Drug Formulary - Unity Health Insurance

June 16, 2014

Table of Contents:FORMULARY INFORMATION ......................................................................................................................3-6CARDIOVASCULAR AGENTS (blood pressure, heart medications)..............................................................7-9ENDOCRINE AGENTS (diabetes, contraceptives, hormone replacement, cholesterol lowering)..............10-15OPHTHALMIC/OTIC (eyes and ears) ....................................................................................................15-16INFECTIOUS DISEASE (antibiotics, antifungals, antivirals) ....................................................................16-18ONCOLOGY/IMMUNOLOGY (cancer, inflammation, rheumatology, multiple sclerosis) ..........................19-20CENTRAL NERVOUS SYSTEM AGENTS (depression, anxiety, sleep, mood, behavioral health,pain management)..........................................................................................................................20-25DERMATOLOGIC AGENTS (acne, rosacea, any topicals) ........................................................................25-27GASTROENTEROLOGY AGENTS (heartburn, ulcers, diarrhea, constipation, nausea) ..............................27-28MISCELLANEOUS ORAL MEDICATIONS ......................................................................................................29RESPIRATORY AGENTS (asthma, allergies) ..........................................................................................29-30PREVENTIVE MEDICATIONS ........................................................................................................................30MEDICAL BENEFIT MEDICATIONS ..............................................................................................................31APPENDIX A..........................................................................................................................................32-35INDEX ..................................................................................................................................................36-64PRIOR AUTHORIZATION FORMULARY EXCEPTION REQUEST FORM ............................................................65To search the on-line version, use “CONTROL-F” and enter the drug name. You may also use the binocularsnoted as “SEARCH” and enter the drug name. The name may be listed multiple times in the document6-16-142

Specialty Pharmaceuticals Program (SP)Medications denoted by “SP” are required to be obtained from a pharmacy participating in the UnitySpecialty Pharmaceuticals network for coverage through Unity. The UW Health Pharmacies are currentlyparticipating in the Unity Specialty Pharmaceuticals network. (This does not include the Arboretum orEvjue locations.) You can contact the UW Health Pharmacy at 1-866-894-3784 to make arrangementsfor receiving the medication (by mail or pick-up at one of the pharmacy locations). Many of these drugsalso require prior authorization (denoted by PA on the formulary). Please see the drug specific criteriafor each product at www.unityhealth.com. The majority of drugs included in Unity’s Specialty Pharmacynetwork have pharmacist-run management programs to maximize patient knowledge and outcomes fromthese medications. This may include additional follow-up from the pharmacist or partial dispensing.The Unity Specialty Pharmacy program DOES NOT apply to medications administered in your physician’soffice, a hospital, or other health care facility. Coverage for medications administered in a health carefacility falls under your Unity medical benefit and may be subject to other requirements. Somemembers have specific benefits that require a greater cost share for medications in the SpecialtyPharmaceuticals Program. Please refer to your Schedule of Benefits to see if you are part of thisprogram. Please refer to www.unityhealth.com for further details on the Unity Specialty PharmaceuticalsProgram.Narrow Therapeutic Index Drugs (NTI)Some medications do not require substitution when a generic product is available. These areexemptions to the generic substitution policy and are designated by “NTI”. Medications that arelisted on the NTI list will be covered at the brand copay if the prescription is filled with the brandname product.Over-the-Counter (OTC)Medications that do not require a prescription are not covered under the pharmacy benefit unlessspecifically listed as approved by the Unity Pharmacy & Therapeutics Committee.General ExclusionsMedications that are designated as excluded means that your prescription benefit plan does not coverthese medications. Examples of these medications include hair loss medications, sexual dysfunctionmedications, infertility medications, most over-the-counter medications, cosmetic treatments andnutritional supplements.Oral Oncology ProgramMedications listed in this section of the formulary have been identified as requiring additionalmonitoring to provide the best patient outcomes and reduce waste. Prescriptions for these medicationsmust be filled at the UW Carbone Cancer Center Pharmacy (608-263-7025) and a pharmacist trainedin cancer therapies will assist a member through their treatment course. During the first three monthsof treatment members will only receive two weeks of medication at a time.RX Outcomes (*)Medications designated by an asterisks (*) are included in the RX Outcomes Benefit. Thesemedications have been shown to improve the overall health of patients with diseases like high bloodpressure (hypertension), high blood sugar (diabetes), and breathing difficulties (asthma) when taken ona daily basis. For members whose employers have purchased the RX Outcomes Benefit, the designatedmedications will process with a $5 copay.6-16-145

Where to find information when you have questionsTopicTo check the formulary status or restriction status ofa drugTo obtain a copy of Unity’s Prescription DrugFormularyTo appeal a Prior Authorization denialTo speak to a clinical pharmacist about why a PriorAuthorization Request was deniedFor criteria for coverage of a medicationEarly refills, vacation supplies, emergency supplies,new member supply, reimbursement of medicationspurchased out-of-pocketTo enroll in the RX90 Extended Supply programTo enroll in the Unity Specialty PharmaceuticalsProgramTo inquire about the RX90 Extended Supply programor the Specialty Pharmaceuticals programWhere Availableunityhealth.com by selecting Members and then Drug Formularyunder Quick Linksunityhealth.com by selecting Members and then Drug Formularyunder Quick LinksUnity Customer Service800-362-3310Unity Clinical Pharmacy Program888-450-4884Unity Clinical Pharmacy Program888-450-4884 or unityhealth.com by selecting Providers, thenPharmacy Information and then Medication Prior Authorizationunityhealth.com by selecting Members, then Using YourPharmacy Benefits and then Understanding Your PharmacyBenefitsUW Health Pharmacy866-894-3784Hometown Pharmacy (does not include Shopko)888-846-1819Mallatt’s Pharmacy and Costume608-238-3106The Medicine Shoppe Pharmacy of McFarland888-247-5534Ballweg Family Pharmacy855-336-4714Eannelli Pharmacy800-717-3396UW Health Pharmacy866-894-3784unityhealth.com by selecting Members, then Using YourPharmacy Benefits and then Understanding Your PharmacyBenefits6-16-146

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierCARDIOVASCULAR AGENTS (Blood Pressure, Heart Rhythm, Heart Medicine)ACE-Inhibitorsbenazepril* enalapril soln (Epaned) moexiprilbenazepril/amlodipinemoexipril/HCTZbenazepril/HCTZ*trandolapril/verapamil (Tarka)captopril*captopril/HCTZ*enalapril*enalapril/HCTZ*fosinopril*fosinopril/HCTZ*lisinopril*lisinopril/HCTZ*perindopril*quinapril*quinapril/HCTZ*ramipril*trandolaprilAngiotensin II Antagonists (ARBS)candesartan* PA amlodipine/olmesartan (Azor)candesartan/HCTZ* PA amlodipine/telmisartanirbesartan*amlodipine/valsartan (Exforge)irbesartan/HCTZ*amlodipine/valsartan/HCTZ (Exforge HCT)losartan*amlodipine/olmesartan/HCTZ (Tribenzor)losartan/HCTZ* azilsartan (Edarbi) Qazilsartan/chlorthalidone (Edarbyclor) Qeprosartaneprosartan/HCTZ (Teveten HCT)olmesartan (Benicar)olmesartan/HCTZ (Benicar HCT)telmisartantelmisartan/HCTZvalsartan (Diovan)valsartan/HCTZBeta Blockersacebutolol propranolol LA (Innopran XL, Inderal XL) betaxololatenolol* carvedilol CR (Coreg CR) Qatenolol/chlorthalidone* metoprolol succinate/HCTZ (Dutoprol) Qbisoprololnadolol/bendroflumethizidebisoprolol/HCTZnebivolol (Bystolic)carvedilol (reserve for CHF)*labetalolmetoprolol/HCTZmetoprolol succinate (XL)*Qmetoprolol tartrate*nadololpindololpropranololpropranolol LA (Inderal LA equiv.)propranolol/HCTZtimololsotalol, sotalol AFPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-147

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierCARDIOVASCULAR AGENTS (Blood Pressure, Heart Rhythm, Heart Medicine)Calcium Channel Blockersamlodipine* nimodipine soln (Nymalize) aliskiren/amlodipine (Tekamlo) Qbenazepril/amlodipine amlodipine/atorvastatin Qdiltiazemamlodipine/olmesartan (Azor)diltiazem ER (12H)*amlodipine/telmisartandiltiazem ER (24H)*amlodipine/valsartan (Exforge)diltiazem LA (Matzim LA, generics)*amlodipine/valsartan/hctz (Exforge HCT)felodipineisradipinenifedipinenicardipinenifedipine ER*nicardipine SR (Cardene SR)nimodipine capsnisoldipineverapamiltrandolapril/verapamil (Tarka)verapamil ER*Diureticsamiloride triamterene (Dyrenium) ethacrynic acid (Edecrin)amiloride/HCTZtolvaptan (Samsca)bumetanide*chlorthalidone*chlorthiazide*clonidine/chlorthalidoneeplerenonePAfurosemide*hydralazine/HCTZhydrochlorothiazide (HCTZ)*indapamide*metolazone*spironolactone*spironolactone/HCTZ*torsemidetriamterene/HCTZ*Adrenergicsclonidineclonidine patchdoxazosinguanabenzguanfacinemethyldopamethyldopa/HCTZprazosinterazosindoxazosin ER (Cardura XL)Antiarrhythmicsamiodarone (generic, Pacerone) NTI amiodarone (Cordarone) NTI dofetilide (Tikosyn)digoxin (generic, Digitek) NTI digoxin (Lanoxin) NTI dronedarone (Multaq)disopyramide NTI disopyramide (Norpace) NTI propafenone SRflecainide disopyramide ER (Norpace CR) NTImexiletine procainamide (Pronestyl) NTIprocainamide NTI quinidine (Quinidex) NTIpropafenonequinidineNTIPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-148

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierCARDIOVASCULAR AGENTS (Blood Pressure, Heart Rhythm, Heart Medicine)Vasodilators/Nitrates/Miscellaneous Cardiovascularhydralazine ambrisentan (Letairis) PA aliskiren (Tekturna) Qhydralazine/HCTZ bosentan (Tracleer) PA aliskiren/amlodipine (Tekamlo) Qhydralazine/reserpine nitroglycerin ointment (Nitro-bid) aliskiren/HCTZ (Tekturna HCT) Qisosorbide dinitrate* nitroglycerin spray (Nitrolingual) aliskiren/amlodipine/HCTZ (Amturnide) Qisosorbide mononitrate nitroglycerin tablets (Nitrostat) isosorbide dinitrate/hydralazine (BiDil)midodrine ranolazine (Ranexa) iloprost (Ventavis) PAnitroglycerin patch treprostinil neb (Tyvaso) macitentan (Opsumit) PAreserpinemecamylamine (Vecamyl)sildenafil (Revatio equiv.)• PA minoxidilnitroglycerin spray (Nitromist equiv.)phenoxybenzamine (Dibenzyline)riociguat (Adempas)PA Qtadalafil (Adcirca)PAtreprostinil diolamine (Orenitram ER) PA Q• Medications used for the treatment of erectile dysfunction are not a covered benefitBlood Related (Antiplatelet, Clotting, Blood Building)aminocaproic acid dabigatran (Pradaxa) Q apixaban (Eliquis)anagrelide dalteparin (Fragmin) aspirin/dipyridamole (Aggrenox)cilostazol darbepoetin for home use (Aranesp) PA deferiprone (Ferriprox)clopidogrel* erythropoeitin for home use (Procrit, Epogen) PA desirudin (Iprivask)dipyridamole filgrastim (Neupogen) eltrombopag (Promacta) PA SP Qenoxaparin oprelvekin (Neumega) PA SP Q fondaparinuxpentoxifylline prasugrel (Effient) PA pegfilgrastim (Neulasta) PA Qticlopidine phytonadione (Mephyton) tinzaparin (Innohep)tranexamic acidrivaroxaban (Xarelto)warfarin (Jantoven, generics)* NTI sargramostim (Leukine)TBO-filgrastim (Granix)ticagrelor (Brilinta)warfarin (Coumadin)NTIPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-149

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)Diabetes Medications – Sulfonylureaschlorpropamideglimepiride*glipizide*glipizide ERglyburide*tolazamidetolbutamideDiabetes Medications – Other Oralacarbose canagliflozin (Invokana) PA Q alogliptin (Nesina) PA Qmetformin* metformin liquid (Riomet) alogliptin/metformin (Kazano) PAmetformin/glipizide sitagliptin (Januvia) Q alogliptin/pioglitazone (Oseni) PA Qmetformin/glyburide* sitagliptin/metformin (Janumet) dapagliflozin (Farxiga) PA Qmetformin ER* (Glucophage XR equiv.) sitagliptin/metformin ER (Janumet XR) linagliptin (Tradjenta) PA Qsitagliptin/simvastatin (Juvisync) Q linagliptin/metformin (Jentadueto) PAmetformin ER (Glumetza)miglitol (Glyset)nategliniderepaglinideDiabetes Medications – TZDrepaglinide/metformin (Prandimet)saxagliptin (Onglyza)saxagliptin/metformin (Kombiglyze XR)pioglitazone alogliptin/pioglitazone (Oseni) PA Qpioglitazone/glimepiridepioglitazone/metformin XR (Actoplus Met XR)pioglitazone/metforminrosiglitazone (Avandia)rosiglitazone/glimepiride (Avandaryl)rosiglitazone/metformin (Avandamet)Diabetes Medications – Insulin and Other Injectionsexenatide (Byetta) ST human insulin (Humulin R vial)exenatide weekly (Bydureon) ST human insulin mix 70/30(Humulin 70/30 vial)human insulin (Novolin R vial)* human insulin mix 70/30 PA(Humulin 70/30 pen)human insulin-concentrated Q human isophane (Humulin N vial)(Humulin R U-500 vial)PA QPAinsulin glargine (Lantus vial, Solostar pen)* human isophane (Humulin N pen) PAhuman insulin mix 70/30insulin lispro (Humalog vial)(Novolin 70/30 vial and pen)*human isophane (Novolin N vial and pen)* insulin lispro (Humalog pen) PAinsulin aspart (Novolog vial and pen)*insulin lispro mix (Humalog mix vial)insulin aspart mix insulin lispro mix (Humalog mix pen) PA(Novolog 70/30 vial and pen)*insulin detemir (Levemir vial and pen)* insulin glulisine (Apidra vial)glucagon kit (GlucaGen) insulin glulisine (Apidra Solostar pen) PAliraglutide (Victoza)PApramlintide (Symlin)Most insulin products (vials and pens) are limited to 30 ml/month; additional quantity requires PAPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1410

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)Diabetes Medications – Test Strips and Other Suppliesinsulin syringes* Test strips-Abbott (Freestyle, Freestyle Lite, Test strips-Lifescan (One Touch Verio IQ) PAFreestyle Insulinx, Precision Xtra)*lancets* Test strips-Bayer (Contour, Contour Next, Test strips-Roche (Accu-Chek, Aviva, Active) PABreeze 2, Ascensia)*needles (for insulin syringes)* Test strips-Lifescan (One Touch Ultra PABlue-Animas pump use only)pen needles (for insulin pens)*Abbott and Bayer glucometers are available at Unity Network Pharmacies for $0 copay (limit 1 meter/fill)Test strips are limited to a quantity of 200/month; Additional quantity requires PADiabetes supplies (insulin syringes, needles, lancets, control solutions) are included in the value tier for RX Outcomes benefits*Cholesterol Lowering Agents – Othercholestyramine colesevelam (Welchol) icosapent ethyl (Vascepa) ST Qcholestyramine light colestipol (Colestid) lomitapide (Juxtapid) PAcolestipol ezetimibe (Zetia) mipomersen (Kynamro) PAniacin extended release omega-3 acid ethylesters (Lovaza) ST Q niacin (Niacor)Cholesterol Lowering Agents - Fibratesfenofibrate (Lofibra equiv.) fenofibrate (Tricor equiv., Antara equiv., STTriglide, Lipofen, Fenoglide)gemfibrozil* fenofibric acid STCholesterol Lowering Agents – Statinsatorvastatin* ezetimibe/simvastatin (Vytorin)• Q amlodipine/atorvastatin Qlovastatin* lovastatin/niacin (Advicor) ezetimibe/atorvastatin (Liptruzet) PA Qpravastatin* rosuvastatin (Crestor) 20, 40 mg PA Q fluvastatin Qsimvastatin•* Q simvastatin/niacin (Simcor) Q fluvastatin XL (Lescol XL) Qsitagliptin/simvastatin (Juvisync) Q lovastatin (Altoprev) Qpitavastatin (Livalo)PA Qrosuvastatin (Crestor) 5, 10 mg PA Q• 80 mg doses require prior authorization (PA)Calcium Metabolism/Osteoporosis – Miscellaneouscalcitriol oral calcitonin nasal (Fortical) conjugated estrogens/bazedoxifene (Duavee)calcitonin nasal (Miacalcin Equiv.) cinacalcet (Sensipar) doxercalciferolergocalciferol teriparatide (Forteo) PA SP Q miglustat (Zavesca) PAraloxifeneparicalcitolOsteoporosis – Bisphosphonatesalendronate risedronate (Actonel, Atelvia) Q alendronate/cholecalciferol (FosamaxD) Qetidronate alendronate effervescent (Binosto) QibandronateQtiludronate (Skelid)PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1411

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)Electrolytes/Minerals/Supplements – Prescription Onlycalcium acetate calcium acetate soln (Phoslyra soln) citric acid/sodium citrate (Bicitra)fluoride drops, chew tab (generic, Epiflur) fluoride (Fluoritab, Ludent, Flurabon) cyanocobalamin/folic acid/pyridoxine (Foltx)folic acid fluoride paste, gel, cream, soln (Prevident) deferasirox (Exjade)prenatal multivitamin* lanthanum (Fosrenol) fluoride tab (Flura-tab, Flura)potassium chloride (generic, Klor-Con) levocarnitine (Carnitor) fluoride lozenge (FluraTab)sevelamer carbonate tab (Renvela equiv.) prenatal multivitamin (NataChew, Natafort, fluoride/xylitol (Fluor-A-Day)Vitafol+DHA)sodium bicarbonate sevelamer (Renagel) potassium phosphate/sodium phosphate(K-Phos)sodium polystyrene sulfonate sevelamer carbonate packet (Renvela) prenatal multivitamin (Prenate, Crnatal,Duet DHA Balanced)sucroferric oxyhydroxide (Velphoro) PAMulti-Phasic Contraceptives (biphasic, triphasic, quadriphasic)Desogestrel/Ethinyl estradiol:Dienogest/Estradiol valerate:Kariva, Azurette, Viorele, Pimtrea Natazia PAVelivet, CaziantLevonorgestrel/Ethinyl estradiol:Levonorgestrel/Ethinyl estradiol: Amethia, Camrese, Daysee (3 copays) PATrivora, Enpresse, Myzilra, Levonest Amethia Lo, Camrese Lo (3 copays) PAQuartettePANorethindrone/Ethinyl estradiol:Necon 10/11Norethindrone/Ethinyl estradiol:Tri-Legest FE, Tilia Fe Aranelle, Leena PANecon 777, Nortrel 777, Cyclafem 777,Alyacen 777, Dasetta 777, Pirmella 777Norgestimate/Ethinyl estradiol:Tri-Previfem, Trinessa, Tri-Sprintec, Tri-Linyah,Tri-EstaryllaNorgestimate/Ethinyl estradiol:Ortho Tri-Cyclen LoContraceptives administered in a clinic are not covered as part of the pharmacy benefit;some benefits allow 3 month supplies to be filled at retail pharmacies; approved claims will have a $0 cost share.PAPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1412

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)Monophasic ContraceptivesDesogestrel/Ethinyl estradiol:Drospirenone/Ethinyl estradiol:Reclipsen, Apri, Emoquette, Enskyce Beyaz, Gianvi, Loryna, Vestura PAOcella, Syeda, Zarah, SafyralPAEthynodiol diacetate/Ethinyl estradiol:Zovia 1/35, Kelnor 1/35Levonorgestrel/Ethinyl estradiol:Zovia 1/50 Amethyst PALevonorgestrel/Ethinyl estradiol:Norethindrone/Ethinyl estradiol:Aviane, Aubra, Lessina, Lutera, Orsythia, Generess FE PASronyx, Falmina Lomedia 24 FE, Minastrin 24 FE PALevora, Portia, Altavera, Marlissa, Kurvelo, LoLoestrin FE, LoMinastrin FE PAChatealBalziva, Briellyn, Zeosa, Zenchent FE, Philith, PAJolessa, Quasense, Introvale (3 copays)GildagiaNorethindrone/Ethinyl estradiol:Norgestrel/Ethinyl estradiol:Junel FE 1.5/30, Microgestin FE 1.5/30, Ogestrel PAGlidess FE 1.5/30Junel FE 1/20, Microgestin FE 1/20,Glidess FE 1/20, Larin FE 1/20Nortrel 0.5/35, Necon 0.5/35, Wera,BreviconNecon 1/35, Nortrel 1/35, Cyclafem 1/35,Alyacen 1/35, Dasetta 1/35,Pirmella 1/35, Norinyl 1/35Necon 1/50Norgestimate/Ethinyl estradiol:Sprintec, Mono-Linyah, Mononessa, Estarylla,PrevifemNoregestrel/Ethinyl estradiol:Cryselle, Low-Ogestrel, ElinestContraceptives administered in a clinic are not covered as part of the pharmacy benefit;some benefits allow 3 month supplies to be filled at retail pharmacies; approved claims will have a $0 cost share.Progestin-Only ContraceptivesCamila, Errin, Heather, Jolivette, NoraBe,JencyclaContraceptives administered in a clinic are not covered as part of the pharmacy benefit;some benefits allow 3 month supplies to be filled at retail pharmacies; approved claims will have a $0 cost share.Other Contraceptiveslevonorgestrel (Next Choice) Q NuvaRinglevonorgestrel (Next Choice One Dose, Q ulipristal (Ella) QMy Way)Xulane PatchQA prescription is required for Emergency Contraceptives to be covered on the pharmacy benefitPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1413

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)Hormone Replacement – Oral Estrogen/Progestinestropipate tab conjugated estrogens tab (Cenestin, Premarin) compounded hormones (estrogen, PAprogesterone)estradiol tab conjugated estrogens/medroxyprogesterone tab conjugated estrogens tab (Enjuvia)(Premphase, Prempro, PremproLo)esterified estrogen/methyltestosterone esterified estrogen tab (Menest) conjugated estrogens/bazedoxifene (Duavee)(Covaryx, EEMT)ethinyl estradiol/norethindrone tab (Jinteli) esterified estrogen/methyltestosterone tab estradiol/norethindrone tab(Syntest)estradiol acetate (Femtrace)estradiol/norgestimate tab (Prefest)estradiol/drospirenone (Angeliq)Hormone Replacement – Transdermal Estrogen/Progestinestradiol weekly patch (Climara equiv.) estradiol twice weekly patch (Vivelle-dot, Alora, estradiol weekly patch (Menostar)Minivelle)estradiol/norethindrone twice weekly patch(Combipatch)estradiol/levonorgestrel weekly patch(ClimaraPro)Quantity limits on patches: 4/month for once weekly patch and 8/month for twice weekly patchHormone Replacement – Topical Estrogen/Progestinconjugated estrogen cream (Premarin cream)estradiol topical gel (Estrasorb, Estrogel,Elestrin, Divigel)estradiol vaginal tab (Vagifem) estradiol vaginal ring (Femring) Qestradiol vaginal cream (Estrace)estradiol vaginal ring (Estring)estradiol spray (Evamist)Hormone Replacement – Testosterone/Progesteronefluoxymesterone (Androxy) methyltestosterone (Testred, Methitest, Android) compounded hormones (progesterone, PAtestosterone)medroxyprogesterone testosterone topical packets (Androgel) norethindrone tabprogesterone testosterone topical (Androgel pump) progesterone suppository (Endometrin, PAFirst Progesterone)testosterone cypionate injection testosterone topical patches (Androderm) progesterone gel (Prochieve, Crinone) PAtestosterone enanthate injection progesterone injection PAtestosterone buccal (Striant)testosterone topical (Fortestra, Axiron)Miscellaneous Hormonesbromocriptine cabergoline (Dostinex) bromocriptine (Cycloset)danazol desmopressin nasal (Stimate) clomiphene - hypogonadism only PAdesmopressin (DDAVP) thyroid pork (Armour Thyroid) corticotropin gel (Acthar HP) PAlevothyroxine (generics) NTI histrelin (Supprelin) degarelix acetate for home use (Firmagon) PAliothyronine levothyroxine (Synthroid, Levothroid, NTI glycerol phenylbutyrate (Ravicti)Levoxyl, Unithroid)megestrol megestrol (Megace, ES) human chorionic gonadotropin for home use- PAhypogonadism only (Novarel, Pregnyl)methimazole nafarelin (Synarel) lanreotide for home use PA SP(Somatuline Depot)octreotide for home use PA octreotide depot for home use PA leuprolide for home use (Lupron, generic) PA(Sandostatin LAR)oxandrolone PA levothyroxine (Tirosint)potassium iodide (SSKI) metreleptin (Myalept) PApropylthiouracil pasireotide (Signifor) PAthyroid pork (Westhroid, Nature-Throid) sapropterin (Kuvan) PAPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1414Q

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierENDOCRINE AGENTS (Cholesterol, Hormones, Diabetes, Osteoporosis, etc.)Growth Hormonessomatropin (Tev-Tropin) PA SP mecasermin (Increlex, Iplex) PA SPsomatropin (Serostim) - AIDS wasting PA SP pegvisomant (Somavert) PA SPsomatropin (Genotropin, Humatrope, PA SPNorditropin, Nutropin, Nutropin AQ,Omnitrope, Saizen, Zorbtive)OPHTHALMIC/OTIC (Eyes/Ears – Allergies, Glaucoma, Inflammation, Infection)Eye Allergyazelastine emedastine (Emadine) alcaftadine (Lastacaft)cromolyn lodoxamide (Alomide) bepostastine (Bepreve)naphazoline olopatadine (Patanol, Pataday) epinastinenedocromil (Alocril)Glaucomabrimonidine apraclonidine 1% (Iopidine) apraclonidine 0.5%carteolol betaxolol (Betoptic S) bimatoprost (Lumigan)dorzolamide brimonidine/timolol (Combigan) brimonidine 0.1% (Alphagan P)dorzolamide/timolol brinzolamide (Azopt) brimonidine/brinzolamide (Simbrinza)latanoprost carbachol (Isopto Carbachol) dorzolamide/timolol PF (Cosopt PF)levobunolol echothiophate (Phospholine) tafluprost (Zioptan)metipranolol timolol (Istalol) unoprostone isopropyl (Rescula)pilocarpine travoprost (Travatan Z)timolol (Timoptic equiv.)timolol XEtravoprost benzalkoniumEye NSAIDS – Inflammationdiclofenac ketorolac PF (Acuvail) bromfenac (generics, Prolensa)fluorometholone nepafenac (Nevanac, Ilevro) difluprednate (Durezol)flurbiprofen prednisolone/sulfacetamide (Blephamide) fluorometholone (FML Forte)ketorolac (0.4%, 0.5%) prednisolone (Pred Forte) NTI fluorometholone (FML SOP)neomycin/bacitracin/polymyxin/hydrocortisone tobramycin/dexamethasone ointment fluorometholone acetate (Flarex)ointment(Tobradex ointment)neomycin/polymyxin/dexamethasoneloteprednol (Alrex, Lotemax)neomycin/polymyxin/hydrocortisonerimexolone (Vexol)prednisolonetobramycin/lotepred (Zylet)prednisolone/sulfacetamidetobramycin/dexamethasone 0.3/0.1% dropsEye Anti-infectivesbacitracin gentamicin/prednisolone (Pred-G) azithromycin (Azasite)tobramycin/dexamethasone 0.3/0.05% drops(Tobradex ST)bacitracin/polymyxin B moxifloxacin (Vigamox, Moxeza) besifloxacin (Besivance)ciprofloxacin dropsciprofloxacin ointment (Ciloxan)erythromycindoxycycline (Alodox kit)gatifloxacinganciclovir (Zirgan)gentamicinlevofloxacin (generics, Iquix)neomycin/polymyxin/gramicidinnatamycin (Natacyn)ofloxacinsulfacetamide (Bleph-10)polymyxin/trimethoprimsulfacetamide ophthalmictobramycinPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1415

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierOPHTHALMIC/OTIC (Eyes/Ears – Allergies, Glaucoma, Inflammation, Infection)Other Miscellaneous Eye Productsatropine homatropine 2% (Isopto Homatropine) benoxinate/fluorescein (Altafluor, Flurox)cyclopentolatecyclosporine (Restasis)homatropine 5%cysteamine (Cystaran)phenylephrinehydroxyamphetamine/tropicamide (Paremyd)proparacaine ophthalmichydroxypropyl cellulose ophthalmic insert(Lacrisert)tetracainescopolamine (Isopto Hyoscine)trifluridinetropicamideMiscellaneous Ear Productsacetic acid ciprofloxacin/hydrocortisone (Cipro HC) antipyrine/benzocaine/zinc (Otozin)antipyrine/benzocaine ciprofloxacin/dexamethasone (Ciprodex) chloroxylenol/benzoc/hydrocortisone (Trioxin)acetic acid/hydrocortisonefluocinolone otic (DermOtic)ciprofloxacin oticofloxacin oticneomycin/polymyxin/hydrocortisone oticPenicillinsamoxicillinamoxicillin/clavulanateamoxicillin/clavulanate ERamoxicillin/clavulanate ESampicillindicloxacillinpenicillin VK (Veetids, PenVee K)CephalosporinscephalexincefpodoximecefdinirINFECTIOUS DISEASEamoxicillin ER (Moxatag)cefaclorcefadroxilcefuroxime (Ceftin)cefprozil (generics, Cefzil)ceftibutencefditorencefixime (Suprax)Quinolonesciprofloxacin norfloxacin (Noroxin) ciprofloxacin XRlevofloxacin oralgatifloxacin (Tequin)moxifloxacin gemifloxacin (Factive) Qlomefloxacin (Maxaquin)ofloxacinMacrolide/Ketolideazithromycin clarithromycin (Biaxin suspension) azithromycin (Zmax) Qclarithromycin erythromycin (Erytab, Emycin) erythromycin ethyl succinate (Eryped)clarithromycin ER telithromycin (Ketek) PA Qerythromycinerythromycin ethyl succinate (EES)erythromycin ethyl succinateerythromycin stearate (Erythrocin)erythromycin/sulfisoxazolePA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1416

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierINFECTIOUS DISEASESulfonamides/Tetracyclinesdoxycycline hyclate tab 20, 100 mg doxycycline hyclate (Oraxyl) demeclocycline (Declomycin)doxycyline hyclate cap 50, 100 mg doxycycline suspension (Vibramycin susp) doxycycline monohydrate tab 150 mgdoxycycline monohydrate tab 50, 75, 100 mg sulfisoxazole (Gantrisin) doxycycline monohydrate cap 75, 150 mg(generics, Adoxa, Oracea)doxycycline monohydrate cap 50, 100 mg tetracycline tabs (Sumycin) doxycycline hyclate DR cap 75, 100 mgminocyclinedoxycycline hyclate DR tab 75, 100, 150 mgsulfadiazinedoxycycline hyclate gel (Atridox)sulfisoxazoletetracycline capsuletrimethoprim/sulfa (TMP-Sulfa, Cotrim,Sulfatrim)Miscellaneous Anti-infectiveschlorhexidine clindamycin granules (Cleocin granules) clofazamine (Lamprene)clindamycin capsules fidaxomicin (Dificid) PA Q fosfomycin (Monurol)methenamine (Urex) interferon alfa-n3 (Alferon) PA SP methenamine/sodium salicylate (Cystex)metronidazole interferon gamma (Actimmune) PA SPneomycin linezolid (Zyvox) PAnitrofurantoinmethenamine (Mandelamine)trimethoprimnitrofurantoin 25 mg (Macrodantin)vancomycin oral rifaximin (Xifaxan) QAnti-Parasiticsparomomycin albendazole (Albenza) nitazoxanide (Alinia)ivermectin (Stromectol)tinidazolepentamidine (Nebupent)praziquantel (Biltricide)Antimalarialsatovaquoneatovaquone/proquanilchloroquinehydroxychloroquinemefloquinequinine 260 mgartemether/lumefantrine (Coartem)primaquinepyrimethamine (Daraprim)quinine 324 mgAntifungalsamphotericin posaconazole susp (Noxafil) PA flucytosineclotrimazole troche terbinafine granules (Lamisil granules) itraconazole (Onmel) PAfluconazolemiconazole (Oravig)griseofulvin posaconazole tab (Noxafil) PAgriseofulvin ultramicrosizeitraconazole (Sporanox equiv.) PAketoconazolenystatinterbinafine tabletsvoriconazolePAAnti-TBdapsone isoniazid/rifampin (Rifamate) bedaquiline (Sirturo)ethambutol isoniazid/pyrazinamide (Rifater) cycloserine (Seromycin)isoniazidethionamide (Trecator)pyrazinamiderifapentine (Priftin)rifabutinrifampinPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1417

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierINFECTIOUS DISEASEAntiviral – Hepatitisadefovir boceprevir (Victrelis) PA SP interferon alfacon (Infergen) PA SPlamivudine entecavir (Baraclude) ribavirin (Ribapak, Moderiba, PARibasphere 400 mg & 600 mg)ribavirin interferon alfa (Intron A) PA SP simeprevir (Olysio) PA SP Q1st line: pegylated interferon PA SP Q telbivudine (Tyzeka)(PegIntron)2nd line: pegylated interferon PA SP Q(Pegasys)ribavirin solution (Rebetol)sofosbuvir (Sovaldi)PA SP Qtelaprevir (Incivek)PA SPAntiviral – HIVabacavir tablets* SP abacavir suspension (Ziagen suspension)* SP maraviroc (Selzentry) SPabacavir/lamivudine/zidovudine* SP abacavir/lamivudine (Epzicom)* SP tipranavir (Aptivus) SPdidanosine* SP atazanavir (Reyataz)* SPlamivudine* SP darunavir (Prezista)* SPlamivudine/zidovudine SP delavirdine (Rescriptor)* SPnevirapine* SP dolutegravir (Tivicay)* SPnevirapine XR* SP efavirenz (Sustiva)* SPstavudine SP efavirenz/emtricitabine/tenofovir (Atripla)* SPzidovudine* SP elvitegravir/cobicistat/emtricitabine/ SPtenofovir (Stribild)*emtricitabine (Emtriva)*emtricitabine/rilpivirine/tenofovir(Complera)*emtricitabine/tenofovir (Truvada)*enfuvirtide (Fuzeon)*etravirine (Intelence)*fosamprenavir (Lexiva)*indinavir (Crixivan)*lopinavir/ritonavir (Kaletra)*nelfinavir (Viracept)*raltegravir (Isentress)*rilpivirine (Edurant)*ritonavir (Norvir)*saquinivir (Invirase)*tenofovir (Viread)*Other Antiviralacyclovir oral oseltamivir (Tamiflu) Q acyclovir topicalamantadine valganciclovir (Valcyte) famciclovirrimantadine zanamivir (Relenza) QvalacyclovirSPSPSPSPSPSPSPSPSPSPSPSPSPSPPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1418

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierONCOLOGY/IMMUNOLOGYAnti-inflammatory/Immunology/Immunosuppressantsallopurinol auranofin (Ridaura) azathioprine (Azasan)azathioprine (Imuran equiv.) colchicine (Colcrys) everolimus (Zortress)cyclosporine NTI cyclosporine (Sandimmune) NTI icatibant (Firazyr)cyclosporine modified (Gengraf) NTI cyclosporine modified (Neoral) NTI pegylated interferon alfa 2b (Sylatron) PAdexamethasone febuxostat (Uloric) PA prednisolone soln (Flo-Pred, Millipred)fludrocortisone penicillamine (Cuprimine, Depen) prednisolone dispersible tab (Orapred ODT)hydrocortisone prednisolone soln (Veripred) prednisone ER (Rayos)hydroxychloroquine prednisolone tab (Millipred) ruxolitinib (Jakafi) PAleflunomide sirolimus 1, 2 mg (Rapamune) tacrolimus ER (Astagraf XL)methylprednisolone subcutaneous immune globulin (Hizentra) PAmycophenolate mofetiltriamcinolone (Aristocort)mycophenolic acidprednisolone soln (Generics)prednisoneprobenecidsirolimus 0.5 mgsulfasalazinetacrolimusOncology/Canceranastrozole busulfan (Myleran) abiraterone (Zytiga) PAbicalutamide chlorambucil (Leukeran) afatinib (Gilotrif) PA Qcapecitabine estramustine (Emcyt) bexarotene (Targretin)cyclophosphamide hydroxyurea (Droxia) cabozantinib (Cometriq) PAetoposide interferon alfa (Intron A) PA SP ceritinib (Zykadia) PAexemestane lapatinib (Tykerb) PA crizotinib (Xalkori) PAflutamide lenalidomide (Revlimid) PA Q dabrafenib (Tafinlar) PAhydroxyurea (Hydrea equiv.) melphalan (Alkeran) ibrutinib (Imbruvica) PAletrozole mesna (Mesnex) leuprolide for home use (generic, Lupron, PAEligard)leucovorin mitotane (Lysodren) mechlorethamine topical (Valchlor)levocarnitine procarbazine (Matulane) pomalidomide (Pomalyst) PAlomustine thioguanine (Tabloid) ponatinib (Iclusig) PAmercaptopurine toremifene (Fareston) regorafenib (Stivarga) PAmethotrexate vorinostat (Zolinza) PA thalidomide (Thalomid)tamoxifen topotecan (Hycamtin) PAtemozolomide PA Q trametinib (Mekinist) PAtretinoin capsulesvandetanib (Caprelsa)PAvismodegib (Erivedge)PAOncology–Oral Oncology Program Medicationsdasatinib (Sprycel) PA SP axitinib (Inlyta) PA SPerlotinib (Tarceva) PA SP Q bosutinib (Bosulif) PA SPimatinib (Gleevec) PA SP enzalutamide (Xtandi) PA SPsorafenib (Nexavar) PA SP everolimus (Afinitor) PA SPsunitinib (Sutent) PA SP everolimus soluble tab (Afinitor Disperz) PA SPnilotinib (Tasigna)PA SP Qpazopanib (Votrient)PA SPvemurafenib (Zelboraf)PA SPPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1419

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierONCOLOGY/IMMUNOLOGYBiologic Response Modifiers for Rheumatologic Disordersmethotrexate 1st line: adalimumab (Humira) PA SP Q abatacept SQ (Orencia) PA SP Q2nd line: certolizumab pegol (Cimzia) PA SP Q anakinra (Kineret) PA SP Q1st line: etanercept (Enbrel) PA SP Q apremilast (Otezla) PA Qgolimumab (Simponi)PA SP Qmethotrexate (Otrexup)PAtocilizumab (Actemra)PA SP Qtofacitinib (Xeljanz)PA SPustekinumab (Stelara)PA SP Qmethotrexate is first line before biologicsMultiple Sclerosis Medicationsglatiramer 20 mg (Copaxone) PA SP dalfampridine (Ampyra) PAinterferon beta-1a (Rebif) PA SP dimethyl fumarate (Tecfidera) PA Qinterferon beta-1b (Extavia) PA SP fingolimod (Gilenya) PA SPglatiramer 40 mg (Copaxone) PA SPinterferon beta-1a (Avonex)PA SPinterferon beta-1b (Betaseron) PA SPteriflunomide (Aubagio)PA QCENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health Sleep, etc.)Antipsychoticsamitriptyline/perphenazine aripiprazole (Abilify) 10, 20, 30 mg PA Q H aripiprazole ODT (Abilify Discmelt) PAchlorpromazine aripiprazole (Abilify) 2, 5, 15 mg PA Q asenapine (Saphris)clozapine NTI clozapine (Clozaril) NTI clozapine suspension (Versacloz)fluphenazine Lithium (Eskalith) NTI clozapine ODT (FazaClo ODT) NTIhaloperidol lithium ER (Lithobid) NTI fluoxetine/olanzapinelithium NTI molindone (Moban) iloperidone (Fanapt)lithium ER NTI pimozide (Orap) lurasidone (Latuda) Qloxapineolanzapine ODTolanzapinepaliperidone (Invega)quetiapinequetiapine ER (Seroquel XR)risperidonerisperidone ODTthioridazinethiothixenetrifluoroperazineziprasidoneAlcohol/Drug Cessationacamprosate buprenorphine/naloxone sublingual film buprenorphine/naloxone sublingual tab(Suboxone)(Zubsolv)buprenorphinebuprenorphine/naloxone sublingual tabdisulfirammethadonenaltrexoneSmoking Cessationbupropion SR* varenicline (Chantix)* nicotine spray (Nicotrol NS)nicotine patch (OTC covered with anicotine inhaler (Nicotrol inhaler)prescription)*Smoking cessation therapy is limited to 180 days per calendar yearPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1420

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierCENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health Sleep, etc.)CNS Stimulants (ADD/ADHD)amphetamine-dextroamphetamine combo atomoxetine (Strattera) armodafinil (Nuvigil) PA Qamphetamine-dextroamphetamine ER combo methylphenidate patch (Daytrana) Q clonidine SRdextroamphetamine (Dexedrine equiv.)dextroamphetamine (Zenzedi)methamphetaminedexmethylphenidatemethylphenidatedexmethylphenidate XRmethylphenidate CD 30:70 guanfacine ER (Intuniv) Q(Metadate CD equiv.)methylphenidate ER (Concerta equiv.) lisdexamfetamine (Vyvanse) Qmethylphenidate SR (Metadate ER equiv.)methylphenidate CD 50:50 (Ritalin LA equiv.)modafinil PA Q methylphenidate ER oral susp. (Quillivant XR)sodium oxybate (Xyrem)PAAntidepressants – Tricyclicamitriptylineamoxapineclomipraminedesipraminedoxepinimipraminenortriptylinemaprotilineprotriptylinetrimipramineimipramine pamoateAntidepressants – SSRI/SNRIcitalopram* fluoxetine tab 10 mg (Sarafem)* desvenlafaxine (Pristiq, PA QDesvenlafaxine Fumarate ER)duloxetine fluoxetine tab 20 mg (Sarafem)* PA fluoxetine weeklyescitalopram* milnacipran (Savella) PA Q fluvoxamine CR Qfluoxetine cap* levomilnacipran (Fetzima) PA Qfluoxetine tab 10, 60 mg (Prozac equiv.)*paroxetine mesylate (Pexeva)fluoxetine tab 20 mg (Prozac equiv.)* PA paroxetine CRfluvoxamine vilazodone (Viibryd) PA Qparoxetine* vortioxetine (Brintellix) PA Qsertraline*venlafaxine IRvenlafaxine ER tabletsvenlafaxine SR capsules*Other Antidepressantsbupropion XL 150/300 mg* Q bupropion XL 450 mg (Forfivo XL) bupropion hbr (Aplenzin) Qbupropion*isocarboxazid (Marplan)bupropion SR* selegiline patch (Emsam) Qnefazodonetrazodone ER (Oleptro) ER)mirtazapine*phenelzinetranylcyprominetrazodone*PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1421

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierCENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health Sleep, etc.)Antianxietyalprazolam clorazepate ER alprazolam ERbuspironeclonazepam ODTchlordiazepoxidemidazolam syrupclonazepamclorazepatediazepamlorazepamoxazepammeprobamateHypnotics (Sleeping)estazolam ramelteon (Rozerem) Q doxepin (Silenor)eszopiclone PA Q quazepamflurazepam tasimelteon (Hetlioz) PA Qtemazepam zolpidem sublingual (Edluar, Intermezzo) Qtriazolam zolpidem CR Qzaleplonzolpidem spray (Zolpimist)zolpidemQAlzheimer's Disease/Other Neurological Diseasedonepezil memantine (Namenda) PA dextromethorphan/quinidine (Nuedexta)galantamine pyridostigmine SR (Mestinon SR) memantine ERC (Namenda XR) PAgalantamine ER Q rivastigminepyridostigminerivastigmine patch (Exelon)riluzoleAnticonvulsants (Seizures)carbamazepine NTI carbamazepine (Tegretol, Carbatrol) NTI carbamazepine (Equetro) NTIcarbamazepine SR NTI carbamazepine SR (Tegretol XR) NTI clobazam (Onfi)clonazepam divalproex sodium (Depakote) NTI diazepam rectaldivalproex sodium NTI divalproex sodium ER (Depakote ER) NTI eslicarbazepine acetate (Aptiom)divalproex sodium ER NTI methsuximide (Celontin) ethotoin (Peganone)ethosuximide phenytoin (Dilantin,Phenytek) NTI ezogabine (Potiga)gabapentin pregabalin (Lyrica) PA Q felbamatelamotrigine primidone (Mysoline) NTI gabapentin soln (Fanatrex)levetiracetam valproic acid (Depakene) NTI gabapentin ER (Horizant)levetiracetam ER gabapentin SR 300 mg (Gralise) Qlorazepam lacosamide (Vimpat) Qoxcarbazepinelamotrigine ODT (Lamictal ODT)phenytoin NTI lamotrigine ER Qphenobarbitaloxcarbazepine ER (Oxtellar XR)primidone NTI perampanel (Fycompa)topiramaterufinamide (Banzel)valproic acid NTI tiagabinezonisamidetopiramate ER (Trokendi XR)valproic acid SA (Stavzor)vigabatrin (Sabril)PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1422

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierCENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health Sleep, etc.)Migraine Productsacetaminophen/butalbital/caffeine/codeine ergotamine/caffeine (Cafergot) acetaminophen/butalbital (Orbivan CF)acetaminophen/butalbital/caffeineacetaminophen/butalbital/caffeine (Orbivan)acetaminophen/dichloralphenazone/acetaminophen/dihydrocodeine/caffeine (Trezix)isomethepteneaspirin/butalbital/caffeineaspirin/dihydrocodeine/caffeinebutorphanol nasal spray Q dihydroergotamine injection PAfor home use (DHE)dihydroergotamine nasal Q isometheptene/acetaminophen/caffeine(Prodrin)methylergonovineMigraine Products – Triptansnaratriptan Q almotriptan (Axert) Qrizatriptan Q eletriptan (Relpax) Qsumatriptan injection Q frovatriptan (Frova) Qsumatriptan tablets Q sumatriptan (Sumavel Dosepro) Qsumatriptan nasal Q sumatriptan/naproxen (Treximet) QzolmitriptanQzolmitriptan nasal (Zomig)QMuscle Relaxants/Muscle Spasmbaclofencarisoprodolcarisoprodol/aspirinchlorzoxazone 500 mgcyclobenzaprinemetaxalonemethocarbamolorphenadrineorphenadrine/aspirin/caffeinetizanidine tabletschlorzoxazone 375, 750 mg (Lorzone)cyclobenzaprine ER (Amrix)dantrolenetizanidine capsulesPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1423

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierCENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health Sleep, etc.)NSAIDS/Pain Relief/Pain medicationsacetaminophen/phenyltolxamine celecoxib (Celebrex) PA Q diclofenac gel (Voltaren gel, Solaraze equiv.)diclofenac sodium fenoprofen 200, 400 mg (Nalfon) diclofenac epolamine patch (Flector patch)diclofenac/misoprostoldiclofenac potassium (Zipsor, Cambia)diflunisaldiclofenac submicronized (Zorvolex)etodolacdiclofenac topical (Pennsaid)fenoprofen 600 mghydrocortisone/lidocaine creamflurbiprofenketorolacibuprofen ketorolac injection for home use Qindomethacinketorolac nasal (Sprix)ketoprofenlidocaine 3% (LidoRX)lidocaine 2% viscousmefenamic acidlidocaine 4%, 5% topicalnaproxen sodium ERlidocaine patchnaproxen sodium (Naprelan)meclofenamate sumatriptan/naproxen (Treximet) Qmeloxicamnabumetonenaproxennaproxen ERnaproxen sodiumoxaprozinpiroxicamsalsalatesulindactolmetinNarcoticsacetaminophen/codeine morphine acetaminophen/hydrocodone (Vicodin, Hycet)acetaminophen/hydrocodone oxycodone (Oxecta) acetaminophen/oxycodone (Magnacet, Xolox)acetaminophen/oxycodone oxycodone ER (Oxycontin) Q acetaminophen/oxycodone ER PA Q(Xartemis XR)codeinebuprenorphine patch (Butrans)fentanyl patch PA Q fentanyl oral (Abstral, Actiq, Fentora, PA Qgeneric)hydromorphone fentanyl transmucosal film (Onsolis) PA Qlevorphanol fentanyl nasal (Lazanda) PA Qmethadone fentanyl sublingual spray (Subsys) PA Qmorphine ER capsule (Kadian equiv.) PA hydrocodone ER (Zohydro ER) PA Qmorphine ER tablet (MS Contin equiv.)hydromorphone ER (Exalgo)oxycodoneibuprofen/hydrocodone(Reprexain, Ibudone)tramadolibuprofen/oxycodonetramadol/acetaminophen morphine ER capsule (Avinza equiv.) PA Qmorphine/naltrexone (Embeda)QoxymorphonePAoxymorphone ERPA Qoxymorphone injection (Numorphan)tapentadol (Nucynta)Qtapentadol ER (Nucynta ER)Qtramadol ER (Conzip, generics)Qtramadol ODT (Rybix ODT)PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1424

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierCENTRAL NERVOUS SYSTEM AGENTS (Mood, Depression, Behavioral Health Sleep, etc.)Parkinson's Diseaseamantadine rasagiline (Azilect) Q apomorphine (Apokyn)benztropinecarbidopa/levodopa/entacaponebromocriptineentacaponecarbidopa pramipexole ER (Mirapex ER) Qcarbidopa/levodoparopinirole XLcarbidopa/levodopa CRrotigotine (Neupro)pramipexoletetrabenazine (Xenazine)ropiniroletolcapone (Tasmar)selegilinetrihexyphenidylOral Acnedoxycycline hyclate tab 100 mgdoxycycline hyclate cap 50, 100 mgdoxycycline monohydrate tab 50, 75, 100 mgdoxycycline monohydrate cap 50, 100 mgisotretinoin (Amnesteem, Claravis, Isotret,Myorisan, Zenatane)minocycline capsulesDERMATOLOGIC AGENTS (Acne, Inflammation, Psoriasis, etc.)doxycycline hyclate DR tab 75, 100, 150 mgdoxycycline hyclate DR cap 75, 100 mgdoxycycline monohydrate tab 150 mgdoxycycline monohydrate cap 75, 150 mgisotretinoin (Absorica)minocycline tabletsminocycline ERTopical Acne – Prescription Strength Only Coveredadapalene cream, gel A

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierDERMATOLOGIC AGENTS (Acne, Inflammation, Psoriasis, etc.)Topical Antibacterial (Rx Only)clindamycin mupirocin nasal ointment (Bactroban Nasal) mafenidegentamicinretapamulin (Altabax)mupirocinsulfanilamide (AVC)silver sulfadiazineTopical Antifungal (Rx Only)butoconazole (Mycelex-3) butenafine (Mentax) ciclopirox nail lacquer PAciclopirox oxiconazole (Oxistat) ciclopirox nail lacquer/nail lacquer PAremover kitclotrimazole sulconazole (Exederm) clotrimazole/betamethasone lotionclotrimazole/betamethasone creameconazole foam (Ecoza)econazole creamketoconazole foamketoconazole creamketoconazole gel (Xolegel)nystatin topicalketoconazole/pyrithione (Xolegel Duo)nystatin/triamcinoloneluliconazole (Luzu)selenium sulfide suspensionmiconazole/zinc oxide/petrolatum (Vusion)naftifine (Naftin)selenium sulfide foam, shampoo (Selrx,Tersi Foam)sertraconazole (Ertaczo)Antivirals, Antiparasitic and Other Topicalscalcipotriene ointment (generics, Calcitrene) becaplermin (Regranex) acyclovir/hydrocortisone (Xerese)calcitriol topical calcipotriene foam (Sorilux) acyclovir/lidocaine (Lidovir)calcipotriene cream (Dovonex equiv.) crotamiton (Eurax) acyclovir topicaldoxepin fluorouracil 0.5% cream (Carac) amlexanox (Aphthasol)fluorouracil pimecrolimus (Elidel) ammonium lactate 12%imiquimod (Aldara equiv.) podofilox gel (Condylox) anthralin (Zithranol-RR)permethrin tacrolimus (Protopic) benzyl alcohol topical (Ulesfia)podofiloxbetamethasone/calcipotrienetriamcinolone oropharyngealbrimonidine gel (Mirvaso)imiquimod (Zyclara)ingenol (Picato)ivermectin topical (Sklice)lindane lotion/shampoolidocaine/tetracaine (Pliaglis)malathionpenciclovir (Denavir)podophyllin topical (Podocon 25)salicylic acid/ceramides (Salex)sinecatechins (Veregen)spinosadurea 47% (Keralac)Corticosteroids – Low Potencyalclometasone hydrocortisone/pramoxine lotion/ointment desonide topical gel/lotion/foam (Tridesilon,(Pramosone)Desonate)desonide topical cream/ointmenthydrocortisone soln (Texacort)dexamethasonehydrocortisone/urea (U-Cort)hydrocortisone butyratehydrocortisone/pramoxine creamhydrocortisone (Rx only)PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1426

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierDERMATOLOGIC AGENTS (Acne, Inflammation, Psoriasis, etc.)Corticosteroids – Medium to High Potencyamcinonide fluocinolone shampoo (Capex) betamethasone/calcipotrienebetamethasone valerate fluocinolone oil (Derma-Smoothe/FS) clocortolonebetamethasone dipropionate flurandrenolide (Cordran, Cordran SP) desoximetasone spray (Topicort)desoximetasone cream/gel/ointment halcinonide (Halog) diflorasonefluocinonide 0.05% fluocinonide 0.1%fluocinolonefluticasone lotionfluticasone cream/ointmentmometasone topicalprednicarbatetriamcinolone topicalCorticosteroids – Very High Potencyaugmented betamethasone diproprionate clobetasol spray (Clobex) clobetasol foamclobetasol topicalhalobetasol/ammonium lactatehalobetasolBiologics & Others for Psoriasis1st line: adalimumab (Humira) PA SP Q acitretin1st line: entanercept (Enbrel) PA SP Q ustekinumab (Stelara) PA SP QGASTROENTEROLOGY AGENTS (Ulcers, Heartburn, Nausea, Diarrhea, Constipation, etc.)H2 Antagonists/UlcercimetidinefamotidinemisoprostolranitidinesucralfateProton Pump Inhibitorsbiskalcitrate/metronidazole/tetracycline (Pylera)ibuprofen/famotidine (Duexis)mepenzolate (Cantil)nizatidine (generic, Axid)1st line: omeprazole, Prilosec OTC covered Q lansoprazole soltab (Prevacid SoluTab - PA Q dexlansoprazole (Dexilant) PA Qwith prescriptionage

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierGASTROENTEROLOGY AGENTS (Ulcers, Heartburn, Nausea, Diarrhea, Constipation, etc.)Antispasmodic, Antidiarrhealatropine/hyoscyamine/phenobarbital/ chlordiazepoxide/clindium (Librax) alosetron (Lotronex) PA Qscopolaminedicyclomine difenoxin/atropine (Motofen) crofelemer (Fulyzaq)diphenoxylate/atropinehyoscyamine/phenyltoloxamine (Digex NF)hyoscyaminephenazopyridine (Rx only)propanthelineConstipation, Miscellaneous GIbalsalazide (Colazal equiv.) budesonide oral (Uceris) Q balsalazide (Giazo)budesonide oral (Entocort equiv.) Q hydrocortisone rectal (Cortifoam) chenodiol (Chenodal)hydrocortisone rectal linaclotide (Linzess) PA Q hydrocortisone/lidocaine rectal(Rectagel HC equiv.)hydrocortisone/lidocaine rectal mesalamine (Pentasa, Asacol HD, Delzicol) laculose soln (Kristalose)(Peranex HC equiv.)lactulose solution (Constulose, Enulose, mesalamine rectal (Canasa) lubiprostone (Amitiza) PA QGenerlac)pancrealipase nitroglycerin rectal ointment (Rectiv) mesalamine (Lialda, Apriso)PEG/electrolytes (generic, TriLyte) olsalazine (Dipentum) methylnaltrexone (Relistor) PA QPEG/electrolytes packets (Gavilyte-G) pancrealipase (Creon, Ultrase, Pancreaze, PEG/electrolytes & bisacodyl (Halflytely Kit)Pertzye, Ultresa, Viokace, Zenpep)sulfasalazine PEG/electrolytes packets (Colyte) PEG/electrolytes & sodium, potassium, andmagnesium sulfate (Suclear)ursodiol PEG/electrolytes/sodium ascorbate Q sodium, potassium and magnesium sulfate(MoviPrep)(Suprep)sodium phosphate (OsmoPrep)sodium picosulfate/magnesium oxide/citric acid(Prepopik)teduglutide (Gattex)PAUrinary Incontinence/BPHalfuzosin mirabegron (Myrbetriq) ST Q darifenacin (Enablex) Qbethanecholdutasteride (Avodart)doxazosindutasteride/tamsulosin (Jalyn)finasteride fesoterodine fumarate (Toviaz) Qflavoxate oxybutynin patch (Oxytrol)∆ Qoxybutyninoxybutynin topical (Gelnique)oxybutynin XL Q silodosin (Rapaflo)prazosin solifenacin (Vesicare) PA Qtamsulosin tadalafil (Cialis)• PA Qterazosintrospium ERtolterodinetrospiumtolterodine ERQ• Medications used for the treatment of erectile dysfunction are not a covered benefit∆ RX covered for menBiologics for Inflammatory Bowel Disease (Crohns, Ulcerative Colitis)1st line: adalimumab (Humira) PA SP Q golimumab (Simponi) PA SP Q2nd line: certolizumab (Cimzia) PA SP QPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1428

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierMISCELLANEOUS ORAL MEDICATIONSacetazolamide ivacaftor (Kalydeco) PA carglumic acid (Carbaglu)cevimelinecysteamine bitartrate (Cystagon, Procysbi)cromolyn sodiumglycopyrrolate (Cuvposa, Glycate)glycopyrrolate (Robinul equiv.) nitisinone (Orfadin) PAmethazolamideparoxetine mesylate (Brisdelle)pilocarpine oralpentosan (Elmiron)sodium phenylbutyrate (Buphenyl)sucralfate paste (Orafate)RESPIRATORY AGENTS (Asthma, Allergies, etc.)Allergy (Antihistamines, Cold Products, Miscellaneous Allergy Medications)cyproheptadinecarbinoxaminebenzonatate desloratadine PAhydroxyzinedesloratadine/pseudoephedrine (Clarinex D) PAdoxylamine (Doxytex)levocetirizinePAmixed grass pollen (Oralair)PA Qshort ragweed pollen (Ragwitek) PA Qtimothy grass pollen (Grastek) PA QOTC antihistamines are not covered as part of the pharmacy benefit (fexofenadine, loratadine, cetirizine, diphenhydramine)Cost of OTC products may be less than the applicable co-payBuy in bulk and buy generic to reduce the cost of therapy for OTC productsNasal Corticosteroids/Antihistamineazelastine nasal antihistamine spray azelastine nasal antihistamine spray (Astepro) azelastine/fluticasone nasal (Dymista) PA(Astelin equiv.)fluticasone nasal budesonide nasal (Rhinocort AQ) PA beclomethasone nasal (Beconase AQ, Qnasl)ipratropium nasal fluticasone furoate nasal (Veramyst) ciclesonide nasal (Omnaris, Zetonna HFA)flunisolide nasalmometasone nasal (Nasonex)olopatadine (Patanase)triamcinolone nasalInhaled Corticosteroidsbudesonide nebulizer solution budesonide inhaler (Pulmicort)* beclomethasone inhaler (QVAR)budesonide-formoterol inhaler (Symbicort)* ciclesonide inhaled (Alvesco)fluticasone inhaler (Flovent)*flunisolide inhaler (Aerospan)fluticasone-salmeterol inhaler (Advair)* fluticasone furoate/vilanterol inhaler(Breo Ellipta)mometasone inhaler (Asmanex)*mometasone-formoterol inhaler (Dulera)*Inhaled Beta Agonistsalbuterol nebulizer solution albuterol HFA (Proventil HFA, Ventolin HFA) arformoterol inhaler (Brovana)albuterol-ipratropium nebulizer solution albuterol-ipratropium inhaler (Combivent) albuterol HFA (ProAir HFA)formoterol inhaler (Foradil)indacaterol (Arcapta)formoterol nebulizer solution (Perforomist) levalbuterol inhaler (Xopenex HFA)salmeterol inhaler (Serevent)levalbuterol nebulizer solutionpirbuterol inhaler (Maxair)PA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1429

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierRESPIRATORY AGENTS (Asthma, Allergies, etc.)Other Inhaled Medicationscromolyn nebulizer solution ipratropium HFA inhaler (Atrovent HFA) aclidinium bromide (Tudorza Pressair)ipratropium tiotropium inhaler (Spiriva) umeclidinum/vilanterol (Anoro Ellipta)ferrous sulfate dropsferrous sulfate oral suspensionaspirin 81 mg, 162 mg, 325 mgaspirin 81 mg, 162 mg, 325 mgfolic acid tablets 400 mcg, 800 mcgfluoride drops and chewable tabletsInhaler assistance devices/spacers are included in the value tier of RX Outcomes benefits*Oral Respiratory Medicationsalbuterol tabs dyphylline (Lufyllin) roflumilast (Daliresp)metaproterenol tabs theophylline (Theo-24, Theocap) NTI zafirlukastmontelukast*zileuton (Zyflo)terbutaline tabstheophyllineNTIOther Respiratory Medicationssodium chloride 3% for inh aztreonam lysine (Cayston) PA Q acetylcysteinesodium chloride 7% for inh colistimethate for inhalation (Coly-mycin) epinephrine injection (Auvi-Q)tobramycin inj for inh dornase alfa (Pulmozyme) Qtobramycin inhalation (TOBI equiv.)epinephrine injection (Epipen, Epipen Jr)sodium chloride 6% for inh (Nebusal)tobramycin inhalation (TOBI Podhaler, PABethkis)PREVENTIVE MEDICATIONS (Prescription required for OTC versions)age 6 to 12 monthsage 6 to 12 monthsfemales age 55 to 79 years, 1 tablet per day dosing, 100 days supplymales age 45 to 79 years, 1 tablet per day dosing, 100 days supplyfemales age 15 to 50 years, 1 tablet per day dosing, 100 days supplyage 6 months to 6 years$0 copay, generics only when availableBuying OTC bottles in larger quantities without a prescription may be more convenientPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1430

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierMEDICAL BENEFIT MEDICATIONSThese medications are clinic administered and covered under the medical benefit but require a PA from theUnity Pharmacy Program. Member costs for these medications is dependent on their medical benefit structure(pharmacy benefit copays do not apply).abobotulinum toxin (Dysport)PAabatacept (Orencia)PAalglucosidase alfa (Myozyme, Lumizyme) PAcanakinumab (Ilaris)PAdenosumab (Prolia, Xgeva)PAeculizumab (Soliris)PAhuman chorionic gonadotropinnot covered as a medical benefit, see PA criteria(Novarel, Pregnyl)human papillomavirus vaccine A covered for members ages 9 to 26(Gardasil, Cervarix)hydroxyprogesterone caproate injection PA(Makena)incobotulinum toxin (Xeomin)PAinfliximab (Remicade)PAnatalizumab (Tysabri)PAomalizumab (Xolair)PAonabotulinum toxin (Botox)PApalivizumab (Synagis)PApegfilgrastim (Neulasta)PArilonacept (Arcalyst)PArimabotulinum toxin (Myobloc)PArituximab (Rituxan) for rheumatology only PA(use for other diagnoses including oncologydo not require prior authorization at this time)romiplostim (Nplate)PAtocilizumab (Actemra)PAustekinumab (Stelara)PAzoster vaccine (Zostavax) A covered for members age 60 and older†† Members whose Unity coverage is sponsored by the State of Wisconsin Employee Trust Fund (ETF) are covered fromage 60 to 64. Members age 65 or older have coverage through their Navitus pharmacy benefitPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1431

Appendix A: Medication Quantity Limit InformationMedication Name (Brand) Dose(s)/Indication Quantity Limit*abatacept (Orencia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4acetaminophen/oxycodone ER (Xartemis XR) . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120afatinib (Gilotrif) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30adalimumab (Humira) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2alendronate (Binosto) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 mg . . . . . . . . . . . . . . . . . . . . . . . . . .4alendronate/cholecalciferol (Fosamax Plus D) . . . . . . . . . . . .35 mg, 70 mg . . . . . . . . . . . . . . . . . . . .4aliskiren (Tekturna) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30aliskiren/amlodipine (Tekamlo) . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30aliskiren/amlodipine/HCTZ (Amturnide) . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30aliskiren/hydrochlorothiazide (Tekturna HCT) . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30almotriptan (Axert) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12alogliptin (Nesina) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30alogliptin/pioglitazone (Oseni) . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30alosetron (Lotronex) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0.5 mg . . . . . . . . . . . . . . . . . . . . . . . . . .90alosetron (Lotronex) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 mg . . . . . . . . . . . . . . . . . . . . . . . . . . .60anakinra (Kineret) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30apremilast (Otezla) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60aprepitant (Emend) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 mg . . . . . . . . . . . . . . . . . . . . . . . . . .1aprepitant (Emend) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 mg . . . . . . . . . . . . . . . . . . . . . . . . . .4aprepitant (Emend) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125 mg . . . . . . . . . . . . . . . . . . . . . . . . .2aprepitant (Emend) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Trifold Kit . . . . . . . . . . . . . . . . . . . . . . . .2 kitsaripiprazole (Abilify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30armodafinil (Nuvigil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30atorvastatin/amlodipine (Caduet) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30atorvastatin/ezetimibe (Liptruzet) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30azilsartan (Edarbi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30azilsartan/chlorthalidone (Edarbyclor) . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30azithromycin (Zmax) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 gm . . . . . . . . . . . . . . . . . . . . . . . . . . .60 ml/prescriptionaztreonam inhalation solution (Cayston) . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84budesonide oral (Entocort EC) . . . . . . . . . . . . . . . . . . . . . . . .3mg . . . . . . . . . . . . . . . . . . . . . . . . . . . .90budesonide oral (Uceris) . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 mg . . . . . . . . . . . . . . . . . . . . . . . . . . .30bupropion hydrobromide (Aplenzin) . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30bupropion XL (Budeprion XL, Wellbutrin XL) . . . . . . . . . . . . . .150 mg . . . . . . . . . . . . . . . . . . . . . . . . .30 or 90bupropion XL (Budeprion XL, Wellbutrin XL) . . . . . . . . . . . . . .300 mg . . . . . . . . . . . . . . . . . . . . . . . . .30butorphanol nasal spray (Stadol) . . . . . . . . . . . . . . . . . . . . . .10 mg/ml . . . . . . . . . . . . . . . . . . . . . . . .4 vialscanagliflozin (Invokana) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30carvedilol CR (Coreg CR) . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30celecoxib (Celebrex) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60certolizumab (Cimzia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2dabigatran (Pradaxa) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60dapagliflozin (Farxiga) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30darifenacin (Enablex) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30desvenlafaxine (Pristiq, Khedezla, Desvenlafaxine ER,Desvenlafaxine Fumarate ER) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30dexlansoprazole (Dexilant) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30dihydroergotamine (Migranal) . . . . . . . . . . . . . . . . . . . . . . . .4 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . .16 mldimethyl fumarate (Tecfidera) . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60dolasetron (Anzemet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30dornase alfa (Pulmozyme) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30eletriptan (Relpax) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12eltrombopag olamine (Promacta) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30erlotinib (Tarceva) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30* Represents # of tablets, capsules, or doses allowed per 30 day period unless stated otherwise326-16-14

Appendix A: Medication Quantity Limit InformationMedication Name (Brand) Dose(s)/Indication Quantity Limit*esomeprazole ( esomeprazole strontium, Nexium) . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30estradiol vaginal ring (Estring/Femring) . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 ring/90 daysestradiol/(combo) bi-weekly transdermal patch(Alora, Combipatch, Vivelle-dot, Minivelle) . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8estradiol/(combo) weekly transdermal patch(Climara, ClimaraPro, Menostar) . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4eszopiclone (Lunesta) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30etanercept (Enbrel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 mg . . . . . . . . . . . . . . . . . . . . . . . . . .8etanercept (Enbrel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 mg . . . . . . . . . . . . . . . . . . . . . . . . . .4fentanyl immediate release (Fentora, Actiq lollipops,Abstral, Onsolis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120fentanyl immediate release nasal (Lazanda) . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 mlfentanyl sublingual spray (Subsys) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120fentanyl transdermal (Duragesic) . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10fesoterodine (Toviaz) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30fidaxomicin (Dificid) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20/prescriptionfluvastatin (Lescol) fluvastatin XL (Lescol XL) . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30fluvoxamine CR (Luvox CR) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60frovatriptan (Frova) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12gabapentin (Gralise) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .300 mg . . . . . . . . . . . . . . . . . . . . . . . . .30gabapentin (Gralise) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .600 mg . . . . . . . . . . . . . . . . . . . . . . . . .90galantamine ER (Razadyne ER) . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30gemifloxacin (Factive) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7/prescriptiongolimumab (Simponi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1granisetron (Kytril) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30granisetron patch (Sancuso) . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 patch/prescriptionguanfacine ER (Intuniv) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30hydrocodone ER (Zohydro ER) . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60human insulin-concentrated (Humulin R U500) . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 mlibandronate (Boniva) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150 mg . . . . . . . . . . . . . . . . . . . . . . . . .1icosapent ethyl (Vascepa) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120ketorolac injection for home use . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 doseslacosamide (Vimpat) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 mg . . . . . . . . . . . . . . . . . . . . . . . . . .140/30 days x 1 fill (for titration)lacosamide (Vimpat) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 mg, 100 mg, 150 mg, 200 mg . . . . .60lamotrigine ER (Lamictal XR) . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30lansoprazole (cap and soltab) (Prevacid) . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30lansoprazole compound kit (First-lansoprazole) . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30lansoprazole/amoxicillin/clarithromycin (PrevPac) . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30lenalidomide (Revlimid) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30levomilnacipran (Fetzima) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30levonorgestrel (Next Choice, Next Choice One Dose) . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 kit/prescriptionlinaclotide (Linzess) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30linagliptin (Tradjenta) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30lisdexamfetamine (Vyvanse) . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30lovastatin (Altoprev) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30lubiprostone (Amitiza) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60lurasidone (Latuda) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30memantine ER (Namenda XR) . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30methylnaltrexone (Relistor) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30methylphenidate transdermal patch (Daytrana) . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30metoprolol succinate XL (Toprol XL) . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60metoprolol succinate/HCTZ (Dutoprol) . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60* Represents # of tablets, capsules, or doses allowed per 30 day period unless stated otherwise336-16-14

Appendix A: Medication Quantity Limit InformationMedication Name (Brand) Dose(s)/Indication Quantity Limit*milnacipran (Savella) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60mirabegron (Myrbetriq) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30mixed grass pollen (Oralair) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30modafinil (Provigil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30morphine ER (Avinza) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30morphine/naltrexone (Embeda) . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60nabilone (Cesamet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14/cyclenaproxen/esomeprazole (Vimovo) . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30naratriptan (Amerge) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18nilotinib (Tasigna) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120Norelgestromin 6 mg/ethinyl estradiol 0.75 mg patch(Xulane) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3omega-3 acid ethyl esters (Lovaza) . . . . . . . . . . . . . . . . . . . .Hypertriglyceremia . . . . . . . . . . . . . . . . . .120omega-3 acid ethyl esters (Lovaza) . . . . . . . . . . . . . . . . . . . .Secondary prevention post-MI . . . . . . . . .30omeprazole (Prilosec, Prilosec OTC) . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90omeprazole/amoxacillin/clarithromycin (Omeclamox-Pak) . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30omeprazole/sodium bicarb (Zegerid) . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30ondansetron (Zofran, Zofran ODT) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30oprelvekin (Neumega) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21/cycleoseltamivir (Tamiflu) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10/prescriptionoxybutynin transdermal patch (Oxytrol) . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10oxybutynin XL (Ditropan XL) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30oxycodone ER (Oxycontin) . . . . . . . . . . . . . . . . . . . . . . . . . . .10 mg, 15 mg, 20 mg, 30 mg, 40 mg . . .90oxycodone ER (Oxycontin) . . . . . . . . . . . . . . . . . . . . . . . . . . .60 mg, 80 mg . . . . . . . . . . . . . . . . . . . .150oxymorphone ER (Opana ER) . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60pantoprazole (Protonix) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60PEG/electrolytes/sodium ascorbate (MoviPrep) . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1/prescriptionpegfilgrastim (Neulasta) . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 dose/prescriptionpegylated interferon (Peg-Intron, Pegasys) . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 dosespitavastatin (Livalo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30pramipexole (Mirapex ER) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30pregabalin (Lyrica) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90rabeprazole (Aciphex, Aciphex Sprinkles) . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30ramelteon (Rozerem) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30rasagiline (Azilect) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30rifaximin (Xifaxan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200 mg . . . . . . . . . . . . . . . . . . . . . . . . .5/day (course varies)riociguat (Adempas) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90risedronate (Actonel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 mg . . . . . . . . . . . . . . . . . . . . . . . . . .4risedronate (Actonel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 mg . . . . . . . . . . . . . . . . . . . . . . . . . .2risedronate (Actonel, Atelvia) . . . . . . . . . . . . . . . . . . . . . . . . .150 mg . . . . . . . . . . . . . . . . . . . . . . . . .1rizatriptan (Maxalt, Maxalt MLT) . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18rosuvastatin (Crestor) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30saxagliptin (Onglyza) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30scopolamine patch (Transderm Scop) . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10selegiline patch (Emsam) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30short ragweed pollen (Ragwitek) . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30simeprevir (Olysio) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30simvastatin (Zocor) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 mg . . . . . . . . . . . . . . . . . . . . . . . . . .45simvastatin (Zocor) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 mg . . . . . . . . . . . . . . . . . . . . . . . . . .30simvastatin/ezetimibe (Vytorin) . . . . . . . . . . . . . . . . . . . . . .40/10 mg, 80/10 mg . . . . . . . . . . . . . .30simvastatin/niacin (Simcor) . . . . . . . . . . . . . . . . . . . . . . . . . .40/500 mg, 40/1000 mg . . . . . . . . . . .30sitagliptan (Januvia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30* Represents # of tablets, capsules, or doses allowed per 30 day period unless stated otherwise346-16-14

Appendix A: Medication Quantity Limit InformationMedication Name (Brand) Dose(s)/Indication Quantity Limit*sitagliptan/simvastatin (Juvisync) . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30sofosbuvir (Sovaldi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30solifenacin (Vesicare) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30sumatriptan (Imitrex) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18sumatriptan injection (Imitrex, Sumavel DosePro) . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18sumatriptan nasal (Imitrex) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12sumatriptan/naproxen (Treximet) . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12tadalafil (Cialis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30tapentadol (Nucynta) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90tapentadol ER (Nucynta ER) . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60tasimelteon (Hetlioz) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30telithromycin (Ketek) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20/prescriptiontemozolomide (Temodar) . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30/prescriptionteriflunomide (Aubagio) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30teriparatide (Forteo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 pen (3 ml)timothy grass pollen (Grastek) . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30tocilizumab (Actemra) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2tolterodine LA (Detrol LA) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30tramadol ER (generics, Ryzolt ER, Ultram ER) . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30treprostinil diolamine (Orenitram ER) . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90ulipristal (Ella) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1ustekinumab (Stelara) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1/12 weeksvilazodone HCl (Viibryd) . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30vortioxetine (Brintellix) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30zanamivir (Relenza) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 inhaler/prescriptionzolmitriptan (Zomig) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12zolmitriptan nasal (Zomig) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12zolpidem (Ambien, Edluar) . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45zolpidem CR (Ambien CR) . . . . . . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30zolpidem sublingual (Intermezzo) . . . . . . . . . . . . . . . . . . . . . .all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20* Represents # of tablets, capsules, or doses allowed per 30 day period unless stated otherwise356-16-14

abacavir......................................................................................18abacavir/lamivudine ..................................................................18abacavir/lamivudine/zidovudine ................................................18abacavir suspension....................................................................18abatacept ......................................................................20, 31, 32Abilify ..................................................................................20, 32Abilify Discmelt ..........................................................................20abiraterone ................................................................................19abobotulinum toxin ....................................................................31Absorica......................................................................................25Abstral ..................................................................................24, 33acamprosate ..............................................................................20Acanya ........................................................................................25acarbose ....................................................................................10Accolate see zafirlukast ..............................................................30Accu-Chek ..................................................................................11Accupril see quinapril....................................................................7Accuretic see quinapril/HCTZ ........................................................7Accutane see isotretinoin ............................................................25acebutolol ....................................................................................7Aceon see perindopril ..................................................................7acetaminophen/butalbital ..........................................................23acetaminophen/butalbital/caffeine ............................................23acetaminophen/butalbital/caffeine/codeine ..............................23acetaminophen/codeine ............................................................24acetaminophen/dichloralphenazone/isometheptene ..................23acetaminophen/dihydrocodeine/caffeine....................................23acetaminophen/hydrocodone......................................................24acetaminophen/oxycodone ..................................................24, 32acetaminophen/oxycodone ER..............................................24, 32acetaminophen/phenyltolxamine ................................................24acetazolamide ............................................................................29acetic acid ..................................................................................16acetic acid/hydrocortisone..........................................................16acetylcysteine ............................................................................30Achromycin see tetracycline..................................................17, 27Aciphex see rabeprazole tab ......................................................27Aciphex Sprinkles..................................................................27, 34acitretin ......................................................................................27aclidinium bromide ....................................................................30Aclovate cream, ointment see alclometasone..............................26Actemra..........................................................................20, 31, 35Acthar HP....................................................................................14Actigall see ursodiol....................................................................28Actimmune..................................................................................17Actiq ....................................................................................24, 33Activella see estradiol/norethindrone tab ....................................14Actonel ................................................................................11, 34Actoplus Met see pioglitazone/metformin ..................................10Actoplus Met XR..........................................................................10Actos see pioglitazone ..........................................................10, 32Acular see ketorolac ......................................................15, 24, 33Acular LS see ketorolac ..................................................15, 24, 33INDEXAcuNeb see albuterol............................................................29, 30Acuvail ........................................................................................15acyclovir oral ..............................................................................18acyclovir topical ....................................................................18, 26acyclovir/hydrocortisone ............................................................26acyclovir/lidocaine......................................................................26Aczone ........................................................................................25Adalat CC see nifedipine ER..........................................................8adalimumab ............................................................20, 27, 28, 32adapalene cream, gel..................................................................25adapalene lotion ........................................................................25adapalene/benzoyl peroxide ......................................................25Adcirca..........................................................................................9Adderall see amphetamine-dextroamphetamine combo ..............21Adderall XR see amphetamine-dextroamphetamine ER combo....21adefovir ......................................................................................18Adempas ................................................................................9, 34Adoxa see doxycycline monohydrate ....................................17, 25Advair..........................................................................................29Advicor........................................................................................11Aerospan ....................................................................................29afatinib ................................................................................19, 32Afeditab see nifedipine ER ............................................................8Afinitor ........................................................................................19Afinitor Disperz............................................................................19Aggrenox ......................................................................................9Agrylin see anagrelide ..................................................................9AK-Con see naphazoline ............................................................15Akne-mycin ................................................................................25AK-Poly-Bac see bacitracin/polymyxin B ....................................15albendazole ................................................................................17Albenza ......................................................................................17albuterol HFA ..............................................................................29albuterol nebulizer solution ........................................................29albuterol tabs..............................................................................30albuterol-ipratropium inhaler ......................................................29albuterol-ipratropium nebulizer solution ......................................29alcaftadine..................................................................................15Alcaine see proparacaine ophthalmic..........................................16alclometasone ............................................................................26Aldactazide see spironolactone/HCTZ............................................8Aldactone see spironolactone ......................................................8Aldara see imiquimod ................................................................26alendronate ..........................................................................11, 32alendronate/cholecalciferol ..................................................11, 32alendronate effervescent ............................................................11Alferon ........................................................................................17alfuzosin ....................................................................................28alglucosidase alfa ......................................................................31Alinia ..........................................................................................17aliskiren ..............................................................................8, 9, 32aliskiren/amlodipine ..........................................................8, 9, 32aliskiren/amlodipine/HCTZ ....................................................9, 326-16-1436

aliskiren/HCTZ ..............................................................................9Alkeran........................................................................................19allopurinol ..................................................................................19almotriptan ..........................................................................23, 32Alocril..........................................................................................15Alodox kit....................................................................................15alogliptin ..............................................................................10, 32alogliptin/metformin ..................................................................10alogliptin/pioglitazone ..........................................................10, 32Alomide ......................................................................................15Alora ....................................................................................14, 33alosetron ..............................................................................28, 32Alphagan see brimonidine ....................................................15, 26Alphagan P see brimonidine ................................................15, 26alprazolam ..................................................................................22alprazolam ER ............................................................................22Alrex............................................................................................15Altabax........................................................................................26Altace see ramipril ......................................................................7Altafluor ......................................................................................16Altavera ......................................................................................13Altoprev ................................................................................11, 33Alvesco ......................................................................................29Alyacen 1/35..............................................................................13Alyacen 777................................................................................12amantadine ..........................................................................18, 25Amaryl see glimepiride................................................................10Ambien see zolpidem............................................................22, 35Ambien CR see zolpidem CR ................................................22, 35ambrisentan..................................................................................9amcinonide ................................................................................27Amerge see naratriptan ........................................................23, 34Amethia ......................................................................................12Amethia Lo..................................................................................12Amethyst ....................................................................................13Amicar see aminocaproic acid ......................................................9amiloride ......................................................................................8amiloride/HCTZ ............................................................................8aminocaproic acid ........................................................................9amiodarone ..................................................................................8Amitiza..................................................................................28, 33amitriptyline..........................................................................20, 21amitriptyline/perphenazine..........................................................20amlexanox ..................................................................................26amlodipine ....................................................................7-9, 11, 32amlodipine/atorvastatin....................................................8, 11, 32amlodipine/olmesartan ............................................................7, 8amlodipine/olmesartan/HCTZ ......................................................7amlodipine/telmisartan ............................................................7, 8amlodipine/valsartan ................................................................7, 8amlodipine/valsartan/HCTZ ......................................................7, 8ammonium lactate 12%..............................................................26Amnesteem ................................................................................25INDEXamoxapine ..................................................................................21amoxicillin ......................................................................16, 27, 33amoxicillin ER..............................................................................16amoxicillin/clavulanate ..............................................................16amoxicillin/clavulanate ER ..........................................................16amoxicillin/clavulanate ES ..........................................................16amphetamine-dextroamphetamine combo ..................................21amphetamine-dextroamphetamine ER combo ............................21amphotericin ..............................................................................17ampicillin ....................................................................................16Ampyra ......................................................................................20Amrix ..........................................................................................23Amturnide ..............................................................................9, 32Anafranil see clomipramine ........................................................21anagrelide ....................................................................................9anakinra ..............................................................................20, 32Anaprox see naproxen sodium ....................................................24Anaprox DS see naproxen sodium ..............................................24Anaspaz see hyoscyamine ..........................................................28anastrozole ................................................................................19Ancobon see flucytosine ............................................................17Androderm..................................................................................14Androgel......................................................................................14Androgel pump............................................................................14Android ......................................................................................14Androxy ......................................................................................14Angeliq........................................................................................14Anoro Ellipta ..............................................................................30Ansaid see flurbiprofen ........................................................15, 24Antabuse see disulfiram..............................................................20Antara see fenofibrate ................................................................11antipyrine/benzocaine ................................................................16antipyrine/benzocaine/zinc ........................................................16Anzemet................................................................................27, 32Apexicon see diflorasone ............................................................27Aphthasol....................................................................................26Apidra vial ..................................................................................10Apidra Solostar pen ....................................................................10apixaban ......................................................................................9Aplenzin................................................................................21, 32Apokyn........................................................................................25apomorphine ..............................................................................25apraclonidine 0.5% ....................................................................15apraclonidine 1%........................................................................15apremilast ............................................................................20, 32aprepitant ............................................................................27, 32Apresazide see hydralazine/HCTZ ..............................................8, 9Apresoline see hydralazine ........................................................8, 9Apri ............................................................................................13Apriso ........................................................................................28Aptiom ........................................................................................22Aptivus........................................................................................18Aralen see chloroquine................................................................176-16-1437

Aranelle ......................................................................................12Aranesp ........................................................................................9Arava see leflunomide ................................................................19Arcalyst ......................................................................................31Arcapta ......................................................................................29arformoterol inhaler ....................................................................29Aricept see donepezil..................................................................22Arimidex see anastrozole ............................................................19aripiprazole ..........................................................................20, 32aripiprazole ODT..........................................................................20Aristocort ....................................................................................19Arixtra see fondaparinux................................................................9armodafinil ..........................................................................21, 32Armour Thyroid ............................................................................14Aromasin see exemestane ..........................................................19Artane see trihexyphenidyl ..........................................................25artemether/lumefantrine ............................................................17Arthrotec see diclofenac/misoprostol..........................................24Asacol HD ..................................................................................28Ascensia ....................................................................................11Asendin see amoxapine ..............................................................21Asmanex ....................................................................................29aspirin/butalbital/caffeine ..........................................................23aspirin/dihydrocodeine/caffeine ................................................23aspirin/dipyridamole ....................................................................9Astagraf XL..................................................................................19Astelin see azelastine nasal antihistamine spray ........................29Astepro ......................................................................................29Atacand see candesartan..............................................................7Atacand HCT see candesartan/HCTZ ............................................7Atarax see hydroxyzine ................................................................29atazanavir ..................................................................................18Atelvia ..................................................................................11, 34atenolol ........................................................................................7atenolol/chlorthalidone ................................................................7Ativan see lorazepam ..................................................................22atomoxetine ................................................................................21atorvastatin ......................................................................8, 11, 32atovaquone ................................................................................17atovaquone/proquanil ................................................................17Atralin ........................................................................................25Atridox ........................................................................................17Atripla ........................................................................................18atropine ................................................................................16, 28atropine/hyoscyamine/phenobarbital/scopolamine ....................28Atrovent HFA................................................................................30Atrovent nasal see ipratropium..............................................29, 30Aubagio ................................................................................20, 35Aubra..........................................................................................13augmented betamethasone diproprionate ..................................27Augmentin ES see amoxicillin/clavulanate ES ............................16Augmentin XR see amoxicillin/clavulanate ER ............................16Auralgan see antipyrine/benzocaine............................................16INDEXauranofin ....................................................................................19Auvi-Q ........................................................................................30Avalide see irbesartan/HCTZ ........................................................7Avandamet..................................................................................10Avandaryl....................................................................................10Avandia ......................................................................................10Avapro see irbesartan....................................................................7Avar ............................................................................................25Avar LS ......................................................................................25AVC ............................................................................................26Avelox see moxifloxacin ........................................................15, 16Aviane ........................................................................................13Avinza see morphine ER capsule ................................................24Aviva ..........................................................................................11Avodart ......................................................................................28Avonex ........................................................................................20Axert ....................................................................................23, 32Axid see nizatidine ......................................................................27Axid ............................................................................................27Axiron..........................................................................................14axitinib........................................................................................19Aygestin see norethindrone tab ..................................................14Azasan ........................................................................................19Azasite ........................................................................................15azathioprine ................................................................................19azelaic acid ................................................................................25azelaic acid/ceramide ................................................................25azelastine ............................................................................15, 29azelastine/fluticasone nasal........................................................29azelastine nasal antihistamine spray ..........................................29Azelex ........................................................................................25Azilect ..................................................................................25, 34azilsartan ..............................................................................7, 32azilsartan/chlorthalidone ........................................................7, 32azithromycin ..................................................................15, 16, 32Azopt ..........................................................................................15Azor ..........................................................................................7, 8aztreonam lysine ........................................................................30Azulfidine see sulfasalazine ..................................................19, 28Azurette ......................................................................................12bacitracin....................................................................................15baclofen......................................................................................23Bactrim see trimethoprim/sulfa ..................................................17Bactroban see mupirocin ............................................................26Bactroban Nasal ........................................................................26balsalazide..................................................................................28Balziva ........................................................................................13Banzel ........................................................................................22Baraclude ..................................................................................18beclomethasone inhaler..............................................................29beclomethasone nasal ................................................................29Beconase AQ ..............................................................................29bedaquiline ................................................................................176-16-1438

enazepril ................................................................................7, 8benazepril/amlodipine ..............................................................7, 8benazepril/HCTZ............................................................................7Bencort ......................................................................................25Benicar ........................................................................................7Benicar HCT ..................................................................................7benoxinate/fluorescein................................................................16Bentyl see dicyclomine................................................................28Benzaclin see clindamycin/benzoyl peroxide ..............................25Benzamycin see benzoyl peroxide/erythromycin..........................25Benziq see benzoyl peroxide/aloe vera........................................25benzonatate ................................................................................29benzyl alcohol topical..................................................................26benzoyl peroxide ........................................................................25benzoyl peroxide/aloe vera..........................................................25benzoyl peroxide/cleanser kit......................................................25benzoyl peroxide/erythromycin....................................................25benzoyl peroxide/hydrocortisone ................................................25benzoyl peroxide/sulfur ..............................................................25benzoyl peroxide/urea ................................................................25benztropine ................................................................................25bepostastine ..............................................................................15Bepreve ......................................................................................15besifloxacin ................................................................................15Besivance ..................................................................................15Betagan see levobunolol ............................................................15betamethasone dipropionate ......................................................27betamethasone valerate..............................................................27betamethasone/calcipotriene ..............................................26, 27Betapace see sotalol ....................................................................7Betapace AF see sotalol AF ..........................................................7Betaseron ..................................................................................20betaxolol ................................................................................7, 15bethanechol................................................................................28Bethkis........................................................................................30Betimol see timolol ................................................................7, 15Betoptic S ..................................................................................15bexarotene..................................................................................19Beyaz ..........................................................................................13Biaxin suspension ......................................................................16Biaxin XL see clarithromycin ER ..................................................16bicalutamide ..............................................................................19Bicitra ........................................................................................12BiDil..............................................................................................9Biltricide......................................................................................17bimatoprost ................................................................................15Binosto ................................................................................11, 32biskalcitrate/metronidazole/tetracycline......................................27bisoprolol......................................................................................7bisoprolol/HCTZ ............................................................................7Bleph-10 see sulfacetamide ophthalmic ....................................15Blephamide ................................................................................15Blocadren see timolol ............................................................7, 15INDEXboceprevir ..................................................................................18Boniva see ibandronate ........................................................11, 33bosentan ......................................................................................9Bosulif ........................................................................................19bosutinib ....................................................................................19Botox ..........................................................................................31Breeze 2 ....................................................................................11Breo Ellipta ................................................................................29Brethine see terbutaline ..............................................................30Brevicon......................................................................................13Brevoxyl ......................................................................................25Briellyn........................................................................................13Brilinta ..........................................................................................9brimonidine ..........................................................................15, 26brimonidine 0.1% ......................................................................15brimonidine gel ..........................................................................26brimonidine/brinzolamide ..........................................................15brimonidine/timolol ....................................................................15Brintellix................................................................................21, 35brinzolamide ..............................................................................15Brisdelle......................................................................................29Bromday see bromfenac ............................................................15bromfenac ..................................................................................15bromocriptine ......................................................................14, 25Brovana ......................................................................................29Budeprion XL see bupropion XL ............................................21, 32budesonide nasal ......................................................................29budesonide nebulizer solution ....................................................29budesonide oral....................................................................28, 32budesonide-formoterol inhaler ....................................................29bumetanide ..................................................................................8Bumex see bumetanide ................................................................8Buphenyl ....................................................................................29buprenorphine ......................................................................20, 24buprenorphine patch ..................................................................24buprenorphine/naloxone sublingual film ....................................20buprenorphine/naloxone sublingual tab......................................20Buproban see bupropion ................................................20, 21, 32bupropion ......................................................................20, 21, 32bupropion hbr ............................................................................21bupropion SR........................................................................20, 21bupropion XL 150/300 mg ........................................................21bupropion XL 450 mg ................................................................21Buspar see buspirone ................................................................22buspirone....................................................................................22busulfan......................................................................................19butenafine ..................................................................................26butoconazole ............................................................................26butorphanol nasal spray........................................................23, 32Butrans ......................................................................................24Bydureon ....................................................................................10Byetta ........................................................................................10Bystolic ........................................................................................76-16-1439

cabergoline ................................................................................14cabozantinib ..............................................................................19Caduet see amlodipine/atorvastatin ................................8, 11, 32Cafergot ......................................................................................23Calan see verapamil..................................................................7, 8Calan SR see verapamil ............................................................7, 8calcipotriene cream ....................................................................26calcipotriene foam ......................................................................26calcipotriene ointment ................................................................26calcitonin nasal ..........................................................................11Calcitrene....................................................................................26calcitriol oral ..............................................................................11calcitriol topical ..........................................................................26calcium acetate ..........................................................................12calcium acetate soln ..................................................................12Cambia ......................................................................................24Camila ........................................................................................13Campral see acamprosate ..........................................................20Camrese ....................................................................................12Camrese Lo ................................................................................12canagliflozin..........................................................................10, 32canakinumab ..............................................................................31Canasa ......................................................................................28candesartan..................................................................................7candesartan/HCTZ ........................................................................7Cantil ..........................................................................................27capecitabine ..............................................................................19Capex..........................................................................................27Capoten see captopril ..................................................................7Capozide see captopril/HCTZ ........................................................7Caprelsa ....................................................................................19captopril........................................................................................7captopril/HCTZ ..............................................................................7Carac ..........................................................................................26Carafate see sucralfate ........................................................27, 29carbachol....................................................................................15Carbaglu ....................................................................................29carbamazepine............................................................................22carbamazepine SR ......................................................................22Carbatrol ....................................................................................22carbidopa ..................................................................................25carbidopa/levodopa....................................................................25carbidopa/levodopa CR ..............................................................25carbidopa/levodopa/entacapone................................................25carbinoxamine ............................................................................29Cardene see nicardipine................................................................8Cardene SR ..................................................................................8Cardizem see diltiazem..................................................................8Cardizem CD see diltiazem ER (24H) ............................................8Cardizem LA see diltiazem LA........................................................8Cardizem SR see diltiazem ER (12H) ............................................8Cardura see doxazosin ............................................................8, 28Cardura XL ....................................................................................8INDEXcarglumic acid ..........................................................................29carisoprodol................................................................................23carisoprodol/aspirin....................................................................23Carnitor ......................................................................................12carteolol......................................................................................15carvedilol ................................................................................7, 32carvedilol CR ..........................................................................7, 32Casodex see bicalutamide ..........................................................19Cataflam see diclofenac potassium ............................................24Catapres see clonidine............................................................8, 21Catapres TTS see clonidine patch..................................................8Cayston ................................................................................30, 32Caziant........................................................................................12Cedax see ceftibuten ..................................................................16CeeNU see lomustine..................................................................19cefaclor ......................................................................................16cefadroxil ....................................................................................16cefdinir........................................................................................16cefditoren....................................................................................16cefixime ......................................................................................16cefpodoxime ..............................................................................16cefprozil ......................................................................................16ceftibuten....................................................................................16Ceftin ..........................................................................................16cefuroxime ..................................................................................16Cefzil ..........................................................................................16Celebrex................................................................................24, 32celecoxib ..............................................................................24, 32Celexa see citalopram ................................................................21Cellcept see mycophenolate ......................................................19Celontin ......................................................................................22Cenestin..................................................................................3, 14cephalexin ..................................................................................16ceritinib ......................................................................................19certolizumab ..................................................................20, 28, 32Cervarix ......................................................................................31Cesamet ..............................................................................27, 34Cetany see mupirocin..................................................................26Cetraxal see ciprofloxacin otic ....................................................16cevimeline ..................................................................................29Chantix........................................................................................20Chateal ......................................................................................13Chenodal ....................................................................................28chenodiol....................................................................................28chlorambucil ..............................................................................19chlordiazepoxide ..................................................................22, 28chlordiazepoxide/clindium ..........................................................28chlorhexidine ..............................................................................17chloroquine ................................................................................17chloroxylenol/benzoc/hydrocortisone ........................................16chlorpromazine............................................................................20chlorpropamide ..........................................................................10chlorthalidone ....................................................................7, 8, 326-16-1440

chlorzoxazone..............................................................................23cholestyramine............................................................................11cholestyramine light ....................................................................11Cialis ....................................................................................28, 35ciclesonide inhaled ....................................................................29ciclesonide nasal ........................................................................29ciclopirox ....................................................................................26ciclopirox nail lacquer ................................................................26ciclopirox nail lacquer/nail lacquer remover kit ..........................26cilostazol ......................................................................................9Ciloxan........................................................................................15Ciloxan see ciprofloxacin ......................................................15, 16cimetidine ..................................................................................27Cimzia ............................................................................20, 28, 32cinacalcet ..................................................................................11Cipro HC ....................................................................................16Cipro XR see ciprofloxacin XR......................................................16Ciprodex......................................................................................16ciprofloxacin ........................................................................15, 16ciprofloxacin drops......................................................................15ciprofloxacin ointment ................................................................15ciprofloxacin otic ........................................................................16ciprofloxacin XR ..........................................................................16ciprofloxacin/dexamethasone......................................................16ciprofloxacin/hydrocortisone ......................................................16citalopram ..................................................................................21citric acid/sodium citrate ............................................................12Claravis see isotretinoin ..............................................................25Claravis ......................................................................................25Clarifoam see sulfacetamide/sulfur 10%/5% cream, cleanser,medicated pads, foam, lotion, suspension............................25Clarinex see desloratadine ..........................................................29Clarinex D ..................................................................................29clarithromycin ..........................................................16, 27, 33, 34clarithromycin ER ........................................................................16Cleocin see clindamycin ................................................17, 25, 26Cleocin capsules see clindamycin capsules ................................17Cleocin granules..........................................................................17Climara see estradiol weekly patch ............................................14ClimaraPro............................................................................14, 33Clindagel ....................................................................................25Clindamax see clindamycin ............................................17, 25, 26clindamycin ....................................................................17, 25, 26clindamycin capsules..................................................................17clindamycin gel ..........................................................................25clindamycin granules ..................................................................17clindamycin kit............................................................................25clindamycin/benzoyl peroxide ....................................................25clindamycin/tretinoin ..................................................................25Clindareach ................................................................................25Clinoril see sulindac....................................................................24clobazam ....................................................................................22clobetasol foam ..........................................................................27INDEXclobetasol topical........................................................................27clobetasol spray..........................................................................27Clobex see clobetasol topical......................................................27clocortolone ................................................................................27Cloderm see clocortolone............................................................27clofazamine ................................................................................17Clomid see clomiphene ..............................................................14clomiphene ................................................................................14clomipramine ..............................................................................21clonazepam ................................................................................22clonazepam ODT ........................................................................22clonidine ................................................................................8, 21clonidine patch ............................................................................8clonidine SR................................................................................21clonidine/chlorthalidone ..............................................................8clopidogrel ....................................................................................9clorazepate ................................................................................22clorazepate ER ............................................................................22Clorpres see clonidine/chlorthalidone ..........................................8clotrimazole ..........................................................................17, 26clotrimazole troche......................................................................17clotrimazole/betamethasone cream ............................................26clotrimazole/betamethasone lotion ............................................26clozapine ....................................................................................20clozapine ODT ............................................................................20clozapine suspension..................................................................20Clozaril see clozapine..................................................................20Clozaril........................................................................................20CNL 8 see ciclopirox nail lacquer/nail lacquer remover kit ..........26Coartem......................................................................................17codeine ................................................................................23, 24Cogentin see benztropine ............................................................25Colazal see balsalazide ..............................................................28colchicine....................................................................................19Colcrys........................................................................................19colesevelam ................................................................................11Colestid see colestipol ................................................................11Colestid ......................................................................................11colestipol ....................................................................................11colistimethate for inhalation........................................................30Coly-mycin ..................................................................................30Colyte ........................................................................................28Combigan....................................................................................15Combipatch ..........................................................................14, 33Combivent ..................................................................................29Combivir see lamivudine/zidovudine ..........................................18Combunox see ibuprofen/oxycodone ..........................................24Cometriq ....................................................................................19Compazine see prochlorperazine ................................................27Compazine..................................................................................27Complera ....................................................................................18compounded hormones ..............................................................14Comtan see entacapone ............................................................256-16-1441

Concerta see methylphenidate ER ..............................................21Condylox ....................................................................................26conjugated estrogen cream ........................................................14conjugated estrogens/bazedoxifene ......................................11, 14conjugated estrogens tab ............................................................14conjugated estrogens/medroxyprogesterone tab..........................14Constulose..................................................................................28Contour ......................................................................................11Contour Next ..............................................................................11Conzip ........................................................................................24Copaxone....................................................................................20Copegus see ribavirin..................................................................18Cordarone ....................................................................................8Cordran ......................................................................................27Cordran SP..................................................................................27Coreg see carvedilol................................................................7, 32Coreg CR ................................................................................7, 32Corgard see nadolol ......................................................................7Cortef see hydrocortisone ............................15, 16, 19, 24-26, 28Cortenema see hydrocortisone rectal ..........................................28corticotropin gel ..........................................................................14Cortifoam....................................................................................28Cortisporin see neomycin/polymyxin/hydrocortisone ............15, 16Cortisporin Otic see neomycin/polymyxin/hydrocortisone otic ....16Cosopt see dorzolamide/timolol..................................................15Cosopt PF ..................................................................................15Cotrim ........................................................................................17Coumadin ....................................................................................9Covaryx ......................................................................................14Cozaar see losartan ......................................................................7Creon..........................................................................................28Crestor..................................................................................11, 34Crinone ......................................................................................14Crixivan ......................................................................................18crizotinib ....................................................................................19Crnatal........................................................................................12crofelemer ..................................................................................28cromolyn ........................................................................15, 29, 30cromolyn nebulizer solution ........................................................30crotamiton ..................................................................................26Cryselle ......................................................................................13Cuprimine ..................................................................................19Cutivate cream and ointment see fluticasone........................27, 29Cuvposa......................................................................................29cyanocobalamin/folic acid/pyridoxine ........................................12Cyclafem 1/35 ..........................................................................13Cyclafem 777 ............................................................................12Cyclessa see Velivet ....................................................................12cyclobenzaprine ..........................................................................23cyclobenzaprine ER ....................................................................23Cyclogyl see cyclopentolate ........................................................16cyclopentolate ............................................................................16cyclophosphamide ......................................................................19INDEXcycloserine..................................................................................17Cycloset ......................................................................................14cyclosporine..........................................................................16, 19cyclosporine modified ................................................................19Cymbalta see duloxetine ............................................................21cyproheptadine ..........................................................................29Cystagon ....................................................................................29Cystaran......................................................................................16cysteamine ..........................................................................16, 29cysteamine bitartrate ..................................................................29Cystex ........................................................................................17Cystospaz see hyoscyamine ........................................................28Cytomel see liothyronine ............................................................14Cytotec see misoprostol........................................................24, 27Cytoxan see cyclophosphamide ..................................................19dabigatran ............................................................................9, 32dabrafenib ..................................................................................19dalfampridine..............................................................................20Daliresp ......................................................................................30Dalmane see flurazepam ............................................................22dalteparin......................................................................................9danazol ......................................................................................14Danocrine see danazol................................................................14dantrolene ..................................................................................23dapagliflozin ........................................................................10, 32dapsone ..............................................................................17, 25dapsone topical ..........................................................................25Daraprim ....................................................................................17darbepoetin ..................................................................................9darifenacin............................................................................28, 32darunavir ....................................................................................18dasatinib ....................................................................................19Dasetta 1/35..............................................................................13Dasetta 777 ..............................................................................12Daypro see oxaprozin ..................................................................24Daysee........................................................................................12Daytrana ..............................................................................21, 33DDAVP ........................................................................................14Decadron see dexamethasone..................................15, 16, 19, 26Declomycin ................................................................................17deferasirox ..................................................................................12deferiprone....................................................................................9degarelix acetate ........................................................................14Delatestryl see testosterone enanthate injection ........................14delavirdine ..................................................................................18Delzicol ......................................................................................28Demadex see torsemide................................................................8demeclocycline ..........................................................................17Demulen 1/35 see Zovia 1/35, Kelnor 1/35..............................13Demulen 1/50 see Zovia 1/50 ..................................................13Denavir ......................................................................................26denosumab ................................................................................31Depakene ..................................................................................226-16-1442

Depakote ....................................................................................22Depen ........................................................................................19Depo-Testosterone see testosterone cypionate injection..............14Derma-Smoothe/FS....................................................................27Dermatop see prednicarbate ......................................................27DermOtic ....................................................................................16desipramine................................................................................21desloratadine..............................................................................29desloratadine/pseudoephedrine ................................................29desmopressin..............................................................................14desmopressin nasal ....................................................................14Desogen see Apri ........................................................................13Desonate ....................................................................................26desonide topical cream/ointment ..............................................26desonide topical gel/lotion/foam................................................26Desowen cream and ointment see desonide topical....................26desoximetasone cream/gel/ointment..........................................27desoximetasone spray ................................................................27Desoxyn see methamphetamine..................................................21Desquam ....................................................................................25desvenlafaxine ......................................................................21, 32Desvenlafaxine ER see desvenlafaxine ..................................21, 32Desvenlafaxine Fumarate ER ................................................21, 32Desyrel see trazodone ................................................................21Detrol see tolterodine ..........................................................28, 35Detrol LA see tolterodine ER........................................................28dexamethasone........................................................15, 16, 19, 26Dexedrine see dextroamphetamine..............................................21dexlansoprazole ....................................................................27, 32dexmethylphenidate ....................................................................21dexmethylphenidate XR ..............................................................21dextroamphetamine ....................................................................21dextromethorphan/quinidine ......................................................22DHE ............................................................................................23Diabinase see chlorpropamide....................................................10Diamox see acetazolamide..........................................................29Diamox Sequels see acetazolamide ............................................29Diastat see diazepam rectal........................................................22diazepam ....................................................................................22diazepam rectal ..........................................................................22Dibenzyline....................................................................................9Diclegis ......................................................................................27diclofenac ............................................................................15, 24diclofenac epolamine patch ........................................................24diclofenac gel..............................................................................24diclofenac potassium ..................................................................24diclofenac sodium ......................................................................24diclofenac submicronized............................................................24diclofenac/misoprostol ..............................................................24dicloxacillin ................................................................................16dicyclomine ................................................................................28didanosine..................................................................................18Didronel see etidronate ..............................................................11INDEXdifenoxin/atropine ......................................................................28Differin see adapalene ................................................................25Dificid ..................................................................................17, 33diflorasone..................................................................................27Diflucan see fluconazole ............................................................17diflunisal ....................................................................................24difluprednate ..............................................................................15Digex NF......................................................................................28Digitek ..........................................................................................8digoxin ..........................................................................................8dihydroergotamine injection ........................................................23dihydroergotamine nasal ............................................................23Dilacor XR see diltiazem ER (24H) ................................................8Dilantin ......................................................................................22Dilaudid see hydromorphone ......................................................24diltiazem ......................................................................................8diltiazem ER (12H)........................................................................8diltiazem ER (24H)........................................................................8dimethyl fumarate ................................................................20, 32Diovan ..........................................................................................7Diovan HCT see valsartan/HCTZ ................................................7, 8Dipentum....................................................................................28diphenoxylate/atropine ..............................................................28Diprolene see betamethasone ..............................................26, 27Diprolene AF see augmented betamethasone..............................27dipyridamole ................................................................................9Disalcid see salsalate ................................................................24disopyramide ................................................................................8disopyramide ER ..........................................................................8disulfiram....................................................................................20Ditropan see oxybutynin........................................................28, 34Ditropan XL see oxybutynin XL ..............................................28, 34Diuril see chlorthiazide ..................................................................8divalproex sodium ......................................................................22divalproex sodium ER..................................................................22Divigel ........................................................................................14dofetilide ......................................................................................8dolasetron ............................................................................27, 32Dolobid see diflunisal..................................................................24Dolophine see methadone....................................................20, 24dolutegravir ................................................................................18donepezil ....................................................................................22Donnatal seeatropine/hyoscyamine/phenobarbital/scopolamine..............28Doral see quazepam ..................................................................22dornase alfa ........................................................................30, 32Doryx see doxycycline hyclate ..............................................17, 25dorzolamide ................................................................................15dorzolamide/timolol....................................................................15dorzolamide/timolol PF ..............................................................15Dostinex see cabergoline ............................................................14Dostinex......................................................................................14Dovonex see calcipotriene cream ................................................266-16-1443

doxazosin................................................................................8, 28doxazosin ER ................................................................................8doxepin ..........................................................................21, 22, 26doxercalciferol ............................................................................11doxycycline ....................................................................15, 17, 25doxylamine ..........................................................................27, 29doxylamine/pyridoxine ................................................................27Doxytex ......................................................................................29Drisdol see ergocalciferol ............................................................11dronabinol ..................................................................................27dronedarone..................................................................................8Droxia ........................................................................................19Duac see clindamycin/benzoyl peroxide......................................25Duavee ................................................................................11, 14Duet DHA Balanced ....................................................................12DuetAct see pioglitazone/glimepiride ..........................................10Duexis ........................................................................................27Dulera ........................................................................................29duloxetine ..................................................................................21Duragesic see fentanyl patch ......................................................24Durasal ......................................................................................25Durezol........................................................................................15dutasteride..................................................................................28dutasteride/tamsulosin ..............................................................28Dutoprol..................................................................................7, 33Dyazide see triamterene/HCTZ ......................................................8Dymista ......................................................................................29Dynacirc CR see isradipine............................................................8Dynapen see dicloxacillin............................................................16dyphylline....................................................................................30Dyrenium see triamterene ............................................................8Dyrenium ......................................................................................8Dysport ......................................................................................31echothiophate ............................................................................15EC-Naprosyn see naproxen ER ....................................................24econazole cream ........................................................................26econazole foam ..........................................................................26Ecoza ..........................................................................................26eculizumab..................................................................................31Edarbi ....................................................................................7, 32Edarbyclor ..............................................................................7, 32Edecrin..........................................................................................8Edluar ..................................................................................22, 35Edurant ......................................................................................18EEMT ..........................................................................................14efavirenz......................................................................................18efavirenz/emtricitabine/tenofovir ................................................18Effexor see venlafaxine IR............................................................21Effexor XR see venlafaxine SR capsules ......................................21Effient ..........................................................................................9Efudex see fluorouracil ................................................................26Elavil see amitriptyline ..........................................................20, 21Eldepryl see selegiline ....................................................21, 25, 34INDEXElestat see epinastine ................................................................15Elestrin........................................................................................14eletriptan ..............................................................................23, 32Elidel ..........................................................................................26Eligard ........................................................................................19Elimite see permethrin ................................................................26Elinest ........................................................................................13Eliquis ..........................................................................................9Ella 13, 35Elmiron ......................................................................................29Elocon see mometasone topical..................................................27eltrombopag ..........................................................................9, 32elvitegravir/cobicistat/emtricitabine/tenofovir ............................18Emadine ....................................................................................15Embeline see clobetasol topical..................................................27Emcyt..........................................................................................19emedastine ................................................................................15Emend ..................................................................................27, 32Emend trifold kit..........................................................................32Emoquette ..................................................................................13Emsam ................................................................................21, 34emtricitabine ..............................................................................18emtricitabine/rilpivirine/tenofovir ................................................18emtricitabine/tenofovir................................................................18Emtriva........................................................................................18Emycin........................................................................................16Enablex ................................................................................28, 32enalapril........................................................................................7enalapril soln ................................................................................7enalapril/HCTZ ..............................................................................7Enbrel ............................................................................20, 27, 33Endometrin ................................................................................14enfuvirtide ..................................................................................18Enjuvia....................................................................................3, 14enoxaparin ....................................................................................9Enpresse ....................................................................................12Enskyce ......................................................................................13entacapone ................................................................................25entecavir ....................................................................................18Entocort see budesonide oral ..............................................28, 32Enulose ......................................................................................28enzalutamide ..............................................................................19Epaned ........................................................................................7Epiduo ........................................................................................25Epiflur ........................................................................................12epinastine ..................................................................................15epinephrine injection ..................................................................30Epipen ........................................................................................30Epipen Jr ....................................................................................30Epivir see lamivudine ..................................................................18Epivir HBV see lamivudine ..........................................................18eplerenone....................................................................................8Epogen..........................................................................................96-16-1444

eprosartan ....................................................................................7eprosartan/HCTZ ..........................................................................7Epzicom ......................................................................................18Equetro ......................................................................................22ergocalciferol ..............................................................................11ergotamine/caffeine....................................................................23Erivedge ......................................................................................19erlotinib ................................................................................19, 32Errin............................................................................................13Ertaczo........................................................................................26Eryped ........................................................................................16Erytab ........................................................................................16Erythrocin....................................................................................16erythromycin ..................................................................15, 16, 25erythromycin ethyl succinate ......................................................16erythromycin stearate..................................................................16erythromycin/sulfisoxazole ..........................................................16erythropoeitin................................................................................9escitalopram ..............................................................................21Esgic see acetaminophen/butalbital/caffeine ............................23Esgic-Plus see acetaminophen/butalbital/caffeine......................23Eskalith ......................................................................................20eslicarbazepine acetate ..............................................................22esomeprazole ................................................................27, 33, 34esomeprazole strontium........................................................27, 33esomeprazole/naproxen........................................................27, 34Estarylla......................................................................................13estazolam ..................................................................................22esterified estrogen tab ................................................................14esterified estrogen/methyltestosterone........................................14Estrace........................................................................................14estradiol acetate ........................................................................14estradiol spray ............................................................................14estradiol tab................................................................................14estradiol topical gel ....................................................................14estradiol twice weekly patch........................................................14estradiol vaginal cream ..............................................................14estradiol vaginal ring ............................................................14, 33estradiol vaginal tab....................................................................14estradiol weekly patch ................................................................14estradiol/drospirenone..........................................................13, 14estradiol/levonorgestrel weekly patch..........................................14estradiol/norethindrone tab ........................................................14estradiol/norethindrone twice weekly patch ................................14estradiol/norgestimate tab..........................................................14estramustine ..............................................................................19Estrasorb ....................................................................................14Estratest see esterified estrogen/methyltestosterone ..................14Estring ..................................................................................14, 33Estrogel ......................................................................................14estrogen/methyltestosterone tab ................................................14estropipate tab ..........................................................................14Estrostep 21 see Tri-Legest FE, Tilia FE ........................................12INDEXEstrostep FE see Tri-Legest FE, Tilia FE ........................................12eszopiclone ..........................................................................22, 33etanercept ............................................................................20, 33ethacrynic acid..............................................................................8ethambutol ................................................................................17ethinyl estradiol/norethindrone tab ............................................14ethionamide................................................................................17ethosuximide ..............................................................................22ethotoin ......................................................................................22etidronate ..................................................................................11etodolac......................................................................................24etoposide....................................................................................19etravirine ....................................................................................18Eulexin see flutamide ..................................................................19Eurax ..........................................................................................26Evamist ......................................................................................14everolimus ..................................................................................19everolimus soluble tab ................................................................19Evista see raloxifene....................................................................11Evoxac see cevimeline ................................................................29Exederm......................................................................................26Exelon see rivastigmine ..............................................................22Exelon patch ..............................................................................22exemestane ................................................................................19exenatide ....................................................................................10exenatide weekly ........................................................................10Exforge ......................................................................................7, 8Exforge HCT ..............................................................................7, 8Exjade ........................................................................................12Extavia ........................................................................................20Extina see ketoconazole foam ....................................................26ezetimibe........................................................................11, 32, 34ezetimibe/atorvastatin ..........................................................11, 32ezetimibe/simvastatin ..........................................................11, 34ezogabine ..................................................................................22Fabior..........................................................................................25Factive ..................................................................................16, 33Falmina ......................................................................................13famciclovir ..................................................................................18famotidine ..................................................................................27Famvir see famciclovir ................................................................18Fanapt ........................................................................................20Fanatrex ......................................................................................22Fareston......................................................................................19Farxiga ..................................................................................10, 32FazaClo ODT................................................................................20febuxostat ..................................................................................19felbamate ..................................................................................22Felbatol see felbamate................................................................22Feldene see piroxicam ................................................................24felodipine......................................................................................8Femara see letrozole ..................................................................19Femcon FE see Zeosa ................................................................136-16-1445

Femhrt see Jinteli........................................................................14Femring ................................................................................14, 33Femtrace ....................................................................................14fenofibrate ..................................................................................11fenofibric acid ............................................................................11Fenoglide ....................................................................................11fenoprofen ..................................................................................24fentanyl nasal..............................................................................24fentanyl oral................................................................................24fentanyl patch ............................................................................24fentanyl sublingual spray ......................................................24, 33fentanyl transmucosal film ..........................................................24Fentora ................................................................................24, 33Ferriprox........................................................................................9fesoterodine fumarate ................................................................28Fetzima ................................................................................21, 33Fexmid see cyclobenzaprine........................................................23Fibricor see fenofibric acid ..........................................................11fidaxomicin ..........................................................................17, 33filgrastim ......................................................................................9Finacea ......................................................................................25Finacea Plus ..............................................................................25finasteride ..................................................................................28fingolimod ..................................................................................20Fioricet see acetaminophen/butalbital/caffeine..........................23Fiorinal see aspirin/butalbital/caffeine ......................................23Firazyr ........................................................................................19Firmagon ....................................................................................14First Progesterone ......................................................................14First-lansoprazole..................................................................27, 33First-omeprazole see omeprazole compound kit..........................27Flagyl see metronidazole ................................................17, 25, 27Flarex ..........................................................................................15flavoxate......................................................................................28flecainide ......................................................................................8Flector ........................................................................................24Flexeril see cyclobenzaprine ........................................................23Flomax see tamsulosin................................................................28Flonase see fluticasone nasal ....................................................29Flo-Pred ......................................................................................19Florinef see fludrocortisone ........................................................19Flovent ........................................................................................29Floxin see ofloxacin ..............................................................15, 16Floxin Otic see ofloxacin otic ......................................................16fluconazole..................................................................................17flucytosine ..................................................................................17fludrocortisone ............................................................................19Flumadine see rimantadine ........................................................18flunisolide nasal..........................................................................29flunisolide inhaler........................................................................29fluocinolone..........................................................................16, 27fluocinolone oil ..........................................................................27fluocinolone otic ........................................................................16INDEXfluocinolone shampoo ................................................................27fluocinonide 0.05% ....................................................................27fluocinonide 0.1% ......................................................................27Fluor-A-Day ................................................................................12fluoride ................................................................................12, 30fluoride/xylitol ............................................................................12Fluoritab......................................................................................12fluorometholone..........................................................................15fluorometholone acetate ............................................................15fluorouracil..................................................................................26fluorouracil 0.5% cream..............................................................26fluoxetine cap ............................................................................21fluoxetine tab ..............................................................................21fluoxetine weekly ........................................................................21fluoxetine/olanzapine..................................................................20fluoxymesterone ..........................................................................14fluphenazine ..............................................................................20Flura ..........................................................................................12flurandrenolide............................................................................27Flura-tab ....................................................................................12flurazepam ..................................................................................22flurbiprofen ..........................................................................15, 24Fluress see benoxinate/fluorescein ............................................16Flurox..........................................................................................16flutamide ....................................................................................19fluticasone cream/ointment ........................................................27fluticasone lotion ........................................................................27fluticasone furoate nasal ............................................................29fluticasone furoate/vilanterol inhaler ..........................................29fluticasone inhaler ......................................................................29fluticasone nasal ........................................................................29fluticasone-salmeterol inhaler ....................................................29fluvastatin ............................................................................11, 33fluvastatin XL ........................................................................11, 33fluvoxamine ..........................................................................21, 33fluvoxamine CR ....................................................................21, 33FML Forte....................................................................................15FML Liquifilm see fluorometholone..............................................15FML SOP ....................................................................................15Focalin see dexmethylphenidate..................................................21Focalin XR see dexmethylphenidate XR ......................................21folic acid ..............................................................................12, 30Foltx............................................................................................12fondaparinux ................................................................................9Foradil ........................................................................................29Forfivo XL ....................................................................................21formoterol inhaler........................................................................29formoterol nebulizer solution ......................................................29Fortamet see metformin ER ........................................................10Forteo ..................................................................................11, 35Fortestra ....................................................................................14Fortical........................................................................................11Fosamax see alendronate ....................................................11, 326-16-1446

FosamaxD ..................................................................................11fosamprenavir ............................................................................18fosfomycin ..................................................................................17fosinopril ......................................................................................7fosinopril/HCTZ ............................................................................7Fosrenol......................................................................................12Fragmin ........................................................................................9Freestyle ....................................................................................11Freestyle Lite ..............................................................................11Freestyle Insulinx ........................................................................11Frova ....................................................................................23, 33frovatriptan ..........................................................................23, 33Fulyzaq........................................................................................28Furadantin see nitrofurantoin ......................................................17furosemide....................................................................................8Fuzeon ........................................................................................18Fycompa ....................................................................................22gabapentin ..........................................................................22, 33gabapentin ER ..........................................................................22gabapentin SR ............................................................................22Gabitril see tiagabine ..................................................................22galantamine..........................................................................22, 33galantamine ER ....................................................................22, 33ganciclovir ..................................................................................15Gantrisin ....................................................................................17Garamycin see gentamicin ....................................................15, 26Gardasil ......................................................................................31Garimide see sulfacetamide/sulfur 10%/5% cream, cleanser,medicated pads, foam, lotion, suspension............................25Gastrocrom see cromolyn sodium ..............................................29gatifloxacin ..........................................................................15, 16Gattex ........................................................................................28Gavilyte-G ..................................................................................28Gelnique ....................................................................................28gemfibrozil ..................................................................................11gemifloxacin..........................................................................16, 33Generess FE................................................................................13Generlac ....................................................................................28Gengraf ......................................................................................19Genotropin..................................................................................15gentamicin............................................................................15, 26Geodon see ziprasidone..............................................................20Gianvi..........................................................................................13Giazo ..........................................................................................28Gildagia ......................................................................................13Gilenya........................................................................................20Gilotrif ..................................................................................19, 32glatiramer 20 mg ........................................................................20glatiramer 40 mg ........................................................................20Gleevec ......................................................................................19Glidess FE 1.5/30 ......................................................................13Glidess FE 1/20 ........................................................................13glimepiride..................................................................................10INDEXglipizide ......................................................................................10glipizide ER ................................................................................10GlucaGen....................................................................................10glucagon kit ................................................................................10Glucotrol see glipizide ................................................................10Glucotrol XL see glipizide ER ......................................................10Glucovance see metformin/glyburide ..........................................10Glumetza ....................................................................................10glyburide ....................................................................................10Glycate........................................................................................29glycerol phenylbutyrate................................................................14glycopyrrolate ............................................................................29Glyset..........................................................................................10golimumab ....................................................................20, 28, 33Golytely packets see PEG/electrolytes packets............................28Gralise ..................................................................................22, 33granisetron............................................................................27, 33granisetron patch..................................................................27, 33Granix ..........................................................................................9Grastek ................................................................................29, 35griseofulvin..................................................................................17griseofulvin ultramicrosize............................................................17GrisPEG see griseofulvin ultramicrosize........................................17guanabenz ....................................................................................8guanfacine........................................................................8, 21, 33Gynazole see butoconazole ........................................................26halcinonide ................................................................................27Halcion see triazolam..................................................................22Haldol see haloperidol ................................................................20Halflytely Kit................................................................................28halobetasol ................................................................................27halobetasol/ammonium lactate ..................................................27Halog ..........................................................................................27Halonate PAC see halobetasol/ammonium lactate......................27haloperidol..................................................................................20HCTZ..............................................................................7-9, 32, 33Hectorol see doxercalciferol ........................................................11Hepsera see adefovir ..................................................................18Hetlioz ..................................................................................22, 35Hizentra ......................................................................................19homatropine 2% ........................................................................16homatropine 5% ........................................................................16Horizant ......................................................................................22Humalog ....................................................................................10Humalog mix ..............................................................................10human chorionic gonadotropin..............................................14, 31human insulin ............................................................................10human insulin-concentrated..................................................10, 33human insulin mix ......................................................................10human isophane ........................................................................10human papillomavirus vaccine ....................................................31Humatin see paromomycin..........................................................17Humatrope..................................................................................156-16-1447

Humira ....................................................................20, 27, 28, 32Humulin N ..................................................................................10Humulin R ............................................................................10, 33Humulin R U-500........................................................................10Humulin 70/30 ..........................................................................10Hycamtin ....................................................................................19Hycet ..........................................................................................24hydralazine................................................................................8, 9hydralazine/HCTZ ......................................................................8, 9hydralazine/reserpine....................................................................9hydrochlorothiazide ................................................................8, 32hydrocodone ER....................................................................24, 33hydrocortisone ..............................................15, 16, 19, 24-26, 28hydrocortisone rectal ..................................................................28hydrocortisone soln ....................................................................26hydrocortisone/lidocaine cream ..................................................24hydrocortisone/lidocaine rectal ..................................................28hydrocortisone/pramoxine cream ................................................26hydrocortisone/pramoxine lotion/ointment..................................26hydrocortisone/urea....................................................................26hydromorphone ..........................................................................24hydroxyamphetamine/tropicamide ..............................................16hydroxychloroquine ..............................................................17, 19hydroxyprogesterone caproate injection ......................................31hydroxypropyl cellulose ophthalmic ............................................16hydroxyurea ................................................................................19hydroxyzine..................................................................................29hyoscyamine................................................................................28hyoscyamine/phenyltoloxamine ..................................................28Hyper-Sal see sodium chloride 7% for inh ..................................30Hytrin see terazosin ................................................................8, 28Hyzaar see losartan/HCTZ ............................................................7ibandronate ..........................................................................11, 33ibrutinib ......................................................................................19Ibudone ......................................................................................24ibuprofen ..............................................................................24, 27ibuprofen/famotidine ..................................................................27ibuprofen/hydrocodone ..............................................................24ibuprofen/oxycodone ..................................................................24icatibant......................................................................................19Iclusig ........................................................................................19Icosapent ethyl ....................................................................11, 33Ilaris............................................................................................31Ilevro ..........................................................................................15iloperidone..................................................................................20iloprost..........................................................................................9imatinib ......................................................................................19Imbruvica....................................................................................19imipramine..................................................................................21imipramine pamoate ..................................................................21imiquimod ..................................................................................26Imitrex injection see sumatriptan injection ............................23, 35Imitrex nasal see sumatriptan nasal......................................23, 35INDEXImitrex tablets see sumatriptan tablets........................................23Imuran see azathioprine..............................................................19Incivek ........................................................................................18incobotulinum toxin ....................................................................31Increlex ......................................................................................15indacaterol..................................................................................29indapamide ..................................................................................8Inderal LA see propranolol LA........................................................7Inderal XL......................................................................................7indinavir......................................................................................18Indocin see indomethacin ..........................................................24indomethacin..............................................................................24Infergen ......................................................................................18infliximab ....................................................................................31ingenol........................................................................................26Inlyta ..........................................................................................19Innohep ........................................................................................9Innopran XL ..................................................................................7Inspra see eplerenone ..................................................................8insulin aspart ..............................................................................10insulin aspart mix........................................................................10insulin detemir ............................................................................10insulin glargine............................................................................10insulin glulisine ..........................................................................10insulin lispro ..............................................................................10insulin lispro mix ........................................................................10insulin syringes............................................................................11Intelence ....................................................................................18interferon alfa ......................................................................18, 19interferon alfacon........................................................................18interferon alfa-n3 ........................................................................17interferon beta-1a ......................................................................20interferon beta-1b ......................................................................20interferon gamma........................................................................17Intermezzo ............................................................................22, 35Intron A ................................................................................18, 19Introvale......................................................................................13Invega ........................................................................................20Invirase ......................................................................................18Invokana ..............................................................................10, 32Iopidine ......................................................................................15Iplex............................................................................................15ipratropium ..........................................................................29, 30ipratropium HFA inhaler ..............................................................30ipratropium nasal........................................................................29Iquix............................................................................................15irbesartan......................................................................................7irbesartan/HCTZ ............................................................................7Isentress ....................................................................................18isocarboxazid ..............................................................................21isometheptene/acetaminophen/caffeine ....................................23isoniazid......................................................................................17isoniazid/pyrazinamide................................................................176-16-1448

isoniazid/rifampin ......................................................................17Isopto Atropine see atropine ................................................16, 28Isopto Carbachol ........................................................................15Isopto Carpine see pilocarpine..............................................15, 29Isopto Homatropine ....................................................................16Isopto Hyoscine ..........................................................................16isosorbide dinitrate........................................................................9isosorbide dinitrate/hydralazine ....................................................9isosorbide mononitrate..................................................................9Isotret ........................................................................................25isotretinoin..................................................................................25isradipine ......................................................................................8Istalol..........................................................................................15itraconazole ................................................................................17ivacaftor......................................................................................29ivermectin ............................................................................17, 26ivermectin topical........................................................................26Jakafi ..........................................................................................19Jalyn ..........................................................................................28Jantoven........................................................................................9Janumet......................................................................................10Janumet XR ................................................................................10Januvia ................................................................................10, 34Jencycla ......................................................................................13Jentadueto ..................................................................................10Jolessa........................................................................................13Jolivette ......................................................................................13Junel FE 1.5/30..........................................................................13Junel FE 1/20 ............................................................................13Juvisync..........................................................................10, 11, 35Juxtapid ......................................................................................11Kadian see morphine ER capsule................................................24Kaletra ........................................................................................18Kalydeco ....................................................................................29Kapidex see Dexilant ............................................................27, 32Kapvay see clonidine SR ............................................................21Kariva..........................................................................................12Kayexalate see sodium polystyrene sulfonate ..............................12Kazano........................................................................................10K-Dur see potassium chloride ....................................................12Keflex see cephalexin..................................................................16Kelnor 1/35................................................................................13Kenalog see triamcinolone topical ..............................................27Keppra see levetiracetam............................................................22Keppra XR see levetiracetam ER..................................................22Keralac ......................................................................................26Kerlone see betaxolol..............................................................7, 15Ketek ....................................................................................16, 35ketoconazole ........................................................................17, 26ketoconazole cream ....................................................................26ketoconazole foam......................................................................26ketoconazole gel ........................................................................26ketoconazole/pyrithione ..............................................................26INDEXketoprofen ..................................................................................24ketorolac ........................................................................15, 24, 33ketorolac injection ................................................................24, 33ketorolac nasal ..........................................................................24ketorolac PF ................................................................................15Khedezla see desvenlafaxine ................................................21, 32Kineret..................................................................................20, 32Klaron see sulfacetamide sodium shampoo, suspension ............25Klonopin see clonazepam ..........................................................22Klor-Con......................................................................................12Kombiglyze XR ............................................................................10K-Phos ........................................................................................12Kristalose....................................................................................28Kurvelo........................................................................................13Kuvan..........................................................................................14Kwell see lindane lotion/shampoo ..............................................26Kynamro ....................................................................................11Kytril see granisetron ............................................................27, 33labetalol........................................................................................7Lac-Hydrin see ammonium lactate 12%......................................26lacosamide ..........................................................................22, 33Lacrisert......................................................................................16lactulose solution........................................................................28Lamictal see lamotrigine ......................................................22, 33Lamictal ODT ..............................................................................22Lamictal XR see lamotrigine ER ............................................22, 33Lamisil see terbinafine ................................................................17Lamisil granules ..........................................................................17lamivudine ..................................................................................18lamivudine/zidovudine ................................................................18lamotrigine............................................................................22, 33lamotrigine ER ......................................................................22, 33lamotrigine ODT ..........................................................................22Lamprene....................................................................................17lancets........................................................................................11Lanoxin ........................................................................................8lanreotide....................................................................................14lansoprazole ........................................................................27, 33lansoprazole compound kit ..................................................27, 33lansoprazole soltab ....................................................................27lansoprazole/amoxicillin/clarithromycin ................................27, 33lanthanum ..................................................................................12Lantus ........................................................................................10Lantus Solostar Pen ....................................................................10lapatinib ....................................................................................19Lariam see mefloquine................................................................17Larin FE 1/20 ............................................................................13Lasix see furosemide ....................................................................8Lastacaft ....................................................................................15latanoprost..................................................................................15Latuda ..................................................................................20, 33Lavoclen-4 ..................................................................................25Lavoclen-8 ..................................................................................256-16-1449

Lazanda................................................................................24, 33Leena..........................................................................................12leflunomide ................................................................................19lenalidomide ........................................................................19, 33Lescol see fluvastatin............................................................11, 33Lescol XL ..............................................................................11, 33Lessina ......................................................................................13Letairis ..........................................................................................9letrozole ......................................................................................19leucovorin ..................................................................................19Leukeran ....................................................................................19Leukine ........................................................................................9leuprolide ............................................................................14, 19levalbuterol inhaler......................................................................29levalbuterol nebulizer solution ....................................................29Levaquin see levofloxacin oral ....................................................16Levbid see hyoscyamine ..............................................................28Levemir ......................................................................................10levetiracetam ..............................................................................22levetiracetam ER ........................................................................22levobunolol ................................................................................15levocarnitine ........................................................................12, 19levocetirizine ..............................................................................29Levo-Dromoran see levorphanol ..................................................24levofloxacin ..........................................................................15, 16levofloxacin oral ..........................................................................16levomilnacipran ....................................................................21, 33Levonest......................................................................................12levonorgestrel ..................................................................12-14, 33Levora ........................................................................................13levorphanol ................................................................................24Levothroid ..................................................................................14levothyroxine ..............................................................................14Levoxyl ........................................................................................14Levsin see hyoscyamine ..............................................................28Lexapro see escitalopram............................................................21Lexiva..........................................................................................18Lialda..........................................................................................28Librax..........................................................................................28Librium see chlordiazepoxide ................................................22, 28Lidamantle HC see hydrocortisone/lidocaine cream....................24Lidex see fluocinonide ................................................................27lidocaine 2% viscous ..................................................................24lidocaine 3% ..............................................................................24lidocaine 4%, 5% topical ............................................................24lidocaine patch ..........................................................................24lidocaine/tetracaine....................................................................26Lidoderm see lidocaine patch ....................................................24LidoRX ........................................................................................24Lidovir ........................................................................................26linaclotide ............................................................................28, 33linagliptin ............................................................................10, 33linagliptin/metformin ..................................................................10INDEXlindane........................................................................................26linezolid ......................................................................................17Linzess..................................................................................28, 33Lioresal see baclofen ..................................................................23liothyronine ................................................................................14Lipitor see atorvastatin ....................................................8, 11, 32Lipofen........................................................................................11Liptruzet................................................................................11, 32liraglutide....................................................................................10lisdexamfetamine..................................................................21, 33lisinopril ........................................................................................7lisinopril/HCTZ ..............................................................................7lithium ........................................................................................20lithium ER ..................................................................................20Lithobid ......................................................................................20Livalo ..................................................................................11, 34Locoid topical see hydrocortisone butyrate..................................26Lodine see etodolac....................................................................24Lodosyn see carbidopa ..............................................................25lodoxamide ................................................................................15Loestrin 24 FE see Lomedia 24 FE..............................................13Loestrin FE 1.5/30 see Junel FE 1.5/30,Microgestin FE 1.5/30 ........................................................13Loestrin FE 1/20 see Junel FE 1/20, Microgestin FE 1/20 ........13Lofibra see fenofibrate ................................................................11LoLoestrin FE ..............................................................................13Lomedia 24 FE............................................................................13LoMinastrin FE ............................................................................13lomefloxacin................................................................................16lomitapide ..................................................................................11Lomotil see diphenoxylate/atropine ............................................28lomustine....................................................................................19Lo-Ovral see Cryselle, Low-Ogestrel ............................................13Lopid see gemfibrozil ..................................................................11lopinavir/ritonavir........................................................................18Lopressor see metoprolol tartrate..................................................7Lopressor HCT see metoprolol/HCTZ..............................................7Loprox see ciclopirox ..................................................................26lorazepam ..................................................................................22Lorcet see acetaminophen/hydrocodone ....................................24Loryna ........................................................................................13Lorzone ......................................................................................23losartan ........................................................................................7losartan/HCTZ ..............................................................................7LoSeasonique see Amethia Lo, Camrese Lo ................................12Lotemax ......................................................................................15Lotensin see benazepril ............................................................7, 8LotensinHCT see benazepril/HCTZ ................................................7loteprednol..................................................................................15Lotrel see benazepril/amlodipine ..............................................7, 8Lotrimin see clotrimazole ......................................................17, 26Lotrisone see clotrimazole/betamethasone ................................26Lotronex................................................................................28, 326-16-1450

lovastatin ..............................................................................11, 33lovastatin/niacin ........................................................................11Lovaza ..................................................................................11, 34Lovenox see enoxaparin ................................................................9Low-Ogestrel ..............................................................................13loxapine ......................................................................................20Loxitane see loxapine..................................................................20Lozol see indapamide ..................................................................8lubiprostone..........................................................................28, 33Ludent ........................................................................................12Lufyllin ........................................................................................30luliconazole ................................................................................26Lumigan......................................................................................15Lumizyme....................................................................................31Lunesta see eszopiclone ......................................................22, 33Lupron ..................................................................................14, 19lurasidone ............................................................................20, 33Lutera ........................................................................................13Luvox CR see fluvoxamine CR................................................21, 33Luxiq see betamethasone valerate ..............................................27Luzu ............................................................................................26Lybrel see Amethyst ....................................................................13Lyrica....................................................................................22, 34Lysodren ....................................................................................19Lysteda see tranexamic acid ........................................................9macitentan....................................................................................9MacroBID see nitrofurantoin........................................................17Macrodantin................................................................................17mafenide ....................................................................................26Magnacet....................................................................................24Makena ......................................................................................31Malarone see atovaquone/proquanil ..........................................17malathion....................................................................................26Mandelamine..............................................................................17maprotiline..................................................................................21maraviroc ....................................................................................18Marinol see dronabinol ..............................................................27Marlissa ......................................................................................13Marplan ......................................................................................21Matulane ....................................................................................19Matzim LA ....................................................................................8Mavik see trandolapril ..............................................................7, 8Maxair ........................................................................................29Maxalt see rizatriptan............................................................23, 34Maxaquin ....................................................................................16Maxiflor see diflorasone ..............................................................27Maxitrol see neomycin/polymyxin/dexamethasone......................15mecamylamine..............................................................................9mecasermin ................................................................................15mechlorethamine topical ............................................................19meclofenamate ..........................................................................24Medrol see methylprednisolone ..................................................19medroxyprogesterone ..................................................................14INDEXmefenamic acid ..........................................................................24mefloquine..................................................................................17Megace see megestrol ................................................................14Megace ......................................................................................14megestrol ....................................................................................14Mekinist ......................................................................................19Mellaril see thioridazine ..............................................................20meloxicam ..................................................................................24melphalan ..................................................................................19memantine ..........................................................................22, 33memantine ERC ..........................................................................22Menest........................................................................................14Menostar ..............................................................................14, 33Mentax........................................................................................26mepenzolate ..............................................................................27Mephyton see phytonadione..........................................................9Mephyton ......................................................................................9meprobamate ............................................................................22Mepron see atovaquone..............................................................17mercaptopurine ..........................................................................19mesalamine ................................................................................28mesalamine ................................................................................28mesalamine rectal ......................................................................28mesna ........................................................................................19Mesnex ......................................................................................19Mestinon see pyridostigmine ......................................................22Mestinon SR ..............................................................................22Metadate CD see methylphenidate CD 30:70 ............................21Metadate ER ..............................................................................21Metaglip see metformin glipizide ................................................10metaproterenol tabs....................................................................30metaxalone ................................................................................23metformin ..................................................................................10metformin ER ..............................................................................10metformin liquid..........................................................................10metformin/glipizide ....................................................................10metformin/glyburide....................................................................10methadone ..........................................................................20, 24Methadose see methadone ..................................................20, 24methamphetamine......................................................................21methazolamide............................................................................29methenamine..............................................................................17methenamine/sodium salicylate ................................................17Methergine see methylergonovine................................................23methimazole ..............................................................................14Methitest ....................................................................................14methocarbamol ..........................................................................23methotrexate ........................................................................19, 20methsuximide..............................................................................22methyldopa ..................................................................................8methyldopa/HCTZ..........................................................................8methylergonovine ........................................................................23methylnaltrexone ..................................................................28, 336-16-1451

methylphenidate ..................................................................21, 33methylphenidate CD 30:70 ........................................................21methylphenidate CD 50:50 ........................................................21methylphenidate ER ....................................................................21methylphenidate ER oral susp.....................................................21methylphenidate patch................................................................21methylphenidate SR ....................................................................21methylprednisolone ....................................................................19methyltestosterone......................................................................14metipranolol................................................................................15metoclopramide..........................................................................27metoclopramide ODT ..................................................................27metolazone ..................................................................................8metoprolol succinate (XL) ......................................................7, 33metoprolol succinate/HCTZ ....................................................7, 33metoprolol tartrate ........................................................................7metoprolol/HCTZ ..........................................................................7Metozolv ....................................................................................27metreleptin..................................................................................14Metrogel see metronidazole ............................................17, 25, 27Metrolotion see metronidazole........................................17, 25, 27metronidazole ................................................................17, 25, 27Mevacor see lovastatin..........................................................11, 33mexiletine......................................................................................8Mexitil see mexiletine ....................................................................8Miacalcin see calcitonin..............................................................11Micardis see telmisartan ..........................................................7, 8Micardis HCT see telmisartan/HCTZ ..............................................7miconazole ..........................................................................17, 26miconazole/zinc oxide/petrolatum ..............................................26Microgestin FE 1.5/30 ................................................................13Microgestin FE 1/20 ..................................................................13Micro-K see potassium chloride ..................................................12Micronase see glyburide..............................................................10Micronor see Camila, Errin, Heather, Jolivette, NoraBe ................13midodrine......................................................................................9Midrin see acetaminophen/dichloralphenazone/isometheptene..23miglitol........................................................................................10miglustat ....................................................................................11Migranal see dihydroergotamine nasal ........................................23Millipred......................................................................................19milnacipran ..........................................................................21, 34Mimvey see estradiol/norethindrone tab ....................................14Minastrin 24 FE ..........................................................................13Minipress see prazosin............................................................8, 28Minivelle ..............................................................................14, 33Minocin see minocycline capsules ..............................................25minocycline capsules ..................................................................25minocycline ER............................................................................25minocycline tablets ....................................................................25minoxidil ......................................................................................9mipomersen................................................................................11mirabegron ..........................................................................28, 34INDEXMirapex see pramipexole ......................................................25, 34Mirapex ER ..........................................................................25, 34Mircette see Kariva......................................................................12mirtazapine ................................................................................21Mirvaso ......................................................................................26misoprostol ..........................................................................24, 27mitotane ....................................................................................19mixed grass pollen ..............................................................29, 34Moban ........................................................................................20modafinil ..............................................................................21, 34Moderiba ....................................................................................18Modicon see Nortrel 0.5/35, Necon 0.5/35, Wera, Brevicon ......13Moduretic see amiloride/HCTZ ......................................................8moexipril ......................................................................................7moexipril/HCTZ..............................................................................7molindone ..................................................................................20mometasone inhaler ..................................................................29mometasone nasal ....................................................................29mometasone topical ..................................................................27mometasone-formoterol inhaler ..................................................29Monodox see doxycycline monohydrate ................................17, 25Mono-Linyah ..............................................................................13Mononessa ................................................................................13Monopril see fosinopril..................................................................7Monopril-HCT see fosinopril/HCTZ ................................................7montelukast ................................................................................30Monurol ......................................................................................17morphine ..............................................................................24, 34morphine ER capsule ..................................................................24morphine ER tablet ....................................................................24Motofen ......................................................................................28Motrin see ibuprofen ............................................................24, 27MoviPrep ..............................................................................28, 34Moxatag......................................................................................16Moxeza ......................................................................................15moxifloxacin..........................................................................15, 16MS Contin see morphine ER tablet..............................................24Mucomyst see acetylcysteine ......................................................30Multaq ..........................................................................................8mupirocin....................................................................................26mupirocin nasal ointment............................................................26My Way ......................................................................................13Myalept ......................................................................................14Myambutol see ethambutol ........................................................17Mycelex see clotrimazole troche ..................................................17Mycelex-3 ..................................................................................26Mycobutin see rifabutin ..............................................................17Mycolog II see nystatin/triamcinolone ........................................26mycophenolate mofetil................................................................19mycophenolic acid ......................................................................19Mydriacyl see tropicamide ..........................................................16Myfortic see mycophenolic acid ..................................................19Myleran ......................................................................................196-16-1452

Myobloc ......................................................................................31Myorisan ....................................................................................25Myozyme ....................................................................................31Myrbetriq ..............................................................................28, 34Mysoline ....................................................................................22Myzilra ........................................................................................12nabilone ..............................................................................27, 34nabumetone................................................................................24nadolol..........................................................................................7nadolol/bendroflumethizide ..........................................................7nafarelin......................................................................................14naftifine ......................................................................................26Naftin..........................................................................................26Nalfon ........................................................................................24naltrexone ......................................................................20, 24, 34Namenda..............................................................................22, 33Namenda XR ........................................................................22, 33naphazoline ................................................................................15Naprelan ....................................................................................24Naprosyn see naproxen......................................23, 24, 27, 34, 35naproxen............................................................23, 24, 27, 34, 35naproxen ER................................................................................24naproxen sodium ........................................................................24naproxen sodium ER ..................................................................24naratriptan............................................................................23, 34Nardil see phenelzine..................................................................21Nasacort AQ see triamcinolone nasal..........................................29Nasonex......................................................................................29NataChew ..................................................................................12Natacyn ......................................................................................15Natafort ......................................................................................12natalizumab ................................................................................31natamycin ..................................................................................15Natazia ......................................................................................12nateglinide..................................................................................10Natroba see spinosad ................................................................26Nature-Throid ..............................................................................14Navane see thiothixene ..............................................................20Nebcin see tobramycin inj ..........................................................30nebivolol ......................................................................................7Nebupent....................................................................................17Nebusal ......................................................................................30Necon 0.5/35 ............................................................................13Necon 1/35................................................................................13Necon 1/50................................................................................13Necon 10/11..............................................................................12Necon 777..................................................................................12nedocromil..................................................................................15needles (for insulin syringes) ......................................................11nefazodone ................................................................................21nelfinavir ....................................................................................18NeoBenz Micro............................................................................25neomycin ..............................................................................15-17INDEXneomycin/bacitracin/polymyxin/hydrocortisone ointment ..........15neomycin/polymyxin/dexamethasone ........................................15neomycin/polymyxin/gramicidin..................................................15neomycin/polymyxin/hydrocortisone ....................................15, 16neomycin/polymyxin/hydrocortisone otic ....................................16Neoral ........................................................................................19Neosporin see neomycin/polymyxin/gramicidin ..........................15NeoSynephrine see phenylephrine ..............................................16nepafenac ..................................................................................15Neptazane see methazolamide....................................................29Nesina ..................................................................................10, 32Neulasta ..........................................................................9, 31, 34Neumega ................................................................................9, 34Neupogen......................................................................................9Neupro........................................................................................25Neurontin see gabapentin ....................................................22, 33Nevanac......................................................................................15nevirapine ..................................................................................18nevirapine XR ..............................................................................18Nexavar ......................................................................................19Nexium ................................................................................27, 33Next Choice ..........................................................................13, 33Next Choice One Dose ..........................................................13, 33niacin ..................................................................................11, 34niacin extended release ..............................................................11Niacor ........................................................................................11Niaspan see niacin extended release ..........................................11nicardipine ....................................................................................8nicardipine SR ..............................................................................8nicotine inhaler ..........................................................................20nicotine patch ............................................................................20nicotine spray..............................................................................20Nicotrol inhaler............................................................................20Nicotrol NS ................................................................................20Nifediac CC see nifedipine ER ......................................................8Nifedical XL see nifedipine ER ......................................................8nifedipine......................................................................................8nifedipine ER ................................................................................8nimodipine caps ..........................................................................8nimodipine soln ............................................................................8Nimotop see nimodipine caps ......................................................8Niravam see alprazolam ..............................................................22nisoldipine ....................................................................................8nitazoxanide................................................................................17nitisinone ....................................................................................29Nitro-bid........................................................................................9Nitrodur see nitroglycerin patch ....................................................9nitrofurantoin ..............................................................................17nitroglycerin ointment....................................................................9nitroglycerin patch ........................................................................9nitroglycerin rectal ointment ........................................................28nitroglycerin spray ........................................................................9nitroglycerin tablets ......................................................................96-16-1453

Nitrolingual....................................................................................9Nitromist see nitroglycerin spray....................................................9Nitrostat ........................................................................................9nizatidine ....................................................................................27Nizoral see ketoconazole ......................................................17, 26Nolvadex see tamoxifen ..............................................................19NoraBe........................................................................................13Nordette see Levora, Portia..........................................................13Norditropin..................................................................................15norethindrone tab ......................................................................14Norflex see orphenadrine ............................................................23norfloxacin ..................................................................................16Norinyl 1/35 ..............................................................................13Norinyl 1/50 see Necon 1/50 ....................................................13Noritate ......................................................................................25Normodyne see labetalol ..............................................................7Noroxin ......................................................................................16Norpace ........................................................................................8Norpace CR ..................................................................................8Norpramin see desipramine ........................................................21NorQD see Camila, Errin, Heather, Jolivette, NoraBe ....................13Nortrel 0.5/35 ............................................................................13Nortrel 1/35 ..............................................................................13Nortrel 777 ................................................................................12nortriptyline ................................................................................21Norvasc see amlodipine ................................................7-9, 11, 32Norvir..........................................................................................18Novarel ................................................................................14, 31Novolin 70/30 ............................................................................10Novolin N ....................................................................................10Novolin R ....................................................................................10Novolog ......................................................................................10Novolog 70/30 ..........................................................................10Noxafil ........................................................................................17Nplate ........................................................................................31Nucynta ................................................................................24, 35Nucynta ER ..........................................................................24, 35Nuedexta ....................................................................................22Nulytely see PEG/electrolytes................................................28, 34Numorphan ................................................................................24Nuox ..........................................................................................25Nutropin......................................................................................15NuvaRing ....................................................................................13Nuvigil ..................................................................................21, 32Nyamyc see nystatin topical........................................................26Nymalize ......................................................................................8nystatin ................................................................................17, 26nystatin topical............................................................................26nystatin/triamcinolone ................................................................26Nystop see nystatin topical ........................................................26Ocella ........................................................................................13octreotide....................................................................................14octreotide depot..........................................................................14INDEXOcufen see flurbiprofen ........................................................15, 24Ocuflox see ofloxacin ............................................................15, 16ofloxacin ..............................................................................15, 16ofloxacin otic ..............................................................................16Ogen see estropipate ..................................................................14Ogestrel ......................................................................................13olanzapine ..................................................................................20olanzapine ODT ..........................................................................20Oleptro ER ..................................................................................21olmesartan................................................................................7, 8olmesartan/HCTZ ..........................................................................7olopatadine ..........................................................................15, 29olsalazine....................................................................................28Olux see clobetasol topical ........................................................27Olux E see clobetasol foam ........................................................27Olysio ..................................................................................18, 34omalizumab ................................................................................31Omeclamox-Pak ....................................................................27, 34omega-3 acid ethylesters ............................................................11omeprazole ..........................................................................27, 34omeprazole/amoxacillin/clarithromycin ................................27, 34omeprazole compound kit ..........................................................27omeprazole/sodium bicarbonate ................................................27Omnaris ......................................................................................29Omnicef see cefdinir ..................................................................16Omnipred see prednisolone ..................................................15, 19Omnitrope ..................................................................................15onabotulinum toxin ....................................................................31ondansetron ........................................................................27, 34ondansetron film ........................................................................27Onfi ............................................................................................22Onglyza ................................................................................10, 34Onmel ........................................................................................17Onsolis ................................................................................24, 33Opana see oxymorphone ......................................................24, 34Opana ER see oxymorphone ER............................................24, 34oprelvekin ..............................................................................9, 34Opsumit ........................................................................................9Optivar see azelastine ..........................................................15, 29Oracea ........................................................................................17Orafate........................................................................................29Oralair ..................................................................................29, 34Oralone see triamcinolone oropharyngeal....................................26Oramorph SR see morphine ER ............................................24, 34Orap............................................................................................20Orapred see prednisolone ....................................................15, 19Orapred ODT ..............................................................................19Oravig ........................................................................................17Oraxyl..........................................................................................17Orbivan ......................................................................................23Orbivan CF ..................................................................................23Orencia ..........................................................................20, 31, 32Orenitram ER ..........................................................................9, 356-16-1454

Orfadin........................................................................................29Orinase see tolbutamide ............................................................10orphenadrine ..............................................................................23orphenadrine/aspirin/caffeine ....................................................23Orsythia ......................................................................................13Ortho Cyclen see Mononessa, Previfem, Sprintec ........................13Ortho Evra Patch see Xulane Patch ......................................13, 34Ortho Novum 1/35 see Necon 1/35, Nortrel 1/35,Cyclafem 1/35 ....................................................................13Ortho Novum 1/50 see Necon 1/50 ..........................................13Ortho Novum 10/11 see Necon 10/11 ......................................12Ortho Novum 777 see Necon 777, Nortrel 777, Cyclafem 777 ..12Ortho-Cept see Apri ....................................................................13OrthoTri-Cyclen see Tri-Previfem, Trinessa, Tri-Sprintec ..................12Orudis see ketoprofen ................................................................24Oruvail see ketoprofen ................................................................24Orvaten see midodrine ..................................................................9oseltamivir ............................................................................18, 34Oseni ....................................................................................10, 32OsmoPrep ..................................................................................28Otozin ........................................................................................16Otrexup ......................................................................................20Otezla ..................................................................................20, 32Ovace see sulfacetamide sodium................................................25Ovace Plus see sulfacetamide sodium ........................................25Ovcon 35 see Balziva, Briellyn, Zeosa, Zenchent..........................13Ovide see malathion ..................................................................26Ovral see Ogestrel ......................................................................13Oxandrin see oxandrolone ..........................................................14oxandrolone ................................................................................14oxaprozin ....................................................................................24oxazepam....................................................................................22oxcarbazepine ............................................................................22oxcarbazepine ER........................................................................22Oxecta ........................................................................................24oxiconazole ................................................................................26Oxistat ........................................................................................26Oxtellar XR ..................................................................................22oxybutynin ............................................................................28, 34oxybutynin patch ........................................................................28oxybutynin topical ......................................................................28oxybutynin XL........................................................................28, 34oxycodone ......................................................................24, 32, 34oxycodone ER ................................................................24, 32, 34Oxycontin..............................................................................24, 34OxyFast see oxycodone ..................................................24, 32, 34oxymorphone ........................................................................24, 34oxymorphone ER ..................................................................24, 34oxymorphone injection ................................................................24Oxytrol ..................................................................................28, 34Pacerone ......................................................................................8Pacnex see benzoyl peroxide ......................................................25paliperidone................................................................................20INDEXpalivizumab ................................................................................31Pamelor see nortriptyline ............................................................21pancrealipase ............................................................................28pantoprazole ........................................................................27, 34pantoprazole powder ..................................................................27Parafon Forte DSC see chlorzoxazone..........................................23Parcopa see carbidopa/levodopa................................................25Paremyd......................................................................................16paricalcitol ..................................................................................11Parlodel see bromocriptine ..................................................14, 25Parnate see tranylcypromine ......................................................21paromomycin ..............................................................................17paroxetine ............................................................................21, 29paroxetine CR..............................................................................21paroxetine mesylate..............................................................21, 29pasireotide..................................................................................14Pataday ......................................................................................15Patanase ....................................................................................29Patanol ......................................................................................15Paxil see paroxetine ..............................................................21, 29Paxil CR see paroxetine CR..........................................................21pazopanib ..................................................................................19Pediapred see prednisolone..................................................15, 19Pediazole see erythromycin/sulfisoxazole ....................................16Pedi-Dri see nystatin ............................................................17, 26PEG/electrolytes ..................................................................28, 34PEG/electrolytes & bisacodyl ......................................................28PEG/electrolytes packets ............................................................28PEG/electrolytes/sodium ascorbate......................................28, 34PEG/electrolytes & sodium, potassium, andmagnesium sulfate ..............................................................28Peganone....................................................................................22Pegasys ................................................................................18, 34pegfilgrastim ....................................................................9, 31, 34PegIntron ....................................................................................18pegvisomant ..............................................................................15pegylated interferon........................................................18, 19, 34pegylated interferon alfa 2b ........................................................19pen needles (for insulin pens) ....................................................11penciclovir ..................................................................................26penicillamine ..............................................................................19penicillin VK ................................................................................16PenLac see ciclopirox nail lacquer ..............................................26Pentam see pentamidine ............................................................17pentamidine................................................................................17Pentasa ......................................................................................28pentosan ....................................................................................29pentoxifylline ................................................................................9PenVee K ....................................................................................16Pepcid see famotidine ................................................................27perampanel ................................................................................22Peranex HC see hydrocortisone/lidocaine rectal..........................28Percocet see acetaminophen/oxycodone ..............................24, 326-16-1455

Perforomist..................................................................................29Peridex see chlorhexidine ............................................................17perindopril ....................................................................................7Periostat see doxycycline monohydrate ................................17, 25permethrin ..................................................................................26perphenazine ..............................................................................20Persantine see dipyridamole..........................................................9Pertzye ........................................................................................28Pexeva ........................................................................................21phenazopyridine..........................................................................28phenelzine ..................................................................................21Phenergan see promethazine ......................................................27phenobarbital ......................................................................22, 28phenoxybenzamine........................................................................9phenylephrine ............................................................................16Phenytek ....................................................................................22phenytoin....................................................................................22Philith ........................................................................................13PhosLo see calcium acetate........................................................12Phoslyra soln ..............................................................................12Phospholine ................................................................................15phytonadione ................................................................................9Picato ........................................................................................26pilocarpine............................................................................15, 29pilocarpine oral ..........................................................................29Pilopine HS see pilocarpine ..................................................15, 29pimecrolimus ..............................................................................26pimozide ....................................................................................20Pimtrea ......................................................................................12pindolol ........................................................................................7pioglitazone ..........................................................................10, 32pioglitazone/glimepiride..............................................................10pioglitazone/metformin ..............................................................10pirbuterol inhaler ........................................................................29Pirmella 1/35 ............................................................................13Pirmella 777 ..............................................................................12piroxicam ....................................................................................24pitavastatin ..........................................................................11, 34Plan B see Next Choice ........................................................13, 33Plan B One-Step see Next Choice One Dose ........................13, 33Plaquenil see hydroxychloroquine..........................................17, 19Plavix see clopidogrel ....................................................................9Plendil see felodipine....................................................................8Pletal see cilostazol ......................................................................9Plexion ........................................................................................25Pliaglis ........................................................................................26Podocon 25 ................................................................................26podofilox ....................................................................................26podofilox gel ..............................................................................26podophyllin topical......................................................................26polymyxin/trimethoprim ..............................................................15pomalidomide ............................................................................19Pomalyst ....................................................................................19INDEXponatinib ....................................................................................19Ponstel see mefenamic acid........................................................24Portia ..........................................................................................13posaconazole susp......................................................................17posaconazole tab........................................................................17potassium chloride......................................................................12potassium iodide ........................................................................14potassium phosphate/sodium ....................................................12Potiga..........................................................................................22Pradaxa ................................................................................9, 32pramipexole..........................................................................25, 34pramipexole ER ..........................................................................25Pramosone..................................................................................26Prandimet ..................................................................................10Prandin see repaglinide ..............................................................10prasugrel ......................................................................................9pravastatin ................................................................................11praziquantel ................................................................................17prazosin ..................................................................................8, 28Precision Xtra ..............................................................................11Precose see acarbose ................................................................10Pred Forte ..................................................................................15Pred-G ........................................................................................15prednicarbate..............................................................................27prednisolone soln........................................................................19prednisolone tab ........................................................................19prednisolone dispersible tab ......................................................19prednisolone/sulfacetamide........................................................15prednisone..................................................................................19prednisone ER ............................................................................19Prefest ........................................................................................14pregabalin ............................................................................22, 34Pregnyl..................................................................................14, 31Prelone see prednisolone......................................................15, 19Premarin ................................................................................3, 14Premarin cream ..........................................................................14Premphase..................................................................................14Prempro ......................................................................................14PremproLo ..................................................................................14prenatal multivitamin ..................................................................12Prenate ......................................................................................12Prepopik ....................................................................................28Prevacid see lansoprazole ....................................................27, 33Prevacid SoluTab ........................................................................27Prevident ....................................................................................12Previfem......................................................................................13PrevPac see lansoprazole/amoxicillin/clarithromycin ............27, 33Prezista ......................................................................................18Priftin ..........................................................................................17Prilosec see omeprazole ......................................................27, 34Prilosec OTC..........................................................................27, 34primaquine..................................................................................17primidone ..................................................................................226-16-1456

Prinivil see lisinopril ......................................................................7Prinzide see lisinopril/HCTZ ..........................................................7Pristiq ..................................................................................21, 32ProAir HFA ..................................................................................29ProBanthine see propantheline ..................................................28probenecid..................................................................................19procainamide ................................................................................8procarbazine ..............................................................................19Procardia XL see nifedipine ER......................................................8Prochieve ....................................................................................14prochlorperazine..........................................................................27prochlorperazine syrup ................................................................27Procrit ..........................................................................................9Procysbi ......................................................................................29Prodrin ........................................................................................23progesterone ..............................................................................14progesterone gel ........................................................................14progesterone injection ................................................................14progesterone suppository ............................................................14Prograf see tacrolimus ..........................................................19, 26Prolensa......................................................................................15Prolia ..........................................................................................31Prolixin see fluphenazine ............................................................20Promacta ................................................................................9, 32promethazine ..............................................................................27Prometrium see progesterone......................................................14Pronestyl ......................................................................................8propafenone..................................................................................8propantheline..............................................................................28proparacaine ..............................................................................16propranolol ..................................................................................7propranolol LA ..............................................................................7propranolol/HCTZ ..........................................................................7propylthiouracil ..........................................................................14Proscar see finasteride................................................................28Prosom see estazolam ................................................................22Protonix see pantoprazole ....................................................27, 34Protonix suspension ....................................................................27Protopic ......................................................................................26protriptyline ................................................................................21Proventil HFA ..............................................................................29Provera see medroxyprogesterone ..............................................14Provigil see modafinil............................................................21, 34Prozac see fluoxetine ............................................................20, 21Prozac Weekly see fluoxetine weekly............................................21Psorcon see diflorasone ..............................................................27Pulmicort ....................................................................................29Pulmozyme ..........................................................................30, 32Purinethol see mercaptopurine....................................................19Pylera..........................................................................................27pyrazinamide ..............................................................................17Pyridium see phenazopyridine ....................................................28pyridostigmine ............................................................................22INDEXpyridostigmine SR ......................................................................22pyrimethamine ............................................................................17Qnasl ..........................................................................................29Qualaquin see quinine 324 mg ..................................................17Quartette ....................................................................................12Quasense....................................................................................13quazepam ..................................................................................22Questran see cholestyramine ......................................................11Questran Light see cholestyramine light ......................................11quetiapine ..................................................................................20quetiapine ER ............................................................................20Quillivant XR................................................................................21quinapril........................................................................................7Quinidex........................................................................................8quinidine ................................................................................8, 22quinine 260 mg ..........................................................................17quinine 324 mg ..........................................................................17Quixin see levofloxacin..........................................................15, 16QVAR ..........................................................................................29rabeprazole cap ..........................................................................27rabeprazole tab ..........................................................................27Ragwitek ..............................................................................29, 34raloxifene ....................................................................................11raltegravir ....................................................................................18ramelteon ............................................................................22, 34ramipril ........................................................................................7Ranexa..........................................................................................9ranitidine ....................................................................................27ranolazine ....................................................................................9Rapaflo ......................................................................................28Rapamune ..................................................................................19rasagiline..............................................................................25, 34Ravicti ........................................................................................14Rayos ..........................................................................................19Razadyne see galantamine....................................................22, 33Razadyne ER see galantamine ER ........................................22, 33Rebetol see ribavirin....................................................................18Rebetol ......................................................................................18Rebif ..........................................................................................20Reclipsen ....................................................................................13Rectagel HC see hydrocortisone/lidocaine rectal ........................28Rectiv..........................................................................................28Reglan see metoclopramide........................................................27regorafenib..................................................................................19Relafen see nabumetone ............................................................24Relenza ................................................................................18, 35Relistor ................................................................................28, 33Relpax ..................................................................................23, 32Remeron see mirtazapine............................................................21Remicade....................................................................................31Renagel ......................................................................................12Renvela ......................................................................................12repaglinide..................................................................................106-16-1457

epaglinide/metformin ................................................................10Reprexain....................................................................................24Requip see ropinirole ..................................................................25Requip XL see ropinirole XL ........................................................25Rescriptor....................................................................................18Rescula ......................................................................................15reserpine ......................................................................................9Restasis ......................................................................................16Restoril see temazepam..............................................................22retapamulin ................................................................................26Retin A see tretinoin..............................................................19, 25Retin A Micro see tretinoin microsphere ......................................25Retrovir see zidovudine................................................................18Revatio see sildenafil ....................................................................9ReVia see naltrexone ......................................................20, 24, 34Revlimid................................................................................19, 33Reyataz ......................................................................................18Rheumatrex see methotrexate ..............................................19, 20Rhinocort AQ ..............................................................................29Rhythmol SR see propafenone SR ................................................8Riax ............................................................................................25Ribapak ......................................................................................18Ribasphere..................................................................................18ribavirin ......................................................................................18ribavirin solution..........................................................................18Ridaura ......................................................................................19rifabutin ......................................................................................17Rifadin see rifampin....................................................................17Rifamate ....................................................................................17rifampin ......................................................................................17rifapentine ..................................................................................17Rifater ........................................................................................17rifaximin................................................................................17, 34rilonacept....................................................................................31rilpivirine ....................................................................................18Rilutek see riluzole ......................................................................22riluzole ........................................................................................22rimabotulinum toxin ....................................................................31Rimactone see rifampin ..............................................................17rimantadine ................................................................................18rimexolone ..................................................................................15riociguat..................................................................................9, 34Riomet ........................................................................................10risedronate ..........................................................................11, 34Risperdal see risperidone............................................................20Risperdal M-Tab see risperidone ODT ..........................................20risperidone..................................................................................20risperidone ODT ..........................................................................20Ritalin see methylphenidate..................................................21, 33Ritalin LA see methylphenidate CD 50:50 ..................................21ritonavir ......................................................................................18Rituxan........................................................................................31rituximab ....................................................................................31INDEXrivaroxaban....................................................................................9rivastigmine ................................................................................22rizatriptan..............................................................................23, 34Robaxin see methocarbamol ......................................................23Robinul see glycopyrrolate ..........................................................29Rocaltrol see calcitriol ..........................................................11, 26roflumilast ..................................................................................30romiplostim ................................................................................31ropinirole ....................................................................................25ropinirole XL................................................................................25Rosanil........................................................................................25rosiglitazone................................................................................10rosiglitazone/glimepiride ............................................................10rosiglitazone/metformin ..............................................................10rosuvastatin ..........................................................................11, 34rotigotine ....................................................................................25Roxicet see acetaminophen/oxycodone ................................24, 32Roxicodone see oxycodone ............................................24, 32, 34Rozerem................................................................................22, 34rufinamide ..................................................................................22ruxolitinib ....................................................................................19Rybix ODT....................................................................................24Ryzolt ER see tramadol ER....................................................24, 35Safyral ........................................................................................13Saizen ........................................................................................15Salagen see pilocarpine oral ......................................................29Salex ..........................................................................................26salicylic acid solution..................................................................25salicylic acid/ceramides..............................................................26salmeterol inhaler ......................................................................29salsalate ....................................................................................24Samsca ........................................................................................8Sanctura see trospium ................................................................28Sanctura XR see trospium ER......................................................28Sancuso ..............................................................................27, 33Sandimmune ..............................................................................19Sandostatin see octreotide..........................................................14Sandostatin LAR ........................................................................14sapropterin..................................................................................14saquinivir ....................................................................................18Sarafem ......................................................................................21sargramostim ................................................................................9Savella..................................................................................21, 34saxagliptin ............................................................................10, 34saxagliptin/metformin ................................................................10scopolamine ............................................................16, 27, 28, 34scopolamine patch ..............................................................27, 34Seasonale see Jolessa, Quasense ..............................................13Seasonique see Amethia, Camrese ............................................12Sectral see acebutolol ..................................................................7selegiline ........................................................................21, 25, 34selegiline patch ....................................................................21, 34selenium sulfide foam, shampoo ................................................266-16-1458

selenium sulfide suspension ......................................................26Selfemra see fluoxetine ........................................................20, 21Selrx............................................................................................26Selzentry ....................................................................................18Sensipar ....................................................................................11Septra see trimethoprim/sulfa ....................................................17Serax see oxazepam ..................................................................22Serevent......................................................................................29Seromycin ..................................................................................17Serophene see clomiphene ........................................................14Seroquel see quetiapine ............................................................20Seroquel XR ................................................................................20Serostim ....................................................................................15sertraconazole ............................................................................26sertraline ....................................................................................21Serzone see nefazodone ............................................................21sevelamer....................................................................................12sevelamer carbonate packet........................................................12sevelamer carbonate tab ............................................................12short ragweed pollen ............................................................29, 34Signifor ......................................................................................14sildenafil ......................................................................................9Silenor ........................................................................................22silodosin ....................................................................................28Silvadene see silver sulfadiazine ................................................26silver sulfadiazine........................................................................26Simbrinza....................................................................................15Simcor ..................................................................................11, 34simeprevir ............................................................................18, 34Simponi..........................................................................20, 28, 33simvastatin ..............................................................10, 11, 34, 35simvastatin/niacin ................................................................11, 34sinecatechins..............................................................................26Sinemet see carbidopa/levodopa ..............................................25Sinemet CR see carbidopa/levodopa CR ....................................25Sinequan see doxepin ....................................................21, 22, 26Singulair see montelukast ..........................................................30sirolimus ....................................................................................19sitagliptin..............................................................................10, 11sitagliptin/metformin ..................................................................10sitagliptin/metformin ER ............................................................10sitagliptin/simvastatin ..........................................................10, 11Sirturo ........................................................................................17Skelaxin see metaxalone ............................................................23Skelid..........................................................................................11Sklice..........................................................................................26sodium bicarbonate..............................................................12, 27sodium chloride 3% for inh ........................................................30sodium chloride 6% for inh ........................................................30sodium chloride 7% for inh ........................................................30sodium oxybate ..........................................................................21sodium phenylbutyrate ................................................................29sodium phosphate................................................................12, 28INDEXsodium polystyrene sulfonate......................................................12sodium, potassium and magnesium sulfate ..............................28sodium picosulfate/magnesium oxide/citric acid ........................28sofosbuvir ............................................................................18, 35Solaraze see diclofenac gel ........................................................24solifenacin ............................................................................28, 35Soliris..........................................................................................31Solodyn see minocycline ER........................................................25Soluclenz RX ..............................................................................25Soma see carisoprodol ..............................................................23somatropin..................................................................................15Somatuline depot........................................................................14Somavert ....................................................................................15Sonata see zaleplon....................................................................22sorafenib ....................................................................................19Soriatane see acitretin ................................................................27Sorilux ........................................................................................26sotalol ..........................................................................................7sotalol AF ......................................................................................7Sotret see isotretinoin ................................................................25Sovaldi..................................................................................18, 35Spectracef see cefditoren............................................................16Spectrazole see econazole ..........................................................26spinosad ....................................................................................26Spiriva ........................................................................................30spironolactone ..............................................................................8spironolactone/HCTZ ....................................................................8Sporanox see itraconazole ..........................................................17Sprintec ......................................................................................13Sprix ..........................................................................................24Sprycel ......................................................................................19Sronyx ........................................................................................13SSKI............................................................................................14Stadol NS see butorphanol nasal spray ................................23, 32Stalevo see carbidopa/levodopa/entacapone ............................25Starlix see nateglinide ................................................................10stavudine ....................................................................................18Stavzor........................................................................................22Stelara ....................................................................20, 27, 31, 35Stelazine see trifluoroperazine ....................................................20Stimate ......................................................................................14Stivarga ......................................................................................19Strattera......................................................................................21Striant ........................................................................................14Stribild ........................................................................................18Stromectol ..................................................................................17subcutaneous immune globulin ..................................................19Suboxone....................................................................................20Subsys..................................................................................24, 33Subutex see buprenorphine ..................................................20, 24Suclear ......................................................................................28sucralfate..............................................................................27, 29sucralfate paste ..........................................................................296-16-1459

sucroferric oxyhydroxide ..............................................................12Sular see nisoldipine ....................................................................8sulconazole ................................................................................26sulfacetamide ophthalmic ..........................................................15sulfacetamide sodium shampoo, suspension ..............................25sulfacetamide sodium wash, cleanser ........................................25sulfacetamide/sulfur 8%/4% suspension....................................25sulfacetamide/sulfur 9%/4% cleanser ........................................25sulfacetamide/sulfur 9%/4.5% cleanser ....................................25sulfacetamide/sulfur 9.5%/5% medicated pads ........................25sulfacetamide/sulfur 9.8%/4.8% cleanser, cream,medicated pads, lotion ........................................................25sulfacetamide/sulfur 10%/1% cleanser......................................25sulfacetamide/sulfur 10%/2% cream, medicated pads ..............25sulfacetamide/sulfur 10%/4% foam, medicated pads ................25sulfacetamide/sulfur 10%/5% cream, cleanser, medicated pads,foam, lotion, suspension ......................................................25sulfadiazine ..........................................................................17, 26Sulfamylon see mafenide............................................................26sulfanilamide ..............................................................................26sulfasalazine ........................................................................19, 28Sulfatrim ....................................................................................17sulfisoxazole ........................................................................16, 17sulindac ......................................................................................24Sumadan see sulfacetamide/sulfur 9%/4.5% cleanser ..............25sumatriptan injection ............................................................23, 35sumatriptan nasal ................................................................23, 35sumatriptan tablets ....................................................................23sumatriptan/naproxen ....................................................23, 24, 35Sumavel Dosepro..................................................................23, 35Sumaxin see sulfacetamide/sulfur ..............................................25Sumycin......................................................................................17sunitinib......................................................................................19Supprelin ....................................................................................14Suprax ........................................................................................16Suprep........................................................................................28Surmontil see trimipramine ........................................................21Sustiva........................................................................................18Sutent ........................................................................................19Syeda..........................................................................................13Sylatron ......................................................................................19Symbicort....................................................................................29Symbyax see fluoxetine/olanzapine ............................................20Symlin ........................................................................................10Symmetrel see amantadine ..................................................18, 25Synagis ......................................................................................31Synalar see fluocinolone ......................................................16, 27Synarel........................................................................................14Syntest........................................................................................14Synthroid ....................................................................................14Tabloid ........................................................................................19Taclonex see betamethasone/calcipotriene ..........................26, 27tacrolimus ............................................................................19, 26INDEXtacrolimus ER..............................................................................19tadalafil ............................................................................9, 28, 35Tafinlar ........................................................................................19tafluprost ....................................................................................15Tagamet see cimetidine ..............................................................27Tambocor see flecainide................................................................8Tamiflu..................................................................................18, 34tamoxifen....................................................................................19tamsulosin ..................................................................................28Tapazole see methimazole ..........................................................14tapentadol ............................................................................24, 35tapentadol ER ......................................................................24, 35Tarceva..................................................................................19, 32Targretin ......................................................................................19Tarka ........................................................................................7, 8tasimelteon ..........................................................................22, 35Tasmar ........................................................................................25tazarotene ..................................................................................25Tazorac........................................................................................25TBO-filgrastim................................................................................9Tecfidera ..............................................................................20, 32teduglutide..................................................................................28Tegretol ......................................................................................22Tegretol XR ..................................................................................22Tekamlo ..............................................................................8, 9, 32Tekturna ..................................................................................9, 32Tekturna HCT ..........................................................................9, 32telaprevir ....................................................................................18telbivudine ................................................................................18telithromycin ........................................................................16, 35telmisartan................................................................................7, 8telmisartan/HCTZ ..........................................................................7temazepam ................................................................................22Temodar see temozolomide ..................................................19, 35Temovate see clobetasol topical..................................................27temozolomide ......................................................................19, 35Tenex see guanfacine........................................................8, 21, 33tenofovir......................................................................................18Tenoretic see atenolol/chlorthalidone............................................7Tenormin see atenolol ..................................................................7Tequin ........................................................................................16terazosin ................................................................................8, 28terbinafine ..................................................................................17terbinafine granules ....................................................................17terbutaline tabs ..........................................................................30teriflunomide ........................................................................20, 35teriparatide ..........................................................................11, 35Tersi Foam ..................................................................................26Tessalon see benzonatate ..........................................................29Test strips-Abbott ........................................................................11Test strips-Bayer ..........................................................................11Test strips-Lifescan......................................................................11Test strips-Roche ........................................................................116-16-1460

testosterone buccal ....................................................................14testosterone cypionate injection..................................................14testosterone enanthate injection ................................................14testosterone topical ....................................................................14testosterone topical packets........................................................14testosterone topical patches ......................................................14Testred ........................................................................................14tetrabenazine ..............................................................................25tetracaine ............................................................................16, 26tetracycline capsule ....................................................................17tetracycline tabs..........................................................................17Teveten see eprosartan..................................................................7Teveten HCT ..................................................................................7Tev-Tropin ....................................................................................15Texacort ......................................................................................26thalidomide ................................................................................19Thalomid ....................................................................................19Theo-24 ......................................................................................30Theocap ......................................................................................30theophylline ................................................................................30thioguanine ................................................................................19thioridazine ................................................................................20thiothixene ..................................................................................20Thorazine see chlorpromazine......................................................20thyroid pork ................................................................................14thyroid pork (Westhroid, Nature-Throid)........................................14tiagabine ....................................................................................22Tiazac see diltiazem ER (24H) ......................................................8ticagrelor ......................................................................................9Ticlid see ticlopidine......................................................................9ticlopidine ....................................................................................9Tigan see trimethobenzamide......................................................27Tikosyn..........................................................................................8Tilia FE........................................................................................12tiludronate ..................................................................................11timolol ....................................................................................7, 15timolol XE....................................................................................15Timoptic see timolol................................................................7, 15Timoptic XE see timolol XE ..........................................................15timothy grass pollen..............................................................29, 35Tindamax see tinidazole ..............................................................17tinidazole ....................................................................................17tinzaparin ......................................................................................9tiotropium inhaler........................................................................30tipranavir ....................................................................................18Tivicay ........................................................................................18tizanidine capsules......................................................................23tizanidine tablets ........................................................................23TMP-Sulfa ..................................................................................17TOBI see tobramycin inhalation ..................................................30TOBI Podhaler ............................................................................30Tobradex dropssee tobramycin/dexamethasone 0.3/0.1% drops ................15INDEXTobradex ointment ......................................................................15Tobradex ST ................................................................................15tobramycin............................................................................15, 30tobramycin inhalation..................................................................30tobramycin inj for inh ..................................................................30tobramycin/dexamethasone 0.3/0.05% drops ..........................15tobramycin/dexamethasone 0.3/0.1% drops..............................15tobramycin/dexamethasone ointment ........................................15tobramycin/lotepred ..................................................................15Tobrex see tobramycin ..........................................................15, 30tocilizumab ....................................................................20, 31, 35tofacitinib....................................................................................20Tofranil see imipramine ..............................................................21Tofranil-PM see imipramine pamoate ..........................................21tolazamide ..................................................................................10tolbutamide ................................................................................10tolcapone....................................................................................25Tolinase see tolazamide ..............................................................10tolmetin ......................................................................................24tolterodine ............................................................................28, 35tolterodine ER ............................................................................28tolvaptan ......................................................................................8Topamax see topiramate ............................................................22Topicort see desoximetasone ......................................................27topiramate ..................................................................................22topiramate ER ............................................................................22topotecan ..................................................................................19Toprol XL see metoprolol succinate (XL) ..................................7, 33toremifene ..................................................................................19torsemide......................................................................................8Toviaz....................................................................................28, 33Tracleer ........................................................................................9Tradjenta ..............................................................................10, 33tramadol ..............................................................................24, 35tramadol ER..........................................................................24, 35tramadol ODT..............................................................................24tramadol/acetaminophen............................................................24trametinib ..................................................................................19Trandate see labetalol ..................................................................7trandolapril ..............................................................................7, 8trandolapril/verapamil ..............................................................7, 8tranexamic acid ............................................................................9TransdermScop ..........................................................................27Tranxene see clorazepate ............................................................22Tranxene SD see clorazepate ER..................................................22tranylcypromine ..........................................................................21Travatan Z....................................................................................15travoprost....................................................................................15travoprost benzalkonium..............................................................15trazodone....................................................................................21trazodone ER ..............................................................................21Trecator ......................................................................................17Trental see pentoxifylline................................................................96-16-1461

treprostinil diolamine ..............................................................9, 35treprostinil neb..............................................................................9tretinoin ................................................................................19, 25tretinoin microsphere ..................................................................25tretinoin capsules........................................................................19Tretin-X........................................................................................25Treximet ..........................................................................23, 24, 35Trezix ..........................................................................................23triamcinolone ..........................................................19, 26, 27, 29triamcinolone oropharyngeal ......................................................26triamcinolone nasal ....................................................................29triamcinolone topical ..................................................................27triamterene....................................................................................8triamterene/HCTZ ..........................................................................8triazolam ....................................................................................22Tribenzor........................................................................................7Tricor see fenofibrate ..................................................................11Tridesilon ....................................................................................26Tri-Estarylla..................................................................................12trifluoroperazine ..........................................................................20trifluridine....................................................................................16Triglide ........................................................................................11trihexyphenidyl ............................................................................25Trilafon see perphenazine............................................................20Tri-Legest FE................................................................................12Trileptal see oxcarbazepine..........................................................22Tri-Linyah ....................................................................................12Trilipix see fenofibric acid ............................................................11Trilyte ..........................................................................................28trimethobenzamide......................................................................27trimethoprim ........................................................................15, 17trimethoprim/sulfa ......................................................................17trimipramine................................................................................21Trimox see amoxicillin ....................................................16, 27, 33Trinessa ......................................................................................12Tri-Norinyl see Aranelle, Leena ....................................................12Trioxin..........................................................................................16Triphasil see Trivora, Enpresse, Myzilra ........................................12Tri-Previfem..................................................................................12Tri-Sprintec..................................................................................12Trivora ........................................................................................12Trizivir see abacavir/lamivudine/zidovudine ................................18Trokendi XR ................................................................................22tropicamide ................................................................................16trospium ....................................................................................28trospium ER ................................................................................28Trusopt see dorzolamide..............................................................15Truvada ......................................................................................18Tudorza Pressair ..........................................................................30Twynsta see amlodipine/telmisartan ........................................7, 8Tykerb..........................................................................................19Tylenol #3 see acetaminophen/codeine......................................24Tysabri ........................................................................................31INDEXTyvaso ..........................................................................................9Tyzeka ........................................................................................18Uceris ..................................................................................28, 32U-Cort ........................................................................................26Ulesfia ........................................................................................26ulipristal................................................................................13, 35Uloric ..........................................................................................19Ultracet see tramadol/acetaminophen ........................................24Ultram see tramadol ............................................................24, 35Ultram ER see tramadol ER ..................................................24, 35Ultrase ........................................................................................28Ultravate see halobetasol............................................................27Ultresa ........................................................................................28umeclidinum/vilanterol ..............................................................30Uniretic see moexipril/HCTZ ..........................................................7Unithroid ....................................................................................14Univasc see moexipril....................................................................7unoprostone isopropyl ................................................................15urea 47%....................................................................................26Urecholine see bethanechol........................................................28Urex see methenamine................................................................17Urex ............................................................................................17Urispas see flavoxate ..................................................................28Uroxatral see alfuzosin ................................................................28URSO see ursodiol ......................................................................28URSO Forte see ursodiol ............................................................28ursodiol ......................................................................................28ustekinumab ............................................................20, 27, 31, 35Vagifem ......................................................................................14valacyclovir..................................................................................18Valchlor ......................................................................................19Valcyte ........................................................................................18valganciclovir ..............................................................................18Valium see diazepam ..................................................................22valproic acid ..............................................................................22valproic acid SA ..........................................................................22valsartan ..................................................................................7, 8valsartan/HCTZ..........................................................................7, 8Valtrex see valacyclovir................................................................18Vancocin see vancomycin oral ....................................................17vancomycin oral ..........................................................................17vandetanib..................................................................................19Vanos see fluocinonide 0.1% ......................................................27Vantin see cefpodoxime ..............................................................16varenicline ..................................................................................20Vascepa................................................................................11, 33Vaseretic see enalapril/HCTZ ........................................................7Vasotec see enalapril ....................................................................7Vecamyl ........................................................................................9Vectical see calcitriol topical ......................................................26Veetids........................................................................................16Velivet ........................................................................................12Velphoro......................................................................................126-16-1462

Veltin ..........................................................................................25vemurafenib ................................................................................19venlafaxine ER tablets ................................................................21venlafaxine IR..............................................................................21venlafaxine SR capsules..............................................................21Ventavis ........................................................................................9Ventolin HFA................................................................................29Veramyst ....................................................................................29verapamil ..................................................................................7, 8verapamil ER ................................................................................8Veregen ......................................................................................26Verelan PM see verapamil ER ........................................................8Veripred ......................................................................................19Versacloz ....................................................................................20Vesanoid see tretinoin capsules ..................................................19Vesicare ................................................................................28, 35Vestura........................................................................................13Vexol ..........................................................................................15Vfend see voriconazole................................................................17Vibramycin see doxycycline monohydrate..............................17, 25Vibramycin susp..........................................................................17Vicodin see acetaminophen/hydrocodone ..................................24Vicoprofen see ibuprofen/hydrocodone ......................................24Victoza........................................................................................10Victrelis ......................................................................................18Videx see didanosine ..................................................................18Vigamox ......................................................................................15Viibryd ..................................................................................21, 35vilazodone ..........................................................................21, 35Vimovo..................................................................................27, 34Vimpat..................................................................................22, 33Viokace ......................................................................................28Viorele ........................................................................................12Viracept ......................................................................................18Viramune see nevirapine ............................................................18Viramune XR see nevirapine XR ..................................................18Virasal ........................................................................................25Viread ........................................................................................18Visken see pindolol ......................................................................7vismodegib ................................................................................19Vitafol+DHA ................................................................................12Vivactil see protriptyline ..............................................................21Vivelle-dot ............................................................................14, 33Voltaren see diclofenac ........................................................15, 24Voltaren gel ................................................................................24voriconazole ..............................................................................17vortioxetine ..........................................................................21, 35Votrient ......................................................................................19Vusion ........................................................................................26Vytorin ..................................................................................11, 34Vyvanse ................................................................................21, 33warfarin ........................................................................................9Welchol ......................................................................................11INDEXWellbutrin see bupropion ................................................20, 21, 32Wellbutrin XL see bupropion XL ............................................21, 32Wera ..........................................................................................13Westhroid....................................................................................14Xalatan see latanoprost ..............................................................15Xalkori ........................................................................................19Xanax see alprazolam ................................................................22Xanax XR see alprazolam ER ......................................................22Xarelto ........................................................................................9Xartemis XR ..........................................................................24, 32Xeljanz ........................................................................................20Xeloda see capecitabine ............................................................19Xenazine ....................................................................................25Xeomin........................................................................................31Xerese ........................................................................................26Xgeva ..........................................................................................31Xibrom see bromfenac ................................................................15Xifaxan..................................................................................17, 34Xodol see acetaminophen/hydrocodone ....................................24Xolair ..........................................................................................31Xolegel ........................................................................................26Xolegel Duo ................................................................................26Xolox ..........................................................................................24Xopenex HFA ..............................................................................29Xtandi ........................................................................................19Xulane Patch ........................................................................13, 34Xyrem..........................................................................................21Xyzal see levocetirizine ................................................................29Yasmin see Ocella, Syeda, Zarah ................................................13Yaz see Gianvi, Loryna ................................................................13zafirlukast ..................................................................................30zaleplon ......................................................................................22Zamicet see acetaminophen/hydrocodone..................................24Zanaflex see tizanidine capsules ................................................23zanamivir ..............................................................................18, 35Zantac see ranitidine ..................................................................27Zarah ..........................................................................................13Zaroxolyn see metolazone ............................................................8Zavesca ......................................................................................11Zebeta see bisoprolol....................................................................7Zegerid see omeprazole/sodium bicarbonate..............................27Zelboraf ......................................................................................19Zemplar see paricalcitol ..............................................................11Zenatane ....................................................................................25Zenchent ....................................................................................13Zenpep........................................................................................28Zenzedi ......................................................................................21Zeosa..........................................................................................13Zerit see stavudine ......................................................................18Zestoretic see lisinopril/HCTZ ........................................................7Zestril see lisinopril........................................................................7Zetia ..........................................................................................11Zetonna HFA................................................................................296-16-1463

Ziac see bisoprolol/HCTZ ..............................................................7Ziagen see abacavir tablets ........................................................18Ziagen suspension ......................................................................18Ziana ..........................................................................................25zidovudine ..................................................................................18zileuton ......................................................................................30Zioptan ......................................................................................15ziprasidone ................................................................................20Zipsor..........................................................................................24Zithromax see azithromycin ............................................15, 16, 32Zmax ....................................................................................16, 32Zocor see simvastatin ..............................................10, 11, 34, 35ZoDerm ......................................................................................25Zofran see ondansetron ........................................................27, 34Zohydro ER ..........................................................................24, 33zolmitriptan ..........................................................................23, 35zolmitriptan nasal ................................................................23, 35Zoloft see sertraline ....................................................................21zolpidem ..............................................................................22, 35zolpidem CR ........................................................................22, 35zolpidem spray............................................................................22zolpidem sublingual ..............................................................22, 35Zolpimist ....................................................................................22Zomig see zolmitriptan..........................................................23, 35zonisamide..................................................................................22Zorbtive ......................................................................................15Zortress ......................................................................................19Zorvolex ......................................................................................24Zovia 1/35..................................................................................13Zovia 1/50..................................................................................13Zovirax see acyclovir oral ............................................................18Zovirax ointment see acyclovir topical ..................................18, 26Zostavax......................................................................................31zoster vaccine ............................................................................31Zubsolv ......................................................................................20Zuplenz ......................................................................................27Zyban see bupropion SR ......................................................20, 21Zyclara ........................................................................................26Zyflo............................................................................................30Zykadia ......................................................................................19Zylet............................................................................................15Zyloprim see allopurinol ..............................................................19Zymaxid see gatifloxacin ......................................................15, 16Zyprexa see olanzapine ..............................................................20Zyprexa zydis see olanzapine ODT ..............................................20Zytiga ..........................................................................................19Zyvox ..........................................................................................17INDEX6-16-1464

Medication Prior Authorization Request Form To view medication prior authorization criteria visit http://www.unityhealth.com/apps/medicationpriorauth/ Direct questions about medication prior authorization criteria to a Unity pharmacist at (888) 450-4884 or (608) 265-7397 To check the status of a PA request contact MedImpact Customer Service at (800) 788-2949 To appeal decisions contact Unity Customer Service at (800) 362-3310 Please complete the form entirely to ensure a prompt review PRIOR AUTHORIZATION REQUESTS ARE ACCEPTED BY FAX OR MAIL ONLYPlease fax to: (888) 450-4711 OR Mail to: Unity Pharmacy ProgramUniversity of Wisconsin Hospital and Clinics600 Highland Ave. Mail code 9475Madison, WI 53792Step 1: Patient and Prescriber Information. (Please print clearly and complete entirely.)Date:Prescriber Name:Patient Name:Patient Date of Birth:Prescriber Phone #:Unity ID Number:Prescriber Fax #:Allergies:Step 2: Diagnosis and Medication Information. (Please print clearly and complete entirely.)Diagnosis:Medication Name: Dose: Schedule: Duration of Therapy:Reason/Clinical Rationale for the Request (Include relevant past medical history and medication trials.)Optional: Pharmacy Name Optional: Pharmacy Phone Optional: Pharmacy FaxStep 3: For Clinic/Physician Administered Medications Only.Administering Provider Name: Provider Phone: Provider Fax:Providing Facility: Facility Phone: Facility Fax:Procedure Code/Description:**Prescribers will be notified by fax and patients will be notified by mail when a decision has been determined.**CONFIDENTIALITY NOTICE: This document(s) comprising this facsimile and cover sheet are intended for use by the party to whomit is addressed, may contain privileged, confidential, and/or trade secret information, and is protected from disclosure underapplicable law. If you are not the addressee, a person authorized to deliver the document to the addressee, or if you have receivedthis transmission in error, please notify the sender immediately. UH01080656-16-14