2003 Three-tier Patient Drug Formulary Guide

2003 Three-tier Patient Drug Formulary Guide Medication Categories Listing Effective June 15, 2003 What is a Formulary Guide? This is a Guide to your Formulary, which is a list of medications preferred by your plan. The specially selected medications on this Guide can help you and your prescriber maximize your plan benefits and minimize prescription medication costs. This list also is available alphabetically on our web site (www.mywhi.com/formulary_default. jhtml). All the medications listed have received FDA approval as safe and effective. A committee of physicians and pharmacists has chosen the medications included on this list. How do I use this Guide? This Guide can help you locate brand and generic medication alternatives that may lower your copayment. Share this Guide with your physician and encourage him or her to authorize a generic alternative for you whenever possible. How does the Formulary impact my copayment? The chart at top right describes the three-tier copayment options your plan provides. The first tier includes less-costly generic medications. These medications generally have the lowest copayment. The second tier includes PREFERRED BRANDS that are on the Formulary. These medications usually fall in the middle copayment tier. The third tier includes non-preferred brands. When a generic version of a brand-name medication becomes available, most brands move to the highest copayment tier. Likewise, if only one generic product is available for a medication, it may be placed on a higher tier. These medications are rarely listed on this Guide since they do not minimize costs as effectively as other medications that are listed. Copayments and coverage of medications and medication categories can vary by plan. This Guide is meant to be a source of general information about the Formulary. THREE-TIER COPAY LEVEL Lowest Copayment Middle Copayment Highest Copayment TYPE OF MEDICATION Most generic medications PREFERRED BRAND medications on the formulary with no generic available Non-preferred brands or brands with a generic available What if my medication is not listed on this Guide? Due to space limitations, not all medications on the Formulary can be listed on this Guide. If you are unable to locate your medication on the list, please keep the following in mind: • Most generic medications are preferred by your plan, usually at the lowest copayment. • When a medication can be used to treat more than one condition, you will find it listed under only one category when possible for ease of reference. Check different categories for your medication or consult the alphabetical guide. • Your medication may have been added to the list after it was printed. Where can I get more information about this Guide? This Guide may change to reflect current medication availability and tier placement. You can find the most recent update www.mywhi.com/formulary_default.jhtml. Our online Formulary Guide is updated regularly every calendar quarter or more often if needed to reflect important changes. It also is listed in alphabetical order. This Guide is subject to change without notice. For assistance, please contact Member Services at 1-800-207-2568. CS306-0603 Under each therapeutic class category heading, generic medications are listed in lower-case (small) letters and preferred brand medications are listed in UPPER-CASE (CAPITAL) letters. ANTINEOPLASTICS/ IMMUNOSUPPRESSANTS All oral antineoplastic and oral immuno-suppressant agents under this class are on the Formulary, if FDA approved. LOW MOLECULAR WEIGHT HEPARINS LOVENOX PLATELET AGGREGATION INHIBITORS dipyridamole PLAVIX enalapril lisinopril moexipril ACCUPRIL ALTACE COZAAR ANGIOTENSIN II RECEPTOR BLOCKER COMBINATIONS AVALIDE HYZAAR ACE INHIBITOR COMBINATIONS captopril/hctz enalapril/hctz lisinopril/hctz ACCURETIC LOTREL BLOOD MODIFIERS ANTICOAGULANTS warfarin COUMADIN ANTIARRHYTHMICS/ CARDIAC GLYCOSIDES amiodarone digoxin sotalol LANOXICAPS MISCELLANEOUS pentoxifylline ext-rel AGRYLIN MEPHYTON ALPHA BLOCKERS doxazosin terazosin BLOOD FORMATION NEUPOGEN PROCRIT CARDIOVASCULAR ACE INHIBITORS Captopril BETA BLOCKERS/COMBINATION PRODUCTS acebutolol atenolol atenolol/chlorthalidone ANGIOTENSIN II RECEPTOR BLOCKERS AVAPRO Walgreens Health Initiatives 2003 Three-tier Patient Drug Formulary Guide Effective June 15, 2003 bisoprolol/hctz labetalol metoprolol nadolol propranolol INDERAL LA TOPROL XL Page 2 erythromycin/benzoyl gel erythromycin topical tretinoin RETIN-A MICRO MIGRAINE Preventative Therapy generic beta blockers generic calcium channel blockers DEPAKOTE ER REMERON SOLTAB WELLBUTRIN SR ZOLOFT INSOMNIA flurazepam hydroxyzine temazepam triazolam AMBIEN RESTORIL 7.5MG CAPSULE SONATA Treatment CAFERGOT IMITREX MAXALT MAXALT MLT ZOMIG ZOMIG ZMT BACTERIAL INFECTIONS silver sulfadiazine BACTROBAN CALCIUM CHANNEL BLOCKERS DIHYDROPYRIDINE nifedipine ext-rel NORVASC diltiazem ext-rel verapamil verapamil ext-rel cholestyramine gemfibrozil lovastatin LESCOL LESCOL XL LIPITOR PRAVACHOL ZETIA CORTICOSTEROIDS Listed by potency: Group I is most potent; Group IV is least potent NONDIHYDROPYRIDINE NON-NARCOTIC COMBINATIONS butalbital compound butalbital/acetaminophen/caffeine butalbital/caffeine/acetaminophen/ codeine MULTIPLE SCLEROSIS AGENTS AVONEX BETASERON REBIF GROUP I CHOLESTEROL-LOWERING OPIOIDS MYASTHENIA GRAVIS AGENTS pyridostigmine acetaminophen/codeine hydrocodone/acetaminophen meperidine propoxyphene/acetaminophen oxycodone oxycodone/acetaminophen betamethasone dipropionate 0.05% ointment, augmented clobetasol propionate 0.05% ointment clobetasol propionate 0.05% cream clobetasol propionate 0.05% gel clobetasol propionate 0.05% solution PARKINSON’S DISEASE amantadine carbidopa/levodopa pergolide COMTAN DOSTINEX MIRAPEX REQUIP GROUP II PAIN—MODERATE TO SEVERE morphine sulfate ext-rel DURAGESIC MS CONTIN (200 mg tablet) MSIR (except oral liquids) OXYCONTIN DIURETICS/ COMBINATION PRODUCTS amiloride/hctz bumetanide chlorthalidone furosemide hydrochlorothiazide spironolactone spironolactone/hctz triamterene/hctz torsemide MYKROX ZAROXOLYN PSYCHOSES haloperidol RISPERDAL SEROQUEL ZYPREXA ZYPREXA ZYDIS MISCELLANEOUS tramadol ANTIANXIETY MEDICATIONS alprazolam buspirone diazepam lorazepam oxazepam betamethasone dipropionate 0.05% ointment betamethasone dipropionate 0.05% cream betamethasone dipropionate 0.05% lotion desoximetasone 0.05% gel desoximetasone 0.25% ointment desoximetasone 0.25% cream diflorasone diacetate 0.5% ointment diflorasone diacetate 0.5% cream fluocinonide 0.05% ointment fluocinonide 0.05% cream fluocinonide 0.05% gel fluocinonide 0.05% solution SEIZURES carbamazepine clonazepam phenobarbital phenytoin ext-rel primidone valproic acid CARBATROL DEPAKENE DEPAKOTE DIASTAT DILANTIN KEPPRA LAMICTAL NEURONTIN PHENYTEK TEGRETOL TEGRETOL XR TRILEPTAL TOPAMAX ZONEGRAN GROUP III NITRATES isosorbide mononitrate ext-rel nitroglycerin ANTIVERTIGO/ANTINAUSEA meclizine prochlorperazine promethazine trimethobenzamide SYMPATHOLYTICS clonidine methyldopa MISCELLANEOUS guanfacine hydralazine PROAMATINE ATTENTION DEFICIT/ HYPERACTIVITY DISORDER amphetamine mixed salts methylphenidate ADDERALL XR CONCERTA METADATE CD METADATE ER CENTRAL NERVOUS SYSTEM ALZHEIMER’S DISEASE ARICEPT EXELON REMINYL desoximetasone 0.05% cream fluocinolone acetonide 0.025% ointment hydrocortisone valerate 0.2% cream betamethasone valerate 0.1% ointment betamethasone valerate 0.1% cream betamethasone valerate 0.1% lotion mometasone furoate 0.1% ointment triamcinolone acetonide 0.025% ointment triamcinolone acetonide 0.025% cream triamcinolone acetonide 0.025% lotion triamcinolone acetonide 0.1% ointment triamcinolone acetonide 0.1% cream triamcinolone acetonide 0.1% lotion triamcinolone acetonide 0.1% paste triamcinolone acetonide 0.5% cream DIPROLENE GEL DIPROLENE LOTION BIPOLAR AGENTS lithium carbonate ESKALITH CR LITHOBID GROUP IV DERMATOLOGY Generic dermatology medications are sometimes given specific names by their manufacturers for ease of reference. These are listed in brackets after the generic name. DEPRESSION ANALGESICS amitriptyline bupropion desipramine doxepin fluoxetine imipramine hcl mirtazapine nortriptyline trazodone CELEXA EFFEXOR EFFEXOR XR LEXAPRO NARDIL PARNATE PAXIL PAXIL CR CONVENTIONAL NSAIDS diclofenac sodium etodolac flurbiprofen ibuprofen indomethacin ketorolac nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac ACNE ACNE ROSACEA FINACEA 15% GEL NORITATE desonide 0.05% ointment desonide 0.05% cream desonide 0.05% lotion fluocinolone acetonide 0.01% cream fluocinolone acetonide 0.01% solution fluocinolone 0.025% cream hydrocortisone 2.5% ointment hydrocortisone 2.5% cream hydrocortisone 2.5% lotion FUNGAL INFECTIONS clotrimazole/betamethasone ketoconazole 2% cream nystatin powder nystatin/triamcinolone LOPROX NIZORAL 2% SHAMPOO ACNE VULGARIS ORAL erythromycin oral isotretinoin [Amnesteem] tetracycline oral TOPICAL clindamycin/benzoyl gel [Duac] clindamycin topical PSORIASIS methotrexate (2.5 mg tablet only) DOVONEX Walgreens Health Initiatives 2003 Three-tier Patient Drug Formulary Guide Effective June 15, 2003 TAZORAC Page 3 REBETOL REBETRON OSTEOPOROSIS AGENTS EVISTA FORTEO FOSAMAX INFECTION ANTIBACTERIAL DRUGS CEPHALOSPORINS First Generation cefadroxil cephalexin SCABIES AND PEDICULOSIS OVIDE MISCELLANEOUS AMEBICIDES mebendazole metronidazole isoniazid VIRAL INFECTIONS CONDYLOX GEL ZOVIRAX 5% OINTMENT THYROID MODIFIERS Generic thyroid medications are often given specific names by their manufacturers for ease of reference. These are listed in brackets after the generic name. levothyroxine sodium [Levothroid, Levoxyl, Unithroid] methimazole ARMOUR THYROID (15 mg, 240 mg, 300 mg tablets) CYTOMEL SYNTHROID THYROLAR MISCELLANEOUS selenium sulfide CARAC CORTIFOAM EFUDEX ELIDEL EMLA FLUOROPLEX PROTOPIC REGRANEX Second Generation cefaclor cefuroxime CEFZIL ANTITUBERCULOSIS AGENTS MALARIA AND OTHER PROTOZOAL INFECTIONS mefloquine DAPSONE MALARONE Third Generation OMNICEF FLUOROQUINOLONES AVELOX CIPRO LEVAQUIN MUSCULOSKELETAL CYCLOOXYGENASE INHIBITORS CELEBREX VIOXX ENDOCRINOLOGY ADRENAL CORTICOSTEROIDS dexamethasone fludrocortisone hydrocortisone methylprednisolone prednisone MACROLIDES MISCELLANEOUS DECLOMYCIN tablets DDAVP tablets erythromycin oral BIAXIN BIAXIN XL ZITHROMAX DMARDS CUPRIMINE RIDAURA GASTROINTESTINAL ANTIEMETICS ZOFRAN ZOFRAN ODT PENICILLINS amoxicillin ampicillin dicloxacillin penicillin VK GOUT AGENTS allopurinol colchicine probenecid ANDROGENS DEPO-TESTOSTERONE DIABETES MELLITUS INSULIN HUMALOG HUMALOG 75/25 HUMULIN 50/50 HUMULIN 70/30 HUMULIN L HUMULIN N HUMULIN R HUMULIN U LANTUS NOVOLIN 70/30 NOVOLIN INNOLET N NOVOLIN INNOLET 70/30 NOVOLIN L NOVOLIN N NOVOLIN R NOVOLOG CROHN’S/INFLAMMATORY BOWEL DISEASE dicyclomine ASACOL CANASA ENTOCORT EC ROWASA SULFONAMIDES GANTRISIN PEDIATRIC RHEUMATOID/OSTEOARTHRITIS hydroxychloroquine HUMIRA TETRACYCLINES doxycycline hyclate minocycline URINARY ANTI-INFECTIVES nitrofurantoin macrocrystals SPASTICITY baclofen carisoprodol cyclobenzaprine methocarbamol tizanidine DANTRIUM DIARRHEA diphenoxylate/atropine COMBINATION ANTIBIOTICS amoxicillin trihydrate/potassium clavulanate sulfamethoxazole/trimethoprim clindamycin oral metronidazole ketoconazole nystatin DIFLUCAN GRIS-PEG LAMISIL VFEND PANCREATIC ENZYMES pancreatic enzyme preparations CREON ENZYMAX KU-ZYME KU-ZYME HP ULTRASE VIOKASE MISCELLANEOUS ANTIBIOTICS OPHTHALMIC/OTIC OPHTHALMIC—ALLERGY cromolyn 4% ophthalmic drops OPTIVAR ZADITOR ANTIFUNGALS ORAL AGENTS glipizide glyburide glyburide micronized metformin ACTOS AMARYL AVANDIA AVANDAMET GLUCOTROL XL GLUCOVANCE PRANDIN PRECOSE PROMOTILITY AGENTS metoclopramide OPHTHALMIC—ANTIBACTERIAL erythromycin ophthalmic gentamicin ophthalmic neomycin/polymyxin B/bacitracin ointment neomycin/polymyxin B/gramicidin solution polymyxin B/trimethoprim sulfacetamide 10% ophthalmic drops tobramycin ophthalmic OCUFLOX ULCERS AND REFLUX (GERD) cimetidine famotidine misoprostol nizatidine omeprazole ranitidine tablets sucralfate ACIPHEX HELIDAC NEXIUM ZANTAC SYRUP ANTIVIRAL DRUGS acyclovir CYTOMEGALOVIRUS CYTOVENE VALCYTE HERPES HIV VALTREX All medications used for the treatment of HIV are on the Formulary, if FDA approved. DIABETES MONITORING ACCU-CHEK Meters/Test Strips CHEMSTRIP BG Test Strips ONE TOUCH Meters/Test Strips OPHTHALMIC— ANTI-INFLAMMATORIES neomycin/polymyxin B/dexamethasone prednisolone 1% ophthalmic drops ACULAR LOTEMAX TOBRADEX MISCELLANEOUS sulfasalazine ursodiol GOLYTELY NULYTELY URSO VISICOL GLUCOSE ELEVATING AGENTS GLUCAGON HEPATITIS AGENTS INTRON A GROWTH HORMONE NUTROPIN NUTROPIN AQ NUTROPIN DEPOT SAIZEN HEPATITIS B EPIVIR-HBV HEPSERA OPHTHALMIC—ANTIVIRAL trifluridine HEPATITIS C INFERGEN PEGASYS PEG-INTRON OPHTHALMIC—GLAUCOMA acetazolamide methazolamide pilocarpine timolol maleate Walgreens Health Initiatives 2003 Three-tier Patient Drug Formulary Guide Effective June 15, 2003 ALPHAGAN ALPHAGAN P BETIMOL LUMIGAN TRUSOPT XALATAN Page 4 Listed below are some nonpreferred medications with generic or preferred formulary brand alternatives available at a lower copayment than nonpreferred medications. Please share this guide with your doctor: MISCELLANEOUS ADVAIR DISKUS ATROVENT MDI COMBIVENT OTHER CONTRACEPTION ORTHO EVRA NUVARING EMERGENCY CONTRACEPTION PLAN B PREVEN SUPPLEMENTS HYPERPHOSPHATEMIA AGENTS PHOSLO RENAGEL OPHTHALMIC—MISCELLANEOUS atropine 1% ophthalmic drops atropine 1% ophthalmic ointment INJECTABLE ESTROGENS/ PROGESTINS DEPO-PROVERA LUNELLE Non-Preferred Aceon OTIC (EAR) antipyrine/benzocaine otic FLOXIN OTIC POTASSIUM SUPPLEMENTS potassium chloride ext-rel MISCELLANEOUS lidocaine viscous VITAMIN PREPARATIONS prenatal vitamin preparations MENOPAUSE/ POSTMENOPAUSAL OSTEOPOROSIS ESTROGENS estradiol estradiol transdermal estropipate CENESTIN CLIMARA (0.025 mg/day and 0.075 mg/day) ESCLIM ESTRADERM ESTRATAB ESTRATEST ESTRATEST HS FEMHRT PREMARIN PREMPHASE PREMPRO VIVELLE VIVELLE-DOT Preferred lisinopril, enalapril, captopril, Accupril, Altace Flovent, Pulmicort, Azmacort Imitrex, Maxalt, Zomig Avapro, Cozaar Avalide, Hyzaar Avapro, Cozaar Avalide, Hyzaar Detrol, Detrol LA Norvasc Norvasc Imitrex, Maxalt, Zomig Avapro, Cozaar Avalide, Hyzaar lisinopril, enalapril, captopril, Accupril, Altace flunisolide, Flonase, Nasacort AQ, Nasonex, Rhinocort Aqua Norvasc omeprazole, Nexium, Aciphex Flovent, Pulmicort, Azmacort Avapro, Cozaar lovastatin, Lipitor, Pravachol, Lescol, Lescol XL Accolate, Singulair Clarinex, Allegra Allegra-D Aerobid/M RESPIRATORY ANTIHISTAMINES— SECOND GENERATION ALLEGRA CLARINEX UROLOGICAL ANESTHETIC AGENTS phenazopyridine Amerge Atacand Atacand HCT Diovan Diovan HCT Ditropan XL Dynacirc Dynacirc CR Frova Micardis Micardis HCT Monopril ANTIHISTAMINE/DECONGESTANT COMBINATIONS ALLEGRA-D SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIA doxazosin terazosin FLOMAX COUGH/COLD PRODUCTS benzonatate guaifenesin guaifenesin/codeine guaifenesin/pseudoephedrine ext-rel hydrocodone/guaifenesin promethazine/codeine URINARY INCONTINENCE oxybutynin DETROL DETROL LA MISCELLANEOUS ELMIRON UROCIT-K PROGESTINS NASAL ASTELIN medroxyprogesterone acetate WOMEN’S HEALTH CONTRACEPTION, ORAL Generic contraceptive medications are often given specific names by their manufacturers for ease of reference. These are listed in brackets after the generic name. VAGINAL PREMARIN VAGINAL STEROIDS flunisolide FLONASE NASACORT AQ NASONEX RHINOCORT AQUA VAGINAL INFECTIONS DIFLUCAN 150 mg tablet METROGEL-VAGINAL MISCELLANEOUS METHERGINE SARAFEM ASTHMA/COPD BETA-AGONIST INHALERS albuterol metered-dose inhaler ALUPENT INHALER FORADIL SEREVENT DISKUS MONOPHASIC Nasarel CORTICOSTEROID INHALED MEDICATIONS AZMACORT FLOVENT FLOVENT ROTADISK PULMICORT TURBUHALER INHALATIONS FOR NEBULIZATION albuterol solution cromolyn ipratropium bromide PULMICORT RESPULES ethinyl estradiol/desogestrel [Apri] ethinyl estradiol/ethynodiol [Zovia] ethinyl estradiol/levonorgestrel [Aviane, Lessina, Levora, Portia] ethinyl estradiol/norethindrone [Necon, Nortrel] ethinyl estradiol/norethindrone [Microgestin] ethinyl estradiol/norethindrone/iron [Microgestin Fe] ethinyl estradiol/norgestimate [Sprintec 28] ethinyl estradiol/norgestrel [Cryselle, Low-Ogestrel, Ogestrel] YASMIN MISCELLANEOUS AGENTS ANTI-ALLERGIC/ANAPHYLAXIS EPIPEN EPIPEN JR. GASTROCROM Plendil Prevacid DRY MOUTH— SJOGREN’S SYNDROME EVOXAC SALAGEN QVAR Teveten Zocor BIPHASIC ethinyl estradiol/desogestrel [Kariva] ethinyl estradiol/norethindrone [Necon] LEUKOTRIENE MODIFIERS ACCOLATE SINGULAIR TRIPHASIC ORAL MEDICATIONS Beta Agonists albuterol Oral Steroids prednisolone syrup prednisone ethinyl estradiol/levonorgestrel [Enpresse, Trivora-28] ethinyl estradiol/norethindrone [Nortrel 7/7/7] CYCLESSA ESTROSTEP FE ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO TRI-NORINYL Zyflo Zyrtec Zyrtec-D PROGESTIN norethindrone [Camila, Errin, Nora-BE]