CMDP Preferred Medications List by amd51223

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2008 CMDP Preferred Medication List—Medication Categories Guide
Effective March 2008


About Your Preferred Medication List (PML)                 Medications Not Found on This Guide
This preferred medication list (also sometimes             Due to space limitations, not all medications on the
referred to as a formulary) is a list of medications       PML could be listed on this Guide. If you are unable
preferred by CMDP. When your doctor prescribes             to locate your medication on this list, please
medications from this list, it can help you make           remember the following:
the most of your pharmacy plan benefits and control        • Most generic medications are preferred by
prescription medication costs. All the medications            CMDP.
on the PML have received U.S. Food and Drug                • For easy reference, when a medication is used to
Administration (FDA) approval as safe and                     treat more than one condition, it usually will be
effective. A committee of doctors and pharmacists             listed under only one category. Check different
has chosen all medications on this list. Medications          categories for your medication.
that are experimental and/or investigational               • CMDP covers all medications when your provider
in nature are not covered.                                    documents medical necessity.
                                                           • Please bring this PML with you when you visit
How to Use This Medication Categories Guide                   your primary care provider.
Use this Guide to locate brand and generic
medication alternatives that are covered under the         Medications Not Covered
CMDP plan. Share this Guide with your doctor,              • Medications not FDA approved or not FDA
and encourage him or her to authorize a generic              approved for the condition, dose, route and
alternative for you or your child in foster care,            frequency for which they are prescribed are not
whenever appropriate.                                        covered by CMDP.
                                                           • Medications that are experimental and/or
What medications require prior                               investigational in nature.
authorizations?                                            • Medications prescribed by the Regional
Some medications or classes require prior                    Behavioral Health Authorities (RBHA).
authorization before they are used and/or have
a limited quantity allowed associated with them.           For More Information About this Guide
These medications or classes are marked in                 This Guide may change to reflect current medication
the guide by a star (*) to alert you.                      availability and coverage and is updated regularly to
                                                           reflect important changes.
Please note: For assistance with prior
authorization, please contact the CMDP                     Please note: For questions and assistance,
Prior Authorization nurse at 602-351-2245 or               please contact Member Services at 602-351-2245
1-800-201-1795 (toll free outside Maricopa                 or 1-800-201-1795 (toll free outside of Maricopa
County).                                                   County).


See reverse for Americans with
Disabilities Act (ADA) Disclosure.                                                                     CS5505D-0907
CMDP 2008 Preferred Medication List                                                Medication Categories Guide
Effective March 2008                                                                                    Page 2

 Equal Opportunity Employer Program. Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI
 & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of
 1973, and the Age Discrimination Act of 1975, the Department prohibits discrimination in admissions,
 programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
 and disability. The Department must make a reasonable accommodation to allow a person with a
 disability to take part in a program, service, or activity. For example, this means that if necessary, the
 Department must provide sign language interpreters for people who are deaf, a wheelchair accessible
 location, or enlarged print materials. It also means that the Department will take any other
 reasonable action that allows you to take part in and understand a program or activity, including
 making reasonable changes to an activity. If you believe that you will not be able to understand or
 take part in a program or activity because of your disability, please let us know of your disability
 needs in advance if at all possible. To request this document in alternative format or for further
 information about this policy, contact Member Services (602) 351-2245 or 1-800-201-1795. TTY/TTD
 Services: 7-1-1. Empleador/Programa con Igualdad de Oportunidades. Para obtener este
 documento en otro formato, comuníquese con Servicios para Miembros al 602.351.2245 o al
 1-800-201-1795.
CMDP 2008 Preferred Medication List                                                                                         Medication Categories Guide
Effective March 2008                                                                                                                                      Page 3

   ANTIASTHMATICS                    ANTI-INFECTIVES                       Injectables          BLOOD FORMATION                   Angiotensin Receptor
      AND COPD                                                 generic                          AND COAGULATION                     Blocker (ARBs)
                                     Antifungal Agents         ceftriaxone sodium                                                    Combinations
                                  generic                                                          Anticoagulants               BRAND
Spacers, peak flow meters, and
                                  fluconazole                  Intravaginal Antibiotics       generic                           AVALIDE
small volume nebulizers ordered
                                  fluconazole 150mg*                                          warfarin [Jantoven]               BENICAR HCT
by your provider are a covered                                 generic
                                  itraconazole                                                                                  HYZAAR
benefit through Walgreens                                      terconazole 0.8% vaginal       BRAND
                                  ketoconazole
Health Initiatives.
                                  nystatin                       cream                        COUMADIN                                Beta-Blockers
                                  terbinafine tablet           BRAND                                                            generic
    Bronchial Dilators                                         METROGEL-VAGINAL GEL               Platelet Inhibitors           acebutolol
                                  BRAND
generic                                                                                       generic                           atenolol
                                  GRIS-PEG
albuterol                         VFEND                                Macrolides             cilostazol                        bisoprolol
albuterol HFA [Ventolin                                                                       dipyridamole                      labetalol
  HFA, ProAir HFA]                                             generic                                                          metoprolol
                                    Antimalarial Agents                                       pentoxifylline ER
ipratropium/albuterol                                          azithromycin                                                     metoprolol ER 25mg,
                                  generic                      clarithromycin                 BRAND                               100mg, 200mg tablet
  solution
ipratropium bromide               hydroxychloroquine           clarithromycin ER              PLAVIX*                           nadolol
theophylline anhydrous            mefloquine                   erythromycin oral                                                propranolol
                                                                                                     Miscellaneous
                                                                                                                                propranolol LA
BRAND                             BRAND                                                       BRAND
                                                                Nitrofuran Derivatives                                          sotalol
ALUPENT INHALER                   MALARONE                                                    AGRYLIN
ATROVENT INHALER                                               generic                                                          BRAND
                                                                                              MEPHYTON
COMBIVENT                                                      nitrofurantoin macrocrystals                                     COREG
                                    Antiparasitic and
FORADIL                                                                                                                         INNOPRAN XL
                                   Antiprotozoal Agents                                          CANCER THERAPY                 TOPROL XL
SEREVENT DISKUS                                                        Penicillins
UNIPHYL                           generic
                                  mebendazole                  generic                        All oral agents under this         Blood Pressure Agents—
                                  metronidazole                amoxicillin [Trimox]           class are on the PML, if FDA            Combinations
  Bronchial Dilator and                                        amoxicillin trihydrate/        approved.                         generic
                                  permethrin
     Glucocorticoid                                              potassium clavulanate                                          amlodipine/benazepril
     Combinations                 BRAND
                                                               ampicillin                       CARDIOVASCULAR                  atenolol/chlorthalidone
                                  OVIDE                        dicloxacillin
BRAND                                                                                                                           bisoprolol/hctz
ADVAIR DISKUS                                                  penicillin V potassium         Blood Pressure Agents             metoprolol/hctz
                                          Antivirals           BRAND                                 ACE Inhibitors                  Calcium Channel
 Corticosteroid Inhaled           generic                      AUGMENTIN ES-600
                                                                                              generic                                    Blockers
      Medications                 acyclovir                      SUSPENSION
                                                               AUGMENTIN XR                   benazepril                        generic
BRAND                                  Cytomegalovirus                                        captopril                         diltiazem
ASMANEX                           BRAND                                                       enalapril                         diltiazem ER [Cartia XT,
FLOVENT HFA
                                                                     Sulfonamides             fosinopril                           Dilt XR, Diltia XT,
                                  VALCYTE
FLOVENT ROTADISK                                               generic                        lisinopril                           Taztia XT]
PULMICORT FLEXHALER                           Herpes           sulfamethoxazole/              moexipril                         felodipine ER
PULMICORT RESPULES                BRAND                          trimethoprim [Sulfatrim]     quinapril                         isradipine
PULMICORT                         FAMVIR                                                      trandolapril                      nifedipine ER [Afeditab CR,
                                                               BRAND
 TURBUHALER                       VALTREX                      GANTRISIN                             ACE Inhibitor                 Nifediac CC, Nifedical XL]
                                                                                                     Combinations               verapamil
  Leukotriene Receptor                                                                                                          verapamil ER
                                       Cephalosporins                Tetracyclines            generic
      Antagonists*                                                                            benazepril/hctz
                                                                                                                                BRAND
                                        1st Generation         generic                                                          NORVASC
                                                               doxycycline hyclate            captopril/hctz
Use in nasal allergies,           generic                                                     enalapril/hctz
requires prior authorization                                   minocycline                                                       Central Nervous System
                                  cefadroxil                                                  fosinopril/hctz
and must first document                                        tetracycline                                                               Agents
                                  cephalexin                                                  lisinopril/hctz
failure on conventional                                                                                                         generic
                                        2nd Generation                                        moexipril/hctz
therapies.                                                       Tuberculosis Agents          quinapril/hctz [Quinaretic]       clonidine
BRAND                             generic                      generic                                                          guanfacine
SINGULAIR                         cefaclor                     isoniazid                        Angiotensin Receptor            hydralazine
                                  cefprozil                    rifampin                           Blockers (ARBs)               methyldopa
                                  cefuroxime                                                  BRAND                             BRAND
  Mast Cell Stabilizers
                                        3rd Generation               Miscellaneous            AVAPRO                            CATAPRES-TTS
generic                                                                                       BENICAR
cromolyn nebulized solution       generic                             Antibiotics
                                                                                              COZAAR
BRAND                             cefdinir                     generic
INTAL INHALER                     cefpodoxime                  clindamycin oral



Generic medications are sometimes given specific names by their manufacturers for ease of reference. These are listed in brackets after the generic name.
CMDP 2008 Preferred Medication List                                                                                          Medication Categories Guide
Effective March 2008                                                                                                                                     Page 4

       Vasodilators                     Thiazides               Non-Narcotic Agents—                 Antidepressants                Attention Deficit
generic                        generic                            Aspirin Containing                                              Hyperactivity Disorder
isosorbide dinitrate           chlorthalidone                  generic                           Medications prescribed by              (ADHD)
isosorbide mononitrate         hydrochlorothiazide             butalbital compound               Value Options, CPSA,
isosorbide mononitrate ER      indapamide                                                        NARBHA, or Cenpatico should     Medications prescribed by
nitroglycerin [Minitran,       metolazone                       Non-Narcotic Agents—             be filled at the appropriate    Value Options, CPSA,
  Nitroquick, Nitrostat,                                               Other                     RBHA pharmacy, using the        NARBHA, or Cenpatico should
  Nitrotab]                          Heart Rhythm              generic                           child’s RBHA ID # and not the   be filled at the appropriate
                                                               butalbital/acetaminophen/         CMDP member card.               RBHA pharmacy, using the
                                      Stabilizers
   Cholesterol Agents                                            caffeine                                Alpha-2                 child’s RBHA ID # and not the
                               generic                                                                                           CMDP member card.
    Cholesterol Binding        amiodarone                             Miscellaneous                 ReceptorAntagonist
         Agents                                                                                  generic                         generic
                                                               generic
                                   Digitalis Glycosides                                          mirtazapine                     amphetamine mixed salts
generic                                                        tramadol
                               generic                                                           mirtazapine soltab              methylphenidate [Methylin]
cholestyramine                                                 tramadol/acetaminophen
                               digoxin                                                                                           methylphenidate ER
BRAND                                                                                                          NDRI                [Methylin ER]
                               BRAND                              Antianxiety Agents
WELCHOL                                                                                          generic                         BRAND
                               LANOXICAPS                      generic
   Cholesterol Reducing        LANOXIN                                                           bupropion                       ADDERALL XR
                                                               alprazolam                        bupropion ER                    CONCERTA
  Agents—Miscellaneous                                         buspirone                                                         METADATE CD
generic                          CENTRAL NERVOUS               diazepam                                        SARI
                                                                                                                                 METADATE ER
gemfibrozil                       SYSTEM AGENTS                lorazepam                         generic                         STRATTERA*
BRAND                                                          oxazepam                          nefazodone                       (requires that patient has
                                       Analgesics                                                trazodone                        failure or intolerance to
ANTARA
NIASPAN                                 Narcotics                   Anticonvulsants                            SNRI
                                                                                                                                  stimulant therapy)
ZETIA*
                               generic                         CMDP covers these                 generic                              Bipolar Agents*
   Cholesterol Reducing        acetaminophen/codeine           medications when indicated        venlafaxine
     Agents—Statins            butalbital/caffeine/            for seizures. Medications
                                                                                                                                 generic
                                 acetaminophen/codeine                                           BRAND                           lithium carbonate*
generic                                                        prescribed by Value Options,      EFFEXOR XR
                               fentanyl transdermal*           CPSA, NARBHA, or Cenpatico                                        lithium carbonate ER*
lovastatin
                               hydrocodone/                    should be filled at the                         SSRI              BRAND
pravastatin
                                 acetaminophen                 appropriate RBHA pharmacy,        The FDA recommends careful      ESKALITH CR*
simvastatin
                               hydrocodone/ibuprofen           using the child’s RBHA ID # and   monitoring of children and      LITHOBID*
BRAND                          meperidine                                                        adolescents on these
                                                               not the CMDP member card.
CRESTOR                        morphine sulfate ER                                               medications.
LIPITOR                        oxycodone                       generic                                                               Migraine Agents
PRAVACHOL                      oxycodone/acetaminophen         carbamazepine                     generic
                                                                                                                                 BRAND
PRAVIGARD PAC                    [Endocet, Roxicet]            clonazepam                        citalopram
                                                                                                                                 IMITREX
                               propoxyphene/                   gabapentin                        fluoxetine
                                                                                                                                 MAXALT
                                 acetaminophen                 phenobarbital                     fluvoxamine*
         Diuretics                                                                               paroxetine
                                                                                                                                 MAXALT MLT
                                                               phenytoin ER                                                      RELPAX
                               BRAND                                                             sertraline
              Loop                                             primidone                                                         ZOMIG
                               OXYCONTIN                       valproic acid
generic                                                                                                        TCA               ZOMIG ZMT
                                Non-Narcotics (NSAIDs)         zonisamide
bumetanide                                                                                       generic
furosemide                     generic                         BRAND                                                                     Sleep Aids
                                                                                                 amitriptyline
torsemide                      diclofenac sodium               CARBATROL
                                                                                                 desipramine                     generic
                               etodolac                        DEPAKENE
    Potassium Sparing                                                                            doxepin                         flurazepam
                               flurbiprofen                    DEPAKOTE
                                                                                                 imipramine                      hydroxyzine
generic                        ibuprofen                       DEPAKOTE ER
                                                                                                 nortriptyline                   temazepam
amiloride                      indomethacin                    DIASTAT
spironolactone                                                 DILANTIN                                Miscellaneous             triazolam
                               ketorolac                                                                                         zolpidem
                               meloxicam                       GABITRIL
    Potassium Sparing                                                                            BRAND
                               nabumetone                      KEPPRA                                                            BRAND
      Combinations                                             LAMICTAL                          SYMBYAX
                               naproxen                                                                                          RESTORIL 7.5MG
generic                        naproxen sodium                 PHENYTEK                                                           CAPSULE
amiloride/hctz                 oxaprozin                       TEGRETOL
spironolactone/hctz            piroxicam                       TEGRETOL XR
triamterene/hctz               sulindac                        TOPAMAX
                                                               TRILEPTAL




Generic medications are sometimes given specific names by their manufacturers for ease of reference. These are listed in brackets after the generic name.
CMDP 2008 Preferred Medication List                                                                                         Medication Categories Guide
Effective March 2008                                                                                                                                           Page 5

  COUGH, COLD, AND              Blood Sugar Increasing              Antihistamines—            Chronic Inflammatory              Pancreatic Enzymes*
  ALLERGY AGENTS                       Agents                             Nose                   Bowel Disorders
                                                                                                                               Requires prior authorization,
      Antiallergy—             BRAND                           BRAND                          generic
                                                                                                                               should be covered under
      Antihistamine            GLUCAGON EMERGENCY              ASTELIN                        mesalamine                       Children’s Rehabilitation
                                KIT                                                           BRAND
      Preparations                                                                                                             Services (CRS) benefits.
                                                                   Anti-Inflammatory          ASACOL                           generic
generic                                  Insulins                    Agents—Eye               CANASA                           pancreatic enzyme
fexofenadine
                               BRAND                           generic                        COLAZAL                            preparation*
loratadine OTC                                                                                ENTOCORT EC
loratadine with                HUMALOG                         neomycin/polymyxin B/
                                                                                              PENTASA                          BRAND
  pseudoephedrine OTC          HUMALOG MIX 50/50                 dexamethasone
                               HUMALOG MIX 75/25                                              ROWASA                           CREON*
                                                               prednisolone 1% drops                                           ENZYMAX*
BRAND                          HUMULIN 50/50
ALLEGRA-D                      HUMULIN 70/30                                                    Diarrhea Treatments            KU-ZYME*
                                                                Antiviral Agents—Eye                                           KU-ZYME HP*
                               HUMULIN L                                                      generic
                                                               generic                                                         PANCREASE MT*
     Cough and Cold            HUMULIN N                                                      diphenoxylate/atropine           PANCRECARB*
      Preparations             HUMULIN R                       trifluridine
                                                                                                [Lonox]                        ULTRASE*
                               HUMULIN U                                                      loperamide OTC
generic                                                                                                                        VIOKASE*
                               LANTUS                              Glaucoma Agents
benzonatate                    NOVOLIN 70/30
promethazine/codeine                                           generic                         Gastric Acid Secretion                Miscellaneous
                               NOVOLIN INNOLET 70/30
                               NOVOLIN INNOLET N               pilocarpine                         Reducers and
                                                               timolol maleate                                                 generic
      Expectorants             NOVOLIN L                                                          Ulcer Therapy                milk of magnesia OTC
generic                        NOVOLIN N                       BRAND                          generic                          sulfasalazine [Sulfazine EC]
guaifenesin                    NOVOLIN R                       ALPHAGAN P                                                      ursodiol
                                                                                              cimetidine
guaifenesin/codeine            NOVOLOG                         BETIMOL                        famotidine                       BRAND
guaifenesin/                   NOVOLOG MIX 70/30               COSOPT                         misoprostol                      URSO
  pseudoephedrine ER           NOVOPEN                         LUMIGAN                        nizatidine
hydrocodone/guaifenesin                                        TRUSOPT                        omeprazole
                                EYE, EAR, NOSE, AND            XALATAN                        ranitidine tablet                       HIV AGENTS
   DIABETIC AGENTS                THROAT AGENTS                                               sucralfate
                                                                 Nose and Ear Topical                                          All medications used for the
   AND MONITORING                                                                             BRAND                            treatment of HIV are on the
                                  Allergy Agents and                Preparations              PREVACID QUICK                   PML, if FDA approved.
  Antidiabetic Agents—           Antihistamines—Eye            generic                         DISSOLVE TABLET
          Oral                 generic                         antipyrine/benzocaine          PRILOSEC OTC                     CMDP strongly encourages
generic                        cromolyn 4% ophthalmic            [A/B Otic]                                                    using a provider skilled in the
glimepiride                      drops                         BRAND                              Intestinal Motility          care of HIV. For assistance with
glipizide                      ketotifen                       BACTROBAN NASAL                        Stimulants               the names of such providers,
glipizide ER                   BRAND                                                          generic                          please call CMDP Medical
glipizide/metformin            OPTIVAR                                Miscellaneous           metoclopramide
                                                                                                                               Services.
glyburide
glyburide/metformin                                            generic
                                 Allergy Agents—Nose           atropine 1% ophthalmic                  Laxatives
glyburide micronized                                                                                                                   HORMONES
metformin                      generic                           drops                        generic
metformin ER                   flunisolide                                                    polyethylene glycol                   Antidiuretic and
                               fluticasone                       GASTROINTESTINAL               3350/electrolyte solution            Vasopressor
BRAND
ACTOS*                                                               AGENTS                   BRAND                                   Hormones*
AVANDAMET                           Antibiotics—Ear
                                                                                              MIRALAX
AVANDARYL*                     BRAND                                Antispasmodics            NULYTELY                         Behavioral therapies, including
AVANDIA*                       FLOXIN OTIC                     generic                        VISICOL                          bed-wetting alarms, have the
PRANDIN                                                        dicyclomine                                                     best long-term results.
PRECOSE                             Antibiotics—Eye                                                 Nausea Agents              generic
STARLIX                                                                                                                        desmopressin nasal*
                               generic                                                        generic
                                                                                                                               desmopressin tablets
 Blood Sugar Diagnostics       erythromycin                                                   meclizine
                               gentamicin [Gentak]                                            ondansetron
BRAND                          neomycin/polymyxin B/                                          ondansetron ODT
ACCU-CHEK [Active,               bacitracin ointment                                          prochlorperazine
 Advantage Comfort Curve,      neomycin/polymyxin B/                                          promethazine
 Aviva, Compact]                 gramicidin solution                                          trimethobenzamide
ONE TOUCH [Basic,              ofloxacin 0.3% solution
 FastTake, OneTouch II,        polymyxin B/trimethoprim
 Profile, SureStep, Ultra]     sulfacetamide
                               tobramycin


Generic medications are sometimes given specific names by their manufacturers for ease of reference. These are listed in brackets after the generic name.
CMDP 2008 Preferred Medication List                                                                                      Medication Categories Guide
Effective March 2008                                                                                                                                 Page 6

     Contraceptives                    Transdermal                 IMMUNE SYSTEM                     Antifungals                       Group III
                                BRAND                                 AGENTS                  generic                         generic
    Oral—Monophasic
                                ORTHO EVRA                                                    clotrimazole/betamethasone      betamethasone valerate
generic                                                        All oral immunosuppressant                                        0.1% cream, lotion,
                                        Diaphragms                                            ketoconazole 2% cream
ethinyl estradiol/desogestrel                                  agents under this class are                                       ointment
                                                                                              nystatin powder
  [Apri]                                                       on the PML, if FDA                                             hydrocortisone valerate
                                                                                              nystatin/triamcinolone
ethinyl estradiol/ethynodiol    Estrogenic Agents and          approved.                                                         0.2% cream, ointment
  [Zovia]                           Combinations                                              BRAND                           mometasone furoate
ethinyl estradiol/levonor-                                      MUSCULOSKELETAL               NIZORAL 2% SHAMPOO                 0.1% ointment, solution
                                generic                                                       NIZORAL AD OTC
  gestrel [Aviane, Lessina,                                         AGENTS                                                    triamcinolone 0.025%
  Levora, Lutera, Portia]       estradiol
                                                                                                                                 cream, lotion, ointment
ethinyl estradiol/norethin-     estradiol transdermal
                                estropipate                         Arthritis Agents            Antineoplastics and           triamcinolone 0.1% cream,
  drone [Microgestin,                                                                          Immunosuppressants                lotion, ointment
  Necon, Nortrel]               BRAND                          generic
                                                               leflunomide                          (Dermatitis)                       Group IV
ethinyl estradiol/norethin-     PREMARIN
  drone/iron [Junel FE,         PREMARIN VAGINAL                                              BRAND                           generic
                                                               Cyclooxygenase (COX-2)
  Microgestin FE]               PREMPHASE                             Inhibitors*             ALDARA                          desonide 0.05% cream,
ethinyl estradiol/norgesti-     PREMPRO                                                       CARAC                              lotion, ointment
  mate [Sprintec 28]                                           BRAND                          EFUDEX                          fluocinolone 0.01% solution
ethinyl estradiol/norgestrel                                   CELEBREX*                      ELIDEL                          hydrocortisone 1% cream
                                     Glucocorticoids
  [Cryselle, Low-Ogestrel,                                                                    PROTOPIC                        hydrocortisone 2.5% cream,
  Ogestrel]                     generic                               Gout Agents                                                lotion, ointment
                                dexamethasone                                                   Antipsoriatic Agents
      Oral—Biphasic             fludrocortisone                generic
                                hydrocortisone                 allopurinol                    BRAND                                Miscellaneous
generic
                                methylprednisolone             colchicine                     DOVONEX                         BRAND
ethinyl estradiol/desogestrel                                  probenecid
                                prednisolone                                                  TAZORAC                         REGRANEX
  [Kariva]
ethinyl estradiol/                 15mg/5ml syrup                                                                             RID OTC lice treatment
  norethindrone [Necon]         prednisone                         Muscle Relaxants                   Antivirals
                                BRAND                          generic                        BRAND                             UROLOGIC AGENTS
      Oral—Triphasic
                                ORAPRED                        baclofen                       ABREVA OTC
generic                                                        carisoprodol                   CONDYLOX                          Urinary pH Modifiers
ethinyl estradiol/                      Progestins             cyclobenzaprine                ZOVIRAX 5% OINTMENT             generic
  desogestrel [Velivet 28]                                     methocarbamol
                                generic                                                                                       potassium citrate ER
ethinyl estradiol/                                             tizanidine
  levonorgestrel [Enpresse,     medroxyprogesterone                                                Corticosteroids
  Trivora-28]                     acetate                                                     Listed by potency: Group I is        Urinary Tract
                                                                SKIN AND MUCOUS               most potent; Group IV is            Anesthetics and
ethinyl estradiol/
  norethindrone [Nortrel                                        MEMBRANE AGENTS               least potent.                         Analgesics
                                   Thyroid Hormones
  7/7/7]
                                generic                           Acne and Vitamin A                    Group I               generic
ethinyl estradiol/
                                levothyroxine sodium               Agents—Topical             generic                         phenazopyridine
  norgestimate [TriNessa,
  Tri-Sprintec]                   [Levoxyl, Unithroid]         generic                        betamethasone dipropionate      BRAND
                                methimazole                                                     augmented 0.05%               ELMIRON
                                                               tretinoin
     Oral—Progestin             propylthiouracil                                                ointment
                                                               BRAND
generic                         BRAND                                                         clobetasol 0.05% cream,              Voiding Agents
                                                               AZELEX                           gel, ointment, solution
norethindrone [Camila, Errin,   ARMOUR THYROID
                                                               DIFFERIN                                                       generic
  Nora-BE]                      CYTOMEL
                                                               RETIN-A MICRO                            Group II              oxybutynin
                                SYNTHROID
        Emergency               THYROLAR                                                      generic                         oxybutynin ER
       Contraception                                                       Antibiotics        betamethasone dipropionate      BRAND
BRAND                                 Miscellaneous            generic                           0.05% cream, lotion,         DETROL*
PLAN B                                                         clindamycin topical               ointment,                    DETROL LA*
                                generic                                                       desoximetasone
                                                               erythromycin/benzoyl gel                                       OXYTROL*
         Injectables            bromocriptine                                                    0.25% cream, ointment        VESICARE*
                                                               erythromycin topical
                                cabergoline                                                   fluocinonide 0.05% cream,
FDA Black Box Warning,                                         silver sulfadiazine [SSD]
                                                                                                 gel, ointment, solution
regarding long-term use.                                                                      triamcinolone 0.5% cream,
BRAND                                                                                            ointment
DEPO-Provera




Generic medications are sometimes given specific names by their manufacturers for ease of reference. These are listed in brackets after the generic name.
CMDP 2008 Preferred Medication List                                                                                             Medication Categories Guide
Effective March 2008                                                                                                                                 Page 7

 VITAMINS, MINERALS,               Smoking Cessation                        Enzymes*                   Multiple Sclerosis
 AND ELECTROLYTES               BRAND                                                                       Agents*
                                                                   Requires prior authorization,
                                HABITROL                                                           BRAND
All generic prenatal vitamins                                      should be covered under
                                NICODERM CQ                                                        AVONEX*
are on the PML.                                                    Children’s Rehabilitation
                                NICORETTE                                                          BETASERON*
generic                                                            Services (CRS) benefits.
                                NICOTINE                                                           COPAXONE*
ferrous sulfate                 NICOTROL                           BRAND                           NOVANTRONE*
                                ZYBAN                              ALDURAZYME*                     REBIF*
       Electrolyte                                                 CEREZYME*
      Replacements                      SPECIALTY                  PULMOZYME*                               Psoriasis*
generic                                 PHARMACY                                                   BRAND
                                       CATEGORIES                     Growth Hormones*
potassium chloride ER                                                                              AMEVIVE*
  [Klor-Con]                                                       BRAND                           RAPTIVA*
                                        Antibiotics*               GENOTROPIN*
  Electrolyte Stabilizers                                          HUMATROPE*                            Miscellaneous*
                                Requires prior authorization,      NORDITROPIN*
BRAND                           should be covered under            NUTROPIN*                       generic
PHOSLO                          Children’s Rehabilitation          NUTROPIN AQ*                    octreotide
RENAGEL                         Services (CRS) benefits.           SAIZEN*                         BRAND
                                BRAND                              SEROSTIM*                       LUPRON*
       Nutritional              TOBI*                                                              SANDOSTATIN LAR*
      Supplements*                                                   Heparin and Related
                                      Antihemophilic                  Agents (LMWH)*               CMDP follows American
Requires prior authorization.                                                                      Academy of Pediatrics
                                         Factors*                  BRAND
The provider must document                                                                         guidelines for determining
medical necessity.                                                 FRAGMIN*                        medical necessity.
                                Requires prior authorization and   LOVENOX*
                                must be obtained through PCH
                                HOPE pharmacy.
    MISCELLANEOUS                                                     Hepatitis Treatment
        AGENTS                                                             Agents*
                                  Anti-Inflammatory                         Hepatitis B
     Antiallergic and
                                 Agents and DMARDs*                BRAND
      Anaphylaxis
                                BRAND                              EPIVIR-HBV*
BRAND                                                              HEPSERA*
                                ENBREL*
ANA-KIT                         HUMIRA*
EPIPEN                                                                      Hepatitis C
                                KINERET*
EPIPEN JR                                                          generic
                                                                   ribavirin*
                                         Antivirals*
      Dry Mouth—                                                   BRAND
  Sjogren’s Syndrome            BRAND
                                                                   INFERGEN*
                                SYNAGIS*
generic                                                            PEGASYS*
pilocarpine tablet                                                 PEG-INTRON*
                                Blood Cell Stimulators*            REBETOL*
BRAND                                                              REBETRON*
EVOXAC                                Red Blood Cells
SALAGEN                         BRAND                                  Immunomodulators
                                EPOGEN*                            BRAND
       Mastocytosis             PROCRIT*                           INTRON A*
BRAND                                White Blood Cells             ROFERON-A*
GASTROCROM                      BRAND
                                                                            Infertility*
                                NEUPOGEN*
   Myasthenia Gravis                                               BRAND
generic                                                            gonadotropin, chorionic,
pyridostigmine                                                       human [Novarel]*
BRAND
MESTINON SYRUP
MESTINON TIMESPAN




Generic medications are sometimes given specific names by their manufacturers for ease of reference. These are listed in brackets after the generic name.
Drug names are the property of their respective owners.

								
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