Formulary_dc

ampicillin, amoxicillin, cloxacillin, dicloxacillin, ORAL------------------------------------------------------------------
amoxicllin w/ potassium clavulanate, penicillin multiple generic options (ex. Apri, etc.) Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Miscellaneous Antiinfectives. . . . . . . . . . . . . . . . . . . .
cefaclor, cefadroxil, cefdinir, cefradine, clindamycin, metronidazole, nitrofurantoin Dapsone, NebuPent, TOBI, Vancocin, Zyvox Necon 10/11, Ogestrel,Ortho Tri-Cyclen Lo, DRUGS FOR CANCER
Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OTHER CONTRACEPTIVES----------------------------------
azithromycin, clarithromycin, erythromycin ethyl cyclophosphamide, etoposide, exemestane, 2013 FOCUS Drug Formulary
PROGESTIN ONLY------------------------------------------------
and Pharmacy Benefit Guidelines
leucovorin, leuprolide acetate, tretinoin, Tetracyclines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Scriptsense Focus Drug Formulary defines
DRUGS FOR DIABETES
the copayment tier status of the medicines most INSULINS --------------------------------------------------------
Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
commonly prescribed for Scriptsense members. It may not include all drugs covered by your Nilandron, Sprycel, Sutent, Tabloid, Tarceva, Temodar, Tasigna, Teslac, prescription drug benefit. For benefit coverage
or restrictions please check your benefit plan
Aminoglycosides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
document(s). This listing is revised from time to
Sulfonamides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
IMMUNOMODULATORS
sulfisoxazole w erythromycin ethylsuccinate sulfamethoxazole w trimethoprim (SMX-TMP) Drugs for Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . .
The coverage tier for each medication has been indicated. Members pay a Tier 1 copay for most ORAL ------------------------------------------------------------
generic drugs and selected OTC medicines. acarbose, glimepiride, glipizide, glipizide XL, Members pay a Tier 2 copay for higher cost Revlimid(PA), Simponi(PA), Thalomid(PA), Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . .
generic drugs and formulary (“preferred”) brand glyburide w/ metformin, glipizide w/ metformin name drugs. Members pay a Tier 3 copay for non- HORMONES
formulary and highest cost brand name drugs. GLUCOCORTICOIDS ---------------------------------------------
dexamethasone, methylprednisolone, prednisolone, prednisone It is recommended that you have this list of Drugs For Viral Infections - Influenza & RSV. . . . . .
medications available when you are with your ANDROGENS---------------------------------------------------
physician and a prescription drug is going to be part of the treatment for a clinical condition. Drugs For Viral Infections - Herpes. . . . . . . . . . . . . . .
ESTROGENS ---------------------------------------------------
Key to Notations:
Drugs For Viral Infections - Hepatitis. . . . . . . . . . . . .
Cenestin, Climara, Divigel, Enjuvia, Evamist, Premarin, Vivelle PA: Prior authorization to ensure clinical
Incivek(PA), Pegasys, Peg-Intron, ribavirin, appropriateness of this or previous therapy with DIABETES RELATED DRUGS & SUPPLIES--------------
other similar medications may be needed before claims for one of these medications will be Drugs For Viral Infections – HIV/AIDS. . . . . . . . . . . . .
ESTROGEN COMBINATIONS------------------------------
ethinyl estradiol & norethindrone acetate ST: A step therapy protocol is in place for this
esterified estrogens & methyltestosterone Basic, One Touch II, One Touch Profile, One medication. If prior medication history does not Touch Ultra,One, Touch Ultra System, One ganciclovir, Hivid, Intelence, Invirase, meet clinical guidelines, authorization may be Touch UltraMini, One Touch Verio,and Verio Isentress, Kaletra, lamivudine, lamivudine w/ zidovudine. Lexiva, Prezista, Rescriptor, PROGESTINS -----------------------------------------------
Accu-Chek Meter, Accu-Chek Miscellaneous., QL: Quantity limitations (maximum number of
tablets/capsules, etc. per month or year) are in MISCELLANEOUS OB/GYN DRUGS-----------------------
Minimed, Surestep Meter, NovoFine Insulin Drugs for Malaria. . . . . . . . . . . . . . . . . . . . . . . . . .
Bravelle (PA), Follistim(PA), Menopur(PA) GROWTH HORMONES ---------------------------------------
Tier 2
DRUGS FOR INFECTIONS
Drugs for Parasites. . . . . . . . . . . . . . . . . . . . . . . . . .
ANTIBIOTICS-------------------------------------------------
CONTRACEPTIVES
THYROID AND ANTITHYROID AGENTS
Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
This document is in effect January 1, 2013. Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ THYROID ---------------------------------------------------------
acetazolamide ER, amiloride, bumetanide, Antileukotrienes. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PSYCHOTHERAPEUTIC AGENTS -----------------------
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . .
amitriptyline, bupropion, SR, XL, citalopram, DRUGS FOR OSTEOPOROSIS
Theophyllines…. . . . . . . . . . . . . . . . . . . . . . . .
doxepin, escitalopram, fluoxetine, imipramine, ANTILIPEMICS
----------------------------------------------
alendronate sodium (generic for Fosamax) paroxetine CR, protriptyline, trazodone, GASTROINTESTINAL
ANTIULCER -----------------------------------------------------
Actonel, Actonel-D, Atelvia, Boniva, Evista, Advicor, Altoprev, Antara, Lescol, Lescol XL, Livalo, Lovaza, Niaspan, Tricor, TriLipix, Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . .
MISCELLANEOUS ENDOCRINE
chlorpromazine, haloperidol, olanzapine, MISCELLANEOUS CARDIOVASCULAR DRUGS---------
Aciphex, Dexilant, PrevPac, Pylera, Zegerid ANTICOAGULANTS/ANTITHROMBOTICS-------------
Abilify, clozapine, Latuda, risperidone ODT, ANTIEMETIC/ANTIVERTIGO -----------------------------
CARDIOVASCULAR DRUGS
dipyridamole, pentoxifylline, ticlopidine, Fanapt, Fazaclo, Geodon, Invega, Saphris, CARDIOTONICS ----------------------------------------------
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS----
ANTI-ANGINA ----------------------------------------------
Aggrenox, Arixtra(PA), Brilinta, Effient, isosorbide dinitrate, isosorbide mononitrate temazepam, triazolam, zaleplon, zolpidem DIGESTANTS ---------------------------------------------------
DRUGS FOR MISCELLANEOUS BLOOD DISORDERS--
BETA-ADRENERGIC BLOCKERS----------------------
Creon, Pancreaze DR, Ultrase, Ultrase MT, Ultrase MT12, Ultrase MT18, Ultrase MT20, CEREBRAL STIMULANTS / ADD-ADHD------------
metoprolol XL, propranolol, propranololLA OTHER GI PRODUCTS -----------------------------------
CALCIUM CHANNEL BLOCKERS -----------------------
RESPIRATORY / ASTHMA
balsalazide, lactulose, mesalamine rectal amlodipine, diltiazemCD, diltiazemSR 24, DRUGS FOR ALLERGY -------------------------------
Oral Antihistamines and Combinations. . . . . . . .
Amitiza(PA), Apriso, Asacol, budesonide EC Alavert, Claritin, loratadine, cetirizine, Nuvigil, Provigil (PA) , Ritalin-LA, Strattera, levocetirizine, montelukast, Zyrtec, Zyrtec-D ANTIARRHYTHMICS ----------------------------------------
Cimzia(PA), Dipentum, Fosrenol, Lotronex, DRUGS FOR ALZHEIMER’S DISEASE-----------------------
Metozolv ODT, Pentasa, Relistor, Renagel, mexiletine, propafenone, quinidine, sotalol Aricept-23, galantamine, galantamine ER, NASAL MEDICATIONS -------------------------------------
GENITO-URINARY
ACE INHIBITORS ---------------------------------------------
benazepril, captopril, enalapril, fosinopril, ANTI-INFECTIVES------------------------------------------
MISCELLANEOUS DRUGS FOR CNS----------------------
lisinopril, moexipril, perindopril, quinapril, Astapro, azelastine nasal spray, Nasonex, INCONTINENCE AGENTS-------------------------------
ANGIOTENSIN II ANTAGONISTS-------------------------
DRUGS FOR ASTHMA / COPD -------------------------------
Detrol, Detrol LA, Gelnique, Oxytrol Patch, Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANALGESICS, NARCOTIC---------------------------------------
DIRECT RENIN INHIBITOR----------------------------------
VAGINAL ANTIINFECTIVES -------------------------------
morphine IR, oxycodone IR, fentanyl patch, clindamycin cream, nystatin, metronidazole, ANTI-ADRENERGIC BLOCKERS–CENTRAL------
Sympathomimetics. . . . . . . . . . . . . . . . . . . . . . . .
COMBINATION ANTIHYPERTENSIVES--------------
AVC Cream, Cleocin Vaginal Tab, Gynazole Arcapta, Foradil, levalbuterol for inhalation, DRUGS FOR BPH-------------------------------------------
alfuzosin, doxazosin, tamsulosin, terazosin, ANALGESICS, NSAIDs ----------------------------------------
diclofenac, diflunisal, etodolac, ibuprofen, Combination Drugs and Others. . . . . . . . . . . . . . . . .
MISCELLANEOUS UROLOGICALS-----------------------
Arthrotec, Celebrex (ST)(QL) Flector Patch, Caverject, Cialis(ST)(QL), Levitra (QL)(ST), Diovan HCT, Edarbyclor, Exforge, Exforge Advair, Atrovent HFA, Combivent, Daliresp, DIURETICS ------------------------------------------------------
MIGRAINE AGENTS-------------------------------------------
CENTRAL NERVOUS SYSTEM
This document is in effect January 1, 2013. Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ SPECIALTY DRUGS
Relpax (QL), sumatriptan(QL) nasal spray and injection, Zomig (QL), Zomig ZMT (QL), Coverage for “Specialty Drugs” varies from
ANTI-INFECTIVE AND ANTI-INFLAMMATORY
plan to plan. Your prescription benefit may
COMBINATIONS ------------------------------------------------
not cover some or all of these items. Please
multiple medicines w/ generics, ofloxacin check your pharmacy benefit information if
ANALGESICS, MISCELLANEOUS ----------------------------
you have questions.
Specialty Drugs are “bioengineered” oral or injectable Cuprimine, Cymbalta, Nucynta, Nucynta ER DERMATOLOGICALS
medicines that target and treat complex medical ACNE -------------------------------------------------------------
conditions including: blood disorders, cancers, ANTICONVULSANTS ---------------------------------------
infertility, hormone or enzyme deficiencies, multiple sulfacetamide sodium external suspension sclerosis, rheumatoid arthritis, and a growing list of sulfacetamide w sulfur external emulsion Specialty drugs are complex compounds and some have unique “handling” requirements. The FDA in selected situations has required dispensing from a Carbatrol, Diastat, Felbatol, Gabitril, Sabril Epiduo, Finacea, Metrogel, Retin-A Micro single pharmacy or a limited set of “approved” DRUGS FOR DEPENDENCY -------------------------------
pharmacies. Some “specialty” drugs are oral tablets ANTIBIOTICS ---------------------------------------------------
or capsules while others require injection. The result Campral, Chantix(QL), Suboxone, Subutex erythromycin, clindamycin, metronidazole, is that many drugs can be distributed directly to DRUGS FOR PARKINSONS DISEASE ----------------------
patients, while others will be sent to physicians or Altabax, Bactroban Nasal Ointment, Noritate home health companies or other professional settings carbidopa/levodopa, pramipexole, ropinirole, ANTIVIRALS ----------------------------------------------------
Azilect, carbidopa/entacapone/levodopa, Most plan sponsors will apply “step edits” or prior authorization criteria prior to the dispensing or FUNGICIDES ----------------------------------------------------
administration of a specialty drug. These requirements ensure appropriate use of a specialty SKELETAL MUSCLE RELAXANTS -------------------------
baclofen, carisoprodol, cyclobenzaprine dantrolene, methocarbamol, tizanidine, etc. Exelderm, Mentax, Naftin, Oxistat, Xolegel TOPICAL ANTI-INFLAMMATORY AGENTS---------
OPHTHALMIC
ANTI-ALLERGIC & RELATED AGENTS---------------------
Tier 1
TOPICAL SCABICIDES/PEDICULICIDES -------------------
Tier 1
lindane lotion or shampoo, malathion lotion, OTHER DERMATOLOGICALS ----------------------------
Tier 1
calcipotriene, Condylox, Elidel, imiquimod, ANTI-GLAUCOMA AGENTS -----------------------------
brimonidine, dipivefrin, betaxolol, carteolol Anamantle HC, Anamantle HC Forte, Anusol latanoprost, levobunolol, metipranolol, timolol, HC, Atopiclair, Dovonex, Fluoroplex, Ovace, Pramosone, Protopic, Solaraze, Soriatane, MISCELLANEOUS
ANTI-INFECTIVE AGENTS--------------------------------
ANTI-INFLAMMATORY AGENTS---------------------------
ANTI-INFECTIVE AND ANTI-INFLAMMATORY
COMBINATIONS ---------------------------------------------
NSAIDS-----------------------------------------------------------
This document is in effect January 1, 2013. Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™

Source: http://www.scriptsense.net/Formulary_DC.pdf