Microsoft word - asc 2011 formulary v 1.doc

Fluconazole* (Diflucan)
GENERIC DRUGS
Itraconazole* (Sporanox)
Ascension Health endorses the use of FDA Ketoconazole* (Nizoral)
Nystatin* (Mycostatin)
encourages the prescribing and dispensing of Terbinafine* (Lamisil)(QL)
these generic medications whenever medically ANTI-MALARIALS ____________________________
Chloroquine* (Aralen)
EXCLUDED DRUGS
Hydroxycchloroquine* (Plaquenil)
Mefloquine* (Lariam)
Ascension Health has excluded the following Quinine* (Qualaquin)
drugs or drug classes from coverage under the ANTI-TUBERCULOSIS AGENTS_________________
pharmacy benefit: cough & cold combinations, Ethambutol* (Myambutol)
allergy ophthalmics (e.g. Patanol), H2 Blockers Isoniazid* (Nydrazid)
Pyrazinamide* (pyrazinamide)
antihistamines (e.g. Allegra, Clarinex), Rifampin* (Rifadin)
meperidine (Demerol), propoxyphene (e.g. OTHER ANTI-INFECTIVES _____________________
Darvocet), medical foods and drug/medical food combinations. Drugs (e.g. infused or vaccines) Clindamycin* (Cleocin)
ASCENSION
Iodoquinol* (iodoquinol)
that must be given by a medical professional are Metronidazole* (Flagyl)
Trimethoprim* (Proloprim)
PRIOR AUTHORIZATION / STEP THERAPY /
QUANTITY LIMITS
ANTI-VIRAL AGENTS
Select drugs require prior authorization (PA) of
ORMULARY
benefits. Medication utilization must meet FDA approved indications as well as Ascension Abacavir/Lamivudine/Zidovudine (Trizivir) Acyclovir* (Zovirax)
Step Therapy Protocols (ST): Step therapy
requires the use of one or more medications before benefits for the use of another medication Amantadine* (Symmetrel)
(CONDENSED VERSION)
Quantity Limits (QL): Ascension Health has
identified a number of select medications which will be subject to quantity limits. A quantity limit prescription medication Ascension Health will JANUARY 2011
Efavirenz/Emtricitabine/Tenofovir (Atripla) cover as a benefit within a defined period of time. Quantity limits may be implemented on a per day basis (e.g. 1 tablet per day), per prescription or Enfuvirtide (Fuzeon)(SP)
Please note: This is not a comprehensive list of SPECIALTY DRUGS
Fanciclovir* (fanciclovir)
Ascension Health has specified certain specialty drugs are to be filled only through the in-house Ganciclovir* (Cytovene)
pharmacies or from Coram. These drugs are noted in the list below with (SP).
approved generic is available, the generic name is bolded and asterisked.
ANTI-INFECTIVE AGENTS
Lopinavir/Ritonavir (Kaletra) Maraviroc (Selzentry) ANTIBIOTICS ________________________________
Cephalosporins .
Cefaclor* (Ceclor)
Cefdinir* (Omnicef)
Ribavirin* (Rebetol)
Cefadroxil* (Duracef)
copayment. Example: Cefaclor* (Ceclor)
Cefprozil* (Cefzil)
means that the generic Cefaclor is Cefuroxime* (Ceftin)
formulary and the brand is non-formulary Cefpodoxime* (Vantin)
Cephalexin* (Keflex)
Macrolides.
Azithromycin* (Zithromax)(QL)
active ingredient is only available as a Clarithromycin XL* (Biaxin XL)
Erythromycin* (Eryc, PCE)
AUTONOMIC AND
Example: Clopidogrel (Plavix) means that Erythromycin/Sulfisoxazole* (Pediazole)
CENTRAL NERVOUS SYSTEM AGENTS
the brand, Plavix is covered and there is Penicillins .
ANALGESICS, NARCOTIC _____________________
no generic available. Plavix is the brand Amoxicillin* (Amoxil)
Acetaminophen/Codeine* (Tylenol w/codeine)
Amoxicillin/Clavulanate* (Augmentin)
Aspirin/Codeine* (Empirin w/codeine)
Ampicillin* (Principen)
If the word 'generic' and the brand name Fentanyl* (Duragesic)(QL)
Dicloxacillin* (Pathocil)
both appear within the parenthesis, both Fentanyl Citrate* (Actiq, Fentora)(PA/QL)
Penicillin* (Veetids)
Hydrocodone/Acetaminophen* (Lortab) (QL)
Quinolones.
Hydromorphone* (Dilaudid)
Ciprofloxacin/XR* (Cipro/XR)
Methadone* (Dolophine)
Example: Phenytoin (Dilantin / generic) Moxifloxacin (Avelox)(QL)
Morphine Sulfate* (MS Contin)(QL)
means that both the brand and generic Sulfonamides .
Oxycodone/Acetaminophen* (Percocet) (QL)
are available. Therefore, the brand Erythromycin/Sulfisoxazole* (Pediazole)
Oxycodone/Aspirin* (Percodan)
Dilantin and the generic phenytoin are on Sulfamethoxazole/Trimethoprim* (Bactrim)
Oxycodone* (Oxycontin)(QL)
Sulfisoxazole* (generic)
Analgesics, Non-Narcotic .
Tetracyclines .
APAP/Isometheptene/Dichlphen* (Midrin)
Doxycycline hyclate* (Vibramycin)
formulary listing shall be considered non- Acetaminophen/Caffeine/Butalbital* (Fioricet)
Minocycline* (Minocin, Dynacin)
Aspirin/Caffeine/Butalbital* (Fiorinal)
Tetracycline* (Sumycin)
Ergotamine/Caffeine* (Cafergot)
ANTIFUNGAL AGENTS (ORAL) _________________
Sumatriptan* (Imitrex)(QL)
Clotrimazole* (Mycelex)
Tramadol* (Ultram)
ANALGESICS, NONSTEROIDAL
Risperidone* (Risperdal)
Nicardipine* (Cardene)
ANTI-INFLAMMATORY ________________________
Thioridazine* (Mellaril)
Nifedipine* (Procardia/Adalat CC)
Diclofenac* (Voltaren)
Thiothixene* (Navane)
Verapamil* (Calan,Verelan)
Etodolac* (etodolac)
Trifluoperazine* (Stelazine)
CENTRALLY ACTING ANTIHYPERTENSIVES______
Fenoprofen* (Nalfon)
SEDATIVES, HYPNOTICS AND ANTI-ANXIETY_____
Clonidine* (Catapres)
Flurbiprofen* (Ansaid)
Alprazolam* (Xanax)
Methyldopa* (generic)
Ibuprofen* (Motrin)
Buspirone* (BuSpar)
DIURETICS __________________________________
Indomethacin* (Indocin)
Chloral Hydrate* (Noctec)
Acetazolamide* (Diamox Sequels)
Ketoprofen* (ketoprofen)
Chlordiazepoxide* (Librium)
Chlorthalidone* (Hygroton)
Ketorolac* (Toradol)
Clorazepate* (generic)
Ethacrynic Acid* (Edecrin)
Meloxicam* (Mobic)
Diazepam* (generic)
Eplerenone* (Inspra)
Nabumetone* (nabumetone)
Flurazepam* (flurazepam)
Furosemide* (Lasix)
Naproxen* (Naprosyn)
Lorazepam* (Ativan)
HCTZ/Triamterene* (Maxzide)
Oxaprozin* (Daypro)
Meprobamate* (Miltown)
Hydrochlorothiazide* (generic)
Piroxicam* (Feldene)
Oxazepam* (Serax)
Indapamide* (generic)
Sulindac* (Clinoril)
Temazepam* (Restoril)
Methazolamide* (generic)
Tolmetin* (Tolectin)
Triazolam* (Halcion)
Metolazone* (Zaroxolyn)
ANALGESICS, SALICYLATES __________________
Zolpidem* (Ambien) (QL)
Spironolactone/HCTZ* (Aldactone)
Aspirin* (generic)
Torsemide* (Demadex)
Chol Sal/Magnesium Salicylate* (generic)
CARDIOVASCULAR AGENTS
Triamterene* (Dyrenium)
Diflunisal* (Dolobid)
ANGIOTENSIN CONVERTING ENZYME
VASODILATORS _____________________________
Salsalate* (Disalcid)
INHIBITORS AND RECEPTOR BLOCKERS _______
Hydralazine* (Apresoline)
ANTICONVULSANTS __________________________
Benazepril/HCTZ* (Lotensin)
Isosorbide Dinitrate* (Isordil)
Carbamazepine* (Tegretol XR/generic)
Benazepril/Amlodipine* (Lotrel)(QL)
Isosorbide Mononitrate* (Imdur, Monoket)
Clonazepam* (Klonopin)
Captopril/HCTZ* (Capoten/Capozide)
Minoxidil* (generic)
Divalproex Sodium* (Depakote
Enalapril/HCTZ* (Vasotec/Vaseretic)
Nitroglycerin* (generic)
Fosinopril/HCTZ* (Monopril)
DERMATOLOGICALS
Ethosuximide* (Zarontin)
Lisinopril/HCTZ* (Zestril/Zestoretic)
Gabapentin* (Neurontin)
Losartan/HCTZ* (Cozaar/Hyzaar)
ACNE ______________________________________
Lamotrigine* (Lamictal)
Moexipril/HCTZ* (Univasc/Uniretic)
Clindamycin* (Cleocin)
Levetiracetam* (Keppra)
Olmesartan (Benicar/ Benicar HCT)(ST)(QL)
Erythromycin* (Emgel)
Mephobarbital* (Mebaral)
Quinapril/HCTZ* (Accupril/Accuretic)
Isotretinoin* (Accutane)
Phenobarbital* (generic)
Ramipril* (Altace/generic)
Metronidazole* (MetroLotion,MetroGel)
Phenytoin* (Dilantin/generic)
Trandolapril* (Mavik)
Minocycline* (Minocin/Solodyne)
Primidone* (Mysoline)
Valsartan/HCTZ (Diovan/Diovan HCT)(ST)(QL)
Sodium Sulfacetamide* (Sulfacet-R)
Oxcarbazepine* (Trileptal)
ANTI-ADRENERGIC BLOCKERS ________________
Tretinoin* (Retin-A) (MAX AGE 34)
Topiramate* (Topamax)
ANTIBIOTICS/ANTIVIRALS _____________________
Valproic Acid* (Depakene)
Doxazosin* (Cardura)
Acyclovir* (Zovirax/generic)
Zonisamide* (Zonegran)
Prazosin* (Minipress)
Metronidazole* (MetroGel,MetroLotion)
ANTIPARKINSON AGENTS _____________________
Terazosin* (Hytrin)
ANTIARRHYTHMICS __________________________
Mupirocin* (Bactroban)
Amantadine* (Symmetrel)
Sodium Sulfacetamide* (Sulfacet-R)
Benztropine* (Cogentin)
Amiodarone* (Cordarone)
FUNGICIDES_________________________________
Bromocriptine* (Parlodel)
Digoxin* (Lanoxin)
Ciclopirox* (Loprox)
Carbidopa/Levodopa* (Sinemet)
Disopyramide* (Norpace)
Clotrimazole/Betamethazone* (Lotrisone)
Pramipexole* (Mirapex)
Flecainide* (Tambocor)
Ketoconazole* (Nizoral)
Ropinirole* (Requip)
Mexiletine* (Mexitil)
Nystatin/Triamcinolone* (Mycolog II)
Selegiline *(Eldepryl)
Procainamide* (Pronestyl)
Trihexyphenidyl* (Artane)
Propafenone* (Rythmol)
TOPICAL ANTI-INFLAMMATORY AGENTS ________
CEREBRAL STIMULANTS______________________
Quinidine Gluconate* (Quinidex)
Low Potency .
Sotalol* (Betapace AF)
Amphet Asp/Amphet/D-Amphet*
Desonide* (Desowen)
ANTICOAGULANTS/ANTITHROMBOTICS _________
(Adderall/Adderall XR)(QL)(MIN AGE 3/6)
Fluocinolone* (Synalar)
Dexmethylphenidate* (Focalin)
Anagrelide* (Agrylin)
Hydrocortisone* (generic)
Dextroamphetamine* (Dexedrine)
Cilostazol* (Pletal)
Medium Potency.
Clopidogrel (Plavix)(QL)
Desoximetasone* (Topicort)
Methylphenidate* (Ritalin)
Dipyridamole* (Persantine)
Fluocinolone* (Synalar)
PSYCHOTHERAPEUTIC AGENTS _______________
Pentoxifylline* (Trental)
Mometasone* (Elocon)
Ticlopidine* (Ticlid)
Antidepressants .
Prednicarbate* (Dermatop E)
Warfarin* (generic/Coumadin)
Triamcinolone* (Aristocort)
Amitriptyline* (Elavil)
ANTILIPEMICS _______________________________
Bupropion/-XL* (Wellbutrin/XL)(QL)
High Potency.
Cholestyramine* (Questran)
Citalopram* (Celexa)
Betamethasone Dipropionate* (Diprosone)
Colestipol* (Colestid)
Desipramine* (Norpramin)
Fluocinonide* (Lidex)
Fenofibrate* (Lofibra)
Doxepin* (Sinequan)
Ultra-High Potency .
Gemfibrozil* (Lopid)
Fluoxetine* (Prozac)
Lovastatin* (Mevacor)
Augmented Betamethasone* (Diprolene)
Fluvoxamine* (Luvox)
Niacin* (Niaspan/generic)
Clobetasol* (Temovate)
Imipramine* (Tofranil)
Pravastatin* (Pravachol)
Diflorasone* (Psorcon)
Mirtazapine* (Remeron)
Simvastatin* (Zocor)
VAGINAL/RECTAL PREPARATIONS _____________
Nortriptyline* (Norpramin)
BETA-ADRENERGIC BLOCKERS________________
Hydrocortisone* (Proctocort)
Paroxetine* (Paxil /CR) (QL)
Mesalamine* (Rowasa)
Sertraline* (Zoloft)
Acebutolol* (Sectral))
Metronidazole* (MetroGel Vaginal)
Trazodone* (trazodone)
Atenolol/Chlorthalidone* (Tenoretic)
Sulfanilamide* (AVC)
Venlafaxine* (Effexor XR/generic)(QL)
Bisoprolol/HCTZ* (Zebeta)
MISCELLANEOUS DERMATOLOGICALS _________
Antimanic Agents .
Carvedilol* (Coreg/CR)
Labetalol* (Trandate)
Calcipotriene* (Dovonex)
Lithium Carbonate* (Eskalith)
Metoprolol/XL/HCTZ* (Lopressor)(QL)
Fluorouracil* (Efudex)
Lithium Citrate* (Cibalith-S)
Lindane* (Kwell)
Antipsychotic Agents .
Nadolol* (Corgard)
Permethrin* (Elimite)
Chlorpromazine* (Thorazine)
Pindolol* (Viskin)
Podofilox* (Condylox)
Clomipramine* (Anafranil)
Propranolol/XL/HCTZ* (Inderal)
Selenium Sulfide* (Selsun RX)
Clozapine* (Clozaril)
Sotalol* (Betapace)
Silver Sulfadiazine* (Silvadene)
Fluphenazine* (Prolixin)
Timolol* (Blocadren)
ENDOCRINE AGENTS
Haloperidol* (Haldol)
CALCIUM CHANNEL BLOCKERS _______________
Loxapine* (Loxitane)
Amlodipine* (Norvasc)(QL)
ANTIDIABETIC AGENTS-INJECTABLE ___________
Perphenazine* (Trilafon)
Diltiazem* (Cardizem)
Prochlorperazine* (Compazine)
Felodipine* (Plendil)
ANTIDIABETIC AGENTS-ORAL _________________
Flutamide* (generic)
Acarbose* (Precose)
OPHTHALMICS
NASAL MEDICATIONS ________________________
Chlorpropamide* (Diabinese)
Fluticasone* (Flonase)
Glimepiride* (Amaryl)
ALPHA-AGONIST_____________________________
Flunisolide* (Nasarel)(QL)
Glipizide* (Glucotrol)
Brimonidine Tartrate* (Alphagan P/generic)
Glipizide/Metformin* (Metaglip)
ANTI-INFECTIVE AGENTS______________________
SKELETAL AGENTS
Glyburide/Metformin* (Glucovance)
Chloramphenicol* (generic)
ANTIRHEUMATICS ___________________________
Glyburide/Micronized* (Glynase)
Ciprofloxacin* (Ciloxin)
Azathioprine* (Imuran)
Metformin* (Glucophage)
Erythromycin* (Romycin)
Hydroxychloroquine* (Plaquenil)
Tolazamide* (Tolinase)
Gentamicin* (Garamycin)
Methotrexate* (Rheumatrex)
Tolbutamide* (Orinase)
Neomycin/Bacitracin/Polymyxin* (NeoSporin)
BONE ENHANCING AGENTS ___________________
ANTIDIABETIC SUPPLIES______________________
Ofloxacin* (Ocuflox)
Alendronate* (Fosamax)(QL)
One Touch are the only test strips included on Polymyxin B/Trimethoprim* (Polytrim)
Calcitonin-Salmon* (Midrin)
formulary. Quantity limits apply.
Sulfacetamide* (Bleph-10)
Etidronate* (Didronel)
ANTITHYROID _______________________________
Tobramycin* (Tobrex)
Methimazole* (Tapazole)
ANTI-INFLAMMATORY AGENTS ________________
SKELETAL MUSCLE RELAXANTS
Propylthiouracil* (generic)
Cromolyn* (Opticrom)
THYROID____________________________________
Dexamethasone* (Maxidex)
Baclofen* (Lioresal)
Levothyroxine* (Synthroid, Levothroid, Levoxyl,
Diclofenac* (Voltaren)
Carisoprodol* (Soma)
Fluorometholone* (Flarex)
Diazepam* (Valium)
Thyroid* (Armour Thyroid)
Flurbiprofen* (Ocufen)
Methocarbamol* (Robaxin)
Prednisolone* (Inflamase Forte)
Tizanidine* (Zanaflex)
GASTROINTESTINAL AGENTS
ANTI-INFECTIVE AND
ANTIEMETIC/ANTIVERTIGO ___________________
ANTI-INFLAMMATORY COMBINATIONS __________
URINARY AGENTS
Granisetron* (Kytril)
Na Sulfacetm/Prednisolone* (Vasocidin)
ANTI-INFECTIVES ____________________________
Meclizine* (Antivert)
Neomy/Bacitracin/Polymyxin/Hydrocort*
Sulfadiazine* (generic)
Metoclopramide* (Reglan)
Sulfisoxazole* (Gantrisin)
Ondansetron* (Zofran)
Neomycin/Dexamethasone* (NeoDecadron)
Trimethoprim/Sulfamethoxazole* (Bactrim,
Prochlorperazine* (Compazine)
Neomycin/Polymyx B/Dexamethasone*
Promethazine* (Phenergan)
CHOLINERGIC AGENTS _______________________
Trimethobenzamide* (Tigan)
ANTIVIRAL AGENTS __________________________
ANTISPASMODIC/GI MOTILITY _________________
Bethanechol* (Urecholine)
Trifluridine* (Viroptic)
Flavoxate* (Urispas)
Belladonna/Phenobarbital* (Donnatal)
BETA-BLOCKERS ____________________________
OTHER URINARY AGENTS_____________________
Clidinium/Chlordiazepoxide* (Librax)
Betaxolol* (Betoptic)
Dicyclomine* (Bentyl)
Phenazopyridine* (Pyridium)
Carteolol* (Ocupress)
Hyoscyamine* (Levsin)
Oxybutynin* (Ditropan)
Levobunolol* (Betagan)
Metoclopromide* (Reglan)
Metipranolol* (OptiPranolol)
Propantheline* (Pro-Banthine)
Timolol* (Timoptic)
VITAMINS AND ELECTROLYTES
ANTIULCER _________________________________
MIOTICS ____________________________________
Misoprostol* (Cytotec)
Pilocarpine* (Isopto Carbachol)
OTHER GI PRODUCTS ________________________
GS REQUIRING STEP THERAPY UGS REQUIRING
MYDRIATICS ________________________________
Balsalazide* (Colazal)
Atropine* (Isopto Atropine)
Hydrocortizone* (generic)
Cyclopentolate* (Cyclogyl)
STEPTHERAPY
Lactulose* (Cephulac)
Mesalamine* (Asacol/Asacol HD/generic)
SYMPATHOMIMETICS_________________________
Dipivefrin* (generic)
Sulfasalazine* (Azulfidine)
Ursodiol* (Actigall)
GLUCOCORTICOIDS
ANTI-INFECTIVE AGENTS______________________
Dexamethasone* (Decadron)
Acetic Acid* (Vosol)
Fludrocortisone* (Florinef)
Acetic Acid/Benzethonium* (generic)
Methylprednisolone* (generic)
Ofloxacin* (Floxin)
Prednisolone* (Prelone)
ANTI-INFECTIVE AND
Prednisone* (generic)
ANTI-INFLAMMATORY COMBINATIONS __________
Acetic acid/Hydrocortisone*(Vosol HC)
GOUT THERAPY
Neomycin/Polymxin/HC* (Cortisporin)
Allopurinol* (Zyloprim)
Colchicine* (generic)
RESPIRATORY
Colchicine/Probenecid* (generic)
Indomethacin* (Indocin)
ANTI-ASTHMATIC AGENTS ____________________
Probenecid* (generic)
Corticosteroids.
Beclomethasone (QVAR)
HORMONES
Budesonide* (Pulmicort)
Budesonide/Formoterol (Symbicort)
ANTIESTROGENS ____________________________
Tamoxifen* (Nolvadex)
Fluticasone/Salmeterol (Advair/Advair HFA) ESTROGENS ________________________________
Sympathomimetics .
Conjugated estrogens (Premarin)
Estradiol* (Estrace)
Metaproterenol* (Alupent)
Estradiol Patch* (Climara)
Estropipate* (Ogen)
Terbutaline* (Brethine)
ESTROGEN COMBINATIONS ___________________
Xanthine Derivatives.
Estrogen, Ester/Methyltestosterone*
Aminophylline* (generic)
Theophylline* (Uniphyl)
PROGESTINS ________________________________
OTHER AGENTS _____________________________
Medroxyprogesterone* (Provera)
Megestrol* (Megace)
Albuterol/Ipratropium* (DuoNeb)
Norethindrone* (Aygestin)
Cromolyn* (Intal)
MISCELLANEOUS HORMONE PRODUCTS________
Finasteride* (Proscar)
Montelukast (Singulair)(QL)
2011 ASCENSION HEALTH PREFERRED FORMULARY BRANDS
GENERICS:
DRUG/DRUG CLASS EXCLUSIONS:
QUANTITY LIMITS (QL):
Ascension Health has excluded the following drugs or drug Ascension Health has identified a number of select classes from coverage under the pharmacy benefit: cough medications which will be subject to quantity limits. A & cold combinations, allergy ophthalmics (e.g. Patanol), H2 quantity limit establishes the maximum amount of a dispensing of these generic medications Blockers (e.g. Zantac, Tagamet), non-sedating prescription medication Ascension Heatlh will cover antihistamines (e.g. Allegra, Clarinex), meperidine as a benefit within a defined period of time. Quantity (Demerol), propoxyphene (e.g. Darvocet), medical foods limits may be implemented on a per day basis (e.g. 1 and drug/medical food combination and drugs requiring tablet per day), per prescription or per 30 days. administration by a health care professional (e.g. infused or PRIOR AUTHORIZATION:
SPECIALTY DRUGS:
STEP THERAPY PROTOCOLS (ST):
Select drugs require prior authorization Ascension Health has specified certain specialty drugs are Step therapy requires the use of one or more
(PA) of benefits. Medication utilization
to be filled only through the in-house pharmacies or from medications before benefits for the use of another must meet FDA approved indications as Coram. well as Ascension Health guidelines. For prior authorization guidelines, visit www.mp.medimpact.com/asc.
SINGULAIR (QL)
AVELOX (QL)
BENICAR / HCT (ST,QL)
DIOVAN / HCT (ST,QL)
ONE TOUCH TEST STRIPS (QL)
ONE TOUCH ULTRA TEST STRIPS (QL)
PLAVIX (QL)
EFFEXOR XR (QL)
FUZEON (SP)
To search the formulary status of a drug, visit www.mp.medimpact.com/asc

Source: http://www.ovhc.com/documents/Human%20Resources/2011%20Formulary%20Drug%20List%20and%20Preferred%20Brands.pdf