Formulary Guide - Horizon NJ Health · Please refer to this guide when prescribing for Horizon NJ...

1

FormularyGuide

horizonNJhealth.com

October 2017

Formulary_Pocket_Guide_October2017_FINAL.indd 1 9/22/17 4:08 PM

1

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 therapyprocedures and other pharmaceutical management methods are available online at horizonNJhealth.com.

Please note that Horizon NJ Health maximum days supply limit is 30 days.

Formulary_Pocket_Guide_October2017_FINAL.indd 1 9/22/17 4:08 PM

2

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_Pocket_Guide_October2017_FINAL.indd 2 9/22/17 4:08 PM

3

GLUCOCORTICOIDS

$$ * + prednisolone, oral solution$$ * + hydrocortisone$$ * + methylprednisolone$$ * + dexamethasone

TESTOSTERONE REPLACEMENT THERAPY$$$$ * + @ Testosterone 12.5mg/1.25g gel pump$$$$ * + @ Testosterone 25mg/2.5g gel packet, 50mg/5g gel packet$$$$ * @ Striant

PENICILLINS

$ + penicillin$ + ampicillin$ * + amoxicillin$ + dicloxacillin$$ * + amoxicillin clavulanate$$ Bicillin LA$$$ * Augmentin XR

TETRACYCLINES$ + doxycycline hyclate$$ + tetracycline HCI$$$ + minocycline HCL caps$$$ + doxycycline monohydrate

CEPHALOSPORINS$ + cephalexin$$ + cefaclor, cefadroxil$$ * + cefdinir$$ * + cefpodoxime$$ * + cefprozil$$ + cefuroxime$$ * Spectracef !!!!!! + ceftriaxone

ANDROGENS

ANTIINFECTIVES

ADRENOCORTICAL STEROIDS

Formulary_Pocket_Guide_October2017_FINAL.indd 3 9/22/17 4:08 PM

4

MACROLIDES$ * + clarithromycin, SR$$ * + azithromycin

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 !!!!!! @ Ambisome

ANTIMALARIAL AGENTS$ + chloroquine$ * + mefloquine$ + primaquine$ + quinine$$ + atovaquone/proguanil$$$ * Coartem

Formulary_Pocket_Guide_October2017_FINAL.indd 4 9/22/17 4:08 PM

5

ANTIRETROVIRAL AGENTS SOME MEMBERS MAY HAVE THEIR HIV/AIDS MEDICATIONS COVERED THROUGH

THE AIDS DRUGS DISTRIBUTION PROGRAM (ADDP).$$$$ * @ + abacavir$$$$ * @ + abacavir /lamivudine!!!!!! * @ Aptivus!!!!!! * @ Atripla!!!!!! * @ Complera!!!!!! * @ Crixivan$$$$ * @ + didanosine!!!!!! * @ Edurant!!!!!! * @ Emtriva!!!!!! * @ Fuzeon!!!!!! * @ Genvoya!!!!!! * @ Intelence!!!!!! * @ Invirase!!!!!! * @ Isentress!!!!!! * @ Kaletra$$$$ * @ + lamivudine$$$$ * @ + lamivudine/zidovudine!!!!!! * @ Lexiva$$$$ * @ + nevirapine!!!!!! * @ Norvir!!!!!! * @ Odefsey!!!!!! * @ Prezista!!!!!! * @ Rescriptor!!!!!! * @ Reyataz!!!!!! * @ Selzentry$$$$ * @ + stavudine!!!!!! * @ Stribild!!!!!! * @ Sustiva!!!!!! * @ Trizivir!!!!!! * @ Truvada!!!!!! * @ Videx!!!!!! * @ Viracept!!!!!! * @ Viramune XR!!!!!! * @ Viread!!!!!! * @ Vitekta$$$$ * @ + zidovudine

MISCELLANEOUS ANTIVIRALS$ ↓ + amantadine$$ * @ + ribavirin tablets, capsules$$$ + acyclovir$$$ * Relenza (5 years and older)$$$ * + oseltamivir

Formulary_Pocket_Guide_October2017_FINAL.indd 5 9/22/17 4:08 PM

6

MISCELLANEOUS ANTIVIRALS (Continued)$$$ * + valacyclovir$$$$ * Famvir!!!!!! * Valcyte, Cytovene

CARDIOVASCULARBETA BLOCKERS

$ + bisoprolol$ + atenolol, metoprolol$ + timolol, pindolol$$ + carvedilol$$ + nadolol$$ + propranolol$$ * + propranolol LA$$$ + labetalol$$$ * + acebutolol$$$ * + betaxolol$$$ * + metoprolol ER$$$ * Hemangeol (2 years and younger)

CALCIUM CHANNEL BLOCKERS$ * + amlodipine$ + diltiazem, SR$ + verapamil, long acting$ + nifedipine$ * + nicardipine$$ * + nifedipine XL$$$$ * Nymalize

ACE INHIBITORS$ * + fosinopril, hydrochlorothiazide$ * + moexipril, hydrochlorothiazide$$ * + enalapril, hydrochlorothiazide$$ * + lisinopril, hydrochlorothiazide$$ * + perindopril$$ * + quinapril, hydrochlorothiazide$$ * + ramipril$$ * + trandolapril

ANGIOTENSIN RECEPTOR BLOCKERS$$ * + losartan, hydrochlorothiazide$$$ * + irbesartan, hydrochlorothiazide$$$ * + valsartan, hydrochlorothiazide

CARDIOVASCULAR

Formulary_Pocket_Guide_October2017_FINAL.indd 6 9/22/17 4:08 PM

7

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 $$ * + rosuvastatin$$ * + niacin ER $$$ * Welchol$$$ * ◊ @ + ezetimibe!!!!!! * @ Repatha

ANTIPLATELET AGENTS$ + aspirin$ + dipyridamole$$$ + ticlopidine$$$$ * + aspirin-dipyridamole ER!!!!!! * Agrylin

ANTICOAGULANT AGENTS$$ warfarin$$$$ * Pradaxa$$$$ * Xarelto$$$$ * Eliquis$$$$ + enoxaparin!!!!!! * Arixtra!!!!!! Fragmin!!!!!! Innohep!!!!!! * Iprivask

Formulary_Pocket_Guide_October2017_FINAL.indd 7 9/22/17 4:08 PM

8

DIURETICS$ + hydrochlorothiazide$ + indapamide$ + furosemide$ + bumetanide$ + torsemide$ + spirinolactone, hydrochlorothiazide$ + triamterene, hydrochlorothiazide$ + metolazone

PULMONARY ARTERIAL HYPERTENSION AGENTS$$$$ * + sildenafil 20mg tablet!!!!!! * Adcirca!!!!!! Flolan!!!!!! * Letairis!!!!!! * Remodulin!!!!!! * Revatio tablet!!!!!! * Tracleer!!!!!! * Tyvaso!!!!!! * Ventavis

HYPNOTIC AGENTS$ ↓ + chloral hydrate$ ∆ + flurazepam$ ↓ + triazolam$ ∆ ↓ + temazepam$$ ↓ + estazolam$$ * ↓ + zaleplon$$ * ↓ + zolpidem

TRICYCLIC ANTIDEPRESSANTS$ * ∆ + amitriptyline$ * ↓ +desipramine$ * ↓ + doxepin$ * ↓ + imipramine HCL $ * ↓ + nortriptyline$$ * ↓ + amoxapine$$ * ↓ + protriptyline$$$ * ↓ + clomipramine$$$ * ↓ + trimipramine

CENTRAL NERVOUS SYSTEM

Formulary_Pocket_Guide_October2017_FINAL.indd 8 9/22/17 4:08 PM

9

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$$$ * ↓ + fluoxetine capsule$$$ * ↓+ paroxetine, CR$$$ * ↓+ sertraline $$$$ * + escitalopram

ANTIPSYCHOTICS$ ↓ + fluphenazine, trifluoperazine$ ↓ + perphenazine$ ↓ + haloperidol, thiothixene$$ ↓ + chlorpromazine$$ ↓ Orap$$ * ↓ risperidone$$ * olanzapine, orally disintegrating tablets$$ * ↓ quetiapine$$ * ↓ ziprasidone$$ * olanzapine/fluoxetine$$$ ↓ + loxapine$$$$ ↓ Moban$$$$ * ↓ aripiprazole$$$$ * ↓ Abilify Maintena $$$$ * ↓ clozapine, orally disintegrating tablets$$$$ * ↓ + paliperidone $$$$ * Zyprexa Relprevv$$$$ * ↓ Risperdal Consta $$$$ * ↓ Invega Sustenna

Formulary_Pocket_Guide_October2017_FINAL.indd 9 9/22/17 4:08 PM

10

MISCELLANEOUS CNS AGENTS$ + lithium citrate, carbonate$$ * + methylphenidate, SR, ER$$ * + dexmethylphenidate$$ * + dextroamphetamine sulfate$$ * + amphetamine-dextroamphetamine, ER$$ * + guanfacine, ER$$$ * + atomoxetine$$$ * + methylphenidate CD$$$$ * @ + modafinil$$$$ * Cuvposa$$$$ * @ Nuedexta

TRIPTANS$$ * + sumatriptan$$ * + rizatriptan, MLT$$ * + naratriptan

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_Pocket_Guide_October2017_FINAL.indd 10 9/22/17 4:08 PM

11

ANTI-ALZHEIMER’S AGENTS$ * + galantamine$$$ * + memantine IR$$$ * + donepezil 5mg, 10mg$$$$ * Exelon, patch

ANALGESICS$$ + hydromorphone$$ * + hydrocodone/acetaminophen 325mg$$ + morphine sulfate immediate release$$ * + oxycodone, with acetaminophen$$ + oxymorphone IR$$$ + morphine sulfate ER, SR$$$ + oxycodone tablet$$$ * + tramadol, ER$$$ * @ + fentanyl patches$$$ @ + oral transmucosal fentanyl citrate$$$$ * @ + oxycodone controlled-release$$$$ * @ Oxycontin

NSAIDS$ + ibuprofen$ ∆ + indomethacin, SR$ ↓ + naproxen sodium$$ + diclofenac sodium$$ Children’s Advil, Motrin$$ + tolmetin$$ + diclofenac potassium $$$ ↓ + ketoprofen$$$ * + nabumetone$$$ * + meloxicam

NSAID COX II INHIBITORS$$$$ * + celecoxib

ANTIVERTIGO AND ANTI-EMETICS$ + meclizine$ + promethazine$ + trimethobenzamide$$ + prochlorperazine$$ * + ondansetron$$$$ * @ Emend

Formulary_Pocket_Guide_October2017_FINAL.indd 11 9/22/17 4:08 PM

12

MULTIPLE SCLEROSIS AGENTS$$$$ * Ampyra!!!!!! * Avonex!!!!!! * Betaseron!!!!!! @ + glatopa!!!!!! * Rebif!!!!!! * Tecfidera!!!!!! * Gilenya

$ Advil Cold and Sinus$ + dextromethorphan$ Dimetapp$ + guaifenesin$ Robitussin$ + promethazine/codeine

TOPICAL CORTICOSTEROIDS (VERY HIGH POTENCY)$$ * + clobetasol 0.05% cream$$ * + clobetasol E 0.05% cream

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

DERMATOLOGICALS/TOPICAL THERAPY

COUGH /COLD

Formulary_Pocket_Guide_October2017_FINAL.indd 12 9/22/17 4:08 PM

13

TOPICAL CORTICOSTEROIDS (MEDIUM POTENCY)$ * + betamethasone valerate 0.1% cream, lotion$ * + desonide cream$ * + fluocinolone acetonide 0.025% cream, ointment$ * + prednicarbate ointment$ * + triamcinolone acetonide 0.1% cream, ointment$ * + triamcinolone acetonide 0.5% cream, ointment$ * + triamcinolone acetonide 0.025% cream, ointment$ * + 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

TOPICAL ANTIFUNGALS$ * + ciclopirox 8% solution$ * + clotrimazole (OTC)$ * + ketoconazole cream$ * + miconazole nitrate (OTC)$ * + ciclopirox cream$ Fungoid$ * + ketoconazole 2% shampoo$ Nizoral A-D shampoo (OTC)$ * + tolnaftate (OTC)$ * + undecylenic acid$$ * + nystatin cream, ointment$$ * + econazole$$ * + nystatin/triamcinolone$$$ Pedi-Dri$$$$ * + clotrimazole/betamethasone cream

Formulary_Pocket_Guide_October2017_FINAL.indd 13 9/22/17 4:08 PM

14

ACNE THERAPYVitamin A derivatives are considered non covered pharmacy benefits for

members 35 years of age and older. $$ * + benzoyl peroxide cream/lotion/gel$$ * + sulfaceamide sodium/sulfur 10-5% emulsion$$ * + metronidazole 0.75% cream, lotion, gel$$$ * Differin OTC 0.1% gel (Not covered if ≥ 35 years old)

OTHER TOPICAL PRODUCTS$ * OTC Abreva$ * + OTC permethrin$$ * ◊ @ Denavir$$ * + mupirocin ointment$$ * + urea 50% nail stick$$$ * @ + imiquimod$$$ * Clindesse$$$ * ◊ @ + malathion lotion$$$ * ◊ @ + tacrolimus ointment$$$ * + diclofenac sodium 1% gel$$$ * @ + acyclovir ointment

PSORIASIS THERAPY$$$ * + calcipotriene!!!!!! @ Amevive

INSULIN THERAPY

$$$$ * Humulin 100 units/mL vials (only 3mL vials for Long-Term Care)$$$$ * Humalog 100 units/mL vials (only 3mL vials for Long-Term Care)$$$$ * Humalog Mix 75/25 vials$$$$ * Basaglar KwikPen

ORAL HYPOGLYCEMIC AGENTS$ * + glimepiride$ * + glipizide, XL$ * + glyburide$$ * + metformin, XR$$ * + metformin/glipizide

ENDOCRINE

Formulary_Pocket_Guide_October2017_FINAL.indd 14 9/22/17 4:08 PM

15

ORAL HYPOGLYCEMIC AGENTS (Continued)$$ * + repaglinide $$ * Precose, Glyset$$ * Riomet$$ * + glyburide/metformin$$ * Welchol$$$ * + nateglinide$$$$ * + pioglitazone, pioglitazone/metformin$$$$ * + pioglitazone/glimepiride$$$$ * + alogliptin$$$$ * + alogliptin/metformin$$$$ * + alogliptin/pioglitazone$$$$ * Avandia, Avandamet, Avandaryl$$$$$ * Jardiance$$$$$ * Synjardy

MISCELLANEOUS HYPOGLYCEMIC AGENTS$$$$$ * Victoza$$$$$ * Bydureon$$$$$ * Symlin

DIABETIC SUPPLIES (MONITORS AND STRIPS)$$ * Insulin syringes (B.D., Monoject)$$ Chemstrip BG$$ * One Touch (all products)$$ * Lancets, pen needle, single use swab

THYROID THERAPY$ levothyroxine$ + propylthiouracil$ + methimazole

Formulary_Pocket_Guide_October2017_FINAL.indd 15 9/22/17 4:08 PM

16

GASTROINTESTINAL

H2-RECEPTOR ANTAGONISTS$$ * Axid AR (OTC)$$ * + nizatidine$$ * + ranitidine (OTC), famotidine (OTC)$$ * + ranitidine syrup

PROTON PUMP INHIBITORS$ * + omeprazole (OTC), OTC omeprazole-magnesium$ * Prevacid 24HR (OTC)$ * Zegerid OTC$ * + pantoprazole$$ * Nexium 24HR (OTC) $$ * + lansoprazole capsules$$ * + legend omeprazole capsules$$ * + rabeprazole 20mg tablet

PANCREATIC ENZYMES!!!!!! Creon!!!!!! Zenpep

HEPATITIS C AGENTS$$ * @ + ribavirin tablets, capsules !!!!!! @ Intron A!!!!!! @ Peg-Intron!!!!!! * @ Pegasys!!!!!! * @ Zepatier

OTHER G.I. DRUGS$ * + dicyclomine$ + metoclopramide $ + polyethylene glycol$$ * + Gavilyte-N, Trilyte (generic Nulytely) $$ + misoprostol $$ + sucralfate$$$ * + alosetron$$$ * @ Amitiza$$$ * Apriso ER!!!!!! @ Cerezyme!!!!!! @ Elelyso

Formulary_Pocket_Guide_October2017_FINAL.indd 16 9/22/17 4:08 PM

17

GROWTH HORMONES!!!!!! @ Humatrope!!!!!! @ Zomacton

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!!!!!! * @ Zarxio!!!!!! * @ Neulasta

INTERFERON ALFA!!!!!! @ Roferon A!!!!!! @ Intron A!!!!!! @ PEG-Intron!!!!!! * @ Pegasys

SODIUM HYALURONATE!!!!!! @ Euflexxa

IMMUNOLOGY, VACCINES AND BIOTECHNOLOGY

Formulary_Pocket_Guide_October2017_FINAL.indd 17 9/22/17 4:08 PM

18

MISCELLANEOUS$$$ @ Benlysta!!!!!! Exjade!!!!!! * @ Arcalyst!!!!!! * @ Synagis

HEREDITARY ANGIOEDEMA THERAPY!!!!!! @ Berinert!!!!!! * @ Cinryze!!!!!! * @ Firazyr!!!!!! @ Kalbitor !!!!!! * @ Ruconest 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 chewing gum (18 years and older)$ * + nicotine lozenge (18 years and older)$ * + nicotine transdermal (18 years and older)$$$$ * + Zyban (18 years and older)$$$$ Evoxac

MISCELLANEOUS

Formulary_Pocket_Guide_October2017_FINAL.indd 18 9/22/17 4:08 PM

19

OPIOID / ALCOHOL ADDICTION TREATMENT

$$ * @ naltrexone$$$ * @ disulfiram$$$ * @ Campral$$$$ * @ buprenorphine$$$$ * @ + buprenorphine/naloxone tablets$$$$ * @ Vivitrol$$$$ * Narcan Nasal Spray

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$$$$ * + calcitonin nasal spray$$$$ + raloxifene$$$$ * Fosamax plus D$$$$ * + risedronate 5mg, 30mg, 35mg

ANTIGOUT$ + allopurinol$$$ * + colchicine capsule

MUSCULOSKELETAL AND RHEUMATOLOGY

Formulary_Pocket_Guide_October2017_FINAL.indd 19 9/22/17 4:08 PM

20

PROGESTINS$ * + medroxyprogesterone$$ * Micronor, Nor QD, Camila, Jolivette, Norlyroc$$ Aygestin$$$ Progesterone Inj, suppos$$$$ * Depo-Provera 150!!!!!! * Makena

ESTROGENS$ + estropipate$ + micronized estradiol$ * + estradiol, estradiol patch, estradiol valerate injection$$ Premarin$$$ Cenestin$$$ Prometrium$$$ Ortho Dienestrol$$$ Menest$$$ 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$$ * + Jinteli 1mg/5mcg $$ * + 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

OBSTETRICS AND GYNECOLOGY

Formulary_Pocket_Guide_October2017_FINAL.indd 20 9/22/17 4:08 PM

21

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$$ * + Tri-Sprintec, TriNessa, Tri-Previfem$$ * + TriNessa Lo$$ * + Velivet$$ * + Tri-Legest Fe, Tilia Fe

VAGINAL AGENTS$ OTC Monistat$ + OTC Clotrimazole$$ * + terconazole cream$$ * + Gynazole-1$$ * Clindesse$$ * Metrogel vaginal$$ * Vagifem

OTHER$$ * + levonorgestrel/Next Choice One Dose (generic Plan B One-Step)$$$$ Lunelle

ANTI-INFECTIVES

$ + tobramycin$ + ciprofloxacin ophthalmic suspension$$ * Ciloxan ophthalmic ointment$$ * + tobramycin-dexamethasone ophthalmic drops$$ * + levofloxacin ophthalmic drops$$ * + ofloxacin ophthalmic drops$$$ * Tobrex ophthalmic ointment$$$$ * Tobradex ophthalmic ointment

ALLERGIC CONJUNCTIVITIS$ Visine-A, Naphcon-A$ + cromolyn$ * Alaway/Zaditor OTC$$$ Alocril$$$ * ◊ @ + olopatadine 0.1%

OPHTHALMOLOGY

Formulary_Pocket_Guide_October2017_FINAL.indd 21 9/22/17 4:08 PM

22

NSAIDS$$ + ketorolac$$$$ * Acular LS$$$$ Voltaren

ANTIGLAUCOMA AGENTS$ * + timolol$ * + latanoprost$$ + dorzolamide hydrochloride/timolol maleate$$ + levobunolol$$ + timolol XE$$$ + apraclonidine$$$ * + brimonidine tartrate 0.2%, 0.15%$$$$ Betoptic S

MACULAR DEGENERATION AGENTS!!!!!! * Eylea!!!!!! * Lucentis!!!!!! * Macugen

ANTI-INFECTIVES

$ * + neomycin/polymixin/bacitracin$$ * + ciprofloxacin 0.2% ear solution$$$ * Cipro HC$$$ + ofloxacin otic$$$ * Ciprodex

MISCELLANEOUS$ * + antipyrine/benzocaine$$ * + acetic acid/aluminum$$$ * + fluocinolone acetonide oil

OTIC

Formulary_Pocket_Guide_October2017_FINAL.indd 22 9/22/17 4:08 PM

23

ANTIHISTAMINES$ * + cetirizine, cetirizine/pseudoephedrine (OTC)$ ∆ + chlorpheniramine (OTC)$ ∆ + cyproheptadine$ ∆ + diphenhydramine (OTC)$ ∆ + hydroxyzine$ + meclizine$ ∆ + promethazine (2 years and older)$ ∆ + tripelennamine $$ ∆ + clemastine$$ ∆ + dexchlorpheniramine$$ * + loratadine, loratadine/pseudoephedrine (OTC)$$ * Alavert$$ * + fexofenadine (180mg, 30mg/5mL), fexofenadine/pseudoephedrine (OTC)$$ * + levocetirizine 5mg tablet$$$ * + 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 Twisthaler, HFA

INTRANASAL STEROIDS$ * + fluticasone$ * Nasacort Allergy 24HR (OTC)

RESPIRATORY

Formulary_Pocket_Guide_October2017_FINAL.indd 23 9/22/17 4:08 PM

24

MISCELLANEOUS PULMONARY AGENTS$ * + benzonatate (11 years and older)$$ * theophylline$$ * + cromolyn nebulizer solution$$$ * + fluticasone/salmeterol (generic AirDuo)$$$ * Atrovent MDI, solution$$$ * Combivent $$$ * + ipratropium albuterol solution$$$ * Accuneb$$$ * + montelukast$$$ * Tilade, nebulizer solution$$$ + acetylcysteine$$$$ * Intal$$$$ * Spiriva Handihaler $$$$ * Tudorza$$$$$ * Pulmozyme!!!!!! * @ Cayston!!!!!! * @ Kalydeco!!!!!! * + tobramycin inhalation solution!!!!!! * @ Xolair!!!!!! * @ Orkambi!!!!!! * @ Nucala

RESPIRATORY DEVICES$ * OptiChamber Advantage, Diamond$ * Respironics OptionHome, Innospire Essence Compressor Nebulizer System

Formulary_Pocket_Guide_October2017_FINAL.indd 24 9/22/17 4:08 PM

25

BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY$$ + doxazosin$$ * + finasteride$$ + tamsulosin$$ + terazosin$$ * + alfuzosin$$ * + dutasteride$$ * + dutasteride/tamsulosin

ANTICHOLINERGICS$ * Oxytrol (OTC)$ * + oxybutynin, XL$ * + trospium$$ * + tolterodine, ER $$$ * + darifenacin ER

INTERSTITIAL CYSTITIS AGENTS$ * + phenazopyridine!!!!!! Elmiron

MISCELLANEOUS$$$$ * @ Lupron, Zoladex, Eligard

UROLOGICS

Formulary_Pocket_Guide_October2017_FINAL.indd 25 9/22/17 4:08 PM

26

MULTIPLE VITAMINS$ Multi-Vitamins (manufacturer Rugby)$ Therems FC$ Freedavite$ + daily-vite$ V-C Forte$ * Citrical-Vit D$ Centrum$ + multivital $ Renax

MULTIPLE VITAMINS WITH IRON$ * + ferrex 150$ * Hematogen FA$ * + hematogen Forte$ * + dualvit F$$ * Ircon

PEDIATRIC MULTIPLE VITAMINS$ * + pediavit$$ * + children’s multivitamin chew$$ * + tri-vitamin$$ * Centrum Kids$$ * multivitamin drops (generic Poly-Vi-Sol)

PRENATAL VITAMINS$ * PNV$ * Vol-tab Rx$ * Vol-plus$ * Trinate$ * OTC One-a-Day Women’s Prenatal with DHA

VITAMINS

Formulary_Pocket_Guide_October2017_FINAL.indd 26 9/22/17 4:08 PM

Horizon NJ Health Pharmacy Department210 Silvia StreetWest Trenton, NJ 08628Phone: 1-800-682-9094Fax: 1-609-538-0847

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. © 2017 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.

horizonNJhealth.com

Formulary_Pocket_Guide_October2017_FINAL.indd 27 9/22/17 4:08 PM