Formulary Guide - Horizon NJ Health

www.horizonNJhealth.com
Formulary
Guide
July 2011
Horizon NJ Health, a partnership, is a wholly owned subsidiary of Horizon Blue Cross Blue Shield of New Jersey.
Horizon Blue Cross Blue Shield of New Jersey are independent licensees of the Blue Cross and Blue Shield Association.
® Registered marks of the Blue Cross and Blue Shield Association.
®’ and SM Registered and service marks of Horizon Blue Cross Blue Shield of New Jersey.
© 2011 Horizon Blue Cross Blue Shield of New Jersey.
Please refer to this guide when prescribing for Horizon NJ Health members. This guide
does not contain a complete list of drugs, rather it lists the preferred drugs within the most
commonly prescribed therapeutic categories.
The medications included in the formulary are reviewed and approved by the Pharmacy and
Therapeutics Committee, which includes practicing Physicians and Pharmacists from the
Horizon NJ Health Provider community. The goal of the formulary is to provide
cost-effective pharmacotherapy based on prospective, concurrent and retrospective review of
medication therapies and utilization.
In order to obtain prior authorization, please contact the Horizon NJ Health Pharmacy
Department at 1-800-682-9094 and be prepared to provide relevant clinical information that
supports the medical necessity of the requested medication.
Note that many over-the-counter products are covered with a prescription and should be
considered first-line therapy when appropriate. This formulary is also available via the Internet
at www.horizonNJhealth.com or by contacting Provider Services at 1-800-682-9091.
KEY:
$ Lowest relative cost
!!!!!! Highest relative cost
+ Brand not covered, use available generic
↓ Dosage reduction below manufacturer
guidelines may be required in patients over 65
∆ Use by patients over 65 is associated with
increased risk; safer alternatives may be available. If used,
dosage should generally be lowered
@ Requires prior authorization for medical
necessity
* Limitations apply
◊ Subject to Step Therapy of first-line agents
Formulary Guide – July 2011
1
ADRENOCORTICAL STEROIDS
GlUcocorticoids
$$
$$
$$
$$
+ prednisolone, oral soln
+ hydrocortisone
+ methylprednisolone
+ dexamethasone
ANDROGENS
TESTOSTERONE REPLACEMENT THERAPY
$$$$ @ Testoderm, Androderm
$$$$ @ Androgel, Testim
$$$$ @ Striant
ANTIINFECTIVES
PENICILLINS
$
$
$
$
$$
$$
$$$
+penicillin
+ampicillin
+amoxicillin
+dicloxacillin
+amoxicillin clauvulante
Bicillin LA
Augmentin XR
$
$$
$$$
$$$
+ doxycycline hyclate
+ tetracycline HCI
+ minocycline HCL caps
+ doxycycline monohydrate
$
$$
$$
$$
$$
$$
$$
!!!!!
+ cephalexin
+ cefaclor, cefadroxil
+ cefdinir
+ cefpodoxime
+ cefprozil
+ cefuroxime
Spectracef
@ + ceftriaxone
TETRACYCLINES
CEPHALOSPORINS
2
Formulary Guide – July 2011
$
$
$
$
$
$$
$$
ERYTHROMYCINS AND OTHER MACROLIDES
+ erythromycin base, delayed release tabs & caps
+ erythromycin ethylsuccinate
+ erythromycin stearate
+ erythromycin w/sulfisoxazole
+ clarithromycin, SR
+ azithromycin
PCE $$
$$$
$$$
$$$
QUINOLONES
+ ciprofloxacin (1 year and older)
Cipro XR (18 years and older)
Avelox (12 years and older)
Levaquin (12 years and older)
$
$
$
$
SULFAS AND RELATED AGENTS
+ sulfisoxazole
+ sulfadiazine
+ sulfamethoxazole and trimethoprim
+ sulfisoxazole and erythromycin
URINARY TRACT AGENTS
$
+ trimethoprim
$$ + nitrofurantoin macrocrystals
$$$ + methenamine mandelate, hippurate
ANTIFUNGAL AGENTS
$
+ griseofulvin ultramicrosize
$
+ nystatin
$$ + fluconazole
$$$ *+ terbinafine tablets
$$$ *+ itraconazole
$$$$ * Sporanox oral
$$$$ Vfend
$$$$ Noxafil
!!!!! @ Ambisome
ANTIMALARIAL AGENTS
$
$
$
$
$$
$$$
+ chloroquine
+ mefloquine
+ primaquine
+ quinine
Malarone
Coartem
Formulary Guide – July 2011
3
ANTIRETROVIRAL AGENTS
Some members may have their HIV/AIDS medications covered through
the AIDS Drugs Distribution Program (ADDP).
!!!!!!
!!!!!! !!!!!! !!!!!! !!!!!! $$$$ !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! $$$$ !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! $$$$ Agenerase
Aptivus
Atripla
Combivir
Crixivan
+ didanosine
Emtriva
Epivir
Epzicom
Fuzeon
Hivid
Intelence
Invirase
Isentress
Kaletra
Lexiva
Norvir
Prezista
Rescriptor
Reyataz
Selzentry
+ stavudine
Sustiva
Trizivir
Truvada
Viracept
Viramune
Viread
Ziagen
+ zidovudine
MISCELLANEOUS ANTIVIRALS
$
↓ + amantadine
$$ @ + ribavirin
$$$ + acyclovir
$$$ @ Relenza (7 years and older)
$$$ @ Tamiflu
$$$ + valacyclovir
$$$$ Famvir
!!!!! Valcyte, Cytovene
CARDIOVASCULAR
4
Formulary Guide – July 2011
CARDIOVASCULAR
BETA BLOCKERS
+ bisoprolol
+ atenolol, metoprolol
+ timolol, pindolol
+ carvedilol
+ nadolol
+ propranolol, LA
+ labetalol
+ acebutolol
+ betaxolol
+ metoprolol ER
CALCIUM CHANNEL BLOCKERS
$
+ amlodipine
$
+ diltiazem, SR
$
+ verapamil, long acting
$
+ nifedipine
$
+ nicardipine
$$ + nifedipine XL
ACE INHIBITORS
$
+ fosinopril, HCTZ
$
+ captopril, HCTZ
$$ + enalapril, HCTZ
$$ + lisinopril, HCTZ
$$ + perindopril
$$ + quinapril, HCTZ
$$ + ramipril
$$ + trandolapril
ANGIOTENSIN RECEPTOR BLOCKERS
$$ + losartan, HCTZ
$$$ Avapro, Avalide
$$$ Diovan, HCT
OTHER ANTIHYPERTENSIVE COMBINATIONS
$$$ + amlodipine/benazepril
$$$ + trandolapril/verapamil
$$$$ Bidil
ANTIARRHYTHMICS
$
+ amiodarone
$
+ disopyramide
$
+ mexiletine
$
+ procainamide
$
+ quinidine
$$$ Multaq
$
$
$
$$
$$
$$
$$$
$$$
$$$
$$$
Formulary Guide – July 2011
5
$
$
$
$
$
$$
$$
$$
$$$
$$$
$$$
$$$
$$$
LIPID/CHOLESTEROL LOWERING AGENTS
+ gemfibrozil
+ niacin
+ cholestyramine
+ colestipol
+ fenofibrate
+ lovastatin
+ pravastatin, simvastatin
Niaspan
Advicor
Lipitor 40 mg and 80 mg
Lovaza
Welchol
◊ Zetia
ANTIPlatelet agents
$
+ aspirin
$
+ dipyridamole
$$$ + ticlopidine
$$$$ Aggrenox
!!!!!! Agrylin
ANTICOAGULANT AGENTS
$$ + warfarin
$$$ Coumadin
$$$$ Pradaxa
!!!!!! Arixtra, Lovenox, Fragmin, Innohep
!!!!!! * Iprivask
DIURETICS
$
$
$
$
$
$
$
$
+ hydrochlorothiazide
+ indapamide
+ furosemide
+ bumetanide
+ torsemide
+ spirinolactone, HCTZ
+ triamterene, HCTZ
+ metolazone
!!!!!!
!!!!!!
!!!!!!
!!!!!!
!!!!!!
!!!!!!
!!!!!!
!!!!!!
PULMONARY ARTERIAL HYPERTENSION AGENTS
Adcirca
@ Flolan
@ Letairis
@ Remodulin
@ Revatio
@ Tracleer
@ Tyvaso
@ Ventavis
6
Formulary Guide – July 2011
CENTRAL NERVOUS SYSTEM
HYPNOTIC AGENTS
$
$
$
$
$$
$$
$$
↓ + chloral hydrate
∆ + flurazepam
↓ + triazolam
∆ ↓ + temazepam
↓ + estazolam
↓ + zaleplon
↓ + zolpidem
$
$
$
$
$
$$
$$
$$$
$$$
TRICYCLIC ANTIDEPRESSANTS
∆ + amitriptyline
↓ +desipramine
↓ + doxepin
↓ + imipramine HCL
↓ + nortriptyline
↓ + amoxapine
↓ + protriptyline
↓ + clomipramine
↓ + trimipramine
MISCELLANEOUS ANTIDEPRESSANTS
$
↓ + trazodone
$
↓ + maprotiline
$$ ↓ + bupropion, SR, XL 300 mg
$$$ ↓ + venlafaxine
$$$$ ↓ Wellbutrin XL 150 mg
$$$$ ↓ Remeron
$$$$ ↓ Effexor XR
$$$$ Cymbalta
MAO INHIBITORS
$$ ↓ Nardil
$$$ ↓ + tranylcypromine
$$$ ↓ Emsam
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
$$$ + citalopram
$$$ ↓ + fluvoxamine
$$$ ↓ + fluoxetine
$$$ ↓+ paroxetine, CR
$$$ ↓+ sertraline
$$$$ Lexapro
Formulary Guide – July 2011
7
ANTIPSYCHOTICS
$
↓ + fluphenazine, trifluoperazine
$
↓ + perphenazine
$
↓ + haloperidol, thiothixene
$$ ↓ + chlorpromazine
$$ ↓ Orap
$$ ↓ + risperidone
$$$ ↓ Serentil
$$$ ↓ + loxapine
$$$$ ↓ Moban
$$$$ ↓ Seroquel, Seroquel XR
$$$$ ↓ Zyprexa, Zydis
$$$$ ↓ Geodon
$$$$ ↓ Abilify, Discmelt
$$$$ ↓ + clozapine
$$$$ Symbyax
$$$$ ↓ Invega
$$$$ Fanapt
$$$$ Latuda
$$$$ Saphris
$$$$ Fazaclo
$$$$ Zyprexa Relprevv
$$$$ ↓ Risperdal Consta
$$$$ ↓ Invega Sustenna
MISCELLANEOUS CNS AGENTS
$
+ lithium citrate, carbonate
$$ + methylphenidate, SR, ER
$$ + dexmethylphenidate
$$ + dextroamphetamine sulfate
$$ + amphetamine-dextroamphetamine, ER
$$$ Strattera
$$$ Adderall XR, Ritalin LA
$$$ Concerta, Metadate CD
$$$$ @ Provigil
$$$$ Savella
Triptans
$$ + * sumatriptan
$$ + * naratriptan
$$$ ◊ * Maxalt, Maxalt MLT
8
Formulary Guide – July 2011
$
$
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$$
!!!!!
!!!!!
Antiseizure Agents
+ phenytoin
+ phenobarbital, primidone
+ carbamazepine, ER
Carbatrol
+ valproic acid
+ gabapentin
+ lamotrigine
+ oxcarbazepine
+ zonisamide
+ divalproex
+ levetiracetam
+ topiramate
Zarontin
Felbatol
Gabitril
ANTIPARKINSONISM AGENTS
$
+ amantadine
$
+ benztropine
$
+ carbidopa-levodopa
$$ + pergolide
$$ + pramipexole
$$ + ropinirole
$$ + selegiline
$$$ + carbidopa-levododa CR
$$$ Carbilev
$$$$ Stalevo
anti-alzheimer’s agents
$
+ galantamine
$$$ Namenda
$$$$ Aricept
$$$$ Exelon, patch
$$
$$
$$
$$
$$
$$
$$$
$$$
$$$
Analgesics
+ hydromorphone
+ hydrocodone
+ hydrocodone/APAP
+ morphine sulfate immediate release
+ oxycodone, with APAP
+ oxymorphone IR
+ morphine sulfate ER
Oxyfast
@ Kadian
Formulary Guide – July 2011
9
Analgesics (Continued)
$$$ + tramadol
$$$ @ + fentanyl patches
$$$ @ + oral transmucosal fentanyl citrate
$$$$ @ + oxycodone, controlled-release
$$$$ @ Oxycontin
NSAIDs
$
$
$
$$
$$
$$
$$
$$
$$$
$$$
$$$
+ ibuprofen
∆ + indomethacin, SR
↓ + naproxen sodium
+ diclofenac sodium
Children’s Advil, Motrin
+ tolmetin
+ oxaprozin, etodolac
+ diclofenac potassium
↓ + ketoprofen, SR
+ nabumetone
+ meloxicam
NSAID COX II INHIBITORS
$$$$ @Celebrex
ANTIVERTIGO AND ANTI-EMETICS
$
+ meclizine
$
+ promethazine
$
+ trimethobenzamide
$$ + prochlorperazine
$$ @ + ondansetron
$$$$ @ Emend
MULTIPLE SCLEROSIS AGENTS
$$$$ * Ampyra
!!!!! @ Avonex
!!!!! @ Betaseron
!!!!! @ Copaxone
!!!!! @ Rebif !!!!! @ Tysabri
!!!!!! @ Gilenya
10
Formulary Guide – July 2011
COUGH /COLD
Some cough/cold products are considered non covered pharmacy benefits
for members 21 years of age and older.
$
$
$
$
$
$
$
$$
Advil Cold and Sinus
Delsym
+ dextromethorphan
Dimetapp
+ guaifenesin
Robitussin
+ promethazine/codeine
Mucinex, D, DM
DERMATOLOGICALS/TOPICAL THERAPY
Some topical agents are considered non covered pharmacy benefits
for members 21 years of age and older.
TOPICAL CORTICOSTEROIDS
(VERY HIGH POTENCY)
$$ + clobetasol 0.05% cream, ointment
$$ + diflorasone diacetate 0.05% ointment
$$ Temovate scalp appl.
$$$ + betamethasone dipropionate 0.05%
(augmented) ointment
TOPICAL CORTICOSTEROIDS
(HIGH POTENCY)
$
+ betamethasone valerate 0.1% ointment
$
+ fluocinonide 0.05% cream
$
+ triamcinolone acetonide 0.1% ointment
$$ + betamethasone dipropionate 0.05% ointment, cream
$$ + desoximetasone 0.25% cream, ointment
$$ + desoximetasone 0.05% gel, cream
$$ + fluocinonide 0.05% gel, ointment, soln
$$$ + diflorasone diacetate 0.05% cream
$
$
$
$
$
$
TOPICAL CORTICOSTEROIDS
(MEDIUM POTENCY)
+ betamethasone dipropionate 0.05% lotion
+ betamethasone valerate 0.1% cream, lotion
+ desonide
+ fluocinolone acetonide 0.025% cream, ointment
+ fluocinolone acetonide 0.01% soln
+ prednicarbate
Formulary Guide – July 2011
11
$
$
$
$
$
$$
$$
TOPICAL CORTICOSTEROIDS
(MEDIUM POTENCY) (Continued)
+ triamcinolone acetonide 0.1% cream, lotion, ointment
+ triamcinolone acetonide 0.5% cream, ointment
+ triamcinolone acetonide 0.025% cream, ointment, lotion
+ mometasone
+ hydrocortisone butyrate solution
+ hydrocortisone valerate 0.2% cream, ointment
Locoid solution
$
$
$
$$
$$
TOPICAL CORTICOSTEROIDS
(LOW POTENCY)
+ hydrocortisone 1%, 0.5% cream, ointment
+ hydrocortisone 1% lotion
+ hydrocortisone acetate 0.5%, 1% cream, ointment
+ alclometasone cream, ointment
+ fluocinolone acetonide cream, solution
TOPICAL ANTIFUNGALS
$
* + ciclopirox 8% solution
$
+ clotrimazole (OTC)
$
+ ketoconazole cream
$
+ miconazole nitrate (OTC)
$
Fungoid
$
+ ketoconazole 2% shampoo
$
Nizoral A-D shampoo (OTC)
$
+ tolnaftate (OTC)
$
+ undecylenic acid
$$ + nystatin cream, ointment
$$ + econazole
$$ + nystatin/triamcinolone
$$$ Pedi-Dri
$$$$ + clotrimazole/betamethasone, cream, lotion
ACNE THERAPY
Vitamin A derivatives are considered non covered pharmacy benefits for
members 35 years of age and older.
$$
$$
$$
$$$
$$$
$$$
$$$
$$$
12
+ benzoyl peroxide cream/lotion, benzoyl peroxide cleansing lotion
+ sulfacetamide sodium w/sulfur cleanser/lotion
+ metronidazole 0.75% cream, lotion, gel
@ + tretinoin (Prior Auth if > 40 yrs old)
+ metronidazole cream
* BenzaClin
@ + adapalene 0.1% gel & cream (Prior Auth if > 40 yrs old)
@ Retin-A liquid (Prior Auth if > 40 yrs old)
Formulary Guide – July 2011
ACNE THERAPY (Continued)
$$$ @ Retin-A Micro (Prior Auth if > 40 yrs old)
$$$ @ Tazorac gel, cream
$$$ @ Azelex (Prior Auth if > 40 yrs old)
$$$$ @ Differin 0.1% Lotion (Prior Auth if > 40 yrs old)
$
$
$$
$$
$$
$$$
$$$
$$$
$$$
$$$
$$$
OTHER TOPICAL PRODUCTS
OTC Abreva
+ OTC permetherin
Denavir
+ mupirocin ointment
Keralac Nailstick
@ Aldara
Clindesse
@ Elidel
@ Ovide
* Voltaren gel
@ Zovirax Ointment
Psoriasis Therapy
$$$ Dovonex
!!!!!! @ Raptiva
!!!!!! @ Amevive
ENDOCRINE
INSULIN THERAPY
$$$ Humulin
$$$ Iletin II
$$$$ Humulin Pen
$$$$ Humalog, Mix 75/25, Pen
$$$$ Lantus
$$$$ Levemir
$
$
$
$$
$$
$$
$$
$$
$$
ORAL HYPOGLYCEMIC AGENTS
+ glimepiride
+ glipizide, XL
+ glyburide
+ metformin, XR
+ metformin/glipizide
Precose, Glyset
Riomet
+ glyburide/metformin
Welchol
Formulary Guide – July 2011
13
$$$
$$$$
$$$$
$$$$
$$$$$
$$$$$
$$$$$
$$$$$
ORAL HYPOGLYCEMIC AGENTS (Continued)
+ nateglinide
Prandin
Actos, ActoplusMet, Avandia, Avandamet, Avandaryl
Duetact
Janumet
Januvia
Onglyza
Kombiglyze
MISCELLANEOUS HYPOGLYCEMIC AGENTS
$$$$$ Byetta
$$$$$ @ Symlin
$$
$$
$$
$$
$$
DIABETIC SUPPLIES (MONITORS AND STRIPS)
Insulin syringes (B.D., Monoject)
Accu-Chek (all products)
Chemstrip BG
One Touch (all products)
Lancets, pen needle, single use swab
$
$
$
+ levoxyl
+ propylthiouracil
+ methimazole
THYROID THERAPY
GASTROINTESTINAL
$$
$$
$$
$$
H2-RECEPTOR ANTAGONISTS
Axid AR (OTC)
+ nizatidine
+ ranitidine (OTC), famotidine (OTC)
+ ranitidine syrup
$
$$
$$
$$
$$ PROTON PUMP INHIBITORS
+ omeprazole (OTC), Prilosec (OTC) (First-line agent for heartburn)
+ pantoprazole
@ + lansoprazole capsules
+ omeprazole
@ Prevacid 24HR
PANCREATIC ENZYMES
$$$$$ Ultrase, Ultrase MT
!!!!!
Creon
14
Formulary Guide – July 2011
OTHER G.I. DRUGS
$
$
$
$$
$$
$$
$$$
$$$
$$$
!!!!!
+ dicyclomine
+ metoclopramide
+ polyethylene glycol
Halflytely
+ misoprostol
+ sucralfate
@ Amitiza
@ Lotronex
Asacol
@ Cerezyme
IMMUNOLOGY, VACCINES AND BIOTECHNOLOGY
GROWTH HORMONES
!!!!!
!!!!!
@ Humatrope
@ Omnitrope
$$
$$ $$ $$ $$ $$ $$ $$ $$ $$ @ Adacel
@ Boostrix
@ Engerix-B
@ Gardasil
@ Havrix
@ Menactra
@ Recombivax HB
@ Twinrix
@ Vaqta
@ Zostavax (60 years and older)
!!!!!
@ Increlex, Iplex
!!!!!
Growth hormone-receptor antagonist
@ Somavert
!!!!!
@ Procrit
VACCINES
INSULIN-LIKE GROWTH FACTOR
ERYTHROID STIMULANTS
COLONY STIMULATING FACTORS
!!!!!! @ Neupogen
!!!!!! @ Neulasta
Formulary Guide – July 2011
15
INTERFERON ALFA
!!!!!
!!!!!
!!!!!
@ Roferon A
@ Intron A
@ PEG-Intron, Pegasys
!!!!!
@ Euflexxa
!!!!!
!!!!!
!!!!!
Exjade
@ Arcalyst
@ Synagis
!!!!!
!!!!!
!!!!!
@ Berinert
@ Cinryze
@ Kalbitor
SODIUM HYALURONATE
MISCELLANEOUS
Hereditary Angioedema therapy
MISCELLANEOUS
IMMUNOSUPPRESSIVE AGENTS
$
$
$
$
$$
!!!!!!
+ azathioprine
+ mycophenolate
+ cyclosporine
+ tacrolimus
Rapamune
Zortress
APPETITE STIMULANTS
$
+ megestrol acetate
$$$ Megace ES
HYPERPARATHYROID TREATMENT
$$$ Zemplar
MOUTH AND THROAT PRODUCTS
$$
Mycelex Troche
$$
Phoslo
ELECTROLYTE SUPPLEMENTATION
POLYMERIC PHOSPHATE BINDERS
$$$$$ Renagel
$$$$$ Fosrenol
$$$$$ Renvela
16
Formulary Guide – July 2011
SMOKING DETERRENTS
$
* + nicotine transdermal (18 years and older)
$$$$ + Zyban (18 years and older)
$$$$ @ Chantix (18 years and older)
$$$$ Evoxac
OPIOID / ALCOHOL ADDICTION TREATMENT
$$ @ naltrexone
$$$ @ disulfiram
$$$ @ Campral
$$$$ @ buprenorphine
$$$$ @ Suboxone
$$$$ @ Vivitrol
MUSCULOSKELETAL AND RHEUMATOLOGY
$
$
$
$
$$
$$
$$
!!!!!
MUSCLE RELAXANTS
+ baclofen
∆+ chlorzoxazone, carisoprodol
∆+ cyclobenzaprine
∆+ diazepam
+ orphenadrine
∆+ methocarbamol
+ tizanidine
@ Botox, Myobloc
MISCELLANEOUS ANTIRHEUMATIC AGENTS
$
+ sulfasalazine
$$ + methotrexate
$$$ + hydroxychloroquine
$$$$ + azathioprine
!!!!! @ Enbrel, Humira
OSTEOPOROSIS THERAPY
$$$ + calcitonin
$$$ + alendronate
$$$$ Miacalcin Nasal
$$$$ Evista
$$$$ Fosamax plus D
$$$$ Actonel 5mg, 30mg, 35mg, Actonel with calcium
Formulary Guide – July 2011
17
OBSTETRICS AND GYNECOLOGY
PROGESTINS
$
+ medroxyprogesterone
$$ Micronor, Nor QD
$$ Aygestin
$$ Crinone
$$$ Progesterone Inj, suppos
$$$$ Depo-Provera 150
ESTROGENS
$
+ estropipate
$
+ micronized estradiol
$
+ estradiol, estradiol valerate injection
$$ Premarin
$$$ Cenestin
$$$ Prometrium
$$$ Ortho Dienestrol
$$$ Climara Pro
$$$ Alora
$$$ Menest
$$$ Estrogel
$$$ Menostar
$$$$ Estring, Femring
$
$
$
$$
$$$
ESTROGEN COMBINATIONS
+ estradiol/norethindrone
Prempro
Premphase
+ norethinedrone acetate/ethinyl estradiol
Estratest, HS
$$
$$
$$
$$
$$
$$
$$
MONOPHASIC ORAL CONTRACEPTIVES
+ ethynodiol/ethinyl estradiol
+ levonorgestrel/ethinyl estradiol
+ norethindrone/ethinyl estradiol +/-Fe
+ desogestrel/ethinyl estradiol
+ norethindrone/mestranol
+ norgestrel/ethinyl estradiol
+ norgestimate/ethinyl estradiol
BIPHASIC ORAL CONTRACEPTIVES
$$ +norethindrone/ethinyl estradiol
$$ + desogestrel/ethinyl estradiol
$$$$ Ortho Evra
18
Formulary Guide – July 2011
$
$$
$$
$$
TRIPHASIC ORAL CONTRACEPTIVES
+ norethindrone/ethinyl estradiol/ferrous fumarate
+ levonorgestrel/ethinyl estradiol
+ norethindrone/ethinyl estradiol
+ norgestimate/ethinyl estradiol
$
$
$$
$$
$$
$$
$$
OTC Monistat
+ OTC Clotrimazole
@ + terconazole
@ Gynazole
Clindesse
Metrogel vaginal
Vagifem
VAGINAL AGENTS
OTHER
$$ levonorgestrel (Next Choice)
$$$$ Lunelle
$$$$ NuvaRing
OPHTHALMOLOGY
ANTI-INFECTIVES
$
+ tobramycin
$$ Ciloxan, Quixin, Vigamox
$$$ Tobrex ophthalmic ointment
$$$$ Tobradex
$$$$ Zirgan
$
$
$
$$$
$$$
$$$
ALLERGIC CONJUNCTIVITIS
Visine-A, Naphcon-A
+ cromolyn
Alaway/Zaditor OTC
Alocril
Lotemax
◊ @ Patanol
NSAIDS
$$ + ketorolac
$$$$ Acular LS
$$$$ Voltaren
Formulary Guide – July 2011
19
$
$$
$$
$$
$$$
$$$
$$$
$$$$
$$$$
$$$$
$$$$
$$$$
ANTIGLAUCOMA AGENTS
+ timolol
+ dorzolamide hydrochloride/timolol maleate
+ levobunolol
+ timolol XE
+ apraclonidine
Azopt
Combigan
Alphagan, P
Betoptic S
Lumigan
Travatan, Z
Xalatan
OTIC
$$$
$$$
$$$
$$$
ANTI-INFECTIVEs
+ neomycin/polymixin/bacitracin
Cipro HC
+ ofloxacin otic
Ciprodex
$
$$
+ antipyrine/benzocaine
+ acetic acid/aluminum
MISCELLANEOUS
RESPIRATORY
ANTIHISTAMINES
$
+ cetirizine, cetirizine/pseudoephedrine (OTC)
$
∆ + chlorpheniramine (OTC)
$
∆ + cyproheptadine
$
∆ + diphenhydramine (OTC)
$
∆ + hydroxyzine
$
+ meclizine
$
∆ + promethazine (2 years and older)
$
∆ + tripelennamine
$$ ∆ + clemastine
$$ ∆ + dexchlorpheniramine
$$ + loratadine, loratadine/pseudoephedrine (OTC)
$$ Alavert
$$ + fexofenadine (180 mg)
$$$ + azelastine nasal spray
$$$ Patanase
20
Formulary Guide – July 2011
$
$$
$$
$$$
$$$
$$$
INHALED BETA AGONISTS
+ albuterol aerosol
+ isoetharine soln
+ albuterol soln for inhalation
Ventolin HFA
Ventolin Rotacaps
Serevent, Diskus
INHALED CORTICOSTEROIDS
$$$ Qvar
$$$ budesonide nebulizer solution (under 9 years of age)
$$$$ Pulmicort respules (under 9 years of age)
$$$$ Flovent HFA
$$$$ Asmanex
INTRANASAL STEROIDS
$
+ fluticasone
$
$$
$$
$$$
$$$
$$$
$$$
$$$
$$$
$$$
$$$$
$$$$
$$$$
$$$$
$$$$$ !!!!! !!!!! !!!!!
$
$
MISCELLANEOUS PULMONARY AGENTS
+ benzonatate (11 years and older)
+ theophylline
+ cromolyn neb. soln
Atrovent MDI, soln
Combivent
Duoneb
Accuneb
@ Singulair (for 4mg strength, no Prior Auth if ≤5 years old)
Tilade, nebul. soln
+ acetylcysteine
Intal
Advair HFA/Diskus
Dulera
Spiriva
Pulmozyme
@ Tobi
@ Cayston
@ Xolair
RESPIRATORY DEVICES
OptiChamber Advantage
Respironics OptionHome Compressor Nebulizer System
Formulary Guide – July 2011
21
UROLOGICS
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
$$ + doxazosin
$$ + finasteride
$$ + tamsulosin
$$ + terazosin
$$$ Avodart
$$$ Jalyn
ANTICHOLINERGICS
$
$
$$
$$
$$$
+ oxybutynin, XL
+ trospium
Detrol, LA
* Oxytrol Patch
Enablex
$
!!!!!
INTERSTITIAL CYSTITIS AGENTS
+ phenazopyridine
Elmiron
MISCELLANEOUS
$$$$ @ Lupron, Zoladex, Eligard
VITAMINS
MULTIPLE VITAMINS
$
$
$
$
$
$
$
$
$
$
$
$
22
Freedavite
+ daily-vite
Citracal
Centrum
+ multivital
Renax
+ corvita
Strovite
Strovite Advance
Strovite Advance +D
Strovite One
Strovite Plus
Formulary Guide – July 2011
$
$
$
$
$
$$
$$
$$$
MULTIPLE VITAMINS WITH IRON
Vitafol
+ ferrex 150
Hematogen FA
+ hematogen Forte
+ dualvit F
Strovite Forte
Ircon
+ corvita 150
$
$$
$$
$$
$$
PEDIATRIC MULTIPLE VITAMINS
+ pediavit
+ children’s multivitamin chew
+ tri-vitamin
Centrum Kids
Poly-Vi-Sol
PRENATAL VITAMINS
$
$
$
$
$
$
$
$$
$
Vitafol-OB
Vitafol-PN
Select-OB
Prenatal 19
Vol-plus
Vol-tab Rx
+ Trinate
OB Complete Tablet
PRENATAL VITAMINS WITH DHA
OTC One-a-Day Women’s Prenatal with DHA
Formulary Guide – July 2011
23
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24
Formulary Guide – June 2011
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Formulary Guide – June 2011
25
Horizon NJ Health Pharmacy Department
210 Silvia Street
West Trenton, NJ 08628
Phone: 1-800-682-9094
Fax: 1-609-538-0847
www.horizonNJhealth.com