Presbyterian Health Plan Presbyterian Insurance Company ...benefits.nmsu.edu/wp-content/uploads/sites/15/2013/...2.3 Theophylline preparations * caffeine citrate solution CAFCIT 3

Generic Name Brand Name Tier

AG = Age Limitation

PA = Prior Authorization Required

QL = Quantity Limits Apply

ST = Step Edit

*

Generic preferred/ Generic equivalent

available

1 Allergy

1.1 Antihistamines - Sedating

* cyproheptadine PERIACTIN 1

* hydroxyzine hcl ATARAX 1

* hydroxyzine pamoate VISTARIL 1

* promethazine PHENERGAN 1

* clemastine fumarate TAVIST 1

1.2 Non/low-sedating Antihistamines

* fexofenadine ALLEGRA 1

fexofenadine suspension ALLEGRA SUSP (AG) 2

1.3 Antihistamine/decongestant combinations

* chlorpheniramine/pseudoephedrine SR DECONAMINE SR 1

1.4 Nasal steroids/antihistamines

* azelastine nasal spray 0.1% ASTELIN 1

beclomethasone nasal inhaler AQ BECONASE AQ (ST) 3

budesonide nasal spray RHINOCORT AQUA (ST) 3

* flunisolide nasal solution NASAREL 1

* fluticasone nasal inhaler FLONASE 1

mometasone nasal inhaler NASONEX (ST) 3

* triamcinolone acetonide nasal inhaler NASACORT AQ 1

1.5 Allergy - misc.

epinephrine self-injection device EPIPEN 2

2 Respiratory Agents

2.1 Oral sympathomimetic (adrenergic) agents

* albuterol tabs PROVENTIL 1

* albuterol ER tabs VOSPIRE ER 1

* terbutaline tabs BRETHINE 1

2.2 Inhaled sympathomimetic (adrenergic) agents

albuterol HFA inhaler PROAIR HFA 2

albuterol HFA inhaler VENTOLIN HFA 2

* albuterol solution for nebs ACCUNEB 1

pirbuterol acetate inhaler MAXAIR 3

salmeterol inhaler SEREVENT DISKUS 2

2012 PHP Commercial-4/PIC Formulary - by Therapeutic Class

Presbyterian Health Plan Presbyterian Insurance Company, Inc.

[MPC071019] Page 1 of 33 February 15, 2012



formoterol inhaler FORADIL 2

2.3 Theophylline preparations

* caffeine citrate solution CAFCIT 3

* theophylline elixir ELIXOPHYLLIN 1

* theophylline timed release 12 hr THEOCRON 1

* theophylline syrup SLO-PHYLLIN 1

* theophylline immediate release THEOLAIR 1

* theophylline timed release 24 hr THEO-24 1

2.4 Anticholinergic

* ipratropium bromide solution for nebs ATROVENT solution for nebs1

ipratropium/albuterol inhaler COMBIVENT 2

* ipratropium/albuterol solution for nebs DUONEB 1

ipratropium bromide inhaler ATROVENT HFA 2

tiotropium bromide inhalation powder SPIRIVA 2

2.5 Mast cell stabilizers

* cromolyn sodium inhaler INTAL 1

2.6 Oral inhaled steroids

beclomethasone inhaler QVAR 2

budesonide dry powder inhaler

PULMICORT

FLEXHALER/TURBUHALER2

* budesonide suspension for inhalation

PULMICORT RESPULES

(AG) 1

budesonide/formoterol inhaler SYMBICORT (ST) (QL) 2

fluticasone inhaler FLOVENT DISKUS 2

fluticasone inhaler FLOVENT HFA 2

fluticasone/salmeterol inhaler ADVAIR DISKUS (ST) (QL) 3

fluticasone/salmeterol inhaler ADVAIR HFA (ST) 2

mometasone inhaler ASMANEX TWISTHALER 2

mometasone/formoterol inhaler DULERA (PA) (QL) 2

2.7 Leukotriene blockers

montelukast SINGULAIR (ST) (QL) 2

* zafirlukast ACCOLATE 1

2.8 Other pulmonary, misc.

* acetylcysteine MUCOMYST 1

dornase alfa PULMOZYME 4

roflumilast DALIRESP (PA) (QL) 2

tobramycin, inhaled TOBI 4

2.9 Endothelin receptor antagonists

3 Cough and Cold

3.1 Non-narcotic antitussives

* benzonatate TESSALON PERLES 1

3.2 Upper Respiratory - Cough/Cold/Allergy Combinations




brompheniramine/pseudoephedrine syp 4-

45mg/5mL SILDEC SYP 3

*

chlorpheniramine/PE/methscopolamine chew

tab 2-10-0.625mg QV-ALLERGY SYP 1

chlorpheniramine/PE/methscopolamine syr 2-

10-1.25mg DALLERGY CHW 3

chlorpheniramine/phenylephrine sus 2-6mg/mL ED CHLORPED SUS D 3

*

chlorpheniramine/phenylephrine sus 4-

5.5mg/5mL RYNATAN PED SUS 1

chlorpheniramine/ phenylephrine sus 4-

20mg/5mL DALLERGY-JR SUS 3

* chlorpheniramine/ phenylephrine tab 9-25mg RYNATAN TAB 1

*

chlorpheniramine/pyrilamine & PE liq 2-10-

10mg/5mL PHENA-S LIQ 1

*

chlorpheniramine/pyrilamine % PE liq 2-12.5-

7.5mg/mL POLY HIST PD LIQ 1

*

chlorpheniramine/pyrilamine & PE tab CR 4-25-

10mg RU-HIST TAB FORTE 1

dextromethorphan-guaifenesin tab SR 12HR

30-600mg MUCINEX DM 3

* guaifenesin/codeine cap 200-9mg PRO-CLEAR CAP 200-9MG 1

* guaifenesin/codeine liq 200-10mg/5mL TUSSO-C LIQ 200-10MG 1

* guaifenesin/codeine liq 300-10mg/5mL DEX-TUSS LIQ 1

* guaifenesin/codeine soln 100-6.3mg/5mL CGU WC LIQ 1

* guaifenesin/codeine soln 100-10mg/5mL CHERATUSSIN SYP AC 1

guaifenesin/codeine tab 300-10mg BRONTEX TAB 3

* hydrocodone/homatropine syp 5-1.5mg/5mL HYDROMET SYP 1

* hydrocodone/homatropine tab 5-1.5mg TUSSIGON 1

* phenylephrine/clorpheniramine/DM syp BRONKIDS SYP 10-2-15 1

phenylephrine/guaifenesin cap 10-390mg DECONEX CAP 10-390MG 3

phenylephrine/guaifenesin cap SR 12HR 30-

400mg GENEXA LA CAP 30-400MG 3

phenylephrine/guaifenesin drops 2.5-50mg/mL

SUPRESS-PE DROP

PEDIATRIC 3

* phenylephrine/guaifenesin liq 7.5-200mg/5mL NARIZ LIQ 7.5-200 1

* phenylephrine/guaifenesin tab 5-200mg LIQUIBID PD-TAB R 1

phenylephrine-guaifenesin tab 10-388mg GILPHEX TR TAB 10-388MG 3

*

phenylephrine/guaifenesin tab SR 12HR 25-

1200mg SIMUC-GP TAB 25-1200 1

* promethazine/codeine syp 6.25-10mg/5mL PROMETH/COD SYP 1

* promethazine/DM syp 6.25-15mg/mL PROMETHAZINE-DM SYP 1




*

promethazine/phenylephrine syp 6.25-

5mg/5mL PROMETH VC SYP 1

*

promethazine/phenylephrine/codeine syp 6.25-

5-10mg/5mL PROMETH VC/ COD SYP 1

pseudoephedrine/bromheniramine/DM liq 12-1-

5mg/mL

RESPERAL-DM DROP 12-1-

5MG 3

*

pseudoephedrine/bromheniramine/DM liq 12.5-

1-3mg/mL ENDACOF-PD DROP 1

pseudoephedrine/brompheniramine/DM liq 15-

1-4mg/mL ACCUHIST DM DROP PED 3

pseudoephedrine/brompheniramine/DM syp 30-

1-20mg/5mL DELTUSS DMX LIQ 3

*


3-15mg/5mL DALLERGY DM SYP 1

*


4-15mg/5mL SILDEC DM SYP 1

*


3-30mg/5mL NEO DM SYP 1

*

pseudoephedrine/cod/guaifenesin syp 30-10-

100mg/5mL SUTTAR SF SYP 1

4 Anti-Infective Agents

4.1 Antihelminticsalbendazole ALBENZA 2

* mebendazole VERMOX (QL) 1

praziquantel BILTRICIDE 3

4.2 Antifungal agents

* ciclopirox 8% nail lacquer PENLAC (PA) (QL) 1

* clotrimazole troche MYCELEX TROCHE 1

* fluconazole tabs. DIFLUCAN 1

* fluconazole suspension DIFLUCAN (QL) 1

griseofulvin ultramicrosize GRIS-PEG 3

* ketoconazole tabs NIZORAL 1

* nystatin MYCOSTATIN 1

* terbinafine LAMISIL (QL) 1

* voriconazole tablet, oral suspension VFEND (PA) (QL) 3

4.3 Cephalosporins first generation

* cephalexin KEFLEX 1

* cefadroxil DURICEF 1

4.4 Cephalosporins second generation

* cefaclor CECLOR 1

* cefprozil CEFZIL 1

* cefuroxime CEFTIN 1

4.5 Cephalosporins third generation

cefdinir OMNICEF 1




cefixime SUPRAX 2

* cefpodoxime VANTIN 1

4.7 Macrolides

* azithromycin ZITHROMAX 1

* clarithromycin BIAXIN (QL) 1

erythromycin base ERYTHROMYCIN TABS 2

* erythromycin ethylsuccinate EES 1

* erythromycin stearate ERYTHROCIN 1

erythromycin tabs delayed release ERY-TAB 2

* erythromycin/sulfisoxazole PEDIAZOLE 1

fidaxomicin DIFICID (PA) (QL) 4

4.8 Penicillins

* penicillin v potassium PEN-VEE K 1

* amoxicillin AMOXIL, TRIMOX 1

* ampicillin PRINCIPEN 1

* dicloxacillin DYNAPEN 1

* amoxicillin/clavulanate AUGMENTIN 1

4.9 Tetracyclines

* demeclocycline DECLOMYCIN 3

* doxycycline hcl 50, 100mg VIBRATAB 1

* tetracycline ACHROMYCIN 1

* minocycline caps MINOCIN 1

4.10 Quinolones

* ciprofloxacin CIPRO 1

ciprofloxacin suspension CIPRO SUSPENSION 2

gemfloxacin FACTIVE 3

* levofloxacin LEVAQUIN 1

norfloxacin NOROXIN 3

* ofloxacin FLOXIN 1

4.11 Antituberculosis

* isoniazid ISONIAZID 1

* ethambutol MYAMBUTOL 1

* pyrazinamide PYRAZINAMIDE 1

rifabutin MYCOBUTIN 2

* rifampin RIFADIN 1

rifapentine PRIFTIN 3

4.12 Antivirals

* amantadine SYMMETREL 1

* acyclovir ZOVIRAX 1

* famciclovir FAMVIR 1

* ganciclovir CYTOVENE 4

oseltamivir TAMIFLU (QL) 3

* valacyclovir VALTREX 1

valganciclovir VALCYTE (PA) (QL) 4




zanamivir RELENZA (QL) 3

4.13 HIV Antivirals

abacavir ZIAGEN 2

abacavir/lamivudine EPZICOM 2

abacavir/lamivudine/zidovudine TRIZIVIR 2

atazanavir REYATAZ 2

darunavir PREZISTA 2

delavirdine RESCRIPTOR 2

didanosine VIDEX 2

* didanosine cap VIDEX EC 1

efavirenz SUSTIVA 2

efavirenz/emtricitabine/tenofovir ATRIPLA 2

emtricitabine EMTRIVA 2

emtricitabine/rilpivirine/tenofovir COMPLERA (SP) 4

emtricitabine/tenofovir TRUVADA 2

enfuvirtide FUZEON 2

etravirine 100mg INTELENCE 100mg 2

fosamprenavir LEXIVA 2

indinavir CRIXIVAN 2

* lamivudine EPIVIR 1

lamivudine solution EPIVIR SOLN 2

* lamivudine/zidovudine COMBIVIR 1

lopinavir/ritonavir KALETRA 2

maraviroc SELZENTRY 2

nelfinavir VIRACEPT 2

nevirapine VIRAMUNE (QL) 2

nevirapine er VIRAMUNE XR (QL) 3

raltegravir ISENTRESS 4

rilpivirine EDURANT (SP) 4

ritonavir NORVIR 2

saquinavir INVIRASE 2

* stavudine ZERIT 1

tenofovir VIREAD 2

tipranavir APTIVUS 2

* zidovudine oral RETROVIR 1

4.14 Antimalarial agents

* chloroquine phosphate ARALEN PHOSPHATE 1

pyrimethamine/sulfadoxine FANSIDAR 2

primaquine PRIMAQUINE 2

* hydroxychloroquine PLAQUENIL 1

4.15 Sulfonamides

* sulfamethoxazole/trimethoprim susp., tabs. BACTRIM, SEPTRA 1

* sulfamethoxazole/trimethoprim DS tabs. BACTRIM DS 1

4.16 Sulfones




dapsone DAPSONE 2

4.17 Urinary

* trimethoprim PROLOPRIM, TRIMPEX 1

* nitrofurantoin MACRODANTIN 1

* nitrofurantoin macrocrystals MACROBID 1

* nitrofurantoin suspension FURADANTIN 1

4.18 Anti-Infectives - misc.

* metronidazole FLAGYL 1

* neomycin NEOMYCIN 1

* clindamycin cap CLEOCIN 1

clindamycin CLEOCIN PEDIATRIC 2

atovaquone MEPRON 2

vancomycin VANCOCIN PULVULES (PA) 4

*

vancomycin injection (compounded

suspension)

VANCOMYCIN INJECTION

COMPOUND1

influenza nasal vaccine, live FLUMIST 2

rifaximin XIFAXAN (PA) (QL) 4

linezolid ZYVOX (PA) 4

4.19 Hepatitis Treatment

boceprevir VICTRELIS (PA) (SP) (QL) 4

interferon alfa 2b INTRON-A (PA) (SP) 4

interferon alfacon-1 INFERGEN (PA) (SP) 4

lamivudine EPIVIR 2

lamivudine EPIVIR HBV 2

peg-interferon alfa-2a PEGASYS (PA) (SP) 4

peg-interferon alfa-2b PEG-INTRON (PA) (SP) 4

* ribavirin REBETOL (PA) (SP) 4

telaprevir INCIVEK (PA) (SP) (QL) 4

4.20 Vaccines

influenza nasal vaccine, live FLUMIST 2

zoster vaccine, live ZOSTAVAX (AG) 2

5 Antineoplastic Agents/Immunosuppressants

5.1 Alkylating agents

altretamine HEXALEN (PA) (SP) 4

busulfan MYLERAN (PA) (SP) 2

chlorambucil LEUKERAN (PA) (SP) 2

cyclophosphamide CYTOXAN 2

estramustine EMCYT (PA) (SP) 3

lomustine CEENU (PA) (SP) 3

melphalan ALKERAN 2

procarbazine MATULANE (PA) (SP) 2

temozolomide TEMODAR (PA) (SP) 4




5.2 Antimetabolites

capecitabine XELODA (PA) (SP) 4

fludarabine OFORTA (PA) (SP) 4

* mercaptopurine PURINETHOL 1

* methotrexate RHEUMATREX, TREXALL 1

* methotrexate injection METHOTREXATE INJ 1

thioguanine TABLOID (PA) (SP) 3

5.3 Androgens

fluoxymesterone ANDROXY (PA) 3

5.4 Anti-androgen

abiraterone ZYTIGA (PA) (SP) 4

* bicalutamide CASODEX 1

* flutamide EULEXIN 1

5.5 Progestin

* megestrol acetate MEGACE 1

* megestrol acetate 625mg/5ml susp. MEGACE ES (PA) 1

5.6 Antiestrogen

* anastrazole ARIMIDEX 1

* exemestane AROMASIN 3

* letrozole FEMARA 3

* tamoxifen citrate NOLVADEX 1

toremifene FARESTON (PA) (SP) 3

5.7 Antineoplastics Agents/Immunosuppressants - misc.

dasatinib SPRYCEL (PA) (SP) 4

erlotinib TARCEVA (PA) (SP) 4

everolimus AFINITOR (PA) (SP) 4

gefitinib IRESSA (PA) 4

imatinib GLEEVEC (PA) (SP) 4

interferon gamma ACTIMMUNE (SP) 4

lenalidomide REVLIMID (PA) (SP) 4

leucovorin tab LEUCOVORIN 1

mesna MESNEX 2

* hydroxyurea HYDREA 1

lenalidomide REVLIMID 4

mitotane LYSODREN 4

peginterferon alfa 2b SYLATRON (PA) (SP) 4

thalidomide THALOMID (PA) 4

topotecan HYCAMTIN (PA) (SP) 4

5.8 Immunosuppressants

* azathioprine IMURAN 1

* cyclosporine SANDIMMUNE 1

* cyclosporine modified GENGRAF, NEORAL 1

* mycophenolate mofetil CELLCEPT 1

mycophenolic acid MYFORTIC 2




sirolimus RAPAMUNE 3

* tacrolimus FK506, PROGRAF 1

5.9 Immunoglobulins

immune globulin subcutaneous - human GAMUNEX-C (PA) 4

immune globulin subcutaneous - human HIZENTRA (PA) 4

immune globulin subcutaneous - human VIVAGLOBIN (PA) 4

5.10 Kinase Inhbitors

crizotinib XALKORI (PA) (SP) 4

lapatinib TYKERB (PA) (SP) 4

nilotinib TASIGNA (PA) (SP) 4

pazopanib VOTRIENT (PA) (SP) 4

ruxolitinib JAKAFI (PA) (SP) 4

sorafenib NEXAVAR (PA) (SP) 4

sunitinib SUTENT (PA) (SP) 4

vandetanib CAPRELSA (PA) 4

vemurafenib ZELBORAF (PA) (SP) 4

5.11 Mitosis Inhibitors

* etoposide caps ETOPOSIDE CAPS (SP) 3

5.12 Differentiating Agents

bexarotene TARGRETIN (PA) (SP) 4

vorinostat ZOLINZA (PA) (SP) 4

6 Autonomic Agents

6.1 Parasympathomimetic (cholinergic) agents

* bethanechol URECHOLINE 1

* pilocarpine tab SALAGEN (QL) 1

* pyridostigmine MESTINON 1

6.2 Anticholinergic agents

* benztropine mesylate COGENTIN 1

* trihexyphenidyl ARTANE 1

6.3 Antiparkinsonian agents

* amantadine SYMMETREL 1

apomorphine APOKYN (PA) (SP) 3

* bromocriptine PARLODEL 1

carbidopa/levodopa/entacapone STALEVO 3

entacapone COMTAN 2

* levodopa and carbidopa SINEMET 1

* levodopa/carbidopa sustained release SINEMET CR 1

* pramipexole MIRAPEX 1

rivastigmine EXELON 3

* ropinirole REQUIP 1

* selegiline ELDEPRYL 1

tolcapone TASMAR 3

6.4 Antimuscarinics / antispasmodics




* belladonna/phenobarb/ergotamine BELLERGAL S 1

* chlordiazepoxide/clidinium bromide LIBRAX 1

darifenacin ENABLEX (ST) 3

* dicyclomine BENTYL 1

* belladonna alkaloids/phenobarbital DONNATAL 1

* hyoscyamine LEVBID/LEVSIN 1

* propantheline PRO-BANTHINE 1

6.5 Alpha-adrenergics (vasopressors)

* midodrine PROAMATINE 1

7 Anticoagulants/Blood Modifiers/Hematopoietic Agents

7.1 Anticoagulants

* enoxaparin LOVENOX (QL) 1

enoxaparin 300 mg/3ml vial LOVENOX 300mg/3ml (QL) 3

* fondaparinux ARIXTRA (PA) 4

* heparin sodium injection HEPARIN 1

* warfarin COUMADIN 1

7.2 Anti-platelets

clopidogrel PLAVIX 2

prasugrel EFFIENT (PA) 3

* ticlopidine TICLID 1

7.3 Anticoagulants and Anti-Platelet misc.

* anagrelide AGRYLIN 1

* cilostazol PLETAL 1

dipyridamole/aspirin AGGRENOX 3

* pentoxifylline TRENTAL 1

7.4 Hematopoietic Agents

darbepoetin alfa ARANESP (PA) 4

epoetin alfa EPOGEN (PA) 4

epoetin alfa PROCRIT (PA) 4

filgrastim NEUPOGEN (PA) 4

oprelvekin NEUMEGA (PA) (SP) 4

pegfilgrastim NEULASTA (PA) 4

7.5 Hemostatic Agents

* aminocaproic acid AMICAR 1

8 Cardiovascular Agents

8.1 Cardiac glycosides

* digoxin tabs LANOXIN TABS 1

8.2 Calcium Antagonists

* amlodipine NORVASC 1

* diltiazem CARDIZEM 1

* diltiazem sustained release DILACOR XR, TIAZAC 1

* felodipine PLENDIL 1

* isradipine DYNACIRC CR 3




* nicardipine CARDENE 1

nicardipine er CARDENE SR 3

* nifedipine PROCARDIA 1

* nifedipine sustained release ADALAT CC 1

* nifedipine sustained release PROCARDIA XL 1

* nimodipine NIMOTOP 1

* nisoldipine 20, 30, 40mg SULAR 1

* verapamil CALAN 1

* verapamil controlled release CALAN SR 1

* verapamil sustained release VERELAN, VERELAN PM 1

8.3 Beta-Adrenergic Antagonists - Nonselective

* nadolol CORGARD 1

penbutolol LEVATOL 3

* pindolol VISKEN 1

* propranolol sustained release INDERAL LA 1

* propranolol INDERAL 1

* sotalol BETAPACE 1

* timolol TIMOLOL 1

8.4 Beta-Adrenergic Antagonists - Selective

* acebutolol SECTRAL 1

* atenolol TENORMIN 1

* betaxolol KERLONE 1

* bisoprolol ZEBETA 1

* metoprolol LOPRESSOR 1

* metoprolol sustained release TOPROL XL 1

nevibolol BYSTOLIC 3

8.5 Beta-Adrenergic Antagonists - Combination Alpha and Beta Blocker

* carvedilol COREG 1

* labetalol NORMODYNE, TRANDATE 1

8.6 Beta-Adrenergic Antagonists - Combination Products

* atenolol/chlorthalidone TENORETIC 1

* bisoprolol/hydrochlorothiazide ZIAC 1

* metoprolol/hydrochlorothiazide LOPRESS HCT 1

8.7 Anti-Arrhythmic Drugs - Class Ia

* procainamide PROCANBID 1

* quinidine sulfate QUINIDINE SULFATE 1

* quinidine gluconate sustained release QUINAGLUTE DURA-TABS 1

* disopyramide NORPACE 1

* disopyramide controlled release NORPACE CR 1

8.8 Anti-Arrhythmic Drugs - Class Ib

* mexiletine MEXITIL 1

8.9 Anti-Arrhythmic Drugs - Class Ic

* flecainide TAMBOCOR 1

* propafenone RYTHMOL 1




8.10 Anti-Arrhythmic Drugs - Class III

* amiodarone CORDARONE 1

dofetilide TIKOSYN 3

dronedarone MULTAQ (PA) (QL) 3

* sotalol BETAPACE 1

8.11 Angiotensin converting enzyme inhibitor

* benazepril LOTENSIN 1

* captopril CAPOTEN 1

* enalapril VASOTEC 1

* fosinopril MONOPRIL 1

* lisinopril ZESTRIL 1

* ramipril ALTACE 1

* moexipril UNIVASC 1

* perindopril ACEON 3

* quinapril ACCUPRIL 1

8.12 Angiotensin combination products

* benazepril/amlodipine LOTREL 1

* benazepril/hydrochlorothiazide LOTENSIN HCT 1

* captopril/hydrochlorothiazide CAPOZIDE 1

* enalapril/hydrochlorothiazide VASERETIC 1

* fosinopril/hydrochlorothiazide MONOPRIL HCT 1

* lisinopril/hydrochlorothiazide ZESTORETIC 1

* moexipril/hydrochlorothiazide UNIRETIC 1

* quinapril/hydrochlorothiazide ACCURETIC 1

8.13 Angiotensin receptor antagonist

* losartan COZAAR 1

* losartan/hydrochlorothiazide HYZAAR 1

olmesartan BENICAR 2

olmesartan/hydrochlorothiazide BENICAR HCT 2

irbesartan AVAPRO 3

irbesartan/hydrochlorothiazide AVALIDE 3

valsartan DIOVAN 2

valsartan/hydrochlorothiazide DIOVAN HCT 2

candesartan ATACAND 3

candesartan/hydrochlorothiazide ATACAND HCT 3

8.14 Anti-Lipemics - HMG-CoA Reductase Inhibitors/Combinations

* atorvastatin LIPITOR (QL) 1

* atorvastatin/amlodipine CADUET (QL) 1

* lovastatin MEVACOR 1

fluvastatin LESCOL 3

fluvastatin LESCOL XL 3

rosuvastatin CRESTOR 2

* simvastatin ZOCOR 1

* pravastatin PRAVACHOL 1




ezetimibe/simvastatin VYTORIN 2

8.15 Anti-Lipemics - misc. Antihyperlipidemics

* cholestyramine QUESTRAN 1

* cholestyramine QUESTRAN LIGHT 1

colesevelam WELCHOL 2

* colestipol COLESTID 1

ezetimibe ZETIA 2

*

fenofibrate micronized capsule 67mg, 134mg,

200mg LOFIBRA 1

* fenofibrate tablet 54mg, 160mg LOFIBRA 1

* gemfibrozil LOPID 1

niacin sustained release NIASPAN 2

niacin/lovastatin ADVICOR (ST) 2

niacin/simvastatin SIMCOR (ST) 2

omega-3-acid ethyl esters LOVAZA (QL) 3

8.16 Alpha Blockers

* prazosin MINIPRESS 1

* doxazosin CARDURA 1

* tamsulosin FLOMAX 1

* terazosin HYTRIN 1

8.17 Centrally Acting Antihypertensives

* clonidine CATAPRES 1

* clonidine transdermal CATAPRES-TTS 1

* methyldopa ALDOMET 1

* methyldopa/hydrochlorothiazide ALDORIL 1

* guanfacine TENEX 1

8.18 Vasodilating Agents

* dipyridamole PERSANTINE 1

* hydralazine APRESOLINE 1

* minoxidil LONITEN 1

phenoxybenzamine DIBENZYLINE 3

sildenafil REVATIO (PA) (QL) 4

8.19 Nitrates

* nitroglycerin sublingual NITROSTAT 1

* nitroglycerin ointment NITRO-BID OINTMENT 1

* isosorbide dinitrate ISORDIL 1

isosorbide dinitrate controlled release DILATRATE SR CAP 2

* isosorbide mononitrate MONOKET 1

* isosorbide mononitrate sustained release IMDUR 1

* nitroglycerin transdermal NITRO-DUR 1

8.20 Cardiac Misc.

ranolazine RANEXA (ST) 3

9 Rheumatologic Agents




9.10 Nonsteroidal anti-inflammatory agents

celecoxib CELEBREX (QL) 3

* diclofenac sodium VOLTAREN 1

* diclofenac sodium extended release VOLTAREN XR 1

diclofenac topical VOLTAREN GEL (ST) (QL) 3

diclofenac/misoprostel ARTHROTEC 3

* diflunisal DOLOBID 1

* etodolac LODINE 1

* flurbiprofen ANSAID 1

* ibuprofen MOTRIN 1

* indomethacin INDOCIN 1

* indomethacin sustained release INDOCIN SR 1

* ketoprofen ORUDIS 1

* ketorolac tab TORADOL (QL) 1

* meloxicam MOBIC 1

* nabumetone RELAFEN 1

* naproxen NAPROSYN 1

* naproxen sodium ANAPROX 1

* naproxen sodium DS ANAPROX DS 1

* oxaprozin DAYPRO 1

* piroxicam FELDENE 1

* salsalate DISALCID 1

* sulindac CLINORIL 1

9.20 Anti-gout

* allopurinol ZYLOPRIM 1

* probenecid BENEMID 1

colchicine COLCRYS 2

febuxostat ULORIC (PA) (QL) 3

9.30 Rheumatologic Agents - misc.

penicillamine CUPRIMINE 2

auranofin RIDAURA 2

* leflunomide ARAVA 1

9.40 Tumor Necrosis Factor Inhibitors

abatacept subcutaneous

ORENCIA SUBCUTANEOUS

(PA) (SP)4

adalimumab HUMIRA (PA) (SP) 4

etanercept ENBREL (PA) (SP) 4

10 Skeletal / Muscle Relaxants

10.10 Skeletal / Muscle Relaxants - misc.

* carisoprodol 350mg SOMA 1

* carisoprodol/asa SOMA COMPOUND 1

* chlorzoxazone PARAFON FORTE DSC 1




* cyclobenzaprine 5mg, 10mg FLEXERIL 1

* methocarbamol tabs. ROBAXIN 1

* baclofen tabs. BACLOFEN 1

* orphenadrine/asa/caffeine forte NORGESIC FORTE 1

* orphenadrine citrate NORFLEX 1

* orphenadrine/asa/caffeine NORGESIC 1

* tizanidine tabs. 2mg, 4mg ZANAFLEX 1

11 Analgesics

11.10 Opiate agonists

* acetaminophen/codeine

TYLENOL #3, TYLENOL #4

(QL)1

* acetaminophen/pentazocine TALACEN (QL) 1

* asa/codeine EMPIRIN #3, EMPIRIN #4 1

* buprenorphine SUBUTEX (PA) 3

* butalbital/asa/caffeine/codeine FIORINAL W/CODEINE 1

* butalbital/acetaminophen/caffeine/codeine FIORICET W/CODEINE (QL)1

* carisoprodol/asa/codeine

SOMA COMPOUND

W/CODEINE1

* codeine CODEINE 1

* fentanyl patches DURAGESIC PATCHES QL) 1

* hydrocodone/acetaminophen VICODIN (QL) 1

* hydrocodone/ibuprofen VICOPROFEN 1

* hydromorphone tabs DILAUDID 1

* meperidine DEMEROL 1

* methadone DOLOPHINE 1

* methadone conc soln 10mg/mL METHADOSE CON 10MG/Ml1

* morphine MORPHINE 1

morphine sulfate extended release AVINZA (ST) (QL) 3

* morphine sustained release ORAMORPH SR 1

* morphine sulfate sustained release KADIAN (ST) QL) 3

* oxycodone OXYFAST 1

* oxycodone 20mg/ml ETH-OXYDOSE 1

* oxycodone/acetaminophen PERCOCET, TYLOX (QL) 1

* oxycodone/asa PERCODAN 1

* oxymorphone ER OPANA ER (ST) (QL) 3

* tramadol ULTRAM (QL) 1

* tramadol/acetaminophen ULTRACET (QL) 1

* tramadol extended release ULTRAM ER (QL) 1

11.20 Migraine treatment

* ergotamine/caffeine CAFERGOT 1




*

isometheptene/dichloralphenazone/acetamino

phen MIDRIN (QL)1

* butalbital/asa/caffeine FIORINAL 1

* butalbital/500mg acetaminophen/caffeine ESGIC PLUS (QL) 1

* butalbital/325mg acetaminophen/caffeine FIORICET (QL) 1

dihydroergotamine mesylate nasal spray MIGRANAL (QL) 2

almotriptan AXERT (QL) 3

eletriptan RELPAX (QL) 2frovatriptan FROVA (QL) 3

* naratriptan AMERGE (QL) 1

rizatriptan MAXALT/MAXALT MLT (QL) 2

* sumatriptan injection, nasal spray, tablets IMITREX (QL) 1

zolmitriptan ZOMIG/ZOMIG ZMT (QL) 3

12 Anti Convulsants

12.10 Barbiturates

* phenobarbital PHENOBARBITAL 1

* primidone MYSOLINE 1

12.20 Hydantoins

* phenytoin DILANTIN 1

12.30 Succinimides

* ethosuximide ZARONTIN 1

12.40 Anticonvulsants - misc.

* carbamazepine TEGRETOL 1

* carbamazepine extended release CARBATROL 1

* carbamazepine sustained release TEGRETOL-XR 1

* clonazepam KLONOPIN 1

diazepam gel DIASTAT (ST) 2

* divalproex sodium DEPAKOTE 1

* divalproex sodium extended release DEPAKOTE ER 1

* felbamate FELBATOL 3

* gabapentin NEURONTIN 1

* lamotrigine LAMICTAL 1

* levetiracetam KEPPRA 1

* oxcarbazepine TRILEPTAL 1

pregabalin LYRICA (PA) (QL) 3

tiagabine GABITRIL 3

* topiramate tablet TOPAMAX 1

* topiramate capsule TOPAMAX SPRINKLE 1

* zonisamide ZONEGRAN 1

13 Psychotherapeutic Agents

13.10 Antidepressants - Tertiary Amines

* doxepin SINEQUAN 1




* amitriptyline ELAVIL 1

* imipramine hcl TOFRANIL 1

* clomipramine ANAFRANIL 1

13.20 Antidepressants - Secondary Amines

* nortriptyline PAMELOR 1

* desipramine NORPRAMIN 1

* amoxapine ASENDIN 1

13.30 Antidepressants - SSRI's

* citalopram CELEXA (QL) 1

escitalopram LEXAPRO (ST) (QL) 2

* fluoxetine capsules and tablets PROZAC (QL) 1

* fluvoxamine LUVOX 1

* paroxetine PAXIL 1

* paroxetine controlled release PAXIL CR (ST) 1

* sertraline ZOLOFT 1

13.40 Antidepressants - misc.

* perphenazine/amitriptyline ETRAFON, TRIAVIL 1

* trazodone DESYREL 1

* mirtazapine

REMERON, REMERON SOL-

TAB1

* bupropion WELLBUTRIN 1

* bupropion sustained release WELLBUTRIN SR (QL) 1

* bupropion extended release WELLBUTRIN XL (QL) 1

* nefazodone SERZONE 1

vilazodone VIIBRYD (PA) (QL) 3

13.50 Antidepressants - MAO Inhibitors

* tranylcypromine PARNATE 1

* phenelzine NARDIL 1

selegiline transdermal EMSAM (PA) (QL) 3

13.60 Antipsychotics - Phenothiazines

* thioridazine MELLARIL 1

* perphenazine TRILAFON 1

* chlorpromazine THORAZINE 1

* fluphenazine PROLIXIN 1

* trifluoperazine STELAZINE 1

13.70 Antipsychotics - Thioxanthenes

* thiothixene NAVANE 1

13.80 Antipsychotics - Butyrophenones

* haloperidol HALDOL 1

13.90 Antipsychotics - Dibenzoxazepines

* loxapine LOXITANE 1

* clozapine CLOZARIL 1

13.10 Antipsychotics - Dihydroindolones




molindone MOBAN 2

13.11 Antipsychotics - Benzisoxazoles

ziprasidone GEODON 2

* risperidone RISPERDAL 1

risperidone injection, long-acting RISPERDAL CONSTA 4

* risperidone M RISPERDAL M (PA) 3

13.12 Antipsychotics - Thienbenzodiazepines

quetiapine SEROQUEL 2

* olanzapine ZYPREXA (QL) 1

* olanzapine ZYPREXA ZYDIS (PA) (QL) 3

13.13 Antipsychotics - Diphenylbutylpiperidine

pimozide ORAP 3

13.14 Antipsychotics - Quinolinone Derivatives

aripiprazole ABILIFY 2

aripiprazole ABILIFY DISCMELT (PA) 3

13.15 Cerebral Stimulants

* dextroamphetamine DEXEDRINE (QL) 1

* methylphenidate RITALIN (QL) 1

* methylphenidate sustained release RITALIN SR (QL) 1

methylphenidate extended release METADATE CD (QL) 2

* amphetamine mixture ADDERALL (QL) 1

* methylphenidate extended release CONCERTA (QL) 1

* amphetamine mixture extended release ADDERALL XR (QL) 1

lisdexamfetamine VYVANSE (QL) 3

modafinil PROVIGIL (PA) (QL) 3

sodium oxybate XYREM 4

13.16 Anxiolytics, Sedatives, and Hypnotics - Benzodiazepines

* chlordiazepoxide LIBRIUM 1

* alprazolam immediate release XANAX 1

* triazolam HALCION 1

* diazepam tablets VALIUM 1

diazepam gel DIASTAT (ST) 1

* oxazepam SERAX 1

* temazepam RESTORIL 1

* lorazepam ATIVAN 1

13.17 Anxiolytics, Sedatives & Hypnotics - misc.

* chloral hydrate NOCTEC 1

* meprobamate MEPROBAMATE 1

* buspirone BUSPAR 1

* zaleplon SONATA 1

eszopiclone LUNESTA (PA) (QL) 3

ramelteon ROZEREM (PA) (QL) 3

* zolpidem AMBIEN (QL) 1




* zolpidem CR AMBIEN CR (PA) (QL) 3

13.18 Antimanic agents

* lithium carbonate immediate release ESKALITH 1

* lithium citrate syrup LITHIUM CITRATE 1

* lithium carbonate sustained release LITHOBID 1

13.19 Alzheimer's

* donepezil 5mg, 10mg ARICEPT (QL) 1

* galantamine RAZADYNE 1

tacrine COGNEX 3

* rivastigmine cap., sol. EXELON 3

memantine NAMENDA 3

13.20 Psychotherapeutics - misc.

atomoxetine STRATTERA (ST) 3

13.21 Antidepressants -NSRI'S

* venlafaxine EFFEXOR 1

* venlafaxine sustained release capsules EFFEXOR XR (ST) (QL) 1

* venlafaxine hcl extended release tablets VENLAFAXINE ER (ST) (QL)1

duloxetine CYMBALTA (PA) (QL) 3

14 Gastro-Intestinal Agents

14.1 Antidiarrheal agents

* diphenoxylate/atropine LOMOTIL 1

14.2 Cathartics and laxatives

* lactulose CONSTULOSE 1

lubiprostone AMITIZA (ST) (QL) 3

* polyethylene glycol/electrolytes COLYTE 1

* polyethylene glycol/electrolytes GLYCOLAX 1

* polyethylene glycol/electrolytes GOLYTELY 1

* polyethylene glycol/electrolytes NULYTELY 1

polyethylene glycol/electrolytes and bisacodyl HALFLYTELY3

14.3 Pancreatic enzymes

pancrelipase CREON 2

pancrelipase PANCREAZE 2

14.4 Antiemetics

aprepitant caps EMEND CAP (PA) (QL) 3

dolasetron tabs ANZEMET (PA) (QL) 3

* granisetron tabs KYTRIL TAB (ST) (QL) 1

* prochlorperazine maleate COMPAZINE 1

* promethazine PHENERGAN 1

* meclizine ANTIVERT 1

* trimethobenzamide TIGAN 1

* ondansetron tab ZOFRAN TAB (QL) 1




* ondansetron ODT ZOFRAN ODT (QL) 1

scopolamine TRANSDERM SCOP 3

14.5 Anti-Ulcer Drugs - H2 Antagonists

* cimetidine TAGAMET 1

* famotidine PEPCID 1

* nizatidine AXID 1

* ranitidine ZANTAC 1

14.6 Anti-Ulcer Drugs - misc.

* misoprostol CYTOTEC 1

* sucralfate CARAFATE 1

* lansoprazole PREVACID (QL) 1

*

lansoprazole delayed release orally

disintegrating tab PREVACID SOLUTAB (PA) 3

* pantoprazole PROTONIX (QL) 1

rabeprazole ACIPHEX (ST) (QL) 2

* omeprazole PRILOSEC (QL) 1

* omeprazole/sod bicarbonate capsule ZEGERID (QL) 1

*

omeprazole/sod bicarbonate powder pkt. 20-

1100, 40-1100mg ZEGERID PDR PKT (QL) 1omeprazole/sod bicarbonate powder pkt. 20-

1680, 40-1680mg

ZEGERID PDR PKT (ST)

(QL)2

bismuth

subsalicylate/metronidazole/tetracycline HELIDAC3

14.7 Antispasmodics

alosetron LOTRONEX 4

* dicyclomine BENTYL 1

* glycopyrrolate ROBINUL 1

* glycopyrrolate ROBINUL FORTE 1

* hyoscyamine LEVBID/LEVSIN

* metoclopramide REGLAN 1

* propantheline PRO-BANTHINE 1

14.8 GI Anti-Inflammatory

* hydrocortisone suppositories ANUSOL-HC 1

* hydrocortisone enema CORTENEMA 1

* sulfasalazine AZULFIDINE 1

mesalamine ASACOL (ST) 2

mesalamine PENTASA (ST) 3

mesalamnie extended release APRISO (ST) (QL) 2

* mesalamine enemas ROWASA 1

* budesonide ENTOCORT EC 3

* balsalazide COLAZAL 1

14.9 Gallstone Solubilizing Agents

* ursodiol ACTIGALL 1




* ursodiol 250 URSO 250 1

* ursodiol 500 URSO FORTE 1

15 Anti-Diabetic Agents

15.10 Insulins

insulins NOVOLIN 2

insulins HUMULIN 3

insulin aspart

NOVOLOG, NOVOLOG MIX

70/30 2

insulin glargine LANTUS 2

insulin detemir LEVEMIR 2

insulin lispro HUMALOG 3

insulin lispro protamine/insulin lispro HUMALOG MIX 3

15.20 Sulfonylureas

* glyburide DIABETA, MICRONASE 1

* glipizide GLUCOTROL 1

* tolazamide TOLINASE 1

* glimepiride AMARYL 1

* glipizide sustained release GLUCOTROL XL 1

15.30 Agents - misc.

* acarbose PRECOSE 1

glucagon GLUCAGON 2

* glyburide/metformin GLUCOVANCE 1

* metformin GLUCOPHAGE 1

* metformin ER GLUCOPHAGE XR 1

* metformin/glipizide METAGLIP 1

metformin/pioglitazone ACTOPLUS MET (ST) 2

metformin/repaglinide PRANDIMET (ST) 3

metformin/rosiglitazone AVANDAMET (ST) 2

* nateglinide STARLIX 1

pioglitazone ACTOS (ST) 2

pioglitazone/glimepiride DUETACT (ST) 2

pramlintide SYMLIN (PA) 3

repaglinide PRANDIN 3

rosiglitazone AVANDIA (ST) 3

exenatide BYETTA (ST) (QL) 2

liraglutide VICTOZA (ST) (QL) 2

saxagliptin ONGLYZA (PA) (QL) 3

saxagliptin/metformin KOMBIGLYZE (PA) (QL) 3sitagliptin JANUVIA (ST) (QL) 2

sitagliptin/metformin JANUMET (ST) (QL) 2

16 Hormones & Synthetic Substitutes

16.1 Adrenals

* dexamethasone DECADRON 1




* fludrocortisone acetate FLORINEF 1

* hydrocortisone CORTEF 1

* methylprednisolone MEDROL 1

* prednisolone PEDIAPRED 1

* prednisone DELTASONE

16.2 Androgens

* danazol DANOCRINE 1

* testosterone cypionate

DEPO-TESTOSTERONE

(PA)1

* testosterone enanthate DELATESTRYL (PA) 1

testosterone topical gel ANDROGEL (PA) (QL) 2

testosterone topical gel FORTESTA (PA) (QL) 2

testosterone topical gel TESTIM (PA) (QL) 3

testosterone transdermal patch ANDRODERM (PA) (QL) 3

16.3 Contraceptives

* desogestrel 0.15mgl/estradiol estradiol 30mcg DESOGEN, ORTHO-CEPT 1

*

desogestrel 0.1, 0.125, 0.15mg/ethinyl

estradiol 25mcg CYCLESSA1

*

desogestrel 0.15mg/ethinyl estradiol 20,

10mcg MIRCETTE1

dienogest/estradiol valerate NATAZIA 3

*

drospirenone 3mg/ethinyl estradiol 20mcg

(GIANVI) YAZ3

* drospirenone 3mg/estradiol 30mcg (Ocella) YASMIN 1

drospirenone 3mg/ethinyl estradiol

0.02mg/levomefolate 0.451mg BEYAZ3

drospirenone 3mg/ethinyl estradiol

0.03mg/levomefolate 0.451mg SAFYRAL3

* ethynodiol 1mg/estradiol 35mcg DEMULEN 1/35 1

* ethynodiol 1mg/estradiol 50mcg DEMULEN 1/50 1

etonogestrel/eyhinyl estradiol vaginal NUVARING 2

* levonorgestrel 0.15mg/ethinyl estradiol 30mcg NORDETTE1

*

levonorgestrel 0.09mg/ethinyl estradiol 20mcg

(Amethyst) LYBREL1

* levonorgestrel 0.1mg/estradiol 20mcg ALESSE 1

* levonorgestrel 0.75mg PLAN B 1

* levonorgestrel triphasic/estradiol triphasic TRI-LEVLEN, TRIPHASIL 1

*

levonorgestrel 0.10mg/ethinyl estradiol 20mcg

(Amethia Lo, Camrese Lo) LoSEASONIQUE3

levonorgestrel 0.15mg/ethinyl estradiol 30mcg SEASONIQUE3




*

levonorgestrel/ethinyl estradiol (Quasense,

Jolessa) SEASONALE1

norelgestromin 0.15mg/ ethinyl estradiol

0.02mg/24hr ORTHO EVRA3

* norethindrone 0.35mg

NOR-QD, ORTHO

MICRONOR1

norethindrone 0.5, 1mg/ethinyl estradiol 35mcg NECON 10/111

* norethindrone 0.4mg/ethinyl estradiol 35mcg OVCON-35 1

norethindrone 1mg/ethinyl estradiol 50mcg OVCON-50 3

* norethindrone 0.5mg/ethinyl estradiol 35mcg BREVICON, MODICON 1

* norethindrone 1mg/ethinyl estradiol 35mcg ORTHO-NOVUM 1/35 1

* norethindrone 1mg/mestranol 50mcg ORTHO-NOVUM 1/50 1

*

norethindrone 0.5, 1, 0.5mg/ethinyl estradiol

35mcg TRI-NORINYL1

*

norethindrone 1mg/ethinyl ethinyl estradiol 20,

30, 35mcg/ ferrous fumarate 1mg ESTROSTEP FE 1

* norethindrone 1.5mg/ethinyl estradiol 30mcg LOESTRIN FE 1.5/30 1

* norethindrone 1mg/ethinyl estradiol 20mcg LOESTRIN 1/20, LOESTRIN FE 1/201

*

norethindrone 0.5, 0.75, 1mg/ethinyl estradiol

35mcg ORTHO-NOVUM 7/7/71

norethindrone 0.75mg/ethinyl estradiol 30mcg,

ferrous fumarate 1mg LOESTRIN 24 FE2

* norgestimate 0.25mg/ethinyl estradiol 35mcg ORTHO-CYCLEN1

*

norgestimate 0.18, 0.215, 0.25mg/ethinyl

estradiol 25mcg ORTHO TRI-CYCLEN LO1

*

norgestimate 0.18, 0.215, 0.25mg /ethinyl

estradiol 35mcg ORTHO TRI-CYCLEN1

* norgestrel 0.5mg/estradiol 50mcg OVRAL 1

* norgestrel 0.3mg/ethinyl estradiol 30mcg LO/OVRAL 1

16.4 Estrogens

conjugated estrogens CENESTIN 3

conjugated estrogens PREMARIN 2

conjugated estrogens PREMARIN VAGINAL 2

esterified estrogens MENEST 2

* estradiol ESTRACE 1

estradiol ESTRACE VAGINAL 2

estradiol ESTRING 3

estradiol FEMRING 3

estradiol vaginal tablet VAGIFEM 2

* estropipate OGEN 1

conjugated estrogens/medroxyprogesterone PREMPHASE, PREMPRO 2

* estradiol patch, weekly CLIMARA 1




estradiol patch, weekly MENOSTAR 2

estradiol patch, bi-weekly ALORA 2

estradiol patch, bi-weekly ESTRADERM 2

estradiol patch, bi-weekly VIVELLE-DOT (QL) 2

estradiol topical emulsion ESTRASORB 3

estradiol topical gel 0.06% ESTROGEL 3

estradiol topical gel 0.1% DIVIGEL 2

estradiol transdermal spray EVAMIST 3

*

estradiol/norethindrone tablets 5mcg/1mg

(Jinteli) FEMHRT1

estradiol/norethindrone tablets 2.5mcg/0.5mg FEMHRT LOW DOSE2

estradiol/norethindrone tablets ACTIVELLA 2

estradiol/norgestimate PREFEST 2

esterified estrogen/testosterone

ESTRATEST, ESTRATEST

HS2

estradiol/norethindrone patch COMBIPATCH (ST) 2

raloxifene EVISTA 2

16.5 Progestins

* medroxyprogesterone PROVERA 1

* norethindrone 5mg AYGESTIN 1

progesterone micronized PROMETRIUM 2

* medroxyprogesterone Inj. DEPO-PROVERA 1

16.6 Infertility

* clomiphene SEROPHENE 1

17 Endocrine Agents

17.1 Osteoporosis

* alendronate FOSAMAX 1

alendronate/cholecalciferol FOSAMAX PLUS D 3

* calcitonin-salmon nasal spray MIACALCIN 1

* etidronate DIDRONEL 1

miacalcin injection MIACALCIN 2

risedronate ACTONEL 2

risedronate ATELVIA 2

risedronate/calcium carbonate ACTONEL WITH CALCIUM 2

teriparatide FORTEO (PA) (SP) 4

17.2 Pituitary

* desmopressin injection DDAVP INJECTION (PA) 4

* desmopressin acetate nasal spray DDAVP NASAL SPRAY 1

* desmopressin tablets DDAVP TABLETS 1




somatropin

NORDITROPIN,

NORDITROPIN NORDIFLEX,

NORDITROPIN FLEXPRO,

(PA) (SP)

4

somatropin TEV-TROPIN (PA) (SP) 4

17.3 Other Endocrine

doxercalciferol HECTOROL 2

mecasermin INCRELEX (PA) (SP) 4

* octreotide acetate SANDOSTATIN 4

17.4 Thyroid Agents

* levothyroxine tab LEVOTHROID, LEVOXYL 1

* levothyroxine tab SYNTHROID 1

* liothyronine CYTOMEL 1

thyroid (porcine) ARMOUR THYROID 2

thyroid (porcine) 48.75, 97.5, 260, 325mg NATURE-THROID 2

17.5 Antithyroid Agents

* propylthiouracil PROPYLTHIOURACIL 1

* methimazole TAPAZOLE 1

18 Oxytocics

18.1 Oxytocics - misc.

* ergonovine maleate ERGOTRATE 1

methylergonovine maleate tab METHERGINE 2

19 Diuretics

19.1 Loop

* bumetanide BUMEX 1

ethacrynic acid EDECRIN 2

* furosemide LASIX 1

19.2 Thiazides

* hydrochlorothiazide ORETIC 1

* metolazone ZAROXOLYN 1

* chlorthalidone CLORPRES 1

19.3 Potassium-sparing diuretics

* amiloride MIDAMOR 1

* amiloride/hydrochlorothiazide MODURETIC 1

* spironolactone ALDACTONE 1

* spironolactone/hydrochlorothiazide ALDACTAZIDE 1

triamterene DYRENIUM 2

* triamterene/hydrochlorothiazide DYAZIDE, MAXZIDE 1

20 Electrolyte Replacements

20.1 Alkalinizing agents

* potassium citrate UROCIT-K 2

20.2 Potassium supplements




* potassium cl controlled release KLOR-CON 1

* potassium cl powder packet K-LOR 1

* potassium cl liquid KAOCHLOR 1

* potassium chloride microencapsulated CR KLOR-CON M 1

20.3 Phosphate binders

* calcium acetate PHOS-LO 1

sevelamer RENAGEL 2

sevelamer RENVELA 2

20.4 PTH regulating agent

cinacalcet SENSIPAR (PA) 3

20.5 Potassium Binders

* sodium polystyrene sulfonate KAYEXALATE 1

20.6 Acidifing agents

* acid phosphates K-PHOS NEUTRAL 1

21 Urinary Tract Agents

21.1 Antispasmodics

* oxybutynin DITROPAN 1

* oxybutynin XL DITROPAN XL 1

tolterodine DETROL 2

tolterodine DETROL LA 2

oxybutynin transdermal OXYTROL (ST) 3

solifenacin VESICARE 2

* trospium SANCTURA (ST) 3

21.2 Analgesics

* phenazopyridine PYRIDIUM 1

21.3 Benign Prostatic Hyperplasia

* alfuzosin UROXATRAL 3

dutasteride AVODART (ST) 3

* finasteride PROSCAR 1

22 Eye Preparations

22.1 Anti-infectives

* sulfacetamide ophth BLEPH-10 1

* bacitracin ophth BACITRACIN 1

* erythromycin ophth ILOTYCIN 1

* gentamicin ophth GENOPTIC. GARAMYCIN 1

* neomycin/polymyxin/gramicidin ophth NEOSPORIN 1

* tobramycin ophth TOBREX 1

* polymixin b/trimethoprim ophth POLYTRIM 1

* ofloxacin ophth OCUFLOX 1

* ciprofloxacin ophth CILOXAN 1

moxifloxacin VIGAMOX 3

gatifloxacin ZYMAR 3

22.2 Anti-infectives/steroid




sulfacetamide/prednisolone ophth

BLEPHAMIDE, BLEPHAMIDE

SOP1

* dexamethasone/neomycin/polymyxin ophth MAXITROL 1

* neomycin/polymyxin/hc ophth CORTISPORIN OPHTH 1

* tobramycin/dexamethasone ophth TOBRADEX 1

22.3 Antivirals

idoxuridine ophth HERPLEX 1

* trifluridine ophth VIROPTIC 1

22.4 Anti-inflammatory agents

* prednisolone acetate ophth PRED FORTE, PRED MILD 1

* prednisolone phosphate ophth INFLAMASE 1

* dexamethasone ophth DECADRON 1

fluorometholone ophth. suspension FML FORTE, FML LIQUIFILM2

fluorometholone ophth. ointment FML OINT 2

loteprednol etabonate 0.5% suspension LOTEMAX SUSP (ST) 2

loteprednol etabonate 0.2% ALREX (ST) 3

rimexolone VEXOL 3

22.5 Misc. anti-inflammatory agents

* diclofenac ophth VOLTAREN 1

* ketorolac 0.5% ophth ACULAR 1

* ketorolac 0.4% ophth ACULAR LS 1

22.6 Carbonic anhydrase inhibitors

* acetazolamide DIAMOX 1

brinzolamide ophth AZOPT 2

* dorzolamide ophth TRUSOPT DROPS 1

* dorzolamide/timolol COSOPT 3

* methazolamide NEPTAZANE 1

22.7 Miotics

* pilocarpine ophth ISOPTO CARPINE 1

carbachol ophth ISOPTO CARBACHOL 2

echothiophate iodide ophth PHOSPHOLINE IODIDE 2

22.8 Mydriatics

* atropine sulfate ophth ISOPTO ATROPINE 1

* cyclopentolate ophth CYCLOGEL 1

homatropine ophth ISOPTO HOMATROPINE 1

scopolamine ophth ISOPTO HYOSCINE 2

* tropicamide ophth MYDRIACYL 1

22.9 Antihistamines

* azelastine ophth OPTIVAR 1

* epinastine ophth ELESTAT 1

olopatadine 0.1% ophth PATANOL 2

olopatadine 0.2% ophth PATADAY 2




pemirolast ophth ALAMAST 3

22.10 Glaucoma

* betaxolol ophth 0.5% BETOPTIC-S 1

bimatoprost ophth LUMIGAN 2

* brimonidine ophth ALPHAGAN P 1

brominidine/timolol COMBIGAN 3

* carteolol ophth OCUPRESS 1

* apraclonidine ophth 0.5% IOPIDINE 1

* dorzolamide TRUSOPT 1

* dorzolamide/timolol COSOPT 3

* latanoprost ophth XALATAN 1

* levobunolol ophth BETAGAN 1

* timolol ophth TIMOPTIC 1

* timolol xe ophth TIMOPTIC XE 1

travoprost TRAVATAN Z 2

22.11 Mast Cell stabilizers

* cromolyn sodium 4% ophth CROLOM 1

lodoxamide ophth ALOMIDE 2

nedocromil ALOCRIL 3

22.12 Other Ophthalmics

cyclosporine ophth RESTASIS 3

23 Otic Preparations

23.1 Anti-Infectives

* acetic acid 2% otic VOSOL 1

* acetic acid/hydrocortisone otic VOSOL HC OTIC 1

* hydrocortisone/neomycin/polymyxin otic CORTISPORIN OTIC 1

* ofloxacin otic solution FLOXIN OTIC 1

ciprofloxacin 0.3%/dexamethasone 0.1% CIPRODEX OTIC 2

ciprofloxacin/hydrocortisone CIPRO HC OTIC 3

23.2 Anesthetics

* benzocaine/antipyrine otic AUROGUARD 1

23.3 Anti-inflammatories

* fluocinolone otic oil 0.01% DERMOTIC 1

24 Oral and Dental Products

24.1 Oral and Dental Products - misc.

* lidocaine viscous VISCOUS XYLOCAINE 1

* triamcinolone in orabase 0.1% ORALONE PASTE 1

25 Skin & Mucous Membrane Agents

25.1 Antibiotics, topical

*

bacitracin/neomycin/polymyxin

B/hydrocortisone crm, oint CORTISPORIN CRM, OINT1

* gentamicin sulfate topical GARAMYCIN TOPICAL 1

* metronidazole topical cream 0.75% METROCREAM 1




* metronidazole topical gel 0.75% METROGEL 1

* metronidazole topical lotion 0.75% METROLOTION 1

* mupirocin topical ointment BACTROBAN OINTMENT 1

* silver sulfadiazine topical SILVADENE 1

25.2 Antivirals

acyclovir topical ZOVIRAX 2

penciclovir topical DENAVIR 2

25.3 Antifungals

* nystatin/triamcinolone topical MYCOLOG II 1

* nystatin topical NILSTAT 1

* econazole topical SPECTAZOLE 1

* ciclopirox topical 0.77% LOPROX 1

* ciclopirox 1% shampoo LOPROX shampoo 1

* clotrimazole/betamethasone diprop. topical LOTRISONE 1

* ketoconazole topical cream, shampoo NIZORAL 1

* ciclopirox topical nail lacquer 8%

PENLAC NAIL LACQUER

(QL)1

25.4 Scabicides & pediculicides

crotamiton EURAX 2

* lindane KWELL 1

* permethrin 5% ELIMITE 1

25.5 Local Anti-Infectives - misc.

* selenium sulfide 2.5% SELSUN 1

hexachlorophene cleaning emulsion PHISOHEX 2

25.6 Anti-Inflammatory Agents - low potency

* alclometasone dipropionate oint ACLOVATE 1

*

fluocinolone acetonide topical crm., oint.; body

oil, soln. 0.01% SYNALAR1

* fluocinolone scalp oil 0.01%

DERMA-SMOOTHE/FS

SCALP1

* hydrocortisone/pramoxine rectal cream ANALPRAM-HC 1

* hydrocortisone/pramoxine rectal foam PROCTOFOAM HC 1

* hydrocortisone topical HYTONE 1

* desonide topical DESOWEN 1

25.7 Anti-Inflammatory Agents - medium potency

* triamcinolone topical KENALOG 1

* betamethasone valerate topical VALISONE 1

* fluticasone CUTIVATE 1

* mometasone 1% topical ELOCON 1

* desoximetasone topical - LP TOPICORT 1

* hydrocortisone valerate topical WESTCORT 1

25.8 Anti-Inflammatory Agents - high potency




*

betamethasone dipropionate augmented

topical DIPROLENE1

* betamethasone dipropionate topical DIPROSONE, MAXIVATE 1

* desoximetasone topical TOPICORT 1

* fluocinonide topical LIDEX 1

* mometasone topical ELOCON 1

* triamcinolone topoical ARISTOCORT 1

25.9 Anti-Inflammatory Agents - very high potency

* augmented betamethasone dipropionate DIPROLENE AF 1

* clobetasol topical crm., gel, oint., sol. TEMOVATE 1

* halobetasol topical ULTRAVATE 1

25.10 Antipruritics & Local Anesthetics

* lidocaine cream, ointment LIDAMANTLE CRM, OINT 1

lidocaine transdermal LIDODERM (PA) (QL) 3

* lidocaine 2% viscous solution XYLOCAINE VISCOUS 1

* lidocaine/prilocaine oint EMLA 1

25.11 Anti-Acne - Antibacterial

azelaic acid topical 15% FINACEA 2

azelaic acid topical 20% AZELEX 2

* clindamycin topical 1% gel, lot, sol CLEOCIN T 1

* benzoyl peroxide/clindamycin BENZACLIN 1

benzoyl peroxide/clindamycin DUAC 2

* benzoyl peroxide/erythromycin BENZAMYCIN 1

* erythromycin topical AKNE-MYCIN 1

25.12 Anti-Acne - Cell Stimulants and Proliferants

* tretinoin topical RETIN-A (AG) 1

* adapalene 0.1% topical cream, gel DIFFERIN (AG) 1

tazarotene topical TAZORAC 2

25.13 Anti-Acne - Keratolytic Agents

* benzoyl peroxide/sulfur SULFOXYL LOTION 1

25.14 Anti-Acne - Oral Agents

* isotretinoin AMNESTEEM 1

25.15 Skin & Mucous Membrane Agents - misc.

* fluorouracil topical EFUDEX 1

* imiquimod 5% topical crm ALDARA 1

* papain/urea/chlorofyllin copper ALLANFILLENZYME 1

dapsone topical ACZONE (PA) 3

becaplermin REGRANEX 3

25.16 Antipsoriatics

tazarotene topical TAZORAC 2

* calcipotriene DOVONEX 1

25.17 Vaginal Preparations

acetic acid vaginal jelly ACI-JEL 2




* metronidazole vaginal METROGEL-VAGINAL 1

* terconazole vaginal TERAZOL

clindamycin vaginal CLEOCIN VAGINAL CREAM1

25.18 Topical Immunomodulators

tacrolimus ointment PROTOPIC (PA) (QL) 3

pimcrolimus cream ELIDEL (PA) (QL) 3

26 Vitamins and Minerals

26.10 Vitamin B

* folic acid FOLIC ACID 1

26.20 Vitamin D

* calcitriol ROCALTROL 1

doxercalciferol HECTOROL 2

* ergocalciferol CALCIFEROL 1

26.30 Vitamin K Activity

phytonadione MEPHYTON 1

26.40 Multivitamins

* b-complex w/ c & folic acid 1mg cap NEPHROCAPS 1

* b-complex w/ c & folic acid 1mg tab STROVITE 1

* prenatal vitamins (Rx only) PRENATAL VITAMINS 1

* multivitamins/fluoride-iron drops POLY-VIT/FE DROP/FL 1

* multivitamins w/ fluoride chew tab MULTIVIT/FL CHW 1

* multivitamins w/ fluoride drops POLY-VIT-FL 1

* renal multivitamin (Rx) NEPHRO-VITE RX 1

26.50 Iron Supplements

26.60 Products-Misc

* sodium fluoride LURIDE 1

27 Alcohol Abuse Prevention/Smoking Cessation

27.10 Alcohol Abuse Prevention - misc.

* disulfiram ANTABUSE 1

* naltrexone tablet REVIA 1

acamprosate CAMPRAL (PA) (QL) 3

27.20 Smoking Cessation

* bupropion sustained release ZYBAN (QL) 1

nicotine nasal spray

NICOTROL NASAL SPRAY

(QL) 3

nicotine inhaler NICOTROL INHALER (QL) 3

varenicline CHANTIX (QL) 3

28 Devices/Diagnostic Aids

28.10 Devices/Diagnostic Aids - misc.

* sodium cl neb HYPERSAL 1

spacer for inhalers 2

insulin syringes, disposable lancets 1




peak flow meter 2

glucose blood test strips (preferred brand) ACCU-CHEK (QL) 1

glucose blood test strips (non-preferred

brands)3

29

* phentermine ADIPEX-P (PA) 3

orlistat XENICAL (PA) 3

30

* buprenorphine SUBUTEX (PA) (QL) 3

buprenorphine/naloxone SUBOXONE (PA) (QL) 3

* naltrexone tablet REVIA 1

31 Multiple Sclerosis

dalfampridine AMPYRA (PA) (SP) (QL) 4

glatiramir COPAXONE (SP) 4

interferon beta-1a AVONEX (SP) 4

interferon beta-1a REBIF (PA) (SP) 4

interferon beta-1b EXTAVIA (PA) (SP) 4

32 Miscellaneous

C1 esterase inhibitor, human CINRYZE (PA) 4

riluzole RILUTEK 4

DISCLAIMER

Explanation of Terms in your Formulary.

You will see these indicators next to some drug names:

Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your benefit

design determines what is covered for you and what your copayment will be. Please refer to your

benefit materials for your specific coverage information.

Anti-Obesity

Opioid Dependence

Please be sure a prescription drug benefit is part of your specific coverage before consulting this

list. If you do not know which list is correct, please contact the Presbyterian Customer Service

Center at (505) 923-5678 or 1-800-356-2219, Monday through Friday from 7:00 a.m. to 6:00 p.m.

TTY users may call 1-877-298-7407.

The medications listed on this Formulary/Preferred Drug Listing (PDL) are subject to change

pursuant to the Formulary/PDL management activities of Presbyterian Health Plan. This list is not

all-inclusive nor does it imply a guarantee of coverage. In addition, coverage for some drugs listed

may be limited to specific dosage forms and/or strengths. Substitution of a generic product for a

brand-name drug is mandatory when a generic equivalent is available. If a member requests the

brand-name drug in this situation, a Prior Authorization may be required and the member must

pay the difference in cost between the generic and branded versions. Non-formulary medications

are not considered for coverage unless trial and failure of formulary alternatives are documented.

1. Prior Authorization (PA) -- a drug that requires prior approval before the Plan will cover it, and

when the patient meets the established criteria. The doctor must submit a Pharmacy Prior

Authorization Form. The doctor can submit the request by fax, phone, or regular mail.




5. Age Limitation (AG) -- a coverage limit based on minimum or maximum age of the member

imposed as a result of safety, efficacy or dosage form considerations.

6. Specialty (SP) -- Tier 4 medications obtained through the pharmacy benefit. Tier 4 medications

are defined as high cost (greater than $600 per 30 day supply) injectable, infused, oral or inhaled

drugs that generally require complex care and supervision. These medications involve unique

distribution and are usually provided by a specialty pharmacy vendor. Specialty pharmaceuticals

are self-administered, meaning they are administered by the patient or to the patient by a family

member or caregiver. Non-formulary medications, when approved by prior authorization, may be

subject to specialty pharmacy requirements.

3. Medical Exception -- a drug that is not on the Plan’s formulary. Non-formulary drugs require

an Exception to the formulary due to allergy, adverse reactions, or no response to all formulary

drugs.

7. Medical Drugs (MED) -- Medications obtained through the medical benefit. Medical drugs are

defined as medications administered in the office or facility that require a health care professional

to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled

drugs. They may involve unique distribution and may be provided by a specialty pharmacy

vendor. Some Medical Drugs may require Benefit Certification before they can be obtained. Office

administered applies to all outpatient settings including, but are not limited to, physician's offices,

emergency rooms, urgent care facilities and outpatient surgery facilities. For a complete list of

Medical Drugs and to determine which require Benefit Certification please see the Presbyterian

Pharmacy web site at: http://www.phs.org/PHS/programs/pharmacy/formulary/index.htm

* = Generics preferred/Generic equivalent available.

2. Step Edit (ST) -- a drug that requires a prescription history of specific drugs in the pharmacy

claims or data system, and these specific drugs must be taken during a given time frame. After

the specific drugs have been taken within the given time frame, online coverage of the newly-

prescribed drug occurs at the pharmacy. Step Edits make it easier to access drugs that would

normally require a Prior Authorization.

4. Quantity Limit (QL) -- a coverage limit on the medication quantity covered for a defined days'

supply (usually 30 or 90 days) based on safety, efficacy and/or dose optimization issues.


Documents

Presbyterian Health Plan Presbyterian Insurance Company ...benefits.nmsu.edu/wp-content/uploads/sites/15/2013/...2.3 Theophylline preparations * caffeine citrate solution CAFCIT 3