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County of San Diego County Medical Services (CMS) Program

DRUG FORMULARY

April 2012

This document has been prepared by AmeriChoice for the County of San Diego and is updated at least quarterly throughout the year. Please be sure to confer with the website at http://www.sdcounty.ca.gov/hhsa/programs/ssp/county_medical_services/index.html to ensure this is the most recent version.

San Diego County CMS Drug Formulary

The County of San Diego has contracted with AmeriChoice as their Administrative Services Organization (ASO) for the County Medical Services (CMS) Program. In turn, AmeriChoice has contracted with InformedRx® to act as the Pharmacy Benefits Manager (PBM). The CMS Pharmacy and Therapeutics (P&T) Committee determines the content of this formulary. Additions to this formulary are recommended by the P&T Committee and must be approved by the County. To request the review of a new product, complete the "Request for Formulary Change" form located at the end of this document and fax to the Medical Management Services Manager at AmeriChoice at (858) 565-4091. FORMULARY FORMAT Generic Products 1. The Formulary is generic based. 2. When a brand name drug is ordered and a generic equivalent is available, the generic will be dispensed by the pharmacy. The prescriber must justify any exception and the "Drug Prior Authorization" form must be completed and faxed to InformedRx® at (866) 511-2202. The Drug Prior Authorization Form is also located at the end of the formulary. Maximum Allowable Limits Except as otherwise noted below, enrollees can receive a 30-day supply of prescribed medications. Exceptions: Certain medications used to treat chronic diseases, such as Aspirin, Lisinopril, Lovastatin, and Insulin, may be filled for a 90-day supply Refills are allowed after 25 days. One vacation supply is allowed every 12 months, to a max of one 60 day supply per medication per 12 months. One "lost prescription" supply is allowed every 12 months, to a max of a 30 day supply for one lost prescription per medication per 12 months. Code 1 Restrictions Products with this notation are limited to prescriber's specialty, to a restricted amount, to specific diagnoses, or to step therapy. Formulary Exclusions Drugs prescribed for cosmetic purposes All OTC products not included in this listing Oral birth control and birth control devices for non-pathological reasons Nicotine and smoking cessation products Experimental drugs Drug and alcohol abuse treatment Authorization Policy Every provider has the right to request coverage of a non-formulary medication. However, medical justification for using a non-formulary medication is required. First, please review any notations found under the "Utilization Management" column in the drug category type of the non-formulary medication. Second, complete the "Drug Prior Authorization" form found at the end of this document and fax to InformedRx® at (866) 511-2202. Additionally, you may contact InformedRx® Customer Service by phone (800-626-0072) which is available 24 hours a day, everyday, to assist with any formulary questions. Denials and Appeals When a product is excluded or is not medically justified, InformedRx ® will issue a provisional denial to the pharmacy and/or the prescriber. As the CMS Medical Director completes the denial, the prescriber and the enrollee are issued written notification. Appeals may be made directly to the LIHP, and instructions for submitting an appeal are incorporated in the denial notice. Formulary Updates This formulary is published on the Web and is updated on a quarterly basis. The most recent document is located at: www2.sdcounty.ca.gov/hhsa/documents/Formulary.pdf

April 2012 Page 2 of 41

San Diego County Drug Formulary

Generic Name Representative Brand Name Utilization Management

INFECTIOUS DISEASE AGENTS Antibiotics Amoxicillin Oral Amoxicillin & Potassium Clavulanate Oral Ampicillin Oral Atovaquone Dicloxacillin Sodium Oral Paromomycin Penicillin G Benzathine Penicillin V Potassium Oral Pentamidine Sulfadiazine Trimethoprim Cephalosporins Cefixime Tab 400mg Oral Cephalexin Monohydrate Cefdinir Oral Cefpodoxime Proxetil Oral Fluroquinolones Ciprofloxacin HCl 250mg, 500mg, 750mg Tab Oral Levofloxacin Tab Oral Macrolides Azithromycin 250mg, 500mg Tab Oral Azithromycin Susp Oral Clarithromycin 250mg, 500mg Tab Oral Erythromycin Base Oral Erythromycin Delayed Release Oral Erythromycin w/EC Particles Oral Erythromycin Ethylsuccinate Oral Erythromycin Stearate Oral Misc. Anti-Infectives Clindamycin HCL Cap Oral Dapsone Oral Metronidazole Tab Oral

April 2012

Trimox Augmentin, Augmentin XR Ampicillin Mepron Dicloxacillin Sodium Paromycin Bicillin LA Pen-VK, Veetids Nebupent, Pentam Lantrisul Trimpex, Proloprim 1.2 MU per syringe (2ml) and 2.4 MU per syringe (4ml) only. Inhaled or injection forms only. Oral form only. Oral form only.

Suprax Keflex Omnicef Vantin

Cipro Levaquin

Limited to 28/14 days. Code 1 Restriction: For diagnosis of Pneumonia. Limited to 10 tablets/10 days.

Zithromax Zithromax Biaxin Erythromycin E-Mycin, Eryc, EryTab PCE E.E.S. Erythrocin

Limited to 6 tablets/fill and 2 fills/month for 250mg; 3 tablets/fill and 2 fills/month for 500mg. Code 1 Restriction: For diagnosis of community-acquired pneumonia only. Limited to 28 tablets/14 days.

Cleocin Dapsone Flagyl

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San Diego County Drug Formulary

Generic Name

Trimethoprim/ Sulfamethoxazole Oral Sulfonamides Sulfisoxazole Powder Sulfisoxazole Acetyl Oral Tetracyclines Doxycycline Hyclate Cap 50mg & 100mg, Tab 100mg Oral Tetracycline HCl Oral Amebicides Iodoquinol Oral Aminoglycosides Neomycin Sulfate Oral Antihelmintics Mebendazole Oral Pyrantel Pamoate Oral Thiabendazole Oral Antifungals Fluconazole Tab 50mg, 100mg, 150mg Oral Flucytosine Itraconazole Caps Ketoconazole Tab Oral Terbinafine Nystatin Antimalarials Chloroquine Phosphate Tab Oral Hydroxychloroquine Sulfate Oral Primaquine Phosphate Oral Pyrimethamine Oral Quinine Sulfate Tab 324mg Oral Antimycobacterial Agents Isoniazid Oral Rifampin Oral Antiviral ­ Herpes Agents

April 2012 Page 4 of 41

Representative Brand Name

Bactrim, Bactrim DS

Utilization Management

Sulfisoxazole Gantrisin

Vibramycin, Vibratab Sumycin

Yodoxin

Neomycin Sulfate, Neo-Fradin

Vermox Pin-X, Antiminth Mintezol

Diflucan Ancobon Sporanox Nizoral Lamisil Mycostatin

Limited to 1 tablet/fill, 2 fills/month. Code1 ­ 100mg approved with the diagnosis of oral thrush.

Aralen Plaquenil Primaquine phosphate Daraprim Qualaquin

Nydrazid Rifadin

Prior Authorization required for Tuberculosis.

San Diego County Drug Formulary

Generic Name

Acyclovir Oral

Representative Brand Name

Utilization Management

Antineoplastic Agents

Zovirax ANTINEOPLASTIC AGENTS Oral agents are covered up to $1500. Prior Authorization required for agents greater than $1500. ENDOCRINE_AND METABOLIC DRUGS

Glucocorticosteroids Cortisone Acetate Oral Dexamethasone Oral Hydrocortisone Tab Oral Prednisolone Prednisolone Sodium Phosphate Powder Prednisolone Sodium Phosphate Oral Prednisone Oral

Cortisone Decadron, Dexone Cortef Prelone Prednisolone Meticorten, Deltasone, Liquid Pred

Mineralocorticoids Fludrocortisone Acetate Oral

Florinef DIABETIC AGENTS Limited to vials only. Novolog Limited to 2 vials/month Novolog Mix Levemir Lantus (vials only) Humalog Humalog Mix 75/25 Humulin R, Novolin R Humulin R Humulin N, Novolin N Humulin 70/30 Novolin 70/30 Humulin 50/50 Humulin L, Novolin L Limited to 2 vials/month Limited to 2 vials/month Limited to 2 vials/month Limited to 2 vials/month Limited to 2 vials/month Limited to 2 vials/month Limited to 4 vials/month Limited to 4 vials/month

Human Insulin sulin Aspart Inj 100 U/mL Insulin Aspart Prot & Aspart Inj 100 U/mL Insulin Detemir Inj U/mL Insulin Glargine Inj 100 U/mL Insulin Lispro Inj 100 U/mL Insulin Lispro Prot & Lispro Inj 100 U/mL (75-25) Insulin Regular Inj 100 U/mL Insulin Regular Inj 500 U/mL Insulin Isophane Inj 100 U/mL Insulin Regular & Isophane Inj 100 U/mL Insulin Regular & Isophane Inj 100 U/mL (50) Insulin Zinc Inj 100 U/mL Sulfonylureas Glimepiride Oral Glipizide Tab Oral Glyburide Oral Glyburide Micronized

April 2012

Amaryl Glucotrol Diabeta, Micronase Glynase

Limited to 1/tablet/day for 1mg & 2mg and 2 tablets/day for 4mg Limited to 120/30 days Limited to 120/30 days

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San Diego County Drug Formulary

Generic Name

Biguanides­Metformin Metformin HCL Oral Other Antidiabetics Glucagon Kit Injection Glucose Chew Tab Oral Thiazolidinediones Pioglitazone Oral Actos Contingent Therapy: Second-line agent to be used in combination with an oral diabetes agent or insulin. Limited to #1/day

Representative Brand Name

Utilization Management

Glucophage Glucagon Kit BD ­ Glucose Chw

Limited to 2500 mg/day

Thyroid Hormones Levothyroxine Sodium Oral Liothyronine Sodium Oral Antithyroid Agents Methimazole Oral Propylthiouracil Oral Vasopressin Cabergoline Oral Desmopressin Acetate Oral, Nasal Spray Synthroid, LThyroxine, Levothroid, Levoxyl, Euthyrox Cytomel Available as "Do Not Substitute"

Tapazole Propylthiouracil (PTU)

Dostinex DDAVP CARDIOVASCULAR AGENTS

Anti-Arrhythmia Disopyramide Phosphate Oral Dofetilide Oral Flecainide Acetate Oral Mexiletine HCL Moricizine HCL Oral Procainamide HCL Oral Propafenone HCL Oral Quinidine Gluconate CR Oral Quinidine Sulfate Tab Oral ACE Inhibitors Benazepril HCL Oral Captopril Oral Enalapril Oral Lisinopril Oral Adrenolytics-Central

Norpace CR Tikosyn Tambocor Mexiletine Ethmozine Pronestyl Rythmol Quinidine Quinidex Lotensin Capoten Vasotec Prinivil, Zestril Avoid in elderly enrollees

April 2012

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San Diego County Drug Formulary

Generic Name

Clonidine HCL Oral Methyldopa Oral

Representative Brand Name

Catapres Aldomet

Utilization Management

Alpha-Blockers Doxazosin Mesylate Oral Prazosin HCL Oral Terazosin Oral Angiotensin II Inhibitors Olmesartan Tabs Losartan Oral

Cardura Minipress Hytrin

Benicar Cozaar Code 1 Restriction: For enrollee failing therapy with or intolerant to ACE Inhibitors.

Angiotensin II Inhibitor Combinations Losartan-HCTZ Oral Hyzaar Code 1 Restriction: For enrollee failing therapy with or intolerant to ACE Inhibitors. Limited to 1/day

Anti-Anginals, Other Dipyridamole Oral

Persantine Enrollees with asthma or COPD at any level of severity should not receive non-selective beta blockers. Inderal, Inderal LA Betapace, Betapace AF Beta-Blockers may worsen airway diseases. Use caution when using these medications in asthma/COPD enrollees. Tenormin Toprol XL Lopressor Enrollees with asthma or COPD at any level of severity should not receive non-selective beta blockers. Code 1 Restriction: For Heart Failure, MI or Diabetes. Limited to 2 tablets/day Code 1 Restriction: For Heart Failure. Limited to 1 tablet/day

Beta-Blockers Non-Selective Propranolol HCL Oral Sotalol HCl Oral

BetaBlockers Cardio-Selective Atenolol Oral Metoprolol Succinate SR Oral Metoprolol Tartrate Oral

Alpha-Beta Blockers Carvedilol Tab Oral Labetalol HCL Oral Calcium Blockers Amlodipine Besylate Oral Diltiazem HCL CR Oral

April 2012

Coreg Trandate, Normodyne

Norvasc Cardizem SR, Diltiazem ER

Limited to 1 tablet/day

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San Diego County Drug Formulary

Generic Name

Diltiazem HCL Oral Diltiazem HCL SR/24hr Oral Nimodipine Cap Oral Verapamil HCL Tab Oral Digitalis Digoxin Oral Lanoxin

Representative Brand Name

Cardizem Dilacor XR Nimotop Calan, Isoptin

Utilization Management

Nitrates Isosorbide Dinitrate Oral Isosorbide Dinitrate SL Oral Isosorbide Mononitrate Oral Nitroglycerin Buccal Oral Nitroglycerin SL Tab & Aer Oral Nitroglycerin Intravenous Soln Nitroglycerin CR Oral Nitroglycerin Oint 2% Transdermal Nitroglycerin TD Transdermal Isordil, Sorbitrate Isosorbide Dinitrate Oral Tabs & Chew Tabs Isordil Monoket, ISMO Imdur Nitrogard Nitrostat, Nitrotab, Nitroquick Nitroglycerin Nitro-Time, Nitroglyn Nitrobid Nitrol Nitro-Dur, Minitran, Transderm-Nitro, Deponit, Nitrodisc

Carbonic Anhydrase Inhibitors Acetazolamide Oral Acetazolamide Methazolamide Oral Neptazane Loop Diuretics Furosemide Oral Potassium Sparing Diuretics Spironolactone Oral 25mg, 50mg, 100mg Thiazides Chlorthalidone 25mg, 50mg, 100mg tablet Oral Hydrochlorthiazide (HCTZ) Oral Indapamide Oral Metolazone Oral Combination Diuretics Spironolaone & HCTZ Oral

April 2012

Lasix

Aldactone

Hygroton Hydrodiuril, Oretic, Esidrix, Microzide Lozol Zaroxolyn

Limited to 1 tablet per day

Code 1: For Impaired Renal Function or CHF

Aldactazide

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San Diego County Drug Formulary

Generic Name

Triamterene & HCTZ Oral Vasodilators Hydralazine HCL Oral Minoxidil Oral Anaphylaxis Therapy Agents Epinephrine HCl Injection (Anaphylaxis) EpinephrineChlorpheniramine Bile Sequestrants Cholestyramine Powder Can Oral Cholestyramine Powder & Packets Oral

Representative Brand Name

Dyazide, Maxzide

Utilization Management

Apresoline Loniten Epipen, Epipen Jr. Ana-Kit Code 1 for Epipen Jr. : Approve for enrollees <30kg

Questran/Lite

Antihyperlipidemics: Fenamates Gemfibrozil Oral Lopid Fenofibrate Oral Lofibra Available as the following strengths; 54mg tablet, 67mg capsule, 134mg capsule, 160mg tablet, and 200 mg capsule.

Antihyperlipidemics: HMG-CoA Reduase Inhibitor Lipitor Atorvastatin Oral 40mg, 80mg Lovastatin Oral Simvastatin Oral Pravastatin Oral Mevacor Zocor Pravachol

Contingent Therapy: For enrollee failing therapy with or intolerant to Simvastatin. 120 day look back Limited to 1 tablet/day

Nicotinic Acid Derivatives Niacin Niacin Tab CR Vitamin B-3 Niaspan Contingent Therapy: For enrollee failing therapy with or intolerant to niacin. Limited to 1 tablet/day

RESPIRATORY AGENTS Antihistamines-Alkylamines

April 2012

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San Diego County Drug Formulary

Generic Name

Cyproheptadine HCL Oral Diphenhydramine HCL capsule, tablet Oral Promethazine HCL Oral Promethazine HCL Suppos Rectal Antihistamines-Non-Sedating Loratadine 10mg Tab Oral (OTC) Nasal Steroids Flunisolide 0.025% Nasal Nasalide Code 1 Restriction: For diagnosis of nasal polyps, chronic sinusitis, or asthma. Limited to 1 unit/month Code 1 Restriction: For diagnosis of nasal polyps, chronic sinusitis, or asthma. Limited to 1 unit/month

Representative Brand Name

Periactin Benadryl, Diphedryl Phenergan, Phenergan Forte Phenergan

Utilization Management

Claritin

Limited to 1 tablet/day

Fluticasone Propionate Nasal

Flonase

Expectorants Organidin NR, Diabetic Tus, Robitussin Cold/Cough, Naldecon Sr

Guaifenesin Oral

Miscellaneous Respiratory Sodium Chloride Soln Nebu 0.9% Decongestant or Decongestant Combinations Phenylephrine-GG Oral Promethazine & Phenylephrine Syrup 6.255mg/5mL Oral Pseudoephedrine HCL Oral Pseudoephedrine w/DM-GG Cap 30-10-200mg Oral Pseudoephedrine-GG/CR Oral Triprolidine & Pseudoephedrine Oral

Broncho Saline

Rescon-GG Phenergan VC Sudafed Robitussin Cod/Cgh, Novahistine-DMX Humibid, Guaifed, Robitussin PE, Guaifed-PD Actifed

Antitussive-Antihistamine Narcotic

April 2012

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San Diego County Drug Formulary

Generic Name Representative Brand Name

Tussi-Organi, Robitussin A-C Phenergan w/Codeine, etc.

Utilization Management

Codine-GG Oral Narcotic (codeine cough syr) Antitussive Non-Narcotic Chlorpheniramine-DM Syrup Oral Dextromethorphan-GG Liquid 10-100mg/5mL Oral Phenylephrine-Chlorphen-DM Oral Phenylephrine-Pyrilamine-DM Oral Promethazine-DM Syrup Oral Pseudoephed-Bromphen-DM Oral PseudoephedCarbinoxamine-DM Liquid Oral Chlorpheniramine & Pseudoephedrine Oral Dexbrompheniramine & Pseudoephedrine Oral Phenylephrine w/DM-GG Oral Anticholinergics Ipratropium Bromide Ipratropium Bromide Inhalation Ipratropium Bromide Inhalation Soln Tiotropium Mast Cell Stabilizers Cromolyn Sodium Solution Beta Adrenergics Albuterol Sulfate Aero Inhalation Albuterol Sulfate Soln Nebu Inhalation Budesonide/Formoterol Fluticasone/Salmeterol Fluticasone/Salmeterol Ipratropium/Albuterol Levalbuterol

Limited to 240 mL/fill, maximum of 3 fills/month.

Scot-Tussin DM SF Robitussin DM, Diabetic Tus DM Cerose-DM Codimal DM, Codituss DM Phenergan DM Dimetane-DX, Bromatane DX Rondec DM Sudafed Plus, ChlorTrimeton, Histex, Deconamine Sudex Tussex

Atrovent HFA Spiriva Handihaler Step Therapy: Trial and failure of Atrovent.

Intal

Limited to 30/month for aerosol solution

Ventolin HFA, ProAir HFA Ventolin, Proventil Symbicort Advair Diskus Advair HFA CombiVent Xopenex HFA

Limited to Proair HFA only and 2 canisters/month

Step therapy: first use1st Line Steroid Inhalers Step therapy: first use 1st Line Steroid Inhalers Step therapy: first use 1st Line Steroid Inhalers

April 2012

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San Diego County Drug Formulary

Generic Name Representative Brand Name

Maxair, Maxair Autohaler Serevent Diskus Brethine Limited to 1 unit/month Contingent Therapy: Use with Albuterol or Lavalbuterol and Steroid.

Utilization Management

Pirbuterol Inhalation Salmeterol Xinafoate Powder Disks Inhalation Terbutaline Sulfate Oral Adrenergic Combinations Albuterol-Ipratropium Aerosol Inhalation Xanthines (Theophylline) Aminophylline Oral Theophylline Cap CR Oral Theophylline Tab Oral Theophylline Tab CR Oral

Combivent

Code 1 Restriction: For diagnosis of COPD All generic Xanthine products are covered.

Aminophyline Slo-Bid, Slo-Phyllin, Theo-24 Slo-Phyllin, Theolair, Quibron-T Theo-Dur, TheolairSR, Uniphyl, Uni-Dur

Steroid Inhalants Beclomethasone Dipropionate Inhal Aero Budesonide Fluticasone Leukotriene Receptor Inhibitors Montelukast Sodium Oral

QVAR Pulmicort Flexhaler Flovent Diskus

Zafirlukast Oral

Zileuton Oral

Contingent Therapy: For enrollee on current therapy with an inhaled steroid. Limited to 30 tablets/month Contingent Therapy: For enrollee on Accolate current therapy with an inhaled steroid. Limited to 60 tablets/month Contingent Therapy: For enrollee on Zyflo current therapy with an inhaled steroid. Limited to 30 tablets/month GASTROINTESTINAL AGENTS Singulair Lomotil, Lonox Imodium, Imodium A-D Limited to 50 tabs or 500ml's/ month

Antiperistaltic Agents Diphenoxylate w/ Atropine Oral Loperamide HCL Oral Belladonna Alkaloids

April 2012

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San Diego County Drug Formulary

Generic Name Representative Brand Name

Levsinex, CystospazM, Levsin, Levsin SL, Anaspaz, Levbid, Colytrol

Utilization Management

Hyoscyamine Sulfate Oral

Antispasmodics Dicyclomine HCL Oral Anticholinergic Combinations Phenobarbital & Belladonna Alkaloids Oral

Bentyl

Donnatal, Donnatal Extentab

H-2 Antagonists For Ulcer: Over 90% of gastric or duodenal ulcers are caused by H. pylori. If test results are positive, enrollees should be treated with antimicrobials. Once H. pylori has been successfully eradicated, continued maintenance therapy with Anti-Ulcer agents is no longer necessary. Pepcid Famotidine Tablet 10mg, 20mg, 40mg Oral Ranitidine HCL Tabs 75mg, Zantac Rx 150mg, 300mg Ranitidine HCL Caps 150mg, Zantac OTC 300mg Oral Anti-Ulcers: Imidazoles (Proton-Pump Inhibitors) For Ulcer: Over 90% of gastric or duodenal ulcers are caused by H. pylori. If test results are positive, enrollees should be treated with antimicrobials. Once H. pylori has been successfully eradicated, continued maintenance therapy with Anti-Ulcer agents is no longer necessary. Omeprazole Magnesium Prilosec (OTC) Limited to 2 tablets/day Tablet Oral Pantoprazole Protonix Miscellaneous Anti-Ulcer Sucralfate Oral

Carafate

Ulcer Anti-Infective W/ Proton Pump Inhibitors Amoxicillin Cap-Clarithro TabPrevPac Lansopraz Cap CR Therapy Pack Oral

Limited 1 fill/6 months

April 2012

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San Diego County Drug Formulary

Generic Name

Anti-Emetics-Anticholinergic Meclizine Oral Promethazine HCL Oral Prochlorperazine Suppos Rectal Prochlorperazine Maleate Oral Prochlorperazine Maleate Cap CR & Tab Oral Prochlorperazine Edisylate Oral Metoclopramide HCL Oral Gallstone Solubilizing Agents Ursodiol Capsule 300mg Oral GI Stimulants Metoclopramide HCL Oral Intestinal Acidifiers Lactulose Syr 10gm/15mL Oral Misc. GI Mesalamine Enema Rectal, Suppos Rectal, Oral Sulfasalazine Tab & EC Oral Cephulac, Enulose Calulose, Cholac, Generlac Code 1 for Encephalopathy

Representative Brand Name

Utilization Management

Antivert Phenergan, Phenergan Forte Compazine Compazine

Compazine Reglan

Actigall

Reglan

Asacol, Canasa, Rowasa, Pentasa Azulfidine

Limited to 2520mL/6 months for enema

ESTROGENS Estrogen Estrogen Vaginal Cream Estradiol Vaginal Cream Estradiol Estropipate Progestins Medroxyprogesterone Acetate Estrace Estrogel Femtrace, Estrace Orth-est/Ogen

Provera

GENITOURINARY PRODUCTS Calcium Acetate (Phosphate Binder) Calcium Acetate (Phosphate PhosLo, Biphos Binder) Cap 667mg Oral Urinary Anti-Infectives

April 2012

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San Diego County Drug Formulary

Generic Name

Nitrofurantoin Susp Oral Nitrofurantoin Macrocrystalline Oral Nitrofurantoin Monohydrate Macrocrystalline Oral Urinary Antispasmodics Bethanechol Chloride Oral Hyoscyamine Tab 0.15 mg Oral Oxybutynin Chloride Tab & Syr Oral Vaginal Anti-Infectives Clindamycin Phosphate CR Vaginal Metronidazole Gel 0.75% Vaginal Vaginal Antifungals Nystatin Tab 100000 U Vaginal Clotrimazole Vaginal Clotrimazole Clotrimazole Tab Cream 1%, Kit Vaginal Miconazole Nitrate Vagina Miconazole Nitrate Vagina Kit, Miconazole Nitrate Cream, Suppos VaginalTerconazole Vaginal Urinary Analgesics Phenazopyridine HCL Tab Oral, Kit Misc. Genitourinary Agents Pentosan Polysulfate Sodium Oral Potassium & Sodium Citrates w/Citric Acid Oral Genitourinary Irrigants Sodium Chloride Irrigation Soln Benzodiazepines Clonazepam Tab Oral

April 2012

Representative Brand Name

Furadantin Macrodantin Macrobid

Utilization Management

Urecholine Cystospaz Ditropan

Cleocin Vaginal Metrogel Vag Gel, Vandazole

Nystatin Vaginal Tab

Gyne-Lotrimin

Monistat

Azo-gesic, Pyridium, Urogesic, Uro Femme Kit

Elmiron Cytra K, Polycitra, Tricitrates Sodium Chloride Irrigation Soln PSYCHOTHERAPEUTIC AGENTS Klonopin Code 1 Restriction: For seizure

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San Diego County Drug Formulary

Generic Name Representative Brand Name

Valium

Utilization Management

Code 1 Restriction: For muscle spasms or seizure. Limited to 60/month.

Diazepam Tab Oral

Miscellaneous Antihistamine Agents Hydroxyzine HCL Oral Atarax Hydroxyzine Pamoate Oral Vistaril Code 1 Restriction: For diagnosis of neuropathy or as an adjunct to pain management. Elavil Ascendin Anafranil Norpramin Sinequan Tofranil Pamelor Vivactil Surmontil

Tricyclic Agents Amitriptyline HCL Oral Amoxapine Oral Clomipramine HCL Oral Desipramine HCL Oral Doxepin HCL Oral Imipramine HCL Oral Nortriptyline HCL Oral Protriptyline HCL Oral Trimipramine Maleate Oral Phenothiazines Prochlorperazine Suppos Rectal Prochlorperazine Maleate Oral Prochlorperazine Maleate Cap CR & Tab Oral Prochlorperazine Edisylate Oral Barbiturate Hypnotics Phenobarbital Oral

Compazine Compazine Compazine

Phenobarbital

Code 1 Restriction: For diagnosis of seizures

ANALGESICS AND ANESTHETICS Salicylates Aspirin Oral Bayer ASA, Empirin, Ascriptin, ASA Low Dose, Ecotrin, Genacote Aspirin Supp Salflex, Disalcid, Amigesic Does not include single source branded products Does not include single source branded products

Aspirin Suppos Rectal Salsalate Oral Salicylate Combinations

April 2012

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San Diego County Drug Formulary

Generic Name

Aspirin Buffered (mg Carbonate-Al Glycinate) 325mg Tab Oral Aspirin Buffered 325mg Tab Oral Analgesics Other Acetaminophen Oral Acetaminophen Suppos Rectal Analgesic-Sedatives Butalbital-Acetaminophen 50-650mg Cap, 50-325mg & 50-650mg Tab Orall Acetaminophen-CaffeineButalbital 325-40-50mg Tab & Cap Oral Aspirin-Caffeine-Butalbital 325-40-50mg Tab & Cap Oral Narcotic Agonist Methadone HCL Oral Morphine Sulfate Tab Oral Morphine Sulfate Tab CR Oral Tramadol HCL Tab Narcotic Combinations Oxycodone w/ Acetaminophen 5-325mg, 7.5-325mg, & 10-325mg Tab Oral Codeine Combinations Acetaminophen w/ Codeine 300-15mg, 300-30mg, 30060mg, 650-30 mg Tab Oral Acetaminophen w/ Codeine Elixir, Soln, Susp Oral Aspirin w/ Codeine 32515mg, 325-30mg, & 325-60mg Tab Oral Tylenol/Codeine #2, #3, #4, Vopac Tylenol/Codeine Empirin/Codeine #2, #3, #4 Dolophine, Methadose MSIR MS Contin, Oramorph SR Ultram

Representative Brand Name

Aspirin Buffered, Gennin ­FC Buffaprin, Buffered ASA

Utilization Management

Tylenol Feverall, Acephen

Phrenilin, Sedapap Esgic, Esgic Plus, Fioricet Fiorinal, Fiortal, Butalbital CPD, Fortabs

Limited to 12 tablets/day Limited to 4 tablets/day Limited to 8 tablets/day Maximum acetaminophen daily dose = 4gm/day

Roxicet

Maximum acetaminophen daily dose = 4gm/day Limited to 60 tablets/month Limited to 500mL/month Limited to 60 tablets/month

April 2012

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San Diego County Drug Formulary

Generic Name Representative Brand Name Utilization Management

Maximum acetaminophen daily dose = 4gm/day Lortab 5mg, Norco 10-325mg, VicodinError! Bookmark not defined., Vicodin ES Lortab Elixer Limited to 500mL/month

Hydrocodone Combinations Acetaminophen w/ Hydrocodone 5-500mg, 7.5750mg, 10-325mg Tab Oral Acetaminophen w/ Hydrocodone 7.5500mg/15mL Soln Oral Opioid Combinations Butalbital-AcetaminophenCaff w/ Cod 50-325-40-30mg Cap Oral Butalbital-Aspirin-Caff w/ Codeine 50-325-40-30mg Cap Oral Phrenilin w/ Codeine

Maximum acetaminophen daily dose = 4gm/day

Fiorinal w/ Codeine

Limited to 60 capsules/month

Nonsteroidal Anti-Inflammatory Agents Diclofenac Potassium Oral Cataflam Diclofenac Sodium EC Oral Voltaren Etodolac Cap & Tab Oral Fenoprofen Calcium Oral Ibuprofen Oral Indomethacin Oral, Suppos Rectal Meloxicam Tab Oral Naproxen Oral Naproxen DR Oral Oxaprozin Oral Piroxicam Oral Sulindac Oral Lodine Nalfon Motrin Indocin Mobic Naprosyn EC-Naprosyn Daypro Feldene Clinoril

Limited to 4 tablets/day Limited to 4 tablets/day Limited to 3 capsules/day for 200mg & 300mg capsules; 3 tablets/day for 400mg tablet and 2 tablets/day for 500mg tablet Limited to 16 tablets/day Limited to FDA approved limit

Limited to 1 tablet/day Code 1: Failure of naproxen or GI disease Limited to 2 tablets/day Limited to 2 capsules/day for 10mg and 1 capsule/day for 20mg Limited to 2 tablets/day

ANTI-RHEUMATIC AND ANTI-PSORIATIC AGENTS Folic Acid Antagonist Methotrexate Oral 2.5mg MIGRAINE AGENTS Migraine Products

April 2012

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San Diego County Drug Formulary

Generic Name

APAP-IsometheptaneDichloral Cap 325-65-100mg Oral Butalbital-Acetaminophen 50-650mg Cap, 50-325mg & 50-650mg Tab Orall Acetaminophen-CaffeineButalbital 325-40-50mg Tab & Cap Oral Aspirin-Caffeine-Butalbital 325-40-50mg Tab & Cap Oral Serotonin Agonist Sumatriptan Spray Nasal Imitrex NS Contingent Therapy: For enrollee failing therapy with or intolerant to Cafergot, Midrin, Fioricet, or Fiorinal. Limited to 6 units/month Contingent Therapy: For enrollee failing therapy with or intolerant to Cafergot, Midrin, Fioricet, or Fiorinal. Limited to 4 packages (8 injections)/month Contingent therapy: For enrollee failing therapy with or intolerant to Cafergot, Midrin, Fioricet, or Fiorinal. Limited to 18 tablets/month for 25mg & 50mg and 9 tablets/month for 100mg

Representative Brand Name

Utilization Management

Midrin

Phrenilin, Sedapap Esgic, Esgic Plus, Fioricet Fiorinal, Fiortal, Butalbital CPD, Fortabs

Sumatriptan Succinate Injection

Imitrex

Sumatriptan Succinate Tab Oral

Imitrex

Ergot Combinations Ergotamine w/ Caffeine 1100mg Tab Oral

Wigraine, Ercaf GOUT AGENTS

Gout Allopurinol Tab Oral Uricosurics Probenecid Oral Probenecid Tab 500 mg Sulfinpyrazone Oral Combination Gout Drugs Colchicine w/Probenecid Oral Coichicine w/Probenecid Tab 0.5-500 mg Oral

Zyloprim

Benemid Anturane

Proben-C NEUROMUSCULAR AGENTS

April 2012

Page 19 of 41

San Diego County Drug Formulary

Generic Name

Hydantoins Phenytoin Chew Tab 50 mg Oral Valproic Acid Divalproex Sodium EC Cap Oral Divalproex Sodium EC Tab Oral Divalproex Sodium SR 24 Hr Tab Oral Valproic Acid Cap 250mg Oral Miscellaneous Anticonvulsants Carbamazepine Tab SR Oral Carbamazepine Chew Tab Oral Carbamazepine Susp Oral Gabapentin 400mg Cap, 400mg, 600mg, & 800mg Tablet Oral Primidone Tablet Oral Zonisamide Capsule Oral Antiparkinsonian Agents Tegretol XR Tegretol Tegretol Neurontin Mysoline Zonegran Code 1 Restriction: Limited to diagnosis of seizure Generic agents in this class are covered (i.e. carbidopa, levodopa, benztropine, etc.) Limited to 6 capsules/day for 400mg capsules, 6 tablets/day for 400mg tablets, 5 tablets/day for 600mg tablets, and 4 tablets/day for 800mg tablets Limited to enrollee intolerant to or failing therapy with carbamazepine tablets

Representative Brand Name

Utilization Management

Dilantin

Depakote Sprinkle Depakote EC Depakote ER Depakene

Central Muscle Relaxants Baclofen Tab Oral Cyclobenzaprine HCL 10mg Tab Oral Methocarbamol Oral Antimyasthenic Agents Neostigmine Bromide Tab 15mg Oral Pyridostigmine Bromide Oral

Lioresal, Lioresal DS Flexeril Robaxin

Limited to 4 tablets/day Limited to 3 tablets/day Limited to 6 tablets/day

Prostigmin Mestinon NUTRITIONAL PRODUCTS

Vitamin B-3 Niacin Oral Vitamin B-6

Niacin

April 2012

Page 20 of 41

San Diego County Drug Formulary

Generic Name

HCL Cap, HLC Cap CR, Tab Oral Vitamin K Phytonadione Tab 5mg Oral Potassium Potassium Chloride Cap CR 8mEq & 10mEq Oral Potassium Chloride Tab CR 8mEq, 10mEq, 15mEq & 20mEq Oral Potassium Chloride Oral Liq 10% & 20% Oral Potassium & Sodium Phosphates for Soln 278-164250mg/75mL, Powder 278164-250mg & 280-160-250mg Oral Potassium Removing Resin Sodium Polystyrene Sulfonate Susp 15gm/60mL Oral/Rectal Sodium Polystyrene Sulfonate Powder Oral Sodium Sodium Chloride Injection

Representative Brand Name

Vitamin B-6

Utilization Management

Code 1 Restriction: For use with INH only

Mephyton

Micro-K Slow-K, Klor-Con, KTabs, K-Dur, Klortrix, Kaon-CL Klorvess, Kaochlor, Kay Ciel KCL, KaonCL SF

Neutraphos

SPS Kayexalate

Normal Saline (IV) HEMATOLOGICAL AGENTS

Folic Acid Folic Acid Oral Iron Ferrous Fumarate Oral Ferrous Gluconate Oral Ferrous Sulfate Oral Coumarin Anticoagulants Warfarin Sodium Tab Oral

Folic Acid

Feostat Ferrous Gluconate Iron, Slow-Fe, Feosol, Fer-In-Sol, Feratab

Coumadin

Platelet Aggregation Inhibitors Dipyridamole Tab Oral Persantine Heparins And Heparinoid-Like Agents Enoxaparin Sodium Injection Lovenox Fondaparinux Sodium 2.5 Arixtra mg/0.5mL Injection

April 2012

Limited to 14 units/6 months Limited to 7 units/7 days

Page 21 of 41

San Diego County Drug Formulary

Generic Name Representative Brand Name Utilization Management

Thienopyridine Derivatives Clopidogrel Bisulfate Tab Oral Plavix Code 1 Restriction: For diagnosis of TIA, stroke, stent, or enrollee failing therapy or intolerant to Aspirin. TOPICAL PRODUCTS Ophthalmic Antibiotics Ciprofloxacin HCL Soln 0.3% Ophthalmic Erythromycin Oint 5mg/gm Ophthalmic Gentamicin Sulfate Soln & Oint 0.3% Ophthalmic Ofloxacin Ophth Soln 0.3% Ophthalmic Sodium Sulfacetamide 10% Ophthalmic Ophthalmic Beta-Blockers Betaxolol HCL Soln -.5% & 1% and Susp 0.25% Ophthalmic Carteolol HCL Soln 1% Ophthalmic Metipranolol HCL Soln 0.3% Ophthalmic Levobunolol HCL Soln 0.25% & 0.5% Ophthalimc Timolol Maleate Soln 0.25% & 0.5% Ophthalmic Timolol Maleate Soln (Gel Forming) 0.25% & 0.5% ophthalmic Ciloxan Llotycin Garamycin, Genoptic Ocuflox Bleph-10, Sod Sulamyd Betoptic, Betoptic-S Ocupress Optipranolol Betagan Timoptic Timoptic XE

Ophthalmic Carbonic Anhydrase Inhibitors Brinzolamide Susp 1% Azopt Ophthalmic Ophthalmic Carbonic Anhydrase Inhibitors ­ Beta-Blocker Combination Dorzolamide-Timolol Soln 2Cosopt 0.5% Ophthalmic Ophthalmic Steroids Dexamethasone Susp 0.1% Ophthalmic Dexamethasone Sodium Phosphate Soln Ophthalmic Fluorometholone Susp Ophthalmic Maxidex Decadron, Dexa-sol FML Liquifilm, FML Forte

April 2012

Page 22 of 41

San Diego County Drug Formulary

Generic Name

Fluorometholone Oint 0.1% Ophthalmic Fluorometholone Acetate Susp 0.1% Ophthalmic Prednisolone Acetate Susp 1% Ophthalmic Prednisolone Sodium Phosphate Soln 1% Ophthalmic Ophthalmic Steroid Combinations Loteprednol etabonateTobramycin Susp 0.5-0.3% Ophthalmic Sulfacetamide SodiumPrednisolone Susp10-0.2% Ophthalmic Sulfacetamide SodiumPrednisolone Oint 10-0.2% Ophthalmic Tobramycin-Dexamethasone Susp & Oint 0.3-0.1% Ophthalmic Neomycin-PolymyxinDexamethasone Susp & Oint 0.1% Ophthalmic Neomycin-Polymyxin-HC Susp Ophthalmic Bacitracin-PolymyxinNeomycin-HC Ophthalmic Oint 1% Zylet

Representative Brand Name

FML S.O.P. Flarex, Eflone Econopred Plus, Omnipred Pred Forte Inflamase Forte

Utilization Management

Blephamide

Blephamide S.O.P.

Tobradex

Maxitrol, Dexacidin Cortisporin Cortisporin, AKSpore HC, Triple Antibiotic

Ophthalmics- Alpha 2 Adrenergic Agonists Brimonidine Soln 0.1% Ophthalmic Alphagan/ Alphagan-P

Prostaglandin Agonists Ophthalmic Latanoprost Soln 0.005% Xalatan Ophthalmic Cycloplegics Atropine Sulfate Soln 1% Ophthalmic

Iso Atropine

April 2012

Page 23 of 41

San Diego County Drug Formulary

Generic Name

Atropine Sulfate Oint 1% Ophthalmic Cyclopentolate HCL Soln 0.5%, 1%, 2% Ophthalmic Homatropine HBr Soln 2%, 5% Ophthalmic Scopolamine HBr Soln 0.25% Ophthalmic Tropicamide Soln 0.5%, 1% Ophthalmic

Representative Brand Name

Ocu-tropine Cyclogyl Iso Homatropine Iso Hyoscine Mydriacyl, Infi-Cyle

Utilization Management

Cycloplegics Mydriatic Combinations Cyclopentolate w/ Cyclomydri Phenylephrine Soln 0.2-1% Ophthalmic Scopolamine w/ Murocoll-2 Phenylephrine Soln 0.3-10% Ophthalmic Ophthalmic Decongestant Combinations Naphazoline w/ Antazoline Vasocon-A Soln 0.05-0.5% Ophthalmic Naphazoline w/ Pheniramine Naphcon-A Soln 0.025-0.3% Ophthalmic Ophthalmics ­ Direct Acting Pilocarpine HCL Soln 0.5%, 1%, 2%, 4%, 6% Ophthalmic Pilocarpine HCL Gel 4% Ophthalmic Adrenergic Mydriatics Dipivefrin Soln 0.1% Ophthalmic Propine-C Iso Carpine, Pilocar Pilopine HS

Ophthalmic Anti-Allergic Olopatadine HCL Soln Ophthalmic Patanol Contingent Therapy: For enrollee failing therapy with or intolerant to Naphcon-A or Vasacon-A

Ophthalmic Non-Steroidal Anti-Inflammatory Agents Diclofenac Sodium Soln 0.1% Voltaren Ophthalmic Flurbiprofen Soln 0.03% Ocufen Ophthalmic Ketorolac Tromethamine Soln Acular LS, Acular 0.4%, 0.5% Ophthalmic

Code 1 Restriction: For Ophthalmologist Limited to #2.5mL/30 days

Code 1 Restriction: For Ophthalmologist Limited to #2.5mL/30 days

April 2012

Page 24 of 41

San Diego County Drug Formulary

Generic Name

Nepafenac Susp 0.1% Ophthalmic Bromfenac Sodium Soln 0.09% Ophthalmic Otic Steroids Hydrocortisone W/ Acetic Acid 1-2% Soln Otic Otic Miscellaneous Acetic Acid 2% Soln Otic Carbamide Peroxide 6.5% Soln Otic

Representative Brand Name

Nevanac Xibrom

Utilization Management

Code 1 Restriction: For Ophthalmologist Limited to #3mL/30 days Code 1 Restriction: For Ophthalmologist Limited to #2.5mL/30 days

Vosol-HC

Vosol Debrox

Otic Steroid Antibiotic Combinations Benzocaine-Antipyrine 1.4Auralgan 5.4% Soln Otic Neomycin-Polymyxin-HC Susp Cortisporin Otic 3.5mg/mL-10000 U/mL-1% Otic Neomycin-Polymyxin-HC Soln 1% Otic Cortisporin Otic Ciprofloxacin-Hydrocortisone Otic Susp 0.2-1% Mouth & Throat (Local) Lidocaine HCL in Viscous Soln 2% (Mouth-Throat) Nystatin Susp 100000 U/mL (Mouth/Throat) Pilocarpine HCL 5mg Tab Oral Triamcinolone Acetonide in Orabase 0.1% (Mouth) Antibiotics ­ Topical Mupirocin 2% Oint External Antifungals ­ Topical Crotamiton External Nystatin External Tolnaftate Power External Topical Antifungals Code 1 Restriction: Must be written by ENT or Emergency Department Physician.

Cipro HC Otic

Lidocaine Viscous Mycostatin, BioStatin Salagen Kenalog DERMATOLOGICAL PRODUCTS Bactroban Limited to 60gm/month

Eurax Mycostatin, Nystop, Pedi-Dri Tinactin

April 2012

Page 25 of 41

San Diego County Drug Formulary

Generic Name Representative Brand Name

Desenex, Lotrimin, Lotrimin AF Nizoral Nizoral Micatin, Monistat Limited to 120mL/month

Utilization Management

Clotrimazole External Ketoconazole Cream 2% External Ketoconazole Shampoo 2% External Miconazole Nitrate Cream 2% External

Antifungals ­ Topical Combinations Clotrimazole w/ Lotrisone Betamethasone Cream, External Nystatin-Triamcinolone Mycolog II Cream & Oint External Burn Products Silver Sulfadiazine Cream 1% External Tar Products Allantoin-Coal Tar and Combinations Shampoo External Coal Tar External Corticosteroids ­ Topical Betamethasone Dipropionate Cream External Fluocinolone Acetonide Cream, Soln External Fluocinonide Cream, Emusified Cream, Gel, Soln, Oint 0.05% External

Silvadene

Tegrin Medicated Shampoo 7% Fototar, G-Tar, Tegrin, Medotar

Diprosone, Maxivate Synalar, Fluorosyn, Lidex, Lidex-E Corticreme, Genasone, Dermacort, Cortaid, Hytone, Dermatex HC, Nutracort, Hydrocort, Cortaid, Nercainal, Lanacort HC, AC/Aloe, Anusol HC, Hydrocort/ AN, Cotacort Aristocort A, Kenalog

Limited to 90gm/mo for cream, & ointment, and 120ml/mo for lotion. Limited to 120 gm/mo for cream, & ointment, and 120ml/mo for solution. Limited to 120 gm/mo for cream, gel & ointment, and 120ml/mo for solution.

Hydrocortisone External

Limited to 120gm/mo for cream & ointment, and 120mL/mo for lotion.

Triamcinolone Acetonide Cream, Ointment External

Limited to 80gm/mo for 0.025%, 0.1% and 45gm/mo for 0.5%

April 2012

Page 26 of 41

San Diego County Drug Formulary

Generic Name Representative Brand Name Utilization Management

Anorectal Products Hydrocortisone w/ Pramoxine Foam 1-1% Rectal Phenylephrine in Hard Fat Suppos 0.25% Rectal Pramoxine Hcl Oint 1% Rectal Pramoxine-HC External Pramoxine w/ Zinc Oxide in Mineral Oil Oint 1-12.5% Rectal Starch Suppositories 51% Rectal Enzymes Papain-Urea Ointment External Papain & Urea-Chlorophyllin Ointment External Trypsin w/ Castor Oil & Peruvian Balsam Ointment External Keratolytics Podofilox Soln & Gel 0.5% External Local Anesthetics ­ Topical Lidocaine HCL Gel 2% External Lidocaine HCL Viscous Soln 2% Mouth/Throat Proctofoam-HC Rectacaine Tucks Analpram-HC, Epifoam, Pramosone Tucks, Anusol Tucks

Accuzyme, Ethezyme Panafil Xenaderm

Condylox

Xylocaine Xylocaine

Scabicides & Pediculocides Crotamiton Cream & Lotion 10% External Malathion 0.5% Lotion External Permethrin Cream Rinse 1% External Permethrin Cream 5% External Pyrethrins-Piperonyl Butoxide External Eurax Ovide Nix Cream Rinse Elimite, Acticin Rid, A-200, Pronto

April 2012

Page 27 of 41

San Diego County Drug Formulary

Generic Name

Miscellaneous Topical Calcipotriene Soln External Coal Tar (Crude) Solution External Diagnostic Reagents Acetone Test Glucose Urine Test-(Glucose Oxidase) Glucose Urine Test-(Copper Sulfate)

Representative Brand Name

Utilization Management

Dovonex Coal Tar DIAGNOSTIC PRODUCTS Acetest, Ketostix Diastix, Clinistix Clinitest Ascencia Contour Ascencia Breeze 2 Chemstrips Chemstrips Limited to 50 per 30 days if not on insulin. If on insulin, allow limit 100 per 30 days. Limited to Bayer Ascencia Contour Ascencia Breeze 2 only. Limited to 51/month. Maximum of 3 fills/prescription

Glucose Blood Test Strips Multiple Urine Test Strips Urine Glucose-Ketones Test Strips

Diabetic Supplies Glucose Blood Calibration Soln Glucose Blood Monitoring Kit

Control Solutions Ascencia Contour Ascencia Breeze 2 B-D Insulin Syringes Lancets Lancets Limited to 1 fill per year. Maximum of $60 per fill. Limited to Ascencia Contour and Breeze 2 products. Limited to 100/month. Maximum of 3 fills/prescription Limited to 51/month. Maximum of 3 fills/prescription Limited to 2 fills/year, maximum $25/prescription Prior Authorization Required

Insulin Syringes Lancets Lancets Devices Transplant Medications

April 2012

Page 28 of 41

A

A-200, 43 AC/Aloe, 41 Accolate, 18 Accuzyme, 42 ACE Inhibitors, 9 Acephen, 25 Acetaminophen Oral, 25 Acetaminophen Suppos Rectal, 25 Acetaminophen w/ Codeine 300-15mg, 300-30mg, 30060mg, 650-30 mg Tab Oral, 27 Acetaminophen w/ Codeine Elixir, 27 Acetaminophen w/ Hydrocodone 5-500mg, 7.5-750mg, 10-325mg Tab Oral, 27 Acetaminophen w/ Hydrocodone 7.5-500mg/15mL Soln, 27 Acetaminophen w/ Hydrocodone Cap, Tab Oral, 27 Acetaminophen-Caffeine-Butalbital 325-40-50mg Tab & Cap Oral, 26, 29 Acetazolamide, 12 Acetazolamide Oral, 12 Acetest, 43 Acetic Acid 2% Soln Otic, 38 Acetone Test, 43 Acticin, 43 Actifed, 15 Actigall, 20 Actos, 8 Acular, 38 Acular LS, 38 Acyclovir Oral, 6 Adrenergic Combinations, 17 Adrenergic Mydriatics, 36, 37 Adrenolytics-Central, 9 Advair Diskus, 17 Advair HFA, 17 AK-Spore HC, 36 Albuterol Sulfate Aero Inhalation, 17 Albuterol Sulfate Soln Nebu Inhalatio, 17 Albuterol-Ipratropium Aerosol Inhalation, 18 Aldactazide, 12 Aldactone, 12 Aldomet, 9 Allantoin-Coal Tar and Combinations Shampoo Externa, 40 Allopurinol Tab Oral, 29 Alpha-Beta Blockers, 10 Alpha-Blockers, 9 Alphagan/ Alphagan-P, 36 Amaryl, 7 Amebicides, 5 Amigesic, 25 Aminoglycosides, 5 Aminophyline, 18 Aminophylline Oral, 18 Amitriptyline HCL Oral, 24 Amlodipine Besylate Oral, 10 Amoxapine Oral, 24 Amoxicillin & Potassium Clavulanate Oral, 3

Amoxicillin Cap-Clarithro Tab-Lansopraz Cap CR Therapy Pack Oral, 20 Amoxicillin Oral, 3 Ampicillin, 3 Ampicillin Oral, 3 Anafranil, 24 Ana-Kit, 13 ANALGESICS AND ANESTHETICS, 25 Analgesics Other, 25 Analgesic-Sedatives, 25 Analpram-HC, 42 Anaspaz, 19 Ancobon, 5 Angiotensin II Inhibitor Combinations, 9 Angiotensin II Inhibitors, 9 Anorectal Product, 41 AntfFungals, 5 Anti-Anginals, 10 Anti-Arrhythmia, 8 Antibiotics, 3 Antibiotics ­ Topical, 39 Anticholinergic Combinations, 19 Anticholinergics, 16 Antidiabetics, 8 Anti-Emetics-Anticholinergic, 20 Antifungals ­ Topical, 39 Antifungals ­ Topical Combinations, 40 Antihelmintics, 5 Antihistamines-Alkylamines, 14 Antihistamines-Non-Sedating, 14 Antihyperlipidemics: HMG-CoA Reduase Inhibitor, 13 Antihyperlipidemics: Fenamates, 13 Antimalarials, 5 Antiminth, 5 Antimyasthenic Agents, 31 Antimycobacterial Agents, 6 Antineoplastic Agents, 6 ANTINEOPLASTIC AGENTS, 6 Antiparkinsonian Agents, 31 Antiperistaltic Agents, 18 Antispasmodics, 19 Antithyroid Agents, 8 Antitussive Non-Narcotic Antitussive, 16 Antitussive-Antihistamine Narcotic, 15 Anti-Ulcers: Imidazoles, 20 Antivert, 20 Antiviral ­ Herpes Agents, 6 Anturane, 30 Anusol, 42 Anusol HC, 41 APAP-Isometheptane-Dichloral Cap 325-65-100mg Oral, 29 Apresoline, 13 Aralen, 5 Aristocort A, 41 Arixtra, 33 ASA Low Dose, 25 Asacol, 21 Ascencia Breeze 2, 44 Ascencia Contour, 44 Ascendin, 24 Ascriptin, 25 Page 29 of 41

April 2012

Aspirin Buffered, 25 Aspirin Buffered (mg Carbonate-Al Glycinate) 325mg Tab Oral, 25 Aspirin Buffered 325mg Tab Oral, 25 Aspirin Oral, 25 Aspirin Supp, 25 Aspirin Suppos Rectal, 25 Aspirin w/ Codeine 325-15mg, 325-30mg, & 325-60mg Tab Oral, 27 Aspirin-Caffeine-Butalbital 325-40-50mg Tab & Cap Oral, 26, 29 Atarax, 24 Atenolol Oral, 10 Atorvastatin Oral, 13 Atovaquone, 3 Atropine Sulfate Oint 1% Ophthalmic, 36 Atropine Sulfate Soln 1% Ophthalmic, 36 Atrovent HFA, 17 Augmentin, 3 Augmentin XR, 3 Auralgan, 38 Azithromycin Susp Oral, 4 Azithromycin Tab Oral, 4 Azo-gesic, 23 Azopt, 34 Azulfidine, 21

Bile Sequestrants, 13 Bio-Statin, 39 Biphos, 22 Bleph-10, 33 Blephamide, 35 Blephamide S.O.P., 35 Brethine, 17 Brinzolamide Susp 1% Ophthalmic, 34 Bromatane DX, 16 Bromfenac Sodium Soln 0.09% Ophthalmic, 38 Broncho Saline, 15 Budesonide, 18 Budesonide/Formoterol, 17 Buffaprin, 25 Buffered ASA, 25 Butalbital CPD, 26, 29 Butalbital-Acetaminophen 50-650mg Cap, 50-325mg & 50-650mg Tab Oral, 26, 29 Butalbital-Acetaminophen-Caff w/ Cod 50-325-40-30mg Cap Oral, 27 Butalbital-Aspirin-Caff w/ Codeine 50-325-40-30mg Cap Oral, 27

C

Cabergoline Oral, 8 Calan, 11 Calcipotriene Soln External, 43 Calcium Acetate (Phosphate Binder) Cap 667mg Oral, 22 Calcium Blockers, 10 Calulose, 21 Canasa, 21 Capoten, 9 Captopril Oral, 9 Carafate, 20 Carbamazepine Chew Tab Oral, 30 Carbamazepine Susp Oral, 30 Carbamazepine Tab SR Oral, 30 Carbamide Peroxide 6.5% Soln Otic, 38 Carbonic Anhydrase Inhibitors, 12 CARDIOVASCULAR AGENTS, 8 Cardizem, 10 Cardizem SR, 10 Cardura, 9 Carteolol HCL Soln 1% Ophthalmic, 34 Carvedilol Tab Oral, 10 Cataflam, 28 Catapres, 9 Cefdinir Oral, 3 Cefixime Tab 400mg Oral, 3 Cefpodoxime Proxetil Oral, 3 Cephalexin Monohydrate, 3 Cephalosporins, 3 Cephulac, 21 Cerose-DM, 16 Chemstrips, 44 Chloroquine Phosphate Tab Oral, 5 Chlorpheniramine & Pseudoephedrine Oral, 16 Chlorpheniramine-DM Syrup Oral, 16 Chlorthalidone Oral, 12 Chlor-Trimeton, 16 Cholac, 21 Page 30 of 41

B

Bacitracin-Polymyxin-Neomycin-HC Ophthalmic Oint 1%, 36 Baclofen Tab Oral, 31 Bactrim, 4 Bactrim DS, 4 Bactroban, 39 Barbiturate Hypnotics, 24 Bayer ASA, 25 BD ­ Glucose Chw, 8 B-D Insulin Syringes, 44 Beclomethasone Dipropionate Inhal Aero, 18 Belladonna Alkaloids, 19 Benadryl, 14 Benazepril HCL Oral, 9 Benemid, 30 Benicar, 9 Bentyl, 19 Benzocaine-Antipyrine 1.4-5.4% Soln Otic, 38 Benzodiazepines, 23 Beta Adrenergics, 17 BetaBlockers Cardio-Selective, 10 Beta-Blockers Non-Selective, 10 Betagan, 34 Betamethasone Dipropionate Cream External, 41 Betapace, 10 Betapace AF, 10 Betaxolol HCL Soln -.5% & 1% and Susp 0.25% Ophthalmic, 34 Bethanechol Chloride Oral, 22 Betoptic, 34 Betoptic-S, 34 Biaxin, 4 Bicillin LA, 3 Biguanides ­Metformin, 8 April 2012

Cholestyramine Powder & Packets Oral, 13 Cholestyramine Powder Can Oral, 13 Ciloxan, 33 Cipro, 3 Cipro HC Otic, 39 Ciprofloxacin HCl 250mg, 500mg, 750mg Tab Oral, 3 Ciprofloxacin HCL Oint & Soln 0.3% Ophthalmic, 33 Ciprofloxacin-Hydrocortisone Otic Susp 0.2-1%, 39 Clarithromycin 250mg, 500mg Tab Oral, 4 Claritin, 14 Cleocin, 4 Cleocin Vaginal, 22 Clindamycin HCL Cap Oral, 4 Clindamycin Phosphate CR Vaginal, 22 Clinistix, 43 Clinoril, 28 Clomipramine HCL Oral, 24 Clonazepam Tab Oral, 23 Clonidine HCL Oral, 9 Clopidogrel Bisulfate Tab Oral, 33 Clotrimazole, 23 Clotrimazole External, 40 Clotrimazole Tab, 23 Clotrimazole Vaginal, 23 Clotrimazole w/ Betamethasone Cream, External, 40 Coal Tar, 43 Coal Tar (Crude) Solution External, 43 Coal Tar External, 40 Codeine Combinations, 26 Codimal DM, 16 Codine-GG Oral, 15 Codituss DM, 16 Colchicine w/Probenecid Oral Coichicine, 30 Colytrol, 19 Combination Diuretics, 12 Combivent, 18 CombiVent, 17 Compazine, 20, 24 Condylox, 42 Control Solutions, 44 Coreg, 10 Cortaid, 41 Cortef, 6 Corticosteroids ­ Topical, 40 Corticreme, 41 Cortisone, 6 Cortisone Acetate Oral, 6 Cortisporin, 36 Cortisporin Otic, 39 Cosopt, 34 Cotacort, 41 Coumadin, 33 Coumarin Anticoagulant, 33 Cozaar, 9 Cream 1%, Kit Vaginal, 23 Cromolyn Sodium Solution, 17 Crotamiton Cream & Lotion 10% External, 43 Crotamiton External, 39 Cyclobenzaprine HCL 10mg Tab Oral, 31 Cyclogyl, 36 Cyclomydri, 37 Cyclopentolate HCL Soln 0.5%, 1%, 2% Ophthalmic, 36 April 2012

Cyclopentolate w/ Phenylephrine Soln 0.2-1% Ophthalmic, 37 Cyproheptadine HCL Oral, 14 Cystospaz, 22 Cystospaz-M, 19 Cytomel, 8 Cytra K, 23

D

Dapsone, 4 Dapsone Oral, 4 Daraprim, 5 Daypro, 28 DDAVP, 8 Debrox, 38 Decadron, 6, 35 Deconamine, 16 Decongestant or Decongestant Combinations, 15 Depakene, 30 Depakote EC, 30 Depakote ER, 30 Depakote Sprinkle, 30 Deponit, 12 Dermacort, 41 Dermatex HC, 41 DERMATOLOGICAL PRODUCTS, 39 Desenex,, 40 Desipramine HCL Oral, 24 Desmopressin Acetate Oral, Nasal Spray, 8 Dexacidin, 36 Dexamethasone Oral, 6 Dexamethasone Sodium Phosphate Soln Ophthalmic, 35 Dexamethasone Susp 0.1% Ophthalmic, 34 Dexa-sol, 35 Dexbrompheniramine & Pseudoephedrine Oral, 16 Dexone, 6 Dextromethorphan-GG Liquid 10-100mg/5mL Oral, 16 Diabeta,, 7 Diabetic, 44 DIABETIC AGENTS, 6 Diabetic Supplies, 44 Diabetic Tus, 14 Diabetic Tus DM, 16 DIAGNOSTIC PRODUCTS, 43 Diagnostic Reagents, 43 Diastix, 43 Diazepam Tab Oral, 24 Diclofenac, 38 Diclofenac Potassium Oral, 28 Diclofenac Sodium EC Oral, 28 Diclofenac Sodium Soln 0.1% Ophthalmic, 38 Dicloxacillin Sodium, 3 Dicloxacillin Sodium Oral, 3 Dicyclomine HCL Oral, 19 Diflucan, 5 Digitalis, 11 Digoxin Oral, 11 Dilacor XR, 11 Dilantin, 30 Diltiazem ER, 10 Diltiazem HCL CR Oral, 10 Page 31 of 41

Diltiazem HCL Oral, 10 Diltiazem HCL SR/24hr Oral, 11 Dimetane-DX, 16 Diphedryl, 14 Diphenhydramine HCL Oral, 14 Diphenoxylate w/ Atropine Oral, 19 Dipivefrin Soln 0.1% Ophthalmic, 36, 37 Diprosone, 41 Dipyridamole Oral, 10 Dipyridamole Tab Oral, 33 Disalcid, 25 Disopyramide Phosphate Oral, 8 Ditropan, 22 Divalproex Sodium EC Cap Oral, 30 Divalproex Sodium EC Tab Oral, 30 Divalproex Sodium SR 24 Hr Tab Oral, 30 Dofetilide Ora, 9 Dolophine, 26 Donnatal, 19 Donnatal Extentab, 19 Dorzolamide-Timolol Soln 2-0.5% Ophthalmic, 34 Dostinex, 8 Dovonex, 43 Doxazosin Mesylate Oral, 9 Doxepin HCL Oral, 24 Doxycycline Hyclate Cap 50mg & 100mg, Tab 100mg Oral, 4 Dyazide, 12

Erythromycin Oint 5mg/gm Ophthalmic, 33 Erythromycin Stearate Oral, 4 Erythromycin w/EC Particles Oral, 4 Esgic, 26, 29 Esgic Plus, 26, 29 Esidrix, 12 Estrace, 21 Estradiol, 21 Estradiol Vaginal Cream, 21 Estrogel, 21 Estrogen, 21 ESTROGENS, 21 Estropipate, 21 Ethezyme, 42 Ethmozine, 9 Etodolac Cap & Tab Oral, 28 Eurax, 39, 43 Euthyrox, 8 Expectorants, 14

F

Famotidine Tablet 40mg Oral, 19 Feldene, 28 Femtrace, 21 Fenofibrate Oral, 13 Fenoprofen Calcium Oral, 28 Feosol, 33 Feostat, 32 Feratab, 33 Fer-In-Sol, 33 Ferrous Fumarate Oral, 32 Ferrous Gluconate, 32 Ferrous Gluconate Oral, 32 Ferrous Sulfate Oral, 33 Feverall, 25 Fioricet, 26, 29 Fiorinal, 26, 29 Fiorinal w/ Codeine, 27 Fiortal, 26, 29 Flagyl, 4 Flarex, 35 Flecainide Acetate Oral, 9 Flexeril, 31 Flonase, 14 Florinef, 6 Flovent Disku, 18 Fluconazole Tab 50mg, 100mg, 150mg Oral, 5 Flucytosine, 5 Fludrocortisone Acetate Oral, 6 Flunisolide 0.025% Nasal, 14 Fluocinolone Acetonide Cream, Oil, Soln External, 41 Fluocinonide Cream, Emusified Cream, Gel, Soln, Oint 0.05% External, 41 Fluorometholone Acetate Susp 0.1% Ophthalmic, 35 Fluorometholone Oint 0.1% Ophthalmic, 35 Fluorometholone Susp Ophthalmic, 35 Fluorosyn, 41 Flurbiprofen Soln 0.03% Ophthalmic, 38 Fluroquinolones, 3 Fluticasone, 18 Fluticasone Propionate Nasal, 14 Fluticasone/Salmeterol, 17 Page 32 of 41

E

E.E.S., 4 EC-Naprosyn, 28 Econopred Plus, 35 Ecotrin, 25 Eflone, 35 Elavil, 24 Elimite, 43 Elixer, 27 Elmiron, 23 Empirin, 25 Empirin/Codeine #2, #3, #4, 27 E-Mycin, 4 Enalapril Oral, 9 ENDOCRINE, 6 Enoxaparin Sodium Injection, 33 Enulose, 21 Enzymes, 42 Epifoam, 42 Epinephrine HCl Injection (Anaphylaxis), 13 Epinephrine-Chlorpheniramine, 13 Epipen, 13 Epipen Jr, 13 Ercaf, 29 Ergot Combinations, 29 Ergotamine w/ Caffeine 1-100mg Tab Oral, 29 Eryc, 4 Ery-Tab, 4 Erythrocin, 4 Erythromycin, 4 Erythromycin Base Oral, 4 Erythromycin Delayed Release Oral, 4 Erythromycin Ethylsuccinate Oral, 4 April 2012

FML Forte, 35 FML Liquifilm, 35 FML S.O.P., 35 Folic Acid, 32 Folic Acid Oral, 32 Fondaparinux Sodium 2.5 mg/0.5mL Injection, 33 Fortabs, 26, 29 Fototar,, 40 Furadantin, 22 Furosemide Oral, 12

G

Gabapentin 400mg Cap, 400mg, 600mg, & 800mg Tablet Oral, 30 Gallstone Solubilizing Agents, 20 Gantrisin, 4 Garamycin, 33 GASTROINTESTINAL AGENTS, 18 Gemfibrozil Oral, 13 Genacote, 25 Genasone, 41 Generlac, 21 Genitourinary Irrigants, 23 GENITOURINARY PRODUCTS, 21 Gennin ­FC, 25 Genoptic, 33 Gentamicin Sulfate Soln & Oint 0.3% Ophthalmic, 33 GI Stimulants, 21 Glimepiride Oral, 7 Glipizide Tab Oral, 7 Glucagon, 8 Glucagon Kit Injection, 8 Glucocorticosteroids, 6 Glucophage, 8 Glucose Blood Monitoring Kit, 44 Glucose Blood Test Strips, 44 Glucose Chew Tab Oral, 8 Glucose Urine Test-(Copper Sulfate), 43 Glucose Urine Test-(Glucose Oxidase), 43 GlucoseBloodCalibrationSoln, 44 Glucotrol, 7 Glyburide Micronized, 7 Glyburide Oral, 7 Glynase, 7 G-Tar, 40 Guaifed, 15 Guaifed-PD. See Guaifenesin Oral, 14 Gyne-Lotrimin, 23

Humulin 50/50, 7 Humulin 70/30, 7 Humulin L, 7 Humulin N, 7 Humulin R, 7 Hydralazine HCL Oral, 13 Hydrochlorthiazide (HCTZ) Oral, 12 Hydrocodone Combinations, 27 Hydrocort, 41 Hydrocort/AN, 41 Hydrocortisone External, 41 Hydrocortisone Tab Oral, 6 Hydrocortisone W/ Acetic Acid 1-2% Soln Otic, 38 Hydrocortisone w/ Pramoxine Foam 1-1% Rectal, 42 Hydrodiuril, 12 Hydroxychloroquine Sulfate Oral, 5 Hydroxyzine HCL Oral, 24 Hydroxyzine Pamoate Oral, 24 Hygroton, 12 Hyoscyamine, 19 Hyoscyamine Sulfate Oral, 19 Hyoscyamine Tab 0.15 mg Oral, 22 Hytone, 41 Hytrin, 9 Hyzaar, 10

I

Ibuprofen Oral, 28 Imdur, 11 Imipramine HCL Oral, 24 Imitrex, 29 Imitrex NS, 29 Imodium, 19 Imodium A-D, 19 Indapamide Oral, 12 Inderal, 10 Inderal LA, 10 Indocin, 28 Indomethacin Oral, Suppos Rectal, 28 INFECTIOUS DISEASE AGENTS, 3 Infi-Cyle, 37 Inflamase Forte, 35 Insulin Aspart Inj 100 U/mL, 7 Insulin Aspart Prot & Aspart Inj 100 U/mL (70-, 7 Insulin Detemir Inj j100 U/mL, 7 Insulin Glargine Inj 100 U/mL, 7 Insulin Isophane Inj 100 U/mL, 7 Insulin Lispro inj100 U/mL, 7 Insulin Lispro Prot & Lispro Inj 100 U/mL (75-25), 7 Insulin Regular & Isophane Inj 100 U/mL, 7 Insulin Regular & Isophane Inj 100 U/mL (50), 7 Insulin Regular Inj 100 U/mL, 7 Insulin Regular Inj 500 U/mL, 7 Insulin Syringes, 44 Insulin Zinc Inj 100 U/mL, 7 Intal, 17 Intestinal Acidifiers, 21 Iodoquinol Oral, 5 Ipratropium Bromide, 17 Ipratropium Bromide Inhalation, 17 Ipratropium Bromide Inhalation Sol, 17 Ipratropium/Albuterol, 17 Page 33 of 41

H

H-2 Antagonists, 19 HCL Cap, HLC Cap CR, Tab Oral, 31 HEMATOLOGICAL AGENTS, 32 Heparins And Heparinoid-Like Agents, 33 Histex, 16 Homatropine HBr Soln 2%, 5% Ophthalmic, 37 Humalog, 7 Humalog Mix 75/25, 7 Human Insulin, 6 Humibid, 15 April 2012

Iron, 33 Irrigation Soln, 23 ISMO, 11 Iso Atropine, 36 Iso Carpine, Pilocar, 37 Iso Homatropine, 37 Iso Hyoscine, 37 Isoniazid Oral, 6 Isoptin, 11 Isordil, 11 Isosorbide Dinitrate Oral, 11 Isosorbide Dinitrate Oral Tabs & Chew Tabs, 11 Isosorbide Dinitrate SL Oral, 11 Isosorbide Mononitrate Oral, 11 Itraconazole Caps, 5

K

Kaochlor, 32 Kaon-CL, 32 Kaon-CL SF, 32 Kay Ciel KCL, 32 Kayexalate, 32 K-Dur, 32 Keflex, 3 Kenalog, 39, 41 Ketoconazole Cream 2% External, 40 Ketoconazole Shampoo 2% External, 40 Ketoconazole Tab Oral, 5 Ketorolac, 38 Ketorolac Tromethamine Soln 0.4%, 0.5% Ophthalmic, 38 Ketostix, 43 Klonopin, 23 Klor-Con, 32 Klortrix, 32 Klorvess, 32 K-Tabs,, 32

Levsinex, 19 Lidex, 41 Lidex-E, 41 Lidocaine HCL Gel 2% External, 43 Lidocaine HCL in Viscous Soln 2% (Mouth-Throat), 39 Lidocaine HCL Viscous Soln 2% Mouth/Throat, 43 Lidocaine Viscous, 39 Lioresal, 31 Lioresal DS, 31 Liothyronine Sodium Oral, 8 Lipitor, 13 Liquid Pred, 6 Lisinopril Oral, 9 Llotycin, 33 Lodine, 28 Lofibra, 13 Lomotil, 19 Loniten, 13 Lonox, 19 Loop Diuretics, 12 Loperamide HCL Oral, 19 Lopid, 13 Lopressor, 10 Loratadine 10mg Tab Oral (OTC), 14 Lortab, 27 Lotensin, 9 Loteprednol etabonate-Tobramycin Susp 0.5-0.3% Ophthalmic, 35 Lotrimin, 40 Lotrimin AF, 40 Lotrisone, 40 Lovastatin Oral, 13 Lovenox, 33 Lozol, 12

M

Macrobid, 22 Macrodantin, 22 Macrolides, 4 Malathion 0.5% Lotion External, 43 Maxair, 17 Maxair Autohaler, 17 Maxidex, 34 Maxitrol, 36 Maxivate, 41 Maxzide, 12 Mebendaxole Oral, 5 Meclizine Oral, 20 Medotar, 40 Medroxyprogesterone Acetate, 21 Meloxicam, 28 Mephyton, 31 Mepron, 3 Mesalamine Enema Rectal, Suppos Rectal, Oral, 21 Mestinon, 31 METABOLIC DRUGS, 6 Metformin HCL Oral, 8 Methadone HCL Oral, 26 Methadose, 26 Methazolamide, 12 Methimazole Oral, 8 Methocarbamol Oral, 31 Page 34 of 41

L

Labetalol HCL Oral, 10 Lactulose Syr 10gm/15mL Oral, 21 Lamisil, 5 Lanacort HC, 41 Lancets, 44 Lancets Devices, 44 Lanoxin, 11 Lantrisul, 3 Lantus, 7 Lasix, 12 Latanoprost Soln 0.005% Ophthalmic, 36 Leukotriene Receptor Inhibitor, 18 Levalbuterol, 17 Levaquin, 3 Levbid, 19 Levemir, 7 Levobunolol HCL Soln 0.25% & 0.5% Ophthalimc, 34 Levofloxacin Tab Oral, 3 Levothroid, 8 Levothyroxine Sodium Oral, 8 Levoxyl, 8 Levsin, 19 Levsin SL, 19 April 2012

Methotrexate Oral, 28 Methyldopa Oral, 9 Meticorten, Deltasone, 6 Metipranolol HCL Soln 0.3% Ophthalmic, 34 Metoclopramide HCL Oral, 20, 21 Metolazone Oral, 12 Metoprolol Succinate SR Oral, 10 Metoprolol Tartrate Oral, 10 Metrogel Vag Gel, 22 Metronidazole Gel 0.75% Vaginal, 22 Metronidazole Tab Oral, 4 Mevacor, 13 Mexiletine, 9 Mexiletine HCI, 9 Micatin, 40 Miconazole Nitrate Cream 2% External, 40 Miconazole Nitrate Cream, Suppos Vaginal, 23 Miconazole Nitrate Vagina, 23 Miconazole Nitrate Vagina Kit, 23 Micro-K, 31 Micronase, 7 Microzide, 12 Midrin, 29 Mineralocorticoids, 6 Minipress, 9 Minitran, 12 Minoxidil Oral, 13 Mintezol, 5 Misc. Anti-Infectives, 4 Misc. Genitourinary Agents, 23 Miscellaneous Anticonvulsants, 30 Miscellaneous Anti-Ulcer, 20 Miscellaneous Respiratory Inhalants, 15 Miscellaneous Topical, 43 Mobic, 28 Monistat, 23, 40 Monoket, 11 Montelukast Sodium Oral, 18 Moricizine HCI Oral, 9 Morphine Sulfate Tab CR Oral, 26 Morphine Sulfate Tab Oral, 26 Motrin, 28 Mouth & Throat (Local), 39 MS Contin, 26 MSIR, 26 Multiple Urine Test Strips, 44 Mupirocin 2% Oint External, 39 Murocoll-2, 37 Mycolog II, 40 Mycostatin, 5, 39 Mydriacyl, 37 Mysoline, 30

N

Naldecon Sr, 14 Nalfon, 28 Naphazoline w/ Pheniramine Soln 0.025-0.3% Ophthalmic, 37 Naprosyn, 28 Naproxen DR Oral, 28 Naproxen Oral, 28 Narcotic, 16 April 2012

Narcotic Agonist, 26 Narcotic Combinations, 26 Nasal Steroids, 14 Nasalide, 14 Nebupent, 3 Neo-Fradin, 5 Neomycin Sulfate, 5 Neomycin Sulfate Oral, 5 Neomycin-Polymyxin-Dexamethasone Susp & Oint 0.1% Ophthalmic, 36 Neomycin-Polymyxin-HC Soln 1% Otic, 39 Neomycin-Polymyxin-HC Susp 3.5mg/mL-10000 U/mL-1% Otic, 39 Neomycin-Polymyxin-HC Susp Ophthalmic, 36 Neostigmine Bromide Tab 15mg Oral, 31 Nepafenac Susp 0.1% Ophthalmic, 38 Neptazane, 12 Nercainal, 41 NEUROMUSCULAR AGENTS, 28, 29, 30 Neurontin, 30 Neutraphos, 32 Nevanac, 38 Niacin, 14, 31 Niacin Oral, 31 Niacin Tab CR, 14 Niaspan, 14 Nicotinic Acid Derivatives, 13 Nilstat, 39 Nimodipine Cap Oral, 11 Nimotop, 11 Nitrates, 11 Nitro, 11 Nitrobid, 11 Nitrodisc, 12 Nitro-Dur, 12 Nitrofurantoin, 22 Nitrofurantoin Macrocrystalline Oral, 22 Nitrofurantoin Monohydrate Macrocrystalline Oral, 22 Nitrofurantoin Susp Oral, 22 Nitrogard, 11 Nitroglycerin, 11 Nitroglycerin Buccal Oral, 11 Nitroglycerin CR Oral, 11 Nitroglycerin Intravenous Soln, 11 Nitroglycerin Oint 2% Transdermal, 11 Nitroglycerin SL Tab & Aer Oral, 11 Nitroglycerin TD Transdermal, 12 Nitroglyn, 11 Nitroquick, 11 Nitrostat,, 11 Nitrotab, 11 Nitro-Time, 11 Nix Cream Rinse, 43 Nizoral, 5, 40 Nonsteroidal Anti-Inflammatory Agents, 27 Norco, 27 Normal Saline (IV), 32 Normodyne, 10 Norpace CR, 8 Norpramin, 24 Nortriptyline HCL Oral, 24 Norvasc, 10 Novahistine-DM, 15 Page 35 of 41

Novolin 70/30, 7 Novolin L, 7 Novolin N, 7 Novolin R, 7 Novolog, 7 Novolog Mix, 7 Nutracort, 41 NUTRITIONAL PRODUCTS, 31 Nydrazid, 6 Nystatin, 5 Nystatin External, 39 Nystatin Susp 100000 U/mL (Mouth/Throat), 39 Nystatin Tab 100000 U Vaginal, 22 Nystatin Vaginal Tab, 22 Nystatin-Triamcinolone Cream & Oint External, 40 Nystop, 39

O

Ocufen, 38 Ocuflox, 33 Ocupress, 34 Ocu-tropine, 36 Ofloxacin Ophth Soln 0.3% Ophthalmic, 33 Olmesartan Oral, 9 Olmesartan Tabs, 9 Olmesartan-HCTZ Oral, 10 Olopatadine HCL Soln Ophthalmic, 38 Omeprazole Magnesium Tablet Oral, 20 Omnicef, 3 Omnipred,, 35 Ophthalmic Anti-Allergic, 38 Ophthalmic Antibiotics, 33 Ophthalmic Beta-Blockers, 34 Ophthalmic Carbonic Anhydrase Inhibitors, 34 Ophthalmic Non-Steroidal Anti-Inflammatory Agents, 38 Ophthalmic Steroid, 34 Ophthalmic Steroid Combinations, 35 Ophthalmics ­ Direct Acting, 37 Opioid Combinations, 27 Optipranolol, 34 Oramorph SR, 26 Oretic, 12 Organidin NR, 14 Orth-est/Ogen, 21 Otic Miscellaneous, 38 Otic Steroid Antibiotic Combinations, 38 Otic Steroids, 38 Ovide, 43 Oxaprozin Oral, 28 Oxybutynin Chloride, 32 Oxybutynin Chloride Tab & Syr Oral, 22 Oxycodone w/ Acetaminophen 5-325mg, 7.5-325mg, & 10-325mg Tab Oral, 26

P

Pamelor, 24 Panafil, 42 Pantoprazole, 20 Papain & Urea-Chlorophyllin Ointment External, 42 Papain-Urea Ointment External, 42 Paromomycin, 3 April 2012

Paromycin, 3 Patanol, 38 PCE, 4 Pedi-Dri, 39 Penicillin G Benzathine, 3 Penicillin V Potassium Oral, 3 Pentam, 3 Pentamidine, 3 Pentasa, 21 Pentosan Polysulfate Sodium Oral, 23 Pen-VK, Veetids, 3 Pepcid, 19 Periactin, 14 Permethrin Cream 5% External, 43 Permethrin Cream Rinse 1% External, 43 Persantine, 10, 33 Phenazopyridine HCL Tab Oral, Kit, 23 Phenergan, 14, 20 Phenergan DM, 16 Phenergan Forte, 14, 20 Phenergan VC, 15 Phenergan w/Codeine, 16 Phenobarbital, 25 Phenobarbital & Belladonna Alkaloids Oral, 19 Phenobarbital Oral, 25 Phenothiazines, 24 Phenylephrine in Hard Fat Suppos 0.25% Recta, 42 Phenylephrine w/DM-GG Oral, 16 Phenylephrine-Chlorphen-DM Oral, 16 Phenylephrine-GG Oral, 15 Phenylephrine-Pyrilamine-DM Oral, 16 Phenytoin Chew Tab 50 mg Oral, 30 PhosLo, 22 Phrenilin, 26, 29 Phrenilin w/ Codeine, 27 Phytonadione Tab 5mg Oral, 31 Pilocarpine HCL 5mg Tab Oral, 39 Pilocarpine HCL Gel 4% Ophthalmic, 37 Pilocarpine HCL Soln 0.5%, 1%, 2%, 4%, 6% Ophthalmic, 37 Pilopine HS, 37 Pin-X, 5 Pioglitazone Oral, 8 Pirbuterol Inhalation, 17 Piroxicam, 28 Piroxicam Ora, 28 Plaquenil, 5 Platelet Aggregation Inhibitors, 33 Plavix, 33 Podofilox Soln & Gel 0.5% External, 42 Polycitra, 23 Potassium, 31 Potassium & Sodium Citrates w/Citric Acid Oral, 23 Potassium & Sodium Phosphates for Soln 278-164250mg/75mL, Powder 278-164-250mg & 280-160250mg Oral, 32 Potassium Chloride Cap CR 8mEq & 10mEq Oral, 31 Potassium Chloride Oral Liq 10% & 20% Oral, 32 Potassium Chloride Tab CR 8mEq, 10mEq, 15mEq & 20mEq Oral, 32 Potassium Removing Resin, 32 Potassium Sparing Diuretics, 12 Pramosone, 42 Page 36 of 41

Pramoxine Hcl Oint 1% Rectal, 42 Pramoxine w/ Zinc Oxide in Mineral Oil Oint 1-12.5% Rectal, 42 Pramoxine-HC External, 42 Pravachol, 13 Pravastatin Oral, 13 Prazosin HCL Oral, 9 Pred Forte, 35 Prednisolone, 6 Prednisolone Sodium Phosphate Powder, 6 Prednisolone Acetate Susp 1% Ophthalmic, 35 Prednisolone Sodium Phosphate Oral, 6 Prednisolone Sodium Phosphate Soln 1% Ophthalmic, 35 Prednisone Oral, 6 Prelone, 6 PrevPac, 20 Prilosec (OTC), 20 Primaquine phosphate, 5 Primaquine Phosphate Oral, 5 Primidone Tablet Oral, 30 Prinivil, Zestril, 9 ProAir HFA, 17 Proben-C, 30 Probenecid Oral Probenecid Tab 500 mg, 30 Procainamide HCI Oral, 9 Prochlorperazine Edisylate Oral, 20, 24 Prochlorperazine Maleate Cap CR & Tab Oral, 20, 24 Prochlorperazine Maleate Oral, 20, 24 Prochlorperazine Suppos Rectal, 20, 24 Proctofoam-HC, 42 Progestins, 21 Proloprim, 3 Promethazine & Phenylephrine Syrup 6.25-5mg/5mL Oral, 15 Promethazine HCL Oral, 14, 20 Promethazine HCL Suppos Rectal, 14 Promethazine-DM Syrup Oral, 16 Pronestyl, 9 Pronto, 43 Propafenone HCI Oral, 9 Propine-C, 37 Propranolol HCL Oral, 10 Propylthiouracil (PTU), 8 Propylthiouracil Oral, 8 Prostaglandin Agonists Ophthalmi, 36 Prostigmin, 31 Protonix, 20 Protriptyline HCL Oral, 24 Proventil, 17 Provera, 21 Pseudoephed-Bromphen-DM Oral, 16 Pseudoephed-Carbinoxamine-DM Liquid Oral, 16 Pseudoephedrine HCL Oral, 15 Pseudoephedrine w/DM-GG Cap 30-10-200mg Oral, 15 Pseudoephedrine-GG/CR Oral, 15 PSYCHOTHERAPEUTIC AGENTS, 23 Pulmicort Flexhaler, 18 Pyrantel Pamoate Ora, 5 Pyrethrins-Piperonyl Butoxide External, 43 Pyridium, 23 Pyridostigmine Bromide Oral, 31 Pyrimethamine Oral, 5 April 2012

Q

Qualaquin, 6 Questran/Lite, 13 Quibron-T, 18 Quinidex, 9 Quinidine, 9 Quinidine Gluconate CR Oral, 9 Quinidine Sulfate Tab Oral, 9 QUININE SULFATE, 6 Quinine Sulfate Tab 324mg Oral, 6 QVAR, 18

R

Ranitidine HCL Tablet 150mg, 300mg Oral, 19 Ranitidine HCL Tabs 75mg, 150mg, 300mg, 19 Rectacaine, 42 Reglan, 20, 21 Rescon-GG, 15 RESPIRATORY AGENTS, 14 Rid, 43 Rifadin, 6 Rifampin Oral, 6 Robaxin, 31 Robitussin, 14 Robitussin A-C, 15 Robitussin Cod/Cgh, 15 Robitussin DM, 16 Robitussin PE, 15 Rondec DM, 16 Rowasa, 21 Roxicet, 26 Rythmal, 9

S

Salagen, 39 Salflex, 25 Salicylate Combinations, 25 Salicylates, 25 Salmeterol Xinafoate Powder Disks Inhalation, 17 Salsalate Oral, 25 Scabicides & Pediculocides, 43 Scopolamine HBr Soln 0.25% Ophthalmic, 37 Scopolamine w/ Phenylephrine Soln 0.3-10% Ophthalmic, 37 Scot-Tussin DM SF, 16 Sedapap, 26, 29 Serevent Diskus, 17 Serotonin Agonist, 29 Silvadene, 40 Silver Sulfadiazine Cream 1% External, 40 Simvastatin Oral, 13 Sinequan, 24 Singulair, 18 Slo-Bid, 18 Slo-Phyllin, 18 Slow-Fe, 33 Slow-K, 32 Sod Sulamyd, 33 Sodium Chloride, 23 Sodium Chloride Injection, 32 Page 37 of 41

Sodium Chloride Irrigation Soln, 23 Sodium Chloride Soln Nebu 0.9%, 15 Sodium Polystyrene Sulfonate Powder Oral, 32 Sodium Polystyrene Sulfonate Susp 15gm/60mL Oral/Rectal, 32 Sodium Sulfacetamide 10% Ophthalmic, 33 Soln, 27 Sorbitrate, 11 Sotalol HCl Oral, 10 Spiriva Handihaler, 17 Spironolactone Oral, 12 Spironolaone & HCTZ Oral, 12 Sporanox, 5 SPS, 32 Starch Suppositories 51% Recta, 42 Steroid Inhalants, 18 Sucralfate Oral, 20 Sudafed, 15 Sudafed Plus, 16 Sudex, 16 Sulfacetamide Sodium-Prednisolone Oint 10-0.2% Ophthalmic, 35 Sulfacetamide Sodium-Prednisolone Susp 100.2%Ophthalmic, 35 Sulfadiazine, 3, 40 Sulfasalazine Tab & EC Oral, 21 Sulfinpyrazone Oral, 30 Sulfisoxazole, 4 Sulfisoxazole Acetyl Oral, 4 Sulfisoxazole Powder, 4 Sulfonamides, 4 Sulfonylureas, 7 Sulindac Oral, 28 Sumatriptan Spray Nasal, 29 Sumatriptan Succinate Injection, 29 Sumatriptan Succinate Tab Oral, 29 Sumycin, 4 Suprax, 3 Surmontil, 24 Symbicort, 17 Synalar, 41 Synthroid, L, 8

T

Tambocor, 9 Tapazole, 8 Tar Products, 40 Tegretol, 30 Tegretol XR, 30 Tegrin, 40 Tegrin Medicated Shampoo 7%, 40 Tenormin, 10 Terazosin Oral, 9 Terbinafine, 5 Terbutaline Sulfate Oral, 17 Terconazole Vaginal, 23 Tetracycline HCl Oral, 4 Tetracyclines, 4 Theo-24, 18 Theo-Dur, 18 Theolair, 18 Theolair-SR, 18 April 2012

Theophylline, 18 Theophylline Cap CR Oral, 18 Theophylline Tab CR Oral, 18 Theophylline Tab Oral, 18 Thiabendaxole Oral, 5 Thiazides, 12 Thiazolidinediones, 8 Thienopyridine Derivatives, 33 Thyroid Hormones, 8 Thyroxine, 8 Tikosyn, 9 Timolol Maleate Soln (Gel Forming) 0.25% & 0.5% ophthalmic, 34 Timolol Maleate Soln 0.25% & 0.5% Ophthalmic, 34 Timoptic, 34 Timoptic XE, 34 Tinactin, 39 Tiotropium, 17 Tobradex, 36 Tobramycin-Dexamethasone Susp & Oint 0.3-0.1% Ophthalmic, 36 Tofranil, 24 Tolnaftate Power External, 39 Topical Antifungals, 39 TOPICAL PRODUCTS, 33 Toprol XL, 10 Tramadol HCL Tab 50mg Oral, 26 Trandate, 10 Transderm-Nitro, 12 Transplant Medications, 44 Triamcinolone Acetonide External, 41 Triamcinolone Acetonide in Orabase 0.1% (Mouth), 39 Triamterene & HCTZ Oral, 12 Tricitrates, 23 Tricyclic Agents, 24 Trimethoprim, 3 Trimethoprim/Sulfamethoxazole Oral, 4 Trimipramine Maleate Oral, 24 Trimox, 3 Trimpex, 3 Triple Antibiotic, 36 Triprolidine & Pseudoephedrine Oral, 15 Tropicamide Soln 0.5%, 1% Ophthalmic, 37 Trypsin w/ Castor Oil & Peruvian Balsam Ointment External, 42 Tucks, 42 Tussex, 16 Tussi-Organi, 15 Tylenol, 25 Tylenol/Codeine, 27 Tylenol/Codeine #2, #3, #4, 27

U

Ulcer Anti-Infective W/ Proton Pump Inhibitor, 20 Ultram, 26 Uni-Dur, 18 Uniphyl, 18 Urecholine, 22 Urinary Analgesics, 23 Urinary Anti-infectives, 22 Urinary Antispasmodics, 22 Urine Glucose-Ketones Test Strips, 44 Page 38 of 41

Uro Femme Kit, 23 Urogesic, 23 Ursodiol Capsule 300mg Oral, 20

W

Warfarin Sodium Tab Oral, 33 Wigraine, 29

V

Vaginal Antifungals, 22 Vaginal Anti-Infectives, 22 Valium, 24 Valproic Acid, 30 Valproic Acid Cap 250mg Oral, 30 Vandazole, 22 Vantin, 3 Vasocon-A, 37 Vasodilators, 12 Vasopressin, 8 Vasotec, 9 Ventolin, 17 Ventolin HFA, 17 Verapamil HCL Tab Oral, 11 Vermox, 5 Vibramycin, 4 Vibratab, 4 Vicodin, 27 Vicodin ES, 27 Vistaril, 24 Vitamin B-, 31 Vitamin B-3, 14 Vitamin B-6, 31 Vivactil, 24 Voltaren, 28, 38 Vopac, 27 Vosol, 38 Vosol-HC, 38 Xalatan, 36 Xanthines, 18 Xenaderm, 42 Xibrom, 38 Xopenex HFA, 17 Xylocaine, 43

X

Y

Yodoxin, 5

Z

Zafirlukast Oral, 18 Zantac, 19 Zantac Rx, 19 Zaroxolyn, 12 Zileuton Oral, 18 Zithromax, 4 Zocor, 13 Zonegran, 31 Zonisamide Capsule Oral, 31 Zovirax, 6 Zyflo, 18 Zylet, 35 Zyloprim, 29

April 2012

Page 39 of 41

SAN DIEGO COUNTY CMS

REQUEST FOR FORMULARY CHANGE FORM Fax Completed Form to (855) 394-7927 Attention: Medical Management Services, Manager

DATE FORM COMPLETED: ____________________ REQUESTED BY: ________________________ ________________________________________________________ SPECIALTY _______________________________________ _______ _____

CLINIC ___________________________________ _

PHONE NUMBER: ___________________ FAX NUMBER: __________________ EMAIL: ____ COMPARABLE DRUG(S) ON FORMULARY: 1) _________________________________ 2) _________________________________ DRUG INFORMATION GENERIC NAME ____________________________ MANUFACTURER _____________________________

__________ __________

BRAND NAME ____________________________________ DOSAGE: ________________________________________

MEDICAL INDICATIONS: __________________________________________________________________________ ______________________________________________________________________________________________ PRECAUTIONS/ALERTS: ____________________________________________________________________________ _______________________________________________________________________________________________ ADVANTAGES AND DISADVANTAGES: (YOU MAY ATTACH REFERENCES OR PUBLICATIONS THAT SUPPORT THE

EFFICACY OF THIS DRUG) __________________________________________________________________________

_______________________________________________________________________________________________ -------------------------------------------------------------------FOR LIHP PROGRAM USE ONLY COMMITTEE COMMENTS: _________________ _______________________________________________

_____________________________________________________________________________________________________ DRUG COST PER MONTH_________________________ POTENTIAL OVERALL COST __________________________________ ADVANTAGE/DISADVANTAGE ______________________________________________________________ ACCEPTED: _______________ REJECTED: __________________ DATE: ________________ DATE ADDED TO FORMULARY _______________________________________________________________

April 2012 Page 40 of 41 FORM 7/01/11

April 2012

Page 41 of 41

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