Healthy is for everyone. Saludable es para todos.

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1 Health Plan of San Mateo 70 Gateway Boulevard, Suite 400 South San Francisco, CA Tel Toll Free TTY Medi-Cal Formulary Formulario de Medicinas de Medi-Cal Healthy is for everyone. Saludable es para todos. Medi-Cal 04 Formulary Formulario de Medicinas Octubre, 00 a Septiembre 30, 0

2 Our Member Services Unit Is Available to Help You Call us at (toll free) or Hearing Impaired: TTY or dial 7-- Phone Office hours Monday through Thursday 8:00 a.m. 6:00 p.m. 8:00 a.m. 5:00 p.m. Friday 9:30 a.m. 6:00 p.m. 9:30 a.m. 5:00 p.m. Large-print Request If you would like a large-print copy of this book, please call Member Services Privacy Statement Health Plan of San Mateo ensures the privacy of your medical record. For questions and more information, please call Member Services. Nuestra Unidad de Servicios al Miembro está disponible para ayudarlo Llámenos al (número telefónico gratuito) o al Miembros con dificultades auditivas: TTY o marque el 7-- Por teléfono Horario de oficina De lunes a jueves 8:00 a.m. 6:00 p.m. 8:00 a.m. 5:00 p.m. Viernes 9:30 a.m. 6:00 p.m. 9:30 a.m. 5:00 p.m. Solicitud de impresión en caracteres grandes Si desea una copia de este manual en letra grande, llame al Departamento de Servicios al Miembro. Declaración de privacidad El Health Plan of San Mateo garantiza la privacidad de su registro médico. Si tiene alguna pregunta o desea obtener más información, llame a Servicios al Miembro. UPDATED MAY 04

3 Health Plan of San Mateo Medi-Cal Medication Formulary (HPSM-Medi-Cal Formulary) What is a formulary? A formulary is a complete list of medications covered by Health Plan of San Mateo (HPSM). The drugs on the formulary have been evaluated to ensure they are safe, effective and economical. Both brand name drugs and generic drugs are included on the formulary. Note: Not every brand name drug has a generic equivalent (equal), but if it is available, the use of the generic equivalent drug is required. The HPSM-Medi-Cal Formulary is a mandatory generic formulary. In addition to HPSM-Medi-Cal members, the prescription drugs listed on the formulary also apply to members in the Healthy Families, Healthy Kids, and HealthWorx programs. Please note that HPSM will not cover certain over-thecounter (OTC) medications for members in Healthy Families, Healthy Kids, and HealthWorx programs. Please refer to the Evidence of Coverage (EOC) handbooks for OTC items that are not covered by HPSM. Use the formulary as reference material The formulary is to help you understand what drugs are covered by HPSM. It will help you to be more involved in your health care choices. Use it as a quick reference and a reminder. If you have any questions, please call a Member Service Representative at or How often is the formulary updated? The formulary is updated every two months. You may find out about the most recent updates on our website at or call a Member Service Representative at or How to look for your drugs in the formulary There are two ways to find your drug in the formulary: By medical condition The formulary begins on page. The drugs in this formulary are grouped into categories related to the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiac Drugs. If you know what your drug is used for, look for the category name in the list that begins on page viii. Then look under the category name for your drug. By alphabetical listing If you are not sure what category of medical condition to look under, you can look for your drug in the Index that begins on page 09. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed.. Look in the Index and find your drug.. Next to your drug, you will see the page number where you can find coverage information. 3. Turn to the page listed in the Index and look for the name of your drug in the first column of the list. The formulary will also have separate columns for drugs that have restrictions such as quantity limits, step therapy requirements, and Code restrictions. The meaning of quantity limits and step therapy, and Code restrictions are described below. Quantity limits (QL): For certain drugs, HPSM limits the amount of the drug that it will cover. For example, HPSM provides 9 tablets per prescription for SUMATRIPTAN 50 mg. This may be in addition to a standard one month or three month supply. Introduction i

4 Step therapy (ST): In some cases, HPSM 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, HPSM may not cover drug B unless you try Drug A first. If Drug A does not work for you, HPSM will then cover Drug B. Code restriction (*): For certain drugs, HPSM restricts the use to a specified condition (diagnosis) or specified criteria. For example, diclofenac sodium (generic for Voltaren) tablet is covered for use in arthritis only. The full details of the Code restrictions starts on 87. What if my prescription is not on the formulary? If your doctor prescribes a drug not found in the formulary, your pharmacist can call your doctor. The doctor may either change the prescription to another drug already on the formulary or ask the pharmacist to submit a Medication Request Form (MRF) to MedImpact Healthcare to request the non-formulary drug. See a copy of a Medication Request Form on page vi. To avoid problems when you take your prescription to the pharmacy, bring the formulary with you to doctor appointments. Check it to make sure the drug your doctor prescribes is on the list before you leave the doctor s office. If it is not, you can tell the doctor right away so that he or she can decide whether or not to change the prescription to another drug that has the same effect and is on the formulary. Your doctor or pharmacist needs to fax a Medication Request Form (MRF)? Your doctor or pharmacist needs to fill out the MRF completely, and fax it to Pharmacy Services, Health Plan of San Mateo at How much will I pay for my medications? In general, for HPSM-Medi-Cal members, you will not be required to pay a copayment. Healthy Families, Healthy Kids, and HealthWorx members have to pay a copayment for your medications. Please refer to the most recent version of the Evidence of Coverage (EOC) handbooks to find out the copayments for brand drug and generic drugs. For More Information For more detailed information about pharmacy benefits, the formulary and prior authorization for medications, please review your EOC handbook. If you have more questions, please call HPSM Member Services: Phone: or Call Center Hours: Monday through Thursday, 8:00 a.m. to 6:00 p.m. and Friday, 9:30 a.m. to 6:00 p.m. Office Hours: Monday through Friday, 8:00 a.m. to 5:00 p.m. Members with hearing or speech impairments can use the California Relay Service (CRS) at (TTY) or dial 7--. ii Introduction

5 Formulario de medicamentos de Health Plan of San Mateo Medi-Cal (Formulario de HPSM-Medi-Cal) Que es un formulario? Un formulario es una lista completa de medicamentos cubiertos por Health Plan of San Mateo (HPSM). Los medicamentos en el formulario han sido evaluados para asegurar que son seguros, efectivos y económicos. En el formulario se incluyen tanto medicamentos de marca como medicamentos genéricos. Nota: No todos los medicamentos de marca tienen un genérico equivalente (igual), pero si está disponible, se requiere el uso de un medicamento genérico equivalente. El formulario HPSM-Medi-Cal es un formulario obligatorio genérico. Además de los miembros de HPSM-Medi-Cal, los medicamentos detallados en el formulario, también aplican para los miembros de los programas de Healthy Families, Healthy Kids, y HealthWorx. Le rogamos tomar nota que HPSM no cubrirá ciertos medicamentos de venta libre (OTC, por sus siglas en inglés) para miembros de los programas de Healthy Families, Healthy Kids, y HealthWorx. Por favor refiérase a los manuales de Evidencia de cobertura (EOC, por sus siglas en inglés) para artículos OTC que no están cubiertos por HPSM. Use el formulario como material de referencia El formulario es para ayudarle a entender cuáles medicamentos están cubiertos por HPSM. Le ayudará a estar más involucrado con sus opciones de cuidado de la salud. Úselo como una referencia rápida y como un recordatorio. Si tiene alguna pregunta, llame a un representante de Servicios al Miembro al ó Qué tan a menudo se actualiza el formulario? El formulario se actualiza cada dos meses. Puede encontrar información sobre las actualizaciones más recientes en nuestro Sitio Web en o llame a un representante de Servicios al Miembro al ó Cómo buscar sus medicamentos en el formulario Hay dos maneras de encontrar su medicamento en el formulario: Por afección médica El formulario empieza en la página. Los medicamentos en este formulario están agrupados en categorías relacionadas al tipo de afección médica que tratan. Por ejemplo, los medicamentos usados para tratar una afección cardiaca, se muestran en la categoría de "Medicamentos cardiacos". Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que empieza en la página viii. Luego busque su medicamento bajo el nombre de categoría. Por lista alfabética Si no está seguro en cuál categoría de afección médica buscar, puede buscar su medicamento en el Índice que empieza en la página 09. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. Se enumeran tanto los medicamentos de marca como los medicamentos genéricos.. Busque en el Índice y encuentre su medicamento.. Al lado de su medicamento, verá el número de la página en donde puede encontrar la información de cobertura. 3. Vaya a la página indicada en el Índice y busque el nombre de su medicamento en la primera columna de la lista. El formulario también tendrá columnas separadas para medicamentos que tienen restricciones tales como límite de cantidad, requisitos de terapia por pasos y restricciones del Código. El significado de límites de cantidad, terapia por pasos y restricciones del código se describen a continuación. Introduction iii

6 Límites de cantidad (QL, por sus siglas en inglés): Para ciertos medicamentos, HPSM limita la cantidad del medicamento que cubrirá. Por ejemplo, HPSM proporciona 9 tabletas por receta de SUMATRIPTAN 50 mg. Esto puede ser además del suministro estándar de uno o tres meses. Terapia por pasos (ST, por sus siglas en inglés): En algunos casos, HPSM requiere que pruebe usted primero ciertos medicamentos para tratar su afección médica, antes que nosotros cubramos otro medicamento para esa afección. Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su afección médica, HPSM podría no cubrir el Medicamento B, a menos que primero pruebe usar el Medicamento A. Si el Medicamento A no es efectivo en su caso, entonces HPSM cubrirá el Medicamento B. Restricción de Código (*): Para ciertos medicamentos, HPSM restringe su uso a una condición específica (diagnostico) o criterios específicos. Por ejemplo, la pastilla de diclofenaco de sodio (genérico para Voltaren) está cubierto únicamente para uso en artritis. Los detalles completos de las restricciones de Código, empiezan en 87. Qué pasa si mi receta médica no está en el formulario? Si su médico le receta un medicamento que no está en el formulario, su farmacéutico puede llamar a su médico. El médico puede ya sea cambiar la receta médica a otro medicamento que ya está en el formulario, o pedir al farmacéutico que presente un Formulario de solicitud de medicamentos (MRF, por sus siglas en inglés) a MedImpact Healthcare para solicitar el medicamento no incluido en el formulario. Vea una copia del formulario de solicitud de medicamentos en la página vi. Para evitar problemas cuando lleve su receta médica a la farmacia, lleve el formulario con usted a las citas con el médico. Revíselo antes de dejar el consultorio del médico, para asegurarse que el medicamento que su médico le está recentando está en la lista. Si no está, le puede decir a su médico en ese mismo momento, para que él o ella decida si cambia o no la receta médica a otro medicamento que tenga el mismo efecto y que esté en el formulario. Su médico o farmacéutico necesita enviar por fax un formulario de solicitud de medicamentos (MRF, por sus siglas en inglés)? Su médico o farmacéutico necesita llenar completamente el MRF y enviarlo por fax a Servicios Farmacéutico, Health Plan of San Mateo al número Cuánto pagaré por mis medicamentos? En general, para los miembros de HPSM-Medi-Cal, usted no tendrá que hacer un copago. Los miembros de Healthy Families, Healthy Kids, y HealthWorx tienen que hacer un copago para sus medicamentos. Consulte la versión más reciente de los manuales de Evidencia de cobertura (EOC, por sus siglas en inglés), para enterarse de los copagos para medicamentos de marca y medicamentos genéricos. Para obtener más información Para información más detallada sobre sus beneficios de farmacia, el formulario y la autorización previa para medicamentos, revise su manual de EOC. Si tiene más preguntas, llame a Servicios al Miembro de HPSM: Teléfono: ó Horarios del Centro de llamadas: Lunes a jueves, de 8:00 a.m. a 6:00 p.m., y viernes, de 9:30 a.m. a 6:00 p.m. Horario de oficina: de lunes a viernes, de 8:00 a.m. a 5:00 p.m. Los Miembros con deficiencias auditivas o del habla pueden utilizar el California Relay Service (CRS) al (TTY) o marcar el 7--. iv Introduction

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8 DO NOT WRITE IN BLOCKED AREAS FOR INTERNAL USE ONLY Medication Request Form (MRF) Attn: HPSM Pharmacy Services Contacted: 70 Gateway Blvd., #400 Approved: Physician: South San Francisco, CA Denied: Pharmacy: Phone: Returned: Patient: Fax: PA # DO NOT WRITE IN BLOCKED AREAS FOR INTERNAL USE ONLY Instructions: This form is to be used by participating physicians and providers to obtain coverage for a non-formulary (NF) drug for which there is no suitable alternative available. Please complete this form and fax to HPSM at If you have any questions regarding the prior authorization (PA) process, please contact HPSM Pharmacy Services at Review Criteria: The following criteria are used in reviewing medication requests:. The use of Formulary Drug Products is contraindicated in the patient.. The patient has failed an appropriate trial of Formulary or related agents. 3. The choices available in the Drug Formulary are not suited for the present patient care need and the drug selected is required for patient safety. 4. The use of a Formulary Drug Product may provoke an underlying medical condition, which would be detrimental to patient care. Medication Request Information (please complete each section of this form prior to transmittal): Patient Name (required): Patient ID # (required): Physician Name (required): Physician Specialty (required): Please check one: - Psychiatry/Mental Health - Other Physician NPI#/DEA # (required):: Patient DOB (required): Physician Area Code and Telephone Number (required): ( ) - Diagnosis (required): Physician Area Code and Fax Number (required): ( ) - Pharmacy used by Member: Pharmacy Telephone and Fax Number: ( ) - ; ( ) - Drug Requested (For Concurrent Atypical Antipsychotic requests, please also submit a Brief Psychiatric Rating Scale BPRS Form) Dose: Length of Treatment (please be specific): Strength: Quantity (per month): Dosage Form (e.g., Injection): Reason for Medication Request (required - please be specific, give detail): Other Medications Tried and/or Failed (required - please be specific, give detail): Other Pertinent History (required - relative or pertaining to this request): Physician Signature: M.D. Date: Revised: Mar 00 by BC Version 00

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10 ALLERGY... ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS... ANTIHISTAMINES - ST GENERATION... ANTIHISTAMINES - ND GENERATION... NASAL ANTICHOLINERGIC... NASAL ANTIHISTAMINE... NASAL ANTI-INFLAMMATORY STEROIDS... SEDATIVE-HYPNOTICS,NON-BARBITURATE... ANTIEMESIS/ANTIVERTIGO... ANTIEMETIC/ANTIVERTIGO AGENTS... ASTHMA... 3 ADRENERGIC AGENTS,CATECHOLAMINES...3 BETA-ADRENERGIC AGENTS...3 BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS...4 BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONS...4 DURABLE MEDICAL EQUIPMENT,MISC...4 GENERAL BRONCHODILATOR AGENTS...4 LEUKOTRIENE RECEPTOR ANTAGONISTS...4 MAST CELL STABILIZERS...4 ORAL INHALED CORTICOSTEROIDS(DOSAGE FORM 408 ONLY)...5 RESPIRATORY AIDS,DEVICES,EQUIPMENT...5 WATER...5 XANTHINES...6 AUTONOMIC NERVOUS SYSTEM DISORDERS... 6 CHOLINESTERASE INHIBITORS...6 BEHAVIORAL HEALTH - ANTIDEPRESSANTS... 6 ALPHA- RECEPTOR ANTAGONIST ANTIDEPRESSANTS...6 NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)...7 SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)...7 SEROTONIN- ANTAGONIST/REUPTAKE INHIBITORS (SARIS)...7 SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)...7 TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS...7 TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB...8 BEHAVIORAL HEALTH - OTHER... 8 ADRENERGICS, AROMATIC, NON-CATECHOLAMINE...8 ANTI-ALCOHOLIC PREPARATIONS...8 ANTI-ANXIETY DRUGS...8 ANTI-MANIA DRUGS...9 ANTIPSYCHOTICS, ATYP, D PARTIAL AGONIST/5HT MIXED...9 ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS...9 ANTIPSYCHOTICS, ATYPICAL, DOPAMINE, & SEROTONIN ANTAG...9 ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS, THIOXANTHENES...0 ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS,BUTYROPHENONES...0 ANTIPSYCHOTICS, DOPAMINE ANTAGONST,DIHYDROINDOLONES...0 ANTI-PSYCHOTICS, PHENOTHIAZINES...0 BARBITURATES...0 CENTRAL NERVOUS SYSTEM STIMULANTS... HYPNOTICS, MELATONIN MT/MT RECEPTOR AGONISTS... NARCOTIC ANTAGONISTS... SEDATIVE-HYPNOTICS, NON-BARBITURATE... TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY... TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE... CARDIOVASCULAR DISEASE - ARRHYTHMIA... ANTIARRHYTHMICS... CARDIOVASCULAR DISEASE - CARDIAC STIMULANT... DIGITALIS GLYCOSIDES... viii Contents

11 CARDIOVASCULAR DISEASE - HYPERTENSION... ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION... ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC...3 ALPHA/BETA-ADRENERGIC BLOCKING AGENTS...3 ALPHA-ADRENERGIC BLOCKING AGENTS...3 ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB...3 ANTIHYPERTENSIVES, ACE INHIBITORS...3 ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST...4 ANTIHYPERTENSIVES, MISCELLANEOUS...4 ANTIHYPERTENSIVES, SYMPATHOLYTIC...4 ANTIHYPERTENSIVES, VASODILATORS...4 BETA-ADRENERGIC BLOCKING AGENTS...4 CALCIUM CHANNEL BLOCKING AGENTS...5 LOOP DIURETICS...5 POTASSIUM SPARING DIURETICS...6 POTASSIUM SPARING DIURETICS IN COMBINATION...6 THIAZIDE AND RELATED DIURETICS...6 CARDIOVASCULAR DISEASE - LIPID IRREGULARITY... 6 ANTIHYPERLIP.HMG COA REDUCT INHIB&CHOLEST.AB.INHIB...6 ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS...6 BILE SALT SEQUESTRANTS...7 LIPOTROPICS...7 NIACIN PREPARATIONS...7 CARDIOVASCULAR DISEASE - VASODILATION... 7 VASODILATORS, CORONARY...7 VASODILATORS, PERIPHERAL...8 CONTRACEPTION/OXYTOCICS... 8 CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC...8 CONTRACEPTIVES,INJECTABLE...8 CONTRACEPTIVES,ORAL...8 CONTRACEPTIVES,TRANSDERMAL...9 OXYTOCICS...9 COUGH AND COLD... 9 ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS...9 DECONGESTANT-EXPECTORANT COMBINATIONS...9 EXPECTORANTS...9 NARCOTIC ANTITUSS-ST GEN. ANTIHISTAMINE-DECONGEST... 0 NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB... 0 NARCOTIC ANTITUSSIVE-ST GENERATION ANTIHISTAMINE... 0 NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION... 0 NON-NARC ANTITUSS-ST GEN. ANTIHISTAMINE-DECONGEST... 0 NON-NARC ANTITUSSIVE-ST GEN ANTIHISTAMINE COMB... 0 NON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMB... 0 NON-NARCOTIC ANTITUSSIVE... NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB... NON-NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS... NOSE PREPARATIONS, VASOCONSTRICTORS(OTC)... SYMPATHOMIMETIC AGENTS... DERMATOLOGY - ACNE... KERATOLYTICS... ROSACEA AGENTS, TOPICAL... VITAMIN A DERIVATIVES... VITAMIN A DERIVATIVES, TOPICAL COSMETIC AGENTS... DERMATOLOGY - ANTIINFECTIVE... ORAL ANTIFUNGAL... TOPICAL ANTIBIOTICS... Contents ix

12 TOPICAL ANTIFUNGALS... 3 TOPICAL ANTIPARASITICS... 3 TOPICAL ANTIVIRALS...4 TOPICAL SULFONAMIDES...4 DERMATOLOGY - ANTIINFLAMMATORY... 4 TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL...4 TOPICAL ANTI-INFLAMMATORY STEROIDAL...4 DERMATOLOGY - ANTIPRURITIC DRUGS... 5 ANTIPRURITICS,TOPICAL... 5 DERMATOLOGY - MISCELLANEOUS... 5 ANTISEBORRHEIC AGENTS... 5 ANTISEPTICS, GENERAL... 5 EMOLLIENTS... 5 IRRIGANTS... 5 LOCAL ANESTHETICS... 6 OXIDIZING AGENTS... 6 PROTECTIVES... 6 TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTS... 6 TOPICAL LOCAL ANESTHETICS... 6 TOPICAL PREPARATIONS, MISCELLANEOUS... 6 TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES... 6 DERMATOLOGY - PIGMENTATION DISORDERS... 7 HYPOPIGMENTATION AGENTS...7 DERMATOLOGY - PSORIASIS/ECZEMA... 7 ANTIPSORIATICS AGENTS...7 TOPICAL IMMUNOSUPPRESSIVE AGENTS...7 DIABETES... 7 ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S)...7 ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE...7 ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S)... 8 ANTIHYPERGLYCEMIC, MEGLINIDES... 8 ANTIHYPERGLYCEMIC, BIGUANIDE TYPE (NON-SULFONYLUREA)... 8 ANTIHYPERGLYCEMIC, INSULIN-REL STIM. & BIGUANIDE CMB... 8 BLOOD SUGAR DIAGNOSTICS... 8 DIABETIC SUPPLIES... 8 HYPERGLYCEMICS... 9 INSULINS... 9 SYRINGES AND ACCESSORIES URINE GLUCOSE TEST AIDS...3 URINE GLUCOSE/ACETONE TEST AIDS,STRIPS...3 EAR - GENERAL DISORDERS... 3 EAR PREPARATIONS, MISC. ANTI-INFECTIVES...3 EAR PREPARATIONS, MISCELLANEOUS (OTC)...3 EAR PREPARATIONS, ANTIBIOTICS...3 EAR PREPARATIONS, LOCAL ANESTHETICS... 3 OTIC PREPARATIONS, ANTI-INFLAMMATORY-ANTIBIOTICS... 3 ELECTROLYTE REGULATION... 3 ELECTROLYTE DEPLETERS... 3 ELECTROLYTE MAINTENANCE... 3 POTASSIUM REPLACEMENT SODIUM/SALINE PREPARATIONS ENDOCRINE DISORDER - OTHER ADRENOCORTICOTROPHIC HORMONES ANTIDIURETIC AND VASOPRESSOR HORMONES ANTINEOPLASTIC LHRH (GNRH) AGONIST, PITUITARY SUPPR BONE RESORPTION INHIBITOR & CALCIUM COMBINATIONS x Contents

13 BONE RESORPTION INHIBITORS CALCIMIMETIC,PARATHYROID CALCIUM ENHANCER GROWTH HORMONES HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS LHRH (GNRH) AGNST PIT. SUP-CENTRAL PRECOCIOUS PUBERTY ENDOCRINE DISORDER - THYROID ANTITHYROID PREPARATIONS...37 IODINE CONTAINING AGENTS...37 THYROID HORMONES...37 EYE - GENERAL DISORDERS EYE ANTIBIOTIC-CORTICOID COMBINATIONS...37 EYE ANTIHISTAMINES...37 EYE ANTIINFLAMMATORY AGENTS...37 EYE ANTIVIRALS EYE LOCAL ANESTHETICS EYE SULFONAMIDES EYE VASOCONSTRICTORS (OTC ONLY) EYE VASOCONSTRICTORS (RX ONLY) OPHTHALMIC ANTIBIOTICS OPHTHALMIC MAST CELL STABILIZERS OPHTHALMIC PREPARATIONS, MISCELLANEOUS EYE - GLAUCOMA CARBONIC ANHYDRASE INHIBITORS MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS MYDRIATICS EYE - MISCELLANEOUS ARTIFICIAL TEARS EYE PREPARATIONS, MISCELLANEOUS (OTC)...4 FLUID REPLACEMENT... 4 IV SOLUTIONS: DEXTROSE AND LACTATED RINGERS...4 IV SOLUTIONS: DEXTROSE AND RINGERS...4 IV SOLUTIONS: DEXTROSE-SALINE...4 IV SOLUTIONS: DEXTROSE-WATER...4 GOUT AND RELATED DISEASES... 4 COLCHICINE... 4 HYPERURICEMIA TX - PURINE INHIBITORS... 4 URICOSURIC AGENTS... 4 HEMATOLOGICAL DISORDERS ANTICOAGULANTS, COUMARIN TYPE ANTIFIBRINOLYTIC AGENTS COAGULANTS HEMATINICS, OTHER HEMORRHEOLOGIC AGENTS HEPARIN AND RELATED PREPARATIONS LEUKOCYTE (WBC) STIMULANTS PLATELET AGGREGATION INHIBITORS PLATELET PROLIFERATION STIMULANTS PLATELET REDUCING AGENTS VITAMIN K PREPARATIONS HORMONAL DEFICIENCY ANDROGENIC AGENTS ESTROGEN/ANDROGEN COMBINATIONS ESTROGENIC AGENTS PROGESTATIONAL AGENTS IMMUNIZATION Contents xi

14 ANTISERA GRAM POSITIVE COCCI VACCINES INFLUENZA A VIRUS PROPHYLAXIS/TREATMENT INFLUENZA VIRUS VACCINES IMMUNOSUPPRESSION/MODULATION IMMUNOMODULATORS...47 IMMUNOSUPPRESSIVES...47 INFECTIOUS DISEASE - BACTERIAL ABSORBABLE SULFONAMIDES...47 CEPHALOSPORINS - ST GENERATION CEPHALOSPORINS - ND GENERATION CEPHALOSPORINS - 3RD GENERATION CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC MACROLIDES NITROFURAN DERIVATIVES OXAZOLIDINONES PENICILLINS QUINOLONES...5 TETRACYCLINES... 5 INFECTIOUS DISEASE - FUNGAL... 5 ANTIFUNGAL AGENTS... 5 ANTIFUNGAL ANTIBIOTICS INFECTIOUS DISEASE - MISCELLANEOUS...53 AMINOGLYCOSIDES ANTIBACTERIAL AGENTS, MISCELLANEOUS ANTILEPROTICS ANTI-MYCOBACTERIUM AGENTS ANTITUBERCULAR ANTIBIOTICS LINCOSAMIDES VANCOMYCIN AND DERIVATIVES INFECTIOUS DISEASE - PARASITIC AMEBACIDES ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS ANTHELMINTICS ANTIMALARIAL DRUGS ANTIPROTOZOAL DRUGS, MISCELLANEOUS INFECTIOUS DISEASE - VIRAL ANTIVIRALS, GENERAL ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI...57 ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI...57 ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB...57 ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS...57 HEPATITIS B TREATMENT AGENTS HEPATITIS C TREATMENT AGENTS INFLAMMATORY DISEASE ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR GLUCOCORTICOIDS GOLD SALTS MINERALOCORTICOIDS NSAIDS (COX NON-SPECIFIC INHIB) & PROSTAGLANDIN CMB NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE xii Contents

15 LOCAL ANESTHESIA... 6 LOCAL ANESTHETICS...6 LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT... 6 BOWEL ANTIINFLAMATORY AGENTS...6 CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT, RECTAL TX...6 DRUG TX-CHRONIC INFLAM. COLON DX, 5-AMINOSALICYLAT...6 HEMORRHOIDAL PREPARATIONS...6 RECTAL PREPARATIONS... 6 RECTAL/LOWER BOWEL PREP., GLUCOCORT. (NON-HEMORR)... 6 LOWER GASTROINTESTINAL DISORDERS - OTHER... 6 AMMONIA INHIBITORS... 6 ANTIDIARRHEALS... 6 BILE SALTS... 6 LAXATIVES AND CATHARTICS... 6 LAXATIVES, LOCAL/RECTAL MEDICAL SUPPLIES DURABLE MEDICAL EQUIPMENT, MISC DURABLE MEDICAL EQUIPMENT, MISC (GROUP ) MISCELLANEOUS AGENTS ANAPHYLAXIS THERAPY AGENTS NEOPLASTIC DISEASE ALKYLATING AGENTS ANTIANDROGENIC AGENTS ANTIBIOTIC ANTINEOPLASTICS ANTIMETABOLITES ANTINEOPLAST EGF RECEPTOR BLOCKER RCMB MC ANTIBODY ANTINEOPLAST HUM VEGF INHIBITOR RECOMB MC ANTIBODY ANTINEOPLASTIC AROMATASE INHIBITORS ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES ANTINEOPLASTICS, MISCELLANEOUS CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS PHOTOACTIVATED, ANTINEOPLASTIC AGENTS (SYSTEMIC) SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM) SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR) STEROID ANTINEOPLASTICS VINCA ALKALOIDS NEUROLOGICAL DISEASE - MISCELLANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS AMYOTROPHIC LATERAL SCLEROSIS AGENTS ORAL/PHARYNGEAL DISORDERS PERIODONTAL COLLAGENASE INHIBITORS OTHER DRUGS ALCOHOL, SYSTEMIC USE APPETITE STIM. FOR ANOREXIA, CACHEXIA, WASTING SYND BLOOD TESTING PREPARATIONS, IN-VITRO BULK CHEMICALS CARBOHYDRATES DIETARY SUPPLEMENT, MISCELLANEOUS FOOD THICKENER GENERAL INHALATION AGENTS IV FAT EMULSIONS METABOLIC DEFICIENCY AGENTS METALLIC POISON, AGENTS TO TREAT NEEDLES/NEEDLELESS DEVICES Contents xiii

16 NUTRITIONAL THERAPY, MED COND SPECIAL FORMULATION PARENTERAL AMINO ACID SOLUTIONS AND COMBINATIONS PROTEIN REPLACEMENT SUSPENDING AGENTS...7 URINE ACETONE TEST AIDS...7 URINE TEST AIDS, MISCELLANEOUS...7 OTHER RESPIRATORY DISORDERS... 7 MUCOLYTICS...7 PAIN MANAGEMENT - ANALGESICS... 7 ANALGESIC, SALICYLATE, BARBITURATE, & XANTHINE CMB...7 ANALGESIC/ANTIPYRETICS, SALICYLATES...7 ANALGESIC/ANTIPYRETICS, NON-SALICYLATE...7 ANALGESICS NARCOTIC, ANESTHETIC ADJUNCT AGENTS... 7 ANALGESICS, NARCOTICS... 7 ANTIMIGRAINE PREPARATIONS NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB...74 NARCOTIC AND SALICYLATE ANALGESIC COMBINATION...74 PARKINSONS DISEASE ANTIPARKINSONISM DRUGS, ANTICHOLINERGIC...74 ANTIPARKINSONISM DRUGS, OTHER...74 SEIZURE DISORDER ANTICONVULSANTS SKELETAL MUSCLE DISORDER SKELETAL MUSCLE RELAXANTS...77 SMOKING CESSATION SMOKING DETERRENT AGENTS (GANGLIONIC STIM, OTHERS)...77 SMOKING DETERRENTS, OTHER...77 UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ANTIFLATULENTS...77 PANCREATIC ENZYMES...77 UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE BELLADONNA ALKALOIDS UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ANTACIDS ANTI-ULCER PREPARATIONS HISTAMINE H-RECEPTOR INHIBITORS INTESTINAL MOTILITY STIMULANTS PROTON-PUMP INHIBITORS URINARY TRACT - FUNCTIONAL DISORDERS ANTICHOLINERGICS, QUATERNARY AMMONIUM ANTICHOLINERGICS/ANTISPASMODICS...8 BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS...8 PARASYMPATHETIC AGENTS...8 URINARY PH MODIFIERS...8 URINARY TRACT ANALGESIC AGENTS...8 URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)...8 URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG...8 URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT...8 VAGINAL DISORDERS... 8 VAGINAL ANTIBIOTICS... 8 VAGINAL ANTIFUNGALS... 8 VAGINAL ESTROGEN PREPARATIONS... 8 VITAMIN AND/OR MINERAL DEFICIENCY... 8 CALCIUM REPLACEMENT... 8 FLUORIDE PREPARATIONS FOLIC ACID PREPARATIONS xiv Contents

17 GERIATRIC VITAMIN PREPARATIONS IRON REPLACEMENT MULTIVITAMIN PREPARATIONS PEDIATRIC VITAMIN PREPARATIONS PRENATAL VITAMIN PREPARATIONS VITAMIN B PREPARATIONS VITAMIN B PREPARATIONS VITAMIN B PREPARATIONS VITAMIN B6 PREPARATIONS VITAMIN D PREPARATIONS Contents xv

18

19 ALLERGY ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS CLARINEX-D 4 HOUR LORATADINE-D HR SEMPREX-D LORATADINE-D 4HR p-ephed sul/ desloratadine p-ephed sul/ loratadine pseudoephedrine hcl/ acrivas p-ephed sul/ loratadine ANTIHISTAMINES - ST GENERATION CHLOR-TRIMETON ALLERGY REPETAB CHLOR-TRIPOLON DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE chlorpheniramine maleate chlorpheniramine maleate dexchlorpheniramine maleate dexchlorpheniramine maleate Tablet, Extended Release Multiphase 4 Hr ST Tab.Sr H Capsule (Hard, Tab.Sr 4H Tablet Sa Syrup Tablet Sa Syrup DIPHENHYDRAMINE HCL diphenhydramine hcl Vial (Sdv, Mdv DIPHENHYDRAMINE MIN- I-JET diphenhydramine hcl Disposable Syringe (Ml) HYDROXYZINE HCL hydroxyzine hcl Tablet HYDROXYZINE HCL hydroxyzine hcl Syrup PROMETHAZINE HCL promethazine hcl Syrup PROMETHAZINE HCL promethazine hcl Ampul (Ml) PROMETHAZINE HCL promethazine hcl Ampul (Ml) PROMETHAZINE HCL promethazine hcl Vial (Sdv, Mdv PROMETHAZINE HCL promethazine hcl Tablet TUSSTAT diphenhydramine hcl Syrup VISTARIL hydroxyzine pamoate Capsule (Hard, VISTARIL hydroxyzine pamoate Suspension, (Final Dose Form) V-R VALU-DRYL diphenhydramine hcl Elixir WAL-DRYL diphenhydramine hcl Capsule (Hard, WAL-DRYL ALLERGY diphenhydramine hcl Tablet WAL-DRYL ALLERGY diphenhydramine hcl Liquid (Gram) Tier Generic Drugs Tier Brand Drugs Code See Glossary

20 WAL-FINATE chlorpheniramine maleate Tablet ANTIHISTAMINES - ND GENERATION ALLEGRA ALLERGY - OTC fexofenadine otc All Forms CETIRIZINE OTC cetirizine otc Tablet CETIRIZINE OTC cetirizine otc Syrup CLARINEX desloratadine Tablet, Rapid ST Dissolve CLARINEX desloratadine Syrup ST CLARINEX desloratadine Tablet ST FEXOFENADINE HCL fexofenadine hcl Tablet ST QL Qs in ds LORATADINE loratadine, Non- LORATADINE loratadine Tablet LORATADINE loratadine Tablet, Rapid Dissolve NASAL ANTICHOLINERGIC IPRATRIOPIUM ipratropium Aerosol, Spray (Gram) NASAL ANTIHISTAMINE ASTELIN azelastine hcl Aerosol, Spray With Pump (Ml) NASAL ANTI-INFLAMMATORY STEROIDS FLUNISOLIDE flunisolide Aerosol, Spray (Gram) FLUTICASONE PROPIONATE fluticasone propionate Spray, Suspension SEDATIVE-HYPNOTICS,NON-BARBITURATE DIPHENHYDRAMINE HCL diphenhydramine hcl Capsule (Hard, PA Prior Authorization ST Step Therapy QL Quantity Limits ANTIEMESIS/ANTIVERTIGO ANTIEMETIC/ANTIVERTIGO AGENTS ANZEMET dolasetron mesylate Tablet QL 3 COMPAZINE prochlorperazine Syrup edisylate KYTRIL granisetron hcl, Non- KYTRIL granisetron hcl Tablet QL 6 MARINOL dronabinol Capsule (Hard, ONDANSETRON HCL ondansetron hcl Tablet PROCHLORPERAZINE EDISYLATE prochlorperazine edisylate Vial (Sdv,Mdv PROCHLORPERAZINE MALEATE prochlorperazine maleate Suppository, Rectal Code

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