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:
• BeaPassportHealthPlanmember.• Needadrugthatismedicallynecessary.• GettheprescriptionfilledataPassportHealthPlannetworkpharmacy.Anetworkpharmacyisonethatis
signedupwithPassportHealthPlan.• FollowallPassportHealthPlanrules.
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?
• Youcanfindtheformularyonourwebsiteatwww.passporthealthplan.com.• Underthesectionthatsays“QuickHits,”clickon“Formulary.”• Youcansearchforadrugbyclickingonthepictureofthe
binoculars right above the drug list on your tool bar.• Next,youwillseeasearchboxtotheright.• Typeinthenameofthedruginthesearchbox.
Ifyouarenotsurehowtospellthedrug,youcansearchbyenteringthefirstfewlettersofthename.Thedrugsarelistedbybothbrandandgenericname.Theboldednamemeanswhichdrug (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 meansyourproviderwillneedtogetapprovalbeforeyoucanhaveyourprescriptionsfilled.Ifyoudonotgetap-proval, Passport Health Plan may not cover the drug.
• Quantity Limits:Forsomedrugs,therearelimitsontheamountPassportHealthPlanwillcover.Thismeansyou may not get the standard one month supply.
• Step Therapy:SometimesPassportHealthPlanrequiresyoutofirsttrycertaindrugstotreatyourmedicalcon-ditionbeforewewillcoveranotherdrugforthatcondition.Forexample,ifDrugAandDrugBbothtreatyourmedicalcondition,PassportHealthPlanmaynotcoverdrugBunlessyoutryDrugAfirst.IfDrugAdoesnotworkforyou,PassportHealthPlanwillthencoverDrugB.
• Too Early to Refill:Ifyouaregivenamonthsupplyofamedicine,PassportHealthPlanwillnotgivearefillofthe prescription until 30 days has passed.
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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. Workwithyourpharmacytofindthepreferreddrug.2. YoucanaskMemberServicesforalistofsimilardrugsthatarepreferredbyPassportHealthPlan.3. Ifthedrugisdenied,youcanfileanappeal.Tofindouthowtodothis,seepages25–28ofyourMember
Handbook.
Can the formulary change?
Yes.PassportHealthPlanmayaddorremovedrugsfromtheformularyduringtheyear.Togetupdatedinformationaboutcovereddrugs,pleasevisitourwebsiteatwww.passporthealthplan.comorcallMemberServicesat1-800-578-0603andpress2.
What are generic drugs?
PassportHealthPlancoversbothbrand-nameandgenericdrugs.Agenericdrughasthesameactiveingredientasthebrand-namedrug.Thismeanstheyworkthesameandhavethesameeffect.GenericdrugsusuallycostlessthanbrandnamedrugsandareapprovedbytheFoodandDrugAdministration(FDA).
How much will I have to pay for covered medicines?
SomePassportHealthPlanmemberspayasmallco-payforeachmedicinetheyfill.
The prescription copay is $1.00 for each prescription, including over-the-counter medicines.
PleaseNote:• Thepharmacymustfillyourprescriptionthefirsttime,evenifyoucannotpay.• Ifyoucannotpaythecopaywhenyougetyourprescription,youshouldpayitthenexttime.• Thepharmacymaytellyoutheywillnotfillyourprescriptionsanymoreifyoudonotpaytheco-pay.
Thosewhodo nothavetopayaco-payarememberswhoare:• 18yearsandunder.• Pregnant.• Receivingserviceswithinthefirst60daysafterdeliveryofababy.• Inanursingfacility.• Inapersonalcarehome.• Inanintermediatecarefacilityforpeoplewithmentalretardation(ICF/MR).• Afosterchildinstatecustody.• AmericanIndiansorAlaskannativesservedthroughKCHIPprogram.• Inhospicecare.
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PASSPORT HEALTH PLAN PREFERRED DRUG LIST
2009
GENERIC NAME BRAND NAME DOSAGE FORM NOTES ACE INHIBITOR MEDICATIONS Benazepril Lotensin Tablet Captopril Capoten Tablet Enalapril Vasotec Tablet Fosinopril Monopril Tablet Lisinopril Zestril, Prinivil Tablet Perindopril Aceon Tablet Trandolapril Mavik Tablet
ACNE MEDICATIONS (ORAL) Doxycycline Vibramycin,
Periostat Capsule, Tablet
Isotretinoin Accutane Capsule Minocycline Minocin Capsule Tetracycline Sumycin Capsule
ACNE MEDICATIONS (TOPICAL) Adapalene* Differin* Gel *PA Required > 21 yo;
Qty limits: 45gms/30 days Benzoyl Peroxide Benzoyl Peroxide Cream, Gel,
Solution Benzoyl Peroxide/ Erythromycin Benzamycin Cream Clindamycin Cleocin T Gel, Solution Erythromycin Erycette,
Akne-mycin Swabs, Gel, Ointment, Solution
Gentamicin Garamycin Cream, Ointment Metronidazole 0.75% Metrogel Gel Mupirocin Bactroban Ointment Sulfacetamide/Sulfur Sulfacet-R Lotion Tretinoin* Avita* Cream, Gel *PA Required > 21 yo;
Qty limits: 45gms/30 days
ALZHEIMERS MEDICATION Donepezil Aricept Tablets, ODT Rivastigmine Exelon Capsules, Patches,
Solution Tacrine Cognex Tablets
ANAPHYLAXIS THERAPY Epinephrine Epipen, Epipen Jr Injection *Qty limit: 2 injections per 30
days
ANALGESIC MEDICATIONS Narcotics Butorphanol Stadol NS Nasal Spray Codeine Codeine Tablet, Solution Fentanyl Transdermal* Duragesic* Patch *Qty limit 10 patches per 30 days Hydromorphone Dilaudid Tablet, Solution,
Suppository Meperidine Demerol Tablet, Syrup Methadone Dolophine Tablet Morphine MSIR Tablet, Solution,
Suppository Morphine Extended Release* Oramorph SR, MS Contin Tablet *Qty limit BID dosing Morphine Extended Release Kadian Capsules Oxycodone Roxicodone Tablet, Solution
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GENERIC NAME BRAND NAME DOSAGE FORM NOTES Propoxyphene Darvon Capsule Tramadol Ultram Tablet
Narcotic Combinations APAP/Butalbital Phrenilin, Phrenilin Forte Tablet APAP/Butalbital/Caffeine Fioricet Tablet APAP/Butalbital/Caffeine/Codeine Fioricet with Codeine Tablet APAP/Codeine Tylenol with Codeine Tablet APAP/Hydrocodone Vicodin, Lortab Tablet 5/500mg, 7.5/500mg,
7.5/750mg, 10/500mg, 10/650mg
APAP/Oxycodone Percocet Tablet APAP/Propoxyphene Darvocet N Tablet ASA/Butalbital/Caffeine Fiorinal Tablet ASA/Butalbital/Caffeine/Codeine Fiorinal with Codeine Tablet ASA/Oxycodone Percodan Tablet Meperidine/Promethazine Meperidine/Promethazine Capsule
NSAIDs (Prescription Strengths Only) Diclofenac Cataflam Tablet Diclofenac Sodium ER Voltaren-XR Tablet Diflunisal Dolobid Tablet Etodolac IR and SA Lodine, Lodine XL Capsule, Tablet Fenoprofen Nalfon Tablet Flurbiprofen Ansaid Tablet Ibuprofen Motrin Tablet, Suspension Indomethacin Indocin Capsule Indomethacin Sustained Release Indocin SR Capsule Ketoprofen IR Orudis Capsule Ketoprofen SA Oruvail Capsule Meclofenamate Meclofenamate Capsule Meloxicam Mobic Tablets Nabumetone Relafen Tablet Naproxen Naprosyn Tablet Naproxen SA Naprelan Tablet Oxaprozin Daypro Tablet Sulindac Clinoril Tablet Tolmetin Tolectin Tablet
COX-2 Inhibitors Celecoxib* Celebrex* Capsule *Step therapy or PA required
SALICYLATES Aspirin Aspirin Tablet Salsalate Disalcid Capsule
ANDROGENS Danazol Danocrine Capsule Methyltestesterone Android Tablet Oxandrolone Oxandrin Tablet Testosterone Transdermal Androgel Gel Testosterone Transdermal Androderm* Patch *PA required Testosterone Buccal Striant Buccal System
ANESTHETICS (TOPICAL) Capsaicin Zostrix Lotion, Cream, Gel Lidocaine Xylocaine Jelly, Ointment
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GENERIC NAME BRAND NAME DOSAGE FORM NOTES
ANESTHETICS (URINARY) Phenazopyridine Pyridium Tablet
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARB) Olmesartan* Benicar* Tablet *Step therapy required: T/F of 2
preferred ACE Inhibitors Valsartan* Diovan* Tablet *Step therapy required: T/F of 2
preferred ACE Inhibitors
ANORECTALS Hydrocortisone Anusol HC Cream, Suppository Hydrocortisone Enema Cortenema Enema
ANTACIDS Aluminum/Magnesium Hydroxide Mylanta Suspension, Tablets Calcium Carbonate Tums Suspension, tablet Magnesium Hydroxide MOM Suspension Aluminum Hydroxide Alternagel Suspension Sodium Bicarbonate Sodium Bicarbonate Tablet
ANTIADRENERGICS Clonidine Catapres Tablet, Patches Doxazosin Cardura Tablet Guanfacine Tenex Tablet Methyldopa Aldomet Tablet, Suspension Prazosin Minipress Capsule Reserpine Resperine Tablet Terazosin Hytrin Capsule
ANTI-ALCOHOLIC MEDICATIONS Disulfiram Antabuse Tablet
ANTIANDROGENS Bicalutamide Casodex Tablet Flutamide Eulexin Capsule Nilutamide Nilandron Tablet
ANTIARRHYTHMICS Amiodarone Cordarone Tablet Disopyramide Norpace Capsule Disopyramide Controlled Release Norpace CR Capsule Dofetilide Tikosyn Capsule Flecainide Tambocor Tablet Mexiletine Mexitil Capsule Moricizine Ethmozine Tablets Procainamide Pronestyl Tablet, Capsule Procainamide Sustained Release Procan SR Tablet Propafenone Rythmol Tablet Quinidine Gluconate Quinaglute Tablet Quinidine Sulfate Quinidine Tablet Quinidine Sulfate Sustained Release Quinidex Tablet
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ANTIBIOTICS (ORAL) Tetracyclines Doxycycline Vibramycin, Doryx Capsule Minocycline Minocin Capsule Tetracycline Sumycin Capsule
Cephalosporins: First Generation Cephalexin Keflex Capsule, Suspension Cephradine Velosef Capsule, Suspension
Cephalosporins: Second Generation Cefaclor Ceclor Capsule
Suspension Cefuroxime Ceftin Tablet
Suspension Cefprozil Ceprozil Suspension Only Cephalosporins: Third Generation Cefdinir Omnicef Capsule, Suspension Cefixime* Suprax* Tablet, Suspension *Qty limit: QD dosing Cefpodoxime Vantin Tablet, Suspension
Erythromycins Azithromycin* Zithromax* Tablet, Suspension *Qty limit: 250mg (6 tab/30days);
500mg (5 tab/30days) Clarithromycin, Clarithromycin ER Biaxin, Biaxin XL * Tablet, Suspension Erythromycin Base Ery-Tab, Eryc Tablet, Capsule Erythromycin Ethylsuccinate E.E.S. Tablet, Suspension Erythromycin Stearate Erythrocin Tablet Erythromycin/Sulfisoxazole Pediazole Suspension
Fluoroquinolones Ciprofloxacin Cipro Tablet, Suspension
Levofloxacin* Levaquin* Tablet, Oral Solution *Qty limit: 5 tab/30 days Moxifloxacin* Avelox* Tablet, Suspension *Qty limit: 5 tab/30 days Ofloxacin Floxin Tablet
Miscellaneous Clindamycin Cleocin Capsule, Suspension
Penicillins Amoxicillin Amoxil Capsule, Suspension Amoxicillin/Pot Clavulanate Augmentin Tablet, Suspension Ampicillin Principen Capsule, Suspension Dicloxacillin Dynapen Capsule, Suspension Penicillin VK PenVee K Tablet, Suspension
Sulfonamides Sulfadiazine Sulfadiazine Tablet Sulfamethoxazole/Trimethoprim Bactrim, Bactrim DS Tablet, Suspension Sulfisoxazole Gantrisin Tablets Suspension
Urinary Tract Medications Fosfomycin Monurol Granules Nitrofurantoin/Macrocrystals/Monohydrate Macrobid Capsule Nitrofurantoin/Macrocrystals Macrodantin Capsule, Suspension Trimethoprim Trimpex, Primsol Tablet
ANTIBIOTICS (TOPICAL) Bacitracin Bacitracin Ointment Polymycin/Bacitracin Polysporin Ointment
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Polymycin/Neomycin/Bacitracin Neosporin Ointment Silver Sulfadiazine SSD Cream
ANTICOAGULANTS Warfarin Coumadin Tablet
ANTICHOLINERGICS (INHALED) Ipratropium Solution Atrovent Solution Ipratropium Inhaler Atrovent Inhaler Tiotropium Spiriva Inhaler
ANTICONVULSANTS Acetazolamide Diamox Capsule Carbamazepine Tegretol Tablet, Suspension Carbamazepine Sustained Release Tegretol XR Tablet Clonazepam Klonopin Tablet Divalproex Sodium Depakote Tablet Divalproex Sodium Depakote Sprinkles Divalproex Sodium Depakote ER Tablet Ethosuximide Zarontin Capsule, Syrup Gabapentin Neurontin Tablet, Capsule Lamotrigine Lamictal* Tablet *Brand is preferred Lamotrigine Chewable Lamictal Dispersible
Chewable Tablet
Levetiracetam Keppra Tablet Mephobarbital Mebaral Tablet Oxcarbazepine Trileptal Tablet Oxcarbazepine Trileptal Suspension Phenobarbital Phenobarbital Tablet,Syrup Phenytoin Dilantin Tablet
Capsule Suspension
Primidone Mysoline Tablet, Suspension Tiagabine Gabitril Tablet Valproic Acid Depakene 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 Nardil Tablet Tranylcypromine Parnate Tablet
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TRICYCLICS Amitriptyline Elavil Tablet Amitriptyline/Chlordiazepoxide Limbitrol Tablet Amoxapine Ascendin Tablet Clomipramine Anafranil Capsule Desipramine Norpramin Tablet Doxepin Sinequan Capsule Imipramine Tofranil Capsule Nortriptyline Pamelor Capsule Protriptyline Vivactil Tablet Mirtazapine Remeron Tablet Trimipramine Surmontil Capsule
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI and SNRI) Citalopram Celexa Tablet Duloxetine * Cymbalta* Tablet *Step Therapy: T/F of 2
antidepressants (SSRIs, venlafaxine IR, bupropion IR, SR,XL) for 4 wks each
Venlafaxine IR Effexor IR Escitalopram* Lexapro* Tablet *Step Therapy: T/F of citalopram
& 1 of the following(SSRIs, venlafaxine IR, bupropion IR, SR,XL) for 4 wks each
Fluoxetine Prozac Capsule Paroxetine, Paroxetine CR Paxil, Paxil CR Tablet Sertraline Zoloft Tablet
ANTIDIARRHEALS Bismuth Subsalicylate Pepto-Bismol Tablet, Suspension Diphenoxylate/Atropine Lomotil Tablet, Solution Loperamide Imodium Capsule, Tablet
ANTIDIURETIC HORMONES Desmopressin Acetate DDAVP Tablet,
*Spray *Spray requires PA
ANTIEMETICS Aprepitant Emend Capsule Ondansetron* Zofran* Tablet,
Solution *Formulary with PA; Qty limits: 4mg, 8mg, 15 tab/30 days,
24mg, 5 tab/30 days Oral Soln. 50ml / 30 days
Promethazine Phenergan Tablet, Syrup, Suppository
Prochlorperazine Regular Release Compazine Tablet, Syrup, Suppository
ANTIESTROGENS Tamoxifen Nolvadex Tablet Toremifene Fareston Tablet
ANTIFUNGALS (ORAL) Fluconazole Diflucan Tablet,
Suspension QL: 150mg tab-4 tablets/28 days
Griseofulvin Microsize Grifulvin V Tablet, Suspension
Griseofulvin Ultramicrosize Gris-PEG Tablet
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Ketoconazole Nizoral Tablet Nystatin Mysostatin Tablet,
Suspension Terbinafine Lamisil Tablet
ANTIFUNGALS (TOPICAL) Gentian Violet Gentian Violet Solution Clotrimazole Lotrimin Cream
Solution Lotion
Ketoconazole Nizoral Cream Miconazole Micatin Cream, Ointment Nystatin Mycostatin Cream, Ointment Nystantin/Triamcinolone Mycolog II Cream, Ointment Tolnaftate Tinactin Cream, Gel
ANTIHISTAMINES (ORAL) Carbinoxamine Palgic Tablet, Capsule,
Liquid Cetirizine Zyrtec OTC Tablet,
Chewables
Cetirizine Zyrtec OTC Syrup Chlorpheniramine Chlor-Trimeton Tablet, Syrup Clemastine Tavist Tablet Cyproheptadine Periactin Tablet Diphenhydramine Benadryl Capsule
Tablet Solution
Hydroxyzine Atarax Tablet Solution
Loratadine OTC Claritin, Alavert Tablet, Syrup
Promethazine Phenergan Tablet Solution
Triprolidine Zymine Syrup
ANTIHISTAMINE/DECONGESTANT COMBINATIONS (ORAL) Cetirizine/Pseudoephedrine Zyrtec-D OTC Tablet Loratadine/Pseudoephedrine Claritin-D Tablet Pseudoephedrine/Triprolodine Actifed Tablet
ANTIHYPERTENSIVE COMBINATIONS Amlodipine / Benazepril Lotrel Capsule Amlodipine/ Valsartan Exforge Tablet *Step therapy required: T/F of
2 preferred ACE Inhibitors Atenolol / Chlorthalidone Tenoretic Tablet Benazepril / HCTZ Lotensin Tablet Bisoprolol / HCTZ Ziac Tablet Capotopril / HCTZ Capozide Tablet Clonidine / Chorthalidone Clorpres Tablet Enalapril / HCTZ Vaseretic Tablet Fosinopril / HCTZ Monopril HCT Tablet Hydralazine / HCTZ Apresazide Capsule Lisinopril / HCTZ Zestoretic, Prinizide Tablet Methyldopa / HCTZ Aldoril Tablet Moexipril / HCTZ Uniretic Tablet Olmesartin / HCTZ* Benicar HCT* Tablet *Step Therapy: T/F preferred
ACE-Inhibitors/HCTZ combination
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Propranolol/HCTZ Inderide Tablet Reserpine/HCTZ Hydropres Tablet Spironolactone/HCTZ Aldactazide Tablet Trandolapril/Verapamil Tarka Tablet Valsartan/HCTZ* Diovan/HCT* Tablet *Step Therapy: T/F preferred
ACE-Inhibitors/HCTZ combination
ANTIHYPERTENSIVES-OTHER Guanabenz Wytensin Tablet
ANTILIPIDEMICS Atorvastatin Lipitor Tablet Cholestyramine Questran, Powder
Questran Light Colestipol Colestid Tablet Fenofibrate Tricor Capsule Fluvastatin Lescol, Lescol XL Capsule Gemfibrozil Lopid Tablet Lovastatin Mevacor Tablet Lovastatin/Niacin Advicor Tablet Nicotinic Acid Niacor/Niaspan Tablet Pravastatin Pravachol Tablet Simvastatin Zocor Tablet Simvastatin/Ezetimibe Vytorin* Tablet *Step Therapy with preferred
generics
ANTIMALARIALS Chloroquine Phosphate Aralen Tablet Hydroxychloroquine Plaquenil Tablet Primaquine Primaquine Tablet Pyrimethamine Daraprim Tablet
ANTIMANICS Lithium Carbonate Eskalith Capsule, Solution Lithium Carbonate CR Lithobid/
Eskalith CR Tablet, Solution
ANTINEOPLASTICS ADJUNCTIVE MEDICATIONS Leucovorin (Folinic Acid) Leucovorin Tablet
ALKYLATING MEDICATIONS Altretamine Hexalen Tablet Busulfan Myleran Tablet Chlorambucil Leukeran Tablet Cyclophosphamide Cytoxan Tablet Estramustine Emcyt Capsule Lomustine CeeNu Capsule Melphalan Alkeran Tablet Temozolomide Temodar Capsule
ANTIMETABOLITES Capecitabine Xeloda Tablet Mercaptopurine Purinethol Tablet Methotrexate Rheumatrex Tablet Thioguanine Thioguanine Capsule
MISCELLANEOUS ANTINEOPLASTICS Anastrozole Arimidex Tablet Exemestane Aromasin Tablet
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Fluorouracil Efudex Cream, Solution Hydroxyurea Hydrea Capsule Letrozole Femara Tablet Mitotane Lysodren Tablet Procarbazine Matulane Tablet
ANTIPARASITICS Dapsone Dapsone Tablet Iodoquinol Yodoxin Tablet Ivermectin Stromectol Tablet Mebendazole Vermox Chewable Tablets Metronidazole Flagyl Tablets
ANTIPARKINSONIANS Amantadine Symmetrel Capsule, Syrup Benztropine Cogentin Tablet Biperiden Akineton Tablet Bromocriptine Mesylate Parlodel Tablet, Capsule Carbidopa/Levodopa Sinement, Sinemet CR Tablet Carbidopa/Levodopa/Entacapone Stalevo Tablet Diphenhydramine Benadryl Capsule, Solution Entacapone Comtan Tablet Levodopa Larodopa Tablet Pramipexole Mirapex Tablet Ropinirole Hydrochloride Requip Tablet Selegiline Eldepryl Tablet, Capsule Tolcapone Tasmar Tablet Trihexyphenidyl Artane Tablet
ANTIPLATELET AGGREGATION MEDICATIONS Aspirin Aspirin Tablet Aspirin/Dipyridamole Aggrenox Capsule Anagrelide Agrylin Capsule Cilostazol Pletal Tablet Clopidogrel Plavix Tablet Dipyridamole Persantine Tablet Ticlopidine Ticlid Tablet
ANTIPSORIATICS (TOPICAL) Anthralin Psoriatec Cream Calcipotriene Dovonex Cream, Ointment
Calcipotriene Dovonex Solution
Tazarotene Tazorac
ANTIPSYCHOTICS Apripiprazole Abilify* Tablet, Solution *Injection requires PA Apripiprazole Abilify Discmelt Rapid Dissolve
Tab Chlorpromazine Thorazine Tablet Clozapine Clozaril Tablet Fluphenazine Prolixin Tablet, Injection Haloperidol Haldol Tablet
Solution Injection
Loxapine Loxitane Capsule, Solution Molindone Moban Tablet Olanzapine Zyprexa Tablet Olanzapine
Perphenazine
Zyprexa Zydis
Trilafon
Oral Disintegrating Tablet Tablet
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Pimozide Orap Tablet Quetiapine Seroquel Tablet
Quetiapine SR Seroquel XR Tablet Risperidone Risperdal Tablet,
Solution Thioridazine Mellaril Tablet, Solution Thiothixene Navane Capsule, Solution Trifluoperazine Stelazine Tablet, Solution Ziprasidone Geodon Capsule
ANTIRHEUMATICS (RA) Auranofin Ridaura Capsule Hydroxychloroquine Plaquenil Tablet Leflunomide Arava Tablet Methotrexate Rheumatrex Tablet Penicillamine Cuprimine Capsule Sulfasalazine Azulfidine Tablet
ANTISEBORRHEICS (TOPICAL) Ketoconazole Nizoral Shampoo Selenium Sulfide Selsun Blue Shampoo Sulfacetamide Klaron Suspension
ANTISPASMODIC/ANTICHOLINERGICS (GI) Dicyclomine Bentyl Capsule Glycopyrrolate Robinul Tablet Hyoscyamine Levsin, Levbid Tablet Propantheline Probanthine Tablet
ANTISPASMODIC/ANTICHOLINERGICS (UROLOGICAL) Darifenacin Hydrobromide Enablex Tablet Methanamine/Methylene Blue/ Atropine Urised Tablet / Hyoscyamine Oxybutynin Ditropan Tablet Solifenacin Succinate Vesicare Tablet Tolterodine Detrol Tablet Tolterodine Extended Release Detrol LA Capsules
ANTITHYROIDS Methimazole Tapazole Tablet Potassium Iodide SSKI Tablet, Solution Propylthiouracil Propylthiouracil Tablet
ANTITUBERCULOSAL MEDICATIONS Ethambutol Myambutol Tablet Isoniazid Nydrazid Tablet Pyrazinamide Pyrazinamide Tablet Rifabutin Mycobutin Capsule Rifampin Rifadin Capsule
ANTIVERTIGO MEDICATION Meclizine Antivert Tablet
ANTIVIRALS (ORAL) Acyclovir Zovirax Capsules
Ointment* *PA Required for Ointment
Famciclovir Famvir Tablet Ganciclovir Cytovene Capsule Valacyclovir Valtrex Tablet
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ANTIVIRALS (TOPICAL) Docosanol Abreva Cream Penciclovir Denavir Cream
ANXIOLYTICS Alprazolam Xanax Tablet Buspirone Buspar Tablet Chlordiazepoxide Librium Capsule Clorazepate Tranxene Tablet Diazepam Valium Tablet Lorazepam Ativan Tablet Oxazepam Serax Tablet
BENIGN PROSTATIC HYPERPLASIA MEDICATIONS Doxazosin Cardura Tablet Dutasteride Avodart Capsule Finasteride Proscar Tablet Tamsulosin Flomax Capsule Terazosin Hytrin Capsule
BETA AGONISTS (INHALED) Albuterol Aerosol Ventolin HFA Inhaler Albuterol Solution* Proventil Solution *0.083%, 0.5 % Isoetharine Isotharine Solution Levalbuterol Xopenex* Solution *Pulmonologists only;
Qty limit 120 vials/30 days Metaproterenol Alupent Inhaler, Solution Salmeterol Serevent Inhaler
BETA AGONISTS (ORAL) Albuterol Proventil Syrup, Tablet Formoterol Foradil Inhaler Terbutaline Brethine Tablet
BETA AGONIST/ANTICHOLINERGIC COMBINATIONS (INHALED) Ipratropium/Albuterol Combivent Inhaler
BETA AGONIST/CORTICOSTEROID COMBINATIONS (INHALED) Fluticasone/Salmeterol Advair, Advair HFA Inhaler Budesonide/Formeterol Symbicort Inhaler
BETA BLOCKERS (ORAL) Atenolol Tenormin Tablet Carvedilol Coreg Tablet Carvedilol Coreg CR Capsule Labetalol Trandate Tablet Metoprolol Lopressor, Toprol XL Tablet Nadolol Corgard Tablet Pindolol Visken Tablet Propranolol, Propranolol SR Inderal, Inderal LA Tablet
Capsule Solution
Sotalol Betapace Tablet Timolol Blocadren Tablet
BONE RESORPTION SUPPRESSORS Alendronate Fosamax Tablet
Alendronate/Vit D3 Fosamax-D Tablet
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Calcitonin Miacalcin Spray Etidronate Didronel Tablet Raloxifene Evista Tablet Risedronate Actonel Tablet
BURN THERAPY (TOPICAL) Silver Sulfadiazine Silvadene Cream
CALCIUM CHANNEL BLOCKER Amlodipine Norvasc Tablet Diltiazem Cardizem Tablet Diltiazem Extended Release Cardizem CD, LA Capsule, Tablet Nifedipine Sustained Release Adalat CC Tablet Nisoldipine Sular Tablet Verapamil Calan Tablet Verapamil SR Calan SR Tablet
CALCIUM METABOLISM Calcitriol Rocaltrol Capsule Dihydrotachysterol (DHT) Vitamin D Tablet Ergocalciferol Vitamin D 2 Capsule
CARDIAC GLYCOSIDES Digoxin Lanoxin Tablet
CHELATORS Succimer Chemet Capsule
CHOLINERGICS (URINARY) Bethanechol Urecholine Tablet
CHOLINERGIC MUSCLE STIMULANTS Neostigmine Prostigmin Tablet Pyridostigmine Mestinon Tablet
CNS STIMULANTS Atomoxetine* Strattera* Capsule *Prior Auth Required Dexmethylphenidate Hydrochloride Focalin Dexmethylphenidate Hydrochloride Focalin XR Capsule Dextroamphetamine Dexedrine Tablet Methylphenidate Controlled Release Concerta Tablet Methylphenidate Sustained Release Ritalin SR Tablet, Capsule Methylphenidate Ritalin Tablet Mixed Amphetamines Extended Release Adderall XR Capsule Mixed Amphetamines Adderall Tablet Lisdexamphetamine Dimesylate Vyvanse Capsule
CONTRACEPTIVE, INJECTABLES Medroxyprogesterone* Depo-Provera* Injection *Female only
CONTRACEPTIVES, ORAL Ethinyl Estradiol 50 mcg/ Norgestrel 0.5 mg Ovral Tablet Ethinyl Estradiol 50mcg/Ethynodiol 1 mg Demulen 1/50, Zovia 1/50 Tablet Ethinyl Estradiol 35 mcg/ Ethynodiol 1mg Demulen 1/35, Zovia 1/35 Tablet Ethinyl Estradiol 30 mcg/Norgestrel 0.3 mg LoOvral, Low-Ogestrol Tablet Ethinyl Estradiol 30mcg/ Desogestrel 0.15 mg Desogen, Ortho-Cept Tablet Ethinyl Estradiol 35mcg/Norethindrone 1mg Nelova 1/35 Tablet Ethinyl Estradiol 30 mcg/Norethindrone 1.5mg Loestrin 1.5/30 Tablet Ethinyl Estradiol 20 mcg/Norethindrone 1mg Loestrin 1/20 Tablet Ethinyl Estradiol 20 mcg/Levonorgestrel 0.1 mg Alesse Tablet
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Ethinyl Estradiol 35 mcg/ Norethindrone 0.5 mg Modicon Tablet Ethinyl Estradiol 35 mcg/ Norethindrone 0.4 mg Ovcon-35 Tablet Ethinyl Estradiol 35 mcg/ Norgestimate 0.25 mg Mononessa, Ortho-Cyclen Tablet 1 mg norethindrone/50 mcg mestranol Ortho-Novum 1/50, Necon Tablet Ethinyl Estradiol 35mcg/Norethindrone 1mg Ortho-Novum 1/35,
Necon 1/35 Tablet
Ethinyl Estradiol 30 mcg/ Drospirenone 3 mg Yasmin Tablet Ethinyl Estradiol 30mcg/ Levonorgestrel 0.15mg Levora Tablet Ethinyl Estradiol/Desogestrel/ Cyclessa Tablet Ethinyl Estradiol/Norethindrone/ Estrostep FE Tablet Ethinyl Estradiol 35/Norethindrone0.75 Ortho-Novum 777, Necon 777 Tablet Ethinyl Estradiol 35/ Norgestimate 0.18 Ortho Tri-Cyclen/Trinessa Tablet Ethinyl Estradiol 35/Norethindrone 0.5 Tri-Norinyl Tablet Norethindrone 0.35 mg Ortho-Micronor Tablet Ethinyl Estradiol 10, 20mcg/ Desogestrel 0.15mg Mircette Tablet Ethinyl Estradiol 35/Norethindrone0.5, 1 mg Ortho-Novum/Necon 10/11 Tablet Ethinyl Estradiol 30,40mcg/ Levonorgestrel .05,.075,.125
Triphasil, Trivora Tablet
CORTICOSTEROIDS (INHALED) Beclomethasone QVAR Inhaler Budesonide* Pulmicort* Inhaler,
Respules* *PA Required: >5 years old *QD dosing for 0.25mg/2ml *QD-BID dosing for 0.5mg/2ml *QD dosing for 1mg/2ml
Flunisolide Aerobid, Aerobid-M Inhaler Fluticasone Flovent HFA Inhaler Fluticasone/Salmeterol Advair, Advair HFA Inhaler Mometasone Furoate Asmanex Twisthaler Inhaler Triamcinolone Azmacort Inhaler
CORTICOSTEROIDS (ORAL) Cortisone Cortone Tablet Dexamethasone Decadron Tablet, Solution Fludrocortisone Florinef Tablet Hydrocortisone Hydrocortisone Tablet Methylprednisolone Medrol Tablet Prednisolone Orapred Syrup Prednisone Orasone Tablet, Solution
CORTICOSTEROIDS (TOPICAL) Group I (Very High Potency)
Augmented Betamethasone Dipropionate Diprolene Ointment Clobetasol 0.05% Temovate Cream, Ointment,
Solution Group II (High Potency)
Amcinonide 0.1% Cyclocort Cream Betamethasone Dipropionate 0.05% Diprosone Cream, Ointment Betamethasone Valerate 0.1% Valisone Ointment Desoximetasone 0.25% Topicort Cream, Ointment Desoximetasone 0.05% Topicort Gel Diflorasone Diacetate 0.05% Psorcon Cream, Ointment Fluocinolone 0.2% Synalar Cream Fluocinolone 0.05% Lidex Ointment
Cream Gel
Triamcinolone Acetonide 0.5% Kenalog Cream Ointment
14
Group III (Medium Potency)
Betamethasone Dipropionate 0.05% Diprosone Lotion Betamethasone Valerate 0.1% Valisone Cream Desoximetasone 0.05% Topical LP Cream Fluocinolone Acetonide 0.025% Synalar Ointment
Cream Fluticasone 0.05%, 0.005% Cutivate Cream, Ointment Hydrocortisone Valerate 0.2% Westcort Cream, Ointment Mometasone 0.1% Elocon Ointment Triamcinolone Acetonide 0.025% Kenalog Ointment, Cream,
Lotion Triamcinolone Acetonide 0.1% Kenalog Ointment, Cream,
Lotion
Group IV (Low Potency)
Desonide 0.05% DesOwen Cream Fluocinolone Acetonide 0.01% Synalar Cream, Solution Hydrocortisone 0.5%, 1%, 2.5% Hytone Cream, Ointment,
Lotion Hydrocortisone/Pramoxine Pramosone Cream, Lotion,
Ointment
COUGH/COLD MEDICATIONS Benzonatate Tessalon Capsule Brompheniramine/Phenylephrine Bromfed PD Capsule Brompheniramine/Pseudoephedrine Bromfed Capsule Brompheniramine/Pseudoephedrine/Dextro. Bromfed DM, Rondec DM Syrup Chlorpheniramine/Phenylephrine Rynatan Tablet
Oral Suspension Chlorpheniramate/Phenylephrine HCl Rondec Syrup Chlorpheniramine/ Phenylephrine HCl Rondec Drops Drops Chlorpheniramine/Pseudoephedrine/Dextro. Rondec DM Drops Drops Guaifenesin Mucinex Tablets Guaifenesin /Codeine Cheracol Syrup Guaifenesin /Dextromethorphan Humibid DM Tablet Guaifenesin /Hydrocodone Hycotuss Syrup Guaifenesin /Phenylephrine Despec Liquid Guaifenesin /Pseudoephedrine Robitussin PE, Entex PSE Syrup, Tablet Guaifenesin /Pseudoephedrine/Dextro. Tussin Cough and Cold Syrup, Capsule Hydrocodone/Homatropine Hycodan Syrup, Tablet Phenyephrine/Pyrilamine/Chlorpheniramine R-Tannate Oral Suspension Promethazine/Codeine Phenergan/Codeine Syrup Promethazine/Phenylephrine Phenergan VC Syrup Promethazine/Phenylephrine/Codeine Phenergan VC/Codeine Syrup Pseudoephedrine/Chlorpheniramine Deconamine Deconamine SR Tablet, Capsule Pseudoephedrine/Hydrocodone HC Tussive-D Syrup
DECONGESTANTS (ORAL) Pseudoephedrine Sudafed Tablet, Solution
DIURETICS Amiloride Midamor Tablet Amiloride/ Hydrochlorothiazide Moduretic Tablet Bumetanide Bumex Tablet Chlorothiazide Diuril Tablet, Suspension Chlorthalidone Hygroton Tablet Furosemide Lasix Tablet, Solution Hydrochlorothiazide Oretic Tablet, Solution Indapamide Lozol Tablet Methyclothiazide Enduron Tablet
15
Metolazone Zaroxolyn Tablet Spironolactone Aldactone Tablet Spironolactone/Hydrochlorothiazide Aldactazide Tablet Torsemide Demadex Tablet Triamterene Dyrenium Capsule Triamterene/Hydrochlorothiazide Maxide, Dyazide Tablet, Capsule
ELECTROLYTES Calcium Acetate PhosLo Tablet Calcium Carbonate Tums Tablet
Suspension Calcium Carbonate/Vitamin D Oscal + D Tablet Magnesium Chloride Slow Mag Tablet Magnesium Oxide Mag Ox Tablet Oral Electrolyte Solution* Pedialyte* Solution *Children 12 and under;
Qty limit of 6000 ml Potassium Chloride K-Dur Tablets,
Capsules, Solution
Potassium Gluconate Kaon Solution Sodium/Potassium Phosphates Neutra-Phos Packet
ELECTROLYTE DEPLETERS Sevelamer Carbonate Renagel Tablet Sevelamer HCL Renvela Tablet Sodium Polystyrene Kayexalate Suspension
ESTROGENS- FEMALE PATIENTS ONLY Conjugated Estrogens Premarin Tablet Esterified Estrogens Menest Tablet Estradiol Estrace Tablet Estradiol Transdermal Climara, Alora, Estraderm,Vivelle Patch Estrogen Vaginal Premarin Cream Estropipate Ortho-Est Tablet
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 *Diagnosis Required:
Chronic Idiopathic Constipation Irritable Bowel Syndrome
Mesalamine Asacol, Pentasa, Canasa
Capsule, Suppository
Misoprostol Cytotec Tablet Olsalazine Dipentum Tablet Pentosan Polysulfate Sodium Elmiron Capsule Simethicone Gas-X Tablets,
Drops, Chew Tabs
Sucralfate Carafate Tablets Sulfasalazine Azufidine Tablet
16
GI STIMULANTS Metoclopramide Reglan Tablet, Solution
GLUCOSE ELEVATORS Glucagon Glucagon Syringe
GOUT MEDICATIONS Allopurinol Zyloprim Tablet Colchicine Colchicine Tablet Probenecid Probenecid Tablet Sulfinpyrazone Anturane Tablet, Capsule
H2 RECEPTOR ANTAGONISTS Cimetidine Tagamet Tablets Famotidine Pepcid Tablets Nizatidine Axid Capsule Ranitidine Zantac Tablet, Solution
HEMORRHEOLOGIC AGENTS Pentoxifyline Trental Tablet
HEMOSTATICS Aminocaproic Acid Amicar Tablet
HIV/AIDS THERAPY Non-Nuclease Reverse Transcriptor Inhibitor (NNRTIs) Lamivudine/Zidovudine Combivir Tablet Emtricitabine Emtriva Capsule Lamivudine (3TC)* Epivir, Epivir-HBV* Tablet, Solution* *Solution Requires PA Abacavir/Lamivudine Epzicom Tablet Zidovudine (AZT) Retrovir Capsule
Tablet Syrup
Abacavir/Lamivudine/Zidovudine Trizivir Tablet Emtricitabine/Tenofovir Truvada Tablet Didanosine (DDI) Videx EC Tablet Tenofovir Viread Tablet Stavudine (D4T) Zerit Capsule, Powder Abacavir Ziagen Tablet, Solution Efavirenz/ Emtricitabine/Tenofovir Atripla Tablet
Nuclease Reverse Transcriptor Inhibitor (NRTIs) Nevirapine Viramune Tablet Efavirenz Sustiva Capsule Delavirdine Rescriptor Tablet
Protease Inhibitors (PI) Atazanavir Reyataz Capsule Darunavir Ethanolate Prezista Tablet Fosamprenavir Lexiva Tablet
Suspension Indinavir Crixivan Capsule Nelfinavir Viracept Tablet, Powder Ritonavir Norvir Capsule, Solution Ritonavir/Lopinavir Kaletra Capsule, Solution Saquinavir Invirase Capsule
17
HYPOGLYCEMIC (ORAL) Chlorpropamide Diabinese Tablet Glimepiride Amaryl Tablet Glipizide Glucotrol Tablet Glipizide Extended Release Glucotrol XL Tablet Glyburide Micronase Tablet Glyburide/Metformin Glucovance Tablet Glyburide Micronized Glynase Tablet Metformin Glucophage Tablet Metformin ER Glucophage XR Tablet Nateglinide* Starlix* Tablet Pioglitazone* Actos* Tablet Pioglitazone/Glimepiride* Duetact* Tablet Pioglitazone/Metformin* Actoplus Met* Tablet Rosiglitazone* Avandia* Tablet Rosiglitazone/Glimepiride* Avandaryl* Tablet Rosiglitazone/Metformin* Avandamet* Tablet Sitagliptin* Januvia* Tablet Sitagliptin / Metformin* Janumet* Tablet
*Step Therapy: concurrent use of metformin, sulfonylureas, or TZD’s
Tolbutamide Tolbutamide Tablet
IMMUNOSUPPRESSIVES Azathioprine Imuran Tablet Cyclosporine Neoral/Sandimmune Capsule Mycophenolate Mofetil Cellcept Capsule Mycophenolate Sodium Myfortic Tablet Tacrolimus Prograf Capsule
INSULINS Human Insulin Humulin Vial, Pen Human Insulin Humalog Vial, Pen Insulin Detemir Levemir Vial, Pen Insulin Glargine Lantus Vial, Cartridge, Pen
INTRANASAL ANTIHISTAMINES Azelastine Astelin Spray
INTRANASAL MAST CELL STABILIZERS Cromolyn Nasal Nasalcrom Spray
INTRANASAL STEROIDS Budesonide Rhinocort Aqua Spray Fluticasone Flonase Spray Mometasone Nasonex Spray
LAXATIVES Bisacodyl Dulcolax Tablet
Suppository Dibasic/Monophasic NaPhosphate Fleet Enema Enema Docusate Calcium Surfak Capsule Docusate Sodium Colace Capsule, Syrup Docusate/Senna Peri-colace Capsule Electrolytes and Laxative Solution Nulytely Powder Glycerin Glycerin Suppository Lactulose Cephulac Syrup Magnesium Citrate Mag Citrate Solution Magnesium Hydroxide MOM Suspension Methylcellulose Citrucel Powder Mineral Oil Mineral Oil Liquid, Emulsion Polyethylene Glycol, Polyethylene Glycol 3350 Miralax, Miralax OTC Powder Psyllium Metamucil Powder Senna Senokot Tablet, Granules
18
LEUKOTRIENE RECEPTOR ANTAGONISTS Montelukast Singulair Tablet
MAST CELL STABILIZERS (INHALED) Cromolyn Sodium Inhaler Intal Inhaler Cromolyn Sodium Solution Intal Solution
METABOLIC DEFICIENCY AGENTS Levocarnitine Carnitor Tablet
MIGRAINE AND CLUSTER HEADACHE THERAPY APAP/Dichloralphenazone/Isometheptene Midrin Capsule Eletriptan* Relpax* Tablet *Qty limit: up to 12 tab/ 30 days Ergotamine/Caffeine Cafergot Tablet
Zolmitriptan* Zomig, Zomig ZMT* Tablet/ Nasal Spray
*Qty limit:: up to 12 tab/ 30 days Nasal Spray (6 units/30 days)
Sumatriptan* Imitrex* Tablet, Nasal Spray, Injection
*Qty limit:: up to 12 tabs/ 30 days Nasal Spray (6 units/ 30 days)
Sumatriptan* Imitrex* Injection * Qty limit :(4 injections/ 30 days)
MUCOLYTICS Acetylcysteine Mucomyst Solution
MUSCLE RELAXANTS Baclofen Lioresal Tablet Carisoprodol Soma Tablet Carisoprodol/ASA Soma Compound Tablet Carisoprodol/ASA/Codeine Soma Compound w/ Codeine Tablet Chlorzoxazone Parafon Forte Tablet Cyclobenzaprine Flexeril Tablet Dantrolene Dantrium Capsule Methocarbamol Robaxin Tablet Orphenadrine Norflex Tablet Orphenadrine/ASA/Caffeine Norgesic Tablet Tizanidine* Zanaflex* Tablet *Capsules require PA
NARCOTIC ANTAGONISTS Naltrexone ReVia Tablet
NITRATES Isosorbide Dinitrate Isordil Tablet Isosorbide Dinitrate Sustained Release Isordil SA Tablet Isosorbide Mononitrate Imdur, Monoket Tablet Nitroglycerin Ointment Nitro-Bid Ointment Nitroglycerin Oral Nitro-Time Capsule Nitroglycerin SL Nitrostat Tablet Transdermal Nitroglycerin Nitro-Dur Patch
OPHTHALMIC ALPHA-2 ADRENERGIC AGONISTS Brimonidine Alphagan Drop
OPHTHALMIC ANTIBIOTICS Bacitracin Bacitracin Ointment Bacitracin/Polymyxin Polyysporin Ointment Ciprofloxacin Ciloxan Drops, Ointment
19
Erythromycin Ilotycin Ointment Gatifloxacin* Zymar* Drops *Ophthalmologists only Gentamicin Sulfate Garamycin Drops Neomycin/Polymyxin/Gramicidin Neomycin/Polymyxin/Bacitracin
Neosporin Neosporin
Drops Ointment
Ofloxacin Ocuflox Drop Polymyxin/Trimethoprim Polytrim Drop Sulfacetamine Bleph 10 Drop, Ointment Tobramycin Tobrex Drop, Ointment
OPHTHALMIC ANTIHISTAMINES Ketotifen Fumarate Zaditor OTC,
Alaway Drops
Olopatadine* Patanol, Pataday* Drops *Step Therapy: Zaditor OTC/ Alaway first
OPHTHALMIC ANTIVIRALS Trifluridine Viroptic Drop
OPHTHALMIC BETA BLOCKERS Betaxolol Betoptic S Drops Carteolol Ocupress Drop Levobunolol Betagan Drop Metipranolol OptiPranolol Drops Timolol Timoptic, Drop, Gel
Timoptic-XE
OPHTHALMIC MAST CELL STABILIZER Cromolyn Sodium Crolom Drop
OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS Brinzolamide Azopt Drop
OPTHALMIC CHOLINESTERASE INHIBITORS Echothiophate Iodide Phoshpholine Iodide Drop
OPTHALMIC DIRECT ACTING MIOTICS Carbachol Isopto Carbachol Drop Pilocarpine Pilocar Drop Pilocarpine Pilopine HS Gel
OPHTHALMIC PROSTAGLANDINS AGONISTS Latanoprost Xalatan Drop
SYMPATHOMIMETICS: Apraclonidine Iopidine Drop
OPHTHALMIC MYDRIATICS Dipivefrin Propine Drop Epinephrine Epifrin Drop
OPHTHALMIC NON-STEROIDALS Flurbiprofen Ocufen Drop Ketorolac Acular, Acular PF Drop,
Droperette Cyclosporine* Restasis* Droperette *Step therapy: Generic artificial
tears OR rheumatologist OR ophthalmologist
OPHTHALMIC STEROID/ANTIBIOTIC COMBINATIONS Neomycin/Polymyxin/Dexamethasone Maxitrol Ointment
20
Neomycin/Polymyxin/HC Cortisporin Drop, Ointment
Sulfacetamide 10%/Prednisolone .25% Vasocidin Drops Tobramycin/Dexamethasone Tobradex Drops
OPHTHALMIC STEROIDS Dexamethasone Decadron Drop,
Ointment Fluorometholone FML, FML Forte,
FML SOP Drop, Ointment
Prednisolone Pred Forte Drop Prednisolone Pred Mild Drop
OPTHALMIC VASOCONSTRICTOR DECONGESTANTS Phenylephrine Neo-Synephrine Drop Naphazoline Albalon Drop
ORAL, MISCELLANEOUS Chlorhexidine Peridex Liquid Sodium Fluoride Prevident Gel, Solution, Tabs,
Cream, Paste Lidocaine Viscous Lidocaine Viscous Liquid
OTIC ANTIBIOTICS Acetic Acid Vosol Drop Acetic Acid/ Aluminum Acetate Domeboro Otic Drop Ciprofloxacin/Dexamethasone Ciprodex Otic Suspension Ofloxacin Floxin Otic Drop
OTIC, MISCELLANEOUS Antipyrine/Benzocaine Antipyrine/Benzocaine Drop
OTIC, STEROID/ANTIBIOTIC COMBINATIONS Acetic Acid/Hydrocortisione Vosol HC Drop Neomycin/Polymyxin/Hydrocortisone Cortisporin Drop
OXYTOCICS Methylergonovine Methergine Tablet
PANCREATIC ENZYMES Amylase/Lipase/Protease Lipram, Viokase Capsule Pancreaslipase Creon Capsule
PHEOCHROMOCYTOMA MEDICATIONS Metyrosine Demser Capsule Phenoxybenzamine Dibenzyline Capsule
PROGESTINS Medroxyprogesterone Provera Tablet Megestrol Megace Tablet,
Suspension Megestrol Megace ES* Suspension *PA required
PROTON PUMP INHIBITORS Lansoprazole* Prevacid* Solutabs *Step Therapy: Prior use of
Omeprazole within the past 12 months. Qty limit: 1 cap/day.
Omeprazole OTC Prilosec OTC Tablet Omeprazole Prilosec Capsule 40mg: use 2-20mg caps/tab
21
Pantoprazole* Protonix Tablet *Step Therapy: Prior use of Omeprazole within the past 12 months. Qty limit: 1 cap/day.
PULMONARY ARTERIAL HYPERTENSION MEDICATION Sildenafil Citrate* Revatio* Tablet *Diagnosis Required:
Pulmonary Arterial Hypertension
SCABICIDES/PEDICULICIDES Crotamiton Eurax Cream, Lotion Lindane* Kwell* Lotion,
Shampoo *Step Therapy Required
Malathion* Ovide* Lotion *Step Therapy Required Permethrin 1% Nix Lotion 1 st Line agent Permethrin 5% Elimite Cream 1 st line agent
SEDATIVES HYPNOTICS Estazolam Prosom Tablet Meprobamate Equanil Tablet Ramelteon Rozerem* Tablet * Step Therapy Required Temazepam Restoril Capsule Triazolam Halcion Tablet Zalpelon Sonata Tablet Zolpidem Ambien Tablet
THYROID HORMONES Levothyroxine Synthroid Tablet Liothyronine Cytomel Tablet
TOPICAL ENZYMES (DEBRIDING MEDICATIONS) Papain/Urea Accuzyme Ointment Trypsin Granulex Spray
TOPICALS, MISCELLANEOUS Imiquimod Aldara* Cream *PA Required Pimecrolimus Elidel* Cream *Preferred for < 18 yo Podofilox Condylox Gel,
Solution Tacrolimus Protopic* Ointment *PA required
VAGINAL ANTI-INFECTIVES Clotrimazole Gyne-Lotrimin Suppository,
Cream Fluconazole* Diflucan* Tablet Qty Limit:: 150mg 4 tab/28 days
Metronidazole Vaginal Metrogel Vaginal Gel Miconazole Monistat Suppository,
Cream Nystatin Mycostatin Tablet Tioconazole Vagistat Ointment Triple Sulfa Vaginal Sultrin Cream
VASODILATORS Hydralazine Apresoline Tablet Minoxidil Loniten Tablet
XANTHINES Aminophylline Aminophylline Tablet,
Liquid