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Transcript of 2018 Covered Drug List - Blue Cross and Blue Shield of ... Covered Drug List. ... an independent...
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2018 Covered Drug List
201804HQ1509 R08/17 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Ser vice & Indemnity Company. HMO Louisiana, Inc. is a subsidiary of Blue Cross and Blue Shield of Louisiana.
Both companies are independent licensees of the Blue Cross and Blue Shield Association.
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Understanding Your Covered Drug List
Blue Cross and Blue Shield of Louisiana and our subsidiary, HMO Louisiana, Inc., along with Express Scripts, an independent company that serves as our pharmacy benefit manager, created this Covered Drug List to help you understand your drug benefits. Because drug benefits can be complex, understanding your benefits is key to getting the most from your health plan.
Throughout the year, our Blue Cross Pharmacy and Therapeutics Committee, a group of Louisiana doctors and pharmacists, reviews published literature about the safety, efficacy and cost of prescription drugs.
You and your doctor always make the final decision for your healthcare needs. The information in this List can help you and your doctor make informed decisions before you fill your next prescription. That way, together you may choose the best drug for you while keeping your costs down.
Please talk to your doctor or pharmacist about any questions or concerns you may have about your drug therapy.
Please Note: Inclusion of a drug in a drug formulary does not guarantee that a member's physician or other authorized prescriber will prescribe the drug for a particular medical condition or mental illness.
Before you fill a prescription for any drug, you should take the following steps, if needed: 1) Check to see if the drugs you take are on the drug List. 2) Talk to your doctor about switching to a drug that is on the List, if needed. Important Notes: This List is intended to include all drugs that your plan covers as of the time the document was created. But
the List may change as changes occur in the marketplace. This List may not apply to all benefit plans. Some benefit plans may have different coverage for specific drugs. The List applies only to prescription drugs that network pharmacies dispense on an outpatient basis. See your member contract or certificate for pharmacy coverage for any exclusions and limitations that apply. How can you find information about your drugs? Use the index at the end of this List to look up a drug you may take to quickly learn several important things: If you must first try one or more prescription drugs before your plan will cover a specific drug for your condition, If your doctor must get prior authorization before your plan will pay for a drug, If your plan limits the quantity that will be covered each time you fill a prescription
04HQ1509 R10/17 i
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Drug Requirements/Limits
generic drug name QPD BRAND DRUG NAME PA; ST
Key: generic drugs are in lower case italics BRAND NAME drugs are in ALL CAPS
Key: PA = Prior authorization QPD = Quantity per dispensing limits ST = Step therapy restrictions SP = Specialty drug restrictions
Example of How Drugs Are Listed:
What do the abbreviations in the Requirements/Limits column mean? PA: Medications requiring prior authorization
We must authorize certain drugs before your plan will pay for them. After considering current medical literature, the Pharmacy and Therapeutics Committee sets up the criteria needed for the drugs to be authorized. Then, Express Scripts processes the prior authorization requests.
If you need prior authorization, have your doctor contact Express Scripts: Call: 18008422015 Fax: 18772515896 For the physician fax form, go to: www.bcbsla.com > Provider > Pharmacy.
ST: Medications requiring participation in the step therapy program For drugs in our step therapy program, you must first try certain prescription drugs (Step 1) before your plan will cover other drugs (Step 2) for your condition. If one of the Step 1 drugs is not right for you, your doctor may call us for a prior authorization for a Step 2 drug. You can find more information about drugs that you must try first at www.bcbsla.com/CoveredDrugs.
QPD: Medications that have quantity per dispensing limits Covered prescriptions have a daysupply limitation (typically up to a 30day supply at a retail pharmacy and up to a 90day supply for mailorder). Your plan also limits the amount of certain drugs that can be dispensed at one time. We call those restrictions quantity per dispensing (QPD) limits.
QPD limits are additional to the daysupply limitation and are based on the manufacturers recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDAapproved recommendations or clinical studies and as determined by Blue Cross. QPD limits or allowances are subject to quantity limits per day supply, per dispensing event or any combination of the two. See your member contract or certificate for the limits for your plan. For a complete list of drugs and their QPD limitations, go to www.bcbsla.com/CoveredDrugs.
SP: Specialty drug restrictions Certain drugs are commonly called specialty drugs. Specialty drugs include biotechnology drugs or other drug products that may require special ordering, handling or customer service. Your policy may limit specialty drugs to the retail day supply listed in your plan (typically a 30day supply). Read your Schedule
04HQ1509 R10/17 ii
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of Benefits for any restrictions that apply to you. For a complete list of specialty drugs, go to www.bcbsla.com/CoveredDrugs.
Questions? If your doctor prescribes a drug that is not in this List, or if you have any questions, call Express Scripts at 18667817533.
For more information and updates, go to: www.bcbsla.com/CoveredDrugs or www.expressscripts.com.
04HQ1509 R10/17 iii
http:www.express-scripts.comwww.bcbsla.com/CoveredDrugswww.bcbsla.com/CoveredDrugs
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Table of Contents
*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*.................................................................................................................5 *Aminoglycosides*....................................................................................................................................................................5 *Analgesics - Anti-Inflammatory*............................................................................................................................................. 6 *Analgesics - Nonnarcotic*....................................................................................................................................................... 8 *Analgesics - Opioid*.............................................................................................................................................................. 10 *Androgens-Anabolic*............................................................................................................................................................ 12 *Anorectal Agents*................................................................................................................................................................. 12 *Anthelmintics*.......................................................................................................................................................................13 *Antianginal Agents*...............................................................................................................................................................13 *Antianxiety Agents*...............................................................................................................................................................13 *Antiarrhythmics*................................................................................................................................................................... 14 *Antiasthmatic And Bronchodilator Agents*..........................................................................................................................14 *Anticoagulants*.....................................................................................................................................................................16 *Anticonvulsants*................................................................................................................................................................... 17 *Antidepressants*...................................................................................................................................................................19 *Antidiabetics*........................................................................................................................................................................20 *Antidiarrheals*...................................................................................................................................................................... 23 *Antidotes And Specific Antagonists*.....................................................................................................................................23 *Antidotes*............................................................................................................................................................................. 23 *Antiemetics*..........................................................................................................................................................................24 *Antifungals*...........................................................................................................................................................................24 *Antihistamines*.....................................................................................................................................................................25 *Antihyperlipidemics*.............................................................................................................................................................25 *Antihypertensives*................................................................................................................................................................26 *Anti-Infective Agents - Misc.*................................................................................................................................................28 *Antimalarials*........................................................................................................................................................................29 *Antimyasthenic Agents*........................................................................................................................................................29 *Antimyasthenic/Cholinergic Agents*.................................................................................................................................... 29 *Antimycobacterial Agents*................................................................................................................................................... 29 *Antineoplastic - Bcl-2 Inhibitors***...................................................................................................................................... 30 *Antineoplastics And Adjunctive Therapies*.......................................................................................................................... 30 *Antiparkinson Agents*.......................................................................................................................................................... 33 *Antipsychotics/Antimanic Agents*........................................................................................................................................34 *Antiretrovirals Adjuvants***.................................................................................................................................................35 *Antivirals*..............................................................................................................................................................................35 *Assorted Classes*.................................................................................................................................................................. 38 *Beta Blockers*....................................................................................................................................................................... 39 *Bile Acid Synthesis Disorder Agents***................................................................................................................................ 40 *Calcium Channel Blockers*....................................................................................................................................................40 *Cardiotonics*.........................................................................................................................................................................41 *Cardiovascular Agents - Misc.*..............................................................................................................................................41 *Cephalosporins*.................................................................................................................................................................... 41 *Contraceptives*.....................................................................................................................................................................42 *Corticosteroids*.................................................................................................................................................................... 47 *Cough/Cold/Allergy* ............................................................................................................................................................. 47 *Cyclin-Dependent Kinases (Cdk) Inhibitors***......................................................................................................................49 *Cystic Fibrosis Agent - Combinations***...............................................................................................................................49 *Dermatologicals*...................................................................................................................................................................49 *Diagnostic Products*.............................................................................................................................................................54 *Digestive Aids*...................................................................................................................................................................... 55
1
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*Direct-Acting P2y12 Inhibitors***.........................................................................................................................................55 *Diuretics*...............................................................................................................................................................................55 *Endocrine And Metabolic Agents - Misc.*.............................................................................................................................56 *Estrogens*............................................................................................................................................................................. 57 *Estrogen-Selective Estrogen Receptor Modulator Comb***................................................................................................58 *Fluoroquinolones*.................................................................................................................................................................58 *Gastrointestinal Agents - Misc.*............................................................................................................................................59 *Genitourinary Agents - Miscellaneous*................................................................................................................................ 60 *Gout Agents*.........................................................................................................................................................................61 *Hematological Agents - Misc.*.............................................................................................................................................. 61 *Hematopoietic Agents*.........................................................................................................................................................62 *Hemostatics*.........................................................................................................................................................................64 *Hepatitis C Agent - Combinations***....................................................................................................................................64 *Hereditary Orotic Aciduria Treatment - Agents**.................................................................................................................64 *Hypnotics*.............................................................................................................................................................................64 *Hypophosphatasia (Hpp) Agents***..................................................................................................................................... 64 *Ibs Agent - Mu-Opioid Receptor Agonists***....................................................................................................................... 65 *Insulin-Incretin Mimetic Combinations***........................................................................................................................... 65 *Isocitrate Dehydrogenase-2 (Idh2) Inhibitors***..................................................................................................................65 *Laxatives*.............................................................................................................................................................................. 65 *Leptin Analogues***............................................................................................................................................................. 67 *Lymphocyte Function-Associated Antigen-1 (Lfa-1) Antag***............................................................................................. 68 *Macrolides*........................................................................................................................................................................... 68 *Medical Devices*...................................................................................................................................................................68 *Migraine Products*............................................................................................................................................................... 69 *Minerals & Electrolytes*....................................................................................................................................................... 69 *Monobactams***..................................................................................................................................................................73 *Mouth/Throat/Dental Agents*............................................................................................................................................. 73 *Multivitamins*.......................................................................................................................................................................74 *Musculoskeletal Therapy Agents*.........................................................................................................................................80 *Nasal Agents - Systemic And Topical*................................................................................................................................... 80 *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb***..............................................................................................81 *Neurogenic Orthostatic Hypotension (Noh) - Agents***......................................................................................................81 *Neuromuscular Agents*........................................................................................................................................................ 81 *Ophthalmic Agents*.............................................................................................................................................................. 81 *Otic Agents*.......................................................................................................................................................................... 85 *Oxytocics*............................................................................................................................................................................. 85 *Passive Immunizing Agents*................................................................................................................................................. 85 *Pcsk9 Inhibitors***............................................................................................................................................................... 85 *Pediatric Multiple Vitamins & Minerals W/ Fluoride***...................................................................................................... 85 *Pediatric Multiple Vitamins W/Fluoride-Iron-Zinc***.......................................................................................................... 85 *Penicillins*.............................................................................................................................................................................86 *Pharmaceutical Adjuvants*...................................................................................................................................................86 *Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors***............................................................................................................... 86 *Phosphodiesterase 4 (Pde4) Inhibitors***............................................................................................................................86 *Poly (Adp-Ribose) Polymerase (Parp) Inhibitors**...............................................................................................................86 *Poly (Adp-Ribose) Polymerase (Parp) Inhibitors***..............................................................................................................86 *Potassium Removing Agents***........................................................................................................................................... 87 *Progestins*............................................................................................................................................................................ 87 *Protease-Activated Receptor-1 (Par-1) Antagonists***........................................................................................................87 *Psychotherapeutic And Neurological Agents - Misc.*...........................................................................................................87 *Pulmonary Fibrosis Agents - Kinase Inhibitors***................................................................................................................ 90 *Pulmonary Fibrosis Agents***.............................................................................................................................................. 90 *Pulmonary Hypertension - Prostacyclin Receptor Agonist***..............................................................................................90
2
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*Respiratory Agents - Misc.*...................................................................................................................................................90 *Serotonin Modulators***..................................................................................................................................................... 91 *Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations***............................................................................................................... 91 *Sinus Node Inhibitors**........................................................................................................................................................ 91 *Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb***........................................................................................ 91 *Sulfonamides*....................................................................................................................................................................... 91 *Tetracyclines*........................................................................................................................................................................91 *Thyroid Agents*.....................................................................................................................................................................92 *Toxoids*................................................................................................................................................................................ 92 *Ulcer Drugs*.......................................................................................................................................................................... 93 *Urinary Anti-Infectives*.........................................................................................................................................................94 *Urinary Antispasmodics*.......................................................................................................................................................95 *Vaccines*...............................................................................................................................................................................95 *Vaginal Products*..................................................................................................................................................................97 *Vasopressors*....................................................................................................................................................................... 97 *Vitamins*...............................................................................................................................................................................98
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4
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Drug Name Requirements/Limits
*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*
*Adhd Agent - Selective Alpha Adrenergic Agonists***
clonidine hcl er QPD
guanfacine hcl er QPD
*Adhd Agent - Selective Norepinephrine Reuptake Inhibitor***
atomoxetine hcl QPD
*Amphetamine Mixtures***
amphetamine-dextroamphet er QPD
amphetamine-dextroamphetamine QPD
MYDAYIS QPD
*Amphetamines***
dextroamphetamine sulfate er QPD
dextroamphetamine sulfate oral solution
dextroamphetamine sulfate oral tablet QPD
methamphetamine hcl QPD
VYVANSE QPD
*Analeptics***
caffeine citrate oral
*Stimulants - Misc.***
armodafinil PA; QPD
DAYTRANA QPD
dexmethylphenidate hcl QPD
dexmethylphenidate hcl er QPD
metadate er oral tablet extended release 20 mg QPD
methylphenidate hcl er (cd) QPD
methylphenidate hcl er (la) QPD
methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg
QPD
methylphenidate hcl er oral tablet extended release 24 hour QPD
methylphenidate hcl oral solution QPD
methylphenidate hcl oral tablet QPD
methylphenidate hcl oral tablet chewable QPD
modafinil PA; QPD
QUILLIVANT XR QPD
*Aminoglycosides*
*Aminoglycosides***
BETHKIS PA; SP; QPD
neomycin sulfate oral
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 5
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Drug Name Requirements/Limits
paromomycin sulfate oral
TOBI PODHALER PA; SP; QPD
tobramycin inhalation PA; SP; QPD
*Analgesics - Anti-Inflammatory*
*Antirheumatic - Janus Kinase (Jak) Inhibitors***
XELJANZ PA; SP; QPD
XELJANZ XR PA; SP; QPD
*Antirheumatic Antimetabolites***
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML
SP; QPD
*Anti-Tnf-Alpha - Monoclonal Antibodies***
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
PA; SP; QPD
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PA; SP; QPD
HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT PA; SP; QPD
HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT PA; SP; QPD
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT PA; SP; QPD
SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QPD
SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QPD
*Anti-Tnf-Alpha - Monoclonoal Antibodies***
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
PA; SP; QPD
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PA; SP; QPD
HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT PA; SP; QPD
HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT PA; SP; QPD
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT PA; SP; QPD
SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QPD
SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QPD
*Cyclooxygenase 2 (Cox-2) Inhibitors***
celecoxib oral QPD
*Gold Compounds***
RIDAURA
*Interleukin-1 Blockers***
ARCALYST SP; QPD
*Interleukin-1 Receptor Antagonist (Il-1Ra)***
KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 6
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Drug Name Requirements/Limits
*Interleukin-6 Receptor Inhibitors***
ACTEMRA SUBCUTANEOUS PA; SP; QPD
*Nonsteroidal Anti-Inflammatory Agent Combinations***
diclofenac-misoprostol oral tablet delayed release
*Nonsteroidal Anti-Inflammatory Agents (Nsaids)***
diclofenac potassium
diclofenac sodium er
diclofenac sodium oral
etodolac er
etodolac oral
fenoprofen calcium oral tablet PA
flurbiprofen oral
ibuprofen oral suspension
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
indomethacin er
indomethacin oral
ketoprofen er PA
ketoprofen oral capsule 75 mg
ketorolac tromethamine oral QPD
meclofenamate sodium oral
mefenamic acid oral PA
meloxicam oral tablet QPD
nabumetone oral
naproxen dr
naproxen oral
naproxen sodium oral tablet 275 mg, 550 mg
oxaprozin
piroxicam oral
sulindac oral
tolmetin sodium PA
*Pyrimidine Synthesis Inhibitors***
leflunomide oral QPD
*Selective Costimulation Modulators***
ORENCIA CLICKJECT PA; SP; QPD
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QPD
*Soluble Tumor Necrosis Factor Receptor Agents***
ENBREL MINI PA; SP; QPD
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 7
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Drug Name Requirements/Limits
ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP; QPD
ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QPD
*Analgesics - Nonnarcotic*
*Analgesics-Sedatives***
butalbital-acetaminophen oral tablet 50-325 mg QPD
butalbital-apap QPD
butalbital-apap-caffeine oral capsule QPD
butalbital-apap-caffeine oral tablet 50-325-40 mg QPD
butalbital-asa-caffeine
butalbital-aspirin-caffeine
tencon oral tablet 50-325 mg QPD
zebutal oral capsule 50-325-40 mg QPD
*Salicylates***
adult aspirin ec low strength
aspir-81
aspirin 81
aspirin adult low dose
aspirin adult low strength
aspirin childrens
aspirin ec low dose
aspirin ec low strength
aspirin ec oral tablet delayed release 81 mg
aspirin low dose adult
aspirin low dose oral tablet chewable
aspirin low dose oral tablet delayed release
aspirin low strength
aspirin oral tablet chewable
aspirin oral tablet delayed release 81 mg
aspir-low
bayer aspirin ec low dose
bayer low dose
childrens aspirin
childrens aspirin low strength
cvs aspirin adult low dose
cvs aspirin adult low strength
cvs aspirin ec oral tablet delayed release 81 mg
cvs aspirin low dose
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 8
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Drug Name Requirements/Limits
diflunisal oral
ec-81 aspirin
ecotrin low strength
eq aspirin adult low dose
eq aspirin low dose oral tablet chewable
eq childrens aspirin
eql aspirin low dose
gnp adult aspirin low strength oral tablet chewable
gnp aspirin low dose
gnp aspirin oral tablet delayed release 81 mg
goodsense aspirin adult low st
goodsense aspirin low dose
goodsense aspirin oral tablet chewable
hm aspirin ec low dose
hm aspirin oral tablet chewable
kls aspirin low dose
kp aspirin
miniprin low dose
px aspirin oral tablet chewable
px enteric aspirin oral tablet delayed release 81 mg
qc aspirin low dose
qc childrens aspirin
ra aspirin adult low dose
ra aspirin adult low strength
ra aspirin childrens
ra aspirin ec adult low st
ra aspirin ec oral tablet delayed release 81 mg
ra childrens aspirin
salsalate oral
sb aspirin adult low strength
sb aspirin oral tablet delayed release
sb childrens aspirin
sb low dose asa ec
sm aspirin adult low strength
sm aspirin ec low strength
sm childrens aspirin
st joseph low dose
tgt aspirin low dose oral tablet delayed release
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 9
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Drug Name Requirements/Limits
tgt aspirin oral tablet chewable
tgt aspirin oral tablet delayed release
tgt childrens aspirin
*Analgesics - Opioid*
*Codeine Combinations***
acetaminophen-codeine PA; QPD
acetaminophen-codeine #2 PA; QPD
acetaminophen-codeine #3 PA; QPD
acetaminophen-codeine #4 PA; QPD
ascomp-codeine PA; QPD
butalbital-apap-caff-cod PA; QPD
butalbital-asa-caff-codeine PA; QPD
*Hydrocodone Combinations***
hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml PA; QPD
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
PA; QPD
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg PA; QPD
lorcet PA; QPD
lorcet hd PA; QPD
lorcet plus oral tablet 7.5-325 mg PA; QPD
verdrocet PA; QPD
vicodin es oral tablet 7.5-300 mg PA; QPD
vicodin hp oral tablet 10-300 mg PA; QPD
vicodin oral tablet 5-300 mg PA; QPD
*Opioid Agonists***
codeine sulfate oral tablet PA
EMBEDA PA; ST; QPD
fentanyl citrate buccal PA; QPD
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
PA; QPD
hydromorphone hcl er PA; QPD
hydromorphone hcl oral PA
hydromorphone hcl rectal PA
HYSINGLA ER PA; QPD
levorphanol tartrate oral PA
meperidine hcl oral PA
methadone hcl intensol PA
methadone hcl oral PA
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 10
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Drug Name Requirements/Limits
methadose oral concentrate 10 mg/ml PA
methadose oral tablet soluble PA
methadose sugar-free PA
morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml PA
morphine sulfate er beads PA; QPD
morphine sulfate er oral capsule extended release 24 hour PA; QPD
morphine sulfate er oral tablet extended release PA; QPD
morphine sulfate oral PA
morphine sulfate rectal PA
NUCYNTA PA
oxycodone hcl oral capsule PA
oxycodone hcl oral concentrate 100 mg/5ml PA
oxycodone hcl oral solution PA
oxycodone hcl oral tablet PA
OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT PA; QPD
oxymorphone hcl PA
oxymorphone hcl er PA; QPD
tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg
QPD
tramadol hcl er oral tablet extended release 24 hour QPD
tramadol hcl oral
*Opioid Combinations***
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg PA; QPD
oxycodone-acetaminophen oral solution PA; QPD
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
PA; QPD
oxycodone-aspirin oral tablet 4.8355-325 mg PA; QPD
oxycodone-ibuprofen PA; QPD
*Opioid Partial Agonists***
butorphanol tartrate nasal QPD
BUTRANS PA; QPD
pentazocine-naloxone hcl
SUBOXONE SUBLINGUAL FILM
ZUBSOLV
*Tramadol Combinations***
tramadol-acetaminophen QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 11
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Drug Name Requirements/Limits
*Androgens-Anabolic*
*Anabolic Steroids***
ANADROL-50
oxandrolone oral
*Androgens***
ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%) PA; QPD
ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)
PA; QPD
danazol oral
METHITEST
testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml
testosterone enanthate intramuscular solution
testosterone gel 12.5 mg/act (1%) transdermal PA; QPD
testosterone gel 50 mg/5gm (1%) transdermal PA; QPD
testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)
PA; QPD
testosterone transdermal solution PA; QPD
*Anorectal Agents*
*Intrarectal Steroids***
colocort
CORTIFOAM
hydrocortisone rectal enema
UCERIS RECTAL
*Nitrate Vasodilating Agents***
RECTIV
*Rectal Anesthetic/Steroids***
hydrocortisone ace-pramoxine rectal cream 1-1 %
hydrocortisone ace-pramoxine rectal cream 2.5-1 % QPD
lidocaine-hydrocortisone ace rectal cream
pramcort rectal
*Rectal Steroids***
anucort-hc
hydrocortisone acetate rectal
hydrocortisone rectal cream
procto-med hc
procto-pak
proctosol hc
proctozone-hc rectal
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 12
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Drug Name Requirements/Limits
*Anthelmintics*
*Anthelmintics***
ALBENZA
BILTRICIDE
EMVERM QPD
ivermectin oral
praziquantel oral
*Antianginal Agents*
*Antianginals-Other***
RANEXA
*Nitrates***
isosorbide dinitrate er
isosorbide dinitrate oral
isosorbide mononitrate
isosorbide mononitrate er
nitro-bid
nitroglycerin er
nitroglycerin sublingual
nitroglycerin transdermal patch 24 hour
nitro-time
*Antianxiety Agents*
*Antianxiety Agents - Misc.***
buspirone hcl oral
hydroxyzine hcl oral syrup
hydroxyzine hcl oral tablet
hydroxyzine pamoate oral
meprobamate
*Benzodiazepines***
alprazolam er
alprazolam intensol
alprazolam oral tablet
alprazolam oral tablet dispersible
alprazolam xr
chlordiazepoxide hcl
clorazepate dipotassium
diazepam intensol
diazepam oral solution 1 mg/ml
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 13
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Drug Name Requirements/Limits
diazepam oral tablet
lorazepam intensol
lorazepam oral
oxazepam
*Antiarrhythmics*
*Antiarrhythmics Type I-A***
disopyramide phosphate oral
NORPACE CR
quinidine gluconate er
quinidine sulfate oral
*Antiarrhythmics Type I-B***
mexiletine hcl oral
*Antiarrhythmics Type I-C***
flecainide acetate
propafenone hcl
propafenone hcl er
*Antiarrhythmics Type Iii***
amiodarone hcl oral
dofetilide
MULTAQ
pacerone oral tablet 100 mg, 200 mg, 400 mg
*Antiasthmatic And Bronchodilator Agents*
*5-Lipoxygenase Inhibitors***
zileuton er PA; QPD
ZYFLO PA; QPD
*Adrenergic Combinations***
ADVAIR DISKUS QPD
ADVAIR HFA QPD
ANORO ELLIPTA QPD
BEVESPI AEROSPHERE PA; QPD
BREO ELLIPTA QPD
COMBIVENT RESPIMAT QPD
DULERA PA; QPD
FLUTICASONE-SALMETEROL QPD
ipratropium-albuterol QPD
STIOLTO RESPIMAT QPD
SYMBICORT QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 14
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Drug Name Requirements/Limits
TRELEGY ELLIPTA QPD
UTIBRON NEOHALER PA; QPD
*Anti-Inflammatory Agents***
cromolyn sodium inhalation
*Beta Adrenergics***
albuterol sulfate er
albuterol sulfate inhalation
albuterol sulfate oral
ARCAPTA NEOHALER PA; QPD
BROVANA PA; QPD
levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml
LEVALBUTEROL TARTRATE PA; QPD
metaproterenol sulfate oral
PERFOROMIST PA; QPD
PROAIR HFA QPD
PROAIR RESPICLICK QPD
PROVENTIL HFA PA; QPD
SEREVENT DISKUS QPD
STRIVERDI RESPIMAT QPD
terbutaline sulfate oral
VENTOLIN HFA QPD
XOPENEX HFA PA; QPD
*Bronchodilators - Anticholinergics***
ATROVENT HFA QPD
INCRUSE ELLIPTA QPD
ipratropium bromide inhalation
SEEBRI NEOHALER PA; QPD
SPIRIVA HANDIHALER QPD
SPIRIVA RESPIMAT QPD
TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED PA; QPD
*Leukotriene Receptor Antagonists***
montelukast sodium oral QPD
zafirlukast QPD
*Selective Phosphodiesterase 4 (Pde4) Inhibitors***
DALIRESP QPD
*Steroid Inhalants***
ALVESCO PA; QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 15
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Drug Name Requirements/Limits
ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT
QPD
ASMANEX 120 METERED DOSES PA; QPD
ASMANEX 14 METERED DOSES PA; QPD
ASMANEX 30 METERED DOSES PA; QPD
ASMANEX 60 METERED DOSES PA; QPD
ASMANEX 7 METERED DOSES PA; QPD
ASMANEX HFA PA; QPD
budesonide inhalation QPD
FLOVENT DISKUS QPD
FLOVENT HFA QPD
PULMICORT FLEXHALER PA; QPD
QVAR INHALATION AEROSOL SOLUTION QPD
QVAR REDIHALER QPD
*Xanthines***
THEO-24
theochron oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg
theophylline
theophylline er
*Anticoagulants*
*Coumarin Anticoagulants***
COUMADIN ORAL
jantoven
warfarin sodium oral
*Direct Factor Xa Inhibitors***
ELIQUIS QPD
ELIQUIS STARTER PACK QPD
SAVAYSA PA; QPD
XARELTO QPD
XARELTO STARTER PACK QPD
*Heparins And Heparinoid-Like Agents***
heparin lock flush intravenous solution 1 unit/ml, 10 unit/ml, 100 unit/ml
heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml
heparin sodium (porcine) pf
heparin sodium lock flush intravenous solution 100 unit/ml
*Low Molecular Weight Heparins***
enoxaparin sodium
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 16
-
Drug Name Requirements/Limits
FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML
*Synthetic Heparinoid-Like Agents***
fondaparinux sodium
*Thrombin Inhibitors - Selective Direct & Reversible***
PRADAXA PA; QPD
*Anticonvulsants*
*Ampa Glutamate Receptor Antagonists***
FYCOMPA
*Anticonvulsants - Benzodiazepines***
clonazepam oral
DIASTAT ACUDIAL
DIASTAT PEDIATRIC
diazepam rectal
KLONOPIN
ONFI ORAL SUSPENSION
ONFI ORAL TABLET 10 MG, 20 MG
*Anticonvulsants - Misc.***
APTIOM QPD
BANZEL
carbamazepine er
carbamazepine oral
CARBATROL
epitol
gabapentin oral capsule
gabapentin oral solution 250 mg/5ml
gabapentin oral tablet
KEPPRA ORAL
KEPPRA XR
LAMICTAL ODT
LAMICTAL ORAL TABLET
LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG
LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR
lamotrigine er
lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg
lamotrigine oral tablet
lamotrigine oral tablet chewable
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 17
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Drug Name Requirements/Limits
lamotrigine oral tablet dispersible
levetiracetam er
levetiracetam oral
LYRICA
MYSOLINE
oxcarbazepine
OXTELLAR XR
primidone oral
QUDEXY XR PA; QPD
roweepra
TEGRETOL ORAL SUSPENSION
TEGRETOL ORAL TABLET
TEGRETOL-XR
TOPAMAX
TOPAMAX SPRINKLE
topiramate oral capsule sprinkle
topiramate oral tablet
TRILEPTAL
TROKENDI XR PA; QPD
VIMPAT ORAL
ZONEGRAN
zonisamide oral
*Carbamates***
felbamate
FELBATOL
*Gaba Modulators***
GABITRIL
SABRIL PA; SP; QPD
tiagabine hcl
vigabatrin PA; SP; QPD
*Hydantoins***
DILANTIN INFATABS
DILANTIN ORAL CAPSULE 100 MG
DILANTIN ORAL CAPSULE 30 MG
DILANTIN ORAL SUSPENSION
PEGANONE
PHENYTEK
phenytoin infatabs
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 18
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Drug Name Requirements/Limits
phenytoin oral suspension 125 mg/5ml
phenytoin oral tablet chewable
phenytoin sodium extended
*Succinimides***
CELONTIN
ethosuximide oral
ZARONTIN
*Valproic Acid***
DEPAKENE ORAL CAPSULE
DEPAKENE ORAL SOLUTION
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE
divalproex sodium er oral tablet extended release 24 hour
divalproex sodium oral capsule delayed release sprinkle
divalproex sodium oral tablet delayed release
valproate sodium oral solution
valproic acid oral capsule
valproic acid oral solution
*Antidepressants*
*Alpha-2 Receptor Antagonists (Tetracyclics)***
mirtazapine oral QPD
*Antidepressants - Misc.***
bupropion hcl er (sr) QPD
bupropion hcl er (xl) QPD
bupropion hcl oral
maprotiline hcl
*Modified Cyclics***
nefazodone hcl
trazodone hcl oral
TRINTELLIX ST
VIIBRYD ORAL TABLET ST; QPD
VIIBRYD STARTER PACK ST; QPD
*Monoamine Oxidase Inhibitors (Maois)***
EMSAM QPD
MARPLAN
phenelzine sulfate oral
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 19
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Drug Name Requirements/Limits
tranylcypromine sulfate
*Selective Serotonin Reuptake Inhibitors (Ssris)***
citalopram hydrobromide QPD
escitalopram oxalate QPD
fluoxetine hcl oral capsule QPD
fluoxetine hcl oral capsule delayed release QPD
fluoxetine hcl oral solution QPD
fluoxetine hcl oral tablet 10 mg, 20 mg QPD
fluvoxamine maleate QPD
fluvoxamine maleate er QPD
paroxetine hcl er QPD
paroxetine hcl oral tablet QPD
sertraline hcl oral QPD
*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)***
desvenlafaxine succinate er QPD
duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg QPD
FETZIMA ST
FETZIMA TITRATION ST
venlafaxine hcl QPD
venlafaxine hcl er oral capsule extended release 24 hour QPD
*Tricyclic Agents***
amitriptyline hcl oral
amoxapine
clomipramine hcl oral
desipramine hcl oral
doxepin hcl oral
imipramine hcl oral
imipramine pamoate
nortriptyline hcl oral
protriptyline hcl
trimipramine maleate oral
*Antidiabetics*
*Alpha-Glucosidase Inhibitors***
acarbose
miglitol
*Antidiabetic - Amylin Analogs***
SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 20
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Drug Name Requirements/Limits
SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; QPD
*Biguanides***
metformin hcl er QPD
metformin hcl oral QPD
*Diabetic Other***
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY
PROGLYCEM SP
*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***
ALOGLIPTIN BENZOATE PA; ST; QPD
JANUVIA ST; QPD
TRADJENTA ST; QPD
*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations***
JANUMET ST; QPD
JANUMET XR ST; QPD
JENTADUETO ST; QPD
JENTADUETO XR ST; QPD
*Dopamine Receptor Agonists - Ergot Derivatives***
CYCLOSET ST
*Human Insulin***
APIDRA PA
APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR PA
FIASP
FIASP FLEXTOUCH
HUMALOG PA
HUMALOG JUNIOR KWIKPEN PA
HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML
PA
HUMALOG MIX 50/50 PA
HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
PA
HUMALOG MIX 75/25 PA
HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
PA
HUMULIN R U-500 (CONCENTRATED)
HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR
LANTUS
LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 21
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Drug Name Requirements/Limits
LEVEMIR
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
NOVOLIN 70/30 RELION
NOVOLIN N
NOVOLIN N RELION
NOVOLIN R
NOVOLIN R RELION
NOVOLOG
NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE
TOUJEO MAX SOLOSTAR
TOUJEO SOLOSTAR
TRESIBA FLEXTOUCH
*Incretin Mimetic Agents (Glp-1 Receptor Agonists)***
BYDUREON BCISE PA; QPD
BYDUREON SUBCUTANEOUS PEN-INJECTOR PA; QPD
BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER PA; QPD
BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; QPD
BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; QPD
TRULICITY PA; QPD
VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; QPD
*Meglitinide Analogues***
nateglinide
repaglinide
*Meglitinide-Biguanide Combinations***
repaglinide-metformin hcl QPD
*Progesterone Receptor Antagonists***
KORLYM PA; SP; QPD
*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors***
FARXIGA ST; QPD
INVOKANA ST; QPD
JARDIANCE ST; QPD
STEGLATRO ST; QPD
*Sulfonylurea-Biguanide Combinations***
glipizide-metformin hcl QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 22
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Drug Name Requirements/Limits
glyburide-metformin QPD
*Sulfonylureas***
chlorpropamide QPD
glimepiride QPD
glipizide er QPD
glipizide oral QPD
glipizide xl QPD
glyburide micronized QPD
glyburide oral QPD
tolazamide QPD
tolbutamide QPD
*Sulfonylurea-Thiazolidinedione Combinations***
pioglitazone hcl-glimepiride QPD
*Thiazolidinedione-Biguanide Combinations***
ACTOPLUS MET XR ST; QPD
pioglitazone hcl-metformin hcl QPD
*Thiazolidinediones***
AVANDIA ORAL TABLET 2 MG, 4 MG ST; QPD
pioglitazone hcl QPD
*Antidiarrheals*
*Antidiarrheal - Chloride Channel Antagonists***
MYTESI SP; QPD
*Antiperistaltic Agents***
diphenoxylate-atropine
loperamide hcl oral capsule
opium
paregoric
*Antidotes And Specific Antagonists*
*Antidotes And Specific Antagonists***
VISTOGARD SP; QPD
*Antidotes*
*Antidotes - Chelating Agents***
CHEMET SP
EXJADE SP
FERRIPROX SP
JADENU SP
JADENU SPRINKLE SP
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 23
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Drug Name Requirements/Limits
*Antidotes***
VISTOGARD SP; QPD
*Opioid Antagonists***
naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml QPD
naloxone hcl injection solution cartridge QPD
naloxone hcl injection solution prefilled syringe QPD
naltrexone hcl oral
NARCAN QPD
*Antiemetics*
*5-Ht3 Receptor Antagonists***
ANZEMET ORAL QPD
granisetron hcl oral QPD
ondansetron QPD
ondansetron hcl oral QPD
*Antiemetic Combinations***
AKYNZEO ORAL QPD
DICLEGIS QPD
*Antiemetics - Anticholinergic***
meclizine hcl oral tablet
scopolamine
trimethobenzamide hcl oral
*Antiemetics - Miscellaneous***
dronabinol
*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists***
aprepitant QPD
EMEND ORAL SUSPENSION RECONSTITUTED QPD
*Antifungals*
*Antifungals***
flucytosine oral
griseofulvin microsize oral
griseofulvin ultramicrosize
nystatin oral tablet
terbinafine hcl oral QPD
*Imidazoles***
ketoconazole oral
*Triazoles***
CRESEMBA ORAL QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 24
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Drug Name Requirements/Limits
fluconazole oral suspension reconstituted
fluconazole oral tablet 100 mg, 200 mg, 50 mg
fluconazole oral tablet 150 mg QPD
itraconazole oral QPD
NOXAFIL ORAL QPD
SPORANOX ORAL SOLUTION QPD
voriconazole oral QPD
*Antihistamines*
*Antihistamines - Ethanolamines***
carbinoxamine maleate oral solution
carbinoxamine maleate oral tablet 4 mg
clemastine fumarate oral tablet 2.68 mg
diphenhydramine hcl oral capsule 50 mg
*Antihistamines - Non-Sedating***
desloratadine oral tablet QPD
*Antihistamines - Phenothiazines***
phenadoz
promethazine hcl oral
promethazine hcl rectal
promethegan
*Antihistamines - Piperidines***
cyproheptadine hcl oral
*Antihyperlipidemics*
*Antihyperlipidemics - Misc.***
omega-3-acid ethyl esters PA
*Bile Acid Sequestrants***
cholestyramine light
cholestyramine oral
colestipol hcl
prevalite
WELCHOL
*Fibric Acid Derivatives***
choline fenofibrate
fenofibrate micronized
fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg
fenofibric acid
gemfibrozil oral
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 25
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Drug Name Requirements/Limits
*Hmg Coa Reductase Inhibitors***
atorvastatin calcium oral tablet 10 mg, 20 mg QPD
atorvastatin calcium oral tablet 40 mg, 80 mg QPD
fluvastatin sodium QPD
fluvastatin sodium er QPD
LIVALO PA; ST; QPD
lovastatin QPD
pravastatin sodium QPD
rosuvastatin calcium oral tablet 10 mg, 5 mg QPD
rosuvastatin calcium oral tablet 20 mg, 40 mg QPD
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg QPD
simvastatin oral tablet 80 mg QPD
*Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb***
ezetimibe-simvastatin QPD
*Intestinal Cholesterol Absorption Inhibitors***
ezetimibe QPD
*Nicotinic Acid Derivatives***
niacin er (antihyperlipidemic)
NIACOR
*Antihypertensives*
*Ace Inhibitor & Calcium Channel Blocker Combinations***
amlodipine besy-benazepril hcl
trandolapril-verapamil hcl er
*Ace Inhibitors & Thiazide/Thiazide-Like***
benazepril-hydrochlorothiazide
captopril-hydrochlorothiazide
enalapril-hydrochlorothiazide
fosinopril sodium-hctz
lisinopril-hydrochlorothiazide QPD
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide
*Ace Inhibitors***
benazepril hcl oral QPD
captopril oral QPD
enalapril maleate oral QPD
EPANED ORAL SOLUTION ST; QPD
fosinopril sodium QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 26
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Drug Name Requirements/Limits
lisinopril oral QPD
moexipril hcl QPD
perindopril erbumine QPD
QBRELIS ST; QPD
quinapril hcl QPD
ramipril QPD
trandolapril QPD
*Adrenolytics-Central & Thiazide/Thiazide-Like Comb***
methyldopa-hydrochlorothiazide
*Agents For Pheochromocytoma***
DEMSER SP
phenoxybenzamine hcl oral
*Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb***
amlodipine besylate-valsartan QPD
amlodipine-olmesartan QPD
telmisartan-amlodipine QPD
*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like***
candesartan cilexetil-hctz
irbesartan-hydrochlorothiazide
losartan potassium-hctz
olmesartan medoxomil-hctz QPD
telmisartan-hctz
valsartan-hydrochlorothiazide
*Angiotensin Ii Receptor Antagonists***
candesartan cilexetil QPD
eprosartan mesylate QPD
irbesartan QPD
losartan potassium QPD
olmesartan medoxomil oral QPD
telmisartan QPD
valsartan QPD
*Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides***
amlodipine-valsartan-hctz QPD
olmesartan-amlodipine-hctz QPD
*Antiadrenergics - Centrally Acting***
clonidine hcl oral
clonidine hcl transdermal QPD
guanfacine hcl oral
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 27
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Drug Name Requirements/Limits
methyldopa oral
*Antiadrenergics - Peripherally Acting***
doxazosin mesylate oral QPD
prazosin hcl oral QPD
terazosin hcl oral QPD
*Beta Blocker & Diuretic Combinations***
atenolol-chlorthalidone
bisoprolol-hydrochlorothiazide
metoprolol-hydrochlorothiazide
nadolol-bendroflumethiazide
propranolol-hctz
*Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb***
TEKTURNA HCT ST
*Direct Renin Inhibitors***
TEKTURNA ST; QPD
*Selective Aldosterone Receptor Antagonists (Saras)***
eplerenone
*Vasodilators***
hydralazine hcl oral
minoxidil oral
*Anti-Infective Agents - Misc.*
*Anti-Infective Agents - Misc.***
metronidazole oral
NEBUPENT
PRIMSOL
tinidazole oral
trimethoprim oral
vancomycin hcl oral
XIFAXAN
*Anti-Infective Misc. - Combinations***
sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml
sulfamethoxazole-trimethoprim oral tablet
sulfatrim pediatric
*Antiprotozoal Agents***
ALINIA
atovaquone oral
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 28
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Drug Name Requirements/Limits
*Leprostatics***
dapsone oral
*Lincosamides***
clindamycin hcl oral
clindamycin palmitate hcl
*Oxazolidinones***
linezolid oral QPD
*Antimalarials*
*Antimalarial Combinations***
atovaquone-proguanil hcl
COARTEM
*Antimalarials***
chloroquine phosphate oral
DARAPRIM PA; SP
hydroxychloroquine sulfate oral
mefloquine hcl
PRIMAQUINE PHOSPHATE ORAL
quinine sulfate oral
*Antimyasthenic Agents*
*Antimyasthenic Agents***
guanidine hcl oral
MESTINON ORAL SYRUP SP
pyridostigmine bromide er
pyridostigmine bromide oral
*Antimyasthenic/Cholinergic Agents***
guanidine hcl oral
MESTINON ORAL SYRUP SP
pyridostigmine bromide er
pyridostigmine bromide oral
*Antimyasthenic/Cholinergic Agents*
guanidine hcl oral
MESTINON ORAL SYRUP SP
pyridostigmine bromide er
pyridostigmine bromide oral
*Antimycobacterial Agents*
*Anti Tb Combinations***
RIFAMATE
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 29
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Drug Name Requirements/Limits
RIFATER
*Antimycobacterial Agents***
CYCLOSERINE ORAL
ethambutol hcl oral
isoniazid oral
PASER
PRIFTIN
pyrazinamide oral
rifabutin
rifampin oral
SIRTURO SP
TRECATOR
*Antineoplastic - Bcl-2 Inhibitors***
*Antineoplastic - Bcl-2 Inhibitors***
VENCLEXTA SP; QPD
VENCLEXTA STARTING PACK SP; QPD
*Antineoplastics And Adjunctive Therapies*
*Alkylating Agents***
HEXALEN SP
MYLERAN SP
*Androgen Biosynthesis Inhibitors***
ZYTIGA SP; QPD
*Antiadrenals***
LYSODREN SP
*Antiandrogens***
bicalutamide QPD
ERLEADA SP; QPD
flutamide QPD
nilutamide SP
XTANDI SP; QPD
*Antiestrogens***
FARESTON
SOLTAMOX
tamoxifen citrate oral
*Antimetabolites***
capecitabine SP
mercaptopurine oral
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 30
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Drug Name Requirements/Limits
methotrexate oral
methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml
SP
methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml SP
TABLOID
*Antineoplastic - Braf Kinase Inhibitors***
TAFINLAR SP; QPD
ZELBORAF SP; QPD
*Antineoplastic - Hedgehog Pathway Inhibitors***
ERIVEDGE SP; QPD
ODOMZO SP; QPD
*Antineoplastic - Histone Deacetylase Inhibitors***
FARYDAK SP
ZOLINZA SP; QPD
*Antineoplastic - Immunomodulators***
POMALYST SP; QPD
*Antineoplastic - Mek Inhibitors***
COTELLIC SP
MEKINIST SP; QPD
*Antineoplastic - Mtor Kinase Inhibitors***
AFINITOR SP; QPD
AFINITOR DISPERZ SP; QPD
*Antineoplastic - Multikinase Inhibitors***
NEXAVAR SP; QPD
RYDAPT SP; QPD
STIVARGA SP; QPD
SUTENT SP; QPD
*Antineoplastic - Proteasome Inhibitors***
NINLARO SP; QPD
*Antineoplastic - Tyrosine Kinase Inhibitors***
ALECENSA SP; QPD
ALUNBRIG SP; QPD
BOSULIF SP; QPD
CABOMETYX SP; QPD
CALQUENCE SP; QPD
CAPRELSA SP; QPD
COMETRIQ (100 MG DAILY DOSE) SP; QPD
COMETRIQ (140 MG DAILY DOSE) SP; QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 31
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Drug Name Requirements/Limits
COMETRIQ (60 MG DAILY DOSE) SP; QPD
GILOTRIF SP; QPD
ICLUSIG SP; QPD
imatinib mesylate SP
IMBRUVICA SP; QPD
INLYTA SP; QPD
IRESSA SP; QPD
LENVIMA 10 MG DAILY DOSE SP; QPD
LENVIMA 14 MG DAILY DOSE SP; QPD
LENVIMA 18 MG DAILY DOSE SP; QPD
LENVIMA 20 MG DAILY DOSE SP; QPD
LENVIMA 24 MG DAILY DOSE SP; QPD
LENVIMA 8 MG DAILY DOSE SP; QPD
NERLYNX SP; QPD
SPRYCEL SP; QPD
TAGRISSO SP; QPD
TARCEVA SP; QPD
TASIGNA SP; QPD
TYKERB SP; QPD
VOTRIENT SP; QPD
XALKORI SP; QPD
ZYKADIA SP; QPD
*Antineoplastic Combinations***
KISQALI FEMARA 200 DOSE SP; QPD
KISQALI FEMARA 400 DOSE SP; QPD
KISQALI FEMARA 600 DOSE SP; QPD
LONSURF SP
*Antineoplastics Misc.***
ACTIMMUNE PA; SP
hydroxyurea oral
MATULANE SP
SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SP; QPD
SYNRIBO SP
*Aromatase Inhibitors***
anastrozole oral QPD
exemestane QPD
letrozole oral QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 32
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Drug Name Requirements/Limits
*Estrogens-Antineoplastic***
EMCYT
*Folic Acid Antagonists Rescue Agents***
leucovorin calcium oral
*Imidazotetrazines***
temozolomide SP
*Janus Associated Kinase (Jak) Inhibitors***
JAKAFI SP; QPD
*Mitotic Inhibitors***
etoposide oral SP
*Nitrogen Mustards***
CYCLOPHOSPHAMIDE ORAL CAPSULE
LEUKERAN
melphalan SP
*Nitrosoureas***
GLEOSTINE SP
*Progestins-Antineoplastic***
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML
megestrol acetate oral suspension 40 mg/ml
megestrol acetate oral tablet
*Retinoids***
tretinoin oral
*Selective Retinoid X Receptor Agonists***
bexarotene SP
*Topoisomerase I Inhibitors***
HYCAMTIN ORAL SP
*Urinary Tract Protective Agents***
MESNEX ORAL SP
*Antiparkinson Agents*
*Antiparkinson Anticholinergics***
benztropine mesylate oral
trihexyphenidyl hcl
*Antiparkinson Dopaminergics***
amantadine hcl oral
bromocriptine mesylate oral
*Antiparkinson Monoamine Oxidase Inhibitors***
rasagiline mesylate oral
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 33
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Drug Name Requirements/Limits
selegiline hcl oral
*Central/Peripheral Comt Inhibitors***
tolcapone
*Decarboxylase Inhibitors***
carbidopa oral
*Levodopa Combinations***
carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg
carbidopa-levodopa oral tablet
carbidopa-levodopa oral tablet dispersible
carbidopa-levodopa-entacapone
RYTARY
*Nonergoline Dopamine Receptor Agonists***
APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE SP
NEUPRO QPD
pramipexole dihydrochloride
pramipexole dihydrochloride er
ropinirole hcl
ropinirole hcl er QPD
*Peripheral Comt Inhibitors***
entacapone
*Antipsychotics/Antimanic Agents*
*Antimanic Agents***
lithium
lithium carbonate er
lithium carbonate oral
*Antipsychotics - Misc.***
EQUETRO
LATUDA QPD
NUPLAZID SP; QPD
VRAYLAR QPD
ziprasidone hcl QPD
*Benzisoxazoles***
FANAPT QPD
FANAPT TITRATION PACK QPD
paliperidone er QPD
risperidone
risperidone m-tab oral tablet dispersible 0.5 mg, 1 mg, 2 mg
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 34
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Drug Name Requirements/Limits
*Butyrophenones***
haloperidol lactate oral
haloperidol oral
*Dibenzodiazepines***
clozapine oral tablet
clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg
CLOZAPINE ORAL TABLET DISPERSIBLE 150 MG, 200 MG
*Dibenzo-Oxepino Pyrroles***
SAPHRIS QPD
*Dibenzothiazepines***
quetiapine fumarate QPD
quetiapine fumarate er QPD
*Dibenzoxazepines***
loxapine succinate oral
*Phenothiazines***
chlorpromazine hcl oral
compro
fluphenazine hcl oral
perphenazine oral
prochlorperazine
prochlorperazine maleate oral
thioridazine hcl oral
trifluoperazine hcl oral
*Quinolinone Derivatives***
aripiprazole QPD
REXULTI QPD
*Thienbenzodiazepines***
olanzapine oral QPD
*Thioxanthenes***
thiothixene oral
*Antiretrovirals Adjuvants***
*Antiretrovirals Adjuvants***
TYBOST SP
*Antivirals*
*Antiretroviral Combinations***
abacavir sulfate-lamivudine SP
abacavir-lamivudine-zidovudine SP
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 35
-
Drug Name Requirements/Limits
ATRIPLA SP
BIKTARVY SP; QPD
CIMDUO SP; QPD
COMPLERA SP
DESCOVY SP
EVOTAZ SP; QPD
GENVOYA SP
JULUCA SP; QPD
KALETRA ORAL TABLET SP
lamivudine-zidovudine
lopinavir-ritonavir SP
ODEFSEY SP
PREZCOBIX SP; QPD
STRIBILD SP
SYMFI SP; QPD
SYMFI LO SP; QPD
TRIUMEQ SP
TRUVADA SP
*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)***
SELZENTRY SP
*Antiretrovirals - Fusion Inhibitors***
FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED SP
*Antiretrovirals - Integrase Inhibitors***
ISENTRESS SP
ISENTRESS HD SP
TIVICAY SP
*Antiretrovirals - Protease Inhibitors***
APTIVUS SP
atazanavir sulfate SP
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG SP
fosamprenavir calcium SP
INVIRASE SP
LEXIVA ORAL SUSPENSION SP
NORVIR SP
PREZISTA ORAL SUSPENSION SP
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG SP
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG SP
REYATAZ ORAL PACKET SP
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 36
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Drug Name Requirements/Limits
ritonavir SP
VIRACEPT ORAL TABLET SP
*Antiretrovirals - Rti-Non-Nucleoside Analogues***
EDURANT SP
efavirenz SP
INTELENCE SP
nevirapine er
nevirapine oral tablet
RESCRIPTOR SP
SUSTIVA SP
*Antiretrovirals - Rti-Nucleoside Analogues-Purines***
abacavir sulfate oral solution SP
abacavir sulfate oral tablet
didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg
VIDEX SP
*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines***
EMTRIVA SP
lamivudine oral solution
lamivudine oral tablet 150 mg, 300 mg
*Antiretrovirals - Rti-Nucleoside Analogues-Thymidines***
stavudine oral capsule
zidovudine
*Antiretrovirals - Rti-Nucleotide Analogues***
tenofovir disoproxil fumarate SP
VIREAD SP
*Cmv Agents***
PREVYMIS ORAL QPD
valganciclovir hcl
*Hepatitis B Agents***
adefovir dipivoxil SP
BARACLUDE ORAL SOLUTION SP
entecavir SP
EPIVIR HBV ORAL SOLUTION SP
lamivudine oral tablet 100 mg
VEMLIDY SP
*Hepatitis C Agents***
moderiba 1200 dose pack QPD
moderiba 800 dose pack QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 37
-
Drug Name Requirements/Limits
moderiba oral tablet 200 mg QPD
moderiba oral tablet therapy pack QPD
PEGASYS PROCLICK PA; SP; QPD
PEGASYS SUBCUTANEOUS SOLUTION PA; SP; QPD
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML PA; SP; QPD
REBETOL ORAL SOLUTION SP; QPD
ribasphere QPD
ribasphere ribapak oral tablet 400 mg, 600 mg QPD
ribasphere ribapak oral tablet therapy pack QPD
ribavirin oral capsule QPD
ribavirin oral tablet 200 mg QPD
SOVALDI PA; SP
*Herpes Agents - Purine Analogues***
acyclovir oral
valacyclovir hcl oral QPD
*Herpes Agents - Thymidine Analogues***
famciclovir oral QPD
*Influenza Agents***
rimantadine hcl
*Neuraminidase Inhibitors***
oseltamivir phosphate QPD
RELENZA DISKHALER QPD
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML QPD
*Assorted Classes*
*Antileprotics***
THALOMID SP
*Chelating Agents***
DEPEN TITRATABS SP
*Cyclosporine Analogs***
cyclosporine modified
cyclosporine oral capsule
gengraf oral capsule 100 mg, 25 mg
gengraf oral solution
SANDIMMUNE ORAL SOLUTION
*Immunomodulators For Myelodysplastic Syndromes***
REVLIMID SP; QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 38
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Drug Name Requirements/Limits
*Inosine Monophosphate Dehydrogenase Inhibitors***
mycophenolate mofetil
mycophenolate sodium
*Irrigation Solutions***
lactated ringers irrigation
ringers irrigation
sterile water for irrigation
tis-u-sol
*Macrolide Immunosuppressants***
RAPAMUNE ORAL SOLUTION
sirolimus oral
tacrolimus oral
ZORTRESS
*Potassium Removing Resins***
kionex
sodium polystyrene sulfonate oral
sodium polystyrene sulfonate rectal suspension 30 gm/120ml
SODIUM POLYSTYRENE SULFONATE RECTAL SUSPENSION 50 GM/200ML
sps
VELTASSA SP; QPD
*Purine Analogs***
azathioprine oral
*Beta Blockers*
*Alpha-Beta Blockers***
carvedilol
carvedilol phosphate er
COREG CR ST
labetalol hcl oral
*Beta Blockers Cardio-Selective***
acebutolol hcl oral
atenolol oral QPD
betaxolol hcl oral
bisoprolol fumarate
BYSTOLIC ST
metoprolol succinate er
metoprolol tartrate oral QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 39
-
Drug Name Requirements/Limits
*Beta Blockers Non-Selective***
HEMANGEOL SP
nadolol oral tablet 20 mg, 40 mg, 80 mg
pindolol
propranolol hcl er
propranolol hcl oral
sotalol hcl (af)
sotalol hcl oral
SOTYLIZE
timolol maleate oral
*Bile Acid Synthesis Disorder Agents***
*Bile Acid Synthesis Disorder Agents***
CHOLBAM PA; SP
*Calcium Channel Blockers*
*Calcium Channel Blockers***
afeditab cr
amlodipine besylate oral
cartia xt
diltiazem cd
diltiazem hcl er beads
diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg
diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg
diltiazem hcl oral
dilt-xr
felodipine er
isradipine
nicardipine hcl oral
nifedical xl oral tablet extended release 24 hour 60 mg
nifedipine er
nifedipine er osmotic release
nifedipine oral
nimodipine oral QPD
nisoldipine er
NYMALIZE ORAL SOLUTION 60 MG/20ML
taztia xt
verapamil hcl er oral capsule extended release 24 hour
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 40
-
Drug Name Requirements/Limits
verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg
verapamil hcl oral
*Cardiotonics*
*Cardiac Glycosides***
digitek
digox
digoxin oral
LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG
*Cardiovascular Agents - Misc.*
*Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb***
amlodipine-atorvastatin QPD
*Nitrate & Vasodilator Combinations***
BIDIL
*Prostaglandin Vasodilators***
ORENITRAM PA; SP
TYVASO PA; SP
TYVASO REFILL PA; SP
TYVASO STARTER PA; SP
VENTAVIS PA; SP
*Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (Sgc)***
ADEMPAS PA; SP; QPD
*Pulmonary Hypertension - Endothelin Receptor Antagonists***
LETAIRIS PA; SP; QPD
OPSUMIT PA; SP
TRACLEER PA; SP
*Pulmonary Hypertension - Phosphodiesterase Inhibitors***
ADCIRCA PA; SP; QPD
REVATIO ORAL SUSPENSION RECONSTITUTED PA; SP; QPD
sildenafil citrate intravenous PA; SP; QPD
sildenafil citrate oral tablet 20 mg PA; QPD
*Selective Cgmp Phosphodiesterase Type 5 Inhibitors***
CIALIS ORAL TABLET 5 MG PA; QPD
*Cephalosporins*
*Cephalosporins - 1St Generation***
cefadroxil
cephalexin
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 41
-
Drug Name Requirements/Limits
*Cephalosporins - 2Nd Generation***
cefaclor
cefaclor er
cefprozil
cefuroxime axetil oral tablet
*Cephalosporins - 3Rd Generation***
cefdinir
cefditoren pivoxil
cefixime
cefpodoxime proxetil
SUPRAX ORAL CAPSULE
SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML
SUPRAX ORAL TABLET CHEWABLE
*Contraceptives*
*Biphasic Contraceptives - Oral***
azurette
bekyree
desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)
kariva
kimidess
pimtrea
viorele
*Combination Contraceptives - Oral***
altavera
alyacen 1/35
apri
aubra
aviane
balziva
blisovi 24 fe
blisovi fe 1.5/30
blisovi fe 1/20
briellyn
chateal
cryselle-28
cyclafem 1/35
cyred
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 42
-
Drug Name Requirements/Limits
dasetta 1/35
delyla
desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg
drospiren-eth estrad-levomefol
drospirenone-ethinyl estradiol
elinest
emoquette
enskyce
estarylla
ethynodiol diac-eth estradiol
falmina
femynor
gianvi
gildess fe 1.5/30
gildess fe 1/20
isibloom
juleber
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
kaitlib fe
kelnor 1/35
kurvelo
larin 1.5/30
larin 1/20
larin 24 fe
larin fe 1.5/30
larin fe 1/20
larissia
layolis fe
lessina
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg
levora 0.15/30 (28)
lillow
loryna
low-ogestrel
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 43
-
Drug Name Requirements/Limits
lutera
marlissa
melodetta 24 fe
mibelas 24 fe
microgestin 1.5/30
microgestin 1/20
microgestin fe 1.5/30
microgestin fe 1/20
mono-linyah
mononessa
necon 0.5/35 (28)
necon 1/35 (28)
nikki
norethin ace-eth estrad-fe
norethindrone acet-ethinyl est
norethin-eth estradiol-fe
norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg
nortrel 0.5/35 (28)
nortrel 1/35 (21)
nortrel 1/35 (28)
ocella
ogestrel
orsythia
philith
pirmella 1/35
portia-28
previfem
rajani
reclipsen
sprintec 28
sronyx
syeda
tarina fe 1/20
tydemy
vestura
vienva
vyfemla
wera
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 44
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Drug Name Requirements/Limits
wymzya fe
zarah
zenchent
zovia 1/35e (28)
*Combination Contraceptives - Transdermal***
xulane
*Combination Contraceptives - Vaginal***
NUVARING
*Continuous Contraceptives - Oral***
amethyst
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg
*Emergency Contraceptives***
econtra ez QPD
ELLA QPD
levonorgestrel oral tablet 1.5 mg QPD
my way QPD
next choice one dose QPD
opcicon one-step QPD
option 2 QPD
react QPD
*Extended-Cycle Contraceptives - Oral***
amethia QPD
amethia lo QPD
ashlyna QPD
camrese QPD
camrese lo QPD
daysee QPD
fayosim QPD
introvale QPD
jolessa QPD
levonorgest-eth est & eth est QPD
levonorgest-eth estrad 91-day QPD
quasense QPD
rivelsa QPD
setlakin QPD
*Progestin Contraceptives - Injectable***
medroxyprogesterone acetate intramuscular QPD
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 45
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Drug Name Requirements/Limits
*Progestin Contraceptives - Oral***
camila
deblitane
errin
heather
jencycla
jolivette
lyza
nora-be
norethindrone oral
norlyda
norlyroc
sharobel
*Triphasic Contraceptives - Oral***
alyacen 7/7/7
aranelle
caziant
cyclafem 7/7/7
dasetta 7/7/7
enpresse-28
leena
levonest
levonorg-eth estrad triphasic
myzilra
necon 7/7/7
norgestim-eth estrad triphasic
nortrel 7/7/7
pirmella 7/7/7
tilia fe
tri femynor
tri-estarylla
tri-legest fe
tri-linyah
tri-lo-estarylla
tri-lo-marzia
tri-lo-sprintec
trinessa (28)
trinessa lo
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 46
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Drug Name Requirements/Limits
tri-previfem
tri-sprintec
trivora (28)
velivet
*Corticosteroids*
*Glucocorticosteroids***
budesonide oral
cortisone acetate oral
deltasone
dexamethasone intensol
dexamethasone oral
hydrocortisone oral
methylprednisolone oral
millipred dp oral tablet therapy pack
millipred oral tablet
prednisolone oral solution
prednisolone oral syrup 15 mg/5ml
prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
prednisolone sodium phosphate oral tablet dispersible
prednisone intensol
prednisone oral
UCERIS ORAL
*Mineralocorticoids***
fludrocortisone acetate oral
*Cough/Cold/Allergy*
*Antitussive - Nonnarcotic***
benzonatate oral capsule 100 mg, 200 mg
*Antitussive - Opioid***
hydrocodone-homatropine
hydromet
tussigon
*Antitussive-Expectorant***
cheratussin ac oral syrup
g tussin ac
guaiatussin ac
guaifenesin ac
guaifenesin-codeine oral solution
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 47
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Drug Name Requirements/Limits
MAR-COF CG EXPECTORANT
m-clear wc
relcof c
robafen ac oral solution
virtussin a/c
*Antitussive-Expectorants-Decongestant***
guaifenesin dac
lortuss ex oral liquid 30-10-100 mg/5ml
tusnel c
virtussin dac
*Decongestant & Antihistamine***
promethazine vc plain oral solution
promethazine-phenylephrine
*Iodine Expectorants***
SSKI
*Misc. Respiratory Inhalants***
HYPERSAL
nebusal inhalation nebulization solution 3 %
NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %
pulmosal
sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 %
*Mucolytics***
acetylcysteine inhalation
*Non-Narc Antitussive-Antihistamine***
promethazine-dm
*Non-Narc Antitussive-Decongestant-Antihistamine***
pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml
*Opioid Antitussive-Antihistamine***
hydrocod polst-cpm polst er oral suspension extended release
promethazine-codeine oral syrup QPD
*Opioid Antitussive-Decongestant-Antihistamine***
MAR-COF BP
promethazine vc/codeine
promethazine-phenyleph-codeine
pseudoeph-chlorphen-hydrocod
rydex
You can find information on what the symbols and abbreviations on this
table mean by going to the beginning of this List. 48
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Drug Name Requirements/Limits
*Cyclin-Dependent Kinases (Cdk) Inhibitors***
*Cyclin-Dependent Kinases (Cdk) Inhibitors***
IBRANCE SP; QPD
KISQALI 200 DOSE SP; QPD
KISQALI 400 DOSE SP; QPD
KISQALI 600 DOSE SP; QPD
VERZENIO SP; QPD
*Cystic Fibrosis Agent - Combinations***
*Cystic Fibrosis Agent - Combinations***
ORKAMBI PA; SP; QPD
*Dermatologicals*
*Acne Antibiotics***
ACZONE EXTERNAL GEL 7.5 % ST
clindacin-p
clindamycin phosphate external foam
clindamycin phosphate external gel
clindamycin phosphate external lotion
clindamycin phosphate external solution
clindamycin phosphate external swab
dapsone external
ery
erygel
erythromycin external
sulfacetamide sodium (acne)
*Acne Combinations***
avar cleanser
benzoyl peroxide-erythromycin
bp 10-1
bp cleansing wash
clindamycin phos-benzoyl perox
clindamycin-tretinoin PA
neuac external gel
sss 10-5
sulfacetamide sodium-sulf