2016 Health Insurance Marketplace. Abridged Formulary

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1 2016 Health Insurance Marketplace Abridged Formulary

2 Understanding your pharmacy benefit can save you money Get the most value out of your pharmacy benefit by reviewing the medications covered under your plan. Taking time to understand how your pharmacy benefit works can help lower your out-of-pocket medication costs. Your pharmacy benefit includes coverage for many medications. We ve listed some of the most common medications in this abridged formulary. Tip: Looking for a complete list of medications covered under your plan? Visit, click on Prescription Tools, then 2016 Group Plans or 2016 Individual and Family Plans. You can also call our Pharmacy Services Department at or How the formulary works A team of on-staff physicians and pharmacists review information on new and existing drugs and regularly update the formulary with drugs that are safe and effective. Our goal is to ensure that you have access to quality, cost-effective medications. Medications are assigned to tiers. Each tier has different cost sharing depending on your coverage as noted in the table below: Medication Tier Types of medications Cost Sharing 1 Most generics Lowest cost share 2 Preferred brands/select generics Medium cost share 3 Non-preferred brands/select generics Higher cost share 4 Specialty medications and some very high cost brand/generic medications Highest cost share *Certain medications are not covered and are considered non-formulary (NF). A member may request a medical exception for a non-formulary prescription medication or medical supply. The exception request may be initiated by the member, or a provider acting on behalf of the member, in writing or by verbal request. For a copy of the formulary exception policy or to start a formulary exception request please contact the Pharmacy Services Department at the number listed below. You have coverage for preventive medications In addition to a healthful lifestyle, preventive medications are important in helping you avoid many types of illnesses and complications from illnesses. You ll notice some preventive medications are covered at 100 percent to make it easier for you to get the medications you need for your health. Have questions? We re here to help.

3 Have questions? We re here to help. Please contact Security Health Plan if you have questions or need to request a prior authorization or a formulary exception. Security Health Plan Attn: Pharmacy Benefit Specialist 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI Phone: or Fax: Note: Benefits vary by plan. Please refer to your plan documents for information specific to your coverage. The formulary listing is subject to change at any time. The formulary may not be allinclusive for medication covered.

4 Prescription Formulary Guide 2016 CURRENT AS OF 1/1/2016 UPPERCASE= Brand name drugs italics= Generic drugs Tier = Generic Tier 2= Preferred Brand Tier 3= Non-preferred Brand Tier 4= Specialty Pharmacy Preventive= preventive Notes PA= Prior Authorization ST= Step Therapy SP= Specialty Pharmacy LA= Limited Access QL= Quantity Limits Drug Tier Notes abacavir-lamivudine-zidovudine acamprosate ACANYA Tier 3 acarbose ACCU-CHEK AVIVA Tier 2 ACCU-CHEK COMPACT PLUS CARE Tier 2 ACCU-CHEK COMPACT TEST Tier 2 ACCU-CHEK MULTICLIX LANCET Tier 2 ACCU-CHEK NANO Tier 2 ACCU-CHEK SMARTVIEW TEST STRIP Tier 2 ACCU-CHEK SOFTCLIX LANCETS Tier 2 ACCU-CHEK VOICEMATE Tier 2 PA acetaminophen-codeine oral tablet acetylcysteine acitretin ACTOPLUS MET XR Tier 2 ACUVAIL (PF) Tier 2 acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir topical adapalene topical cream PA; Prior authorization > 50 yrs old adapalene topical gel 0.1 % PA; Prior authorization > 50 yrs old 1

5 ADCIRCA Tier 4 PA; QL; SP ADVAIR DISKUS Tier 2 QL ADVAIR HFA Tier 2 QL AFINITOR ORAL TABLET 10 MG, 5 MG Tier 3 PA; SP AFINITOR ORAL TABLET 2.5 MG, 7.5 MG Tier 3 PA; SP alclometasone ALDARA Tier 3 alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg 2 alfuzosin allegra allergy allopurinol ALOMIDE Tier 2 ALORA Tier 2 QL ALPHAGAN P OPHTHALMIC DROPS 0.1 % Tier 2 alprazolam amantadine HCl oral capsule amantadine HCl oral solution amcinonide topical cream amiloride oral amiodarone oral tablet 200 mg, 400 mg amitriptyline amlodipine amlodipine-atorvastatin amlodipine-benazepril amoxapine amoxicillin oral tablet 500 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule 500 mg anagrelide QL

6 anastrozole ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) Tier 2 Tier 2 ANORO ELLIPTA Tier 2 QL ANZEMET ORAL Tier 2 QL APOKYN Tier 2 apraclonidine ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML Tier 4 aripiprazole ARMOUR THYROID Tier 2 ASACOL HD Tier 2 aspirin oral tablet 325 mg Preventive QL aspirin oral tablet,chewable Preventive QL aspirin, buffered Preventive QL aspirin-dipyridamole atenolol atorvastatin PA; QL PA; QL ATRALIN Tier 3 PA; Prior authorization > 50 yrs old atropine ophthalmic AVONEX (WITH ALBUMIN) Tier 4 SP AVONEX INTRAMUSCULAR SYRINGE KIT Tier 4 SP azathioprine azelastine ophthalmic AZILECT Tier 2 AZOPT Tier 2 bacitracin ophthalmic baclofen BACTROBAN NASAL Tier 2 SP 3

7 BACTROBAN TOPICAL CREAM Tier 3 BANZEL Tier 3 BARACLUDE Tier 4 SP benazepril benzonatate oral capsule 100 mg, 200 mg benzoyl peroxide topical cleanser 10 %, 5 % betaxolol ophthalmic BETOPTIC S Tier 2 BEYAZ 4 Preventive bicalutamide bisoprolol fumarate BLEPHAMIDE Tier 2 BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE Tier 2 brimonidine bromfenac budesonide dr & er budesonide inhalation budesonide oral BUFFERED ASPIRIN Preventive QL buspirone butalbital-acetaminophen butorphanol tartrate nasal QL BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON Tier 2 BYETTA Tier 2 calcipotriene topical ointment calcipotriene topical solution calcipotriene-betamethasone calcitonin (salmon) calcitriol oral CAMRESE CAMRESE LO Preventive Preventive

8 CANASA Tier 2 candesartan-hydrochlorothiazid capecitabine Tier1 PA; SP CAPEX Tier 2 CAPRELSA Tier 3 PA; LA captopril CARAC Tier 2 CARAFATE ORAL SUSPENSION Tier 2 carbidopa carbamazepine oral tablet CARBATROL Tier 2 carbidopa-levodopa carteolol carvedilol CAYSTON Tier 4 LA cefaclor oral capsule cefadroxil oral capsule cefadroxil oral tablet cefdinir cefpodoxime cefprozil cefuroxime axetil oral tablet celecoxib CELLCEPT Tier 2 cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cetirizine oral solution 1 mg/ml cetirizine oral tablet cetirizine oral tablet,chewable cevimeline 5

9 CHANTIX Tier 2 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations. chlordiazepoxide HCl chlorothiazide chlorpropamide chlorzoxazone ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical suspension CILOXAN OPHTHALMIC OINTMENT Tier 2 cimetidine HCl oral cimetidine oral tablet 300 mg, 400 mg, 800 mg CIPRO HC Tier 2 CIPRODEX Tier 2 ciprofloxacin HCl ophthalmic ciprofloxacin HCl oral citalopram clarithromycin clindamycin HCl clindamycin-benzoyl peroxide clindamycin palmitate HCl clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab clobetasol topical lotion clobetasol topical shampoo clomipramine clonazepam oral tablet clonidine 6

10 clonidine HCl oral tablet clopidogrel clorpres clotrimazole mucous membrane clotrimazole-betamethasone topical cream clozapine oral tablet 200 mg clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg Tier 2 COARTEM Tier 2 colchicine oral tablet colestipol COLY-MYCIN S Tier 2 COMBIGAN Tier 2 COMBIPATCH Tier 2 COPAXONE Tier 4 SP COPEGUS Tier 4 SP cortisone CORTISPORIN-TC Tier 3 COUMADIN ORAL Tier 2 CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 6,000-19,000-30,000 UNIT Tier 2 CRESTOR Tier 2 cromolyn inhalation cromolyn ophthalmic cyanocobalamin (vitamin B-12) injection cyclobenzaprine oral tablet CYCLOGYL OPHTHALMIC DROPS 0.5 % Tier 2 CYCLOGYL OPHTHALMIC DROPS 1 %, 2 % Tier 3 CYCLOMYDRIL Tier 2 cyclopentolate cyclosporine modified oral capsule 100 mg, 25 mg cyclosporine modified oral solution 7

11 cyclosporine oral capsule cyproheptadine CYTOMEL Tier 3 CYTRA-3 Tier 2 dapsone Tier 2 demeclocycline oral DENAVIR Tier 2 DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG, 250 MG, 500 MG DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG, 250 MG, 500 MG 8 Tier 2 Tier 3 desonide desoximetasone topical cream desoximetasone topical gel desoximetasone topical ointment 0.25 % desvenlafaxine fumarate Tier 3 dexamethasone oral tablet 0.5 mg, 1 mg, 2 mg DEXILANT Tier 3 PA; ST dexmethylphenidate oral capsule,er biphasic mg, 30 mg, 40 mg dexmethylphenidate oral tablet dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamine-amphetamine oral capsule,extended release 24hr DIASTAT Tier 2 DIASTIX Tier 2 diazepam oral tablet diazepam rectal Tier 2 diclofenac potassium diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (DR/EC) 50 mg, 75 mg

12 diclofenac-misoprostol dicloxacillin didanosine DIFFERIN TOPICAL GEL 0.3 % Tier 3 PA; Prior authorization > 50 yrs old DIFFERIN TOPICAL LOTION Tier 2 PA; Prior authorization > 50 yrs old DIFICID Tier 2 PA; QL diflorasone diflunisal digoxin oral tablet DILANTIN EXTENDED Tier 2 DILANTIN INFATABS Tier 2 diltiazem HCl oral capsule, extended release diltiazem HCl oral capsule,ext release degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24hr diltiazem HCl oral tablet disopyramide phosphate oral capsule disulfiram donepezil dorzolamide dorzolamide-timolol doxazosin doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate doxercalciferol oral doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg doxycycline hyclate oral tablet,delayed release (DR/EC) doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg dronabinol 9

13 DUREZOL Tier 2 dutasteride econazole topical EDECRIN Tier 2 EFFEXOR XR Tier 3 ELIDEL Tier 2 ELIQUIS Tier 2 ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML Tier 2 ELMIRON Tier 2 EMCYT Tier 2 EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG 10 Tier 2 PA; QL EMEND ORAL CAPSULE,DOSE PACK Tier 2 PA; QL EMTRIVA ORAL CAPSULE Tier 2 ENABLEX Tier 2 QL enalapril maleate ENBREL Tier 4 PA; SP enoxaparin subcutaneous syringe epinastine EPIVIR HBV ORAL SOLUTION Tier 2 EPIVIR ORAL SOLUTION Tier 2 eplerenone EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML Tier 4 eprosartan EPZICOM Tier 2 ERIVEDGE Tier 3 PA; SP erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet erythromycin-benzoyl peroxide escitalopram oxalate SP

14 esomeprazole PA; ST estradiol oral estradiol transdermal patch weekly estradiol-norethindrone acet oral tablet mg ESTRING Tier 2 estropipate ethosuximide oral capsule etidronate disodium etodolac etoposide oral SP EVOXAC Tier 3 exemestane EXJADE Tier 2 PA EXTAVIA SUBCUTANEOUS KIT Tier 4 SP FABIOR Tier 2 PA famciclovir famotidine oral tablet 20 mg, 40 mg felbamate oral tablet FELBATOL Tier 3 FEMARA Tier 3 PA; Prior authorization > 45 yrs old FEMHRT LOW DOSE Tier 3 fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenoprofen oral tablet fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr ferrous sulfate oral drops ferrous sulfate oral liquid ferrous sulfate oral solution Preventive Preventive Preventive fexofenadine oral tablet 180 mg, 60 mg fexofenadine-pseudoephedrine finasteride oral tablet 5 mg QL 11

15 FLAGYL ER Tier 2 FLAREX Tier 2 FLOVENT DISKUS Tier 2 FLOVENT HFA Tier 2 fluconazole flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) 12 fluocinolone topical cream fluocinolone topical ointment fluocinolone topical solution fluocinonide fluorometholone fluorouracil topical cream 5 % fluorouracil topical solution 5 % fluoxetine oral capsule 10 mg, 20 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral tablet 10 mg, 20 mg flurazepam flurbiprofen fluticasone nasal QL fluticasone topical cream fluticasone topical ointment fluvastatin oral capsule FML FORTE Tier 2 FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 35 MG Tier 2 folic acid oral tablet 400 mcg, 800 mcg Preventive QL folic acid-vit B6-vit B12 oral tablet mg fondaparinux FORTEO Tier 4 PA; SP fosinopril furosemide oral tablet gabapentin oral capsule

16 gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG Tier 2 gemfibrozil oral gentamicin topical GILENYA Tier 4 PA; QL; SP GLEEVEC Tier 3 PA; SP glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT Tier 2 GLUCAGON EMERGENCY KIT (HUMAN) Tier 2 glyburide glyburide micronized glyburide-metformin granisetron HCl oral griseofulvin microsize oral suspension griseofulvin ultramicrosize haloperidol heparin lock flush (porcine) intravenous solution 100 unit/ml HEPSERA Tier 4 SP HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML Tier 4 Tier 4 hydralazine oral hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-chlorpheniramine hydrocodone-homatropine oral syrup mg/5 ml PA; LA PA; SP 13

17 hydrocodone-ibuprofen oral tablet mg hydrocortisone butyrate hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 8 mg 14 hydroquinone hydroxyurea hydroxyzine HCl oral solution 10 mg/5 ml hydroxyzine HCl oral tablet ibandronate oral IBRANCE Tier 3 PA; LA ibuprofen oral tablet 400 mg, 600 mg, 800 mg imipramine HCl IMITREX NASAL SPRAY,NON-AEROSOL 20 MG/ACTUATION, 5 MG/ACTUATION Tier 2 INCRELEX Tier 4 PA: SP indomethacin oral INLYTA Tier 3 PA; SP INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML Tier 4 INTUNIV ER Tier 3 iodoquinol-hc IOPIDINE OPHTHALMIC DROPPERETTE Tier 2 IOPIDINE OPHTHALMIC DROPS Tier 3 ipratropium bromide nasal irbesartan irbesartan-hydrochlorothiazide ISENTRESS ORAL TABLET Tier 2 QL ISENTRESS ORAL TABLET,CHEWABLE Tier 2 ISORDIL Tier 2 isosorbide dinitrate oral isosorbide mononitrate ISTALOL Tier 2 itraconazole PA QL QL PA; SP

18 JANUMET Tier 2 QL JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, MG Tier 2 JANUVIA Tier 2 QL KALETRA Tier 3 KEPPRA ORAL Tier 3 ketoconazole oral ketoconazole topical cream ketoconazole topical shampoo ketoprofen oral capsule ketorolac intramuscular solution ketorolac ophthalmic ketorolac oral QL KINERET Tier 4 PA; LA KLOR-CON/25 Tier 2 labetalol oral LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 MG, 200 MG, 25 MG, 50 MG Tier 2 LAMICTAL ORAL TABLET Tier 2 lamivudine oral tablet lamivudine-zidovudine lamotrigine oral tablet lamotrigine oral tablet disintegrating, dose pk 25 mg (21) -50 mg (7), 50 mg (42) -100 mg (14) lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible LANOXIN ORAL TABLET 125 MCG, 250 MCG Tier 2 lansoprazole oral capsule,delayed release(dr/ec) LANTUS Tier 2 LANTUS SOLOSTAR Tier 2 latanoprost leflunomide QL 15

19 letrozole PA; Prior authorization > 45 yrs old leucovorin calcium oral tablet 25 mg, 5 mg LEUKINE INJECTION RECON SOLN Tier 4 PA; SP leuprolide subcutaneous kit SP levalbuterol HCl LEVEMIR Tier 2 levetiracetam intravenous levetiracetam oral tablet extended release 24 hr levofloxacin ophthalmic levofloxacin oral levorphanol tartrate levothyroxine oral LEXIVA Tier 2 lidocaine HCl mucous membrane lidocaine 5% patch QL lindane linezolid PA LINZESS Tier 2 liothyronine oral lisinopril lomustine oral capsule 100 mg, 40 mg Tier 2 loratadine lorazepam oral tablet losartan losartan-hydrochlorothiazide LOTRONEX Tier 3 PA; QL lovastatin LUMIGAN OPHTHALMIC DROPS 0.01 % Tier 3 LYSODREN Tier 2 malathion maprotiline MEDROL ORAL TABLET 2 MG Tier 2 16

20 medroxyprogesterone oral megestrol oral suspension 625 mg/5 ml megestrol oral tablet memantine MENOSTAR Tier 2 MEPHYTON Tier 2 meprobamate mercaptopurine mesalamine rectal metaproterenol oral tablet metaxalone oral tablet 800 mg metformin oral tablet metformin oral tablet extended release 24hr 1,000 mg methadone oral tablet QL methazolamide oral methimazole oral tablet 10 mg, 5 mg METHITEST Tier 2 methocarbamol oral methotrexate sodium methylphenidate oral capsule, ER biphasic mg, 20 mg, 30 mg, 40 mg methylphenidate oral capsule,er biphasic methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet extended release 20 mg methylphenidate oral tablet extended release 24hr methylprednisolone metoclopramide HCl oral tablet metoprolol succinate metoprolol tartrate oral metronidazole oral 17

21 metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical lotion metronidazole vaginal mexiletine MIACALCIN INJECTION Tier 2 midazolam oral syrup 2 mg/ml MIGRANAL Tier 3 QL minocycline oral capsule minoxidil oral misoprostol modafinil oral tablet 100 mg, 200 mg PA; QL moexipril mometasone montelukast oral tablet QL montelukast oral tablet,chewable QL morphine concentrate oral solution morphine oral tablet QL morphine rectal suppository 5 mg moxifloxacin MOZOBIL Tier 4 PA; SP mupirocin mycophenolate sodium MYFORTIC Tier 3 MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40 MG 18 nadolol NAMENDA ORAL SOLUTION Tier 3 NAMENDA XR Tier 2 naproxen oral tablet naproxen oral tablet,delayed release (DR/EC) naproxen sodium oral tablet 275 mg, 550 mg naratriptan QL

22 NARDIL Tier 3 NASCOBAL Tier 2 NASONEX Tier 2 NATACYN Tier 2 NATAZIA Preventive nefazodone neomycin neomycin-polymyxin-hc otic NEORAL Tier 2 NEULASTA SUBCUTANEOUS SYRINGE Tier 4 PA; SP NEUPOGEN Tier 4 PA; SP NEVANAC Tier 2 NEXAVAR Tier 3 PA; SP niacin oral tablet extended release 24 hr NIASPAN EXTENDED-RELEASE Tier 3 nicardipine oral NICODERM CQ Tier 3 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations. NICORETTE BUCCAL GUM Tier 3 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations. nicotine Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations. nicotine (polacrilex) buccal gum Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations. 19

23 nicotine (polacrilex) buccal lozenge 2 mg Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations. NICOTROL Tier 2 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations. NICOTROL NS Tier 2 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations. nimodipine nisoldipine NITRO-BID Tier 2 nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitrofurantoin oral susp nitroglycerin oral nitroglycerin transdermal patch 24 hour nitroglycerin translingual spray,non-aerosol NITROLINGUAL Tier 3 nizatidine NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) Tier 4 norethindrone acetate nortriptyline NOVOLIN 70/30 Tier 2 NOVOLIN N Tier 2 NOVOLIN R Tier 2 NOVOLOG Tier 2 NOVOLOG FLEXPEN Tier 2 NOVOLOG MIX Tier 2 PA; SP 20

24 NOVOLOG MIX FLEXPEN Tier 2 NOVOLOG PENFILL Tier 2 NOVOPEN ECHO Tier 2 NOXAFIL ORAL SUSPENSION Tier 2 PA NUCYNTA ER Tier 2 QL NUEDEXTA Tier 2 PA; QL NUVARING NUVIGIL ORAL TABLET 150 MG, 250 MG, 50 MG Preventive Tier 2 nystatin oral PA; QL octreotide acetate injection solution PA; SP ofloxacin ophthalmic ofloxacin otic OGESTREL (28) Preventive olanzapine oral omeprazole ondansetron ondansetron HCl oral ONETOUCH DELICA LANC DEVICE Tier 2 ONETOUCH DELICA LANCETS 33 GAUGE Tier 2 ONETOUCH SURESOFT LANCING DEV Tier 2 ONETOUCH ULTRA CONTROL Tier 2 ONETOUCH ULTRA2 Tier 2 ONETOUCH ULTRAMINI Tier 2 ONETOUCH ULTRASOFT LANCETS Tier 2 ONETOUCH VERIO Tier 2 OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR Tier 2 oxaprozin oxazepam oxcarbazepine OXISTAT Tier 2 oxybutynin chloride oral QL 21

25 oxycodone oral tablet 15 mg, 30 mg, 5 mg QL OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG 22 Tier 2 oxymorphone oral tablet QL PANCREAZE Tier 2 pantoprazole oral paroxetine HCl oral tablet paroxetine HCl oral tablet extended release 24 hr PATADAY Tier 2 PATANOL Tier 2 PAXIL ORAL SUSPENSION Tier 2 PEGASYS SUBCUTANEOUS SOLUTION Tier 4 PA; SP PEGINTRON Tier 4 PA; SP penicillin V potassium PENTASA Tier 2 perindopril erbumine permethrin phenazopyridine oral tablet 100 mg, 200 mg phenelzine phenobarbital oral elixir phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg phenytoin oral suspension phenytoin oral tablet,chewable PHOSPHOLINE IODIDE Tier 2 pilocarpine HCl ophthalmic drops 1 %, 2 %, 4 % pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piroxicam PLAN B ONE-STEP Tier 3 QL

26 podofilox polyethylene glycol 3350 Tier 3 polyethylene glycol 3350 oral potassium bicarb-citric acid potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral tablet extended release 10 meq, 8 meq potassium chloride oral tablet,er particles/crystals PRADAXA Tier 2 QL pramipexole PRANDIMET Tier 2 PRANDIN ORAL TABLET 0.5 MG Tier 3 pravastatin prazosin oral PRECISION XTRA TEST Tier 2 PA PRED FORTE Tier 2 PRED MILD Tier 2 prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) prednisone oral tablet PREFEST Tier 2 PREMARIN ORAL Tier 2 PREMARIN VAGINAL Tier 2 PREMPHASE Tier 2 PREMPRO Tier 2 PREZISTA ORAL TABLET 800 MG Tier 2 PRILOSEC OTC primidone PROAIR HFA Tier 2 PROAIR RESPICLICK Tier 2 23

27 prochlorperazine PROCRIT Tier 4 SP progesterone micronized PROGLYCEM Tier 2 PROGRAF ORAL Tier 2 PROMACTA ORAL TABLET 25 MG, 50 MG Tier 4 promethazine-codeine PROMETRIUM Tier 3 propafenone propranolol oral tablet propylthiouracil PROTOPIC Tier 2 PULMOZYME Tier 4 SP QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION 24 Tier 2 QUALAQUIN Tier 3 PA quetiapine quinapril rabeprazole raloxifene ramipril ranitidine HCl oral capsule ranitidine HCl oral syrup ranitidine HCl oral tablet 300 mg RAPAMUNE ORAL SOLUTION Tier 2 RAPAMUNE ORAL TABLET 0.5 MG Tier 3 RAPAMUNE ORAL TABLET 1 MG, 2 MG Tier 2 RELENZA DISKHALER Tier 2 repaglinide oral tablet 1 mg, 2 mg RESCRIPTOR Tier 2 RESTASIS Tier 2 RETIN-A MICRO Tier 3 PA; Prior Authorization > 50 yrs old

28 RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.04 %, 0.1 % Tier 3 REVLIMID Tier 3 PA; LA RHEUMATREX Tier 2 ribavirin oral capsule SP ribavirin oral tablet 200 mg SP RIDAURA Tier 2 rifabutin rifampin oral rimantadine risedronate oral tablet QL risperidone oral tablet rivastigmine patch rivastigmine tartrate rizatriptan QL ropinirole oral tablet salsalate SANCUSO Tier 2 PA; QL SANDIMMUNE ORAL Tier 2 SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT Tier 4 selenium sulfide SENSIPAR Tier 2 SEREVENT DISKUS Tier 2 QL SEROQUEL Tier 3 ST sertraline sildenafil 20 mg tablet silver sulfadiazine simvastatin SINGULAIR ORAL TABLET Tier 3 QL SINGULAIR ORAL TABLET,CHEWABLE 5 MG Tier 3 sirolimus oral tablet 0.5 mg PA; Prior Authorization > 50 yrs old PA; SP QL 25

29 sodium chloride inhalation solution for nebulization 0.9 %, 7 % sodium fluoride oral drops sodium fluoride oral tablet,chewable Preventive Preventive sodium polystyrene sulfonate oral powder SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG Tier 3 sotalol oral SOVALDI Tier 4 PA spinosad Tier 8 SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION Tier 2 SPIRIVA WITH HANDIHALER Tier 2 spironolactone SPORANOX Tier 3 PA SPRYCEL Tier 3 PA; SP stavudine STRATTERA Tier 2 SUBOXONE SUBLINGUAL FILM Tier 2 sucralfate oral tablet sulfacetamide sodium (acne) sulfacetamide sodium ophthalmic drops sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w) sulfamethoxazole-trimethoprim oral sulfasalazine sumatriptan Tier 2 QL sumatriptan succinate oral QL sumatriptan succinate subcutaneous cartridge QL sumatriptan succinate subcutaneous pen injector QL sumatriptan succinate subcutaneous solution QL SURMONTIL Tier 3 SUSTIVA Tier 2 26

30 SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG Tier 3 SYMBICORT Tier 2 QL SYMLINPEN 120 Tier 2 SYMLINPEN 60 Tier 2 SYNTHROID Tier 3 tacrolimus oral TAMIFLU ORAL CAPSULE Tier 2 PA; SP tamoxifen May be covered under preventive benefit for women at increased risk of breast cancer. tamsulosin TASIGNA ORAL CAPSULE 200 MG Tier 3 PA; SP TASMAR ORAL TABLET 100 MG Tier 3 TAZORAC Tier 2 PA; Prior Authorization > 50 yrs old TEGRETOL ORAL SUSPENSION 100 MG/5 ML TEGRETOL ORAL SUSPENSION 100 MG/5 ML Tier 2 Tier 3 TEGRETOL ORAL TABLET 200 MG Tier 2 TEGRETOL ORAL TABLET 200 MG Tier 3 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 400 MG TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 200 MG, 400 MG Tier 3 Tier 2 telmisartan telmisartan-hydrochlorothiazid oral tablet mg, mg temazepam oral capsule 15 mg, 30 mg TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, 20 MG, 250 MG Tier 3 terazosin terbinafine HCl oral terconazole TESTIM Tier 3 PA PA; SP 27

31 testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram) 28 tetracycline PA; QL PA; QL THALOMID Tier 3 PA; SP thiothixene THYROLAR-1 Tier 2 tiagabine TIKOSYN Tier 2 QL timolol maleate tinidazole tizanidine QL TOBI Tier 4 LA TOBRADEX OPHTHALMIC OINTMENT Tier 2 TOBREX OPHTHALMIC OINTMENT Tier 2 tolazamide oral tablet 250 mg tolbutamide tolterodine tolterodine er topiramate tramadol oral tablet QL tramadol oral tablet extended release 24 hr QL tramadol-acetaminophen QL trandolapril tranexamic acid oral TRANSDERM-SCOP Tier 2 TRAVATAN Z Tier 2 travoprost (benzalkonium) trazodone tretinoin topical PA; Prior Authorization > 50 yrs old triazolam

32 TRIBENZOR Tier 3 QL trimethobenzamide oral TRIZIVIR Tier 2 TRUVADA Tier 2 TUDORZA PRESSAIR Tier 2 TUSSIONEX PENNKINETIC ER Tier 3 TYKERB Tier 3 PA; LA TYVASO Tier 4 LA TYVASO REFILL KIT Tier 4 LA TYVASO STARTER KIT Tier 4 LA TYZEKA Tier 2 ULESFIA Tier 2 ULORIC Tier 2 valacyclovir VALCYTE Tier 2 valsartan VECTICAL Tier 2 venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg venlafaxine oral tablet VENTAVIS Tier 4 LA VENTOLIN HFA Tier 2 VERAMYST Tier 3 ST verapamil oral VEREGEN Tier 2 VEXOL Tier 2 VICTOZA 2 PAK Tier 2 VICTOZA 3 PAK Tier 2 VIGAMOX Tier 2 VIMPAT ORAL TABLET Tier 3 QL VIRAMUNE Tier 3 VIRAMUNE XR Tier 2 VIRAZOLE Tier 2 29

33 VIREAD ORAL TABLET 300 MG Tier 2 VIVELLE-DOT Tier 2 VIVOTIF BERNA VACCINE Preventive voriconazole oral tablet PA VOTRIENT Tier 3 PA; SP warfarin WELCHOL ORAL TABLET Tier 2 QL XALKORI Tier 3 PA; LA XARELTO ORAL TABLET Tier 2 XTANDI Tier 3 PA; SP XULANE Preventive YAZ (28) Tier 3 zafirlukast zaleplon QL ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG Tier 3 ZENATANE ORAL CAPSULE 10 MG, 20 MG, 40 MG ZETIA Tier 2 QL ZIAGEN Tier 3 zidovudine ZIOPTAN (PF) Tier 2 ziprasidone HCl ZIRGAN Tier 2 ZOLINZA Tier 3 PA; SP zolpidem oral tablet 10 mg, 5 mg QL zolpidem oral tablet,ext release multiphase 6.25 mg zonisamide ZORTRESS Tier 2 ZOVIRAX TOPICAL CREAM Tier 2 ZOVIRAX TOPICAL OINTMENT Tier 3 QL 30

34 Index A abacavir-lamivudinezidovudine... 1 acamprosate... 1 ACANYA... 1 acarbose... 1 ACCU-CHEK AVIVA... 1 ACCU-CHEK COMPACT PLUS CARE... 1 ACCU-CHEK COMPACT TEST... 1 ACCU-CHEK MULTICLIX LANCET... 1 ACCU-CHEK NANO... 1 ACCU-CHEK SMARTVIEW TEST STRIP... 1 ACCU-CHEK SOFTCLIX LANCETS... 1 acetaminophen-codeine... 1 acetylcysteine... 1 acitretin... 1 ACTOPLUS MET XR... 1 ACUVAIL (PF)... 1 acyclovir... 1 adapalene... 1 ADCIRCA... 2 ADDERALL XR... 2 ADVAIR DISKUS... 2 ADVAIR HFA... 2 AFINITOR... 2 alclometasone... 2 ALDARA... 2 alendronate... 2 alfuzosin... 2 ALLEGRA ALLERGY... 2 allopurinol... 2 ALOMIDE... 2 ALORA... 2 ALPHAGAN P... 2 alprazolam... 2 amantadine HCl... 2 amcinonide... 2 amiloride... 2 amiodarone... 2 amitriptyline... 2 amlodipine... 2 amlodipine-atorvastatin... 2 amlodipine-benazepril... 2 amoxapine... 2 amoxicillin... 2 amoxicillin-pot clavulanate... 2 ampicillin... 2 anagrelide... 2 anastrozole... 3 ANDRODERM... 3 ANDROGEL... 3 ANORO ELLIPTA... 3 ANZEMET... 3 APOKYN... 3 apraclonidine... 3 ARANESP (IN POLYSORBATE)... 3 aripiprazole... 3 ARMOUR THYROID... 3 ASACOL HD... 3 aspirin... 3 aspirin, buffered... 3 aspirin-dipyridamole... 3 atenolol... 3 atorvastatin... 3 ATRALIN... 3 atropine... 3 AVONEX... 3 AVONEX (WITH ALBUMIN)... 3 azathioprine... 3 azelastine... 3 AZILECT... 3 AZOPT... 3 B bacitracin... 3 baclofen... 3 BACTROBAN... 3 BACTROBAN NASAL... 4 BANZEL... 4 BARACLUDE... 4 benazepril... 4 benzonatate... 4 benzoyl peroxide... 4 betaxolol... 4 BETOPTIC S... 4 BEYAZ... 4 bicalutamide... 4 bisoprolol fumarate... 4 BLEPHAMIDE... 4 BREO ELLIPTA... 4 brimonidine... 4 bromfenac... 4 budesonide... 4 BUFFERED ASPIRIN... 4 buspirone... 4 butalbital-acetaminophen... 4 butorphanol tartrate... 4 BYDUREON... 4 BYETTA... 4 C calcipotriene... 4 calcipotriene-betamethasone.. 4 calcitonin (salmon)... 4 calcitriol... 4 CAMRESE... 4 CAMRESE LO... 4 CANASA... 5 candesartan-hydrochlorothiazid... 5 CAPEX... 5 capecitabine 5 CAPRELSA... 5 captopril... 5 CARAC... 5 CARAFATE... 5 carbidopa 5 carbamazepine... 5 CARBATROL... 5 carbidopa-levodopa... 5 carteolol... 5 carvedilol... 5 CAYSTON... 5 cefaclor... 5 cefadroxil... 5 cefdinir... 5 cefpodoxime... 5 cefprozil... 5 cefuroxime axetil... 5 celecoxib... 5 CELLCEPT... 5 cephalexin... 5 cetirizine... 5 cevimeline... 5 CHANTIX... 6 chlordiazepoxide HCl... 6 chlorothiazide... 6 chlorpropamide... 6 chlorzoxazone

35 ciclopirox... 6 CILOXAN... 6 cimetidine... 6 cimetidine HCl... 6 CIPRO HC... 6 CIPRODEX... 6 ciprofloxacin HCl... 6 citalopram... 6 clarithromycin... 6 clindamycin HCl... 6 clindamycin-benzoyl peroxide6 clindamycin palmitate HCl... 6 clindamycin phosphate... 6 clobetasol... 6 clomipramine... 6 clonazepam... 6 clonidine... 7 clonidine HCl... 7 clopidogrel... 7 CLORPRES... 7 clotrimazole... 7 clotrimazole-betamethasone... 7 clozapine... 7 COARTEM... 7 colchicine... 7 colestipol... 7 COLY-MYCIN S... 7 COMBIGAN... 7 COMBIPATCH... 7 COPAXONE... 7 COPEGUS... 7 cortisone... 7 CORTISPORIN-TC... 7 COUMADIN... 7 CREON... 7 CRESTOR... 7 cromolyn... 7 cyanocobalamin (vitamin B- 12)... 7 cyclobenzaprine... 7 CYCLOGYL... 7 CYCLOMYDRIL... 8 cyclopentolate... 8 cyclosporine... 7,8 cyclosporine modified... 7,8 cyproheptadine... 8 CYTOMEL... 8 CYTRA D dapsone demeclocycline... 8 DENAVIR... 8 DEPAKOTE... 8 desonide... 8 desoximetasone... 8 desvenlafaxine fumarate... 8 dexamethasone... 8 DEXILANT... 8 dexmethylphenidate... 8 dextroamphetamine... 8 dextroamphetamineamphetamine... 8 DIASTAT... 8 DIASTIX... 8 diazepam... 8 diclofenac potassium... 8 diclofenac sodium... 8 diclofenac-misoprostol... 9 dicloxacillin... 9 didanosine... 9 DIFFERIN... 9 DIFICID... 9 diflorasone... 9 diflunisal... 9 digoxin... 9 DILANTIN EXTENDED... 9 DILANTIN INFATABS... 9 diltiazem HCl... 9 disopyramide phosphate... 9 disulfiram... 9 donepezil... 9 dorzolamide... 9 dorzolamide-timolol... 9 doxazosin... 9 doxepin... 9 doxercalciferol... 9 doxycycline hyclate... 9 doxycycline monohydrate... 9 dronabinol... 9 DUREZOL dutasteride.10 E econazole EDECRIN EFFEXOR XR ELIDEL ELIQUIS ELIXOPHYLLIN ELMIRON EMCYT EMEND EMTRIVA ENABLEX enalapril maleate ENBREL enoxaparin ENTOCORT EC epinastine EPIVIR EPIVIR HBV eplerenone EPOGEN eprosartan EPZICOM ERIVEDGE erythromycin erythromycin-benzoyl peroxide escitalopram oxalate esomeprazole 11 estradiol estradiol-norethindrone acet. 11 ESTRING estropipate ethosuximide etidronate disodium etodolac etoposide EVOXAC exemestane EXJADE EXTAVIA F FABIOR famciclovir famotidine felbamate FELBATOL FEMARA FEMHRT LOW DOSE fenofibrate micronized fenoprofen fentanyl ferrous sulfate fexofenadine fexofenadine-pseudoephedrine finasteride FLAGYL ER FLAREX... 12

36 FLOVENT DISKUS FLOVENT HFA fluconazole flunisolide fluocinolone fluocinonide fluorometholone fluorouracil fluoxetine flurazepam flurbiprofen fluticasone fluvastatin FML FORTE FOCALIN XR folic acid folic acid-vit B6-vit B fondaparinux FORTEO fosinopril furosemide G gabapentin... 12,13 GABITRIL gemfibrozil gentamicin GILENYA GLEEVEC glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glyburide glyburide micronized glyburide-metformin granisetron HCl griseofulvin microsize griseofulvin ultramicrosize H haloperidol heparin lock flush (porcine). 13 HEPSERA HUMIRA hydralazine hydrocodone-acetaminophen 13 hydrocodone-chlorpheniramine hydrocodone-homatropine hydrocodone-ibuprofen hydrocortisone butyrate hydromorphone hydroquinone hydroxyurea hydroxyzine HCl I ibandronate IBRANCE ibuprofen imipramine HCl IMITREX INCRELEX indomethacin INLYTA INTRON A INTUNIV ER iodoquinol-hc IOPIDINE ipratropium bromide irbesartan irbesartan-hydrochlorothiazide ISENTRESS ISORDIL isosorbide dinitrate isosorbide mononitrate ISTALOL itraconazole J JANUMET JANUMET XR JANUVIA K KALETRA KEPPRA ketoconazole ketoprofen ketorolac KINERET KLOR-CON/ L labetalol LAMICTAL LAMICTAL ODT lamivudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR latanoprost leflunomide letrozole leucovorin calcium LEUKINE leuprolide levalbuterol HCl LEVEMIR levetiracetam levofloxacin levorphanol tartrate levothyroxine LEXIVA lidocaine HCl LIDODERM lindane LINZESS liothyronine lisinopril LODOSYN lomustine loratadine lorazepam losartan losartan-hydrochlorothiazide 16 LOTRONEX lovastatin LUMIGAN LYSODREN M malathion maprotiline MEDROL medroxyprogesterone megestrol memantine MENOSTAR MEPHYTON meprobamate mercaptopurine mesalamine metaproterenol metaxalone metformin methadone methazolamide methimazole METHITEST methocarbamol

37 methotrexate sodium methylphenidate methylprednisolone metoclopramide HCl metoprolol succinate metoprolol tartrate metronidazole... 17,18 mexiletine MIACALCIN midazolam MIGRANAL minocycline minoxidil MIRALAX misoprostol modafinil moexipril mometasone montelukast morphine morphine concentrate moxifloxacin MOZOBIL mupirocin mycophenolate sodium MYFORTIC MYORISAN N nadolol NAMENDA NAMENDA XR naproxen naproxen sodium naratriptan NARDIL NASCOBAL NASONEX NATACYN NATAZIA nefazodone neomycin neomycin-polymyxin-hc NEORAL NEULASTA NEUPOGEN NEVANAC NEXAVAR niacin NIASPAN EXTENDED- RELEASE nicardipine NICODERM CQ NICORETTE nicotine nicotine (polacrilex)... 19,20 NICOTROL NICOTROL NS nimodipine nisoldipine NITRO-BID nitrofurantoin macrocrystal.. 20 nitrofurantoin monohyd/mcryst nitrofurantoin susp 20 nitroglycerin NITROLINGUAL nizatidine NORDITROPIN FLEXPRO 20 norethindrone acetate nortriptyline NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOVOPEN ECHO NOXAFIL NUCYNTA ER NUEDEXTA NUVARING NUVIGIL nystatin O octreotide acetate ofloxacin OGESTREL (28) olanzapine omeprazole ondansetron ondansetron HCl ONETOUCH DELICA LANC DEVICE ONETOUCH DELICA LANCETS ONETOUCH SURESOFT LANCING DEV ONETOUCH ULTRA CONTROL ONETOUCH ULTRA ONETOUCH ULTRAMINI. 21 ONETOUCH ULTRASOFT LANCETS ONETOUCH VERIO OPANA ER oxaprozin oxazepam oxcarbazepine OXISTAT oxybutynin chloride oxycodone OXYCONTIN oxymorphone P PANCREAZE pantoprazole paroxetine HCl PATADAY PATANOL PAXIL PEGASYS PEGINTRON penicillin V potassium PENTASA perindopril erbumine permethrin phenazopyridine phenelzine phenobarbital phenytoin PHOSPHOLINE IODIDE pilocarpine HCl pindolol pioglitazone pioglitazone-glimepiride...22 pioglitazone-metformin piroxicam PLAN B ONE-STEP podofilox polyethylene glycol potassium bicarb-citric acid.. 23 potassium chloride PRADAXA pramipexole..23 PRANDIMET PRANDIN pravastatin... 23

38 prazosin PRECISION XTRA TEST PRED FORTE PRED MILD prednisolone prednisolone sodium phosphate prednisone PREFEST PREMARIN PREMPHASE PREMPRO PREZISTA PRILOSEC OTC primidone PROAIR HFA PROAIR RESPICLICK prochlorperazine PROCRIT progesterone micronized PROGLYCEM PROGRAF PROMACTA promethazine-codeine PROMETRIUM propafenone propranolol propylthiouracil PROTOPIC PULMOZYME Q QNASL QUALAQUIN quetiapine quinapril R rabeprazole raloxifene ramipril ranitidine HCl RAPAMUNE RELENZA DISKHALER repaglinide RESCRIPTOR RESTASIS RETIN-A MICRO RETIN-A MICRO PUMP REVLIMID RHEUMATREX ribavirin RIDAURA rifabutin rifampin rimantadine risedronate risperidone rivastigmine patch.25 rivastigmine tartrate rizatriptan ropinirole S salsalate SANCUSO SANDIMMUNE SANDOSTATIN LAR DEPOT selenium sulfide SENSIPAR SEREVENT DISKUS SEROQUEL sertraline sildenafil...25 silver sulfadiazine simvastatin SINGULAIR sirolimus sodium chloride sodium fluoride sodium polystyrene sulfonate SORIATANE sotalol SOVALDI spinosad SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone SPORANOX SPRYCEL stavudine STRATTERA SUBOXONE sucralfate sulfacetamide sodium sulfacetamide sodium (acne) 26 sulfacetamide sodium-sulfur 26 sulfamethoxazole-trimethoprim sulfasalazine sumatriptan sumatriptan succinate SURMONTIL SUSTIVA SUTENT SYMBICORT SYMLINPEN SYMLINPEN SYNTHROID T tacrolimus TAMIFLU tamoxifen tamsulosin TASIGNA TASMAR TAZORAC TEGRETOL TEGRETOL XR telmisartan telmisartan-hydrochlorothiazid temazepam TEMODAR terazosin terbinafine HCl terconazole TESTIM testosterone...28 tetracycline THALOMID thiothixene THYROLAR tiagabine TIKOSYN timolol maleate tinidazole tizanidine TOBI TOBRADEX TOBREX tolazamide tolbutamide tolterodine topiramate tramadol tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP

39 TRAVATAN Z travoprost (benzalkonium) trazodone tretinoin triazolam TRIBENZOR trimethobenzamide TRIZIVIR TRUVADA TUDORZA PRESSAIR TUSSIONEX PENNKINETIC ER TYKERB TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA U ULESFIA ULORIC V valacyclovir VALCYTE valsartan VECTICAL venlafaxine VENTAVIS VENTOLIN HFA VERAMYST verapamil VEREGEN VEXOL VFEND VICTOZA 29 VIGAMOX VIMPAT VIRAMUNE VIRAMUNE XR VIRAZOLE VIREAD VIVELLE-DOT VIVOTIF BERNA VACCINE voriconazole VOTRIENT W warfarin WELCHOL X XALKORI XARELTO XTANDI XULANE Y YAZ (28) Z zafirlukast zaleplon ZEMPLAR ZENATANE ZETIA ZIAGEN zidovudine ZIOPTAN (PF) ziprasidone HCl ZIRGAN ZOLINZA zolpidem zonisamide ZORTRESS ZOVIRAX

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