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Microsoft word - 2010 chip formulary updated 080110.doc

2010 Formulary

Introduction
from the Health Partners Pharmacy
Prescription quantities cannot be altered Health Partners, Inc. is pleased to provide department when applicable.
unless approved by the physician, and must be within the limits of the plan’s days supply. KidzPartners (Children’s Health Insurance The Health Partners P&T Committee will Prescribed medications or regimens that are non-formulary require prior authorization. inclusion in the formulary. The evaluation process includes a literature review, and therapy in an ambulatory setting. Excluded professionals. Formal reviews are prepared If a member presents at a pharmacy with a manufacturers who have not contracted with authorization, whether for a non-formulary immediately, Health Partners will allow the pharmacy to dispense an interim supply of approved by the Health Partners Pharmacy products have been selected to provide the
If the recipient is in immediate need of the most clinically appropriate and cost-
medication in the professional judgment of effective medications for KidzPartners
the pharmacist and if the prescription is for a new medication (one that the recipient has not taken before or that is taken for an acute management of a specific patient. In those condition), Health Partners will allow the instances, the unlisted medication may be formulary inclusion an attempt will be made pharmacy to dispense a 5-day supply of the to examine the drug relative to similar drugs currently on formulary. In addition, entire pharmacy the opportunity to initiate the reviewed. This review process may result in The KidzPartners Formulary is organized by therapeutic class in an effort to continually promote the most clinically useful and cost- prescribed for the treatment of an illness or pharmacologic class or disease state. Each condition that is chronic in nature in which section contains a list of drugs selected to there has not been a break in treatment for be on this formulary. Prescribing a drug greater than 34 Days), Health Partners will product that is available generically is exceptions are noted, all applicable dosage medication is eligible for coverage. The prescriber is urged to prescribe in amounts member, with a copy to the prescriber, an that adhere to accepted standards of care. advance written notice of the reduction or termination of the medication at least 10 determined by the dispensing pharmacist to days prior to the end of the period for which Specific limits based on FDA guidelines, the medication was previously authorized. The actions of the Health Partners P&T
Committee are communicated through
standards of care may apply to medication Health Partners will respond to the request the Provider Newsletter to all physicians
for prior authorization within 24 hours from and posted on our website. Pharmacy
when the request was received. If the prior providers in the KidzPartners network
will be notified through correspondence
ratings of generic drugs are available by • All brand name medications when there referring to the FDA reference Approved is an A-rated generic equivalent available medication, either alone or along with other Drug Products with Therapeutic Equivalence medication that the recipient may be taking, would jeopardize the health and safety of • Medications used for non-FDA approved generic can be substituted with the full • Prescription costs that exceed $1000 expectation that the substituted product will produce the same clinical effect and safety • Prescriptions that exceed set plan limits This formulary lists all specific strengths and dosage forms that are covered. When a
• Prescriptions processed by non-network strength or dosage form is specified,
State laws or regulation may indicate the only the product identified will be
ability to practice generic substitution for covered. Other strengths/ dosage forms
selected products or categories of drugs. of the referenced product are not
covered.
that are repackaged or distributed under a For specific questions please contact the should always be considered therapeutically
To request a prior authorization the
equivalent and substitutable for the source physician or a member of his/her staff
should contact Health Partners either by
fax at 866-240-3712, or phone at 215-991-
Generic substitution is the process by which 4300. All non-emergency requests can be
a generic equivalent is dispensed rather faxed 24 hours per day; calls should be
placed from 9:00 A.M. to 5:00 P.M.,
Monday through Friday.
therapy. Health Partners will not cover any drugs by companies that do not participate business hours, the call should be made to in the Federal Rebate Program or are DESI subsequently made a determination of fully 1-888-888-1212. The call will be evaluated
effective for most of these products and they prescriptions for drugs with A-rated generics products remain classified as less than fully The physician may use the Health Partners effective while awaiting final administrative Prior Authorization/Medical Exception form disposition. Also classified as DESI are or a letter of request, but must include the The MAC list sets a ceiling price for the many products listed as identical, similar, or following information for quick and prescription drugs. This price will typically cover the acquisition of most generics but not branded versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA’s review and approval process. This process • Days supply (duration of therapy) and utilized appropriately, Prior Authorization specific products. These medications may require Prior Authorization for the following The FDA has given the generic an “A” rating • Non-formulary medications, or benefit determined the generic is therapeutically exceptions required by medical necessity • Additional clinical information that may substitute for the knowledge, expertise, skill prescriber, Health Partners will render a his/her choice of prescription drugs. Health Partners does not assume responsibility for Director will review each prior authorization request and make the final decision. After provider based upon reliance, in whole or in part, on the information contained herein. pharmacist will prepare the request for the denial/approval letter. A denial letter will be mailed to the member or parent/guardian. A copy of the member denial letter is also Administration (FDA) publishes guidelines on the safest and most efficient ways to use The information contained in this document certain drugs. Many drug products on the If the Prior Authorization/Medical Exception KidzPartners Formulary have quantity limits licensing agreement. The information may based upon the dosage described in product submit a written appeal to Health Partners’ not be copied in whole or in part without the Complaint & Grievance Unit explaining the written permission of Health Partners. All medical necessity of the medical treatment Drugs subject to quantity limits may change. business hours, the prescribing physician Trade names are the intellectual property of Step therapy is a process that encourages the use of medications preferred by Health Partners as the first course of treatment. If the preferred medication is not clinically Health Partners supports appropriate use of injectables and has established procedures for prescribing and suppliers. Under the direction of the Health Partners Pharmacy department, the physician provider has the primary responsibility for obtaining Prior Authorization for medications included in responses will be reviewed and considered. medications, although not limited to, can be obtained through the retail pharmacy benefit GENERIC NAME
BRAND NAME
fluphenazine decanoate Prolixin Decanoate KidzPartners Formulary and its appendices is provided by Health Partners solely for the convenience of medical providers. Health TABLE OF CONTENTS
ANALGESICS . 1
ANALGESIC, NON-SALICYLATE & BARBITURATE COMB. . 1
ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMB. 1
ANALGESIC/ANTIPYRETICS, SALICYLATES . 1
ANALGESIC/ANTIPYRETICS,NON-SALICYLATE . 1
ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATION . 1
ANALGESICS, NARCOTICS . 1
ANTIMIGRAINE PREPARATIONS . 3
NARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMB . 3
NARCOTIC & SALICYLATE ANALGESICS, BARB.& XANTHINE. 3
NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB . 3
NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE. 3
URINARY TRACT ANALGESIC AGENTS. 4
ANESTHETICS . 4
LOCAL ANESTHETICS . 4
URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE) . 4
ANTIARTHRITICS . 4
ANALGESIC/ANTIPYRETICS, SALICYLATES . 4
ANTI-ARTHRITIC AND CHELATING AGENTS. 4
ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS . 4
ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR. 4
ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR . 4
COLCHICINE. 4
GOLD SALTS . 4
HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS . 4
NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE. 4
URICOSURIC AGENTS . 6
ANTIASTHMATICS. 6
BETA-ADRENERGIC AGENTS . 6
BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS . 7
BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONS . 7
GENERAL BRONCHODILATOR AGENTS . 7
LEUKOTRIENE RECEPTOR ANTAGONISTS . 7
MAST CELL STABILIZERS . 7
MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E(IGE) . 7
MUCOLYTICS . 7
NASAL MAST CELL STABILIZERS AGENTS . 7
XANTHINES . 7
ANTIDOTES. 8
NARCOTIC ANTAGONISTS . 8
ANTIHISTAMINE AND DECONGESTANT COMBINATION . 8
1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS . 8
ANTIHISTAMINES . 8
ANTIHISTAMINES - 1ST GENERATION . 8
ANTIHISTAMINES - 2ND GENERATION . 8
EYE ANTIHISTAMINES . 9
ANTIINFECTIVES . 9
ABSORBABLE SULFONAMIDES . 9
AMINOGLYCOSIDES. 9
ANTITUBERCULAR ANTIBIOTICS . 9
CEPHALOSPORINS - 1ST GENERATION. 9
CEPHALOSPORINS - 2ND GENERATION . 10
CEPHALOSPORINS - 3RD GENERATION . 10
LINCOSAMIDES . 10
MACROLIDES . 10
NITROFURAN DERIVATIVES . 11
PENICILLINS. 11
TETRACYCLINES . 12
VAGINAL ANTIBIOTICS . 12
VAGINAL ANTIFUNGALS . 12
VANCOMYCIN AND DERIVATIVES . 13
ANTIINFECTIVES/MISCELLANEOUS . 13
AMEBACIDES . 13
ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS . 13
ANTHELMINTICS. 13
ANTIFUNGAL AGENTS. 13
ANTIFUNGAL ANTIBIOTICS. 13
ANTILEPROTICS . 13
ANTIMALARIAL DRUGS . 13
ANTI-MYCOBACTERIUM AGENTS . 13
ANTIVIRAL MONOCLONAL ANTIBODIES. 14
ANTIVIRALS, GENERAL . 14
ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB. 14
ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG . 14
ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB . 14
ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS. 14
ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI. 14
ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI . 14
ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI . 15
ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB . 15
ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS. 15
ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR. 15
ARTV CMB NUCLEOSIDE,NUCLEOTIDE,&NON-NUCLEOSIDE RTI. 15
CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC. . 15
HEPATITIS C TREATMENT AGENTS. 15
QUINOLONES . 16
ANTINEOPLASTICS. 16
ALKYLATING AGENTS . 16
ANTIANDROGENIC AGENTS . 16
ANTIMETABOLITES . 16
ANTINEOPLASTIC - AROMATASE INHIBITORS. 17
ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. . 17
ANTINEOPLASTICS,MISCELLANEOUS . 17
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM) . 17
SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR) . 17
STEROID ANTINEOPLASTICS . 17
TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTS. 17
ANTIPARKINSON DRUGS. 17
ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC. 17
AUTONOMIC DRUGS. 17
ADRENERGICS, AROMATIC, NON-CATECHOLAMINE. 17
ANAPHYLAXIS THERAPY AGENTS . 18
BETA-ADRENERGIC BLOCKING AGENTS . 18
BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATED . 19
PARASYMPATHETIC AGENTS . 19
BIOLOGICALS. 19
ANTISERA. 19
BLOOD. 19
ANTICOAGULANTS,COUMARIN TYPE . 19
ANTIFIBRINOLYTIC AGENTS. 20
HEMATINICS,OTHER . 20
HEMORRHEOLOGIC AGENTS . 20
HEPARIN AND RELATED PREPARATIONS . 20
PLATELET AGGREGATION INHIBITORS. 20
CARDIAC DRUGS . 21
ANTIARRHYTHMICS . 21
CALCIUM CHANNEL BLOCKING AGENTS . 21
DIGITALIS GLYCOSIDES. 23
VASODILATORS,CORONARY. 23
CARDIOVASCULAR. 23
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION . 23
ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC . 24
ALPHA/BETA-ADRENERGIC BLOCKING AGENTS. 24
ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB . 24
ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKR. 24
ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS . 24
ANTIHYPERTENSIVES, ACE INHIBITORS . 25
ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST . 25
ANTIHYPERTENSIVES, SYMPATHOLYTIC . 25
ANTIHYPERTENSIVES, VASODILATORS . 26
BILE SALT SEQUESTRANTS . 26
LIPOTROPICS. 26
CNS DRUGS . 26
ANTICONVULSANTS . 26
CONTRACEPTIVES . 28
CONTRACEPTIVES,INJECTABLE. 28
CONTRACEPTIVES,ORAL. 28
CONTRACEPTIVES,TRANSDERMAL . 29
COUGH/COLD PREPARATIONS. 29
ANTITUSSIVES,NON-NARCOTIC . 29
DECONGESTANT-EXPECTORANT COMBINATIONS. 29
NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST . 30
NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE . 30
NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMB. . 30
NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION. 30
NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST . 30
NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB. . 30
DIAGNOSTIC . 30
BLOOD SUGAR DIAGNOSTICS . 30
URINE ACETONE TEST AIDS. 30
URINE MULTIPLE TEST AIDS . 30
URINE TEST AIDS,MISCELLANEOUS . 31
DIURETICS . 31
CARBONIC ANHYDRASE INHIBITORS . 31
LOOP DIURETICS. 31
POTASSIUM SPARING DIURETICS . 31
POTASSIUM SPARING DIURETICS IN COMBINATION . 31
THIAZIDE AND RELATED DIURETICS. 31
EENT PREPS. 32
EAR PREPARATIONS, MISC. ANTI-INFECTIVES. 32
EAR PREPARATIONS,ANTIBIOTICS . 32
EAR PREPARATIONS,LOCAL ANESTHETICS . 32
EYE ANTIBIOTIC-CORTICOID COMBINATIONS . 32
EYE ANTIINFLAMMATORY AGENTS. 32
EYE ANTIVIRALS . 33
EYE SULFONAMIDES . 33
EYE VASOCONSTRICTORS (RX ONLY). 33
MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS. 33
MYDRIATICS. 33
NASAL ANTI-INFLAMMATORY STEROIDS. 34
NOSE PREPARATIONS, MISCELLANEOUS (RX) . 34
OPHTHALMIC ANTIBIOTICS . 34
OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE . 34
OPHTHALMIC MAST CELL STABILIZERS . 34
OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICS . 34
ELECT/CALORIC/H2O . 34
ELECTROLYTE DEPLETERS . 34
FLUORIDE PREPARATIONS . 35
HYPERGLYCEMICS . 35
IODINE CONTAINING AGENTS . 35
POTASSIUM REPLACEMENT . 35
URINARY PH MODIFIERS. 35
GASTROINTESTINAL . 35
AMMONIA INHIBITORS. 35
ANTICHOLINERGICS,QUATERNARY AMMONIUM. 36
ANTICHOLINERGICS/ANTISPASMODICS. 36
ANTIDIARRHEALS . 36
ANTIEMETIC/ANTIVERTIGO AGENTS. 36
ANTI-ULCER PREPARATIONS. 36
ANTI-ULCER-H.PYLORI AGENTS . 37
BELLADONNA ALKALOIDS . 37
BILE SALTS . 37
CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TX . 37
DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT . 37
HISTAMINE H2-RECEPTOR INHIBITORS . 37
INTESTINAL MOTILITY STIMULANTS . 38
LAXATIVES AND CATHARTICS . 38
PANCREATIC ENZYMES . 38
PROTON-PUMP INHIBITORS . 38
RECTAL PREPARATIONS . 38
HORMONES . 39
ANDROGENIC AGENTS. 39
ANTIDIURETIC AND VASOPRESSOR HORMONES . 39
GLUCOCORTICOIDS. 39
GROWTH HORMONES. 40
LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS . 40
LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY . 40
MINERALOCORTICOIDS . 40
OXYTOCICS. 41
PROGESTATIONAL AGENTS. 41
RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR). 41
HYPOGLYCEMICS . 41
ANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB. . 41
ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S) . 41
ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS . 41
ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE . 41
ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S) . 42
ANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA) . 42
ANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMB. 42
ANTIHYPERGLYCEMIC,INSULIN-RESPONSE & RELEASE COMB.. 42
ANTIHYPERGLYCM,INSUL-RESP.ENHANCER & BIGUANIDE CMB. 42
INSULINS . 42
IMMUNOSUPPRESANT . 43
IMMUNOSUPPRESSIVES . 43
TOPICAL IMMUNOSUPPRESSIVE AGENTS . 44
MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG . 44
DIABETIC SUPPLIES . 44
DURABLE MEDICAL EQUIPMENT,MISC(GROUP 1). 44
RESPIRATORY AIDS,DEVICES,EQUIPMENT. 44
MUSCLE RELAXANTS. 44
SKELETAL MUSCLE RELAXANTS . 44
PRE-NATAL VITAMINS. 44
PRENATAL VITAMIN PREPARATIONS . 44
PSYCHOTHERAPEUTIC DRUGS . 46
ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS . 46
ANTI-ANXIETY DRUGS . 46
ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINES. 47
ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED . 47
ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS . 47
ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG. 47
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES. 48
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES . 48
ANTIPSYCHOTICS,DOPAMINE ANTAGONST,DIHYDROINDOLONES. 48
ANTI-PSYCHOTICS,PHENOTHIAZINES. 49
BIPOLAR DISORDER DRUGS . 49
MAOIS - NON-SELECTIVE & IRREVERSIBLE . 49
NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) . 49
SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) . 50
SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) . 50
SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) . 50
TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS . 51
TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS. 51
TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB . 51
TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY . 52
TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE . 52
SEDATIVE/HYPNOTICS. 52
BARBITURATES. 52
SEDATIVE-HYPNOTICS,NON-BARBITURATE . 52
SKIN PREPS. 53
ACNE AGENTS,SYSTEMIC. 53
ACNE AGENTS,TOPICAL . 53
ANTIPERSPIRANTS . 53
ANTIPRURITICS,TOPICAL. 53
ANTIPSORIATIC AGENTS,SYSTEMIC . 53
ANTIPSORIATICS AGENTS . 53
ANTISEBORRHEIC AGENTS . 53
EMOLLIENTS . 53
HYPOPIGMENTATION AGENTS . 54
IMMUNOMODULATORS . 54
KERATOLYTICS . 54
ROSACEA AGENTS, TOPICAL . 54
TOPICAL ANTIBIOTICS . 54
TOPICAL ANTIFUNGALS. 55
TOPICAL ANTI-INFLAMMATORY STEROIDAL . 56
TOPICAL ANTIPARASITICS . 57
TOPICAL ANTIVIRALS. 58
TOPICAL LOCAL ANESTHETICS. 58
TOPICAL SULFONAMIDES. 58
VITAMIN A DERIVATIVES. 58
VITAMIN A DERIVATIVES, TOPICAL COSMETIC AGENTS . 58
SMOKING DETERRENTS . 58
SMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS). 58
SMOKING DETERRENTS, OTHER . 59
THYROID PREPS . 59
ANTITHYROID PREPARATIONS . 59
THYROID HORMONES. 59
UNCLASSIFIED DRUG PRODUCTS. 59
AGENTS TO TREAT MULTIPLE SCLEROSIS. 59
ANTI-ALCOHOLIC PREPARATIONS. 59
APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND. . 59
BULK CHEMICALS. 60
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS. 60
DENTAL AIDS AND PREPARATIONS. 60
METALLIC POISON,AGENTS TO TREAT . 60
URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT. 60
VITAMINS . 60
FOLIC ACID PREPARATIONS . 60
NIACIN PREPARATIONS . 60
PEDIATRIC VITAMIN PREPARATIONS. 60
VITAMIN B PREPARATIONS . 60
VITAMIN B12 PREPARATIONS . 61
VITAMIN D PREPARATIONS . 61
VITAMIN K PREPARATIONS . 61
ANALGESICS
ANALGESIC,
NON-SALICYLATE & BARBITURATE
ANALGESIC,NON-
SALICYLATE,BARBITURATE,&XANTHINE CMB
ANALGESICS, NARCOTIC AGONIST AND NSAID
COMBINATION
ANALGESIC/ANTIPYRETICS, SALICYLATES
ANALGESICS,
NARCOTICS
ANALGESIC/ANTIPYRETICS,NON-SALICYLATE
NARC.&
NON-SAL.ANALGESIC,BARBITURATE
&XANTHINE CMB
NARCOTIC & SALICYLATE ANALGESICS, BARB.&
XANTHINE
NARCOTIC
ANALGESIC & NON-SALICYLATE
ANALGESIC COMB
CYCLOOXYGENASE INHIBITOR - TYPE
ANTIMIGRAINE
PREPARATIONS
URINARY TRACT ANALGESIC AGENTS
ANESTHETICS
ANESTHETICS
ANTI-INFLAMMATORY,
PYRIMIDINE SYNTHESIS
INHIBITOR
URINARY TRACT ANESTHETIC/ANALGESIC AGNT
(AZO-DYE)
COLCHICINE
ANTIARTHRITICS
ANALGESIC/ANTIPYRETICS, SALICYLATES
HYPERURICEMIA
- XANTHINE OXIDASE
ANTI-ARTHRITIC AND CHELATING AGENTS
INHIBITORS
ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS
CYCLOOXYGENASE INHIBITOR - TYPE
ANTI-INFLAMMATORY TUMOR NECROSIS
FACTOR INHIBITOR
URICOSURIC
ANTIASTHMATICS
BETA-ADRENERGIC
BETA-ADRENERGIC AND ANTICHOLINERGIC
MONOCLONAL
ANTIBODIES
COMBINATIONS
IMMUNOGLOBULIN E(IGE)
BETA-ADRENERGIC AND GLUCOCORTICOID
MUCOLYTICS
COMBINATIONS
NASAL MAST CELL STABILIZERS AGENTS
XANTHINES
GENERAL BRONCHODILATOR AGENTS
LEUKOTRIENE
RECEPTOR ANTAGONISTS
MAST CELL STABILIZERS
ANTIDOTES
NARCOTIC
ANTAGONISTS
ANTIHISTAMINE AND DECONGESTANT
COMBINATION
ANTIHISTAMINE & DECONGESTANT
COMBINATIONS
ANTIHISTAMINES
ANTIHISTAMINES
1ST GENERATION
ANTIHISTAMINES
2ND GENERATION
ANTIHISTAMINES
ANTIINFECTIVES
ABSORBABLE
SULFONAMIDES
AMINOGLYCOSIDES
ANTITUBERCULAR
ANTIBIOTICS
CEPHALOSPORINS - 1ST GENERATION
CEPHALOSPORINS - 2ND GENERATION
LINCOSAMIDES
MACROLIDES
CEPHALOSPORINS - 3RD GENERATION
NITROFURAN
DERIVATIVES
PENICILLINS
ANTIFUNGALS
TETRACYCLINES
ANTIBIOTICS
VANCOMYCIN
AND DERIVATIVES
ANTIINFECTIVES/MISCELLANEOUS
AMEBACIDES
ANAEROBIC
ANTIPROTOZOAL-ANTIBACTERIAL
ANTILEPROTICS
ANTIMALARIAL
ANTHELMINTICS
ANTIFUNGAL
ANTI-MYCOBACTERIUM
ANTIFUNGAL
ANTIBIOTICS
ANTIVIRAL MONOCLONAL ANTIBODIES
ANTIVIRALS,
ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS
ANTIVIRALS,
HIV-SPECIFIC,
NON-NUCLEOSIDE,
ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC
ANTIVIRALS,
HIV-SPECIFIC,
NUCLEOSIDE
PROTEASE INHIB
ANALOG, RTI
ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-
NUCLEOTIDE ANALOG
ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG,
ANTIVIRALS,
HIV-SPECIFIC,
NUCLEOTIDE
ANALOG, RTI
ANTIVIRALS,HIV-1 INTEGRASE STRAND
TRANSFER INHIBTR
ANTIVIRALS,
HIV-SPECIFIC,
PROTEASE
INHIBITOR COMB
NUCLEOSIDE,NUCLEOTIDE,&NON-
NUCLEOSIDE RTI
CHEMOTHERAPEUTICS,
ANTIBACTERIAL, MISC.
ANTIVIRALS,
HIV-SPECIFIC,
PROTEASE
INHIBITORS
HEPATITIS C TREATMENT AGENTS
QUINOLONES
ANTIANDROGENIC
ANTIMETABOLITES
ANTINEOPLASTICS
ALKYLATING

ANTINEOPLASTIC
AROMATASE INHIBITORS
TOPICAL ANTINEOPLASTIC & PREMALIGNANT
LESION AGNTS
ANTINEOPLASTIC
LHRH(GNRH)
AGONIST,PITUITARY SUPPR.
ANTIPARKINSON DRUGS
ANTIPARKINSONISM
DRUGS,ANTICHOLINERGIC
ANTINEOPLASTICS,MISCELLANEOUS
AUTONOMIC DRUGS
SELECTIVE ESTROGEN RECEPTOR
ADRENERGICS, AROMATIC, NON-
MODULATORS (SERM)
CATECHOLAMINE
SELECTIVE
RETINOID
X RECEPTOR AGONISTS
ANTINEOPLASTICS
ANAPHYLAXIS THERAPY AGENTS
BETA-ADRENERGIC
BLOCKING AGENTS
ANTICOAGULANTS,COUMARIN
BETA-ADRENERGIC
BLOCKING
AGENTS/THIAZIDE & RELATED
PARASYMPATHETIC
BIOLOGICALS
ANTISERA
ANTIFIBRINOLYTIC
HEMATINICS,OTHER
PLATELET AGGREGATION INHIBITORS
HEMORRHEOLOGIC
RELATED PREPARATIONS

CARDIAC DRUGS
ANTIARRHYTHMICS
CALCIUM CHANNEL BLOCKING AGENTS
DIGITALIS
GLYCOSIDES
VASODILATORS,CORONARY
CARDIOVASCULAR
INHIBITOR/CALCIUM CHANNEL BLOCKER
COMBINATION
INHIBITOR/THIAZIDE & THIAZIDE-LIKE
DIURETIC
ANGIOTENSIN
RECEPTOR ANTGNST &
CALC.CHANNEL BLOCKR
ALPHA/BETA-ADRENERGIC BLOCKING AGENTS
ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE
INHIBITORS
ANGIOTENSIN
RECEPTOR ANTAG./THIAZIDE
DIURETIC COMB
ANTIHYPERTENSIVES,
INHIBITORS
ANTIHYPERTENSIVES,
ANGIOTENSIN
RECEPTOR
ANTAGONIST
ANTIHYPERTENSIVES,
SYMPATHOLYTIC
LIPOTROPICS
CNS DRUGS
ANTICONVULSANTS
ANTIHYPERTENSIVES,
VASODILATORS
SEQUESTRANTS
CONTRACEPTIVES,ORAL
CONTRACEPTIVES
CONTRACEPTIVES,INJECTABLE
CONTRACEPTIVES,TRANSDERMAL
COUGH/COLD PREPARATIONS
ANTITUSSIVES,NON-NARCOTIC
DECONGESTANT-EXPECTORANT
COMBINATIONS

NARCOTIC
ANTITUSS-1ST GEN. ANTIHISTAMINE-
NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-
DECONGEST
DECONGEST
NARCOTIC
ANTITUSSIVE-1ST GENERATION
ANTIHISTAMINE
NON-NARC ANTITUSSIVE-1ST GEN
NARCOTIC
ANTITUSSIVE-ANTICHOLINERGIC
ANTIHISTAMINE COMB.
TAB Y DIAGNOSTIC
BLOOD SUGAR DIAGNOSTICS
NARCOTIC
ANTITUSSIVE-EXPECTORANT
COMBINATION
URINE ACETONE TEST AIDS
URINE MULTIPLE TEST AIDS
URINE TEST AIDS,MISCELLANEOUS
POTASSIUM SPARING DIURETICS IN
COMBINATION
DIURETICS
CARBONIC ANHYDRASE INHIBITORS
THIAZIDE AND RELATED DIURETICS
DIURETICS
POTASSIUM SPARING DIURETICS
EENT PREPS
EAR PREPARATIONS, MISC. ANTI-INFECTIVES
ANTIINFLAMMATORY
PREPARATIONS,ANTIBIOTICS
EAR PREPARATIONS,LOCAL ANESTHETICS
ANTIBIOTIC-CORTICOID COMBINATIONS
ANTIVIRALS
MIOTICS/OTHER INTRAOC. PRESSURE
REDUCERS
SULFONAMIDES
EYE VASOCONSTRICTORS (RX ONLY)
MYDRIATICS
OPHTHALMIC
ANTI-INFLAMMATORY
IMMUNOMODULATOR-TYPE
NASAL ANTI-INFLAMMATORY STEROIDS
OPHTHALMIC
MAST CELL STABILIZERS
NOSE PREPARATIONS, MISCELLANEOUS (RX)
PREPARATIONS,ANTI-INFLAMMATORY-
ANTIBIOTICS
OPHTHALMIC
ANTIBIOTICS
ELECT/CALORIC/H2O
ELECTROLYTE
DEPLETERS
FLUORIDE
PREPARATIONS
URINARY PH MODIFIERS
HYPERGLYCEMICS
GASTROINTESTINAL
INHIBITORS
IODINE CONTAINING AGENTS
POTASSIUM
REPLACEMENT

ANTICHOLINERGICS,QUATERNARY
AMMONIUM
ANTICHOLINERGICS/ANTISPASMODICS
ANTIDIARRHEALS
ANTIEMETIC/ANTIVERTIGO
ANTI-ULCER
PREPARATIONS
ANTI-ULCER-H.PYLORI
HISTAMINE H2-RECEPTOR INHIBITORS
BELLADONNA
ALKALOIDS
CHRONIC INFLAM. COLON DX, 5-A-
SALICYLAT,RECTAL TX
TX-CHRONIC
INFLAM. COLON DX,5-
AMINOSALICYLAT
PANCREATIC
INTESTINAL
MOTILITY
STIMULANTS
LAXATIVES
AND CATHARTICS
PROTON-PUMP
INHIBITORS
PREPARATIONS
HORMONES
ANDROGENIC
ANTIDIURETIC
VASOPRESSOR HORMONES
GLUCOCORTICOIDS
HORMONES
LHRH(GNRH) AGONIST ANALOG PITUITARY
SUPPRESSANTS
LHRH(GNRH)AGNST
PIT.SUP-CENTRAL
PRECOCIOUS PUBERTY
MINERALOCORTICOIDS

OXYTOCICS
ANTIHYPERGLYCEMIC,
INHIBITORS
PROGESTATIONAL
ANTIHYPERGLYCEMIC,
INSULIN-RELEASE
STIMULANT TYPE
RECTAL/LOWER BOWEL PREP.,GLUCOCORT.
(NON-HEMORR)
HYPOGLYCEMICS
ANTIHYPERGLY, (DPP-4) INHIBITOR &
BIGUANIDE COMB.
ANTIHYPERGLYCEMIC,
ALPHA-GLUCOSIDASE
INHIB (N-S)
ANTIHYPERGLYCEMIC,INSULIN-REL
STIM.&
BIGUANIDE CMB
ANTIHYPERGLYCEMIC,INSULIN-RESPONSE &
RELEASE COMB.
ANTIHYPERGLYCEMIC,
INSULIN-RESPONSE
ENHANCER (N-S)
ANTIHYPERGLYCM,INSUL-RESP.ENHANCER
BIGUANIDE CMB
ANTIHYPERGLYCEMIC,BIGUANIDE
TYPE(NON-
INSULINS
SULFONYLUREA)
IMMUNOSUPPRESANT
IMMUNOSUPPRESSIVES
MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS
IMMUNOSUPPRESSIVE AGENTS
MISCELLANEOUS MEDICAL SUPPLIES, DEVICES,
NON-DRUG
DIABETIC
SUPPLIES
DURABLE MEDICAL EQUIPMENT,MISC(GROUP 1)
RESPIRATORY
AIDS,DEVICES,EQUIPMENT
PRE-NATAL VITAMINS
PRENATAL
VITAMIN PREPARATIONS
ANTI-ANXIETY
PSYCHOTHERAPEUTIC DRUGS
RECEPTOR
ANTAGONIST
ANTIDEPRESSANTS
ANTIPSYCHOTICS, DOPAMINE & SEROTONIN
ANTAGONISTS
ANTIPSYCH,DOPAMINE
ANTAG.,DIPHENYLBUTYLPIPERIDINES
ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,&
SEROTONIN ANTAG
ANTIPSYCHOTICS, ATYP, D2 PARTIAL
AGONIST/5HT MIXED
ABILIFY DISCMELT 10 MG TABLET QL, PA < age 6 ABILIFY DISCMELT 15 MG TABLET QL, PA < age 6 ANTIPSYCHOTICS,DOPAMINE
ANTAGONISTS,
THIOXANTHENES
RISPERIDONE 1 MG/ML SOLUTION QL, PA < age 6 ANTIPSYCHOTICS,DOPAMINE
ANTAGONISTS,BUTYROPHENONES
ANTIPSYCHOTICS,DOPAMINE
ANTAGONST,DIHYDROINDOLONES
ANTI-PSYCHOTICS,PHENOTHIAZINES
BIPOLAR DISORDER DRUGS
MAOIS - NON-SELECTIVE & IRREVERSIBLE
NOREPINEPHRINE AND DOPAMINE REUPTAKE
INHIB (NDRIS)
SELECTIVE SEROTONIN REUPTAKE INHIBITOR
SEROTONIN-2
ANTAGONIST/REUPTAKE
INHIBITORS (SARIS)
SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB
TRICYCLIC
ANTIDEPRESSANT/BENZODIAZEPINE
COMBINATNS
TRICYCLIC
ANTIDEPRESSANT/PHENOTHIAZINE
COMBINATNS
TRICYCLIC
ANTIDEPRESSANTS & REL. NON-SEL.
RU-INHIB
TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD),
NRI-TYPE
TX FOR ATTENTION DEFICIT-
HYPERACT(ADHD)/NARCOLEPSY
SEDATIVE/HYPNOTICS
BARBITURATES
SEDATIVE-HYPNOTICS,NON-BARBITURATE
ANTIPERSPIRANTS
ANTIPRURITICS,TOPICAL
SKIN PREPS
AGENTS,SYSTEMIC
ANTIPSORIATIC
AGENTS,SYSTEMIC
ANTIPSORIATICS
ANTISEBORRHEIC
AGENTS,TOPICAL
EMOLLIENTS
ROSACEA AGENTS, TOPICAL
HYPOPIGMENTATION
IMMUNOMODULATORS
ANTIBIOTICS
KERATOLYTICS
ANTIFUNGALS
ANTI-INFLAMMATORY
STEROIDAL
ANTIPARASITICS
SMOKING DETERRENTS
DETERRENT
AGENTS (GANGLIONIC
STIM,OTHERS)
ANTIVIRALS
ANESTHETICS
SULFONAMIDES
DERIVATIVES
DERIVATIVES, TOPICAL COSMETIC
SMOKING DETERRENTS, OTHER
THYROID PREPS
UNCLASSIFIED DRUG PRODUCTS
ANTITHYROID
PREPARATIONS
AGENTS TO TREAT MULTIPLE SCLEROSIS
HORMONES
ANTI-ALCOHOLIC
PREPARATIONS
APPETITE STIM. FOR
ANOREXIA,CACHEXIA,WASTING SYND.
VITAMINS
CHEMICALS
FOLIC ACID PREPARATIONS
CHEMOTHERAPY
RESCUE/ANTIDOTE AGENTS
PREPARATIONS
PEDIATRIC VITAMIN PREPARATIONS
DENTAL AIDS AND PREPARATIONS
METALLIC POISON,AGENTS TO TREAT
PREPARATIONS
ANTISPASMODIC/ANTIINCONTINENCE AGENT
PREPARATIONS
Y VITAMIN
PREPARATIONS
PREPARATIONS

Source: http://kidzpartners-uat.kidzpartners.com/ES/PDF/Formulary.pdf