Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
1
FormularyGuide
horizonNJhealth.com
October 2017
Formulary_Pocket_Guide_October2017_FINAL.indd 1 9/22/17 4:08 PM
1
Please refer to this guide when prescribing for Horizon NJ Health members. This guide does not contain a complete list of drugs, rather it lists the preferred drugs within the most commonly prescribed therapeutic categories.
The medications included in the formulary are reviewed and approved by the Pharmacy and Therapeutics Committee, which includes practicing Physicians and Pharmacists from the Horizon NJ Health Provider community. The goal of the formulary is to provide cost-effective pharmacotherapy based on prospective, concurrent and retrospective review of medication therapies and utilization.
In order to request prior authorization or for a hard copy of the formulary, please contact the Horizon NJ Health Pharmacy Department at 1-800-682-9094 and be prepared to provide relevant clinical information that supports the medical necessity of the requested medication.
Note that many over-the-counter products are covered with a prescription and should be considered first-line therapy when appropriate. This formulary as well as a listing of limitations, prior authorization criteria, generic substitution procedures, step therapyprocedures and other pharmaceutical management methods are available online at horizonNJhealth.com.
Please note that Horizon NJ Health maximum days supply limit is 30 days.
Formulary_Pocket_Guide_October2017_FINAL.indd 1 9/22/17 4:08 PM
2
KEY:$ Lowest relative cost
!!!!!! Highest relative cost
+ Brand not covered, use available generic
↓ Dosage reduction below manufacturer guidelines may be required in patients over 65
∆ Use by patients over 65 is associated with increased risk; safer alternatives may be available. If used, dosage should generally be lowered
@ Requires prior authorization for medical necessity
* Limitations apply
◊ Subject to Step Therapy of first-line agents
Formulary_Pocket_Guide_October2017_FINAL.indd 2 9/22/17 4:08 PM
3
GLUCOCORTICOIDS
$$ * + prednisolone, oral solution$$ * + hydrocortisone$$ * + methylprednisolone$$ * + dexamethasone
TESTOSTERONE REPLACEMENT THERAPY$$$$ * + @ Testosterone 12.5mg/1.25g gel pump$$$$ * + @ Testosterone 25mg/2.5g gel packet, 50mg/5g gel packet$$$$ * @ Striant
PENICILLINS
$ + penicillin$ + ampicillin$ * + amoxicillin$ + dicloxacillin$$ * + amoxicillin clavulanate$$ Bicillin LA$$$ * Augmentin XR
TETRACYCLINES$ + doxycycline hyclate$$ + tetracycline HCI$$$ + minocycline HCL caps$$$ + doxycycline monohydrate
CEPHALOSPORINS$ + cephalexin$$ + cefaclor, cefadroxil$$ * + cefdinir$$ * + cefpodoxime$$ * + cefprozil$$ + cefuroxime$$ * Spectracef !!!!!! + ceftriaxone
ANDROGENS
ANTIINFECTIVES
ADRENOCORTICAL STEROIDS
Formulary_Pocket_Guide_October2017_FINAL.indd 3 9/22/17 4:08 PM
4
MACROLIDES$ * + clarithromycin, SR$$ * + azithromycin
QUINOLONES$$ * + ciprofloxacin (1 year and older)$$ * + levofloxacin (12 years and older)$$$ * + ciprofloxacin ER (18 years and older)$$$ * + moxifloxacin (12 years and older)
SULFAS AND RELATED AGENTS$ + sulfisoxazole$ + sulfadiazine$ * + sulfamethoxazole and trimethoprim$ + sulfisoxazole and erythromycin
URINARY TRACT AGENTS$ + trimethoprim$$ + nitrofurantoin macrocrystals$$$ + methenamine mandelate, hippurate
ANTIFUNGAL AGENTS$ + griseofulvin ultramicrosize$ * + nystatin$$ * + fluconazole$$$ * + terbinafine tablets$$$ * + itraconazole$$$ + flucytosine$$$$ * Sporanox oral solution !!!!!! @ Ambisome
ANTIMALARIAL AGENTS$ + chloroquine$ * + mefloquine$ + primaquine$ + quinine$$ + atovaquone/proguanil$$$ * Coartem
Formulary_Pocket_Guide_October2017_FINAL.indd 4 9/22/17 4:08 PM
5
ANTIRETROVIRAL AGENTS SOME MEMBERS MAY HAVE THEIR HIV/AIDS MEDICATIONS COVERED THROUGH
THE AIDS DRUGS DISTRIBUTION PROGRAM (ADDP).$$$$ * @ + abacavir$$$$ * @ + abacavir /lamivudine!!!!!! * @ Aptivus!!!!!! * @ Atripla!!!!!! * @ Complera!!!!!! * @ Crixivan$$$$ * @ + didanosine!!!!!! * @ Edurant!!!!!! * @ Emtriva!!!!!! * @ Fuzeon!!!!!! * @ Genvoya!!!!!! * @ Intelence!!!!!! * @ Invirase!!!!!! * @ Isentress!!!!!! * @ Kaletra$$$$ * @ + lamivudine$$$$ * @ + lamivudine/zidovudine!!!!!! * @ Lexiva$$$$ * @ + nevirapine!!!!!! * @ Norvir!!!!!! * @ Odefsey!!!!!! * @ Prezista!!!!!! * @ Rescriptor!!!!!! * @ Reyataz!!!!!! * @ Selzentry$$$$ * @ + stavudine!!!!!! * @ Stribild!!!!!! * @ Sustiva!!!!!! * @ Trizivir!!!!!! * @ Truvada!!!!!! * @ Videx!!!!!! * @ Viracept!!!!!! * @ Viramune XR!!!!!! * @ Viread!!!!!! * @ Vitekta$$$$ * @ + zidovudine
MISCELLANEOUS ANTIVIRALS$ ↓ + amantadine$$ * @ + ribavirin tablets, capsules$$$ + acyclovir$$$ * Relenza (5 years and older)$$$ * + oseltamivir
Formulary_Pocket_Guide_October2017_FINAL.indd 5 9/22/17 4:08 PM
6
MISCELLANEOUS ANTIVIRALS (Continued)$$$ * + valacyclovir$$$$ * Famvir!!!!!! * Valcyte, Cytovene
CARDIOVASCULARBETA BLOCKERS
$ + bisoprolol$ + atenolol, metoprolol$ + timolol, pindolol$$ + carvedilol$$ + nadolol$$ + propranolol$$ * + propranolol LA$$$ + labetalol$$$ * + acebutolol$$$ * + betaxolol$$$ * + metoprolol ER$$$ * Hemangeol (2 years and younger)
CALCIUM CHANNEL BLOCKERS$ * + amlodipine$ + diltiazem, SR$ + verapamil, long acting$ + nifedipine$ * + nicardipine$$ * + nifedipine XL$$$$ * Nymalize
ACE INHIBITORS$ * + fosinopril, hydrochlorothiazide$ * + moexipril, hydrochlorothiazide$$ * + enalapril, hydrochlorothiazide$$ * + lisinopril, hydrochlorothiazide$$ * + perindopril$$ * + quinapril, hydrochlorothiazide$$ * + ramipril$$ * + trandolapril
ANGIOTENSIN RECEPTOR BLOCKERS$$ * + losartan, hydrochlorothiazide$$$ * + irbesartan, hydrochlorothiazide$$$ * + valsartan, hydrochlorothiazide
CARDIOVASCULAR
Formulary_Pocket_Guide_October2017_FINAL.indd 6 9/22/17 4:08 PM
7
OTHER ANTIHYPERTENSIVE COMBINATIONS$$$ + amlodipine/benazepril$$$ + trandolapril/verapamil$$$$ * Bidil
ANTIARRHYTHMICS$ + amiodarone$ + disopyramide$ + mexiletine$ + procainamide$ + quinidine$$$ * Multaq
LIPID/CHOLESTEROL LOWERING AGENTS$ + gemfibrozil$ + niacin$ + cholestyramine$ + colestipol$ * + fenofibrate$$ * + lovastatin$$ * + pravastatin$$ * + simvastatin$$ * + atorvastatin $$ * + rosuvastatin$$ * + niacin ER $$$ * Welchol$$$ * ◊ @ + ezetimibe!!!!!! * @ Repatha
ANTIPLATELET AGENTS$ + aspirin$ + dipyridamole$$$ + ticlopidine$$$$ * + aspirin-dipyridamole ER!!!!!! * Agrylin
ANTICOAGULANT AGENTS$$ warfarin$$$$ * Pradaxa$$$$ * Xarelto$$$$ * Eliquis$$$$ + enoxaparin!!!!!! * Arixtra!!!!!! Fragmin!!!!!! Innohep!!!!!! * Iprivask
Formulary_Pocket_Guide_October2017_FINAL.indd 7 9/22/17 4:08 PM
8
DIURETICS$ + hydrochlorothiazide$ + indapamide$ + furosemide$ + bumetanide$ + torsemide$ + spirinolactone, hydrochlorothiazide$ + triamterene, hydrochlorothiazide$ + metolazone
PULMONARY ARTERIAL HYPERTENSION AGENTS$$$$ * + sildenafil 20mg tablet!!!!!! * Adcirca!!!!!! Flolan!!!!!! * Letairis!!!!!! * Remodulin!!!!!! * Revatio tablet!!!!!! * Tracleer!!!!!! * Tyvaso!!!!!! * Ventavis
HYPNOTIC AGENTS$ ↓ + chloral hydrate$ ∆ + flurazepam$ ↓ + triazolam$ ∆ ↓ + temazepam$$ ↓ + estazolam$$ * ↓ + zaleplon$$ * ↓ + zolpidem
TRICYCLIC ANTIDEPRESSANTS$ * ∆ + amitriptyline$ * ↓ +desipramine$ * ↓ + doxepin$ * ↓ + imipramine HCL $ * ↓ + nortriptyline$$ * ↓ + amoxapine$$ * ↓ + protriptyline$$$ * ↓ + clomipramine$$$ * ↓ + trimipramine
CENTRAL NERVOUS SYSTEM
Formulary_Pocket_Guide_October2017_FINAL.indd 8 9/22/17 4:08 PM
9
MISCELLANEOUS ANTIDEPRESSANTS$ * ↓ + trazodone$ * ↓ + maprotiline$$ * ↓ + bupropion, SR, XL 300 mg $$$ * ↓ + venlafaxine, ER$$$$ * ↓ Wellbutrin XL 150 mg$$$$ * ↓ + mirtazapine $$$$ * + duloxetine
MAO INHIBITORS$$ * ↓ Nardil $$$ * ↓ + tranylcypromine$$$ * ↓ Emsam
SELECTIVE SEROTONIN REUPTAKE INHIBITORS$$$ * + citalopram$$$ * ↓ + fluvoxamine$$$ * ↓ + fluoxetine capsule$$$ * ↓+ paroxetine, CR$$$ * ↓+ sertraline $$$$ * + escitalopram
ANTIPSYCHOTICS$ ↓ + fluphenazine, trifluoperazine$ ↓ + perphenazine$ ↓ + haloperidol, thiothixene$$ ↓ + chlorpromazine$$ ↓ Orap$$ * ↓ risperidone$$ * olanzapine, orally disintegrating tablets$$ * ↓ quetiapine$$ * ↓ ziprasidone$$ * olanzapine/fluoxetine$$$ ↓ + loxapine$$$$ ↓ Moban$$$$ * ↓ aripiprazole$$$$ * ↓ Abilify Maintena $$$$ * ↓ clozapine, orally disintegrating tablets$$$$ * ↓ + paliperidone $$$$ * Zyprexa Relprevv$$$$ * ↓ Risperdal Consta $$$$ * ↓ Invega Sustenna
Formulary_Pocket_Guide_October2017_FINAL.indd 9 9/22/17 4:08 PM
10
MISCELLANEOUS CNS AGENTS$ + lithium citrate, carbonate$$ * + methylphenidate, SR, ER$$ * + dexmethylphenidate$$ * + dextroamphetamine sulfate$$ * + amphetamine-dextroamphetamine, ER$$ * + guanfacine, ER$$$ * + atomoxetine$$$ * + methylphenidate CD$$$$ * @ + modafinil$$$$ * Cuvposa$$$$ * @ Nuedexta
TRIPTANS$$ * + sumatriptan$$ * + rizatriptan, MLT$$ * + naratriptan
ANTISEIZURE AGENTS$ phenytoin$ + phenobarbital, primidone$$ carbamazepine, ER$$ Carbatrol$$ + valproic acid$$ * + gabapentin$$ * + lamotrigine$$ + oxcarbazepine$$ * + zonisamide$$ + divalproex$$ * + levetiracetam, ER$$ * + topiramate$$$ + felbamate$$$ + ethosuximide!!!!!! tiagabine
ANTIPARKINSONISM AGENTS$ + amantadine$ * + benztropine$ * + carbidopa-levodopa$$ + pergolide$$ * + pramipexole$$ * + ropinirole, ER$$ * + selegiline$$$ + carbidopa-levodopa CR$$$ * + carbidopa-levodopa-entacapone
Formulary_Pocket_Guide_October2017_FINAL.indd 10 9/22/17 4:08 PM
11
ANTI-ALZHEIMER’S AGENTS$ * + galantamine$$$ * + memantine IR$$$ * + donepezil 5mg, 10mg$$$$ * Exelon, patch
ANALGESICS$$ + hydromorphone$$ * + hydrocodone/acetaminophen 325mg$$ + morphine sulfate immediate release$$ * + oxycodone, with acetaminophen$$ + oxymorphone IR$$$ + morphine sulfate ER, SR$$$ + oxycodone tablet$$$ * + tramadol, ER$$$ * @ + fentanyl patches$$$ @ + oral transmucosal fentanyl citrate$$$$ * @ + oxycodone controlled-release$$$$ * @ Oxycontin
NSAIDS$ + ibuprofen$ ∆ + indomethacin, SR$ ↓ + naproxen sodium$$ + diclofenac sodium$$ Children’s Advil, Motrin$$ + tolmetin$$ + diclofenac potassium $$$ ↓ + ketoprofen$$$ * + nabumetone$$$ * + meloxicam
NSAID COX II INHIBITORS$$$$ * + celecoxib
ANTIVERTIGO AND ANTI-EMETICS$ + meclizine$ + promethazine$ + trimethobenzamide$$ + prochlorperazine$$ * + ondansetron$$$$ * @ Emend
Formulary_Pocket_Guide_October2017_FINAL.indd 11 9/22/17 4:08 PM
12
MULTIPLE SCLEROSIS AGENTS$$$$ * Ampyra!!!!!! * Avonex!!!!!! * Betaseron!!!!!! @ + glatopa!!!!!! * Rebif!!!!!! * Tecfidera!!!!!! * Gilenya
$ Advil Cold and Sinus$ + dextromethorphan$ Dimetapp$ + guaifenesin$ Robitussin$ + promethazine/codeine
TOPICAL CORTICOSTEROIDS (VERY HIGH POTENCY)$$ * + clobetasol 0.05% cream$$ * + clobetasol E 0.05% cream
TOPICAL CORTICOSTEROIDS (HIGH POTENCY)$ * + betamethasone valerate 0.1% ointment$ * + fluocinonide 0.05% cream, gel$ * + triamcinolone acetonide 0.1% ointment$$ * + betamethasone dipropionate 0.05% ointment$$ * + desoximetasone 0.25% cream, ointment$$ * + desoximetasone 0.05% gel$$ * + fluocinonide 0.05% ointment
DERMATOLOGICALS/TOPICAL THERAPY
COUGH /COLD
Formulary_Pocket_Guide_October2017_FINAL.indd 12 9/22/17 4:08 PM
13
TOPICAL CORTICOSTEROIDS (MEDIUM POTENCY)$ * + betamethasone valerate 0.1% cream, lotion$ * + desonide cream$ * + fluocinolone acetonide 0.025% cream, ointment$ * + prednicarbate ointment$ * + triamcinolone acetonide 0.1% cream, ointment$ * + triamcinolone acetonide 0.5% cream, ointment$ * + triamcinolone acetonide 0.025% cream, ointment$ * + mometasone
TOPICAL CORTICOSTEROIDS (LOW POTENCY)$ * + hydrocortisone 1%, 0.5% cream, ointment$ * + hydrocortisone 1% lotion$ + hydrocortisone acetate 0.5%, 1% cream, ointment$$ * + alclometasone cream, ointment$$ * + fluocinolone acetonide 0.01% cream
TOPICAL ANTIFUNGALS$ * + ciclopirox 8% solution$ * + clotrimazole (OTC)$ * + ketoconazole cream$ * + miconazole nitrate (OTC)$ * + ciclopirox cream$ Fungoid$ * + ketoconazole 2% shampoo$ Nizoral A-D shampoo (OTC)$ * + tolnaftate (OTC)$ * + undecylenic acid$$ * + nystatin cream, ointment$$ * + econazole$$ * + nystatin/triamcinolone$$$ Pedi-Dri$$$$ * + clotrimazole/betamethasone cream
Formulary_Pocket_Guide_October2017_FINAL.indd 13 9/22/17 4:08 PM
14
ACNE THERAPYVitamin A derivatives are considered non covered pharmacy benefits for
members 35 years of age and older. $$ * + benzoyl peroxide cream/lotion/gel$$ * + sulfaceamide sodium/sulfur 10-5% emulsion$$ * + metronidazole 0.75% cream, lotion, gel$$$ * Differin OTC 0.1% gel (Not covered if ≥ 35 years old)
OTHER TOPICAL PRODUCTS$ * OTC Abreva$ * + OTC permethrin$$ * ◊ @ Denavir$$ * + mupirocin ointment$$ * + urea 50% nail stick$$$ * @ + imiquimod$$$ * Clindesse$$$ * ◊ @ + malathion lotion$$$ * ◊ @ + tacrolimus ointment$$$ * + diclofenac sodium 1% gel$$$ * @ + acyclovir ointment
PSORIASIS THERAPY$$$ * + calcipotriene!!!!!! @ Amevive
INSULIN THERAPY
$$$$ * Humulin 100 units/mL vials (only 3mL vials for Long-Term Care)$$$$ * Humalog 100 units/mL vials (only 3mL vials for Long-Term Care)$$$$ * Humalog Mix 75/25 vials$$$$ * Basaglar KwikPen
ORAL HYPOGLYCEMIC AGENTS$ * + glimepiride$ * + glipizide, XL$ * + glyburide$$ * + metformin, XR$$ * + metformin/glipizide
ENDOCRINE
Formulary_Pocket_Guide_October2017_FINAL.indd 14 9/22/17 4:08 PM
15
ORAL HYPOGLYCEMIC AGENTS (Continued)$$ * + repaglinide $$ * Precose, Glyset$$ * Riomet$$ * + glyburide/metformin$$ * Welchol$$$ * + nateglinide$$$$ * + pioglitazone, pioglitazone/metformin$$$$ * + pioglitazone/glimepiride$$$$ * + alogliptin$$$$ * + alogliptin/metformin$$$$ * + alogliptin/pioglitazone$$$$ * Avandia, Avandamet, Avandaryl$$$$$ * Jardiance$$$$$ * Synjardy
MISCELLANEOUS HYPOGLYCEMIC AGENTS$$$$$ * Victoza$$$$$ * Bydureon$$$$$ * Symlin
DIABETIC SUPPLIES (MONITORS AND STRIPS)$$ * Insulin syringes (B.D., Monoject)$$ Chemstrip BG$$ * One Touch (all products)$$ * Lancets, pen needle, single use swab
THYROID THERAPY$ levothyroxine$ + propylthiouracil$ + methimazole
Formulary_Pocket_Guide_October2017_FINAL.indd 15 9/22/17 4:08 PM
16
GASTROINTESTINAL
H2-RECEPTOR ANTAGONISTS$$ * Axid AR (OTC)$$ * + nizatidine$$ * + ranitidine (OTC), famotidine (OTC)$$ * + ranitidine syrup
PROTON PUMP INHIBITORS$ * + omeprazole (OTC), OTC omeprazole-magnesium$ * Prevacid 24HR (OTC)$ * Zegerid OTC$ * + pantoprazole$$ * Nexium 24HR (OTC) $$ * + lansoprazole capsules$$ * + legend omeprazole capsules$$ * + rabeprazole 20mg tablet
PANCREATIC ENZYMES!!!!!! Creon!!!!!! Zenpep
HEPATITIS C AGENTS$$ * @ + ribavirin tablets, capsules !!!!!! @ Intron A!!!!!! @ Peg-Intron!!!!!! * @ Pegasys!!!!!! * @ Zepatier
OTHER G.I. DRUGS$ * + dicyclomine$ + metoclopramide $ + polyethylene glycol$$ * + Gavilyte-N, Trilyte (generic Nulytely) $$ + misoprostol $$ + sucralfate$$$ * + alosetron$$$ * @ Amitiza$$$ * Apriso ER!!!!!! @ Cerezyme!!!!!! @ Elelyso
Formulary_Pocket_Guide_October2017_FINAL.indd 16 9/22/17 4:08 PM
17
GROWTH HORMONES!!!!!! @ Humatrope!!!!!! @ Zomacton
VACCINES$$ * @ Adacel$$ * @ Boostrix$$ * @ Engerix-B$$ * @ Gardasil$$ * @ Havrix$$ * @ Menactra$$ * @ Recombivax HB$$ * @ Twinrix$$ * @ Vaqta$$ * @ Zostavax (50 years and older)
INSULIN-LIKE GROWTH FACTOR!!!!!! Increlex
GROWTH HORMONE-RECEPTOR ANTAGONIST!!!!!! @ Somavert
GROWTH HORMONE-RELEASING FACTOR!!!!!! * Egrifta
ERYTHROID STIMULANTS!!!!!! @ Procrit
COLONY STIMULATING FACTORS!!!!!! * @ Zarxio!!!!!! * @ Neulasta
INTERFERON ALFA!!!!!! @ Roferon A!!!!!! @ Intron A!!!!!! @ PEG-Intron!!!!!! * @ Pegasys
SODIUM HYALURONATE!!!!!! @ Euflexxa
IMMUNOLOGY, VACCINES AND BIOTECHNOLOGY
Formulary_Pocket_Guide_October2017_FINAL.indd 17 9/22/17 4:08 PM
18
MISCELLANEOUS$$$ @ Benlysta!!!!!! Exjade!!!!!! * @ Arcalyst!!!!!! * @ Synagis
HEREDITARY ANGIOEDEMA THERAPY!!!!!! @ Berinert!!!!!! * @ Cinryze!!!!!! * @ Firazyr!!!!!! @ Kalbitor !!!!!! * @ Ruconest MISCELLANEOUS
IMMUNOSUPPRESSIVE AGENTS$ + azathioprine$ + mycophenolate$ + cyclosporine$ + tacrolimus$$ Rapamune!!!!!! Zortress
APPETITE STIMULANTS$ * + megestrol acetate
HYPERPARATHYROID TREATMENT$$$ Zemplar
MOUTH AND THROAT PRODUCTS$$ + clotrimazole troche$$ Prevident
ELECTROLYTE SUPPLEMENTATION$$ Phoslo
POLYMERIC PHOSPHATE BINDERS$$$$$ Renagel$$$$$ Fosrenol$$$$$ * Renvela tablets
SMOKING DETERRENTS$ * + nicotine chewing gum (18 years and older)$ * + nicotine lozenge (18 years and older)$ * + nicotine transdermal (18 years and older)$$$$ * + Zyban (18 years and older)$$$$ Evoxac
MISCELLANEOUS
Formulary_Pocket_Guide_October2017_FINAL.indd 18 9/22/17 4:08 PM
19
OPIOID / ALCOHOL ADDICTION TREATMENT
$$ * @ naltrexone$$$ * @ disulfiram$$$ * @ Campral$$$$ * @ buprenorphine$$$$ * @ + buprenorphine/naloxone tablets$$$$ * @ Vivitrol$$$$ * Narcan Nasal Spray
MUSCLE RELAXANTS$ + baclofen$ ∆+ chlorzoxazone, carisoprodol$ * ∆+ cyclobenzaprine$ ∆+ diazepam$$ + orphenadrine$$ ∆+ methocarbamol$$ * + tizanidine!!!!!! * @ Botox!!!!!! @ Myobloc
MISCELLANEOUS ANTIRHEUMATIC AGENTS$ + sulfasalazine$$ + methotrexate$$$ + hydroxychloroquine$$$$ + azathioprine!!!!!! * @ Enbrel, Humira
OSTEOPOROSIS THERAPY$$$ + calcitonin$$$ * + alendronate$$$$ * + calcitonin nasal spray$$$$ + raloxifene$$$$ * Fosamax plus D$$$$ * + risedronate 5mg, 30mg, 35mg
ANTIGOUT$ + allopurinol$$$ * + colchicine capsule
MUSCULOSKELETAL AND RHEUMATOLOGY
Formulary_Pocket_Guide_October2017_FINAL.indd 19 9/22/17 4:08 PM
20
PROGESTINS$ * + medroxyprogesterone$$ * Micronor, Nor QD, Camila, Jolivette, Norlyroc$$ Aygestin$$$ Progesterone Inj, suppos$$$$ * Depo-Provera 150!!!!!! * Makena
ESTROGENS$ + estropipate$ + micronized estradiol$ * + estradiol, estradiol patch, estradiol valerate injection$$ Premarin$$$ Cenestin$$$ Prometrium$$$ Ortho Dienestrol$$$ Menest$$$ Estrogel$$$ * Menostar$$$$ Estring, Femring
ESTROGEN COMBINATIONS$ + estradiol/norethindrone$ Prempro$ Premphase$$ + norethinedrone acetate/ethinyl estradiol$$$ Estratest, HS
MONOPHASIC ORAL CONTRACEPTIVES$$ * + Norinyl 1+50, Necon 1/50, Genora 1/50$$ * + Zovia 1/50$$ * + Norinyl 1+35, Nortrel 1/35, Necon 1+35, Genora 1/35, Alyacen$$ * + Necon, Nortrel, Brevicon 5/35$$ * + Jinteli 1mg/5mcg $$ * + Sprintec, Mononessa, Previfem$$ * + Zovia 1/35, Kelnor$$ * + Microgestin Fe, Junel Fe, Gildess +/- Fe, Larin Fe$$ * + Low-Ogestrel, Cryselle$$ * + Apri$$ * + Levora, Portia, Altavera, Chateal-28$$ * + Aviane, Lessina, Lutera, Orsythia-28
OBSTETRICS AND GYNECOLOGY
Formulary_Pocket_Guide_October2017_FINAL.indd 20 9/22/17 4:08 PM
21
BIPHASIC ORAL CONTRACEPTIVES$$ * + Necon 10/11$$ * + Kariva, Azurette, Viorele, Pimtrea
TRIPHASIC ORAL CONTRACEPTIVES$ * + Aranelle, Leena$$ * + Nortrel 7/7/7, Necon 7/7/7, Alyacen 7/7/7$$ * + Trivora, Enpresse$$ * + Tri-Sprintec, TriNessa, Tri-Previfem$$ * + TriNessa Lo$$ * + Velivet$$ * + Tri-Legest Fe, Tilia Fe
VAGINAL AGENTS$ OTC Monistat$ + OTC Clotrimazole$$ * + terconazole cream$$ * + Gynazole-1$$ * Clindesse$$ * Metrogel vaginal$$ * Vagifem
OTHER$$ * + levonorgestrel/Next Choice One Dose (generic Plan B One-Step)$$$$ Lunelle
ANTI-INFECTIVES
$ + tobramycin$ + ciprofloxacin ophthalmic suspension$$ * Ciloxan ophthalmic ointment$$ * + tobramycin-dexamethasone ophthalmic drops$$ * + levofloxacin ophthalmic drops$$ * + ofloxacin ophthalmic drops$$$ * Tobrex ophthalmic ointment$$$$ * Tobradex ophthalmic ointment
ALLERGIC CONJUNCTIVITIS$ Visine-A, Naphcon-A$ + cromolyn$ * Alaway/Zaditor OTC$$$ Alocril$$$ * ◊ @ + olopatadine 0.1%
OPHTHALMOLOGY
Formulary_Pocket_Guide_October2017_FINAL.indd 21 9/22/17 4:08 PM
22
NSAIDS$$ + ketorolac$$$$ * Acular LS$$$$ Voltaren
ANTIGLAUCOMA AGENTS$ * + timolol$ * + latanoprost$$ + dorzolamide hydrochloride/timolol maleate$$ + levobunolol$$ + timolol XE$$$ + apraclonidine$$$ * + brimonidine tartrate 0.2%, 0.15%$$$$ Betoptic S
MACULAR DEGENERATION AGENTS!!!!!! * Eylea!!!!!! * Lucentis!!!!!! * Macugen
ANTI-INFECTIVES
$ * + neomycin/polymixin/bacitracin$$ * + ciprofloxacin 0.2% ear solution$$$ * Cipro HC$$$ + ofloxacin otic$$$ * Ciprodex
MISCELLANEOUS$ * + antipyrine/benzocaine$$ * + acetic acid/aluminum$$$ * + fluocinolone acetonide oil
OTIC
Formulary_Pocket_Guide_October2017_FINAL.indd 22 9/22/17 4:08 PM
23
ANTIHISTAMINES$ * + cetirizine, cetirizine/pseudoephedrine (OTC)$ ∆ + chlorpheniramine (OTC)$ ∆ + cyproheptadine$ ∆ + diphenhydramine (OTC)$ ∆ + hydroxyzine$ + meclizine$ ∆ + promethazine (2 years and older)$ ∆ + tripelennamine $$ ∆ + clemastine$$ ∆ + dexchlorpheniramine$$ * + loratadine, loratadine/pseudoephedrine (OTC)$$ * Alavert$$ * + fexofenadine (180mg, 30mg/5mL), fexofenadine/pseudoephedrine (OTC)$$ * + levocetirizine 5mg tablet$$$ * + azelastine nasal spray
INHALED BETA AGONISTS$ * + albuterol aerosol$$ + isoetharine solution$$ * + albuterol solution for inhalation$$$ * Ventolin HFA $$$ * Serevent, Diskus
INHALED CORTICOSTEROIDS$$$ * Qvar$$$ * budesonide nebulizer solution (under 9 years of age)$$$$ * Pulmicort respules (under 9 years of age)$$$$ * Flovent HFA$$$$ * Asmanex Twisthaler, HFA
INTRANASAL STEROIDS$ * + fluticasone$ * Nasacort Allergy 24HR (OTC)
RESPIRATORY
Formulary_Pocket_Guide_October2017_FINAL.indd 23 9/22/17 4:08 PM
24
MISCELLANEOUS PULMONARY AGENTS$ * + benzonatate (11 years and older)$$ * theophylline$$ * + cromolyn nebulizer solution$$$ * + fluticasone/salmeterol (generic AirDuo)$$$ * Atrovent MDI, solution$$$ * Combivent $$$ * + ipratropium albuterol solution$$$ * Accuneb$$$ * + montelukast$$$ * Tilade, nebulizer solution$$$ + acetylcysteine$$$$ * Intal$$$$ * Spiriva Handihaler $$$$ * Tudorza$$$$$ * Pulmozyme!!!!!! * @ Cayston!!!!!! * @ Kalydeco!!!!!! * + tobramycin inhalation solution!!!!!! * @ Xolair!!!!!! * @ Orkambi!!!!!! * @ Nucala
RESPIRATORY DEVICES$ * OptiChamber Advantage, Diamond$ * Respironics OptionHome, Innospire Essence Compressor Nebulizer System
Formulary_Pocket_Guide_October2017_FINAL.indd 24 9/22/17 4:08 PM
25
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY$$ + doxazosin$$ * + finasteride$$ + tamsulosin$$ + terazosin$$ * + alfuzosin$$ * + dutasteride$$ * + dutasteride/tamsulosin
ANTICHOLINERGICS$ * Oxytrol (OTC)$ * + oxybutynin, XL$ * + trospium$$ * + tolterodine, ER $$$ * + darifenacin ER
INTERSTITIAL CYSTITIS AGENTS$ * + phenazopyridine!!!!!! Elmiron
MISCELLANEOUS$$$$ * @ Lupron, Zoladex, Eligard
UROLOGICS
Formulary_Pocket_Guide_October2017_FINAL.indd 25 9/22/17 4:08 PM
26
MULTIPLE VITAMINS$ Multi-Vitamins (manufacturer Rugby)$ Therems FC$ Freedavite$ + daily-vite$ V-C Forte$ * Citrical-Vit D$ Centrum$ + multivital $ Renax
MULTIPLE VITAMINS WITH IRON$ * + ferrex 150$ * Hematogen FA$ * + hematogen Forte$ * + dualvit F$$ * Ircon
PEDIATRIC MULTIPLE VITAMINS$ * + pediavit$$ * + children’s multivitamin chew$$ * + tri-vitamin$$ * Centrum Kids$$ * multivitamin drops (generic Poly-Vi-Sol)
PRENATAL VITAMINS$ * PNV$ * Vol-tab Rx$ * Vol-plus$ * Trinate$ * OTC One-a-Day Women’s Prenatal with DHA
VITAMINS
Formulary_Pocket_Guide_October2017_FINAL.indd 26 9/22/17 4:08 PM
Horizon NJ Health Pharmacy Department210 Silvia StreetWest Trenton, NJ 08628Phone: 1-800-682-9094Fax: 1-609-538-0847
Horizon NJ Health is part of the Horizon Blue Cross Blue Shield of New Jersey enterprise, an independent licensee of the Blue Cross and Blue Shield Association. © 2017 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.
horizonNJhealth.com
Formulary_Pocket_Guide_October2017_FINAL.indd 27 9/22/17 4:08 PM