Fidelis Care Formulary · Detrol Detrol LA Dexedrine Spansule dextroamphetamine tabs 5 mg, 10 mg...

Fidelis Care Formulary 08/01/2020

INTRODUCTION ...................................................................................................................................................................................................... 4 NOTICE OF NONDISCRIMINATION ....................................................................................................................................................................... 4 PREFACE ................................................................................................................................................................................................................. 6 PHARMACY AND THERAPEUTICS COMMITTEE ................................................................................................................................................. 6 DRUG LIST PRODUCT DESCRIPTIONS ................................................................................................................................................................ 6 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 7 NON-PREFERRED REQUEST ................................................................................................................................................................................ 7 QUANTITY LIMITATIONS ........................................................................................................................................................................................ 8 SPECIALTY DRUGS .............................................................................................................................................................................................. 11 PRIOR AUTHORIZATION ...................................................................................................................................................................................... 11 STEP THERAPY .................................................................................................................................................................................................... 13 APPEALS INFORMATION/PROCESS .................................................................................................................................................................. 13 EDITOR ................................................................................................................................................................................................................... 13 NOTICE ................................................................................................................................................................................................................... 14 LEGEND ................................................................................................................................................................................................................. 14 ANALGESICS......................................................................................................................................................................................................... 15

ANALGESICS, OTHER ................................................................................................................................................................................ 15 NSAIDs ......................................................................................................................................................................................................... 15 NSAIDs, TOPICAL ....................................................................................................................................................................................... 15 COX-2 INHIBITORS ..................................................................................................................................................................................... 15 GOUT ........................................................................................................................................................................................................... 15 OPIOID ANALGESICS ................................................................................................................................................................................. 15 NON-OPIOID ANALGESICS ........................................................................................................................................................................ 16

ANTI-INFECTIVES ................................................................................................................................................................................................. 16 ANTIBACTERIALS ....................................................................................................................................................................................... 16 ANTIFUNGALS ............................................................................................................................................................................................ 17 ANTIMALARIALS ......................................................................................................................................................................................... 17 ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 17 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 19 ANTIVIRALS................................................................................................................................................................................................. 19 MISCELLANEOUS ....................................................................................................................................................................................... 19

ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 20 ALKYLATING AGENTS ............................................................................................................................................................................... 20 ANTIMETABOLITES .................................................................................................................................................................................... 20 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 20 IMMUNOMODULATORS ............................................................................................................................................................................. 20 KINASE INHIBITORS ................................................................................................................................................................................... 21 KINASE INHIBITORS FOR CML ................................................................................................................................................................. 21 MISCELLANEOUS ....................................................................................................................................................................................... 21

CARDIOVASCULAR .............................................................................................................................................................................................. 21 ACE INHIBITORS ........................................................................................................................................................................................ 21 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 21 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 21 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 22 ADRENOLYTICS, CENTRAL/DIURETIC COMBINATION .......................................................................................................................... 22 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 22 ALPHA BLOCKERS ..................................................................................................................................................................................... 22 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 22 ANTIARRHYTHMICS ................................................................................................................................................................................... 22 ANTILIPEMICS............................................................................................................................................................................................. 22 BETA-BLOCKERS ....................................................................................................................................................................................... 23 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 23 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 23 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 24 DIURETICS .................................................................................................................................................................................................. 24

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NITRATES .................................................................................................................................................................................................... 24 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 24 MISCELLANEOUS ....................................................................................................................................................................................... 25

CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 25 ANTIANXIETY .............................................................................................................................................................................................. 25 ANTICONVULSANTS .................................................................................................................................................................................. 25 ANTIDEMENTIA ........................................................................................................................................................................................... 26 ANTIDEPRESSANTS .................................................................................................................................................................................. 26 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 26 ANTIPSYCHOTICS ...................................................................................................................................................................................... 27 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 27 FIBROMYALGIA .......................................................................................................................................................................................... 28 HUNTINGTON'S DISEASE AGENTS .......................................................................................................................................................... 28 HYPNOTICS ................................................................................................................................................................................................. 28 MIGRAINE .................................................................................................................................................................................................... 28 MOOD STABILIZERS .................................................................................................................................................................................. 28 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 28 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 29 MYASTHENIA GRAVIS ............................................................................................................................................................................... 29 NARCOLEPSY/CATAPLEXY ....................................................................................................................................................................... 29 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 29

ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 29 ANDROGENS .............................................................................................................................................................................................. 29 ANTIDIABETICS .......................................................................................................................................................................................... 30 CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 31 CALCIUM REGULATORS ........................................................................................................................................................................... 31 CONTRACEPTIVES .................................................................................................................................................................................... 31 ENDOMETRIOSIS ....................................................................................................................................................................................... 33 ESTROGENS ............................................................................................................................................................................................... 33 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 34 FERTILITY REGULATORS .......................................................................................................................................................................... 34 GLUCOCORTICOIDS .................................................................................................................................................................................. 34 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 34 HUMAN GROWTH HORMONES AND RELATED DISORDERS ................................................................................................................ 34 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 34 PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 34 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 34 PROGESTINS, ORAL .................................................................................................................................................................................. 34 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 35 THYROID AGENTS ..................................................................................................................................................................................... 35 UREA CYCLE DISORDERS ........................................................................................................................................................................ 35 VASOPRESSINS ......................................................................................................................................................................................... 35 MISCELLANEOUS ....................................................................................................................................................................................... 35

GASTROINTESTINAL ........................................................................................................................................................................................... 35 ANTACIDS ................................................................................................................................................................................................... 35 ANTIDIARRHEALS ...................................................................................................................................................................................... 35 ANTIEMETICS ............................................................................................................................................................................................. 35 ANTISPASMODICS ..................................................................................................................................................................................... 36 CHOLELITHOLYTICS .................................................................................................................................................................................. 36 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 36 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 36 IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 36 LAXATIVES/STOOL SOFTENERS .............................................................................................................................................................. 36 OPIOID-INDUCED CONSTIPATION ........................................................................................................................................................... 37 PANCREATIC ENZYMES ............................................................................................................................................................................ 37 PROSTAGLANDINS .................................................................................................................................................................................... 37 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 37 SALIVA STIMULANTS ................................................................................................................................................................................. 37 STEROIDS, RECTAL ................................................................................................................................................................................... 37 MISCELLANEOUS ....................................................................................................................................................................................... 37

GENITOURINARY .................................................................................................................................................................................................. 37 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 37 URINARY ANTISPASMODICS .................................................................................................................................................................... 38 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 38 MISCELLANEOUS ....................................................................................................................................................................................... 38

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HEMATOLOGIC ..................................................................................................................................................................................................... 38 ANTICOAGULANTS .................................................................................................................................................................................... 38 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 38 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS ........................................................................ 38 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 39 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 39 THROMBOCYTOPENIA AGENTS .............................................................................................................................................................. 39 MISCELLANEOUS ....................................................................................................................................................................................... 39

IMMUNOLOGIC AGENTS ...................................................................................................................................................................................... 39 AUTOIMMUNE AGENTS ............................................................................................................................................................................. 39 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 40 IMMUNOMODULATORS ............................................................................................................................................................................. 40 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 40 VACCINES ................................................................................................................................................................................................... 40

NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................ 40 ELECTROLYTES ......................................................................................................................................................................................... 40 VITAMINS AND MINERALS ........................................................................................................................................................................ 41

RESPIRATORY ...................................................................................................................................................................................................... 41 ANAPHYLAXIS TREATMENT AGENTS...................................................................................................................................................... 41 ANTICHOLINERGICS .................................................................................................................................................................................. 41 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 42 ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 42 ANTIHISTAMINES, NONSEDATING ........................................................................................................................................................... 42 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 42 ANTIHISTAMINE/DECONGESTANT COMBINATIONS .............................................................................................................................. 42 ANTITUSSIVE .............................................................................................................................................................................................. 42 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 42 BETA AGONISTS ........................................................................................................................................................................................ 43 CYSTIC FIBROSIS ...................................................................................................................................................................................... 43 LEUKOTRIENE MODULATORS .................................................................................................................................................................. 43 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 43 NASAL DECONGESTANTS ........................................................................................................................................................................ 43 NASAL STEROIDS ...................................................................................................................................................................................... 43 RESPIRATORY DEVICES ........................................................................................................................................................................... 43 RESPIRATORY SYNCYTIAL VIRUS ........................................................................................................................................................... 43 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 44 STEROID INHALANTS ................................................................................................................................................................................ 44 XANTHINES ................................................................................................................................................................................................. 44 MISCELLANEOUS ....................................................................................................................................................................................... 44

TOPICAL ................................................................................................................................................................................................................ 44 DERMATOLOGY ......................................................................................................................................................................................... 44 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 47 OPHTHALMIC .............................................................................................................................................................................................. 47 OTIC ............................................................................................................................................................................................................. 49

INDEX ..................................................................................................................................................................................................................... 50

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INTRODUCTION Fidelis Care is pleased to provide the Fidelis Care Formulary for Child Health Plus (CHP), HealthierLife (HARP) and Medicaid members as a useful reference and informational tool. The Fidelis Care Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for members.

The drugs on this formulary have been reviewed by the Fidelis Care Pharmacy and Therapeutics (P&T) Committee and found appropriate for formulary inclusion. The clinical information within the formulary is primarily derived from medical literature and is reviewed and approved by the P&T Committee.

This edition incorporates drugs added to the formulary since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the Fidelis Care Formulary is reflective of current medical practice as of the date of review.

The information contained in the Fidelis Care Formulary and its appendices is provided by Fidelis Care, solely for the convenience of medical providers. Fidelis Care does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The Fidelis Care Formulary is not intended to be a substitute for the knowledge, expertise, skill, and judgment of the medical provider in their choice of prescription drugs. Fidelis Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

NOTICE OF NONDISCRIMINATION Fidelis Care complies with Federal civil rights laws. Fidelis Care does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Fidelis Care provides the following:

• Free aids and services to people with disabilities to help you communicate with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats

• Free language services to people whose first language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, call Fidelis Care at 1-888-343-3547. For TTY/TDD services, call 1-800-421-1220. If you believe that Fidelis Care has not given you these services or treated you differently because of race, color, national origin, age, disability or sex, you can file a grievance with Fidelis Care by: • Mail: 95-25 Queens Boulevard, Rego Park, NY 11374 • Phone: 1-718-896-6500 (TTY: 1-800-421-1220) • Fax: 1-718-896-3557 • In person: 95-25 Queens Boulevard, Rego Park, NY 11374 • Email: [email protected] You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by: • Web: Office for Civil Rights Complaint Portal at:

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf • Mail: U.S. Department of Health and Human Services

200 Independence Avenue SW., Room 509F, HHH Building Washington, DC 20201 Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html

• Phone: 1-800-368-1019 (TTY/TDD 800-537-7697)

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PREFACE The Fidelis Care Formulary is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by generic name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the Fidelis Care Formulary.

PHARMACY AND THERAPEUTICS COMMITTEE The Fidelis Care P&T Committee considers all new-to-market drugs for inclusion in the formulary. The evaluation includes a literature review and expert external opinion may also be sought. Formal reviews are prepared that typically address the following information:

• Safety • Efficacy • Comparison studies • Approved indications • Adverse effects • Contraindications/Warnings/Precautions • Pharmacokinetics • Patient administration/compliance considerations • Medical outcome and pharmacoeconomic studies • Cost

When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently on the formulary. In addition, entire therapeutic classes are periodically evaluated.

All the information in the Fidelis Care Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted. Listed products on the document generally include all strengths and dosage forms of the cited brand-name product. ondansetron Zofran Oral solution, tablets, disintegrating tablets, and all strengths of Zofran would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is on the document. Other strengths/dosage forms, including injectable dosage forms of the reference product are not. acyclovir caps, tabs Zovirax The capsules and tablets of Zovirax are on the document. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry. Extended-release and delayed-release products require their own entry. tolterodine Detrol The immediate-release product listing of Detrol alone would not include the extended-release product Detrol LA. tolterodine ext-rel Detrol LA A separate entry for Detrol LA confirms that the extended-release product is on the document.

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Dosage forms on the document will be consistent with the category and use where listed. nystatin The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI-INFECTIVES section of the document.

GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora. Fidelis Care has a mandatory generic pharmacy benefit. If a medication is available as generic, then the generic product must be dispensed. Certain specific products are exempt from the mandatory generic requirement and are indicated as such within the formulary. Exempt products include: Clozaril, Coumadin, Dilantin, Lanoxin, Levoxyl, Neoral, Sandimmune, Synthroid, Tegretol, Unithroid and Zarontin. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

• Approved by the U.S. Food and Drug Administration (FDA) for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.

• Tested in humans to assure the generic is absorbed into the bloodstream in a similar time and amount compared to the brand-name drug. Generics may be different from the brand in size, color and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.

• Manufactured in the same strength and dosage form as the brand-name drugs.

When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug.

NON-PREFERRED REQUEST Acknowledging the medical necessity for certain non-preferred drugs in specific patient populations, Fidelis Care has developed a means of review for authorizing coverage of non-preferred drugs when medical necessity warrants their use. The non-preferred request review policy permits coverage of non-preferred drugs when at least one of the following criteria is met:

1. Documented allergic/adverse reaction to a preferred agent. 2. Documented failure of preferred agents. 3. Documented patient stability/control issues in patients with concomitant drug/disease states where

a preferred agent is contraindicated or a change in therapy is not advisable.

In making decisions with regard to non-preferred request and the overall formulary, Fidelis Care applies recommendations of national evidence-based guidelines, professional expertise and judgment. Fidelis Care looks for the appropriate usages of drugs and drug products as established by or in: (1) evidence-based national guidelines, (2) peer-reviewed literature, (3) the American Hospital Formulary Service-Drug Information, (4) the American Medical Association-Drug Evaluations, (5) the United States Pharmacopeia-Drug Information, (6) other such standard compendia, and (7) the professional guidance of pharmacists.

Fidelis Care adheres to Article 49 guidelines for providing responses to non-preferred requests. All requests will be reviewed and decision on these requests made within 3 business days from the day of receipt. Generally, requests are processed in the order received. However, urgent requests should be identified as such when submitted, and will be reviewed within the same day, if feasible. A response will be forwarded to the requesting provider as soon as a determination has been made on the request (both verbal and written). Members will be notified of the decision verbally and by a letter as well.

To request a non-preferred medication, prescribers need to fill out and fax over to Fidelis a "Medication Request Form." To obtain the form, providers may contact Fidelis Care at 1-888-343-3547 or download the form from Fidelis' Web site: https://www.fideliscare.org/Provider/Provider-Resources/Pharmacy-Services

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QUANTITY LIMITATIONS Quantity Limits (QL) provide for a maximum quantity of a drug product that a member may receive per prescription over a specified period of time.

The following brand-name drugs, and generic versions if available, are subject to QL:

abacavir abacavir/lamivudine abacavir/lamivudine/zidovudine Abilify tabs acamprosate Accolate Aciphex Actos Actoplus Met Adderall Adderall XR Admelog Advair Diskus Airduo Respiclick Albenza albuterol inhalation solution Aldara Alinia Allevess Alphagan P Ambien Ambien CR Amerge Anoro Ellipta Anusol-HC Anzemet Aptivus Arnuity Ellipta Arthritis & Muscle Pain Relief Arthritis Pain Cream Asmanex HFA Ativan Atripla Atrovent HFA Avalide Avapro Avodart Azilect bacitracin ophthalmic ointment Baqsimi Baraclude tabs Basaglar BD Ultrafine insulin syringes and needles Benicar Benicar HCT Bicillin L-A Biktarvy bimatoprost 0.03% Boniva brimonidine 0.2% buprenorphine/naloxone sublingual tabs bupropion ext-rel buspirone

butalbital/acetaminophen butalbital/acetaminophen/caffeine tabs - Esgic Calan SR tabs capsaicin crm, patch 0.025% Capzasin Gel Relief Capzasin-HP Capzasin-P Castiva cefpodoxime Celebrex 50 mg, 100 mg, 200 mg Chantix chlordiazepoxide chloroquine Cimduo Ciprodex clobetasol propionate gel 0.05% clobetasol propionate lotion 0.05% clomiphene Colcrys Combivent Respimat Complera Concerta condoms, female condoms, male Condylox gel Crestor Crixivan Cutter Backwoods Insect Repellent Cutter Skinsations Insect Repellent Cymbalta Delstrigo Depo-Subq Provera 104 Derma-Smoothe/FS Descovy Detrol Detrol LA Dexedrine Spansule dextroamphetamine tabs 5 mg, 10 mg diaphragm diclofenac sodium soln 1.5% didanosine delayed-rel Differin gel (only OTC covered) Dilaudid Diovan Diovan HCT Dolophine Dovato Dovonex dronabinol Duragesic Edurant Effexor XR Effient

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Elmiron Emend caps Emtriva Enablex Entocort EC epinephrine auto-injector Epipen Epipen Jr. Epivir-HBV tabs estazolam Eucrisa Evista Evotaz Fiorinal First-Lansoprazole First-Omeprazole Firvanq fluocinolone acetonide solution 0.01% flurazepam fluticasone nasal spray Focalin Focalin XR Fosamax 35 mg, 40 mg, 70 mg fosamprenavir tabs Freestyle Freedom Lite kits and test strips Freestyle Insulinx Lite kits and test strips Freestyle Lite kits and test strips Fuzeon Genvoya granisetron Guadalupano Hepsera Humulin N Humulin R Humulin 70/30 hydrocodone/acetaminophen 7.5/325 mg/15 mL hydrocodone/ibuprofen Icy Hot Imitrex Incruse Ellipta indomethacin indomethacin ext-rel Insulin Aspart Intelence Intuniv Invirase ipratropium-albuterol inhalation solution ipratropium inhalation solution ipratropium nasal spray Isentress Isentress HD Juluca Kaletra tabs Kazano ketoconazole crm 2% Klonopin tabs Kyleena lamivudine lamivudine/zidovudine

lancets levalbuterol inhalation solution Levaquin Lexapro lidocaine crm, patch 4% - Aspercreme/Lidocaine lidocaine/hydrocortisone kit lidocaine/prilocaine Lidoderm Liletta Lipitor l-methylfolate lovastatin Lovaza Lunesta Lynparza Lyrica Lysteda Malarone Miacalcin Mirapex ER Maxalt/Maxalt-MLT mefloquine Mepron Metadate CD Methylin Micardis Micardis HCT Mirena mometasone cream, lotion, ointment 0.1% Monurol morphine moxifloxacin tabs MS Contin Namenda Nasacort Allergy 24HR Natrapel Insect Repellent Nesina Neurontin Nexium 24HR Nexium 40 mg Nexplanon Nicoderm CQ Nicorette Nicotrol Inhaler Nicotrol NS Nimotop Norco Norvir Novolin N Novolin R Novolin 70/30 Nutritional Supplements nystatin/triamcinolone Odefsey Off Active Insect Repellent Off Deep Woods Insect Repellent Off Family Care Insect Repellent omeprazole delayed-rel caps, tabs omeprazole magnesium delayed-rel caps

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Omnipod Dash Oseni oxazepam oxycodone caps, tabs oxymorphone ext-rel Ozempic Paragard Pataday (only OTC covered) Paxil CR pentoxifylline ext-rel Percocet Percodan Pifeltro Piroxicam Pravachol Precision Xtra kits and test strips Prevacid Prevacid 24HR Prezcobix Prezista Prilosec OTC primaquine Pristiq Proair HFA Proair Respiclick Proctofoam-HC Protonix Protopic Proventil HFA Pulmicort Respules Reliaderm Repel Sportsmen Insect Repellent Repel Sportsmen Max Insect Repellent Requip XL Restoril 15 mg, 30 mg Reyataz Rhinocort Allergy Rifamate Risperdal Ritalin Ritalin LA rivastigmine caps Santyl Savaysa Sawyer Insect Repellent Segluromet Selzentry Serevent Seroquel XR Seroquel 100 mg Shingrix Singulair Skyla Solu-Cortef 100 mg/mL Spiriva Respimat 1.25 mcg stavudine Steglatro Steglujan Stiolto Respimat

Strattera Stribild Suboxone film Sustiva Symbicort Symbyax Symfi Symfi Lo Symtuza Tamiflu tinidazole Tivicay tramadol ext-rel tabs triamcinolone nasal spray Triumeq trospium ext-rel Trulicity Truvada Tybost Tylenol w/Codeine Ultracet Ultram Uroxatral Valium Vancocin 125 mg Ventolin HFA verapamil Verelan SR Vesicare Vfend tabs Vibramycin suspension Vicoprofen Victoza Viracept Viramune Viramune XR Viread Voltaren gel (only OTC covered) Wixela Inhub Xalatan Xanax tabs Xanax XR Xopenex HFA Xyzal zaleplon Zenzedi Zetia zidovudine Ziks Zocor Zofran zoledronic acid Zomig nasal spray Zomig/Zomig-ZMT Zostavax Zostrix HP Zostrix Natural Zyprexa/Zyprexa Zydis

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SPECIALTY DRUGS Specialty pharmaceuticals are used in the management of complex chronic or genetic conditions and certain catastrophic diseases. They are often injectable medications, but they may also include oral agents. Specialty drugs identified in the document by (SP) are available through AcariaHealth Specialty Pharmacy.

Fidelis Care requires prior authorization (PA) for many drugs before they will be approved for coverage. Prior authorization for specialty drugs should be obtained by the physician's office prior to AcariaHealth Specialty Pharmacy being contacted. The physician's office must contact Fidelis Care by telephone at 1-888-343-3547 or by fax at 1-877-533-2405 to obtain a prior authorization. Once prior authorization is obtained, getting started with AcariaHealth Specialty Pharmacy is easy. Providers may contact AcariaHealth Specialty Pharmacy by telephone at 1-844-584-1072 or by fax at 1-833-368-6385. Additional information can also be found online at acariahealth.com. AcariaHealth Specialty Pharmacy provides comprehensive patient education, clinical programs and support, and access to multilingual health care experts and pharmacists 24 hours a day.

PRIOR AUTHORIZATION The advantages of Prior Authorization (PA) are: 1) enforcement of treatment protocols/guidelines, 2) prevention of drug use for unlabeled indications, 3) the ability to "risk manage" drugs with serious side effects, 4) decreased utilization of certain drugs, and 5) cost control.

Prior authorized drugs cannot be obtained through Fidelis' pharmacy benefit unless the prior authorization process has been completed. The procedure for prior authorization of a non-specialty drug is as follows:

When the patient takes the prescription for a drug requiring prior authorization to a community pharmacist with an on-line system, the community pharmacist will enter the Fidelis Care member eligibility number and drug. The community pharmacist will receive the message "prior authorization required" on their computer screen and they will not be able to put the prescription through the system. The pharmacist must contact the physician's office and instruct them to call Fidelis Care at 1-888-343-3547 and indicate that they need a prior authorization for a Fidelis Care patient. The physician should be prepared to supply the following information: 1) patient name, ID number, and date of birth, 2) physician name, address and phone number, 3) drug name, strength and directions, 4) diagnosis and clinical information as indicated on the "Medication Request Form." Once Fidelis receives the completed "Medication Request Form," the request will be reviewed to determine if it meets medical necessity criteria for the drug in question.

If the patient does meet the criteria, a prior authorization will be entered into the on-line system, and the community pharmacist will be able to bill the prescription. If the patient does not meet the established criteria, prior authorization will not be granted. Fidelis Care staff will be responsible for notifying the physician regarding the approval/denial.

The criteria of use for each drug follows the FDA-approved labeled indications and standards of physicians' practice. These criteria can change based on newly approved indications and/or at least two well-designed peer-reviewed studies showing effectiveness and safety.

Fidelis Care adheres to Article 49 guidelines for providing responses to prior authorization requests. Urgent requests should be identified as such when submitted. A response will be forwarded to the physician as soon as determination has been made on the request. Requests are processed in the order received.

Fidelis Care currently requires prior authorization for the following drugs, and generic versions, if available:

abacavir/lamivudine/zidovudine Abilify Maintena Actiq Adcirca Adderall Adderall XR Advate Adynovate Afinitor Afstyla Alphanate

Alphanine SD Alprolix Amerge Amitiza amitriptyline Amnesteem Androgel Aranesp Aristada Aristada Initio Atripla Aubagio

Avonex Benefix Benlysta subcutaneous Bosulif Buphenyl Cayston Ciprodex Claravis Coagadex codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin liquid

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codeine/promethazine codeine/promethazine/phenylephrine Complera Concerta Copaxone Corifact Kit Cosentyx Creon Cubicin Cyramza Cystagon DDAVP tabs Delatestryl Depen Depo-Provera 400 mg/mL Depo-Testosterone Dexedrine Spansule dextroamphetamine tabs 5 mg, 10 mg Diclegis didanosine delayed-rel Dibenzyline doxepin dronabinol Edurant Eloctate Emend caps Enbrel Epclusa Erivedge Esperoct Eucrisa Exjade Extavia Feiba NF Feraheme Ferrlecit First-Lansoprazole First-Omeprazole Flolan Focalin Focalin XR Fulphila Fuzeon Gazyva Gilenya Gilotrif Gleevec glyburide glyburide/metformin Glynase Hemlibra Hemofil M Humate-P Humira hydrocodone/homatropine Idelvion Imbruvica

imipramine HCl Imitrex inj, nasal spray Increlex InFeD Intron A Invega Invega Sustenna Invega Trinza isotretinoin Ixinity Jadenu Jivi Juluca Kaletra solution Kevzara Koate Koate-DVI Kogenate FS Kovaltry Kuvan Letairis Leukine leuprolide acetate Lidoderm Lomotil Lupron Depot Lynparza Lysodren Macrobid Macrodantin Matulane Mayzent Mekinist Metadate CD Methylin methyltestosterone Mononine Movantik Myorisan Nexavar nitrofurantoin Norditropin Norpramin Novoeight Novoseven RT Nuvigil Nuwiq nystatin/triamcinolone Obizur Odefsey Opsumit Orfadin Orilissa Pamelor Pegasys Perseris Plegridy Pomalyst Primsol

Profilnine Prolia Promacta tabs Protopic Provigil Pulmicort Respules Pulmozyme Ranexa Rebif Recombinate Regranex Remodulin Repatha Retacrit Retin-A Revatio Revlimid ribavirin caps, tabs Risperdal Consta Ritalin Ritalin LA Rixubis Rubraca Rydapt Sandostatin Sandostatin LAR Santyl Selzentry Sensipar Serostim Siliq sofosbuvir/velpatasvir Somavert Soriatane Sporanox Sprycel stavudine Sutent Symbyax Synagis Synarel Tafinlar Tamiflu suspension Tarceva Targretin caps Tasigna Tecfidera Temodar Testim Thalomid Tikosyn Tobi Tracleer tramadol ext-rel tabs tretinoin caps Tretten Tygacil Tykerb Tylenol w/Codeine

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Tymlos Tyvaso Udenyca Ultracet Ultram Valchlor Venofer Ventavis Vonvendi Votrient Wilate

Xeljanz Xeljanz XR Xeloda Xenazine Xifaxan Xiidra Xylocaine Xyntha Xyrem Zarxio Zenatane

Zenzedi Ziextenzo Zocor 80 mg Zolinza Zykadia Zyprexa Zyprexa Relprevv Zyprexa Zydis Zyvox

STEP THERAPY

Step Therapy (ST) requires the use of one or more prerequisite drugs that meet specific conditions prior to the use of another drug or drugs. Fidelis Care requires step therapy for the following drugs, and generic versions if available:

Ambien CR Amerge Avodart Enablex First-Lansoprazole First-Omeprazole Kazano l-methylfolate levalbuterol inhalation solution Lyrica Metrogel 1% Namenda Natroba Nesina Omnipod Dash Oseni Ovide

oxymorphone ext-rel Ozempic Razadyne ER Renvela tabs rivastigmine caps Segluromet Spiriva Respimat 1.25 mcg Seroquel XR Steglatro Steglujan SymlinPen tinidazole Trulicity Victoza Zomig Zomig nasal spray Zomig-ZMT

APPEALS INFORMATION/PROCESS For appeals information/process call Fidelis Care at 1-888-FIDELIS (343-3547) or visit the Fidelis Care Web site at: https://www.fideliscare.org/Provider/Provider-Resources/Pharmacy-Services

EDITOR Your comments and suggestions regarding the Fidelis Care Formulary are encouraged. Your input is vital to the continued success of the Fidelis Care Formulary. All responses will be reviewed and considered. Please send your comments to:

Pharmacy Manager Fidelis Care 59-17 Junction Blvd Elmhurst, NY 11373

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NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of Fidelis Care. ©2020. All rights reserved.

The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with Fidelis Care. These trademarked brand names are included for informational purposes only and are not intended to imply or suggest any affiliation between Fidelis Care and such third-party pharmaceutical companies.

Fidelis Care does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by Fidelis Care. When viewing this formulary via the Internet, please be advised that the document is updated periodically and changes may appear prior to their effective date to allow for client notification.

LEGEND AL Age Limit OTC Over-the-counter product. Covered only with valid prescription. PA Prior Authorization QL Quantity Limit SP Specialty Drug ST Step Therapy boldface Indicates generic availability delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for

clarification

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ANALGESICS ANALGESICS, OTHER OTC acetaminophen TYLENOL NSAIDs OTC aspirin BAYER OTC aspirin buffered BUFFERIN OTC aspirin delayed-rel ECOTRIN OTC ibuprofen ADVIL OTC naproxen sodium ALEVE diclofenac sodium delayed-rel 50 mg, 75 mg diclofenac sodium ext-rel diflunisal etodolac etodolac ext-rel flurbiprofen ibuprofen QL indomethacin 25 mg, 50 mg QL indomethacin ext-rel ketorolac meloxicam MOBIC nabumetone naproxen sodium naproxen tabs NAPROSYN oxaprozin DAYPRO QL piroxicam sulindac NSAIDs, TOPICAL OTC, QL diclofenac sodium gel 1% VOLTAREN GEL QL diclofenac sodium soln 1.5% COX-2 INHIBITORS QL celecoxib 50 mg, 100 mg, 200 mg CELEBREX GOUT allopurinol ZYLOPRIM QL colchicine COLCRYS colchicine/probenecid probenecid OPIOID ANALGESICS Note: Per State of New York regulation, opioid analgesic prescriptions are limited to 4 per 30 days. Additional prescriptions require a PA. Excluded from this PA criteria are members who have cancer, sickle cell disease or are on hospice care. The quantity of opioid products covered (including those that are combined with acetaminophen, aspirin or ibuprofen) will be limited to up to 90 morphine milligram equivalents (MME) per day. For members who are opioid-naïve, first fill will be limited to seven days. PA*, QL codeine/acetaminophen TYLENOL w/CODEINE QL fentanyl transdermal DURAGESIC PA fentanyl transmucosal ACTIQ QL hydrocodone/acetaminophen NORCO QL hydrocodone/acetaminophen soln 7.5/325 mg/15 mL QL hydrocodone/ibuprofen QL hydromorphone tabs DILAUDID Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only.

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QL methadone tabs 5 mg, 10 mg DOLOPHINE QL morphine QL morphine ext-rel MS CONTIN morphine suppository QL oxycodone caps, tabs oxycodone solution 5 mg/5 mL oxycodone/acetaminophen 5 mg/325 mg/5 mL solution QL oxycodone/acetaminophen 5/325 PERCOCET QL oxycodone/aspirin PERCODAN QL, ST oxymorphone ext-rel PA**, QL tramadol 50 mg ULTRAM PA, QL tramadol ext-rel tabs PA**, QL tramadol/acetaminophen ULTRACET PA* Prior authorization required for members 12 years of age and younger PA** Prior authorization required for members 17 years of age and younger NON-OPIOID ANALGESICS OTC acetaminophen/caffeine EXCEDRIN TENSION

HEADACHE OTC aspirin/caffeine BACK & BODY QL butalbital/acetaminophen QL butalbital/acetaminophen/caffeine tabs - Esgic QL butalbital/aspirin/caffeine FIORINAL ANTI-INFECTIVES ANTIBACTERIALS Cephalosporins First Generation cefadroxil cephalexin KEFLEX Second Generation cefaclor cefprozil cefuroxime axetil Third Generation cefdinir QL cefpodoxime Erythromycins/Macrolides azithromycin ZITHROMAX clarithromycin clarithromycin ext-rel erythromycin base erythromycin delayed-rel erythromycin ethylsuccinate E.E.S. erythromycin stearate Fluoroquinolones ciprofloxacin CIPRO QL levofloxacin LEVAQUIN QL moxifloxacin

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only.

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Penicillins amoxicillin amoxicillin/clavulanate AUGMENTIN ampicillin dicloxacillin penicillin VK QL penicillin G benzathine BICILLIN L-A Sulfonamides sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim DS sulfadiazine Tetracyclines demeclocycline doxycycline hyclate caps 50 mg, 100 mg VIBRAMYCIN doxycycline hyclate tabs 20 mg, 100 mg doxycycline monohydrate caps 50 mg, 100 mg QL doxycycline monohydrate suspension 25 mg/5 mL VIBRAMYCIN doxycycline monohydrate tabs 50 mg, 100 mg minocycline MINOCIN ANTIFUNGALS clotrimazole troches fluconazole DIFLUCAN griseofulvin microsize tabs griseofulvin ultramicrosize PA itraconazole SPORANOX ketoconazole terbinafine tabs voriconazole inj VFEND QL voriconazole tabs VFEND ANTIMALARIALS QL atovaquone/proguanil MALARONE QL chloroquine QL mefloquine QL primaquine ANTIRETROVIRAL AGENTS Limit of four different antiretroviral agents per month. If additional antiretroviral agents are needed, a PA is required. Antiretroviral Adjuvants QL cobicistat TYBOST Antiretroviral Combinations QL abacavir/lamivudine PA, QL abacavir/lamivudine/zidovudine QL lamivudine/zidovudine QL abacavir/dolutegravir/lamivudine TRIUMEQ QL atazanavir/cobicistat EVOTAZ QL bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY QL darunavir/cobicistat PREZCOBIX QL darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA QL dolutegravir/lamivudine DOVATO PA, QL dolutegravir/rilpivirine JULUCA


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QL doravirine/lamivudine/tenofovir disoproxil fumarate DELSTRIGO PA, QL efavirenz/emtricitabine/tenofovir disoproxil fumarate ATRIPLA QL efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI QL efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI LO QL elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA QL elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD PA, QL emtricitabine/rilpivirine/tenofovir alafenamide ODEFSEY PA, QL emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA QL emtricitabine/tenofovir alafenamide DESCOVY QL emtricitabine/tenofovir disoproxil fumarate TRUVADA QL lamivudine/tenofovir disoproxil fumarate CIMDUO Chemokine Receptor Antagonists PA, QL maraviroc SELZENTRY Fusion Inhibitors PA, SP, QL enfuvirtide FUZEON Integrase Inhibitors QL dolutegravir TIVICAY QL raltegravir ISENTRESS QL raltegravir ISENTRESS HD Non-nucleoside Reverse Transcriptase Inhibitors QL efavirenz SUSTIVA QL nevirapine VIRAMUNE QL nevirapine ext-rel VIRAMUNE XR QL doravirine PIFELTRO QL etravirine INTELENCE PA, QL rilpivirine EDURANT Nucleoside Reverse Transcriptase Inhibitors QL abacavir PA, QL didanosine delayed-rel QL lamivudine PA, QL stavudine QL zidovudine QL emtricitabine EMTRIVA Nucleotide Reverse Transcriptase Inhibitors QL tenofovir disoproxil fumarate VIREAD Protease Inhibitors QL atazanavir REYATAZ QL fosamprenavir tabs lopinavir/ritonavir soln KALETRA PA* lopinavir/ritonavir soln KALETRA QL ritonavir NORVIR QL darunavir PREZISTA fosamprenavir susp LEXIVA QL indinavir CRIXIVAN QL lopinavir/ritonavir tabs KALETRA QL nelfinavir VIRACEPT QL saquinavir mesylate INVIRASE


18

QL tipranavir APTIVUS PA* Prior authorization is required for brand product ANTITUBERCULAR AGENTS ethambutol MYAMBUTOL isoniazid pyrazinamide rifampin RIFADIN QL rifampin/isoniazid RIFAMATE ANTIVIRALS Cytomegalovirus Agents valganciclovir VALCYTE Hepatitis Agents Hepatitis B QL adefovir dipivoxil HEPSERA QL entecavir tabs BARACLUDE QL lamivudine tabs EPIVIR-HBV QL tenofovir disoproxil fumarate VIREAD entecavir soln BARACLUDE Hepatitis C PA, SP ribavirin caps, tabs PA, SP sofosbuvir/velpatasvir EPCLUSA Herpes Agents acyclovir caps, suspension, tabs ZOVIRAX famciclovir valacyclovir VALTREX Influenza Agents QL oseltamivir caps TAMIFLU PA*, QL oseltamivir suspension TAMIFLU zanamivir RELENZA PA* Prior authorization required for members 9 years of age and older MISCELLANEOUS OTC pyrantel - Reese's Pinworm Medicine QL albendazole ALBENZA QL atovaquone MEPRON clindamycin CLEOCIN dapsone PA daptomycin CUBICIN ivermectin STROMECTOL PA linezolid ZYVOX methenamine mandelate metronidazole tabs FLAGYL PA* nitrofurantoin ext-rel MACROBID PA* nitrofurantoin macrocrystals MACRODANTIN PA** nitrofurantoin suspension rifabutin MYCOBUTIN PA tigecycline TYGACIL ST, QL tinidazole


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trimethoprim QL vancomycin caps 125 mg VANCOCIN QL fosfomycin MONUROL QL nitazoxanide ALINIA pentamidine aerosol NEBUPENT PA rifaximin XIFAXAN PA trimethoprim solution PRIMSOL QL vancomycin oral soln FIRVANQ PA* Prior authorization only required for members of age 65 and older PA** Prior authorization required for members 10 years of age and older ANTINEOPLASTIC AGENTS ALKYLATING AGENTS cyclophosphamide caps melphalan ALKERAN PA, SP temozolomide TEMODAR busulfan MYLERAN chlorambucil LEUKERAN lomustine GLEOSTINE PA mechlorethamine gel VALCHLOR ANTIMETABOLITES PA, SP capecitabine XELODA mercaptopurine thioguanine TABLOID HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide CASODEX flutamide Antiestrogens fulvestrant FASLODEX tamoxifen toremifene FARESTON Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA Luteinizing Hormone-Releasing Hormone (LHRH) Agonists PA, SP leuprolide acetate PA, SP leuprolide acetate LUPRON DEPOT Progestins megestrol acetate PA medroxyprogesterone acetate 400 mg/mL DEPO-PROVERA IMMUNOMODULATORS PA, SP lenalidomide REVLIMID PA, SP pomalidomide POMALYST PA, SP thalidomide THALOMID


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KINASE INHIBITORS PA, SP erlotinib TARCEVA PA, SP everolimus AFINITOR PA, SP afatinib GILOTRIF PA, SP bosutinib BOSULIF PA, SP ceritinib ZYKADIA PA, SP dabrafenib TAFINLAR PA, SP dasatinib SPRYCEL PA, SP ibrutinib IMBRUVICA PA, SP lapatinib TYKERB PA, SP midostaurin RYDAPT PA, SP nilotinib TASIGNA PA, SP pazopanib VOTRIENT PA, SP sorafenib NEXAVAR PA, SP sunitinib SUTENT PA, SP trametinib MEKINIST KINASE INHIBITORS FOR CML PA, SP imatinib mesylate GLEEVEC MISCELLANEOUS PA, SP bexarotene caps TARGRETIN dexrazoxane ZINECARD etoposide hydroxyurea HYDREA SP leucovorin inj leucovorin tabs PA tretinoin caps hydroxyurea DROXIA PA mitotane LYSODREN PA, SP obinutuzumab GAZYVA PA, SP, QL olaparib LYNPARZA PA procarbazine MATULANE PA ramucirumab CYRAMZA PA, SP rucaparib RUBRACA PA, SP vismodegib ERIVEDGE PA, SP vorinostat ZOLINZA CARDIOVASCULAR ACE INHIBITORS benazepril LOTENSIN enalapril VASOTEC fosinopril lisinopril ZESTRIL quinapril ACCUPRIL ramipril ALTACE trandolapril ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril LOTREL ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide LOTENSIN HCT enalapril/hydrochlorothiazide VASERETIC fosinopril/hydrochlorothiazide lisinopril/hydrochlorothiazide ZESTORETIC Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only.

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quinapril/hydrochlorothiazide ACCURETIC ADRENOLYTICS, CENTRAL clonidine CATAPRES clonidine transdermal CATAPRES-TTS guanfacine ADRENOLYTICS, CENTRAL/DIURETIC COMBINATION clonidine/chlorthalidone ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone INSPRA spironolactone ALDACTONE ALPHA BLOCKERS doxazosin CARDURA prazosin MINIPRESS terazosin ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS QL irbesartan AVAPRO QL irbesartan/hydrochlorothiazide AVALIDE losartan COZAAR losartan/hydrochlorothiazide HYZAAR QL olmesartan BENICAR QL olmesartan/hydrochlorothiazide BENICAR HCT QL telmisartan MICARDIS QL telmisartan/hydrochlorothiazide MICARDIS HCT QL valsartan DIOVAN QL valsartan/hydrochlorothiazide DIOVAN HCT ANTIARRHYTHMICS amiodarone tabs 200 mg, 400 mg disopyramide NORPACE PA, SP dofetilide TIKOSYN flecainide mexiletine propafenone propafenone ext-rel RYTHMOL SR quinidine sulfate sotalol BETAPACE sotalol BETAPACE AF disopyramide ext-rel NORPACE CR ANTILIPEMICS Bile Acid Resins cholestyramine QUESTRAN/QUESTRAN

LIGHT colestipol COLESTID Cholesterol Absorption Inhibitors QL ezetimibe ZETIA Fibrates fenofibrate caps 67 mg, 134 mg, 200 mg fenofibrate tabs 48 mg, 54 mg, 145 mg, 160 mg


22

fenofibric acid delayed-rel tabs 35 mg, 105 mg gemfibrozil LOPID HMG-CoA Reductase Inhibitors QL atorvastatin LIPITOR QL lovastatin QL pravastatin PRAVACHOL QL rosuvastatin CRESTOR PA, QL simvastatin ZOCOR PA Required only for products containing 80 mg of simvastatin Niacins OTC niacin ext-rel SLO-NIACIN niacin ext-rel NIASPAN Omega-3 Fatty Acids QL omega-3 acid ethyl esters LOVAZA PCSK9 Inhibitors PA, SP evolocumab REPATHA BETA-BLOCKERS atenolol TENORMIN bisoprolol carvedilol COREG labetalol TRANDATE metoprolol succinate ext-rel TOPROL-XL metoprolol tartrate 25 mg, 50 mg, 100 mg LOPRESSOR nadolol CORGARD pindolol propranolol propranolol ext-rel INDERAL LA timolol BETA-BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone bisoprolol/hydrochlorothiazide ZIAC CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine NORVASC felodipine ext-rel nifedipine ext-rel nifedipine ext-rel PROCARDIA XL QL nimodipine NIMOTOP Nondihydropyridines diltiazem CARDIZEM diltiazem ext-rel CARDIZEM CD diltiazem ext-rel TIAZAC diltiazem ext-rel, except 120 mg CARDIZEM LA QL verapamil QL verapamil ext-rel caps 120 mg, 180 mg, 240 mg VERELAN SR QL verapamil ext-rel tabs CALAN SR


23

DIGITALIS GLYCOSIDES * digoxin LANOXIN digoxin pediatric elixir * Mandatory generic requirement does not apply DIURETICS Carbonic Anhydrase Inhibitors acetazolamide acetazolamide ext-rel methazolamide Loop Diuretics bumetanide furosemide LASIX torsemide Potassium-sparing Diuretics amiloride spironolactone ALDACTONE Thiazides and Thiazide-like Diuretics chlorthalidone hydrochlorothiazide indapamide metolazone Diuretic Combinations amiloride/hydrochlorothiazide spironolactone/hydrochlorothiazide 25 mg/25 mg ALDACTAZIDE triamterene/hydrochlorothiazide DYAZIDE triamterene/hydrochlorothiazide MAXZIDE triamterene/hydrochlorothiazide MAXZIDE-25 NITRATES Oral isosorbide dinitrate oral 5 mg, 10 mg, 20 mg, 30 mg ISORDIL isosorbide mononitrate isosorbide mononitrate ext-rel Sublingual nitroglycerin sublingual NITROSTAT Transdermal nitroglycerin transdermal nitroglycerin transdermal NITRO-DUR nitroglycerin ointment NITRO-BID PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA, SP ambrisentan LETAIRIS PA, SP bosentan TRACLEER PA, SP macitentan OPSUMIT Phosphodiesterase Inhibitors PA, SP sildenafil REVATIO


24

PA, SP tadalafil ADCIRCA Prostaglandin Vasodilators PA, SP epoprostenol sodium FLOLAN PA, SP iloprost VENTAVIS PA, SP treprostinil REMODULIN PA, SP treprostinil TYVASO MISCELLANEOUS hydralazine methyldopa methyldopa/hydrochlorothiazide midodrine PA phenoxybenzamine DIBENZYLINE PA ranolazine ext-rel RANEXA CENTRAL NERVOUS SYSTEM ANTIANXIETY Benzodiazepines QL alprazolam ext-rel XANAX XR QL alprazolam tabs XANAX QL chlordiazepoxide QL clonazepam tabs KLONOPIN QL diazepam VALIUM QL lorazepam ATIVAN QL oxazepam Miscellaneous QL buspirone fluvoxamine ANTICONVULSANTS * carbamazepine TEGRETOL carbamazepine ext-rel CARBATROL carbamazepine ext-rel TEGRETOL-XR diazepam rectal gel DIASTAT divalproex sodium delayed-rel DEPAKOTE divalproex sodium ext-rel DEPAKOTE ER * ethosuximide ZARONTIN QL gabapentin NEURONTIN lamotrigine LAMICTAL lamotrigine ext-rel LAMICTAL XR levetiracetam KEPPRA levetiracetam ext-rel KEPPRA XR oxcarbazepine TRILEPTAL phenobarbital phenytoin DILANTIN INFATABS * phenytoin sodium extended DILANTIN phenytoin sodium extended PHENYTEK primidone MYSOLINE tiagabine GABITRIL topiramate sprinkle caps, tabs TOPAMAX valproic acid zonisamide ZONEGRAN * Mandatory generic requirement does not apply Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only.

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ANTIDEMENTIA donepezil ARICEPT galantamine RAZADYNE ST galantamine ext-rel RAZADYNE ER ST, QL memantine NAMENDA ST, QL rivastigmine caps ANTIDEPRESSANTS Monoamine Oxidase Inhibitors (MAOIs) phenelzine NARDIL tranylcypromine PARNATE isocarboxazid MARPLAN Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram CELEXA QL escitalopram LEXAPRO fluoxetine caps PROZAC fluvoxamine QL paroxetine HCl ext-rel PAXIL CR paroxetine HCl tabs PAXIL sertraline ZOLOFT Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) QL desvenlafaxine ext-rel PRISTIQ QL duloxetine delayed-rel CYMBALTA venlafaxine QL venlafaxine ext-rel caps EFFEXOR XR Tricyclic Antidepressants (TCAs) PA* amitriptyline PA* desipramine NORPRAMIN PA* doxepin PA* imipramine HCl PA* nortriptyline PAMELOR PA* Prior authorization only required for members of age 65 and older Miscellaneous Agents bupropion bupropion ext-rel WELLBUTRIN SR bupropion ext-rel WELLBUTRIN XL mirtazapine REMERON mirtazapine orally disintegrating tabs REMERON SOLTAB trazodone 50 mg, 100 mg, 150 mg ANTIPARKINSONIAN AGENTS amantadine benztropine bromocriptine PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel carbidopa/levodopa/entacapone STALEVO entacapone COMTAN pramipexole MIRAPEX QL pramipexole ext-rel MIRAPEX ER QL rasagiline AZILECT


26

ropinirole QL ropinirole ext-rel REQUIP XL selegiline trihexyphenidyl ANTIPSYCHOTICS Atypicals QL aripiprazole tabs ABILIFY * clozapine CLOZARIL PA*, QL olanzapine ZYPREXA PA*, QL olanzapine orally disintegrating tabs ZYPREXA ZYDIS PA*, QL olanzapine/fluoxetine SYMBYAX PA paliperidone ext-rel INVEGA quetiapine SEROQUEL QL quetiapine 100 mg SEROQUEL ST, QL quetiapine ext-rel SEROQUEL XR QL risperidone RISPERDAL ziprasidone GEODON PA aripiprazole ext-rel inj ABILIFY MAINTENA PA aripiprazole lauroxil ext-rel inj ARISTADA PA aripiprazole lauroxil ext-rel inj ARISTADA INITIO PA olanzapine pamoate ext-rel inj ZYPREXA RELPREVV PA paliperidone palmitate ext-rel inj INVEGA SUSTENNA PA paliperidone palmitate ext-rel inj INVEGA TRINZA PA risperidone ext-rel inj PERSERIS PA risperidone long-acting inj RISPERDAL CONSTA AL Covered for members age 6 or older * Mandatory generic requirement does not apply PA* Prior authorization only required for members under 18 years of age Miscellaneous chlorpromazine fluphenazine haloperidol haloperidol decanoate inj HALDOL DECANOATE loxapine perphenazine pimozide thioridazine thiothixene trifluoperazine ATTENTION DEFICIT HYPERACTIVITY DISORDER PA, QL amphetamine/dextroamphetamine mixed salts ADDERALL PA, QL amphetamine/dextroamphetamine mixed salts ext-rel ADDERALL XR QL atomoxetine STRATTERA PA, QL dexmethylphenidate FOCALIN PA, QL dexmethylphenidate ext-rel FOCALIN XR PA, QL dextroamphetamine ext-rel DEXEDRINE SPANSULE PA, QL dextroamphetamine tabs 5 mg, 10 mg PA, QL dextroamphetamine tabs 5 mg, 10 mg - Zenzedi QL guanfacine ext-rel INTUNIV PA, QL methylphenidate METHYLIN PA, QL methylphenidate RITALIN PA, QL methylphenidate ext-rel CONCERTA


27

PA, QL methylphenidate ext-rel 10 mg, 20 mg, 30 mg, 40 mg RITALIN LA PA, QL methylphenidate ext-rel 10 mg, 20 mg, 30 mg, 40 mg, 50 mg,

60 mg METADATE CD

PA Required for members over 18 years of age FIBROMYALGIA ST, QL pregabalin LYRICA HUNTINGTON'S DISEASE AGENTS PA, SP tetrabenazine XENAZINE HYPNOTICS Benzodiazepines QL estazolam QL flurazepam QL temazepam 15 mg, 30 mg RESTORIL Nonbenzodiazepines OTC diphenhydramine NYTOL OTC doxylamine UNISOM OTC melatonin QL eszopiclone LUNESTA QL zaleplon *, QL zolpidem AMBIEN ST, QL zolpidem ext-rel AMBIEN CR * Gender restriction - In accordance with product labeling, females must begin therapy with 5 mg dose. MIGRAINE Selective Serotonin Agonists Note: Limit of 1 prescription in class per 25 days. ST, PA, QL naratriptan AMERGE QL rizatriptan MAXALT QL rizatriptan orally disintegrating tabs MAXALT-MLT PA, QL sumatriptan injection IMITREX PA, QL sumatriptan nasal spray IMITREX QL sumatriptan tabs IMITREX ST, QL zolmitriptan ZOMIG ST, QL zolmitriptan orally disintegrating tabs ZOMIG-ZMT ST, QL zolmitriptan nasal spray ZOMIG PA Required for members under 18 years of age Miscellaneous OTC acetaminophen/aspirin/caffeine EXCEDRIN MIGRAINE MOOD STABILIZERS lithium carbonate lithium carbonate ext-rel tabs 300 mg LITHOBID lithium carbonate ext-rel tabs 450 mg MULTIPLE SCLEROSIS AGENTS PA, SP glatiramer COPAXONE PA, SP dimethyl fumarate delayed-rel TECFIDERA PA, SP fingolimod GILENYA Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only.

28

PA, SP interferon beta-1a AVONEX PA, SP interferon beta-1a REBIF PA, SP interferon beta-1b EXTAVIA PA, SP peginterferon beta-1a PLEGRIDY PA, SP siponimod MAYZENT PA, SP teriflunomide AUBAGIO MUSCULOSKELETAL THERAPY AGENTS baclofen 10 mg, 20 mg chlorzoxazone 500 mg cyclobenzaprine 5 mg, 10 mg dantrolene DANTRIUM methocarbamol ROBAXIN orphenadrine/aspirin/caffeine tizanidine tabs ZANAFLEX MYASTHENIA GRAVIS pyridostigmine MESTINON pyridostigmine ext-rel MESTINON TIMESPAN NARCOLEPSY/CATAPLEXY PA armodafinil NUVIGIL PA modafinil PROVIGIL PA sodium oxybate XYREM PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents QL acamprosate calcium disulfiram ANTABUSE naltrexone microspheres VIVITROL Opioid Antagonists naloxone inj naltrexone naloxone nasal spray NARCAN Partial Opioid Agonists buprenorphine sublingual Partial Opioid Agonist/Opioid Antagonist Combinations QL buprenorphine/naloxone sublingual film SUBOXONE FILM QL buprenorphine/naloxone sublingual tabs Smoking Deterrents OTC, QL nicotine polacrilex gum, lozenge NICORETTE OTC, QL nicotine transdermal NICODERM CQ QL bupropion ext-rel QL nicotine inhaler NICOTROL INHALER QL nicotine nasal spray NICOTROL NS QL varenicline CHANTIX ENDOCRINE AND METABOLIC ANDROGENS PA methyltestosterone PA testosterone cypionate inj DEPO-TESTOSTERONE PA testosterone enanthate inj DELATESTRYL Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only.

29

PA testosterone gel 1% ANDROGEL PA testosterone gel 1% TESTIM ANTIDIABETICS Alpha-glucosidase Inhibitors acarbose PRECOSE Amylin Analogs ST pramlintide SYMLINPEN Biguanides metformin metformin ext-rel 500 mg, 750 mg Biguanide/Sulfonylurea Combinations glipizide/metformin PA* glyburide/metformin PA* Prior authorization only required for members of age 65 and older Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ST, QL alogliptin NESINA Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations ST, QL alogliptin/metformin KAZANO Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations ST, QL alogliptin/pioglitazone OSENI Incretin Mimetic Agents ST, QL dulaglutide TRULICITY ST, QL liraglutide VICTOZA ST, QL semaglutide OZEMPIC Insulins QL insulin aspart protamine 70%/insulin aspart 30% INSULIN ASPART QL insulin glargine BASAGLAR QL insulin human HUMULIN R QL insulin human NOVOLIN R QL insulin isophane human HUMULIN N QL insulin isophane human NOVOLIN N QL insulin isophane human 70%/regular 30% HUMULIN 70/30 QL insulin isophane human 70%/regular 30% NOVOLIN 70/30 QL insulin lispro ADMELOG Insulin Sensitizers QL pioglitazone ACTOS Insulin Sensitizer/Biguanide Combinations QL pioglitazone/metformin ACTOPLUS MET Meglitinides nateglinide STARLIX repaglinide


30

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors ST, QL ertugliflozin STEGLATRO Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations ST, QL ertugliflozin/metformin SEGLUROMET Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase (DPP-4) Inhibitor Combinations ST, QL ertugliflozin/sitagliptin STEGLUJAN Sulfonylureas glimepiride AMARYL glipizide GLUCOTROL glipizide ext-rel GLUCOTROL XL PA* glyburide PA* glyburide, micronized GLYNASE tolbutamide PA* Prior authorization only required for members of age 65 and older Supplies OTC, QL blood glucose monitoring kits, test strips FREESTYLE FREEDOM LITE

kits and test strips OTC, QL blood glucose monitoring kits, test strips FREESTYLE INSULINX kits

and test strips OTC, QL blood glucose monitoring kits, test strips FREESTYLE LITE kits and test

strips OTC, QL blood glucose monitoring kits, test strips PRECISION XTRA kits and test

strips OTC, QL insulin syringes, needles BD ULTRAFINE insulin

syringes and needles OTC, QL lancets ST, QL insulin infusion disposable pump OMNIPOD DASH CALCIUM RECEPTOR ANTAGONISTS PA, SP cinacalcet SENSIPAR CALCIUM REGULATORS Bisphosphonates alendronate tabs 5 mg, 10 mg FOSAMAX QL alendronate tabs 35 mg, 40 mg, 70 mg FOSAMAX QL ibandronate BONIVA QL, SP zoledronic acid Calcitonins QL calcitonin-salmon MIACALCIN Parathyroid Hormones PA, SP abaloparatide TYMLOS Miscellaneous PA, SP denosumab PROLIA CONTRACEPTIVES EE = ethinyl estradiol


31

Monophasic 20 mcg Estrogen drospirenone/EE 3/20 YAZ drospirenone/EE/levomefolate 3/20 and levomefolate BEYAZ levonorgestrel/EE 0.1/20 norethindrone acetate/EE 1/20 LOESTRIN 1/20 norethindrone acetate/EE 1/20 (24) and iron norethindrone acetate/EE 1/20 and iron LOESTRIN FE 1/20 norethindrone acetate/EE 1/20 and iron chewable MINASTRIN 24 FE 25 mcg Estrogen norethindrone acetate/EE 0.8/25 and iron GENERESS FE 30 mcg Estrogen desogestrel/EE 0.15/30 - Apri drospirenone/EE 3/30 YASMIN drospirenone/EE/levomefolate 3/30 and levomefolate SAFYRAL levonorgestrel/EE 0.15/30 norethindrone acetate/EE 1.5/30 LOESTRIN 1.5/30 norethindrone acetate/EE 1.5/30 and iron LOESTRIN FE 1.5/30 norgestrel/EE 0.3/30 35 mcg Estrogen ethynodiol diacetate/EE 1/35 norethindrone/EE 0.4/35 norethindrone/EE 0.4/35 and iron chewable norethindrone/EE 0.5/35 norethindrone/EE 1/35 norgestimate/EE 0.25/35 50 mcg Estrogen ethynodiol diacetate/EE 1/50 norgestrel/EE 0.5/50 - Ogestrel Biphasic desogestrel/EE MIRCETTE Triphasic desogestrel/EE levonorgestrel/EE norethindrone/EE norethindrone/EE ORTHO-NOVUM 7/7/7 norethindrone/EE and iron ESTROSTEP FE norgestimate/EE norgestimate/EE ORTHO TRI-CYCLEN LO Extended Cycle levonorgestrel/EE 0.1/20 and EE 10 LOSEASONIQUE levonorgestrel/EE 0.15/20, 0.15/25, 0.15/30 and EE 10 QUARTETTE levonorgestrel/EE 0.15/30 levonorgestrel/EE 0.15/30 and EE 10 SEASONIQUE Continuous levonorgestrel/EE 0.09/20


32

Progestin Only norethindrone ORTHO MICRONOR Emergency Contraception OTC levonorgestrel - Next Choice One Dose PLAN B ONE-STEP ulipristal ELLA Implant QL etonogestrel implant NEXPLANON Injectable medroxyprogesterone acetate 150 mg/mL DEPO-PROVERA QL medroxyprogesterone acetate 104 mg/0.65 mL DEPO-SUBQ PROVERA 104 Intrauterine Devices QL intrauterine copper contraceptive PARAGARD QL levonorgestrel releasing IUD KYLEENA QL levonorgestrel releasing IUD LILETTA QL levonorgestrel releasing IUD MIRENA QL levonorgestrel releasing IUD SKYLA Transdermal norelgestromin/EE Vaginal etonogestrel/EE ring NUVARING Miscellaneous OTC, QL condoms, female OTC, QL condoms, male OTC nonoxynol-9 CONCEPTROL OTC nonoxynol-9 GYNOL II OTC nonoxynol-9 SHUR-SEAL QL diaphragm ENDOMETRIOSIS danazol PA elagolix ORILISSA PA nafarelin SYNAREL ESTROGENS Oral estradiol ESTRACE estrogens, conjugated PREMARIN estrogens, esterified MENEST Transdermal estradiol CLIMARA estradiol VIVELLE-DOT estradiol/levonorgestrel CLIMARA PRO Vaginal estradiol vaginal cream ESTRACE estradiol vaginal tabs - Yuvafem estradiol vaginal ring FEMRING estrogens, conjugated cream PREMARIN


33

ESTROGEN/PROGESTINS Oral EE/norethindrone acetate FEMHRT EE/norethindrone acetate - Jinteli estradiol/norethindrone acetate ACTIVELLA estradiol/norgestimate PREFEST estrogens, conjugated/medroxyprogesterone PREMPHASE estrogens, conjugated/medroxyprogesterone PREMPRO Transdermal estradiol/norethindrone acetate COMBIPATCH FERTILITY REGULATORS Ovulation Stimulants, Synthetic *, AL, QL clomiphene * Gender restriction - Coverage for females only AL Covered for female members 21 to 44 years of age GLUCOCORTICOIDS cortisone acetate dexamethasone fludrocortisone hydrocortisone CORTEF QL hydrocortisone inj 100 mg/mL SOLU-CORTEF methylprednisolone MEDROL prednisolone sodium phosphate solution 5 mg/5 mL prednisolone syrup prednisone GLUCOSE ELEVATING AGENTS QL glucagon nasal powder BAQSIMI glucagon, human recombinant GLUCAGON EMERGENCY

KIT glucagon, human recombinant GLUCAGON HYPOKIT HUMAN GROWTH HORMONES AND RELATED DISORDERS PA, SP mecasermin INCRELEX PA, SP somatropin NORDITROPIN PA, SP somatropin SEROSTIM HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) ROCALTROL doxercalciferol HECTOROL paricalcitol ZEMPLAR PHENYLKETONURIA TREATMENT AGENTS PA, SP sapropterin KUVAN PHOSPHATE BINDER AGENTS calcium acetate ST sevelamer carbonate tabs RENVELA PROGESTINS, ORAL medroxyprogesterone acetate PROVERA norethindrone AYGESTIN


34

progesterone, micronized PROMETRIUM SELECTIVE ESTROGEN RECEPTOR MODULATORS QL raloxifene EVISTA THYROID AGENTS Antithyroid Agents methimazole TAPAZOLE propylthiouracil Thyroid Supplements * levothyroxine SYNTHROID * levothyroxine UNITHROID * levothyroxine - Levoxyl levothyroxine tabs liothyronine CYTOMEL thyroid ARMOUR THYROID thyroid NATURE-THROID thyroid NP THYROID thyroid WP THYROID * Mandatory generic requirement does not apply UREA CYCLE DISORDERS PA, SP sodium phenylbutyrate BUPHENYL VASOPRESSINS desmopressin spray DDAVP PA desmopressin tabs DDAVP desmopressin spray STIMATE MISCELLANEOUS cabergoline levocarnitine CARNITOR PA, SP nitisinone ORFADIN PA, SP octreotide acetate SANDOSTATIN PA, SP cysteamine bitartrate CYSTAGON PA, SP octreotide acetate SANDOSTATIN LAR PA, SP pegvisomant SOMAVERT GASTROINTESTINAL ANTACIDS OTC alumina/magnesia MAALOX OTC alumina/magnesia/simethicone MYLANTA OTC aluminum hydroxide OTC calcium carbonate TUMS ANTIDIARRHEALS OTC bismuth subsalicylate PEPTO-BISMOL OTC loperamide IMODIUM A-D PA * diphenoxylate/atropine LOMOTIL PA* Prior authorization required for members 65 years of age and older ANTIEMETICS OTC dimenhydrinate DRAMAMINE Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only.

35

PA, QL aprepitant caps EMEND PA doxylamine/pyridoxine delayed-rel DICLEGIS PA, QL dronabinol QL granisetron meclizine metoclopramide REGLAN QL ondansetron ZOFRAN prochlorperazine promethazine injection promethazine oral soln, syrup, tabs promethazine supp 12.5 mg, 25 mg trimethobenzamide TIGAN QL dolasetron ANZEMET ANTISPASMODICS dicyclomine BENTYL glycopyrrolate tabs hyoscyamine sulfate LEVSIN hyoscyamine sulfate ext-rel LEVBID hyoscyamine sulfate ext-rel caps hyoscyamine sulfate orally disintegrating tabs propantheline scopolamine methylbromide CHOLELITHOLYTICS ursodiol ACTIGALL ursodiol URSO H2 RECEPTOR ANTAGONISTS OTC cimetidine TAGAMET HB OTC famotidine PEPCID AC cimetidine famotidine PEPCID INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide QL budesonide delayed-rel caps ENTOCORT EC mesalamine delayed-rel caps DELZICOL mesalamine delayed-rel tabs ASACOL HD mesalamine delayed-rel tabs LIALDA mesalamine ext-rel caps APRISO sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS mesalamine ext-rel caps PENTASA Rectal Agents hydrocortisone enema mesalamine rectal suspension ROWASA IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation/Chronic Idiopathic Constipation PA lubiprostone AMITIZA LAXATIVES/STOOL SOFTENERS OTC docusate sodium COLACE


36

OTC magnesium citrate soln OTC polyethylene glycol 3350 MIRALAX OTC psyllium METAMUCIL lactulose soln peg 3350/electrolytes peg 3350/electrolytes GOLYTELY OPIOID-INDUCED CONSTIPATION PA naloxegol MOVANTIK PANCREATIC ENZYMES PA pancrelipase delayed-rel CREON PROSTAGLANDINS misoprostol CYTOTEC PROTON PUMP INHIBITORS OTC, QL lansoprazole delayed-rel 15 mg PREVACID 24HR OTC, QL omeprazole magnesium delayed-rel caps OTC, QL omeprazole magnesium delayed-rel tabs PRILOSEC OTC OTC omeprazole/sodium bicarbonate ZEGERID OTC OTC, QL esomeprazole magnesium delayed-rel NEXIUM 24HR OTC, QL omeprazole delayed-rel tabs QL esomeprazole delayed-rel caps 40 mg NEXIUM QL lansoprazole delayed-rel 30 mg PREVACID QL omeprazole delayed-rel caps QL pantoprazole delayed-rel tabs PROTONIX QL rabeprazole ACIPHEX PA *, ST *, QL lansoprazole suspension FIRST-LANSOPRAZOLE PA *, ST *, QL omeprazole suspension FIRST-OMEPRAZOLE PA* Prior authorization required for members 4 years of age and older ST* Step therapy required for members 3 years of age and younger SALIVA STIMULANTS cevimeline EVOXAC pilocarpine tabs SALAGEN STEROIDS, RECTAL QL hydrocortisone cream ANUSOL-HC QL lidocaine/hydrocortisone kit QL hydrocortisone acetate/pramoxine foam PROCTOFOAM-HC MISCELLANEOUS cromolyn sodium GASTROCROM sucralfate tabs GENITOURINARY BENIGN PROSTATIC HYPERPLASIA QL alfuzosin ext-rel UROXATRAL *, ST, QL dutasteride AVODART * finasteride PROSCAR tamsulosin FLOMAX * Gender restriction - Coverage for males only Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only.

37

URINARY ANTISPASMODICS ST, QL darifenacin ext-rel ENABLEX oxybutynin oxybutynin ext-rel DITROPAN XL QL solifenacin VESICARE QL tolterodine DETROL QL tolterodine ext-rel DETROL LA trospium QL trospium ext-rel VAGINAL ANTI-INFECTIVES OTC clotrimazole GYNE-LOTRIMIN OTC miconazole MONISTAT clindamycin cream CLEOCIN metronidazole gel 0.75% terconazole butoconazole GYNAZOLE-1 clindamycin suppository CLEOCIN MISCELLANEOUS bethanechol URECHOLINE phenazopyridine PYRIDIUM potassium citrate ext-rel UROCIT-K sodium citrate/citric acid QL pentosan polysulfate sodium ELMIRON HEMATOLOGIC ANTICOAGULANTS Injectable enoxaparin LOVENOX heparin Oral * warfarin COUMADIN apixaban ELIQUIS QL edoxaban SAVAYSA rivaroxaban 2.5 mg XARELTO * Mandatory generic requirement does not apply Synthetic Heparinoid-like Agents fondaparinux ARIXTRA HEMATOPOIETIC GROWTH FACTORS PA, SP darbepoetin alfa ARANESP PA, SP epoetin alfa-epbx RETACRIT PA, SP filgrastim-sndz ZARXIO PA, SP pegfilgrastim-bmez ZIEXTENZO PA, SP pegfilgrastim-cbqv UDENYCA PA, SP pegfilgrastim-jmdb FULPHILA PA, SP sargramostim LEUKINE HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS PA, SP antihemophilic factor (human) HEMOFIL M PA, SP antihemophilic factor (human) KOATE PA, SP antihemophilic factor (human) KOATE-DVI Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only.

38

PA, SP antihemophilic factor (recombinant porcine) OBIZUR PA, SP antihemophilic factor (recombinant) ADVATE PA, SP antihemophilic factor (recombinant) AFSTYLA PA, SP antihemophilic factor (recombinant) ELOCTATE PA, SP antihemophilic factor (recombinant) KOGENATE FS PA, SP antihemophilic factor (recombinant) KOVALTRY PA, SP antihemophilic factor (recombinant) NOVOEIGHT PA, SP antihemophilic factor (recombinant) NUWIQ PA, SP antihemophilic factor (recombinant) RECOMBINATE PA, SP antihemophilic factor (recombinant) XYNTHA PA, SP antihemophilic factor (recombinant) pegylated ADYNOVATE PA, SP antihemophilic factor (recombinant) pegylated-aucl JIVI PA, SP antihemophilic factor (recombinant), glycopegylated-exei ESPEROCT PA, SP antihemophilic factor/von Willebrand factor complex (human) ALPHANATE PA, SP antihemophilic factor/von Willebrand factor complex (human) HUMATE-P PA, SP antihemophilic factor/von Willebrand factor complex (human) WILATE PA, SP anti-inhibitor coagulant complex FEIBA NF PA, SP coagulation factor IX ALPHANINE SD PA, SP coagulation factor IX MONONINE PA, SP coagulation factor IX (recombinant) ALPROLIX PA, SP coagulation factor IX (recombinant) BENEFIX PA, SP coagulation factor IX (recombinant) IDELVION PA, SP coagulation factor IX (recombinant) IXINITY PA, SP coagulation factor IX (recombinant) RIXUBIS PA, SP coagulation factor VIIa (recombinant) NOVOSEVEN RT PA, SP coagulation factor X (human) COAGADEX PA, SP coagulation factor XIII A-subunit (recombinant) TRETTEN PA, SP emicizumab-kxwh HEMLIBRA PA, SP factor IX complex PROFILNINE PA, SP factor XIII concentrate (human) CORIFACT KIT PA, SP von Willebrand factor (recombinant) VONVENDI PLATELET AGGREGATION INHIBITORS OTC aspirin 81 mg clopidogrel PLAVIX dipyridamole QL prasugrel EFFIENT PLATELET SYNTHESIS INHIBITORS anagrelide AGRYLIN THROMBOCYTOPENIA AGENTS PA, SP eltrombopag tabs PROMACTA MISCELLANEOUS cilostazol PA, SP deferasirox EXJADE PA, SP deferasirox tabs 90 mg, 180 mg, 360 mg JADENU QL pentoxifylline ext-rel QL tranexamic acid LYSTEDA IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS PA, SP adalimumab HUMIRA PA, SP brodalumab SILIQ PA, SP etanercept ENBREL Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only.

39

PA, SP sarilumab KEVZARA PA, SP secukinumab COSENTYX PA, SP tofacitinib XELJANZ PA, SP tofacitinib ext-rel XELJANZ XR DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate 2.5 mg PA penicillamine DEPEN IMMUNOMODULATORS Interferons PA, SP interferon alfa-2b INTRON A PA, SP peginterferon alfa-2a PEGASYS IMMUNOSUPPRESSANTS Antimetabolites azathioprine IMURAN mycophenolate mofetil CELLCEPT Calcineurin Inhibitors * cyclosporine SANDIMMUNE * cyclosporine, modified NEORAL tacrolimus PROGRAF * Mandatory generic requirement does not apply Rapamycin Derivatives sirolimus RAPAMUNE Systemic Lupus Erythematosus PA, SP belimumab subcutaneous BENLYSTA VACCINES * influenza vaccine AFLURIA * influenza vaccine FLUARIX * influenza vaccine FLUCELVAX * influenza vaccine FLULAVAL * influenza vaccine FLUZONE AL, QL zoster vaccine SHINGRIX AL, QL zoster vaccine ZOSTAVAX * For members 18 years of age and younger, vaccine must be billed to Vaccine For Children (VFC) program AL Covered for members age 50 or older NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel caps 8 mEq, 10 mEq potassium chloride ext-rel tabs 20 mEq potassium chloride liquid 20 mEq/15 mL, 40 mEq/15 mL Miscellaneous OTC electrolyte solution, oral PEDIALYTE


40

VITAMINS AND MINERALS Folic Acid Agents folic acid ST, QL l-methylfolate Prenatal Vitamins prenatal vitamins/carbonyl iron/docusate/folic acid - Prenatal AD prenatal vitamins/ferrous fumarate/docusate/folic acid - Prenatal

19

prenatal vitamins/DHA/ferrous fumarate/folic acid ZATEAN-PN DHA Miscellaneous OTC ascorbic acid VITAMIN C OTC calcium carbonate OS-CAL OTC cholecalciferol (D3) VITAMIN D3 OTC cyanocobalamin tabs 1000 mcg VITAMIN B-12 OTC ergocalciferol (D2) VITAMIN D2 OTC ferrous gluconate FERGON OTC ferrous sulfate FEOSOL OTC magnesium oxide MAG-OX OTC multivitamins/minerals CENTRUM OTC niacin OTC omega-3 fatty acids FISH OIL OTC omega-3 fatty acids/vitamin E FISH OIL OTC pyridoxine VITAMIN B-6 OTC thiamine VITAMIN B-1 OTC vitamin A VITAMIN A OTC vitamin E VITAMIN E cyanocobalamin injection VITAMIN B-12 ergocalciferol (D2) * fluoride drops, tabs multivitamins, pediatric * multivitamins/fluoride drops, tabs * multivitamins/fluoride/iron drops, tabs multivitamins/iron, pediatric phytonadione MEPHYTON PA sodium ferric gluconate injection FERRLECIT * vitamin ADC/fluoride drops * vitamin ADC/fluoride/iron drops PA ferumoxytol FERAHEME PA iron dextran INFED PA iron sucrose injection VENOFER * Covered for members through 17 years of age RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS QL epinephrine auto-injector QL epinephrine auto-injector EPIPEN QL epinephrine auto-injector EPIPEN JR. ANTICHOLINERGICS QL ipratropium inhalation solution QL ipratropium, CFC-free aerosol ATROVENT HFA ST, QL, AL tiotropium 1.25 mcg SPIRIVA RESPIMAT


41

QL umeclidinium INCRUSE ELLIPTA AL Covered for members age 6 years or older ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting QL ipratropium/albuterol inhalation solution QL ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT Long Acting QL tiotropium/olodaterol STIOLTO RESPIMAT QL umeclidinium/vilanterol ANORO ELLIPTA ANTIHISTAMINES, LOW SEDATING OTC cetirizine ZYRTEC OTC, QL levocetirizine XYZAL QL levocetirizine XYZAL ANTIHISTAMINES, NONSEDATING OTC fexofenadine ALLEGRA OTC loratadine CLARITIN OTC loratadine orally disintegrating tabs, 5 mg CLARITIN REDITABS ANTIHISTAMINES, SEDATING OTC chlorpheniramine CHLOR-TRIMETON ALLERGY OTC diphenhydramine BENADRYL clemastine cyproheptadine hydroxyzine HCl, except inj hydroxyzine pamoate VISTARIL ANTIHISTAMINE/DECONGESTANT COMBINATIONS OTC cetirizine/pseudoephedrine ext-rel ZYRTEC-D 12 Hour OTC chlorpheniramine/phenylephrine ACTIFED COLD & ALLERGY OTC dexbrompheniramine/pseudoephedrine ext-rel DRIXORAL OTC fexofenadine/pseudoephedrine ext-rel ALLEGRA-D OTC loratadine/pseudoephedrine ext-rel CLARITIN-D ANTITUSSIVE benzonatate TESSALON ANTITUSSIVE COMBINATIONS Opioid PA, QL codeine/chlorpheniramine/pseudoephedrine PA, QL codeine/guaifenesin liquid PA, QL codeine/guaifenesin/pseudoephedrine PA, QL codeine/promethazine PA, QL codeine/promethazine/phenylephrine PA, QL hydrocodone/homatropine PA Prior authorization required for members 18 years of age and younger Non-opioid OTC dextromethorphan/guaifenesin ROBITUSSIN COUGH +

CHEST CONGESTION DM OTC dextromethorphan/guaifenesin/pseudoephedrine ROBITUSSIN MULTI-


42

SYMPTOM COLD

dextromethorphan/promethazine BETA AGONISTS Inhalants Short Acting QL albuterol inhalation solution QL albuterol sulfate, CFC-free aerosol PROAIR HFA QL albuterol sulfate, CFC-free aerosol PROVENTIL HFA QL albuterol sulfate, CFC-free aerosol VENTOLIN HFA ST, QL levalbuterol inhalation solution QL levalbuterol tartrate, CFC-free aerosol XOPENEX HFA QL albuterol sulfate aerosol powder breath-activated PROAIR RESPICLICK Long Acting QL salmeterol xinafoate SEREVENT Oral Agents albuterol albuterol ext-rel terbutaline CYSTIC FIBROSIS PA, SP tobramycin inhalation solution TOBI PA aztreonam lysine inhalation solution CAYSTON PA, SP dornase alfa PULMOZYME LEUKOTRIENE MODULATORS QL, * montelukast SINGULAIR QL, * zafirlukast ACCOLATE * May be dispensed as a 90-day supply NASAL ANTIHISTAMINES azelastine spray 0.1% NASAL DECONGESTANTS OTC oxymetazoline spray AFRIN OTC phenylephrine spray NEO-SYNEPHRINE NASAL STEROIDS OTC, QL budesonide spray RHINOCORT ALLERGY OTC, QL triamcinolone acetonide spray NASACORT ALLERGY 24HR QL fluticasone spray RESPIRATORY DEVICES respiratory devices AEROTRACH PLUS HOLDING

CHAMBER respiratory devices BREATHERITE PRODUCTS respiratory devices EASIVENT PRODUCTS respiratory devices INSPIREASE PRODUCTS respiratory devices MICROCHAMBER

PRODUCTS RESPIRATORY SYNCYTIAL VIRUS PA, SP palivizumab SYNAGIS


43

STEROID/BETA AGONIST COMBINATIONS QL, * budesonide/formoterol SYMBICORT QL, * fluticasone/salmeterol AIRDUO RESPICLICK QL, * fluticasone/salmeterol - Wixela Inhub ADVAIR DISKUS * May be dispensed as a 90-day supply STEROID INHALANTS PA, QL, * budesonide inhalation solution PULMICORT RESPULES QL, * fluticasone furoate ARNUITY ELLIPTA QL, * mometasone ASMANEX HFA PA Required for members over 8 years of age * May be dispensed as a 90-day supply XANTHINES * theophylline ext-rel tabs * theophylline ext-rel caps THEO-24 * theophylline liquid ELIXOPHYLLIN * May be dispensed as a 90-day supply MISCELLANEOUS OTC cromolyn nasal spray NASALCROM OTC sodium chloride OCEAN QL ipratropium nasal spray sodium chloride TOPICAL DERMATOLOGY Acne Oral PA isotretinoin PA isotretinoin - Amnesteem PA isotretinoin - Claravis PA isotretinoin - Myorisan PA isotretinoin - Zenatane Topical benzoyl peroxide BENZAC AC clindamycin gel, lotion, solution, swabs CLEOCIN T erythromycin gel 2% erythromycin solution PA tretinoin RETIN-A OTC, QL adapalene gel 0.1% DIFFERIN Actinic Keratosis fluorouracil crm 5% EFUDEX Antibiotics OTC bacitracin gentamicin mupirocin oint silver sulfadiazine SILVADENE


44

Antifungals OTC clotrimazole LOTRIMIN AF OTC miconazole MICATIN OTC tolnaftate TINACTIN OTC terbinafine LAMISIL AT clotrimazole/betamethasone crm QL ketoconazole crm 2% nystatin PA, QL nystatin/triamcinolone PA Required for members 5 years of age and older Antipsoriatics Oral PA acitretin SORIATANE Topical anthralin QL calcipotriene DOVONEX PA Required for quantity of 60 gm and larger Antiseborrheics ketoconazole shampoo 2% NIZORAL SHAMPOO selenium sulfide lotion 2.5% Atopic Dermatitis PA, QL tacrolimus PROTOPIC PA, QL crisaborole ointment 2% EUCRISA Corticosteroids Low Potency OTC hydrocortisone cream, ointment 0.5%, 1% QL alclometasone cream, ointment 0.05% fluocinolone acetonide cream 0.01% QL fluocinolone acetonide solution 0.01% hydrocortisone cream 2.5% hydrocortisone lotion 1% Medium Potency QL betamethasone valerate cream, lotion, ointment 0.1% QL fluocinolone acetonide cream, ointment 0.025% QL fluocinolone acetonide oil 0.01% DERMA-SMOOTHE/FS QL fluticasone propionate cream 0.05%, ointment 0.005% CUTIVATE QL mometasone cream, lotion, ointment 0.1% triamcinolone acetonide cream, lotion, ointment 0.025% triamcinolone acetonide cream, lotion, ointment 0.1% High Potency QL betamethasone dipropionate augmented cream 0.05% DIPROLENE AF QL betamethasone dipropionate cream, lotion, ointment 0.05% QL fluocinonide cream, gel, ointment 0.05% fluocinonide emollient cream 0.05% fluocinonide solution 0.05% triamcinolone acetonide cream, ointment 0.5%


45

Very High Potency QL betamethasone dipropionate augmented ointment 0.05% DIPROLENE clobetasol propionate emollient cream 0.05% QL clobetasol propionate gel 0.05% QL clobetasol propionate lotion 0.05% CLOBEX QL halobetasol propionate cream, ointment 0.05% ULTRAVATE Emollients ammonium lactate 12% Local Analgesics OTC, QL capsaicin crm 0.1% CAPZASIN-HP OTC, QL capsaicin crm, patch 0.025% OTC, QL lidocaine crm, patch 4% - Aspercreme/Lidocaine OTC lidocaine/menthol patch 4/1% LIDOPATCH OTC, QL capsaicin crm 0.033% ZOSTRIX NATURAL OTC, QL capsaicin crm 0.035% CAPZASIN-P OTC, QL capsaicin crm 0.075% ARTHRITIS PAIN CREAM OTC, QL capsaicin lotion 0.035% CASTIVA OTC, QL capsaicin plaster 0.15% GUADALUPANO OTC, QL capsaicin stick 0.075% ZOSTRIX HP OTC, QL capsaicin/menthol gel 0.025/10% CAPZASIN GEL RELIEF OTC, QL capsaicin/menthol patch 0.025/5% ICY HOT OTC, QL capsaicin/menthol patch 0.05/5% ALLEVESS OTC, QL capsaicin/menthol/methyl salicylate crm 0.025/1/12% ZIKS OTC, QL capsaicin/menthol/methyl salicylate crm 0.035/10/25% RELIADERM OTC, QL lidocaine/menthol crm 4/1% ICY HOT OTC, QL lidocaine/trolamine salicylate/capsaicin soln 4/10/0.035% ARTHRITIS & MUSCLE PAIN

RELIEF PA lidocaine gel 2% XYLOCAINE PA, QL lidocaine patch 5% LIDODERM Local Anesthetics QL lidocaine/prilocaine crm 2.5/2.5% Rosacea metronidazole cream 0.75% METROCREAM metronidazole gel 0.75% ST metronidazole gel 1% METROGEL metronidazole lotion 0.75% METROLOTION Scabicides and Pediculicides OTC permethrin 1% NIX CREME RINSE OTC pyrethrins/piperonyl butoxide 4% A-200 SHAMPOO OTC pyrethrins/piperonyl butoxide 4% LICE KILLING SHAMPOO OTC pyrethrins/piperonyl butoxide 4% RID SHAMPOO ST spinosad NATROBA ST malathion OVIDE permethrin 5% Miscellaneous Skin and Mucous Membrane OTC, QL insect repellent, DEET 7% CUTTER SKINSATIONS OTC, QL insect repellent, DEET 15% OFF ACTIVE OTC, QL insect repellent, DEET 15% OFF FAMILY CARE OTC, QL insect repellent, DEET 25% CUTTER BACKWOODS OTC, QL insect repellent, DEET 25% OFF DEEP WOODS


46

OTC, QL insect repellent, DEET 25% REPEL SPORTSMEN OTC, QL insect repellent, DEET 40% REPEL SPORTSMEN MAX OTC, QL insect repellent, picaridin 20% NATRAPEL OTC, QL insect repellent, picaridin 20% SAWYER QL imiquimod ALDARA podofilox solution CONDYLOX trypsin/balsam/castor oil PA becaplermin REGRANEX PA, QL collagenase SANTYL MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Steroids - Mouth/Throat triamcinolone paste Miscellaneous chlorhexidine gluconate PERIDEX OPHTHALMIC Antiallergics OTC ketotifen ZADITOR OTC, QL olopatadine PATADAY cromolyn sodium Anti-infectives Ointments are also available for many of the products and they should be considered on the drug list. QL bacitracin ciprofloxacin solution CILOXAN erythromycin gentamicin levofloxacin neomycin/polymyxin B/gramicidin ofloxacin OCUFLOX polymyxin B/bacitracin polymyxin B/trimethoprim POLYTRIM sulfacetamide solution 10% BLEPH-10 tobramycin solution TOBREX Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone ointment neomycin/polymyxin B/dexamethasone MAXITROL neomycin/polymyxin B/hydrocortisone suspension sulfacetamide/prednisolone phosphate 10%/0.25% tobramycin/dexamethasone suspension 0.3%/0.1% TOBRADEX sulfacetamide/prednisolone acetate 10%/0.2% BLEPHAMIDE tobramycin/dexamethasone ointment 0.3%/0.1% TOBRADEX Anti-inflammatories Ointments are also available for many of the products and they should be considered on the drug list. Nonsteroidal diclofenac sodium flurbiprofen


47

ketorolac 0.4% ACULAR LS ketorolac 0.5% ACULAR Steroidal dexamethasone sodium phosphate fluorometholone FML prednisolone acetate 1% PRED FORTE fluorometholone 0.25% FML FORTE fluorometholone ointment 0.1% FML S.O.P. prednisolone acetate 0.12% PRED MILD prednisolone phosphate 1% Antivirals trifluridine Beta-blockers Nonselective carteolol levobunolol timolol maleate TIMOPTIC timolol maleate gel TIMOPTIC-XE timolol hemihydrate BETIMOL Selective betaxolol BETOPTIC S Carbonic Anhydrase Inhibitors Topical dorzolamide TRUSOPT Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate COSOPT Dry Eye Disease PA lifitegrast XIIDRA Mydriatics cyclopentolate CYCLOGYL homatropine ISOPTO HOMATROPINE tropicamide atropine cyclopentolate/phenylephrine CYCLOMYDRIL Parasympathomimetics pilocarpine ISOPTO CARPINE Prostaglandins QL bimatoprost 0.03% QL latanoprost XALATAN Sympathomimetics QL brimonidine 0.15% ALPHAGAN P QL brimonidine 0.2% Miscellaneous OTC artificial tears ointment, solution


48

OTC sodium chloride MURO-128 OTIC Anti-infectives acetic acid ofloxacin otic Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/hydrocortisone CORTISPORIN OTIC PA, QL ciprofloxacin/dexamethasone CIPRODEX


49

INDEX

A A-200 SHAMPOO, 46 abacavir, 18 abacavir/dolutegravir/lamivudine, 17 abacavir/lamivudine, 17 abacavir/lamivudine/zidovudine, 17 abaloparatide, 31 ABILIFY, 27 ABILIFY MAINTENA, 27 acamprosate calcium, 29 acarbose, 30 ACCOLATE, 43 ACCUPRIL, 21 ACCURETIC, 22 acetaminophen, 15 acetaminophen/aspirin/caffeine, 28 acetaminophen/caffeine, 16 acetazolamide, 24 acetazolamide ext-rel, 24 acetic acid, 49 ACIPHEX, 37 acitretin, 45 ACTIFED COLD & ALLERGY, 42 ACTIGALL, 36 ACTIQ, 15 ACTIVELLA, 34 ACTOPLUS MET, 30 ACTOS, 30 ACULAR, 48 ACULAR LS, 48 acyclovir caps, suspension, tabs, 19 adalimumab, 39 adapalene gel 0.1%, 44 ADCIRCA, 25 ADDERALL, 27 ADDERALL XR, 27 adefovir dipivoxil, 19 ADMELOG, 30 ADVAIR DISKUS, 44 ADVATE, 39 ADVIL, 15 ADYNOVATE, 39 AEROTRACH PLUS HOLDING CHAMBER, 43 afatinib, 21 AFINITOR, 21 AFLURIA, 40 AFRIN, 43 AFSTYLA, 39 AGRYLIN, 39 AIRDUO RESPICLICK, 44 albendazole, 19 ALBENZA, 19 albuterol, 43 albuterol ext-rel, 43 albuterol inhalation solution, 43 albuterol sulfate aerosol powder breath-activated, 43 albuterol sulfate, CFC-free aerosol, 43 alclometasone cream, ointment 0.05%, 45 ALDACTAZIDE, 24 ALDACTONE, 22, 24 ALDARA, 47 alendronate tabs 35 mg, 40 mg, 70 mg, 31

alendronate tabs 5 mg, 10 mg, 31 ALEVE, 15 alfuzosin ext-rel, 37 ALINIA, 20 ALKERAN, 20 ALLEGRA, 42 ALLEGRA-D, 42 ALLEVESS, 46 allopurinol, 15 alogliptin, 30 alogliptin/metformin, 30 alogliptin/pioglitazone, 30 ALPHAGAN P, 48 ALPHANATE, 39 ALPHANINE SD, 39 alprazolam ext-rel, 25 alprazolam tabs, 25 ALPROLIX, 39 ALTACE, 21 alumina/magnesia, 35 alumina/magnesia/simethicone, 35 aluminum hydroxide, 35 amantadine, 26 AMARYL, 31 AMBIEN, 28 AMBIEN CR, 28 ambrisentan, 24 AMERGE, 28 amiloride, 24 amiloride/hydrochlorothiazide, 24 amiodarone tabs 200 mg, 400 mg, 22 AMITIZA, 36 amitriptyline, 26 amlodipine, 23 amlodipine/benazepril, 21 ammonium lactate 12%, 46 amoxicillin, 17 amoxicillin/clavulanate, 17 amphetamine/dextroamphetamine mixed salts, 27 amphetamine/dextroamphetamine mixed salts ext-rel, 27 ampicillin, 17 anagrelide, 39 anastrozole, 20 ANDROGEL, 30 ANORO ELLIPTA, 42 ANTABUSE, 29 anthralin, 45 antihemophilic factor (human), 38 antihemophilic factor (recombinant porcine), 39 antihemophilic factor (recombinant), 39 antihemophilic factor (recombinant) pegylated, 39 antihemophilic factor (recombinant) pegylated-aucl, 39 antihemophilic factor (recombinant), glycopegylated-exei, 39 antihemophilic factor/von Willebrand factor complex (human), 39 anti-inhibitor coagulant complex, 39 ANUSOL-HC, 37 ANZEMET, 36 apixaban, 38 aprepitant caps, 36 APRISO, 36 APTIVUS, 19 ARANESP, 38 ARAVA, 40

50

ARICEPT, 26 ARIMIDEX, 20 aripiprazole ext-rel inj, 27 aripiprazole lauroxil ext-rel inj, 27 aripiprazole tabs, 27 ARISTADA, 27 ARISTADA INITIO, 27 ARIXTRA, 38 armodafinil, 29 ARMOUR THYROID, 35 ARNUITY ELLIPTA, 44 AROMASIN, 20 ARTHRITIS & MUSCLE PAIN RELIEF, 46 ARTHRITIS PAIN CREAM, 46 artificial tears ointment, solution, 48 ASACOL HD, 36 ascorbic acid, 41 ASMANEX HFA, 44 aspirin, 15 aspirin 81 mg, 39 aspirin buffered, 15 aspirin delayed-rel, 15 aspirin/caffeine, 16 atazanavir, 18 atazanavir/cobicistat, 17 atenolol, 23 atenolol/chlorthalidone, 23 ATIVAN, 25 atomoxetine, 27 atorvastatin, 23 atovaquone, 19 atovaquone/proguanil, 17 ATRIPLA, 18 atropine, 48 ATROVENT HFA, 41 AUBAGIO, 29 AUGMENTIN, 17 AVALIDE, 22 AVAPRO, 22 AVODART, 37 AVONEX, 29 AYGESTIN, 34 azathioprine, 40 azelastine spray 0.1%, 43 AZILECT, 26 azithromycin, 16 aztreonam lysine inhalation solution, 43 AZULFIDINE, 36 AZULFIDINE EN-TABS, 36 B bacitracin, 44, 47 BACK & BODY, 16 baclofen 10 mg, 20 mg, 29 balsalazide, 36 BAQSIMI, 34 BARACLUDE, 19 BASAGLAR, 30 BAYER, 15 BD ULTRAFINE insulin syringes and needles, 31 becaplermin, 47 belimumab subcutaneous, 40 BENADRYL, 42 benazepril, 21 benazepril/hydrochlorothiazide, 21 BENEFIX, 39

BENICAR, 22 BENICAR HCT, 22 BENLYSTA, 40 BENTYL, 36 BENZAC AC, 44 benzonatate, 42 benzoyl peroxide, 44 benztropine, 26 betamethasone dipropionate augmented cream 0.05%, 45 betamethasone dipropionate augmented ointment 0.05%, 46 betamethasone dipropionate cream, lotion, ointment 0.05%,

45 betamethasone valerate cream, lotion, ointment 0.1%, 45 BETAPACE, 22 BETAPACE AF, 22 betaxolol, 48 bethanechol, 38 BETIMOL, 48 BETOPTIC S, 48 bexarotene caps, 21 BEYAZ, 32 bicalutamide, 20 BICILLIN L-A, 17 bictegravir/emtricitabine/tenofovir alafenamide, 17 BIKTARVY, 17 bimatoprost 0.03%, 48 bismuth subsalicylate, 35 bisoprolol, 23 bisoprolol/hydrochlorothiazide, 23 BLEPH-10, 47 BLEPHAMIDE, 47 blood glucose monitoring kits, test strips, 31 BONIVA, 31 bosentan, 24 BOSULIF, 21 bosutinib, 21 BREATHERITE PRODUCTS, 43 brimonidine 0.15%, 48 brimonidine 0.2%, 48 brodalumab, 39 bromocriptine, 26 budesonide delayed-rel caps, 36 budesonide inhalation solution, 44 budesonide spray, 43 budesonide/formoterol, 44 BUFFERIN, 15 bumetanide, 24 BUPHENYL, 35 buprenorphine sublingual, 29 buprenorphine/naloxone sublingual film, 29 buprenorphine/naloxone sublingual tabs, 29 bupropion, 26 bupropion ext-rel, 26, 29 buspirone, 25 busulfan, 20 butalbital/acetaminophen, 16 butalbital/acetaminophen/caffeine tabs - Esgic, 16 butalbital/aspirin/caffeine, 16 butoconazole, 38 C cabergoline, 35 CALAN SR, 23 calcipotriene, 45 calcitonin-salmon, 31 calcitriol (1,25-D3), 34

51

calcium acetate, 34 calcium carbonate, 35, 41 capecitabine, 20 capsaicin crm 0.033%, 46 capsaicin crm 0.035%, 46 capsaicin crm 0.075%, 46 capsaicin crm 0.1%, 46 capsaicin crm, patch 0.025%, 46 capsaicin lotion 0.035%, 46 capsaicin plaster 0.15%, 46 capsaicin stick 0.075%, 46 capsaicin/menthol gel 0.025/10%, 46 capsaicin/menthol patch 0.025/5%, 46 capsaicin/menthol patch 0.05/5%, 46 capsaicin/menthol/methyl salicylate crm 0.025/1/12%, 46 capsaicin/menthol/methyl salicylate crm 0.035/10/25%, 46 CAPZASIN GEL RELIEF, 46 CAPZASIN-HP, 46 CAPZASIN-P, 46 carbamazepine, 25 carbamazepine ext-rel, 25 CARBATROL, 25 carbidopa/levodopa, 26 carbidopa/levodopa ext-rel, 26 carbidopa/levodopa/entacapone, 26 CARDIZEM, 23 CARDIZEM CD, 23 CARDIZEM LA, 23 CARDURA, 22 CARNITOR, 35 carteolol, 48 carvedilol, 23 CASODEX, 20 CASTIVA, 46 CATAPRES, 22 CATAPRES-TTS, 22 CAYSTON, 43 cefaclor, 16 cefadroxil, 16 cefdinir, 16 cefpodoxime, 16 cefprozil, 16 cefuroxime axetil, 16 CELEBREX, 15 celecoxib 50 mg, 100 mg, 200 mg, 15 CELEXA, 26 CELLCEPT, 40 CENTRUM, 41 cephalexin, 16 ceritinib, 21 cetirizine, 42 cetirizine/pseudoephedrine ext-rel, 42 cevimeline, 37 CHANTIX, 29 chlorambucil, 20 chlordiazepoxide, 25 chlorhexidine gluconate, 47 chloroquine, 17 chlorpheniramine, 42 chlorpheniramine/phenylephrine, 42 chlorpromazine, 27 chlorthalidone, 24 CHLOR-TRIMETON ALLERGY, 42 chlorzoxazone 500 mg, 29 cholecalciferol (D3), 41 cholestyramine, 22

cilostazol, 39 CILOXAN, 47 CIMDUO, 18 cimetidine, 36 cinacalcet, 31 CIPRO, 16 CIPRODEX, 49 ciprofloxacin, 16 ciprofloxacin solution, 47 ciprofloxacin/dexamethasone, 49 citalopram, 26 clarithromycin, 16 clarithromycin ext-rel, 16 CLARITIN, 42 CLARITIN REDITABS, 42 CLARITIN-D, 42 clemastine, 42 CLEOCIN, 19, 38 CLEOCIN T, 44 CLIMARA, 33 CLIMARA PRO, 33 clindamycin, 19 clindamycin cream, 38 clindamycin gel, lotion, solution, swabs, 44 clindamycin suppository, 38 clobetasol propionate emollient cream 0.05%, 46 clobetasol propionate gel 0.05%, 46 clobetasol propionate lotion 0.05%, 46 CLOBEX, 46 clomiphene, 34 clonazepam tabs, 25 clonidine, 22 clonidine transdermal, 22 clonidine/chlorthalidone, 22 clopidogrel, 39 clotrimazole, 38, 45 clotrimazole troches, 17 clotrimazole/betamethasone crm, 45 clozapine, 27 CLOZARIL, 27 COAGADEX, 39 coagulation factor IX, 39 coagulation factor IX (recombinant), 39 coagulation factor VIIa (recombinant), 39 coagulation factor X (human), 39 coagulation factor XIII A-subunit (recombinant), 39 cobicistat, 17 codeine/acetaminophen, 15 codeine/chlorpheniramine/pseudoephedrine, 42 codeine/guaifenesin liquid, 42 codeine/guaifenesin/pseudoephedrine, 42 codeine/promethazine, 42 codeine/promethazine/phenylephrine, 42 COLACE, 36 colchicine, 15 colchicine/probenecid, 15 COLCRYS, 15 COLESTID, 22 colestipol, 22 collagenase, 47 COMBIPATCH, 34 COMBIVENT RESPIMAT, 42 COMPLERA, 18 COMTAN, 26 CONCEPTROL, 33 CONCERTA, 27

52

condoms, female, 33 condoms, male, 33 CONDYLOX, 47 COPAXONE, 28 COREG, 23 CORGARD, 23 CORIFACT KIT, 39 CORTEF, 34 cortisone acetate, 34 CORTISPORIN OTIC, 49 COSENTYX, 40 COSOPT, 48 COUMADIN, 38 COZAAR, 22 CREON, 37 CRESTOR, 23 crisaborole ointment 2%, 45 CRIXIVAN, 18 cromolyn nasal spray, 44 cromolyn sodium, 37, 47 CUBICIN, 19 CUTIVATE, 45 CUTTER BACKWOODS, 46 CUTTER SKINSATIONS, 46 cyanocobalamin injection, 41 cyanocobalamin tabs 1000 mcg, 41 cyclobenzaprine 5 mg, 10 mg, 29 CYCLOGYL, 48 CYCLOMYDRIL, 48 cyclopentolate, 48 cyclopentolate/phenylephrine, 48 cyclophosphamide caps, 20 cyclosporine, 40 cyclosporine, modified, 40 CYMBALTA, 26 cyproheptadine, 42 CYRAMZA, 21 CYSTAGON, 35 cysteamine bitartrate, 35 CYTOMEL, 35 CYTOTEC, 37 D dabrafenib, 21 danazol, 33 DANTRIUM, 29 dantrolene, 29 dapsone, 19 daptomycin, 19 darbepoetin alfa, 38 darifenacin ext-rel, 38 darunavir, 18 darunavir/cobicistat, 17 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 17 dasatinib, 21 DAYPRO, 15 DDAVP, 35 deferasirox, 39 deferasirox tabs 90 mg, 180 mg, 360 mg, 39 DELATESTRYL, 29 DELSTRIGO, 18 DELZICOL, 36 demeclocycline, 17 denosumab, 31 DEPAKOTE, 25 DEPAKOTE ER, 25

DEPEN, 40 DEPO-PROVERA, 20, 33 DEPO-SUBQ PROVERA 104, 33 DEPO-TESTOSTERONE, 29 DERMA-SMOOTHE/FS, 45 DESCOVY, 18 desipramine, 26 desmopressin spray, 35 desmopressin tabs, 35 desogestrel/EE, 32 desogestrel/EE 0.15/30 - Apri, 32 desvenlafaxine ext-rel, 26 DETROL, 38 DETROL LA, 38 dexamethasone, 34 dexamethasone sodium phosphate, 48 dexbrompheniramine/pseudoephedrine ext-rel, 42 DEXEDRINE SPANSULE, 27 dexmethylphenidate, 27 dexmethylphenidate ext-rel, 27 dexrazoxane, 21 dextroamphetamine ext-rel, 27 dextroamphetamine tabs 5 mg, 10 mg, 27 dextroamphetamine tabs 5 mg, 10 mg - Zenzedi, 27 dextromethorphan/guaifenesin, 42 dextromethorphan/guaifenesin/pseudoephedrine, 42 dextromethorphan/promethazine, 43 diaphragm, 33 DIASTAT, 25 diazepam, 25 diazepam rectal gel, 25 DIBENZYLINE, 25 DICLEGIS, 36 diclofenac sodium, 47 diclofenac sodium delayed-rel 50 mg, 75 mg, 15 diclofenac sodium ext-rel, 15 diclofenac sodium gel 1%, 15 diclofenac sodium soln 1.5%, 15 dicloxacillin, 17 dicyclomine, 36 didanosine delayed-rel, 18 DIFFERIN, 44 DIFLUCAN, 17 diflunisal, 15 digoxin, 24 digoxin pediatric elixir, 24 DILANTIN, 25 DILANTIN INFATABS, 25 DILAUDID, 15 diltiazem, 23 diltiazem ext-rel, 23 diltiazem ext-rel, except 120 mg, 23 dimenhydrinate, 35 dimethyl fumarate delayed-rel, 28 DIOVAN, 22 DIOVAN HCT, 22 diphenhydramine, 28, 42 diphenoxylate/atropine, 35 DIPROLENE, 46 DIPROLENE AF, 45 dipyridamole, 39 disopyramide, 22 disopyramide ext-rel, 22 disulfiram, 29 DITROPAN XL, 38 divalproex sodium delayed-rel, 25

53

divalproex sodium ext-rel, 25 docusate sodium, 36 dofetilide, 22 dolasetron, 36 DOLOPHINE, 16 dolutegravir, 18 dolutegravir/lamivudine, 17 dolutegravir/rilpivirine, 17 donepezil, 26 doravirine, 18 doravirine/lamivudine/tenofovir disoproxil fumarate, 18 dornase alfa, 43 dorzolamide, 48 dorzolamide/timolol maleate, 48 DOVATO, 17 DOVONEX, 45 doxazosin, 22 doxepin, 26 doxercalciferol, 34 doxycycline hyclate caps 50 mg, 100 mg, 17 doxycycline hyclate tabs 20 mg, 100 mg, 17 doxycycline monohydrate caps 50 mg, 100 mg, 17 doxycycline monohydrate suspension 25 mg/5 mL, 17 doxycycline monohydrate tabs 50 mg, 100 mg, 17 doxylamine, 28 doxylamine/pyridoxine delayed-rel, 36 DRAMAMINE, 35 DRIXORAL, 42 dronabinol, 36 drospirenone/EE 3/20, 32 drospirenone/EE 3/30, 32 drospirenone/EE/levomefolate 3/20 and levomefolate, 32 drospirenone/EE/levomefolate 3/30 and levomefolate, 32 DROXIA, 21 dulaglutide, 30 duloxetine delayed-rel, 26 DURAGESIC, 15 dutasteride, 37 DYAZIDE, 24 E E.E.S., 16 EASIVENT PRODUCTS, 43 ECOTRIN, 15 edoxaban, 38 EDURANT, 18 EE/norethindrone acetate, 34 EE/norethindrone acetate - Jinteli, 34 efavirenz, 18 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 18 efavirenz/lamivudine/tenofovir disoproxil fumarate, 18 EFFEXOR XR, 26 EFFIENT, 39 EFUDEX, 44 elagolix, 33 electrolyte solution, oral, 40 ELIQUIS, 38 ELIXOPHYLLIN, 44 ELLA, 33 ELMIRON, 38 ELOCTATE, 39 eltrombopag tabs, 39 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 18 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate,

18 EMEND, 36

emicizumab-kxwh, 39 emtricitabine, 18 emtricitabine/rilpivirine/tenofovir alafenamide, 18 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 18 emtricitabine/tenofovir alafenamide, 18 emtricitabine/tenofovir disoproxil fumarate, 18 EMTRIVA, 18 ENABLEX, 38 enalapril, 21 enalapril/hydrochlorothiazide, 21 ENBREL, 39 enfuvirtide, 18 enoxaparin, 38 entacapone, 26 entecavir soln, 19 entecavir tabs, 19 ENTOCORT EC, 36 EPCLUSA, 19 epinephrine auto-injector, 41 EPIPEN, 41 EPIPEN JR., 41 EPIVIR-HBV, 19 eplerenone, 22 epoetin alfa-epbx, 38 epoprostenol sodium, 25 ergocalciferol (D2), 41 ERIVEDGE, 21 erlotinib, 21 ertugliflozin, 31 ertugliflozin/metformin, 31 ertugliflozin/sitagliptin, 31 erythromycin, 47 erythromycin base, 16 erythromycin delayed-rel, 16 erythromycin ethylsuccinate, 16 erythromycin gel 2%, 44 erythromycin solution, 44 erythromycin stearate, 16 escitalopram, 26 esomeprazole delayed-rel caps 40 mg, 37 esomeprazole magnesium delayed-rel, 37 ESPEROCT, 39 estazolam, 28 ESTRACE, 33 estradiol, 33 estradiol vaginal cream, 33 estradiol vaginal ring, 33 estradiol vaginal tabs - Yuvafem, 33 estradiol/levonorgestrel, 33 estradiol/norethindrone acetate, 34 estradiol/norgestimate, 34 estrogens, conjugated, 33 estrogens, conjugated cream, 33 estrogens, conjugated/medroxyprogesterone, 34 estrogens, esterified, 33 ESTROSTEP FE, 32 eszopiclone, 28 etanercept, 39 ethambutol, 19 ethosuximide, 25 ethynodiol diacetate/EE 1/35, 32 ethynodiol diacetate/EE 1/50, 32 etodolac, 15 etodolac ext-rel, 15 etonogestrel implant, 33 etonogestrel/EE ring, 33

54

etoposide, 21 etravirine, 18 EUCRISA, 45 everolimus, 21 EVISTA, 35 evolocumab, 23 EVOTAZ, 17 EVOXAC, 37 EXCEDRIN MIGRAINE, 28 EXCEDRIN TENSION HEADACHE, 16 exemestane, 20 EXJADE, 39 EXTAVIA, 29 ezetimibe, 22 F factor IX complex, 39 factor XIII concentrate (human), 39 famciclovir, 19 famotidine, 36 FARESTON, 20 FASLODEX, 20 FEIBA NF, 39 felodipine ext-rel, 23 FEMARA, 20 FEMHRT, 34 FEMRING, 33 fenofibrate caps 67 mg, 134 mg, 200 mg, 22 fenofibrate tabs 48 mg, 54 mg, 145 mg, 160 mg, 22 fenofibric acid delayed-rel tabs 35 mg, 105 mg, 23 fentanyl transdermal, 15 fentanyl transmucosal, 15 FEOSOL, 41 FERAHEME, 41 FERGON, 41 FERRLECIT, 41 ferrous gluconate, 41 ferrous sulfate, 41 ferumoxytol, 41 fexofenadine, 42 fexofenadine/pseudoephedrine ext-rel, 42 filgrastim-sndz, 38 finasteride, 37 fingolimod, 28 FIORINAL, 16 FIRST-LANSOPRAZOLE, 37 FIRST-OMEPRAZOLE, 37 FIRVANQ, 20 FISH OIL, 41 FLAGYL, 19 flecainide, 22 FLOLAN, 25 FLOMAX, 37 FLUARIX, 40 FLUCELVAX, 40 fluconazole, 17 fludrocortisone, 34 FLULAVAL, 40 fluocinolone acetonide cream 0.01%, 45 fluocinolone acetonide cream, ointment 0.025%, 45 fluocinolone acetonide oil 0.01%, 45 fluocinolone acetonide solution 0.01%, 45 fluocinonide cream, gel, ointment 0.05%, 45 fluocinonide emollient cream 0.05%, 45 fluocinonide solution 0.05%, 45 fluoride drops, tabs, 41

fluorometholone, 48 fluorometholone 0.25%, 48 fluorometholone ointment 0.1%, 48 fluorouracil crm 5%, 44 fluoxetine caps, 26 fluphenazine, 27 flurazepam, 28 flurbiprofen, 15, 47 flutamide, 20 fluticasone furoate, 44 fluticasone propionate cream 0.05%, ointment 0.005%, 45 fluticasone spray, 43 fluticasone/salmeterol, 44 fluticasone/salmeterol - Wixela Inhub, 44 fluvoxamine, 25, 26 FLUZONE, 40 FML, 48 FML FORTE, 48 FML S.O.P., 48 FOCALIN, 27 FOCALIN XR, 27 folic acid, 41 fondaparinux, 38 FOSAMAX, 31 fosamprenavir susp, 18 fosamprenavir tabs, 18 fosfomycin, 20 fosinopril, 21 fosinopril/hydrochlorothiazide, 21 FREESTYLE FREEDOM LITE kits and test strips, 31 FREESTYLE INSULINX kits and test strips, 31 FREESTYLE LITE kits and test strips, 31 FULPHILA, 38 fulvestrant, 20 furosemide, 24 FUZEON, 18 G gabapentin, 25 GABITRIL, 25 galantamine, 26 galantamine ext-rel, 26 GASTROCROM, 37 GAZYVA, 21 gemfibrozil, 23 GENERESS FE, 32 gentamicin, 44, 47 GENVOYA, 18 GEODON, 27 GILENYA, 28 GILOTRIF, 21 glatiramer, 28 GLEEVEC, 21 GLEOSTINE, 20 glimepiride, 31 glipizide, 31 glipizide ext-rel, 31 glipizide/metformin, 30 GLUCAGON EMERGENCY KIT, 34 GLUCAGON HYPOKIT, 34 glucagon nasal powder, 34 glucagon, human recombinant, 34 GLUCOTROL, 31 GLUCOTROL XL, 31 glyburide, 31 glyburide, micronized, 31

55

glyburide/metformin, 30 glycopyrrolate tabs, 36 GLYNASE, 31 GOLYTELY, 37 granisetron, 36 griseofulvin microsize tabs, 17 griseofulvin ultramicrosize, 17 GUADALUPANO, 46 guanfacine, 22 guanfacine ext-rel, 27 GYNAZOLE-1, 38 GYNE-LOTRIMIN, 38 GYNOL II, 33 H HALDOL DECANOATE, 27 halobetasol propionate cream, ointment 0.05%, 46 haloperidol, 27 haloperidol decanoate inj, 27 HECTOROL, 34 HEMLIBRA, 39 HEMOFIL M, 38 heparin, 38 HEPSERA, 19 homatropine, 48 HUMATE-P, 39 HUMIRA, 39 HUMULIN 70/30, 30 HUMULIN N, 30 HUMULIN R, 30 hydralazine, 25 HYDREA, 21 hydrochlorothiazide, 24 hydrocodone/acetaminophen, 15 hydrocodone/acetaminophen soln 7.5/325 mg/15 mL, 15 hydrocodone/homatropine, 42 hydrocodone/ibuprofen, 15 hydrocortisone, 34 hydrocortisone acetate/pramoxine foam, 37 hydrocortisone cream, 37 hydrocortisone cream 2.5%, 45 hydrocortisone cream, ointment 0.5%, 1%, 45 hydrocortisone enema, 36 hydrocortisone inj 100 mg/mL, 34 hydrocortisone lotion 1%, 45 hydromorphone tabs, 15 hydroxychloroquine, 40 hydroxyurea, 21 hydroxyzine HCl, except inj, 42 hydroxyzine pamoate, 42 hyoscyamine sulfate, 36 hyoscyamine sulfate ext-rel, 36 hyoscyamine sulfate ext-rel caps, 36 hyoscyamine sulfate orally disintegrating tabs, 36 HYZAAR, 22 I ibandronate, 31 ibrutinib, 21 ibuprofen, 15 ICY HOT, 46 IDELVION, 39 iloprost, 25 imatinib mesylate, 21 IMBRUVICA, 21 imipramine HCl, 26 imiquimod, 47

IMITREX, 28 IMODIUM A-D, 35 IMURAN, 40 INCRELEX, 34 INCRUSE ELLIPTA, 42 indapamide, 24 INDERAL LA, 23 indinavir, 18 indomethacin 25 mg, 50 mg, 15 indomethacin ext-rel, 15 INFED, 41 influenza vaccine, 40 insect repellent, DEET 15%, 46 insect repellent, DEET 25%, 46, 47 insect repellent, DEET 40%, 47 insect repellent, DEET 7%, 46 insect repellent, picaridin 20%, 47 INSPIREASE PRODUCTS, 43 INSPRA, 22 INSULIN ASPART, 30 insulin aspart protamine 70%/insulin aspart 30%, 30 insulin glargine, 30 insulin human, 30 insulin infusion disposable pump, 31 insulin isophane human, 30 insulin isophane human 70%/regular 30%, 30 insulin lispro, 30 insulin syringes, needles, 31 INTELENCE, 18 interferon alfa-2b, 40 interferon beta-1a, 29 interferon beta-1b, 29 intrauterine copper contraceptive, 33 INTRON A, 40 INTUNIV, 27 INVEGA, 27 INVEGA SUSTENNA, 27 INVEGA TRINZA, 27 INVIRASE, 18 ipratropium inhalation solution, 41 ipratropium nasal spray, 44 ipratropium, CFC-free aerosol, 41 ipratropium/albuterol inhalation solution, 42 ipratropium/albuterol, CFC-free aerosol, 42 irbesartan, 22 irbesartan/hydrochlorothiazide, 22 iron dextran, 41 iron sucrose injection, 41 ISENTRESS, 18 ISENTRESS HD, 18 isocarboxazid, 26 isoniazid, 19 ISOPTO CARPINE, 48 ISOPTO HOMATROPINE, 48 ISORDIL, 24 isosorbide dinitrate oral 5 mg, 10 mg, 20 mg, 30 mg, 24 isosorbide mononitrate, 24 isosorbide mononitrate ext-rel, 24 isotretinoin, 44 isotretinoin - Amnesteem, 44 isotretinoin - Claravis, 44 isotretinoin - Myorisan, 44 isotretinoin - Zenatane, 44 itraconazole, 17 ivermectin, 19 IXINITY, 39

56

J JADENU, 39 JIVI, 39 JULUCA, 17 K KALETRA, 18 KAZANO, 30 KEFLEX, 16 KEPPRA, 25 KEPPRA XR, 25 ketoconazole, 17 ketoconazole crm 2%, 45 ketoconazole shampoo 2%, 45 ketorolac, 15 ketorolac 0.4%, 48 ketorolac 0.5%, 48 ketotifen, 47 KEVZARA, 40 KLONOPIN, 25 KOATE, 38 KOATE-DVI, 38 KOGENATE FS, 39 KOVALTRY, 39 KUVAN, 34 KYLEENA, 33 L labetalol, 23 lactulose soln, 37 LAMICTAL, 25 LAMICTAL XR, 25 LAMISIL AT, 45 lamivudine, 18 lamivudine tabs, 19 lamivudine/tenofovir disoproxil fumarate, 18 lamivudine/zidovudine, 17 lamotrigine, 25 lamotrigine ext-rel, 25 lancets, 31 LANOXIN, 24 lansoprazole delayed-rel 15 mg, 37 lansoprazole delayed-rel 30 mg, 37 lansoprazole suspension, 37 lapatinib, 21 LASIX, 24 latanoprost, 48 leflunomide, 40 lenalidomide, 20 LETAIRIS, 24 letrozole, 20 leucovorin inj, 21 leucovorin tabs, 21 LEUKERAN, 20 LEUKINE, 38 leuprolide acetate, 20 levalbuterol inhalation solution, 43 levalbuterol tartrate, CFC-free aerosol, 43 LEVAQUIN, 16 LEVBID, 36 levetiracetam, 25 levetiracetam ext-rel, 25 levobunolol, 48 levocarnitine, 35 levocetirizine, 42 levofloxacin, 16, 47

levonorgestrel - Next Choice One Dose, 33 levonorgestrel releasing IUD, 33 levonorgestrel/EE, 32 levonorgestrel/EE 0.09/20, 32 levonorgestrel/EE 0.1/20, 32 levonorgestrel/EE 0.1/20 and EE 10, 32 levonorgestrel/EE 0.15/20, 0.15/25, 0.15/30 and EE 10, 32 levonorgestrel/EE 0.15/30, 32 levonorgestrel/EE 0.15/30 and EE 10, 32 levothyroxine, 35 levothyroxine - Levoxyl, 35 levothyroxine tabs, 35 LEVSIN, 36 LEXAPRO, 26 LEXIVA, 18 LIALDA, 36 LICE KILLING SHAMPOO, 46 lidocaine crm, patch 4% - Aspercreme/Lidocaine, 46 lidocaine gel 2%, 46 lidocaine patch 5%, 46 lidocaine viscous, 47 lidocaine/hydrocortisone kit, 37 lidocaine/menthol crm 4/1%, 46 lidocaine/menthol patch 4/1%, 46 lidocaine/prilocaine crm 2.5/2.5%, 46 lidocaine/trolamine salicylate/capsaicin soln 4/10/0.035%, 46 LIDODERM, 46 LIDOPATCH, 46 lifitegrast, 48 LILETTA, 33 linezolid, 19 liothyronine, 35 LIPITOR, 23 liraglutide, 30 lisinopril, 21 lisinopril/hydrochlorothiazide, 21 lithium carbonate, 28 lithium carbonate ext-rel tabs 300 mg, 28 lithium carbonate ext-rel tabs 450 mg, 28 LITHOBID, 28 l-methylfolate, 41 LOESTRIN 1.5/30, 32 LOESTRIN 1/20, 32 LOESTRIN FE 1.5/30, 32 LOESTRIN FE 1/20, 32 LOMOTIL, 35 lomustine, 20 loperamide, 35 LOPID, 23 lopinavir/ritonavir soln, 18 lopinavir/ritonavir tabs, 18 LOPRESSOR, 23 loratadine, 42 loratadine orally disintegrating tabs, 5 mg, 42 loratadine/pseudoephedrine ext-rel, 42 lorazepam, 25 losartan, 22 losartan/hydrochlorothiazide, 22 LOSEASONIQUE, 32 LOTENSIN, 21 LOTENSIN HCT, 21 LOTREL, 21 LOTRIMIN AF, 45 lovastatin, 23 LOVAZA, 23 LOVENOX, 38

57

loxapine, 27 lubiprostone, 36 LUNESTA, 28 LUPRON DEPOT, 20 LYNPARZA, 21 LYRICA, 28 LYSODREN, 21 LYSTEDA, 39 M MAALOX, 35 macitentan, 24 MACROBID, 19 MACRODANTIN, 19 magnesium citrate soln, 37 magnesium oxide, 41 MAG-OX, 41 MALARONE, 17 malathion, 46 maraviroc, 18 MARPLAN, 26 MATULANE, 21 MAXALT, 28 MAXALT-MLT, 28 MAXITROL, 47 MAXZIDE, 24 MAXZIDE-25, 24 MAYZENT, 29 mecasermin, 34 mechlorethamine gel, 20 meclizine, 36 MEDROL, 34 medroxyprogesterone acetate, 34 medroxyprogesterone acetate 104 mg/0.65 mL, 33 medroxyprogesterone acetate 150 mg/mL, 33 medroxyprogesterone acetate 400 mg/mL, 20 mefloquine, 17 megestrol acetate, 20 MEKINIST, 21 melatonin, 28 meloxicam, 15 melphalan, 20 memantine, 26 MENEST, 33 MEPHYTON, 41 MEPRON, 19 mercaptopurine, 20 mesalamine delayed-rel caps, 36 mesalamine delayed-rel tabs, 36 mesalamine ext-rel caps, 36 mesalamine rectal suspension, 36 MESTINON, 29 MESTINON TIMESPAN, 29 METADATE CD, 28 METAMUCIL, 37 metformin, 30 metformin ext-rel 500 mg, 750 mg, 30 methadone tabs 5 mg, 10 mg, 16 methazolamide, 24 methenamine mandelate, 19 methimazole, 35 methocarbamol, 29 methotrexate 2.5 mg, 40 methyldopa, 25 methyldopa/hydrochlorothiazide, 25 METHYLIN, 27

methylphenidate, 27 methylphenidate ext-rel, 27 methylphenidate ext-rel 10 mg, 20 mg, 30 mg, 40 mg, 28 methylphenidate ext-rel 10 mg, 20 mg, 30 mg, 40 mg, 50 mg,

60 mg, 28 methylprednisolone, 34 methyltestosterone, 29 metoclopramide, 36 metolazone, 24 metoprolol succinate ext-rel, 23 metoprolol tartrate 25 mg, 50 mg, 100 mg, 23 METROCREAM, 46 METROGEL, 46 METROLOTION, 46 metronidazole cream 0.75%, 46 metronidazole gel 0.75%, 38, 46 metronidazole gel 1%, 46 metronidazole lotion 0.75%, 46 metronidazole tabs, 19 mexiletine, 22 MIACALCIN, 31 MICARDIS, 22 MICARDIS HCT, 22 MICATIN, 45 miconazole, 38, 45 MICROCHAMBER PRODUCTS, 43 midodrine, 25 midostaurin, 21 MINASTRIN 24 FE, 32 MINIPRESS, 22 MINOCIN, 17 minocycline, 17 MIRALAX, 37 MIRAPEX, 26 MIRAPEX ER, 26 MIRCETTE, 32 MIRENA, 33 mirtazapine, 26 mirtazapine orally disintegrating tabs, 26 misoprostol, 37 mitotane, 21 MOBIC, 15 modafinil, 29 mometasone, 44 mometasone cream, lotion, ointment 0.1%, 45 MONISTAT, 38 MONONINE, 39 montelukast, 43 MONUROL, 20 morphine, 16 morphine ext-rel, 16 morphine suppository, 16 MOVANTIK, 37 moxifloxacin, 16 MS CONTIN, 16 multivitamins, pediatric, 41 multivitamins/fluoride drops, tabs, 41 multivitamins/fluoride/iron drops, tabs, 41 multivitamins/iron, pediatric, 41 multivitamins/minerals, 41 mupirocin oint, 44 MURO-128, 49 MYAMBUTOL, 19 MYCOBUTIN, 19 mycophenolate mofetil, 40 MYLANTA, 35

58

MYLERAN, 20 MYSOLINE, 25 N nabumetone, 15 nadolol, 23 nafarelin, 33 naloxegol, 37 naloxone inj, 29 naloxone nasal spray, 29 naltrexone, 29 naltrexone microspheres, 29 NAMENDA, 26 NAPROSYN, 15 naproxen sodium, 15 naproxen tabs, 15 naratriptan, 28 NARCAN, 29 NARDIL, 26 NASACORT ALLERGY 24HR, 43 NASALCROM, 44 nateglinide, 30 NATRAPEL, 47 NATROBA, 46 NATURE-THROID, 35 NEBUPENT, 20 nelfinavir, 18 neomycin/polymyxin B/bacitracin/hydrocortisone ointment,

47 neomycin/polymyxin B/dexamethasone, 47 neomycin/polymyxin B/gramicidin, 47 neomycin/polymyxin B/hydrocortisone, 49 neomycin/polymyxin B/hydrocortisone suspension, 47 NEORAL, 40 NEO-SYNEPHRINE, 43 NESINA, 30 NEURONTIN, 25 nevirapine, 18 nevirapine ext-rel, 18 NEXAVAR, 21 NEXIUM, 37 NEXIUM 24HR, 37 NEXPLANON, 33 niacin, 41 niacin ext-rel, 23 NIASPAN, 23 NICODERM CQ, 29 NICORETTE, 29 nicotine inhaler, 29 nicotine nasal spray, 29 nicotine polacrilex gum, lozenge, 29 nicotine transdermal, 29 NICOTROL INHALER, 29 NICOTROL NS, 29 nifedipine ext-rel, 23 nilotinib, 21 nimodipine, 23 NIMOTOP, 23 nitazoxanide, 20 nitisinone, 35 NITRO-BID, 24 NITRO-DUR, 24 nitrofurantoin ext-rel, 19 nitrofurantoin macrocrystals, 19 nitrofurantoin suspension, 19 nitroglycerin ointment, 24

nitroglycerin sublingual, 24 nitroglycerin transdermal, 24 NITROSTAT, 24 NIX CREME RINSE, 46 NIZORAL SHAMPOO, 45 nonoxynol-9, 33 NORCO, 15 NORDITROPIN, 34 norelgestromin/EE, 33 norethindrone, 33, 34 norethindrone acetate/EE 0.8/25 and iron, 32 norethindrone acetate/EE 1.5/30, 32 norethindrone acetate/EE 1.5/30 and iron, 32 norethindrone acetate/EE 1/20, 32 norethindrone acetate/EE 1/20 (24) and iron, 32 norethindrone acetate/EE 1/20 and iron, 32 norethindrone acetate/EE 1/20 and iron chewable, 32 norethindrone/EE, 32 norethindrone/EE 0.4/35, 32 norethindrone/EE 0.4/35 and iron chewable, 32 norethindrone/EE 0.5/35, 32 norethindrone/EE 1/35, 32 norethindrone/EE and iron, 32 norgestimate/EE, 32 norgestimate/EE 0.25/35, 32 norgestrel/EE 0.3/30, 32 norgestrel/EE 0.5/50 - Ogestrel, 32 NORPACE, 22 NORPACE CR, 22 NORPRAMIN, 26 nortriptyline, 26 NORVASC, 23 NORVIR, 18 NOVOEIGHT, 39 NOVOLIN 70/30, 30 NOVOLIN N, 30 NOVOLIN R, 30 NOVOSEVEN RT, 39 NP THYROID, 35 NUVARING, 33 NUVIGIL, 29 NUWIQ, 39 nystatin, 45 nystatin/triamcinolone, 45 NYTOL, 28 O obinutuzumab, 21 OBIZUR, 39 OCEAN, 44 octreotide acetate, 35 OCUFLOX, 47 ODEFSEY, 18 OFF ACTIVE, 46 OFF DEEP WOODS, 46 OFF FAMILY CARE, 46 ofloxacin, 47 ofloxacin otic, 49 olanzapine, 27 olanzapine orally disintegrating tabs, 27 olanzapine pamoate ext-rel inj, 27 olanzapine/fluoxetine, 27 olaparib, 21 olmesartan, 22 olmesartan/hydrochlorothiazide, 22 olopatadine, 47

59

omega-3 acid ethyl esters, 23 omega-3 fatty acids, 41 omega-3 fatty acids/vitamin E, 41 omeprazole delayed-rel caps, 37 omeprazole delayed-rel tabs, 37 omeprazole magnesium delayed-rel caps, 37 omeprazole magnesium delayed-rel tabs, 37 omeprazole suspension, 37 omeprazole/sodium bicarbonate, 37 OMNIPOD DASH, 31 ondansetron, 36 OPSUMIT, 24 ORFADIN, 35 ORILISSA, 33 orphenadrine/aspirin/caffeine, 29 ORTHO MICRONOR, 33 ORTHO TRI-CYCLEN LO, 32 ORTHO-NOVUM 7/7/7, 32 OS-CAL, 41 oseltamivir caps, 19 oseltamivir suspension, 19 OSENI, 30 OVIDE, 46 oxaprozin, 15 oxazepam, 25 oxcarbazepine, 25 oxybutynin, 38 oxybutynin ext-rel, 38 oxycodone caps, tabs, 16 oxycodone solution 5 mg/5 mL, 16 oxycodone/acetaminophen 5 mg/325 mg/5 mL solution, 16 oxycodone/acetaminophen 5/325, 16 oxycodone/aspirin, 16 oxymetazoline spray, 43 oxymorphone ext-rel, 16 OZEMPIC, 30 P paliperidone ext-rel, 27 paliperidone palmitate ext-rel inj, 27 palivizumab, 43 PAMELOR, 26 pancrelipase delayed-rel, 37 pantoprazole delayed-rel tabs, 37 PARAGARD, 33 paricalcitol, 34 PARLODEL, 26 PARNATE, 26 paroxetine HCl ext-rel, 26 paroxetine HCl tabs, 26 PATADAY, 47 PAXIL, 26 PAXIL CR, 26 pazopanib, 21 PEDIALYTE, 40 peg 3350/electrolytes, 37 PEGASYS, 40 pegfilgrastim-bmez, 38 pegfilgrastim-cbqv, 38 pegfilgrastim-jmdb, 38 peginterferon alfa-2a, 40 peginterferon beta-1a, 29 pegvisomant, 35 penicillamine, 40 penicillin G benzathine, 17 penicillin VK, 17

pentamidine aerosol, 20 PENTASA, 36 pentosan polysulfate sodium, 38 pentoxifylline ext-rel, 39 PEPCID, 36 PEPCID AC, 36 PEPTO-BISMOL, 35 PERCOCET, 16 PERCODAN, 16 PERIDEX, 47 permethrin 1%, 46 permethrin 5%, 46 perphenazine, 27 PERSERIS, 27 phenazopyridine, 38 phenelzine, 26 phenobarbital, 25 phenoxybenzamine, 25 phenylephrine spray, 43 PHENYTEK, 25 phenytoin, 25 phenytoin sodium extended, 25 phytonadione, 41 PIFELTRO, 18 pilocarpine, 48 pilocarpine tabs, 37 pimozide, 27 pindolol, 23 pioglitazone, 30 pioglitazone/metformin, 30 piroxicam, 15 PLAN B ONE-STEP, 33 PLAQUENIL, 40 PLAVIX, 39 PLEGRIDY, 29 podofilox solution, 47 polyethylene glycol 3350, 37 polymyxin B/bacitracin, 47 polymyxin B/trimethoprim, 47 POLYTRIM, 47 pomalidomide, 20 POMALYST, 20 potassium chloride ext-rel caps 8 mEq, 10 mEq, 40 potassium chloride ext-rel tabs 20 mEq, 40 potassium chloride liquid 20 mEq/15 mL, 40 mEq/15 mL, 40 potassium citrate ext-rel, 38 pramipexole, 26 pramipexole ext-rel, 26 pramlintide, 30 prasugrel, 39 PRAVACHOL, 23 pravastatin, 23 prazosin, 22 PRECISION XTRA kits and test strips, 31 PRECOSE, 30 PRED FORTE, 48 PRED MILD, 48 prednisolone acetate 0.12%, 48 prednisolone acetate 1%, 48 prednisolone phosphate 1%, 48 prednisolone sodium phosphate solution 5 mg/5 mL, 34 prednisolone syrup, 34 prednisone, 34 PREFEST, 34 pregabalin, 28 PREMARIN, 33

60

PREMPHASE, 34 PREMPRO, 34 prenatal vitamins/carbonyl iron/docusate/folic acid - Prenatal

AD, 41 prenatal vitamins/DHA/ferrous fumarate/folic acid, 41 prenatal vitamins/ferrous fumarate/docusate/folic acid -

Prenatal 19, 41 PREVACID, 37 PREVACID 24HR, 37 PREZCOBIX, 17 PREZISTA, 18 PRILOSEC OTC, 37 primaquine, 17 primidone, 25 PRIMSOL, 20 PRISTIQ, 26 PROAIR HFA, 43 PROAIR RESPICLICK, 43 probenecid, 15 procarbazine, 21 PROCARDIA XL, 23 prochlorperazine, 36 PROCTOFOAM-HC, 37 PROFILNINE, 39 progesterone, micronized, 35 PROGRAF, 40 PROLIA, 31 PROMACTA, 39 promethazine injection, 36 promethazine oral soln, syrup, tabs, 36 promethazine supp 12.5 mg, 25 mg, 36 PROMETRIUM, 35 propafenone, 22 propafenone ext-rel, 22 propantheline, 36 propranolol, 23 propranolol ext-rel, 23 propylthiouracil, 35 PROSCAR, 37 PROTONIX, 37 PROTOPIC, 45 PROVENTIL HFA, 43 PROVERA, 34 PROVIGIL, 29 PROZAC, 26 psyllium, 37 PULMICORT RESPULES, 44 PULMOZYME, 43 pyrantel - Reese's Pinworm Medicine, 19 pyrazinamide, 19 pyrethrins/piperonyl butoxide 4%, 46 PYRIDIUM, 38 pyridostigmine, 29 pyridostigmine ext-rel, 29 pyridoxine, 41 Q QUARTETTE, 32 QUESTRAN/QUESTRAN LIGHT, 22 quetiapine, 27 quetiapine 100 mg, 27 quetiapine ext-rel, 27 quinapril, 21 quinapril/hydrochlorothiazide, 22 quinidine sulfate, 22

R rabeprazole, 37 raloxifene, 35 raltegravir, 18 ramipril, 21 ramucirumab, 21 RANEXA, 25 ranolazine ext-rel, 25 RAPAMUNE, 40 rasagiline, 26 RAZADYNE, 26 RAZADYNE ER, 26 REBIF, 29 RECOMBINATE, 39 REGLAN, 36 REGRANEX, 47 RELENZA, 19 RELIADERM, 46 REMERON, 26 REMERON SOLTAB, 26 REMODULIN, 25 RENVELA, 34 repaglinide, 30 REPATHA, 23 REPEL SPORTSMEN, 47 REPEL SPORTSMEN MAX, 47 REQUIP XL, 27 respiratory devices, 43 RESTORIL, 28 RETACRIT, 38 RETIN-A, 44 REVATIO, 24 REVLIMID, 20 REYATAZ, 18 RHINOCORT ALLERGY, 43 ribavirin caps, tabs, 19 RID SHAMPOO, 46 rifabutin, 19 RIFADIN, 19 RIFAMATE, 19 rifampin, 19 rifampin/isoniazid, 19 rifaximin, 20 rilpivirine, 18 RISPERDAL, 27 RISPERDAL CONSTA, 27 risperidone, 27 risperidone ext-rel inj, 27 risperidone long-acting inj, 27 RITALIN, 27 RITALIN LA, 28 ritonavir, 18 rivaroxaban 2.5 mg, 38 rivastigmine caps, 26 RIXUBIS, 39 rizatriptan, 28 rizatriptan orally disintegrating tabs, 28 ROBAXIN, 29 ROBITUSSIN COUGH + CHEST CONGESTION DM, 42 ROBITUSSIN MULTI-SYMPTOM COLD, 43 ROCALTROL, 34 ropinirole, 27 ropinirole ext-rel, 27 rosuvastatin, 23 ROWASA, 36 RUBRACA, 21

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rucaparib, 21 RYDAPT, 21 RYTHMOL SR, 22 S SAFYRAL, 32 SALAGEN, 37 salmeterol xinafoate, 43 SANDIMMUNE, 40 SANDOSTATIN, 35 SANDOSTATIN LAR, 35 SANTYL, 47 sapropterin, 34 saquinavir mesylate, 18 sargramostim, 38 sarilumab, 40 SAVAYSA, 38 SAWYER, 47 scopolamine methylbromide, 36 SEASONIQUE, 32 secukinumab, 40 SEGLUROMET, 31 selegiline, 27 selenium sulfide lotion 2.5%, 45 SELZENTRY, 18 semaglutide, 30 SENSIPAR, 31 SEREVENT, 43 SEROQUEL, 27 SEROQUEL XR, 27 SEROSTIM, 34 sertraline, 26 sevelamer carbonate tabs, 34 SHINGRIX, 40 SHUR-SEAL, 33 sildenafil, 24 SILIQ, 39 SILVADENE, 44 silver sulfadiazine, 44 simvastatin, 23 SINEMET, 26 SINGULAIR, 43 siponimod, 29 sirolimus, 40 SKYLA, 33 SLO-NIACIN, 23 sodium chloride, 44, 49 sodium citrate/citric acid, 38 sodium ferric gluconate injection, 41 sodium oxybate, 29 sodium phenylbutyrate, 35 sofosbuvir/velpatasvir, 19 solifenacin, 38 SOLU-CORTEF, 34 somatropin, 34 SOMAVERT, 35 sorafenib, 21 SORIATANE, 45 sotalol, 22 spinosad, 46 SPIRIVA RESPIMAT, 41 spironolactone, 22, 24 spironolactone/hydrochlorothiazide 25 mg/25 mg, 24 SPORANOX, 17 SPRYCEL, 21 STALEVO, 26

STARLIX, 30 stavudine, 18 STEGLATRO, 31 STEGLUJAN, 31 STIMATE, 35 STIOLTO RESPIMAT, 42 STRATTERA, 27 STRIBILD, 18 STROMECTOL, 19 SUBOXONE FILM, 29 sucralfate tabs, 37 sulfacetamide solution 10%, 47 sulfacetamide/prednisolone acetate 10%/0.2%, 47 sulfacetamide/prednisolone phosphate 10%/0.25%, 47 sulfadiazine, 17 sulfamethoxazole/trimethoprim, 17 sulfamethoxazole/trimethoprim DS, 17 sulfasalazine, 36 sulfasalazine delayed-rel, 36 sulindac, 15 sumatriptan injection, 28 sumatriptan nasal spray, 28 sumatriptan tabs, 28 sunitinib, 21 SUSTIVA, 18 SUTENT, 21 SYMBICORT, 44 SYMBYAX, 27 SYMFI, 18 SYMFI LO, 18 SYMLINPEN, 30 SYMTUZA, 17 SYNAGIS, 43 SYNAREL, 33 SYNTHROID, 35 T TABLOID, 20 tacrolimus, 40, 45 tadalafil, 25 TAFINLAR, 21 TAGAMET HB, 36 TAMIFLU, 19 tamoxifen, 20 tamsulosin, 37 TAPAZOLE, 35 TARCEVA, 21 TARGRETIN, 21 TASIGNA, 21 TECFIDERA, 28 TEGRETOL, 25 TEGRETOL-XR, 25 telmisartan, 22 telmisartan/hydrochlorothiazide, 22 temazepam 15 mg, 30 mg, 28 TEMODAR, 20 temozolomide, 20 tenofovir disoproxil fumarate, 18, 19 TENORMIN, 23 terazosin, 22 terbinafine, 45 terbinafine tabs, 17 terbutaline, 43 terconazole, 38 teriflunomide, 29 TESSALON, 42

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TESTIM, 30 testosterone cypionate inj, 29 testosterone enanthate inj, 29 testosterone gel 1%, 30 tetrabenazine, 28 thalidomide, 20 THALOMID, 20 THEO-24, 44 theophylline ext-rel caps, 44 theophylline ext-rel tabs, 44 theophylline liquid, 44 thiamine, 41 thioguanine, 20 thioridazine, 27 thiothixene, 27 thyroid, 35 tiagabine, 25 TIAZAC, 23 TIGAN, 36 tigecycline, 19 TIKOSYN, 22 timolol, 23 timolol hemihydrate, 48 timolol maleate, 48 timolol maleate gel, 48 TIMOPTIC, 48 TIMOPTIC-XE, 48 TINACTIN, 45 tinidazole, 19 tiotropium 1.25 mcg, 41 tiotropium/olodaterol, 42 tipranavir, 19 TIVICAY, 18 tizanidine tabs, 29 TOBI, 43 TOBRADEX, 47 tobramycin inhalation solution, 43 tobramycin solution, 47 tobramycin/dexamethasone ointment 0.3%/0.1%, 47 tobramycin/dexamethasone suspension 0.3%/0.1%, 47 TOBREX, 47 tofacitinib, 40 tofacitinib ext-rel, 40 tolbutamide, 31 tolnaftate, 45 tolterodine, 38 tolterodine ext-rel, 38 TOPAMAX, 25 topiramate sprinkle caps, tabs, 25 TOPROL-XL, 23 toremifene, 20 torsemide, 24 TRACLEER, 24 tramadol 50 mg, 16 tramadol ext-rel tabs, 16 tramadol/acetaminophen, 16 trametinib, 21 TRANDATE, 23 trandolapril, 21 tranexamic acid, 39 tranylcypromine, 26 trazodone 50 mg, 100 mg, 150 mg, 26 treprostinil, 25 tretinoin, 44 tretinoin caps, 21 TRETTEN, 39

triamcinolone acetonide cream, lotion, ointment 0.025%, 45 triamcinolone acetonide cream, lotion, ointment 0.1%, 45 triamcinolone acetonide cream, ointment 0.5%, 45 triamcinolone acetonide spray, 43 triamcinolone paste, 47 triamterene/hydrochlorothiazide, 24 trifluoperazine, 27 trifluridine, 48 trihexyphenidyl, 27 TRILEPTAL, 25 trimethobenzamide, 36 trimethoprim, 20 trimethoprim solution, 20 TRIUMEQ, 17 tropicamide, 48 trospium, 38 trospium ext-rel, 38 TRULICITY, 30 TRUSOPT, 48 TRUVADA, 18 trypsin/balsam/castor oil, 47 TUMS, 35 TYBOST, 17 TYGACIL, 19 TYKERB, 21 TYLENOL, 15 TYLENOL w/CODEINE, 15 TYMLOS, 31 TYVASO, 25 U UDENYCA, 38 ulipristal, 33 ULTRACET, 16 ULTRAM, 16 ULTRAVATE, 46 umeclidinium, 42 umeclidinium/vilanterol, 42 UNISOM, 28 UNITHROID, 35 URECHOLINE, 38 UROCIT-K, 38 UROXATRAL, 37 URSO, 36 ursodiol, 36 V valacyclovir, 19 VALCHLOR, 20 VALCYTE, 19 valganciclovir, 19 VALIUM, 25 valproic acid, 25 valsartan, 22 valsartan/hydrochlorothiazide, 22 VALTREX, 19 VANCOCIN, 20 vancomycin caps 125 mg, 20 vancomycin oral soln, 20 varenicline, 29 VASERETIC, 21 VASOTEC, 21 venlafaxine, 26 venlafaxine ext-rel caps, 26 VENOFER, 41 VENTAVIS, 25 VENTOLIN HFA, 43

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verapamil, 23 verapamil ext-rel caps 120 mg, 180 mg, 240 mg, 23 verapamil ext-rel tabs, 23 VERELAN SR, 23 VESICARE, 38 VFEND, 17 VIBRAMYCIN, 17 VICTOZA, 30 VIRACEPT, 18 VIRAMUNE, 18 VIRAMUNE XR, 18 VIREAD, 18, 19 vismodegib, 21 VISTARIL, 42 vitamin A, 41 VITAMIN A, 41 vitamin ADC/fluoride drops, 41 vitamin ADC/fluoride/iron drops, 41 VITAMIN B-1, 41 VITAMIN B-12, 41 VITAMIN B-6, 41 VITAMIN C, 41 VITAMIN D2, 41 VITAMIN D3, 41 vitamin E, 41 VITAMIN E, 41 VIVELLE-DOT, 33 VIVITROL, 29 VOLTAREN GEL, 15 von Willebrand factor (recombinant), 39 VONVENDI, 39 voriconazole inj, 17 voriconazole tabs, 17 vorinostat, 21 VOTRIENT, 21 W warfarin, 38 WELLBUTRIN SR, 26 WELLBUTRIN XL, 26 WILATE, 39 WP THYROID, 35 X XALATAN, 48 XANAX, 25 XANAX XR, 25 XARELTO, 38 XELJANZ, 40 XELJANZ XR, 40 XELODA, 20 XENAZINE, 28 XIFAXAN, 20 XIIDRA, 48 XOPENEX HFA, 43 XYLOCAINE, 46

XYNTHA, 39 XYREM, 29 XYZAL, 42 Y YASMIN, 32 YAZ, 32 Z ZADITOR, 47 zafirlukast, 43 zaleplon, 28 ZANAFLEX, 29 zanamivir, 19 ZARONTIN, 25 ZARXIO, 38 ZATEAN-PN DHA, 41 ZEGERID OTC, 37 ZEMPLAR, 34 ZESTORETIC, 21 ZESTRIL, 21 ZETIA, 22 ZIAC, 23 zidovudine, 18 ZIEXTENZO, 38 ZIKS, 46 ZINECARD, 21 ziprasidone, 27 ZITHROMAX, 16 ZOCOR, 23 ZOFRAN, 36 zoledronic acid, 31 ZOLINZA, 21 zolmitriptan, 28 zolmitriptan nasal spray, 28 zolmitriptan orally disintegrating tabs, 28 ZOLOFT, 26 zolpidem, 28 zolpidem ext-rel, 28 ZOMIG, 28 ZOMIG-ZMT, 28 ZONEGRAN, 25 zonisamide, 25 ZOSTAVAX, 40 zoster vaccine, 40 ZOSTRIX HP, 46 ZOSTRIX NATURAL, 46 ZOVIRAX, 19 ZYKADIA, 21 ZYLOPRIM, 15 ZYPREXA, 27 ZYPREXA RELPREVV, 27 ZYPREXA ZYDIS, 27 ZYRTEC, 42 ZYRTEC-D 12 Hour, 42 ZYVOX, 19

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