FORMULARY (List of Covered Drugs)

This document includes Passport Health Plan’s complete formulary as of January 22, 2009.

What is the Passport Health Plan formulary?

The formulary is a list of preferred drugs covered by Passport Health Plan. To get a drug on our formulary, you must:

• BeaPassportHealthPlanmember.• Needadrugthatismedicallynecessary.• GettheprescriptionfilledataPassportHealthPlannetworkpharmacy.Anetworkpharmacyisonethatis

signedupwithPassportHealthPlan.• FollowallPassportHealthPlanrules.

The formulary is not a complete list of covered drugs covered by Passport Health Plan. Some drugs not listed may be covered, if medically necessary. These drugs may or may not need prior-authorization.

How do I find my drug on the formulary?

• Youcanfindtheformularyonourwebsiteatwww.passporthealthplan.com.• Underthesectionthatsays“QuickHits,”clickon“Formulary.”• Youcansearchforadrugbyclickingonthepictureofthe

binoculars right above the drug list on your tool bar.• Next,youwillseeasearchboxtotheright.• Typeinthenameofthedruginthesearchbox.

Ifyouarenotsurehowtospellthedrug,youcansearchbyenteringthefirstfewlettersofthename.Thedrugsarelistedbybothbrandandgenericname.Theboldednamemeanswhichdrug (brand or generic) is available.

Are there any limits to the drugs you have been prescribed?

Some covered drugs may have limits on them. This could include:

• Prior-Authorization: Some medicines must be approved by Passport Health Plan before you can get them. This meansyourproviderwillneedtogetapprovalbeforeyoucanhaveyourprescriptionsfilled.Ifyoudonotgetap-proval, Passport Health Plan may not cover the drug.

• Quantity Limits:Forsomedrugs,therearelimitsontheamountPassportHealthPlanwillcover.Thismeansyou may not get the standard one month supply.

• Step Therapy:SometimesPassportHealthPlanrequiresyoutofirsttrycertaindrugstotreatyourmedicalcon-ditionbeforewewillcoveranotherdrugforthatcondition.Forexample,ifDrugAandDrugBbothtreatyourmedicalcondition,PassportHealthPlanmaynotcoverdrugBunlessyoutryDrugAfirst.IfDrugAdoesnotworkforyou,PassportHealthPlanwillthencoverDrugB.

• Too Early to Refill:Ifyouaregivenamonthsupplyofamedicine,PassportHealthPlanwillnotgivearefillofthe prescription until 30 days has passed.

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What if my drug is not on the formulary?

Remember, not all drugs are listed on the formulary. If Passport Health Plan does not cover your drug, you have 3 options:

1. Workwithyourpharmacytofindthepreferreddrug.2. YoucanaskMemberServicesforalistofsimilardrugsthatarepreferredbyPassportHealthPlan.3. Ifthedrugisdenied,youcanfileanappeal.Tofindouthowtodothis,seepages25–28ofyourMember

Handbook.

Can the formulary change?

Yes.PassportHealthPlanmayaddorremovedrugsfromtheformularyduringtheyear.Togetupdatedinformationaboutcovereddrugs,pleasevisitourwebsiteatwww.passporthealthplan.comorcallMemberServicesat1-800-578-0603andpress2.

What are generic drugs?

PassportHealthPlancoversbothbrand-nameandgenericdrugs.Agenericdrughasthesameactiveingredientasthebrand-namedrug.Thismeanstheyworkthesameandhavethesameeffect.GenericdrugsusuallycostlessthanbrandnamedrugsandareapprovedbytheFoodandDrugAdministration(FDA).

How much will I have to pay for covered medicines?

SomePassportHealthPlanmemberspayasmallco-payforeachmedicinetheyfill.

The prescription copay is $1.00 for each prescription, including over-the-counter medicines.

PleaseNote:• Thepharmacymustfillyourprescriptionthefirsttime,evenifyoucannotpay.• Ifyoucannotpaythecopaywhenyougetyourprescription,youshouldpayitthenexttime.• Thepharmacymaytellyoutheywillnotfillyourprescriptionsanymoreifyoudonotpaytheco-pay.

Thosewhodo nothavetopayaco-payarememberswhoare:• 18yearsandunder.• Pregnant.• Receivingserviceswithinthefirst60daysafterdeliveryofababy.• Inanursingfacility.• Inapersonalcarehome.• Inanintermediatecarefacilityforpeoplewithmentalretardation(ICF/MR).• Afosterchildinstatecustody.• AmericanIndiansorAlaskannativesservedthroughKCHIPprogram.• Inhospicecare.

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PASSPORT HEALTH PLAN PREFERRED DRUG LIST

2009

GENERIC NAME BRAND NAME DOSAGE FORM NOTES ACE INHIBITOR MEDICATIONS Benazepril Lotensin Tablet Captopril Capoten Tablet Enalapril Vasotec Tablet Fosinopril Monopril Tablet Lisinopril Zestril, Prinivil Tablet Perindopril Aceon Tablet Trandolapril Mavik Tablet

ACNE MEDICATIONS (ORAL) Doxycycline Vibramycin,

Periostat Capsule, Tablet

Isotretinoin Accutane Capsule Minocycline Minocin Capsule Tetracycline Sumycin Capsule

ACNE MEDICATIONS (TOPICAL) Adapalene* Differin* Gel *PA Required > 21 yo;

Qty limits: 45gms/30 days Benzoyl Peroxide Benzoyl Peroxide Cream, Gel,

Solution Benzoyl Peroxide/ Erythromycin Benzamycin Cream Clindamycin Cleocin T Gel, Solution Erythromycin Erycette,

Akne-mycin Swabs, Gel, Ointment, Solution

Gentamicin Garamycin Cream, Ointment Metronidazole 0.75% Metrogel Gel Mupirocin Bactroban Ointment Sulfacetamide/Sulfur Sulfacet-R Lotion Tretinoin* Avita* Cream, Gel *PA Required > 21 yo;

Qty limits: 45gms/30 days

ALZHEIMERS MEDICATION Donepezil Aricept Tablets, ODT Rivastigmine Exelon Capsules, Patches,

Solution Tacrine Cognex Tablets

ANAPHYLAXIS THERAPY Epinephrine Epipen, Epipen Jr Injection *Qty limit: 2 injections per 30

days

ANALGESIC MEDICATIONS Narcotics Butorphanol Stadol NS Nasal Spray Codeine Codeine Tablet, Solution Fentanyl Transdermal* Duragesic* Patch *Qty limit 10 patches per 30 days Hydromorphone Dilaudid Tablet, Solution,

Suppository Meperidine Demerol Tablet, Syrup Methadone Dolophine Tablet Morphine MSIR Tablet, Solution,

Suppository Morphine Extended Release* Oramorph SR, MS Contin Tablet *Qty limit BID dosing Morphine Extended Release Kadian Capsules Oxycodone Roxicodone Tablet, Solution

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GENERIC NAME BRAND NAME DOSAGE FORM NOTES Propoxyphene Darvon Capsule Tramadol Ultram Tablet

Narcotic Combinations APAP/Butalbital Phrenilin, Phrenilin Forte Tablet APAP/Butalbital/Caffeine Fioricet Tablet APAP/Butalbital/Caffeine/Codeine Fioricet with Codeine Tablet APAP/Codeine Tylenol with Codeine Tablet APAP/Hydrocodone Vicodin, Lortab Tablet 5/500mg, 7.5/500mg,

7.5/750mg, 10/500mg, 10/650mg

APAP/Oxycodone Percocet Tablet APAP/Propoxyphene Darvocet N Tablet ASA/Butalbital/Caffeine Fiorinal Tablet ASA/Butalbital/Caffeine/Codeine Fiorinal with Codeine Tablet ASA/Oxycodone Percodan Tablet Meperidine/Promethazine Meperidine/Promethazine Capsule

NSAIDs (Prescription Strengths Only) Diclofenac Cataflam Tablet Diclofenac Sodium ER Voltaren-XR Tablet Diflunisal Dolobid Tablet Etodolac IR and SA Lodine, Lodine XL Capsule, Tablet Fenoprofen Nalfon Tablet Flurbiprofen Ansaid Tablet Ibuprofen Motrin Tablet, Suspension Indomethacin Indocin Capsule Indomethacin Sustained Release Indocin SR Capsule Ketoprofen IR Orudis Capsule Ketoprofen SA Oruvail Capsule Meclofenamate Meclofenamate Capsule Meloxicam Mobic Tablets Nabumetone Relafen Tablet Naproxen Naprosyn Tablet Naproxen SA Naprelan Tablet Oxaprozin Daypro Tablet Sulindac Clinoril Tablet Tolmetin Tolectin Tablet

COX-2 Inhibitors Celecoxib* Celebrex* Capsule *Step therapy or PA required

SALICYLATES Aspirin Aspirin Tablet Salsalate Disalcid Capsule

ANDROGENS Danazol Danocrine Capsule Methyltestesterone Android Tablet Oxandrolone Oxandrin Tablet Testosterone Transdermal Androgel Gel Testosterone Transdermal Androderm* Patch *PA required Testosterone Buccal Striant Buccal System

ANESTHETICS (TOPICAL) Capsaicin Zostrix Lotion, Cream, Gel Lidocaine Xylocaine Jelly, Ointment

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GENERIC NAME BRAND NAME DOSAGE FORM NOTES

ANESTHETICS (URINARY) Phenazopyridine Pyridium Tablet

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARB) Olmesartan* Benicar* Tablet *Step therapy required: T/F of 2

preferred ACE Inhibitors Valsartan* Diovan* Tablet *Step therapy required: T/F of 2

preferred ACE Inhibitors

ANORECTALS Hydrocortisone Anusol HC Cream, Suppository Hydrocortisone Enema Cortenema Enema

ANTACIDS Aluminum/Magnesium Hydroxide Mylanta Suspension, Tablets Calcium Carbonate Tums Suspension, tablet Magnesium Hydroxide MOM Suspension Aluminum Hydroxide Alternagel Suspension Sodium Bicarbonate Sodium Bicarbonate Tablet

ANTIADRENERGICS Clonidine Catapres Tablet, Patches Doxazosin Cardura Tablet Guanfacine Tenex Tablet Methyldopa Aldomet Tablet, Suspension Prazosin Minipress Capsule Reserpine Resperine Tablet Terazosin Hytrin Capsule

ANTI-ALCOHOLIC MEDICATIONS Disulfiram Antabuse Tablet

ANTIANDROGENS Bicalutamide Casodex Tablet Flutamide Eulexin Capsule Nilutamide Nilandron Tablet

ANTIARRHYTHMICS Amiodarone Cordarone Tablet Disopyramide Norpace Capsule Disopyramide Controlled Release Norpace CR Capsule Dofetilide Tikosyn Capsule Flecainide Tambocor Tablet Mexiletine Mexitil Capsule Moricizine Ethmozine Tablets Procainamide Pronestyl Tablet, Capsule Procainamide Sustained Release Procan SR Tablet Propafenone Rythmol Tablet Quinidine Gluconate Quinaglute Tablet Quinidine Sulfate Quinidine Tablet Quinidine Sulfate Sustained Release Quinidex Tablet

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ANTIBIOTICS (ORAL) Tetracyclines Doxycycline Vibramycin, Doryx Capsule Minocycline Minocin Capsule Tetracycline Sumycin Capsule

Cephalosporins: First Generation Cephalexin Keflex Capsule, Suspension Cephradine Velosef Capsule, Suspension

Cephalosporins: Second Generation Cefaclor Ceclor Capsule

Suspension Cefuroxime Ceftin Tablet

Suspension Cefprozil Ceprozil Suspension Only Cephalosporins: Third Generation Cefdinir Omnicef Capsule, Suspension Cefixime* Suprax* Tablet, Suspension *Qty limit: QD dosing Cefpodoxime Vantin Tablet, Suspension

Erythromycins Azithromycin* Zithromax* Tablet, Suspension *Qty limit: 250mg (6 tab/30days);

500mg (5 tab/30days) Clarithromycin, Clarithromycin ER Biaxin, Biaxin XL * Tablet, Suspension Erythromycin Base Ery-Tab, Eryc Tablet, Capsule Erythromycin Ethylsuccinate E.E.S. Tablet, Suspension Erythromycin Stearate Erythrocin Tablet Erythromycin/Sulfisoxazole Pediazole Suspension

Fluoroquinolones Ciprofloxacin Cipro Tablet, Suspension

Levofloxacin* Levaquin* Tablet, Oral Solution *Qty limit: 5 tab/30 days Moxifloxacin* Avelox* Tablet, Suspension *Qty limit: 5 tab/30 days Ofloxacin Floxin Tablet

Miscellaneous Clindamycin Cleocin Capsule, Suspension

Penicillins Amoxicillin Amoxil Capsule, Suspension Amoxicillin/Pot Clavulanate Augmentin Tablet, Suspension Ampicillin Principen Capsule, Suspension Dicloxacillin Dynapen Capsule, Suspension Penicillin VK PenVee K Tablet, Suspension

Sulfonamides Sulfadiazine Sulfadiazine Tablet Sulfamethoxazole/Trimethoprim Bactrim, Bactrim DS Tablet, Suspension Sulfisoxazole Gantrisin Tablets Suspension

Urinary Tract Medications Fosfomycin Monurol Granules Nitrofurantoin/Macrocrystals/Monohydrate Macrobid Capsule Nitrofurantoin/Macrocrystals Macrodantin Capsule, Suspension Trimethoprim Trimpex, Primsol Tablet

ANTIBIOTICS (TOPICAL) Bacitracin Bacitracin Ointment Polymycin/Bacitracin Polysporin Ointment

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Polymycin/Neomycin/Bacitracin Neosporin Ointment Silver Sulfadiazine SSD Cream

ANTICOAGULANTS Warfarin Coumadin Tablet

ANTICHOLINERGICS (INHALED) Ipratropium Solution Atrovent Solution Ipratropium Inhaler Atrovent Inhaler Tiotropium Spiriva Inhaler

ANTICONVULSANTS Acetazolamide Diamox Capsule Carbamazepine Tegretol Tablet, Suspension Carbamazepine Sustained Release Tegretol XR Tablet Clonazepam Klonopin Tablet Divalproex Sodium Depakote Tablet Divalproex Sodium Depakote Sprinkles Divalproex Sodium Depakote ER Tablet Ethosuximide Zarontin Capsule, Syrup Gabapentin Neurontin Tablet, Capsule Lamotrigine Lamictal* Tablet *Brand is preferred Lamotrigine Chewable Lamictal Dispersible

Chewable Tablet

Levetiracetam Keppra Tablet Mephobarbital Mebaral Tablet Oxcarbazepine Trileptal Tablet Oxcarbazepine Trileptal Suspension Phenobarbital Phenobarbital Tablet,Syrup Phenytoin Dilantin Tablet

Capsule Suspension

Primidone Mysoline Tablet, Suspension Tiagabine Gabitril Tablet Valproic Acid Depakene Capsule, Syrup

ANTIDEPRESSANTS NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS Bupropion IR, SR, XL Wellbutrin IR, SR, XL Tablet

TETRACYCLICS Maprotiline Ludiomil Tablet

TRIAZOLOPYRIDINES Trazodone Desyrel Tablet

MONOAMINE OXIDASE INHIBITORS Phenelzine Nardil Tablet Tranylcypromine Parnate Tablet

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TRICYCLICS Amitriptyline Elavil Tablet Amitriptyline/Chlordiazepoxide Limbitrol Tablet Amoxapine Ascendin Tablet Clomipramine Anafranil Capsule Desipramine Norpramin Tablet Doxepin Sinequan Capsule Imipramine Tofranil Capsule Nortriptyline Pamelor Capsule Protriptyline Vivactil Tablet Mirtazapine Remeron Tablet Trimipramine Surmontil Capsule

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI and SNRI) Citalopram Celexa Tablet Duloxetine * Cymbalta* Tablet *Step Therapy: T/F of 2

antidepressants (SSRIs, venlafaxine IR, bupropion IR, SR,XL) for 4 wks each

Venlafaxine IR Effexor IR Escitalopram* Lexapro* Tablet *Step Therapy: T/F of citalopram

& 1 of the following(SSRIs, venlafaxine IR, bupropion IR, SR,XL) for 4 wks each

Fluoxetine Prozac Capsule Paroxetine, Paroxetine CR Paxil, Paxil CR Tablet Sertraline Zoloft Tablet

ANTIDIARRHEALS Bismuth Subsalicylate Pepto-Bismol Tablet, Suspension Diphenoxylate/Atropine Lomotil Tablet, Solution Loperamide Imodium Capsule, Tablet

ANTIDIURETIC HORMONES Desmopressin Acetate DDAVP Tablet,

*Spray *Spray requires PA

ANTIEMETICS Aprepitant Emend Capsule Ondansetron* Zofran* Tablet,

Solution *Formulary with PA; Qty limits: 4mg, 8mg, 15 tab/30 days,

24mg, 5 tab/30 days Oral Soln. 50ml / 30 days

Promethazine Phenergan Tablet, Syrup, Suppository

Prochlorperazine Regular Release Compazine Tablet, Syrup, Suppository

ANTIESTROGENS Tamoxifen Nolvadex Tablet Toremifene Fareston Tablet

ANTIFUNGALS (ORAL) Fluconazole Diflucan Tablet,

Suspension QL: 150mg tab-4 tablets/28 days

Griseofulvin Microsize Grifulvin V Tablet, Suspension

Griseofulvin Ultramicrosize Gris-PEG Tablet

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Ketoconazole Nizoral Tablet Nystatin Mysostatin Tablet,

Suspension Terbinafine Lamisil Tablet

ANTIFUNGALS (TOPICAL) Gentian Violet Gentian Violet Solution Clotrimazole Lotrimin Cream

Solution Lotion

Ketoconazole Nizoral Cream Miconazole Micatin Cream, Ointment Nystatin Mycostatin Cream, Ointment Nystantin/Triamcinolone Mycolog II Cream, Ointment Tolnaftate Tinactin Cream, Gel

ANTIHISTAMINES (ORAL) Carbinoxamine Palgic Tablet, Capsule,

Liquid Cetirizine Zyrtec OTC Tablet,

Chewables

Cetirizine Zyrtec OTC Syrup Chlorpheniramine Chlor-Trimeton Tablet, Syrup Clemastine Tavist Tablet Cyproheptadine Periactin Tablet Diphenhydramine Benadryl Capsule

Tablet Solution

Hydroxyzine Atarax Tablet Solution

Loratadine OTC Claritin, Alavert Tablet, Syrup

Promethazine Phenergan Tablet Solution

Triprolidine Zymine Syrup

ANTIHISTAMINE/DECONGESTANT COMBINATIONS (ORAL) Cetirizine/Pseudoephedrine Zyrtec-D OTC Tablet Loratadine/Pseudoephedrine Claritin-D Tablet Pseudoephedrine/Triprolodine Actifed Tablet

ANTIHYPERTENSIVE COMBINATIONS Amlodipine / Benazepril Lotrel Capsule Amlodipine/ Valsartan Exforge Tablet *Step therapy required: T/F of

2 preferred ACE Inhibitors Atenolol / Chlorthalidone Tenoretic Tablet Benazepril / HCTZ Lotensin Tablet Bisoprolol / HCTZ Ziac Tablet Capotopril / HCTZ Capozide Tablet Clonidine / Chorthalidone Clorpres Tablet Enalapril / HCTZ Vaseretic Tablet Fosinopril / HCTZ Monopril HCT Tablet Hydralazine / HCTZ Apresazide Capsule Lisinopril / HCTZ Zestoretic, Prinizide Tablet Methyldopa / HCTZ Aldoril Tablet Moexipril / HCTZ Uniretic Tablet Olmesartin / HCTZ* Benicar HCT* Tablet *Step Therapy: T/F preferred

ACE-Inhibitors/HCTZ combination

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Propranolol/HCTZ Inderide Tablet Reserpine/HCTZ Hydropres Tablet Spironolactone/HCTZ Aldactazide Tablet Trandolapril/Verapamil Tarka Tablet Valsartan/HCTZ* Diovan/HCT* Tablet *Step Therapy: T/F preferred

ACE-Inhibitors/HCTZ combination

ANTIHYPERTENSIVES-OTHER Guanabenz Wytensin Tablet

ANTILIPIDEMICS Atorvastatin Lipitor Tablet Cholestyramine Questran, Powder

Questran Light Colestipol Colestid Tablet Fenofibrate Tricor Capsule Fluvastatin Lescol, Lescol XL Capsule Gemfibrozil Lopid Tablet Lovastatin Mevacor Tablet Lovastatin/Niacin Advicor Tablet Nicotinic Acid Niacor/Niaspan Tablet Pravastatin Pravachol Tablet Simvastatin Zocor Tablet Simvastatin/Ezetimibe Vytorin* Tablet *Step Therapy with preferred

generics

ANTIMALARIALS Chloroquine Phosphate Aralen Tablet Hydroxychloroquine Plaquenil Tablet Primaquine Primaquine Tablet Pyrimethamine Daraprim Tablet

ANTIMANICS Lithium Carbonate Eskalith Capsule, Solution Lithium Carbonate CR Lithobid/

Eskalith CR Tablet, Solution

ANTINEOPLASTICS ADJUNCTIVE MEDICATIONS Leucovorin (Folinic Acid) Leucovorin Tablet

ALKYLATING MEDICATIONS Altretamine Hexalen Tablet Busulfan Myleran Tablet Chlorambucil Leukeran Tablet Cyclophosphamide Cytoxan Tablet Estramustine Emcyt Capsule Lomustine CeeNu Capsule Melphalan Alkeran Tablet Temozolomide Temodar Capsule

ANTIMETABOLITES Capecitabine Xeloda Tablet Mercaptopurine Purinethol Tablet Methotrexate Rheumatrex Tablet Thioguanine Thioguanine Capsule

MISCELLANEOUS ANTINEOPLASTICS Anastrozole Arimidex Tablet Exemestane Aromasin Tablet

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Fluorouracil Efudex Cream, Solution Hydroxyurea Hydrea Capsule Letrozole Femara Tablet Mitotane Lysodren Tablet Procarbazine Matulane Tablet

ANTIPARASITICS Dapsone Dapsone Tablet Iodoquinol Yodoxin Tablet Ivermectin Stromectol Tablet Mebendazole Vermox Chewable Tablets Metronidazole Flagyl Tablets

ANTIPARKINSONIANS Amantadine Symmetrel Capsule, Syrup Benztropine Cogentin Tablet Biperiden Akineton Tablet Bromocriptine Mesylate Parlodel Tablet, Capsule Carbidopa/Levodopa Sinement, Sinemet CR Tablet Carbidopa/Levodopa/Entacapone Stalevo Tablet Diphenhydramine Benadryl Capsule, Solution Entacapone Comtan Tablet Levodopa Larodopa Tablet Pramipexole Mirapex Tablet Ropinirole Hydrochloride Requip Tablet Selegiline Eldepryl Tablet, Capsule Tolcapone Tasmar Tablet Trihexyphenidyl Artane Tablet

ANTIPLATELET AGGREGATION MEDICATIONS Aspirin Aspirin Tablet Aspirin/Dipyridamole Aggrenox Capsule Anagrelide Agrylin Capsule Cilostazol Pletal Tablet Clopidogrel Plavix Tablet Dipyridamole Persantine Tablet Ticlopidine Ticlid Tablet

ANTIPSORIATICS (TOPICAL) Anthralin Psoriatec Cream Calcipotriene Dovonex Cream, Ointment

Calcipotriene Dovonex Solution

Tazarotene Tazorac

ANTIPSYCHOTICS Apripiprazole Abilify* Tablet, Solution *Injection requires PA Apripiprazole Abilify Discmelt Rapid Dissolve

Tab Chlorpromazine Thorazine Tablet Clozapine Clozaril Tablet Fluphenazine Prolixin Tablet, Injection Haloperidol Haldol Tablet

Solution Injection

Loxapine Loxitane Capsule, Solution Molindone Moban Tablet Olanzapine Zyprexa Tablet Olanzapine

Perphenazine

Zyprexa Zydis

Trilafon

Oral Disintegrating Tablet Tablet

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Pimozide Orap Tablet Quetiapine Seroquel Tablet

Quetiapine SR Seroquel XR Tablet Risperidone Risperdal Tablet,

Solution Thioridazine Mellaril Tablet, Solution Thiothixene Navane Capsule, Solution Trifluoperazine Stelazine Tablet, Solution Ziprasidone Geodon Capsule

ANTIRHEUMATICS (RA) Auranofin Ridaura Capsule Hydroxychloroquine Plaquenil Tablet Leflunomide Arava Tablet Methotrexate Rheumatrex Tablet Penicillamine Cuprimine Capsule Sulfasalazine Azulfidine Tablet

ANTISEBORRHEICS (TOPICAL) Ketoconazole Nizoral Shampoo Selenium Sulfide Selsun Blue Shampoo Sulfacetamide Klaron Suspension

ANTISPASMODIC/ANTICHOLINERGICS (GI) Dicyclomine Bentyl Capsule Glycopyrrolate Robinul Tablet Hyoscyamine Levsin, Levbid Tablet Propantheline Probanthine Tablet

ANTISPASMODIC/ANTICHOLINERGICS (UROLOGICAL) Darifenacin Hydrobromide Enablex Tablet Methanamine/Methylene Blue/ Atropine Urised Tablet / Hyoscyamine Oxybutynin Ditropan Tablet Solifenacin Succinate Vesicare Tablet Tolterodine Detrol Tablet Tolterodine Extended Release Detrol LA Capsules

ANTITHYROIDS Methimazole Tapazole Tablet Potassium Iodide SSKI Tablet, Solution Propylthiouracil Propylthiouracil Tablet

ANTITUBERCULOSAL MEDICATIONS Ethambutol Myambutol Tablet Isoniazid Nydrazid Tablet Pyrazinamide Pyrazinamide Tablet Rifabutin Mycobutin Capsule Rifampin Rifadin Capsule

ANTIVERTIGO MEDICATION Meclizine Antivert Tablet

ANTIVIRALS (ORAL) Acyclovir Zovirax Capsules

Ointment* *PA Required for Ointment

Famciclovir Famvir Tablet Ganciclovir Cytovene Capsule Valacyclovir Valtrex Tablet

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ANTIVIRALS (TOPICAL) Docosanol Abreva Cream Penciclovir Denavir Cream

ANXIOLYTICS Alprazolam Xanax Tablet Buspirone Buspar Tablet Chlordiazepoxide Librium Capsule Clorazepate Tranxene Tablet Diazepam Valium Tablet Lorazepam Ativan Tablet Oxazepam Serax Tablet

BENIGN PROSTATIC HYPERPLASIA MEDICATIONS Doxazosin Cardura Tablet Dutasteride Avodart Capsule Finasteride Proscar Tablet Tamsulosin Flomax Capsule Terazosin Hytrin Capsule

BETA AGONISTS (INHALED) Albuterol Aerosol Ventolin HFA Inhaler Albuterol Solution* Proventil Solution *0.083%, 0.5 % Isoetharine Isotharine Solution Levalbuterol Xopenex* Solution *Pulmonologists only;

Qty limit 120 vials/30 days Metaproterenol Alupent Inhaler, Solution Salmeterol Serevent Inhaler

BETA AGONISTS (ORAL) Albuterol Proventil Syrup, Tablet Formoterol Foradil Inhaler Terbutaline Brethine Tablet

BETA AGONIST/ANTICHOLINERGIC COMBINATIONS (INHALED) Ipratropium/Albuterol Combivent Inhaler

BETA AGONIST/CORTICOSTEROID COMBINATIONS (INHALED) Fluticasone/Salmeterol Advair, Advair HFA Inhaler Budesonide/Formeterol Symbicort Inhaler

BETA BLOCKERS (ORAL) Atenolol Tenormin Tablet Carvedilol Coreg Tablet Carvedilol Coreg CR Capsule Labetalol Trandate Tablet Metoprolol Lopressor, Toprol XL Tablet Nadolol Corgard Tablet Pindolol Visken Tablet Propranolol, Propranolol SR Inderal, Inderal LA Tablet

Capsule Solution

Sotalol Betapace Tablet Timolol Blocadren Tablet

BONE RESORPTION SUPPRESSORS Alendronate Fosamax Tablet

Alendronate/Vit D3 Fosamax-D Tablet

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Calcitonin Miacalcin Spray Etidronate Didronel Tablet Raloxifene Evista Tablet Risedronate Actonel Tablet

BURN THERAPY (TOPICAL) Silver Sulfadiazine Silvadene Cream

CALCIUM CHANNEL BLOCKER Amlodipine Norvasc Tablet Diltiazem Cardizem Tablet Diltiazem Extended Release Cardizem CD, LA Capsule, Tablet Nifedipine Sustained Release Adalat CC Tablet Nisoldipine Sular Tablet Verapamil Calan Tablet Verapamil SR Calan SR Tablet

CALCIUM METABOLISM Calcitriol Rocaltrol Capsule Dihydrotachysterol (DHT) Vitamin D Tablet Ergocalciferol Vitamin D 2 Capsule

CARDIAC GLYCOSIDES Digoxin Lanoxin Tablet

CHELATORS Succimer Chemet Capsule

CHOLINERGICS (URINARY) Bethanechol Urecholine Tablet

CHOLINERGIC MUSCLE STIMULANTS Neostigmine Prostigmin Tablet Pyridostigmine Mestinon Tablet

CNS STIMULANTS Atomoxetine* Strattera* Capsule *Prior Auth Required Dexmethylphenidate Hydrochloride Focalin Dexmethylphenidate Hydrochloride Focalin XR Capsule Dextroamphetamine Dexedrine Tablet Methylphenidate Controlled Release Concerta Tablet Methylphenidate Sustained Release Ritalin SR Tablet, Capsule Methylphenidate Ritalin Tablet Mixed Amphetamines Extended Release Adderall XR Capsule Mixed Amphetamines Adderall Tablet Lisdexamphetamine Dimesylate Vyvanse Capsule

CONTRACEPTIVE, INJECTABLES Medroxyprogesterone* Depo-Provera* Injection *Female only

CONTRACEPTIVES, ORAL Ethinyl Estradiol 50 mcg/ Norgestrel 0.5 mg Ovral Tablet Ethinyl Estradiol 50mcg/Ethynodiol 1 mg Demulen 1/50, Zovia 1/50 Tablet Ethinyl Estradiol 35 mcg/ Ethynodiol 1mg Demulen 1/35, Zovia 1/35 Tablet Ethinyl Estradiol 30 mcg/Norgestrel 0.3 mg LoOvral, Low-Ogestrol Tablet Ethinyl Estradiol 30mcg/ Desogestrel 0.15 mg Desogen, Ortho-Cept Tablet Ethinyl Estradiol 35mcg/Norethindrone 1mg Nelova 1/35 Tablet Ethinyl Estradiol 30 mcg/Norethindrone 1.5mg Loestrin 1.5/30 Tablet Ethinyl Estradiol 20 mcg/Norethindrone 1mg Loestrin 1/20 Tablet Ethinyl Estradiol 20 mcg/Levonorgestrel 0.1 mg Alesse Tablet

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Ethinyl Estradiol 35 mcg/ Norethindrone 0.5 mg Modicon Tablet Ethinyl Estradiol 35 mcg/ Norethindrone 0.4 mg Ovcon-35 Tablet Ethinyl Estradiol 35 mcg/ Norgestimate 0.25 mg Mononessa, Ortho-Cyclen Tablet 1 mg norethindrone/50 mcg mestranol Ortho-Novum 1/50, Necon Tablet Ethinyl Estradiol 35mcg/Norethindrone 1mg Ortho-Novum 1/35,

Necon 1/35 Tablet

Ethinyl Estradiol 30 mcg/ Drospirenone 3 mg Yasmin Tablet Ethinyl Estradiol 30mcg/ Levonorgestrel 0.15mg Levora Tablet Ethinyl Estradiol/Desogestrel/ Cyclessa Tablet Ethinyl Estradiol/Norethindrone/ Estrostep FE Tablet Ethinyl Estradiol 35/Norethindrone0.75 Ortho-Novum 777, Necon 777 Tablet Ethinyl Estradiol 35/ Norgestimate 0.18 Ortho Tri-Cyclen/Trinessa Tablet Ethinyl Estradiol 35/Norethindrone 0.5 Tri-Norinyl Tablet Norethindrone 0.35 mg Ortho-Micronor Tablet Ethinyl Estradiol 10, 20mcg/ Desogestrel 0.15mg Mircette Tablet Ethinyl Estradiol 35/Norethindrone0.5, 1 mg Ortho-Novum/Necon 10/11 Tablet Ethinyl Estradiol 30,40mcg/ Levonorgestrel .05,.075,.125

Triphasil, Trivora Tablet

CORTICOSTEROIDS (INHALED) Beclomethasone QVAR Inhaler Budesonide* Pulmicort* Inhaler,

Respules* *PA Required: >5 years old *QD dosing for 0.25mg/2ml *QD-BID dosing for 0.5mg/2ml *QD dosing for 1mg/2ml

Flunisolide Aerobid, Aerobid-M Inhaler Fluticasone Flovent HFA Inhaler Fluticasone/Salmeterol Advair, Advair HFA Inhaler Mometasone Furoate Asmanex Twisthaler Inhaler Triamcinolone Azmacort Inhaler

CORTICOSTEROIDS (ORAL) Cortisone Cortone Tablet Dexamethasone Decadron Tablet, Solution Fludrocortisone Florinef Tablet Hydrocortisone Hydrocortisone Tablet Methylprednisolone Medrol Tablet Prednisolone Orapred Syrup Prednisone Orasone Tablet, Solution

CORTICOSTEROIDS (TOPICAL) Group I (Very High Potency)

Augmented Betamethasone Dipropionate Diprolene Ointment Clobetasol 0.05% Temovate Cream, Ointment,

Solution Group II (High Potency)

Amcinonide 0.1% Cyclocort Cream Betamethasone Dipropionate 0.05% Diprosone Cream, Ointment Betamethasone Valerate 0.1% Valisone Ointment Desoximetasone 0.25% Topicort Cream, Ointment Desoximetasone 0.05% Topicort Gel Diflorasone Diacetate 0.05% Psorcon Cream, Ointment Fluocinolone 0.2% Synalar Cream Fluocinolone 0.05% Lidex Ointment

Cream Gel

Triamcinolone Acetonide 0.5% Kenalog Cream Ointment

14

Group III (Medium Potency)

Betamethasone Dipropionate 0.05% Diprosone Lotion Betamethasone Valerate 0.1% Valisone Cream Desoximetasone 0.05% Topical LP Cream Fluocinolone Acetonide 0.025% Synalar Ointment

Cream Fluticasone 0.05%, 0.005% Cutivate Cream, Ointment Hydrocortisone Valerate 0.2% Westcort Cream, Ointment Mometasone 0.1% Elocon Ointment Triamcinolone Acetonide 0.025% Kenalog Ointment, Cream,

Lotion Triamcinolone Acetonide 0.1% Kenalog Ointment, Cream,

Lotion

Group IV (Low Potency)

Desonide 0.05% DesOwen Cream Fluocinolone Acetonide 0.01% Synalar Cream, Solution Hydrocortisone 0.5%, 1%, 2.5% Hytone Cream, Ointment,

Lotion Hydrocortisone/Pramoxine Pramosone Cream, Lotion,

Ointment

COUGH/COLD MEDICATIONS Benzonatate Tessalon Capsule Brompheniramine/Phenylephrine Bromfed PD Capsule Brompheniramine/Pseudoephedrine Bromfed Capsule Brompheniramine/Pseudoephedrine/Dextro. Bromfed DM, Rondec DM Syrup Chlorpheniramine/Phenylephrine Rynatan Tablet

Oral Suspension Chlorpheniramate/Phenylephrine HCl Rondec Syrup Chlorpheniramine/ Phenylephrine HCl Rondec Drops Drops Chlorpheniramine/Pseudoephedrine/Dextro. Rondec DM Drops Drops Guaifenesin Mucinex Tablets Guaifenesin /Codeine Cheracol Syrup Guaifenesin /Dextromethorphan Humibid DM Tablet Guaifenesin /Hydrocodone Hycotuss Syrup Guaifenesin /Phenylephrine Despec Liquid Guaifenesin /Pseudoephedrine Robitussin PE, Entex PSE Syrup, Tablet Guaifenesin /Pseudoephedrine/Dextro. Tussin Cough and Cold Syrup, Capsule Hydrocodone/Homatropine Hycodan Syrup, Tablet Phenyephrine/Pyrilamine/Chlorpheniramine R-Tannate Oral Suspension Promethazine/Codeine Phenergan/Codeine Syrup Promethazine/Phenylephrine Phenergan VC Syrup Promethazine/Phenylephrine/Codeine Phenergan VC/Codeine Syrup Pseudoephedrine/Chlorpheniramine Deconamine Deconamine SR Tablet, Capsule Pseudoephedrine/Hydrocodone HC Tussive-D Syrup

DECONGESTANTS (ORAL) Pseudoephedrine Sudafed Tablet, Solution

DIURETICS Amiloride Midamor Tablet Amiloride/ Hydrochlorothiazide Moduretic Tablet Bumetanide Bumex Tablet Chlorothiazide Diuril Tablet, Suspension Chlorthalidone Hygroton Tablet Furosemide Lasix Tablet, Solution Hydrochlorothiazide Oretic Tablet, Solution Indapamide Lozol Tablet Methyclothiazide Enduron Tablet

15

Metolazone Zaroxolyn Tablet Spironolactone Aldactone Tablet Spironolactone/Hydrochlorothiazide Aldactazide Tablet Torsemide Demadex Tablet Triamterene Dyrenium Capsule Triamterene/Hydrochlorothiazide Maxide, Dyazide Tablet, Capsule

ELECTROLYTES Calcium Acetate PhosLo Tablet Calcium Carbonate Tums Tablet

Suspension Calcium Carbonate/Vitamin D Oscal + D Tablet Magnesium Chloride Slow Mag Tablet Magnesium Oxide Mag Ox Tablet Oral Electrolyte Solution* Pedialyte* Solution *Children 12 and under;

Qty limit of 6000 ml Potassium Chloride K-Dur Tablets,

Capsules, Solution

Potassium Gluconate Kaon Solution Sodium/Potassium Phosphates Neutra-Phos Packet

ELECTROLYTE DEPLETERS Sevelamer Carbonate Renagel Tablet Sevelamer HCL Renvela Tablet Sodium Polystyrene Kayexalate Suspension

ESTROGENS- FEMALE PATIENTS ONLY Conjugated Estrogens Premarin Tablet Esterified Estrogens Menest Tablet Estradiol Estrace Tablet Estradiol Transdermal Climara, Alora, Estraderm,Vivelle Patch Estrogen Vaginal Premarin Cream Estropipate Ortho-Est Tablet

ESTROGEN/PROGESTIN COMBINATIONS- FEMALE PATIENTS ONLY Conjugated Estrogens/Medroxyprogesterone Prempro, Premphase Tablet Ethinyl Estradiol 5mcg/Norethindrone 1mg Femhrt Tablet

ESTROGEN/ANDROGEN COMBINATIONS Estrogen/Methyltestosterone Estratest Tablet

GALLSTONE SOLUBILIZERS Ursodiol Actigall Capsule

GI MEDICATIONS, MISCELLANEOUS Lubiprostone Amitiza Capsule *Diagnosis Required:

Chronic Idiopathic Constipation Irritable Bowel Syndrome

Mesalamine Asacol, Pentasa, Canasa

Capsule, Suppository

Misoprostol Cytotec Tablet Olsalazine Dipentum Tablet Pentosan Polysulfate Sodium Elmiron Capsule Simethicone Gas-X Tablets,

Drops, Chew Tabs

Sucralfate Carafate Tablets Sulfasalazine Azufidine Tablet

16

GI STIMULANTS Metoclopramide Reglan Tablet, Solution

GLUCOSE ELEVATORS Glucagon Glucagon Syringe

GOUT MEDICATIONS Allopurinol Zyloprim Tablet Colchicine Colchicine Tablet Probenecid Probenecid Tablet Sulfinpyrazone Anturane Tablet, Capsule

H2 RECEPTOR ANTAGONISTS Cimetidine Tagamet Tablets Famotidine Pepcid Tablets Nizatidine Axid Capsule Ranitidine Zantac Tablet, Solution

HEMORRHEOLOGIC AGENTS Pentoxifyline Trental Tablet

HEMOSTATICS Aminocaproic Acid Amicar Tablet

HIV/AIDS THERAPY Non-Nuclease Reverse Transcriptor Inhibitor (NNRTIs) Lamivudine/Zidovudine Combivir Tablet Emtricitabine Emtriva Capsule Lamivudine (3TC)* Epivir, Epivir-HBV* Tablet, Solution* *Solution Requires PA Abacavir/Lamivudine Epzicom Tablet Zidovudine (AZT) Retrovir Capsule

Tablet Syrup

Abacavir/Lamivudine/Zidovudine Trizivir Tablet Emtricitabine/Tenofovir Truvada Tablet Didanosine (DDI) Videx EC Tablet Tenofovir Viread Tablet Stavudine (D4T) Zerit Capsule, Powder Abacavir Ziagen Tablet, Solution Efavirenz/ Emtricitabine/Tenofovir Atripla Tablet

Nuclease Reverse Transcriptor Inhibitor (NRTIs) Nevirapine Viramune Tablet Efavirenz Sustiva Capsule Delavirdine Rescriptor Tablet

Protease Inhibitors (PI) Atazanavir Reyataz Capsule Darunavir Ethanolate Prezista Tablet Fosamprenavir Lexiva Tablet

Suspension Indinavir Crixivan Capsule Nelfinavir Viracept Tablet, Powder Ritonavir Norvir Capsule, Solution Ritonavir/Lopinavir Kaletra Capsule, Solution Saquinavir Invirase Capsule

17

HYPOGLYCEMIC (ORAL) Chlorpropamide Diabinese Tablet Glimepiride Amaryl Tablet Glipizide Glucotrol Tablet Glipizide Extended Release Glucotrol XL Tablet Glyburide Micronase Tablet Glyburide/Metformin Glucovance Tablet Glyburide Micronized Glynase Tablet Metformin Glucophage Tablet Metformin ER Glucophage XR Tablet Nateglinide* Starlix* Tablet Pioglitazone* Actos* Tablet Pioglitazone/Glimepiride* Duetact* Tablet Pioglitazone/Metformin* Actoplus Met* Tablet Rosiglitazone* Avandia* Tablet Rosiglitazone/Glimepiride* Avandaryl* Tablet Rosiglitazone/Metformin* Avandamet* Tablet Sitagliptin* Januvia* Tablet Sitagliptin / Metformin* Janumet* Tablet

*Step Therapy: concurrent use of metformin, sulfonylureas, or TZD’s

Tolbutamide Tolbutamide Tablet

IMMUNOSUPPRESSIVES Azathioprine Imuran Tablet Cyclosporine Neoral/Sandimmune Capsule Mycophenolate Mofetil Cellcept Capsule Mycophenolate Sodium Myfortic Tablet Tacrolimus Prograf Capsule

INSULINS Human Insulin Humulin Vial, Pen Human Insulin Humalog Vial, Pen Insulin Detemir Levemir Vial, Pen Insulin Glargine Lantus Vial, Cartridge, Pen

INTRANASAL ANTIHISTAMINES Azelastine Astelin Spray

INTRANASAL MAST CELL STABILIZERS Cromolyn Nasal Nasalcrom Spray

INTRANASAL STEROIDS Budesonide Rhinocort Aqua Spray Fluticasone Flonase Spray Mometasone Nasonex Spray

LAXATIVES Bisacodyl Dulcolax Tablet

Suppository Dibasic/Monophasic NaPhosphate Fleet Enema Enema Docusate Calcium Surfak Capsule Docusate Sodium Colace Capsule, Syrup Docusate/Senna Peri-colace Capsule Electrolytes and Laxative Solution Nulytely Powder Glycerin Glycerin Suppository Lactulose Cephulac Syrup Magnesium Citrate Mag Citrate Solution Magnesium Hydroxide MOM Suspension Methylcellulose Citrucel Powder Mineral Oil Mineral Oil Liquid, Emulsion Polyethylene Glycol, Polyethylene Glycol 3350 Miralax, Miralax OTC Powder Psyllium Metamucil Powder Senna Senokot Tablet, Granules

18

LEUKOTRIENE RECEPTOR ANTAGONISTS Montelukast Singulair Tablet

MAST CELL STABILIZERS (INHALED) Cromolyn Sodium Inhaler Intal Inhaler Cromolyn Sodium Solution Intal Solution

METABOLIC DEFICIENCY AGENTS Levocarnitine Carnitor Tablet

MIGRAINE AND CLUSTER HEADACHE THERAPY APAP/Dichloralphenazone/Isometheptene Midrin Capsule Eletriptan* Relpax* Tablet *Qty limit: up to 12 tab/ 30 days Ergotamine/Caffeine Cafergot Tablet

Zolmitriptan* Zomig, Zomig ZMT* Tablet/ Nasal Spray

*Qty limit:: up to 12 tab/ 30 days Nasal Spray (6 units/30 days)

Sumatriptan* Imitrex* Tablet, Nasal Spray, Injection

*Qty limit:: up to 12 tabs/ 30 days Nasal Spray (6 units/ 30 days)

Sumatriptan* Imitrex* Injection * Qty limit :(4 injections/ 30 days)

MUCOLYTICS Acetylcysteine Mucomyst Solution

MUSCLE RELAXANTS Baclofen Lioresal Tablet Carisoprodol Soma Tablet Carisoprodol/ASA Soma Compound Tablet Carisoprodol/ASA/Codeine Soma Compound w/ Codeine Tablet Chlorzoxazone Parafon Forte Tablet Cyclobenzaprine Flexeril Tablet Dantrolene Dantrium Capsule Methocarbamol Robaxin Tablet Orphenadrine Norflex Tablet Orphenadrine/ASA/Caffeine Norgesic Tablet Tizanidine* Zanaflex* Tablet *Capsules require PA

NARCOTIC ANTAGONISTS Naltrexone ReVia Tablet

NITRATES Isosorbide Dinitrate Isordil Tablet Isosorbide Dinitrate Sustained Release Isordil SA Tablet Isosorbide Mononitrate Imdur, Monoket Tablet Nitroglycerin Ointment Nitro-Bid Ointment Nitroglycerin Oral Nitro-Time Capsule Nitroglycerin SL Nitrostat Tablet Transdermal Nitroglycerin Nitro-Dur Patch

OPHTHALMIC ALPHA-2 ADRENERGIC AGONISTS Brimonidine Alphagan Drop

OPHTHALMIC ANTIBIOTICS Bacitracin Bacitracin Ointment Bacitracin/Polymyxin Polyysporin Ointment Ciprofloxacin Ciloxan Drops, Ointment

19

Erythromycin Ilotycin Ointment Gatifloxacin* Zymar* Drops *Ophthalmologists only Gentamicin Sulfate Garamycin Drops Neomycin/Polymyxin/Gramicidin Neomycin/Polymyxin/Bacitracin

Neosporin Neosporin

Drops Ointment

Ofloxacin Ocuflox Drop Polymyxin/Trimethoprim Polytrim Drop Sulfacetamine Bleph 10 Drop, Ointment Tobramycin Tobrex Drop, Ointment

OPHTHALMIC ANTIHISTAMINES Ketotifen Fumarate Zaditor OTC,

Alaway Drops

Olopatadine* Patanol, Pataday* Drops *Step Therapy: Zaditor OTC/ Alaway first

OPHTHALMIC ANTIVIRALS Trifluridine Viroptic Drop

OPHTHALMIC BETA BLOCKERS Betaxolol Betoptic S Drops Carteolol Ocupress Drop Levobunolol Betagan Drop Metipranolol OptiPranolol Drops Timolol Timoptic, Drop, Gel

Timoptic-XE

OPHTHALMIC MAST CELL STABILIZER Cromolyn Sodium Crolom Drop

OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS Brinzolamide Azopt Drop

OPTHALMIC CHOLINESTERASE INHIBITORS Echothiophate Iodide Phoshpholine Iodide Drop

OPTHALMIC DIRECT ACTING MIOTICS Carbachol Isopto Carbachol Drop Pilocarpine Pilocar Drop Pilocarpine Pilopine HS Gel

OPHTHALMIC PROSTAGLANDINS AGONISTS Latanoprost Xalatan Drop

SYMPATHOMIMETICS: Apraclonidine Iopidine Drop

OPHTHALMIC MYDRIATICS Dipivefrin Propine Drop Epinephrine Epifrin Drop

OPHTHALMIC NON-STEROIDALS Flurbiprofen Ocufen Drop Ketorolac Acular, Acular PF Drop,

Droperette Cyclosporine* Restasis* Droperette *Step therapy: Generic artificial

tears OR rheumatologist OR ophthalmologist

OPHTHALMIC STEROID/ANTIBIOTIC COMBINATIONS Neomycin/Polymyxin/Dexamethasone Maxitrol Ointment

20

Neomycin/Polymyxin/HC Cortisporin Drop, Ointment

Sulfacetamide 10%/Prednisolone .25% Vasocidin Drops Tobramycin/Dexamethasone Tobradex Drops

OPHTHALMIC STEROIDS Dexamethasone Decadron Drop,

Ointment Fluorometholone FML, FML Forte,

FML SOP Drop, Ointment

Prednisolone Pred Forte Drop Prednisolone Pred Mild Drop

OPTHALMIC VASOCONSTRICTOR DECONGESTANTS Phenylephrine Neo-Synephrine Drop Naphazoline Albalon Drop

ORAL, MISCELLANEOUS Chlorhexidine Peridex Liquid Sodium Fluoride Prevident Gel, Solution, Tabs,

Cream, Paste Lidocaine Viscous Lidocaine Viscous Liquid

OTIC ANTIBIOTICS Acetic Acid Vosol Drop Acetic Acid/ Aluminum Acetate Domeboro Otic Drop Ciprofloxacin/Dexamethasone Ciprodex Otic Suspension Ofloxacin Floxin Otic Drop

OTIC, MISCELLANEOUS Antipyrine/Benzocaine Antipyrine/Benzocaine Drop

OTIC, STEROID/ANTIBIOTIC COMBINATIONS Acetic Acid/Hydrocortisione Vosol HC Drop Neomycin/Polymyxin/Hydrocortisone Cortisporin Drop

OXYTOCICS Methylergonovine Methergine Tablet

PANCREATIC ENZYMES Amylase/Lipase/Protease Lipram, Viokase Capsule Pancreaslipase Creon Capsule

PHEOCHROMOCYTOMA MEDICATIONS Metyrosine Demser Capsule Phenoxybenzamine Dibenzyline Capsule

PROGESTINS Medroxyprogesterone Provera Tablet Megestrol Megace Tablet,

Suspension Megestrol Megace ES* Suspension *PA required

PROTON PUMP INHIBITORS Lansoprazole* Prevacid* Solutabs *Step Therapy: Prior use of

Omeprazole within the past 12 months. Qty limit: 1 cap/day.

Omeprazole OTC Prilosec OTC Tablet Omeprazole Prilosec Capsule 40mg: use 2-20mg caps/tab

21

Pantoprazole* Protonix Tablet *Step Therapy: Prior use of Omeprazole within the past 12 months. Qty limit: 1 cap/day.

PULMONARY ARTERIAL HYPERTENSION MEDICATION Sildenafil Citrate* Revatio* Tablet *Diagnosis Required:

Pulmonary Arterial Hypertension

SCABICIDES/PEDICULICIDES Crotamiton Eurax Cream, Lotion Lindane* Kwell* Lotion,

Shampoo *Step Therapy Required

Malathion* Ovide* Lotion *Step Therapy Required Permethrin 1% Nix Lotion 1 st Line agent Permethrin 5% Elimite Cream 1 st line agent

SEDATIVES HYPNOTICS Estazolam Prosom Tablet Meprobamate Equanil Tablet Ramelteon Rozerem* Tablet * Step Therapy Required Temazepam Restoril Capsule Triazolam Halcion Tablet Zalpelon Sonata Tablet Zolpidem Ambien Tablet

THYROID HORMONES Levothyroxine Synthroid Tablet Liothyronine Cytomel Tablet

TOPICAL ENZYMES (DEBRIDING MEDICATIONS) Papain/Urea Accuzyme Ointment Trypsin Granulex Spray

TOPICALS, MISCELLANEOUS Imiquimod Aldara* Cream *PA Required Pimecrolimus Elidel* Cream *Preferred for < 18 yo Podofilox Condylox Gel,

Solution Tacrolimus Protopic* Ointment *PA required

VAGINAL ANTI-INFECTIVES Clotrimazole Gyne-Lotrimin Suppository,

Cream Fluconazole* Diflucan* Tablet Qty Limit:: 150mg 4 tab/28 days

Metronidazole Vaginal Metrogel Vaginal Gel Miconazole Monistat Suppository,

Cream Nystatin Mycostatin Tablet Tioconazole Vagistat Ointment Triple Sulfa Vaginal Sultrin Cream

VASODILATORS Hydralazine Apresoline Tablet Minoxidil Loniten Tablet

XANTHINES Aminophylline Aminophylline Tablet,

Liquid

22

Theophylline Uniphyl, Theodur Liquid, Capsule, Tablet

© 2009 PASSPORT HEALTH PLAN (PHA-09101)