Physician and Pharmacist Reference Guide October 2008 Value Plus For the most up-to-date drug list visit www.caremark.com The Caremark Value Plus 3-Tier Formulary, formerly the PharmaCare Value Plus 3-Tier Formulary, is a guide within select therapeutic categories for clients, plan participants and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. HEALTH CARE PROVIDER THERAPEUTIC CATEGORIES Your patient is covered under a prescription benefit plan administered by Antidiabetic Agents 2 Caremark. As a way to help manage health care costs, authorize generic Allergy, Cough & Cold 2 substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list. Anti-Infective Agents 2 Please note: Antineoplastic 2 ● Generics should be considered the first line of prescribing. Autonomic and Central Nervous System Agents 2 ● This drug list represents a summary of prescription coverage. It is not inclusive Cardiovascular Agents 3 and does not guarantee coverage. Contraceptives 3 ● The plan participant’s specific prescription benefit plan may have a different Corticosteroids 4 copay1 for specific products on the list. Dermatologicals 4 ● Unless specifically indicated, drug list products will include all dosage forms. Diagnostics 4 ● Log in to www.caremark.com to check coverage and copay information for a specific medicine. Gastrointestinal Agents 4 Gout Agents 4 Hematopoietic Growth Factors 4 PLAN PARTICIPANT Hormones 4 Your benefit plan provides you with a prescription benefit program administered Immunologic Agents 4 by Caremark. Ask your doctor to consider prescribing, when medically appropriate, Immunosuppressive Agents 4 a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor. Ophthalmics 4 Please note: Osteoporosis Agents 5 ● Your specific prescription benefit plan design may not cover certain categories, Otics 5 regardless of their appearance in this document. Phosphate Binder Agents 5 ● For specific information regarding your prescription benefit coverage and copay1 Respiratory/Asthma 5 information, please visit our Web site at www.caremark.com or contact a Skeletal Muscle Relaxants 5 Caremark Customer Care representative. Thyroid and Antithyroid Agents 5 ● Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in Urinary Agents 5 your doctor prescribing, when medically appropriate, a different brand-name Vaginal Preparations 5 product or generic equivalent in place of your original prescription. Vitamins 5 Your specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. For specific information, visit our Web site at www.caremark.com or contact a Caremark Customer Care representative. Page 1 of 5 ANTIDIABETIC AGENTS ANTITUSSIVE SULFONAMIDES ANTINEOPLASTIC ANALGESICS, SALICYLATES sulfamethoxazole- INSULINS COMBINATIONS diflunisal trimethoprim DS Generally, self-administered codeine-chlorpheniramine- single source brand drugs salsalate RAPID-ACTING INSULINS TETRACYCLINES pseudoephedrine indicated for the treatment APIDRA ANTICONVULSANTS codeine-guaifenesin doxycycline hyclate of cancer are formulary. HUMALOG minocycline carbamazepine HUMULIN R codeine-guaifenesin- pseudoephedrine tetracycline AUTONOMIC AND clonazepam NOVOLIN R ORACEA CENTRAL NERVOUS ethosuximide NOVOLOG codeine-promethazine codeine-promethazine- OTHER ANTI-INFECTIVES SYSTEM AGENTS gabapentin INTERMEDIATE-ACTING phenylephrine chloroquine ALZHEIMER’S AGENTS lamotrigine ODT INSULINS dextromethorphan- clindamycin phenobarbital HUMALOG MIX ARICEPT brompheniramine- dapsone phenytoin HUMULIN MIX EXELON pseudoephedrine ethambutol primidone HUMULIN N NAMENDA dextromethorphan- isoniazid valproic acid NOVOLIN MIX RAZADYNE promethazine mefloquine zonisamide NOVOLIN N RAZADYNE ER hydrocodone-homatropine metronidazole CARBATROL NOVOLOG MIX nitrofurantoin macrocrystals ANALGESICS, NARCOTIC DEPAKOTE LONG-ACTING INSULINS NASAL CORTICOSTEROIDS pyrazinamide codeine-acetaminophen DEPAKOTE ER LANTUS flunisolide rifampin fentanyl transdermal DEPAKOTE SPRINKLE LEVEMIR fluticasone trimethoprim hydrocodone- DIASTAT NASACORT AQ DILANTIN INFATAB ORAL ALINIA acetaminophen NASONEX FURADANTIN hydromorphone GABITRIL acarbose RHINOCORT AQUA MALARONE morphine KEPPRA glimepiride VERAMYST TINDAMAX morphine ext-rel LAMICTAL tablet glipizide TOBI morphine supp LYRICA glipizide ext-rel NASAL ANTIHISTAMINES VANCOCIN oxycodone TEGRETOL XR glipizide-metformin ASTELIN ZYVOX oxycodone ext-rel TOPAMAX glyburide oxycodone soln TRILEPTAL glyburide-metformin ANTI-INFECTIVE AGENTS ANTIFUNGAL AGENTS oxycodone-acetaminophen metformin ANTIPARKINSON AGENTS ANTHELMINTICS fluconazole AVINZA metformin ext-rel mebendazole itraconazole KADIAN benztropine ACTOPLUS MET terbinafine tablet OPANA ER bromocriptine ACTOS ANTIBIOTICS carbidopa-levodopa ANTIVIRALS OXYCONTIN DUETACT CEPHALOSPORINS carbidopa-levodopa ext-rel JANUMET cefaclor acyclovir ANALGESICS, selegiline JANUVIA cefdinir ganciclovir NON-NARCOTIC trihexyphenidyl PRANDIN cephalexin ribavirin butalbital-acetaminophen- APOKYN BARACLUDE MACROLIDES caffeine AZILECT OTHER DIABETIC AGENTS EPIVIR HBV azithromycin butalbital-aspirin-caffeine COMTAN BYETTA HEPSERA clarithromycin tramadol MIRAPEX GLUCAGEN HYPOKIT INFERGEN clarithromycin ext-rel PARCOPA GLUCAGON EMERGENCY KIT INTRON A ANALGESICS, erythromycin REQUIP SYMLIN PEGASYS NONSTEROIDAL delayed-rel STALEVO PEGINTRON ANTI-INFLAMMATORY erythromycin ethylsuccinate ALLERGY, PEGINTRON REDIPEN diclofenac ANXIOLYTICS, SEDATIVES, erythromycin stearate COUGH & COLD REBETOL soln etodolac AND HYPNOTICS ANTIHISTAMINE/ PENICILLINS TAMIFLU ibuprofen alprazolam DECONGESTANTS amoxicillin TYZEKA indomethacin buspirone amoxicillin-clavulanate cyproheptadine VALCYTE indomethacin ext-rel diazepam dicloxacillin fexofenadine VALTREX meloxicam lorazepam penicillin VK nabumetone oxazepam hydroxyzine HCl Generally, self-administered ALLEGRA-D QUINOLONES naproxen temazepam ciprofloxacin ext-rel single source brand drugs indicated for the treatment naproxen sodium triazolam ciprofloxacin tablet of HIV are formulary. oxaprozin zolpidem AVELOX sulindac LUNESTA LEVAQUIN Your specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. For specific information, visit our Web site at www.caremark.com or contact a Caremark Customer Care representative. Page 2 of 5 CEREBRAL STIMULANTS ANTIMANIC AGENTS PERIPHERALLY ACTING COMBINATION CONTRACEPTIVES lithium carbonate doxazosin amphetamine- ANTIHYPERTENSIVES EE = ethinyl estradiol lithium carbonate ext-rel terazosin dextroamphetamine amlodipine-benazepril ME = mestranol FLOMAX dexmethylphenidate ANTIPSYCHOTIC AGENTS atenolol-chlorthalidone MONOPHASIC dextroamphetamine chlorpromazine ANTIARRHYTHMICS bisoprolol- clozapine desogestrel-EE dextroamphetamine ext-rel amiodarone hydrochlorothiazide fluphenazine ethynodiol diacetate-EE methylphenidate digoxin fosinopril- haloperidol levonorgestrel-EE methylphenidate ext-rel disopyramide hydrochlorothiazide perphenazine norethindrone acetate-EE ADDERALL XR disopyramide ext-rel lisinopril- thioridazine norethindrone CONCERTA flecainide hydrochlorothiazide thiothixene acetate-EE-iron DAYTRANA mexiletine metoprolol- trifluoperazine norethindrone-EE FOCALIN XR propafenone hydrochlorothiazide ABILIFY norethindrone-ME METADATE CD sotalol quinapril- FAZACLO norgestimate-EE METHYLIN sotalol AF hydrochlorothiazide GEODON norgestrel-EE RITALIN LA RYTHMOL SR ATACAND HCT INVEGA Apri STRATTERA TIKOSYN AVALIDE VYVANSE RISPERDAL BENICAR HCT Aviane SEROQUEL ANTICOAGULANTS/ CADUET Cryselle MIGRAINE AGENTS ZYPREXA ANTITHROMBOTICS MICARDIS HCT Junel dihydroergotamine warfarin Lessina CARDIOVASCULAR TARKA ergotamine-caffeine tablet AGGRENOX TEKTURNA HCT Levora IMITREX AGENTS ARIXTRA Low-Ogestrel MAXALT ALDOSTERONE COUMADIN DIRECT RENIN INHIBITORS Microgestin MIGRANAL ANTAGONISTS FRAGMIN TEKTURNA Microgestin FE ZOMIG Mononessa spironolactone INNOHEP DIURETICS Necon 1/50 MULTIPLE SCLEROSIS LOVENOX ANGIOTENSIN II furosemide Nortrel AGENTS PLAVIX ANTAGONISTS hydrochlorothiazide Portia COPAXONE ATACAND 2 ANTILIPEMICS metolazone Previfem REBIF AVAPRO cholestyramine spironolactone- Quasense hydrochlorothiazide OBSESSIVE-COMPULSIVE BENICAR colestipol Sprintec torsemide DISORDER AGENTS MICARDIS fenofibrate Zovia pravastatin triamterene- fluvoxamine YASMIN ANGIOTENSIN simvastatin hydrochlorothiazide CONVERTING ENZYME YAZ PSYCHOTHERAPEUTIC ADVICOR INHIBITORS PULMONARY BIPHASIC AGENTS LIPITOR HYPERTENSION fosinopril LOVAZA desogestrel-EE ANTIDEPRESSANTS REVATIO lisinopril NIASPAN Kariva amitriptyline TRACLEER quinapril SIMCOR bupropion TRIPHASIC ramipril TRICOR VASODILATORS bupropion ext-rel desogestrel-EE trandolapril VYTORIN citalopram dipyridamole levonorgestrel-EE WELCHOL clomipramine ANTI-ADRENERGIC hydralazine norethindrone-EE ZETIA desipramine AGENTS