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Introduction

DRUGS FOR INFECTIONS
Drugs for Parasites. . . . . . . . . . . . . . . . . . . . . . . . . .
ANTIBIOTICS-------------------------------------------------
CONTRACEPTIVES
Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ORAL------------------------------------------------------------------
ampicillin, amoxicillin, cloxacillin, dicloxacillin, multiple generic options (ex. Apri, etc.) Miscellaneous Antiinfectives. . . . . . . . . . . . . . . . . . . .
amoxicllin w/ potassium clavulanate, penicillin clindamycin, metronidazole, nitrofurantoin Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
cefaclor, cefadroxil, cefdinir, cefradine, Dapsone, NebuPent, TOBI, Vancocin, Zyvox 2013 FOCUS Drug Formulary
Necon 10/11, Ogestrel,Ortho Tri-Cyclen Lo, DRUGS FOR CANCER
and Pharmacy Benefit Guidelines
OTHER CONTRACEPTIVES----------------------------------
Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
cyclophosphamide, etoposide, exemestane, The MedBen Focus Drug Formulary
azithromycin, clarithromycin, erythromycin ethyl defines the copayment tier status of the
leucovorin, leuprolide acetate, tretinoin, PROGESTIN ONLY------------------------------------------------
medicines most commonly prescribed for
MedBen members. It may not include all
Tetracyclines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Afinitor, Alkeran, CeeNu, Emcyt, Fareston, DRUGS FOR DIABETES
drugs covered by your prescription drug
INSULINS --------------------------------------------------------
benefit. For benefit coverage or
restrictions please check your benefit plan
Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
document(s). This listing is revised from
time to time as new drugs and new
prescribing information becomes
Aminoglycosides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
available.
IMMUNOMODULATORS
Sulfonamides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The coverage tier for each medication has
sulfisoxazole w erythromycin ethylsuccinate been indicated. Members pay a Tier 1
sulfamethoxazole w trimethoprim (SMX-TMP) cyclosporine, cyclosporine modified, Azasan, Enbrel(PA), Humira(PA), copay for most generic drugs and selected
Drugs for Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . .
OTC medicines. Members pay a Tier 2
ORAL ------------------------------------------------------------
copay for higher cost generic drugs and
acarbose, glimepiride, glipizide, glipizide XL, Revlimid(PA), Simponi(PA) , Thalomid(PA), formulary (“preferred”) brand name drugs.
Members pay a Tier 3 copay for non-
glyburide w/ metformin, glipizide w/ metformin Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . .
HORMONES
formulary and highest cost brand name
GLUCOCORTICOIDS ---------------------------------------------
It is recommended that you have this list of
Drugs For Viral Infections - Influenza & RSV. . . . . .
medications available when you are with
ANDROGENS---------------------------------------------------
your physician and a prescription drug is
going to be part of the treatment for a
ESTROGENS ---------------------------------------------------
clinical condition.
Drugs For Viral Infections - Herpes. . . . . . . . . . . . . . .
Cenestin, Climara, Divigel, Enjuvia, Evamist, Key to Notations:
Drugs For Viral Infections - Hepatitis. . . . . . . . . . . . .
PA: Prior authorization to ensure clinical
DIABETES RELATED DRUGS & SUPPLIES--------------
Incivek(PA), Pegasys, Peg-Intron, ribavirin, appropriateness of this or previous
therapy with other similar medications may
ESTROGEN COMBINATIONS------------------------------
be needed before claims for one of these
Drugs For Viral Infections – HIV/AIDS. . . . . . . . . . . . .
medications will be accepted.
ethinyl estradiol & norethindrone acetate esterified estrogens & methyltestosterone Basic, One Touch II, One Touch Profile, One ST: A step therapy protocol is in place for
Touch Ultra,One, Touch Ultra System, One this medication. If prior medication history
Touch UltraMini, One Touch Verio,and Verio ganciclovir, Hivid, Intelence, Invirase, does not meet clinical guidelines,
Isentress, Kaletra, lamivudine, lamivudine w/ PROGESTINS -----------------------------------------------
authorization may be required prior to
zidovudine. Lexiva, Prezista, Rescriptor, Accu-Chek Meter, Accu-Chek Miscellaneous., acceptance of claims.
MISCELLANEOUS OB/GYN DRUGS-----------------------
Minimed, Surestep Meter, NovoFine Insulin QL: Quantity limitations (maximum
number of tablets/capsules, etc. per month
Bravelle (PA), Follistim(PA), Menopur(PA) Drugs for Malaria. . . . . . . . . . . . . . . . . . . . . . . . . .
or year) are in place for this medication.
GROWTH HORMONES ---------------------------------------
This document is in effect January 1, 2013. Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ THYROID AND ANTITHYROID AGENTS
DIURETICS ------------------------------------------------------
CENTRAL NERVOUS SYSTEM
acetazolamide ER, amiloride, bumetanide, Antileukotrienes. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THYROID ---------------------------------------------------------
PSYCHOTHERAPEUTIC AGENTS -----------------------
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . .
amitriptyline, bupropion, SR, XL, citalopram, Theophyllines…. . . . . . . . . . . . . . . . . . . . . . . .
DRUGS FOR OSTEOPOROSIS
doxepin, escitalopram, fluoxetine, imipramine, ANTILIPEMICS
----------------------------------------------
alendronate sodium (generic for Fosamax) GASTROINTESTINAL
paroxetine CR, protriptyline, trazodone, ANTIULCER -----------------------------------------------------
Actonel, Actonel-D, Atelvia, Boniva, Evista, Advicor, Altoprev, Antara, Lescol, Lescol XL, Livalo, Lovaza, Niaspan, Tricor, TriLipix, Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . .
MISCELLANEOUS ENDOCRINE
chlorpromazine, haloperidol, olanzapine, MISCELLANEOUS CARDIOVASCULAR DRUGS---------
ANTICOAGULANTS/ANTITHROMBOTICS-------------
Aciphex, Dexilant, PrevPac, Pylera, Zegerid ANTIEMETIC/ANTIVERTIGO -----------------------------
Abilify, clozapine, Latuda, risperidone ODT, CARDIOVASCULAR DRUGS
dipyridamole, pentoxifylline, ticlopidine, Fanapt, Fazaclo, Geodon, Invega, Saphris, CARDIOTONICS ----------------------------------------------
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS----
ANTI-ANGINA ----------------------------------------------
Aggrenox, Arixtra(PA), Brilinta, Effient, isosorbide dinitrate, isosorbide mononitrate DIGESTANTS ---------------------------------------------------
temazepam, triazolam, zaleplon, zolpidem DRUGS FOR MISCELLANEOUS BLOOD DISORDERS--
Creon, Pancreaze DR, Ultrase, Ultrase MT, BETA-ADRENERGIC BLOCKERS----------------------
Ultrase MT12, Ultrase MT18, Ultrase MT20, CEREBRAL STIMULANTS / ADD-ADHD------------
metoprolol XL, propranolol, propranololLA OTHER GI PRODUCTS -----------------------------------
RESPIRATORY / ASTHMA
balsalazide, lactulose, mesalamine rectal CALCIUM CHANNEL BLOCKERS -----------------------
DRUGS FOR ALLERGY -------------------------------
amlodipine, diltiazemCD, diltiazemSR 24, Oral Antihistamines and Combinations. . . . . . . .
Amitiza(PA), Apriso, Asacol, budesonide EC Alavert, Claritin, loratadine, cetirizine, levocetirizine, montelukast, Zyrtec, Zyrtec-D Nuvigil, Provigil (PA) , Ritalin-LA, Strattera, Cimzia(PA), Dipentum, Fosrenol, Lotronex, ANTIARRHYTHMICS ----------------------------------------
Metozolv ODT, Pentasa, Relistor, Renagel, DRUGS FOR ALZHEIMER’S DISEASE-----------------------
mexiletine, propafenone, quinidine, sotalol NASAL MEDICATIONS -------------------------------------
Aricept-23, galantamine, galantamine ER, GENITO-URINARY
ACE INHIBITORS ---------------------------------------------
ANTI-INFECTIVES------------------------------------------
benazepril, captopril, enalapril, fosinopril, Astapro, azelastine nasal spray, Nasonex, MISCELLANEOUS DRUGS FOR CNS----------------------
lisinopril, moexipril, perindopril, quinapril, INCONTINENCE AGENTS-------------------------------
ANGIOTENSIN II ANTAGONISTS-------------------------
DRUGS FOR ASTHMA / COPD -------------------------------
Detrol, Detrol LA, Gelnique, Oxytrol Patch, Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
VAGINAL ANTIINFECTIVES -------------------------------
ANALGESICS, NARCOTIC---------------------------------------
DIRECT RENIN INHIBITOR----------------------------------
clindamycin cream, nystatin, metronidazole, morphine IR, oxycodone IR, fentanyl patch, ANTI-ADRENERGIC BLOCKERS–CENTRAL------
Sympathomimetics. . . . . . . . . . . . . . . . . . . . . . . .
AVC Cream, Cleocin Vaginal Tab, Gynazole COMBINATION ANTIHYPERTENSIVES--------------
Arcapta, Foradil, levalbuterol for inhalation, DRUGS FOR BPH-------------------------------------------
alfuzosin, doxazosin, tamsulosin, terazosin, ANALGESICS, NSAIDs ----------------------------------------
diclofenac, diflunisal, etodolac, ibuprofen, Combination Drugs and Others. . . . . . . . . . . . . . . . .
MISCELLANEOUS UROLOGICALS-----------------------
Caverject, Cialis(ST)(QL), Levitra (QL)(ST), Arthrotec, Celebrex (ST)(QL) Flector Patch, Diovan HCT, Edarbyclor, Exforge, Exforge Advair, Atrovent HFA, Combivent, Daliresp, This document is in effect January 1, 2013. Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ MIGRAINE AGENTS-------------------------------------------
NSAIDS-----------------------------------------------------------
SPECIALTY DRUGS
Relpax (QL), sumatriptan(QL) nasal spray Coverage for “Specialty Drugs” varies from
and injection, Zomig (QL), Zomig ZMT (QL), plan to plan. Your prescription benefit may
ANTI-INFECTIVE AND ANTI-INFLAMMATORY
not cover some or all of these items. Please
COMBINATIONS ------------------------------------------------
check your pharmacy benefit information if
multiple medicines w/ generics, ofloxacin you have questions.
ANALGESICS, MISCELLANEOUS ----------------------------
Specialty Drugs are “bioengineered” oral or injectable medicines that target and treat complex medical Cuprimine, Cymbalta, Nucynta, Nucynta ER DERMATOLOGICALS
conditions including: blood disorders, cancers, ACNE -------------------------------------------------------------
infertility, hormone or enzyme deficiencies, multiple ANTICONVULSANTS ---------------------------------------
sclerosis, rheumatoid arthritis, and a growing list of sulfacetamide sodium external suspension sulfacetamide w sulfur external emulsion Specialty drugs are complex compounds and some have unique “handling” requirements. The FDA in selected situations has required dispensing from a single pharmacy or a limited set of “approved” Carbatrol, Diastat, Felbatol, Gabitril, Sabril Epiduo, Finacea, Metrogel, Retin-A Micro pharmacies. Some “specialty” drugs are oral tablets DRUGS FOR DEPENDENCY -------------------------------
or capsules while others require injection. The result ANTIBIOTICS ---------------------------------------------------
is that many drugs can be distributed directly to Campral, Chantix(QL), Suboxone, Subutex erythromycin, clindamycin, metronidazole, patients, while others will be sent to physicians or DRUGS FOR PARKINSONS DISEASE ----------------------
home health companies or other professional settings Altabax, Bactroban Nasal Ointment, Noritate carbidopa/levodopa, pramipexole, ropinirole, ANTIVIRALS ----------------------------------------------------
Most plan sponsors will apply “step edits” or prior Azilect, carbidopa/entacapone/levodopa, authorization criteria prior to the dispensing or administration of a specialty drug. These FUNGICIDES ----------------------------------------------------
requirements ensure appropriate use of a specialty SKELETAL MUSCLE RELAXANTS -------------------------
baclofen, carisoprodol, cyclobenzaprine dantrolene, methocarbamol, tizanidine, etc. Exelderm, Mentax, Naftin, Oxistat, Xolegel TOPICAL ANTI-INFLAMMATORY AGENTS---------
OPHTHALMIC
ANTI-ALLERGIC & RELATED AGENTS---------------------
TOPICAL SCABICIDES/PEDICULICIDES -------------------
lindane lotion or shampoo, malathion lotion, OTHER DERMATOLOGICALS ----------------------------
calcipotriene, Condylox, Elidel, imiquimod, ANTI-GLAUCOMA AGENTS -----------------------------
brimonidine, dipivefrin, betaxolol, carteolol Anamantle HC, Anamantle HC Forte, Anusol latanoprost, levobunolol, metipranolol, timolol, HC, Atopiclair, Dovonex, Fluoroplex, Ovace, Pramosone, Protopic, Solaraze, Soriatane, MISCELLANEOUS
ANTI-INFECTIVE AGENTS--------------------------------
ANTI-INFLAMMATORY AGENTS---------------------------
ANTI-INFECTIVE AND ANTI-INFLAMMATORY
COMBINATIONS ---------------------------------------------
This document is in effect January 1, 2013. Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™

Source: http://www.medben.biz/pdffiles/rxfocusclass2013.pdf

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