Table of Contents Section Page 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 patientвЂ™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 вЂњMedical Necessity formвЂќ 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 BioScripвЂ™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 BioScripвЂ™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 HygieneвЂ™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 вЂў Valid Maryland Medicaid and DEA numbers are required. Physicians without numbers should contact ScripSolutions at 1-800-230-8189. вЂў Refill too soon - 75% of the dayвЂ™s supply must elapse before the prescription can be refilled. вЂў 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. вЂў No vacation fills are allowed. вЂў 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 вЂ“ for initial episode only. (b) Oral herpes infection вЂ“ 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 PagetвЂ™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 PagetвЂ™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 вЂњPolicy for Injectable DrugsвЂќ 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 вЂ“ 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 вЂњtriple therapyвЂќ; 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 вЂњPolicy for Injectable DrugsвЂќ 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) AlzheimerвЂ™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 вЂ“ treatment failure of two formulary agents of different classes. (b) Neovascular вЂ“ treatment failure of a topical formulary betablocker. (c) Congenital вЂ“ 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 ParkinsonвЂ™s disease Criteria: (a) Diagnosis of idiopathic ParkinsonвЂ™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 вЂњPolicy for Injectable DrugsвЂќ 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 KaposiвЂ™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 вЂњPolicy for Injectable DrugsвЂќ 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 вЂњPolicy for Injectable DrugsвЂќ 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 physicianвЂ™s office. For injectable medications administered by a healthcare professional, please refer to the вЂњPolicy for Injectable DrugsвЂќ in the beginning of this formulary. PA-14 Prior Authorization Guidelines GENERIC: MEMANTINE BRAND: NAMENDA В® INDICATION: (1) AlzheimerвЂ™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 вЂњPolicy for Injectable DrugsвЂќ 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: BarrettвЂ™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 ParkinsonвЂ™s disease. Criteria: (a) Diagnosis of idiopathic ParkinsonвЂ™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, twiceвЂ“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 вЂњPolicy for Injectable DrugsвЂќ 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 Auranoп¬Ѓn 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 Ciproп¬‚oxacin* 2 Ciproп¬‚oxacin* 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 Disulп¬Ѓram 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/Sulп¬Ѓsoxazole* 2 Esteriп¬Ѓed 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 Galtiп¬‚oxacin 21 Ganciclovir* 4 GANTRISIN 2 GARAMYCIN 2 GARAMYCIN 21 GARAMYCIN TOPICAL 23 Gemп¬Ѓbrozil* 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 moxiп¬‚oxacin 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 Nelп¬Ѓnavir 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 Oп¬‚oxacin 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 Podoп¬Ѓlox 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 Sulп¬Ѓsoxazole* 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 Triп¬‚uridine 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