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Table of Contents
Section
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INTRODUCTION ................................................................................. I-1
ANTI-INFECTIVE AGENTS .................................................................. 1
BIOLOGICALS........................................................................................ 4
ANTINEOPLASTICS .............................................................................. 4
ENDOCRINE & METABOLIC DRUGS................................................. 5
CARDIOVASCULAR AGENTS ............................................................. 8
RESPIRATORY AGENTS .................................................................... 11
GASTROINTESTINAL AGENTS......................................................... 12
GENITOURINARY ............................................................................... 14
CENTRAL NERVOUS SYSTEM DRUGS ........................................... 15
ANALGESICS & ANESTHETICS........................................................ 15
NEUROMUSCULAR DRUGS .............................................................. 17
NUTRITIONAL PRODUCTS................................................................ 18
HEMATOLOGICAL AGENTS ............................................................. 19
BEHAVIORAL HEALTH AGENTS ..................................................... 20
TOPICAL PRODUCTS.......................................................................... 21
MISCELLANEOUS PRODUCTS ......................................................... 24
PRIOR AUTHORIZATION GUIDELINES ......................................PA-1
INDEX ..............................................................................................IDX-1
FGGGG
BioScrip/Jai Medical Systems
2006 Therapeutic Formulary
This formulary describes the circumstances under which pharmacies
participating in a particular medical benefit program will be reimbursed for
medications dispensed to patients covered by the program. This formulary
does not:
a) Require or prohibit the prescribing or dispensing of any medication.
b) Substitute for the independent professional judgment of the physician
or pharmacist.
c) Relieve the physician or pharmacist of any obligation to the patient or
others.
I. Non-Prescription Medication Policy
This program does not cover most over-the-counter medications (OTC).
The only exceptions to this policy are listed within the program formulary.
Furthermore, an OTC medication can be reimbursed only if it is written on
a valid prescription form by a licensed prescriber.
II. Unapproved Use of Formulary Medication
Medication coverage under this program is limited to non-experimental
indications as approved by the FDA. Other indications, which are
accepted as safe and effective by the balance of current medical opinion
and available scientific evidence, may also be covered. BioScrip, utilizing
the procedures outlined in section IV, will make decisions about
reimbursement for these other indications. Experimental, investigational
drugs, and drugs used for cosmetic purposes are not eligible for coverage.
III. Prior Authorization Procedure
To promote the most appropriate utilization of selected high risk and/or
high cost medication, a prior authorization procedure has been created.
The criteria for this system has been established by the BioScrip/Jai
Medical Systems program with input from pharmacists and
I-1
physician practitioners and in consideration of the available medical
literature. The Pharmacy and Therapeutics Committee will have final
approval responsibility for this list. In order for a dispensed prior
authorization medication to be reimbursed to the pharmacy, the patient’s
prescribing physician must apply for pre-authorization for a specific
patient and drug. The physician may phone or fax BioScrip to request
prior authorization:
BioScrip
Prior Authorization Desk
2787 Charter Street
Columbus, Ohio 43228
(800) 555-8513
(800) 583-6010 (fax)
Please have patient information, including member I.D. number,
complete diagnosis, medication history and current medications
readily available.
These phone lines are dedicated to physicians making requests for prior
authorization medication and non-formulary items. Members cannot be
assisted if they call the prior-authorization toll-free number. For emergent
requests for drugs requiring prior-authorization, a response will be made
within 24 business hours. For Non-Emergent requests for drugs requiring
prior-authorization, a response will be provided within 72 hours of receipt
of information. If the request is approved, information in the on-line
pharmacy claims processing system will be changed to allow the specific
patient to receive this specific drug. A prior authorization number will be
issued to the prescribing physician and is to be clearly written on the top of
the prescription to inform the dispensing pharmacist of the approval. This
number is for identification purposes only and does not need to be
submitted for adjudication to occur. If the request is denied, information
about the denial will be provided to the physician.
In addition to those products that require prior authorization all injectables
(except Depo-Provera, Insulin, Glucagon Kit, and Epi-Pen) require prior
approval. Questions about injectable drugs administered by homehealth or
healthcare providers should be directed to Jai Medical Systems Provider
Relations at 1-888-JAI-1999.
I-2
IV. Unique Patient Needs Non-Formulary Medication
This formulary attempts to provide appropriate and cost effective drug
therapy to all participants in the BioScrip/Jai Medical Systems program. If
a patient requires medication that is not covered by the formulary, a
request can be made for payment for the non-covered item. It is
anticipated that such exceptions will be rare, and that formulary
medications will be appropriate to treat the vast majority of medical
conditions. Requests for non-formulary medications should be made in
writing (on the “Medical Necessity form” if possible) and mailed or faxed
to:
BioScrip
Medical Necessity Desk
2787 Charter Street
Columbus, Ohio 43228
(800) 555-8513
(800) 583-6010 (fax)
Appropriate documentation must be provided to support the request. For
emergent requests for drugs requiring prior-authorization, a response will
be made within 24 business hours. For Non-Emergent requests for drugs
requiring prior-authorization, a response will be provided within 72 hours
of receipt of information. Approval of non-formulary items will be based
upon criteria developed by the Pharmacy and Therapeutics Committee of
Jai Medical Systems and BioScrip.
Physicians are expected to comply with this formulary when prescribing
medication for those patients covered by the BioScrip/Jai Medical Systems
plan. If a pharmacist receives a prescription for a non-formulary
medication, the pharmacist should attempt to contact the prescribing
physician to request a change to a product included in this formulary
guide.
The pharmacy will not be reimbursed for non-formulary medications. In
an emergency situation outside of BioScrip’s regular business hours,
where the physician cannot be contacted, the pharmacist is authorized
to dispense a 72 hour emergency supply of a medication, unless the
medication is classified as a DESI, LTE or specifically excluded drug
category (see section VI) product.
The pharmacist should contact BioScrip’s Help Desk at
(800) 213-5640 during regular business hours to arrange for
reimbursement for the emergency supply.
I-3
V. Newly Marketed Products
Newly marketed drug products will not normally be placed on the
formulary during their first year on the market. Exceptions to this rule will
be made on a case by case basis using the medical necessity procedure.
VI. Specific Exclusions
The following drug categories are not part of the BioScrip/Jai Medical
Systems formulary and are not covered by the 72-hour emergency supply
reimbursement policy:
Antiobesity products
Biologicals
Blood and blood plasma
Cosmetic drugs
Cough and cold products (except those listed in formulary)
DESI drugs
Diagnostic products (except those listed in formulary)
Erectile Dysfunction
Injectables (except for in-home use administered by patient)
Medical supplies and durable medical equipment (except certain
diabetic supplies)
Most vitamins
Nutritional and dietary supplements
Research drugs
Topical minoxidil
VII.
Specific Exclusions for PAC members
In addition to the above exclusions PAC members are also excluded from
the following:
HIV drugs
Mental Health drugs are excluded (except when written by a Jai
PCP)
I-4
VIII. Mandatory Generic Substitution
Generic substitution is mandatory when a generic equivalent is available.
All branded products that have 3 or more generic equivalents available will
be reimbursed at the maximum allowable cost.
IX. Behavioral Health Medication Policy
Please refer to the Maryland Department of Health and Mental Hygiene’s
Mental Health Formulary for a complete listing of behavioral health
medications. Any behavioral health medications that are covered by Jai
Medical Systems are listed in the prescription formulary.
X. General Parameters
•
Valid Maryland Medicaid and DEA numbers are required. Physicians
without numbers should contact ScripSolutions at
1-800-230-8189.
•
Refill too soon - 75% of the day’s supply must elapse before the
prescription can be refilled.
•
Maximum allowable quantity is a 30 days supply. The quantity limit
on narcotics is 120 units per 30 days; most other medications have a
400-unit maximum limit per month. If necessary, a healthcare provider
may obtain a quantity override by contacting BioScrip.
•
No vacation fills are allowed.
•
No overrides for lost or stolen prescriptions are allowed.
I-5
XI. Where to Call?
PHYSICIANS
Formulary Questions:
BioScrip
(800) 555-8513
Medical Necessity:
BioScrip
(800) 555-8513
Prior Authorization:
BioScrip
(800) 555-8513
Provider Relations:
Jai Medical Systems, Inc.
(888) JAI-1999
PHARMACISTS
Provider Network Questions:
BioScrip
(800) 230-8187
Provider Relations:
BioScrip
(800) 213-5640
XII. Abbreviations
Providers are encouraged to prescribe generically available drugs
whenever possible and to prescribe first-line lower cost options when
appropriate. Drugs are ranked by cost with the following abbreviations:
*
=
$
$$
$$$
$$$$
$$$$$
=
=
=
=
=
This product has a MAC price attached to some or
all strengths.
Cost per Rx is <$20
Cost per Rx is <$40
Cost per Rx is $40 - $80
Cost per Rx is $80 - $160
Cost per Rx is >$160
I-6
XIII. Reference
Quarterly changes can be made to this formulary. For reference purposes,
The Department of Health and Mental Hygiene operates a website that is
updated regularly with any additions and/or subtractions to this list of
medications. Jai Medical Systems participates in the Maryland
HealthChoice Medicaid Program. As a Managed Care Organization
participating with HealthChoice, Jai Medical Systems formulary can be
found at the website listed below:
www.mdmahealthchoicerx.com
I-7
FGGGG
Prescription Formulary
FGGGG
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
AMOXIL
TOTACILLIN
BICILLIN
PEN VEE K
no chewables
I. ANTI-INFECTIVE AGENTS
PENICILLINS
$
$
$
$
Amoxicillin*
Ampicillin*
Penicillin G Benzathine
Penicillin V Potassium*
Penicillinase-resistant
$ Cloxacillin Sodium
CLOXAPEN
Prior Authorization Required
$ Dicloxacillin Sodium*
DYCILL
$ Oxacillin*
OXACILLIN
Penicillin Combinations
$$$ Amox & K Clav*
AUGMENTIN
no chewables
Cephalosporins - 1st Generation
$ Cephalexin*
$ Cephradine*
KEFLEX
VELOSEF
no tablets
Cephalosporins - 2nd Generation
$$$ Cefaclor*
$$$ Cefprozil*
$$$ Cefuroxime*
$$$ Loracarbef
CECLOR
CEFZIL
CEFTIN
LORABID SUSPENSION
CEPHALOSPORINS
Cephalosporins - 3rd Generation
$$$ Ceftriaxone*
ROCEPHIN
$$$$ Cefdinir
OMNICEF
Prior Authorization Required
oral tablets only
covered for children
under 12 yrs old
suspension only
MACROLIDE ANTIBIOTICS
Erythromycins
$ Erythromycin Base*
$ Erythromycin Estolate*
$ Erythromycin Ethylsuccinate*
$ Erythromycin Stearate*
ERY-TAB
ILOSONE
E.E.S.
ERYTHROCIN
Lincomycins
$$ Clindamycin*
CLEOCIN
Misc. Macrolide Antibiotics
$$$ Azithromycin*
ZITHROMAX
(requires PA after 1 x 1gm susp. single dose dispensed)
$$$ Clarithromycin*
BIAXIN
Prior Authorization Required
1
no 500mg tabs
no chewables
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
VIBRAMYCIN
SUMYCIN
no tablets
TETRACYCLINES
$ Doxycycline*
$ Tetracycline*
FLUOROQUINOLONES
$$$ Ciprofloxacin*
CIPRO
(requires PA after 1 tablet dispensed)
$$$$ Moxifloxacin
AVELOX
Prior Authorization Required
ANTIMALARIAL
$ Chloroquine*
$ Hydroxychloroquine*
$ Quinine*
ARALEN
PLAQUENIL
QUININE
no 500mg tabs
ANTHELMINTIC
$$ Albendazole
$$$$$ Mebendazole*
$$$$$ Pyrantel Pamoate
ALBENZA
VERMOX
PIN - X
OTC product
GARAMYCIN
NEOMYCIN
tablets only
AMINOGLYCOSIDES
$ Gentamicin Sulfate*
$ Neomycin Sulfate*
SULFONAMIDES
$
$
$
$
$$
Erythromycin/Sulfisoxazole*
Sulfadiazine*
Sulfasalazine*
Trimethoprim/Sulfamethoxazole*
Sulfisoxazole*
PEDIAZOLE
MICROSULFON
AZULFIDINE
BACTRIM / DS
GANTRISIN
ANTIMYCOBACTERIAL AGENTS
$
$$$
$$$
$$$$
$$$$$
$$$$$
$$$$$
Isoniazid*
Cycloserine
Ethionamide
Rifabutin
Ethambutol*
Pyrazinamide*
Rifampin*
INH
SEROMYCIN
TRECATOR-SC
MYCOBUTIN
MYAMBUTOL
PYRAZINAMIDE
RIFADIN
MISC. ANTIINFECTIVES
$ Metronidazole*
$ Trimethoprim*
Leprostatics
$ Dapsone*
FLAGYL
PROLOPRIM
DAPSONE
2
no EN tabs
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
ANTIFUNGALS
$ Griseofulvin Microsize
$ Griseofulvin Ultramicrosize*
$$ Nystatin*
GRIFULVIN V
GRIS-PEG
MYCOSTATIN
Imidazole-Related Antifungals
$ Miconazole*
MONISTAT
$$$ Ketoconazole*
NIZORAL
$$$$ Itraconazole*
SPORANOX
Prior Authorization Required
Triazoles
$$$$ Fluconazole*
DIFLUCAN
Prior Authorization Required
(requires PA after 1 x 150mg dispensed)
ANTIVIRAL
Antiretrovirals - Protease Inhibitors
$$$$$ Indinavir Sulfate
CRIXIVAN
$$$$$ Nelfinavir Mesylate
VIRACEPT
$$$$$ Ritonavir
NORVIR
$$$$$ Saquinavir
FORTOVASE / INVIRASE
$$$$$ Tenofovir
VIREAD
$$$$$ Atazanavir
REYATAZ
$$$$$ Fosamprenavir Calcium
LEXIVA
$$$$$ Tripranavir
APTIVUS
Prior Authorization Required
Antiretrovirals - RTI-Nucleoside Analogues
$$$$$ Abacavir
$$$$$ Amprenavir
$$$$$ Delavirdine
$$$$$ Didanosine
$$$$$ Efavirenz
$$$$$ Emtricitabine
$$$$$ Lamivudine
$$$$$ Nevirapine
$$$$$ Stavudine
$$$$$ Zalcitabine
$$$$$ Zidovudine*
ZIAGEN
AGENERASE
RESCRIPTOR
VIDEX / VIDEX EC
SUSTIVA
EMTRIVA
EPIVIR
VIRAMUNE
ZERIT
HIVID
RETROVIR
Antiretroviral Combinations
$$$$$ Abacavir/Lamivudine
$$$$$ Abacavir/Lamivudine/Zidovudine
$$$$$ Lopinavir/Ritonavir
$$$$$ Tenofovir disoproxil/Emtricitabine
$$$$$ Zidovudine/lamivudine
EPZICOM
TRIZIVIR
KALETRA
TRUVADA
COMBIVIR
3
OTC product
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
CMV Agents
$$$$ Ganciclovir*
Fusion Inhibitor
$$$$$ Enfuvirtide
Brand Name
Annotation
CYTOVENE
FUZEON
Prior Authorization Required
Hepatic Agents
$$$$$ Peginterferon
PEG-INTRON
$$$$$ Ribavirin*
REBETOL
Prior Authorization Required
Herpes Agents
$$ Amantadine*
$$$ Acyclovir*
SYMMETREL
ZOVIRAX
ANTIMALARIAL
$ Pyrimethamine
DARAPRIM
II. BIOLOGICALS
ANTISERA
Antiviral Monoclonal Antibodies
$$$$$ Palivizumab
SYNAGIS
Prior Authorization Required
III. ANTINEOPLASTICS
ANTINEOPLASTICS
Alkylating Agents
$$$$$ Busulfan
MYLERAN
Nitrogen Mustards
$$$$$ Chlorambucil
$$$$$ Cyclophosphamide*
$$$$$ Melphalan
LEUKERAN
CYTOXAN
ALKERAN
Nitrosoureas
$$$$$ Lomustine
CEENU
Antimetabolites
$$$$ Methotrexate*
$$$$$ Capecitabine
$$$$$ Fluouracil*
$$$$$ Mercaptopurine*
$$$$$ Thioguanine
RHEUMATREX
XELODA
EFUDEX
PURINETHOL
THIOGUANINE
Androgens-Antineoplastic
$$$$$ Testolactone
TESLAC
4
PA for ointment
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Progestins-Antineoplastic
$$$$ Megestrol*
MEGACE
Antiandrogens
$$$$$ Flutamide*
EULEXIN
Aromatase Inhibitors
$$$$$ Letrozole
FEMARA
Annotation
Antineoplastic Hormones Misc.
$$$$$ Tamoxifen*
NOLVADEX
$$$$$ Leuprolide
LUPRON
Prior Authorization Required
Mitotic Inhibitors
$$$$ Etoposide*
VEPESID
Antineoplastics Misc.
$ Procarbazine
MATULANE
$$$$ Hydroxyurea*
HYDREA
$$$$$ Mitotane
LYSODREN
$$$$$ Interferon Alfa-2A
ROFERON-A
$$$$$ Interferon Alfa-2B
INTRON-A
$$$$$ Interferon Alfa-n3
ALFERON N
$$$$$ Interferon Beta-1a
AVONEX
$$$$$ Interferon Beta-1b*
BETASERON
Prior Authorization Required
IV. ENDOCRINE & METABOLIC DRUGS
CORTICOSTEROIDS
Glucocorticosteroids
$ Cortisone*
$ Dexamethasone*
$ Hydrocortisone*
$ Methylprednisolone*
$ Prednisolone*
$ Prednisone*
$$$ Prednisolone Na Phosphate*
CORTONE
DECADRON
CORTEF
MEDROL
PRELONE
DELTASONE
PEDIAPRED
Mineralocorticoids
$$ Fludrocortisone*
FLORINEF
ANDROGEN-ANABOLIC
Androgens
$$ Fluoxymesterone*
$$$ Methyltestosterone
$$$$$ Danocrine
HALOTESTIN
ANDROID
DANAZOL
ESTROGENS
$ Estradiol*
$$ Esterified Estrogens
ESTRACE
MENEST
5
no dose paks
no dose paks
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
$$ Estrogens, Conjugated
PREMARIN
$$$$ Estradiol Patch*
CLIMARA
Prior Authorization Required
Estrogen Combinations
$$ Conjugated Estrogens &
Medroxyprogesterone*
PREMPRO
CONTRACEPTIVES
Progestin OC's
$$$ Norethindrone*
ERRIN, CAMILA
Combinations OC's
$$ Ethynodiol Diacet & Eth Estrad*
$$ Levonorgestrel & Eth Estradiol*
$$ Norethindrone & Eth Estradiol*
$$ Norgestrel & Ethinyl Estradiol*
$$ Desogest/Eth Est & Ethin Estradiol*
$$ Desogestral & Ethinyl Estradiol*
$$$ Norgestimate & Ethinyl Estradiol*
$$$ Norelgestromin-Ethinyl Estradiol
ZOVIA
AVIANE, LEVORA
NECON, MICROGESTIN FE, NORTREL
CRYSELLE
KARIVA
APRI, ORTHOCEPT
SPRINTEC
ORTHO EVRA PATCH
Triphasic OC's
$$ Levonorgestrel-Eth Estradiol*
$$ Norethindrone-Ethinyl Estrad*
$$$ Norgestimate-Ethinyl Estradiol*
TRIVORA
NORTREL 7/7/7, NECON 7/7/7, TRI-NORINYL
ORTHO TRI-CYCLEN
PROGESTINS
$ Medroxyprogesterone*
$ Norethindrone*
$$$ Medroxyprogesterone Depot*
PROVERA
AYGESTIN
DEPO-PROVERA
tabs only/females only
150mg inj. only
ANTIDIABETIC
Thiazolidinediones/Combination
$$$$
Rosiglitazone Maleate-Metformin Hcl
AVANDAMET
$$$$
Rosiglitazone Maleate
AVANDIA
Prior Authorization Required
Human Insulin
$Insulin Aspart
$ Insulin Isophane
$ Insulin Isophane
$ Insulin Lispro
$ Insulin Reg & Isophane
$ Insulin Reg & NPH
$ Insulin Reg & NPH
$ Insulin Regular
$ Insulin Regular
$ Insulin Zinc
$ Insulin Zinc Extended
NOVOLOG
HUMULIN N
NOVOLIN N
HUMALOG
HUMULIN 50/50
HUMULIN 70/30
NOVOLIN 70/30
HUMULIN R
NOVOLIN R
HUMULIN L
HUMULIN U
$$ Insulin Glargine
LANTUS
Prior Authorization Required
6
vials only
vials only
vials only
vials only / age limit<18yrs
vials only
vials only
vials only
vials only
vials only
vials only
vials only
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Sulfonylureas
$ Acetohexamide*
$ Chlorpropamide*
$ Tolazamide*
$ Tolbutamide*
$$ Glipizide*
$$ Glyburide*
Brand Name
DYMELOR
DIABINESE
TOLINASE
ORINASE
GLUCOTROL/XL
DIABETA, GLYNASE
Alpha-Glucosidase Inhibitors
$$ Acarbose
PRECOSE
Prior Authorization Required
Incretin Mimetic
$$$$$ Exenatide
BYETTA
Prior Authorization Required
Diabetic Other
$$ Metformin*
$$$ Glucagon
GLUCOPHAGE
GLUCAGON
THYROID
Thyroid Hormones
$ Levothyroxine*
$ Liothyronine
$ Thyroid*
LEVOXYL,SYNTHROID
CYTOMEL
THYROID
Antithyroid Agents
$ Methimazole*
$ Propylthiouracil*
TAPAZOLE
PROPYLTHIOURACIL
OXYTOCICS
$ Ergonovine
$ Methylergonovine
ERGOTRATE
METHERGINE
MISC. ENDOCRINE
Calcium Regulators
$$$$$ Calcitonin (Salmon)
MIACALCIN NASAL
$$$$ Calcitonin (Salmon)
MIACALCIN INJ
Prior Authorization Required
Hormone Receptor Modulators
$$$ Raloxifene
EVISTA
Prior Authorization Required
Gonadotropin Releasing Hormones
$$$$$ Nafarelin
SYNAREL
Prior Authorization Required
Growth Hormone
$$$$$ Somatropin
HUMATROPE ONLY
Prior Authorization Required
7
Annotation
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Posterior Pituitary
$$$ Alendronate
FOSAMAX ONLY
$$$$ Desmopressin*
DDAVP
Prior Authorization Required
Annotation
(all dosage forms)
V. CARDIOVASCULAR AGENTS
CARDIOTONICS
Digitalis
$ Digoxin*
LANOXIN
ANTIANGINAL AGENTS
Nitrates
$
$
$$$
$$
Isosorbide Dinitrate*
ISORDIL, ISORDIL TEMBIDS
Nitroglycerin (oral)*
NITROL, NITROSTAT
Nitroglycerin (topical)*
NITRODUR,NITROBID
Isosorbide Mononitrate*
IMDUR
Prior Authorization Required
Antianginals-Other
$ Dipyridamole*
PERSANTINE
BETA BLOCKERS
Beta Blockers Non-Selective
$ Propranolol*
INDERAL / LA
$ Timolol*
BLOCADREN
$$$$ Sotalol*
BETAPACE
$$$ Carvedilol
COREG
Prior Authorization Required
Beta Blockers Cardio-Selective
$ Atenolol*
$ Metoprolol Tartrate*
TENORMIN
LOPRESSOR
Alpha-Beta Blockers
$$$ Labetalol*
NORMODYNE
CALCIUM BLOCKERS
$$
$$
$$$
$$$
$$$
Felodipine*
Verapamil*
Diltiazem*
Nifedipine*
Amlodipine
PLENDIL
CALAN, SR
CARDIZEM/CD,DILACOR/XR
ADALAT CC, PROCARDIA XL
NORVASC
ANTIARRHYTHMIC
$
$
$
$$$
Disopyramide*
Procainamide*
Quinidine Sulfate*
Flecainide*
NORPACE, CR
PRONESTYL, PROCANBID
QUINORA
TAMBOCOR
8
no caps
BioScrip/Jai Medical Systems Therapeutic Formulary
$$$$
$$$$
$$$$
$$$$
Generic Name
Brand Name
Amiodarone*
Mexiletine*
Moricizine
Propafenone*
CORDARONE
MEXITIL
ETHMOZINE
RYTHMOL
Annotation
ANTIHYPERTENSIVE
ACE Inhibitors
$ Captopril*
$$ Benazepril*
$$ Enalapril*
$$ Fosinopril*
$$ Lisinopril*
ACE II Inhibitors
$$$$ Irbesartan
CAPOTEN
LOTENSIN
VASOTEC
MONOPRIL
ZESTRIL
AVAPRO
Prior Authorization Required
Adrenolytics - Central
$ Clonidine*
$ Guanfacine*
$ Methyldopa*
CATAPRES
TENEX
ALDOMET
Adrenolytics - Peripheral
$ Reserpine*
RESERPINE
no patches
Alpha Blockers
$ Prazosin*
MINIPRESS
$$$ Phenoxybenzamine
DIBENZYLINE
$$$ Terazosin*
HYTRIN
$$$ Tamsulosin
FLOMAX
Prior Authorization Required
Vasodilators
$ Hydralazine*
$ Minoxidil*
APRESOLINE
LONITEN
Reserpine Combinations
$ Hydralazine-Reserpine-HCTZ*
$ Reserpine & HCTZ*
SER-AP-ES
HYDROPRES
Beta Blocker Combinations
$ Atenolol & Chlorthalidone*
$ Propranolol & HCTZ*
TENORETIC
INDERIDE
Ace Inhibitors & Diazides
$$ Lisinopril & HCTZ*
ZESTORETIC
Adrenolytics-Central & Thiazides
$ Methyldopa & HCTZ*
$$ Clonidine & Chlorthalidone*
ALDORIL
COMBIPRES
Vasodilators & Thiazides
$ Hydralazine & HCTZ*
APRESAZIDE
9
no LA
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
Carbonic Anhydrase Inhibitors
$ Acetazolamide*
$$$ Methazolamide*
DIAMOX
NEPTAZANE
no sequels
Loop Diuretics
$ Furosemide*
LASIX
Potassium Sparing Diuretics
$ Spironolactone*
ALDACTONE
Thiazides
$ Chlorothiazide*
$ Chlorthalidone*
$ Hydrochlorothiazide*
$ Methyclothiazide*
$ Metolazone*
$$ Indapamide*
DIURIL
HYGROTON
HYDRODIURIL
ENDURON
ZAROXOLYN
LOZOL
Combination Diuretics
$ Spironolactone & HCTZ*
$ Triamterene & HCTZ*
ALDACTAZIDE
MAXZIDE
Osmotic Diuretics
$ Glycerin Supp.*
GLYCERIN
DIURETICS
adult, infant, child
PRESSORS
Emergency Kits
$$ Epinephrine
EPI-PEN, EPI-PEN JR
ANTIHYPERLIPIDEMIC
Bile Sequestrants
$$$ Cholestyramine*
$$$ Colestipol
QUESTRAN, LIGHT
COLESTID
cans only
cans only
NIACIN
LOPID
OTC (slow release)
Misc.
$ Niacin*
$$$ Gemfibrozil*
HMG CoA Reductase Inhibitors
$$$ Fluvastatin
LESCOL
$$$ Simvastatin
ZOCOR
LIPITOR
$$$$ Atorvastatin
$$$ Pravastatin
PRAVACHOL
Prior Authorization Required
10
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
Antihistamines - Alkylamines
$ Dexchlorpheniramine*
POLARAMINE
no syrup
Antihistamines - Ethanolamines
$ Diphenhydramine*
BENADRYL
OTC product
Antihistamines - Non Sedating
$$$ Cetirizine
$$$ Fexofenadine*
$$$ Fexofenadine / Pseudoephedrine
$$ Loratadine*
$$ Loratadine / Pseudoephedrine*
ZYRTEC
ALLEGRA
ALLEGRA-D 12hr, 24hr
ALAVERT, CLARITIN
CLARITIN-D 12hr, 24hr
30 or 60 per 30 days
30 or 60 per 30 days
OTC product
OTC product
Antihistamines - Phenothiazines
$$$$$ Promethazine*
PHENERGAN
Antihistamines - Piperidines
$ Cyproheptadine*
PERIACTIN
VI.RESPIRATORY AGENTS
ANTIHISTAMINES
SYSTEMIC AND TOPICAL NASAL PRODUCTS
Nasal Steroids
$$ Flunisolide*
$$ Triamcinolone
$$$ Fluticasone
NASALIDE
NASACORT AQ
FLONASE
Steroid Inhalants
$$$ Triamcinolone
$$$ Fluticasone
AZMACORT
FLOVENT HFA
Mucolytics
$$ Acetylcysteine*
MUCOMYST
ANTIASTHMATIC
Anticholinergics
$$ Ipratropium*
$$$ Ipratropium
$$$$ Tiotropium
ATROVENT/NASAL
ATROVENT HFA
SPIRIVA
Anti-Inflammatory Agents
$$$ Cromolyn (inhalation)
$$$ Cromolyn (nasal)
$$$ Nedocromil
INTAL
NASALCROM
TILADE
Beta Adrenergics
$$ Isoetharine*
$$ Pirbuterol
$$ Terbutaline*
$$$ Salmeterol
BRONKOSOL
MAXAIR AUTOHALER
BRETHINE/BRETHAIRE
SEREVENT
11
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
Adrenergic Combinations
COMBIVENT
$$ Albuterol-Ipratropium
$$$ Salmeterol-Fluticasone
ADVAIR
Prior Authorization Required
Sympathomimetic Agents
$ Albuterol*
$ Pseudoephedrine HCL*
PROVENTIL
PSEUDOEPHEDRINE
Mixed Adrenergics
$$ Epinephrine
EPI-PEN, EPI-PEN JR
Xanthines
$ Aminophylline*
$ Theophylline*
AMINOPHYLLINE
THEO-24, UNIPHYL
Leukotriene Receptor Antagonists
$$$ Montelukast Sodium
SINGULAIR
no rotocaps
OTC product
COUGH/COLD/ALLERGY
Expectorants
$ Guaifenesin*
$ Guaifenesin/DM*
GUAIFENESIN
GUAIFENESIN DM
OTC product
OTC product
Cough/Cold/Allergy Combinations
$ Carbinoxamine & Pseudoephedrine*
CARDEC
$ Carbinoxamine & Pseudoephedrine/DM* CARDEC DM
$ Codeine-GG*
ROBITUSSIN AC
$$ Hydrocodone-GG*
HYCOTUSS
$$ Pseudoephedrine-GG*
DURATUSS
VII. GASTROINTESTINAL AGENTS
LAXATIVES
Surfactant Laxatives
$ Docusate Sodium*
COLACE
OTC product
Stimulant Laxatives
$ Bisacodyl*
DULCOLAX
OTC product
Bulk Laxatives
$ Polycarbophil Calcium
FIBERCON
OTC product
Miscellaneous Laxatives
$ Glycerin*
$ Lactulose*
$ PEG-Electrolyte*
GLYCERIN
CHRONULAC
GOLYTELY
OTC product
12
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
LOMOTIL
IMODIUM
OTC product
ANTIDIARRHEALS
Antiperistaltic Agents
$ Diphenoxylate w/ Atropine*
$ Loperamide*
Misc Antidiarrheal Agents
$ Bismuth Subsalicylate*
PEPTO-BISMOL
$$$$$ Octreotide Acetate
SANDOSTATIN
Prior Authorization Required
no tabs, OTC
ANTACIDS
Antacids - Aluminum Salts
$ Aluminum Hydroxide Gel*
AMPHOGEL
OTC product
Antacids - Calcium Salts
$ Calcium Carbonate*
OS-CAL
OTC product
Antacid Combinations
$ Al Hydrox-Mag Carb*
$ Aluminum & Magnesium Hydroxide*
MAALOX
MYLANTA
no tabs, OTC
no tabs, OTC
ULCER DRUGS
Belladonna Alkaloids
$ Hyoscyamine Sulfate*
LEVSIN
Quaternary Anticholinergics
$ Propantheline Bromide*
PRO-BANTHINE
Antispasmodics
$ Dicyclomine*
BENTYL
H-2 Antagonists
$$$ Cimetidine*
$$$ Famotidine*
$$$ Ranitidine*
$$$ Nizatidine
TAGAMET
PEPCID
ZANTAC
AXID
Prior Authorization Required
tabs only
Proton Pump Inhibitors
$$ Omeprazole
PRILOSEC OTC
$$$$ Lansoprazole
PREVACID
$$$$ Omeprazole*
PRILOSEC RX
Prior Authorization Required
Misc. Anti-Ulcer
$$$$ Sucralfate*
CARAFATE
Prior Authorization Required
ANTIEMETICS
Antiemetics - Anticholinergic
$ Meclizine*
$$ Prochlorperazine*
ANTIVERT
COMPAZINE
13
no SR
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
5-HT3 Receptor Antagonists
$$ Ondansetron HCL
ZOFRAN
Prior Authorization Required
DIGESTIVE AIDS
Digestive Aids - Mixtures
VIOKASE
$$$ Amylase-Lipase-Protease Reg.Rls*
$$$$ Amylase-Lipase-Protease*
CREON
Prior Authorization Required
MISC. GI
GI Stimulants
$ Metoclopramide*
REGLAN
no 5mg tabs
Inflammatory Bowel Agents
$ Sulfasalazine*
$$$$ Mesalamine
$$$$ Mesalamine
AZULFIDINE
ASACOL
PENTASA,ROWASA
no EN tabs
VIII. GENITOURINARY
URINARY ANTIINFECTIVES
$
$
$$
$$
Methenamine Mandelate*
Trimethoprim*
Nitrofurantoin*
Nitrofurantoin Macrocrystals*
MANDELAMINE
TRIMPEX
FURADANTIN
MACRODANTIN
URINARY ANTISPASMODICS
$
$
$$
$$
Bethanechol*
Hyoscyamine*
Flavoxate*
Oxybutynin*
URECHOLINE
LEVSINEX
URISPAS
DITROPAN
VAGINAL PRODUCTS
Vaginal Antiinfectives
$ Nystatin*
NYSTATIN
$$ Clindamycin
CLEOCIN
AVC
$$ Sulfanilamide
$$ Metronidazole
METROGEL
Prior Authorization Required
Imidazole-Related Antifungals
$ Butoconazole Nitrate
$ Clotrimazole*
$ Miconazole*
FEMSTAT
MYCELEX
MONISTAT
Vaginal Antiinfective Combinations
$ Triple Sulfas Vaginal*
SULTRIN
14
OTC product
OTC product
OTC product
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
MISCELLANEOUS GENITOURINARY PRODUCTS
Citrates
$ Sodium Citrate & Citric Acid*
BICITRA
Urinary Analgesics
$ Phenazopyridine*
PYRIDIUM
IX. CENTRAL NERVOUS SYSTEM DRUGS
ANTIPSYCHOTICS
Phenothiazines
$$ Prochlorperazine*
COMPAZINE
no SR
HYPNOTICS
Barbiturate Hypnotics
$ Butabarbital
$ Mephobarbital
$ Phenobarbital*
BUTISOL
MEBARAL
PHENOBARBITAL
Non-Barbiturate Hypnotics
$ Midazolam*
VERSED
Prior Authorization Required
Antihistamine Hypnotics
$ Diphenhydramine*
BENADRYL
OTC product
HYDERGINE
no liquid caps
MISC PSYCHOTHERAPEUTIC
$ Ergoloid Mesylates*
X. ANALGESICS & ANESTHETICS
ANALGESICS - NonNarcotic
Salicylates
$ Aspirin zero order*
$$ Salsalate*
ZORPRIN
DISALCID
Salicylate Combinations
$ Aspirin Enteric Coated*
$ Aspirin with Buffers*
$$$$ Choline & Mag Salicylate*
ECOTRIN
ASPIRIN BUFFERED
TRILISATE
OTC product
OTC product
Analgesics Other
$ Acetaminophen*
TYLENOL
OTC product
Analgesics - Sedatives
$ APAP/Caffeine/Butalbital*
$ Aspirin/Caffeine/Butalbital*
FIORICET
FIORINAL
15
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
ANALGESICS - Narcotic
Narcotic Agonists
$ Codeine Phosphate*
CODEINE PHOSPHATE
$ Codeine Sulfate*
CODEINE SULFATE
$ Meperidine*
DEMEROL
$$$ Hydromorphone*
DILAUDID
$ Methadone*
METHADONE
$$$ Morphine Sulfate*
MSIR
$$$$ Morphine Sulfate SR*
MS CONTIN
$$$$ Morphine Sulfate SR*
ORAMORPH SR
$$$$ Naltrexone*
REVIA
$$$ Fentanyl*
DURAGESIC
$$$ Tramadol*
ULTRAM
Prior Authorization Required
Narcotic Agonist-Antagonist
$$$$$ Buprenorphine Hcl-Naloxone Hcl
SUBOXONE
Opiate Partial Agonist
$$$$ Buprenorphine Hcl
SUBUTEX
Narcotic Combinations
$ Oxycodone w/ Acetaminophen*
PERCOCET
$ Oxycodone w/ Aspirin*
QL = 120
5/500 tabs and caps,
5/325 tabs and soln
PERCODAN
Codeine Combinations
$ Acetaminophen w/ Codeine*
$ Aspirin w/ Codeine*
TYLENOL / COD
EMIPRIN / COD
Hydrocodone Combinations
$$$ Acetaminophen w/ Hydrocodone*
VICODIN (5/500 )
Propoxyphene Combinations
$ Propoxyphene w/ APAP*
DARVOCET N-100
100mg tabs
ANTI-RHEUMATIC
NSAID's
$ Ibuprofen*
$$ Fenoprofen*
$$ Indomethacin*
$$ Naproxen Sodium*
$$ Naproxen*
$$ Piroxicam
$$ Sulindac*
Gold Compounds
$$$ Auranofin
MOTRIN
NALFON
INDOCIN
ANAPROX
NAPROSYN
FELDENE
CLINORIL
RIDAURA
Prior Authorization Required
16
no SR or supp.
no EC
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Anti-Rheumatic Antimetabolite
$$$$ Methotrexate*
Brand Name
Annotation
RHEUMATREX
GOUT
$ Allopurinol*
$ Colchicine*
ZYLOPRIM
COLCHICINE
Uricosurics
$ Probenecid*
PROBENECID
LOCAL ANESTHETICS
$ Lidocaine*
LIDOCAINE
MIGRAINE PRODUCTS
$$ Ergotamine mesylates*
HYDERGINE
$$$$ Sumatriptan Tablets
IMITREX
$$$$ Sumatriptan Injection
IMITREX
Prior Authorization Required
Migraine Combinations
$$ Ergotamine w/ Caffeine
(no nasal spray)
CAFERGOT
XI. NEUROMUSCULAR AGENTS
ANTICONVULSANT
Hydantoins
$$ Phenytoin*
$$$ Ethotoin
DILANTIN
PEGANONE
Succinimides
$$$ Ethosuximide*
$$$ Methsuximide
ZARONTIN
CELONTIN
Miscellaneous Anticonvulsants
$$$$$ Primidone*
MYSOLINE
ANTIPARKINSONIAN
COMT Inhibitors
$$$ Entacapone
COMTAN
Prior Authorization Required
Dopaminergic
$ Amantadine*
SYMMETREL
$$$$ Bromocriptine*
PARLODEL
$$ Ropinirole
REQUIP
Prior Authorization Required
Levodopa Combinations
$$$ Carbidopa-Levodopa*
SINEMET, CR
Monoamine Oxidase Inhibitor
$$$$ Selegiline*
ELDEPRYL
17
no postpartum use
no 100-25 CR
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
MUSCULOSKELETAL THERAPY AGENTS
Central Muscle Relaxants
$ Cyclobenzaprine*
$ Methocarbamol*
$$ Baclofen*
FLEXERIL
ROBAXIN
LIORESAL
Direct Muscle Relaxants
$$$$ Dantrolene*
DANTRIUM
Prior Authorization Required
Muscle Relaxant Combinations
$ Methocarbamol w/ Aspirin*
ROBAXISAL
ANTIMYASTHENIC AGENTS
Antimyasthenic Agents
$$$$ Pyridostigmine*
Benzothiazoles
$$$$$ Riluzole
MESTINON
RILUTEK
Prior Authorization Required
XII. NUTRITIONAL PRODUCTS
VITAMINS
Water Soluble Vitamins
$ Niacin*
$ Vitamin B-3*
NIACIN
VITAMIN B-3
Oil Soluble Vitamins
$ Vitamin A*
AQUASOL A
Vitamin D
$$ Calcitriol*
$$ Ergocalciferol*
ROCALTROL
DRISDOL
MULTIVITAMINS
$
$
$
$
$
$
$$$
Folic Acid & Vitamin B Complex*
Multiple Vitamin*
Pediatric Multivitamins w/Fluoride*
Pediatric Vitamins*
Prenatal MV & Min w/FE-FA*
Prenatal Vitamins*
Multiple Vitamin w/ Minerals*
NEPHROCAPS
ONE-A-DAY
POLY-VI-FLOR
CHILDS COMPLETE
PRENATAL-1
MATERNA
BEROCCA PLUS
18
OTC product
6mos to 16 years only
OTC product
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
CITRATES
$ Sodium Citrate & Citric Acid*
BICITRA
MINERALS & ELECTROLYTES
Calcium
$ Calcium Acetate
$ Calcium Carbonate*
PHOSLO
OS-CAL
Fluoride
$ Sodium Fluoride*
LURIDE
Potassium
$ Potassium Chloride Capsule*
$ Potassium Chloride Liquid*
$ Potassium Chloride Tablet*
MICRO-K
KAOCHLOR
KLOR-CON
Electrolyte Mixtures
$ Oral Electrolytes*
PEDIALYTE
OTC procuct
LOFENALAC
PHENYL-FREE
OTC procuct
OTC procuct
caps only
OTC product
DIETARY PRODUCTS
$$ Infant Foods
$$ Phenyl-Free
MISCELLANEOUS NUTRITIONAL PRODUCTS
$$ Nutritional Supplements
ENSURE, PEDIASURE, BOOST,
SUSTACAL, RESTORE, VIVONEX
Prior Authorization Required
(Nutritional Supplements are not limited to this list)
XIII. HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
Cobalamines
$ Folic Acid*
FOLVITE
$$$$$ Leucovorin Calcium*
LEUCOVORIN
$ Cyanocobalamin*
VITAMIN B-12
$ Hydroxocobalamin*
HYDROBEXAN
Prior Authorization Required
Iron
$ Ferrous Gluconate*
$ Ferrous Sulfate*
FERGON
FEOSOL
Hematopoietic Growth Factors
$$$$Darbopoetin
ARANESP
Erythropoietins
$$$$$ Epoetin Alfa
EPOGEN,PROCRIT
19
OTC procuct
OTC procuct
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Leukocytes
$$$$$ Filgrastim
Brand Name
Annotation
NEUPOGEN
Prior Authorization Required
ANTICOAGULANTS
Coumarin Anticoagulants
$$ Warfarin Sodium*
COUMADIN
Heparin Agents
$$$ Enoxaparin
LOVENOX
HEMOSTATICS
Hemostatics - Topical
$$$$ Thrombin
THROMBIN
Prior Authorization Required
MISC. HEMATOLOGICAL
Antihemophilic Products
$$$$$ Antihemophilic Factor (Human)
ALPHANATE
$$$$$ Antihemophilic Factor (Porcine)
HYATE:C
$$$$$ Antihemophilic Factor (Recombinant)
BIOCLATE
$$$$$ Antiinhibitor Coagulant Complex
AUTOPLEX T
$$$$$ Antithrombin III (Human)
THROMBAT III
Prior Authorization Required
Platelet Aggregation Inhibitors
$$$ Clopidogrel
PLAVIX
Hematorheological
$$$ Pentoxifylline*
TRENTAL
Prior Authorization Required
XIV. BEHAVIORAL HEALTH AGENTS
Misc. Antianxiety
$$$ Droperidol
INAPSINE
Prior Authorization Required
MISC PSYCHOTHERAPEUTIC
Smoking Deterrents
$$$$ Nicotine*
HABITROL, NICOTROL, PROSTEP
NICODERM, NICODERM CQ
20
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
Misc Psychotherapeutic
ANTABUSE
$ Disulfiram
$$$$ Acamprosate
CAMPRAL
$$$$ Donepezil
ARICEPT
$$$$ Memantine
NAMENDA
Prior Authorization Required
ANTICONVULSANT
Misc. Anticonvulsants
$$ Carbamazepine*
TEGRETOL
$$ Primidone*
MYSOLINE
$$$$ Gabapentin*
NEURONTIN
$$$$ Lamotrigine
LAMICTAL
$$$$ Topiramate
TOPAMAX
Prior Authorization Required
XV. TOPICAL AGENTS
OPHTHALMIC
Antibiotics
$ Bacitracin*
AK-TRACIN
$ Erythromycin*
ILOTYCIN
$ Gentamicin Sulfate*
GARAMYCIN
$$ Ciprofloxacin*
CILOXAN
$$$$ Gatifloxacin
ZYMAR
Prior Authorization Required unless trial with Cipro
Anti Allergic
$$$ Levocabastine
LIVOSTIN
$$$ Lodoxamine
ALOMIDE
$$$ Olopatadine
PATANOL
Sulfonamides
$ Sodium Sulfacetamide*
BLEPH-10
Antivirals
$ Vidarabine
$$$ Trifluridine*
VIRA-A
VIROPTIC
Antiinfective Combinations
$ Bacitracin-Polymyxin B*
$ Neomycin-Bac Zn-Polymyxin*
$ Neomycin-Polymy-Gramicidin*
POLYSPORIN
NEOSPORIN
AK-SPORE
Beta-Blockers
$$ Metipranolol*
$$ Timolol*
$$$ Betaxolol
OPTIPRANOLOL
BETIMOL, TIMOPTIC
BETOPTIC,BETOPTIC S
Steroids
$ Dexamethasone*
$$ Prednisolone Acetate*
DECADRON
PRED FORTE, MILD
21
no XE
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Steroid Combinations
$ Bacitracin-Polymyxin-Neomycin-HC*
$ Neomycin-Dexamethasone*
$ Neomycin-Polymyxin-Dexamethasone*
$ Neomycin-Polymyxin-HC*
$ Sulfacetamide Sod-Prednisolone*
AK-SPORE HC
NEO-DECADRON
MAXITROL
CORTISPORIN
VASOCIDIN
Cycloplegics
$ Atropine Sulfate*
ISOPTO ATROPINE
Decongestants
$ Naphazoline*
$ Phenylephrine*
VASOCON
MYDFRIN
Ophthalmic NSAID's
$$ Flurbiprofen*
OCUFEN
Miotics - Direct Acting
$ Pilocarpine*
ISOPTO-CARPINE
Miotics - Cholinesterase Inhibitors
$$ Echothiophate Iodide
PHOSPHOLINE
Adrenergic Agents
$$ Dipivefrin*
PROPINE
Prostaglandins
$$$ Latanoprost
XALATAN
Prior Authorization Required
Carbonic Anhydrase Inhibitors
$$ Dorzolamide
TRUSOPT
Prior Authorization Required
OTIC
Steroids
$ Hydrocortisone w/Acetic Acid*
VOSOL-HC
Miscellaneous
$ Acetic Acid in Propylene Glycol*
VOSOL
Antibiotics & Steroid-Antibiotic Combinations
$ Neomycin-Polymyxin-HC*
CORTISPORIN
Antibiotics
$$$ Ofloxacin
FLOXIN
Anti Infective
$ Carbamide Peroxide*
DEBROX
Analgesic Combinations
$$$ Benzocaine & Antipyrine*
AURALGAN
22
Annotation
no Ocusert
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Annotation
MOUTH & THROAT (Local)
Antiinfectives - Throat
$ Clotrimazole*
$ Nystatin*
MYCELEX TROCHE
NYSTATIN
ANORECTAL
Rectal Steroids
$ Hydrocortisone*
$$ Hydrocortisone*
ANUSOL-HC
PROCTOCREAM
2.5% cream
2.5% cream
Antibiotics - Topical
$ Bacitracin*
$ Gentamicin Sulfate*
$ Neomycin Sulfate*
$$ Mupirocin*
BACITRACIN
GARAMYCIN
NEOMYCIN
BACTROBAN
OTC product
Antibiotic Mixtures Topical
$ Neomycin-Bacitracin-Polymyxin*
NEOSPORIN
OTC product
Antibiotic Steroid Combinations
$ Neomycin-Polymyxin-HC*
CORTISPORIN
Imidazole-Related Antifungals (Topical)
$ Miconazole*
$$ Clotrimazole*
$$ Metronidazole
MONISTAT
LOTRIMIN
METROGEL
OTC product
OTC product
Antifungals
$$ Nystatin*
NYSTATIN
no powder
Antifungals - Topical Combinations
$ Nystatin-Triamcinolone*
MYCOLOG II
Antipsoriatics
$$$ Calcipotriene
DOVONEX
Antiseborrheic Products
$ Sulfacetamide Sodium*
SODIUM SULAMYD
Burn Products
$ Silver Sulfadiazine*
SILVADENE
Tar Products
$ Coal Tar*
COAL TAR SHAMPOO
Enzymes - Topical
$$ Collagenase
SANTYL
Keratolytics/Antimitotics
$$$ Podofilox
CONDYLOX
DERMATOLOGICAL
23
1% only
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Brand Name
Local Anesthetics - Topical
$ Lidocaine viscous*
XYLOCAINE VISCOUS
Scabicides & Pediculocides
$ Lindane*
$$ Permethrin*
$$ Permethrin*
KWELL
ELIMITE
NIX
Misc. Topical
$$$ Fluorouracil*
$$$ Pimecrolimus
EFUDEX
ELIDEL
Antiviral Topical
$$ Acyclovir
Annotation
OTC product
ZOVIRAX
Prior Authorization Required
Corticosteroids - Topical
$ Betamethasone Dipropionate*
$ Betamethasone Valerate*
$ Desonide*
$ Fluocinonide Acetonide*
$ Hydrocortisone*
$ Triamcinolone Acetonide in Orabase*
$ Triamcinolone Acetonide*
$$ Clobetasol Propionate*
$$ Fluocinonide*
DIPROSONE
VALISONE
DESOWEN
SYNALAR
HYTONE
KENALOG / ORABASE
KENALOG
TEMOVATE
LIDEX
Acne Products
$ Benzoyl Peroxide*
$$$ Tretinoin*
BENZAC-W
RETIN-A
Acne Antibiotics
$$ Clindamycin Phosphate*
$$ Erythromycin Gel*
CLEOCIN GEL
AKNE-MYCIN
OTC product
Ages 0-21 only
XVI. MISCELLANEOUS PRODUCTS
ANTIDOTES
$ Ipecac*
IPECAC
DIAGNOSTIC PRODUCTS
Diagnostic Reagents
$ Acetone Tablets
$ Acetone Test*
$ Glucose Urine Test*
$$ Glucose Blood*
ACETEST
KETOSTIX
CLINITEST
GLUCOFILM
24
OTC product
BioScrip/Jai Medical Systems Therapeutic Formulary
Generic Name
Radiographic Contrast Media Iodinated
$ Iopanoic Acid
Brand Name
TELEPAQUE
MEDICAL DEVICES
Parenteral Therapy Supplies
$ Disposable Needles & Syringes*
B-D INSULIN SYRINGE
Diabetic Supplies
$ Calibration Solution*
$ Lancet Device*
$ Lancets*
$$ Blood Glucose Monitoring Tests*
CALIBRATION SOLUTION
HYPOLET
LANCETS
GLUCOMETER
Misc. Devices
$ Alcohol Swabs*
ALCOHOL PADS
CONTRACEPTIVES
$ Condoms
ASSORTED CLASSES
Chelating Agents
$$$ Penicillamine
CUPRIMINE
$$$$ Succimer
CHEMET
Prior Authorization Required
Immunosuppressive Agents
$$$$$ Cyclosporine
$$$$$ Cyclosporine Microsize*
SANDIMMUNE
NEORAL
Inosine Monophosphate Dehydrogenase Inhibitors
$$$$$ Mycophenolate Mofetil
CELLCEPT
$$$$$ Mycophenolate Sodium
MYFORTIC
Purine Analogs
$$$$ Azathioprine*
IMURAN
K Removing Resin
$$$$ Sodium Polystyrene Sulfonate*
KAYEXALATE
25
Annotation
FGGGG
Prior Authorization Guidelines
FGGGG
Prior Authorization Guidelines
GENERIC: ACAMPROSATE
BRAND:
CAMPRALВ®
INDICATION:
(1) Maintenance of abstinence for alcohol-dependent patients who
are abstinent at treatment initiation.
Criteria:
(a) Patient must be abstinent at treatment initiation.
(b) Treatment must be part of a comprehensive management
program that includes psychosocial support.
(c) Patient must be opiate dependent.
GENERIC: ACARBOSE
BRAND:
PRECOSEВ®
INDICATION:
(1) Type 2 diabetes mellitus
Criteria:
(a) Failure of maximal doses of one oral sulfonylurea (e.g.,
glyburide 20mg daily or equivalent). Failure is defined as
Hemoglobin A1c> 7.0.
GENERIC: ACYCLOVIR TOPICAL OINTMENT
BRAND:
ZOVIRAX В® 5%
INDICATIONS:
(1) Herpes genitalis
(2) Oral herpes infection
Criteria:
(a) Herpes genitalis – for initial episode only.
(b) Oral herpes infection – for immunocompromised patients
only.
PA-1
Prior Authorization Guidelines
GENERIC: ALENDRONATE
BRAND:
FOSAMAXВ®
INDICATIONS:
(1) Treatment of Paget's disease
(2) Osteoporosis
(3) Prevention of osteoporosis (5mg tablet)
Criteria:
(a) Diagnosis of Paget’s disease or
(b) For the diagnosis of osteoporosis: bone density measurement >
2 standard deviations below premenopausal mean; or
(c) Documented osteoporosis as evidenced by one of the
following:
- atraumatic fractures
- loss of height due to vertebral compression
- x-ray evidence of osteopenia; or
(d) Long-term glucocorticoid treatment; or
(e) Continued loss of bone density despite estrogen therapy
(documented); or
(f) For prevention or treatment of osteoporosis in postmenopausal
women in whom estrogen therapy is contraindicated (e.g., ERpositive cancers, recurrent DVT, etc).
* Patients must be ambulatory and be instructed to, and be able to,
either stand or sit upright for 30 minutes post dose. Patients must
not have erosive esophagitis or any diagnosis indicative of a
delayed esophageal emptying disorder. If documentation of
osteoporosis is available, please submit with PA request.
GENERIC: AMYLASE-LIPASE-PROTEASE
BRAND:
CREONВ®
INDICATION:
(1) Pancreatic insufficiency disorders (i.e., cystic fibrosis, etc.)
Criteria:
(a) Diagnosis of cystic fibrosis; or
(b) Failure of formulary enzyme replacement therapy.
PA-2
Prior Authorization Guidelines
GENERIC: ANTIHEMOPHILIC FACTORS
BRAND:
ALPHANATE В®, HYATE-C В®, BIOCLATE В®,
AUTOPLEX-T В®, THROMBAT III В®
INDICATION:
(1) Hemophilia A
Criteria:
(a) Diagnosis of Hemophilia A.
GENERIC: AURANOFIN
BRAND:
RIDAURAВ®
INDICATION:
(1) Management of Rheumatoid arthritis in adults
Criteria:
(a) Failure of 3 formulary NSAIDS; and
(b) Failure of 1 formulary DMARD.
* Oral gold may take up to 6 months to show benefits.
GENERIC: AZITHROMYCIN
BRAND:
ZITHROMAXВ®
(PA after 1x1g suspension single dose dispensed)
INDICATIONS:
(1) Acute bacterial exacerbations of COPD
(2) Community-acquired pneumonia
(3) Genital ulcer disease
(4) Pelvic inflammatory disease
(5) Pharyngitis and tonsillitis
(6) Skin and skin structure infections
(7) Acute otitis media
Criteria:
(a) Failure of a recent treatment trial (within 30 days) with at least
one standard first-line formulary antibiotic, EXCEPT in cases
of children > 6 months of age with community-acquired
pneumonia; or
(b) Mycobacterium avium complex (MAC) prophylaxis in HIV
patients.
PA-3
Prior Authorization Guidelines
GENERIC: CALCITONIN-SALMON/HUMAN
BRAND:
MIACALCINВ®
INDICATIONS:
(1) Mild to moderate Paget's disease
(2) Osteoporosis
Criteria:
(a) Diagnosis of Paget’s disease
(b) For the diagnosis of osteoporosis, documented osteoporosis
as evidenced by one of the following:
- atraumatic fractures
- loss of height due to vertebral compression
- x-ray evidence of osteopenia; or
(c) Established vertebral fractures; or
(d) Established osteopenia (> 2 standard deviations) but no
demonstrated fractures; or
(e) Multiple risk factors such as chronic immobility,
glucocorticoid therapy; or
(f) Primary hyperparathyroidism and contraindications to surgical
treatment; or
(g) Contraindications to estrogen therapy.
* For injectable medications administered by a healthcare professional,
please refer to the “Policy for Injectable Drugs” in the beginning of
this formulary.
* If documentation of osteoporosis is available, please submit with PA
request.
GENERIC: CARVEDILOL
BRAND:
COREGВ®
INDICATIONS:
(1) Hypertension
(2) Congestive heart failure (CHF)
Criteria:
(a) Diagnosis of CHF; or
(b) For the diagnosis of hypertension, failure of two formulary
beta-blockers, a diuretic, an ACE inhibitor and a calcium
channel blocker.
PA-4
Prior Authorization Guidelines
GENERIC: CEFDINIR SUSPENSION
BRAND:
OMNICEFВ®
INDICATIONS:
(1) CAP
(2) Acute exacerbations of chronic bronchitis
(3) Acute maxillary sinusitis
(4) Pharyngitis / Tonsillitis
(5) Uncomplicated skin and skin structure infections
(6) Acute bacterial otitis media – pediatrics only
Criteria:
(a) Recent failure (within 30 days) of at least one standard firstline formulary antibiotic in absence of culture; or
(b) Documentation of cultured organism with sensitivity to only
cefdinir, other third generation cephalosporin OR
contraindications to all other sensitive antibiotics.
GENERIC: CIPROFLOXACIN
BRAND:
CIPROВ®
(PA after 1 tablet dispensed)
INDICATIONS:
(1) Lower respiratory tract infections and acute sinusitis
(2) Skin and skin structure infections
(3) Bone infections
(4) Infectious diarrhea
(5) Typhoid fever
(6) STDs, UTIs and chronic bacterial prostatitis
(7) Complicated intra-abdominal infections
Criteria:
(a) Diagnosis of one of the following infections
- Pseudomonas aeruginosa infection
- Osteomyelitis
- Typhoid fever
- Cystic fibrosis
- Gonorrhea
- Complicated intra-abdominal infection; or
(b) For other infections, the patient has failed a recent treatment
trial (within 30 days) with at least one standard first-line
formulary antibiotic; or
(c) Patient has multiple drug allergies to appropriate first-line
formulary antibiotics; or
PA-5
Prior Authorization Guidelines
(d) Diagnosis of chronic prostatitis in males > 35 years of age who
have failed, or are intolerant to SMX / TMP therapy; or
(e) Treatment of MAC infection in patients intolerant to rifampin
and ciprofloxacin is part of “triple therapy”; or
(f) Culture sensitivity to fluoroquinolones only.
GENERIC: CLARITHROMYCIN
BRAND:
BIAXINВ®
INDICATIONS:
(1) Streptococcal pharyngitis
(2) Sinusitis
(3) Acute otitis media
(4) Acute bacterial exacerbation of chronic bronchitis
(5) Community acquired pneumonia
(6) Uncomplicated skin and skin structure infection
(7) Peptic ulcer disease due to H. pylori infection
(8) Treatment and prevention of MAC
Criteria:
(a) Failure of a recent treatment trial (within 30 days) with at least
one standard first-line formulary antibiotic; or
(b) Treatment or prophylaxis of MAC infection; or
(c) Treatment of H. pylori infection in peptic ulcer disease.
GENERIC: CLOXACILLIN
BRAND:
CLOXAPENВ®
INDICATION:
(1) Treatment of infections due to penicillinase-producing
staphylococci
Criteria:
(a) Diagnosis of staphylococcal infection; and
(b) Failure of dicloxacillin sodium.
GENERIC: CYANOCOBALAMIN (HYDROXYCOBALAMIN)
BRAND:
VITAMIN B-12В®
INDICATION:
(1) Vitamin B-12 deficiency
PA-6
Prior Authorization Guidelines
Criteria:
(a) Patients who lack intrinsic factor; or
(b) Patients who are on long-term PPI therapy; or
(c) Patients with a partial or complete gastrectomy.
* For injectable medications administered by a healthcare professional,
please refer to the “Policy for Injectable Drugs” in the beginning of this
formulary.
GENERIC: DANTROLENE
BRAND:
DANTRIUMВ®
INDICATION:
(1) Spasticity resulting from upper motor neuron disorders
Criteria:
(a) Demonstrated failure of, or intolerance to, Baclofen
(Lioresol В®).
GENERIC: DESMOPRESSIN
BRAND:
DDAVP SPRAYВ®
INDICATIONS (oral and intranasal formulations only):
(1) Central cranial diabetes insipidus (CCDI)
(2) Primary nocturnal enuresis
Criteria:
(a) Diagnosis of CCDI; or
(b) For the treatment of enuresis, age 6 to 18 years; and
(c) Failure of behavior modification for 6 months (e.g., alarms, no
beverages after 5pm, special diapers etc.).
* Renewals for the indication of nocturnal enuresis will require the
documentation of a retrial of behavior modification.
GENERIC: DONEPEZIL
BRAND:
ARICEPTВ®
INDICATION:
(1) Alzheimer’s disease: for the treatment of mildly to moderately
severe cases of dementia.
Criteria:
(a) Dementia must be confirmed by clinical evaluation; and
(b) Documented dementia is either mildly or moderately severe.
PA-7
Prior Authorization Guidelines
GENERIC: DORZOLAMIDE
BRAND:
TRUSOPTВ®
INDICATIONS:
(1) Elevated IOP
(2) Glaucoma (open angle, neovascular, congenital)
Criteria:
(a) Open angle glaucoma – treatment failure of two formulary
agents of different classes.
(b) Neovascular – treatment failure of a topical formulary betablocker.
(c) Congenital – treatment failure of a topical formulary betablocker.
GENERIC: DROPERIDOL
BRAND:
INAPSINEВ®
INDICATIONS:
(1) Tranquilization
(2) Premedication
(3) Neuroleptanalgesia
Criteria:
(a) Must be approved by JAI Medical Director.
GENERIC: ENFUVIRTIDE
BRAND:
FUZEONВ®
INDICATION:
(1) Treatment of HIV-1 infection in combination with other
antiretroviral agents in treatment-experienced patients with
evidence of HIV-1 replication despite on-going antiretroviral
therapy
Criteria:
(a) Documented failure of at least two HAART regimens; and
(b) The patient is using FuzeonВ® in combination with a HAART
regimen of at least two antiretrovirals; and
(c) The patient and/or caregiver received appropriate education,
training and support from FuzeonВ® administration.
PA-8
Prior Authorization Guidelines
GENERIC: ENTACAPONE
BRAND:
COMTANВ®
INDICATION:
(1) As an adjunct to levodopa/carbidopa to treat patients with
idiopathic Parkinson’s disease
Criteria:
(a) Diagnosis of idiopathic Parkinson’s disease; and
(b) Patient is receiving concomitant levodopa/carbidopa therapy.
GENERIC: ESTROGEN, TRANSDERMAL
BRAND:
CLIMARAВ®
INDICATIONS:
(1) Symptoms of menopause
(2) Atrophic vaginitis or urethritis
(3) Kraurosis vulvae
(4) Female hypogonadism
(5) Female castration
(6) Primary ovarian failure
(7) Osteoporosis
Criteria:
(a) Failure of formulary estrogen products.
GENERIC: EXENATIDE
BRAND:
BYETTAВ®
INDICATION:
(1) Adjunctive therapy of type 2 diabetes mellitus
Criteria:
(a) Diagnosis of type 2 diabetes; and
(b) Failure or intolerance to sulfonylureas and/or metformin at
optimal dosing. Failure defined as Hemoglobin A1c > 7.0; and
(c) Patient > 18 years of age
PA-9
Prior Authorization Guidelines
GENERIC: FENTANYL
BRAND:
DURAGESICВ®
INDICATION:
(1) Management of chronic pain
Criteria:
(a) Patient is unable to take oral medication;
(b) Patient has allergies to formulary medications;
(c) Patient has failed treatment trials with formulary medications;
(d) Patient has breakthrough pain.
GENERIC: FILGRASTIM
BRAND:
NEUPOGENВ®
INDICATIONS:
(1) Prevention of neutropenia in patients receiving
myleosuppressive chemotherapy for non-myeloid
malignancies
(2) Patients undergoing peripheral blood progenitor cell collection
and therapy
(3) Patients with severe chronic neutropenia
Criteria:
(a) The patient is undergoing peripheral blood progenitor cell
collection and therapy; or
(b) Diagnosis of severe chronic neutropenia with an absolute
neutrophil count (ANC) < 1,000; or
(c) ANC nadir of < 1,000 neutrophils to previous chemotherapy.
Once this has been documented, approval will be given to
prophylax for all future chemo cycles.
* For injectable medications administered by a healthcare professional,
please refer to the “Policy for Injectable Drugs” in the beginning of
this formulary.
* Please indicate estimated duration of therapy.
GENERIC: FLUCONAZOLE
BRAND:
DIFLUCANВ®
(PA required after 1x 150mg tablet dispensed)
INDICATIONS:
(1) Vaginal candidiasis
(2) Cryptococcal meningitis
(3) Serious systemic candidial infections
(4) Oropharyngeal and esophageal candidiasis
PA-10
Prior Authorization Guidelines
Criteria:
(a) Any of the above diagnoses; except
(b) For the diagnosis of oropharngeal candidiasis, failure of
nystatin therapy; and
(c) For the diagnosis of vaginal candidiasis, patients who are
immunocompromised and/or have recurrent or refractory
infections.
GENERIC: GABAPENTIN
BRAND:
NEURONTINВ®
INDICATION:
(1) Partial seizures (with or without generalization)
Criteria:
(a) Demonstrated failure of, or intolerance to, at least two other
formulary anticonvulsants; or
(b) Patient has been stabilized on gabapentin therapy.
GENERIC: GATIFLOXACIN
BRAND:
ZYMARВ®
INDICATION:
(1) Bacterial conjuntivitis
Criteria:
(a) Failure of, contraindication to, or intolerance to ciprofloxacin
ophthalmic formulation.
GENERIC: INSULIN GLARGINE
BRAND:
LANTUSВ®
INDICATION:
(1) Diabetes mellitus: types 1 or 2 insulin dependent where basal
insulin is required for glycemia control
Criteria:
(a) Treatment of uncontrolled diabetes; and
(b) Documented therapeutic failure with insulin NPH, 70/30 or
other long-acting insulin; or
(c) Frequent episodes of hypoglycemia on insulin therapy; or
(d) Episodes of documented nocturnal hypoglycemia on insulin
regimen; or
(c) Patients < 18 years of age with failure to adhere to other
insulin therapy
PA-11
Prior Authorization Guidelines
GENERIC: INSULIN LISPRO
BRAND:
HUMALOGВ®
INDICATIONS:
(1) Diabetes mellitus: types 1 or 2 insulin dependent
(2) In combination with SFUs in the treatment of high blood sugar
in children >3 years of age and adults >65 years of age
Criteria:
(a) Frequent episodes of hypoglycemia on a regular insulin
regimen; or
(b) Poor post-prandial glucose control on multiple injection
regimens; or
(c) Treatment of brittle diabetics (defined as those patients who
have difficulty controlling blood sugar levels with their current
regimen and who have had several treatment failures in the
past); or
(d) Patients on sliding scale insulin regimens; or
(e) Patients < 18 years of age.
Criteria for approval for Humalog pens:
(a) Patient meets the above criteria; and
(b) Patient has significant visual impairment; or
(c) Patient has difficulty with dexterity (i.e., rheumatoid arthritis
of the hands, etc.); or
(d) Patient has an implanted insulin pump (for insulin cartridges
only)
GENERIC: INTERFERON ALPHA
BRAND:
ROFERON-AВ®, INTRON-AВ®, and ALFERONВ®
INDICATIONS:
(1) Hairy cell leukemia
(2) AIDS-related Kaposi’s sarcoma
(3) Chronic hepatitis B or C
(4) Malignant melanoma
Criteria:
(a) Any of the above diagnoses.
*For injectable medications administered by a healthcare professional,
please refer to the “Policy for Injectable Drugs” in the beginning of
this formulary.
PA-12
Prior Authorization Guidelines
GENERIC: INTERFERON BETA
BRAND:
AVONEXВ® and BETASERONВ®
INDICATIONS:
(1) Relapsing-remitting multiple sclerosis
(2) Relapsing-progressive multiple sclerosis
Criteria:
(a) Patient must have a diagnosis of multiple sclerosis.
* For injectable medications administered by a healthcare professional,
please refer to the “Policy for Injectable Drugs” in the beginning of
this formulary.
GENERIC: IRBESARTAN
BRAND:
AVAPROВ®
INDICATION:
(1) Hypertension
Criteria:
(a) Failure of three formulary ACE inhibitors; or
(b) Intolerance to at least one formulary ACE inhibitor.
GENERIC: ISOSORBIDE MONONITRATE
BRAND:
IMDURВ®
INDICATION:
(1) Prevention of angina pectoris
Criteria:
(a) Failure of formulary nitrates.
GENERIC: ITRACONAZOLE
BRAND:
SPORANOXВ®
INDICATIONS:
(1) Histoplasmosis infections
(2) Aspergillosis infections
(3) Blastomycosis
Criteria:
(a) Any of the above diagnoses.
PA-13
Prior Authorization Guidelines
GENERIC: LAMOTRIGINE
BRAND:
LAMICTALВ®
INDICATION:
(1) Partial seizures or generalized seizures with LGS.
Criteria:
(a) Failure/contraindication of two formulary anticonvulsants.
(b) Patient has been maintained on requested anticonvulsant.
GENERIC: LATANOPROST
BRAND:
XALATANВ®
INDICATIONS:
(1) For reduction of elevated IOP
(2) Open angle glaucoma and ocular hypertension
Criteria:
(a) Failure of treatment trials with two formulary agents.
GENERIC: LEUPROLIDE
BRAND:
LUPRONВ®
INDICATIONS:
(1) Advanced prostate cancer
(2) Central precocious puberty
(3) Endometriosis
(4) Uterine leiomyomata (fibroids)
Criteria:
(a) Diagnosis of advanced prostate cancer, precocious puberty or
fibroids; or
(b) For the diagnosis of endometriosis, failure of NSAIDS and
oral contraceptives or endometriosis diagnosed by
laparoscopy.
*Note: This agent is ordinarily administered at the physician’s office.
For injectable medications administered by a healthcare professional,
please refer to the “Policy for Injectable Drugs” in the beginning of
this formulary.
PA-14
Prior Authorization Guidelines
GENERIC: MEMANTINE
BRAND:
NAMENDA В®
INDICATION:
(1) Alzheimer’s disease: for treatment of moderate-to-severe cases
of dementia
Criteria:
(a) Dementia must be confirmed by clinical evaluation; and
(b) Documented dementia is either moderate or severe
GENERIC: METRONIDAZOLE VAGINAL GEL
BRAND:
METROGELВ®
INDICATION:
(1) Bacterial vaginosis
Criteria:
(a) Pregnancy; or
(b) Intolerance to oral metronidazole.
GENERIC: MIDAZOLAM
BRAND:
VERSEDВ®
INDICATIONS:
(1) Preoperative sedation
(2) Sedation/Anesthesia (IV)
(3) Treatment of epileptic seizures
Criteria:
(a) Must be approved by JAI Medical Director
GENERIC: MOXIFLOXACIN
BRAND:
AVELOXВ®
INDICATION:
(1) Acute bacterial sinusitis
(2) Acute bacterial exacerbations of chronic bronchitis
(3) Uncomplicated skin and skin structure infections
(4) Community-acquired pneumonia
Criteria:
(a) For any of the listed indications, failure of, or intolerance to at
least one appropriate formulary antibiotic within the past 30
days, unless contraindicated; or
(b) The patient has drug allergies to appropriate first-line
formulary antibiotics; or
PA-15
Prior Authorization Guidelines
(c) Cultures show sensitivity to AveloxВ® only; or
(d) Patient discharged on AveloxВ® from the hospital and needs to
continue regimen.
GENERIC: NAFARELIN
BRAND:
SYNARELВ®
INDICATIONS:
(1) Central precocious puberty
(2) Endometriosis
Criteria:
(a) Diagnosis of central precocious puberty; or
(b) For the diagnosis of endometriosis in patients > 18 years of
age, failure of NSAIDs and oral contraceptives, or
endometriosis diagnosed by laparoscopy.
GENERIC: NIZATIDINE
BRAND:
AXIDВ®
INDICATIONS:
(1) Treatment or prevention of duodenal or gastric ulcers
(2) Esophagitis and heartburn due to GERD
Criteria:
(a) Failure of, or intolerance to, cimetidine and ranitidine at
adequate doses; or
(b) Significant renal disease (CrCl < 20mL/min); or
(c) Significant liver disease; or
(d) Potential, clinically significant, drug interactions with
formulary H2RAs.
GENERIC: NUTRITIONAL SUPPLEMENTS
BRAND:
ENSUREВ®, PEDIASUREВ®, BOOSTВ®, SUSTACALВ®,
RESTOREВ®, VIVONEXВ®
INDICATION:
(1) Nutritional supplementation
Criteria:
(a) Patient must have enteral access via one of the following:
nasogastric (NG) tube, nasoduodenal (ND) tube, nasojejunal
(NJ) tube, percutaneous endoscopic gastrostomy (PEG) or
percutaneous endoscopic jejunostomy (PEJ).
PA-16
Prior Authorization Guidelines
GENERIC: OCTREOTIDE
BRAND:
SANDOSTATINВ®
INDICATIONS:
(1) Symptomatic treatment of severe diarrhea and flushing
episodes associated with metastatic carcinoid tumors
(2) Profuse, watery diarrhea associated with vasoactive intestinal
peptide (VIP) secreting tumors
(3) To reduce the blood levels of growth hormone and IGF-I
associated with acromegaly
Criteria:
(a) Any of the above diagnoses; and
(b) For the diagnosis of acromegaly, the patient has had an
inadequate response to, or can not be treated with surgical
resection, pituitary irradiation and bromocriptine at maximally
tolerated doses.
* For injectable medications administered by a healthcare professional,
please refer to the “Policy for Injectable Drugs” in the beginning of
this formulary.
GENERIC: OMEPRAZOLE and LANSOPRAZOLE
BRAND:
PRILOSECВ® and PREVACIDВ®
INDICATIONS:
(1) GERD
(2) Duodenal or gastric ulcers
(3) Pathological hypersecretory conditions
(4) Treatment of H. pylori
Criteria:
(a) GERD: (Savary Miller classification)
Grade 0-1: Failure of an adequate H2RA trial (e.g., cimetidine
1600mg/d or ranitidine 600mg/d)
Grade 2-3: No H2R-antagonist failure required for short-term
PPI approval
*Re-approvals for GERD (Grade 0-3) require the retrial of a H2RA
(high dose)
Grade 4-5: Barrett’s Esophagitis or strictures
(b) PUD:
Failure of a formulary H2RA at adequate doses (e.g.,
cimetidine 800mg/d or ranitidine 300mg/d) and
documentation of H. pylori test results.
PA-17
Prior Authorization Guidelines
(c) H. pylori:
As part of standard treatment regimen: i.e., Pepto Bismol
525mg qid, metronidazole 250mg qid, tetracycline 500mg qid,
and omeprazole 20mg bid or lansoprazole 15mg bid; for 1 to 2
weeks.
* Submission of objective evidence (i.e., EGD results, if available)
along with the PA request is encouraged and will accelerate the prior
authorization process.
GENERIC: ONDANSETRON
BRAND:
ZOFRANВ®
INDICATIONS:
(1) Chemotherapy induced nausea and vomiting
(2) Post-operative nausea and vomiting
(3) Radiation induced nausea and vomiting
Criteria:
(a) For patients who are receiving chemotherapy; or
(b) Failure of two formulary antiemetics; or
(c) For pregnant patients with hyperemesis non-responsive to
metoclopramide.
GENERIC: PALIVIZUMAB
BRAND:
SYNAGISВ®
INDICATION:
(1) Respiratory syncytical virus (RSV)
Criteria:
(a) Infants and children at high risk for developing RSV (as
defined by the American Academy of Pediatrics guidelines on
the prevention of RSV infection).
GENERIC: PEGINTERFERON ALFA-2B
BRAND:
PEG-INTRONВ®
INDICATION:
(1) Initial treatment of chronic hepatitis C in patients with
compensated liver disease.
Criteria:
(a) Diagnosis of chronic hepatitis C.
PA-18
Prior Authorization Guidelines
GENERIC: PENTOXIFYLLINE
BRAND:
TRENTALВ®
INDICATION:
(1) Intermittent claudication
Criteria:
(a) Pain on walking or ABI < 0.8; or
(b) Diabetic foot ulcer; or
(c) Gangrene; or
(d) Risk of, or existing, amputation.
GENERIC: PRAVASTATIN
BRAND:
PRAVACHOLВ®
INDICATIONS:
(1) Treatment of primary hypercholesterolemia and mixed
dyslipidemia
(2) Treatment of hypertriglyceridema
(3) Treatment of primary dysbetalipoproteinemia
(4) Primary prevention of coronary events in
hypercholesterolemic patients without evident coronary heart
disease
(5) Secondary prevention of cardiovascular events in patients with
clinically evident CHD.
Criteria:
(a) Patients without CHD and with > 2 CHD risk factors and LDL
cholesterol remains > 130 mg/dL; or
(b) In patients without CHD and fewer than 2 risk factors and
LDL cholesterol remains > 160mg/dL; and
(c) Failure of at least two formulary statins; or
(d) Patient has diabetes mellitus or CHD and LDL cholesterol >
100mg/dL; or
(e) Patient may experience drug interactions with formulary
statins.
PA-19
Prior Authorization Guidelines
GENERIC: RALOXIFENE
BRAND:
EVISTAВ®
INDICATION:
(1) Treatment and prevention of osteoporosis in postmenopausal
women
Criteria:
(a) Personal or family history of breast cancer; or
(b) Intolerable side effects to at least one formulary estrogen.
GENERIC: RIBAVIRIN
BRAND:
REBETOLВ®
INDICATION:
(1) Indicated only in combination with a recombinant interferon
alfa-2b product for the treatment of chronic hepatitis C.
Criteria:
(a) Diagnosis of chronic hepatitis C; and
(b) Patient is receiving concomitant recombinant interferon alfa2b therapy.
GENERIC: RILUZOLE
BRAND:
RILUTEKВ®
INDICATION:
(1) Amytrophic lateral sclerosis (ALS)
Criteria:
(a) Diagnosis of ALS.
GENERIC: ROPINROLE
BRAND:
REQUIPВ®
INDICATION:
(1) For the treatment of signs and symptoms of idiopathic
Parkinson’s disease.
Criteria:
(a) Diagnosis of idiopathic Parkinson’s disease.
GENERIC: ROSIGLITAZONE
BRAND:
AVANDIAВ®
INDICATION:
(1) For the treatment of type 2 diabetes mellitus as a monotherapy
or in combination with sulfonylureas, metformin or insulin.
PA-20
Prior Authorization Guidelines
Criteria:
(a) Diagnosis of type 2 diabetes; and
(b) Failure of, or contraindication to, an oral formulary
antidiabetic agent, including: sulfonylureas or metformin.
Failure is defined as a hemoglobin A1c >7.0.
GENERIC: ROSIGLITAZONE/METFORMIN
BRAND:
AVANDAMETВ®
INDICATION:
(1) For the treatment of type 2 diabetes mellitus in patients who
have been on combination rosiglitazone and metformin, or not
adequately controlled on metformin alone.
Criteria:
(a) Diagnosis of type 2 diabetes; and
(b) The patient is currently receiving treatment with rosiglitazone
and metformin; or
(c) The patient is inadequately controlled on metformin therapy
alone. Failure is defined as a hemoglobin A1c >7.0.
GENERIC: SALMETEROL/FLUTICASONE
BRAND:
ADVAIRВ®
INDICATION:
(1) Long-term, twice–daily maintenance treatment of asthma in
patients 12 years of age and older.
Criteria:
(a) Failure of a formulary inhaled corticosteroid; or
(b) Patient has compliance issues with current therapy and use of
the combination product will improve compliance.
GENERIC: SOMATROPIN
BRAND:
HUMATROPEВ®
INDICATION:
(1) Long term treatment of children who have growth failure due
to a lack of adequate, endogenous growth hormone secretion
Criteria:
(a) Height is > 2.5 standard deviations below the mean for age; or
(b) Growth velocity is subnormal (age specific growth rate at <
25th percentile); and
(c) Delayed bone age; and
(d) A subnormal GH response to a provocative stimulation test.
PA-21
Prior Authorization Guidelines
в€—
в€—
To continue therapy, requests will be reviewed every six months.
For injectable medications administered by a healthcare professional,
please refer to the “Policy for Injectable Drugs” in the beginning of
this formulary.
GENERIC: SUCCIMER
BRAND:
CHEMETВ®
INDICATIONS:
(1) Treatment of lead poisoning in children with blood lead levels
> 45 mcg/dl
(2) Unlabeled uses: Succimer may be beneficial in the treatment
of other heavy metal poisonings
Criteria:
(a) Diagnosis of lead poisoning with blood levels > 45mcg/dl;
and
(b) Child is hospitalized; or
(c) Child was started on the medication in the hospital and needs
to continue upon discharge.
GENERIC: SUCRALFATE
BRAND:
CARAFATEВ®
INDICATIONS:
(1) Gastric ulcers
(2) Duodenal ulcers
(3) Gastritis
(4) GERD
Criteria:
(a) Failure of, or intolerance to, a formulary H2RA at an adequate
dose; or
(b) Diagnosis of bile reflux; and
(c) Not concurrently used with an H2RA or proton-pump
inhibitor.
PA-22
Prior Authorization Guidelines
GENERIC: SUMATRIPTAN (tablets and injection only)
BRAND:
IMITREXВ®
INDICATION:
(1) Acute treatment of migraine headache
Criteria:
(a) Failure of, or intolerance to, at least two traditional formulary
agents (e.g., narcotics, ergotamine, NSAIDS); or
(b) Unsuccessful concurrent or previous use of migraine
prophylaxis medications (e.g., beta-blockers, calcium channel
blockers, tri-cyclic antidepressants or anticonvulsants) if a
patient experiences more than two migraines per month; and
(c) Successful trial of sumatriptan injection in the office or
emergency room to ensure safety and efficacy.
GENERIC: TAMSULOSIN
BRAND:
FLOMAXВ®
INDICATION:
(1) Treatment of signs and symptoms of benign prostatic
hypertrophy (BPH)
Criteria:
(a) Diagnosis (positive signs and symptoms) of BPH.
GENERIC: THROMBIN
BRAND:
THROMBINARВ®
INDICATION:
(1) Hemostasis
Criteria:
(a) Diagnoses of a bleeding disorder.
GENERIC: TIPRANAVIR
BRAND:
APTIVUSВ®
INDICATION:
(1) Adjunctive therapy, with ritonavir, of HIV-1 in highly
treatment experienced patients or with HIV-1 strains resistant
to multiple protease inhibitors
PA-23
Prior Authorization Guidelines
Criteria:
(a) Diagnosis of HIV-1 and
(b) Co-prescribed with 200mg ritonavir BID; and
(c) Patient is highly treatment (HAART) experienced; or
(d) HIV-1 strain is resistant to multiple protease inhibitors.
GENERIC: TOPIRAMATE
BRAND:
TOPAMAXВ®
INDICATION:
(1) Partial seizures or generalized seizures with LGS.
Criteria:
(a) Failure/contraindication of two formulary anticonvulsants.
(b) Patient has been maintained on requested anticonvulsant.
GENERIC: TRAMADOL
BRAND:
ULTRAMВ®
INDICATION:
(1) Moderate to moderately severe pain
Criteria:
(a) Failure of at least two formulary NSAIDs; and
(b) Failure of at least two formulary narcotics; and
(c) Patient does not have a codeine allergy; and
(d) Patient does not have a seizure disorder.
PA-24
FGGGG
Index
FGGGG
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
Page
Abacavir
3
Abacavir / Lamivudine
3
Abacavir / Lamivudine / Zidovudine 3
Acamprosate
21
Acarbose
7
Acetaminophen w/ Codeine*
16
Acetaminophen w/ Hydrocodone* 16
Acetaminophen*
15
Acetazolamide*
10
ACETEST
24
Acetic Acid in Propylene Glycol*
22
Acetohexamide*
7
Acetone Tablets
24
Acetone Test*
24
Acetylcysteine*
11
Acyclovir
24
Acyclovir*
4
ADALAT CC
8
ADVAIR
12
AGENERASE
3
AKNE-MYCIN
24
AK-SPORE
21
AK-SPORE HC
22
AK-TRACIN
21
Al Hydrox-Mag Carb*
13
ALAVERT
11
Albendazole
2
ALBENZA
2
Albuterol*
12
Albuterol-Ipratropium
12
ALCOHOL PADS
25
Alcohol Swabs*
25
ALDACTAZIDE
10
ALDACTONE
10
ALDOMET
9
ALDORIL
9
Alendronate
8
ALFERON N
5
ALKERAN
4
ALLEGRA
11
ALLEGRA-D
11
Allopurinol*
17
ALOMIDE
21
ALPHANATE
20
Aluminum & Magnesium Hydroxide* 13
Aluminum Hydroxide Gel*
13
Amantadine*
4
Amantadine*
17
Aminophylline*
12
Amiodarone*
9
Amlodipine
8
Amox & K Clav
1
Product Name
Page
Amoxicillin*
1
AMOXIL
1
AMPHOGEL
13
Ampicillin*
1
Amprenavir
3
Amylase-Lipase-Protease
14
Amylase-Lipase-Protease Reg.Rls 14
ANAPROX
16
ANDROID
5
ANTABUSE
21
Antihemophilic Factor (Human)
20
Antihemophilic Factor (Porcine)
20
Antihemophilic Factor (Recombinant) 20
Antiinhibitor Coagulant Complex
20
Antithrombin III (Human)
20
ANTIVERT
13
ANUSOL-HC
23
APAP/Caffeine/Butalbital*
15
APRESAZIDE
9
APRESOLINE
9
APRI
6
APTIVUS
3`
AQUASOL A
18
ARALEN
2
ARANESP
19
ARICEPT
21
ASACOL
14
ASPIRIN BUFFERED
15
Aspirin Enteric Coated*
15
Aspirin w/ Codeine*
16
Aspirin with Buffers*
15
Aspirin zero order*
15
Aspirin/Caffeine/Butalbital*
15
Atazanavir
3
Atenolol & Chlorthalidone*
9
Atenolol*
8
Atorvastatin
10
Atropine Sulfate*
22
ATROVENT HFA
11
ATROVENT/NASAL
11
AUGMENTIN
1
AURALGAN
22
Auranofin
16
AUTOPLEX T
20
AVANDAMET
6
AVANDIA
6
AVAPRO
9
AVC
14
AVELOX
2
AVIANE
6
AVONEX
5
AXID
13
IDX-1
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
Page
AYGESTIN
6
Azathioprine*
25
Azithromycin*
1
AZMACORT
11
AZULFIDINE
2
AZULFIDINE
14
Bacitracin*
21
Bacitracin* topical
23
Bacitracin-Polymyxin B*
21
Bacitracin-Polymyxin-Neomycin-HC 22
Baclofen*
18
BACTRIM/DS
2
BACTROBAN
23
B-D INSULIN SYRINGE
25
BENADRYL
11
BENADRYL
15
Benazepril*
9
BENTYL
13
BENZAC W
24
Benzocaine & Antipyrine*
22
Benzoyl Peroxide*
24
BEROCCA PLUS
18
Betamethasone Dipropionate*
24
Betamethasone Valerate*
24
BETAPACE
8
BETASERON
5
Betaxolol
21
Bethanechol*
14
BETIMOL
21
BETOPTIC/BETOPTIC S
21
BIAXIN
1
BICILLIN
1
BICITRA
19
BICITRA
15
BIOCLATE
20
Bisacodyl*
12
Bismuth Subsalicylate
13
BLEPH-10
21
BLOCADREN
8
Blood Glucose Monitoring Tests*
25
BOOST
19
BRETHINE/BRETHAIRE
11
Bromocriptine*
17
BRONKOSOL
11
Buprenorphine Hcl
16
Buprenorphine-Naloxone Hcl
16
Busulfan
4
Butabarbital
15
BUTISOL
15
Butoconazole Nitrate
14
BYETTA
7
CAFERGOT
17
Product Name
Page
CALAN/SR
8
Calcipotriene
23
Calcitonin (Salmon)
7
Calcitriol
18
Calcium Acetate
19
Calcium Carbonate*
19
Calcium Carbonate*
13
Calibration Solution
25
CAMILA
6
CAMPRAL
21
Capecitabine
4
CAPOTEN
9
Captopril*
9
CARAFATE
13
Carbamazepine*
21
Carbamide Peroxide
22
Carbidopa-Levodopa*
17
Carbinoxamine & Pseudoephedrine* 12
Carbinoxamine & Pseudoephedrine/DM* 12
CARDEC/CARDEC DM
12
CARDIZEM/CD
8
Carvedilol
8
CATAPRES
9
CECLOR
1
CEENU
4
Cefaclor*
1
Cefdinir
1
Cefprozil*
1
CEFTIN
1
Ceftriaxone*
1
Cefuroxime*
1
CEFZIL
1
CELLCEPT
25
CELONTIN
17
Cephalexin*
1
Cephradine*
1
Cetirizine
11
CHEMET
25
CHILDS COMPLETE
18
Chlorambucil
4
Chloroquine*
2
Chlorothiazide*
10
Chlorpropamide*
7
Chlorthalidone*
10
Cholestyramine*
10
Choline & Mag Salicylate*
15
CHRONULAC
12
CILOXAN
21
Cimetidine*
13
CIPRO
2
Ciprofloxacin*
2
Ciprofloxacin* otic
21
IDX-2
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
Page
Clarithromycin*
1
CLARITIN
11
CLARITIN-D
11
CLEOCIN
14
CLEOCIN
1
CLEOCIN GEL
24
CLIMARA
6
Clindamycin
14
Clindamycin Phosphate*
24
Clindamycin*
1
CLINITEST
24
CLINORIL
16
Clobetasol Propionate
24
Clonidine & Chlorthalidone*
9
Clonidine*
9
Clopidogrel
20
Clotrimazole*
23
Clotrimazole* vaginal
14
Cloxacillin Sodium
1
CLOXAPEN
1
Coal Tar shampoo
23
Codeine Phosphate
16
Codeine Sulfate*
16
Codeine-GG*
12
COLACE
12
Colchicine*
17
COLESTID
10
Colestipol
10
Collagenase
23
COMBIPRES
9
COMBIVENT
12
COMBIVIR
3
COMPAZINE
13
COMPAZINE
15
COMTAN
17
Condoms
25
CONDYLOX
23
Conjugated Estrogens & Medroxy
6
CORDARONE
9
COREG
8
CORTEF
5
Cortisone
5
CORTISPORIN OTIC
22
CORTISPORIN TOPICAL
23
CORTONE
5
COUMADIN
20
CREON
14
CRIXIVAN
3
Cromolyn (inhalation)
11
Cromolyn (nasal)
11
CRYSELLE
6
CUPRIMINE
25
Product Name
Page
Cyanocobalamin*
19
Cyclobenzaprine*
18
Cyclophosphamide*
4
Cycloserine
2
Cyclosporine
25
Cyclosporine Microsize
25
Cyproheptadine*
11
CYTOMEL
7
CYTOVENE
4
CYTOXAN
4
DANAZOL
5
Danazol
5
DANTRIUM
18
Dantrolene*
18
Dapsone
2
DARAPRIM
4
Darbopoetin
19
DARVOCET N-100
16
DDAVP
8
DEBROX
22
DECADRON
5
DECADRON Opth
21
Delavirdine
3
DELTASONE
5
DEMEROL
16
DEPO-PROVERA
6
Desmopressin*
8
Desogest/Eth Est & Eth Estradiol
6
Desogestral/Ethinyl Estradiol
6
Desonide*
24
DESOWEN
24
Dexamethasone*
5
Dexamethasone*
21
Dexchlorpheniramine*
11
DIABETA
7
DIABINESE
7
DIAMOX
10
DIBENZYLINE
9
Dicloxacillin Sodium*
1
Dicyclomine*
13
Didanosine
3
DIFLUCAN
3
Digoxin*
8
DILACOR/XR
8
DILANTIN
17
DILAUDID
16
Diltiazem*
8
Diphenhydramine*
11
Diphenhydramine*
15
Diphenoxylate w/ Atropine
13
Dipivefrin*
22
DIPROSONE
24
IDX-3
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
Page
Dipyridamole*
8
DISALCID
15
Disopyramide*
8
Disposable Needles & Syringes*
25
Disulfiram
21
DITROPAN
14
DIURIL
10
Docusate Sodium*
12
Donepezil
21
Dorzolamide
22
DOVONEX
23
Doxycycline*
2
DRISDOL
18
Droperidol
20
DULCOLAX
12
DURAGESIC
16
DURATUSS
12
DYCILL
1
DYMELOR
7
E.E.S.
1
Echothiophate Iodide
22
ECOTRIN
15
Efavirenz
3
EFUDEX
4
EFUDEX
24
ELDEPRYL
17
ELIDEL
24
ELIMITE
24
EMIPRIN/COD
16
Emtricitabine
3
EMTRIVA
3
Enalapril*
9
ENDURON
10
Enfuvirtide
4
Enoxaparin
20
ENSURE
19
Entacapone
17
Epinephrine
10
Epinephrine
12
EPI-PEN/EPI-PEN JR
10
EPI-PEN/EPI-PEN JR
12
EPIVIR
3
Epoetin Alfa
19
EPOGEN
19
EPZICOM
3
Ergocalciferol
18
Ergoloid Mesylates*
15
Ergonovine
7
Ergotamine mesylates
17
Ergotamine w/ Caffeine
17
ERGOTRATE
7
ERRIN
6
Product Name
Page
ERY-TAB
1
ERYTHROCIN
1
Erythromycin Base*
1
Erythromycin Estolate*
1
Erythromycin Ethylsuccinate*
1
Erythromycin Gel*
24
Erythromycin Stearate*
1
Erythromycin* ophthalmic
21
Erythromycin/Sulfisoxazole*
2
Esterified Estrogens
5
ESTRACE
5
Estradiol Patch*
6
Estradiol*
5
Estrogens, Conjugated
6
Ethambutol*
2
Ethionamide
2
ETHMOZINE
9
Ethosuximide
17
Ethotoin
17
Ethynodiol Diacet & Eth Estrad
6
Etoposide*
5
EULEXIN
5
EVISTA
7
Exenatide
7
Famotidine*
13
FELDENE
16
Felodipine*
8
FEMARA
5
FEMSTAT
14
Fenoprofen*
16
Fentanyl*
16
FEOSOL
19
FERGON
19
Ferrous Gluconate*
19
Ferrous Sulfate*
19
Fexofenadine / Pseudoephedrine
11
Fexofenadine*
11
FIBERCON
12
Filgrastim
20
FIORICET
15
FIORINAL
15
FLAGYL
2
Flavoxate*
14
Flecainide*
8
FLEXERIL
18
FLOMAX
9
FLONASE
11
FLORINEF
5
FLOVENT HFA
11
FLOXIN
22
Fluconazole*
3
Fludrocortisone*
5
IDX-4
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
Page
Flunisolide*
11
Fluocinonide Acetonide*
24
Fluocinonide*
24
Fluorouracil*
24
Fluorouracil*
4
Fluoxymesterone
5
Flurbiprofen*
22
Flutamide*
5
Fluticasone
11
Fluvastatin
10
Folic Acid & Vitamin B Complex*
18
Folic Acid*
19
FOLVITE
19
FORTOVASE
3
FOSAMAX
8
Fosamprenavir Calcium
3
Fosinopril*
9
FURADANTIN
14
Furosemide*
10
FUZEON
4
Gabapentin*
21
Galtifloxacin
21
Ganciclovir*
4
GANTRISIN
2
GARAMYCIN
2
GARAMYCIN
21
GARAMYCIN TOPICAL
23
Gemfibrozil*
10
Gentamicin Sulfate*
2
Gentamicin Sulfate*
21
Gentamicin Sulfate* topical
23
Glipizide*
7
Glucagon
7
GLUCOFILM
24
GLUCOMETER
25
GLUCOPHAGE
7
Glucose Blood*
24
Glucose Urine Test*
24
GLUCOTROL/XL
7
Glyburide*
7
GLYCERIN SUPP.
10
Glycerin Supp.
10
Glycerin*
12
GLYNASE
7
GOLYTELY
12
GRIFULVIN V
3
Griseofulvin Microsize
3
Griseofulvin Ultramicrosize
3
GRIS-PEG
3
Guaifenesin*
12
Guaifenesin/DM*
12
Guanfacine*
9
Product Name
HABITROL
HALOTESTIN
HIVID
HUMALOG
HUMATROPE
HUMULIN 50/50
HUMULIN 70/30
HUMULIN L
HUMULIN N
HUMULIN R
HUMULIN U
HYATE:C
HYCOTUSS
HYDERGINE
HYDERGINE
Hydralazine & HCTZ*
Hydralazine*
Hydralazine-Reserpine-HCTZ*
HYDREA
HYDROBEXAN
Hydrochlorothiazide*
Hydrocodone-GG*
Hydrocortisone
Hydrocortisone w/Acetic Acid*
Hydrocortisone*
Hydrocortisone*
HYDRODIURIL
Hydromorphone*
HYDROPRES
Hydroxocobalamin*
Hydroxychloroquine*
Hydroxyurea*
HYGROTON
Hyoscyamine Sulfate*
Hyoscyamine*
HYPOLET
HYTONE
HYTRIN
Ibuprofen*
ILOSONE
ILOTYCIN
IMDUR
IMITREX
IMODIUM
IMURAN
INAPSINE
Indapamide*
INDERAL/LA
INDERIDE
Indinavir Sulfate
INDOCIN
Indomethacin*
IDX-5
Page
20
5
3
6
7
6
6
6
6
6
6
20
12
15
17
9
9
9
5
19
10
12
23
22
5
24
10
16
9
19
2
5
10
13
14
25
24
9
16
1
21
8
17
13
25
20
10
8
9
3
16
16
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
Infant Foods
INH
Insulin Aspart
Insulin Glargine
Insulin Isophane
Insulin Lispro
Insulin Reg & Isophane
Insulin Reg & NPH
Insulin Regular
Insulin Zinc
Insulin Zinc Extended
INTAL
Interferon Alfa-2A
Interferon Alfa-2B
Interferon Alfa-n3
Interferon Beta-1a
Interferon Beta-1b*
INTRON-A
INVIRASE
Iopanoic Acid
Ipecac*
Ipratropium*
Irbesartan
Isoetharine*
Isoniazid*
ISOPTO ATROPINE
ISOPTO-CARPINE
ISORDIL/ISORDIL TEMBIDS
Isosorbide Dinitrate*
Isosorbide Mononitrate*
Itraconazole*
KALETRA
KAOCHLOR
KARIVA
KAYEXALATE
KEFLEX
KENALOG
KENALOG/ORABASE
Ketoconazole*
KETOSTIX
KLOR-CON
KWELL
Labetalol*
Lactulose*
LAMICTAL
Lamivudine
Lamotrigine
Lancet Device
Lancets
LANOXIN
Lansoprazole
LANTUS
Page
19
2
6
6
6
6
6
6
6
6
6
11
5
5
5
5
5
5
3
25
24
11
9
11
2
22
22
8
8
8
3
3
19
6
25
1
24
24
3
24
19
24
8
12
21
3
21
25
25
8
13
6
Product Name
LASIX
Latanoprost
LESCOL
Letrozole
LEUCOVORIN
Leucovorin Calcium*
LEUKERAN
Leuprolide
Levocabastine
Levonorgestrel-Eth Estradiol
LEVORA
Levothyroxine*
LEVOXYL
LEVSIN
LEVSINEX
LEXIVA
LIDEX
Lidocaine viscous*
Lidocaine*
Lindane*
LIORESAL
Liothyronine
LIPITOR
Lisinopril & HCTZ*
Lisinopril*
LIVOSTIN
Lodoxamine
LOFENALAC
LOMOTIL
Lomustine
LONITEN
Loperamide*
LOPID
Lopinavir/Ritonavir
LOPRESSOR
LORABID SUSPENSION
Loracarbef
Loratadine / Pseudoephedrine*
Loratadine*
LOTENSIN
LOTRIMIN
LOVENOX
LOZOL
LUPRON
LURIDE
LYSODREN
MAALOX
MACRODANTIN
MANDELAMINE
MATERNA
MATULANE
MAXAIR AUTOHALER
IDX-6
Page
10
22
10
5
19
19
4
5
21
6
6
7
7
13
14
3
24
24
17
24
18
7
10
9
9
21
21
19
13
4
9
13
10
3
8
1
1
11
11
9
23
20
10
5
19
5
13
14
14
18
5
11
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
MAXITROL
MAXZIDE
MEBARAL
Mebendazole*
Meclizine*
MEDROL
Medroxyprogesterone Depot*
Medroxyprogesterone*
MEGACE
Megestrol*
Melphalan
Memantine
MENEST
Meperidine*
Mephobarbital
Mercaptopurine*
Mesalamine
MESTINON
Metformin*
METHADONE
Methazolamide*
Methenamine Mandelate*
METHERGINE
Methimazole*
Methocarbamol w/ Aspirin*
Methocarbamol*
Methotrexate*
Methotrexate*
Methsuximide
Methyclothiazide*
Methyldopa & HCTZ*
Methyldopa*
Methylergonovine
Methylprednisolone*
Methyltestosterone
Metipranolol*
Metoclopramide*
Metolazone*
Metoprolol Tartrate*
METROGEL
METROGEL
Metronidazole
Metronidazole
Metronidazole*
Mexiletine*
MEXITIL
MIACALCIN INJ
MIACALCIN NASAL
Miconazole
Miconazole
Miconazole*
MICROGESTIN FE
Page
22
10
15
2
13
5
6
6
5
5
4
21
5
16
15
4
14
18
7
16
10
14
7
7
18
18
4
17
17
10
9
9
7
5
5
21
14
10
8
14
23
14
23
2
9
9
7
7
3
14
23
6
Product Name
MICRO-K
MICROSULFON
Midazolam
MINIPRESS
Minoxidil*
Mitotane
MONISTAT
MONISTAT
MONISTAT
MONOPRIL
Montelukast Sodium
Moricizine*
Morphine Sulfate SR*
Morphine Sulfate*
MOTRIN
moxifloxacin
MS CONTIN
MSIR
MUCOMYST
Multiple Vitamin w/ Minerals*
Multiple Vitamin*
Mupirocin*
MYAMBUTOL
MYCELEX
MYCELEX TROCHE
MYCOBUTIN
MYCOLOG II
Mycophenolate Mofetil
Mycophenolate Sodium
MYCOSTATIN
MYDFRIN
MYFORTIC
MYLANTA
MYLERAN
MYSOLINE
MYSOLINE
Nafarelin
NALFON
Naltrexone*
NAMENDA
Naphazoline*
NAPROSYN
Naproxen Sodium*
Naproxen*
NASACORT AQ
NASALCROM
NASALIDE
NECON
NECON 7/7/7
Nedocromil
Nelfinavir Mesylate
NEO-DECADRON
IDX-7
Page
19
2
15
9
9
5
3
14
23
9
12
9
16
16
16
2
16
16
11
18
18
23
2
14
23
2
23
25
25
3
22
25
13
4
17
21
7
16
16
21
22
16
16
16
11
11
11
6
6
11
3
22
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
Page
NEOMYCIN
23
NEOMYCIN
2
Neomycin Sulfate*
2
Neomycin Sulfate*
23
Neomycin-Bac Zn-Polymyxin*
21
Neomycin-Bacitracin-Polymyxin*
23
Neomycin-Dexamethasone*
22
Neomycin-Polymy-Gramicidin*
21
Neomycin-Polymyxin-Dexamethasone* 22
Neomycin-Polymyxin-HC Opth*
22
Neomycin-Polymyxin-HC Topical
23
NEORAL
25
NEOSPORIN
23
NEOSPORIN
21
NEPHROCAPS
18
NEPTAZANE
10
NEUPOGEN
20
NEURONTIN
21
Nevirapine
3
Niacin*
10
Niacin*
18
NICODERM/NICODERM CQ
20
Nicotine
20
NICOTROL
20
Nifedipine*
8
NITROBID
8
NITRODUR
8
Nitrofurantoin Macrocrystals*
14
Nitrofurantoin*
14
Nitroglycerin (oral)*
8
Nitroglycerin (topical)*
8
NITROL
8
NITROSTAT
8
NIX
24
Nizatidine
13
NIZORAL
3
NOLVADEX
5
Norelgestromin-Ethinyl Estradiol
6
Norethindrone*
6
Norethindrone-Ethinyl Estrad
6
Norgestimate/Ethinyl Estradiol
6
Norgestrel & Ethinyl Estradiol
6
NORMODYNE
8
NORPACE/CR
8
NORTREL
6
NORTREL 7/7/7
6
NORVASC
8
NORVIR
3
NOVOLIN 70/30
6
NOVOLIN N
6
NOVOLIN R
6
NOVOLOG
6
Product Name
Page
Nutritional Supplements
19
Nystatin*
3
Nystatin* local
23
Nystatin* vaginal
14
Nystatin-Triamcinolone*
23
Octreotide Acetate
13
OCUFEN
22
Ofloxacin
22
Olopatadine
21
Omeprazole
13
OMNICEF
1
Ondansetron HCL
14
ONE-A-DAY
18
OPTIPRANOLOL
21
Oral Electrolytes
19
ORAMORPH SR
16
ORINASE
7
ORTHO EVRA PATCH
6
ORTHO TRI CYCLEN
6
ORTHOCEPT
6
OS-CAL
13
OS-CAL
19
Oxacillin
1
OXACILLIN
1
Oxybutynin*
14
Oxycodone w/ Acetaminophen*
16
Oxycodone w/ Aspirin*
16
Palivizumab
4
PARLODEL
17
PATANOL
21
PEDIALYTE
19
PEDIAPRED
5
PEDIASURE
19
Pediatric Multivitamins w/Fluoride
18
Pediatric Vitamins*
18
PEDIAZOLE
2
PEGANONE
17
PEG-Electrolyte
12
Peginterferon
4
PEG-INTRON
4
PEN VEE K
1
Penicillamine
25
Penicillin G Benzathine
1
Penicillin V Potassium*
1
PENTASA
14
Pentoxifylline
20
PEPCID
13
PEPTO-BISMOL
13
PERCOCET
16
PERCODAN
16
PERIACTIN
11
Permethrin*
24
IDX-8
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
PERSANTINE
Phenazopyridine*
PHENERGAN
Phenobarbital*
Phenoxybenzamine
Phenylephrine*
Phenyl-Free
Phenytoin*
PHOSLO
PHOSPHOLINE
Pilocarpine*
Pimecrolimus Cream
PIN-X
Pirbuterol
Piroxicam
PLAQUENIL
PLAVIX
PLENDIL
Podofilox
POLARAMINE
Polycarbophil Calcium
POLYSPORIN
POLY-VI-FLOR
Potassium Chloride Capsule*
Potassium Chloride Liquid*
Potassium Chloride Tablet*
PRAVACHOL
Pravastatin
Prazosin*
PRECOSE
PRED FORTE/MILD
Prednisolone Acetate*
Prednisolone Na Phosphate*
Prednisolone*
Prednisone*
PRELONE
PREMARIN
PREMPRO
Prenatal MV & Min w/FE-FA*
Prenatal Vitamins*
PRENATAL-1
PREVACID
PRILOSEC, OTC
PRILOSEC, RX
Primidone
Primidone*
PRO-BANTHINE
Probenecid*
Procainamide*
PROCANBID
Procarbazine
PROCARDIA XL
Page
8
15
11
15
9
22
19
17
19
22
22
24
2
11
16
2
20
8
23
11
12
21
18
19
19
19
10
10
9
7
21
21
5
5
5
5
6
6
18
18
18
13
13
13
21
17
13
17
8
8
5
8
Product Name
Prochlorperazine
Prochlorperazine*
PROCRIT
PROCTOCREAM
PROLOPRIM
Promethazine*
PRONESTYL
Propafenone*
Propantheline Bromide*
PROPINE
Propoxyphene w/ APAP*
Propranolol & HCTZ*
Propranolol*
Propylthiouracil*
PROSTEP
PROVENTIL
PROVERA
PSEUDOEPHEDRINE
Pseudoephedrine HCL*
Pseudoephedrine-GG
PURINETHOL
Pyrantel Pamoate
Pyrazinamide*
PYRIDIUM
Pyridostigmine*
Pyrimethamine
QUESTRAN/LIGHT
Quinidine Sulfate*
Quinine*
QUINORA
Raloxifene
Ranitidine*
REBETOL
REGLAN
REQUIP
RESCRIPTOR
RESERPINE
Reserpine & HCTZ
Reserpine*
RESTORE
RETIN-A
RETROVIR
REVIA
REYATAZ
RHEUMATREX
RHEUMATREX
Ribavirin
RIDAURA
Rifabutin
RIFADIN
Rifampin*
RILUTEK
IDX-9
Page
15
13
19
23
2
11
8
9
13
22
16
9
8
7
20
12
6
12
12
12
4
2
2
15
18
4
10
8
2
8
7
13
4
14
17
3
9
9
9
19
24
3
16
3
4
17
4
16
2
2
2
18
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
Page
Riluzole
18
Ritonavir
3
ROBAXIN
18
ROBAXISAL
18
ROBITUSSIN AC
12
ROCALTROL
18
ROCEPHIN
1
ROFERON-A
5
Ropinirole
17
Rosiglitazone Maleate
6
Rosiglitazone Maleate/Metformin Hcl. 6
ROWASA
14
RYTHMOL
9
Salmeterol
11
Salmeterol-Fluticasone
12
Salsalate*
15
SANDIMMUNE
25
SANDOSTATIN
13
SANTYL
23
Saquinavir
3
Selegiline*
17
SER-AP-ES
9
SEREVENT
11
SEROMYCIN
2
SILVADENE
23
Silver Sulfadiazine*
23
Simvastatin
10
SINEMET/CR
17
SINGULAIR
12
Sodium Citrate & Citric Acid
15
Sodium Citrate & Citric Acid
19
Sodium Fluoride
19
Sodium Polystyrene Sulfonate
25
SODIUM SULAMYD
23
Sodium Sulfacetamide*
21
Somatropin
7
Sotalol*
8
SPIRIVA
11
Spironolactone & HCTZ*
10
Spironolactone*
10
SPORANOX
3
SPRINTEC
6
Stavudine
3
SUBOXONE
16
SUBUTEX
16
Succimer
25
Sucralfate*
13
Sulfacetamide Sodium
23
Sulfacetamide Sod-Prednisolone* 22
Sulfadiazine*
2
Sulfanilamide
14
Sulfasalazine*
2
Product Name
Page
Sulfasalazine*
14
Sulfisoxazole*
2
Sulindac*
16
SULTRIN
14
Sumatriptan Injection
17
Sumatriptan Tablets
17
SUMYCIN
2
SUSTACAL
19
SUSTIVA
3
SYMMETREL
4
SYMMETREL
17
SYNAGIS
4
SYNALAR
24
SYNAREL
7
SYNTHROID
7
TAGAMET
13
TAMBOCOR
8
Tamoxifen*
5
Tamsulosin
9
TAPAZOLE
7
TEGRETOL
21
TELEPAQUE
25
TEMOVATE
24
TENEX
9
Tenofovir
3
Tenofovir Disoproxil/Emptricitabine
3
TENORETIC
9
TENORMIN
8
Terazosin*
9
Terbutaline
11
TESLAC
4
Testolactone
4
Tetracycline*
2
THEO-24
12
Theophylline*
12
Thioguanine
4
THIOGUANINE
4
THROMBAT III
20
Thrombin
20
THYROID
7
Thyroid*
7
TILADE
11
Timolol*
8
Timolol*
21
TIMOPTIC
21
Tiotropium
11
Tolazamide*
7
Tolbutamide*
7
TOLINASE
7
TOPAMAX
21
Topiramate
21
TOTACILLIN
1
IDX-10
BioScrip/Jai Medical Systems Therapeutic Formulary
Product Name
Page
Tramadol*
16
TRECATOR-SC
2
TRENTAL
20
Tretinoin*
24
Triamcinolone
11
Triamcinolone Acetonide in Orabase* 24
Triamcinolone Acetonide*
24
Triamterene & HCTZ*
10
Trifluridine
21
TRILISATE
15
Trimethoprim
14
Trimethoprim*
2
Trimethoprim/Sulfamethoxazole*
2
TRIMPEX
14
TRI-NORINYL
6
Triple Sulfas Vaginal*
14
Tripranavir
3
TRIVORA
6
TRIZIVIR
3
TRUSOPT
22
TRUVADA
3
TYLENOL
15
TYLENOL/COD
16
ULTRAM
16
UNIPHYL
12
URECHOLINE
14
URISPAS
14
VALISONE
24
VASOCIDIN
22
VASOCON
22
VASOTEC
9
VELOSEF
1
VEPESID
5
Verapamil*
8
VERMOX
2
VERSED
15
VIBRAMYCIN
2
VICODIN (5/500 )
16
Vidarabine
21
VIDEX
3
VIDEX EC
3
VIOKASE
14
VIRA-A
21
VIRACEPT
3
VIRAMUNE
3
VIREAD
3
VIROPTIC
21
Vitamin A*
18
VITAMIN B-12
19
Vitamin B-3*
18
VIVONEX
19
VOSOL
22
Product Name
VOSOL-HC
Warfarin Sodium*
XALATAN
XELODA
XYLOCAINE VISCOUS
Zalcitabine
ZANTAC
ZARONTIN
ZAROXOLYN
ZERIT
ZESTORETIC
ZESTRIL
ZIAGEN
Zidovudine*
Zidovudine/lamivudine
ZITHROMAX
ZOCOR
ZOFRAN
ZORPRIN
ZOVIA
ZOVIRAX
ZOVIRAX
ZYLOPRIM
ZYMAR
ZYRTEC
IDX-11
Page
22
20
22
4
24
3
13
17
10
3
9
9
3
3
3
1
10
14
15
6
4
24
17
21
11
NOTES
NOTES
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