Allergy

MediCal Managed Care
HEALTH PLAN OF SAN JOAQUIN
DRUG FORMULARY
Foreword
This document provides physicians and pharmacists with a method to begin to evaluate the
various drug products available. The medical treatment of patients is frequently relative to the
practical application of drug therapy. Due to the vast availability of medication therapy and
treatment modalities, a reasonable program of drug product selection and drug usage must be
developed. The goal of the Drug Formulary is to enhance the physician and pharmacist’s abilities
to provide optimal cost effective drug therapy for patients.
The development, maintenance, and improvement of this process are evolutionary and require constant attention. The Formulary is a continually reviewed and revised list of drugs, which mirror the prevailing clinical opinion of the P & T and Formulary Committees. Unfortunately, this dynamic process does not allow this document to be completely accurate at all times. To accommodate the necessary changes of this document, updates are sent regularly. How to Use the Drug Formulary
The Drug Formulary is a list of covered and preferred drug agents for members. All drugs are
listed by their generic names and most common proprietary (branded) name. The Drug
Formulary may be accessed by using either the generic or proprietary name (in small capital
letters) and by therapeutic drug category. The brand names listed are for reference use only, and
do not denote coverage, unless specifically noted. Any drug not found in this Formulary listing
shall be considered a Non-Formulary drug.
All drugs are listed in each category in alphabetical order by generic name. Where an FDA
approved generic is available for the listed generic name, the generic name is bolded.
For certain agents within the Drug Formulary, a recommended prescribing guideline may apply. These are denoted throughout the document using the following symbols: Coverage may depend on prescribing physician’s specialty or board certification Requires specific physician request process Coverage may be limited to specific quantities per prescription and/or time period Coverage may depend on previous use of another drug Benefit Coverage and Limitations
This printed Formulary does not provide information regarding the specific coverage and
limitations an individual member may have. Many members have specific benefit inclusions,
exclusions, copays, or a lack of coverage, which are not reflected in the Drug Formulary.
The Drug Formulary applies only to outpatient drugs provided to members, and does not apply to
medications used in inpatient settings. If a member has any specific questions regarding their
coverage, they should contact their Plan Sponsor or MedImpact at (800) 788-2949.
ALLERGY
2nd Gen Antihistamine & Decongestant
Combinations

p-ephed sul/loratadine
Antihistamines
chlorpheniramine maleate
Antihistamines - 1st Generation
chlorpheniramine maleate
CHLOR-TRIMETON CHLOR-TRIMETON ALLERGY REPETAB clemastine fumarate
cyproheptadine hcl
diphenhydramine hcl
ALLERGY MEDICATION BENADRYL BENADRYL ALLERGY hydroxyzine hcl
hydroxyzine pamoate
promethazine hcl
Antihistamines - 2nd Generation
loratadine
Nasal Anti-Inflammatory Steroids
fluticasone propionate
Nasal Antihistamine
Nasal Mast Cell Stabilizers Agents
cromolyn sodium
ANTIEMESIS/ANTIVERTIGO
Antiemetic/Antivertigo Agents
meclizine hcl
prochlorperazine maleate
promethazine hcl
trimethobenzamide hcl
trimethobenzamide hcl/b-caine
Adrenergic Agents,Catecholamines
epinephrine
isoetharine hcl
Beta-Adrenergic Agents
albuterol
albuterol sulfate
metaproterenol sulfate
terbutaline sulfate
Beta-Adrenergics And Glucocorticoids
Combination

General Bronchodilator Agents
ipratropium bromide
Leukotriene Receptor Antagonists
Mast Cell Stabilizers
cromolyn sodium
Monoclonal Antibodies To Immunoglobulin E(ige)
Oral Inhaled Corticosteroids(dosage Form 408
Respiratory Aids,Devices,Equipment
DEVILBISS COMPACT DEVILBISS PULMO-AIDE DEVILBISS PULMOMATE PULMO-AIDE SUNRISE COMPRESSOR-NEBULIZER COOL MIST DYNAMIST 370-F EVAPORATIVE HUMIDIFIERHUMIDIFIER VICKS COOL MIST HUMIDIFIER AEROCHAMBER BREATHERITE EASIVENT OPTICHAMBER VORTEX AIRS DISPOSABLE NEBULIZER DEVILBISS LC PLUS NEBULIZER NEBULIZER W/PEDIATRIC MASK COMP-AIR NEBULIZER COMPRESSOR COMPRSESSOR NEBULIZERNEBULIZER W/COMPRESSOR ASSESS ASSESS PEAK FLOW METERPEAK FLOW METER PEAK-AIR PERSONAL BEST AEROGEAR ASTHMA ACTION KIT ASTHMAPACK I ASTHMAPACK II ASTHMAPACK III ONE FLOW FVC SAFEGUARD 285 SAFEGUARD 76 STEAM VAPORIZER VICKS VAPORIZER WARM STEAM VAPORIZER CHARCOAL FILTER CLEAN START HEALTHGUARD CHARCOAL FILTER HUMIDIFIER ADAPTER KAZ INHALANT Xanthines
caffeine citrated
theophylline anhydrous
AUTONOMIC NERVOUS SYSTEM DISORDERS
Cholinesterase Inhibitors
pyridostigmine bromide
BEHAVIORAL HEALTH - ANTIDEPRESSANTS
Alpha-2 Receptor Antagonist Antidepressants
mirtazapine
Norepinephrine And Dopamine Reuptake Inhib
bupropion hcl
Selective Serotonin Reuptake Inhibitor (ssris)
citalopram hydrobromide
fluoxetine hcl
paroxetine hcl
sertraline hcl
Serotonin-2 Antagonist/Reuptake Inhibitors (saris)
nefazodone hcl
trazodone hcl
Serotonin-Norepinephrine Reuptake-Inhib (snris)
venlafaxine hcl
Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib
amitriptyline hcl
clomipramine hcl
desipramine hcl
doxepin hcl
imipramine hcl
nortriptyline hcl
BEHAVIORAL HEALTH - OTHER
Adrenergics, Aromatic, Non-Catecholamine
amphet asp/amphet/d-amphet
d-amphetamine sulfate
Anti-Alcoholic Preparations
Anti-Anxiety Drugs
alprazolam
buspirone hcl
chlordiazepoxide hcl
lorazepam
Antihistamines - 1st Generation
Barbiturates
phenobarbital
Central Nervous System Stimulants
F 1 pemoline
Sedative-Hypnotics,Non-Barbiturate
chloral hydrate
diphenhydramine hcl
temazepam
Tx For Attention Deficit-
Hyperact(adhd)/Narcolepsy

methylphenidate hcl
Tx For Attention Deficit-Hyperact.(adhd), Nri-Type
CARDIOVASCULAR DISEASE - ARRHYTHMIA
Antiarrhythmics
amiodarone hcl
disopyramide phosphate
flecainide acetate
mexiletine hcl
procainamide hcl
quinidine gluconate
quinidine sulfate
CARDIOVASCULAR DISEASE - CARDIAC
STIMULANT
Digitalis Glycosides
CARDIOVASCULAR DISEASE -
HYPERTENSION
Alpha-Adrenergic Blocking Agents
doxazosin mesylate
prazosin hcl
terazosin hcl
Alpha/Beta-Adrenergic Blocking Agents
labetalol hcl
Beta-Adrenergic Blocking Agents
atenolol
betaxolol hcl
metoprolol succinate
propranolol hcl
timolol maleate
Calcium Channel Blocking Agents
diltiazem hcl
nifedipine
verapamil hcl
Hypotensives, Ace Inhibitors
benazepril hcl
benazepril/hydrochlorothiazide
captopril
captopril/hydrochlorothiazide
enalapril maleate
enalapril/hydrochlorothiazide
lisinopril
lisinopril/hydrochlorothiazide
Hypotensives,Angiotensin Receptor Antagonist
Hypotensives,Sympatholytic
clonidine hcl
CATAPRES-TTS 1 CATAPRES-TTS 2 CATAPRES-TTS 3 guanabenz acetate
guanfacine hcl
methyldopa
methyldopa/hydrochlorothiazide
Hypotensives,Vasodilators
hydralazine hcl
Loop Diuretics
furosemide
Osmotic Diuretics
Potassium Sparing Diuretics
spironolactone
Potassium Sparing Diuretics In Combination
spironolact/hydrochlorothiazid
triamterene/hydrochlorothiazid
Thiazide And Related Diuretics
hydrochlorothiazide
metolazone
CARDIOVASCULAR DISEASE - LIPID
IRREGULARITY
Bile Salt Sequestrants
cholestyramine/aspartame
cholestyramine/sucrose
Lipotropics
gemfibrozil
CARDIOVASCULAR DISEASE -
VASODILATION
Vasodilators,Coronary
isosorbide dinitrate
isosorbide mononitrate
nitroglycerin
Vasodilators,Peripheral
ergoloid mesylates
CONTRACEPTION/OXYTOCICS
Contraceptives,Injectable
medroxyprogesterone acet
Contraceptives,Intravaginal
ADVANTAGE 24 CONCEPTROL GYNOL II GYNOL II EXTRA STRENGTH VCF nonoxynol 9
Contraceptives,Oral
desog-et estra/ethin estra
desogestrel-ethinyl estradiol
ethynodiol d-ethinyl estradiol
levonorgestrel-eth estra
noreth a-et estra/fe fumarate
norethindrone
norethindrone a-e estradiol
norethindrone-ethinyl estrad
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
Contraceptives,Transdermal
Oxytocics
COUGH AND COLD
1st Gen Antihist-Decon-Nsaid,Cox Nonspec
1st Gen Antihist-Decongest-Anticholinergic Comb
AH-CHEW II ALLERX PE DALLERGY EXTENDRYL JR RESCON phenylephrine/chlor-mal/scop
1st Gen Antihistamine & Decongestant
Combinations

p-ephed hcl/brompheniramin
p-ephed hcl/dp-hydram hcl
p-ephed hcl/triprolidine hcl
phenylephrine hcl/chlor-mal
phenylephrine hcl/prometh hcl
phenylephrine/brompheniramine
phenylephrine/chlor-tan
phenylephrine/pyril tan
phenylephrine/pyril tan/cp
pseudoephedrine hcl/chlor-mal
1st Gen Antihistamine-Decongestant-Analgesic
p-ephed hcl/acetaminophn/cp
1st Gen Antihistamine-Decongestant-Expectorant
Antitussives,Non-Narcotic
benzonatate
dextromethorphan hbr
BENYLIN DM ROBITUSSIN ROBITUSSIN PEDIATRIC Cough And/Or Cold Preparations
car-b-pen ta/ephed tan/pe/cp
d-methorphan hb/p-ephed hcl
d-methorphan hb/p-ephed hcl/cp
dm hb/p-epd hcl/apap/cp
p-ephed hcl/acetaminophen
p-ephed hcl/triprolidine hcl
Decongest-Analgesic,Non-Salicylate Comb.
p-ephed hcl/acetaminophen
Decongestant-Expectorant Combinations
AMBIFED-G POLY-VENT RESPA-1ST TOURO LA TOURO LA-LD guaifenesin/p-ephed hcl
guaifenesin/phenylephrine hcl
Decongestant-Nsaid, Cox Non-Spec Comb.
ibuprofen/pseudoephedrine hcl
Expectorant Combinations Other
Expectorants
ALLFEN NALDECON SENIOR EX NUMOBID VITA-NUMONYL EX guaifenesin
Narcotic Antituss-1st Gen. Antihistamine-Decongest
p-ephed hcl/cod/chlorphenir
phenylephrine hcl/cod/prometh
phenylephrine/hydrocodone/cp
phenylephrine/hydrocodone/d-cp
Narcotic Antituss-Decongestant-Expectorant Comb
guaifenesin/p-ephed hcl/cod
guaifenesin/p-ephed hcl/hcod
guaifenesin/phenylephrine/hcod
Narcotic Antitussive-1st Generation Antihistamine
codeine/promethazine hcl
Narcotic Antitussive-Anticholinergic Comb.
hydrocodone bit/homatropine
Narcotic Antitussive-Expectorant Combination
guaifenesin/codeine phos
guaifenesin/hydrocodone bit
pot guaiaco/hydrocodone bit
Non-Narc Antitus-1st Gen Antihist-Decon-Analges
dm hb/p-ephed hcl/apap/doxylam
dm hb/pseudoephed/acetamin/cp
666 COUGH & COLD TRIAMINIC TRIAMINIC COLD/COUGH/FEVER Non-Narc Antitus-1st Gen Antihist-Decongest-
guaifen/d-methorphan hb/pe/bpm
Non-Narc Antituss-1st Gen. Antihistamine-
Decongest

car-b-pen ta/ephed tan/pe/cp
car-b-pen ta/phenylephrine/pyr
d-methorp tan/p-epd tan/cp
d-methorp tan/pe/br-phenir
d-methorphan hb/p-epd hcl/bpm
d-methorphan hb/p-ephed hcl/cp
d-methorphan hb/pe/chlorphenir
dm hb/p-ephed hcl/carbinox
Non-Narc Antitussive-1st Gen Antihistamine Comb.
car-b-pen ta/chlor-tan
d-methorphan hb/prometh hcl
Non-Narcotic Antituss-Decongestant-Expectorant
guaifen/d-methorphan hb/pe
guaifen/dm hb/p-ephedrine
Non-Narcotic Antitussive And Expectorant Comb.
guaifenesin/d-methorphan hb
AQUATAB DM DURADEX FORTE RESPA-DM ROBITUSSIN DM Non-Narcotic Antitussive-Decongestant
Combinations

d-methorphan hb/p-ephed hcl
DIMETAPP ROBITUSSIN TUSSIN MAXIMUM STRENGTH COUGH Non-Narcotic Antitussive-Decongestant-Analgesic
d-methorphan hb/p-epd hcl/apap
INFANT TYLENOL COLD TYLENOL INFANTS PLUS COLD-COUG Sympathomimetic Agents
phenylephrine hcl
LITTLE COLDS MEDI-PHENYL NASOP SUDAFED PE pseudoephedrine hcl
DIMETAPP DECONGESTANT ELIXSURE CONGESTION SUDAFED SUDO GEST SUPHEDRINE DERMATOLOGY - ACNE
Acne Agents,Systemic
F 1 isotretinoin
Keratolytics
benzoyl peroxide
podofilox
Rosacea Agents, Topical
metronidazole
Vitamin A Derivatives
tretinoin
DERMATOLOGY - ANTIINFECTIVE
Laxatives And Cathartics
Topical Antibiotics
bacitracin
bacitracin zinc
bacitracin/polymyxin b sulfate
clindamycin phosphate
erythromycin base
erythromycin base/ethanol
gentamicin sulfate
neomy sulf/baci zn/poly/pram
neomy sulf/bacitra/poly/lido
neomy sulf/bacitra/poly/pram
neomy sulf/bacitra/polymyxin b
neomy sulf/polymyx b sulf/pram
neomy sulf/polymyx b sulf/pram
Topical Antifungals
clotrimazole
ketoconazole
miconazole nitrate
FUNGOID FUNGOID TINCTURE NAIL KIT LOTRIMIN AF ZEASORB-AF nystatin
nystatin/triamcin
tolnaftate
Topical Antiparasitics
permethrin
piperonyl butoxide/pyrethrins
Topical Sulfonamides
silver sulfadiazine
DERMATOLOGY - ANTIINFLAMMATORY
Topical Anti-Inflammatory Steroidal
betamethasone valerate
desonide
fluocinolone acetonide
fluocinonide
fluocinonide/emollient
hydrocortisone
hydrocortisone acetate
triamcinolone acetonide
Topical Antibiotics/Antiinflammatory,Steroidal
DERMATOLOGY - MISCELLANEOUS
Antiseborrheic Agents
selenium sulfide
Antiseptics,General
ALCOHOL PREP PADS ALCOHOL PREP SWABS ALCOHOL SWABS ALCOHOL WIPE Emollients
ammonium lactate
glycerin
lactic acid
Irrigants
acetic acid
neomy sulf/polymyxin b sulfate
sodium cl 0.45pc irrig. soln
sodium cl irrig soln
water for irrigation,sterile
Protectives
calamine
Solvents
Topical Antineoplastic & Premalignant Lesion
fluorouracil
Topical Local Anesthetics
Topical Preparations,Miscellaneous
calcium acetate/al sulfate
Topical/Mucous Membr./Subcut. Enzymes
papain/urea
papain/urea/chlorophyllin
trypsin/balsam peru/castor oil
DERMATOLOGY - PSORIASIS/ECZEMA
Antipsoriatic Agents,Systemic
Antipsoriatics Agents
anthralin
Topical Immunosuppressive Agents
DIABETES
Blood Sugar Diagnostics
FREESTYLE TEST STRIPS ONE TOUCH TEST STRIPS ONE TOUCH ULTRA TEST STRIPS Diabetic Supplies
ACCU-CHEK B-D LANCET DEVICE ONE TOUCH GLUCOSE CONTROL SOLN OT ULTRA/FAST TK CNTRL SOLN SOFTCLIX ACCU-CHEK AUTOLANCET DEVICE W-LANCETS LANCING DEVICE ULTRATLC LANCETS-DEVICE Hyperglycemics
Hypoglycemics, Alpha-Glucosidase Inhib Type (n-
Hypoglycemics, Biguanide Type (non-
Sulfonylureas)

metformin hcl
Hypoglycemics, Insulin-Release Stimulant Type
chlorpropamide
glimepiride
glipizide
glyburide
tolbutamide
Hypoglycemics, Insulin-Response Enhancer (n-S)
Insulins
hum insulin nph/reg insulin hm
insulin nph human recom
insulin regular human rec
Syringes And Accessories
BD INSULIN SYRINGE MICRO-FINE BD INSULIN SYRINGE ULT-FINE II BD INSULIN SYRINGE ULTRA-FINE INSULIN SYRINGE ULTRA COMFORT BD INSULIN SYRINGE MICRO-FINE BD INSULIN SYRINGE ULT-FINE II BD INSULIN SYRINGE ULTRA-FINE INSULIN SYRINGE ULTRA COMFORT BD SAFETYGLIDE MEDSAVER MONOJECT SYRINGE SYRINGE SYRINGE W/NEEDLE BD INSULIN SYRINGE MICRO-FINE BD INSULIN SYRINGE ULT-FINE II BD INSULIN SYRINGE ULTRA-FINE INSULIN SYRINGE ULTRA COMFORT ALLERGIST TRAY ALLERGY SYRINGE MONOJECT TUBERCULIN SYRINGE SAFETYGLIDE TUBERCULIN SYRINGE BD SYRINGE BULK SYRINGE INSULIN SYRINGE MONOJECT TUBERCULIN SYRINGE TUBERCULIN SYRINGE ANTI-STICK ALLERGY INSULIN SYRINGE MONOJECT INSULIN SAFETY SYRNG SURE COMFORT ULTRA COMFORT SYRINGE/PRECISIONGLIDE NEEDLE TERUMO HYPODERMIC NEEDLE/SYRIN VANISHPOINT syringe w-needle,disposb,0.5ml ALLERGIST BULK SYRINGE EXEL SYRINGE GLASPAK SAFETY-LOK SAFETY SYRINGE SYRINGE BULK MONOJECT MONOJECT DISPOSABLE SYRINGE MONOJECT SAFETY SYRINGE SYRINGE W/OUT NEEDLE BULK SYRINGE EXEL SYRINGE MONOJECT MONOJECT DISPOSABLE SYRINGE SYRINGE BULK SYRINGE EXEL SYRINGE SYRINGE BULK TERUMO SYRINGE BULK SYRINGE MONOJECT MONOJECT SYRINGE SAFETY-LOK SAFETY BULK SYRINGE EXEL SYRINGE GLASPAK SAFETY-LOK SAFETY SYRINGE BD SYRINGE BULK SYRINGE SYRINGE SYRINGE BULK SYRINGE W/OUT NEEDLE MONOJECT MONOJECT SYRINGE MONOJECT SYRINGE PHARMACY TRAY SYRINGE W/OUT NEEDLE MONOJECT MAGELLAN SYRINGE MONOJECT TUBERCULIN SAFETY SYR SAFETY-LOK SAFETY SYRINGES TERUMO SURGUARD2 BD INTEGRA SYRINGE INTEGRA SAFETY SYRINGE W/SHIELD SAFETY-LOK SAFETY SYRINGES SAFETY-LOK SYRINGES SAFETY-LOK SAFETY SYRINGES SECUREGARD TERUMO SURGUARD2 ALLERGIST TRAY SYR/DETACH NDL ALLERGIST TRAY SYR/PERM NEEDLE MONOJECT ALLERGY TRAY/NEEDLE ALLERGIST SYRINGE TRAYALLERGIST TRAY ALLERGIST TRAY SYR/PERM NEEDLE Urine Glucose Test Aids
EAR - GENERAL DISORDERS
Ear Preparations, Misc. Anti-Infectives
acetic acid
acetic acid/aluminum acetate
acetic acid/hydrocortisone
Ear Preparations,Antibiotics
neomy sulf/polymyx b sulf/hc
Ear Preparations,Local Anesthetics
antipyrine/benzocaine/glycerin
Otic Preparations,Anti-Inflammatory-Antibiotics
ELECTROLYTE REGULATION
Electrolyte Depleters
sodium polystyrene sulfonate
Electrolyte Maintenance
electrolyte,oral
Potassium Replacement
potassium chloride
Sodium/Saline Preparations
normal saline
ENDOCRINE DISORDER - OTHER
Antidiuretic And Vasopressor Hormones
desmopressin (nonrefrigerated)
Antineoplastic Lhrh(gnrh) Agonist,Pituitary Suppr.
Bone Resorption Inhibitor & Vitamin D
Combinations

Bone Resorption Inhibitors
Calcimimetic,Parathyroid Calcium Enhancer
Hyperparathyroid Tx Agents - Vitamin D Analog-
Lhrh(gnrh) Agonist Analog Pituitary Suppressants
Lhrh(gnrh)agnst Pit.sup-Central Precocious
ENDOCRINE DISORDER - THYROID
Antithyroid Preparations
methimazole
propylthiouracil
Thyroid Hormones
levothyroxine sodium
EYE - GENERAL DISORDERS
Eye Antibiotic-Corticoid Combinations
neo/polymyx b sulf/dexameth
neomy sulf/bacitrac zn/poly/hc
neomy sulf/polymyx b sulf/hc
neomycin sulfate/dex na ph
Eye Antihistamines
Eye Antiinflammatory Agents
dexamethasone sod phosphate
fluorometholone
flurbiprofen sodium
prednisolone acetate
prednisolone sod phosphate
Eye Antivirals
trifluridine
Eye Local Anesthetics
proparacaine hcl
Eye Sulfonamides
na sulfacetm/prednis sp
sulfacetamide sodium
Eye Vasoconstrictors (otc Only)
naphazoline hcl
naphazoline hcl/phenir mal
Eye Vasoconstrictors (rx Only)
naphazoline hcl
phenylephrine hcl
Ophthalmic Antibiotics
bacitracin
bacitracin/polymyxin b sulfate
erythromycin base
gentamicin sulfate
neomy sulf/bacitra/polymyxin b
neomy sulf/gramicid d/poly
polymyxin b sulfate/tmp
tobramycin sulfate
Ophthalmic Mast Cell Stabilizers
cromolyn sodium
EYE - GLAUCOMA
Carbonic Anhydrase Inhibitors
acetazolamide
methazolamide
Miotics/Other Intraoc. Pressure Reducers
betaxolol hcl
brimonidine tartrate
carbachol
carteolol hcl
levobunolol hcl
metipranolol
pilocarpine hcl
timolol maleate
Mydriatics
atropine sulfate
cyclopentolate hcl
dipivefrin hcl
homatropine hbr
tropicamide
GOUT AND RELATED DISEASES
Colchicine
colchicine
colchicine/probenecid
Hyperuricemia Tx - Purine Inhibitors
allopurinol
Uricosuric Agents
probenecid
HEMATOLOGICAL DISORDERS
Anticoagulants,Coumarin Type
warfarin sodium
Hematinics,Other
Hemorrheologic Agents
pentoxifylline
Heparin And Related Preparations
heparin sodium,porcine
Leukocyte (wbc) Stimulants
Platelet Aggregation Inhibitors
dipyridamole
Vitamin K Preparations
HORMONAL DEFICIENCY
Estrogen/Androgen Combinations
estrogen,ester/me-testosterone
Estrogenic Agents
estradiol
estropipate
Progestational Agents
medroxyprogesterone acet
norethindrone acetate
IMMUNOSUPPRESSION/MODULATION
Immunomodulators
Immunosuppressives
azathioprine
cyclosporine, modified
INFECTIOUS DISEASE - BACTERIAL
Absorbable Sulfonamides
sulfamethoxazole/trimethoprim
Cephalosporins - 1st Generation
Cephalosporins - 2nd Generation
cefaclor
Cephalosporins - 3rd Generation
Chemotherapeutics, Antibacterial, Misc.
methenamine hippurate
methenamine mandelate
trimethoprim
Ketolides
Macrolides
azithromycin
ery e-succ/sulfisoxazole
erythromycin base
erythromycin ethylsuccinate
Nitrofuran Derivatives
nitrofurantoin macrocrystal
nitrofurantoin/nitrofuran mac
Oxazolidinones
Penicillins
amox tr/potassium clavulanate
amoxicillin trihydrate
ampicillin trihydrate
dicloxacillin sodium
penicillin v potassium
Quinolones
ciprofloxacin hcl
Tetracyclines
doxycycline hyclate
tetracycline hcl
INFECTIOUS DISEASE - FUNGAL
Antifungal Agents
clotrimazole
fluconazole
ketoconazole
Antifungal Antibiotics
griseofulvin ultramicrosize
griseofulvin,microsize
nystatin
INFECTIOUS DISEASE - MISCELLANEOUS
Aminoglycosides
gentamicin sulfate
neomycin sulfate
Anti-Mycobacterium Agents
ethambutol hcl
isoniazid
pyrazinamide
Antileprotics
Antitubercular Antibiotics
rifampin
rifampin/isoniazid
Lincosamides
clindamycin hcl
INFECTIOUS DISEASE - PARASITIC
Amebacides
Anaerobic Antiprotozoal-Antibacterial Agents
metronidazole
Anthelmintics
mebendazole
pyrantel pamoate
Antimalarial Drugs
chloroquine phosphate
hydroxychloroquine sulfate
quinine sulfate
Antiprotozoal Drugs,Miscellaneous
INFECTIOUS DISEASE - VIRAL
Antivirals, General
acyclovir
ganciclovir
Hepatitis C Treatment Agents
ribavirin
REBETRON 1000 REBETRON 1200 REBETRON 600 INFLAMMATORY DISEASE
Anti-Arthritic And Chelating Agents
Anti-Arthritic, Folate Antagonist Agents
Anti-Inflammatory Tumor Necrosis Factor
Inhibitor

Glucocorticoids
cortisone acetate
dexamethasone
dexamethasone sod phosphate
hydrocortisone
methylprednisolone
prednisolone
prednisolone sod phosphate
prednisone
Gold Salts
gold sodium thiomalate
Mineralocorticoids
fludrocortisone acetate
Nsaids, Cyclooxygenase Inhibitor - Type
etodolac
ibuprofen
indomethacin
naproxen
sulindac
LOCAL ANESTHESIA
Local Anesthetics
lidocaine hcl
LOWER GASTROINTESTINAL DISORDERS -
BOWEL INFLAMMAT
Bowel Antiinflamatory Agents
sulfasalazine
Chronic Inflam. Colon Dx, 5-A-Salicylat,Rectal Tx
mesalamine
Drug Tx-Chronic Inflam. Colon Dx,5-
Aminosalicylat

Hemorrhoidal Preparations
phenylephrine hcl
phenylephrine hcl
pramoxine hcl
Rectal Preparations
hydrocortisone
hydrocortisone acetate
Rectal/Lower Bowel Prep.,Glucocort. (non-Hemorr)
hydrocortisone
LOWER GASTROINTESTINAL DISORDERS -
OTHER
Ammonia Inhibitors
lactulose
Antidiarrheals
bismuth subsalicylate
diphenoxylate hcl/atrop sulf
loperamide hcl
paregoric
Bile Salts
ursodiol
Laxatives And Cathartics
bisacodyl
docusate sodium
magnesium citrate
magnesium hydroxide
polyethylene glycol 3350
psyllium seed
psyllium seed/dextrose
psyllium seed/sucrose
AGORAL LITTLE TUMMYS SENNA HERBAL LAXATIVE sennosides
sod chloride/nahco3/kcl/peg's
sod sulf/sod/nahco3/kcl/peg's
Laxatives, Local/Rectal
bisacodyl
glycerin
MEDICAL SUPPLIES
Durable Medical Equipment,Misc(group 1)
FREESTYLE LANCETS LANCETS MICROLET ONE TOUCH LANCETS SOFTCLIX Durable Medical Equipment,Miscellaneous
A.I.R.S. NEBULIZER EASIVENT NEBULIZER NEBULIZER CUP WITH TUBING OPTICHAMBER Incontinence Supplies
BED PAD CURITY UNDERPADS DEPEND UNDERPADS SECURE UNDERPADS UNDERPAD Syringes And Accessories
Thermometers
B-D SENTINEL THERMOMETER BABY THERMOMETER BABY THERMOMETER-MICHIGAN BRITE SIGHT THERMOMETER FEVER THERMOMETER BASAL THERMOMETER DIGITAL THERMOMETER FEVER THERMOMETER PRO-CEPTION BASAL THERMOMETER BRITE SIGHT THERMOMETER DIGITAL THERMOMETER FEVER THERMOMETER FEVER THERMOMETER-IMPRINTED THERMOMETER DIGITAL THERMOMETER ELECTRONIC THERMOMETER FEVER THERMOMETER THERMOMETER B-D SENTINEL THERMOMETER BABY THERMOMETER FEVER THERMOMETER TEMPORAL SCANNER THERMOMETER DISPOSABLE THERMOMETER FOREHEAD THERMOMETER MISCELLANEOUS AGENTS
Anaphylaxis Therapy Agents
NEOPLASTIC DISEASE
Alkylating Agents
cyclophosphamide
hydroxyurea
Antiandrogenic Agents
flutamide
Antimetabolites
mercaptopurine
methotrexate sodium
Antineoplastics,Miscellaneous
etoposide
Chemotherapy Rescue/Antidote Agents
leucovorin calcium
Selective Estrogen Receptor Modulators (serm)
tamoxifen citrate
Steroid Antineoplastics
megestrol acetate
NEUROLOGICAL DISEASE -
MISCELLANEOUS
Agents To Treat Multiple Sclerosis
ORAL/PHARYNGEAL DISORDERS
Dental Aids And Preparations
chlorhexidine gluconate
triamcinolone acetonide
OTHER DRUGS
Appetite Stim. For Anorexia,Cachexia,Wasting
megestrol acetate
ATLAS CONDOMS TROJAN TROJAN ENZ TRUSTEX-RIA KIMONO KIMONO MAXX KIMONO MICROTHIN TRUSTEX-RIA General Inhalation Agents
sodium cl for inhalation
Infant Formulas
infant formula w-iron
NEOCATE SIMILAC ALIMENTUM SIMILAC NEOSURE ADVANCE Metabolic Deficiency Agents
levocarnitine
Nose Preparations, Vasoconstrictors(otc)
phenylephrine hcl
Phosphate Replacement
naph,mb-db/k ph,mbdb
Protein Replacement
levocarnitine
Solvents
glycerin
Urine Acetone Test Aids
CHEMSTRIP K KETOCARE KETONE KETOSTIX KETOSTIX REAGENT Urine Glucose/Acetone Test Aids,Strips
urine gluc-acet comb.tst,strip DIASCREEN urine gluc-acet comb.tst,strip CHEMSTRIP DIASCREEN 10 DIASCREEN 2GK REAGENTDIASCREEN 3 REAGENT KETO-DIASTIX REAGENT OTHER RESPIRATORY DISORDERS
Mucolytics
acetylcysteine
PAIN MANAGEMENT - ANALGESICS
Analgesic/Antipyretics, Salicylates
ASPERGUM BAYER 8-HOUR HALFPRIN STANBACK ANALGESIC BAYER CHILDREN'S ASPIRIN ECOTRIN ZORPRIN chol sal/magnesium salicylate
salsalate
Analgesic/Antipyretics,Non-Salicylate
APAP 500 ELIXSURE FEVER/PAIN FEVERALL STANBACK AF acetaminophen
TYLENOL TYLENOL ARTHRITIS TYLENOL EXTRA STRENGTH Analgesics,Narcotics
codeine phos/acetaminophen
TYLENOL W/CODEINE NO.3TYLENOL W/CODEINE NO.4 codeine phos/aspirin
F 1 fentanyl
hydrocodone bit/acetaminophen
levorphanol tartrate
meperidine hcl
methadone hcl
morphine sulfate
tramadol hcl
Antimigraine Preparations
ergotamine tartrate/caffeine
isometheptene/apap/dichlphen
PARKINSONS DISEASE
Antiparkinsonism Drugs,Other
carbidopa/levodopa
SINEMET CR SINEMET-25/100 SINEMET-25/250 pergolide mesylate
selegiline hcl
Pituitary Suppressive Agents
bromocriptine mesylate
SEIZURE DISORDER
Anticonvulsants
carbamazepine
clonazepam
ethosuximide
gabapentin
lamotrigine
phenytoin
phenytoin sodium
phenytoin sodium extended
primidone
valproate sodium
valproic acid
SKELETAL MUSCLE DISORDER
Skeletal Muscle Relaxants
baclofen
dantrolene sodium
SMOKING CESSATION
Smoking Deterrent Agents (ganglionic Stim,Others)
nicotine
NICOTINE TRANSDERMAL NICOTROL NICOTROL NS nicotine polacrilex
UPPER GASTROINTESTINAL DISORDERS -
DIGESTIVE
Pancreatic Enzymes
CREON 10 CREON 20 CREON 5 KU-ZYME HP PANCREASE MT 4 amylase/lipase/protease
UPPER GASTROINTESTINAL DISORDERS -
SPASTIC DISEASE
Anticholinergics,Quaternary Ammonium
glycopyrrolate
propantheline bromide
Belladonna Alkaloids
atropine sulfate
belladonna alkaloids/phenobarb
hyoscyamine sulfate
UPPER GASTROINTESTINAL DISORDERS -
ULCER DISEASE
Antacids
calcium carbonate
mag hydrox/al hydrox/simeth
MAALOX PLUS EXTRA STRENGTH MYLANTA MYLANTA DOUBLE-STRENGTH magnesium hydroxide/al hydrox
Anti-Ulcer Preparations
misoprostol
sucralfate
Anti-Ulcer-H.pylori Agents
Histamine H2-Receptor Inhibitors
cimetidine
cimetidine hcl
ranitidine hcl
Intestinal Motility Stimulants
metoclopramide hcl
URINARY TRACT - FUNCTIONAL DISORDERS
Anticholinergics/Antispasmodics
dicyclomine hcl
Benign Prostatic Hypertrophy/Micturition Agents
Parasympathetic Agents
bethanechol chloride
Urinary Ph Modifiers
citric acid/sodium citrate
phosphorus #1
potassium citrate
Urinary Tract Anesthetic/Analgesic Agnt (azo-Dye)
phenazopyridine hcl
Urinary Tract Antispasmodic/Antiincontinence
oxybutynin chloride
VAGINAL DISORDERS
Vaginal Antibiotics
clindamycin phosphate
metronidazole
Vaginal Antifungals
clotrimazole
miconazole nitrate
terconazole
Vaginal Estrogen Preparations
Vaginal Sulfonamides
VITAMIN AND/OR MINERAL DEFICIENCY
Calcium Replacement
calcium carbonate
calcium carbonate/vitamin d2
Fluoride Preparations
sodium fluoride
FLUOR-A-DAY FLUORABON PREVIDENT THERA-FLUR-N Folic Acid Preparations
folic acid
Iron Replacement
ferrous sulfate
Pediatric Vitamin Preparations
fluoride ion/iron/vit a,c&d
fluoride ion/multivitamins
fluoride ion/multivits w-fe
fluoride ion/vit a,c&d
Prenatal Vitamin Preparations
p-nat vit/iron,carb/doss/ca/fa
pnv comb.no1/iron,carb/doss/fa
pnv w-o ca no3/fe fumarate/fa
prenatal vit/fe fum/doss/fa
prenatal vit/fe fumarate/fa
prenatal vit/fe fumarate/fa/se
prenatal vit/fe ps cmplx/fa
prenatal vit/fecbngl/doss/fa
prenatal vit/iron,carbonyl/fa
prenatal vits w-ca,fe,fa(<1mg)
Vitamin B Preparations
Vitamin B12 Preparations
Vitamin B6 Preparations
pyridoxine hcl
Vitamin D Preparations
calcitriol
ergocalciferol
WEIGHT REDUCTION
Anorexic Agents
phentermine hcl
Fat Absorption Decreasing Agents
MEDICATION PRESCRIBING LIMITATIONS
AGE RESTRICTIONS
- ACCUTANE
IF AGE <= 5, STEP THERAPY NOT REQUIRED. IF AGE <= 5, STEP THERAPY NOT REQUIRED. GENDER EDITS
- ALESSE-28
PHYSICIAN SPECIALTY EDIT
- ACCUTANE
DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. DRUG COVERAGE MAY DEPEND ON PHYSICIAN SPECIALTY. PRIOR AUTHORIZATION
- ACTIMMUNE
- ADIPEX-P
- AGGRENOX
- ALTACE
- ARANESP
- ARICEPT
- ARICEPT ODT
- AVONEX
- AVONEX ADMINISTRATION PACK
- BETASERON
- CELLCEPT
- COMMIT
- COPAXONE
- COPEGUS
- CYCLOSPORINE
- CYLERT
- DERMAFLEX
- DIPENTUM
- ELIGARD
- ENBREL
- EPOGEN
- EXELON - FOSRENOL - HUMIRA - INFERGEN - INTRON A - LAMISIL - LEUKINE - LIDODERM - LUPRON DEPOT - LUPRON DEPOT-PED - MERIDIA - MYFORTIC - NEOCATE - NEORAL - NEULASTA - NEUPOGEN - NICODERM CQ - NICORETTE - NICOTINE TRANSDERMAL - NICOTROL - NICOTROL NS - NUTRAMIGEN LIPIL - PEG-INTRON - PEG-INTRON REDIPEN - PEGASYS - PROCRIT - PROGRAF - RAPAMUNE - REBETOL - REBETOL - REBETRON 1000 - REBETRON 1200 - REBETRON 600 - REBIF - RENAGEL - RIBASPHERE - ROFERON-A - SENSIPAR - SIMILAC ALIMENTUM - SIMILAC ALIMENTUM - SIMILAC NEOSURE ADVANCE - SPIRIVA - TRILEPTAL - VESANOID - VIRAZOLE - VYTORIN - XENICAL - XOLAIR - XOPENEX - ZEMPLAR - ZYVOX QUANTITY RESTRICTIONS - Limits apply to all available
strengths unless otherwise noted.
Tier 1
- AEROGEAR ASTHMA ACTION KIT LIMITS QUANTITY TO 2 IN 365 DAYS. - AUTOLANCET DEVICE W-LANCETS LIMITS QUANTITY TO 102 IN 30 DAYS. Quantity limit may differ for new fill/refill. - OT ULTRA/FAST TK CNTRL SOLN LIMITS QUANTITY TO 102 IN 30 DAYS. DAYS SUPPLY LIMIT MAY DIFFER FOR NEW FILL/REFILL. STEP THERAPY EDITS
- ADDERALL XR

Source: http://www.hpsj.com/common/mcl-hf-hk-hc-formulary-200701.pdf