kaiser permanente nf, restricted formulary and criteria...

Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)

Formulary Alternative(s) Comments

Accolate tab (Zafirlukast) 20 mg BID ICS inhaler (QVAR or *Flovent or Asmanex) plus a long acting B2-agonist (Serevent) OR an ICS and B2 agonist

*Flovent 110mcg/puff & 220mcg/puff are non-formulary. If patient is already using steroid and serevent inhaler and asthma symptoms persist, candidate for singulair

Accu-Check Advantage blood glucose test strips One Touch Ultra glucose test strips One Touch Ultra 2 machine -only

Lifescan monitor is formulary and may be obtained, by prescription, at KP pharmacy at co-payment. Members will be charged full price for Lifescan monitor at Eckerd

Accupril tablet (Quinapril) 10-20 mg QD Prinivil (Lisinopril) tablet 10 mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Accupril tablet (Quinapril)40-80 mg QD Prinivil (Lisinopril) tablet 20-40 mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Accuretic (Quinapril/HCTZ 10/12.5mg) see strengths below

Lisinopril/HCTZ 10/12.5MG QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Accuretic (Quinapril/HCTZ 20/12.5mg; 20/25mg) Lisinopril/HCTZ 20/12.5MG QD or 20/25mg QD

TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Accutane caps (Isotretinoin)10-40 mg BID Sotret (Isotretinoin) Or, consider antibiotic, if no previous trial: Tetracycline caps 500 mg QD-BID or Minocycline 50 mg QD-TID

Physician should place a dated Sotret qualification sticker on Rx that must be dated w/in 7 days of date Rx is picked up.

Aceon (Perindopril) 4-8mg QD Prinivil (Lisinopril) 20mg-40mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Non-formulary conversion document 02.08.xls




Aciphex tablet (Rabeprazole) 20-60 mg QD to BID OTC Prilosec 20 to 40mg QD Aciphex is a NF No Initial Fill drug. If Prilosec 40mg QD failure, then consider NF No Initial Fill drug, Protonix titrated up to 80mg QD. (Protonix 40mg=Aciphex 20mg=Prilosec 20mg) Must document failure or intolerance to Prilosec 40mg QD if requesting PPI coverage.

Aclovate (Aclometasone) 0.05% cream, oint DesOwen (Desonide) 0.05% cream, oint, lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion

Low potency topical corticosteroids.

Activella (1mg 17beta estradiol / 0.5mg norethindrone acetate)

Estrace (17beta estradiol) 1mg QD plus NorQD 0.35mg (norethindrone) QD

Two individual prescriptions are required. Norethindrone 0.35mg functional equivalent dosing to Norethindrone acetate 0.5mg.

Actonel (Residronate) 5mg QD or 35mg Qweek tablets

Fosamax (Alendronate) 5mg QD or 35mg every week for osteoporosis prevention OR Fosamax 10mg QD or 70mg w/D Q week for osteoporosis treatment. Fosamax 70mg/75ml liquid & Fosamax w/D tablets available. Fosamax w/D is the preferred formulary alternative for once-weekly dosing if a 70mg dose is required for the treatment of osteoporosis .

If preventing osteoporosis, convert 5mg Actonel QD to 5mg Fosamax QD OR convert 35mg Actonel once a week to Fosamax 35mg [37.5ml] PO once a week. Fosamax Liquid is the preferred formulary alternative for this dose : 37.5ml = 35mg dose. If treating osteoporosis, convert 5mg Actonel QD to 10mg Fosamax QD OR convert 35mg Actonel once weekly to Fosamax w/D once weekly. Fosamax w/D tablets is the preferred formulary alternative when a 70mg dose is required for once-weekly treatment of osteoporosis .

Actonel (Residronate) 30mg tablet (30mg tablet is only indicated for Paget's disease treatment)

Treatment Paget's Disease: Fosamax 40mg QD

.

Actoplus Met Metformin & pioglitazone as 2 separate agents

Acular (ketorolac) 0.5% ophth soln If using for allergic conjunctivitis: OTC Opcon-A (pheniramine and naphazoline) If treating post-op inflammation: Voltaren 0.1% ophth soln

Acular PF (preservative free) 0.5% If using for allergic conjunctivitis: OTC Opcon-A (pheniramine and naphazoline) If treating post-op inflammation: Voltaren 0.1% ophth soln

Adalat CC (Nifedipine XL) 30, 60, 90 mg tab Nifedipine XL 30, 60 or 90 mg tablet TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Adderall (Amphetamine mixtures) XR extended release 5mg, 10mg, 15mg, 20mg, 25mg, 30mg capsules

Adderall regular release 5, 10, 20, 30mg tablets, Concerta 18, 27, 36 and 54mg tablets, Methylphenidate 5, 10, 20mg and SR 20mg; Methylin (Methylphenidate) ER 10mg; or generic Dexedrine spansules (Dextroamphetamine) 5, 10, 15mg Controlled substances level 2 requiring prescription written by prescriber.

Adderall XR is restricted to pediatrics, child neurology and behavioral health. Titrate to appropriate dosage using Adderall regular release tablets before transitioning to once daily Adderall XR. Document failed trial on Methylphenidate, Dextroamphetamine and Adderall IR products before a Non-formulary Product is considered.





Advair (Fluticasone/Salmeterol 100/50, 250/50, 500/50) diskus oral inhaler

Advair 100/50 i puff BID = QVAR 80mcg i puff BID & Serevent 50mcg diskus i puff BID -OR Flovent 44mcg ii puffs BID & Serevent 50mcg i puff BID;

Advair restricted to Peds Pulm, Pulmonology and Allergy. Document failure on 1 combination of alternatives QVAR and Serevent -or- Asmanex and Serevent before nonformulary product considered. **Advair 500/50 may warrant approval because of high dose of steroid ingredient . If

Advair 250/50 i puff BID = QVAR patient has failed a trial on QVAR 40 inhaler, 80mcg ii puffs BID & Serevent 50mcg i consider Flovent (Fluticasone) 44/puff inhaler puff BID -OR AND Serevent (Salmeterol) 50mcg diskus. Asmanex 220mcg i puff BID [or ii puffs QHS] & Serevent 50mcg diskus i puff BID

Advair 500/50 i puff BID -submit .nf form

Advicor (niacin ER/lovastatin) 500/20mg or OTC Slo-niacin or Time-release niacin. Do not recommend flush-free niacin. For 1000/20mg QHS Initiate at 500 mg QD titrated up by 500mg

every 4 weeks up to desired dose plus Rx Lovastatin 20MG QPM with meal.

improving HDL, regular niacin is recommended. Titrate immediate release niacin 100 mg QD x 1week, then 200 mg QDx 1 week, 300 mg QD x 1 week, 500 mg QD x 1 week, then 500 mg BID thereafter. Slow release or Time release niacin is preferred for LDL lowering. Counsel pt to take niacin with food and try taking an aspirin 30 minutes before niacin to prevent flushing and itching. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 8:30AM and 5:30PM.

Aerobid oral inhaler (Flunisolide) ii-iiii puffs BID QVAR (Beclomethasone HFA) oral inhaler 80 mcg i-ii puffs BID or Asmanex (mometasone furoate) oral dry powder inhaler 200mcg per puff inhale i-ii puffs QHS (or i puff BID)

QVAR is the preferred formulary alternative. If patient has failed QVAR, consider Asmanex i-ii puffs QHS.

Aeroseb-HC (Hydrocortisone) aerosol 0.5% OTC Hydrocortisone 0.5% cream If require a product for the scalp, consider Synalar (Fluocinolone) soln or oil 0.01% (low potency)

Akineton (Biperiden) 2mg tablet 2mg BID-TID Cogentin (Benztropine) tablet 1-4mg QD-BID

Parkinson's drug therapy

Alamast (Pemirolast) 0.1% ophthalmic solution i-ii For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual drops QID (Pheniramine & Naphazoline) or OTC

Zaditor 0.25% [NOTE: OTC products are not a covered benefit]

action antihistamine/mast cell stabilizers, are dosed twice daily, and have the same FDA approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing NF product: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

Albuterol (Proventil or Ventolin) nebulizer solution Albuterol 20% concentrated nebulizer Premixed nebulized solutions are non formulary. 0.083% 3 ml via nebulizer TID-QID solution 0.5 ml with 2.5 ml saline via

nebulizer TID-QID Component medications are available separately, Albuterol 20% soln (formulary) and OTC saline for nebulizer dilution

Aldactone 50 &100 mg tabs Spironolactone (generic Aldactone) 25 mg 50 mg and 100 mg tablets are non-formulary. May substitute 25 mg tablets as appropriate to obtain 50 mg or 100 mg dose.

Alesse (0.1 Levonorgestrel/20mcg EE) Levlen (0.15mg Levonorgestrel / 30mcg EE) May consider Microgestin FE 1/20 (1mg or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 Norethindrone/ 20mcg EE) Document at least 3 days, 0.075mg Lvngl/40mcg EE x 5 days, formulary alternatives before 0.125mg lvngl/ 30mcg EE x 10 days) prescribing/approving a NF product.





Allegra (Fexofenadine) 180mg tabs Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray per nostril QD and/or Claritin OTC or Zyrtec OTC

Allegra remains formulary for Medicare Part D patients. Intranasal steroid (Nasarel or Flonase) more effective than nonsedating antihistamines for allergic rhinitis.

Allegra-D (Fexofenadine 60mg and Pseudoephedrine Nasarel ii sprays each nostril BID or generic Allegra (not Allegra-D) remains formulary for 120mg) caps Flonase (fluticasone) i spray each nostril

QD and/or Claritin D OTC or Zyrtec D OTC Medicare Part D patients. Allegra-D is excluded from the benefit because pseudoephedrine is available OTC.

Alocril (Nedocromil) 2% ophth soln For allergic conjunctivitis: OTC Opcon-A (Pheniramine & Naphazoline) or OTC Zaditor 0.25% [NOTE: OTC products are not a covered benefit]

OTC Zaditor 0.25% and Patanol are both dual action antihistamine/mast cell stabilizers, are dosed twice daily, and have the same FDA approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product: dexamethasone 0.1% ophth soln or prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

Alomide (Lodoxamide) ophth 0.1% ophth soln (mast cell stabilizing properties)

For allergic conjunctivitis: OTC Opcon-A (Pheniramine & Naphazoline) or OTC Zaditor 0.25% [NOTE: OTC products are not a covered benefit]

OTC Zaditor 0.25% and Patanol are both dual action antihistamine/mast cell stabilizers, are dosed twice daily, and have the same FDA approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product: dexamethasone 0.1% ophth soln or prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

Alora (Estradiol transdermal system) delivers 0.025, 0.05, 0.075, 0.1 mg Estradiol transdermally per day when each 9cm2, 18cm2, 27cm2 and 36cm2 patch applied twice weekly

Climara 0.025mg, 0.0375mg, 0.05mg, 0.06mg, 0.075mg, 0.1mg patches apply one patch weekly; or Estrace 0.5, 1 or 2mg (Estradiol)

If an estrogen patch is required, Climara.

Alphagan P (Brimonidine 0.15%) ophth solution i drop in affected eye TID

Brimonidine 0.2% ophth solution 1 drop in affected eye TID

Other formulary alternatives include: Propine (Dipivefrin 0.1%) i drop BID or Levobunolol 0.25%-0.5% or Timolol i drop in affected eye(s) BID if a beta-blocker trial has not been used.

Alrex (Loteprednol) 0.2% ophth soln i drop QID Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

Post op inflammation: [Loteprednol 0.5% (Lotemax) less effective than Prednisolone Acetate 1% in treatment of acute anterior uveitis]

Altace (Ramipril) 1.25 - 20mg QD Prinivil (Lisinopril) 5mg-40mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics





Altocor (Lovastatin extended release) 10mg, 20mg, 40mg or 60mg

Lovastatin 10mg, 20mg, or 40mg tablets Altocor 10mg QD equivalent to Lovastatin 10mg QD dose. Simvastatin (generic Zocor) is another formulary option: Altocor 40 mg is equivalent to Lovastatin 40 mg or Simvastatin 20 mg. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Amaryl (Glimepiride) tablet 1-4 mg QD Glyburide (generic Micronase) 2.5-10 mg QD or Glipizide (generic Glucotrol) 5-15 mg QD or Metformin (Glucophage) 500 mg BID or Actos 15mg QD

Dose of Glyburide, Glipizide, Metformin and Actos must be titrated based on individual needs.

Amaryl (Glimepiride) tablet 4mg BID or 8 mg QD Glyburide (generic Micronase) 7.5-10 mg BID or Glipizide (generic Glucotrol) or 10-20 mg BID or Metformin (Glucophage) 850 mg BID or Actos 15mg 1 - 3 tablets QD

Dose of Glyburide, Glipizide, Metformin and Actos must be titrated based on individual needs. Consider other oral antidiabetics such as Glipizide in patients >65 due to prolonged half life of Glyburide.

Ambien (Zolpidem) tabs 10 mg QHS Generic Ambien (Zolpidem 5 & 10mg) Consider lower doses in geriatric patients.

Ambien CR (Zolpidem controlled-release) 6.25mg and 12.5mg tablets

Zolpidem 5 - 10mg 1T PO QHS Consider lower doses in geriatric patients.

Amerge (Naratriptan) 2.5mg Maxalt (Rizatriptan) MLT 10mg tablet (Maxalt MLT 5mg tablet is also available)

Maxalt MLT 10 mg is preferred, QTY limit of 9 tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Quantity limit for Non-formulary Amerge 2.5 mg tablets is 9 tablets/copay).

Americaine (Benzocaine) 20% otic drops Auralgan Otic drops (benzocaine/antipyrine/glycerin)

.

Amevive (Alefacept) IM or IV injection (requires administration in medical office, not covered by outpatient drug benefit)

Humira or Enbrel. Amevive requires administration in the medical clinic under the medical benefit rather than under the drug benefit and cannot be dispensed at a copayment from a pharmacy. Amevive coverage criteria for psoriasis: (1) patient is an adult with moderate to severe chronic plaque psoriasis, and (2) has a documented failure, or is not a candidate for topical or systemic therapies (methotrexate, acitretin, PUVA, UVB), and (3) patient has a documented failure, or is not a candidate for a combination of the above treatment options, (4) prescriber must be a Dermatologist

Amiloride 5mg Spironolactone (generic Aldactone) 25 mg .

Amitiza 24 mcg capsules Lactulose, Polyehtylene glycol 3350 [OTC Miralax]

Amoxicillin 875mg tablet Amoxicillin 500mg capsules Convert from Amoxicillin 875mg to #2 Amoxicillin 500mg capsules

Amiloride/HCTZ 5/50mg QD Triamterene/HCTZ 75/50mg 1/2-1 QD .





Androgel (Testosterone) 1% gel Androderm 2.5 mg/24 hr - 5 mg/24 hr transdermal patch; Testosterone injection 400 mg IM q2-4weeks administered in medical office. Injectables administered in a medical office are covered under the medical office benefit, NOT the drug benefit and are not available from a pharmacy for a copayment. Methyltestosterone (generic Android or Testred) tabs 10-20 mg QD-BID or Fluoxymesterone (Halotestin) 10 mg QD (tablets require baseline and periodic liver function testing).

Document indication for medication and failure on alternatives. (If patient is using for Sexual Dysfunction confirm sexual dysfunction benefits.)

Ansaid tabs (Flurbiprofen) 100 mg BID Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg - 750mg #1-2 QD-

BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.

Antara (Fenofibrate) 43mg, 87mg, & 130mg Fenofibrate 54mg and 160mg QD OR Gemfibrozil 600mg BID

If patient is on Antara (Fenofibrate) 130mg capsule QD convert to Fenofibrate 160mg QD; If patient is on Antara 43mg, convert to Fenofibrate 54 mg QD. Fenofibrate preferred if pt also taking statin. If pt has reduced renal function, consider offering gemfibrozil 600mg BID which is safer per kidney guidelines. Cost of fenofibrate and gemfibrozil similar. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Antivert (Meclizine) 12.5mg, 25mg or 50mg all strengths available OTC OTC medications are not covered by the drug benefit

Anzemet 100mg tablet Zofran (Ondansetron) tabs 4mg-8mg BID, Zofran oral liquid & IV available via pediatric Zofran (ondansetron) ODT 4mg-8mg floorstock for in office dose to break pediatric n/v

cycle & allow hydration in children unable to use phenergan safely (</= 2 yoa)

Apidra 100 Units/mL (U-100) 10mL vials or 3mL 1 Unit of Apidra has the same glucose- Pyridium plus (Phenazopyridine 150mg, 0.3mg cartridge system(for use in Opticlick) lowering effects as 1 Unit of Regular Human

Insulin [Novolin R is administered 30 minutes prior to a meal].

Hyoscyamine, 15mg Butabarbital)

Apri (0.15mg Desogestrel/ EE 0.03mg) generic Levlen (0.15mg Levonorgestrel / 30mcg EE) Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE) Desogen or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg

days, 0.075mg Lvngl/40mcg EE x 5 days, EE) or Sprintec (0.25mg Norgestimate/35mcg EE) 0.125mg Lvngl/ 30mcg EE x 10 days) or Tri-Sprintec, generic Ortho-Tricyclen, (0.18mg

Norgestimate x 7 days, 0.215mg Norgestimate x 7 days, 0.25mg Norgestimate x 7 days/ 35 mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Aricept ODT (Donepezil orally disintegrating tablet) 5mg or 10mg

Aricept (Donepezil) 5mg or 10mg

Armour Thyroid Tablet 15mg (1/4 grain); Levothroid (levothyroxine) 1 grain Armour thyroid converts to 50 - 60 mcg of 30mg (1/2 grain); 60mg (1 grain); 90mg (1&1/2 grain); levothroid. Calculate each conversion 120mg (2 grains); 180mg (3 grains); 240mg (4 grains); individually 300mg (5 grains) levothyroxine and liothyronine





Arthrotec (Diclofenac/Misoprostol) 50/200 or 75/200 TID

Monotherapy with Relafen (nabumetone) 500mg to 750mg 1-2T QD - BID (first choice) or Lodine (etodolac) 200-500mg Q8-12H up to 1200mg/day or Voltaren (diclofenac) 50 - 75mg TID AND Cytotec (misoprostol) 200mcg TID

If patient high risk for GI bleed and NSAID is required, consider: nambumetone (Relafen) 500mg to 750mg #1-2 QD-BID or etodolac (Lodine) 200-500mg Q8-12H up to 1200mg/day or Salsalate (Disalcid)1500mg BID or choline magnesium trisalicylate (Trilisate) 750mg BID-TID. Consider adding Prilosec OTC 20mg QD to further reduce GI risk. Other formulary NSAIDS include: Ibuprofen (generic Motrin) tabs 600-800 mg TID or naproxen 500mg BID or sulindac (Clinoril) 200mg BID

Astelin (Azelastine) ii puffs each nostril BID Nasarel ii sprays each nostril BID or generic Flonase (fluticasone) i spray each nostril QD or OTC Claritin or OTC Zyrtec

Document diagnosis (Consider OTC Claritin or OTC Zyrtec and Nasarel or Flonase before prescribing Astelin unless being used for Vasomotor rhinitis.)

Atacand (Candesartan) tab 8-32 mg QD Prinivil (lisinopril) 10-20 mg QD or Cozaar (losartan) 25 mg - 100mg tab QD

Prinivil is preferred, if no previous ACE inhibitor trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion equivalents: Atacand 4mg = Prinivil 5mg = Cozaar 25mg; Atacand 8mg = Prinivil 10mg = Cozaar 25mg; Atacand 16mg = Prinivil 20mg = Cozaar 50mg; Atacand 32mg = Prinivil 40mg = Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Atacand HCT (Candesartan/HCTZ) tab 16/12.5mg, 32/12.5mg QD

Lisinopril/HCTZ 10/12.5mg, 20/12.5mg QD or Cozaar(losartan) 25 mg - 100mg QD AND HCTZ (hydrochlorothiazide) 12.5mg QD

Prinivil is preferred, if no previous ACE inhibitor trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion equivalents: Atacand 4mg = Prinivil 5mg = Cozaar 25mg; Atacand 8mg = Prinivil 10mg = Cozaar 25mg; Atacand 16mg = Prinivil 20mg = Cozaar 50mg; Atacand 32mg = Prinivil 40mg = Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Atrovent nasal spray 0.03% or 0.6% ii sprays each nostril BID-QID

Nasarel ii sprays each nostril BID or generic Flonase (fluticasone) i spray each nostril QD

Inhaled steroid sprays are used for allergic rhinitis, not for common cold.

Atrovent HFA (ipratropium bromide) oral inhaler Atrovent (ipratropium bromide) oral inhaler Puff per puff conversion; differ only in the propellant used.

Augmentin 125mg/5ml suspension Augmentin 200mg/5ml suspension , Augmentin 250mg/5ml suspension Augmentin 400mg/5ml suspension ,





Augmentin XR (1000mg Amoxicillin/62.5mg Clavulanic Acid) #2 Q 12 Hours = 2000mg Amoxicillin / 125mg Clavulanic Acid Q 12 Hours

Alternatively may consider generic Augmentin 875mg (875mg Amoxicillin/125mg Clavulanic Acid) #1 Q 12 Hours PLUS Amoxicillin 500mg capsules 2 PO Q 12 hours

Alternatively may consider: Cefuroxime 250mg Q 12 hours OR Biaxin 250mg Q 12 hours OR Avelox 400mg QD

Avage (Tazarotene) 0.1% Cream Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price.

Avalide (Irbesartan/HCTZ) tabs 75/12.5 - 300/12.5 mg Lisinopril/HCTZ 10/12.5MG, 20/12.5MG OR Prinivil is preferred, if no previous ACE inhibitor QD 20/25MG QD -OR- Cozaar (losartan) 25 - trial. If angiotensin 2 receptor blocker is required,

100 mg QD AND HCTZ 12.5mg QD convert to Cozaar. Conversion equivalents: Avapro 75mg = Prinivil 5mg = Cozaar 25mg; Avapro 150mg = Prinivil 10-20mg = Cozaar 50mg; Avapro 300 = Prinivil 20-40mg = Cozaar 50-100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Avandamet: 2/500: Rosiglitazone 2 mg and metformin Metformin & Actos (pioglitazone) are Conversion equivalents: Avandia 2mg=Actos hydrochloride 500 mg; Avandamet: 4/500: formulary agents. 15mg; Avandia 4mg = Actos 30mg; Avandia Rosiglitazone 4 mg and metformin hydrochloride 500 8mg=Actos 45mg. (At KP pharmacies, Actos 15 mg; Avandamet: 2/1000: Rosiglitazone 2 mg and mg tablet is the only strength available). metformin hydrochloride 1000 mg; Avandamet: 4/1000: Rosiglitazone 4 mg and metformin hydrochloride 1000 mg

Avandia (Rosiglitazone) 2 - 8 mg QD or divided BID Actos 15 - 45 mg QD Conversion equivalents: Avandia 2mg=Actos 15mg; Avandia 4mg = Actos 30mg; Avandia 8mg=Actos 45mg. (At KP pharmacies, Actos 15 mg tablet is the only strength available).

Avapro (Irbesartan) tabs 75 - 300 mg QD Prinivil (lisinopril) 2.5 - 40 mg QD or Cozaar (losartan) 25 - 100 mg QD

Prinivil is preferred, if no previous ACE inhibitor trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion equivalents: Avapro 75mg = Prinivil 5mg = Cozaar 25mg; Avapro 150mg = Prinivil 10-20mg = Cozaar 50mg; Avapro 300 = Prinivil 20-40mg = Cozaar 50-100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

AVC (Sulfanilamide) vaginal cream No Formulary alternative OTC Monistat vaginal cream or Vagistat

Aviane (0.1 Levonorgestrel/20mcg EE) Levlen (0.15mg Levonorgestrel / 30mcg EE) May consider Microgestin FE 1/20 (1mg or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 Norethindrone/ 20mcg EE) Document at least 3 days, 0.075mg Lvngl/40mcg EE x 5 days, formulary alternatives before 0.125mg lvngl/ 30mcg EE x 10 days) prescribing/approving a NF product.





Avinza (Morphine Sulfate Extended Release Capsules) 30mg, 60mg, 90mg, 120mg QD Capsules contain both immediate release and extended release morphine beads.

Generic of MS Contin covered (morphine controlled release) 15mg, 30mg, 60mg, 100mg, 200mg BID & as necessary, Morphine immediate release tablet 10mg, 30mg, Roxanol (morphine solution 10mg/5ml, 20mg/5ml, 100mg/5ml)

Avinza capsules are dosed daily & contain both immediate release and extended release morphine. When converting from Avinza, calculate total daily Morphine dose QD. Divide total daily morphine dose by 2 to yield generic MS Contin dose to administer BID. If prescribing immediate release morphine for break thru pain, remember to subtract from the total daily morphine when calculating generic MS Contin dose.

Avodart 0.5mg (Dutasteride) Proscar (Finasteride) 5mg Alpha blockers:Doxazosin (generic Cardura) titrated to therapeutic doses (e.g. Doxazosin 2mg 1/2 tab po QHS X 1 week, then 1 tab po QHS x 2 weeks, then 2 tabs po QHS and follow-up w/MD for refill) or Terazosin (generic Hytrin) titrated slowly to therapeutic doses. (eg. 1mg QHS days 1-3, 2mg QHS days 4-15 then 5mg QHS, if necessary may further increase to 10mg QHS).

Axert (Almotriptan) 12.5mg Maxalt (Rizatriptan) MLT 10mg tablet (Maxalt MLT 5mg tablet is also available)

Maxalt MLT 10 mg is preferred, QTY limit of 9 tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Quantity limit for Non-formulary Axert is 6 tablets per copay

Axid puvules 300mg QD or 150mg BID Cimetidine (Tagamet) 400mg BID or 800mg QD -or Ranitidine (Zantac) 300mg QD -or Famotidine (Pepcid) 40mg QD

OTC alternatives: Pepcid OTC 20mg or Zantac OTC 75mg or 150mg

Azelex (Azelaic acid) 20% cream BID Acne treatment alternatives: Tretinoin 0.025% cream (Retin-A or Avita cream brand names) -or 2% Erythromycin solution & 5% Benzoyl Peroxide aqueous gel -or clindamycin 1% solution or sulfacet R lotion or clindamycin 1% gel & 5% Benzoyl Peroxide aqueous gel Rosacea treatment alternative: metronidazole 0.75% cream BID

Smallest available tube Tretinoin covered per copay, larger tubes not covered. Benzamycin and Benzaclin are nonformulary, but 2% Erythromycin solution & 5% Benzoyl Peroxide aqueous gel OR 1 % Clindamycin gel & 5% Benzoyl Peroxide aqueous gel, respectively, may be prescribed separately and purchased as a pack for one copayment at a Kaiser Permanente pharmacy. At Eckerd, the patient must purchase the OTC product, at KP it will be included at no charge.

Azmacort (triamcinolone) oral inhaler ii-iiii puffs BID-TID

QVAR (beclomethasone HFA) 80mcg/puff oral inhaler, i-ii puffs BID OR Asmanex (mometasone furoate) oral dry powder inhaler 200mcg/puff i-ii puffs QHS (or i puff BID)

QVAR is almost 4 times as potent as Azmacort (2 puffs Azmacort 100mcg/puff = 1 puff QVAR 80 mcg/puff) If patient has failed trial with QVAR consider conversion to Asmanex.

Beclovent (Beclomethasone CFC) 42mcg/puff oral inhaler ii-iiii puffs BID-TID

QVAR (Beclomethasone HFA) 40mcg/puff oral inhaler i-ii puffs BID -or Flovent 44mcg/puff i-ii puffs BID

QVAR is twice as potent as Beclovent (2 puffs Beclovent 42mcg/puff = 1 puff QVAR 40 mcg/puff) and equipotent to Flovent 44mcg (1 puff QVAR 40mcg = 1 puff Flovent 44mcg/puff). QVAR remains the preferred inhaled corticosteroid at KP GA.

Beconase AQ (beclomethasone) 0.42% nasal spray ii sprays each nostril BID


If the child is less then 4 years old, Nasonex may warrant approval as Nasarel is not indicated for patients less than 6 years old & Flonase is not indicated in patients less than 4 years old.





Benicar (Olmesartan) 20-40mg QD Prinivil (Lisinopril) 20-40mg QD or Cozaar(Losartan) 50mg - 100mg tab QD

Prinivil is preferred, if no previous ACE inhibitor trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion equivalents: Benicar 20mg = Prinivil 20mg = Cozaar 50mg; Benicar 40mg = Prinivil 40mg = Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Benicar HCT (Olmesartan/HCTZ) 20/12.5mg or 40/12.5mg

Lisinopril/HCTZ 10/12.5mg, 20/12.5mg OR 20/25mg QD or Cozaar (Losartan) 50mg -100mg tab QD PLUS HCTZ 25mg 1/2 tablet QAM


Benicar HCT (Olmesartan/HCTZ) 40/25mg Lisinopril/HCTZ 10/12.5mg, 20/12.5mg or 20/25mg QD or Cozaar(Losartan) 50 mg -100mg tab QD PLUS HCTZ 25mg tablet QAM


Benzac AC wash 2.5% wash affected area QD-BID OTC Benzoyl Peroxide wash QD-BID Benzac AC wash is available OTC; not covered BenzaClin topical gel (Benzoyl Peroxide/Clindamycin)

Separate Rxs for either 2% Erythromycin solution PLUS 5% Benzoyl Peroxide aqueous gel OR Clindamycin 1% gel PLUS 5% Benzoyl Peroxide aqueous gel

Benzamycin and Benzaclin are nonformulary, but 2% Erythromycin solution & 5% Benzoyl Peroxide aqueous gel OR 1 % Clindamycin gel & 5% Benzoyl Peroxide aqueous gel, respectively, may be prescribed separately and purchased as a pack for one copayment at a Kaiser Permanente pharmacy. At Eckerd, the patient will receive Erythromycin 2% soln OR Clindamycin 1% gel at a copayment & must purchase the OTC Benzoyl Peroxide product, at KP the OTC will be included at no additional charge.





Benzamycin topical gel (Benzoyl Peroxide/Erythromycin)

Separate Rxs for 2% Erythromycin solution PLUS 5% Benzoyl Peroxide aqueous gel

Benzamycin is nonformulary, but 2% Erythromycin solution & 5% Benzoyl Peroxide aqueous gel may be prescribed separately and purchased as a pack for one copayment at a Kaiser Permanente pharmacy. At Eckerd, the patient will receive Erythromycin 2% soln for a copayment & must purchase the OTC Benzoyl Peroxide product, at KP the OTC will be included at no additional charge.

Beta-val (Betamethasone valerate) 0.1% cream [MEDIUM potency]

Triamcinolone (generic Aristocort) cream, oint 0.1% or Valisone (Betamethasone valerate) 0.1% lotion

If failed other alternatives, consider increasing to high potency topical corticosteroid fluocinonide (Lidex) 0.05% cream, oint, or gel

Beta-val (Betamethasone valerate) 0.1% ointment [high potency]

Lidex (Fluocinonide) 0.05% cream, oint, gel, soln or Diprolene AF (Augmented Betamethasone) 0.05%

High potency topical corticosteroids.

Betaxon (Levobetaxolol) 0.5% ophth soln i drop in affected eye BID

Betoptic (Betaxolol) 0.5% ophth soln i drop in affected eye BID

Timoptic (Timolol) another formulary alternative

Betimol (Timolol) ophth soln 0.25 and 0.5% Timolol ophth soln 0.25% and 0.5% . BG Logic Blood Glucose Strips One Touch Ultra glucose test strips One

Touch Ultra 2 machine -only Lifescan monitor is formulary and may be obtained, by prescription, at KP pharmacy at co-payment. Members will be charged full price for Lifescan monitor at Eckerd. If the patient's insulin pump requires the use of a companion BG monitor requiring NF BG strips, please note brand of pump and companion BG monitor on NF Rx for Freestyle or BG Logic BG strips.

Biaxin XL (Clarithromycin XL) 500mg #2 QD Biaxin (Clarithromycin) 500mg BID Convert on a mg per mg basis. Regular release dose divided every 12 hours (ie. Biaxin XL 1000mg QD converts to Biaxin 500mg Q12H)

BiDil (20mg isosorbide dinitrate/37.5mg hydralazine) Isosorbide dinitrate 20mg + hydralazine 25mg 1 & 1/2 tabs (equals one tablet of BiDil)

BiDil's dosing per package insert is 1-2 tabs TID. Therefore, if patient is taking 2 tabs TID of BiDil, formulary conversion is isosorbide dinitrate 20mg 2 tabs TID + hydralazine 25mg 3 tabs TID.

Blocadren (Timolol) 5, 10, 20mg tabs 10-20mg BID Atenolol (Tenormin) 25-100mg QD or Metoprolol 100 - 400mg QD or Propranolol 40 - 320mg BID

Propranolol is available as 10, 20, 40, 60, 80, 90mg tabs. Inderal LA is non-formulary TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Blood glucose strips, Non Lifescan brands One Touch Ultra glucose test strips One Touch Ultra 2 machine -only

Lifescan monitor is formulary and may be obtained, by prescription, at KP pharmacy for a co-payment. Members will be charged full price for Lifescan monitor at Eckerd

Boniva 2.5mg QD or 150mg monthly Fosamax (Alendronate) 5mg QD or 35mg every week for osteoporosis prevention OR Fosamax 10mg QD or Fosamax w/D Q week for osteoporosis treatment. Fosamax w/D 70mg tablet and Fosamax 70mg/75ml liquid available.

For Fosamax 35mg Qweek dose, consider Fosamax Liquid [37.5ml] PO once a week. Fosamax Liquid is the preferred formulary alternative for this dose: 37.5ml = 35mg dose.





Botox injection Criteria Restricted Medication Criteria Restricted Medication. Provider phones KP QRM to request authorization consideration 404-364-7320. Botox (Myoblock) requires administration in the medical clinic under the medical benefit rather than under the drug benefit and cannot be dispensed at a copayment from a pharmacy.

Brethaire (Terbutaline) 0.2mg aerosol inhaler Albuterol oral inhaler . Bumex (Bumetanide) 0.5,1,2mg tabs Furosemide (generic Lasix) tablets Bumetanide 1mg converts to Furosemide 40mg

Byetta (exanatide) 5mcg/dose and 10mcg/dose prefilled pen

Criteria Restricted Medication. Provider phones KP QRM to request authorization consideration 404-364-7320.

Calan (Verapamil) SR tabs 120-240 mg QD Verapamil SR tabs (generic Calan SR) 120, 180, 240 mg tabs 120-240mg QD

Substitute on a mg for mg basis. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Calderol (Calcifediol) 20, 50 mcg caps 300-350mcg/wk titrated to effect

Rocaltrol (Calcitriol) 0.25, 0.5mcg caps 0.25-1mcg/day titrated to effect or Calciferol (Ergocalciferol) 50,000 units/capsule 15,000-20,000 units/day titrated to effect

.

Campral (Acamprosate) 333mg #2 tablets TID Disulfiram 250mg QD or Revia (Naltrexone) 50mg QD

Patients failing to respond to, tolerate or not eligible for Disulfiram, due to DM, cardiovascular disease, epilepsy or significant renal/hepatic insufficiency, consider Naltrexone 50mg QD. Naltrexone demonstrated a lower relapse rate, longer time to first relapse & higher number of abstinence days during alcohol dependence treatment trial versus Campral. Campral may be taken concomitantly with opiates. [Campral: Available Part D group]

Capex (Fluocinolone) 0.01% shampoo Fluocinolone 0.01% solution . Captique injectable gel N/A Cosmetic use drug. Not covered on drug benefit.

Member pays retail price. Carac (Fluorouracil) 0.5% cream Fluorouracil 1 and 5% cream Used for actinic or solar keratosis of the face or

scalp Cardene SR (Nicardipine) 30 - 60mg BID Nifedipine XL 30-90mg QD; or Diltia XT

(diltiazem) 120-480mg QD If treating hypertension, consider conversion to a beta blocker (metoprolol, atenolol) or Hydrochlorothiazide or ACEI (lisinopril) or, if not monotherapy, alpha blocker (doxazosin,terazosin) TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics





Cardizem (Diltiazem) CD 120, 180, 240, 300, 360 mg caps 120-480mg QD

Diltia (Diltiazem) XT 120, 180 and 240mg caps 120-480mg QD

Convert on a mg for mg basis. If Cardizem CD 300mg, consider conversion to either Diltia XT 240mg QD or #2 180mg (360mg dose) QD. Cartia XT request conversion to Diltia XT. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics

Cardizem (Diltiazem) SR 60, 90, 120mg caps 60-120mg BID


Cardizem SR 60mg BID=Diltia XT 120mg QD, Cardizem SR 90mg BID=Diltia XT 180mg QD, Cardizem SR 120mg BID=Diltia XT 240 QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Carmol-HC (Urea/HC) 1 % cream OTC Hydrocortisone 1% cream Alternative product available OTC Carmol 40% (Urea) OTC alternatives: Carmol 20% cream or

Ultra Mide 25% lotion .

Cartrol (Carteolol) 2.5, 5mg tabs 2.5 - 10mg QD Atenolol (Tenormin) 25 - 100mg QD or Metoprolol 100 - 400mg QD or Propranolol 40 - 320mg bid

Propranolol is available as 10, 20, 40, 60, 80, 90mg tabs. Inderal LA is non-formulary TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Casodex (Bicalutamide) 50mg QD Eulexin (Flutamide) 250mg TID Both in the same family of antiandrogens. Catapres TTS-1 patch applied weekly Clonidine (generic Catapres) tablet 0.1 mg

QD Clonidine patch is non formulary, tablets are formulary

Catapres TTS-2 patch applied weekly Clonidine (generic Catapres) tablet 0.2 mg QD

Clonidine patch is non formulary, tablets are formulary

Catapres TTS-3 patch applied weekly Clonidine (generic Catapres) tablet 0.3 mg QD

Clonidine patch is non formulary, tablets are formulary

Caverject inj 10 mcg N/A Caverject is not covered for sexual dysfunction unless member's group has purchased sexual dysfunction rider for additional coverage.

Cedax (Ceftibuten) suspension Omnicef 125mg/5ml; Pediazole (Erythromycin & Sulfamethoxazole); Augmentin 125-250mg/5ml or 200-400mg chew tabs;Amoxicillin 125-250mg/5ml; Biaxin 125-250mg/5ml; Cefaclor suspension

.





Ceftin (Cefuroxime) 500mg tablets Cefuroxime 250mg tablets In most instances, 250mg BID is sufficient dosing. When 500mg BID dosing is required, mg to mg conversion. (eg. One cefuroxime 500mg tablet BID converts to Two Cefuroxime 250mg tablets)

Ceftin suspension Omnicef 125mg/5ml; Pediazole (Erythromycin & Sulfamethoxazole); Augmentin 125-250mg/5ml or 200-400mg chew tabs;Amoxicillin 125-250mg/5ml; Biaxin 125-250mg/5ml; Cefaclor suspension

Cefuroxime 250mg tablets remain on formulary, Ceftin suspension is non-formulary

Cefzil suspension 30 mg/kg/day divided BID TMP-SMX (generic Septra or Bactrim) 6-12 mg/kg/day (TMP) divided BID or Sulfisoxazole/Erythromycin (generic Pediazole) 68 mg/kg/day (Erythromycin) divided TID or Cefaclor (generic Ceclor) 20-40 mg/kg/day divided BID-TID or Augmentin 45 mg/kg/day (Amoxicillin/Clavulanate) divided BID

Pharmacologically, Cefaclor is the closest antibiotic alternative to Cefzil.

Celebrex (celecoxib) 100 - 200mg BID ***Caution may increase cardiovascular toxicity***

Relafen (Nambumetone) 500mg or 750mg 1 - 2 QD-BID or Etodolac (gen. Lodine) 200-500mg Q8-12H up to 1200mg/day or Ibuprofen (gen. Motrin) tabs 600-800 mg TID or Naproxen (gen. Naprosyn) 500mg BID or Sulindac (gen. Clinoril) 200mg BID or Diclofenac (gen. Voltaren) 75mg BID or Mobic (Meloxicam) 7.5mg or 15mg OR, if COX 2 inhibitor is appropriate (GI SCORE > 20), see next column. Clinical trials document: Adding PPI like, Prilosec OTC 20mg QD, to NSAID therapy results in GI ulcer risk equivalent to that with Cox 2 inhibitors

Cox 2 inhibitor (Celebrex) is a NF No Initial Fill agent, due to safety concerns with its use. KP NSAID GI SCORE tool will assist provider to determining if pt is a candidate for Cox-2 inhibitor benefit coverage. If pt SCORE >20 and patient has failed a reasonable trial on each of these low GI risk NSAIDs PLUS PPI: Relafen 500mg or 750mg 1 - 2 QD-BID PLUS Prilosec 20mg QD; Etodolac 400-500mg BID PLUS Prilosec 20mg QD; Salsalate 750mg 1-2 BID PLUS Prilosec 20mg QD, meets criteria for Cox 2 inhibitor coverage. If pt SCORE < 20 and NSAID is required, consider: Nambumetone (Relafen) 500mg #1-2 QD-BID or etodolac (Lodine) 200-500mg Q8-12H up to 1200mg/day or Salsalate (Disalcid) 1500mg BID or Choline Magnesium Trisalicylate (Trilisate) 750mg BID-TID.

Cenestin (Synthetic Conjugated Estrogen) tabs 0.3-1.25 mg QD

Estrace (Estradiol) 0.5 - 2 mg po QD Prescribed for relief of vasomotor symptoms due to menopause. 0.5mg estradiol = 0.3mg Cenestin; 0.75mg estradiol (1&1/2 0.5mg tablet)=0.45mg Cenestin; 1mg estradiol = 0.625mg Cenestin; 1.5mg estradiol (1&1/2 1mg tablet) = 0.9mg Cenestin; 2mg estradiol = 1.25mg Cenestin)

Cerumenex (Triethanolamine Polypeptide Oleate-Condensate 10% ear wax removal drops

OTC ear wax removal drops Use OTC ear wax removal product ie Debrox (Carbamide Peroxide)

Chantix (Varenicline) oral tablets 1mg BID OTC Nicotrol (Nicotine transdermal system) 5, 10, 15mg/day

Smoking cessation products are non formulary

Chibroxin (Norfloxacin) ophth soln Ocuflox (Ofloxacin) ophth soln .

Chlorhexidine topical soln N/A Available OTC. May be substituted without calling provider.

Choledyl (Oxtriphylline) tab (oxtriphylline=approximately 64% theophylline)

Theophylline (generic TheoDur) Convert according to appropriate daily dose of theophylline OR consider inhaled Albuterol and/or QVAR (Beclomethazone HFA)

Chromagen (Ferrous Fumarate 70mg, Cyanocobalamin 10mcg, Ascorbic acid 150mg)

OTC alternatives: Niferex 150mg (Polysaccharide-iron complex) or Ferrous Fumarate 200mg: With or Without OTC B12 100mcg plus vitamin C 250mg

Pt may also opt to pay full price for Rx Chromagen. Vitamins components available OTC





Chromagen Forte (Ferrous Fumarate 151mg, Folic acid 1mg, Cyanocobalamin 10mcg, Ascorbic acid 60mg)

OTC alternatives: Niferex 150mg (Polysaccharide-iron complex) or Ferrous Fumarate 200mg: plus B12 100mcg plus vitamin c 100mg plus Rx Folic Acid 1mg QD

Pt may also opt to pay full price for Rx Chromagen. Vitamins components available OTC

Cialis (Tadalafil) none Cialis is not covered for sexual dysfunction unless member's group has purchased sexual dysfunction rider for additional coverage.

Ciloxan (Ciprofloxacin) ophth soln Ocuflox (Ofloxacin) ophth soln . Cipro HC otic soln Cortisporin otic (neomycin/polymyxin/HC) 3

drops TID, Or gentamicin ophthalmic solution 0.3% 3 drops TID -or-Neomycin/polymyxin/dexamethasone ophth susp 0.1% 3 drops TID; If fluoroquinolone antibiotic necessary: Ofloxacin 0.3% ophthalmic solution 5-10 drops into ear(s) BID.

Ciprodex is reserved primarily for use in Acute Otitis Media when patient has tubes. Other formulary otic solutions include: Vosol (Acetic Acid) or Vosol HC (Acetic Acid and Hydrocortisone)

Clarinex (Desloratadine) 5mg tabs Claritin OTC or Zyrtec OTC Clarinex not covered by drug benefit. Claritin and Zyrtec available OTC. Intranasal steroids (Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray each nostril QD) more effective than nonsedating antihistamines for allergic rhinitis.

Claritin tabs or redi-tabs 10 mg QD Claritin OTC or Zyrtec OTC Claritin not covered by drug benefit. Claritin and Zyrtec available OTC. Intranasal steroids (Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray each nostril QD) more effective than nonsedating antihistamines for allergic rhinitis.

Claritin-D 24 hour tabs 10 mg (240 mg Pseudoephedrine) QD

Claritin-D and Zyrtec-D available OTC. Claritin D not covered by drug benefit. Claritin D and Zyrtec D available OTC. Intranasal steroids (Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray each nostril QD) is more effective than nonsedating antihistamines for allergic rhinitis.

Claritin-D tabs 5 mg (120 mg Pseudoephedrine) BID Claritin-D and Zyrtec-D available OTC. Claritin D not covered by drug benefit. Claritin D and Zyrtec D available OTC. Intranasal steroids (Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray each nostril QD) is more effective than nonsedating antihistamines for allergic rhinitis.

Cleocin 2% vaginal cream 5 gm vaginally QD x 1 week, vaginal suppository

Metronidazole (generic Flagyl) tabs 2 gm (500 mg x 4 tablets) for 1 dose

Metronidazole tablets more effective than cream/gel

ClimaraPro (Estradiol/Levonorgestrel transdermal patches) 0.045mg/0.015mg

Climara (Estradiol) 0.05mg patch PLUS medroxyprogesterone 2.5-5mg QD

Also available: Climara 0.025mg, 0.0375mg, .05mg, 0.06mg, 0.075mg, 0.1mg patches apply one patch weekly; or Oral Estradiol 0.5, 1 or 2mg

Clindagel (clindamycin 1%) Generic clindamycin phosphate gel 1% (Cleocin T gel)

Clindesse (Clindamycin phosphate) 2% cream single dose formulation


Metronidazole tablets more effective than cream/gel. If failed alternatives and vaginal clindamycin required, NF alternative is Clindamycin 2% vaginal cream QD x 1 week.





Cloderm (Clocortolone Pivalate) 0.1% cream [medium potency]

Triamcinolone (generic Aristocort or Kenalog) cream, oint 0.1%

If failed other alternatives, consider increasing to high potency topical corticosteroid Fluocinonide (Lidex) 0.05% cream, oint, or gel

ClosDes Pack (Desonide 1% Cream, 15 gm tube, & OTC Clotrimazole 1%, 15 gm tube) Available as a combination package at KP pharmacies only.

Combination package containing Desonide 1% cream 15 gm tube & Clotrimazole 1% 15 gm tube available for one copay at KP pharmacies only

Outside of KP, Desonide 1% available for one copay. Patient may purchase Clotrimazole 1% as an OTC product at outside pharmacies.

Codiclear DH Syrup (5 mg Hydrocodone/100 mg Guaifenesin) 5ml Q4H PC & HS

Robitussin AC generic Syrup (10 mg Codeine/100 mg Guaifenesin) 10 ml Q4H or Robitussin DAC .

Other alternatives: Phenergan VC with Codeine or Phenergan with Codeine syrup or Hycodan tablets

Colazal (Balsalazide) #3 750 mg caps TID (total daily dose of 6.75 grams) for 8 weeks ulcerative colitis

Asacol (Mesalamine released primarily in colon) 400mg #2 TID for 6 wks OR Pentasa 250mg #4 QID or 500mg #2 QID for 8 wks OR Dipentum 250mg #4 BID OR Azulfidine (Sulfasalazine) 500mg #2 TID-QID

Treatment for ulcerative colitis. Colazal is broken down in the body to form Mesalamine.

Colestid flavored/unflavored granules bulk powder 1-3 teaspoonfuls QD-BID or packet 1-3 packets QD-BID

Questran bulk powder 1-3 scoopfuls QD-BID or Questran packets 1-3 packets QD-BID or Colestid 1 gm tablet i-iiii tablets QD-BID

.

CombiPatch (0.05mg Estradiol / 0.14 Norethindrone or 0.05mg Estradiol/ 0.25mg Norethindrone patches) apply 1 patch, replacing patch twice wkly

Estrace 0.5, 1 or 2mg (Estradiol) AND Medroxyprogesterone 2.5 or 5mg

Combination estrogen and progesterone patch is non formulary. Convert to oral estrogen and progesterone QD.

Combunox (Oxycodone 5mg / ibuprofen 400mg) combination tabs

Generic MS Contin (Morphine controlled release) 15,30,60,100,200mg PLUS ibuprofen 400mg tablets; generic Percocet or Percodan (oxycodone 5mg/325mg apap or asa, respectively), Tylox (oxycodone 5mg/500mg apap), generic Demerol 50mg, 100mg, Fentanyl patches 25mcg, 50mcg, 75mcg, 100mcg/hr

Many alternative narcotic pain relievers No fixed conversion ratios will fit all patients, especially when large opioid doses are involved. The following is a starting point and may need individual adjustment or titration: Oxycontin package insert states that multiplying the daily oxycontin dose by 2, yields a suggested daily Morphine dose.

Compazine (Prochlorperazine) spansules Compazine tablets or suppositories Spansules are non formulary, tablets and supp are formulary

Condylox topical solution Condylox 0.5% gel BID x 3 days then withold x 4 days. May repeat cycle up to 4 times

Solution is non formulary, gel is formulary

Copegus (Ribavirin) 200mg tab generic Ribavirin 200mg capsule Cordran (Flurandrenolide) 0.025%-0.05% cream, oint, 0.05% lotion or 4mcg/cm2 tape [Medium potency]

Triamcinolone (generic Aristocort) cream, oint 0.1%

If failed other alternatives, consider increasing steroid potency to fluocinonide (Lidex) 0.05% cream, oint, or gel

Cortef Susp (10mg/5mL Hydrocortisone) 20-240 mg/day

Prelone Syrup generic or Orapred (15mg/5mL) divide Cortef dose by 4 when converting

N/A

Corzide (Bendroflumethiazide/Nadolol) 5/40 or 5/80mg Convert to two Rx products Hydrochlorothiazide 25mg and either Nadolol 40mg or Nadolol 80mg

Match the Nadolol dose to the original combination product Nadolol dose. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Cosopt (Dorzolamide 2%/Timolol 0.5%) i drop in affected eye BID

Azopt (Brinzolamide 1%) i drop TID and Timoptic (Timolol 0.5%) i drop BID

Combination product, Cosopt, is non formulary. Individual medications, (Azopt and Timoptic not XE) are formulary.





Cotazyme (Pancrelipase enzymes) Pancrease (Pancrelipase enzymes) or pangestyme

Pangestyme is a generic of Pancrease

Cough and Cold Products OTC equivalents available All cough and cold medications are non-formulary with the exception of Codeine, Hydrocodone, methscopalamine, and Promethazine containing products.

Coumadin (Warfarin) tablet Warfarin tablet (Barr generic brand) Brand name non formulary. Covera-HS (Verapamil controlled release) 180, 240mg tabs 180-480mg QHS

Verapamil SR tabs (generic Calan SR) 180, 240mg tabs 180-480mg QHS

Substitute on a mg for mg basis. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Cozaar (Losartan) 50mg tablets (50mg strength is NF) Cozaar (Losartan) 25mg #2 QD or 100mg 1/2 tablet QD -or if ACE Inhibitor naïve, Lisinopril 20mg QD

Cozaar 50mg strength is non-formulary, please prescribe 25mg or 100mg tablets. If ACE Inhibitor naïve, consider conversion to Lisinopril: Cozaar 50mg QD = Lisinopril 20mg QD. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretic

Creon (Pancrelipase enzymes) Pancrease (Pancrelipase enzymes) Pangestyme is a generic of Pancrease Crestor (Rosuvastatin) 10mg Lovastatin 80 mg QPM w/ meal or

Simvastatin 40 mg QPM Doses of lovastatin > 40mg QD and simvastatin > 20mg QD are not recommended in combination with Diltiazem, Verapamil, Amiodarone, or a protease inhibitor. Continue crestor to minimize drug interaction and chance for muscle aches. If crestor is continued, use half tablets. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD, crestor > 5mg QD not recommended with cyclosporine. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Crestor (Rosuvastatin) 20mg Simvastatin 80 mg QPM Doses of lovastatin > 40mg QD and simvastatin > 20mg QD are not recommended in combination with Diltiazem, Verapamil, Amiodarone, or a protease inhibitor. Continue crestor to minimize drug interaction and chance for muscle aches. If crestor is continued, use half tablets. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD, crestor > 5mg QD not recommended with cyclosporine. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM. If pt is also on gemfibrozil, please consult PCRS for recommendations.





Crestor (Rosuvastatin) 40mg Consider simvastatin 80mg QD plus Slo-Niacin/ time release niacin or BAS first if appropriate. Otherwise, Vytorin 10/80 mg QHS can be considered.

Doses of lovastatin > 40mg QD and simvastatin > 20mg QD are not recommended in combination with Diltiazem, Verapamil, Amiodarone, or a protease inhibitor. Continue crestor to minimize drug interaction and chance for muscle aches. If crestor is continued, use half tablets. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD, crestor > 5mg QD not recommended with cyclosporine.For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM. If pt is also on gemfibrozil, please consult PCRS for recommendations.

Crestor (Rosuvastatin) 80mg No formulary alternative at this dosage. Cresylate (M-Cresyl acetate) 25% otic Domeboro (Aluminum Acetate and Acetic

Acid) otic N/A

Crinone (Progesterone) 4% vaginal gel Medroxyprogesterone 2.5 mg QD Crinone 4% vaginal gel is non-formulary, used for post-menopausal hormone replacement.

Crinone (Progesterone) 8% vaginal gel N/A Crinone 8% vaginal gel is used for fertility treatment and is covered only for those patient groups who have purchased a fertility treatment rider to expand their drug benefit.

Crolom (Cromolyn) 4% ophth soln i-ii drops q6hrs (mast cell stabilizing properties)


OTC Zaditor 0.25% and Patanol are both dual action antihistamine/mast cell stabilizers, are dosed twice daily, and have the same FDA approved indications. If treating steroid responsive inflammatory condition: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

Cryselle (0.3 Norgestrel / 30mcg EE) tablet i QD Levlen (0.15mg Levonorgestrel / 30mcg EE) May consider Tri-Norinyl (.5/1/.5 Norethindrone/ or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 35 EE) or Microgestin FE (1 mg Norethindrone/ 20 days, 0.075mg Lvngl/40mcg EE x 5 days, EE) or Zovia 1/35 (1mg Ethynodiol Diacetate/ 35 0.125mg Lvngl/ 30mcg EE x 10 days) EE) Document at least 3 formulary

alternatives before prescribing/approving a NF product.

Cutivate (Fluticasone) 0.05% cream, 0.005% oint [medium potency]

Triamcinolone (generic Aristocort, Kenalog) cream, oint 0.1%

If failed other alternatives, consider increasing steroid potency to Fluocinonide (Lidex) 0.05% cream, oint, or gel

Cyanocobalamin (vitamin b12) injection OTC: Vitamin B12 1mg orally TSPMG clinical practice resource indicates oral b12 may be used in pernicious anemia

Cyclessa (tricyclic Desogestrel/EE) 0.1mg/25mcg x Microgestin 1/20 (1mg Other formulary alternatives: Tri-Norinyl (0.5mg 7days; 0.125mg/25mcg x 7days; 0.15mg/25mcg x 7 Norethindrone/20mcg EE) or Microgestin Norethindrone x 7days, 1mg NE x 7 days, 0.5mg days (generic soon available as Velivet by 1.5/30 (1.5NE/30mcgEE) or Levlen (0.15 NE x 7 days/ 35 mcg EE) or Zovia 1/35 Barr) Levonorgestrel/30mcg EE) or Tri-Levlen (Ethynodiol 1mg/35mcg EE), Brevicon (.5mg NE/

(0.05mg Levonorgestrel & 30mcg EE x 6 35mcg EE), Zovia1/35 (Ethynodiol 1mg/35mcg days, 0.075mg Lvn & 40 EE x 5 days, EE), Norinyl 1/35 (1mg NE/ 35mcg EE) Norinyl 0.125mg Lvn & 30mcg EE x 10 days) 1/50 (1mg NE/ 50mcg Mestranol), or NorQD (0.35

NE only) A Desogestrel containing product substitution is not available on formulary. Document at least 3 formulary alternatives before prescribing/approving a NF product.

Cyclocort (Amcinonide) 0.1% cream, oint, lotion [high potency]

Lidex (fluocinonide) 0.05% cream, oint, gel, soln or Diprolene AF (augmented betamethasone) 0.05%

High potency topical corticosteroids. If require a lotion, consider stepping down to medium potency Valisone (betamethasone valerate) 0.1% lotion





Cymbalta (duloxetine) 20mg If treating depression: Fluoxetine 20mg or Citalopram 20mg or Sertraline 25mg or Venlafaxine IR 25mg BID or Effexor XR 37.5mg (Effexor XR restricted to psychiatry and mental health ). Titrate to response. Sertraline added to formulary as of 3/8/07. Document response to all formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.

If treating neuropathic pain: Nortriptyline (if <65 yrs old: 25mg QHS, increase dose 25mg/day at 3-7 day intervals prn. If > 65 years old: 10mg QHS, increase dose 10mg/day at 3-7 day intervals prn). Consider adding Gabapentin if needed. Consider topical capsaicin OTC if area is small. (Duloxetine is available to MMA group )

Cytomel (liothyronine) tablet 25-75 mcg QD Levothroid tabs 0.05-0.1 mg QD, see suggested conversions in next column

If interested in converting, please refer to approximate conversions: 15-37.5mg cytomel = 50-60mcg levothroid; 37.5mg cytomel = 75-90mcg levothroid; 50mcg cytomel = 100-120mcg levothroid; 75mcg cytomel = 150-180 levothroid.

Cytovene (gancyclovir) cap 1000mg TID maintenance therapy for CMV retinitis (following induction with IV gancyclovir or insertion of vitrasert)

Valcyte 450mg tablet Valcyte (valgancyclovir) - CMV prophylaxis 900mg QD; AIDS or s/p organ transplantation 900mg BID (Treatment doses if Crcl 40-59 = 450mg BID;crcl 25-39 = 450mg QD;crcl 10 - 24 = 450mg Q 2 days; dialysis - valcyte not recommended; also adjust for WBC)

Darvocet-N 50 & -N 100 APAP 1000mg TID-QID, CAUTION: propoxyphene/acetaminophen (Propoxyphene/acetaminophen) Hydrocodone/APAP 5/500mg 1/2 -1T TID, (generic Darvocet) and other propoxyphene

Nabumetone 500mg BID, Etodolac 300mg - combinations are on the list to be avoided in 400mg BID -TID the elderly due to increased risks for falls.

[Available Part D group]

Darvon & Darvon-N (Propoxyphene) APAP 1000mg TID-QID, CAUTION: propoxyphene/acetaminophen Hydrocodone/APAP 5/500mg 1/2 -1T TID, (generic Darvocet) and other propoxyphene Nabumetone 500mg BID, Etodolac 300mg - combinations are on the list to be avoided in 400mg BID -TID the elderly due to increased risks for falls.

[Available Part D group]

Daytrana (Methylphenidate) Concerta 18,27,36,54mg, or Methylin ER 10mg, Methylphenidate 5, 10, 20mg and SR 20mg; or generic Dexedrine spansules (Dextroamphetamine) 5, 10, 15mg or Adderall regular release 5, 10, 20, 30mg tablets or Adderall XR 5,10,20,25,30mg capsules. Controlled substances level 2 requiring prescription written by prescriber. Methylphenidate is the preferred formulary alternative.

Adderall XR is restricted to pediatrics, child neurology and behavioral health. Titrate to appropriate dosage using adderall regular release tablets before transitioning to once daily Adderall XR. Document failed trial on Methylphenidate, Dextroamphetamine and Adderall IR products before a Non-formulary Product is considered.

Daypro (Oxaprozin) 600mg tab 1200- 1800mg QD Relafen (Nambumetone) 500mg or 750mg 1 Additional formulary alternatives: Salsalate - 2 QD-BID or Etodolac (Lodine) 200-500mg (Disalcid)1500mg BID or choline magnesium Q8-12H up to 1200mg/day or Ibuprofen trisalicylate (Trilisate) 750mg BID-TID or (Motrin) tabs 600-800mg TID or Naproxen Indomethacin 25-50mg TID. (Naprosyn) 500mg BID or Sulindac (Clinoril) 200mg BID or Diclofenac (Voltaren) 75mg BID or Mobic (Meloxicam) 7.5mg or 15mg





Decadron (Dexamethasone sodium phosphate) 0.1% cream [low potency]

DesOwen (Desonide) 0.05% cream, oint, lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion


Decaspray (Dexamethasone) aerosol spray [low potency]

DesOwen (Desonide) 0.05% cream, oint, lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion


Demadex (Torsemide) tabs 5-100 mg QD Furosemide (generic Lasix) tabs 10-200 mg per day

Multiply daily Demadex dose by 2 to obtain daily furosemide dose (example: Demadex 10 mg QD x 2 = furosemide 20 mg QD). Furosemide doses > 60 mg/day should be divided BID.

Demulen 1/35 compak i QD Zovia 1/35 (generic Demulen) i QD May be substituted without calling provider.

Demulen 1/50 compak i QD Zovia 1/50 (generic Demulen) i QD May be substituted without calling provider.

Denavir Cream (Penciclovir) apply Q2H while awake X 4 days

Herpes Labialis: OTC Abreva. OTC Carmex or Orabase to prevent drying and fissuring. Domoboro soaks may relieve itching and dry blisters; Acyclovir (generic Zovirax) tab 400 mg TID x 5 days

OTC Abreva (Docosanol cream) has been shown to reduce herpes labialis course by 18 hours. Abreva blocks viral entry into cells; therefore, not likely to lead to viral resistance. [ Available Part D group]

Depakote ER (Divalproex sodium extended release) Depakote (Divalproex sodium) tablets regular release are covered

Depakote ER does not offer clinical benefit over Depakote regular release. Unlike Depakote, Depakote ER may not be dosed higher than 1000mg/day

Depo-Testosterone 200 mg/ml inj Methyltestosterone (generic Android or Testred) tabs 10-20 mg QD-BID or Fluoxymesterone (Halotestin) 10 mg QD Check baseline and periodic liver function tests if using oral supplementation.

Testosterone injection 400 mg IM q2-4weeks administered in medical office. Injectables administered in a medical office are covered under the medical office benefit, NOT the drug benefit and are not available from a pharmacy for a copayment.

Dermatop (Prednicarbate 0.1%) Lidex (Fluocinonide) 0.05% cream, oint, gel or Diprolene AF (Augmented Betamethasone) 0.05%

High potency topical corticosteroids. If require a lotion, consider stepping down to medium potency Valisone (Betamethasone valerate) 0.1% lotion

Desogen (Desogestrel 0.15mg/EE 30mcg) 28 tabs i QD

Levlen (0.15mg Levonorgestrel / 30mcg EE) or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 days, 0.075mg Lvngl/40mcg EE x 5 days, 0.125mg Lvngl/ 30mcg EE x 10 days)

Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE) or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg EE) or Sprintec (0.25mg Norgestimate/35mcg EE) or Tri-Sprintec, generic Ortho-Tricyclen, (0.18mg Norgestimate x 7 days, 0.215mg Norgestimate x 7 days, 0.25mg Norgestimate x 7 days/ 35 mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Detrol Regular Release (Tolterodine) tab 1-2mg BID (regular release is non formulary)

Oxybutynin (generic Ditropan) 5-10 mg tab i QD-BID (immediate release tablet) or Oxybutynin XL (generic Ditropan XL) 5-15mg QD or Oxytrol patch

.

Detrol LA (Tolterodine long-acting) 2-4mg QD (removed from formulary as of 7/1/07)

Oxybutynin (generic Ditropan) 5-10 mg tab i QD-BID (immediate release tablet) or Oxybutynin XL (generic Ditropan XL) 5-15mg QD or Oxytrol patch

Dextrostix blood glucose test strips One Touch Ultra glucose test strips One Touch Ultra 2 machine -only

Lifescan monitor is formulary and may be obtained, by prescription, at KP pharmacy at a co-payment. Members will be charged full price for Lifescan monitor at Eckerd





DHT (Dihydrotachyesterol) aka Hytakerol 0.125, 0.2, Rocaltrol (Calcitriol) 0.25, 0.5mcg caps 0.25-0.4mg tabs 0.1-0.25mg QD and titrate to effect 1mcg/day titrated to effect or Calciferol

(Ergocalciferol) 50,000 units/capsule 15,000-20,000 units/day titrated to effect

Diatx (1.5mg B1;1.5mg B2; 20mg B3; 10mg B5; 50mg B6; 1mcg B12; 60mg C; 5mg folic acid; 300mg d Biotin)

OTC Nephro-vite (Vitamin C 100mg, folate 0.8mg, niacin B3 20mg, thiamin B1 1.5mg, riboflavin B2 1.7mg, Pantothenic Acid B5 5mg, Pyridoxine B6 10mg, Cyanocobalamin B12 6mcg, d biotin 300mcg) PLUS folic acid OTC (if need greater than .8mg in Nephro Vite)

Nephro-vite OTC NDC # 54391-0002-01.

Didrex (Benzphetamine) N/A Weight loss agents not covered.

Differin (Adapalene) 0.1% gel and cream Retin A Micro 0.04% and 0.1% gel, 20gm or Retin A Micro is restricted to Dermatology. Retin-A 0.01% 15gm gel or Retin A 0.1% Only the smallest unit size is covered for Retin A 20gm cream products. Covered only for the treatment of acne,

member pays copay. Not covered for cosmetic treatment (wrinkles), member pays full price.

Diflucan (Fluconazole) tab 50mg, 100mg, 200mg tab QD

50mg, 100mg and 200mg strengths are not covered for vaginal yeast infections.

Diflucan (Fluconazole) tab 150 mg i x 1 dose Fluconazole 150mg strength is Formulary with a quantity limit of 1 tablet per copay. Fluconazole 150mg covered for vaginal yeast infections when OTC vaginal preps cannot be used.

Diflunisal (generic Dolobid) tabs 500 mg BID Ibuprofen (Motrin) tabs 600-800 mg TID or Additional formulary alternatives: Diclofenac Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg 1 - 2

QD-BID or Etodolac (Lodine) 200-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg .

Diltiazem Gel (compounded formulation for anal fissure, not commercially available)

Nitroglycerin 0.2% Ointment (commercially available), apply very small amount (to avoid/minimize absorption related side effects) via Q-tip to anal fissure

.

Diovan (Valsartan) 80-320 mg QD Prinivil (Lisinopril) 5-40mg QD or Cozaar 25-100mg QD

Prinivil (Lisinopril) is preferred, if no previous ACE inhibitor trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion: Diovan 80mg=Prinivil 5-10mg=Cozaar 25mg; Diovan 160mg=Prinivil 10-20mg=Cozaar 50mg; Diovan 320mg=Prinivil 20-40mg=Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics





Diovan HCT (160mg Valsartan/ 12.5mg Hydrochlorothiazide) QD

Prinzide (lisinopril & HCTZ) 10/12.5mg, 20/12.5mg or 20/25mg OR Cozaar 50mg (25mg tabs x 2=50mg) QD plus HCTZ (Hydrochlorothiazide) 25 mg 1/2 tab QD

Prinzide (lisinopril & HCTZ) is preferred, if no previous ACE inhibitor trial. Must have separate prescription for HCTZ if Cozaar prescribed. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Diovan HCT 80mg Valsartan /12.5mg Hydrochlorothiazide QD

Prinivil 5-10 mg QD or Cozaar 25mg tab QD plus HCTZ (hydrochlorothiazide) 25 mg 1/2 tab QD or Prinzide (lisinopril & HCTZ) 10/12.5mg

Prinivil (lisinopril)+ HCTZ or Prinzide is preferred, if no previous ACE inhibitor trial. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Diprosone (Betamethasone Dipropionate) 0.05% cream, oint [high potency]



Diprosone (Betamethasone Dipropionate) 0.05% lotion [medium potency]

Valisone (Betamethasone Valerate) 0.1% lotion or Triamcinolone (generic Aristocort or Kenalog) cream, oint 0.1%


Ditropan (Oxybutynin) XL 5-10 mg tab i QD Oxybutynin (generic Ditropan) 5-10 mg tab i QD-BID (immediate release tablet) or Oxybutynin XL (generic Ditropan XL) 5-15mg QD or Oxytrol patch

Diuril (Chlorothiazide) tablet Hydrochlorothiazide tablet N/A

Divigel (Estradiol) .1% 0.25mg estradiol/day, 0.5mg estradiol/day, and 1.0mg estradiol/day

Climara (.025mg, .0375mg, .05mg, .06mg, .075mg, .075mg, .1mg patches) apply 1 patch a week; Estrace (Estradiol) .5mg-2mg po daily, OR Premarin Vaginal Cream

Divigel (Estradiol) .1% is available in 3 doses of 0.25mg, 0.5mg, and 1.0mg corresponding to Estradiol 0.25mg, 0.5mg, and 1.0mg

Dolobid (Diflunisal) tabs 500 mg BID Ibuprofen (generic Motrin) tabs 600-800 mg TID or Salsalate (Disalcid)1500mg BID or Naproxen 500mg BID or Sulindac (Clinoril) 200mg BID

Additional formulary alternatives: Diclofenac (Voltaren) 75mg BID or Choline Magnesium Trisalicylate (Trilisate) 750mg BID-TID or Nambumetone (Relafen) 500mg or 750mg #1-2 QD-BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.

Donnatal elixir Antispasmodic elixir (generic Donnatal) Generic may be substituted. Brand is non-formulary and not covered.

Doryx 100mg (Doxycycline) Doxycycline 50mg or 100mg .





Duac gel (Clindamycin gel/Benzoyl peroxide gel) Separate Rxs for either 2% Erythromycin solution PLUS 5% Benzoyl Peroxide aqueous gel OR Clindamycin 1% gel PLUS 5% Benzoyl Peroxide aqueous gel

Benzamycin and Duac are nonformulary, but 2% Erythromycin solution & 5% Benzoyl Peroxide aqueous gel OR 1 % Clindamycin gel & 5% Benzoyl Peroxide aqueous gel, respectively, may be prescribed separately and purchased as a pack for one copayment at a Kaiser Permanente pharmacy. At Eckerd, the patient will receive Erythromycin 2% soln OR Clindamycin 1% gel at a copayment & must purchase the OTC Benzoyl Peroxide product, at KP the OTC will be included at no additional charge.

DuoNeb (Albuterol 3mg/Ipratropium 0.5mg) inhalation solution for use with nebulizer

Combivent (Albuterol/Ipratropium) oral inhaler

Albuterol inhalation solution 0.5% 20ml AND Ipratropium 0.02% 2.5ml for use with nebulizer

Duricef (Cefadroxil) cap 500 mg BID Cephalexin (generic Keflex) cap 500 mg BID

First generation cephalosporins

Dyazide (Triamterene 37.5 mg/HCTZ 25 mg) tabs Triamterene 75 mg/HCTZ 50 mg (generic Maxzide) 1/2 tab dose

Cut Generic Maxzide tablet in half to obtain equivalent dose.

Dynabac (Dirithromycin) tab: 500 mg QD for 7-14 days (adults)

Erythromycin (base or estolate) 250-500 mg Q6-8H (adult)

Dynabac offers no clinical advantage over erythromycin when dosed appropriately

Dynacin (Minocycline HCL) 50, 75, or 100mg Capsules

Minocycline 50mg or 100mg capsules .

Dynacirc (Isradipine) caps 10 mg BID Nifedipine XL (generic Procardia XL) tab 60 mg QD

Nifedipine XL, generic of Procardia XL, is covered. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Dynacirc (Isradipine) caps 2.5 mg BID Nifedipine XL tab 30 mg QD Nifedipine XL, generic of Procardia XL, is covered. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Dynacirc (Isradipine) caps 5 mg BID Nifedipine XL tab 30 mg QD Nifedipine XL, generic of Procardia XL, is covered. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Edecrin (Ethacrynic acid) 25 and 50mg loop diuretic Lasix (Furosemide) Or, if allergic to sulfonamide drugs, Spironolactone

Dose of converted diuretic to be adjusted for each individual





Effexor (Venlafaxine) XR caps 37.5-225 mg QD Venlafaxine IR 25mg - 100mg BID or Effexor XR is restricted to Psychiatry and Prozac (Fluoxetine) caps 20 mg QD or Mental Health. Venlafaxine IR is formulary Celexa (Citalopram) 20mg QD or Sertraline without restrictions. Prozac is the preferred 25-100 mg QD. Please titrate to response formulary SSRI. (Prozac may also be prescribed

to manage hot flashes in women with a history of breast cancer) [Effexor XR: Available Part D]

Efudex (Fluorouracil) 2% cream, soln Efudex 5% cream, Fluoroplex 1% Efudex 2% is non formulary

Elestat (Epinastine) 0.05% ophth soln For allergic conjunctivitis: OTC Opcon-A (Pheniramine & Naphazoline) first line option; or OTC Zaditor 0.25% [NOTE: OTC products are not a covered benefit] Formulary alternatives: prednisolone.

OTC Zaditor 0.25% and Patanol are both dual action antihistamine/mast cell stabilizers, are dosed twice daily, and have the same FDA approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID. Consider at least 2 formulary products before prescribing/authorizing a NF product.

Eldoquin (Hydroquinone) cream or lotion No formulary alternative Cosmetic drug is not covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they are also being used as cosmetic therapy and are not covered.

Eligard (Leuprolide acetate) 7.5mg injection Lupron or Eligard to be supplied by the prescribing physician and administered in MD office under the patient's medical benefit.

TSPMG physicians provide injectables administered in medical office through floor stock. If network physicians cannot obtain Lupron or Eligard, please complete KP NF Rx form for Lupron requesting benefit coverage at the time of dispensing.

Elocon (Mometasone) 0.1% cream, oint, lotion [medium potency]

Triamcinolone (generic Aristocort/ gen. Kenalog) cream, oint 0.1%; If elocon lotion use gen. Valisone (Betamethasone Valerate) 0.1% lotion


Emadine (Emedastine) .05% ophth soln 1 drop QID For allergic conjunctivitis: OTC Opcon-A (Pheniramine & Naphazoline) or OTC Zaditor 0.25% [NOTE: OTC products are not a covered benefit]

OTC Zaditor 0.25% and Patanol are both dual action antihistamine/mast cell stabilizers, are dosed twice daily, and have the same FDA approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

Emend (Aprepitant) 125mg prior to chemotherapy Zofran (Ondansetron) 24 mg and Emend is NF, consider adding only after failed then 80mg on days 2 and 3. (neurokinin 1 receptor Dexamethasone 12mg PO prior to Zofran & Dexamethasone combination therapy. antagonist) chemotherapy followed by 8mg PO QD on Emend is administered as part of a three drug

days 2 thru 4 regimen including Zofran, Dexamethasone and Emend.

Embeline E (Clobetasol propionate) 0.05% emollient cream

Temovate (Clobetasol) 0.05% cream, oint, gel, scalp soln or Diprolene (Augmented Betamethasone Dipropionate) 0.05% oint

Very high potency topical corticosteroids.

E-mycin tablet EC 333 mg TID or 500 mg BID Ery-tab 333 mg TID or 500 mg BID Different Erythromycin formulations





Enablex (Darifenacin) extended release 7.5mg and 15mg tablets

Oxybutinin (generic Ditropan) 5-10 mg tab i QD-BID (immediate release tablet) or Oxybutynin XL (generic Ditropan XL) 5-15mg QD or Oxytrol patch

.

Enjuvia (Synthetic Conjugated Estrogens) 0.3mg-1.25mg

Estrace (Estradiol) 0.5, 1 or 2mg QD Estradiol (generic estrace) preferred. 0.5mg Estradiol = 0.3mg Premarin; 0.75mg Estradiol (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin

Enpresse (0.05mg Levonorgestrel/ 30mcg EE x 6 days, 0.075mg Lvngl/ 40 mcg EE x 5 days, 0.125mg Lvngl/30mcg EE x 10 days)

Tri-Levlen (0.05 Lvngl/30mcg EE x 6 days, 0.075mg Lvngl/40mcg EE x 5 days, 0.125mg Lvngl/30mcg EE x 10days)

Document at least 3 formulary alternatives before prescribing/approving a NF product.

Entex LA OTC Robitussin CF or Congestac All cough and cold medications with OTC equivalents are non-formulary with exception of Codeine, Hydrocodone, and Promethazine containing products.

Entocort (budesonide) Asacol (Mesalamine released primarily in colon) 400mg #2 TID for 6 wks OR Pentasa 250mg #4 QID or 500mg #2 QID for 8 wks OR Dipentum 250mg #4 BID OR Azulfidine (Sulfasalazine) 500mg #2 TID-QID

E-pilo (Epinephrine 1% and Pilocarpine 1,2,4 or 6%) i-ii drops QD - QID

Epinephrine 1% i-ii drops QD - QID AND Pilocarpine 1, 2, 4, or 6% i-ii drops QD -QID

Combination eye drop is not covered, but component eye drops are individually covered.

Epivir HBV (lamivudine) tablet Epivir 150 mg tablet QD Esclim (Estradiol transdermal patches) apply twice weekly Patch strengths 5mg, 7.5mg, 10mg 15mg, 20mg deliver 0.025mg, 0.0375mg, 0.05mg, 0.075mg, 0.1mg Estradiol QD



Esgic tabs Butalbital Compound 1-2 tabs Q4H (max: 6 tabs/day)

.

Estraderm transdermal patch 0.05 mg/day Climara .025mg, 0.0375mg, .05mg, 0.06mg, 0.075mg, 0.1mg patches apply one patch weekly; or Estrace 0.5, 1 or 2mg (Estradiol)


Estraderm transdermal patch 0.1 mg/day Climara 0.025mg, 0.0375mg, .05mg, 0.06mg, 0.075mg, 0.1mg patches apply one patch weekly; or Estrace 0.5, 1 or 2mg (Estradiol)


Estrasorb (estradiol topical emulsion) 1.74 gram foil pouch

Climara 0.025mg, 0.0375mg, .05mg, 0.06mg, 0.075mg, 0.1mg patches apply one patch weekly; or Estrace (Estradiol) 0.5mg (note larger estrogen dose when administered orally) or Premarin Vaginal Cream

The dose of estradiol topical emulsion for the treatment of moderate to severe vasomotor symptoms is 3.48 grams daily (two foil pouches of 1.74 grams, one half dose rubbed into the thigh and calf area of each leg) which delivers 0.05 milligrams of estradiol per day

Estratab tablet 0.3-1.25 mg QD Climara 0.025mg, 0.0375mg, .05mg, 0.06mg, 0.075mg, 0.1mg patches apply one patch weekly; or Estrace 0.5, 1 or 2mg (Estradiol)


Estratest and Estratest HS tab Syntest DS and Syntest HS respectively EstroGel (Estradiol gel) 1.25gm Climara 0.025mg, 0.0375mg, .05mg,

0.06mg, 0.075mg, 0.1mg patches apply one patch weekly; or Estrace (Estradiol) 0.5mg (note larger estrogen dose when administered orally) or Premarin Vaginal Cream

The dose of estradiol gel for the treatment of moderate to severe vasomotor symptoms is 1.25 grams daily (two foil pouches of 1.74 grams, one half dose rubbed into the thigh and calf area of each leg) which delivers 0.75 milligrams of estradiol





EstroStep (1mg Norethindrone/20mcg EE x 5day, Tri-Norinyl (0.5mg NE/35mcg EE x7 day, Or may consider Microgestin FE (1mg NE/20mcg 1mg NE/30mcg EE x 7 day, 1mg NE/35mcg EE x 9 1mg NE/35mcg EE x 7 day, 0.5mg NE/35 EE x 21 day plus 75mg Ferrous Fumarate) day) mcg EE x 7 day) or Norinyl 1/35 (1mg

NE/35mcg EE) plus OTC Iron Supplement (Ferrous Fumerate 75 mg)

EstroStep FE (1mg Norethindrone/20mcg EE x 5day, Tri-Norinyl (0.5mg NE/35mcg EE x7 day, Or may consider Microgestin FE (1mg NE/20mcg 1mg NE/30mcg EE x 7 day, 1mg NE/35mcg EE x 9 1mg NE/35mcg EE x 7 day, 0.5mg NE/35 EE x 21 day plus 75mg Ferrous Fumarate) day, 75mg Ferrous Fumarate x 7 days) mcg EE x 7 day) or Norinyl 1/35 (1mg Document at least 3 formulary alternatives

NE/35mcg EE) plus OTC Iron Supplement before prescribing/approving a NF product. (Ferrous Fumerate 75 mg)

Ethyl Chloride spray (topical anesthetic, vapocoolant) OTC topical anesthetic alternatives: Aerofreeze spray (topical anesthetic, vapocoolant) OR OTC L-M-X4 (4% topical lidocaine cream) or OTC Lidosense 4 (4% topical lidocaine cream) or Rx Lidocaine 4% topical soln apply to affected area Q3-4H

Pt may also choose to purchase NF Ethyl Chloride spray at full prescription price.

Ethyol inj N/A Ethyol is indicated for prevention of xerostomia in patients receiving radiation therapy (head and neck cancer). Northside Radiation Therapy group may prescribe up to 20 vials for a member to pick up at KP facility pharmacy only (zero copay, pharmacist override), to be administered prior to radiation therapy.

Evoxac (Cevimeline) 30mg capsules TID Pilocarpine 3% ophthalmic solns 5 - 10 drops TID taken orally

N/A

Exelderm (Sulconazole) 1% cream OTC Lamisil AT or clotrimazole containing OTC products: Lotrimin AF or OTC Mycelex or OTC Micatin cream

Clotrimazole or Terbinafine (Lamisil) for tinea pedis, tinea corporis, tinea circinata (ringworm of body), tinea cruris, tinea inguinalis (jock itch), tinea versicolor; Clotrimazole for intertrigo (rash in body folds or beneath breasts) or candidiasis (including rash on penis or corners of mouth) [OTC alternatives are not recommended for tinea capitis (ringworm of scalp), tinea faceii or barbae (ringworm of the beard…barber's itch]

Exforge (Amlodipine/Valsartan) Amlodipine(Norvasc) generic 5mg or 10mg+ Prinivil (Lisinopril) is preferred, if no previous ACE 5/160, 10/160, 5/325, 10/325mg Prinivil (Lisinopril) 5-40mg QD or Cozaar

(Losartan) 25-100mg QD inhibitor trial. If angiotensin 2 receptor blocker is required, convert to Cozaar.

Conversion: Diovan 160mg=Prinivil 10-20mg=Cozaar 50mg;

Diovan 320mg=Prinivil 20-40mg=Cozaar 100mg

TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretic





Famvir (Famcyclovir) 125, 250, 500mg tabs Herpes Herpes zoster Acyclovir 800mg Q4H, 5 Acyclovir only oral antiviral covered for herpes. zoster 500mg Q8H x 7 days; genital herpes times daily x 7 days (10 days if For recommendations please see TSPMG clinical recurrence 125mg BID x 5 days immunocompromised); genital herpes

acyclovir 400mg TID x 7-10 days (5 days when treating recurrences, may use 800mg BID x 5 days for recurrence); chronic suppressive therapy 400mg BID, titrate to lowest effective suppressive dose

practice resource

Felbatol (Felbamate) Tegretol (carbamazepine), Neurontin (gabapentin), Topamax (topiramate), Tranxene (clorazepate), Lamotrigine 5-25mg chews and Lamictal 100mg-200mg oral tablets

Adjunctive therapy for partial seizures [conversion to a formulary alternative not recommended when patient is stable on non formulary antiseizure medication for seizure management]

Feldene (Piroxicam) Relafen (Nambumetone) 500mg or 750mg 1 Additional formulary alternatives: Salsalate - 2 QD-BID or Etodolac (Lodine) 200-500mg (Disalcid)1500mg BID or choline magnesium Q8-12H up to 1200mg/day or Ibuprofen trisalicylate (Trilisate) 750mg BID-TID or (Motrin) tabs 600-800mg TID or Naproxen Indomethacin 25-50mg TID. CAUTION: Feldene (Naprosyn) 500mg BID or Sulindac (Piroxicam) is on the list to be avoided in the (Clinoril) 200mg BID or Diclofenac elderly due to increased risks of GI complications. (Voltaren) 75mg BID or Mobic (Meloxicam) [Available Part D group] 7.5mg or 15mg

Femhrt (5mcg Ethinyl Estradiol / 1 mg Norethindrone acetate)

Estradiol 0.5mg or 1mg QD plus Medroxyprogesterone 2.5-5mg QD

Two individual prescriptions are required. 0.5mg Estradiol = 0.3mg Premarin; 0.75mg Estradiol (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin

Femstat (2% Butoconazole) vaginal cream OTC OTC Mycelex3 (2% butoconazole) Other OTC alternatives include: Monistat vaginal cream or Vagistat

Products that are available Over the Counter are not covered by the drug benefit.

Fenesin (Guaifenesin) ER tabs 600 mg BID OTC Mucinex (600mg Guaifenesin long acting) or OTC Guaifenesin 400mg regular release or OTC Guaifenesin syrup ii teaspoonfuls Q4H or OTC Guaifenesin gel cap ii capsules Q6H (generic Robitussin)

Cold products are non formulary. Member may select OTC product or pay cash for prescription cold product

Fenesin tablet SA OTC Mucinex (600mg Guaifenesin long acting) or OTC Guaifenesin 400mg regular release or OTC Guaifenesin syrup ii teaspoonfuls Q4H or OTC Guaifenesin gel cap ii capsules Q6H (generic Robitussin)

Cold products are non formulary. Member may select OTC product or pay cash for prescription cold product

Ferrlicit injectable InFeD injectable

Finevin or Finacea (Azelaic Acid) Cream Acne treatment alternatives: Tretinoin 0.025% cream (Retin-A or Avita cream brand names) or 2% Erythromycin solution & 5% Benzoyl Peroxide aqueous gel or clindamycin 1% solution or sulfacet R lotion or clindamycin 1% gel & 5% Benzoyl Peroxide aqueous gel Rosacea treatment alternative: metronidazole 0.75% cream BID

Smallest available tube Tretinoin covered per copay, larger tubes not covered. Benzamycin and Benzaclin are nonformulary, but 2% Erythromycin solution & 5% Benzoyl Peroxide aqueous gel OR 1 % Clindamycin gel & 5% Benzoyl Peroxide aqueous gel, respectively, may be prescribed separately and purchased as a pack for one copayment at a Kaiser Permanente pharmacy. At Eckerd, the patient must purchase the OTC product, at KP it will be included at no charge.

Fioricet/Codeine caps Fioricet tabs (Butalbital/apap/caff), tylenol #3 (generic), Fiorinal with Codeine (Butalbital Compound with Codeine)

.





Flomax (Tamsulosin) 0.4-0.8 mg QD Doxazosin (generic Cardura) titrated to therapeutic doses (eg. Doxazosin 2mg 1/2 tab PO QHS X 1 week, then 1 tab QHS x 2 weeks, then 2 tabs QHS and follow-up w/MD for refill) -or- Terazosin (Hytrin) titrated slowly to therapeutic doses (eg. Terazosin 1mg po QHS x 3 nights then 2 caps QHS x 7 nights, then 5 caps QHS and follow-up with MD for refill)

Restricted to Urology and KP Hospitalists.

Flovent (Fluticasone) 110mcg/puff and 220mcg/puff i-ii puffs BID

QVAR 80mcg/puff i-ii puffs PO BID or Asmanex (mometasone furoate) oral dry powder inhaler 200mcg per puff inhale i-ii puffs QHS (or i puff BID)

QVAR is the preferred corticosteroid formulary alternative. The dry powder inhaler Asmanex (mometasone) may offer another formulary ICS alternative for patients ≥ 12 yrs old more likely to adhere to once daily maintenance therapy. Asmanex is considered equipotent to fluticasone and approx twice as potent as beclomethasone.

Florone (Diflorasone) 0.05% cream, oint Lidex (Fluocinonide) 0.05% cream, oint, gel, soln or Diprolene AF (Augmented Betamethasone) 0.05%


Floxin tab 200 mg BID Cipro tab 250 mg BID Cipro and Avelox are formulary quinolones Floxin tab 300 mg BID Cipro tab 500 mg BID Cipro and Avelox are formulary quinolones Floxin tab 400 mg BID Cipro tab 500 mg BID Cipro and Avelox are formulary quinolones Floxin (Ofloxacin) 0.3% Otic Solution 5ml bottle Ofloxacin 0.3% Ophthalmic solution 5ml

bottle Ophthalmic solution may be administered in the ear

Fluocinonide 0.05% soln Fluocinolone 0.01% soln or Fluocinonide 0.05% cream, gel or ointment

Fluocinonide is a high potency steroid. Fluocinolone is a low potency steroid.

Fluonid (Fluocinolone) 0.01% soln Synalar (Fluocinolone) 0.01% soln Generic available Fluor-op (Fluorometholone) 0.1% ophth susp FML (Fluorometholone 0.1%) ophth susp The smallest available unit size only Fluorouracil 2% cream Fluorouracil 1% or 5% cream 2% is non formulary Flurosyn (Fluocinolone) 0.01% cream DesOwen (Desonide) 0.05% cream, oint,

lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion


FML Forte (Fluorometholone) 0.25% ophth susp FML (Fluorometholone 0.1%) ophth susp; Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln

Eye drops are covered for the smallest available unit size only

FML-S (Fluorometholone 0.1%/Sulfacetamide10%) FML (Fluorometholone 0.1%) AND Bleph-10 (Sulfacetamide 10%) Or Blephamide (Prednisolone 0.2% / Sulfacetamide 10%)

FML-S is non formulary, but component eye drops are formulary individually. Eye drops are covered for the smallest available unit size only.

Focalin (Dexmethylphenidate) 2.5 to 10mg BID Methylphenidate 5 to 20mg BID No clinical advantage of Focalin over Ritalin. Plasma-level data suggest the d-enantiomer is bioequivalent to racemic methylphenidate in a 1:2 dose ratio (eg, 5 mg dexmethylphenidate bioequivalent to 10 mg methylphenidate) Document failed trial on Methylphenidate, Dextroamphetamine and Adderall IR products before a Non-formulary Product is considered

Folic Acid 1mg OTC (National Vitamin Company brand) FolpaceRx (folic acid 2.05mg; hydroxycobalamin B12a 425mcg; pyridoxine B6 25mg; d-alpha tocopheryl succinate Vit E 100IU; magnesium oxide 100mg)

OTC vitamin supplement components

Foradil (Formoterol) dry powder oral inhaler 12mcg/puff i puff BID

Serevent (Salmeterol) diskus 50mcg i puff BID

Fortamet (Metformin extended release) 500mg, 1000mg tablets

Metformin regular release 500mg, 850mg or 1000mg tablets

Metformin ER is also a formulary alternative.





Forteo (Teriparatide) 20mcg injection recombinant human parathyroid hormone subcutaneous injection

Fosamax 10mg QD or Fosamax w/ D 70mg Q week for osteoporosis treatment.

Fortovase (Saquinavir) cap Invirase (saquinavir) 200mg capsule New patients may self refer to ID by phoning 770-431-4360.

Fosamax (Alendronate) 70mg plain tablet Fosamax w/D 70 mg Q week is formulary. Fosrenol (Lanthanum carbonate) 250mg or 500mg Tablets

Phoslo 667mg (Calcium Acetate) tablet ii-iiii tablets with each meal

Lanthanum and Sevelamer are Calcium-/Aluminum-free Phosphate binders for hypophosphatemia in patients with end stage renal disease. If a NF calcium/aluminum free phosphate binder is required, Sevelamer is KP NF alternative of choice.

Fragmin (Dalteparin) injection Lovenox (Enoxaparin) injections Limit of 10 syringes Lovenox, 5 day supply, for initial fill

Freestyle Blood Glucose test strips One Touch Ultra glucose test strips One Touch Ultra 2 machine -only

Lifescan monitor is formulary and may be obtained, by prescription, at KP pharmacy at co-payment. Members will be charged full price for Lifescan monitor at Eckerd. If the patient's insulin pump requires the use of a companion BG monitor requiring NF BG strips, please note brand of pump and companion BG monitor on NF Rx for Freestyle or BG Logic BG strips.

Frova (Frovatriptan) 2.5mg Maxalt (Rizatriptan) MLT 10mg tablet (Maxalt MLT 5mg tablet is also available)

Maxalt MLT 10 mg is preferred, QTY limit of 9 tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Quantity limit for Non-formulary Frova is 9 tablets per copay

Fulvicin U/F (Griseofulvin microsized) Grifulvin V 500mg tablets and Grifulvin suspension (125mg/ml) Dosing:Adults 500-1000mg as single or divided doses; Children: 10-20 mg/kg/day in single or divided doses

Fulvicin U/F is no longer available from the manufacturer

Fulvicin P/G (Griseofulvin ultra-microsized) Grifulvin V 500mg tablets and Grifulvin suspension (125mg/ml) Dosing:Adults 500-1000mg as single or divided doses; Children: 10-20 mg/kg/day in single or divided doses

Griseofulvin ultra-microsized products are no longer being manufactured. Griseofulvin microsized remains available. Griseofulvin conversion factor: 0.66mg ultramicrosize = 1mg microsize (eg. Ultramicrosize 330mg=microsize 500mg)

Gabitril (Tiagabine) Tegretol (carbamazepine), Neurontin (gabapentin), Topamax (topiramate), Tranxene (clorazepate), Lamotrigine 5-25mg chews and Lamictal 100mg-200mg oral tablets

Adjunctive therapy for partial seizures [conversion to a formulary alternative not recommended when patient is stable on non formulary antiseizure medication for seizure management]

Generet-500 w/folic tab SA i QD OTC prenatal vitamin i QD Prescription prenatal vitamins are not covered Geodon (Ziprasidone) 20-80mg bid Seroquel (Quetiapine) 25, 100, 200, 300mg

or Zyprexa (Olanzapine) 2.5, 5, 7.5, 10, 15mg tabs 10-15mg qd or Risperdal (Risperidone) 4-6mg qd

Consider 1/2 tablet dosing whenever possible. (eg. Seroquel 200mg 1/2 tablet for Seroquel 100mg dose. Risperdal 1mg 1/2 tablet for Risperdal 0.5mg dose.) [Ziprasidone: Available Part D group]

Glucose meter One Touch Ultra glucose test strips One Touch Ultra 2 machine -only

Lifescan monitor is formulary and may be obtained, by prescription, at KP pharmacy at a co-payment. Members will be charged full price for Lifescan monitor at Eckerd

Glucotrol (Glipizide) XL tab 10 mg QD Glipizide (generic Glucotrol) tab 10 mg QD XL Glucotrol (glipizide XL) is non-formulary, regular release is formulary and is equally effective

Glucotrol (Glipizide) XL tab 20 mg QD Glipizide (generic Glucotrol) tab 10 mg BID XL Glucotrol (glipizide XL) is non-formulary, regular release is formulary and is equally effective





Glucotrol (Glipizide) XL tab 5 mg QD Glipizide (generic Glucotrol) tab 5 mg QD XL Glucotrol (glipizide XL) is non-formulary, regular release is formulary and is equally effective

Glucovance (Glyburide/Metformin) 1.25/250mg, 2.5/500, 5/500 tabs BID

Glyburide 1.25-5mg tab BID AND Metformin 500mg BID

Combination product is non-formulary, but component medications are formulary individually. In order to increase metformin efficacy, consider converting Glucovance 1.25/250mg BID to glyburide 1.25mg BID PLUS metformin 500mg BID.

Glynase (Micronized Glyburide) tab 1.5 mg QD Glyburide (generic Micronase) tab 2.5 mg QD

Glynase (Micronized Glyburide) is non formulary, regular Glyburide is formulary. Consider other oral antidiabetics such as Glipizide in patients >65 due to prolonged half life of Glyburide.

Glynase (Micronized Glyburide) tab 3 mg QD Glyburide (generic Micronase) tab 5 mg QD Glynase (Micronized Glyburide) is non formulary, regular Glyburide is formulary. Consider other oral antidiabetics such as Glipizide in patients >65 due to prolonged half life of Glyburide.

Glynase (Micronized Glyburide) tab 6 mg BID Glyburide (generic Micronase) tab 10 mg BID

Glynase (Micronized Glyburide) is non formulary, regular Glyburide is formulary. Consider other oral antidiabetics such as Glipizide in patients >65 due to prolonged half life of Glyburide.

Glynase (Micronized Glyburide) tab 6 mg QD Glyburide (generic Micronase) tab 10 mg QD

Glynase (Micronized Glyburide) is non formulary, regular Glyburide is formulary

Glyset (Miglitol) 25 - 100mg TID Glyburide (generic Micronase) 2.5-5 mg QD Alpha-glucosidase inhibitors are non formulary.

GoLYTELY (Polyethylene Glycol electrolyte soln) Colyte (Polyethylene Glycol 3350) powder (only stable 48 hours after mixing) for bowel cleaning

.

Gris-PEG (Griseofulvin Ultramicrosized) Grifulvin V 500mg tablets and Grifulvin suspension (125mg/ml) Dosing:Adults 500-1000mg as single or divided doses; Children: 10-20 mg/kg/day in single or divided doses

Griseofulvin Ultra-microsized products are no longer being manufactured. Griseofulvin microsized remains available. Griseofulvin conversion factor: 0.66mg ultramicrosize = 1mg microsize (eg. Ultramicrosize 330mg=microsize 500mg)

Grisactin (Griseofulvin Microsized) Grifulvin V 500mg tablets and Grifulvin suspension (125mg/ml) Dosing:Adults 500-1000mg as single or divided doses; Children: 10-20 mg/kg/day in single or divided doses

Grisactin is no longer available from manufacturer.

Grisactin Ultra (Griseofulvin Ultramicrosized) Grifulvin V 500mg tablets and Grifulvin suspension (125mg/ml) Dosing:Adults 500-1000mg as single or divided doses; Children: 10-20 mg/kg/day in single or divided doses

Griseofulvin Ultra-microsized products are no longer being manufactured. Griseofulvin microsized remains available. Griseofulvin conversion factor: 0.66mg ultramicrosize = 1mg microsize (eg. Ultramicrosize 330mg=microsize 500mg)

Guaifenesin LA tab i BID OTC Mucinex (600mg Guaifenesin long acting) or OTC 400mg Guaifenesin regular release or OTC Guaifenesin syrup ii teaspoonfuls Q4H or OTC Guaifenesin gel cap ii capsules Q6H (generic Robitussin)

All cough and cold medications with OTC equivalents are non-formulary with exception of codeine, hydrocodone, and promethazine containing products.

Gynezole 1 (2% butoconazole) vaginal cream OTC Mycelex3 (2% butoconazole) Other OTC alternatives include: Monistat vaginal cream or Vagistat

Products that are available over the counter are not covered by the drug benefit.





H Pylori treatment pack (only available at KP pharmacies for one copayment. At Eckerd, dispense as Rx for Metronidazole 500mg QID #56 & Tetracycline 500mg QID #56 and OTC Pepto-bismol 2 tablets QID & Prilosec OTC 20mg BID

Metronidazole 500mg QID, Tetracycline 500mg QID (or Amoxicillin if Ten allergic), and Pepto-bismol 2 tabs QID x 14 days and Prilosec OTC 20mg BID -- packet of all 4 available for one copayment at KP pharmacies

Alternative, if failed first treatment course: Biaxin (Clarithromycin) 500mg bid, Flagyl (Metronidazole) 500mg bid and Prilosec OTC 20mg bid x 14 days Either treatment pack is recommended for 14 days; however, if patient able to tolerate at least 7 days may not be necessary to initiate alternate H Pylori treatment course.

Habitrol (Nicotine transdermal system) 7, 14, 21mg/day

OTC Nicotrol (Nicotine transdermal system) 5, 10, 15mg/day

Nicotine replacement products are non formulary

Halcion (Triazolam) tabs 0.125-0.25 mg at HS Temazepam (generic Restoril) 15-30 mg capsule at HS or Oxazepam (gen Serax) 10-30mg or Lorazepam 0.5mg QHS or Hydroxyzine (generic Atarax) 10-25 mg at HS

Consider lower doses in geriatric patients. Consider OTC melatonin to reduce benzodiazepine usage Caution: do not abruptly discontinue benzodiazepines after long-term use. [Haloperidol: Available Part D group]

Halog (Halcinonide) 0.1% cream, oint [high potency] Lidex (Fluocinonide) 0.05% cream, oint, gel, soln or Diprolene AF (Augmented Betamethasone) 0.05%


Helidac (250mg Metronidazole QID, 500mg HP Pack: Tetracycline 500 mg QID x 14 HP Pack (Helicobacter pylori treatment pack) Tetracycline QID, 2x262mg Bismuth subsalicylate QID days, Metronidazole 500 mg QID x 14 days, Individual components dispensed as 2 individual x 14 days) Bismuth subsalicylate 2 tabs QID x 14 days

and Prilosec OTC 20mg BID x 14 days (HP Pack available at KP pharmacies for one copayment)

prescriptions (500mg Metronidazole QID and 500mg Tetracycline QID) PLUS OTC Pepto Bismol (bismuth subsalicylate) & Prilosec OTC at Eckerds. [If member allergic to or failed TEN, substitute Amoxicillin 500mg QID] Second line alternative: Prilosec OTC 20mg BID, Biaxin 500mg BID, and Flagyl 500mg BID or Amoxicillin 1000mg BID x 14 days

Hemocyte Plus OTC equivalent (Fe 106 mg, B1, B2, B3, B5, B6, B12, C 200 mg, folic acid 1 mg)

Vitamins components available OTC in one or more OTC preparations for equivalency.

Hibiclens (Chlorhexidine) top soln N/A Available OTC, may be substituted. HMS (Medrysone) 1% ophth susp For allergic conjunctivitis: OTC Opcon-A

(Pheniramine & Naphazoline) or OTC Zaditor 0.25% [NOTE: OTC products are not a covered benefit]

OTC Zaditor 0.25% and Patanol are both dual action antihistamine/mast cell stabilizers, are dosed twice daily, and have the same FDA approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product :Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

Humabid LA OTC Mucinex (600mg Guaifenesin long acting) or OTC Guaifenesin 400mg regular release or OTC Guaifenesin syrup ii teaspoonfuls Q4H or OTC Guaifenesin gel cap ii capsules Q6H (generic Robitussin)


Humalog (insulin Lispro) inj 100 u/ml NovoLog (insulin Aspart) U-100 vial, OR, if no previous trial on regular insulin, consider conversion to Novolin Regular Insulin

Humalog converts to Novolog on a unit for unit basis. [Humalog and NovoLog are administered 15 minutes prior to meals, whereas Novolin R is administered 30-60 minutes before meals.] Novolog vial is compatible with currently marketed insulin pumps. NF Novolog cartridge is preferred if older pump requiring cartridge.





Humalog Mix 50/50 (50% insulin lispro protamine/ 50% insulin lispro) vial 100 u/ml

Consider conversion to both Novolin NPH and either NovoLog or Novolin R, individually. Converting physician specifies the number of units of each. Draw the NovoLog or Novolin R (which ever ordered) into the syringe before drawing the NPH into the syringe.

[Humalog and NovoLog are administered 15 minutes prior to meals, whereas Novolin R is administered 30-60 minutes before meals.] eg. 20 units of Humalog mix 50/50 converts to 10 units of NovoLog mixed with 10 units of Novolin NPH to equal a total of 20 units mixed insulin

Humalog Mix 75/25 (75% insulin lispro protamine / 25% insulin lispro) vial 100u/ml

Consider conversion to Novolin 70/30 (70% isophane insulin susp / 30% regular insulin OR both Novolin NPH and NovoLog, individually. Converting physician specifies the number of units of each. Draw the NovoLog into the syringe before drawing the NPH into the syringe

Consider Novolin 70/30 [Humalog and NovoLog are administered 15 minutes prior to meals, whereas Novolin R is administered 30-60 minutes before meals.] eg. 20 units of humalog mix 75/25 converts to 20 units of novolin 70/30 OR 20 units of humalog mix 75/25 converts to 15 units NPH and 5 units NovoLog.

Humalog pen NovoLog (insulin Aspart) U-100 vial, OR, if no previous trial on regular insulin, consider conversion to Novolin Regular Insulin

Humalog converts to Novolog on a unit for unit basis. Humalog is administered 15 minutes prior to meals, Novolin R is administered 30-60 minutes before meals. Insulin pens are non-formulary. However, Insulin pens may be available thru the NF Rx process when the physician documents the member is unable to accurately draw up insulin due to young age, visual impairment, Parkinson's Disease, rheumatoid arthritis or upper extremity amputation; or, when administering doses less than 5 units; or, when pediatric patient's school or day care requires use of insulin cartridge device for insulin administration while outside of their primary caretaker's care.

Humatrope (Human Growth Hormone) vial Criteria Restricted Medication. Once approved, the approval and date range for approval is noted in the Kaiser pharmacy computer system. Norditropin (somatropin) is preferred growth hormone and must be tried prior to approval for other growth hormone products

Criteria Restricted Medication. Pediatric Endocrinologist phone KP QRM to request authorization consideration 404-364-7320. May only be dispensed at a Kaiser Pharmacy. Normally vials are approved. If Humatrope cartridges are medically necessary, Novofine 30 needle tips will be dispensed. The prescribing Endocrinologist will provide the Humatropen.

Humegon injection Repronex injection May be substituted on a unit for unit basis without calling practitioner. Menotropins are only covered for members with fertility benefit.

Humibid DM tablet SA i tablet BID OTC Mucinex (600mg Guaifenesin long acting) or OTC Guaifenesin 400mg regular release or OTC Guaifenesin syrup ii teaspoonfuls Q4H or OTC Guaifenesin gel cap ii capsules Q6H (generic Robitussin)

All cough and cold medications with OTC equivalents are non-formulary with exception of Codeine, Hydrocodone, and Promethazine containing products.

Humibid LA tabs i tablet BID OTC Mucinex (600mg Guaifenesin long acting) or OTC Guaifenesin 400mg regular release or OTC Guaifenesin syrup ii teaspoonfuls Q4H or OTC Guaifenesin gel cap ii capsules Q6H (generic Robitussin)


Humorsol (Demecarium) 0.125 - 0.25% ophth soln reversible cholinesterase inhibitor

Phospholine iodide (echothiophate 0.03-0.25%) ophth soln irreversible cholinesterase inhibitor

Cholinesterase inhibitors to reduce IOP in glaucoma. Smallest package size is formulary. Ophthalmologist to determine appropriateness of conversion and dose.





Humulin N, R, L or U-100 vials Novolin N or R U-100 vials May be substituted without calling provider. Penfills are not covered. Humulin Ultralente and Lente will soon be discontinued by manufacturer.

Humulin R 500 units/ml vials Novolin R 100 units/ml vials If injection volume of 100units/ml concentration can be safely administered SQ, do not convert to more concentrated 500units/ml.

Hylaform Plus (hylan-b) gel N/A Cosmetic use drug. Not covered on drug benefit. Member pays retail price.

Hycodan (Hydrocodone/Homatropine) syrup i teaspoonful Q4-6H prn

Hydrocodone/Homatropine (Hycodan) tab i tablet Q4-6H prn

Hycodan syrup is non-formulary, tablets are formulary. Robitussin AC generic Syrup (10 mg Codeine/100 mg Guaifenesin) 10 ml Q4H or Robitussin DAC; phenergan VC with codeine or phenergan with codeine syrup

Hydroquinone cream or lotion No formulary alternative Cosmetic use drug. Not covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they are also being used as cosmetic therapy and are not covered.

Hydroxyzine pamoate caps (generic Vistaril) 25-50 mg TID-QID

Hydroxyzine HCl tabs (generic Atarax) 25-50 mg TID-QID

Substitute on a mg for mg basis.

Hygroton (chlorthalidone) tabs Hydrochlorothiazide tabs . Hytakerol (Dihydrotachyesterol) aka DHT 0.125, 0.2, 0.4mg tabs 0.1-0.25mg qd and titrate to effect

Rocaltrol (Calcitriol) 0.25, 0.5mcg caps 0.25-1mcg/day titrated to effect or Calciferol (Ergocalciferol) 50,000 units/capsule 15,000-20,000 units/day titrated to effect

.

Hyzaar tabs 100mg (Cozaar100/HCTZ25) QD or 50mg (Cozaar 50mg/HCTZ 12.5mg) BID

Cozaar 100 mg QD plus Hydrochlorothiazide 25 mg tablet QD.

Two separate prescriptions for Cozaar and HCTZ are required. TSPMG guidelines recommend trial on ACEI (Prinivil) before prescribing ARB (Cozaar)

Hyzaar tabs 50mg (Cozaar 50mg/12.5mg HCTZ) i tablet QD

Cozaar 50 mg QD plus Hydrochlorothiazide 25 mg 1/2 tablet QD.

Two separate prescriptions for Cozaar and HCTZ are required. TSPMG guidelines recommend trial on ACEI (Prinivil) before prescribing ARB (Cozaar)

Iletin NPH, R &L 100U/ml vial Novolin NPH, R & L 100U/ML vials May be substituted on a unit for unit basis Ilozyme (Pancrelipase enzymes) Pancrease (pancrelipase enzymes) or

pangestyme Pangestyme is a generic of Pancrease

Imitrex (Sumatriptan) 25 tabs OR 100mg tabs Maxalt (Rizatriptan) MLT 10mg tablet (Maxalt MLT 5mg tablet is also available)

Maxalt MLT 10 mg is preferred, QTY limit of 9 tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms.

Imitrex 5 mg nasal spray Imitrex 20 mg nasal spray Imitrex 20 mg nasal spray is significantly more effective than Imitrex 5 mg nasal spray. The same precautions and contraindications apply for both strengths of nasal spray. Maximum prescription quantity for Imitrex 20 mg spray is 6 bottles/prescription.

Indapamide tab (generic Lozol)1.25 mg QD Hydrochlorothiazide (HCTZ) tab 12.5 mg QD

N/A

Indapamide tab 2.5 mg QD Hydrochlorothiazide (HCTZ) tab 25 mg QD N/A

Indapamide tab 5 mg QD Hydrochlorothiazide (HCTZ) tab 50 mg QD N/A





Inderal LA (Propranolol) capsule Atenolol 25, 50mg, 100mg tablets QD or metoprolol 50mg,100mg tablets QD-BID -or- Propranolol (10, 20, 40, 60, 80, 90mg tabs) 40-320mg divided BID-TID or Nadolol 20, 40, 80, 120, 160mg tablets QD HTN: may effectively use Atenolol, Metoprolol, Nadolol or Propranolol regular release. For Migraine Prophylaxis: Propranolol regular release BID - TID, Nadolol, Metoprolol or Atenolol. For Tremor Prophylaxis: Propranolol regular release BID-TID, Metoprolol or Nadolol.

Migraine or Tremor Prophylaxis: Propranolol tabs 80-320mg divided BID - TID -OR- Metoprolol (less than 80mg, Propranolol converts to 50mg Metoprolol; 80-120mg of Propranolol converts to 100mg Metoprolol; 120-160mg Propranolol converts to 150mg Metoprolol; >160mg Propranolol converts to 200mg Metoprolol divide dose BID) -OR- Nadolol 80mg-240mg QD (2mg Propranolol roughly equivalent to 1mg Nadolol); Atenolol is an option for migraine, not tremor (less than 160mg Propranolol converts to Atenolol 50mg QD, more than 160mg Propranolol converts to Atenolol 100mg QD (beta blocker dosages are titrated to patient's lowest effective dose)

Infergen (interferon alpha con) Peg-Intron (Pegylated Interferon alpha 2 b injection) vials OR Redipen OR Pegasys (Pegylated Interferon alpha 2 a injection) vials or prefilled syringe

Per Hepatitis C clinic, Infergen generally reserved for patients who have failed to maintain clearance of viral load with Peg-Intron or Pegasys. If no response to Infergen in 12 weeks, consider d/c Infergen.

Innohep (Tinzaparin) injection Lovenox (Enoxaparin) injections Limit of 10 syringes Lovenox, 5 day supply, for initial fill

Inspirease spacer device EZ spacer or aerochamber spacer devices N/A

Inspra (Eplerenone) 25-100mg QD If using for CHF and desire aldosterone antagonism formulary alternative is: Spironolactone 25mg tablets

Use 25mg Spironolactone tablets to obtain 50mg or 100mg dose. If prescribing to treat HTN: consider HCTZ 25mg QD or another first line antihypertensive medication ie. Metoprolol, Atenolol, Lisinopril.

Intrinsa (Testosterone) Transdermal Estratest or Estratest HS oral Medications used expressly for the treatment of sexual dysfunction are excluded from the drug benefit. Patients without a sexual dysfunction benefit may choose to purchase Intrinsa at the full retail price. Intrinsa is marketed to modestly improve sexual desire in women with hypoactive sexual desire following surgically-induced menopause on concurrent estrogen therapy.

Iressa (Gefitinib) Platinum containing combination chemotherapy with paclitaxel or Docetaxel chemotherapy

Iressa Survival Evaluation in Lung Cancer (ISEL) trial compared Iressa with best supportive care in the treatment of Non small cell lung cancer patients who had received one to two prior chemotherapy regimens. Iressa treatment was not associated with a significant survival improvement.

Isoptin (Verapamil) SR tabs 120, 180, 240mg QD Verapamil SR tabs (generic Calan SR) 120, 180, 240 mg tabs 120-240mg QD

Substitute on a mg for mg basis. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine Calcium channel Blocker to Beta Blocker, ACE-Inhibitor and Thiazide Diuretics

Januvia (sitagliptin) 25mg, 50mg and 100mg oral Metformin regular release 500mg, 850mg or TSPMG guidelines suggest: tablets 1000mg tablets twice daily dosing -or- Second line - metformin plus sulfonylurea

extended release 500mg-750mg tabs up to Third line - Actos 15-45mg QD 4 tablets, once daily dosing Januvia provided no significant advantages over

metformin or SFUs to obtain glucose goals.





Jenest-28 (0.5mg Norethindrone/ 35mcg Ethinyl Estradiol x 10 days, 1mg NE/ 35mcg EE x 11 days)

Tri-Levlen (EE 30/40/30 / Levonorgestrel 0.05/.075/.125)

Other alternatives: Norinyl 1/35 (EE35/Norethindrone 1mg) OR Microgestin FE (EE 20mcgl/ Norethindrone 1mg) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Junel 1/20 (1mg Norethindrone / 20 mcg) Microgestin FE (1mg Norethindrone/ 20 mcg EE x 21 days then 75mg Ferrous Fumarate x 7 days


Kariva (20 mcg Ethinyl Estradiol / 0.15mg Desogestrel)

Levlen (0.15mg Levonorgestrel / 30mcg EE) or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 days, 0.075mg Lvngl/40mcg EE x 5 days, 0.125mg Lvngl/ 30mcg EE x 10 days) or Microgestin FE 1/20 (1mg Norethindrone / 20mcg EE)

A Desogestrel containing product substitution is not available on formulary. or may consider Brevicon (0.5mg Norethindrone/ 35 EE) or Zovia 1/35 (Ethynodiol Diacetate 1mg/ 35mcg EE) or Norinyl 1/35 (Norethindrone 1mg/ 35mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

K-Dur (Potassium Chloride) tab K-Tab (10meq/tab) K-Tab tablets cannot be split, prescribe in appropriate dosage. Potassium is slowly released from a wax matrix as it passes thru the GI tract. The expended inert, porous, wax/polymer matrix is not absorbed and may be excreted intact in the stool.

Kerlone (Betaxolol) 10, 20mg tabs 10-20mg qd Atenolol (gen Tenormin) 25-100mg QD or Metoprolol 100 - 400mg QD or Propranolol 40 - 320mg BID

Propranolol is available as 10, 20, 40, 60, 80, 90mg tabs. Inderal LA is non-formulary. Atenolol max dose is 200mg QD; Metoprolol maximum dose is 450mg daily in divided doses; Propranolol maximum dose is 480mg per day in divided doses

Ketek (Telithromycin) 800mg QD Biaxin 500mg BID or Avelox (Moxifloxacin) 400 mg QD or Augmentin 875 mg BID or Cefuroxime (gen Ceftin) 250mg BID

.

Ketoprofen (generic Orudis) 100-300mg daily (divided TID-QID)

Ibuprofen (generic Motrin) tabs 600-800 mg TID or Salsalate (Disalcid)1500mg BID or Naproxen 500mg BID or Sulindac (Clinoril) 200mg BID

Additional formulary alternatives: Diclofenac (Voltaren) 75mg BID or Choline Magnesium Trisalicylate (Trilisate) 750mg BID-TID or Nambumetone (Relafen) 500mg or 750mg #1-2 QD-BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.

Ketorolac (generic Toradol) tab 10 mg Q4-6H PRN Ibuprofen 800 mg TID PRN or Naproxen 250-500 mg Q6-8H or sulindac (Clinoril) 200mg BID or diclofenac (Voltaren) 75mg BID or Relafen 500mg or 750mg 1 -2 QD -BID or etodolac (Lodine) 200-500mg Q8-12H up to 1200mg/day or Mobic (Meloxicam) 7.5mg or 15mg

Due to the risk of renal failure and GI bleeding, ketorolac tablets should not be administered more than 5 days. Ketorolac tablets are FDA approved for use after Ketorolac injection only.

Kineret (Anakinra) IL-1 blocker Enbrel 25 mg SQ twice weekly (TNF blocker)

Klaron Lotion (Sulfacetamide only) Sulfacetamide/sulfur lotion N/A K-Lor or K-Lyte (Potassium Chloride) 25 meq packets Potassium Chloride 20meq packet Prescribe according to meq per packet

Kytril (granisitron) 1mg BID Zofran (ondansetron) 100mg QD Lac-Hydrin cream 12% Ammonium Lactate lotion OTC May be substituted without calling provider. Lacriserts (Hydroxypropyl Methylcellulose) Hydroxypropyl Methylcellulose is available

in various OTC products (Clear Eyes, Alcon ophthalmic solution)

OTC products are available





Lamisil (Terbinafine) 250mg tab Fungal nail infection is considered cosmetic treatment and is not covered Unless : fungal culture positive and i) If a finger nail, limited to one 6 week treatment course, ii) If a toe nail, only covered if the patient has diabetes or vascular disease, then restricted to one 12 wk course.

Lantus (Insulin Glargine) vials dosed QHS Novolin NPH (Humulin Ultralente will soon be discontinued by manufacturer)

Restricted to Pediatric Endocrinology and Endocrinology. Must call practitioner for conversion. Lantus must not be mixed or diluted with any other insulin or solution. Insulin pens are non-formulary. Lantus Insulin pens are not generally covered for pediatrics, as once daily administration may be administered under the primary caregiver's care. Insulin pens may be available thru the NF Rx process when the physician documents the member is unable to accurately draw up insulin due to young age, visual impairment, Parkinson's Disease, rheumatoid arthritis or upper extremity amputation; or, when administering doses less than 5 units; or, when pediatric patient's school or day care requires use of insulin cartridge device for insulin administration while outside of their primary caretaker's care.

Lescol (Fluvastatin) 20 mg QHS Lovastatin 10mg QHS or Simvastatin 20 mg QHS

Simvastatin 20mg dose would be expected to provide significantly more LDL lowering than lescol 20mg dose. Consider maximizing dose of Lovastatin to 80mg QPM or Simvastatin to 80 mg QHS before determining that the formulary alternatives are ineffective. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Lescol (Fluvastatin) 40 mg QHS Lovastatin 20 mg QHS or Simvastatin 20 mg QHS

Simvastatin 20mg dose would be expected to provide significantly more LDL lowering than lescol 40mg dose. Consider maximizing dose of Lovastatin to 80mg QPM or Simvastatin to 80 mg QHS before determining that the formulary alternatives are ineffective. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Lescol (Fluvastatin) 80 mg QHS Lovastatin 40 mg QHS or Simvastatin 20 mg QHS

Consider maximizing dose of Lovastatin to 80mg QPM or Simvastatin to 80mg QHS before determining that the formulary alternatives are ineffective. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM

Lescol XL (Fluvastatin) 80mg QHS Lovastatin 40 mg QHS or Simvastatin 20mg

Consider Maximizing dose of Lovastatin to 80mg QPM and Simvastatin to 80mg QHS before determining that the formulary alternatives are ineffective. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM





Lessina ((0.1mg Levonorgestrel/20mcg Ethinyl Estradiol)


or may consider Microgestin FE 1/20 (1mg Norethindrone/ 20mcg ee) or Brevicon (0.5mg Norethindrone/ 35 EE) or Zovia 1/35 (Ethynodiol Diacetate 1mg/ 35mcg EE) or Norinyl 1/35 (Norethindrone 1mg/ 35mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Letaris (ambrisentan) 5mg, 10mg tablets

Remodulin (Trepostinil), Flolan (epoprostenol) and Tracleer (Bosentan)

Flolan requires administration in the medical clinic under the drug benefit.

Leukine (Sargramostim) injection N/A No refills, pt must present a new rx for each fill

Levaquin 500 mg QD for sinusitis Avelox (Moxifloxacin) 400 mg QD See TSPMG Practice Resource for recommendations

Levaquin tab 250 mg QD for UTI Cipro 250 - 500 mg BID Do not use Avelox for UTI Levaquin (levofloxacin) tab 500 mg QD for bronchitis or community acquired pneumonia

Avelox (moxifloxacin) 400 mg QD or generic Augmentin 875 mg BID or Biaxin 500 mg BID

.

Levatol (Pensutolol) 20mg tabs 20 - 40mg QD Atenolol (gen Tenormin) 25 - 100mg QD or Metoprolol 100 - 400mg QD or Propranolol 40 - 320mg bid

Propranolol is available as 10, 20, 40, 60, 80, 90mg tabs. Inderal LA is Non-formulary. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Levbid tab 0.375 mg BID Hyoscyamine (Levsin) 0.125 mg tab TID-QID

N/A

Levemir (detemir) long-acting insulin; administered once or twice daily

Novolin NPH Must call practitioner for conversion. Changing the basal insulin to Levemir can be done on a unit-to-unit basis, then adjusted to meet glycemic targets. Levemir must not be mixed or diluted with any other insulin or solution. Levemir is not to be used in infusion pumps. Insulin pens are non-formulary.

Levitra (Vardenafil) 2.5mg, 5mg, 10mg, 20mg none Levitra is not covered for sexual dysfunction unless member's group has purchased sexual dysfunction rider for additional coverage. Consider Levitra 20mg 1/2 tablet when prescribing Levitra 10mg dose to reduce patient expense.

Levlite (0.1mg Levonorgestrel/20mcg Ethinyl Estradiol) [generic now manufactured: Lessina; Alesse; Aviane]


or may consider Microgestin FE 1/20 (1mg Norethindrone/ 20mcg ee) or Brevicon (0.5mg Norethindrone/ 35 EE) or Zovia 1/35 (Ethynodiol Diacetate 1mg/ 35mcg EE) or Norinyl 1/35 (Norethindrone 1mg/ 35mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Levora ((0.15 Levonorgestrel/30mcg EE) Levlen (0.15 Levonorgestrel/30mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.





Lexapro (Escitalopram) 5mg, 10mg, 20mg Prozac (Fluoxetine) caps 10-40 mg QD or Celexa (Citalopram) 20 - 40mg or Sertraline 25-100mg QD, conversion dosing to be determined by physician

Lexapro (Escitalopram) is the S-isomer of Celexa (Citalopram). Consider a trial on Citalopram 20-40mg prior to Lexapro 10-20mg. Citalopram 20mg dosing equivalent is Lexapro 10mg.Consider Citalopram 40mg 1/2 tablet for Citalopram 20mg dose. Document response to all formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.

Lexxel (Enalapril/Felodipine) 5/2.5mg, 5/5mg Prinivil (Lisinopril) 5mg QD AND Felodipine Combination product is non formulary. Felodipine extended release tabs ER 2.5mg or 5mg 2.5mg is equivalent to generic Nifedipine XL 30mg

or Diltia XT 120mg; felodipine ER 5mg = generic Nifedipine XL 30 to 60mg or Diltia XT 240mg.

Liadla (Meslamine) 1.2 g delayed-release tablets Asacol (Mesalamine released primarily in colon) 400mg #2 TID for 6 wks OR Pentasa 250mg #4 QID or 500mg #2 QID for 8 wks OR Dipentum 250mg #4 BID OR Azulfidine (Sulfasalazine) 500mg #2 TID-QID

Lidoderm 5% (Lidocaine) Patch Lidocaine topical gel (per chronic pain guideline) or OTC L-M-X4 (4% topical lidocaine cream) or OTC Lidosense 4 (4% topical lidocaine cream) or OTC Axsain cream (4% lidocaine combined with 0.25% capsaicin cream)

Capsaicin cream is another OTC alternative for post herpetic neuralgia.

Limbrel (flavocoxid) capsules **this is a prescription If physician would like to consider an Limbrel is a food supplement marketed for an anti-food supplement, not an FDA approved drug. The alternative anti-inflammatory agent, inflammatory effect. Though a prescription is product consists of Flavonoids and flavans from consider these formulary required, this food supplement is not covered by phytochemical food source materials which may alternatives:Relafen (Nambumetone) the KP drug benefit. The patient may choose to posses anti-inflammatory and analgesic properties. 500mg or 750mg 1 - 2 QD-BID or Etodolac

(gen. Lodine) 200-500mg Q8-12H up to 1200mg/day or Ibuprofen (gen. Motrin) tabs 600-800 mg TID or Naproxen (gen. Naprosyn) 500mg BID or Sulindac (gen. Clinoril) 200mg BID or Diclofenac (gen. Voltaren) 75mg BID or Mobic (Meloxicam) 7.5mg or 15mg

purchase this food supplement at the full prescription price .

Lipitor tab 10 mg QD Lovastatin 40mg QPM w/ meal OR Simvastatin 20mg po QPM

If pt needs Lipitor, use half tabs. Consider maximizing dose of Lovastatin to 80mg and Simvastatin to 80mg before determining that the formulary alternatives are ineffective. See box below for drug interactions. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Lipitor tab 20 mg QD Lovastatin 80 mg QPM w/ meal or Simvastatin 40 mg QPM

Doses of lovastatin > 40mg QD and simvastatin > 20mg QD are not recommended in combination with Diltiazem, Verapamil, Amiodarone, or a protease inhibitor. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD not recommended with cyclosporine. Continue Lipitor to minimize drug interaction and chance for muscle aches. If Lipitor is continued, use half tablets. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.





Lipitor tab 40 mg QD Simvastatin 80 mg QPM Doses of lovastatin > 40mg QD and simvastatin > 20mg QD are not recommended in combination with Diltiazem, Verapamil, Amiodarone, or a protease inhibitor. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD not recommended with cyclosporine. Continue Lipitor to minimize drug interaction and chance for muscle aches. If Lipitor is continued, use half tablets. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Lipitor tab 80 mg QD Consider simvastatin 80mg QD plus Slo-Niacin/ time release niacin or BAS first if appropriate. Otherwise, Vytorin 10/80 mg QHS can be considered.

Doses of lovastatin > 40mg QD and simvastatin > 20mg QD are not recommended in combination with Diltiazem, Verapamil, Amiodarone, or a protease inhibitor. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD not recommended with cyclosporine. Continue Lipitor to minimize drug interaction and chance for muscle aches. If Lipitor is continued, use half tablets. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Livostin (Levocabastine) .05% i drop QID up to 2 weeks (antihistamine eye drop)


OTC Zaditor 0.25% and Patanol are both dual action antihistamine/mast cell stabilizers, are dosed twice daily, and have the same FDA approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product : Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

Locoid (Hydrocortisone Butyrate) 0.1% topical oint, soln [medium potency]

Triamcinolone (generic Aristocort or Kenalog) cream, oint 0.1% OR Valisone (Betamethasone Valerate) 0.1% lotion (if lotion needed)


Locoid Lipocream (hydrocortisone) 0.1% Kenalog (Triamcinolone) 0.1% cream, oint -or- Lidex (Fluocinonide) 0.025-0.05% cream, oint

Locoid lipocream is restricted to Dermatology.

Lodine XR tabs 400-600 mg QD Etodolac ( gen. Lodine) 200-500mg Q8-12H Salsalate (Disalcid)1500mg BID or choline up to 1200mg/day or Relafen magnesium trisalicylate (Trilisate) 750mg BID-TID (Nambumetone) 500mg or 750mg tablet #2 or nambumetone (Relafen) 500mg or 750mg #1-QD-BID or Ibuprofen (gen. Motrin) tabs 600- 2 QD-BID 800 mg TID or Naproxen (gen. Naprosyn) 500mg BID or Sulindac (gen. Clinoril) 200mg BID Diclofenac (gen. Voltaren) 75mg BID or Mobic (Meloxicam) 7.5mg or 15mg

Loestrin 21 (1mg Norethindrone/ 20 mcg EE) Microgestin FE (1mg Norethindrone/ 20 Final 7 days of Loestrin FE pack are iron rather mcg EE x 21 days then 75mg Ferrous than placebo tablets. (NF Giselle are equivalent Fumarate x 7 days to microgestin 1/20, with 7 placebo rather than

iron tabs) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Loestrin 24 Fe Levlen, microgestin fe 1/20 and 1.5/30, zovia 1/35, norinyl 1+35, brevicon, Norinyl 1+50, trilevlen, trinorinyl, depo-provera injection

All-flex diaphragms or paragard T380 and Mirena (levonorgestrel) IUDs also formulary contraceptive options Document at least 3 formulary alternatives before prescribing/approving a NF product.





Loniten (Minoxidil) tablet 10-40 mg QD Minoxidil 10-40mg QD is on the formulary Minoxidil is not covered for the treatment of male pattern baldness.

Lo/Ovral-28 (0.3 Norgestrel / 30mcg EE) tablet i QD [generic Lo/Ovral is also manufactured, Low-Ogestrel, Cryselle]


May consider Tri-Norinyl (.5/1/.5 Norethindrone/ 35 EE) or Microgestin FE (1 mg Norethindrone/ 20 EE) or Zovia 1/35 (1mg Ethynodiol Diacetate/ 35 EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Loprox (Ciclopirox) lotion Lamisil AT Cream OTC Loprox non formulary. Lorabid (Loracarbef) suspension Omnicef 125mg/5ml; pediazole

(Erythromycin & Sulfamethoxazole); Augmentin 125-250mg/5ml or 200-400mg chew tabs;Amoxicillin 125-250mg/5ml; Biaxin 125-250mg/5ml; cefaclor suspension

.

Lortab elixir Generic Tylenol #3 elixir (Codeine 12mg/acetaminophen120mg per 5ml) or (Hydrocodone/acetaminophen (generic Lortab) tabs, caps

N/A

Lotemax (Loteprednol) 0.5% ophth soln i-ii drops QID Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

[Loteprednol 0.5% (Lotemax) less effective than Prednisolone Acetate 1% in treatment of acute anterior uveitis]

Lotensin (Benazepril) 5-80 mg QD (generic also marketed)

Prinivil (Lisinopril) tab 5-80 mg QD Substitute on a mg for mg basis. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-Inhibitor and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Lotrel (Amlodipine/Benazepril) 2.5/10, 5/10, 5/20mg, 10/20mg tabs

Nifedipine XL 30mg or 60mg OR Diltia XT 120mg - 480mg QD OR Felodipine ER 2.5mg-10mg OR Amlodipine 2.5mg-10mg AND Prinivil (Lisinopril) 10 or 20mg QD

Amlodipine 2.5, 5 & 10mg are equivalent to Nifedipine XL 30, 30 &60mg, respectively OR Diltia XT 120, 240 & 360mg respectively OR Felodipine ER 2.5, 5 & 10mg respectively; Benazepril 10 -20mg is equivalent to Lisinopril 10 -20 mg. Convert to either Amlodipine & Lisinopril, Nifedipine XL & Lisinopril or Diltia XT & Lisinopril or Felodipine ER & Lisinopril.

Lotrisone (Clotrimazole/Betamethasone) cream apply to affected area BID

OTC Lotrimin (Clotrimazole) cream plus Rx Desonide 0.05% cream apply both creams to affected area BID

Lotrisone/Desonide combination pack only available at KP facility pharmacies for a single copay. At Eckerd pharmacy, patient will pay one copay for Desonide and will purchase OTC Lotrimin (Clotrimazole) cream at full OTC price.

Lotronex (Alosetron) Generic Levsin 0.125mg Last line agent for women with severe diarrhea prominent Irritable bowel syndrome. Lotronex not available at all pharmacies due to restricted prescribing process. [Alosetron: Available Part D group]

Lovenox Lovenox is formulary Lovenox initial dispensing limit of 10 syringes, 5 day supply. Larger quantities will need approval from Pharmacy call 404-365-4234





Low-Ogestrel (0.3 Norgestrel / 30mcg EE) tablet i QD Levlen (0.15mg Levonorgestrel / 30mcg EE) or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 days, 0.075mg Lvngl/40mcg EE x 5 days, 0.125mg Lvngl/ 30mcg EE x 10 days)

May consider Tri-Norinyl (.5/1/.5 Norethindrone/ 35 EE) or Microgestin FE (1 mg Norethindrone/ 20 EE) or Zovia 1/35 (1mg Ethynodiol Diacetate/ 35 EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Lozol (Indapamide) tab 1.25 mg QD Hydrochlorothiazide (HCTZ) tab 12.5 mg QD

N/A

Lozol (Indapamide) tab 2.5 mg QD Hydrochlorothiazide (HCTZ) tab 25 mg QD N/A

Lozol (Indapamide) tab 5 mg QD Hydrochlorothiazide (HCTZ) tab 50 mg QD N/A

Lunesta (Eszopiclone) 1mg, 2mg or 3mg tablets Temazepam (generic Restoril) 15-30 mg capsule at HS or Oxazepam (gen Serax) 10-30mg or Lorazepam 0.5mg QHS or Hydroxyzine (generic Atarax) 10-25 mg at HS, Trazodone 50-100mg QHS, or Zolpidem (gen Ambien) 5-10mg

Consider lower doses in geriatric patients. Consider OTC Melatonin to reduce benzodiazepine usage Caution: do not abruptly discontinue benzodiazepines after long-term use. Caution: do not abruptly discontinue benzodiazepines after long-term use. Document failed trial on at least 1 Benzodiazepine, Trazodone, and Zolpidem before prescribing NF product.

Lupron 1 mg/0.2 mg 2-wk kit Lupron or Eligard to be supplied by the prescribing physician and administered in MD office under the patient's medical benefit.

TSPMG physicians provide injectables administered in medical office through floor stock. If network physicians cannot obtain Lupron, please complete KP NF Rx form requesting benefit coverage at the time of Lupron dispensing.

Lupron depot 3.75 mg kit Lupron or Eligard to be supplied by the prescribing physician and administered in MD office under the patient's medical benefit.

TSPMG physicians provide injectables administered in medical office through floor stock. If network physicians cannot obtain Lupron, please complete KP NF Rx form requesting benefit coverage at the time of Lupron dispensing.

Lustra (Hydroquinone) cream 4% No formulary alternative Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.

Luvox tab 25-100 mg QD or 100-150 mg BID Consult Psychiatrist to determine appropriateness of conversion to Prozac.

When conversion appropriate, Prozac is the preferred agent. Initiation of low-dose Prozac 20 mg QD with dosage titration to desired response is suggested.

Luxiq (Betamethasone Valerate) foam for scalp Synalar (Fluocinolone) 0.01% soln, oil or Temovate (Clobetasol) .0.05% scalp soln (Restricted to Derm)

Luxiq is medium potency, Synalar 0.01% is a low potency topical corticosteroid product,

Lyrica (pregabalin) capsules ** Gabapentin 100mg, 300mg and 400mg capsules

If treating neuropathic pain: Nortriptyline is considered first-line agent (if <65 yrs old: 25mg QHS, increase dose 25mg/day at 3-7 day intervals prn. If > 65 years old: 10mg QHS, increase dose 10mg/day at 3-7 day intervals prn).**For discontinuation, Lyrica should be tapered gradually over a minimum 1 week period rather than abruptly discontinued per manufacturer





Mavik (Trandolapril) 1, 2, 4mg tabs 1-4mg QD Prinivil (Lisinopril) 5 - 40mg QD Prinivil is preferred ACE inhibitor. Conversion equivalents: Mavik 1mg=Prinivil 5-10mg; Mavik 2mg=Prinivil 10-20mg; Mavik 4mg=Prinivil 20-40mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Maxair (Pirbuterol) 0.2 mg oral inhaler ii puffs Q4H prn Ventolin oral inhaler ii puffs Q4H prn Substitute on a puff for puff basis.

Maxalt (Rizatriptan) Maxalt (Rizatriptan) MLT 10mg tablet (Maxalt MLT 5mg tablet is also available)

Dose on a mg for mg basis. QTY limit of #9 tabs per co-pay. Patients on Propranolol require dose reduction of Maxalt or Maxalt MLT to 5 mg.

Maxiflor (Diflorasone) 0.05% cream, oint Lidex (Fluocinonide) 0.05% cream, oint, gel, soln or Diprolene AF (Augmented Betamethasone) 0.05%


Maxivate (Betamethasone Dipropionate) 0.05% cream, oint



Maxivate (Betamethasone Dipropionate) 0.05% lotion [medium potency]

Valisone (Betamethasone Valerate) 0.1% lotion or Triamcinolone (generic Aristocort, Kenalog) cream, oint 0.1%


Maxzide (Triamterene/HCTZ) 75/50 tablet Triamterene/hydrochlorothiazide 75/50 mg (generic Maxzide) tabs

May be substituted mg for mg without calling practitioner. Brand name is non-formulary

Mazanor (mazindol) n/a Weight loss agents not covered.

Medrol 2, 8, 16, 24 & 32 mg tabs Methylprednisolone 4 mg (generic Medrol) tab

Methylprednisolone 4 mg tablet may be substituted to obtain appropriate dose without calling provider.

Melanex (Hydroquinone) soln 3% N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.

Mentax (Butenafine) 1% cream OTC Lotrimin Ultra (Butenafine) 1% cream Mentax not covered since also available as Lotrimin Ultra available over-the-counter

Meridia caps 10-15 mg QD N/A Agents for obesity or weight loss not covered. Patient pays full retail price.

Metadate CD 20mg (Methylphenidate) Concerta 18,27,36,54mg, or Methylin ER 10mg, Methylphenidate 5, 10, 20mg and SR 20mg; or generic Dexedrine spansules (Dextroamphetamine) 5, 10, 15mg or Adderall regular release 5, 10, 20, 30mg tablets or Adderall XR 5,10,20,25,30mg capsules. Controlled substances level 2 requiring prescription written by prescriber. Methylphenidate is the preferred formulary alternative.

Adderall XR is restricted to pediatrics, child neurology and behavioral health. Titrate to appropriate dosage using adderall regular release tablets before transitioning to once daily Adderall XR. Document failed trial on Methylphenidate, Dextroamphetamine and Adderall IR products before a Non-formulary Product is considered.





Metadate ER 10mg or 20mg (Methylphenidate) Methylin ER 10mg (methylphenidate), Concerta, Methylphenidate 5, 10, 20mg and SR 20mg; or generic Dexedrine spansules (Dextroamphetamine) 5, 10, 15mg or Adderall regular release 5, 10, 20, 30mg tablets or Adderall XR 5,10,20,25,30mg capsules. Controlled substances level 2 requiring prescription written by prescriber. Methylphenidate is the preferred formulary alternative.

Adderall XR is restricted to pediatrics, child neurology and behavioral health. Titrate to appropriate dosage using adderall regular release tablets before transitioning to once daily Adderall XR. Document failed trial on Methylphenidate, Dextroamphetamine and Adderall IR products before a Non-formulary Product is considered. Methylphenidate is the preferred formulary alternative.

Metimyd (10% Sulfacetamide/ 0.5% Prednisolone) ophth oint or soln

Blephamide (10% Sulfacetamide/ 0.2 % Prednisolone) ophth oint or soln

.

Metrogel vaginal gel 0.75% i applicatorful vaginally BID x 5 days


Vaginal gel not covered, oral tablets offer greater efficacy. Metrogel vaginal gel is only manufactured as 45 gram package.

Metrogel 1% Metrogel 0.75% Availabe at internal KP pharmacies only Micardis (Telmisartan) 40-80 mg tab QD Prinivil (Lisinopril) 10-20 mg QD or Cozaar

(Losartan) 25-50 mg tab QD Prinivil is preferred, if no previous ACE inhibitor trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion: Micardis 40mg=Prinivil 10-20mg=Cozaar 25mg; Micardis 80mg=Prinivil 20-40mg=Cozaar 50mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Micardis HCT (Telmisartan/HCTZ) 40/12.5mg- Prinivil (lisinopril) 10-20 mg QD or Cozaar Prinivil is preferred, if no previous ACE inhibitor 80/12.5mg tab QD (losartan) 25-50 mg tab QD AND HCTZ trial. If angiotensin 2 receptor blocker is required,

12.5mg QD convert to Cozaar. Conversion: Micardis 40mg=Prinivil 10-20mg=Cozaar 25mg AND a prescription for HCTZ 12.5mg QD; Micardis 80mg=Prinivil 20-40mg=Cozaar 50mg AND a prescription for HCTZ 12.5mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-Inhibitor and Thiazide Diuretics

Microgestin (1mg Norethindrone/ 20 mcg) Microgestin FE (1mg Norethindrone/ 20 mcg EE x 21 days then 75mg Ferrous Fumarate x 7 days


Micronor (Norethindrone) 0.35mg {other generic names: Camila, Nora-Be, Errin, Jolivette}

NorQD (norethindrone) 0.35mg May substitute without contacting practitioner

Miralax (polyethylene glycol 3350) . Miralax is now available OTC. OTC products are not a covered benefit.





Mircette (20 mcg Ethinyl Estradiol / 0.15mg Desogestrel) [generic Mircette is now manufactured: Kariva]

Levlen (0.15mg Levonorgestrel / 30mcg EE) or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 days, 0.075mg Lvngl/40mcg EE x 5 days, 0.125mg Lvngl/ 30mcg EE x 10 days) or Microgestin FE 1/20 (1mg Norethindrone / 20mcg EE)

A Desogestrel containing product substitution is not available on formulary. or may consider Brevicon (0.5mg Norethindrone/ 35 EE) or Zovia 1/35 (Ethynodiol Diacetate 1mg/ 35mcg EE) or Norinyl 1/35 (Norethindrone 1mg/ 35mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Modicon (0.5mg Norethindrone / 35 mcg EE) generic Brevicon (0.5mg Norethindrone / 35 mcg EE)

May substitute without contacting practitioner

Mononessa (0.25mg Norgestimate/ 35mcg EE) Sprintec (0.25mg Norgestimate/ 35 mcg EE)


Monopril (Fosinopril) tab 10-80 mg QD Prinivil (Lisinopril) tab 10-80 mg QD Substitute on a mg for mg basis. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

MS Contin (Morphine CR) Generic of MS Contin covered (Morphine controlled release) 15mg, 30mg, 60mg, 100mg, 200mg Morphine immediate release tablet 10mg, 30mg, roxanol (Morphine solution 10mg/5ml, 20mg/5ml, 100mg/5ml)

Generic Percocet or Percodan (Oxycodone 5mg/325mg APAP or ASA, respectively), Tylox (Oxycodone 5mg/500mg APAP), generic Demerol 50mg, 100mg, Fentanyl patches 25mcg, 50mcg, 75mcg, 100mcg/hr

Mupirocin 2% Cream Mupirocin 2% Ointment . MUSE supps N/A Muse is not covered for sexual dysfunction unless

member's group has purchased sexual dysfunction rider for additional coverage.

Mysoline tablets Primidone tabs (generic Mysoline) May be substituted on a mg for mg basis without calling practitioner. Brands are non-formulary

Naftin (Naftifine) 1% cream or gel OTC Lamisil AT or Clotrimazole containing OTC products: Lotrimin AF or OTC Mycelex or OTC Micatin cream

Clotrimazole or Terbinafine (Lamisil) for tinea pedis, tinea corporis, tinea circinata (ringworm of body), tinea cruris, tinea inguinalis (jock itch), tinea versicolor; Clotrimazole for intertrigo (rash in body folds or beneath breasts) or candidiasis (including rash on penis or corners of mouth) [OTC alternatives are not recommended for tinea capitis (ringworm of scalp), tinea faceii or barbae (ringworm of the beard…barber's itch or fungal nails]

Nalfon (Fenoprofen) 300-600 mg TID - QID Ibuprofen (generic Motrin) tabs 600-800 mg TID or Salsalate (Disalcid)1500mg BID or Naproxen 500mg BID or Sulindac (Clinoril) 200mg BID

Additional formulary alternatives: Diclofenac (Voltaren) 75mg BID or Choline Magnesium Trisalicylate (Trilisate) 750mg BID-TID or Nambumetone (Relafen) 500mg or 750mg 1-2 QD-BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.

Nasacort or Nasacort AQ or Nasacort HFA (Triamcinolone) 25mcg/spray nasal inhaler ii sprays each nostril BID


Please document failure of both Nasarel & generic Flonase (fluticasone) before prescribing/approving a NF product.





Nasalide (Flunisolide) 25mcg/spray nasal spray ii sprays in each nostril BID-TID



Nascobal (Cyanocobalamin) nasal spray OTC B12 (cyanocobalamin) 1mg tablet orally QD

See TSPMG Adult Practice Resource for Anemia.

Nasonex (mometasone) nasal spray ii sprays each nostril QD



Necon 0.5/35 (0.5mg Norethindrone/ 35 mcg EE) Brevicon (0.5mg Norethindrone/ 35mcgEE) Another alternative: generic Demulen (1mg Ethynodiol Diacetate / 35mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Necon 1/35 (1mg Norethindrone/ 35 mcg EE) Norinyl 1/35 (1mg Norethindrone/ 35mcg EE)

N/A

Necon 1/50 (1mg Norethindrone/ 50 mcg EE) Norinyl 1+50 (1mg NE/mestranol 0.5mg) or Zovia (generic Demulen) 1/50 (1mg Ethynodiol Diacetate / 50mcg EE) i QD


Necon 10/11 (0.5mg Norethindrone/ 35mcg Ethinyl Estradiol x 10 days, 1mg NE / 35mcg EE x 11 days)

Brevicon (0.5mg NE/35mcg EE) or Norinyl 1/35 (1mg NE/35mcg EE) or Tri-Norinyl (0.5mg NE x 7days, 1mg NE x 7 days, 0.5mg NE x 7 days /35mcg EE)


Nelova 0.5/35 (0.5mg Norethindrone / 35 mcg EE) Brevicon (0.5mg Norethindrone/ 35mcgEE) or generic Demulen (1mg Ethynodiol Diacetate / 35mcg EE)

N/A

Nelova 1/35 (1mg Norethindrone / 35 mcg EE) Norinyl 1/35 (1mg Norethindrone/ 35mcg EE)

N/A

Nelova 1/50M (1mg Norethindrone/ 50 mcg EE) Norinyl 1+50 (1mg NE/Mestranol 0.5mg) or Zovia (generic Demulen) 1/50 (1mg Ethynodiol Diacetate / 50mcg EE) i QD


Nelova 10/11 (0.5mg Norethindrone/ 35mcg Ethinyl Estradiol x 10 days, 1mg NE/ 35mcg EE x 11 days)

Brevicon (0.5mg NE/35mcg EE) or Norinyl 1/35 (1mg NE/35mcg EE) or Tri-Norinyl (0.5mg NE x 7days, 1mg NE x 7 days, 0.5mg NE x 7 days /35mcg EE)


Neo-Synalar (Neomycin/Fluocinolone) 0.025% cream Triamcinolone (generic Aristocort, Kenalog) cream, oint 0.1%

If failed other alternatives, consider increasing steroid potency to fluocinonide (Lidex) 0.05% cream, oint, or gel. Pt may also use OTC neomycin, in addition to Rx topical steroid, if needed.

Nephrocaps (Vitamin C 100mg, folate 1mg, niacin B3 20mg, thiamin B1 1.5mg, riboflavin B2 1.7mg, Pantothenic Acid B5 5mg, Pyridoxine B6 10mg, Cyanocobalamin B12 6mcg, biotin 150mcg)

OTC Nephro-vite (Vitamin C 100mg, folate 0.8mg, niacin B3 20mg, thiamin B1 1.5mg, riboflavin B2 1.7mg, Pantothenic Acid B5 5mg, Pyridoxine B6 10mg, Cyanocobalamin B12 6mcg, biotin 300mcg)

Nephro-vite OTC NDC # 54391-0002-01

Nephro-Vite RX (Vitamin C 60mg, folate 1mg, niacin B3 20mg, thiamin B1 1.5mg, riboflavin B2 1.7mg, Pantothenic Acid B5 10mg, Pyridoxine B6 10mg, Cyanocobalamin B12 6mcg, biotin 300mcg)

OTC Nephro-vite (Vitamin C 60mg, folate 0.8mg, niacin B3 20mg, thiamin B1 1.5mg, riboflavin B2 1.7mg, Pantothenic Acid B5 10mg, Pyridoxine B6 10mg, Cyanocobalamin B12 6mcg, biotin 300mcg)

Nephro-vite OTC NDC # 54391-0002-01





Neulasta (Pegfilgrastim) injection Neupogen (Filgrastim) injection Pegylated Filgrastim prolongs the Filgrastim half life, resulting in one Neulasta injection roughly comparable to 11 daily Neupogen injections. MD to address dosage conversion individually.

Neupogen (Filgrastim) injection N/A No refills. Requires a new Rx for each fill Neupro Patch (Rotigotine) 2mg, 4mg and 6mg patch Carbidopa/Levodopa

Entecapone (Comtan) Benztropine (Cogentin) Tolcapone (Tasmar)

Tolcapone (Tasmar) is on the formulary but all other therapies should be tried first due to risk of death or hepatic failure. The patient and the prescriber must complete informed consent forms provided by the manufacturer

Neutrogena Melanex N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.

Nexium (Esomeprazole) DR 20mg cap 20-40mg QD OTC Prilosec 20mg - 40mg QD Nexium is a NF No Initial Fill drug. If Prilosec 40mg QD failure, consider NF No Initial Fill drug, Protonix titrated up to 80mg QD. (Protonix 40mg=Nexium 20mg=Prilosec 20mg) Must document failure or intolerance to Prilosec 40mg QD if requesting PPI coverage.

Niaspan (Niacin extended release) 500mg, 750mg, 1000mg tablets

Contact Prescriber to request conversion to OTC niacin. (Do NOT recommend flush-free niacin)

Niaspan may be appropriate if OTC niacin ineffective or if pt intolerant. If patient not taking a statin, consider converting to Lovastatin or Simvastatin. For LDL lowering consider Slo-niacin or Time-release niacin: 500 mg QD titrated up by 500mg every 4 weeks up to desired dose. Maximum 2000mg daily dose. For HDL increase or to lower Lipoprotein a 'Lp(a)', consider niacin immediate release: initiate Niacin IR daily after dinner: titrate dose from 100mg QD x 1 week; 200mg QD x 1 week; then 300mg QD x 1 week; then 500mg QD, titrate up to lowest effective & tolerated dose. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Nicoderm (Nicotine) Transdermal system 7,14,21mg/day

OTC Nicotrol (Nicotine transdermal system) 5, 10, 15mg/day

Nicotine replacement products are non formulary.

Nicorette (Nicotine) gum OTC Nicotrol (Nicotine transdermal system) 5, 10, 15mg/day


Niferex-150 forte (150mg polysaccharide iron complex, 1mg folic acid, 25mcg B12) capsule i QD

OTC Niferex-150 plus OTC B12 100mcg and Folic acid 0.4mg or plus folic acid 1mg Rx

OTC products available: Niferex 150mg, B12 100mcg, Folic acid 0.4mg

Nitro-Dur (Nitroglycerin) transdermal 0.1,0.2,0.4, 0.6mg/hr patches

Minitran (Nitroglycerin) transdermal 0.1, 0.2, 0.4, 0.6mg/hr patches

Nitro-Dur 0.3 and 0.8mg/hr patches are covered, since Minitran is not available in these 2 strengths.





Nizoral (Ketoconazole) cream Lamisil AT cream available OTC. Nizoral tablets are covered. Clotrimazole or Terbinafine (Lamisil AT) for tinea pedis, tinea corporis, tinea circinata (ringworm of body), tinea cruris, tinea inguinalis (jock itch), tinea versicolor; Clotrimazole for intertrigo (rash in body folds or beneath breasts) or candidiasis (including rash on penis or corners of mouth) [OTC alternatives are not recommended for tinea capitis (ringworm of scalp), tinea faceii or barbae (ringworm of the beard…barber's itch or fungal nails]

Nizoral (Ketoconazole) shampoo 2% Nizoral A-D shampoo available OTC or Selenium sulfide 2.5% shampoo is formulary alternative

Nizoral A-D shampoo available OTC

Nordette (0.15 Levonorgestrel/30mcg EE) Levlen (0.15 Levonorgestrel/30mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Norflex (Orphenadrine Citrate) 100mg Flexeril (Cyclobenzaprine) 10mg tab or Robaxin (Methocarbamol) 750mg tab or Soma (Carisoprodol) 350mg or Parafon Forte DSC (Chlorzoxazone) 500mg

Use Cyclobenzaprine 10mg 1/2 tablet for Cyclobenzaprine 5mg.

Norgesic (25mg Orphenadrine Citrate/385mg Aspirin/30mg Caffeine)

Flexeril (Cyclobenzaprine) 10mg tab or Robaxin (Methocarbamol) 750mg tab or Soma (Carisoprodol) 350mg or Parafon Forte DSC (Chlorzoxazone) 500mg

Pt may also take OTC aspirin or ibuprofen, for analgesia. Use Cyclobenzaprine 10mg 1/2 tablet for Cyclobenzaprine 5mg.

Noritate (Metronidazole) 1% cream Metrocream 0.75% cream or Metrogel 0.75% gel

Noroxin tablet 400 mg BID Cipro tab 500 mg BID . Norplant system (discontinued by manufacturer) . . Novolin L U - 100 vial (Novolin Lente no longer manufactured)

Novolin N U-100 vial Both Novolin L and NPH are intermediate acting insulins.

Novolin N Penfill Novolin N U-100 vial Insulin pens are non-formulary. However, Insulin pens may be available thru the NF Rx process when the physician documents the member is unable to accurately draw up insulin due to young age, visual impairment, Parkinson's Disease, rheumatoid arthritis or upper extremity amputation; or, when administering doses less than 5 units; or, when pediatric patient's school or day care requires use of insulin cartridge device for insulin administration while outside of their primary caretaker's care.

Novolin R Penfill Novolin R U-100 vial Insulin pens are non-formulary. However, Insulin pens may be available thru the NF Rx process when the physician documents the member is unable to accurately draw up insulin due to young age, visual impairment, Parkinson's Disease, rheumatoid arthritis or upper extremity amputation; or, when administering doses less than 5 units; or, when pediatric patient's school or day care requires use of insulin cartridge device for insulin administration while outside of their primary caretaker's care.





NovoLog 70/30 (70% Insulin aspart protamine / 30% Insulin aspart) penfill

Novolin 70/30 administering the same units per dose as previous NovoLog 70/30 regimen (administer Novolin 70/30 30 minutes prior to a meal, administer NovoLog 15 minutes prior to a meal) OR Novolin NPH (intermediate acting) administering 70% of previous NovoLog 70/30 as NPH PLUS Novolin R (short acting insulin) vials administering 30% of previous NovoLog 70/30 dose (administering Regular 30 minutes prior to a meal) OR, if an Endocrinologist, 70% of dose from Novolin NPH (intermediate acting) plus 30% of dose from Novolog (short acting insulin) Physician to specify the number of units of each insulin. Draw the NovoLog or Novolin R (whichever ordered) into the syringe before drawing the NPH into the syringe.

Novolog 70/30 penfills non-formulary. Insulin pens are non-formulary. However, Insulin pens may be available thru the NF Rx process when the physician documents the member is unable to accurately draw up insulin due to young age, visual impairment, Parkinson's Disease, rheumatoid arthritis or upper extremity amputation; or, when administering doses less than 5 units; or, when pediatric patient's school or day care requires use of insulin cartridge device for insulin administration while outside of their primary caretaker's care. Novolog is administered 15 minutes prior to meals, whereas Novolin R is administered 30-60 minutes before meal

NuvaRing (Etonogestrel 0.12mg/EE 0.015mg released per day)

Levlen, microgestin fe 1/20 and 1.5/30, zovia 1/35, norinyl 1+35, brevicon, Norinyl 1+50, trilevlen, trinorinyl, depo-provera injection Document at least 3 formulary alternatives before prescribing/approving a NF product.

All-flex diaphragms or paragard T380 and Mirena (levonorgestrel) IUDs also formulary contraceptive options. NuvaRing may not be suitable for women with conditions that make the vagina more susceptible to vaginal irritation/vaginitis. Consider oral progestin only contraception with NorQD to minimize oral contraceptive associated BP elevation.

Nuquin HP cream 4% (Solaquin forte) topical depigmenting agent--cosmetic use, no formulary agent available.

Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they are also being used as cosmetic therapy and are not covered.

Ocufen (Flurbiprofen 0.03%) ophth soln If using for allergic conjunctivitis: OTC Opcon-A (Pheniramine & Naphazoline) If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product consider at least 2 formulary products before prescribing/authorizing a NF product: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

.

Ocupress (Carteolol) 1% ophth soln i drop in affected eye BID

Timoptic (Timolol) ophth soln 0.25-0.5% i drop in affected eye(s) BID or Betoptic (Betaxolol) 0.5% or Betagan (Levabunolol) 0.25-0.5%

N/A

Ogestrel (0.5mg Norgestrel/ 50mcg EE) tablets i QD Norinyl 1+50 (1mg Norethindrone/ 50mcg Mestranol) i QD or Zovia (generic Demulen) 1/50 (1mg Ethynodiol Diacetate/50mcg EE) i QD


Olux (Clobetasol) 0.05% foam Temovate (Clobetasol) 0.05% scalp soln Omacor (Omega-3 acid ethyl ester) .

This is a prescription omega-3 fatty acid product. It is a dietary supplement. Dietary supplements are not eligible for drug benefit coverage.

Omnicef (Cefdinir) capsule 300mg Cefuroxime 250mg or Augmentin or Bactrim DS or Biaxin

Omnicef suspension 125mg or 250mg/5ml are formulary; Omnicef capsules are non-formulary





Optivar (Azelastine) 0.05% ophth soln For allergic conjunctivitis: OTC Opcon-A (Pheniramine & Naphazoline) or OTC Zaditor 0.25% [NOTE: OTC products are not a covered benefit]


Ortho-Cept 28 (0.15mg Desogestrel/ 30mcg EE) tab i Levlen (0.15mg Levonorgestrel / 30mcg EE) Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE) QD or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg

days, 0.075mg Lvngl/40mcg EE x 5 days, EE) or Sprintec (0.25mg Norgestimate/35mcg EE) 0.125mg Lvngl/ 30mcg EE x 10 days) or Tri-Sprintec, generic Ortho-Tricyclen, (0.18mg

Norgestimate x 7 days, 0.215mg Norgestimate x 7 days, 0.25mg Norgestimate x 7 days/ 35 mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Ortho-Cyclen (0.25mg Norgestimate/ 35mcg EE) (generics:sprintec, mononessa)

Sprintec (0.25mg Norgestimate/ 35 mcg EE)


Ortho Evra (150 Norelgestromin/ 20 EE) contraceptive Microgestin 1/20 (1mg Norethindrone / Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE) patch {Norelgestromin is a metabolite of 20mcg EE) or Levlen (0.15 Levonorgestrel / or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg Norgestimate} 30mcg EE) or Sprintec (0.25mg EE) or Norinyl 1/50 (1mg NE/ 50mcg Mestranol),

Norgestimate/35 mcg EE) or Brevicon or Tri-Norinyl (0.5mg Norethindrone x 7days, 1mg (.5mg NE/ 35mcg EE), or Norinyl 1/35 (1mg NE x 7 days, 0.5mg NE x 7 days/ 35 mcg EE) OR NE/ 35mcg EE) Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x

6 days, 0.075mg Lvngl & 40mcg EE x 5 days, 0.125mg Lvngl & 30mcg EE x 10 days)or Nor-qd (0.35 NE only) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Ortho-Novum 1/35 (1mg NE/35mcg EE) Norinyl 1/35 (1mg Norethindrone/35mcgEE)

.

Ortho-Novum 1/50 (1mg Norethindrone/ Mestranol 50mcg)

Norinyl 1/50 (1mg Norethindrone/ 50mcg Mestranol)

Ortho-Novum 10/11 (0.5mg Norethindrone/ 35mcg Brevicon (0.5mg NE/35mcg EE) or Norinyl Aranelle is a generic name for Tri-Norinyl (0.5mg Ethinyl Estradiol x 10 days, 1mg NE/ 35mcg EE x 1/35 (1mg NE/35mcg EE) or Tri-norinyl Norethindrone x 7days, 1mg NE x 7 days, 0.5mg 11days) {generic: Necon 10/11} (0.5mg NE x 7days, 1mg NE x 7 days, NE x 7 days/ 35 mcg EE) Document at least 3

0.5mg NE x 7 days /35mcg EE) formulary alternatives before prescribing/approving a NF product.

Ortho-prefest (1mg 17beta Estradiol / 90 mcg Estrace (Estradiol) 0.5 - 2mg plus Two individual prescriptions are required. 0.5mg Norgestimate cyclic) Medroxyprogesterone 2.5-5mg QD or plus Estradiol = 0.3mg Premarin; 0.75mg Estradiol

NorQD 0.35mg (norethindrone) QD (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin





Ortho-Novum 7/7/7 (0.5mg NE x 7 days, 0.75mg NE x 7 days, 1 mg NE x 7 days/ 35 mcg EE)

Nortrel 7/7/7 (0.5mg NE x 7 days, 0.75mg NE x 7 days, 1 mg NE x 7 days/ 35 mcg EE)

Tri-Norinyl (0.5mg Norethindrone x 7days, 1mg NE x 7 days, 0.5mg NE x 7 days/ 35 mcg EE) OR Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x 6 days, 0.075mg Lvngl & 40mcg EE x 5 days, 0.125mg Lvngl & 30mcg EE x 10 days Document at least 3 formulary alternatives before prescribing/approving a NF product.

Ortho-tricyclen (0.18mg Norgestimate x 7 days, Tri-Sprintec (0.18mg Norgestimate x 7 days, Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x 0.215mg Norgestimate x 7 days, 0.25mg 0.215mg Norgestimate x 7 days, 0.25mg 6 days, 0.075mg Lvngl & 40mcg EE x 5 days, Norgestimate x 7 days/ 35 mcg EE) Norgestimate x 7 days/ 35 mcg EE); or,

Sprintec (0.25mg Norgestimate/ 35 mcg EE), or Zovia1/35 (Ethynodiol 1mg/35mcg EE) or Tri-Norinyl (0.5mg Norethindrone x 7days, 1mg NE x 7 days, 0.5mg NE x 7 days/ 35 mcg EE)

0.125mg Lvgn & 30mcg EE x 10 days) or Brevicon (.5mg NE/ 35mcg EE), Levlen (0.15 Lvngl/30mcg EE), Microgestin 1/20 (1 NE/20mcg EE), Microgestin 1.5/30 (1.5 NE/30 EE), Norinyl 1/35 (1mg NE/ 35mcg EE) Norinyl 1/50 (1mg NE/ 50mcg Mestranol), or NorQD (0.35 NE only) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Ortho Tri-Cyclen Lo (0.18mg Norgestimate x 7 days, Tri-Sprintec (0.18mg Norgestimate x 7 days, Microgestin FE 1/20 (1 NE/20mcg EE), Tri-Levlen 0.215mg Norgestimate x 7 days, 0.25mg 0.215mg Norgestimate x 7 days, 0.25mg (0.05mg Levonorgestrel & 30mcg EE x 6 days, Norgestimate x 7 days/ 25 mcg EE) Norgestimate x 7 days/ 35 mcg EE); or,

Sprintec (0.25mg Norgestimate/ 35 mcg EE), or Zovia1/35 (Ethynodiol 1mg/35mcg EE) or Tri-Norinyl (0.5mg Norethindrone x 7days, 1mg NE x 7 days, 0.5mg NE x 7 days/ 35 mcg EE)

0.075mg Lvngl & 40mcg EE x 5 days, 0.125mg Lvgn & 30mcg EE x 10 days) or Brevicon (.5mg NE/ 35mcg EE), Levlen (0.15 Lvngl/30mcg EE), Microgestin FE 1.5/30 (1.5 NE/30 EE), Norinyl 1/35 (1mg NE/ 35mcg EE) Norinyl 1/50 (1mg NE/ 50mcg Mestranol), or NorQD (0.35 NE only) Document at least 3 formulary alternatives before prescribing/approving a NF product.

Orudis (Ketoprofen) 50mg - 75mg TID - QID Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg 1-2 QD-

BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg..

Oruvail (Ketoprofen ER) 100 - 200mg QD Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg 1-2 QD-


Ovcon 35 (0.4mg norethindrone/ 35mcg EE) Brevicon (0.5mg ne/35mcg EE) or Norinyl Document at least 3 formulary alternatives 1/35 (1mg ne/35mcg EE) or Tri-Norinyl before prescribing/approving a NF product. (0.5mg ne x 7days, 1mg ne x 7 days, 0.5mg ne x 7 days /35mcg EE)

Ovcon 50 Zovia (generic Demulen) 1/50 (1mg Ethynodiol Diacetate/50mcg EE) i QD or Norinyl 1+50 (1mg Norethindrone/ 50mcg Mestranol) i QD


Ovral (0.5mg Norgestrel/ 50mcg EE) tablets i QD Norinyl 1+50 (1mg Norethindrone/ 50mcg Document at least 3 formulary alternatives (generic Ovral (Ogestrel) is now manufactured) Mestranol) i QD or Zovia (generic Demulen)

1/50 (1mg Ethynodiol Diacetate/50mcg EE) i QD

before prescribing/approving a NF product.





Ovrette (Norgestrel 0.075mg) qd Nor-QD (Norethindrone 0.35mg) QD Document at least 3 formulary alternatives before prescribing/approving a NF product.

Oxistat (Oxiconazole cream) OTC Lamisil AT or clotrimazole containing OTC products: Lotrimin AF or OTC Mycelex or OTC Micatin cream


Oxycodone IR Oxycodone 5mg/325mg APAP Morphine sulfate immediate release 15 or 30mg tabs [Morphine 30-40mg converts to Oxycodone 15-30mg]

Oxycontin 160 mg ER Generic oxycodone extended release (available in 10mg, 20mg, 40mg & 80mg strengths)

Palladone (hydromorphone hcl) extended release 12mg, 16mg, 24mg, 32mg capsules

Hydromorphone regular release 2mg or 4mg tablets

Do not consume any form of alcohol while taking Palladone as it will result in destruction of extended release mechanism, acute drug release and overdose potential.

Panretin (Alitretinoin) 0.1% topical gel Criteria: (1)Patient has AIDS-related KS, and (2) has signs and symptoms indicative of localized disease (e.g. few lesions,low rate of growth,no visceral KS identified, no fevers, drenching night sweats or weight loss, no prior opportunistic infection), and (3) has failed cryotherapy (this is treatment of choice), OR (4) patient not considered candidate for other treatment options, or patient has failed other treatment options.

Paremyd (Hydroxyamphetamine hydrobromide 1%/Tropicide 0.25%) ophth soln

Cyclogyl (Cyclopentolate) ophth soln Pupil dilation in ophth. Diagnostic procedures and eye exams

Patanol (Olopatadine) 0.1% For allergic conjunctivitis: OTC Opcon-A (Pheniramine & Naphazoline) or OTC Zaditor 0.25% [NOTE: OTC products are not a covered benefit]


Paxil (Paroxetine regular release) 10 - 40mg tabs and Paxil CR (Paroxetine Controlled Release) 12.5mg, 25mg tabs (Paxil regular release is non-formulary as of 1/1/2008)

Prozac caps 10-40 mg QD or Celexa (Citalopram) 20-40mg QD or Sertraline 25 -100mg QD (added to formulary Mar 8th 2007)

The controlled-release product is non formulary. Paxil 10mg bioequivalent to Paxil CR 12.5mg. Paxil (Paroxetine) is non-formulary as of 1/1/2008. Document response to all formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.

Peak Flow Meter Not covered by drug benefit Obtain peak flow meter at MD office

PediaPred (5mg/5ml Prednisolone) Prelone 5mg or15mg/5ml, Orapred 15mg/5ml

Watch change in solution strength, Prelone available 5mg/5ml and 15mg /5ml





Penlac (Ciclopirox) 8% topical solution N/A Penlac demonstrates a very low cure rate. Fungal nail infection is considered cosmetic treatment and is not covered Unless : fungal culture positive and i) If a finger nail, limited to one 6 week treatment course, ii) If a toe nail, only covered if the patient has diabetes or vascular disease, then restricted to one 12 wk course.

Percocet tablet 2.5mg, 7.5mg or 10mg Oxycodone preparations

Oxycodone 5mg/325mg acetaminophen (generic Percocet) or Oxycodone 5mg/500mg acetaminophen (generic Tylox)

Brand names non-formulary. Controlled substance level 2 requires hand written Rx by physician

Pergonal injection Repronex injection May be substituted on a unit for unit basis without calling practitioner. Menotropins are only covered for members with fertility benefit rider.

Periostat (Doxycycline) caps 20 mg BID up to 9 months

Doxycycline 50mg capsule QD OR 100 mg tablets 1/4 tab (25 mg) BID

Periostat is not covered. Member will pay full price if dispensed Periostat.

Phendimetrazine N/A Weight loss agents not covered. Phentermine HCL caps N/A Weight loss agents not covered. Pilagan (Pilocarpine nitrate) 1 - 4% ophth soln i-ii drops in affected eye TID-QID

Pilocarpine HCL (generic Isopto Carpine) 0.25-10% ophth soln i-ii drops in affected eye TID-QID OR Isopto Carbachol (Carbachol) 0.75-2.25% ophth soln ii drops in affected eye TID

Direct acting miotics to lower IOP in glaucoma

Plexion (Sodium Sulfacetamide 10% and Sulfur 5%) lotion

Sulfacetamide/sulfur lotion

Poly-pred (Neomycin/Polymyxin/Prednisolone) ophth susp or ophth oint

Maxitrol (Dexamethasone/Neomycins/Poly-myxin) ophth susp or ophth oint

.

Ponstel (Mefenamic acid) 250mg QID (not recommended for longer than 1 week)

Ibuprofen (generic Motrin) tabs 600-800 mg TID or Salsalate (Disalcid)1500mg BID or Naproxen 500mg BID or Sulindac (Clinoril) 200mg BID

Additional formulary alternatives: Diclofenac (Voltaren) 75mg BID or Choline Magnesium Trisalicylate (Trilisate) 750mg BID-TID or Nambumetone (Relafen) 500mg or 750mg 1-2 QD-BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.

Portia (0.15 Levonorgestrel/30mcg EE) Levlen (0.15 Levonorgestrel/30mcg EE) . Pramasone (Pramoxine 1%/Hydrocortisone 2.5%) lotion

Pramasone (Pramoxine 1%/Hydrocortisone 2.5%) Rectal foam

OTC Amlactin AP (ammonium lactate 12%/Pramoxine 1%) or HC cream 2.5% & OTC Benadryl cream

Prandin (Repaglinide) 1-4 mg TID Glyburide (generic Micronase) 5-10 mg QD-BID or Metformin 500mg BID or Glipizide

Both Prandin and Glyburide stimulate beta cell receptors to increase insulin production

Premarin Estradiol 0.5mg-2mg QD 0.5mg Estradiol = 0.3mg Premarin; 0.75mg Estradiol (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin

Premphase packets: premarin 0.625mg QD days 1-14, then (premarin / medroxyprogesterone) 0.625mg/5mg tab i QD days 15-28

Estrace (Estradiol) 1mg QD plus Medroxyprogesterone 5mg QD days 15 thru 28


Prempro (Premarin / Medroxyprogesterone)0.45/1.5mg QD

Estrace (Estradiol) 0.75mg (1&1/2 0.5mg Estradiol tablet) QD PLUS Medroxyprogesterone 1/2 to one 2.5mg tablet QD






Prempro (Premarin / Medroxyprogesterone) 0.625/2.5mg -0.625mg/5mg tab i QD

Estrace (Estradiol) 1mg QD plus Medroxyprogesterone 2.5-5mg QD


Prenatal vitamins no formulary alternative Prenatal vitamins are available OTC Prevacid-DR (Lansoprazole) cap 15-30 mg QD OTC Prilosec 20mg - 40mg QD Prevacid is a NF No Initial Fill Drug. If Prilosec

40mg QD failure, consider NF No Initial Fill drug, Protonix titrated up to 80mg QD. (Protonix 40mg=Prevacid 30mg=Prilosec 20mg) Must document failure or intolerance to Prilosec 40mg QD if requesting PPI coverage.

Preven Emergency Contraception kit (0.25mg Levonorgestrel/0.05 Ethinyl Estradiol) 2 tablets now then 2 tablets in 2 hours

Levlen (0.15mg Levonorgestrel / 0.03mg Ethinyl Estradiol) #4 Levlen tablets now and then repeat in 12 hours OR Plan B (0.75mg Levonorgestrel) 1 tablet now then 1 tablet in 2 hours

Must be taken within 72 hours of unprotected intercourse.

Prevpack (Prevacid DR (Lansoprazole) 30mg BID, Biaxin (Clarithromycin) 500mg BID and Amoxicillin 500mg QID x 10-14 days)

HP Pack: Tetracycline 500 mg QID x 14 days, Metronidazole 500 mg QID x 14 days, Bismuth subsalicylate 2 tabs QID x 14 days & Prilosec OTC 20mg BID x 14 days (HP Pack available at KP pharmacies for one copayment)

HP Pack (Helicobacter pylori treatment pack) Individual components dispensed as 2 individual prescriptions PLUS OTC Pepto Bismol & Prilosec OTC at Eckerd. Second line alternative: Prilosec OTC 20mg BID, Biaxin 500mg BID, and Flagyl 500mg BID or Amoxicillin 1000mg BID x 14 days

Prilosec (Omeprazole) 20mg cap 20-60mg QD OTC Prilosec 20mg tablet. (If cannot swallow tablet, OTC prilosec will disperse in 5cc of water in less than 60 seconds with gentle agitation)

If patient has failed Prilosec 40mg QD, consider NF No Initial Fill drug, Protonix titrated up to 80mg daily (Protonix 40mg=Prilosec 20mg). Must document failure or intolerance to Prilosec 40mg QD if requesting PPI coverage; Initial dosing for kids >/= 20kg or 3 years of age is Prilosec 20mg QD

Proamatine (midodrine) 2.5-10 mg TID Fludrocortisone (generic Florinef) dosing to be determined by prescriber.

Consider Fludrocortisone if patient has not yet been stabilized on Midodrine. If orthostatic hypotension stabilized on Midodrine, consider continuing Midodrine.

Procardia XL tablet 30-90 mg QD Nifedipine XL 30, 60 or 90 mg tablet We cover generic Procardia XL (nifedipine XL) instead of generic Adalat CC (nifedipine XL). Substitute on a mg per mg basis. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Proctocort 1% (1% Hydrocortisone) cream Proctofoam HC (1% Hydrocortisone/pramoxine 1%) OR Hydrocortisone cream 2.5% with rectal tip OR Hydrocortisone 25mg suppository

Select appropriate option

Proctocream HC (2.5% Hydrocortisone cream) or (1% Hydrocortisone and 1% Pramoxine)

Proctofoam HC (1% Hydrocortisone/Pramoxine 1%) OR Hydrocortisone cream 2.5% with rectal tip OR Hydrocortisone 25mg suppository






Proctosol HC Cream 2.5% Proctofoam HC (1% Hydrocortisone/pramoxine 1%) OR Hydrocortisone cream 2.5% with rectal tip OR Hydrocortisone 25mg suppository


Profen II tab 37.5-600 i tablet BID OTC congestac (60mg Pseudoephedrine and 400mg Guaifenesin/tablet) Q6H or OTC Mucinex (600mg Guaifenesin long acting) or OTC Guaifenesin 400mg regular release plus OTC Pseudoephedrine

All cough and cold medications are non-formulary with the exception of Codeine, Hydrocodone, and Promethazine containing products.

Prometrium capsule 100 mg QD-BID Medroxyprogesterone 2.5-5 mg QD or Aygestin (norethindrone) 5mg

If Prometrium is being used in early pregnancy, coverage is addressed by the fertility benefit.

Propecia N/A Cosmetic drug use is not covered under drug benefit. Propecia for male pattern baldness or removal of female facial hair is considered cosmetic. Member pays full retail price.

ProStep (Nicotine) Transdermal system 11,22mg/day OTC Nicotrol (Nicotine transdermal system) 5, 10, 15mg/day


Protonix (Pantoprazole) 40mg QD to BID Prilosec OTC 20 - 40mg QD Protonix is a NF No Initial Fill drug. If patient has failed Prilosec (Omeprazole) titrated up to 40mg daily, consider NF No Initial Fill drug, Protonix. Must document failure or intolerance to Prilosec 40mg QD if requesting PPI coverage.

Protopic (Tacrolimus) 0.03% and 0.1% oint Corticosteroid potency to be determined by ind patient need. very high potency: Diprolene (augmented Betamethasone Dipropionate) 0.05% oint or Temovate (Clobetasol) 0.05% cream, oint, gel, scalp soln. High potency: Lidex (Fluocinonide) 0.05% cream, oint, gel, soln or Diprolene AF (Augmented Betamethasone) 0.05% Medium potency: Triamcinolone (generic Aristocort, Kenalog) cream, oint 0.1% or Valisone (Betamethasone Valerate) 0.1% lotion or Locoid Lipocream (Hydrocortisone Butyrated) 0.1% Low potency: DesOwen (Desonide) 0.05% cream, oint, lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion

Locoid lipocream restricted to derm. Covered corticosteroid topicals listed by potency under formulary alternative column. ***Protopic is preferred over Elidel for diagnosis of Vitiligo and should be approved for that condition***

Proventil (Albuterol) oral inhaler ii puffs Q4H prn Albuterol oral inhaler ii puffs Q4H prn May be substituted on a puff for puff basis without calling practitioner.

Proventil HFA (Albuterol) oral inhaler ii puffs Q4H prn Albuterol oral inhaler ii puffs Q4H prn May be substituted on a puff for puff basis.

Proventil (Albuterol) tabs, SR tabs, oral soln, neb soln Albuterol (generic Ventolin) immediate release tablets or oral inhaler

Extended release Albuterol tablets are no longer manufactured. Consider Albuterol inhaler or immediate release tablets. If long acting beta 2 agonist necessary, consider serevent inhaler. If steroid inhaler necessary, QVAR (Beclomethasone) inhaler is preferred formulary agent

Provera tablets 2.5-10 mg QD Medroxyprogesterone tabs 2.5 -10 mg QD May be substituted on a mg for mg basis without calling practitioner.





Prozac (Fluoxetine) Weekly 90mg enteric coated capsule

Prozac (Fluoxetine) 20mg QD Prozac Weekly is non formulary, Prozac administered daily is formulary. Document response to all formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.

Psorcon (Diflorasone) 0.05% cream, oint (emolient base oint)



Psorcon (Diflorasone) 0.05% oint (not the emolient base oint)

Diprolene (Augmented Betamethasone Dipropionate) 0.05% oint or Temovate (Clobetasol) 0.05% cream, oint, gel, scalp soln


Pulmicort (Budesonide) 200 mcg turbuhaler i-ii puff BID

QVAR (Beclomethasone HFA) 80mcg i-ii puffs BID or Asmanex (Mometasone furoate) oral dry powder inhaler 200mcg per puff i - ii puffs QHS (or i puff BID)

QVAR 80mcg (preferred agent) is equipotent to Pulmicort 200mcg. If patient has failed QVAR, consider Asmanex (≥12 yrs old). Asmanex is equipotent to fluticasone and approx twice as potent as budesonide and beclomethasone. QVAR remains the preferred inhaled corticosteroid at KP GA. TSPMG guidelines support Pulmicort when an oral inhaled steroid is needed during pregnancy.

Pulmicort (Budesonide) respules for nebulization If child can use inhaler, consider (5-11 yoa) QVAR 40mcg i puff BID

Pulmicort respules are formulary when nebulization is required. Pulmicort is the only inhaled steroid available for nebulization.

Pyridium (Phenazopyridine) 100mg or 200mg tablets OTC Pyridium 95mg or 100mg tablets .

Pyridium plus (Phenazopyridine 150mg, 0.3mg Hyoscyamine, 15mg Butabarbital)

OTC generic Pyridium (95mg or 100mg Phenazopyridine) with or without Rx generic Levsin (Hyoscyamine 0.125mg)

Pyridium 95mg or 100mg OTC

Quinamm (Quinine sulfate) tabs N/A Available on exception basis for malaria. Not covered for leg cramps since potential risk outweighs potential benefit.

Quixin (Levofloxacin) 0.5% ophth soln Ofloxacin 0.3% or Gentamicin 0.3% or Tobramycin 0.3% or Sodium Sulfacetamide ophth soln or Zymar 0.3%

Lasik ophthalmic surgery is not a covered benefit. Medications related to non covered procedures, eg. Lasik surgery, are not covered by the drug benefit.

Raptiva (Efalizumab) Humira preferred in psoriasis. Raptiva coverage criteria for psoriasis: (1) patient is an adult with moderate to severe chronic plaque psoriasis, and (2) has a documented failure, or is not a candidate for topical or systemic therapies (methotrexate, acitretin, PUVA, UVB), and (3) patient has a documented failure, or is not a candidate for a combination of the above treatment options, (4) prescriber must be a Dermatologist

Razadyne (Galantamine) 8-16mg BID Aricept (Donazepril) 5 - 10mg tab QD;Exelon Consider Aricept 10mg 1/2 tablet when prescribing Aricept 5mg.

Relenza 5 mg dose inhalation (diskhaler device) Oseltamivir (Tamiflu) See special criteria for oseltamivir during flu season only.

Relpax (Eletriptan) 20mg, 40mg Maxalt (Rizatriptan) MLT 10mg tablet (Maxalt MLT 5mg tablet is also available)

Maxalt MLT 10 mg is preferred, QTY limit of 9 tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Quantity limit for Non-formulary Relpax is 6 tablets per copay





Remeron (Mirtazapine) Sol-Tab15mg or 30mg Mirtazapine regular release tablets 15mg, 30mg or 45mg Or, Prozac (Fluoxetine) caps 10-40 mg QD or Celexa (Citalopram) 20 - 40mg QD or Paxil (Paroxetine) tabs 20-40 mg QD

Consider Celexa 40mg 1/2 tablet when prescribing Celexa 20mg. Consider Paroxetine 40mg 1/2 tablet when prescribing Paroxetine 20mg dose. [Mirtazapine - Available Part D group]

Remicade (Infliximab) administered IV TNF blocker Enbrel 25 mg SQ twice weekly. Humira preferred in psoriasis.

Remicade is provided and administered at a KP Infusion center. Physician to provide referral to KP infusion center for Remicade administration (contact Jill Broner at Cumberland 770-431-4367 or at SWD Kim 770-603-3572). IV infusion to be ordered by Rheumatology or GI. Refer practitioner questions regarding medical benefit coverage to provider relations.

Reminyl (Galantamine) 8-16mg BID Aricept (Donazepril) 5 - 10mg tab QD Consider Aricept 10mg 1/2 tablet when prescribing Aricept 5mg.

Renagel (Sevelamer) 800-1600mg with each meal Phoslo 667mg (Calcium acetate) tablet ii-iiii tablets with each meal

Sevelamer is a calcium-/aluminum-free phosphate binder for hypophosphatemia in patients with end stage renal disease

Renova (Tretinoin) 0.02% cream N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price.

Rescula (Unoprostone isopropyl) 0.15% ophth soln Lumigan (Bimatoprost) 0.03% ophth solution 1 drop in affected eye QHS

Prostamide analog to reduce IOP in glaucoma. Lumigan is not as effective when administered more often than QD. Separate Lumigan from administration of other eye drops by at least 5 minutes.

Restoril (Temazepam) 7.5mg QHS Temazepam (generic Restoril) 15 mg capsule at HS or Oxazepam (gen Serax) 10-30mg or Lorazepam 0.5mg QHS or Hydroxyzine (generic Atarax) 10-25 mg at HS or Trazodone 50-100mg QHS

Temazepam 15mg and 30mg strengths are available on the formulary.

Retin-A (Tretinoin) 0.025% cream or gel Avita (Tretinoin) 0.025% cream or gel Formulary for acne only. Smallest unit size is covered. Drugs for cosmetic use (eg. Wrinkles) are not covered on drug benefit, member will retail price.

Retin-A micro gel 0.04% or 0.1% apply QHS Retin-A cream 0.1% (20 gm tube) apply QHS or Retin-A gel 0.025% (15 gm tube) apply QHS

Retin A Micro gel is restricted to Dermatology. Formulary for acne only. Smallest unit size is covered. Drugs for cosmetic use (eg. Wrinkles) are not covered on drug benefit, member will retail price.

Revatio (Sildenafil) 20mg TID Tracleer (Bosetan) Rhinocort (Budesonide) nasal spray ii-iiii sprays each nostril BID



Riomet (Metformin) oral solution Metformin oral tablets .

Ritalin LA (Methylphenidate HCL extended release) 20, 30 & 40mg beaded capsules

Concerta 18, 27, 36, 54mg, or Methylin ER 10mg (methylphenidate), Methylphenidate 5, 10, 20mg and SR 20mg; or generic Dexedrine spansules (Dextroamphetamine) 5, 10, 15mg or Adderall regular release 5, 10, 20, 30mg tablets or Adderall XR 5, 10, 20, 25, 30mg capsules. Controlled substances level 2 requiring prescription written by prescriber. Methylphenidate is the preferred formulary alternative.

Adderall XR is restricted to pediatrics, child neurology and behavioral health. Titrate to appropriate dosage using adderall regular release tablets before transitioning to once daily Adderall XR.





Rowasa suppositories Cortenema 100mg/60ml, Rowasa enema or Canasa (Mesalamine) 1000mg suppository

Rowasa suppositories are unavailable from mftr indefinitely (10/01) so Rowasa removed from formulary and replaced by Canasa suppositories

Rozerem (Ramelteon) 8mg QHS Generic Ambien (Zolpidem 5 & 10mg) has been added to the formulary as of 6/1/07. Please consider less costly alternatives before prescribing Zolpidem. Oxazepam (gen Serax) 10-30mg or Lorazepam 0.5mg QHS or Hydroxyzine (generic Atarax) 10-25 mg at HS or Trazodone 50-100mg QHS or Temazepam (generic Restoril) 15-30 mg capsule at HS are all much less costly than Zolpidem.

Consider lower doses in geriatric patients. Consider OTC Melatonin to reduce benzodiazepine usage Caution: do not abruptly discontinue benzodiazepines after long-term use. Document failed trial on at least 1 Benzodiazepine, Trazodone, and Zolpidem before prescribing NF product.

Rynatan suspension (Chlorpheniramine, Phenylephrine) new formulation removed Pyrilamine

Nasarel ii sprays each nostril BID or generic Flonase (fluticasone) i spray each nostril QD or OTC Claritin syrup and OTC Phenylephrine HCl

OTC alternatives: Triaminic cold and cough; cold and allergy (see Triaminic dosing sheet) or Robitussin product sheet. Claritin syrup OTC

Saizen (Somatotropin) injection Criteria Restricted Medication. Once approved, the approval and date range for approval is noted in the Kaiser pharmacy computer system. Norditropin (somatropin) is preferred growth hormone and must be tried prior to approval for other growth hormone products

Criteria Restricted Medication. Pediatric Endocrinologist phone KP QRM to request authorization consideration 404-364-7320.

Salagen (Pilocarpine) 5mg tablets Pilocarpine 4% (4mg/0.1ml) ophthalmic soln 3 drops TID taken orally (equivalent to 5mg Pilocarpine TID)

Symptomatic treatment. Please consider titrating the number of drops and frequency of administration to patient's response and tolerance. {Pilocarpine 6% (6mg/0.1ml) ophthalmic soln 2 drops TID (equiv to 6mg Pilocarpine TID}

Sanorex (Mazindol) N/A Weight loss agents not covered.

Santyl 30gm (Collagenase) Accuzyme (papain-urea) ointment 30gm Santyl on MMA formulary only. Accuzyme first line formulary option

Sarafem (Fluoxetine) 20mg caps Prozac (Fluoxetine) 20mg QD Document response to all formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.

Sculptra (poly-l-lactic acid) N/A Cosmetic use drug. Not covered on drug benefit. Member pays retail price.

Seasonale (Levonorgestrel 0.15mg / Ethinyl Estradiol 30mcg) 84 active tablets followed by 7 placebo tabs = 90 day supply

Levlen (Levonorgestrel 0.15mg /30mcg Ethinyl Estradiol) 28 day packet

Instruct pt to take one active Levlen tablet per day for 84 days (do not take the 7 placebo tablets included with the first 3 Levlen packets) on day 85 patient will take one placebo tablet daily for 7 days

Semprex D OTC products, Dimetapp Semprex D is an Antihistamine/Decongestant combo

Serzone (Nefazodone) 100-300mg BID Consider Prozac caps 10-40 mg QD or Celexa (Citalopram) 20-40mg QD or Paxil tabs 20-40 mg QD

Brand name Serzone is no longer manufactured. Generic Nefazodone is manufactured but remains NF.

Singulair 4mg chew tab or granules OR 5mg chew tab QD

ICS inhaler (QVAR or *Flovent or Asmanex) plus a long acting B2-agonist (Serevent) OR an ICS and B2 agonist






Singulair 5-10 mg QD ICS inhaler (QVAR or *Flovent or Asmanex) plus a long acting B2-agonist (Serevent) OR an ICS and B2 agonist


Skelaxin (Metaxalone) 400mg-800mg TID-QID Flexeril (Cyclobenzaprine) 10mg tab or Robaxin (Methocarbamol) 750mg tab or Soma (Carisoprodol) 350mg or Parafon Forte DSC (Chlorzoxazone) 500mg

Use Cyclobenzaprine 10mg 1/2 tablet for Cyclobenzaprine 5mg.

Solage (Mequinol 2%, Tretinoin 0.01%) N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.

Solaquin-Forte cream or gel N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.

Soma Compound (200mg carisoprodol/325mg aspirin) Soma (carisoprodol) 350mg plus OTC aspirin

Other Formulary alternatives include: Flexeril (Cyclobenzaprine) 10mg tab or Robaxin (Methocarbamol) 750mg tab or Parafon Forte DSC (Chlorzoxazone) 500mg plus OTC aspirin

Sonata (Zaleplon) capsule 10 mg at HS Temazepam (generic Restoril) 15-30 mg capsule at HS or Oxazepam (gen Serax) 10-30mg or Lorazepam 0.5mg QHS or Hydroxyzine (generic Atarax) 10-25 mg at HS, Trazodone 50-100mg QHS, or Zolpidem (gen Ambien) 5-10mg

Consider lower doses in geriatric patients. Consider OTC melatonin to reduce benzodiazepine usage Caution: do not abruptly discontinue benzodiazepines after long-term use. Caution: do not abruptly discontinue benzodiazepines after long-term use. Document failed trial on at least 1 Benzodiazepine, Trazodone, and Zolpidem before prescribing NF product.

Soriatane (Acitretin) cap N/A Soriatane is restricted to Dermatology.

Spectazole (Econazole) cream OTC Lamisil AT or Clotrimazole containing OTC products: Lotrimin AF or OTC Mycelex or OTC Micatin cream


Stadol NS 10 mg/ml i spray in one nostril Q3-4H Ibuprofen 600-800 mg TID or Acetaminophen with Codeine i-ii tablets Q6H or morphine or Oxycodone / acetaminophen or NSAID

The Federal Drug Enforcement Agency (DEA) ranks Stadol nasal spray among the top abused drugs.

Stalevo 50 (12.5mg Carbidopa / 50mg Levodopa/ 200mg Entacapone)

25mg Carbidopa / 100mg Levodopa regular release 1/2 tablet PLUS Comtan (Entacapone) 200mg tablet

.

Stalevo 100 (25mg Carbidopa/ 100mg Levodopa/200mgEntacapone)

25mg Carbidopa /100mg Levodopa regular release tablet PLUS Comtan (Entacapone) 200mg tablet

.

Stalevo 150 (37.5mg Carbidopa/ 150mg Levodopa/200mgEntacapone)

25mg Carbidopa /100mg Levodopa regular release 1 &1/2 tablets PLUS Comtan (Entacapone) 200mg tablet

.





Starlix (Nateglinide) 120mg TID Glyburide (generic Micronase) 5-10 mg QD-BID or Glucophage (Metformin) 500mg BID or glipizide

Both Starlix and Glyburide stimulate beta cell receptors to increase insulin production. Caution patient to monitor for big shifts when changing diabetic Rx. Consider other oral antidiabetics such as Glipizide in patients >65 due to prolonged half life of Glyburide.

Strattera (Atomoxetine) 10mg, 18mg, 25mg, 40mg and 60mg

Concerta 18,27,36,54mg, or Methylin ER 10mg (Methlyphenidate) Methylphenidate 5, 10, 20mg and SR 20mg; or generic Dexedrine spansules (Dextroamphetamine) 5, 10, 15mg or Adderall regular release 5, 10, 20, 30mg tablets or Adderall XR 5,10,20,25,30mg capsules. Controlled substances level 2 requiring prescription written by prescriber. Methylphenidate is the preferred formulary alternative.

Adderall XR is restricted to pediatrics, child neurology and behavioral health. Titrate to appropriate dosage using adderall regular release tablets before transitioning to once daily Adderall XR. Document failed trial on Methylphenidate, Dextroamphetamine and Adderall IR products before a Non-formulary Product is considered. Methylphenidate is the preferred formulary alternative.

Sular (Nisoldipine) 10-40mg QD Nifedipine XL (generic Procardia XL) 30-90mg QD or Felodipine ER (generic Plendil) 2.5mg-10mg, or Amlodipine (generic Norvasc) 2.5mg-10mg or Diltia XT (Diltiazem) 120-480mg QD

Nisoldipine 10-20, 30 & 40mg are equivalent to Nifedipine XL 30, 60 &90mg, respectively OR Felodipine ER 2.5mg, 5mg & 10mg respectively, OR Amlodipine 2.5mg, 5mg, & 10mg respectively OR Diltia XT 120, 240 & 360-480mg respectively TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Supartz (Hyaluronic sodium) Criteria Restricted Medication. Provider phones KP QRM to request authorization consideration 404-364-7320.

Suprax 200-400 mg tablets or suspension Ceftin 250 mg tab BID or Augmentin 500 mg tab BID or Biaxin (no XL) 500mg BID Suspensions: Omnicef 125mg/5ml; pediazole (erythromycin & sulfamethoxazole); augmentin 125-250mg/5ml or 200-400mg chew tabs;amoxicillin 125-250mg/5ml; Biaxin 125-250mg/5ml

Ceftin tablets are formulary. Ceftin suspension is non-formulary.

Symbicort (Budesonide/Formeterol 80/4.5, 160/4.5, Turbuhaler)

For the 80/4.5 dose try: QVAR 80 mcg i puff BID & Serevent 50 mcg i puff BID OR Asmanex i puff qhs & Serevent 50 mcg i puff BID

For the 160/4.5 dose try: QVAR 80 mcg ii puffs BID & Serevent 50 mcg i puff BID OR Asmanex ii puffs qhs or i puff BID & Serevent 50 mcg i puff BID

Symbyax (Olanzapine/Fluoxetine) 6mg/25mg; Zyprexa (Olanzapine) 2.5mg, 5mg, Each component of this combination product is 6mg/50mg; 12mg/25mg; and 12mg/50mg 7.5mg,10mg or 15mg tabs PLUS Fluoxetine Formulary when dispensed individually as Zyprexa

20mg capsules 5mg or 10mg QD and Fluoxetine 20mg #1 or #2 QD.





Symlin (pramlintide) 0.6mg/ml injection Criteria Restricted Medication. Provider phone KP QRM 404-364-7320 to request authorization consideration.

Synagis (Palivizumab) injection is a humanized monoclonal antibody targeted to the F protein of respiratory syncytial virus (RSV)

N/A Injectables administered in medical office and are covered under medical office benefit, not drug benefit. Synagis is only covered when administered in a Kaiser Permanente office. Call KP Synagis clinic (770) 931-6059 for more information.

Synalar (Fluocinolone) 0.01% cream [low potency] DesOwen (Desonide) 0.05% cream, oint, lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion

Low potency topical corticosteroids. Synalar 0.01% soln and oil are covered. Synalar 0.025% cream, oint and synalar 0.2% are not covered.

Synalar (fluocinolone) 0.025% cream, oint [medium potency]

Triamcinolone (generic Aristocort) cream, oint 0.1% or Valisone (betamethasone valerate) 0.1% lotion or Locoid lipocream (hydrocortisone butyrate) 0.1% apply to affected area BID

Locoid lipocream is restricted to Dermatology. If failed other alternatives, consider increasing steroid potency to fluocinonide (Lidex) 0.05% cream, oint, or gel

Synalar (Fluocinolone) 0.2% cream [high potency] Lidex (Fluocinonide) 0.05% cream, oint, gel, soln or Diprolene AF (Augmented Betamethasone) 0.05%


Synthroid tablet 0.025-0.3 mg QD Levothroid tabs 0.025-0.3 mg QD Substitute on a mg for mg basis. (ie. if Synthroid 0.1mg convert to levothroid 0.1mg)

Taclonex (Calcipotriene and betamethasone) Dovonex (calcipotriene) and Betamethasone diprionate ointment 0.05%

Talwin NX i tablet Q3-4H Acetaminophen with codeine (generic Tylenol #3) i-ii tablets Q6H

.

Tamiflu (Oseltamivir) capsule 75 mg Tamiflu must be initiated w/in 48 hrs of symptom onset

Amantadine caps 100 mg BID Amantadine dose should be reduced to 100 mg QD in adults > 65 years of age. Pediatric dose is 4.4 mg/kg/day, max 150 mg/day. Rimantadine (Flumadine) 100mg tablets are also available. (Tamiflu covers flu strains A and B, Amantadine covers strain A only)

Tarceva (Erlotinib) 25mg, 100mg, 150mg tablets Platinum containing combination chemotherapy with paclitaxel or Docetaxel chemotherapy

Tarceva indicated for local advanced or metastatic non-small cell lung cancer after failure of at least one prior chemotherapy regimen (platinum containing first line)

Targretin (Bexarotene) 1% topical gel interferon alpha, topical carmustine Criteria: (1) patient has cutaneous T-cell lymphoma (CTCL) and (2) patient has cutaneous lesions, and (3) patient has failed interferon alfa, topical carmustine, PUVA, electron beam radiotherapy OR (5) patient is not considered candidate or has failed other treatment options





Tarka (Trandolapril/Verapamil) 1mg/240mg, 2/180mg, 4/240mg tablets

Prinivil (Lisinopril) 5-40mg QD AND Verapamil SR 180mg or 240mg

Combination product is not covered. Conversion Trandolapril 1mg=Prinivil 5-10mg; Trandolapril 2mg=Prinivil 10-20mg; Trandolapril 4mg=Prinivil 20-40mg. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Tasmar (Tolcapone) tab 100-200 mg TID Comtan (Entacapone) 200 mg tabs with each dose of Levodopa/Carbidopa, MAX 1600mg/day

Tasmar is on the formulary; however, all other Parkinson's therapies should be tried before Tasmar due to risk of severe hepatic damage and death, liver function tests must be completed every two weeks while on therapy. Patient and practitioner must complete informed consent (provided by manufacturer) prior to initiation of therapy.

Tazorac (Tazarotene) 0.05%, 0.1% cream (severe psoriasis)

For Psoriasis: Dovonex (Calcipotriene) 0.005% oint or Diprolene (Augmented Betamethasone) oint or Temovate (Clobetasol) oint, cream or Lidex (Fluocinonide) 0.05% oint, cream For Acne: Retin-A cream 0.1% (20 gm tube) apply QHS or Retin-A gel 0.025% (15 gm tube) apply QHS or Retin A Micro gel

If failed several very high potency steroids, consider Tazorac severe psoriasis. (Betamethasone Dipropionate 0.05% cream demonstrates good efficacy when nec to use a steroid crm w/ Tazorac) Acne: Retin A Microgel is restricted to Dermatology. Smallest unit size is covered, larger tubes are not covered. Retin-A, Differin not covered for cosmetic use (wrinkles)

Taztia XT (Diltiazem extended release) 120, 180, 240, 300, 360mg 120 - 480mg QD


Substitute on a mg for mg basis. Convert Taztia XT 300mg to Diltia XT 240mg or 360mg (#2 x 180mg), Taztia XT 480mg convert to Diltia XT 480mg (#2 x 240mg cap) TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Teczem (5mg Enalapril/180mg Diltiazem) extended release tab

Prinivil (Lisinopril) 5mg QD AND Diltia XT (Diltiazem) 180mg QD

Combination product is non formulary. Individual medications are formulary. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Tegison (Etretinate) capsules Soritaine (Acitretin) capsules Soriatane is restricted to Dermatology.





Tegretol-XR (Carbamazepine) 100, 200, 400mg tab BID

Carbatrol (Carbamazepine) 200, 300mg extended release caps BID

Substitute on a mg for mg basis to produce same total daily dose. Note Carbatrol strengths differ from Tegretol XR strengths.

Tekturna (Aliskerin) 150 mg and 300 mg tablets Lisinopril 10 -20 mg daily or Cozaar 25-100 mg daily

Tenex tablet 1 mg QD Clonidine (generic Catapres) tab 0.1 mg BID or Methyldopa (generic Aldomet) 250 mg TID

Titrate dose to blood pressure response. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Tenoretic (Atenolol / Chlorthalidone) 50/25, 100/25mg Atenolol (generic Tenormin) 50mg-100mg AND 25mg Hydrochlorothiazide

TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Tenuate (Diethylpropion) N/A Weight loss agents not covered. Tequin (Gatifloxacin) tab 400 mg QD x 7-10 days for bronchitis ; 400 mg QD x 7-14 days for community-acquired pneumonia ; 400 mg QD x 10 days for sinusitis

If treating URTI: Avelox (moxifloxacin) 400mg QD or generic Augmentin 875 mg BID or Biaxin 500 mg BID If treating UTI: Fluoroquinolone of choice is Cipro or consider Bactrim DS.

Terazol vaginal cream or suppositories Diflucan (Fluconazole) 150mg tablet OTC products are available. In keeping with treatment recommendations, Fluconazole 150mg quantity is limited to 1 tablet per copay.

Tessalon perles (Benzonatate) Phenergan syrup, Phen. VC with Codeine, Phen with codeine; Robitussin AC or Robitussin DAC; Hycodan tablets (not syrup) or OTC products

Phenergan VC (promethazine, phenylephrine, codeine); Robitussin AC (guaifenesin, codeine); Robitussin DAC (Guaifenesin, codeine, pseudoephedrine); Hycodan tabs (hydrocodone/homatropine) OR OTC products

Testoderm TTS 5 mg transdermal patch QD are no longer manufactured.

Androderm 2.5mg-5mg/24 hour transdermal patches; Testosterone injection 400 mg IM q2-4weeks administered in medical office. Injectables administered in a medical office are covered under the medical office benefit, NOT the drug benefit and are not available from a pharmacy for a copayment. Methyltestosterone (generic Android or Testred) tabs 10-20 mg QD-BID or Fluoxymesterone (Halotestin) 10 mg QD (tablets require baseline and periodic liver function testing)






Testoderm Scrotal patch 4mg or 6mg/24 hours are no longer manufactured, will remain available until supply exhausted

Androderm 2.5mg-5mg/24 hour transdermal patches; Testosterone injection 400 mg IM q2-4weeks administered in medical office. Injectables administered in a medical office are covered under the medical office benefit, NOT the drug benefit and are not available from a pharmacy for a copayment. Methyltestosterone (generic Android or Testred) tabs 10-20 mg QD-BID or Fluoxymesterone (Halotestin) 10 mg QD (tablets require baseline and periodic liver function testing)


Testosterone 2 to 3% manually compounded in cream base

N/A commercially available NF product Testosterone 2% in moisturizing cream ndc# 65628-021-01

Testosterone 2 to 3% manually compounded in an ointment base

N/A commercially available NF product Testosterone 2% in ointment ndc# 65628-020-01

Testosterone cyp 200 mg/ml injected Q 2-4 weeks Testosterone injection 400 mg IM q2-4weeks administered in medical office. Injectables administered in a medical office are covered under the medical office benefit, NOT the drug benefit and are not available from a pharmacy for a copayment. Methyltestosterone (generic Android or Testred) tabs 10-20 mg QD-BID or Fluoxymesterone (Halotestin) 10 mg QD (tablets require baseline and periodic liver function testing); Androderm 2.5mg-5mg/24 hour transdermal patches

Tevetan (Eprosartan) 400, 600mg tabs 400-800mg QD (also available as Tevetan HCT (Tevetan and HCTZ)

Prinivil (Lisinopril) 10 - 40mg QD or Cozaar (Losartan) 25 - 100mg QD

Prinivil is preferred, if no previous ACE inhibitor trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion: Tevetan 400mg=Prinivil10mg=Cozaar 25mg; Tevetan 600mg=Prinivil 20mg=Cozaar 50mg; Tevetan 800mg=Prinivil 40mg=Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Thalidomide 50mg capsules N/A Prescriber must contact mnfctr, Selgine, @ 1-888-423-5436 to obtain authorization # which is then written on the prescription. Prescriptions are then filled at STEPS participating Eckerd pharmacies.





Tiamate (Diltiazem extended release) 120, 180, 240mg 120 - 480 mg QD

Diltia (Diltiazem) XT 120, 180, 240mg caps 120-480mg QD

Substitute on a mg for mg basis. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Tiazac (Diltiazem extended release) 120, 180, 240, 300, 360mg 120 - 540mg QD

Diltia (Diltiazem) XT 120, 180, 240mg caps 120-480mg QD

Substitute on a mg for mg basis. Convert Tiazac 300mg to Diltia XT 240mg or 360mg (#2 x 180mg) Tiazac 480mg convert to Diltia XT 480mg (#2 x 240mg cap) TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Ticlid (Ticlopidine) 250mg BID Aggrenox (dipyridamole/asa) 25/200mg BID (if CVA) Or, Plavix 75mg QD (if cardiac stent, PTCA, MI or if CVA and ASA intolerant)

Aspirin therapy remains first line option. Formulary alternatives are available for patients who have failed aspirin trial or who are not candidates for aspirin trial.

Tikosyn (Dofetilide) 125-500mcg capsules BID N/A Tikosyn is available at specific Eckerd pharmacies. Call 1-877-TIKOSYN to locate the nearest Eckerd pharmacy. The Eckerd pharmacist will verify that the prescriber is documented in the database as participating in the TIKOSYN educational distribution program.

Tilade (Nedocromil) 2 puffs QID QVAR (Beclomethasone HFA) 40mcg/puff oral inhaler, i-ii puffs BID -OR- Flovent (Fluticasone) 44mcg/puff oral inhaler, i - ii puffs BID -OR- Intal (Cromolyn) 2 puffs QID

Inhaled corticosteroid QVAR preferred

Timoptic-XE (Timolol gel forming soln) 0.25-0.5% i drop in affected eye(s) QD

Timoptic ophth sol'n 0.25-0.5% i drop in affected eye(s) BID

Timoptic XE (gel forming solution allows QD administration with equivalent efficacy) is non formulary, timolol ophthalmic solution (BID administration initially, in some patients physician may reduce to QD when IOP stable) is formulary. If physician requests alternative beta blocker: Betoptic (Betaxolol) 0.25-0.5% i drop BID or Betagan (Levobunolol) 0.25-0.5% i drop BID are also formulary

Tindamax (Tinidazole) 250mg, 500mg tablets Metronidazole tablets Equal efficacy with metronidazole in treatment of non-metronidazole resistant trichomoniasis or giardiasis

Tolectin (Tolmetin) 200, 300, 600mg caps 200 - Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac 600mg TID TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium

Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg 1-2 QD-






Topamax tablet Seizure formulary alternatives - Tegretol, Neurontin, Lamictal, Depakote, Depakene, Keppra [R], Trileptal [R]

Topamax is restricted to Neurology. Please consider half tablets when prescribing.

Topicort (Desoximetasone) 0.05% cream Triamcinolone (generic Aristocort, Kenalog) cream, oint 0.1% or Valisone (Betamethasone Valerate) 0.1% lotion or Locoid Lipocream (Hydrocortisone Butyrate) 0.1% apply to affected area BID

Locoid lipocream is restricted to Dermatology. If failed other alternatives, consider increasing steroid potency to Fluocinonide (Lidex) 0.05% cream, oint, or gel.

Topicort (Desoximetasone) 0.25% cream, oint or 0.05% gel



Toradol (Ketorolac) tab 10 mg Q6H Ibuprofen (generic Motrin) 600-800 mg TID or Acetaminophen w/codeine (generic Tylenol #3) i-ii Q6H

Due to the risk of renal failure and GI bleeding, ketorolac tablets should not be administered more than 5 days. Ketorolac tablets are FDA approved for use after ketorolac injection only.

Toradol (Ketorolac) tab 10mg Q4-6H prn Ibuprofen 800 mg TID PRN or Naproxen 250-500 mg Q6-8H or sulindac (Clinoril) 200mg BID or diclofenac (Voltaren) 75mg BID or Relafen 500mg tab #2 QD - BID or etodolac (Lodine) 200-500mg Q8-12H up to 1200mg/day or Mobic (Meloxicam) 7.5mg or 15mg.

Due to the risk of renal failure and GI bleeding, ketorolac tablets should not be administered more than 5 days. Ketorolac tablets are FDA approved for use after ketorolac injection only.

Transderm-Nitro (Nitroglycerin) transdermal patch 0.1, 0.2,0.3, 0.4, 0.6, 0.8mg/hr patches

Minitran (Nitroglycerin) transdermal 0.1, 0.2, 0.4, 0.6mg/hr patches

Nitro-Dur 0.3 and 0.8mg/hr patches are covered, since Minitran is not available in these 2 strengths.

Tranxene-SD (Clorazepate) 11.25mg, 22.5mg QD Clorazepate (generic Tranxene) 3.25, 7.5, 15mg TID

Tranxene-SD 11.25mg QD = Clorazepate 3.25mg TID; Tranxene-SD 22.5mg QD = Clorazepate 7.5mg TID

Travatan (Travaprost) 1 drop in affected eye QHS Lumigan (Bimatoprost) 0.03% ophth solution 1 drop in affected eye QHS

Prostamide analog to reduce IOP in glaucoma. Not recommended to dose Travatan or Lumigan more frequently than qd. Separate administration from other eye drops by at least 5 minutes.

Triamcinolone acetonide (generic Kenalog or Aristocort) 0.5% cream, oint

Lidex (Fluocinonide) 0.05% cream, oint, gel or Diprolene AF (Augmented Betamethasone) 0.05%


Tricor (all formulations and doses 48mg to 200mg QD)

Fenofibrate 160 mg QD or 54 mg QD. If pt on Tricor dose < 100mg daily, convert to 54mg dose, if on dose > 100mg daily convert to 160mg QD.

Fenofibrate preferred if pt also taking statin. If pt has reduced renal function, consider offering gemfibrozil 600mg BID which is safer per kidney guidelines. Cost of fenofibrate and gemfibrozil similar. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Trileptal (Oxcarbazepine) tabs or liquid Tegretol (carbamazepine), Neurontin (gabapentin), Topamax (topiramate), Tranxene (clorazepate), Lamotrigine 5-25mg chews and Lamictal 100mg-200mg oral tablets

Trileptal is restricted to Neurology and Behavioral Health for the initial prescription fill. Reserved for patients with a good therapeutic response to Carbamazepine, but poor tolerability or drug interactions with Carbamazepine. Lamictal 25mg oral tablets are non-formulary as of 3/22/07; if a 25mg dose is required, Lamotrigine chewables are preferred.





Tri-Luma (Fluocinolone Acetonide 0.01%, Hydroquinone 4%, Tretinoin 0.05%) cream

N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.

Trinalin (1mg Azatadine / 120mg Pseudoephedrine) repetab i Q12H

OTC Chlor-Trimeton 12-hour Relief i tablet BID or OTC Drixoral Cold & Allergy i tablet BID

All cough and cold medications are non-formulary with the exception of Codeine, Hydrocodone, and Promethazine containing products.

Tri-Nasal (Triamcinolone) nasal spray Nasarel ii sprays each nostril BID or generic Flonase (fluticasone) i spray each nostril QD


Triphasil (0.05mg Levonorgestrel/ 30mcg EE x 6 days, 0.075mg Lvngl/ 40 mcg EE x 5 days, 0.125mg Lvngl/30mcg EE x 10 days)



Trivora-28 (0.05mg Levonorgestrel/ 30mcg EE x 6 days, 0.075mg Lvngl/ 40 mcg EE x 5 days, 0.125mg Lvngl/30mcg EE x 10 days)



Trusopt (Dorzolamide) 2% ophth soln i drop in affected eye TID

Azopt (Brinzolamide) 1% ophth susp i drop in affected eye TID

.

Tussionex (Chlorpheniramine 8mg and Hydrocodone 10mg) suspension

Phenergan syrup, Phen. VC with Codeine, Phen with codeine; Robitussin AC or Robitussin DAC; Hycodan tablets (not syrup) or OTC products

Phenergan VC (promethazine, phenylephrine, codeine); Robitussin AC (guaifenesin, codeine); Robitussin DAC (Guaifenesin, codeine, pseudoephedrine); Hycodan tabs (hydrocodone/homatropine) OR OTC products

Tympagesic (5% Benzocaine, 5% Antipyrine, 0.25% Phenylephrine, propylene glycol) Otic drops

Auralgan Otic (1.4% Benzocaine, 5.4% Antipyrine, Glycerin)

N/A

Tysabri (natalizumab) once every 4 weeks in a dose of 300 mg diluted in 100 ml Normal Saline given intravenously over about one hour

Must go through through manufacturer's TOUCH program and then meet QRM criteria. Criteria Restricted Medication Natalizumab

should usually be reserved for use in patients who have had an inadequate response to other MS therapies or patients who are not able to tolerate other MS therapies. Patients who are stable and well-controlled on other MS therapies should not be changed to natalizumab.

Ultracet (Tramadol 37.5mg/APAP 325mg) Q4-6H Tramadol 50mg Q 4 - 6 hours PLUS OTC Acetaminophen 325mg Q 4 - 6 hours

Acetaminophen w/codeine (generic Tylenol #3) i-ii Q6H or NSAID.

Ultrase (Pancrelipase enzymes) Pancrease (Pancrelipase enzymes) or Pangestyme


Ultravate (Halobetasol) 0.05% cream, oint Diprolene (Augmented Betamethasone Dipropionate) 0.05% oint or Temovate (Clobetasol) 0.05% cream, oint, gel, scalp soln


Uniphyl T.R. tab 400 mg QD generic Theo-Dur tab 200 mg BID N/A Uniphyl T.R. tab 600 mg QD generic Theo-Dur tab 300 mg BID N/A Uniretic (Moexipril/HCTZ) 7.5/12.5 and 15/25mg Prinivil (Lisinopril) 5mg - 40mg QD and

HCTZ 12.5mg - 25mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics





Univasc (Moexipril) 7.5, 15mg tabs 7.5 - 30mg QD Prinivil (Lisinopril) 5mg - 40mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Urised tablet Usept or Urinary Antiseptic #2 which are Methenamine compound (generic Urised)

May be substituted tablet for tablet without calling practitioner.

Urispas (Flavoxate) tabs Ditropan (Oxybutynin) tablets or Oxytrol patch

.

Uroxatral (Alfuzosin) 2.5mg IR QID; 5mg ER BID or 10mg ER QD

Doxazosin (generic Cardura) titrated to therapeutic doses (e.g. Doxazosin 2mg 1/2 tab po QHS X 1 week, then 1 tab po QHS x 2 weeks, then 2 tabs po QHS and follow-up w/MD for refill) or Terazosin (generic Hytrin) titrated slowly to therapeutic doses. (eg. 1mg QHS days 1-3, 2mg QHS days 4-15 then 5mg QHS, if necessary may further increase to 10mg QHS

Both agents are alpha-1 adrenoceptor antagonists and are capable of producing first-dose orthostatic hypotension. When initiating therapy, dose titration will help minimize orthostatic hypotension risk.

Uticort (Betamethasone Benzoate) 0.025% cream Triamcinolone (generic Aristocort, Kenalog) cream, oint 0.1%

If failed other alternatives, consider increasing steroid potency to fluocinonide (Lidex) 0.05% cream, oint, or gel

Vagifem (25.8mcg Estradiol vaginal tablets) Premarin vaginal cream 1/2 to 2 grams inserted vaginally daily to several times weekly

.

Valisone (Betamethasone Valerate) 0.1% cream Triamcinolone (generic Aristocort) cream, oint 0.1% or Valisone (betamethasone valerate) 0.1% lotion


Valisone (Betamethasone Valerate) 0.1% ointment Lidex (Fluocinonide) 0.05% cream, oint, gel, soln or Diprolene AF (Augmented Betamethasone) 0.05%


Valisone reduced strength (Betamethasone Valerate) 0.01% cream

Hydrocortisone 2.5% cream, oint or lotion Hydrocortisone 0.5-1% is available OTC

Valtrex (Valacyclovir) 500mg tab Herpes Zoster 1000 mg TID x 7 days; recurrent genital herpes 500 mg BID x 5 days

Herpes zoster Acyclovir 800mg Q4H, 5 times daily x 7 days (10 days if immunocompromised); genital herpes acyclovir 400mg TID x 7-10 days (5 days when tx recurrence, may use 800mg BID x 5 days for recurrence); chronic suppressive therapy 400mg BID, titrate to lowest effective suppressive dose

Valacyclovir is broken down into Acyclovir by the body. Herpes Labialis: consider OTC Abreva, Carmex or Orabase or oral Acyclovir if unresponsive to OTC therapy.

Vancenase (beclomethasone) nasal inhaler (pts ≥6 yrs old)



Vanceril oral inhaler ii-iiii puffs BID-TID QVAR (Beclomethasone HFA) 40mcg/puff oral inhaler, i-ii puffs BID.

QVAR is twice as potent as Vanceril (2 puffs 42mcg/puff = 1 puff QVAR 40 mcg/puff) and equipotent to Flovent 44mcg (1 puff QVAR 40mcg = 1 puff Flovent 44mcg/puff). QVAR remains the preferred inhaled corticosteroid at KP GA.





Vaniqa (Eflornithine) 13.9% cream N/A Drugs for cosmetic use are NOT covered on drug benefit. (Vaniqa removes unwanted facial hair.) Member pays retail price.

Vanlev (Omapatrilat) 10 - 80mg QD [dual vasopeptidase (metalloprotease) inhibitor--ACEI and neutral endopeptidase inhibitor] CHF dose: 10 -40mg QD HTN dose: 20 - 80mg QD

Lisinopril 20 - 80mg QD (one trial compares lisinopril 20mg to Vanlev 20-40mg) may consider adding HCTZ 12.5mg QD to maintain dual mechanism of action provided by Vanlev; lisinopril/HCTZ 10/12.5, 20/12.5 or 20/25mg or Cozaar 25 - 100mg QD

No dual vasopeptidase alternative on formulary. Prinivil (ACEI) is closest mechanistic alternative with or without HCTZ. Conversion dose should be individualized and adjusted to patient response.

Vanos (fluocionide) Lidex (anhydrous fluocinonide cream); Lidex-E (aqueous fluocinonide cream)

Vantin (Cefpodoxime) suspension Omnicef 125mg/5ml; Pediazole (Erythromycin & Sulfamethoxazole); Augmentin 125-250mg/5ml or 200-400mg chew tabs;Amoxicillin 125-250mg/5ml; Biaxin 125-250mg/5ml; Cefaclor suspension

.

Vaseretic tablet 10-25 mg ii tablets QD Lisinopril/HCTZ 20/25mg QD Two individual prescriptions are required. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Vaseretic tablet 10-25 mg QD Lisinopril/HCTZ 10/12.5mg, 20/12.5mg, 20/25mg QD

Two individual prescriptions are required. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Vaseretic tablet 5-12.5 mg QD Lisinopril/ HCTZ 10/12.5mg 1/2-1tab QD Two individual prescriptions are required. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Vasosulf (15% Sulfacetamide/ 0.125% Phenylephrine) 15% Sulfacetamide ophth soln AND OTC Phenylephrine 0.12% ophth soln

Combination product is non formulary. Sulfacetamide ophth soln is formulary and phenylephrine ophth soln is over the counter.

Ventolin Albuterol





Veramyst (Fluticasone) 27.5 mcg/inhalation Generic Nasarel (flunisolide) ii sprays each nostril BID or generic Flonase (fluticasone) i spray each nostril QD or QVAR i-ii puffs BID

Verelan (Verapamil) 120, 180, 240, 360mg QD Verapamil SR tabs (generic Calan SR) 120, 180, 240mg tabs 120-240 mg QD

Convert on a mg for mg basis. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Verelan PM (Verapamil) 100, 200, 300mg caps 100-400mg QHS

Verapamil SR tabs (generic Calan SR) 120, 180, 240mg tabs QD

Conversion equivalents: Verelan PM 100mg = Verapamil SR 120mg; Verelan PM 200mg = Verapamil SR 180-240mg; Verelan PM 300mg = Verapamil SR 240-360mg; Verelan PM 400mg = Verapamil SR 360mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Vesicare (Solifenacin succinate) 5mg and 10mg tablets

Oxybutinin (generic Ditropan) 5-10 mg tab i QD-BID (immediate release tablet) or Oxybutynin XL (generic Ditropan XL) 5-15mg QD or Oxytrol patch

If failed oxybutynin (regular and XL) consider Detrol LA (Detrol 1mg BID is equivalent to Detrol LA 2mg QD) If initiating Detrol therapy, the initial recommended dose Detrol LA is 4 mg QD; may decrease to 2 mg QD depending on tolerability and response.

Vexol (Rimexolone) ophth susp 1% i-ii drops in affected eye(s) QID

Consider at least 2 formulary products before prescribing/authorizing a NF product: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

N/A

Vfend (voriconazole) . Consult with an ID specialist Viagra 25, 50, 100mg tabs N/A Member's group must have purchased sexual

dysfunction rider for coverage. Consider Viagra 100mg 1/2 tablet when prescribing Viagra 50mg dose to reduce patient expense.

Vicon forte or Magna C-7 forte i QD Vitamins components available OTC as: OTC Stresstabs + Zinc i QD or OTC Centrum Silver i QD or other OTC vitamins

N/A

Vicoprofen (7.5mg Hydrocodone/ 200mg Ibuprofen) Hydrocodone/Acetaminophen in the following strengths: 5mg/500mg; 7.5mg/500mg; 7.5mg/650mg, 10mg/650mg, 7.5mg/750mg AND OTC ibuprofen 200mg

Generics of the following used: Lortab 7.5/500; Lorcet plus 7.5mg/650mg; Lorcet 10mg/650mg; Vicodin 5mg/500mg; Vicodin 5mg/500mg; Vicodin ES 7.5mg/750mg.





Vigamox (Moxifloxacin) 0.5% Ofloxacin 0.3% or Gentamicin 0.3% or Tobramycin 0.3% or Sodium Sulfacetamide ophth soln or Zymar 0.3%

Lasik ophthalmic surgery is not a covered benefit. Medications related to non covered procedures are not covered by the drug benefit.

Viokase (Pancrelipase enzymes) Pancrease (Pancrelipase enzymes) or Pangestyme


Viquin forte no formulary alternative Cosmetic use drug. Not covered on drug benefit. Member pays full retail price.

Visken (Pindolol) 5, 10mg tabs 5-30mg BID Atenolol (generic tenormin) 25 - 100mg QD or metoprolol 100 - 400mg QD or propranolol 40 - 320mg BID

Propranolol is available as 10, 20, 40, 60, 80, 90mg tabs. Inderal LA is non-formulary. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics

Vistaril (Hydroxyzine Pamoate) cap 25-50 mg TID-QID Hydroxyzine HCl tabs (generic Atarax) 25-50 mg TID-QID

Vivelle (Estradiol) transdermal patch apply twice weekly 2.17mg, 3.28mg, 4.33mg, 6.57mg, 8.66mg patches deliver 0.025mg/day, 0.0375mg/day, 0.05mg/day, 0.075mg/day, 0.1mg/day respectively.



Vivelle-DOT (Estradiol) transdermal patch apply twice weekly 0.78mg, 1.17mg, 1.56mg, patches deliver 0.05mg/day, 0.075mg/day, 0.1mg/day respectively. 66% smaller patch size than Vivelle

Climara .025mg, 0.0375mg, .05mg, 0.06mg .075mg, .1mg patches apply one patch weekly; or Estrace 0.5, 1 or 2mg (Estradiol)

If an estrogen patch is required, Climara. NF Vivelle DOT delivers the same estradiol dose as NF Vivelle, though actual patch size is smaller. Vivelle and Vivelle DOT are AB rated equivalents. NF Vivelle, not NF Vivelle DOT, may be dispensed at KP pharmacies.

Volmax (Albuterol extended release) tablets Consider Albuterol inhaler, QVAR (Beclomethasone) inhaler if asthma and not using steroid inhaler, Serevent inhaler if long acting beta 2 agonist necessary, or immediate release albuterol tablets.

Extended release Albuterol tablets are no longer manufactured.

Vytorin (Ezetimibe/Simvastatin) 10/10, 10/20, 10/40 (effective 9/05,Vytorin 10/80mg is formulary)

Consider trying Simvastatin (generic Zocor) PLUS either: Cholestyramine powder OR Cholestyramine light powder 4-8 gm BID OR Slo-niacin OR Time-release niacin 500 mg BID OR Colestid 1gm tablets 2-4gm BID. Cholestyramine preferred over Colestid. The effects of Ezetimibe on cardiovascular morbidity and mortality have not been established. For vytorin 10-40mg dose, consider vytorin 10-80mg tablet, 1/2 tablet po QD.

Vytorin 10/80mg is formulary. Vytorin may be appropriate if simvastatin 80mg QD plus niacin or BAS was ineffective OR if pt on concurrent medication(s) whose absorption would be inhibited by BAS such as tranplant medications. Vytorin is preferred over use of zetia plus statin as separate prescriptions. All other Vytorin doses other than 10/80 mg are non-formulary. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Wellbutrin SR 200mg (Bupropion) Wellbutrin SR 150mg or Wellbutrin 75mg or 100mg tablets.


Wellbutrin XL 150mg & 300mg QD Wellbutrin SR (bupropion SR) 150mg or Wellbutrin (bupropion 75mg or 100mg) tablets

[Wellbutrin XL: Available Part D group]





Welchol (Colesevelam) 3 tabs BID Consider Cholestyramine powder 4 - 8gm QD -OR- Colestid (colestipol) 1gm tablets: 2 gm BID or 4gm QD -OR- if a statin is not already being used, consider Lovastatin 20-40mg QPM -OR- Simvastatin 20mg QHS -Or- Vytorin 10/80 -OR- Zetia

Welchol is a bile acid sequestrant, reducing LDL cholesterol by 18%. Cholestyramine/Colestipol reduce LDL cholesterol by 30%. Statins reduce LDL cholesterol by 30-60%. May prefer to avoid all BAS including welchol for pts on cyclosporine or HIV meds. Welchol may have less binding effects than other BAS. BAS therapy may be preferred over statin for patients with very elevated liver tests. Consider adding OTC Slo-Niacin 500mg QD titrated to BID to statin before adding BAS, if appropriate for pt. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Westcort (Hydrocortisone valerate) cream, oint 0.2% apply to affected are BID [medium potency]

Triamcinolone (generic Aristocort, Kenalog) cream, oint 0.1%


Xalatan ophth sol'n 1 drop in affected eye QD - BID Lumigan (Bimatoprost) 0.03% ophth solution 1 drop in affected eye QHS

Prostamide analog to reduce IOP in glaucoma. Lumigan is not as effective when administered more often than QD. Convert Xalatan 1 drop BID to lumigan 1 drop QD. separate Lumigan from administration of other eye drops by at least 5 minutes.

Xanax XR 0.5mg, 1mg, 2mg or 3mg tablets QD alprazolam 0.25mg, 0.5mg, 1mg, 2mg When converting, Xanax XR once daily is equivalent to the same total daily dose of alprazolam (generic Xanax) immediate-release administered in divided doses TID (e.g. Xanax XR 2mg would convert to alprazolam 0.5mg TID -QID)

Xatral (Alfuzosin) 7.5 - 10mg divided into 3 daily doses (alpha 1 adrenergic blocker)

Doxazosin (generic Cardura) titrated to therapeutic doses (e.g. Doxazosin 2mg 1/2 tab po QHS X 1 week, then 1 tab po QHS x 2 weeks, then 2 tabs po QHS and follow-up w/MD for refill) or Terazosin (generic Hytrin) titrated slowly to therapeutic doses. (eg. 1mg QHS days 1-3, 2mg QHS days 4-15 then 5mg QHS, if necessary may further increase to 10mg QHS

Unless converting from an equivalent dose of an alpha adrenergic blocker, titrate Terazosin slowly to therapeutic doses.

Xenical cap 120 mg TID N/A Agents for weight loss or obesity are not covered. Patient pays full retail price.

Xifaxan (Rifaximin) 200mg #2 BID x 3 days for travelers' diarrhea

For Travelers' Diarrhea: Ciprofloxacin 500mg BID x 3 days

.

Xolair (Omalizumab) injectable (not self administered, to be provided by physician in office)

Criteria Restricted Medication Criteria Restricted Medication. Provider phone KP QRM 404-364-7320 to request authorization consideration.

Xopenex inhalation solution 0.625 mg TID-QID via nebulizer

Albuterol inhalation solution 2.5 mg TID-QID via nebulizer

N/A

Xylocaine 2% jelly Lidocaine topical gel (per chronic pain guideline) or OTC L-M-X4 (4% topical lidocaine cream) or OTC Lidosense 4 (4% topical lidocaine cream) or OTC Axsain cream (4% lidocaine combined with 0.25% capsaicin cream)

N/A





Xyzal (Levocetirizine) tablets Claritin OTC or Zyrtec OTC Intranasal steroids (Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray each nostril QD) more effective than nonsedating antihistamines for allergic rhinitis.

Yasmin 28 (3 mg Drospirenone/ 30 mcg EE) Sprintec, generic Ortho-Cyclen, (0.25mg Norgestimate/ 35 mcg EE) or Zovia 1/35 (Ethynodiol 1mg/35mcg EE)

Levlen (0.15 Levonorgestrel/ 30 mcg EE) or Microgestin 1.5/30 (1.5 Norethindrone/30mcg EE) or Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x 6 days, 0.075mg Lvngl & 40mcg EE x 5 days, 0.125mg Lvngl & 30mcg EE x 10 days) or Brevicon (.5mg ne/ 35EE), Microgestin 1/20 (1 NE/20mcg EE), Zovia1/35 (Ethynodiol 1mg/35 EE), Norinyl 1/35 (1mg NE/ 35mcg EE) Norinyl 1/50 (1mg NE/ 50mcg Mestranol), or NORQD (0.35 NE only) Document diagnosis (If PCOS is the reason for the request then benefit coverage may be extended).

Zaditor (ketotifen) .025% ophth soln For allergic conjunctivitis: OTC Opcon-A (Pheniramine & Naphazoline) or OTC Zaditor 0.25% [NOTE: OTC products are not a covered benefit]

OTC Zaditor 0.25% and Patanol are both dual action antihistamine/mast cell stabilizers, are dosed twice daily, and have the same FDA approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product : Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

Zegerid (Omeprazole) powder for oral suspension 20mg

OTC Prilosec 20mg tablet. (If cannot swallow tablet, OTC prilosec will disperse in 5cc of water in less than 60 seconds with gentle agitation. Dose should be taken immediately after dispersal in liquid.)

Prilosec OTC

Zelnorm (Tegaserod) 2mg BID 5HT4 agonist [also branded zelmac]

Lactulose 3 tablespoonsful QD to TID OR OTC Miralax (Polyethylene glycol powder for oral solution) 17gm in 8 ounces of water QD OR other OTC bulk forming laxatives for constipation

Miralax is now available OTC. OTC products are not a covered benefit. Prescribers are encouraged to to consider OTC options if appropriate. Zelnorm used for shortterm treatment of women with irritable bowel syndrome and primary symptom constipation. (Zelnorm available MMA group)

Zestril (Lisinopril) Lisinopril (generic prinivil)





Zetia (Ezetimibe) 10mg QD tablet OTC Slo-Niacin/ Time Release niacin 500mg OR cholestyramine powder 4 - 8gm BID OR Colestid (colestipol) 1gm tablets 2-4gm BID OR if a statin is not already being used, consider Lovastatin 20-40mg QPM OR Simvastatin 20mg QHS

Zetia monotherapy may be appropriate only if pt has intolerance to MULTIPLE statins. Note that zetia is not recommended to use in combination with gemfibrozil. The effects of Ezetimibe on cardiovascular morbidity and mortality have not been established. Zetia is expected to lower LDL 15 -20% compared to statins that can lower LDL 30-60%. Zetia is no more effective than BAS therapy in lowering cholesterol. Adding Zetia to statin therapy may be appropriate if max dose statin plus niacin or BAS was ineffective OR if pt is not appropriate candidate for niacin or BAS OR if pt has intolerance to simvastatin or Vytorin. Vytorin is preferred over use of zetia plus statin as separate prescriptions. All other Vytorin doses other than 10/80 mg are non-formulary. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.

Zoloft (Sertraline) tab 25-100 mg QD Prozac caps 10-40 mg QD or Celexa Prozac is the preferred agent. Initiation of low-(Citalopram) 20-40mg QD or Sertraline 25 - dose Prozac with dosage titration to desired 100mg QD (added to formulary Mar 8th response is suggested. Document response to 2007) all formulary SSRI alternatives before

prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.

Zofran (Ondansetron) tabs 4mg-8mg BID & Zofran Limited to 14 day supply per prescription, Zofran oral liquid & IV available via pediatric (ondansetron) ODT 4mg-8mg per 30 days floorstock for in office dose to break pediatric n/v

cycle & allow hydration in children unable to use phenergan safely (</= 2 yoa)

Zomig (Zolmitriptan) 2.5-5 mg tab prn for migraine headache

Maxalt (Rizatriptan) MLT 10mg tablet (Maxalt MLT 5mg tablet is also available)

Maxalt MLT 10 mg is preferred, Maxalt MLT QTY limit of 9 tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Quantity limit for Non-formulary Zomig 5mg is 3 tablets per copay; for Zomig 2.5mg it's 6 tablets per copay.

Zomig (Zolmitriptan) 5mg Nasal Spray Maxalt (Rizatriptan) MLT 10mg orally disintegrating tablet (Maxalt MLT 5mg tablet is also available) QTY limit of 9 tablets/copay OR, if nasal spray required, Imitrex 20mg Nasal Spray

Imitrex 20 mg nasal spray is significantly more effective than Imitrex 5 mg nasal spray. The same precautions and contraindications apply for both strengths of nasal spray. Maximum prescription quantity for Imitrex 20 mg spray is 6 bottles/prescription.

Zonegran (Zonisamide) tab Neurontin (gabapentin), Topamax (topiramate), Tranxene (clorazepate), Tegretol (carbamazepine), Lamotrigine 5-25mg chews and Lamictal 100mg-200mg oral tablets

Adjunctive therapy for partial seizures in adults > 16 yrs of age. Lamictal 25mg oral tablets are non-formulary as of 3/22/07; if a 25mg dose is required, Lamotrigine chewables are preferred.





Zovirax 5% ointment 6 times per day x 7 days TSPMG clinical practice resource encourages treatment with oral Acyclovir (generic Zovirax) tab. 1st episode Herpes simplex: 400mg TID x 7-10 days, recurrence 800mg BID x 5 days, suppression 400mg BID titrate to lowest effective dose. Herpes Zoster: acyclovir 800mg 5 times per day x 7-10 days.

Principles and Practice of Infectious Disease "discourages use of topical acyclovir" stating that it "offers no significant clinical benefit in HSV infections" Acyclovir ointment is ineffective in treatment or prevention of herpes labialis. Consider OTC Abreva ( shortened the course by 18 hours) or Carmex or Orabase for herpes labialis to prevent drying and fissuring. Domoboro soaks may relieve itching and dry blisters. Consider OTC Capsaicin cream for pain associated with shingles.

Zyban (Bupropion SR) 150mg OTC Nicotrol (Nicotine transdermal system) 5, 10, 15mg/day


Zyflo tab 600 mg QID ICS inhaler (QVAR or *Flovent or Asmanex) plus a long acting B2-agonist (Serevent) OR an ICS and B2 agonist

*Flovent 110mcg/puff & 220mcg/puff are non-formulary .

Zylet (loteprednol etabonate 0.5% / tobramycin 0.3%) ophthalmic suspension

Tobramycin 0.3% ophth drops PLUS either: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID

Post op inflammation (when steroids not desired): Voltaren 0.1% ophth soln [Loteprednol 0.5% (Lotemax) less effective than Prednisolone Acetate 1% in treatment of acute anterior uveitis]

Zyprexa zydis (Olanzapine) orally disintegrating tabs 5, 10, 15, 20mg

Seroquel (quetiapine) or Zyprexa (olanzapine) 2.5, 5, 7.5, 10, 15mg tabs or Risperdal (risperidone)

Consider using 1/2 tablet dosing whenever appropriate (eg. Seroquel 200mg 1/2 tablet for Seroquel 100mg dose or Risperdal 1mg 1/2 tablet for Risperdal 0.5mg dose.)

Zyrtec tab 5 -10 mg QD Claritin and Zyrtec available OTC. Nasarel ii spray per nostril BID or generic Flonase (fluticasone) 1SP EN QD

Intranasal steroids (Nasarel or Flonase) more effective than nonsedating antihistamines for allergic rhinitis.

Zyrtec-D 5/120MG Claritin D and Zyrtec D available OTC. Nasarel ii spray per nostril BID or generic Flonase (fluticasone) 1SP EN QD

Intranasal steroids (Nasarel or Flonase) more effective than nonsedating antihistamines for allergic rhinitis. Zyrtec-D is excluded from the benefit because pseudoephedrine is available OTC.

Zyrtec syrup Claritin and Zyrtec syrups available OTC. Intranasal steroids (Nasarel or Flonase) more effective than nonsedating antihistamines for allergic rhinitis.

zzPrepared: February 8, 1998 Beth Barham, Pharm.D. zzUpdated: April 10, 2000 Theresa Betteker, Pharm.D zzUpdated: August 18, 1999 Beth Barham, Pharm.D. zzUpdated: August 18, 1999 Beth Barham, Pharm.D. zzUpdated: December 7, 1999 Beth Barham, Pharm.D. zzUpdated: July 25, 2001 Debbi Baker, Pharm. D. zzUpdated: August 14, 2001 Debbi Baker, Pharm. D. zzUpdated: September 13, 2001 Debbi Baker, Pharm. D. zzUpdated: October 31, 2001 Debbi Baker, Pharm. D. zzUpdated: November 21, 2001 Debbi Baker, Pharm. D. zzUpdated: January 8, 2002 Beth Barham, Pharm.D. zzUpdated: April 10, 2002 Debbi Baker, Pharm. D. zzUpdated: April 22, 2002 Debbi Baker, Pharm. D. zzUpdated: June 19, 2002 Debbi Baker, Pharm. D. zzUpdated: July 22, 2002 Debbi Baker, Pharm. D. zzUpdated: September 13, 2001 Debbi Baker, Pharm. D. zzupdated: December 11, 2002 Debbi Baker, Pharm. D. zzUpdated: January 8, 2003 Debbi Baker, Pharm. D. zzUpdated: March 26, 2003 Debbi Baker, Pharm. D.





zzUpdated: July 11, 2003 Debbi Baker, Pharm. D. zzUpdated: July 18, 2003 Debbi Baker, Pharm. D. zzUpdated: September 26, 2003 Debbi Baker, Pharm. D. zzUpdated: October 22, 2003 Debbi Baker, Pharm. D. zzUpdated: November 12, 2003 Debbi Baker, Pharm. D. zzUpdated: December 2, 2003 Debbi Baker, Pharm. D. zzUpdated: February 10, 2004 Debbi Baker, Pharm. D. zzUpdated: February 27, 2004 Debbi Baker, Pharm. D. zzUpdated: March 15, 2004 Debbi Baker, Pharm. D. zzUpdated: April 19, 2004 Debbi Baker, Pharm. D. zzUpdated: May 14,2004 Debbi Baker, Pharm. D. zzUpdated: July 13, 2004 Debbi Baker, Pharm. D. zzUpdated: September 15, 2004 Debbi Baker, Pharm. D. zzUpdated: October 19, 2004 Debbi Baker, Pharm. D. zzUpdated: November 12, 2004 Debbi Baker, Pharm. D. zzUpdated: December 20, 2004 Debbi Baker, Pharm. D. zzUpdated: January 25, 2005 Debbi Baker, Pharm. D. zzUpdated: February 15, 2005 Debbi Baker, Pharm. D. zzUpdated: March 31, 2005 Debbi Baker, Pharm. D. zzUpdated: May 20,2005 Debbi Baker, Pharm. D. zzUpdated: June 7, 2005 Debbi Baker, Pharm. D. zzUpdated: July 7, 2005 Debbi Baker, Pharm. D. zzUpdated: July 11, 2005 Elizabeth Flores, Pharm.D. zzUpdated: July 21, 2005 Elizabeth Flores, Pharm.D. zzUpdated: August 15,2005 Phyllis Lockridge, Pharm.D. zzUpdated: August 25, 2005 Jacinda Byrd-Smith, Pharm. D. zzUpdated: September 14,2005 Debbi Baker, Pharm. D. zzUpdated: September 21,2005 Phyllis Lockridge, Pharm.D. zzUpdated: September 27,2005 Phyllis Lockridge, Pharm.D. zzUpdaated: January 25, 2006 Phyllis Lockridge, Pharm.D. zzUpdated: March 1, 2006 Phyllis Lockridge, Pharm.D. zzUpdated: June ***, 2006 Pat daCosta, Pharm.D. zzUpdated: August 21, 2006 Pat daCosta, Pharm.D. zzUpdated: December 7, 2006 Pat daCosta, Pharm.D. zzUpdated: February 21, 2007 Pat daCosta, Pharm.D. zzUpdated: March 16, 2007 Pat daCosta, Pharm.D. zzUpdated: May 29, 2007 Pat daCosta, Pharm.D. zzUpdated: August 22, 2007 Charnelda Gray, Pharm.D., BCPS zzUpdated: December 5, 2007 Charnelda Gray, Pharm.D., BCPS zzUpdated: February 25, 2008 Dionne Maddox, Pharm.D.


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