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Seton Care Plus Formulary 2016 Last updated on 12/2016

Tier Drug Name Prior Auth QLL 1 2 Chapter 1: Anesthetics 1.1 Topical Anesthetics Lidocaine-Prilocaine X Chapter 2: Antiinfectives 2.1.1 Cephalosporins Cefaclor ER X Cefadroxil X Cefprozil X Cefuroxime X 2.1.2 Clindamycins HCL X 2.1.3.1 2.1.3.2 Other Macrolides

Azithromycin X QLL

2.1.4 Penicillins Amox tr-Potassium Clavulanate X Amoxicillin-Clavulanate ER X Sodium X 2.1.5 Sufonamides 2.1.6 Minocycline HCL X HCL X 2.1.7 Urinary Antiinfectives 2.1.8 Quinolones LEVAQUIN X 2.2 Topical Antibacterial Drugs Mupirocin X 2.3 Oral Drug X GRIFULVIN V X 2.4.1 Vaginal Terconazole X 2.4.2 Other Topical Antifungals Ketoconazole X 2.4.3 Topical Antifungal-Corticosteroid Comb -Betamethasone X -Triamcinolone X 2.5.1 Antiretrovirals & Protease Inhibitors VIREAD X PA 2.5.2 Other Antiviral Drugs Amantadine X Ribapak X RELENZA X PA TAMIFLU X 2.6 Topical Antiviral Drugs 2.7.1 Antituberculosis Drugs Rifampin X 2.7.2 Plasmodicides Mefloquine HCL X 2.7.3 Trichomonocides 2.8.1 Other Antiinfective Drugs Bacitracin X 2.8.2 Aminoglycosides Gentamicin Sulfate X Tobramycin Sulfate X Chapter 3: Antineoplastic/Immunosuppressant Drugs 3.1 Antineoplastic/Immunosuppressant Drugs Anagrelide HCL X Anastrozole X Azathioprine X PA Hydroxyurea X Leflunomide X Leucovorin Calcium X Megestrol Acetate X Mercaptopurine X Methotrexate X Tamoxifen Citrate X Tretinoin X PA Chapter 4: Cardiovascular Medications 4.1 Cardiac Glycosides 4.2 Calcium Antagonists Cartia XT X Nifediac CC X Nifedical XL X X PA 4.3.1 Loop Diuretics Bumetanide X 4.3.2 Thiazide and Related Drugs Metolazone X 4.3.3 Potassium Sparing Diuretics Eplerenone X 4.4 Beta Adrenergic Antagonist Drugs Labetalol HCL X Nadolol X Pindolol X 4.5.1 Vasodilator Antihypertensives Prazosin HCL X 4.5.2 Centrally Acting Antihypertensives 4.5.3.1 Angiotensin Converting Enzyme Inhibitors 4.5.3.2 Angiotensin II Receptor Antagonists 4.5.4 Other Antihypertensives Moexipril-Hydrochlorothiazide X 4.6 Nitrates Nitroglycerin Patch X NITROSTAT X 4.7.1 Class 1C Flecainide Acetate X Propafenone HCL X 4.7.2 AMiodarones

Amiodarone HCL X

4.8.1 Hypolipoproteinemics Cholestyramine X Colestipol HCL X NIASPAN X PA 4.8.2 HMG-COA Reductase Inhibitors 4.9 Other Cardiovascular Drug Pentoxifylline X Chapter 5: Autonomic and CNS Medications 5.1.1 Analgesics Butorphanol Tartrate X 5.1.1.1 Classic II Narcotics 5.1.1.2 Class III Noarcotics 5.1.2 Drugs to Prevent and Treat Butalbital Compound-Codeine X Butalbial-Aspirin-Caffeine X 5.2.1 Anxiolytics Alprazolam ER/XR X Chlordiazepoxide HCL X Clorazepate Dipotassium X Diazepam X Lorazepam X PA QLL Oxazepam X 5.2.2 Sedative/Hypnotic Drugs Estazolam X Flurazepam HCL X Temazepam X Triazolam X 5.3 Antimania Drugs 5.4.1 Carbamazepines Oxcarbazepine X TEGRETOL XR X 5.4.2 Anticonvulsant Benzodiazepines Clonazepam X 5.4.3 Hydantoins 5.4.4 Valproic Acid and Derivatives DEPAKOTE X QLL DEPAKOTE ER X QLL 5.4.5 Anticonvulsant Barbiturates X Primidone X 5.4.6 Other Anticonvulsants Zonisamide X 5.5.1.1 Tertiary Amines Clomipramine HCL X 5.5.1.2 Secondary Amines Desipramine HCL X 5.5.1.3 Selective Serotonin Reuptake Inhibitors Fluvoxamine Maleate X 5.5.1.4 Other Antidepressants 5.5.2 MAO Inhibitors Tranylcypromine Sulfate X 5.6 Antivertigo and Antiemetric Drugs Dronabinol X Granisetron HCL X HCL X Promethegan X 5.7.1 Antiparkinson Anticholinergic Drug 5.7.2 Other Antiparkinson Drugs Bromocriptine Mesylate X Pramipexole Dihydrochloride X 5.8 Antipsychotic Drugs Clozapine X Perphenazine X SEROQUEL X QLL 5.8.1 Aliphatic Phenothiazines HCL X 5.9.1 CNS Stimulant Drugs Dexmethylphenidate HCL X Dextroamphetamine Sulfate X PA>18yrs Dextroamphetamine-amphetamine X PA>18yrs Metadate ER X PA>18yrs Methylin X PA>18yrs Methylphenidate HCL X PA>18yrs Methylphenidate SR/ER X PA>18yrs 5.9.2 Other CNS/Autonomic Drugs Atropine Sulfate X Naltrexone HCL X Pyridostigmine Bromide X 5.9.3 Antidementia Drugs Galantamine HBR X Rivastigmine X 5.9.4 Smoking Cessation Products Chapter 6: Dermatological Medications 6.1 Topical Corticosteroid Drugs Betamethasone Valerate X Clobetasol Propionate X Desonide X Desoximetasone X Fluocinolone Acetonide X Fluocinonide X 6.2 Antipruritic Drugs 6.3 Antiacne Drugs Adapalene X PA Benzoyl Peroxide X Erythromcyin-Benzoyl Peroxide X 6.3.1 Accutanes Isotretinoin X 6.4 Antipsoriasis and Antieczema Drugs Calcipotriene X Sulfacetamide Sodium X 6.5.1 Topical Dermatological Drugs Fluorouracil X Tretinoin X PA 6.5.2 Scabicides X Chapter 7: Ear-Nose-Throat Medications 7.1 Drugs affecting the Ear 7.2 Drugs affecting the Nose 7.3 Drugs affecting the Throat and Mouth Chapter 8: Endocrine Medications 8.1.1 Insulin HUMALOG X PA QLL LANTUS X PA QLL NOVOLOG X PA QLL 8.1.2 Oral Hypoglycemic Drugs Acarbose X 8.1.3 Insulin Sensitizers 8.2.1 Glucocortioid Drugs X X Prednisolone Sodium Phosphate X Veripred 20 X 8.2.2 Mineralocorticoid Drugs Fludrocortisone Acetate X 8.3.1 Thyroid Supplements 8.3.2 Antithyroid Drugs 8.4 Other Endocrine Drugs Calcitonin Nasal Spray X Desmopressin Acetate X Chapter 9: Gastrointestinal Medications 9.1 OTC H2 Antagonists 9.2 Antidiarrheal Drugs Diphenoxylate-Atropine X 9.3 Antispasmodics/ Drugs affect GI motility Chlordiazepoxide-Clidinium X Hyoscyamine Sulfate X 9.4 Antiulcer Drugs Cimetidine X 9.4.1 Other Antiulcer Drugs Misoprostol X Sucralfate X 9.4.2 Proton Pump Inhibitors 9.4.2.1 Proton Pump Inhibitors – OTC 9.5 Other GI Drugs Peg 3350-Eletrolytes X Proctosol-HC X Proctozone-HC X Trilyte w/ Flavor Packets X Ursodiol X Chapter 10: Musculoskeletal Medications 10.1.1 Salicylates and Related Drugs Choline Mag Trisalicylate X Diflunisal X Salsalate X 10.1.2 Non-Steroidal Antiinflammatory Agents Flurbiprofen X Ketorolac tromethamine X Nabumetone X Oxaprozin X Piroxicam X Sulindac X 10.2 Drugs to prevent and treat Gout Probenecid X 10.3.1 Direct Muscle Relaxant 10.3.2 CNS Muscle Relanxants Carisoprodol X Chlorzoxazone X Metaxalone X Orphenadrine Citrate X Chapter 11: Nutrition, Blood 11.1.1 Therapeutic Vitamins & Minerals Eliphos X Levocarnite X 11.1.2 Flouride Products 11.2 Potassium Supplements 11.3.1 Oral Anticoagulants, Vitamin K 11.3.2 Heparin and Heparin Antagonists Enoxaparin Sodium X Heparin Sodium X PA 11.4 Antiplatelet Drugs 11.5 Blood Detoxicants Enulose X Chapter 12: Obstetrical & Gynecological Medications 12.1.1 Specialized OB/GYN Drugs Leuprolide Acetate X PA Novarel X 12.1.2 OB/GYN Topical Antiinfectives Vandazole X 12.2 Ovulatory Stimulants 12.3 Androgen Drugs Testosterone Cypionate X PA 12.4 Estrogen Drugs MENEST X 12.4.1 Estrogen/Progestin Combinations COMBIPATCH X 12.4.2 Selective Estrogen Receptor Modulator EVISTA X PA QLL 12.5 Progestin Drugs Errin X Jolivette X Nora-BE X Norethindrone Acetate X in oil X 12.6 Contraceptives None Chapter 13: Opthalmic Medications 13.1.1 Ophthalmic Topical Antibacterial Drugs Bacitracin X Neomycin-Bacitracin-Polymyxin X

Sulfacetamide Sodium X

13.1.2 Opthalmic topical Antiviral Drugs Trifluridine X 13.2 Opthalmic Corticosteroid Drugs X PA QLL Prednisolone Acetate X QLL FML FORTE X PA QLL PRED FORTE X PA QLL 13.3 Opthalmic Antiinfective/Corticoseroids 13.4 Antiglaucoma Drugs Acetazolamide X Brimonidine Tartrate X ALPHAGAN P X PA QLL BETOPTICS X PA QLL XALATAN X PA QLL 13.5 Other Opthalmic Drugs Atropine Sulfate X Cromolyn Sodium X ACULAR X PA QLL ALOCRIL X PA QLL ALOMIDE X PA QLL Chapter 14: Respiratory Medications 14.1.1 Beta-2 Adrenergic Drugs PROAIR HFA X PA QLL XOPENEX X PA QLL 14.1.2 Methlyxanthine Drugs 14.1.3 Other Drugs for Asthma Budesonide X COMBIVENT X PA QLL EPIPEN X PA EPIPEN X PA FLOVENT DISKUS X PA QLL FLOVENT HFA X PA QLL 14.2 Antihistamines Arbinoxa X Cyproheptadine HCL X Diphenhydramine HCL X Fexofenadine HCL X Levocetrizine Dihydrochloride X 14.3 Antitussive and Expectant Drugs 14.4 Other Respiratory Drugs PULMOZYME X PA Chapter 15: Urological Medication 15.1.1 Anticholinergic Antispasmodics DETROL X PA 15.1.2 Cholinergic Stimulants Bethanechol Chloride X 15.1.3 Urinary Anesthetics 15.1.4 Other Genitouinary Products Potassium Citrate X Chapter 16: Diagnostic & Miscellaneous Medications 16.1 Appetite Suppressants Phentermine HCL X