PRESCRIPTION DRUG - Public Employees' Benefits Program (PEBP)

$$$ INTRON A(PAR) Spec. Pharm.; 10mmu InjPen (4th Tier)X$$$$$ PEGASYS(PAR); QLL=5 units/Rx Spec.Pharm.X$$$$$ PEG-INTRON(PAR); QLL=5 units/Rx Spec.Pharm.;X$$ REBIF(PAR); QLL=15/30 days Spec.Pharm.X$ ROFERON-A (PAR) X10.2.4 INTERLEUKINS$$$ NEUMEGA X!!!!! PROLEUKIN Spec. Pharm. X10.2.5 THROMBOPOIETIN STIMULANTS!!!!! NPLATE NOT COVERED!!!!! PROMACTA (PAR); Spec. Pharm. XCHAPTER 11: MUSCULOSKELETAL MEDICATIONS11.1.1 SALICYLATES AND RELATED DRUGS$ choline mag. trisalicylate X$ salsalate (M) X11.1.2 NON-STEROIDAL ANTIINFLAMMATORY AGENTS$ diclofenac potassium(M) X$ diclofenac sodium (M) X$ etodolac (M) X$ fenoprofen(M) X$ flurbiprofen(M) X$ ibuprofen (M) X$ indomethacin (M) X$ ketoprofen (M) X$ ketorolac(M) QLL= 20/Rx X$ meclofenamate(M) X$ meloxicam (M) X$ nabumetone X$ naproxen (M) X$ naproxen sodium (M) X$ oxaprozin (M) X$ piroxicam(M) X$ sulindac(M) X$ tolmentin(M) X$$$ ANAPROX* X naproxen sodium$$ ANSAID* X flurbiprofen$$$ CATAFLAM* X diclofenac potassium$$$$$ CELEBREXQLL=30 caps/Rx (ST) history ofTWO of the following NSAIDS:diclofenac sodium, etodolac,ibuprofen, indomethacin,ketoprofen, naproxen, piroxicam,sulindac OR prednisone, warfarin,CoumadinX$$ CLINORIL* X sulindac$$$ EC-NAPROSYN* X naproxen$$$ FELDENE* X piroxicam$$$$$ FLECTORQLL=30 patches per month (ST)history of two generic or OTCNSAIDS. Age edit 6 years old orolder X diclofenac sodium$$$$$ MOBIC* X meloxicam$$$ MOTRIN* X ibuprofen$$$ NALFON* X fenoprofen$$$ NAPROSYN* X naproxen$$$ VOLTAREN* X diclofenac sodium$$$ VOLTAREN GEL NOT COVERED11.1.3 OTHER DRUGS FOR ARTHRITIS$$ methotrexate (M) X$$$ hydroxychloroquine (M) X!!!!! CIMZIA (PAR) Spec. Pharm X!!!!! CUPRIMINE (PAR) Spec. Pharm X!!!!! ENBREL (PAR) Spec. Pharm X!!!!! HUMIRA (PAR) Spec. Pharm X!!!!! KINERET (PAR) Spec. Pharm X!!!!! ORENCIA SUB-Q INJECTION (PAR) Spec. Pharm X!!!!! RIDAURA Spec. Pharm X!!!!! SIMPONI (PAR) Spec. Pharm X$$ TREXALL X11.1.4 DRUGS FOR PSORIASIS!!!!! ENBREL (PAR) Spec. Pharm X(PAR) (ST) Spec. PharmDermatologist prescribed onlyX!!!!! RAPTIVA11.2 DRUGS TO PREVENT AND TREAT GOUT$ allopurinol (M) X$ colchicine (M) X$ probenecid (M) X$ probenecid/ colchicine X$$$ ULORICQLL= 30/month Age Edit= 18 yearsof age and older (ST) history ofgeneric allopurinolX$$ ZYLOPRIM* X allopurinol11.3.1 DIRECT MUSCLE RELAXANTS$ baclofen (M) X$ diazepam(M) X$$$ VALIUM* X diazepam11.3.2 CNS MUSCLE RELAXANTS$ carisoprodol (M) X$ chlorzoxazone (M) X$ cyclobenzaprine hcl (M) X$ methocarbamol (M) X$ orphenadrine (M) X$$$ AMRIX QLL= #30 per month X$$ FLEXERIL* X cyclobenzaprine hcl$$ LORZONE (ST) generic chlorzoxazone chlorzoxazone$$ PARAFON FORTE DSC* X chlorzoxazone$$$ ROBAXIN* X methocarbamol$$$$$ SKELAXIN X$$$$$ SOMA* X carisoprodol12.1.2 VITAMINS & MINERALS & RELATED PRODUCTS$ multi-vit/fluoride X$ multi-vit/fluoride w/iron X$ tri-vit/fluoride X$ tri-vit/fluoride w/iron X$$ FOLBEE X17