Formulary Guide - Horizon NJ Health

horizonNJhealth.com
Formulary
Guide
January 2015
Horizon NJ Health is part of the Horizon Blue Cross Blue Shield of New Jersey enterprise,
an independent licensee of the Blue Cross and Blue Shield Association.
© 2015 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, NJ 07105
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 request prior authorization or for a hard copy of the formulary, 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 as well as a listing of
limitations, prior authorization criteria, generic substitution procedures, step therapy
procedures and other pharmaceutical management methods are available via the Internet
at www.horizonNJhealth.com.
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 – January 2015
1
ADRENOCORTICAL STEROIDS
$$
$$
$$
$$
GlUcocorticoids
* + prednisolone, oral solution
* + hydrocortisone
* + methylprednisolone
* + dexamethasone
ANDROGENS
TESTOSTERONE REPLACEMENT THERAPY
$$$$ * @ Testoderm, Androderm
$$$$ * @ Androgel 1%
$$$$ * @ Striant
ANTIINFECTIVES
PENICILLINS
$+penicillin
$+ampicillin
$
* +amoxicillin
$+dicloxacillin
$$ * +amoxicillin clavulanate
$$ Bicillin LA
$$$ * Augmentin XR
TETRACYCLINES
$
$$
$$$
$$$
+ doxycycline hyclate
+ tetracycline HCI
+ minocycline HCL caps
+ doxycycline monohydrate
$
$$
$$
$$
$$
$$
$$
!!!!!!
+ cephalexin
+ cefaclor, cefadroxil
* + cefdinir
* + cefpodoxime
* + cefprozil
+ cefuroxime
* Spectracef
+ ceftriaxone
CEPHALOSPORINS
2
Formulary Guide – January 2015
$
$
$
$
$
$$
$$
ERYTHROMYCINS AND OTHER MACROLIDES
+ erythromycin base, delayed release tabs & caps
+ erythromycin ethylsuccinate
+ erythromycin stearate
+ erythromycin w/sulfisoxazole
* + clarithromycin, SR
* + azithromycin
PCE $$
$$
$$$
$$$
QUINOLONES
* + ciprofloxacin (1 year and older)
* + levofloxacin (12 years and older)
* + ciprofloxacin ER (18 years and older)
* + moxifloxacin (12 years and older)
$
$
$
$
SULFAS AND RELATED AGENTS
+ sulfisoxazole
+ sulfadiazine
* + sulfamethoxazole and trimethoprim
+ sulfisoxazole and erythromycin
URINARY TRACT AGENTS
$
+ trimethoprim
$$ + nitrofurantoin macrocrystals
$$$ + methenamine mandelate, hippurate
ANTIFUNGAL AGENTS
$
+ griseofulvin ultramicrosize
$
* + nystatin
$$ * + fluconazole
$$$ * + terbinafine tablets
$$$ * + itraconazole
$$$ + flucytosine
$$$$ * Sporanox oral solution
$$$$ * + voriconazole
$$$$ * Noxafil
!!!!!! @ Ambisome
$
$
$
$
$$
$$$
ANTIMALARIAL AGENTS
+ chloroquine
* + mefloquine
+ primaquine
+ quinine
+ atovaquone/proguanil
* Coartem
Formulary Guide – January 2015
3
ANTIRETROVIRAL AGENTS
Some members may have their HIV/AIDS medications covered through
the AIDS Drugs Distribution Program (ADDP).
$$$$ !!!!!!
!!!!!! !!!!!! !!!!!! $$$$ !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! $$$$ $$$$ !!!!!! $$$$ !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! $$$$ !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! $$$$ * @ + abacavir
* @ Aptivus
* @ Atripla
* @ Complera
* @ Crixivan
* @ + didanosine
* @ Edurant
* @ Emtriva
* @ Epzicom
* @ Fuzeon
* @ Intelence
* @ Invirase
* @ Isentress
* @ Kaletra
* @ + lamivudine
* @ + lamivudine/zidovudine
* @ Lexiva
* @ + nevirapine
* @ Norvir
* @ Prezista
* @ Rescriptor
* @ Reyataz
* @ Selzentry
* @ + stavudine
* @ Stribild
* @ Sustiva
* @ Trizivir
* @ Truvada
* @ Videx
* @ Viracept
* @ Viramune XR
* @ Viread
* @ + zidovudine
MISCELLANEOUS ANTIVIRALS
$
↓ + amantadine
$$ * @ + ribavirin tablets, capsules
$$$ + acyclovir
$$$ * Relenza (5 years and older)
$$$ * Tamiflu
$$$ * + valacyclovir
$$$$ * Famvir
4
Formulary Guide – January 2015
MISCELLANEOUS ANTIVIRALS (Continued)
!!!!!! * Valcyte, Cytovene
!!!!!! * @ Victrelis
!!!!!! * @ Incivek
CARDIOVASCULAR
BETA BLOCKERS
+ bisoprolol
+ atenolol, metoprolol
+ timolol, pindolol
+ carvedilol
+ nadolol
+ propranolol
* + propranolol LA
+ labetalol
* + acebutolol
* + betaxolol
* + metoprolol ER
CALCIUM CHANNEL BLOCKERS
$
* + amlodipine
$
+ diltiazem, SR
$
+ verapamil, long acting
$
+ nifedipine
$
* + nicardipine
$$ * + nifedipine XL
$$$$ * Nymalize
ACE INHIBITORS
$
* + fosinopril, hydrochlorothiazide
$
* + captopril, hydrochlorothiazide
$
* + moexipril, hydrochlorothiazide
$$ * + enalapril, hydrochlorothiazide
$$ * + lisinopril, hydrochlorothiazide
$$ * + perindopril
$$ * + quinapril, hydrochlorothiazide
$$ * + ramipril
$$ * + trandolapril
ANGIOTENSIN RECEPTOR BLOCKERS
$$ * + losartan, hydrochlorothiazide
$$$ * + irbesartan, hydrochlorothiazide
$$$ * + valsartan, hydrochlorothiazide
$
$
$
$$
$$
$$
$$
$$$
$$$
$$$
$$$
Formulary Guide – January 2015
5
OTHER ANTIHYPERTENSIVE COMBINATIONS
$$$ + amlodipine/benazepril
$$$ + trandolapril/verapamil
$$$$ * Bidil
ANTIARRHYTHMICS
$
+ amiodarone
$
+ disopyramide
$
+ mexiletine
$
+ procainamide
$
+ quinidine
$$$ * Multaq
LIPID/CHOLESTEROL LOWERING AGENTS
$
+ gemfibrozil
$
+ niacin
$
+ cholestyramine
$
+ colestipol
$
* + fenofibrate
$$ * + lovastatin
$$ * + pravastatin
$$ * + simvastatin
$$ * + atorvastatin
$$ * Niaspan
$$$ * Advicor
$$$ * Welchol
$$$ * ◊ @ Zetia
ANTIPlatelet agents
$
+ aspirin
$
+ dipyridamole
$$$ + ticlopidine
$$$$ * Aggrenox
!!!!!! * Agrylin
ANTICOAGULANT AGENTS
$$warfarin
$$$$ * Pradaxa
$$$$ * Eliquis
$$$$ * Xarelto 10mg
!!!!!! * Arixtra
!!!!!!Lovenox
!!!!!!Fragmin
!!!!!!Innohep
!!!!!! * Iprivask
6
Formulary Guide – January 2015
$
$
$
$
$
$
$
$
DIURETICS
+ hydrochlorothiazide
+ indapamide
+ furosemide
+ bumetanide
+ torsemide
+ spirinolactone, hydrochlorothiazide
+ triamterene, hydrochlorothiazide
+ metolazone
PULMONARY ARTERIAL HYPERTENSION AGENTS
$$$$ * + sildenafil 20mg tablet
!!!!!! * Adcirca
!!!!!!Flolan
!!!!!! * Letairis
!!!!!! * Remodulin
!!!!!! * Revatio vial, powder
!!!!!! * Tracleer
!!!!!! * Tyvaso
!!!!!! * Ventavis
CENTRAL NERVOUS SYSTEM
HYPNOTIC AGENTS
$
$
$
$
$$
$$
$$
↓ + chloral hydrate
∆ + flurazepam
↓ + triazolam
∆ ↓ + temazepam
↓ + estazolam
* ↓ + zaleplon
* ↓ + zolpidem
$
$
$
$
$
$$
$$
$$$
$$$
TRICYCLIC ANTIDEPRESSANTS
* ∆ + amitriptyline
* ↓ +desipramine
* ↓ + doxepin
* ↓ + imipramine HCL
* ↓ + nortriptyline
* ↓ + amoxapine
* ↓ + protriptyline
* ↓ + clomipramine
* ↓ + trimipramine
Formulary Guide – January 2015
7
MISCELLANEOUS ANTIDEPRESSANTS
$
* ↓ + trazodone
$
* ↓ + maprotiline
$$ * ↓ + bupropion, SR, XL 300 mg
$$$ * ↓ + venlafaxine, ER
$$$$ * ↓ Wellbutrin XL 150 mg
$$$$ * ↓ + mirtazapine
$$$$ * + duloxetine
MAO INHIBITORS
$$ * ↓ Nardil
$$$ * ↓ + tranylcypromine
$$$ * ↓ Emsam
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
$$$ * + citalopram
$$$ * ↓ + fluvoxamine
$$$ * ↓ + fluoxetine
$$$ * ↓+ paroxetine, CR
$$$ * ↓+ sertraline
$$$$ * + escitalopram
ANTIPSYCHOTICS
$
↓ + fluphenazine, trifluoperazine
$
↓ + perphenazine
$
↓ + haloperidol, thiothixene
$$ ↓ + chlorpromazine
$$ ↓ Orap
$$* ↓ risperidone
$$ * olanzapine, orally disintegrating tablets
$$* ↓ quetiapine
$$* ↓ ziprasidone
$$ * olanzapine/fluoxetine
$$$ ↓ + loxapine
$$$$ ↓ Moban
$$$$* ↓ Abilify, Discmelt, Maintena
$$$$* ↓ clozapine, orally disintegrating tablets
$$$$* ↓ Invega
$$$$ * Fanapt
$$$$ * Latuda
$$$$ * Saphris
$$$$ * Zyprexa Relprevv
$$$$* ↓ Risperdal Consta
$$$$* ↓ Invega Sustenna
8
Formulary Guide – January 2015
MISCELLANEOUS CNS AGENTS
$
+ lithium citrate, carbonate
$$ * + methylphenidate, SR, ER
$$ * + dexmethylphenidate
$$ * + dextroamphetamine sulfate
$$ * + amphetamine-dextroamphetamine, ER
$$$ * Strattera
$$$ * + methylphenidate CD
$$$$ * @ + modafinil
$$$$ * Cuvposa
$$$$ * @ Nuedexta
Triptans
$$
$$
$$
* + sumatriptan
* + naratriptan
* +◊ rizatriptan, MLT
Antiseizure Agents
$phenytoin
$
+ phenobarbital, primidone
$$ carbamazepine, ER
$$Carbatrol
$$ + valproic acid
$$ * + gabapentin
$$ * + lamotrigine
$$ + oxcarbazepine
$$ * + zonisamide
$$ + divalproex
$$ * + levetiracetam, ER
$$ * + topiramate
$$$ + felbamate
$$$ + ethosuximide
!!!!!!tiagabine
ANTIPARKINSONISM AGENTS
$
+ amantadine
$
* + benztropine
$
* + carbidopa-levodopa
$$ + pergolide
$$ * + pramipexole
$$ * + ropinirole, ER
$$ * + selegiline
$$$ + carbidopa-levodopa CR
$$$ * + carbidopa-levodopa-entacapone
Formulary Guide – January 2015
9
anti-alzheimer’s agents
* + galantamine
$
$$$ * Namenda
$$$$ * Aricept
$$$$ * Exelon, patch
Analgesics
$$ + hydromorphone
$$ * + hydrocodone/acetaminophen
$$ + morphine sulfate immediate release
$$ * + oxycodone, with acetaminophen
$$ + oxymorphone IR
$$$ + morphine sulfate ER, SR
$$$Oxyfast
$$$ * + tramadol, ER
$$$ * @ + fentanyl patches
$$$ @ + oral transmucosal fentanyl citrate
$$$$ * @ + oxycodone controlled-release
$$$$ * @ Oxycontin
NSAIDs
$
$
$
$$
$$
$$
$$
$$
$$$
$$$
$$$
+ ibuprofen
∆ + indomethacin, SR
↓ + naproxen sodium
+ diclofenac sodium
Children’s Advil, Motrin
+ tolmetin
+ oxaprozin, etodolac
+ diclofenac potassium
↓ + ketoprofen
* + nabumetone
* + meloxicam
NSAID COX II INHIBITORS
$$$$ * ◊ @ Celebrex (Prior Auth if < 60 years old)
ANTIVERTIGO AND ANTI-EMETICS
$
+ meclizine
$
+ promethazine
$
+ trimethobenzamide
$$ + prochlorperazine
$$ * + ondansetron
$$$$ * Aloxi
$$$$ * @ Emend
10
Formulary Guide – January 2015
MULTIPLE SCLEROSIS AGENTS
$$$$ * Ampyra
!!!!!! * Avonex
!!!!!! * Betaseron
!!!!!! * Copaxone 20mg/mL
!!!!!! * Rebif
!!!!!! * Tecfidera
!!!!!! * @ Gilenya
COUGH /COLD
$
Advil Cold and Sinus
$Delsym
$
+ dextromethorphan
$Dimetapp
$
+ guaifenesin
$Robitussin
$
+ promethazine/codeine
$$
Mucinex, D, DM
DERMATOLOGICALS/TOPICAL THERAPY
$$
$$
$$
TOPICAL CORTICOSTEROIDS (VERY HIGH POTENCY)
* + clobetasol 0.05% gel
* + clobetasol emollient 0.05% cream
* + halobetasol proprionate 0.05% cream, ointment
$
$
$
$$
$$
$$
$$
TOPICAL CORTICOSTEROIDS (HIGH POTENCY)
* + betamethasone valerate 0.1% ointment
* + fluocinonide 0.05% cream, gel
* + triamcinolone acetonide 0.1% ointment
* + betamethasone dipropionate 0.05% ointment
* + desoximetasone 0.25% cream, ointment
* + desoximetasone 0.05% gel
* + fluocinonide 0.05% ointment
Formulary Guide – January 2015
11
$
$
$
$
$
$
$
$
$
TOPICAL CORTICOSTEROIDS (MEDIUM POTENCY)
* + betamethasone valerate 0.1% cream, lotion
* + desonide cream
* + fluocinolone acetonide 0.025% cream, ointment
* + prednicarbate
* + triamcinolone acetonide 0.1% cream, ointment
* + triamcinolone acetonide 0.1% lotion
* + triamcinolone acetonide 0.5% cream, ointment
* + triamcinolone acetonide 0.025% cream, ointment, lotion
* + mometasone
$
$
$
$$
$$
TOPICAL CORTICOSTEROIDS (LOW POTENCY)
* + hydrocortisone 1%, 0.5% cream, ointment
* + hydrocortisone 1% lotion
+ hydrocortisone acetate 0.5%, 1% cream, ointment
* + alclometasone cream, ointment
* + fluocinolone acetonide 0.01% cream, solution
TOPICAL ANTIFUNGALS
$
* + ciclopirox 8% solution
$
* + clotrimazole (OTC)
$
* + ketoconazole cream
$
* + miconazole nitrate (OTC)
$Fungoid
$
* + ketoconazole 2% shampoo
$
Nizoral A-D shampoo (OTC)
$
* + tolnaftate (OTC)
$
* + undecylenic acid
$$ * + nystatin cream, ointment
$$ * + econazole
$$ * + nystatin/triamcinolone
$$$Pedi-Dri
$$$$ * + clotrimazole/betamethasone, cream, lotion
12
Formulary Guide – January 2015
ACNE THERAPY
Vitamin A derivatives are considered non covered pharmacy benefits for
members 35 years of age and older.
$$
$$
$$
$$$
$$$
$$$
$$$
* + benzoyl peroxide cream/lotion/gel
* + sulfacetamide sodium with sulfur cleanser/lotion
* + metronidazole 0.75% cream, lotion, gel
* + tretinoin
* @ + adapalene 0.1% gel & cream (Not covered if ≥ 35 years old)
* ◊ @ Tazorac gel, cream
* Azelex
$
$
$$
$$
$$
$$$
$$$
$$$
$$$
$$$
$$$
OTHER TOPICAL PRODUCTS
* OTC Abreva
* + OTC permethrin
* ◊ @ Denavir
* + mupirocin ointment
* + urea 50% nail stick
* @ + imiquimod
* Clindesse
* ◊ @ + malathion lotion
* ◊ @ Elidel
* Voltaren gel
* @ + acyclovir ointment
Psoriasis Therapy
$$$ * + calcipotriene
!!!!!! @ Amevive
ENDOCRINE
INSULIN THERAPY
$$$$ * Humulin, Pen (only 3mL vials for Long-Term Care)
$$$$ * Humalog, Pen (only 3mL vials for Long-Term Care)
$$$$ * Humalog Mix 75/25
$$$$ * Lantus vials
$$$$ * Levemir vials
$
$
$
$$
$$
ORAL HYPOGLYCEMIC AGENTS
* + glimepiride
* + glipizide, XL
* + glyburide
* + metformin, XR
* + metformin/glipizide
Formulary Guide – January 2015
13
$$
$$
$$
$$
$$
$$$
$$$$
$$$$
$$$$
$$$$
$$$$$
$$$$$
ORAL HYPOGLYCEMIC AGENTS (Continued)
* + repaglinide
* Precose, Glyset
* Riomet
* + glyburide/metformin
* Welchol
* + nateglinide
* + pioglitazone, pioglitazone/metformin
* + pioglitazone/glimepiride
* Avandia, Avandamet, Avandaryl
* Janumet XR
* Janumet
* Januvia
MISCELLANEOUS HYPOGLYCEMIC AGENTS
$$$$$ * Victoza
$$$$$ * Bydureon
$$$$$ * Symlin
$$
$$
$$
$$
$$
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
THYROID THERAPY
$levothyroxine
$
+ propylthiouracil
$
+ methimazole
GASTROINTESTINAL
14
Formulary Guide – January 2015
GASTROINTESTINAL
H2-RECEPTOR ANTAGONISTS
$$
$$
$$
$$
* Axid AR (OTC)
* + nizatidine
* + ranitidine (OTC), famotidine (OTC)
* + ranitidine syrup
$
$
$
$
$$ $$
$$
PROTON PUMP INHIBITORS
* + omeprazole (OTC), Prilosec (OTC) (First-line agent for heartburn)
* Prevacid 24HR (OTC) (First-line agent for heartburn)
* Zegerid OTC (First-line agent for heartburn)
* + pantoprazole (First-line agent)
* ◊ @ Nexium 24HR (OTC)
* ◊ @ + lansoprazole capsules
* + omeprazole
!!!!!!
!!!!!!
$$
!!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! !!!!!! PANCREATIC ENZYMES
Creon
Zenpep
HEPATITIS C AGENTS
* @ + ribavirin tablets, capsules
@ Intron A
@ Peg-Intron
* @ Pegasys
* @ Victrelis
* @ Incivek
* @ Sovaldi
* @ Olysio
* @ Harvoni
OTHER G.I. DRUGS
$
* + dicyclomine
$
+ metoclopramide
$
+ polyethylene glycol
$$ Halflytely
$$ + misoprostol
$$ + sucralfate
$$$ * @ Amitiza
$$$ * Lotronex
$$$ * Apriso ER
!!!!!!@ Cerezyme
!!!!!! @ Elelyso
Formulary Guide – January 2015
15
IMMUNOLOGY, VACCINES AND BIOTECHNOLOGY
GROWTH HORMONES
!!!!!! @ Humatrope
!!!!!! @ Omnitrope
VACCINES
$$
$$ $$ $$ $$ $$ $$ $$ $$ $$ * @ Adacel
* @ Boostrix
* @ Engerix-B
* @ Gardasil
* @ Havrix
* @ Menactra
* @ Recombivax HB
* @ Twinrix
* @ Vaqta
* @ Zostavax (50 years and older)
INSULIN-LIKE GROWTH FACTOR
!!!!!!Increlex
Growth hormone-receptor antagonist
!!!!!! @ Somavert
Growth hormone-RELEASING FACTOR
!!!!!! * Egrifta
ERYTHROID STIMULANTS
!!!!!! @ Procrit
COLONY STIMULATING FACTORS
!!!!!! * @ Granix
!!!!!! * @ Neulasta
INTERFERON ALFA
!!!!!!
!!!!!!
!!!!!!
!!!!!!
@ Roferon A
@ Intron A
@ PEG-Intron
* @ Pegasys
SODIUM HYALURONATE
!!!!!! @ Euflexxa
16
Formulary Guide – January 2015
MISCELLANEOUS
$$$ @ Benlysta
!!!!!!Exjade
!!!!!! * @ Arcalyst
!!!!!! * @ Synagis
Hereditary Angioedema therapy
!!!!!!
!!!!!!
!!!!!!
!!!!!!
@ Berinert
* @ Cinryze
* @ Firazyr
@ Kalbitor
MISCELLANEOUS
MISCELLANEOUS
IMMUNOSUPPRESSIVE AGENTS
$
+ azathioprine
$
+ mycophenolate
$
+ cyclosporine
$
+ tacrolimus
$$Rapamune
!!!!!!Zortress
APPETITE STIMULANTS
$* + megestrol acetate
HYPERPARATHYROID TREATMENT
$$$Zemplar
MOUTH AND THROAT PRODUCTS
$$ + clotrimazole troche
$$Prevident
ELECTROLYTE SUPPLEMENTATION
$$Phoslo
POLYMERIC PHOSPHATE BINDERS
$$$$$ Renagel
$$$$$ Fosrenol
$$$$$ * Renvela tablets
SMOKING DETERRENTS
$
* + nicotine transdermal (18 years and older)
$$$$ * + Zyban (18 years and older)
$$$$ * @ Chantix (18 years and older)
$$$$Evoxac
Formulary Guide – January 2015
17
OPIOID / ALCOHOL ADDICTION TREATMENT
$$ * @ naltrexone
$$$ * @ disulfiram
$$$ * @ Campral
$$$$ * @ buprenorphine
$$$$ * @ + buprenorphine/naloxone tablets
$$$$ * @ Vivitrol
MUSCULOSKELETAL AND RHEUMATOLOGY
MUSCULOSKELETAL AND RHEUMATOLOGY
$
$
$
$
$$
$$
$$
!!!!!!
!!!!!!
MUSCLE RELAXANTS
+ baclofen
∆+ chlorzoxazone, carisoprodol
* ∆+ cyclobenzaprine
∆+ diazepam
+ orphenadrine
∆+ methocarbamol
* + tizanidine
* @ Botox
@ Myobloc
MISCELLANEOUS ANTIRHEUMATIC AGENTS
$
+ sulfasalazine
$$ + methotrexate
$$$ + hydroxychloroquine
$$$$ + azathioprine
!!!!!! * @ Enbrel, Humira
OSTEOPOROSIS THERAPY
$$$ + calcitonin
$$$ * + alendronate
$$$$ * Miacalcin Nasal
$$$$Evista
$$$$ * Fosamax plus D
$$$$ * Actonel 5mg, 30mg, 35mg, Actonel with calcium
ANTIGOUT
$
+ allopurinol
$$$ * Colcrys
OBSTETRICS AND GYNECOLOGY
18
Formulary Guide – January 2015
OBSTETRICS AND GYNECOLOGY
PROGESTINS
$
* + medroxyprogesterone
$$ * Micronor, Nor QD, Camila, Jolivette, Norlyroc
$$Aygestin
$$$ Progesterone Inj, suppos
$$$$ * Depo-Provera 150
!!!!!! * Makena
ESTROGENS
$
+ estropipate
$
+ micronized estradiol
$
+ estradiol, estradiol valerate injection
$$Premarin
$$$Cenestin
$$$Prometrium
$$$ Ortho Dienestrol
$$$ * Climara Pro
$$$ * Alora
$$$Menest
$$$Estrogel
$$$ * Menostar
$$$$ Estring, Femring
ESTROGEN COMBINATIONS
$
+ estradiol/norethindrone
$Prempro
$Premphase
$$ + norethinedrone acetate/ethinyl estradiol
$$$ Estratest, HS
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$
$$
MONOPHASIC ORAL CONTRACEPTIVES
* + Norinyl 1+50, Necon 1/50, Genora 1/50
* + Zovia 1/50
* + Norinyl 1+35, Nortrel 1/35, Necon 1+35, Genora 1/35, Alyacen
* + Necon, Nortrel, Brevicon 5/35
* + Femhrt 1mg/0.005mg
* + Sprintec, Mononessa, Previfem
* + Zovia 1/35, Kelnor
* + Microgestin Fe, Junel Fe, Gildess +/- Fe, Larin Fe
* + Low-Ogestrel, Cryselle
* + Apri
* + Levora, Portia, Altavera, Chateal-28
* + Aviane, Lessina, Lutera, Orsythia-28
Formulary Guide – January 2015
19
$$
$$
BIPHASIC ORAL CONTRACEPTIVES
* + Necon 10/11
* + Kariva, Azurette, Viorele, Pimtrea
$
$$
$$
$$
$$
$$
TRIPHASIC ORAL CONTRACEPTIVES
* + Aranelle, Leena
* + Nortrel 7/7/7, Necon 7/7/7, Alyacen 7/7/7
* + Trivora, Enpresse
* + Tri-Sprintec, TriNessa, Tri-Previfem
* + Velivet
* + Tri-Legest Fe, Tilia Fe
$
$
$$
$$
$$
$$
$$
OTC Monistat
+ OTC Clotrimazole
* ◊ @ + terconazole
◊ @ Gynazole
* Clindesse
* Metrogel vaginal
* Vagifem
VAGINAL AGENTS
OTHER
$$ * levonorgestrel (generic Plan B)
$$$$Lunelle
OPHTHALMOLOGY
ANTI-INFECTIVES
$
+ tobramycin
$
+ ciprofloxacin ophthalmic suspension
$$ * Ciloxan ophthalmic ointment
$$ * + tobramycin-dexamethasone ophthalmic drops
$$ * Quixin
$$$ * Vigamox
$$$ * Tobrex ophthalmic ointment
$$$$ * Tobradex ophthalmic ointment
$$$$ * Zirgan
ALLERGIC CONJUNCTIVITIS
$
Visine-A, Naphcon-A
$
+ cromolyn
$
* Alaway/Zaditor OTC
$$$Alocril
$$$ * Lotemax solution
$$$* ◊ @ Patanol
20
Formulary Guide – January 2015
NSAIDS
$$ + ketorolac
$$$$ * Acular LS
$$$$Voltaren
ANTIGLAUCOMA AGENTS
$ * + timolol
$ * + latanoprost
$$ + dorzolamide hydrochloride/timolol maleate
$$ + levobunolol
$$ + timolol XE
$$$ + apraclonidine
$$$Azopt
$$$$ * Alphagan, P
$$$$ Betoptic S
MACULAR DEGENERATION AGENTS
!!!!!! * Eylea
!!!!!! * Lucentis
!!!!!! * Macugen
OTIC
$$$
$$$
$$$
$$$
ANTI-INFECTIVEs
* + neomycin/polymixin/bacitracin
* Cipro HC
+ ofloxacin otic
* Ciprodex
MISCELLANEOUS
$
* + antipyrine/benzocaine
$$ * + acetic acid/aluminum
$$$ * + fluocinolone acetonide oil
Formulary Guide – January 2015
21
RESPIRATORY
ANTIHISTAMINES
$
* + cetirizine, cetirizine/pseudoephedrine (OTC)
$
∆ + chlorpheniramine (OTC)
$
∆ + cyproheptadine
$
∆ + diphenhydramine (OTC)
$
∆ + hydroxyzine
$
+ meclizine
$
∆ + promethazine (2 years and older)
$
∆ + tripelennamine
$$ ∆ + clemastine
$$ ∆ + dexchlorpheniramine
$$ * + loratadine, loratadine/pseudoephedrine (OTC)
ANTIHISTAMINES (Continued)
$$ * Alavert
$$ * + fexofenadine (180mg), fexofenadine/pseudoephedrine (OTC)
$$$ * + azelastine nasal spray
$
$$
$$
$$$
$$$
INHALED BETA AGONISTS
* + albuterol aerosol
+ isoetharine solution
* + albuterol solution for inhalation
* Ventolin HFA
* Serevent, Diskus
INHALED CORTICOSTEROIDS
$$$ * Qvar
$$$ * budesonide nebulizer solution (under 9 years of age)
$$$$ * Pulmicort respules (under 9 years of age)
$$$$ * Flovent HFA
$$$$ * Asmanex
$
$
22
INTRANASAL STEROIDS
* + fluticasone
* Nasacort Allergy 24HR (OTC)
Formulary Guide – January 2015
$
$$
$$
$$$
$$$
$$$
$$$
$$$
$$$
$$$
$$$$
$$$$
$$$$
$$$$
$$$$
$$$$$ !!!!!! !!!!!! !!!!!! !!!!!!
$
$
MISCELLANEOUS PULMONARY AGENTS
* + benzonatate (11 years and older)
* theophylline
* + cromolyn nebulizer solution
* Atrovent MDI, solution
* Combivent
* + ipratropium albuterol solution
* Accuneb
* + montelukast
* Tilade, nebulizer solution
+ acetylcysteine
* Intal
* Advair HFA/Diskus
* Dulera
* Spiriva
* Tudorza
* Pulmozyme
* @ Cayston
* @ Kalydeco
* + tobramycin inhalation solution
* @ Xolair
RESPIRATORY DEVICES
* OptiChamber Advantage, Diamond
* Respironics OptionHome, Innospire Essence Compressor Nebulizer System
UROLOGICS
$$
$$
$$
$$
$$
$$$
$$$
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
+ doxazosin
* + finasteride
+ tamsulosin
+ terazosin
* + alfuzosin
* Avodart
* Jalyn
$
$
$
$$
$$$
* Oxytrol (OTC)
* + oxybutynin, XL
* + trospium
* + tolterodine, ER
* Enablex
ANTICHOLINERGICS
Formulary Guide – January 2015
23
VITAMINS
INTERSTITIAL CYSTITIS AGENTS
$
* + phenazopyridine
!!!!!!Elmiron
MISCELLANEOUS
$$$$ * @ Lupron, Zoladex, Eligard
VITAMINS
MULTIPLE VITAMINS
$Freedavite
$
+ daily-vite
$
* Citracal
$Centrum
$
+ multivital
$Renax
$
* + corvita
$Strovite
$
* Strovite Advance
$
Strovite Advance +D
$
Strovite One
$
Strovite Plus
$
$
$
$
$
$$
$$
$$$
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
* multivitamin drops (generic Poly-Vi-Sol)
24
Formulary Guide – January 2015
PRENATAL VITAMINS
$
$
$
$
$
$
$
$$
$
$
* Vitafol-OB
* Vitafol-PN
* Select-OB
* Prenatal 19
* Vol-plus
* Vol-tab Rx
* + Trinate
* Nestabs
PRENATAL VITAMINS WITH DHA
* OTC One-a-Day Women’s Prenatal with DHA
* Vitafol-One
Formulary Guide – January 2015
25
Horizon NJ Health Pharmacy Department
210 Silvia Street
West Trenton, NJ 08628
Phone: 1-800-682-9094
Fax: 1-609-538-0847
horizonNJhealth.com