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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

Source: https://www.catalystrx.com/www/shared/docs/totalHealthCare/THC_CSHCS_Preferred_Drug_List_April_2013.pdf

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