Fopg 2653.4 web version

Rx Selections™
Formulary File Sheet
Key Therapeutic Drug Categories
Oral Erythromycins
Antilipidemics
= Lowest relative cost to plan sponsor.
FORMULARY PRODUCTS
FORMULARY PRODUCTS
! ! ! ! ! = Highest relative cost to plan sponsor.
PLAN SPONSOR’S
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
= The recommended dose for people 65 and older is often lower DRUG NAME
RELATIVE COST
than the manufacturer’s usual dosing guidelines.
GENERICS
GENERICS
= Use by people 65 and older is generally not recommended.
Erythromycin Base Tablet, Enteric Coated (E-Mycin) The side effects may not be obvious, but may be serious.
Erythromycin Ethylsuccinate (E.E.S.) Cholestyramine/Aspartame (Questran Light) Safer medications may be available. If used, lower dosages Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole) $ Erythromycin Stearate (Erythrocin Stearate) = Weigh risk of birth defects or other adverse outcomes.
ANTI-INFECTIVES
Oral Antifungals
Oral Quinolones
FORMULARY PRODUCTS
FORMULARY PRODUCTS
PLAN SPONSOR’S
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
DRUG NAME
RELATIVE COST
Angiotensin II Blockers
GENERICS
Griseofulvin Ultramicrosize (Fulvicin P/G) FORMULARY PRODUCTS
Cipro XR (Ciprofloxacin HCl/Betaine Comb) PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Hyzaar (Losartan Potassium/Hydrochlorothiazide) Oral Urinary Tract Agents
FORMULARY PRODUCTS
PLAN SPONSOR’S
Diovan HCT (Valsartan/Hydrochlorothiazide) Oral Cephalosporins
DRUG NAME
RELATIVE COST
Micardis HCT (Telmisartan/Hydrochlorothiazide) FORMULARY PRODUCTS
PLAN SPONSOR’S
GENERICS
DRUG NAME
RELATIVE COST
Beta Blockers
GENERICS
Nitrofurantoin Macrocrystal (Macrodantin) FORMULARY PRODUCTS
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Macrobid (Nitrofurantoin/Nitrofurantoin Macrocrystal) GENERICS
Oral Misc. Agents
Ceftin Suspension (Cefuroxime Axetil) ▲Metoprolol Tartrate (Lopressor) FORMULARY PRODUCTS
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Ceftin 125mg Tablet (Cefuroxime Axetil) GENERICS
▲Propranolol HCl Sustained Action (Inderal LA) Oral Penicillins
FORMULARY PRODUCTS
Neomycin Sulfate (Neomycin Sulfate) PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
GENERICS
Tobi (Tobramycin/0.25 Normal Saline) Penicillin V Potassium (Pen-Vee K) Vaginal Antifungals
Amoxicillin Trihydrate/Potassium Clavulanate (Augmentin) $$$$ (Metoprolol Succinate Tablet, Sustained Release 24 hr) FORMULARY PRODUCTS
PLAN SPONSOR’S
Augmentin ES (Amoxicillin Trihydrate/Potassium Clavulanate)$$$ DRUG NAME
RELATIVE COST
Augmentin (Amoxicillin Trihydrate/Potassium Clavulanate) $$$$ Calcium Channel Blockers
GENERICS
Augmentin XR (Amoxicillin Trihydrate/ FORMULARY PRODUCTS
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Oral Sulfas
GENERICS
FORMULARY PRODUCTS
Terazol (Terconazole Cream with Applicator) PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Terazol (Terconazole Suppository, Vaginal) GENERICS
Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole) $ ARDIOVASCULAR
▲Verapamil HCl Tablet, Sustained Action (Calan SR) Sulfamethoxazole/Trimethoprim (Bactrim DS) ACE Inhibitors
Diltiazem HCl Capsule, Sustained Release 24 hr FORMULARY PRODUCTS
Oral Tetracyclines
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Diltiazem HCl Capsule, Sustained Release 12 hr FORMULARY PRODUCTS
PLAN SPONSOR’S
GENERICS
DRUG NAME
RELATIVE COST
GENERICS
Laser-Drilled Formulation (Procardia XL) ▲ Accupril (Quinapril HCl/Magnesium Carbonate) Vibramycin (Doxycycline Calcium Syrup) Nitroglycerin Patches
Estrogens/Combinations
G.I. (Ulcer)
FORMULARY PRODUCTS
FORMULARY PRODUCTS
PLAN SPONSOR’S
PLAN SPONSOR’S
Ulcer Drugs
DRUG NAME
RELATIVE COST
DRUG NAME
RELATIVE COST
FORMULARY PRODUCTS
GENERICS
PLAN SPONSOR’S
GENERICS
DRUG NAME
RELATIVE COST
Nitroglycerin Patch,Transdermal 24 Hours (Transderm-Nitro) $$$ GENERICS
Estradiol Patch, Transdermal Weekly (Climara) Cimetidine HCl Liquid (ml) (Tagamet) Nitro-Dur (Nitroglycerin Patch, Transdermal 24 Hours) Methyltestosterone/Estrogens, Esterified (Estratest H.S.) Adrenergic Antagonists & Related Drugs
Methyltestosterone/Estrogens, Esterified (Estratest) FORMULARY PRODUCTS
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Climara (Estradiol Patch, Transdermal Weekly) GENERICS
Combipatch (Estradiol/Norethindrone Acetate) Nexium (Esomeprazole Magnesium Trihydrate) Estraderm (Estradiol Patch, Transdermal Biweekly) Estratest H.S. (Methyltestosterone/Estrogens, Esterified) Femhrt (Ethinyl Estradiol/Norethindrone Acetate) Other Ulcer Therapy
FORMULARY PRODUCTS
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Conjugated/Medroxyprogesterone Acetate) GENERICS
Prempro (Estrogens, Conjugated/Medroxyprogesterone Acetate) $$ Catapres-TTS (Clonidine HCl Patch, Transdermal Weekly) $$$$ Vivelle (Estradiol Patch, Transdermal Biweekly) Estratest (Methyltestosterone/Estrogens, Esterified) Carafate (Sucralfate Suspension, Oral (Final Dose Form)) ENDOCRINE
PSYCHOTHERAPEUTICS
Premarin (Estrogens, Conjugated Cream (Grams)) Insulin Therapy
FORMULARY PRODUCTS
Oral Contraceptives
Tricyclic Antidepressants
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
FORMULARY PRODUCTS
FORMULARY PRODUCTS
PLAN SPONSOR’S
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
DRUG NAME
RELATIVE COST
Humulin 50/50 Vial (Insulin NPH S-S/Regular Insulin GENERICS
GENERICS
Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol (Mircette) Humulin 70/30 Vial (Insulin NPH Human Recombinant/ $$ Desogestrel-Ethinyl Estradiol (Ortho-Cept) Ethynodiol D-Ethinyl Estradiol (Demulen) Humulin L Vial (Insulin Zinc Human Rec) Levonorgestrel-Ethinyl Estradiol (Alesse) Humulin N Vials (Insulin NPH Human Recombinant) Levonorgestrel-Ethinyl Estradiol (Nordette) Humulin R Vials (Insulin Regular Human Rec) Levonorgestrel-Ethinyl Estradiol (Triphasil) Humulin U Vial (Insulin Zinc Extended Human Rec) Lantus Vial (Insulin Glargine,Human Recombinant Analog) $$$ Iletin I Lente Vial (Insulin Zinc, Beef-Pork) Norethindrone A-E Estradiol/Ferrous Fumarate (Loestrin Fe) $$ Iletin I NPH Vial (Insulin Isophane NPH, Beef-Pork) Norethindrone-Ethinyl Estradiol (Modicon) Iletin I Regular (Beef-Pork) Vial (Insulin Regular, Beef-Pork) $$$$ Norethindrone-Ethinyl Estradiol (Ortho-Novum) Misc. Antidepressants
Iletin II Lente (Pork) Vial (Insulin Zinc, Pork Purified) Norethindrone-Mestranol (Ortho-Novum) FORMULARY PRODUCTS
PLAN SPONSOR’S
Iletin II NPH (Pork) Vial (Insulin Isophane, Pork Pure) Norgestrel-Ethinyl Estradiol (Lo/Ovral) DRUG NAME
RELATIVE COST
Iletin II Regular (Pork) Vial (Insulin, Pork Purified) Norgestrel-Ethinyl Estradiol (Ovral) GENERICS
Norgestimate-Ethinyl Estradiol (Ortho-Cyclen) (Insulin Lispro (NPL)/Insulin Lispro, Human Rec. Anlog) Humalog Vial (Insulin Lispro, Human Rec. Anlog) Alesse (Levonorgestrel-Ethinyl Estradiol) Humulin 70/30 Cartridge (Insulin NPH Cyclessa (Desogestrel-Ethinyl Estradiol) Human Recombinant/Insulin Regular Human Rec) Demulen (Ethynodiol D-Ethinyl Estradiol) Humulin 70/30 Disposable Syringe (Insulin NPH Estrostep Fe (Norethindrone A-E Estradiol/Ferrous Fumarate) $$ Human Recombinant/Insulin Regular Human Rec) Loestrin (Norethindrone A-E Estradiol) Humulin N Cartridge (Insulin NPH Human Recombinant) $$$$$ Loestrin Fe (Norethindrone A-E Estradiol/Ferrous Fumarate) $$ Humulin N Disposable Syringe (Insulin NPH Lo/Ovral (Norgestrel-Ethinyl Estradiol) Humulin R Cartridge (Insulin Regular Human Rec) Mircette (Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol) Humalog Cartridge (Insulin Lispro, Human Rec. Anlog) Modicon (Norethindrone-Ethinyl Estradiol) FORMULARY PRODUCTS
PLAN SPONSOR’S
Nordette (Levonorgestrel-Ethinyl Estradiol) DRUG NAME
RELATIVE COST
(Insulin Lispro, Human Rec. Anlog) GENERICS
Ortho Tri-Cyclen (Norgestimate-Ethinyl Estradiol) (Insulin Lispro (NPL)/Insulin Lispro, Human Rec. Anlog) Ortho Tri-Cyclen Lo (Norgestimate-Ethinyl Estradiol) Ortho-Cept (Desogestrel-Ethinyl Estradiol) Oral Hypoglycemics
Ortho-Cyclen (Norgestimate-Ethinyl Estradiol) FORMULARY PRODUCTS
PLAN SPONSOR’S
Ortho-Novum (Norethindrone-Ethinyl Estradiol) DRUG NAME
RELATIVE COST
Ortho-Novum (Norethindrone-Mestranol) GENERICS
FORMULARY PRODUCTS
Triphasil (Levonorgestrel-Ethinyl Estradiol) PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Yasmin (Ethinyl Estradiol/Drospirenone) Preven (Levonorgestrel-Ethinyl Estradiol/Pregnancy Test Kit) $$$ ▲Parnate (Tranylcypromine Sulfate) ▲Glucotrol XL (Glipizide Tablet, Osmotic Blood Glucose Test Strips
Anxiolytics
FORMULARY PRODUCTS
PLAN SPONSOR’S
FORMULARY PRODUCTS
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
DRUG NAME
RELATIVE COST
Glucovance (Glyburide/Metformin HCl) GENERICS
▲Metaglip (Glipizide/Metformin HCl) Accu-Chek (Blood Sugar Diagnostic Strip) Chemstrip BG (Blood Sugar Diagnostic Strip) Fast Take (Blood Sugar Diagnostic Strip) OneTouch (Blood Sugar Diagnostic Strip) Avandamet (Rosiglitazone/Metformin HCl) OneTouch Ultra Test Strips (Blood Sugar Diagnostic) ▲Clorazepate Dipotassium (Tranxene T-Tab) Surestep (Blood Sugar Diagnostic Strip) Tracer BG (Blood Sugar Diagnostic Strip) Antipsychotics
NSAID COX II Inhibitors
Beta Agonists
FORMULARY PRODUCTS
FORMULARY PRODUCTS
FORMULARY PRODUCTS
PLAN SPONSOR’S
PLAN SPONSOR’S
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
DRUG NAME
RELATIVE COST
DRUG NAME
RELATIVE COST
GENERICS
GENERICS
Albuterol Sulfate Solution, Non-Oral (Proventil) Albuterol Aerosol (gm) (Proventil) RESPIRATORY (Allergy/Asthma)
Metaproterenol Sulfate Solution, Non-Oral (Alupent) Antihistamines
Isoetharine HCl Solution, Non-Oral (Bronkosol) FORMULARY PRODUCTS
PLAN SPONSOR’S
▲Thiothixene HCl Concentrate, Oral (Navane) DRUG NAME
RELATIVE COST
▲Haloperidol Lactate Concentrate, Oral (Haldol) Alupent (Metaproterenol Sulfate Aerosol w/Adapter (gm)) GENERICS
Proventil (Albuterol Sulfate Tablet, Multiphasic Release) Proventil HFA (Albuterol Sulfate Aerosol w/Adapter (gm)) (Albuterol Sulfate Capsule, with Inhalation Device) Serevent (Salmeterol Xinafoate Aerosol w/Adapter (gm)) (Salmeterol Xinafoate Disk, with Inhalation Device) Astelin (Azelastine HCl Aerosol, Spray w/Pump (ml)) Xopenex (Levalbuterol HCl Solution, Non-Oral) Intranasal Corticosteroids
FORMULARY PRODUCTS
Inhaled Corticosteroids
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Hypnotic Agents
FORMULARY PRODUCTS
PLAN SPONSOR’S
GENERICS
FORMULARY PRODUCTS
DRUG NAME
RELATIVE COST
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
Flovent Rotadisk (Fluticasone Propionate Disk, GENERICS
Rhinocort (Budesonide Aerosol w/Adapter (gm)) Flonase (Fluticasone Propionate Aerosol, Spray, (gm)) Vanceril (Beclomethasone Dipropionate Aerosol Nasacort AQ (Triamcinolone Acetonide Aerosol, Spray, (gm)) $$$ Nasonex (Mometasone Furoate Aerosol, Spray, (gm)) Vanceril Double Strength (Beclomethasone Rhinocort Aqua (Budesonide Spray, Non-Aerosol (ml)) NSAIDS (Pain Relievers)
Dipropionate Aerosol w/Adapter (gm)) Flovent (Fluticasone Propionate Aerosol w/Adapter (gm)) MISCELLANEOUS
Pulmicort (Budesonide Aerosol Powder, Breath Activated) FORMULARY PRODUCTS
Pulmicort (Budesonide Ampul for Nebulization (ml)) PLAN SPONSOR’S
FORMULARY PRODUCTS
PLAN SPONSOR’S
DRUG NAME
RELATIVE COST
DRUG NAME
RELATIVE COST
Misc. Pulmonary Agents
GENERICS
GENERICS
FORMULARY PRODUCTS
PLAN SPONSOR’S
Calcitonin, Salmon, Synthetic (Miacalcin) DRUG NAME
RELATIVE COST
GENERICS
Nuvaring (Etonogestrel/Ethinyl-Estradiol) Cromolyn Sodium Ampul for Nebulization (ml) (Intal) ▲Indomethacin Capsule, Sustained Action (Indocin SR) Ortho Evra (Ethinyl Estradiol/Norelgestromin) Acetylcysteine Vial, Nebulizer (Mucomyst) Ipratropium Bromide Solution, Non-Oral (Atrovent) Atrovent (Ipratropium Bromide Aerosol w/Adapter (gm)) Miacalcin (Calcitonin, Salmon, Synthetic) Combivent (Albuterol Sulfate/Ipratropium Bromide Tilade (Nedocromil Sodium Aerosol w/Adapter (gm)) Intal (Cromolyn Sodium Aerosol (gm)) ▲Ketoprofen Capsule, 24 hr Sustained Release Pellets (Oruvail) $$$ ▲Naproxen Sodium Tablet, Sustained Action (Naprelan) Advair Diskus (Fluticasone Propionate/Salmeterol Xinafoate Disk, with Inhalation Device) ▲Etodolac Tablet, Sustained Release 24 hr (Lodine XL) Pulmozyme (Dornase Alfa Solution, Non-Oral) How to use: Please copy this original sheet and place in your patient’s file, to reference when prescribing for patients whose plans use the Rx Selections Formulary.
For a complete listing of formulary and nonformulary drugs, please refer to the Rx Selections Formulary book or visit our website— www.medcohealth.com.

Source: http://cornerstoneins.net/PDF_Files/NATIONWIDE/NW_RxSelections_FormularyFileSheet.pdf