Introduction

DRUGS FOR INFECTIONS
Drugs for Parasites. . . . . . . . . . . . . . . . . . . . . . . . . .
EMERGENCY CONTRACEPTION-----------------------
ANTIBIOTICS-------------------------------------------------
OTHER CONTRACEPTIVES----------------------------------
Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Miscellaneous Antiinfectives. . . . . . . . . . . . . . . . . . . . .
DRUGS FOR DIABETES
2006 Drug Formulary
INSULINS --------------------------------------------------------
Novolin R, L, N, 70/30, Novalog, Novolog Mix and Pharmacy Benefit Guidelines
Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
cefaclor, cefadroxil, cefradine, cefpodoxime, DRUGS FOR CANCER
The Pharmaceutical Horizons Drug Formulary ORAL ------------------------------------------------------------
defines the copayment tier status of the glimepiride, glipizide, glipizide XL, glyburide Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmaceutical Horizons members. It may not azithromycin, clarithromycin, erythromycin include all drugs covered by your prescription Myleran, Nolvadex, Temodar (PA), Teslac, restrictions please check your benefit plan Biaxin, Dynabac, PCE Disperstabs, Zithromax document(s). This listing is revised from time Tetracyclines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gleevec (PA), Iressa (PA), Tarceva (PA), to time as new drugs and new prescribing HORMONES
Adoxa, Doryx, Dynacin, Monodox, Periostat GLUCOCORTICOIDS ---------------------------------------------
Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The coverage tier for each medication has been indicated. Members pay a Tier 1 copay OTHER ------------------------------------------------------------
Avelox, Avelox ABC, Cipro, Factive, Floxin, ANDROGENS---------------------------------------------------
medicines. Members pay a Tier 2 copay for Aminoglycosides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THYROID AND ANTITHYROID AGENTS
(“preferred”) brand name drugs. Members pay ESTROGENS ---------------------------------------------------
THYROID ---------------------------------------------------------
Sulfonamides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a Tier 3 copay for non-formulary and highest Drugs for Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . .
DRUGS FOR OSTEOPOROSIS
It is recommended that you have this list of medications available when you are with your physician and a prescription drug is going to Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . .
Evista, Miacalcin/NS (generic available) ESTROGEN AND ANDROGENS --------------------------
ESTROGEN AND PROGESTERONES-------------------
MISCELLANEOUS ENDOCRINE
Key to Notations:
Climera Pro, Prefest, Premphase, Prempro Drugs For Viral Infections. . . . . . . . . . . . . . . . . . . . . . .
Carnitor, DDAVP spray and tablets, Dostinex PROGESTINS -----------------------------------------------
PA: Prior authorization may be required for
CARDIOVASCULAR DRUGS
this medication. Please refer to the boxed Fortovase, ganciclovir, Hivid, Invirase, CARDIOTONICS ----------------------------------------------
Sustiva, Trizivir, Truvada, Valcyte, Valtrex, CONTRACEPTIVES
ST: A step therapy protocol is in place for this
Videx, Viracept, Viramune, Viread, Zerit, ORAL MONO-PHASIC ----------------------------------------
ANTI-ANGINA ----------------------------------------------
medication. Claims for this medication will be multiple generic options (ex. Apri, etc.) isosorbide dinitrate, isosorbide mononitrate covered based on the enrollee's previous nitroglycerin subligual tabs and patches medication history. If prior medication history BETA-ADRENERGIC BLOCKERS----------------------
does not meet clinical guidelines, prior ORAL BIPHASIC ----------------------------------------
multiple generic options (ex. Kariva, etc.) ORAL TRI-PHASIC ----------------------------------------
QL: Quantity limitations (maximum number of
Copegus (PA), Rebetol (PA), Ribavirin (PA) multiple generic options (ex. Cesia, Tri- CALCIUM CHANNEL BLOCKERS -----------------------
tablets/capsules, etc. per retail prescription) Drugs for Malaria. . . . . . . . . . . . . . . . . . . . . . . . . .
are in place for this medication. Please refer chloroquine, hydroxychloroquine, quinine PROGESTIN ONLY------------------------------------------------
multiple generic options (ex. Camilla, etc.) This document is in effect beginning January 1, 2006. Formulary consultation and administrative support to provided by: ANTIARRHYTHMICS ----------------------------------------
NASAL MEDICATIONS -------------------------------------
INCONTINENCE AGENTS-------------------------------
Imitrex injection Kits* (QL), Imitrex Tabs (QL), Imitrex Nasal Spray (QL) Maxalt (QL), mexiletine, propafenone, quinidine, sotalol Astelin, Atrovent, Flonase, Rhinocort Aqua Detrol, Detrol LA, Enablex, Oxytrol Patch VAGINAL PREPARATIONS -------------------------------
ACE INHIBITORS ---------------------------------------------
nystatin, triple sulfa vaginal, terconazole benazepril, captopril, enalapril, fosinopril, COUGH AND COLD MEDICATIONS -------------------------
ANTICONVULSANTS ---------------------------------------
DRUGS FOR ASTHMA / COPD -------------------------------
DRUGS FOR BPH-------------------------------------------
Monopril, Prinivil, Univasc, Vasotec, Zestril Sympathomimetics. . . . . . . . . . . . . . . . . . . . . . . .
Depakote, Diastat, Dilantin, gabapentin, ANGIOTENSIN II ANTAGONISTS-------------------------
Accuneb, Foradil, Proventil HFA, Serevent, Atacand, Benicar, Diovan, Micardis, Teveten CENTRAL NERVOUS SYSTEM
Felbatol, Lyrica, Neurontin, Tegretol XR, ANTI-ADRENERGIC BLOCKERS–CENTRAL------
Combination Drugs and Others. . . . . . . . . . . . . . . . .
PSYCHOTHERAPEUTIC AGENTS -----------------------
DRUGS FOR PARKINSONS DISEASE ----------------------
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTI-ADRENERGIC BLOCKERS–PERIPHERAL --
trihexyphenidyl and other generic options COMBINATION ANTIHYPERTENSIVES--------------
Theophyllines…. . . . . . . . . . . . . . . . . . . . . . . .
multiple medicines w/ generic alternatives Effexor, Effexor XR, Lexapro, paroxetine, Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SKELETAL MUSCLE RELAXANTS -------------------------
baclofen, carisoprodol, cyclobenzaprine Antileukotrienes. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . .
OPHTHALMIC
ANTI-ALLERGIC AGENTS----------------------------------
GASTROINTESTINAL
ANTIULCER -----------------------------------------------------
Abilify, clozaril, Geodon, Risperdal, Seroquel Alamast, Alocril, Alomide, Elestat, Emadine, dicyclomine, misoprostol, propantheline, DIURETICS ------------------------------------------------------
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS----
ANTI-GLAUCOMA AGENTS -----------------------------
brimonidine, dipivefrin, betaxolol, carteolol levobunolol, metipranolol, timolol, etc. ANTILIPEMICS ----------------------------------------------
CEREBRAL STIMULANTS--------------------------------
ANTI-INFECTIVE AGENTS--------------------------------
ANTIEMETIC/ANTIVERTIGO -----------------------------
Advicor, Altoprev, Crestor, Lescol, Lescol XL hydroxyzine, meclizine, prochlorperazine ofloxacin, sulfacetaminde, tobramycin, etc. MISCELLANEOUS CARDIOVASCULAR DRUGS---------
DRUGS FOR ALZHEIMER’S DISEASE-----------------------
ANTI-INFLAMMATORY AGENTS---------------------------
Flolan*(PA), Remodulin*(PA), Tracleer (PA), MULTIPLE SCLEROSIS AGENTS---------------------------
ANTICOAGULANTS/ANTITHROMBOTICS-------------
DIGESTANTS ---------------------------------------------------
dipyridamole, pentoxifylline, ticlopidine ANALGESICS, NARCOTIC---------------------------------------
ANTI-INFECTIVE AND ANTI-INFLAMMATORY
COMBINATIONS ---------------------------------------------
OTHER GI PRODUCTS -----------------------------------
Arixtra* (PA) Fragmin*(PA), Innohep*(PA), ANALGESICS, NSAIDs ----------------------------------------
NSAIDS-----------------------------------------------------------
RESPIRATORY / ASTHMA
diclofenac, diflunisal, etodolac, ibuprofen, DRUGS FOR ALLERGY -------------------------------
Oral Antihistamines and Combinations. . . . . . . .
RHEUMATOID ARTHRITIS AGENTS-----------------
ANTI-INFECTIVE AND ANTI-INFLAMMATORY
GENITO-URINARY
Allegra, Allegra D, Clarinex, Singulair, MIGRAINE AGENTS-------------------------------------------
COMBINATIONS ------------------------------------------------
ANTI-INFECTIVES------------------------------------------
This document is in effect beginning January 1, 2006. Formulary consultation and administrative support to provided by: DERMATOLOGICALS
MISC-DIAGNOSTICS ---------------------------------------
Tier 2
ACNE -------------------------------------------------------------
Coverage for diabetes test strips varies. Azelex (PA), Differin, Retin-A Micro (PA) ANTIBIOTICS ---------------------------------------------------
Tier 1
erythromycin, clindamycin, metronidazole Coverage for self-administered injectibles indicated with an asterisk (*) varies. Your prescription benefit ANTIVIRALS ----------------------------------------------------
may not cover these items. Please check your FUNGICIDES ----------------------------------------------------
clotrimazole, clotrimazole/betamethasone, Your plan may require authorization or documentation of previous therapy with other similar medications before the following medications will be covered: TOPICAL ANTI-INFLAMMATORY AGENTS---------
Low - Intermediate Potency . . . . . . . . . . . . . . . . .
Aclovate, Cloderm, Cordran, Locoid, Pandel Highest Potency . . . . . . . . . . . . . . . . . . . . . . . . . . .
INNOHEP, IRESSA, KINERET, KYTRIL, LEVITRA, OTHER DERMATOLOGICALS ----------------------------
REMODULIN, REVATIO, RILUTEK, SANDOSTATIN, VIAGRA, VENTAVIS, XELODA, XOLAIR, XOPENEX, Your plan may apply limiits on the amount of MISCELLANEOUS
medicine that a pharmacy can dispense for the CAVERJECT, CIALIS, CELEBREX, EDEX, EMEND, FROVA, IMITREX, KYTRIL, LEVITRA, MARINOL, This document is in effect beginning January 1, 2006. Formulary consultation and administrative support to provided by:

Source: http://www.pharmaceuticalhorizons.com/formulary/Formulary_042_Focus_Class.pdf