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Prescription Drug Program Formulary Effective July 1, 2008

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Prescription Drug Program Formulary Effective July 1, 2008 PRESCRIPTION DRUG PROGRAM FORMULARY EFFECTIVE JULY 1, 2008 www.MyIBXTPA.com a b Dear Participant: In an effort to continue our commitment to provide you with comprehensive prescription drug coverage, a formulary feature is included in your prescription drug benefit. A formulary is a list of selected FDA-approved prescription medications reviewed by the Pharmacy and Therapeutics Committee. These prescription medications have been selected for their reported medical effectiveness, safety, and value, while providing you with the highest level of coverage under your prescription program. The following information serves as a guide when reviewing the list of formulary drugs on the following pages. • Bolded drug = Formulary generic available at lowest copay • Non-bolded drug = Formulary brand available at middle copay • Drug in parenthesis ( ) = Non-formulary brand drug available at the highest copay. It is displayed next to the equivalent formulary generic Drug that is available at the lowest copay. For example: amoxicillin is the formulary generic drug available at the lowest copay. (Amoxil) is the non-formulary brand available at the highest copay. In most cases when brand drugs have a generic equivalent, the generic version is formulary and the brand version is non-formulary. • Covered brand drugs not listed are non-formulary and are available at the highest copay. The above information is highlighted in a key box indicated on every other page of the formulary list. Our pharmacy benefits manager, FutureScripts®, continuously monitors effectiveness and safety of drugs and drug prescribing patterns. 1 Please note: Because prescription drug programs vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change. Please call 1-888-678-7013 for any questions about your prescription drug benefit. Please discuss any questions or concerns about your drug therapy with your physician or pharmacist. Prescription Drug Program Formulary information can also be obtained at www.MyIBXTPA.com. Dear Physician: This is a listing of formulary medications to be considered for your patient, a Prescription Drug Program Formulary participant. Please refer to this Prescription Drug Program Formulary in order to choose a medication. Because prescription drug programs vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change. Please understand that this formulary is not intended as a substitute for your independent professional judgment. Rather, it is offered as a tool to help our members recognize formulary drugs. We hope that you will refer to the formulary as a guide to prescribing formulary drugs. 2 1. ANTIBIOTICS & DRUG NAME OTHER DRUGS USED FOR clarithromycin (Biaxin) INFECTION clarithromycin SR 24 hr DRUG NAME (Biaxin XL) clindamycin (Cleocin) acyclovir (Zovirax) clotrimazole troches Agenerase (Mycelex) amantadine (Symmetrel) Combivir amoxicillin (Amoxil) Crixivan amoxicillin/clavulanate Dapsone (Augmentin) Daraprim ampicillin (Principen) demeclocycline Augmentin XR (Declomycin) Atripla dicloxacillin azithromycin 250mg, didanosine delayed-rel 500mg, 600mg 200mg, 250mg, (Zithromax) 400mg (Videx EC) cefaclor (Ceclor) doxycycline hyclate cefaclor ER (Vibramycin, Periostat) cefadroxil for susp doxycycline 250mg/5ml (Duricef) monohydrate (Monodox) cefadroxil 500mg/5ml Emtriva suspension (Duricef) Epivir cefdinir (Omnicef) Epzicom cefuroxime axetil (Ceftin) erythromycin, cephalexin (Keflex) delayed release chloroquine phosphate (Eryc, Ery-Tab) (Aralen) erythromycin Cipro oral suspension ethylsuccinate (EES, ciprofloxacin tabs (Cipro) EryPed) Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract 3 1. ANTIBIOTICS & DRUG NAME OTHER DRUGS USED FOR methenamine hippurate INFECTION (Cont.) (Hiprex, Urex) DRUG NAME metronidazole (Flagyl) minocycline caps erythromycin stearate (Minocin, Dynacin) (Erythrocin) minocycline tabs erythromycin suspension Mintezol w/sulfa (Pediazole) Mycobutin ethambutol (Myambutol) nitrofurantoin famciclovir (Famvir) macrocrystals Fansidar (Macrodantin) Flagyl ER Norvir fluconazole (Diflucan) nystatin (Mycostatin) Fortovase ofloxacin (Floxin) Fuzeon penicillin VK (Veetids) ganciclovir (Cytovene) phenazopyridine Gris-PEG (Pyridium) griseofulvin microsize Prezista suspension (Grifulvin V) Primaquine Grifulvin V tabs pyrazinamide Hepsera Rescriptor HIVID Reyataz hydroxychloroquine ribavirin (Rebetol) (Plaquenil) rifampin (Rifadin) Isentress Rifater isoniazid rimantadine itraconazole (Sporonax) (Flumadine) Kaletra Selzentry ketoconazole tabs sulfamethoxazole/tmp (Nizoral tabs) (Septra DS) Levaquin sulfisoxazole tabs Lexiva Sustiva mebendazole (Vermox) Tamiflu mefloquine (Lariam) terbinafine tablets Mepron (Lamisil Tablets) methenamine-hysoc- tetracycline (Sumycin) meth blue-sod Tobi phosphenyl sal tab Trizivir 120mg hyoscyamine Truvada (Urimar) Valcyte Valtrex Vfend 4 1. ANTIBIOTICS & DRUG NAME OTHER DRUGS USED FOR cyclosporine modified INFECTION (Cont.) (Neoral) DRUG NAME danazol 200mg (Danocrine) Videx Emcyt Videx EC 125mg etoposide (VePesid) Viracept Fareston Viramune Femara Viread flutamide (Eulexin) Xifaxan Gleevec Zerit Hexalen Ziagen hydroxyurea (Hydrea) zidovudine 300mg, leucovorin calcium 10mg/ml syrup Leukeran (Retrovir) Lysodren 2. CANCER & ORGAN Matulane TRANSPLANT DRUGS megestrol (Megace) mercaptopurine DRUG NAME (Purinethol) Alkeran methotrexate Aromasin Myleran azathioprine (Imuran) prednisone (Deltasone) Casodex Prograf CeeNU Rapamune Cellcept tamoxifen (Nolvadex) cyclophosphamide Targretin (Cytoxan) Temodar cyclosporine thioguanine (Sandimmune) Xeloda Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract 5 3. PAIN, NERVOUS DRUG NAME SYSTEM, & PSYCH carbidopa/levodopa CR DRUG NAME (Sinemet CR) Celontin Abilify chlorpromazine acetaminophen with choline magnesium codeine (Tylenol with trisalicylate Codeine #2, #3, #4) citalopram (Celexa) acetazolamide clomipramine HCl Adderall XR (Anafranil) alprazolam (Xanax) clonazepam (Klonopin) amantadine (Symmetrel) clonazepam wafer tablet amitriptyline (Klonopin wafer tablet) amoxapine clozapine (Clozaril) apap/butalbital codeine tabs (Phrenilin, Phrenilin Forte) Comtan apap-salicylamide- Concerta phenyltolox-caffeine Depakote cap 325-250-20-50mg Depakote ER (Durulac cap) desipramine (Norpramin) Aricept dexmethylphenidate Aricept ODT (Focalin) aspirin with codeine dextroamphetamine/ Avinza amphetamine mixture benztropine (Adderall) bromocriptine mesylate diazepam (Valium) (Parlodel) diclofenac potassium buproprion XL (Cataflam) (Wellbutrin XL) diclofenac sodium bupropion (Wellbutrin) (Voltaren XR) bupropion ER diflunisal (Dolobid) (Wellbutrin SR) doxepin (Sinequan) buspirone (BuSpar) Duragesic 12mcg butalbital/apap/ ergotamine/caffeine caffeine (Fioricet) supp (Cafergot) butalbital/aspirin/ ergotamine/caffeine caffeine (Fiorinal) tabs (Cafergot) butalbital/aspirin/ ethosuximide (Zarontin) caffeine/codeine etodolac (Lodine XL) (Fiorinal with Codeine) fenoprofen calcium carbamazepine (Tegretol) (Nalfon) carbidopa/levodopa fentanyl citrate OTFC (Sinemet) (Actiq) 6 3. PAIN, NERVOUS DRUG NAME SYSTEM, & PSYCH (Cont.) Imitrex NS DRUG NAME indomethacin (Indocin SR) isometheptene/ fentanyl transdermal dichloralphenazone/ (Duragesic) apap (Midrin) fluoxetine (Prozac) ketoprofen (Oruvail, Orudis) fluphenazine ketorolac (Toradol oral) flurbiprofen (Ansaid) Lamictal fluvoxamine lamotrigine Disp tabs gabapentin (Neurontin) 5mg, 25mg (Lamictal haloperidol Chew Tabs 5mg, 25mg) hydrocodone/ Lexapro acetaminophen lithium carbonate (Vicodin, Norco, Maxidone) (Eskalith) hydrocodone/ lithium carbonate SR acetaminophen elixir (Eskalith CR, Lithobid) (Lortab) lorazepam (Ativan) hydrocodone/ loxapine (Loxitane) acetaminophen ES maprotiline (Vicodin ES) Maxalt, Maxalt-MLT hydrocodone/ibuprofen meclofenamate (Vicoprofen) meperidine HCl syrup hydromorphone HCl (Demerol) supps (Dilaudid) meperidine HCl tabs hydromorphone HCl (Demerol) tabs (Dilaudid) methadone (Dolophine) ibuprofen (Motrin) methamphetamine ibuprofen/oxycodone HCl (Desoxyn) (Combunox) methylphenidate, SR imipramine (Tofranil) (Ritalin SR) Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract 7 3. PAIN, NERVOUS DRUG NAME SYSTEM, & PSYCH (Cont.) Parnate DRUG NAME paroxetine tabs (Paxil) perphenazine migergot (Cafergot)
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