List by therapeutic class

REGENCY PREFFERED FORMULARY EFFECTIVE 1/01/04
FORMULARY NEW ADD LIST
Aromasin
Beconase AQ
Benicar
Copegus
Dovonex
Femara
Lantus
Nimotop
Pegasys
Rebif
Singular Granules
Soriatane
Vfend
PRODUCTS NO LONGER ON FORMULARY
Non-formulary
Formulary
Generic nifedipine, diltiazem, verapamil Generic nifedipine, diltiazem, verapamil List by Therapeutic Class
PAR=Prior Authorization QL=Quantity Limits
ST=Step Therapy required
VA=Value Added List
ANTI-INFECTIVES
MENTAL HEALTH
amitriptyline/chlordiazepoxide (Limbitrol®) amphetamine/dextroamphetamine (Adderall®) chloroquine phosphate (Aralen phosphate®) erythromycin ethyl succinate (EryPed®, EES®) erythromycin/sulfisoxazole (Pediazole®) trimethoprim/sulfamethoxazole (Septra®, Stromectol® Vancocin® Zithromax® (QL) ANTIVIRALS
NEUROLOGICAL
chloral hydrate (Somnote®, Aquachloral®) BONE AND JOINT
Cuprimine® Enbrel® (PAR) Kineret® (PAR) OPHTHALMIC
acetazolamide (Diamox®) (VA)
ONCOLOGY
phenylephrine ophthalmic (AK-Dilate®) pilocarpine ophthalmic (Isopto Carpine®) polymyxin B/trimethoprim ophthalmic (Polytrim®) prednisolone acetate ophthalmic (Pred Forte®) CARDIOVASCULAR
prednisolone sodium phosphate ophthalmic sodium sulfacetamide ophthalmic (Bleph-10®) hydrochlorothiazide/triamterene (Dyazide®) (VA) lisinopril (Zestril, Prinivil®) lisinopril/hctz (Zestoretic, Prinzide®) methyclothiazide (Enduron®) methyldopa/hctz (Aldoril®) metoprolol (Lopressor®) (VA) PAIN/INFLAMMATION/HEADACHE
nitroglycerin (Nitrobid, Nitrostat®) (VA) acetominophen/butalbital/caffeine (Fioricet®) acetominophen/butalbital/caffeine/codeine aspirin/butalbital/caffeine (Fiorinal®) aspirin/butalbital/caffeine/codeine (Fiorinal aspirin/caffeine/orphenadrine (Norgesic®) quinidine sulfate (Quinidex Extentabs®) (VA) aspirin/carisoprodol/codeine (Soma Compound ergot/caff/bell alk/phenobarb (Cafergot P-B®) sulindac (Clinoril®) tramadol (Ultram®) Cafergot® DIABETES
glipizide (Glucotrol, Glucotrol XL®) (VA) Humalog insulins® Humulin insulins® Iletin II insulins® RESPIRATORY
aminophylline (Panamin®) cromolyn inhaled (Intal®) dyphylline (Dilor®) EAR/NOSE/THROAT
benzocaine/antipyrine otic (Auralagan®) guaifenesin/hydrocodone (Vicodin Tuss®) SKIN
amcinonide (Cyclocort®)
ENDOCRINE/HORMONES
bacitracin/HC/neomycin/polymyxin B ophthalmic betamethasone valerate topical (Luxiq®) betamethasone/clotriamazole (Lotrisone®) levothyroxine (Levothroid®, Levoxyl®) (VA) hydrocortisone/pramoxine topical (Proctocream ketoconazole topical (Nizoral topical®) nystatin/triamcinolone topical (Mycolog-II®) silver sulfadiazine topical (Sivadene®) timolol ophthalmic (Betimol, Timoptic®) GASTROINTESTINAL
loperamide (Imodium®) metoclopramide (Reglan®) (VA) nizatidine (Axid®) polyethylene glycol/electrolytes (Colyte®) trimethobenzamide (Tigan®) ursodiol (Urso®) Actigall® WOMEN'S HEALTH
estradiol transdermal (Estraderm®, Alora®, Ortho Micronor® Ortho Tri-Cyclen® Ortho-Cept® IMMUNE SYSTEMS
LIPID LOWERING
lovastatin (Mevacor®) Advicor® Colestid® Lipitor® Niaspan® Alphabetized List
PAR=Prior Authorization QL=Quantity Limits apply
VA=Value Added List
ST=Step Therapy
required
acetaminophen/hydrocodone (Vicodin, Lortab®) ketoconazole topical (Nizoral topical®) acetominophen/butalbital/caffeine (Fioricet®) acetominophen/butalbital/caffeine/codeine (Fioricet with Codeine®) acetominophen/dichloralphenazone/ isometheptene (Midrin®) levothyroxine (Levothroid®, Levoxyl®) (VA) lisinopril/hctz (Zestoretic, Prinzide®) amitriptyline/chlordiazepoxide (Limbitrol®) amoxicillin/clavulanate (Augmentin®) amphetamine/dextroamphetamine (Adderall®) ampicillin (Omnipen®) anthralin topical (Drithocreme®) Anzamet® (QL) aspirin/butalbital/caffeine (Fiorinal®) aspirin/butalbital/caffeine/codeine (Fiorinal aspirin/caffeine/orphenadrine (Norgesic®) aspirin/carisoprodol/codeine (Soma Compound Metrogel® metronidazole (Flagyl®) mexiletine (Mexitil®) benzocaine/antipyrine otic (Auralagan®) betamethasone valerate topical (Luxiq®) betamethasone/clotriamazole (Lotrisone®) bethanechol (Urecholine®) (VA) Betimol® nicardipine (Cardene®) nifedipine (Adalat®) (VA) nitroglycerin (Nitrobid, Nitrostat®) (VA) nystatin/triamcinolone topical (Mycolog-II®) cefazolin (Kefzol®) cefuroxime (Ceftin®) chloral hydrate (Somnote®, Aquachloral®) chloroquine phosphate (Aralen phosphate®) cimetidine (Tagamet®) (VA) Cipro® citric acid/sodium citrate (Bicitra®) pilocarpine ophthalmic (Isopto Carpine®) polyethylene glycol/electrolytes (Colyte®) Pred Mild® prednisolone (Pediapred®) prednisolone acetate ophthalmic (Pred Forte®) prednisolone sodium phosphate ophthalmic (Inflamase Forte®) prednisone (Deltasone®) promethazine/codeine (Phenergan with Codeine®) digoxin (Lanoxin®) (VA) Dilantin® (VA) diltiazem (Cardizem®) (VA) quinidine sulfate (Quinidex Extentabs®) (VA) Diprolene® dipyridamole (Persantine®) (VA) disopyramide (Norpace®) (VA) doxazosin (Cardura®) doxepin (Sinequan®) Epipen® Epivir® ergoloid mesylates (Ergot®) ergot/caff/bell alk/phenobarb (Cafergot P-B®) erythromycin ethyl succinate (EryPed®, EES®) erythromycin/sulfisoxazole (Pediazole®) silver sulfadiazine topical (Sivadene®) estradiol transdermal (Estraderm®, Alora®, sodium sulfacetamide ophthalmic (Bleph-10®) sulfamethoxazole (Gatanol®) sulfaspirinlazine (Azulfidine®) sulfinpyrazone (Anturane®) (VA) sulfisoxazole (Gantrisin®) sulindac (Clinoril®) fluorometholone ophthalmic (Flarex®, FML timolol ophthalmic (Betimol, Timoptic®) glipizide (Glucotrol, Glucotrol XL®) (VA) guaifenesin/hydrocodone (Vicodin Tuss®) trimethoprim/sulfamethoxazole (Septra®, Bactim®) Hivid® homatropine ophthalmic (Isopto Homatropine®) hydrochlorothiazide (Microzide®) (VA) hydrochlorothiazide/spironolactone (Aldactazide®) (VA) Iletin II insulins® imipramine (Tofranil®) Imitrex® (QL)

Source: http://www.aeholland.com/REGENCEFORMULARY2003.pdf