Project access formulary - updated 2006 (3).xls

CATEGORY
DRUG NAME
HOW SUPPLIED
2 1. ALLERGIC DISORDERS
Chlorpheniramine,Pyrilamine, Phenylephrine (Rynatan) Chlorpheniramine tan-phenylephrine (Rynatan 14 2. CARDIOVASCULAR SYSTEM
15
Capsule 120mg, 180mg, 240mg $$ generic only Amlodipine (Norvasc) - Prior Authorization Clopidogrel (Plavix) - Prior Authorization Required Tablets 5mg, 10mg, 20mg, 40mg $ generic only 1/2 tablet programTablets 2.5mg, 5mg, 10mg, Tablets 5mg, 10mg, 20mg, 40mg $$ generic only 38 CATEGORY
DRUG NAME
HOW SUPPLIED
63 3. DERMATOLOGICAL AGENTS
400gm size half the cost per gram, more cost effective due to A. Topical Anti-Infective Creams Silver Sulfadiazine 1% (Silvadene) 71 CATEGORY
DRUG NAME
HOW SUPPLIED
Miconazole (Monastat 7) Vaginal Cream 45mg 4. EYE, EAR AND THROAT
77 AGENTS
78
Sulfacetamide Sodium 10% (Sodium Sulamyd) Ofloxacin Ophth Soln 0.3% (Occuflox Ophthalmic) Polymixin B sulfate, neomycin, hydrocortisone suspension 89
90
91
92 5. ENDOCRINE SYSTEM
93
Tablets 500mg, 850mg, 1000mg $$ generic only Oral Contraceptives (All available generics) 112 CATEGORY
DRUG NAME
HOW SUPPLIED
6. GASTROINTESTINAL
121 SYSTEM
122
$ generic only MAC .374$ generic only no mac awp's $ generic only$ generic only (capsules not Sodium biophosphate/sodium phosphate (Fleet Enema) Polyethylene glycol 3350 (Miralax, Glycolax) Suppository (adult and pediatric) $ generic only Polyethylene glycol 3350, NaCl, KCl, Sodium Bicarb, 152 CATEGORY
DRUG NAME
HOW SUPPLIED
153 7. INFESTATIONS
154
156
157 8. INFECTIONS
158
$ generic only$$ generic only (250mg dose Ciprofloxacin (Cipro) use as second line agent only Levofloxacin (Levaquin) use as second line agent only Sulfamethaxazole/Trimethoprim DS (Septra DS) $ generic onlynot available generic/ use Nitrofurantoin Macrocyrstalline (Macrobid) Valacyclovir (Valtrex) - prior authorization use as second 190 CATEGORY
DRUG NAME
HOW SUPPLIED
9. MUSCULOSKELETAL
191 SYSTEM
192
$ generic only
$ generic only slightly more
expensive than
cyclobenzaprine
$ generic only costs less than
cyclobenzaprine
201
202
203 10. NEOPLASMS
204
Leuprolide (Lupron) - Prior authorization Ondansetron (Zofran) - prior authorization 209 11. NEUROLOGY
Pramipexole (Mirapex) - Prior authorization Gabapentin (Neurontin) - Prior authorization - for seizure Lamotrigine (Lamictal) - Prior Authorization Diazepam (Diastat) pediatric dose only
Dichloralphenazone, isomeheptene, acetaminophen 227 CATEGORY
DRUG NAME
HOW SUPPLIED
12. NUTRITIONAL
228 SUPPLEMENTS
229
Tablets, Capsules 10meq 20meq $ generic only Prenatal Vitamins (Natalins RX, Stuart Natal) Pediatric multivitamin with fluoride (Poly-Vi-Flor) 236
237
238 13. PAIN
239
Tablet 50/325/40mg
Morphine Sulfate (MS Contin) - Prior authorization Celecoxib (Celebrex) - Prior Authorization Required 256
257
258 14. PSYCHIATRY
263 CATEGORY
DRUG NAME
HOW SUPPLIED
Bupropion SR (Wellbutrin SR) - NOT for smoking $ generic only (40mg generic
still very high priced)
Lithium Carbonate (LithoBid)
Tablets slow release 300mg
no generic
Divalproex sodium (Depakote)
Tablet 125mg, 250mg, 500mg
$$ no generic
Diazepam (Valium)
Tablet 2mg, 5mg, 10mg
$ generic only
Tablet 0.25mg, 0.5mg, 1mg, 2mg $ generic only 287 15. RESPIRATORY AGENTS
$ generic only (generic may be
hard to get)
$ generic only (not repetabs)
Salmeterol/Fluticasone (Advair) - Prior Authorization $$$
$$ (about $20 less per inhaler
Beclomethasone Dipropionate (Q-Var)
than Azmacort)
$ ( AWP is 9.24)
298 CATEGORY
DRUG NAME
HOW SUPPLIED
B. Antitussive Agents Promethazine/Codeine Guaifenesin/Dextromethorphan (Robitussin DM) 16. RHEUMATOLOGY

Source: http://www.spcms.org/projectaccess/standard_formulary.pdf