FORMULARY. (List of Covered Drugs) This document includes Passport Health Plan s complete formulary as of January 22, 2009.

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1 FORMULARY (List of Covered Drugs) This document includes Passport Health Plan s complete formulary as of January 22, 2009.

2 What is the Passport Health Plan formulary? The formulary is a list of preferred drugs covered by Passport Health Plan. To get a drug on our formulary, you must: Be a Passport Health Plan member. Need a drug that is medically necessary. Get the prescription filled at a Passport Health Plan network pharmacy. A network pharmacy is one that is signed up with Passport Health Plan. Follow all Passport Health Plan rules. The formulary is not a complete list of covered drugs covered by Passport Health Plan. Some drugs not listed may be covered, if medically necessary. These drugs may or may not need prior-authorization. How do I find my drug on the formulary? You can find the formulary on our website at Under the section that says Quick Hits, click on Formulary. You can search for a drug by clicking on the picture of the binoculars right above the drug list on your tool bar. Next, you will see a search box to the right. Type in the name of the drug in the search box. If you are not sure how to spell the drug, you can search by entering the first few letters of the name. The drugs are listed by both brand and generic name. The bolded name means which drug (brand or generic) is available. Are there any limits to the drugs you have been prescribed? Some covered drugs may have limits on them. This could include: Prior-Authorization: Some medicines must be approved by Passport Health Plan before you can get them. This means your provider will need to get approval before you can have your prescriptions filled. If you do not get approval, Passport Health Plan may not cover the drug. Quantity Limits: For some drugs, there are limits on the amount Passport Health Plan will cover. This means you may not get the standard one month supply. Step Therapy: Sometimes Passport Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Passport Health Plan may not cover drug B unless you try Drug A first. If Drug A does not work for you, Passport Health Plan will then cover Drug B. Too Early to Refill: If you are given a month supply of a medicine, Passport Health Plan will not give a refill of the prescription until 30 days has passed. i

3 What if my drug is not on the formulary? Remember, not all drugs are listed on the formulary. If Passport Health Plan does not cover your drug, you have 3 options: 1. Work with your pharmacy to find the preferred drug. 2. You can ask Member Services for a list of similar drugs that are preferred by Passport Health Plan. 3. If the drug is denied, you can file an appeal. To find out how to do this, see pages of your Member Handbook. Can the formulary change? Yes. Passport Health Plan may add or remove drugs from the formulary during the year. To get updated information about covered drugs, please visit our website at or call Member Services at and press 2. What are generic drugs? Passport Health Plan covers both brand-name and generic drugs. A generic drug has the same active ingredient as the brand-name drug. This means they work the same and have the same effect. Generic drugs usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA). How much will I have to pay for covered medicines? Some Passport Health Plan members pay a small co-pay for each medicine they fill. The prescription copay is $1.00 for each prescription, including over-the-counter medicines. Please Note: The pharmacy must fill your prescription the first time, even if you cannot pay. If you cannot pay the copay when you get your prescription, you should pay it the next time. The pharmacy may tell you they will not fill your prescriptions anymore if you do not pay the co-pay. Those who do not have to pay a co-pay are members who are: 18 years and under. Pregnant. Receiving services within the first 60 days after delivery of a baby. In a nursing facility. In a personal care home. In an intermediate care facility for people with mental retardation (ICF/MR). A foster child in state custody. American Indians or Alaskan natives served through KCHIP program. In hospice care. ii

4 PASSPORT HEALTH PLAN PREFERRED DRUG LIST 2009 GENERIC NAME BRAND NAME DOSAGE FORM NOTES ACE INHIBITOR MEDICATIONS Benazepril Lotensin Tablet Captopril Capoten Tablet Enalapril Vasotec Tablet Fosinopril Monopril Tablet Lisinopril Zestril, Prinivil Tablet Perindopril Aceon Tablet Trandolapril Mavik Tablet ACNE MEDICATIONS (ORAL) Doxycycline Vibramycin, Capsule, Tablet Periostat Isotretinoin Accutane Capsule Minocycline Minocin Capsule Tetracycline Sumycin Capsule ACNE MEDICATIONS (TOPICAL) Adapalene* Differin* Gel *PA Required > 21 yo; Qty limits: 45gms/30 days Benzoyl Peroxide Benzoyl Peroxide Cream, Gel, Solution Benzoyl Peroxide/ Erythromycin Benzamycin Cream Clindamycin Cleocin T Gel, Solution Erythromycin Erycette, Akne-mycin Swabs, Gel, Ointment, Solution Gentamicin Garamycin Cream, Ointment Metronidazole 0.75% Metrogel Gel Mupirocin Bactroban Ointment Sulfacetamide/Sulfur Sulfacet-R Lotion Tretinoin* Avita* Cream, Gel *PA Required > 21 yo; Qty limits: 45gms/30 days ALZHEIMERS MEDICATION Donepezil Aricept Tablets, ODT Rivastigmine Exelon Capsules, Patches, Solution Tacrine Cognex Tablets ANAPHYLAXIS THERAPY Epinephrine Epipen, Epipen Jr Injection *Qty limit: 2 injections per 30 days ANALGESIC MEDICATIONS Narcotics Butorphanol Stadol NS Nasal Spray Codeine Codeine Tablet, Solution Fentanyl Transdermal* Duragesic* Patch *Qty limit 10 patches per 30 days Hydromorphone Dilaudid Tablet, Solution, Suppository Meperidine Demerol Tablet, Syrup Methadone Dolophine Tablet Morphine MSIR Tablet, Solution, Suppository Morphine Extended Release* Oramorph SR, MS Contin Tablet *Qty limit BID dosing Morphine Extended Release Kadian Capsules Oxycodone Roxicodone Tablet, Solution 1

5 GENERIC NAME BRAND NAME DOSAGE FORM NOTES Propoxyphene Darvon Capsule Tramadol Ultram Tablet Narcotic Combinations APAP/Butalbital Phrenilin, Phrenilin Forte Tablet APAP/Butalbital/Caffeine Fioricet Tablet APAP/Butalbital/Caffeine/Codeine Fioricet with Codeine Tablet APAP/Codeine Tylenol with Codeine Tablet APAP/Hydrocodone Vicodin, Lortab Tablet 5/500mg, 7.5/500mg, 7.5/750mg, 10/500mg, 10/650mg APAP/Oxycodone Percocet Tablet APAP/Propoxyphene Darvocet N Tablet ASA/Butalbital/Caffeine Fiorinal Tablet ASA/Butalbital/Caffeine/Codeine Fiorinal with Codeine Tablet ASA/Oxycodone Percodan Tablet Meperidine/Promethazine Meperidine/Promethazine Capsule NSAIDs (Prescription Strengths Only) Diclofenac Cataflam Tablet Diclofenac Sodium ER Voltaren-XR Tablet Diflunisal Dolobid Tablet Etodolac IR and SA Lodine, Lodine XL Capsule, Tablet Fenoprofen Nalfon Tablet Flurbiprofen Ansaid Tablet Ibuprofen Motrin Tablet, Suspension Indomethacin Indocin Capsule Indomethacin Sustained Release Indocin SR Capsule Ketoprofen IR Orudis Capsule Ketoprofen SA Oruvail Capsule Meclofenamate Meclofenamate Capsule Meloxicam Mobic Tablets Nabumetone Relafen Tablet Naproxen Naprosyn Tablet Naproxen SA Naprelan Tablet Oxaprozin Daypro Tablet Sulindac Clinoril Tablet Tolmetin Tolectin Tablet COX-2 Inhibitors Celecoxib* Celebrex* Capsule *Step therapy or PA required SALICYLATES Aspirin Aspirin Tablet Salsalate Disalcid Capsule ANDROGENS Danazol Danocrine Capsule Methyltestesterone Android Tablet Oxandrolone Oxandrin Tablet Testosterone Transdermal Androgel Gel Testosterone Transdermal Androderm* Patch *PA required Testosterone Buccal Striant Buccal System ANESTHETICS (TOPICAL) Capsaicin Zostrix Lotion, Cream, Gel Lidocaine Xylocaine Jelly, Ointment 2

6 GENERIC NAME BRAND NAME DOSAGE FORM NOTES ANESTHETICS (URINARY) Phenazopyridine Pyridium Tablet ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARB) Olmesartan* Benicar* Tablet *Step therapy required: T/F of 2 preferred ACE Inhibitors Valsartan* Diovan* Tablet *Step therapy required: T/F of 2 preferred ACE Inhibitors ANORECTALS Hydrocortisone Anusol HC Cream, Suppository Hydrocortisone Enema Cortenema Enema ANTACIDS Aluminum/Magnesium Hydroxide Mylanta Suspension, Tablets Calcium Carbonate Tums Suspension, tablet Magnesium Hydroxide MOM Suspension Aluminum Hydroxide Alternagel Suspension Sodium Bicarbonate Sodium Bicarbonate Tablet ANTIADRENERGICS Clonidine Catapres Tablet, Patches Doxazosin Cardura Tablet Guanfacine Tenex Tablet Methyldopa Aldomet Tablet, Suspension Prazosin Minipress Capsule Reserpine Resperine Tablet Terazosin Hytrin Capsule ANTI-ALCOHOLIC MEDICATIONS Disulfiram Antabuse Tablet ANTIANDROGENS Bicalutamide Casodex Tablet Flutamide Eulexin Capsule Nilutamide Nilandron Tablet ANTIARRHYTHMICS Amiodarone Cordarone Tablet Disopyramide Norpace Capsule Disopyramide Controlled Release Norpace CR Capsule Dofetilide Tikosyn Capsule Flecainide Tambocor Tablet Mexiletine Mexitil Capsule Moricizine Ethmozine Tablets Procainamide Pronestyl Tablet, Capsule Procainamide Sustained Release Procan SR Tablet Propafenone Rythmol Tablet Quinidine Gluconate Quinaglute Tablet Quinidine Sulfate Quinidine Tablet Quinidine Sulfate Sustained Release Quinidex Tablet 3

7 ANTIBIOTICS (ORAL) Tetracyclines Doxycycline Vibramycin, Doryx Capsule Minocycline Minocin Capsule Tetracycline Sumycin Capsule Cephalosporins: First Generation Cephalexin Keflex Capsule, Suspension Cephradine Velosef Capsule, Suspension Cephalosporins: Second Generation Cefaclor Ceclor Capsule Suspension Cefuroxime Ceftin Tablet Suspension Cefprozil Ceprozil Suspension Only Cephalosporins: Third Generation Cefdinir Omnicef Capsule, Suspension Cefixime* Suprax* Tablet, Suspension *Qty limit: QD dosing Cefpodoxime Vantin Tablet, Suspension Erythromycins Azithromycin* Zithromax* Tablet, Suspension *Qty limit: 250mg (6 tab/30days); 500mg (5 tab/30days) Clarithromycin, Clarithromycin ER Biaxin, Biaxin XL * Tablet, Suspension Erythromycin Base Ery-Tab, Eryc Tablet, Capsule Erythromycin Ethylsuccinate E.E.S. Tablet, Suspension Erythromycin Stearate Erythrocin Tablet Erythromycin/Sulfisoxazole Pediazole Suspension Fluoroquinolones Ciprofloxacin Cipro Tablet, Suspension Levofloxacin* Levaquin* Tablet, Oral Solution *Qty limit: 5 tab/30 days Moxifloxacin* Avelox* Tablet, Suspension *Qty limit: 5 tab/30 days Ofloxacin Floxin Tablet Miscellaneous Clindamycin Cleocin Capsule, Suspension Penicillins Amoxicillin Amoxil Capsule, Suspension Amoxicillin/Pot Clavulanate Augmentin Tablet, Suspension Ampicillin Principen Capsule, Suspension Dicloxacillin Dynapen Capsule, Suspension Penicillin VK PenVee K Tablet, Suspension Sulfonamides Sulfadiazine Sulfadiazine Tablet Sulfamethoxazole/Trimethoprim Bactrim, Bactrim DS Tablet, Suspension Sulfisoxazole Gantrisin Tablets Suspension Urinary Tract Medications Fosfomycin Monurol Granules Nitrofurantoin/Macrocrystals/Monohydrate Macrobid Capsule Nitrofurantoin/Macrocrystals Macrodantin Capsule, Suspension Trimethoprim Trimpex, Primsol Tablet ANTIBIOTICS (TOPICAL) Bacitracin Bacitracin Ointment Polymycin/Bacitracin Polysporin Ointment 4

8 Polymycin/Neomycin/Bacitracin Neosporin Ointment Silver Sulfadiazine SSD Cream ANTICOAGULANTS Warfarin Coumadin Tablet ANTICHOLINERGICS (INHALED) Ipratropium Solution Atrovent Solution Ipratropium Inhaler Atrovent Inhaler Tiotropium Spiriva Inhaler ANTICONVULSANTS Acetazolamide Diamox Capsule Carbamazepine Tegretol Tablet, Suspension Carbamazepine Sustained Release Tegretol XR Tablet Clonazepam Klonopin Tablet Divalproex Sodium Depakote Tablet Divalproex Sodium Depakote Sprinkles Divalproex Sodium Depakote ER Tablet Ethosuximide Zarontin Capsule, Syrup Gabapentin Neurontin Tablet, Capsule Lamotrigine Lamictal* Tablet *Brand is preferred Lamotrigine Chewable Lamictal Dispersible Tablet Chewable Levetiracetam Keppra Tablet Mephobarbital Mebaral Tablet Oxcarbazepine Trileptal Tablet Oxcarbazepine Trileptal Suspension Phenobarbital Phenobarbital Tablet,Syrup Phenytoin Dilantin Tablet Capsule Suspension Primidone Mysoline Tablet, Suspension Tiagabine Gabitril Tablet Valproic Acid Depakene Capsule, Syrup ANTIDEPRESSANTS NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS Bupropion IR, SR, XL Wellbutrin IR, SR, XL Tablet TETRACYCLICS Maprotiline Ludiomil Tablet TRIAZOLOPYRIDINES Trazodone Desyrel Tablet MONOAMINE OXIDASE INHIBITORS Phenelzine Nardil Tablet Tranylcypromine Parnate Tablet 5

9 TRICYCLICS Amitriptyline Elavil Tablet Amitriptyline/Chlordiazepoxide Limbitrol Tablet Amoxapine Ascendin Tablet Clomipramine Anafranil Capsule Desipramine Norpramin Tablet Doxepin Sinequan Capsule Imipramine Tofranil Capsule Nortriptyline Pamelor Capsule Protriptyline Vivactil Tablet Mirtazapine Remeron Tablet Trimipramine Surmontil Capsule SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI and SNRI) Citalopram Celexa Tablet Duloxetine * Cymbalta* Tablet *Step Therapy: T/F of 2 antidepressants (SSRIs, venlafaxine IR, bupropion IR, SR,XL) for 4 wks each Venlafaxine IR Effexor IR Escitalopram* Lexapro* Tablet *Step Therapy: T/F of citalopram & 1 of the following(ssris, venlafaxine IR, bupropion IR, SR,XL) for 4 wks each Fluoxetine Prozac Capsule Paroxetine, Paroxetine CR Paxil, Paxil CR Tablet Sertraline Zoloft Tablet ANTIDIARRHEALS Bismuth Subsalicylate Pepto-Bismol Tablet, Suspension Diphenoxylate/Atropine Lomotil Tablet, Solution Loperamide Imodium Capsule, Tablet ANTIDIURETIC HORMONES Desmopressin Acetate DDAVP Tablet, *Spray ANTIEMETICS Aprepitant Emend Capsule Ondansetron* Zofran* Tablet, Solution *Spray requires PA *Formulary with PA; Qty limits: 4mg, 8mg, 15 tab/30 days, 24mg, 5 tab/30 days Oral Soln. 50ml / 30 days Promethazine Phenergan Tablet, Syrup, Suppository Prochlorperazine Regular Release Compazine Tablet, Syrup, Suppository ANTIESTROGENS Tamoxifen Nolvadex Tablet Toremifene Fareston Tablet ANTIFUNGALS (ORAL) Fluconazole Diflucan Tablet, Suspension Griseofulvin Microsize Grifulvin V Tablet, Suspension Griseofulvin Ultramicrosize Gris-PEG Tablet QL: 150mg tab-4 tablets/28 days 6

10 Ketoconazole Nizoral Tablet Nystatin Mysostatin Tablet, Suspension Terbinafine Lamisil Tablet ANTIFUNGALS (TOPICAL) Gentian Violet Gentian Violet Solution Clotrimazole Lotrimin Cream Solution Lotion Ketoconazole Nizoral Cream Miconazole Micatin Cream, Ointment Nystatin Mycostatin Cream, Ointment Nystantin/Triamcinolone Mycolog II Cream, Ointment Tolnaftate Tinactin Cream, Gel ANTIHISTAMINES (ORAL) Carbinoxamine Palgic Tablet, Capsule, Liquid Cetirizine Zyrtec OTC Tablet, Chewables Cetirizine Zyrtec OTC Syrup Chlorpheniramine Chlor-Trimeton Tablet, Syrup Clemastine Tavist Tablet Cyproheptadine Periactin Tablet Diphenhydramine Benadryl Capsule Tablet Solution Hydroxyzine Atarax Tablet Solution Loratadine OTC Claritin, Alavert Tablet, Syrup Promethazine Phenergan Tablet Solution Triprolidine Zymine Syrup ANTIHISTAMINE/DECONGESTANT COMBINATIONS (ORAL) Cetirizine/Pseudoephedrine Zyrtec-D OTC Tablet Loratadine/Pseudoephedrine Claritin-D Tablet Pseudoephedrine/Triprolodine Actifed Tablet ANTIHYPERTENSIVE COMBINATIONS Amlodipine / Benazepril Lotrel Capsule Amlodipine/ Valsartan Exforge Tablet *Step therapy required: T/F of 2 preferred ACE Inhibitors Atenolol / Chlorthalidone Tenoretic Tablet Benazepril / HCTZ Lotensin Tablet Bisoprolol / HCTZ Ziac Tablet Capotopril / HCTZ Capozide Tablet Clonidine / Chorthalidone Clorpres Tablet Enalapril / HCTZ Vaseretic Tablet Fosinopril / HCTZ Monopril HCT Tablet Hydralazine / HCTZ Apresazide Capsule Lisinopril / HCTZ Zestoretic, Prinizide Tablet Methyldopa / HCTZ Aldoril Tablet Moexipril / HCTZ Uniretic Tablet Olmesartin / HCTZ* Benicar HCT* Tablet *Step Therapy: T/F preferred ACE-Inhibitors/HCTZ combination 7

11 Propranolol/HCTZ Inderide Tablet Reserpine/HCTZ Hydropres Tablet Spironolactone/HCTZ Aldactazide Tablet Trandolapril/Verapamil Tarka Tablet Valsartan/HCTZ* Diovan/HCT* Tablet *Step Therapy: T/F preferred ACE-Inhibitors/HCTZ combination ANTIHYPERTENSIVES-OTHER Guanabenz Wytensin Tablet ANTILIPIDEMICS Atorvastatin Lipitor Tablet Cholestyramine Questran, Powder Questran Light Colestipol Colestid Tablet Fenofibrate Tricor Capsule Fluvastatin Lescol, Lescol XL Capsule Gemfibrozil Lopid Tablet Lovastatin Mevacor Tablet Lovastatin/Niacin Advicor Tablet Nicotinic Acid Niacor/Niaspan Tablet Pravastatin Pravachol Tablet Simvastatin Zocor Tablet Simvastatin/Ezetimibe Vytorin* Tablet *Step Therapy with preferred generics ANTIMALARIALS Chloroquine Phosphate Aralen Tablet Hydroxychloroquine Plaquenil Tablet Primaquine Primaquine Tablet Pyrimethamine Daraprim Tablet ANTIMANICS Lithium Carbonate Eskalith Capsule, Solution Lithium Carbonate CR Lithobid/ Eskalith CR Tablet, Solution ANTINEOPLASTICS ADJUNCTIVE MEDICATIONS Leucovorin (Folinic Acid) Leucovorin Tablet ALKYLATING MEDICATIONS Altretamine Hexalen Tablet Busulfan Myleran Tablet Chlorambucil Leukeran Tablet Cyclophosphamide Cytoxan Tablet Estramustine Emcyt Capsule Lomustine CeeNu Capsule Melphalan Alkeran Tablet Temozolomide Temodar Capsule ANTIMETABOLITES Capecitabine Xeloda Tablet Mercaptopurine Purinethol Tablet Methotrexate Rheumatrex Tablet Thioguanine Thioguanine Capsule MISCELLANEOUS ANTINEOPLASTICS Anastrozole Arimidex Tablet Exemestane Aromasin Tablet 8

12 Fluorouracil Efudex Cream, Solution Hydroxyurea Hydrea Capsule Letrozole Femara Tablet Mitotane Lysodren Tablet Procarbazine Matulane Tablet ANTIPARASITICS Dapsone Dapsone Tablet Iodoquinol Yodoxin Tablet Ivermectin Stromectol Tablet Mebendazole Vermox Chewable Tablets Metronidazole Flagyl Tablets ANTIPARKINSONIANS Amantadine Symmetrel Capsule, Syrup Benztropine Cogentin Tablet Biperiden Akineton Tablet Bromocriptine Mesylate Parlodel Tablet, Capsule Carbidopa/Levodopa Sinement, Sinemet CR Tablet Carbidopa/Levodopa/Entacapone Stalevo Tablet Diphenhydramine Benadryl Capsule, Solution Entacapone Comtan Tablet Levodopa Larodopa Tablet Pramipexole Mirapex Tablet Ropinirole Hydrochloride Requip Tablet Selegiline Eldepryl Tablet, Capsule Tolcapone Tasmar Tablet Trihexyphenidyl Artane Tablet ANTIPLATELET AGGREGATION MEDICATIONS Aspirin Aspirin Tablet Aspirin/Dipyridamole Aggrenox Capsule Anagrelide Agrylin Capsule Cilostazol Pletal Tablet Clopidogrel Plavix Tablet Dipyridamole Persantine Tablet Ticlopidine Ticlid Tablet ANTIPSORIATICS (TOPICAL) Anthralin Psoriatec Cream Calcipotriene Dovonex Cream, Ointment Calcipotriene Dovonex Solution Tazarotene Tazorac ANTIPSYCHOTICS Apripiprazole Abilify* Tablet, Solution *Injection requires PA Apripiprazole Abilify Discmelt Rapid Dissolve Tab Chlorpromazine Thorazine Tablet Clozapine Clozaril Tablet Fluphenazine Prolixin Tablet, Injection Haloperidol Haldol Tablet Solution Injection Loxapine Loxitane Capsule, Solution Molindone Moban Tablet Olanzapine Zyprexa Tablet Olanzapine Zyprexa Zydis Oral Disintegrating Tablet Perphenazine Trilafon Tablet 9

13 Pimozide Orap Tablet Quetiapine Seroquel Tablet Quetiapine SR Seroquel XR Tablet Risperidone Risperdal Tablet, Solution Thioridazine Mellaril Tablet, Solution Thiothixene Navane Capsule, Solution Trifluoperazine Stelazine Tablet, Solution Ziprasidone Geodon Capsule ANTIRHEUMATICS (RA) Auranofin Ridaura Capsule Hydroxychloroquine Plaquenil Tablet Leflunomide Arava Tablet Methotrexate Rheumatrex Tablet Penicillamine Cuprimine Capsule Sulfasalazine Azulfidine Tablet ANTISEBORRHEICS (TOPICAL) Ketoconazole Nizoral Shampoo Selenium Sulfide Selsun Blue Shampoo Sulfacetamide Klaron Suspension ANTISPASMODIC/ANTICHOLINERGICS (GI) Dicyclomine Bentyl Capsule Glycopyrrolate Robinul Tablet Hyoscyamine Levsin, Levbid Tablet Propantheline Probanthine Tablet ANTISPASMODIC/ANTICHOLINERGICS (UROLOGICAL) Darifenacin Hydrobromide Enablex Tablet Methanamine/Methylene Blue/ Atropine Urised Tablet / Hyoscyamine Oxybutynin Ditropan Tablet Solifenacin Succinate Vesicare Tablet Tolterodine Detrol Tablet Tolterodine Extended Release Detrol LA Capsules ANTITHYROIDS Methimazole Tapazole Tablet Potassium Iodide SSKI Tablet, Solution Propylthiouracil Propylthiouracil Tablet ANTITUBERCULOSAL MEDICATIONS Ethambutol Myambutol Tablet Isoniazid Nydrazid Tablet Pyrazinamide Pyrazinamide Tablet Rifabutin Mycobutin Capsule Rifampin Rifadin Capsule ANTIVERTIGO MEDICATION Meclizine Antivert Tablet ANTIVIRALS (ORAL) Acyclovir Zovirax Capsules Ointment* *PA Required for Ointment Famciclovir Famvir Tablet Ganciclovir Cytovene Capsule Valacyclovir Valtrex Tablet 10

14 ANTIVIRALS (TOPICAL) Docosanol Abreva Cream Penciclovir Denavir Cream ANXIOLYTICS Alprazolam Xanax Tablet Buspirone Buspar Tablet Chlordiazepoxide Librium Capsule Clorazepate Tranxene Tablet Diazepam Valium Tablet Lorazepam Ativan Tablet Oxazepam Serax Tablet BENIGN PROSTATIC HYPERPLASIA MEDICATIONS Doxazosin Cardura Tablet Dutasteride Avodart Capsule Finasteride Proscar Tablet Tamsulosin Flomax Capsule Terazosin Hytrin Capsule BETA AGONISTS (INHALED) Albuterol Aerosol Ventolin HFA Inhaler Albuterol Solution* Proventil Solution *0.083%, 0.5 % Isoetharine Isotharine Solution Levalbuterol Xopenex* Solution *Pulmonologists only; Qty limit 120 vials/30 days Metaproterenol Alupent Inhaler, Solution Salmeterol Serevent Inhaler BETA AGONISTS (ORAL) Albuterol Proventil Syrup, Tablet Formoterol Foradil Inhaler Terbutaline Brethine Tablet BETA AGONIST/ANTICHOLINERGIC COMBINATIONS (INHALED) Ipratropium/Albuterol Combivent Inhaler BETA AGONIST/CORTICOSTEROID COMBINATIONS (INHALED) Fluticasone/Salmeterol Advair, Advair HFA Inhaler Budesonide/Formeterol Symbicort Inhaler BETA BLOCKERS (ORAL) Atenolol Tenormin Tablet Carvedilol Coreg Tablet Carvedilol Coreg CR Capsule Labetalol Trandate Tablet Metoprolol Lopressor, Toprol XL Tablet Nadolol Corgard Tablet Pindolol Visken Tablet Propranolol, Propranolol SR Inderal, Inderal LA Tablet Capsule Solution Sotalol Betapace Tablet Timolol Blocadren Tablet BONE RESORPTION SUPPRESSORS Alendronate Fosamax Tablet Alendronate/Vit D 3 Fosamax-D Tablet 11

15 Calcitonin Miacalcin Spray Etidronate Didronel Tablet Raloxifene Evista Tablet Risedronate Actonel Tablet BURN THERAPY (TOPICAL) Silver Sulfadiazine Silvadene Cream CALCIUM CHANNEL BLOCKER Amlodipine Norvasc Tablet Diltiazem Cardizem Tablet Diltiazem Extended Release Cardizem CD, LA Capsule, Tablet Nifedipine Sustained Release Adalat CC Tablet Nisoldipine Sular Tablet Verapamil Calan Tablet Verapamil SR Calan SR Tablet CALCIUM METABOLISM Calcitriol Rocaltrol Capsule Dihydrotachysterol (DHT) Vitamin D Tablet Ergocalciferol Vitamin D 2 Capsule CARDIAC GLYCOSIDES Digoxin Lanoxin Tablet CHELATORS Succimer Chemet Capsule CHOLINERGICS (URINARY) Bethanechol Urecholine Tablet CHOLINERGIC MUSCLE STIMULANTS Neostigmine Prostigmin Tablet Pyridostigmine Mestinon Tablet CNS STIMULANTS Atomoxetine* Strattera* Capsule *Prior Auth Required Dexmethylphenidate Hydrochloride Focalin Dexmethylphenidate Hydrochloride Focalin XR Capsule Dextroamphetamine Dexedrine Tablet Methylphenidate Controlled Release Concerta Tablet Methylphenidate Sustained Release Ritalin SR Tablet, Capsule Methylphenidate Ritalin Tablet Mixed Amphetamines Extended Release Adderall XR Capsule Mixed Amphetamines Adderall Tablet Lisdexamphetamine Dimesylate Vyvanse Capsule CONTRACEPTIVE, INJECTABLES Medroxyprogesterone* Depo-Provera* Injection *Female only CONTRACEPTIVES, ORAL Ethinyl Estradiol 50 mcg/ Norgestrel 0.5 mg Ovral Tablet Ethinyl Estradiol 50mcg/Ethynodiol 1 mg Demulen 1/50, Zovia 1/50 Tablet Ethinyl Estradiol 35 mcg/ Ethynodiol 1mg Demulen 1/35, Zovia 1/35 Tablet Ethinyl Estradiol 30 mcg/norgestrel 0.3 mg LoOvral, Low-Ogestrol Tablet Ethinyl Estradiol 30mcg/ Desogestrel 0.15 mg Desogen, Ortho-Cept Tablet Ethinyl Estradiol 35mcg/Norethindrone 1mg Nelova 1/35 Tablet Ethinyl Estradiol 30 mcg/norethindrone 1.5mg Loestrin 1.5/30 Tablet Ethinyl Estradiol 20 mcg/norethindrone 1mg Loestrin 1/20 Tablet Ethinyl Estradiol 20 mcg/levonorgestrel 0.1 mg Alesse Tablet 12

16 Ethinyl Estradiol 35 mcg/ Norethindrone 0.5 mg Modicon Tablet Ethinyl Estradiol 35 mcg/ Norethindrone 0.4 mg Ovcon-35 Tablet Ethinyl Estradiol 35 mcg/ Norgestimate 0.25 mg Mononessa, Ortho-Cyclen Tablet 1 mg norethindrone/50 mcg mestranol Ortho-Novum 1/50, Necon Tablet Ethinyl Estradiol 35mcg/Norethindrone 1mg Ortho-Novum 1/35, Tablet Necon 1/35 Ethinyl Estradiol 30 mcg/ Drospirenone 3 mg Yasmin Tablet Ethinyl Estradiol 30mcg/ Levonorgestrel 0.15mg Levora Tablet Ethinyl Estradiol/Desogestrel/ Cyclessa Tablet Ethinyl Estradiol/Norethindrone/ Estrostep FE Tablet Ethinyl Estradiol 35/Norethindrone0.75 Ortho-Novum 777, Necon 777 Tablet Ethinyl Estradiol 35/ Norgestimate 0.18 Ortho Tri-Cyclen/Trinessa Tablet Ethinyl Estradiol 35/Norethindrone 0.5 Tri-Norinyl Tablet Norethindrone 0.35 mg Ortho-Micronor Tablet Ethinyl Estradiol 10, 20mcg/ Desogestrel 0.15mg Mircette Tablet Ethinyl Estradiol 35/Norethindrone0.5, 1 mg Ortho-Novum/Necon 10/11 Tablet Ethinyl Estradiol 30,40mcg/ Levonorgestrel.05,.075,.125 Triphasil, Trivora Tablet CORTICOSTEROIDS (INHALED) Beclomethasone QVAR Inhaler Budesonide* Pulmicort* Inhaler, Respules* Flunisolide Aerobid, Aerobid-M Inhaler Fluticasone Flovent HFA Inhaler Fluticasone/Salmeterol Advair, Advair HFA Inhaler Mometasone Furoate Asmanex Twisthaler Inhaler Triamcinolone Azmacort Inhaler *PA Required: >5 years old *QD dosing for 0.25mg/2ml *QD-BID dosing for 0.5mg/2ml *QD dosing for 1mg/2ml CORTICOSTEROIDS (ORAL) Cortisone Cortone Tablet Dexamethasone Decadron Tablet, Solution Fludrocortisone Florinef Tablet Hydrocortisone Hydrocortisone Tablet Methylprednisolone Medrol Tablet Prednisolone Orapred Syrup Prednisone Orasone Tablet, Solution CORTICOSTEROIDS (TOPICAL) Group I (Very High Potency) Augmented Betamethasone Dipropionate Diprolene Ointment Clobetasol 0.05% Temovate Cream, Ointment, Solution Group II (High Potency) Amcinonide 0.1% Cyclocort Cream Betamethasone Dipropionate 0.05% Diprosone Cream, Ointment Betamethasone Valerate 0.1% Valisone Ointment Desoximetasone 0.25% Topicort Cream, Ointment Desoximetasone 0.05% Topicort Gel Diflorasone Diacetate 0.05% Psorcon Cream, Ointment Fluocinolone 0.2% Synalar Cream Fluocinolone 0.05% Lidex Ointment Cream Gel Triamcinolone Acetonide 0.5% Kenalog Cream Ointment 13

17 Group III (Medium Potency) Betamethasone Dipropionate 0.05% Diprosone Lotion Betamethasone Valerate 0.1% Valisone Cream Desoximetasone 0.05% Topical LP Cream Fluocinolone Acetonide 0.025% Synalar Ointment Cream Fluticasone 0.05%, 0.005% Cutivate Cream, Ointment Hydrocortisone Valerate 0.2% Westcort Cream, Ointment Mometasone 0.1% Elocon Ointment Triamcinolone Acetonide 0.025% Kenalog Ointment, Cream, Lotion Triamcinolone Acetonide 0.1% Kenalog Ointment, Cream, Lotion Group IV (Low Potency) Desonide 0.05% DesOwen Cream Fluocinolone Acetonide 0.01% Synalar Cream, Solution Hydrocortisone 0.5%, 1%, 2.5% Hytone Cream, Ointment, Lotion Hydrocortisone/Pramoxine Pramosone Cream, Lotion, Ointment COUGH/COLD MEDICATIONS Benzonatate Tessalon Capsule Brompheniramine/Phenylephrine Bromfed PD Capsule Brompheniramine/Pseudoephedrine Bromfed Capsule Brompheniramine/Pseudoephedrine/Dextro. Bromfed DM, Rondec DM Syrup Chlorpheniramine/Phenylephrine Rynatan Tablet Oral Suspension Chlorpheniramate/Phenylephrine HCl Rondec Syrup Chlorpheniramine/ Phenylephrine HCl Rondec Drops Drops Chlorpheniramine/Pseudoephedrine/Dextro. Rondec DM Drops Drops Guaifenesin Mucinex Tablets Guaifenesin /Codeine Cheracol Syrup Guaifenesin /Dextromethorphan Humibid DM Tablet Guaifenesin /Hydrocodone Hycotuss Syrup Guaifenesin /Phenylephrine Despec Liquid Guaifenesin /Pseudoephedrine Robitussin PE, Entex PSE Syrup, Tablet Guaifenesin /Pseudoephedrine/Dextro. Tussin Cough and Cold Syrup, Capsule Hydrocodone/Homatropine Hycodan Syrup, Tablet Phenyephrine/Pyrilamine/Chlorpheniramine R-Tannate Oral Suspension Promethazine/Codeine Phenergan/Codeine Syrup Promethazine/Phenylephrine Phenergan VC Syrup Promethazine/Phenylephrine/Codeine Phenergan VC/Codeine Syrup Pseudoephedrine/Chlorpheniramine Deconamine Deconamine SR Tablet, Capsule Pseudoephedrine/Hydrocodone HC Tussive-D Syrup DECONGESTANTS (ORAL) Pseudoephedrine Sudafed Tablet, Solution DIURETICS Amiloride Midamor Tablet Amiloride/ Hydrochlorothiazide Moduretic Tablet Bumetanide Bumex Tablet Chlorothiazide Diuril Tablet, Suspension Chlorthalidone Hygroton Tablet Furosemide Lasix Tablet, Solution Hydrochlorothiazide Oretic Tablet, Solution Indapamide Lozol Tablet Methyclothiazide Enduron Tablet 14

18 Metolazone Zaroxolyn Tablet Spironolactone Aldactone Tablet Spironolactone/Hydrochlorothiazide Aldactazide Tablet Torsemide Demadex Tablet Triamterene Dyrenium Capsule Triamterene/Hydrochlorothiazide Maxide, Dyazide Tablet, Capsule ELECTROLYTES Calcium Acetate PhosLo Tablet Calcium Carbonate Tums Tablet Suspension Calcium Carbonate/Vitamin D Oscal + D Tablet Magnesium Chloride Slow Mag Tablet Magnesium Oxide Mag Ox Tablet Oral Electrolyte Solution* Pedialyte* Solution *Children 12 and under; Qty limit of 6000 ml Potassium Chloride K-Dur Tablets, Capsules, Solution Potassium Gluconate Kaon Solution Sodium/Potassium Phosphates Neutra-Phos Packet ELECTROLYTE DEPLETERS Sevelamer Carbonate Renagel Tablet Sevelamer HCL Renvela Tablet Sodium Polystyrene Kayexalate Suspension ESTROGENS- FEMALE PATIENTS ONLY Conjugated Estrogens Premarin Tablet Esterified Estrogens Menest Tablet Estradiol Estrace Tablet Estradiol Transdermal Climara, Alora, Estraderm,Vivelle Patch Estrogen Vaginal Premarin Cream Estropipate Ortho-Est Tablet ESTROGEN/PROGESTIN COMBINATIONS- FEMALE PATIENTS ONLY Conjugated Estrogens/Medroxyprogesterone Prempro, Premphase Tablet Ethinyl Estradiol 5mcg/Norethindrone 1mg Femhrt Tablet ESTROGEN/ANDROGEN COMBINATIONS Estrogen/Methyltestosterone Estratest Tablet GALLSTONE SOLUBILIZERS Ursodiol Actigall Capsule GI MEDICATIONS, MISCELLANEOUS Lubiprostone Amitiza Capsule *Diagnosis Required: Chronic Idiopathic Constipation Irritable Bowel Syndrome Mesalamine Asacol, Pentasa, Canasa Capsule, Suppository Misoprostol Cytotec Tablet Olsalazine Dipentum Tablet Pentosan Polysulfate Sodium Elmiron Capsule Simethicone Gas-X Tablets, Drops, Chew Tabs Sucralfate Carafate Tablets Sulfasalazine Azufidine Tablet 15

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