provider reference guide - p3 health partners · 2019-06-25 · the medications listed in this...

PROVIDERREFERENCE GUIDE

Drug Formulary

2018

3

The medications listed in this guide are intended to provide sufficient options to treat patients who require treatment with a medication from that pharmacologic or therapeutic class. The

medications have been based upon the clinical appropriateness and cost-effectiveness for patients. A non-preferred unlisted

medication may be used for proper medical management of a specific patient, but there is no guarantee or assurance that P3 will

approve, and/or reimburse the patient for the use of non-preferred unlisted medications. The medications represented

have been reviewed by the Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The guide is reflective

of current medical practice as of the date of review.

For a complete list of medications, please refer toyour patients plan formulary.

5

CONTENTSANTI-INFECTIVES

CARDIOVASCULAR

EYE, EAR, NOSE, THROAT (ENT)

ENDOCRINOLOGY

GASTROINTESTINAL

GENITOURINARY

INTEGUMENTARY (SKIN)

MUSCULOSKELETAL

NEUROLOGICAL

PAIN

PSYCHIATRY

PULMONARY

MISCELLANEOUS

6

8

11

12

15

16

17

19

20

22

23

25

27

* Beers List: Medications to be avoided in the elderly.

SUPD: Statins use in Persons with Diabetes

RAS: Renin Angiotensin System

Italicized: Quality Measure Medication

6

GENERIC BRAND NAME COST







ANTIBIOTICS

Sulfamethoxazole-Trimethoprim Bactrim $

Azithromycin

Erythromycin

Clarithromycin

Zithromax

EryTab

Biaxin

Amoxicillin

Dicloxacillin

Penicillin

Amoxicillin-Clavulanate

Amoxil

Dycill

Augmentin

$

$

$

$$

$

$

$$

Cephalexin

Cefdinir

Cefuroxime

Cefixime

Keflex

Omnicef

Ceftin

Suprax

Ciprofloxacin

Levofloxacin

Moxifloxacin

Cipro

Levaquin

Avelox

$

$$

$$

Metronidazole Flagyl $

$

$$

$$

$$$

Doxycycline

Minocycline

Vibramycin

Minocin

$

$

SULFA

MACROLIDE

B LACTAM

CEPHALOSPORIN

QUINOLONE

TETRACYCLINE

ANAEROBIC

ANTI

-INFE

CTIV

ES

7

GENERIC BRAND NAME COSTClotrimazole troche

Nystatin

Fluconazole

Terbinafine

Itraconazole

Voriconazole

Mycelex

Nystop

Diflucan

Lamisil

Sporanox

Vfend


$

$

$

$

$$

$$$

ANTIFUNGALS

GENERIC BRAND NAME COSTANTIVIRALSAcyclovir

Oseltamivir

Valacyclovir

Famciclovir

Zovirax

Tamiflu

Valtrex

Famvir

$

$$

$$

$$$

HEPATITIS B AGENTSEntecavir

Lamivudine

Tenofovira

Adefovir

Baraclude

Epivir HBV

Viread

Hepsera

$$

$$

$$

$$$

ANTI-IN

FECTIVES

8





ACE INHIBITORS [RAS]

Benazepril

Lisinopril

Quinapril

Lotensin

Prinivil

Accupril

$

$

$

ANGIOTENSIN RECEPTOR BLOCKERS [RAS]

Losartan

Olmesartan

Valsartan

Cozaar

Benicar

Diovan

$

$$

$$

BETA BLOCKERS

Atenolol

Carvedilol

Metoprolol succinate (ER)

Metoprolol tartrate

Propranolol

Labetalol

Sotalol

Tenormin

Coreg

Toprol XL

Lopressor

Inderal

Trandate

Betapace

$

$

$

$

$

$$

$$

ANTICOAGULANTS/ANTIPLATELETS

Clopidogrel

Warfarin

Apixaban

Dabigatran

Enoxaparin

Rivaroxaban

Prasugrel

Plavix

Coumadin

Eliquis

Pradaxa

Lovenox

Xarelto

Effient

$

$

$$

$$

$$

$$

$$

CARD

IOVA

SCU

LAR

9

GENERIC BRAND NAME COSTCALCIUM CHANNEL BLOCKERS

Amlodipine

Nifedipine*

Nifedipine ER 24h

Felodipine

Diltiazem

Diltiazem ER 24h

Verapamil

Verapamil ER tablet

Norvasc

Procardia

Procardia XL

Plendil

Cardizem

Cardizem LA

Calan

Calan SR

$

$

$

$

$

$

$


LIPID LOWERING AGENTS

Cholestyramine powder/packet

Colestipol

Questran

Colestid

$$

$$

GENERIC BRAND NAME COSTFenofibrate

Gemfibrozil

Omega 3

Tricor

Lopid

Lovaza

$$

$$

$$

Fibrates

GENERIC BRAND NAME COSTNiacin Niaspan $$

Niacin

GENERIC BRAND NAME COSTAtorvastatin

Lovastatin

Pravastatin

Simvastatin

Rosuvastatin

Lipitor

Mevacor

Pravachol

Zocor

Crestor

$

$

$

$

$$

HMG-CoA Reductase Inhibitors (Statins)

CARDIO

VASCULAR

Bile Acid Sequestrants

[SUPD]

10



CARD

IOVA

SCU

LAR

NITRATES

Isosorbide dinitrate

Isosorbide mononitrate

Nitroglycerin sublingual

Nitroglycerin transdermal

Isordil

Imdur

NitroStat

Minitran

$

$

$

$

DIURETIC AGENTS

Furosemide

Hydrochlorothiazide

Spironolactone

Metolazone

Bumetanide

Lasix

Microzide

Aldactone

Zaroxolyn

Bumex

$

$

$

$$

$$

11

GENERIC BRAND NAME COSTGLAUCOMA

Dorzolamide

Latanoprost

Timolol

Bimatoprost

Brimonidine/Timolol

Brinzolamide

Dorzolamide/Timolol

Travoprost

GENERIC BRAND NAME COSTOPHTHALMIC ANTIBIOTICS

Erythromycin ointment

Trimethoprim-polymyxin B

Ofloxacin

Ciprofloxacin solution

Moxifloxacin

Polytrim

Ocuflox

Ciloxan

Vigamox

$

$

$

$

$$

GENERIC BRAND NAME COSTOTIC ANTIBIOTICS

Ciprofloxacin solution

Cipro/Dexamethasone susp.

Cipro/hydrocortisone susp.

Neomycin, polymyxin B andhydrocortisone

Ofloxacin

Cetraxal

Ciprodex

Cipro HC

Cortisporin

Floxin

$

$$

$$

$$

$$

Trusopt

Xalatan

Timoptic

Lumigan

Combigan

Azopt

Cosopt

Travatan Z

$

$

$

$$$

$$$

$$$

$$$

$$$

EYE, EAR, NO

SE, THRO

AT (ENT)

12

GENERIC BRAND NAME COSTGlucophage

Glucophage XR

GENERIC BRAND NAME COSTJanuvia

DIABETES

GENERIC BRAND NAME COSTByetta

Tanzeum

Trulicity

Victoza

GENERIC BRAND NAME COSTInvokana

Jardiance

Metformin

Metformin

Sitagliptin


$$$

Glucotrol

Glucotrol XL

Amaryl

DPP-4

$

$


Biguanide

Actos

Exenatide

Albiglutide

Dulaglutide

Liraglutide

$$$

$$$

$$$

$$$

GLP-1 Agonists

Canagliflozin

Empagliflozin

$$$

$$$

SGLT-2

Glipizide

Glipizide ER

Glimepiride

$

$

$

Sulfonylureas

Pioglitazone

$

END

OCR

INO

LOG

Y

$

Thiazolidinedione

[ORAL DIABETICS]

[ORAL DIABETICS]

[ORAL DIABETICS]

[ORAL DIABETICS]

[ORAL DIABETICS]

[NON-INSULIN INJECTABLE]

13

GENERIC BRAND NAME COSTBasaglar

Levemir

Lantus

Insulin glargine

Insulin detemir

Insulin glargine

$$

$$$

$$$

GENERIC BRAND NAME COSTvial/pen

vial/pen

vial/pen

vial/pen

vial/pen

vial pen

vial

vial/pen

vial/pen

vial

Apidra

Humalog

Humalog Mix 50/50

Humalog Mix 75/25

Humulin 70/30

Humulin N

Humulin R 100 u/mL

Novolin 70/30

Novolin N

Novolin R

$$$

$$$

$$$

$$$

$$$

$$$

$$$

$$$

$$$

$$$

GENERIC BRAND NAME COSTEstradiol patch (twice weekly)*

Estradiol patch (weekly)*

Estradiol tablets*

Estradiol vaginal cream

Conjugated equine estrogen (oral)*

Conjugated equine estrogens

Estradiol vaginal ring

Vivelle-Dot

Climara

Estrace

Estrace 0.01%

Premarin tablets

Premarin vaginal cream

Estring

$

$

$

$$

$$$

$$$

$$$

Estrogen Derivatives

END

OCRIN

OLO

GY

Long Acting Insulins *vials preferred

Long Acting Insulins *vials preferred

14


HORMONE REPLACEMENT DRUGS

Testosterone cypionate 100 mg/ml, 200 mg/ml intramuscular oil

Testosterone enanthate 200 mg/mlintramuscular oil

Testosterone 1% 50 mg packets

Testosterone 1% gel tube

Testosterone 1% 25 mg packets, pump

Testosterone 1% gel tube/pump

Testosterone 2% gel pump

Testosterone transdermal patch

$

$

$$

$$

$$$

$$$

$$$

$$$

Androgens

GENERIC BRAND NAME COSTHYPERPARATHYROID

Calcium Acetate

Calcitriol

Cinacalcet

Doxercalciferol

Paricalcitol

Sevelamer

Phoslo

Rocaltrol

Sensipar

Hectorol

Zemplar

Renvela

GENERIC BRAND NAME COSTLevothroid, Levoxyl, Synthroid

Cytomel

THYROID

Levothyroxine

Liothyronine

$

$$

Hypothyroid

GENERIC BRAND NAME COSTPropylthiouracil

Tapazole

Propylthiouracil

Methimazole

$

$

Hyperthyroid

$

$$

$$

$$

$$

$$$

END

OCR

INO

LOG

Y

Androgel

Testim

Androgel

Vogelxo

Fortesta

Androderm

15

GENERIC BRAND NAME COSTBOWEL TREATMENT AGENTS

Balsalazide

Dicyclomine*

Linaclotide

Lubiprostone

Mesalamine

Mesalamine

Colazal

Bentyl

Linzess

Amitiza

Mesalamine rectal

Asacol,Delzicol, Lialda

$

$

$$

$$

$$

$$$

GENERIC BRAND NAME COSTANTIEMETICSMetoclopramide*

Ondansetron

Prochlorperazine

Promethazine*

Reglan

Zofran

Compazine

Phenergan

$

$

$

$

GENERIC BRAND NAME COSTGALLSTONEUrsodiol Actigall

GENERIC BRAND NAME COSTH2 BLOCKERSFamotidine

Ranitidine

Pepcid

Zantac

GENERIC BRAND NAME COSTPROTON PUMP INHIBITORSOmeprazole*

Pantoprazole*

Esomeprazole*

Prilosec

Protonix Tab

Nexium

$

$

$$

$

$

GASTRO

INTEN

STINAL

$

16

GENERIC BRAND NAME COSTBENIGN PROSTATIC HYPERPLASIADoxazosin*

Finasteride

Tamsulosin

Terazosin*

Alfuzosin

Cardura

Proscar

Flomax

Hytrin

Uroxatral

$

$

$

$

$$

GENERIC BRAND NAME COSTBLADDER CONTROLOxybutynin

Oxybutynin XL

Tolterodine

Tolterodine LA

Trospium

Solifenacin

Ditropan

Ditropan XL

Detrol

Detrol LA

Sanctura

Vesicare

$

$$

$$

$$

$$

$$$

GEN

ITO

URI

NAR

Y

17




Hydrocortisone 2.5% ointment, cream or lotion

Hydrocortisone $

Betamethasone valerate 0.1% lotion

Triamcinolone acetonide 0.025% cream or lotion

Diprolene

Kenalog

$

$

Betamethasone dipropionate 0.05% lotion or betamethasone valerate 0.1% cream

Fluocinolone acetonide 0.025% cream

Fluticasone propionate 0.05% cream

Triamcinolone acetonide 0.1% lotion or 0.025% ointment

Diprolene

Synalar

Cutivate

Kenalog

$

$

$

$

GENERIC BRAND NAME COSTMometasone furoate 0.1% creamor solution

Triamcinolone acetonide 0.1%cream or ointment

Elocon

Kenalog

$

$

Medium Potency (Group 4)

TOPICAL STEROIDSLeast Potent (Group 7)

GENERIC BRAND NAME COSTPSORIASIS DRUGSCalcipotriene topical

Methotrexate

Azathioprine

Acitretin

Dovonex

Rheumatrex

Imuran

Soriatane

$

$

$

$$

INTEG

UM

ENTARY (SKIN

)

Low Potency (Group 6)

Lower-medium Potency (Group 5)

18

GENERIC BRAND NAME COSTMometasone furoate 0.1% ointment

Triamcinolone acetonide 0.5% ointment or cream

Elocon

Kenalog

$

$

High/Medium Potency (Group 3)

GENERIC BRAND NAME COSTUltra High Potency (Group 1)


INTE

GU

MEN

TARY

(SKI

N)

Betamethasone dipropionate 0.05% ointment or augmented cream

Desoximetasone 0.25% cream

Fluocinonide 0.05% ointment, gel or solution

Diprolene

Tropicort

Lidex

$

$$$

Betamethasone dipropionate augmented 0.05% ointment, lotion or gel

Halobetasol propionate 0.05% cream or ointment

Clobetasol propionate 0.05% cream,ointment or gel

Diprolene

Ultravate

Temovate

High Potency (Group 2)

$

$

$$$

19

GENERIC BRAND NAME COSTOSTEOPOROSISAlendronate

Ibandronate

Risedronate

Fosamax

Boniva

Actonel

$

$$

$$

GENERIC BRAND NAME COSTGOUTAllopurinol

Probenecid

Colchicine

Febuxostat

GENERIC BRAND NAME COSTRHEUMATOID ARTHRITIS Methotrexate

Sulfasalazine

Hydroxychloroquine

Leflunomide

Rheumatrex

Azulfidine

Plaquenil

Arava

$

$

$$

$$

Zyloprim

Colcrys

Uloric

$

$

$$

$$

MU

SCULO

SKELETAL

20




GENERIC BRAND NAME COSTDEMENTIADonepezil

Memantine

Rivastigmine

Galantamine

Aricept

Nameda

Exelon caps

Razadyne

$

$$

$$

$$

MIGRAINE

Butalbital/APAP/caffeine tablets*

Rizatriptan

Sumatriptan

Esgic

Maxalt/Maxalt MLT

Imitrex

$$

$$

$$

MULTIPLE SCLEROSISDimethyl fumarate

Glatiramer

Interferon Beta-1A

Interferon Beta-1A

Interferon Beta-1A

Interferon Beta-1B

Tecfidera

Copaxone

Avonex Kit

Avonex Auto-injector kit

Rebif

Betaseron

PARKINSON’S DISEASECarbidopa-Levodopa

Pramipexole

Ropinirole

Carbidopa-Levodopa

Selegiline

Carbidopa-Levodopa-Entacapone

Entacapone

Sinemet

Mirapex

Requip

Sinemet CR

Eldepryl

Stalevo

Comtan

$

$

$

$$

$$

$$$

$$$

NEU

ROLO

GIC

AL

$$$$

$$$$

$$$$

$$$$

$$$$

$$$$

21

GENERIC BRAND NAME COSTSEIZURE CONTROL DRUGS

Carbamazepine

Ethosuximide

Gabapentin Cap, Tab

Lamotrigine Tab

Levetiracetam

Oxcarbazepine

Phenytoin Extended Cap

Primidone

Tiagabine

Valproic Acid

Zonisamide

Carbamazepine SR

Divalproex Sodium

Lamotrigine extended release

Levetiracetam extended release

Pregabalin

Tegretol

Zarontin

Neurontin

Lamictal

Keppra

Trileptal

Dilantin

Mysoline

Gabitril

Depakene

Zonegran

Tegretol XR

Depakote DR, ER

Lamictal XR

Keppra XR

Lyrica

$

$

$

$

$

$

$

$

$

$

$

$$

$$

$$

$$

$$

NEU

ROLO

GICAL

22

GENERIC BRAND NAME COSTOPIOID ANTAGONISTSNaloxone Narcan $

GENERIC BRAND NAME COSTNON-STEROIDAL ANTI-INFLAMMATORY (NSAIDS)

GENERIC BRAND NAME COSTOPIOIDSCodeine/Acetaminophen

Hydrocodone/Acetaminophen

Oxycodone/Acetaminophen

Codeine/Acetaminophen solution

Codeine

Hydromorphone

Morphine sulfate solution

Morphine Sulfate ER

Morphine Sulfate IR

Oxycodone 20 mg/ml oral concentrate

Oxycodone 5 mg/5 ml solution

Oxycodone IR

Tramadol

Oxycodone ER

Norco, Vicodin

Percocet

Dilaudid

MS Contin

Oxycontin

Roxicodone

Ultram

Oxycontin

$

$

$

$

$

$

$

$

$

$

$

$

$

$$

Ibuprofen*

Naproxen*

Celecoxib

Meloxicam*

Indomethacin*

Motrin

Naprosyn

Celebrex

Mobic

Indocin

$

$

$$

$$

$$

GENERIC BRAND NAME COSTMUSCLE RELAXANTSBaclofen

Cyclobenzaprine*

Methocarbamol*

Tizanidine

Lioresal

Flexeril

Robaxin

Zanaflex

$

$

$

$

PAIN

23

GENERIC BRAND NAME COSTDuloxetine

Venlafaxine

Cymbalta

Effexor, Effexor XR

$

$

SNRI

GENERIC BRAND NAME COSTCitalopram

Escitalopram

Fluoxetine

Paroxetine*

Sertraline

Celexa

Lexapro

Prozac

Paxil

Zoloft

$

$

$

$

$

SSRI

GENERIC BRAND NAME COSTAmitriptyline*

Nortriptyline*

Bupropion SR/XL

Elavil

Pamelor

Wellbutrin SR/XL

GENERIC BRAND NAME COSTANTIPSYCHOTICSHaloperidol*

Risperidone*

Aripiprazole*

Olanzapine*

Quetiapine*

Ziprasidone*

Haldol

Risperdal

Abilify

Zyprexa

Seroquel

Geodon

$

$

$$

$$

$$

$$

$

$

$

TCAs

GENERIC BRAND NAME COSTBuspirone

Mirtazapine

Trazodone

Buspar

Remeron

Desyrel

$

$

$

Other

ANTIDEPRESSANTSPYSCH

IATRY

24

GENERIC BRAND NAME COSTSLEEP AIDSEszopiclone*

Ramelteon

Zaleplon*

Zolpidem *

Lunesta

Rozerem

Sonata

Ambien

$

$

$

$

GENERIC BRAND NAME COSTMOOD STABILIZERSLithium Carbonate capsule Eskalith,Lithobid $

PSYC

HIA

TRY

25

GENERIC BRAND NAME COSTANTICHOLINERGICS (LONG ACTING)Tiotropium Spiriva Handihaler $$$

GENERIC BRAND NAME COSTBETA AGONISTS (SHORT ACTING)Levalbuterol

Albuterol Neb Solution

Albuterol Sulfate

Albuterol Sulfate

Albuterol Sulfate

Xopenex HFA

Albuterol Sulfate Inhalation

ProAir HFA

Proventil HFA

Ventolin HFA

$

$$

$$

$$

$$

GENERIC BRAND NAME COSTBETA AGONISTS (LONG ACTING)Salmeterol Serevent $$$

GENERIC BRAND NAME COSTINHALED CORTICOSTEROIDSBeclomethasone Dipropinonate

Fluticasone propionate

QVAR

Flovent HFA

$$$

$$$

GENERIC BRAND NAME COSTANTICHOLINERGICS (SHORT ACTING)

PULM

ON

ARY

Ipratropium/Albuterol Soln.

Ipratropium

Ipratropium/Albuterol

Ipratropium Neb Solution

Ipratropium/Albuterol Soln.

Atrovent

Combivent Respimat

Atrovent HFA

$

$$

$$$

$$$

26

GENERIC BRAND NAME COSTLEUKOTRIENE RECEPTOR ANTAGONISTMontelukast Singulair $

GENERIC BRAND NAME COSTINHALED CORTICOSTEROIDS/LONG ACTING BETA AGONISTS

Fluticasone-Salmeterol

Budesonide-Formoterol

Mometasone-Formoterol

Fluticasone-Vilanterol

Advair Diskus

Symbicort

Dulera

Breo Ellipta

$$$

$$$

$$$

$$$

PULM

ON

ARY

27

GENERIC BRAND NAME COSTDISEASE MODIFYING BIOLOGICSGolimumab

Abatacept

Adalimumab

Anakinra

Apremilast

Certolizumab

Etanercept

Secukinumab

Tocilizumab

Tofacitinib

Ustekinumab

Simponi

Orencia

Humira

Kineret

Otezla

Cimzia

Enbrel

Cosentyx

Actemra

Xeljanz, Xeljanz XR

Stelara

$$$$

$$$$

$$$$

$$$$

$$$$

$$$$

$$$$

$$$$

$$$$

$$$$

$$$$

GENERIC BRAND NAME COSTCOLONY STIMULATING FACTORS

MISCELLAN

EOU

S

Darbepoetin Alfa

Epoetin Alfa

Filgrastim

Aranesp

Procrit

Neupogen

$$$

$$$

$$$

provider reference guide - p3 health partners · 2019-06-25 · the medications listed in this...

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