NITRATES

isosorbide dinitrate ext-rel tabs

isosorbide dinitrate oral (ISORDIL®)

isosorbide dinitrate sublingual (ISORDIL® S.L.)

isosorbide mononitrate ext-rel (IMDUR®)

nitroglycerin sublingual (NITROSTAT®)

nitroglycerin transdermal (NITREK®)

nitroglycerin transdermal (TRANSDERM-NITRO®)

NITRO-DUR®

NITROLINGUAL®

LIPID LOWERING AGENTS

cholestyramine (QUESTRAN®/QUESTRAN®-LIGHT)

cholestyramine pkt (QUESTRAN®/QUESTRAN®-LIGHT)

gemfibrozil (LOPID®)

COLESTID®

LESCOL/XL

LIPITOR®

PRAVACHOL

NIACOR®

NIASPAN®

TRICOR®

Pain and Inflammatory Diseases

PAIN, NSAID ANALGESICS

ibuprofen (MOTRIN®)

naproxen (NAPROSYN®)

naproxen sodium (ANAPROX®)

VIOXX®

CELEBREX

PAIN, OPIOID AND OTHER ANALGESICS

Mild To Moderate Pain

propoxyphene hcl (DARVON®)

propoxyphene nap/acetaminophen (DARVOCET-N®)

Moderate To Moderately Severe Pain

codeine/acetaminophen (TYLENOL® #2/3/4)

hydrocodone/acetaminophen 2.5/500 (LORTAB® 2.5/500)

hydrocodone/acetaminophen tabs 5/500 (VICODIN®)

hydrocodone/acetaminophen 7.5/500 (LORTAB® 7.5/500)

hydrocodone/acetaminophen 7.5/750 (VICODIN ES®)

hydrocodone/acetaminophen 10/650 (LORCET® 10)

oxycodone (OXYIR®)

oxycodone/acetaminophen, 5/325 only (PERCOCET®)

oxycodone/aspirin (PERCODAN®)

CAPITAL® w/CODEINE

Moderate To Severe Pain

codeine sulfate

hydromorphone (DILAUDID®)

meperidine (DEMEROL®)

morphine (MSIR®)

morphine ext-rel (MS CONTIN®)

morphine, rectal (RMS® SUPPOSITORIES)

ACTIQ®

DURAGESIC®

OXYCONTIN®

Tension Headaches

acetaminophen/butalbital/caffeine (FIORICET®)

aspirin/butalbital/caffeine (FIORINAL®)

ARTHRITIS

Anti-Inflammatory Drugs: Rheumatoid and Osteoarthritis

ibuprofen (MOTRIN®)

indomethacin (INDOCIN®)

naproxen (NAPROSYN®)

naproxen sodium (ANAPROX®)

sulfasalazine (AZULFIDINE®)

salsalate (DISALCID™)

sulindac (CLINORIL®)

CYTOTEC® (adjunctive)

VIOXX®

Disease Modifying Antirheumatic Drugs (DMARDs): Rheumatoid Arthritis—Additional

azathioprine (IMURAN®)

hydroxychloroquine (PLAQUENIL®)

methotrexate (RHEUMATREX®)

ARAVA™

CUPRIMINE®

RIDAURA®

GOUT

allopurinol (ZYLOPRIM®)

colchicine

probenecid

Psychiatric

DEPRESSION

amitriptyline (ELAVIL®)

amitriptyline/perphenazine

amoxapine

bupropion (WELLBUTRIN®)

clomipramine (ANAFRANIL®)

desipramine (NORPRAMIN®)

doxepin (SINEQUAN®)

fluoxetine (PROZAC)

imipramine hcl (TOFRANIL®)

maprotiline (LUDIOMIL®)

nortriptyline (PAMELOR®)

trazodone (DESYREL®)

CELEXA™

LEXAPRO

PARNATE®

PAXIL®

REMERON®

REMERON SOLTAB

WELLBUTRIN® SR

ZOLOFT®

BIPOLAR DISORDER

lithium carbonate

DEPAKOTE®

ESKALITH CR®

LITHOBID®

PSYCHOSES

chlorpromazine (THORAZINE®)

clozapine (CLOZARIL®)

fluphenazine (PROLIXIN®)

haloperidol (HALDOL®)

loxapine (LOXITANE®)

perphenazine (TRILAFON®)

thioridazine (MELLARIL®)

thiothixene (NAVANE®)

trifluoperazine (STELAZINE®)

RISPERDAL®

SEROQUEL®

ZYPREXA®

ATTENTION DEFICIT DISORDER

dextroamphetamine (DEXEDRINE®)

methylphenidate (RITALIN®)

methylphenidate ext-rel (RITALIN-SR®)

pemoline (CYLERT®)

DEXEDRINE® SPANSULE®

METADATE™ ER 10mg

ANXIETY

alprazolam (XANAX®)

chlordiazepoxide hcl (LIBRIUM®)

clorazepate (TRANXENE®)

diazepam (VALIUM®)

hydroxyzine hcl (ATARAX®)

hydroxyzine pamoate (VISTARIL®)

lorazepam (ATIVAN®)

oxazepam (SERAX®)

BUSPAR®

INSOMNIA

chloral hydrate

estazolam (PROSOM™)

flurazepam (DALMANE®)

hydroxyzine hcl (ATARAX®)

hydroxyzine pamoate (VISTARIL®)

temazepam (RESTORIL®)

triazolam (HALCION®)

AMBIEN®

SONATA®

NARCOLEPSY

dextroamphetamine (DEXEDRINE®)

methylphenidate (RITALIN®)

methylphenidate ext-rel (RITALIN-SR®)

DEXEDRINE® SPANSULE®

METADATE™ ER 10mg

PROVIGIL®

SMOKING DETERRENTS

nicotine transdermal (HABITROL®)

ZYBAN®

ALCOHOL DETERRENTS

disulfiram (ANTABUSE®)

Eye

The following lists are generally based upon solution formulations. Ointments are also available for many of the products and they should be considered on formulary.

ANTI-INFECTIVES

bacitracin (AK-TRACIN®)

bacitracin/polymyxin (POLYSPORIN®)

erythromycin (ILOTYCIN®)

gentamicin (GARAMYCIN®)

neomycin/polymyxin/gramicidin (NEOSPORIN®)

polymyxin/trimethoprim (POLYTRIM®)

sulfacetamide 10% (BLEPH®-10)

tobramycin (TOBREX®)

OCUFLOX®

ANTIVIRALS

VIRA-A®

VIROPTIC®

ANTI-INFLAMMATORIES

dexamethasone sodium phosphate (DECADRON®)

diclofenac sodium (VOLTAREN®)

fluorometholone (FML®)

fluorometholone acetate (FLAREX®)

neomycin/dexamethasone (NEODECADRON®)

neomycin/polymyxin/dexamethasone (MAXITROL®)

prednisolone acetate 1% (PRED FORTE®)

prednisolone phosphate 0.125% (INFLAMASE® MILD)

prednisolone phosphate 1% (INFLAMASE® FORTE)

sulfacetamide 10%/prednisolone 0.25% (VASOCIDIN®)

ACULAR®

CORTISPORIN®

LOTEMAX®

PRED-G®

PRED MILD®

TOBRADEX®

VOLTAREN®

GLAUCOMA

Oral

acetazolamide (DIAMOX®)

methazolamide (NEPTAZANE®)

DIAMOX® SEQUELS®

Topical

dipivefrin (PROPINE®)

levobunolol (BETAGAN®)

pilocarpine (ISOPTO® CARPINE)

timolol maleate (TIMOPTIC®)

ALPHAGAN®

AZOPT®

BETIMOL®

LUMIGAN

PHOSPHOLINE IODIDE®

PILOPINE HS® GEL

ALLERGY

cromolyn sodium (CROLOM®)

ALOCRIL™

ALAMAST™

ALOMIDE®

EMADINE®

LIVOSTIN®

PATANOL®

ZADITOR™

OPHTHALMIC DRUGS, MISCELLANEOUS

atropine (ISOPTO® ATROPINE)

cyclopentolate (CYCLOGYL®)

homatropine (ISOPTO® HOMATROPINE)

naphazoline (ALBALON®)

Ear, Nose, and Throat

EAR

Antimicrobials

acetic acid (VOSOL® OTIC)

acetic acid/aluminum acetate (DOMEBORO® OTIC)

acetic acid/hydrocortisone (VOSOL® HC OTIC)

neomycin/polymyxin/hydrocortisone (CORTISPORIN® OTIC)

CIPRO® HC OTIC

FLOXIN® OTIC

Miscellaneous

benzocaine/antipyrine (AURALGAN® OTIC)

CERUMENEX®

NOSE

Steroid

FLONASE®

NASACORT®

NASACORT® AQ

NASONEX®

RHINOCORT®

RHINOCORT® AQUA™

TRI-NASAL®

Other

ASTELIN®

ATROVENT®

MOUTH AND THROAT

chlorhexidine gluconate (PERIDEX®)

lidocaine viscous (XYLOCAINE®)

triamcinolone paste (KENALOG® IN ORABASE®)

EVOXAC™

PERIOSTAT®

SALAGEN®

Gastrointestinal Drugs

DIARRHEA

diphenoxylate/atropine (LOMOTIL®)

loperamide (IMODIUM®)

PANCREATIC ENZYMES

pancrelipase (VIOKASE®)

pancrelipase delayed-rel (ULTRASE®)

CREON®

PANCREASE® MT

ULTRASE® MT

EMESIS

meclizine (ANTIVERT®)

metoclopramide (REGLAN®)

prochlorperazine (COMPAZINE®)

promethazine (PHENERGAN®)

trimethobenzamide (TIGAN®) d

KYTRIL®

TORECAN®

ZOFRAN®

ULCERS/REFLUX (GERD)

Peptic Ulcer Treatment

cimetidine (TAGAMET®)

ranitidine tabs (ZANTAC®)

sucralfate (CARAFATE®)

ACIPHEX

HELIDAC™

PREVPAC™

PRILOSEC®

NEXIUM®

SPASM

dicyclomine (BENTYL®)

hyoscyamine sulfate (LEVSIN®)

hyoscyamine sulfate ext-rel (LEVBID®)

hyoscyamine sulfate ext-rel (LEVSINEX® TIMECAPS®)

INFLAMMATORY BOWEL DISEASE

hydrocortisone enema (CORTENEMA®)

sulfasalazine (AZULFIDINE®)

ASACOL®

AZULFIDINE EN-TABS®

DIPENTUM®

CORTIFOAM®

FIV-ASA

PENTASA®

ROWASA®

GASTROINTESTINAL DRUGS, MISCELLANEOUS

electrolyte soln/PEG (GOLYTELY®)

lactulose (CEPHULAC®)

lactulose (CHRONULAC®)

MIRALAX®

NULYTELY®

VISICOL™

Diabetes Mellitus

INSULINS

Brand name insulin preparations noted, and animal derived insulins, plus syringes and needles are in tier 2. All other brand name human insulin preparations are in tier 3.

HUMALOG®

HUMULIN® OTC

NOVOLIN OTC

NOVOLG

LANTUS

VELOSULIN® BR OTC

ORAL AGENTS

glipizide (GLUCOTROL®)

glyburide (DIABETA®)

glyburide (MICRONASE®)

glyburide micronized (GLYNASE®)

ACTOS™

AMARYL®

AVANDIA®

GLUCOTROL XL®

PRANDIN™

PRECOSE®

STARLIX

GLUCOSE ELEVATING

GLUCAGON

MONITORING

Diabetes Monitoring Products

Accu-Chek™ kits;

Accu-Chek™, Chemstrip bG®, and Tracer bG™ blood glucose test strips;

Lancets;

Accu-Chek™ glucose control solution;

Chemstrip® urine test strips

Lifescan Fast Take

Women’s Health

MENOPAUSAL SYMPTOMS/OSTEOPOROSIS

Estrogens-Systemic

estradiol (ESTRACE®)

estradiol transdermal (ALORA®)

estradiol transdermal (CLIMARA®)

estropipate (OGEN®)

CENISTIN

COMBIPATCH™

ESCLIM

ESTRADERM®

ESTRATEST®

FEMHRT®

ORTHO-PREFEST™

PREMARIN®

PREMPHASE®

PREMPRO™

VIVELLE®

Estrogens-Vaginal

ESTRING®

PREMARIN® cream

VAGIFEM®

Progestins-Systemic

medroxyprogesterone acetate (PROVERA®)

AYGESTIN®

PROMETRIUM®

Progestins-Vaginal

CRINONE® 4%

CRINONE® 8%

Selective Estrogen Receptor Modulators

EVISTA®

Other

FOSAMAX®

MIACALCIN® inj, nasal

VAGINAL INFECTIONS

metronidazole tabs (FLAGYL® ORAL)

triple sulfa (SULTRIN®)

CLEOCIN®

DIFLUCAN® 150 ORAL

METROGEL-VAGINAL®

TERAZOL® 3/7

PREMENSTRUAL DYSPHORIC DISORDER

SARAFEM™

ORAL CONTRACEPTIVES

Monophasic

EE/desogestrel

EE/ethynodiol diacetate (ZOVIA® 1/35)

EE/ethynodiol diacetate (ZOVIA® 1/50)

EE/levonorgestrel (LEVORA)

EE/norethindrone (MODICON)

EE/norethindrone (ORTHO-NOVUM1+35)

EE/norgestrel (LO-OGESTRAL)

EE/norgestrel (OVRAL®)

ME/norethindrone (NORINYL® 1+50)

LEVORA

LOESTRIN® (FE)

LOW-OGESTRL

MIRCETTE™

MODICON

NECON

ORTHO-CEPT

ORTHO-CYCLEN

ORTHO-NOVUM

OVCON® 35

OVCON® 50

OVRAL®

YASMIN

EE = ethinyl estradiol; ME = mestranol

Triphasic

EE/levonorgestrel (TRIVORA®)

EE = ethinyl estradiol

CYCLESSA

ESTROSTEP® FE

ORTHO TRI-CYCLEN

TRI-NORINYL®

TRIVORA®

Progestin

MICRONOR

NOR-QD®

OVRETTE®

Hormones

ADRENAL CORTICOSTEROIDS

dexamethasone (DECADRON®)

hydrocortisone (CORTEF®)

methylprednisolone (MEDROL®)

prednisolone (PRELONE® SYRUP)

prednisone (DELTASONE®)

FLORINEF®

PEDIAPRED®

THYROID REPLACEMENT AND ANTITHYROID AGENTS

levothyroxine (LEVOXYL®)

levothyroxine (SYNTHROID®)

methimazole (TAPAZOLE®)

propylthiouracil

thyroid (ARMOUR® THYROID)

Skin

BACTERIAL INFECTIONS, TOPICAL

gentamicin (GARAMYCIN®)

silver sulfadiazine (SILVADENE®)

BACTROBAN®

FUNGAL INFECTIONS, TOPICAL

clotrimazole (LOTRIMIN®)

ketoconazole (NIZORAL®)

nystatin (MYCOSTATIN®)

nystatin/triamcinolone (MYCOLOG®-II)

LOPROX®

LOTRISONE®

MENTAX®

MONISTAT-DERM®

OXISTAT®

SPECTAZOLE®

VIRAL INFECTIONS, TOPICAL

ALDARA™

CONDYLOX®

ZOVIRAX®

ACNE VULGARIS

benzoyl peroxide (BENZAC® AC) #

clindamycin gel, soln (CLEOCIN T®)

erythromycin gel 2% (EMGEL®)

erythromycin soln (T-STAT®)

sulfacetamide/sulfur (NOVACET®)

ACCUTANE

AZELEX®

BENZAMYCIN®

CLEOCIN T® lotion

DIFFERIN®

KLARON®

TRIAZ®

ACNE ROSACEA

METROCREAM®

METROGEL®

METROLOTION™

NORITATE™

CORTICOSTEROIDS, TOPICAL

Products are grouped based upon relative potency. The formulary generally includes all strengths and usual dosage forms for all the products cited.

Low Potency

desonide oint 0.05% (DESOWEN®)

hydrocortisone crm 2.5% (HYTONE®)

ACLOVATE®

Medium Potency

betamethasone valerate crm/oint/lotion 0.1% (VALISONE®)

desoximetasone crm 0.05% (TOPICORT®)

fluocinolone acetonide crm/oint 0.025%/soln 0.01% (SYNALAR®)

hydrocortisone valerate crm/oint 0.2% (WESTCORT®)

triamcinolone acetonide crm/lotion 0.025% (KENALOG®)

triamcinolone acetonide crm/oint/lotion 0.1% (KENALOG®)

CORDRAN®

CUTIVATE®

ELOCON®

High Potency

betamethasone dipropionate crm/oint/lotion 0.05% (DIPROSONE®)

desoximetasone crm/oint 0.25%/gel 0.05% (TOPICORT®)

diflorasone diacetate crm 0.05% (PSORCON®)

fluocinonide crm/oint/gel 0.05% (LIDEX®)

triamcinolone acetonide crm 0.5% (KENALOG®)

Very High Potency

betamethasone dipropionate augmented oint 0.05% (DIPROLENE®)

clobetasol propionate crm/oint 0.05% (TEMOVATE®)

diflorasone diacetate oint 0.05% (PSORCON®)

CORDRAN® tape

DIPROLENE® AF

DIPROLENE® gel, lotion

ULTRAVATE®

SCABIES AND PEDICULOSIS

lindane

permethrin 5% (ELIMITE®)

EURAX®

PSORIASIS AND SEBORRHEA

methotrexate

selenium sulfide shampoo 2.5% (SELSUN®)

CAPITROL®

DOVONEX®

NIZORAL®SHAMPOO

SORIATANE®

TAZORAC®

TOPICALS, MISCELLANEOUS

hydrocortisone cream (PROCTOCREAM®-HC 2.5%)

EFUDEX®

EMLA®

FLUOROPLEX®

LAC-HYDRIN®

LIDODERM®

PROTOPIC®

REGRANEX®

Respiratory Drugs

ASTHMA

Inhalers

Bronchodilator Inhalers

albuterol (PROVENTIL®)

SEREVENT®

SEREVENT® DISKUS®

Steroid Inhalers

FLOVENT®

FLOVENT® ROTADISK®

PULMICORT TURBUHALER

VANCERIL®

Other Inhalers

ADVAIR DISKUS

ATROVENT®

COMBIVENT®

INTAL®

TILADE®

Inhalation Solutions

albuterol sulfate (PROVENTIL®)

cromolyn sodium (INTAL®)

ipratropium bromide (ATROVENT®)

PULMICORT RESPULES™

Oral Agents

Theophyllines

Solids–All Ext-Rel

theophylline caps (SLO-BID®)

theophylline tabs (THEO-DUR®)

THEO-24®

UNI-DUR®

UNIPHYL®

Liquids

theophylline

Leukotriene Modifiers

ACCOLATE®

SINGULAIR

Beta Agonists

albuterol sulfate (PROVENTIL®)

BRETHINE®

PROVENTIL® REPETABS®

VOLMAX®

ANTITUSSIVES AND EXPECTORANTS

benzonatate (TESSALON®)

codeine/bromodiphenhydramine (AMBENYL®)

codeine/brompheniramine/phenylpropanolamine (POLY-HISTINE CS®)

codeine/chlorpheniramine/pseudoephedrine (NOVAHISTINE® DH)

codeine/guaifenesin (ROBITUSSIN A-C®)

codeine/promethazine (PHENERGAN® w/CODEINE)

codeine/promethazine/phenylephrine (PHENERGAN® VC w/CODEINE)

codeine/pseudoephedrine/guaifenesin (ROBITUSSIN®-DAC)

dextromethorphan/brompheniramine/phenylpropanolamine (POLY-HISTINE DM®)

dextromethorphan/carbinoxamine/pseudoephedrine (RONDEC®-DM)

dextromethorphan/promethazine (PHENERGAN® DM)

guaifenesin ext-rel (HUMIBID® L.A.)

guaifenesin/phenylpropanolamine ext-rel (ENTEX® LA)

hydrocodone/homatropine (HYCODAN®)

hydrocodone/phenylpropanolamine (HYCOMINE®)

ANTIHISTAMINES

First Generation

Antihistamines

clemastine 2.68 mg (TAVIST®)

cyproheptadine (PERIACTIN®)

diphenhydramine 50 mg

hydroxyzine hcl (ATARAX®)

hydroxyzine pamoate (VISTARIL®)

promethazine (PHENERGAN®)

Antihistamine/Decongestant Combinations

brompheniramine 6 mg/pseudoephedrine 60 mg ext-rel (BROMFED-PD®)

brompheniramine 12 mg/pseudoephedrine 120 mg ext-rel (BROMFED®)

carbinoxamine 4 mg/pseudoephedrine 60 mg (RONDEC®)

chlorpheniramine 12 mg/phenylpropanolamine 75 mg ext-rel (ORNADE®)

chlorpheniramine 8 mg/pseudoephedrine 120 mg ext-rel (DECONAMINE® SR)

Second Generation

Antihistamines

ALLEGRA®

CLARITIN®

CLARINEX

Antihistamine/Decongestant Combinations

ALLEGRA-D®

CLARITIN-D® 12 HOUR

CLARITIN-D® 24 HOUR

Supplements

VITAMINS

The formulary includes the following brand name prescription prenatal vitamins with 1 mg of folic acid and generic versions from other manufacturers: Chromagen OB, Materna, Natachew, Natafort, Natalcare, Natalcare Plus, Nestabs CBF, Nestabs FA, Niferex PN Forte, Prenatal MR90 Fe, Prenatal Plus, Prenatal Rx, Prenatal Z, Prenate Advance and Ultra Natalcare. Generic versions are in Tier 1 and brands are in Tier 2.

Miscellaneous Drugs

Anaphylaxis Emergency

ANA-KIT®

EPIPEN®

EPIPEN® JR

Cystic Fibrosis

PULMOZYME®

TOBI®

Diabetes Insipidus

desmopressin nasal (DDAVP®)

DDAVP® tabs

Orthostatic Hypotension

PROAMATINE®

Paget’s Disease

ACTONEL™

DIDRONEL®

FOSAMAX®

Phosphate Binders

PHOSLO®

RENAGEL®

Primary Biliary Cirrhosis

URSO®

Primary Nocturnal Enuresis

desmopressin nasal (DDAVP®)

DDAVP® tabs

Radiolucent Gallstone Solubilizing Agent

ACTIGALL®

Subarachnoid Hemorrhage

NIMOTOP®

Urologic Disorders

bethanechol (URECHOLINE®)

oxybutynin (DITROPAN®)

phenazopyridine (PYRIDIUM®)

DETROL®

DETROL LA®

PROPANTHELINE

URISPAS®

Uterine Stimulants

METHERGINE®

Wilson’s Disease

CUPRIMINE®

GALZIN™