Prescription Drug Formulary by HC12073008550

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									Procare Formulary #3744                                                                                                           Rev. 7-09
                                                                                                                                                     THIRD TIER
                                               FIRST TIER (GENERICS)                         SECOND TIER (PREFERRED)                           (NON- PREFERRED)
                                                                                                                                              list is not all-inclusive
ALLERGY / COUGH-COLD
Antihistamines/Decongestants          brompheniramine/combo,                          None                                        Atarax, Bromfed/PD/SR, Conex, Durahist
                                      carbinoxamine/combo, cyproheptadine,                                                        PE, Rondec, Rynatan/Ped. Susp, Trinalin,
                                      hydroxyzine HCl/Pamoate, generic                                                            Vistaril, Histex IE, Semprex-D, Allegra/D
                                      Rynatan-S, generic Phergan/VC,                                                              24hr/180, Clarinex/D, Clarinex Redi-tab,
                                      fexofenadine, others,                                                                       Lodrane/D, PolyHist DM, Pediatex, J-Tan,
                                                                                                                                  Nasop, Ahist, Qdall AR, Durahist-D, Brovex
                                                                                                                                  SR,Xyzal


Expectorant/Cough Products            benzonatate, generic Hycodan, generic   none                                                Atuss HD/HX, Analplex DMX, Duratuss,
                                      Novahistine DH, guaifenesin/codeine                                                         Entex LA, Humibid DM/LA, Hycodan,
                                      combinations,                                                                               Monteflu HC, Novahistine/DH,
                                      guaifenesin/pseudoephedrine                                                                 Phenergan/Codeine/DM/VC,
                                      combinations, promethazine combinations                                                     Rondec/DM/TR, Tessalon, Tussionex,
                                                                                                                                  Tusso-HC
Mucolytic Agents                      acetylcysteine                                  none                                        Mucomyst
Nasal Medications                     flunisolide spray, fluticasone nasal            Astelin, Nasonex                            Atrovent Nasal, Beconase AQ, Flonase,
                                      ipratropium spray                                                                           Omnaris, Nasacort AQ, Nasarel,
                                                                                                                                  Nasalide,Patanase, Rhinocort AQ, Tri-
                                                                                                                                  Nasal,Veramyst
ALZHEIMER
                                      galantamine                                     Aricept, Aricept-ODT, Exelon, Namenda       Cognex, Exelon Patches, Razadyne

BLADDER / URINARY
Acidifiers                            none                                            K-Phos                                      none
Alkalinizers                          generic Bicitra, generic Polycitra/LC/K         none                                        Bicitra, Polycitra/LC/K, Urocit-K, Oracit
Analgesics                            phenazopyridine                                 none                                        Pyridium
Anticholinergics                      oxybutynin/ER                                   Detrol /LA,Vesicare                         Ditropan/XL, Oxytrol, Sanctura/XR, Enablex

Cholinergics                          bethanechol                                     Urecholine                                  none
Misc. Urinary agents                  flavoxate                                       Elmiron                                     Urispas
BLOOD PRODUCTS
Anticoagulants/Antithrombotics        dipyridamole, warfarin, heparin, ticlopidine, Aggrenox, Arixtra, Coumadin, Lovenox,         Agrylin, Ticlid, Persantine, Fragmin*
                                      anagrelide, clopidogrel                       Plavix
Other Blood Modifiers                 pentoxifylline, cilostazol                    Aranesp*, Epogen*, Procrit*                   Pletal, Trental, Actimmue*, Neulasta*,
                                                                                                                                  Neupogen*,
CANCER DRUGS
(restrictions or prior approval may   generics                                        FDA-indicated brands (no generic            FDA-indicated brands (generic available)
apply)                                                                                available)
CARDIOVASCULAR
ACE Inhibitors                        benazepril, captopril, enalapril, lisinopril,   none                                        Aceon, Accupril, Altace,Capoten, Lotensin,
                                      fosinopril, moexipril, quinapril,                                                           Mavik, Monopril, Prinivil, Zestril, Vasotec,
                                      ramipril,trandolapril                                                                       Univasc
Angiotensin II Antagonists            none                                            Cozaar,Diovan                               Avapro, Benicar, Micardis, Teveten,
                                                                                                                                  Atacand,
Anti-Adrenergic, Cental Acting        clonidine, methyldopa, guanfacine               none                                        Aldomet, Catapres, Catapres TTS Patch,
                                                                                                                                  Dibenzyline
Anti-Adrenergic, Peripheral           doxazosin, terazosin, prazosin                  none                                        Cardura/Cardura-XL, Hytrin, Minipress
Antiarrhythmics                       amiodarone, digoxin, disopyramide/SR,           Lanoxin, Pacerone                           Betapace/AF, Cordarone, Ethmozine,
                                      flecainide, mexiletine, procainamide/SR,                                                    Mexitil, Norpace/CR, Procanbid, Pronestyl,
                                      propafenone, quindine/gluconate/sulfate,                                                    Rythmol, Tambocor, Tonocard, Tikosyn
                                      sotalol
Antilipidemics                        cholestyramine, colestipol, fenofibrate,        Crestor, Lipitor, Lovaza,Niaspan, Tricor,   Advicor, Antara, Colestid, Pravachol,
                                      gemfibrozil, lovastatin, pravastatin,           Welchol, Zetia                              Altoprev, Lescol/XL, Lofibra, Lopid,
                                      simvastatin                                                                                 Mevacor, Questran, Simcor, Triglide,
                                                                                                                                  Vytorin, Zocor
Beta-Blockers                         acebutolol, atenolol, betaxolol,carvedilol,     CoregCR, Innopran XL                        Inderal, Blocadren, Bystolic, Coreg,
                                      bisoprolol, labetalol, metoprolol/ER,                                                       Corgard, Kerlone, Inderal LA, Lopressor,
                                      nadolol, pindolol, propranolol/LA, timolol                                                  Tenormin, Toprol XL, Trandate, Normodyne,
                                                                                                                                  Zebeta
Calcium Channel Blockers              isradipine, nifedipine XL/CC, diltiazem  Sular                                              Plendil, Nimotop, Adalat CC, Calan/SR,
                                      SR/ER/XR/CD, nicardipine,                                                                   Cardene/SR, Cardizem/SR/CD/LA, Covera
                                      nimodipine,nisoldipine,verapamil/SR/XR/E                                                    HS, Dilacor XR, Dynacirc/CR, Procardia/XL,
                                      R/PM, felodipine, Amlodipine                                                                Tiazac, Verelan/PM, Norvasc


Renin Inhibitors                      none                                          Tekturna/HCT
                                                                                 Page 1 of 6                                      none
Procare Formulary #3744                                                                                                    Rev. 7-09
                                                                                                                                            THIRD TIER
                                               FIRST TIER (GENERICS)                      SECOND TIER (PREFERRED)                     (NON- PREFERRED)
                                                                                                                                     list is not all-inclusive
Diuretics                              acetazolamide, HCTZ,                                                                Aldactazide, Aldactone, Bumex, Inspra,
                                       eplerenone,spironolactone/HCTZ,                                                     Demadex, Diamox Sequels, Dyazide,
                                       spironolactone, bumetanide,                                                         Maxide, Moduretic, Lasix, Zaroxolyn, Lozol
                                       chlorthalidone, furosemide, indapamide,
                                       methazolamide, metolazone, torsemide,
                                       triamterene/HCTZ
Combination Anti-Hypertensive          amlodipine/benzazepril,atenolol/chlorthalid Caduet,Hyzaar, BiDil,Exforge,Diovan     Azor,Accuretic, Atacand HCT, Avalide,
                                       one, benzepril/HCTZ, bisoprolol/HCTZ,       HCT                                     Lotrel, Aldoril, Benicar HCT, Capozide,
                                       captopril/HCTZ, enalapril/HCTZ,                                                     Inderide, Lotensin HCT,
                                       fosinopril/HCTZ,                                                                    Lopresssor/HCT,Micardis HCT, Monopril
                                       hydralazine/reserpine/HCTZ,                                                         HCT, Prinzide, Tenoretic, Teveten HCT,
                                       lisinopril/HCTZ, methyldopa/HCTZ,                                                   Vaseretic, Zestoretic, Ziac
                                       propranolol/HCTZ, metoprolol/HCTZ,
                                       quinapril/HCTZ
Vasodialators                          hydralazine, isosorbide (various forms),    none                                    Deponit, Imdur, Isordil, Loniten, Minitran,
                                       nitroglycerin (various forms)                                                       NitroBid, NitroDur, Nitrostat SL, Ranexa,
                                                                                                                           Transderm-Nitro
DERMATOLOGIC
Acne (check with plan for coverage Amnesteem, sodium sulfacetamide/sulfur, Benzaclin, Differin, Duac                       Accutane, Avita, Benzamycin, Finacea,
guidelines)                        tretinoin cr/oint/gel, generic Benzamycin                                               Klaron, Retin-A cr/oint/gel/micro-gel,
                                   gel, generic Plexion cleanser, generic                                                  Sulfacet-R, Plexion cleanser, Tazorac
                                   Zoderm Cleanser, generic Klaron, Tretin-X                                               cr/gel, Triaz, Zoderm Cleanser



Antibiotic, Topical                    clindamycin (various forms), erythromycin Metrogel                                  Altabax, Bactroban cream/oint, Cleocin-T
                                       (various forms), gentamicin cr/oint,                                                (various forms), MetroCream, Metrolotion,
                                       metronidazole, mupirocin, silver                                                    Noritate, Silvadene, Evoclin
                                       sulfadiazine
Anti-Inflammatory Agents               betamethasone diprop., aug.                 Clobex Spray, Locoid                    Aclovate, Derma-Smoothe FS, Aristocort,
                                       betamethasone diprop., betamethasone                                                Capex Shampoo, Cordran Tape, Cutivate,
                                       valerate, clotrimazole/betamethasone,                                               Cyclocort, Dermatop, Desowen,
                                       clobetasol prop., desonide,                                                         Diprolene/AF, Diprosone, Elocon
                                       desoximetasone, fluocinonide,                                                       cr/oint/lotion, Halog, Hytone, Kenalog,
                                       fluocinolone, fluticasone, halobetasol,                                             Maxiflor, Lidex, Locoid, Lotrisone
                                       hydrocortisone 2.5%, hydrocortisone                                                 Cream/Lotion, Luxiq Foam, Olux, Psorcon,
                                       butyrate, hydrocortisone valerate,                                                  Synalar, Taclonex, Temovate, Topicort,
                                       mometasone, triamcinolone,                                                          Valisone, Westcort, Ultravate
                                       alclometasone ointment, prednicarbate


Anti-Psoriatics                        none                                        Dovonex, Elidel, Tazorac Gel            Drithocreme, Raptiva, Protoptic
Anti-Pruritics/ Anesthetics, Topical lidocaine oint/gel/cr/viscous, selenium sulf. none                                    Selsun Rx, Xylocaine oint/gel/soln/viscous
                                     2.5% shampoo
Anti-Virals, Topical                 none                                          Zovirax oint                            Denavir oint
Depigmentation                       hydroquinone                                  none                                    Claripel, Eldoquin/Forte, Lustra/AF,
                                                                                                                           Solaquin/Forte, Epiquin
Psoralens                              none                                        none                                    Oxsoralen / Ultra, 8-MOP
Misc. Topicals                         sodium chloride irrigation soln.,           Aldara                                  Oxistat, Spectazole, Regencare Condylox,
                                       fluorouracil cream, ketoconazole                                                    Efudex, Fluoroplex, Regranex, Elimite,
                                       cr/shampoo, nystatin cr, econazole cr.,                                             Loprox, Carmol cream/lotion,
                                       Acticin, urea cream/lotion, ciclopirox                                              Penlac,Nizoral,PShampoo, Nuox


DIABETES
Anti-Diabetic Agents                   none                                        Apidra, Byetta, Humalog, Humulin (all
                                                                                   types), Lantus, Levemir, Novolin (all
                                                                                   types),Novolog, Glucagon, Symlin
Anti-Diabetic Agents, Oral             glipizide/ER, metformin/ER,                 Actos, Actosplus Met,Avandia,           Amaryl, Diabeta, Diabenese,
                                       glyburide/micronized, glimepiride,          Avandamet, Avandaryl, Duetact,Glyset,   Glucophage/XR, Glucotrol/XL, Glumetza,
                                       metformin/glipizide                         Januvia, Prandin, Starlix,Janumet       Glynase, Glucovance, Metaglip, Micronase,
                                                                                                                           Prandimet, Precose, Riomet soln., Fortamet

EAR
Anti-Infective Agents              generic VoSol,ofloxacin otic             none                                           VoSol,Floxin otic
Anti-Infective/Anti-Inflamm.Combo. generic Cortisporin Otic, generic VoSol   Ciprodex                                      Cipro HC, Cortisporin Otic, VoSol HC, Zoto
                                   HC otic                                                                                 HC
Local Anesthetic/Analgesic         generic Auralgan                         none                                           Auralgan
ELECTROLYTES
Potassium Agents                   potassium chloride (various forms)    Page 2 of 6                                       K-Dur, Slow-K, Micro-K, K-Lyte, K-Lor,
                                                                                                                           others
Procare Formulary #3744                                                                                                 Rev. 7-09
                                                                                                                                        THIRD TIER
                                            FIRST TIER (GENERICS)                       SECOND TIER (PREFERRED)                   (NON- PREFERRED)
                                                                                                                                 list is not all-inclusive
Potassium/Phosphate Removal         SPS                                          Phoslo, Renagel, Fosrenol, Fosrenol    Kayexalate,Renvela
                                                                                 Chewable
EYE
Anesthetics                         proparacaine, tetracaine                     none                                   Alcaine, Pontocaine
Anti-Allergy                        cromolyn, ketotifen                          Optivar, Patanol                       Alomide, Livostin, Opticrom
Anti-Infective                      bacitracin, chloramphenicol, ciprofloxacin                                          Chloroptic, Ciloxan, Ocuflox, Polytrim,
                                    opth soln., erythromycin, gentamycin,                                               Vigamox, Zymar, Tobrex Oin't/Soln., Bleph
                                    generic Neosporin, generic Polytrim,                                                10, Quixin
                                    sulfacetamide sod. 10%, tobramycin,
                                    ciprofloxacin opth., ofloxacin opth.


Anti-Inflammatory                  dexamethasone,                            FML Forte / S.O.P.                         Decadron, FML/S, Flarex, Inflamase Forte,
                                   diclofenac,fluorometholone, prednisolone,                                            Maxidex, Pred Forte, Pred Mild, Ocufen,
Anti-Infective/Anti-Inflamm.Combo. prednisolone sod. phos
                                   Dexacidin, sulfacetamide/prednisolone,    Tobradex                                   Voltaren Cortisporin Opth., Maxitrol,
                                                                                                                        Pred-G,
                                   dexamethasone/neomycin                                                               NeoDecadron, Vasocidin

Anti-Viral                          trifluridine                                 none                                   Viroptic
Beta-Blockers                       betaxolol, levobunolol, metipranolol,        Betoptic-S                             Betagan, Combigan,Optipranolol,
                                    timolol/XE                                                                          Timoptic/XE
Carbonic Anhydrase Inhibitors       Dorzolamide, Dorzolamide/timolol             Azopt                                  Trusopt, Cosopt
Miotics                             pilocarpine                                  Isopto-Carbachol (all strengths)       Mydriacyl, Phospholine Iodide
NSAID's                             flurbiprofen                                 none                                   Acular/LS, Ocufen, Voltaren, Xibrom
Prostaglandin Analogues             none                                         Xalatan, Lumigan                       Travatan
Miscellaneous                       brimonidine, dipivefrin                      Alphagan-P                             Alphagan, Restasis, Propine, Rescula
GASTROINTESTINAL
Anorectal                           hydrocortisone enema/supp/cream,             Cortifoam                              Proctocort, Proctofoam, Anusol cream/supp,
                                    pramoxine                                                                           Rectagel HC
Anti-Diarrheal                      diphenoxylate/atropine                       none                                   Lomotil, Alinia
H2 Antagonists                      cimetidine, nizatidine, ranitidine/ Syrup,                                          Tagamet, Axid/Liquid, Zantac/ Syrup,
                                    famotidine                                                                          Pepcid
Proton Pump Inhibitors (quantity    omeprazole, pantoprazole, Prilosec OTC       Nexium, Prevacid                       Aciphex, Prilosec, Protonix, Zegerid
limits may apply)
Other Antiulcer                     misoprostol, sucralfate, proprantheline      none                                   Prevpac, Carafate, Cytotec, Helidac,
                                                                                                                        Probanthine
Antiemtic/Antivertigo               meclizine, ondansetron,                      Emend                                  Antivert, Aloxi,Transderm-Scop,
                                    dronabinol,granisetron,prochlorperazine,                                            Anzemet*,Cesamet, Compazine, *, Kytril*,
                                    promethazine, trimethobenazmide/supp                                                Marinol,Phenergan/supp, Tigan/supp,
                                                                                                                        Zofran
Antispasmotic/GI Motility           dicyclomine/solution, metoclopramide,        none                                   Bentyl/Syrup, Donnatal, Levsin, Levsinex,
                                    chlordiazepoxide/clin, hyoscyamine/CR,                                              Librax, Reglan, Symax Duotab, Nulev
                                    belladonna/phenobarb

Bowel Evacuants                     peg 3350/electrolytes                        Nulytely, Half-                        Amitiza, Colyte
                                                                                 Lytely,Golytely,Moviprep,Osmoprep,
                                                                                 Visicol
Digestants                          generic pancrelipase                         Creon, Digex, Pancrease (all forms),   Kutrase, Ku-Zyme/HP, Viokase
                                                                                 Panokase, Ultrase (all forms)
Gallstone Agents                    ursodiol                                     Urso                                   Actigall
Other GI Products                   balsalazide, lactulose, sulfasalazine/EC,    Entocort, Asacol, Canasa Supp.,        Azulfidine/EN,Lialda, Enulose, Lotronex,
                                    mesalamine enema, peg 3350                   Dipentum, Pentasa                      Colazal, Miralax, Rowasa

GOUT
                                    allopurinol, colchicine,                     none                                   Indocin, Zyloprim, Benemid, Col-benemid
                                    colchicine/probenecid, indomethacin
HIV-ANTI-VIRALS
(medications may require prior      generics                                     FDA-indicated brands (no generic       FDA-indicated brands (generic available)
approval)                                                                        available)
INFECTION
Amebecides                          metronidazole                                none                                   Flagyl/ER
Antihelmintics                      mebendazole                                  Mintezol                               Vermox




                                                                              Page 3 of 6
Procare Formulary #3744                                                                                                    Rev. 7-09
                                                                                                                                            THIRD TIER
                                            FIRST TIER (GENERICS)                        SECOND TIER (PREFERRED)                      (NON- PREFERRED)
                                                                                                                                     list is not all-inclusive
Antibiotics                         amoxicillin, ampicillin, generic              Augmentin/XR/ES, Cleocin 75, Gantrisin   Adoxa, Avelox, Biaxin/XL, PCE, Bactrim/DS,
                                    Augmentin/ES, azithromycin,                   Susp, Ketek, Levaquin, Lorabid Susp      Ceclor, Ceftin Cefzil, Cipro/XR, Cleocin,
                                    cefaclor,cefdinir, cefpodoxime, cefprozil,                                             Dispermox, Doryx, Doryx DR, Duricef,
                                    cefuroxime, cephalexin, clarithromycin,                                                Dynacin, Eryc, Eryped Chew, Ery-Tab,
                                    clindamycin, dicloxacillin, doxycycline,                                               Fexmid, Floxin, Keflex, Lorabid Caps,
                                    erythromycins, minocycline, generic                                                    Maxaquin, Minocin, Monodox, Noroxin,
                                    Pediazole, penicillin VK,                                                              Omnicef,Oracea, Pediazole, Periostat,
                                    sulfameth/trimethoprim, sulfisoxazole,                                                 Septra/DS, Spectracef, Tequin, Vantin,
                                    tetracycline, ciprofloxacin/XR, cefadroxil,                                            Vibramycin, Zagam, Zithromax Tab, Zmax
                                    ofloxacin


Antifungals                         griseofulvin, ketoconazole, nystatin,         Vfend                                    Ancoban, Mycostatin, Nizoral, Diflucan,
                                    fluconazole,terbinafine                                                                Gris-Peg, Lamisil*, Sporonax*
Other Anti-Infectives               methenamine combinations, nitrofurantoin, Mepron, NebuPent                             Dapsone, Flagyl/ER, Furadantin, Macrobid,
                                    metronidazole, neomycin, trimethoprim                                                  Macrodantin, Tindamax, Trimpex, Urised,
                                                                                                                           Vancocin, Zyvox*
Anti-Malarials                      chloroquine, hydroxychloroquine, quinine                                               Aralen, Daraprim, Lariam, Malarone,
                                    sulfate, mefloquine                                                                    Plaquenil, Primaquine
Anti-Tuberculosis                   isoniazid, isonarif, pyrazinamide, rifampin, Mycobutin, Rifater                        Myambutol, Rifadrin, Rifamate
                                    ethambutol
Anti-Virals                         amantadine, acyclovir (oral),                Copegus*, Cytovene, Epivir, Pegasys,      Baraclude, Hepsera*, Famvir, PegIntron*,
                                    famciclovir,rimantidine, ribavirin           Tamiflu, Tyzeka, Valtrex                  Rebetrol*, Symmetrel, ,Zovirax (oral), Intron-
                                                                                                                           A, Infergen, Relenza, Flumadine

Misc. Immune System                 azathioprine, cyclosporine                    Cellcept, Prograf, Rapamune              Imuran, Myfortic,Neoral, Sandimmune,
                                                                                                                           Sandostatin
MEN'S HEALTH
Hormone Therapy                     testosterone                                  Androderm Patch, Androgel                Android, Testim, Striant, Depo-Testosterone

Impotence (check with plan for      none                                          Viagra*                                  Muse*, Edex*, Cialis*, Caverject*, Levitra*
coverage guidelines)
Prostate Health                     flutamide, finasteride                        Avodart, Flomax                          Casodex, Eulexin, Proscar, Uroxatral
MENTAL HEALTH
Anxiolytics, Sedatives, Hypnotics   alprazolam/ER, buspirone, chloral hydrate, Ambien CR                                   Ambien, Ativan, Buspar, Dalmane, Halcion,
                                    chlordiazepoxide, clorazepate, lorazepam,                                              Librium, Lunesta, Miltown, Niravam,
                                    diazepam, flurazepam, meprobamate,                                                     Restoril, Rozerem, Serax, Somnote,
                                    oxazepam, temazepam,                                                                   Sonata, Tranxene, Valium, Xanax/XR
                                    triazolam,zaleplon,zolpidem
Cerebral Stimulants                 generic Adderal, generic Dexedrine/SR, Adderall XR,Concerta, Strattera,Vyvanse Adderall, Metadate CD, Provigil,Metadate
                                    dexmethylphendidate,methylphenidate/SR                                         ER, Ritalin LA, Daytrana, Dexedrine, Cylert,
                                    , pemoline                                                                     Focalin/XR

Muscle Stimulants                   pyridostigmine bromide                      Mestinon
Antidepressants                     amitriptyiline, amitriptyline/perphenazine, Cymbalta, Effexor XR, Lexapro, Pristiq,    Anafranil, Celexa, Desyrel, Effexor, Elavil,
                                    amoxapine, bupropion/SR/XL, citalopram, Venlafaxine XR                                 EMSAM, Nardil, Norpramin, Pamelor,
                                    clomipramine, desipramine, doxepin,                                                    Parnate, Paxil/CR, Pexeva, Prozac Weekly,
                                    fluoxetine, fluvoxamine, imipramine,                                                   Remeron/Sol-Tab, Sarafem, Serzone,
                                    mirtazapine, nefazodone, nortriptyline,                                                Sinequan, Surmontil, Symbyax, Tofranil/PM,
                                    paroxetine/ER, sertraline, tranylcypromine,                                            Triavil, Vivactil, Wellbutrin/SR/XL, Zoloft
                                    trazodone, trimipramine, venlafaxine



Antipsychotics                      chlorpromazine, clozapine, fluphenazine,      Abilify, Geodon, Seroquel/XR,            Clozaril, Risperdal, Serentil, others
                                    haloperidol, perphenazine,                    Zyprexa/Zydis
                                    risperidone,thioridazine, thiothixene,
                                    trifluoperazine


Antimania Agents                    lithium carbonate reg and SR) 150mg,          Carbatrol                                Equetro, Eskalith/CR, Lithobid
                                    300mg, 600mg
MULTIPLE SCLEROSIS
                                    none                                          none                                     Avonex*, Betaseron*, Copaxone*, Rebif*
MUSCLE RELAXANTS
                                    baclofen, carisoprodol/ASA,                                                            Amrix,Dantrium, Flexeril,Fexmid, Parafon
                                    cyclobenzaprine, dantrolene, diazepam,                                                 Forte, Robaxin, Skelaxin, Soma/Compound,
                                    methocarbamol/ASA, chlorzoxazone,                                                      Valium, Zanaflex Tab/Cap
                                    tizantidine
                                                                             Page 4 of 6
OSTEOPOROSIS
Procare Formulary #3744                                                                                                       Rev. 7-09
                                                                                                                                                THIRD TIER
                                             FIRST TIER (GENERICS)                       SECOND TIER (PREFERRED)                          (NON- PREFERRED)
                                                                                                                                         list is not all-inclusive
                                     etidronate,alendronate                       Actonel Actonel                             Didronel, Forteo*, Fortical, Fosamax,
                                                                                  w/Calcium,Boniva,Fosamax-D, Evista          Miacalcin, Skelid
PAIN RELIEF
Analgesics, Narcotic                 ASA/codeine, APAP/codeine,               Oxycontin                                       Actiq, Kadian, Avinza, B&O supprettes,
                                     belladona&opium supp., butalbital/ASA                                                    Darvocet-N, Darvon-N, Darvon Cmpd.,
                                     combinations, butalbital/APAP/codeine,                                                   Darvon, Darvon-65, Demerol, Dilaudid,
                                     butorphanol nasal, hydrocodone                                                           Duragesic, Fentora, Fiorinal/Codeine,
                                     combinations, fentanyl, hydromorphone,                                                   Fioricet/Codeine, Lagesic, Lortab, Lorcet,
                                     merperidine, methadone, morphine IR/SR                                                   MS Contin, Percocet, Percodan, Reprexain,
                                     cap, tab, soln., oxycodone combinations,                                                 Stadol NS, Talwin NX, Trycet, Tylenol
                                     propoxyphene combinations, generic                                                       w/codeine, Xodol, Viodin/ES/HP,
                                     Talwin NX, fentanyl transdermal, generic                                                 Vicoprofen, Norco, Combunox, Vopac
                                     Oxycontin


Analgesics, Salicylates              aspirin SR, choline mag. trisalicylate,      none                                        Dolobid, Trilisate, Easprin
                                     difluinsal, salsalate
COX - 2 Inhibitors (prior approval   none                                         none                                        Celebrex*
may apply)
Non-steroidal Anti-Inflammatory      diclofenac sodium and potassium/SA,          none                                        Anaprox/DS, Ansaid, Arthrotec, Cataflam,
                                     etodolacSA, fenoprofen, flubiprofen,                                                     Clinoril, Daypro, Feldene, Indocin,
                                     ibuprofen, indomethacin, ketoprofen,                                                     Lodine/XL, Mobic, Motrin, Naprosyn,
                                     ketorolac (qty restrictions),                                                            Oruvail, Prevacid NapraPac, Relafen,
                                     meclofenamate, mefenamic acid,                                                           Tolectin/DS, Toradol (qty restrictions),
                                     meloxicam, nabumetone, naproxen,                                                         Ultracet, Ultram, Ultram ER, Voltaren/XR
                                     oxaprozin, piroxicam, sulindac, tolmetin

Migraine (quantity restrictions may butalbital combinations, Sumatriptan,         Cafergot, Maxalt/MLT,                       Ergomar, Amerge, Axert, Fioricet, Fiorinal,
apply)                              tramadol, tramadol/APAP                       Migranal,Zomig/ZMT                          Frova, Imitrex, Midrin, Relpax, Treximet,

PARKINSON'S DISEASE
                                     amantadine, benztropine, bromocriptine,      Comtan, Mirapex                             Apokyn, Cogentin, Dostinex, Eldepryl,
                                     cabergoline, carbidopa/L-dopa,                                                           Parcopa, Parlodel, Requip/XL, Sinemet/CR,
                                     carbidopa/L-dopa SA, selegiline,                                                         Stalevo, Symmetrel, Tasmar, Dopar,
                                     ropinirole,trihexyphenidil                                                               Zelapar


RESPIRATORY / ALLERGY
Adrenergic                           none                                         Epipen/Jr.                                  none
Corticosteroids                      none                                         Advair,Asmanex, Azmacort, Flovent,           Aerobid/M/HFA,Alvesco
                                                                                  Pulmicort flexihaler/ Respules, Qvar,
                                                                                  Symbicort
Leukotrienes                         none                                         Singulair                                   Accolate, Zyflo/CR
Sypathomimetic                       albuterol tab,/syrup/inhaler/HFA,            Foradil, Perforomist, ProAir HFA,           Alupent, Brethine tab,, Brovana, Maxair,
                                     metoproterenol syrup, terbutaline            Proventil HFA, Serevent, Xopenex Inh        Proventil tab/soln/inhaler, Ventolin inhaler,
                                                                                  Sol'n                                       Xopenex HFA,Ventolin HFA, Volmax

Xanthine Derivatives                 theophylline/SR, tab, cap, soln              Theo-24, Uniphyl                            Theolair
Other agents                         cromolyn inh. soln., ipratropium inh.        Atrovent, Combivent, Intal, Spiriva         Atrovent Inh. Soln., DuoNeb, Pulmozyme,
                                     soln.,albuterol/ipratrop.inh.soln.                                                       Tilade,
RHEUMATOID ARTHRITIS
                                     hydroxychloroquine, methotrexate,            Humira*, Enbrel*, Kineret*                  Plaquenil, Arava, Cuprimine, Depen,
                                     leflunomide                                                                              Ridaura
SEIZURE
Barbiturates                         phenobarbital                                none                                        Mebaral
Hydantoins                           phenytoin                                    Dilantin
Succinimide Derivatives              ethosuximide                                 Zarontin                                    Celontin
Misc. Agents                         carbamazepine, clonazepam, gabapentin,       Depakote/ER, Felbatol, Gabitril, Tegretol   Depakene, Klonopin/Wafer, Keppra,
                                     levetiracetam, oxcarbazepine,primidone,      XR, Topamax, Keppra XR, Diastat Rectal      Lamictal, Lyrica, Mysoline,
                                     valproic acid, lamotrigine, zonisamide                                                   Neurontin,Tegretol, Trileptal, Zonegran
SMOKING CESSATION
(check with plan for coverage        generics                                     none                                        brands
guidelines)
STEROIDS
                                     cortisone, dexamethasone,                                                                Cortef , Decadron, Hydrocortone, Medrol ,
                                     hydrocortisone, methylprednisolone,                                                      Pediapred, Prelone syrup
                                     prednisolone, prednisone
THYROID
Thyroid Antagonist                   methimazole, propylthiouracil                none
                                                                               Page 5 of 6                                    Tapazole
Procare Formulary #3744                                                                                                    Rev. 7-09
                                                                                                                                            THIRD TIER
                                             FIRST TIER (GENERICS)                       SECOND TIER (PREFERRED)                      (NON- PREFERRED)
                                                                                                                                     list is not all-inclusive
Thyroid Hormone                      levothyroxine                                Synthroid, Levoxyl, Armour Thyroid,      Cytomel, Levothroid
                                                                                  Nature-Thyroid, Thyrolar
WEIGHT LOSS
(check with plan for coverage        phentermine*, diethylpropion*                none                                     Adipex-P*, Ionamin*, Meridia*, Xenical*,
guidelines)                                                                                                                Tenuate*
WOMEN'S HEALTH
Anti-Estrogens, etc.                 tamoxifen                                    Nolvadex                                 Arimidex, Femara
Fertililty Induction Agents (check   clomiphene*, serophene*, HCG*                Cetrotide, Follistim, Gonal-F            Novarel*, Antagon*, Menopur*, Bravelle*,
with plan for coverage guidelines)                                                                                         Fertinex*, Luveris*, Pergonal*, Repronex*,
                                                                                                                           Ovidrel*, Profasi/Pregnyl*, Clomid

Hormones                             estradiol, estropipate, generic              Alora, Cenestin, Climara/PRO,            Activella,Estratest/HS, Aygestin,
                                     activella,medroxyprogesterone,               Estraderm, Estring, Femhrt, Menest,      Combipatch, Crinone 8%, Esclim, Enjuvia,
                                     norethindrone                                Premarin, Prempro, Premphase,            Estrace/Vaginal Cream, Femring, Femtrace,
                                                                                  Prometrium, Vagifem, Vivelle , Synarel   Menostar, Ogen, Ortho-Est, Ortho-Prefest,
                                                                                                                           Provera, Estrasorb
Oral Contraceptives (check with      Apri, Aviane, Camila, Cryselle, Enpresse, Lybrel, Ortho Tri-Cyclen LO, Seasonique,    Alesse, Brevicon, Cyclessa, Demulen,
plan for coverage guidelines)        Junel, Kariva, Lessina, Levora, Low-       Yaz                                        Desogen,Estrostep FE, Levlen, Loestrin/FE,
                                     Ogestrel, Microgestin, Mononessa, Necon,                                              Lo/Ovral, Micronor, Mircette, Modicon,
                                     Nora-BE, Nor-QD, Nortrel,                                                             Nordette, Norinyl, Ortho-Cept, Ortho-Cyclen,
                                     Ocella,Ogestrel, Portia, Previfem, Solia,                                             Ortho-Novum, Ortho Tri-Cyclen, Ovcon-
                                     Sprintec, Trivora, Trinessa, Tri-Sprintec,                                            35/50, Tri-Levlen, Seasonale, Tri-Norinyl,
                                     Tri-legest FE,Velivet, Zovia, others                                                  Triphasil,Yasmin, others


Misc. Contraceptives (check with     generic Depo-Provera                         Ortho-Evra, Nuvaring                     Depo-Provera, Lunelle
plan for coverage guidelines)

Oxytocic Agents                      pitocin                                                                               Methergine, Oxytocin
Vaginal Preparations                 miconazole vag. Supp, nystatin vag. Tab,     Gynazole-1                               Amino-Cerv, Cleocin Vag/Ovules,
                                     triple sulfa vag. cr., terconazole vaginal                                            Clindesse, Monistat Supp., Metrogel
                                     cream, Vandazole                                                                      Vaginal, Mycostatin Vag Tabs, Terazol-3,
                                                                                                                           Terazol-7/supp.
MISCELLANEOUS
Misc. Central Nervous System         naltrexone                                   Antabuse, Rilutek                        Revia, Subtex, Campral
Growth Hormone                       none                                         Humatrope,Nutropin/AQ                    Genotropin,Norditropin,Omnitrope,
                                                                                                                           Saizen,Zorbtive
Misc. Endocrine Agents               danazol, fludrocortisone, desmopressin       Stimate                                  DDAVP tablets, Danocrine, Florinef,
                                     nasal soln./tabs                                                                      Cortrosyn, Synarel*, Sensipar
Pulmonary Arterial Hypertension      none                                       none                                       Ventavis,Remodulin,Letairis,Tracleer,
(PAH)                                                                                                                      Revatio
Sialogogues                           pilocarpine tabs                          Evoxac                                     Salagen
Misc.                                                                                                                      Megace ES
* = indicates medication may require prior approval/authorization, check with plan for coverage guidelines
Medications Eligible for Half-Tablet Program Include (and generic forms of): Citalopram,Cozaar,Crestor,Diovan,Lexapro,Lipitor,Paroxetine,Metoprolol
Citalopram,Cozaar,Crestor,Diovan,Lexapro,Lipitor,Paroxetine,Metoprolol ER,Sertaline,and Simvastatin.
This list is to be used as a guide only. The inclusion of a medication on this list does not guarantee coverage as plan specifications may vary. New generic
medications may become available between formulary updates, resulting in a shift in the corresponding brand name drug. Specific questions on a particular drug or
co-payment should be directed to the ProAct Helpdesk. Brand name drugs not listed are considered 3rd Tier.




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