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Preferred Drug List (PDL) OREGON HEALTH PLAN

TrilliumOHP.com

MCA_EK16V5 Approved 01/01/2019 OHP-TRIL-17-195

1-877-600-5472 TTY: 711

http:TrilliumOHP.com

Pharmacy Program

Trillium Community Health Plan’s goal is to offer the right drug coverage to our members. We work with doctors and pharmacists to make sure we offer drugs used to

treat many conditions and illnesses. Trillium covers prescription and some over the

counter drugs when they are ordered by a licensed prescriber. The pharmacy program

does not cover all drugs. Some drugs need our prior approval. Some have a limit on

the amount of drug that can be given.

Sometimes you must get Trillium’s prior approval. Even with approval, we will not pay if you are no longer on OHP or if the treatment isn’t covered by OHP. To be paid, the treatment must follow treatment guidelines. This might include step therapy, meaning

trying less costly treatment options first.

Medications newly approved by the FDA (Food and Drug Administration) require prior-

approval until reviewed by our Pharmacy and Therapeutics Committee.

Filling a Prescription

You can have your prescriptions filled at a Trillium network pharmacy. At the pharmacy,

you will need to give the pharmacist your prescription and your ID card. You can find a

pharmacy that is in network by calling a Trillium Member Services Representative at

541-485-2155; Toll Free: 1-877-600-5472, or by using the Find a Provider tool on our

website at https://providersearch.trilliumhealthplan.com. You do not have to pay for

covered drugs.

The Trillium preferred drug list has a large number of brand name and generic drugs on

it. Trillium asks that doctors prescribe medication from the Trillium preferred drug list

for their patients who are members of Trillium. Some drugs will need your doctor to

submit a prior approval request before the medication can be given to you at the

pharmacy. These drugs are on the prior approval list. All prior approval reviews are

done by a licensed clinical pharmacist using the Trillium Pharmacy and Therapeutics

Committee’s guidelines.

Trillium will cover the drug if it is decided that:

1. There is a medical reason that you need the specific drug.

2. Other drugs on the preferred drug list have not worked for you.

Once approved, your doctor will be contacted.

If the information given does not meet requirements for the requested drug, we will

contact you and your doctor, and tell you about the appeal process.

https://providersearch.trilliumhealthplan.com/

Generic Drugs

Generic drugs work the same as brand name drugs. When there is a generic drug

available, your doctor will need to ask for a prior approval for the brand name drug. We

will review the prior authorization and cover the brand name drug if there is a medical

reason you need the brand name drug.

Specialty Drugs

Retail pharmacies do not have specialty drugs. You can get these drugs from our specialty pharmacy, AcariaHealth. Your doctor may need to ask for a prior approval for you to receive a specialty drug.

Over-the-Counter Medications

Trillium will pay for over the counter drugs that are on the preferred drug list. To be

covered, your doctor will need to write you a prescription for the drug.

72-Hour Emergency Supply Policy

If you have an urgent need for a drug, your doctor can ask Trillium for an urgent

preapproval. Trillium will look at these requests within 24 hours. If we cannot look at

the request in time, Trillium will let the pharmacy give you the drug for three days.

Step Therapy

Some drugs listed on the Trillium preferred drug list may need you to try other drugs

before you can receive the step therapy drug. If Trillium has a record that you have

tried this drug, the step therapy drug is covered. If Trillium does not have a record that

you have tried this drug, your doctor may need to submit a prior approval.

Dispensing Limits, Quantity Limits, and Age Limits

Trillium may limit how much of a drug you can get at one time. You may get up to a 30

day supply for each new or refill of a non-controlled drug. Most prescriptions can be

refilled after 24 days. Some drugs on the Trillium preferred drug list may have an age

limit, which is set by the Food and Drug Administration (FDA). If your doctor feels that

you have a medical reason for getting a larger amount of the drug, or that you should

receive a drug even if you do not meet the age limit, they can ask for a prior approval.

Appropriate Use and Safety Edits

Your health and safety are important to Trillium. One way we keep you safe is

through Point-of-Sale (POS) changes at the time a prescription is processed at the

pharmacy. These changes are based on FDA recommendations and promote safe

and effective medication use.

Pharmacy Benefit Exclusions

These medications are not covered by Trillium:

Medications that do not have an FDA-approved use; Medications that are not medically necessary; Experimental or investigation medications; Medication products for a diagnosis that is not covered by the Oregon

Health Plan;

Medications that are an excluded service under the Oregon Health Plan; Medications to treat mental illness (therapeutic classes 7 and 11); Medications to help you get pregnant; Home pregnancy kits; Cosmetic or hair-growth medications; and

Medicare Part D covered drugs for dual members.

Mail Order Program

If you are taking a drug to treat a long-term medical condition or illness, you may be

able to get a 60-day supply of your drug by mail. Please contact a Trillium Member

Service Representative if you have any questions.

Do you think Trillium Community Health Plan (TCHP) has treated you unfairly? Trillium must follow state and federal civil rights laws. It cannot treat people unfairly

in any of its programs or activities because of a person’s:

Age Gender identity Race Sexual orientation Color Marital status Religion Disability National Origin Sex

Everyone has a right to enter, exit and use buildings and services. They also have the right to get information in a way they understand. Trillium will make reasonable changes to policies, practices, and procedures by talking with you about your needs.

To report concerns or to get more information, please contact Member Services at 541-485-2155; Toll Free: 1-877-600-5472; TTY: 1-877-600-5473, Monday through Friday, 8:00 a.m. to 5:00 p.m. At other times – including Saturday, Sunday, and federal holidays – you can leave a voicemail. We will return your call the following business day. The call is free.

You also have a right to file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights. Contact that office one of these ways:

Web: www.hhs.gov Email: [email protected] Phone: 1-800-368-1019, 1-800-537-7697 (TDD) Mail: 200 Independence Ave., SW, Room 509F HHH Bldg.

Washington, D.C. 20201

http://www.hhs.gov/mailto:[email protected]

English

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Română (Romanian) :مكبلاو مصلا فتاه

លួ ចូ

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Cushite

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Tier Definition:

F Preferred Drugs

NF Non-formulary

CO Carve Out Drugs

Legend Description

AL Age Limit Drug is limited to specific age.

PA Prior

Authorization Prior Authorization required before prescription can be filled.

QL Quantity Limit There is a limit on the amount of drug covered per prescription, or

within a specific time frame.

Rx/OTC Rx/OTC Product has both Rx and OTC National Drug Codes.

SP Specialty

Drug

Specialty drugs are high-cost drugs used to treat complex or rare

conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia and may be limited to a specific

pharmacy.

ST Step Therapy Requires trial and failure of one or more preferred products prior to

coverage.

Drug Name DrugTier Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Use amphetamine-dextroamphetamine)

NF

ADDERALL XR CP24 (Use amphetamine-dextroamphetamine)

NF QL(2 ea daily)

ADZENYS ER SUER NF

amphetamine-dextroamphetamine cp24 5mg-5 mg-5 mg-5 mg, 2.5mg-2.5 mg-2.5 mg-2.5 mg,7.5 mg-7.5 mg-7.5 mg-7.5mg, 1.25 mg-1.25 mg-1.25mg-1.25 mg, 3.75 mg-3.75mg-3.75 mg-3.75 mg, 6.25mg-6.25 mg-6.25 mg-6.25 mg

F

QL(2 ea daily)

amphetamine-dextroamphetamine tabs 5mg-5 mg-5 mg-5 mg, 2.5mg-2.5 mg-2.5 mg-2.5 mg,7.5 mg-7.5 mg-7.5 mg-7.5mg, 1.25 mg-1.25 mg-1.25mg-1.25 mg, 3.75 mg-3.75mg-3.75 mg-3.75 mg,1.875 mg-1.875 mg-1.875mg-1.875 mg, 3.125 mg-3.125 mg-3.125 mg-3.125 mg

F

DEXEDRINE CP24 (Use dextroamphetaminesulfate)

NF PA; QL(2 eadaily)

dextroamphetamine sulfatecp24 5 mg, 10 mg, 15 mg F

PA; QL(2 eadaily)

dextroamphetamine sulfatetabs 5 mg, 10 mg F

VYVANSE CAPS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

F PA; QL(2 eadaily)

Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps CO


clonidine hcl (adhd) tb12 CO

guanfacine hcl (adhd) tb24 CO INTUNIV TB24 (Use guanfacine hcl (adhd)) CO

KAPVAY TB12 (Use clonidine hcl (adhd)) CO

STRATTERA CAPS (Use atomoxetine hcl) CO

Stimulants - Misc. armodafinil tabs CO CONCERTA TBCR (Use methylphenidate hcl) NF

QL(2 ea daily)

dexmethylphenidate hclcp24 5 mg, 10 mg, 15 mg,20 mg, 25 mg, 30 mg, 35mg, 40 mg

F

QL(2 ea daily)

dexmethylphenidate hcltabs 5 mg, 10 mg, 2.5 mg F

FOCALIN TABS (Use dexmethylphenidate hcl) NF

FOCALIN XR CP24 (Use dexmethylphenidate hcl) NF

QL(2 ea daily)

methylphenidate hcl cp2410 mg, 20 mg, 30 mg, 40 mg

F QL(2 ea daily)

methylphenidate hcl cpcr10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg

F QL(2 ea daily)

methylphenidate hcl tabs 5mg, 10 mg, 20 mg F

methylphenidate hcl tb2418 mg, 27 mg, 36 mg, 54 mg

F QL(2 ea daily)

methylphenidate hcl tbcr 10mg, 18 mg, 20 mg, 27 mg,36 mg, 54 mg

F QL(2 ea daily)

modafinil tabs CO NUVIGIL TABS (Use armodafinil) CO

PROVIGIL TABS (Use modafinil) CO

RELEXXII TBCR NF

Oregon Trillium OHP Updated September 1, 2020

1


RITALIN LA CP24 (Use methylphenidate hcl) NF

QL(2 ea daily)

RITALIN TABS (Use methylphenidate hcl) NF

ALTERNATIVE MEDICINES

Alternative Medicine - C's coenzyme q10(ubidecarenone) caps 30mg, 50 mg, 100 mg

F PA; QL(3 eadaily)

Q-GEL CAPS F PA; QL(3 eadaily) Alternative Medicine - S's st john's wort (hypericumperforatum) caps CO

st john's wort (hypericumperforatum) tabs CO

ST JOHNS WORT CAPS 450 MG, 1000 MG CO

Alternative Medicine Combinations glucosamine-chondroitincaps 400 mg-500 mg, 500mg-400 mg

F QL(3 ea daily)

glucosamine-chondroitintabs 400 mg-500 mg, 500mg-400 mg, 400 mg-400mg-500 mg-500 mg

F

QL(3 ea daily)

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections Aminoglycosides ARIKAYCE SUSP F PA; SP

KITABIS PAK NEBU (Use tobramycin) NF

SP

neomycin sulfate tabs F

paromomycin sulfate caps F TOBI NEBU (Use tobramycin) NF

SP

tobramycin nebu 300mg/5ml F

SP

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditions


Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

F PA; SP

HUMIRA PEN PNKT F PA; SP

HUMIRA PEN-CD/UC/HSSTARTER PNKT F

PA; SP

HUMIRA PEN-PS/UVSTARTER PNKT F

PA; SP

HUMIRA PSKT F PA; SP

SIMPONI SOAJ F PA; SP

SIMPONI SOSY F PA; SP

Antirheumatic - Enzyme Inhibitors XELJANZ TABS F PA; SP

XELJANZ XR TB24 F PA; SP

Interleukin-6 Receptor Inhibitors KEVZARA SOAJ F PA; SP

KEVZARA SOSY F PA; SP

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL CAPS (Use ibuprofen) NF

ADVIL MIGRAINE CAPS (Use ibuprofen) NF

ADVIL TABS (Use ibuprofen) NF

ALEVE ARTHRITIS TABS (Use naproxen sodium) NF

ALEVE TABS (Use naproxen sodium) NF

ANAPROX DS TABS (Use naproxen sodium) NF

CELEBREX CAPS (Use celecoxib) NF

PA

celecoxib caps F PA

CHILDRENS ADVIL SUSP (Use ibuprofen) NF

RX/OTC


2


CHILDRENS MOTRIN SUSP (Use ibuprofen) NF

RX/OTC

diclofenac potassium tabs50 mg F

diclofenac sodium tb24 or 100 mg F

diclofenac sodium tbec or 25 mg, 50 mg, 75 mg F

EC-NAPROSYN TBEC (Use naproxen) NF

flurbiprofen tabs F

ibuprofen caps 200 mg F

ibuprofen susp 100 mg/5ml F RX/OTC

ibuprofen susp 40 mg/ml,50 mg/1.25ml F

ibuprofen tabs 100 mg, 200mg, 400 mg, 600 mg, 800 mg

F

INDOCIN SUSP OR 25 MG/5ML F

indomethacin caps 25 mg,50 mg F

INFANTS ADVIL SUSP (Use ibuprofen) NF

ketoprofen caps 50 mg, 75 mg F

KETOROLAC TROMETHAMINE SOLN NA 15.75 MG/SPRAY

F PA

ketorolac tromethamine tabs or 10 mg F

meloxicam tabs F MOBIC TABS (Use meloxicam) NF

MOTRIN INFANTS DROPS SUSP (Use ibuprofen)

NF

nabumetone tabs F NAPROSYN SUSP (Use naproxen) NF

NAPROSYN TABS (Use naproxen) NF


naproxen sodium tabs 220mg, 275 mg, 550 mg F

naproxen susp F

naproxen tabs F

naproxen tbec F

SPRIX SOLN F PA

sulindac tabs F

Phosphodiesterase 4 (PDE4) Inhibitors OTEZLA TABS F PA; SP

OTEZLA TBPK F PA; SP

Pyrimidine Synthesis Inhibitors ARAVA TABS (Use leflunomide) NF

QL(1 ea daily)

leflunomide tabs F QL(1 ea daily)

Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT F PA; SP

ENBREL SOLR 25 MG F PA; SP

ENBREL SOSY 50 MG/ML,25 MG/0.5ML F

PA; SP

ENBREL SURECLICK SOAJ F

PA; SP

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions Analgesic Combinations butalbital-acetaminophentabs 325 mg-50 mg F

butalbital-acetaminophen-caffeine caps 300 mg-50mg-40 mg, 325 mg-50 mg-40 mg

F

butalbital-acetaminophen-caffeine tabs 325 mg-50mg-40 mg

F

butalbital-aspirin-caffeinecaps 50 mg-40 mg-325 mg F


3


BUTALBITAL/ACETAMINOPHEN CAPS (Use butalbital-acetaminophen)

NF

ESGIC TABS (Use butalbital-acetaminophen-caffeine)

NF

FIORICET CAPS (Use butalbital-acetaminophen-caffeine)

NF

FIORINAL CAPS (Use butalbital-aspirin-caffeine) NF

Analgesics Other acetaminophen caps or500 mg F

acetaminophen chew or 80mg, 160 mg F

acetaminophen elix or 160mg/5ml, 80 mg/2.5ml F

acetaminophen liqd or 160mg/5ml, 500 mg/15ml,1000 mg/30ml

F

acetaminophen soln or 100mg/ml, 160 mg/5ml, 650mg/20.3ml, 325mg/10.15ml

F

acetaminophen supp re120 mg, 650 mg F

acetaminophen susp or160 mg/5ml, 80 mg/2.5ml,650 mg/20.3ml

F

acetaminophen tabs or 325mg, 500 mg F

acetaminophen tbcr or 650 mg F

FEVERALL INFANTS SUPP F

FEVERALL JUNIOR STRENGTH SUPP F

NORTEMP INFANTS SUSP F

TYLENOL 8 HOUR ARTHRITISPAIN TBCR (Use acetaminophen)

NF

TYLENOL 8 HOUR TBCR (Use acetaminophen) NF


TYLENOL CHILDRENS CHEWABLES/PAIN +FEVER CHEW (Use acetaminophen)

NF

TYLENOL CHILDRENS SUSP (Use acetaminophen)

NF

TYLENOL EXTRA STRENGTH TABS (Use acetaminophen)

NF

TYLENOL INFANTS PAIN+FEVER SUSP (Use acetaminophen)

NF

TYLENOL INFANTS SUSP (Use acetaminophen) NF

TYLENOL TABS (Use acetaminophen) NF

Salicylates aspirin chew or 81 mg F ASPIRIN SUPP RE 300 MG, 600 MG F

aspirin tabs or 325 mg, 500 mg F

aspirin tbec or 81 mg, 324mg, 325 mg, 500 mg F

ECOTRIN MAXIMUM STRENGTH TBEC (Use aspirin)

NF

ECOTRIN REGULAR STRENGTH TBEC (Use aspirin)

NF

salsalate tabs F

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint Conditions Opioid Agonists

CODEINE SULFATE TABS 15 MG, 60 MG F

Smart PA; Max 7 days per fill, 2fills per 180days;AL(Atleast 12 yrsold)


4


CODEINE SULFATE TABS 30 MG (Use codeine sulfate)

F


codeine sulfate tabs 30 mg,60 mg F


CONZIP CP24 NF

DILAUDID SOLN IJ 1 MG/ML, 2 MG/ML, 4MG/ML (Use hydromorphone hcl)

NF

DILAUDID TABS OR 2 MG, 4 MG, 8 MG (Use hydromorphone hcl)

NF

Smart PA; Max 7 days per fill, 2fills per 180days

DOLOPHINE TABS (Use methadone hcl) NF

PA

DURAGESIC PT72 (Use fentanyl) NF

PA

fentanyl pt72 12 mcg/hr, 25mcg/hr, 50 mcg/hr, 75mcg/hr, 100 mcg/hr

F PA

FENTORA TABS NF

HYDROMORPHONE HCL SUPP RE 3 MG F


hydromorphone hcl tabs or2 mg, 4 mg, 8 mg F


meperidine hcl tabs or 50mg, 100 mg F


methadone hcl tabs or 5 mg, 10 mg F

PA

MORPHINE SULFATE SOLN IV 10 MG/ML (Use morphine sulfate)

NF


morphine sulfate soln or 10mg/5ml, 20 mg/5ml F

PA

morphine sulfate tabs or 15mg, 30 mg F


morphine sulfate tbcr or100 mg F

PA; QL(36 eaper 31 daysretail)

morphine sulfate tbcr or 15 mg F


morphine sulfate tbcr or200 mg F






MS CONTIN TBCR 100 MG (Use morphine sulfate) NF










oxycodone hcl caps 5 mg F Smart PA; Max 7 days per fill, 2fills per 180days

oxycodone hcl soln 5mg/5ml F

150ml/365days;QL(150ml per 365days retail)

oxycodone hcl t12a 10 mg,15 mg, 20 mg, 30 mg, 40mg, 60 mg, 80 mg

F PA


5


oxycodone hcl tabs 5 mg,10 mg, 15 mg, 20 mg, 30 mg

F


ROXICODONE TABS (Use oxycodone hcl) NF


tramadol hcl tabs 50 mg F


ULTRAM TABS (Use tramadol hcl) NF


Opioid Combinations

acetaminophen w/ codeinesoln 120 mg/5ml-12mg/5ml

F

QL(500 ml per365 daysretail); AL(Atleast 12 yrsold)

acetaminophen w/ codeinetabs 300 mg-15 mg, 300mg-30 mg, 300 mg-60 mg

F


butalbital-acetaminophen-caffeine w/ codeine caps F


butalbital-aspirin-caffeinew/cod caps 50 mg-40 mg-30 mg-325 mg

F



FIORICET/CODEINECAPS (Use butalbital-acetaminophen-caffeine w/codeine)

NF


FIORINAL/CODEINE #3CAPS (Use butalbital-aspirin-caffeine w/cod)

NF


hydrocodone-acetaminophen soln 2.5mg/5ml-108 mg/5ml, 5mg/10ml-217 mg/10ml, 7.5mg/15ml-325 mg/15ml

F

QL(500 ml per365 days retail)

hydrocodone-acetaminophen tabs 5 mg-300 mg, 5 mg-325 mg, 10mg-300 mg, 10 mg-325mg, 2.5 mg-325 mg, 7.5mg-300 mg, 7.5 mg-325 mg

F


NORCO TABS (Use hydrocodone-acetaminophen)

NF


oxycodone w/acetaminophen tabs F


PERCOCET TABS (Use oxycodone w/acetaminophen)

NF


TYLENOL/CODEINE #3TABS (Use acetaminophenw/ codeine)

NF


TYLENOL/CODEINE #4TABS (Use acetaminophenw/ codeine)

NF


Opioid Partial Agonists


6


buprenorphine hcl subl sl 2mg, 8 mg F

QL(3 ea daily)

buprenorphine hcl-naloxone hcl dihydrate film F

QL(3 ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl F

QL(3 ea daily)

SUBOXONE FILM (Use buprenorphine hcl-naloxone hcl dihydrate)

NF QL(3 ea daily)

ZUBSOLV SUBL 5.7 MG-1.4 MG, 1.4 MG-0.36 MG NF

PA

ANDROGENS-ANABOLIC - Drugs to RegulateHormones Androgens ANDROGEL GEL 50 MG/5GM, 25 MG/2.5GM(Use testosterone)

NF

danazol caps F DEPO-TESTOSTERONE SOLN (Use testosterone cypionate)

NF AL(At least 17yrs old)

TESTIM GEL (Use testosterone) NF

testosterone cypionate solnim 100 mg/ml, 200 mg/ml F

AL(At least 17yrs old)

testosterone enanthate soln im 200 mg/ml F


VOGELXO GEL (Use testosterone) NF

VOGELXO PUMP GEL (Use testosterone) NF

ANORECTAL AND RELATED PRODUCTS -Rectal Drugs to Treat Pain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Use hydrocortisone (intrarectal)) NF

CORTIFOAM FOAM F

hydrocortisone (intrarectal)enem 100 mg/60ml F

Rectal Combinations PROCTOFOAM HC FOAM 1 %-1 % F

Rectal Steroids


ANUSOL-HC CREA (Use hydrocortisone (rectal)) NF

hydrocortisone (rectal) crea2.5 % F

ANTACIDS

Antacid Combinations alum & mag hydrox-simethicone chew F

alum & mag hydrox-simethicone liqd F

alum & mag hydrox-simethicone susp F

DI-GEL SUSP 282 MG/5ML-25 MG/5ML-87MG/5ML

F

GELUSIL CHEW (Use alum & mag hydrox-simethicone)

NF

HYVEE ADVANCED ANTACID MAXIMUM STRENGTH SUSP (Use alum & mag hydrox-simethicone)

NF

Antacids - Bicarbonate sodium bicarbonate (antacid) tabs F

Antacids - Calcium Salts ANTACID CHEW F

ANTACID SOFT CHEWS CHEW F

calcium carbonate (antacid)chew F

calcium carbonate (antacid) susp F

CALCIUM CARBONATE TABS 648 MG F

CVS ANTACID SOFT CHEWS ULTRA STRENGTH CHEW

F

MAALOX CHEW F

TUMS CHEW (Use calcium carbonate (antacid)) F


7


TUMS CHEWY BITES CHEW (Use calcium carbonate (antacid))

NF

TUMS CHEWY DELIGHTS CHEW F

TUMS E-X 750 CHEW (Use calcium carbonate (antacid))

NF

TUMS EXTRA STRENGTH 750 CHEW (Use calcium carbonate (antacid))

NF

TUMS KIDS CHEW (Use calcium carbonate (antacid))

NF

TUMS LASTING EFFECTS CHEW (Use calcium carbonate (antacid))

F

TUMS SMOOTHIES CHEW (Use calcium carbonate (antacid))

NF

TUMS ULTRA 1000 CHEW (Use calcium carbonate (antacid))

NF

Antacids - Magnesium Salts MAGNESIUM OXIDE CAPS 400 MG F

magnesium oxide tabs 250mg, 400 mg, 420 mg F

URO MAG CAPS F

URO-MAG CAPS F

ANTHELMINTICS - Drugs to Treat WormInfections Anthelmintics BILTRICIDE TABS (Use praziquantel) NF

ivermectin tabs 3 mg F

praziquantel tabs 600 mg F

pyrantel pamoate susp F REESES PINWORM MEDICINE TABS F

STROMECTOL TABS (Use ivermectin) NF


ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial Infections Anti-infective Agents - Misc. FLAGYL TABS 250 MG, 500 MG (Use metronidazole)

NF

metronidazole tabs or 250 mg, 500 mg F

PRIMSOL SOLN F

trimethoprim tabs F

TRIMPEX SOLN F

Anti-infective Misc. - Combinations BACTRIM DS TABS (Use sulfamethoxazole-trimethoprim)

NF

BACTRIM TABS (Use sulfamethoxazole-trimethoprim)

NF

sulfamethoxazole-trimethoprim susp or 40mg/5ml-200 mg/5ml

F

sulfamethoxazole-trimethoprim tabs or 80 mg-400 mg, 160 mg-800 mg

F

Cyclic Lipopeptides DAPTOMYCIN SOLR 350 MG (Use daptomycin) NF

Glycopeptides VANCOCIN CAPS (Use vancomycin hcl) NF

QL(2 ea daily)

VANCOCIN HCL CAPS (Use vancomycin hcl) NF

QL(4 ea daily)

vancomycin hcl caps or125 mg F

QL(4 ea daily)

vancomycin hcl caps or250 mg F

QL(2 ea daily)

VANCOMYCIN HCL SOLN IV 0.9 %-1 GM/200ML F

vancomycin hcl solr iv 1gm, 5 gm, 500 mg, 750 mg,1000 mg

F


8


VANCOMYCIN HYDROCHLORIDE/DEXTROSE SOLN 5 %-1 GM/200ML, 5 %-500MG/100ML, 5 %-750MG/150ML

F

VANCOMYCIN HYDROCHLORIDE/SODIUM CHLORIDE SOLN

F

VANCOMYCIN SOLN 0.9 %-500 MG/100ML, 0.9 %-750 MG/150ML

F

Leprostatics dapsone tabs or 25 mg,100 mg F

Lincosamides CLEOCIN CAPS OR 75 MG, 150 MG, 300 MG (Use clindamycin hcl)

NF

CLEOCIN PEDIATRIC GRANULES SOLR (Use clindamycin palmitatehydrochloride)

NF

clindamycin hcl caps F clindamycin palmitatehydrochloride solr 75mg/5ml

F

Oxazolidinones linezolid susr or 100 mg/5ml F

PA

linezolid tabs or 600 mg F PA

ZYVOX SUSR OR 100 MG/5ML (Use linezolid) NF

PA

ZYVOX TABS OR 600 MG (Use linezolid) NF

PA

ANTIANGINAL AGENTS - Drugs to Treat ChestPain Nitrates ISORDIL TITRADOSE TABS 5 MG (Use isosorbide dinitrate)

NF

isosorbide dinitrate tabs 5 mg, 10 mg, 20 mg, 30 mg F


isosorbide dinitrate tbcr 40 mg F

isosorbide mononitrate tabs F isosorbide mononitrate tb24 F

NITRO-DUR PT24 0.1 MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.6 MG/HR (Use nitroglycerin)

NF

NITRO-DUR PT24 0.3 MG/HR, 0.8 MG/HR F

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

F

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg F

NITROSTAT SUBL (Use nitroglycerin) NF

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc. buspirone hcl tabs CO

droperidol soln CO

DROPERIDOL SOLN CO

hydroxyzine hcl syrp or 10mg/5ml F

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg F

hydroxyzine pamoate caps F

meprobamate tabs CO VISTARIL CAPS (Use hydroxyzine pamoate) NF

Benzodiazepines ALPRAZOLAM INTENSOL CONC CO

alprazolam tabs CO

alprazolam tb24 CO

alprazolam tbdp CO


9


ATIVAN TABS OR 0.5 MG, 1 MG, 2 MG (Use lorazepam)

CO

chlordiazepoxide hcl caps CO clorazepate dipotassiumtabs CO

diazepam conc or 5 mg/ml CO DIAZEPAM SOAJ IM 10 MG/2ML CO

diazepam soln ij 5 mg/ml CO

diazepam soln or 5 mg/5ml CO diazepam tabs or 2 mg, 5mg, 10 mg CO

lorazepam conc or 2 mg/ml CO lorazepam tabs or 0.5 mg,1 mg, 2 mg CO

oxazepam caps CO TRANXENE T TABS (Use clorazepate dipotassium) CO

VALIUM TABS (Use diazepam) CO

XANAX TABS (Use alprazolam) CO

XANAX XR TB24 (Use alprazolam) CO

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps F

NORPACE CAPS (Use disopyramide phosphate) NF

NORPACE CR CP12 F

quinidine gluconate tbcr or324 mg F

quinidine sulfate tabs F

Antiarrhythmics Type I-B


mexiletine hcl caps 150mg, 200 mg, 250 mg F

Antiarrhythmics Type I-C flecainide acetate tabs F propafenone hcl tabs 150mg, 225 mg, 300 mg F

Antiarrhythmics Type III amiodarone hcl tabs or 100 mg, 200 mg, 400 mg F

CORDARONE TABS (Use amiodarone hcl) NF

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu F CROMOLYN SODIUM NEBU F

Bronchodilators - Anticholinergics ATROVENT HFA AERS F

INCRUSE ELLIPTA AEPB F

ipratropium bromide soln F TUDORZA PRESSAIR AEPB F

Leukotriene Modulators ACCOLATE TABS (Use zafirlukast) NF

montelukast sodium chew F

montelukast sodium pack F

montelukast sodium tabs F SINGULAIR CHEW (Use montelukast sodium) NF

SINGULAIR PACK (Use montelukast sodium) NF

SINGULAIR TABS (Use montelukast sodium) NF

zafirlukast tabs F


10


Steroid Inhalants ASMANEX HFA AERO 100 MCG/ACT, 200 MCG/ACT F

ASMANEX TWISTHALER 120 METERED DOSES AEPB

F


F


F


F


F

budesonide (inhalation)susp 0.25 mg/2ml, 0.5mg/2ml

F AL(Up to 8 yrsold )

FLOVENT DISKUS AEPB F

FLOVENT HFA AERO F

PULMICORT FLEXHALER AEPB F

PULMICORT SUSP 0.25 MG/2ML, 0.5 MG/2ML(Use budesonide (inhalation))

NF

AL(Up to 8 yrsold )

QVAR REDIHALER AERB F

Sympathomimetics ADVAIR DISKUS AEPB (Use fluticasone-salmeterol)

NF 1 rtl pack lmtamt,30 rtl packlmt day(s),

AIRDUO RESPICLICK 113/14 AEPB NF



albuterol sulfate aers in 108 mcg/act F

ALBUTEROL SULFATE NEBU IN 0.5 % F


albuterol sulfate nebu in 0.63 mg/3ml, 0.083 %, 0.5%, 1.25 mg/3ml, 2.5mg/0.5ml

F

albuterol sulfate syrp or 2mg/5ml F

albuterol sulfate tabs or 2 mg, 4 mg F

albuterol sulfate tb12 or 4 mg, 8 mg F

budesonide-formoterol fumarate dihydrate aero F

COMBIVENT RESPIMAT AERS F

DULERA AERO 5 MCG/ACT-100 MCG/ACT,5 MCG/ACT-200MCG/ACT

F

fluticasone-salmeterol aepb14 mcg/act-55 mcg/act, 14mcg/act-113 mcg/act, 14mcg/act-232 mcg/act

F

fluticasone-salmeterol aepb50 mcg/dose-100mcg/dose, 50 mcg/dose-250 mcg/dose, 50mcg/dose-500 mcg/dose

F

1 rtl pack lmtamt,30 rtl packlmt day(s),

ipratropium-albuterol soln F

levalbuterol hcl nebu F

levalbuterol tartrate aero F Generic Required metaproterenol sulfate syrp F

metaproterenol sulfate tabs F PROAIR HFA AERS (Use albuterol sulfate) F

PROAIR RESPICLICK AEPB F

PROVENTIL HFA AERS (Use albuterol sulfate) F

SEREVENT DISKUS AEPB F

QL(60 ea per30 days retail)

SYMBICORT AERO NF


11


terbutaline sulfate tabs or 5 mg, 2.5 mg F

VENTOLIN HFA AERS (Use albuterol sulfate) F

XOPENEX CONCENTRATE NEBU (Use levalbuterol hcl)

NF

XOPENEX HFA AERO F

XOPENEX NEBU (Use levalbuterol hcl) NF

Xanthines ELIXOPHYLLIN ELIX F

theophylline soln F

theophylline tb12 F

theophylline tb24 F

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants COUMADIN TABS (Use warfarin sodium) NF

warfarin sodium tabs F

Direct Factor Xa Inhibitors

BEVYXXA CAPS F QL(42 ea per42 days retail)

ELIQUIS STARTER PACK TABS F

QL(74 ea per30 days retail)2rtl MAX fill,365 rtl day(s)supply,

ELIQUIS TABS F QL(2 ea daily)

XARELTO TABS 10 MG F

Max 35 days oftherapy per365 days;QL(35 eaper 365 daysretail)

Heparins And Heparinoid-Like Agents

enoxaparin sodium soln ij300 mg/3ml F

QL(6 mldaily,84 ml per14 days retail)


enoxaparin sodium soln sc100 mg/ml, 150 mg/ml F

QL(2 mldaily,28 ml per14 days retail)

enoxaparin sodium soln sc30 mg/0.3ml F

QL(0.6 mldaily,9 ml per14 days retail)





enoxaparin sodium soln sc80 mg/0.8ml, 120 mg/0.8ml F


FRAGMIN SOLN 10000 UNIT/ML, 2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML, 12500UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML

F

Max 5 fills per30 days;SP

HEPARIN LOCK FLUSH SOLN NF

HEPARIN SODIUM/SODIUMCHLORIDE 0.9% SOLN IV 1000 UNIT/500ML-0.9 %(Use heparin (porcine) in sodium chloride)

NF

LOVENOX SOLN IJ 300 MG/3ML (Use enoxaparinsodium)

NF QL(6 mldaily,84 ml per14 days retail)

LOVENOX SOLN SC 100 MG/ML, 150 MG/ML (Use enoxaparin sodium)

NF QL(2 mldaily,28 ml per14 days retail)

LOVENOX SOLN SC 30 MG/0.3ML (Use enoxaparinsodium)

NF QL(0.6 mldaily,9 ml per14 days retail)






12


LOVENOX SOLN SC 80 MG/0.8ML, 120 MG/0.8ML(Use enoxaparin sodium)


ANTICONVULSANTS - Drugs to Treat Seizures

Anticonvulsants - Benzodiazepines clobazam tabs 10 mg, 20 mg F

PA

clonazepam tabs 0.5 mg, 1mg, 2 mg F

DIASTAT ACUDIAL GEL F QL(1 ea per 31days retail)

DIASTAT PEDIATRIC GEL F QL(1 ea per 31days retail)

diazepam (anticonvulsant)gel 10 mg F

Generic Required;QL(1ea per 31 daysretail)

diazepam (anticonvulsant)gel 20 mg, 2.5 mg F

QL(1 ea per 31days retail)

KLONOPIN TABS (Use clonazepam) NF

NAYZILAM SOLN F PA; QL(10 eaper 30 daysretail)

ONFI TABS 10 MG, 20 MG (Use clobazam) NF

PA

VALTOCO LIQD F PA; QL(10 eaper 30 daysretail)

VALTOCO LQPK F PA; QL(10 eaper 30 daysretail)

Anticonvulsants - Misc. BANZEL TABS 200 MG, 400 MG F

PA; SP

carbamazepine chew or100 mg F

carbamazepine cp12 or100 mg, 200 mg, 300 mg F

CARBAMAZEPINE POWD XX F

carbamazepine susp or100 mg/5ml F

carbamazepine tabs or 200 mg F


carbamazepine tb12 or 100mg, 200 mg, 400 mg F

CARBATROL CP12 (Use carbamazepine) F

gabapentin caps 100 mg,300 mg, 400 mg F

QL(9 ea daily)

gabapentin tabs 600 mg F QL(6 ea daily)

gabapentin tabs 800 mg F QL(4 ea daily)

KEPPRA SOLN OR 100 MG/ML (Use levetiracetam) F

KEPPRA TABS OR 250 MG, 500 MG, 750 MG, 1000 MG (Use levetiracetam)

F

KEPPRA XR TB24 (Use levetiracetam) F

LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use lamotrigine)

CO

LAMICTAL ODT KIT CO

LAMICTAL ODT KIT (Use lamotrigine) CO

LAMICTAL ODT TBDP 25 MG, 50 MG, 100 MG, 200 MG (Use lamotrigine)

CO

LAMICTAL STARTER/NOTTAKING CARBAMAZEPINE KIT (Use lamotrigine)

CO

LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATE KIT (Use lamotrigine)

CO

LAMICTAL STARTER/TAKINGVALPROATE KIT (Use lamotrigine)

CO

LAMICTAL TABS (Use lamotrigine) CO

LAMICTAL XR KIT CO


13


LAMICTAL XR TB24 25 MG, 50 MG, 100 MG, 200 MG, 250 MG, 300 MG (Use lamotrigine)

CO

lamotrigine chew or 5 mg,25 mg CO

lamotrigine kit or 25 mg, CO lamotrigine tabs or 25 mg,100 mg, 150 mg, 200 mg CO

lamotrigine tb24 or 25 mg,50 mg, 100 mg, 200 mg,250 mg, 300 mg

CO

lamotrigine tbdp or 25 mg,50 mg, 100 mg, 200 mg CO

levetiracetam soln or 100 mg/ml, 500 mg/5ml F

levetiracetam tabs or 250 mg, 500 mg, 750 mg, 1000 mg

F

levetiracetam tb24 or 500 mg, 750 mg F

LYRICA CAPS 25 MG, 50 MG, 75 MG, 100 MG, 150 MG, 200 MG, 225 MG, 300 MG (Use pregabalin)

NF

PA

MYSOLINE TABS (Use primidone) NF

NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use gabapentin)

F QL(9 ea daily)

NEURONTIN TABS 600 MG (Use gabapentin) F

QL(6 ea daily)

NEURONTIN TABS 800 MG (Use gabapentin) F

QL(4 ea daily)

oxcarbazepine susp F

oxcarbazepine tabs F pregabalin caps 25 mg, 50mg, 75 mg, 100 mg, 150mg, 200 mg, 225 mg, 300 mg

F

PA

primidone tabs F

QUDEXY XR CS24 NF


TEGRETOL SUSP (Use carbamazepine) F

TEGRETOL TABS (Use carbamazepine) F

TEGRETOL-XR TB12 (Use carbamazepine) F

TOPAMAX SPRINKLE CPSP (Use topiramate) F

TOPAMAX TABS (Use topiramate) F

topiramate cpsp 15 mg, 25 mg F

topiramate tabs 25 mg, 50mg, 100 mg, 200 mg F

TRILEPTAL SUSP (Use oxcarbazepine) F

TRILEPTAL TABS (Use oxcarbazepine) F

VIMPAT TABS OR 50 MG, 100 MG, 150 MG, 200 MG F

PA

ZONEGRAN CAPS (Use zonisamide) NF

zonisamide caps F

GABA Modulators GABITRIL TABS (Use tiagabine hcl) NF

tiagabine hcl tabs F

Hydantoins DILANTIN CAPS 100 MG (Use phenytoin sodiumextended)

F

DILANTIN CAPS 30 MG F

DILANTIN INFATABS CHEW (Use phenytoin) NF

DILANTIN-125 SUSP (Use phenytoin) NF

PHENYTEK CAPS (Use phenytoin sodiumextended)

F

phenytoin chew F phenytoin sodium extended caps F


14


phenytoin susp F

Succinimides ethosuximide caps F

ethosuximide soln F ZARONTIN CAPS (Use ethosuximide) NF

ZARONTIN SOLN (Use ethosuximide) NF

Valproic Acid DEPACON SOLN (Use valproate sodium) CO

DEPAKENE CAPS (Use valproic acid) CO

DEPAKENE SOLN (Use valproate sodium) CO

DEPAKOTE ER TB24 (Use divalproex sodium) CO

DEPAKOTE SPRINKLES CSDR (Use divalproexsodium)

CO

DEPAKOTE TBEC (Use divalproex sodium) CO

divalproex sodium csdr or125 mg CO

divalproex sodium tb24 or250 mg, 500 mg CO

divalproex sodium tbec or125 mg, 250 mg, 500 mg CO

valproate sodium soln iv100 mg/ml, 500 mg/5ml CO

valproate sodium soln or250 mg/5ml CO

valproic acid caps or CO

ANTIDEPRESSANTS - Drugs to TreatDepression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs CO

mirtazapine tbdp CO REMERON SOLTAB TBDP (Use mirtazapine) CO


REMERON TABS (Use mirtazapine) CO

Antidepressants - Misc. APLENZIN TB24 CO

bupropion hcl tabs CO

bupropion hcl tb12 CO

bupropion hcl tb24 CO

FORFIVO XL TB24 CO

maprotiline hcl tabs CO WELLBUTRIN SR TB12 (Use bupropion hcl) CO

WELLBUTRIN XL TB24 (Use bupropion hcl) CO

GABA Receptor Modulator - Neuroactive Steroid ZULRESSO SOLN CO SP

Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 CO

MARPLAN TABS CO

NARDIL TABS (Use phenelzine sulfate) CO

PARNATE TABS (Use tranylcypromine sulfate) CO

phenelzine sulfate tabs CO tranylcypromine sulfatetabs CO

N-Methyl-D-aspartic acid (NMDA) Receptor SPRAVATO 56MG DOSE SOPK CO

SPRAVATO 84MG DOSE SOPK CO

Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS (Use citalopram hydrobromide) CO

citalopram hydrobromidesoln CO


15


citalopram hydrobromidetabs CO

escitalopram oxalate soln CO

escitalopram oxalate tabs CO

fluoxetine hcl caps CO

fluoxetine hcl cpdr CO

fluoxetine hcl soln CO

fluoxetine hcl tabs CO FLUOXETINE HYDROCHLORIDE TABS (Use fluoxetine hcl)

CO

fluvoxamine maleate cp24 CO

fluvoxamine maleate tabs CO LEXAPRO TABS (Use escitalopram oxalate) CO

paroxetine hcl tabs CO

paroxetine hcl tb24 CO PAXIL CR TB24 (Use paroxetine hcl) CO

PAXIL SUSP 10 MG/5ML CO

PAXIL TABS 10 MG, 20 MG, 30 MG, 40 MG (Use paroxetine hcl)

CO

PEXEVA TABS CO

PROZAC CAPS (Use fluoxetine hcl) CO

sertraline hcl conc CO

sertraline hcl tabs CO ZOLOFT CONC (Use sertraline hcl) CO

ZOLOFT TABS (Use sertraline hcl) CO

Serotonin Modulators


nefazodone hcl tabs CO

trazodone hcl tabs CO

TRINTELLIX TABS CO

VIIBRYD STARTER PACK KIT CO

VIIBRYD TABS CO

Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use duloxetine hcl) CO

DESVENLAFAXINE ER TB24 CO

desvenlafaxine succinate tb24 CO

desvenlafaxine tb24 CO DRIZALMA SPRINKLE CSDR CO

duloxetine hcl cpep CO EFFEXOR XR CP24 (Use venlafaxine hcl) CO

FETZIMA CP24 CO

FETZIMA TITRATION PACK C4PK CO

KHEDEZLA TB24 CO

PRISTIQ TB24 (Use desvenlafaxine succinate) CO

venlafaxine hcl cp24 CO

venlafaxine hcl tabs CO

venlafaxine hcl tb24 CO

Tricyclic Agents amitriptyline hcl tabs CO

amoxapine tabs CO ANAFRANIL CAPS (Use clomipramine hcl) CO


16


clomipramine hcl caps CO

desipramine hcl tabs CO

doxepin hcl caps CO

doxepin hcl conc CO

imipramine hcl tabs CO

imipramine pamoate caps CO NORPRAMIN TABS (Use desipramine hcl) CO

nortriptyline hcl caps CO

nortriptyline hcl soln CO PAMELOR CAPS (Use nortriptyline hcl) CO

protriptyline hcl tabs CO SURMONTIL CAPS (Use trimipramine maleate) CO

TOFRANIL TABS (Use imipramine hcl) CO

trimipramine maleate caps CO

ANTIDIABETICS - Drugs to Regulate BloodSugar Alpha-Glucosidase Inhibitors acarbose tabs F PRECOSE TABS (Use acarbose) NF

Antidiabetic Combinations ACTOPLUS MET TABS (Use pioglitazone hcl-metformin hcl)

NF

alogliptin-metformin hcltabs F

Generic Required

alogliptin-pioglitazone tabs F Generic Required DUETACT TABS (Use pioglitazone hcl-glimepiride)

NF


JANUMET TABS F PA

pioglitazone hcl-glimepiridetabs F

pioglitazone hcl-metforminhcl tabs F

SEGLUROMET TABS F PA

Biguanides GLUCOPHAGE TABS (Use metformin hcl) NF

GLUCOPHAGE XR TB24 (Use metformin hcl) NF

metformin hcl tabs 500 mg,850 mg, 1000 mg F

metformin hcl tb24 500 mg,750 mg F

Diabetic Other BAQSIMI ONE PACK POWD F

QL(0.069 eadaily)

BAQSIMI TWO PACK POWD F

QL(0.069 eadaily)

BD GLUCOSE CHEW F

CVS GLUCOSE CHEW 4 GM F

CVS SOFT GLUCOSE CHEW F

DEX4 QUICK DISSOLVE GLUCOSE CHEW F

dextrose (diabetic use) gel40 %, 15 gm/38gm F

GLUCAGEN HYPOKIT SOLR F

GLUCAGON EMERGENCY KIT KIT F

GLUCOSE CHEW 4 GM F

GNP GLUCOSE CHEW 4 GM F

GNP QUICK DISSOLVE GLUCOSE CHEW F

GVOKE PFS SOSY F QL(0.02 mldaily)


17


LEADER QUICK DISSOLVE GLUCOSE CHEW

F

SM GLUCOSE CHEW 4 GM F

WALGREENS GLUCOSE CHEW 4 GM F

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

alogliptin benzoate tabs F Generic Required JANUVIA TABS F PA

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON BCISE AUIJ F PA; QL(3.4 mlper 28 daysretail)

BYDUREON PEN PEN F PA; QL(4 eaper 28 daysretail)

BYDUREON SRER F PA; QL(4 eaper 28 daysretail)

BYETTA SOPN 10 MCG/0.04ML F

PA; QL(2.4 mlper 30 daysretail)

BYETTA SOPN 5 MCG/0.02ML F

PA; QL(1.2 mlper 30 daysretail)

TRULICITY SOPN F PA

VICTOZA SOPN F PA; QL(9 mlper 30 daysretail)

Insulin Sensitizing Agents ACTOS TABS (Use pioglitazone hcl) NF

pioglitazone hcl tabs F

Insulin ADMELOG SOLN 100 UNIT/ML F

ADMELOG SOLOSTAR SOPN 100 UNIT/ML F

BASAGLAR KWIKPEN SOPN 100 UNIT/ML F


HUMALOG MIX 50/50KWIKPEN SUPN F

HUMALOG MIX 50/50SUSP F

HUMALOG MIX 75/25KWIKPEN SUPN F

HUMALOG MIX 75/25SUSP F

HUMULIN 70/30 KWIKPENSUPN F

HUMULIN 70/30 SUSP F

HUMULIN N KWIKPEN SUPN F

HUMULIN N SUSP F

HUMULIN R SOLN F

HUMULIN R U-500 (CONCENTRATED) SOLN F

HUMULIN R U-500 KWIKPEN SOPN F


INSULIN ASPART PROTAMINE/INSULINASPART FLEXPEN SUPN

F

INSULIN ASPART PROTAMINE/INSULINASPART SUSP

F

INSULIN LISPRO PROTAMINE/INSULINLISPRO KWIKPEN SUPN

F

NOVOLIN 70/30 FLEXPENRELION SUPN F

NOVOLIN 70/30 FLEXPENSUPN F

NOVOLIN 70/30 RELIONSUSP F

NOVOLIN 70/30 SUSP F

NOVOLIN N FLEXPEN RELION SUPN F

NOVOLIN N FLEXPEN SUPN F

NOVOLIN N RELION SUSP F

NOVOLIN N SUSP F


18


NOVOLIN R RELION SOLN F

NOVOLIN R SOLN F

NOVOLOG MIX 70/30PREFILLED FLEXPEN SUPN

F

NOVOLOG MIX 70/30SUSP F

Sodium-Glucose Co-Transporter 2 (SGLT2) JARDIANCE TABS F PA

STEGLATRO TABS F PA

Sulfonylureas AMARYL TABS (Use glimepiride) NF

chlorpropamide tabs F

glimepiride tabs F

glipizide tabs F

glipizide tb24 F GLUCOTROL TABS (Use glipizide) NF

GLUCOTROL XL TB24 (Use glipizide) NF

glyburide micronized tabs F glyburide tabs 5 mg, 2.5mg, 1.25 mg F

GLYNASE TABS (Use glyburide micronized) NF

tolazamide tabs F

tolbutamide tabs F

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat Diarrhea Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chew262 mg F


bismuth subsalicylate susp262 mg/15ml, 525mg/15ml, 525 mg/30ml,527 mg/30ml, 1050mg/30ml

F

bismuth subsalicylate tabs262 mg F

PEPTO BISMOL TABS (Use bismuth subsalicylate) NF

PEPTO-BISMOL CHEW (Use bismuth subsalicylate) NF

PEPTO-BISMOL MAX STRENGTH SUSP (Use bismuth subsalicylate)

NF

PEPTO-BISMOL SUSP (Use bismuth subsalicylate) NF

PEPTO-BISMOL TO-GO CHEW (Use bismuth subsalicylate)

NF

Antiperistaltic Agents diphenoxylate w/ atropineliqd 2.5 mg/5ml-0.025mg/5ml

F

diphenoxylate w/ atropinetabs 2.5 mg-0.025 mg F

QL(8 ea daily)

IMODIUM A-D CAPS 2 MG (Use loperamide hcl) NF

QL(8 ea daily);RX/OTC

IMODIUM A-D TABS 2 MG (Use loperamide hcl) NF

QL(8 ea daily)

LOMOTIL TABS (Use diphenoxylate w/ atropine) NF

QL(8 ea daily)

loperamide hcl caps 2 mg F QL(8 ea daily);RX/OTC loperamide hcl tabs 2 mg F QL(8 ea daily)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Opioid Antagonists naltrexone hcl tabs F NARCAN LIQD 4 MG/0.1ML F

VIVITROL SUSR F PA; SP

ANTIEMETICS - Drugs to Treat Nausea andVomiting


19


5-HT3 Receptor Antagonists ondansetron hcl soln or 4 mg/5ml F


ondansetron hcl tabs or 24 mg F

QL(1 ea daily)

ondansetron hcl tabs or 4 mg, 8 mg F

QL(4 ea daily)

ondansetron tbdp F QL(4 ea daily)

ZOFRAN ODT TBDP (Use ondansetron) NF

QL(4 ea daily)

ZOFRAN SOLN 4 MG/5ML(Use ondansetron hcl) NF


ZOFRAN TABS 4 MG, 8 MG (Use ondansetron hcl) NF

QL(4 ea daily)

Antiemetics - Anticholinergic meclizine hcl chew 25 mg F meclizine hcl tabs 25 mg,12.5 mg F

RX/OTC

Antiemetics - Miscellaneous dronabinol caps F PA

MARINOL CAPS (Use dronabinol) NF

PA

Substance P/Neurokinin 1 (NK1) Receptor EMEND SOLR IV 150 MG (Use fosaprepitantdimeglumine)

NF

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungals nystatin tabs 500000 unit F

terbinafine hcl tabs F

Imidazole-Related Antifungals DIFLUCAN SUSR 10 MG/ML, 40 MG/ML (Use fluconazole)

NF QL(100 ml per365 days retail)

DIFLUCAN TABS 50 MG, 100 MG, 150 MG, 200 MG (Use fluconazole)

NF QL(14 ea per31 days retail)

fluconazole susr 10 mg/ml,40 mg/ml F



fluconazole tabs 50 mg,100 mg, 150 mg, 200 mg F


itraconazole caps 100 mg F PA

ketoconazole tabs F SPORANOX CAPS 100 MG (Use itraconazole) NF

PA

SPORANOX PULSEPAK CAPS (Use itraconazole) NF

PA

VFEND TABS 50 MG, 200 MG (Use voriconazole) NF

PA

voriconazole tabs or 50 mg,200 mg F

PA

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines CHLOR-TRIMETON TABS 4 MG (Use chlorpheniramine maleate)

NF

chlorpheniramine maleatetabs 4 mg F

Antihistamines - Ethanolamines ALER-DRYL TABS F

BENADRYL ALLERGY CAPS (Use diphenhydramine hcl)

NF

BENADRYL ALLERGY CHILDRENS CHEW (Use diphenhydramine hcl)

NF

BENADRYL ALLERGY CHILDRENS LIQD (Use diphenhydramine hcl)

NF

BENADRYL ALLERGY TABS (Use diphenhydramine hcl)

NF

diphenhydramine hcl capsor 25 mg, 50 mg F

diphenhydramine hcl chewor 12.5 mg F

diphenhydramine hcl elix or12.5 mg/5ml F

RX/OTC

diphenhydramine hcl liqd or25 mg/10ml, 50 mg/20ml,12.5 mg/5ml

F


20


diphenhydramine hcl tabsor 25 mg F

Antihistamines - Non-Sedating cetirizine hcl soln 1 mg/ml,5 mg/5ml F

RX/OTC

cetirizine hcl syrp 1 mg/ml,5 mg/5ml F

RX/OTC

cetirizine hcl tabs 5 mg, 10 mg F

CLARITIN ALLERGY CHILDRENS SYRP (Use loratadine)

NF

CLARITIN CHEW 5 MG (Use loratadine) NF

CLARITIN CHILDRENS CHEW (Use loratadine) NF

CLARITIN REDITABS TBDP 10 MG (Use loratadine)

NF

CLARITIN SYRP 5 MG/5ML (Use loratadine) NF

CLARITIN TABS 10 MG (Use loratadine) NF

loratadine chew 5 mg F

loratadine soln 5 mg/5ml F

loratadine syrp 5 mg/5ml F

loratadine tabs 10 mg F

loratadine tbdp 10 mg F ZYRTEC ALLERGY TABS (Use cetirizine hcl) NF

ZYRTEC CHILDRENS ALLERGY SOLN (Use cetirizine hcl)

NF RX/OTC

Antihistamines - Phenothiazines promethazine hcl soln or6.25 mg/5ml F

promethazine hcl supp re25 mg, 50 mg, 12.5 mg F

promethazine hcl syrp or6.25 mg/5ml F


promethazine hcl tabs or25 mg, 50 mg, 12.5 mg F

Antihistamines - Piperidines cyproheptadine hcl syrp F

cyproheptadine hcl tabs F

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Antihyperlipidemics - Combinations ezetimibe-simvastatin tabs F VYTORIN TABS (Use ezetimibe-simvastatin) NF

Bile Acid Sequestrants cholestyramine light pack F

cholestyramine light powd F

cholestyramine pack F

cholestyramine powd F COLESTID FLAVORED GRAN (Use colestipol hcl) NF

COLESTID FLAVORED PACK (Use colestipol hcl) NF

COLESTID GRAN (Use colestipol hcl) NF

COLESTID PACK (Use colestipol hcl) NF

COLESTID TABS (Use colestipol hcl) NF

colestipol hcl gran F

colestipol hcl pack F

colestipol hcl tabs F QUESTRAN LIGHT POWD (Use cholestyramine light) NF

QUESTRAN PACK (Use cholestyramine) NF

QUESTRAN POWD (Use cholestyramine) NF

Fibric Acid Derivatives


21


fenofibrate micronized caps F fenofibrate tabs 48 mg, 54mg, 145 mg, 160 mg F

FIBRICOR TABS 35 MG, 105 MG NF

gemfibrozil tabs 600 mg F

LIPOFEN CAPS NF

LOPID TABS (Use gemfibrozil) NF

TRICOR TABS (Use fenofibrate) NF

TRIGLIDE TABS (Use fenofibrate) NF

HMG CoA Reductase Inhibitors atorvastatin calcium tabs 10 mg, 20 mg F

QL(1 ea daily)

atorvastatin calcium tabs 40 mg, 80 mg F

CRESTOR TABS (Use rosuvastatin calcium) NF

ST; 3 months atorvastatin 80mg first;QL(1ea daily)

LIPITOR TABS 10 MG, 20 MG (Use atorvastatin calcium)

NF QL(1 ea daily)

LIPITOR TABS 40 MG, 80 MG (Use atorvastatin calcium)

NF

lovastatin tabs F PRAVACHOL TABS (Use pravastatin sodium) NF

pravastatin sodium tabs F

rosuvastatin calcium tabs F ST; 3 months atorvastatin 80mg first;QL(1ea daily)

simvastatin tabs 5 mg, 10mg, 20 mg, 40 mg, 80 mg F

ZOCOR TABS (Use simvastatin) NF

Intestinal Cholesterol Absorption Inhibitors


ezetimibe tabs 10 mg F ZETIA TABS (Use ezetimibe) NF

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tabs F

niacin (antihyperlipidemic)tbcr F

NIASPAN TBCR (Use niacin (antihyperlipidemic)) NF

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure ACE Inhibitors ACCUPRIL TABS (Use quinapril hcl) NF

ALTACE CAPS (Use ramipril) NF

benazepril hcl tabs F

captopril tabs F

enalapril maleate tabs F

fosinopril sodium tabs F

lisinopril tabs F LOTENSIN TABS (Use benazepril hcl) NF

moexipril hcl tabs F

perindopril erbumine tabs F PRINIVIL TABS (Use lisinopril) NF

quinapril hcl tabs F

ramipril caps F

trandolapril tabs F VASOTEC TABS (Use enalapril maleate) NF

ZESTRIL TABS (Use lisinopril) NF


22


Angiotensin II Receptor Antagonists AVAPRO TABS (Use irbesartan) NF

COZAAR TABS (Use losartan potassium) NF

DIOVAN TABS (Use valsartan) NF

QL(1 ea daily)

irbesartan tabs F losartan potassium tabs or25 mg, 50 mg, 100 mg F

valsartan tabs F QL(1 ea daily)

Antiadrenergic Antihypertensives CARDURA TABS (Use doxazosin mesylate) NF

CATAPRES TABS (Use clonidine hcl) NF

CLONIDINE HCL POWD XX F

clonidine hcl tabs or 0.1 mg, 0.2 mg, 0.3 mg F

CLONIDINE HYDROCHLORIDE POWD F

doxazosin mesylate tabs or1 mg, 2 mg, 4 mg, 8 mg F

guanfacine hcl tabs F

methyldopa tabs F MINIPRESS CAPS (Use prazosin hcl) NF

prazosin hcl caps F

terazosin hcl caps F

Antihypertensive Combinations ACCURETIC TABS (Use quinapril-hydrochlorothiazide)

NF

atenolol & chlorthalidone tabs F

AVALIDE TABS (Use irbesartan-hydrochlorothiazide)

NF


benazepril &hydrochlorothiazide tabs F

bisoprolol &hydrochlorothiazide tabs F

captopril &hydrochlorothiazide tabs F

CORZIDE TABS 40 MG-5 MG NF

DIOVAN HCT TABS (Use valsartan-hydrochlorothiazide)

NF QL(1 ea daily)

enalapril maleate &hydrochlorothiazide tabs F

HYZAAR TABS (Use losartan potassium &hydrochlorothiazide)

NF

irbesartan-hydrochlorothiazide tabs F

lisinopril &hydrochlorothiazide tabs F

losartan potassium &hydrochlorothiazide tabs F

LOTENSIN HCT TABS (Use benazepril &hydrochlorothiazide)

NF

moexipril-hydrochlorothiazide tabs F

quinapril-hydrochlorothiazide tabs F

TENORETIC 100 TABS (Use atenolol & chlorthalidone)

NF

TENORETIC 50 TABS (Use atenolol & chlorthalidone)

NF

valsartan-hydrochlorothiazide tabs F

QL(1 ea daily)

VASERETIC TABS (Use enalapril maleate &hydrochlorothiazide)

NF

ZESTORETIC TABS (Use lisinopril &hydrochlorothiazide)

NF

ZIAC TABS (Use bisoprolol& hydrochlorothiazide) NF

Direct Renin Inhibitors


23


TEKTURNA TABS (Use aliskiren fumarate) NF

Vasodilators hydralazine hcl tabs or 10mg, 25 mg, 50 mg, 100 mg F

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarials chloroquine phosphatetabs 250 mg, 500 mg F

CHLOROQUINE PHOSPHATE TABS 500 MG

F

DARAPRIM TABS F SP

hydroxychloroquine sulfatetabs F

KRINTAFEL TABS 150 MG F QL(2 ea per 30days retail)

mefloquine hcl tabs F PLAQUENIL TABS (Use hydroxychloroquine sulfate) F

PRIMAQUINE PHOSPHATE TABS (Use primaquine phosphate)

NF

primaquine phosphate tabs26.3 mg F

pyrimethamine tabs F SP

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents MESTINON SOLN (Use pyridostigmine bromide) NF

MESTINON TABS (Use pyridostigmine bromide) NF

pyridostigmine bromidesoln 60 mg/5ml F

pyridostigmine bromidetabs 60 mg F

RUZURGI TABS F PA; QL(10 eadaily); SP ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)


Antimycobacterial Agents ethambutol hcl tabs F

isoniazid syrp or 50 mg/5ml F ISONIAZID TABS OR 100 MG F

isoniazid tabs or 100 mg,300 mg F

MYAMBUTOL TABS (Use ethambutol hcl) NF

pyrazinamide tabs F RIFADIN CAPS OR 150 MG, 300 MG (Use rifampin) NF

rifampin caps or 150 mg,300 mg F

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents TEPADINA SOLR (Use thiotepa) NF

SP

Antimetabolites cytarabine soln F SP

GEMCITABINE HYDROCHLORIDE SOLN 1 GM/10ML, 2 GM/20ML,200 MG/2ML

NF

mercaptopurine tabs 50 mg F methotrexate sodium soln ij50 mg/2ml, 250 mg/10ml F

methotrexate sodium tabs or 2.5 mg F

TABLOID TABS F SP

TREXALL TABS F

Antineoplastic - Hormonal and Related Agents anastrozole tabs 1 mg F ARIMIDEX TABS (Use anastrozole) NF

FASLODEX SOLN (Use fulvestrant) NF


24


FEMARA TABS (Use letrozole) NF

letrozole tabs 2.5 mg F

megestrol acetate susp F

megestrol acetate tabs F

tamoxifen citrate tabs F

Antineoplastic Antibiotics DAUNORUBICIN HYDROCHLORIDE SOLN 20 MG/4ML (Use daunorubicin hcl)

NF

SP

Antineoplastics Misc. HYDREA CAPS (Use hydroxyurea) NF

hydroxyurea caps 500 mg F

Chemotherapy Rescue/Antidote Agents leucovorin calcium tabs or 5 mg, 10 mg, 25 mg F

Mitotic Inhibitors TAXOTERE CONC (Use docetaxel) NF

SP

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease Antiparkinson Anticholinergics benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg F

trihexyphenidyl hcl soln F

trihexyphenidyl hcl tabs F

Antiparkinson COMT Inhibitors COMTAN TABS (Use entacapone) NF

entacapone tabs 200 mg F

Antiparkinson Dopaminergics amantadine hcl caps F

amantadine hcl syrp F


amantadine hcl tabs F bromocriptine mesylate caps F

bromocriptine mesylatetabs F

carbidopa-levodopa tabs10 mg-100 mg, 25 mg-100mg, 25 mg-250 mg

F

carbidopa-levodopa tbcr 25mg-100 mg, 50 mg-200 mg F

carbidopa-levodopa-entacapone tabs F

MIRAPEX TABS (Use pramipexoledihydrochloride)

NF

PARLODEL CAPS (Use bromocriptine mesylate) NF

PARLODEL TABS (Use bromocriptine mesylate) NF

pramipexoledihydrochloride tabs 0.125mg, 0.25 mg, 0.75 mg, 0.5mg, 1 mg, 1.5 mg

F

REQUIP TABS (Use ropinirole hydrochloride) NF

ropinirole hydrochloridetabs 0.25 mg, 0.5 mg, 1mg, 2 mg, 3 mg, 4 mg, 5 mg

F

SINEMET CR TBCR (Use carbidopa-levodopa) NF

SINEMET TABS (Use carbidopa-levodopa) NF

STALEVO 100 TABS NF

STALEVO 125 TABS NF

STALEVO 150 TABS NF

STALEVO 200 TABS NF

STALEVO 50 TABS NF

STALEVO 75 TABS NF

Antiparkinson Monoamine Oxidase Inhibitors


25


ELDEPRYL CAPS (Use selegiline hcl) NF

selegiline hcl caps 5 mg F

selegiline hcl tabs 5 mg F

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders Antimanic Agents lithium carbonate caps CO

lithium carbonate tabs CO

lithium carbonate tbcr CO

LITHIUM SOLN CO

LITHOBID TBCR (Use lithium carbonate) CO

Antipsychotics - Misc. CAPLYTA CAPS CO

EQUETRO CP12 CO

GEODON CAPS (Use ziprasidone hcl) CO

GEODON SOLR (Use ziprasidone mesylate) CO

LATUDA TABS CO

NUPLAZID CAPS CO

NUPLAZID TABS CO

VRAYLAR CAPS CO

VRAYLAR CPPK CO

ziprasidone hcl caps CO

ziprasidone mesylate solr CO

Benzisoxazoles FANAPT TABS CO

FANAPT TITRATION PACK TABS CO


INVEGA SUSTENNA SUSY CO

INVEGA TB24 (Use paliperidone) CO

INVEGA TRINZA SUSY CO

paliperidone tb24 CO

PERSERIS PRSY CO SP

RISPERDAL CONSTA SRER CO

RISPERDAL SOLN (Use risperidone) CO

RISPERDAL TABS (Use risperidone) CO

risperidone soln CO

risperidone tabs CO

risperidone tbdp CO

Butyrophenones HALDOL DECANOATE 100 SOLN (Use haloperidoldecanoate)

CO

HALDOL DECANOATE 50 SOLN (Use haloperidoldecanoate)

CO

HALDOL SOLN (Use haloperidol lactate) CO

haloperidol decanoate soln CO

haloperidol lactate conc CO

haloperidol lactate soln CO

haloperidol tabs CO

Dibenzapines ADASUVE AEPB CO

clozapine tabs CO

clozapine tbdp CO


26


CLOZARIL TABS (Use clozapine) CO

FAZACLO TBDP CO

loxapine succinate caps CO

olanzapine solr CO

olanzapine tabs CO

olanzapine tbdp CO

quetiapine fumarate tabs CO

quetiapine fumarate tb24 CO

SAPHRIS SUBL CO

SECUADO PT24 CO

SEROQUEL TABS (Use quetiapine fumarate) CO

SEROQUEL XR TB24 (Use quetiapine fumarate) CO

VERSACLOZ SUSP CO

ZYPREXA RELPREVV SUSR CO

ZYPREXA SOLR (Use olanzapine) CO

ZYPREXA TABS (Use olanzapine) CO

ZYPREXA ZYDIS TBDP (Use olanzapine) CO

Dihydroindolones molindone hcl tabs CO

Phenothiazines CHLORPROMAZINE HCL SOLN IJ 25 MG/ML, 50MG/2ML

CO

chlorpromazine hcl tabs or10 mg, 25 mg, 50 mg, 100mg, 200 mg

CO

fluphenazine decanoatesoln CO


fluphenazine hcl conc or 5mg/ml CO

fluphenazine hcl elix or 2.5mg/5ml CO

fluphenazine hcl soln ij 2.5mg/ml CO

fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg CO

perphenazine tabs CO prochlorperazine maleatetabs F

prochlorperazine supp F

thioridazine hcl tabs CO

trifluoperazine hcl tabs CO

Quinolinone Derivatives ABILIFY MAINTENA PRSY CO

ABILIFY MAINTENA SRER CO

ABILIFY MYCITE TABS CO

ABILIFY TABS (Use aripiprazole) CO

aripiprazole soln CO

aripiprazole tabs CO

aripiprazole tbdp CO

ARISTADA INITIO PRSY CO

ARISTADA PRSY CO

REXULTI TABS CO

Thioxanthenes thiothixene caps CO

ANTISEPTICS & DISINFECTANTS

Iodine Antiseptics BETADINE SOLN 10 % (Use povidone-iodine) NF


27


BETADINE SURGICAL SCRUB SOLN (Use povidone-iodine)

NF

povidone-iodine oint 10 % F povidone-iodine soln 10 %,7.5 % F

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals abacavir sulfate soln F

abacavir sulfate tabs F abacavir sulfate-lamivudine tabs 600 mg-300 mg F

QL(1 ea daily)

abacavir sulfate-lamivudine-zidovudine tabs 300 mg-150 mg-300 mg

F

APTIVUS CAPS F

APTIVUS SOLN F

atazanavir sulfate caps 150mg, 200 mg, 300 mg F

ATRIPLA TABS F ST

BIKTARVY TABS F

CIMDUO TABS F

COMBIVIR TABS (Use lamivudine-zidovudine) NF

COMPLERA TABS F ST

CRIXIVAN CAPS F

DELSTRIGO TABS F ST; QL(1 eadaily)

DESCOVY TABS F

didanosine cpdr F

DOVATO TABS F

EDURANT TABS F


efavirenz caps F

efavirenz tabs F

EMTRIVA CAPS F

EMTRIVA SOLN F

EPIVIR SOLN (Use lamivudine) NF

EPIVIR TABS (Use lamivudine) NF

EPZICOM TABS (Use abacavir sulfate-lamivudine)

NF QL(1 ea daily)

EVOTAZ TABS F

fosamprenavir calcium tabs F

GENVOYA TABS F

INTELENCE TABS F

INVIRASE CAPS F

INVIRASE TABS F

ISENTRESS HD TABS F QL(2 ea daily)

ISENTRESS TABS 400 MG F

JULUCA TABS F

KALETRA TABS 100 MG-25 MG, 200 MG-50 MG F

lamivudine soln F

lamivudine tabs F lamivudine-zidovudine tabs 150 mg-300 mg F

LEXIVA SUSP 50 MG/ML F

LEXIVA TABS 700 MG (Use fosamprenavircalcium)

NF

nevirapine susp F


28


nevirapine tabs F

nevirapine tb24 F

NORVIR CAPS 100 MG NF

NORVIR SOLN 80 MG/ML NF

NORVIR TABS 100 MG (Use ritonavir) NF

ODEFSEY TABS F ST

PIFELTRO TABS F

PREZCOBIX TABS F

PREZISTA TABS 75 MG, 150 MG, 600 MG, 800 MG F

RESCRIPTOR TABS F

RETROVIR CAPS (Use zidovudine) NF

RETROVIR SYRP (Use zidovudine) NF

REYATAZ CAPS 150 MG, 200 MG, 300 MG (Use atazanavir sulfate)

NF

ritonavir tabs 100 mg F SELZENTRY TABS 150 MG, 300 MG F

stavudine caps F

STRIBILD TABS F

SUSTIVA CAPS (Use efavirenz) NF

SUSTIVA TABS (Use efavirenz) NF

SYMTUZA TABS F ST; QL(1 eadaily)

TEMIXYS TABS F

tenofovir disoproxilfumarate tabs F

TIVICAY TABS 50 MG F


TRIUMEQ TABS F

TRIZIVIR TABS (Use abacavir sulfate-lamivudine-zidovudine)

NF

TRUVADA TABS 300 MG-200 MG F

TYBOST TABS F

VIDEX EC CPDR NF

VIDEXPEDIATRIC SOLR F

VIRACEPT TABS F

VIRAMUNE SUSP (Use nevirapine) NF

VIRAMUNE TABS (Use nevirapine) NF

VIRAMUNE XR TB24 (Use nevirapine) NF

VIREAD TABS 150 MG, 200 MG, 250 MG F

VIREAD TABS 300 MG (Use tenofovir disoproxilfumarate)

NF

ZERIT CAPS (Use stavudine) NF

ZERIT SOLR NF

ZIAGEN SOLN (Use abacavir sulfate) NF

ZIAGEN TABS (Use abacavir sulfate) NF

zidovudine caps F

zidovudine syrp F

zidovudine tabs F

CMV Agents VALCYTE TABS 450 MG (Use valganciclovir hcl) NF

200 perlifetime;

valganciclovir hcl tabs 450 mg F

200 perlifetime;

Hepatitis Agents


29


EPCLUSA TABS F PA; SP

EPIVIR HBV SOLN 5 MG/ML F

EPIVIR HBV TABS 100 MG (Use lamivudine (hbv)) NF

lamivudine (hbv) tabs F

MAVYRET TABS F PA; SP

PEGASYS PROCLICK SOLN F

PA; SP

PEGASYS SOLN F PA; SP

PEGINTRON KIT F PA; SP

SOFOSBUVIR/VELPATASVIR TABS F

PA; SP

Herpes Agents acyclovir caps F

acyclovir susp F

acyclovir tabs F

famciclovir tabs F QL(2 ea daily)

valacyclovir hcl tabs F QL(2 ea daily)

VALTREX TABS (Use valacyclovir hcl) NF

QL(2 ea daily)

ZOVIRAX CAPS OR 200 MG (Use acyclovir) NF

ZOVIRAX SUSP OR 200 MG/5ML (Use acyclovir) NF

ZOVIRAX TABS OR 400 MG, 800 MG (Use acyclovir)

NF

Influenza Agents FLUMADINE TABS NF

oseltamivir phosphate capsor 30 mg F







oseltamivir phosphate susror 6 mg/ml F

300mls/ 180days;QL(180ml per 180days retail)

RELENZA DISKHALER AEPB F

10 per 180days;QL(20 eaper 180 daysretail)

rimantadine hydrochloridetabs 100 mg F

TAMIFLU CAPS 30 MG (Use oseltamivir phosphate)






TAMIFLU SUSR 6 MG/ML(Use oseltamivir phosphate)

NF

300mls/ 180days;QL(180ml per 180days retail)

BETA BLOCKERS - Drugs to Treat High BloodPressure Alpha-Beta Blockers carvedilol tabs F COREG TABS (Use carvedilol) NF

labetalol hcl tabs or 100 mg, 200 mg, 300 mg F

Beta Blockers Cardio-Selective atenolol tabs F

bisoprolol fumarate tabs F LOPRESSOR TABS (Use metoprolol tartrate) NF

metoprolol succinate tb24 F QL(1 ea daily)

metoprolol tartrate tabs or25 mg, 50 mg, 100 mg F

TENORMIN TABS (Use atenolol) NF

TOPROL XL TB24 (Use metoprolol succinate) NF

QL(1 ea daily)


30


Beta Blockers Non-Selective BETAPACE TABS (Use sotalol hcl) NF

CORGARD TABS (Use nadolol) NF

INDERAL LA CP24 (Use propranolol hcl) NF

nadolol tabs F

pindolol tabs F propranolol hcl cp24 or 60mg, 80 mg, 120 mg, 160 mg

F

propranolol hcl soln or 20mg/5ml F


propranolol hcl soln or 40mg/5ml F


propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

F

sotalol hcl tabs F

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure Calcium Channel Blockers ADALAT CC TB24 (Use nifedipine) NF

amlodipine besylate tabs F CALAN SR TBCR (Use verapamil hcl) NF

CALAN TABS (Use verapamil hcl) NF

CARDIZEM CD CP24 (Use diltiazem hcl coated beads) NF

CARDIZEM TABS (Use diltiazem hcl) NF

diltiazem hcl coated beads cp24 120 mg, 180 mg, 240mg, 300 mg, 360 mg

F

diltiazem hcl cp12 or 60mg, 90 mg, 120 mg F

diltiazem hcl cp24 or 120mg, 180 mg, 240 mg F


diltiazem hcl extended release beads cp24 F

diltiazem hcl tabs or 30 mg,60 mg, 90 mg, 120 mg F

felodipine tb24 F nicardipine hcl caps or 20mg, 30 mg F

nifedipine caps F

nifedipine tb24 F NORVASC TABS (Use amlodipine besylate) NF

PROCARDIA CAPS (Use nifedipine) NF

PROCARDIA XL TB24 (Use nifedipine) NF

TIAZAC CP24 (Use diltiazem hcl extended release beads)

NF

verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 240 mg, 300 mg, 360 mg

F

verapamil hcl tabs or 40mg, 80 mg, 120 mg F

verapamil hcl tbcr or 120mg, 180 mg, 240 mg F

VERELAN CP24 (Use verapamil hcl) NF

VERELAN PM CP24 (Use verapamil hcl) F

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm Cardiac Glycosides digoxin soln or 0.05 mg/ml F digoxin tabs or 0.125 mg,0.25 mg, 125 mcg, 250 mcg

F

LANOXIN TABS OR 125 MCG, 250 MCG (Use digoxin)

NF

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation Conditions


31


Cardioplegic Solutions PLEGISOL SOLN (Use cardioplegic soln) NF

Pulmonary Hypertension - Endothelin Receptor ambrisentan tabs F PA; SP

bosentan tabs F PA; SP

LETAIRIS TABS (Use ambrisentan) NF

PA; SP

OPSUMIT TABS F PA; SP

TRACLEER TABS 125 MG, 62.5 MG (Use bosentan)

NF PA; SP

TRACLEER TBSO 32 MG F PA; SP

Pulmonary Hypertension - Phosphodiesterase ADCIRCA TABS (Use tadalafil (pulmonaryhypertension))

NF PA; SP

REVATIO TABS OR 20 MG (Use sildenafil citrate (pulmonary hypertension))

NF PA; SP

sildenafil citrate (pulmonaryhypertension) tabs or 20 mg

F PA; SP

tadalafil (pulmonaryhypertension) tabs 20 mg F

PA; SP

Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS F PA; SP

Transthyretin Stabilizers

VYNDAMAX CAPS F PA; QL(1 eadaily); SP

VYNDAQEL CAPS F PA; QL(4 eadaily); SP CEPHALOSPORINS - Drugs to Treat BacterialInfections Cephalosporins - 1st Generation cefadroxil caps F

cefadroxil susr F


cefadroxil tabs F cephalexin caps 250 mg,500 mg, 750 mg F

cephalexin susr 125mg/5ml, 250 mg/5ml F

KEFLEX CAPS (Use cephalexin) NF

Cephalosporins - 2nd Generation cefaclor caps F

cefaclor susr F

cefprozil susr F

cefprozil tabs F

cefuroxime axetil tabs F

Cephalosporins - 3rd Generation cefdinir caps F

cefdinir susr F

cefpodoxime proxetil susr F

cefpodoxime proxetil tabs F

CHEMICALS

Bulk Chemicals - L's LAMOTRIGINE POWD XX CO

Bulk Chemicals - M's METRONIDAZOLE BENZOATE POWD F

Bulk Chemicals - V's SODIUM VALPROATE POWD CO

VALPROATE SODIUM POWD XX CO

CONTRACEPTIVES - Drugs to PreventPregnancy Combination Contraceptives - Oral desogestrel & ethinylestradiol tabs F


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desogestrel-ethinylestradiol (biphasic) tabs F

desogestrel-ethinylestradiol (triphasic) tabs F

drospirenone-ethinylestradiol tabs 3 mg-0.02mg, 3 mg-0.03 mg

F

ESTROSTEP FE TABS (Use norethindrone acetate-ethinyl estradiol-fe)

NF

ethynodiol diacet & ethestrad tabs F

levonorgestrel & ethestradiol tabs F

levonorgestrel-eth estradiol(triphasic) tabs F

levonorgestrel-ethinylestradiol (91-day) tabs F

levonorgestrel-ethinylestradiol (continuous) tabs F

LOESTRIN 1.5/30-21TABS (Use norethindrone acet & eth estra)

NF

LOESTRIN 1/20-21 TABS(Use norethindrone acet & eth estra)

NF

LOESTRIN FE 1.5/30TABS (Use norethin acet & estrad-fe)

NF

LOESTRIN FE 1/20 TABS(Use norethin acet & estrad-fe)

NF

LOSEASONIQUE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NF

MIRCETTE TABS (Use desogestrel-ethinylestradiol (biphasic))

NF

norethin acet & estrad-fe tabs 75 mg-20 mcg-1 mg,75 mg-30 mcg-1.5 mg

F

norethindrone & eth estradiol tabs F

norethindrone acet & eth estra tabs F


norethindrone acetate-ethinyl estradiol-fe tabs 75mg-1 mg

F

norethindrone-eth estradiol (triphasic) tabs F

norgestimate-ethinylestradiol (triphasic) tabs F

norgestimate-ethinylestradiol tabs 0.25 mg-35 mcg

F

norgestrel & ethinylestradiol tabs F

ORTHO TRI-CYCLEN LO TABS (Use norgestimate-ethinyl estradiol (triphasic))

NF

ORTHO TRI-CYCLEN TABS (Use norgestimate-ethinyl estradiol (triphasic))

NF

ORTHO-CYCLEN TABS (Use norgestimate-ethinylestradiol)

NF

ORTHO-NOVUM 1/35TABS (Use norethindrone & eth estradiol)

NF

ORTHO-NOVUM 7/7/7TABS (Use norethindrone-eth estradiol (triphasic))

NF

SEASONIQUE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NF

TRI-NORINYL 28 TABS (Use norethindrone-eth estradiol (triphasic))

NF

YASMIN 28 TABS (Use drospirenone-ethinylestradiol)

NF

YAZ TABS (Use drospirenone-ethinylestradiol)

NF

Combination Contraceptives - Transdermal norelgestromin-ethinylestradiol ptwk F

QL(10 ea perfill retail)

Combination Contraceptives - Vaginal etonogestrel-ethinylestradiol ring 0.12 mg/24hr-0.015 mg/24hr

F


33


NUVARING RING (Use etonogestrel-ethinylestradiol)

NF

Copper Contraceptives - IUD PARAGARD INTRAUTERINE COPPER CONTRACEPTIVE T380A IUD

F

SP

Emergency Contraceptives ELLA TABS F

levonorgestrel (emergencyoc) tabs 1.5 mg F

PLAN B ONE-STEP TABS (Use levonorgestrel(emergency oc))

NF

Progestin Contraceptives - IUD KYLEENA IUD F SP

LILETTA IUD F SP

MIRENA IUD F SP

SKYLA IUD F SP

Progestin Contraceptives - Implants NEXPLANON IMPL F SP

Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSP (Use medroxyprogesteroneacetate (contraceptive))

NF

QL(1 ml per fillretail)

DEPO-PROVERA CONTRACEPTIVE SUSY (Use medroxyprogesteroneacetate (contraceptive))

NF

DEPO-SUBQ PROVERA 104 SUSY F

medroxyprogesteroneacetate (contraceptive) susp

F QL(1 ml per fillretail)

medroxyprogesteroneacetate (contraceptive) susy

F

Progestin Contraceptives - Oral


norethindrone (contraceptive) tabs 0.35 mg

F

ORTHO MICRONOR TABS (Use norethindrone (contraceptive))

NF

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions Glucocorticosteroids budesonide cpep 3 mg F CELESTONE-SOLUSPAN SUSP (Use betamethasone sod phosphate & acetate)

NF

CORTEF TABS (Use hydrocortisone) NF

cortisone acetate tabs F DEPO-MEDROL SUSP 40 MG/ML (Use methylprednisolone acetate)

NF

dexamethasone elix 0.5 mg/5ml F

DEXAMETHASONE INTENSOL CONC F

dexamethasone soln 0.5 mg/5ml F

dexamethasone tabs 0.75 mg, 0.5 mg, 1 mg, 2 mg, 4mg, 6 mg, 1.5 mg

F

ENTOCORT EC CPEP (Use budesonide) NF

hydrocortisone tabs F KENALOG-40 SUSP (Use triamcinolone acetonide) NF

MEDROL DOSEPAK TBPK (Use methylprednisolone) NF

MEDROL TABS 2 MG F

MEDROL TABS 4 MG, 8 MG, 16 MG, 32 MG (Use methylprednisolone)

NF

methylprednisolone tabs F


34


methylprednisolone tbpk F

MILLIPRED TABS 5 MG F

PEDIAPRED SOLN (Use prednisolone sodiumphosphate)

NF

prednisolone sodiumphosphate soln or 5mg/5ml, 15 mg/5ml

F

prednisolone soln F

prednisone soln F

prednisone tabs F

prednisone tbpk F

SOLU-CORTEF SOLR F QL(10 ea per365 days retail) Mineralocorticoids fludrocortisone acetate tabs F

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy Symptoms Antitussives benzonatate caps 100 mg,200 mg F

DELSYM COUGH CHILDRENS SUER (Use dextromethorphanpolistirex)

NF

DELSYM SUER (Use dextromethorphanpolistirex)

NF

dextromethorphanpolistirex lqcr 30 mg/5ml F

dextromethorphanpolistirex suer 30 mg/5ml F

hydrocodone w/homatropine syrp F


hydrocodone w/homatropine tabs F


TESSALON PERLES CAPS (Use benzonatate) NF

Cough/Cold/Allergy Combinations


CHERACOL PLUS LIQD (Use dextromethorphan-guaifenesin)

NF

CHERACOL-D COUGH LIQD (Use dextromethorphan-guaifenesin)

NF

dextromethorphan-guaifenesin liqd 5 mg/5ml-100 mg/5ml, 10 mg/5ml-100 mg/5ml, 10 mg/5ml-200 mg/5ml, 20 mg/5ml-300 mg/5ml, 30 mg/5ml-200 mg/5ml, 20 mg/10ml-200 mg/10ml, 20 mg/10ml-400 mg/10ml, 20 mg/20ml-400 mg/20ml, 15 mg/7.5ml-150 mg/7.5ml, 20 mg/5ml-20 mg/5ml-300 mg/5ml-300mg/5ml, 30 mg/5ml-30mg/5ml-200 mg/5ml-200mg/5ml

F

dextromethorphan-guaifenesin syrp 10mg/5ml-100 mg/5ml, 10mg/5ml-10 mg/5ml-100mg/5ml-100 mg/5ml

F

DOUBLE-TUSSIN DM LIQD (Use dextromethorphan-guaifenesin)

NF

guaifenesin-codeine liqd F

guaifenesin-codeine soln F

guaifenesin-codeine syrp F

M-CLEAR WC SOLN F

MAR-COF CG EXPECTORANT LIQD (Use guaifenesin-codeine)

NF

promethazine w/codeinesoln F


promethazine w/codeine syrp F


promethazine-dm soln F


35


promethazine-dm syrp F ROBITUSSIN PEAK COLD COUGH+ CHEST CONGESTION DM MAX STRENGTH LIQD (Use dextromethorphan-guaifenesin)

NF

ROBITUSSIN PEAK COLD DM SYRP (Use dextromethorphan-guaifenesin)

NF

SUPRESS DM PEDIATRIC LIQD F

VICKS DAYQUIL MUCUS CONTROL DM LIQD F

Expectorants guaifenesin liqd F

guaifenesin soln F

guaifenesin syrp F

guaifenesin tabs F

guaifenesin tb12 F MUCINEX MAXIMUM STRENGTH TB12 (Use guaifenesin)

NF

MUCINEX TB12 (Use guaifenesin) NF

Misc. Respiratory Inhalants HYPER-SAL NEBU (Use sodium chloride (inhalant)) NF

HYPERSAL NEBU 7 % (Use sodium chloride (inhalant))

NF

sodium chloride (inhalant) aers F

sodium chloride (inhalant)nebu F

Mucolytics acetylcysteine soln F

DERMATOLOGICALS - Drugs to Treat SkinConditions


Acne Products CLEOCIN-T GEL (Use clindamycin phosphate(topical))

NF

CLINDAGEL GEL (Use clindamycin phosphate(topical))

NF

DIFFERIN GEL 0.1 % (Use adapalene) NF

RX/OTC

DIFFERIN GEL 0.1 % (Use adapalene) F

PA; RX/OTC

RETIN-A CREA 0.05 % (Use tretinoin) NF

PA

tretinoin crea 0.05 % F PA

Anti-inflammatory Agents - Topical FLECTOR PTCH NF

Antibiotics - Topical BACIGUENT OINT EX (Use bacitracin (topical)) NF

bacitracin (topical) oint 500unit/gm F

bacitracin zinc oint F

bacitracin-polymyxin b oint F

CENTANY OINT 2 % F

gentamicin sulfate (topical) crea F

gentamicin sulfate (topical)oint F

mupirocin oint 2 % F neomycin-bacitracin-polymyxin oint F

NEOSPORIN ORIGINAL OINT (Use neomycin-bacitracin-polymyxin)

NF

POLYSPORIN OINT (Use bacitracin-polymyxin b) NF

Antifungals - Topical butenafine hcl crea 1 % F RX/OTC


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CICLODAN SOLUTION KIT KIT NF

clotrimazole (topical) crea 1% F

RX/OTC

econazole nitrate crea 1 % F

EXELDERM CREA NF

GENTIAN VIOLET SOLN 1 % F

oregon health plan trilliumohp · preferred drug list (pdl) oregon health plan trilliumohp.com...

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