Preferred Drug Formulary

Transcription

1 Drug Formulary Effective August 2018 ACE Inhibitors Alzheimer s Agents benazepril captopril fosinopril lisinopril moexipril quinapril ramipril trandolapril donepezil galantamine ER capsules memanine IR tablets rivastigmine capsules enalapril perindopril Anaphylaxis Kits Epinephrine autoinjector (Twinject) EpiPen Angiotensin Blockers Anticoagulants Injectable Post Hip/Knee DVT Prophylaxis Anticonvulsants Antidepressants Other candesartan losartan losartan HCT irbesartan Irbesartan HCT enoxaparin heparin carbamazepine divalproex gabapentin lamotrigine oxcarbazepine phenobarbital phenytoin primidone topiramate IR tablets & capsules topiramate ER sprinkle capsules zonisamide bupropion bupropion SR tablets duloxetine mirtazapine tablet & ODT trazodone venlafaxine immediate release tablets venlafaxine ER Namenda XR Namenda Solution Namzeric Rivastigmine capsules rivastigmine patch olmesartan olmesartan HCT Edarbi eprosartan telmisartan telmisartan HCT valsartan valsartan HCT fondaparinux Fragmin levetiracetam XR Oxtellar XR Trokendi XR Aplenzin bupropion XL-24H tablets Fetzima Forfivo XL Oleptro Pristiq Viibryd Page 1 of 8

2 Symbria Rx Services Drug Formulary Effective August 2018 Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs) Antidiabetic Agents DPP-4 Inhibitors Antidiabetic Agents GLP-1 Receptor Agonists Antidiabetic Agents - Other Antiemetic/Antivertigo Agents Antifungals Topical Antiparkinson Agents citalopram fluoxetine paroxetine tablet sertraline alogliptin Tradjenta Tanzeum Bydureon Trulicity glimeperide glipizide glipizide/metformin metformin metformin ER pioglitazone pioglitazone/metformin meclizine metoclopramide ondansetron ODT ciclopirox cream clotrimazole clotrimazole/betamethasone cream ketoconazole miconazole nystatin terbinafine carbidopa-levodopa pramipexole ropinirole escitalopram fluvoxamine ER Pexeva Trintellix Januvia Janumet Jentadueto Janumet XR Kombiglyze XR Onglyza Oseni Bydureon Byetta Victoza Trulicity Farxiga Metformin ER modified release Invokana Jardiance Riomet Anzemet dronabinol ondansetron solution prochlorperazine Sancuso Zuplenz ciclopirox susp, shampoo, gel clotrimazole/betamethasone lotion econazole Ertaczo Exelderm Luzu 1% Mentax Naftin nystatin/triamcinolone Oxistat Duopa suspension Neupro Rytary *More expensive than other preferred choice(s) but less than most non-formulary items. Page 2 of 8

3 Symbria Rx Services Drug Formulary Effective August 2018 Antipsychotics 2 nd generation Benign Prostatic Hyperplasia (BPH) Agents Alpha Adrenergic Blockers Beta-Adrenergic Blocking Agents quetiapine risperidone ziprasidone alfuzosin doxazosin tamsulosin terazosin atenolol labetalol metoprolol tartrate metoprolol succinate C. Difficile Treatment vancomycin oral compound solution metronidazole aripiprazole Fanapt Latuda Olanzapine Paliperidone ER Rexulti risperidone oral solution Saphris Vraylar Cardura XL Rapaflo Chronic Gout Therapy Allopurinol Uloric COX-2 Inhibitors meloxicam celecoxib Vivlodex Bystolic carvedilol ER capsules Dificid vancomycin capsules Xifaxan Glaucoma Agents Alpha-2 Agonists brimonidine 0.2% brimonidine 0.1% brimonidine 0.15% Simbrinza 1%/0.2% (brinzolamide 1% /brimonidine 0.2%) Glaucoma Agents Carbonic Anydrase Inhibitors Glaucoma Agents Beta-Adrenergic Antagonists dorzolamide betaxolol 0.5% carteolol levobunolol metipranolol timolol Azopt Betoptic-S 0.25% Glaucoma Agents Prostaglandins latanoprost 0.005% bimatoprost 0.03%, 0.01% Travatan Z 0.004% Zioptan % Histamine 1 Antagonists (Non- Sedating) Histamine 2 Antagonists loratadine cetirizine tablets fexofenadine famotidine tablets (may be crushed) ranitidine (may be crushed) cetirizine syrup desloratadine levocetirizine Loratadine ODT famotidine suspension ranitidine syrup *More expensive than other preferred choice(s) but less than most non-formulary items. Page 3 of 8

4 Symbria Rx Services Drug Formulary Effective August 2018 Inhaled Anticholinergic Agents Inhaled Beta-Adrenergic (Short Acting) Inhaled Long-Acting Beta-Adrenergic Agents (LABA) Inhaled Long-Acting Beta-Adrenergic (LABA) and Long-Acting Muscarinic Antagonist (LAMA) Agents Insulins Laxatives ipratropium 0.02% solution ipratropium/albuterol sulfate solution Spiriva Handihaler albuterol inhalation solution ipratropium/albuterol sulfate solution Ventolin HFA Striverdi Respimat Anoro Ellipta Admelog Basaglar Humalog vial 3ML Humalog Mix 75/25 vial Humulin 70/30 vial 3ML Humulin NPH vial 3ML Humulin R vial 3 ML Bisacodyl Colace Miralax Senna Senna-S Atrovent HFA Combivent Respimat Incruse Ellipta Spiriva Respimat Tudorza Combivent Respimat levalbuterol Maxair ProAir HFA Proventil HFA Xopenex HFA Arcapta Brovana Perforomist Serevent Diskus Bevespi Stiolto Utibron neohaler Apidra Fiasp Humalog 200 u/ml Humalog Mix 75/25 pens Lantus Levemir Novolin 70/30 Novolin N Novolin R Novolog Mix 70/30 Novolog Toujeo Tresiba Amitiza Linzess Movantik Symproic Leukocyte Growth Factor (G-CSF) Granix Neupogen Lipotropics Other cholestyramine colestipol fenofibrate (48mg, 50mg, 54mg, 67mg, 134mg, 145mg, 160mg, 200mg) fenofibrate micronized (43mg, 67mg, 134mg, 200mg) fenofibric acid 35mg, 45mg gemfibrozil omega 3 fatty acids (fish oil OTC) Antara Epanova fenofibric acid 105mg fenofibrate (40mg, 120mg, 150mg) fenofibrate micronized 130mg, 135mg omega-3-acid ethyl ester Praluent injection Repatha injection Vascepa Welchol *More expensive than other preferred choice(s) but less than most non-formulary items. Page 4 of 8

5 Symbria Rx Services Drug Formulary Effective August 2018 Lipotropics Statins & Combinations Low Molecular Weight Heparins (LMWHs) and Related atorvastatin lovastatin pravastatin simvastatin See Anticoagulants Altoprev Ezetimibe/Simvastatin Livalo rosuvastatin See Anticoagulants Multiple Sclerosis Agents Extavia Betaseron Muscle Relaxants cyclobenzaprine 10 mg Amrix Narcotic Pain Agents Neuropathic Pain Agents - Oral fentanyl transdermal patch (not for intermittent pain) hydrocodone/acetaminophen hydromorphone morphine sulfate ER 12H tablet morphine sulfate IR oxycodone/acetaminophen oxycodone IR duloxetine gabapentin fentanyl lozenge Fentora Hysingla morphine ER 24H capsule Nucynta Nucynta ER oxycodone ER Zohydro ER Lyrica Neuropathic Pain Agents Topical Ophthalmics Antibiotics lidocaine 4% patch menthol cream/gel/pach trolamine salicylate cream/lotion Ophthalmics Anti-inflammatory diclofenac 0.1% ketorolac 0.4% flurbiprofen 0.03% bacitracin ophthalmic ointment ciprofloxacin 0.3% solution erythromycin 0.5% ointment gentamicin 0.3% solution & ointment levofloxacin 0.5% solution moxifloxacin 0.5% solution ofloxacin 0.3% solution sulfacetamide sodium 10% solution tobramycin 0.3% solution tobramycin-dexamethasone 0.3%-0.1% lidocaine 5% patch Azasite 1% solution Besivance 0.6% solution Ciloxan 0.3% ointment gatifloxacin 0.5% solution Moxeza 0.5% solution Tobrex 0.3% ointment Acuvail 0.45% Bromfenac 0.09% Bromsite 0.09% Ilevro 0.3% ketorolac 0.5% Nevanac 0.1% Prolensa 0.07% Vexol 1% *More expensive than other preferred choice(s) but less than most non-formulary items. Page 5 of 8

6 Symbria Rx Services Drug Formulary Effective August 2018 Osteoporosis Treatments alendronate oral solution alendronate tablet Binosto calcitonin nasal etidronate Forteo Fosamax Plus D ibandronate Miacalcin Injection Prolia raloxifene risedronate IR & ER Xgeva Other Endocrine/Metabolism megestrol suspension 200 mg/5 ml Megace ES 625 mg/5 ml Phosphate Binders Platelet Aggregation Inhibitors Primary Pulmonary Hypertension Agents Proton Pump Inhibitors and Other Gastrointestinals Sedative Hypnotics calcium acetate tablets Renvela (2 nd line*) clopidogrel cilostazol sildenafil 20mg omeprazole omeprazole OTC pantoprazole sucralfate tablets (can be crushed) Zegerid OTC temazepam 15mg, 30mg zaleplon zolpidem calcium acetate capsules Fosrenol Renagel Renvela powder packets aspirin-dipyridamole ER Brilinta Effient Zontivity Adcirca Cialis Tracleer Uptravi Viagra Carafate suspension Dexilant esomeprazole lansoprazole Prevacid solutab rabeprazole Zegerid (omeprazole/sodium bicarbonate) Belsomra doxepin 3mg & 6mg Edluar (zolpidem sublingual) eszopiclone Intermezzo Rozerem temazepam 7.5mg temazepam 22.5mg zolpidem ER *More expensive than other preferred choice(s) but less than most non-formulary items. Page 6 of 8

7 Symbria Rx Services Drug Formulary Effective August 2018 Steroids - Inhaled Steroids - Nasal Steroids Topical (High potency) Topical Antibiotics Ulcerative Colitis Agents Arnuity Ellipta Breo Ellipta budesonide nebules budesonide Flonase OTC flunisolide fluticasone Nasacort OTC betamethasone valerate 0.1% oint betamethasone dip 0.05% cream triamcinolone 0.5% cream metronidazole 0.75% lotion mupirocin 2% ointment balsalazide budesonide 3mg capsules mesalamine 4gm enema Advair Advair HFA Alvesco HFA Asmanex Dulera Flovent Pulmicort 1mg/2ml nebs Pulmicort Flexhaler Qvar Symbicort Beconase AQ Dymista mometasone Omnaris triamcinolone AQ Veramyst Zetonna amcinonide 0.1 % cream, lotion, ointment betamethasone diprop augmented 0.05% lotion, creambetamethasone dipropionate 0.05% ointment desoximetasone 0.05% cream, gel, ointment diflorasone 0.05% cream fluocinonide 0.05 % cream, gel, ointment Halog 0.1% cream, ointment metronidazole 0.75% cream & gel metronidazole 1% gel mupirocin 2% cream Noritate 1% cream Apriso Asacol HDCanasa suppository Delzicol Giazo Humira Lialda Pentasa Uceris *More expensive than other preferred choice(s) but less than most non-formulary items. Page 7 of 8

8 Symbria Rx Services Drug Formulary Effective August 2018 Urinary Anti-Incontinence Agents Vitamins & Minerals oxybutynin XL Oxytrol for Women patch (OTC) tolterodine LA trospium potassium Cl 20mEq tablets (dissolve in water) Enablex Gelnique Myrbetriq Oxytrol (Rx) patch tolterodine Toviaz trospium ER Vesicare potassium 20mEq powder packets *More expensive than other preferred choice(s) but less than most non-formulary items. Page 8 of 8