PRX prescriber formulary

Transcription

July 2012
PARTNERS RX STANDARD FORMULARY 2012
We are pleased to provide you with our Formulary Drug List. This list is not intended to imply coverage, so please
refer to your plan document for detailed information about your drug benefit coverage.
Medications are listed as Tier 1 Generic, Tier 2 Brand, and Tier 3 Brand. Medications listed as “Specialty Drugs” are
used to treat complex medical conditions that require special handling, administration, and member care
management. Depending on your pharmacy benefit design, specialty drugs may be part of a specialty benefit with
specific coverage and copay requirements that differ from drugs in Tiers 1 – 3. If you do not have a defined specialty
benefit, your copay may be based on whether the drug is Generic or Brand, therefore Tier 1 or Tier 3 copays may
apply.
Our Pharmacy and Therapeutics Committee dedicates many hours to the clinical analysis and evaluation of peer
reviewed literature and medical care guidelines to determine a drug’s safety and efficacy. After this rigorous clinical
evaluation, the committee weighs the financial implications of a drug compared to other similar drugs and selects
medications for Tier 1 and Tier 2 placement based on the drugs’ safety, efficacy and cost-effectiveness. Please note
all drugs on the Formulary Drug List are subjected to periodic review and amendment without notice.
For the most up-to-date Formulary Drug list visit our website at www.partnersrx.com. Under “Quick Links: Formulary”
select “Look up your prescription drug’s formulary status here” then enter your “Rx Grp #”, and finally type in
your drug name in the Search bar. Or, you can call our toll-free Partners Rx Customer Service Help desk at: 1-800659-4112.
Please keep in mind when a generic medication is chosen, patients pay the lowest copay available under their
pharmacy benefit plan. When clinically appropriate, please consider choosing a generic product.
Thank you for your support of the Drug Formulary.
TABLE OF CONTENTS
PAGE
1.0 Analgesics………………………………………………………………………………………………… ………………………2
2.0 Anesthetics………………………………………………………………………………………………………………………. 4
3.0 Antibiotics………………………………………………………………………………………………………………………….4
4.0 Anti-Neoplastics/Immunosuppressants………………………………………………………………………………………...9
5.0 Cardiovascular Agents…………………………………………………………………………………………………………...10
6.0 Central Nervous System Agents………………………………………………………………………………………………. 14
7.0 Dermatologicals………………………………………………………………………………………………………………….. 18
8.0 Eyes, Ears, Nose, Mouth and Throat………………………………………………………………………………………….. 20
9.0 Endocrine Agents………………………………………………………………………………………………………………… 23
10.0 Gastrointestinal Agents…………………………………………………………………………………………………………25
11.0 Blood Modifiers, Nutritionals and Electrolytes………………………………………………………………………………. 27
12.0 Obstetrics/Gynecology………………………………………………………………………………………………………… 28
13.0 Respiratory Agents……………………………………………………………………………………………………………...30
14.0 Skeletal Muscle Relaxants……………………………………………………………………………………………………. 32
15.0 Urologicals……………………………………………………………………………………………………………………….32
16.0 Immunologicals, Vaccines and Biotechnology Drugs……………………………………………………………………… 32
17.0 Therapeutic Devices and Supplies……………………………………………………………………………………………34
KEY
Generic medications – lower case (example)
Brand medications – Leading Capital Letter (Example)
BRAND medications with generic equivalent products available- ALL CAPS (EXAMPLE)
PA – Prior Authorization needed under some benefits. Check your plan document for coverage details.
QL – Quantity Limits Apply under some benefits. Check your plan document for coverage details.
ST – Step Therapy Requirements under some benefits. Check your plan document for coverage details.
NTI – Narrow Therapeutic Index drugs
© 2012 Partners Rx. All rights expressly reserved.
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
(See your plan documents)
1.0 ANALGESICS
AGENTS FOR MIGRAINE
apap/caffeine/butalb
Zomig, Zomig ZMT, spray, QL
AMERGE, QL
apap/caffeine/butalbital/codeine
Axert, QL
asa/caffeine/butalbital
butalbital compound w/codeine
butorphanol NS, QL
divalproex ER
ergotamine/caffeine
isometh/dichlor/apap
CAFERGOT SUPPOSITORY
DARVON COMPOUND
DEPAKOTE ER
DHE 45
Ergomar
ESGIC, ESGIC PLUS
FIORICET,
FIORICET/CODEINE, QL
FIORINAL,
FIORINAL/CODEINE, QL
Frova, QL
IMITREX TABS, SPR, INJ, QL
Maxalt, Maxalt MLT, QL
MIDRIN
Migranal, QL
Relpax, QL
STADOL NS, QL
Sumavel Dosepro, QL, ST
Treximet, QL, ST
naratriptan, QL
orbivan (butalbital/APAP/cod),
QL
sumatriptan tabs, spray,inj, QL
DMARDS
azathioprine
cyclophosphamide
hydroxychloroquine
leflunomide
methotrexate
prednisone
sulfasalazine, EC
Cuprimine
Ridaura
allopurinol
colchicine/probenecid
probenecid
sulfinpyrazone
Colcrys QL
Uloric, QL, ST
Arava, PA
AZULFIDINE, ENTABS
CYTOXAN
Depen
DELTASONE
IMURAN
PLAQUENIL
Myochrysine
RHEUMATREX
Solganal
Trexall
Actemra, PA
Cimzia, QL, PA
cyclosporine
Enbrel, PA
Humira, PA
Kineret, PA, QL
NEORAL, PA
Orencia, PA, QL
SANDIMMUNE, PA
Simponi, PA, QL
Zortress, PA
GOUT MEDICATIONS
ZYLOPRIM
Krystexxa, PA
CHELATING AGENTS
Depen
Syprine
MISCELLANEOUS ANALGESICS
tramadol, QL
tramadol ER, QL
tramadol SR biphasic, QL,ST
tramadol/APAP, QL
Gralise, QL, ST
Ofirmev, QL
RYZOLT, ST, QL
ULTRAM , ER QL
Qutenza
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Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
NARCOTIC ANALGESICS
buprenorphine, PA, QL
codeine
fentanyl patch, QL
hydromorphone, QL
levorphanol
meperidine, QL
methadone
morphine supp
morphine sulfate, QL
morphine SR, QL
oxycodone; ER, QL, ST
oxycodone/ibuprofen QL
oxymorphone
pentazocine NX
Abstral, PA, QL
Actiq, PA, QL
Avinza, QL
BUPRENEX, PA, QL
Butrans PA, QL
Cesamet, PA
COMBUNOX, QL
Conzip, PA, QL
DEMEROL, QL
DARVON, Darvon N
DILAUDID, QL
DOLOPHINE
DURAGESIC, QL
Exalgo, QL, ST
Embeda, QL
KADIAN, QL
Lazanda Spray PA, QL
LEVO-DROMORAN
MS CONTIN, QL
MSIR
Nucynta, ST, QL
Nucynta ER, PA, QL
Onsolis, PA,QL
OPANA, QL
Opana ER, QL
ORAMORPH SR, QL
ORLAAM
Oxecta, QL
OXYCONTIN, ST,QL
OXYFAST
RMS SUPP
ROXANOL, ROXANOL-T QL
ROXICODONE
Suboxone film, PA, QL
Suboxone, PA, QL
SUBUTEX, PA, QL
TALWIN NX
NARCOTIC ANALGESIC COMBINATIONS
asa/codeine
butalbital/asa/caffeine/codeine
butalbital/apap/caffeine/codeine,
QL
codeine/apap QL
hydrocodone/apap, QL
meperidine w/promethazine
oxycodone/apap, QL
oxycodone/aspirin
pentazocine/apap
propoxyphene/apap, QL
propoxyphene cmpd/cod
ANEXSIA, QL
CAPITAL WITH CODEINE, QL
Cocet Plus, QL
DARVOCET A500, QL
DARVOCET-N, QL
DARVON COMPOUND
FIORINAL/CODEINE
FIORICET/CODEINE, QL
HYCET
Liquicet, QL
LORCET, LORCET PLUS, QL
LORTAB & NORCO, QL
PERCOCET 5, 7.5, 10 MG, QL
Percocet 2.5 MG, QL
PERCODAN
ROXICET 5/500 TAB, SOL, QL
3
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Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
Synalgos DC
TALACEN
TYLENOL W/COD, QL
TYLOX, QL
VICODIN, QL
VICODIN E.S, QL
VICOPROFEN, QL
Zydone, QL
NONSTEROIDAL ANTI-INFLAMMATORIES
diclofenac potassium, QL
diclofenac, ER
etodolac, ER
fenoprofen
flurbiprofen
ibuprofen
indomethacin IR & CR QL
ketoprofen, SA
ketorolac, QL
meclofenamate
meloxicam
nabumetone
naproxen, E.C.
naproxen sodium, DS, QL
oxaprozin
piroxicam
sulindac
tolmetin
ANAPROX, DS, QL
Arthrotec, QL
CATAFLAM, QL
Celebrex, ST, QL
CLINORIL
DAYPRO
E.C. – NAPROSYN
FELDENE
Flector Patch, QL
INDOCIN IR & CR, QL
Indocin supp & susp, QL
MOBIC, MOBIC Susp, QL
MOTRIN
NALFON
NAPRELAN, QL
NAPROSYN
Neoprofen Inj, QL
Ponstel, QL
Solareze, QL
Sprix, QL
Vimovo, QL, ST
Voltaren Gel, QL
VOLTAREN, XR
Zipsor, QL
Caldolor Inj, QL
SALICYLATES
asa cr 800mg
choline & magnesium salicylates
diflunisal
salsalate
ZORPRIN
2.0 ANESTHETICS
TOPICAL LOCAL ANESTHETICS
lidocaine
lidocaine/hydrocortisone
lidocaine/prilocaine
Lidoderm, QL
EMLA
XYLOCAINE
3.0 ANTIBIOTICS
AMEBICIDES
paromomycin
Yodoxin
HUMATIN
ANTIFUNGALS-ORAL
clotrimazole troche
fluconazole tab, soln
flucytosine oral
itraconazole cap
ketoconazole
Lamisil granules, PA
ANCOBAN
DIFLUCAN
GRIFULVIN V TAB, SUSP
Gris-Peg
LAMISIL TAB
4
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
nystatin
terbinafine
voriconazole PA, QL
Specialty Drugs
MYCELEX TROCHE
MYCOSTATIN
NIZORAL
Oravig, QL
SPORANOX; soln, PA
VFEND, PA,QL
Vfend IV, PA
ANTIFUNGALS-TOPICAL
ciclopirox
clotrimazole/ betamethasone
econazole
hydrocortisone/clioquinol
ketoconazole
ketoconazole foam 2%
miconazole nitrate
nystatin
nystatin/triamcinolone
Loprox gel, shampoo
mebendazole
Mintezol tab, susp
atovaquone/proguanil
chloroquine phosphate
hydroxychloroquine
mefloquine
Daraprim
Fansidar
Primaquine
pentamidine
Mepron
ethambutol
isoniazid
pyrazinamide
rifampin
rimactane
Mycobutin
Priftin, QL
Rifamate
Rifater
CNL8 Nail Kit
Ertaczo
Exelderm cr, soln
EXTINA 2%
Lamisil Spray
LOPROX TS
LOTRIMIN
LOTRISONE
Mentax
MONISTAT-DERM
MYCOSTATIN
Naftin
NIZORAL
Oxistat
Penlac, PA, QL
SPECTAZOLE
ANTIHELMINTICS
Albenza
Biltricide
Stromectol
VERMOX
ANTIMALARIALS
ARALEN
Coartem
Halfan
MALARONE
PLAQUENIL
Qualaquin, PA, QL
ANTIPROTAZOALS
Nebupent
PENTAM
ANTITUBERCULOSIS
MYAMBUTOL
RIFADIN
Trecator
ANTIVIRALS-ORAL
acyclovir
amantadine
famciclovir
ganciclovir
rimantadine
valacyclovir
CYTOVENE
FAMVIR
FLUMADINE
Relenza, QL
Tamiflu cap, susp, QL
SYMMETREL
Baraclude, QL
Copegus, PA
Epivir HBV tab, soln
Hepsera
Incivek, PA, QL
Infergen, PA
5
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Valcyte, QL
VALTREX
ZOVIRAX
Specialty Drugs
REBETOL SOLN, PA
ribavirin caps PA
RibaTab, RibaPak,
RibaSphere PA
Tyzeka
Victrelis, PA, QL
Viread
ANTIVIRALS-TOPICAL
Zovirax cream, ointment
Denavir
CEPHALOSPORINS
cefaclor, ER
cefadroxil
cefdinir
cefuroxime
cephalexin
cephradine
cefpodoxime, susp
cefprozil
Ceftin 250/5 susp, QL
CECLOR; CECLOR CD
Cedax
CEFTIN TABS, QL
CEFTIN 125/5 susp, QL
CEFZIL
DURICEF
KEFLEX
Keftab
Lorabid
OMNICEF
Rocephin, QL
Spectracef
Suprax, QL
Teflaro, PA
VANTIN, susp
VELOSEF
FLUOROQUINOLONES
ciprofloxacin, QL
levofloxacin, QL
ofloxacin, QL
Avelox, QL
Cinobac
CIPRO TAB, QL
Cipro XR, susp, QL
Factive, QL
FLOXIN, QL
LEVAQUIN, QL
Maxaquin, QL
Noroxin, QL
LEPROSTATICS
Dapsone
Lamprene
MACROLIDES
clarithromycin, XL
erythromycin
erythromycin base
erythromycin ethylsuc.
erythromycin stearate
erythromycin/sulfisoxazole
BIAXIN
BIAXIN XL
Dynabac
E-MYCIN
E.E.S.
Ery-tab
ERYC
Eryped
PCE
PEDIAZOLE
ZITHROMAX TAB, susp, QL
Zmax susp, QL
6
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
ANTIRETROVIRALS - NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
Edurant
Intelence
Rescriptor
Sustiva
Viramune tab, susp
Viramune XR
ANTIRETROVIRALS - NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITOR (NRTI) ANALOGUES
didanosine
Emtriva
EPIVIR
lamivudine
RETROVIR
stavudine
VIDEX, VIDEX EC
ZERIT
Ziagen
zidovudine
ANTIRETROVIRAL COMBINATIONS
Atripla
COMBIVIR
Complera, PA
Epzicom
Kaletra
lamivudine/zidovudine
Trizivir
Truvada
ANTIRETROVIRALS - PROTEASE INHIBITORS
Aptivus
Crixivan
Fortovase
Invirase
Lexiva
Norvir
Prezista
Reyataz
Viracept
ANTIRETROVIRALS – MISCELLANEOUS
Isentress
ANTIRETROVIRALS – CCR5 ANTAGONISTS
Selzentry
PENICILLINS
amoxicillin
Augmentin XR, QL
AMOXIL
amoxicillin/clavulanate, QL
Augmentin chew 250, QL
AUGMENTIN, ES, QL
ampicillin
cloxacillin
dicloxacillin
penicillin VK
Augmentin susp 125/5, QL
AUGMENTIN XR, QL
Geocillin
Moxatag
OMNIPEN
TRIMOX
V-CILLIN K
7
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
sulfadiazine
sulfamethoxazole/trimeth, DS
Gantrisin
Tier 3
Brand Products
Specialty Drugs
SULFONAMIDES
BACTRIM, DS
SEPTRA, DS
TETRACYCLINES
doxycycline hyclate
doxycycline monohydrate
minocycline
minocycline SR
tetracycline
ADOXA, QL, ST
Declomycin
DORYX
DYNACIN
MINOCIN
MONODOX
Oraxyl
PERIOSTAT
SOLODYN
SUMYCIN
VIBRAMYCIN
VIBRATAB
TOPICAL ANTIBIOTICS
gentamicin
mupirocin ointment
silver sulfadiazine
Bactroban cream, nasal
Akne-Mycin
BACTROBAN OINTMENT
Cortisporin
GARAMYCIN
SILVADENE
Sulfamylon
URINARY ANTI-INFECTIVES
methenamine
nitrofurantoin mono
nitrofurantoin
nitrofurantoin oral suspension
trimethoprim
FURADANTIN
HIPREX
MACROBID
MACRODANTIN
Monurol
Neggram
Primsol
PROLOPRIM
TRIMPEX
UREX
MISCELLANEOUS ANTIINFECTIVES
clindamycin
metronidazole
neomycin
tinidazole
Furoxone tab, liquid
Alinia
CLEOCIN
DIFICID, PA
FLAGYL
Flagyl ER
Ketek
Malarone
Synercid
TINDAMAX
Vibativ, ST
Xifaxan
Zyvox, PA, QL
Fuzeon, QL, PA
Vancocin cap, inj
INTERSTITIAL CYSTITIS AGENTS
Elmiron
Rimso-50
8
PRX0102_0712
July 2012
4.0 ANTI-NEOPLASTICS/IMMUNOSUPPRESSANTS
ALKYLATING AGENTS
cyclophosphamide
Alkeran tablet
CEENU capsule
CYTOXAN
Hexalen
Leukeran
Alkeran Inj
Myleran
Treanda, PA
ANTINEOPLASTIC – HORMONAL AGENTS
Temodar oral & IV
ANTINEOPLASTIC – HORMONAL AGENTS – ANTIANDROGEN
bicalutamide
flutamide
CASODEX
Eulexin
Nilandron
ANTINEOPLASTIC – HORMONAL AGENTS – ANTIESTROGEN
tamoxifen
Fareston
NOLVADEX
Faslodex
ANTINEOPLASTIC – HORMONAL AGENTS – AROMATASE INHIBITORS
anastrozole
exemestane
letrozole PA
ARIMIDEX
AROMASIN
FEMARA, PA
ANTINEOPLASTIC – HORMONAL AGENTS – PROGESTINS
megestrol
MEGACE
Megace ES
GONADOTROPIN – RELEASING HORMONE AGONISTS/ANTAGONISTS (GRHA)
SYNAREL, PA
Viadur, PA
Cetrotide
Degarelix
Eligard, PA
Gonal F, PA
Lup Dep Ped, PA
LUPRON, Lupron DEPOT,
PA
leuprolide PA
Trelstar & Trellstar Depot,
PA
Zoladex
PURINETHOL
RHEUMATREX
Almita, PA
Caprelsa, PA, QL
Folotyn, PA
Jakafi, PA, QL
Xalkori, PA, QL
Xeloda
ANTIMETABOLITES
mercaptopurine
methotrexate
Tabloid
IMMUNOSUPPRESSANTS/IMMUNOMODULATORS
azathioprine
dexamethasone
prednisone
DECADRON
DELTASONE
IMURAN
Amevive, PA
Arzerra, PA
Avastin, PA
Benlysta, PA
CELLCEPT, PA
cyclosporine
Erwinaze, PA
Gengraf
Hecoria
Ilaris, PA,QL
Myfortic
mycophenolate mofetil
9
PRX0102_0712
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Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
NEORAL
PROGRAF
Rapamune
Revlimid, PA, QL
SANDIMMUNE
tacrolimus
Thalomid, PA, QL
MISCELLANEOUS ANTINEOPLASTICS
hydroxyurea
leucovorin
Droxia
Emcyt
HYDREA
Kepivance
Lysodren
Matulane
Targretin, PA
Abraxane, PA
Adcetris, PA
Afinitor, PA, QL
Campath, PA
Docefrez
Eligard, PA
etoposide
gemcitabine
GEMZAR
Gleevec ,PA,QL
Gliadel
Havalen, PA
Herceptin, PA
Hycamtin po & IV
Iressa, PA,QL
Istodax, PA
Ixempra
Jevtana
mitoxantrone, PA
Nexavar, PA, QL
octreotide, PA
Ontak, PA
Proleukin, PA
Sandostatin, PA
Sprycel, PA, QL
Sutent, PA, QL
Sylatron, PA
Tarceva, PA, QL
Tasigna, PA, QL
Taxotere (docetaxol)
topotecan
Torisel, PA QL
Totect, PA
tretinoin oral
Tykerb, PA, QL
Vectibix, PA
Velcade, PA
Votrient, PA, QL
Yervoy, PA
Zelboraf, PA, QL
Zinecard, PA
Zolinza, PA, QL
Zytiga, PA
5.0 CARDIOVASCULAR AGENTS
ACE INHIBITORS/COMBINATIONS
benazepril/benazepril hctz, QL
benazepril/amlodipine, QL
ACCUPRIL, QL
ACEON, QL
10
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
captopril/captopril hctz
enalapril/enalapril hctz
fosinopril/fosinopril hctz, QL
lisinopril/lisinopril hctz, QL
moexipril
moexipril/hctz
perindopril
quinapril/quanipril hctz
ramipril, QL
trandolapril
trandolapril/verapamil
Tier 3
Brand Products
Specialty Drugs
ACCURETIC, QL
ALTACE, QL
CAPOTEN/CAPOZIDE
Lexxel
LOTENSIN/LOTENSIN HCT, QL
LOTREL,QL
MAVIK, QL
MONOPRIL/ HCT, QL
PRINIVIL/PRINZIDE, QL
TARKA
Tekamlo, QL
Tekturna, QL, ST
UNIVASC, QL
UNIRETIC, QL
VASOTEC/VASERETIC
ZESTRIL/ZESTORETIC, QL
ANGIOTENSIN RECEPTOR BLOCKERS/COMBINATIONS
eprosartan, QL
irbesartan, QL
irbesartan-HCTZ, QL
losartan, QL
losartan/HCTZ, QL
Azor
Benicar/Benicar HCT, QL
Diovan/Diovan HCT, QL
Exforge/Exforge HCT, ST, QL
Amturnide, QL, ST
Atacand/Atacand HCT, QL
AVAPRO/AVALIDE, QL
COZAAR/HYZAAR, QL
Edarbi QL, ST
Micardis/Micardis HCT, QL
TEVETEN/Teveten HCT, QL
Tribenzor, QL, ST
Twynsta, QL, ST
Valturna, QL, ST
ALPHA BETA BLOCKERS
carvedilol
labetalol
COREG
Coreg CR, QL ,ST
TRANDATE
CENTRALLY ACTING & COMBINATIONS – ANTIADRENERGICS
clonidine
guanabenz
guanfacine
methyldopa/ hctz
ALDORIL
CATAPRES
CATAPRES– TTS
Kapvay, QL, ST
Nexiclon XR, QL
TENEX
ANTIADRENERGICS – PERIPHERALLY ACTING
doxazosin
prazosin
terazosin
CARDURA
HYTRIN
MINIPRESS
HMG CO A REDUCTASE INHIBITORS (STATINS)/COMBINATIONS
atorvastatin, QL
atorvastatin/amlodipine, QL
lovastatin
pravastatin, QL
simvastatin, QL
simvastatin 80mg only, PA, QL
Crestor, QL
Advicor, QL
Altoprev, QL
CADUET, QL
Juvisync, QL
Lescol, Lescol XL, QL
LIPITOR, QL
Livalo, QL
MEVACOR, QL
PRAVACHOL, QL
Pravigard
Simcor, QL, ST
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PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
Vytorin, QL, ST
ZOCOR, QL
ZOCOR 80mg only, PA,QL
FIBRATES
fenofibrate, QL
gemfibrozil, QL
Antara, QL
Tricor, QL
Fenoglide, QL
Fibricor, QL
Lipofen QL
LOFIBRA, QL
LOPID, QL
Triglide, QL
Trilipix, QL
MISCELLANEOUS
Lovaza, QL
Zetia, ST
BILE ACID SEQUESTRANTS
cholestyramine
cholestyramine lite
colestipol
locholest, locholest lite
prevalite
Welchol, QL
COLESTID
QUESTRAN, LITE
NICOTINIC ACID (NIACIN)
Niaspan, QL
Niacor
ANTIARRHYTHMICS
amiodarone
disopyramide, CR
flecainide
mexiletine
procainamide, SR
propafenone, SR
quinidine gluconate,CR
quinidine sulfate,ER
sotalol
sotalol AF
CORDARONE (NTI)
Ethmozine
Norpace CR 100mg
Pacerone (NTI)
Procanbid
BETAPACE, AF
MEXITIL
Multaq, PA
NORPACE, C.R.
RYTHMOL, SR
TAMBOCOR
Tikosyn
Nexterone
BETA-ADRENERGIC ANTAGONISTS/COMBINATIONS
acebutolol
atenolo/chlorthalidone
betaxolol
bisoprolol; bisoprolol/hctz
metoprolol, XL
metoprol/hctz
nadolol
pindolol
propranolol, LA
propranolol/hctz
timolol
Bystolic, QL
BLOCADREN
CORGARD
Corzide
INDERAL,LA; INDERIDE
Innopran XL
KERLONE
Levatol
LOPRESSOR/ HCT
SECTRAL
TENORMIN, TENORETIC
Timolide
TOPROL XL
ZEBETA
ZIAC
CALCIUM ANTAGONISTS
amlodipine, QL
amlodipine/atorvastatin, QL
cartia XT, QL
ADALAT CC, QL
CADUET, QL
CALAN, SR
12
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
diltia XT, QL
diltiazem
diltiazem CR, QL
diltiazem CD
diltiazem SR, QL
felodipine, QL
nicardipine
nifedipine; nifedipine ER, QL
nisoldipine, QL
taztia XT
verapamil; verapamil SR
Specialty Drugs
CARDENE; Cardene SR, QL
CARDIZEM/ SR / CD, QL
Cardizem LA, QL
Covera HS
DILACOR XR, QL
DYNACIRC; DYNACIRC CR, QL
ISOPTIN, SR
Nimotop
NORVASC, QL
PLENDIL, QL
PROCARDIA/ XL, QL
SULAR, QL
TIAZAC, QL
Vascor
VERELAN; Verelan PM, QL
CARDIAC GLYCOSIDES
Digitek
digoxin
LANOXIN (NTI) tab, elixir, inj
DIURETICS
amiloride
amiloride/hctz
bumetanide
chlorothiazide
chlorthalidone
furosemide
hydrochlorothiazide
indapamide
methychlothiazide
metolazone
spironolactone/ hctz
torsemide
triamterene/hctz
ALDACTONE; ALDACTAZIDE
BUMEX
DEMADEX
DIURIL
DYAZIDE
Dyrenium
ENDURON
ESIDRIX
HYDRODIURIL
HYGROTON
LASIX
LOZOL
MAXZIDE
MICROZIDE
MIDAMOR
MODURETIC
ZAROXOLYN
NITRATES
isosorbide dinitrate
isosorbide mononitrate
nitroglycerin
nitroglycerin ointment
nitroglycerin patch
nitroglycerin SR
Minitran
Nitrobid
Nitro-Dur
Nitrolingual Spray
Nitrostat SL
BiDil, QL
Dilatrate SR
IMDUR
ISMO
ISORDIL
MONOKET
Nitrogard
Nitromist
OTHER CARDIOVASCULARS
Cialis, QL
Ranexa
Staxyn, GE, QL
Adcirca, PA, QL
eprostenol, PA
FLOLAN, PA
Letairis, PA, QL
Remodulin, PA
Revatio, PA
Samsca, PA, QL
Tracleer, PA, QL
Tyvaso, PA, QL
13
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
Veltri, PA
Ventavis, QL
PHEOCHROMOCYTOMA AGENTS
Dibenzyline
PRESSORS
midodrine
PROAMATINE
PERIPHERAL VASODILATORS & COMBINATIONS
hydralazine; hydralazine/hctz
minoxidil
APRESOLINE; APRESAZIDE
LONITEN
PLATELET AGGREGATION INHIBITORS/ANTICOAGULANTS/PVD AGENTS
anagrelide
cilostazol
dipyridamole
pentoxifylline
ticlopidine
warfarin
Coumadin (NTI)
Effient, QL
Pradaxa, QL
Xarelto, QL
Aggrenox
AGRYLIN
Innohep
PERSANTINE
TICLID
TRENTAL
ARIXTRA
Corifact, PA
enoxaparin
fondaparinux
Firazyr, PA
Fragmin
LOVENOX
Riastap, PA
MISCELLANEOUS HEMATOLOGIC PRODUCTS
Lysteda, QL
Berinert,PA
Cinzre, PA
Kalbitor, PA
6.0 CENTRAL NERVOUS SYSTEM AGENTS
ANTIANXIETY
alprazolam & SR, QL
alprazolam ODT, QL
buspirone
chlordiazepoxide, QL
clonazepam
clorazepate, QL
diazepam
hydroxyzine HCl, pamoate
lorazepam, QL
meprobamate
oxazepam, QL
ATARAX
ATIVAN, QL
BUSPAR
KLONOPIN
LIBRIUM
MILTOWN
NIRVAM, QL
SERAX, QL
TRANXENE, QL
VALIUM
XANAX, XR , QL
diazepam inj
ANTICONVULSANTS-BARBITURATES
mephobarbital
phenobarbital
primidone
MEBARAL
MYSOLINE
ANTICONVULSANTS-HYDANTOINS
phenytoin; phenytoin extended
Dilantin (NTI) cap, chew tab,
susp
Phenytek (NTI)
ethosuximide
Zarontin (NTI)
Peganone
ANTICONVULSANTS-SUCCINIMIDES
Celontin
ANTICONVULSANTS-MISCELLANEOUS
carbamazepine, XR
clonazepam, QL
clonazepam ODT, QL
Carbatrol (NTI)
DEPAKOTE SPRINKLES; ER
(NTI)
Gabitril
Banzel
DEPAKENE
Onfi, PA
Sabril, PA, QL
DEPAKOTE
14
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
diazepam rectal, QL
divalproex, ER, sprinkles
felbamate
gabapentin capsule, tablet
lamotrigine
levetiracetam, QL
levetiracetam XR
oxcarbazepine
topiramate
valproic acid
zonisamide
Lamictal XR, QL
Neurontin soln
TEGRETOL XR (NTI)
ZONEGRAN (NTI)
DIASTAT, QL
FELBATOL
Gralise, QL, ST
Horizant, ST, QL
KEPPRA, QL
KEPPRA XR, QL
KLONOPIN, QL
LAMICTAL, QL
Lyrica, PA
NEURONTIN CAPS, TABS
Stavzor
TEGRETOL TAB, CHEW, SOLN
TOPAMAX & SPRINKLE
Specialty Drugs
TRILEPTAL
Vimpat
ANTIDEPRESSANTS – MAO INHIBITORS
tranylcypromine
Nardil
Marplan
PARNATE
ANTIDEPRESSANTS – SSRIS
citalopram, QL
escitalopram, QL
fluoxetine, QL
fluvoxamine
paroxetine
sertraline, QL
CELEXA, QL
LEXAPRO, QL
LUVOX, CR, QL
PAXIL, CR , SUSP, QL
Pexeva, QL
PROZAC, QL
Prozac weekly, QL
SARAFEM, QL
Viibryd, QL
ZOLOFT, QL
ANTIDEPRESSANTS-SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS
venlafaxine
venlafaxine XR
Cymbalta
Pristiq, QL
EFFEXOR
EFFEXOR XR, QL
Savella, QL, ST
ANTIDEPRESSANTS – TRICYCLICS
amitriptyline
amitriptyline/perphenazine
amoxapine
clomipramine
desipramine
doxepin
imipramine
nortriptyline
protriptyline
ANAFRANIL
AVENTYL
ELAVIL
NORPRAMIN
PAMELOR
SINEQUAN
SURMONTIL
TOFRANIL
Tofranil – PM
TRIAVIL
Vivactil
ANTIDEPRESSANTS – MISCELLANEOUS
amitriptyline/chlordiazepoxide
bupropion, ER, XL
maprotiline
mirtazapine
nefazodone
trazodone
Aplenzin, QL
DESYREL
LIMBITROL, DS
LUDIOMIL
Oleptro, QL
REMERON
SERZONE
WELLBUTRIN, XL, QL
15
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
ANTIEMETIC AND ANTIVERTIGOS
dronabinol
granisetron, QL
meclizine
metoclopramide, QL
ondansetron, QL
prochlorperazine
promethazine
trimethobenzamide
Compazine Syrup
Torecan
Transderm – Scop
ANTIVERT
Anzemet, QL
COMPAZINE TAB, SUPP
Emend, QL
KYTRIL TAB, SOLN, QL
MARINOL
PHENERGAN
REGLAN, QL
Sancuso, QL
TIGAN
ZOFRAN TAB,ODT,SOL, QL
ZOFRAN INJ
Zuplenz, QL
Aloxi
granisetron inj
ANTIMANIA AGENTS
lithium
ESKALITH, CR
LITHOBID
ANTIPARKINSON
amantadine
benztropine
bromocriptine tablet
carbidopa/levodopa, CR
diphenhydramine 50mg
pergolide
pramipexole
selegiline
ropinirole
trihexyphenidyl
Comtan
Akineton
ARTANE
COGENTIN
ELDEPRYL
Larodopa
MIRAPEX
Mirapex XR, ST, QL
PARLODEL
PERMAX
REQUIP
Requip XL, ST, QL
SINEMET; SINEMET CR
Stalevo
SYMMETREL
Tasmar
Zelapar
Apokyn, PA
ANTIPSYCHOTICS
chlorpromazine
clozapine, QL
fluphenazine
haloperidol
haldolperidol deconate
loxapine
olanzapine
olanzapine ODT
olanzapine/ fluoxetine
perphenazine
quetiapine
risperidone, M-tab, solution
thioridazine
thiothixene
trifluoperazine
ziprasidone, QL, ST
Abilify, QL
Seroquel XR
Abilify INJ
CLOZARIL, QL
Fanapt, ST, QL
Fazaclo, QL
Fazaclo ODT
GEODON,QL,ST
Geodon INJ
HALDOL
Invega, QL, ST
Invega Sust
Latuda, QL,ST
LOXITANE
MELLARIL
Moban
NAVANE
Orap
PROLIXIN
RISPERDAL, M-TAB, SOLN
Risperdal Consta,inj
16
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
Rybix ODT, QL
SEROQUEL
Saphris, QL
Serentil
STELAZINE
SYMBYAX
THORAZINE
TRILAFON
ZYPREXA, ZYPREXA ZYDIS
Zyprexa Relp, QL
CHOLINESTERASE INHIBITORS
donepezil
donepezil ODT
galantamine, ER
rivastigmine capsulet
ARICEPT
Aricept 23mg, ST
Cognex
EXELON capsule
EXELON patch
RAZADYNE,ER
SEDATIVE & HYPNOTICS
chloral hydrate
estazolam, QL
flurazepam, QL
midazolam oral syrup
temazepam QL
triazolam QL
zaleplon, QL
zolpidem, QL
zolpidem CR, QL
AMBIEN, CR, QL, ST
DALMANE QL
Doral QL
Edluar Sub, QL, ST
HALCION QL
Lunesta, QL, ST
NOCTEC
Placidyl
RESTORIL QL
Rozerem, QL, ST
Silenor, QL
SOMNOTE
SONATA, QL, ST
Zolpimist QL
midazolam inj
STIMULANTS
amphetamine
amphetamine/dextroamphetamine tab. QL
amphetamine/dextroamphetamine cap SR, QL
dexmethylphenidate
dextroamphetamine, SR, QL
methylphenidale solution
methylphenidate, S.R.
modafinil, PA, QL
pemoline
Vyvanse, QL
ADDERALL, XR, QL
Concerta
CYLERT
Desoxyn
DEXEDRINE, QL
DEXTROSTAT
FOCALIN, XR QL
Metadate CD, ER
METHYLIN, ER
PROVIGIL, PA, QL
RITALIN, S.R., LA
SUBSTANCE ABUSE
bupropion
disulfiram
naltrexone
ANTABUSE
REVIA
Relistor, PA
INTUNIV, QL, ST
Kapvay, ST, QL
Ampyra, PA, QL
Botox, PA
MISCELLANEOUS CNS
pyridostigmine
Mestinon timespan
Namenda, QL
17
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Rilutek
Strattera, QL, ST
MESTINON
Namenda XR, QL
Nexiclon XR, QL
Nuedexta, PA
Prostigmin
Subutex & Suboxone, QL, PA
Specialty Drugs
Dysport, PA
Myobloc, PA
Xenazine, PA
Xeomin, PA
Xyrem, PA, QL
7.0 DERMATOLOGICALS
ANTIACNE – ORAL
amnesteem, QL
doxycycline hyclate
Isotretinoin, QL
minocycline, SR
ACCUTANE, QL
DORYX
MINOCIN CAPSULES
ANTIACNE – TOPICAL
adaplene gel, QL
benzoyl peroxide foam
benzoyl peroxide
benzoyl peroxide/urea
clindamycin
clindamycin/benzoyl peroxide,
QL
erythromycin
metronidazole
sod. sulfacetamide/sulfur, QL
tretinoin
Avar
Differin cr, pad, soln, QL
Duac, Duac CS, QL
Finacea, QL
Finacea Kit, QL, ST
Plexion SCT
Akne-Mycin
Atralin
A/T/S TOPICAL SOLUTION
AVITA
Azelex cream
BENZAC
Retin-A Liquid
BENZACLIN, QL
BENZAGEL
BENZAMYCIN
BENZEFOAM ULTRA
Brevoxyl
CLEOCIN-T GEL, LOT, PAD,
SOL
Clenia
Clindagel
Desquam E
DIFFERIN GEL 0.1% & 0.3%,
QL
Differin Lotion, QL
Epiduo
Epiduo gel, QL
ERYCETTE 2% PLEDGETS
ERYDERM 2% TOP. SOL.
ERYMAX 2% TOP. SOL.
EVOCLIN, QL
KLARON LOTION
METROCREAM, METROGEL
METROLOTION
Noritate
PANOXYL, AQ
Phisohex
RETIN-A; MICROGEL
Rosula Products, QL
SULFACET-R
Tretin-X
Triaz
Veltin gel, QL
Ziana, QL
ZODERM
18
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
ORAL ANTIPRURITIC AGENTS
cyproheptadine
diphenhydramine
fexofenadine & D, QL
hydroxyzine HCl, pamoate
Allegra & D, QL
ATARAX
PERIACTIN
VISTARIL
Zyrtec, QL
ANTIPSORIASIS/ECZEMA/DERMATITIS
methotrexate
Capitrol shampoo
Atopiclair
Amevive, PA
calcipotriene
selenium sulfide
Dovonex cr, oint
DOVONEX SOL
Elidel, ST, QL
Protopic, ST, QL
RHEUMATREX
Sebizon
SELSUN
Soriatane, QL
Tazorac
Trexall
Cimzia, PA, QL
Enbrel, PA
Humira, PA
Raptiva, PA
Remicade, PA
Stelara, PA, QL
ASTRINGENT
aluminum chloride sol
DRYSOL
Formaldehyde Spray 10%
Xerac A.C.
BURN THERAPY
nitrofurazone
silver sulfadiazine
FURACIN
SILVADENE
Sulfamylon
CORTICOSTEROIDS-TOPICAL
amcinonide
betamethasone dipropionate
betamethasone valerate
clobetasol
desonide
desoximetasone
diflorasone diacetate
fluocinolone acetonide
fluocinonide
halobetasol
hydrocortisone
mometasone
triamcinolone acetonide
Aclovate
ARISTOCORT
Cloderm
Cordran; SP; Tape, QL
CUTIVATE
CYCLOCORT
DERMA-SMOOTHE/F.S.
DERMATOP
Desonate
DESOWEN CR/LOTION
Diprolene Gel/Lot/Oint/AF
Diprosone
ELOCON OINT, LOTION
First Hydrocortisone
Halog
HYTONE
KENALOG AEROSOL
LIDEX; LIDEX-E
Locoid
Luxiq
Momexin
OLUX
PSORCON; E
SYNALAR, H.P.
TEMOVATE
TEXACORT
TOPICORT; TOPICORT LP
TRIDESILON
19
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
ULTRAVATE
VALISONE
Vanoxide H.C. Lotion
Verdeso
WESTCORT
Zyclara, QL
Zypram
KERATOLYTICS
podofilox soln
salicylic acid film 27.5%
Aldara, QL
Condylox gel
CONDYLOX SOLUTION
Keralyt
Salvax Duo
VIRASAL
MISCELLANEOUS
fluorouracil
sunscreen/hydroquinone
trypsin/balsam peru/castor oil
urea
Carac
Fluoroplex cream
Accuzyme
EFUDEX
GRANULEX
Kerafoam 42
LAC-HYDRIN
Oxsoralen
Panretin
Regranex
Santyl Ointment
SOLAQUIN FORTE
Solaraze QL
Vectical ointment, PA
VIQUIN FORTE
Zithranol RR
Zonalon
Xiaflex Inj
SCABICIDES/PEDICULICIDES
acticin
benzyl benzoate
lindane
permethrin
ELIMITE
Eurax
KWELL
Ovide
Ulesfia
8.0 EYES, EARS, NOSE, MOUTH AND THROAT
MOUTH AND THROAT/TEETH
chlorhexidine
doxycycline
lidocaine viscous
pilocarpine
sodium fluoride
stannous fluoride
triamcinolone acetonide
Evoxac
Aphthasol
GELKAM
KENALOG IN ORABASE
PERIDEX
PERIOSTAT
PREVIDENT
SALAGEN
XYLOCAINE VISCOUS
NASAL STEROIDS
flunisolide spray QL
fluticasone nasal spray
triamcinolone nasal spray, QL
Nasonex QL
Beconase AQ, QL
FLONASE NS, QL
NASACORT AQ, HFA, QL
NASALIDE, QL
Nasarel, QL
Omnaris, QL
20
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
RHINOCORT AQUA, QL
Tri-Nasal, QL
Veramyst, QL
NASAL MISCELLANEOUS
azelastine NS, QL
butorphanol NS, QL
ipratropium NS, QL
sumatriptan NS, QL
Astepro, QL
ASTELIN, QL
ATROVENT NASAL SPR, QL
IMITREX NASAL SPR, QL
Patanase, QL
STADOL NASAL SPR, QL
OPHTHALMICS – ANTI-ALLERGY/DECONGESTANTS
azelastine, QL
cromolyn sodium, QL
epinastine, QL
ketotifen, QL
olopatadine
Alamast, QL
Alocril, QL
Alomide, QL
Bepreve
CROLOM, QL
ELESTAT, QL
Emadine, QL
Lasacaft, QL, ST
OPTICROM, QL
Optivar, QL
Pataday
Patanol, QL
ZADITOR, QL
OPHTHALMICS – ANTIBIOTICS
bacitracin zinc/polymyxin B
chloramphenicol oint
ciprofloxacin, QL
erythromycin
gentamicin
neomycin/polymyxin/bacitracin
neomycin/polymyxin/gramicidin
ofloxacin, QL
polymyxin/ trimethoprim
sulfacetamide solution
tobramycin
tobramycin/dexamethasone
A.K. – Tracin
Chloroptic Solution
Vigamox, QL
acetazolamide
apraclonidine
betaxolol
brimonidine (0.15 & 0.2%)
carteolol hcl
dipivefrin hcl
dorzolamide
dorzolamide/timolol
latanoprost
levobunolol
methazolamide
metipranolol
pilocarpine hcl
Alphagan P (0.1%)
Azopt
Betimol
Betoptic-S
Osmoglyn
Travatan, Z
Besivance, QL
BLEPH-10
CILOXAN OINT, SOLN, QL
GARAMYCIN
Iquix, QL
NEOSPORIN SOLN
NEOSPORIN OINT
OCUFLOX,QL
POLYSPORIN
POLYTRIM
Quixin, QL
Ocudox Kit , QL
TOBREX, TOBRADEX
Tobradex ST, QL
Vasosulf
Zymar, QL
Zymaxid, QL
OPHTHALMICS – ANTIGLAUCOMA
ALPHAGAN P (0.15%)
BETAGAN
Combigan, QL
COSOPT
DIAMOX
Diamox Sequels
Epifrin
Epinal
IOPIDINE
Isopto Carbachol
ISOPTO CARPINE
Istalol
Lumigan
21
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
timolol
Specialty Drugs
Lumigan Sol, QL
NEPTAZANE
OCUPRESS
OPTIPRANOLOL
Phospholine Iodide
PILOCAR
Pilopine H.S. gel
Propine
Rescula
TIMOPTIC/ XE
TRUSOPT
XALATAN
OPHTHALMICS – ANTIVIRALS
trifluridine
Vira-A
VIROPTIC
Zirgan, QL
OPHTHALMICS – ANTI-INFLAMMATORIES
bacitracin/polymyxin/neomycin/
hydrocortisone
bromfenac QL
dexamethasone
diclofenac, QL
flurbiprofen sodium
fluorometholone
ketorolac ophth, QL
neomycin/polymyxin/
dexamethasone
neomycin/dexamethasone
neomycin/polymyxin/
hydrocortisone
prednisolone
sulfacetamide/prednisolon
tobramycin/dexamethasone
blephamide oint, susp
Acular PF, QL
Acuvail, QL
ACULAR LS, QL
Alrex
Brombay, QL
Cetapred
DECADRON
Durezol
ECONOPRED PLUS
F.M.L. S, S.O.P., Forte
FML Oint.
HMS
Pred Mild
Tobradex oint
Eflone
F.M.L. LIQUIFILM Oint.
Flarex
INFLAMASE MILD, FORTE
Lastacaft, QL
Lotemax
MAXITROL
Nevanac, QL
OCUFEN, QL
OMNIPRED
Poly-Pred
Pred-G oint, susp
PRED FORTE
Tobradex S , QL
TOBRADEX SUSP
VASOCIDIN
Vexol
VOLTAREN, QL
XIBROM, QL
Zylet
OPHTHALMICS – MISCELLANEOUS
atropine sulfate
cyclopentolate
homatropine
naphazoline
naphazoline/antazoline
neosynephrine
phenylephrine
tropicamide
ISOPTO HOMATROPINE
Vasocon-A
ALBALON
CYCLOGYL
ISOPTO ATROPINE
Isopto Hyoscine
Lacriserts
Membraneblue
MYDRIACYL
NEO-SYNEPHRINE
Eylea
Lucentis
Macugen
Trisence
Visudyne
22
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
Restasis, PA, QL
VASOCON
OTIC
acetic acid
acetic acid/aluminum acetate
acetic acid/hydrocortisone
antipyrine/benzocaine
fluocinolone otic oil
neomycin/polymyxin/
hydrocortisone
ofloxacin, QL
otozon
pramoxine/hc/chloroxylenol
Cerumenex
Ciprodex
Zoto-H.C. Otic
AURALGAN
Cetraxal Otic
Cipro Otic Drops
Cortane-b
CORTISPORIN OTIC
DOMEBORO
DERMOTIC
FLOXIN OTIC, QL
NEOTIC
TYMPAGESIC
Trioxin Otic
VOSOL; VOSOL HC
Zinotic ES
9.0 ENDOCRINE AGENTS
ANDROGENS, ANDROGEN INHIBITORS/ANABOLIC STEROIDS
danazol
testosterone, PA
Androderm, PA, QL
Androgel, PA, QL
Anadrol, PA
Android, PA
Axiron, PA, QL
DANOCRINE
DELATESTRYL
DEPO-TESTOSTERONE
First Testosterone
Fortesta, PA, QL
Hybolin, PA
Methitest
Oxandrin, PA
Striant, PA, QL
Testoderm, PA
Testopel, PA
Testim, PA
Testred
Winstrol, PA
ANTITHYROID
propylthiouracil
methimazole
TAPAZOLE
BISPHOSPHONATES/OSTEOPOROSIS AGENTS/PAGETS DISEASE
alendronate, QL
calcitonin (salmon, synth)
ibandronate, QL
Actonel, w/ calcium, QL
Evista
Atelvia, QL, ST
BONIVA, QL
CALCIMAR
Didronel
Fortical, QL
FOSAMAX, QL
Fosamax-D, QL
Miacalcin, QL
Skelid
Boniva inj
Forteo, PA
Prolia, PA
Reclast inj
Zometa inj
ESTROGEN & ESTROGEN/ANDROGEN COMBINATIONS
estradiol
Alora
ACTIVELLA
23
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July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
estradiol/norethindrone
estrogen injection
estrogen patch
estropipate
norethindrone/e-estradiol
Cenestin
Climara Pro
Enjuvia
Estraderm
Estring
Menest
Natazia
Premarin (oral, cream)
Premphase
Prempro
Prempro Low Dose
Vagifem
Valergen
Vivelle; Vivelle-Dot
Angeliq
CLIMARA
Combipatch
Delestrogen
Depo-Estradiol
Esclim
ESTINYL
Estrace
Estratest/ HS
Estrasorb
Estratab
Estrogel
Evamist
FEMHRT
Femring
GYNODIOL
OGEN
ORTHO-EST
Prefest
Syntest DS, HS
Specialty Drugs
GLUCOCORTICOIDS
dexamethasone
hydrocortisone
methylprednisolone
prednisolone
prednisone
Hydrocortone
Medrol 2mg ONLY
CORTEF
DECADRON
DELTASONE
Depo-Medrol
Flo- Pred Sus
MEDROL
Millipred DP
Orapred
PEDIAPRED
PRELONE
HYPERGLYCEMICS
Glucagon
Proglycem
HYPOGLYCEMICS
acarbose, QL
chlorpropamide, QL
glipizide; ER
glipizide/metformin, QL
glyburide; micronized
glyburide/metformin, QL
metformin; ER QL
nateglinide, QL
tolazamide, QL
tolbutamide, QL
Actos, QL
Actos Plus Met, QL
Actos Plus Met XR, QL
Avandamet, QL, PA
Avandaryl, QL,PA
Avandia, QL,PA
Byetta, ST,QL
Duetact, QL
Glyset, QL
Janumet, QL
Januvia, QL
Onglyza, QL
Prandin, QL
Prandimet, QL
Symlin, Pen
AMARYL
DIABETA
DIABINESE, QL
FORTAMET, QL
GLUCOPHAGE, XR QL
GLUCOTROL, XL
GLUCOVANCE, QL
Glumetza, QL
GLYNASE PRESTAB
Juvisync, QL
Kombiglyze, QL, ST
METAGLIP, QL
MICRONASE
PRECOSE, QL
Riomet, QL
STARLIX, QL
Tradjenta, QL, ST
Victoza, ST, QL
INSULIN
Apidra, ST
Humalog, Humalog Mix
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July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
Humulin
Lantus, Solostar
Levemir
Novolin
Novolog, Novolog Mix
THYROID
levothyroxine
levoxyl
liothyronine
Levothroid (NTI)
SYNTHROID (NTI)
calcitriol
desmopressin acetate
fludrocortisone
Cytadren
D.H.T. tab, soln
Armour Thyroid
CYTOMEL
Nature-thyroid
Thyrolar
UNITHROID
MISCELLANEOUS
Cycloset, PA, QL
DDAVP
Dostinex
FLORINEF
ROCALTROL
Stimate
Vectical, PA
Acthar HP, PA
Aldurazyme, PA
Elaprase, PA
Fabrazyme, PA
Increlex, PA
Kuvan
Lumizyme, PA
Myozyme, PA
Orfadin
Sensipar
Somatuline, PA
VPRIV, PA
10.0 GASTROINTESTINAL AGENTS
ANTICHOLINERGICS/MOTILITY/ANTISPASMODICS
belladonna/phenobarbital
bethanechol
chlordiazepoxide/clidinium
dicyclomine
glycopyrrolate
hyoscyamine
methscopolamine bromide
metoclopramide
neosol
propantheline
Anaspaz
BENTYL
Cantil
DONNATAL
LEVBID
LEVSIN, SL; LEVSINEX
LIBRAX
NULEV
PAMINE
PRO-BANTHINE
Rectiv
REGLAN, QL
ROBINUL
URECHOLINE
ANTIDIARRHEAL
diphenoxylate/atropine
loperamide
paregoric
LOMOTIL
ANTI-INFLAMMATORIES
balsalazide
budesonide SR
hydrocortisone
hydrocortisone enema
hydrocortisone/pramoxine
sulfasalazine, EC
Asacol
Apriso
Canasa
Pentasa
Proctofoam – H.C.
ANALPRALM HC CR, LOT
ANUSOL H.C. 2.5, SUPP
AZULFIDINE, ENTABS
COLAZAL
CORTENEMA
Cortifoam
Dipentum
ENTOCORT EC
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Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
Lialda
Pramosone cr, oint, lot
PROCTOCORT; CRM-H.C.
Rowasa
Z-PRAM KIT
H2 RECEPTOR ANTAGONISTS
cimetidine
famotidine
nizatidine
ranitidine
Zantac effervescent
AXID
PEPCID
TAGAMET
ZANTAC
H.PYLORI
Helidac
Prevpac
Tritec
PROTECTANTS
misoprostol
sucralfate
Carafate suspension
CARAFATE
CYTOTEC
PROTON PUMP INHIBITORS
lansoprazole, QL
lansoprazole solutab, QL
omeprazole
omeprazole/bicarbonate
pantoprazole, QL
Aciphex, ST, QL
Dexilant (Kapidex), ST, QL
Nexium, ST, QL
PREVACID, ST, QL
Prevacid NapraPAC, ST, QL
Prilosec, ST, QL
PROTONIX oral & inj, ST, QL
ZEGERID, ST, QL
LAXATIVES
glycolax
lactulose
polyethylene glycol-electrolyte
CEPHULAC
CHRONULAC
COLYTE
GOLYTELY SOLUTION QL
MIRALAX
Nulytely
Suprep Bowel, QL
MISCELLANEOUS
pancrelipase
ursodiol, forte
Creon
Ultrase
Zenpep
ACTIGALL
Amitiza, QL
Gastrocrom
Kuzyme
Lipram
Lotronex
Pancrecarb, Pangestyme
Panges, Pancrease, MT
Pancreaze
UROSO, UROSO FORTE
Viokase
Carbaglu,
Remicade, PA
26
PRX0102_0712
July 2012
11.0 BLOOD MODIFIERS, NUTRITIONALS AND ELECTROLYTES
PLATELET AGGREGATION INHIBITORS/ANTICOAGULANT/PVD AGENTS
anagrelide
cilostazol
dipyridamole
pentoxifylline
ticlopidine,QL
warfarin
calcium acetate
Coumadin (NTI)
Effient, QL
Plavix,QL
Pradaxa QL
Xarelto, QL
Aggrenox
AGRYLIN
Brilinta, PA, QL
Innohep
PERSANTINE
PLETAL
TICLID, QL
TRENTAL
PHOSPHATE BINDERS
Renegel
ELIPHOS
Renvela
Phoslyra
ARIXTRA
Corifact, PA
Firazyr, PA
enoxaparin
fondaparinux
Fragmin
LOVENOX
Riastap, PA
POTASSIUM SUPPLEMENTS
potassium chloride
Kaon – CL tab, liquid
Klorcon powder, tab
K-DUR
K-LOR
K-LYTE CL
K-Lyte DS
K-TAB
MICRO-K
POTASSIUM REMOVING RESIN
sodium polystyrene sulfonate
KAYEXALATE
PRENATAL VITAMINS
hip prenatal (generic)
multivitamins w/folic acid
ob complete with DHA (generic)
prenatal w/docusate, iron, folic
acid
prenatal multivitamins and
minerals/iron/folic acid
Duet DHA/FER Omega-3
OB Complete
BEROCCA PLUS
Chromagen OB
Duet
Embrex 600
MATERNA
NATAFORT
NATALINS
NESTABS CBF
NESTABS FA
Precare
Premesis
PRENATE ADVANCE
PRENATE ULTRA
Select-OB+ DHA Pak
Vitafol PN
ZENATE
VITAMINS/MINERALS/SUPPLEMENTS
aminobenzoate
calcitriol
folic acid
iron/B12/folic acid
iron combination capsule
iron/intrinsic factor/B12
multivitamins w/fluoride
renaphro
sodium fluoride
triple vitamins w/fluoride
Calciferol drops, inj
DHT
Aquasol A soln, inj
CHROMAGEN
CHROMAGEN FORTE
Feraheme
Folgard
Foltx
Galzin
Hectoral
Hytakerol
LURIDE
Nascobal
NEPHROCAPS
Niferex; NIFEREX-150 F
POLY-VI-FLOR
27
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Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
POTABA
ROCALTROL
TRI-VI-FLOR
TRINSICON
MISCELLANEOUS
aminocaproic acid
levocarnitine
phospha 250
pot. citrate – citric acid
pot & sod cit w/citric acid
sodium citrate & citric acid
Cytra-2, Cytra-3, Cytra-K
Fosrenol
K-PHOS
Mephyton
Phos-Lo tab, cap
Renagel tab, cap
AMICAR
BICITRA
CARNITOR
Chemet
Desferal
Lysteda, QL
Oracit
POLYCITRA; POLYCITRA-K
Renvela
UROCIT-K
Carbaglu
Cerezyme, PA
Exjade
Ferriprox
Sucraid
Zemplar
12.0 OBSTETRICS/GYNECOLOGY
ANTIFUNGALS-VAGINAL
fluconazole 150mg tab., QL
nystatin
terconazole
DIFLUCAN 150MG TAB, QL
Femstat
Gynazole-1
Mycelex
MYCOSTATIN
TERAZOL 3, 7 CR, SUPP, QL
ANTI-INFECTIVES - VAGINAL
triple sulfa
clindamycin
metronidazole
CLEOCIN VAGINAL
METROGEL VAGINAL
DIAPHRAGMS
All brands are formulary
MONOPHASICS – ORAL CONTRACEPTIVES
apri
amethyst
aviane
cryselle
drospirenone/ethinyl estradiol
jolessa
kelnor
lessina
levora
low ogestrel
microgestin, fe
necon
nortrel
ocella
ogestrel
portia
reclipsen
sprintec
zeosa
zovia
Beyaz
Natazia
Safyral
ALESSE
BREVICON
DEMULEN
DESOGEN
FEMCON FE
LEVLEN
LEVLITE
LOESTRIN, FE, 21
LO/OVRAL
LYBREL
MODICON
NORDETTE
NORINYL
ORTHO-CEPT
ORTHO-CYCLEN
ORTHO-NOVUM
OVCON
OVRAL
SEASONALE
YASMIN
YAZ
28
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July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
BIPHASICS – ORAL CONTRACEPTIVES
estradiol- levonorgestrel, QL
estradiol-norethindrone
kariva
necon 10/11
enpresse
necon 7/7/7
tilia fe
tri-legest fe
tri-nessa
tri-sprintec
trivora
velivet
ACTIVELLA
Generess Fe
LO SEASONIQUE, QL
MIRCETTE
ORTHO-NOVUM 10/11
SEASONIQUE
TRIPHASICS – ORAL CONTRACEPTIVES
Ortho Tri-Cyclen Lo
CYCLESSA
ESTROSTEP FE
ORTHO-NOVUM 7/7/7
ORTHO TRI-CYCLEN
Tri-Norinyl
TRIPHASIL
TRI-LEVLEN
TRI LO-SPRINTEC
PROGESTIN ONLY – ORAL CONTRACEPTIVES
camila
errin
jolivette
nora-be
NOR-Q.D.
ORTHO MICRONOR
Ovrette
INJECTABLE CONTRACEPTIVES
medroxyprogesterone, QL
DEPO-PROVERA 150MG, QL
Lunelle
MISCELLANEOUS CONTRACEPTIVES
Nuvaring
Ortho Evra
Ella, QL
Plan B Next Choice, QL
Plan B One Step, QL
Preven, QL
Mirena
OVULATORY STIMULANTS
clomiphene
CLOMID
SEROPHENE
Synarel, PA
Bravelle, PA
CHOREX
chorionic gonadotropin
Follistim
GONAL-F
Luveris
MENOPUR, PA
NOVAREL
Ovidrel
PREGNYL
PROFASI
Repronex, PA
OXYTOCICS
methylergonovine tab, inj
oxytocin
Cervidil
METHERGINE TAB, INJ
Prepidil
PROGESTINS
medroxyprogesterone
norethindrone
progesterone micro
AYGESTIN
Crinone gel
Prochieve gel
PROMETRIUM
PROVERA
Crinone insert
Makena, PA
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Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
PROSTAGLANDINS
Prostin E2
MISCELLANEOUS
acetic acid vaginal
amino-acid urea vaginal
terbutaline
AMINO-CERV CREAM
BRETHINE
Cetrotide
Ganirelix
13.0 RESPIRATORY AGENTS
ANTIHISTAMINES – NON-SEDATING
fexofenadine
clemastine fumarate
ALLEGRA, QL
Clarinex & D, QL
Clarinex RDT
ANTIHISTAMINES – OTHER
brompheniramine SR
Poly-Histine elixir
Respa-Br
TAVIST
XYZAL, QL
levocetirizine, QL
ANTIHISTAMINE & DECONGESTANTS
chlorpheniramine/pse
fexofenadine- D (PSE), QL
phenyleph/chlorphen/ carbeta
promethazine/ phenylephrine
chlorphen/pyrilamine/
phenylephrine
pse/carbinoxamine
pse/hydrocod/carbinx
ALLEGRA-D, QL
ATROHIST PED SPRINKLE
DECONAMINE S.R.
Extendryl S.R.
HISTEX HC, SR
Mescolor
NOVAFED A
PHENERGAN V.C. SYRUP
POLY-HISTINE D
RONDEC DM SYRUP
RONDEC TR
RYNATAN
Semprex-D
Tanafed
Trinalin
Tussi-12
Zyrtec-D, QL
DECONGESTANT/EXPECTORANT/ANTITUSSIVE COMBINATIONS
benzonatate
dextromethorphan/guaifen
guaifenesin
guaifenesin/pseudoephed.
guaifenesin S.R.
phenyleph-ephed-cpd w/
carbetapentane
potassium iodide
promethazine/ dextromethorphan
pseudoephedrine-gg & gg
pseudoephed/ dexchlorphen/dm
Humibid Sprinkle
Deconsal II
DURATUSS G
ENTEX LA, PSE
Guaifed PD
HUMIBID D.M.
Humibid D.M. Sprinkle
Humibid L.A.
PHENERGAN D.M.
RYNATUSS
SYN-RX
S.S.K.I.
TESSALON PERLES
TUSSI-ORGANIDIN DM/NR
ZEPHREX L.A.
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Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
NARCOTIC ANTITUSSIVE/EXPECTORANT/DECONGESTANTS
guaifenesin/codeine
guaifenesin/hydrocodone
hydrocodone w/homatropine
phenyleph/chlorphen/w
hydrocodone
phenyleph hcl/hydrocod bit/cp
phenyleph-pyrilamine w/
hydrocodone
phenylephrine/promethazine/
codeine
promethazine/codeine
CODICLEAR D.H.
CODIMAL D.H.
ENDAL H.D.
HISTUSSIN H.C.
HYCODAN SYRUP
PHENERGAN/CODEINE
PHENERGAN V.C./CODEINE
Prolex D.H.
TUSSI-ORGANIDIN N.R.
Tussionex
BRONCHODILATORS AND RELATED MEDICATIONS
albuterol, QL
ipratropium bromide, QL
levalbuterol, QL
metaproterenol, QL
terbutaline
albuterol/ipratropium
Accuneb
Advair, QL
Atrovent Inhaler, HFA QL
Combivent, QL
Foradil, QL
ProAir HFA, QL
Serevent Diskus, QL
Spiriva, QL
Symbicort Inhaler, QL
Xopenex HFA, QL
Arcapta, QL
ATROVENT SOLN, QL
BRETHINE
Brovana, QL
Daliresp, PA, QL
Dulera, ST
DUONEB
Maxair, QL
Perforomist
Proventil HFA, QL
Ventolin H.F.A., QL
Vospire ER
Xopenex Neb Soln
LEUKOTRIENE RECEPTOR ANTAGONISTS/MODIFIERS
zafirlukast
Singulair tab, chew
aminophylline
dyphylline
theophylline syrup, elixir
theophylline, CR, ER, SR
Uniphyl
cromolyn
budesonide neb
Asmanex, QL
Azmacort, QL
Flovent, HFA, Rotadisk, QL
Intal MDI
Pulmicort Flexhaler, QL
Qvar, QL
acetylcysteine
Epipen, QL
Tilade
ACCOLATE
Zyflo, QL
Zyflo, CR, QL
METHYLXANTHINES
ELIXOPHYLLIN
LUFYLLIN
THEO-24
THEOCHRON
INHALED ANTIINFLAMMATORY
Aerobid, Aerobid-M, QL
INTAL SOLN
MISCELLANEOUS
MUCOMYST
Twinject, QL
Aralast, PA
Cayston, PA
Glassia, PA
Kalydeco, PA
Prolastin C, PA
Pulmozyme, PA
TOBI
Xolair, PA
Zemaira, PA
31
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July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
14.0 SKELETAL MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS
baclofen
carisoprodol, cpd, codeine
chlorzoxazone
cyclobenzaprine
dantrolene sodium
diazepam
methocarbamol
orphenadrine, cpd, forte
tizanidine
DANTRIUM
FEXMID
FLEXERIL
LIORESAL
NORFLEX
NORGESIC, FORTE
PARAFON, FORTE
ROBAXIN
Skelaxin
SOMA, SOMA COMPOUND,
COMPOUND CODEINE
VALIUM
ZANAFLEX
Gablofen
Lioresal INT
15.0 UROLOGICALS
UROLOGICALS
alfuzosin
dimethyl sulfoxide
doxazosin
flavoxate
finesteride
meth/salicylate/atropine
/hyos/benzoic
meth/hyos/meth blue/sod
biphos/phenyl
oxybutynin, XL
phenazopyridine
tamsulosin, QL
terazosin
trospium
Detrol; Detrol LA
Vesicare, QL
Avodart, QL
CARDURA
Cardura XL, QL, ST
DITROPAN; DITROPAN XL
Elmiron
Enablex
FLOMAX, QL
Gelnique, ST,QL
HYTRIN
Jalyn, QL
Oxytrol
PROSCAR
PYRIDIUM
Rapaflo, ST, QL
SANCTURA
Sanctura, XR
TOVIAZ, ST
Uribel, QL
URISED, URISPAS
UROGESIC BLUE
UROXATRAL, QL
16.0 IMMUNOLOGICALS, VACCINES AND BIOTECHNOLOGY DRUGS
GROWTH HORMONES AND ANTAGONISTS
Egrifta, PA, QL
Flebogamma, PA
Gammaplex, PA
Genotropin, PA
Hizentra, PA
Humatrope, PA
Norditropin, PA
Nutropin, PA
Nutropin, AQ, PA
Omnitrope
32
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
Protropin, PA
Saizen, PA
Serostim, PA,QL
SOMAVERT, PA
Tev-Tropin, PA
Zorbtive, PA,QL
INTERFERONS/IMMUNOMODULATORS
Actemra, PA
Actimmune
Alferon-N, PA
Arcalyst, PA
Avonex, PA, QL
Betaseron, PA, ST
Copaxone, PA, QL
Extavia, PA, QL
Gilenya, QL, PA
Infergen, PA
Intron-A, PA
Nulojix, PA
Pegasys, PA
Peg-Intron, PA
Rebif, PA, QL
Sylatron, PA
Synagis, PA
Thalomid, PA, QL
Tysabri, PA
Xgeva, PA, QL
INTERLEUKIN
Proleukin, PA
HEMATOPOIETIC GROWTH FACTORS
Aranesp, PA
Epogen, PA
Leukine, PA
Mozobil, PA
Neulasta, PA
Neumega, PA
Neupogen, PA
Nplate, PA
Omontys, PA
Procrit, PA
Promacta, PA
MISCELLANEOUS
Adagen
Berinert, PA
Ceredase, PA
Cinryze, PA
Euflexxa
Firazyr , PA
Gonal F PA
Naglazyme, PA
Prolastin, PA
Synvisc
33
PRX0102_0712
July 2012
Tier 1
Generic Products
Tier 2
Brand Products
Tier 3
Brand Products
Specialty Drugs
Zavesca, PA
VACCINES
Adacel
Afluria
Cervarix
Flulaval, Flumist
Gardasil
Havrix
Hiberix
Infanrix
Ixiaro
JE-Vax
Menactra
Menveo
Prevnar
Rotarix
Twinrix
Zostavax
17.0 THERAPEUTIC DEVICES AND SUPPLIES
METERS AND TEST STRIPS
Accu-Chek (Meters, Strips),
QL
Bayer (Meters, Strips), QL
Exactech (Meter&Strips), ST, QL
Fast Take (Meters, Strips), QL
Freestyle (Meter &Strips), ST,
QL
Glucometer (Meter, Strips),
ST,QL
One Touch (Meter&Strips),
ST,QL
Precision (Meter&Strips), ST, QL
Prestige (Meter&Strips), ST,QL
Sof-Tact (Meter&Strips), ST,QL
TrueTrack (Meter&Strips), ST,
QL
34
PRX0102_0712

PRX prescriber formulary

Transcription

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