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TABLE OF CONTENTS
INTRODUCTION................................................................................................................................................................. 2
HOW TO USE THIS LIST .................................................................................................................................................. 2
COVERAGE AND LIMITATIONS ................................................................................................................................... 3
PHARMACY SAVINGS PROGRAMS .............................................................................................................................. 4
CONTACT US ...................................................................................................................................................................... 5
DRUG FORMULARY LIST ............................................................................................................................................... 6
ANTI-INFECTIVE DRUGS ................................................................................................................................................ 6
AUTOIMMUNE INFLAMMATORY DISORDERS ........................................................................................................ 8
BLOOD MODIFYING DRUGS .......................................................................................................................................... 8
CANCER DRUGS ................................................................................................................................................................ 9
CENTRAL NERVOUS SYSTEM ....................................................................................................................................... 9
GASTROINTESTINAL DRUGS ...................................................................................................................................... 12
GENITOURINARY DRUGS ............................................................................................................................................. 13
HEART AND CIRCULATORY DRUGS......................................................................................................................... 14
HORMONES, DIABETES, TEST SUPPLIES, AND RELATED DRUGS................................................................... 17
MISCELLANEOUS CATEGORIES (INCLUDES SUPPLIES AND DEVICES) ....................................................... 20
MULTIPLE SCLEROSIS .................................................................................................................................................. 20
NEUROMUSCULAR DRUGS .......................................................................................................................................... 20
PAIN-RELIEF DRUGS...................................................................................................................................................... 22
RESPIRATORY AGENTS ................................................................................................................................................ 24
SUPPLEMENTS ................................................................................................................................................................. 25
TOPICAL DRUGS ............................................................................................................................................................. 25
MANAGED DOSE LIMITATIONS (MDL) .................................................................................................................... 30
PREAUTHORIZATION (PA) ........................................................................................................................................... 32
STEP-THERAPY (ST) ....................................................................................................................................................... 34
SPECIALTY DRUG LIST ................................................................................................................................................. 36
INDEX .................................................................................................................................................................................. 38
ph-comform-0913
INTRODUCTION
This is the 2013 Health Alliance Drug
Formulary. In order to assist members and providers
in choosing covered prescription drugs for
treatment, we encourage members to show this list
to their physicians and pharmacists. In addition, we
encourage prescribers to use this list when
considering treatment options. Final decisions
regarding treatment options are made between the
physician and patient.
The formulary is subject to change at any time.
Members can access the most up-to-date version of
this list by visiting the Pharmacy section of
HealthAlliance.org. In addition, members can login
to CatamaranRx.com to access specific drug
coverage and pricing information.
The formulary does not provide information
about an individuals specific coverage. Please refer
to your plan documents for complete coverage
details.
THERAPEUTIC CLASS
Then by sub-type (if applicable).
SUB-TYPE
And last by additional sub-type (if applicable).
ADDITIONAL SUB-TYPE
Covered brand-name drugs are listed in all
CAPITAL letters, followed by the generic name.
Generics
Like brand drugs, generic drugs go through an
approval process by the Food and Drug
Administration (FDA) and must meet similar
standards of effectiveness and chemical make-up as
branded drugs.
The main difference between the reference brand
drug and its generic equivalent is that the generic
often costs much less.
As a general rule, generic drugs have the lowest
member copayment. Typically, when a generic
enters the market the brand drug moves to Tier 3.
Members who choose the brand name after the
release of a generic version may pay the copayment
plus the difference in cost between the brand and
generic drug. Generic drugs can help members save
on out-of-pocket medication costs.
Generic Equivalent vs. Generic Alternative
Generic equivalents are medications that contain
the same active ingredient, with the same strength
and dosage form as the brand medication. Generic
equivalents are as safe and effective and produce
the same results as the brand counterpart.
Generic alternatives can produce the same
intended effect on the body as the comparable
brand. Generic alternatives are medications that
work like a particular brand drug and are used to
treat the same condition. However, the active
ingredient in a generic alternative is different from
the brand medication.
Talk to Your Doctor
If your doctor writes a prescription for a brand
drug that does not have a generic equivalent,
consider asking if an appropriate generic alternative
is available.
As a patient, you can tell your pharmacist you
are interested in generics. In most situations, your
pharmacist can substitute a generic equivalent for
its brand counterpart without a new prescription
from your doctor.
For more information on generics, visit
AskForGenerics.org.
Depending on your plan, you may have a threetier or a six-tier copayment structure. Refer to your
description of coverage documents for details. Your
pharmacy benefit includes coverage for the majority
of prescription drugs, though some exclusions may
apply.
Utilization Management
Some drugs on this list require utilization
management (UM), i.e. preauthorization, managed
dose limitations and step-therapy. If UM applies to
a drug, it is indicated with one of the following
symbols in the column next to the drug name.
Rxtra
General Exclusions
A. Over-the-counter (OTC) medications and
their equivalents are not covered, unless
otherwise specified within the Formulary.
Nicotine smoking-cessation products (e.g.,
transdermal nicotine, nicotine gum, nicotine
inhaler) coverage is based on specific
member benefits.
B. Any drugs used for cosmetic purposes are
not covered.
C. Experimental drugs, or any drug product
used in an experimental manner, are not
covered.
D. Replacement of lost or stolen medication is
not covered.
E. Non-self-administered injectable drugs,
unless otherwise noted, are not covered
through the pharmacy benefit. Refer to your
description of coverage materials for details.
F. Foreign drugs and drugs not approved by the
FDA are not covered.
Retail 90
Value-Based Benefit
Value-Based Benefit
Drug Class
Diabetes
Asthma
Hypertension
High
Cholesterol
Drug Name
All generics
Vials, pens and
cartridges for
Lilly insulin
All generics,
Ventolin HFA
QVAR
All generics
All generics
Formulary
Status
Tier 1
$20 copayment
Tier 1
$20 copayment
Tier 1
Tier 1
ACCU-CHEK
ACCU-CHEK Aviva System
ACCU-CHEK Nano System
ACCU-CHEK Compact Plus System
To get an ACCU-CHEK product, call
1-888-605-9872
Or visit meters.accu-chek.com
Freestyle Lite and Freestyle InsuLinx
FreeStyle Lite System
FreeStyle Freedom Lite System
FreeStyle InsuLinx System
To get an Abbott product, call
1-866-224-8892 and mention Health Alliance
Or visit www.myfreestyle.com/meterprogram
*InsuLinx systems are limited to one free product per
member every three years.
CONTACT US
Health Alliance Pharmacy Department
301 S. Vine St.
Urbana, IL 61801-3347
1-800-851-3379, option 4
HealthAlliance.org
OTHER COVERAGE
NOTES
PA
Specialty
ANTI-INFECTIVE DRUGS
CEPHALOSPORINS
cefdinir (Omnicef)
cefpodoxime (Vantin)
cefprozil (Cefzil)
cefuroxime (Ceftin)
FLUOROQUINOLONES
ciprofloxacin (Cipro)
CIPRO SUSPENSIONciprofloxacin suspension
levofloxacin (Levaquin)
FUNGAL INFECTIONS
fluconazole (Diflucan)
flucytosine (Ancoban)
griseofulvin microsize (Fulvicin, Grisfulvin)
GRIFULVIN Vgriseofulvin
GRIS-PEGgriseofulvin
itraconazole (Sporanox)
ketoconazole tablets (Nizoral)
nystatin oral (Mycostatin)
terbinafine (Lamisil)
voriconazole (Vfend)
HEPATITIS
EPIVIR HBVlamivudine
MACROLIDES
azithromycin (Zithromax)
clarithromycin (Biaxin)
clarithromycin ER (Biaxin XL)
E.E.S. GRANULESerythromycin ethylsuccinate
OTHER ANTI-INFECTIVES
erythromycin/sulfisoxazole (Pediazole)
MEPRONatovaquone suspension
metronidazole (Flagyl)
sulfamethoxazole/trimethoprim (Bactrim)
trimethoprim
TINDAMAXtinidazole
6
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
PA
PA
Specialty
Specialty
vancomycin (Vancocin)
PENICILLINS
amoxicillin/potassium clavulanate (Augmentin)
amoxicillin/potassium clavulanate ER (Augmentin XR)
amoxicillin (Amoxil)
dicloxacillin (Dicloxacillin)
penicillin v potassium (Veetids)
TETRACYCLINES
VIBRAMYCIN SYRUPdoxycycline syrup
minocycline (Minocin)
doxycycline hyclate (Vibramycin)
TUBERCULOSIS
ethambutol (Myambutol)
isoniazid (Laniazid, Nydrazid)
isoniazid/rifampin (Rifamate)
MYCOBUTINrifabutin
pyrazinamide
rifampin (Rifadin)
VIRAL INFECTIONS
HEPATITIS C
PEGASYSpeginterferon alfa-2a
PEG INTRONpeginterferon-2a
HERPES
acyclovir (Zovirax)
famciclovir (Famvir)
valacyclovir (Valtrex)
HIV/AIDS
APTIVUStipranavir
ATRIPLAefavirenz-emtricitabine-tenofovir
CRIXIVANindinavir
didanosine DR (Videc EC)
EMTRIVAemtricitabine
EPZICOMabacavir-lamivudine
INVIRASEsaquinavir
ISENTRESSraltegravir
KALETRAlopinavir-ritonavir
lamivudine (Epivir)
UTILIZATION
MANAGEMENT
lamivudine/zidovudine (Combivir)
NORVIR SOLUTIONritonavir
stavudine (Zerit)
RESCRIPTORdelavirdine
REYATAZatazanavir
SELZENTRYmaraviroc
SUSTIVAefavirenz
TRIZIVIRabacavir sulfate-lamivudine-zidovudine
TRUVADAemtricitabine-tenofovir disoproxil fumarate
VIDEX PEDIATRICdidanosine solution
VIRAMUNEnevirapine
VIRAMUNE XRnevirapine
VIREADtenofovir
ZIAGENabacavir
zidovudine (Retrovir)
OTHER COVERAGE
NOTES
PA
MALARIA
atovaquone/proguanil 250-100 mg (Malarone)
chloroquine phosphate (Aralen)
COARTEMartemether-lumefantrine
hydroxychloroquine (Plaquenil)
mefloquine (Larium)
primaquine
PA
PA
PA
Specialty
Specialty
Specialty
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
PA
Specialty
CANCER DRUGS
ALKERANmelphalan
anastrozole (Arimidex)
bicalutamide (Casodex)
CEENUlomustine
EMCYT estramustine
exemestane (Aromasin)
flutamide (Eulexin)
FARESTONtoremifene
HEXALEN altretamine
hydroxyurea (Hydrea)
letrozole (Femara)
leucovorin calcium tablets (Folinic acid)
LEUKERAN chlorambucil
LYSODRENmitotane
MATULANE procarbazine
megestrol (Megace)
mercaptopurine (Purinethol)
MESNEXmesna
methotrexate (Trexall)
MYLERANbusulfan
NILANDRONnilutamide
TABLOIDthioguanine
tamoxifen (Nolvadex)
TARGRETINbexarotene
TREXALLmethotrexate
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
diazepam (Valium)
hydroxyzine (Atarax, Vistaril)
lorazepam (Ativan)
DEPRESSION
bupropion ext-release (Wellbutrin SR, Wellbutrin XL)
citalopram (Celexa)
clomipramine (Anafranil)
desipramine (Norpramin)
doxepin (Sinequan)
escitalopram (Lexapro)
fluoxetine (Prozac)
imipramine hcl (Tofranil)
mirtazapine (Remeron, Remeron SolTab)
nortriptyline (Pamelor)
paroxetine hcl (Paxil)
paroxetine hcl ER (Paxil CR)
PAXILparoxetine HCL, oral suspension
phenelzine (Nardil)
sertraline (Zoloft)
tranylcypromine (Parnate)
trazodone (Desyrel)
venlafaxine (Effexor)
venlafaxine ER (Effexor XR)
MDL
MDL
HYPERACTIVITY/NARCOLEPSY
amphetamine/detroamphetamine (Adderall)
dextroamphetamine
dextroamphetamine ER (Dexedrine Spansule)
METADATE CDmethylphenidate HCL
METHYLINmethylphenidate HCL
methylphenidate ER capsules, tablets (Ritalin LA, Ritalin SR)
methylphenidate tablets (Ritalin)
MDL
10
UTILIZATION
MANAGEMENT
EXELONrivastigmine
galantamine (Razadyne)
galantamine ER (Razadyne ER)
naltrexone (ReVia)
NAMENDAmemantine
NICOTROL INHALERnicotine inhaler system
NICOTROL NSnicotine, nasal spray
SARAFEMfluoxetine
OTHER COVERAGE
NOTES
MDL
MDL
ST
ST
Tier 3
ST
SLEEP AIDS
estazolam (Prosom)
phenobarbital
temazepam (Restoril)
zaleplon (Sonata)
zolpidem (Ambien)
zolpidem ER (Ambien CR)
11
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
GASTROINTESTINAL DRUGS
DIGESTIVE ENZYMES
CREONpancrelipase
ZENPEPpancrelipase
MDL
MDL
PA
ULCER/REFLUX
CARAFATE SUSPENSIONsucralfate
cimetidine (Tagamet)
dicyclomine (Bentyl)
12
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
famotidine (Pepcid)
glycopyrrolate (Robinul)
hyoscyamine (Anaspaz, Levsin/SL)
hyoscyamine ER (Levbid, Symax Duotab)
lansoprazole DR (Prevacid)
methscopolamine (Pamine, Pamine Forte)
misoprostol (Cytotec)
omeprazole DR (Prilosec)
pantoprazole DR (Protonix)
ranitidine (Zantac)
sucralfate tablets (Carafate)
GENITOURINARY DRUGS
alfuzosin (Uroxatral)
AVODARTdutasteride
CARDURA XL-doxazosin mesylate
finasteride (Proscar)
JALYNdutasteride-tamsulosin
tamsulosin (Flomax)
VAGINAL PRODUCTS
CLEOCINclindamycin phosphate
clindamycin vaginal cream (Cleocin)
ENDOMETRINprogesterone
13
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
ESTRACEestradiol
ESTRINGestradiol
metronidazole (MetroGel-Vaginal)
terconazole (Terazol)
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
atenolol (Tenormin)
atenolol/chlorthalidone (Tenoretic)
bisoprolol (Zebeta)
bisoprolol/hydrochlorothiazide (Ziac)
carvedilol (Coreg)
COREG CRcarvedilol
labetalol (Trandate)
metoprolol succinate ER (Toprol XL)
metoprolol tartrate (Lopressor)
nadolol (Corgard)
propranolol ER (Inderal LA)
propranolol tablets (Inderal)
CHEST PAIN
DILATRATE SRisosorbide dinitrate CR
isosorbide dinitrate (Isordil)
isosorbide mononitrate (Monoket)
isosorbide mononitrate ER (Imdur)
ISORDIL TITRADOSEisosorbide dinitrate
NITRO-BIDnitroglycerin
NITRO-DURnitroglycerin patch
nitroglycerin (Nitro-Dur)
NITROMISTnitroglycerin lingual
NITROSTATnitroglycerin SL
CHOLESTEROL LOWERING
ADVICORniacin-lovastatin
atorvastatin (Lipitor)
cholestyramine (Questran, Questran Light)
colestipol (Colestid)
CRESTORrosuvastatin
ST
ST
15
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
ST
ERECTILE DYSFUNCTION
CAVERJECTalprostadil for injection
CIALIStadalafil
EDEXalprostadil for injection kit
MUSEalprostadil urethral pellet
ST
Tier 3
FLUID RETENTION
acetazolamide (Diamox)
acetazolamide ER (Diamox Sequels)
amiloride (Midamor)
amiloride/hydrochlorothiazide (Moduretic)
bumetanide (Bumex)
chlorthalidone (Thalitone)
furosemide (Lasix)
hydrochlorothiazide (Microzide, Hydrodiuril)
indapamide (Lozol)
methazolamide (Neprazane)
metolazone (Zaroxolyn)
spironolactone (Aldactone)
spironolactone/hydrochlorothiazide (Aldactazide)
THALITONEchlorthalidone
torsemide (Demadex)
HEART RHYTHM
amiodarone (Cordarone, Pacerone)
clonidine (Catapres, Catapres-TTS)
disopyramide (Norpace)
flecainide (Tambocor)
MULTAQdronedarone
NORPACE CRdisopyramide
propafenone (Rythmol)
16
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
CORTICOSTEROIDS
budesonide ER (Entocort EC)
dexamethasone
DEXAMETHASONE INTENSOLdexamethasone
fludrocortisones (Florinef)
hydrocortisone (Cortef)
methylprednisolone (Medrol)
MILLIPRED prednisolone
PREDNISONE INTENSOLprednisone
prednisolone (Prelone)
prednisolone sodium phosphate (Orapred, Pediapred)
prednisone tablets
17
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
DIABETES
acarbose (Precose)
DUETACTpioglitazone -glimepiride
glimepiride (Amaryl)
glipizide (Glucotrol)
glipizide ER (Glucotrol XL)
GLUCAGENglucagon
GLUCAGON EMERGENCY KITglucagon
glyburide (Micronase)
glyburide micronized (Glynase)
glyburide/metformin (Glucovance)
JENTADUETOlinagliptin/metformin
metformin (Glucophage)
metformin ER (Glucophage XR, Fortamet)
nateglinide (Starlix)
pioglitazone (Actos)
pioglitazone-metformin (Actoplus met)
pioglitazone-metformin SR (Actoplus met XR)
TRADJENTAlinagliptin
VICTOZAliraglutide
PA
ST
ST
ST
ST
ST
DIABETES-INSULINS
BASAL INSULIN
LANTUSinsulin glargine
LANTUS SOLOSTARinsulin glargine
RAPID ACTING INSULIN
APIDRAinsulin glulisine
APIDRA SOLOSTARinsulin glulisine
HUMALOGinsulin lispro
SHORT ACTING INSULIN
HUMULINinsulin human nph, reg
MDL
MDL
MDL
MDL
MDL
MDL
DIABETESTESTING SUPPLIES
ACCU-CHEK NANO METER (Free by mail)
ACCU-CHEK AVIVA METER (Free by mail)
ACCU-CHEK COMPACT PLUS METER (Free by mail)
ACCU-CHEK COMPACT TEST STRIPS
ACCU-CHEK SMART VIEW TEST STRIPS
ACCU-CHEK AVIVA PLUS TESTS STRIPS
ACCU-CHEK COMFORT CURVE TEST STRIPS
MDL
MDL
MDL
MDL
MDL
MDL
MDL
18
UTILIZATION
MANAGEMENT
MDL
MDL
OTHER COVERAGE
NOTES
MDL
MDL
MDL
MDL
MDL
ESTROGENS
ALORAestradiol
estradiol (Climara, Estrace)
estradiol/norethindrone acetate (Activella)
estropiopate (Ogen, Ortho-Est)
FEMHRT LOW DOSEnorethindrone acetate-ethinyl estradiol
MENESTesterified estrogens
MENOSTARestradiol
norethindrone acetate/ethinyl estradiol
VIVELLE-DOTestradiol
INFERTILITY
clomiphene (Clomid)
FOLLISTIM AQfollitropin
PA
PA
Specialty
PA
Specialty
MALE HORMONES
ANDROGELtestosterone gel
danazol (Danocrine)
OTHER HORMONES
alendronate tablets (Fosamax)
cabergoline (Dostinex)
calcitonin-salmon (Miacalcin)
calcitriol (Rocaltrol)
desmopressin (DDVAP)
etidronate (Didronal)
EVISTAraloxifene
ibandronate oral (Boniva)
propylthiouracil
RECLASTzoledronic acid
STIMATEdesmopressin
19
SYNARELnafarelin
TEV TROPINsomatropin
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
PA
Specialty
PROGESTINS
medroxyprogesterone acetate (Provera)
norethindrone acetate (Aygestin)
progesterone micronized (Prometrium)
THYROID REGULATION
ARMOUR THYROIDthyroid
levothyroxine (Synthroid, Levoxyl)
liothyronine (Cytomel)
methimazole (Tapazole)
SYNTHROIDlevothyroxine
THYROLARliotrix (T3-T4)
MULTIPLE SCLEROSIS
AVONEXinterferon beta-1a
BETASERONinterferon beta-1b
COPAXONEglaitamer
PA
PA
PA
Specialty
Specialty
Specialty
NEUROMUSCULAR DRUGS
MUSCLE RELAXANTS
baclofen (Lioresal)
chlorzoxazone (Parafon)
cyclobenzaprine (Flexeril, Fexmid)
20
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
dantrolene (Dantrium)
metaxalone (Skelaxin)
methocarbamol (Robaxin)
orphenadrine citrate ER (Norflex)
orphenadrine/aspirin/caffeine (Norgesic)
tizanidine (Zanaflex)
PARKINSON'S DISEASE
amantadine (Symmetrel)
benztropine (Cogentin)
bromocriptine (Parlodel)
carbidopa/levodopa (Parcopa, Sinemet)
carbidopa/levodopa ER (Sinemet CR)
pramipexole (Mirapex)
REQUIP XLropinirole hydrochloride
ropinirole (Requip)
selegiline (Eldepryl)
trihexyphenidyl (Artane)
SEIZURES
BANZEL rufinamide
carbamazepine (Tegretol)
carbamazepine ER (Carbatrol, Tegretol-XR)
CARBATROLcarbamazepine
clonazepam (Klonopin)
DEPAKENEvalproic acid
DEPAKOTEdivalproex sodium
DEPAKOTE SPRINKLESdivalproex sodium
DILANTINphenytoin sodium extended
divalproex DR (Depakote Sprinkles, Depakote)
divalproex ER (Depakote ER)
ethosuximide (Zarontin)
FELBATOL felbamate
gabapentin (Neurontin)
21
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
GABITRILtiagabine HCL
KLONOPINclonazepam
LAMICTALlamotrigine
LAMICTAL XRlamotrigine
lamotrigine (Lamictal)
levetiracetam (Keppra)
MYSOLINEprimidone
NEURONTINgabapentin
oxcarbazepine (Trileptal)
phenytoin sodium ER (Dilantin, Phenytek)
phenytoin suspenion (Dilantin)
primidone (Mysolutionine)
TEGRETOLcarbamazepine
TEGRETOL-XRcarbamazepine
topiramate (Topamax Sprinkle, Topamax)
TOPAMAXtopiramate
valproic acide (Depakene)
ZARONTINethosuximide
ZONEGRANzonisamide
zonisamide (Zonegran)
PAIN-RELIEF DRUGS
GOUT
allopurinol (Zyloprim)
COLCRYS colchicine
probenecid (Benemid)
ULORIC--febuxostat
Tier 3
MIGRAINE HEADACHES
acetaminophen/isometheptene/dichloralphenazone (Midrin)
naratriptan (Amerge)
MIGRANALdihydroergotamine mesylate
sumatriptan injection, tablets (Imitrex)
TREXIMETsumatriptan-naproxen sodium
MDL
MDL
MDL
NARCOTIC DRUGS
acetaminophen/codeine (Tylenol w/Codeine)
buprenorphine (Subutex)
22
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
PA
MDL
MDL
NON-NARCOTIC DRUGS
butalbital/acetaminophen (Sedapap)
butalbital/acetaminophen/caffeine (Esgic, Esgic Plus, Fioricet)
butalbital/aspirin/caffeine (Fiorinal)
PHRENILIN FORTEbutalbital-acetaminophen
salsalate (Disalcid)
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
sulindac (Clinoril)
RESPIRATORY AGENTS
ASTHMA/COPD
ADVAIRfluticasone-salmeterol
albuterol 0.63 mg/3 mL, 1.25 mg/3 ml (Accuneb)
albuterol inhaler solution, 0.0835, 0.5% (Ventolin)
albuterol syrup, tablets (Ventolin)
ATROVENT HFAipratropium bromide HFA
budesonide ER (Pulmicort Respules)
COMBIVENT RESPIMATipratropium-albuterol
cromolym sodium inhal solution (Intal)
ELIXOPHYLLINtheophylline
FLOVENTfluticasone propionate
FORADIL AEROLIZERformoterol fumarate
ipratropium inhalersolution (Atrovent, Aerovent)
ipratropium/albuterol (Duoneb)
MAXAIR AUTOHALERpirbuterol acetate
montelukast sodium (Singulair)
PULMICORT FLEXHALERbudesonide
QVARbeclomethasone dipropionate
SEREVENT DISKUSsalmeterol xinafoate
SPIRIVAtiotropium bromide
SPIRIVA HANDIHALERtiotropium
SYMBICORTbudesonide-formoterol
terbutaline (Brethine)
THEO-24theophylline
theophylline ER (Theo-Dur)
TUDORZA aclidinium bromide
VENTOLIN HFAalbuterol HFA
zafirlukast (Accolate)
MDL
MDL
NASAL ANTIHISTAMINE
ASTEPROazelastine HCL nasal
azelastine (Astelin)
24
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
SUPPLEMENTS
VITAMINS
ergocalciferol (Drisdol)
GALZINzinc acetate
MEPHYTONphytonadione
NASCOBALcyanocobalamin
MULTIVITAMINS
prenatal vitamin/folic acid - all generics
TOPICAL DRUGS
ANORECTAL AGENTS
ANALPRAM EHC-pramoxine
CORTIFOAMhydrocortisone acetate rectal foam
hydrocortisone acetate rectal cream, suppository
(Anusolution-HC, Proctocort)
hydrocortisone enema (Cortenema)
EAR
acetic acid ear solution
benzocaine/antipyrine ear solution
hydrocortisone/acetic acid ear solution
neomycin/polymyxin B/hydrocortisone ear solution,
suspension (Cortisporin)
ofloxacin ear solution (Floxin otic)
EYE
ANTI-INFECTIVE
bacitracin/polymyxin B eye ointment
ciprofloxacin eye solution (Ciloxan)
erythromycin eye ointment
25
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
Tier 3
26
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
Tier 3
SKIN CONDITIONS/PRODUCTS
ACNE
adapalene (Differin)
clindamycin (Cleocin-T)
erythromycin gel, pads, solution
metronidazole (Metrocream, Metrolotion)
27
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
PA
ANTI-INFECTIVES
ciclopirox gel, shampoo (Loprox)
ciclopirox solution (Penlac)
econazole (Spectazole)
ketoconazole (Nizoral)
mupirocin ointment (Bactroban)
nystatatin topical
silver sulfadiazine (Silvadene)
CORTICOSTEROIDS
alclometasone (Aclovate)
amcinonide cream (Cyclocort)
betamethasone dipropionate (Diprosone)
betamethasone dipropionate, augmented (Diprolene)
betamethasone valerate cream, lotion
clobetasol (Olux, Temovate)
desonide (Desowen)
desoximetasone cream, 0.25%; gel; ointment 0.25% (Topicort)
diflorasone ointment
fluocinolone acetonide oil (Derma-Smoothe/FS)
fluocinonide
fluticasone propionate (Cutivate)
halobetasol (Ultravate)
hydrcortisone valerate (Westcort)
hydrocortisone topical
mometasone (Elocon)
triamcinolone cream; lotion; ointment, 0.025%, 0.1%
OTHER SKIN PRODUCTS
8-MOPmethoxsalen, capsule 10 mg
aluminum chloride (Drysol)
calcipotriene solution (Dovonex)
fluorouracil (Efudex)
imiquimod (Aldara)
lidocaine topical (Xylocaine)
lindane
OXSORALEN ULTRAmethoxsalen
permethrin
podofilox (Condylox)
PROTOPICtacrolimus
28
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
MDL
Tier 3
29
Drug Class
ACNE
ASTHMA
BEHAVIORAL
HEALTH:
ADHD
BEHAVIORAL
HEALTH:
Depression
Drug Name
isotretinoin oral (Claravis and
Amnesteem)
Arcapta Neohaler
Asmanex
Flovent HFA
QVAR
Ventolin HFA
Quillivant XRTM
citalopram
Cymbalta, 30mg or 60mg
Cymbalta, 20mg
sertraline
ENDOCRINE:
blood glucose test strips
Diabetes
insulin vials
insulin pens
Januvia, JuvisyncTM, Janumet XR,
OnglyzaTM, KobmiglyzeTM XR,
Tradjenta
Janumet, Jentadueto
ENDOCRINE:
Caverject/Edex/Muse
Impotency
Cialis
Levitra
StaxynTM
Viagra
GASTROINTESTINAL: Emend
Emesis
Sancuso
HEMATOLOGICAL
Xarelto 10 mg
DISORDERS
INFECTIOUS
Incivek
DISEASE:
Victrelis
Hepatitis C
INFECTIOUS
Relenza
DISEASE:
Influenza
Tamiflu
LOWER GI
DISORDERS: Irritable
Bowel Syndrome
Amitiza
LinzessTM
30 caps
1 inhaler
24gm (2 inhalers)
2 inhalers
3 inhalers
180ml
90-Day Supply
(Mail Order)*
*maximum of 6
months of treatment
90 caps
3 inhalers
72gm (6 inhalers)
6 inhalers
9 inhalers
N/A
30 tablets
30 capsules
60 capsules
60 tablets
150 test strips
60ml (6 vials)
4 boxes
30 tablets
90 tablets
90 capsules
180 capsules
180 tablets
450 test strips
180ml (18 vials)
12 boxes
90 tablets
60 tablets
6 units
4 tablets1
4 tablets1
4 tablets1
4 tablets1
6 tablets
1 patch
35 tablets/6 months
180 tablets
18 units
12 tablets1
12 tablets1
12 tablets1
12 tablets1
18 tablets
3 patches
N/A
180 tablets
360 tablets
N/A
N/A
N/A
30-Day Supply
N/A
N/A
180 capsules
90 capsules
Drug Class
NEUROLOGY:
Migraine
NEUROLOGY:
Narcolepsy
PAIN
MANAGEMENT
SMOKING
CESSATION
Drug Name
Axert
Amerge (naratriptan)
Frova
Imitrex/Sumavel (sumatriptan) injectable
Imitrex (sumatriptan) - nasal
30-Day Supply
9 tablets
9 tablets
9 tablets
2 kits
(4 injections)
6 nasal spray devices
9 tablets
12 tablets
8 units
9 tablets
9 tablets
9 tablets
30 tablets
30 tablets
60 tablets
60 tablets
60 tablets
15 patches
60 tablets
60 tablets
120 tablets
60 tablets
20 tablets
60 tablets
5 nasal spray units
30 units
60 tablets
90-Day Supply
(Mail Order)*
27 tablets
27 tablets
27 tablets
6 kits
(12 injections)
18 nasal spray
devices
27 tablets
36 tablets
24 units
27 tablets
27 tablets
27 tablets
90 tablets
90 tablets
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
180 tabs/0 refill
Please Note: This applies to most Health Alliance plans. If you have questions, please
contact the Pharmacy Department at 1-800-851-3379, option 4.
1
ph-MDLdrugs-0613
DRUGS REQUIRING
PREAUTHORIZATION
The table below outlines the medications requiring a review by the Clinical Pharmacist, and
if necessary, a Health Alliance Medical Director. If a provider wished for coverage of a drug
designated as preauthorization required (PA), they must provide documentation to meet criteria
for that particular medication. Provider must request prior authorization from Health Alliance for
drugs on the following list:
Drug Class
Drug Name
Comments
ASTHMA
Advair (fluticasone-salmeterol)
500/50mcg only
BEHAVIORAL
HEALTH:
ADHD
Quillivant XR (methylphenidate
suspension)
BEHAVIORAL
HEALTH:
Antidepressants
Pristiq (desvenlafaxine)
Viibryd (vilazodone)
Cymbalta (duloxetine)
BEHAVIORAL
HEALTH:
Narcolepsy
Provigil (modafinil)
Nuvigil (armodafinil)
CARDIOVASCULAR:
Lipotropics
Vytorin (simvastatin/ezetimibe)
Zetia (ezetimibe)
DERMATOLOGY
tretinoin
Finacea (azelaic acid)
Picato (ingenol mebutate)
Tazorac (tazarotene)
Aczone (dapsone)
Documentation of a non-cosmetic
diagnosis (acne, actinic keratosis, ect).
Trial of a Tier 1 agent.
DIABETES:
DPP4 Inhibitors
Januvia (sitagliptin)
Janumet (sitagliptin-metformin)
Janumet XR (sitagliptin-metformin ER)
Juvisync (sitagliptin-simvastatin)
Onglyza (saxagliptin)
Kombiglyze (saxagliptin-metformin)
Kombiglyze XR (saxagliptin-metformin
ER)
DIABETES:
GLP1
Byetta (exenatide)
Bydureon (exenatide ER)
DIABETES, MISC.
Becaplermin (Regranex)
Drug Class
Drug Name
Comments
INFECTIOUS
DISEASE:
Antibacterial, Misc
INFLAMMATORY
DISEASE:
NSAIDs
Celebrex (celecoxib)
LOWER GI
DISORDERS:
Irritable Bowel
Syndrome
Amitiza (lubiprostone)
Linzess (linaclotide)
Lotronex (alosetron)
LOWER GI
DISORDERS:
Narcotic antagonists
Relistor (methylnaltrexone)
NASAL AGENTS
Dymista (azelastine/fluticasone)
NEUROLOGICAL
DISEASE: GABA
analogs
Lyrica (Pregabalin)
Gratise (Gabapentin ER)
Horizant (Gabapentin ER)
NEUROLOGICAL
DISEASE: Botulinum
toxins
Botox (onabotulinumtoxinA)
Xeomin (incoboluminumtoxinA)
Myobloc (rimabotulinumtoxinB)
NEUROLOGICAL
DISEASE:
Fibromyalgia agents
Savella (milnacipran)
PAIN
MANAGEMENT:
Analgesics, Narcotics
Butrans (buprenorphine)
UPPER GI
Aciphex (rabeprazole);
Dexilant (dexlansoprazole);
DISORDERS;
Anti-ulcer preparations Nexium (esomeprazole);
Zegerid (omeprazole/sod bicarb)
Note: This is an incomplete list. Products with one year or less from the date of product launch
are excluded from coverage.
Please Note: This applies to most Health Alliance plans. If you have questions,
please contact the Pharmacy Department at 1-800-851-3379, option 4.
ph-preauthdrugs-0613
DRUGS REQUIRING
STEP-THERAPY
Step-Therapy (ST)
If a drug is covered as a step-therapy medication, one or more prerequisite medications must
be tried rst before the step-therapy medication will be covered under the pharmacy benet.
Prerequisite medications and their corresponding step-therapy medications are used to treat the
same conditions. If it is medically necessary, a step-therapy medication can be obtained without
trying a prerequisite medication rst. In this case, the members physician must request coverage
for a step-therapy medication as a medical exception.
Drug Class
Step-Therapy (ST)
Medication
ASTHMA
Bronchodilating
Ventolin HFA
BEHAVIORAL HEALTH
Anti-anxiety
Niravam (alprazolam)
alprazolam
BEHAVIORAL HEALTH
Atypical antipsychotic
Symbyax
(olanzapine and fluoxetine)
Abilify (aripiprazole)
Invega (paliperidone)
Seroquel XR (quetiapine)
Fanapt (iloperidone)
Latuda (lurasidone)
Saphris (asenapine)
risperidone, olanzapine,
quetiapine or ziprasidone
BEHAVIORAL HEALTH
Antidepressants NDRI
Aplenzin (bupropion)
bupropion
BEHAVIORAL HEALTH
Antidepressants SARI
Oleptro (trazodone)
trazodone
BEHAVIORAL HEALTH
Opioid dependence
generic buprenorphine/naloxone
tablets
CARDIOVASCULAR
Statins
Advicor (lovastatin/niacin)
Altoprev (lovastatin ER)
Crestor (rosuvastatin)
Caduet (atorvastatin/
amlodipine)
Livalo (pitavastatin)
Lescol XL (fluvastatin)
atorvastatin
Daliresp (roflumilast)
DERMATOLOGY
Topical anti-infective
Denavir (penciclovir)
acyclovir
Prerequisite Medication
DERMATOLOGY
Local anesthetic
Lidoderm (lidocaine)
gabapentin
DERMATOLOGY
Topical anti-inflammatory
Voltaren gel
Drug Class
Step-Therapy (ST)
Medication
Prerequisite Medication
DIABETES
TZDs (Thiazolidinedione)
Actos (pioglitazone)
Actoplus Met
Actoplus Met XR
Duetact
Avandia (rosiglitazone)
Avandaryl
Avandamet
metformin or a sulfonylurea
(glimepiride, chlorpropamide,
glipizide, glyburide, tolbutamide,
tolazamide)
DIABETES
DPP4 (Dipeptidyl/Peptidase IV)
Tradjenta (linagliptin)
Jentadueto (linagliptin/
metformin)
metformin or a sulfonylurea
DIABETES
GLP-1 (Glucagon-like peptide-1)
Victoza (liraglutide)
metformin or a sulfonylurea
ENDOCRINE
Bone
Actonel (risedronate)
Atelvia (risedronate)
Binosto (alendronate)
alendronate or ibandronate
ENDOCRINE
Testosterone replacement
Androderm (testosterone
transdermal)
Axiron (testosterone topical)
Fortesta (testosterone gel)
Testim (testosterone gel)
Striant (testosterone buccal)
HEMATOLOGICAL DISORDER
Anti-Platelet
Brilinta (ticagrelor)
Effient (prasugrel)
Plavix (clopidogrel)
clopidogrel
HEMATOLOGICAL DISORDER
Thrombin Inhibitors
Eliquis (apixaban)
Pradaxa (dabigatran)
Xarelto (rivaroxaban)
warfarin
HYPERPARATHYROID AGENT
Zemplar (paricalcitol)
calcitriol or Vitamin D
INFECTIOUS DISEASE
Antibiotic
Dificid (fidaxomicin)
metronidazole or vancomycin
INFLAMMATORY DISEASE
Vimovo (esomeprazole/
naproxen)
PAIN MANAGEMENT
Long Acting Opioid
PAIN MANAGEMENT
Short Acting Opioid
Nucynta (tapentadol)
Tier 1 opioid
Ryzolt (tramadol)
tramadol ER
tramadol IR
SEDATIVE-HYPNOTICS
Lunesta (eszopiclone)
ZolpiMist (zolpidem)
Silenor (doxepin)
zolpidem/zolpidem ER and
zaleplon
Fexmid (cyclobenzaprine)
URINARY TRACT
Cialis (tadalafil) once daily
BPH (Benign Prostatic Hypertrophy)
ph-stdruglistMEMB-0413
cyclobenzaprine
tamsulosin, alfuzosin, Rapaflo,
finasteride, Avodart or Jalyn
(dutasteride/tamsulosin)
Specialty medications are usually prescribed for complex, ongoing conditions. To be eective, they often
have special instructions or need to be administered by a health care professional. The medications Health
Alliance classies as specialty are listed below.
Age-Related Macular Edema
Eylea (M)*
Lucentis (M)*
Macugen (M)*
Visudyne (M)*
Antiemetic Intravenous
Aloxi (M)
Anzemet (M)
Emend (M)
granisetron (M)
Kytril (M)
Autoimmune Inammatory Disorders
Actemra (M)*
Amevive (M)*
Arcalyst (M)*
Benlysta (M)*(NF)
Cimzia*
Enbrel*
Humira*
Ilaris (M)*
Kineret*
Orencia (M)*
Orencia Sub Q*
Remicade (M)*
Simponi*
Stelara* (M)
Blood Modiers
Aranesp*
Epogen*
Leukine*
Neulasta*
Neumega*
Neupogen*
Nplate (M)*
Procrit*
Promacta*
Bone Resorption
Aredia (M)*
Boniva IV (M)*
Forteo*
Prolia (M)*
Xgeva (M)*
zoledronic acid (M)*
Clotting Disorders
Advate (M)*
Alphanate/VWF (M)*
Alphanine SD (M)*
Bebulin VH (M)*
BeneFIX (M)*
Feiba NF (M)*
Feiba VH (M)*
Helixate FS (M)*
Hemofil M (M)*
Humate-P (M)*
Koate-DVI (M)*
Kogenate FS (M)*
Monoclate-P (M)*
Mononine (M)*
NovoSeven RT (M)*
Profilnine SD (M)*
Recombinate (M)*
Wilate (M)*
Xyntha (M)*
Cystic Fibrosis
Cayston*
Kalydeco*
Pulmozyme*
TOBI*
Enzyme Deciencies
Aldurazyme (M)*
Carbaglu* (NF)
Ceredase (M)*(NF)
Cerezyme (M)*(NF)
Cinryze (M)*(NF)
Elaprase (M)*(NF)
Fabrazyme (M)*(NF)
Kuvan* (NF)
Lumizyme (M)*(NF)
Myozyme (M)*(NF)
Naglazyme (M)*(NF)
Orfadin* (NF)
Sucraid* (NF)
Vpriv (M)*(NF)
Zavesca*(NF)
Growth Hormone
Genotropin*
Humatrope*
Increlex*
Norditropin*
Nutropin AQ*
Omnitrope*
Protropin*
Saizen*
Serostim*
Tev-Tropin*
Zorbtive*
Hepatitis C
Copegus*
Incivek*
Infergen*
Pegasys*
Peg-Intron*
Rebetrol*
Rebetron*
Ribapak*
Ribasphere*
RibaTab*
ribavirin*
Roferon-A*
Sylatron injection (M)
Victrelis*
Hereditary Angioedema
Berinert (M)*(NF)
Kalbitor (M)*(NF)
Firazyr*(NF)
HIV
Atripla
Complera
Fuzeon
Selzentry
Stribild
Trizivir
Truvada
HIV Lipodystrophy
Egrifta* (NF)
Immune Globulin
Carimune NF (M)*
CytoGam (M)*
Flebogamma DIF (M)*
Gamastan S/D (M)*
Gammagard (M)*
Gammaplex (M)*
Gamunex (M)*
Gamunex-C (M)*
Hizentra*
Hyperrho S/D (M)*
Nabi-HB (M)*
Octagam (M)*
Privigen (M)*
RhoGAM Plus (M)
Rhophylac (M)
WinRho SDF (M)
Infertility
Bravelle*
Cetrotide*
chorionic gonadotropin*
Delestrogen*
Follistim AQ*
ganirelix*
Gonal-F*
Lupron subQ*
Luveris*
Menopur*
Novarel*
Ovidrel*
Pregnyl*
progesterone in oil*
Repronex*
Key
(M) Medical Benet
* Requires Preauthorization
Bolded items are preferred agents
(NF) Non-Formulary drugs
Lung Disorders
Actimmune*
Aralast (M)*(NF)
Aralast NP (M)*(NF)
Glassia (M)*(NF)
Prolastin C (M)*(NF)
Synagis (M)*
Xolair (M)*
Zemaira (M)*(NF)
Multiple Sclerosis
Ampyra* (NF)
Avonex*
Betaseron*
Copaxone*
Extavia*
Gilenya*
Rebif*
Tysabri (M)*
Oncology
Abraxane (M)
Adcetris (M)
Adriamycin (M)
Adrucil (M)
Afinitor*
Alferon N (M)*
Alimta (M)
Alkeran (M)
Ara-C (M)
Arranon (M)
Arzerra (M)
Avastin (M)*
Bexxar (M)
BiCNU (M)
Blenoxane (M)
Busulfex (M)
calcium folinate (M)
Campath (M)
Camptosar (M)
CARBOplatin (M)
Cerubidine (M)
cisplatin (M)
Clolar (M)
Cosmegen (M)
Cytoxan (M)
Dacogen (M)
Daunoxome (M)
DepoCyt (M)
Doxil (M)
DTIC-Dome (M)
Efudex (M)
Eligard (M)*
Elitek (M)*
Ellence (M)
Eloxatin (M)
Elspar (M)
Erbitux (M)*
Erivedge*
Erwinaze (M)
Etopophos (M)
Faslodex (M)
Firmagon (M)
Fludara injectable (M)
Fludara oral*
Folotyn (M)
FUDR (M)
Fusilev (M)
Gemzar (M)
Gleevec*
ph-memspeclist-0713
Halaven (M)
Herceptin (M)*
Hycamtin (M)
Idamycin PFS (M)
Ifex (M)
Inlyta*
Intron A (M)
Istodax (M)
Ixempra (M)
Jakafi*
Jevtana (M)
Kepivance (M)
Leustatin (M)
Mekinist* (NF)
methotrexate (M)
Mitomycin (M)
Mozobil (M)*
Mustargen (M)
Mylotarg (M)
Navelbine (M)
Nexavar*
Nipent (M)
Oncaspar (M)
Ontak (M)
Onxol (M)
Orthoclone OKT 3 (M)
Paraplatin (M)
Perjeta (M)*
Platinol-AQ (M)
Proleukin (M)
Provenge (M)*(NF)
Revlimid*
Rituxan (M)*
Sprycel*
Sutent*
Tafinlar* (NF)
Tarceva*
Targretin*
Tasigna*
Taxol (M)
Taxotere (M)
Temodar*
Tespa (M)
Thalomid*
Thioplex (M)
Torisel (M)
Treanda (M)
Trelstar Depot (M)*
Trisenox (M)
Tykerb*
Valstar (M)
Vectibix (M)*
Velban (M)
Velcade (M)
VePesid (M)
Vidaza (M)
Vincasar (M)
Votrient*
Vumon (M)
Xalkori*
Xeloda*
Yervoy (M)
Zanosar (M)
Zelboraf*
Zevalin (M)
Zoladex (M)*
Zolinza*
Zostress*
Zytiga*
Oncology Adjuvant
amifostine (M)
Duraclon (M)
Ethyol (M)
Ganite (M)
Kepivance (M)
pamidronate (M)
Other
Acthar HP*(NF)
Adagen (M)*
Apokyn*
chenodiol*
Exjade*
Ferriprox*
Jetrea (M)*(NF)
Korlym*
Krystexxa (M)*
Lupron Depot (M)*
Novantrone (M)
octreotide*
Procysbi* (NF)
Rilutek
Sabril*
Samsca*
Sandostatin*
Sandostatin LAR depot (M)*
Sensipar*
Sirturo* (NF)
Soliris (M)*
Somatuline Depot (M)*
Somavert* (NF)
Supprelin LA (M)*(NF)
Vantas (M)
Vivitrol (M)
voriconazole*
Xenazine* (NF)
Xiaflex (M)*(NF)
Xyrem* (NF)
Pregnancy Support
Makena* (NF)
Pulmonary Hypertension
Adcirca*
epoprostenol sodium (M)*
Flolan (M)*
Letairis*
Remodulin (M)*
sildenafil*
Tracleer*
Tyvaso*
Veletri (M)*
Ventavis*
Viscosupplementation
Euflexxa (M)
Hyalgan (M)
OrthoVisc (M)
Supartz (M)
Synvisc (M)
Synvisc One (NF)
INDEX
#
5-AMINOSALICYLIC ACID .........................................................12
8-MOP .............................................................................................28
A
acarbose (Precose) .......................................................................18
ACCU-CHEK ACTIVE TEST STRIPS ........................................19
ACCU-CHEK AVIVA METER .......................................................18
ACCU-CHEK AVIVA PLUS TESTS STRIPS .............................18
ACCU-CHEK COMFORT CURVE TEST STRIPS ....................18
ACCU-CHEK COMPACT PLUS METER ...................................18
ACCU-CHEK COMPACT TEST STRIPS ...................................18
ACCU-CHEK NANO METER .......................................................18
ACCU-CHEK SMART VIEW TEST STRIPS ..............................18
acebutolol (Sectral) ........................................................................14
acetaminophen (Ultracet) ............................................................23
acetaminophen/codeine ................................................................22
acetaminophen/isometheptene/dichloralphenazone (Midrin) .22
acetazolamide (Diamox) ...............................................................16
acetazolamide ER (Diamox Sequels) .........................................16
acetic acid ear solution..................................................................25
acyclovir (Zovirax)...........................................................................7
ADVAIR...........................................................................................24
ADVICOR........................................................................................15
ainocycline (Minocin) .......................................................................7
albuterol...........................................................................................24
albuterol inhaler solution ...............................................................24
albuterol syrup, tablets ..................................................................24
alclometasone (Aclovate) .............................................................28
alendronate tablets (Fosamax) ....................................................19
alfuzosin (Uroxatral) .....................................................................13
ALKERAN ........................................................................................9
allopurinol (Zyloprim) .....................................................................22
ALOMIDE........................................................................................26
ALORA ............................................................................................19
ALPHAGAN P ................................................................................26
alprazolam (Xanax)..........................................................................9
amantadine (Symmetrel)...............................................................21
amiloride (Midamor).......................................................................16
amiloride/hydrochlorothiazide (Moduretic) ................................16
amiodarone (Cordarone, Pacerone) .........................................16
amitriptyline .......................................................................................9
amlodipine (Norvasc) ....................................................................15
amlodipine/benazepril (Lotrel) ......................................................15
amoxicillin (Amoxil).........................................................................7
amoxicillin/potassium clavulanate (Augmentin) ...........................7
amoxicillin/potassium clavulanate ER (Augmentin XR)..............7
amphetamine/detroamphetamine (Adderall)..............................10
AMTURNIDE ..................................................................................17
B
baclofen (Lioresal) ......................................................................... 20
balsalazide (Colazal) ..................................................................... 12
BANZEL ......................................................................................... 21
benazepril (Lotensin)..................................................................... 14
benazepril/hydrochlorothiazide (Lotensin HCT) ........................ 14
BENICAR ....................................................................................... 14
benztropine (Cogentin) ................................................................. 21
betamethasone dipropionate (Diprosone).................................. 28
betamethasone dipropionate, augmented (Diprolene) ............. 28
betamethasone valerate cream, lotion ....................................... 28
BETASERON ................................................................................. 20
BETOPTIC-S.................................................................................. 26
bicalutamide (Casodex) .................................................................. 9
bisoprolol (Zebeta)......................................................................... 15
bisoprolol/hydrochlorothiazide (Ziac) .......................................... 15
BLEPHAMIDE S.O.P.................................................................... 27
brimonidine eye solution, 0.2%.................................................... 26
bromocriptine (Parlodel) ............................................................... 21
budesonide ER (Entocort EC) ..................................................... 17
budesonide ER (Pulmicort Respules) ......................................... 24
bumetanide (Bumex) ..................................................................... 16
38
C
cabergoline (Dostinex) ..................................................................19
calcipotriene solution (Dovonex) ..................................................28
calcitonin-salmon (Miacalcin) .......................................................19
calcitriol (Rocaltrol) ........................................................................19
CANASA .........................................................................................12
captopril (Capoten) ........................................................................14
captopril/hydrochlorothiazide (Capozide) ...................................14
CARAFATE SUSPENSION .........................................................12
carbamazepine (Tegretol).............................................................21
carbamazepine ER (Carbatrol, Tegretol-XR) .............................21
CARBATROL .................................................................................21
carbidopa/levodopa (Parcopa, Sinemet) ....................................21
carbidopa/levodopa ER (Sinemet CR) ........................................21
CARDURA XL ................................................................................13
carteolol eye solution (Ocupress) ................................................26
carvedilol (Coreg)...........................................................................15
CAVERJECT ..................................................................................16
CEENU ..............................................................................................9
cefdinir (Omnicef) ..........................................................................6
cefpodoxime (Vantin)....................................................................6
cefprozil (Cefzil) .............................................................................6
cefuroxime (Ceftin) ........................................................................6
CELLCEPT .....................................................................................20
CHANTIX ........................................................................................10
chlorhexidine oral rinse (Peridex) ................................................27
chloroquine phosphate (Aralen) ....................................................8
chlorpromazine (Thorazaine) .......................................................11
chlorthalidone 25 mg, 50 mg (Thalitone) ....................................16
chlorzoxazone (Parafon) ..............................................................20
cholestyramine (Questran, Questran Light) ...............................15
CIALIS .............................................................................................16
ciclopirox gel, shampoo (Loprox) .................................................28
cilostazol (Pletal) ..............................................................................8
cimetidine (cimetidine) ..................................................................12
CIPRO SUSPENSION ....................................................................6
ciprofloxacin (Cipro) .....................................................................6
citalopram (Celexa)........................................................................10
clarithromycin (Biaxin) .................................................................6
clarithromycin ER (Biaxin XL) ....................................................6
CLEOCIN ........................................................................................13
D
danazol (Danocrine) ...................................................................... 19
dantrolene (Dantrium) ................................................................... 21
DELZICOL ...................................................................................... 12
DEPAKENE ................................................................................... 21
DEPAKOTE ................................................................................... 21
DEPAKOTE SPRINKLES ............................................................ 21
desipramine (Norpramin) .............................................................. 10
desmopressin (DDVAP)................................................................ 19
desonide (Desowen) ..................................................................... 28
desoximetasone cream, 0.25%; gel; ointment 0.25% (Topicort)
.................................................................................................... 28
DEXAMETHASONE INTENSOL ................................................ 17
dextroamphetamine....................................................................... 10
dextroamphetamine ER (Dexedrine Spansule) ......................... 10
diclofenac eye solution (Voltaren) ............................................... 26
diclofenac potassium..................................................................... 23
diclofenac sodium DR (Voltaren) ............................................... 23
diclofenac sodium ER ................................................................... 23
dicloxacillin (Dicloxacillin)............................................................. 7
dicyclomine (Bentyl) ...................................................................... 12
didanosine DR (Videc EC) ............................................................. 7
diflorasone ointment ...................................................................... 28
digoxin (Lanoxin) ........................................................................... 17
DILANTIN ....................................................................................... 21
39
DILATRATE SR .............................................................................15
DILAUDID-5 ...................................................................................23
diltiazem ER....................................................................................15
diltizaem (Cardizem)......................................................................15
DIOVAN ..........................................................................................14
DIOVAN HCT .................................................................................14
DIPENTUM .....................................................................................12
diphenoxylate/atropine tablets (Lomotil) .....................................12
dipyridamole (Persantine) ...............................................................8
disopyramide (Norpace)................................................................16
disulfiram (Antabuse) ....................................................................10
divalproex DR (Depakote Sprinkles, Depakote) ........................21
divalproex ER (Depakote ER) ......................................................21
donepezil (Aricept, Aricept ODT) .................................................10
dorzolamide eye solution (Trusopt) .............................................26
dorzolamide/timolol maleate eye solution (Cosopt) ..................26
doxazosin (Cardura) ......................................................................17
doxepin (Sinequan) ......................................................................10
doxycycline hyclate (Vibramycin) .................................................7
DROXIA ............................................................................................8
DUETACT .......................................................................................18
E
E.E.S. GRANULES .........................................................................6
econazole (Spectazole) ................................................................28
EDEX ...............................................................................................16
ELIXOPHYLLIN .............................................................................24
EMCYT ..............................................................................................9
EMEND ...........................................................................................12
EMSAM ...........................................................................................10
EMTRIVA ..........................................................................................7
enalapril (Vasotec) .........................................................................14
enalapril/hydrochlorothiazide (Vaseretic) ...................................14
ENBREL ............................................................................................8
ENDOMETRIN ...............................................................................13
enoxaparin (Lovenox)......................................................................8
EPIPEN ...........................................................................................24
EPIPEN-JR 2-PAK ........................................................................24
EPIVIR HBV .....................................................................................6
eplerenone (Inspra) .......................................................................17
EPZICOM ..........................................................................................7
EQUETRO ......................................................................................11
erythromycin eye ointment ...........................................................25
erythromycin gel, pads, solution ..................................................27
erythromycin/sulfisoxazole (Pediazole) ...................................6
escitalopram (Lexapro) .................................................................10
estazolam (Prosom) ......................................................................11
ESTRACE .......................................................................................14
estradiol (Climara, Estrace) ..........................................................19
estradiol/norethindrone acetate (Activella) ...............................19
ESTRING ........................................................................................14
estropiopate (Ogen, Ortho-Est)....................................................19
F
famciclovir (Famvir) ......................................................................... 7
famotidine (Pepcid) ....................................................................... 13
FARESTON ...................................................................................... 9
FAZACLO....................................................................................... 11
FELBATOL .................................................................................... 21
felodipine ER (Plendil) .................................................................. 15
FEMHRT LOW DOSE .................................................................. 19
fenofibrate, micronized (Liofibra) ................................................. 16
fentanyl oral lozenge (Actiq) ....................................................... 23
fentanyl patch (Duragesic) .......................................................... 23
finasteride (Proscar) ................................................................... 13
FLAREX .......................................................................................... 27
flecainide (Tambocor) ................................................................... 16
FLOVENT ....................................................................................... 24
fluconazole (Diflucan) .................................................................. 6
flucytosine (Ancoban) .................................................................. 6
fludrocortisones (Florinef)............................................................. 17
fluocinonide .................................................................................... 28
fluorometholone eye suspenion, 0.1% (FML Liquifilm) ............ 27
FLUOROQUINOLONES ................................................................. 6
fluorouracil (Efudex) ...................................................................... 28
fluoxetine (Prozac)......................................................................... 10
fluphenazine hcl tablets (Prolixin)................................................ 11
flurbiprofen eye solution (Ocufen) ............................................... 26
flutamide (Eulexin) ........................................................................... 9
fluticasone propionate (Cutivate)................................................. 28
FML FORTE ................................................................................... 27
folic acid tablets, 1 mg .................................................................... 8
FOLLISTIM AQ .............................................................................. 19
FORADIL AEROLIZER ................................................................ 24
fosinopril (Monopril) ....................................................................... 14
FRAGMIN ......................................................................................... 8
FREESTYLE FREEDOM LITE BLOOD GLUCOSE SYSTEM 19
FREESTYLE INSULINX BLOOD GLUCOSE SYST ............... 19
FREESTYLE INSULINX TEST STRIPS..................................... 19
FREESTYLE LITE BLOOD GLUCOSE MONITORING
SYSTEM .................................................................................... 19
FREESTYLE LITE TEST STRIPS .............................................. 19
furosemide (Lasix) ......................................................................... 16
40
G
gabapentin (Neurontin) .................................................................21
GABITRIL .......................................................................................22
galantamine (Razadyne) ...............................................................11
galantamine ER (Razadyne ER)..................................................11
GALZIN ...........................................................................................25
gemfibrozil (Lopid) ........................................................................16
gentamicin eye ointment, solution (Garamycin) ........................26
glimepiride (Amaryl).......................................................................18
glipizde (Glucotrol) .........................................................................18
glipizde ER (Glucotrol XL) ............................................................18
GLUCAGEN ...................................................................................18
GLUCAGON EMERGENCY KIT .................................................18
glyburide (Micronase) ....................................................................18
glyburide micronized (Glynase) ...................................................18
glyburide/metformin (Glucovance)...............................................18
granisetron (Kytril) .........................................................................12
GRIFULVIN V ...................................................................................6
griseofulvin microsize (Fulvicin, Grisfulvin) ...........................6
GRIS-PEG ........................................................................................6
guanfacine (Tenex) ........................................................................17
J
JALYN ............................................................................................ 13
H
halobetasolution (Ultravate) .........................................................28
haloperidol (Haldol)........................................................................11
HEXALEN .........................................................................................9
hlycopyrrolate (Robinul) ................................................................13
homatropine eye solution (Isopto Homatropine) .......................26
HUMALOG .....................................................................................18
HUMIRA ............................................................................................8
HUMULIN........................................................................................18
hydralazine (Apresolutionine).......................................................17
hydrcortisone valerate (Westcort)................................................28
hydrochlorothiazide (Microzide, Hydrodiuril) ..........................16
hydrocodone/acetaminophen (Vicodin, Lorcet, Lortab,
Norco) ........................................................................................23
hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen) ..23
hydrocortisone (Cortef) ................................................................17
hydrocortisone acetate ..................................................................25
hydrocortisone enema (Cortenema) ...........................................25
hydrocortisone topical ...................................................................28
hydrocortisone/acetic acid ear solution.......................................25
hydromorphone tablets .................................................................23
hydroxychloroquine..........................................................................8
hydroxyurea (Hydrea)......................................................................9
hydroxyzine (Atarax, Vistaril) .......................................................10
hyoscyamine (Anaspaz, Levsin/SL) ............................................13
hyoscyamine ER (Levbid, Symax Duotab) .................................13
I
ibandronate oral (Boniva) .............................................................19
K
KALETRA......................................................................................... 7
ketoconazole (Nizoral) .................................................................. 28
ketoconazole tablets (Nizoral) .................................................... 6
ketoprofen (Oruvail) ..................................................................... 23
ketorolac eye solution (Acular, Acular LS) ................................. 27
KLONOPIN ................................................................................. 22
L
labetalol (Trandate) ....................................................................... 15
lactulose (Enulose) ....................................................................... 12
LAMICTAL ..................................................................................... 22
LAMICTAL XR ............................................................................... 22
lamivudine (Epivir) ........................................................................... 7
lamivudine/zidovudine (Combivir) ................................................ 8
lamotrigine (Lamictal).................................................................... 22
LANOXIN ........................................................................................ 17
lansoprazole DR ............................................................................ 13
lantanoprost eye solution (Xalatan) ............................................ 26
LANTUS ......................................................................................... 18
LANTUS SOLOSTAR .................................................................. 18
LASTACAFT alcaftadine ........................................................ 27
LATUDAlurasidone ................................................................. 11
leflunomide (Arava)....................................................................... 23
letrozole (Femara) ........................................................................... 9
leucovorin calcium tablets .............................................................. 9
LEUKERAN ..................................................................................... 9
levetiracetam (Keppra) ................................................................. 22
41
M
MACRODANTIN ............................................................................13
MATULANE......................................................................................9
MAXAIR AUTOHALER ................................................................24
meclizine (Antivert) .......................................................................12
medroxyprogesterone acetate (Provera) ...................................20
mefloquine (Larium)........................................................................8
megestrol (Megace).........................................................................9
meloxicam (Mobic) ........................................................................23
MENEST .........................................................................................19
MENOSTAR ...................................................................................19
MEPHYTON ...................................................................................25
MEPRONatovaquone suspension .........................................6
mercaptopurine (Purinethol) ...........................................................9
mesalamine (Asacol) .....................................................................12
mesalamine powder (5-aminosalicylic acid) .........................12
MESNEX ...........................................................................................9
MESTINON .....................................................................................21
MESTINON TIMESPAN ...............................................................21
METADATE CD .............................................................................10
metaxalone (Skelaxin) ...................................................................21
metformin (Glucophage) ...............................................................18
metformin ER (Glucophage XR) ..................................................18
methadone solution .......................................................................23
methadone tablets .........................................................................23
methazolamide (Neprazane) ........................................................16
methimazole (Tapaxzole) .............................................................20
N
nadolol (Corgard) ........................................................................... 15
NALFON ......................................................................................... 23
naltrexone (ReVia)......................................................................... 11
NAMENDA ..................................................................................... 11
naproxen (Naprosyn) ................................................................... 23
naproxen DR (EC-Naprosyn) ..................................................... 23
naproxen sodium (Anaprox) ....................................................... 23
naratriptan (Amerge) ..................................................................... 22
NASCOBAL ................................................................................... 25
nateglinide (Starlix)........................................................................ 18
neomycin/polymyxin B/bacitracin/hydrocortisone eye ointment
.................................................................................................... 27
neomycin/polymyxin B/dexamethasone eye ointment,
suspenion (Maxitrolo) .............................................................. 27
neomycin/polymyxin B/gramicidin eye solution (Neosporin) ... 26
neomycin/polymyxin B/hydrocortisone ear solution, suspension
(Cortisporin) .............................................................................. 25
42
O
ofloxacin ear solution (Floxin otic) ...............................................25
ofloxacin eye solution (Ocuflox) ...................................................26
triamcinolone cream; lotion...........................................................28
olanzapine (Zyprexa, Zyprexa Zydis)..........................................11
omeprazole DR (Prilosec).............................................................13
ondansetron (Zofran, Zofran ODT) ..............................................12
OPANA ER .....................................................................................23
ORACIT...........................................................................................13
oral contraceptives......................................................................17
orphenadrine citrate ER (Norflex) ................................................21
orphenadrine/aspirin/caffeine (Norgesic)....................................21
oxaprozin (Daypro) .......................................................................23
oxcarbazepine (Trileptal) ..............................................................22
OXSORALEN ULTR .....................................................................28
oxybutynin (Ditropan) ....................................................................13
oxybutynin ER (Ditropan XL) ......................................................13
oxycodone (Roxicodone) ............................................................23
oxycodone/acetaminophen...........................................................23
oxycodone/aspirin (Percodan) .....................................................23
P
pantoprazole DR (Protonix) ..........................................................13
paroxetine hcl (Paxil) .....................................................................10
paroxetine hcl ER (Paxil CR) .......................................................10
PAXIL ..............................................................................................10
PEG INTRON ...................................................................................7
PEGASYS......................................................................................... 7
penicillin v potassium (Veetids) .................................................... 7
PENTASA....................................................................................... 12
pentoxifylline ER (Trental) .............................................................. 9
perindopril (Aceon) ........................................................................ 14
permethrin....................................................................................... 28
perphenazine (Trilafon)................................................................. 11
phenelzine (Nardil) ....................................................................... 10
phenobarbital ................................................................................. 11
phenytoin sodium ER (Dilantin, Phenytek) ................................ 22
phenytoin suspenion (Dilantin) .................................................... 22
PHOSPHOLINE IODIDE .............................................................. 27
PHRENILIN FORTE ...................................................................... 23
pilocarpine (Salagen) .................................................................... 27
pilocarpine eye solution, 1%, 2%, 4% (Isopto Carpine) ........... 26
PILOPINE HS ................................................................................ 27
pioglitazone (Actos)...................................................................... 18
pioglitazone-metformin (Actoplus met) ..................................... 18
pioglitazone-metformin SR ........................................................... 18
piroxicam (Feldene) ...................................................................... 23
podofilox (Condylox) ..................................................................... 28
polymyxin B/trimethoprim eye solution (Polytrim) ..................... 26
POTABA ......................................................................................... 21
potassium chloride ER .................................................................. 25
potassium citrate ER (Urocit-K) ............................................... 13
potassium citrate/citric acid .......................................................... 13
potassium citrate/citric acid (Polycitra-K) ................................... 13
POTASSIUM P-AMINOBENZOATE .......................................... 21
potassium phosphate/sodium phosphates (K-Phos Neutral) .. 25
pramipexole (Mirapex) .................................................................. 21
pravastatin (Pravachol) ................................................................. 16
prazosin (Minipress) ...................................................................... 17
PRECISION XTRA BLOOD GLUCOSE SYSTEM ................... 19
PRED MILD .................................................................................... 27
PRED-G .......................................................................................... 27
PRED-G S.O.P. ............................................................................. 27
prednisolone (Prelone)................................................................. 17
prednisolutionone acetate eye suspenion (Pred Forte) ........... 27
prednisolutionone sodium phosphate (Orapred, Pediapred) .. 17
PREDNISONE INTENSOL .......................................................... 17
prednisone tablets ......................................................................... 17
prenatal vitamin/folic acid - all generics...................................... 25
primaquine ........................................................................................ 8
primidone (Mysolutionine) ............................................................ 22
probenecid (Benemid)................................................................... 22
prochlorperazine (Compazine) .................................................... 11
progesterone micronized (Prometrium) .................................... 20
PROGRAF ...................................................................................... 20
PROMACTA ..................................................................................... 9
propafenone (Rythmol) ................................................................. 16
propafenone ER (Rythmol SR) .................................................... 17
propranolol ER (Inderal LA) ......................................................... 15
propranolol tablets (Inderal) ......................................................... 15
43
propylthiouracil ...............................................................................19
PULMICORT FLEXHALER .........................................................24
pyrazinamide ....................................................................................7
pyridostigmine (Mestinon).............................................................21
Q
quetiapine (Seroquel) ....................................................................11
quinapril (Accupril) .........................................................................14
quinapril/hydrochlorothiazide (Accuretic)....................................14
quinidine gluconate ER (Quinaglute) ..........................................17
quinidine sulfate (Quinidex).........................................................17
QVAR ..............................................................................................24
R
ramipril (Altace) ..............................................................................14
ranitidine (Zantac) ..........................................................................13
RAPAMUNE ...................................................................................20
RECLAST .......................................................................................19
RELISTOR ......................................................................................12
REMICADE .......................................................................................8
REQUIP XL ....................................................................................21
RESCRIPTOR ..................................................................................8
REYATAZ .........................................................................................8
RIDAURA........................................................................................23
rifampin (Rifadin) ..............................................................................7
risperidone (Risperdal, Risperdal-M tablets)..............................11
ropinirole (Requip) .........................................................................21
S
salsalate (Disalcid) .......................................................................23
SANCUSO ......................................................................................12
SANDIMMUNE...............................................................................20
SARAFEM ......................................................................................11
selegiline (Eldepryl) .......................................................................21
selenium sulfide (Selsun)..............................................................29
SELZENTRY ....................................................................................8
SEREVENT DISKUS ....................................................................24
SEROQUEL XR .............................................................................11
sertraline (Zoloft) ............................................................................10
SFROWASA ...................................................................................12
silver sulfadiazine (Silvadene)......................................................28
SIMCOR ..........................................................................................16
simvastatin (Zocor) ........................................................................16
sodium citrate/citric acid................................................................13
sodium citrate/citric acid (Shohls) ..........................................13
sodium fluoride ...............................................................................25
sodium fluoride (Prevident)...........................................................27
sodium polystyrene sulfonate.......................................................20
SORIATANE ..................................................................................29
sotalol (Betapace, Betapace AF) .................................................17
SPIRIVA ..........................................................................................24
T
TABLOID .......................................................................................... 9
tacrolimus (Prograf) ....................................................................... 20
tamoxifen (Nolvadex) ...................................................................... 9
tamsulosin (Flomax) ...................................................................... 13
TARGRETIN .................................................................................... 9
TEGRETOL .................................................................................... 22
TEGRETOL-XR ............................................................................. 22
TEKAMLO ...................................................................................... 17
TEKTURNA .................................................................................... 17
TEKTURNA HCT........................................................................... 17
temazepam (Restoril).................................................................... 11
terazosin (Hytrin) ........................................................................... 17
terbinafine (Lamisil) ...................................................................... 6
terbutaline (Brethine)..................................................................... 24
terconazole (Terazol) .................................................................... 14
TEV TROPIN .................................................................................. 20
THALITONE ................................................................................... 16
THEO-24 ......................................................................................... 24
theophylline ER (Theo-Dur) ......................................................... 24
thiothixene (Navane) ..................................................................... 11
THYROLAR ................................................................................... 20
timolol maleate eye solution (Timoptic, Timoptic XE) ............... 26
TIMOPTIC OCUDOSE.................................................................. 26
TINDAMAX....................................................................................... 6
tizanidine (Zanaflex) ...................................................................... 21
TOBRADEX ................................................................................... 27
TOBRADEX ST ............................................................................. 27
tobramycin eye solution (Tobrex) ................................................ 26
tobramycin/dexamethasone eye suspenion (Tobradex) .......... 27
TOBREX ......................................................................................... 26
TOPAMAX ...................................................................................... 22
44
U
ULORIC...........................................................................................22
UROCIT-K 15 .............................................................................13
urosdiol (Actigall, Urso 250, Urso Forte) ....................................12
V
valacyclovir (Valtrex) ......................................................................7
valproic acide (Depakene) ............................................................22
vancomycin (Vancocin)................................................................7
venlafaxine (Effexor)......................................................................10
W
warfarin (Coumadin)........................................................................ 9
WELCHOL ..................................................................................... 16
Z
zafirlukast (Accolate ..................................................................... 24
zaleplon (Sonata) .......................................................................... 11
ZARONTIN ..................................................................................... 22
ZENPEP.......................................................................................... 12
ZIAGEN............................................................................................. 8
zidovudine (Retrovir) ....................................................................... 8
ziprasidone (Geodon) ................................................................... 11
zolpidem (Ambien)......................................................................... 11
zolpidem ER(Ambien CR) ............................................................ 11
ZONEGRAN ................................................................................... 22
zonisamide (Zonegran) ................................................................. 22
ZYMAXID gatifloxacin............................................................. 26
45