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2014 Prescription Drug List
UnitedHealthcare & Affiliated Companies
1
Table of Contents
2014 Prescription Drug List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-5
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Prescription Drug List Medication Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Tier Designations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Over-the-Counter and Therapeutically Equivalent Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Keys to Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Generic Medication Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Specialty Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Medications Requiring Notification and Other Pharmacy Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
How to Obtain Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Chapters
1 . Anti-Infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2 . Antineoplastic & Immunosuppressant Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3 . Autonomic & CNS Drugs, Neurology & Psych . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
4 . Cardiovascular, Hypertension & Lipids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
5 . Dermatologicals/Topical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
6 . Ear, Nose & Throat Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
7 . Endocrine/Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
8 . Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
9 . Immunology, Vaccines & Biotechnology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
10 . Musculoskeletal & Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
11 . Obstetrics & Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
12 . Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
13 . Respiratory, Allergy, Cough & Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
14 . Urologicals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
15 . Vitamins, Hematinics & Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
16 . Diagnostics & Miscellaneous Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Brand Only Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
November 2013
3
IntroductionThe UnitedHealthcare Prescription Drug List (PDL)1 provides a list of medications in various therapeutic classes for use in meeting the prescription medication needs of your patients who are our members . This list is intended for use with UnitedHealthcare health plans and affiliated companies’ pharmacy benefit plan designs . The PDL applies only to prescription medications dispensed to outpatients and does not include inpatient medications or medications obtained or administered in a physician’s office . The PDL does not define benefit coverage . Benefit coverage is determined by the member’s pharmacy benefit plan .2 This means that there may be medications listed on the PDL that are not covered under a particular member’s pharmacy benefit plan .
You may also access PDL information by visiting our website at UnitedHealthcareOnline.com .
Prescription Drug List Medication OverviewTier decisions are made by our PDL Management Committee based on clinical, economic, and other factors . The PDL Management Committee is comprised of senior UnitedHealth Group physician and business leaders . The UnitedHealth Group National Pharmacy & Therapeutics (P&T) Committee, comprised of physicians and pharmacists, reviews new and existing medications and provides clinical guidance to the PDL Management Committee . Guidance is based on similarities and differences compared with other medications that treat the same disease or condition .
The tier placement of a medication on the PDL may change . While medications change tiers infrequently, such changes generally occur two times per calendar year . Additionally, when a brand-name medication becomes available as a generic, the tier status of the brand-name medication and its corresponding generic will be evaluated . When a medication changes tiers, your patient may be required to pay more or less for that medication . These changes may occur without prior notice to you or your patient . However, you may visit our website at UnitedHealthcareOnline.com for the most up-to-date information for a particular medication . And your patient can find the most up-to-date tier status and cost* information for a particular medication by visiting our member website at myuhc .com® and/or calling the toll-free member phone number located on his or her health care ID card .
Tier DesignationsPrescription medications are categorized within three tiers on the PDL .3 Each tier is assigned a cost,* which is determined by the member’s pharmacy benefit plan . You may refer to the PDL as a guide to select the most appropriate medication with the lowest member cost for your patients .
Tier 1 Tier 1 medications are your patient’s lowest-cost option . Members can maximize their cost savings when you prescribe Tier 1 medications, if you decide they are appropriate for your patient’s treatment .
Tier 2 Tier 2 medications are your patient’s midrange-cost option . Consider Tier 2 medications if no Tier 1 medication is appropriate to treat your patient’s condition .
Tier 3 Tier 3 medications are your patient’s highest-cost option . If your patient is currently taking a medication in Tier 3, you may want to determine if there is an appropriate alternative in Tier 1 or Tier 2 .
You and your patient make decisions about health care and medication treatments .
Note: If the member has a “closed” pharmacy benefit (a two-tier pharmacy benefit plan that does not cover medications classified in Tier 3 of this PDL), medications in Tier 3 are generally not covered, except under certain processes consistent with applicable law . Compounded medications, those medications containing one or more ingredients that are prepared onsite by a pharmacist, are classified at the Tier 3 level, provided that the individual ingredients used in compounding are covered under the pharmacy benefit .
Note: Some members have a four-tier prescription plan and these are noted as T4 throughout the document . Members with a four-tier prescription plan should refer to their enrollment materials, check the Medication Pricing / Coverage information on our member website or call the toll-free member phone number provided on their health care ID card for more information about their benefit plan .
Note: Not all medications are represented in this PDL . Only the most commonly prescribed medications are included .
2014 Prescription Drug List
* UnitedHealthcare operates a wide number of benefit programs and products, and some benefit programs may have alternative benefit designs . Physicians should always check the member’s specific benefit prior to prescribing medications .
Tier 1 Tier 2 Tier 3Your patient’s Your patient’s Your patient’slowest-cost midrange-cost highest-costmedications medications medications
4
Over-the-Counter and Therapeutically Equivalent MedicationsFor some conditions, you and your patient may decide that an over-the-counter (OTC) medication is the most appropriate treatment . According to UnitedHealthcare benefit design, OTC medications are defined as medications that do not require a prescription by federal or state law to be dispensed . In some instances, OTC medications are listed on the PDL for reference purposes only . OTC medications may cost less than the member’s out-of-pocket expense for prescription medications .
Therapeutically equivalent means that medications can be expected to produce essentially the same therapeutic outcome and toxicity or adverse event .
If the patient or physician requests a therapeutically equivalent product or an OTC product, the patient may be required to pay the entire cost of the product as they may not be covered under the member’s pharmacy benefit . Please refer to the member’s pharmacy benefit plan .
Keys To Symbols
Generic Medication Policy While there are exceptions, generic medications are generally included on the PDL in Tier 1 . If a generic medication does not offer significant financial savings over the brand, it may be placed in the same tier as the brand or in a higher tier . Medications with a generic equivalent are noted in the PDL with a + symbol . If you decide that it is appropriate, consider prescribing generic medications when available in Tier 1 .
Note that when a brand-name medication becomes available as a generic, that brand-name product may move to a higher tier . Members may be required to pay more for a prescription when a higher-tier brand-name product is dispensed . The member’s payment is determined by the pharmacy benefit plan . When generic substitution conflicts with state regulations or restrictions, the pharmacist must obtain approval from the prescribing physician or other health care professional to substitute the generic equivalent .
Specialty MedicationsSome members may have coverage for self-administered injectable and oral specialty medications through their pharmacy benefit plan . You will find these medications included in the body of this document within the appropriate therapeutic categories . UnitedHealthcare has developed a Specialty Pharmacy Program including requiring the majority of specialty medications be obtained through a designated specialty pharmacy . These medications are noted by DSP throughout the document . The specialty pharmacy program includes specialty pharmacies, each selected based on their clinical expertise for the targeted therapeutic classes, quality of services and cost . Their pharmacists are trained to help educate members and create personalized plans, if needed, for these specialty medications, which may help improve treatment adherence .
Participating members should be instructed to call the toll-free member number on the back of their ID card where a representative will answer questions about our program and then transfer them to a specialty pharmacy based on their particular specialty medication prescription .
* UnitedHealthcare operates a wide number of benefit programs and products, and some benefit programs may have alternative benefit designs . Physicians should always check the member’s specific benefit prior to prescribing medications .
Symbols
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverageMC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated PharmacySL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications .
5
Medications Requiring Notification and Other Pharmacy Programs Selected medications may require notification (or prior authorization) and review to be eligible for coverage under the member’s pharmacy benefit plan . Such medications have a notation “N” (for notification) in this booklet . The pharmacy benefit may exclude coverage of medications for certain uses .
The medications requiring notification/prior authorization are noted throughout the document with an “N” notation and the clinical criteria are available on our website at UnitedHealthcareOnline.com . The criteria reflect UnitedHealth Group National Pharmacy and Therapeutics Committee decisions . For a member to receive benefit coverage for a medication requiring notification, the physician or the physician’s designee must provide information to the call center .
Some benefit plans may include our Step Therapy program . Step Therapy offers a “stepwise” approach to therapy for certain high-cost medications and requires that a member first try a more cost-effective medication before another high-cost medication . Such medications have a notation “ST” (for Step Therapy) .
Supply limits define the maximum supply of medication per copayment or period of time . Supply limits are based on several factors that may include FDA-approved dosing guidelines as defined in the product package insert, medical literature, guidelines or supportive data . Such medications have a notation “SL” (for supply limit) .
The Refill and Save Program (also known as Adherence Incentive) encourages members to adhere to their treatment regimen by rewarding them with a discount on their copayment/coinsurance for refilling their prescription within the defined time period . Eligible medications have an “RS” notation (RS for Refill and Save) .
Some medications can safely be split in half offering our members a cost-saving opportunity . The physician provides a prescription for twice the strength and half the quantity and the member cuts each tablet in half with a tablet splitter . Eligible medications have a “1/2T” notation in this booklet . Not all patients are appropriate for tablet splitting, and the physician must agree to the patient’s participation in this voluntary program .
To receive pharmacy benefit coverage on some medications, a member is required to fill their prescription through a designated Mail Order Pharmacy or stay at retail with a lower-tier alternative . Such medications have an “SDP” notation in this booklet .
How to Obtain Authorization?The Online Prior Authorization tool (available through UnitedHealthCareOnline .com) is easy to use . The majority of online prior authorizations are approved in real time, and an auto-population feature provides 95 percent of a member’s information . The OptumRx Prior Authorization team is also available by phone at 800-711-4555 .
1 In certain documents the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL) .” This change in descriptive terms does not affect your patient’s benefit coverage .
2 Where differences are noted, the benefit plan documents will govern .
3 In certain documents Tier 1 was referred to as “generics;” Tier 2 was referred to as “preferred brands” or “brand-name” on the PDL; and Tier 3 was referred to as “non-preferred brands,” “not on the PDL,” or “brand-name not on the PDL .” These changes in descriptive terms do not affect your patient’s benefit coverage .
7
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
1. Anti-Infectives
1.1 PenicillinsTIER 1
+ Amoxicillin Trihydrate Capsule, Chewable Tablet, Suspension, Tablet (Amoxil)
+ Amoxicillin Trihydrate/Potassium Clavulanate (Augmentin 200, 400 mg Susp .; 200, 400 mg Chewable Tablet; 500, 875 mg Tablet; Augmentin ES 600 mg Suspension; Augmentin 250-62 .5 mg/5 ml Suspension)
+ Dicloxacillin Sodium Capsule (Dynapen)+ Penicillin V Potassium (Pen-Vee K)
TIER 2 Augmentin (Amoxicillin Trihydrate/
Potassium Clavulanate)TIER 3
Amoxicillin Clavulanate ER Tablet, Sustained-Release 12 Hour (Augmentin XR)*** E T4
1.2 TetracyclinesTIER 1
+ Doxycycline Hyclate (Vibra-Tabs, Vibramycin, Periostat)
+ Doxycycline Monohydrate Capsule (Monodox)
+ Minocycline HCl (Dynacin, Minocin)+ Tetracycline HCl (Achromycin V)
TIER 3 Adoxa E T4+ Doxycycline Hyclate Tablet,
Enteric-Coated (Doryx)*** E T4+ Doxycycline Monohydrate Capsule
(Adoxa 150 mg)*** E T4 Oracea T4+ Minocycline HCl Tablet,
Extended-Release 24 Hour (Solodyn 45, 90, 135 mg)***
Solodyn T4 Vibramycin Suspension
1.3 Cephalosporins1.3.1 FIRST GENERATION CEPHALOSPORINS
TIER 1+ Cefadroxil Hydrate (Duricef)+ Cephalexin Monohydrate (Keflex)
1.3.2 SECOND GENERATION CEPHALOSPORINS
TIER 1+ Cefaclor (Ceclor, Ceclor CD)+ Cefpodoxime Tablet (Vantin)+ Cefprozil (Cefzil)+ Cefuroxime Axetil Suspension
125 mg/5 ml (Ceftin)+ Cefuroxime Axetil Tablet (Ceftin)
TIER 3 Ceftin Suspension
1.3.3 THIRD GENERATION CEPHALOSPORINS
TIER 1+ Cefditoren Pivoxil (Spectracef)
TIER 2+ Cefdinir (Omnicef)**
TIER 3 Cedax Suprax Tablet, Capsule, Suspension T4
1.4 Erythromycins & Other Macrolides1.4.1 ERYTHROMYCINS & OTHER MACROLIDES
TIER 1+ Azithromycin (Zithromax)+ Clarithromycin Tablet (Biaxin)+ Erythromycin Base Capsule,
Delayed-Release (Eryc)+ Erythromycin Base Tablet, Enteric-Coated
250, 333 mg (E-Mycin, Ery-Tab)+ Erythromycin Ethylsuccinate (E .E .S .)+ Erythromycin Ethylsuccinate/Sulfisoxazole
Acetyl (Pediazole)
TIER 2+ Clarithromycin Suspension (Biaxin)**+ Clarithromycin Sustained-Release Tablet
(Biaxin XL)**
TIER 3 PCE Zmax
8© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
1. Anti-Infectives
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
1.5 Quinolones1.5.1 FLUOROQUINOLONES
TIER 1+ Ciprofloxacin Tablet (Cipro)+ Levofloxacin (Levaquin Tablet, Solution)+ Ofloxacin (Floxin)
TIER 2 Cipro Suspension (Ciprofloxacin)
TIER 3 Avelox T4+ Ciprofloxacin Tablet, Sustained-Release
24 Hour (Cipro XR)*** Factive Noroxin
1.6 Sulfas & Related AgentsTIER 1
+ Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole)
+ Sulfadiazine (Sulfadiazine)+ Sulfamethoxazole/Trimethoprim (Bactrim,
Bactrim DS, Septra, Septra DS)
1.7 Urinary Tract AgentsTIER 1
+ Methenamine Mandelate (Methenamine Mandelate)
+ Nitrofurantoin Macrocrystal (Macrodantin 50, 100 mg)
+ Nitrofurantoin Suspension, Oral (Furadantin)+ Nitrofurantoin/Nitrofurantoin Macrocrystal
(Macrobid)+ Trimethoprim (Proloprim)
TIER 2 Macrodantin 25 mg
TIER 3 Monurol Primsol
1.8 Antivirals1.8.1 MISCELLANEOUS ANTIVIRALS
TIER 1+ Acyclovir (Zovirax) Adefovir (Hepsera) DSP+ Amantadine HCl (Symmetrel)+ Ganciclovir (Cytovene) + Ribavirin (Copegus) DSP+ Ribavirin (Rebetol Capsules) DSP+ Rimantadine HCl Tablet (Flumadine)
TIER 2 Baraclude DSP Epivir HBV DSP+ Famciclovir (Famvir)** SL Incivek DSP N SL Rebetol Solution DSP+ Valacyclovir HCl (Valtrex)** SL Valcyte SL
TIER 3 Relenza SL Ribapak*** DSP E T4 Tamiflu SL Tyzeka DSP Victrelis DSP N SL
9
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
1. Anti-Infectives
1.8.2 HIV/AIDS THERAPY
TIER 1+ Abacavir Sulfate Tablet (Ziagen) DSP+ Didanosine Capsule, Enteric-Coated
(Videx EC) DSP+ Lamivudine Tablet (Epivir)+ Nevirapine (Viramune) DSP+ Stavudine (Zerit) DSP+ Zidovudine (Retrovir) DSP+ Zidovudine/Lamivudine (Combivir) DSP
TIER 2 Aptivus DSP Atripla DSP Complera DSP Crixivan DSP Emtriva DSP Edurant DSP Epivir DSP Epzicom DSP Fuzeon DSP Intelence DSP Invirase DSP Isentress DSP Kaletra DSP Lexiva DSP Norvir DSP Prezista DSP Rescriptor DSP Reyataz DSP Selzentry DSP N Sustiva DSP Trizivir DSP Truvada DSP N Viracept DSP Viramune XR DSP Viread DSP Ziagen DSP
TIER 3 Stribild DSP N
1.9 Antifungal AgentsTIER 1
+ Clotrimazole Troche (Mycelex)+ Fluconazole (Diflucan)+ Flucytosine (Ancobon)+ Griseofulvin Microsize (Grifulvin V)+ Griseofulvin Ultramicrosize (Gris-Peg)+ Itraconazole Capsule (Sporanox
Capsule) SL+ Ketoconazole (Nizoral)+ Nystatin (Mycostatin)+ Terbinafine HCl Tablet (Lamisil) SL+ Voriconazole (Vfend) SL
TIER 2 Noxafil Sporanox Solution, Oral
(Itraconazole Solution, Oral)TIER 3
Lamisil Granules SL Onmel E SL T4
1.10 VancomycinTIER 1
+ Vancomycin HCl (Vancocin HCl) SL
1.11 Miscellaneous Anti-infectives1.11.1 MISCELLANEOUS ANTI-INFECTIVES
TIER 1+ Clindamycin HCl (Cleocin HCl
150, 300 mg)+ Neomycin Sulfate (Neomycin Sulfate)
TIER 2 Cayston N SL Cleocin HCl 75 mg+ Clindamycin Palmitate HCl
(Cleocin Palmitate)** Dapsone Tobi Nebs DSP N SL Zyvox SL
TIER 3 Dificid SL Ketek Xifaxan SL
10© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
1. Anti-Infectives
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
1.11.2 ANTIPARASITICS
TIER 1+ Metronidazole (Flagyl)+ Paromomycin Sulfate (Humatin)
TIER 2 Albenza Alinia SL Biltricide Mepron NebuPent Stromectol
TIER 3 Flagyl ER Tablet+ Tinidazole (Tindamax)***
1.11.3 ANTIMALARIALS
TIER 1+ Chloroquine Phosphate (Aralen Phosphate)+ Hydroxychloroquine Sulfate (Plaquenil)+ Mefloquine HCl (Lariam)+ Quinine Sulfate (Qualaquin) SL
TIER 2+ Atovaquone/Proguanil HCl (Malarone)** Coartem Daraprim Primaquine
1.11.4 ANTIMYCOBACTERIALS
TIER 1+ Ethambutol HCl (Myambutol)+ Isoniazid (Isoniazid)+ Pyrazinamide (Pyrazinamide)+ Rifampin (Rifadin)+ Rifampin/Isoniazid (Rifamate)
TIER 2 Priftin Rifater
11
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
2. Antineoplastic & Immunosuppressant Drugs
2.1 Antineoplastic & Immunosuppressant Drugs2.1.1 ALKYLATING AGENTS
TIER 1+ Cyclophosphamide (Cytoxan) Temozolamide (Temodar) DSP N
TIER 2 Alkeran CeeNu Leukeran Myleran
2.1.2 ANTIMETABOLITES
TIER 1+ Mercaptopurine (Purinethol)+ Methotrexate Sodium (Methotrexate)
TIER 2 Rheumatrex, Trexall Xeloda DSP SL
2.1.3 ANDROGENS, ESTROGENS, HORMONES & RELATED DRUGS
2.1.3.1 ANDROGENS
TIER 2+ Oxandrolone (Oxandrin)**
2.1.3.2 HORMONES
TIER 1+ Megestrol Acetate (Megace)
TIER 3 Megace ES
2.1.3.3 ANTIESTROGENS
TIER 1+ Anastrozole (Arimidex)+ Letrozole (Femara)+ Tamoxifen (Nolvadex)
TIER 2+ Exemestane (Aromasin)** Fareston (Toremifene Citrate)
TIER 3 Soltamox E T4
2.1.3.4 ANTIANDROGENS
TIER 1+ Bicalutamide (Casodex)+ Flutamide (Eulexin)
TIER 2 Nilandron
2.1.4 IMMUNOSUPPRESSANT DRUGS
TIER 1+ Azathioprine (Imuran)+ Cyclosporine, Modified (Gengraf) DSP+ Mycophenolate Mofetil Capsule, Tablet
(CellCept) DSP+ Tacrolimus Anhydrous (Prograf) DSP
TIER 2 CellCept DSP Rapamune DSP
TIER 3 Azasan Myfortic DSP T4 Neoral DSP T4 Sandimmune DSP T4
2.1.5 MISCELLANEOUS ANTINEOPLASTIC DRUGS
TIER 1+ Etoposide (VePesid)+ Hydroxyurea (Hydrea)+ Leuprolide Acetate (Lupron 1 mg/0 .2 ml) N+ Octreotide Acetate (Sandostatin) DSP N
TIER 2 Afinitor DSP N SL Bosulif DSP N SL Caprelsa DSP N SL Droxia Emcyt Erivedge DSP N SL Gleevec DSP N SL Hexalen Hycamtin DSP N SL Jakafi DSP N SL Lysodren Matulane Nexavar DSP N SL Revlimid DSP N SL Sutent DSP N SL Sylatron DSP N SL Tarceva DSP N SL Tasigna DSP N SL Thalomid DSP N SL+ Tretinoin (Vesanoid)** DSP SL Tykerb DSP N SL Votrient DSP N SL Xalkori DSP N SL Zelboraf DSP N SL Zolinza DSP SL Zytiga DSP N SL
TIER 3 Somatuline Depot DSP T4 Sprycel DSP N SL ST Xtandi DSP N SL ST
12© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
2. Antineoplastic & Immunosuppressant Drugs
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
2.2 Adjunctive Agents2.2.1 ADJUNCTIVE AGENTS
TIER 1+ Leucovorin Calcium (Leucovorin Calcium
5, 25 mg)
TIER 2 Aranesp DSP SL Epogen DSP SL Leucovorin Calcium 10, 15 mg
(Leucovorin Calcium) Leukine DSP Neupogen DSP Procrit DSP SL
13
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
3. Autonomic & CNS Drugs, Neurology & Psych
3.1 Narcotic Analgesics3.1.1 NARCOTICS
TIER 1+ Codeine Sulfate (Codeine Sulfate) Duragesic* SL+ Hydromorphone HCl (Dilaudid)+ Levorphanol Tartrate (Levo-Dromoran)+ Methadone HCl (Dolophine HCl)+ Meperidine HCl (Demerol)+ Morphine Sulfate Solution, Oral
(MSIR 20 mg/ml)+ Morphine Sulfate Solution, Oral (Roxanol)+ Morphine Sulfate Tablet, Sustained-Action
(MS Contin) SL+ Oxycodone HCl (Roxicodone, OxyIR)+ Oxycodone HCl Concentrate, Oral
(OxyFAST)
TIER 2 Codeine Phosphate (Codeine
Phosphate)+ Fentanyl Citrate Lollipop (Actiq)** N SL MSIR Opana ER SL OxyContin SL+ Oxymorphone Tablet (Opana)** SL
TIER 3 Abstral E N SL T4 Avinza SL T4 Butrans SL ST T4 Exalgo SL T4+ Fentanyl Transdermal (Duragesic)*** SL T4 Fentora E N SL T4 Lazanda N SL + Morphine Sulfate Capsule,
Extended-Release Pellets (Kadian)*** E SL T4 Onsolis N SL+ Oxymorphone HCl Tablet,
Sustained-Release 12 Hour (Opana ER)*** SL
Subsys N SL
3.1.2 COMBINATION NARCOTIC /ANALGESICS
TIER 1+ Acetaminophen/Caffeine/Butalbital
(Fioricet) SL+ Aspirin/Caffeine/Butalbital (Fiorinal) Aspirin/Caffeine/Dihydrocodone
(Synalgos-DC) + Codeine Phosphate/Acetaminophen
(Tylenol w/Codeine) SL+ Codeine Phosphate/Acetaminophen/
Caffeine/Butalbital (Fioricet w/Codeine) SL
+ Codeine Phosphate/Aspirin/Caffeine/ Butalbital (Fiorinal w/Codeine 30 mg)
+ Dihydrocodeine Bit/Acetaminophen/ Caffeine (Panlor SS, Panlor DC) SL
+ Hydrocodone Bit/Acetaminophen (Lorcet, Lortab, Norco, Vicodin, Vicodin ES, Vicodin HP, Xodol) SL
+ Ibuprofen/Hydrocodone (Vicoprofen)+ Oxycodone HCl/Acetaminophen (Tylox) SL+ Oxycodone HCl/Acetaminophen Tablet
(Percocet) SL+ Oxycodone HCl/Ibuprofen (Combunox)+ Oxycodone/Aspirin (Percodan)
TIER 2+ Hydrocodone Bit/Acetaminophen
Solution, Oral (Hycet)** SL
TIER 3 Zolvit E T4
14© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
3. Autonomic & CNS Drugs, Neurology & Psych
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
3.2 Non-Narcotic Analgesics3.2.1 MISCELLANEOUS ANALGESICS
TIER 1+ Pentazocine HCl/Acetaminophen
(Talacen)+ Pentazocine HCl/Naloxone HCl
(Talwin NX)+ Tramadol HCl (Ultram)+ Tramadol HCl/Acetaminophen
(Ultracet) SL
TIER 2+ Butorphanol Tartrate Aerosol, Spray
(Stadol)** SL+ Tramadol HCl Tablet, Sustained-Release
24 Hour (Ultram ER)** SL
TIER 3 Conzip E SL T4 Nucynta SL T4 Nucynta ER SL T4 Rybix ODT E SL T4+ Tramadol HCl Tablet, Extended-Release
Multiphase 24 Hour (Ryzolt)*** E SL T4
3.2.2 NARCOTIC ANTAGONISTS/OPIOID DEPENDENCE
TIER 1+ Buphrenorphine Hydrochloride
(Subutex) N SL+ Naltrexone HCl (ReVia)
TIER 2+ Buphrenorphine HCl/Naloxone
HCl Tablet, Sublingual (Suboxone)** N SL Suboxone Film N SL
3.3 Migraine & Cluster Headache TherapyTIER 1
+ Acetaminophen/Caffeine/Butalbital (Fioricet) SL
+ Aspirin/Caffeine/Butalbital (Fiorinal)+ Dihydroergotamine Mesylate (D .H .E .45)+ Dihydroergotamine Mesylate Aerosol,
Spray with Pump (Migranal)+ Isometheptene Mucate/Acetaminophen/
Dichloralphenazone (Midrin)+ Naratriptan HCl (Amerge) SL+ Sumatriptan Succinate Injection
(Imitrex Injection) SL+ Sumatriptan Succinate Tablet
(Imitrex Tablet) SL
TIER 2 Ergomar Relpax SL Rizatriptan Benzoate Tablet (Maxalt)** SL+ Sumatriptan Succinate Nasal Spray
(Imitrex Nasal Spray)** SL
TIER 3 Alsuma E SL T4 Axert SDP SL Cafergot Frova SDP SL Migranal T4 Rizatriptan Benzoate Tablet,
Disintegrating (Maxalt MLT)*** SL Sumavel Dosepro SL Treximet E SL T4 Zolmitriptan (Zomig)*** SL Zolmitriptan Orally Disintegrating Tablet
(Zomig-ZMT)*** SL Zomig Nasal Spray SL
15
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
3. Autonomic & CNS Drugs, Neurology & Psych
3.4 Antiparkinsonism AgentsTIER 1
+ Amantadine HCl (Symmetrel)+ Benztropine Mesylate (Cogentin)+ Bromocriptine Mesylate (Parlodel)+ Carbidopa/Levodopa (Sinemet)+ Carbidopa/Levodopa/Entacapone
(Stalevo)+ Carbidopa/Levodopa Tablet,
Rapid Dissolve (Parcopa)+ Carbidopa/Levodopa Tablet,
Sustained-Action (Sinemet CR)+ Entacapone (Comtan)+ Pramipexole Di-HCl (Mirapex)+ Ropinirole HCl (Requip)+ Selegiline HCl (Eldepryl)+ Trihexyphenidyl HCl (Artane)
TIER 2 Apokyn DSP Tasmar
TIER 3 Azilect Mirapex ER E T4+ Ropinirole HCl Tablet, Extended-Release
24 Hour (Requip XL)*** E T4 Zelapar
3.5 AnticonvulsantsTIER 1
+ Carbamazepine (Tegretol)+ Clonazepam (Klonopin)+ Diazepam, Rectal (Diastat Acudial) SL+ Divalproex Sodium Tablet (Depakote)+ Divalproex Sodium Tablet,
Sustained-Release (Depakote ER)+ Ethosuximide (Zarontin)+ Felbamate (Felbatol)+ Gabapentin (Neurontin)+ Lamotrigine 5, 25 mg Chewable Tablet
(Lamictal Chewable)+ Lamotrigine Tablet (Lamictal)+ Levetiracetam (Keppra)+ Oxcarbazepine (Trileptal)+ Phenobarbital (Phenobarbital)+ Phenytoin (Dilantin)+ Phenytoin Sodium (Phenytek)+ Phenytoin Sodium Extended (Dilantin)+ Primidone (Mysoline)+ Tiagabine HCl (Gabitril)+ Topiramate Capsule, Sprinkle (Topamax)+ Topiramate Tablet (Topamax)+ Valproic Acid (Depakene)+ Zonisamide (Zonegran)
TIER 2+ Carbamazepine Tablet, Sustained-Release
12 Hour (Tegretol XR)** Celontin Dilantin+ Divalproex Sodium (Depakote Sprinkle)**+ Levetiracetam Tablet, Extended-Release
24 Hour (Keppra XR)** Mysoline Peganone Sabril Tegretol
16© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
3. Autonomic & CNS Drugs, Neurology & Psych
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
TIER 3 Banzel N+ Carbamazepine Capsule,
Extended-Release Multiphase 12 Hour (Carbatrol)***
Depakote ER N ST T4 Equetro Keppra N ST T4 Keppra XR N ST T4 Lamictal N ST T4 Lamictal Dose Pack N ST Lamictal ODT N ST T4 Lamotrigine Orally Disintegrating Tablet
(Lamictal ODT)*** ST Lamotrigine Tablet, Extended-Release
24 Hour (Lamictal XR)*** ST Lyrica SDP SL T4 Onfi N Potiga N Stavzor ST Topamax N ST T4 Vimpat N
3.6 Miscellaneous Neurological TherapyTIER 1
+ Donepezil HCl Tablet (Aricept)+ Galantamine Capsule 24 Hour
Sustained-Release Pellets (Razadyne ER)
+ Galantamine Tablet, Solution (Razadyne)+ Nimodipine (Nimotop)+ Rivastigmine Tartrate Capsule (Exelon)
TIER 2 Ampyra DSP N SL Avonex DSP N SL Betaseron DSP N SL Copaxone DSP N SL+ Donepezil HCl Tablet, Rapid Dissolve
(Aricept ODT)** Mytelase Nuedexta Tecfidera DSP N SL
TIER 3 Aubagio DSP N SL ST T4 Donepezil 23 mg (Aricept 23 mg)*** E T4 Exelon Solution Extavia DSP E N SL
ST T4 Gilenya DSP N SL ST Gralise E SL T4 Horizant E SL T4 Namenda T4 Rebif DSP N SL
ST T4
3.7 Muscle Relaxants & Antispasmodic Therapy3.7.1 MYASTHENIA GRAVIS
TIER 1+ Pyridostigmine Bromide Tablet
(Mestinon 60 mg)
TIER 2 Mestinon Prostigmin
17
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
3. Autonomic & CNS Drugs, Neurology & Psych
3.8 Psychotherapeutic Drugs3.8.1 HYPNOTIC AGENTS
TIER 1+ Chloral Hydrate (Chloral Hydrate)+ Estazolam (ProSom)+ Flurazepam HCl (Dalmane)+ Temazepam (Restoril)+ Triazolam (Halcion)+ Zaleplon (Sonata) SL+ Zolpidem Tartrate (Ambien) SL
TIER 3 Edluar E SL ST T4 Intermezzo E SL ST T4 Lunesta SL ST T4 Rozerem SL ST Sonata SL ST Silenor E SL T4+ Zolpidem Tartrate Tablet,
Multiphasic-Release (Ambien CR)*** SL ST T4 Zolpimist SL ST T4
3.8.2 ANTIDEPRESSANT AGENTS
3.8.2.1 TRICYCLICS
TIER 1+ Amitriptyline HCl (Elavil)+ Amoxapine (Asendin 50, 100 mg)+ Clomipramine HCl (Anafranil)+ Desipramine HCl (Norpramin)+ Doxepin HCl (Sinequan)+ Imipramine Pamoate (Tofranil-PM)+ Nortriptyline HCl (Pamelor)+ Protriptyline HCl (Vivactil)
3.8.2.2 MISCELLANEOUS ANTIDEPRESSANTS
TIER 1+ Bupropion HCl (Wellbutrin)+ Bupropion HCl Tablet, Sustained-Action
(Wellbutrin SR)+ Bupropion HCl Tablet, Sustained-Release
24 Hour (Wellbutrin XL)+ Maprotiline HCl (Ludiomil)+ Mirtazapine (Remeron)+ Mirtazapine Dispersible Tablet
(Remeron SolTab)+ Nefazodone HCl (Serzone)+ Trazodone HCl (Desyrel)+ Venlafaxine HCl Capsule,
Sustained-Release 24 Hour (Effexor XR)
TIER 3 Aplenzin E SL T4 Cymbalta SDP SL Desvenlafaxine E SL T4 Forfivo E SL T4 Oleptro ER E SL T4 Pristiq RS SL + Venlafaxine HCl Tablet,
Extended-Release 24 Hour (Venlafaxine HCl ER)*** E SL T4
3.8.2.3 MAO INHIBITORS
TIER 1+ Phenelzine Sulfate (Nardil)+ Tranylcypromine Sulfate (Parnate)
TIER 3 Emsam Marplan
18© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
3. Autonomic & CNS Drugs, Neurology & Psych
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
3.8.2.4 SELECTIVE SEROTONIN REUPTAKE INHIBITORS
TIER 1+ Citalopram Hydrobromide (Celexa)+ Escitalopram Tablet (Lexapro) 1/2T+ Fluoxetine Capsule, Delayed-Release
(Prozac Weekly) SL+ Fluoxetine HCl Capsule (Prozac)+ Fluoxetine HCl Tablet (Sarafem)+ Fluvoxamine Maleate (Luvox)+ Paroxetine HCl Tablet (Paxil)+ Sertraline HCl (Zoloft) 1/2T
TIER 3+ Escitalopram Solution, Oral (Lexapro)***+ Fluvoxamine Maleate Capsule,
Extended-Release 24 Hour (Luvox CR)*** SL+ Paroxetine HCl Sustained-Release,
24 Hour (Paxil CR)*** SL Pexeva 1/2T SL Viibryd SDP SL T4
3.8.3 ANTIPSYCHOTICS
3.8.3.1 PHENOTHIAZINES
TIER 1+ Chlorpromazine HCl Tablet
(Thorazine 200 mg)+ Fluphenazine HCl (Prolixin)+ Perphenazine (Trilafon)+ Thioridazine HCl (Mellaril)+ Trifluoperazine HCl (Stelazine)
3.8.3.2 BUTYROPHENONES
TIER 1+ Haloperidol (Haldol)+ Haloperidol Lactate Concentrate, Oral
(Haldol)
3.8.3.3 MISCELLANEOUS ANTIPSYCHOTICS
TIER 1+ Clozapine (Clozaril)+ Clozapine Orally Disintegrating Tablet
(FazaClo)+ Olanzapine Tablet (Zyprexa) SL+ Quetiapine Fumarate (Seroquel) SL+ Risperidone Tablet, Rapid Dissolve
(Risperdal M-Tab)+ Risperidone Solution (Risperdal)+ Risperidone Tablet (Risperdal)+ Thiothixene (Navane)
TIER 2 Clozaril (Clozapine)+ Olanzapine/Fluoxetine (Symbyax)** SL+ Ziprasidone (Geodon)** SL
TIER 3 Abilify 1/2T SL T4 Fanapt SL T4 Invega SL T4 Latuda SL T4+ Olanzapine Tablet, Rapid Dissolve
(Zyprexa Zydis)*** SL Saphris SL T4 Seroquel XR SL T4
19
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
3. Autonomic & CNS Drugs, Neurology & Psych
3.8.4 MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS
TIER 1+ Amphetamine Aspartate/Amphetamine
Sulfate/Dextroamphetamine (Adderall) N+ D-Amphetamine Sulfate Tablet,
Capsule, Sustained-Action (Dexedrine) N
-+ Lithium Carbonate (Eskalith)+ Lithium Carbonate, Sustained-Action
(Eskalith CR)+ Lithium Carbonate Tablet,
Sustained-Action (Lithobid)+ Lithium Citrate (Lithium Citrate)+ Methamphetamine HCl (Desoxyn) N+ Methylphenidate HCl
(Methylin Solution, Oral) N+ Methylphenidate HCl
(Ritalin, Ritalin SR) N+ Methylphenidate HCl Tablet,
Sustained-Action (Metadate ER) N
TIER 2 Adderall XR** N SL Intuniv SL Vyvanse N SL
TIER 3+ Amphetamine Aspartate/Amphetamine
Sulfate/Dextroamphetamine Capsule, Sustained-Release 24 Hour (Adderall XR)** E N SL T4
Clonidine Extended-Release (Kapvay)*** E T4 Daytrana N SL T4 Focalin XR N SL T4 Methylin Tablet, Chewable N+ Methylphenidate HCl Capsule,
Extended-Release Multiphase (Ritalin LA)*** N SL
+ Methylphenidate HCl Capsule, Extended-Release Multiphase 30-70 (Metadate CD)*** N SL T4
+ Methylphenidate HCl Tablet, Extended-Release 24 Hour (Concerta)*** N SL T4
+ Modafinil (Provigil)*** E N SL T4 Nuvigil N SL T4 Strattera SL T4 Xyrem N SL T4
3.8.5 ANXIOLYTICS
TIER 1+ Alprazolam (Xanax)+ Alprazolam Tablet, Rapid Dissolve (Niravam)+ Alprazolam Tablet, Sustained-Release
24 Hour (Xanax XR)+ Buspirone HCl (Buspar)+ Chlordiazepoxide HCl (Librium)+ Diazepam (Valium)+ Lorazepam (Ativan)+ Lorazepam Concentrate, Oral
(Lorazepam Intensol)+ Oxazepam (Serax)
20© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
4. Cardiovascular, Hypertension & Lipids
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
4.1 Antiarrhythmic AgentsTIER 1
+ Amiodarone HCl (Cordarone)2
+ Disopyramide Phosphate Capsule (Norpace)+ Flecainide Acetate (Tambocor)2
+ Mexiletine HCl (Mexitil)+ Propafenone HCl (Rythmol)+ Quinidine Gluconate (Quinidine Gluconate)+ Quinidine Sulfate (Quinidine Sulfate)+ Quinidine Sulfate Tablet, Sustained-Action
(Quinidex)+ Sotalol HCl (Betapace, Betapace AF)
TIER 2 Multaq Norpace CR Tikosyn1, 2
TIER 3+ Propafenone Capsule, Sustained-Release
12 Hour (Rythmol SR)***1 This drug is only available to hospitals and prescribers who have received appropriate
education in the initiation and dosing of Tikosyn .
2 Cardiologist consultation suggested .
4.2 Cardiac GlycosidesTIER 1
+ Digoxin (Lanoxin)
TIER 2+ Lanoxin (Digoxin)
4.3 Nitrates4.3.1 RAPID ACTING NITRATES
TIER 2 Nitrostat (Nitroglycerin)
TIER 3 Nitroglycerin Spray (Nitromist)*** SL + Nitroglycerin Spray, Non-Aerosol
(Nitrolingual)*** E SL T4
4.3.2 LONG ACTING NITRATES
TIER 1+ Isosorbide Dinitrate Tablet
(Isordil 5, 10, 20, 30 mg)+ Isosorbide Dinitrate Tablet, Sublingual
(Isordil 2 .5, 5 mg)+ Isosorbide Mononitrate (ISMO)+ Isosorbide Mononitrate Tablet,
Sustained-Release 24 Hour (Imdur)+ Nitroglycerin Capsule, Sustained-Action
(Nitro-Bid)+ Nitroglycerin Patch, Transdermal 24 Hour
(Transderm-Nitro)
TIER 2 Isordil 40 mg
TIER 3 Dilatrate-SR Nitro-Dur
4.4 Coagulation Therapy4.4.1 ANTICOAGULANTS
TIER 1+ Warfarin Sodium (Coumadin)
TIER 2+ Coumadin Xarelto SL
TIER 3 Pradaxa SL T4
4.4.2 ANTIPLATELET DRUGS
TIER 1+ Cilostazol (Pletal)+ Clopidogrel Bisulfate (Plavix)+ Dipyridamole (Persantine)+ Ticlopidine HCl (Ticlid)
TIER 3 Aggrenox Brilinta N SL T4 Effient SL T4
4.4.3 HEPARIN
TIER 1+ Heparin Sodium (Heparin)
TIER 2+ Fondaparinux Sodium (Arixtra)** SL+ Enoxaparin (Lovenox)** SL
TIER 3 Fragmin SL T4 Innohep SL
21
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
4. Cardiovascular, Hypertension & Lipids
4.4.4 VITAMIN K
TIER 2 Mephyton (Phytonadione)
4.4.5 HEMOSTATICS
TIER 1+ Aminocaproic Acid Solution (Amicar)+ Aminocaproic Acid Tablet (Amicar 500 mg)
TIER 2 Aminocaproic Acid Tablet 1000 mg
(Aminocaproic Acid)TIER 3
Promacta DSP N T4
4.4.6 MISCELLANEOUS COAGULATION AGENTS
TIER 1 Pentoxifylline Tablet, Sustained-Action
(Trental)
TIER 2 Advate DSP Alphanate vonWillebrand DSP Alphanine SD DSP Bebulin DSP Benefix DSP Feiba DSP Helixate FS DSP Hemofil-M DSP Humate-P DSP Koate-DVI DSP Kogenate FS DSP Monoclate-P DSP Mononine DSP Novoseven DSP Profilnine SD DSP Recombinate DSP Xyntha DSP
TIER 3 Stimate
4.5 Antihypertensive Therapy4.5.1 THIAZIDE & RELATED DIURETICS
TIER 1+ Amiloride HCl (Midamor)+ Amiloride HCl/Hydrochlorothiazide (Moduretic)+ Bumetanide (Bumex)+ Chlorothiazide Tablet (Diuril)+ Furosemide (Lasix)+ Hydrochlorothiazide (HydroDIURIL, Microzide)+ Metolazone (Zaroxolyn)+ Spironolactone (Aldactone)+ Spironolactone/Hydrochlorothiazide
(Aldactazide 25-25 mg)+ Triamterene/Hydrochlorothiazide
(Dyazide, Maxzide)
TIER 2 Aldactazide 50-50 mg Diuril 250 mg/5 ml+ Eplerenone (Inspra)**
TIER 3 Dyrenium Edecrin
22© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
4. Cardiovascular, Hypertension & Lipids
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
4.5.2 BETA BLOCKERS
TIER 1+ Acebutolol HCl (Sectral)+ Atenolol (Tenormin)+ Betaxolol HCl (Kerlone)+ Carvedilol (Coreg)+ Labetalol HCl (Normodyne)+ Metoprolol Succinate Tablet,
Sustained-Release 24 Hour (Toprol XL 25 mg)
+ Metoprolol Tartrate (Lopressor)+ Nadolol (Corgard)+ Pindolol (Visken)+ Propranolol HCl Tablet (Inderal)
TIER 2 Bystolic+ Metoprolol Succinate Tablet,
Sustained-Release 24 Hour (Toprol XL 50, 100, 200 mg)**
+ Propranolol HCl Sustained-Action Capsule (Inderal LA)**
TIER 3 Coreg CR E SL T4 Innopran XL Levatol
4.5.3 CALCIUM CHANNEL BLOCKERS
4.5.3.1 CALCIUM CHANNEL BLOCKERS/ NON-DIHYDROPYRIDINES
TIER 1+ Diltiazem HCl (Cardizem)+ Diltiazem HCl Capsule, Controlled-Release
(Dilacor XR)+ Diltiazem HCl Capsule, Sustained-Release
12 Hour (Cardizem SR)+ Verapamil HCl (Calan)+ Verapamil HCl (Verelan)+ Verapamil HCl Tablet, Sustained-Action
(Calan SR)
TIER 2 Cardizem LA 120 mg+ Diltiazem HCl Capsule, Sustained-Action
(Tiazac)**+ Diltiazem HCl Capsule, Sustained-Release
24 Hour (Cardizem CD)**+ Diltiazem HCl Tablet, Sustained-Release 24 Hour
(Cardizem LA 180, 240, 300, 360, 420 mg)**
TIER 3+ Verapamil HCl Capsule, 24 Hour
Sustained-Release Pellets (Verelan PM)***
4.5.3.2 CALCIUM CHANNEL BLOCKERS/DIHYDROPYRIDINES
TIER 1+ Amlodipine Besylate (Norvasc)+ Felodipine (Plendil)+ Nicardipine HCl (Cardene)+ Nifedipine (Procardia)+ Nifedipine Tablet, Osmotic Laser-Drilled
Formulation (Procardia XL)
TIER 2+ Nisoldipine (Sular)**
TIER 3 Cardene SR
23
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
4. Cardiovascular, Hypertension & Lipids
4.5.4 ACE INHIBITORS
TIER 1+ Benazepril HCl (Lotensin)+ Enalapril Maleate (Vasotec)+ Lisinopril (Prinivil, Zestril)+ Moexipril HCl (Univasc) 1/2T+ Ramipril (Altace)+ Trandolapril (Mavik) 1/2T
TIER 2+ Perindopril (Aceon)** 1/2T
4.5.5 ADRENERGIC ANTAGONISTS & RELATED DRUGS
TIER 1+ Clonidine HCl (Catapres)+ Doxazosin Mesylate (Cardura)+ Guanfacine HCl (Tenex)+ Prazosin HCl (Minipress)+ Terazosin HCl (Hytrin)
TIER 3 Cardura XL+ Clonidine Patch, Transdermal Weekly
(Catapres-TTS)*** SL Nexiclon XR E T4
4.5.6 AGENTS FOR PHEOCHROMOCYTOMA
TIER 2 Dibenzyline
4.5.7 VASODILATORS
TIER 1+ Hydralazine HCl (Apresoline)
TIER 2 BiDil
4.5.8 OTHER ANTIHYPERTENSIVE COMBINATIONS
TIER 1+ Benazepril/Hydrochlorothiazide (Lotensin HCT)+ Bisoprolol Fumarate/Hydrochlorothiazide (Ziac)+ Captopril/Hydrochlorothiazide (Capozide)+ Enalapril Maleate/Hydrochlorothiazide
(Vaseretic)+ Lisinopril/Hydrochlorothiazide
(Prinzide, Zestoretic)+ Metoprolol/Hydrochlorothiazide
(Lopressor HCT)+ Nadolol/Bendroflumethiazide (Corzide)+ Propranolol HCl/Hydrochlorothiazide
(Inderide)
TIER 2+ Amlodipine/Benazepril (Lotrel)** SL Clorpres Dutoprol SL+ Quinapril HCl/Hydrochlorothiazide
(Accuretic)**
TIER 3 Azor E SL T4 Exforge E SL T4 Exforge HCT E SL T4+ Trandolapril/Verapamil (Tarka)*** Tribenzor E SL T4 Twynsta E SL T4
24© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
4. Cardiovascular, Hypertension & Lipids
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
4.5.9 ANGIOTENSIN II RECEPTOR BLOCKERS AND RENIN INHIBITOR
TIER 1+ Eprosartan Hydrochloride (Teveten) SL+ Losartan Potassium (Cozaar) 1/2T+ Losartan Potassium/Hydrochlorothiazide
(Hyzaar)
TIER 2 Benicar 1/2T SL Benicar HCT SL+ Irbesartan (Avapro)** 1/2T SL+ Irbesartan/Hydrochlorothiazide
(Avalide)** SL Micardis SL Micardis HCT SL+ Valsartan/Hydrochlorothiazide
(Diovan HCT)** SL
TIER 3 Amturnide E SL T4 Candesartan (Atacand) 1/2T SL + Candesartan/Hydrochlorothiazide
(Atacand HCT)*** SL Diovan 1/2T SL Edarbi SL Edarbyclor SL Tekamlo E SL T4 Tekturna SDP SL Tekturna HCT SDP SL Teveten HCT SL
4.6 Lipid/Cholesterol Lowering AgentsTIER 1
+ Atorvastatin Calcium (Lipitor) 1/2T SL+ Cholestyramine/Aspartame (Questran Light)+ Cholestyramine/Sucrose (Questran)+ Colestipol HCl (Colestid)+ Fenofibric Acid (Fibricor)+ Fluvastatin Sodium (Lescol) SL+ Gemfibrozil (Lopid)+ Lovastatin (Mevacor)+ Pravastatin (Pravachol) 1/2T+ Simvastatin (Zocor) 1/2T
TIER 2 Crestor 1/2T SL+ Fenofibrate 54, 160 mg (Lofibra)**+ Fenofibrate Micronized (Antara)** Lipofen Niaspan Welchol
TIER 3 Advicor SL Altoprev E SL T4+ Amlodipine/Atorvastatin (Caduet)*** E SL T4 Choline Fenofibrate (Trilipix)*** E T4 + Fenofibrate Nanocrystallized
48, 145 mg (Tricor)*** E T4 Fenoglide Lescol XL SL Livalo SL T4 Lovaza N T4 Niacin Extended-Release (Niaspan) T4 Simcor SL T4 Triglide Trilipix E T4 Vascepa N T4 Vytorin SL T4 Zetia SL T4
4.7 Miscellaneous Cardiovascular AgentsTIER 2
Ranexa
25
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
5. Dermatologicals/Topical Therapy
5.1 Topical Corticosteroids5.1.1 TOPICAL CORTICOSTEROIDS VERY HIGH
POTENCY
TIER 1+ Betamethasone Dipropionate/Propylene
Glycol Ointment (Diprolene 0 .05%)+ Clobetasol Propionate Cream
(Temovate E 0 .05%)+ Clobetasol Propionate Cream, Gel, Ointment
(Temovate 0 .05%)+ Clobetasol Propionate Solution, Non-Oral
(Temovate 0 .05%)+ Diflorasone Diacetate Ointment (Psorcon)+ Halobetasol Propionate Cream, Ointment
(Ultravate)
TIER 3+ Clobetasol Propionate Foam (Olux)*** SL+ Clobetasol Propionate Foam (Olux-E)*** SL+ Clobetasol Propionate Lotion (Clobex)*** SL+ Clobetasol Propionate Shampoo
(Clobex)*** E SL T4
5.1.2 TOPICAL CORTICOSTEROIDS HIGH POTENCY
TIER 1+ Amcinonide Cream, Ointment
(Cyclocort 0 .1%)+ Betamethasone Dipropionate Cream, Lotion,
Ointment (Diprosone 0 .05%, Maxivate 0 .05%)
+ Betamethasone Dipropionate/Propylene Glycol Gel, Lotion (Diprolene 0 .05%)
+ Betamethasone DP Augmented Cream 0.05% (Diprolene AF Cream)
+ Betamethasone Valerate Ointment (Valisone 0 .1%)
+ Desoximetasone Cream, Gel, Ointment (Topicort)
+ Diflorasone Diacetate Cream (Psorcon 0 .05%)
+ Diflorasone Diacetate/Emollient Cream (Psorcon E 0 .05%)
+ Fluocinonide Cream, Gel, Ointment, Solution, Non-Oral (Lidex 0 .05%)
+ Fluocinonide/Emollient Cream (Lidex-E 0 .05%)
+ Triamcinolone Acetonide Cream (Aristocort 0 .5%, Kenalog 0 .5%)
+ Triamcinolone Acetonide Ointment (Aristocort HP 0 .5%)
TIER 3 Halog Vanos SL
5.1.3 TOPICAL CORTICOSTEROIDS MEDIUM POTENCY
TIER 1+ Betamethasone Valerate Cream, Lotion
(Valisone 0 .1%)+ Desoximetasone Cream (Topicort)+ Fluocinolone Acetonide Cream, Ointment
(Synalar 0 .025%)+ Fluticasone Propionate Cream
(Cutivate 0 .05%)+ Fluticasone Propionate Ointment
(Cutivate 0 .005%)+ Hydrocortisone Butyrate Ointment, Solution,
Non-Oral (Locoid 0 .1%)+ Hydrocortisone Valerate Cream, Ointment
(Westcort 0 .2%)+ Mometasone Furoate Cream, Ointment,
Solution (Elocon)+ Prednicarbate Cream (Dermatop 0 .1%)+ Triamcinolone Acetonide Cream
(Aristocort 0 .025%)+ Triamcinolone Acetonide Cream, Ointment
(Aristocort 0 .1%, Kenalog 0 .1%)+ Triamcinolone Acetonide Lotion
(Kenalog 0 .025%, 0 .1%)
TIER 3+ Betamethasone Valerate Foam (Luxiq)*** SL Cloderm SL Cordran + Fluticasone Propionate
(Cutivate Lotion)*** MC Hydrocortisone Butyrate Cream
(Locoid Lipocream) E SL Locoid Lipocream E SL T4 Locoid Lotion E SL T4 Pandel Cream Trianex E SL T4
5.1.4 TOPICAL CORTICOSTEROIDS LOW POTENCY
TIER 1+ Alclometasone Dipropionate Cream,
Ointment 0.05% (Aclovate 0 .05%)+ Desonide Cream, Ointment
(DesOwen 0 .05%, Tridesilon 0 .05%)+ Desonide Lotion (DesOwen 0 .05%)+ Fluocinolone Acetonide
(Derma-Smoothe/FS)+ Fluocinolone Acetonide Solution Non-Oral
(Synalar 0 .01%)+ Hydrocortisone Cream, Ointment
(Hytone 2 .5%)+ Hydrocortisone Lotion (Hytone 2 .5%)
TIER 3 Desonate SL Verdeso SL
26© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
5. Dermatologicals/Topical Therapy
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
5.2 Topical AnestheticsLocal Anesthetics No prescription local anesthetics administered in hospital or office environments are covered under the outpatient prescription drug benefit plan . See also Chapter 8, GI Medications for anorectal medications and Chapter 6, ENT Medications .
Topical Anesthetics No prescription topical anesthetics administered in hospital or office environments are covered under the outpatient prescription drug benefit plan . See also Chapter 8, GI Medications for anorectal medications and Chapter 6, ENT Medications .
TIER 1+ Lidocaine HCl Gel, Ointment, Solution
(Xylocaine)
TIER 2 Lidocaine Adhesive Patch (Lidoderm) SL
TIER 3 Emla
5.3 Therapy For AcneSome prescription non-combination benzoyl peroxide products are not covered . Numerous benzoyl peroxide products in various forms and strengths are available over-the-counter .
TIER 1+ Clindamycin Phosphate (Cleocin T)+ Erythromycin Base/Benzoyl Peroxide
(Benzamycin)+ Erythromycin Base/Ethyl Alcohol
(A/T/S, Emgel, Erygel, T-Stat)+ Erythromycin Base/Ethyl Alcohol Swab,
Medicated (Erycette)+ Metronidazole (Metrolotion)+ Metronidazole Cream (Metrocream)+ Metronidazole Gel (Metrogel 0 .75%)+ Sulfacetamide Sodium/Sulfur
(Clenia, Plexion, Sulfacet-R)+ Tretinoin Cream (Avita) N+ Tretinoin Cream, Gel (Retin-A) N
TIER 2 Amnesteem (Accutane)** N Benzamycin Claravis (Accutane)** N Differin Cream, Gel 0 .1%^^ N SL Myorisan (Accutane)** N Sotret (Accutane)** N Zenatane (Accutane)** N
TIER 3 Absorica E N T4 Acanya E SL T4 Aczone SL T4+ Adapalene (Differin Cream, Gel 0 .1%)*** N SL Atralin MC N SL T4 Avita Gel N SL Azelex SL Benzaclin 1%-5% E SL T4 Clindagel E SL T4+ Clindamycin Phosphate Foam 1%
(Evoclin)*** SL Clindamycin Phosphate/Benzoyl
Peroxide Gel (Benzaclin 1%-5%)*** SL+ Clindamycin Phosphate/Benzoyl
Peroxide Gel (Duac) E SL T4 Differin Gel 0 .3% N SL Differin Lotion N SL Epiduo SL Finacea T4 Metronidazole Gel 1% (Metrogel 1%)*** E MC T4 Noritate MC Retin-A Micro E N SL T4 Tazorac N SL T4 Tretin-X N SL+ Tretinoin Microspheres
(Retin-A Micro)*** E N SL T4 Veltin E SL T4 Ziana E SL T4
5.4 Topical AntibacterialsTIER 1
+ Gentamicin Sulfate (Garamycin)+ Mupirocin Ointment (Bactroban) SL+ Sulfacetamide Sodium Suspension, Topical
(Klaron)
TIER 3 Altabax SL Centany E T4+ Mupirocin Calcium Cream
(Bactroban)***
27
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
5. Dermatologicals/Topical Therapy
5.5 Topical AntifungalsTIER 1
+ Ciclopirox Cream, Gel, Lotion (Loprox 0 .77%) + Ciclopirox Solution, Non-Oral (Penlac)+ Clotrimazole/Betamethasone Dipropionate
(Lotrisone)+ Econazole Nitrate (Spectazole 1%)+ Ketoconazole Cream, Shampoo
(Nizoral 2%)+ Nystatin (Mycostatin)+ Nystatin/Triamcinolone Acetonide (Mycolog II)
TIER 2+ Ciclopirox Shampoo (Loprox 1%)**
TIER 3 Ertaczo Exelderm+ Ketoconazole Foam (Extina)*** SL Loprox Shampoo MC Mentax Naftin T4 Oxistat Vusion MC Xolegel MC
5.6 Topical AntiviralsTIER 3
+ Acyclovir Ointment (Zovirax)*** SL Denavir Xerese E T4 Zovirax Cream SL T4
5.7 Burn TherapyTIER 1
+ Silver Sulfadiazine (Silvadene)
5.8 Topical EnzymesTIER 3
Optase Santyl Xenaderm
5.9 KeratolyticsTIER 3
Keralyt Scalp E T4
5.10 Antipsoriatic/AntiseborrheicTIER 1
Acitretin (Soriatane) + Calcipotriene Solution, Topical
(Dovonex) SL+ Calcitrol Ointment (Vectical) SL+ Hydrocortisone Acetate/Pramoxine
Cream (Pramosone 2 .5%-1%)
TIER 2+ Calcipotriene Cream, Ointment
(Dovonex)** SL Enbrel DSP N SL Stelara DSP N SL
TIER 3 Humira DSP N SL
ST T4 Sorilux E SL T4 Taclonex SL T4
5.11 Topical Scabicides/PediculicidesTIER 1
+ Lindane (Lindane Lotion, Shampoo) SL+ Malathion (Ovide)+ Permethrin (Elimite)
TIER 2 Eurax
TIER 3 Sklice SL T4 + Spinosad (Natroba)***
28© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
5. Dermatologicals/Topical Therapy
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
5.12 Miscellaneous DermatologicalsNote: OTC medications are not on the Prescription Drug List, but are listed for information purposes .
AmLactin (Ammonium Lactate) - OTCTIER 1
+ Doxepin Cream (Zonalon)+ Fluorouracil (Efudex)+ Podofilox Liquid (Condylox Liquid)+ Urea 40% Emulsion (Umecta)
TIER 2+ Imiquimod (Aldara)** SL Oxsoralen-Ultra Protopic N SL Regranex N
TIER 3 Carmol HC Cream Condylox Gel Elidel N SL Panretin Gel Picato SL Solaraze Gel Umecta E T4 Umecta PD E T4 Uramaxin GT E T4 Zyclara E SL T4
29
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
6. Ear, Nose & Throat Medications
6.1 Intranasal SteroidsTIER 1
+ Flunisolide (Nasarel)+ Fluticasone Propionate (Flonase) SL
TIER 2 Omnaris SL Zetonna SL
TIER 3 Beconase AQ E SL T4 Dymista E SL T4 Nasonex SL Qnasl SL Rhinocort Aqua SL T4+ Triamcinolone Acetonide
(Nasacort AQ)*** SL Veramyst E SL T4
6.2 Miscellaneous Otic PreparationsTIER 1
+ Acetic Acid (VoSol)+ Acetic Acid/Hydrocortisone (VoSol HC)+ Ofloxacin (Floxin Otic)
TIER 3 Cetraxal
6.3 Otic Steroid/AntibioticTIER 1
+ Neomycin Sulfate/Polymyxin B Sulfate/ Hydrocortisone (Cortisporin)
TIER 2 Ciprodex
TIER 3 Cipro HC Suspension, Drops Coly-Mycin S Suspension, Drops Cortisporin-TC Suspension, Drops
6.4 Miscellaneous AgentsTIER 1
+ Cevimeline HCl (Evoxac)+ Chlorhexidine Gluconate (Peridex)+ Lidocaine HCl (Xylocaine)+ Pilocarpine HCl (Salagen 5 mg)+ Sodium Fluoride Gel (Prevident 1 .1%)+ Triamcinolone Acetonide
(Kenalog in Orabase)
TIER 3 Astepro E SL T4 Atrovent Aerosol, Spray+ Azelastine HCl (Astelin)*** SL Patanase SL T4 Tyzine
30© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
7. Endocrine/Diabetes
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
7.1 Antithyroid AgentsTIER 1
+ Methimazole (Tapazole)+ Propylthiouracil (Propylthiouracil)
7.2 Thyroid HormonesTIER 1
+ Levothyroxine (Levothroid)
TIER 2+ Levothyroxine Sodium (Levoxyl)**+ Liothyronine Sodium (Cytomel)**+ Synthroid Tirosint
TIER 3 Armour Thyroid Thyrolar
7.3 Adrenal HormonesTIER 1
+ Dexamethasone (Decadron)+ Fludrocortisone Acetate (Florinef Acetate)+ Hydrocortisone Tablet (Cortef)+ Methylprednisolone Tablet, Dose Pack
(Medrol 4, 16, 32 mg) Orapred+ Prednisolone Sodium Phosphate Solution, Oral
(Pediapred)+ Prednisolone Syrup (Prelone)+ Prednisone (Meticorten)
TIER 2 Medrol 2, 8, 24 mg Pediapred
TIER 3 Acthar H .P . DSP N SL
ST T4 Celestone Oral Solution Orapred ODT Flo-Pred E T4 Rayos E T4
7.4 Miscellaneous Hormones7.4.1 ANDROGENS
TIER 1+ Danazol (Danocrine)
TIER 2 Androderm SL Android+ Oxandrolone (Oxandrin)** Testim SL
TIER 3 Androgel E SL T4 Axiron E SL T4 Fortesta E SL T4 Striant SL
7.4.2 MISCELLANEOUS AGENTS
TIER 1+ Calcitriol (Rocaltrol)+ Desmopressin Acetate (DDAVP)+ Octreotide Acetate (Octreotide Acetate) DSP N Paricalcitol (Zemplar) DSP
TIER 2+ Cabergoline (Dostinex)**+ Calcitonin Salmon Nasal Spray
(Miacalcin)**+ Calcitonin, Salmon, Synthetic Nasal
Spray (Fortical)** Hectorol Kuvan DSP N SL Samsca DSP SL Synarel
TIER 3 Sensipar DSP T4
31
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
7. Endocrine/Diabetes
7.4.3 GONADOTROPIN & RELATED AGENTS
Coverage is determined by the consumer’s prescription drug benefit plan .
TIER 2 Cetrotide (Cetrorelix Acetate) DSP
TIER 3 Ganirelix Acetate DSP
7.5 Diabetes Therapy7.5.1 INSULIN THERAPY
TIER 1 Humalog Mix 50-50 Vial Humalog Mix 75-25 Vial Humalog Vial Humulin 70-30 Vial Humulin N Vial Humulin R Vial
TIER 2 Humalog KwikPen Humalog Mix 50/50 KwikPen Humalog Mix 75/25 KwikPen Humulin 70-30 KwikPen Humulin N KwikPen Lantus Vial Levemir Vial
TIER 3 Apidra Solostar SDP T4 Apidra Vial SDP T4 Lantus Solostar Pen/Cartridge T4 Levemir Flexpen T4 Novolin Vial SDP T4 NovoLog 70-30 Flexpen SDP T4 NovoLog 70-30 Vial SDP T4 NovoLog Flexpen SDP T4 NovoLog Vial SDP T4
7.5.2 NON-INSULIN HYPOGLYCEMIC AGENTS
TIER 1+ Acarbose (Precose)+ Glimepiride (Amaryl)+ Glipizide (Glucotrol)+ Glipizide Tablet, Osmotic Laser-Drilled
Formulation (Glucotrol XL)+ Glyburide (DiaBeta)+ Glyburide, Micronized (Glynase)+ Glyburide/Metformin HCl (Glucovance)+ Metformin HCl (Glucophage)+ Metformin HCl Sustained-Release
(Glucophage XR)+ Pioglitazone HCl/Glimepiride (Duetact) SL
TIER 2 Byetta SL+ Glipizide/Metformin HCl (Metaglip)** Glyset Jentadueto SL Kazano SL Kombiglyze XR SL+ Nateglinide (Starlix)** SL Nesina SL Onglyza SL Oseni SL+ Pioglitazone HCl (Actos)** 1/2T SL+ Pioglitazone HCl/Metformin HCl
(Actoplus Met)** SL Repaglinide (Prandin)** SL Tradjenta SL
TIER 3 Actoplus Met XR SDP SL Avandamet SL Avandaryl SL Avandia SL Bydureon SL Glumetza T4 Janumet SDP SL T4 Janumet XR SDP SL T4 Januvia SDP SL T4+ Metformin HCl Tablet, Extended-Release
24 Hour (Fortamet)*** Riomet Solution, Oral Symlin SL Victoza SL
7.5.3 GLUCOSE ELEVATING AGENTS
TIER 2 Glucagen SL Glucagon
(Glucagon, Human Recombinant) SL Glucagon Emergency Kit (Glucagon Kit) SL
32© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
7. Endocrine/Diabetes
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
7.5.4 INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQUIPMENT
TIER 1 Accu-Chek Aviva Plus Accu-Chek Nano SmartView One Touch Ultra 2 System One Touch Ultra Mini System One Touch Verio IQ System
7.5.5 BLOOD GLUCOSE MONITORING SUPPLIES
TIER 1 Accu-Chek Active Test Strips SL Accu-Chek Aviva Plus Test Strips SL Accu-Chek Comfort Curve Test Strips SL Accu-Chek Compact Test Strips SL Accu-Chek SmartView SL One Touch Test Strips SL One Touch Ultra Test Strips SL One Touch Verio IQ Test Strips SL
TIER 3 Ascensia Autodisc Test Strips SDP SL T4 Ascensia Breeze 2 Test Strips SDP SL T4 Contour Next Test Strips SDP SL T4 Contour Test Strips SDP SL T4 Freestyle Insulinx SDP SL T4 Freestyle Lite Test Strips SDP SL T4 Freestyle Test Strips SDP SL T4 Precision Xtra Test Strips SDP SL T4
Diabetic supplies may not be covered . This is determined by the consumer’s prescription drug benefit plan .
33
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
8. Gastroenterology
8.1 Ulcer Therapy8.1.1 H2 ANTAGONISTS
TIER 1+ Cimetidine Tablet, Liquid (Tagamet)+ Famotidine Suspension, Oral (Pepcid)+ Ranitidine HCl Syrup (Zantac Syrup)
TIER 2+ Nizatidine Solution, Oral (Axid Oral Solution)**
8.1.2 PROSTAGLANDINS
TIER 1+ Misoprostol (Cytotec)
8.1.3 OTHER ULCER THERAPY
TIER 1+ Sucralfate Tablet (Carafate)
TIER 2 Lansoprazole/Amoxicillin/Clarithromycin
(Prevpac) SL E
TIER 3 Carafate Oral Suspension Helidac E SL T4 Omeclamox Pak SL Prevpac E SL T4 Pylera SL
8.1.4 PROTON PUMP INHIBITORS
TIER 1+ Omeprazole (Prilosec)+ Pantoprazole (Protonix)
TIER 3 Dexilant SL+ Lansoprazole Capsule,
Delayed-Release (Prevacid)*** E SL T4+ Lansoprazole Tablet, Rapid Dissolve,
Delayed-Release (Prevacid Solutab)*** E SL T4 Nexium Capsule E SL Nexium Suspension SL+ Omeprazole/Sodium Bicarbonate
Capsule (Zegerid)*** E SL T4 Prevacid Capsule, Delayed-Release
(Enteric-Coated) E SL Rabeprazole (Aciphex)*** SL Zegerid Capsule E SL T4 Zegerid Packet SL
8.2 Antidiarrheals & Antispasmodics8.2.1 ANTIDIARRHEALS
TIER 1+ Diphenoxylate HCl/Atropine Sulfate (Lomotil)
TIER 3 Motofen
8.2.2 ANTISPASMODICS
TIER 1+ Dicyclomine HCl Tablet (Bentyl)+ Glycopyrrolate (Robinul, Robinul Forte)+ Hyoscyamine Sulfate (Levsin, Levsin/SL)+ Hyoscyamine Sulfate Capsule, Sustained-Release
12 Hour (Levsinex)+ Hyoscyamine Sulfate Drops (Spasdel)+ Hyoscyamine Sulfate Tablet, Rapid Dissolve
(Nulev)+ Hyoscyamine Sulfate Tablet, Sustained-Release
12 Hour (Levbid)
TIER 3 Cantil Symax Duotab
8.2.3 COMBINATION ANTICHOLINERGICS
TIER 1+ Belladonna Alkaloids/Phenobarbital (Donnatal)
TIER 3 Donnatal Tablet, Sustained-Action
34© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
8. Gastroenterology
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
8.3 Miscellaneous Gastrointestinal Agents8.3.1 BILE ACIDS
TIER 1+ Ursodiol (Actigall, URSO 250, URSO Forte)
8.3.2 DIGESTIVE ENZYMES
TIER 2 Creon Sucraid Zenpep
TIER 3 Pancreaze SDP Pertzye E T4 Ultresa E T4 Viokace E T4
8.3.3 MISCELLANEOUS GASTROINTESTINAL AGENTS
TIER 1+ Balsalazide Disodium (Colazal)+ Cromolyn Sodium (Gastrocrom)+ Hydrocortisone (Cortenema)+ Hydrocortisone Acetate Suppository, Rectal
(Anusol-HC)+ Hydrocortisone Acetate/Pramoxine HCl
(Analpram-HC)+ Hydrocortisone Cream
(ProctoCream-HC 2 .5%, Anusol-HC 2 .5%)
+ Lactulose (Cephulac, Chronulac)+ Mesalamine Enema (Rowasa)+ Metoclopramide HCl (Reglan)+ Sulfasalazine Tablet (Azulfidine)+ Sulfasalazine Tablet, Enteric-Coated
(Azulfidine)
TIER 2 Apriso+ Budesonide Capsule,
Sustained-Release (Entocort EC)** Canasa Cortifoam Lialda Lotronex N SL Relistor
TIER 3 Amitiza N SL T4 Asacol HD E T4 Delzicol E T4 Dipentum Kristalose Metozolv ODT E T4 Osmoprep Pentasa E T4 Procort E T4 Rectiv N SL Uceris Visicol
8.3.4 ANTIVERTIGO & ANTIEMETIC AGENTS
TIER 1+ Dronabinol (Marinol)+ Ondansetron HCl (Zofran)+ Ondansetron HCl Tablet, Rapid Dissolve
(Zofran ODT)+ Prochlorperazine Maleate Tablet
(Compazine)+ Promethazine HCl (Phenergan)+ Trimethobenzamide HCl Capsule
(Tigan 250, 300 mg)
TIER 2 Antivert 50 mg Emend SL+ Granisetron HCl Tablet (Kytril)** SL
TIER 3 Anzemet SL Cesamet Sancuso E SL T4 Transderm-Scop Zuplenz E SL T4
8.3.5 BOWEL EVACUANTS
TIER 1+ Polyethylene Glycol 3350 Powder (Glycolax)+ Sod Chloride/NaHCO3/KCl/PEGs
(Nulytely w/Flavor Packs)+ Sodium Sulfate/Sodium/Sodium Bicarbonate/
Potassium Chloride/Polyethylene Glycols (Colyte)
+ Sodium Sulfate/Sodium/Sodium Bicarbonate/ Potassium Chloride/Polyethylene Glycols Solution, Reconstituted, Oral (GoLYTELY)
TIER 2 GoLYTELY
TIER 3 Halflytely Moviprep Prepopik Suclear Suprep
35
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
9. Immunology, Vaccines & Biotechnology
9.1 Biotechnology Drugs9.1.1 ERYTHROID STIMULANTS
TIER 2 Aranesp DSP SL Epogen DSP SL Procrit DSP SL
9.1.2 MYELOID STIMULANTS
TIER 2 Leukine DSP Mozobil DSP Neupogen DSP
TIER 3 Neulasta DSP
9.1.3 INTERFERONS
TIER 2 Actimmune DSP N SL Alferon N Pegasys DSP N SL
TIER 3 Infergen DSP N SL T4 Intron A DSP N T4 Peg-Intron DSP N
SL ST T4
9.1.4 GROWTH HORMONES
TIER 2 Increlex DSP N SL Nutropin DSP N SL Nutropin AQ DSP N SL Nutropin AQ NuSpin DSP N SL Saizen DSP N SL Tev-Tropin DSP N SL
TIER 3 Egrifta DSP N T4 Genotropin DSP E N SL T4 Humatrope DSP E N SL T4 Norditropin DSP E N SL T4 Omnitrope DSP E N SL T4 Serostim DSP N SL T4 Zorbtive DSP N SL
9.1.5 INTERLEUKINS
TIER 2 Arcalyst N SL Neumega DSP
36© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
10. Musculoskeletal & Rheumatology
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
Note: OTC medications are not on the Prescription Drug list, but are listed for informational purposes.
10.1 Nsaid Agents10.1.1 NSAIDS
TIER 1+ Diclofenac Potassium (Cataflam)+ Diclofenac Sodium (Voltaren)+ Diclofenac Sodium Tablet, Sustained-Release
24 Hour (Voltaren-XR)+ Etodolac (Lodine)+ Etodolac Tablet, Sustained-Release 24 Hour
(Lodine XL)+ Fenoprofen Calcium (Nalfon)+ Flurbiprofen (Ansaid)+ Ibuprofen (Motrin)+ Indomethacin (Indocin)+ Indomethacin Capsule, Sustained-Action
(Indocin SR)+ Ketoprofen (Orudis)+ Ketoprofen Capsule, 24 Hour
Sustained-Release (Oruvail 200 mg)+ Ketorolac Tromethamine (Toradol)+ Meclofenamate Sodium (Meclomen)+ Meloxicam (Mobic)+ Nabumetone (Relafen)+ Naproxen (EC-Naprosyn)+ Naproxen (Naprosyn)+ Naproxen Sodium (Anaprox, Anaprox DS)+ Oxaprozin (Daypro)+ Piroxicam (Feldene)+ Sulindac (Clinoril)
TIER 2+ Tolmetin Sodium (Tolectin)**+ Tolmetin Sodium (Tolectin DS)** Voltaren Gel
TIER 3 Cambia E SL T4+ Diclofenac Sodium/Misoprostol
(Arthrotec)*** Duexis E SL T4 Flector E T4+ Mefenamic Acid (Ponstel)*** Naprelan E T4 Pennsaid E T4 Sprix Vimovo E SL T4 Zipsor E T4
10.1.1.1 NSAIDS - SPECIFIC COX-II INHIBITORS
TIER 3 Celebrex SL T4
10.1.2 SALICYLATES
TIER 1+ Salsalate (Salflex)
10.2 Gout TherapyTIER 1
+ Allopurinol (Zyloprim)+ Probenecid (Benemid)
TIER 2 Colcrys
TIER 3 Uloric SL T4
10.3 Other Rheumatologicals10.3.1 MISCELLANEOUS RHEUMATOLOGICAL AGENTS
TIER 1+ Azathioprine (Imuran)+ Hydroxychloroquine Sulfate (Plaquenil)+ Leflunomide (Arava)+ Methotrexate Sodium (Methotrexate)+ Sulfasalazine Tablet (Azulfidine)+ Sulfasalazine Tablet, Enteric-Coated
(Azulfidine)
TIER 2 Cimzia DSP N SL Cuprimine Enbrel DSP N SL Simponi DSP N SL Trexall
TIER 3 Humira DSP N
SL ST T4 Kineret DSP N SL Orencia DSP N SL Savella SL T4 Xeljanz DSP N
SL ST T4
37
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
10. Musculoskeletal & Rheumatology
10.3.2 MUSCLE RELAXANTS & ANTISPASMODIC THERAPY
TIER 1+ Baclofen (Lioresal)+ Carisoprodol (Soma 350 mg)+ Chlorzoxazone (Parafon Forte DSC)+ Cyclobenzaprine HCl (Flexeril)+ Dantrolene Sodium (Dantrium)+ Diazepam (Valium)+ Methocarbamol (Robaxin)+ Tizanidine HCl Tablet (Zanaflex)+ Trospium Chloride (Sanctura)
TIER 2+ Orphenadrine (Norflex)**+ Orphenadrine/Aspirin/Caffeine
(Norgesic, Norgesic Forte)**
TIER 3+ Carisoprodol (Soma 250 mg)*** E T4+ Cyclobenzaprine Capsule,
Extended-Release 24 Hour (Amrix)*** E T4 Lorzone E T4+ Metaxalone (Skelaxin 800 mg)***+ Tizanidine HCl Capsule (Zanaflex)***
10.4 Osteoporosis TherapyTIER 1
+ Alendronate Sodium (Fosamax) SL
TIER 2+ Calcitonin Salmon Nasal Spray
(Miacalcin)**+ Calcitonin, Salmon, Synthetic Nasal
Spray (Fortical)** Evista Forteo DSP N+ Ibandronate Sodium (Boniva)** SL
TIER 3 Actonel SL Atelvia E SL T4 Binosto E SL T4 Fosamax Plus D SL
38© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
11. Obstetrics & Gynecology
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
11.1 Contraceptives & Related Agents11.1.1 MONOPHASIC/BIPHASIC/TRIPHASIC AGENTS
TIER 1+ Desogestrel-Ethinyl Estradiol (Desogen) Ella SL+ Ethinyl Estradiol/Desogestrel (Cyclessa)+ Ethynodiol D-Ethinyl Estradiol (Demulen)+ Levonorgestrel-Ethinyl Estradiol (Alesse)+ Levonorgestrel-Ethinyl Estradiol (Nordette)+ Levonorgestrel-Ethinyl Estradiol (Triphasil) Natazia + Norethindrone A-E Estradiol/Ferrous
Fumarate (Loestrin Fe)+ Norethindrone-Ethinyl Estradiol (Modicon)+ Norethindrone-Ethinyl Estradiol
(Ortho-Novum 1-0 .035 mg)+ Norethindrone-Ethinyl Estradiol
(Ortho-Novum 10-11)+ Norethindrone-Ethinyl Estradiol (TriNorinyl)+ Norethindrone-Mestranol
(Ortho-Novum 1-0 .05 mg)+ Norethindrone-Mestranol
(Ortho-Novum 2-0 .1 mg)+ Norgestrel-Ethinyl Estradiol (Lo/Ovral) Ortho Tri-Cyclen* Ortho-Cyclen* Ortho-Novum 7/7/7* Plan B Yasmin*
TIER 2+ Desogestrel-Ethinyl Estradiol/Ethinyl
Estradiol (Mircette)**+ Levonorgestrel-Eth Estr/Ethinyl Estradiol
(LoSeasonique)** MC+ Levonorgestrel-Ethinyl Estradiol Tablet,
Dosepak, 3 month (Seasonale)** MC+ Norethindrone A-E Estradiol
(Loestrin)**+ Norethindrone-Ethinyl Estradiol
(Ovcon 35)**+ Norgestrel-Ethinyl Estradiol (Ovral)** Nuvaring Yaz^^
TIER 3 Beyaz E T4+ Ethinyl Estradiol/Drospirenone
(Yasmin)***+ Ethinyl Estradiol/Drospirenone (Yaz)*** Generess Fe E T4+ Levonorgestrel-Eth Estr/Ethinyl
Estradiol (Seasonique)*** MC+ Levonorgestrel-Ethinyl Estradiol
(Lybrel)*** Lo Loestrin Fe Loestrin 24 Fe+ Norethindrone A-E Estradiol/Ferrous
Fumarate (Estrostep Fe)***+ Norethindrone-Ethinyl Estradiol
(Ortho-Novum 7/7/7)***+ Norethindrone-Ethinyl Estradiol /Iron
Tablet, Chewable (Femcon Fe)***+ Norgestimate-Ethinyl Estradiol
(Ortho Tri-Cyclen)***+ Norgestimate-Ethinyl Estradiol
(Ortho-Cyclen)*** Ortho Evra Ortho Tri-Cyclen Lo Ovcon Safyral E T4
11.2 OxytocicsTIER 1
+ Methylergonovine Maleate (Methergine)
11.3 Estrogens & Progestins11.3.1 PROGESTINS
TIER 1+ Medroxyprogesterone Acet
(Depo-Provera 150 mg/ml) MC+ Medroxyprogesterone Acet (Provera)+ Norethindrone Acetate (Aygestin) Ortho Micronor*
TIER 2 Crinone1 N Depo-SubQ Provera MC+ Progesterone, Micronized (Prometrium)**
TIER 3 Endometrin N+ Norethindrone (Ortho Micronor)*** Nor-Q-D1Benefit determines coverage of treatment of infertility .
39
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
11. Obstetrics & Gynecology
11.3.2 ESTROGENS
TIER 1+ Estradiol (Estrace)+ Estradiol Patch, Transdermal Weekly
(Climara) SL+ Estropipate Tablet (Ogen)
TIER 2 Cenestin Climara SL Divigel Enjuvia Estrace Cream with Applicator Estring MC SL Evamist Vagifem Vivelle-Dot SL
TIER 3 Alora SL Elestrin Estrasorb SL Estrogel SL Femring MC SL Menest Menostar Patch, Transdermal Weekly SL Premarin
11.3.3 ESTROGEN COMBINATIONS
TIER 2+ Estradiol/Norethindrone Acetate (Activella)** Prefest (Estradiol/Norgestimate)
TIER 3 Angeliq Climara Pro SL Combipatch SL+ Norethindrone Acetate/Ethinyl Estradiol
(Femhrt)*** Premphase Prempro
11.4 Miscellaneous OB/GYN11.4.1 DRUGS TO TREAT INFERTILITY /IVF AGENTS
Coverage is determined by the consumer’s prescription drug benefit plan .
TIER 1+ Clomiphene Citrate (Clomid)+ Clomiphene Citrate (Serophene)+ Leuprolide Acetate (Lupron 1 mg/0 .2 ml) N
TIER 2 Cetrotide DSP Gonal-F DSP Gonal-F RFF DSP
TIER 3 Bravelle DSP ST T4 Follistim AQ DSP ST T4 Menopur DSP T4 Ovidrel DSP Repronex DSP T4
11.4.2 VAGINAL CLEANSER/ANTI-INFECTIVES
TIER 1+ Clindamycin Phosphate Cream w/Applicator
(Cleocin Phosphate)+ Metronidazole Vaginal Gel (Metrogel Vaginal)
TIER 2 AVC Cleocin Phosphate Clindesse
11.4.3 VAGINAL ANTIFUNGALS
TIER 1+ Fluconazole (Diflucan 150 mg)+ Terconazole Cream w/Applicator (Terazol)+ Terconazole Suppository, Vaginal (Terazol)
TIER 3 Gynazole-1
11.4.4 SPECIALIZED OB/GYN DRUGS
TIER 1+ Terbutaline Sulfate (Brethine)
TIER 2 Synarel+ Tranexamic Acid (Lysteda)** SL
40© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
12. Ophthalmology
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
12.1 Beta-BlockersTIER 1
+ Betaxolol HCl (Betoptic)+ Carteolol HCl (Ocupress)+ Levobunolol HCl (Betagan)+ Metipranolol (OptiPranolol)+ Timolol Maleate (Timoptic-XE)+ Timolol Maleate Drops (Timoptic)
TIER 2 Betimol SL
TIER 3 Betoptic S Istalol
12.2 Direct Acting MioticsTIER 1
+ Pilocarpine HCl (Isopto Carpine 0 .5%, 1%, 2%, 4%, 6%)
TIER 2 Pilopine HS
12.3 Other Glaucoma DrugsTIER 1
+ Dorzolamide HCl (Trusopt)+ Latanoprost (Xalatan) SL
TIER 2 Azopt SL Combigan SL+ Dorzolamide HCl/Timolol Maleate
(Cosopt)** Lumigan SL Travatan Z SL
TIER 3 Cosopt PF E SL T4+ Travoprost (Travatan)*** ST Zioptan SL ST
12.4 Oral Drugs For GlaucomaTIER 1
+ Acetazolamide (Diamox)+ Acetazolamide Capsule, Sustained-Action
(Diamox Sequel)+ Methazolamide (Neptazane)
12.5 Cycloplegic MydriaticsTIER 1
+ Atropine Sulfate (Isopto Atropine)+ Cyclopentolate HCl (Cyclogyl 1%, 2%)+ Tropicamide (Mydriacyl)
TIER 2 Isopto Homatropine (Homatropine HBr)
TIER 3 Cyclogyl 0 .5 Paremyd
12.6 Non-Steroidal Anti-Inflammatory Agents
TIER 1+ Diclofenac Sodium (Voltaren)+ Flurbiprofen Sodium (Ocufen)+ Ketorolac Tromethamine (Acular)+ Ketorolac Tromethamine (Acular LS) SL
TIER 3 Acuvail E SL T4 Bromday E SL T4+ Bromfenac Sodium (Xibrom)*** SL Nevanac SL T4
12.7 Vasoconstrictor DecongestantsTIER 1
+ Naphazoline HCl (Albalon)+ Phenylephrine HCl (Neo-Synephrine)
41
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
12. Ophthalmology
12.8 AntibioticsTIER 1
+ Bacitracin/Polymyxin B Sulfate (Polysporin)+ Ciprofloxacin HCl Drops (Ciloxan)+ Erythromycin Base (Ilotycin)+ Gentamicin Sulfate (Garamycin)+ Levofloxacin (Quixin)+ Neomycin Sulfate/Bacitracin/Polymyxin B
Ointment (Neosporin)+ Neomycin Sulfate/Gramicidin D/Polymyxin B
Drops (Neosporin)+ Ofloxacin (Ocuflox)+ Polymyxin B Sulfate/Trimethoprim
(Polytrim)+ Tobramycin Sulfate Drops (Tobrex)
TIER 3 Azasite SL Ciloxan Ointment Gatifloxacin (generic Zymaxid) SL Moxeza T4 Natacyn Tobrex Ointment Vigamox T4
12.9 SulfonamidesTIER 1
+ Sulfacetamide Sodium (Bleph-10, Sodium Sulamyd)
12.10 SteroidsTIER 1
+ Dexamethasone Sodium Phosphate (Decadron)
+ Fluorometholone (FML)+ Prednisolone Acetate (Pred Forte)+ Prednisolone Sodium Phosphate
(Inflamase Forte)
TIER 2 FML Forte Pred Mild Vexol
TIER 3 Alrex SL T4 Durezol T4 Lotemax Ointment, Suspension SL T4
12.11 Steroid-Antibiotic CombinationsTIER 1
+ Neomycin Sulfate/Bacitracin Zinc/Polymyxin B/Hydrocortisone Ointment (Cortisporin)
+ Neomycin Sulfate/Polymyxin B Sulfate/ Hydrocortisone Suspension, Drops (Cortisporin)
+ Neomycin/Polymyxin B Sulfate/ Dexamethasone (Maxitrol)
TIER 2+ Tobramycin/Dexamethasone Suspension
(Tobradex)**
TIER 3 Pred-G Tobradex ST E SL T4 Zylet
12.12 Steroid-Sulfonamide CombinationsTIER 1
+ Sulfacetamide Sodium/Prednisolone Sodium Phosphate (Vasocidin)
TIER 2 Blephamide S .O .P .
TIER 3 Blephamide Suspension, Drops
12.13 SympathomimeticsTIER 1
+ Apraclonidine HCl Drops (Iopidine 0 .5%)
TIER 2 Alphagan P SL+ Brimonidine Tartrate 0.15%
(Alphagan P)*** SL
TIER 3 Iopidine 1%
42© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
12. Ophthalmology
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
12.14 Miscellaneous OphthalmologicsTIER 1
+ Cromolyn Sodium (Crolom)
TIER 2 Lacrisert
TIER 3 Alocril Alomide+ Azelastine HCl Drops (Optivar)*** SL Bepreve E SL T4 Emadine E T4+ Epinastine HCl Drops (Elestat)*** E SL T4 Lastacaft SL Pataday E SL T4 Patanol E SL T4 Restasis N SL T4
12.15 AntiviralsTIER 1
+ Trifluridine (Viroptic)
TIER 3 Zirgan SL
43
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
13. Respiratory, Allergy, Cough & Cold
13.1 Antihistamine & Antiallergenic AgentsNote: OTC medications are not on the Prescription Drug List, but are listed for information purposes . If a prescription product is identical to an OTC product in strength and dosage form, the prescription product is not included in the drug list .
Claritin (Loratadine Tablet, Syrup) - OTC
13.1.1 ANTIHISTAMINES
TIER 1+ Clemastine Fumarate (Tavist)+ Cyproheptadine HCl (Periactin)+ Hydroxyzine HCl (Atarax)+ Hydroxyzine Pamoate Capsule (Vistaril)+ Levocetirizine Dihydrochloride Tablet
(Xyzal) SL+ Promethazine HCl (Phenergan)
TIER 2 Vistaril Suspension
TIER 3+ Desloratadine (Clarinex)*** E SL+ Levocetirizine Dihydrochloride Solution,
Oral (Xyzal)*** SL
13.1.2 ADRENERGICS
TIER 2 Epipen SL Epipen Jr SL
TIER 3 Auvi-Q E SL T4
13.2 Cough & Cold TherapyAntitussive and Expectorant Drugs Only prescription antitussive and expectorant drugs are included in the Prescription Drug List . The use of OTC antitussive and expectorant products is recommended when possible . While not all comparable OTC alternatives to prescription products are provided below, where applicable at least one is listed for informational purposes .
13.2.1 ANTITUSSIVE COMBINATIONS
TIER 1+ Codeine/Promethazine HCl
(Phenergan w/Codeine)+ Dextromethorphan HBr/Pseudoephedrine
HCl/Brompheniramine (Bromfed-DM)+ Guaifenesin/Codeine Phosphate
(Robitussin A-C)+ Guaifenesin/Pseudoephedrine HCl/
Codeine (Robitussin-DAC)+ Phenylephrine HCl/Codeine/
Promethazine (Phenergan VC w/Codeine)
+ Phenylephrine HCl/Hydrocodone Bit/ Chlorpheniramine (Histussin HC)
TIER 3+ Hydrocodone/Chlorpheniramine
Suspension, Sustained-Release 12 Hour (Tussionex)*** SL
Zutripro SL
Antihistamine/Decongestant Combinations Only prescription antihistamine/decongestants are included in the Prescription Drug List . The use of OTC antihistamine/decongestant products is recommended when possible . While not all comparable OTC alternatives to prescription products are provided below, where applicable at least one is listed for informational purposes . Strength is listed in mg .
Claritin-D (Pseudoephedrine Sulfate/Loratadine) - OTC
13.2.3 DECONGESTANT/ANTIHISTAMINES
TIER 1+ Phenylephrine HCl/Promethazine HCl
(Phenergan VC)
TIER 3 Clarinex-D E SL
44© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
13. Respiratory, Allergy, Cough & Cold
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
13.3 Pulmonary Agents13.3.1 XANTHINES
TIER 1+ Theophylline Anhydrous Tablet,
Extended-Release 12 Hour (Theochron)
TIER 3 Elixophyllin Elixir Lufyllin Tablet Theo-24
13.3.2 BETA AGONISTS ORAL
TIER 1+ Albuterol Sulfate (Proventil, Ventolin)+ Metaproterenol Sulfate (Alupent)+ Terbutaline Sulfate (Brethine)
13.3.3 INHALED BETA AGONISTS
TIER 1+ Albuterol Sulfate Solution (AccuNeb,
Proventil)+ Metaproterenol Sulfate Solution,
Non-Oral (Alupent) Ventolin HFA (Albuterol Sulfate
HFA Aerosol) SL
TIER 2 Foradil SL
TIER 3 Brovana SL Perforomist SL Proair HFA SL Proventil HFA SL Serevent Diskus SL Xopenex HFA SL+ Levalbuterol HCl (Xopenex Vial,
Nebulizer)*** E SL T4
13.3.4 INHALED CORTICOSTEROIDS
TIER 1 Alvesco SL Asmanex SL QVAR SL
TIER 2+ Budesonide Inhalation Suspension
(Pulmicort Respules 0 .25 mg/2 ml, 0 .5 mg/2 ml)** SL
Pulmicort Respules 1 mg/2 ml SL
TIER 3 Flovent Diskus SDP SL Flovent HFA SDP SL T4 Pulmicort Flexhaler SDP SL T4
13.3.5 INTRANASAL STEROIDS
TIER 1+ Flunisolide (Nasarel)+ Fluticasone Propionate (Flonase) SL
TIER 2 Omnaris SL Zetonna SL
TIER 3 Beconase AQ E SL T4 Dymista E SL T4 Nasonex SL Qnasl SL Rhinocort Aqua SL T4+ Triamcinolone Acetonide
(Nasacort AQ)*** SL Veramyst E SL T4
13.3.6 MISCELLANEOUS PULMONARY AGENTS
TIER 1+ Acetylcysteine Vial, Nebulizer (Mucomyst)+ Cromolyn Sodium Ampul for Nebulization
(Intal)+ Ipratropium Bromide Solution, Non-Oral
(Atrovent)+ Montelukast Sodium (Singulair) SL+ Sildenafil Citrate (Revatio) DSP N SL+ Zafirlukast (Accolate) SL
TIER 2+ Albuterol Sulfate/Ipratropium Solution,
Non-Oral (Duoneb)** Letairis DSP N Pulmozyme DSP N SL Spiriva SL Tracleer DSP N Tudorza Pressair SL Tyvaso DSP N Ventavis DSP N
TIER 3 Adcirca DSP N SL T4 Advair Diskus RS SL Advair HFA RS SL Atrovent HFA SL Combivent Respimat SL Daliresp N SL Dulera RS SL Symbicort SDP SL T4 Zyflo Zyflo CR SL
45
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
14. Urologicals
14.1 Cholinergic StimulantsTIER 1
+ Bethanechol Chloride (Urecholine)
14.2 Anticholinergics & AntispasmodicsTIER 1
+ Dicyclomine HCl Tablet (Bentyl)+ Flavoxate HCl (Urispas)+ Hyoscyamine Sulfate (Levsin, Levsin/SL)+ Hyoscyamine Sulfate Capsule,
Sustained-Release 12 Hour (Levsinex)+ Hyoscyamine Sulfate Drops (Spasdel)+ Hyoscyamine Sulfate Tablet, Rapid Dissolve
(Nulev)+ Hyoscyamine Sulfate Tablet,
Sustained-Release 12 Hour (Levbid)+ Oxybutynin Chloride (Ditropan)+ Trospium Chloride (Sanctura)
TIER 2+ Oxybutynin Chloride Tablet,
Sustained-Release (Ditropan XL)**
TIER 3 Detrol LA E T4 Enablex E T4 Gelnique E T4 Myrbetriq E T4 Oxytrol E T4+ Tolterodine Tartrate (Detrol)*** E T4 Toviaz+ Trospium Chloride Capsule,
Sustained-Release 24 Hour (Sanctura XR)*** E T4
Vesicare E T4
14.3 Urinary AnestheticsTIER 1
+ Phenazopyridine HCl (Pyridium)
14.4 Miscellaneous UrologicalsTIER 1
+ Citric Acid/Sodium Citrate (Bicitra)
TIER 2 Elmiron K-Phos M .F . K-Phos Original Oracit Renacidin
TIER 3 Caverject SL Cialis1 SL T4 Edex SL Levitra1 SL T4 Muse SL Staxyn1 E SL T4 Viagra1 SL T41 Patient must be an adult male (over 18 years of age) and should not be using concomitant nitrate
products (e .g ., nitroglycerin) nor be receiving other drugs for treatment of sexual dysfunction (e .g ., Caverject, Muse) .
14.5 Benign Prostatic Hyperplasia (BPH) Therapy
TIER 1+ Alfuzosin HCl (Uroxatral)+ Doxazosin Mesylate (Cardura)+ Finasteride (Proscar)+ Tamsulosin HCl (Flomax)+ Terazosin HCl (Hytrin)
TIER 3 Avodart N SDP T4 Cialis SL ST T4 Jalyn E T4 Rapaflo T4
46© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
15. Vitamins, Hematinics & Electrolytes
MC Multiple copayN Notification or Prior Authorization required**RS May be eligible for the Refill and Save ProgramSDP Select Designated Pharmacy
SL Supply limitST Step TherapyT4 May be covered on Tier 4 in selected benefits
+ Generic equivalent available1/2T Eligible for Half Tablet ProgramDSP Designated Specialty ProgramE May be excluded from coverage
** Depending on your patient’s benefit, they may have notification or prior authorization requirements for select medications.
15.1 Vitamins & HematinicsInjectable vitamins are not included in the Prescription Drug List .
Multivitamins are NOT included in the Prescription Drug List as various OTC products are available .
TIER 1+ Fluoride Ion/Iron/Multivitamins (Poly-Vi-Flor w/Iron)+ Fluoride Ion/Iron/Vitamins A,C, and D
(Tri-Vi-Flor w/Iron)+ Fluoride Ion/Multivitamins (Poly-Vi-Flor)+ Fluoride Ion/Vitamins A,C, and D (Tri-Vi-Flor)+ Prenatal Vit/Fe Fumarate/FA (Prenatal)+ Sodium Fluoride (Luride)
TIER 2+ PNV No. 52/Iron B-G Suc-Pro/FA Tablet (Duet
Stuartnatal 29 mg-1 mg)**+ PNV48/Iron Na Feredetat/Fa/Omega 3
(Duet DHA with Ferrazone)**+ Prenat Vit Comb 10/Iron/Fa/DHA
(Vitafol-OB + DHA)**
TIER 3 Nascobal+ PNN W-Ca #68/Iron/Fa #1/DHA
(Prenate Essential 28-1-300 mg)***+ PNV W-Ca #40/Iron Fum/Fa CMB #1
(Prenate Elite 27 mg -1 mg)***+ PNV Combo #47/Iron/Fa #1/DHA
(Prenate DHA 27-1-300 mg)***+ PNV39/Iron Fumarate/Fa/DSS/DHA
(Prenexa 30-1 .2-55)***+ PNV39/Iron CBN&Gluc/FA/DSS/DHA
(Citranatal Assure)***+ PNV66/Iron Fumarate/Fa/DSS/DHA
(Prenexa 27-1 .25-55)***
15.2 Electrolytes15.2.1 POTASSIUM
TIER 1+ Potassium Chloride (K-Dur)+ Potassium Chloride Capsule, Sustained-Action
(Micro-K)+ Potassium Chloride Packet (Klor-Con 25mEq)+ Potassium Chloride Tablet, Sustained-Action
(K-Tab, Slow-K)
TIER 3 K-Tab
15.2.2 OTHER ELECTROLYTES
TIER 1+ Calcium Acetate (PhosLo)
47
Please refer to page 4 for a definition of notations/symbols.
* Products listed in Tier 1 may be covered in Tier 3 in a non-standard Prescription Drug List *** Products listed in Tier 3 may be covered in Tier 1 in a non-standard Prescription Drug List ** Products listed in Tier 2 may be covered in Tier 1 in a non-standard Prescription Drug List ^̂ Products listed in Tier 2 may be covered in Tier 3 in a non-standard Prescription Drug List
© 2013 UnitedHealthCare Services, Inc. All rights reserved. 1/14
16. Diagnostics & Miscellaneous Agents
16.1 Miscellaneous AgentsTIER 1
Acamprosate (Campral) + Anagrelide HCl (Agrylin)+ Disulfiram (Antabuse)+ Etidronate Disodium (Didronel)+ Levocarnitine (Carnitor)+ Midodrine HCl (ProAmatine)+ Pilocarpine HCl (Salagen) Riluzole (Rilutek) + Sodium Polystyrene Sulfonate (Kayexalate)
TIER 2 Carbaglu Chemet Exjade DSP N Fosrenol Renagel Renvela
TIER 3 Ferriprox DSP N SL T4
16.2 Smoking DeterrentsTIER 1
+ Bupropion HCl Tablet, Sustained-Action (Zyban)1
+ Nicotine Patch, Transdermal 24 Hour (Habitrol)1
TIER 3 Chantix1 T4 Nicotrol Inhaler T4 Nicotrol NS1 T41 Smoking cessation product coverage is determined by the consumer’s prescription drug
benefit plan .
16.3 AnorexiantsAppetite Suppressants (e .g . Ionamin, Meridia, Xenical, etc ., and amphetamines when used as appetite suppressants) are Tier 3 . Coverage is determined by the consumer’s prescription drug benefit plan .
48
Brand Only ExclusionsMedication Name Coverage Status Covered Alternative(s)
Actiq Brand Only Exclusion fentanyl lozenge (generic Actiq) Actos Brand Only Exclusion pioglitazone (generic Actos) Adderall Brand Only Exclusion amphetamine/dextroamphetamine immediate-release (generic Adderall) Adoxa tablet Brand Only Exclusion doxycycline hyclate (generic Vibra-Tab), doxycycline monohydrate tablets
(generic Adoxa tablets) Ambien Brand Only Exclusion zolpidem (generic Ambien) Ambien CR Brand Only Exclusion zolpidem (generic Ambien), zolpidem extended-release (generic Ambien CR) Arimidex Brand Only Exclusion anastrozole (generic Arimidex) Astelin Brand Only Exclusion azelastine nasal spray (generic Astelin) Ativan Brand Only Exclusion lorazepam (generic Ativan) Benzaclin jar Brand Only Exclusion clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) Celexa Brand Only Exclusion citalopram (generic Celexa) Concerta Brand Only Exclusion methylphenidate immediate-release (generic Ritalin), methylphenidate
extended release (generic Concerta), Adderall XR, Vyvanse Diovan HCT Brand Only Exclusion valsartan/hydrochlorothiazide (generic Diovan HCT) Effexor XR Brand Only Exclusion venlafaxine extended-release capsule (generic Effexor XR) Entocort EC Brand Only Exclusion budesonide (generic Entocort EC) Femara Brand Only Exclusion letrozole (generic Femara) Flomax Brand Only Exclusion tamsulosin (generic Flomax) Geodon Brand Only Exclusion ziprasidone (generic Geodon) Imitrex injection & tablets Brand Only Exclusion sumatriptan injection, tablets (generic Imitrex) Lexapro Brand Only Exclusion escitalopram (generic Lexapro) Lipitor Brand Only Exclusion atorvastatin (generic Lipitor) Maxalt Brand Only Exclusion rizatriptan (generic Maxalt) Maxalt-MLT Brand Only Exclusion rizatriptan (generic Maxalt), rizatriptan orally disintegrating tablet (generic Maxalt MLT) Metadate CD Brand Only Exclusion methylphenidate immediate-release (generic Ritalin), methylphenidate
extended release (generic Concerta), Adderall XR, Vyvanse Monodox Brand Only Exclusion doxycycline hyclate (generic Vibramycin), doxycycline monohydrate (generic Monodox) Natroba Brand Only Exclusion malathion (generic Ovide), permethrin (generic Elimite), spinosad
(generic Natroba) Optivar Brand Only Exclusion azelastine (generic Optivar), Lastacaft Percocet Brand Only Exclusion acetaminophen/oxycodone (generic Percocet) Plavix Brand Only Exclusion clopidogrel (generic Plavix) Prilosec Capsules Brand Only Exclusion omeprazole (generic Prilosec) Protonix Brand Only Exclusion pantoprazole (generic Protonix) Prozac Brand Only Exclusion fluoxetine (generic Prozac) Revatio Brand Only Exclusion sildenafil (generic Revatio) Risperdal Brand Only Exclusion risperidone (generic Risperdal) Seroquel Brand Only Exclusion quetiapine (generic Seroquel) Singulair Chewable Tablet Brand Only Exclusion montelukast chewable tablet (generic Singulair) Singulair Tablet Brand Only Exclusion montelukast (generic Singulair) Skelaxin Brand Only Exclusion metaxalone (generic Skelaxin) Valium Brand Only Exclusion diazepam (generic Valium) Valtrex Brand Only Exclusion valacyclovir (generic Valtrex) Wellbutrin SR Brand Only Exclusion bupropion exteneded-release (generic Wellbutrin SR) Wellbutrin XL Brand Only Exclusion bupropion exteneded-release (generic Wellbutrin XL) Xanax Brand Only Exclusion alprazolam (generic Xanax) Xanax XR Brand Only Exclusion alprazolam extended-release (generic Xanax XR) Zoloft Brand Only Exclusion sertraline (generic Zoloft) Zovirax Ointment Brand Only Exclusion acyclovir ointment (generic Zovirax) Zyprexa Brand Only Exclusion olanzapine (generic Zyprexa) Zyprexa Zydis Brand Only Exclusion olanzapine (generic Zyprexa), olanzapine orally disintegrating tablet
(generic Zyprexa Zydis)
49
2014 Prescription Drug List Medication Index
AA/T/S . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Abacavir Sulfate Tablet . . . . . . . . . . . . . 9Abilify . . . . . . . . . . . . . . . . . . . . . . . . . . 18Absorica . . . . . . . . . . . . . . . . . . . . . . . . 26Abstral . . . . . . . . . . . . . . . . . . . . . . . . . . 13Acamprosate . . . . . . . . . . . . . . . . . . . . 47Acanya . . . . . . . . . . . . . . . . . . . . . . . . . 26Acarbose . . . . . . . . . . . . . . . . . . . . . . . 31Accolate . . . . . . . . . . . . . . . . . . . . . . . . 44Accu-Chek Active Test Strips . . . . . . 32Accu-Chek Aviva Plus . . . . . . . . . . . . . 32Accu-Chek Aviva Plus Test Strips . . . 32Accu-Chek Comfort Curve
Test Strips . . . . . . . . . . . . . . . . . . . . . 32Accu-Chek Compact Test Strips . . . . 32Accu-Chek Nano SmartView . . . . . . . 32Accu-Chek SmartView . . . . . . . . . . . . 32AccuNeb . . . . . . . . . . . . . . . . . . . . . . . 44Accuretic . . . . . . . . . . . . . . . . . . . . . . . 23Accutane . . . . . . . . . . . . . . . . . . . . . . . 26Acebutolol HCl . . . . . . . . . . . . . . . . . . 22Aceon . . . . . . . . . . . . . . . . . . . . . . . . . . 23Acetaminophen/Caffeine/
Butalbital . . . . . . . . . . . . . . . . . . . 13, 14acetaminophen/oxycodone . . . . . . . . . 48Acetazolamide . . . . . . . . . . . . . . . . . . . 40Acetazolamide Capsule,
Sustained-Action . . . . . . . . . . . . . . . 40Acetic Acid . . . . . . . . . . . . . . . . . . . . . . 29Acetic Acid/Hydrocortisone . . . . . . . . 29Acetylcysteine Vial, Nebulizer . . . . . . . 44Achromycin V . . . . . . . . . . . . . . . . . . . . . 7Aciphex . . . . . . . . . . . . . . . . . . . . . . . . . 33Acitretin . . . . . . . . . . . . . . . . . . . . . . . . 27Aclovate 0 .05% . . . . . . . . . . . . . . . . . . 25Acthar H .P . . . . . . . . . . . . . . . . . . . . . . . 30Actigall . . . . . . . . . . . . . . . . . . . . . . . . . 34Actimmune . . . . . . . . . . . . . . . . . . . . . . 35Actiq . . . . . . . . . . . . . . . . . . . . . . . . 13, 48Activella . . . . . . . . . . . . . . . . . . . . . . . . 39Actonel . . . . . . . . . . . . . . . . . . . . . . . . . 37Actoplus Met . . . . . . . . . . . . . . . . . . . . 31Actoplus Met XR . . . . . . . . . . . . . . . . . 31Actos . . . . . . . . . . . . . . . . . . . . . . . . 31, 48Acular . . . . . . . . . . . . . . . . . . . . . . . . . . 40Acular LS . . . . . . . . . . . . . . . . . . . . . . . 40Acuvail . . . . . . . . . . . . . . . . . . . . . . . . . 40Acyclovir . . . . . . . . . . . . . . . . . . . 8, 27, 48Acyclovir Ointment . . . . . . . . . . . . 27, 48Aczone . . . . . . . . . . . . . . . . . . . . . . . . . 26Adapalene . . . . . . . . . . . . . . . . . . . . . . 26
Adcirca . . . . . . . . . . . . . . . . . . . . . . . . . 44Adderall . . . . . . . . . . . . . . . . . . . . . 19, 48Adderall XR . . . . . . . . . . . . . . . . . . 19, 48Adefovir . . . . . . . . . . . . . . . . . . . . . . . . . 8Adoxa . . . . . . . . . . . . . . . . . . . . . . . . 7, 48Adoxa 150 mg . . . . . . . . . . . . . . . . . . . . 7Adoxa tablet . . . . . . . . . . . . . . . . . . . . . 48Adoxa tablets . . . . . . . . . . . . . . . . . . . . 48Advair Diskus . . . . . . . . . . . . . . . . . . . . 44Advair HFA . . . . . . . . . . . . . . . . . . . . . . 44Advate . . . . . . . . . . . . . . . . . . . . . . . . . . 21Advicor . . . . . . . . . . . . . . . . . . . . . . . . . 24Afinitor . . . . . . . . . . . . . . . . . . . . . . . . . 11Aggrenox . . . . . . . . . . . . . . . . . . . . . . . 20Agrylin . . . . . . . . . . . . . . . . . . . . . . . . . . 47Albalon . . . . . . . . . . . . . . . . . . . . . . . . . 40Albenza . . . . . . . . . . . . . . . . . . . . . . . . . 10Albuterol Sulfate . . . . . . . . . . . . . . . . . 44Albuterol Sulfate/Ipratropium Solution,
Non-Oral . . . . . . . . . . . . . . . . . . . . . . 44Albuterol Sulfate HFA Aerosol . . . . . . 44Albuterol Sulfate Solution . . . . . . . . . . 44Alclometasone Dipropionate Cream,
Ointment 0 .05% . . . . . . . . . . . . . . . . 25Aldactazide 25-25 mg . . . . . . . . . . . . 21Aldactazide 50-50 mg . . . . . . . . . . . . 21Aldactone . . . . . . . . . . . . . . . . . . . . . . . 21Aldara . . . . . . . . . . . . . . . . . . . . . . . . . . 28Alendronate Sodium . . . . . . . . . . . . . . 37Alesse . . . . . . . . . . . . . . . . . . . . . . . . . . 38Alferon N . . . . . . . . . . . . . . . . . . . . . . . 35Alfuzosin HCl . . . . . . . . . . . . . . . . . . . . 45Alinia . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Alkeran . . . . . . . . . . . . . . . . . . . . . . . . . 11Allopurinol . . . . . . . . . . . . . . . . . . . . . . . 36Alocril . . . . . . . . . . . . . . . . . . . . . . . . . . 42Alomide . . . . . . . . . . . . . . . . . . . . . . . . . 42Alora . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Alphagan P . . . . . . . . . . . . . . . . . . . . . . 41Alphanate vonWillebrand . . . . . . . . . . 21Alphanine SD . . . . . . . . . . . . . . . . . . . . 21Alprazolam . . . . . . . . . . . . . . . . . . . 19, 48alprazolam extended-release . . . . . . . 48Alprazolam Tablet, Rapid Dissolve . . . 19Alprazolam Tablet, Sustained-Release
24 Hour . . . . . . . . . . . . . . . . . . . . . . . 19Alrex . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Alsuma . . . . . . . . . . . . . . . . . . . . . . . . . 14Altabax . . . . . . . . . . . . . . . . . . . . . . . . . 26Altace . . . . . . . . . . . . . . . . . . . . . . . . . . 23Altoprev . . . . . . . . . . . . . . . . . . . . . . . . 24Alupent . . . . . . . . . . . . . . . . . . . . . . . . . 44
Alvesco . . . . . . . . . . . . . . . . . . . . . . . . . 44Amantadine HCl . . . . . . . . . . . . . . . 8, 15Amaryl . . . . . . . . . . . . . . . . . . . . . . . . . . 31Ambien . . . . . . . . . . . . . . . . . . . . . . 17, 48Ambien CR . . . . . . . . . . . . . . . . . . . 17, 48Amcinonide Cream, Ointment . . . . . . 25Amerge . . . . . . . . . . . . . . . . . . . . . . . . . 14Amicar . . . . . . . . . . . . . . . . . . . . . . . . . . 21Amicar 500 mg . . . . . . . . . . . . . . . . . . 21Amiloride HCl . . . . . . . . . . . . . . . . . . . . 21Amiloride HCl/Hydrochlorothiazide . . 21Aminocaproic Acid . . . . . . . . . . . . . . . 21Aminocaproic Acid Solution . . . . . . . . 21Aminocaproic Acid Tablet . . . . . . . . . . 21Aminocaproic Acid Tablet 1000 mg . 21Amiodarone HCl . . . . . . . . . . . . . . . . . 20Amitiza . . . . . . . . . . . . . . . . . . . . . . . . . 34Amitriptyline HCl . . . . . . . . . . . . . . . . . 17AmLactin - OTC . . . . . . . . . . . . . . . . . . 28Amlodipine/Atorvastatin . . . . . . . . . . . 24Amlodipine/Benazepril . . . . . . . . . . . . 23Amlodipine Besylate . . . . . . . . . . . . . . 22Ammonium Lactate - OTC . . . . . . . . . 28Amnesteem . . . . . . . . . . . . . . . . . . . . . 26Amoxapine . . . . . . . . . . . . . . . . . . . . . . 17Amoxicillin Clavulanate ER Tablet,
Sustained-Release 12 Hour . . . . . . . 7Amoxicillin Trihydrate/Potassium
Clavulanate . . . . . . . . . . . . . . . . . . . . . 7Amoxicillin Trihydrate Capsule,
Chewable Tablet, Suspension, Tablet . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Amoxil . . . . . . . . . . . . . . . . . . . . . . . . . . . 7amphetamine/dextroamphetamine
immediate-release . . . . . . . . . . . . . . 48Amphetamine Aspartate/Amphetamine
Sulfate/Dextroamphetamine . . . . . . 19Amphetamine Aspartate/Amphetamine
Sulfate/Dextroamphetamine Capsule, Sustained-Release 24 Hour . . . . . . 19
Ampyra . . . . . . . . . . . . . . . . . . . . . . . . . 16Amrix . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Amturnide . . . . . . . . . . . . . . . . . . . . . . . 24Anafranil . . . . . . . . . . . . . . . . . . . . . . . . 17Anagrelide HCl . . . . . . . . . . . . . . . . . . 47Analpram-HC . . . . . . . . . . . . . . . . . . . . 34Anaprox, Anaprox DS . . . . . . . . . . . . . 36Anastrozole . . . . . . . . . . . . . . . . . . . 11, 48Ancobon . . . . . . . . . . . . . . . . . . . . . . . . . 9Androderm . . . . . . . . . . . . . . . . . . . . . . 30Androgel . . . . . . . . . . . . . . . . . . . . . . . . 30Android . . . . . . . . . . . . . . . . . . . . . . . . . 30
50
2014 Prescription Drug List Medication Index
Angeliq . . . . . . . . . . . . . . . . . . . . . . . . . 39Ansaid . . . . . . . . . . . . . . . . . . . . . . . . . . 36Antabuse . . . . . . . . . . . . . . . . . . . . . . . 47Antara . . . . . . . . . . . . . . . . . . . . . . . . . . 24Antivert 50 mg . . . . . . . . . . . . . . . . . . . 34Anusol-HC . . . . . . . . . . . . . . . . . . . . . . 34Anusol-HC 2 .5% . . . . . . . . . . . . . . . . . 34Anzemet . . . . . . . . . . . . . . . . . . . . . . . . 34Apidra Solostar . . . . . . . . . . . . . . . . . . 31Apidra Vial . . . . . . . . . . . . . . . . . . . . . . 31Aplenzin . . . . . . . . . . . . . . . . . . . . . . . . 17Apokyn . . . . . . . . . . . . . . . . . . . . . . . . . 15Apraclonidine HCl Drops . . . . . . . . . . 41Apresoline . . . . . . . . . . . . . . . . . . . . . . 23Apriso . . . . . . . . . . . . . . . . . . . . . . . . . . 34Aptivus . . . . . . . . . . . . . . . . . . . . . . . . . . 9Aralen Phosphate . . . . . . . . . . . . . . . . 10Aranesp . . . . . . . . . . . . . . . . . . . . . 12, 35Arava . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Arcalyst . . . . . . . . . . . . . . . . . . . . . . . . . 35Aricept . . . . . . . . . . . . . . . . . . . . . . . . . 16Aricept 23 mg . . . . . . . . . . . . . . . . . . . 16Aricept ODT . . . . . . . . . . . . . . . . . . . . . 16Arimidex . . . . . . . . . . . . . . . . . . . . . 11, 48Aristocort 0 .025% . . . . . . . . . . . . . . . . 25Aristocort 0 .1% . . . . . . . . . . . . . . . . . . 25Aristocort 0 .5%, Kenalog 0 .5% . . . . . 25Aristocort HP 0 .5% . . . . . . . . . . . . . . . 25Arixtra . . . . . . . . . . . . . . . . . . . . . . . . . . 20Armour Thyroid . . . . . . . . . . . . . . . . . . . 30Aromasin . . . . . . . . . . . . . . . . . . . . . . . . 11Artane . . . . . . . . . . . . . . . . . . . . . . . . . . 15Arthrotec . . . . . . . . . . . . . . . . . . . . . . . . 36Asacol HD . . . . . . . . . . . . . . . . . . . . . . 34Ascensia Autodisc Test Strips . . . . . . 32Ascensia Breeze 2 Test Strips . . . . . . 32Asendin 50, 100 mg . . . . . . . . . . . . . . 17Asmanex . . . . . . . . . . . . . . . . . . . . . . . . 44Aspirin/Caffeine/Butalbital . . . . . . 13, 14Aspirin/Caffeine/Dihydrocodone . . . . 13Astelin . . . . . . . . . . . . . . . . . . . . . . . 29, 48Astepro . . . . . . . . . . . . . . . . . . . . . . . . . 29Atacand . . . . . . . . . . . . . . . . . . . . . . . . 24Atacand HCT . . . . . . . . . . . . . . . . . . . . 24Atarax . . . . . . . . . . . . . . . . . . . . . . . . . . 43Atelvia . . . . . . . . . . . . . . . . . . . . . . . . . . 37Atenolol . . . . . . . . . . . . . . . . . . . . . . . . . 22Ativan . . . . . . . . . . . . . . . . . . . . . . . 19, 48atorvastatin . . . . . . . . . . . . . . . . . . . 24, 48Atorvastatin Calcium . . . . . . . . . . . . . . 24Atovaquone/Proguanil HCl . . . . . . . . . 10Atralin . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Atripla . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Atropine Sulfate . . . . . . . . . . . . . . . 33, 40Atrovent . . . . . . . . . . . . . . . . . . . . . 29, 44Atrovent Aerosol, Spray . . . . . . . . . . . 29Atrovent HFA . . . . . . . . . . . . . . . . . . . . 44Aubagio . . . . . . . . . . . . . . . . . . . . . . . . 16Augmentin . . . . . . . . . . . . . . . . . . . . . . . 7Augmentin 200, 400 mg Susp . . . . . . . 7Augmentin 250-62 .5 mg/5 ml
Suspension . . . . . . . . . . . . . . . . . . . . . 7Augmentin ES 600 mg Suspension . . 7Augmentin XR . . . . . . . . . . . . . . . . . . . . 7Auvi-Q . . . . . . . . . . . . . . . . . . . . . . . . . . 43Avalide . . . . . . . . . . . . . . . . . . . . . . . . . 24Avandamet . . . . . . . . . . . . . . . . . . . . . . 31Avandaryl . . . . . . . . . . . . . . . . . . . . . . . 31Avandia . . . . . . . . . . . . . . . . . . . . . . . . . 31Avapro . . . . . . . . . . . . . . . . . . . . . . . . . . 24AVC . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Avelox . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Avinza . . . . . . . . . . . . . . . . . . . . . . . . . . 13Avita . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Avita Gel . . . . . . . . . . . . . . . . . . . . . . . . 26Avodart . . . . . . . . . . . . . . . . . . . . . . . . . 45Avonex . . . . . . . . . . . . . . . . . . . . . . . . . 16Axert . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Axid Oral Solution . . . . . . . . . . . . . . . . 33Axiron . . . . . . . . . . . . . . . . . . . . . . . . . . 30Aygestin . . . . . . . . . . . . . . . . . . . . . . . . 38Azasan . . . . . . . . . . . . . . . . . . . . . . . . . 11Azasite . . . . . . . . . . . . . . . . . . . . . . . . . 41Azathioprine . . . . . . . . . . . . . . . . . . 11, 36Azelastine . . . . . . . . . . . . . . . . .29, 42, 48Azelastine HCl . . . . . . . . . . . . . . . . 29, 42Azelastine HCl Drops . . . . . . . . . . . . . 42Azelastine Nasal Spray . . . . . . . . . . . . 48Azelex . . . . . . . . . . . . . . . . . . . . . . . . . . 26Azilect . . . . . . . . . . . . . . . . . . . . . . . . . . 15Azithromycin . . . . . . . . . . . . . . . . . . . . . . 7Azopt . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Azor . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Azulfidine . . . . . . . . . . . . . . . . . . . . 34, 36BBacitracin/Polymyxin B Sulfate . . . . . 41Baclofen . . . . . . . . . . . . . . . . . . . . . . . . 37Bactrim, Bactrim DS . . . . . . . . . . . . . . . 8Bactroban . . . . . . . . . . . . . . . . . . . . . . . 26Balsalazide Disodium . . . . . . . . . . . . . 34Banzel . . . . . . . . . . . . . . . . . . . . . . . . . . 16Baraclude . . . . . . . . . . . . . . . . . . . . . . . . 8Bebulin . . . . . . . . . . . . . . . . . . . . . . . . . 21Beconase AQ . . . . . . . . . . . . . . . . 29, 44
Belladonna Alkaloids/Phenobarbital . 33Benazepril/Hydrochlorothiazide . . . . . 23Benazepril HCl . . . . . . . . . . . . . . . . . . . 23Benefix . . . . . . . . . . . . . . . . . . . . . . . . . 21Benemid . . . . . . . . . . . . . . . . . . . . . . . . 36Benicar . . . . . . . . . . . . . . . . . . . . . . . . . 24Benicar HCT . . . . . . . . . . . . . . . . . . . . 24Bentyl . . . . . . . . . . . . . . . . . . . . . . . 33, 45Benzaclin . . . . . . . . . . . . . . . . . . . . 26, 48Benzaclin 1%-5% . . . . . . . . . . . . . . . . 26Benzaclin jar . . . . . . . . . . . . . . . . . . . . . 48Benzamycin . . . . . . . . . . . . . . . . . . . . . 26Benztropine Mesylate . . . . . . . . . . . . . 15Bepreve . . . . . . . . . . . . . . . . . . . . . . . . 42Betagan . . . . . . . . . . . . . . . . . . . . . . . . 40Betamethasone Dipropionate/
Propylene Glycol Gel, Lotion . . . . . 25Betamethasone Dipropionate/
Propylene Glycol Ointment . . . . . . . 25Betamethasone Dipropionate Cream,
Lotion, Ointment . . . . . . . . . . . . . . . . 25Betamethasone DP Augmented
Cream 0 .05% . . . . . . . . . . . . . . . . . . 25Betamethasone Valerate Cream,
Lotion . . . . . . . . . . . . . . . . . . . . . . . . . 25Betamethasone Valerate Foam . . . . . 25Betamethasone Valerate Ointment . . 25Betapace, Betapace AF . . . . . . . . . . . 20Betaseron . . . . . . . . . . . . . . . . . . . . . . . 16Betaxolol HCl . . . . . . . . . . . . . . . . . 22, 40Bethanechol Chloride . . . . . . . . . . . . . 45Betimol . . . . . . . . . . . . . . . . . . . . . . . . . 40Betoptic . . . . . . . . . . . . . . . . . . . . . . . . 40Betoptic S . . . . . . . . . . . . . . . . . . . . . . 40Beyaz . . . . . . . . . . . . . . . . . . . . . . . . . . 38Biaxin . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Biaxin XL . . . . . . . . . . . . . . . . . . . . . . . . . 7Bicalutamide . . . . . . . . . . . . . . . . . . . . 11Bicitra . . . . . . . . . . . . . . . . . . . . . . . . . . 45BiDil . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Biltricide . . . . . . . . . . . . . . . . . . . . . . . . 10Binosto . . . . . . . . . . . . . . . . . . . . . . . . . 37Bisoprolol Fumarate/
Hydrochlorothiazide . . . . . . . . . . . . . 23Bleph-10, Sodium Sulamyd . . . . . . . . 41Blephamide S .O .P . . . . . . . . . . . . . . . . 41Blephamide Suspension, Drops . . . . . 41Boniva . . . . . . . . . . . . . . . . . . . . . . . . . . 37Bosulif . . . . . . . . . . . . . . . . . . . . . . . . . . 11Bravelle . . . . . . . . . . . . . . . . . . . . . . . . . 39Brethine . . . . . . . . . . . . . . . . . . . . . 39, 44Brilinta . . . . . . . . . . . . . . . . . . . . . . . . . . 20
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2014 Prescription Drug List Medication Index
Brimonidine Tartrate 0 .15% . . . . . . . . 41Bromday . . . . . . . . . . . . . . . . . . . . . . . . 40Bromfed-DM . . . . . . . . . . . . . . . . . . . . 43Bromfenac Sodium . . . . . . . . . . . . . . . 40Bromocriptine Mesylate . . . . . . . . . . . 15Brovana . . . . . . . . . . . . . . . . . . . . . . . . 44Budesonide . . . . . . . . . . . . . . .34, 44, 48Budesonide Capsule,
Sustained-Release . . . . . . . . . . . . . . 34Budesonide Inhalation Suspension . . 44Bumetanide . . . . . . . . . . . . . . . . . . . . . 21Bumex . . . . . . . . . . . . . . . . . . . . . . . . . . 21Buphrenorphine HCl/Naloxone HCl
Tablet, Sublingual . . . . . . . . . . . . . . . 14Buphrenorphine Hydrochloride . . . . . 14Bupropion Exteneded-Release . . . . . 48Bupropion HCl . . . . . . . . . . . . . . . . 17, 47Bupropion HCl Tablet,
Sustained-Action . . . . . . . . . . . . 17, 47Bupropion HCl Tablet,
Sustained-Release 24 Hour . . . . . . 17Buspar . . . . . . . . . . . . . . . . . . . . . . . . . 19Buspirone HCl . . . . . . . . . . . . . . . . . . . 19Butorphanol Tartrate Aerosol, Spray . 14Butrans . . . . . . . . . . . . . . . . . . . . . . . . . 13Bydureon . . . . . . . . . . . . . . . . . . . . . . . 31Byetta . . . . . . . . . . . . . . . . . . . . . . . . . . 31Bystolic . . . . . . . . . . . . . . . . . . . . . . . . . 22CCabergoline . . . . . . . . . . . . . . . . . . . . . 30Caduet . . . . . . . . . . . . . . . . . . . . . . . . . 24Cafergot . . . . . . . . . . . . . . . . . . . . . . . . 14Calan . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Calan SR . . . . . . . . . . . . . . . . . . . . . . . 22Calcipotriene Cream, Ointment . . . . . 27Calcipotriene Solution, Topical . . . . . . 27Calcitonin, Salmon, Synthetic
Nasal Spray . . . . . . . . . . . . . . . . 30, 37Calcitonin Salmon Nasal Spray . . 30, 37Calcitriol . . . . . . . . . . . . . . . . . . . . . . . . 30Calcitrol Ointment . . . . . . . . . . . . . . . . 27Calcium Acetate . . . . . . . . . . . . . . . . . 46Cambia . . . . . . . . . . . . . . . . . . . . . . . . . 36Campral . . . . . . . . . . . . . . . . . . . . . . . . 47Canasa . . . . . . . . . . . . . . . . . . . . . . . . . 34Candesartan . . . . . . . . . . . . . . . . . . . . 24Candesartan/Hydrochlorothiazide . . . 24Cantil . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Capozide . . . . . . . . . . . . . . . . . . . . . . . 23Caprelsa . . . . . . . . . . . . . . . . . . . . . . . . 11Captopril/Hydrochlorothiazide . . . . . . 23Carafate . . . . . . . . . . . . . . . . . . . . . . . . 33
Carafate Oral Suspension . . . . . . . . . 33Carbaglu . . . . . . . . . . . . . . . . . . . . . . . . 47Carbamazepine . . . . . . . . . . . . . . . 15, 16Carbamazepine Capsule,
Extended-Release Multiphase 12 Hour . . . . . . . . . . . . . . . . . . . . . . . 16
Carbamazepine Tablet, Sustained-Release 12 Hour . . . . . . 15
Carbatrol . . . . . . . . . . . . . . . . . . . . . . . . 16Carbidopa/Levodopa . . . . . . . . . . . . . 15Carbidopa/Levodopa/Entacapone . . 15Carbidopa/Levodopa Tablet,
Rapid Dissolve . . . . . . . . . . . . . . . . . 15Carbidopa/Levodopa Tablet,
Sustained-Action . . . . . . . . . . . . . . . 15Cardene . . . . . . . . . . . . . . . . . . . . . . . . 22Cardene SR . . . . . . . . . . . . . . . . . . . . . 22Cardizem . . . . . . . . . . . . . . . . . . . . . . . 22Cardizem CD . . . . . . . . . . . . . . . . . . . . 22Cardizem LA 120 mg . . . . . . . . . . . . . 22Cardizem LA 180, 240, 300,
360, 420 mg . . . . . . . . . . . . . . . . . . . 22Cardizem SR . . . . . . . . . . . . . . . . . . . . 22Cardura . . . . . . . . . . . . . . . . . . . . . . 23, 45Cardura XL . . . . . . . . . . . . . . . . . . . . . . 23Carisoprodol . . . . . . . . . . . . . . . . . . . . 37Carmol HC Cream . . . . . . . . . . . . . . . 28Carnitor . . . . . . . . . . . . . . . . . . . . . . . . . 47Carteolol HCl . . . . . . . . . . . . . . . . . . . . 40Carvedilol . . . . . . . . . . . . . . . . . . . . . . . 22Casodex . . . . . . . . . . . . . . . . . . . . . . . . 11Cataflam . . . . . . . . . . . . . . . . . . . . . . . . 36Catapres . . . . . . . . . . . . . . . . . . . . . . . . 23Catapres-TTS . . . . . . . . . . . . . . . . . . . 23Caverject . . . . . . . . . . . . . . . . . . . . . . . 45Cayston . . . . . . . . . . . . . . . . . . . . . . . . . 9Ceclor, Ceclor CD . . . . . . . . . . . . . . . . . 7Cedax . . . . . . . . . . . . . . . . . . . . . . . . . . . 7CeeNu . . . . . . . . . . . . . . . . . . . . . . . . . 11Cefaclor . . . . . . . . . . . . . . . . . . . . . . . . . 7Cefadroxil Hydrate . . . . . . . . . . . . . . . . . 7Cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . 7Cefditoren Pivoxil . . . . . . . . . . . . . . . . . . 7Cefpodoxime Tablet . . . . . . . . . . . . . . . . 7Cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . 7Ceftin . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Ceftin Suspension . . . . . . . . . . . . . . . . . 7Cefuroxime Axetil Suspension
125 mg/5 ml . . . . . . . . . . . . . . . . . . . . 7Cefuroxime Axetil Tablet . . . . . . . . . . . . 7Cefzil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Celebrex . . . . . . . . . . . . . . . . . . . . . . . . 36
Celestone Oral Solution . . . . . . . . . . . 30Celexa . . . . . . . . . . . . . . . . . . . . . . . 18, 48CellCept . . . . . . . . . . . . . . . . . . . . . . . . 11Celontin . . . . . . . . . . . . . . . . . . . . . . . . 15Cenestin . . . . . . . . . . . . . . . . . . . . . . . . 39Centany . . . . . . . . . . . . . . . . . . . . . . . . 26Cephalexin Monohydrate . . . . . . . . . . . 7Cephulac . . . . . . . . . . . . . . . . . . . . . . . 34Cesamet . . . . . . . . . . . . . . . . . . . . . . . . 34Cetraxal . . . . . . . . . . . . . . . . . . . . . . . . 29Cetrorelix Acetate . . . . . . . . . . . . . . . . 31Cetrotide . . . . . . . . . . . . . . . . . . . . 31, 39Cevimeline HCl . . . . . . . . . . . . . . . . . . 29Chantix . . . . . . . . . . . . . . . . . . . . . . . . . 47Chemet . . . . . . . . . . . . . . . . . . . . . . . . . 47Chloral Hydrate . . . . . . . . . . . . . . . . . . 17Chlordiazepoxide HCl . . . . . . . . . . . . . 19Chlorhexidine Gluconate . . . . . . . . . . 29Chloroquine Phosphate . . . . . . . . . . . 10Chlorothiazide Tablet . . . . . . . . . . . . . . 21Chlorpromazine HCl Tablet . . . . . . . . 18Chlorzoxazone . . . . . . . . . . . . . . . . . . . 37Cholestyramine/Aspartame . . . . . . . . 24Cholestyramine/Sucrose . . . . . . . . . . 24Choline Fenofibrate . . . . . . . . . . . . . . . 24Chronulac . . . . . . . . . . . . . . . . . . . . . . . 34Cialis . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Ciclopirox Cream, Gel, Lotion . . . . . . 27Ciclopirox Shampoo . . . . . . . . . . . . . . 27Ciclopirox Solution, Non-Oral . . . . . . 27Cilostazol . . . . . . . . . . . . . . . . . . . . . . . 20Ciloxan . . . . . . . . . . . . . . . . . . . . . . . . . 41Ciloxan Ointment . . . . . . . . . . . . . . . . . 41Cimetidine Tablet, Liquid . . . . . . . . . . . 33Cimzia . . . . . . . . . . . . . . . . . . . . . . . . . . 36Cipro . . . . . . . . . . . . . . . . . . . . . . . . . 8, 29Cipro HC Suspension, Drops . . . . . . 29Cipro Suspension . . . . . . . . . . . . . . . . . 8Cipro XR . . . . . . . . . . . . . . . . . . . . . . . . . 8Ciprodex . . . . . . . . . . . . . . . . . . . . . . . . 29Ciprofloxacin . . . . . . . . . . . . . . . . . . 8, 41Ciprofloxacin HCl Drops . . . . . . . . . . . 41Ciprofloxacin Tablet . . . . . . . . . . . . . . . . 8Ciprofloxacin Tablet,
Sustained-Release 24 Hour . . . . . . . 8Citalopram . . . . . . . . . . . . . . . . . . . 18, 48Citalopram Hydrobromide . . . . . . . . . 18Citranatal Assure . . . . . . . . . . . . . . . . . 46Citric Acid/Sodium Citrate . . . . . . . . . 45Claravis . . . . . . . . . . . . . . . . . . . . . . . . . 26Clarinex . . . . . . . . . . . . . . . . . . . . . . . . . 43Clarinex-D . . . . . . . . . . . . . . . . . . . . . . 43
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2014 Prescription Drug List Medication Index
Clarithromycin Suspension . . . . . . . . . . 7Clarithromycin Sustained-Release
Tablet . . . . . . . . . . . . . . . . . . . . . . . . . . 7Clarithromycin Tablet . . . . . . . . . . . . . . . 7Claritin - OTC . . . . . . . . . . . . . . . . . . . . 43Claritin-D - OTC . . . . . . . . . . . . . . . . . 43Clemastine Fumarate . . . . . . . . . . . . . 43Clenia . . . . . . . . . . . . . . . . . . . . . . . . . . 26Cleocin HCl 150, 300 mg . . . . . . . . . . 9Cleocin HCl 75 mg . . . . . . . . . . . . . . . . 9Cleocin Palmitate . . . . . . . . . . . . . . . . . 9Cleocin Phosphate . . . . . . . . . . . . . . . 39Cleocin T . . . . . . . . . . . . . . . . . . . . . . . 26Climara . . . . . . . . . . . . . . . . . . . . . . . . . 39Climara Pro . . . . . . . . . . . . . . . . . . . . . 39Clindagel . . . . . . . . . . . . . . . . . . . . . . . 26Clindamycin 1%/Benzoyl Peroxide
5% gel . . . . . . . . . . . . . . . . . . . . . . . . 48Clindamycin HCl . . . . . . . . . . . . . . . . . . 9Clindamycin Palmitate HCl . . . . . . . . . . 9Clindamycin Phosphate . . . . . . . . 26, 39Clindamycin Phosphate/Benzoyl
Peroxide Gel . . . . . . . . . . . . . . . . . . . 26Clindamycin Phosphate Cream
w/Applicator . . . . . . . . . . . . . . . . . . . 39Clindamycin Phosphate Foam 1% . . . 26Clindesse . . . . . . . . . . . . . . . . . . . . . . . 39Clinoril . . . . . . . . . . . . . . . . . . . . . . . . . . 36Clobetasol Propionate Cream . . . . . . 25Clobetasol Propionate Cream, Gel,
Ointment . . . . . . . . . . . . . . . . . . . . . . 25Clobetasol Propionate Foam . . . . . . . 25Clobetasol Propionate Lotion . . . . . . . 25Clobetasol Propionate Shampoo . . . . 25Clobetasol Propionate Solution,
Non-Oral . . . . . . . . . . . . . . . . . . . . . . 25Clobex . . . . . . . . . . . . . . . . . . . . . . . . . . 25Cloderm . . . . . . . . . . . . . . . . . . . . . . . . 25Clomid . . . . . . . . . . . . . . . . . . . . . . . . . 39Clomiphene Citrate . . . . . . . . . . . . . . . 39Clomipramine HCl . . . . . . . . . . . . . . . . 17Clonazepam . . . . . . . . . . . . . . . . . . . . . 15Clonidine Extended-Release . . . . . . . 19Clonidine HCl . . . . . . . . . . . . . . . . . . . 23Clonidine Patch, Transdermal
Weekly . . . . . . . . . . . . . . . . . . . . . . . . 23Clopidogrel . . . . . . . . . . . . . . . . . . . 20, 48Clopidogrel Bisulfate . . . . . . . . . . . . . . 20Clorpres . . . . . . . . . . . . . . . . . . . . . . . . 23Clotrimazole/Betamethasone
Dipropionate . . . . . . . . . . . . . . . . . . . 27Clotrimazole Troche . . . . . . . . . . . . . . . . 9
Clozapine . . . . . . . . . . . . . . . . . . . . . . . 18Clozapine Orally Disintegrating
Tablet . . . . . . . . . . . . . . . . . . . . . . . . . 18Clozaril . . . . . . . . . . . . . . . . . . . . . . . . . 18Coartem . . . . . . . . . . . . . . . . . . . . . . . . 10Codeine/Promethazine HCl . . . . . . . . 43Codeine Phosphate . . . . . . . . . . . . 13, 43Codeine Phosphate/Acetaminophen . 13Codeine Phosphate/Acetaminophen/
Caffeine/Butalbital . . . . . . . . . . . . . . 13Codeine Phosphate/Aspirin/Caffeine/
Butalbital . . . . . . . . . . . . . . . . . . . . . . 13Codeine Sulfate . . . . . . . . . . . . . . . . . . 13Cogentin . . . . . . . . . . . . . . . . . . . . . . . . 15Colazal . . . . . . . . . . . . . . . . . . . . . . . . . 34Colcrys . . . . . . . . . . . . . . . . . . . . . . . . . 36Colestid . . . . . . . . . . . . . . . . . . . . . . . . 24Colestipol HCl . . . . . . . . . . . . . . . . . . . 24Coly-Mycin S Suspension, Drops . . . 29Colyte . . . . . . . . . . . . . . . . . . . . . . . . . . 34Combigan . . . . . . . . . . . . . . . . . . . . . . . 40Combipatch . . . . . . . . . . . . . . . . . . . . . 39Combivent Respimat . . . . . . . . . . . . . . 44Combivir . . . . . . . . . . . . . . . . . . . . . . . . . 9Combunox . . . . . . . . . . . . . . . . . . . . . . 13Compazine . . . . . . . . . . . . . . . . . . . . . . 34Complera . . . . . . . . . . . . . . . . . . . . . . . . 9Comtan . . . . . . . . . . . . . . . . . . . . . . . . . 15Concerta . . . . . . . . . . . . . . . . . . . . 19, 48Condylox Gel . . . . . . . . . . . . . . . . . . . . 28Condylox Liquid . . . . . . . . . . . . . . . . . . 28Contour Next Test Strips . . . . . . . . . . 32Contour Test Strips . . . . . . . . . . . . . . . 32Conzip . . . . . . . . . . . . . . . . . . . . . . . . . 14Copaxone . . . . . . . . . . . . . . . . . . . . . . . 16Copegus . . . . . . . . . . . . . . . . . . . . . . . . . 8Cordarone . . . . . . . . . . . . . . . . . . . . . . 20Cordran . . . . . . . . . . . . . . . . . . . . . . . . 25Coreg . . . . . . . . . . . . . . . . . . . . . . . . . . 22Coreg CR . . . . . . . . . . . . . . . . . . . . . . . 22Corgard . . . . . . . . . . . . . . . . . . . . . . . . 22Cortef . . . . . . . . . . . . . . . . . . . . . . . . . . 30Cortenema . . . . . . . . . . . . . . . . . . . . . . 34Cortifoam . . . . . . . . . . . . . . . . . . . . . . . 34Cortisporin . . . . . . . . . . . . . . . . . . . 29, 41Cortisporin-TC Suspension, Drops . . 29Corzide . . . . . . . . . . . . . . . . . . . . . . . . . 23Cosopt . . . . . . . . . . . . . . . . . . . . . . . . . 40Cosopt PF . . . . . . . . . . . . . . . . . . . . . . 40Coumadin . . . . . . . . . . . . . . . . . . . . . . . 20Cozaar . . . . . . . . . . . . . . . . . . . . . . . . . 24Creon . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Crestor . . . . . . . . . . . . . . . . . . . . . . . . . 24Crinone . . . . . . . . . . . . . . . . . . . . . . . . . 38Crixivan . . . . . . . . . . . . . . . . . . . . . . . . . . 9Crolom . . . . . . . . . . . . . . . . . . . . . . . . . 42Cromolyn Sodium . . . . . . . . . .34, 42, 44Cromolyn Sodium Ampul for
Nebulization . . . . . . . . . . . . . . . . . . . 44Cuprimine . . . . . . . . . . . . . . . . . . . . . . . 36Cutivate 0 .005% . . . . . . . . . . . . . . . . . 25Cutivate 0 .05% . . . . . . . . . . . . . . . . . . 25Cutivate Lotion . . . . . . . . . . . . . . . . . . . 25Cyclessa . . . . . . . . . . . . . . . . . . . . . . . . 38Cyclobenzaprine Capsule,
Extended-Release 24 Hour . . . . . . . 37Cyclobenzaprine HCl . . . . . . . . . . . . . 37Cyclocort 0 .1% . . . . . . . . . . . . . . . . . . 25Cyclogyl 0 .5 . . . . . . . . . . . . . . . . . . . . . 40Cyclogyl 1%, 2% . . . . . . . . . . . . . . . . . 40Cyclopentolate HCl . . . . . . . . . . . . . . . 40Cyclophosphamide . . . . . . . . . . . . . . . 11Cyclosporine, Modified . . . . . . . . . . . . 11Cymbalta . . . . . . . . . . . . . . . . . . . . . . . 17Cyproheptadine HCl . . . . . . . . . . . . . . 43Cytomel . . . . . . . . . . . . . . . . . . . . . . . . 30Cytotec . . . . . . . . . . . . . . . . . . . . . . . . . 33Cytovene . . . . . . . . . . . . . . . . . . . . . . . . 8Cytoxan . . . . . . . . . . . . . . . . . . . . . . . . . 11DD-Amphetamine Sulfate Tablet,
Capsule, Sustained-Action . . . . . . . 19D .H .E .45 . . . . . . . . . . . . . . . . . . . . . . . . 14Daliresp . . . . . . . . . . . . . . . . . . . . . . . . 44Dalmane . . . . . . . . . . . . . . . . . . . . . . . . 17Danazol . . . . . . . . . . . . . . . . . . . . . . . . . 30Danocrine . . . . . . . . . . . . . . . . . . . . . . . 30Dantrium . . . . . . . . . . . . . . . . . . . . . . . . 37Dantrolene Sodium . . . . . . . . . . . . . . . 37Dapsone . . . . . . . . . . . . . . . . . . . . . . . . . 9Daraprim . . . . . . . . . . . . . . . . . . . . . . . . 10Daypro . . . . . . . . . . . . . . . . . . . . . . . . . 36Daytrana . . . . . . . . . . . . . . . . . . . . . . . . 19DDAVP . . . . . . . . . . . . . . . . . . . . . . . . . 30Decadron . . . . . . . . . . . . . . . . . . . . 30, 41Delzicol . . . . . . . . . . . . . . . . . . . . . . . . . 34Demerol . . . . . . . . . . . . . . . . . . . . . . . . 13Demulen . . . . . . . . . . . . . . . . . . . . . . . . 38Denavir . . . . . . . . . . . . . . . . . . . . . . . . . 27Depakene . . . . . . . . . . . . . . . . . . . . . . . 15Depakote . . . . . . . . . . . . . . . . . . . . 15, 16Depakote ER . . . . . . . . . . . . . . . . . 15, 16Depakote Sprinkle . . . . . . . . . . . . . . . . 15Depo-Provera 150 mg/ml . . . . . . . . . . 38
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2014 Prescription Drug List Medication Index
Depo-SubQ Provera . . . . . . . . . . . . . . 38Derma-Smoothe/FS . . . . . . . . . . . . . . 25Dermatop 0 .1% . . . . . . . . . . . . . . . . . . 25Desipramine HCl . . . . . . . . . . . . . . . . . 17Desloratadine . . . . . . . . . . . . . . . . . . . . 43Desmopressin Acetate . . . . . . . . . . . . 30Desogen . . . . . . . . . . . . . . . . . . . . . . . . 38Desogestrel-Ethinyl Estradiol . . . . . . . 38Desogestrel-Ethinyl Estradiol/
Ethinyl Estradiol . . . . . . . . . . . . . . . . 38Desonate . . . . . . . . . . . . . . . . . . . . . . . 25Desonide Cream, Ointment . . . . . . . . 25Desonide Lotion . . . . . . . . . . . . . . . . . . 25DesOwen 0 .05% . . . . . . . . . . . . . . . . . 25Desoximetasone Cream . . . . . . . . . . . 25Desoximetasone Cream, Gel,
Ointment . . . . . . . . . . . . . . . . . . . . . . 25Desoxyn . . . . . . . . . . . . . . . . . . . . . . . . 19Desvenlafaxine . . . . . . . . . . . . . . . . . . . 17Desyrel . . . . . . . . . . . . . . . . . . . . . . . . . 17Detrol . . . . . . . . . . . . . . . . . . . . . . . . . . 45Detrol LA . . . . . . . . . . . . . . . . . . . . . . . 45Dexamethasone . . . . . . . . . . . . . . . 30, 41Dexamethasone Sodium Phosphate . 41Dexedrine . . . . . . . . . . . . . . . . . . . . . . . 19Dexilant . . . . . . . . . . . . . . . . . . . . . . . . . 33Dextromethorphan HBr/
Pseudoephedrine HCl/Brompheniramine . . . . . . . . . . . . . . . 43
DiaBeta . . . . . . . . . . . . . . . . . . . . . . . . . 31Diamox . . . . . . . . . . . . . . . . . . . . . . . . . 40Diamox Sequel . . . . . . . . . . . . . . . . . . . 40Diastat Acudial . . . . . . . . . . . . . . . . . . . 15Diazepam . . . . . . . . . . . . . 15, 19, 37, 48Diazepam, Rectal . . . . . . . . . . . . . . . . . 15Dibenzyline . . . . . . . . . . . . . . . . . . . . . . 23Diclofenac Potassium . . . . . . . . . . . . . 36Diclofenac Sodium . . . . . . . . . . . . 36, 40Diclofenac Sodium/Misoprostol . . . . . 36Diclofenac Sodium Tablet,
Sustained-Release 24 Hour . . . . . . 36Dicloxacillin Sodium Capsule . . . . . . . . 7Dicyclomine HCl Tablet . . . . . . . . . 33, 45Didanosine Capsule, Enteric-Coated . 9Didronel . . . . . . . . . . . . . . . . . . . . . . . . 47Differin Cream, Gel 0 .1% . . . . . . . . . . 26Differin Gel 0 .3% . . . . . . . . . . . . . . . . . 26Differin Lotion . . . . . . . . . . . . . . . . . . . . 26Dificid . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Diflorasone Diacetate/Emollient
Cream . . . . . . . . . . . . . . . . . . . . . . . . 25Diflorasone Diacetate Cream . . . . . . . 25
Diflorasone Diacetate Ointment . . . . . 25Diflucan . . . . . . . . . . . . . . . . . . . . . . . 9, 39Diflucan 150 mg . . . . . . . . . . . . . . . . . 39Digoxin . . . . . . . . . . . . . . . . . . . . . . . . . 20Dihydrocodeine Bit/Acetaminophen/
Caffeine . . . . . . . . . . . . . . . . . . . . . . . 13Dihydroergotamine Mesylate . . . . . . . 14Dihydroergotamine Mesylate Aerosol,
Spray with Pump . . . . . . . . . . . . . . . 14Dilacor XR . . . . . . . . . . . . . . . . . . . . . . 22Dilantin . . . . . . . . . . . . . . . . . . . . . . . . . 15Dilatrate-SR . . . . . . . . . . . . . . . . . . . . . 20Dilaudid . . . . . . . . . . . . . . . . . . . . . . . . . 13Diltiazem HCl . . . . . . . . . . . . . . . . . . . . 22Diltiazem HCl Capsule,
Controlled-Release . . . . . . . . . . . . . 22Diltiazem HCl Capsule,
Sustained-Action . . . . . . . . . . . . . . . 22Diltiazem HCl Capsule,
Sustained-Release 12 Hour . . . . . . 22Diltiazem HCl Capsule,
Sustained-Release 24 Hour . . . . . . 22Diltiazem HCl Tablet,
Sustained-Release 24 Hour . . . . . . 22Diovan . . . . . . . . . . . . . . . . . . . . . . . 24, 48Diovan HCT . . . . . . . . . . . . . . . . . . 24, 48Dipentum . . . . . . . . . . . . . . . . . . . . . . . 34Diphenoxylate HCl/Atropine Sulfate . 33Diprolene 0 .05% . . . . . . . . . . . . . . . . . 25Diprolene AF Cream . . . . . . . . . . . . . . 25Diprosone 0 .05%, Maxivate 0 .05% . . 25Dipyridamole . . . . . . . . . . . . . . . . . . . . 20Disopyramide Phosphate Capsule . . 20Disulfiram . . . . . . . . . . . . . . . . . . . . . . . 47Ditropan . . . . . . . . . . . . . . . . . . . . . . . . 45Ditropan XL . . . . . . . . . . . . . . . . . . . . . 45Diuril . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Diuril 250 mg/5 ml . . . . . . . . . . . . . . . . 21Divalproex Sodium . . . . . . . . . . . . . . . . 15Divalproex Sodium Tablet . . . . . . . . . . 15Divalproex Sodium Tablet,
Sustained-Release . . . . . . . . . . . . . . 15Divigel . . . . . . . . . . . . . . . . . . . . . . . . . . 39Dolophine HCl . . . . . . . . . . . . . . . . . . . 13Donepezil 23 mg . . . . . . . . . . . . . . . . . 16Donepezil HCl Tablet . . . . . . . . . . . . . 16Donepezil HCl Tablet,
Rapid Dissolve . . . . . . . . . . . . . . . . . 16Donnatal . . . . . . . . . . . . . . . . . . . . . . . . 33Donnatal Tablet, Sustained-Action . . 33Doryx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Dorzolamide HCl . . . . . . . . . . . . . . . . . 40
Dorzolamide HCl/Timolol Maleate . . . 40Dostinex . . . . . . . . . . . . . . . . . . . . . . . . 30Dovonex . . . . . . . . . . . . . . . . . . . . . . . . 27Doxazosin Mesylate . . . . . . . . . . . . 23, 45Doxepin Cream . . . . . . . . . . . . . . . . . . 28Doxepin HCl . . . . . . . . . . . . . . . . . . . . . 17Doxycycline Hyclate . . . . . . . . . . . . . 7, 48Doxycycline Hyclate Tablet,
Enteric-Coated . . . . . . . . . . . . . . . . . . 7Doxycycline Monohydrate . . . . . . . . 7, 48Doxycycline Monohydrate Capsule . . . 7Doxycycline Monohydrate Tablets . . . 48Dronabinol . . . . . . . . . . . . . . . . . . . . . . 34Droxia . . . . . . . . . . . . . . . . . . . . . . . . . . 11Duac . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Duet DHA with Ferrazone . . . . . . . . . . 46Duet Stuartnatal 29 mg-1 mg . . . . . . 46Duetact . . . . . . . . . . . . . . . . . . . . . . . . . 31Duexis . . . . . . . . . . . . . . . . . . . . . . . . . . 36Dulera . . . . . . . . . . . . . . . . . . . . . . . . . . 44Duoneb . . . . . . . . . . . . . . . . . . . . . . . . . 44Duragesic . . . . . . . . . . . . . . . . . . . . . . . 13Durezol . . . . . . . . . . . . . . . . . . . . . . . . . 41Duricef . . . . . . . . . . . . . . . . . . . . . . . . . . 7Dutoprol . . . . . . . . . . . . . . . . . . . . . . . . 23Dyazide . . . . . . . . . . . . . . . . . . . . . . . . . 21Dymista . . . . . . . . . . . . . . . . . . . . . . 29, 44Dynacin, Minocin . . . . . . . . . . . . . . . . . . 7Dynapen . . . . . . . . . . . . . . . . . . . . . . . . . 7Dyrenium . . . . . . . . . . . . . . . . . . . . . . . 21EE-Mycin, Ery-Tab . . . . . . . . . . . . . . . . . . 7E .E .S . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7EC-Naprosyn . . . . . . . . . . . . . . . . . . . . 36Econazole Nitrate . . . . . . . . . . . . . . . . . 27Edarbi . . . . . . . . . . . . . . . . . . . . . . . . . . 24Edarbyclor . . . . . . . . . . . . . . . . . . . . . . 24Edecrin . . . . . . . . . . . . . . . . . . . . . . . . . 21Edex . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Edluar . . . . . . . . . . . . . . . . . . . . . . . . . . 17Edurant . . . . . . . . . . . . . . . . . . . . . . . . . . 9Effexor XR . . . . . . . . . . . . . . . . . . . 17, 48Effient . . . . . . . . . . . . . . . . . . . . . . . . . . 20Efudex . . . . . . . . . . . . . . . . . . . . . . . . . . 28Egrifta . . . . . . . . . . . . . . . . . . . . . . . . . . 35Elavil . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Eldepryl . . . . . . . . . . . . . . . . . . . . . . . . . 15Elestat . . . . . . . . . . . . . . . . . . . . . . . . . . 42Elestrin . . . . . . . . . . . . . . . . . . . . . . . . . 39Elidel . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Elimite . . . . . . . . . . . . . . . . . . . . . . . 27, 48Elixophyllin Elixir . . . . . . . . . . . . . . . . . . 44
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2014 Prescription Drug List Medication Index
Ella . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Elmiron . . . . . . . . . . . . . . . . . . . . . . . . . 45Elocon . . . . . . . . . . . . . . . . . . . . . . . . . . 25Emadine . . . . . . . . . . . . . . . . . . . . . . . . 42Emcyt . . . . . . . . . . . . . . . . . . . . . . . . . . 11Emend . . . . . . . . . . . . . . . . . . . . . . . . . . 34Emgel . . . . . . . . . . . . . . . . . . . . . . . . . . 26Emla . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Emsam . . . . . . . . . . . . . . . . . . . . . . . . . 17Emtriva . . . . . . . . . . . . . . . . . . . . . . . . . . 9Enablex . . . . . . . . . . . . . . . . . . . . . . . . . 45Enalapril Maleate . . . . . . . . . . . . . . . . . 23Enalapril Maleate/
Hydrochlorothiazide . . . . . . . . . . . . . 23Enbrel . . . . . . . . . . . . . . . . . . . . . . . 27, 36Endometrin . . . . . . . . . . . . . . . . . . . . . . 38Enjuvia . . . . . . . . . . . . . . . . . . . . . . . . . . 39Enoxaparin . . . . . . . . . . . . . . . . . . . . . . 20Entacapone . . . . . . . . . . . . . . . . . . . . . 15Entocort EC . . . . . . . . . . . . . . . . . . 34, 48Epiduo . . . . . . . . . . . . . . . . . . . . . . . . . 26Epinastine HCl Drops . . . . . . . . . . . . . 42Epipen . . . . . . . . . . . . . . . . . . . . . . . . . . 43Epipen Jr . . . . . . . . . . . . . . . . . . . . . . . . 43Epivir . . . . . . . . . . . . . . . . . . . . . . . . . . 8, 9Epivir HBV . . . . . . . . . . . . . . . . . . . . . . . 8Eplerenone . . . . . . . . . . . . . . . . . . . . . . 21Epogen . . . . . . . . . . . . . . . . . . . . . . 12, 35Eprosartan Hydrochloride . . . . . . . . . . 24Epzicom . . . . . . . . . . . . . . . . . . . . . . . . . 9Equetro . . . . . . . . . . . . . . . . . . . . . . . . . 16Ergomar . . . . . . . . . . . . . . . . . . . . . . . . 14Erivedge . . . . . . . . . . . . . . . . . . . . . . . . 11Ertaczo . . . . . . . . . . . . . . . . . . . . . . . . . 27Eryc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Erycette . . . . . . . . . . . . . . . . . . . . . . . . 26Erygel . . . . . . . . . . . . . . . . . . . . . . . . . . 26Erythromycin Base . . . . . . . . . . . 7, 26, 41Erythromycin Base/
Benzoyl Peroxide . . . . . . . . . . . . . . . 26Erythromycin Base/Ethyl Alcohol . . . . 26Erythromycin Base/Ethyl
Alcohol Swab, Medicated . . . . . . . . 26Erythromycin Base Capsule,
Delayed-Release . . . . . . . . . . . . . . . . 7Erythromycin Base Tablet,
Enteric-Coated 250, 333 mg . . . . . . 7Erythromycin Ethylsuccinate . . . . . . . 7, 8Erythromycin Ethylsuccinate/
Sulfisoxazole Acetyl . . . . . . . . . . . . 7, 8Escitalopram . . . . . . . . . . . . . . . . . 18, 48Escitalopram Solution, Oral . . . . . . . . 18
Escitalopram Tablet . . . . . . . . . . . . . . . 18Eskalith . . . . . . . . . . . . . . . . . . . . . . . . . 19Eskalith CR . . . . . . . . . . . . . . . . . . . . . 19Estazolam . . . . . . . . . . . . . . . . . . . . . . . 17Estrace . . . . . . . . . . . . . . . . . . . . . . . . . 39Estrace Cream with Applicator . . . . . 39Estradiol . . . . . . . . . . . . . . . . . . . . . 38, 39Estradiol/Norethindrone Acetate . . . . 39Estradiol/Norgestimate . . . . . . . . . . . . 39Estradiol Patch, Transdermal Weekly . 39Estrasorb . . . . . . . . . . . . . . . . . . . . . . . 39Estring . . . . . . . . . . . . . . . . . . . . . . . . . . 39Estrogel . . . . . . . . . . . . . . . . . . . . . . . . 39Estropipate Tablet . . . . . . . . . . . . . . . . 39Estrostep Fe . . . . . . . . . . . . . . . . . . . . . 38Ethambutol HCl . . . . . . . . . . . . . . . . . . 10Ethinyl Estradiol/Desogestrel . . . . . . . 38Ethinyl Estradiol/Drospirenone . . . . . . 38Ethosuximide . . . . . . . . . . . . . . . . . . . . 15Ethynodiol D-Ethinyl Estradiol . . . . . . 38Etidronate Disodium . . . . . . . . . . . . . . 47Etodolac . . . . . . . . . . . . . . . . . . . . . . . . 36Etodolac Tablet, Sustained-Release
24 Hour . . . . . . . . . . . . . . . . . . . . . . . 36Etoposide . . . . . . . . . . . . . . . . . . . . . . . 11Eulexin . . . . . . . . . . . . . . . . . . . . . . . . . . 11Eurax . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Evamist . . . . . . . . . . . . . . . . . . . . . . . . . 39Evista . . . . . . . . . . . . . . . . . . . . . . . . . . 37Evoclin . . . . . . . . . . . . . . . . . . . . . . . . . 26Evoxac . . . . . . . . . . . . . . . . . . . . . . . . . 29Exalgo . . . . . . . . . . . . . . . . . . . . . . . . . . 13Exelderm . . . . . . . . . . . . . . . . . . . . . . . . 27Exelon . . . . . . . . . . . . . . . . . . . . . . . . . . 16Exelon Solution . . . . . . . . . . . . . . . . . . 16Exemestane . . . . . . . . . . . . . . . . . . . . . 11Exforge . . . . . . . . . . . . . . . . . . . . . . . . . 23Exforge HCT . . . . . . . . . . . . . . . . . . . . 23Exjade . . . . . . . . . . . . . . . . . . . . . . . . . . 47Extavia . . . . . . . . . . . . . . . . . . . . . . . . . . 16Extina . . . . . . . . . . . . . . . . . . . . . . . . . . 27FFactive . . . . . . . . . . . . . . . . . . . . . . . . . . 8Famciclovir . . . . . . . . . . . . . . . . . . . . . . . 8Famotidine Suspension, Oral . . . . . . . 33Famvir . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Fanapt . . . . . . . . . . . . . . . . . . . . . . . . . . 18Fareston . . . . . . . . . . . . . . . . . . . . . . . . 11FazaClo . . . . . . . . . . . . . . . . . . . . . . . . . 18Feiba . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Felbamate . . . . . . . . . . . . . . . . . . . . . . . 15Felbatol . . . . . . . . . . . . . . . . . . . . . . . . . 15
Feldene . . . . . . . . . . . . . . . . . . . . . . . . . 36Felodipine . . . . . . . . . . . . . . . . . . . . . . . 22Femara . . . . . . . . . . . . . . . . . . . . . . 11, 48Femcon Fe . . . . . . . . . . . . . . . . . . . . . . 38Femhrt . . . . . . . . . . . . . . . . . . . . . . . . . . 39Femring . . . . . . . . . . . . . . . . . . . . . . . . . 39Fenofibrate 54, 160 mg . . . . . . . . . . . 24Fenofibrate Micronized . . . . . . . . . . . . 24Fenofibrate Nanocrystallized
48, 145 mg . . . . . . . . . . . . . . . . . . . . 24Fenofibric Acid . . . . . . . . . . . . . . . . . . . 24Fenoglide . . . . . . . . . . . . . . . . . . . . . . . 24Fenoprofen Calcium . . . . . . . . . . . . . . 36Fentanyl Citrate Lollipop . . . . . . . . . . . 13Fentanyl Lozenge . . . . . . . . . . . . . . . . . 48Fentanyl Transdermal . . . . . . . . . . . . . . 13Fentora . . . . . . . . . . . . . . . . . . . . . . . . . 13Ferriprox . . . . . . . . . . . . . . . . . . . . . . . . 47Fibricor . . . . . . . . . . . . . . . . . . . . . . . . . 24Finacea . . . . . . . . . . . . . . . . . . . . . . . . . 26Finasteride . . . . . . . . . . . . . . . . . . . . . . 45Fioricet . . . . . . . . . . . . . . . . . . . . . . 13, 14Fioricet w/Codeine . . . . . . . . . . . . . . . 13Fiorinal . . . . . . . . . . . . . . . . . . . . . . 13, 14Fiorinal w/Codeine 30 mg . . . . . . . . . 13Flagyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Flagyl ER Tablet . . . . . . . . . . . . . . . . . . 10Flavoxate HCl . . . . . . . . . . . . . . . . . . . . 45Flecainide Acetate . . . . . . . . . . . . . . . . 20Flector . . . . . . . . . . . . . . . . . . . . . . . . . . 36Flexeril . . . . . . . . . . . . . . . . . . . . . . . . . . 37Flo-Pred . . . . . . . . . . . . . . . . . . . . . . . . 30Flomax . . . . . . . . . . . . . . . . . . . . . . . 45, 48Flonase . . . . . . . . . . . . . . . . . . . . . . 29, 44Florinef Acetate . . . . . . . . . . . . . . . . . . 30Flovent Diskus . . . . . . . . . . . . . . . . . . . 44Flovent HFA . . . . . . . . . . . . . . . . . . . . . 44Floxin . . . . . . . . . . . . . . . . . . . . . . . . . 8, 29Floxin Otic . . . . . . . . . . . . . . . . . . . . . . 29Fluconazole . . . . . . . . . . . . . . . . . . . 9, 39Flucytosine . . . . . . . . . . . . . . . . . . . . . . . 9Fludrocortisone Acetate . . . . . . . . . . . 30Flumadine . . . . . . . . . . . . . . . . . . . . . . . . 8Flunisolide . . . . . . . . . . . . . . . . . . . 29, 44Fluocinolone Acetonide . . . . . . . . . . . 25Fluocinolone Acetonide Cream,
Ointment . . . . . . . . . . . . . . . . . . . . . . 25Fluocinolone Acetonide Solution
Non-Oral . . . . . . . . . . . . . . . . . . . . . . 25Fluocinonide/Emollient Cream . . . . . . 25Fluocinonide Cream, Gel, Ointment,
Solution, Non-Oral . . . . . . . . . . . . . . 25
55
2014 Prescription Drug List Medication Index
Fluoride Ion/Iron/Multivitamins . . . . . . 46Fluoride Ion/Iron/Vitamins A,C, and D 46Fluoride Ion/Multivitamins . . . . . . . . . . 46Fluoride Ion/Vitamins A,C, and D . . . . 46Fluorometholone . . . . . . . . . . . . . . . . . 41Fluorouracil . . . . . . . . . . . . . . . . . . . . . . 28Fluoxetine . . . . . . . . . . . . . . . . . . . . 18, 48Fluoxetine Capsule,
Delayed-Release . . . . . . . . . . . . . . . 18Fluoxetine HCl Capsule . . . . . . . . . . . 18Fluoxetine HCl Tablet . . . . . . . . . . . . . 18Fluphenazine HCl . . . . . . . . . . . . . . . . 18Flurazepam HCl . . . . . . . . . . . . . . . . . . 17Flurbiprofen . . . . . . . . . . . . . . . . . . 36, 40Flurbiprofen Sodium . . . . . . . . . . . . . . 40Flutamide . . . . . . . . . . . . . . . . . . . . . . . 11Fluticasone Propionate . . . . . .25, 29, 44Fluticasone Propionate Cream . . . . . . 25Fluticasone Propionate Ointment . . . 25Fluvastatin Sodium . . . . . . . . . . . . . . . 24Fluvoxamine Maleate . . . . . . . . . . . . . . 18Fluvoxamine Maleate Capsule,
Extended-Release 24 Hour . . . . . . . 18FML . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41FML Forte . . . . . . . . . . . . . . . . . . . . . . . 41Focalin XR . . . . . . . . . . . . . . . . . . . . . . 19Follistim AQ . . . . . . . . . . . . . . . . . . . . . 39Fondaparinux Sodium . . . . . . . . . . . . . 20Foradil . . . . . . . . . . . . . . . . . . . . . . . . . . 44Forfivo . . . . . . . . . . . . . . . . . . . . . . . . . . 17Fortamet . . . . . . . . . . . . . . . . . . . . . . . . 31Forteo . . . . . . . . . . . . . . . . . . . . . . . . . . 37Fortesta . . . . . . . . . . . . . . . . . . . . . . . . . 30Fortical . . . . . . . . . . . . . . . . . . . . . . 30, 37Fosamax . . . . . . . . . . . . . . . . . . . . . . . . 37Fosamax Plus D . . . . . . . . . . . . . . . . . . 37Fosrenol . . . . . . . . . . . . . . . . . . . . . . . . 47Fragmin . . . . . . . . . . . . . . . . . . . . . . . . . 20Freestyle Insulinx . . . . . . . . . . . . . . . . . 32Freestyle Lite Test Strips . . . . . . . . . . . 32Freestyle Test Strips . . . . . . . . . . . . . . 32Frova . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Furadantin . . . . . . . . . . . . . . . . . . . . . . . . 8Furosemide . . . . . . . . . . . . . . . . . . . . . . 21Fuzeon . . . . . . . . . . . . . . . . . . . . . . . . . . 9GGabapentin . . . . . . . . . . . . . . . . . . . . . 15Gabitril . . . . . . . . . . . . . . . . . . . . . . . . . 15Galantamine Capsule 24 Hour
Sustained-Release Pellets . . . . . . . 16Galantamine Tablet, Solution . . . . . . . 16Ganciclovir . . . . . . . . . . . . . . . . . . . . . . . 8
Ganirelix Acetate . . . . . . . . . . . . . . . . . 31Garamycin . . . . . . . . . . . . . . . . . . . 26, 41Gastrocrom . . . . . . . . . . . . . . . . . . . . . 34Gatifloxacin . . . . . . . . . . . . . . . . . . . . . . 41Gelnique . . . . . . . . . . . . . . . . . . . . . . . . 45Gemfibrozil . . . . . . . . . . . . . . . . . . . . . . 24Generess Fe . . . . . . . . . . . . . . . . . . . . . 38Gengraf . . . . . . . . . . . . . . . . . . . . . . . . 11Genotropin . . . . . . . . . . . . . . . . . . . . . . 35Gentamicin Sulfate . . . . . . . . . . . . 26, 41Geodon . . . . . . . . . . . . . . . . . . . . . 18, 48Gilenya . . . . . . . . . . . . . . . . . . . . . . . . . 16Gleevec . . . . . . . . . . . . . . . . . . . . . . . . 11Glimepiride . . . . . . . . . . . . . . . . . . . . . . 31Glipizide . . . . . . . . . . . . . . . . . . . . . . . . 31Glipizide/Metformin HCl . . . . . . . . . . . 31Glipizide Tablet, Osmotic
Laser-Drilled Formulation . . . . . . . . 31Glucagen . . . . . . . . . . . . . . . . . . . . . . . 31Glucagon . . . . . . . . . . . . . . . . . . . . . . . 31Glucagon, Human Recombinant . . . . 31Glucagon Emergency Kit . . . . . . . . . . 31Glucagon Kit . . . . . . . . . . . . . . . . . . . . 31Glucophage . . . . . . . . . . . . . . . . . . . . . 31Glucophage XR . . . . . . . . . . . . . . . . . . 31Glucotrol . . . . . . . . . . . . . . . . . . . . . . . . 31Glucotrol XL . . . . . . . . . . . . . . . . . . . . . 31Glucovance . . . . . . . . . . . . . . . . . . . . . 31Glumetza . . . . . . . . . . . . . . . . . . . . . . . 31Glyburide . . . . . . . . . . . . . . . . . . . . . . . 31Glyburide/Metformin HCl . . . . . . . . . . 31Glyburide, Micronized . . . . . . . . . . . . . 31Glycolax . . . . . . . . . . . . . . . . . . . . . . . . 34Glycopyrrolate . . . . . . . . . . . . . . . . . . . 33Glynase . . . . . . . . . . . . . . . . . . . . . . . . . 31Glyset . . . . . . . . . . . . . . . . . . . . . . . . . . 31GoLYTELY . . . . . . . . . . . . . . . . . . . . . . 34Gonal-F . . . . . . . . . . . . . . . . . . . . . . . . . 39Gonal-F RFF . . . . . . . . . . . . . . . . . . . . 39Gralise . . . . . . . . . . . . . . . . . . . . . . . . . 16Granisetron HCl Tablet . . . . . . . . . . . . 34Grifulvin V . . . . . . . . . . . . . . . . . . . . . . . . 9Gris-Peg . . . . . . . . . . . . . . . . . . . . . . . . . 9Griseofulvin Microsize . . . . . . . . . . . . . . 9Griseofulvin Ultramicrosize . . . . . . . . . . 9Guaifenesin/Codeine Phosphate . . . . 43Guaifenesin/Pseudoephedrine HCl/
Codeine . . . . . . . . . . . . . . . . . . . . . . . 43Guanfacine HCl . . . . . . . . . . . . . . . . . . 23Gynazole-1 . . . . . . . . . . . . . . . . . . . . . . 39HHabitrol . . . . . . . . . . . . . . . . . . . . . . . . . 47
Halcion . . . . . . . . . . . . . . . . . . . . . . . . . 17Haldol . . . . . . . . . . . . . . . . . . . . . . . . . . 18Halflytely . . . . . . . . . . . . . . . . . . . . . . . . 34Halobetasol Propionate Cream,
Ointment . . . . . . . . . . . . . . . . . . . . . . 25Halog . . . . . . . . . . . . . . . . . . . . . . . . . . 25Haloperidol . . . . . . . . . . . . . . . . . . . . . . 18Haloperidol Lactate Concentrate,
Oral . . . . . . . . . . . . . . . . . . . . . . . . . . 18Hectorol . . . . . . . . . . . . . . . . . . . . . . . . 30Helidac . . . . . . . . . . . . . . . . . . . . . . . . . 33Helixate FS . . . . . . . . . . . . . . . . . . . . . . 21Hemofil-M . . . . . . . . . . . . . . . . . . . . . . . 21Heparin . . . . . . . . . . . . . . . . . . . . . . . . . 20Heparin Sodium . . . . . . . . . . . . . . . . . . 20Hepsera . . . . . . . . . . . . . . . . . . . . . . . . . 8Hexalen . . . . . . . . . . . . . . . . . . . . . . . . . 11Histussin HC . . . . . . . . . . . . . . . . . . . . 43Homatropine HBr . . . . . . . . . . . . . . . . 40Horizant . . . . . . . . . . . . . . . . . . . . . . . . 16Humalog KwikPen . . . . . . . . . . . . . . . . 31Humalog Mix 50-50 Vial . . . . . . . . . . . 31Humalog Mix 50/50 KwikPen . . . . . . . 31Humalog Mix 75-25 Vial . . . . . . . . . . . 31Humalog Mix 75/25 KwikPen . . . . . . . 31Humalog Vial . . . . . . . . . . . . . . . . . . . . 31Humate-P . . . . . . . . . . . . . . . . . . . . . . . 21Humatin . . . . . . . . . . . . . . . . . . . . . . . . 10Humatrope . . . . . . . . . . . . . . . . . . . . . . 35Humira . . . . . . . . . . . . . . . . . . . . . . 27, 36Humulin 70-30 KwikPen . . . . . . . . . . . 31Humulin 70-30 Vial . . . . . . . . . . . . . . . 31Humulin N KwikPen . . . . . . . . . . . . . . . 31Humulin N Vial . . . . . . . . . . . . . . . . . . . 31Humulin R Vial . . . . . . . . . . . . . . . . . . . 31Hycamtin . . . . . . . . . . . . . . . . . . . . . . . . 11Hycet . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Hydralazine HCl . . . . . . . . . . . . . . . . . . 23Hydrea . . . . . . . . . . . . . . . . . . . . . . . . . 11Hydrochlorothiazide . . . . . 21, 23, 24, 48Hydrocodone/Chlorpheniramine
Suspension, Sustained-Release 12 Hour . . . . . . . . . . . . . . . . . . . . . . . 43
Hydrocodone Bit/Acetaminophen . . . 13Hydrocodone Bit/Acetaminophen
Solution, Oral . . . . . . . . . . . . . . . . . . 13Hydrocortisone . .25, 27, 29, 30, 34, 41Hydrocortisone Acetate/
Pramoxine Cream . . . . . . . . . . . . . . . 27Hydrocortisone Acetate/
Pramoxine HCl . . . . . . . . . . . . . . . . . 34
56
2014 Prescription Drug List Medication Index
Hydrocortisone Acetate Suppository, Rectal . . . . . . . . . . . . . 34
Hydrocortisone Butyrate Cream . . . . 25Hydrocortisone Butyrate Ointment,
Solution, Non-Oral . . . . . . . . . . . . . . 25Hydrocortisone Cream . . . . . . . . . 25, 34Hydrocortisone Cream, Ointment . . . 25Hydrocortisone Lotion . . . . . . . . . . . . . 25Hydrocortisone Tablet . . . . . . . . . . . . . 30Hydrocortisone Valerate Cream,
Ointment . . . . . . . . . . . . . . . . . . . . . . 25HydroDIURIL . . . . . . . . . . . . . . . . . . . . 21Hydromorphone HCl . . . . . . . . . . . . . . 13Hydroxychloroquine Sulfate . . . . . 10, 36Hydroxyurea . . . . . . . . . . . . . . . . . . . . . 11Hydroxyzine HCl . . . . . . . . . . . . . . . . . 43Hydroxyzine Pamoate Capsule . . . . . . 43Hyoscyamine Sulfate . . . . . . . . . . . 33, 45Hyoscyamine Sulfate Capsule,
Sustained-Release 12 Hour . . . 33, 45Hyoscyamine Sulfate Drops . . . . . 33, 45Hyoscyamine Sulfate Tablet,
Rapid Dissolve . . . . . . . . . . . . . . 33, 45Hyoscyamine Sulfate Tablet,
Sustained-Release 12 Hour . . . 33, 45Hytone 2 .5% . . . . . . . . . . . . . . . . . . . . 25Hytrin . . . . . . . . . . . . . . . . . . . . . . . . 23, 45Hyzaar . . . . . . . . . . . . . . . . . . . . . . . . . . 24IIbandronate Sodium . . . . . . . . . . . . . . 37Ibuprofen . . . . . . . . . . . . . . . . . . . . 13, 36Ibuprofen/Hydrocodone . . . . . . . . . . . 13Ilotycin . . . . . . . . . . . . . . . . . . . . . . . . . . 41Imdur . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Imipramine Pamoate . . . . . . . . . . . . . . 17Imiquimod . . . . . . . . . . . . . . . . . . . . . . . 28Imitrex . . . . . . . . . . . . . . . . . . . . . . . 14, 48Imitrex Injection . . . . . . . . . . . . . . . 14, 48Imitrex injection & tablets . . . . . . . . . . 48Imitrex Nasal Spray . . . . . . . . . . . . . . . 14Imitrex Tablet . . . . . . . . . . . . . . . . . . . . 14Imuran . . . . . . . . . . . . . . . . . . . . . . . 11, 36Incivek . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Increlex . . . . . . . . . . . . . . . . . . . . . . . . . 35Inderal . . . . . . . . . . . . . . . . . . . . . . . . . . 22Inderal LA . . . . . . . . . . . . . . . . . . . . . . . 22Inderide . . . . . . . . . . . . . . . . . . . . . . . . . 23Indocin . . . . . . . . . . . . . . . . . . . . . . . . . 36Indocin SR . . . . . . . . . . . . . . . . . . . . . . 36Indomethacin . . . . . . . . . . . . . . . . . . . . 36Indomethacin Capsule,
Sustained-Action . . . . . . . . . . . . . . . 36
Infergen . . . . . . . . . . . . . . . . . . . . . . . . . 35Inflamase Forte . . . . . . . . . . . . . . . . . . . 41Innohep . . . . . . . . . . . . . . . . . . . . . . . . . 20Innopran XL . . . . . . . . . . . . . . . . . . . . . 22Inspra . . . . . . . . . . . . . . . . . . . . . . . . . . 21Intal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Intelence . . . . . . . . . . . . . . . . . . . . . . . . . 9Intermezzo . . . . . . . . . . . . . . . . . . . . . . 17Intron A . . . . . . . . . . . . . . . . . . . . . . . . . 35Intuniv . . . . . . . . . . . . . . . . . . . . . . . . . . 19Invega . . . . . . . . . . . . . . . . . . . . . . . . . . 18Invirase . . . . . . . . . . . . . . . . . . . . . . . . . . 9Iopidine 0 .5% . . . . . . . . . . . . . . . . . . . . 41Iopidine 1% . . . . . . . . . . . . . . . . . . . . . 41Ipratropium Bromide Solution,
Non-Oral . . . . . . . . . . . . . . . . . . . . . . 44Irbesartan . . . . . . . . . . . . . . . . . . . . . . . 24Irbesartan/Hydrochlorothiazide . . . . . 24Isentress . . . . . . . . . . . . . . . . . . . . . . . . . 9ISMO . . . . . . . . . . . . . . . . . . . . . . . . . . 20Isometheptene Mucate/
Acetaminophen/ Dichloralphenazone . . . . . . . . . . . . . 14
Isoniazid . . . . . . . . . . . . . . . . . . . . . . . . 10Isopto Atropine . . . . . . . . . . . . . . . . . . 40Isopto Carpine
0 .5%, 1%, 2%, 4%, 6% . . . . . . . . . 40Isopto Homatropine . . . . . . . . . . . . . . . 40Isordil 2 .5, 5 mg . . . . . . . . . . . . . . . . . . 20Isordil 40 mg . . . . . . . . . . . . . . . . . . . . 20Isordil 5, 10, 20, 30 mg . . . . . . . . . . . 20Isosorbide Dinitrate Tablet . . . . . . . . . 20Isosorbide Dinitrate Tablet,
Sublingual . . . . . . . . . . . . . . . . . . . . . 20Isosorbide Mononitrate . . . . . . . . . . . . 20Isosorbide Mononitrate Tablet,
Sustained-Release 24 Hour . . . . . . 20Istalol . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Itraconazole Capsule . . . . . . . . . . . . . . . 9Itraconazole Solution, Oral . . . . . . . . . . 9JJakafi . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Jalyn . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Janumet . . . . . . . . . . . . . . . . . . . . . . . . 31Janumet XR . . . . . . . . . . . . . . . . . . . . . 31Januvia . . . . . . . . . . . . . . . . . . . . . . . . . 31Jentadueto . . . . . . . . . . . . . . . . . . . . . . 31KK-Dur . . . . . . . . . . . . . . . . . . . . . . . . . . . 46K-Phos M .F . . . . . . . . . . . . . . . . . . . . . . 45K-Phos Original . . . . . . . . . . . . . . . . . . 45K-Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
K-Tab, Slow-K . . . . . . . . . . . . . . . . . . . 46Kadian . . . . . . . . . . . . . . . . . . . . . . . . . . 13Kaletra . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Kapvay . . . . . . . . . . . . . . . . . . . . . . . . . 19Kayexalate . . . . . . . . . . . . . . . . . . . . . . 47Kazano . . . . . . . . . . . . . . . . . . . . . . . . . 31Keflex . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Kenalog 0 .025%, 0 .1% . . . . . . . . . . . 25Kenalog 0 .1% . . . . . . . . . . . . . . . . . . . 25Kenalog in Orabase . . . . . . . . . . . . . . . 29Keppra . . . . . . . . . . . . . . . . . . . . . . 15, 16Keppra XR . . . . . . . . . . . . . . . . . . . 15, 16Keralyt Scalp . . . . . . . . . . . . . . . . . . . . 27Kerlone . . . . . . . . . . . . . . . . . . . . . . . . . 22Ketek . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Ketoconazole . . . . . . . . . . . . . . . . . . 9, 27Ketoconazole Cream, Shampoo . . . . 27Ketoconazole Foam . . . . . . . . . . . . . . . 27Ketoprofen . . . . . . . . . . . . . . . . . . . . . . 36Ketoprofen Capsule, 24 Hour
Sustained-Release . . . . . . . . . . . . . . 36Ketorolac Tromethamine . . . . . . . . 36, 40Kineret . . . . . . . . . . . . . . . . . . . . . . . . . 36Klaron . . . . . . . . . . . . . . . . . . . . . . . . . . 26Klonopin . . . . . . . . . . . . . . . . . . . . . . . . 15Klor-Con 25mEq . . . . . . . . . . . . . . . . . 46Koate-DVI . . . . . . . . . . . . . . . . . . . . . . . 21Kogenate FS . . . . . . . . . . . . . . . . . . . . 21Kombiglyze XR . . . . . . . . . . . . . . . . . . . 31Kristalose . . . . . . . . . . . . . . . . . . . . . . . 34Kuvan . . . . . . . . . . . . . . . . . . . . . . . . . . 30Kytril . . . . . . . . . . . . . . . . . . . . . . . . . . . 34LLabetalol HCl . . . . . . . . . . . . . . . . . . . . 22Lacrisert . . . . . . . . . . . . . . . . . . . . . . . . 42Lactulose . . . . . . . . . . . . . . . . . . . . . . . 34Lamictal . . . . . . . . . . . . . . . . . . . . . 15, 16Lamictal Chewable . . . . . . . . . . . . . . . 15Lamictal Dose Pack . . . . . . . . . . . . . . . 16Lamictal ODT . . . . . . . . . . . . . . . . . . . . 16Lamictal XR . . . . . . . . . . . . . . . . . . . . . 16Lamisil . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Lamisil Granules . . . . . . . . . . . . . . . . . . 9Lamivudine Tablet . . . . . . . . . . . . . . . . . 9Lamotrigine 5, 25 mg
Chewable Tablet . . . . . . . . . . . . . . . . 15Lamotrigine Orally
Disintegrating Tablet . . . . . . . . . . . . 16Lamotrigine Tablet . . . . . . . . . . . . . 15, 16Lamotrigine Tablet,
Extended-Release 24 Hour . . . . . . . 16Lanoxin . . . . . . . . . . . . . . . . . . . . . . . . . 20
57
2014 Prescription Drug List Medication Index
Lansoprazole/Amoxicillin/ Clarithromycin . . . . . . . . . . . . . . . . . . 33
Lansoprazole Capsule, Delayed-Release . . . . . . . . . . . . . . . 33
Lansoprazole Tablet, Rapid Dissolve, Delayed-Release . . . . . . . . . . . . . . . 33
Lantus Solostar Pen/Cartridge . . . . . . 31Lantus Vial . . . . . . . . . . . . . . . . . . . . . . 31Lariam . . . . . . . . . . . . . . . . . . . . . . . . . . 10Lasix . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Lastacaft . . . . . . . . . . . . . . . . . . . . . 42, 48Latanoprost . . . . . . . . . . . . . . . . . . . . . 40Latuda . . . . . . . . . . . . . . . . . . . . . . . . . . 18Lazanda . . . . . . . . . . . . . . . . . . . . . . . . 13Leflunomide . . . . . . . . . . . . . . . . . . . . . 36Lescol . . . . . . . . . . . . . . . . . . . . . . . . . . 24Lescol XL . . . . . . . . . . . . . . . . . . . . . . . 24Letairis . . . . . . . . . . . . . . . . . . . . . . . . . 44Letrozole . . . . . . . . . . . . . . . . . . . . . 11, 48Leucovorin Calcium . . . . . . . . . . . . . . . 12Leucovorin Calcium 10, 15 mg . . . . . 12Leucovorin Calcium 5, 25 mg . . . . . . 12Leukeran . . . . . . . . . . . . . . . . . . . . . . . . 11Leukine . . . . . . . . . . . . . . . . . . . . . . 12, 35Leuprolide Acetate . . . . . . . . . . . . 11, 39Levalbuterol HCl . . . . . . . . . . . . . . . . . 44Levaquin Tablet, Solution . . . . . . . . . . . 8Levatol . . . . . . . . . . . . . . . . . . . . . . . . . 22Levbid . . . . . . . . . . . . . . . . . . . . . . . 33, 45Levemir Flexpen . . . . . . . . . . . . . . . . . . 31Levemir Vial . . . . . . . . . . . . . . . . . . . . . 31Levetiracetam . . . . . . . . . . . . . . . . . . . . 15Levetiracetam Tablet,
Extended-Release 24 Hour . . . . . . . 15Levitra . . . . . . . . . . . . . . . . . . . . . . . . . . 45Levo-Dromoran . . . . . . . . . . . . . . . . . . 13Levobunolol HCl . . . . . . . . . . . . . . . . . 40Levocarnitine . . . . . . . . . . . . . . . . . . . . 47Levocetirizine Dihydrochloride
Solution, Oral . . . . . . . . . . . . . . . . . . 43Levocetirizine Dihydrochloride Tablet 43Levofloxacin . . . . . . . . . . . . . . . . . . . 8, 41Levonorgestrel-Eth Estr/Ethinyl
Estradiol . . . . . . . . . . . . . . . . . . . . . . 38Levonorgestrel-Ethinyl Estradiol . . . . . 38Levonorgestrel-Ethinyl Estradiol
Tablet, Dosepak, 3 month . . . . . . . . 38Levorphanol Tartrate . . . . . . . . . . . . . . 13Levothroid . . . . . . . . . . . . . . . . . . . . . . . 30Levothyroxine . . . . . . . . . . . . . . . . . . . . 30Levothyroxine Sodium . . . . . . . . . . . . . 30Levoxyl . . . . . . . . . . . . . . . . . . . . . . . . . 30
Levsin, Levsin/SL . . . . . . . . . . . . . . 33, 45Levsinex . . . . . . . . . . . . . . . . . . . . . 33, 45Lexapro . . . . . . . . . . . . . . . . . . . . . . 18, 48Lexiva . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Lialda . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Librium . . . . . . . . . . . . . . . . . . . . . . . . . 19Lidex-E 0 .05% . . . . . . . . . . . . . . . . . . . 25Lidex 0 .05% . . . . . . . . . . . . . . . . . . . . . 25Lidocaine Adhesive Patch . . . . . . . . . 26Lidocaine HCl . . . . . . . . . . . . . . . . 26, 29Lidocaine HCl Gel, Ointment,
Solution . . . . . . . . . . . . . . . . . . . . . . . 26Lidoderm . . . . . . . . . . . . . . . . . . . . . . . 26Lindane . . . . . . . . . . . . . . . . . . . . . . . . . 27Lindane Lotion, Shampoo . . . . . . . . . . 27Lioresal . . . . . . . . . . . . . . . . . . . . . . . . . 37Liothyronine Sodium . . . . . . . . . . . . . . 30Lipitor . . . . . . . . . . . . . . . . . . . . . . . 24, 48Lipofen . . . . . . . . . . . . . . . . . . . . . . . . . 24Lisinopril . . . . . . . . . . . . . . . . . . . . . . . . 23Lisinopril/Hydrochlorothiazide . . . . . . 23Lithium Carbonate . . . . . . . . . . . . . . . . 19Lithium Carbonate,
Sustained-Action . . . . . . . . . . . . . . . 19Lithium Carbonate Tablet,
Sustained-Action . . . . . . . . . . . . . . . 19Lithium Citrate . . . . . . . . . . . . . . . . . . . 19Lithobid . . . . . . . . . . . . . . . . . . . . . . . . . 19Livalo . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Lo/Ovral . . . . . . . . . . . . . . . . . . . . . . . . 38Lo Loestrin Fe . . . . . . . . . . . . . . . . . . . 38Locoid 0 .1% . . . . . . . . . . . . . . . . . . . . . 25Locoid Lipocream . . . . . . . . . . . . . . . . 25Locoid Lotion . . . . . . . . . . . . . . . . . . . . 25Lodine . . . . . . . . . . . . . . . . . . . . . . . . . . 36Lodine XL . . . . . . . . . . . . . . . . . . . . . . . 36Loestrin . . . . . . . . . . . . . . . . . . . . . . . . . 38Loestrin 24 Fe . . . . . . . . . . . . . . . . . . . 38Loestrin Fe . . . . . . . . . . . . . . . . . . . . . . 38Lofibra . . . . . . . . . . . . . . . . . . . . . . . . . . 24Lomotil . . . . . . . . . . . . . . . . . . . . . . . . . 33Lopid . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Lopressor . . . . . . . . . . . . . . . . . . . . 22, 23Lopressor HCT . . . . . . . . . . . . . . . . . . 23Loprox 0 .77% . . . . . . . . . . . . . . . . . . . 27Loprox 1% . . . . . . . . . . . . . . . . . . . . . . 27Loprox Shampoo . . . . . . . . . . . . . . . . . 27Loratadine Tablet, Syrup - OTC . . . . . 43Lorazepam . . . . . . . . . . . . . . . . . . . 19, 48Lorazepam Concentrate, Oral . . . . . . 19Lorazepam Intensol . . . . . . . . . . . . . . . 19Lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Lortab . . . . . . . . . . . . . . . . . . . . . . . . . . 13Lorzone . . . . . . . . . . . . . . . . . . . . . . . . . 37Losartan Potassium . . . . . . . . . . . . . . . 24Losartan Potassium/
Hydrochlorothiazide . . . . . . . . . . . . . 24LoSeasonique . . . . . . . . . . . . . . . . . . . 38Lotemax Ointment, Suspension . . . . . 41Lotensin . . . . . . . . . . . . . . . . . . . . . . . . 23Lotensin HCT . . . . . . . . . . . . . . . . . . . . 23Lotrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Lotrisone . . . . . . . . . . . . . . . . . . . . . . . . 27Lotronex . . . . . . . . . . . . . . . . . . . . . . . . 34Lovastatin . . . . . . . . . . . . . . . . . . . . . . . 24Lovaza . . . . . . . . . . . . . . . . . . . . . . . . . . 24Lovenox . . . . . . . . . . . . . . . . . . . . . . . . . 20Ludiomil . . . . . . . . . . . . . . . . . . . . . . . . 17Lufyllin Tablet . . . . . . . . . . . . . . . . . . . . 44Lumigan . . . . . . . . . . . . . . . . . . . . . . . . 40Lunesta . . . . . . . . . . . . . . . . . . . . . . . . . 17Lupron 1 mg/0 .2 ml . . . . . . . . . . . . 11, 39Luride . . . . . . . . . . . . . . . . . . . . . . . . . . 46Luvox . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Luvox CR . . . . . . . . . . . . . . . . . . . . . . . 18Luxiq . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Lybrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Lyrica . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Lysodren . . . . . . . . . . . . . . . . . . . . . . . . 11Lysteda . . . . . . . . . . . . . . . . . . . . . . . . . 39MMacrobid . . . . . . . . . . . . . . . . . . . . . . . . 8Macrodantin 25 mg . . . . . . . . . . . . . . . . 8Macrodantin 50, 100 mg . . . . . . . . . . . 8Malarone . . . . . . . . . . . . . . . . . . . . . . . . 10Malathion . . . . . . . . . . . . . . . . . . . . 27, 48Maprotiline HCl . . . . . . . . . . . . . . . . . . 17Marinol . . . . . . . . . . . . . . . . . . . . . . . . . 34Marplan . . . . . . . . . . . . . . . . . . . . . . . . . 17Matulane . . . . . . . . . . . . . . . . . . . . . . . . 11Mavik . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Maxalt . . . . . . . . . . . . . . . . . . . . . . . 14, 48Maxalt-MLT . . . . . . . . . . . . . . . . . . . . . . 48Maxalt MLT . . . . . . . . . . . . . . . . . . . 14, 48Maxitrol . . . . . . . . . . . . . . . . . . . . . . . . . 41Maxzide . . . . . . . . . . . . . . . . . . . . . . . . . 21Meclofenamate Sodium . . . . . . . . . . . 36Meclomen . . . . . . . . . . . . . . . . . . . . . . . 36Medrol 2, 8, 24 mg . . . . . . . . . . . . . . . 30Medrol 4, 16, 32 mg . . . . . . . . . . . . . . 30Medroxyprogesterone Acet . . . . . . . . 38Mefenamic Acid . . . . . . . . . . . . . . . . . . 36Mefloquine HCl . . . . . . . . . . . . . . . . . . 10Megace . . . . . . . . . . . . . . . . . . . . . . . . . 11
58
2014 Prescription Drug List Medication Index
Megace ES . . . . . . . . . . . . . . . . . . . . . 11Megestrol Acetate . . . . . . . . . . . . . . . . 11Mellaril . . . . . . . . . . . . . . . . . . . . . . . . . . 18Meloxicam . . . . . . . . . . . . . . . . . . . . . . . 36Menest . . . . . . . . . . . . . . . . . . . . . . . . . 39Menopur . . . . . . . . . . . . . . . . . . . . . . . . 39Menostar Patch,
Transdermal Weekly . . . . . . . . . . . . . 39Mentax . . . . . . . . . . . . . . . . . . . . . . . . . 27Meperidine HCl . . . . . . . . . . . . . . . . . . 13Mephyton . . . . . . . . . . . . . . . . . . . . . . . 21Mepron . . . . . . . . . . . . . . . . . . . . . . . . . 10Mercaptopurine . . . . . . . . . . . . . . . . . . 11Mesalamine Enema . . . . . . . . . . . . . . . 34Mestinon . . . . . . . . . . . . . . . . . . . . . . . . 16Mestinon 60 mg . . . . . . . . . . . . . . . . . . 16Metadate CD . . . . . . . . . . . . . . . . . 19, 48Metadate ER . . . . . . . . . . . . . . . . . . . . 19Metaglip . . . . . . . . . . . . . . . . . . . . . . . . 31Metaproterenol Sulfate . . . . . . . . . . . . 44Metaproterenol Sulfate Solution,
Non-Oral . . . . . . . . . . . . . . . . . . . . . . 44Metaxalone . . . . . . . . . . . . . . . . . . . 37, 48Metformin HCl . . . . . . . . . . . . . . . . . . . 31Metformin HCl Sustained-Release . . 31Metformin HCl Tablet,
Extended-Release 24 Hour . . . . . . . 31Methadone HCl . . . . . . . . . . . . . . . . . . 13Methamphetamine HCl . . . . . . . . . . . . 19Methazolamide . . . . . . . . . . . . . . . . . . . 40Methenamine Mandelate . . . . . . . . . . . . 8Methergine . . . . . . . . . . . . . . . . . . . . . . 38Methimazole . . . . . . . . . . . . . . . . . . . . . 30Methocarbamol . . . . . . . . . . . . . . . . . . 37Methotrexate . . . . . . . . . . . . . . . . . 11, 36Methotrexate Sodium . . . . . . . . . . 11, 36Methylergonovine Maleate . . . . . . . . . 38Methylin Solution, Oral . . . . . . . . . . . . 19Methylin Tablet, Chewable . . . . . . . . . 19Methylphenidate Extended-Release . 48Methylphenidate HCl . . . . . . . . . . . . . 19Methylphenidate HCl Capsule,
Extended-Release Multiphase . . . . 19Methylphenidate HCl Capsule,
Extended-Release Multiphase 30-70 . . . . . . . . . . . . . . . . . . . . . . . . 19
Methylphenidate HCl Tablet, Extended-Release 24 Hour . . . . . . . 19
Methylphenidate HCl Tablet, Sustained-Action . . . . . . . . . . . . . . . 19
Methylphenidate Immediate-Release . 48
Methylprednisolone Tablet, Dose Pack . . . . . . . . . . . . . . . . . . . . . 30
Meticorten . . . . . . . . . . . . . . . . . . . . . . 30Metipranolol . . . . . . . . . . . . . . . . . . . . . 40Metoclopramide HCl . . . . . . . . . . . . . . 34Metolazone . . . . . . . . . . . . . . . . . . . . . . 21Metoprolol/Hydrochlorothiazide . . . . . 23Metoprolol Succinate Tablet,
Sustained-Release 24 Hour . . . . . . 22Metoprolol Tartrate . . . . . . . . . . . . . . . . 22Metozolv ODT . . . . . . . . . . . . . . . . . . . 34Metrocream . . . . . . . . . . . . . . . . . . . . . 26Metrogel 0 .75% . . . . . . . . . . . . . . . . . . 26Metrogel 1% . . . . . . . . . . . . . . . . . . . . 26Metrogel Vaginal . . . . . . . . . . . . . . . . . 39Metrolotion . . . . . . . . . . . . . . . . . . . . . . 26Metronidazole . . . . . . . . . . . . . .10, 26, 39Metronidazole Cream . . . . . . . . . . . . . 26Metronidazole Gel . . . . . . . . . . . . . . . . 26Metronidazole Gel 1% . . . . . . . . . . . . 26Metronidazole Vaginal Gel . . . . . . . . . 39Mevacor . . . . . . . . . . . . . . . . . . . . . . . . 24Mexiletine HCl . . . . . . . . . . . . . . . . . . . 20Mexitil . . . . . . . . . . . . . . . . . . . . . . . . . . 20Miacalcin . . . . . . . . . . . . . . . . . . . . 30, 37Micardis . . . . . . . . . . . . . . . . . . . . . . . . 24Micardis HCT . . . . . . . . . . . . . . . . . . . . 24Micro-K . . . . . . . . . . . . . . . . . . . . . . . . . 46Microzide . . . . . . . . . . . . . . . . . . . . . . . 21Midamor . . . . . . . . . . . . . . . . . . . . . . . . 21Midodrine HCl . . . . . . . . . . . . . . . . . . . 47Midrin . . . . . . . . . . . . . . . . . . . . . . . . . . 14Migranal . . . . . . . . . . . . . . . . . . . . . . . . 14Minipress . . . . . . . . . . . . . . . . . . . . . . . 23Minocycline HCl . . . . . . . . . . . . . . . . . . 7Minocycline HCl Tablet,
Extended-Release 24 Hour . . . . . . . . 7Mirapex . . . . . . . . . . . . . . . . . . . . . . . . . 15Mirapex ER . . . . . . . . . . . . . . . . . . . . . . 15Mircette . . . . . . . . . . . . . . . . . . . . . . . . . 38Mirtazapine . . . . . . . . . . . . . . . . . . . . . . 17Mirtazapine Dispersible Tablet . . . . . . 17Misoprostol . . . . . . . . . . . . . . . . . . . 33, 36Mobic . . . . . . . . . . . . . . . . . . . . . . . . . . 36Modafinil . . . . . . . . . . . . . . . . . . . . . . . . 19Modicon . . . . . . . . . . . . . . . . . . . . . . . . 38Moduretic . . . . . . . . . . . . . . . . . . . . . . . 21Moexipril HCl . . . . . . . . . . . . . . . . . . . . 23Mometasone Furoate Cream,
Ointment, Solution . . . . . . . . . . . . . . 25Monoclate-P . . . . . . . . . . . . . . . . . . . . . 21Monodox . . . . . . . . . . . . . . . . . . . . . . 7, 48
Mononine . . . . . . . . . . . . . . . . . . . . . . . 21Montelukast . . . . . . . . . . . . . . . . . . 44, 48Montelukast Chewable Tablet . . . . . . 48Montelukast Sodium . . . . . . . . . . . . . . 44Monurol . . . . . . . . . . . . . . . . . . . . . . . . . . 8Morphine Sulfate Capsule,
Extended-Release Pellets . . . . . . . . 13Morphine Sulfate Solution, Oral . . . . . 13Morphine Sulfate Tablet,
Sustained-Action . . . . . . . . . . . . . . . 13Motofen . . . . . . . . . . . . . . . . . . . . . . . . 33Motrin . . . . . . . . . . . . . . . . . . . . . . . . . . 36Moviprep . . . . . . . . . . . . . . . . . . . . . . . . 34Moxeza . . . . . . . . . . . . . . . . . . . . . . . . . 41Mozobil . . . . . . . . . . . . . . . . . . . . . . . . . 35MS Contin . . . . . . . . . . . . . . . . . . . . . . 13MSIR . . . . . . . . . . . . . . . . . . . . . . . . . . . 13MSIR 20 mg/ml . . . . . . . . . . . . . . . . . . 13Mucomyst . . . . . . . . . . . . . . . . . . . . . . . 44Multaq . . . . . . . . . . . . . . . . . . . . . . . . . . 20Mupirocin Calcium Cream . . . . . . . . . 26Mupirocin Ointment . . . . . . . . . . . . . . . 26Muse . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Myambutol . . . . . . . . . . . . . . . . . . . . . . 10Mycelex . . . . . . . . . . . . . . . . . . . . . . . . . . 9Mycolog II . . . . . . . . . . . . . . . . . . . . . . . 27Mycophenolate Mofetil Capsule,
Tablet . . . . . . . . . . . . . . . . . . . . . . . . . 11Mycostatin . . . . . . . . . . . . . . . . . . . . 9, 27Mydriacyl . . . . . . . . . . . . . . . . . . . . . . . 40Myfortic . . . . . . . . . . . . . . . . . . . . . . . . . 11Myleran . . . . . . . . . . . . . . . . . . . . . . . . . 11Myorisan . . . . . . . . . . . . . . . . . . . . . . . . 26Myrbetriq . . . . . . . . . . . . . . . . . . . . . . . 45Mysoline . . . . . . . . . . . . . . . . . . . . . . . . 15Mytelase . . . . . . . . . . . . . . . . . . . . . . . . 16NNabumetone . . . . . . . . . . . . . . . . . . . . . 36Nadolol . . . . . . . . . . . . . . . . . . . . . . 22, 23Nadolol/Bendroflumethiazide . . . . . . . 23Naftin . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Nalfon . . . . . . . . . . . . . . . . . . . . . . . . . . 36Naltrexone HCl . . . . . . . . . . . . . . . . . . 14Namenda . . . . . . . . . . . . . . . . . . . . . . . 16Naphazoline HCl . . . . . . . . . . . . . . . . . 40Naprelan . . . . . . . . . . . . . . . . . . . . . . . . 36Naprosyn . . . . . . . . . . . . . . . . . . . . . . . 36Naproxen . . . . . . . . . . . . . . . . . . . . . . . 36Naproxen Sodium . . . . . . . . . . . . . . . . 36Naratriptan HCl . . . . . . . . . . . . . . . . . . 14Nardil . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Nasacort AQ . . . . . . . . . . . . . . . . . 29, 44
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2014 Prescription Drug List Medication Index
Nasarel . . . . . . . . . . . . . . . . . . . . . . 29, 44Nascobal . . . . . . . . . . . . . . . . . . . . . . . 46Nasonex . . . . . . . . . . . . . . . . . . . . . 29, 44Natacyn . . . . . . . . . . . . . . . . . . . . . . . . 41Natazia . . . . . . . . . . . . . . . . . . . . . . . . . 38Nateglinide . . . . . . . . . . . . . . . . . . . . . . 31Natroba . . . . . . . . . . . . . . . . . . . . . . 27, 48Navane . . . . . . . . . . . . . . . . . . . . . . . . . 18NebuPent . . . . . . . . . . . . . . . . . . . . . . . 10Nefazodone HCl . . . . . . . . . . . . . . . . . 17Neo-Synephrine . . . . . . . . . . . . . . . . . . 40Neomycin/Polymyxin B Sulfate/
Dexamethasone . . . . . . . . . . . . . . . . 41Neomycin Sulfate . . . . . . . . . . . . 9, 29, 41Neomycin Sulfate/Bacitracin/
Polymyxin B Ointment . . . . . . . . . . . 41Neomycin Sulfate/Bacitracin Zinc/
Polymyxin B/Hydrocortisone Ointment . . . . . . . . . . . . . . . . . . . . . . 41
Neomycin Sulfate/Gramicidin D/Polymyxin B Drops . . . . . . . . . . . . . . 41
Neomycin Sulfate/Polymyxin B Sulfate/Hydrocortisone . . . . . . . 29, 41
Neomycin Sulfate/Polymyxin B Sulfate/Hydrocortisone Suspension, Drops . . . . . . . . . . . . . . 41
Neoral . . . . . . . . . . . . . . . . . . . . . . . . . . 11Neosporin . . . . . . . . . . . . . . . . . . . . . . . 41Neptazane . . . . . . . . . . . . . . . . . . . . . . 40Nesina . . . . . . . . . . . . . . . . . . . . . . . . . . 31Neulasta . . . . . . . . . . . . . . . . . . . . . . . . 35Neumega . . . . . . . . . . . . . . . . . . . . . . . 35Neupogen . . . . . . . . . . . . . . . . . . . . 12, 35Neurontin . . . . . . . . . . . . . . . . . . . . . . . 15Nevanac . . . . . . . . . . . . . . . . . . . . . . . . 40Nevirapine . . . . . . . . . . . . . . . . . . . . . . . 9Nexavar . . . . . . . . . . . . . . . . . . . . . . . . . 11Nexiclon XR . . . . . . . . . . . . . . . . . . . . . 23Nexium Capsule . . . . . . . . . . . . . . . . . . 33Nexium Suspension . . . . . . . . . . . . . . . 33Niacin Extended-Release . . . . . . . . . . 24Niaspan . . . . . . . . . . . . . . . . . . . . . . . . . 24Nicardipine HCl . . . . . . . . . . . . . . . . . . 22Nicotine Patch, Transdermal 24 Hour 47Nicotrol Inhaler . . . . . . . . . . . . . . . . . . . 47Nicotrol NS . . . . . . . . . . . . . . . . . . . . . 47Nifedipine . . . . . . . . . . . . . . . . . . . . . . . 22Nifedipine Tablet, Osmotic
Laser-Drilled Formulation . . . . . . . . 22Nilandron . . . . . . . . . . . . . . . . . . . . . . . 11Nimodipine . . . . . . . . . . . . . . . . . . . . . . 16Nimotop . . . . . . . . . . . . . . . . . . . . . . . . 16
Niravam . . . . . . . . . . . . . . . . . . . . . . . . . 19Nisoldipine . . . . . . . . . . . . . . . . . . . . . . 22Nitro-Bid . . . . . . . . . . . . . . . . . . . . . . . . 20Nitro-Dur . . . . . . . . . . . . . . . . . . . . . . . . 20Nitrofurantoin/Nitrofurantoin
Macrocrystal . . . . . . . . . . . . . . . . . . . . 8Nitrofurantoin Macrocrystal . . . . . . . . . 8Nitrofurantoin Suspension, Oral . . . . . . 8Nitroglycerin . . . . . . . . . . . . . . . . . . 20, 45Nitroglycerin Capsule,
Sustained-Action . . . . . . . . . . . . . . . 20Nitroglycerin Patch, Transdermal
24 Hour . . . . . . . . . . . . . . . . . . . . . . . 20Nitroglycerin Spray . . . . . . . . . . . . . . . 20Nitroglycerin Spray, Non-Aerosol . . . . 20Nitrolingual . . . . . . . . . . . . . . . . . . . . . . 20Nitromist . . . . . . . . . . . . . . . . . . . . . . . . 20Nitrostat . . . . . . . . . . . . . . . . . . . . . . . . 20Nizatidine Solution, Oral . . . . . . . . . . . 33Nizoral . . . . . . . . . . . . . . . . . . . . . . . . 9, 27Nizoral 2% . . . . . . . . . . . . . . . . . . . . . . 27Nolvadex . . . . . . . . . . . . . . . . . . . . . . . . 11Nor-Q-D . . . . . . . . . . . . . . . . . . . . . . . . 38Norco . . . . . . . . . . . . . . . . . . . . . . . . . . 13Nordette . . . . . . . . . . . . . . . . . . . . . . . . 38Norditropin . . . . . . . . . . . . . . . . . . . . . . 35Norethindrone . . . . . . . . . . . . . . . . 38, 39Norethindrone-Ethinyl Estradiol . . . . . 38Norethindrone-Ethinyl Estradiol /
Iron Tablet, Chewable . . . . . . . . . . . 38Norethindrone-Mestranol . . . . . . . . . . 38Norethindrone A-E Estradiol . . . . . . . . 38Norethindrone A-E Estradiol/
Ferrous Fumarate . . . . . . . . . . . . . . . 38Norethindrone Acetate . . . . . . . . . 38, 39Norethindrone Acetate/
Ethinyl Estradiol . . . . . . . . . . . . . . . . 39Norflex . . . . . . . . . . . . . . . . . . . . . . . . . . 37Norgesic, Norgesic Forte . . . . . . . . . . 37Norgestimate-Ethinyl Estradiol . . . . . . 38Norgestrel-Ethinyl Estradiol . . . . . . . . 38Noritate . . . . . . . . . . . . . . . . . . . . . . . . . 26Normodyne . . . . . . . . . . . . . . . . . . . . . . 22Noroxin . . . . . . . . . . . . . . . . . . . . . . . . . . 8Norpace . . . . . . . . . . . . . . . . . . . . . . . . 20Norpace CR . . . . . . . . . . . . . . . . . . . . . 20Norpramin . . . . . . . . . . . . . . . . . . . . . . . 17Nortriptyline HCl . . . . . . . . . . . . . . . . . 17Norvasc . . . . . . . . . . . . . . . . . . . . . . . . 22Norvir . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Novolin Vial . . . . . . . . . . . . . . . . . . . . . . 31NovoLog 70-30 Flexpen . . . . . . . . . . . 31
NovoLog 70-30 Vial . . . . . . . . . . . . . . 31NovoLog Flexpen . . . . . . . . . . . . . . . . . 31NovoLog Vial . . . . . . . . . . . . . . . . . . . . 31Novoseven . . . . . . . . . . . . . . . . . . . . . . 21Noxafil . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Nucynta . . . . . . . . . . . . . . . . . . . . . . . . 14Nucynta ER . . . . . . . . . . . . . . . . . . . . . 14Nuedexta . . . . . . . . . . . . . . . . . . . . . . . 16Nulev . . . . . . . . . . . . . . . . . . . . . . . . 33, 45Nulytely w/Flavor Packs . . . . . . . . . . . 34Nutropin . . . . . . . . . . . . . . . . . . . . . . . . 35Nutropin AQ . . . . . . . . . . . . . . . . . . . . . 35Nutropin AQ NuSpin . . . . . . . . . . . . . . 35Nuvaring . . . . . . . . . . . . . . . . . . . . . . . . 38Nuvigil . . . . . . . . . . . . . . . . . . . . . . . . . . 19Nystatin . . . . . . . . . . . . . . . . . . . . . . . 9, 27Nystatin/Triamcinolone Acetonide . . . 27OOctreotide Acetate . . . . . . . . . . . . 11, 30Ocufen . . . . . . . . . . . . . . . . . . . . . . . . . 40Ocuflox . . . . . . . . . . . . . . . . . . . . . . . . . 41Ocupress . . . . . . . . . . . . . . . . . . . . . . . 40Ofloxacin . . . . . . . . . . . . . . . . . . . 8, 29, 41Ogen . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Olanzapine . . . . . . . . . . . . . . . . . . . 18, 48Olanzapine/Fluoxetine . . . . . . . . . . . . . 18Olanzapine Orally
Disintegrating Tablet . . . . . . . . . . . . 48Olanzapine Tablet . . . . . . . . . . . . . . . . 18Olanzapine Tablet, Rapid Dissolve . . . 18Oleptro ER . . . . . . . . . . . . . . . . . . . . . . 17Olux . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Olux-E . . . . . . . . . . . . . . . . . . . . . . . . . . 25Omeclamox Pak . . . . . . . . . . . . . . . . . . 33Omeprazole . . . . . . . . . . . . . . . . . . 33, 48Omeprazole/Sodium Bicarbonate
Capsule . . . . . . . . . . . . . . . . . . . . . . . 33Omnaris . . . . . . . . . . . . . . . . . . . . . 29, 44Omnicef . . . . . . . . . . . . . . . . . . . . . . . . . 7Omnitrope . . . . . . . . . . . . . . . . . . . . . . 35Ondansetron HCl . . . . . . . . . . . . . . . . 34Ondansetron HCl Tablet,
Rapid Dissolve . . . . . . . . . . . . . . . . . 34One Touch Test Strips . . . . . . . . . . . . . 32One Touch Ultra 2 System . . . . . . . . . 32One Touch Ultra Mini System . . . . . . . 32One Touch Ultra Test Strips . . . . . . . . 32One Touch Verio IQ System . . . . . . . . 32One Touch Verio IQ Test Strips . . . . . 32Onfi . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Onglyza . . . . . . . . . . . . . . . . . . . . . . . . . 31Onmel . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
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2014 Prescription Drug List Medication Index
Onsolis . . . . . . . . . . . . . . . . . . . . . . . . . 13Opana . . . . . . . . . . . . . . . . . . . . . . . . . . 13Opana ER . . . . . . . . . . . . . . . . . . . . . . . 13Optase . . . . . . . . . . . . . . . . . . . . . . . . . 27OptiPranolol . . . . . . . . . . . . . . . . . . . . . 40Optivar . . . . . . . . . . . . . . . . . . . . . . 42, 48Oracea . . . . . . . . . . . . . . . . . . . . . . . . . . 7Oracit . . . . . . . . . . . . . . . . . . . . . . . . . . 45Orapred . . . . . . . . . . . . . . . . . . . . . . . . 30Orapred ODT . . . . . . . . . . . . . . . . . . . . 30Orencia . . . . . . . . . . . . . . . . . . . . . . . . . 36Orphenadrine . . . . . . . . . . . . . . . . . . . . 37Orphenadrine/Aspirin/Caffeine . . . . . 37Ortho-Cyclen . . . . . . . . . . . . . . . . . . . . 38Ortho-Novum 1-0 .035 mg . . . . . . . . . 38Ortho-Novum 1-0 .05 mg . . . . . . . . . . 38Ortho-Novum 10-11 . . . . . . . . . . . . . . 38Ortho-Novum 2-0 .1 mg . . . . . . . . . . . 38Ortho-Novum 7/7/7 . . . . . . . . . . . . . . 38Ortho Evra . . . . . . . . . . . . . . . . . . . . . . 38Ortho Micronor . . . . . . . . . . . . . . . . . . 38Ortho Tri-Cyclen . . . . . . . . . . . . . . . . . 38Ortho Tri-Cyclen Lo . . . . . . . . . . . . . . . 38Orudis . . . . . . . . . . . . . . . . . . . . . . . . . . 36Oruvail 200 mg . . . . . . . . . . . . . . . . . . 36Oseni . . . . . . . . . . . . . . . . . . . . . . . . . . 31Osmoprep . . . . . . . . . . . . . . . . . . . . . . 34Ovcon . . . . . . . . . . . . . . . . . . . . . . . . . . 38Ovcon 35 . . . . . . . . . . . . . . . . . . . . . . . 38Ovide . . . . . . . . . . . . . . . . . . . . . . . 27, 48Ovidrel . . . . . . . . . . . . . . . . . . . . . . . . . 39Ovral . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Oxandrin . . . . . . . . . . . . . . . . . . . . . 11, 30Oxandrolone . . . . . . . . . . . . . . . . . . 11, 30Oxaprozin . . . . . . . . . . . . . . . . . . . . . . . 36Oxazepam . . . . . . . . . . . . . . . . . . . . . . 19Oxcarbazepine . . . . . . . . . . . . . . . . . . . 15Oxistat . . . . . . . . . . . . . . . . . . . . . . . . . . 27Oxsoralen-Ultra . . . . . . . . . . . . . . . . . . 28Oxybutynin Chloride . . . . . . . . . . . . . . 45Oxybutynin Chloride Tablet,
Sustained-Release . . . . . . . . . . . . . . 45Oxycodone/Aspirin . . . . . . . . . . . . . . . 13Oxycodone HCl . . . . . . . . . . . . . . . . . . 13Oxycodone HCl/Acetaminophen . . . . 13Oxycodone HCl/Acetaminophen
Tablet . . . . . . . . . . . . . . . . . . . . . . . . . 13Oxycodone HCl/Ibuprofen . . . . . . . . . 13Oxycodone HCl Concentrate, Oral . . 13OxyContin . . . . . . . . . . . . . . . . . . . . . . 13OxyFAST . . . . . . . . . . . . . . . . . . . . . . . . 13
Oxymorphone HCl Tablet, Sustained-Release 12 Hour . . . . . . 13
Oxymorphone Tablet . . . . . . . . . . . . . . 13Oxytrol . . . . . . . . . . . . . . . . . . . . . . . . . . 45PPamelor . . . . . . . . . . . . . . . . . . . . . . . . . 17Pancreaze . . . . . . . . . . . . . . . . . . . . . . . 34Pandel Cream . . . . . . . . . . . . . . . . . . . 25Panlor SS, Panlor DC . . . . . . . . . . . . . 13Panretin Gel . . . . . . . . . . . . . . . . . . . . . 28Pantoprazole . . . . . . . . . . . . . . . . . 33, 48Parafon Forte DSC . . . . . . . . . . . . . . . 37Parcopa . . . . . . . . . . . . . . . . . . . . . . . . 15Paremyd . . . . . . . . . . . . . . . . . . . . . . . . 40Paricalcitol . . . . . . . . . . . . . . . . . . . . . . 30Parlodel . . . . . . . . . . . . . . . . . . . . . . . . . 15Parnate . . . . . . . . . . . . . . . . . . . . . . . . . 17Paromomycin Sulfate . . . . . . . . . . . . . 10Paroxetine HCl Sustained-Release,
24 Hour . . . . . . . . . . . . . . . . . . . . . . . 18Paroxetine HCl Tablet . . . . . . . . . . . . . 18Pataday . . . . . . . . . . . . . . . . . . . . . . . . . 42Patanase . . . . . . . . . . . . . . . . . . . . . . . . 29Patanol . . . . . . . . . . . . . . . . . . . . . . . . . 42Paxil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Paxil CR . . . . . . . . . . . . . . . . . . . . . . . . 18PCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Pediapred . . . . . . . . . . . . . . . . . . . . . . . 30Pediazole . . . . . . . . . . . . . . . . . . . . . . 7, 8Peg-Intron . . . . . . . . . . . . . . . . . . . . . . . 35Peganone . . . . . . . . . . . . . . . . . . . . . . . 15Pegasys . . . . . . . . . . . . . . . . . . . . . . . . 35Pen-Vee K . . . . . . . . . . . . . . . . . . . . . . . 7Penicillin V Potassium . . . . . . . . . . . . . . 7Penlac . . . . . . . . . . . . . . . . . . . . . . . . . . 27Pennsaid . . . . . . . . . . . . . . . . . . . . . . . . 36Pentasa . . . . . . . . . . . . . . . . . . . . . . . . . 34Pentazocine HCl/Acetaminophen . . . 14Pentazocine HCl/Naloxone HCl . . . . 14Pentoxifylline Tablet,
Sustained-Action . . . . . . . . . . . . . . . 21Pepcid . . . . . . . . . . . . . . . . . . . . . . . . . . 33Percocet . . . . . . . . . . . . . . . . . . . . . 13, 48Percodan . . . . . . . . . . . . . . . . . . . . . . . 13Perforomist . . . . . . . . . . . . . . . . . . . . . . 44Periactin . . . . . . . . . . . . . . . . . . . . . . . . 43Peridex . . . . . . . . . . . . . . . . . . . . . . . . . 29Perindopril . . . . . . . . . . . . . . . . . . . . . . 23Periostat . . . . . . . . . . . . . . . . . . . . . . . . . 7Permethrin . . . . . . . . . . . . . . . . . . . 27, 48Perphenazine . . . . . . . . . . . . . . . . . . . . 18Persantine . . . . . . . . . . . . . . . . . . . . . . 20
Pertzye . . . . . . . . . . . . . . . . . . . . . . . . . 34Pexeva . . . . . . . . . . . . . . . . . . . . . . . . . . 18Phenazopyridine HCl . . . . . . . . . . . . . . 45Phenelzine Sulfate . . . . . . . . . . . . . . . . 17Phenergan . . . . . . . . . . . . . . . . . . . 34, 43Phenergan VC . . . . . . . . . . . . . . . . . . . 43Phenergan VC w/Codeine . . . . . . . . . 43Phenergan w/Codeine . . . . . . . . . . . . 43Phenobarbital . . . . . . . . . . . . . . . . . 15, 33Phenylephrine HCl . . . . . . . . . . . . 40, 43Phenylephrine HCl/Codeine/
Promethazine . . . . . . . . . . . . . . . . . . 43Phenylephrine HCl/Hydrocodone Bit/
Chlorpheniramine . . . . . . . . . . . . . . . 43Phenylephrine HCl/Promethazine HCl 43Phenytek . . . . . . . . . . . . . . . . . . . . . . . . 15Phenytoin . . . . . . . . . . . . . . . . . . . . . . . 15Phenytoin Sodium . . . . . . . . . . . . . . . . 15Phenytoin Sodium Extended . . . . . . . 15PhosLo . . . . . . . . . . . . . . . . . . . . . . . . . 46Phytonadione . . . . . . . . . . . . . . . . . . . . 21Picato . . . . . . . . . . . . . . . . . . . . . . . . . . 28Pilocarpine HCl . . . . . . . . . . . .29, 40, 47Pilopine HS . . . . . . . . . . . . . . . . . . . . . 40Pindolol . . . . . . . . . . . . . . . . . . . . . . . . . 22pioglitazone . . . . . . . . . . . . . . . . . . 31, 48Pioglitazone HCl . . . . . . . . . . . . . . . . . 31Pioglitazone HCl/Glimepiride . . . . . . . 31Pioglitazone HCl/Metformin HCl . . . . 31Piroxicam . . . . . . . . . . . . . . . . . . . . . . . 36Plan B . . . . . . . . . . . . . . . . . . . . . . . . . . 38Plaquenil . . . . . . . . . . . . . . . . . . . . . 10, 36Plavix . . . . . . . . . . . . . . . . . . . . . . . . 20, 48Plendil . . . . . . . . . . . . . . . . . . . . . . . . . . 22Pletal . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Plexion . . . . . . . . . . . . . . . . . . . . . . . . . 26PNN W-Ca #68/Iron/Fa #1/DHA . . 46PNV39/Iron CBN&Gluc/FA/DSS/
DHA . . . . . . . . . . . . . . . . . . . . . . . . . . 46PNV39/Iron Fumarate/Fa/DSS/
DHA . . . . . . . . . . . . . . . . . . . . . . . . . . 46PNV48/Iron Na Feredetat/Fa/
Omega 3 . . . . . . . . . . . . . . . . . . . . . . 46PNV66/Iron Fumarate/Fa/DSS/
DHA . . . . . . . . . . . . . . . . . . . . . . . . . . 46PNV Combo #47/Iron/Fa #1/
DHA . . . . . . . . . . . . . . . . . . . . . . . . . . 46PNV No . 52/Iron B-G Suc-Pro/
FA Tablet . . . . . . . . . . . . . . . . . . . . . . 46PNV W-Ca #40/Iron Fum/
Fa CMB #1 . . . . . . . . . . . . . . . . . . . 46Podofilox Liquid . . . . . . . . . . . . . . . . . . 28
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2014 Prescription Drug List Medication Index
Poly-Vi-Flor . . . . . . . . . . . . . . . . . . . . . . 46Poly-Vi-Flor w/Iron . . . . . . . . . . . . . . . . 46Polyethylene Glycol 3350 Powder . . 34Polymyxin B Sulfate/Trimethoprim . . . 41Polysporin . . . . . . . . . . . . . . . . . . . . . . . 41Polytrim . . . . . . . . . . . . . . . . . . . . . . . . . 41Ponstel . . . . . . . . . . . . . . . . . . . . . . . . . 36Potassium Chloride . . . . . . . . . . . . 34, 46Potassium Chloride Capsule,
Sustained-Action . . . . . . . . . . . . . . . 46Potassium Chloride Packet . . . . . . . . 46Potassium Chloride Tablet,
Sustained-Action . . . . . . . . . . . . . . . 46Potiga . . . . . . . . . . . . . . . . . . . . . . . . . . 16Pradaxa . . . . . . . . . . . . . . . . . . . . . . . . . 20Pramipexole Di-HCl . . . . . . . . . . . . . . . 15Pramosone 2 .5%-1% . . . . . . . . . . . . . 27Prandin . . . . . . . . . . . . . . . . . . . . . . . . . 31Pravachol . . . . . . . . . . . . . . . . . . . . . . . 24Pravastatin . . . . . . . . . . . . . . . . . . . . . . 24Prazosin HCl . . . . . . . . . . . . . . . . . . . . 23Precision Xtra Test Strips . . . . . . . . . . 32Precose . . . . . . . . . . . . . . . . . . . . . . . . 31Pred-G . . . . . . . . . . . . . . . . . . . . . . . . . 41Pred Forte . . . . . . . . . . . . . . . . . . . . . . . 41Pred Mild . . . . . . . . . . . . . . . . . . . . . . . 41Prednicarbate Cream . . . . . . . . . . . . . 25Prednisolone Acetate . . . . . . . . . . . . . 41Prednisolone Sodium
Phosphate . . . . . . . . . . . . . . . . . . 30, 41Prednisolone Sodium Phosphate
Solution, Oral . . . . . . . . . . . . . . . . . . 30Prednisolone Syrup . . . . . . . . . . . . . . . 30Prednisone . . . . . . . . . . . . . . . . . . . . . . 30Prefest . . . . . . . . . . . . . . . . . . . . . . . . . 39Prelone . . . . . . . . . . . . . . . . . . . . . . . . . 30Premarin . . . . . . . . . . . . . . . . . . . . . . . . 39Premphase . . . . . . . . . . . . . . . . . . . . . . 39Prempro . . . . . . . . . . . . . . . . . . . . . . . . 39Prenat Vit Comb 10/Iron/Fa/DHA . . . 46Prenatal . . . . . . . . . . . . . . . . . . . . . . . . 46Prenatal Vit/Fe Fumarate/FA . . . . . . . 46Prenate DHA 27-1-300 mg . . . . . . . . 46Prenate Elite 27 mg -1 mg . . . . . . . . . 46Prenate Essential 28-1-300 mg . . . . 46Prenexa 27-1 .25-55 . . . . . . . . . . . . . . 46Prenexa 30-1 .2-55 . . . . . . . . . . . . . . . 46Prepopik . . . . . . . . . . . . . . . . . . . . . . . . 34Prevacid . . . . . . . . . . . . . . . . . . . . . . . . 33Prevacid Capsule, Delayed-Release
(Enteric-Coated) . . . . . . . . . . . . . . . 33Prevacid Solutab . . . . . . . . . . . . . . . . . 33
Prevident 1 .1% . . . . . . . . . . . . . . . . . . 29Prevpac . . . . . . . . . . . . . . . . . . . . . . . . . 33Prezista . . . . . . . . . . . . . . . . . . . . . . . . . . 9Priftin . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Prilosec . . . . . . . . . . . . . . . . . . . . . . 33, 48Prilosec Capsules . . . . . . . . . . . . . . . . 48Primaquine . . . . . . . . . . . . . . . . . . . . . . 10Primidone . . . . . . . . . . . . . . . . . . . . . . . 15Primsol . . . . . . . . . . . . . . . . . . . . . . . . . . 8Prinivil . . . . . . . . . . . . . . . . . . . . . . . . . . 23Prinzide . . . . . . . . . . . . . . . . . . . . . . . . . 23Pristiq . . . . . . . . . . . . . . . . . . . . . . . . . . 17Proair HFA . . . . . . . . . . . . . . . . . . . . . . 44ProAmatine . . . . . . . . . . . . . . . . . . . . . . 47Probenecid . . . . . . . . . . . . . . . . . . . . . . 36Procardia . . . . . . . . . . . . . . . . . . . . . . . 22Procardia XL . . . . . . . . . . . . . . . . . . . . 22Prochlorperazine Maleate Tablet . . . . 34Procort . . . . . . . . . . . . . . . . . . . . . . . . . 34Procrit . . . . . . . . . . . . . . . . . . . . . . . 12, 35ProctoCream-HC 2 .5% . . . . . . . . . . . 34Profilnine SD . . . . . . . . . . . . . . . . . . . . 21Progesterone, Micronized . . . . . . . . . . 38Prograf . . . . . . . . . . . . . . . . . . . . . . . . . 11Prolixin . . . . . . . . . . . . . . . . . . . . . . . . . 18Proloprim . . . . . . . . . . . . . . . . . . . . . . . . 8Promacta . . . . . . . . . . . . . . . . . . . . . . . 21Promethazine HCl . . . . . . . . . . . . . 34, 43Prometrium . . . . . . . . . . . . . . . . . . . . . . 38Propafenone Capsule,
Sustained-Release 12 Hour . . . . . . 20Propafenone HCl . . . . . . . . . . . . . . . . . 20Propranolol HCl/
Hydrochlorothiazide . . . . . . . . . . . . . 23Propranolol HCl Sustained-Action
Capsule . . . . . . . . . . . . . . . . . . . . . . . 22Propranolol HCl Tablet . . . . . . . . . . . . 22Propylthiouracil . . . . . . . . . . . . . . . . . . 30Proscar . . . . . . . . . . . . . . . . . . . . . . . . . 45ProSom . . . . . . . . . . . . . . . . . . . . . . . . . 17Prostigmin . . . . . . . . . . . . . . . . . . . . . . 16Protonix . . . . . . . . . . . . . . . . . . . . . . 33, 48Protopic . . . . . . . . . . . . . . . . . . . . . . . . 28Protriptyline HCl . . . . . . . . . . . . . . . . . 17Proventil . . . . . . . . . . . . . . . . . . . . . . . . 44Proventil HFA . . . . . . . . . . . . . . . . . . . . 44Provera . . . . . . . . . . . . . . . . . . . . . . . . . 38Provigil . . . . . . . . . . . . . . . . . . . . . . . . . 19Prozac . . . . . . . . . . . . . . . . . . . . . . . 18, 48Prozac Weekly . . . . . . . . . . . . . . . . . . . 18Pseudoephedrine Sulfate/
Loratadine - OTC . . . . . . . . . . . . . . . 43
Psorcon . . . . . . . . . . . . . . . . . . . . . . . . 25Psorcon 0 .05% . . . . . . . . . . . . . . . . . . 25Psorcon E 0 .05% . . . . . . . . . . . . . . . . 25Pulmicort Flexhaler . . . . . . . . . . . . . . . 44Pulmicort Respules 0 .25 mg/2 ml,
0 .5 mg/2 ml . . . . . . . . . . . . . . . . . . . 44Pulmicort Respules 1 mg/2 ml . . . . . . 44Pulmozyme . . . . . . . . . . . . . . . . . . . . . . 44Purinethol . . . . . . . . . . . . . . . . . . . . . . . 11Pylera . . . . . . . . . . . . . . . . . . . . . . . . . . 33Pyrazinamide . . . . . . . . . . . . . . . . . . . . 10Pyridium . . . . . . . . . . . . . . . . . . . . . . . . 45Pyridostigmine Bromide Tablet . . . . . . 16QQnasl . . . . . . . . . . . . . . . . . . . . . . . 29, 44Qualaquin . . . . . . . . . . . . . . . . . . . . . . . 10Questran . . . . . . . . . . . . . . . . . . . . . . . . 24Questran Light . . . . . . . . . . . . . . . . . . . 24Quetiapine . . . . . . . . . . . . . . . . . . . 18, 48Quetiapine Fumarate . . . . . . . . . . . . . . 18Quinapril HCl/Hydrochlorothiazide . . 23Quinidex . . . . . . . . . . . . . . . . . . . . . . . . 20Quinidine Gluconate . . . . . . . . . . . . . . 20Quinidine Sulfate . . . . . . . . . . . . . . . . . 20Quinidine Sulfate Tablet,
Sustained-Action . . . . . . . . . . . . . . . 20Quinine Sulfate . . . . . . . . . . . . . . . . . . 10Quixin . . . . . . . . . . . . . . . . . . . . . . . . . . 41QVAR . . . . . . . . . . . . . . . . . . . . . . . . . . 44RRabeprazole . . . . . . . . . . . . . . . . . . . . . 33Ramipril . . . . . . . . . . . . . . . . . . . . . . . . . 23Ranexa . . . . . . . . . . . . . . . . . . . . . . . . . 24Ranitidine HCl Syrup . . . . . . . . . . . . . . 33Rapaflo . . . . . . . . . . . . . . . . . . . . . . . . . 45Rapamune . . . . . . . . . . . . . . . . . . . . . . 11Rayos . . . . . . . . . . . . . . . . . . . . . . . . . . 30Razadyne . . . . . . . . . . . . . . . . . . . . . . . 16Razadyne ER . . . . . . . . . . . . . . . . . . . . 16Rebetol Capsules . . . . . . . . . . . . . . . . . 8Rebetol Solution . . . . . . . . . . . . . . . . . . 8Rebif . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Recombinate . . . . . . . . . . . . . . . . . . . . 21Rectiv . . . . . . . . . . . . . . . . . . . . . . . . . . 34Reglan . . . . . . . . . . . . . . . . . . . . . . . . . . 34Regranex . . . . . . . . . . . . . . . . . . . . . . . 28Relafen . . . . . . . . . . . . . . . . . . . . . . . . . 36Relenza . . . . . . . . . . . . . . . . . . . . . . . . . . 8Relistor . . . . . . . . . . . . . . . . . . . . . . . . . 34Relpax . . . . . . . . . . . . . . . . . . . . . . . . . . 14Remeron . . . . . . . . . . . . . . . . . . . . . . . . 17Remeron SolTab . . . . . . . . . . . . . . . . . 17
62
2014 Prescription Drug List Medication Index
Renacidin . . . . . . . . . . . . . . . . . . . . . . . 45Renagel . . . . . . . . . . . . . . . . . . . . . . . . 47Renvela . . . . . . . . . . . . . . . . . . . . . . . . . 47Repaglinide . . . . . . . . . . . . . . . . . . . . . 31Repronex . . . . . . . . . . . . . . . . . . . . . . . 39Requip . . . . . . . . . . . . . . . . . . . . . . . . . 15Requip XL . . . . . . . . . . . . . . . . . . . . . . . 15Rescriptor . . . . . . . . . . . . . . . . . . . . . . . . 9Restasis . . . . . . . . . . . . . . . . . . . . . . . . 42Restoril . . . . . . . . . . . . . . . . . . . . . . . . . 17Retin-A . . . . . . . . . . . . . . . . . . . . . . . . . 26Retin-A Micro . . . . . . . . . . . . . . . . . . . . 26Retrovir . . . . . . . . . . . . . . . . . . . . . . . . . . 9Revatio . . . . . . . . . . . . . . . . . . . . . . 44, 48ReVia . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Revlimid . . . . . . . . . . . . . . . . . . . . . . . . 11Reyataz . . . . . . . . . . . . . . . . . . . . . . . . . . 9Rheumatrex, Trexall . . . . . . . . . . . . . . . 11Rhinocort Aqua . . . . . . . . . . . . . . . 29, 44Ribapak . . . . . . . . . . . . . . . . . . . . . . . . . . 8Ribavirin . . . . . . . . . . . . . . . . . . . . . . . . . 8Rifadin . . . . . . . . . . . . . . . . . . . . . . . . . . 10Rifamate . . . . . . . . . . . . . . . . . . . . . . . . 10Rifampin . . . . . . . . . . . . . . . . . . . . . . . . 10Rifampin/Isoniazid . . . . . . . . . . . . . . . . 10Rifater . . . . . . . . . . . . . . . . . . . . . . . . . . 10Rilutek . . . . . . . . . . . . . . . . . . . . . . . . . . 47Riluzole . . . . . . . . . . . . . . . . . . . . . . . . . 47Rimantadine HCl Tablet . . . . . . . . . . . . 8Riomet Solution, Oral . . . . . . . . . . . . . 31Risperdal . . . . . . . . . . . . . . . . . . . . 18, 48Risperdal M-Tab . . . . . . . . . . . . . . . . . . 18Risperidone . . . . . . . . . . . . . . . . . . 18, 48Risperidone Solution . . . . . . . . . . . . . . 18Risperidone Tablet . . . . . . . . . . . . . . . . 18Risperidone Tablet, Rapid Dissolve . . 18Ritalin . . . . . . . . . . . . . . . . . . . . . . . 19, 48Ritalin, Ritalin SR . . . . . . . . . . . . . . . . . 19Ritalin LA . . . . . . . . . . . . . . . . . . . . . . . 19Rivastigmine Tartrate Capsule . . . . . . 16Rizatriptan . . . . . . . . . . . . . . . . . . . 14, 48Rizatriptan Benzoate Tablet . . . . . . . . 14Rizatriptan Benzoate Tablet,
Disintegrating . . . . . . . . . . . . . . . . . . 14Rizatriptan Orally
Disintegrating Tablet . . . . . . . . . . . . 48Robaxin . . . . . . . . . . . . . . . . . . . . . . . . . 37Robinul, Robinul Forte . . . . . . . . . . . . . 33Robitussin-DAC . . . . . . . . . . . . . . . . . . 43Robitussin A-C . . . . . . . . . . . . . . . . . . 43Rocaltrol . . . . . . . . . . . . . . . . . . . . . . . . 30Ropinirole HCl . . . . . . . . . . . . . . . . . . . 15
Ropinirole HCl Tablet, Extended-Release 24 Hour . . . . . . . 15
Rowasa . . . . . . . . . . . . . . . . . . . . . . . . . 34Roxanol . . . . . . . . . . . . . . . . . . . . . . . . . 13Roxicodone, OxyIR . . . . . . . . . . . . . . . 13Rozerem . . . . . . . . . . . . . . . . . . . . . . . . 17Rybix ODT . . . . . . . . . . . . . . . . . . . . . . 14Rythmol . . . . . . . . . . . . . . . . . . . . . . . . . 20Rythmol SR . . . . . . . . . . . . . . . . . . . . . 20Ryzolt . . . . . . . . . . . . . . . . . . . . . . . . . . 14SSabril . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Safyral . . . . . . . . . . . . . . . . . . . . . . . . . . 38Saizen . . . . . . . . . . . . . . . . . . . . . . . . . . 35Salagen . . . . . . . . . . . . . . . . . . . . . 29, 47Salagen 5 mg . . . . . . . . . . . . . . . . . . . . 29Salflex . . . . . . . . . . . . . . . . . . . . . . . . . . 36Salsalate . . . . . . . . . . . . . . . . . . . . . . . . 36Samsca . . . . . . . . . . . . . . . . . . . . . . . . . 30Sanctura . . . . . . . . . . . . . . . . . . . . . 37, 45Sanctura XR . . . . . . . . . . . . . . . . . . . . . 45Sancuso . . . . . . . . . . . . . . . . . . . . . . . . 34Sandimmune . . . . . . . . . . . . . . . . . . . . 11Sandostatin . . . . . . . . . . . . . . . . . . . . . 11Santyl . . . . . . . . . . . . . . . . . . . . . . . . . . 27Saphris . . . . . . . . . . . . . . . . . . . . . . . . . 18Sarafem . . . . . . . . . . . . . . . . . . . . . . . . 18Savella . . . . . . . . . . . . . . . . . . . . . . . . . 36Seasonale . . . . . . . . . . . . . . . . . . . . . . . 38Seasonique . . . . . . . . . . . . . . . . . . . . . 38Sectral . . . . . . . . . . . . . . . . . . . . . . . . . 22Selegiline HCl . . . . . . . . . . . . . . . . . . . 15Selzentry . . . . . . . . . . . . . . . . . . . . . . . . . 9Sensipar . . . . . . . . . . . . . . . . . . . . . . . . 30Septra, Septra DS . . . . . . . . . . . . . . . . . 8Serax . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Serevent Diskus . . . . . . . . . . . . . . . . . . 44Serophene . . . . . . . . . . . . . . . . . . . . . . 39Seroquel . . . . . . . . . . . . . . . . . . . . . 18, 48Seroquel XR . . . . . . . . . . . . . . . . . . . . . 18Serostim . . . . . . . . . . . . . . . . . . . . . . . . 35Sertraline . . . . . . . . . . . . . . . . . . . . 18, 48Sertraline HCl . . . . . . . . . . . . . . . . . . . 18Serzone . . . . . . . . . . . . . . . . . . . . . . . . 17Sildenafil . . . . . . . . . . . . . . . . . . . . . 44, 48Sildenafil Citrate . . . . . . . . . . . . . . . . . 44Silenor . . . . . . . . . . . . . . . . . . . . . . . . . . 17Silvadene . . . . . . . . . . . . . . . . . . . . . . . 27Silver Sulfadiazine . . . . . . . . . . . . . . . . 27Simcor . . . . . . . . . . . . . . . . . . . . . . . . . 24Simponi . . . . . . . . . . . . . . . . . . . . . . . . . 36Simvastatin . . . . . . . . . . . . . . . . . . . . . . 24
Sinemet . . . . . . . . . . . . . . . . . . . . . . . . 15Sinemet CR . . . . . . . . . . . . . . . . . . . . . 15Sinequan . . . . . . . . . . . . . . . . . . . . . . . 17Singulair . . . . . . . . . . . . . . . . . . . . . 44, 48Singulair Chewable Tablet . . . . . . . . . 48Singulair Tablet . . . . . . . . . . . . . . . . . . 48Skelaxin . . . . . . . . . . . . . . . . . . . . . . 37, 48Skelaxin 800 mg . . . . . . . . . . . . . . . . . 37Sklice . . . . . . . . . . . . . . . . . . . . . . . . . . 27Sod Chloride/NaHCO3/KCl/PEGs . 34Sodium Fluoride . . . . . . . . . . . . . . . 29, 46Sodium Fluoride Gel . . . . . . . . . . . . . . 29Sodium Polystyrene Sulfonate . . . . . . 47Sodium Sulfate/Sodium/Sodium
Bicarbonate/Potassium Chloride/Polyethylene Glycols . . . . . . . . . . . . 34
Sodium Sulfate/Sodium/Sodium Bicarbonate/Potassium Chloride/Polyethylene Glycols Solution, Reconstituted, Oral . . . . . . . . . . . . . 34
Solaraze Gel . . . . . . . . . . . . . . . . . . . . . 28Solodyn . . . . . . . . . . . . . . . . . . . . . . . . . . 7Solodyn 45, 90, 135 mg . . . . . . . . . . . . 7Soltamox . . . . . . . . . . . . . . . . . . . . . . . . 11Soma 250 mg . . . . . . . . . . . . . . . . . . . 37Soma 350 mg . . . . . . . . . . . . . . . . . . . 37Somatuline Depot . . . . . . . . . . . . . . . . 11Sonata . . . . . . . . . . . . . . . . . . . . . . . . . 17Soriatane . . . . . . . . . . . . . . . . . . . . . . . 27Sorilux . . . . . . . . . . . . . . . . . . . . . . . . . . 27Sotalol HCl . . . . . . . . . . . . . . . . . . . . . . 20Sotret . . . . . . . . . . . . . . . . . . . . . . . . . . 26Spasdel . . . . . . . . . . . . . . . . . . . . . 33, 45Spectazole 1% . . . . . . . . . . . . . . . . . . 27Spectracef . . . . . . . . . . . . . . . . . . . . . . . 7Spinosad . . . . . . . . . . . . . . . . . . . . 27, 48Spiriva . . . . . . . . . . . . . . . . . . . . . . . . . . 44Spironolactone . . . . . . . . . . . . . . . . . . . 21Spironolactone/Hydrochlorothiazide . 21Sporanox Capsule . . . . . . . . . . . . . . . . . 9Sporanox Solution, Oral . . . . . . . . . . . . 9Sprix . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Sprycel . . . . . . . . . . . . . . . . . . . . . . . . . 11Stadol . . . . . . . . . . . . . . . . . . . . . . . . . . 14Stalevo . . . . . . . . . . . . . . . . . . . . . . . . . 15Starlix . . . . . . . . . . . . . . . . . . . . . . . . . . 31Stavudine . . . . . . . . . . . . . . . . . . . . . . . . 9Stavzor . . . . . . . . . . . . . . . . . . . . . . . . . 16Staxyn . . . . . . . . . . . . . . . . . . . . . . . . . . 45Stelara . . . . . . . . . . . . . . . . . . . . . . . . . 27Stelazine . . . . . . . . . . . . . . . . . . . . . . . . 18Stimate . . . . . . . . . . . . . . . . . . . . . . . . . 21
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Strattera . . . . . . . . . . . . . . . . . . . . . . . . 19Striant . . . . . . . . . . . . . . . . . . . . . . . . . . 30Stribild . . . . . . . . . . . . . . . . . . . . . . . . . . 9Stromectol . . . . . . . . . . . . . . . . . . . . . . 10Suboxone . . . . . . . . . . . . . . . . . . . . . . . 14Suboxone Film . . . . . . . . . . . . . . . . . . . 14Subsys . . . . . . . . . . . . . . . . . . . . . . . . . 13Subutex . . . . . . . . . . . . . . . . . . . . . . . . . 14Suclear . . . . . . . . . . . . . . . . . . . . . . . . . 34Sucraid . . . . . . . . . . . . . . . . . . . . . . . . . 34Sucralfate Tablet . . . . . . . . . . . . . . . . . 33Sular . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Sulfacet-R . . . . . . . . . . . . . . . . . . . . . . 26Sulfacetamide Sodium . . . . . . . . . 26, 41Sulfacetamide Sodium/Prednisolone
Sodium Phosphate . . . . . . . . . . . . . . 41Sulfacetamide Sodium/Sulfur . . . . . . . 26Sulfacetamide Sodium Suspension,
Topical . . . . . . . . . . . . . . . . . . . . . . . . 26Sulfadiazine . . . . . . . . . . . . . . . . . . . 8, 27Sulfamethoxazole/Trimethoprim . . . . . . 8Sulfasalazine Tablet . . . . . . . . . . . . 34, 36Sulfasalazine Tablet,
Enteric-Coated . . . . . . . . . . . . . . 34, 36Sulindac . . . . . . . . . . . . . . . . . . . . . . . . 36sumatriptan injection, tablets . . . . . . . 48Sumatriptan Succinate Injection . . . . 14Sumatriptan Succinate Nasal Spray . 14Sumatriptan Succinate Tablet . . . . . . 14Sumavel Dosepro . . . . . . . . . . . . . . . . 14Suprax Tablet, Capsule,
Suspension . . . . . . . . . . . . . . . . . . . . . 7Suprep . . . . . . . . . . . . . . . . . . . . . . . . . 34Sustiva . . . . . . . . . . . . . . . . . . . . . . . . . . 9Sutent . . . . . . . . . . . . . . . . . . . . . . . . . . 11Sylatron . . . . . . . . . . . . . . . . . . . . . . . . . 11Symax Duotab . . . . . . . . . . . . . . . . . . . 33Symbicort . . . . . . . . . . . . . . . . . . . . . . . 44Symbyax . . . . . . . . . . . . . . . . . . . . . . . . 18Symlin . . . . . . . . . . . . . . . . . . . . . . . . . . 31Symmetrel . . . . . . . . . . . . . . . . . . . . 8, 15Synalar 0 .01% . . . . . . . . . . . . . . . . . . . 25Synalar 0 .025% . . . . . . . . . . . . . . . . . . 25Synalgos-DC . . . . . . . . . . . . . . . . . . . . 13Synarel . . . . . . . . . . . . . . . . . . . . . . 30, 39Synthroid . . . . . . . . . . . . . . . . . . . . . . . 30TT-Stat . . . . . . . . . . . . . . . . . . . . . . . . . . 26Taclonex . . . . . . . . . . . . . . . . . . . . . . . . 27Tacrolimus Anhydrous . . . . . . . . . . . . . 11Tagamet . . . . . . . . . . . . . . . . . . . . . . . . 33Talacen . . . . . . . . . . . . . . . . . . . . . . . . . 14
Talwin NX . . . . . . . . . . . . . . . . . . . . . . . 14Tambocor . . . . . . . . . . . . . . . . . . . . . . . 20Tamiflu . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Tamoxifen . . . . . . . . . . . . . . . . . . . . . . . 11Tamsulosin . . . . . . . . . . . . . . . . . . . 45, 48Tamsulosin HCl . . . . . . . . . . . . . . . . . . 45Tapazole . . . . . . . . . . . . . . . . . . . . . . . . 30Tarceva . . . . . . . . . . . . . . . . . . . . . . . . . 11Tarka . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Tasigna . . . . . . . . . . . . . . . . . . . . . . . . . 11Tasmar . . . . . . . . . . . . . . . . . . . . . . . . . 15Tavist . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Tazorac . . . . . . . . . . . . . . . . . . . . . . . . . 26Tecfidera . . . . . . . . . . . . . . . . . . . . . . . . 16Tegretol . . . . . . . . . . . . . . . . . . . . . . . . . 15Tegretol XR . . . . . . . . . . . . . . . . . . . . . . 15Tekamlo . . . . . . . . . . . . . . . . . . . . . . . . . 24Tekturna . . . . . . . . . . . . . . . . . . . . . . . . 24Tekturna HCT . . . . . . . . . . . . . . . . . . . . 24Temazepam . . . . . . . . . . . . . . . . . . . . . 17Temodar . . . . . . . . . . . . . . . . . . . . . . . . 11Temovate 0 .05% . . . . . . . . . . . . . . . . . 25Temovate E 0 .05% . . . . . . . . . . . . . . . 25Temozolamide . . . . . . . . . . . . . . . . . . . 11Tenex . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Tenormin . . . . . . . . . . . . . . . . . . . . . . . . 22Terazol . . . . . . . . . . . . . . . . . . . . . . . . . . 39Terazosin HCl . . . . . . . . . . . . . . . . . 23, 45Terbinafine HCl Tablet . . . . . . . . . . . . . . 9Terbutaline Sulfate . . . . . . . . . . . . . 39, 44Terconazole Cream w/Applicator . . . . 39Terconazole Suppository, Vaginal . . . . 39Testim . . . . . . . . . . . . . . . . . . . . . . . . . . 30Tetracycline HCl . . . . . . . . . . . . . . . . . . 7Tev-Tropin . . . . . . . . . . . . . . . . . . . . . . . 35Teveten . . . . . . . . . . . . . . . . . . . . . . . . . 24Teveten HCT . . . . . . . . . . . . . . . . . . . . 24Thalomid . . . . . . . . . . . . . . . . . . . . . . . . 11Theo-24 . . . . . . . . . . . . . . . . . . . . . . . . 44Theochron . . . . . . . . . . . . . . . . . . . . . . 44Theophylline Anhydrous Tablet,
Extended-Release 12 Hour . . . . . . . 44Thioridazine HCl . . . . . . . . . . . . . . . . . 18Thiothixene . . . . . . . . . . . . . . . . . . . . . . 18Thorazine 200 mg . . . . . . . . . . . . . . . . 18Thyrolar . . . . . . . . . . . . . . . . . . . . . . . . . 30Tiagabine HCl . . . . . . . . . . . . . . . . . . . 15Tiazac . . . . . . . . . . . . . . . . . . . . . . . . . . 22Ticlid . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Ticlopidine HCl . . . . . . . . . . . . . . . . . . 20Tigan 250, 300 mg . . . . . . . . . . . . . . . 34Tikosyn . . . . . . . . . . . . . . . . . . . . . . . . . 20
Timolol Maleate . . . . . . . . . . . . . . . . . . 40Timolol Maleate Drops . . . . . . . . . . . . 40Timoptic . . . . . . . . . . . . . . . . . . . . . . . . 40Timoptic-XE . . . . . . . . . . . . . . . . . . . . . 40Tindamax . . . . . . . . . . . . . . . . . . . . . . . . 10Tinidazole . . . . . . . . . . . . . . . . . . . . . . . 10Tirosint . . . . . . . . . . . . . . . . . . . . . . . . . 30Tizanidine HCl Capsule . . . . . . . . . . . 37Tizanidine HCl Tablet . . . . . . . . . . . . . . 37Tobi Nebs . . . . . . . . . . . . . . . . . . . . . . . . 9Tobradex . . . . . . . . . . . . . . . . . . . . . . . . 41Tobradex ST . . . . . . . . . . . . . . . . . . . . . 41Tobramycin/Dexamethasone
Suspension . . . . . . . . . . . . . . . . . . . . 41Tobramycin Sulfate Drops . . . . . . . . . . 41Tobrex . . . . . . . . . . . . . . . . . . . . . . . . . . 41Tobrex Ointment . . . . . . . . . . . . . . . . . . 41Tofranil-PM . . . . . . . . . . . . . . . . . . . . . . 17Tolectin . . . . . . . . . . . . . . . . . . . . . . . . . 36Tolectin DS . . . . . . . . . . . . . . . . . . . . . . 36Tolmetin Sodium . . . . . . . . . . . . . . . . . 36Tolterodine Tartrate . . . . . . . . . . . . . . . 45Topamax . . . . . . . . . . . . . . . . . . . . . 15, 16Topicort . . . . . . . . . . . . . . . . . . . . . . . . . 25Topiramate Capsule, Sprinkle . . . . . . . 15Topiramate Tablet . . . . . . . . . . . . . . . . . 15Toprol XL 25 mg . . . . . . . . . . . . . . . . . 22Toprol XL 50, 100, 200 mg . . . . . . . . 22Toradol . . . . . . . . . . . . . . . . . . . . . . . . . 36Toremifene Citrate . . . . . . . . . . . . . . . . 11Toviaz . . . . . . . . . . . . . . . . . . . . . . . . . . 45Tracleer . . . . . . . . . . . . . . . . . . . . . . . . . 44Tradjenta . . . . . . . . . . . . . . . . . . . . . . . . 31Tramadol HCl . . . . . . . . . . . . . . . . . . . . 14Tramadol HCl/Acetaminophen . . . . . . 14Tramadol HCl Tablet, Extended-Release
Multiphase 24 Hour . . . . . . . . . . . . . 14Tramadol HCl Tablet, Sustained-Release
24 Hour . . . . . . . . . . . . . . . . . . . . . . . 14Trandolapril . . . . . . . . . . . . . . . . . . . . . . 23Trandolapril/Verapamil . . . . . . . . . . . . . 23Tranexamic Acid . . . . . . . . . . . . . . . . . . 39Transderm-Nitro . . . . . . . . . . . . . . . . . . 20Transderm-Scop . . . . . . . . . . . . . . . . . 34Tranylcypromine Sulfate . . . . . . . . . . . 17Travatan . . . . . . . . . . . . . . . . . . . . . . . . 40Travatan Z . . . . . . . . . . . . . . . . . . . . . . . 40Travoprost . . . . . . . . . . . . . . . . . . . . . . . 40Trazodone HCl . . . . . . . . . . . . . . . . . . . 17Trental . . . . . . . . . . . . . . . . . . . . . . . . . . 21Tretin-X . . . . . . . . . . . . . . . . . . . . . . . . . 26Tretinoin . . . . . . . . . . . . . . . . . . . . . 11, 26
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Tretinoin Cream . . . . . . . . . . . . . . . . . . 26Tretinoin Cream, Gel . . . . . . . . . . . . . . 26Tretinoin Microspheres . . . . . . . . . . . . 26Trexall . . . . . . . . . . . . . . . . . . . . . . . 11, 36Treximet . . . . . . . . . . . . . . . . . . . . . . . . . 14Tri-Vi-Flor . . . . . . . . . . . . . . . . . . . . . . . 46Tri-Vi-Flor w/Iron . . . . . . . . . . . . . . . . . 46Triamcinolone Acetonide . 25, 27, 29, 44Triamcinolone Acetonide Cream . . . . 25Triamcinolone Acetonide Cream,
Ointment . . . . . . . . . . . . . . . . . . . . . . 25Triamcinolone Acetonide Lotion . . . . . 25Triamcinolone Acetonide Ointment . . 25Triamterene/Hydrochlorothiazide . . . . 21Trianex . . . . . . . . . . . . . . . . . . . . . . . . . . 25Triazolam . . . . . . . . . . . . . . . . . . . . . . . . 17Tribenzor . . . . . . . . . . . . . . . . . . . . . . . . 23Tricor . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Tridesilon 0 .05% . . . . . . . . . . . . . . . . . 25Trifluoperazine HCl . . . . . . . . . . . . . . . 18Trifluridine . . . . . . . . . . . . . . . . . . . . . . . 42Triglide . . . . . . . . . . . . . . . . . . . . . . . . . 24Trihexyphenidyl HCl . . . . . . . . . . . . . . . 15Trilafon . . . . . . . . . . . . . . . . . . . . . . . . . 18Trileptal . . . . . . . . . . . . . . . . . . . . . . . . . 15Trilipix . . . . . . . . . . . . . . . . . . . . . . . . . . 24Trimethobenzamide HCl Capsule . . . 34Trimethoprim . . . . . . . . . . . . . . . . . . . 8, 41TriNorinyl . . . . . . . . . . . . . . . . . . . . . . . . 38Triphasil . . . . . . . . . . . . . . . . . . . . . . . . . 38Trizivir . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Tropicamide . . . . . . . . . . . . . . . . . . . . . 40Trospium Chloride . . . . . . . . . . . . . 37, 45Trospium Chloride Capsule,
Sustained-Release 24 Hour . . . . . . 45Trusopt . . . . . . . . . . . . . . . . . . . . . . . . . 40Truvada . . . . . . . . . . . . . . . . . . . . . . . . . . 9Tudorza Pressair . . . . . . . . . . . . . . . . . 44Tussionex . . . . . . . . . . . . . . . . . . . . . . . 43Twynsta . . . . . . . . . . . . . . . . . . . . . . . . . 23Tykerb . . . . . . . . . . . . . . . . . . . . . . . . . . 11Tylenol w/Codeine . . . . . . . . . . . . . . . . 13Tylox . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Tyvaso . . . . . . . . . . . . . . . . . . . . . . . . . . 44Tyzeka . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Tyzine . . . . . . . . . . . . . . . . . . . . . . . . . . 29UUceris . . . . . . . . . . . . . . . . . . . . . . . . . . 34Uloric . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Ultracet . . . . . . . . . . . . . . . . . . . . . . . . . 14Ultram . . . . . . . . . . . . . . . . . . . . . . . . . . 14Ultram ER . . . . . . . . . . . . . . . . . . . . . . . 14
Ultravate . . . . . . . . . . . . . . . . . . . . . . . . 25Ultresa . . . . . . . . . . . . . . . . . . . . . . . . . 34Umecta . . . . . . . . . . . . . . . . . . . . . . . . . 28Umecta PD . . . . . . . . . . . . . . . . . . . . . . 28Univasc . . . . . . . . . . . . . . . . . . . . . . . . . 23Uramaxin GT . . . . . . . . . . . . . . . . . . . . 28Urea 40% Emulsion . . . . . . . . . . . . . . 28Urecholine . . . . . . . . . . . . . . . . . . . . . . 45Urispas . . . . . . . . . . . . . . . . . . . . . . . . . 45Uroxatral . . . . . . . . . . . . . . . . . . . . . . . . 45URSO 250, URSO Forte . . . . . . . . . . 34Ursodiol . . . . . . . . . . . . . . . . . . . . . . . . 34VVagifem . . . . . . . . . . . . . . . . . . . . . . . . . 39Valacyclovir . . . . . . . . . . . . . . . . . . . . 8, 48Valacyclovir HCl . . . . . . . . . . . . . . . . . . . 8Valcyte . . . . . . . . . . . . . . . . . . . . . . . . . . 8Valisone 0 .1% . . . . . . . . . . . . . . . . . . . 25Valium . . . . . . . . . . . . . . . . . . . .19, 37, 48Valproic Acid . . . . . . . . . . . . . . . . . . . . 15Valsartan/Hydrochlorothiazide . . . 24, 48Valtrex . . . . . . . . . . . . . . . . . . . . . . . . 8, 48Vancocin HCl . . . . . . . . . . . . . . . . . . . . . 9Vancomycin HCl . . . . . . . . . . . . . . . . . . 9Vanos . . . . . . . . . . . . . . . . . . . . . . . . . . 25Vantin . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Vascepa . . . . . . . . . . . . . . . . . . . . . . . . 24Vaseretic . . . . . . . . . . . . . . . . . . . . . . . . 23Vasocidin . . . . . . . . . . . . . . . . . . . . . . . 41Vasotec . . . . . . . . . . . . . . . . . . . . . . . . . 23Vectical . . . . . . . . . . . . . . . . . . . . . . . . . 27Veltin . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Venlafaxine Extended-Release
Capsule . . . . . . . . . . . . . . . . . . . . . . . 48Venlafaxine HCl Capsule,
Sustained-Release 24 Hour . . . . . . 17Venlafaxine HCl ER . . . . . . . . . . . . . . . 17Venlafaxine HCl Tablet,
Extended-Release 24 Hour . . . . . . . 17Ventavis . . . . . . . . . . . . . . . . . . . . . . . . 44Ventolin . . . . . . . . . . . . . . . . . . . . . . . . . 44Ventolin HFA . . . . . . . . . . . . . . . . . . . . 44VePesid . . . . . . . . . . . . . . . . . . . . . . . . . 11Veramyst . . . . . . . . . . . . . . . . . . . . . 29, 44Verapamil HCl . . . . . . . . . . . . . . . . . . . 22Verapamil HCl Capsule, 24 Hour
Sustained-Release Pellets . . . . . . . 22Verapamil HCl Tablet,
Sustained-Action . . . . . . . . . . . . . . . 22Verdeso . . . . . . . . . . . . . . . . . . . . . . . . . 25Verelan . . . . . . . . . . . . . . . . . . . . . . . . . 22Verelan PM . . . . . . . . . . . . . . . . . . . . . . 22
Vesanoid . . . . . . . . . . . . . . . . . . . . . . . . 11Vesicare . . . . . . . . . . . . . . . . . . . . . . . . 45Vexol . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Vfend . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Viagra . . . . . . . . . . . . . . . . . . . . . . . . . . 45Vibra-Tab . . . . . . . . . . . . . . . . . . . . . . . 48Vibra-Tabs . . . . . . . . . . . . . . . . . . . . . . . 7Vibramycin . . . . . . . . . . . . . . . . . . . . 7, 48Vibramycin Suspension . . . . . . . . . . . . . 7Vicodin, Vicodin ES, Vicodin HP . . . . 13Vicoprofen . . . . . . . . . . . . . . . . . . . . . . 13Victoza . . . . . . . . . . . . . . . . . . . . . . . . . 31Victrelis . . . . . . . . . . . . . . . . . . . . . . . . . . 8Videx EC . . . . . . . . . . . . . . . . . . . . . . . . . 9Vigamox . . . . . . . . . . . . . . . . . . . . . . . . 41Viibryd . . . . . . . . . . . . . . . . . . . . . . . . . . 18Vimovo . . . . . . . . . . . . . . . . . . . . . . . . . 36Vimpat . . . . . . . . . . . . . . . . . . . . . . . . . . 16Viokace . . . . . . . . . . . . . . . . . . . . . . . . . 34Viracept . . . . . . . . . . . . . . . . . . . . . . . . . . 9Viramune . . . . . . . . . . . . . . . . . . . . . . . . . 9Viramune XR . . . . . . . . . . . . . . . . . . . . . 9Viread . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Viroptic . . . . . . . . . . . . . . . . . . . . . . . . . 42Visicol . . . . . . . . . . . . . . . . . . . . . . . . . . 34Visken . . . . . . . . . . . . . . . . . . . . . . . . . . 22Vistaril . . . . . . . . . . . . . . . . . . . . . . . . . . 43Vistaril Suspension . . . . . . . . . . . . . . . 43Vitafol-OB + DHA . . . . . . . . . . . . . . . . 46Vivactil . . . . . . . . . . . . . . . . . . . . . . . . . . 17Vivelle-Dot . . . . . . . . . . . . . . . . . . . . . . 39Voltaren . . . . . . . . . . . . . . . . . . . . . . 36, 40Voltaren-XR . . . . . . . . . . . . . . . . . . . . . 36Voltaren Gel . . . . . . . . . . . . . . . . . . . . . 36Voriconazole . . . . . . . . . . . . . . . . . . . . . . 9VoSol . . . . . . . . . . . . . . . . . . . . . . . . . . 29VoSol HC . . . . . . . . . . . . . . . . . . . . . . . 29Votrient . . . . . . . . . . . . . . . . . . . . . . . . . 11Vusion . . . . . . . . . . . . . . . . . . . . . . . . . . 27Vytorin . . . . . . . . . . . . . . . . . . . . . . . . . . 24Vyvanse . . . . . . . . . . . . . . . . . . . . . . 19, 48WWarfarin Sodium . . . . . . . . . . . . . . . . . 20Welchol . . . . . . . . . . . . . . . . . . . . . . . . . 24Wellbutrin . . . . . . . . . . . . . . . . . . . . 17, 48Wellbutrin SR . . . . . . . . . . . . . . . . . 17, 48Wellbutrin XL . . . . . . . . . . . . . . . . . 17, 48Westcort 0 .2% . . . . . . . . . . . . . . . . . . . 25XXalatan . . . . . . . . . . . . . . . . . . . . . . . . . 40Xalkori . . . . . . . . . . . . . . . . . . . . . . . . . . 11Xanax . . . . . . . . . . . . . . . . . . . . . . . 19, 48
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2014 Prescription Drug List Medication Index
Xanax XR . . . . . . . . . . . . . . . . . . . . 19, 48Xarelto . . . . . . . . . . . . . . . . . . . . . . . . . 20Xeljanz . . . . . . . . . . . . . . . . . . . . . . . . . . 36Xeloda . . . . . . . . . . . . . . . . . . . . . . . . . . 11Xenaderm . . . . . . . . . . . . . . . . . . . . . . . 27Xerese . . . . . . . . . . . . . . . . . . . . . . . . . . 27Xibrom . . . . . . . . . . . . . . . . . . . . . . . . . 40Xifaxan . . . . . . . . . . . . . . . . . . . . . . . . . . 9Xodol . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Xolegel . . . . . . . . . . . . . . . . . . . . . . . . . 27Xopenex HFA . . . . . . . . . . . . . . . . . . . . 44Xopenex Vial, Nebulizer . . . . . . . . . . . . 44Xtandi . . . . . . . . . . . . . . . . . . . . . . . . . . 11Xylocaine . . . . . . . . . . . . . . . . . . . . 26, 29Xyntha . . . . . . . . . . . . . . . . . . . . . . . . . . 21Xyrem . . . . . . . . . . . . . . . . . . . . . . . . . . 19Xyzal . . . . . . . . . . . . . . . . . . . . . . . . . . . 43YYasmin . . . . . . . . . . . . . . . . . . . . . . . . . 38Yaz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38ZZafirlukast . . . . . . . . . . . . . . . . . . . . . . . 44Zaleplon . . . . . . . . . . . . . . . . . . . . . . . . 17Zanaflex . . . . . . . . . . . . . . . . . . . . . . . . 37Zantac Syrup . . . . . . . . . . . . . . . . . . . . 33Zarontin . . . . . . . . . . . . . . . . . . . . . . . . 15Zaroxolyn . . . . . . . . . . . . . . . . . . . . . . . 21Zegerid . . . . . . . . . . . . . . . . . . . . . . . . . 33Zegerid Capsule . . . . . . . . . . . . . . . . . 33Zegerid Packet . . . . . . . . . . . . . . . . . . . 33Zelapar . . . . . . . . . . . . . . . . . . . . . . . . . 15Zelboraf . . . . . . . . . . . . . . . . . . . . . . . . 11Zemplar . . . . . . . . . . . . . . . . . . . . . . . . . 30Zenatane . . . . . . . . . . . . . . . . . . . . . . . 26Zenpep . . . . . . . . . . . . . . . . . . . . . . . . . 34Zerit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Zestoretic . . . . . . . . . . . . . . . . . . . . . . . 23Zestril . . . . . . . . . . . . . . . . . . . . . . . . . . 23Zetia . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Zetonna . . . . . . . . . . . . . . . . . . . . . 29, 44Ziac . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Ziagen . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Ziana . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Zidovudine . . . . . . . . . . . . . . . . . . . . . . . 9Zidovudine/Lamivudine . . . . . . . . . . . . . 9Zioptan . . . . . . . . . . . . . . . . . . . . . . . . . 40Ziprasidone . . . . . . . . . . . . . . . . . . 18, 48Zipsor . . . . . . . . . . . . . . . . . . . . . . . . . . 36Zirgan . . . . . . . . . . . . . . . . . . . . . . . . . . 42Zithromax . . . . . . . . . . . . . . . . . . . . . . . . 7Zmax . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Zocor . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Zofran . . . . . . . . . . . . . . . . . . . . . . . . . . 34Zofran ODT . . . . . . . . . . . . . . . . . . . . . 34Zolinza . . . . . . . . . . . . . . . . . . . . . . . . . . 11Zolmitriptan . . . . . . . . . . . . . . . . . . . . . 14Zolmitriptan Orally Disintegrating
Tablet . . . . . . . . . . . . . . . . . . . . . . . . . 14Zoloft . . . . . . . . . . . . . . . . . . . . . . . . 18, 48Zolpidem . . . . . . . . . . . . . . . . . . . . . 17, 48Zolpidem Extended-Release . . . . . . . 48Zolpidem Tartrate . . . . . . . . . . . . . . . . . 17Zolpidem Tartrate Tablet,
Multiphasic-Release . . . . . . . . . . . . . 17Zolpimist . . . . . . . . . . . . . . . . . . . . . . . . 17Zolvit . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Zomig . . . . . . . . . . . . . . . . . . . . . . . . . . 14Zomig-ZMT . . . . . . . . . . . . . . . . . . . . . 14Zomig Nasal Spray . . . . . . . . . . . . . . . 14Zonalon . . . . . . . . . . . . . . . . . . . . . . . . . 28Zonegran . . . . . . . . . . . . . . . . . . . . . . . 15Zonisamide . . . . . . . . . . . . . . . . . . . . . . 15Zorbtive . . . . . . . . . . . . . . . . . . . . . . . . . 35Zovirax . . . . . . . . . . . . . . . . . . . . . 8, 27, 48Zovirax Cream . . . . . . . . . . . . . . . . . . . 27Zovirax Ointment . . . . . . . . . . . . . . . . . 48Zuplenz . . . . . . . . . . . . . . . . . . . . . . . . . 34Zutripro . . . . . . . . . . . . . . . . . . . . . . . . . 43Zyban . . . . . . . . . . . . . . . . . . . . . . . . . . 47Zyclara . . . . . . . . . . . . . . . . . . . . . . . . . 28Zyflo . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Zyflo CR . . . . . . . . . . . . . . . . . . . . . . . . 44Zylet . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Zyloprim . . . . . . . . . . . . . . . . . . . . . . . . 36Zymaxid . . . . . . . . . . . . . . . . . . . . . . . . . 41Zyprexa . . . . . . . . . . . . . . . . . . . . . . 18, 48Zyprexa Zydis . . . . . . . . . . . . . . . . . 18, 48Zytiga . . . . . . . . . . . . . . . . . . . . . . . . . . 11Zyvox . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
UnitedHealthcare Physician PDL Booklet 1/14 Created November, 2013© 2013 UnitedHealthCare Services, Inc . All rights reserved .