Apple HealthPreferred Drug List

DUR Board Meeting

Donna Sullivan, PharmDChief Pharmacy Officer February 20, 2019

ANTIBIOTICS

2

AMINOGLYCOSIDES - ORALPreferred Non-PreferredNEOMYCIN SULFATE NONEPAROMOMYCIN SULFATE

ANTIBIOTICS

3

ANTI-INFECTIVE AGENTS - MISC - ORALPreferred Non-PreferredMETRONIDAZOLE TABS FLAGYLTINIDAZOLE METRONIDAZOLE CAPS

XIFAXAN TINDAMAX

ANTIBIOTICS

4

ANTIMYCOBACTERIAL AGENTS - ORALPreferred Non-PreferredCYCLOSERINE RIFAMPIN MYAMBUTOLETHAMBUTOL HCL SIRTURO MYCOBUTIN

ISONIAZID TRECATOR PASERPRIFTIN RIFADINPYRAZINAMIDE RIFAMATERIFABUTIN RIFATER

ANTIBIOTICS

5

FLUOROQUINOLONES - ORALPreferred Non-PreferredCIPROFLOXACIN AVELOX LEVAQUINLEVOFLOXACIN TABS

BAXDELALEVOFLOXACIN SOLN

CIPRO MOXIFLOXACIN HCLCIPROFLOXACIN ER OFLOXACIN

ANTIBIOTICS

6

GLYCOPEPTIDES - ORALPreferred Non-PreferredFIRVANQ VANCOCIN HCLVANCOMYCIN HCL

ANTIBIOTICS

7

LEPROSTATICS - ORALPreferred Non-PreferredDAPSONE NONE

ANTIBIOTICS

8

LINCOSAMIDES - ORALPreferred Non-PreferredCLINDAMYCIN HCL CLEOCINCLINDAMYCIN PALMITATE HCL

ANTIBIOTICS

9

MACROLIDES - ORALPreferred Non-PreferredAZITHROMYCIN CLARITHROMYCIN ER ERYPED 400CLARITHROMYCIN DIFICID ERYTHROCIN STEARATE

ERY-TAB E.E.S. 400 ERYTHROMYCIN BASE

ERYTHROMYCIN E.E.S. GRANULES PCEERYTHROMYCIN ETHYLSUCCINATE ERYPED 200 ZITHROMAX

ANTIBIOTICS

10

OXAZOLIDINONES - ORALPreferred Non-PreferredLINEZOLID SIVEXTRO

ZYVOX

ANTIBIOTICS

11

PENICILLINASE-RESISTANT PENICILLINS - ORALPreferred Non-PreferredDICLOXACILLIN SODIUM NONE

ANTIDOTES AND SPECIFIC ANTAGONISTS

12

CHELATING AGENTSPreferred Non-PreferredEXJADE NONEFERRIPROX

JADENU

ANTIFUNGALS

13

ORALPreferred Non-PreferredCLOTRIMAZOLE ANCOBON NOXAFILFLUCONAZOLE CRESEMBA ONMEL

GRISEOFULVIN DIFLUCAN SPORANOX

ITRACONAZOLE SOLN FLUCYTOSINE TOLSURAKETOCONAZOLE GRIS-PEG VFENDNYSTATIN ITRACONAZOLE CAPS VORICONAZOLETERBINAFINE HCL LAMISIL

ANTIPARASITICS

14

ANTIPROTOZOAL AGENTSPreferred Non-PreferredALINIA MEPRONATOVAQUONE

DERMATOLOGICS

15

ACNE PRODUCTS - ORALPreferred Non-PreferredAMNESTEEM ABSORICACLARAVIS

ISOTRETINOINMYORISANZENATANE

DERMATOLOGICS

16

AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTSPreferred Non-PreferredNONE VEREGEN*

*PA REQUIRED

DERMATOLOGICS

17

ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICALPreferred Non-PreferredAMELUZ EFUDEXDICLOFENAC SODIUM CARAC

FLUOROURACIL 5% CREAM/SOLN FLUOROURACIL 0.5% CREAMLEVULAN KERASTICKPANRETINPICATOTARGRETINTOLAKVALCHLOR

DERMATOLOGICS

18

ANTIPSORIATICS - ORALPreferred Non-PreferredACITRETIN METHOXSALEN

OXSORALEN ULTRA

SORIATANE

DERMATOLOGICS

19

DERMATOLOGICS : ANTIPSORIATICS - TOPICALPreferred Non-PreferredCALCIPOTRIENE CALCITRIOLCALCITRENE DOVONEX

SORILUXTAZAROTENETAZORACVECTICAL

DERMATOLOGICS

20

ECZEMA AGENTSPreferred Non-PreferredNONE DUPIXENT*

*PA REQUIRED

DERMATOLOGICS

21

ENZYMES - TOPICALPreferred Non-PreferredNONE SANTYL*

*PA REQUIRED

DERMATOLOGICS

22

PHOSPHODIESTERASE 4 (PDE4) INHIBITORSPreferred Non-PreferredNONE EUCRISA*

*PA REQUIRED

DERMATOLOGICS

23

ROSACEA AGENTSPreferred Non-PreferredAZELAIC ACID DOXYCYCLINE NORITATEFINACEA METROCREAM ORACEA

METRONIDAZOLE METROGEL RHOFADE

ROSADAN METROLOTION ROSADAN KITMIRVASO SOOLANTRA

DERMATOLOGICS

24

TOPICAL STEROIDS - HIGH POTENCYPreferred

BETAMETHASONE VALERATE CREAM, OINTMENT

CALCIPOTRIENE/ BETAMETHASONE DIPROPIONATE

TRIAMCINOLONE ACETONIDE CREAM, LOTION, OINTMENT

TRIDERM

DERMATOLOGICS

25

TOPICAL STEROIDS - HIGH POTENCY CONTINUEDNon-Preferred

AMCINONIDE DERMASORB TAAPEXICON E DESOXIMETASONEAUGMENTED BETAMETHASONE DIPROPIONATE DIFLORASONE DIACETATEBETAMETHASONE DIPROPIONATE DIPROLENEBETAMETHASONE VALERATE DIPROLENE AFCAPEX ENSTILARCLODAN KIT FLUOCINOLONE ACETONIDEDERMA-SMOOTHE/FS BODY FLUOCINOLONE ACETONIDE BODYDERMA-SMOOTHE/FS SCALP FLUOCINOLONE ACETONIDE SCALP

DERMATOLOGICS

26

TOPICAL STEROIDS - HIGH POTENCY CONTINUEDNon-Preferred

FLUOCINONIDE SYNALARFLUOCINONIDE EMULSIFIED BASE SYNALAR CREAM KITFLUOCINONIDE EMULSIFIED BASE SYNALAR OINTMENT KITFLURANDRENOLIDE SYNALAR TSHALOG TACLONEXKENALOG TOPICORTLUXIQ TRIAMCINOLONE ACETONIDEPSORCON TRIANEXSERNIVO VANOS

DERMATOLOGICS

27

TOPICAL STEROIDS - MEDIUM POTENCYPreferred

FLUTICASONE PROPIONATE CREAM, OINTMENT

MOMETASONE FUROATE

Non-Preferred

CLOCORTOLONE PIVALATE /PUMP ELOCON LOCOIDCLODERM /PUMP FLUTICASONE PROPIONATE LOCOID LIPOCREAM

CUTIVATEHYDROCORTISONE BUTYRATE PANDEL

DERMASORB HCHYDROCORTISONE VALERATE PREDNICARBATE

DERMATOLOGICS

28

TOPICAL STEROIDS - VERY HIGH POTENCYPreferred

CLOBETASOL PROPIONATE CREAM, GEL, OINTMENT, SOLUTION

HALOBETASOL PROPIONATE

Non-Preferred

BRYHALI CLODAN OLUXCLOBETASOL PROPIONATE FOAM, LIQUID, LOTION, SHAMPOO CORDRAN TEMOVATECLOBETASOL PROPIONATE EMOLLIENT CREAM, FOAM HALAC ULTRAVATECLOBEX LEXETTE

ENDOCRINE AND METABOLIC AGENTS

29

ANDROGENS - OTHERPreferred Non-PreferredDANAZOL NONE

ENDOCRINE AND METABOLIC AGENTS

30

BONE DENSITY REGULATORS - BISPHOSPHONATESPreferred Non-PreferredALENDRONATE SODIUM

ACTONELIBANDRONATE SODIUMSOLN

IBANDRONATE SODIUMTABS ATELVIA

PAMIDRONATE DISODIUM

ZOLEDRONIC ACID BINOSTO RECLAST

BONIVARISEDRONATE SODIUM/ DR

ETIDRONATE DISODIUM ZOMETAFOSAMAX

ENDOCRINE AND METABOLIC AGENTS

31

BONE DENSITY REGULATORS - CALCITONINSPreferred Non-PreferredCALCITONIN SALMON MIACALCIN

ENDOCRINE AND METABOLIC AGENTS

32

BONE DENSITY REGULATORS - SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)

Preferred Non-PreferredRALOXIFENE HYDROCHLORIDE EVISTA

ENDOCRINE AND METABOLIC AGENTS

33

BONE DENSITY REGULATORS - RANK LIGAND INHIBITORSPreferred Non-PreferredPROLIA* NONEXGEVA*

*PA REQUIRED

ENDOCRINE AND METABOLIC AGENTS

34

BONE DENSITY REGULATORS - PARATHYROID HORMONE DERIVATIVES

Preferred Non-PreferredFORTEO NATPARA

TYMLOS

ENDOCRINE AND METABOLIC AGENTS

35

ESTROGEN / ANDROGEN COMBINATIONSPreferred Non-PreferredESTERIFIED ESTROGENS/METHYLTESTOSTERONE NONE

ENDOCRINE AND METABOLIC AGENTS

36

ESTROGEN / PROGESTIN COMBINATIONSPreferred Non-PreferredAMABELZ JINTELI ACTIVELLAANGELIQ LOPREEZA FEMHRT LOW DOSE

CLIMARA PRO MIMVEY /LO PREFEST

COMBIPATCH

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL

ESTRADIOL/ NORETHINDRONE ACETATE PREMPHASEFYAVOLV PREMPROJEVANTIQUE LO

ENDOCRINE AND METABOLIC AGENTS

37

ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS

Preferred Non-PreferredDUAVEE* NONE

*PA REQUIRED

ENDOCRINE AND METABOLIC AGENTS

38

ESTROGENS - INJECTABLEPreferred Non-PreferredDEPO-ESTRADIOL DELESTROGENESTRADIOL VALERATE PREMARIN

ENDOCRINE AND METABOLIC AGENTS

39

ESTROGENS - ORALPreferred Non-PreferredESTRADIOL ESTRACEESTROPIPATE

MENESTPREMARIN

ENDOCRINE AND METABOLIC AGENTS

40

ESTROGENS - TOPICALPreferred Non-PreferredESTRADIOL ALORA

CLIMARA

DIVIGELELESTRINEVAMISTMENOSTARMINIVELLEVIVELLE-DOT

ENDOCRINE AND METABOLIC AGENTS

41

ESTROGENS - VAGINALPreferred Non-PreferredESTRADIOL ESTRACEESTRING FEMRING

PREMARIN VAGIFEMYUVAFEM

ENDOCRINE AND METABOLIC AGENTS

42

METABOLIC MODIFIERS - PHENYLKETONURIA (PKU) AGENTSPreferred Non-Preferred

PALYNZIQ*

*PA REQUIRED

ENDOCRINE AND METABOLIC AGENTS

43

METABOLIC MODIFIERS - TRIPEPTIDY PEPTIDASE 1 DEFICIENCY AGENTS

Preferred Non-PreferredBRINEURA*

*PA REQUIRED

ENDOCRINE AND METABOLIC AGENTS

44

METABOLIC MODIFIERS - X-LINKED HYPOPHOSPHATEMIA (XLH) AGENTS

Preferred Non-PreferredCRYSVITA*

*PA REQUIRED

ENDOCRINE AND METABOLIC AGENTS

45

THYROID AGENTS - ANTITHYROID AGENTSPreferred Non-PreferredMETHIMAZOLE TAPAZOLEPROPYLTHIOURACIL

ENDOCRINE AND METABOLIC AGENTS

46

THYROID AGENTS - THYROID HORMONE - ORALPreferred Non-PreferredARMOUR THYROID CYTOMELLEVO-T SYNTHROID

LEVOTHYROXINE SODIUM THYROLARLEVOTHYROXINE/LIOTHYRONINE TIROSINTLEVOXYLLIOTHYRONINE SODIUMNP THYROIDUNITHROID

MISCELLANEOUS THERAPEUTIC CLASSES

47

CHELATING AGENTSPreferred Non-PreferredCUPRIMINE SYPRINEDEPEN TITRATABS D-PENAMINE

TRIENTINE HYDROCHLORIDE

MISCELLANEOUS THERAPEUTIC CLASSES

48

POTASSIUM REMOVING AGENTSPreferred Non-PreferredKIONEX LOKELMASODIUM POLYSTYRENE SULFONATE

SPSVELTASSA