FlexRx Drug Formulary - Carleton College...FlexRx Drug Formulary, October 2009 2HOW TO USE THIS FORMULARY This formulary is organized into broad treatment categories. In most categories,

FlexRx Drug Formulary, October 2009 1

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FlexRx Drug FormularyOctober 2009

INTRODUCTION

Blue Cross and Blue Shield of Minnesota and Blue Plus are pleased to present the FlexRx drug formulary (drug list). Our goal is to give members access to safe and effective prescription drugs at a reasonable cost.

Brand-name drugs are not included in this formulary unless they are listed. Blue Cross may choose to not add a drug to the formulary because of effectiveness or safety concerns, or because a similar, more cost-effective drug is already on the formulary. New drugs are non-formulary (NF) until reviewed by the Pharmacy and Therapeutics (P&T) Committee and Coverage Committee.

Blue Cross encourages providers to prescribe formulary drugs.

PHARMACY AND THERAPEUTICS (P&T) COMMITTEE AND COVERAGE COMMITTEE

The Blue Cross Coverage Committee selects drugs for this formulary based on recommendations of an independent Pharmacy and Therapeutics (P&T) Committee that includes practicing physicians and pharmacists. Decisions to add or remove drugs from the FlexRx formulary are based on the drug’s safety, effectiveness, uniqueness and cost. The P&T Committee and Coverage Committee meet at least quarterly. All drugs are reviewed each year as required by the National Committee on Quality Assurance (NCQA) standards.

You can find recent changes and the current version of the formulary at bluecrossmn.com.

FORMULARY GUIDELINES

The requirement of P&T and Coverage Committee review is a precondition of Blue Cross coverage and:

Blue Cross contracts and stated herein; and

administered in any manner that is approved by the U. S. Food and Drug Administration (FDA); and

medical devices legally used when administered in any manner that is not mentioned in the labeling approved by the FDA (referred to as an “off-label” use). Use of a medication or medical device for an indication, dosage form, dose regimen, population, or other use parameter not mentioned in the approved labeling is considered to be an “off-label” use.

These guidelines in no way imply that members should not receive specific services based on the recommendation of the provider. These guidelines govern coverage and not clinical practices. Providers are responsible for giving medical advice and treating members. Members with specific health care needs should consult an appropriate health care provider.

Members and providers have the right to appeal coverage decisions. These rights are explained in member and provider plan documents. Members with questions about appeal rights should call customer service at the number on the back of their member ID card. Providers can call provider services at 651.662.5200 or toll free at 800.262.0820.

This information is not an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage. All products and coverage guidelines are subject to applicable laws and regulations. Member or provider coverage is contingent on all the applicable terms, conditions, limitations and exclusions of member or provider plan documents.

GENERIC DRUGS

Blue Cross encourages use of generic drugs as a way to provide high-quality, cost-effective care. Generic drugs are safe, effective and cost less than brand-name drugs. Members will likely pay a lower copayment or coinsurance for a generic drug.

Frequently asked questions about generics

Are generics as good as brand-name drugs? Both brand-name and generic drugs must be approved by the FDA. Generic drugs meet the same high standards as brand-name drugs.

Why should I take generics rather than brand-name drugs? We must all do our part to make health care affordable. One way is to be wise buyers of drugs. Generics provide the same effectiveness and safety as their brand-name counterparts, but for a lower cost. These lower costs generally mean lower copayments for members. Generics also save money for your health plan, so it can help keep insurance premiums as low as possible.

How can I take advantage of lower-cost generics? Ask your pharmacist for a generic whenever available. Also, talk with your doctor or other provider about prescribing generic drugs. Most drug classes include some generic drugs.


HOW TO USE THIS FORMULARY

This formulary is organized into broad treatment categories. In most categories, drugs are listed by drug class (e.g., penicillins) or drugs for a specific medical condition, like diabetes.

Generic drugs are shown in lowercase bold type. Most generic drugs are followed by a brand-name drug (in parentheses) to help you recognize the drug. The brand-name drug is listed for information only and is not on the formulary.

Example: lisinopril (Prinivil – brand is NF)

Brand-name drugs on the formulary are shown in capital letters.

Example: NIASPAN

All strengths and dosage forms of the immediate-release lisinopril generic or NIASPAN brand-name drug are on the formulary. Exceptions are usually noted. Oral liquid forms of generic or brand-name drugs are considered an alternative to tablets or capsules. They are on the formulary without being noted.

Separate drug listings are required for some dosage forms, including: extended-release, delayed-release, oral disintegrating tablets, injectables, nasal, ophthalmic, otic, rectal, topical patches and topical products.

Keycaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . capsuleschew tabs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . chewable tabletsconc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .concentratecrm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . creamdelayed-release . . . . . . . . . . . . . . . . . . . . . . . . . . . .enteric coatedext-release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . extended-releaseinhal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . inhalationinj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . injectionlotn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lotionNF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . non-formularyODT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . orally disintegrating tabsoint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ointmentsoln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . solutionsupp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . suppositoriessusp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . suspensiontabs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . tablets

Compounded prescriptionsCompounded prescriptions contain two or more drugs mixed together. The end product cannot be available in an equivalent commercial form. Plus, at least one ingredient must be an FDA-approved prescription drug. Compounded prescriptions are processed according to member benefits.

Injectable drugsSelf-injectable drugs are generally part of the pharmacy benefit and may be included on the formulary. Injectable drugs are processed according to member benefits.

Some injectable drugs that need to be administered by a health care professional are covered only under the plan’s medical benefit.

Medical suppliesMany diabetic supplies and spacers used with oral inhalers purchased in pharmacies are available on this formulary.

BENEFIT UPDATES

Specialty drugsBlue Cross has an optional specialty pharmacy network. Members with this benefit must obtain their specialty drugs from an in-network specialty provider or they will pay 100 percent of the drug cost. The in-network specialty pharmacies are:

Drugs covered by this specialty drug benefit are listed at bluecrossmn.com.

Over-the-counter (OTC) drugsBlue Cross has an OTC drug benefit. Members with this coverage may receive an eligible OTC product at their lowest cost. Covered OTC drugs require a prescription. Members can get a one-month supply of the following drugs with this benefit:

PROTON PUMP INHIBITORS:Prilosec OTC

NON-SEDATING ANTIHISTAMINESloratadineloratadine/pseudoephedrine combination products

The program limits coverage to formulary and OTC drugs in these classes. Non-formulary drugs in these classes are not covered.


MANAGING DRUG USAGE

Prior Authorization (PA)Some drugs require prior authorization (PA) because of their high potential for misuse or overuse. Coverage may be approved after certain criteria are met. Approval is required for claims to process at network pharmacies. Policies regarding the covered uses of drugs and drug classes requiring PA can be found at bluecrossmn.com. For more information, call provider services at 651.662.5200 or toll free at 800.262.0820.

A written request for PA can be submitted by mail or fax.

Mailing address: Blue Cross and Blue Shield of Minnesota Medical Utilization Review Department P.O. Box 64265 St. Paul, MN 55164-0265Fax number: 651.662.2810

Step Therapy (ST)Step therapy programs help manage the cost of expensive drugs by redirecting members to equally effective, less expensive alternatives. Formulary and non-formulary drugs may be subject to step therapy. Formulary drugs subject to step therapy have “ST” behind them. If a member does not meet the criteria in the automated review of the member’s claims, their doctor can submit a request for review. Forms for the review process are at providers.bluecrossmn.com in the Forms section.

Quantity Limits (QL)Certain drugs have quantity limits (QL) to encourage appropriate drug usage, enhance drug therapy and reduce costs. The QL is the maximum quantity that can be dispensed over a given period of time. Formulary and non-formulary drugs may have quantity limits.

Drugs that have quantity limits as of October 1, 2009 (this list may change):

Product name QL per month

Actonel 5 mg, 30 mg (F). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 tablets

Actonel 35 mg (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 tablets

Actonel 150 mg (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 tablet

Actonel with calcium (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .one 28-day blister pack

Amerge (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 tablets

Axert (NF). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 tablets

Boniva 2.5 mg (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 tablets

Boniva 150 mg (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 blister pack

Boniva injection (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 kit/90 days

butorphanol nasal spray (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 x 2.5 mL

Cafergot tablets: generic version (F), brand (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 tablets

Cialis (NF) (no coverage for women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 tablets

Commit lozenges: generic version (F), brand (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .680 lozenges

Detrol (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 tablets

Detrol LA (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 capsules

D.H.E. 45: generic version, brand (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 ampules

Ditropan syrup: generic version (F), brand (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600 mL

Ditropan tablets: generic version (F), brand (NF). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 tablets

Ditropan XL 5 mg: generic version (F), brand (NF). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 tablets

Ditropan XL 10 mg, 15 mg: generic version(F), brand (NF) . . . . . . . . . . . . . . . . . . . . . . . . .60 tablets

Enablex (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 tablets

Ergomar (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 tablets

Fosamax solution (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 bottles

Fosamax tablets, 5 mg, 10 mg, 40 mg: generic version (F), brand (NF) . . . . . . . . . . . . . . .30 tablets

Fosamax tablets, 35 mg, 70 mg: generic version (F), brand (NF) . . . . . . . . . . . . . . . . . . . . .4 tablets

Fosamax Plus D (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 tablets

Frova (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 tablets

Imitrex injection brand (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 syringes

Imitrex injection: generic version (F), brand (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 vials

Imitrex nasal spray brand (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 spray units

Imitrex tablets: generic version (F), brand (NF). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 tablets

Levitra (NF) (no coverage for women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 tablets

Maxalt, Maxalt MLT (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 tablets

Migergot (F). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 supp

Migranal Nasal Spray (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 ampules

Nicorette gum (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816 pieces

Nicotrol oral inhaler (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 inhalers

Nicotrol nasal spray (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 bottles

Oxytrol (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 patches

Relpax (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 tablets

Sanctura (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 tablets

Sanctura XR (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 capsules

Treximet (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 tablets

VESIcare (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 tablets

Viagra (F) (no coverage for women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 tablets

Zomig, Zomig ZMT (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 tablets

Zomig nasal spray (F). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 spray units

MEDICATION AUTHORIZATION REQUESTS

Prescribers may submit a Physician Request for Formulary Exception form for their patients. This form requests an exception for the following reasons:

Formulary exceptions:

with a closed formulary benefit plan

a mandatory generic plan

Quantity exceptions:

Step Therapy:

not meet automated step therapy criteria at the point of service (pharmacy)


To obtain a Physician Request for Formulary Exception form call provider services at 651.662.5200 or 800.262.0820.

You can also go to providers.bluecrossmn.com in the Forms section.

Please submit completed request forms to:Blue Cross and Blue Shield of Minnesota and Blue Plus1305 Corporate Center DriveClinical Review DepartmentEagan, MN 55121Fax: 1.877.480.8130

FORMULARY ADDITION REQUEST

Any health care provider may request in writing that the Blue Cross Coverage Committee consider adding or deleting a drug from the formulary. All formulary requests are brought before the Committee.


ANTI-INFECTIVE DRUGSPENICILLINS

amoxicillin

AMOXICILLIN chew tabs, 400 mg

amoxicillin/potassium clavulanate (Augmentin – brand is NF)

ampicillin caps

AMPICILLIN susp

AUGMENTIN – 8 hr dosing

AUGMENTIN XR

dicloxacillin

penicillin v potassium

CEPHALOSPORINS

cefadroxil

cefdinir (Omnicef – brand is NF)

cefpodoxime (Vantin – brand is NF)

cefprozil

ceftriaxone (Rocephin – brand is NF)

cefuroxime (Ceftin – brand is NF)

cephalexin (Keflex – brand is NF)

SUPRAX

MACROLIDES

azithromycin (Zithromax – brand is NF)

clarithromycin (Biaxin – brand is NF)

clarithromycin ext-release (Biaxin XL – brand is NF)

ERY-TAB

ERYTHROCIN STEARATE

ERYTHROMYCIN delayed-release caps

erythromycin ethylsuccinate

ERYTHROMYCIN FILMTABS

erythromycin/sulfisoxazole

ZITHROMAX packets, 1 g

TETRACYCLINES

demeclocycline (Declomycin – brand is NF)

doxycycline hyclate

doxycycline monohydrate caps, tabs (Andoxa, Monodox - brands are NF)

minocycline caps, tabs (Minocin, Dynacin – brands are NF)

tetracycline

FLUOROQUINOLONES

CIPRO susp

ciprofloxacin ext-release (Cipro XR – brand is NF)

ciprofloxacin tabs (Cipro – brand is NF)

LEVAQUIN

ofloxacin

AMINOGLYCOSIDES

neomycin sulfate

paromomycin

TOBI


SULFONAMIDES

sulfamethoxazole/trimethoprim (Bactrim, Septra – brands are NF)

TUBERCULOSIS

ethambutol (Myambutol – brand is NF)

ISONIAZID syrup

isoniazid tabs

isoniazid/rifampin (Rifamate – brand is NF)

MYCOBUTIN

pyrazinamide

rifampin (Rifadin – brand is NF)

FUNGAL INFECTIONS

fluconazole (Diflucan – brand is NF)

GRIFULVIN V tabs

griseofulvin microsize susp (Grifulvin V – brand is NF)

itraconazole caps (Sporanox – brand is NF)

ketoconazole

NOXAFIL

nystatin oral powder

nystatin oral tabs

terbinafine tabs (Lamisil – brand is NF)

VFEND

VIRAL INFECTIONS

Cytomegalovirus

GANCICLOVIR

VALCYTE

Hepatitis

BARACLUDE

EPIVIR-HBV

HEPSERA

INTRON A

PEG-INTRON

PEGASYS

ribavirin caps (Rebetol – brand is NF)

ribavirin tabs (Copegus – brand is NF)

ribavirin tabs, 400 mg, 600 mg

Herpes

acyclovir (Zovirax – brand is NF)

famciclovir (Famvir – brand is NF)

VALTREX

HIV/AIDS

APTIVUS

ATRIPLA

COMBIVIR

CRIXIVAN

didanosine delayed-release (Videx EC – brand is NF)

EMTRIVA

EPIVIR

EPZICOM


FUZEON

INTELENCE

INVIRASE

ISENTRESS

KALETRA

LEXIVA

NORVIR

PREZISTA

RESCRIPTOR

REYATAZ

SELZENTRY

stavudine (Zerit – brand is NF)

SUSTIVA

TRIZIVIR

TRUVADA

VIDEX

VIRACEPT

VIRAMUNE

VIREAD

ZERIT soln

ZIAGEN

zidovudine (Retrovir – brand is NF)

Influenza

amantadine caps, syrup

TAMIFLU

MALARIA

chloroquine phosphate (Aralen – brand is NF)

FANSIDAR

hydroxychloroquine (Plaquenil – brand is NF)

MALARONE

mefloquine (Lariam – brand is NF)

PRIMAQUINE PHOSPHATE

WORM INFECTIONS

ALBENZA

BILTRICIDE

MEBENDAZOLE

STROMECTOL

OTHER ANTI-INFECTIVES

CLEOCIN PEDIATRIC

clindamycin (Cleocin – brand is NF)

DAPSONE

metronidazole (Flagyl – brand is NF)

NEBUPENT

trimethoprim

VANCOCIN

ZYVOX


IMMUNIZING AGENTSSYNAGIS – PA

CANCER DRUGS The list of drugs shown below includes selected oral and injectable cancer drugs on the formulary. However, all generic cancer drugs are on the formulary. All brand drugs are on the formulary until a generic version becomes available and has been added to the formulary. Typically, after the generic has been added, the corresponding brand is removed from the formulary. An entire listing of generic and brand cancer drugs on formulary is found at this website under “2009 Drug List - Alphabetical”.

AFINITOR

ALKERAN

ARIMIDEX

AROMASIN

bicalutamide (Casodex)

CASODEX

CEENU

CYCLOPHOSPHAMIDE

EMCYT

ETOPOSIDE caps

FARESTON

FEMARA

flutamide

GLEEVEC

HEXALEN

HYCAMTIN

hydroxyurea (Hydrea – brand is NF)

INTRON A

IRESSA

LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg

leucovorin calcium tabs, 5 mg, 25 mg

LEUKERAN

leuprolide (Lupron – brand is NF)

LUPRON DEPOT

LYSODREN

MATULANE

megestrol (Megace – brand is NF)

mercaptopurine (Purinethol – brand is NF)

MESNEX tabs

methotrexate

MYLERAN

NEXAVAR

NILANDRON

SPRYCEL

SUTENT

TABLOID

tamoxifen

TARCEVA

TARGRETIN

TASIGNA

TEMODAR


tretinoin (Vesanoid – brand is NF)

TYKERB

XELODA

ZOLADEX

ZOLINZA

HORMONES, DIABETES AND RELATED DRUGSCORTICOSTEROIDS

cortisone acetate

dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, 6 mg

DEXAMETHASONE soln; tabs, 1 mg, 2 mg

DEXAMETHASONE INTENSOL

ENTOCORT EC

fludrocortisone

hydrocortisone (Cortef – brand is NF)

methylprednisolone (Medrol – brand is NF)

prednisolone soln (Prelone – brand is NF)

prednisolone sodium phosphate soln (Orapred, Pediapred – brands are NF)

prednisone

PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg

MALE HORMONES

ANDRODERM

ANDROGEL

ANDROID

ANDROXY

danazol

METHITEST

testosterone cypionate (Depo-Testosterone – brand is NF)

testosterone enanthate (Delatestryl – brand is NF)

ESTROGENS

ACTIVELLA 0.5/0.1 mg

COMBIPATCH

DIVIGEL

ESTRADERM

estradiol patches (Climara – brand is NF)

estradiol tabs (Estrace – brand is NF)

estradiol/norethindrone acetate 1/0.5 mg (Activella – brand is NF)

ESTROGEL

estropipate (Ogen – brand is NF)

PREMARIN

PREMPHASE

PREMPRO

VIVELLE-DOT

PROGESTINS

medroxyprogesterone acetate (Provera – brand is NF)

norethindrone acetate (Aygestin – brand is NF)

PROMETRIUM


BIRTH CONTROL

desogestrel/ethinyl estradiol (Cyclessa – brand is NF)

desogestrel/ethinyl estradiol (Mircette – brand is NF)

desogestrel/ethinyl estradiol (Ortho-Cept – brand is NF)

drospirenone/ethinyl estradiol (Yasmin – brand is NF)

ethynodiol/ethinyl estradiol (Demulen 1/35 – brand is NF)

levonorgestrel – Next Choice, 0.75 mg (Plan B)

levonorgestrel/ethinyl estradiol (Alesse – brand is NF)

levonorgestrel/ethinyl estradiol (Levlite – brand is NF)

levonorgestrel/ethinyl estradiol (Nordette – brand is NF)

levonorgestrel/ethinyl estradiol (Seasonale – brand is NF)

levonorgestrel/ethinyl estradiol (Triphasil – brand is NF)

medroxyprogesterone acetate inj, 150 mg/mL (Depo-Provera – brand is NF)

NECON 10/11

norethindrone (Nor-QD – brand is NF)

norethindrone (Ortho Micronor – brand is NF)

norethindrone acetate/ethinyl estradiol (Loestrin – brand is NF)

norethindrone acetate/ethinyl estradiol/Fe (Loestrin Fe – brand is NF)

norethindrone/ethinyl estradiol (Modicon – brand is NF)

norethindrone/ethinyl estradiol (Ortho-Novum 1/35 – brand is NF)

norethindrone/ethinyl estradiol (Ortho-Novum 7/7/7 – brand is NF)

norethindrone/ethinyl estradiol (Ovcon 35 – brand is NF)

norethindrone/ethinyl estradiol (Tri-Norinyl – brand is NF)

norethindrone/mestranol (Ortho-Novum 1/50 – brand is NF)

norgestimate/ethinyl estradiol (Ortho Tri-Cyclen – brand is NF)

norgestimate/ethinyl estradiol (Ortho-Cyclen – brand is NF)

norgestrel/ethinyl estradiol (Lo/Ovral – brand is NF)

NUVARING

OGESTREL

ORTHO EVRA

ORTHO TRI-CYCLEN LO

PLAN B 0.75 mg

YAZ

ZOVIA 1/50

INFERTILITY

CETROTIDE – PA applied to select Blue Cross groups.

chorionic gonadotropin

clomiphene (Clomid – brand is NF)

GONAL-F – PA applied to select Blue Cross groups.

OVIDREL – PA applied to select Blue Cross groups.

REPRONEX – PA applied to select Blue Cross groups.

DIABETES

acarbose (Precose – brand is NF)

ACTOPLUS MET

ACTOS

BYETTA

chlorpropamide

DUETACT


glimepiride (Amaryl – brand is NF)

glipizide (Glucotrol – brand is NF)

glipizide ext-release (Glucotrol XL – brand is NF)

glipizide/metformin (Metaglip – brand is NF)

GLUCAGON

glyburide (Micronase – brand is NF)

glyburide micronized (Glynase – brand is NF)

glyburide/metformin (Glucovance – brand is NF)

GLYBURIDE, distributor of Diabeta

JANUMET

JANUVIA

metformin (Glucophage – brand is NF)

metformin ext-release (Glucophage XR – brand is NF)

SYMLIN

INSULIN

The formulary includes vials and insulin pens for the insulin products listed. Humulin R 500 units/mL, and Humulin 50/50 are only available in vials.

Rapid-Acting Insulins

HUMALOG

NOVOLOG

Short-Acting Insulins

HUMULIN R

NOVOLIN R

Intermediate-Acting Insulins

HUMALOG MIX 50/50

HUMALOG MIX 75/25

HUMULIN N

HUMULIN 50/50

HUMULIN 70/30

NOVOLIN N

NOVOLIN 70/30

NOVOLOG MIX 70/30

Basal Insulins

LANTUS

LEVEMIR

THYROID REGULATION

levothyroxine – includes Levoxyl (Synthroid – brand is NF)

liothyronine (Cytomel – brand is NF)

methimazole (Tapazole – brand is NF)

propylthiouracil

GROWTH HORMONE

INCRELEX – PA

OMNITROPE – PA

OTHER HORMONES AND RELATED DRUGS

ACTONEL – QL

ALDURAZYME

alendronate tabs (Fosamax – brand is NF) – QL

cabergoline

calcitonin-salmon nasal – includes Fortical (Miacalcin)


desmopressin inj (DDAVP – brand is NF)

desmopressin nasal (DDAVP – brand is NF)

desmopressin tabs (DDAVP – brand is NF)

EVISTA

FABRAZYME

FOSAMAX soln – QL

HECTOROL caps

leuprolide (Lupron – brand is NF)

LUPRON DEPOT

METHERGINE

MIACALCIN inj

MIACALCIN nasal

NAGLAZYME

octreotide (Sandostatin – brand is NF)

SANDOSTATIN LAR DEPOT

SENSIPAR

SOMAVERT

STIMATE

ZOLADEX

HEART AND CIRCULATORY DRUGSANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS

benazepril (Lotensin – brand is NF)

benazepril/hydrochlorothiazide (Lotensin HCT – brand is NF)

captopril

captopril/hydrochlorothiazide

enalapril (Vasotec – brand is NF)

enalapril/hydrochlorothiazide (Vaseretic – brand is NF)

fosinopril (Monopril – brand is NF)

fosinopril/hydrochlorothiazide (Monopril HCT – brand is NF)

lisinopril (Prinivil – brand is NF)

lisinopril/hydrochlorothiazide (Prinzide – brand is NF)

moexipril (Univasc – brand is NF)

moexipril/hydrochlorothiazide (Uniretic – brand is NF)

quinapril (Accupril – brand is NF)

quinapril/hydrochlorothiazide (Accuretic – brand is NF)

ramipril caps (Altace – brand is NF)

trandolapril (Mavik – brand is NF)

ANGIOTENSIN II RECEPTOR BLOCKERS (ARBS) AND COMBINATIONS

COZAAR

DIOVAN

DIOVAN HCT

HYZAAR

BETA BLOCKERS AND COMBINATIONS

acebutolol (Sectral – brand is NF)

atenolol (Tenormin – brand is NF)

atenolol/chlorthalidone (Tenoretic – brand is NF)

bisoprolol (Zebeta – brand is NF)

bisoprolol/hydrochlorothiazide (Ziac – brand is NF)


carvedilol (Coreg – brand is NF)

labetalol (Trandate – brand is NF)

metoprolol succinate ext-release (Toprol XL – brand is NF)

metoprolol tartrate (Lopressor – brand is NF)

METOPROLOL/HYDROCHLOROTHIAZIDE 100/50 mg

metoprolol/hydrochlorothiazide 50/25 mg, 100/25 mg (Lopressor HCT – brand is NF)

NADOLOL 160 mg

nadolol 20 mg, 40 mg, 80 mg (Corgard – brand is NF)

PINDOLOL

propranolol ext-release (Inderal LA – brand is NF)

PROPRANOLOL soln

propranolol tabs

propranolol/hydrochlorothiazide 40/25

PROPRANOLOL/HYDROCHLOROTHIAZIDE 80/25

TIMOLOL

CALCIUM CHANNEL BLOCKERS AND COMBINATIONS

amlodipine (Norvasc – brand is NF)

amlodipine/benazepril (Lotrel – brand is NF)

diltiazem (Cardizem – brand is NF)

diltiazem ext-release (Dilacor XR – brand is NF)

diltiazem ext-release (Tiazac – brand is NF)

diltiazem ext-release – 12 hr

diltiazem ext-release – 24 hr (Cardizem CD – brand is NF)

felodipine ext-release

LOTREL 5/40, 10/40

nifedipine ext-release (Adalat CC – brand is NF)

nifedipine ext-release (Procardia XL – brand is NF)

verapamil (Calan – brand is NF)

verapamil ext-release (Calan SR – brand is NF)

verapamil ext-release (Verelan – brand is NF)

verapamil ext-release (Verelan PM – brand is NF)

CHEST PAIN (ANGINA)

isosorbide dinitrate oral tabs (Isordil – brand is NF)

isosorbide mononitrate (Monoket – brand is NF)

isosorbide mononitrate ext-release

NITRO-BID oint

nitroglycerin patches (Nitro-Dur – brand is NF)

nitroglycerin sublingual tabs (Nitrostat)

NITROLINGUAL

NITROSTAT

CHOLESTEROL LOWERING

cholestyramine (Questran, Questran Light – brands are NF)

colestipol tabs (Colestid – brand is NF)

CRESTOR – ST

fenofibrate micronized caps, 67 mg, 134 mg, 200 mg (Lofibra – brand is NF)

fenofibrate tabs, 54 mg, 160 mg (Lofibra – brand is NF)

gemfibrozil (Lopid – brand is NF)

lovastatin (Mevacor – brand is NF)


NIASPAN

pravastatin (Pravachol – brand is NF)

simvastatin (Zocor – brand is NF)

TRICOR

TRILIPIX

ZETIA

FLUID REDUCTION

acetazolamide

acetazolamide ext-release (Diamox Sequels – brand is NF)

amiloride (Midamor – brand is NF)

amiloride/hydrochlorothiazide

bumetanide (Bumex – brand is NF)

chlorothiazide

chlorthalidone 25 mg, 50 mg

furosemide soln, 10 mg/mL; tabs (Lasix – brand is NF)

hydrochlorothiazide caps (Microzide – brand is NF)

hydrochlorothiazide tabs, 25 mg, 50 mg

indapamide

methazolamide

metolazone (Zaroxolyn – brand is NF)

spironolactone (Aldactone – brand is NF)

spironolactone/hydrochlorothiazide tabs, 25/25 (Aldactazide – brand is NF)

torsemide (Demadex – brand is NF)

triamterene/hydrochlorothiazide caps, 37.5/25, 50/25 (Dyazide – brand is NF)

triamterene/hydrochlorothiazide tabs, 37.5/25, 75/50 (Maxzide-25, Maxzide – brands are NF)

HEART RHYTHM

amiodarone

disopyramide (Norpace – brand is NF)

disopyramide ext-release 150 mg (Norpace CR – brand is NF)

flecainide (Tambocor – brand is NF)

MEXILETINE

NORPACE CR 100 mg

propafenone (Rythmol – brand is NF)

quinidine gluconate ext-release

quinidine sulfate

QUINIDINE SULFATE ext-release

sotalol (Betapace – brand is NF)

sotalol AF (Betapace AF – brand is NF)

OTHER HEART RELATED DRUGS

CATAPRES-TTS

clonidine (Catapres – brand is NF)

DIBENZYLINE

DIGOXIN soln

digoxin tabs (Lanoxin – brand is NF)

doxazosin (Cardura – brand is NF)

epoprostenol (Flolan – brand is NF)

guanfacine (Tenex – brand is NF)

hydralazine


methyldopa

midodrine (Proamatine – brand is NF)

minoxidil

prazosin (Minipress – brand is NF)

REMODULIN

REVATIO – PA

terazosin

TRACLEER

VENTAVIS

ERECTILE DYSFUNCTION

CAVERJECT

MUSE

VIAGRA – QL

BEE STING KITS

EPIPEN

EPIPEN JR

RESPIRATORY DRUGSANTIHISTAMINES

cyproheptadine

fexofenadine (Allegra – brand is NF)

loratadine – Non-formulary (may have coverage in an OTC program) (Claritin – brand is NF)

promethazine supp

promethazine syrup, tabs

NASAL PRODUCTS

ASTELIN

ASTEPRO

BACTROBAN nasal

flunisolide 25 mcg/spray

FLUNISOLIDE 29 mcg/spray

fluticasone (Flonase – brand is NF)

ipratropium (Atrovent – brand is NF)

NASACORT AQ

NASONEX

COUGH/COLD/ALLERGY

acetylcysteine

ALLEGRA-D 12 hr, 24 hr

benzonatate (Tessalon – brand is NF)

brompheniramine/pseudoephedrine ext-release caps, 6/60

codeine/guaifenesin soln, 10/100 per 5 mL

loratadine/pseudoephedrine ext-release – Non-formulary (may have coverage in an OTC program) (Claritin-D – brand is NF)

ASTHMA/COPD

ACCOLATE

ADVAIR DISKUS

ADVAIR HFA

albuterol sulfate inhal soln

albuterol sulfate syrup, tabs

ASMANEX

ATROVENT HFA


AZMACORT

COMBIVENT

cromolyn sodium inhal soln

ELIXOPHYLLIN

FLOVENT HFA

FORADIL AEROLIZER

ipratropium inhal soln

ipratropium/albuterol sulfate (Duoneb – brand is NF)

MAXAIR AUTOHALER

PROAIR HFA

PULMICORT RESPULES

SEREVENT DISKUS

SINGULAIR

SPIRIVA HANDIHALER

SYMBICORT

terbutaline (Brethine – brand is NF)

theophylline ext-release tabs – 12 hr – Theochron

theophylline ext-release tabs – 24 hr (Uniphyl – brand is NF)

VENTOLIN HFA

OTHER RESPIRATORY DRUGS

PROLASTIN

PULMOZYME

GASTROINTESTINAL DRUGSLAXATIVES

lactulose – Constulose

PEG – electrolytes for soln (Colyte – brand is NF)

PEG – electrolytes for soln (Nulytely – brand is NF)

DIARRHEA

diphenoxylate/atropine (Lomotil – brand is NF)

paregoric

ULCER/GERD

ACIPHEX – ST

CARAFATE susp

cimetidine

dicyclomine (Bentyl – brand is NF)

famotidine (Pepcid – brand is NF)

glycopyrrolate (Robinul – brand is NF)

hyoscyamine (Levsin – brand is NF)

hyoscyamine ext-release tabs (Levbid – brand is NF)

hyoscyamine ODT

methscopolamine (Pamine – brand is NF)

misoprostol (Cytotec – brand is NF)

nizatidine (Axid – brand is NF)

omeprazole delayed-release (Prilosec – brand is NF)

pantoprazole delayed-release tabs (Protonix) – ST

PREVPAC

PRILOSEC OTC: Non-formulary (may have coverage in an OTC program)

PROPANTHELINE BROMIDE 15 mg


PROTONIX – ST

PYLERA

ranitidine (Zantac – brand is NF)

sucralfate tabs (Carafate – brand is NF)

NAUSEA AND VOMITING

dronabinol (Marinol – brand is NF)

EMEND caps

granisetron tabs (Kytril – brand is NF)

meclizine (Antivert – brand is NF)

meclizine tabs, 32 mg

ondansetron inj (Zofran – brand is NF)

ondansetron oral soln, tabs (Zofran – brand is NF)

ondansetron ODT (Zofran ODT – brand is NF)

scopolamine (Scopace – brand is NF)

TRANSDERM-SCOP

trimethobenzamide caps (Tigan – brand is NF)

DIGESTIVE ENZYMES

CREON

LIPRAM-UL

PANCREASE MT

PANCRECARB MS

PANCRELIPASE IR tabs, 30-8-30

ULTRASE/MT

VIOKASE

OTHER GASTROINTESTINAL DRUGS

ASACOL 400 mg

balsalazide (Colazal – brand is NF)

calcium acetate (Phoslo)

CANASA

lactulose – Enulose

LIALDA

mesalamine enema

metoclopramide (Reglan – brand is NF)

PENTASA

PHOSLO

RENVELA

sulfasalazine (Azulfidine – brand is NF)

ursodiol caps (Actigall – brand is NF)

GENITOURINARY DRUGSURINARY TRACT INFECTIONS

FURADANTIN

MACRODANTIN 25 mg

methenamine hippurate (Hiprex, Urex – brands are NF)

methenamine mandelate/sodium biphosphate (Uroqid-Acid No. 2 – brand is NF)

nitrofurantoin macrocrystals (Macrodantin – brand is NF)

nitrofurantoin monohydrate/macrocrystals (Macrobid – brand is NF)

phenazopyridine (Pyridium – brand is NF)


URINARY TRACT SPASMS

bethanechol (Urecholine – brand is NF)

DETROL – QL

DETROL LA – QL

hyoscyamine

oxybutynin – QL

oxybutynin ext-release (Ditropan XL – brand is NF) – QL

VESICARE – QL

VAGINAL PRODUCTS

ACID JELLY

CLEOCIN supp

clindamycin crm (Cleocin – brand is NF)

CLINDESSE

ESTRACE crm

metronidazole (MetroGel-Vaginal – brand is NF)

PREMARIN crm

terconazole (Terazol – brand is NF)

VAGIFEM

OTHER GENITOURINARY DRUGS

AVODART

CYSTAGON

CYTRA-3

ELMIRON

finasteride (Proscar – brand is NF)

FLOMAX

K-PHOS MF

K-PHOS NO. 2

potassium citrate ext-release (Urocit-K – brand is NF)

potassium citrate/citric acid powder, soln (Polycitra-K – brand is NF)

sodium citrate/citric acid (Bicitra – brand is NF)

TRICITRATES

CENTRAL NERVOUS SYSTEM DRUGSANXIETY

alprazolam (Xanax – brand is NF)

ALPRAZOLAM INTENSOL

buspirone 5 mg, 10 mg, 15 mg, 30 mg (Buspar – brand is NF)

BUSPIRONE 7.5 mg

DIAZEPAM oral soln

diazepam tabs (Valium – brand is NF)

DIAZEPAM INTENSOL

hydroxyzine hcl

hydroxyzine pamoate (Vistaril – brand is NF)

lorazepam (Ativan – brand is NF)

lorazepam conc (Lorazepam Intensol)

LORAZEPAM INTENSOL

DEPRESSION

amitriptyline

bupropion (Wellbutrin – brand is NF)


bupropion ext-release – 12 hr (Wellbutrin SR – brand is NF)

bupropion ext-release – 24 hr (Wellbutrin XL – brand is NF)

citalopram (Celexa – brand is NF)

clomipramine (Anafranil – brand is NF)

desipramine (Norpramin – brand is NF)

doxepin

EFFEXOR XR – ST

fluoxetine (Prozac – brand is NF)

imipramine hcl (Tofranil – brand is NF)

mirtazapine (Remeron – brand is NF)

mirtazapine ODT (Remeron Soltab – brand is NF)

NARDIL

nortriptyline (Pamelor – brand is NF)

paroxetine hcl (Paxil – brand is NF)

paroxetine hcl ext-release, 12.5 mg, 25 mg (Paxil CR – brand is NF)

PAXIL CR 37.5 mg – ST

sertraline (Zoloft – brand is NF)

tranylcypromine (Parnate – brand is NF)

trazodone

venlafaxine (Effexor – brand is NF) – ST

VENLAFAXINE ER tabs – ST

PSYCHOTIC AND BIPOLAR DISORDERS

chlorpromazine

clozapine 25 mg, 50 mg, 100 mg (Clozaril – brand is NF)

fluphenazine decanoate

FLUPHENAZINE HCL elixir, soln

fluphenazine hcl tabs

GEODON

haloperidol decanoate (Haldol – brand is NF)

haloperidol lactate oral soln

haloperidol tabs

lithium carbonate caps

LITHIUM CARBONATE caps, 150 mg; tabs, 300 mg

lithium carbonate ext-release 300 mg (Lithobid – brand is NF)

lithium carbonate ext-release 450 mg

lithium citrate

loxapine

MOBAN

perphenazine

prochlorperazine supp

prochlorperazine tabs

RISPERDAL M-TAB 1 mg, 3 mg, 4 mg

risperidone (Risperdal – brand is NF)

risperidone ODT, 0.5 mg, 2 mg, 3 mg, 4 mg (Risperdal M-Tab – brand is NF)

SEROQUEL

SEROQUEL XR

thiothixene (Navane – brand is NF)

trifluoperazine


SLEEP AIDS

chloral hydrate syrup

estazolam

phenobarbital

PHENOBARBITAL 64.8 mg, 97.2 mg

RESTORIL 7.5 mg

temazepam 15 mg, 30 mg (Restoril – brand is NF)

zaleplon (Sonata – brand is NF)

zolpidem (Ambien – brand is NF)

HYPERACTIVITY/NARCOLEPSY

ADDERALL XR

amphetamine/dextroamphetamine mixed salts (Adderall – brand is NF)

CONCERTA

dextroamphetamine ext-release (Dexedrine Spansule – brand is NF)

dextroamphetamine tabs, 5 mg

METADATE CD

methylphenidate (Ritalin – brand is NF)

methylphenidate ext-release (Ritalin SR – brand is NF)

PROVIGIL

STRATTERA

MULTIPLE SCLEROSIS

AVONEX

COPAXONE

REBIF

TOBACCO CESSATION

The formulary includes all prescription (Rx) and over-the-counter (OTC) nicotine-containing products. Coverage of Rx and/or OTCs may vary depending on the member’s benefit design.

bupropion ext-release (Zyban)

CHANTIX

nicotine gum (Nicorette) – OTC, QL

nicotine lozenges (Commit) – OTC, QL

nicotine patches (Nicoderm CQ) – OTC

NICOTROL INHALER – QL

NICOTROL NS – QL

ZYBAN

OTHER CENTRAL NERVOUS SYSTEM DRUGS

ANTABUSE

ARICEPT

ARICEPT ODT

CAMPRAL

EXELON caps, soln

EXELON patches

NAMENDA

ORAP

WEIGHT LOSS

MERIDIA

XENICAL


PAIN RELIEF DRUGSNON-NARCOTIC DRUGS

butalbital/acetaminophen tabs, 50/325 (Phrenilin – brand is NF)

butalbital/acetaminophen tabs, 50/650 (Sedapap – brand is NF)

butalbital/acetaminophen/caffeine caps, 50/325/40 (Esgic – brand is NF)

butalbital/acetaminophen/caffeine tabs, 50/325/40 (Fioricet – brand is NF)

butalbital/acetaminophen/caffeine tabs, 50/500/40 (Esgic Plus – brand is NF)

butalbital/aspirin/caffeine caps, 50/325/40 (Fiorinal – brand is NF)

butalbital/aspirin/caffeine tabs, 50/325/40

ketorolac

salsalate

NARCOTIC DRUGS

acetaminophen/codeine (Tylenol w/Codeine – brand is NF)

AVINZA

butalbital/aspirin/caffeine/codeine caps (Fiorinal w/Codeine – brand is NF)

CODEINE SULFATE 15 mg

codeine sulfate 30 mg, 60 mg

DILAUDID-5

fentanyl patches (Duragesic – brand is NF)

hydrocodone/acetaminophen caps, 5/500

hydrocodone/acetaminophen soln, 7.5/500 per 15 mL (Lortab – brand is NF)

hydrocodone/acetaminophen tabs, 10/750 (Maxidone – brand is NF)

hydrocodone/acetaminophen tabs, 2.5/500, 5/500, 7.5/500, 10/500 (Lortab – brand is NF)

hydrocodone/acetaminophen tabs, 5/325, 7.5/325, 10/325 (Norco – brand is NF)

hydrocodone/acetaminophen tabs, 5/500, 7.5/750, 10/660 (Vicodin, Vicodin ES, Vicodin HP – brands are NF)

hydrocodone/acetaminophen tabs, 7.5/650, 10/650 (Lorcet, Lorcet Plus – brands are NF)

hydrocodone/ibuprofen tabs, 10/200 (Ibudone – brand is NF)

hydrocodone/ibuprofen tabs, 5/200 (Reprexain – brand is NF)

hydrocodone/ibuprofen tabs, 7.5/200 (Vicoprofen – brand is NF)

HYDROMORPHONE supp

hydromorphone tabs (Dilaudid – brand is NF)

methadone conc, tabs

METHADONE soln, 5 mg/5 mL, 10 mg/5 mL

morphine sulfate conc, soln, tabs

morphine sulfate ext-release (MS Contin – brand is NF)

MORPHINE SULFATE oral soln, 10 mg/5 mL, 20 mg/5 mL; supp

naltrexone (ReVia – brand is NF)

oxycodone caps (OxyIR – brand is NF)

oxycodone conc, soln, tabs (Roxicodone – brand is NF)

oxycodone ext-release (OxyContin)

oxycodone/acetaminophen caps, 5/500 (Tylox – brand is NF)

oxycodone/acetaminophen tabs, 5/325, 7.5/325, 7.5/500, 10/325, 10/650 (Percocet – brand is NF)

oxycodone/aspirin tabs, 5/325 (Percodan – brand is NF)

OXYCONTIN

propoxyphene hcl/acetaminophen tabs, 65/650

propoxyphene napsylate/acetaminophen tabs, 50/325, 100/650 (Darvocet-N – brand is NF)

ROXICET soln


SUBOXONE

SUBUTEX

tramadol (Ultram – brand is NF)

tramadol/acetaminophen (Ultracet – brand is NF)

RHEUMATOID AND OSTEOARTHRITIS

CELEBREX

diclofenac sodium delayed-release (Voltaren – brand is NF)

DICLOFENAC SODIUM delayed-release 25 mg

diclofenac sodium ext-release (Voltaren-XR – brand is NF)

ENBREL

etodolac

HUMIRA

ibuprofen

indomethacin

indomethacin ext-release (Indocin SR – brand is NF)

ketoprofen

leflunomide (Arava – brand is NF)

MECLOFENAMATE

meloxicam tabs (Mobic – brand is NF)

methotrexate inj

methotrexate tabs, 2.5 mg

nabumetone

naproxen (Naprosyn – brand is NF)

naproxen sodium (Anaprox – brand is NF)

piroxicam (Feldene – brand is NF)

RIDAURA

sulindac (Clinoril – brand is NF)

MIGRAINE HEADACHES

acetaminophen/isometheptene/dichloralphenazone (Midrin – brand is NF)

divalproex ext-release (Depakote ER)

ergotamine/caffeine tabs (Cafergot – brand is NF) – QL

IMITREX inj kit – QL

IMITREX nasal – QL

MIGERGOT – QL

MIGRANAL – QL

sumatriptan tabs (Imitrex – brand is NF) – QL

sumatriptan vials, 6 mg (Imitrex – brand is NF) – QL

ZOMIG nasal – QL

ZOMIG tabs – QL

ZOMIG ZMT – QL

GOUT

allopurinol

colchicine

probenecid

probenecid/colchicine

NEUROMUSCULAR DRUGSSEIZURES

BANZEL


carbamazepine (Tegretol – brand is NF)

carbamazepine ext-release 200 mg, 400 mg (Tegretol-XR)

CARBATROL

CELONTIN

clonazepam (Klonopin – brand is NF)

DIASTAT

DILANTIN

divalproex delayed-release sprinkle caps, tabs (Depakote Sprinkles, Depakote – brands are NF)

divalproex ext-release (Depakote ER – brand is NF)

ethosuximide (Zarontin – brand is NF)

FELBATOL

gabapentin caps, tabs (Neurontin – brand is NF)

LAMICTAL Starter Kit

lamotrigine (Lamictal – brand is NF)

levetiracetam (Keppra – brand is NF)

NEURONTIN soln

oxcarbazepine tabs (Trileptal – brand is NF)

PEGANONE

phenytoin sodium extended (Dilantin)

phenytoin susp (Dilantin)

primidone (Mysoline – brand is NF)

TEGRETOL-XR

topiramate sprinkle caps, tabs (Topamax Sprinkle, Topamax – brands are NF)

TRILEPTAL susp

valproic acid (Depakene – brand is NF)

zonisamide (Zonegran – brand is NF)

PARKINSON’S DISEASE

amantadine caps, syrup

APOKYN

benztropine

bromocriptine (Parlodel – brand is NF)

carbidopa/levodopa (Sinemet – brand is NF)

carbidopa/levodopa ext-release (Sinemet CR – brand is NF)

carbidopa/levodopa ODT (Parcopa – brand is NF)

COMTAN

MIRAPEX

ropinirole (Requip – brand is NF)

selegiline caps (Eldepryl – brand is NF)

STALEVO

trihexyphenidyl

MUSCLE RELAXANTS

baclofen

chlorzoxazone

cyclobenzaprine (Flexeril – brand is NF)

dantrolene (Dantrium – brand is NF)

methocarbamol (Robaxin – brand is NF)

orphenadrine citrate ext-release

orphenadrine/aspirin/caffeine 25/385/30


ORPHENADRINE/ASPIRIN/CAFFEINE 50/770/60

SKELAXIN

tizanidine tabs (Zanaflex – brand is NF)

OTHER NEUROMUSCULAR DRUGS

MESTINON syrup

MESTINON TIMESPAN

pyridostigmine tabs (Mestinon – brand is NF)

RILUTEK

SUPPLEMENTSVITAMINS

calcitriol (Rocaltrol – brand is NF)

ergocalciferol caps (Drisdol – brand is NF)

MEPHYTON

PHYTONADIONE inj, 10 mg/mL

phytonadione inj 1 mg/0.5 mL

MULTIVITAMINS

pediatric multivitamins/fluoride

pediatric multivitamins/fluoride/iron

pediatric vitamins ADC/fluoride

pediatric vitamins ADC/fluoride/iron

prenatal multivitamins/1 mg folic acid

MINERALS AND ELECTROLYTES

K-PHOS

potassium bicarbonate/chloride effervescent tabs, 25 mEq (K-Lyte/Cl – brand is NF)

potassium chloride ext-release caps, 10 mEq (Micro-K 10 – brand is NF)

potassium chloride ext-release tabs, 10 mEq (K-Tabs – brand is NF)

potassium chloride ext-release tabs, 10 mEq, 20 mEq

potassium chloride ext-release tabs, 8 mEq

potassium chloride packets, 20 mEq (K-Lor – brand is NF)

potassium chloride soln, 10%, 20%

potassium phosphate/sodium phosphates (K-Phos Neutral – brand is NF)

sodium fluoride chew tabs, drops; tabs, 2.2 mg

SODIUM FLUORIDE soln, 0.55 mg/drop; tabs, 1.1 mg

SSKI

BLOOD MODIFYING DRUGSADVATE – PA

AGGRENOX

ALPHANINE SD – PA

aminocaproic acid inj (Amicar – brand is NF)

aminocaproic acid syrup, tabs (Amicar – brand is NF)

anagrelide (Agrylin – brand is NF)

ARANESP

BEBULIN VH – PA

BENEFIX – PA

CEREDASE

CEREZYME

cilostazol (Pletal – brand is NF)

cyanocobalamin inj


FEIBA VH – PA

folic acid tabs, 1 mg

GENARC – PA

HELIXATE FS – PA

HEMOFIL M – PA

HUMATE-P – PA

KOATE-DVI – PA

KOGENATE FS – PA

LOVENOX

MONOCLATE-P – PA

MONONINE – PA

NEULASTA

NEUMEGA

NEUPOGEN

NOVOSEVEN – PA

NOVOSEVEN RT – PA

pentoxifylline ext-release (Trental – brand is NF)

PLAVIX 75 mg

PROCRIT

PROFILNINE – PA

RECOMBINATE – PA

REFACTO – PA

warfarin (Coumadin – brand is NF)

XYNTHA – PA

TOPICAL DRUGSEYE

Anti-infectives

AZASITE

bacitracin/polymyxin B oint

CILOXAN oint

ciprofloxacin soln (Ciloxan – brand is NF)

erythromycin oint

gentamicin oint, soln

NATACYN

neomycin/polymyxin B/bacitracin oint

neomycin/polymyxin B/gramicidin soln (Neosporin – brand is NF)

ofloxacin soln (Ocuflox – brand is NF)

polymyxin B/trimethoprim soln (Polytrim – brand is NF)

sulfacetamide sodium soln (Bleph-10 – brand is NF)

tobramycin soln (Tobrex – brand is NF)

TOBREX oint

trifluridine soln (Viroptic – brand is NF)

VIGAMOX

Steroids and Combination Products

ALREX

BLEPHAMIDE

BLEPHAMIDE S.O.P.

dexamethasone sodium phosphate soln


fluorometholone susp (FML Liquifilm – brand is NF)

FML

LOTEMAX

neomycin/polymyxin B/bacitracin/hydrocortisone oint

neomycin/polymyxin B/dexamethasone oint, susp (Maxitrol – brand is NF)

prednisolone acetate susp (Pred Forte – brand is NF)

PREDNISOLONE SODIUM PHOSPHATE soln, 1%

sulfacetamide sodium/prednisolone soln

TOBRADEX

tobramycin/dexamethasone susp (Tobradex)

ZYLET

Glaucoma

ALPHAGAN P

AZOPT

BETAXOLOL soln

brimonidine soln, 0.2%

carteolol soln

dorzolamide (Trusopt – brand is NF)

dorzolamide/timolol maleate (Cosopt – brand is NF)

levobunolol soln (Betagan – brand is NF)

metipranolol soln (Optipranolol – brand is NF)

pilocarpine soln (Isopto Carpine – brand is NF)

timolol maleate gel-forming soln (Timoptic-XE – brand is NF)

timolol maleate soln (Timoptic – brand is NF)

TRAVATAN

TRAVATAN Z

XALATAN

Other Eye Products

ACULAR

ACULAR LS

atropine sulfate oint, soln (Isopto Atropine – brand is NF)

cromolyn sodium soln (Crolom – brand is NF)

cyclopentolate soln (Cyclogyl – brand is NF)

diclofenac soln (Voltaren – brand is NF)

flurbiprofen soln (Ocufen – brand is NF)

homatropine soln (Isopto Homatropine – brand is NF)

OPTIVAR

PATANOL

XIBROM

EAR

acetic acid

benzocaine/antipyrine

CIPRO HC

CIPRODEX

hydrocortisone/acetic acid

neomycin/polymyxin B/hydrocortisone (Cortisporin – brand is NF)

ofloxacin (Floxin Otic – brand is NF)


MOUTH AND THROAT (LOCAL)

chlorhexidine oral rinse (Peridex – brand is NF)

clotrimazole troche (Mycelex – brand is NF)

EVOXAC

lidocaine viscous

nystatin susp

pilocarpine tabs (Salagen – brand is NF)

sodium fluoride crm, gel (Prevident – brand is NF)

triamcinolone paste

ANORECTAL

CORTIFOAM

hydrocortisone acetate supp, 25 mg (Anusol-HC – brand is NF)

hydrocortisone crm, 2.5% (Anusol-HC – brand is NF)

hydrocortisone enema

SKIN CONDITIONS/PRODUCTS

Acne

AZELEX

BENZACLIN

clindamycin (Cleocin-T – brand is NF)

DIFFERIN

DUAC CS

erythromycin gel

erythromycin pads, soln, 2%

erythromycin/benzoyl peroxide (Benzamycin – brand is NF)

FINACEA, NF = Finacea Plus

isotretinoin caps

METROGEL 1%

metronidazole (Metrolotion – brand is NF)

metronidazole gel, 0.75%

metronidazole 0.75% (Metrocream – brand is NF)

sulfacetamide sodium lotn (Klaron – brand is NF)

sulfacetamide sodium/sulfur crm, emulsion (Plexion – brand is NF)

sulfacetamide sodium/sulfur lotn

SULFACETAMIDE SODIUM/SULFUR 10%/5%, susp

TAZORAC

tretinoin, NF = Avita gel (Retin-A – brand is NF)

Anti-infectives

BACTROBAN crm

ciclopirox (Loprox – brand is NF)

DENAVIR

econazole

gentamicin

ketoconazole crm

ketoconazole shampoo, 2% (Nizoral – brand is NF)

LOPROX shampoo

mupirocin oint (Bactroban), NF = Centany

nystatin (Mycostatin – brand is NF)

silver sulfadiazine (Silvadene – brand is NF)

ZOVIRAX oint


Corticosteroids

alclometasone (Aclovate – brand is NF)

betamethasone dipropionate

betamethasone dipropionate, augmented (Diprolene – brand is NF)

betamethasone valerate

clobetasol (Olux – brand is NF)

clobetasol (Temovate – brand is NF)

clotrimazole/betamethasone (Lotrisone – brand is NF)

DERMA-SMOOTHE/FS oil

desonide (Desowen – brand is NF)

desoximetasone (Topicort – brand is NF)

diflorasone, NF = emollient crm

FLUOCINOLONE

fluocinonide

fluticasone propionate (Cutivate – brand is NF)

halobetasol (Ultravate – brand is NF)

hydrocortisone butyrate (Locoid – brand is NF)

hydrocortisone valerate (Westcort – brand is NF)

hydrocortisone 2.5%

mometasone (Elocon – brand is NF)

nystatin/triamcinolone

triamcinolone

TRIAMCINOLONE oint, 0.05%

Other Skin Products

ALDARA

aluminum chloride soln (Drysol – brand is NF)

calcipotriene soln (Dovonex – brand is NF)

CARAC

CONDYLOX gel

DOVONEX crm

doxepin crm (Zonalon – brand is NF)

DRITHO-CREME HP

ELIDEL

EMLA/TEGADERM

FLUOROPLEX

fluorouracil crm, soln, 5% (Efudex – brand is NF)

FLUOROURACIL soln, 2%

lidocaine jelly, 2%; oint, 5%; soln, 4% (Xylocaine – brand is NF)

lidocaine/prilocaine crm (Emla – brand is NF)

LIDODERM

lindane lotn

LINDANE shampoo

malathion (Ovide)

OVIDE

OXSORALEN-ULTRA soft gelatin caps

PANRETIN

permethrin crm, 5% (Elimite – brand is NF)

podofilox soln (Condylox – brand is NF)


PROTOPIC

selenium sulfide 2.5% (Selsun – brand is NF)

SOLARAZE

SORIATANE CK Kit

SYNERA

TARGRETIN gel

MISCELLANEOUS CATEGORIES (includes supplies and devices)

DIABETIC SUPPLIES

Meters, Blood Glucose Control Reagents, Blood Glucose Test Strips

ACCU-CHEK ACTIVE

ACCU-CHEK ADVANTAGE

ACCU-CHEK AVIVA

ACCU-CHEK COMFORT CURVE

ACCU-CHEK COMPACT

ACCU-CHEK INSTANT

ASCENSIA AUTODISC

ASCENSIA ELITE/ELITE XL

BREEZE/BREEZE 2

CONTOUR

Insulin Syringes, Lancets and Lancet Devices

All insulin syringes and pen needles are on formulary; suggested products are listed.

BD INSULIN SYRINGES

BD LANCET DEVICES

BD ULTRAFINE PEN NEEDLES

LANCETS (all)

MICROLET/MICROLET 2 LANCET DEVICES

ROCHE DIAGNOSTICS LANCET DEVICES

ORAL INHALER-ASSIST DEVICES – SPACERS

The formulary includes a number of products available only as brand products. The most commonly prescribed are AEROCHAMBER, EASIVENT, E-Z SPACER, INSPIREASE and MICROCHAMBER.

MISCELLANEOUS DRUGS

azathioprine (Imuran – brand is NF)

CELLCEPT

CHEMET

CUPRIMINE

cyclosporine (Sandimmune – brand is NF)

cyclosporine modified caps, 25 mg, 100 mg; soln (Neoral – brand is NF)

mycophenolate mofetil caps, tabs (Cellcept)

MYFORTIC

PROGRAF

RAPAMUNE

REVLIMID

sodium polystyrene sulfonate

SPS

SYPRINE

tacrolimus caps (Prograf)

THALOMID

2746-A © Prime Therapeutics LLC 09/09

Documents

FlexRx Drug Formulary - Carleton College...FlexRx Drug Formulary, October 2009 2HOW TO USE THIS FORMULARY This formulary is organized into broad treatment categories. In most categories,