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FlexRx Drug Formulary, October 2009 1
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FlexRx Drug FormularyOctober 2009
INTRODUCTION
Blue Cross and Blue Shield of Minnesota and Blue Plus are pleased to present the FlexRx drug formulary (drug list). Our goal is to give members access to safe and effective prescription drugs at a reasonable cost.
Brand-name drugs are not included in this formulary unless they are listed. Blue Cross may choose to not add a drug to the formulary because of effectiveness or safety concerns, or because a similar, more cost-effective drug is already on the formulary. New drugs are non-formulary (NF) until reviewed by the Pharmacy and Therapeutics (P&T) Committee and Coverage Committee.
Blue Cross encourages providers to prescribe formulary drugs.
PHARMACY AND THERAPEUTICS (P&T) COMMITTEE AND COVERAGE COMMITTEE
The Blue Cross Coverage Committee selects drugs for this formulary based on recommendations of an independent Pharmacy and Therapeutics (P&T) Committee that includes practicing physicians and pharmacists. Decisions to add or remove drugs from the FlexRx formulary are based on the drug’s safety, effectiveness, uniqueness and cost. The P&T Committee and Coverage Committee meet at least quarterly. All drugs are reviewed each year as required by the National Committee on Quality Assurance (NCQA) standards.
You can find recent changes and the current version of the formulary at bluecrossmn.com.
FORMULARY GUIDELINES
The requirement of P&T and Coverage Committee review is a precondition of Blue Cross coverage and:
Blue Cross contracts and stated herein; and
administered in any manner that is approved by the U. S. Food and Drug Administration (FDA); and
medical devices legally used when administered in any manner that is not mentioned in the labeling approved by the FDA (referred to as an “off-label” use). Use of a medication or medical device for an indication, dosage form, dose regimen, population, or other use parameter not mentioned in the approved labeling is considered to be an “off-label” use.
These guidelines in no way imply that members should not receive specific services based on the recommendation of the provider. These guidelines govern coverage and not clinical practices. Providers are responsible for giving medical advice and treating members. Members with specific health care needs should consult an appropriate health care provider.
Members and providers have the right to appeal coverage decisions. These rights are explained in member and provider plan documents. Members with questions about appeal rights should call customer service at the number on the back of their member ID card. Providers can call provider services at 651.662.5200 or toll free at 800.262.0820.
This information is not an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage. All products and coverage guidelines are subject to applicable laws and regulations. Member or provider coverage is contingent on all the applicable terms, conditions, limitations and exclusions of member or provider plan documents.
GENERIC DRUGS
Blue Cross encourages use of generic drugs as a way to provide high-quality, cost-effective care. Generic drugs are safe, effective and cost less than brand-name drugs. Members will likely pay a lower copayment or coinsurance for a generic drug.
Frequently asked questions about generics
Are generics as good as brand-name drugs? Both brand-name and generic drugs must be approved by the FDA. Generic drugs meet the same high standards as brand-name drugs.
Why should I take generics rather than brand-name drugs? We must all do our part to make health care affordable. One way is to be wise buyers of drugs. Generics provide the same effectiveness and safety as their brand-name counterparts, but for a lower cost. These lower costs generally mean lower copayments for members. Generics also save money for your health plan, so it can help keep insurance premiums as low as possible.
How can I take advantage of lower-cost generics? Ask your pharmacist for a generic whenever available. Also, talk with your doctor or other provider about prescribing generic drugs. Most drug classes include some generic drugs.
FlexRx Drug Formulary, October 2009 2
HOW TO USE THIS FORMULARY
This formulary is organized into broad treatment categories. In most categories, drugs are listed by drug class (e.g., penicillins) or drugs for a specific medical condition, like diabetes.
Generic drugs are shown in lowercase bold type. Most generic drugs are followed by a brand-name drug (in parentheses) to help you recognize the drug. The brand-name drug is listed for information only and is not on the formulary.
Example: lisinopril (Prinivil – brand is NF)
Brand-name drugs on the formulary are shown in capital letters.
Example: NIASPAN
All strengths and dosage forms of the immediate-release lisinopril generic or NIASPAN brand-name drug are on the formulary. Exceptions are usually noted. Oral liquid forms of generic or brand-name drugs are considered an alternative to tablets or capsules. They are on the formulary without being noted.
Separate drug listings are required for some dosage forms, including: extended-release, delayed-release, oral disintegrating tablets, injectables, nasal, ophthalmic, otic, rectal, topical patches and topical products.
Keycaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . capsuleschew tabs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . chewable tabletsconc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .concentratecrm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . creamdelayed-release . . . . . . . . . . . . . . . . . . . . . . . . . . . .enteric coatedext-release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . extended-releaseinhal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . inhalationinj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . injectionlotn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lotionNF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . non-formularyODT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . orally disintegrating tabsoint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ointmentsoln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . solutionsupp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . suppositoriessusp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . suspensiontabs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . tablets
Compounded prescriptionsCompounded prescriptions contain two or more drugs mixed together. The end product cannot be available in an equivalent commercial form. Plus, at least one ingredient must be an FDA-approved prescription drug. Compounded prescriptions are processed according to member benefits.
Injectable drugsSelf-injectable drugs are generally part of the pharmacy benefit and may be included on the formulary. Injectable drugs are processed according to member benefits.
Some injectable drugs that need to be administered by a health care professional are covered only under the plan’s medical benefit.
Medical suppliesMany diabetic supplies and spacers used with oral inhalers purchased in pharmacies are available on this formulary.
BENEFIT UPDATES
Specialty drugsBlue Cross has an optional specialty pharmacy network. Members with this benefit must obtain their specialty drugs from an in-network specialty provider or they will pay 100 percent of the drug cost. The in-network specialty pharmacies are:
Drugs covered by this specialty drug benefit are listed at bluecrossmn.com.
Over-the-counter (OTC) drugsBlue Cross has an OTC drug benefit. Members with this coverage may receive an eligible OTC product at their lowest cost. Covered OTC drugs require a prescription. Members can get a one-month supply of the following drugs with this benefit:
PROTON PUMP INHIBITORS:Prilosec OTC
NON-SEDATING ANTIHISTAMINESloratadineloratadine/pseudoephedrine combination products
The program limits coverage to formulary and OTC drugs in these classes. Non-formulary drugs in these classes are not covered.
FlexRx Drug Formulary, October 2009 3
MANAGING DRUG USAGE
Prior Authorization (PA)Some drugs require prior authorization (PA) because of their high potential for misuse or overuse. Coverage may be approved after certain criteria are met. Approval is required for claims to process at network pharmacies. Policies regarding the covered uses of drugs and drug classes requiring PA can be found at bluecrossmn.com. For more information, call provider services at 651.662.5200 or toll free at 800.262.0820.
A written request for PA can be submitted by mail or fax.
Mailing address: Blue Cross and Blue Shield of Minnesota Medical Utilization Review Department P.O. Box 64265 St. Paul, MN 55164-0265Fax number: 651.662.2810
Step Therapy (ST)Step therapy programs help manage the cost of expensive drugs by redirecting members to equally effective, less expensive alternatives. Formulary and non-formulary drugs may be subject to step therapy. Formulary drugs subject to step therapy have “ST” behind them. If a member does not meet the criteria in the automated review of the member’s claims, their doctor can submit a request for review. Forms for the review process are at providers.bluecrossmn.com in the Forms section.
Quantity Limits (QL)Certain drugs have quantity limits (QL) to encourage appropriate drug usage, enhance drug therapy and reduce costs. The QL is the maximum quantity that can be dispensed over a given period of time. Formulary and non-formulary drugs may have quantity limits.
Drugs that have quantity limits as of October 1, 2009 (this list may change):
Product name QL per month
Actonel 5 mg, 30 mg (F). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 tablets
Actonel 35 mg (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 tablets
Actonel 150 mg (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 tablet
Actonel with calcium (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .one 28-day blister pack
Amerge (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 tablets
Axert (NF). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 tablets
Boniva 2.5 mg (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 tablets
Boniva 150 mg (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 blister pack
Boniva injection (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 kit/90 days
butorphanol nasal spray (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 x 2.5 mL
Cafergot tablets: generic version (F), brand (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 tablets
Cialis (NF) (no coverage for women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 tablets
Commit lozenges: generic version (F), brand (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .680 lozenges
Detrol (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 tablets
Detrol LA (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 capsules
D.H.E. 45: generic version, brand (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 ampules
Ditropan syrup: generic version (F), brand (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600 mL
Ditropan tablets: generic version (F), brand (NF). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 tablets
Ditropan XL 5 mg: generic version (F), brand (NF). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 tablets
Ditropan XL 10 mg, 15 mg: generic version(F), brand (NF) . . . . . . . . . . . . . . . . . . . . . . . . .60 tablets
Enablex (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 tablets
Ergomar (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 tablets
Fosamax solution (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 bottles
Fosamax tablets, 5 mg, 10 mg, 40 mg: generic version (F), brand (NF) . . . . . . . . . . . . . . .30 tablets
Fosamax tablets, 35 mg, 70 mg: generic version (F), brand (NF) . . . . . . . . . . . . . . . . . . . . .4 tablets
Fosamax Plus D (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 tablets
Frova (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 tablets
Imitrex injection brand (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 syringes
Imitrex injection: generic version (F), brand (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 vials
Imitrex nasal spray brand (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 spray units
Imitrex tablets: generic version (F), brand (NF). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 tablets
Levitra (NF) (no coverage for women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 tablets
Maxalt, Maxalt MLT (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 tablets
Migergot (F). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 supp
Migranal Nasal Spray (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 ampules
Nicorette gum (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816 pieces
Nicotrol oral inhaler (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 inhalers
Nicotrol nasal spray (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 bottles
Oxytrol (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 patches
Relpax (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 tablets
Sanctura (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 tablets
Sanctura XR (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 capsules
Treximet (NF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 tablets
VESIcare (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 tablets
Viagra (F) (no coverage for women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 tablets
Zomig, Zomig ZMT (F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 tablets
Zomig nasal spray (F). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 spray units
MEDICATION AUTHORIZATION REQUESTS
Prescribers may submit a Physician Request for Formulary Exception form for their patients. This form requests an exception for the following reasons:
Formulary exceptions:
with a closed formulary benefit plan
a mandatory generic plan
Quantity exceptions:
Step Therapy:
not meet automated step therapy criteria at the point of service (pharmacy)
FlexRx Drug Formulary, October 2009 4
To obtain a Physician Request for Formulary Exception form call provider services at 651.662.5200 or 800.262.0820.
You can also go to providers.bluecrossmn.com in the Forms section.
Please submit completed request forms to:Blue Cross and Blue Shield of Minnesota and Blue Plus1305 Corporate Center DriveClinical Review DepartmentEagan, MN 55121Fax: 1.877.480.8130
FORMULARY ADDITION REQUEST
Any health care provider may request in writing that the Blue Cross Coverage Committee consider adding or deleting a drug from the formulary. All formulary requests are brought before the Committee.
FlexRx Drug Formulary, October 2009 5
ANTI-INFECTIVE DRUGSPENICILLINS
amoxicillin
AMOXICILLIN chew tabs, 400 mg
amoxicillin/potassium clavulanate (Augmentin – brand is NF)
ampicillin caps
AMPICILLIN susp
AUGMENTIN – 8 hr dosing
AUGMENTIN XR
dicloxacillin
penicillin v potassium
CEPHALOSPORINS
cefadroxil
cefdinir (Omnicef – brand is NF)
cefpodoxime (Vantin – brand is NF)
cefprozil
ceftriaxone (Rocephin – brand is NF)
cefuroxime (Ceftin – brand is NF)
cephalexin (Keflex – brand is NF)
SUPRAX
MACROLIDES
azithromycin (Zithromax – brand is NF)
clarithromycin (Biaxin – brand is NF)
clarithromycin ext-release (Biaxin XL – brand is NF)
ERY-TAB
ERYTHROCIN STEARATE
ERYTHROMYCIN delayed-release caps
erythromycin ethylsuccinate
ERYTHROMYCIN FILMTABS
erythromycin/sulfisoxazole
ZITHROMAX packets, 1 g
TETRACYCLINES
demeclocycline (Declomycin – brand is NF)
doxycycline hyclate
doxycycline monohydrate caps, tabs (Andoxa, Monodox - brands are NF)
minocycline caps, tabs (Minocin, Dynacin – brands are NF)
tetracycline
FLUOROQUINOLONES
CIPRO susp
ciprofloxacin ext-release (Cipro XR – brand is NF)
ciprofloxacin tabs (Cipro – brand is NF)
LEVAQUIN
ofloxacin
AMINOGLYCOSIDES
neomycin sulfate
paromomycin
TOBI
FlexRx Drug Formulary, October 2009 6
SULFONAMIDES
sulfamethoxazole/trimethoprim (Bactrim, Septra – brands are NF)
TUBERCULOSIS
ethambutol (Myambutol – brand is NF)
ISONIAZID syrup
isoniazid tabs
isoniazid/rifampin (Rifamate – brand is NF)
MYCOBUTIN
pyrazinamide
rifampin (Rifadin – brand is NF)
FUNGAL INFECTIONS
fluconazole (Diflucan – brand is NF)
GRIFULVIN V tabs
griseofulvin microsize susp (Grifulvin V – brand is NF)
itraconazole caps (Sporanox – brand is NF)
ketoconazole
NOXAFIL
nystatin oral powder
nystatin oral tabs
terbinafine tabs (Lamisil – brand is NF)
VFEND
VIRAL INFECTIONS
Cytomegalovirus
GANCICLOVIR
VALCYTE
Hepatitis
BARACLUDE
EPIVIR-HBV
HEPSERA
INTRON A
PEG-INTRON
PEGASYS
ribavirin caps (Rebetol – brand is NF)
ribavirin tabs (Copegus – brand is NF)
ribavirin tabs, 400 mg, 600 mg
Herpes
acyclovir (Zovirax – brand is NF)
famciclovir (Famvir – brand is NF)
VALTREX
HIV/AIDS
APTIVUS
ATRIPLA
COMBIVIR
CRIXIVAN
didanosine delayed-release (Videx EC – brand is NF)
EMTRIVA
EPIVIR
EPZICOM
FlexRx Drug Formulary, October 2009 7
FUZEON
INTELENCE
INVIRASE
ISENTRESS
KALETRA
LEXIVA
NORVIR
PREZISTA
RESCRIPTOR
REYATAZ
SELZENTRY
stavudine (Zerit – brand is NF)
SUSTIVA
TRIZIVIR
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE
VIREAD
ZERIT soln
ZIAGEN
zidovudine (Retrovir – brand is NF)
Influenza
amantadine caps, syrup
TAMIFLU
MALARIA
chloroquine phosphate (Aralen – brand is NF)
FANSIDAR
hydroxychloroquine (Plaquenil – brand is NF)
MALARONE
mefloquine (Lariam – brand is NF)
PRIMAQUINE PHOSPHATE
WORM INFECTIONS
ALBENZA
BILTRICIDE
MEBENDAZOLE
STROMECTOL
OTHER ANTI-INFECTIVES
CLEOCIN PEDIATRIC
clindamycin (Cleocin – brand is NF)
DAPSONE
metronidazole (Flagyl – brand is NF)
NEBUPENT
trimethoprim
VANCOCIN
ZYVOX
FlexRx Drug Formulary, October 2009 8
IMMUNIZING AGENTSSYNAGIS – PA
CANCER DRUGS The list of drugs shown below includes selected oral and injectable cancer drugs on the formulary. However, all generic cancer drugs are on the formulary. All brand drugs are on the formulary until a generic version becomes available and has been added to the formulary. Typically, after the generic has been added, the corresponding brand is removed from the formulary. An entire listing of generic and brand cancer drugs on formulary is found at this website under “2009 Drug List - Alphabetical”.
AFINITOR
ALKERAN
ARIMIDEX
AROMASIN
bicalutamide (Casodex)
CASODEX
CEENU
CYCLOPHOSPHAMIDE
EMCYT
ETOPOSIDE caps
FARESTON
FEMARA
flutamide
GLEEVEC
HEXALEN
HYCAMTIN
hydroxyurea (Hydrea – brand is NF)
INTRON A
IRESSA
LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg
leucovorin calcium tabs, 5 mg, 25 mg
LEUKERAN
leuprolide (Lupron – brand is NF)
LUPRON DEPOT
LYSODREN
MATULANE
megestrol (Megace – brand is NF)
mercaptopurine (Purinethol – brand is NF)
MESNEX tabs
methotrexate
MYLERAN
NEXAVAR
NILANDRON
SPRYCEL
SUTENT
TABLOID
tamoxifen
TARCEVA
TARGRETIN
TASIGNA
TEMODAR
FlexRx Drug Formulary, October 2009 9
tretinoin (Vesanoid – brand is NF)
TYKERB
XELODA
ZOLADEX
ZOLINZA
HORMONES, DIABETES AND RELATED DRUGSCORTICOSTEROIDS
cortisone acetate
dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, 6 mg
DEXAMETHASONE soln; tabs, 1 mg, 2 mg
DEXAMETHASONE INTENSOL
ENTOCORT EC
fludrocortisone
hydrocortisone (Cortef – brand is NF)
methylprednisolone (Medrol – brand is NF)
prednisolone soln (Prelone – brand is NF)
prednisolone sodium phosphate soln (Orapred, Pediapred – brands are NF)
prednisone
PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg
MALE HORMONES
ANDRODERM
ANDROGEL
ANDROID
ANDROXY
danazol
METHITEST
testosterone cypionate (Depo-Testosterone – brand is NF)
testosterone enanthate (Delatestryl – brand is NF)
ESTROGENS
ACTIVELLA 0.5/0.1 mg
COMBIPATCH
DIVIGEL
ESTRADERM
estradiol patches (Climara – brand is NF)
estradiol tabs (Estrace – brand is NF)
estradiol/norethindrone acetate 1/0.5 mg (Activella – brand is NF)
ESTROGEL
estropipate (Ogen – brand is NF)
PREMARIN
PREMPHASE
PREMPRO
VIVELLE-DOT
PROGESTINS
medroxyprogesterone acetate (Provera – brand is NF)
norethindrone acetate (Aygestin – brand is NF)
PROMETRIUM
FlexRx Drug Formulary, October 2009 10
BIRTH CONTROL
desogestrel/ethinyl estradiol (Cyclessa – brand is NF)
desogestrel/ethinyl estradiol (Mircette – brand is NF)
desogestrel/ethinyl estradiol (Ortho-Cept – brand is NF)
drospirenone/ethinyl estradiol (Yasmin – brand is NF)
ethynodiol/ethinyl estradiol (Demulen 1/35 – brand is NF)
levonorgestrel – Next Choice, 0.75 mg (Plan B)
levonorgestrel/ethinyl estradiol (Alesse – brand is NF)
levonorgestrel/ethinyl estradiol (Levlite – brand is NF)
levonorgestrel/ethinyl estradiol (Nordette – brand is NF)
levonorgestrel/ethinyl estradiol (Seasonale – brand is NF)
levonorgestrel/ethinyl estradiol (Triphasil – brand is NF)
medroxyprogesterone acetate inj, 150 mg/mL (Depo-Provera – brand is NF)
NECON 10/11
norethindrone (Nor-QD – brand is NF)
norethindrone (Ortho Micronor – brand is NF)
norethindrone acetate/ethinyl estradiol (Loestrin – brand is NF)
norethindrone acetate/ethinyl estradiol/Fe (Loestrin Fe – brand is NF)
norethindrone/ethinyl estradiol (Modicon – brand is NF)
norethindrone/ethinyl estradiol (Ortho-Novum 1/35 – brand is NF)
norethindrone/ethinyl estradiol (Ortho-Novum 7/7/7 – brand is NF)
norethindrone/ethinyl estradiol (Ovcon 35 – brand is NF)
norethindrone/ethinyl estradiol (Tri-Norinyl – brand is NF)
norethindrone/mestranol (Ortho-Novum 1/50 – brand is NF)
norgestimate/ethinyl estradiol (Ortho Tri-Cyclen – brand is NF)
norgestimate/ethinyl estradiol (Ortho-Cyclen – brand is NF)
norgestrel/ethinyl estradiol (Lo/Ovral – brand is NF)
NUVARING
OGESTREL
ORTHO EVRA
ORTHO TRI-CYCLEN LO
PLAN B 0.75 mg
YAZ
ZOVIA 1/50
INFERTILITY
CETROTIDE – PA applied to select Blue Cross groups.
chorionic gonadotropin
clomiphene (Clomid – brand is NF)
GONAL-F – PA applied to select Blue Cross groups.
OVIDREL – PA applied to select Blue Cross groups.
REPRONEX – PA applied to select Blue Cross groups.
DIABETES
acarbose (Precose – brand is NF)
ACTOPLUS MET
ACTOS
BYETTA
chlorpropamide
DUETACT
FlexRx Drug Formulary, October 2009 11
glimepiride (Amaryl – brand is NF)
glipizide (Glucotrol – brand is NF)
glipizide ext-release (Glucotrol XL – brand is NF)
glipizide/metformin (Metaglip – brand is NF)
GLUCAGON
glyburide (Micronase – brand is NF)
glyburide micronized (Glynase – brand is NF)
glyburide/metformin (Glucovance – brand is NF)
GLYBURIDE, distributor of Diabeta
JANUMET
JANUVIA
metformin (Glucophage – brand is NF)
metformin ext-release (Glucophage XR – brand is NF)
SYMLIN
INSULIN
The formulary includes vials and insulin pens for the insulin products listed. Humulin R 500 units/mL, and Humulin 50/50 are only available in vials.
Rapid-Acting Insulins
HUMALOG
NOVOLOG
Short-Acting Insulins
HUMULIN R
NOVOLIN R
Intermediate-Acting Insulins
HUMALOG MIX 50/50
HUMALOG MIX 75/25
HUMULIN N
HUMULIN 50/50
HUMULIN 70/30
NOVOLIN N
NOVOLIN 70/30
NOVOLOG MIX 70/30
Basal Insulins
LANTUS
LEVEMIR
THYROID REGULATION
levothyroxine – includes Levoxyl (Synthroid – brand is NF)
liothyronine (Cytomel – brand is NF)
methimazole (Tapazole – brand is NF)
propylthiouracil
GROWTH HORMONE
INCRELEX – PA
OMNITROPE – PA
OTHER HORMONES AND RELATED DRUGS
ACTONEL – QL
ALDURAZYME
alendronate tabs (Fosamax – brand is NF) – QL
cabergoline
calcitonin-salmon nasal – includes Fortical (Miacalcin)
FlexRx Drug Formulary, October 2009 12
desmopressin inj (DDAVP – brand is NF)
desmopressin nasal (DDAVP – brand is NF)
desmopressin tabs (DDAVP – brand is NF)
EVISTA
FABRAZYME
FOSAMAX soln – QL
HECTOROL caps
leuprolide (Lupron – brand is NF)
LUPRON DEPOT
METHERGINE
MIACALCIN inj
MIACALCIN nasal
NAGLAZYME
octreotide (Sandostatin – brand is NF)
SANDOSTATIN LAR DEPOT
SENSIPAR
SOMAVERT
STIMATE
ZOLADEX
HEART AND CIRCULATORY DRUGSANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS
benazepril (Lotensin – brand is NF)
benazepril/hydrochlorothiazide (Lotensin HCT – brand is NF)
captopril
captopril/hydrochlorothiazide
enalapril (Vasotec – brand is NF)
enalapril/hydrochlorothiazide (Vaseretic – brand is NF)
fosinopril (Monopril – brand is NF)
fosinopril/hydrochlorothiazide (Monopril HCT – brand is NF)
lisinopril (Prinivil – brand is NF)
lisinopril/hydrochlorothiazide (Prinzide – brand is NF)
moexipril (Univasc – brand is NF)
moexipril/hydrochlorothiazide (Uniretic – brand is NF)
quinapril (Accupril – brand is NF)
quinapril/hydrochlorothiazide (Accuretic – brand is NF)
ramipril caps (Altace – brand is NF)
trandolapril (Mavik – brand is NF)
ANGIOTENSIN II RECEPTOR BLOCKERS (ARBS) AND COMBINATIONS
COZAAR
DIOVAN
DIOVAN HCT
HYZAAR
BETA BLOCKERS AND COMBINATIONS
acebutolol (Sectral – brand is NF)
atenolol (Tenormin – brand is NF)
atenolol/chlorthalidone (Tenoretic – brand is NF)
bisoprolol (Zebeta – brand is NF)
bisoprolol/hydrochlorothiazide (Ziac – brand is NF)
FlexRx Drug Formulary, October 2009 13
carvedilol (Coreg – brand is NF)
labetalol (Trandate – brand is NF)
metoprolol succinate ext-release (Toprol XL – brand is NF)
metoprolol tartrate (Lopressor – brand is NF)
METOPROLOL/HYDROCHLOROTHIAZIDE 100/50 mg
metoprolol/hydrochlorothiazide 50/25 mg, 100/25 mg (Lopressor HCT – brand is NF)
NADOLOL 160 mg
nadolol 20 mg, 40 mg, 80 mg (Corgard – brand is NF)
PINDOLOL
propranolol ext-release (Inderal LA – brand is NF)
PROPRANOLOL soln
propranolol tabs
propranolol/hydrochlorothiazide 40/25
PROPRANOLOL/HYDROCHLOROTHIAZIDE 80/25
TIMOLOL
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS
amlodipine (Norvasc – brand is NF)
amlodipine/benazepril (Lotrel – brand is NF)
diltiazem (Cardizem – brand is NF)
diltiazem ext-release (Dilacor XR – brand is NF)
diltiazem ext-release (Tiazac – brand is NF)
diltiazem ext-release – 12 hr
diltiazem ext-release – 24 hr (Cardizem CD – brand is NF)
felodipine ext-release
LOTREL 5/40, 10/40
nifedipine ext-release (Adalat CC – brand is NF)
nifedipine ext-release (Procardia XL – brand is NF)
verapamil (Calan – brand is NF)
verapamil ext-release (Calan SR – brand is NF)
verapamil ext-release (Verelan – brand is NF)
verapamil ext-release (Verelan PM – brand is NF)
CHEST PAIN (ANGINA)
isosorbide dinitrate oral tabs (Isordil – brand is NF)
isosorbide mononitrate (Monoket – brand is NF)
isosorbide mononitrate ext-release
NITRO-BID oint
nitroglycerin patches (Nitro-Dur – brand is NF)
nitroglycerin sublingual tabs (Nitrostat)
NITROLINGUAL
NITROSTAT
CHOLESTEROL LOWERING
cholestyramine (Questran, Questran Light – brands are NF)
colestipol tabs (Colestid – brand is NF)
CRESTOR – ST
fenofibrate micronized caps, 67 mg, 134 mg, 200 mg (Lofibra – brand is NF)
fenofibrate tabs, 54 mg, 160 mg (Lofibra – brand is NF)
gemfibrozil (Lopid – brand is NF)
lovastatin (Mevacor – brand is NF)
FlexRx Drug Formulary, October 2009 14
NIASPAN
pravastatin (Pravachol – brand is NF)
simvastatin (Zocor – brand is NF)
TRICOR
TRILIPIX
ZETIA
FLUID REDUCTION
acetazolamide
acetazolamide ext-release (Diamox Sequels – brand is NF)
amiloride (Midamor – brand is NF)
amiloride/hydrochlorothiazide
bumetanide (Bumex – brand is NF)
chlorothiazide
chlorthalidone 25 mg, 50 mg
furosemide soln, 10 mg/mL; tabs (Lasix – brand is NF)
hydrochlorothiazide caps (Microzide – brand is NF)
hydrochlorothiazide tabs, 25 mg, 50 mg
indapamide
methazolamide
metolazone (Zaroxolyn – brand is NF)
spironolactone (Aldactone – brand is NF)
spironolactone/hydrochlorothiazide tabs, 25/25 (Aldactazide – brand is NF)
torsemide (Demadex – brand is NF)
triamterene/hydrochlorothiazide caps, 37.5/25, 50/25 (Dyazide – brand is NF)
triamterene/hydrochlorothiazide tabs, 37.5/25, 75/50 (Maxzide-25, Maxzide – brands are NF)
HEART RHYTHM
amiodarone
disopyramide (Norpace – brand is NF)
disopyramide ext-release 150 mg (Norpace CR – brand is NF)
flecainide (Tambocor – brand is NF)
MEXILETINE
NORPACE CR 100 mg
propafenone (Rythmol – brand is NF)
quinidine gluconate ext-release
quinidine sulfate
QUINIDINE SULFATE ext-release
sotalol (Betapace – brand is NF)
sotalol AF (Betapace AF – brand is NF)
OTHER HEART RELATED DRUGS
CATAPRES-TTS
clonidine (Catapres – brand is NF)
DIBENZYLINE
DIGOXIN soln
digoxin tabs (Lanoxin – brand is NF)
doxazosin (Cardura – brand is NF)
epoprostenol (Flolan – brand is NF)
guanfacine (Tenex – brand is NF)
hydralazine
FlexRx Drug Formulary, October 2009 15
methyldopa
midodrine (Proamatine – brand is NF)
minoxidil
prazosin (Minipress – brand is NF)
REMODULIN
REVATIO – PA
terazosin
TRACLEER
VENTAVIS
ERECTILE DYSFUNCTION
CAVERJECT
MUSE
VIAGRA – QL
BEE STING KITS
EPIPEN
EPIPEN JR
RESPIRATORY DRUGSANTIHISTAMINES
cyproheptadine
fexofenadine (Allegra – brand is NF)
loratadine – Non-formulary (may have coverage in an OTC program) (Claritin – brand is NF)
promethazine supp
promethazine syrup, tabs
NASAL PRODUCTS
ASTELIN
ASTEPRO
BACTROBAN nasal
flunisolide 25 mcg/spray
FLUNISOLIDE 29 mcg/spray
fluticasone (Flonase – brand is NF)
ipratropium (Atrovent – brand is NF)
NASACORT AQ
NASONEX
COUGH/COLD/ALLERGY
acetylcysteine
ALLEGRA-D 12 hr, 24 hr
benzonatate (Tessalon – brand is NF)
brompheniramine/pseudoephedrine ext-release caps, 6/60
codeine/guaifenesin soln, 10/100 per 5 mL
loratadine/pseudoephedrine ext-release – Non-formulary (may have coverage in an OTC program) (Claritin-D – brand is NF)
ASTHMA/COPD
ACCOLATE
ADVAIR DISKUS
ADVAIR HFA
albuterol sulfate inhal soln
albuterol sulfate syrup, tabs
ASMANEX
ATROVENT HFA
FlexRx Drug Formulary, October 2009 16
AZMACORT
COMBIVENT
cromolyn sodium inhal soln
ELIXOPHYLLIN
FLOVENT HFA
FORADIL AEROLIZER
ipratropium inhal soln
ipratropium/albuterol sulfate (Duoneb – brand is NF)
MAXAIR AUTOHALER
PROAIR HFA
PULMICORT RESPULES
SEREVENT DISKUS
SINGULAIR
SPIRIVA HANDIHALER
SYMBICORT
terbutaline (Brethine – brand is NF)
theophylline ext-release tabs – 12 hr – Theochron
theophylline ext-release tabs – 24 hr (Uniphyl – brand is NF)
VENTOLIN HFA
OTHER RESPIRATORY DRUGS
PROLASTIN
PULMOZYME
GASTROINTESTINAL DRUGSLAXATIVES
lactulose – Constulose
PEG – electrolytes for soln (Colyte – brand is NF)
PEG – electrolytes for soln (Nulytely – brand is NF)
DIARRHEA
diphenoxylate/atropine (Lomotil – brand is NF)
paregoric
ULCER/GERD
ACIPHEX – ST
CARAFATE susp
cimetidine
dicyclomine (Bentyl – brand is NF)
famotidine (Pepcid – brand is NF)
glycopyrrolate (Robinul – brand is NF)
hyoscyamine (Levsin – brand is NF)
hyoscyamine ext-release tabs (Levbid – brand is NF)
hyoscyamine ODT
methscopolamine (Pamine – brand is NF)
misoprostol (Cytotec – brand is NF)
nizatidine (Axid – brand is NF)
omeprazole delayed-release (Prilosec – brand is NF)
pantoprazole delayed-release tabs (Protonix) – ST
PREVPAC
PRILOSEC OTC: Non-formulary (may have coverage in an OTC program)
PROPANTHELINE BROMIDE 15 mg
FlexRx Drug Formulary, October 2009 17
PROTONIX – ST
PYLERA
ranitidine (Zantac – brand is NF)
sucralfate tabs (Carafate – brand is NF)
NAUSEA AND VOMITING
dronabinol (Marinol – brand is NF)
EMEND caps
granisetron tabs (Kytril – brand is NF)
meclizine (Antivert – brand is NF)
meclizine tabs, 32 mg
ondansetron inj (Zofran – brand is NF)
ondansetron oral soln, tabs (Zofran – brand is NF)
ondansetron ODT (Zofran ODT – brand is NF)
scopolamine (Scopace – brand is NF)
TRANSDERM-SCOP
trimethobenzamide caps (Tigan – brand is NF)
DIGESTIVE ENZYMES
CREON
LIPRAM-UL
PANCREASE MT
PANCRECARB MS
PANCRELIPASE IR tabs, 30-8-30
ULTRASE/MT
VIOKASE
OTHER GASTROINTESTINAL DRUGS
ASACOL 400 mg
balsalazide (Colazal – brand is NF)
calcium acetate (Phoslo)
CANASA
lactulose – Enulose
LIALDA
mesalamine enema
metoclopramide (Reglan – brand is NF)
PENTASA
PHOSLO
RENVELA
sulfasalazine (Azulfidine – brand is NF)
ursodiol caps (Actigall – brand is NF)
GENITOURINARY DRUGSURINARY TRACT INFECTIONS
FURADANTIN
MACRODANTIN 25 mg
methenamine hippurate (Hiprex, Urex – brands are NF)
methenamine mandelate/sodium biphosphate (Uroqid-Acid No. 2 – brand is NF)
nitrofurantoin macrocrystals (Macrodantin – brand is NF)
nitrofurantoin monohydrate/macrocrystals (Macrobid – brand is NF)
phenazopyridine (Pyridium – brand is NF)
FlexRx Drug Formulary, October 2009 18
URINARY TRACT SPASMS
bethanechol (Urecholine – brand is NF)
DETROL – QL
DETROL LA – QL
hyoscyamine
oxybutynin – QL
oxybutynin ext-release (Ditropan XL – brand is NF) – QL
VESICARE – QL
VAGINAL PRODUCTS
ACID JELLY
CLEOCIN supp
clindamycin crm (Cleocin – brand is NF)
CLINDESSE
ESTRACE crm
metronidazole (MetroGel-Vaginal – brand is NF)
PREMARIN crm
terconazole (Terazol – brand is NF)
VAGIFEM
OTHER GENITOURINARY DRUGS
AVODART
CYSTAGON
CYTRA-3
ELMIRON
finasteride (Proscar – brand is NF)
FLOMAX
K-PHOS MF
K-PHOS NO. 2
potassium citrate ext-release (Urocit-K – brand is NF)
potassium citrate/citric acid powder, soln (Polycitra-K – brand is NF)
sodium citrate/citric acid (Bicitra – brand is NF)
TRICITRATES
CENTRAL NERVOUS SYSTEM DRUGSANXIETY
alprazolam (Xanax – brand is NF)
ALPRAZOLAM INTENSOL
buspirone 5 mg, 10 mg, 15 mg, 30 mg (Buspar – brand is NF)
BUSPIRONE 7.5 mg
DIAZEPAM oral soln
diazepam tabs (Valium – brand is NF)
DIAZEPAM INTENSOL
hydroxyzine hcl
hydroxyzine pamoate (Vistaril – brand is NF)
lorazepam (Ativan – brand is NF)
lorazepam conc (Lorazepam Intensol)
LORAZEPAM INTENSOL
DEPRESSION
amitriptyline
bupropion (Wellbutrin – brand is NF)
FlexRx Drug Formulary, October 2009 19
bupropion ext-release – 12 hr (Wellbutrin SR – brand is NF)
bupropion ext-release – 24 hr (Wellbutrin XL – brand is NF)
citalopram (Celexa – brand is NF)
clomipramine (Anafranil – brand is NF)
desipramine (Norpramin – brand is NF)
doxepin
EFFEXOR XR – ST
fluoxetine (Prozac – brand is NF)
imipramine hcl (Tofranil – brand is NF)
mirtazapine (Remeron – brand is NF)
mirtazapine ODT (Remeron Soltab – brand is NF)
NARDIL
nortriptyline (Pamelor – brand is NF)
paroxetine hcl (Paxil – brand is NF)
paroxetine hcl ext-release, 12.5 mg, 25 mg (Paxil CR – brand is NF)
PAXIL CR 37.5 mg – ST
sertraline (Zoloft – brand is NF)
tranylcypromine (Parnate – brand is NF)
trazodone
venlafaxine (Effexor – brand is NF) – ST
VENLAFAXINE ER tabs – ST
PSYCHOTIC AND BIPOLAR DISORDERS
chlorpromazine
clozapine 25 mg, 50 mg, 100 mg (Clozaril – brand is NF)
fluphenazine decanoate
FLUPHENAZINE HCL elixir, soln
fluphenazine hcl tabs
GEODON
haloperidol decanoate (Haldol – brand is NF)
haloperidol lactate oral soln
haloperidol tabs
lithium carbonate caps
LITHIUM CARBONATE caps, 150 mg; tabs, 300 mg
lithium carbonate ext-release 300 mg (Lithobid – brand is NF)
lithium carbonate ext-release 450 mg
lithium citrate
loxapine
MOBAN
perphenazine
prochlorperazine supp
prochlorperazine tabs
RISPERDAL M-TAB 1 mg, 3 mg, 4 mg
risperidone (Risperdal – brand is NF)
risperidone ODT, 0.5 mg, 2 mg, 3 mg, 4 mg (Risperdal M-Tab – brand is NF)
SEROQUEL
SEROQUEL XR
thiothixene (Navane – brand is NF)
trifluoperazine
FlexRx Drug Formulary, October 2009 20
SLEEP AIDS
chloral hydrate syrup
estazolam
phenobarbital
PHENOBARBITAL 64.8 mg, 97.2 mg
RESTORIL 7.5 mg
temazepam 15 mg, 30 mg (Restoril – brand is NF)
zaleplon (Sonata – brand is NF)
zolpidem (Ambien – brand is NF)
HYPERACTIVITY/NARCOLEPSY
ADDERALL XR
amphetamine/dextroamphetamine mixed salts (Adderall – brand is NF)
CONCERTA
dextroamphetamine ext-release (Dexedrine Spansule – brand is NF)
dextroamphetamine tabs, 5 mg
METADATE CD
methylphenidate (Ritalin – brand is NF)
methylphenidate ext-release (Ritalin SR – brand is NF)
PROVIGIL
STRATTERA
MULTIPLE SCLEROSIS
AVONEX
COPAXONE
REBIF
TOBACCO CESSATION
The formulary includes all prescription (Rx) and over-the-counter (OTC) nicotine-containing products. Coverage of Rx and/or OTCs may vary depending on the member’s benefit design.
bupropion ext-release (Zyban)
CHANTIX
nicotine gum (Nicorette) – OTC, QL
nicotine lozenges (Commit) – OTC, QL
nicotine patches (Nicoderm CQ) – OTC
NICOTROL INHALER – QL
NICOTROL NS – QL
ZYBAN
OTHER CENTRAL NERVOUS SYSTEM DRUGS
ANTABUSE
ARICEPT
ARICEPT ODT
CAMPRAL
EXELON caps, soln
EXELON patches
NAMENDA
ORAP
WEIGHT LOSS
MERIDIA
XENICAL
FlexRx Drug Formulary, October 2009 21
PAIN RELIEF DRUGSNON-NARCOTIC DRUGS
butalbital/acetaminophen tabs, 50/325 (Phrenilin – brand is NF)
butalbital/acetaminophen tabs, 50/650 (Sedapap – brand is NF)
butalbital/acetaminophen/caffeine caps, 50/325/40 (Esgic – brand is NF)
butalbital/acetaminophen/caffeine tabs, 50/325/40 (Fioricet – brand is NF)
butalbital/acetaminophen/caffeine tabs, 50/500/40 (Esgic Plus – brand is NF)
butalbital/aspirin/caffeine caps, 50/325/40 (Fiorinal – brand is NF)
butalbital/aspirin/caffeine tabs, 50/325/40
ketorolac
salsalate
NARCOTIC DRUGS
acetaminophen/codeine (Tylenol w/Codeine – brand is NF)
AVINZA
butalbital/aspirin/caffeine/codeine caps (Fiorinal w/Codeine – brand is NF)
CODEINE SULFATE 15 mg
codeine sulfate 30 mg, 60 mg
DILAUDID-5
fentanyl patches (Duragesic – brand is NF)
hydrocodone/acetaminophen caps, 5/500
hydrocodone/acetaminophen soln, 7.5/500 per 15 mL (Lortab – brand is NF)
hydrocodone/acetaminophen tabs, 10/750 (Maxidone – brand is NF)
hydrocodone/acetaminophen tabs, 2.5/500, 5/500, 7.5/500, 10/500 (Lortab – brand is NF)
hydrocodone/acetaminophen tabs, 5/325, 7.5/325, 10/325 (Norco – brand is NF)
hydrocodone/acetaminophen tabs, 5/500, 7.5/750, 10/660 (Vicodin, Vicodin ES, Vicodin HP – brands are NF)
hydrocodone/acetaminophen tabs, 7.5/650, 10/650 (Lorcet, Lorcet Plus – brands are NF)
hydrocodone/ibuprofen tabs, 10/200 (Ibudone – brand is NF)
hydrocodone/ibuprofen tabs, 5/200 (Reprexain – brand is NF)
hydrocodone/ibuprofen tabs, 7.5/200 (Vicoprofen – brand is NF)
HYDROMORPHONE supp
hydromorphone tabs (Dilaudid – brand is NF)
methadone conc, tabs
METHADONE soln, 5 mg/5 mL, 10 mg/5 mL
morphine sulfate conc, soln, tabs
morphine sulfate ext-release (MS Contin – brand is NF)
MORPHINE SULFATE oral soln, 10 mg/5 mL, 20 mg/5 mL; supp
naltrexone (ReVia – brand is NF)
oxycodone caps (OxyIR – brand is NF)
oxycodone conc, soln, tabs (Roxicodone – brand is NF)
oxycodone ext-release (OxyContin)
oxycodone/acetaminophen caps, 5/500 (Tylox – brand is NF)
oxycodone/acetaminophen tabs, 5/325, 7.5/325, 7.5/500, 10/325, 10/650 (Percocet – brand is NF)
oxycodone/aspirin tabs, 5/325 (Percodan – brand is NF)
OXYCONTIN
propoxyphene hcl/acetaminophen tabs, 65/650
propoxyphene napsylate/acetaminophen tabs, 50/325, 100/650 (Darvocet-N – brand is NF)
ROXICET soln
FlexRx Drug Formulary, October 2009 22
SUBOXONE
SUBUTEX
tramadol (Ultram – brand is NF)
tramadol/acetaminophen (Ultracet – brand is NF)
RHEUMATOID AND OSTEOARTHRITIS
CELEBREX
diclofenac sodium delayed-release (Voltaren – brand is NF)
DICLOFENAC SODIUM delayed-release 25 mg
diclofenac sodium ext-release (Voltaren-XR – brand is NF)
ENBREL
etodolac
HUMIRA
ibuprofen
indomethacin
indomethacin ext-release (Indocin SR – brand is NF)
ketoprofen
leflunomide (Arava – brand is NF)
MECLOFENAMATE
meloxicam tabs (Mobic – brand is NF)
methotrexate inj
methotrexate tabs, 2.5 mg
nabumetone
naproxen (Naprosyn – brand is NF)
naproxen sodium (Anaprox – brand is NF)
piroxicam (Feldene – brand is NF)
RIDAURA
sulindac (Clinoril – brand is NF)
MIGRAINE HEADACHES
acetaminophen/isometheptene/dichloralphenazone (Midrin – brand is NF)
divalproex ext-release (Depakote ER)
ergotamine/caffeine tabs (Cafergot – brand is NF) – QL
IMITREX inj kit – QL
IMITREX nasal – QL
MIGERGOT – QL
MIGRANAL – QL
sumatriptan tabs (Imitrex – brand is NF) – QL
sumatriptan vials, 6 mg (Imitrex – brand is NF) – QL
ZOMIG nasal – QL
ZOMIG tabs – QL
ZOMIG ZMT – QL
GOUT
allopurinol
colchicine
probenecid
probenecid/colchicine
NEUROMUSCULAR DRUGSSEIZURES
BANZEL
FlexRx Drug Formulary, October 2009 23
carbamazepine (Tegretol – brand is NF)
carbamazepine ext-release 200 mg, 400 mg (Tegretol-XR)
CARBATROL
CELONTIN
clonazepam (Klonopin – brand is NF)
DIASTAT
DILANTIN
divalproex delayed-release sprinkle caps, tabs (Depakote Sprinkles, Depakote – brands are NF)
divalproex ext-release (Depakote ER – brand is NF)
ethosuximide (Zarontin – brand is NF)
FELBATOL
gabapentin caps, tabs (Neurontin – brand is NF)
LAMICTAL Starter Kit
lamotrigine (Lamictal – brand is NF)
levetiracetam (Keppra – brand is NF)
NEURONTIN soln
oxcarbazepine tabs (Trileptal – brand is NF)
PEGANONE
phenytoin sodium extended (Dilantin)
phenytoin susp (Dilantin)
primidone (Mysoline – brand is NF)
TEGRETOL-XR
topiramate sprinkle caps, tabs (Topamax Sprinkle, Topamax – brands are NF)
TRILEPTAL susp
valproic acid (Depakene – brand is NF)
zonisamide (Zonegran – brand is NF)
PARKINSON’S DISEASE
amantadine caps, syrup
APOKYN
benztropine
bromocriptine (Parlodel – brand is NF)
carbidopa/levodopa (Sinemet – brand is NF)
carbidopa/levodopa ext-release (Sinemet CR – brand is NF)
carbidopa/levodopa ODT (Parcopa – brand is NF)
COMTAN
MIRAPEX
ropinirole (Requip – brand is NF)
selegiline caps (Eldepryl – brand is NF)
STALEVO
trihexyphenidyl
MUSCLE RELAXANTS
baclofen
chlorzoxazone
cyclobenzaprine (Flexeril – brand is NF)
dantrolene (Dantrium – brand is NF)
methocarbamol (Robaxin – brand is NF)
orphenadrine citrate ext-release
orphenadrine/aspirin/caffeine 25/385/30
FlexRx Drug Formulary, October 2009 24
ORPHENADRINE/ASPIRIN/CAFFEINE 50/770/60
SKELAXIN
tizanidine tabs (Zanaflex – brand is NF)
OTHER NEUROMUSCULAR DRUGS
MESTINON syrup
MESTINON TIMESPAN
pyridostigmine tabs (Mestinon – brand is NF)
RILUTEK
SUPPLEMENTSVITAMINS
calcitriol (Rocaltrol – brand is NF)
ergocalciferol caps (Drisdol – brand is NF)
MEPHYTON
PHYTONADIONE inj, 10 mg/mL
phytonadione inj 1 mg/0.5 mL
MULTIVITAMINS
pediatric multivitamins/fluoride
pediatric multivitamins/fluoride/iron
pediatric vitamins ADC/fluoride
pediatric vitamins ADC/fluoride/iron
prenatal multivitamins/1 mg folic acid
MINERALS AND ELECTROLYTES
K-PHOS
potassium bicarbonate/chloride effervescent tabs, 25 mEq (K-Lyte/Cl – brand is NF)
potassium chloride ext-release caps, 10 mEq (Micro-K 10 – brand is NF)
potassium chloride ext-release tabs, 10 mEq (K-Tabs – brand is NF)
potassium chloride ext-release tabs, 10 mEq, 20 mEq
potassium chloride ext-release tabs, 8 mEq
potassium chloride packets, 20 mEq (K-Lor – brand is NF)
potassium chloride soln, 10%, 20%
potassium phosphate/sodium phosphates (K-Phos Neutral – brand is NF)
sodium fluoride chew tabs, drops; tabs, 2.2 mg
SODIUM FLUORIDE soln, 0.55 mg/drop; tabs, 1.1 mg
SSKI
BLOOD MODIFYING DRUGSADVATE – PA
AGGRENOX
ALPHANINE SD – PA
aminocaproic acid inj (Amicar – brand is NF)
aminocaproic acid syrup, tabs (Amicar – brand is NF)
anagrelide (Agrylin – brand is NF)
ARANESP
BEBULIN VH – PA
BENEFIX – PA
CEREDASE
CEREZYME
cilostazol (Pletal – brand is NF)
cyanocobalamin inj
FlexRx Drug Formulary, October 2009 25
FEIBA VH – PA
folic acid tabs, 1 mg
GENARC – PA
HELIXATE FS – PA
HEMOFIL M – PA
HUMATE-P – PA
KOATE-DVI – PA
KOGENATE FS – PA
LOVENOX
MONOCLATE-P – PA
MONONINE – PA
NEULASTA
NEUMEGA
NEUPOGEN
NOVOSEVEN – PA
NOVOSEVEN RT – PA
pentoxifylline ext-release (Trental – brand is NF)
PLAVIX 75 mg
PROCRIT
PROFILNINE – PA
RECOMBINATE – PA
REFACTO – PA
warfarin (Coumadin – brand is NF)
XYNTHA – PA
TOPICAL DRUGSEYE
Anti-infectives
AZASITE
bacitracin/polymyxin B oint
CILOXAN oint
ciprofloxacin soln (Ciloxan – brand is NF)
erythromycin oint
gentamicin oint, soln
NATACYN
neomycin/polymyxin B/bacitracin oint
neomycin/polymyxin B/gramicidin soln (Neosporin – brand is NF)
ofloxacin soln (Ocuflox – brand is NF)
polymyxin B/trimethoprim soln (Polytrim – brand is NF)
sulfacetamide sodium soln (Bleph-10 – brand is NF)
tobramycin soln (Tobrex – brand is NF)
TOBREX oint
trifluridine soln (Viroptic – brand is NF)
VIGAMOX
Steroids and Combination Products
ALREX
BLEPHAMIDE
BLEPHAMIDE S.O.P.
dexamethasone sodium phosphate soln
FlexRx Drug Formulary, October 2009 26
fluorometholone susp (FML Liquifilm – brand is NF)
FML
LOTEMAX
neomycin/polymyxin B/bacitracin/hydrocortisone oint
neomycin/polymyxin B/dexamethasone oint, susp (Maxitrol – brand is NF)
prednisolone acetate susp (Pred Forte – brand is NF)
PREDNISOLONE SODIUM PHOSPHATE soln, 1%
sulfacetamide sodium/prednisolone soln
TOBRADEX
tobramycin/dexamethasone susp (Tobradex)
ZYLET
Glaucoma
ALPHAGAN P
AZOPT
BETAXOLOL soln
brimonidine soln, 0.2%
carteolol soln
dorzolamide (Trusopt – brand is NF)
dorzolamide/timolol maleate (Cosopt – brand is NF)
levobunolol soln (Betagan – brand is NF)
metipranolol soln (Optipranolol – brand is NF)
pilocarpine soln (Isopto Carpine – brand is NF)
timolol maleate gel-forming soln (Timoptic-XE – brand is NF)
timolol maleate soln (Timoptic – brand is NF)
TRAVATAN
TRAVATAN Z
XALATAN
Other Eye Products
ACULAR
ACULAR LS
atropine sulfate oint, soln (Isopto Atropine – brand is NF)
cromolyn sodium soln (Crolom – brand is NF)
cyclopentolate soln (Cyclogyl – brand is NF)
diclofenac soln (Voltaren – brand is NF)
flurbiprofen soln (Ocufen – brand is NF)
homatropine soln (Isopto Homatropine – brand is NF)
OPTIVAR
PATANOL
XIBROM
EAR
acetic acid
benzocaine/antipyrine
CIPRO HC
CIPRODEX
hydrocortisone/acetic acid
neomycin/polymyxin B/hydrocortisone (Cortisporin – brand is NF)
ofloxacin (Floxin Otic – brand is NF)
FlexRx Drug Formulary, October 2009 27
MOUTH AND THROAT (LOCAL)
chlorhexidine oral rinse (Peridex – brand is NF)
clotrimazole troche (Mycelex – brand is NF)
EVOXAC
lidocaine viscous
nystatin susp
pilocarpine tabs (Salagen – brand is NF)
sodium fluoride crm, gel (Prevident – brand is NF)
triamcinolone paste
ANORECTAL
CORTIFOAM
hydrocortisone acetate supp, 25 mg (Anusol-HC – brand is NF)
hydrocortisone crm, 2.5% (Anusol-HC – brand is NF)
hydrocortisone enema
SKIN CONDITIONS/PRODUCTS
Acne
AZELEX
BENZACLIN
clindamycin (Cleocin-T – brand is NF)
DIFFERIN
DUAC CS
erythromycin gel
erythromycin pads, soln, 2%
erythromycin/benzoyl peroxide (Benzamycin – brand is NF)
FINACEA, NF = Finacea Plus
isotretinoin caps
METROGEL 1%
metronidazole (Metrolotion – brand is NF)
metronidazole gel, 0.75%
metronidazole 0.75% (Metrocream – brand is NF)
sulfacetamide sodium lotn (Klaron – brand is NF)
sulfacetamide sodium/sulfur crm, emulsion (Plexion – brand is NF)
sulfacetamide sodium/sulfur lotn
SULFACETAMIDE SODIUM/SULFUR 10%/5%, susp
TAZORAC
tretinoin, NF = Avita gel (Retin-A – brand is NF)
Anti-infectives
BACTROBAN crm
ciclopirox (Loprox – brand is NF)
DENAVIR
econazole
gentamicin
ketoconazole crm
ketoconazole shampoo, 2% (Nizoral – brand is NF)
LOPROX shampoo
mupirocin oint (Bactroban), NF = Centany
nystatin (Mycostatin – brand is NF)
silver sulfadiazine (Silvadene – brand is NF)
ZOVIRAX oint
FlexRx Drug Formulary, October 2009 28
Corticosteroids
alclometasone (Aclovate – brand is NF)
betamethasone dipropionate
betamethasone dipropionate, augmented (Diprolene – brand is NF)
betamethasone valerate
clobetasol (Olux – brand is NF)
clobetasol (Temovate – brand is NF)
clotrimazole/betamethasone (Lotrisone – brand is NF)
DERMA-SMOOTHE/FS oil
desonide (Desowen – brand is NF)
desoximetasone (Topicort – brand is NF)
diflorasone, NF = emollient crm
FLUOCINOLONE
fluocinonide
fluticasone propionate (Cutivate – brand is NF)
halobetasol (Ultravate – brand is NF)
hydrocortisone butyrate (Locoid – brand is NF)
hydrocortisone valerate (Westcort – brand is NF)
hydrocortisone 2.5%
mometasone (Elocon – brand is NF)
nystatin/triamcinolone
triamcinolone
TRIAMCINOLONE oint, 0.05%
Other Skin Products
ALDARA
aluminum chloride soln (Drysol – brand is NF)
calcipotriene soln (Dovonex – brand is NF)
CARAC
CONDYLOX gel
DOVONEX crm
doxepin crm (Zonalon – brand is NF)
DRITHO-CREME HP
ELIDEL
EMLA/TEGADERM
FLUOROPLEX
fluorouracil crm, soln, 5% (Efudex – brand is NF)
FLUOROURACIL soln, 2%
lidocaine jelly, 2%; oint, 5%; soln, 4% (Xylocaine – brand is NF)
lidocaine/prilocaine crm (Emla – brand is NF)
LIDODERM
lindane lotn
LINDANE shampoo
malathion (Ovide)
OVIDE
OXSORALEN-ULTRA soft gelatin caps
PANRETIN
permethrin crm, 5% (Elimite – brand is NF)
podofilox soln (Condylox – brand is NF)
FlexRx Drug Formulary, October 2009 29
PROTOPIC
selenium sulfide 2.5% (Selsun – brand is NF)
SOLARAZE
SORIATANE CK Kit
SYNERA
TARGRETIN gel
MISCELLANEOUS CATEGORIES (includes supplies and devices)
DIABETIC SUPPLIES
Meters, Blood Glucose Control Reagents, Blood Glucose Test Strips
ACCU-CHEK ACTIVE
ACCU-CHEK ADVANTAGE
ACCU-CHEK AVIVA
ACCU-CHEK COMFORT CURVE
ACCU-CHEK COMPACT
ACCU-CHEK INSTANT
ASCENSIA AUTODISC
ASCENSIA ELITE/ELITE XL
BREEZE/BREEZE 2
CONTOUR
Insulin Syringes, Lancets and Lancet Devices
All insulin syringes and pen needles are on formulary; suggested products are listed.
BD INSULIN SYRINGES
BD LANCET DEVICES
BD ULTRAFINE PEN NEEDLES
LANCETS (all)
MICROLET/MICROLET 2 LANCET DEVICES
ROCHE DIAGNOSTICS LANCET DEVICES
ORAL INHALER-ASSIST DEVICES – SPACERS
The formulary includes a number of products available only as brand products. The most commonly prescribed are AEROCHAMBER, EASIVENT, E-Z SPACER, INSPIREASE and MICROCHAMBER.
MISCELLANEOUS DRUGS
azathioprine (Imuran – brand is NF)
CELLCEPT
CHEMET
CUPRIMINE
cyclosporine (Sandimmune – brand is NF)
cyclosporine modified caps, 25 mg, 100 mg; soln (Neoral – brand is NF)
mycophenolate mofetil caps, tabs (Cellcept)
MYFORTIC
PROGRAF
RAPAMUNE
REVLIMID
sodium polystyrene sulfonate
SPS
SYPRINE
tacrolimus caps (Prograf)
THALOMID
2746-A © Prime Therapeutics LLC 09/09