BCBS Pharmacy

FEP 4 Tier Rx Drug Formulary (807) Basic Option
Effective October 1, 2012

The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name
drugs. Also included in the formulary are Tier 3, non-preferred brand-name drugs and Tier 4, specialty drugs.
Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your
physician to prescribe a preferred brand-name drug.
The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and costeffective.
Click on the category name in the Table of Contents below to go directly to that page
INTRODUCTION....................................................................................................................................................................................................... 5
PREFACE ................................................................................................................................................................................................................. 5
PRIOR APPROVAL .................................................................................................................................................................................................. 6
QUANTITY ALLOWANCES ..................................................................................................................................................................................... 6
PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...................................................................................................................................... 6
PRODUCT SELECTION CRITERIA......................................................................................................................................................................... 6
FORMULARY PRODUCT DESCRIPTIONS ............................................................................................................................................................ 6
GENERIC SUBSTITUTION ...................................................................................................................................................................................... 7
DRUG EFFICACY STUDY IMPLEMENTATION DRUGS ........................................................................................................................................ 7
EDITOR..................................................................................................................................................................................................................... 8
NOTICE..................................................................................................................................................................................................................... 8
LEGEND ................................................................................................................................................................................................................... 8
ANALGESICS........................................................................................................................................................................................................... 9
ANALGESICS, OTHER .................................................................................................................................................................................. 9
NSAIDs ........................................................................................................................................................................................................... 9
NSAIDs, COMBINATIONS ............................................................................................................................................................................. 9
NSAIDs, TOPICAL ......................................................................................................................................................................................... 9
COX-2 INHIBITORS ....................................................................................................................................................................................... 9
GOUT ............................................................................................................................................................................................................. 9
OPIOID ANALGESICS ................................................................................................................................................................................. 10
OPIOID ANALGESICS, CII .......................................................................................................................................................................... 10
NON-OPIOID ANALGESICS........................................................................................................................................................................ 10
VISCOSUPPLEMENTS ............................................................................................................................................................................... 10
ANTI-INFECTIVES ................................................................................................................................................................................................. 11
ANTIBACTERIALS ....................................................................................................................................................................................... 11
ANTIFUNGALS ............................................................................................................................................................................................ 12
ANTIMALARIALS ......................................................................................................................................................................................... 13
ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 13
ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 14
ANTIVIRALS................................................................................................................................................................................................. 14
MISCELLANEOUS ....................................................................................................................................................................................... 15
ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 15
ALKYLATING AGENTS ............................................................................................................................................................................... 15
ANTIMETABOLITES .................................................................................................................................................................................... 15
HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 16
IMMUNOMODULATORS ............................................................................................................................................................................. 16
KINASE INHIBITORS ................................................................................................................................................................................... 16
TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 17
MISCELLANEOUS ....................................................................................................................................................................................... 17
CARDIOVASCULAR .............................................................................................................................................................................................. 18
ACE INHIBITORS......................................................................................................................................................................................... 18
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 18
ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 18
ADRENOLYTICS, CENTRAL....................................................................................................................................................................... 19
ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 19
1
ALPHA BLOCKERS ..................................................................................................................................................................................... 19

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 19
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 19
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 19
ANTIARRHYTHMICS ................................................................................................................................................................................... 19
ANTILIPEMICS............................................................................................................................................................................................. 20
BETA-BLOCKERS ....................................................................................................................................................................................... 20
BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 21
CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 21
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 21
DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 21
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 21
DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...................................................................................... 21
DIURETICS .................................................................................................................................................................................................. 22
NITRATES .................................................................................................................................................................................................... 22
NITRATE/VASODILATOR COMBINATIONS .............................................................................................................................................. 22
PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 22
MISCELLANEOUS ....................................................................................................................................................................................... 23
CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 23
ANTIANXIETY .............................................................................................................................................................................................. 23
ANTICONVULSANTS .................................................................................................................................................................................. 23
ANTIDEMENTIA ........................................................................................................................................................................................... 24
ANTIDEPRESSANTS .................................................................................................................................................................................. 24
ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 25
ANTIPSYCHOTICS ...................................................................................................................................................................................... 25
ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 26
FIBROMYALGIA........................................................................................................................................................................................... 26
HUNTINGTON'S DISEASE AGENTS .......................................................................................................................................................... 26
HYPNOTICS................................................................................................................................................................................................. 26
MIGRAINE .................................................................................................................................................................................................... 27
MOOD STABILIZERS .................................................................................................................................................................................. 27
MULTIPLE SCLEROSIS .............................................................................................................................................................................. 27
MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 28
MYASTHENIA GRAVIS ............................................................................................................................................................................... 28
NARCOLEPSY/CATAPLEXY....................................................................................................................................................................... 28
PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 28
MISCELLANEOUS ....................................................................................................................................................................................... 28
ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 28
ANDROGENS .............................................................................................................................................................................................. 28
ANTIDIABETICS .......................................................................................................................................................................................... 29
CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 30
CALCIUM REGULATORS ........................................................................................................................................................................... 30
CONTRACEPTIVES .................................................................................................................................................................................... 31
ENDOMETRIOSIS ....................................................................................................................................................................................... 33
ESTROGENS ............................................................................................................................................................................................... 33
ESTROGEN/PROGESTINS ......................................................................................................................................................................... 33
FERTILITY REGULATORS.......................................................................................................................................................................... 33
GLUCOCORTICOIDS .................................................................................................................................................................................. 34
GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 34
HUMAN GROWTH HORMONES ................................................................................................................................................................. 34
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 34
INSULIN-LIKE GROWTH FACTOR-1 AGENTS .......................................................................................................................................... 34
PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 34
PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 34
PROGESTINS .............................................................................................................................................................................................. 35
SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 35
THYROID AGENTS ..................................................................................................................................................................................... 35
VASOPRESSINS ......................................................................................................................................................................................... 35
MISCELLANEOUS ....................................................................................................................................................................................... 35
GASTROINTESTINAL ........................................................................................................................................................................................... 36
ANTIDIARRHEALS ...................................................................................................................................................................................... 36
ANTIEMETICS ............................................................................................................................................................................................. 36
ANTISPASMODICS ..................................................................................................................................................................................... 36
CHOLELITHOLYTICS .................................................................................................................................................................................. 36
H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 36
INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 36
IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 37
LAXATIVES .................................................................................................................................................................................................. 37
PANCREATIC ENZYMES ............................................................................................................................................................................ 37
PROSTAGLANDINS .................................................................................................................................................................................... 37
PROTON PUMP INHIBITORS ..................................................................................................................................................................... 37
SALIVA STIMULANTS ................................................................................................................................................................................. 37
STEROIDS, RECTAL ................................................................................................................................................................................... 37
ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 38
MISCELLANEOUS ....................................................................................................................................................................................... 38
GENITOURINARY .................................................................................................................................................................................................. 38
BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 38
URINARY ANTISPASMODICS .................................................................................................................................................................... 38
VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 38
MISCELLANEOUS ....................................................................................................................................................................................... 38
HEMATOLOGIC ..................................................................................................................................................................................................... 39
ANTICOAGULANTS .................................................................................................................................................................................... 39
HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 39
HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS ........................................................................ 39
HEREDITARY ANGIOEDEMA AGENTS ..................................................................................................................................................... 40
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 40
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 40
PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 40
PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 40
STEM CELL MOBILIZERS ........................................................................................................................................................................... 40
MISCELLANEOUS ....................................................................................................................................................................................... 40
IMMUNOLOGIC AGENTS...................................................................................................................................................................................... 40
BIOLOGIC DISEASE-MODIFYING AGENTS .............................................................................................................................................. 40
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 41
IMMUNE GLOBULINS ................................................................................................................................................................................. 41
IMMUNOMODULATORS ............................................................................................................................................................................. 41
IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 41
NUTRITIONAL/SUPPLEMENTS............................................................................................................................................................................ 42
ELECTROLYTES ......................................................................................................................................................................................... 42
VITAMINS AND MINERALS ........................................................................................................................................................................ 42
RESPIRATORY ...................................................................................................................................................................................................... 43
ANAPHYLAXIS TREATMENT AGENTS ..................................................................................................................................................... 43
ANTICHOLINERGICS .................................................................................................................................................................................. 43
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 43
ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 43
ANTIHISTAMINES, NONSEDATING ........................................................................................................................................................... 43
ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 43
ANTIHISTAMINE/DECONGESTANT COMBINATIONS .............................................................................................................................. 43
ANTITUSSIVES............................................................................................................................................................................................ 43
ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 43
BETA AGONISTS ........................................................................................................................................................................................ 43
CYSTIC FIBROSIS ...................................................................................................................................................................................... 44
LEUKOTRIENE RECEPTOR MODIFIERS .................................................................................................................................................. 44
MAST CELL STABILIZERS ......................................................................................................................................................................... 44
NASAL ANTIHISTAMINES .......................................................................................................................................................................... 44
NASAL STEROIDS ...................................................................................................................................................................................... 44
PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 44
STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 44
STEROID INHALANTS ................................................................................................................................................................................ 44
XANTHINES ................................................................................................................................................................................................. 45
MISCELLANEOUS ....................................................................................................................................................................................... 45
TOPICAL ................................................................................................................................................................................................................ 45
DERMATOLOGY.......................................................................................................................................................................................... 45
MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 48
OPHTHALMIC .............................................................................................................................................................................................. 48
OTIC ............................................................................................................................................................................................................. 51
WEBSITES ............................................................................................................................................................................................................. 52
INDEX ..................................................................................................................................................................................................................... 54
INTRODUCTION
FEP is pleased to provide the 2012 FEP 4 Tier Rx Drug Formulary as a useful reference for drug product
selection. The drugs on the FEP 4 Tier Rx Drug Formulary have been reviewed by the FEP Pharmacy and
Therapeutics (P&T) Committee and FEP physicians and pharmacists and found appropriate for preferred
status.
"4 Tier" refers to four tiers of cost sharing by the member. Tier 1 is the lowest member copayment
share, Tier 2 and Tier 4 are intermediate, and Tier 3 is the highest copayment. Practitioners who select
clinically appropriate drugs from Tier 1, Tier 2 and Tier 4 will be choosing the most cost-effective drugs for
their patients who have drug benefits administered through FEP.
All the information in the FEP 4 Tier Rx Drug Formulary is provided as a reference for drug therapy selection.
Specific drug selection for an individual patient rests solely with the prescriber.
National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov,
on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this
publication.
PREFACE
The formulary is organized by sections, which refer to either a drug class or disease state. Unless exceptions
are noted, generally all dosage forms and strengths of the drug cited are included in the formulary.
The FEP 4 Tier Rx Drug Formulary is an open formulary, but FEP may impose restrictions or not reimburse
for specific drug products or types of products. For example, drugs and supplies for weight loss are excluded
from the pharmacy benefit. In addition, over-the-counter (OTC) products, with the exception of insulin and
diabetes monitoring products, are generally not included in the pharmacy benefit. Some OTC products are
listed in the formulary for informational purposes only.
The formulary is separated by Tiers in the following manner:
Basic Option Retail Pharmacy
Tier 1
Tier 2
Tier 3
Up to $10.00
Up to $40.00
50%*
*With a minimum payment of $50.00 or the cost of the drug
Tier 4
Up to $50.00
Basic Option Specialty Pharmacy

Tier 4
Up to $40.00
Tier 1: Lowest member copayment: all generic drugs, including preferred as well as non-preferred generic
products.
Tier 2: Intermediate member copayment: preferred brand-name products.
Tier 3: Highest member copayment: all non-preferred brand-name products. In most cases, there are
clinically appropriate alternatives in Tier 1 or Tier 2 for products found in Tier 3.
Tier 4: Intermediate member copayment: specialty products
Drug products shown in boldface type in Tier 2, Tier 3 and Tier 4 have generic versions. All generic drug
products are Tier 1.
All drugs that are preferred are noted in their respective tiers of the drug lists throughout this formulary.
Drugs may be reviewed by the FEP P&T Committee and designated non-preferred. These drugs are listed
in Tier 3. Also, FEP may designate certain drugs as non-preferred, typically if the cost-effectiveness is less
than other similar drugs. Generic versions of non-preferred drugs, whether listed or not, are always in Tier 1.
PRIOR APPROVAL
Prior approval (PA) is required for certain drugs before FEP will cover them. The prescribing physician may
request PA by calling toll-free 1-877-727-3784. The list of prior approval medications is subject to change.
For a current list of medications that require prior approval please see our Prior Approval web page.
QUANTITY ALLOWANCES
Quantity allowances have been established for some of the medications covered by FEP. Requests for
quantities greater than allowed can be submitted to the Prior Approval program by the prescribing
physician by calling toll-free 1-877-727-3784. The list of medications that have quantity allowances is subject
to change. For a current list of medications with quantity allowances please see our Prior Approval web
page.
PHARMACY AND THERAPEUTICS (P&T) COMMITTEE

The role of the FEP P&T Committee includes the evaluation of new medications, and making
recommendations to FEP for their designation as preferred or non-preferred on the FEP 4 Tier Rx Drug
Formulary. The FEP P&T Committee is made up of physicians and pharmacists who are not employees or
agents of, nor have financial interest in FEP.
PRODUCT SELECTION CRITERIA

The FEP P&T Committee will consider U.S. Food and Drug Administration (FDA) approved drugs for
preferred status designation. The evaluation includes a literature review; expert opinion may also be sought.
Formal reviews are prepared that typically address the following information:
Safety
Efficacy
Comparison studies
Drug interactions
Approved indications
Formulation and administration
Adverse effects
Contraindications
Pharmacokinetics
Patient compliance considerations
Medical outcome and pharmacoeconomic studies
When a new drug is considered for preferred status, an attempt will be made to examine the drug relative to
similar drugs currently preferred. In addition, entire therapeutic classes are periodically reviewed. The class
review process may result in a designation of non-preferred status to drug(s) in a particular therapeutic class,
in an effort to continually promote the most clinically useful and cost-effective agents.
Drugs evaluated by the P&T Committee and not classified as preferred receive a non-preferred designation
in the FEP 4 Tier Rx Drug Formulary. This designation indicates the P&T Committee's belief that the drug
offers no important clinical or cost advantage over comparable preferred drugs, or that there is currently
insufficient information to determine its appropriate clinical role, or that questions remain regarding safety
and effectiveness. In an open formulary environment, non-preferred drugs are covered under FEP's
pharmacy benefit. However, there may be additional costs incurred by the patient to receive a non-preferred
medication. Physicians are encouraged to prescribe preferred drugs.
All the information in the FEP 4 Tier Rx Drug Formulary is provided as a reference for drug therapy selection.
The final choice of a specific drug selection for an individual patient rests solely with the prescriber.
FORMULARY PRODUCT DESCRIPTIONS

To assist in understanding which specific strengths and dosage forms are preferred, examples are noted
below. The general principles shown in the examples can usually be extended to other entries in the book.
Any exceptions are noted.
Preferred products include all strengths and dosage forms of the cited brand-name product.
aripiprazole
Abilify
Oral tablets, oral disintegrating tablets, solution and all strengths of Abilify would be included in this listing.
When a strength or dosage form is specified, only the specified strength and dosage form is
preferred. Other strengths/dosage forms of the reference product are not.
acyclovir caps, susp, tabs
Zovirax
The capsules, suspension and tablets of Zovirax are preferred. From this entry, the cream and ointment
cannot be assumed to be on the list unless there is a specific entry.
Extended-release and delayed-release products require their own entry.
tolterodine
Detrol
The immediate-release product listing of Detrol alone would not include the extended-release product
Detrol LA.
tolterodine ext-rel
Detrol LA
A separate entry for Detrol LA confirms that the extended-release product is on the formulary.
Dosage forms will be consistent with the category and use where listed.
neomycin/polymyxin B/hydrocortisone
Cortisporin
Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this
entry, the topical cream cannot be assumed to be on the list unless there is an entry for this product in
the DERMATOLOGY section of the formulary.
GENERIC SUBSTITUTION
Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed
brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms
of the generic name in boldface type may be generically available. In addition, boldface type may indicate
that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.
One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower
than their brand-name equivalents. Generic drugs are:
Approved by the FDA for safety and effectiveness, and are manufactured under the same strict
standards that apply to brand-name drugs.
Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and to
the same extent as the brand-name drug. Generics may be different from the brand in size, color,
and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like
the brand-name drug.
Manufactured in the same strength and dosage form as the brand-name drugs.
When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same
clinical effect and safety profile as the brand-name drug.
DRUG EFFICACY STUDY IMPLEMENTATION DRUGS

Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of
effectiveness for FDA approval. Since 1962, all new drugs are required to be both safe and effective before
they can be marketed. The legislation that resulted in this change also applies retroactively to all drugs
approved as safe from 1938-1962. The Drug Efficacy Study Implementation (DESI) program was established
by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a
determination of fully effective was made for most of these products and they remain in the marketplace. A
few DESI products remain classified as "less than fully effective" while awaiting final administrative
disposition. Also classified as DESI are many products listed as identical, similar, or related to actual DESI
products.
EDITOR
Your comments and suggestions regarding this FEP 4 Tier Rx Drug Formulary are encouraged. Your input is
vital to this formulary's continued success. All responses will be reviewed and considered. Please send your
comments to:
FEP Rx Drug Formulary - MC 145
P.O. Box 52115
Phoenix, AZ 85072-2115
NOTICE
The information contained in this FEP 4 Tier Rx Drug Formulary and its appendices is provided by FEP,
solely for the convenience of medical providers. FEP does not warrant or assure accuracy of such
information nor is it intended to be comprehensive in nature. The FEP 4 Tier Rx Drug Formulary is not a
complete list of all covered medications. This FEP 4 Tier Rx Drug Formulary is not intended to be a
substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of
prescription drugs. FEP assumes no responsibility for the actions or omissions of any medical provider based
upon reliance, in whole or in part, on the information contained herein. The medical provider should consult
the drug manufacturer's product literature or standard references for more detailed information.
The information contained in this document is proprietary. The information may not be copied in whole or in
part without the written permission of FEP. 2012. All rights reserved.
This document contains references to brand-name prescription drugs that are trademarks or registered
trademarks of pharmaceutical manufacturers not affiliated with FEP.
If viewing this formulary via Internet, please be advised that the formulary is updated periodically and
changes may appear prior to their effective date.
LEGEND
d
OTC
DESI drug
Over the counter
PA
Prior Approval
boldface
Indicates generic availability; boldface may not apply to every strength or dosage
form under the listed generic name
delayed-rel
Delayed-release (also known as enteric-coated), refer to the reference brand listed

for clarification
ext-rel
Extended-release (also known as sustained-release), refer to the reference brand

listed for clarification
ANALGESICS
Practice guidelines of pain management are available at:
http://www.asahq.org
ANALGESICS, OTHER
Treatment recommendations for osteoarthritis are available at:
http://www.rheumatology.org
acetaminophen inj
OFIRMEV
Tier 3
VOLTAREN XR
Tier 3
MOBIC
Tier 3
NAPROSYN
ANAPROX
DAYPRO
FELDENE
CLINORIL
CALDOLOR
ARTHROTEC
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
NALFON
INDOCIN susp
SPRIX
NAPRELAN
Tier 3
Tier 3
Tier 3
Tier 3
NSAIDs, COMBINATIONS
naproxen/esomeprazole delayed-rel
VIMOVO
Tier 3
NSAIDs, TOPICAL
diclofenac sodium gel
VOLTAREN GEL
Tier 2
COX-2 INHIBITORS
PA
celecoxib
CELEBREX
Tier 2
ZYLOPRIM
Tier 3
COLCRYS
ULORIC
KRYSTEXXA
Tier 2
Tier 2
Tier 4
NSAIDs
PA
choline magnesium trisalicylate

diclofenac sodium delayed-rel
diclofenac sodium ext-rel
diflunisal
etodolac
etodolac ext-rel
flurbiprofen
ibuprofen
indomethacin
indomethacin ext-rel
ketoprofen
ketoprofen ext-rel
ketorolac
meloxicam
nabumetone
naproxen
naproxen sodium
oxaprozin
piroxicam
sulindac
ibuprofen inj
diclofenac sodium delayed-rel/
misoprostol
fenoprofen
indomethacin susp
ketorolac tromethamine nasal spray
naproxen sodium ext-rel
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
GOUT
PA
allopurinol
probenecid
colchicine
febuxostat
pegloticase
Tier 1
Tier 1
OPIOID ANALGESICS
Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at:
http://www.nccn.org
Opioid guidelines in the management of chronic non-malignant pain are available at:
http://www.asipp.org/Guidelines.htm
butalbital/acetaminophen/caffeine/
codeine
butalbital/aspirin/caffeine/codeine
butorphanol nasal spray
codeine/acetaminophen
hydrocodone/acetaminophen
tramadol
tramadol ext-rel
codeine/acetaminophen susp
buprenorphine transdermal
OPIOID ANALGESICS, CII
fentanyl transdermal
PA
fentanyl transmucosal
hydromorphone
morphine
morphine ext-rel
morphine ext-rel
morphine supp
oxycodone
oxycodone concentrate 20 mg/mL
oxycodone soln
oxycodone/acetaminophen 5/325
oxymorphone
PA
fentanyl citrate buccal
hydromorphone ext-rel
morphine ext-rel
oxycodone ext-rel
oxymorphone ext-rel
tapentadol
tapentadol ext-rel
PA
fentanyl citrate buccal
PA
fentanyl citrate nasal spray
PA
fentanyl sublingual spray
PA
fentanyl sublingual tablets
NON-OPIOID ANALGESICS
butalbital/acetaminophen
butalbital/acetaminophen/caffeine
butalbital/aspirin/caffeine
butalbital/acetaminophen
ziconotide
VISCOSUPPLEMENTS
PA
high molecular weight hyaluronan
PA
hylan G-F 20
PA
hylan G-F 20
Tier 1
FIORICET w/CODEINE
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
FIORINAL w/CODEINE
Tier 3
TYLENOL w/CODEINE
LORCET
LORTAB
VICODIN
ULTRAM
ULTRAM ER
CAPITAL w/CODEINE
BUTRANS
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
DURAGESIC
ACTIQ
DILAUDID
Tier 3
Tier 3
Tier 3
KADIAN
MS CONTIN
Tier 2
Tier 3
ROXICODONE
Tier 3
PERCOCET
OPANA
FENTORA
EXALGO
AVINZA
OXYCONTIN
OPANA ER
NUCYNTA
NUCYNTA ER
ONSOLIS
LAZANDA
SUBSYS
ABSTRAL
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
FIORICET
FIORINAL
PHRENILIN FORTE
PRIALT
Tier 3
Tier 3
Tier 2
Tier 4
ORTHOVISC
SYNVISC
SYNVISC-ONE
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
10
PA
PA
PA
sodium hyaluronate
sodium hyaluronate
sodium hyaluronate
EUFLEXXA
HYALGAN
SUPARTZ
Tier 4
Tier 4
Tier 4
ANTI-INFECTIVES
Hepatitis: CDC recommendations on the treatment of hepatitis are available at:
http://www.cdc.gov/hepatitis/index.htm
Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at:
http://www.aasld.org
HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at:
http://www.aidsinfo.nih.gov
Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at:
http://www.americanheart.org
Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at:
http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm
International Travel: CDC recommendations for international travel are available at:
http://www.cdc.gov/travel
Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at:
http://www.cdc.gov/std/treatment/default.htm
Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use
for treatment of nonspecific upper respiratory tract infection in adults are available at:
http://www.cdc.gov/ncidod/guidelines/guidelines_topic_ar.htm
Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at:
http://www.idsociety.org
ANTIBACTERIALS
Cephalosporins
First Generation
cephalexin
Tier 1
Second Generation
cefaclor
cefoxitin
cefprozil
cefuroxime axetil
Tier 1
Tier 1
Tier 1
Tier 1
Third Generation
cefdinir
cefditoren
cefotaxime
cefpodoxime
ceftazidime
ceftriaxone
ceftibuten
Fourth Generation
cefepime
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
KEFLEX
Tier 3
MEFOXIN
Tier 3
CEFTIN
Tier 3
SPECTRACEF
CLAFORAN
Tier 3
Tier 3
FORTAZ
ROCEPHIN
CEDAX
Tier 3
Tier 3
Tier 3
Tier 1
11
Fifth Generation
ceftaroline fosamil
Erythromycins/Macrolides
azithromycin
clarithromycin
clarithromycin ext-rel
erythromycin delayed-rel
erythromycin ethylsuccinate
erythromycin stearate
erythromycin/sulfisoxazole
azithromycin
fidaxomicin
erythromycin delayed-rel
erythromycin dispertabs
Fluoroquinolones
ciprofloxacin ext-rel
ciprofloxacin tabs
levofloxacin
ofloxacin
ciprofloxacin susp
moxifloxacin
gemifloxacin
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
TEFLARO
Tier 2
ZITHROMAX
BIAXIN
BIAXIN XL
Tier 3
Tier 3
Tier 3
E.E.S.
Tier 3
ZMAX
DIFICID
ERY-TAB
PCE
Tier 2
Tier 2
Tier 3
Tier 3
CIPRO tabs
LEVAQUIN
Tier 3
Tier 3
CIPRO susp
AVELOX
FACTIVE
Tier 2
Tier 2
Tier 3
KETEK
Tier 3
AUGMENTIN
AUGMENTIN XR
Tier 3
Tier 3
UNASYN
Tier 3
ZOSYN
MOXATAG
Tier 3
Tier 3
VIBRAMYCIN
ADOXA
MONODOX
DYNACIN
MINOCIN
SOLODYN
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
DIFLUCAN
SPORANOX caps
Tier 3
Tier 3
LAMISIL
VFEND
Tier 3
Tier 2
Ketolides
telithromycin
Penicillins
amoxicillin, except film-coated tabs
amoxicillin/clavulanate
amoxicillin/clavulanate ext-rel
amoxicillin/clavulanate susp 600 mg
ampicillin
ampicillin sodium/sulbactam sodium
dicloxacillin
penicillin VK
piperacillin/tazobactam
amoxicillin ext-rel
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tetracyclines
doxycycline hyclate
doxycycline monohydrate
minocycline
minocycline
minocycline ext-rel
tetracycline
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
ANTIFUNGALS
clotrimazole troches
fluconazole
PA
itraconazole caps
ketoconazole tabs
nystatin
PA
terbinafine tabs
voriconazole
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
12
amphotericin B lipid complex

amphotericin B lipid complex
anidulafungin
griseofulvin ultramicrosize
posaconazole
griseofulvin microsize
itraconazole oral soln
micafungin
ABELCET
AMPHOTEC
ERAXIS
GRIS-PEG
NOXAFIL
GRIFULVIN V
SPORANOX oral soln
MYCAMINE
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
MALARONE
ARALEN
Tier 2
Tier 3
COARTEM
DARAPRIM
Tier 2
Tier 2
COMBIVIR
EPZICOM
TRIZIVIR
ATRIPLA
COMPLERA
TRUVADA
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Chemokine Receptor Antagonists

maraviroc
SELZENTRY
Tier 4
Fusion Inhibitors
enfuvirtide
FUZEON
Tier 4
Integrase Inhibitors
raltegravir
ISENTRESS
Tier 4
Tier 1
VIRAMUNE
RESCRIPTOR
SUSTIVA
INTELENCE
VIRAMUNE XR
EDURANT
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
ZIAGEN
VIDEX EC
EPIVIR
ZERIT
RETROVIR
VIDEX soln
EMTRIVA
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Nucleotide Reverse Transcriptase Inhibitors

tenofovir
VIREAD
Tier 4
Protease Inhibitors
atazanavir
REYATAZ
Tier 4
ANTIMALARIALS
atovaquone/proguanil
chloroquine
mefloquine
primaquine
artemether/lumefantrine
pyrimethamine
ANTIRETROVIRAL AGENTS
Antiretroviral Combinations
lamivudine/zidovudine
abacavir/lamivudine
abacavir/lamivudine/zidovudine
efavirenz/emtricitabine/tenofovir
emtricitabine/rilpivirine/tenofovir
emtricitabine/tenofovir
Non-nucleoside Reverse Transcriptase Inhibitors

nevirapine
delavirdine
efavirenz
etravirine
nevirapine ext-rel
rilpivirine
Nucleoside Reverse Transcriptase Inhibitors
abacavir
didanosine delayed-rel
lamivudine
stavudine
zidovudine
didanosine soln
emtricitabine
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
13
darunavir
fosamprenavir
indinavir
lopinavir/ritonavir
nelfinavir
ritonavir
saquinavir mesylate
tipranavir
ANTITUBERCULAR AGENTS
ethambutol
isoniazid
pyrazinamide
rifampin
rifabutin
rifampin/isoniazid/pyrazinamide
rifapentine
ANTIVIRALS
Cytomegalovirus Agents
foscarnet
ganciclovir
ganciclovir inj
cidofovir
PA
valganciclovir
cytomegalovirus immune globulin
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Hepatitis Agents
Hepatitis B
adefovir dipivoxil
entecavir
lamivudine
telbivudine
Hepatitis C
PA
PA
PA
PA
PA
PA
PA
PA
ribavirin caps
ribavirin caps - Ribasphere
ribavirin tabs
ribavirin tabs - Ribapak
ribavirin tabs - Ribatab
boceprevir
ribavirin oral soln
telaprevir
Herpes Agents
acyclovir caps, susp, tabs
famciclovir
valacyclovir
Influenza Agents
amantadine, except tabs
rimantadine
oseltamivir
zanamivir
Respiratory Syncytial Virus Agents
palivizumab
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
PREZISTA
LEXIVA
CRIXIVAN
KALETRA
VIRACEPT
NORVIR
INVIRASE
APTIVUS
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
MYAMBUTOL
Tier 3
RIFADIN
MYCOBUTIN
RIFATER
PRIFTIN
Tier 3
Tier 2
Tier 2
Tier 2
CYTOVENE inj
VISTIDE
VALCYTE
CYTOGAM
Tier 4
Tier 2
Tier 2
Tier 4
HEPSERA
BARACLUDE
EPIVIR-HBV
TYZEKA
Tier 4
Tier 4
Tier 4
Tier 4
REBETOL
Tier 4
COPEGUS
Tier 4
VICTRELIS
REBETOL
INCIVEK
Tier 4
Tier 4
Tier 4
ZOVIRAX
FAMVIR
VALTREX
Tier 3
Tier 3
Tier 3
FLUMADINE
TAMIFLU
RELENZA
Tier 3
Tier 2
Tier 2
SYNAGIS
Tier 4
14
MISCELLANEOUS
aztreonam
clindamycin
dapsone
meropenem
methenamine hippurate, prophylaxis
metronidazole tabs
nitrofurantoin ext-rel
nitrofurantoin macrocrystals
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim DS
tinidazole
trimethoprim
vancomycin
atovaquone
daptomycin
ertapenem
imipenem/cilastatin
linezolid
nitazoxanide
rifaximin
doripenem
telavancin
tigecycline
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
AZACTAM
CLEOCIN
Tier 3
Tier 3
MERREM
HIPREX
FLAGYL
MACROBID
MACRODANTIN
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
TINDAMAX
Tier 3
VANCOCIN
MEPRON
CUBICIN
INVANZ
PRIMAXIN
ZYVOX
ALINIA
XIFAXAN
DORIBAX
VIBATIV
TYGACIL
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
HEXALEN
MYLERAN
LEUKERAN
CEENU
TREANDA
BUSULFEX
BICNU
GLIADEL WAFER
MUSTARGEN
ALKERAN
ZANOSAR
TEMODAR
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
FLUDARA
GEMZAR
PURINETHOL
Tier 4
Tier 4
Tier 3
ANTINEOPLASTIC AGENTS
Clinical practice guidelines in oncology are available at:
http://www.asco.org
http://www.nccn.org
ALKYLATING AGENTS
cyclophosphamide
ifosfamide/mesna
cyclophosphamide inj
thiotepa
altretamine
busulfan
chlorambucil
lomustine
bendamustine
busulfan
carmustine
carmustine
mechlorethamine
melphalan
streptozocin
temozolomide
ANTIMETABOLITES
cladribine
cytarabine
floxuridine
fludarabine
gemcitabine
mercaptopurine
thioguanine
Tier 1
Tier 1
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
15
capecitabine
clofarabine
cytarabine liposome
pemetrexed
pentostatin
pralatrexate
rasburicase
XELODA
CLOLAR
DEPOCYT
ALIMTA
NIPENT
FOLOTYN
ELITEK
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
CASODEX
Tier 3
NILANDRON
ZYTIGA
Tier 2
Tier 4
FARESTON
FASLODEX
Tier 2
Tier 4
ARIMIDEX
AROMASIN
FEMARA
Tier 3
Tier 2
Tier 2
Gonadotropin-Releasing Hormone (GnRH) Antagonists

degarelix acetate
FIRMAGON
Tier 4
Luteinizing Hormone-releasing Hormone (LHRH) Agonists

leuprolide acetate
Tier 1
goserelin acetate
histrelin acetate
PA
leuprolide acetate
PA
leuprolide acetate
PA
leuprolide acetate
triptorelin pamoate
triptorelin pamoate
triptorelin pamoate
ZOLADEX
VANTAS
ELIGARD
LUPRON DEPOT
LUPRON DEPOT-PED
TRELSTAR
TRELSTAR DEPOT
TRELSTAR LA
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
MEGACE
MEGACE ES
Tier 3
Tier 2
IMMUNOMODULATORS
lenalidomide
thalidomide
REVLIMID
THALOMID
Tier 4
Tier 4
KINASE INHIBITORS
PA
vandetanib
axitinib
PA
crizotinib
dasatinib
erlotinib
everolimus
imatinib mesylate
lapatinib
nilotinib
CAPRELSA
INLYTA
XALKORI
SPRYCEL
TARCEVA
AFINITOR
GLEEVEC
TYKERB
TASIGNA
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
HORMONAL ANTINEOPLASTIC AGENTS

Antiandrogens
bicalutamide
flutamide
nilutamide
abiraterone
Antiestrogens
tamoxifen
toremifene
fulvestrant
Aromatase Inhibitors
anastrozole
exemestane
letrozole
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Progestins
megestrol acetate
megestrol acetate susp
Tier 1
16
PA
PA
pazopanib
ruxolitinib
sorafenib
sunitinib
temsirolimus
vemurafenib
TOPOISOMERASE INHIBITORS
topotecan inj
topotecan
MISCELLANEOUS
amifostine
bleomycin sulfate
carboplatin
cisplatin
dactinomycin
daunorubicin
dexrazoxane
dexrazoxane
etoposide
hydroxyurea
irinotecan
leucovorin calcium
mesna inj
mitomycin
mitoxantrone
vincristine
vinorelbine
epirubicin
vinblastine
mitotane
procarbazine
PA
sipuleucel-T
aldesleukin
PA
alemtuzumab
arsenic trioxide
asparaginase
PA
asparaginase Erwinia chrysanthemi
azacitidine
BCG live vaccine
BCG live vaccine
PA
bevacizumab
bexarotene caps
bortezomib
PA
brentuximab vedotin
cabazitaxel
cetuximab
daunorubicin citrate liposomal
decitabine
denileukin diftitox
docetaxel
doxorubicin liposomal
epirubicin
eribulin
etoposide phosphate
PA
ipilimumab
VOTRIENT
JAKAFI
NEXAVAR
SUTENT
TORISEL
ZELBORAF
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
HYCAMTIN inj
HYCAMTIN
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
ETHYOL
Tier 4
COSMEGEN
CERUBIDINE
TOTECT
ZINECARD
Tier 4
Tier 4
Tier 4
Tier 4
HYDREA
CAMPTOSAR
Tier 3
Tier 4
MESNEX inj
Tier 3
NAVELBINE
Tier 4
LYSODREN
MATULANE
PROVENGE
PROLEUKIN
CAMPATH
TRISENOX
ELSPAR
ERWINAZE
VIDAZA
THERACYS
TICE BCG
AVASTIN
TARGRETIN caps
VELCADE
ADCETRIS
JEVTANA
ERBITUX
DAUNOXOME
DACOGEN
ONTAK
TAXOTERE
DOXIL
ELLENCE
HALAVEN
ETOPOPHOS
YERVOY
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
17
PA
PA
PA
PA
PA
ixabepilone
levoleucovorin calcium
mesna tabs 400 mg
methoxsalen inj
nelarabine
ofatumumab
oxaliplatin
paclitaxel protein-bound particles
panitumumab
pegaspargase
pertuzumab
porfimer sodium
rituximab
romidepsin
samarium sm 153 lexidronam
teniposide
tositumomab
trastuzumab
valrubicin
vismodegib
vorinostat
IXEMPRA
FUSILEV
MESNEX
UVADEX
ARRANON
ARZERRA
ELOXATIN
ABRAXANE
VECTIBIX
ONCASPAR
PERJETA
PHOTOFRIN
RITUXAN
ISTODAX
QUADRAMET
VUMON
BEXXAR
HERCEPTIN
VALSTAR
ERIVEDGE
ZOLINZA
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
CARDIOVASCULAR
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure
is available at:
http://www.nhlbi.nih.gov/guidelines/hypertension
Guidelines for the evaluation and management of cardiovascular diseases in adults are available at:
http://www.acc.org
http://www.heartfailureguideline.org
ACE INHIBITORS
Guidelines for the use of ACE inhibitors are available at:
http://professional.diabetes.org
http://www.acc.org
benazepril
enalapril
fosinopril
lisinopril
lisinopril
perindopril
quinapril
ramipril
trandolapril
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
LOTENSIN
VASOTEC
Tier 3
Tier 3
PRINIVIL
ZESTRIL
ACEON
ACCUPRIL
ALTACE
MAVIK
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

benazepril/amlodipine
Tier 1
LOTREL
trandolapril/verapamil ext-rel
TARKA
ACE INHIBITOR/DIURETIC COMBINATIONS
benazepril/hydrochlorothiazide
captopril/hydrochlorothiazide
enalapril/hydrochlorothiazide
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
LOTENSIN HCT
Tier 3
VASERETIC
Tier 3
18
fosinopril/hydrochlorothiazide
lisinopril/hydrochlorothiazide
lisinopril/hydrochlorothiazide
quinapril/hydrochlorothiazide
Tier 1
Tier 1
Tier 1
Tier 1
PRINZIDE
ZESTORETIC
ACCURETIC
Tier 3
Tier 3
Tier 3
ADRENOLYTICS, CENTRAL
clonidine
clonidine transdermal
Tier 1
Tier 1
CATAPRES
CATAPRES-TTS
Tier 3
Tier 3
ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone
spironolactone
Tier 1
Tier 1
INSPRA
ALDACTONE
Tier 3
Tier 3
ALPHA BLOCKERS
Guidelines for the use of alpha blockers in various patient populations are available at:
doxazosin
prazosin
terazosin
Tier 1
Tier 1
Tier 1
CARDURA
MINIPRESS
Tier 3
Tier 3
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS

Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at:
http://professional.diabetes.org
eprosartan
irbesartan
irbesartan/hydrochlorothiazide
losartan
losartan/hydrochlorothiazide
telmisartan
telmisartan/hydrochlorothiazide
azilsartan
eprosartan/hydrochlorothiazide
olmesartan
olmesartan/hydrochlorothiazide
valsartan
valsartan/hydrochlorothiazide
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
TEVETEN
AVAPRO
AVALIDE
COZAAR
HYZAAR
MICARDIS
MICARDIS HCT
EDARBI
TEVETEN HCT
BENICAR
BENICAR HCT
DIOVAN
DIOVAN HCT
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine/olmesartan
AZOR
amlodipine/telmisartan
TWYNSTA
amlodipine/valsartan
EXFORGE
Tier 2
Tier 2
Tier 2
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS

amlodipine/valsartan/hydrochlorothiazide
EXFORGE HCT
olmesartan/amlodipine/hydrochlorothiazide
TRIBENZOR
Tier 2
Tier 3
ANTIARRHYTHMICS
Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at:
http://www.acc.org
amiodarone
disopyramide
flecainide
mexiletine
Tier 1
Tier 1
Tier 1
Tier 1
CORDARONE
NORPACE
TAMBOCOR
Tier 3
Tier 3
Tier 3
19
propafenone ext-rel
quinidine gluconate ext-rel
quinidine sulfate ext-rel
sotalol
disopyramide ext-rel
dronedarone
dofetilide
Tier 1
Tier 1
Tier 1
Tier 1
RYTHMOL SR
Tier 3
BETAPACE
NORPACE CR
MULTAQ
TIKOSYN
Tier 3
Tier 2
Tier 2
Tier 4
ANTILIPEMICS
The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III) is available at:
http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
Antilipemic Combinations
ezetimibe/simvastatin
VYTORIN
Tier 3
QUESTRAN/QUESTRAN LIGHT
COLESTID
WELCHOL
Tier 3
Tier 3
Tier 2
ZETIA
Tier 2
Tier 1
LOPID
LIPOFEN
ANTARA
TRICOR
TRILIPIX
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
LIPITOR
LESCOL
MEVACOR
PRAVACHOL
ZOCOR
CRESTOR
LESCOL XL
LIVALO
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
Tier 3
Niacins/Combinations
niacin ext-rel
niacin ext-rel/lovastatin
niacin ext-rel/simvastatin
NIASPAN
ADVICOR
SIMCOR
Tier 2
Tier 2
Tier 2
Omega-3 Fatty Acids

omega-3 acid ethyl esters
LOVAZA
Tier 3
Bile Acid Resins

cholestyramine pkt
colestipol
colesevelam
Tier 1
Tier 1
Cholesterol Absorption Inhibitors

ezetimibe
Fibrates
gemfibrozil
fenofibrate
fenofibrate, micronized
fenofibrate, micronized
fenofibric acid
HMG-CoA Reductase Inhibitors
atorvastatin
fluvastatin
lovastatin
pravastatin
simvastatin
rosuvastatin
fluvastatin ext-rel
pitavastatin
BETA-BLOCKERS
Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at:
http://www.acc.org
acebutolol
atenolol
carvedilol
Tier 1
Tier 1
Tier 1
SECTRAL
TENORMIN
COREG
Tier 3
Tier 3
Tier 3
20
metoprolol
metoprolol ext-rel
pindolol
propranolol
propranolol ext-rel
carvedilol phosphate ext-rel
esmolol
nebivolol
penbutolol
propranolol ext-rel
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
LOPRESSOR
TOPROL-XL
Tier 3
Tier 3
INDERAL LA
COREG CR
BREVIBLOC
BYSTOLIC
LEVATOL
INNOPRAN XL
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
BETA-BLOCKER/DIURETIC COMBINATIONS
Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at:
http://www.acc.org
atenolol/chlorthalidone
bisoprolol/hydrochlorothiazide
metoprolol/hydrochlorothiazide
metoprolol succinate ext-rel/
hydrochlorothiazide
Tier 1
Tier 1
Tier 1
TENORETIC
ZIAC
LOPRESSOR HCT
DUTOPROL
Tier 3
Tier 3
Tier 3
Tier 3
CALCIUM CHANNEL BLOCKERS

Dihydropyridines
amlodipine
felodipine ext-rel
nicardipine
nifedipine ext-rel
nifedipine ext-rel
nimodipine
nisoldipine ext-rel
isradipine ext-rel
nicardipine ext-rel
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
NORVASC
Tier 3
ADALAT CC
PROCARDIA XL
NIMOTOP
SULAR
DYNACIRC CR
CARDENE SR
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 3
Nondihydropyridines
diltiazem
diltiazem ext-rel
diltiazem ext-rel
diltiazem ext-rel 360 mg
diltiazem ext-rel, except 360 mg
verapamil
verapamil ext-rel
verapamil ext-rel
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
CARDIZEM
DILACOR XR
TIAZAC
CARDIZEM CD
CARDIZEM CD
CALAN
CALAN SR
COVERA-HS
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

amlodipine/atorvastatin
Tier 1
CADUET
Tier 3
DIGITALIS GLYCOSIDES
digoxin
LANOXIN
Tier 2
TEKTURNA
TEKTURNA HCT
Tier 2
Tier 2
Tier 1
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS

aliskiren
aliskiren/hydrochlorothiazide
DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

aliskiren/amlodipine
TEKAMLO
Tier 3
21
DIURETICS
Carbonic Anhydrase Inhibitors
acetazolamide
acetazolamide ext-rel
methazolamide
Loop Diuretics
bumetanide
furosemide
torsemide
ethacrynic acid
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
DIAMOX SEQUELS
Tier 3
LASIX
DEMADEX
EDECRIN
Tier 3
Tier 3
Tier 3
Potassium-sparing Diuretics
amiloride
Tier 1
Thiazides and Thiazide-like Diuretics

chlorthalidone
hydrochlorothiazide
indapamide
metolazone
Tier 1
Tier 1
Tier 1
Tier 1
ZAROXOLYN
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
ALDACTAZIDE
DYAZIDE
MAXZIDE
MAXZIDE-25
Tier 3
Tier 3
Tier 3
Tier 3
Diuretic Combinations
amiloride/hydrochlorothiazide
spironolactone/hydrochlorothiazide
triamterene/hydrochlorothiazide
37.5/25
triamterene/hydrochlorothiazide 50/25
Tier 1
NITRATES
Oral
isosorbide dinitrate oral
isosorbide mononitrate
isosorbide mononitrate ext-rel
Tier 1
Tier 1
Tier 1
ISORDIL
Tier 3
IMDUR
Tier 3
nitroglycerin sublingual spray

nitroglycerin sublingual
Tier 1
NITROLINGUAL
NITROSTAT
Tier 3
Tier 2
NITRO-DUR
Tier 3
NITRATE/VASODILATOR COMBINATIONS
isosorbide dinitrate/hydralazine
BIDIL
Tier 2
PULMONARY ARTERIAL HYPERTENSION

Endothelin Receptor Antagonists
PA
ambrisentan
PA
bosentan
LETAIRIS
TRACLEER
Tier 4
Tier 4
Phosphodiesterase Inhibitors
PA
sildenafil
PA
tadalafil
REVATIO
ADCIRCA
Tier 4
Tier 4
Sublingual
Transdermal
nitroglycerin transdermal
nitroglycerin transdermal
Tier 1
Tier 1
22
Prostaglandin Vasodilators
PA
epoprostenol sodium
PA
iloprost
PA
treprostinil
PA
treprostinil
MISCELLANEOUS
hydralazine
midodrine
minoxidil
ranolazine ext-rel
FLOLAN
VENTAVIS
REMODULIN
TYVASO
Tier 2
Tier 4
Tier 4
Tier 4
RANEXA
Tier 2
XANAX
XANAX XR
Tier 3
Tier 3
KLONOPIN
TRANXENE T-TAB
VALIUM
ATIVAN
Tier 3
Tier 3
Tier 3
Tier 3
ANAFRANIL
Tier 3
VISTARIL
LUVOX CR
Tier 3
Tier 2
TEGRETOL
TEGRETOL-XR
DIASTAT
DEPAKOTE
ZARONTIN
FELBATOL
NEURONTIN
LAMICTAL
KEPPRA
KEPPRA XR
TRILEPTAL
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
Tier 2
Tier 3
DILANTIN
MYSOLINE
TOPAMAX
DEPAKENE
ZONEGRAN
EQUETRO
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 1
Tier 1
Tier 1
CENTRAL NERVOUS SYSTEM

Practice guidelines for psychiatric disorders are available at:
http://www.psych.org
ANTIANXIETY
Benzodiazepines
alprazolam
alprazolam ext-rel
chlordiazepoxide
clonazepam tabs
clorazepate
diazepam
lorazepam
oxazepam
Miscellaneous
buspirone
clomipramine
fluvoxamine
hydroxyzine HCl
hydroxyzine pamoate
fluvoxamine ext-rel
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
ANTICONVULSANTS
Practice guidelines for the treatment of epilepsy are available at:
http://www.aan.com
carbamazepine
carbamazepine ext-rel
diazepam rectal gel
divalproex sodium delayed-rel
ethosuximide
felbamate
gabapentin
lamotrigine
levetiracetam
levetiracetam ext-rel
oxcarbazepine
phenobarbital
phenytoin sodium extended
primidone
topiramate
valproic acid
zonisamide
carbamazepine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
23
ezogabine
lacosamide
lamotrigine ext-rel
lamotrigine orally disintegrating tablets
oxcarbazepine susp
phenytoin
pregabalin
rufinamide
tiagabine
valproic acid delayed-rel
clobazam
vigabatrin
POTIGA
VIMPAT
LAMICTAL XR
LAMICTAL ODT
TRILEPTAL susp
DILANTIN INFATABS
LYRICA
BANZEL
GABITRIL
STAVZOR
ONFI
SABRIL
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 4
ARICEPT (except 23 mg)

ARICEPT ODT
RAZADYNE
RAZADYNE ER
EXELON
NAMENDA
EXELON PATCH
ARICEPT 23 mg
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 3
ANTIDEMENTIA
Practice guidelines for the management of dementia are available at:
http://www.aan.com
donepezil
donepezil orally disintegrating tabs
galantamine
galantamine ext-rel
rivastigmine
memantine
rivastigmine transdermal
donepezil
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
ANTIDEPRESSANTS
Although these agents are primarily indicated for depression, some of these are also approved for other indications, including
bipolar disorder, obsessive-compulsive disorder, panic disorder, and premenstrual dysphoric disorder.
Guidelines for the evaluation and management of bipolar and depressive disorders are available at:
Monoamine Oxidase Inhibitors (MAOIs)
phenelzine
tranylcypromine
selegiline transdermal
isocarboxazid
Selective Serotonin Reuptake Inhibitors (SSRIs)
citalopram
escitalopram
fluoxetine
fluoxetine delayed-rel
paroxetine HCl
paroxetine HCl ext-rel
sertraline
fluoxetine
paroxetine mesylate
vilazodone
Tier 1
Tier 1
NARDIL
PARNATE
EMSAM
MARPLAN
Tier 3
Tier 3
Tier 2
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
CELEXA
LEXAPRO
PROZAC
PROZAC WEEKLY
PAXIL
PAXIL CR
ZOLOFT
SARAFEM
PEXEVA
VIIBRYD
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)*

* Indicates the proposed mechanism of action, based on the American Psychiatric Association Summary of Treatment
Recommendations.
venlafaxine
venlafaxine ext-rel
Tier 1
Tier 1
EFFEXOR XR
Tier 3
24
venlafaxine ext-rel tabs

duloxetine delayed-rel
desvenlafaxine ext-rel
Tricyclic Antidepressants (TCAs)
amitriptyline
desipramine
doxepin
imipramine HCl
imipramine pamoate
nortriptyline
protriptyline
Miscellaneous Agents
amitriptyline/perphenazine
bupropion
bupropion ext-rel
bupropion ext-rel
mirtazapine
nefazodone
trazodone
trazodone ext-rel
bupropion ext-rel
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
CYMBALTA
PRISTIQ
Tier 2
Tier 3
NORPRAMIN
Tier 3
TOFRANIL
TOFRANIL-PM
PAMELOR
VIVACTIL
Tier 3
Tier 3
Tier 3
Tier 3
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
REMERON
Tier 3
Tier 3
Tier 3
Tier 3
OLEPTRO
FORFIVO XL
Tier 2
Tier 3
ANTIPARKINSONIAN AGENTS
Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at:
http://www.aan.com
amantadine, except tabs
benztropine
bromocriptine
carbidopa/levodopa
carbidopa/levodopa
carbidopa/levodopa ext-rel
carbidopa/levodopa/entacapone
diphenhydramine
pramipexole
ropinirole
ropinirole ext-rel
selegiline caps
trihexyphenidyl
entacapone
pramipexole ext-rel
rasagiline mesylate
selegiline orally disintegrating tabs
tolcapone
rotigotine transdermal
apomorphine
ANTIPSYCHOTICS
Atypicals
clozapine
clozapine orally disintegrating tablets
olanzapine
olanzapine/fluoxetine
quetiapine
risperidone
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
PARLODEL
PARCOPA
SINEMET
SINEMET CR
STALEVO
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
MIRAPEX
REQUIP
REQUIP XL
ELDEPRYL
Tier 3
Tier 3
Tier 2
Tier 3
COMTAN
MIRAPEX ER
AZILECT
ZELAPAR
TASMAR
NEUPRO
APOKYN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 4
CLOZARIL
FAZACLO
ZYPREXA/ZYPREXA ZYDIS
SYMBYAX
SEROQUEL
RISPERDAL
Tier 3
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
25
ziprasidone
aripiprazole
paliperidone palmitate
quetiapine ext-rel
risperidone long-acting inj
asenapine
iloperidone
lurasidone
olanzapine pamoate
paliperidone ext-rel
Miscellaneous
fluphenazine
haloperidol
loxapine
perphenazine
thioridazine
thiothixene
trifluoperazine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
GEODON
ABILIFY
INVEGA SUSTENNA
SEROQUEL XR
RISPERDAL CONSTA
SAPHRIS
FANAPT
LATUDA
ZYPREXA RELPREVV
INVEGA
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
LOXITANE
Tier 3
ATTENTION DEFICIT HYPERACTIVITY DISORDER

Guidelines for the evaluation and management of attention deficit disorder are available at:
http://www.aacap.org
http://www.aap.org
PA
Tier 1
ADDERALL
Tier 3
Tier 1
ADDERALL XR
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
FOCALIN
Tier 3
DEXEDRINE SPANSULE
RITALIN
CONCERTA
RITALIN LA
RITALIN-SR
STRATTERA
FOCALIN XR
INTUNIV
VYVANSE
METADATE CD
DAYTRANA
KAPVAY
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
FIBROMYALGIA
milnacipran
SAVELLA
Tier 3
HUNTINGTON'S DISEASE AGENTS

PA
tetrabenazine
XENAZINE
Tier 4
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
amphetamine/dextroamphetamine
mixed salts
amphetamine/dextroamphetamine
mixed salts ext-rel
dexmethylphenidate
dextroamphetamine
dextroamphetamine ext-rel
methylphenidate
methylphenidate ext-rel
atomoxetine
dexmethylphenidate ext-rel
guanfacine ext-rel
lisdexamfetamine
methylphenidate transdermal
clonidine ext-rel
HYPNOTICS
Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic
insomnia in adults are available at:
http://www.aasmnet.org
Benzodiazepines
estazolam
Tier 1
26
flurazepam
temazepam
quazepam
Nonbenzodiazepines
chloral hydrate
zaleplon
zolpidem
zolpidem ext-rel
butabarbital
chloral hydrate
ramelteon
secobarbital
zolpidem sublingual
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
RESTORIL
DORAL
Tier 3
Tier 3
SONATA
AMBIEN
AMBIEN CR
BUTISOL SODIUM
SOMNOTE
ROZEREM
SECONAL
EDLUAR
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
SILENOR
Tier 3
Tricyclics
doxepin
MIGRAINE
Guidelines for prevention and management of migraine headaches are available at:
http://www.aan.com
Ergotamine Derivatives
dihydroergotamine inj
ergotamine/caffeine supp
ergotamine/caffeine
Tier 1
D.H.E. 45
MIGERGOT
CAFERGOT
Tier 3
Tier 2
Tier 3
Tier 1
Tier 1
AMERGE
IMITREX
MAXALT/MAXALT-MLT
ZOMIG/ZOMIG-ZMT
FROVA
Tier 3
Tier 3
Tier 2
Tier 2
Tier 3
Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations

sumatriptan/naproxen sodium
TREXIMET
Tier 3
Selective Serotonin Agonists

naratriptan
sumatriptan
rizatriptan
zolmitriptan
frovatriptan
Miscellaneous
d
acetaminophen/dichloralphenazone/
isometheptene
MOOD STABILIZERS
lithium carbonate
lithium carbonate ext-rel tabs 300 mg
lithium carbonate ext-rel tabs 450 mg
Tier 1
Tier 1
Tier 1
Tier 1
LITHOBID
Tier 3
AMPYRA
GILENYA
COPAXONE
AVONEX
REBIF
BETASERON
EXTAVIA
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
MULTIPLE SCLEROSIS
Practice guidelines for multiple sclerosis are available at:
http://www.aan.com
PA
dalfampridine ext-rel
fingolimod
glatiramer
interferon beta-1a
interferon beta-1a
interferon beta-1b
interferon beta-1b
27
natalizumab
TYSABRI
Tier 4
FLEXERIL
DANTRIUM
LIORESAL INTRATHECAL
AMRIX
Tier 3
Tier 3
Tier 2
Tier 3
Tier 1
MESTINON
MESTINON TIMESPAN
MESTINON syrup
Tier 3
Tier 2
Tier 2
Tier 1
PROVIGIL
XYREM
NUVIGIL
Tier 3
Tier 2
Tier 3
Tier 1
Tier 1
ANTABUSE
REVIA
CAMPRAL
VIVITROL
Tier 2
Tier 3
Tier 3
Tier 4
SUBOXONE
Tier 2
NUEDEXTA
Tier 2
ZYBAN
Tier 3
CHANTIX
Tier 2
MISCELLANEOUS
Amyotrophic Lateral Sclerosis
riluzole
RILUTEK
Tier 2
Botulinum Toxins
PA
abobotulinumtoxinA
PA
incobotulinumtoxinA
PA
onabotulinumtoxinA
PA
rimabotulinumtoxinB
DYSPORT
XEOMIN
BOTOX
MYOBLOC
Tier 4
Tier 4
Tier 4
Tier 4
MUSCULOSKELETAL THERAPY AGENTS

baclofen
cyclobenzaprine
dantrolene
baclofen intrathecal
cyclobenzaprine ext-rel
MYASTHENIA GRAVIS
pyridostigmine tabs 60 mg
pyridostigmine ext-rel tabs 180 mg
pyridostigmine syrup
NARCOLEPSY/CATAPLEXY
PA
modafinil
sodium oxybate
PA
armodafinil
PSYCHOTHERAPEUTIC-MISCELLANEOUS
Alcohol Deterrents
disulfiram
naltrexone
acamprosate calcium
naltrexone microspheres
Opioid Antagonists
naloxone inj
Partial Opioid Agonists/Combinations
buprenorphine
buprenorphine/naloxone
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Pseudobulbar Affect
dextromethorphan/quinidine
Smoking Deterrents
bupropion ext-rel
OTC
nicotine transdermal
varenicline
Tier 1
Tier 1
ENDOCRINE AND METABOLIC

ANDROGENS
Clinical practice guidelines for the treatment of hypogonadism are available at:
http://www.aace.com
testosterone cypionate
Tier 1
28
testosterone enanthate
testosterone gel
testosterone transdermal
testosterone gel
testosterone soln
Tier 1
ANDROGEL
ANDRODERM
FORTESTA
AXIRON
Tier 2
Tier 2
Tier 3
Tier 3
PRECOSE
GLYSET
Tier 3
Tier 2
SYMLINPEN
Tier 2
Tier 1
Tier 1
Tier 1
GLUCOPHAGE
FORTAMET
GLUCOPHAGE XR
RIOMET
Tier 3
Tier 2
Tier 3
Tier 2
Tier 1
Tier 1
METAGLIP
GLUCOVANCE
Tier 3
Tier 3
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

saxagliptin
sitagliptin phosphate
linagliptin
ONGLYZA
JANUVIA
TRADJENTA
Tier 2
Tier 2
Tier 3
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations

saxagliptin/metformin ext-rel
sitagliptin/metformin
linagliptin/metformin
sitagliptin/metformin ext-rel
KOMBIGLYZE XR
JANUMET
JENTADUETO
JANUMET XR
Tier 2
Tier 2
Tier 3
Tier 3
ANTIDIABETICS
Guidelines of treatment and management of diabetes are available at:
http://professionals.diabetes.org
Alpha-glucosidase Inhibitors
acarbose
miglitol
Tier 1
Amylin Analogs
pramlintide
Biguanides
metformin
metformin ext-rel
metformin ext-rel
metformin soln
Biguanide/Sulfonylurea Combinations
glipizide/metformin
glyburide/metformin
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/HMG-CoA Reductase Inhibitor Combinations

sitagliptin/simvastatin
JUVISYNC
Tier 3
Incretin Mimetic Agents

exenatide
liraglutide
BYETTA
VICTOZA
Tier 2
Tier 2
NOVOLOG
NOVOLOG MIX 70/30
Tier 2
Tier 2
LEVEMIR
LANTUS
APIDRA
HUMULIN R
NOVOLIN R
HUMULIN N
NOVOLIN N
HUMULIN 70/30
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Insulins
OTC
OTC
OTC
OTC
OTC
insulin aspart
insulin aspart protamine 70%/
insulin aspart 30%
insulin detemir
insulin glargine
insulin glulisine
insulin human
insulin human
insulin isophane human
insulin isophane human
insulin isophane human 70%/regular 30%
29
OTC
insulin isophane human 70%/regular 30%

insulin lispro
insulin lispro protamine/insulin lispro
NOVOLIN 70/30
HUMALOG
HUMALOG MIX
Tier 2
Tier 2
Tier 2
Tier 1
ACTOS
AVANDIA
Tier 2
Tier 2
Tier 1
ACTOPLUS MET
ACTOPLUS MET XR
AVANDAMET
Tier 2
Tier 2
Tier 2
DUETACT
AVANDARYL
Tier 2
Tier 2
STARLIX
PRANDIN
Tier 3
Tier 2
PRANDIMET
Tier 2
AMARYL
GLUCOTROL
GLUCOTROL XL
DIABETA
GLYNASE
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
ACCU-CHEK test strips

ONETOUCH test strips
BD INSULIN SYRINGES
SOFTCLIX LANCET DEVICE
SOFTTOUCH LANCET DEVICE
ONETOUCH LANCETS
SOFTCLIX LANCETS
SOFTTOUCH LANCETS
CHEMSTRIP K URINE KETONE STRIPS
CHEMSTRIP UGK URINE GLUCOSE/
KETONE STRIPS
CHEMSTRIP UG URINE GLUCOSE
STRIPS
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Miscellaneous
bromocriptine
CYCLOSET
Tier 3
CALCIUM RECEPTOR ANTAGONISTS

cinacalcet
SENSIPAR
Tier 4
Insulin Sensitizers
pioglitazone
rosiglitazone
Insulin Sensitizer/Biguanide Combinations
pioglitazone/metformin
pioglitazone/metformin ext-rel
rosiglitazone/metformin
Insulin Sensitizer/Sulfonylurea Combinations
pioglitazone/glimepiride
rosiglitazone/glimepiride
Meglitinides
nateglinide
repaglinide
Tier 1
Meglitinide/Biguanide Combinations
repaglinide/metformin
Sulfonylureas
glimepiride
glipizide
glipizide ext-rel
glyburide
glyburide, micronized
Supplies
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
blood glucose test strips

blood glucose test strips
insulin syringes
lancet device
lancet device
lancets
lancets
lancets
urine test strips
urine test strips
OTC
urine test strips
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
CALCIUM REGULATORS
Guidelines of treatment and management of osteoporosis are available at:
http://www.aace.com
http://www.nof.org
30
Bisphosphonates
alendronate
etidronate
ibandronate
pamidronate
ibandronate inj
risedronate
tiludronate
alendronate/vitamin D3
zoledronic acid
zoledronic acid
Tier 1
Tier 1
Tier 1
Tier 1
FOSAMAX
DIDRONEL
BONIVA
Tier 3
Tier 3
Tier 3
BONIVA inj
ACTONEL
SKELID
FOSAMAX PLUS D
RECLAST
ZOMETA
Tier 2
Tier 2
Tier 2
Tier 3
Tier 4
Tier 4
MIACALCIN
MIACALCIN inj
Tier 3
Tier 3
Parathyroid Hormones
teriparatide
FORTEO
Tier 4
Miscellaneous
denosumab
denosumab
PROLIA
XGEVA
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
YAZ
Tier 3
LOESTRIN 1/20
LOESTRIN FE 1/20
LOESTRIN 24 FE
Tier 3
Tier 3
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
DESOGEN
ORTHO-CEPT
YASMIN
NORDETTE
Tier 3
Tier 3
Tier 3
Tier 3
LOESTRIN 1.5/30
LOESTRIN FE 1.5/30
Tier 3
Tier 3
Tier 1
Tier 1
LO/OVRAL
Tier 3
OVCON 35
BREVICON
MODICON
NORINYL 1+35
ORTHO-NOVUM 1/35
ORTHO-CYCLEN
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Calcitonins
calcitonin-salmon spray
calcitonin-salmon inj
Tier 1
CONTRACEPTIVES
EE = ethinyl estradiol
ME = mestranol
Monophasic
20 mcg Estrogen
drospirenone/EE 3/20 - Gianvi
levonorgestrel/EE 0.1/20
norethindrone acetate/EE 1/20
norethindrone acetate/EE 1/20 and iron
norethindrone acetate/EE 1/20 and iron
30 mcg Estrogen
desogestrel/EE 0.15/30
desogestrel/EE 0.15/30
drospirenone/EE 3/30
levonorgestrel/EE 0.15/30 - Levora
norethindrone acetate/EE 1.5/30
norethindrone acetate/EE 1.5/30 and
iron
norgestrel/EE 0.3/30
norgestrel/EE 0.3/30 - Low-Ogestrel
35 mcg Estrogen
ethynodiol diacetate/EE 1/35 Zovia 1/35
norethindrone/EE 0.4/35
norethindrone/EE 1/35
norgestimate/EE 0.25/35
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
31
50 mcg Estrogen
ethynodiol diacetate/EE 1/50 Zovia 1/50
norethindrone/ME 1/50
norgestrel/EE 0.5/50
Tier 1
Tier 1
Tier 1
NORINYL 1+50
Tier 3
OVCON 50
Tier 3
Biphasic
desogestrel/EE
norethindrone/EE
Tier 1
MIRCETTE
NECON 10/11
Tier 3
Tier 3
desogestrel/EE
levonorgestrel/EE - Trivora
norethindrone acetate/EE and iron
norethindrone/EE
norethindrone/EE
norgestimate/EE
norgestimate/EE
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
CYCLESSA
Tier 3
ESTROSTEP FE
ORTHO-NOVUM 7/7/7
TRI-NORINYL
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
NATAZIA
Tier 2
LOSEASONIQUE
SEASONALE
SEASONIQUE
Tier 3
Tier 3
Tier 2
NOR-QD
ORTHO MICRONOR
Tier 3
Tier 3
ELLA
Tier 2
IMPLANON
NEXPLANON
Tier 4
Tier 4
DEPO-PROVERA
Tier 3
Progestin Intrauterine Device

levonorgestrel releasing IUD
MIRENA
Tier 4
Transdermal
norelgestromin/EE
ORTHO EVRA
Tier 2
NUVARING
Tier 2
Triphasic
Four Phase
estradiol valerate and dienogest/
estradiol valerate
Extended Cycle
levonorgestrel/EE 0.1/20 and EE 10
levonorgestrel/EE 0.15/30 and EE 10
Tier 1
Tier 1
Tier 1
Continuous
levonorgestrel/EE 0.09/20 - Amethyst
Progestin Only
norethindrone
norethindrone
Emergency Contraception
levonorgestrel - Next Choice
ulipristal
Tier 1
Tier 1
Tier 1
Tier 1
Implant
etonogestrel implant
etonogestrel implant
Injectable
medroxyprogesterone acetate 150
mg/mL
Tier 1
Vaginal
etonogestrel/EE ring
32
ENDOMETRIOSIS
danazol
PA
nafarelin
Tier 1
SYNAREL
Tier 2
ESTROGENS
Guidelines of treatment and management of hormone therapy and menopause are available at:
http://www.menopause.org
Injectable
estradiol valerate
Tier 1
DELESTROGEN
Tier 2
estradiol
estrogens,
esterified/methyltestosterone
estropipate
estrogens, conjugated
estrogens, conjugated, synthetic B
Tier 1
Tier 1
ESTRACE
Tier 3
PREMARIN
ENJUVIA
Tier 2
Tier 2
CLIMARA
VIVELLE-DOT
ESTROGEL
EVAMIST
ALORA
Tier 3
Tier 2
Tier 2
Tier 2
Tier 3
ESTRACE
FEMRING
VAGIFEM
PREMARIN crm
Tier 2
Tier 2
Tier 2
Tier 2
FEMHRT
ACTIVELLA
PREFEST
PREMPHASE
Tier 2
Tier 3
Tier 2
Tier 2
PREMPRO
Tier 2
CLIMARA PRO
COMBIPATCH
Tier 2
Tier 3
CLOMID
LUTREPULSE
CETROTIDE
OVIDREL
GONAL-F
GONAL-F RFF
FOLLISTIM AQ
GANIRELIX
MENOPUR
Tier 3
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Oral
Transdermal
estradiol
estradiol
estradiol transdermal gel
estradiol transdermal spray
estradiol
Tier 1
Tier 1
Vaginal
estradiol vaginal crm
estradiol vaginal ring
estradiol vaginal tabs
estrogens, conjugated crm
ESTROGEN/PROGESTINS
Oral
EE/norethindrone acetate
estradiol/norethindrone acetate
estradiol/norgestimate
estrogens,
conjugated/medroxyprogesterone
estrogens,
conjugated/medroxyprogesterone
Tier 1
Tier 1
Transdermal
estradiol/levonorgestrel
estradiol/norethindrone acetate
FERTILITY REGULATORS
PA
chorionic gonadotropin
PA
clomiphene
PA
gonadorelin
PA
cetrorelix
PA
choriogonadotropin alfa
PA
follitropin alfa
PA
follitropin alfa
PA
follitropin beta
PA
ganirelix acetate
PA
menotropins
Tier 1
Tier 1
33
PA
PA
menotropins
urofollitropin
REPRONEX
BRAVELLE
Tier 4
Tier 4
CORTEF
MEDROL
Tier 3
Tier 3
ORAPRED
Tier 3
PRELONE
Tier 3
MILLIPRED
ORAPRED ODT
Tier 2
Tier 2
RAYOS
Tier 3
PROGLYCEM
GLUCAGON EMERGENCY KIT
Tier 2
Tier 2
GENOTROPIN
HUMATROPE
NORDITROPIN
NUTROPIN AQ NUSPIN
NUTROPIN/NUTROPIN AQ
OMNITROPE
SAIZEN
SEROSTIM
TEV-TROPIN
ZORBTIVE
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS

calcitriol (1,25-D3)
Tier 1
doxercalciferol
paricalcitol
ROCALTROL
HECTOROL
ZEMPLAR
Tier 3
Tier 2
Tier 2
INSULIN-LIKE GROWTH FACTOR-1 AGENTS

PA
mecasermin
INCRELEX
Tier 4
PHENYLKETONURIA TREATMENT AGENTS

PA
sapropterin
KUVAN
Tier 4
PHOSLO
FOSRENOL
RENAGEL
RENVELA
Tier 3
Tier 2
Tier 2
Tier 2
GLUCOCORTICOIDS
cortisone acetate
dexamethasone
fludrocortisone
hydrocortisone
methylprednisolone
prednisolone
prednisolone sodium phosphate
5 mg/5 mL
prednisolone syrup
prednisone
prednisolone sodium phosphate orally
disintegrating tablet
prednisone
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
GLUCOSE ELEVATING AGENTS

diazoxide
glucagon, human recombinant
HUMAN GROWTH HORMONES
Guidelines for use of growth hormone are available at:
http://www.aace.com
PA
PA
PA
PA
PA
PA
PA
PA, *
PA
PA
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
* Indicated for AIDS wasting only
PHOSPHATE BINDER AGENTS

calcium acetate
lanthanum
sevelamer
sevelamer carbonate
Tier 1
34
PROGESTINS
Injectable
hydroxyprogesterone caproate
MAKENA
Tier 4
PROVERA
AYGESTIN
PROMETRIUM
Tier 3
Tier 3
Tier 3
ENDOMETRIN
Tier 2
EVISTA
Tier 2
Tier 1
Tier 1
TAPAZOLE
Tier 3
Tier 1
Tier 1
Tier 1
SYNTHROID
Tier 2
CYTOMEL
THYROLAR
ARMOUR THYROID
Tier 3
Tier 3
Tier 3
Tier 1
DDAVP
Tier 3
Tier 1
Tier 1
Tier 1
Tier 4
CARNITOR
Tier 3
SANDOSTATIN
Tier 4
ACETADOTE
CYANOKIT
ZAVESCA
ORFADIN
ADAGEN
SYPRINE
GANITE
KORLYM
FABRAZYME
LUMIZYME
MYOZYME
ACTHAR H.P.
CYSTAGON
NAGLAZYME
SUPPRELIN LA
ELAPRASE
CEREZYME
SOMATULINE DEPOT
ALDURAZYME
SANDOSTATIN LAR
SOMAVERT
ELELYSO
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Oral
PA
medroxyprogesterone acetate
norethindrone acetate
progesterone, micronized
Vaginal
PA
progesterone supp
Tier 1
Tier 1
Tier 1
SELECTIVE ESTROGEN RECEPTOR MODULATORS

raloxifene
THYROID AGENTS
Antithyroid Agents
methimazole
propylthiouracil
Thyroid Supplements
levothyroxine
levothyroxine - Levoxyl
liothyronine
liotrix
thyroid
VASOPRESSINS
desmopressin
MISCELLANEOUS
levocarnitine
methylergonovine
octreotide acetate
corticotropin powder
acetylcysteine
hydroxocobalamin
miglustat
nitisinone
pegademase, bovine
trientine
gallium nitrate
PA
mifepristone
PA
agalsidase beta
PA
alglucosidase alfa
PA
alglucosidase alfa
PA
corticotropin
cysteamine
PA
galsulfase
histrelin acetate
PA
idursulfase
PA
imiglucerase
lanreotide acetate
PA
laronidase
octreotide acetate
pegvisomant
PA
taliglucerase alfa
35
PA
PA
tesamorelin
thyrotropin alfa
tolvaptan
velaglucerase alfa
EGRIFTA
THYROGEN
SAMSCA
VPRIV
Tier 4
Tier 4
Tier 4
Tier 4
GASTROINTESTINAL
Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at:
http://www.acg.gi.org
http://www.gastro.org
ANTIDIARRHEALS
diphenoxylate/atropine
loperamide
opium tincture
Tier 1
Tier 1
Tier 1
LOMOTIL
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
MARINOL
Tier 3
ANTIVERT
REGLAN
ZOFRAN
Tier 3
Tier 3
Tier 3
TIGAN
EMEND
ANZEMET
SANCUSO
ZUPLENZ
ALOXI
TRANSDERM SCOP
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
DONNATAL
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
BENTYL
LEVSIN
LEVBID
Tier 3
Tier 3
Tier 3
CHOLELITHOLYTICS
ursodiol
ursodiol
ursodiol
Tier 1
Tier 1
Tier 1
ACTIGALL
URSO
URSO FORTE
Tier 3
Tier 3
Tier 3
H2 RECEPTOR ANTAGONISTS
cimetidine
*
famotidine
famotidine susp
nizatidine
ranitidine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
PEPCID
PEPCID susp
AXID
ZANTAC
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
COLAZAL
ENTOCORT EC
Tier 3
Tier 2
ANTIEMETICS
dronabinol
granisetron
meclizine
metoclopramide
ondansetron
prochlorperazine
promethazine
trimethobenzamide
aprepitant
dolasetron
granisetron transdermal
ondansetron oral soluble film
palonosetron
scopolamine transdermal
ANTISPASMODICS
d
atropine/hyoscyamine/scopolamine/
phenobarbital
dicyclomine
hyoscyamine sulfate
hyoscyamine sulfate ext-rel
propantheline 15 mg
* Except 20 mg
INFLAMMATORY BOWEL DISEASE
Oral Agents
balsalazide
budesonide delayed-rel caps
36
sulfasalazine
sulfasalazine delayed-rel
mesalamine delayed-rel tabs
mesalamine ext-rel caps
mesalamine ext-rel caps
olsalazine
AZULFIDINE
AZULFIDINE EN-TABS
ASACOL
ASACOL HD
LIALDA
APRISO
PENTASA
DIPENTUM
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
ROWASA
CORTIFOAM
CANASA
Tier 3
Tier 2
Tier 2
IRRITABLE BOWEL SYNDROME

Irritable Bowel Syndrome with Constipation
lubiprostone
AMITIZA
Tier 2
Irritable Bowel Syndrome with Diarrhea

alosetron
LOTRONEX
Tier 3
COLYTE
GOLYTELY
NULYTELY
MOVIPREP
OSMOPREP
VISICOL
SUPREP
Tier 3
Tier 2
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
HALFLYTELY
Tier 3
CREON
PANCREAZE
VIOKACE
ZENPEP
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
CYTOTEC
Tier 3
Tier 1
Tier 1
Tier 1
PRILOSEC
ZEGERID
PROTONIX
NEXIUM
DEXILANT
ACIPHEX
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
Tier 3
Tier 1
SALAGEN
EVOXAC
Tier 3
Tier 2
Tier 1
ANUSOL-HC 2.5%
Tier 3
Rectal Agents
hydrocortisone enema
mesalamine rectal susp
hydrocortisone acetate foam
mesalamine supp
Tier 1
Tier 1
Tier 1
Tier 1
LAXATIVES
lactulose
peg 3350/electrolytes
sodium phosphates
sodium phosphates
sodium sulfate/potassium sulfate/
magnesium sulfate
peg 3350/electrolytes + bisacodyl
Tier 1
Tier 1
Tier 1
Tier 1
PANCREATIC ENZYMES
pancrelipase delayed-rel
PROSTAGLANDINS
misoprostol
PROTON PUMP INHIBITORS
omeprazole delayed-rel
omeprazole/sodium bicarbonate
pantoprazole delayed-rel
esomeprazole delayed-rel
dexlansoprazole delayed-rel
rabeprazole delayed-rel
SALIVA STIMULANTS
pilocarpine tabs
cevimeline
STEROIDS, RECTAL
hydrocortisone crm
37
d
d
hydrocortisone acetate/pramoxine foam

hydrocortisone acetate/pramoxine foam
EPIFOAM
PROCTOFOAM-HC
Tier 2
Tier 2
PYLERA
Tier 2
GASTROCROM
CARAFATE
RELISTOR
SUCRAID
CARAFATE susp
ENTEREG
CUVPOSA
RECTIV
KEPIVANCE
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 4
PROSCAR
FLOMAX
AVODART
JALYN
RAPAFLO
CIALIS
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 3
DITROPAN XL
DETROL
SANCTURA
TOVIAZ
OXYTROL
VESICARE
DETROL LA
SANCTURA XR
ENABLEX
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 1
Tier 1
Tier 1
METROGEL-VAGINAL
TERAZOL 3
TERAZOL 7
CLEOCIN vaginal supp
Tier 3
Tier 3
Tier 3
Tier 2
Tier 1
Tier 1
Tier 1
URECHOLINE
PYRIDIUM
UROCIT-K
ELMIRON
UROCIT-K 15 mEq
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
ULCER THERAPY COMBINATIONS

bismuth subsalicylate + metronidazole +
tetracycline
MISCELLANEOUS
cromolyn sodium
sucralfate
methylnaltrexone
sacrosidase
sucralfate susp
alvimopan
glycopyrrolate
nitroglycerin rectal oint 0.4%
PA
palifermin
Tier 1
Tier 1
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
Guidelines for the management of BPH are available at:
http://www.auanet.org/guidelines
PA
alfuzosin ext-rel
finasteride
tamsulosin
dutasteride
dutasteride/tamsulosin
silodosin
tadalafil 2.5 mg, 5 mg
URINARY ANTISPASMODICS
oxybutynin
oxybutynin ext-rel
tolterodine
trospium
fesoterodine ext-rel
oxybutynin transdermal
solifenacin succinate
tolterodine ext-rel
trospium ext-rel
darifenacin ext-rel
VAGINAL ANTI-INFECTIVES
metronidazole
terconazole
terconazole
clindamycin supp
MISCELLANEOUS
bethanechol
phenazopyridine
potassium citrate
pentosan polysulfate sodium
potassium citrate 15 mEq
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
38
HEMATOLOGIC
ANTICOAGULANTS
Injectable
enoxaparin
dalteparin
desirudin
tinzaparin
Tier 1
LOVENOX
FRAGMIN
IPRIVASK
INNOHEP
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
COUMADIN
PRADAXA
XARELTO
Tier 3
Tier 2
Tier 2
Tier 1
ARIXTRA
Tier 2
CYSTADANE
Tier 2
Oral
warfarin
dabigatran etexilate
rivaroxaban
Synthetic Heparinoid-like Agents
fondaparinux
Miscellaneous
betaine anhydrous
HEMATOPOIETIC GROWTH FACTORS
Guidelines for the management of neutropenia are available at:
http://www.asco.org
Guidelines for the management of anemia associated with chronic kidney disease are available at:
http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm#guidelines
PA
PA
PA
PA
PA
PA
PA
peginesatide
darbepoetin alfa
epoetin alfa
epoetin alfa
filgrastim
oprelvekin
pegfilgrastim
romiplostim
sargramostim
OMONTYS
ARANESP
EPOGEN
PROCRIT
NEUPOGEN
NEUMEGA
NEULASTA
NPLATE
LEUKINE
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS

Guidelines of treatment and management of hemophilia are available at:
http://www.hemophilia.org
factor IX concentrate
AHF, human/VWF, human
antihemophilic factor
antihemophilic factor, recombinant
anti-inhibitor coagulant complex
coagulation factor VIIa
desmopressin spray
BEBULIN VH
HUMATE-P
ALPHANATE
HEMOFIL M
KOATE-DVI
MONOCLATE-P
ADVATE
HELIXATE FS
KOGENATE FS
RECOMBINATE
REFACTO
XYNTHA
FEIBA VH IMMUNO
NOVOSEVEN RT
STIMATE
ALPHANINE SD
BEBULIN
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
39
factor XIII concentrate
fibrinogen
VWF, human/factor VIII complex
BENEFIX
MONONINE
PROFILNINE SD
CORIFACT
RIASTAP
WILATE
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
HEREDITARY ANGIOEDEMA AGENTS

PA
ecallantide
PA
C1 esterase inhibitor
PA
C1 esterase inhibitor
PA
icatibant
KALBITOR
BERINERT
CINRYZE
FIRAZYR
Tier 2
Tier 4
Tier 4
Tier 4
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS

eltrombopag
PROMACTA
Tier 4
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS

PA
eculizumab
SOLIRIS
PLATELET AGGREGATION INHIBITORS
clopidogrel
dipyridamole
ticlopidine
dipyridamole ext-rel/aspirin
prasugrel
ticagrelor
PLATELET SYNTHESIS INHIBITORS
anagrelide
Tier 1
Tier 1
Tier 1
Tier 1
STEM CELL MOBILIZERS

plerixafor
MISCELLANEOUS
cilostazol
deferoxamine
pentoxifylline ext-rel
tranexamic acid
alteplase
PA
deferiprone
PA
protein C concentrate, human
tranexamic acid
PA
deferasirox
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
PLAVIX
PERSANTINE
Tier 3
Tier 3
AGGRENOX
EFFIENT
BRILINTA
Tier 2
Tier 2
Tier 3
AGRYLIN
Tier 3
MOZOBIL
Tier 4
PLETAL
DESFERAL
TRENTAL
CYKLOKAPRON inj
CATHFLO ACTIVASE
FERRIPROX
CEPROTIN
LYSTEDA
EXJADE
Tier 3
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
ORENCIA
HUMIRA
KINERET
CIMZIA
ENBREL
SIMPONI
REMICADE
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
IMMUNOLOGIC AGENTS
Guidelines for the management of rheumatic diseases are available at:
BIOLOGIC DISEASE-MODIFYING AGENTS
PA
abatacept
adalimumab
anakinra
certolizumab pegol
etanercept
golimumab
PA
infliximab
40
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

hydroxychloroquine
Tier 1
leflunomide
Tier 1
methotrexate
Tier 1
methotrexate
penicillamine
auranofin
IMMUNE GLOBULINS
hepatitis B immune globulin
hepatitis B immune globulin
PA
immune globulin, gamma
PA
immune globulin, gamma
PA
immune globulin, gamma (IGG)
PA
immune globulin, gamma (IGG)
PA
immune globulin, intravenous
PA
PA
PA
PA
PA
PA
PA
immune globulin, subcutaneous
Rho (D) immune globulin
PLAQUENIL
ARAVA
Tier 3
Tier 3
RHEUMATREX
CUPRIMINE
RIDAURA
Tier 2
Tier 2
Tier 3
HEPAGAM B
HYPERHEP B S-D
GAMASTAN S-D
GAMUNEX-C
GAMMAKED
GAMMAPLEX
CARIMUNE NF
FLEBOGAMMA
GAMMAGARD LIQUID
GAMMAGARD S-D
GAMUNEX
OCTAGAM
PRIVIGEN
HIZENTRA
HYPERRHO S-D
MICRHOGAM
MICRHOGAM PLUS
RHOGAM
RHOGAM PLUS
RHOPHYLAC
WINRHO SDF
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
INTRON A
INFERGEN
ACTIMMUNE
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
SYLATRON
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
ILARIS
ARCALYST
ACTEMRA
Tier 4
Tier 4
Tier 4
IMURAN
CELLCEPT
CELLCEPT suspension
Tier 3
Tier 4
Tier 4
IMMUNOMODULATORS
CDC recommendations on the treatment of hepatitis are available at:
http://www.cdc.gov/hepatitis/index.htm
Guidelines for the management of hepatitis are available at:
Interferons
PA
PA
PA
PA
PA
PA
PA
interferon alfa-2b
interferon alfacon-1
interferon gamma-1b, recombinant
peginterferon alfa-2a
peginterferon alfa-2b
Miscellaneous
PA
canakinumab
PA
rilonacept
tocilizumab
IMMUNOSUPPRESSANTS
Antimetabolites
azathioprine
mycophenolate mofetil
mycophenolate mofetil
Tier 1
Tier 1
41
mycophenolate sodium delayed-rel
MYFORTIC
Tier 4
SANDIMMUNE
NEORAL
PROGRAF
Tier 4
Tier 4
Tier 4
Rapamycin Derivatives
everolimus
sirolimus
ZORTRESS
RAPAMUNE
Tier 4
Tier 4
Miscellaneous
belatacept
PA
belimumab
NULOJIX
BENLYSTA
Tier 4
Tier 4
DUET DHA
PRENATE ELITE
CITRANATAL RX
VITAFOL-OB
VITAFOL-PN
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
DRISDOL
LURIDE
LURIDE LOZI-TABS
Tier 3
Tier 3
Tier 3
FERRLECIT
PREVIDENT
Tier 2
Tier 3
NASCOBAL
FERAHEME
VENOFER
MEPHYTON
GALZIN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Calcineurin Inhibitors
cyclosporine
cyclosporine, modified
tacrolimus
Tier 1
Tier 1
Tier 1
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
Potassium
potassium chloride ext-rel
potassium chloride liquid
potassium chloride powder
Tier 1
Tier 1
Tier 1
VITAMINS AND MINERALS

Folic Acid Agents
folic acid
Tier 1
Prenatal Vitamins
prenatal vitamins/folic acid
prenatal vitamins/docusate/folic acid
Miscellaneous
cyanocobalamin inj
ergocalciferol (D2)
fluoride drops
fluoride tabs
multivitamins/fluoride drops, tabs
multivitamins/fluoride/iron drops, tabs
sodium ferric gluconate inj
sodium fluoride
vitamin ADC/fluoride drops
vitamin ADC/fluoride/iron drops
cyanocobalamin spray
ferumoxytol inj
iron sucrose inj
phytonadione
zinc acetate
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
42
RESPIRATORY
Guidelines to the management, prevention, or treatment of COPD and asthma are available at:
http://www.aaaai.org
http://www.ginasthma.com
http://www.goldcopd.com
http://www.nhlbi.nih.gov
The Allergy Report and guidelines for allergy-related conditions are available at:
ANAPHYLAXIS TREATMENT AGENTS
epinephrine
epinephrine
EPIPEN
EPIPEN JR.
Tier 2
Tier 2
SPIRIVA
ATROVENT HFA
Tier 2
Tier 3
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS

ipratropium/albuterol soln
Tier 1
ipratropium/albuterol
DUONEB
COMBIVENT
Tier 3
Tier 2
ANTIHISTAMINES, LOW SEDATING

levocetirizine
Tier 1
XYZAL
Tier 3
ANTIHISTAMINES, NONSEDATING
desloratadine
Tier 1
CLARINEX
Tier 2
ANTIHISTAMINES, SEDATING
cyproheptadine
diphenhydramine
hydroxyzine HCl
hydroxyzine pamoate
promethazine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
VISTARIL
Tier 3
CLARINEX-D
Tier 2
TESSALON
Tier 3
ZUTRIPRO
Tier 3
REZIRA
Tier 3
ACCUNEB
VENTOLIN
PROAIR HFA
Tier 3
Tier 3
Tier 2
ANTICHOLINERGICS
ipratropium soln
tiotropium
ipratropium, CFC-free aerosol
Tier 1
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
desloratadine/pseudoephedrine ext-rel
ANTITUSSIVES
benzonatate
ANTITUSSIVE COMBINATIONS
Opioid
codeine/promethazine
codeine/promethazine/phenylephrine
hydrocodone/homatropine
hydrocodone/chlorpheniramine/
pseudoephedrine
hydrocodone/pseudoephedrine
BETA AGONISTS
Inhalants
Short Acting
albuterol soln
albuterol soln
albuterol sulfate, CFC-free aerosol
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
43

PROVENTIL HFA
VENTOLIN HFA
Tier 2
Tier 2
formoterol inhalation caps

salmeterol xinafoate
arformoterol soln
indacaterol
FORADIL
SEREVENT DISKUS
BROVANA
ARCAPTA NEOHALER
Tier 2
Tier 2
Tier 3
Tier 3
VOSPIRE ER
Tier 3
CAYSTON
PULMOZYME
KALYDECO
TOBI
Tier 3
Tier 4
Tier 4
Tier 4
SINGULAIR
ACCOLATE
ZYFLO CR
Tier 2
Tier 3
Tier 3
ASTELIN
ASTEPRO
PATANASE
Tier 3
Tier 2
Tier 3
FLONASE
NASACORT AQ
RHINOCORT AQUA
VERAMYST
NASONEX
BECONASE AQ
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 3
PHOSPHODIESTERASE-4 INHIBITORS
roflumilast
DALIRESP
Tier 3
STEROID/BETA AGONIST COMBINATIONS

budesonide/formoterol
fluticasone/salmeterol
fluticasone/salmeterol, CFC-free aerosol
mometasone/formoterol
SYMBICORT
ADVAIR
ADVAIR HFA
DULERA
Tier 2
Tier 2
Tier 2
Tier 2
PULMICORT RESPULES
QVAR
PULMICORT FLEXHALER
FLOVENT
Tier 3
Tier 2
Tier 2
Tier 2
Long Acting
Oral Agents
albuterol
albuterol ext-rel
metaproterenol
terbutaline
Tier 1
Tier 1
Tier 1
Tier 1
CYSTIC FIBROSIS
aztreonam lysine inhalation soln
PA
dornase alfa
PA
ivacaftor
tobramycin inhalation soln
LEUKOTRIENE RECEPTOR MODIFIERS
montelukast
zafirlukast
zileuton ext-rel
MAST CELL STABILIZERS
cromolyn soln
NASAL ANTIHISTAMINES
azelastine spray
azelastine spray
olopatadine
NASAL STEROIDS
flunisolide spray
fluticasone spray
triamcinolone acetonide spray
budesonide spray
fluticasone furoate spray
mometasone spray
beclomethasone spray
STEROID INHALANTS
budesonide inhalation suspension
beclomethasone, CFC-free aerosol
budesonide
fluticasone
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
44
fluticasone, CFC-free aerosol

mometasone
ciclesonide
XANTHINES
caffeine citrate
theophylline ext-rel tabs
theophylline ext-rel caps
theophylline liquid
MISCELLANEOUS
ipratropium spray
alpha-1 proteinase inhibitor
alpha-1 proteinase inhibitor
PA
omalizumab
Tier 1
Tier 1
Tier 1
FLOVENT HFA
ASMANEX
ALVESCO
Tier 2
Tier 2
Tier 3
CAFCIT
Tier 3
THEO-24
ELIXOPHYLLIN
Tier 2
Tier 2
ATROVENT spray
ARALAST NP
GLASSIA
XOLAIR
Tier 3
Tier 4
Tier 4
Tier 4
TOPICAL
DERMATOLOGY
Acne
Guidelines for the care and treatment of acne vulgaris are available at:
http://www.aad.org
Oral
Topical
PA
PA
PA
PA
PA
PA
isotretinoin
Tier 1
adapalene
benzoyl peroxide
clindamycin gel, lotion, soln
clindamycin swabs
clindamycin/benzoyl peroxide
clindamycin/benzoyl peroxide
erythromycin gel 2%
erythromycin soln
erythromycin/benzoyl peroxide
tretinoin
adapalene/benzoyl peroxide
clindamycin/tretinoin
tretinoin
tretinoin gel microsphere
azelaic acid
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
DIFFERIN
BENZAC AC
CLEOCIN T
Tier 3
Tier 3
Tier 3
BENZACLIN
DUAC
Tier 3
Tier 2
BENZAMYCIN
RETIN-A
EPIDUO
ZIANA
ATRALIN
RETIN-A MICRO
AZELEX
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 1
EFUDEX
SOLARAZE
FLUOROPLEX
CARAC
Tier 3
Tier 2
Tier 2
Tier 3
BACTROBAN
SILVADENE
ALTABAX
SULFAMYLON
Tier 3
Tier 3
Tier 2
Tier 3
LOPROX
Tier 3
Actinic Keratosis
fluorouracil
diclofenac sodium
fluorouracil
fluorouracil
Antibiotics
gentamicin
mupirocin
silver sulfadiazine
retapamulin
mafenide
Tier 1
Tier 1
Tier 1
ciclopirox
Tier 1
Antifungals
45
PA
clotrimazole
clotrimazole/betamethasone
econazole
ketoconazole
nystatin
ketoconazole 2%
miconazole nitrate/zinc oxide
naftifine
oxiconazole
sertaconazole
sulconazole
terbinafine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
XOLEGEL
VUSION
NAFTIN
OXISTAT
ERTACZO
EXELDERM
LAMISIL
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Antipsoriatics
Guidelines of care for the management and treatment of psoriasis with topical therapies are available at:
http://www.aad.org
Injectable
ustekinumab
STELARA
Tier 4
acitretin
methoxsalen oral
SORIATANE
OXSORALEN-ULTRA
Tier 2
Tier 2
Tier 1
DOVONEX
DRITHOCREME HP
TACLONEX
VECTICAL
TAZORAC
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
NIZORAL SHAMPOO
SELSUN
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
ACLOVATE
DESOWEN
Tier 3
Tier 3
VERDESO
DESONATE
CAPEX
PRAMOSONE
PRAMOSONE E
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
TOPICORT LP
Tier 3
Tier 1
Tier 1
DERMA-SMOOTHE/FS
CUTIVATE
Tier 2
Tier 3
Oral
Topical
PA
PA
PA
calcipotriene
anthralin
betamethasone dipropionate/calcipotriene
calcitriol oint
tazarotene
Antiseborrheics
ketoconazole shampoo 2%
selenium sulfide shampoo 2.5%
Corticosteroids
Low Potency
alclometasone crm, oint 0.05%
desonide crm, lotion, oint 0.05%
fluocinolone acetonide soln 0.01%
hydrocortisone crm 2.5%
hydrocortisone lotion 1%
desonide foam 0.05%
desonide gel 0.05%
fluocinolone shampoo 0.01%
pramoxine/hydrocortisone
pramoxine/hydrocortisone/emollient
Medium Potency
betamethasone valerate crm, lotion,
oint 0.1%
desoximetasone crm, oint 0.05%
fluocinolone acetonide crm,
oint 0.025%
fluocinolone acetonide oil 0.01%
fluticasone propionate crm,
lotion 0.05%, oint 0.005%
Tier 1
46
hydrocortisone butyrate crm, lotion,

oint, soln 0.1%
hydrocortisone valerate crm, oint 0.2%
mometasone crm, lotion, oint 0.1%
triamcinolone acetonide crm,
lotion 0.025%
triamcinolone acetonide crm, lotion,
oint 0.1%
flurandrenolide crm 0.05%
flurandrenolide lotion 0.05%
flurandrenolide tape
hydrocortisone probutate crm 0.1%
clocortolone pivalate crm 0.1%
hydrocortisone butyrate crm 0.1%
High Potency
amcinonide crm, lotion, oint 0.1%
betamethasone dipropionate
augmented crm 0.05%
augmented lotion 0.05%
betamethasone dipropionate crm,
lotion, oint 0.05%
desoximetasone crm, oint 0.25%,
gel 0.05%
diflorasone diacetate crm 0.05%
fluocinonide crm, gel, oint, soln 0.05%
triamcinolone acetonide crm 0.5%
diflorasone diacetate emollient crm 0.05%
halcinonide crm, oint 0.1%
Very High Potency
augmented gel, oint 0.05%
clobetasol propionate crm, gel, lotion,
oint 0.05%
clobetasol propionate lotion,
shampoo 0.05%
diflorasone diacetate oint 0.05%
halobetasol propionate crm,
oint 0.05%
clobetasol propionate spray 0.05%
fluocinonide crm 0.1%
Tier 1
LOCOID
Tier 3
Tier 1
Tier 1
Tier 1
WESTCORT
ELOCON
Tier 3
Tier 3
CORDRAN SP
CORDRAN
CORDRAN
PANDEL
CLODERM
LOCOID LIPOCREAM
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 1
Tier 1
DIPROLENE AF
Tier 3
Tier 1
DIPROLENE
Tier 3
TOPICORT
Tier 3
APEXICON E
HALOG
Tier 2
Tier 3
Tier 1
DIPROLENE
Tier 3
Tier 1
TEMOVATE
Tier 3
Tier 1
CLOBEX
Tier 3
Tier 1
Tier 1
ULTRAVATE
Tier 3
CLOBEX
VANOS
Tier 2
Tier 2
LAC-HYDRIN
MIMYX
URAMAXIN
URAMAXIN GT
Tier 3
Tier 2
Tier 2
Tier 2
ELIDEL
PROTOPIC
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Emollients
ammonium lactate 12%
emollient crm
urea
urea 45%
Tier 1
Immunomodulators
Guidelines for the treatment of atopic dermatitis are available at:
http://www.aad.org
pimecrolimus
tacrolimus
47
Local Analgesics
lidocaine patch
capsaicin 8% patch
Local Anesthetics
lidocaine
lidocaine/prilocaine
LIDODERM
QUTENZA
Tier 2
Tier 3
Tier 1
Tier 1
XYLOCAINE
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
METROCREAM
Tier 3
METROLOTION
Tier 3
ORACEA
METROGEL
FINACEA
NORITATE
Tier 2
Tier 2
Tier 3
Tier 3
NATROBA
ULESFIA
EURAX
SKLICE
Tier 2
Tier 2
Tier 2
Tier 2
ZONALON
ALDARA
CONDYLOX
ZOVIRAX crm, oint
PANRETIN
REGRANEX
ALCORTIN A
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
ZYCLARA
TACHOSIL
XERESE
PHISOHEX
VEREGEN
RENOVA
XIAFLEX
ALFERON N
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Rosacea
metronidazole crm 0.75%
metronidazole gel 0.75%
metronidazole lotion 0.75%
sulfacetamide/sulfur
metronidazole gel 1%
azelaic acid gel
metronidazole crm
Scabicides and Pediculicides
lindane
permethrin 5%
spinosad
benzyl alcohol
crotamiton
ivermectin
Miscellaneous Skin and Mucous Membrane
doxepin crm
imiquimod
podofilox
acyclovir
alitretinoin
becaplermin
d
hydrocortisone/aloe polysaccharide/
iodoquinol
imiquimod
absorbable fibrin sealant
acyclovir/hydrocortisone
hexachlorophene
sinecatechins
PA
tretinoin emollient
PA
collagenase clostridium histolyticum
PA
interferon alfa-n3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
MOUTH/THROAT/DENTAL AGENTS
Anesthetics - Topical Oral
lidocaine viscous
Tier 1
Steroids - Mouth/Throat
triamcinolone paste
Tier 1
OPHTHALMIC
Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at:
http://one.aao.org
Antiallergics
cromolyn sodium
Tier 1
48
epinastine
phenylephrine
lodoxamide
loteprednol 0.2%
olopatadine
alcaftadine
bepotastine
Tier 1
Tier 1
ELESTAT
Tier 3
ALOMIDE
ALREX
PATANOL
LASTACAFT
BEPREVE
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
NATACYN
Tier 2
CILOXAN
Tier 3
NEOSPORIN
OCUFLOX
Tier 3
Tier 3
POLYTRIM
BLEPH-10
TOBREX
AZASITE
BESIVANCE
VIGAMOX
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
MAXITROL
Tier 3
TOBRADEX
PRED-G
BLEPHAMIDE SOP
Tier 3
Tier 2
Tier 2
ZYLET
Tier 3
VOLTAREN
OCUFEN
ACULAR
BROMDAY
NEVANAC
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
FML
PRED FORTE
Tier 3
Tier 3
MAXIDEX
OZURDEX
Tier 2
Tier 2
Antifungals
natamycin
Anti-infectives
bacitracin
ciprofloxacin
erythromycin
gentamicin
levofloxacin
neomycin/polymyxin B/gramicidin
ofloxacin
polymyxin B/bacitracin
polymyxin B/trimethoprim
sulfacetamide soln 10%
tobramycin
azithromycin
besifloxacin
moxifloxacin
Anti-infective/Anti-inflammatory Combinations
neomycin/dexamethasone
neomycin/polymyxin B/
dexamethasone
neomycin/polymyxin B/
hydrocortisone susp
sulfacetamide/prednisolone phosphate
10%/0.25%
tobramycin/dexamethasone
gentamicin/prednisolone acetate
sulfacetamide/prednisolone acetate oint
10%/0.2%
tobramycin/loteprednol
Anti-inflammatories
Nonsteroidal
bromfenac sodium
diclofenac sodium
flurbiprofen
ketorolac 0.5%
bromfenac sodium
nepafenac
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Steroidal
dexamethasone sodium phosphate
fluorometholone
prednisolone acetate 1%
prednisolone phosphate 1%
dexamethasone
dexamethasone
Tier 1
Tier 1
Tier 1
Tier 1
49
fluorometholone acetate
loteprednol 0.5%
prednisolone acetate 0.12%
rimexolone
difluprednate
FLAREX
LOTEMAX
PRED MILD
VEXOL
DUREZOL
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
VIROPTIC
ZIRGAN
Tier 3
Tier 2
BETAGAN
OPTIPRANOLOL
TIMOPTIC
TIMOPTIC-XE
BETIMOL
ISTALOL
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
BETOPTIC S
Tier 2
TRUSOPT
AZOPT
Tier 3
Tier 2
Carbonic Anhydrase Inhibitor/Beta-blocker Combinations

dorzolamide/timolol maleate
Tier 1
COSOPT
Tier 3
Immunomodulators
cyclosporine, emulsion
RESTASIS
Tier 2
Parasympathomimetics
pilocarpine
PILOPINE HS GEL
Tier 3
XALATAN
LUMIGAN
TRAVATAN Z
ZIOPTAN
Tier 3
Tier 2
Tier 2
Tier 3
ALPHAGAN P 0.15%
Tier 3
CYCLOGYL
ISOPTO HOMATROPINE
ALPHAGAN P 0.1%
ISOPTO HYOSCINE
Tier 3
Tier 3
Tier 2
Tier 2
COMBIGAN
Tier 2
Antivirals
trifluridine
ganciclovir
Beta-blockers
Nonselective
carteolol
levobunolol
metipranolol
timolol maleate
timolol maleate gel
timolol hemihydrate
timolol maleate
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Selective
betaxolol
Carbonic Anhydrase Inhibitors
Topical
dorzolamide
brinzolamide
Prostaglandins
latanoprost
bimatoprost
travoprost
tafluprost
Sympathomimetics
atropine
brimonidine 0.15%
brimonidine 0.2%
cyclopentolate
homatropine
brimonidine 0.1%
scopolamine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Sympathomimetic/Beta-blocker Combinations
brimonidine/timolol
Miscellaneous
naphazoline
Tier 1
50
aflibercept
pegaptanib sodium
ranibizumab
verteporfin
EYLEA
MACUGEN
LUCENTIS
VISUDYNE
Tier 4
Tier 4
Tier 4
Tier 4
OTIC
Clinical practice guidelines for the treatment of otitis media are available at:
http://www.aap.org
Anti-infectives
acetic acid
acetic acid/aluminum acetate
ofloxacin otic
ciprofloxacin otic
Anti-infective/Anti-inflammatory Combinations
acetic acid/hydrocortisone
neomycin/polymyxin B/hydrocortisone
ciprofloxacin/dexamethasone
ciprofloxacin/hydrocortisone
Miscellaneous
fluocinolone acetonide
hydrocortisone/neomycin/colistin/
thonzonium
hydrocortisone/pramoxine/chloroxylenol
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
CETRAXAL
Tier 2
CORTISPORIN OTIC
CIPRODEX
CIPRO HC OTIC
Tier 3
Tier 2
Tier 2
DERMOTIC
CORTISPORIN-TC OTIC
Tier 2
Tier 3
CORTANE-B
Tier 3
51
WEBSITES
Agency for Healthcare Research and Quality
http://www.ahrq.gov
Alzheimer's Association
http://www.alz.org
American Academy of Allergy, Asthma and
Immunology
American Academy of Child & Adolescent Psychiatry
http://www.aacap.org
American Academy of Dermatology
http://www.aad.org
American Academy of Neurology
http://www.aan.com
American Academy of Ophthalmology
http://www.aao.org
American Academy of Pediatrics
http://www.aap.org
American Association for the Study of Liver Disease
American Association of Clinical Endocrinologists
http://www.aace.com
American Association of Diabetes Educators
http://www.diabeteseducator.org
American Cancer Society
http://www.cancer.org
American College of Allergy, Asthma and Immunology
http://www.acaai.org
American College of Cardiology
http://www.acc.org
American College of Chest Physicians
http://www.chestnet.org
American Congress of Obstetricians and

Gynecologists
http://www.acog.org
American Diabetes Association
http://www.diabetes.org
American Gastroenterological Association
http://www.gastro.org
American Headache Society Committee for Headache
Education
http://www.achenet.org
American Heart Association
American Lung Association
http://www.lungusa.org
American Medical Association
http://www.ama-assn.org
American Psychiatric Association
American Society of Anesthesiologists
American Society of Clinical Oncology
http://www.asco.org
American Society of Interventional Pain Physicians
http://www.asipp.org
American Urological Association
http://www.auanet.org
Centers for Disease Control and Prevention
http://www.cdc.gov
Guideline topics: AIDS
http://www.cdc.gov/hiv/resources/guidelines/index.htm
American College of Gastroenterology

http://www.acg.gi.org

Guideline topics: Sexually Transmitted Diseases
http://www.cdc.gov/std/treatment/default.htm
American College of Physicians

http://www.acponline.org
CVS Caremark
http://www.caremark.com
American College of Rheumatology

The Food and Drug Administration

http://www.fda.gov
52
Global Initiative for Asthma

http://www.ginasthma.com
National Foundation for Infectious Diseases

http://www.nfid.org
Infectious Diseases Society of America

http://www.idsociety.org
National Guideline Clearinghouse

http://www.guideline.gov
Institute for Safe Medication Practices

http://www.ismp.org
National Heart, Lung and Blood Institute

http://www.nhlbi.nih.gov
Johns Hopkins AIDS Service

http://www.hopkins-aids.edu
National Institutes of Health

http://www.nih.gov
Juvenile Diabetes Research Foundation International

http://www.jdf.org
National Kidney Foundation

http://www.kidney.org
MedWatch
http://www.fda.gov/medwatch
National Osteoporosis Foundation

http://www.nof.org
National Agricultural Library

http://www.nal.usda.gov
North American Menopause Society

http://www.menopause.org
National Cancer Institute

http://www.cancer.gov/cancerinformation
United States Department of Health and Human

Services
http://www.hhs.gov
National Comprehensive Cancer Network

http://www.nccn.org
World Health Organization

http://www.who.int
53
INDEX
A
abacavir, 13
abacavir/lamivudine, 13
abacavir/lamivudine/zidovudine, 13
abatacept, 40
ABELCET, 13
ABILIFY, 26
abiraterone, 16
abobotulinumtoxinA, 28
ABRAXANE, 18
absorbable fibrin sealant, 48
ABSTRAL, 10
acamprosate calcium, 28
acarbose, 29
ACCOLATE, 44
ACCU-CHEK test strips, 30
ACCUNEB, 43
ACCUPRIL, 18
ACCURETIC, 19
acebutolol, 20
ACEON, 18
ACETADOTE, 35
acetaminophen inj, 9
acetaminophen/dichloralphenazone/isometheptene, 27
acetazolamide, 22
acetazolamide ext-rel, 22
acetic acid, 51
acetic acid/aluminum acetate, 51
acetic acid/hydrocortisone, 51
acetylcysteine, 35
ACIPHEX, 37
acitretin, 46
ACLOVATE, 46
ACTEMRA, 41
ACTHAR H.P., 35
ACTIGALL, 36
ACTIMMUNE, 41
ACTIQ, 10
ACTIVELLA, 33
ACTONEL, 31
ACTOPLUS MET, 30
ACTOPLUS MET XR, 30
ACTOS, 30
ACULAR, 49
acyclovir, 48
acyclovir caps, susp, tabs, 14
acyclovir/hydrocortisone, 48
ADAGEN, 35
ADALAT CC, 21
adalimumab, 40
adapalene, 45
adapalene/benzoyl peroxide, 45
ADCETRIS, 17
ADCIRCA, 22
ADDERALL, 26
ADDERALL XR, 26
adefovir dipivoxil, 14
ADOXA, 12
ADVAIR, 44
ADVAIR HFA, 44
ADVATE, 39
ADVICOR, 20
AFINITOR, 16
aflibercept, 51
agalsidase beta, 35
AGGRENOX, 40
AGRYLIN, 40
AHF, human/VWF, human, 39
albuterol, 44
albuterol ext-rel, 44
albuterol soln, 43
albuterol sulfate, CFC-free aerosol, 43, 44
alcaftadine, 49
alclometasone crm, oint 0.05%, 46
ALCORTIN A, 48
ALDACTAZIDE, 22
ALDACTONE, 19
ALDARA, 48
aldesleukin, 17
ALDURAZYME, 35
alemtuzumab, 17
alendronate, 31
alendronate/vitamin D3, 31
ALFERON N, 48
alfuzosin ext-rel, 38
alglucosidase alfa, 35
ALIMTA, 16
ALINIA, 15
aliskiren, 21
aliskiren/amlodipine, 21
aliskiren/hydrochlorothiazide, 21
alitretinoin, 48
ALKERAN, 15
allopurinol, 9
ALOMIDE, 49
ALORA, 33
alosetron, 37
ALOXI, 36
alpha-1 proteinase inhibitor, 45
ALPHAGAN P 0.1%, 50
ALPHAGAN P 0.15%, 50
ALPHANATE, 39
ALPHANINE SD, 39
alprazolam, 23
alprazolam ext-rel, 23
ALREX, 49
ALTABAX, 45
ALTACE, 18
alteplase, 40
altretamine, 15
ALVESCO, 45
alvimopan, 38
amantadine, except tabs, 14, 25
AMARYL, 30
AMBIEN, 27
AMBIEN CR, 27
ambrisentan, 22
amcinonide crm, lotion, oint 0.1%, 47
AMERGE, 27
amifostine, 17
amiloride, 22
amiloride/hydrochlorothiazide, 22
amiodarone, 19
AMITIZA, 37
amitriptyline, 25
amitriptyline/perphenazine, 25
amlodipine, 21
amlodipine/atorvastatin, 21
54
amlodipine/olmesartan, 19
amlodipine/telmisartan, 19
amlodipine/valsartan, 19
amlodipine/valsartan/hydrochlorothiazide, 19
ammonium lactate 12%, 47
amoxicillin ext-rel, 12
amoxicillin, except film-coated tabs, 12
amoxicillin/clavulanate, 12
amoxicillin/clavulanate ext-rel, 12
amoxicillin/clavulanate susp 600 mg, 12
amphetamine/dextroamphetamine mixed salts, 26
amphetamine/dextroamphetamine mixed salts ext-rel, 26
AMPHOTEC, 13
amphotericin B lipid complex, 13
ampicillin, 12
ampicillin sodium/sulbactam sodium, 12
AMPYRA, 27
AMRIX, 28
ANAFRANIL, 23
anagrelide, 40
anakinra, 40
ANAPROX, 9
anastrozole, 16
ANDRODERM, 29
ANDROGEL, 29
anidulafungin, 13
ANTABUSE, 28
ANTARA, 20
anthralin, 46
antihemophilic factor, 39
antihemophilic factor, recombinant, 39
anti-inhibitor coagulant complex, 39
ANTIVERT, 36
ANUSOL-HC 2.5%, 37
ANZEMET, 36
APEXICON E, 47
APIDRA, 29
APOKYN, 25
apomorphine, 25
aprepitant, 36
APRISO, 37
APTIVUS, 14
ARALAST NP, 45
ARALEN, 13
ARANESP, 39
ARAVA, 41
ARCALYST, 41
ARCAPTA NEOHALER, 44
arformoterol soln, 44
ARICEPT (except 23 mg), 24
ARICEPT 23 mg, 24
ARICEPT ODT, 24
ARIMIDEX, 16
aripiprazole, 26
ARIXTRA, 39
armodafinil, 28
ARMOUR THYROID, 35
AROMASIN, 16
ARRANON, 18
arsenic trioxide, 17
artemether/lumefantrine, 13
ARTHROTEC, 9
ARZERRA, 18
ASACOL, 37
ASACOL HD, 37
asenapine, 26
ASMANEX, 45
asparaginase, 17
asparaginase Erwinia chrysanthemi, 17
ASTELIN, 44
ASTEPRO, 44
atazanavir, 13
atenolol, 20
atenolol/chlorthalidone, 21
ATIVAN, 23
atomoxetine, 26
atorvastatin, 20
atovaquone, 15
atovaquone/proguanil, 13
ATRALIN, 45
ATRIPLA, 13
atropine, 50
atropine/hyoscyamine/scopolamine/phenobarbital, 36
ATROVENT HFA, 43
ATROVENT spray, 45
AUGMENTIN, 12
AUGMENTIN XR, 12
auranofin, 41
AVALIDE, 19
AVANDAMET, 30
AVANDARYL, 30
AVANDIA, 30
AVAPRO, 19
AVASTIN, 17
AVELOX, 12
AVINZA, 10
AVODART, 38
AVONEX, 27
AXID, 36
AXIRON, 29
axitinib, 16
AYGESTIN, 35
azacitidine, 17
AZACTAM, 15
AZASITE, 49
azathioprine, 41
azelaic acid, 45
azelaic acid gel, 48
azelastine spray, 44
AZELEX, 45
AZILECT, 25
azilsartan, 19
azithromycin, 12, 49
AZOPT, 50
AZOR, 19
aztreonam, 15
aztreonam lysine inhalation soln, 44
AZULFIDINE, 37
AZULFIDINE EN-TABS, 37
bacitracin, 49
baclofen, 28
baclofen intrathecal, 28
BACTROBAN, 45
balsalazide, 36
BANZEL, 24
BARACLUDE, 14
BCG live vaccine, 17
BD INSULIN SYRINGES, 30
BEBULIN, 39
BEBULIN VH, 39
becaplermin, 48
55
beclomethasone spray, 44
beclomethasone, CFC-free aerosol, 44
BECONASE AQ, 44
belatacept, 42
belimumab, 42
benazepril, 18
benazepril/amlodipine, 18
benazepril/hydrochlorothiazide, 18
bendamustine, 15
BENEFIX, 40
BENICAR, 19
BENICAR HCT, 19
BENLYSTA, 42
BENTYL, 36
BENZAC AC, 45
BENZACLIN, 45
BENZAMYCIN, 45
benzonatate, 43
benzoyl peroxide, 45
benztropine, 25
benzyl alcohol, 48
bepotastine, 49
BEPREVE, 49
BERINERT, 40
besifloxacin, 49
BESIVANCE, 49
BETAGAN, 50
betaine anhydrous, 39
betamethasone dipropionate augmented crm 0.05%, 47
betamethasone dipropionate augmented gel, oint 0.05%, 47
betamethasone dipropionate augmented lotion 0.05%, 47
betamethasone dipropionate crm, lotion, oint 0.05%, 47
betamethasone dipropionate/calcipotriene, 46
betamethasone valerate crm, lotion, oint 0.1%, 46
BETAPACE, 20
BETASERON, 27
betaxolol, 50
bethanechol, 38
BETIMOL, 50
BETOPTIC S, 50
bevacizumab, 17
bexarotene caps, 17
BEXXAR, 18
BIAXIN, 12
BIAXIN XL, 12
bicalutamide, 16
BICNU, 15
BIDIL, 22
bimatoprost, 50
bismuth subsalicylate + metronidazole + tetracycline, 38
bisoprolol/hydrochlorothiazide, 21
bleomycin sulfate, 17
BLEPH-10, 49
BLEPHAMIDE SOP, 49
blood glucose test strips, 30
boceprevir, 14
BONIVA, 31
BONIVA inj, 31
bortezomib, 17
bosentan, 22
BOTOX, 28
BRAVELLE, 34
brentuximab vedotin, 17
BREVIBLOC, 21
BREVICON, 31
BRILINTA, 40
brimonidine 0.1%, 50
brimonidine/timolol, 50
brinzolamide, 50
BROMDAY, 49
bromfenac sodium, 49
bromocriptine, 25, 30
BROVANA, 44
budesonide, 44
budesonide delayed-rel caps, 36
budesonide inhalation suspension, 44
budesonide spray, 44
budesonide/formoterol, 44
bumetanide, 22
buprenorphine, 28
buprenorphine transdermal, 10
buprenorphine/naloxone, 28
bupropion, 25
bupropion ext-rel, 25, 28
buspirone, 23
busulfan, 15
BUSULFEX, 15
butabarbital, 27
butalbital/acetaminophen, 10
butalbital/acetaminophen/caffeine, 10
butalbital/acetaminophen/caffeine/codeine, 10
butalbital/aspirin/caffeine, 10
butalbital/aspirin/caffeine/codeine, 10
BUTISOL SODIUM, 27
butorphanol nasal spray, 10
BUTRANS, 10
BYETTA, 29
BYSTOLIC, 21
C1 esterase inhibitor, 40
cabazitaxel, 17
CADUET, 21
CAFCIT, 45
CAFERGOT, 27
caffeine citrate, 45
CALAN, 21
CALAN SR, 21
calcipotriene, 46
calcitonin-salmon inj, 31
calcitonin-salmon spray, 31
calcitriol (1,25-D3), 34
calcitriol oint, 46
calcium acetate, 34
CALDOLOR, 9
CAMPATH, 17
CAMPRAL, 28
CAMPTOSAR, 17
canakinumab, 41
CANASA, 37
capecitabine, 16
CAPEX, 46
CAPITAL w/CODEINE, 10
CAPRELSA, 16
capsaicin 8% patch, 48
captopril/hydrochlorothiazide, 18
CARAC, 45
CARAFATE, 38
CARAFATE susp, 38
carbamazepine, 23
carbamazepine ext-rel, 23
56
carbidopa/levodopa, 25
carbidopa/levodopa ext-rel, 25
carbidopa/levodopa/entacapone, 25
carboplatin, 17
CARDENE SR, 21
CARDIZEM, 21
CARDIZEM CD, 21
CARDURA, 19
CARIMUNE NF, 41
carmustine, 15
CARNITOR, 35
carteolol, 50
carvedilol, 20
carvedilol phosphate ext-rel, 21
CASODEX, 16
CATAPRES, 19
CATAPRES-TTS, 19
CATHFLO ACTIVASE, 40
CAYSTON, 44
CEDAX, 11
CEENU, 15
cefaclor, 11
cefdinir, 11
cefditoren, 11
cefepime, 11
cefotaxime, 11
cefoxitin, 11
cefpodoxime, 11
cefprozil, 11
ceftaroline fosamil, 12
ceftazidime, 11
ceftibuten, 11
CEFTIN, 11
ceftriaxone, 11
cefuroxime axetil, 11
CELEBREX, 9
celecoxib, 9
CELEXA, 24
CELLCEPT, 41
CELLCEPT suspension, 41
cephalexin, 11
CEPROTIN, 40
CEREZYME, 35
certolizumab pegol, 40
CERUBIDINE, 17
CETRAXAL, 51
cetrorelix, 33
CETROTIDE, 33
cetuximab, 17
cevimeline, 37
CHANTIX, 28
CHEMSTRIP K URINE KETONE STRIPS, 30
CHEMSTRIP UG URINE GLUCOSE STRIPS, 30
CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS, 30
chloral hydrate, 27
chlorambucil, 15
chlordiazepoxide, 23
chloroquine, 13
chlorthalidone, 22
cholestyramine pkt, 20
choline magnesium trisalicylate, 9
choriogonadotropin alfa, 33
chorionic gonadotropin, 33
CIALIS, 38
ciclesonide, 45
ciclopirox, 45
cidofovir, 14
cilostazol, 40
CILOXAN, 49
cimetidine, 36
CIMZIA, 40
cinacalcet, 30
CINRYZE, 40
CIPRO HC OTIC, 51
CIPRO susp, 12
CIPRO tabs, 12
CIPRODEX, 51
ciprofloxacin, 49
ciprofloxacin ext-rel, 12
ciprofloxacin otic, 51
ciprofloxacin susp, 12
ciprofloxacin tabs, 12
ciprofloxacin/dexamethasone, 51
ciprofloxacin/hydrocortisone, 51
cisplatin, 17
citalopram, 24
CITRANATAL RX, 42
cladribine, 15
CLAFORAN, 11
CLARINEX, 43
CLARINEX-D, 43
clarithromycin, 12
clarithromycin ext-rel, 12
CLEOCIN, 15
CLEOCIN T, 45
CLEOCIN vaginal supp, 38
CLIMARA, 33
CLIMARA PRO, 33
clindamycin, 15
clindamycin gel, lotion, soln, 45
clindamycin supp, 38
clindamycin swabs, 45
clindamycin/benzoyl peroxide, 45
clindamycin/tretinoin, 45
CLINORIL, 9
clobazam, 24
clobetasol propionate crm, gel, lotion, oint 0.05%, 47
clobetasol propionate lotion, shampoo 0.05%, 47
clobetasol propionate spray 0.05%, 47
CLOBEX, 47
clocortolone pivalate crm 0.1%, 47
CLODERM, 47
clofarabine, 16
CLOLAR, 16
CLOMID, 33
clomiphene, 33
clomipramine, 23
clonazepam tabs, 23
clonidine, 19
clonidine ext-rel, 26
clonidine transdermal, 19
clopidogrel, 40
clorazepate, 23
clotrimazole, 46
clotrimazole troches, 12
clotrimazole/betamethasone, 46
clozapine, 25
clozapine orally disintegrating tablets, 25
CLOZARIL, 25
coagulation factor VIIa, 39
COARTEM, 13
codeine/acetaminophen, 10
57
codeine/acetaminophen susp, 10
codeine/promethazine, 43
codeine/promethazine/phenylephrine, 43
COLAZAL, 36
colchicine, 9
COLCRYS, 9
colesevelam, 20
COLESTID, 20
colestipol, 20
collagenase clostridium histolyticum, 48
COLYTE, 37
COMBIGAN, 50
COMBIPATCH, 33
COMBIVENT, 43
COMBIVIR, 13
COMPLERA, 13
COMTAN, 25
CONCERTA, 26
CONDYLOX, 48
COPAXONE, 27
COPEGUS, 14
CORDARONE, 19
CORDRAN, 47
CORDRAN SP, 47
COREG, 20
COREG CR, 21
CORIFACT, 40
CORTANE-B, 51
CORTEF, 34
corticotropin, 35
corticotropin powder, 35
CORTIFOAM, 37
cortisone acetate, 34
CORTISPORIN OTIC, 51
CORTISPORIN-TC OTIC, 51
COSMEGEN, 17
COSOPT, 50
COUMADIN, 39
COVERA-HS, 21
COZAAR, 19
CREON, 37
CRESTOR, 20
CRIXIVAN, 14
crizotinib, 16
cromolyn sodium, 38, 48
cromolyn soln, 44
crotamiton, 48
CUBICIN, 15
CUPRIMINE, 41
CUTIVATE, 46
CUVPOSA, 38
cyanocobalamin inj, 42
cyanocobalamin spray, 42
CYANOKIT, 35
CYCLESSA, 32
cyclobenzaprine, 28
cyclobenzaprine ext-rel, 28
CYCLOGYL, 50
cyclopentolate, 50
cyclophosphamide, 15
cyclophosphamide inj, 15
CYCLOSET, 30
cyclosporine, 42
cyclosporine, emulsion, 50
cyclosporine, modified, 42
CYKLOKAPRON inj, 40
CYMBALTA, 25
cyproheptadine, 43
CYSTADANE, 39
CYSTAGON, 35
cysteamine, 35
cytarabine, 15
cytarabine liposome, 16
CYTOGAM, 14
cytomegalovirus immune globulin, 14
CYTOMEL, 35
CYTOTEC, 37
CYTOVENE inj, 14
D.H.E. 45, 27
dabigatran etexilate, 39
DACOGEN, 17
dactinomycin, 17
dalfampridine ext-rel, 27
DALIRESP, 44
dalteparin, 39
danazol, 33
DANTRIUM, 28
dantrolene, 28
dapsone, 15
daptomycin, 15
DARAPRIM, 13
darbepoetin alfa, 39
darifenacin ext-rel, 38
darunavir, 14
dasatinib, 16
daunorubicin, 17
daunorubicin citrate liposomal, 17
DAUNOXOME, 17
DAYPRO, 9
DAYTRANA, 26
DDAVP, 35
decitabine, 17
deferasirox, 40
deferiprone, 40
deferoxamine, 40
degarelix acetate, 16
delavirdine, 13
DELESTROGEN, 33
DEMADEX, 22
denileukin diftitox, 17
denosumab, 31
DEPAKENE, 23
DEPAKOTE, 23
DEPOCYT, 16
DEPO-PROVERA, 32
DERMA-SMOOTHE/FS, 46
DERMOTIC, 51
DESFERAL, 40
desipramine, 25
desirudin, 39
desloratadine, 43
desloratadine/pseudoephedrine ext-rel, 43
desmopressin, 35
desmopressin spray, 39
DESOGEN, 31
desogestrel/EE, 32
desogestrel/EE 0.15/30, 31
DESONATE, 46
desonide crm, lotion, oint 0.05%, 46
desonide foam 0.05%, 46
desonide gel 0.05%, 46
58
DESOWEN, 46
desoximetasone crm, oint 0.05%, 46
desoximetasone crm, oint 0.25%, gel 0.05%, 47
desvenlafaxine ext-rel, 25
DETROL, 38
DETROL LA, 38
dexamethasone, 34, 49
dexamethasone sodium phosphate, 49
DEXEDRINE SPANSULE, 26
DEXILANT, 37
dexlansoprazole delayed-rel, 37
dexmethylphenidate, 26
dexmethylphenidate ext-rel, 26
dexrazoxane, 17
dextroamphetamine, 26
dextroamphetamine ext-rel, 26
dextromethorphan/quinidine, 28
DIABETA, 30
DIAMOX SEQUELS, 22
DIASTAT, 23
diazepam, 23
diazepam rectal gel, 23
diazoxide, 34
diclofenac sodium, 45, 49
diclofenac sodium delayed-rel, 9
diclofenac sodium delayed-rel/misoprostol, 9
diclofenac sodium ext-rel, 9
diclofenac sodium gel, 9
dicloxacillin, 12
dicyclomine, 36
didanosine delayed-rel, 13
didanosine soln, 13
DIDRONEL, 31
DIFFERIN, 45
DIFICID, 12
diflorasone diacetate crm 0.05%, 47
diflorasone diacetate emollient crm 0.05%, 47
diflorasone diacetate oint 0.05%, 47
DIFLUCAN, 12
diflunisal, 9
difluprednate, 50
digoxin, 21
dihydroergotamine inj, 27
DILACOR XR, 21
DILANTIN, 23
DILANTIN INFATABS, 24
DILAUDID, 10
diltiazem, 21
diltiazem ext-rel, 21
diltiazem ext-rel 360 mg, 21
diltiazem ext-rel, except 360 mg, 21
DIOVAN, 19
DIOVAN HCT, 19
DIPENTUM, 37
diphenhydramine, 25, 43
diphenoxylate/atropine, 36
DIPROLENE, 47
DIPROLENE AF, 47
dipyridamole, 40
dipyridamole ext-rel/aspirin, 40
disopyramide, 19
disopyramide ext-rel, 20
disulfiram, 28
DITROPAN XL, 38
divalproex sodium delayed-rel, 23
docetaxel, 17
dofetilide, 20
dolasetron, 36
donepezil, 24
donepezil orally disintegrating tabs, 24
DONNATAL, 36
DORAL, 27
DORIBAX, 15
doripenem, 15
dornase alfa, 44
dorzolamide, 50
dorzolamide/timolol maleate, 50
DOVONEX, 46
doxazosin, 19
doxepin, 25, 27
doxepin crm, 48
doxercalciferol, 34
DOXIL, 17
doxorubicin liposomal, 17
doxycycline hyclate, 12
doxycycline monohydrate, 12, 48
DRISDOL, 42
DRITHOCREME HP, 46
dronabinol, 36
dronedarone, 20
drospirenone/EE 3/20 - Gianvi, 31
drospirenone/EE 3/30, 31
DUAC, 45
DUET DHA, 42
DUETACT, 30
DULERA, 44
duloxetine delayed-rel, 25
DUONEB, 43
DURAGESIC, 10
DUREZOL, 50
dutasteride, 38
dutasteride/tamsulosin, 38
DUTOPROL, 21
DYAZIDE, 22
DYNACIN, 12
DYNACIRC CR, 21
DYSPORT, 28
E.E.S., 12
ecallantide, 40
econazole, 46
eculizumab, 40
EDARBI, 19
EDECRIN, 22
EDLUAR, 27
EDURANT, 13
EE/norethindrone acetate, 33
efavirenz, 13
efavirenz/emtricitabine/tenofovir, 13
EFFEXOR XR, 24
EFFIENT, 40
EFUDEX, 45
EGRIFTA, 36
ELAPRASE, 35
ELDEPRYL, 25
ELELYSO, 35
ELESTAT, 49
ELIDEL, 47
ELIGARD, 16
ELITEK, 16
ELIXOPHYLLIN, 45
ELLA, 32
59
ELLENCE, 17
ELMIRON, 38
ELOCON, 47
ELOXATIN, 18
ELSPAR, 17
eltrombopag, 40
EMEND, 36
emollient crm, 47
EMSAM, 24
emtricitabine, 13
emtricitabine/rilpivirine/tenofovir, 13
emtricitabine/tenofovir, 13
EMTRIVA, 13
ENABLEX, 38
enalapril, 18
enalapril/hydrochlorothiazide, 18
ENBREL, 40
ENDOMETRIN, 35
enfuvirtide, 13
ENJUVIA, 33
enoxaparin, 39
entacapone, 25
entecavir, 14
ENTEREG, 38
ENTOCORT EC, 36
EPIDUO, 45
EPIFOAM, 38
epinastine, 49
epinephrine, 43
EPIPEN, 43
EPIPEN JR., 43
epirubicin, 17
EPIVIR, 13
EPIVIR-HBV, 14
eplerenone, 19
epoetin alfa, 39
EPOGEN, 39
epoprostenol sodium, 23
eprosartan, 19
eprosartan/hydrochlorothiazide, 19
EPZICOM, 13
EQUETRO, 23
ERAXIS, 13
ERBITUX, 17
ergocalciferol (D2), 42
ergotamine/caffeine, 27
ergotamine/caffeine supp, 27
eribulin, 17
ERIVEDGE, 18
erlotinib, 16
ERTACZO, 46
ertapenem, 15
ERWINAZE, 17
ERY-TAB, 12
erythromycin, 49
erythromycin delayed-rel, 12
erythromycin dispertabs, 12
erythromycin ethylsuccinate, 12
erythromycin gel 2%, 45
erythromycin soln, 45
erythromycin stearate, 12
erythromycin/benzoyl peroxide, 45
erythromycin/sulfisoxazole, 12
escitalopram, 24
esmolol, 21
esomeprazole delayed-rel, 37
estazolam, 26
ESTRACE, 33
estradiol, 33
estradiol transdermal gel, 33
estradiol transdermal spray, 33
estradiol vaginal crm, 33
estradiol vaginal ring, 33
estradiol vaginal tabs, 33
estradiol valerate, 33
estradiol valerate and dienogest/estradiol valerate, 32
estradiol/levonorgestrel, 33
estradiol/norethindrone acetate, 33
estradiol/norgestimate, 33
ESTROGEL, 33
estrogens, conjugated, 33
estrogens, conjugated crm, 33
estrogens, conjugated, synthetic B, 33
estrogens, conjugated/medroxyprogesterone, 33
estrogens, esterified/methyltestosterone, 33
estropipate, 33
ESTROSTEP FE, 32
etanercept, 40
ethacrynic acid, 22
ethambutol, 14
ethosuximide, 23
ethynodiol diacetate/EE 1/35 - Zovia 1/35, 31
ethynodiol diacetate/EE 1/50 - Zovia 1/50, 32
ETHYOL, 17
etidronate, 31
etodolac, 9
etodolac ext-rel, 9
etonogestrel implant, 32
etonogestrel/EE ring, 32
ETOPOPHOS, 17
etoposide, 17
etoposide phosphate, 17
etravirine, 13
EUFLEXXA, 11
EURAX, 48
EVAMIST, 33
everolimus, 16, 42
EVISTA, 35
EVOXAC, 37
EXALGO, 10
EXELDERM, 46
EXELON, 24
EXELON PATCH, 24
exemestane, 16
exenatide, 29
EXFORGE, 19
EXFORGE HCT, 19
EXJADE, 40
EXTAVIA, 27
EYLEA, 51
ezetimibe, 20
ezetimibe/simvastatin, 20
ezogabine, 24
FABRAZYME, 35
FACTIVE, 12
factor IX concentrate, 39, 40
factor XIII concentrate, 40
famciclovir, 14
famotidine, 36
famotidine susp, 36
FAMVIR, 14
60
FANAPT, 26
FARESTON, 16
FASLODEX, 16
FAZACLO, 25
febuxostat, 9
FEIBA VH IMMUNO, 39
felbamate, 23
FELBATOL, 23
FELDENE, 9
felodipine ext-rel, 21
FEMARA, 16
FEMHRT, 33
FEMRING, 33
fenofibrate, 20
fenofibrate, micronized, 20
fenofibric acid, 20
fenoprofen, 9
fentanyl citrate buccal, 10
fentanyl citrate nasal spray, 10
fentanyl sublingual spray, 10
fentanyl sublingual tablets, 10
fentanyl transdermal, 10
fentanyl transmucosal, 10
FENTORA, 10
FERAHEME, 42
FERRIPROX, 40
FERRLECIT, 42
ferumoxytol inj, 42
fesoterodine ext-rel, 38
fibrinogen, 40
fidaxomicin, 12
filgrastim, 39
FINACEA, 48
finasteride, 38
fingolimod, 27
FIORICET, 10
FIORICET w/CODEINE, 10
FIORINAL, 10
FIORINAL w/CODEINE, 10
FIRAZYR, 40
FIRMAGON, 16
FLAGYL, 15
FLAREX, 50
FLEBOGAMMA, 41
flecainide, 19
FLEXERIL, 28
FLOLAN, 23
FLOMAX, 38
FLONASE, 44
FLOVENT, 44
FLOVENT HFA, 45
floxuridine, 15
fluconazole, 12
FLUDARA, 15
fludarabine, 15
fludrocortisone, 34
FLUMADINE, 14
flunisolide spray, 44
fluocinolone acetonide, 51
fluocinolone acetonide crm, oint 0.025%, 46
fluocinolone acetonide oil 0.01%, 46
fluocinolone acetonide soln 0.01%, 46
fluocinolone shampoo 0.01%, 46
fluocinonide crm 0.1%, 47
fluocinonide crm, gel, oint, soln 0.05%, 47
fluoride drops, 42
fluoride tabs, 42
fluorometholone, 49
fluorometholone acetate, 50
FLUOROPLEX, 45
fluorouracil, 45
fluoxetine, 24
fluoxetine delayed-rel, 24
fluphenazine, 26
flurandrenolide crm 0.05%, 47
flurandrenolide lotion 0.05%, 47
flurandrenolide tape, 47
flurazepam, 27
flurbiprofen, 9, 49
flutamide, 16
fluticasone, 44
fluticasone furoate spray, 44
fluticasone propionate crm, lotion 0.05%, oint 0.005%, 46
fluticasone spray, 44
fluticasone, CFC-free aerosol, 45
fluticasone/salmeterol, 44
fluticasone/salmeterol, CFC-free aerosol, 44
fluvastatin, 20
fluvastatin ext-rel, 20
fluvoxamine, 23
fluvoxamine ext-rel, 23
FML, 49
FOCALIN, 26
FOCALIN XR, 26
folic acid, 42
FOLLISTIM AQ, 33
follitropin alfa, 33
follitropin beta, 33
FOLOTYN, 16
fondaparinux, 39
FORADIL, 44
FORFIVO XL, 25
formoterol inhalation caps, 44
FORTAMET, 29
FORTAZ, 11
FORTEO, 31
FORTESTA, 29
FOSAMAX, 31
FOSAMAX PLUS D, 31
fosamprenavir, 14
foscarnet, 14
fosinopril, 18
fosinopril/hydrochlorothiazide, 19
FOSRENOL, 34
FRAGMIN, 39
FROVA, 27
frovatriptan, 27
fulvestrant, 16
furosemide, 22
FUSILEV, 18
FUZEON, 13
gabapentin, 23
GABITRIL, 24
galantamine, 24
galantamine ext-rel, 24
gallium nitrate, 35
galsulfase, 35
GALZIN, 42
GAMASTAN S-D, 41
GAMMAGARD LIQUID, 41
GAMMAGARD S-D, 41
61
GAMMAKED, 41
GAMMAPLEX, 41
GAMUNEX, 41
GAMUNEX-C, 41
ganciclovir, 14, 50
ganciclovir inj, 14
GANIRELIX, 33
ganirelix acetate, 33
GANITE, 35
GASTROCROM, 38
gemcitabine, 15
gemfibrozil, 20
gemifloxacin, 12
GEMZAR, 15
GENOTROPIN, 34
gentamicin, 45, 49
gentamicin/prednisolone acetate, 49
GEODON, 26
GILENYA, 27
GLASSIA, 45
glatiramer, 27
GLEEVEC, 16
GLIADEL WAFER, 15
glimepiride, 30
glipizide, 30
glipizide ext-rel, 30
glipizide/metformin, 29
GLUCAGON EMERGENCY KIT, 34
glucagon, human recombinant, 34
GLUCOPHAGE, 29
GLUCOPHAGE XR, 29
GLUCOTROL, 30
GLUCOTROL XL, 30
GLUCOVANCE, 29
glyburide, 30
glyburide, micronized, 30
glyburide/metformin, 29
glycopyrrolate, 38
GLYNASE, 30
GLYSET, 29
golimumab, 40
GOLYTELY, 37
gonadorelin, 33
GONAL-F, 33
GONAL-F RFF, 33
goserelin acetate, 16
granisetron, 36
granisetron transdermal, 36
GRIFULVIN V, 13
griseofulvin microsize, 13
griseofulvin ultramicrosize, 13
GRIS-PEG, 13
guanfacine ext-rel, 26
HERCEPTIN, 18
hexachlorophene, 48
HEXALEN, 15
high molecular weight hyaluronan, 10
HIPREX, 15
histrelin acetate, 16, 35
HIZENTRA, 41
homatropine, 50
HUMALOG, 30
HUMALOG MIX, 30
HUMATE-P, 39
HUMATROPE, 34
HUMIRA, 40
HUMULIN 70/30, 29
HUMULIN N, 29
HUMULIN R, 29
HYALGAN, 11
HYCAMTIN, 17
HYCAMTIN inj, 17
hydralazine, 23
HYDREA, 17
hydrochlorothiazide, 22
hydrocodone/acetaminophen, 10
hydrocodone/chlorpheniramine/pseudoephedrine, 43
hydrocodone/homatropine, 43
hydrocodone/pseudoephedrine, 43
hydrocortisone, 34
hydrocortisone acetate foam, 37
hydrocortisone acetate/pramoxine foam, 38
hydrocortisone butyrate crm 0.1%, 47
hydrocortisone butyrate crm, lotion, oint, soln 0.1%, 47
hydrocortisone crm, 37
hydrocortisone crm 2.5%, 46
hydrocortisone enema, 37
hydrocortisone lotion 1%, 46
hydrocortisone probutate crm 0.1%, 47
hydrocortisone valerate crm, oint 0.2%, 47
hydrocortisone/aloe polysaccharide/iodoquinol, 48
hydrocortisone/neomycin/colistin/thonzonium, 51
hydrocortisone/pramoxine/chloroxylenol, 51
hydromorphone, 10
hydromorphone ext-rel, 10
hydroxocobalamin, 35
hydroxychloroquine, 41
hydroxyprogesterone caproate, 35
hydroxyurea, 17
hydroxyzine HCl, 23, 43
hydroxyzine pamoate, 23, 43
hylan G-F 20, 10
hyoscyamine sulfate, 36
hyoscyamine sulfate ext-rel, 36
HYPERHEP B S-D, 41
HYPERRHO S-D, 41
HYZAAR, 19
HALAVEN, 17
halcinonide crm, oint 0.1%, 47
HALFLYTELY, 37
halobetasol propionate crm, oint 0.05%, 47
HALOG, 47
haloperidol, 26
HECTOROL, 34
HELIXATE FS, 39
HEMOFIL M, 39
HEPAGAM B, 41
hepatitis B immune globulin, 41
HEPSERA, 14
ibandronate, 31
ibandronate inj, 31
ibuprofen, 9
ibuprofen inj, 9
icatibant, 40
idursulfase, 35
ifosfamide/mesna, 15
ILARIS, 41
iloperidone, 26
iloprost, 23
imatinib mesylate, 16
62
IMDUR, 22
imiglucerase, 35
imipenem/cilastatin, 15
imipramine HCl, 25
imipramine pamoate, 25
imiquimod, 48
IMITREX, 27
immune globulin, gamma, 41
immune globulin, gamma (IGG), 41
immune globulin, intravenous, 41
immune globulin, subcutaneous, 41
IMPLANON, 32
IMURAN, 41
INCIVEK, 14
incobotulinumtoxinA, 28
INCRELEX, 34
indacaterol, 44
indapamide, 22
INDERAL LA, 21
indinavir, 14
INDOCIN susp, 9
indomethacin, 9
indomethacin ext-rel, 9
indomethacin susp, 9
INFERGEN, 41
infliximab, 40
INLYTA, 16
INNOHEP, 39
INNOPRAN XL, 21
INSPRA, 19
insulin aspart, 29
insulin aspart protamine 70%/insulin aspart 30%, 29
insulin detemir, 29
insulin glargine, 29
insulin glulisine, 29
insulin human, 29
insulin isophane human, 29
insulin isophane human 70%/regular 30%, 29, 30
insulin lispro, 30
insulin lispro protamine/insulin lispro, 30
insulin syringes, 30
INTELENCE, 13
interferon alfa-2b, 41
interferon alfacon-1, 41
interferon alfa-n3, 48
interferon beta-1a, 27
interferon beta-1b, 27
interferon gamma-1b, recombinant, 41
INTRON A, 41
INTUNIV, 26
INVANZ, 15
INVEGA, 26
INVEGA SUSTENNA, 26
INVIRASE, 14
ipilimumab, 17
ipratropium soln, 43
ipratropium spray, 45
ipratropium, CFC-free aerosol, 43
ipratropium/albuterol, 43
ipratropium/albuterol soln, 43
IPRIVASK, 39
irbesartan, 19
irbesartan/hydrochlorothiazide, 19
irinotecan, 17
iron sucrose inj, 42
ISENTRESS, 13
isocarboxazid, 24
isoniazid, 14
ISOPTO HOMATROPINE, 50
ISOPTO HYOSCINE, 50
ISORDIL, 22
isosorbide dinitrate oral, 22
isosorbide dinitrate/hydralazine, 22
isosorbide mononitrate, 22
isosorbide mononitrate ext-rel, 22
isotretinoin, 45
isradipine ext-rel, 21
ISTALOL, 50
ISTODAX, 18
itraconazole caps, 12
itraconazole oral soln, 13
ivacaftor, 44
ivermectin, 48
ixabepilone, 18
IXEMPRA, 18
JAKAFI, 17
JALYN, 38
JANUMET, 29
JANUMET XR, 29
JANUVIA, 29
JENTADUETO, 29
JEVTANA, 17
JUVISYNC, 29
KADIAN, 10
KALBITOR, 40
KALETRA, 14
KALYDECO, 44
KAPVAY, 26
KEFLEX, 11
KEPIVANCE, 38
KEPPRA, 23
KEPPRA XR, 23
KETEK, 12
ketoconazole, 46
ketoconazole 2%, 46
ketoconazole shampoo 2%, 46
ketoconazole tabs, 12
ketoprofen, 9
ketoprofen ext-rel, 9
ketorolac, 9
ketorolac 0.5%, 49
ketorolac tromethamine nasal spray, 9
KINERET, 40
KLONOPIN, 23
KOATE-DVI, 39
KOGENATE FS, 39
KOMBIGLYZE XR, 29
KORLYM, 35
KRYSTEXXA, 9
KUVAN, 34
LAC-HYDRIN, 47
lacosamide, 24
lactulose, 37
LAMICTAL, 23
LAMICTAL ODT, 24
LAMICTAL XR, 24
LAMISIL, 12, 46
lamivudine, 13, 14
63
lamivudine/zidovudine, 13
lamotrigine, 23
lamotrigine ext-rel, 24
lamotrigine orally disintegrating tablets, 24
lancet device, 30
lancets, 30
LANOXIN, 21
lanreotide acetate, 35
lanthanum, 34
LANTUS, 29
lapatinib, 16
laronidase, 35
LASIX, 22
LASTACAFT, 49
latanoprost, 50
LATUDA, 26
LAZANDA, 10
leflunomide, 41
lenalidomide, 16
LESCOL, 20
LESCOL XL, 20
LETAIRIS, 22
letrozole, 16
leucovorin calcium, 17
LEUKERAN, 15
LEUKINE, 39
leuprolide acetate, 16
LEVAQUIN, 12
LEVATOL, 21
LEVBID, 36
LEVEMIR, 29
levetiracetam, 23
levetiracetam ext-rel, 23
levobunolol, 50
levocarnitine, 35
levocetirizine, 43
levofloxacin, 12, 49
levoleucovorin calcium, 18
levonorgestrel - Next Choice, 32
levonorgestrel releasing IUD, 32
levonorgestrel/EE - Trivora, 32
levonorgestrel/EE 0.09/20 - Amethyst, 32
levonorgestrel/EE 0.1/20, 31
levonorgestrel/EE 0.1/20 and EE 10, 32
levonorgestrel/EE 0.15/30, 31, 32
levonorgestrel/EE 0.15/30 - Levora, 31
levonorgestrel/EE 0.15/30 and EE 10, 32
levothyroxine, 35
levothyroxine - Levoxyl, 35
LEVSIN, 36
LEXAPRO, 24
LEXIVA, 14
LIALDA, 37
lidocaine, 48
lidocaine patch, 48
lidocaine viscous, 48
lidocaine/prilocaine, 48
LIDODERM, 48
linagliptin, 29
linagliptin/metformin, 29
lindane, 48
linezolid, 15
LIORESAL INTRATHECAL, 28
liothyronine, 35
liotrix, 35
LIPITOR, 20
LIPOFEN, 20
liraglutide, 29
lisdexamfetamine, 26
lisinopril, 18
lisinopril/hydrochlorothiazide, 19
lithium carbonate, 27
lithium carbonate ext-rel tabs 300 mg, 27
lithium carbonate ext-rel tabs 450 mg, 27
LITHOBID, 27
LIVALO, 20
LO/OVRAL, 31
LOCOID, 47
LOCOID LIPOCREAM, 47
lodoxamide, 49
LOESTRIN 1.5/30, 31
LOESTRIN 1/20, 31
LOESTRIN 24 FE, 31
LOESTRIN FE 1.5/30, 31
LOESTRIN FE 1/20, 31
LOMOTIL, 36
lomustine, 15
loperamide, 36
LOPID, 20
lopinavir/ritonavir, 14
LOPRESSOR, 21
LOPRESSOR HCT, 21
LOPROX, 45
lorazepam, 23
LORCET, 10
LORTAB, 10
losartan, 19
losartan/hydrochlorothiazide, 19
LOSEASONIQUE, 32
LOTEMAX, 50
LOTENSIN, 18
LOTENSIN HCT, 18
loteprednol 0.2%, 49
loteprednol 0.5%, 50
LOTREL, 18
LOTRONEX, 37
lovastatin, 20
LOVAZA, 20
LOVENOX, 39
loxapine, 26
LOXITANE, 26
lubiprostone, 37
LUCENTIS, 51
LUMIGAN, 50
LUMIZYME, 35
LUPRON DEPOT, 16
LUPRON DEPOT-PED, 16
lurasidone, 26
LURIDE, 42
LURIDE LOZI-TABS, 42
LUTREPULSE, 33
LUVOX CR, 23
LYRICA, 24
LYSODREN, 17
LYSTEDA, 40
M
MACROBID, 15
MACRODANTIN, 15
MACUGEN, 51
mafenide, 45
MAKENA, 35
MALARONE, 13
64
maraviroc, 13
MARINOL, 36
MARPLAN, 24
MATULANE, 17
MAVIK, 18
MAXALT/MAXALT-MLT, 27
MAXIDEX, 49
MAXITROL, 49
MAXZIDE, 22
MAXZIDE-25, 22
mecasermin, 34
mechlorethamine, 15
meclizine, 36
MEDROL, 34
medroxyprogesterone acetate, 35
medroxyprogesterone acetate 150 mg/mL, 32
mefloquine, 13
MEFOXIN, 11
MEGACE, 16
MEGACE ES, 16
megestrol acetate, 16
megestrol acetate susp, 16
meloxicam, 9
melphalan, 15
memantine, 24
MENOPUR, 33
menotropins, 33, 34
MEPHYTON, 42
MEPRON, 15
mercaptopurine, 15
meropenem, 15
MERREM, 15
mesalamine delayed-rel tabs, 37
mesalamine ext-rel caps, 37
mesalamine rectal susp, 37
mesalamine supp, 37
mesna inj, 17
mesna tabs 400 mg, 18
MESNEX, 18
MESNEX inj, 17
MESTINON, 28
MESTINON syrup, 28
MESTINON TIMESPAN, 28
METADATE CD, 26
METAGLIP, 29
metaproterenol, 44
metformin, 29
metformin ext-rel, 29
metformin soln, 29
methazolamide, 22
methenamine hippurate, prophylaxis, 15
methimazole, 35
methotrexate, 41
methoxsalen inj, 18
methoxsalen oral, 46
methylergonovine, 35
methylnaltrexone, 38
methylphenidate, 26
methylphenidate ext-rel, 26
methylphenidate transdermal, 26
methylprednisolone, 34
metipranolol, 50
metoclopramide, 36
metolazone, 22
metoprolol, 21
metoprolol ext-rel, 21
metoprolol succinate ext-rel/hydrochlorothiazide, 21

metoprolol/hydrochlorothiazide, 21
METROCREAM, 48
METROGEL, 48
METROGEL-VAGINAL, 38
METROLOTION, 48
metronidazole, 38
metronidazole crm, 48
metronidazole crm 0.75%, 48
metronidazole gel 0.75%, 48
metronidazole gel 1%, 48
metronidazole lotion 0.75%, 48
metronidazole tabs, 15
MEVACOR, 20
mexiletine, 19
MIACALCIN, 31
MIACALCIN inj, 31
micafungin, 13
MICARDIS, 19
MICARDIS HCT, 19
miconazole nitrate/zinc oxide, 46
MICRHOGAM, 41
MICRHOGAM PLUS, 41
midodrine, 23
mifepristone, 35
MIGERGOT, 27
miglitol, 29
miglustat, 35
MILLIPRED, 34
milnacipran, 26
MIMYX, 47
MINIPRESS, 19
MINOCIN, 12
minocycline, 12
minocycline ext-rel, 12
minoxidil, 23
MIRAPEX, 25
MIRAPEX ER, 25
MIRCETTE, 32
MIRENA, 32
mirtazapine, 25
misoprostol, 37
mitomycin, 17
mitotane, 17
mitoxantrone, 17
MOBIC, 9
modafinil, 28
MODICON, 31
mometasone, 45
mometasone crm, lotion, oint 0.1%, 47
mometasone spray, 44
mometasone/formoterol, 44
MONOCLATE-P, 39
MONODOX, 12
MONONINE, 40
montelukast, 44
morphine, 10
morphine ext-rel, 10
morphine supp, 10
MOVIPREP, 37
MOXATAG, 12
moxifloxacin, 12, 49
MOZOBIL, 40
MS CONTIN, 10
MULTAQ, 20
multivitamins/fluoride drops, tabs, 42
65
multivitamins/fluoride/iron drops, tabs, 42

mupirocin, 45
MUSTARGEN, 15
MYAMBUTOL, 14
MYCAMINE, 13
MYCOBUTIN, 14
mycophenolate mofetil, 41
mycophenolate sodium delayed-rel, 42
MYFORTIC, 42
MYLERAN, 15
MYOBLOC, 28
MYOZYME, 35
MYSOLINE, 23
nabumetone, 9
nafarelin, 33
naftifine, 46
NAFTIN, 46
NAGLAZYME, 35
NALFON, 9
naloxone inj, 28
naltrexone, 28
naltrexone microspheres, 28
NAMENDA, 24
naphazoline, 50
NAPRELAN, 9
NAPROSYN, 9
naproxen, 9
naproxen sodium, 9
naproxen sodium ext-rel, 9
naproxen/esomeprazole delayed-rel, 9
naratriptan, 27
NARDIL, 24
NASACORT AQ, 44
NASCOBAL, 42
NASONEX, 44
NATACYN, 49
natalizumab, 28
natamycin, 49
NATAZIA, 32
nateglinide, 30
NATROBA, 48
NAVELBINE, 17
nebivolol, 21
NECON 10/11, 32
nefazodone, 25
nelarabine, 18
nelfinavir, 14
neomycin/dexamethasone, 49
neomycin/polymyxin B/dexamethasone, 49
neomycin/polymyxin B/gramicidin, 49
neomycin/polymyxin B/hydrocortisone, 51
neomycin/polymyxin B/hydrocortisone susp, 49
NEORAL, 42
NEOSPORIN, 49
nepafenac, 49
NEULASTA, 39
NEUMEGA, 39
NEUPOGEN, 39
NEUPRO, 25
NEURONTIN, 23
NEVANAC, 49
nevirapine, 13
nevirapine ext-rel, 13
NEXAVAR, 17
NEXIUM, 37
NEXPLANON, 32
niacin ext-rel, 20
niacin ext-rel/lovastatin, 20
niacin ext-rel/simvastatin, 20
NIASPAN, 20
nicardipine, 21
nicardipine ext-rel, 21
nicotine transdermal, 28
nifedipine ext-rel, 21
NILANDRON, 16
nilotinib, 16
nilutamide, 16
nimodipine, 21
NIMOTOP, 21
NIPENT, 16
nisoldipine ext-rel, 21
nitazoxanide, 15
nitisinone, 35
NITRO-DUR, 22
nitrofurantoin ext-rel, 15
nitrofurantoin macrocrystals, 15
nitroglycerin rectal oint 0.4%, 38
nitroglycerin sublingual, 22
nitroglycerin sublingual spray, 22
nitroglycerin transdermal, 22
NITROLINGUAL, 22
NITROSTAT, 22
nizatidine, 36
NIZORAL SHAMPOO, 46
NORDETTE, 31
NORDITROPIN, 34
norelgestromin/EE, 32
norethindrone, 32
norethindrone acetate, 35
norethindrone acetate/EE 1.5/30, 31
norethindrone acetate/EE 1.5/30 and iron, 31
norethindrone acetate/EE 1/20, 31
norethindrone acetate/EE 1/20 and iron, 31
norethindrone acetate/EE and iron, 32
norethindrone/EE, 32
norethindrone/EE 0.4/35, 31
norethindrone/EE 0.5/35, 31
norethindrone/EE 1/35, 31
norethindrone/EE 1/50, 32
norethindrone/ME 1/50, 32
norgestimate/EE, 32
norgestimate/EE 0.25/35, 31
norgestrel/EE 0.3/30, 31
norgestrel/EE 0.3/30 - Low-Ogestrel, 31
norgestrel/EE 0.5/50, 32
NORINYL 1+35, 31
NORINYL 1+50, 32
NORITATE, 48
NORPACE, 19
NORPACE CR, 20
NORPRAMIN, 25
NOR-QD, 32
nortriptyline, 25
NORVASC, 21
NORVIR, 14
NOVOLIN 70/30, 30
NOVOLIN N, 29
NOVOLIN R, 29
NOVOLOG, 29
NOVOLOG MIX 70/30, 29
NOVOSEVEN RT, 39
66
NOXAFIL, 13
NPLATE, 39
NUCYNTA, 10
NUCYNTA ER, 10
NUEDEXTA, 28
NULOJIX, 42
NULYTELY, 37
NUTROPIN AQ NUSPIN, 34
NUTROPIN/NUTROPIN AQ, 34
NUVARING, 32
NUVIGIL, 28
nystatin, 12, 46
OCTAGAM, 41
octreotide acetate, 35
OCUFEN, 49
OCUFLOX, 49
ofatumumab, 18
OFIRMEV, 9
ofloxacin, 12, 49
ofloxacin otic, 51
olanzapine, 25
olanzapine pamoate, 26
olanzapine/fluoxetine, 25
OLEPTRO, 25
olmesartan, 19
olmesartan/amlodipine/hydrochlorothiazide, 19
olmesartan/hydrochlorothiazide, 19
olopatadine, 44, 49
olsalazine, 37
omalizumab, 45
omega-3 acid ethyl esters, 20
omeprazole delayed-rel, 37
omeprazole/sodium bicarbonate, 37
OMNITROPE, 34
OMONTYS, 39
onabotulinumtoxinA, 28
ONCASPAR, 18
ondansetron, 36
ondansetron oral soluble film, 36
ONETOUCH LANCETS, 30
ONETOUCH test strips, 30
ONFI, 24
ONGLYZA, 29
ONSOLIS, 10
ONTAK, 17
OPANA, 10
OPANA ER, 10
opium tincture, 36
oprelvekin, 39
OPTIPRANOLOL, 50
ORACEA, 48
ORAPRED, 34
ORAPRED ODT, 34
ORENCIA, 40
ORFADIN, 35
ORTHO EVRA, 32
ORTHO MICRONOR, 32
ORTHO TRI-CYCLEN, 32
ORTHO TRI-CYCLEN LO, 32
ORTHO-CEPT, 31
ORTHO-CYCLEN, 31
ORTHO-NOVUM 1/35, 31
ORTHO-NOVUM 7/7/7, 32
ORTHOVISC, 10
oseltamivir, 14
OSMOPREP, 37
OVCON 35, 31
OVCON 50, 32
OVIDREL, 33
oxaliplatin, 18
oxaprozin, 9
oxazepam, 23
oxcarbazepine, 23
oxcarbazepine susp, 24
oxiconazole, 46
OXISTAT, 46
OXSORALEN-ULTRA, 46
oxybutynin, 38
oxybutynin ext-rel, 38
oxybutynin transdermal, 38
oxycodone, 10
oxycodone concentrate 20 mg/mL, 10
oxycodone ext-rel, 10
oxycodone soln, 10
oxycodone/acetaminophen 5/325, 10
OXYCONTIN, 10
oxymorphone, 10
oxymorphone ext-rel, 10
OXYTROL, 38
OZURDEX, 49
paclitaxel protein-bound particles, 18

palifermin, 38
paliperidone ext-rel, 26
paliperidone palmitate, 26
palivizumab, 14
palonosetron, 36
PAMELOR, 25
pamidronate, 31
PANCREAZE, 37
pancrelipase delayed-rel, 37
PANDEL, 47
panitumumab, 18
PANRETIN, 48
pantoprazole delayed-rel, 37
PARCOPA, 25
paricalcitol, 34
PARLODEL, 25
PARNATE, 24
paroxetine HCl, 24
paroxetine HCl ext-rel, 24
paroxetine mesylate, 24
PATANASE, 44
PATANOL, 49
PAXIL, 24
PAXIL CR, 24
pazopanib, 17
PCE, 12
peg 3350/electrolytes, 37
peg 3350/electrolytes + bisacodyl, 37
pegademase, bovine, 35
pegaptanib sodium, 51
pegaspargase, 18
PEGASYS, 41
pegfilgrastim, 39
peginesatide, 39
peginterferon alfa-2a, 41
peginterferon alfa-2b, 41
PEGINTRON, 41
PEGINTRON REDIPEN, 41
pegloticase, 9
67
pegvisomant, 35
pemetrexed, 16
penbutolol, 21
penicillamine, 41
penicillin VK, 12
PENTASA, 37
pentosan polysulfate sodium, 38
pentostatin, 16
pentoxifylline ext-rel, 40
PEPCID, 36
PEPCID susp, 36
PERCOCET, 10
perindopril, 18
PERJETA, 18
permethrin 5%, 48
perphenazine, 26
PERSANTINE, 40
pertuzumab, 18
PEXEVA, 24
phenazopyridine, 38
phenelzine, 24
phenobarbital, 23
phenylephrine, 49
phenytoin, 24
phenytoin sodium extended, 23
PHISOHEX, 48
PHOSLO, 34
PHOTOFRIN, 18
PHRENILIN FORTE, 10
phytonadione, 42
pilocarpine, 50
pilocarpine tabs, 37
PILOPINE HS GEL, 50
pimecrolimus, 47
pindolol, 21
pioglitazone, 30
pioglitazone/glimepiride, 30
pioglitazone/metformin, 30
pioglitazone/metformin ext-rel, 30
piperacillin/tazobactam, 12
piroxicam, 9
pitavastatin, 20
PLAQUENIL, 41
PLAVIX, 40
plerixafor, 40
PLETAL, 40
podofilox, 48
polymyxin B/bacitracin, 49
polymyxin B/trimethoprim, 49
POLYTRIM, 49
porfimer sodium, 18
posaconazole, 13
potassium chloride ext-rel, 42
potassium chloride liquid, 42
potassium chloride powder, 42
potassium citrate, 38
potassium citrate 15 mEq, 38
POTIGA, 24
PRADAXA, 39
pralatrexate, 16
pramipexole, 25
pramipexole ext-rel, 25
pramlintide, 29
PRAMOSONE, 46
PRAMOSONE E, 46
pramoxine/hydrocortisone, 46
pramoxine/hydrocortisone/emollient, 46
PRANDIMET, 30
PRANDIN, 30
prasugrel, 40
PRAVACHOL, 20
pravastatin, 20
prazosin, 19
PRECOSE, 29
PRED FORTE, 49
PRED MILD, 50
PRED-G, 49
prednisolone, 34
prednisolone acetate 0.12%, 50
prednisolone acetate 1%, 49
prednisolone phosphate 1%, 49
prednisolone sodium phosphate, 34
prednisolone sodium phosphate 5 mg/5 mL, 34
prednisolone sodium phosphate orally disintegrating tablet, 34
prednisolone syrup, 34
prednisone, 34
PREFEST, 33
pregabalin, 24
PRELONE, 34
PREMARIN, 33
PREMARIN crm, 33
PREMPHASE, 33
PREMPRO, 33
prenatal vitamins/docusate/folic acid, 42
prenatal vitamins/folic acid, 42
PRENATE ELITE, 42
PREVIDENT, 42
PREZISTA, 14
PRIALT, 10
PRIFTIN, 14
PRILOSEC, 37
primaquine, 13
PRIMAXIN, 15
primidone, 23
PRINIVIL, 18
PRINZIDE, 19
PRISTIQ, 25
PRIVIGEN, 41
PROAIR HFA, 43
probenecid, 9
procarbazine, 17
PROCARDIA XL, 21
prochlorperazine, 36
PROCRIT, 39
PROCTOFOAM-HC, 38
PROFILNINE SD, 40
progesterone supp, 35
progesterone, micronized, 35
PROGLYCEM, 34
PROGRAF, 42
PROLEUKIN, 17
PROLIA, 31
PROMACTA, 40
promethazine, 36, 43
PROMETRIUM, 35
propafenone ext-rel, 20
propantheline 15 mg, 36
propranolol, 21
propranolol ext-rel, 21
propylthiouracil, 35
PROSCAR, 38
protein C concentrate, human, 40
68
PROTONIX, 37
PROTOPIC, 47
protriptyline, 25
PROVENGE, 17
PROVENTIL HFA, 44
PROVERA, 35
PROVIGIL, 28
PROZAC, 24
PROZAC WEEKLY, 24
PULMICORT FLEXHALER, 44
PULMICORT RESPULES, 44
PULMOZYME, 44
PURINETHOL, 15
PYLERA, 38
pyrazinamide, 14
PYRIDIUM, 38
pyridostigmine ext-rel tabs 180 mg, 28
pyridostigmine syrup, 28
pyridostigmine tabs 60 mg, 28
pyrimethamine, 13
QUADRAMET, 18
quazepam, 27
QUESTRAN/QUESTRAN LIGHT, 20
quetiapine, 25
quetiapine ext-rel, 26
quinapril, 18
quinapril/hydrochlorothiazide, 19
quinidine gluconate ext-rel, 20
quinidine sulfate ext-rel, 20
QUTENZA, 48
QVAR, 44
rabeprazole delayed-rel, 37
raloxifene, 35
raltegravir, 13
ramelteon, 27
ramipril, 18
RANEXA, 23
ranibizumab, 51
ranitidine, 36
ranolazine ext-rel, 23
RAPAFLO, 38
RAPAMUNE, 42
rasagiline mesylate, 25
rasburicase, 16
RAYOS, 34
RAZADYNE, 24
RAZADYNE ER, 24
REBETOL, 14
REBIF, 27
RECLAST, 31
RECOMBINATE, 39
RECTIV, 38
REFACTO, 39
REGLAN, 36
REGRANEX, 48
RELENZA, 14
RELISTOR, 38
REMERON, 25
REMICADE, 40
REMODULIN, 23
RENAGEL, 34
RENOVA, 48
RENVELA, 34
repaglinide, 30
repaglinide/metformin, 30
REPRONEX, 34
REQUIP, 25
REQUIP XL, 25
RESCRIPTOR, 13
RESTASIS, 50
RESTORIL, 27
retapamulin, 45
RETIN-A, 45
RETIN-A MICRO, 45
RETROVIR, 13
REVATIO, 22
REVIA, 28
REVLIMID, 16
REYATAZ, 13
REZIRA, 43
RHEUMATREX, 41
RHINOCORT AQUA, 44
Rho (D) immune globulin, 41
RHOGAM, 41
RHOGAM PLUS, 41
RHOPHYLAC, 41
RIASTAP, 40
ribavirin caps, 14
ribavirin caps - Ribasphere, 14
ribavirin oral soln, 14
ribavirin tabs, 14
ribavirin tabs - Ribapak, 14
ribavirin tabs - Ribatab, 14
RIDAURA, 41
rifabutin, 14
RIFADIN, 14
rifampin, 14
rifampin/isoniazid/pyrazinamide, 14
rifapentine, 14
RIFATER, 14
rifaximin, 15
rilonacept, 41
rilpivirine, 13
RILUTEK, 28
riluzole, 28
rimabotulinumtoxinB, 28
rimantadine, 14
rimexolone, 50
RIOMET, 29
risedronate, 31
RISPERDAL, 25
RISPERDAL CONSTA, 26
risperidone, 25
risperidone long-acting inj, 26
RITALIN, 26
RITALIN LA, 26
RITALIN-SR, 26
ritonavir, 14
RITUXAN, 18
rituximab, 18
rivaroxaban, 39
rivastigmine, 24
rivastigmine transdermal, 24
rizatriptan, 27
ROCALTROL, 34
ROCEPHIN, 11
roflumilast, 44
romidepsin, 18
romiplostim, 39
69
ropinirole, 25
ropinirole ext-rel, 25
rosiglitazone, 30
rosiglitazone/glimepiride, 30
rosiglitazone/metformin, 30
rosuvastatin, 20
rotigotine transdermal, 25
ROWASA, 37
ROXICODONE, 10
ROZEREM, 27
rufinamide, 24
ruxolitinib, 17
RYTHMOL SR, 20
SABRIL, 24
sacrosidase, 38
SAIZEN, 34
SALAGEN, 37
salmeterol xinafoate, 44
samarium sm 153 lexidronam, 18
SAMSCA, 36
SANCTURA, 38
SANCTURA XR, 38
SANCUSO, 36
SANDIMMUNE, 42
SANDOSTATIN, 35
SANDOSTATIN LAR, 35
SAPHRIS, 26
sapropterin, 34
saquinavir mesylate, 14
SARAFEM, 24
sargramostim, 39
SAVELLA, 26
saxagliptin, 29
saxagliptin/metformin ext-rel, 29
scopolamine, 50
scopolamine transdermal, 36
SEASONALE, 32
SEASONIQUE, 32
secobarbital, 27
SECONAL, 27
SECTRAL, 20
selegiline caps, 25
selegiline orally disintegrating tabs, 25
selegiline transdermal, 24
selenium sulfide shampoo 2.5%, 46
SELSUN, 46
SELZENTRY, 13
SENSIPAR, 30
SEREVENT DISKUS, 44
SEROQUEL, 25
SEROQUEL XR, 26
SEROSTIM, 34
sertaconazole, 46
sertraline, 24
sevelamer, 34
sevelamer carbonate, 34
sildenafil, 22
SILENOR, 27
silodosin, 38
SILVADENE, 45
silver sulfadiazine, 45
SIMCOR, 20
SIMPONI, 40
simvastatin, 20
sinecatechins, 48
SINEMET, 25
SINEMET CR, 25
SINGULAIR, 44
sipuleucel-T, 17
sirolimus, 42
sitagliptin phosphate, 29
sitagliptin/metformin, 29
sitagliptin/metformin ext-rel, 29
sitagliptin/simvastatin, 29
SKELID, 31
SKLICE, 48
sodium ferric gluconate inj, 42
sodium fluoride, 42
sodium hyaluronate, 11
sodium oxybate, 28
sodium phosphates, 37
sodium sulfate/potassium sulfate/magnesium sulfate, 37
SOFTCLIX LANCET DEVICE, 30
SOFTCLIX LANCETS, 30
SOFTTOUCH LANCET DEVICE, 30
SOFTTOUCH LANCETS, 30
SOLARAZE, 45
solifenacin succinate, 38
SOLIRIS, 40
SOLODYN, 12
somatropin, 34
SOMATULINE DEPOT, 35
SOMAVERT, 35
SOMNOTE, 27
SONATA, 27
sorafenib, 17
SORIATANE, 46
sotalol, 20
SPECTRACEF, 11
spinosad, 48
SPIRIVA, 43
spironolactone, 19
spironolactone/hydrochlorothiazide, 22
SPORANOX caps, 12
SPORANOX oral soln, 13
SPRIX, 9
SPRYCEL, 16
STALEVO, 25
STARLIX, 30
stavudine, 13
STAVZOR, 24
STELARA, 46
STIMATE, 39
STRATTERA, 26
streptozocin, 15
SUBOXONE, 28
SUBSYS, 10
SUCRAID, 38
sucralfate, 38
sucralfate susp, 38
SULAR, 21
sulconazole, 46
sulfacetamide soln 10%, 49
sulfacetamide/prednisolone acetate oint 10%/0.2%, 49
sulfacetamide/prednisolone phosphate 10%/0.25%, 49
sulfacetamide/sulfur, 48
sulfamethoxazole/trimethoprim, 15
sulfamethoxazole/trimethoprim DS, 15
SULFAMYLON, 45
sulfasalazine, 37
sulfasalazine delayed-rel, 37
70
sulindac, 9
sumatriptan, 27
sumatriptan/naproxen sodium, 27
sunitinib, 17
SUPARTZ, 11
SUPPRELIN LA, 35
SUPREP, 37
SUSTIVA, 13
SUTENT, 17
SYLATRON, 41
SYMBICORT, 44
SYMBYAX, 25
SYMLINPEN, 29
SYNAGIS, 14
SYNAREL, 33
SYNTHROID, 35
SYNVISC, 10
SYNVISC-ONE, 10
SYPRINE, 35
TACHOSIL, 48
TACLONEX, 46
tacrolimus, 42, 47
tadalafil, 22
tadalafil 2.5 mg, 5 mg, 38
tafluprost, 50
taliglucerase alfa, 35
TAMBOCOR, 19
TAMIFLU, 14
tamoxifen, 16
tamsulosin, 38
TAPAZOLE, 35
tapentadol, 10
tapentadol ext-rel, 10
TARCEVA, 16
TARGRETIN caps, 17
TARKA, 18
TASIGNA, 16
TASMAR, 25
TAXOTERE, 17
tazarotene, 46
TAZORAC, 46
TEFLARO, 12
TEGRETOL, 23
TEGRETOL-XR, 23
TEKAMLO, 21
TEKTURNA, 21
TEKTURNA HCT, 21
telaprevir, 14
telavancin, 15
telbivudine, 14
telithromycin, 12
telmisartan, 19
telmisartan/hydrochlorothiazide, 19
temazepam, 27
TEMODAR, 15
TEMOVATE, 47
temozolomide, 15
temsirolimus, 17
teniposide, 18
tenofovir, 13
TENORETIC, 21
TENORMIN, 20
TERAZOL 3, 38
TERAZOL 7, 38
terazosin, 19
terbinafine, 46
terbinafine tabs, 12
terbutaline, 44
terconazole, 38
teriparatide, 31
tesamorelin, 36
TESSALON, 43
testosterone cypionate, 28
testosterone enanthate, 29
testosterone gel, 29
testosterone soln, 29
testosterone transdermal, 29
tetrabenazine, 26
tetracycline, 12
TEVETEN, 19
TEVETEN HCT, 19
TEV-TROPIN, 34
thalidomide, 16
THALOMID, 16
THEO-24, 45
theophylline ext-rel caps, 45
theophylline ext-rel tabs, 45
theophylline liquid, 45
THERACYS, 17
thioguanine, 15
thioridazine, 26
thiotepa, 15
thiothixene, 26
THYROGEN, 36
thyroid, 35
THYROLAR, 35
thyrotropin alfa, 36
tiagabine, 24
TIAZAC, 21
ticagrelor, 40
TICE BCG, 17
ticlopidine, 40
TIGAN, 36
tigecycline, 15
TIKOSYN, 20
tiludronate, 31
timolol hemihydrate, 50
timolol maleate, 50
timolol maleate gel, 50
TIMOPTIC, 50
TIMOPTIC-XE, 50
TINDAMAX, 15
tinidazole, 15
tinzaparin, 39
tiotropium, 43
tipranavir, 14
TOBI, 44
TOBRADEX, 49
tobramycin, 49
tobramycin inhalation soln, 44
tobramycin/dexamethasone, 49
tobramycin/loteprednol, 49
TOBREX, 49
tocilizumab, 41
TOFRANIL, 25
TOFRANIL-PM, 25
tolcapone, 25
tolterodine, 38
tolterodine ext-rel, 38
tolvaptan, 36
TOPAMAX, 23
71
TOPICORT, 47
TOPICORT LP, 46
topiramate, 23
topotecan, 17
topotecan inj, 17
TOPROL-XL, 21
toremifene, 16
TORISEL, 17
torsemide, 22
tositumomab, 18
TOTECT, 17
TOVIAZ, 38
TRACLEER, 22
TRADJENTA, 29
tramadol, 10
tramadol ext-rel, 10
trandolapril, 18
trandolapril/verapamil ext-rel, 18
tranexamic acid, 40
TRANSDERM SCOP, 36
TRANXENE T-TAB, 23
tranylcypromine, 24
trastuzumab, 18
TRAVATAN Z, 50
travoprost, 50
trazodone, 25
trazodone ext-rel, 25
TREANDA, 15
TRELSTAR, 16
TRELSTAR DEPOT, 16
TRELSTAR LA, 16
TRENTAL, 40
treprostinil, 23
tretinoin, 45
tretinoin emollient, 48
tretinoin gel microsphere, 45
TREXIMET, 27
triamcinolone acetonide crm 0.5%, 47
triamcinolone acetonide crm, lotion 0.025%, 47
triamcinolone acetonide crm, lotion, oint 0.1%, 47
triamcinolone acetonide spray, 44
triamcinolone paste, 48
triamterene/hydrochlorothiazide, 22
triamterene/hydrochlorothiazide 37.5/25, 22
triamterene/hydrochlorothiazide 50/25, 22
TRIBENZOR, 19
TRICOR, 20
trientine, 35
trifluoperazine, 26
trifluridine, 50
trihexyphenidyl, 25
TRILEPTAL, 23
TRILEPTAL susp, 24
TRILIPIX, 20
trimethobenzamide, 36
trimethoprim, 15
TRI-NORINYL, 32
triptorelin pamoate, 16
TRISENOX, 17
TRIZIVIR, 13
trospium, 38
trospium ext-rel, 38
TRUSOPT, 50
TRUVADA, 13
TWYNSTA, 19
TYGACIL, 15
TYKERB, 16
TYLENOL w/CODEINE, 10
TYSABRI, 28
TYVASO, 23
TYZEKA, 14
ULESFIA, 48
ulipristal, 32
ULORIC, 9
ULTRAM, 10
ULTRAM ER, 10
ULTRAVATE, 47
UNASYN, 12
URAMAXIN, 47
URAMAXIN GT, 47
urea, 47
urea 45%, 47
URECHOLINE, 38
urine test strips, 30
UROCIT-K, 38
UROCIT-K 15 mEq, 38
urofollitropin, 34
URSO, 36
URSO FORTE, 36
ursodiol, 36
ustekinumab, 46
UVADEX, 18
VAGIFEM, 33
valacyclovir, 14
VALCYTE, 14
valganciclovir, 14
VALIUM, 23
valproic acid, 23
valproic acid delayed-rel, 24
valrubicin, 18
valsartan, 19
valsartan/hydrochlorothiazide, 19
VALSTAR, 18
VALTREX, 14
VANCOCIN, 15
vancomycin, 15
vandetanib, 16
VANOS, 47
VANTAS, 16
varenicline, 28
VASERETIC, 18
VASOTEC, 18
VECTIBIX, 18
VECTICAL, 46
velaglucerase alfa, 36
VELCADE, 17
vemurafenib, 17
venlafaxine, 24
venlafaxine ext-rel, 24
venlafaxine ext-rel tabs, 25
VENOFER, 42
VENTAVIS, 23
VENTOLIN, 43
VENTOLIN HFA, 44
VERAMYST, 44
verapamil, 21
verapamil ext-rel, 21
VERDESO, 46
VEREGEN, 48
72
verteporfin, 51
VESICARE, 38
VEXOL, 50
VFEND, 12
VIBATIV, 15
VIBRAMYCIN, 12
VICODIN, 10
VICTOZA, 29
VICTRELIS, 14
VIDAZA, 17
VIDEX EC, 13
VIDEX soln, 13
vigabatrin, 24
VIGAMOX, 49
VIIBRYD, 24
vilazodone, 24
VIMOVO, 9
VIMPAT, 24
vinblastine, 17
vincristine, 17
vinorelbine, 17
VIOKACE, 37
VIRACEPT, 14
VIRAMUNE, 13
VIRAMUNE XR, 13
VIREAD, 13
VIROPTIC, 50
VISICOL, 37
vismodegib, 18
VISTARIL, 23, 43
VISTIDE, 14
VISUDYNE, 51
VITAFOL-OB, 42
VITAFOL-PN, 42
vitamin ADC/fluoride drops, 42
vitamin ADC/fluoride/iron drops, 42
VIVACTIL, 25
VIVELLE-DOT, 33
VIVITROL, 28
VOLTAREN, 49
VOLTAREN GEL, 9
VOLTAREN XR, 9
voriconazole, 12
vorinostat, 18
VOSPIRE ER, 44
VOTRIENT, 17
VPRIV, 36
VUMON, 18
VUSION, 46
VWF, human/factor VIII complex, 40
VYTORIN, 20
VYVANSE, 26
warfarin, 39
WELCHOL, 20
WELLBUTRIN, 25
WELLBUTRIN SR, 25
WELLBUTRIN XL, 25
WESTCORT, 47
WILATE, 40
WINRHO SDF, 41
XALATAN, 50
XALKORI, 16
XANAX, 23
XANAX XR, 23
XARELTO, 39
XELODA, 16
XENAZINE, 26
XEOMIN, 28
XERESE, 48
XGEVA, 31
XIAFLEX, 48
XIFAXAN, 15
XOLAIR, 45
XOLEGEL, 46
XYLOCAINE, 48
XYNTHA, 39
XYREM, 28
XYZAL, 43
YASMIN, 31
YAZ, 31
YERVOY, 17
zafirlukast, 44
zaleplon, 27
zanamivir, 14
ZANOSAR, 15
ZANTAC, 36
ZARONTIN, 23
ZAROXOLYN, 22
ZAVESCA, 35
ZEGERID, 37
ZELAPAR, 25
ZELBORAF, 17
ZEMPLAR, 34
ZENPEP, 37
ZERIT, 13
ZESTORETIC, 19
ZESTRIL, 18
ZETIA, 20
ZIAC, 21
ZIAGEN, 13
ZIANA, 45
ziconotide, 10
zidovudine, 13
zileuton ext-rel, 44
zinc acetate, 42
ZINECARD, 17
ZIOPTAN, 50
ziprasidone, 26
ZIRGAN, 50
ZITHROMAX, 12
ZMAX, 12
ZOCOR, 20
ZOFRAN, 36
ZOLADEX, 16
zoledronic acid, 31
ZOLINZA, 18
zolmitriptan, 27
ZOLOFT, 24
zolpidem, 27
zolpidem ext-rel, 27
zolpidem sublingual, 27
ZOMETA, 31
ZOMIG/ZOMIG-ZMT, 27
ZONALON, 48
ZONEGRAN, 23
zonisamide, 23
73
ZORBTIVE, 34
ZORTRESS, 42
ZOSYN, 12
ZOVIRAX, 14
ZOVIRAX crm, oint, 48
ZUPLENZ, 36
ZUTRIPRO, 43
ZYBAN, 28
ZYCLARA, 48
ZYFLO CR, 44
ZYLET, 49
ZYLOPRIM, 9
ZYPREXA RELPREVV, 26
ZYPREXA/ZYPREXA ZYDIS, 25
ZYTIGA, 16
ZYVOX, 15
74

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FEP 4 Tier Rx Drug Formulary (807) Basic Option

Effective October 1, 2012

ALPHA BLOCKERS ..................................................................................................................................................................................... 19

Basic Option Specialty Pharmacy

PHARMACY AND THERAPEUTICS (P&T) COMMITTEE

PRODUCT SELECTION CRITERIA

FORMULARY PRODUCT DESCRIPTIONS

DRUG EFFICACY STUDY IMPLEMENTATION DRUGS

Delayed-release (also known as enteric-coated), refer to the reference brand listed

Extended-release (also known as sustained-release), refer to the reference brand

choline magnesium trisalicylate

amphotericin B lipid complex

Chemokine Receptor Antagonists

Nucleotide Reverse Transcriptase Inhibitors

Non-nucleoside Reverse Transcriptase Inhibitors

Gonadotropin-Releasing Hormone (GnRH) Antagonists

Luteinizing Hormone-releasing Hormone (LHRH) Agonists

HORMONAL ANTINEOPLASTIC AGENTS

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

ALDOSTERONE RECEPTOR ANTAGONISTS

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS

Omega-3 Fatty Acids

Bile Acid Resins

Cholesterol Absorption Inhibitors

CALCIUM CHANNEL BLOCKERS

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS

DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

Thiazides and Thiazide-like Diuretics

nitroglycerin sublingual spray

PULMONARY ARTERIAL HYPERTENSION

CENTRAL NERVOUS SYSTEM

ARICEPT (except 23 mg)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)*

venlafaxine ext-rel tabs

ATTENTION DEFICIT HYPERACTIVITY DISORDER

HUNTINGTON'S DISEASE AGENTS

Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations

Selective Serotonin Agonists

MUSCULOSKELETAL THERAPY AGENTS

ENDOCRINE AND METABOLIC

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/HMG-CoA Reductase Inhibitor Combinations

Incretin Mimetic Agents

insulin isophane human 70%/regular 30%

ACCU-CHEK test strips

CALCIUM RECEPTOR ANTAGONISTS

blood glucose test strips

urine test strips

Progestin Intrauterine Device

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS

INSULIN-LIKE GROWTH FACTOR-1 AGENTS

PHENYLKETONURIA TREATMENT AGENTS

GLUCOSE ELEVATING AGENTS

* Indicated for AIDS wasting only

PHOSPHATE BINDER AGENTS

SELECTIVE ESTROGEN RECEPTOR MODULATORS

IRRITABLE BOWEL SYNDROME

Irritable Bowel Syndrome with Diarrhea

hydrocortisone acetate/pramoxine foam

ULCER THERAPY COMBINATIONS