Total Health Care CSHCS Preferred Drug Formulary April 2013
Total Health Care’s (THC) Preferred drug formulary is a list of drugs that contains some of the most commonly prescribed medications within selected therapeutic classes. The list contains drugs that are considered to be safe and effective. Drugs listed in bold have FDA approved generic equivalents available, and because Total Health Care is a mandatory generic plan, only the generic forms will be covered. THC’s Pharmacy and Therapeutic Committee has been established to review and evaluate medications for inclusion on the THC Therapeutic Drug Formulary. This Committee meets on a quarterly basis and is comprised of Physicians, Pharmacists and other health care professionals. Changes may occur throughout the year and plan exclusions may override this list. For a complete drug listing, you may refer to THC’s website at
Drug Criteria Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800- 826-2862. For a complete list of drugs and definitions of these limits please refer to the expanded formulary Drug Management Utilization Tools
Prior Authorization Medications that require prior authorization (PA) will need an approval before the pharmacy provider can dispense them. Medications requiring PA are indicated in the Preferred Drug Formulary with a “PA” notation. To obtain coverage for these medications, a prescriber must complete a Request for Prior Authorization form. The form can be found on the THC website at
Quantity Limits/Age limits Specific medications as indicated on the Preferred Drug Formulary have quantity or age restrictions on the drug that will be dispensed for member. Medications that have quantity limits or age limits placed are indicated on the Preferred Drug Formulary with a “QL” notation for quantity and “AL” for age. Generic Substitution THC requires the mandatory use of generics. When there is a generic version of a brand name drug, THC pharmacies will automatically give the generic version. Gender Edits Coverage may depend on patient gender. Medications that have a Gender Edit are indicated with a “GE” on the formulary. OTC (Over-the-Counter) Drugs indicated with “OTC” are available over-the-counter and are covered on the formulary when authorized with a prescription order. Health Living Pharmacy Total Health Care works exclusively with Healthy Living Pharmacy (HLP) to provide Diabetic testing supplies to our members. Diabetic testing supplies include glucometers, test strips, lancets, alcohol swabs and ketone strips. These supplies are to be filled through Healthy Living Pharmacy. They are indicated on the formulary with “HLP”. If you have any questions about our diabetic supply program, please contact Healthy Living Pharmacy at 1-866-779- 8512. Step Therapy Step-therapy (ST) requires that an alternative, first line drug be tried and failed before the requested medication can be dispensed. The on-line claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line drug was filled. Medications requiring step therapy are indicated on the Preferred Drug Formulary with a “ST” notation. Step Therapy Criteria Therapy Class First Line Second Line Step Therapy Criteria
Formulary Antiasthmatic: Advair 100/50 Dulera
Cefpodoxime Cefuroxime Cephalexin Ciprofloxacin Clindamycin Dicloxacillin Doxycycline Erythromycin Penicillin SMZ-TMP Tetracycline
Prior use of first line agent within the last 90 days.
Prior use of a first line agent within the last 90 days.
2013 CSHCS Preferred Formulary Formulary changes can occur at any time Generic Drugs = BOLD text Brand-Name Drugs = non-BOLD text Generic Name - Reference Name Comments ANTI-INFECTIVES PENICILLINS amoxicillin amoxicillin/clavulanate amoxicillin/clavulanate
– AUGMENTIN SUSPENSION 200/5, 400/5 and ES
ampicillin dicloxacillin penicillin v potassium CEPHALOSPORINS cefaclor cefadroxil cefdinir cefpodoxime cefprozil cefuroxime axetil cephalexin MACROLIDES azithromycin clarithromycin, clarithromycin er erythromycin SULFONAMIDES & COMBINATIONS erythromycin/sulfisoxazole sulfadiazine sulfamethoxazole/trimethoprim TETRACYCLINES doxycycline hyclate minocycline tetracycline doxycycline hyclate MISCELLANEOUS ANTI-BACTERIALS & ANTI-MYCOBACTERIALS clindamycin hcl metronidazole QUINOLONES ciprofloxacin levofloxacin ANTIVIRAL AGENTS ORAL ANTIVIRAL AGENTS - ANTI-INFLUENZA amantadine rimantadine ANTIVIRAL AGENTS - HERPES acyclovir CARDIOVASCULAR MEDICATIONS CARDIAC GLYCOSIDES digoxin CALCIUM ANTAGONISTS amlodipine diltiazem, diltiazem er
– CARDIZEM, CARDIZEM CD, CARTIA XT, DILACOR XR,
felodipine er nicardipine nifedipine er verapamil DIURETICS acetazolamide amiloride amiloride/hydrochlorothiazide bumetanide chlorothiazide chlorthalidone furosemide hydrochlorothiazide indapamide metolazone spironolactone, spironolactone/hydrochlorothiazide torsemide triamterene/hydrochlorothiazide BETA-ADRENERGIC ANTAGONIST AGENTS & COMBINATIONS acebutolol atenolol, atenolol/chlorthalidone bisoprolol/hydrochlorothiazide carvedilol labetalol metoprolol succinate metoprolol tartrate metoprolol/hydrochlorothiazide pindolol propranolol, propranolol er propranolol/hydrochlorothiazide ACE INHIBITORS & COMBINATIONS benazepril, benazepril/hydrochlorothiazide benazepril/amlodipine besylate captopril, captopril-HCT enalapril, enalapril/HCT fosinopril lisinopril, lisinopril-HCT quinapril, quinapril-HCT trandolapril ANGIOTENSIN II RECEPTOR ANTAGONISTS & COMBINATIONS losartan, losartan-HCT ANTILIPEMIC AGENTS HMG-COA REDUCTASE INHIBITORS lovastatin pravastatin simvastatin atorvastatin calcium ANTILIPEMIC AGENTS - OTHER cholestyramine/sucrose colestipol fenofibrate micronized gemfibrozil ANTIPLATELET AGENTS clopidogrel AUTONOMIC & CNS MEDICATIONS ANALGESICS (NARCOTIC) hydromorphone meperidine methadone morphine, morphine er oxycodone tramadol ANALGESIC COMBINATIONS acetaminophen/caffeine/dihydrocodeine codeine/acetaminophen hydrocodone/acetaminophen oxycodone/acetaminophen oxycodone/aspirin TRIPTAN AGENTS sumatriptan tablets DERMATOLOGICAL AGENTS ANTI-ACNE AGENTS erythromycin solution benzoyl peroxide gel sulfacetamide/sulfur clindamycin phosphate erythromycin gel tretinoin TOPICAL ANTIFUNGAL AGENTS clotrimazole ciclopirox econazole nitrate ketoconazole miconazole TOPICAL ANTIFUNGAL & CORTICOSTEROID COMBINATIONS clotrimazole/betamethasone nystatin/triamcinolone EAR, NOSE & THROAT AGENTS NASAL CORTICOSTEROIDS flunisolide fluticasone propionate ENDOCRINE MEDICATIONS ANTIDIABETIC AGENTS - BIGUANIDES metformin, metformin er ANTIDIABETIC AGENTS - SULFONYLUREAS chlorpropamide glimepiride glipizide, glipizide er glyburide ANTIDIABETIC AGENTS - THIAZOLIDINEDIONES pioglitazone ANTIDIABETIC AGENTS - DPP-IV INHIBITORS sitagliptin ANTIDIABETIC AGENTS - COMBINATIONS pioglitazone/glimepiride ANTIDIABETIC AGENTS - OTHER acarbose INSULIN insulin detemir BISPHOSPHONATES & RELATED AGENTS alendronate GASTROINTESTINAL MEDICATIONS H-2 ANTAGONIST AGENTS cimetidine famotidine ranitidine PROTON PUMP INHIBITORS lansoprazole lansoprazole suspension omeprazole
– PRILOSEC 20mg CAPSULE (Rx); Prilosec-OTC
omeprazole suspension pantoprazole MUSCULOSKELETAL MEDICATIONS NON-STEROIDAL ANTI-INFLAMMATORY AGENTS diclofenac potassium diclofenac sodium, diclofenac sodium er etodolac , etodolac er ibuprofen indomethacin, indomethacin er ketoprofen ketorolac meloxicam nabumetone naproxen, naproxen sodium SKELETAL MUSCLE AGENTS baclofen carisoprodol cyclobenzaprine methocarbamol tizanidine OBSTETRICAL & GYNECOLOGICAL MEDICATIONS ORAL ESTROGEN AGENTS estradiol estropipate TRANSDERMAL ESTROGEN AGENTS estradiol transdermal ESTROGEN / PROGESTIN COMBINATION AGENTS estradiol/norethindrone ethinyl estradiol/norethindrone PROGESTIN AGENTS medroxyprogesterone norethindrone CONTRACEPTIVE AGENTS ethinyl estradiol/desogestrel
– LO/OVRAL, ORTHO-CEPT, DESOGEN, VELIVET, CAZIANT
ethinyl estradiol/ethynodiol diacetate ethinyl estradiol/levonorgestrel
– LEVLEN, TRI-LEVLEN, TRIPHASIL, TRIVORA, ALESSE,
ethinyl estradiol/norethindrone
– BREVICON, MODICON, LOESTRIN 1/20, ON 1/35, ON 777,
ethinyl estradiol/norethindrone and iron ethinyl estradiol/norgestimate medroxyprogesterone acetate mestranol/norethindrone levonorgestrel OPHTHALMIC MEDICATIONS OPHTHALMIC TOPICAL ANTI-INFECTIVE AGENTS bacitracin/polymyxin b bacitracin ciprofloxacin erythromycin gentamicin ophthalmic solution neomycin/bacitracin/polymyxin b neomycin/polymyxin b/gramicidin sulfacetamide sodium tobramycin trifluridine OPHTHALMIC ANTIHISTAMINES ketotifen fumarate azelastine naphazoline naphazoline/pheniramine tetrahydrozoline GLAUCOMA AGENTS betaxolol brimonidine carteolol dorzolamide dorzolamide/timolol homatropine levobunolol metipranolol latanoprost RESPIRATORY AGENTS BRONCHODILATORS - BETA AGONISTS albuterol tablets, solution, nebulizer PULMONARY CORTICOSTEROIDS budesonide
– FLOVENT DISKUS 50mcg, 100mcg, FLOVENT HFA 44mcg
LEUKOTRIENE MODIFIERS montelukast COUGH & COLD THERAPY ANTIHISTAMINES cetirizine chlorpheniramine clemastine 2.68mg clemastine syrup cyproheptadine diphenhydramine (all forms) fexofenadine loratadine (all forms) UROLOGICAL AGENTS OVERACTIVE BLADDER AGENTS oxybutynin oxybutynin er BENIGN PROSTATIC HYPERTROPHY AGENTS doxazosin finasteride tamsulosin terazosin DIABETIC SUPPLIES
– BD MICROFINE, BD MICROFINE ULTRA FINE SYRINGES
MISCELLANEOUS AGENTS SMOKING CESSATION AGENTS bupropion ext-release nicotine gum nicotine transdermal
QL - 60 tabs per 30 days; 3 fills per lifetime
PROBABILIDAD y ESTAD´ISTICA (61.06, Industriales)1. La probabilidad de que un emisor de mensajes sea fuente de spam es 0.1. El 90 % de los mensajesspam tiene la palabra Viagra, mientras que s´olo el 15 % de los mensajes no spam la tienen. Unreceptor ha recibido 4 mensajes de la misma fuente y en exactamente 2 de ellos detect´o la palabraViagra, ¿cu´al es la probabilidad de que la fuente sea
THIS FORM IS REQUIRED: Please Return Up to three weeks prior to your camp sessions: Please mail : PO Box 138, West Guilford, ON, K0M 2S0 Within three weeks of your camp session: Please DO NOT MAIL ; bring on registration day. Camper Personal Information Name:______________________________________Dates Attending:_______________________ Year:____________ Address:___________________
Total Health Care CSHCS 
2013 CSHCS Preferred Formulary