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					               GROSSMONT-CUYAMACA
                COMMUNITY COLLEGE
                    DISTRICT

                                Direct Health Plan
                               Drug List/Formulary
                                December 1, 2005


    Price reflective of directions most commonly written by Grossmont-Cuyamaca
Community College District prescribers. This is not to be construed as a recommendation
               for a treatment modality, but only for illustrative pricing.




              D:\Docstoc\Working\pdf\d4184663-9047-4807-b02a-b97dbf272f6f.doc
INTRODUCTION ............................................................................................................................................ 4
   FUNCTIONS AND SCOPE ........................................................................................................................... 5
   PRESCRIBING POLICIES .......................................................................................................................... 6
   GENERIC SUBSTITUTION POLICY ............................................................................................................ 6
   FORMULARY ADDITIONS ......................................................................................................................... 7
ANTI-INFECTIVES ......................................................................................................................................... 8
   ANTIBIOTICS (ADULT) ................................................................................................................................... 8
     Acne Vulgaris ....................................................................................................................................... 8
     Animal Bites ......................................................................................................................................... 8
     Bronchitis (acute exacerbation of chronic) ......................................................................................... 8
     Cellulitis/Impetigo............................................................................................................................... 8
     Chlamydia trachomatis ........................................................................................................................ 8
     Community Acquired Pneumonia ........................................................................................................ 8
     Gonorrhea and Chlamydia ................................................................................................................... 8
     Otitis Media .......................................................................................................................................... 8
     Pharyngitis (Strep) .............................................................................................................................. 8
     Prostatitis ............................................................................................................................................. 8
     Sinusitis ................................................................................................................................................ 8
     Urethritis Corvicitis (non-Gonococcal) ................................................................................................ 9
     Urinary Tract Infection ........................................................................................................................ 9
     Miscellaneous Antibacterials ............................................................................................................... 9
   ANTIBIOTICS (PEDIATRIC).............................................................................................................................. 9
     Otitis Media .......................................................................................................................................... 9
     Acute Sinusitis...................................................................................................................................... 9
     Group A Strep (Strep Throat) .............................................................................................................. 9
     Impetigo ............................................................................................................................................... 9
     Pneumonia ........................................................................................................................................... 9
     Urinary Tract Infections....................................................................................................................... 9
     Gastroenteritis – etiology Shigella ...................................................................................................... 9
   ANTIBIOTICS – TOPICAL ............................................................................................................................... 10
     Antifungals – Oral .............................................................................................................................. 10
     Antifungals – Topical ......................................................................................................................... 10
     Antiparasitics ..................................................................................................................................... 10
     Antiprotozoals .................................................................................................................................... 10
     Antivirals ............................................................................................................................................ 11
     Leprostatics ........................................................................................................................................ 11
     Pediculocides ..................................................................................................................................... 11
ANTINEOPLASTICS & IMMUNOSUPPRESSANTS ........................................................................................ 12
   ANTINEOPLASTICS ....................................................................................................................................... 12
   HEMATOPOIETIC AGENTS .............................................................................................................................. 12
   IMMUNOSUPPRESSANTS ................................................................................................................................ 12
CARDIOVASCULAR AGENTS ....................................................................................................................... 12
   ANGIOTENSIN CONVERTING ENZYME ............................................................................................................... 12
   INHIBITORS ............................................................................................................................................... 12
   ANGIOTENSIN II RECEPTOR BLOCKER (ARB) .................................................................................................. 13
   ANTI-ANGINALS .......................................................................................................................................... 13
   ANTI-ARRHYTHMICS .................................................................................................................................... 13
   ANTIHYPERLIPIDEMICS ................................................................................................................................. 13
   BETA BLOCKERS .......................................................................................................................................... 13
   BLOOD FLOW/COAGULATION MODIFIERS ........................................................................................................ 13
   CALCIUM CHANNEL BLOCKER ......................................................................................................................... 14
   COMBINATION CCB & ACE........................................................................................................................... 14
   DIURETICS ................................................................................................................................................. 14
   SYMPATHOLYTICS AND VASODILATORS ............................................................................................................ 14




                                                                              1
CENTRAL NERVOUS SYSTEM AGENTS ........................................................................................................ 15
   ANTICONVULSANTS ...................................................................................................................................... 15
   ANTIDEPRESSANTS....................................................................................................................................... 15
   ANTIPARKINSONS AGENTS ............................................................................................................................ 15
   ANTIPSYCHOTICS ........................................................................................................................................ 15
   ANXIOLYTICS .............................................................................................................................................. 16
   BLOOD FLOW/COAGULATION MODIFIERS ........................................................................................................ 16
   CEREBRAL STIMULANTS ................................................................................................................................ 16
   MANIC-DEPRESSIVE AGENTS ......................................................................................................................... 16
   MIGRAINE/HEADACHE AGENTS ...................................................................................................................... 16
   MULTIPLE SCLEROSIS AGENTS ....................................................................................................................... 16
   PSYCHOTROPICS.......................................................................................................................................... 16
   SEDATIVES/HYPNOTICS ............................................................................................................................... 16
   SMOKING DETERRENTS ................................................................................................................................. 17
   MISCELLANEOUS CNS AGENTS ...................................................................................................................... 17
DERMATOLOGIC AGENTS ........................................................................................................................... 18
   ACNE AGENTS ............................................................................................................................................. 18
   ANTIPSORIATICS/ANTISEBORRHEICS .............................................................................................................. 18
   ANTIVIRALS – TOPICALS ............................................................................................................................... 18
   CORTICOSTEROIDS – TOPICAL ....................................................................................................................... 18
     Group I – Very High Potency ............................................................................................................. 18
     Group II – High Potency .................................................................................................................... 18
     Group III – Medium Potency ............................................................................................................. 18
     Group IV – Low Potency .................................................................................................................... 18
   MISCELLANEOUS DERMATOLOGICAL PRODUCTS ................................................................................................. 19
GASTROINTESTINALS ................................................................................................................................ 19
   ANTIBACTERIALS/ANTI-INFLAMMATORIES ....................................................................................................... 19
   ANTICHOLINERGICS/ANTISPASMODICS ........................................................................................................... 19
   ANTI-DIARRHEALS ...................................................................................................................................... 19
   ANTI-EMETICS ............................................................................................................................................ 19
   DIGESTANT ENZYMES ................................................................................................................................... 19
   GALLSTONE SOLUBILIZING AGENTS ................................................................................................................ 19
   GI STIMULANTS .......................................................................................................................................... 20
   HEPATITIS ................................................................................................................................................. 20
   LAXATIVES ................................................................................................................................................. 20
   ULCER TREATMENT AND PREVENTION .............................................................................................................. 20
   MISCELLANEOUS GI PRODUCTS ..................................................................................................................... 20
GENITOURINARIES .................................................................................................................................... 20
   ALPHA ADRENERGIC BLOCKERS ...................................................................................................................... 20
   ANALEGISICS .............................................................................................................................................. 20
   ANTICHOLINERGICS/ANTISPASMODICS ........................................................................................................... 20
   CHOLINERGICS ............................................................................................................................................ 20
   MISCELLANEOUS GENTOURINARY AGENTS ........................................................................................................ 21
   PROSTATE CANCER/BLADDER CANCER ............................................................................................................ 21
METABOLIC/ENDOCRINE AGENTS ............................................................................................................. 22
   ANDROGENS ............................................................................................................................................... 22
   ANTIRHEUMATOIDS ...................................................................................................................................... 22
   ANTITHYROIDS ........................................................................................................................................... 22
   CORTICOSTEROIDS – ORAL ........................................................................................................................... 22
   CONTRACEPTION DEVICES ............................................................................................................................. 22
   DIABETIC SUPPLIES ..................................................................................................................................... 22
   ESTROGENS ................................................................................................................................................ 22
   GOUT AGENTS ............................................................................................................................................. 22
   HYPOGLYCEMICS ......................................................................................................................................... 23
   ORAL CONTRACEPTIVES ................................................................................................................................ 23
   PROGESTINS ............................................................................................................................................... 23
   THYROID REPLACEMENTS .............................................................................................................................. 23
                                                                              2
    OVULATION STIMULANTS .............................................................................................................................. 23
    MISCELLANEOUS ENDOCRINE AGENTS ............................................................................................................. 24
MUSCOLOSKETETAL AGENTS ..................................................................................................................... 24
    ANALGESICS/NARCOTICS ............................................................................................................................. 24
    MUSCLE RELAXANTS..................................................................................................................................... 24
    NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ............................................................................................... 24
NUTRITION SUPPLEMENTS ........................................................................................................................ 25

VITAMINS/ELECTROLYTES ........................................................................................................................ 25
    ELECTROLYTE SUPPLEMENTS .......................................................................................................................... 25
    VITAMINS .................................................................................................................................................. 25
OPHTHALMIC AGENTS ................................................................................................................................ 26
    ANTI-INFLAMMATORY/ALLERGY AGENTS ......................................................................................................... 26
    ANTI-INFECTIVES ........................................................................................................................................ 26
    GLAUCOMA AGENTS ..................................................................................................................................... 26
    CYCLOPLEGIC MYDRIATICS ........................................................................................................................... 27
OTIC AGENTS .............................................................................................................................................. 28

RESPIRATORY AGENTS .............................................................................................................................. 29
    ALLERGY/COUGH/COLD ........................................................................................................................ 29
    ANTIHISTAMINES ........................................................................................................................................ 29
    INTRANASAL ANTIHISTAMINES ....................................................................................................................... 29
    ANTIHISAMINES/DECONGESTANTS ................................................................................................................. 29
    ANTITUSSIVES/MUCOLYTIC EXPECTORANTS ..................................................................................................... 29
    ANTI-ASTHMATIC/COPD BRONCHODILATORS ................................................................................................. 29
    CORTICOSTEROIDS ...................................................................................................................................... 29
    ANTICHOLINERGICS ..................................................................................................................................... 30
    LEUKOTRIENE INHIBITOR (LPI) .................................................................................................................... 30
    INTRANASAL STEROIDS ................................................................................................................................ 30
    INTRANASAL SPRAYS – MISCELLANEOUS ......................................................................................................... 30

ALPHA INDEX .............................................................................................................................31




                                                                               3
                                   INTRODUCTION

When a prescription drug is indicated in the patient’s treatment, prescribers are
encouraged to prescribe from the drugs contained on the Medication List. Effective use
of the List is based on the support of our member physicians, midlevel practioners and
pharmacists. We greatly appreciate your cooperation and welcome your continued
input.

Pharmaceutical agents are grouped by “therapeutic class.” Agents are listed in
ascending order of cost, by their generic name followed by their most common brand
name in parentheses. An index is also provided with agents listed alphabetically both
by generic and most common brand name giving specific page reference. Cost is
reflective of the most commonly written directions. This will allow relative cost
comparisons between drugs in each therapeutic class for a course of therapy.

Patient’s co-payment is $10 for up to a 30 day supply of a generic formulation, $25 for
up to a 30 day supply of a preferred branded product, or $50 for listed but non preferred
agents. Only listed agents are covered.



 THE GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT PHARMACY
                 AND THERAPEUTICS COMMITTEE

The GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT Pharmacy and Therapeutics
Committee is an advisory group consisting of physicians, pharmacists and other
professionals. This committee serves as the governing body for the Medication List.




                                           4
                                     PURPOSE

The primary purpose of the GROSSMONT-CUYAMACA COMMUNITY COLLEGE
DISTRICT Pharmacy & Therapeutics Committee is to develop and assist the monitoring
of the Medication List.


                                 FUNCTIONS AND SCOPE

The GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT Pharmacy &
Therapeutics Committee shall have the following functions:

   1. To serve in an advisory capacity in all matters pertaining to the use of drugs.
   2. To develop a Medication List of covered drugs and provide for its periodic revision.
   3. The selection of items to be included on the list will be based on objective evaluation of
      their therapeutic merits, safety, and cost. The committee will attempt to minimize
      duplication of the same basic drug type.
   4. To establish programs and procedures that help ensure cost effective drug therapy.
   5. To establish or plan suitable educational programs for patients,
      physicians and otherprofessional staff on matters related to drug
      therapy.
   6. To recommend policies and procedures for dispensing generic and therapeutic
      alternates.
   7. To suggest criteria for inclusion of additional drugs based on the following:
          a. Does drug meet a justifiable need not already met by a drug on the List, or is it
              recommended to replace a drug?
          b. If drug is to replace another agent, is it of equal or superior therapeutic value?
              Does it display fewer and/or less severe adverse effects?
          c. Indications for use, pharmacology and biopharmaceuticals efficacy as
              documented by clinical studies, including side effects and toxicity profiles.
          d. What is the FDA rating?
          e. What is the comparative cost of therapy?




                                               5
                                 PRESCRIBING POLICIES

In order to maintain standardization throughout the pharmacy program, the following
guidelines should be followed:

   1. Each prescription should be for one (1) patient only, or if for more than one patient (i.e.,
      a family) each family member’s name should be on the prescription. This will allow for
      the proper assessment of copays by the pharmacy.
   2. There should be no more than two drug orders per prescription blank, to ensure the
      clarity of each prescription.
   3. Patients being tried on a new drug or new drug regimen should be given only sufficient
      amounts to provide for the trial period. Ten (10) day supply for tablets/capsules, 120ml
      for liquids, 30gm for topicals). A new prescription for a larger quantity may be written at
      the time of re-evaluation of the patient’s progress. In general, no more than a one month
      supply (30 days) of medication should be prescribed until after the member has been
      stabilized on a particular drug/dosage.
   4. Generic substitution is mandatory.
   5. In order to reduce the risk of adverse effects to patient drugs are not covered when
      prescribed for experimental, investigational or non-FDA approved purposes,

                            GENERIC SUBSTITUTION POLICY

The dispensing of FDA approved generic medications is mandatory. However, certain
therapeutic agents have unique physical and biopharmaceuticals characteristics that
can vary from manufacturer to manufacturer. These differences are significant and
could compromise patient care. Therefore, the following drugs should only be
prescribed with the recommended brand name medication and the DO NOT
SUBSTITUTE or DISPENSE AS WRITTEN (DNS OR DAW) indication:

                             Brand Name             Generic Name
                              Lanoxin                 Digoxin
                              Dilantin                Phenytoin




                                               6
                             FORMULARY ADDITIONS

Any network physician or pharmacist may initiate a request for a drug or supply to be
added to the Medication List. Requests may be submitted on forms provided for this
purpose.




                                         7
         ANTI-INFECTIVES

Antibiotics (Adult)
Acne Vulgaris
$$       Tetracycline
$$       Doxycycline
$$$      Minocycline (generic Minocin)
Animal Bites
$$$      Amoxicillin/Clavulanate (generic Augmentin) 875mg
Bronchitis (acute exacerbation of chronic)
$        Sulfamethoxazole/Trimethoprim (generic Septra DS)
$        Doxycycline
$$$      Cefuroxime (generic Ceftin)
$$$      Cefprozil (Cefzil)
Cellulitis/Impetigo
$         Cephalexin (generic Keflex)
$         Dicloxacillin (generic Dynapen)
Chlamydia trachomatis
$         Azithromycin (Zithromax) (1 gram single dose)
Community Acquired Pneumonia
<60 yrs old
Drug of choice     -Doxycycline or      Erythromycin
Refractory case -Augmentin
>60yrs old or COPD< yrs old
Drug of choice -Azythromycin or Clarithromycin
Refreactory cases -Augmentin,Or a Quinolone
$        Doxycycline
$        Erythromycin (Ery-Tab)
$$       Azithromycin (Zithromax) Qty limit 6/one copayment
$$       Clarithromycin (Biaxin 7-Pk) Qty limit 7/one copayment
$$       Gatifloxacin (Tequin)
$$$      Levofloxacin (Levaquin)
$$$      Moxifloxacin (Avelox) Third Tier
$$$      Amoxicillin/Clavulanate (generic Augmentin)
Gonorrhea and Chlamydia
$        Cefixime (Suprax) Single dose+Doxycycline
Otitis Media
$          Sulfamethoxazole/Trimethoprim (generic Septra DS)
$         Amoxicillin (generic Amoxil)
$$$       Amoxicillin/Clavulanate (Augmentin/ Augmentin ES)
Pharyngitis (Strep)
$         Penicillin VK
Prostatitis
$         Sulfamethoxazole/Trimethoprim (generic Septra DS)
$         Doxycycline
$$$$      Ciprofloxacin (Cipro)
Sinusitis
$         Sulfamethoxazole/Trimethoprim (generic Septra DS)
$         Doxycycline
$         Amoxicillin (generic Amoxil)
$$$       Cefdinir (Omnicef)
$$$       Clarithromycin (Biaxin 7-Pk) 2 pks Qty limit 7/one copayment
$$$       Amoxicillin/Clavulanate (generic Augmentin)

                                                       8
Urethritis Cervicitis (Non-Gonococcal)
$     Doxycycline
Urinary Tract Infection
$     Sulfamethoxazole/Trimethoprim (generic Septra DS)
$     Doxycycline (generic)
$     Cephalexin (generic Keflex)
$     Amoxicillin (generic Amoxil)
$     Trimethoprim (generic)
$     Nitrofurantoin (generic Macrodantin)
$$    Nitrofurantoin (MacroBID)
$$$   Ciprofloxacin (Cipro)
Miscellaneous Antibacterials
$     Ampicillin (generic)

Antibiotics (Pediatric)
Otitis Media
$     Amoxicillin (generic Amoxil)
$     Amoxicillin Chewable Tablets (generic Amoxil)
$$    Azithromycin (Zithromax)
$$    Amoxicillin/Clavulanate (Augmentin ES)
$$$   Cefuroxime Axetil (Ceftin)
Acute Sinusitis
$     Amoxicillin (generic Amoxil)
$     Amoxicillin Chewable Tablets (generic Amoxil)
$$    Azithromycin (Zithromax)
$$    Amoxicillin/Clavulanate (Augmentin ES)
$$$   Cefdinir (Omnicef)
Group A Strep (Strep Throat)
$     Penicillin
$     Erythromycin Estolate (generic E.E.S.)
$     Erythromycin Estolate (generic Ilosone)
Impetigo
$     Cephalexin (generic Keflex)
$     Erythromycin Ethylsuccinate (generic E.E.S.)
$     Mupirocin (Bactroban) Ointment
Pneumonia
$     Erythromycin/Sulfasoxazole (generic Pediazole)
$$    Azithromycin (Zithromax)
$$$   Clarithromycin (Biaxin)
Urinary Tract Infections
$     Trimethoprim and Sulfamethoxazole (TMP-SMZ)
$$$   Cefixime (Suprax)
Gastroenteritis – etiology Shigella
$$$   Cefixime (Suprax)




                                                 9
Antibiotics – Topical
(OTC Bacitracin or Polysporin products should be tried first)

$       Gentamicin (generic Garamycin)
$       Triple Sulfa (generic Sultrin)
$       Erythromycin (generic A/T/S)
$       Silver sulfadiazine (generic Silvadene)
$       Clindamycin (generic Cleocin T)
$       Mupirocin (Bactroban)
$$      Clindamycin (Cleocin T 1% 60ml lotion)
$$      Clindamycin Vaginal Cream (Cleocin Vaginal)
Antifungals – Oral
$       Nystatin (generic Mycostatin)
$$$     Clotrimazole (Mycelex Troche) (10mg 5x a day x14 days)
$$$     Griseofulvin (generic Grifulvin V 125/5ml) Age restriction <13 years old
$$$     Ketoconazole (generic Nizoral)
$$$$$   Fluconazole (Diflucan) Age restriction >12 years old
$$$$$   Terbinafine (Lamisil) Third Tier
$$$$$   Itraconazole (Sporanox PulsePak) Third Tier
Antifungals – Topical
(OTC Lotrimin, Gyne-Lotrimin, Montistat 7, Femstat should be tried first)
$       Nystatin (generic Mycostatin)
$       Iodochlorhydroxyquin/HC (Clioquinol/HC)
$       Clotrimazole/Betamethasone (generic Lotrisone)
$       Ketoconazole (generic Nizoral)
$       Econazole Nitrate (Spectazole Cream 1% 15gm)
$$      Terconazole (Terazol 7)
Antiparasitics
$       Chloroquine phosphate (generic Aralen)
$       Hydroxychloroquine Sulfate (generic Plaquenil)
$       Mebendazole (generic Vermox)
$       Sulfadoxine/Pyrimethamine (Fansidar) Quantity Limit of 1/mo
$$      Mefloquine (Lariam) Quantity Limit of 4/mo
Antiprotozoals
$       Metronidazole (generic Flagyl)
$$$     Furazolidone (Furoxone)
Antituberculars
$       Isoniazid (generic INH)
$$$     Ethambutol (Myambutol)
$$$     Pyrazinamide
$$$     Rifampin (generic Rifadin, Rimactane)




                                                    10
Antivirals
$     Amantadine (generic Symmetrel)
$$    Acyclovir (generic Zovirax)
HIV nucleoside analogs
$$$$$ Zalcitabine (ddC, Hivid)
$$$$$ Didanosine (ddl, Videx)
$$$$$ Lamivudine (3TC, Epivir)
$$$$$ Stavudine (d4T, Zerit)
$$$$$ Zidovudine (AZT, Retrovir)
HIV Protease Inhibitors
Cost per day
$$$$$ Indinavir sulfate (Crixivan)
$$$$$ Nelfinavir mesylate (Viracept)
$$$$$ Saquinavir (Fortovase)
$$$$$ Ritonavir (Norvir)
$$$$$ Lopinavir/Ritonavir (Kaletra)
HIV Non-nucleoside Reverse Transcriptase Inhibitors
$$$$$ Delavirdine mesylate (Rescriptor)
$$$$$ Nevirapine (Viramune)
$$$$$ Efavirenz (Sustiva)
CMV
$$$$$ Ganciclovir (Cytovene)
Leprostatics
$        Dapsone (generic Avlosulfon)
Pediculocides
(OTC NIX, RID or A-200 should be tried first)
$      Crotamiton (Eurax)
$      Lindane (generic Kwell)
$$     Permethrin (Elimite)




                                                11
ANTINEOPLASTICS & IMMUNOSUPPRESSANTS

Antineoplastics
$$$     Melphalan (Alkeran)
$$$     Tamoxifen (generic Nolvadex)
$$$     Flutamide (Eulexin)
$$$$    Megestrol Acetate (generic Megace)
$$$$    Procarbazine (Matulane)
$$$$    Methotrexate
$$$$$   Busulfan (Myleran) Third Tier
$$$$$   Bicalutamide (Casodex) Third Tier
$$$$$   Capecitabine (Xeloda) Third Tier
$$$$$   Cycolphosphamide (Cytoxan) Third Tier
$$$$$   Etoposide (VePesid) Third Tier
$$$$$   Chlorambucil (Leukeran) Third Tier
$$$$$   Estramustine Phosphate sodium (Emcyt) Third Tier
$$$$$   Lomustine (CeeNu) Third Tier
$$$$$   6-MP (Purinethol) Third Tier
$$$$$   6-thioguanine (Thioguanine) Third Tier
$$$$$   Tretinoin (Vesanoid) Third Tier

Hematopoietic Agents
$$$$$   Darbepoetin alfa (Aranesp) Third Tier
$$$$$   Epoetin (Procrit) Third Tier
$$$$$   Filgrastim (Neupogen) Third Tier
$$$$$   Pegfilgrastim (Neulasta) Third Tier

Immunosuppressants
$$$$ Tacrolimus (Prograf) Third Tier
$$$$$ Mycophenolate (CellCept) Third Tier
$$$$$ Sirolimus (Rapamune) Qty Limit 60 tab/month Third Tier

CARDIOVASCULAR AGENTS

Angiotensin Converting Enzyme

Inhibitors
$       Captopril (generic Capoten)
$       Lisinopril (generic Zestril/Prinivil)
$$      Lisinopril/HCTZ (generic Zestoretic)
$$      Moexipril (Univasc)
$$      Moexipril/HCTZ (Uniretic)
$$      Trandolapril (Mavik)
$$      Benazepril (Lotensin) Third Tier
$$      Benazepril/HCTZ (Lotensin HCT) Third Tier
$$      Ramipril (Altace)




                                                12
Angiotensin II Receptor Blocker (ARB)
$$      Olmesartan (Benicar)
$$      Olmesartan/HCTZ (Benicar HCT)
$$$     Irbesartan (Avapro) Third Tier
$$$     Valsartan (Diovan) Third Tier
$$$     Valsartan/HCTZ (Diovan HCT) Third Tier

Anti-anginals
$       Isosorbide Dinitrate (generic Isordil)
$       Nitroglycerin (Nitrostat)
$       Isosorbide Mononitrate (generic Imdur)
$$$     Nitroglycerin (generic Nitrodur Patch) Third Tier

Anti-arrhythmics
$       Digoxin (Lanoxin)
$$      Quinidine Gluconate (generic Quinaglute)
$$      Procainamide (generic Procan SR)
$$      Mexiletine (generic Mexitil)
$$      Amiodarone (generic Cordarone)
$$$     Disopyramide (generic Norpace, Norpace CR)
$$$     Sotalol (generic Betapace)
$$$$    Flecainide (Tambocor)
$$$$$   Propafenone (Rythmol)

Antihyperlipidemics
$       Gemfibrozil (generic lopid) (600 BID)
$$      Niacin Extended Release (Niaspan)
$$      Fluvastatin (Lescol, Lescol XL)
$$      Colestipol (Colestid)
$$      Lovastatin/Niaspan (Advicor)
$$      Lovastatin Extended Release (Altocor)
$$      Lovastatin (generic Mevacor)
$$$     Simvastatin/Ezetimibe (Vytorin all strengths)
$$$     Atorvastatin (Lipitor) Third Tier
$$$     Ezetimibe (Zetia) Must have a history of a trial on a statin before this will be covered
$$$$    Fenofibrate (Tricor) Third Tier

Beta Blockers
$       Atenolol (generic Tenormin)
$       Propranolol (generic Inderal)
$$$     Propranolol Long Acting (Inderal LA) Third Tier
$       Metoprolol (generic Lopressor)
$       Labetalol (generic Normodyne)
$$      Metoprolol ER (Toprol XL) Third Tier
$$      Carvedilol (Coreg) Third Tier

Blood Flow/Coagulation Modifiers
Prescribe Aspirin for stroke prevention as first line therapy
$      Dipyridamole (generic Persantine)
$      Warfarin sodium (generic Coumadin)
$$$    Clopidogrel Bisulfate (Plavix)
$$$$$ Enoxaparin (Lovenox) Qty Limit 10/copayment - Third Tier


                                                    13
Calcium Channel Blocker
$      Verapamil SR (generic Calan SR)
$$     Nisoldipine (Sular)
$$     Diltiazem Extended Release (generic Dilacor XR)
$$     Felodipine (Plendil)
$$$    Amlodipine (Norvasc) Third Tier
$$$    Nifedipine Extended Release (Adalat CC) Third Tier

Combination CCB & ACE
$$     Amlodipine/Benazepril (Lotrel)

Diuretics
$      Hydrochlorothiazide (generic Hydrodiuril)
$      Furosemide (generic Lasix)
$      Triamterene/HCTZ (generic Dyazide, Maxzide)
$      Spironolactone (generic Aldactone)
$      Bumetanide (Bumex)
$$     Metolazone (Zaroxolyn)

Sympatholytics and Vasodilators
Cost Effective Medications
$      Hydralazine (generic Apresoline)
$      Clonidine (generic Catapres)
$      Prazosin (generic Minipress)
$      Minoxidil (generic Loniten)
$      Doxazosin (generic Cardura)
$      Terazosin (generic Hytrin)
$      Methyldopa (generic Aldomet)




                                                14
CENTRAL NERVOUS SYSTEM AGENTS

Anticonvulsants
$      Phenobarbital (generic Luminal)
$      Carbamazepine (generic Tegretol)
$      Valproic Acid (generic Depakene)
$$     Phenytoin (Dilantin)
$$     Clonazepam (generic Klonopin)
$$     Primidone (generic Mysoline)
$$$    Gabapentin (Neurontin
$$$    Divalproex sodium (Depakote)
$$$    Levetiracetam (Keppra)
$$$$   Ethosuximide (Zarontin) Third Tier
$$$$   Zonisamide (Zonegran) Third Tier
$$$$   Oxcarbazepine (Trileptal) Third Tier

Antidepressants
$      Desipramine (generic Norpramin)
$      Trazodone (generic Desyrel)
$      Doxepin HCL (generic Sinequan, Adapin)
$      Nortriptyline (generic Pamelor)
$      Imipramine HCL (generic Tofranil)
$      Fluoxetine (generic Prozac)
$$$    Escitalopram (Lexapro)
$$$    Mirtazapine (Remeron)
$$$    Paroxetine (Paxil) Third Tier
$$$    Phenelzine (Nardil)
$$$    Citalopram (Celexa) Third Tier
$$$    Sertraline (Zoloft) Third Tier
$$$    Venlafaxine (Effexor XR) Third Tier
$$$    Nafazodone HCl (Serzone) Third Tier – Qty Limit 60/month
$$$    Bupropion (generic Wellbutrin SR)Third Tier

Antiparkinsons Agents
$      Benztropine Mesylate (generic Cogentin)
$      Trihexyphenidyl (generic Artane)
$      Amatadine (generic Symmetrel)
$$     Carbidopa/Levodopa (generic Sinemet)
$$     Selegiline (generic Eldepryl)
$$     Entacapone (Comtan)
$$     Pramipexole (Mirapex) Third Tier
$$     Ropinirole (Requip) Third Tier
$$$    Tolacapone (Tasmar) Third Tier
$$$    Bromocriptine (generic Parlodel)
$$$$   Pergolide Mesylate (Permax) Third Tier

Antipsychotics
$$$$   Risperidone (Risperdal)
$$$$   Ziprasidone (Geodon) 20mg
$$$$   Quetiapine (Seroquel) Third Tier




                                                 15
Anxiolytics
$       Alprazolam (generic Xanax)
$$      Lorazepam (generic Ativan)
$$$     Paroxetine (Paxil) Third Tier
$$$     Clorazepate (generic Tranxene)

Blood Flow/Coagulation Modifiers
$$$     Clopidogrel Bisulfate (Plavix) (one QD)
$$$     Aspirin 25mg/dipyridamole ER 200mg (Aggrenox) Third Tier

Cerebral Stimulants
$       Methylphenidate (generic Ritalin)
$$$     Methylphenidate (Concerta) Age Restriction<13 years old - Third Tier
$$$     Amphetamine Mixture (Adderall Adderall XR) Qty Limit for IR 60/month for XR 30 per
        month - Third Tier
$$$     Pemoline (Cylert) Age Restriction <13 years old – Third Tier

Manic-Depressive Agents
$       Lithium carbonate (generic Eskalith)

Migraine/Headache Agents
$$      Butalbital/APAP/Caffeine (generic EsgicPlus, Fioricet)
$       APAP/Isometheptane/Dichloralphenazone (generic Midrin)
$       Ergotamine Tartrate/Caffeine (generic Cafergot)
$       D.H.E. (Migranal Nasal Spray)
$$      Butalbital/Aspirin/Caffeine (generic Fiorinal)
$$      Butalbital/APAP/Caffeine/Codeine (generic Esgic w/Codeine, Fioricet w/Codeine)
$$      Butalbital/ASA/Caffeine/Codeine (generic Fiorinal w/Codeine)
$$      Almotriptan (Axert) Quantity Limit-6/month
$$$     Zolmitriptan (Zomig) Quantity Limit-6/month - Third Tier
$$$     Rizatriptan (Maxalt) Quantity Limit-6/month -Third Tier
$$$     Sumatriptan (Imitrex tablets) Quantity Limit-9 tablets or 3 Nasal Spray or 1 unit(2 doses)
        injectable/month -Third Tier

Multiple Sclerosis Agents
$$$$$ Glatiramer (Copaxone) Third Tier
$$$$$ Interferon Beta-1B (Betaseron) Third Tier
$$$$$ Interferon Beta-1A (Rebif) Third Tier

Psychotropics
$       Haloperidol (generic Haldol)
$       Thioridazine (generic Mellaril)
$       Fluphenazine (generic Prolixin)
$       Trifluoperazine (generic Stelazine)
$$$     Prochlorperazine (generic Compazine)
$$$$$   Clozapine (Clozaril) Third Tier

Sedatives/Hypnotics
$       Temazepam (generic Restoril)
$       Lorazepam (generic Ativan)




                                                  16
Smoking Deterrents
OTC Nicotine Gum (OTC Nicorette,Nicotrol, or Nicoderm Patch should be tried first. Should be used in
conjunction with a stop smoking program.
$$$$ Nicotine Transdermal (Habitrol) Third Tier

Miscellaneous CNS Agents
$       Amitriptyline (generic Elavil) For the treatment of chronic pain (i.e. peripheral neuropath or
postherpetic neuralgia)
$$$     Galantamine (Reminyl) Third Tier
$$$$ Modafinil (Provigil) Third Tier




                                                    17
DERMATOLOGIC AGENTS

Acne Agents
(OTC Benzyl Peroxide products should
 be tried first)
$     Erythromycin Solution 2% (generic T-Stat 60cc)
$     Clindamycin 1% solution (generic Cleocin T)
$$    Tretinoin (Retin-A) Age restriction <28 years old
$$    Azelaic Acid (generic Azelex) Age restriction <28 years old
$$    Adapalene (Differin) Qty Limit 15gm/copayment
      Coverage limited to gel or cream
$$    Clindamycin/Benzoyl Peroxide (BenzaClin)
$$$   Clindamycin (Cleocin T 1% lotion)
$$$$$ Isotretinoin (Accutane) Third Tier

Antipsoriatics/Antiseborrheics
$       Selenium Sulfide (generic Selsun)
$       Chloroxine (Capitrol)
$       Anthralin (Drithocreme 0.1% cream)
$$      Calcipotriene (Dovonex 0.005%)

Antivirals – Topicals
$$$     Acyclovir (Zovirax 5% ointment)

Corticosteroids – Topical
Group I – Very High Potency
$      Clobetasol (generic Temovate 0.05% cream)
$      Diflorasone diacetate (generic Psorcon)
$$     Halobetasol Propionate(Ultravate 0.05% cream)
$$     Betamethasone (Diprolene 0.05% ointment)
Group II – High Potency
$      Triamcinolone (generic Kenalog 1% ointment)
$      Fluocinonide (generic Lidex, Lidex E 0.05% cream)
$$     Halcinonide (Halog, Halog E 0.1% cream)
Group III – Medium Potency
$      Fluocinolone (generic Synalar 0.025% cream)
$      Hydrocortisone Valerate (Westcort 0.2% cream)
$      Flurndrenolide Tape(Cordran)
$      Mometasone Furoate (Elocon 0.1% cream)
Group IV – Low Potency
(OTC Hydrocotisone 1% should be tried first)
$       Hydrocortisone (generic Hytone 2.5% cream)
$       Desonide Cream or Ointment (generic DesOwen, Tridesilon 0.05% cream)
$$      Fluocinolone Acetonide (Derma Smooth FS Oil 0.01%)
$$      Fluocinolone Acetonide(Capex,[F&S] Shampoo 0.01%
$$      Hydrocortisone/Pramoxine (Pramosone 2.5%)




                                                18
Miscellaneous Dermatological Products
$     Aluminum Chloride-Hexahydrate(generic Drysol)
$$    Zonalon (generic Doxepin HCL 5% cream)
$$    Metronidazole cream (Noritate, Metrogel)
$$    Sulfur/Sulfacetamide (Sulfacet-R 10%-5%)
$$    Papain-Urea (Accuzyme) Ointment 30gm
$$$   Tacrolimus (Protopic 0.03%) Qty Limit 30gms/one copayment
$$$   Tretinoin (generic Renova)(0.05% cream Third Tier
$$$   Fluorouracil (Fluoroplex 1%, Efudex 5% cream)
$$$   Papain-Urea-Chlorophyllin Copper Complex Sodium(Panafil Ointment) Qty Limit 30gms/one
      copayment
$$$$ Imiquimod (Aldara) Qty restriction 1 box of 12/one copayment
$$$$$ Becaplermin Gel (Regranex) Qty Limit 15gms/one copayment - Third Tier

GASTROINTESTINALS

Antibacterials/Anti-inflammatories
$        Hydrocortisone, generic Proctosol)
$$       Sulfasalazine (generic Azulfidine)
$$$      Hydrocortisone (generic Cortenema. Cortifoam) Qty Limit 60ml pkg of 7/one copayment
$$$      Sulfasalazine (Azulfidine En-Tabs) Third Tier
$$$      Mesalamine (Rowasa, Pentasa, Asacol) Qty Limit 7-60ml bottles/one copayment

Anticholinergics/Antispasmodics
$        Phenobarbital/Belladonna Alkaloids SR (generic Donnatal Extentabs)
$        Phenobarbital/Belladonna Alkaloids (generic Donnatal)
$        L-Hyoscyamine SL (generic Levsin SL)
$        Chlordiazepoxide/Clindinum (generic Librax)
$        L-Hyoscyamine SR (generic Levsinex)
$        L-Hyoscyamine (generic Levsin)
$$       Dicyclomine (generic Bentyl)
$$       Propantheline (generic Pro-Banthine)

Anti-Diarrheals
(OTC Imodium AD should be used first)
$$       Diphenoxylate/Atropine sulfate (generic Lomotil)

Anti-Emetics
$$       Trimethobenzamide (generic Tigan)
$$       Promethazine (generic Phenergan)
$$$      Prochlorperazine (generic Compazine)
$$$      Transderm Scop (1 patch Q4 days, cost per patch) Qty Limit 4 patches/copayment
$$$$     Ondansetron (Zofran)(2-8mg tabs) Qty Limit 6 tab/28 days
$$$$$    Granisetron (Kytril (2-1mg tab) Qty Limit 6 tab/28 days - Third Tier

Digestant Enzymes
$$$$ Ku-Zyme
$$$$ Creon 20
$$$$$ Pancrelipase(Lipase, Protease, Amylase) Third Tier

Gallstone Solubilizing Agents
$$$$     Ursodeoxycholic acid (URSO 250)
$$$$     Ursodiol (generic Actigall 300mg)
                                                     19
GI Stimulants
$       Metoclopramide (generic Reglan)

Hepatitis
$$$$$ Ribavrin (Rebetol) Third Tier
$$$$$ Peginterferon alfa-2b (Peg-Intron) Qty limit 2 kits/28 days - Third Tier


Laxatives
(OTC Methycellulose or Psyllium
should be considered first)
$       Lactulose (generic Cephulac, Chronulac)
$       Polyethylene Glycol-Electrolyte Solution (generic Colyte)
$$      Polyethylene Glycol 3350 (MiraLax)(527gm) Third Tier

Ulcer Treatment and Prevention
(OTC Tagamet HB, Zantac or Maalox Plus should be considered first)
$       Ranitidine (generic Zantac)
$       Cimetidine (generic Tagamet)
$$$     Pantoprazole Sodium (Protonix) Third Tier
$$$     Sucralfate (Carafate)
$$$$    Rabeprazole (Aciphex) Third Tier

Miscellaneous GI Products
$$$   Tegaserod (Zelnorm) Third Tier
$$$$ Cyclosporin A (Gengraf)
$$$$$ Pilocarpine (Salagen) Third Tier


GENITOURINARIES

Alpha Adrenergic Blockers
$       Doxazosin (generic Cardura)
$       Terazosin (generic Hytrin)
$$      Tamsulosin (Flomax) Third Tier
$$$     Finasteride (Proscar) Third Tier

Analegisics
$       Phenazopyridine (generic Pyridium)

Anticholinergics/Antispasmodics
$       Imipramine (generic Tofranil)
$       Oxybutynin (generic Ditropan)
$       Hyoscyamine ER (generic Levsinex)
$$$     Oxybutynin (Ditropan XL) Third Tier
$$$     Tolterodine tartrate (Detrol LA) Third Tier
        Coverage Limited to long acting formulation
$$$     Desmopressin (DDAVP) Qty Limit 5ml bottle/one copayment – Third Tier

Cholinergics
$$$     Bethanechol (generic Urecholine)




                                                    20
Prostate Cancer/Bladder Cancer
$$$$$ Bicalutamide (Casodex) Third Tier
$$$$$ Flutamide (Eulexin) Third Tier


Miscellaneous Gentourinary Agents
$$$$   Pentosan polysulfate sodium (Elmiron) Third Tier




                                                21
METABOLIC/ENDOCRINE AGENTS

Androgens
$$$     Methyltestosterone (Methitest) Third Tier
$$$$    Testosterone (Androgel 1%, Androderm) Restricted to males - Third Tier

Antirheumatoids
$$      Hydroxychloroquine Sulfate (generic Plaquenil)
$$      Azathioprine (Imuran)
$$$     Penicillamine (Cuprimine)
$$$     Methotrexate (generic Rheumatrex)
$$$$$   Leflunomide (Arava) Third Tier
$$$$$   Etanercept (Enbrel) Qty Limit 8 vials/28 days - Third Tier

Antithyroids
$       Propylthiouracil (generic PTU)
$$      Methimazole (generic Tapazole)

Corticosteroids – Oral
$       Prednisone (generic Deltasone,Orasone)
$       Dexamethasone (generic Decadron)
$       Methylprednisolone (generic Medrol)
$       Cortisone Acetate (generic Cortone)
$$      Fludrocortisone (Florinef)
$$      Prednisolone (generic Prelone Syrup)

Contraception Devices
$       Koro-Flex Diaphragm

Diabetic Supplies
$       Lancets Qty Limit 200/one copayment
$$      Insulin Syringes Qty Limit 100/one copayment
$$$     Blood Glucose Test Strips Qty Limit 100/one copayment

Estrogens
$       Esterified Estrogens (Menest)
$       Estradiol (generic Estrace)
$       Estropipate (generic Ogen)
$$      Conjugated Estrogens (Premarin)
$$      Estradiol transdermal (generic Climara, Vivelle)
$$      Norethindrone/Ethinyl estradiol (Femhrt)
$$      Norethindrone/Estradiol (Activella)
$$      Esterified Estrogens/Methyltestosterone (Estratest)
$$      Estradiol (Estrace Vaginal Cream, Estring)

Gout Agents
$       Allopurinol (generic Zyloprim)
$       Colchicine
$$      Probenecid (generic Benemid)

                                                   22
Hypoglycemics
$         Glipizide (generic Glucotrol)
$         Glyburide (generic Micronase)
$$        Insulin (Humulin, Novolin)
$$        Insulin Glargine (Lantus)
$$        Insulin Lispro (Humalog/
$$        Insulin Aspart (Novalog)
$$        Acarbose (Precose)
$$        Metformin (generic Glucophage)
$$        Metformin/Glyburide (Glucovance)
$$$       Repaglinide (Prandin)
$$$       Nateglinide (Starlix)
$$$$      Rosiglitazone (Avandia)
$$$$      Pioglitazone (Actos)

Contraceptives
Cost Effective Medications
$         Norethindrone/Mestranol (generic Ortho Novum 1/50)
$         Norethindrone/Ethinyl Estradiol (generic Ortho Novum 1/35)
$$        Levonorgesterol (Plan B) Qty limit 2 tab/30 days
$$        Desogestrel/Ethinyl estradiol (Desogen)
$$        Norethindrone/Ethinyl estradiol (Tri-Norinyl)
$$        Drospirenone/Ethinyl Estradiol (Yasmin)
$$        Desogestrel/ethinyl estradiol (Mircette)
$$        Levonorgestrel/Ethinyl Estradiol(generic Levlen, Tri-Levlen)(Nordette, Triphasil)
$$        Norethindrone acetate/Ethinyl estradiol (Loestrin 1/20, Loestrin 1.5/30)
$$        Desogestrel/Ethinyl estradiol (generic Ortho-Cept)
$$        Norethindrone/Ethinyl estradiol (generic Ortho-Novum 7/7/7)
$$        Norgestimate/Ethinyl estradiol (Ortho-Cyclen, Ortho-Tri-Cyclen)
$$        Levonorgestrel/Ethinyl estradiol (generic Alesse)
$$        Norgestrel/Ethinyl estradiol (generic Lo/Ovral)
$$        Norethindrone (Nor-Q.D.)
$$        Levonorgesterol (Plan B)
$$        Norelgestromin/Ethinyl Estradiol (Ortho Evra Patch)

Progestins
$         Medroxyprogesterone (generic Provera)
$         Megestrol Acetate (generic Megace)
$$        Progesterone (Prometrium)

Thyroid Replacements
$         Levothyroxine (Levoxyl,Levothroid)

Ovulation Stimulants
$         Clomiphene (generic Clomid, Serophene) Qty limity 10 tab/30 days
          Benefit - Infertility 50% copay




                                                     23
Miscellaneous Endocrine Agents
$$$     Risedronate (Actonel)
$$$     Alendronate Sodium (Fosamax) Third Tier
$$$     Raloxifene (Evista) Third Tier
$$$     Calcitonin (Miacalcin Nasal Spray) Third Tier
$$$$    Bromocriptine (Parlodel)
$$$$    Etidronate (Didronel) Third Tier
$$$$$   Danazol (generic Danocrine)
$$$$$   Somatrem (Protropin) Third Tier
$$$$$   Somatropin (Humatrope) Third Tier


MUSCOLOSKETETAL AGENTS

Analgesics/Narcotics
$       Hydrocodone bitartrate/APAP (generic Vicodin)
$       Oxycodone/Aspirin (generic Percodan)
$       Morphine sulfate elixir (generic Roxanol)
$       Oxycodone HCL/APAP (generic Percocet)
$       APAP Codeine (generic Tylenol w/Codeine)
$       Propoxyphene napsylate/APAP (generic Darvocet-N)
$$$$    Morphine sulfate ER (generic MS Contin)
$$$$$   Oxycodone controlled release (OxyContin) Third Tier
$$$$$   Fentanyl transdermal patch (Duragesic) Third Tier

Muscle Relaxants
$       Cyclobenzaprine (generic Flexeril)
$       Baclofen (generic Lioresal)
$$      Methocarbamol (generic Robaxin)
$$$     Carisoprodol (generic Soma)

Non-Steroidal Anti-inflammatory Agents
(OTC aspirin, APAP, Ibuprofen (Motrin IB), Naproxen (Aleve), Ketoprofen (Orudis KT) should be tried first)
$       Piroxicam (generic Feldene)
$       Indomethacin (generic Indocin)
$       Ibuprofen (generic Motrin)
$       Naproxen sodium (generic Anaprox)
$       Sulindac (generic Clinoril)
$       Naproxen (generic Naprosyn)
$       Ketoprofen (generic Orudis)
$       Etodolac (generic Lodine)
$$      Diflunisal (generic Dolobid)
$$      Nabumetone (generic Relafen)
$$$     Melozicam (Mobic)
$$$     Tolmetin sodium (generic Tolectin)




                                                        24
NUTRITION SUPPLEMENTS

VITAMINS/ELECTROLYTES

Electrolyte Supplements
$       Potasium Chloride liquid
$       Potassium Chloride (generic Micro K)

Vitamins
(OTC prenatal vitamins with 0.8mg Folic Acid are available)
$       Ergocalaciferol (Vitamin D-2)
$       Folic Acid
$       Vitamin A (generic Aquasol A)
$       Prenatal Vitamins with Folic Acid (generic Materna, Prenate 90)
$       Phytonadione (Vitamin K, Mephyton)




                                                       25
OPHTHALMIC AGENTS
(Naphcon, Vasocon, Naphcon A and Vasocon A are available OTC)


Anti-inflammatory/Allergy Agents
$       Prednisolone Na phosphate (generic Inflamase)
$       Phenylephrine (generic Mydfrin)
$       Suprofen (Profenal)
$       Prednisolone acetate (generic Pred Forte)
$       Fluorometholone (generic FML, Fluor-Op)
$       Dexamethasone phosphate (generic Decadron)
$       Flurbiprofen (Ocufen)
$       Loteprednol (Lotemax)
$$      Rimexolone 1% (Vexol)
$$      Cromolyn Sodium (generic Crolom)
$$      Ketotifen (Zaditor)
$$      Azelastin (Optivar)

Anti-Infectives
$       Erythromycin (generic Ilotycin)
$       Gentamicin (generic Garamycin)
$       Neomycin/PolymixinB/Dexamethasone (generic Maxitrol, Dexacidin)
$       Neomycin/PolymixinB/Hydrocortisone (generic Cortisporin)
$       Tobramycin (generic Tobrex)
$       Sulfacetamide/Prednisolone Phosphate (generic Vasocidin)
$       Sodium Sulfacetamide/Prednisolone 10/0.25% (generic Blephamide)
$       Sulfacetamide/Phenylephrine (Vasosulf)
$       Sodium Sulfacetamide (generic Sodium Sulamyd, Bleph 10)
$       Polymycin B/Trimethoprim (generic Polytrim)
$$      Vidarabine (Vira-A)
$$      Prednisolone/Gentamicin (Pred-G)
$$      Ciprofloxacin (Ciloxan)
$$      Tobramycin/Dexamethasone (Tobradex)(5ml)
$$$     Trifluridine (generic Viroptic)

Glaucoma Agents
$       Timolol (generic Timoptic)
$       Levobunolol (generic Betagan)
$       Dipivefrin (generic Propine)
$       Acetazolamide (generic Diamox)
$       Pilocarpine (generic Isopto Carpine Pilocar)
$$      Dorzolamide Hydrocloride (Trusopt)
$$      Betaxolol (Betoptic, Betoptic S)
$$      Pilocarpine/Epinephrine (P1E1)
$$      Echothiophate Iodide (Phospholine Iodide)
$$      Brimonidine Tartrate (Alphagan)
$$      Carbachol (Isopto Carbachol)
$$      Methazolamide (generic Neptazane)
$$      Dorzolamide/Timolol (Cosopt)
$$      Latanoprost (Xalatan)
$$      Bimatoprost (Lumigan)




                                                       26
Cycloplegic Mydriatics
$     Atropine (generic Isopto Atropine)
$     Homatropine (generic Isopto-Homatropine)
$     Scopolamine (Isopto Hyoscine)
$     Dicyclomine/Chlorobutanol (Cyclogyl)




                                             27
OTIC AGENTS
$    Acetic acid (generic Vosol)
$    Acetic acid/Hydrocortisone (generic Vosol HC)
$    Neomycin/Polymyxin B/Hydrocortisone (generic Cortisporin)
$$   Polymyxin B/Hydrocortisone (Otobiotic)
$$   Ofloxacin otic solution (Floxin)
$$   Neomycin/Polymyxin B/Hydrocortisone (Pediotic)




                                              28
RESPIRATORY AGENTS

ALLERGY/COUGH/COLD

Antihistamines
(OTC Chlor-Trimeton, Nolahist and Benadryl should be tried first)
$        Promethazine (generic Phenergan)
$        Hydroxyzine HCL (generic Atarax)
$        Cyproheptadine (generic Periactin)
$        Tripelennamine (generic PBZ)
$$$      Cetirizine (Zyrtec) Third Tier
$$$      Fexofenadine HCL (Allegra) Third Tier

Intranasal Antihistamines
$$$      Azelastine HCL (Astelin)

Antihisamines/Decongestants
(OTC Drixoral, Benadryl, Actifed and Sudafed should be tried first)
$        Phenylephrine/Chlorpheniramine/Methscopolamine (Extendryl Jr Chewable and Sr)
$$       Brompheniramine/Pseudoephedrine (generic Ultrabrom-PD, Bromfed-PD)
$$       Guaifensen 600mg/Pseudoephedrine 120mg (generic Entex PSE)

Antitussives/Mucolytic Expectorants
(OTC Dimetapp, Robitussin, Robitussin DM and Delsym should be considered first)
$        Guiafenesin/Codeine (generic Robitussin AC)
$        Hydrocodone/Homatropine (generic Hycodan)
$        Guiafenesin L.A. (generic Humibid LA/Fenesin)
$        Promethazine/Codeine (generic Phenergan Codeine)
$        Benzonatate (generic Tessalon Perles)
$        Guiafenesin SR (Duratuss G)

Anti-Asthmatic/COPD Bronchodilators
$$       Albuterol MDI (generic Proventil, Ventolin)
$$       Albuterol (generic Proventil)
$$       Theophylline (generic Theo-Dur, Theochron
$$       Terbutaline (Brethine, Bricanyl)
$$       Albuterol MDI (Proventil HFA)
$$       Albuterol (Proventil Repetabs)
$$       Ipratropium/Albuterol (Combivent) Qty Limit 1 inhaler/copayment
$$$      Salmeterol (Serevent)
$$$$     Salmeterol/Fluticasone (Advair diskus)
$$$$     Levalbuterol (Xopenex) Third Tier

Corticosteroids
$$       Fluticasone Propronate (Flovent)
$$       Budesonide (Pulmicort Turbuhaler)
$$       Beclomethasone (QVAR)
$$$      Budesonide (Pulmicort Respules) Age Restriction <6 years old
$$$      Triamcinolone Acetonide (Azmacort) Third Tier




                                                        29
Anticholinergics
$$    Ipratropium bromide (Atrovent)
$$$   Tiotropium (Spiriva) (18 mcg capsule per inhalation) Third Tier


Leukotriene Inhibitor (LPI)
$$$   Zafirlukast (Accolate) Third Tier
$$$   Montelukast (Singulair) Third Tier

Miscellaneous
$$$   Cromolyn sodium (Intal)
$$$   Nedocromil Sodium (Tilade)
$$$   Epinephrine Injection (Epipen, Epipen Jr)

Intranasal Steroids
$$    Triamcinolone (Nasacort AQ)
$$    Fluticasone Propionate (Flonase)
$$    Beclomethasone (Vancenase AQ Double Strength)
$$    Budesonide (Rhinocort AQ)
$$$   Beclomethasone Dipropionate (Beconase AQ) Third Tier
$$$   Mometasone Furoate (Nasonex)

Intranasal Sprays – Miscellaneous
$$    Ipratropium Bromide (Atrovent Nasal Spray 0.03%)




                                                  30
                                                          ALPHA INDEX

3TC ............................................................. 11        Anthralin .................................................... 17
6-MP ........................................................... 12         APAP Codeine ............................................ 23
6-thioguanine ............................................ 12               APAP/Isometheptane/Dichloralphenazone ...... 15
A/T/S ...........................................................9          Apresoline .................................................. 14
Acarbose .................................................... 22            Aquasol A ................................................... 24
Accolate ..................................................... 29           Aralen .......................................................... 11
Accutane .................................................... 17            Aranesp ...................................................... 12
Accuzyme ................................................... 17             Arava .......................................................... 21
Acetazolamide ........................................... 25                Artane ........................................................ 15
Acetic acid.................................................. 27            Asacol .......................................................... 18
Acetic acid/Hydrocortisone ...................... 27                        Aspirin 25mg/dipyridamole ER ................ 15
Aciphex ...................................................... 19           Astelin ........................................................ 28
Actifed ......................................................... 28        Atarax ........................................................ 28
Actigall ....................................................... 18         Atenolol ...................................................... 13
Activella ..................................................... 21          Ativan ................................................... 15, 16
Actonel ....................................................... 22          Atropine ..................................................... 25
Actos .......................................................... 22         Atrovastatin ............................................... 13
Acyclovir .............................................. 11, 17             Atrovent ..................................................... 29
Adalat CC ................................................... 14            Atrovent Nasal Spray ................................ 29
Adapin ........................................................ 14          Augmentin ............................................... 8, 9
Adderall ...................................................... 15          Augmentin ES ..............................................9
Adderall XR ................................................ 15             Avandia ...................................................... 22
Advair diskus ............................................. 28              Avapro ........................................................ 12
Advicor ....................................................... 13          Avelox ..........................................................8
Aggrenox ................................................... 15             Avlosulfon .................................................. 11
Albuterol .................................................... 28           Axert .......................................................... 15
Albuterol MDI ............................................ 28               Azathioprine .............................................. 21
Aldactone ................................................... 14            Azelaic Acid ................................................ 17
Aldara ......................................................... 18         Azelastine HCL ........................................... 28
Aldomet...................................................... 14            Azelex......................................................... 17
Aleese......................................................... 22          Azithromycin ........................................... 8, 9
Alendronate Sodium ................................. 22                     Azmacort .................................................... 28
Alkeran ....................................................... 12          AZT ............................................................. 11
Allegra ........................................................ 28         Azulfidine ................................................... 18
Allopurinol ................................................. 21            Azulfidine En-Tabs .................................... 18
Alphagan .................................................... 25            Bacitracin .....................................................9
Alprazolam ................................................. 15             Baclofen ..................................................... 23
Aluminum Chloride-Hexahydrate ............. 17                              Bacroban ......................................................9
Amantadine ............................................... 11               Bactroban .................................................. 10
Amatadine ................................................. 15              Becaplermin ............................................... 18
Amiodarone ............................................... 13               Beclomethasone .................................. 28, 29
Amitriptyline .............................................. 16             Beclomethasone Dipropionate ................. 29
Amlodipine ................................................. 13             Beconase AQ .............................................. 29
Amlodipine/Benazepril ............................. 14                      Benadryl ....................................................... 28
Amoxicillin ............................................... 8, 9            Benazepril .................................................. 12
Amoxicillin Chewable Tablets ....................9                          Benazepril/HCTZ ....................................... 12
Amoxicillin/Clavulanate ......................... 8, 9                      Benemid ..................................................... 21
Amoxil ...................................................... 8, 9          Benicar ....................................................... 12
Amphetamine Mixture .............................. 15                       Bentyl ......................................................... 18
Ampicillin .....................................................9           BenzaClin ................................................... 17
Amylase ..................................................... 18            Benzonatate .............................................. 28
Anaprox ..................................................... 23            Benztropine Mesylate ............................... 15
Androderm ................................................. 21              Benzyl Peroxide ............................................ 17
Androgel .................................................... 21            Betagan ...................................................... 25

                                                                       31
Betamethasone ............................................. 17             Cetirizine .................................................... 28
Betapace .................................................... 13           Chlorambucil ............................................. 12
Betaseron................................................... 16            Chlordiazepoxide/Clindinum .................... 18
Betaxolol .................................................... 25          Chloroquine phosphate .................................. 11
Bethanechol ............................................... 19             Chloroxine ................................................. 17
Betoptic...................................................... 25          Chlor-Trimeton ............................................. 28
Betoptic S .................................................. 25           Chronulac ................................................... 19
Biaxin ....................................................... 8, 9        Ciloxan ....................................................... 25
Bicalutamide ........................................ 12, 19               Cimetidine.................................................. 19
Bimatoprost ............................................... 25             Cipro ......................................................... 8, 9
Bleph 10 ..................................................... 25          Ciprofloxacin ..................................... 8, 9, 25
Blephamide ................................................ 25             Citalopram ................................................. 14
Blood Glucose Test Strips ......................... 21                     Clarithromycin ......................................... 8, 9
Brethine ..................................................... 28          Cleocin T .......................................... 9, 10, 17
Bricanyl ...................................................... 28         Cleocin Vaginal .......................................... 10
Brimonidine Tartrate................................. 25                   Climara ....................................................... 21
Bromfed-PD ............................................... 28              Clindamycin ..................................... 9, 10, 17
Bromocriptine ...................................... 15, 22                Clindamycin Vaginal Cream ...................... 10
Brompheniramine/Pseudoephedrine....... 28                                  Clindamycin/Benzoyl Peroxide ................ 17
Budesonide .......................................... 28, 29               Clinoril ........................................................ 23
Bumetanide ............................................... 14              Clobetasol .................................................... 17
Bumex ........................................................ 14          Clomid.......................................................... 22
Bupropion .................................................. 15            Clomiphene .................................................. 22
Busulfan ..................................................... 12          Clonazepam ............................................... 14
Butalbital/APAP/Caffeine ................................ 15               Clonidine .................................................... 14
Butalbital/APAP/Caffeine/Codeine................... 15                     Clopidogrel Bisulfate ........................... 13, 15
Butalbital/ASA/Caffeine/Codeine .................... 15                    Clorazepate ................................................ 15
Butalbital/Aspirin/Caffeine ...................... 15                      Clotrimazole .............................................. 10
Cafergot ..................................................... 15          Clotrimazole/Betamethasone ......................... 10
Calan SR ..................................................... 13          Clozapine ................................................... 16
Calcipotriene ................................................. 17         Clozaril ....................................................... 16
Calcitonin ................................................... 22          Cogentin..................................................... 15
Capecitabine .............................................. 12             Colchicine .................................................. 21
Capex ......................................................... 17         Colestid ...................................................... 13
Capitrol ...................................................... 17         Colestipol ................................................... 13
Capoten ...................................................... 12          Colyte .......................................................... 19
Captopril .................................................... 12          Combivent.................................................. 28
Carafate ..................................................... 19          Compazine ........................................... 16, 18
Carbachol ................................................... 25           Comtan....................................................... 15
Carbamazepine .......................................... 14                Concerta..................................................... 15
Carbidopa/Levodopa ................................ 15                     Conjugated Estrogens ............................... 21
Cardura ................................................ 14, 19            Copaxone ................................................... 16
Carisoprodol .............................................. 23             Cordarone .................................................. 13
Carvedilol ................................................... 13          Cordran ...................................................... 17
Casodex ............................................... 12, 19             Coreg .......................................................... 13
Catapres ..................................................... 14          Cortenema ................................................. 18
CeeNu ......................................................... 12         Cortifoam ................................................... 18
Cefdinir .................................................... 8, 9         Cortisone Acetate ...................................... 21
Cefixime ..................................................... 8, 9        Cortisporin ........................................... 25, 27
Ceftin............................................................9        Cortone ...................................................... 21
Cefuroxime Axetil........................................9                 Cosopt ........................................................ 25
Celexa ........................................................ 14         Coumadin ................................................... 13
CellCept ...................................................... 12         Creon 20 .................................................... 18
Central Nervous System Agents                                              Crixivan ........................................................ 11
   Migraine/Headache Agents ..................... 1                        Crolom........................................................ 25
Cephalexin ............................................... 8, 9            Cromolyn sodium ...................................... 29
Cephulac .................................................... 19           Cromolyn Sodium ...................................... 25
                                                                      32
Crotamiton ................................................. 11              Diprolene...................................................... 17
Cuprimine .................................................. 21              Dipyridamole ............................................. 13
Cyclobenzaprine ........................................ 23                  Disopyramide ............................................ 13
Cyclogyl...................................................... 26            Ditropan ..................................................... 19
Cyclosporin A ................................................ 19            Ditropan XL ................................................ 19
Cycolphosphamide .................................... 12                     Divalproex sodium .................................... 14
Cylert.......................................................... 15          Dolobid ........................................................ 23
Cyproheptadine ......................................... 28                  Donnatal ...................................................... 18
Cytovene ...................................................... 11           Donnatal Extentabs................................... 18
Cytoxan ...................................................... 12            Dorzolamide Hydrocloride ........................ 25
D.H.E. ......................................................... 15          Dorzolamide/Timolol ................................ 25
d4T ............................................................. 11         Dovonex ....................................................... 17
Danazol ...................................................... 22            Doxazosin ............................................ 14, 19
Danocrine .................................................. 22              Doxepin HCL .............................................. 14
Dapsone ..................................................... 11             Doxepin HCL 5% cream ............................ 17
Darbepoetin alfa ........................................ 12                 Doxycycline ............................................. 8, 9
Darvocet-N ................................................ 23               Drithocreme ............................................... 17
DDAVP ......................................................... 19           Drixoral ........................................................ 28
ddc .............................................................. 11        Drospirenone/Ethinyl Estradiol ....................... 22
ddl .............................................................. 11        Drysol ......................................................... 17
Decadron.............................................. 21, 25                Duragesic ................................................... 23
Delavirdine mesylare ..................................... 11                Duratuss G ................................................. 28
Delsym ......................................................... 28          Dyazide ...................................................... 14
Deltasone ................................................... 21             Dynapen .......................................................8
Depakene ................................................... 14              E.E.S. ............................................................9
Depakote ................................................... 14              Echothiophate Iodide................................ 25
Derma Smooth FS Oil ................................ 17                      Econazole Nitrate .......................................... 11
Desipramine .............................................. 14                Efavirenz ...................................................... 11
Desmopressin ............................................... 19              Effexor XR .................................................. 14
Desogen ..................................................... 22             Efudex ........................................................ 18
Desogestrel/Ethinyl estradiol .................. 22                          Elavil........................................................... 16
Desonide Cream ........................................ 17                   Eldepryl ...................................................... 15
DesOwen .................................................... 17              Elimite ........................................................ 11
Desyrel ....................................................... 14           Elocon .......................................................... 17
Detrol LA .................................................... 19            Emcyt ......................................................... 12
Dexacidin ................................................... 25             Enbrel .......................................................... 21
Dexamethasone ........................................ 21                    Enoxaparin ................................................. 13
Dexamethasone phosphate ...................... 25                            Entacapone ................................................ 15
Diabetic Supplies........................................... 21              Entex PSE ..................................................... 28
Diamox ....................................................... 25            Epinephrine Injection ............................... 29
Dicloxacillin .................................................8             Epipen ........................................................ 29
Dicyclomine ............................................... 18               Epipen Jr .................................................... 29
Dicyclomine/Chlorobutanol...................... 26                           Epivir .......................................................... 11
Didanosine ................................................. 11              Epoetin ....................................................... 12
Didronel ..................................................... 22            Ergocalaciferol ........................................... 24
Diflorasone diacetate ..................................... 17               Ergotamine Tartrate/Caffeine .................. 15
Diflucan ........................................................ 10         Ery-Tab.........................................................8
Diflunisal ...................................................... 23         Erythromycin ..................................... 8, 9, 25
Digoxin ....................................................... 13           Erythromycin Estolate.................................9
Dilacor XR .................................................. 13             Erythromycin Ethylsuccinate ......................9
Dilantin ...................................................... 14           Erythromycin Solution 2% ............................. 17
Diltiazem Extended Release ..................... 13                          Erythromycin/Sulfasoxazole ......................9
Dimetapp ..................................................... 28            Escitalopram .............................................. 14
Diovan ........................................................ 12           Esgic w/codeine ............................................ 15
Diovan HCT .................................................. 13             EsgicPlus ...................................................... 15
Diphenoxylate/Atropine sulfate ...................... 18                     Eskalith ........................................................ 15
Dipivefrin ................................................... 25            Esterified Estrogens .................................. 21
                                                                        33
Esterified Estrogens/Methyltestosterone 21                                   FORMULARY ADDITIONS.................................7
Estrace ....................................................... 21           Fortovase ..................................................... 11
Estrace Vaginal Cream .............................. 21                      Fosamax ..................................................... 22
Estradiol ..................................................... 21           FS Shampoo ............................................... 17
Estradiol transdermal ............................... 21                     FUNCTIONS AND SCOPE .................................5
Estramustine Phosphate sodium .............. 12                              Furazolidone .............................................. 11
Estratest .................................................... 21            Furosemide ................................................ 14
Estropipate ................................................ 21              Furoxone .................................................... 11
Etanercept .................................................... 21           Gabapentin ................................................ 14
Ethambutol ................................................ 11               Galantamine .............................................. 16
Ethosuximide ............................................. 14                Ganciclovir .................................................... 11
Etidronate .................................................. 22             Garamycin .............................................. 9, 25
Etodolac ..................................................... 23            Gatifloxacin ....................................................8
Etoposide ................................................... 12             Gemfibrozil ................................................... 13
Eulexin ................................................. 12, 19             generic Hytrin ............................................ 14
Eurax .......................................................... 11          GENERIC SUBSTITUTION POLICY ....................6
Evista ......................................................... 22          Gengraf ........................................................ 19
Extendryl Jr Chewable and Sr .................. 28                           Genora 1/35 .............................................. 22
Fansidar ..................................................... 11            Genora 1/50 .............................................. 22
Feldene ...................................................... 23            Gentamicin ............................................ 9, 25
Felodipine .................................................. 13             Glatiramer .................................................. 16
Femhrt ....................................................... 21            Glipizide ..................................................... 22
Femstat ........................................................ 10          Glucophage ................................................ 22
Fenofibrate ................................................ 13              Glucotrol .................................................... 22
Fentanyl transdermal patch ..................... 23                          Glucovance ................................................ 22
Fexofenadine HCL ..................................... 28                    Glyburide ................................................... 22
Filgrastim ................................................... 12            Granisetron ................................................ 18
Finasteride ................................................. 19             Grifulvin V .................................................. 10
Fioricet ......................................................... 15        Griseofulvin ............................................... 10
Fioricet w/Codeine ........................................ 15               Guaifensen 600mg/Pseudoephedrine ............. 28
Fiorinal ....................................................... 15          Guiafenesin L.A. ........................................ 28
Fiorinal w/codeine ......................................... 15              Guiafenesin SR .......................................... 28
Flagyl.......................................................... 11          Guiafenesin/Codeine ................................ 28
Flecainide ................................................... 13            Gyne-Lotrimin ............................................... 10
Flexeril ....................................................... 23          Habitrol ...................................................... 16
Flomax ......................................................... 19          Halcinonide ................................................ 17
Flonase ....................................................... 29           Haldol ......................................................... 16
Florinef ....................................................... 21          Halobetasol Propionate .................................. 17
Flovent ....................................................... 28           Halog .......................................................... 17
Floxin ........................................................... 27        Halog E ....................................................... 17
Fludrocortisone ......................................... 21                 Haloperidol ................................................ 16
Fluocinolone .............................................. 17               Hivid ............................................................ 11
Fluocinolone Acetonide ............................. 17                      Homatropine .............................................. 25
Fluocinonide .............................................. 17               Humalog..................................................... 22
Fluorometholone ....................................... 25                   Humatrope ................................................. 23
Fluor-Op ..................................................... 25            Humibid LA/Fenesin ................................. 28
Fluoroplex .................................................. 18             Humulin ..................................................... 22
Fluorouracil................................................ 18              Hycodan ..................................................... 28
Fluoxetine .................................................. 14             Hydralazine ................................................ 14
Fluphenazine ............................................. 16                Hydrochlorothiazide .................................. 14
Flurbiprofen ............................................... 25              Hydrocodone bitartrate/APAP ................. 23
Flurndrenolide Tape .................................. 17                    Hydrocodone/Homatropine...................... 28
Flutamide ............................................. 12, 19               Hydrocortisone .................................... 17, 18
Fluticasone Propionate ............................. 29                      Hydrocortisone Valerate ........................... 17
Fluticasone Propronate ............................. 28                      Hydrocortisone/Pramoxine ...................... 17
Fluvastatin ................................................. 13             hydrocotisone 1% ......................................... 17
Folic Acid .................................................... 24           Hydrodiuril ................................................. 14
                                                                        34
Hydroxyzine HCL ....................................... 28                   Labetalol .................................................... 13
Hyoscyamine ER ........................................ 19                   Lactulose .................................................... 19
Hyroxychloroqine Sulfate ......................... 21                        Lamivudine ................................................ 11
Hyroxychloroquine Sulfate ....................... 11                         Lancets ....................................................... 21
Hytone ....................................................... 17            Lanoxin ...................................................... 13
Hytrin ........................................................... 19        Lantus ........................................................ 22
Ibuprofen ................................................... 23             Lariam ........................................................ 11
Ilosone .........................................................9           Lasix ........................................................... 14
Ilotycin ....................................................... 25          Latanoprost ............................................... 25
Imdur ......................................................... 13           Leflunomide ............................................... 21
Imipramine ................................................ 19               Lescol ......................................................... 13
Imipramine HCL ........................................ 14                   Lescol XL .................................................... 13
Imiquimod ................................................. 18               Leukeran .................................................... 12
Imitrex ....................................................... 15           Levalbuterol ............................................... 28
Immunosuppressants .................................... 12                   LevaQuin ......................................................8
Imuran ....................................................... 21            Levetiracetam ............................................ 14
Inderal ....................................................... 13           Levlen ......................................................... 22
Inderal LA .................................................. 13             Levobunolol ............................................... 25
Indinavir sulfate ............................................ 11            Levofloxacin ................................................8
Indocin ....................................................... 23           Levonorgesterol ........................................ 22
Indomethacin ............................................ 23                 Levonorgestrel/ethinyl estradiol ............. 22
Inflamase ................................................... 25             Levonorgestrel/Ethinyl estradiol ............. 22
INH ............................................................. 11         Levothroid.................................................. 22
Insulin ........................................................ 22          Levothyroxine............................................ 22
Insulin Glargine ......................................... 22                Levoxyl ....................................................... 22
Insulin Syringes ........................................ 21                 Levsin ......................................................... 18
Intal ........................................................... 29         Levsin SL .................................................... 18
Interferon Beta-1A ........................................ 16               Levsinex ............................................... 18, 19
Interferon Beta-1B .................................... 16                   Lexapro ...................................................... 14
INTRODUCTION .............................................4                  L-Hyoscyamine .......................................... 18
Iodochlorhydroxyquin/HC .............................. 10                    L-Hyoscyamine SL ..................................... 18
Ipratropium bromide ................................ 29                      L-Hyoscyamine SR .................................... 18
Ipratropium Bromide ................................ 29                      Librax ......................................................... 18
Ipratropium/Albuterol .............................. 28                      Lidex........................................................... 17
Irbesartan .................................................. 12             Lidex E ....................................................... 17
Isoniazid .................................................... 11            Lindane ...................................................... 11
Isopto Atropine ......................................... 25                 Lioresal ...................................................... 23
Isopto Carbachol ....................................... 25                  Lipase ......................................................... 18
Isopto Carpine Pilocar .............................. 25                     Lipitor ......................................................... 13
Isopto Hyoscine......................................... 26                  Lisinopril .................................................... 12
Isopto-Homatropine ................................. 25                      Lisinopril/HCTZ ......................................... 12
Isordil ......................................................... 13         Lispro ......................................................... 22
Isosorbide Dinitrate .................................. 13                   Lithium carbonate ......................................... 15
Isosorbide Mononitrate ............................ 13                       Lo/Ovral ..................................................... 22
Isotretinoin ................................................ 17             Loestrin 1.5/30 ............................................. 22
Itraconazole .............................................. 10               Loestrin 1/20 ................................................ 22
Keflex ....................................................... 8, 9          Lomotil ......................................................... 18
Kenalog Ointment ..................................... 17                    Lomustine .................................................. 12
Keppra........................................................ 14            Loniten ....................................................... 14
Ketoconazole ................................................ 10             lopid............................................................. 13
Ketoprofen ................................................. 23              Lopressor ................................................... 13
Ketotifen .................................................... 25            Lorazepam ........................................... 15, 16
Klonopin ..................................................... 14            Lotemax ....................................................... 25
Koro-Flex Diaphragm ................................ 21                      Lotensin ..................................................... 12
Ku-Zyme .................................................... 18              Lotensin HCT ............................................. 12
Kwell .......................................................... 11          Loteprednol .................................................. 25
Kytril .......................................................... 18         Lotrel .......................................................... 14
                                                                        35
Lotrimin........................................................ 10         Mirtazapine ................................................ 14
Lotrisone ...................................................... 10         Mobic ........................................................... 23
Lovastatin/Niaspan................................... 13                    Modafinil .................................................... 16
Lovenox ..................................................... 13            Moexipril .................................................... 12
Lumigan ..................................................... 25            Moexipril/HCTZ ......................................... 12
Luminal ...................................................... 14           Mometasone Furoate............................... 17, 29
Maalox Plus .................................................. 19           Montelukast ............................................... 29
MacroBID .....................................................9             Montistat 7 ................................................... 10
Macrodantin.................................................9               Morphine sulfate ....................................... 23
Materna ...................................................... 24           Morphine sulfate elixir .............................. 23
Matulane .................................................... 12            Motrin......................................................... 23
Maxalt ........................................................ 15          Moxifloxacin ................................................8
Maxide ....................................................... 14           Mupirocin ............................................... 9, 10
Maxitrol ...................................................... 25          Myambutol ................................................. 11
Mebendazole ............................................. 11                Mycelex Troche ......................................... 10
Medrol ........................................................ 21          Mycophenolate .......................................... 12
Medroxyprogesterone ............................... 22                      Mycostatin ................................................. 10
Mefloquine ................................................. 11             Mydfrin ....................................................... 25
Megace ................................................. 12, 22             Myleran ...................................................... 12
Megestrol Acetate ............................... 12, 22                    Mysoline ..................................................... 14
Mellaril ....................................................... 16         Nafazodone ................................................ 14
Melozicam .................................................... 23           Naphcon ....................................................... 25
Melphalan .................................................. 12             Naphcon A .................................................... 25
Menest ....................................................... 21           Naprosyn .................................................... 23
Mephyton ................................................... 24             Naproxen ................................................... 23
Mesalamine .................................................. 18            Naproxen sodium ...................................... 23
Metformin .................................................. 22             Nardil ......................................................... 14
Metformin/Glyburide ................................ 22                     Nasacort AQ ............................................... 29
Methazolamide .......................................... 25                 Nasonex ..................................................... 29
Methimazole .............................................. 21               Nateglinide ................................................ 22
Methocarbamol ......................................... 23                  Nedocromil Sodium ................................... 29
Methotrexate ....................................... 12, 21                 Nelfinavir mesylare........................................ 11
Methyldopa ................................................ 14              Neomycin/Polymixin B/Dexamethasone 25
Methylphenidate ........................................... 15              Neomycin/Polymixin B/Hydrocortisone .. 25
Methylprednisolone .................................. 21                    Neomycin/Polymyxin B/Hydrocortisone . 27
Methyltestosterone ................................... 21                   Neptazane .................................................. 25
Metoclopramide ........................................ 18                  Neulasta ..................................................... 12
Metolazone ................................................ 14              Neupogen .................................................. 12
Metoprolol ................................................. 13             Neurontin ................................................... 14
Metoprolol ER ............................................ 13               Nevirapine .................................................... 11
Metrogel ..................................................... 17           Niacin Extended Release .......................... 13
Metronidazole ............................................ 11               Niaspan ...................................................... 13
Metronidazole cream ................................ 17                     Nicotine Transdermal ................................ 16
Mexiletine .................................................. 13            Nifedipine Extended Release .................... 14
Mexitil ........................................................ 13         Nisoldipine ................................................. 13
Miacalcin Nasal Spray ............................... 22                    Nitrodur ..................................................... 13
Micro K ....................................................... 24          Nitrofurantoin .............................................9
Micronase .................................................. 22             Nitroglycerin .............................................. 13
Midrin........................................................... 15        Nitrostat..................................................... 13
Migranal Nasal Spray ................................ 15                    Nizoral.......................................................... 10
Minipress ................................................... 14            Nolahist ........................................................ 28
Minocin® .....................................................8             Nolvadex .................................................... 12
Minocycline ..................................................8             Nordette ..................................................... 22
Minoxidil .................................................... 14           Norethindrone ........................................... 22
MiraLax ...................................................... 19           Norethindrone acetate/Ethinyl estradiol .......... 22
Mirapex ...................................................... 15           Norethindrone/Estradiol .......................... 21
Mircette ...................................................... 22          Norethindrone/Ethinyl estradiol ........ 21, 22
                                                                       36
Norethindrone/Ethinyl Estradiol .............. 22                            Percodan .................................................... 23
Norethindrone/Mestranol ........................ 22                          Pergolide Mesylate .................................... 15
Norgestrel/Ethinyl estradiol ..................... 22                        Periactin ..................................................... 28
Norgetimate/Ethinyl estradiol ................. 22                           Permax ....................................................... 15
Noritate ...................................................... 17           Permethrin ................................................. 11
Normodyne ................................................ 13                Persantine.................................................. 13
Norpace ...................................................... 13            Phenazopyridine ........................................ 19
Norpace CR ................................................ 13               Phenelzine ................................................. 14
Norpramin .................................................. 14              Phenergan ........................................... 18, 28
Nor-Q.D. ..................................................... 22            Phenergan with Codeine........................... 28
Nortriptyline .............................................. 14              Phenobarbital ............................................ 14
Norvasc ...................................................... 13            Phenobarbital/Belladonna Alkaloids ................ 18
Norvir ........................................................... 11        Phenobarbital/Belladonna Alkaloids SR .. 18
Novolin ....................................................... 22           Phenylephrine ........................................... 25
Nystatin ..................................................... 10            Phenylephrine/Chlorpheniramine/Methsco
Ocufen ........................................................ 25              polamine ................................................ 28
Ofloxacin otic solution ................................... 27               Phenytoin ................................................... 14
Ogen ........................................................... 21          Phospholine Iodide ................................... 25
Olmesartan ................................................ 12               Phytonadione ............................................ 24
Omnicef .................................................... 8, 9            Pilocarpine .............................................. 19, 25
Ondansetron ................................................. 18             Pilocarpine/Epinephrine ........................... 25
Oramorph SR ............................................. 23                 Pioglitazone ............................................... 22
Orasone ...................................................... 21            Piroxicam ................................................... 23
Ortho-Cept ................................................. 22              Plan B ......................................................... 22
Ortho-Cyclen ............................................. 22                Plaquenil .............................................. 11, 21
Ortho-Novum 7/7/7 ................................. 22                       Plavix ................................................... 13, 15
Ortho-Tri-Cyclen........................................ 22                  Plendil ........................................................ 13
Orudis......................................................... 23           Polyethylene Glycol3350 .......................... 19
Otobiotic .................................................... 27            Polyethylene Glycol-Electrolyte Solution .......... 19
Oxcarbazepine ........................................... 14                 Polymyxin B/Hydrocortisone ................... 27
Oxybutynin ................................................ 19               Polysporin ....................................................9
Oxycodone controlled release .................. 23                           Potasium Chloride liquid ........................... 24
Oxycodone HCL/APAP .............................. 23                         Potassium Chloride ................................... 24
Oxycodone/Aspirin ................................... 23                     Pramipexole............................................... 15
OxyContin .................................................. 23              Pramosone ................................................. 17
P1E1 ........................................................... 25          Prandin....................................................... 22
Pamelor ...................................................... 14            Prazosin ..................................................... 14
Panafil .......................................................... 18        Precose ...................................................... 22
Pancrelipase .............................................. 18               Pred Forte .................................................. 25
Pantoprazole Sodium ................................ 19                      Pred-G ........................................................ 25
Papain-Urea Ointment .............................. 17                       Prednisolone .............................................. 21
Papain-Urea-Chlorophyllin Copper Complex .... 18                             Prednisolone acetate ................................ 25
Parlodel ................................................ 15, 22             Prednisolone Na phosphate ...................... 25
Paroxetine ........................................... 14, 15                Prednisolone/Gentamicin ......................... 25
Paxil ..................................................... 14, 15           Prednisone ................................................. 21
PBZ ............................................................. 28         Prelone Syrup ............................................ 21
Pediazole .....................................................9             Premarin .................................................... 21
Pediotic ...................................................... 27           Prenatal Vitamins with Folic Acid ............ 24
Pegfilgrastim ............................................. 12               Prenate 90 ................................................. 24
Peginterferon alfa-2b ............................... 18                     PRESCRIBING POLICIES FOR OUTPATIENT ......6
Peg-Intron ................................................. 18              Primidone .................................................. 14
Pemoline .................................................... 15             Prinivil ........................................................ 12
Penicillamine ............................................. 21               Pro-Banthine ............................................. 18
Penicillin .........................................................9        Probenecid ................................................. 21
Penicillin VK .................................................8             Procabazine ............................................... 12
Pentasa ........................................................ 18          Procainamide ............................................. 13
Percocet ..................................................... 23            Procan SR .................................................. 13
                                                                        37
Prochlorperazine ................................. 16, 18                    Retrovir ...................................................... 11
Procrit ........................................................ 12          Rheumatrex ............................................... 21
Proctosol .................................................... 18            Rhinocort AQ ............................................. 29
Profenal ..................................................... 25            Ribavrin ..................................................... 18
Progesterone ............................................. 22                Rifampin .................................................... 11
Prograf ....................................................... 12           Rimactane .................................................. 11
Prolixin ....................................................... 16          Rimexolone 1% ......................................... 25
Promethazine ...................................... 18, 28                   Risedronate ............................................... 22
Promethazine/Codeine ............................. 28                        Risperdal .................................................... 15
Prometrium................................................ 22                Risperidone ................................................ 15
Propafenone .............................................. 13                Ritalin .......................................................... 15
Propantheline ............................................ 18                Ritonavir....................................................... 11
Propine ....................................................... 25           Rizatriptan ................................................. 15
Propoxyphene napsylate/APAP ............... 23                               Robaxin ...................................................... 23
Propranolol ................................................ 13              Robitussin .................................................... 28
Propranolol Long Acting ........................... 13                       Robitussin AC ............................................ 28
Propylthiouracil ......................................... 21                Robitussin DM ............................................... 28
Proscar ....................................................... 19           Ropinirole .................................................. 15
Protease ..................................................... 18            Rosiglitazone ............................................. 22
Protonix ..................................................... 19            Rowasa ........................................................ 18
Protopic...................................................... 17            Rythmol ..................................................... 13
Protropin .................................................... 23            Salagen ........................................................ 19
Proventil .................................................... 28            Salmeterol/Fluticasone ............................ 28
Proventil HFA ............................................. 28               Sameterol .................................................. 28
Proventil Repetabs .................................... 28                   Saquinavir .................................................... 11
Provera ...................................................... 22            Scopolamine .............................................. 26
Provigil ....................................................... 16          Selegiline ................................................... 15
Prozac ........................................................ 14           Selenium Sulfide ....................................... 17
Psorcon ........................................................ 17          Selsun ........................................................ 17
PTU ............................................................. 21         Septra DS .....................................................8
Pulmicort Turbuhaler ................................ 28                     Septra DS .....................................................8
Purinethol .................................................. 12             Septra DS .....................................................8
PURPOSE .....................................................5               Septra DS .....................................................8
Pyrazinamide ............................................. 11                Septra DS .....................................................9
Pyridium..................................................... 19             Serevent..................................................... 28
Quetiapine ................................................. 15              Serophene .................................................... 22
Quinaglute ................................................. 13              Seroquel ..................................................... 15
Quinidine Gluconate.................................. 13                     Sertraline ................................................... 14
QVAR .......................................................... 28           Serzone ...................................................... 14
Rabeprazole ............................................... 19               Silvadene .....................................................9
Rafadin ....................................................... 11           Silver sulfadiazine .......................................9
Raloxifene .................................................. 22             Sinemet ...................................................... 15
Ranitidine .................................................. 19             Sinequan .................................................... 14
Rapamune .................................................. 12               Singulair ..................................................... 29
READING THE FORMULARY ........................4                              Sirolimus .................................................... 12
Rebetol ....................................................... 18           Sodium Sulamyd........................................ 25
Rebif ............................................................ 16        Sodium Sulfacetamide .............................. 25
Reglan ........................................................ 18           Sodium Sulfacetamide/Prednisolone ...... 25
Regranex ................................................... 18              Soma .......................................................... 23
Remeron .................................................... 14              Somatrem .................................................. 23
Reminyl ...................................................... 16            Somatropin ................................................ 23
Renova ....................................................... 18            Sotalol ........................................................ 13
Repaglinide ................................................ 22              Spectazole Cream ......................................... 11
Requip ........................................................ 15           Spironolactone .......................................... 14
Rescriptor ..................................................... 11          Sporanox .................................................... 10
Restoril....................................................... 16           Starlix......................................................... 22
Retin-A ....................................................... 17           Stavudine ................................................... 11
                                                                        38
Stelazine .................................................... 16           Tolectin ...................................................... 23
Sucralfate .................................................. 19            Tolmetin sodium........................................ 23
Sudafed........................................................ 28          Tolterodine tartrate .................................. 19
Sular ........................................................... 13        Transderm Scop ............................................ 18
Sulfacetamide/Phenylephrine .................. 25                           Tranxene .................................................... 15
Sulfacetamide/Prednisolone Phosphate . 25                                   Trazodone .................................................. 14
Sulfacet-R .................................................. 17            Tretinoin ........................................ 12, 17, 18
Sulfadoxine/Pyrimethamine .................... 11                           Triamcinolone ...................................... 17, 29
Sulfamethoxazole/Trimethoprim ........... 8, 9                              Triamcinolone Acetonide .......................... 28
Sulfasalazine ............................................. 18              Triamterene/HCTZ .................................... 14
Sulfur/Sulfacetamide ................................ 17                    Tricor .......................................................... 13
Sulindac ..................................................... 23           Tridesilon ................................................... 17
Sultrin ..........................................................9         Trifluoperazine .......................................... 16
Sumatriptan ............................................... 15              Trifluridine ................................................. 25
Suprax ....................................................... 8, 9         Trihexyphenidyl ......................................... 15
Suprofen .................................................... 25            Trileptal...................................................... 14
Sustiva ......................................................... 11        Tri-Levlen ................................................... 22
Symmetrel ........................................... 11, 15                Trimethobenzamide .................................. 18
Synalar ....................................................... 17          Trimethoprim...............................................9
Tacrolimus ........................................... 12, 17               Trimethoprim/Sulfamethoxazole ...............9
Tagamet ..................................................... 19            Tri-Norinyl ................................................. 22
Tagamet HB ................................................. 19             Tripelennamine ......................................... 28
Tambocor ................................................... 13             Triphasil ..................................................... 22
Tamoxifen .................................................. 12             Triple Sulfa ..................................................9
Tamsulosin ................................................... 19           Troprol XL .................................................. 13
Tapazole ..................................................... 21           Trusopt ....................................................... 25
Tasmar ....................................................... 15           T-Stat........................................................... 17
Tavist D ....................................................... 28         Tylenol w/Codeine .................................... 23
Tegretol...................................................... 14           Ultrabrom-PD ............................................ 28
Temazepam ............................................... 16                Ultravate ...................................................... 17
Temovate ..................................................... 17           Uniretic ...................................................... 12
Tenormin.................................................... 13             Univasc....................................................... 12
Tequin ...........................................................8         Urecholine.................................................. 19
Terazol 7 ...................................................... 11         URSO 250 ................................................... 18
Terazosin ............................................. 14, 19              Ursodeoxycholic acid ................................ 18
Terbutaline ................................................ 28             Ursodiol ...................................................... 18
Terconazole .................................................. 11           Valproic Acid .............................................. 14
Tessalon Perles .......................................... 28               Valsartan .................................................... 12
Testosterone .............................................. 21              Valsartan/HCTZ............................................. 13
Testred ....................................................... 21          Vancenase AQ Double Strength ............... 29
Tetracycline .................................................8             Vanceril DS ................................................ 28
Theochron .................................................. 28             Vasocidin ................................................... 25
Theo-Dur .................................................... 28            Vasocon ....................................................... 25
Theophylline .............................................. 28              Vasosulf ..................................................... 25
Thioguanine ............................................... 12              Venlafaxine ................................................ 14
Thioridazine ............................................... 16             Ventolin...................................................... 28
Tigan .......................................................... 18         VePesid ...................................................... 12
Tilade ......................................................... 29         Verapamil SR ............................................. 13
Timolol ....................................................... 25          Vermox ....................................................... 11
Timoptic ..................................................... 25           Vesanoid .................................................... 12
TMP-SMZ ......................................................9             Vexol .......................................................... 25
Tobradex .................................................... 25            Vicodin ....................................................... 23
Tobramycin ................................................ 25              Vidarabine.................................................. 25
Tobramycin/Dexamethasone ................... 25                             Videx .......................................................... 11
Tobrex ........................................................ 25          Vioform HC ................................................... 10
Tofranil................................................. 14, 19            Vira-A ......................................................... 25
Tolacapone ................................................ 15              Viracept........................................................ 11
                                                                       39
Viramune...................................................... 11          Zalcitabine .................................................... 11
Viroptic....................................................... 25         Zantac .......................................................... 19
Vitamin A ................................................... 24           Zarontin ..................................................... 14
Vitamin D-2................................................ 24             Zaroxolyn ................................................... 14
Vitamin K ................................................... 24           Zerit ............................................................ 11
Vivelle ........................................................ 21        Zestoretic ................................................... 12
Voltaren ..................................................... 23          Zestril ......................................................... 12
Vosol .......................................................... 27        Zidovudine ................................................. 11
Vosol HC ..................................................... 27          Zithromax ................................................ 8, 9
Warfarin sodium ........................................ 13                Zofran .......................................................... 18
Wellbutrin SR ............................................ 15              Zolmitriptan ............................................... 15
Westcort .................................................... 17           Zoloft .......................................................... 14
Xalatan ....................................................... 25         Zomig ......................................................... 15
Xanax ......................................................... 15         Zonalon ...................................................... 17
Xeloda ........................................................ 12         Zonegran .................................................... 14
Xopenex ..................................................... 28           Zonisamide ................................................ 14
Yasmin ......................................................... 22        Zovirax ................................................. 11, 17
Zaditor ....................................................... 25         Zyloprim ..................................................... 21
Zafirlukast ................................................. 29           Zyrtec ......................................................... 28




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posted:7/26/2010
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Description: ANTI INFECTIVES acne