BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
I. ANTI-INFECTIVE AGENTS
PENICILLINS
$ Amoxicillin* AMOXIL no chewables
$ Ampicillin* TOTACILLIN
$ Penicillin G Benzathine BICILLIN
$ Penicillin V Potassium* PEN VEE K
Penicillinase-resistant
$ Cloxacillin Sodium CLOXAPEN
Prior Authorization Required
$ Dicloxacillin Sodium* DYCILL
$ Oxacillin OXACILLIN
Penicillin Combinations
$$$ Amox & K Clav AUGMENTIN no chewables
CEPHALOSPORINS
Cephalosporins - 1st Generation
$ Cephalexin* KEFLEX no tablets
$ Cephradine* VELOSEF
Cephalosporins - 2nd Generation
$$$ Cefaclor* CECLOR
$$$ Cefprozil CEFZIL
$$$ Cefuroxime CEFTIN oral tablets only
$$$ Loracarbef LORABID SUSPENSION covered for children
under 12 yrs old
Cephalosporins - 3rd Generation
$$$ Ceftriaxone ROCEPHIN
$$$$ Cefixime SUPRAX
Prior Authorization Required
(requires PA after 1 tablet dispensed)
MACROLIDE ANTIBIOTICS
Erythromycins
$ Erythromycin Base* ERY-TAB
$ Erythromycin Estolate* ILOSONE no 500mg tabs
$ Erythromycin Ethylsuccinate* E.E.S. no chewables
$ Erythromycin Stearate* ERYTHROCIN
Lincomycins
$$ Clindamycin* CLEOCIN
Misc. Macrolide Antibiotics
$$$ Azithromycin ZITHROMAX
(requires PA after 1 x 1gm susp. single dose dispensed)
$$$ Clarithromycin BIAXIN
Prior Authorization Required
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
TETRACYCLINES
$ Doxycycline* VIBRAMYCIN
$ Tetracycline* SUMYCIN no tablets
FLUOROQUINOLONES
$$$ Ciprofloxacin CIPRO
(requires PA after 1 tablet dispensed)
$$$ Lomefloxacin MAXAQUIN
$$$$ Moxifloxacin AVELOX
Prior Authorization Required
ANTIMALARIAL
$ Chloroquine* ARALEN no 500mg tabs
$ Hydroxychloroquine PLAQUENIL
$ Quinine QUININE
ANTHELMINTIC
$$ Albendazole ALBENZA
$$$$$ Mebendazole VERMOX
$$$$$ Pyrantel Pamoate ANTIMINTH
AMINOGLYCOSIDES
$ Gentamicin Sulfate* GARAMYCIN
$ Neomycin Sulfate* NEOMYCIN tablets only
SULFONAMIDES
$ Erythromycin/Sulfisoxazole* PEDIAZOLE
$ Sulfadiazine* MICROSULFON
$ Sulfamethoxazole GANTANOL
$ Sulfasalazine AZULFIDINE no EN tabs
$ Trimethoprim/Sulfamethoxazole* BACTRIM / DS
$$ Sulfisoxazole* GANTRISIN
ANTIMYCOBACTERIAL AGENTS
$ Isoniazid* INH
$$$ Cycloserine* SEROMYCIN
$$$ Ethionamide* TRECATOR-SC
$$$$ Rifabutin MYCOBUTIN
$$$$$ Ethambutol MYAMBUTOL
$$$$$ Pyrazinamide PYRAZINAMIDE
$$$$$ Rifampin RIFADIN
MISC. ANTIINFECTIVES
$ Metronidazole* FLAGYL
$ Trimethoprim* PROLOPRIM
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Chloramphenicols
$$ Chloramphenicol* CHLOROMYCETIN
Leprostatics
$ Dapsone DAPSONE
ANTIFUNGALS
$ Griseofulvin Microsize GRIFULVIN V
$ Griseofulvin Ultramicrosize GRISEOFULVIN
$$ Nystatin* MYCOSTATIN
Imidazole-Related Antifungals
$ Miconazole MONISTAT OTC product
$$$ Ketoconazole NIZORAL
$$$$ Itraconazole SPORANOX
Prior Authorization Required
Triazoles
$$$$ Fluconazole DIFLUCAN
Prior Authorization Required
(requires PA after 1 x 150mg dispensed)
ANTIVIRAL
Antiretrovirals - Protease Inhibitors
$$$$$ Amprenavir AGENERASE
$$$$$ Indinavir Sulfate CRIXIVAN
$$$$$ Nelfinavir Mesylate VIRACEPT
$$$$$ Ritonavir NORVIR
$$$$$ Saquinavir FORTOVASE, INVIRASE
$$$$$ Tenofovir VIREAD
$$$$$ Atazanavir REYATAZ
$$$$$ Fosamprenavir Calcium LEXIVA
Antiretrovirals - RTI-Nucleoside Analogues
$$$$$ Abacavir ZIAGEN
$$$$$ Delavirdine RESCRIPTOR
$$$$$ Didanosine VIDEX
$$$$$ Efavirenz SUSTIVA
$$$$$ Lamivudine EPIVIR
$$$$$ Nevirapine VIRAMUNE
$$$$$ Stavudine ZERIT
$$$$$ Zalcitabine HIVID
$$$$$ Zidovudine RETROVIR
Antiretroviral Combinations
$$$$$ Abacavir/Lamivudine/Zidovudine TRIZIVIR
$$$$$ Lopinavir/Ritonavir KALETRA
$$$$$ Zidovudine/lamivudine COMBIVIR
$$$$$ Abacavir/Lamivudine EPZICOM
$$$$$ Tenofovir disoproxil/Emtricitabine TRUVADA
CMV Agents
$$$$ Ganciclovir CYTOVENE
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Hepatic Agents
$$$$$ Peginterferon PEG-INTRON
$$$$$ Ribavirin REBETOL
Prior Authorization Required
Herpes Agents
$$ Amantadine* SYMMETREL
$$$ Acyclovir* ZOVIRAX PA for ointment
ANTIMALARIAL
$ Pyrimethamine DARAPRIM
II. BIOLOGICALS
ANTISERA
Antiviral Monoclonal Antibodies
$$$$$ Palivizumab SYNAGIS
Prior Authorization Required
III. ANTINEOPLASTICS
ANTINEOPLASTICS
Alkylating Agents
$$$$$ Busulfan MYLERAN
$$$$$ Pipobroman VERCYTE
Nitrogen Mustards
$$$$$ Chlorambucil LEUKERAN
$$$$$ Cyclophosphamide* CYTOXAN
$$$$$ Melphalan ALKERAN
$$$$$ Uracil Mustard URACIL MUSTARD
Nitrosoureas
$$$$$ Lomustine CEENU
Antimetabolites
$$$$ Methotrexate* RHEUMATREX
$$$$$ Capecitabine XELODA
$$$$$ Fluouracil EFUDEX
$$$$$ Mercaptopurine PURINETHOL
$$$$$ Thioguanine THIOGUANINE
Androgens-Antineoplastic
$$$$$ Testolactone TESLAC
Progestins-Antineoplastic
$$$$ Megestrol* MEGACE
Antiandrogens
$$$$$ Flutamide EULEXIN
Aromatase Inhibitors
$$$$$ Letrozole FEMARA
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Antineoplastic Hormones Misc.
$$$$$ Tamoxifen NOLVADEX
$$$$$ Leuprolide LUPRON
Prior Authorization Required
Mitotic Inhibitors
$$$$ Etoposide VEPESID
Antineoplastics Misc.
$ Procarbazine MATULANE
$$$$ Hydroxyurea HYDREA
$$$$$ Mitotane LYSODREN
$$$$$ Interferon Alfa-2A ROFERON-A
$$$$$ Interferon Alfa-2B INTRON-A
$$$$$ Interferon Alfa-n3 ALFERON N
$$$$$ Interferon Beta-1a AVONEX
$$$$$ Interferon Beta-1b* BETASERON
Prior Authorization Required
IV. ENDOCRINE & METABOLIC DRUGS
CORTICOSTEROIDS
Glucocorticosteroids
$ Cortisone CORTONE
$ Dexamethasone* DECADRON no dose paks
$ Hydrocortisone* CORTEF
$ Methylprednisolone* MEDROL no dose paks
$ Prednisolone* PRELONE
$ Prednisone* DELTASONE
$$$ Prednisolone Na Phosphate PEDIAPRED
Mineralocorticoids
$$ Fludrocortisone FLORINEF
ANDROGEN-ANABOLIC
Androgens
$$ Fluoxymesterone HALOTESTIN
$$$ Methyltestosterone ANDROID
$$$$$ Danazol DANOCRINE
ESTROGENS
$ Diethylstilbestrol D.E.S.
$ Estradiol* ESTRACE
$$ Dienestrol ORTHO-DIENESTROL
$$ Esterified Estrogens ESTRATAB
$$ Estrogens, Conjugated PREMARIN
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
$$$$ Estradiol Patch CLIMARA
Prior Authorization Required
Estrogen Combinations
$$ Conjugated Estrogens &
Medroxyprogesterone* PREMPRO
CONTRACEPTIVES
Progestin OC's
$$$ Norethindrone ERRIN, CAMILA
Combinations OC's
$$ Ethynodiol Diacet & Eth Estrad ZOVIA
$$ Levonorgestrel & Eth Estradiol AVIANE, LEVORA
$$ Norethindrone & Eth Estradiol NECON, MICROGESTIN FE, NORTREL
$$ Norgestrel & Ethinyl Estradiol CRYSELLE
$$ Desogest/Eth Est & Ethin Estradiol KARIVA
$$ Desogestral & Ethinyl Estradiol APRI, ORTHOCEPT
$$$ Norgestimate & Ethinyl Estradiol SPRINTEC
$$ Norgestimate-Ethinyl Estradiol PREVEN 3 kits per year
$$$ Norelgestromin-Ethinyl Estradiol ORTHO EVRA PATCH
Triphasic OC's
$$ Levonorgestrel-Eth Estradiol TRIVORA
$$ Norethindrone-Ethinyl Estrad NORTREL 7/7/7, NECON 7/7/7, TRI-NORINYL
$$$ Norgestimate-Ethinyl Estradiol ORTHO TRI-CYCLEN
PROGESTINS
$ Medroxyprogesterone PROVERA tabs only/females only
$ Norethindrone AYGESTIN
$$$ Medroxyprogesterone Depot DEPO-PROVERA 150mg inj. only
ANTIDIABETIC
Thiazolidinediones/Combination
$$$$ Rosiglitazone Maleate-Metformin Hcl AVANDAMET
$$$$ Rosiglitazone Maleate AVANDIA
Prior Authorization Required
Human Insulin
$ Insulin Isophane HUMULIN N ONLY
$ Insulin Reg & Isophane HUMULIN 50/50 ONLY
$ Insulin Reg & NPH HUMULIN 70/30 ONLY
$ Insulin Regular HUMULIN R ONLY
$ Insulin Zinc HUMULIN L ONLY
$ Insulin Zinc Extended HUMULIN U ONLY
$ Insulin Lispro HUMALOG
$$ Insulin Glargine LANTUS
Prior Authorization Required
Sulfonylureas
$ Acetohexamide DYMELOR
$ Chlorpropamide* DIABINESE
$ Tolazamide* TOLINASE
$ Tolbutamide* ORINASE
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
$$ Glipizide* GLUCOTROL/XL
$$ Glyburide* DIABETA, GLYNASE
Alpha-Glucosidase Inhibitors
$$ Acarbose PRECOSE
Prior Authorization Required
Diabetic Other
$$ Metformin GLUCOPHAGE
$$$ Glucagon GLUCAGON
THYROID
Thyroid Hormones
$ Levothyroxine LEVOXYL,SYNTHROID
$ Liothyronine CYTOMEL
$ Thyroid* THYROID
Antithyroid Agents
$ Methimazole TAPAZOLE
$ Propylthiouracil* PROPYLTHIOURACIL
OXYTOCICS
$ Ergonovine ERGOTRATE
$ Methylergonovine METHERGINE
MISC. ENDOCRINE
Calcium Regulators
$$$$$ Calcitonin (Salmon) MIACALCIN NASAL
$$$$ Calcitonin (Salmon) MIACALCIN INJ
Prior Authorization Required
Hormone Receptor Modulators
$$$ Raloxifene EVISTA
Prior Authorization Required
Gonadotropin Releasing Hormones
$$$$$ Nafarelin SYNAREL
Prior Authorization Required
Growth Hormone
$$$$$ Somatropin HUMATROPE ONLY
Prior Authorization Required
Posterior Pituitary
$$$ Alendronate FOSAMAX ONLY
$$$$ Desmopressin DDAVP (all dosage forms)
Prior Authorization Required
V. CARDIOVASCULAR AGENTS
CARDIOTONICS
Digitalis
$ Digoxin LANOXIN no caps
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
ANTIANGINAL AGENTS
Nitrates
$ Isosorbide Dinitrate* ISORDIL, ISORDIL TEMBIDS
$ Nitroglycerin (oral)* NITROL, NITROSTAT
$$$ Nitroglycerin (topical)* NITRODUR,NITROBID
$$ Isosorbide Mononitrate* IMDUR
Prior Authorization Required
Antianginals-Other
$ Dipyridamole* PERSANTINE
BETA BLOCKERS
Beta Blockers Non-Selective
$ Propranolol* INDERAL / LA
$ Timolol BLOCADREN
$$$$ Sotalol BETAPACE
$$$ Carvedilol COREG
Prior Authorization Required
Beta Blockers Cardio-Selective
$ Atenolol* TENORMIN
$ Metoprolol Tartrate* LOPRESSOR
Alpha-Beta Blockers
$$$ Labetalol NORMODYNE
CALCIUM BLOCKERS
$$ Felodipine PLENDIL
$$ Verapamil* CALAN, SR
$$$ Diltiazem* CARDIZEM/CD,DILACOR/XR
$$$ Nifedipine* ADALAT CC, PROCARDIA XL
$$$ Amlodipine NORVASC
ANTIARRHYTHMIC
$ Disopyramide* NORPACE, CR
$ Procainamide* PRONESTYL, PROCANBID
$ Quinidine Sulfate* QUINORA
$$ Quinidine Gluconate* QUINAGLUTE DURATABS
$$$ Flecainide TAMBOCOR
$$$ Tocainide TONOCARD
$$$$ Amiodarone CORDARONE
$$$$ Mexiletine MEXITIL
$$$$ Moricizine ETHMOZINE
$$$$ Propafenone RYTHMOL
ANTIHYPERTENSIVE
ACE Inhibitors
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
$ Captopril* CAPOTEN
$$ Benazepril LOTENSIN
$$ Enalapril* VASOTEC
$$ Fosinopril MONOPRIL
$$ Lisinopril ZESTRIL
ACE II Inhibitors
$$$$ Irbesartan AVAPRO
Prior Authorization Required
Adrenolytics - Central
$ Clonidine* CATAPRES no patches
$ Guanfacine TENEX
$ Methyldopa* ALDOMET
Adrenolytics - Peripheral
$ Reserpine* RESERPINE
Alpha Blockers
$ Prazosin* MINIPRESS
$$$ Phenoxybenzamine DIBENZYLINE
$$$ Terazosin* HYTRIN
$$$ Tamsulosin FLOMAX
Prior Authorization Required
Vasodilators
$ Hydralazine* APRESOLINE
$ Minoxidil* LONITEN
Reserpine Combinations
$ Hydralazine-Reserpine-HCTZ* SER-AP-ES
$ Reserpine & HCTZ HYDROPRES
Beta Blocker Combinations
$ Atenolol & Chlorthalidone* TENORETIC
$ Propranolol & HCTZ* INDERIDE no LA
Ace Inhibitors & Diazides
$$ Lisinopril & HCTZ ZESTORETIC
Adrenolytics-Central & Thiazides
$ Methyldopa & Chlorothiazide ALDOCLOR
$ Methyldopa & HCTZ* ALDORIL
$$ Clonidine & Chlorthalidone* COMBIPRES
Vasodilators & Thiazides
$ Hydralazine & HCTZ* APRESAZIDE
DIURETICS
Carbonic Anhydrase Inhibitors
$ Acetazolamide* DIAMOX no sequels
$$$ Methazolamide NEPTAZANE
Loop Diuretics
$ Furosemide* LASIX
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Potassium Sparing Diuretics
$ Spironolactone* ALDACTONE
Thiazides
$ Chlorothiazide* DIURIL
$ Chlorthalidone* HYGROTON
$ Hydrochlorothiazide* HYDRODIURIL
$ Methyclothiazide* ENDURON
$ Metolazone ZAROXOLYN
$$ Indapamide* LOZOL
Combination Diuretics
$ Spironolactone & HCTZ* ALDACTAZIDE
$ Triamterene & HCTZ* MAXZIDE
Osmotic Diuretics
$ Glycerin Supp. GLYCERIN adult, infant, child
PRESSORS
Emergency Kits
$$ Epinephrine EPI-PEN, EPI-PEN JR
$$ Epinephrine & Chlorpheniramine ANA-KIT
ANTIHYPERLIPIDEMIC
Bile Sequestrants
$$$ Cholestyramine* QUESTRAN, LIGHT cans only
$$$ Colestipol COLESTID cans only
Misc.
$ Niacin* NIACIN OTC (slow release)
$$$ Gemfibrozil* LOPID
HMG CoA Reductase Inhibitors
$$$ Fluvastatin LESCOL
$$$ Simvastatin ZOCOR
$$$$ Atorvastatin LIPITOR
$$$ Pravastatin PRAVACHOL
Prior Authorization Required
MISCELLANEOUS CARDIOVASCULAR
Impotence Agents
$$$ Sildenafil VIAGRA 6 per 30 days
Prior Authorization Required
VI.RESPIRATORY AGENTS
ANTIHISTAMINES
Antihistamines - Alkylamines
$ Dexchlorpheniramine* POLARAMINE no syrup
Antihistamines - Ethanolamines
$ Diphenhydramine* BENADRYL OTC product
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Antihistamines - Non Sedating
$$ Fexofenadine ALLEGRA,ALLEGRA D 60 per 30 days
$$ Loratadine ALAVERT, CLARITIN OTC product
Antihistamines - Phenothiazines
$$$$$ Promethazine* PHENERGAN
Antihistamines - Piperidines
$ Cyproheptadine* PERIACTIN
SYSTEMIC AND TOPICAL NASAL PRODUCTS
Nasal Steroids
$$ Beclomethasone* BECONASE/VANCENASE/AQ
$$ Flunisolide NASALIDE
$$ Triamcinolone NASACORT AQ
Steroid Inhalants
$$ Beclomethasone VANCERIL
$$$ Triamcinolone AZMACORT
$$$ Fluticasone FLOVENT
Mucolytics
$$ Acetylcysteine* MUCOMYST
ANTIASTHMATIC
Anticholinergics
$$ Ipratropium ATROVENT/NASAL
Anti-Inflammatory Agents
$$$ Cromolyn (inhalation) INTAL
$$$ Cromolyn (nasal) NASALCROM
$$$ Nedocromil TILADE
Beta Adrenergics
$$ Isoetharine* BRONKOSOL
$$ Pirbuterol MAXAIR AUTOHALER
$$ Terbutaline BRETHINE/BRETHAIRE
$$$ Salmeterol SEREVENT
Adrenergic Combinations
$$ Albuterol-Ipratropium COMBIVENT
$$$ Salmeterol-Fluticasone ADVAIR
Prior Authorization Required
Sympathomimetic Agents
$ Albuterol* PROVENTIL no rotocaps
$ Pseudoephedrine HCL* PSEUDOEPHEDRINE OTC product
$ Albuterol PROVENTIL REPETABS
Prior Authorization Required
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Mixed Adrenergics
$$ Epinephrine EPI-PEN, EPI-PEN JR
$$ Epinephrine & Chlorpheniramine ANA-KIT
Xanthines
$ Aminophylline* AMINOPHYLLINE
$ Theophylline* THEO-24, UNIPHYL
Leukotriene Receptor Antagonists
$$$ Montelukast Sodium SINGULAIR
Prior Authorization Required
COUGH/COLD/ALLERGY
Expectorants
$ Guaifenesin* GUAIFENESIN OTC product
$ Guaifenesin/DM* GUAIFENESIN DM OTC product
Cough/Cold/Allergy Combinations
$ Carbinoxamine & Pseudoephedrine CARDEC
$ Carbinoxamine & Pseudoephedrine/DM CARDEC DM
$ Codeine-GG ROBITUSSIN AC
$$ Hydrocodone-GG HYCOTUSS
$$ Pseudoephedrine-GG DURATUSS
VII. GASTROINTESTINAL AGENTS
LAXATIVES
Surfactant Laxatives
$ Docusate Sodium* COLACE OTC product
Stimulant Laxatives
$ Bisacodyl DULCOLAX OTC product
Bulk Laxatives
$ Polycarbophil Calcium FIBERALL OTC product
Laxative Combinations
$ Psyllium w/Bran FIBERALL OTC product
Miscellaneous Laxatives
$ Glycerin* GLYCERIN OTC product
$ Lactulose* CHRONULAC
$ PEG-Electrolyte GOLYTELY
ANTIDIARRHEALS
Antiperistaltic Agents
$ Diphenoxylate w/ Atropine LOMOTIL
$ Loperamide* IMODIUM OTC product
Misc Antidiarrheal Agents
$ Bismuth Subsalicylate PEPTO-BISMOL no tabs, OTC
$$$$$ Octreotide Acetate SANDOSTATIN
Prior Authorization Required
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
ANTACIDS
Antacids - Aluminum Salts
$ Aluminum Hydroxide Gel* AMPHOGEL OTC product
Antacids - Calcium Salts
$ Calcium Carbonate* OS-CAL OTC product
Antacid Combinations
$ Al Hydrox-Mag Carb* MAALOX no tabs, OTC
$ Aluminum & Magnesium Hydroxide* MYLANTA no tabs, OTC
ULCER DRUGS
Belladonna Alkaloids
$ Hyoscyamine Sulfate LEVSIN
Quaternary Anticholinergics
$ Propantheline Bromide* PRO-BANTHINE
Antispasmodics
$ Dicyclomine* BENTYL
H-2 Antagonists
$$$ Cimetidine* TAGAMET
$$$ Famotidine* PEPCID tabs only
$$$ Ranitidine* ZANTAC
$$$ Nizatidine AXID
Prior Authorization Required
Proton Pump Inhibitors
$$ Omeprazole PRILOSEC OTC
$$$$ Lansoprazole PREVACID
$$$$ Omeprazole PRILOSEC RX
Prior Authorization Required
Misc. Anti-Ulcer
$$$$ Sucralfate* CARAFATE
Prior Authorization Required
ANTIEMETICS
Antiemetics - Anticholinergic
$ Meclizine* ANTIVERT
$$ Prochlorperazine COMPAZINE no SR
5-HT3 Receptor Antagonists
$$ Ondansetron HCL ZOFRAN
Prior Authorization Required
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
DIGESTIVE AIDS
Digestive Aids - Mixtures
$$$ Amylase-Lipase-Protease Reg.Rls VIOKASE
$$$$ Amylase-Lipase-Protease CREON
Prior Authorization Required
MISC. GI
GI Stimulants
$ Metoclopramide* REGLAN no 5mg tabs
Inflammatory Bowel Agents
$ Sulfasalazine* AZULFIDINE no EN tabs
$$$$ Mesalamine ASACOL
$$$$ Mesalamine PENTASA,ROWASA
VIII. GENITOURINARY
URINARY ANTIINFECTIVES
$ Methenamine Mandelate* MANDELAMINE
$ Trimethoprim TRIMPEX
$$ Nitrofurantoin* FURADANTIN
$$ Nitrofurantoin Macrocrystals* MACRODANTIN
URINARY ANTISPASMODICS
$ Bethanechol* URECHOLINE
$ Hyoscyamine LEVSINEX
$$ Flavoxate URISPAS
$$ Oxybutynin DITROPAN
VAGINAL PRODUCTS
Vaginal Antiinfectives
$ Nystatin* NYSTATIN
$$ Clindamycin CLEOCIN
$$ Sulfanilamide AVC
$$ Metronidazole METROGEL
Prior Authorization Required
Imidazole-Related Antifungals
$ Butoconazole Nitrate FEMSTAT OTC product
$ Clotrimazole* MYCELEX OTC product
$ Miconazole MONISTAT OTC product
Vaginal Antiinfective Combinations
$ Triple Sulfas Vaginal* SULTRIN
Vaginal Estrogens
$$ Dienestrol ORTHO-DIENESTROL
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
MISCELLANEOUS GENITOURINARY PRODUCTS
Citrates
$ Sodium Citrate & Citric Acid BICITRA
Urinary Analgesics
$ Phenazopyridine* PYRIDIUM
IX. CENTRAL NERVOUS SYSTEM DRUGS
ANTIPSYCHOTICS
Phenothiazines
$$ Prochlorperazine COMPAZINE no SR
HYPNOTICS
Barbiturate Hypnotics
$ Butabarbital BUTISOL
$ Mephobarbital MEBARAL
$ Phenobarbital* PHENOBARBITAL
Non-Barbiturate Hypnotics
$ Midazolam VERSED
Prior Authorization Required
Antihistamine Hypnotics
$ Diphenhydramine* BENADRYL OTC product
MISC PSYCHOTHERAPEUTIC
$ Ergoloid Mesylates* HYDERGINE no liquid caps
X. ANALGESICS & ANESTHETICS
ANALGESICS - NonNarcotic
Salicylates
$ Aspirin zero order* ZORPRIN
$$ Salsalate* DISALCID
Salicylate Combinations
$ Aspirin Enteric Coated* ECOTRIN OTC product
$ Aspirin with Buffers* ASPIRIN BUFFERED OTC product
$$$$ Choline & Mag Salicylate* TRILISATE
Analgesics Other
$ Acetaminophen* TYLENOL OTC product
Analgesics - Sedatives
$ APAP/Caffeine/Butalbital* FIORICET
$ Aspirin/Caffeine/Butalbital* FIORINAL
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
ANALGESICS - Narcotic
Narcotic Agonists
$ Codeine Phosphate CODEINE PHOSPHATE
$ Codeine Sulfate* CODEINE SULFATE
$ Meperidine* DEMEROL
$$$ Hydromorphone* DILAUDID
$ Methadone METHADONE
$$$ Morphine Sulfate* MSIR
$$$$ Morphine Sulfate SR MS CONTIN
$$$$ Morphine Sulfate SR ORAMORPH SR
$$$$ Naltrexone REVIA
$$$ Fentanyl DURAGESIC
$$$ Tramadol ULTRAM
Prior Authorization Required
Narcotic Agonist-Antagonist
$$$$$ Buprenorphine Hcl-Naloxone Hcl SUBOXONE
Opiate Partial Agonist
$$$$ Buprenorphine Hcl SUBUTEX
Narcotic Combinations
$ Oxycodone w/ Acetaminophen* PERCOCET
$ Oxycodone w/ Aspirin* PERCODAN
Codeine Combinations
$ Acetaminophen w/ Codeine* TYLENOL / COD
$ Aspirin w/ Codeine* EMIPRIN / COD
Hydrocodone Combinations
$$$ Acetaminophen w/ Hydrocodone* VICODIN (5/500 )
Propoxyphene Combinations
$ Propoxyphene w/ APAP* DARVOCET N-100 100mg tabs
ANTI-RHEUMATIC
NSAID's
$ Ibuprofen* MOTRIN
$$ Fenoprofen* NALFON
$$ Indomethacin* INDOCIN no SR or supp.
$$ Naproxen Sodium* ANAPROX
$$ Naproxen* NAPROSYN no EC
$$ Piroxicam FELDENE
$$ Sulindac* CLINORIL
Gold Compounds
$$$ Auranofin RIDAURA
Prior Authorization Required
16
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Anti-Rheumatic Antimetabolite
$$$$ Methotrexate* RHEUMATREX
GOUT
$ Allopurinol* ZYLOPRIM
$ Colchicine* COLCHICINE
Uricosurics
$ Probenecid* PROBENECID
LOCAL ANESTHETICS
$ Lidocaine* LIDOCAINE
MIGRAINE PRODUCTS
$$ Ergotamine mesylates HYDERGINE
$$$$ Sumatriptan Tablets IMITREX
$$$$ Sumatriptan Injection IMITREX (no nasal spray)
Prior Authorization Required
Migraine Combinations
$$ Ergotamine w/ Caffeine CAFERGOT
XI. NEUROMUSCULAR AGENTS
ANTICONVULSANT
Hydantoins
$ Mephenytoin MESANTOIN
$$ Phenytoin DILANTIN
$$$ Ethotoin PEGANONE
Oxazolidinediones
$$ Trimethadione TRIDIONE
Succinimides
$$$ Ethosuximide ZARONTIN
$$$ Methsuximide CELONTIN
$$$ Phensuximide MILONTIN
Miscellaneous Anticonvulsants
$$$$$ Primidone MYSOLINE
ANTIPARKINSONIAN
COMT Inhibitors
$$$ Entacapone COMTAN
Prior Authorization Required
Dopaminergic
$ Amantadine* SYMMETREL
$$$$ Bromocriptine PARLODEL no postpartum use
$$ Ropinirole REQUIP
Prior Authorization Required
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Levodopa Combinations
$$$ Carbidopa-Levodopa* SINEMET, CR no 100-25 CR
Monoamine Oxidase Inhibitor
$$$$ Selegiline ELDEPRYL
MUSCULOSKELETAL THERAPY AGENTS
Central Muscle Relaxants
$ Cyclobenzaprine* FLEXERIL
$ Methocarbamol* ROBAXIN
$$ Baclofen* LIORESAL
Direct Muscle Relaxants
$$$$ Dantrolene DANTRIUM
Prior Authorization Required
Muscle Relaxant Combinations
$ Methocarbamol w/ Aspirin* ROBAXISAL
ANTIMYASTHENIC AGENTS
Antimyasthenic Agents
$$$$ Pyridostigmine MESTINON
Benzothiazoles
$$$$$ Riluzole RILUTEK
Prior Authorization Required
XII. NUTRITIONAL PRODUCTS
VITAMINS
Water Soluble Vitamins
$ Niacin* NIACIN
$ Vitamin B-3* VITAMIN B-3
Oil Soluble Vitamins
$ Vitamin A* AQUASOL A
Vitamin D
$$ Calcitriol ROCALTROL
$$ Ergocalciferol DRISDOL
MULTIVITAMINS
$ Folic Acid & Vitamin B Complex* NEPHROCAPS
$ Multiple Vitamin* ONE-A-DAY OTC procuct
$ Pediatric Multivitamins w/Fluoride POLY-VI-FLOR 6mos to 16 years only
$ Pediatric Vitamins* CHILDS COMPLETE OTC procuct
$ Prenatal MV & Min w/FE-FA* PRENATAL-1
$ Prenatal Vitamins* MATERNA
$$$ Multiple Vitamin w/ Minerals* BEROCCA PLUS
18
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
CITRATES
$ Sodium Citrate & Citric Acid BICITRA
MINERALS & ELECTROLYTES
Calcium
$ Calcium Acetate PHOSLO
$ Calcium Carbonate* OS-CAL OTC procuct
Fluoride
$ Sodium Fluoride LURIDE
Potassium
$ Potassium Chloride Capsule* MICRO-K
$ Potassium Chloride Liquid* KAYCIEL
$ Potassium Chloride Tablet* KLOR-CON
Electrolyte Mixtures
$ Oral Electrolytes PEDIALYTE OTC procuct
DIETARY PRODUCTS
$$ Infant Foods LOFENALAC OTC procuct
$$ Phenyl-Free PHENYL-FREE OTC procuct
MISCELLANEOUS NUTRITIONAL PRODUCTS
$$ Nutritional Supplements ENSURE, PEDIASURE, BOOST,
SUSTACAL, RESTORE, VIVONEX
Prior Authorization Required
(Nutritional Supplements are not limited to this list)
XIII. HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
Cobalamines
$ Folic Acid* FOLVITE
$$$$$ Leucovorin Calcium* LEUCOVORIN
$ Cyanocobalamin* VITAMIN B-12
$ Hydroxocobalamin* HYDROBEXAN
Prior Authorization Required
Iron
$ Ferrous Gluconate* FERGON OTC procuct
$ Ferrous Sulfate* FEOSOL OTC procuct
Hematopoietic Growth Factors
$$$$Darbopoetin ARANESP
Erythropoietins
$$$$$ Epoetin Alfa EPOGEN,PROCRIT
Leukocytes
$$$$$ Filgrastim NEUPOGEN
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Prior Authorization Required
ANTICOAGULANTS
Coumarin Anticoagulants
$$ Warfarin Sodium COUMADIN
Heparin Agents
$$$ Enoxaparin LOVENOX
Prior Authorization Required
HEMOSTATICS
Hemostatics - Topical
$$$$ Thrombin THROMBIN
Prior Authorization Required
MISC. HEMATOLOGICAL
Antihemophilic Products
$$$$$ Antihemophilic Factor (Human) ALPHANATE
$$$$$ Antihemophilic Factor (Porcine) HYATE:C
$$$$$ Antihemophilic Factor (Recombinant) BIOCLATE
$$$$$ Antiinhibitor Coagulant Complex AUTOPLEX T
$$$$$ Antithrombin III (Human) THROMBAT III
Prior Authorization Required
Platelet Aggregation Inhibitors
$$$ Clopidogrel PLAVIX
Prior Authorization Required
Hematorheological
$$$ Pentoxifylline TRENTAL
Prior Authorization Required
XIV. BEHAVIORAL HEALTH AGENTS
Misc. Antianxiety
$$$ Droperidol INAPSINE
Prior Authorization Required
Phenothiazines
$$ Promazine SPARINE
MISC PSYCHOTHERAPEUTIC
Smoking Deterrents
$$$$ Nicotine HABITROL, NICOTROL, PROSTEP
NICODERM, NICODERM CQ
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Misc Psychotherapeutic
$ Disulfiram* ANTABUSE
$$$$ Donepezil ARICEPT
Prior Authorization Required
ANTICONVULSANT
Misc. Anticonvulsants
$$ Carbamazepine* TEGRETOL
Primidone MYSOLINE
$$$$ Gabapentin NEURONTIN
$$$$ Lamotrigine LAMICTAL
$$$$ Topiramate TOPAMAX
Prior Authorization Required
XV. TOPICAL AGENTS
OPHTHALMIC
Antibiotics
$ Bacitracin* AK-TRACIN
$ Chloramphenicol CHLOROPTIC
$ Erythromycin* ILOTYCIN
$ Gentamicin Sulfate* GARAMYCIN
$$ Ciprofloxacin CILOXAN
$$$$ Gatifloxacin ZYMAR
Prior Authorization Required unless trial with Cipro
Anti Allergic
$$$ Levocabastine LIVOSTIN
$$$ Lodoxamine ALOMIDE
$$$ Olopatadine PATANOL
Sulfonamides
$ Sodium Sulfacetamide* SULAMYD
Antivirals
$ Vidarabine VIRA-A
$$$ Idoxuridine HERPLEX
$$$ Trifluridine VIROPTIC
Antiinfective Combinations
$ Bacitracin-Polymyxin B* POLYSPORIN
$ Neomycin-Bac Zn-Polymyxin* NEOSPORIN
$ Neomycin-Polymy-Gramicidin* AK-SPORE
Beta-Blockers
$$ Metipranolol OPTIPRANOLOL
$$ Timolol BETIMOL, TIMOPTIC no XE
$$$ Betaxolol BETOPTIC,BETOPTIC S
Steroids
$ Dexamethasone* DECADRON
$$ Prednisolone Acetate* PRED FORTE, MILD
Steroid Combinations
$ Bacitracin-Polymyxin-Neomycin-HC AK-SPORE HC
$ Neomycin-Dexamethasone* NEO-DECADRON
21
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
$ Neomycin-Polymyxin-Dexamethasone* MAXITROL
$ Neomycin-Polymyxin-HC CORTISPORIN
$ Sulfacetamide Sod-Prednisolone VASOCIDIN
Cycloplegics
$ Atropine Sulfate* ISOPTO ATROPINE
Decongestants
$ Naphazoline* VASOCON
$ Phenylephrine* MYDFRIN
Ophthalmic NSAID's
$$ Flurbiprofen OCUFEN
Miotics - Direct Acting
$ Pilocarpine* ISOPTO-CARPINE no Ocusert
Miotics - Cholinesterase Inhibitors
$ Demecarium Bromide HUMORSOL
$ Physostigmine Sulfate ESERINE
$$ Echothiophate Iodide PHOSPHOLINE
Adrenergic Agents
$$ Dipivefrin* PROPINE
Prostaglandins
$$$ Latanoprost XALATAN
Prior Authorization Required
Carbonic Anhydrase Inhibitors
$$ Dorzolamide TRUSOPT
Prior Authorization Required
OTIC
Steroids
$ Hydrocortisone w/Acetic Acid* VOSOL-HC
Miscellaneous
$ Acetic Acid in Propylene Glycol* VOSOL
Antibiotics & Steroid-Antibiotic Combinations
$ Neomycin-Polymyxin-HC* CORTISPORIN
$$ Chloramphenicol CHLOROMYCETIN
$$ Polymyxin B-HC OTOBIOTIC
Antibiotics
$$$ Ofloxacin FLOXIN
Anti Infective
$ Carbamide Peroxide DEBROX
Analgesic Combinations
$$$ Benzocaine & Antipyrine* AURALGAN
22
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
MOUTH & THROAT (Local)
Antiinfectives - Throat
$ Clotrimazole* MYCELEX TROCHE
$ Nystatin* NYSTATIN
ANORECTAL
Rectal Steroids
$ Hydrocortisone ANUSOL-HC 2.5% cream
$$ Hydrocortisone PROCTOCREAM 2.5% cream
DERMATOLOGICAL
Antibiotics - Topical
$ Bacitracin* BACITRACIN OTC product
$ Gentamicin Sulfate* GARAMYCIN
$ Neomycin Sulfate* NEOMYCIN
$$ Mupirocin BACTROBAN
Antibiotic Mixtures Topical
$ Neomycin-Bacitracin-Polymyxin* NEOSPORIN OTC product
Antibiotic Steroid Combinations
$ Neomycin-Dexamethasone NEO-DECADRON
$ Neomycin-Polymyxin-HC CORTISPORIN
Imidazole-Related Antifungals (Topical)
$ Miconazole* MONISTAT OTC product
$$ Clotrimazole* LOTRIMIN OTC product
$$ Metronidazole METROGEL
Antifungals
$$ Nystatin* NYSTATIN no powder
Antifungals - Topical Combinations
$ Nystatin-Triamcinolone* MYCOLOG II
Antipsoriatics
$$$ Calcipotriene DOVONEX
Antiseborrheic Products
$ Sulfacetamide Sodium SODIUM SULAMYD
Burn Products
$ Silver Sulfadiazine* SILVADENE
Tar Products
23
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
$ Coal Tar COAL TAR SHAMPOO 1% only
Enzymes - Topical
$$ Collagenase SANTYL
Enzyme Mixtures-Topical
$ Chloramphenicol w/ Fibrinolysin &
Desoxyribonuclease ELASE-CHLOROMYCETIN
$ Fibrinolysin & Desoxyribonuclease ELASE
Keratolytics/Antimitotics
$$$ Podofilox CONDYLOX
Local Anesthetics - Topical
$ Lidocaine viscous* XYLOCAINE VISCOUS
Scabicides & Pediculocides
$ Lindane* KWELL
$$ Permethrin* ELIMITE
$$ Permethrin* NIX OTC product
Misc. Topical
$$$ Fluorouracil* EFUDEX
$$$ Pimecrolimus ELIDEL
Antiviral Topical
$$ Acyclovir ZOVIRAX
Prior Authorization Required
Corticosteroids - Topical
$ Betamethasone Dipropionate* DIPROSONE
$ Betamethasone Valerate* VALISONE
$ Desonide* DESOWEN
$ Fluocinonide Acetonide* SYNALAR
$ Hydrocortisone* HYTONE OTC product
$ Triamcinolone Acetonide in Orabase* KENALOG / ORABASE
$ Triamcinolone Acetonide* KENALOG
$$ Clobetasol Propionate TEMOVATE
$$ Dexamethasone DECADRON
$$ Fluocinonide* LIDEX
Acne Products
$$$ Tretinoin RETIN-A Ages 0-21 only
Acne Antibiotics
$$ Clindamycin Phosphate CLEOCIN GEL
$$ Erythromycin Gel AKNE-MYCIN
XVI. MISCELLANEOUS PRODUCTS
ANTIDOTES
$ Ipecac* IPECAC OTC product
DIAGNOSTIC PRODUCTS
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BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name Brand Name Annotation
Diagnostic Reagents
$ Acetone Tablets ACETEST
$ Acetone Test* KETOSTIX
$ Glucose Urine Test* CLINITEST
$$ Glucose Blood* GLUCOFILM
Radiographic Contrast Media Iodinated
$ Iopanoic Acid TELEPAQUE
MEDICAL DEVICES
Parenteral Therapy Supplies
$ Disposable Needles & Syringes* B-D INSULIN SYRINGE
Diabetic Supplies
$ Calibration Solution CALIBRATION SOLUTION
$ Lancet Device HYPOLET
$ Lancets LANCETS
$$ Blood Glucose Monitoring Tests* GLUCOMETER
Misc. Devices
$ Alcohol Swabs* ALCOHOL PADS
CONTRACEPTIVES
$ Condoms
ASSORTED CLASSES
Chelating Agents
$$$ Penicillamine CUPRIMINE
$$$$ Succimer CHEMET
Prior Authorization Required
Immunosuppressive Agents
$$$$$ Cyclosporine SANDIMMUNE
$$$$$ Cyclosporine Microsize NEORAL
$$$$$ Mycophenolate Sodium MYFORTIC
Inosine Monophosphate Dehydrogenase Inhibitors
$$$$$ Mycophenolate Mofetil CELLCEPT
Purine Analogs
$$$$ Azathioprine IMURAN
K Removing Resin
$$$$ Sodium Polystyrene Sulfonate KAYEXALATE
25