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HMSA Drug Formulary

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HMSA Drug Formulary March 23, 2004 MEMORANDUM TO: Participating Pharmacies FROM: John T. Berthiaume, M.D. Medical Director, Pharmacy Management SUBJECT: Updated HMSA Drug Formulary Enclosed is the comprehensive updated formulary, effective April 1. This copy incorporates the changes listed in the Formulary Update sent to you in February. Please replace the current formulary sections in your pharmacy handbook with the enclosed version. If you have any questions, please call an HMSA Provider Teleservice Representative at 948- 6330 on Oahu or 1 (800) 790-4672 from the Neighbor Islands. PM04-010 HMSA DRUG FORMULARY 4/1/04 - Page 1 Code THERAPEUTIC CATEGORY LISTING 1 I. Anti-infectives A. Antibiotics 1. Penicillins - non-penicillinase resistant 2 I. Anti-infectives A. Antibiotics 2. Penicillins - penicillinase resistant 3 I. Anti-infectives A. Antibiotics 3. Cephalosporins 4 I. Anti-infectives A. Antibiotics 4. Fluoroquinolones 5 I. Anti-infectives A. Antibiotics 5. Tetracyclines 6 I. Anti-infectives A. Antibiotics 6. Macrolides 7 I. Anti-infectives A. Antibiotics 7. Vancomycin 8 I. Anti-infectives A. Antibiotics 8. Lincosamides 9 I. Anti-infectives A. Antibiotics 9. Aminoglycoside 10 I. Anti-infectives A. Antibiotics 10. Sulfonamides 11 I. Anti-Infectives A. Antibiotics 11. Vaginal preparations 12 I. Anti-infectives B. Antifungal agents 1. Oral 13 I. Anti-Infectives B. Antifungal agents 2. Vaginal preparations OTC considerations: clotrimazole (Gyne-Lotrimin 3, Mycelex-7), miconazole (Monistat 7), tioconazole (Vagistat-1), butoconazole (Femstat 3) 14 I. Anti-infectives C. Antimalarial 15 I. Anti-infectives D. Antituberculous 16 I. Anti-infectives E. Amebicides 17 I. Anti-infectives F. Antiviral agents 1. Nucleoside Reverse-transcriptase Inhibitors (NRTI) 18 I. Anti-infectives F. Antiviral agents 2. Non-Nucleotide Reverse-transcriptase Inhibitors (NNRTI) 19 I. Anti-infectives F. Antiviral agents 3. Nucleotide Reverse transcriptase inhibitor 20 I. Anti-infectives F. Antiviral agents 3. Protease Inhibitors 21 I. Anti-infectives F. Antiviral agents 4. Agents for influenza 22 I. Anti-infectives F. Antiviral agents 5. Other 23 I. Anti-infectives G. Leprostatics 24 I. Anti-infectives H. Antihelmintics 25 I. Anti-infectives I. Other 26 II. Anti-neoplastics A. Alkylating Agents 27 II. Anti-neoplastics B. Antimetabolites 28 II. Anti-neoplastics C. Hormones 29 II. Anti-neoplastics D. Mitotic Inhibitors 30 II. Anti-neoplastics E. Other HMSA DRUG FORMULARY 4/1/04 - Page 2 31 III. Blood Modifiers A. Folic acid derivatives 32 III. Blood Modifiers B. Vitamin B 33 III. Blood Modifiers C. Vitamin K 34 III. Blood Modifiers D. Antiplatelet agents OTC consideration: apsirin 35 III. Blood Modifiers E. Anticoagulants 36 III. Blood Modifiers F. Hemorrheologic agent 37 IV. Cardiovasculars A. Diuretics 1. Thiazide and related diuretics 38 IV. Cardiovasculars A. Diuretics 2. Loop diuretics 39 IV. Cardiovasculars A. Diuretics 3. Potassium-Sparing diuretics 40 IV. Cardiovasculars A. Diuretics 4. Carbonic anhydrase inhibitors 41 IV. Cardiovasculars A. Diuretics 5. Diuretic combinations 42 IV. Cardiovasculars B. Cardiac Glycosides 43 IV. Cardiovasculars C. Nitrates 44 IV. Cardiovasculars D. Anti-arrhythmic agents 45 IV. Cardiovasculars E. Calcium channel blocking agents 1. Benzothiazepine 46 IV. Cardiovasculars E. Calcium channel blocking agents 2. Dihydropyridine 47 IV. Cardiovasculars E. Calcium channel blocking agents 3. Diphenylalkylamine 48 IV. Cardiovasculars E. Calcium channel blocking agents 4. Other 49 IV. Cardiovasculars F. Beta-adrenergic blocking agents 1. Non-selective agents 50 IV. Cardiovasculars F. Beta-adrenergic blocking agents 2. Beta-1 selective agents Inhibits beta-2 receptors (bronchial and vascular) at higher doses. 51 IV. Cardiovasculars G. Alpha/beta-adrenergic blocking agents 52 IV. Cardiovasculars H. Anti-adrenergic agents-centrally located 53 IV. Cardiovasculars I. Anti-adrenergic agents-peripherally located 1. Alpha-1 adrenergic block 54 IV. Cardiovasculars I. Anti-adrenergic agents-peripherally located 2. Other 55 IV. Cardiovasculars J. Vasodilators 56 IV. Cardiovasculars K. Angiotensin converting enzyme inhibitors 57 IV. Cardiovasculars L. Angiotensin II Receptor Antagonists 58 IV. Cardiovasculars M. Agents for Pheochromocytoma 59 IV. Cardiovasculars N. Antihyperlipidemic Agents 1. Bile Acid Sequestrants 60 IV. Cardiovasculars N. Antihyperlipidemic Agents 2. HMG-CoA Reductase Inhibitors 61 IV. Cardiovasculars N. Antihyperlipidemic Agents 3. Other HMSA DRUG FORMULARY 4/1/04 - Page 3 62 V. Central Nervous System Agents A. CNS Stimulants 63 V. Central Nervous System Agents B. Analgesics 1. Narcotic Agonist Analgesics 64 V. Central Nervous System Agents B. Analgesics 2. Narcotic Agonist-Antagonist Analgesics 65 V. Central Nervous System Agents B. Analgesics 3. Central Analgesics 66 V. Central Nervous System Agents B. Analgesics 4. Salicylates OTC considerations: aspirin, sodium salicylate, choline salicylate (Arthropan), magnesium salicylate (Doan's) 67 V. Central Nervous System Agents B. Analgesics 5. Non-Narcotic Analgesic Combinations 68 V. Central Nervous System Agents B. Analgesics 6. Non-Steroidal Anti-inflammatory Agents (NSAIDs) a. Non-selective NSAIDs OTC considerations: ibuprofen (Advil, Motrin), ketoprofen (Orudis KT), naproxen sodium (Aleve) 69 V. Central Nervous System Agents B. Analgesics 6. Non-Steroidal Anti-inflammatory Agents (NSAIDs) b. COX-2 selective 70 V. Central Nervous System Agents C. Abortive Agents for Migraine 1. 5HT-1 Receptor Agonists 71 V. Central Nervous System Agents C. Abortive Agents for Migraine 2. Other 72 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 1. Anti-dopaminergics 73 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 2. Anti-cholinergics OTC considerations: cyclizine (Marezine), meclizine (Bonine), diphenhydramine (Benadryl), dimenhydrinate (Dramamine) 74 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 3. Other OTC consideration: phosphorated carohydrate solution (Emetrol) 75 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 4. 5HT-3 Receptor Antagonists 76 V. Central Nervous System Agents E. Anti-Anxiety 1. Benzodiazepines 77 V. Central Nervous System Agents E. Anti-Anxiety 2. Other 78 V. Central Nervous System Agents F. Anti-depressants 1. Tricyclic compounds-Tertiary amines 79 V. Central Nervous System Agents F. Anti-depressants 2. Tricyclic compounds - Secondary amines 80 V. Central Nervous System Agents F. Anti-depressants 3. Tetracyclics 81 V. Central Nervous System Agents F. Anti-depressants 4. Triazolopyridine 82 V. Central Nervous System Agents F. Anti-depressants 5. Aminoketone 83 V. Central Nervous System Agents F. Anti-depressants 6. Phenethylamine 84 V. Central Nervous System Agents F. Anti-depressants 7. Phenylpiperazine 85 V. Central Nervous System Agents F. Anti-depressants 8. Selective serotonin reuptake inhibitors 86 V. Central Nervous System Agents F. Anti-depressants 9. Monoamine oxidase inhibitors 87 V. Central Nervous System Agents G. Anti-psychotic 1. Phenothiazines - aliphatic 88 V. Central Nervous System Agents G. Anti-psychotic 2. Phenothiazines - piperazine HMSA DRUG FORMULARY 4/1/04 - Page 4 89 V. Central Nervous System Agents G. Anti-psychotic 3. Phenothiazines - piperidine 90 V. Central Nervous System Agents G. Anti-psychotic 4. Thioxanthenes 91 V. Central Nervous System Agents G. Anti-psychotic 5. Butyrophenone 92 V. Central Nervous System Agents G. Anti-psychotic 6. Diphenylbutylpiperadine 93 V. Central Nervous System Agents G. Anti-psychotic 7. Dihydroindolones 94 V. Central Nervous System Agents G. Anti-psychotic 8. Dibenzepine 95 V. Central Nervous System Agents G. Anti-psychotic 9. Atypicals 96 V. Central Nervous System Agents G. Anti-psychotic 10. Anti-manic agents 97 V. Central Nervous System Agents H. Cholinesterase inhibitors 98 V. Central Nervous System Agents I. Sedatives and hypnotics, non-barbiturates 1. Benzodiazepines 99 V. Central Nervous System Agents I. Sedatives and hypnotics, non-barbiturates 2. Other OTC considerations: doxylamine succinate (Unisom), diphenhydramine (Nytol, Sominex) 100 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 1. Long-acting 101 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 2. Intermediate-acting 102 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 3. Short-acting 103 V. Central Nervous System Agents K. Anticonvulsants 1. Hydantoins 104 V. Central Nervous System Agents K. Anticonvulsants 2. Succinimides 105 V. Central Nervous System Agents K. Anticonvulsants 3. Oxazolidinediones 106 V. Central Nervous System Agents K. Anticonvulsants 4. Benzodiazepines 107 V. Central Nervous System Agents K. Anticonvulsants 5. Other 108 V. Central Nervous System Agents L. Skeletal muscle relaxants 1. Centrally acting 109 V. Central Nervous System Agents L. Skeletal muscle relaxants 2. Direct acting 110 V. Central Nervous System Agents M. Antiparkinson agents 1. Anti-cholinergics 111 V. Central Nervous System Agents M. Antiparkinson agents 2. Other 112 V. Central Nervous System Agents N. Cholinergic muscle stimulants 113 V. Central Nervous System Agents O. Agents for dependency and withdrawal 1. Alcohol 114 V. Central Nervous System Agents O. Agents for dependency and withdrawal 2. Narcotic agonists 115 V. Central Nervous System Agents O. Agents for dependency and withdrawal 3. Narcotic antagonists 116 V. Central Nervous System Agents O. Agents for dependency and withdrawal 4. Nicotine OTC considerations:
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