRAL
.....................................................................................................................................................................
14ALDOSTERONE RECEPTOR ANTAGONISTS
.........................................................................................................................................
14ALPHA BLOCKERS
....................................................................................................................................................................................
14ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS
..........................................................................................
14ANTIARRHYTHMICS
.................................................................................................................................................................................
14ANTILIPEMICS
...........................................................................................................................................................................................
14BETA-BLOCKERS
......................................................................................................................................................................................
15BETA-BLOCKER/DIURETIC COMBINATIONS
.........................................................................................................................................
15CALCIUM CHANNEL BLOCKERS
.............................................................................................................................................................
15DIGITALIS GLYCOSIDES
..........................................................................................................................................................................
16DIURETICS
.................................................................................................................................................................................................
16HEART FAILURE
........................................................................................................................................................................................
16NITRATES
..................................................................................................................................................................................................
16PULMONARY ARTERIAL HYPERTENSION
.............................................................................................................................................
16MISCELLANEOUS
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17
CENTRAL NERVOUS SYSTEM
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17ANTIANXIETY
............................................................................................................................................................................................
17ANTICONVULSANTS
.................................................................................................................................................................................
17
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ANTIDEMENTIA
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18ANTIDEPRESSANTS
.................................................................................................................................................................................
18ANTIPARKINSONIAN AGENTS
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19ANTIPSYCHOTICS
....................................................................................................................................................................................
19ATTENTION DEFICIT HYPERACTIVITY DISORDER
...............................................................................................................................
19FIBROMYALGIA
.........................................................................................................................................................................................
20HYPNOTICS
...............................................................................................................................................................................................
20MIGRAINE
..................................................................................................................................................................................................
20MOOD STABILIZERS
.................................................................................................................................................................................
20MULTIPLE SCLEROSIS AGENTS
.............................................................................................................................................................
20MUSCULOSKELETAL THERAPY AGENTS
..............................................................................................................................................
20MYASTHENIA GRAVIS
..............................................................................................................................................................................
21NARCOLEPSY
...........................................................................................................................................................................................
21PSYCHOTHERAPEUTIC-MISCELLANEOUS
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21
ENDOCRINE AND METABOLIC
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21ANDROGENS
.............................................................................................................................................................................................
21ANTIDIABETICS
.........................................................................................................................................................................................
22CALCIUM REGULATORS
..........................................................................................................................................................................
23CONTRACEPTIVES
...................................................................................................................................................................................
23ENDOMETRIOSIS
......................................................................................................................................................................................
24ESTROGENS
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24ESTROGEN/PROGESTINS
.......................................................................................................................................................................
25FERTILITY REGULATORS
........................................................................................................................................................................
25GLUCOCORTICOIDS
.................................................................................................................................................................................
25GLUCOSE ELEVATING AGENTS
.............................................................................................................................................................
25HUMAN GROWTH HORMONES
...............................................................................................................................................................
25HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS
................................................................................................................
25PHENYLKETONURIA TREATMENT AGENTS
..........................................................................................................................................
25PHOSPHATE BINDER AGENTS
...............................................................................................................................................................
25POTASSIUM-REMOVING AGENTS
..........................................................................................................................................................
25PROGESTINS
............................................................................................................................................................................................
26SELECTIVE ESTROGEN RECEPTOR MODULATORS
............................................................................................................................
26THYROID AGENTS
....................................................................................................................................................................................
26UREA CYCLE DISORDERS
.......................................................................................................................................................................
26VASOPRESSIN RECEPTOR ANTAGONISTS
..........................................................................................................................................
26VASOPRESSINS
........................................................................................................................................................................................
26MISCELLANEOUS
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26
GASTROINTESTINAL
..........................................................................................................................................................................................
26ANTIDIARRHEALS
.....................................................................................................................................................................................
26ANTIEMETICS
............................................................................................................................................................................................
26ANTISPASMODICS
....................................................................................................................................................................................
27CHOLELITHOLYTICS
................................................................................................................................................................................
27H2 RECEPTOR ANTAGONISTS
.................................................................................................................................................................
27INFLAMMATORY BOWEL DISEASE
.........................................................................................................................................................
27LAXATIVES/STOOL SOFTENERS
............................................................................................................................................................
27OPIOID-INDUCED CONSTIPATION
..........................................................................................................................................................
27PANCREATIC ENZYMES
..........................................................................................................................................................................
27PROSTAGLANDINS
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27PROTON PUMP INHIBITORS
....................................................................................................................................................................
27SALIVA STIMULANTS
................................................................................................................................................................................
27STEROIDS, RECTAL
.................................................................................................................................................................................
28MISCELLANEOUS
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28
GENITOURINARY
................................................................................................................................................................................................
28BENIGN PROSTATIC HYPERPLASIA
.......................................................................................................................................................
28URINARY ANTISPASMODICS
...................................................................................................................................................................
28VAGINAL ANTI-INFECTIVES
.....................................................................................................................................................................
28MISCELLANEOUS
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28
HEMATOLOGIC
....................................................................................................................................................................................................
28ANTICOAGULANTS
...................................................................................................................................................................................
28HEMATOPOIETIC GROWTH FACTORS
...................................................................................................................................................
29PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS
.......................................................................................................
29PLATELET AGGREGATION INHIBITORS
.................................................................................................................................................
29PLATELET SYNTHESIS INHIBITORS
.......................................................................................................................................................
29THROMBOCYTOPENIA AGENTS
.............................................................................................................................................................
29MISCELLANEOUS
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29
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IMMUNOLOGIC AGENTS
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29AUTOIMMUNE AGENTS
............................................................................................................................................................................
29DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)
................................................................................................................
29HEREDITARY ANGIOEDEMA AGENTS
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30IMMUNOMODULATORS
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30IMMUNOSUPPRESSANTS
........................................................................................................................................................................
30
NUTRITIONAL/SUPPLEMENTS
..........................................................................................................................................................................
30ELECTROLYTES
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30VITAMINS AND MINERALS
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30
RESPIRATORY
.....................................................................................................................................................................................................
31ANAPHYLAXIS TREATMENT AGENTS
....................................................................................................................................................
31ANTICHOLINERGICS
................................................................................................................................................................................
31ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
..........................................................................................................................
31ANTIHISTAMINES, LOW SEDATING
........................................................................................................................................................
31ANTIHISTAMINES, SEDATING
.................................................................................................................................................................
31ANTIHISTAMINE/DECONGESTANT COMBINATIONS
............................................................................................................................
31ANTITUSSIVES
..........................................................................................................................................................................................
31ANTITUSSIVE COMBINATIONS
................................................................................................................................................................
32BETA AGONISTS
.......................................................................................................................................................................................
32CYSTIC FIBROSIS
.....................................................................................................................................................................................
32LEUKOTRIENE MODULATORS
................................................................................................................................................................
32MAST CELL STABILIZERS
........................................................................................................................................................................
32MEDICAL SUPPLIES
.................................................................................................................................................................................
32NASAL ANTIHISTAMINES
.........................................................................................................................................................................
32NASAL STEROIDS
.....................................................................................................................................................................................
32RESPIRATORY SYNCYTIAL VIRUS
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32SEVERE ASTHMA AGENTS
......................................................................................................................................................................
33STEROID/BETA AGONIST COMBINATIONS
............................................................................................................................................
33STEROID INHALANTS
...............................................................................................................................................................................
33XANTHINES
...............................................................................................................................................................................................
33MISCELLANEOUS
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33
TOPICAL
...............................................................................................................................................................................................................
33DERMATOLOGY
........................................................................................................................................................................................
33MOUTH/THROAT/DENTAL AGENTS
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35OPHTHALMIC
............................................................................................................................................................................................
35OTIC
...........................................................................................................................................................................................................
36
WEBSITES
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37INDEX
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39
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INTRODUCTION We are pleased to provide the 2020 MetroPlus Health
Plan Formulary as a useful reference and informational tool. This
document can assist medical providers in selecting clinically
appropriate and cost-effective products for their patients. The
drugs represented have been reviewed by a National Pharmacy and
Therapeutics (P&T) Committee and are approved for inclusion.
The document is reflective of current medical practice as of the
date of review. The information contained in this document and its
appendices is provided solely for the convenience of medical
providers. We do not warrant or assure accuracy of such information
nor is it intended to be comprehensive in nature. This document is
not intended to be a substitute for the knowledge, expertise, skill
and judgment of the medical provider in his or her choice of
prescription drugs. All the information in the document is provided
as a reference for drug therapy selection. Specific drug selection
for an individual patient rests solely with the prescriber. The
document is subject to state-specific regulations and rules,
including, but not limited to, those regarding generic
substitution, controlled substance schedules, preference for brands
and mandatory generics whenever applicable. We assume no
responsibility for the actions or omissions of any medical provider
based upon reliance, in whole or in part, on the information
contained herein. The medical provider should consult the drug
manufacturer's product literature or standard references for more
detailed information. National guidelines can be found on the
National Guideline Clearinghouse site at https://www.ahrq.gov/gam/,
on the websites listed under each therapeutic class and on the
sites listed in the Websites section of this publication.
PREFACE The document is organized by sections. Each section is
divided by therapeutic drug class primarily defined by mechanism of
action. Products are listed by generic name with brand name for
reference only. Unless the cited drug is available as an injectable
or an exception is specifically noted, generally, all applicable
oral dosage forms and strengths of the drug cited are included in
the document. Drugs represented in this document may have varying
cost to the plan member based on the plan's benefit structure.
Generic medications typically are available at the lower cost,
brand-name medications on the document will generally cost more
than generics. Generics should be considered the first line of
prescribing subject to applicable rules.
DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which
specific strengths and dosage forms on the document are covered,
examples are noted below. The general principles shown in the
examples can usually be extended to other entries in the document.
Any exceptions are noted. Listed products on the document generally
include all strengths and dosage forms of the cited brand-name
product. pregabalin Lyrica Oral capsules, oral solution and all
strengths of Lyrica would be included in this listing. When a
strength or dosage form is specified, only the specified strength
and dosage form is on the document. Other strengths/dosage forms,
including injectable dosage forms of the reference product are not.
esomeprazole magnesium delayed-rel suspension 2.5 mg, 5 mg, 10
mg Nexium suspension
The oral suspension dosage form of Nexium is on the document.
From this entry, the oral capsule cannot be assumed to be on the
list unless there is a separate entry. Extended-release and
delayed-release products require their own entry. tofacitinib
Xeljanz The immediate-release product listing of Xeljanz alone
would not include the extended-release product Xeljanz XR.
tofacitinib ext-rel Xeljanz XR A separate entry for Xeljanz XR
confirms that the extended-release product is on the document.
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Dosage forms on the document will be consistent with the
category and use where listed. nystatin The above nystatin entry
listed in the TOPICAL/DERMATOLOGY section is limited to the topical
dosage forms. From this entry the oral formulations cannot be
assumed to be on the list unless there is an entry for this product
in the ANTI-INFECTIVES section of the document.
GENERIC SUBSTITUTION
Generic substitution is a pharmacy action whereby a generic
version is dispensed rather than a prescribed brand-name product.
Boldface type indicates generic availability. However, not all
strengths or dosage forms of the generic name in boldface type may
be generically available. In most instances, a brand-name drug for
which a generic product becomes available will become
non-formulary, with the generic product covered in its place, upon
release of the generic product to the market. However, the document
is subject to state specific regulations and rules regarding
generic substitution and mandatory generic rules apply where
appropriate. Generic drugs are usually priced lower than their
brand-name equivalents. Prescription generic drugs are:
• Approved by the U.S. Food and Drug Administration (FDA) for
safety and effectiveness, and are manufactured under the same
strict standards that apply to brand-name drugs.
• Tested in humans to assure the generic is absorbed into the
bloodstream in a similar rate and extent compared to the brand-name
drug (bioequivalence). Generics may be different from the brand in
size, color and inactive ingredients, but this does not alter their
effectiveness or ability to be absorbed just like the brand-name
drug.
• Manufactured in the same strength and dosage form as the
brand-name drugs.
When a generic drug is substituted for a brand-name drug, you
can expect the generic to produce the same clinical effect and
safety profile as the brand-name drug (therapeutic
equivalence).
NON-COVERED MEDICATIONS • Pharmaceuticals determined by the FDA
to be less than effective and identical, related, or similar
drugs
(commonly referred to as DESI 5 and 6 drugs). • MetroPlus only
covers drugs from manufacturers participating in the Federal
Medicaid drug rebate program.
OVER-THE-COUNTER DRUG COVERAGE MetroPlus covers over-the-counter
(OTC) drugs that obtain fiscal orders that meet Medicaid criteria.
These include select medications in the following categories:
analgesic and antipyretic, antacid, anti-diarrheal, antihistamine,
anti-vertigo, artificial tears and ocular/oral lubricants, chronic
renal disease, cough and cold, dermatological, family planning,
fecal softener and laxative, hematinic, insulin, pediculicide,
smoking cessation agents, and vitamins/minerals. All categories are
represented on the formulary. However, not every item made by every
manufacturer is covered. Furthermore, not all formulations and/or
package sizes are covered. Quantities may also be limited based on
acute/episodic vs. chronic/maintenance uses. For the most
up-to-date list of covered OTC products, please reference:
https://www.emedny.org/info/formfile.aspx
SPECIALTY PLAN DESIGN Specialty Guideline Management (SGM) SGM
is our utilization management program that helps ensure appropriate
utilization for specialty medication based on currently accepted
evidence-based medicine guidelines. SGM is designed to help ensure
safety and efficacy while preventing off-guideline utilization.
Medications which may be included in the SGM program are identified
in the document as “SGM” for your reference. Prescribers may call
1-866-814-5506 to enroll patients in Specialty plan design.
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PLAN DESIGN The document represents a closed formulary plan
design. The medications listed on the document are covered by the
plan as represented. Certain medications on the list are covered if
utilization management criteria are met (i.e., Step Therapy, Prior
Authorization, Quantity Limits, etc.); requests for use of such
medications outside of their listed criteria will be reviewed for
medical necessity. If a medication is not listed on the document, a
formulary exception may be requested for coverage. Medical
necessity or formulary exception requests will be reviewed based on
drug-specific prior authorization criteria or standard
non-formulary prescription request criteria.
LEGEND
AL Age Limit OTC Over the counter PA Prior Authorization PA, QL
Quantity Limit is applied after Prior Authorization approval QL
Quantity Limit SGM Specialty Guideline Management ST Step Therapy
boldface Indicates generic availability; boldface may not apply to
every strength or dosage form under the
listed generic name delayed-rel Delayed-release (also known as
enteric-coated), refer to the reference brand listed for
clarification ext-rel Extended-release (also known as
sustained-release), refer to the reference brand listed for
clarification
NOTICE The information contained in this document is
proprietary. The information may not be copied in whole or in part
without written permission. ©2020. All rights reserved. This
document contains references to brand-name prescription drugs that
are trademarks or registered trademarks of pharmaceutical
manufacturers. MetroPlus Health Plan does not operate the
websites/organizations listed here, nor is it responsible for the
availability or reliability of the websites' content. These
listings do not imply or constitute an endorsement, sponsorship or
recommendation by MetroPlus Health Plan. Please be advised that
this document is updated periodically and changes may appear prior
to their effective date to allow for client notification.
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ANALGESICS Practice guidelines of pain management are available
at: https://www.asahq.org Treatment recommendations for
osteoarthritis are available at: https://www.rheumatology.org
NSAIDs diclofenac sodium delayed-rel diclofenac sodium ext-rel
diflunisal etodolac etodolac ext-rel flurbiprofen ibuprofen QL
ketorolac meloxicam MOBIC nabumetone naproxen NAPROSYN naproxen
sodium oxaprozin DAYPRO sulindac COX-2 INHIBITORS PA celecoxib
CELEBREX GOUT allopurinol ZYLOPRIM QL colchicine tabs COLCRYS
probenecid OPIOID ANALGESICS Practice Guidelines for Cancer Pain
Management (includes WHO analgesic ladder) are available at:
https://www.asahq.org https://www.nccn.org Opioid guidelines in the
management of chronic non-malignant pain are available at:
https://www.asipp.org/ASIPP-Guidelines.html The quantity of opioid
products covered (including those that are combined with
acetaminophen, aspirin or ibuprofen) will be limited to up to 90
morphine milligram equivalents (MMEs) per day based on a 30-day
supply. Members may be subject to additional quantity limit
restrictions, including a first-fill limit of 7 days (for members
who are opioid-naïve) and 90 days of treatment per 365 days. QL
codeine/acetaminophen PA, QL fentanyl transdermal DURAGESIC QL
hydrocodone/acetaminophen NORCO PA, QL hydromorphone ext-rel QL
hydromorphone tabs DILAUDID PA, QL methadone tabs 5 mg, 10 mg
DOLOPHINE QL morphine PA, QL morphine ext-rel MS CONTIN QL
oxycodone QL oxycodone ROXICODONE QL oxycodone/acetaminophen
PERCOCET QL oxycodone/acetaminophen solution QL oxycodone/aspirin
PERCODAN QL tramadol 50 mg ULTRAM
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PA, QL tramadol ext-rel tabs QL tramadol/acetaminophen ULTRACET
NON-OPIOID ANALGESICS QL butalbital/acetaminophen/caffeine ESGIC QL
butalbital/aspirin/caffeine FIORINAL ANTI-INFECTIVES Practice
guidelines and statements developed and endorsed by the Infectious
Diseases Society of America are available at:
https://www.idsociety.org Hepatitis: CDC recommendations on the
treatment of hepatitis are available at:
https://www.cdc.gov/hepatitis/Resources/ Guidelines for the
management of chronic hepatitis by the American Association for the
Study of Liver Disease are available at: https://www.aasld.org
HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S.
Department of Health and Human Services are available at:
https://www.aidsinfo.nih.gov Infective Endocarditis: American Heart
Association recommendations for the prevention of bacterial
endocarditis are available at: https://professional.heart.org
Influenza: Recommendations of the Advisory Committee on
Immunization Practices are available at:
https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html
International Travel: CDC recommendations for international travel
are available at: https://wwwnc.cdc.gov/travel Respiratory Tract
Infection/Antibiotic Use/Community Acquired Pneumonia/Other:
Principles of appropriate antibiotic use for treatment of
nonspecific upper respiratory tract infection in adults are
available at:
https://www.cdc.gov/pneumonia/management-prevention-guidelines.html
Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases
Guidelines are available at:
https://www.cdc.gov/std/treatment/default.htm ANTIBACTERIALS
Aminoglycosides neomycin Cephalosporins Cephalosporin Combinations
PA ceftolozane/tazobactam ZERBAXA First Generation cefadroxil
cephalexin KEFLEX Second Generation cefprozil cefuroxime axetil
Third Generation cefdinir Erythromycins/Macrolides azithromycin
ZITHROMAX clarithromycin
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clarithromycin ext-rel erythromycin base erythromycin
delayed-rel erythromycin ethylsuccinate E.E.S. erythromycin
stearate Fluoroquinolones ciprofloxacin tabs CIPRO levofloxacin
Penicillins amoxicillin amoxicillin/clavulanate AUGMENTIN
ampicillin dicloxacillin penicillin G BICILLIN L-A penicillin VK
Sulfonamides sulfadiazine sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim DS Tetracyclines doxycycline
monohydrate caps 50 mg, 100 mg doxycycline monohydrate suspension
VIBRAMYCIN doxycycline monohydrate tabs 50 mg, 75 mg, 100 mg
minocycline MINOCIN tetracycline ANTIFUNGALS clotrimazole troches
fluconazole DIFLUCAN griseofulvin microsize suspension griseofulvin
ultramicrosize PA, QL itraconazole caps SPORANOX nystatin QL
terbinafine tabs PA voriconazole VFEND ANTIMALARIALS QL
atovaquone/proguanil MALARONE QL chloroquine QL mefloquine
ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants QL cobicistat TYBOST
Antiretroviral Combinations QL abacavir/dolutegravir/lamivudine
TRIUMEQ QL abacavir/lamivudine EPZICOM QL
abacavir/lamivudine/zidovudine TRIZIVIR QL atazanavir/cobicistat
EVOTAZ QL bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY
QL darunavir/cobicistat PREZCOBIX QL
darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA QL
dolutegravir/lamivudine DOVATO
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QL dolutegravir/rilpivirine JULUCA QL
efavirenz/emtricitabine/tenofovir disoproxil fumarate ATRIPLA QL
efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI QL
efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI LO QL
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA
QL elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil
fumarate STRIBILD QL emtricitabine/rilpivirine/tenofovir
alafenamide ODEFSEY QL emtricitabine/rilpivirine/tenofovir
disoproxil fumarate COMPLERA QL, * emtricitabine/tenofovir
alafenamide DESCOVY QL, * emtricitabine/tenofovir disoproxil
fumarate TRUVADA QL lamivudine/tenofovir disoproxil fumarate CIMDUO
QL lamivudine/zidovudine COMBIVIR * Documentation may be required
for select instances in which product labeling dictates monitoring
Chemokine Receptor Antagonists QL maraviroc SELZENTRY Integrase
Inhibitors QL dolutegravir TIVICAY QL raltegravir ISENTRESS
Non-nucleoside Reverse Transcriptase Inhibitors QL efavirenz
SUSTIVA QL etravirine INTELENCE QL nevirapine VIRAMUNE QL
nevirapine ext-rel VIRAMUNE XR QL rilpivirine EDURANT Nucleoside
Reverse Transcriptase Inhibitors QL abacavir ZIAGEN QL didanosine
delayed-rel QL emtricitabine EMTRIVA QL lamivudine EPIVIR QL
stavudine QL zidovudine RETROVIR Nucleotide Reverse Transcriptase
Inhibitors QL tenofovir disoproxil fumarate VIREAD Protease
Inhibitors QL atazanavir REYATAZ QL darunavir PREZISTA QL
fosamprenavir LEXIVA QL indinavir CRIXIVAN QL lopinavir/ritonavir
KALETRA QL nelfinavir VIRACEPT QL ritonavir NORVIR QL saquinavir
mesylate INVIRASE QL tipranavir APTIVUS ANTITUBERCULAR AGENTS
ethambutol MYAMBUTOL isoniazid pyrazinamide rifampin RIFADIN
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ANTIVIRALS Cytomegalovirus Agents QL valganciclovir VALCYTE
Hepatitis Agents Hepatitis B adefovir dipivoxil HEPSERA entecavir
solution BARACLUDE entecavir tabs BARACLUDE lamivudine tabs
EPIVIR-HBV Hepatitis C #, SGM glecaprevir/pibrentasvir MAVYRET SGM
ribavirin caps, tabs 200mg SGM sofosbuvir/velpatasvir # MAVYRET for
genotypes 1, 2, 3, 4, 5, 6 Herpes Agents acyclovir caps,
suspension, tabs ZOVIRAX famciclovir valacyclovir VALTREX Influenza
Agents QL oseltamivir TAMIFLU MISCELLANEOUS ST atovaquone MEPRON
clindamycin CLEOCIN dapsone ivermectin STROMECTOL PA linezolid
ZYVOX PA linezolid injection ZYVOX QL mebendazole EMVERM
metronidazole FLAGYL nitrofurantoin ext-rel MACROBID nitrofurantoin
macrocrystals MACRODANTIN nitrofurantoin suspension PA
pyrimethamine DARAPRIM rifabutin MYCOBUTIN trimethoprim QL
vancomycin VANCOCIN ANTINEOPLASTIC AGENTS Clinical practice
guidelines in oncology are available at: https://www.asco.org
https://www.nccn.org ALKYLATING AGENTS busulfan MYLERAN
chlorambucil LEUKERAN cyclophosphamide caps lomustine GLEOSTINE
melphalan ALKERAN SGM temozolomide TEMODAR ANTIMETABOLITES SGM
capecitabine XELODA
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12
mercaptopurine methotrexate TREXALL HORMONAL ANTINEOPLASTIC
AGENTS Antiandrogens bicalutamide CASODEX SGM enzalutamide XTANDI
flutamide Antiestrogens SGM fulvestrant FASLODEX tamoxifen
toremifene FARESTON Aromatase Inhibitors anastrozole ARIMIDEX
exemestane AROMASIN letrozole FEMARA Luteinizing Hormone-Releasing
Hormone (LHRH) Agonists SGM goserelin acetate ZOLADEX SGM
leuprolide acetate SGM leuprolide acetate LUPRON DEPOT SGM
triptorelin pamoate TRELSTAR Gonadotropin Releasing Hormone (GnRH)
Antagonists SGM degarelix acetate FIRMAGON Progestins megestrol
acetate MEGACE IMMUNOMODULATORS SGM lenalidomide REVLIMID KINASE
INHIBITORS SGM afatinib GILOTRIF SGM axitinib INLYTA SGM bosutinib
BOSULIF SGM, QL cabozantinib CABOMETYX SGM cabozantinib COMETRIQ
SGM ceritinib ZYKADIA SGM dabrafenib TAFINLAR SGM dasatinib SPRYCEL
SGM erlotinib TARCEVA SGM everolimus AFINITOR SGM ibrutinib
IMBRUVICA SGM idelalisib ZYDELIG SGM imatinib mesylate GLEEVEC SGM
lapatinib TYKERB SGM lenvatinib LENVIMA SGM midostaurin RYDAPT SGM
nilotinib TASIGNA SGM palbociclib IBRANCE SGM pazopanib VOTRIENT
SGM ponatinib ICLUSIG SGM regorafenib STIVARGA SGM ruxolitinib
JAKAFI SGM sorafenib NEXAVAR
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SGM sunitinib SUTENT SGM trametinib MEKINIST SGM vandetanib
CAPRELSA SGM vemurafenib ZELBORAF MISCELLANEOUS SGM bexarotene caps
TARGRETIN etoposide hydroxyurea HYDREA leucovorin mitotane LYSODREN
SGM niraparib ZEJULA SGM olaparib LYNPARZA SGM panobinostat FARYDAK
procarbazine MATULANE SGM rucaparib RUBRACA tretinoin caps QL
uridine triacetate VISTOGARD SGM venetoclax VENCLEXTA SGM
vismodegib ERIVEDGE SGM vorinostat ZOLINZA CARDIOVASCULAR The
Eighth Report of the Joint National Committee on Prevention,
Detection, Evaluation and Treatment of High Blood Pressure is
available at:
https://jamanetwork.com/journals/jama/fullarticle/1791497
Guidelines for the evaluation and management of cardiovascular
diseases in adults are available at: https://www.acc.org
https://professional.heart.org ACE INHIBITORS Guidelines for the
use of ACE inhibitors are available at:
https://jamanetwork.com/journals/jama/fullarticle/1791497
https://professional.diabetes.org https://www.acc.org
https://professional.heart.org benazepril LOTENSIN captopril
enalapril VASOTEC fosinopril lisinopril ZESTRIL quinapril ACCUPRIL
ramipril ALTACE trandolapril ACE INHIBITOR/CALCIUM CHANNEL BLOCKER
COMBINATIONS amlodipine/benazepril LOTREL ACE INHIBITOR/DIURETIC
COMBINATIONS benazepril/hydrochlorothiazide LOTENSIN HCT
captopril/hydrochlorothiazide enalapril/hydrochlorothiazide
VASERETIC fosinopril/hydrochlorothiazide
lisinopril/hydrochlorothiazide ZESTORETIC
quinapril/hydrochlorothiazide ACCURETIC
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ADRENOLYTICS, CENTRAL clonidine CATAPRES clonidine transdermal
CATAPRES-TTS guanfacine ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone
INSPRA spironolactone ALDACTONE ALPHA BLOCKERS Guidelines for the
use of alpha blockers in various patient populations are available
at: https://jamanetwork.com/journals/jama/fullarticle/1791497
doxazosin CARDURA prazosin MINIPRESS terazosin ANGIOTENSIN II
RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use
of angiotensin II receptor antagonists in various patient
populations are available at:
https://jamanetwork.com/journals/jama/fullarticle/1791497
https://professional.diabetes.org irbesartan AVAPRO
irbesartan/hydrochlorothiazide AVALIDE losartan COZAAR
losartan/hydrochlorothiazide HYZAAR valsartan DIOVAN
valsartan/hydrochlorothiazide DIOVAN HCT ANTIARRHYTHMICS Guidelines
for the use of antiarrhythmics and cardiac glycosides in various
patient populations are available at: https://www.acc.org
amiodarone disopyramide NORPACE disopyramide ext-rel NORPACE CR SGM
dofetilide TIKOSYN flecainide propafenone propafenone ext-rel
RYTHMOL SR sotalol BETAPACE sotalol BETAPACE AF ANTILIPEMICS The
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA
Guideline on the Management of Blood Cholesterol is available at:
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625 Bile
Acid Resins cholestyramine QUESTRAN/QUESTRAN LIGHT colestipol
COLESTID Cholesterol Absorption Inhibitors ezetimibe ZETIA Fibrates
fenofibrate fenofibrate TRICOR
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15
gemfibrozil LOPID HMG-CoA Reductase Inhibitors atorvastatin
LIPITOR lovastatin pravastatin PRAVACHOL ST rosuvastatin CRESTOR
simvastatin ZOCOR Niacins niacin ext-rel NIASPAN Omega-3 Fatty
Acids PA icosapent ethyl VASCEPA PCSK9 Inhibitors SGM evolocumab
REPATHA BETA-BLOCKERS Guidelines for the use of beta-blockers and
beta-blocker combinations in various patient populations are
available at:
https://jamanetwork.com/journals/jama/fullarticle/1791497
https://www.acc.org atenolol TENORMIN bisoprolol carvedilol COREG
labetalol metoprolol succinate ext-rel TOPROL-XL metoprolol
tartrate 25 mg, 50 mg, 100 mg LOPRESSOR nadolol CORGARD pindolol
propranolol propranolol ext-rel INDERAL LA timolol
BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of
beta-blockers and diuretic combinations in various patient
populations are available at:
https://jamanetwork.com/journals/jama/fullarticle/1791497
https://www.acc.org atenolol/chlorthalidone TENORETIC
bisoprolol/hydrochlorothiazide ZIAC metoprolol/hydrochlorothiazide
LOPRESSOR HCT CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine
NORVASC felodipine ext-rel nifedipine ext-rel nifedipine ext-rel
PROCARDIA XL Nondihydropyridines diltiazem CARDIZEM diltiazem
ext-rel diltiazem ext-rel CARDIZEM CD diltiazem ext-rel TIAZAC
diltiazem ext-rel, except 120 mg CARDIZEM LA verapamil ext-rel
CALAN SR
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16
verapamil ext-rel VERELAN PM DIGITALIS GLYCOSIDES digoxin
LANOXIN digoxin pediatric elixir DIURETICS Carbonic Anhydrase
Inhibitors acetazolamide acetazolamide ext-rel methazolamide Loop
Diuretics bumetanide furosemide LASIX torsemide Potassium-sparing
Diuretics amiloride Thiazides and Thiazide-like Diuretics
chlorthalidone hydrochlorothiazide indapamide metolazone Diuretic
Combinations amiloride/hydrochlorothiazide
spironolactone/hydrochlorothiazide ALDACTAZIDE
triamterene/hydrochlorothiazide DYAZIDE
triamterene/hydrochlorothiazide MAXZIDE HEART FAILURE ivabradine
CORLANOR sacubitril/valsartan ENTRESTO NITRATES Oral isosorbide
dinitrate oral ISORDIL isosorbide mononitrate isosorbide
mononitrate ext-rel nitroglycerin ext-rel Sublingual nitroglycerin
sublingual NITROSTAT Transdermal nitroglycerin ointment NITRO-BID
nitroglycerin transdermal nitroglycerin transdermal NITRO-DUR
PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists SGM
ambrisentan LETAIRIS SGM bosentan TRACLEER Phosphodiesterase
Inhibitors SGM sildenafil REVATIO
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17
Prostaglandin Vasodilators SGM epoprostenol sodium FLOLAN SGM
iloprost VENTAVIS SGM treprostinil REMODULIN SGM treprostinil
TYVASO MISCELLANEOUS hydralazine methyldopa midodrine CENTRAL
NERVOUS SYSTEM Practice guidelines for psychiatric disorders are
available at: https://www.psychiatry.org ANTIANXIETY
Benzodiazepines QL alprazolam XANAX QL chlordiazepoxide QL
clonazepam tabs KLONOPIN QL diazepam VALIUM QL lorazepam ATIVAN QL
oxazepam Miscellaneous buspirone QL* clomipramine ANAFRANIL
fluvoxamine QL* Only applies to members of age 65 and older
ANTICONVULSANTS Practice guidelines for the treatment of epilepsy
are available at: https://www.aan.com carbamazepine TEGRETOL
carbamazepine ext-rel CARBATROL carbamazepine ext-rel TEGRETOL-XR
diazepam rectal gel DIASTAT divalproex sodium delayed-rel DEPAKOTE
divalproex sodium ext-rel DEPAKOTE ER ethosuximide ZARONTIN QL
gabapentin NEURONTIN lamotrigine LAMICTAL levetiracetam KEPPRA
levetiracetam injection KEPPRA oxcarbazepine TRILEPTAL
phenobarbital phenytoin DILANTIN INFATABS phenytoin sodium extended
DILANTIN phenytoin sodium extended PHENYTEK primidone MYSOLINE
tiagabine GABITRIL topiramate sprinkle caps, tabs TOPAMAX valproic
acid SGM vigabatrin SABRIL zonisamide ZONEGRAN
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18
ANTIDEMENTIA Practice guidelines for the management of dementia
are available at: https://www.aan.com donepezil ARICEPT galantamine
RAZADYNE galantamine ext-rel RAZADYNE ER PA* memantine NAMENDA PA
rivastigmine caps, solution PA rivastigmine transdermal EXELON
PATCH PA* Only applies to members < 30 years of age
ANTIDEPRESSANTS Although these agents are primarily indicated for
depression, some of these are also approved for other indications,
including bipolar disorder, obsessive-compulsive disorder, panic
disorder and premenstrual dysphoric disorder. Guidelines for the
evaluation and management of bipolar and depressive disorders are
available at: https://www.psychiatry.org Monoamine Oxidase
Inhibitors (MAOIs) isocarboxazid MARPLAN phenelzine NARDIL
tranylcypromine PARNATE Selective Serotonin Reuptake Inhibitors
(SSRIs) citalopram CELEXA escitalopram LEXAPRO fluoxetine PROZAC
paroxetine HCl ext-rel PAXIL CR paroxetine HCl tabs PAXIL
sertraline ZOLOFT Serotonin Norepinephrine Reuptake Inhibitors
(SNRIs) PA duloxetine delayed-rel CYMBALTA venlafaxine venlafaxine
ext-rel EFFEXOR XR Tricyclic Antidepressants (TCAs) QL*
amitriptyline QL* desipramine NORPRAMIN QL* doxepin QL* imipramine
HCl QL* nortriptyline PAMELOR QL* Only applies to members of age 65
and older Miscellaneous Agents bupropion bupropion ext-rel
WELLBUTRIN SR bupropion ext-rel WELLBUTRIN XL mirtazapine REMERON
trazodone
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19
ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis
and treatment of Parkinson's disease are available at:
https://www.aan.com amantadine benztropine PA bromocriptine
PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel
carbidopa/levodopa orally disintegrating tabs
carbidopa/levodopa/entacapone STALEVO entacapone COMTAN pramipexole
MIRAPEX ropinirole selegiline trihexyphenidyl ANTIPSYCHOTICS
Atypicals aripiprazole ABILIFY aripiprazole ext-rel injection
ABILIFY MAINTENA aripiprazole lauroxil ext-rel injection ARISTADA
aripiprazole lauroxil ext-rel injection ARISTADA INITIO
aripiprazole orally disintegrating tabs PA asenapine SAPHRIS
clozapine CLOZARIL clozapine orally disintegrating tabs PA
iloperidone FANAPT PA lurasidone LATUDA olanzapine ZYPREXA PA
paliperidone ext-rel INVEGA paliperidone palmitate ext-rel
injection INVEGA SUSTENNA paliperidone palmitate ext-rel injection
INVEGA TRINZA quetiapine SEROQUEL PA quetiapine ext-rel SEROQUEL XR
risperidone RISPERDAL risperidone long-acting injection RISPERDAL
CONSTA ziprasidone GEODON Miscellaneous chlorpromazine fluphenazine
fluphenazine decanoate injection fluphenazine injection haloperidol
haloperidol decanoate injection HALDOL DECANOATE haloperidol
lactate injection HALDOL perphenazine SGM pimavanserin NUPLAZID
thiothixene trifluoperazine ATTENTION DEFICIT HYPERACTIVITY
DISORDER Guidelines for the evaluation and management of attention
deficit disorder are available at: https://www.aacap.org
https://www.aap.org QL amphetamine/dextroamphetamine mixed salts
ADDERALL
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20
QL amphetamine/dextroamphetamine mixed salts ext-rel ADDERALL XR
ST, QL atomoxetine STRATTERA QL dexmethylphenidate FOCALIN QL
dextroamphetamine ext-rel DEXEDRINE SPANSULE QL dextroamphetamine
tabs 5 mg, 10 mg QL methylphenidate RITALIN QL methylphenidate
ext-rel QL methylphenidate ext-rel CONCERTA ST, QL methylphenidate
ext-rel 20 mg, 30 mg, 40 mg RITALIN LA QL methylphenidate ext-rel
tabs 20 mg - Metadate ER QL methylphenidate solution, tabs METHYLIN
FIBROMYALGIA PA milnacipran SAVELLA PA, QL pregabalin LYRICA
HYPNOTICS Practice parameters for the treatment of sleep disorders
and clinical guidelines for the evaluation and management of
chronic insomnia are available at: https://aasm.org Benzodiazepines
QL temazepam RESTORIL Nonbenzodiazepines QL zolpidem AMBIEN
MIGRAINE Guidelines for prevention and management of migraine
headaches are available at: https://www.aan.com Selective Serotonin
Agonists ST, QL naratriptan AMERGE ST, QL rizatriptan MAXALT QL
sumatriptan IMITREX QL sumatriptan injection IMITREX QL sumatriptan
nasal spray IMITREX ST, QL zolmitriptan ZOMIG MOOD STABILIZERS
lithium carbonate lithium carbonate ext-rel tabs 300 mg LITHOBID
lithium carbonate ext-rel tabs 450 mg lithium citrate MULTIPLE
SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are
available at: https://www.aan.com SGM fingolimod GILENYA SGM
glatiramer COPAXONE SGM interferon beta-1a REBIF SGM interferon
beta-1b EXTAVIA SGM teriflunomide AUBAGIO MUSCULOSKELETAL THERAPY
AGENTS baclofen 10 mg, 20 mg QL carisoprodol SOMA
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21
chlorzoxazone 500 mg cyclobenzaprine 5 mg, 10 mg dantrolene
DANTRIUM methocarbamol ROBAXIN orphenadrine ext-rel tizanidine tabs
ZANAFLEX MYASTHENIA GRAVIS pyridostigmine MESTINON pyridostigmine
ext-rel MESTINON TIMESPAN NARCOLEPSY PA armodafinil NUVIGIL
PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate
calcium disulfiram ANTABUSE naltrexone microspheres VIVITROL Opioid
Antagonists naloxone injection QL naloxone nasal spray NARCAN
naltrexone Partial Opioid Agonists buprenorphine sublingual Partial
Opioid Agonist/Opioid Antagonist Combinations QL
buprenorphine/naloxone sublingual Pseudobulbar Affect PA
dextromethorphan/quinidine NUEDEXTA Smoking Deterrents Treating
Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline
is available at:
https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html
bupropion ext-rel nicotine inhaler NICOTROL nicotine nasal spray
NICOTROL NS varenicline CHANTIX ENDOCRINE AND METABOLIC ANDROGENS
Clinical practice guidelines for the treatment of hypogonadism are
available at: https://www.aace.com PA testosterone cypionate
DEPO-TESTOSTERONE PA testosterone enanthate DELATESTRYL PA
testosterone gel FORTESTA PA testosterone gel 25 mg/2.5 g
ANDROGEL
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22
ANTIDIABETICS Guidelines of treatment and management of diabetes
are available at: https://professional.diabetes.org
Alpha-glucosidase Inhibitors acarbose PRECOSE Biguanides metformin
metformin ext-rel Biguanide/Sulfonylurea Combinations
glipizide/metformin METAGLIP Dipeptidyl Peptidase-4 (DPP-4)
Inhibitors ST alogliptin Dipeptidyl Peptidase-4 (DPP-4)
Inhibitor/Biguanide Combinations ST alogliptin/metformin Incretin
Mimetic Agents ST dulaglutide TRULICITY ST liraglutide VICTOZA
Insulins insulin human HUMULIN R insulin human NOVOLIN R insulin
isophane human HUMULIN N insulin isophane human NOVOLIN N insulin
isophane human 70%/regular 30% HUMULIN 70/30 insulin isophane human
70%/regular 30% NOVOLIN 70/30 insulin aspart protamine 70%/insulin
aspart 30% NOVOLOG MIX 70/30 insulin glargine BASAGLAR insulin
lispro ADMELOG insulin lispro protamine/insulin lispro HUMALOG MIX
Insulin Sensitizers pioglitazone ACTOS Insulin Sensitizer/Biguanide
Combinations pioglitazone/metformin ACTOPLUS MET Insulin
Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride
DUETACT Meglitinides nateglinide STARLIX repaglinide Sodium-Glucose
Co-Transporter 2 (SGLT2) Inhibitors PA* empagliflozin JARDIANCE ST
ertugliflozin STEGLATRO PA* Covered for cardiovascular indication
Sulfonylureas glimepiride AMARYL glipizide GLUCOTROL
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23
glipizide ext-rel GLUCOTROL XL Supplies OTC, QL alcohol swabs
OTC blood glucose monitoring kits, test strips FREESTYLE FREEDOM
LITE kits and
test strips OTC blood glucose monitoring kits, test strips
FREESTYLE INSULINX kits and test
strips OTC blood glucose monitoring kits, test strips FREESTYLE
LITE kits and test strips OTC blood glucose monitoring kits, test
strips PRECISION XTRA kits and test strips OTC insulin syringes,
needles BD ULTRAFINE insulin syringes and
needles OTC lancets OTC, QL multiple urine test products
KETO-DIASTIX OTC, QL multiple urine test products MULTISTIX CALCIUM
REGULATORS Guidelines of treatment and management of osteoporosis
are available at: https://www.aace.com https://www.nof.org
Bisphosphonates alendronate tabs FOSAMAX Calcitonins
calcitonin-salmon MIACALCIN CONTRACEPTIVES EE = ethinyl estradiol
In accordance with the Comprehensive Contraception Coverage Act
(CCCA), contraceptives may be dispensed as a 12-month supply at one
time. Monophasic † † Products in this category may be dispensed as
a 12-month supply at one time. 20 mcg Estrogen drospirenone/EE 3/20
YAZ levonorgestrel/EE 0.1/20 norethindrone acetate/EE 1/20 LOESTRIN
1/20 norethindrone acetate/EE 1/20 and iron LOESTRIN FE 1/20 30 mcg
Estrogen desogestrel/EE 0.15/30 - Apri drospirenone/EE 3/30 YASMIN
levonorgestrel/EE 0.15/30 norethindrone acetate/EE 1.5/30 LOESTRIN
1.5/30 norethindrone acetate/EE 1.5/30 and iron LOESTRIN FE 1.5/30
norgestrel/EE 0.3/30 35 mcg Estrogen ethynodiol diacetate/EE 1/35
norethindrone/EE 0.4/35 norethindrone/EE 0.5/35 norethindrone/EE
1/35 norgestimate/EE 0.25/35
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24
50 mcg Estrogen ethynodiol diacetate/EE 1/50 norgestrel/EE
0.5/50 Biphasic † † Products in this category may be dispensed as a
12-month supply at one time. desogestrel/EE MIRCETTE Triphasic † †
Products in this category may be dispensed as a 12-month supply at
one time. desogestrel/EE levonorgestrel/EE norethindrone/EE
norgestimate/EE Progestin Only † † Products in this category may be
dispensed as a 12-month supply at one time. norethindrone ORTHO
MICRONOR Emergency Contraception QL ulipristal ELLA Injectable † †
Products in this category may be dispensed as a 12-month supply at
one time. QL medroxyprogesterone acetate 104 mg/0.65 mL DEPO-SUBQ
PROVERA 104 QL medroxyprogesterone acetate 150 mg/mL DEPO-PROVERA
Transdermal † † Products in this category may be dispensed as a
12-month supply at one time. norelgestromin/EE Vaginal † † Products
in this category may be dispensed as a 12-month supply at one time.
etonogestrel/EE ring NUVARING Miscellaneous QL diaphragm
ENDOMETRIOSIS danazol nafarelin SYNAREL ESTROGENS Guidelines of
treatment and management of hormone therapy and menopause are
available at: https://www.menopause.org
https://www.aace.com/files/menopause.pdf Oral estradiol ESTRACE
Transdermal estradiol CLIMARA
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25
Vaginal estradiol vaginal tabs VAGIFEM estrogens, conjugated
cream PREMARIN ESTROGEN/PROGESTINS Oral EE/norethindrone acetate
FEMHRT EE/norethindrone acetate - Jinteli estradiol/norethindrone
acetate ACTIVELLA Transdermal estradiol/norethindrone acetate
COMBIPATCH FERTILITY REGULATORS Ovulation Stimulants, Synthetic PA,
QL clomiphene GLUCOCORTICOIDS dexamethasone fludrocortisone
hydrocortisone CORTEF methylprednisolone MEDROL methylprednisolone
2 mg MEDROL methylprednisolone injection SOLU-MEDROL prednisolone
sodium phosphate orally disintegrating tabs ORAPRED ODT
prednisolone sodium phosphate solution 5 mg/5 mL,
15 mg/5 mL, 25 mg/5 mL
prednisolone syrup PRELONE prednisone GLUCOSE ELEVATING AGENTS
QL glucagon, human recombinant GLUCAGEN HYPOKIT QL glucagon, human
recombinant GLUCAGON EMERGENCY KIT HUMAN GROWTH HORMONES Guidelines
for use of growth hormone are available at:
https://www.aace.com/publications/guidelines SGM somatropin
NORDITROPIN SGM somatropin SEROSTIM SGM somatropin ZORBTIVE
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3)
ROCALTROL doxercalciferol HECTOROL paricalcitol ZEMPLAR
PHENYLKETONURIA TREATMENT AGENTS SGM sapropterin KUVAN PHOSPHATE
BINDER AGENTS calcium acetate sevelamer carbonate tabs ST
sucroferric oxyhydroxide VELPHORO POTASSIUM-REMOVING AGENTS sodium
polystyrene sulfonate
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26
PROGESTINS Injectable SGM hydroxyprogesterone caproate MAKENA
Oral medroxyprogesterone acetate PROVERA norethindrone acetate
AYGESTIN progesterone, micronized PROMETRIUM SELECTIVE ESTROGEN
RECEPTOR MODULATORS raloxifene EVISTA THYROID AGENTS Antithyroid
Agents methimazole TAPAZOLE propylthiouracil Thyroid Supplements
levothyroxine levothyroxine SYNTHROID levothyroxine - Levoxyl
liothyronine CYTOMEL UREA CYCLE DISORDERS SGM sodium phenylbutyrate
BUPHENYL VASOPRESSIN RECEPTOR ANTAGONISTS SGM tolvaptan SAMSCA
VASOPRESSINS PA desmopressin spray PA desmopressin spray, tabs
DDAVP MISCELLANEOUS cabergoline SGM cysteamine CYSTAGON
GASTROINTESTINAL Guidelines for the treatment and management of
various gastrointestinal diseases/conditions are available at:
https://gi.org https://www.gastro.org ANTIDIARRHEALS
diphenoxylate/atropine LOMOTIL loperamide ANTIEMETICS PA, QL
aprepitant caps EMEND QL dronabinol QL granisetron tabs meclizine
metoclopramide REGLAN QL ondansetron ZOFRAN prochlorperazine
promethazine promethazine suppository trimethobenzamide TIGAN
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27
ANTISPASMODICS chlordiazepoxide/clidinium dicyclomine BENTYL
glycopyrrolate tabs 1 mg, 2 mg hyoscyamine sulfate LEVSIN
hyoscyamine sulfate ext-rel LEVBID hyoscyamine sulfate ext-rel caps
hyoscyamine sulfate orally disintegrating tabs CHOLELITHOLYTICS
ursodiol ACTIGALL ursodiol URSO H2 RECEPTOR ANTAGONISTS cimetidine
famotidine PEPCID nizatidine INFLAMMATORY BOWEL DISEASE Oral Agents
balsalazide budesonide delayed-rel caps ENTOCORT EC mesalamine
ext-rel caps APRISO sulfasalazine AZULFIDINE sulfasalazine
delayed-rel AZULFIDINE EN-TABS Rectal Agents hydrocortisone enema
mesalamine rectal suspension ROWASA mesalamine suppository CANASA
LAXATIVES/STOOL SOFTENERS lactulose solution peg 3350/electrolytes
peg 3350/electrolytes GOLYTELY peg 3350/electrolytes NULYTELY
OPIOID-INDUCED CONSTIPATION naloxegol MOVANTIK PANCREATIC ENZYMES
PA pancrelipase VIOKACE PA pancrelipase delayed-rel CREON PA
pancrelipase delayed-rel ZENPEP PROSTAGLANDINS misoprostol CYTOTEC
PROTON PUMP INHIBITORS AL*, QL esomeprazole magnesium delayed-rel
suspension 2.5 mg,
5 mg, 10 mg NEXIUM
QL omeprazole delayed-rel caps PRILOSEC QL pantoprazole
delayed-rel tabs PROTONIX AL* Covered for < 1 year only SALIVA
STIMULANTS pilocarpine tabs SALAGEN
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28
STEROIDS, RECTAL hydrocortisone cream ANUSOL-HC 2.5%
hydrocortisone cream PROCTOCORT 1% MISCELLANEOUS PA* glycopyrrolate
CUVPOSA sucralfate tabs PA* Covered for 3-16 years of age
GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the
management of BPH are available at:
https://www.auanet.org/guidelines alfuzosin ext-rel UROXATRAL
doxazosin CARDURA finasteride PROSCAR tamsulosin FLOMAX terazosin
URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel DITROPAN XL
trospium * Gender restriction - Coverage for females VAGINAL
ANTI-INFECTIVES clindamycin cream CLEOCIN clotrimazole
metronidazole miconazole terconazole MISCELLANEOUS bethanechol
pentosan polysulfate sodium ELMIRON phenazopyridine PYRIDIUM
potassium citrate ext-rel UROCIT-K HEMATOLOGIC Guidelines of
treatment and management of hemophilia are available at:
https://www.hemophilia.org ANTICOAGULANTS CHEST guidelines are
available at:
https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular
Injectable enoxaparin LOVENOX
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29
Oral apixaban ELIQUIS rivaroxaban XARELTO * warfarin COUMADIN *
Both Coumadin and warfarin are covered. Synthetic Heparinoid-like
Agents fondaparinux ARIXTRA HEMATOPOIETIC GROWTH FACTORS Guidelines
for the management of neutropenia are available at:
https://www.asco.org Guidelines for the management of anemia
associated with chronic kidney disease are available at:
https://www.kidney.org/professionals/guidelines#guidelines SGM
darbepoetin alfa ARANESP SGM filgrastim-sndz ZARXIO SGM
pegfilgrastim-cbqv UDENYCA PAROXYSMAL NOCTURNAL HEMOGLOBINURIA
(PNH) AGENTS SGM eculizumab SOLIRIS PLATELET AGGREGATION INHIBITORS
clopidogrel PLAVIX dipyridamole prasugrel EFFIENT ticagrelor
BRILINTA PLATELET SYNTHESIS INHIBITORS anagrelide AGRYLIN
THROMBOCYTOPENIA AGENTS SGM eltrombopag tabs PROMACTA MISCELLANEOUS
cilostazol IMMUNOLOGIC AGENTS Guidelines for the management of
rheumatic diseases are available at: https://www.rheumatology.org
AUTOIMMUNE AGENTS SGM adalimumab HUMIRA SGM brodalumab SILIQ SGM
etanercept ENBREL SGM sarilumab KEVZARA SGM, QL secukinumab
COSENTYX SGM tofacitinib XELJANZ SGM tofacitinib ext-rel XELJANZ XR
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine
PLAQUENIL leflunomide ARAVA methotrexate SGM methotrexate injection
RASUVO
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30
HEREDITARY ANGIOEDEMA AGENTS SGM C1 esterase inhibitor CINRYZE
SGM C1 esterase inhibitor, recombinant RUCONEST IMMUNOMODULATORS
CDC recommendations on the treatment of hepatitis are available at:
https://www.cdc.gov/hepatitis/Resources/ Guidelines for the
management of hepatitis are available at: https://www.aasld.org
Interferons SGM interferon alfa-2b INTRON A SGM peginterferon
alfa-2a PEGASYS Miscellaneous SGM canakinumab ILARIS
IMMUNOSUPPRESSANTS Antimetabolites azathioprine AZASAN azathioprine
IMURAN mycophenolate mofetil CELLCEPT Calcineurin Inhibitors
cyclosporine SANDIMMUNE cyclosporine, modified NEORAL tacrolimus
PROGRAF Rapamycin Derivatives sirolimus RAPAMUNE
NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium
bicarbonate effervescent tabs 25 mEq potassium chloride ext-rel
potassium chloride ext-rel K-TAB potassium chloride liquid
Miscellaneous potassium phosphate K-PHOS VITAMINS AND MINERALS
Folic Acid/Combinations folic acid folic acid/vitamin B6/vitamin
B12 Prenatal Vitamins prenatal vitamins/carbonyl
iron/docusate/folic acid - Prenatal
AD
prenatal vitamins/carbonyl iron/ferrous fumarate/folic acid +
DHA CITRANATAL MEDLEY prenatal vitamins/carbonyl iron/folic acid -
Prenatabs Rx prenatal vitamins/DHA/docusate/folic acid CITRANATAL
90 DHA prenatal vitamins/DHA/docusate/folic acid CITRANATAL DHA
prenatal vitamins/DHA/docusate/folic acid CITRANATAL HARMONY
prenatal vitamins/docusate/folic acid CITRANATAL RX prenatal
vitamins/docusate/folic acid + DHA CITRANATAL ASSURE
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31
prenatal vitamins/ferrous fumarate/docusate/folic acid -
Prenatal 19
prenatal vitamins/folic acid + pyridoxine CITRANATAL B-CALM
Miscellaneous cyanocobalamin injection ergocalciferol (D2) fluoride
drops, tabs multivitamins/fluoride drops, tabs
multivitamins/fluoride/iron drops, tabs phytonadione MEPHYTON
vitamin ADC/fluoride drops vitamin ADC/fluoride/iron drops vitamin
B complex/vitamin C/folic acid NEPHROCAPS RESPIRATORY Guidelines to
the management, prevention, or treatment of COPD and asthma are
available at: https://www.aaaai.org https://ginasthma.org
https://goldcopd.org https://www.nhlbi.nih.gov The Allergy Report
and guidelines for allergy-related conditions are available at:
https://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS QL epinephrine
EPIPEN QL epinephrine EPIPEN JR. QL epinephrine auto-injector
ANTICHOLINERGICS QL ipratropium inhalation solution QL tiotropium
SPIRIVA RESPIMAT QL umeclidinium INCRUSE ELLIPTA
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting QL
ipratropium/albuterol inhalation solution ANTIHISTAMINES, LOW
SEDATING cetirizine ANTIHISTAMINES, SEDATING clemastine
cyproheptadine diphenhydramine hydroxyzine HCl hydroxyzine pamoate
VISTARIL ANTIHISTAMINE/DECONGESTANT COMBINATIONS
promethazine/phenylephrine ANTITUSSIVES Clinical practice
guidelines are available at:
https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf
benzonatate TESSALON
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32
ANTITUSSIVE COMBINATIONS Opioid
codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin liquid
codeine/guaifenesin/pseudoephedrine codeine/promethazine
codeine/promethazine/phenylephrine hydrocodone/homatropine
Non-opioid dextromethorphan/brompheniramine/pseudoephedrine
dextromethorphan/promethazine BETA AGONISTS Inhalants Short Acting
QL albuterol inhalation solution QL albuterol sulfate, CFC-free
aerosol Long Acting Hand-held Active Inhalation QL olodaterol,
CFC-free aerosol STRIVERDI RESPIMAT Oral Agents albuterol albuterol
ext-rel terbutaline CYSTIC FIBROSIS SGM dornase alfa PULMOZYME SGM
elexacaftor/tezacaftor/ivacaftor + ivacaftor TRIKAFTA SGM ivacaftor
KALYDECO SGM lumacaftor/ivacaftor ORKAMBI SGM tobramycin inhalation
solution KITABIS PAK SGM tobramycin inhalation solution TOBI
LEUKOTRIENE MODULATORS montelukast SINGULAIR MAST CELL STABILIZERS
QL cromolyn inhalation solution MEDICAL SUPPLIES OTC, QL mask OTC,
QL nebulizer OTC sodium chloride inhalation solution OTC, QL spacer
AEROCHAMBER OTC, QL vaporizer sodium chloride inhalation solution
NASAL ANTIHISTAMINES QL azelastine spray NASAL STEROIDS QL
flunisolide spray RESPIRATORY SYNCYTIAL VIRUS SGM palivizumab
SYNAGIS
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33
SEVERE ASTHMA AGENTS SGM omalizumab XOLAIR STEROID/BETA AGONIST
COMBINATIONS QL budesonide/formoterol SYMBICORT AL*, QL
fluticasone/salmeterol 100/50 ADVAIR DISKUS ST, QL
mometasone/formoterol DULERA AL* Covered for ages 4-11 years only
STEROID INHALANTS QL budesonide inhalation suspension PULMICORT
RESPULES QL fluticasone FLOVENT DISKUS QL fluticasone, CFC-free
aerosol FLOVENT HFA QL mometasone ASMANEX QL mometasone, CFC-free
aerosol ASMANEX HFA XANTHINES theophylline ext-rel caps THEO-24
theophylline ext-rel tabs theophylline liquid theophylline liquid
ELIXOPHYLLIN MISCELLANEOUS ipratropium nasal spray TOPICAL
DERMATOLOGY Acne Guidelines for the care and treatment of acne
vulgaris are available at:
https://www.aad.org/practicecenter/quality/clinical-guidelines Oral
PA isotretinoin PA isotretinoin - Amnesteem PA isotretinoin -
Claravis PA isotretinoin - Myorisan PA isotretinoin - Zenatane
Topical benzoyl peroxide, except foam QL clindamycin gel, lotion,
solution CLEOCIN T QL erythromycin gel 2% QL erythromycin solution
sulfacetamide lotion 10% KLARON PA tretinoin RETIN-A Actinic
Keratosis fluorouracil cream 4% TOLAK fluorouracil cream 5% EFUDEX
Antibiotics gentamicin mupirocin ointment silver sulfadiazine
SILVADENE Antifungals QL ciclopirox LOPROX
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34
QL clotrimazole QL ketoconazole cream 2% QL nystatin
Antipsoriatics Guidelines of care for the management and treatment
of psoriasis with topical therapies are available at:
https://www.aad.org Topical ST, QL calcipotriene ointment, solution
0.005% DOVONEX Antiseborrheics ketoconazole shampoo 2% selenium
sulfide lotion 2.5% Atopic Dermatitis Guidelines for the treatment
of atopic dermatitis are available at:
https://www.aad.org/practicecenter/quality/clinical-guidelines ST*
tacrolimus PROTOPIC ST* tacrolimus 0.1%: In addition to clinical
criteria, the member must be at least 16 years of age.
Corticosteroids Low Potency alclometasone cream, ointment 0.05%
fluocinolone acetonide solution 0.01% QL hydrocortisone cream,
lotion, ointment 2.5% Medium Potency QL betamethasone valerate
cream, lotion, ointment 0.1% fluocinolone acetonide cream, ointment
0.025% QL fluticasone propionate cream 0.05%, ointment 0.005%
CUTIVATE hydrocortisone butyrate solution 0.1% LOCOID QL mometasone
cream, lotion, ointment 0.1% QL triamcinolone acetonide cream,
lotion, ointment 0.025% QL triamcinolone acetonide cream, lotion,
ointment 0.1% High Potency QL betamethasone dipropionate augmented
cream 0.05% DIPROLENE AF QL betamethasone dipropionate cream,
lotion, ointment 0.05% desoximetasone cream 0.25% TOPICORT QL
fluocinonide cream, gel, ointment 0.05% fluocinonide solution 0.05%
QL triamcinolone acetonide cream, ointment 0.5% Very High Potency
QL betamethasone dipropionate augmented ointment 0.05% DIPROLENE
clobetasol propionate solution 0.05% QL halobetasol propionate
cream, ointment 0.05% ULTRAVATE Emollients ammonium lactate 12%
Local Analgesics PA lidocaine patch LIDODERM
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35
Local Anesthetics QL lidocaine/prilocaine cream
lidocaine/prilocaine kit Rosacea metronidazole cream 0.75%
METROCREAM metronidazole gel 0.75% ST metronidazole gel 1% METROGEL
metronidazole lotion 0.75% METROLOTION Scabicides and Pediculicides
ST malathion OVIDE permethrin ST spinosad NATROBA Miscellaneous
Skin and Mucous Membrane imiquimod ALDARA podofilox solution
CONDYLOX MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral
lidocaine viscous Steroids - Mouth/Throat triamcinolone paste
Miscellaneous chlorhexidine PERIDEX AL sodium fluoride PREVIDENT AL
Covered to maximum patient age of 21 OPHTHALMIC Preferred Practice
Pattern Guidelines for the treatment of various ophthalmic
conditions are available at: https://one.aao.org Antiallergics
cromolyn sodium Antifungals natamycin NATACYN Anti-infectives
bacitracin ciprofloxacin solution CILOXAN erythromycin gentamicin
levofloxacin moxifloxacin VIGAMOX neomycin/polymyxin B/gramicidin
ofloxacin OCUFLOX polymyxin B/bacitracin polymyxin B/trimethoprim
POLYTRIM sulfacetamide solution 10% BLEPH-10 tobramycin solution
TOBREX Anti-infective/Anti-inflammatory Combinations
neomycin/polymyxin B/bacitracin/hydrocortisone ointment
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36
neomycin/polymyxin B/dexamethasone MAXITROL neomycin/polymyxin
B/hydrocortisone suspension sulfacetamide/prednisolone phosphate
10%/0.25% tobramycin/dexamethasone suspension 0.3%/0.1% TOBRADEX
Anti-inflammatories Nonsteroidal diclofenac sodium ketorolac 0.4%
ACULAR LS ketorolac 0.5% ACULAR Steroidal dexamethasone sodium
phosphate fluorometholone 0.1% suspension FML LIQUIFILM
prednisolone acetate 1% PRED FORTE prednisolone phosphate 1%
Antivirals trifluridine Beta-blockers Nonselective levobunolol
timolol hemihydrate BETIMOL timolol maleate TIMOPTIC timolol
maleate gel TIMOPTIC-XE Selective betaxolol 0.5% Carbonic Anhydrase
Inhibitors Topical dorzolamide TRUSOPT Carbonic Anhydrase
Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate
COSOPT Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations
brinzolamide/brimonidine SIMBRINZA Prostaglandins latanoprost
XALATAN Sympathomimetics brimonidine 0.15% ALPHAGAN P brimonidine
0.2% OTIC Clinical practice guidelines for the treatment of otitis
media are available at: https://www.aap.org Anti-infectives acetic
acid ofloxacin otic Anti-infective/Anti-inflammatory Combinations
ciprofloxacin/dexamethasone CIPRODEX neomycin/polymyxin
B/hydrocortisone
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WEBSITES Agency for Healthcare Research and Quality
https://www.ahrq.gov Alzheimer's Association https://www.alz.org
American Academy of Allergy, Asthma and Immunology
https://www.aaaai.org American Academy of Child & Adolescent
Psychiatry https://www.aacap.org American Academy of Dermatology
https://www.aad.org American Academy of Neurology
https://www.aan.com American Academy of Ophthalmology
https://www.aao.org American Academy of Pediatrics
https://www.aap.org American Association for the Study of Liver
Disease https://www.aasld.org American Association of Clinical
Endocrinologists https://www.aace.com American Association of
Diabetes Educators https://www.diabeteseducator.org American Cancer
Society https://www.cancer.org American College of Allergy, Asthma
and Immunology https://www.acaai.org American College of Cardiology
https://www.acc.org American College of Chest Physicians
https://www.chestnet.org American College of Gastroenterology
https://gi.org American College of Physicians
https://www.acponline.org American College of Rheumatology
https://www.rheumatology.org
American Congress of Obstetricians and Gynecologists
https://www.acog.org American Diabetes Association
http://www.diabetes.org American Gastroenterological Association
https://www.gastro.org American Headache Society Committee for
Headache Education https://americanheadachesociety.org American
Heart Association https://professional.heart.org American Lung
Association https://www.lung.org American Medical Association
https://www.ama-assn.org American Psychiatric Association
https://www.psychiatry.org American Society of Anesthesiologists
https://www.asahq.org American Society of Clinical Oncology
https://www.asco.org American Society of Interventional Pain
Physicians https://www.asipp.org American Urological Association
https://www.auanet.org Centers for Disease Control and Prevention
https://www.cdc.gov Centers for Disease Control and Prevention
Guideline topics: AIDS https://www.cdc.gov/hiv/default.html Centers
for Disease Control and Prevention Guideline topics: Sexually
Transmitted Diseases https://www.cdc.gov/std/treatment/default.htm
CVS Caremark https://www.caremark.com The Food and Drug
Administration https://www.fda.gov
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Global Initiative for Asthma https://ginasthma.org Infectious
Diseases Society of America https://www.idsociety.org Institute for
Safe Medication Practices https://www.ismp.org Johns Hopkins AIDS
Service https://www.thebody.com/content/art12096.html Juvenile
Diabetes Research Foundation International https://www.jdrf.org
MedWatch https://www.fda.gov/Safety/MedWatch/default.htm National
Agricultural Library https://www.nal.usda.gov National Cancer
Institute https://www.cancer.gov/about-cancer National
Comprehensive Cancer Network https://www.nccn.org
National Foundation for Infectious Diseases http://www.nfid.org
National Guideline Clearinghouse https://www.ahrq.gov National
Heart, Lung and Blood Institute https://www.nhlbi.nih.gov National
Institutes of Health https://www.nih.gov National Kidney Foundation
https://www.kidney.org National Osteoporosis Foundation
https://www.nof.org North American Menopause Society
https://www.menopause.org United States Department of Health and
Human Services https://www.hhs.gov World Health Organization
https://www.who.int
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39
INDEX
Aabacavir, 10 abacavir/dolutegravir/lamivudine, 9
abacavir/lamivudine, 9 abacavir/lamivudine/zidovudine, 9 ABILIFY,
19 ABILIFY MAINTENA, 19 acamprosate calcium, 21 acarbose, 22
ACCUPRIL, 13 ACCURETIC, 13 acetazolamide, 16 acetazolamide ext-rel,
16 acetic acid, 36 ACTIGALL, 27 ACTIVELLA, 25 ACTOPLUS MET, 22
ACTOS, 22 ACULAR, 36 ACULAR LS, 36 acyclovir caps, suspension,
tabs, 11 adalimumab, 29 ADDERALL, 19 ADDERALL XR, 20 adefovir
dipivoxil, 11 ADMELOG, 22 ADVAIR DISKUS, 33 AEROCHAMBER, 32
afatinib, 12 AFINITOR, 12 AGRYLIN, 29 albuterol, 32 albuterol
ext-rel, 32 albuterol inhalation solution, 32 albuterol sulfate,
CFC-free aerosol, 32 alclometasone cream, ointment 0.05%, 34
alcohol swabs, 23 ALDACTAZIDE, 16 ALDACTONE, 14 ALDARA, 35
alendronate tabs, 23 alfuzosin ext-rel, 28 ALKERAN, 11 allopurinol,
7 alogliptin, 22 alogliptin/metformin, 22 ALPHAGAN P, 36
alprazolam, 17 ALTACE, 13 amantadine, 19 AMARYL, 22 AMBIEN, 20
ambrisentan, 16 AMERGE, 20 amiloride, 16
amiloride/hydrochlorothiazide, 16 amiodarone, 14 amitriptyline, 18
amlodipine, 15 amlodipine/benazepril, 13 ammonium lactate 12%, 34
amoxicillin, 9
amoxicillin/clavulanate, 9 amphetamine/dextroamphetamine mixed
salts, 19 amphetamine/dextroamphetamine mixed salts ext-rel, 20
ampicillin, 9 ANAFRANIL, 17 anagrelide, 29 anastrozole, 12
ANDROGEL, 21 ANTABUSE, 21 ANUSOL-HC 2.5%, 28 apixaban, 29
aprepitant caps, 26 APRISO, 27 APTIVUS, 10 ARANESP, 29 ARAVA, 29
ARICEPT, 18 ARIMIDEX, 12 aripiprazole, 19 aripiprazole ext-rel
injection, 19 aripiprazole lauroxil ext-rel injection, 19
aripiprazole orally disintegrating tabs, 19 ARISTADA, 19 ARISTADA
INITIO, 19 ARIXTRA, 29 armodafinil, 21 AROMASIN, 12 asenapine, 19
ASMANEX, 33 ASMANEX HFA, 33 atazanavir, 10 atazanavir/cobicistat, 9
atenolol, 15 atenolol/chlorthalidone, 15 ATIVAN, 17 atomoxetine, 20
atorvastatin, 15 atovaquone, 11 atovaquone/proguanil, 9 ATRIPLA, 10
AUBAGIO, 20 AUGMENTIN, 9 AVALIDE, 14 AVAPRO, 14 axitinib, 12
AYGESTIN, 26 AZASAN, 30 azathioprine, 30 azelastine spray, 32
azithromycin, 8 AZULFIDINE, 27 AZULFIDINE EN-TABS, 27 Bbacitracin,
35 baclofen 10 mg, 20 mg, 20 balsalazide, 27 BARACLUDE, 11
BASAGLAR, 22 BD ULTRAFINE insulin syringes and needles, 23
benazepril, 13 benazepril/hydrochlorothiazide, 13 BENTYL, 27
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40
benzonatate, 31 benzoyl peroxide, except foam, 33 benztropine,
19 betamethasone dipropion