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Microsoft word - 2016 ah65 preferred rx individual formulary - update 9.16--final

AmeriHealth 65® Preferred Rx HMO
2016 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
FID 16215, Version 21 This formulary was updated on 9/01/16. For more recent information or other questions, please contact AmeriHealth 65 Preferred Rx at 1-866-569-5190 or, for TTY/TDD users, 711, seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail. Or visit www.amerihealthmedicare.com. Note to existing members: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take.
When this drug list (formulary) refers to "we," "us," or "our," it means AmeriHealth HMO, Inc. When it refers to "plan" or "our plan," it means AmeriHealth 65 Preferred Rx. This document includes a list of the drugs (formulary) for our plan, which is current as of 9/01/16. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. Y0041_HM_16_31013 Accepted 6/8/2015 What is the AmeriHealth 65 Preferred Rx Formulary?
A formulary is a list of covered drugs selected by AmeriHealth 65 Preferred Rx in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. AmeriHealth 65 Preferred Rx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an AmeriHealth 65 Preferred Rx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 9/01/16. To get updated information about the drugs covered by AmeriHealth 65 Preferred Rx, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid-year non-maintenance formulary change, all affected members will receive a notification of changes to the formulary. How do I use the Formulary?
There are two ways to find your drug within the formulary: Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, "Cardiovascular Agents." If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 52. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
AmeriHealth 65 Preferred Rx covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:  Prior Authorization: AmeriHealth 65 Preferred Rx requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from AmeriHealth 65 Preferred Rx before you fill your prescriptions. If you don't get approval, AmeriHealth 65 Preferred Rx may not cover the drug.  Quantity Limits: For certain drugs, AmeriHealth 65 Preferred Rx limits the amount of the drug that our
plan will cover. For example, AmeriHealth 65 Preferred Rx provides 30 units per prescription for CRESTOR. This may be in addition to a standard one-month or three-month supply.  Step Therapy: In some cases, AmeriHealth 65 Preferred Rx requires you to first try certain drugs to
treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, AmeriHealth 65 Preferred Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AmeriHealth 65 Preferred Rx will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask AmeriHealth 65 Preferred Rx to make an exception to these restrictions or limits, or for a list of other similar drugs that may treat your health condition. See the section, "How do I request an exception to the AmeriHealth 65 Preferred Rx formulary?" on page ii for information about how to request an exception. What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact our Member Help Team and ask if your drug is covered. If you learn that AmeriHealth 65 Preferred Rx does not cover your drug, you have two options:  You can ask our Member Help Team for a list of similar drugs that are covered by AmeriHealth 65 Preferred Rx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by AmeriHealth 65 Preferred Rx.  You can ask AmeriHealth 65 Preferred Rx to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the AmeriHealth 65 Preferred Rx Formulary?
You can ask AmeriHealth 65 Preferred Rx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.  You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.  You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug.  You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, AmeriHealth 65 Preferred Rx limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, AmeriHealth 65 Preferred Rx will only approve your request for an exception if the alternative drugs included on the plan's formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization
restriction exception. When you request a formulary, tiering, or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request. Generally, we
must make our decision within 72 hours of getting your prescriber's supporting statement. You can request
an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by
waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no
later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increments, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If a transition occurs due to a member changing setting, such as moving from a home residence to a long-term care facility and then back again, our plan has a method in place to ensure that you have access to your medication. If your change of setting cannot be identified by the automated system, the pharmacy can notify our plan of the setting change and provide you with your needed medications. You will receive notice that you must either switch to a therapeutically appropriate drug on the plan's formulary or request an exception to continue taking the requested drug. For more information
For more detailed information about your AmeriHealth 65 Preferred Rx prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about AmeriHealth 65 Preferred Rx, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. AmeriHealth 65 Preferred Rx's Formulary
The formulary that begins on the next page provides coverage information about the drugs covered by AmeriHealth 65 Preferred Rx. If you have trouble finding your drug in the list, turn to the Index that begins on page 52. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lowercase italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if AmeriHealth 65 Preferred Rx has any special requirements for coverage of your drug.  Prior Authorization (PA): AmeriHealth 65 Preferred Rx requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from AmeriHealth 65 Preferred Rx before you fill your prescriptions. If you don't get approval, AmeriHealth 65 Preferred Rx may not cover the drug. Prior authorization requirements are determined by a non-partisan committee of actively practicing physicians, other prescribers, pharmacists, nurses, administrators, quality improvement managers, and other health care professionals and staff who participate in the medication-use process.  Quantity Limits (QL): For certain drugs, AmeriHealth 65 Preferred Rx limits the amount of the drug that
our plan will cover. For example, AmeriHealth 65 Preferred Rx provides 30 units per prescription for CRESTOR. This may be in addition to a standard one-month or three-month supply.  Step Therapy (ST): In some cases, AmeriHealth 65 Preferred Rx requires you to first try certain drugs
to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, AmeriHealth 65 Preferred Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AmeriHealth 65 Preferred Rx will then cover Drug B. The Drug Tier column of the chart lists the drug tier. The drug tier is the level of formulary cost-sharing for which the member is responsible. See your Evidence of Coverage for more information about cost-sharing amounts. Drug Name
Analgesics - Drugs used to control pain; painkillers
ABSTRAL
QL (120 EA per 30 days) PA acetaminophen/codeine #3 QL (180 EA per 30 days) acetaminophen/codeine soln QL (2700 ML per 30 days) acetaminophen/codeine tabs 300mg; 15mg, 300mg; 60mg QL (180 EA per 30 days) QL (180 EA per 30 days) PA QL (180 EA per 30 days) PA butalbital/acetaminophen/caffeine caps QL (180 EA per 30 days) PA butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg QL (180 EA per 30 days) PA QL (180 EA per 30 days) PA butorphanol tartrate inj butorphanol tartrate nasal soln QL (8 ML per 30 days) QL (4 EA per 28 days) celecoxib caps codeine sulfate tabs QL (180 EA per 30 days) diclofenac potassium diclofenac sodium dr diclofenac sodium er diclofenac sodium/misoprostol diflunisal tabs duramorph endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg QL (240 EA per 30 days) etodolac er fentanyl citrate oral transmucosal QL (120 EA per 30 days) PA fentanyl pt72 12mcg/hr QL (15 EA per 30 days) fentanyl pt72 100mcg/hr, 25mcg/hr, 37.5mcg/hr, 50mcg/hr, 62.5mcg/hr, 2 QL (15 EA per 30 days) PA 75mcg/hr, 87.5mcg/hr FENTORA QL (120 EA per 30 days) PA QL (60 EA per 30 days) PA flurbiprofen tabs hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 7.5mg/15ml 2 QL (3600 ML per 30 days) hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 2 QL (180 EA per 30 days) 300mg; 7.5mg, 325mg; 2.5mg hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 2 QL (180 EA per 30 days) 7.5mg hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg; 200mg, 7.5mg; 200mg 2 QL (150 EA per 30 days) hydromorphone hcl er QL (120 EA per 30 days) PA hydromorphone hcl liqd QL (1500 ML per 30 days) hydromorphone hcl inj 2mg/ml hydromorphone hcl inj 500mg/50ml hydromorphone hcl tabs 2mg QL (240 EA per 30 days) hydromorphone hcl tabs 4mg, 8mg QL (240 EA per 30 days) PA ibuprofen susp You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 1 Drug Name
Analgesics - Drugs used to control pain; painkillers
ibuprofen tabs 400mg, 600mg, 800mg
indomethacin er indomethacin caps ketoprofen er ketoprofen caps ketorolac tromethamine tabs 10mg QL (20 EA per 30 days) PA QL (180 EA per 30 days) lorcet hd QL (180 EA per 30 days) lorcet plus tabs 325mg; 7.5mg QL (180 EA per 30 days) lortab tabs QL (180 EA per 30 days) meloxicam susp, tabs methadone hcl inj methadone hcl oral soln, tabs morphine sulfate er cp24 30mg, 45mg, 60mg, 75mg, 90mg QL (30 EA per 30 days) morphine sulfate er cp24 120mg QL (30 EA per 30 days) PA morphine sulfate er cp24 10mg, 20mg, 30mg, 50mg QL (60 EA per 30 days) morphine sulfate er cp24 100mg, 60mg, 80mg QL (60 EA per 30 days) PA morphine sulfate er tbcr 15mg, 30mg QL (90 EA per 30 days) morphine sulfate er tbcr 100mg, 200mg, 60mg QL (90 EA per 30 days) PA morphine sulfate tabs QL (180 EA per 30 days) morphine sulfate inj 10mg/ml, 2mg/ml, 4mg/ml, 8mg/ml morphine sulfate oral soln 10mg/5ml, 20mg/5ml QL (1000 ML per 30 days) morphine sulfate oral soln 100mg/5ml QL (150 ML per 30 days) nabumetone nalbuphine hcl inj naproxen dr naproxen sodium cr naproxen sodium er tb24 500mg naproxen sodium tabs 275mg, 550mg naproxen susp, tabs oxaprozin oxycodone hcl er t12a 10mg, 15mg, 20mg QL (90 EA per 30 days) oxycodone hcl er t12a 30mg, 40mg, 60mg, 80mg QL (90 EA per 30 days) PA oxycodone hcl caps QL (180 EA per 30 days) oxycodone hcl conc QL (180 ML per 30 days) oxycodone hcl soln QL (900 ML per 30 days) oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg QL (180 EA per 30 days) oxycodone hcl tabs 30mg QL (180 EA per 30 days) PA oxycodone/acetaminophen soln QL (1000 ML per 30 days) oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 2 QL (240 EA per 30 days) 5mg, 325mg; 7.5mg oxycodone/aspirin QL (240 EA per 30 days) QL (240 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 2 Drug Name
Analgesics - Drugs used to control pain; painkillers
oxymorphone hydrochloride er tb12 10mg, 15mg, 5mg, 7.5mg
QL (90 EA per 30 days) oxymorphone hydrochloride er tb12 20mg, 30mg, 40mg QL (90 EA per 30 days) PA oxymorphone hydrochloride tabs 5mg QL (180 EA per 30 days) oxymorphone hydrochloride tabs 10mg QL (180 EA per 30 days) PA piroxicam caps reprexain tabs 10mg; 200mg QL (150 EA per 30 days) SUBSYS LIQD 100MCG, 200MCG, 400MCG, 600MCG, 800MCG QL (120 EA per 30 days) PA sulindac tabs tencon tabs 325mg; 50mg QL (180 EA per 30 days) PA tolmetin sodium caps tolmetin sodium tabs 600mg tramadol hcl er cp24 100mg, 200mg, 300mg tramadol hcl tabs tramadol hydrochloride/acetaminophen QL (240 EA per 30 days) vicodin es tabs 300mg; 7.5mg QL (180 EA per 30 days) vicodin hp tabs 300mg; 10mg QL (180 EA per 30 days) vicodin tabs 300mg; 5mg QL (180 EA per 30 days) QL (3600 ML per 30 days) zebutal caps 325mg; 50mg; 40mg QL (180 EA per 30 days) PA Anesthetics - Drugs used to produce a local anesthetic effect
lidocaine hcl jelly
lidocaine hcl external soln lidocaine hcl inj 0.5%, 2% lidocaine viscous lidocaine/prilocaine crea lidocaine oint lidocaine ptch QL (90 EA per 30 days) PA Anti-Addiction/Substance Abuse Treatment Agents - Drugs to help avoid addictive substances i.e, alcohol,
nicotine or narcotics
acamprosate calcium dr
BUNAVAIL FILM 2.1MG; 0.3MG QL (120 EA per 30 days) PA BUNAVAIL FILM 6.3MG; 1MG QL (30 EA per 30 days) PA BUNAVAIL FILM 4.2MG; 0.7MG QL (90 EA per 30 days) PA buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg QL (120 EA per 30 days) PA buprenorphine hcl/naloxone hcl subl 8mg; 2mg QL (90 EA per 30 days) PA buprenorphine hcl subl QL (120 EA per 30 days) PA CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH PAK CHANTIX TABS 0.5MG, 1MG disulfiram tabs naloxone hcl inj naltrexone hcl tabs You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 3 Drug Name
Anti-Addiction/Substance Abuse Treatment Agents - Drugs to help avoid addictive substances i.e, alcohol,
nicotine or narcotics
NICOTROL INHALER
ZUBSOLV SUBL 1.4MG; 0.36MG, 2.9MG; 0.71MG QL (120 EA per 30 days) PA ZUBSOLV SUBL 11.4MG; 2.9MG QL (30 EA per 30 days) PA ZUBSOLV SUBL 8.6MG; 2.1MG QL (60 EA per 30 days) PA ZUBSOLV SUBL 5.7MG; 1.4MG QL (90 EA per 30 days) PA Antibacterials - Drugs used to treat infections caused by certain germs (bacteria)
ALCOHOL PREP PADS
amikacin sulfate inj 500mg/2ml amoxicillin amoxicillin/clavulanate potassium amoxicillin/clavulanate potassium er ampicillin ampicillin sodium inj 10gm, 125mg, 1gm azithromycin inj, pack, susr, tabs aztreonam inj 1gm bacitracin inj, oint bactocill in dextrose cefaclor er cefadroxil cefazolin sodium inj 10gm, 1gm, 1gm; 5%, 500mg cefepime inj 1gm, 2gm/50ml; 5%, 2gm cefotaxime sodium inj 1gm, 2gm, 500mg cefotetan cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 4 Drug Name
Antibacterials - Drugs used to treat infections caused by certain germs (bacteria)
cefuroxime axetil
cefuroxime sodium inj 1.5gm, 7.5gm, 750mg cephalexin chloramphenicol sodium succinate ciprofloxacin er ciprofloxacin hcl soln, tabs ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% ciprofloxacin susr ciprofloxacin inj 400mg/40ml clarithromycin er clarithromycin susr, tabs clindacin pac clindamax clindamycin hcl caps clindamycin palmitate hcl clindamycin phosphate in d5w clindamycin phosphate crea, foam, gel, lotn, external soln, swab clindamycin phosphate inj 600mg/4ml colistimethate sodium demeclocycline hcl dicloxacillin sodium QL (60 EA per 30 days) PA DORIBAX INJ 500MG doxycycline hyclate dr doxycycline hyclate caps, inj, tabs doxycycline monohydrate caps, tabs doxycycline caps 150mg, 75mg doxycycline susr e.e.s. 400 ERYTHROCIN LACTOBIONATE ERYTHROCIN STEARATE erythromycin base erythromycin ethylsuccinate tabs erythromycin cpep, gel, oint, soln gatifloxacin You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 5 Drug Name
Antibacterials - Drugs used to treat infections caused by certain germs (bacteria)
gentak
gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9%, 1.2mg/ml; 2 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9% gentamicin sulfate crea, inj, external oint, ophthalmic oint, ophthalmic 2 soln ilotycin isotonic gentamicin inj 0.8mg/ml; 0.9% levofloxacin levofloxacin in d5w inj 5%; 500mg/100ml, 5%; 750mg/150ml lincomycin hcl inj linezolid susr QL (1680 ML per 28 days) PA linezolid tabs QL (56 EA per 28 days) PA linezolid inj 600mg/300ml MACRODANTIN CAPS 25MG meropenem inj 500mg methenamine hippurate metronidazole in nacl 0.79% metronidazole vaginal metronidazole caps, crea, gel, lotn, tabs minocycline hcl er minocycline hcl caps, tabs moxifloxacin hcl mupirocin crea, oint nafcillin sodium inj 10gm, 1gm nafcillin inj 0; 1gm/50ml neomycin sulfate tabs neomycin/polymyxin b sulfates neomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 3.5mg/ml; 10000unit/ml nitrofurantoin macrocrystals nitrofurantoin monohydrate nitrofurantoin monohydrate/macrocrystals nitrofurantoin susp ofloxacin oxacillin sodium inj 10gm, 2gm paromomycin sulfate You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 6 Drug Name
Antibacterials - Drugs used to treat infections caused by certain germs (bacteria)
penicillin g potassium in iso-osmotic dextrose inj 0; 40000unit/ml, 0;
60000unit/ml penicillin g potassium inj 5000000unit penicillin g procaine penicillin g sodium penicillin v potassium piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm piperacillin/tazobactam inj 4gm; 0.5gm polymyxin b sulfate inj silver sulfadiazine crea QL (6 EA per 30 days) PA sodium sulfacetamide soln streptomycin sulfate inj sulfacetamide sodium oint, susp sulfadiazine tabs sulfamethoxazole/trimethoprim ds SUPRAX CAPS, CHEW SUPRAX SUSR 500MG/5ML tazicef inj 1gm, 2gm, 6gm tetracycline hcl caps tobramycin sulfate ophthalmic soln tobramycin sulfate inj 10mg/ml, 80mg/2ml trimethoprim tabs vancomycin hcl caps vancomycin hcl inj 1000mg, 10gm, 500mg vandazole XIFAXAN TABS 200MG XIFAXAN TABS 550MG QL (1680 ML per 28 days) PA Anticonvulsants - Drugs used to prevent or control seizures
APTIOM
BRIVIACT INJ, ORAL SOLN BRIVIACT TABS 10MG QL (60 EA per 30 days) BRIVIACT TABS 100MG, 25MG, 50MG, 75MG QL (60 EA per 30 days) carbamazepine er carbamazepine chew, susp, tabs You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 7 Drug Name
Anticonvulsants - Drugs used to prevent or control seizures
CELONTIN
CEREBYX INJ 500MG PE/10ML clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg QL (270 EA per 30 days) clonazepam odt tbdp 2mg QL (300 EA per 30 days) clonazepam tabs 0.5mg, 1mg QL (270 EA per 30 days) clonazepam tabs 2mg QL (300 EA per 30 days) diazepam gel 10mg, 2.5mg, 20mg DILANTIN CAPS 30MG divalproex sodium divalproex sodium dr divalproex sodium er ethosuximide felbamate fosphenytoin sodium inj 100mg pe/2ml gabapentin caps, soln, tabs GABITRIL TABS 12MG, 16MG lamotrigine er lamotrigine odt lamotrigine chew, tabs levetiracetam levetiracetam er QL (900 ML per 30 days) PA LYRICA CAPS 225MG, 300MG QL (60 EA per 30 days) PA LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG QL (90 EA per 30 days) PA QL (480 ML per 30 days) ONFI TABS 10MG, 20MG QL (60 EA per 30 days) oxcarbazepine phenobarbital elix QL (1500 ML per 30 days) phenobarbital tabs QL (90 EA per 30 days) phenytoin sodium extended phenytoin sodium inj phenytoin chew, susp primidone tabs tiagabine hydrochloride topiramate er You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 8 Drug Name
Anticonvulsants - Drugs used to prevent or control seizures
topiramate cpsp, tabs
valproate sodium inj valproic acid syrp 250mg/5ml VIMPAT ORAL SOLN, TABS zonisamide Antidementia Agents - Drugs used in the management of dementia
donepezil hcl
ergoloid mesylates tabs galantamine hydrobromide memantine hcl memantine hcl titration pak memantine hydrochloride soln NAMENDA TITRATION PAK NAMENDA XR TITRATION PACK rivastigmine tartrate rivastigmine transdermal system Antidepressants - Drugs used to manage depression and other related conditions
amitriptyline hcl tabs
amoxapine bupropion hcl sr bupropion hcl xl bupropion hcl tabs citalopram hydrobromide clomipramine hcl caps desipramine hcl tabs desvenlafaxine er duloxetine hcl cpep escitalopram oxalate FETZIMA TITRATION PACK fluoxetine dr QL (4 EA per 28 days) fluoxetine hcl caps, soln, tabs fluvoxamine maleate fluvoxamine maleate er imipramine hcl tabs You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 9 Drug Name
Antidepressants - Drugs used to manage depression and other related conditions
imipramine pamoate
maprotiline hcl mirtazapine mirtazapine odt nefazodone hcl nortriptyline hcl caps, soln paroxetine hcl paroxetine hcl er phenelzine sulfate protriptyline hcl sertraline hcl conc, tabs tranylcypromine sulfate trazodone hcl tabs trimipramine maleate caps venlafaxine hcl venlafaxine hcl er VIIBRYD STARTER PACK Antiemetics - Drugs used to help with nausea and vomiting
AKYNZEO
QL (180 EA per 30 days) dronabinol QL (12 EA per 30 days) PA EMEND CAPS 125MG QL (4 EA per 30 days) PA EMEND CAPS 40MG, 80MG QL (8 EA per 30 days) PA granisetron hcl tabs QL (60 EA per 30 days) PA granisetron hcl inj 0.1mg/ml, 1mg/ml meclizine hcl tabs ondansetron hcl oral soln ondansetron hcl inj 4mg/2ml ondansetron hcl tabs 24mg QL (14 EA per 28 days) PA ondansetron hcl tabs 4mg, 8mg QL (45 EA per 30 days) PA ondansetron odt QL (45 EA per 30 days) PA You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 10 Drug Name
Antiemetics - Drugs used to help with nausea and vomiting
phenadoz supp 12.5mg
phenergan supp promethazine hcl inj, supp, syrp, tabs promethegan supp 25mg, 50mg QL (4 EA per 28 days) PA trimethobenzamide hcl caps Antifungals - Drugs used to treat infections caused by a fungus i.e. athlete's foot, ringworm
ABELCET
amphotericin b ciclopirox ciclopirox nail lacquer ciclopirox olamine crea clotrimazole crea, soln, troc econazole nitrate crea ERAXIS INJ 100MG fluconazole in dextrose inj 56mg/ml; 400mg/200ml fluconazole in nacl inj 200mg/100ml; 0.9% fluconazole susr, tabs flucytosine griseofulvin microsize griseofulvin ultramicrosize gynazole-1 itraconazole caps ketoconazole crea, foam, sham, tabs naftifine hcl naftifine hydrochloride nystatin crea, oint, powd, susp, tabs oxiconazole nitrate You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 11 Drug Name
Antifungals - Drugs used to treat infections caused by a fungus i.e. athlete's foot, ringworm
OXISTAT
terbinafine hcl tabs terconazole voriconazole inj, susr, tabs zazole crea 0.8% Antigout Agents - Drugs used to manage gout
allopurinol tabs
colchicine caps, tabs probenecid tabs Antimigraine Agents - Drugs used for migraine headaches
almotriptan malate
QL (8 EA per 30 days) QL (4 EA per 90 days) PA dihydroergotamine mesylate inj dihydroergotamine mesylate nasal soln QL (8 ML per 28 days) frovatriptan succinate QL (12 EA per 30 days) methylergonovine maleate naratriptan hcl QL (8 EA per 30 days) QL (6 EA per 30 days) rizatriptan benzoate QL (12 EA per 30 days) rizatriptan benzoate odt QL (12 EA per 30 days) sumatriptan succinate refill QL (8 ML per 30 days) sumatriptan succinate tabs QL (8 EA per 30 days) sumatriptan succinate inj 6mg/0.5ml QL (8 ML per 30 days) sumatriptan soln QL (8 EA per 30 days) timolol maleate tabs 10mg, 20mg, 5mg zolmitriptan odt QL (6 EA per 30 days) zolmitriptan tabs QL (6 EA per 30 days) Antimyasthenic Agents - Drugs used to manage muscle weakness in people with myasthenia gravis
guanidine hcl
MESTINON TIMESPAN pyridostigmine bromide tabs, tbcr Antimycobacterials - Drugs used to treat infections caused by certain germs (mycobacteria)
CAPASTAT SULFATE
dapsone tabs ethambutol hcl isoniazid inj, syrp, tabs pyrazinamide tabs You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 12 Drug Name
Antimycobacterials - Drugs used to treat infections caused by certain germs (mycobacteria)
rifabutin
rifampin caps, inj Antineoplastics - Drugs used to treat/manage cancer
ABRAXANE
adrucil inj 500mg/10ml AFINITOR DISPERZ ALIMTA INJ 500MG amifostine anastrozole tabs azacitidine bicalutamide bleomycin sulfate inj 30unit carboplatin inj 150mg/15ml cisplatin inj 100mg/100ml cladribine cyclophosphamide caps cytarabine aqueous dacarbazine inj 200mg DARZALEX INJ 100MG/5ML daunorubicin hcl decitabine dexrazoxane inj 250mg DOCEFREZ INJ 20MG docetaxel inj 80mg/4ml, 80mg/8ml You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 13 Drug Name
Antineoplastics - Drugs used to treat/manage cancer
doxorubicin hcl liposome
doxorubicin hcl inj 2mg/ml epirubicin hcl inj 50mg/25ml ERBITUX INJ 100MG/50ML etoposide inj 500mg/25ml exemestane fludarabine phosphate inj 50mg fluorouracil inj 2.5gm/50ml flutamide FOLOTYN INJ 40MG/2ML gemcitabine hcl inj 1gm GLEOSTINE CAPS 5MG GLEOSTINE CAPS 10MG, 40MG GLEOSTINE CAPS 100MG hydroxyurea caps idarubicin hcl inj 10mg/10ml ifosfamide inj 1gm imatinib mesylate irinotecan inj 100mg/5ml IXEMPRA KIT INJ 45MG You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 14 Drug Name
Antineoplastics - Drugs used to treat/manage cancer
KADCYLA INJ 100MG
LENVIMA 10 MG DAILY DOSE LENVIMA 14 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE letrozole leucovorin calcium tabs leucovorin calcium inj 100mg, 350mg levoleucovorin calcium melphalan hydrochloride mercaptopurine tabs mitomycin inj 20mg mitoxantrone hcl OPDIVO INJ 40MG/4ML oxaliplatin inj 100mg/20ml paclitaxel inj 300mg/50ml RITUXAN INJ 500MG/50ML You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 15 Drug Name
Antineoplastics - Drugs used to treat/manage cancer
SYLATRON
SYLVANT INJ 100MG tamoxifen citrate tabs toposar inj 1gm/50ml topotecan hcl inj 4mg TREANDA INJ 100MG tretinoin caps 10mg VECTIBIX INJ 100MG/5ML VENCLEXTA STARTING PACK QL (84 EA per 365 days) PA VENCLEXTA TABS 50MG QL (30 EA per 30 days) PA VENCLEXTA TABS 10MG QL (60 EA per 30 days) PA VENCLEXTA TABS 100MG QL (120 EA per 30 days) PA vinblastine sulfate inj 1mg/ml vincasar pfs vincristine sulfate vinorelbine tartrate inj 50mg/5ml YERVOY INJ 50MG/10ML QL (200 ML per 365 days) PA ZALTRAP INJ 100MG/4ML Antiparasitics - Drugs used to treat infections caused by parasites
ALBENZA
You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 16 Drug Name
Antiparasitics - Drugs used to treat infections caused by parasites
ALINIA
atovaquone atovaquone/proguanil hcl chloroquine phosphate tabs hydroxychloroquine sulfate tabs ivermectin tabs lindane sham malathion mefloquine hcl permethrin crea primaquine phosphate tabs quinine sulfate tinidazole tabs Antiparkinson Agents - Drugs used to manage Parkinson's disease
APOKYN
benztropine mesylate inj, tabs bromocriptine mesylate caps, tabs carbidopa/levodopa er carbidopa/levodopa odt carbidopa tabs entacapone pramipexole dihydrochloride pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg, 2.25mg, 2 3mg, 4.5mg ropinirole er ropinirole hcl selegiline hcl caps, tabs tolcapone trihexyphenidyl hcl Antipsychotics - Drugs used to manage symptoms associated with psychiatric disorders
ABILIFY MAINTENA
aripiprazole odt You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 17 Drug Name
Antipsychotics - Drugs used to manage symptoms associated with psychiatric disorders
aripiprazole tabs
chlorpromazine hcl tabs chlorpromazine hcl inj 50mg/2ml clozapine clozapine odt FANAPT TITRATION PACK fluphenazine decanoate inj fluphenazine hcl conc, elix, inj, tabs haloperidol decanoate haloperidol lactate haloperidol conc, tabs INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/0.5ML INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ML, 234MG/1.5ML INVEGA TRINZA loxapine succinate molindone hydrochloride QL (60 EA per 30 days) PA olanzapine olanzapine odt paliperidone er perphenazine tabs prochlorperazine prochlorperazine edisylate inj prochlorperazine maleate tabs quetiapine fumarate RISPERDAL CONSTA INJ 12.5MG, 25MG RISPERDAL CONSTA INJ 37.5MG, 50MG risperidone risperidone odt thioridazine hcl tabs thiothixene trifluoperazine hcl tabs You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 18 Drug Name
Antipsychotics - Drugs used to manage symptoms associated with psychiatric disorders
VERSACLOZ
QL (14 EA per 365 days) ST QL (30 EA per 30 days) ST ziprasidone hcl ZYPREXA RELPREVV INJ 210MG Antispasticity Agents - Drugs used to prevent or relieve muscle spasms
baclofen tabs
dantrolene sodium caps QL (8.96 EA per 28 days) PA GABLOFEN INJ 10000MCG/20ML, 40000MCG/20ML, 50MCG/ML 4 PA LIORESAL INTRATHECAL INJ 0.05MG/ML, 10MG/20ML, 10MG/5ML tizanidine hcl caps, tabs XEOMIN INJ 50UNIT Antivirals - Drugs used to manage infections caused by viruses
abacavir
abacavir sulfate/lamivudine/zidovudine acyclovir sodium inj 50mg/ml acyclovir caps, oint, susp, tabs adefovir dipivoxil QL (30 EA per 30 days) amantadine hcl caps, syrp, tabs QL (600 ML per 30 days) cidofovir didanosine entecavir QL (30 EA per 30 days) famciclovir tabs ganciclovir inj INTRON A W/DILUENT INJ 10MU You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 19 Drug Name
Antivirals - Drugs used to manage infections caused by viruses
INTRON A INJ 6000000UNIT/ML
INTRON A INJ 18MU, 50MU ISENTRESS CHEW, PACK lamivudine MODERIBA 1200 DOSE PACK MODERIBA 800 DOSE PACK moderiba tabs nevirapine nevirapine er PEG-INTRON REDIPEN PEGASYS PROCLICK PREZISTA TABS 150MG, 600MG, 75MG, 800MG RELENZA DISKHALER QL (60 EA per 180 days) RETROVIR IV INFUSION RIBASPHERE RIBAPAK TABS 0 ribasphere ribapak tabs 400mg, 600mg ribasphere caps ribasphere tabs 200mg, 400mg ribasphere tabs 600mg ribavirin rimantadine hcl stavudine QL (540 ML per 30 days) TAMIFLU CAPS 45MG, 75MG QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 20 Drug Name
Antivirals - Drugs used to manage infections caused by viruses
TAMIFLU CAPS 30MG
QL (60 EA per 30 days) TIVICAY TABS 10MG, 25MG TIVICAY TABS 50MG trifluridine soln valacyclovir hcl tabs 500mg QL (60 EA per 30 days) valacyclovir hcl tabs 1000mg QL (90 EA per 30 days) valganciclovir VIDEX PEDIATRIC SOLR 2GM VIRAMUNE XR TB24 100MG QL (112 EA per 365 days) PA zidovudine Anxiolytics - Drugs used to manage anxiety
alprazolam intensol
QL (300 ML per 30 days) alprazolam tabs 0.25mg, 0.5mg QL (120 EA per 30 days) alprazolam tabs 2mg QL (150 EA per 30 days) alprazolam tabs 1mg QL (60 EA per 30 days) buspirone hcl tabs clorazepate dipotassium tabs 15mg QL (180 EA per 30 days) clorazepate dipotassium tabs 3.75mg, 7.5mg QL (90 EA per 30 days) diazepam intensol QL (240 ML per 30 days) diazepam soln 1mg/ml QL (1200 ML per 30 days) diazepam tabs 10mg, 2mg, 5mg QL (120 EA per 30 days) doxepin hcl caps, conc estazolam QL (30 EA per 30 days) lorazepam intensol QL (150 ML per 30 days) lorazepam tabs 0.5mg QL (180 EA per 30 days) lorazepam tabs 1mg, 2mg QL (90 EA per 30 days) oxazepam caps 15mg, 30mg QL (120 EA per 30 days) oxazepam caps 10mg QL (180 EA per 30 days) triazolam QL (10 EA per 30 days) Bipolar Agents - Drugs used as mood-stabilizers
lithium
You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 21 Drug Name
Bipolar Agents - Drugs used as mood-stabilizers
lithium carbonate er
lithium carbonate caps, tabs valproic acid caps 250mg Blood Glucose Regulators - Drugs used to maintain normal blood sugar levels
acarbose
alogliptin alogliptin/metformin hcl BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM glimepiride tabs 1mg, 2mg QL (120 EA per 30 days) glimepiride tabs 4mg QL (60 EA per 30 days) glipizide er tb24 2.5mg, 5mg QL (120 EA per 30 days) glipizide er tb24 10mg QL (60 EA per 30 days) glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg QL (120 EA per 30 days) glipizide/metformin hcl tabs 2.5mg; 250mg QL (180 EA per 30 days) glipizide tabs 10mg QL (120 EA per 30 days) glipizide tabs 5mg QL (240 EA per 30 days) GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT glyburide micronized tabs 3mg QL (120 EA per 30 days) PA glyburide micronized tabs 1.5mg QL (240 EA per 30 days) PA glyburide micronized tabs 6mg QL (60 EA per 30 days) PA glyburide/metformin hcl QL (120 EA per 30 days) PA glyburide tabs 5mg QL (120 EA per 30 days) PA glyburide tabs 1.25mg, 2.5mg QL (240 EA per 30 days) PA QL (60 EA per 30 days) JANUMET XR TB24 1000MG; 100MG QL (30 EA per 30 days) JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG QL (60 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 22 Drug Name
Blood Glucose Regulators - Drugs used to maintain normal blood sugar levels
KOMBIGLYZE XR
LEVEMIR FLEXTOUCH metformin hcl er tb24 500mg QL (120 EA per 30 days) metformin hcl er tb24 1000mg, 750mg QL (60 EA per 30 days) metformin hcl tabs 500mg QL (150 EA per 30 days) metformin hcl tabs 1000mg QL (60 EA per 30 days) metformin hcl tabs 850mg QL (90 EA per 30 days) nateglinide tabs 60mg QL (180 EA per 30 days) nateglinide tabs 120mg QL (90 EA per 30 days) NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 PREFILLED FLEXPEN pioglitazone hcl QL (30 EA per 30 days) pioglitazone hcl-glimepiride QL (30 EA per 30 days) pioglitazone hcl/metformin hcl QL (90 EA per 30 days) repaglinide/metformin hydrochloride QL (150 EA per 30 days) repaglinide tabs 2mg QL (240 EA per 30 days) repaglinide tabs 0.5mg QL (360 EA per 30 days) repaglinide tabs 1mg QL (480 EA per 30 days) QL (765 ML per 30 days) tolazamide tabs 250mg QL (120 EA per 30 days) tolazamide tabs 500mg QL (60 EA per 30 days) tolbutamide QL (180 EA per 30 days) Blood Products/Modifiers/Volume Expanders - Drugs that work on the blood for a variety of medical
conditions ( i.e, blood thinners, red blood cell stimulators)
AGGRENOX
anagrelide hydrochloride You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 23 Drug Name
Blood Products/Modifiers/Volume Expanders - Drugs that work on the blood for a variety of medical
conditions ( i.e, blood thinners, red blood cell stimulators)
ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 100MCG/ML,
10MCG/0.4ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 25MCG/0.42ML, 25MCG/ML, 300MCG/0.6ML, 300MCG/ML, 40MCG/0.4ML, 40MCG/ML, 500MCG/ML, 60MCG/0.3ML, 60MCG/ML argatroban inj 125mg/125ml; 0.9%, 250mg/2.5ml cilostazol clopidogrel dipyridamole tabs enoxaparin sodium fondaparinux sodium FRAGMIN INJ 10000UNIT/ML, 12500UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML, 2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML, 95000UNIT/3.8ML GRANIX heparin sodium/d5w heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml jantoven LEUKINE INJ 250MCG QL (2.4 ML per 28 days) PROMACTA TABS 12.5MG, 25MG, 50MG tranexamic acid inj, tabs warfarin sodium tabs XARELTO STARTER PACK Cardiovascular Agents - Drugs used to treat conditions associated with the heart
acebutolol hcl caps
acetazolamide er acetazolamide sodium acetazolamide tabs afeditab cr You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 24 Drug Name
Cardiovascular Agents - Drugs used to treat conditions associated with the heart
amiloride hcl tabs
amiodarone hcl inj 50mg/ml amiodarone hcl tabs 200mg, 400mg amlodipine besylate/atorvastatin calcium QL (30 EA per 30 days) amlodipine besylate/benazepril hydrochloride amlodipine besylate/valsartan tabs 10mg; 160mg, 10mg; 320mg, 5mg; 1 QL (30 EA per 30 days) 320mg amlodipine besylate/valsartan tabs 5mg; 160mg QL (60 EA per 30 days) amlodipine besylate tabs amlodipine/valsartan/hctz tabs 10mg; 12.5mg; 160mg, 10mg; 25mg; QL (30 EA per 30 days) 160mg, 10mg; 25mg; 320mg, 5mg; 25mg; 160mg amlodipine/valsartan/hctz tabs 5mg; 12.5mg; 160mg QL (60 EA per 30 days) atenolol tabs atorvastatin calcium QL (30 EA per 30 days) benazepril hcl/hydrochlorothiazide benazepril hcl tabs betaxolol hcl tabs 10mg, 20mg bisoprolol fumarate bisoprolol fumarate/hydrochlorothiazide bumetanide candesartan cilexetil candesartan cilexetil/hydrochlorothiazide captopril tabs cartia xt carvedilol chlorothiazide chlorothiazide sodium chlorthalidone tabs 25mg, 50mg cholestyramine light pack clonidine hcl ptwk, tabs colestipol hcl gran, tabs QL (60 EA per 30 days) PA QL (30 EA per 30 days) digitek tabs 0.125mg QL (30 EA per 30 days) digitek tabs 0.25mg QL (30 EA per 30 days) PA digoxin inj You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 25 Drug Name
Cardiovascular Agents - Drugs used to treat conditions associated with the heart
digoxin oral soln
QL (150 ML per 30 days) digoxin tabs 125mcg QL (30 EA per 30 days) digoxin tabs 250mcg QL (30 EA per 30 days) PA diltiazem cd cp24 240mg diltiazem hcl er cp24 120mg, 180mg, 300mg, 360mg, 420mg diltiazem hcl er cp12 diltiazem hcl tabs diltiazem hcl inj 100mg, 50mg/10ml disopyramide phosphate dofetilide enalapril maleate/hydrochlorothiazide enalapril maleate tabs QL (60 EA per 30 days) PA eplerenone eprosartan mesylate ethacrynate sodium felodipine er fenofibrate fenofibrate micronized fenofibric acid fenofibric acid dr flecainide acetate fluvastatin fluvastatin sodium er fosinopril sodium fosinopril sodium/hydrochlorothiazide furosemide inj, oral soln, tabs gemfibrozil tabs guanfacine hcl hydralazine hcl inj, tabs hydrochlorothiazide caps, tabs indapamide irbesartan isosorbide dinitrate er isosorbide dinitrate tabs isosorbide mononitrate isosorbide mononitrate er You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 26 Drug Name
Cardiovascular Agents - Drugs used to treat conditions associated with the heart
isradipine
QL (4 ML per 28 days) PA labetalol hcl inj, tabs LANOXIN TABS 187.5MCG, 62.5MCG QL (30 EA per 30 days) lisinopril losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; QL (30 EA per 30 days) 100mg losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg QL (60 EA per 30 days) losartan potassium tabs 100mg QL (30 EA per 30 days) losartan potassium tabs 25mg, 50mg QL (60 EA per 30 days) lovastatin tabs 10mg QL (30 EA per 30 days) lovastatin tabs 20mg, 40mg QL (60 EA per 30 days) matzim la methazolamide methyclothiazide tabs methyldopa methyldopate hcl metolazone metoprolol succinate er metoprolol tartrate inj metoprolol tartrate tabs 100mg, 25mg, 50mg mexiletine hcl midodrine hcl minoxidil tabs moexipril hcl nadolol tabs niacin er nicardipine hcl caps, inj nifedical xl nifedipine er nifedipine caps nimodipine caps nisoldipine nisoldipine er You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 27 Drug Name
Cardiovascular Agents - Drugs used to treat conditions associated with the heart
NITRO-BID
nitroglycerin lingual soln nitroglycerin transdermal nitroglycerin inj omega-3-acid ethyl esters pentoxifylline er perindopril erbumine phenoxybenzamine hydrochloride QL (2 ML per 28 days) PA pravastatin sodium QL (30 EA per 30 days) prazosin hcl prevalite powd procainamide hcl inj propafenone hcl propafenone hcl er propranolol hcl er propranolol hcl inj, oral soln, tabs quinapril hcl quinidine gluconate cr quinidine gluconate inj quinidine sulfate QL (3 ML per 28 days) PA REPATHA SURECLICK QL (3 ML per 28 days) PA reserpine tabs rosuvastatin calcium QL (30 EA per 30 days) simvastatin tabs 40mg, 80mg QL (30 EA per 30 days) simvastatin tabs 10mg, 20mg, 5mg QL (45 EA per 30 days) sotalol hcl (af) tabs 120mg sotalol hcl tabs 160mg, 240mg, 80mg spironolactone tabs taztia xt You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 28 Drug Name
Cardiovascular Agents - Drugs used to treat conditions associated with the heart
TEKTURNA
QL (30 EA per 30 days) ST QL (30 EA per 30 days) ST telmisartan QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) torsemide tabs trandolapril trandolapril/verapamil hcl valsartan/hydrochlorothiazide tabs 12.5mg; 320mg, 25mg; 320mg QL (30 EA per 30 days) valsartan/hydrochlorothiazide tabs 12.5mg; 160mg, 12.5mg; 80mg, QL (60 EA per 30 days) 25mg; 160mg valsartan tabs 320mg QL (30 EA per 30 days) valsartan tabs 160mg, 40mg, 80mg QL (60 EA per 30 days) verapamil hcl er verapamil hcl sr cp24 360mg verapamil hcl inj, tabs QL (30 EA per 30 days) QL (30 EA per 30 days) Central Nervous System Agents - Drugs that act through the nervous system (brain) to treat a variety of
medical conditions
amphetamine/dextroamphetamine tabs
QL (60 EA per 30 days) PA QL (60 EA per 30 days) PA QL (1 EA per 28 days) AVONEX INJ 30MCG/0.5ML QL (1 EA per 28 days) AVONEX INJ 30MCG/VIAL QL (4 EA per 28 days) QL (15 EA per 30 days) clonidine hcl er QL (120 EA per 30 days) PA COPAXONE INJ 40MG/ML QL (12 ML per 28 days) COPAXONE INJ 20MG/ML QL (30 ML per 30 days) dexedrine tabs 5mg QL (150 EA per 30 days) dexedrine tabs 10mg QL (180 EA per 30 days) dextroamphetamine sulfate tabs 5mg QL (150 EA per 30 days) dextroamphetamine sulfate tabs 10mg QL (180 EA per 30 days) QL (30 ML per 30 days) guanfacine er QL (30 EA per 30 days) PA methylphenidate hcl chew QL (180 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 29 Drug Name
Central Nervous System Agents - Drugs that act through the nervous system (brain) to treat a variety of
medical conditions
methylphenidate hcl tabs 10mg
QL (180 EA per 30 days) PA methylphenidate hcl tabs 20mg, 5mg QL (90 EA per 30 days) PA methylphenidate hydrochloride soln 5mg/5ml QL (1800 ML per 30 days) PA methylphenidate hydrochloride soln 10mg/5ml QL (900 ML per 30 days) PA QL (60 EA per 30 days) PA QL (1 ML per 28 days) PLEGRIDY STARTER PACK QL (1 ML per 28 days) procentra QL (1800 ML per 30 days) SAVELLA TITRATION PACK QL (30 EA per 30 days) TECFIDERA STARTER PACK QL (120 EA per 365 days) TECFIDERA CPDR 120MG QL (14 EA per 365 days) TECFIDERA CPDR 240MG QL (60 EA per 30 days) QL (30 EA per 30 days) PA zenzedi tabs 5mg QL (150 EA per 30 days) zenzedi tabs 10mg QL (180 EA per 30 days) Dental and Oral Agents - Drugs used to treat teeth and gum disease
cevimeline hcl
chlorhexidine gluconate oral rinse periogard pilocarpine hcl tabs 7.5mg pilocarpine hydrochloride triamcinolone in orabase Dermatological Agents - Drugs used to treat skin disorders
8-MOP
acitretin adapalene crea, gel ammonium lactate crea, lotn calcipotriene calcipotriene/betamethasone dipropionate calcitriol oint 3mcg/gm claravis caps 10mg, 20mg, 40mg You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 30 Drug Name
Dermatological Agents - Drugs used to treat skin disorders
claravis caps 30mg
clindamycin/benzoyl peroxide gel 5%; 1% clotrimazole/betamethasone dipropionate COSENTYX SENSOREADY PEN CURITY GAUZE PADS 2"X2" diclofenac sodium gel 1% diclofenac sodium gel 3% diclofenac sodium transdermal soln 1.5% doxepin hydrochloride erythromycin/benzoyl peroxide fluorouracil crea 0.5%, 5% fluorouracil external soln 2%, 5% imiquimod crea methoxsalen caps podofilox soln procto-med hc selenium sulfide lotn STELARA INJ 45MG/0.5ML QL (3.5 ML per 365 days) PA STELARA INJ 90MG/ML QL (7 ML per 365 days) PA tacrolimus oint 0.03%, 0.1% tretinoin microsphere tretinoin crea 0.025%, 0.05%, 0.1% tretinoin gel 0.01%, 0.025%, 0.05% Enzyme Replacement/Modifiers - Drugs used to treat enzyme deficiency diseases
ADAGEN
You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 31 Drug Name
Enzyme Replacement/Modifiers - Drugs used to treat enzyme deficiency diseases
ALDURAZYME
FABRAZYME INJ 35MG ORFADIN CAPS 10MG, 2MG, 5MG sodium phenylbutyrate powd STRENSIQ INJ 40MG/ML, 80MG/0.8ML Gastrointestinal Agents - Drugs used to treat conditions associated with the digestive system (e.g., stomach,
intestine)
alosetron hydrochloride
atropine sulfate inj 0.05mg/ml, 0.1mg/ml cimetidine hcl cimetidine tabs constulose cromolyn sodium conc 100mg/5ml dicyclomine hcl esomeprazole sodium famotidine premixed famotidine susr famotidine inj 20mg/2ml You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 32 Drug Name
Gastrointestinal Agents - Drugs used to treat conditions associated with the digestive system (e.g., stomach,
intestine)
famotidine tabs 20mg, 40mg
gavilyte-c gavilyte-g gavilyte-h gavilyte-n/flavor pack glycopyrrolate tabs glycopyrrolate inj 4mg/20ml lactulose soln QL (112 EA per 180 days) loperamide hcl caps methscopolamine bromide metoclopramide hcl inj, oral soln, tabs metoclopramide odt misoprostol nizatidine QL (80 EA per 180 days) omeprazole cpdr QL (30 EA per 30 days) pantoprazole sodium peg-3350/nacl/na bicarbonate/kcl polyethylene glycol 3350 powd QL (120 EA per 180 days) ranitidine hcl caps, syrp ranitidine hcl inj 150mg/6ml ranitidine hcl tabs 150mg, 300mg sucralfate tabs SUPREP BOWEL PREP ursodiol caps, tabs Genitourinary Agents - Drugs used to treat conditions affecting the urinary tract or reproductive organs
alfuzosin hcl er
bethanechol chloride tabs calcium acetate caps darifenacin hydrobromide er doxazosin doxazosin mesylate tabs 1mg, 2mg, 8mg You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 33 Drug Name
Genitourinary Agents - Drugs used to treat conditions affecting the urinary tract or reproductive organs
dutasteride
dutasteride/tamsulosin hydrochloride finasteride tabs 5mg flavoxate hcl oxybutynin chloride er oxybutynin chloride syrp, tabs tamsulosin hcl terazosin hcl tolterodine tartrate tolterodine tartrate er trospium chloride trospium chloride er Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Corticosteroid drugs that can be used for a
variety of conditions such as inflammation
a-hydrocort
alclometasone dipropionate amcinonide apexicon e augmented betamethasone dipropionate betamethasone dipropionate crea, lotn, oint betamethasone valerate crea, foam, lotn, oint clobetasol propionate e clobetasol propionate foam, gel, liqd, lotn, oint, sham, soln cormax scalp application cortisone acetate tabs DEPO-MEDROL INJ 20MG/ML desonide crea, lotn, oint desoximetasone crea, gel, oint dexamethasone intensol dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 34 Drug Name
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Corticosteroid drugs that can be used for a
variety of conditions such as inflammation
dexamethasone elix, tabs
diflorasone diacetate fludrocortisone acetate tabs fluocinolone acetonide body fluocinolone acetonide crea 0.01%, 0.025% fluocinolone acetonide oint 0.025% fluocinolone acetonide soln 0.01% fluocinonide-e fluocinonide crea 0.1% fluocinonide gel, oint, soln flurandrenolide fluticasone propionate crea 0.05% fluticasone propionate lotn 0.05% fluticasone propionate oint 0.005% halobetasol propionate hydrocortisone butyrate (lipophilic) hydrocortisone butyrate oint, soln hydrocortisone valerate hydrocortisone crea 1%, 2.5% hydrocortisone lotn 2.5% hydrocortisone oint 1%, 2.5% hydrocortisone tabs 10mg, 20mg, 5mg methylprednisolone acetate inj methylprednisolone dose pack methylprednisolone sodiumsuccinate inj 125mg, 40mg methylprednisolone tabs mometasone furoate crea 0.1% mometasone furoate oint 0.1% mometasone furoate soln 0.1% prednicarbate prednisolone sodium phosphate odt prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml prednisone intensol prednisone soln, tabs procto-pak proctosol hc proctozone-hc SOLU-CORTEF INJ 250MG triamcinolone acetonide aers, crea, lotn, oint You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 35 Drug Name
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs used to replace growth hormones
desmopressin acetate inj, nasal soln, tabs
GENOTROPIN MINIQUICK INJ 0.2MG GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG H.P. ACTHAR HUMATROPE COMBO PACK HUMATROPE INJ 12MG, 24MG, 6MG NORDITROPIN FLEXPRO NUTROPIN AQ NUSPIN 10 NUTROPIN AQ NUSPIN 20 NUTROPIN AQ NUSPIN 5 SAIZEN CLICK.EASY Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs used to increase
testosterone or estrogen levels
amethia
ANDROGEL PUMP GEL 1.62% blisovi 24 fe blisovi fe 1.5/30 blisovi fe 1/20 You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 36 Drug Name
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs used to increase
testosterone or estrogen levels
CLIMARA PRO
cryselle-28 cyclafem 1/35 cyclafem 7/7/7 danazol caps deblitane DELESTROGEN INJ 10MG/ML DEPO-SUBQ PROVERA 104 desogestrel/ethinyl estradiol tabs 0; 0 DIVIGEL GEL 0.5MG/0.5GM drospirenone/ethinyl estradiol emoquette ENJUVIA TABS 0.3MG, 0.45MG, 0.9MG enpresse-28 estradiol valerate inj 20mg/ml, 40mg/ml estradiol/norethindrone acetate estradiol pttw, ptwk, tabs estropipate tabs gildess 1.5/30 gildess 24 fe hydroxyprogesterone caproate inj introvale jolivette junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 junel fe 24 kaitlib fe You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 37 Drug Name
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs used to increase
testosterone or estrogen levels
kariva
kelnor 1/35 larin 1.5/30 larin 1/20 larin fe 1.5/30 larin fe 1/20 layolis fe levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg levonorgestrel/ethinyl estradiol levora 0.15/30-28 lomedia 24 fe medroxyprogesterone acetate inj, tabs megestrol acetate susp, tabs methyltestosterone caps microgestin 1.5/30 microgestin 1/20 microgestin fe microgestin fe 1.5/30 mimvey lo mononessa necon 0.5/35-28 necon 1/35 necon 1/50-28 necon 10/11-28 necon 7/7/7 You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 38 Drug Name
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs used to increase
testosterone or estrogen levels
norethindrone & ethinyl estradiol ferrous fumarate
norethindrone acetate/ethinyl estradiol/ferrous fumarate norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 5mcg; 1mg 2 PA norethindrone acetate tabs norethindrone tabs norgestimate/ethinyl estradiol tabs 0; 0 nortrel 0.5/35 (28) nortrel 1/35 nortrel 7/7/7 oxandrolone tabs pirmella 1/35 portia-28 PREMARIN CREA, INJ progesterone caps raloxifene hydrochloride reclipsen sprintec 28 tarina fe 1/20 testosterone cypionate inj testosterone enanthate inj testosterone pump testosterone gel tri-legest fe tri-lo-estarylla tri-lo-sprintec tri-previfem tri-sprintec You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 39 Drug Name
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs used to increase
testosterone or estrogen levels
trinessa
trivora-28 wymzya fe zenchent fe zovia 1/35e zovia 1/50e Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs used to treat or increase thyroid levels
levothyroxine sodium tabs
levothyroxine sodium inj 100mcg liothyronine sodium inj, tabs unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg
Hormonal Agents, Suppressant (Adrenal) - Drugs used to treat adrenal cortical cancer
LYSODREN
Hormonal Agents, Suppressant (Parathyroid) - Drugs used to treat high calcium levels in people with chronic
kidney disease
SENSIPAR TABS 30MG
SENSIPAR TABS 60MG, 90MG Hormonal Agents, Suppressant (Pituitary) - Drugs used to treat prostate cancer and other conditions
associated with an overactive pituitary gland
cabergoline
FIRMAGON INJ 80MG FIRMAGON INJ 120MG leuprolide acetate inj LUPRON DEPOT-PED INJ 11.25MG, 15MG LUPRON DEPOT INJ 3.75MG LUPRON DEPOT INJ 11.25MG, 22.5MG, 30MG, 45MG, 7.5MG You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 40 Drug Name
Hormonal Agents, Suppressant (Pituitary) - Drugs used to treat prostate cancer and other conditions
associated with an overactive pituitary gland
octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml
octreotide acetate inj 1000mcg/ml, 500mcg/ml SANDOSTATIN LAR DEPOT QL (60 ML per 30 days) PA SOMATULINE DEPOT TRELSTAR MIXJECT Hormonal Agents, Suppressant (Thyroid) - Drugs used to lower thyroid levels
methimazole tabs
propylthiouracil tabs Immunological Agents - Drugs that work with the immune system to manage a variety of medical conditions
ACTEMRA
azathioprine inj, tabs bcg vaccine BIVIGAM INJ 10GM/100ML carimune nanofiltered inj 6gm CELLCEPT INTRAVENOUS cyclosporine modified cyclosporine caps, inj diphtheria/tetanus toxoids adsorbed pediatric ENBREL SURECLICK QL (8 ML per 28 days) ENBREL INJ 25MG/0.5ML QL (4.08 ML per 28 days) PA QL (8 EA per 28 days) PA ENBREL INJ 50MG/ML QL (8 ML per 28 days) PA QL (27 ML per 30 days) PA You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 41 Drug Name
Immunological Agents - Drugs that work with the immune system to manage a variety of medical conditions
FLEBOGAMMA DIF INJ 10%
gammagard liquid inj 2.5gm/25ml GAMMAKED INJ 1GM/10ML GAMMAPLEX INJ 10GM/200ML GAMUNEX-C INJ 1GM/10ML gengraf caps 100mg, 25mg gengraf soln QL (2 EA per 28 days) PA HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK QL (6 EA per 365 days) PA QL (2 EA per 28 days) PA HUMIRA PEN-CROHNS DISEASESTARTER QL (12 EA per 365 days) PA IMOVAX RABIES (H.D.C.V.) IPOL INACTIVATED IPV leflunomide MENOMUNE-A/C/Y/W-135 methotrexate sodium inj 1gm/40ml, 1gm methotrexate tabs mycophenolate mofetil mycophenolic acid dr OCTAGAM INJ 1GM/20ML, 2GM/20ML OTREXUP INJ 10MG/0.4ML, 15MG/0.4ML, 17.5MG/0.4ML, 20MG/0.4ML, 22.5MG/0.4ML, 25MG/0.4ML, 7.5MG/0.4ML PEDVAX HIB PRIVIGEN INJ 20GM/200ML You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 42 Drug Name
Immunological Agents - Drugs that work with the immune system to manage a variety of medical conditions
RAPAMUNE SOLN
SIMULECT INJ 20MG sirolimus tabs SYNAGIS INJ 50MG/0.5ML tacrolimus caps 0.5mg, 1mg, 5mg tetanus/diphtheria toxoids-adsorbed VARIZIG INJ 125UNIT/1.2ML ZORTRESS TABS 0.25MG ZORTRESS TABS 0.5MG, 0.75MG Inflammatory Bowel Disease Agents - Drugs used to manage disorders in the colon and/or intestines
balsalazide disodium
budesonide cpep 3mg hydrocortisone enem 100mg/60ml mesalamine kit sulfasalazine tabs, tbec You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 43 Drug Name
Metabolic Bone Disease Agents - Drugs used to treat bone disorders
alendronate sodium soln
QL (300 ML per 28 days) alendronate sodium tabs 10mg, 40mg, 5mg QL (30 EA per 30 days) alendronate sodium tabs 35mg, 70mg QL (4 EA per 28 days) calcitriol caps 0.25mcg, 0.5mcg calcitriol inj 1mcg/ml calcitriol oral soln 1mcg/ml doxercalciferol etidronate disodium QL (2.4 ML per 28 days) PA ibandronate sodium inj ibandronate sodium tabs QL (1 EA per 30 days) pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml paricalcitol risedronate sodium dr QL (4 EA per 28 days) risedronate sodium tabs 150mg QL (1 EA per 30 days) risedronate sodium tabs 5mg QL (30 EA per 30 days) risedronate sodium tabs 35mg QL (4 EA per 28 days) risedronate sodium tabs 30mg QL (90 EA per 365 days) zoledronic acid inj 5mg/100ml zoledronic acid inj 4mg/5ml QL (10 ML per 30 days) ZOMETA INJ 4MG/100ML Miscellaneous Therapeutic Agents
MYALEPT
ORFADIN SUSP 4MG/ML Ophthalmic Agents - Drugs used in the eye to treat eye conditions
ALOCRIL
ALPHAGAN P SOLN 0.1% apraclonidine atropine sulfate ophthalmic soln 1% azelastine hcl ophthalmic soln 0.05% bacitracin/polymyxin b betaxolol hcl soln 0.5% bimatoprost brimonidine tartrate bromfenac carteolol hcl You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 44 Drug Name
Ophthalmic Agents - Drugs used in the eye to treat eye conditions
COMBIGAN
cromolyn sodium soln 4% QL (60 ML per 28 days) PA dexamethasone sodium phosphate ophthalmic soln 0.1% diclofenac sodium ophthalmic soln 0.1% dorzolamide hcl dorzolamide hcl/timolol maleate epinastine hcl fluorometholone flurbiprofen sodium ketorolac tromethamine soln 0.4%, 0.5% latanoprost levobunolol hcl metipranolol olopatadine hcl ophthalmic soln 0.1% PHOSPHOLINE IODIDE pilocarpine hcl soln 1%, 2%, 4% polymyxin b sulfate/trimethoprim sulfate prednisolone acetate prednisolone sodium phosphate ophthalmic soln 1% proparacaine hcl QL (60 EA per 30 days) sulfacetamide sodium/prednisolone sodium phosphate timolol maleate ophthalmic gel forming timolol maleate soln 0.25%, 0.5% You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 45 Drug Name
Ophthalmic Agents - Drugs used in the eye to treat eye conditions
travoprost
Otic Agents - Drugs used in the ear to treat ear conditions
acetasol hc
acetic acid fluocinolone acetonide oil 0.01% hydrocortisone/acetic acid neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; 10000unit/ml
Respiratory Tract/Pulmonary Agents - Drugs used to manage conditions in the lungs
acetylcysteine soln
ADRENALIN INJ 1MG/ML QL (60 EA per 30 days) QL (12 GM per 30 days) albuterol sulfate er albuterol sulfate syrp, tabs albuterol sulfate nebu aminophylline ARALAST NP INJ 500MG ARCAPTA NEOHALER QL (25.8 GM per 30 days) azelastine hcl nasal soln 0.1%, 0.15% budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml budesonide nasal susp 32mcg/act COMBIVENT RESPIMAT QL (8 GM per 30 days) cromolyn sodium nebu 20mg/2ml cyproheptadine hcl syrp, tabs desloratadine desloratadine odt diphenhydramine hcl inj QL (13 GM per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 46 Drug Name
Respiratory Tract/Pulmonary Agents - Drugs used to manage conditions in the lungs
epinephrine inj
FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST QL (120 EA per 30 days) FLOVENT DISKUS AEPB 250MCG/BLIST QL (240 EA per 30 days) FLOVENT HFA AERO 44MCG/ACT QL (10.6 GM per 30 days) FLOVENT HFA AERO 110MCG/ACT QL (12 GM per 30 days) FLOVENT HFA AERO 220MCG/ACT QL (24 GM per 30 days) flunisolide fluticasone propionate susp 50mcg/act FORADIL AEROLIZER QL (60 EA per 30 days) ipratropium bromide/albuterol sulfate ipratropium bromide nasal soln ipratropium bromide inhalation soln levalbuterol hcl nebu 0.31mg/3ml, 0.63mg/3ml levalbuterol nebu levocetirizine dihydrochloride soln, tabs metaproterenol sulfate syrp, tabs mometasone furoate susp 50mcg/act montelukast sodium QL (30 EA per 30 days) olopatadine hcl nasal soln 0.6% ORENITRAM TBCR 0.125MG ORENITRAM TBCR 0.25MG, 1MG, 2.5MG QL (120 EA per 30 days) PA QL (17 GM per 30 days) PROAIR RESPICLICK QL (2 EA per 30 days) QL (60 EA per 30 days) sildenafil SPIRIVA HANDIHALER QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 47 Drug Name
Respiratory Tract/Pulmonary Agents - Drugs used to manage conditions in the lungs
SPIRIVA RESPIMAT
QL (4 GM per 30 days) QL (10.2 GM per 30 days) terbutaline sulfate inj, tabs theophylline cr tb12 100mg, 200mg theophylline er tb24 theophylline er tb12 300mg, 450mg theophylline soln tobramycin TUDORZA PRESSAIR QL (87 ML per 30 days) PA TYZINE PEDIATRIC NASAL DROPS QL (270 ML per 30 days) PA QL (36 GM per 30 days) QL (30 GM per 30 days) zafirlukast QL (60 EA per 30 days) Skeletal Muscle Relaxants - Drugs that act on muscles to relieve pain associated with spasms
carisoprodol/aspirin
carisoprodol tabs cyclobenzaprine hcl tabs methocarbamol tabs Sleep Disorder Agents - Drugs used to manage sleep disorders
armodafinil
eszopiclone QL (30 EA per 30 days) PA modafinil tabs 100mg QL (30 EA per 30 days) PA modafinil tabs 200mg QL (60 EA per 30 days) PA temazepam caps 15mg, 22.5mg, 30mg QL (30 EA per 30 days) temazepam caps 7.5mg QL (60 EA per 30 days) QL (30 EA per 30 days) PA zolpidem tartrate QL (30 EA per 30 days) PA zolpidem tartrate er QL (30 EA per 30 days) PA Therapeutic Nutrients/Minerals/Electrolytes - Vitamins and minerals used to maintain normal levels
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes aminosyn ii 8.5%/electrolytes You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 48 Drug Name
Therapeutic Nutrients/Minerals/Electrolytes - Vitamins and minerals used to maintain normal levels
AMINOSYN M
ammonium chloride CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 10% CLINIMIX 4.25%/DEXTROSE 20% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 4.25%/DEXTROSE 5% CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX E 2.75%/DEXTROSE 10% CLINIMIX E 2.75%/DEXTROSE 5% CLINIMIX E 4.25%/DEXTROSE 10% CLINIMIX E 4.25%/DEXTROSE 25% CLINIMIX E 4.25%/DEXTROSE 5% CLINIMIX E 5%/DEXTROSE 15% CLINIMIX E 5%/DEXTROSE 20% CLINIMIX E 5%/DEXTROSE 25% clinisol sf 15% dextrose 10%/nacl 0.45% dextrose 10% flex container dextrose 10%/nacl 0.2% dextrose 2.5%/sodium chloride 0.45% dextrose 5% dextrose 5%/nacl 0.2% dextrose 5%/nacl 0.225% dextrose 5%/nacl 0.33% dextrose 5%/nacl 0.45% dextrose 5%/nacl 0.9% dextrose 5%/potassium chloride 0.15% EXJADE TBSO 125MG EXJADE TBSO 250MG, 500MG fomepizole FREAMINE HBC 6.9% hepatamine INTRALIPID INJ 30GM/100ML You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 49 Drug Name
Therapeutic Nutrients/Minerals/Electrolytes - Vitamins and minerals used to maintain normal levels
intralipid inj 20gm/100ml
IONOSOL-B/DEXTROSE 5% IONOSOL-MB/DEXTROSE 5% ISOLYTE-P/DEXTROSE 5% K-TAB TBCR 20MEQ kcl 0.075%/d5w/nacl 0.45% kcl 0.15%/d5w/lr kcl 0.15%/d5w/nacl 0.2% kcl 0.15%/d5w/nacl 0.225% kcl 0.15%/d5w/nacl 0.9% kcl 0.3%/d5w/nacl 0.45% kcl 0.3%/d5w/nacl 0.9% kionex powd klor-con 10 klor-con 8 klor-con m15 klor-con m20 klor-con sprinkle lactated ringers dextrose 5% viaflex lactated ringers irrigation lactated ringers viaflex levocarnitine inj, oral soln, tabs magnesium sulfate inj 50% normosol-m in d5w normosol-r in d5w nutrilipid physiolyte physiosol irrigation PLASMA-LYTE-56/D5W plenamine potassium chloride 0.15% /nacl 0.45% viaflex potassium chloride 0.15% d5w/nacl 0.33% potassium chloride 0.15% d5w/nacl 0.45% potassium chloride 0.15%/nacl 0.9% potassium chloride 0.22% d5w/nacl 0.45% potassium chloride 0.3%/ nacl 0.9% potassium chloride 0.3%/d5w You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 50 Drug Name
Therapeutic Nutrients/Minerals/Electrolytes - Vitamins and minerals used to maintain normal levels
potassium chloride er
potassium chloride oral soln potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml potassium citrate er PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml PROCALAMINE ringers injection ringers irrigation sodium chloride 0.45% viaflex sodium chloride 0.9% sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5% sodium fluoride tabs 1mg sodium lactate inj 5meq/ml sodium polystyrene sulfonate susp sterile water irrigation tpn electrolytes You can find information on what the symbols and abbreviations on this table mean by going to pg. iv. 51 Drug Name
ALBENZA 16albuterol sulfate Drug Name
albuterol sulfate er alclometasone dipropionate ALCOHOL PREP PADS abacavir sulfate/lamivudine/zidovudine ABILIFY MAINTENA alendronate sodium alfuzosin hcl er acamprosate calcium dr allopurinol almotriptan malate acebutolol hcl alogliptin acetaminophen/codeine #3 alogliptin/metformin hcl acetasol hc acetazolamide alosetron hydrochloride acetazolamide er acetazolamide sodium acetic acid alprazolam acetylcysteine alprazolam intensol acitretin amantadine hcl amcinonide acyclovir acyclovir sodium amifostine amikacin sulfate amiloride hcl adapalene aminophylline adefovir dipivoxil AMINOSYN 7%/ELECTROLYTES aminosyn 8.5%/electrolytes aminosyn ii 8.5%/electrolytes afeditab cr AFINITOR DISPERZ amiodarone hcl a-hydrocort amitriptyline hcl amlodipine besylate
Drug Name
Drug Name
amlodipine besylate/atorvastatin calcium amlodipine besylate/benazepril hydrochloride amlodipine besylate/valsartan atorvastatin calcium ammonium chloride atovaquone ammonium lactate atovaquone/proguanil hcl amoxapine amoxicillin atropine sulfate amoxicillin/clavulanate potassium atropine sulfate amoxicillin/clavulanate potassium er amphotericin b augmented betamethasone dipropionate ampicillin ampicillin sodium anagrelide hydrochloride anastrozole azacitidine apexicon e azathioprine azelastine hcl azelastine hcl apraclonidine azithromycin aztreonam ARANESP ALBUMIN FREE bacitracin bacitracin/polymyxin b ARCAPTA NEOHALER argatroban bactocill in dextrose aripiprazole balsalazide disodium aripiprazole odt armodafinil bcg vaccine BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"
Drug Name
Drug Name
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" BD INSULIN SYRINGE brimonidine tartrate ULTRAFINE/0.5ML/30G X 1/2" BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" bromfenac BD PEN NEEDLE/ULTRAFINE/29G X bromocriptine mesylate budesonide budesonide benazepril hcl bumetanide benazepril hcl/hydrochlorothiazide buprenorphine hcl buprenorphine hcl/naloxone hcl benztropine mesylate bupropion hcl bupropion hcl sr betamethasone dipropionate bupropion hcl xl betamethasone valerate buspirone hcl betaxolol hcl betaxolol hcl bethanechol chloride butorphanol tartrate bicalutamide cabergoline calcipotriene calcipotriene/betamethasone dipropionate bimatoprost calcitriol bisoprolol fumarate calcitriol bisoprolol fumarate/hydrochlorothiazide calcium acetate bleomycin sulfate blisovi 24 fe blisovi fe 1.5/30 candesartan cilexetil blisovi fe 1/20 candesartan cilexetil/hydrochlorothiazide CAPASTAT SULFATE captopril
Drug Name
Drug Name
CHANTIX CONTINUING MONTH PAK carbamazepine CHANTIX STARTING MONTH PAK carbamazepine er carbidopa chloramphenicol sodium succinate carbidopa/levodopa er chlorhexidine gluconate oral rinse carbidopa/levodopa odt chloroquine phosphate chlorothiazide carboplatin chlorothiazide sodium carimune nanofiltered chlorpromazine hcl carisoprodol chlorthalidone cholestyramine light carteolol hcl ciclopirox cartia xt ciclopirox nail lacquer carvedilol ciclopirox olamine cidofovir cilostazol cefaclor er cefadroxil cimetidine cefazolin sodium cimetidine hcl cefotaxime sodium ciprofloxacin cefotetan ciprofloxacin er cefoxitin sodium ciprofloxacin hcl cefpodoxime proxetil ciprofloxacin i.v.-in d5w cefprozil cisplatin ceftazidime citalopram hydrobromide cladribine ceftriaxone sodium cefuroxime axetil cefuroxime sodium clarithromycin celecoxib clarithromycin er CELLCEPT INTRAVENOUS clindacin pac cephalexin clindamax clindamycin hcl clindamycin palmitate hcl clindamycin phosphate clindamycin phosphate in d5w clindamycin/benzoyl peroxide cevimeline hcl CLINIMIX 2.75%/DEXTROSE 5%
Drug Name
Drug Name
CLINIMIX 4.25%/DEXTROSE 10% CLINIMIX 4.25%/DEXTROSE 20% CLINIMIX 4.25%/DEXTROSE 25% cormax scalp application CLINIMIX 4.25%/DEXTROSE 5% cortisone acetate CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% COSENTYX SENSOREADY PEN CLINIMIX E 2.75%/DEXTROSE 10% CLINIMIX E 2.75%/DEXTROSE 5% CLINIMIX E 4.25%/DEXTROSE 10% CLINIMIX E 4.25%/DEXTROSE 25% CLINIMIX E 4.25%/DEXTROSE 5% CLINIMIX E 5%/DEXTROSE 15% CLINIMIX E 5%/DEXTROSE 20% CLINIMIX E 5%/DEXTROSE 25% cromolyn sodium clinisol sf 15% cromolyn sodium clobetasol propionate cromolyn sodium clobetasol propionate e cryselle-28 clomipramine hcl CURITY GAUZE PADS 2"X2" clonazepam clonazepam odt cyclafem 1/35 clonidine hcl cyclafem 7/7/7 clonidine hcl er cyclobenzaprine hcl clopidogrel cyclophosphamide clorazepate dipotassium cyclosporine clotrimazole cyclosporine modified clotrimazole/betamethasone dipropionate cyproheptadine hcl clozapine clozapine odt codeine sulfate colchicine cytarabine aqueous colestipol hcl dacarbazine colistimethate sodium COMBIVENT RESPIMAT dantrolene sodium darifenacin hydrobromide er constulose
Drug Name
Drug Name
daunorubicin hcl diclofenac sodium dr deblitane diclofenac sodium er decitabine diclofenac sodium/misoprostol dicloxacillin sodium dicyclomine hcl didanosine demeclocycline hcl diflorasone diacetate diflunisal DEPO-ESTRADIOL 37 dihydroergotamine mesylate DEPO-SUBQ PROVERA 104 diltiazem cd desipramine hcl diltiazem hcl desloratadine diltiazem hcl er desloratadine odt desmopressin acetate desogestrel/ethinyl estradiol diphenhydramine hcl diphtheria/tetanus toxoids adsorbed desoximetasone pediatric desvenlafaxine er dipyridamole dexamethasone disopyramide phosphate dexamethasone intensol disulfiram dexamethasone sodium phosphate dexamethasone sodium phosphate divalproex sodium dexedrine divalproex sodium dr dexrazoxane divalproex sodium er dextroamphetamine sulfate dextrose 10%/nacl 0.45% dextrose 10% flex container docetaxel dextrose 10%/nacl 0.2% dofetilide dextrose 2.5%/sodium chloride 0.45% donepezil hcl dextrose 5% dextrose 5%/nacl 0.2% dorzolamide hcl dextrose 5%/nacl 0.225% dorzolamide hcl/timolol maleate dextrose 5%/nacl 0.33% doxazosin dextrose 5%/nacl 0.45% doxazosin mesylate dextrose 5%/nacl 0.9% doxepin hcl dextrose 5%/potassium chloride 0.15% doxepin hydrochloride doxercalciferol diazepam intensol doxorubicin hcl diclofenac potassium doxorubicin hcl liposome diclofenac sodium diclofenac sodium doxycycline
Drug Name
Drug Name
doxycycline hyclate doxycycline hyclate dr doxycycline monohydrate dronabinol drospirenone/ethinyl estradiol epinastine hcl epinephrine duloxetine hcl duramorph epirubicin hcl dutasteride dutasteride/tamsulosin hydrochloride eplerenone eprosartan mesylate e.e.s. 400 econazole nitrate ergoloid mesylates ERYTHROCIN LACTOBIONATE ERYTHROCIN STEARATE erythromycin emoquette erythromycin base erythromycin ethylsuccinate erythromycin/benzoyl peroxide escitalopram oxalate enalapril maleate esomeprazole sodium enalapril maleate/hydrochlorothiazide estazolam ENBREL SURECLICK estradiol estradiol valerate estradiol/norethindrone acetate enoxaparin sodium estropipate enpresse-28 eszopiclone entacapone ethacrynate sodium entecavir ethambutol hcl ethosuximide
Drug Name
Drug Name
etidronate disodium fluconazole fluconazole in dextrose etodolac er fluconazole in nacl flucytosine etoposide fludarabine phosphate fludrocortisone acetate flunisolide fluocinolone acetonide fluocinolone acetonide exemestane fluocinolone acetonide body fluocinonide fluocinonide-e fluorometholone famciclovir fluorouracil famotidine fluorouracil famotidine premixed fluoxetine dr fluoxetine hcl FANAPT TITRATION PACK fluphenazine decanoate fluphenazine hcl flurandrenolide flurbiprofen flurbiprofen sodium felbamate flutamide felodipine er fluticasone propionate fluticasone propionate fenofibrate fluvastatin fenofibrate micronized fluvastatin sodium er fenofibric acid fluvoxamine maleate fenofibric acid dr fluvoxamine maleate er fentanyl citrate oral transmucosal fomepizole fondaparinux sodium FORADIL AEROLIZER FETZIMA TITRATION PACK fosinopril sodium finasteride fosinopril sodium/hydrochlorothiazide fosphenytoin sodium flavoxate hcl FREAMINE HBC 6.9% frovatriptan succinate flecainide acetate furosemide
Drug Name
Drug Name
glyburide gabapentin glyburide micronized glyburide/metformin hcl glycopyrrolate galantamine hydrobromide gammagard liquid granisetron hcl griseofulvin microsize ganciclovir griseofulvin ultramicrosize guanfacine er guanfacine hcl gatifloxacin guanidine hcl gynazole-1 gavilyte-c gavilyte-g gavilyte-h halobetasol propionate gavilyte-n/flavor pack haloperidol gemcitabine hcl haloperidol decanoate gemfibrozil haloperidol lactate heparin sodium GENOTROPIN MINIQUICK heparin sodium/d5w hepatamine gentamicin sulfate gentamicin sulfate/0.9% sodium chloride HUMATROPE COMBO PACK gildess 1.5/30 HUMIRA PEDIATRIC CROHNS gildess 24 fe DISEASE STARTER PACK HUMIRA PEN-CROHNS hydralazine hcl glimepiride hydrocodone bitartrate/acetaminophen glipizide glipizide er glipizide/metformin hcl hydrocortisone GLUCAGEN HYPOKIT hydrocortisone GLUCAGON EMERGENCY KIT hydrocortisone butyrate
Drug Name
Drug Name
hydrocortisone butyrate (lipophilic) IPOL INACTIVATED IPV hydrocortisone valerate ipratropium bromide hydrocortisone/acetic acid ipratropium bromide/albuterol sulfate hydromorphone hcl irbesartan hydromorphone hcl er hydroxychloroquine sulfate hydroxyprogesterone caproate hydroxyurea irinotecan ibandronate sodium ISOLYTE-P/DEXTROSE 5% ibuprofen isoniazid isosorbide dinitrate idarubicin hcl isosorbide dinitrate er ifosfamide isosorbide mononitrate isosorbide mononitrate er isotonic gentamicin isradipine imatinib mesylate itraconazole imipramine hcl ivermectin imipramine pamoate imiquimod IMOVAX RABIES (H.D.C.V.) indapamide indomethacin indomethacin er jolivette INTRON A W/DILUENT introvale junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 junel fe 24 kaitlib fe IONOSOL-B/DEXTROSE 5% IONOSOL-MB/DEXTROSE 5%
Drug Name
Drug Name
kcl 0.075%/d5w/nacl 0.45% larin 1.5/30 kcl 0.15%/d5w/lr larin 1/20 kcl 0.15%/d5w/nacl 0.2% larin fe 1.5/30 kcl 0.15%/d5w/nacl 0.225% larin fe 1/20 kcl 0.15%/d5w/nacl 0.9% latanoprost kcl 0.3%/d5w/nacl 0.45% kcl 0.3%/d5w/nacl 0.9% layolis fe kelnor 1/35 leflunomide ketoconazole LENVIMA 10 MG DAILY DOSE ketoprofen LENVIMA 14 MG DAILY DOSE ketoprofen er LENVIMA 18 MG DAILY DOSE ketorolac tromethamine LENVIMA 20 MG DAILY DOSE ketorolac tromethamine LENVIMA 24 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE letrozole leucovorin calcium klor-con 10 klor-con 8 leuprolide acetate klor-con m15 levalbuterol klor-con m20 levalbuterol hcl klor-con sprinkle LEVEMIR FLEXTOUCH levetiracetam levetiracetam er levobunolol hcl levocarnitine labetalol hcl levocetirizine dihydrochloride levofloxacin lactated ringers dextrose 5% viaflex levofloxacin in d5w lactated ringers irrigation levoleucovorin calcium lactated ringers viaflex lactulose levonorgestrel and ethinyl estradiol levonorgestrel/ethinyl estradiol lamivudine levora 0.15/30-28 levothyroxine sodium lamotrigine lamotrigine er lamotrigine odt lidocaine lidocaine hcl
Drug Name
Drug Name
lidocaine hcl jelly maprotiline hcl lidocaine viscous lincomycin hcl matzim la meclizine hcl linezolid medroxyprogesterone acetate mefloquine hcl LIORESAL INTRATHECAL liothyronine sodium megestrol acetate lisinopril meloxicam melphalan hydrochloride lithium carbonate memantine hcl lithium carbonate er memantine hcl titration pak memantine hydrochloride lomedia 24 fe loperamide hcl MENOMUNE-A/C/Y/W-135 42 lorazepam lorazepam intensol mercaptopurine lorcet hd meropenem lorcet plus mesalamine losartan potassium losartan potassium/hydrochlorothiazide MESTINON TIMESPAN metaproterenol sulfate lovastatin metformin hcl loxapine succinate metformin hcl er methadone hcl methazolamide methenamine hippurate LUPRON DEPOT-PED methimazole methocarbamol methotrexate methotrexate sodium methoxsalen methscopolamine bromide magnesium sulfate methyclothiazide methyldopa malathion
Drug Name
Drug Name
methyldopate hcl methylergonovine maleate molindone hydrochloride methylphenidate hcl mometasone furoate methylphenidate hydrochloride mometasone furoate mononessa methylprednisolone acetate montelukast sodium methylprednisolone dose pack methylprednisolone sodiumsuccinate morphine sulfate morphine sulfate er metipranolol moxifloxacin hcl metoclopramide hcl metoclopramide odt metolazone mupirocin metoprolol succinate er metoprolol tartrate metronidazole mycophenolate mofetil metronidazole in nacl 0.79% mycophenolic acid dr metronidazole vaginal mexiletine hcl nabumetone microgestin 1.5/30 microgestin 1/20 microgestin fe nafcillin microgestin fe 1.5/30 nafcillin sodium midodrine hcl naftifine hcl naftifine hydrochloride nalbuphine hcl mimvey lo naloxone hcl naltrexone hcl minocycline hcl NAMENDA TITRATION PAK minocycline hcl er minoxidil NAMENDA XR TITRATION PACK mirtazapine mirtazapine odt misoprostol naproxen dr mitomycin naproxen sodium mitoxantrone hcl naproxen sodium cr naproxen sodium er modafinil naratriptan hcl MODERIBA 1200 DOSE PACK MODERIBA 800 DOSE PACK nateglinide moexipril hcl
Drug Name
Drug Name
nitroglycerin necon 0.5/35-28 nitroglycerin lingual necon 1/35 nitroglycerin transdermal necon 1/50-28 necon 10/11-28 necon 7/7/7 nizatidine nefazodone hcl neomycin sulfate NORDITROPIN FLEXPRO norethindrone neomycin/polymyxin b sulfates norethindrone & ethinyl estradiol ferrous norethindrone acetate norethindrone acetate/ethinyl estradiol norethindrone acetate/ethinyl estradiol/ferrous fumarate norgestimate/ethinyl estradiol normosol-m in d5w normosol-r in d5w nevirapine nortrel 0.5/35 (28) nevirapine er nortrel 1/35 nortrel 7/7/7 nortriptyline hcl niacin er nicardipine hcl NICOTROL INHALER nifedical xl nifedipine NOVOLOG MIX 70/30 nifedipine er NOVOLOG MIX 70/30 PREFILLED nimodipine nisoldipine nisoldipine er nitrofurantoin nutrilipid nitrofurantoin macrocrystals NUTROPIN AQ NUSPIN 10 nitrofurantoin monohydrate NUTROPIN AQ NUSPIN 20 nitrofurantoin monohydrate/macrocrystals NUTROPIN AQ NUSPIN 5
Drug Name
Drug Name
oxcarbazepine oxiconazole nitrate oxybutynin chloride oxybutynin chloride er oxycodone hcl oxycodone hcl er octreotide acetate oxymorphone hydrochloride ofloxacin oxymorphone hydrochloride er olanzapine paclitaxel olanzapine odt paliperidone er pamidronate disodium olopatadine hcl olopatadine hcl pantoprazole sodium paricalcitol omega-3-acid ethyl esters paromomycin sulfate omeprazole paroxetine hcl paroxetine hcl er ondansetron hcl ondansetron odt peg-3350/nacl/na bicarbonate/kcl PEGASYS PROCLICK PEG-INTRON REDIPEN penicillin g potassium penicillin g potassium in iso-osmotic oxacillin sodium penicillin g procaine oxaliplatin penicillin g sodium oxandrolone penicillin v potassium oxaprozin
Drug Name
Drug Name
pentoxifylline er portia-28 potassium chloride perindopril erbumine potassium chloride 0.15% /nacl 0.45% periogard potassium chloride 0.15% d5w/nacl 0.33% permethrin potassium chloride 0.15% d5w/nacl 0.45% perphenazine potassium chloride 0.15%/nacl 0.9% potassium chloride 0.22% d5w/nacl 0.45% potassium chloride 0.3%/ nacl 0.9% potassium chloride 0.3%/d5w phenelzine sulfate potassium chloride er phenergan potassium citrate er phenobarbital phenoxybenzamine hydrochloride phenytoin phenytoin sodium pramipexole dihydrochloride phenytoin sodium extended pramipexole dihydrochloride er pravastatin sodium PHOSPHOLINE IODIDE prazosin hcl physiolyte physiosol irrigation prednicarbate pilocarpine hcl prednisolone acetate pilocarpine hcl prednisolone sodium phosphate pilocarpine hydrochloride prednisolone sodium phosphate prednisolone sodium phosphate odt prednisone prednisone intensol pioglitazone hcl pioglitazone hcl/metformin hcl pioglitazone hcl-glimepiride piperacillin sodium/tazobactam sodium pirmella 1/35 prevalite piroxicam PLASMA-LYTE-148 50 PLASMA-LYTE-56/D5W 50 primaquine phosphate PLEGRIDY STARTER PACK primidone plenamine podofilox polyethylene glycol 3350 polymyxin b sulfate PROAIR RESPICLICK polymyxin b sulfate/trimethoprim sulfate probenecid
Drug Name
Drug Name
procainamide hcl quinine sulfate procentra prochlorperazine prochlorperazine edisylate raloxifene hydrochloride prochlorperazine maleate procto-med hc ranitidine hcl procto-pak proctosol hc proctozone-hc progesterone reclipsen RELENZA DISKHALER promethazine hcl promethegan propafenone hcl propafenone hcl er proparacaine hcl propranolol hcl repaglinide propranolol hcl er repaglinide/metformin hydrochloride propylthiouracil REPATHA SURECLICK reprexain protriptyline hcl reserpine RETROVIR IV INFUSION pyrazinamide pyridostigmine bromide ribasphere RIBASPHERE RIBAPAK ribavirin quetiapine fumarate rifabutin quinapril hcl quinidine gluconate quinidine gluconate cr rimantadine hcl quinidine sulfate ringers injection
Drug Name
Drug Name
ringers irrigation risedronate sodium risedronate sodium dr RISPERDAL CONSTA simvastatin risperidone sirolimus risperidone odt rivastigmine tartrate sodium chloride rivastigmine transdermal system sodium chloride 0.45% viaflex rizatriptan benzoate sodium chloride 0.9% rizatriptan benzoate odt sodium fluoride ropinirole er sodium lactate ropinirole hcl sodium phenylbutyrate rosuvastatin calcium sodium polystyrene sulfonate sodium sulfacetamide SOMATULINE DEPOT SAIZEN CLICK.EASY sotalol hcl sotalol hcl (af) SPIRIVA HANDIHALER SANDOSTATIN LAR DEPOT SPIRIVA RESPIMAT spironolactone sprintec 28 SAVELLA TITRATION PACK selegiline hcl selenium sulfide stavudine sterile water irrigation sertraline hcl streptomycin sulfate sildenafil silver sulfadiazine sucralfate
Drug Name
Drug Name
sulfacetamide sodium TECFIDERA STARTER PACK sulfacetamide sodium/prednisolone sodium phosphate sulfadiazine telmisartan sulfamethoxazole/trimethoprim ds sulfasalazine temazepam sumatriptan sumatriptan succinate sumatriptan succinate refill terazosin hcl terbinafine hcl SUPREP BOWEL PREP terbutaline sulfate terconazole testosterone testosterone cypionate testosterone enanthate testosterone pump tetanus/diphtheria toxoids-adsorbed tetracycline hcl theophylline theophylline cr theophylline er thioridazine hcl tacrolimus thiothixene tacrolimus tamoxifen citrate tamsulosin hcl tiagabine hydrochloride timolol maleate tarina fe 1/20 timolol maleate timolol maleate ophthalmic gel forming tinidazole taztia xt tizanidine hcl
Drug Name
Drug Name
trihexyphenidyl hcl tobramycin tri-legest fe tobramycin sulfate tri-lo-estarylla tri-lo-sprintec tolazamide trimethobenzamide hcl tolbutamide trimethoprim tolcapone trimipramine maleate tolmetin sodium tolterodine tartrate tolterodine tartrate er tri-previfem topiramate topiramate er tri-sprintec topotecan hcl trivora-28 torsemide trospium chloride tpn electrolytes trospium chloride er tramadol hcl tramadol hcl er TUDORZA PRESSAIR tramadol hydrochloride/acetaminophen trandolapril trandolapril/verapamil hcl tranexamic acid TRANSDERM-SCOP 11 tranylcypromine sulfate travoprost trazodone hcl TYZINE PEDIATRIC NASAL DROPS TRELSTAR MIXJECT unithroid tretinoin tretinoin tretinoin microsphere triamcinolone acetonide valacyclovir hcl triamcinolone in orabase triazolam valganciclovir valproate sodium valproic acid trifluoperazine hcl valproic acid trifluridine valsartan
Drug Name
Drug Name
vancomycin hcl vandazole voriconazole VENCLEXTA STARTING PACK warfarin sodium venlafaxine hcl wymzya fe venlafaxine hcl er XARELTO STARTER PACK verapamil hcl verapamil hcl er verapamil hcl sr vicodin es vicodin hp zafirlukast VIIBRYD STARTER PACK vinblastine sulfate vincasar pfs vincristine sulfate vinorelbine tartrate
Drug Name
zenchent fe ZENPEP 32zenzedi ZEPATIER 21ZETIA 29ZIAGEN 21zidovudine ziprasidone hcl ZIRGAN 21zoledronic acid ZOLINZA 16zolmitriptan zolmitriptan odt zolpidem tartrate zolpidem tartrate er ZOMACTON 36ZOMETA 44zonisamide ZONTIVITY 24ZORBTIVE 36ZORTRESS 43ZOSTAVAX 43zovia 1/35e zovia 1/50e ZUBSOLV 4ZYDELIG 16ZYKADIA 16ZYLET 46ZYPREXA RELPREVV This formulary was updated on 9/01/16. For more recent information or if you have other questions, please contact AmeriHealth 65 Preferred Rx at 1-866-569-5190 or, for TTY/TDD users, 711, seven days a week from 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail. Or visit www.amerihealthmedicare.com. Benefits underwritten by AmeriHealth HMO, Inc. AmeriHealth HMO, Inc. is an HMO plan with a Medicare contract. Enrollment in AmeriHealth HMO, Inc. depends on contract renewal. This information is available for free in other languages. Please call our Member Help Team at 1-866-569-5190 or, for TTY/TDD users, 711, seven days a week from 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail. Or visit www.amerihealthmedicare.com. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestra Ayuda Miembro del Equipo a 1-866-569-5190 o, para los usuarios de TTY/TDD, 711, siete días a la semana 08 a.m.-8 p.m., o visite www.amerihealthmedicare.com.

Source: https://www.amerihealthmedicare.com/pdfs/find_a_drug/2016_ah_nj_individual_formulary.pdf