prescribing guide 500h - 2020 - caremark · sitagliptin/metformin ext-rel janumet xr a separate...
TRANSCRIPT
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Prescribing Guide 500H - 2020
05/01/2020
INTRODUCTION....................................................................................................................................................................................................... 4 PREFACE ................................................................................................................................................................................................................. 4 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...................................................................................................................................... 5 DRUG LIST PRODUCT DESCRIPTIONS ................................................................................................................................................................ 5 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 5 LEGEND ................................................................................................................................................................................................................... 6 NOTICE ..................................................................................................................................................................................................................... 6 ANALGESICS........................................................................................................................................................................................................... 7
NSAIDs ........................................................................................................................................................................................................... 7 NSAIDs, COMBINATIONS ............................................................................................................................................................................. 7 NSAIDs, TOPICAL ......................................................................................................................................................................................... 7 COX-2 INHIBITORS ....................................................................................................................................................................................... 7 GOUT ............................................................................................................................................................................................................. 7 OPIOID ANALGESICS ................................................................................................................................................................................... 7 NON-OPIOID ANALGESICS .......................................................................................................................................................................... 8 VISCOSUPPLEMENTS ................................................................................................................................................................................. 8
ANTI-INFECTIVES ................................................................................................................................................................................................... 8 ANTIBACTERIALS ......................................................................................................................................................................................... 8 ANTIFUNGALS .............................................................................................................................................................................................. 9 ANTIMALARIALS ........................................................................................................................................................................................... 9 ANTIRETROVIRAL AGENTS ........................................................................................................................................................................ 9 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 10 ANTIVIRALS................................................................................................................................................................................................. 10 MISCELLANEOUS ....................................................................................................................................................................................... 11
ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 11 ALKYLATING AGENTS ............................................................................................................................................................................... 11 ANTIMETABOLITES .................................................................................................................................................................................... 11 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 12 IMMUNOMODULATORS ............................................................................................................................................................................. 12 KINASE INHIBITORS ................................................................................................................................................................................... 12 TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 12 MISCELLANEOUS ....................................................................................................................................................................................... 12
CARDIOVASCULAR .............................................................................................................................................................................................. 13 ACE INHIBITORS......................................................................................................................................................................................... 13 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 13 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 13 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 13 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 13 ALPHA BLOCKERS ..................................................................................................................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 14 ANTIARRHYTHMICS ................................................................................................................................................................................... 14 ANTILIPEMICS............................................................................................................................................................................................. 15 BETA-BLOCKERS ....................................................................................................................................................................................... 15 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 16 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 16 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 16 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 16 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 16 DIURETICS .................................................................................................................................................................................................. 16 HEART FAILURE ......................................................................................................................................................................................... 17 NITRATES .................................................................................................................................................................................................... 17 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 17 MISCELLANEOUS ....................................................................................................................................................................................... 17
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CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 18 ANTIANXIETY .............................................................................................................................................................................................. 18 ANTICONVULSANTS .................................................................................................................................................................................. 18 ANTIDEMENTIA ........................................................................................................................................................................................... 18 ANTIDEPRESSANTS .................................................................................................................................................................................. 19 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 19 ANTIPSYCHOTICS ...................................................................................................................................................................................... 20 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 20 FIBROMYALGIA........................................................................................................................................................................................... 21 HYPNOTICS................................................................................................................................................................................................. 21 MIGRAINE .................................................................................................................................................................................................... 21 MOOD STABILIZERS .................................................................................................................................................................................. 21 MOVEMENT DISORDERS .......................................................................................................................................................................... 22 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 22 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 22 MYASTHENIA GRAVIS ............................................................................................................................................................................... 22 NARCOLEPSY ............................................................................................................................................................................................. 22 POSTHERPETIC NEURALGIA (PHN) ......................................................................................................................................................... 22 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 22
ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 23 ACROMEGALY ............................................................................................................................................................................................ 23 ANDROGENS .............................................................................................................................................................................................. 23 ANTIDIABETICS .......................................................................................................................................................................................... 23 ANTIOBESITY .............................................................................................................................................................................................. 25 CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 25 CALCIUM REGULATORS ........................................................................................................................................................................... 25 CARNITINE DEFICIENCY AGENTS ........................................................................................................................................................... 25 CONTRACEPTIVES .................................................................................................................................................................................... 25 ENDOMETRIOSIS ....................................................................................................................................................................................... 26 ESTROGENS ............................................................................................................................................................................................... 26 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 27 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................. 27 FERTILITY REGULATORS .......................................................................................................................................................................... 27 GAUCHER DISEASE ................................................................................................................................................................................... 27 GLUCOCORTICOIDS .................................................................................................................................................................................. 27 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 27 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ....................................................................................................................................... 27 HUMAN GROWTH HORMONES ................................................................................................................................................................. 27 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 28 PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 28 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 28 POTASSIUM-REMOVING AGENTS............................................................................................................................................................ 28 PROGESTINS .............................................................................................................................................................................................. 28 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 28 THYROID AGENTS ..................................................................................................................................................................................... 28 VASOPRESSINS ......................................................................................................................................................................................... 28 MISCELLANEOUS ....................................................................................................................................................................................... 28
GASTROINTESTINAL ........................................................................................................................................................................................... 28 ANTIDIARRHEALS ...................................................................................................................................................................................... 28 ANTIEMETICS ............................................................................................................................................................................................. 29 ANTISPASMODICS ..................................................................................................................................................................................... 29 CHOLELITHOLYTICS .................................................................................................................................................................................. 29 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 29 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 29 IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 29 LAXATIVES .................................................................................................................................................................................................. 30 OPIOID-INDUCED CONSTIPATION ........................................................................................................................................................... 30 PANCREATIC ENZYMES ............................................................................................................................................................................ 30 PROSTAGLANDINS .................................................................................................................................................................................... 30 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 30 SALIVA STIMULANTS ................................................................................................................................................................................. 30 STEROIDS, RECTAL ................................................................................................................................................................................... 30 ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 30 MISCELLANEOUS ....................................................................................................................................................................................... 30
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GENITOURINARY .................................................................................................................................................................................................. 30 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 30 ERECTILE DYSFUNCTION ......................................................................................................................................................................... 30 URINARY ANTISPASMODICS .................................................................................................................................................................... 31 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 31 MISCELLANEOUS ....................................................................................................................................................................................... 31
HEMATOLOGIC ..................................................................................................................................................................................................... 31 ANTICOAGULANTS .................................................................................................................................................................................... 31 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 31 HEMOPHILIA A AGENTS ............................................................................................................................................................................ 32 HEMOPHILIA B AGENTS ............................................................................................................................................................................ 32 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 32 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 32 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 32 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 32 STEM CELL MOBILIZERS ........................................................................................................................................................................... 32 THROMBOCYTOPENIA AGENTS .............................................................................................................................................................. 32 MISCELLANEOUS ....................................................................................................................................................................................... 32
IMMUNOLOGIC AGENTS ...................................................................................................................................................................................... 32 ALLERGENIC EXTRACTS .......................................................................................................................................................................... 32 AUTOIMMUNE AGENTS ‡ ........................................................................................................................................................................... 32 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 33 HEREDITARY ANGIOEDEMA ..................................................................................................................................................................... 33 IMMUNOMODULATORS ............................................................................................................................................................................. 33 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 33
NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................ 33 ELECTROLYTES ......................................................................................................................................................................................... 33 VITAMINS AND MINERALS ........................................................................................................................................................................ 33
RESPIRATORY ...................................................................................................................................................................................................... 34 ANAPHYLAXIS TREATMENT AGENTS ..................................................................................................................................................... 34 ANTICHOLINERGICS .................................................................................................................................................................................. 34 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 34 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ........................................................................................ 34 ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 34 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 34 ANTITUSSIVES............................................................................................................................................................................................ 35 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 35 BETA AGONISTS ........................................................................................................................................................................................ 35 CYSTIC FIBROSIS ...................................................................................................................................................................................... 35 LEUKOTRIENE MODULATORS .................................................................................................................................................................. 35 MAST CELL STABILIZERS ......................................................................................................................................................................... 35 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 36 NASAL STEROIDS/COMBINATIONS ......................................................................................................................................................... 36 PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 36 PULMONARY ENZYME DEFICIENCY AGENTS ........................................................................................................................................ 36 PULMONARY FIBROSIS AGENTS ............................................................................................................................................................. 36 SEVERE ASTHMA AGENTS ....................................................................................................................................................................... 36 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 36 STEROID INHALANTS ................................................................................................................................................................................ 36 XANTHINES ................................................................................................................................................................................................. 36 MISCELLANEOUS ....................................................................................................................................................................................... 36
TOPICAL ................................................................................................................................................................................................................ 36 DERMATOLOGY.......................................................................................................................................................................................... 36 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 39 OPHTHALMIC .............................................................................................................................................................................................. 39 OTIC ............................................................................................................................................................................................................. 41
WEBSITES ............................................................................................................................................................................................................. 42 INDEX ..................................................................................................................................................................................................................... 44
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INTRODUCTION
We are pleased to provide the 2020 Prescribing Guide as a useful reference and informational tool. The Prescribing Guide can assist practitioners in selecting clinically appropriate and cost-effective products for their patients.
The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The Prescribing Guide is reflective of current medical practice as of the date of review.
The information contained in this Prescribing Guide and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This Prescribing Guide is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in the Prescribing Guide is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.
We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.
National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/, on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication.
PREFACE
The Prescribing Guide is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the Prescribing Guide. Generics should be considered the first line of prescribing. Individual pharmacy benefit plans may impose restrictions or not reimburse some products. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are usually not included in the pharmacy benefit. Pharmacy law requires a valid prescription for the purchase of needles and syringes in certain states. OTC products are listed for informational purposes. If covered in the pharmacy benefit, OTC products require a valid prescription. Drugs represented in the Prescribing Guide may have varying cost to the plan member. Prescription benefit plan may alter coverage of certain products or vary copay amounts based on the condition being treated. Generic medications typically are available at the lowest cost, brand-name medications on the Prescribing Guide will generally cost more than generics, and brand-name medications not on the list will generally cost the most. The tiered format places drugs into tiers or levels of cost sharing by the plan member in the following manner: Tier 1: Lowest plan member copayment: All generic drugs, including those on the Prescribing Guide. Tier 2: Intermediate plan member copayment: Preferred brand-name products on the Prescribing Guide
selected for Tier 2. Tier 3: Highest plan member copayment: Brand-name products on the Prescribing Guide not selected for
Tier 2, and all non-preferred brand-name products. In most cases, there will be reasonable alternatives in Tier 1 or Tier 2 for products found in this highest tier.
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PHARMACY AND THERAPEUTICS (P&T) COMMITTEE
The services of an independent National Pharmacy and Therapeutics Committee ("P&T Committee") are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of clinical professionals from across the United States. The P&T Committee's voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited to meet with the P&T Committee, but no CVS Caremark® employee may vote on issues before the P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.
DRUG LIST PRODUCT DESCRIPTIONS
To assist in understanding which specific strengths and dosage forms are on the Prescribing Guide, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted. Products on the Prescribing Guide include all strengths and dosage forms of the cited brand-name product. cefixime Suprax Oral capsules, oral chewable tablets, oral suspension and all strengths of Suprax would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is on the Prescribing Guide. Other strengths/dosage forms of the reference product are not. acyclovir caps, tabs Zovirax The capsules and tablets of Zovirax are on the Prescribing Guide. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry. Extended-release and delayed-release products require their own entry. sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR. sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the Prescribing Guide. Dosage forms on the Prescribing Guide will be consistent with the category and use where listed. nystatin The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI-INFECTIVES section of the Prescribing Guide.
GENERIC SUBSTITUTION
Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.
One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:
Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.
Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.
Manufactured in the same strength and dosage form as the brand-name drugs.
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When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug. Brand-name drugs having a generic available may:
Incur higher copayment (tier 3)
Require payment of the difference in price between generic and brand, in addition to copayment
Require mandatory generic dispensing
LEGEND
OTC Over the counter
boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name
delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification
ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for clarification
NOTICE
The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2020 CVS Caremark. All rights reserved.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark.
When viewing the Prescribing Guide via the Internet, please be advised that the Prescribing Guide is updated periodically and changes may appear prior to their effective date to allow for client notification.
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ANALGESICS
Practice guidelines of pain management are available at: https://www.asahq.org NSAIDs
diclofenac sodium delayed-rel Tier 1 diflunisal Tier 1
etodolac Tier 1
ibuprofen Tier 1
nabumetone Tier 1 naproxen sodium tabs Tier 1
naproxen tabs Tier 1
sulindac Tier 1 meloxicam Tier 3 MOBIC
oxaprozin Tier 3 DAYPRO
NSAIDs, COMBINATIONS
diclofenac sodium delayed-rel/misoprostol Tier 1
NSAIDs, TOPICAL
* diclofenac sodium gel 1% Tier 1
diclofenac sodium soln Tier 1
* Listing does not include NDC 69499031866. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. COX-2 INHIBITORS
celecoxib Tier 3 CELEBREX GOUT
colchicine Tier 1
probenecid Tier 1 febuxostat Tier 2 ULORIC
allopurinol Tier 3 ZYLOPRIM
OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html buprenorphine transdermal Tier 1
codeine/acetaminophen Tier 1
fentanyl transdermal Tier 1 fentanyl transmucosal lozenge Tier 1
hydromorphone ext-rel Tier 1
methadone Tier 1
morphine Tier 1 morphine ext-rel Tier 1
morphine supp Tier 1
oxycodone caps, tabs 5 mg Tier 1 oxycodone concentrate 20 mg/mL Tier 1
oxycodone/acetaminophen 5/325 Tier 1
tramadol ext-rel Tier 1 buprenorphine Tier 2 BELBUCA
fentanyl sublingual spray Tier 2 SUBSYS
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morphine/naltrexone ext-rel Tier 2 EMBEDA
oxycodone ext-rel Tier 2 XTAMPZA ER tapentadol Tier 2 NUCYNTA
tapentadol ext-rel Tier 2 NUCYNTA ER
hydrocodone/acetaminophen Tier 3 NORCO
hydromorphone Tier 3 DILAUDID morphine ext-rel Tier 3 KADIAN
morphine ext-rel Tier 3 MS CONTIN
oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL Tier 3 ROXICODONE tramadol Tier 3 ULTRAM
NON-OPIOID ANALGESICS butalbital/acetaminophen/caffeine tabs Tier 3 ESGIC
butalbital/aspirin/caffeine Tier 3 FIORINAL
VISCOSUPPLEMENTS
sodium hyaluronate Tier 2 DUROLANE
sodium hyaluronate Tier 2 GEL-ONE
sodium hyaluronate Tier 2 GELSYN-3 sodium hyaluronate Tier 2 SUPARTZ FX
sodium hyaluronate Tier 2 VISCO-3
ANTI-INFECTIVES
Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm ANTIBACTERIALS Cephalosporins First Generation
cefadroxil Tier 1
cephalexin Tier 3 KEFLEX
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Second Generation
cefprozil Tier 1 cefuroxime axetil Tier 1
Third Generation cefdinir Tier 1
cefixime Tier 2 SUPRAX
Erythromycins/Macrolides
clarithromycin Tier 1
clarithromycin ext-rel Tier 1
erythromycin delayed-rel Tier 1 erythromycin ethylsuccinate Tier 1
erythromycin stearate Tier 1
fidaxomicin Tier 2 DIFICID azithromycin Tier 3 ZITHROMAX
Fluoroquinolones ciprofloxacin Tier 3 CIPRO
levofloxacin Tier 3 LEVAQUIN
moxifloxacin Tier 3 AVELOX
Penicillins
amoxicillin Tier 1
amoxicillin/clavulanate ext-rel Tier 1 ampicillin Tier 1
dicloxacillin Tier 1
penicillin VK Tier 1 amoxicillin/clavulanate Tier 3 AUGMENTIN
Tetracyclines doxycycline hyclate 20 mg Tier 1
minocycline Tier 1
tetracycline Tier 1
doxycycline hyclate Tier 3 VIBRAMYCIN ANTIFUNGALS
clotrimazole troches Tier 1 griseofulvin ultramicrosize Tier 1
itraconazole Tier 1
nystatin Tier 1 terbinafine tabs Tier 1
fluconazole Tier 3 DIFLUCAN
voriconazole Tier 3 VFEND
ANTIMALARIALS
chloroquine Tier 1
mefloquine Tier 1 atovaquone/proguanil Tier 3 MALARONE
ANTIRETROVIRAL AGENTS Antiretroviral Combinations
abacavir/dolutegravir/lamivudine Tier 2 TRIUMEQ
atazanavir/cobicistat Tier 2 EVOTAZ bictegravir/emtricitabine/tenofovir alafenamide Tier 2 BIKTARVY
darunavir/cobicistat Tier 2 PREZCOBIX
efavirenz/emtricitabine/tenofovir disoproxil fumarate Tier 2 ATRIPLA efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 2 SYMFI
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efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 2 SYMFI LO
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide Tier 2 GENVOYA elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate Tier 2 STRIBILD
emtricitabine/rilpivirine/tenofovir alafenamide Tier 2 ODEFSEY
emtricitabine/rilpivirine/tenofovir disoproxil fumarate Tier 2 COMPLERA
emtricitabine/tenofovir alafenamide Tier 2 DESCOVY emtricitabine/tenofovir disoproxil fumarate Tier 2 TRUVADA
lamivudine/tenofovir disoproxil fumarate Tier 2 CIMDUO
lamivudine/tenofovir disoproxil fumarate Tier 2 TEMIXYS abacavir/lamivudine Tier 3 EPZICOM
lamivudine/zidovudine Tier 3 COMBIVIR
Fusion Inhibitors
enfuvirtide Tier 3 FUZEON
Integrase Inhibitors
dolutegravir Tier 2 TIVICAY
raltegravir Tier 2 ISENTRESS
Non-nucleoside Reverse Transcriptase Inhibitors
efavirenz Tier 1
nevirapine Tier 1 nevirapine ext-rel Tier 1
etravirine Tier 3 INTELENCE
rilpivirine Tier 3 EDURANT Nucleoside Reverse Transcriptase Inhibitors
stavudine Tier 1 abacavir tabs Tier 3 ZIAGEN
didanosine delayed-rel Tier 3 VIDEX EC
emtricitabine Tier 3 EMTRIVA
lamivudine Tier 3 EPIVIR zidovudine Tier 3 RETROVIR
Nucleotide Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate Tier 3 VIREAD
Protease Inhibitors atazanavir Tier 1
darunavir Tier 2 PREZISTA
ritonavir Tier 2 NORVIR lopinavir/ritonavir soln Tier 3 KALETRA
lopinavir/ritonavir tabs Tier 3 KALETRA
ANTITUBERCULAR AGENTS isoniazid Tier 1
pyrazinamide Tier 1
ethambutol Tier 3 MYAMBUTOL rifampin Tier 3 RIFADIN
ANTIVIRALS Cytomegalovirus Agents
valganciclovir Tier 1
Hepatitis Agents Hepatitis B
entecavir tabs Tier 1 lamivudine Tier 1
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tenofovir alafenamide Tier 2 VEMLIDY
entecavir soln Tier 3 BARACLUDE Hepatitis C
ribavirin Tier 1 † ledipasvir/sofosbuvir Tier 2 HARVONI † sofosbuvir/velpatasvir Tier 2 EPCLUSA † sofosbuvir/velpatasvir/voxilaprevir Tier 2 VOSEVI
† HARVONI only for genotypes 1, 4, 5, and 6 EPCLUSA for genotypes 1, 2, 3, 4, 5, 6 VOSEVI for use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). Herpes Agents
famciclovir Tier 1
valacyclovir Tier 1 acyclovir caps, tabs Tier 3 ZOVIRAX
Influenza Agents
oseltamivir Tier 1 zanamivir Tier 2 RELENZA
MISCELLANEOUS dapsone Tier 1
linezolid Tier 1
nitrofurantoin macrocrystals Tier 1 sulfamethoxazole/trimethoprim Tier 1
sulfamethoxazole/trimethoprim DS Tier 1
tinidazole Tier 1 trimethoprim Tier 1
mebendazole chewable Tier 2 EMVERM
rifaximin 550 mg Tier 2 XIFAXAN
clindamycin Tier 3 CLEOCIN ivermectin Tier 3 STROMECTOL
metronidazole Tier 3 FLAGYL
nitrofurantoin ext-rel Tier 3 MACROBID nitrofurantoin susp Tier 3 FURADANTIN
vancomycin caps Tier 3 VANCOCIN
ANTINEOPLASTIC AGENTS
Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org ALKYLATING AGENTS
cyclophosphamide caps Tier 1
busulfan Tier 3 MYLERAN chlorambucil Tier 3 LEUKERAN
melphalan Tier 3 ALKERAN
temozolomide Tier 3 TEMODAR ANTIMETABOLITES
mercaptopurine Tier 1 capecitabine Tier 3 XELODA
methotrexate Tier 3 TREXALL
thioguanine Tier 3 TABLOID
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HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens abiraterone Tier 1
flutamide Tier 1
abiraterone Tier 2 YONSA apalutamide Tier 2 ERLEADA
darolutamide Tier 2 NUBEQA
enzalutamide Tier 2 XTANDI
bicalutamide Tier 3 CASODEX Antiestrogens
tamoxifen Tier 1 Aromatase Inhibitors
anastrozole Tier 3 ARIMIDEX exemestane Tier 3 AROMASIN
letrozole Tier 3 FEMARA
Luteinizing Hormone-Releasing Hormone (LHRH) Agonists
leuprolide acetate Tier 1
leuprolide acetate Tier 2 ELIGARD leuprolide acetate Tier 2 LUPRON DEPOT
Progestins
megestrol acetate tabs Tier 1 IMMUNOMODULATORS
lenalidomide Tier 3 REVLIMID pomalidomide Tier 3 POMALYST
thalidomide Tier 3 THALOMID
KINASE INHIBITORS
erlotinib Tier 1
imatinib mesylate Tier 1 bosutinib Tier 2 BOSULIF
cabozantinib Tier 2 CABOMETYX
dasatinib Tier 2 SPRYCEL
everolimus Tier 2 AFINITOR gefitinib Tier 2 IRESSA
midostaurin Tier 2 RYDAPT
palbociclib Tier 2 IBRANCE ribociclib Tier 2 KISQALI
ribociclib + letrozole Tier 2 KISQALI FEMARA CO-PACK
lapatinib Tier 3 TYKERB pazopanib Tier 3 VOTRIENT
sunitinib Tier 3 SUTENT
TOPOISOMERASE INHIBITORS
topotecan caps Tier 3 HYCAMTIN
MISCELLANEOUS etoposide Tier 1
tretinoin caps Tier 1
niraparib Tier 2 ZEJULA olaparib Tier 2 LYNPARZA
rucaparib Tier 2 RUBRACA
sonidegib Tier 2 ODOMZO uridine triacetate Tier 2 VISTOGARD
13
bexarotene caps Tier 3 TARGRETIN
hydroxyurea Tier 3 HYDREA mitotane Tier 3 LYSODREN
procarbazine Tier 3 MATULANE
vorinostat Tier 3 ZOLINZA
CARDIOVASCULAR
The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org
captopril Tier 1
fosinopril Tier 1 perindopril Tier 1
trandolapril Tier 1
benazepril Tier 3 LOTENSIN enalapril Tier 3 VASOTEC
lisinopril Tier 3 ZESTRIL
quinapril Tier 3 ACCUPRIL ramipril Tier 3 ALTACE
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril Tier 3 LOTREL
trandolapril/verapamil ext-rel Tier 3 TARKA
ACE INHIBITOR/DIURETIC COMBINATIONS captopril/hydrochlorothiazide Tier 1
fosinopril/hydrochlorothiazide Tier 1
benazepril/hydrochlorothiazide Tier 3 LOTENSIN HCT enalapril/hydrochlorothiazide Tier 3 VASERETIC
lisinopril/hydrochlorothiazide Tier 3 ZESTORETIC
quinapril/hydrochlorothiazide Tier 3 ACCURETIC ADRENOLYTICS, CENTRAL
guanfacine Tier 1 clonidine Tier 3 CATAPRES
clonidine transdermal Tier 3 CATAPRES-TTS
ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone Tier 3 INSPRA
spironolactone Tier 3 ALDACTONE
14
ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497
terazosin Tier 1 doxazosin Tier 3 CARDURA
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org
candesartan Tier 1 candesartan/hydrochlorothiazide Tier 1
eprosartan Tier 1
irbesartan Tier 1
irbesartan/hydrochlorothiazide Tier 1 olmesartan Tier 1
olmesartan/hydrochlorothiazide Tier 1
valsartan Tier 1 valsartan/hydrochlorothiazide Tier 1
losartan Tier 3 COZAAR
losartan/hydrochlorothiazide Tier 3 HYZAAR
telmisartan Tier 3 MICARDIS telmisartan/hydrochlorothiazide Tier 3 MICARDIS HCT
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/telmisartan Tier 1
amlodipine/valsartan Tier 1
amlodipine/olmesartan Tier 3 AZOR ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS
amlodipine/valsartan/hydrochlorothiazide Tier 1 olmesartan/amlodipine/hydrochlorothiazide Tier 3 TRIBENZOR
ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org amiodarone Tier 1
flecainide Tier 1
propafenone Tier 1 sotalol Tier 1
dronedarone Tier 2 MULTAQ
disopyramide Tier 3 NORPACE
disopyramide ext-rel Tier 3 NORPACE CR dofetilide Tier 3 TIKOSYN
propafenone ext-rel Tier 3 RYTHMOL SR
15
ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625 Bile Acid Resins
colesevelam Tier 1
cholestyramine Tier 3 QUESTRAN/QUESTRAN LIGHT colestipol Tier 3 COLESTID
Cholesterol Absorption Inhibitors ezetimibe Tier 1
Fibrates * fenofibrate Tier 1
fenofibrate Tier 3 ANTARA
fenofibrate Tier 3 LIPOFEN fenofibric acid delayed-rel Tier 3 TRILIPIX
gemfibrozil Tier 3 LOPID
* Listing does not include fenofibrate tablet 120 mg. HMG-CoA Reductase Inhibitors/Combinations atorvastatin Tier 1
fluvastatin Tier 1
lovastatin Tier 1 rosuvastatin Tier 1
ezetimibe/simvastatin Tier 3 VYTORIN
pravastatin Tier 3 PRAVACHOL
simvastatin Tier 3 ZOCOR Niacins
niacin ext-rel Tier 3 NIASPAN Omega-3 Fatty Acids
icosapent ethyl Tier 2 VASCEPA omega-3 acid ethyl esters Tier 3 LOVAZA
PCSK9 Inhibitors evolocumab Tier 2 REPATHA
BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org
atenolol Tier 1
bisoprolol Tier 1 carvedilol phosphate ext-rel Tier 1
labetalol Tier 1
metoprolol succinate ext-rel Tier 1 pindolol Tier 1
propranolol Tier 1
nebivolol Tier 2 BYSTOLIC
carvedilol Tier 3 COREG metoprolol tartrate Tier 3 LOPRESSOR
nadolol Tier 3 CORGARD
propranolol ext-rel Tier 3 INDERAL LA
16
BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org
atenolol/chlorthalidone Tier 1
bisoprolol/hydrochlorothiazide Tier 3 ZIAC
metoprolol/hydrochlorothiazide Tier 3 LOPRESSOR HCT CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine Tier 1
felodipine ext-rel Tier 1
nifedipine ext-rel Tier 3 ADALAT CC nifedipine ext-rel Tier 3 PROCARDIA XL
Nondihydropyridines * diltiazem ext-rel Tier 1
diltiazem ext-rel Tier 3 TIAZAC
verapamil ext-rel Tier 3 CALAN SR
* Listing does not include generic CARDIZEM LA CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
amlodipine/atorvastatin Tier 3 CADUET
DIGITALIS GLYCOSIDES
digoxin 0.125 mg, 0.25 mg Tier 1
digoxin ped elixir Tier 1
digoxin 0.0625 mg, 0.1875 mg Tier 3 LANOXIN DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS
aliskiren Tier 1 aliskiren/hydrochlorothiazide Tier 2 TEKTURNA HCT
DIURETICS Carbonic Anhydrase Inhibitors
acetazolamide Tier 1
acetazolamide ext-rel Tier 1 methazolamide Tier 1
Loop Diuretics bumetanide Tier 1
torsemide Tier 1
furosemide Tier 3 LASIX Potassium-sparing Diuretics
amiloride Tier 1
triamterene Tier 1 Thiazides and Thiazide-like Diuretics
chlorthalidone Tier 1 hydrochlorothiazide Tier 1
indapamide Tier 1
metolazone Tier 1
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Diuretic Combinations
amiloride/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 3 ALDACTAZIDE
triamterene/hydrochlorothiazide Tier 3 DYAZIDE
triamterene/hydrochlorothiazide Tier 3 MAXZIDE
HEART FAILURE
isosorbide dinitrate/hydralazine Tier 2 BIDIL
ivabradine Tier 2 CORLANOR sacubitril/valsartan Tier 2 ENTRESTO
NITRATES Oral
isosorbide dinitrate ext-rel tabs Tier 1
isosorbide mononitrate Tier 1 isosorbide mononitrate ext-rel Tier 1
isosorbide dinitrate oral Tier 3 ISORDIL
Sublingual/Translingual
nitroglycerin lingual spray Tier 3 NITROLINGUAL
nitroglycerin sublingual Tier 3 NITROSTAT Transdermal
nitroglycerin transdermal Tier 1
nitroglycerin transdermal Tier 3 NITRO-DUR PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists
ambrisentan Tier 1
bosentan Tier 1
macitentan Tier 2 OPSUMIT Phosphodiesterase Inhibitors
tadalafil Tier 1 sildenafil Tier 3 REVATIO
Prostacyclin Receptor Agonists selexipag Tier 2 UPTRAVI
Prostaglandin Vasodilators treprostinil ext-rel Tier 2 ORENITRAM
epoprostenol sodium Tier 3 FLOLAN
Soluble Guanylate Cyclase Stimulators
riociguat Tier 2 ADEMPAS
MISCELLANEOUS
hydralazine Tier 1
methyldopa Tier 1
midodrine Tier 1 ranolazine ext-rel Tier 1
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CENTRAL NERVOUS SYSTEM
Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org ANTIANXIETY Benzodiazepines alprazolam Tier 1
oxazepam Tier 1
clonazepam Tier 3 KLONOPIN diazepam Tier 3 VALIUM
lorazepam Tier 3 ATIVAN
Miscellaneous buspirone Tier 1
fluvoxamine Tier 1
clomipramine Tier 3 ANAFRANIL ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com
carbamazepine ext-rel Tier 1 clobazam Tier 1
lamotrigine Tier 1
lamotrigine ext-rel Tier 1 lamotrigine orally disintegrating tabs Tier 1
phenobarbital Tier 1
tiagabine Tier 1 topiramate ext-rel Tier 1
vigabatrin Tier 1
zonisamide Tier 1
lacosamide Tier 2 VIMPAT oxcarbazepine ext-rel Tier 2 OXTELLAR XR
perampanel Tier 2 FYCOMPA
topiramate ext-rel Tier 2 TROKENDI XR carbamazepine Tier 3 TEGRETOL
carbamazepine ext-rel Tier 3 CARBATROL
diazepam rectal gel Tier 3 DIASTAT
divalproex sodium delayed-rel Tier 3 DEPAKOTE divalproex sodium ext-rel Tier 3 DEPAKOTE ER
ethosuximide Tier 3 ZARONTIN
gabapentin Tier 3 NEURONTIN levetiracetam Tier 3 KEPPRA
levetiracetam ext-rel Tier 3 KEPPRA XR
oxcarbazepine Tier 3 TRILEPTAL phenytoin Tier 3 DILANTIN INFATABS
phenytoin sodium extended Tier 3 DILANTIN
primidone Tier 3 MYSOLINE
topiramate Tier 3 TOPAMAX valproic acid Tier 3 DEPAKENE
ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com
memantine ext-rel Tier 1
rivastigmine Tier 1
memantine/donepezil Tier 2 NAMZARIC
19
donepezil Tier 3 ARICEPT
galantamine Tier 3 RAZADYNE galantamine ext-rel Tier 3 RAZADYNE ER
memantine Tier 3 NAMENDA
rivastigmine transdermal Tier 3 EXELON
ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder. Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 3 NARDIL
tranylcypromine Tier 3 PARNATE
Selective Serotonin Reuptake Inhibitors (SSRIs)
escitalopram Tier 1
fluoxetine Tier 1 vilazodone Tier 2 VIIBRYD
vortioxetine Tier 2 TRINTELLIX
citalopram Tier 3 CELEXA
paroxetine HCl Tier 3 PAXIL paroxetine HCl ext-rel Tier 3 PAXIL CR
sertraline Tier 3 ZOLOFT
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
desvenlafaxine ext-rel Tier 1
duloxetine delayed-rel Tier 1 venlafaxine Tier 1
venlafaxine ext-rel Tier 1
Tricyclic Antidepressants (TCAs)
amitriptyline Tier 1
doxepin Tier 1
desipramine Tier 3 NORPRAMIN imipramine HCl Tier 3 TOFRANIL
nortriptyline Tier 3 PAMELOR
Miscellaneous Agents
bupropion Tier 1
trazodone Tier 1 bupropion ext-rel Tier 3 WELLBUTRIN SR
bupropion ext-rel Tier 3 WELLBUTRIN XL
mirtazapine Tier 3 REMERON
ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com
amantadine Tier 1 benztropine Tier 1
carbidopa/levodopa orally disintegrating tabs Tier 1
pramipexole ext-rel Tier 1
rasagiline Tier 1 ropinirole Tier 1
selegiline Tier 1
20
trihexyphenidyl Tier 1
rotigotine transdermal Tier 2 NEUPRO bromocriptine Tier 3 PARLODEL
carbidopa/levodopa Tier 3 SINEMET
carbidopa/levodopa ext-rel Tier 3 SINEMET CR
carbidopa/levodopa/entacapone Tier 3 STALEVO entacapone Tier 3 COMTAN
pramipexole Tier 3 MIRAPEX
ropinirole ext-rel Tier 3 REQUIP XL ANTIPSYCHOTICS Atypicals aripiprazole Tier 1
quetiapine ext-rel Tier 1
aripiprazole ext-rel inj Tier 2 ABILIFY MAINTENA aripiprazole lauroxil ext-rel inj Tier 2 ARISTADA
aripiprazole lauroxil ext-rel inj Tier 2 ARISTADA INITIO
cariprazine Tier 2 VRAYLAR
lurasidone Tier 2 LATUDA clozapine Tier 3 CLOZARIL
olanzapine Tier 3 ZYPREXA
quetiapine Tier 3 SEROQUEL risperidone Tier 3 RISPERDAL
risperidone long-acting injection Tier 3 RISPERDAL CONSTA
ziprasidone Tier 3 GEODON
Miscellaneous
chlorpromazine Tier 1
fluphenazine Tier 1 haloperidol Tier 1
perphenazine Tier 1
thiothixene Tier 1 trifluoperazine Tier 1
ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org
amphetamine/dextroamphetamine mixed salts Tier 1
^ amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 dextroamphetamine Tier 1
guanfacine ext-rel Tier 1
methylphenidate ext-rel Tier 1 amphetamine/dextroamphetamine mixed salts ext-rel Tier 2 MYDAYIS
lisdexamfetamine Tier 2 VYVANSE
atomoxetine Tier 3 STRATTERA
dexmethylphenidate Tier 3 FOCALIN dexmethylphenidate ext-rel Tier 3 FOCALIN XR
dextroamphetamine ext-rel Tier 3 DEXEDRINE SPANSULE
methylphenidate Tier 3 METHYLIN methylphenidate Tier 3 RITALIN
^ methylphenidate ext-rel Tier 3 CONCERTA
^ Listing does not include certain NDCs. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.
21
FIBROMYALGIA
pregabalin Tier 1 HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: https://aasm.org Benzodiazepines
temazepam Tier 3 RESTORIL
Nonbenzodiazepines
eszopiclone Tier 1
ramelteon Tier 1 zolpidem sublingual Tier 1
suvorexant Tier 2 BELSOMRA
zolpidem Tier 3 AMBIEN zolpidem ext-rel Tier 3 AMBIEN CR
Tricyclics doxepin Tier 2 SILENOR
MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com Ergotamine Derivatives
ergotamine/caffeine tabs Tier 1
dihydroergotamine inj Tier 3 D.H.E. 45 Monoclonal Antibodies
erenumab-aooe Tier 2 AIMOVIG fremanezumab-vfrm Tier 2 AJOVY
galcanezumab-gnlm Tier 2 EMGALITY
Selective Serotonin Agonists
naratriptan Tier 1
sumatriptan inj Tier 2 ZEMBRACE SYMTOUCH
sumatriptan nasal powder Tier 2 ONZETRA XSAIL zolmitriptan nasal spray Tier 2 ZOMIG
eletriptan Tier 3 RELPAX
rizatriptan Tier 3 MAXALT sumatriptan Tier 3 IMITREX
sumatriptan inj Tier 3 IMITREX
sumatriptan nasal spray Tier 3 IMITREX zolmitriptan Tier 3 ZOMIG
Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations
sumatriptan/naproxen sodium Tier 2 TREXIMET MOOD STABILIZERS
lithium carbonate Tier 1 lithium carbonate ext-rel tabs 450 mg Tier 1
lithium carbonate ext-rel tabs 300 mg Tier 3 LITHOBID
22
MOVEMENT DISORDERS
tetrabenazine Tier 1 deutetrabenazine Tier 2 AUSTEDO
valbenazine Tier 2 INGREZZA
MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: https://www.aan.com
dimethyl fumarate delayed-rel Tier 2 TECFIDERA
fingolimod Tier 2 GILENYA glatiramer Tier 2 COPAXONE
interferon beta-1a Tier 2 REBIF
interferon beta-1b Tier 2 BETASERON
natalizumab Tier 2 TYSABRI siponimod Tier 2 MAYZENT
teriflunomide Tier 2 AUBAGIO
MUSCULOSKELETAL THERAPY AGENTS
baclofen Tier 1
carisoprodol Tier 1 chlorzoxazone Tier 1
* cyclobenzaprine Tier 1
orphenadrine/aspirin/caffeine Tier 1
dantrolene Tier 3 DANTRIUM metaxalone Tier 3 SKELAXIN
methocarbamol Tier 3 ROBAXIN
tizanidine tabs Tier 3 ZANAFLEX * Listing does not include cyclobenzaprine tablet 7.5 mg. MYASTHENIA GRAVIS
pyridostigmine Tier 1
pyridostigmine ext-rel Tier 1 NARCOLEPSY
armodafinil Tier 1 solriamfetol Tier 2 SUNOSI
POSTHERPETIC NEURALGIA (PHN) gabapentin ext-rel Tier 2 GRALISE
PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents
acamprosate calcium Tier 1
disulfiram Tier 3 ANTABUSE Opioid Antagonists
naloxone inj Tier 1 naltrexone Tier 1
naloxone nasal spray Tier 2 NARCAN
Partial Opioid Agonist/Opioid Antagonist Combinations
buprenorphine/naloxone sublingual Tier 1
buprenorphine/naloxone sublingual tabs Tier 2 ZUBSOLV
Pseudobulbar Affect Agents
dextromethorphan/quinidine Tier 2 NUEDEXTA
23
Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html
bupropion ext-rel Tier 1 varenicline Tier 3 CHANTIX
Vasomotor Symptom Agents paroxetine mesylate Tier 1
ENDOCRINE AND METABOLIC
ACROMEGALY
lanreotide acetate Tier 2 SOMATULINE DEPOT pegvisomant Tier 2 SOMAVERT
ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com
testosterone cypionate Tier 1
testosterone enanthate Tier 1
testosterone gel Tier 1 testosterone soln Tier 1
testosterone transdermal Tier 2 ANDRODERM
ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org Alpha-glucosidase Inhibitors acarbose Tier 3 PRECOSE
Amylin Analogs pramlintide Tier 2 SYMLINPEN
Biguanides
metformin Tier 3 GLUCOPHAGE metformin ext-rel Tier 3 GLUCOPHAGE XR
Biguanide/Sulfonylurea Combinations glipizide/metformin Tier 1
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors sitagliptin phosphate Tier 2 JANUVIA
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations sitagliptin/metformin Tier 2 JANUMET
sitagliptin/metformin ext-rel Tier 2 JANUMET XR
Incretin Mimetic Agents
dulaglutide Tier 2 TRULICITY
liraglutide Tier 2 VICTOZA semaglutide Tier 2 OZEMPIC
Incretin Mimetic Agent/Insulin Combinations
liraglutide/insulin degludec Tier 2 XULTOPHY lixisenatide/insulin glargine Tier 2 SOLIQUA
24
Insulins
insulin aspart Tier 2 FIASP insulin aspart Tier 2 NOVOLOG
insulin aspart protamine 70%/insulin aspart 30% Tier 2 NOVOLOG MIX 70/30
insulin degludec Tier 2 TRESIBA
insulin detemir Tier 2 LEVEMIR insulin glargine Tier 2 BASAGLAR
insulin human Tier 2 HUMULIN R U-500
OTC insulin human Tier 2 NOVOLIN R OTC insulin isophane human Tier 2 NOVOLIN N
OTC insulin isophane human 70%/regular 30% Tier 2 NOVOLIN 70/30
Insulin Sensitizers
pioglitazone Tier 1
Insulin Sensitizer/Biguanide Combinations
pioglitazone/metformin Tier 3 ACTOPLUS MET
Insulin Sensitizer/Sulfonylurea Combinations
pioglitazone/glimepiride Tier 3 DUETACT
Meglitinides
nateglinide Tier 1
repaglinide Tier 3 PRANDIN
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors
dapagliflozin Tier 2 FARXIGA
empagliflozin Tier 2 JARDIANCE Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations
dapagliflozin/metformin ext-rel Tier 2 XIGDUO XR empagliflozin/metformin Tier 2 SYNJARDY
empagliflozin/metformin ext-rel Tier 2 SYNJARDY XR
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations
empagliflozin/linagliptin Tier 2 GLYXAMBI
Sulfonylureas
glimepiride Tier 3 AMARYL
glipizide Tier 3 GLUCOTROL
glipizide ext-rel Tier 3 GLUCOTROL XL Supplies
blood glucose continuous monitoring receivers, sensors, transmitters
Tier 2 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK AVIVA PLUS kits and test strips
blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK COMPACT PLUS kits and test strips
blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK GUIDE kits and test strips
blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK SMARTVIEW kits and test strips
insulin infusion disposable pump Tier 2 OMNIPOD INSULIN INFUSION PUMP
insulin infusion disposable pump Tier 2 V-GO INSULIN INFUSION PUMP OTC insulin syringes, needles Tier 2 BD ULTRAFINE
insulin syringes and needles
25
ANTIOBESITY Guidelines of treatment and management of obesity are available at: https://www.aace.com https://www.nhlbi.nih.gov/health-topics/managing-overweight-obesity-in-adults
liraglutide Tier 2 SAXENDA
CALCIUM RECEPTOR ANTAGONISTS cinacalcet Tier 2 SENSIPAR
CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org Bisphosphonates alendronate Tier 3 FOSAMAX
ibandronate Tier 3 BONIVA
risedronate Tier 3 ACTONEL risedronate delayed-rel Tier 3 ATELVIA
Calcitonins
calcitonin-salmon spray Tier 1 Parathyroid Hormones
abaloparatide Tier 2 TYMLOS teriparatide Tier 2 FORTEO
Miscellaneous denosumab Tier 2 PROLIA
CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1
CONTRACEPTIVES EE = ethinyl estradiol ME = mestranol Monophasic 20 mcg Estrogen drospirenone/EE 3/20 Tier 1
drospirenone/EE/levomefolate 3/20 and levomefolate Tier 1
levonorgestrel/EE 0.1/20 - Lessina Tier 1
norethindrone acetate/EE 1/20 and iron chewable Tier 1 norethindrone acetate/EE 1/20 Tier 3 LOESTRIN 1/20
norethindrone acetate/EE 1/20 and iron Tier 3 LOESTRIN FE 1/20
30 mcg Estrogen
desogestrel/EE 0.15/30 Tier 1
drospirenone/EE/levomefolate 3/30 and levomefolate Tier 1 levonorgestrel/EE 0.15/30 - Levora Tier 1
norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1
drospirenone/EE 3/30 Tier 3 YASMIN
norethindrone acetate/EE 1.5/30 Tier 3 LOESTRIN 1.5/30 norethindrone acetate/EE 1.5/30 and iron Tier 3 LOESTRIN FE 1.5/30
26
35 mcg Estrogen
ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1 norethindrone/EE 0.5/35 Tier 1
norethindrone/EE 1/35 Tier 1
norgestimate/EE 0.25/35 Tier 1
norethindrone/EE 1/35 Tier 3 ORTHO-NOVUM 1/35 Biphasic
desogestrel/EE Tier 3 MIRCETTE Triphasic
desogestrel/EE Tier 1 levonorgestrel/EE - Trivora Tier 1
norgestimate/EE Tier 1
norethindrone/EE Tier 3 ORTHO-NOVUM 7/7/7 Extended Cycle
levonorgestrel/EE 0.15/30 Tier 1 levonorgestrel/EE 0.1/20 and EE 10 Tier 3 LOSEASONIQUE
levonorgestrel/EE 0.15/30 and EE 10 Tier 3 SEASONIQUE
Progestin Only
norethindrone Tier 1
norethindrone Tier 3 ORTHO MICRONOR
Injectable
medroxyprogesterone acetate 150 mg/mL Tier 3 DEPO-PROVERA
Progestin Intrauterine Devices
levonorgestrel releasing IUD Tier 2 KYLEENA
levonorgestrel releasing IUD Tier 2 MIRENA levonorgestrel releasing IUD Tier 2 SKYLA
Transdermal norelgestromin/EE Tier 1
Vaginal etonogestrel/EE ring Tier 2 NUVARING
ENDOMETRIOSIS danazol Tier 1
elagolix Tier 2 ORILISSA
ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf Oral estrogens, conjugated Tier 2 PREMARIN
estradiol Tier 3 ESTRACE
Transdermal
estradiol Tier 1
estradiol Tier 2 DIVIGEL estradiol Tier 2 EVAMIST
estradiol Tier 3 CLIMARA
27
Vaginal
estradiol vaginal crm Tier 1 estradiol vaginal ring Tier 2 ESTRING
estrogens, conjugated crm Tier 2 PREMARIN
estradiol vaginal tabs Tier 3 VAGIFEM
ESTROGEN/PROGESTINS Oral EE/norethindrone acetate - Jinteli Tier 1
estradiol/norethindrone Tier 1
estrogens, conjugated/medroxyprogesterone Tier 2 PREMPHASE
estrogens, conjugated/medroxyprogesterone Tier 2 PREMPRO Transdermal
estradiol/levonorgestrel Tier 2 CLIMARA PRO estradiol/norethindrone acetate Tier 2 COMBIPATCH
ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS conjugated estrogens/bazedoxifene Tier 2 DUAVEE
FERTILITY REGULATORS GNRH/LHRH Antagonists
ganirelix acetate Tier 1
cetrorelix Tier 2 CETROTIDE Ovulation Stimulants, Gonadotropins
choriogonadotropin alfa Tier 2 OVIDREL follitropin alfa Tier 2 GONAL-F
Ovulation Stimulants, Synthetic clomiphene Tier 1
GAUCHER DISEASE
eliglustat Tier 2 CERDELGA imiglucerase Tier 2 CEREZYME
GLUCOCORTICOIDS dexamethasone Tier 1
fludrocortisone Tier 1
prednisolone Tier 1 prednisone Tier 1
hydrocortisone Tier 3 CORTEF
methylprednisolone Tier 3 MEDROL GLUCOSE ELEVATING AGENTS
glucagon, human recombinant Tier 2 GLUCAGEN HYPOKIT
glucagon, human recombinant Tier 2 GLUCAGON EMERGENCY KIT HEREDITARY TYROSINEMIA TYPE 1 AGENTS
nitisinone Tier 2 ORFADIN HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines somatropin Tier 2 GENOTROPIN
somatropin Tier 2 HUMATROPE
28
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS
calcitriol (1,25-D3) Tier 3 ROCALTROL doxercalciferol Tier 3 HECTOROL
paricalcitol Tier 3 ZEMPLAR
PHENYLKETONURIA TREATMENT AGENTS
sapropterin Tier 3 KUVAN
PHOSPHATE BINDER AGENTS
calcium acetate Tier 1
sevelamer carbonate Tier 1
calcium acetate Tier 2 PHOSLYRA sucroferric oxyhydroxide Tier 2 VELPHORO
POTASSIUM-REMOVING AGENTS patiromer sorbitex Tier 2 VELTASSA
sodium zirconium cyclosilicate Tier 2 LOKELMA
PROGESTINS Oral
medroxyprogesterone acetate Tier 3 PROVERA megestrol acetate susp Tier 3 MEGACE ES
norethindrone acetate Tier 3 AYGESTIN
progesterone, micronized Tier 3 PROMETRIUM
Vaginal
progesterone gel Tier 2 CRINONE
progesterone vaginal inserts Tier 2 ENDOMETRIN SELECTIVE ESTROGEN RECEPTOR MODULATORS
ospemifene Tier 2 OSPHENA raloxifene Tier 3 EVISTA
THYROID AGENTS Antithyroid Agents
propylthiouracil Tier 1
methimazole Tier 3 TAPAZOLE Thyroid Supplements
levothyroxine Tier 1 levothyroxine - Levoxyl Tier 1
levothyroxine Tier 2 SYNTHROID
liothyronine Tier 3 CYTOMEL VASOPRESSINS
desmopressin spray, tabs Tier 3 DDAVP
MISCELLANEOUS
cabergoline Tier 1
GASTROINTESTINAL
Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org ANTIDIARRHEALS
loperamide Tier 1 diphenoxylate/atropine Tier 3 LOMOTIL
29
ANTIEMETICS
doxylamine/pyridoxine delayed-rel Tier 1 granisetron Tier 1
meclizine Tier 1
prochlorperazine Tier 1
promethazine Tier 1 scopolamine transdermal Tier 1
granisetron transdermal Tier 2 SANCUSO
rolapitant Tier 2 VARUBI dronabinol Tier 3 MARINOL
metoclopramide Tier 3 REGLAN
ondansetron Tier 3 ZOFRAN trimethobenzamide Tier 3 TIGAN
ANTISPASMODICS hyoscyamine sulfate ext-rel caps Tier 1
hyoscyamine sulfate orally disintegrating tabs Tier 1
dicyclomine Tier 3 BENTYL
hyoscyamine sulfate Tier 3 LEVSIN hyoscyamine sulfate ext-rel Tier 3 LEVBID
CHOLELITHOLYTICS ursodiol Tier 3 ACTIGALL
ursodiol Tier 3 URSO
H2 RECEPTOR ANTAGONISTS
cimetidine Tier 1
ranitidine Tier 1 famotidine Tier 3 PEPCID
INFLAMMATORY BOWEL DISEASE Oral Agents
balsalazide Tier 1
budesonide delayed-rel caps Tier 1
budesonide ext-rel Tier 1 mesalamine delayed-rel caps Tier 1
mesalamine delayed-rel tabs Tier 1
mesalamine ext-rel caps Tier 2 APRISO mesalamine ext-rel caps Tier 2 PENTASA
sulfasalazine Tier 3 AZULFIDINE
sulfasalazine delayed-rel Tier 3 AZULFIDINE EN-TABS Rectal Agents
hydrocortisone enema Tier 1
mesalamine supp Tier 1 hydrocortisone acetate foam Tier 2 CORTIFOAM
mesalamine susp Tier 3 ROWASA
IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation
linaclotide Tier 2 LINZESS lubiprostone Tier 2 AMITIZA
Irritable Bowel Syndrome with Diarrhea alosetron Tier 1
eluxadoline Tier 2 VIBERZI
30
LAXATIVES
lactulose soln Tier 1 sodium sulfate/potassium sulfate/magnesium sulfate Tier 2 SUPREP
peg 3350/electrolytes Tier 3 GOLYTELY
peg 3350/electrolytes Tier 3 NULYTELY
OPIOID-INDUCED CONSTIPATION
naldemedine Tier 2 SYMPROIC
naloxegol Tier 2 MOVANTIK PANCREATIC ENZYMES
pancrelipase Tier 2 VIOKACE pancrelipase delayed-rel Tier 2 CREON
pancrelipase delayed-rel Tier 2 ZENPEP
PROSTAGLANDINS
misoprostol Tier 3 CYTOTEC
PROTON PUMP INHIBITORS
esomeprazole delayed-rel Tier 1
lansoprazole delayed-rel Tier 1 pantoprazole delayed-rel Tier 1
dexlansoprazole delayed-rel Tier 2 DEXILANT
omeprazole delayed-rel Tier 3 PRILOSEC
SALIVA STIMULANTS
cevimeline Tier 3 EVOXAC
pilocarpine tabs Tier 3 SALAGEN STEROIDS, RECTAL
hydrocortisone acetate/pramoxine foam Tier 2 PROCTOFOAM-HC hydrocortisone crm Tier 3 ANUSOL-HC
ULCER THERAPY COMBINATIONS lansoprazole + amoxicillin + clarithromycin Tier 1
bismuth/metronidazole/tetracycline Tier 2 PYLERA
MISCELLANEOUS
sucralfate Tier 1
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines alfuzosin ext-rel Tier 1
dutasteride/tamsulosin Tier 1
silodosin Tier 1 dutasteride Tier 3 AVODART
finasteride Tier 3 PROSCAR
tamsulosin Tier 3 FLOMAX ERECTILE DYSFUNCTION Guidelines for the management of erectile dysfunction are available at: https://www.auanet.org/guidelines Alprostadil Agents alprostadil supp Tier 2 MUSE
31
Phosphodiesterase Inhibitors
sildenafil Tier 1 tadalafil Tier 1
URINARY ANTISPASMODICS darifenacin ext-rel Tier 1
oxybutynin Tier 1
solifenacin Tier 1
tolterodine ext-rel Tier 1 trospium Tier 1
trospium ext-rel Tier 1
fesoterodine ext-rel Tier 2 TOVIAZ mirabegron ext-rel Tier 2 MYRBETRIQ
oxybutynin ext-rel Tier 3 DITROPAN XL
tolterodine Tier 3 DETROL VAGINAL ANTI-INFECTIVES
terconazole Tier 1
clindamycin crm Tier 3 CLEOCIN metronidazole Tier 3 METROGEL-VAGINAL
MISCELLANEOUS bethanechol Tier 3 URECHOLINE
potassium citrate ext-rel Tier 3 UROCIT-K
HEMATOLOGIC
Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular Injectable
enoxaparin Tier 1 dalteparin Tier 3 FRAGMIN
Oral warfarin Tier 1
apixaban Tier 2 ELIQUIS
rivaroxaban Tier 2 XARELTO Synthetic Heparinoid-like Agents
fondaparinux Tier 3 ARIXTRA HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines darbepoetin alfa Tier 2 ARANESP
epoetin alfa-epbx Tier 2 RETACRIT
filgrastim-aafi Tier 2 NIVESTYM
pegfilgrastim Tier 2 NEULASTA pegfilgrastim-cbqv Tier 2 UDENYCA
32
HEMOPHILIA A AGENTS
antihemophilic factor (recombinant) Tier 2 KOGENATE FS antihemophilic factor (recombinant) Tier 2 KOVALTRY
antihemophilic factor (recombinant) Tier 2 NOVOEIGHT
antihemophilic factor (recombinant) pegylated Tier 2 ADYNOVATE
antihemophilic factor (recombinant) pegylated-aucl Tier 2 JIVI human coagulation factor VIII (rDNA) simoctocog alfa Tier 2 NUWIQ
HEMOPHILIA B AGENTS coagulation factor IX (recombinant) glycopegylated Tier 2 REBINYN
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS eltrombopag Tier 3 PROMACTA
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS eculizumab Tier 3 SOLIRIS
PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1
dipyridamole Tier 1
prasugrel Tier 1 ticagrelor Tier 2 BRILINTA
dipyridamole ext-rel/aspirin Tier 3 AGGRENOX
PLATELET SYNTHESIS INHIBITORS anagrelide Tier 3 AGRYLIN
STEM CELL MOBILIZERS plerixafor Tier 3 MOZOBIL
THROMBOCYTOPENIA AGENTS lusutrombopag Tier 2 MULPLETA
MISCELLANEOUS cilostazol Tier 1
IMMUNOLOGIC AGENTS
Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org ALLERGENIC EXTRACTS grass mixed pollen allergen extract Tier 2 ORALAIR
ragweed pollen allergen extract Tier 2 RAGWITEK
timothy grass pollen allergen extract Tier 2 GRASTEK
AUTOIMMUNE AGENTS ‡
adalimumab Tier 2 HUMIRA
apremilast Tier 2 OTEZLA etanercept Tier 2 ENBREL
guselkumab Tier 2 TREMFYA
risankizumab-rzaa Tier 2 SKYRIZI secukinumab Tier 2 COSENTYX
tofacitinib Tier 2 XELJANZ
tofacitinib ext-rel Tier 2 XELJANZ XR upadacitinib Tier 2 RINVOQ
ustekinumab Tier 2 STELARA SUBCUTANEOUS
‡ Coverage may be altered or copay amounts may vary based on the condition being treated (e.g., psoriasis).
33
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)
methotrexate Tier 1 methotrexate auto-injector Tier 2 RASUVO
hydroxychloroquine Tier 3 PLAQUENIL
leflunomide Tier 3 ARAVA
HEREDITARY ANGIOEDEMA
C1 esterase inhibitor, recombinant Tier 2 RUCONEST
icatibant Tier 2 FIRAZYR IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of hepatitis are available at: https://www.aasld.org Interferons
interferon alfa-2b Tier 3 INTRON A
peginterferon alfa-2a Tier 3 PEGASYS peginterferon alfa-2b Tier 3 SYLATRON
Miscellaneous canakinumab Tier 3 ILARIS
IMMUNOSUPPRESSANTS Antimetabolites
mycophenolate mofetil Tier 1
mycophenolate sodium delayed-rel Tier 1 azathioprine Tier 3 AZASAN
azathioprine Tier 3 IMURAN
Calcineurin Inhibitors
cyclosporine Tier 1
cyclosporine, modified Tier 1
tacrolimus Tier 1 Rapamycin Derivatives
sirolimus Tier 1
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES Potassium potassium chloride ext-rel Tier 1
potassium chloride liquid Tier 1
VITAMINS AND MINERALS Folic Acid/Combinations
folic acid Tier 1
folic acid/vitamin B6/vitamin B12 Tier 1 Prenatal Vitamins
prenatal vitamins Tier 1 prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL 90 DHA
prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL DHA
prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL HARMONY prenatal vitamins/docusate/folic acid Tier 2 CITRANATAL RX
34
prenatal vitamins/docusate/folic acid + DHA Tier 2 CITRANATAL ASSURE
prenatal vitamins/folic acid + pyridoxine Tier 2 CITRANATAL B-CALM Miscellaneous
cyanocobalamin inj Tier 1
ergocalciferol (D2) Tier 1 fluoride drops Tier 1
fluoride tabs Tier 1
multivitamins/fluoride drops, tabs Tier 1 multivitamins/fluoride/iron drops, tabs Tier 1
vitamin ADC/fluoride drops Tier 1
vitamin ADC/fluoride/iron drops Tier 1
RESPIRATORY
Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS
epinephrine auto-injector Tier 1 epinephrine auto-injector Tier 2 EPIPEN
epinephrine auto-injector Tier 2 EPIPEN JR.
ANTICHOLINERGICS
ipratropium soln Tier 1
tiotropium Tier 2 SPIRIVA umeclidinium bromide Tier 2 INCRUSE ELLIPTA
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting
ipratropium/albuterol soln Tier 1
Long Acting
glycopyrrolate/formoterol Tier 2 BEVESPI AEROSPHERE
tiotropium/olodaterol Tier 2 STIOLTO RESPIMAT
umeclidinium/vilanterol Tier 2 ANORO ELLIPTA ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS
fluticasone/umeclidinium/vilanterol Tier 2 TRELEGY ELLIPTA ANTIHISTAMINES, LOW SEDATING
levocetirizine Tier 1 ANTIHISTAMINES, SEDATING
clemastine 2.68 mg Tier 1 cyproheptadine Tier 1
hydroxyzine HCl Tier 1
35
ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf
* benzonatate Tier 3 TESSALON * Listing does not include NDCs 69336012615 and 69499032915. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. ANTITUSSIVE COMBINATIONS Opioid
codeine/guaifenesin liquid Tier 1 codeine/guaifenesin/pseudoephedrine Tier 1
codeine/promethazine Tier 1
codeine/promethazine/phenylephrine Tier 1
hydrocodone/homatropine Tier 1 Non-opioid
dextromethorphan/brompheniramine/pseudoephedrine Tier 1 dextromethorphan/promethazine Tier 1
BETA AGONISTS Inhalants Short Acting
albuterol soln Tier 1 albuterol sulfate, CFC-free aerosol Tier 1
levalbuterol tartrate, CFC-free aerosol Tier 1
Long Acting Hand-held Active Inhalation
olodaterol, CFC-free aerosol Tier 2 STRIVERDI RESPIMAT salmeterol xinafoate Tier 2 SEREVENT
Nebulized Passive Inhalation formoterol inhalation soln Tier 2 PERFOROMIST
Oral Agents albuterol Tier 1
albuterol ext-rel Tier 1
terbutaline Tier 1 CYSTIC FIBROSIS
tobramycin inhalation soln Tier 1
tobramycin inhalation soln Tier 2 BETHKIS dornase alfa Tier 3 PULMOZYME
LEUKOTRIENE MODULATORS montelukast Tier 1
zafirlukast Tier 1
zileuton ext-rel Tier 1 MAST CELL STABILIZERS
cromolyn soln Tier 1
36
NASAL ANTIHISTAMINES
azelastine spray Tier 1 azelastine spray Tier 3 ASTEPRO
olopatadine spray Tier 3 PATANASE
NASAL STEROIDS/COMBINATIONS
flunisolide spray Tier 1
fluticasone spray Tier 1
mometasone spray Tier 1 azelastine/fluticasone spray Tier 2 DYMISTA
PHOSPHODIESTERASE-4 INHIBITORS roflumilast Tier 2 DALIRESP
PULMONARY ENZYME DEFICIENCY AGENTS alpha-1 proteinase inhibitor Tier 2 PROLASTIN-C
PULMONARY FIBROSIS AGENTS nintedanib Tier 2 OFEV
pirfenidone Tier 2 ESBRIET
SEVERE ASTHMA AGENTS
benralizumab Tier 2 FASENRA
dupilumab Tier 2 DUPIXENT
mepolizumab Tier 2 NUCALA omalizumab Tier 2 XOLAIR
STEROID/BETA AGONIST COMBINATIONS budesonide/formoterol Tier 2 SYMBICORT
fluticasone/salmeterol Tier 2 ADVAIR DISKUS
fluticasone/salmeterol, CFC-free aerosol Tier 2 ADVAIR HFA fluticasone/vilanterol Tier 2 BREO ELLIPTA
STEROID INHALANTS beclomethasone breath-activated aerosol Tier 2 QVAR REDIHALER
budesonide Tier 2 PULMICORT FLEXHALER
fluticasone Tier 2 ARNUITY ELLIPTA
fluticasone Tier 2 FLOVENT DISKUS fluticasone, CFC-free aerosol Tier 2 FLOVENT HFA
budesonide inhalation susp Tier 3 PULMICORT RESPULES
XANTHINES
theophylline ext-rel tabs Tier 1
MISCELLANEOUS
ipratropium spray Tier 1
TOPICAL
DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Oral isotretinoin Tier 1
37
Topical
adapalene Tier 1 clindamycin gel Tier 1
clindamycin/benzoyl peroxide Tier 1
erythromycin gel 2% Tier 1
erythromycin soln Tier 1 tretinoin Tier 1
tretinoin - Avita Tier 1
tretinoin gel microsphere Tier 1 adapalene/benzoyl peroxide Tier 2 EPIDUO
adapalene/benzoyl peroxide Tier 2 EPIDUO FORTE
tazarotene Tier 2 TAZORAC benzoyl peroxide Tier 3 BENZAC AC
clindamycin gel, lotion, soln Tier 3 CLEOCIN T
clindamycin/benzoyl peroxide Tier 3 DUAC
erythromycin/benzoyl peroxide Tier 3 BENZAMYCIN sulfacetamide lotion 10% Tier 3 KLARON
tretinoin Tier 3 RETIN-A
Actinic Keratosis
fluorouracil crm 5%, soln 5%, soln 2% Tier 1
fluorouracil crm 4% Tier 2 TOLAK imiquimod Tier 2 ZYCLARA
ingenol mebutate Tier 2 PICATO
Antibiotics
gentamicin Tier 1
mupirocin oint Tier 1
silver sulfadiazine Tier 3 SILVADENE Antifungals
clotrimazole Tier 1 econazole Tier 1
ketoconazole crm 2% Tier 1
luliconazole Tier 1 nystatin Tier 1
naftifine Tier 2 NAFTIN
ciclopirox Tier 3 LOPROX
Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org Oral acitretin Tier 3 SORIATANE
methoxsalen oral Tier 3 OXSORALEN-ULTRA
Topical
calcipotriene oint, soln 0.005% Tier 1
Antiseborrheics
selenium sulfide lotion 2.5% Tier 1
ketoconazole shampoo 2% Tier 3 NIZORAL
38
Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Injectable
dupilumab Tier 2 DUPIXENT
Topical pimecrolimus Tier 1
tacrolimus Tier 1
crisaborole Tier 2 EUCRISA Corticosteroids Low Potency alclometasone crm, oint 0.05% Tier 1
fluocinolone acetonide soln 0.01% Tier 1
hydrocortisone crm 2.5% Tier 1 hydrocortisone lotion 1% Tier 1
desonide crm, lotion, oint 0.05% Tier 3 DESOWEN
Medium Potency
betamethasone valerate crm, lotion, oint 0.1% Tier 1
desoximetasone crm, oint 0.05% Tier 1
fluocinolone acetonide crm, oint 0.025% Tier 1 fluticasone propionate crm, lotion 0.05%, oint 0.005% Tier 1
hydrocortisone butyrate crm, oint, soln 0.1% Tier 1
hydrocortisone valerate crm, oint 0.2% Tier 1 triamcinolone acetonide crm, lotion 0.025% Tier 1
triamcinolone acetonide crm, lotion, oint 0.1% Tier 1
mometasone crm, lotion, oint 0.1% Tier 3 ELOCON High Potency
betamethasone dipropionate crm, lotion, oint 0.05% Tier 1
desoximetasone crm, oint 0.25%, gel 0.05% Tier 1 fluocinonide crm, gel, oint, soln 0.05% Tier 1
triamcinolone acetonide crm 0.5% Tier 1
betamethasone dipropionate augmented crm 0.05% Tier 3 DIPROLENE AF betamethasone dipropionate augmented lotion 0.05% Tier 3 DIPROLENE
Very High Potency clobetasol propionate foam 0.05% Tier 1
betamethasone dipropionate augmented gel, oint 0.05% Tier 3 DIPROLENE
clobetasol propionate crm, gel, oint, soln 0.05% Tier 3 TEMOVATE clobetasol propionate lotion, shampoo 0.05% Tier 3 CLOBEX
halobetasol propionate crm, oint 0.05% Tier 3 ULTRAVATE
Emollients ammonium lactate 12% Tier 3 LAC-HYDRIN
Local Analgesics lidocaine patch Tier 3 LIDODERM
Local Anesthetics lidocaine/prilocaine Tier 1
Rosacea azelaic acid gel Tier 1
doxycycline monohydrate delayed-rel caps Tier 1
39
metronidazole gel 0.75% Tier 1
azelaic acid foam Tier 2 FINACEA FOAM ivermectin Tier 2 SOOLANTRA
metronidazole crm 0.75% Tier 3 METROCREAM
metronidazole gel 1% Tier 3 METROGEL
metronidazole lotion 0.75% Tier 3 METROLOTION Scabicides and Pediculicides
permethrin 5% Tier 1 malathion Tier 3 OVIDE
Miscellaneous Skin and Mucous Membrane imiquimod Tier 1
podofilox Tier 3 CONDYLOX
MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral
lidocaine viscous Tier 1 Protectants - Mouth/Throat
benzyl alcohol/carbomer 941/glycerin Tier 2 MUGARD soy phospholipid/glycerol dioleate Tier 2 EPISIL
Steroids - Mouth/Throat
triamcinolone paste Tier 1 OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org Antiallergics
azelastine Tier 1
cromolyn sodium Tier 1 alcaftadine Tier 2 LASTACAFT
olopatadine Tier 2 PAZEO
olopatadine Tier 3 PATADAY
olopatadine Tier 3 PATANOL Anti-infectives
bacitracin Tier 1 erythromycin Tier 1
gentamicin Tier 1
levofloxacin Tier 1 neomycin/polymyxin B/gramicidin Tier 1
polymyxin B/bacitracin Tier 1
sulfacetamide oint 10% Tier 1
besifloxacin Tier 2 BESIVANCE ciprofloxacin oint Tier 2 CILOXAN
moxifloxacin Tier 2 MOXEZA
ciprofloxacin soln Tier 3 CILOXAN moxifloxacin Tier 3 VIGAMOX
ofloxacin Tier 3 OCUFLOX
polymyxin B/trimethoprim Tier 3 POLYTRIM sulfacetamide soln 10% Tier 3 BLEPH-10
tobramycin Tier 3 TOBREX
40
Anti-infective/Anti-inflammatory Combinations
neomycin/polymyxin B/bacitracin/hydrocortisone oint Tier 1 neomycin/polymyxin B/hydrocortisone susp Tier 1
sulfacetamide/prednisolone phosphate 10%/0.25% Tier 1
tobramycin/dexamethasone oint 0.3%/0.1% Tier 2 TOBRADEX
tobramycin/dexamethasone susp 0.3%/0.05% Tier 2 TOBRADEX ST neomycin/polymyxin B/dexamethasone Tier 3 MAXITROL
tobramycin/dexamethasone susp 0.3%/0.1% Tier 3 TOBRADEX
Anti-inflammatories Nonsteroidal
bromfenac sodium Tier 1 diclofenac sodium Tier 1
ketorolac tromethamine Tier 2 ACUVAIL
nepafenac Tier 2 ILEVRO nepafenac Tier 2 NEVANAC
ketorolac Tier 3 ACULAR
Steroidal
dexamethasone sodium phosphate Tier 1
fluorometholone Tier 1
loteprednol Tier 1 prednisolone acetate 1% Tier 1
dexamethasone Tier 2 MAXIDEX
difluprednate Tier 2 DUREZOL fluorometholone Tier 2 FML FORTE
fluorometholone Tier 2 FML S.O.P.
prednisolone acetate Tier 2 PRED MILD prednisolone phosphate 1% Tier 3
Antivirals
trifluridine Tier 1 Beta-blockers Nonselective
levobunolol Tier 1
timolol maleate gel Tier 1
timolol hemihydrate Tier 2 BETIMOL timolol maleate Tier 3 TIMOPTIC
Selective betaxolol Tier 2 BETOPTIC S
Carbonic Anhydrase Inhibitors Topical
brinzolamide Tier 2 AZOPT
dorzolamide Tier 3 TRUSOPT Carbonic Anhydrase Inhibitor/Beta-blocker Combinations
dorzolamide/timolol maleate Tier 3 COSOPT Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations
brinzolamide/brimonidine Tier 2 SIMBRINZA Dry Eye Disease
cyclosporine, emulsion Tier 2 RESTASIS lifitegrast Tier 2 XIIDRA
41
Prostaglandins
bimatoprost Tier 2 LUMIGAN travoprost Tier 2 TRAVATAN Z
latanoprost Tier 3 XALATAN
Retinal Disorders
aflibercept Tier 2 EYLEA
ranibizumab Tier 2 LUCENTIS
Rho Kinase Inhibitors
netarsudil Tier 2 RHOPRESSA
Rho Kinase Inhibitor/Prostaglandin Combinations
netarsudil/latanoprost Tier 2 ROCKLATAN
Sympathomimetics
brimonidine 0.2% Tier 1
brimonidine Tier 2 ALPHAGAN P Sympathomimetic/Beta-blocker Combinations
brimonidine/timolol Tier 2 COMBIGAN OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org Anti-infectives
acetic acid Tier 1
ofloxacin otic Tier 1
Anti-infective/Anti-inflammatory Combinations
neomycin/polymyxin B/hydrocortisone Tier 1
ciprofloxacin/dexamethasone Tier 2 CIPRODEX
42
WEBSITES
Agency for Healthcare Research and Quality https://www.ahrq.gov Alzheimer's Association https://www.alz.org American Academy of Allergy, Asthma and Immunology https://www.aaaai.org American Academy of Child & Adolescent Psychiatry https://www.aacap.org American Academy of Dermatology https://www.aad.org American Academy of Neurology https://www.aan.com American Academy of Ophthalmology https://www.aao.org American Academy of Pediatrics https://www.aap.org American Association for the Study of Liver Disease https://www.aasld.org American Association of Clinical Endocrinologists https://www.aace.com American Association of Diabetes Educators https://www.diabeteseducator.org American Cancer Society https://www.cancer.org American College of Allergy, Asthma and Immunology https://www.acaai.org American College of Cardiology https://www.acc.org American College of Chest Physicians https://www.chestnet.org American College of Gastroenterology https://gi.org American College of Physicians https://www.acponline.org American College of Rheumatology https://www.rheumatology.org
American Congress of Obstetricians and Gynecologists https://www.acog.org American Diabetes Association http://www.diabetes.org American Gastroenterological Association https://www.gastro.org American Headache Society Committee for Headache Education https://americanheadachesociety.org American Heart Association https://professional.heart.org American Lung Association https://www.lung.org American Medical Association https://www.ama-assn.org American Psychiatric Association https://www.psychiatry.org American Society of Anesthesiologists https://www.asahq.org American Society of Clinical Oncology https://www.asco.org American Society of Interventional Pain Physicians https://www.asipp.org American Urological Association https://www.auanet.org Centers for Disease Control and Prevention https://www.cdc.gov Centers for Disease Control and Prevention Guideline topics: AIDS https://www.cdc.gov/hiv/default.html Centers for Disease Control and Prevention Guideline topics: Sexually Transmitted Diseases https://www.cdc.gov/std/treatment/default.htm CVS Caremark https://www.caremark.com The Food and Drug Administration https://www.fda.gov
43
Global Initiative for Asthma https://ginasthma.org Infectious Diseases Society of America https://www.idsociety.org Institute for Safe Medication Practices https://www.ismp.org Johns Hopkins AIDS Service https://www.thebody.com/content/art12096.html Juvenile Diabetes Research Foundation International https://www.jdrf.org MedWatch https://www.fda.gov/Safety/MedWatch/default.htm National Agricultural Library https://www.nal.usda.gov National Cancer Institute https://www.cancer.gov/about-cancer National Comprehensive Cancer Network https://www.nccn.org
National Foundation for Infectious Diseases http://www.nfid.org National Guideline Clearinghouse https://www.ahrq.gov National Heart, Lung and Blood Institute https://www.nhlbi.nih.gov National Institutes of Health https://www.nih.gov National Kidney Foundation https://www.kidney.org National Osteoporosis Foundation https://www.nof.org North American Menopause Society https://www.menopause.org United States Department of Health and Human Services https://www.hhs.gov World Health Organization https://www.who.int
44
INDEX
A abacavir tabs, 10 abacavir/dolutegravir/lamivudine, 9 abacavir/lamivudine, 10 abaloparatide, 25 ABILIFY MAINTENA, 20 abiraterone, 12 acamprosate calcium, 22 acarbose, 23 ACCU-CHEK AVIVA PLUS kits and test strips, 24 ACCU-CHEK COMPACT PLUS kits and test strips, 24 ACCU-CHEK GUIDE kits and test strips, 24 ACCU-CHEK SMARTVIEW kits and test strips, 24 ACCUPRIL, 13 ACCURETIC, 13 acetazolamide, 16 acetazolamide ext-rel, 16 acetic acid, 41 acitretin, 37 ACTIGALL, 29 ACTONEL, 25 ACTOPLUS MET, 24 ACULAR, 40 ACUVAIL, 40 acyclovir caps, tabs, 11 ADALAT CC, 16 adalimumab, 32 adapalene, 37 adapalene/benzoyl peroxide, 37 ADEMPAS, 17 ADVAIR DISKUS, 36 ADVAIR HFA, 36 ADYNOVATE, 32 AFINITOR, 12 aflibercept, 41 AGGRENOX, 32 AGRYLIN, 32 AIMOVIG, 21 AJOVY, 21 albuterol, 35 albuterol ext-rel, 35 albuterol soln, 35 albuterol sulfate, CFC-free aerosol, 35 alcaftadine, 39 alclometasone crm, oint 0.05%, 38 ALDACTAZIDE, 17 ALDACTONE, 13 alendronate, 25 alfuzosin ext-rel, 30 aliskiren, 16 aliskiren/hydrochlorothiazide, 16 ALKERAN, 11 allopurinol, 7 alosetron, 29 alpha-1 proteinase inhibitor, 36 ALPHAGAN P, 41 alprazolam, 18 alprostadil supp, 30 ALTACE, 13 amantadine, 19 AMARYL, 24 AMBIEN, 21
AMBIEN CR, 21 ambrisentan, 17 amiloride, 16 amiloride/hydrochlorothiazide, 17 amiodarone, 14 AMITIZA, 29 amitriptyline, 19 amlodipine, 16 amlodipine/atorvastatin, 16 amlodipine/benazepril, 13 amlodipine/olmesartan, 14 amlodipine/telmisartan, 14 amlodipine/valsartan, 14 amlodipine/valsartan/hydrochlorothiazide, 14 ammonium lactate 12%, 38 amoxicillin, 9 amoxicillin/clavulanate, 9 amoxicillin/clavulanate ext-rel, 9 amphetamine/dextroamphetamine mixed salts, 20 amphetamine/dextroamphetamine mixed salts ext-rel, 20 ampicillin, 9 ANAFRANIL, 18 anagrelide, 32 anastrozole, 12 ANDRODERM, 23 ANORO ELLIPTA, 34 ANTABUSE, 22 ANTARA, 15 antihemophilic factor (recombinant), 32 antihemophilic factor (recombinant) pegylated, 32 antihemophilic factor (recombinant) pegylated-aucl, 32 ANUSOL-HC, 30 apalutamide, 12 apixaban, 31 apremilast, 32 APRISO, 29 ARANESP, 31 ARAVA, 33 ARICEPT, 19 ARIMIDEX, 12 aripiprazole, 20 aripiprazole ext-rel inj, 20 aripiprazole lauroxil ext-rel inj, 20 ARISTADA, 20 ARISTADA INITIO, 20 ARIXTRA, 31 armodafinil, 22 ARNUITY ELLIPTA, 36 AROMASIN, 12 ASTEPRO, 36 atazanavir, 10 atazanavir/cobicistat, 9 ATELVIA, 25 atenolol, 15 atenolol/chlorthalidone, 16 ATIVAN, 18 atomoxetine, 20 atorvastatin, 15 atovaquone/proguanil, 9 ATRIPLA, 9 AUBAGIO, 22 AUGMENTIN, 9 AUSTEDO, 22
45
AVELOX, 9 AVODART, 30 AYGESTIN, 28 AZASAN, 33 azathioprine, 33 azelaic acid foam, 39 azelaic acid gel, 38 azelastine, 39 azelastine spray, 36 azelastine/fluticasone spray, 36 azithromycin, 9 AZOPT, 40 AZOR, 14 AZULFIDINE, 29 AZULFIDINE EN-TABS, 29
B bacitracin, 39 baclofen, 22 balsalazide, 29 BARACLUDE, 11 BASAGLAR, 24 BD ULTRAFINE insulin syringes and needles, 24 beclomethasone breath-activated aerosol, 36 BELBUCA, 7 BELSOMRA, 21 benazepril, 13 benazepril/hydrochlorothiazide, 13 benralizumab, 36 BENTYL, 29 BENZAC AC, 37 BENZAMYCIN, 37 benzonatate, 35 benzoyl peroxide, 37 benztropine, 19 benzyl alcohol/carbomer 941/glycerin, 39 besifloxacin, 39 BESIVANCE, 39 betamethasone dipropionate augmented crm 0.05%, 38 betamethasone dipropionate augmented gel, oint 0.05%, 38 betamethasone dipropionate augmented lotion 0.05%, 38 betamethasone dipropionate crm, lotion, oint 0.05%, 38 betamethasone valerate crm, lotion, oint 0.1%, 38 BETASERON, 22 betaxolol, 40 bethanechol, 31 BETHKIS, 35 BETIMOL, 40 BETOPTIC S, 40 BEVESPI AEROSPHERE, 34 bexarotene caps, 13 bicalutamide, 12 bictegravir/emtricitabine/tenofovir alafenamide, 9 BIDIL, 17 BIKTARVY, 9 bimatoprost, 41 bismuth/metronidazole/tetracycline, 30 bisoprolol, 15 bisoprolol/hydrochlorothiazide, 16 BLEPH-10, 39 blood glucose continuous monitoring receivers, sensors,
transmitters, 24 blood glucose monitoring kits, test strips, 24 BONIVA, 25 bosentan, 17 BOSULIF, 12
bosutinib, 12 BREO ELLIPTA, 36 BRILINTA, 32 brimonidine, 41 brimonidine 0.2%, 41 brimonidine/timolol, 41 brinzolamide, 40 brinzolamide/brimonidine, 40 bromfenac sodium, 40 bromocriptine, 20 budesonide, 36 budesonide delayed-rel caps, 29 budesonide ext-rel, 29 budesonide inhalation susp, 36 budesonide/formoterol, 36 bumetanide, 16 buprenorphine, 7 buprenorphine transdermal, 7 buprenorphine/naloxone sublingual, 22 buprenorphine/naloxone sublingual tabs, 22 bupropion, 19 bupropion ext-rel, 19, 23 buspirone, 18 busulfan, 11 butalbital/acetaminophen/caffeine tabs, 8 butalbital/aspirin/caffeine, 8 BYSTOLIC, 15
C C1 esterase inhibitor, recombinant, 33 cabergoline, 28 CABOMETYX, 12 cabozantinib, 12 CADUET, 16 CALAN SR, 16 calcipotriene oint, soln 0.005%, 37 calcitonin-salmon spray, 25 calcitriol (1,25-D3), 28 calcium acetate, 28 canakinumab, 33 candesartan, 14 candesartan/hydrochlorothiazide, 14 capecitabine, 11 captopril, 13 captopril/hydrochlorothiazide, 13 carbamazepine, 18 carbamazepine ext-rel, 18 CARBATROL, 18 carbidopa/levodopa, 20 carbidopa/levodopa ext-rel, 20 carbidopa/levodopa orally disintegrating tabs, 19 carbidopa/levodopa/entacapone, 20 CARDURA, 14 cariprazine, 20 carisoprodol, 22 carvedilol, 15 carvedilol phosphate ext-rel, 15 CASODEX, 12 CATAPRES, 13 CATAPRES-TTS, 13 cefadroxil, 8 cefdinir, 9 cefixime, 9 cefprozil, 9 cefuroxime axetil, 9 CELEBREX, 7
46
celecoxib, 7 CELEXA, 19 cephalexin, 8 CERDELGA, 27 CEREZYME, 27 cetrorelix, 27 CETROTIDE, 27 cevimeline, 30 CHANTIX, 23 chlorambucil, 11 chloroquine, 9 chlorpromazine, 20 chlorthalidone, 16 chlorzoxazone, 22 cholestyramine, 15 choriogonadotropin alfa, 27 ciclopirox, 37 cilostazol, 32 CILOXAN, 39 CIMDUO, 10 cimetidine, 29 cinacalcet, 25 CIPRO, 9 CIPRODEX, 41 ciprofloxacin, 9 ciprofloxacin oint, 39 ciprofloxacin soln, 39 ciprofloxacin/dexamethasone, 41 citalopram, 19 CITRANATAL 90 DHA, 33 CITRANATAL ASSURE, 34 CITRANATAL B-CALM, 34 CITRANATAL DHA, 33 CITRANATAL HARMONY, 33 CITRANATAL RX, 33 clarithromycin, 9 clarithromycin ext-rel, 9 clemastine 2.68 mg, 34 CLEOCIN, 11, 31 CLEOCIN T, 37 CLIMARA, 26 CLIMARA PRO, 27 clindamycin, 11 clindamycin crm, 31 clindamycin gel, 37 clindamycin gel, lotion, soln, 37 clindamycin/benzoyl peroxide, 37 clobazam, 18 clobetasol propionate crm, gel, oint, soln 0.05%, 38 clobetasol propionate foam 0.05%, 38 clobetasol propionate lotion, shampoo 0.05%, 38 CLOBEX, 38 clomiphene, 27 clomipramine, 18 clonazepam, 18 clonidine, 13 clonidine transdermal, 13 clopidogrel, 32 clotrimazole, 37 clotrimazole troches, 9 clozapine, 20 CLOZARIL, 20 coagulation factor IX (recombinant) glycopegylated, 32 codeine/acetaminophen, 7 codeine/guaifenesin liquid, 35 codeine/guaifenesin/pseudoephedrine, 35
codeine/promethazine, 35 codeine/promethazine/phenylephrine, 35 colchicine, 7 colesevelam, 15 COLESTID, 15 colestipol, 15 COMBIGAN, 41 COMBIPATCH, 27 COMBIVIR, 10 COMPLERA, 10 COMTAN, 20 CONCERTA, 20 CONDYLOX, 39 conjugated estrogens/bazedoxifene, 27 COPAXONE, 22 COREG, 15 CORGARD, 15 CORLANOR, 17 CORTEF, 27 CORTIFOAM, 29 COSENTYX, 32 COSOPT, 40 COZAAR, 14 CREON, 30 CRINONE, 28 crisaborole, 38 cromolyn sodium, 39 cromolyn soln, 35 cyanocobalamin inj, 34 cyclobenzaprine, 22 cyclophosphamide caps, 11 cyclosporine, 33 cyclosporine, emulsion, 40 cyclosporine, modified, 33 cyproheptadine, 34 CYTOMEL, 28 CYTOTEC, 30
D D.H.E. 45, 21 DALIRESP, 36 dalteparin, 31 danazol, 26 DANTRIUM, 22 dantrolene, 22 dapagliflozin, 24 dapagliflozin/metformin ext-rel, 24 dapsone, 11 darbepoetin alfa, 31 darifenacin ext-rel, 31 darolutamide, 12 darunavir, 10 darunavir/cobicistat, 9 dasatinib, 12 DAYPRO, 7 DDAVP, 28 denosumab, 25 DEPAKENE, 18 DEPAKOTE, 18 DEPAKOTE ER, 18 DEPO-PROVERA, 26 DESCOVY, 10 desipramine, 19 desmopressin spray, tabs, 28 desogestrel/EE, 26 desogestrel/EE 0.15/30, 25
47
desonide crm, lotion, oint 0.05%, 38 DESOWEN, 38 desoximetasone crm, oint 0.05%, 38 desoximetasone crm, oint 0.25%, gel 0.05%, 38 desvenlafaxine ext-rel, 19 DETROL, 31 deutetrabenazine, 22 dexamethasone, 27, 40 dexamethasone sodium phosphate, 40 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM, 24 DEXEDRINE SPANSULE, 20 DEXILANT, 30 dexlansoprazole delayed-rel, 30 dexmethylphenidate, 20 dexmethylphenidate ext-rel, 20 dextroamphetamine, 20 dextroamphetamine ext-rel, 20 dextromethorphan/brompheniramine/pseudoephedrine, 35 dextromethorphan/promethazine, 35 dextromethorphan/quinidine, 22 DIASTAT, 18 diazepam, 18 diazepam rectal gel, 18 diclofenac sodium, 40 diclofenac sodium delayed-rel, 7 diclofenac sodium delayed-rel/misoprostol, 7 diclofenac sodium gel 1%, 7 diclofenac sodium soln, 7 dicloxacillin, 9 dicyclomine, 29 didanosine delayed-rel, 10 DIFICID, 9 DIFLUCAN, 9 diflunisal, 7 difluprednate, 40 digoxin 0.0625 mg, 0.1875 mg, 16 digoxin 0.125 mg, 0.25 mg, 16 digoxin ped elixir, 16 dihydroergotamine inj, 21 DILANTIN, 18 DILANTIN INFATABS, 18 DILAUDID, 8 diltiazem ext-rel, 16 dimethyl fumarate delayed-rel, 22 diphenoxylate/atropine, 28 DIPROLENE, 38 DIPROLENE AF, 38 dipyridamole, 32 dipyridamole ext-rel/aspirin, 32 disopyramide, 14 disopyramide ext-rel, 14 disulfiram, 22 DITROPAN XL, 31 divalproex sodium delayed-rel, 18 divalproex sodium ext-rel, 18 DIVIGEL, 26 dofetilide, 14 dolutegravir, 10 donepezil, 19 dornase alfa, 35 dorzolamide, 40 dorzolamide/timolol maleate, 40 doxazosin, 14 doxepin, 19, 21 doxercalciferol, 28 doxycycline hyclate, 9
doxycycline hyclate 20 mg, 9 doxycycline monohydrate delayed-rel caps, 38 doxylamine/pyridoxine delayed-rel, 29 dronabinol, 29 dronedarone, 14 drospirenone/EE 3/20, 25 drospirenone/EE 3/30, 25 drospirenone/EE/levomefolate 3/20 and levomefolate, 25 drospirenone/EE/levomefolate 3/30 and levomefolate, 25 DUAC, 37 DUAVEE, 27 DUETACT, 24 dulaglutide, 23 duloxetine delayed-rel, 19 dupilumab, 36, 38 DUPIXENT, 36, 38 DUREZOL, 40 DUROLANE, 8 dutasteride, 30 dutasteride/tamsulosin, 30 DYAZIDE, 17 DYMISTA, 36
E econazole, 37 eculizumab, 32 EDURANT, 10 EE/norethindrone acetate - Jinteli, 27 efavirenz, 10 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 9 efavirenz/lamivudine/tenofovir disoproxil fumarate, 9, 10 elagolix, 26 eletriptan, 21 ELIGARD, 12 eliglustat, 27 ELIQUIS, 31 ELOCON, 38 eltrombopag, 32 eluxadoline, 29 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 10 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate, 10 EMBEDA, 8 EMGALITY, 21 empagliflozin, 24 empagliflozin/linagliptin, 24 empagliflozin/metformin, 24 empagliflozin/metformin ext-rel, 24 emtricitabine, 10 emtricitabine/rilpivirine/tenofovir alafenamide, 10 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 10 emtricitabine/tenofovir alafenamide, 10 emtricitabine/tenofovir disoproxil fumarate, 10 EMTRIVA, 10 EMVERM, 11 enalapril, 13 enalapril/hydrochlorothiazide, 13 ENBREL, 32 ENDOMETRIN, 28 enfuvirtide, 10 enoxaparin, 31 entacapone, 20 entecavir soln, 11 entecavir tabs, 10 ENTRESTO, 17 enzalutamide, 12 EPCLUSA, 11
48
EPIDUO, 37 EPIDUO FORTE, 37 epinephrine auto-injector, 34 EPIPEN, 34 EPIPEN JR., 34 EPISIL, 39 EPIVIR, 10 eplerenone, 13 epoetin alfa-epbx, 31 epoprostenol sodium, 17 eprosartan, 14 EPZICOM, 10 erenumab-aooe, 21 ergocalciferol (D2), 34 ergotamine/caffeine tabs, 21 ERLEADA, 12 erlotinib, 12 erythromycin, 39 erythromycin delayed-rel, 9 erythromycin ethylsuccinate, 9 erythromycin gel 2%, 37 erythromycin soln, 37 erythromycin stearate, 9 erythromycin/benzoyl peroxide, 37 ESBRIET, 36 escitalopram, 19 ESGIC, 8 esomeprazole delayed-rel, 30 ESTRACE, 26 estradiol, 26 estradiol vaginal crm, 27 estradiol vaginal ring, 27 estradiol vaginal tabs, 27 estradiol/levonorgestrel, 27 estradiol/norethindrone, 27 estradiol/norethindrone acetate, 27 ESTRING, 27 estrogens, conjugated, 26 estrogens, conjugated crm, 27 estrogens, conjugated/medroxyprogesterone, 27 eszopiclone, 21 etanercept, 32 ethambutol, 10 ethosuximide, 18 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 26 etodolac, 7 etonogestrel/EE ring, 26 etoposide, 12 etravirine, 10 EUCRISA, 38 EVAMIST, 26 everolimus, 12 EVISTA, 28 evolocumab, 15 EVOTAZ, 9 EVOXAC, 30 EXELON, 19 exemestane, 12 EYLEA, 41 ezetimibe, 15 ezetimibe/simvastatin, 15
F famciclovir, 11 famotidine, 29 FARXIGA, 24
FASENRA, 36 febuxostat, 7 felodipine ext-rel, 16 FEMARA, 12 fenofibrate, 15 fenofibric acid delayed-rel, 15 fentanyl sublingual spray, 7 fentanyl transdermal, 7 fentanyl transmucosal lozenge, 7 fesoterodine ext-rel, 31 FIASP, 24 fidaxomicin, 9 filgrastim-aafi, 31 FINACEA FOAM, 39 finasteride, 30 fingolimod, 22 FIORINAL, 8 FIRAZYR, 33 FLAGYL, 11 flecainide, 14 FLOLAN, 17 FLOMAX, 30 FLOVENT DISKUS, 36 FLOVENT HFA, 36 fluconazole, 9 fludrocortisone, 27 flunisolide spray, 36 fluocinolone acetonide crm, oint 0.025%, 38 fluocinolone acetonide soln 0.01%, 38 fluocinonide crm, gel, oint, soln 0.05%, 38 fluoride drops, 34 fluoride tabs, 34 fluorometholone, 40 fluorouracil crm 4%, 37 fluorouracil crm 5%, soln 5%, soln 2%, 37 fluoxetine, 19 fluphenazine, 20 flutamide, 12 fluticasone, 36 fluticasone propionate crm, lotion 0.05%, oint 0.005%, 38 fluticasone spray, 36 fluticasone, CFC-free aerosol, 36 fluticasone/salmeterol, 36 fluticasone/salmeterol, CFC-free aerosol, 36 fluticasone/umeclidinium/vilanterol, 34 fluticasone/vilanterol, 36 fluvastatin, 15 fluvoxamine, 18 FML FORTE, 40 FML S.O.P., 40 FOCALIN, 20 FOCALIN XR, 20 folic acid, 33 folic acid/vitamin B6/vitamin B12, 33 follitropin alfa, 27 fondaparinux, 31 formoterol inhalation soln, 35 FORTEO, 25 FOSAMAX, 25 fosinopril, 13 fosinopril/hydrochlorothiazide, 13 FRAGMIN, 31 fremanezumab-vfrm, 21 FURADANTIN, 11 furosemide, 16
49
FUZEON, 10 FYCOMPA, 18
G gabapentin, 18 gabapentin ext-rel, 22 galantamine, 19 galantamine ext-rel, 19 galcanezumab-gnlm, 21 ganirelix acetate, 27 gefitinib, 12 GEL-ONE, 8 GELSYN-3, 8 gemfibrozil, 15 GENOTROPIN, 27 gentamicin, 37, 39 GENVOYA, 10 GEODON, 20 GILENYA, 22 glatiramer, 22 glimepiride, 24 glipizide, 24 glipizide ext-rel, 24 glipizide/metformin, 23 GLUCAGEN HYPOKIT, 27 GLUCAGON EMERGENCY KIT, 27 glucagon, human recombinant, 27 GLUCOPHAGE, 23 GLUCOPHAGE XR, 23 GLUCOTROL, 24 GLUCOTROL XL, 24 glycopyrrolate/formoterol, 34 GLYXAMBI, 24 GOLYTELY, 30 GONAL-F, 27 GRALISE, 22 granisetron, 29 granisetron transdermal, 29 grass mixed pollen allergen extract, 32 GRASTEK, 32 griseofulvin ultramicrosize, 9 guanfacine, 13 guanfacine ext-rel, 20 guselkumab, 32
H halobetasol propionate crm, oint 0.05%, 38 haloperidol, 20 HARVONI, 11 HECTOROL, 28 human coagulation factor VIII (rDNA) simoctocog alfa, 32 HUMATROPE, 27 HUMIRA, 32 HUMULIN R U-500, 24 HYCAMTIN, 12 hydralazine, 17 HYDREA, 13 hydrochlorothiazide, 16 hydrocodone/acetaminophen, 8 hydrocodone/homatropine, 35 hydrocortisone, 27 hydrocortisone acetate foam, 29 hydrocortisone acetate/pramoxine foam, 30 hydrocortisone butyrate crm, oint, soln 0.1%, 38 hydrocortisone crm, 30 hydrocortisone crm 2.5%, 38 hydrocortisone enema, 29
hydrocortisone lotion 1%, 38 hydrocortisone valerate crm, oint 0.2%, 38 hydromorphone, 8 hydromorphone ext-rel, 7 hydroxychloroquine, 33 hydroxyurea, 13 hydroxyzine HCl, 34 hyoscyamine sulfate, 29 hyoscyamine sulfate ext-rel, 29 hyoscyamine sulfate ext-rel caps, 29 hyoscyamine sulfate orally disintegrating tabs, 29 HYZAAR, 14
I ibandronate, 25 IBRANCE, 12 ibuprofen, 7 icatibant, 33 icosapent ethyl, 15 ILARIS, 33 ILEVRO, 40 imatinib mesylate, 12 imiglucerase, 27 imipramine HCl, 19 imiquimod, 37, 39 IMITREX, 21 IMURAN, 33 INCRUSE ELLIPTA, 34 indapamide, 16 INDERAL LA, 15 ingenol mebutate, 37 INGREZZA, 22 INSPRA, 13 insulin aspart, 24 insulin aspart protamine 70%/insulin aspart 30%, 24 insulin degludec, 24 insulin detemir, 24 insulin glargine, 24 insulin human, 24 insulin infusion disposable pump, 24 insulin isophane human, 24 insulin isophane human 70%/regular 30%, 24 insulin syringes, needles, 24 INTELENCE, 10 interferon alfa-2b, 33 interferon beta-1a, 22 interferon beta-1b, 22 INTRON A, 33 ipratropium soln, 34 ipratropium spray, 36 ipratropium/albuterol soln, 34 irbesartan, 14 irbesartan/hydrochlorothiazide, 14 IRESSA, 12 ISENTRESS, 10 isoniazid, 10 ISORDIL, 17 isosorbide dinitrate ext-rel tabs, 17 isosorbide dinitrate oral, 17 isosorbide dinitrate/hydralazine, 17 isosorbide mononitrate, 17 isosorbide mononitrate ext-rel, 17 isotretinoin, 36 itraconazole, 9 ivabradine, 17 ivermectin, 11, 39
50
J JANUMET, 23 JANUMET XR, 23 JANUVIA, 23 JARDIANCE, 24 JIVI, 32
K KADIAN, 8 KALETRA, 10 KEFLEX, 8 KEPPRA, 18 KEPPRA XR, 18 ketoconazole crm 2%, 37 ketoconazole shampoo 2%, 37 ketorolac, 40 ketorolac tromethamine, 40 KISQALI, 12 KISQALI FEMARA CO-PACK, 12 KLARON, 37 KLONOPIN, 18 KOGENATE FS, 32 KOVALTRY, 32 KUVAN, 28 KYLEENA, 26
L labetalol, 15 LAC-HYDRIN, 38 lacosamide, 18 lactulose soln, 30 lamivudine, 10 lamivudine/tenofovir disoproxil fumarate, 10 lamivudine/zidovudine, 10 lamotrigine, 18 lamotrigine ext-rel, 18 lamotrigine orally disintegrating tabs, 18 LANOXIN, 16 lanreotide acetate, 23 lansoprazole + amoxicillin + clarithromycin, 30 lansoprazole delayed-rel, 30 lapatinib, 12 LASIX, 16 LASTACAFT, 39 latanoprost, 41 LATUDA, 20 ledipasvir/sofosbuvir, 11 leflunomide, 33 lenalidomide, 12 letrozole, 12 LEUKERAN, 11 leuprolide acetate, 12 levalbuterol tartrate, CFC-free aerosol, 35 LEVAQUIN, 9 LEVBID, 29 LEVEMIR, 24 levetiracetam, 18 levetiracetam ext-rel, 18 levobunolol, 40 levocarnitine, 25 levocetirizine, 34 levofloxacin, 9, 39 levonorgestrel releasing IUD, 26 levonorgestrel/EE - Trivora, 26 levonorgestrel/EE 0.1/20 - Lessina, 25 levonorgestrel/EE 0.1/20 and EE 10, 26
levonorgestrel/EE 0.15/30, 26 levonorgestrel/EE 0.15/30 - Levora, 25 levonorgestrel/EE 0.15/30 and EE 10, 26 levothyroxine, 28 levothyroxine - Levoxyl, 28 LEVSIN, 29 lidocaine patch, 38 lidocaine viscous, 39 lidocaine/prilocaine, 38 LIDODERM, 38 lifitegrast, 40 linaclotide, 29 linezolid, 11 LINZESS, 29 liothyronine, 28 LIPOFEN, 15 liraglutide, 23, 25 liraglutide/insulin degludec, 23 lisdexamfetamine, 20 lisinopril, 13 lisinopril/hydrochlorothiazide, 13 lithium carbonate, 21 lithium carbonate ext-rel tabs 300 mg, 21 lithium carbonate ext-rel tabs 450 mg, 21 LITHOBID, 21 lixisenatide/insulin glargine, 23 LOESTRIN 1.5/30, 25 LOESTRIN 1/20, 25 LOESTRIN FE 1.5/30, 25 LOESTRIN FE 1/20, 25 LOKELMA, 28 LOMOTIL, 28 loperamide, 28 LOPID, 15 lopinavir/ritonavir soln, 10 lopinavir/ritonavir tabs, 10 LOPRESSOR, 15 LOPRESSOR HCT, 16 LOPROX, 37 lorazepam, 18 losartan, 14 losartan/hydrochlorothiazide, 14 LOSEASONIQUE, 26 LOTENSIN, 13 LOTENSIN HCT, 13 loteprednol, 40 LOTREL, 13 lovastatin, 15 LOVAZA, 15 lubiprostone, 29 LUCENTIS, 41 luliconazole, 37 LUMIGAN, 41 LUPRON DEPOT, 12 lurasidone, 20 lusutrombopag, 32 LYNPARZA, 12 LYSODREN, 13
M macitentan, 17 MACROBID, 11 MALARONE, 9 malathion, 39 MARINOL, 29 MATULANE, 13
51
MAXALT, 21 MAXIDEX, 40 MAXITROL, 40 MAXZIDE, 17 MAYZENT, 22 mebendazole chewable, 11 meclizine, 29 MEDROL, 27 medroxyprogesterone acetate, 28 medroxyprogesterone acetate 150 mg/mL, 26 mefloquine, 9 MEGACE ES, 28 megestrol acetate susp, 28 megestrol acetate tabs, 12 meloxicam, 7 melphalan, 11 memantine, 19 memantine ext-rel, 18 memantine/donepezil, 18 mepolizumab, 36 mercaptopurine, 11 mesalamine delayed-rel caps, 29 mesalamine delayed-rel tabs, 29 mesalamine ext-rel caps, 29 mesalamine supp, 29 mesalamine susp, 29 metaxalone, 22 metformin, 23 metformin ext-rel, 23 methadone, 7 methazolamide, 16 methimazole, 28 methocarbamol, 22 methotrexate, 11, 33 methotrexate auto-injector, 33 methoxsalen oral, 37 methyldopa, 17 METHYLIN, 20 methylphenidate, 20 methylphenidate ext-rel, 20 methylprednisolone, 27 metoclopramide, 29 metolazone, 16 metoprolol succinate ext-rel, 15 metoprolol tartrate, 15 metoprolol/hydrochlorothiazide, 16 METROCREAM, 39 METROGEL, 39 METROGEL-VAGINAL, 31 METROLOTION, 39 metronidazole, 11, 31 metronidazole crm 0.75%, 39 metronidazole gel 0.75%, 39 metronidazole gel 1%, 39 metronidazole lotion 0.75%, 39 MICARDIS, 14 MICARDIS HCT, 14 midodrine, 17 midostaurin, 12 minocycline, 9 mirabegron ext-rel, 31 MIRAPEX, 20 MIRCETTE, 26 MIRENA, 26 mirtazapine, 19 misoprostol, 30
mitotane, 13 MOBIC, 7 mometasone crm, lotion, oint 0.1%, 38 mometasone spray, 36 montelukast, 35 morphine, 7 morphine ext-rel, 7, 8 morphine supp, 7 morphine/naltrexone ext-rel, 8 MOVANTIK, 30 MOXEZA, 39 moxifloxacin, 9, 39 MOZOBIL, 32 MS CONTIN, 8 MUGARD, 39 MULPLETA, 32 MULTAQ, 14 multivitamins/fluoride drops, tabs, 34 multivitamins/fluoride/iron drops, tabs, 34 mupirocin oint, 37 MUSE, 30 MYAMBUTOL, 10 mycophenolate mofetil, 33 mycophenolate sodium delayed-rel, 33 MYDAYIS, 20 MYLERAN, 11 MYRBETRIQ, 31 MYSOLINE, 18
N nabumetone, 7 nadolol, 15 naftifine, 37 NAFTIN, 37 naldemedine, 30 naloxegol, 30 naloxone inj, 22 naloxone nasal spray, 22 naltrexone, 22 NAMENDA, 19 NAMZARIC, 18 naproxen sodium tabs, 7 naproxen tabs, 7 naratriptan, 21 NARCAN, 22 NARDIL, 19 natalizumab, 22 nateglinide, 24 nebivolol, 15 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 40 neomycin/polymyxin B/dexamethasone, 40 neomycin/polymyxin B/gramicidin, 39 neomycin/polymyxin B/hydrocortisone, 41 neomycin/polymyxin B/hydrocortisone susp, 40 nepafenac, 40 netarsudil, 41 netarsudil/latanoprost, 41 NEULASTA, 31 NEUPRO, 20 NEURONTIN, 18 NEVANAC, 40 nevirapine, 10 nevirapine ext-rel, 10 niacin ext-rel, 15 NIASPAN, 15 nifedipine ext-rel, 16
52
nintedanib, 36 niraparib, 12 nitisinone, 27 NITRO-DUR, 17 nitrofurantoin ext-rel, 11 nitrofurantoin macrocrystals, 11 nitrofurantoin susp, 11 nitroglycerin lingual spray, 17 nitroglycerin sublingual, 17 nitroglycerin transdermal, 17 NITROLINGUAL, 17 NITROSTAT, 17 NIVESTYM, 31 NIZORAL, 37 NORCO, 8 norelgestromin/EE, 26 norethindrone, 26 norethindrone acetate, 28 norethindrone acetate/EE 1.5/30, 25 norethindrone acetate/EE 1.5/30 and iron, 25 norethindrone acetate/EE 1/20, 25 norethindrone acetate/EE 1/20 and iron, 25 norethindrone acetate/EE 1/20 and iron chewable, 25 norethindrone/EE, 26 norethindrone/EE 0.5/35, 26 norethindrone/EE 1/35, 26 norgestimate/EE, 26 norgestimate/EE 0.25/35, 26 norgestrel/EE 0.3/30 - Low-Ogestrel, 25 NORPACE, 14 NORPACE CR, 14 NORPRAMIN, 19 nortriptyline, 19 NORVIR, 10 NOVOEIGHT, 32 NOVOLIN 70/30, 24 NOVOLIN N, 24 NOVOLIN R, 24 NOVOLOG, 24 NOVOLOG MIX 70/30, 24 NUBEQA, 12 NUCALA, 36 NUCYNTA, 8 NUCYNTA ER, 8 NUEDEXTA, 22 NULYTELY, 30 NUVARING, 26 NUWIQ, 32 nystatin, 9, 37
O OCUFLOX, 39 ODEFSEY, 10 ODOMZO, 12 OFEV, 36 ofloxacin, 39 ofloxacin otic, 41 olanzapine, 20 olaparib, 12 olmesartan, 14 olmesartan/amlodipine/hydrochlorothiazide, 14 olmesartan/hydrochlorothiazide, 14 olodaterol, CFC-free aerosol, 35 olopatadine, 39 olopatadine spray, 36 omalizumab, 36
omega-3 acid ethyl esters, 15 omeprazole delayed-rel, 30 OMNIPOD INSULIN INFUSION PUMP, 24 ondansetron, 29 ONZETRA XSAIL, 21 OPSUMIT, 17 ORALAIR, 32 ORENITRAM, 17 ORFADIN, 27 ORILISSA, 26 orphenadrine/aspirin/caffeine, 22 ORTHO MICRONOR, 26 ORTHO-NOVUM 1/35, 26 ORTHO-NOVUM 7/7/7, 26 oseltamivir, 11 ospemifene, 28 OSPHENA, 28 OTEZLA, 32 OVIDE, 39 OVIDREL, 27 oxaprozin, 7 oxazepam, 18 oxcarbazepine, 18 oxcarbazepine ext-rel, 18 OXSORALEN-ULTRA, 37 OXTELLAR XR, 18 oxybutynin, 31 oxybutynin ext-rel, 31 oxycodone caps, tabs 5 mg, 7 oxycodone concentrate 20 mg/mL, 7 oxycodone ext-rel, 8 oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL, 8 oxycodone/acetaminophen 5/325, 7 OZEMPIC, 23
P palbociclib, 12 PAMELOR, 19 pancrelipase, 30 pancrelipase delayed-rel, 30 pantoprazole delayed-rel, 30 paricalcitol, 28 PARLODEL, 20 PARNATE, 19 paroxetine HCl, 19 paroxetine HCl ext-rel, 19 paroxetine mesylate, 23 PATADAY, 39 PATANASE, 36 PATANOL, 39 patiromer sorbitex, 28 PAXIL, 19 PAXIL CR, 19 PAZEO, 39 pazopanib, 12 peg 3350/electrolytes, 30 PEGASYS, 33 pegfilgrastim, 31 pegfilgrastim-cbqv, 31 peginterferon alfa-2a, 33 peginterferon alfa-2b, 33 pegvisomant, 23 penicillin VK, 9 PENTASA, 29 PEPCID, 29 perampanel, 18
53
PERFOROMIST, 35 perindopril, 13 permethrin 5%, 39 perphenazine, 20 phenelzine, 19 phenobarbital, 18 phenytoin, 18 phenytoin sodium extended, 18 PHOSLYRA, 28 PICATO, 37 pilocarpine tabs, 30 pimecrolimus, 38 pindolol, 15 pioglitazone, 24 pioglitazone/glimepiride, 24 pioglitazone/metformin, 24 pirfenidone, 36 PLAQUENIL, 33 plerixafor, 32 podofilox, 39 polymyxin B/bacitracin, 39 polymyxin B/trimethoprim, 39 POLYTRIM, 39 pomalidomide, 12 POMALYST, 12 potassium chloride ext-rel, 33 potassium chloride liquid, 33 potassium citrate ext-rel, 31 pramipexole, 20 pramipexole ext-rel, 19 pramlintide, 23 PRANDIN, 24 prasugrel, 32 PRAVACHOL, 15 pravastatin, 15 PRECOSE, 23 PRED MILD, 40 prednisolone, 27 prednisolone acetate, 40 prednisolone acetate 1%, 40 prednisolone phosphate 1%, 40 prednisone, 27 pregabalin, 21 PREMARIN, 26, 27 PREMPHASE, 27 PREMPRO, 27 prenatal vitamins, 33 prenatal vitamins/DHA/docusate/folic acid, 33 prenatal vitamins/docusate/folic acid, 33 prenatal vitamins/docusate/folic acid + DHA, 34 prenatal vitamins/folic acid + pyridoxine, 34 PREZCOBIX, 9 PREZISTA, 10 PRILOSEC, 30 primidone, 18 probenecid, 7 procarbazine, 13 PROCARDIA XL, 16 prochlorperazine, 29 PROCTOFOAM-HC, 30 progesterone gel, 28 progesterone vaginal inserts, 28 progesterone, micronized, 28 PROLASTIN-C, 36 PROLIA, 25 PROMACTA, 32
promethazine, 29 PROMETRIUM, 28 propafenone, 14 propafenone ext-rel, 14 propranolol, 15 propranolol ext-rel, 15 propylthiouracil, 28 PROSCAR, 30 PROVERA, 28 PULMICORT FLEXHALER, 36 PULMICORT RESPULES, 36 PULMOZYME, 35 PYLERA, 30 pyrazinamide, 10 pyridostigmine, 22 pyridostigmine ext-rel, 22
Q QUESTRAN/QUESTRAN LIGHT, 15 quetiapine, 20 quetiapine ext-rel, 20 quinapril, 13 quinapril/hydrochlorothiazide, 13 QVAR REDIHALER, 36
R ragweed pollen allergen extract, 32 RAGWITEK, 32 raloxifene, 28 raltegravir, 10 ramelteon, 21 ramipril, 13 ranibizumab, 41 ranitidine, 29 ranolazine ext-rel, 17 rasagiline, 19 RASUVO, 33 RAZADYNE, 19 RAZADYNE ER, 19 REBIF, 22 REBINYN, 32 REGLAN, 29 RELENZA, 11 RELPAX, 21 REMERON, 19 repaglinide, 24 REPATHA, 15 REQUIP XL, 20 RESTASIS, 40 RESTORIL, 21 RETACRIT, 31 RETIN-A, 37 RETROVIR, 10 REVATIO, 17 REVLIMID, 12 RHOPRESSA, 41 ribavirin, 11 ribociclib, 12 ribociclib + letrozole, 12 RIFADIN, 10 rifampin, 10 rifaximin 550 mg, 11 rilpivirine, 10 RINVOQ, 32 riociguat, 17 risankizumab-rzaa, 32 risedronate, 25
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risedronate delayed-rel, 25 RISPERDAL, 20 RISPERDAL CONSTA, 20 risperidone, 20 risperidone long-acting injection, 20 RITALIN, 20 ritonavir, 10 rivaroxaban, 31 rivastigmine, 18 rivastigmine transdermal, 19 rizatriptan, 21 ROBAXIN, 22 ROCALTROL, 28 ROCKLATAN, 41 roflumilast, 36 rolapitant, 29 ropinirole, 19 ropinirole ext-rel, 20 rosuvastatin, 15 rotigotine transdermal, 20 ROWASA, 29 ROXICODONE, 8 RUBRACA, 12 rucaparib, 12 RUCONEST, 33 RYDAPT, 12 RYTHMOL SR, 14
S sacubitril/valsartan, 17 SALAGEN, 30 salmeterol xinafoate, 35 SANCUSO, 29 sapropterin, 28 SAXENDA, 25 scopolamine transdermal, 29 SEASONIQUE, 26 secukinumab, 32 selegiline, 19 selenium sulfide lotion 2.5%, 37 selexipag, 17 semaglutide, 23 SENSIPAR, 25 SEREVENT, 35 SEROQUEL, 20 sertraline, 19 sevelamer carbonate, 28 sildenafil, 17, 31 SILENOR, 21 silodosin, 30 SILVADENE, 37 silver sulfadiazine, 37 SIMBRINZA, 40 simvastatin, 15 SINEMET, 20 SINEMET CR, 20 siponimod, 22 sirolimus, 33 sitagliptin phosphate, 23 sitagliptin/metformin, 23 sitagliptin/metformin ext-rel, 23 SKELAXIN, 22 SKYLA, 26 SKYRIZI, 32 sodium hyaluronate, 8 sodium sulfate/potassium sulfate/magnesium sulfate, 30
sodium zirconium cyclosilicate, 28 sofosbuvir/velpatasvir, 11 sofosbuvir/velpatasvir/voxilaprevir, 11 solifenacin, 31 SOLIQUA, 23 SOLIRIS, 32 solriamfetol, 22 somatropin, 27 SOMATULINE DEPOT, 23 SOMAVERT, 23 sonidegib, 12 SOOLANTRA, 39 SORIATANE, 37 sotalol, 14 soy phospholipid/glycerol dioleate, 39 SPIRIVA, 34 spironolactone, 13 spironolactone/hydrochlorothiazide, 17 SPRYCEL, 12 STALEVO, 20 stavudine, 10 STELARA SUBCUTANEOUS, 32 STIOLTO RESPIMAT, 34 STRATTERA, 20 STRIBILD, 10 STRIVERDI RESPIMAT, 35 STROMECTOL, 11 SUBSYS, 7 sucralfate, 30 sucroferric oxyhydroxide, 28 sulfacetamide lotion 10%, 37 sulfacetamide oint 10%, 39 sulfacetamide soln 10%, 39 sulfacetamide/prednisolone phosphate 10%/0.25%, 40 sulfamethoxazole/trimethoprim, 11 sulfamethoxazole/trimethoprim DS, 11 sulfasalazine, 29 sulfasalazine delayed-rel, 29 sulindac, 7 sumatriptan, 21 sumatriptan inj, 21 sumatriptan nasal powder, 21 sumatriptan nasal spray, 21 sumatriptan/naproxen sodium, 21 sunitinib, 12 SUNOSI, 22 SUPARTZ FX, 8 SUPRAX, 9 SUPREP, 30 SUTENT, 12 suvorexant, 21 SYLATRON, 33 SYMBICORT, 36 SYMFI, 9 SYMFI LO, 10 SYMLINPEN, 23 SYMPROIC, 30 SYNJARDY, 24 SYNJARDY XR, 24 SYNTHROID, 28
T TABLOID, 11 tacrolimus, 33, 38 tadalafil, 17, 31 tamoxifen, 12
55
tamsulosin, 30 TAPAZOLE, 28 tapentadol, 8 tapentadol ext-rel, 8 TARGRETIN, 13 TARKA, 13 tazarotene, 37 TAZORAC, 37 TECFIDERA, 22 TEGRETOL, 18 TEKTURNA HCT, 16 telmisartan, 14 telmisartan/hydrochlorothiazide, 14 temazepam, 21 TEMIXYS, 10 TEMODAR, 11 TEMOVATE, 38 temozolomide, 11 tenofovir alafenamide, 11 tenofovir disoproxil fumarate, 10 terazosin, 14 terbinafine tabs, 9 terbutaline, 35 terconazole, 31 teriflunomide, 22 teriparatide, 25 TESSALON, 35 testosterone cypionate, 23 testosterone enanthate, 23 testosterone gel, 23 testosterone soln, 23 testosterone transdermal, 23 tetrabenazine, 22 tetracycline, 9 thalidomide, 12 THALOMID, 12 theophylline ext-rel tabs, 36 thioguanine, 11 thiothixene, 20 tiagabine, 18 TIAZAC, 16 ticagrelor, 32 TIGAN, 29 TIKOSYN, 14 timolol hemihydrate, 40 timolol maleate, 40 timolol maleate gel, 40 TIMOPTIC, 40 timothy grass pollen allergen extract, 32 tinidazole, 11 tiotropium, 34 tiotropium/olodaterol, 34 TIVICAY, 10 tizanidine tabs, 22 TOBRADEX, 40 TOBRADEX ST, 40 tobramycin, 39 tobramycin inhalation soln, 35 tobramycin/dexamethasone oint 0.3%/0.1%, 40 tobramycin/dexamethasone susp 0.3%/0.05%, 40 tobramycin/dexamethasone susp 0.3%/0.1%, 40 TOBREX, 39 tofacitinib, 32 tofacitinib ext-rel, 32 TOFRANIL, 19 TOLAK, 37
tolterodine, 31 tolterodine ext-rel, 31 TOPAMAX, 18 topiramate, 18 topiramate ext-rel, 18 topotecan caps, 12 torsemide, 16 TOVIAZ, 31 tramadol, 8 tramadol ext-rel, 7 trandolapril, 13 trandolapril/verapamil ext-rel, 13 tranylcypromine, 19 TRAVATAN Z, 41 travoprost, 41 trazodone, 19 TRELEGY ELLIPTA, 34 TREMFYA, 32 treprostinil ext-rel, 17 TRESIBA, 24 tretinoin, 37 tretinoin - Avita, 37 tretinoin caps, 12 tretinoin gel microsphere, 37 TREXALL, 11 TREXIMET, 21 triamcinolone acetonide crm 0.5%, 38 triamcinolone acetonide crm, lotion 0.025%, 38 triamcinolone acetonide crm, lotion, oint 0.1%, 38 triamcinolone paste, 39 triamterene, 16 triamterene/hydrochlorothiazide, 17 TRIBENZOR, 14 trifluoperazine, 20 trifluridine, 40 trihexyphenidyl, 20 TRILEPTAL, 18 TRILIPIX, 15 trimethobenzamide, 29 trimethoprim, 11 TRINTELLIX, 19 TRIUMEQ, 9 TROKENDI XR, 18 trospium, 31 trospium ext-rel, 31 TRULICITY, 23 TRUSOPT, 40 TRUVADA, 10 TYKERB, 12 TYMLOS, 25 TYSABRI, 22
U UDENYCA, 31 ULORIC, 7 ULTRAM, 8 ULTRAVATE, 38 umeclidinium bromide, 34 umeclidinium/vilanterol, 34 upadacitinib, 32 UPTRAVI, 17 URECHOLINE, 31 uridine triacetate, 12 UROCIT-K, 31 URSO, 29
56
ursodiol, 29 ustekinumab, 32
V VAGIFEM, 27 valacyclovir, 11 valbenazine, 22 valganciclovir, 10 VALIUM, 18 valproic acid, 18 valsartan, 14 valsartan/hydrochlorothiazide, 14 VANCOCIN, 11 vancomycin caps, 11 varenicline, 23 VARUBI, 29 VASCEPA, 15 VASERETIC, 13 VASOTEC, 13 VELPHORO, 28 VELTASSA, 28 VEMLIDY, 11 venlafaxine, 19 venlafaxine ext-rel, 19 verapamil ext-rel, 16 VFEND, 9 V-GO INSULIN INFUSION PUMP, 24 VIBERZI, 29 VIBRAMYCIN, 9 VICTOZA, 23 VIDEX EC, 10 vigabatrin, 18 VIGAMOX, 39 VIIBRYD, 19 vilazodone, 19 VIMPAT, 18 VIOKACE, 30 VIREAD, 10 VISCO-3, 8 VISTOGARD, 12 vitamin ADC/fluoride drops, 34 vitamin ADC/fluoride/iron drops, 34 voriconazole, 9 vorinostat, 13 vortioxetine, 19 VOSEVI, 11 VOTRIENT, 12 VRAYLAR, 20 VYTORIN, 15 VYVANSE, 20
W warfarin, 31 WELLBUTRIN SR, 19 WELLBUTRIN XL, 19
X XALATAN, 41 XARELTO, 31 XELJANZ, 32 XELJANZ XR, 32 XELODA, 11 XIFAXAN, 11 XIGDUO XR, 24 XIIDRA, 40 XOLAIR, 36 XTAMPZA ER, 8 XTANDI, 12 XULTOPHY, 23
Y YASMIN, 25 YONSA, 12
Z zafirlukast, 35 ZANAFLEX, 22 zanamivir, 11 ZARONTIN, 18 ZEJULA, 12 ZEMBRACE SYMTOUCH, 21 ZEMPLAR, 28 ZENPEP, 30 ZESTORETIC, 13 ZESTRIL, 13 ZIAC, 16 ZIAGEN, 10 zidovudine, 10 zileuton ext-rel, 35 ziprasidone, 20 ZITHROMAX, 9 ZOCOR, 15 ZOFRAN, 29 ZOLINZA, 13 zolmitriptan, 21 zolmitriptan nasal spray, 21 ZOLOFT, 19 zolpidem, 21 zolpidem ext-rel, 21 zolpidem sublingual, 21 ZOMIG, 21 zonisamide, 18 ZOVIRAX, 11 ZUBSOLV, 22 ZYCLARA, 37 ZYLOPRIM, 7 ZYPREXA, 20