Drug Formulary - Pharmacy

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Drug Formulary - Pharmacy
FORMULARY
(List of Covered Drugs)
This document includes Passport Health Plan’s complete
formulary as of January 22, 2009.
What is the Passport Health Plan formulary?
The formulary is a list of preferred drugs covered by Passport Health Plan. To get a drug on our formulary, you
must:
• Be a Passport Health Plan member.
• Need a drug that is medically necessary.
• Get the prescription filled at a Passport Health Plan network pharmacy. A network pharmacy is one that is
signed up with Passport Health Plan.
• Follow all Passport Health Plan rules.
The formulary is not a complete list of covered drugs covered by Passport Health Plan. Some drugs not listed may
be covered, if medically necessary. These drugs may or may not need prior-authorization.
How do I find my drug on the formulary?
• You can find the formulary on our website at www.passporthealthplan.com.
• Under the section that says “Quick Hits,” click on “Formulary.”
• You can search for a drug by clicking on the picture of the
binoculars right above the drug list on your tool bar.
• Next, you will see a search box to the right.
• Type in the name of the drug in the search box.
If you are not sure how to spell the drug, you can search by
entering the first few letters of the name. The drugs are listed by
both brand and generic name. The bolded name means which
drug (brand or generic) is available.
Are there any limits to the drugs you have
been prescribed?
Some covered drugs may have limits on them. This could include:
• Prior-Authorization: Some medicines must be approved by Passport Health Plan before you can get them. This
means your provider will need to get approval before you can have your prescriptions filled. If you do not get approval, Passport Health Plan may not cover the drug.
• Quantity Limits: For some drugs, there are limits on the amount Passport Health Plan will cover. This means
you may not get the standard one month supply.
• Step Therapy: Sometimes Passport Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your
medical condition, Passport Health Plan may not cover drug B unless you try Drug A first. If Drug A does not
work for you, Passport Health Plan will then cover Drug B.
• Too Early to Refill: If you are given a month supply of a medicine, Passport Health Plan will not give a refill of
the prescription until 30 days has passed.
i
What if my drug is not on the formulary?
Remember, not all drugs are listed on the formulary. If Passport Health Plan does not cover your drug, you have 3
options:
1. Work with your pharmacy to find the preferred drug.
2. You can ask Member Services for a list of similar drugs that are preferred by Passport Health Plan.
3. If the drug is denied, you can file an appeal. To find out how to do this, see pages 25 – 28 of your Member
Handbook.
Can the formulary change?
Yes. Passport Health Plan may add or remove drugs from the formulary during the year. To get updated information
about covered drugs, please visit our website at www.passporthealthplan.com or call Member Services at 1-800578-0603 and press 2.
What are generic drugs?
Passport Health Plan covers both brand-name and generic drugs. A generic drug has the same active ingredient as
the brand-name drug. This means they work the same and have the same effect. Generic drugs usually cost less than
brand name drugs and are approved by the Food and Drug Administration (FDA).
How much will I have to pay for covered medicines?
Some Passport Health Plan members pay a small co-pay for each medicine they fill.
The prescription copay is $1.00 for each prescription, including over-the-counter medicines.
Please Note:
• The pharmacy must fill your prescription the first time, even if you cannot pay.
• If you cannot pay the copay when you get your prescription, you should pay it the next time.
• The pharmacy may tell you they will not fill your prescriptions anymore if you do not pay the co-pay.
Those who do not have to pay a co-pay are members who are:
• 18 years and under.
• Pregnant.
• Receiving services within the first 60 days after delivery of a baby.
• In a nursing facility.
• In a personal care home.
• In an intermediate care facility for people with mental retardation (ICF/MR).
• A foster child in state custody.
• American Indians or Alaskan natives served through KCHIP program.
• In hospice care.
ii
PASSPORT HEALTH PLAN
PREFERRED DRUG LIST
2009
GENERIC NAME
ACE INHIBITOR MEDICATIONS
Benazepril
Captopril
Enalapril
Fosinopril
Lisinopril
Perindopril
Trandolapril
BRAND NAME
DOSAGE FORM
Lotensin
Capoten
Vasotec
Monopril
Zestril, Prinivil
Aceon
Mavik
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Capsule, Tablet
Isotretinoin
Minocycline
Tetracycline
Vibramycin,
Periostat
Accutane
Minocin
Sumycin
ACNE MEDICATIONS (TOPICAL)
Adapalene*
Differin*
Gel
Benzoyl Peroxide
Benzoyl Peroxide
Benzoyl Peroxide/ Erythromycin
Clindamycin
Erythromycin
Gentamicin
Metronidazole 0.75%
Mupirocin
Sulfacetamide/Sulfur
Tretinoin*
Benzamycin
Cleocin T
Erycette,
Akne-mycin
Garamycin
Metrogel
Bactroban
Sulfacet-R
Avita*
Cream, Gel,
Solution
Cream
Gel, Solution
Swabs, Gel,
Ointment, Solution
Cream, Ointment
Gel
Ointment
Lotion
Cream, Gel
ALZHEIMERS MEDICATION
Donepezil
Rivastigmine
Aricept
Exelon
Tacrine
Cognex
Tablets, ODT
Capsules, Patches,
Solution
Tablets
ANAPHYLAXIS THERAPY
Epinephrine
Epipen, Epipen Jr
Injection
ANALGESIC MEDICATIONS
Narcotics
Butorphanol
Codeine
Fentanyl Transdermal*
Hydromorphone
Stadol NS
Codeine
Duragesic*
Dilaudid
Meperidine
Methadone
Morphine
Demerol
Dolophine
MSIR
Morphine Extended Release*
Morphine Extended Release
Oxycodone
Oramorph SR, MS Contin
Kadian
Roxicodone
Nasal Spray
Tablet, Solution
Patch
Tablet, Solution,
Suppository
Tablet, Syrup
Tablet
Tablet, Solution,
Suppository
Tablet
Capsules
Tablet, Solution
NOTES
ACNE MEDICATIONS (ORAL)
Doxycycline
Capsule
Capsule
Capsule
*PA Required > 21 yo;
Qty limits: 45gms/30 days
*PA Required > 21 yo;
Qty limits: 45gms/30 days
*Qty limit: 2 injections per 30
days
*Qty limit 10 patches per 30 days
*Qty limit BID dosing
1
GENERIC NAME
Propoxyphene
Tramadol
BRAND NAME
Darvon
Ultram
DOSAGE FORM
Capsule
Tablet
Narcotic Combinations
APAP/Butalbital
APAP/Butalbital/Caffeine
APAP/Butalbital/Caffeine/Codeine
APAP/Codeine
APAP/Hydrocodone
Phrenilin, Phrenilin Forte
Fioricet
Fioricet with Codeine
Tylenol with Codeine
Vicodin, Lortab
Tablet
Tablet
Tablet
Tablet
Tablet
APAP/Oxycodone
APAP/Propoxyphene
ASA/Butalbital/Caffeine
ASA/Butalbital/Caffeine/Codeine
ASA/Oxycodone
Meperidine/Promethazine
Percocet
Darvocet N
Fiorinal
Fiorinal with Codeine
Percodan
Meperidine/Promethazine
Tablet
Tablet
Tablet
Tablet
Tablet
Capsule
NSAIDs (Prescription Strengths Only)
Diclofenac
Diclofenac Sodium ER
Diflunisal
Etodolac IR and SA
Fenoprofen
Flurbiprofen
Ibuprofen
Indomethacin
Indomethacin Sustained Release
Ketoprofen IR
Ketoprofen SA
Meclofenamate
Meloxicam
Nabumetone
Naproxen
Naproxen SA
Oxaprozin
Sulindac
Tolmetin
Cataflam
Voltaren-XR
Dolobid
Lodine, Lodine XL
Nalfon
Ansaid
Motrin
Indocin
Indocin SR
Orudis
Oruvail
Meclofenamate
Mobic
Relafen
Naprosyn
Naprelan
Daypro
Clinoril
Tolectin
Tablet
Tablet
Tablet
Capsule, Tablet
Tablet
Tablet
Tablet, Suspension
Capsule
Capsule
Capsule
Capsule
Capsule
Tablets
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
COX-2 Inhibitors
Celecoxib*
Celebrex*
Capsule
SALICYLATES
Aspirin
Salsalate
Aspirin
Disalcid
Tablet
Capsule
ANDROGENS
Danazol
Methyltestesterone
Oxandrolone
Testosterone Transdermal
Testosterone Transdermal
Testosterone Buccal
Danocrine
Android
Oxandrin
Androgel
Androderm*
Striant
Capsule
Tablet
Tablet
Gel
Patch
Buccal System
ANESTHETICS (TOPICAL)
Capsaicin
Lidocaine
Zostrix
Xylocaine
Lotion, Cream, Gel
Jelly, Ointment
NOTES
5/500mg, 7.5/500mg,
7.5/750mg, 10/500mg,
10/650mg
*Step therapy or PA required
*PA required
2
GENERIC NAME
BRAND NAME
DOSAGE FORM
ANESTHETICS (URINARY)
Phenazopyridine
Pyridium
Tablet
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARB)
Olmesartan*
Benicar*
Tablet
Valsartan*
Diovan*
Tablet
ANORECTALS
Hydrocortisone
Hydrocortisone Enema
Anusol HC
Cortenema
Cream, Suppository
Enema
ANTACIDS
Aluminum/Magnesium Hydroxide
Calcium Carbonate
Magnesium Hydroxide
Aluminum Hydroxide
Sodium Bicarbonate
Mylanta
Tums
MOM
Alternagel
Sodium Bicarbonate
Suspension, Tablets
Suspension, tablet
Suspension
Suspension
Tablet
ANTIADRENERGICS
Clonidine
Doxazosin
Guanfacine
Methyldopa
Prazosin
Reserpine
Terazosin
Catapres
Cardura
Tenex
Aldomet
Minipress
Resperine
Hytrin
Tablet, Patches
Tablet
Tablet
Tablet, Suspension
Capsule
Tablet
Capsule
ANTI-ALCOHOLIC MEDICATIONS
Disulfiram
Antabuse
Tablet
ANTIANDROGENS
Bicalutamide
Flutamide
Nilutamide
Casodex
Eulexin
Nilandron
Tablet
Capsule
Tablet
ANTIARRHYTHMICS
Amiodarone
Disopyramide
Disopyramide Controlled Release
Dofetilide
Flecainide
Mexiletine
Moricizine
Procainamide
Procainamide Sustained Release
Propafenone
Quinidine Gluconate
Quinidine Sulfate
Quinidine Sulfate Sustained Release
Cordarone
Norpace
Norpace CR
Tikosyn
Tambocor
Mexitil
Ethmozine
Pronestyl
Procan SR
Rythmol
Quinaglute
Quinidine
Quinidex
Tablet
Capsule
Capsule
Capsule
Tablet
Capsule
Tablets
Tablet, Capsule
Tablet
Tablet
Tablet
Tablet
Tablet
NOTES
*Step therapy required: T/F of 2
preferred ACE Inhibitors
*Step therapy required: T/F of 2
preferred ACE Inhibitors
3
ANTIBIOTICS (ORAL)
Tetracyclines
Doxycycline
Minocycline
Tetracycline
Vibramycin, Doryx
Minocin
Sumycin
Capsule
Capsule
Capsule
Cephalosporins: First Generation
Cephalexin
Cephradine
Keflex
Velosef
Capsule, Suspension
Capsule, Suspension
Cephalosporins: Second Generation
Cefaclor
Ceclor
Cefuroxime
Ceftin
Cefprozil
Cephalosporins: Third Generation
Cefdinir
Cefixime*
Cefpodoxime
Ceprozil
Capsule
Suspension
Tablet
Suspension
Suspension Only
Omnicef
Suprax*
Vantin
Capsule, Suspension
Tablet, Suspension
Tablet, Suspension
Erythromycins
Azithromycin*
Zithromax*
Tablet, Suspension
Clarithromycin, Clarithromycin ER
Erythromycin Base
Erythromycin Ethylsuccinate
Erythromycin Stearate
Erythromycin/Sulfisoxazole
Biaxin, Biaxin XL *
Ery-Tab, Eryc
E.E.S.
Erythrocin
Pediazole
Tablet, Suspension
Tablet, Capsule
Tablet, Suspension
Tablet
Suspension
Fluoroquinolones
Ciprofloxacin
Cipro
Tablet, Suspension
Levofloxacin*
Moxifloxacin*
Ofloxacin
Levaquin*
Avelox*
Floxin
Tablet, Oral Solution *Qty limit: 5 tab/30 days
Tablet, Suspension
*Qty limit: 5 tab/30 days
Tablet
Miscellaneous
Clindamycin
Cleocin
Capsule, Suspension
Penicillins
Amoxicillin
Amoxicillin/Pot Clavulanate
Ampicillin
Dicloxacillin
Penicillin VK
Amoxil
Augmentin
Principen
Dynapen
PenVee K
Capsule, Suspension
Tablet, Suspension
Capsule, Suspension
Capsule, Suspension
Tablet, Suspension
Sulfonamides
Sulfadiazine
Sulfamethoxazole/Trimethoprim
Sulfisoxazole
Sulfadiazine
Bactrim, Bactrim DS
Gantrisin
Tablet
Tablet, Suspension
Tablets Suspension
Urinary Tract Medications
Fosfomycin
Nitrofurantoin/Macrocrystals/Monohydrate
Nitrofurantoin/Macrocrystals
Trimethoprim
Monurol
Macrobid
Macrodantin
Trimpex, Primsol
Granules
Capsule
Capsule, Suspension
Tablet
ANTIBIOTICS (TOPICAL)
Bacitracin
Polymycin/Bacitracin
Bacitracin
Polysporin
Ointment
Ointment
*Qty limit: QD dosing
*Qty limit: 250mg (6 tab/30days);
500mg (5 tab/30days)
4
Polymycin/Neomycin/Bacitracin
Silver Sulfadiazine
Neosporin
SSD
Ointment
Cream
ANTICOAGULANTS
Warfarin
Coumadin
Tablet
ANTICHOLINERGICS (INHALED)
Ipratropium Solution
Ipratropium Inhaler
Tiotropium
Atrovent
Atrovent
Spiriva
Solution
Inhaler
Inhaler
Capsule
Tablet, Suspension
Tablet
Tablet
Tablet
Levetiracetam
Mephobarbital
Oxcarbazepine
Oxcarbazepine
Phenobarbital
Phenytoin
Diamox
Tegretol
Tegretol XR
Klonopin
Depakote
Depakote Sprinkles
Depakote ER
Zarontin
Neurontin
Lamictal*
Lamictal Dispersible
Chewable
Keppra
Mebaral
Trileptal
Trileptal
Phenobarbital
Dilantin
Primidone
Tiagabine
Valproic Acid
Mysoline
Gabitril
Depakene
ANTICONVULSANTS
Acetazolamide
Carbamazepine
Carbamazepine Sustained Release
Clonazepam
Divalproex Sodium
Divalproex Sodium
Divalproex Sodium
Ethosuximide
Gabapentin
Lamotrigine
Lamotrigine Chewable
Tablet
Capsule, Syrup
Tablet, Capsule
Tablet
Tablet
*Brand is preferred
Tablet
Tablet
Tablet
Suspension
Tablet,Syrup
Tablet
Capsule
Suspension
Tablet, Suspension
Tablet
Capsule, Syrup
ANTIDEPRESSANTS
NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS
Bupropion IR, SR, XL
Wellbutrin IR, SR, XL
Tablet
TETRACYCLICS
Maprotiline
Ludiomil
Tablet
TRIAZOLOPYRIDINES
Trazodone
Desyrel
Tablet
MONOAMINE OXIDASE INHIBITORS
Phenelzine
Tranylcypromine
Nardil
Parnate
Tablet
Tablet
5
TRICYCLICS
Amitriptyline
Amitriptyline/Chlordiazepoxide
Amoxapine
Clomipramine
Desipramine
Doxepin
Imipramine
Nortriptyline
Protriptyline
Mirtazapine
Trimipramine
Elavil
Limbitrol
Ascendin
Anafranil
Norpramin
Sinequan
Tofranil
Pamelor
Vivactil
Remeron
Surmontil
Tablet
Tablet
Tablet
Capsule
Tablet
Capsule
Capsule
Capsule
Tablet
Tablet
Capsule
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI and SNRI)
Citalopram
Celexa
Duloxetine *
Cymbalta*
Tablet
Tablet
Venlafaxine IR
Escitalopram*
Effexor IR
Lexapro*
Tablet
Fluoxetine
Paroxetine, Paroxetine CR
Sertraline
Prozac
Paxil, Paxil CR
Zoloft
Capsule
Tablet
Tablet
ANTIDIARRHEALS
Bismuth Subsalicylate
Diphenoxylate/Atropine
Loperamide
Pepto-Bismol
Lomotil
Imodium
Tablet, Suspension
Tablet, Solution
Capsule, Tablet
ANTIDIURETIC HORMONES
Desmopressin Acetate
DDAVP
Tablet,
*Spray
ANTIEMETICS
Aprepitant
Ondansetron*
Emend
Zofran*
Capsule
Tablet,
Solution
Promethazine
Phenergan
Prochlorperazine Regular Release
Compazine
Tablet, Syrup,
Suppository
Tablet, Syrup,
Suppository
ANTIESTROGENS
Tamoxifen
Toremifene
Nolvadex
Fareston
Tablet
Tablet
ANTIFUNGALS (ORAL)
Fluconazole
Diflucan
Griseofulvin Microsize
Grifulvin V
Griseofulvin Ultramicrosize
Gris-PEG
Tablet,
Suspension
Tablet,
Suspension
Tablet
*Step Therapy: T/F of 2
antidepressants (SSRIs, venlafaxine
IR, bupropion IR, SR,XL) for
4 wks each
*Step Therapy: T/F of citalopram
& 1 of the following(SSRIs,
venlafaxine IR, bupropion IR,
SR,XL) for 4 wks each
*Spray requires PA
*Formulary with PA;
Qty limits: 4mg, 8mg,
15 tab/30 days,
24mg, 5 tab/30 days
Oral Soln. 50ml / 30 days
QL: 150mg tab-4 tablets/28 days
6
Ketoconazole
Nystatin
Nizoral
Mysostatin
Terbinafine
Lamisil
ANTIFUNGALS (TOPICAL)
Gentian Violet
Clotrimazole
Gentian Violet
Lotrimin
Ketoconazole
Miconazole
Nystatin
Nystantin/Triamcinolone
Tolnaftate
Nizoral
Micatin
Mycostatin
Mycolog II
Tinactin
ANTIHISTAMINES (ORAL)
Carbinoxamine
Palgic
Cetirizine
Zyrtec OTC
Cetirizine
Chlorpheniramine
Clemastine
Cyproheptadine
Diphenhydramine
Zyrtec OTC
Chlor-Trimeton
Tavist
Periactin
Benadryl
Hydroxyzine
Atarax
Loratadine OTC
Claritin, Alavert
Promethazine
Phenergan
Triprolidine
Zymine
Tablet
Tablet,
Suspension
Tablet
Solution
Cream
Solution
Lotion
Cream
Cream, Ointment
Cream, Ointment
Cream, Ointment
Cream, Gel
Tablet, Capsule,
Liquid
Tablet,
Chewables
Syrup
Tablet, Syrup
Tablet
Tablet
Capsule
Tablet
Solution
Tablet
Solution
Tablet,
Syrup
Tablet
Solution
Syrup
ANTIHISTAMINE/DECONGESTANT COMBINATIONS (ORAL)
Cetirizine/Pseudoephedrine
Zyrtec-D OTC
Loratadine/Pseudoephedrine
Claritin-D
Pseudoephedrine/Triprolodine
Actifed
Tablet
Tablet
Tablet
ANTIHYPERTENSIVE COMBINATIONS
Amlodipine / Benazepril
Amlodipine/ Valsartan
Lotrel
Exforge
Capsule
Tablet
Atenolol / Chlorthalidone
Benazepril / HCTZ
Bisoprolol / HCTZ
Capotopril / HCTZ
Clonidine / Chorthalidone
Enalapril / HCTZ
Fosinopril / HCTZ
Hydralazine / HCTZ
Lisinopril / HCTZ
Methyldopa / HCTZ
Moexipril / HCTZ
Olmesartin / HCTZ*
Tenoretic
Lotensin
Ziac
Capozide
Clorpres
Vaseretic
Monopril HCT
Apresazide
Zestoretic, Prinizide
Aldoril
Uniretic
Benicar HCT*
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Capsule
Tablet
Tablet
Tablet
Tablet
*Step therapy required: T/F of
2 preferred ACE Inhibitors
*Step Therapy: T/F preferred
ACE-Inhibitors/HCTZ
combination
7
Propranolol/HCTZ
Reserpine/HCTZ
Spironolactone/HCTZ
Trandolapril/Verapamil
Valsartan/HCTZ*
Inderide
Hydropres
Aldactazide
Tarka
Diovan/HCT*
Tablet
Tablet
Tablet
Tablet
Tablet
ANTIHYPERTENSIVES-OTHER
Guanabenz
Wytensin
Tablet
Tablet
Powder
Colestipol
Fenofibrate
Fluvastatin
Gemfibrozil
Lovastatin
Lovastatin/Niacin
Nicotinic Acid
Pravastatin
Simvastatin
Simvastatin/Ezetimibe
Lipitor
Questran,
Questran Light
Colestid
Tricor
Lescol, Lescol XL
Lopid
Mevacor
Advicor
Niacor/Niaspan
Pravachol
Zocor
Vytorin*
ANTIMALARIALS
Chloroquine Phosphate
Hydroxychloroquine
Primaquine
Pyrimethamine
Aralen
Plaquenil
Primaquine
Daraprim
Tablet
Tablet
Tablet
Tablet
Eskalith
Lithobid/
Eskalith CR
Capsule, Solution
Tablet, Solution
ANTINEOPLASTICS
ADJUNCTIVE MEDICATIONS
Leucovorin (Folinic Acid)
Leucovorin
Tablet
ALKYLATING MEDICATIONS
Altretamine
Busulfan
Chlorambucil
Cyclophosphamide
Estramustine
Lomustine
Melphalan
Hexalen
Myleran
Leukeran
Cytoxan
Emcyt
CeeNu
Alkeran
Tablet
Tablet
Tablet
Tablet
Capsule
Capsule
Tablet
Temozolomide
Temodar
Capsule
ANTIMETABOLITES
Capecitabine
Mercaptopurine
Methotrexate
Thioguanine
Xeloda
Purinethol
Rheumatrex
Thioguanine
Tablet
Tablet
Tablet
Capsule
MISCELLANEOUS ANTINEOPLASTICS
Anastrozole
Exemestane
Arimidex
Aromasin
Tablet
Tablet
ANTILIPIDEMICS
Atorvastatin
Cholestyramine
ANTIMANICS
Lithium Carbonate
Lithium Carbonate CR
Tablet
Capsule
Capsule
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
*Step Therapy: T/F preferred
ACE-Inhibitors/HCTZ
combination
*Step Therapy with preferred
generics
8
Fluorouracil
Hydroxyurea
Letrozole
Mitotane
Procarbazine
Efudex
Hydrea
Femara
Lysodren
Matulane
Cream, Solution
Capsule
Tablet
Tablet
Tablet
ANTIPARASITICS
Dapsone
Iodoquinol
Ivermectin
Mebendazole
Metronidazole
Dapsone
Yodoxin
Stromectol
Vermox
Flagyl
Tablet
Tablet
Tablet
Chewable Tablets
Tablets
ANTIPARKINSONIANS
Amantadine
Benztropine
Biperiden
Bromocriptine Mesylate
Carbidopa/Levodopa
Carbidopa/Levodopa/Entacapone
Diphenhydramine
Entacapone
Levodopa
Pramipexole
Ropinirole Hydrochloride
Selegiline
Tolcapone
Trihexyphenidyl
Symmetrel
Cogentin
Akineton
Parlodel
Sinement, Sinemet CR
Stalevo
Benadryl
Comtan
Larodopa
Mirapex
Requip
Eldepryl
Tasmar
Artane
Capsule, Syrup
Tablet
Tablet
Tablet, Capsule
Tablet
Tablet
Capsule, Solution
Tablet
Tablet
Tablet
Tablet
Tablet, Capsule
Tablet
Tablet
ANTIPLATELET AGGREGATION MEDICATIONS
Aspirin
Aspirin
Aspirin/Dipyridamole
Aggrenox
Anagrelide
Agrylin
Cilostazol
Pletal
Clopidogrel
Plavix
Dipyridamole
Persantine
Ticlopidine
Ticlid
Tablet
Capsule
Capsule
Tablet
Tablet
Tablet
Tablet
ANTIPSORIATICS (TOPICAL)
Anthralin
Calcipotriene
Psoriatec
Dovonex
Cream
Cream, Ointment
Calcipotriene
Dovonex
Solution
Tazarotene
Tazorac
ANTIPSYCHOTICS
Apripiprazole
Apripiprazole
Abilify*
Abilify Discmelt
Chlorpromazine
Clozapine
Fluphenazine
Haloperidol
Thorazine
Clozaril
Prolixin
Haldol
Loxapine
Molindone
Olanzapine
Olanzapine
Loxitane
Moban
Zyprexa
Zyprexa Zydis
Perphenazine
Trilafon
Tablet, Solution
Rapid Dissolve
Tab
Tablet
Tablet
Tablet, Injection
Tablet
Solution
Injection
Capsule, Solution
Tablet
Tablet
Oral Disintegrating
Tablet
Tablet
*Injection requires PA
9
Pimozide
Quetiapine
Orap
Seroquel
Tablet
Tablet
Quetiapine SR
Risperidone
Seroquel XR
Risperdal
Thioridazine
Thiothixene
Trifluoperazine
Ziprasidone
Mellaril
Navane
Stelazine
Geodon
Tablet
Tablet,
Solution
Tablet, Solution
Capsule, Solution
Tablet, Solution
Capsule
ANTIRHEUMATICS (RA)
Auranofin
Hydroxychloroquine
Leflunomide
Methotrexate
Penicillamine
Sulfasalazine
Ridaura
Plaquenil
Arava
Rheumatrex
Cuprimine
Azulfidine
Capsule
Tablet
Tablet
Tablet
Capsule
Tablet
ANTISEBORRHEICS (TOPICAL)
Ketoconazole
Selenium Sulfide
Sulfacetamide
Nizoral
Selsun Blue
Klaron
Shampoo
Shampoo
Suspension
ANTISPASMODIC/ANTICHOLINERGICS (GI)
Dicyclomine
Bentyl
Glycopyrrolate
Robinul
Hyoscyamine
Levsin, Levbid
Propantheline
Probanthine
ANTISPASMODIC/ANTICHOLINERGICS (UROLOGICAL)
Darifenacin Hydrobromide
Enablex
Methanamine/Methylene Blue/ Atropine
Urised
/ Hyoscyamine
Oxybutynin
Ditropan
Solifenacin Succinate
Vesicare
Tolterodine
Detrol
Tolterodine Extended Release
Detrol LA
Capsule
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Capsules
ANTITHYROIDS
Methimazole
Potassium Iodide
Propylthiouracil
Tapazole
SSKI
Propylthiouracil
Tablet
Tablet, Solution
Tablet
ANTITUBERCULOSAL MEDICATIONS
Ethambutol
Isoniazid
Pyrazinamide
Rifabutin
Rifampin
Myambutol
Nydrazid
Pyrazinamide
Mycobutin
Rifadin
Tablet
Tablet
Tablet
Capsule
Capsule
ANTIVERTIGO MEDICATION
Meclizine
Antivert
Tablet
ANTIVIRALS (ORAL)
Acyclovir
Zovirax
Capsules
Ointment*
Famciclovir
Ganciclovir
Valacyclovir
Famvir
Cytovene
Valtrex
Tablet
Capsule
Tablet
*PA Required for
Ointment
10
ANTIVIRALS (TOPICAL)
Docosanol
Penciclovir
Abreva
Denavir
Cream
Cream
ANXIOLYTICS
Alprazolam
Buspirone
Chlordiazepoxide
Clorazepate
Diazepam
Lorazepam
Oxazepam
Xanax
Buspar
Librium
Tranxene
Valium
Ativan
Serax
Tablet
Tablet
Capsule
Tablet
Tablet
Tablet
Tablet
BENIGN PROSTATIC HYPERPLASIA MEDICATIONS
Doxazosin
Cardura
Dutasteride
Avodart
Finasteride
Proscar
Tamsulosin
Flomax
Terazosin
Hytrin
Tablet
Capsule
Tablet
Capsule
Capsule
BETA AGONISTS (INHALED)
Albuterol Aerosol
Albuterol Solution*
Isoetharine
Levalbuterol
Ventolin HFA
Proventil
Isotharine
Xopenex*
Inhaler
Solution
Solution
Solution
Metaproterenol
Salmeterol
Alupent
Serevent
Inhaler, Solution
Inhaler
BETA AGONISTS (ORAL)
Albuterol
Formoterol
Terbutaline
Proventil
Foradil
Brethine
Syrup, Tablet
Inhaler
Tablet
BETA AGONIST/ANTICHOLINERGIC COMBINATIONS (INHALED)
Ipratropium/Albuterol
Combivent
Inhaler
BETA AGONIST/CORTICOSTEROID COMBINATIONS (INHALED)
Fluticasone/Salmeterol
Advair, Advair HFA
Budesonide/Formeterol
Symbicort
Inhaler
Inhaler
BETA BLOCKERS (ORAL)
Atenolol
Carvedilol
Carvedilol
Labetalol
Metoprolol
Nadolol
Pindolol
Propranolol, Propranolol SR
Tenormin
Coreg
Coreg CR
Trandate
Lopressor, Toprol XL
Corgard
Visken
Inderal, Inderal LA
Sotalol
Timolol
Betapace
Blocadren
Tablet
Tablet
Capsule
Tablet
Tablet
Tablet
Tablet
Tablet
Capsule
Solution
Tablet
Tablet
BONE RESORPTION SUPPRESSORS
Alendronate
Fosamax
Tablet
Alendronate/Vit D3
Fosamax-D
Tablet
*0.083%, 0.5 %
*Pulmonologists only;
Qty limit 120 vials/30 days
11
Calcitonin
Etidronate
Raloxifene
Risedronate
Miacalcin
Didronel
Evista
Actonel
Spray
Tablet
Tablet
Tablet
BURN THERAPY (TOPICAL)
Silver Sulfadiazine
Silvadene
Cream
CALCIUM CHANNEL BLOCKER
Amlodipine
Diltiazem
Diltiazem Extended Release
Nifedipine Sustained Release
Nisoldipine
Verapamil
Verapamil SR
Norvasc
Cardizem
Cardizem CD, LA
Adalat CC
Sular
Calan
Calan SR
Tablet
Tablet
Capsule, Tablet
Tablet
Tablet
Tablet
Tablet
CALCIUM METABOLISM
Calcitriol
Dihydrotachysterol (DHT)
Ergocalciferol
Rocaltrol
Vitamin D
Vitamin D 2
Capsule
Tablet
Capsule
CARDIAC GLYCOSIDES
Digoxin
Lanoxin
Tablet
CHELATORS
Succimer
Chemet
Capsule
CHOLINERGICS (URINARY)
Bethanechol
Urecholine
Tablet
CHOLINERGIC MUSCLE STIMULANTS
Neostigmine
Pyridostigmine
Prostigmin
Mestinon
Tablet
Tablet
CNS STIMULANTS
Atomoxetine*
Dexmethylphenidate Hydrochloride
Dexmethylphenidate Hydrochloride
Dextroamphetamine
Methylphenidate Controlled Release
Methylphenidate Sustained Release
Methylphenidate
Mixed Amphetamines Extended Release
Mixed Amphetamines
Lisdexamphetamine Dimesylate
Strattera*
Focalin
Focalin XR
Dexedrine
Concerta
Ritalin SR
Ritalin
Adderall XR
Adderall
Vyvanse
Capsule
CONTRACEPTIVE, INJECTABLES
Medroxyprogesterone*
Depo-Provera*
Injection
CONTRACEPTIVES, ORAL
Ethinyl Estradiol 50 mcg/ Norgestrel 0.5 mg
Ethinyl Estradiol 50mcg/Ethynodiol 1 mg
Ethinyl Estradiol 35 mcg/ Ethynodiol 1mg
Ethinyl Estradiol 30 mcg/Norgestrel 0.3 mg
Ethinyl Estradiol 30mcg/ Desogestrel 0.15 mg
Ethinyl Estradiol 35mcg/Norethindrone 1mg
Ethinyl Estradiol 30 mcg/Norethindrone 1.5mg
Ethinyl Estradiol 20 mcg/Norethindrone 1mg
Ethinyl Estradiol 20 mcg/Levonorgestrel 0.1 mg
Ovral
Demulen 1/50, Zovia 1/50
Demulen 1/35, Zovia 1/35
LoOvral, Low-Ogestrol
Desogen, Ortho-Cept
Nelova 1/35
Loestrin 1.5/30
Loestrin 1/20
Alesse
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
*Prior Auth Required
Capsule
Tablet
Tablet
Tablet, Capsule
Tablet
Capsule
Tablet
Capsule
*Female only
12
Ethinyl Estradiol 35 mcg/ Norethindrone 0.5 mg
Ethinyl Estradiol 35 mcg/ Norethindrone 0.4 mg
Ethinyl Estradiol 35 mcg/ Norgestimate 0.25 mg
1 mg norethindrone/50 mcg mestranol
Ethinyl Estradiol 35mcg/Norethindrone 1mg
Modicon
Ovcon-35
Mononessa, Ortho-Cyclen
Ortho-Novum 1/50, Necon
Ortho-Novum 1/35,
Necon 1/35
Ethinyl Estradiol 30 mcg/ Drospirenone 3 mg
Yasmin
Ethinyl Estradiol 30mcg/ Levonorgestrel 0.15mg Levora
Ethinyl Estradiol/Desogestrel/
Cyclessa
Ethinyl Estradiol/Norethindrone/
Estrostep FE
Ethinyl Estradiol 35/Norethindrone0.75
Ortho-Novum 777, Necon 777
Ethinyl Estradiol 35/ Norgestimate 0.18
Ortho Tri-Cyclen/Trinessa
Ethinyl Estradiol 35/Norethindrone 0.5
Tri-Norinyl
Norethindrone 0.35 mg
Ortho-Micronor
Ethinyl Estradiol 10, 20mcg/ Desogestrel 0.15mg Mircette
Ethinyl Estradiol 35/Norethindrone0.5, 1 mg
Ortho-Novum/Necon 10/11
Ethinyl Estradiol 30,40mcg/
Triphasil, Trivora
Levonorgestrel .05,.075,.125
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
CORTICOSTEROIDS (INHALED)
Beclomethasone
Budesonide*
QVAR
Pulmicort*
Inhaler
Inhaler,
Respules*
Flunisolide
Fluticasone
Fluticasone/Salmeterol
Mometasone Furoate
Triamcinolone
Aerobid, Aerobid-M
Flovent HFA
Advair, Advair HFA
Asmanex Twisthaler
Azmacort
Inhaler
Inhaler
Inhaler
Inhaler
Inhaler
CORTICOSTEROIDS (ORAL)
Cortisone
Dexamethasone
Fludrocortisone
Hydrocortisone
Methylprednisolone
Prednisolone
Prednisone
Cortone
Decadron
Florinef
Hydrocortisone
Medrol
Orapred
Orasone
Tablet
Tablet, Solution
Tablet
Tablet
Tablet
Syrup
Tablet, Solution
Diprolene
Temovate
Ointment
Cream, Ointment,
Solution
Amcinonide 0.1%
Betamethasone Dipropionate 0.05%
Betamethasone Valerate 0.1%
Desoximetasone 0.25%
Desoximetasone 0.05%
Diflorasone Diacetate 0.05%
Fluocinolone 0.2%
Fluocinolone 0.05%
Cyclocort
Diprosone
Valisone
Topicort
Topicort
Psorcon
Synalar
Lidex
Triamcinolone Acetonide 0.5%
Kenalog
Cream
Cream, Ointment
Ointment
Cream, Ointment
Gel
Cream, Ointment
Cream
Ointment
Cream
Gel
Cream
Ointment
*PA Required: >5 years old
*QD dosing for 0.25mg/2ml
*QD-BID dosing for 0.5mg/2ml
*QD dosing for 1mg/2ml
CORTICOSTEROIDS (TOPICAL)
Group I (Very High Potency)
Augmented Betamethasone Dipropionate
Clobetasol 0.05%
Group II (High Potency)
13
Group III (Medium Potency)
Betamethasone Dipropionate 0.05%
Betamethasone Valerate 0.1%
Desoximetasone 0.05%
Fluocinolone Acetonide 0.025%
Diprosone
Valisone
Topical LP
Synalar
Fluticasone 0.05%, 0.005%
Hydrocortisone Valerate 0.2%
Mometasone 0.1%
Triamcinolone Acetonide 0.025%
Cutivate
Westcort
Elocon
Kenalog
Triamcinolone Acetonide 0.1%
Kenalog
Lotion
Cream
Cream
Ointment
Cream
Cream, Ointment
Cream, Ointment
Ointment
Ointment, Cream,
Lotion
Ointment, Cream,
Lotion
Group IV (Low Potency)
Desonide 0.05%
Fluocinolone Acetonide 0.01%
Hydrocortisone 0.5%, 1%, 2.5%
DesOwen
Synalar
Hytone
Cream
Cream, Solution
Cream, Ointment,
Lotion
Cream, Lotion,
Ointment
Hydrocortisone/Pramoxine
Pramosone
COUGH/COLD MEDICATIONS
Benzonatate
Brompheniramine/Phenylephrine
Brompheniramine/Pseudoephedrine
Brompheniramine/Pseudoephedrine/Dextro.
Chlorpheniramine/Phenylephrine
Tessalon
Bromfed PD
Bromfed
Bromfed DM, Rondec DM
Rynatan
Chlorpheniramate/Phenylephrine HCl
Chlorpheniramine/ Phenylephrine HCl
Chlorpheniramine/Pseudoephedrine/Dextro.
Guaifenesin
Guaifenesin /Codeine
Guaifenesin /Dextromethorphan
Guaifenesin /Hydrocodone
Guaifenesin /Phenylephrine
Guaifenesin /Pseudoephedrine
Guaifenesin /Pseudoephedrine/Dextro.
Hydrocodone/Homatropine
Phenyephrine/Pyrilamine/Chlorpheniramine
Promethazine/Codeine
Promethazine/Phenylephrine
Promethazine/Phenylephrine/Codeine
Pseudoephedrine/Chlorpheniramine
Pseudoephedrine/Hydrocodone
Rondec
Rondec Drops
Rondec DM Drops
Mucinex
Cheracol
Humibid DM
Hycotuss
Despec
Robitussin PE, Entex PSE
Tussin Cough and Cold
Hycodan
R-Tannate
Phenergan/Codeine
Phenergan VC
Phenergan VC/Codeine
Deconamine Deconamine SR
HC Tussive-D
Capsule
Capsule
Capsule
Syrup
Tablet
Oral Suspension
Syrup
Drops
Drops
Tablets
Syrup
Tablet
Syrup
Liquid
Syrup, Tablet
Syrup, Capsule
Syrup, Tablet
Oral Suspension
Syrup
Syrup
Syrup
Tablet, Capsule
Syrup
DECONGESTANTS (ORAL)
Pseudoephedrine
Sudafed
Tablet, Solution
DIURETICS
Amiloride
Amiloride/ Hydrochlorothiazide
Bumetanide
Chlorothiazide
Chlorthalidone
Furosemide
Hydrochlorothiazide
Indapamide
Methyclothiazide
Midamor
Moduretic
Bumex
Diuril
Hygroton
Lasix
Oretic
Lozol
Enduron
Tablet
Tablet
Tablet
Tablet, Suspension
Tablet
Tablet, Solution
Tablet, Solution
Tablet
Tablet
14
Metolazone
Spironolactone
Spironolactone/Hydrochlorothiazide
Torsemide
Triamterene
Triamterene/Hydrochlorothiazide
Zaroxolyn
Aldactone
Aldactazide
Demadex
Dyrenium
Maxide, Dyazide
Tablet
Tablet
Tablet
Tablet
Capsule
Tablet, Capsule
ELECTROLYTES
Calcium Acetate
Calcium Carbonate
PhosLo
Tums
Calcium Carbonate/Vitamin D
Magnesium Chloride
Magnesium Oxide
Oral Electrolyte Solution*
Oscal + D
Slow Mag
Mag Ox
Pedialyte*
Tablet
Tablet
Suspension
Tablet
Tablet
Tablet
Solution
Potassium Chloride
K-Dur
Potassium Gluconate
Sodium/Potassium Phosphates
Kaon
Neutra-Phos
Tablets,
Capsules,
Solution
Solution
Packet
ELECTROLYTE DEPLETERS
Sevelamer Carbonate
Sevelamer HCL
Sodium Polystyrene
Renagel
Renvela
Kayexalate
Tablet
Tablet
Suspension
ESTROGENS- FEMALE PATIENTS ONLY
Conjugated Estrogens
Esterified Estrogens
Estradiol
Estradiol Transdermal
Estrogen Vaginal
Estropipate
Premarin
Tablet
Menest
Tablet
Estrace
Tablet
Climara, Alora, Estraderm,VivellePatch
Premarin
Cream
Ortho-Est
Tablet
*Children 12 and under;
Qty limit of 6000 ml
ESTROGEN/PROGESTIN COMBINATIONS- FEMALE PATIENTS ONLY
Conjugated Estrogens/Medroxyprogesterone
Prempro, Premphase
Tablet
Ethinyl Estradiol 5mcg/Norethindrone 1mg
Femhrt
Tablet
ESTROGEN/ANDROGEN COMBINATIONS
Estrogen/Methyltestosterone
Estratest
Tablet
GALLSTONE SOLUBILIZERS
Ursodiol
Actigall
Capsule
GI MEDICATIONS, MISCELLANEOUS
Lubiprostone
Amitiza
Capsule
Mesalamine
Asacol, Pentasa,
Canasa
Capsule,
Suppository
Misoprostol
Olsalazine
Pentosan Polysulfate Sodium
Simethicone
Cytotec
Dipentum
Elmiron
Gas-X
Sucralfate
Sulfasalazine
Carafate
Azufidine
Tablet
Tablet
Capsule
Tablets,
Drops,
Chew Tabs
Tablets
Tablet
*Diagnosis Required:
Chronic Idiopathic Constipation
Irritable Bowel Syndrome
15
GI STIMULANTS
Metoclopramide
Reglan
Tablet, Solution
GLUCOSE ELEVATORS
Glucagon
Glucagon
Syringe
GOUT MEDICATIONS
Allopurinol
Colchicine
Probenecid
Sulfinpyrazone
Zyloprim
Colchicine
Probenecid
Anturane
Tablet
Tablet
Tablet
Tablet, Capsule
H2 RECEPTOR ANTAGONISTS
Cimetidine
Famotidine
Nizatidine
Ranitidine
Tagamet
Pepcid
Axid
Zantac
Tablets
Tablets
Capsule
Tablet, Solution
HEMORRHEOLOGIC AGENTS
Pentoxifyline
Trental
Tablet
HEMOSTATICS
Aminocaproic Acid
Amicar
Tablet
HIV/AIDS THERAPY
Non-Nuclease Reverse Transcriptor Inhibitor
(NNRTIs)
Lamivudine/Zidovudine
Emtricitabine
Lamivudine (3TC)*
Abacavir/Lamivudine
Zidovudine (AZT)
Combivir
Emtriva
Epivir, Epivir-HBV*
Epzicom
Retrovir
Abacavir/Lamivudine/Zidovudine
Emtricitabine/Tenofovir
Didanosine (DDI)
Tenofovir
Stavudine (D4T)
Abacavir
Efavirenz/ Emtricitabine/Tenofovir
Trizivir
Truvada
Videx EC
Viread
Zerit
Ziagen
Atripla
Tablet
Capsule
Tablet, Solution*
Tablet
Capsule
Tablet
Syrup
Tablet
Tablet
Tablet
Tablet
Capsule, Powder
Tablet, Solution
Tablet
Nuclease Reverse Transcriptor Inhibitor
(NRTIs)
Nevirapine
Efavirenz
Delavirdine
Viramune
Sustiva
Rescriptor
Tablet
Capsule
Tablet
Protease Inhibitors (PI)
Atazanavir
Darunavir Ethanolate
Fosamprenavir
Reyataz
Prezista
Lexiva
Indinavir
Nelfinavir
Ritonavir
Ritonavir/Lopinavir
Saquinavir
Crixivan
Viracept
Norvir
Kaletra
Invirase
Capsule
Tablet
Tablet
Suspension
Capsule
Tablet, Powder
Capsule, Solution
Capsule, Solution
Capsule
*Solution Requires PA
16
HYPOGLYCEMIC (ORAL)
Chlorpropamide
Glimepiride
Glipizide
Glipizide Extended Release
Glyburide
Glyburide/Metformin
Glyburide Micronized
Metformin
Metformin ER
Nateglinide*
Pioglitazone*
Pioglitazone/Glimepiride*
Pioglitazone/Metformin*
Rosiglitazone*
Rosiglitazone/Glimepiride*
Rosiglitazone/Metformin*
Sitagliptin*
Sitagliptin / Metformin*
Tolbutamide
Diabinese
Amaryl
Glucotrol
Glucotrol XL
Micronase
Glucovance
Glynase
Glucophage
Glucophage XR
Starlix*
Actos*
Duetact*
Actoplus Met*
Avandia*
Avandaryl*
Avandamet*
Januvia*
Janumet*
Tolbutamide
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
IMMUNOSUPPRESSIVES
Azathioprine
Cyclosporine
Mycophenolate Mofetil
Mycophenolate Sodium
Tacrolimus
Imuran
Neoral/Sandimmune
Cellcept
Myfortic
Prograf
Tablet
Capsule
Capsule
Tablet
Capsule
INSULINS
Human Insulin
Human Insulin
Insulin Detemir
Insulin Glargine
Humulin
Humalog
Levemir
Lantus
Vial, Pen
Vial, Pen
Vial, Pen
Vial, Cartridge, Pen
INTRANASAL ANTIHISTAMINES
Azelastine
Astelin
Spray
INTRANASAL MAST CELL STABILIZERS
Cromolyn Nasal
Nasalcrom
Spray
INTRANASAL STEROIDS
Budesonide
Fluticasone
Mometasone
Rhinocort Aqua
Flonase
Nasonex
Spray
Spray
Spray
LAXATIVES
Bisacodyl
Dulcolax
Dibasic/Monophasic NaPhosphate
Docusate Calcium
Docusate Sodium
Docusate/Senna
Electrolytes and Laxative Solution
Glycerin
Lactulose
Magnesium Citrate
Magnesium Hydroxide
Methylcellulose
Mineral Oil
Polyethylene Glycol, Polyethylene Glycol 3350
Psyllium
Senna
Fleet Enema
Surfak
Colace
Peri-colace
Nulytely
Glycerin
Cephulac
Mag Citrate
MOM
Citrucel
Mineral Oil
Miralax, Miralax OTC
Metamucil
Senokot
Tablet
Suppository
Enema
Capsule
Capsule, Syrup
Capsule
Powder
Suppository
Syrup
Solution
Suspension
Powder
Liquid, Emulsion
Powder
Powder
Tablet, Granules
*Step Therapy: concurrent
use of metformin, sulfonylureas,
or TZD’s
17
LEUKOTRIENE RECEPTOR ANTAGONISTS
Montelukast
Singulair
Tablet
MAST CELL STABILIZERS (INHALED)
Cromolyn Sodium Inhaler
Cromolyn Sodium Solution
Intal
Intal
Inhaler
Solution
METABOLIC DEFICIENCY AGENTS
Levocarnitine
Carnitor
Tablet
MIGRAINE AND CLUSTER HEADACHE THERAPY
APAP/Dichloralphenazone/Isometheptene
Midrin
Eletriptan*
Relpax*
Ergotamine/Caffeine
Cafergot
Capsule
Tablet
Tablet
*Qty limit: up to 12 tab/ 30 days
Zolmitriptan*
Zomig, Zomig ZMT*
Tablet/
Nasal Spray
*Qty limit:: up to 12 tab/ 30 days
Nasal Spray (6 units/30 days)
Sumatriptan*
Imitrex*
*Qty limit:: up to 12 tabs/ 30 days
Nasal Spray (6 units/ 30 days)
Sumatriptan*
Imitrex*
Tablet,
Nasal Spray,
Injection
Injection
MUCOLYTICS
Acetylcysteine
Mucomyst
Solution
MUSCLE RELAXANTS
Baclofen
Carisoprodol
Carisoprodol/ASA
Carisoprodol/ASA/Codeine
Chlorzoxazone
Cyclobenzaprine
Dantrolene
Methocarbamol
Orphenadrine
Orphenadrine/ASA/Caffeine
Tizanidine*
Lioresal
Soma
Soma Compound
Soma Compound w/ Codeine
Parafon Forte
Flexeril
Dantrium
Robaxin
Norflex
Norgesic
Zanaflex*
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Capsule
Tablet
Tablet
Tablet
Tablet
NARCOTIC ANTAGONISTS
Naltrexone
ReVia
Tablet
NITRATES
Isosorbide Dinitrate
Isosorbide Dinitrate Sustained Release
Isosorbide Mononitrate
Nitroglycerin Ointment
Nitroglycerin Oral
Nitroglycerin SL
Transdermal Nitroglycerin
Isordil
Isordil SA
Imdur, Monoket
Nitro-Bid
Nitro-Time
Nitrostat
Nitro-Dur
Tablet
Tablet
Tablet
Ointment
Capsule
Tablet
Patch
OPHTHALMIC ALPHA-2 ADRENERGIC AGONISTS
Brimonidine
Alphagan
Drop
OPHTHALMIC ANTIBIOTICS
Bacitracin
Bacitracin/Polymyxin
Ciprofloxacin
Ointment
Ointment
Drops, Ointment
Bacitracin
Polyysporin
Ciloxan
* Qty limit :(4 injections/ 30 days)
*Capsules require PA
18
Erythromycin
Gatifloxacin*
Gentamicin Sulfate
Neomycin/Polymyxin/Gramicidin
Neomycin/Polymyxin/Bacitracin
Ofloxacin
Polymyxin/Trimethoprim
Sulfacetamine
Tobramycin
Ilotycin
Zymar*
Garamycin
Neosporin
Neosporin
Ocuflox
Polytrim
Bleph 10
Tobrex
Ointment
Drops
Drops
Drops
Ointment
Drop
Drop
Drop, Ointment
Drop, Ointment
Drops
Olopatadine*
Zaditor OTC,
Alaway
Patanol, Pataday*
OPHTHALMIC ANTIVIRALS
Trifluridine
Viroptic
Drop
Betoptic S
Ocupress
Betagan
OptiPranolol
Timoptic,
Timoptic-XE
Drops
Drop
Drop
Drops
Drop, Gel
Crolom
Drop
OPHTHALMIC ANTIHISTAMINES
Ketotifen Fumarate
OPHTHALMIC BETA BLOCKERS
Betaxolol
Carteolol
Levobunolol
Metipranolol
Timolol
OPHTHALMIC MAST CELL STABILIZER
Cromolyn Sodium
Drops
OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS
Brinzolamide
Azopt
Drop
OPTHALMIC CHOLINESTERASE INHIBITORS
Echothiophate Iodide
Phoshpholine Iodide
Drop
OPTHALMIC DIRECT ACTING MIOTICS
Carbachol
Pilocarpine
Pilocarpine
Drop
Drop
Gel
Isopto Carbachol
Pilocar
Pilopine HS
OPHTHALMIC PROSTAGLANDINS AGONISTS
Latanoprost
Xalatan
Drop
SYMPATHOMIMETICS:
Apraclonidine
Iopidine
Drop
OPHTHALMIC MYDRIATICS
Dipivefrin
Epinephrine
Propine
Epifrin
Drop
Drop
OPHTHALMIC NON-STEROIDALS
Flurbiprofen
Ketorolac
Ocufen
Acular, Acular PF
Cyclosporine*
Restasis*
Drop
Drop,
Droperette
Droperette
OPHTHALMIC STEROID/ANTIBIOTIC
COMBINATIONS
Neomycin/Polymyxin/Dexamethasone
Maxitrol
Ointment
*Ophthalmologists only
*Step Therapy: Zaditor OTC/
Alaway first
*Step therapy: Generic artificial
tears OR rheumatologist OR
ophthalmologist
19
Neomycin/Polymyxin/HC
Cortisporin
Sulfacetamide 10%/Prednisolone .25%
Tobramycin/Dexamethasone
Vasocidin
Tobradex
OPHTHALMIC STEROIDS
Dexamethasone
Decadron
Fluorometholone
Prednisolone
Prednisolone
FML, FML Forte,
FML SOP
Pred Forte
Pred Mild
OPTHALMIC VASOCONSTRICTOR DECONGESTANTS
Phenylephrine
Neo-Synephrine
Naphazoline
Albalon
Drop,
Ointment
Drops
Drops
Drop,
Ointment
Drop,
Ointment
Drop
Drop
Drop
Drop
ORAL, MISCELLANEOUS
Chlorhexidine
Sodium Fluoride
Peridex
Prevident
Lidocaine Viscous
Lidocaine Viscous
Liquid
Gel, Solution, Tabs,
Cream, Paste
Liquid
OTIC ANTIBIOTICS
Acetic Acid
Acetic Acid/ Aluminum Acetate
Ciprofloxacin/Dexamethasone
Ofloxacin
Vosol
Domeboro Otic
Ciprodex Otic
Floxin Otic
Drop
Drop
Suspension
Drop
OTIC, MISCELLANEOUS
Antipyrine/Benzocaine
Antipyrine/Benzocaine
Drop
OTIC, STEROID/ANTIBIOTIC COMBINATIONS
Acetic Acid/Hydrocortisione
Vosol HC
Neomycin/Polymyxin/Hydrocortisone
Cortisporin
Drop
Drop
OXYTOCICS
Methylergonovine
Methergine
Tablet
PANCREATIC ENZYMES
Amylase/Lipase/Protease
Pancreaslipase
Lipram, Viokase
Creon
Capsule
Capsule
PHEOCHROMOCYTOMA
MEDICATIONS
Metyrosine
Phenoxybenzamine
Demser
Dibenzyline
Capsule
Capsule
PROGESTINS
Medroxyprogesterone
Megestrol
Provera
Megace
Megestrol
Megace ES*
Tablet
Tablet,
Suspension
Suspension
PROTON PUMP INHIBITORS
Lansoprazole*
Prevacid*
Solutabs
Omeprazole OTC
Omeprazole
Prilosec OTC
Prilosec
Tablet
Capsule
*PA required
*Step Therapy: Prior use of
Omeprazole within the past 12
months. Qty limit: 1 cap/day.
40mg: use 2-20mg caps/tab
20
Pantoprazole*
Protonix
PULMONARY ARTERIAL HYPERTENSION MEDICATION
Sildenafil Citrate*
Revatio*
Tablet
*Step Therapy:
Prior use of Omeprazole
within the past 12 months.
Qty limit: 1 cap/day.
Tablet
*Diagnosis Required:
Pulmonary Arterial
Hypertension
SCABICIDES/PEDICULICIDES
Crotamiton
Lindane*
Eurax
Kwell*
Malathion*
Permethrin 1%
Permethrin 5%
Ovide*
Nix
Elimite
Cream, Lotion
Lotion,
Shampoo
Lotion
Lotion
Cream
SEDATIVES HYPNOTICS
Estazolam
Meprobamate
Ramelteon
Temazepam
Triazolam
Zalpelon
Zolpidem
Prosom
Equanil
Rozerem*
Restoril
Halcion
Sonata
Ambien
Tablet
Tablet
Tablet
Capsule
Tablet
Tablet
Tablet
THYROID HORMONES
Levothyroxine
Liothyronine
Synthroid
Cytomel
Tablet
Tablet
TOPICAL ENZYMES (DEBRIDING MEDICATIONS)
Papain/Urea
Accuzyme
Trypsin
Granulex
*Step Therapy Required
*Step Therapy Required
1 st Line agent
1 st line agent
* Step Therapy Required
Ointment
Spray
TOPICALS, MISCELLANEOUS
Imiquimod
Pimecrolimus
Podofilox
Aldara*
Elidel*
Condylox
Tacrolimus
Protopic*
VAGINAL ANTI-INFECTIVES
Clotrimazole
Gyne-Lotrimin
Fluconazole*
Diflucan*
Metronidazole Vaginal
Miconazole
Metrogel Vaginal
Monistat
Nystatin
Tioconazole
Triple Sulfa Vaginal
Mycostatin
Vagistat
Sultrin
Gel
Suppository,
Cream
Tablet
Ointment
Cream
VASODILATORS
Hydralazine
Minoxidil
Apresoline
Loniten
Tablet
Tablet
XANTHINES
Aminophylline
Aminophylline
Tablet,
Liquid
Cream
Cream
Gel,
Solution
Ointment
Suppository,
Cream
Tablet
*PA Required
*Preferred for < 18 yo
*PA required
Qty Limit:: 150mg 4 tab/28 days
21
Theophylline
Uniphyl, Theodur
Liquid,
Capsule,
Tablet
22
© 2009 PASSPORT HEALTH PLAN (PHA-09101)

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