Post on 16-Mar-2020
FID 20089
2020 Step Therapy
1
ANTIDEPRESSANTS,
SEROTONIN/NOREPINEPHRINE REUPTAKE
INHIBITORS LEON 2020
Products Affected
Step 1: bupropion HCl 100 mg tablet
bupropion HCl 75 mg tablet
bupropion HCl SR 100 mg tablet,12 hr
sustained-release
bupropion HCl SR 150 mg tablet,12 hr
sustained-release
bupropion HCl SR 200 mg tablet,12 hr
sustained-release
bupropion HCl XL 150 mg 24 hr tablet,
extended release
bupropion HCl XL 300 mg 24 hr tablet,
extended release
citalopram 10 mg tablet
citalopram 10 mg/5 mL oral solution
citalopram 20 mg tablet
citalopram 40 mg tablet
duloxetine 20 mg capsule,delayed release
duloxetine 30 mg capsule,delayed release
duloxetine 40 mg capsule,delayed release
duloxetine 60 mg capsule,delayed release
escitalopram 10 mg tablet
escitalopram 20 mg tablet
escitalopram 5 mg tablet
escitalopram 5 mg/5 mL oral solution
fluoxetine 10 mg capsule
fluoxetine 10 mg tablet
fluoxetine 20 mg capsule
fluoxetine 20 mg tablet
fluoxetine 20 mg/5 mL (4 mg/mL) oral
solution
fluoxetine 40 mg capsule
fluoxetine 90 mg capsule,delayed release
fluvoxamine 100 mg tablet
fluvoxamine 25 mg tablet
fluvoxamine 50 mg tablet
fluvoxamine ER 100 mg capsule,extended
release 24 hr
fluvoxamine ER 150 mg capsule,extended
release 24 hr
mirtazapine 15 mg disintegrating tablet
mirtazapine 15 mg tablet
mirtazapine 30 mg disintegrating tablet
mirtazapine 30 mg tablet
mirtazapine 45 mg disintegrating tablet
mirtazapine 45 mg tablet
mirtazapine 7.5 mg tablet
paroxetine 10 mg tablet
paroxetine 20 mg tablet
paroxetine 30 mg tablet
paroxetine 40 mg tablet
paroxetine ER 12.5 mg tablet,extended
release 24 hr
paroxetine ER 25 mg tablet,extended
release 24 hr
paroxetine ER 37.5 mg tablet,extended
release 24 hr
sertraline 100 mg tablet
sertraline 20 mg/mL oral concentrate
sertraline 25 mg tablet
sertraline 50 mg tablet
trazodone 100 mg tablet
trazodone 150 mg tablet
trazodone 300 mg tablet
trazodone 50 mg tablet
venlafaxine 100 mg tablet
venlafaxine 25 mg tablet
venlafaxine 37.5 mg tablet
venlafaxine 50 mg tablet
venlafaxine 75 mg tablet
venlafaxine ER 150 mg capsule,extended
release 24 hr
venlafaxine ER 150 mg tablet,extended
release 24 hr
venlafaxine ER 225 mg tablet,extended
release 24 hr
2
venlafaxine ER 37.5 mg capsule,extended
release 24 hr
venlafaxine ER 37.5 mg tablet,extended
release 24 hr
venlafaxine ER 75 mg capsule,extended
release 24 hr
venlafaxine ER 75 mg tablet,extended
release 24 hr
Step 2: desvenlafaxine ER 100 mg tablet,extended
release 24 hr
desvenlafaxine ER 50 mg tablet,extended
release 24 hr
desvenlafaxine succinate ER 100 mg
tablet,extended release 24 hr
desvenlafaxine succinate ER 25 mg
tablet,extended release 24 hr
desvenlafaxine succinate ER 50 mg
tablet,extended release 24 hr
Fetzima 120 mg capsule,extended release
Fetzima 20 mg (2)-40 mg (26)
capsule,extended release,24 hr,dose pack
Fetzima 20 mg capsule,extended release
Fetzima 40 mg capsule,extended release
Fetzima 80 mg capsule,extended release
Paxil 10 mg/5 mL oral suspension
Trintellix 10 mg tablet
Trintellix 20 mg tablet
Trintellix 5 mg tablet
Viibryd 10 mg (7)-20 mg (23) tablets in a
dose pack
Viibryd 10 mg tablet
Viibryd 20 mg tablet
Viibryd 40 mg tablet
Details
Criteria Step-1 Drugs: bupropion, citalopram, duloxetine, escitalopram,
fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline, trazodone
and venlafaxine. Step-2 Drugs: desvenlafaxine er, Fetzima, Paxil
Suspension, Trintellix and Viibryd. The member must have tried a 30 day
supply or more of at least two Step-1 drugs within the same step therapy
group within the previous 180 days as evidenced by a previous paid claim
under the prescription benefit or by physician documented use. Step-2
drugs are not covered unless the above step therapy criteria are met.
Patients who are currently taking or who have taken a step 2 drug at any
time in the past and discontinued their use may receive authorization
without trials of step 1 drugs. For patients with suicidal ideation, step 1
drugs do not need to be tried.
3
BETA-ADRENERGIC BLOCKING AGENTS LEON
2020
Products Affected
Step 1: carvedilol 12.5 mg tablet
carvedilol 25 mg tablet
carvedilol 3.125 mg tablet
carvedilol 6.25 mg tablet
Step 2: carvedilol phosphate ER 10 mg
capsule,ext.release24hr multiphase
carvedilol phosphate ER 20 mg
capsule,ext.release24hr multiphase
carvedilol phosphate ER 40 mg
capsule,ext.release24hr multiphase
carvedilol phosphate ER 80 mg
capsule,ext.release24hr multiphase
Details
Criteria Step-1 Drug: carvedilol tabs. Step-2 Drug: carvedilol ER caps. The
member must have tried a 30 day supply or more of one Step-1 drug
within the same step therapy group within the previous 130 days as
evidenced by a previous paid claim under the prescription benefit or by
physician documented use. Step-2 drug is not covered unless the above
step therapy criteria are met.
4
FIBRINIC ACID DERIVATIVES LEON 2020
Products Affected
Step 1: fenofibrate 150 mg capsule
fenofibrate 160 mg tablet
fenofibrate 50 mg capsule
fenofibrate 54 mg tablet
fenofibrate micronized 130 mg capsule
fenofibrate micronized 134 mg capsule
fenofibrate micronized 200 mg capsule
fenofibrate micronized 43 mg capsule
fenofibrate micronized 67 mg capsule
fenofibrate nanocrystallized 145 mg tablet
fenofibrate nanocrystallized 48 mg tablet
fenofibric acid (choline) 135 mg
capsule,delayed release
fenofibric acid (choline) 45 mg
capsule,delayed release
fenofibric acid 105 mg tablet
fenofibric acid 35 mg tablet
gemfibrozil 600 mg tablet
Step 2: fenofibrate 120 mg tablet fenofibrate 40 mg tablet
Details
Criteria Step-1 Drugs: fenofibrate 43mg, 48mg, 50mg, 54mg, 67mg, 130mg,
134mg, 145mg, 150mg, 160mg, 200mg and fenofibrinic acid 35mg,
45mg, 105mg, 135mg and gemfibrozil. Step-2 Drugs: fenofibrate 40mg
and 120mg. The member must have tried a 30 day supply or more of at
least one Step-1 drug within the same step therapy group within the
previous 130 days as evidenced by a previous paid claim under the
prescription benefit or by physician documented use. Step-2 drugs are not
covered unless the above step therapy criteria are met.
5
INJECTABLE DIABETIC COMBINATIONS LEON
2020
Products Affected
Step 1: Bydureon 2 mg/0.65 mL subcutaneous
pen injector
Bydureon BCise 2 mg/0.85 mL
subcutaneous auto-injector
Humulin 70/30 U-100 Insulin 100 unit/mL
subcutaneous suspension
Humulin 70/30 U-100 Insulin KwikPen
100 unit/mL subcutaneous
Humulin N NPH U-100 Insulin (isophane
susp) 100 unit/mL subcutaneous
Humulin N NPH U-100 Insulin KwikPen
100 unit/mL (3 mL) subcutaneous
Lantus Solostar U-100 Insulin 100
unit/mL (3 mL) subcutaneous pen
Lantus U-100 Insulin 100 unit/mL
subcutaneous solution
Levemir FlexTouch U-100 Insulin 100
unit/mL (3 mL) subcutaneous pen
Levemir U-100 Insulin 100 unit/mL
subcutaneous solution
Ozempic 0.25 mg or 0.5 mg (2 mg/1.5
mL) subcutaneous pen injector
Ozempic 1 mg/dose (2 mg/1.5 mL)
subcutaneous pen injector
Toujeo Max U-300 SoloStar 300 unit/mL
(3 mL) subcutaneous insulin pen
Toujeo SoloStar U-300 Insulin 300
unit/mL (1.5 mL) subcutaneous pen
Tresiba FlexTouch U-100 insulin 100
unit/mL (3 mL) subcutaneous pen
Tresiba FlexTouch U-200 insulin 200
unit/mL (3 mL) subcutaneous pen
Tresiba U-100 Insulin 100 unit/mL
subcutaneous solution
Trulicity 0.75 mg/0.5 mL subcutaneous
pen injector
Trulicity 1.5 mg/0.5 mL subcutaneous pen
injector
Victoza 3-Pak 0.6 mg/0.1 mL (18 mg/3
mL) subcutaneous pen injector
Step 2: Soliqua 100/33 100 unit-33 mcg/mL
subcutaneous insulin pen
Xultophy 100/3.6 100 unit-3.6 mg/mL (3
mL) subcutaneous insulin pen
Details
Criteria Step-1 Drugs: basal insulin or GLP-1 agonist. Step-2 Drugs: Soliqua
and Xultophy. The member must have tried a 30 day supply or more of
any one Step-1 drug within the same step therapy group within the
previous 180 days as evidenced by a previous paid claim under the
prescription benefit or by physician documented use. Step-2 drug is not
covered unless the above step therapy criteria are met.
6
METABOLIC BONE DISEASE AGENTS LEON
2020
Products Affected
Step 1: alendronate 10 mg tablet
alendronate 35 mg tablet
alendronate 40 mg tablet
alendronate 5 mg tablet
alendronate 70 mg tablet
alendronate 70 mg/75 mL oral solution
ibandronate 150 mg tablet
Step 2: Binosto 70 mg effervescent tablet
Fosamax Plus D 70 mg-2,800 unit tablet
Fosamax Plus D 70 mg-5,600 unit tablet
risedronate 150 mg tablet
risedronate 30 mg tablet
risedronate 35 mg tablet
risedronate 35 mg tablet (12 pack)
risedronate 35 mg tablet (4 pack)
risedronate 35 mg tablet,delayed release
risedronate 5 mg tablet
Details
Criteria Step-1 Drugs: alendronate sodium tablets and solution, and ibandronate
sodium tablets. Step-2 Drugs: Binosto, Fosamax Plus D and risedronate
sodium tablets. The member must have tried a 30 day supply or more of
at least two Step-1 drugs within the same step therapy group within the
previous 180 days as evidenced by a previous paid claim under the
prescription benefit or by physician documented use. Step-2 drugs are not
covered unless the above step therapy criteria are met, or unless the
diagnosis is Paget's Disease, osteoporosis in men, or glucocorticoid-
induced osteoporosis, in which case the member would only need to try a
30 day supply of alendronate within the previous 180 days before
risedronate would be covered.
7
OPHTHALMIC ANTIGLAUCOMA AGENTS LEON
2020
Products Affected
Step 1: dorzolamide 2 % eye drops
Step 2: Azopt 1 % eye drops,suspension
Details
Criteria Step-1 Drugs: dorzolamide. Step-2 Drug: Azopt (brinzolamide). The
member must have tried a 30 day supply or more of one Step-1 drug
within the same step therapy group within the previous 130 days as
evidenced by a previous paid claim under the prescription benefit or by
physician documented use. Step-2 drug is not covered unless the above
step therapy criteria are met.
8
OPHTHALMIC ANTIHISTAMINES LEON 2020
Products Affected
Step 1: ketotifen 0.025 % (0.035 %) eye drops
olopatadine 0.1 % eye drops
olopatadine 0.2 % eye drops
Step 2: azelastine 0.05 % eye drops
epinastine 0.05 % eye drops
Pazeo 0.7 % eye drops
Details
Criteria Step-1 Drugs: ketotifen fumarate OTC, olopatadine 0.1%, and
olopatadine 0.2%. Step-2 Drugs: azelastine, epinastine, and Pazeo
(olopatadine 0.7%). The member must have tried a 30 day supply or
more of at least two Step-1 drugs within the same step therapy group
within the previous 90 days as evidenced by a previous paid claim under
the prescription benefit or by physician documented use. Step-2 drugs are
not covered unless the above step therapy criteria are met.
9
PROTON PUMP INHIBITORS LEON 2020
Products Affected
Step 1: esomeprazole magnesium 20 mg
capsule,delayed release
esomeprazole magnesium 40 mg
capsule,delayed release
lansoprazole 15 mg capsule,delayed
release
lansoprazole 15 mg delayed
release,disintegrating tablet
lansoprazole 30 mg capsule,delayed
release
lansoprazole 30 mg delayed
release,disintegrating tablet
omeprazole 10 mg capsule,delayed release
omeprazole 20 mg capsule,delayed release
omeprazole 40 mg capsule,delayed release
pantoprazole 20 mg tablet,delayed release
pantoprazole 40 mg tablet,delayed release
rabeprazole 20 mg tablet,delayed release
Step 2: Dexilant 30 mg capsule, delayed release
Dexilant 60 mg capsule, delayed release
Protonix 40 mg granules delayed-release
packet
Details
Criteria Step-1 Drugs: esomeprazole magnesium, lansoprazole, Rx omeprazole,
pantoprazole and rabeprazole. Step-2 Drugs: Dexilant and Protonix
Granules (pantoprazole). The member must have tried a 30 day supply or
more of at least two Step-1 drugs within the same step therapy group
within the previous 180 days as evidenced by a previous paid claim under
the prescription benefit or by physician documented use. Step-2 drugs are
not covered unless the above step therapy criteria are met.
10
RHOPRESSA/ROCKLATAN LEON 2020
Products Affected
Step 1: Alphagan P 0.1 % eye drops
Azopt 1 % eye drops,suspension
betaxolol 0.5 % eye drops
Betimol 0.25 % eye drops
Betimol 0.5 % eye drops
Betoptic S 0.25 % eye drops,suspension
bimatoprost 0.03 % eye drops
brimonidine 0.15 % eye drops
brimonidine 0.2 % eye drops
carteolol 1 % eye drops
Combigan 0.2 %-0.5 % eye drops
dorzolamide 2 % eye drops
dorzolamide 22.3 mg-timolol 6.8 mg/mL
eye drops
dorzolamide-timolol (PF) 2 %-0.5 % eye
drops in a dropperette
latanoprost 0.005 % eye drops
levobunolol 0.5 % eye drops
Lumigan 0.01 % eye drops
Phospholine Iodide 0.125 % eye drops
pilocarpine 1 % eye drops
pilocarpine 2 % eye drops
pilocarpine 4 % eye drops
Simbrinza 1 %-0.2 % eye
drops,suspension
timolol maleate 0.25 % eye drops
timolol maleate 0.25 % eye gel forming
solution
timolol maleate 0.5 % eye drops
timolol maleate 0.5 % eye gel forming
solution
Timoptic Ocudose (PF) 0.5 % eye drops in
a dropperette
travoprost 0.004 % eye drops
Step 2: Rhopressa 0.02 % eye drops Rocklatan 0.02 %-0.005 % eye drops
Details
Criteria Step-1 Drugs: Alphagan P, Azopt, betaxolol, betimol, betopic-S,
bimatoprost, brimonidine, carteolol, Combigan, dorzolamide,
dorzolamide/timolol, dorzolamide/timolol PF, latanoprost, levobunolol,
Lumigan, phospholine iodide, pilocarpine, Simbrinza, timolol, timolol
ophthalmic gel forming solution, Timoptic Ocudose, travoprost. Step-2
Drugs: Rocklatan, Rhopressa. The member must have tried a 30 day
supply or more of at least one Step-1 drug within the same step therapy
group within the previous 180 days as evidenced by a previous paid claim
under the prescription benefit or by physician documented use. Step-2
drugs are not covered unless the above step therapy criteria are met.
11
TOPICAL ANTIFUNGAL DRUGS LEON 2020
Products Affected
Step 1: ciclopirox 0.77 % topical cream
ciclopirox 0.77 % topical suspension
ciclopirox 8 % topical solution
clotrimazole 1 % topical cream
ketoconazole 2 % shampoo
ketoconazole 2 % topical cream
miconazole nitrate 2 % topical cream
miconazole nitrate 2 % topical spray
powder
Remedy Antifungal 2 % topical powder
Step 2: ciclopirox 0.77 % topical gel
ciclopirox 1 % shampoo
Ertaczo 2 % topical cream
luliconazole 1 % topical cream
Luzu 1 % topical cream
naftifine 1 % topical cream
naftifine 2 % topical cream
oxiconazole 1 % topical cream
Oxistat 1 % lotion
Details
Criteria Step-1 Drugs: ciclopirox 0.77% topical suspension, ciclopirox 0.77%
cream, ciclopirox 8% solution, clotrimazole OTC, ketoconazole 2%
cream, ketoconazole 2% shampoo and miconazole OTC. Step-2 Drugs:
ciclopirox 0.77% gel, ciclopirox 1% shampoo, Ertaczo, luliconazole 1%
cream, Luzu 1% cream, naftifine 1% cream, naftifine 2% cream,
oxiconazole nitrate 1% cream and Oxistat 1% lotion. The member must
have tried a 30 day supply or more of at least two Step-1 drugs within the
same step therapy group within the previous 180 days as evidenced by a
previous paid claim under the prescription benefit or by physician
documented use. Step-2 drugs are not covered unless the above step
therapy criteria are met.
12
TOPICAL ANTI-INFLAMMATORIES LEON 2020
Products Affected
Step 1: fluocinonide 0.05 % topical gel
fluocinonide 0.05 % topical ointment
fluocinonide 0.1 % topical cream
Fluocinonide-E 0.05 % topical cream
mometasone 0.1 % topical cream
mometasone 0.1 % topical ointment
triamcinolone acetonide 0.025 % lotion
triamcinolone acetonide 0.025 % topical
cream
triamcinolone acetonide 0.025 % topical
ointment
triamcinolone acetonide 0.1 % lotion
triamcinolone acetonide 0.1 % topical
cream
triamcinolone acetonide 0.1 % topical
ointment
triamcinolone acetonide 0.5 % topical
cream
triamcinolone acetonide 0.5 % topical
ointment
Triderm 0.1 % topical cream
Step 2: desoximetasone 0.05 % topical cream
desoximetasone 0.05 % topical gel
desoximetasone 0.05 % topical ointment
desoximetasone 0.25 % topical cream
desoximetasone 0.25 % topical ointment
Details
Criteria Step-1 Drugs: fluocinonide (ointment, gel, cream), fluocinonide-E cream,
mometasone (cream, ointment), triamcinolone (cream, lotion, ointment)
and Triderm cream. Step-2 Drug: desoximetasone (cream, gel,
ointment). The member must have tried a 30 day supply or more of at
least one Step-1 drug within the same step therapy group within the
previous 180 days as evidenced by a previous paid claim under the
prescription benefit or by physician documented use. Step-2 drugs are not
covered unless the above step therapy criteria are met.
13
XHANCE LEON 2020
Products Affected
Step 1: mometasone 50 mcg/actuation nasal spray
Step 2: Xhance 93 mcg/actuation breath activated
aerosol
Details
Criteria Step-1 Drug: mometasone furoate nasal spray. Step-2 Drug: Xhance. The
member must have tried a 30 day supply or more of one Step-1 drug
within the same step therapy group within the previous 180 days as
evidenced by a previous paid claim under the prescription benefit or by
physician documented use. Step-2 drug is not covered unless the above
step therapy criteria are met.
14
Index
A alendronate 10 mg tablet ............................. 6
alendronate 35 mg tablet ............................. 6
alendronate 40 mg tablet ............................. 6
alendronate 5 mg tablet ............................... 6
alendronate 70 mg tablet ............................. 6
alendronate 70 mg/75 mL oral solution ...... 6
Alphagan P 0.1 % eye drops ..................... 10
azelastine 0.05 % eye drops ........................ 8
Azopt 1 % eye drops,suspension .......... 7, 10
B betaxolol 0.5 % eye drops ......................... 10
Betimol 0.25 % eye drops ......................... 10
Betimol 0.5 % eye drops ........................... 10
Betoptic S 0.25 % eye drops,suspension .. 10
bimatoprost 0.03 % eye drops ................... 10
Binosto 70 mg effervescent tablet ............... 6
brimonidine 0.15 % eye drops .................. 10
brimonidine 0.2 % eye drops .................... 10
bupropion HCl 100 mg tablet ................. 1, 2
bupropion HCl 75 mg tablet ................... 1, 2
bupropion HCl SR 100 mg tablet,12 hr
sustained-release ................................. 1, 2
bupropion HCl SR 150 mg tablet,12 hr
sustained-release ................................. 1, 2
bupropion HCl SR 200 mg tablet,12 hr
sustained-release ................................. 1, 2
bupropion HCl XL 150 mg 24 hr tablet,
extended release .................................. 1, 2
bupropion HCl XL 300 mg 24 hr tablet,
extended release .................................. 1, 2
Bydureon 2 mg/0.65 mL subcutaneous pen
injector .................................................... 5
Bydureon BCise 2 mg/0.85 mL
subcutaneous auto-injector ...................... 5
C carteolol 1 % eye drops ............................. 10
carvedilol 12.5 mg tablet............................. 3
carvedilol 25 mg tablet................................ 3
carvedilol 3.125 mg tablet........................... 3
carvedilol 6.25 mg tablet............................. 3
carvedilol phosphate ER 10 mg
capsule,ext.release24hr multiphase ......... 3
carvedilol phosphate ER 20 mg
capsule,ext.release24hr multiphase ......... 3
carvedilol phosphate ER 40 mg
capsule,ext.release24hr multiphase ......... 3
carvedilol phosphate ER 80 mg
capsule,ext.release24hr multiphase ......... 3
ciclopirox 0.77 % topical cream ............... 11
ciclopirox 0.77 % topical gel .................... 11
ciclopirox 0.77 % topical suspension........ 11
ciclopirox 1 % shampoo............................ 11
ciclopirox 8 % topical solution ................. 11
citalopram 10 mg tablet .......................... 1, 2
citalopram 10 mg/5 mL oral solution...... 1, 2
citalopram 20 mg tablet .......................... 1, 2
citalopram 40 mg tablet .......................... 1, 2
clotrimazole 1 % topical cream ................. 11
Combigan 0.2 %-0.5 % eye drops ............ 10
D desoximetasone 0.05 % topical cream ...... 12
desoximetasone 0.05 % topical gel ........... 12
desoximetasone 0.05 % topical ointment.. 12
desoximetasone 0.25 % topical cream ...... 12
desoximetasone 0.25 % topical ointment.. 12
desvenlafaxine ER 100 mg tablet,extended
release 24 hr ............................................ 2
desvenlafaxine ER 50 mg tablet,extended
release 24 hr ............................................ 2
desvenlafaxine succinate ER 100 mg
tablet,extended release 24 hr ................... 2
desvenlafaxine succinate ER 25 mg
tablet,extended release 24 hr ................... 2
desvenlafaxine succinate ER 50 mg
tablet,extended release 24 hr ................... 2
Dexilant 30 mg capsule, delayed release .... 9
Dexilant 60 mg capsule, delayed release .... 9
dorzolamide 2 % eye drops ................... 7, 10
dorzolamide 22.3 mg-timolol 6.8 mg/mL
eye drops ............................................... 10
dorzolamide-timolol (PF) 2 %-0.5 % eye
drops in a dropperette............................ 10
duloxetine 20 mg capsule,delayed release . 1,
2
duloxetine 30 mg capsule,delayed release . 1,
2
15
duloxetine 40 mg capsule,delayed release . 1,
2
duloxetine 60 mg capsule,delayed release . 1,
2
E epinastine 0.05 % eye drops........................ 8
Ertaczo 2 % topical cream ........................ 11
escitalopram 10 mg tablet ....................... 1, 2
escitalopram 20 mg tablet ....................... 1, 2
escitalopram 5 mg tablet ......................... 1, 2
escitalopram 5 mg/5 mL oral solution .... 1, 2
esomeprazole magnesium 20 mg
capsule,delayed release ........................... 9
esomeprazole magnesium 40 mg
capsule,delayed release ........................... 9
F fenofibrate 120 mg tablet ............................ 4
fenofibrate 150 mg capsule ......................... 4
fenofibrate 160 mg tablet ............................ 4
fenofibrate 40 mg tablet .............................. 4
fenofibrate 50 mg capsule ........................... 4
fenofibrate 54 mg tablet .............................. 4
fenofibrate micronized 130 mg capsule ...... 4
fenofibrate micronized 134 mg capsule ...... 4
fenofibrate micronized 200 mg capsule ...... 4
fenofibrate micronized 43 mg capsule ........ 4
fenofibrate micronized 67 mg capsule ........ 4
fenofibrate nanocrystallized 145 mg tablet . 4
fenofibrate nanocrystallized 48 mg tablet ... 4
fenofibric acid (choline) 135 mg
capsule,delayed release ........................... 4
fenofibric acid (choline) 45 mg
capsule,delayed release ........................... 4
fenofibric acid 105 mg tablet ...................... 4
fenofibric acid 35 mg tablet ........................ 4
Fetzima 120 mg capsule,extended release .. 2
Fetzima 20 mg (2)-40 mg (26)
capsule,extended release,24 hr,dose pack 2
Fetzima 20 mg capsule,extended release .... 2
Fetzima 40 mg capsule,extended release .... 2
Fetzima 80 mg capsule,extended release .... 2
fluocinonide 0.05 % topical gel ................ 12
fluocinonide 0.05 % topical ointment ....... 12
fluocinonide 0.1 % topical cream ............. 12
Fluocinonide-E 0.05 % topical cream ....... 12
fluoxetine 10 mg capsule ........................ 1, 2
fluoxetine 10 mg tablet ........................... 1, 2
fluoxetine 20 mg capsule ........................ 1, 2
fluoxetine 20 mg tablet ........................... 1, 2
fluoxetine 20 mg/5 mL (4 mg/mL) oral
solution ................................................ 1, 2
fluoxetine 40 mg capsule ........................ 1, 2
fluoxetine 90 mg capsule,delayed release1, 2
fluvoxamine 100 mg tablet ..................... 1, 2
fluvoxamine 25 mg tablet ....................... 1, 2
fluvoxamine 50 mg tablet ....................... 1, 2
fluvoxamine ER 100 mg capsule,extended
release 24 hr ........................................ 1, 2
fluvoxamine ER 150 mg capsule,extended
release 24 hr ........................................ 1, 2
Fosamax Plus D 70 mg-2,800 unit tablet .... 6
Fosamax Plus D 70 mg-5,600 unit tablet .... 6
G gemfibrozil 600 mg tablet ........................... 4
H Humulin 70/30 U-100 Insulin 100 unit/mL
subcutaneous suspension ........................ 5
Humulin 70/30 U-100 Insulin KwikPen 100
unit/mL subcutaneous ............................. 5
Humulin N NPH U-100 Insulin (isophane
susp) 100 unit/mL subcutaneous ............. 5
Humulin N NPH U-100 Insulin KwikPen
100 unit/mL (3 mL) subcutaneous .......... 5
I ibandronate 150 mg tablet ........................... 6
K ketoconazole 2 % shampoo ....................... 11
ketoconazole 2 % topical cream ............... 11
ketotifen 0.025 % (0.035 %) eye drops....... 8
L lansoprazole 15 mg capsule,delayed release9
lansoprazole 15 mg delayed
release,disintegrating tablet..................... 9
lansoprazole 30 mg capsule,delayed release9
lansoprazole 30 mg delayed
release,disintegrating tablet..................... 9
Lantus Solostar U-100 Insulin 100 unit/mL
(3 mL) subcutaneous pen ........................ 5
Lantus U-100 Insulin 100 unit/mL
subcutaneous solution ............................. 5
latanoprost 0.005 % eye drops .................. 10
16
Levemir FlexTouch U-100 Insulin 100
unit/mL (3 mL) subcutaneous pen .......... 5
Levemir U-100 Insulin 100 unit/mL
subcutaneous solution ............................. 5
levobunolol 0.5 % eye drops ..................... 10
luliconazole 1 % topical cream ................. 11
Lumigan 0.01 % eye drops ....................... 10
Luzu 1 % topical cream ............................ 11
M miconazole nitrate 2 % topical cream ....... 11
miconazole nitrate 2 % topical spray powder
............................................................... 11
mirtazapine 15 mg disintegrating tablet .. 1, 2
mirtazapine 15 mg tablet ......................... 1, 2
mirtazapine 30 mg disintegrating tablet .. 1, 2
mirtazapine 30 mg tablet ......................... 1, 2
mirtazapine 45 mg disintegrating tablet .. 1, 2
mirtazapine 45 mg tablet ......................... 1, 2
mirtazapine 7.5 mg tablet ........................ 1, 2
mometasone 0.1 % topical cream ............. 12
mometasone 0.1 % topical ointment ......... 12
mometasone 50 mcg/actuation nasal spray 13
N naftifine 1 % topical cream ....................... 11
naftifine 2 % topical cream ....................... 11
O olopatadine 0.1 % eye drops ....................... 8
olopatadine 0.2 % eye drops ....................... 8
omeprazole 10 mg capsule,delayed release 9
omeprazole 20 mg capsule,delayed release 9
omeprazole 40 mg capsule,delayed release 9
oxiconazole 1 % topical cream ................. 11
Oxistat 1 % lotion ..................................... 11
Ozempic 0.25 mg or 0.5 mg (2 mg/1.5 mL)
subcutaneous pen injector ....................... 5
Ozempic 1 mg/dose (2 mg/1.5 mL)
subcutaneous pen injector ....................... 5
P pantoprazole 20 mg tablet,delayed release . 9
pantoprazole 40 mg tablet,delayed release . 9
paroxetine 10 mg tablet ........................... 1, 2
paroxetine 20 mg tablet ........................... 1, 2
paroxetine 30 mg tablet ........................... 1, 2
paroxetine 40 mg tablet ........................... 1, 2
paroxetine ER 12.5 mg tablet,extended
release 24 hr ........................................ 1, 2
paroxetine ER 25 mg tablet,extended release
24 hr .................................................... 1, 2
paroxetine ER 37.5 mg tablet,extended
release 24 hr ........................................ 1, 2
Paxil 10 mg/5 mL oral suspension .............. 2
Pazeo 0.7 % eye drops ................................ 8
Phospholine Iodide 0.125 % eye drops ..... 10
pilocarpine 1 % eye drops ......................... 10
pilocarpine 2 % eye drops ......................... 10
pilocarpine 4 % eye drops ......................... 10
Protonix 40 mg granules delayed-release
packet ...................................................... 9
R rabeprazole 20 mg tablet,delayed release ... 9
Remedy Antifungal 2 % topical powder ... 11
Rhopressa 0.02 % eye drops ..................... 10
risedronate 150 mg tablet ............................ 6
risedronate 30 mg tablet .............................. 6
risedronate 35 mg tablet .............................. 6
risedronate 35 mg tablet (12 pack) .............. 6
risedronate 35 mg tablet (4 pack) ................ 6
risedronate 35 mg tablet,delayed release .... 6
risedronate 5 mg tablet ................................ 6
Rocklatan 0.02 %-0.005 % eye drops ....... 10
S sertraline 100 mg tablet ........................... 1, 2
sertraline 20 mg/mL oral concentrate ..... 1, 2
sertraline 25 mg tablet ............................. 1, 2
sertraline 50 mg tablet ............................. 1, 2
Simbrinza 1 %-0.2 % eye drops,suspension
............................................................... 10
Soliqua 100/33 100 unit-33 mcg/mL
subcutaneous insulin pen ........................ 5
T timolol maleate 0.25 % eye drops ............. 10
timolol maleate 0.25 % eye gel forming
solution .................................................. 10
timolol maleate 0.5 % eye drops ............... 10
timolol maleate 0.5 % eye gel forming
solution .................................................. 10
Timoptic Ocudose (PF) 0.5 % eye drops in a
dropperette ............................................ 10
Toujeo Max U-300 SoloStar 300 unit/mL (3
mL) subcutaneous insulin pen ................ 5
Toujeo SoloStar U-300 Insulin 300 unit/mL
(1.5 mL) subcutaneous pen ..................... 5
17
travoprost 0.004 % eye drops.................... 10
trazodone 100 mg tablet .......................... 1, 2
trazodone 150 mg tablet .......................... 1, 2
trazodone 300 mg tablet .......................... 1, 2
trazodone 50 mg tablet ............................ 1, 2
Tresiba FlexTouch U-100 insulin 100
unit/mL (3 mL) subcutaneous pen .......... 5
Tresiba FlexTouch U-200 insulin 200
unit/mL (3 mL) subcutaneous pen .......... 5
Tresiba U-100 Insulin 100 unit/mL
subcutaneous solution ............................. 5
triamcinolone acetonide 0.025 % lotion ... 12
triamcinolone acetonide 0.025 % topical
cream ..................................................... 12
triamcinolone acetonide 0.025 % topical
ointment ................................................ 12
triamcinolone acetonide 0.1 % lotion ....... 12
triamcinolone acetonide 0.1 % topical cream
............................................................... 12
triamcinolone acetonide 0.1 % topical
ointment ................................................ 12
triamcinolone acetonide 0.5 % topical cream
............................................................... 12
triamcinolone acetonide 0.5 % topical
ointment ................................................ 12
Triderm 0.1 % topical cream .................... 12
Trintellix 10 mg tablet ................................ 2
Trintellix 20 mg tablet ................................ 2
Trintellix 5 mg tablet .................................. 2
Trulicity 0.75 mg/0.5 mL subcutaneous pen
injector .................................................... 5
Trulicity 1.5 mg/0.5 mL subcutaneous pen
injector .................................................... 5
V venlafaxine 100 mg tablet ....................... 1, 2
venlafaxine 25 mg tablet ......................... 1, 2
venlafaxine 37.5 mg tablet ...................... 1, 2
venlafaxine 50 mg tablet ......................... 1, 2
venlafaxine 75 mg tablet ......................... 1, 2
venlafaxine ER 150 mg capsule,extended
release 24 hr ........................................ 1, 2
venlafaxine ER 150 mg tablet,extended
release 24 hr ........................................ 1, 2
venlafaxine ER 225 mg tablet,extended
release 24 hr ........................................ 1, 2
venlafaxine ER 37.5 mg capsule,extended
release 24 hr ............................................ 2
venlafaxine ER 37.5 mg tablet,extended
release 24 hr ............................................ 2
venlafaxine ER 75 mg capsule,extended
release 24 hr ............................................ 2
venlafaxine ER 75 mg tablet,extended
release 24 hr ............................................ 2
Victoza 3-Pak 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous pen injector ....................... 5
Viibryd 10 mg (7)-20 mg (23) tablets in a
dose pack ................................................. 2
Viibryd 10 mg tablet ................................... 2
Viibryd 20 mg tablet ................................... 2
Viibryd 40 mg tablet ................................... 2
X Xhance 93 mcg/actuation breath activated
aerosol ................................................... 13
Xultophy 100/3.6 100 unit-3.6 mg/mL (3
mL) subcutaneous insulin pen ................ 5