PRESCRIPTION DRUG - Public Employees' Benefits Program (PEBP)

Hometown Health Commercial FormularyJanuary 1, 2012Spec. Pharm.=20% Co-pay; Tier 1 (level 1)= generic; Tier 2 (level 2)= BRAND, formulary (preferred); Tier 3 (level 3)= BRAND, non-formulary (non-preferred); Tier 4 (level four)= SpecialPharmaceutical; ST= step therapy, PA= prior authorization, QLL= quantity level limit.SUGGESTED PREFFEREDALTERNATIVESDRUG NAME PA/QLL/ST TIER1 2 3 41.2 TOPICAL ANESTHETICS$ lidocaine hcl viscous (M) X$$ LIDODERM X lidocaine hcl viscous2.1.1 CEPHALOSPORINS$ cefaclor (M) X$ cefaclor er (M) X$ cefadroxil (M) X$ cefdinir (M) X$ cefprozil (M) X$ cefpodoxime tablet (M) X$ cefuroxime (M) X$ cephalexin (M) X$$ SPECTRACEF X cefaclor, cefuroxime$$$ CEDAX X cefdinir, cefpodoxime$$$ CEFTIN* X cefuroxime$$$ CEFZIL* X cefprozil$$$ DURICEF* X cefadroxil$$$ KEFLEX* X cephalexin$$$$ LORABID X cefaclor, cefprozil, cefuroxime$$$ OMNICEF* X cefdinir$$$ SUPRAX X cefdinir$$$ SUPRAX suspension X cefdinir$$$ VANTIN* X cefpodixime tablet$$$ VANTIN suspension X cefdinir2.1.3 CLINDAMYCINS$ clindamycin hcl (M) X$$$ CLEOCIN* X clindamycin2.1.4 ERYTHROMYCINS$ erythrocin stearate (M) X$ erythromycin(M) X$ erythromycin ethylsuccinate (M) X$$ ERYC* X erythromycin$$ ERYPED* X erythromycin ethylsuccinate$$ ERY-TAB X$$ PCE X erythromycin2.1.4.1 OTHER MACROLIDESQLL=8 tabs/RX (250mg); 10/Rx(500mg);15mL x 2 bottles(100mg/5mL);15ml, 22.5ml, 30ml x$ azithromycin(M)3 bottles (200mg/5mL) X$ clarithromycin (M) X$$ clarithromycin XL (M) XQLL=8 tabs/RX (250mg); 10/Rx(500mg);15mL x 2 bottles(100mg/5mL);15ml, 22.5ml, 30ml x$$ ZITHROMAX*3 bottles (200mg/5mL) X$$$ BIAXIN* X clarithromycin$$$ BIAXIN Suspension X clarithromycin$$$ BIAXIN XL * X clarithromycin XL(PAR) Specialty pharmacy - FDAapproved diagnosis$$$ DIFICIDX2.1.5 PENICILLINS$ amoxicillin (M) X$ ampicillin (M) X$ penicillin v potassium (M) X$$ dicloxacillin(M) X$$ amoxicillin clavulanate potassium (M) X$$$ AUGMENTIN* X amoxicillin clavulanate potassium$$ AUGMENTIN ES-600* X amoxicillin clavulanate potassium$$$ AUGMENTIN XR X amoxicillin clavulanate potassium$$ GEOCILLIN X$$$$ MOXATAG NOT COVERED2.1.6 SULFONAMIDES$ erythromycin w/sulfisoxazole (M) X$ sulfamethoxazole/trimethoprim (M) X$$ BACTRIM/BACTRIM DS* X sulfamethoxazole/trimethoprim$ GANTRISIN X$$ PEDIAZOLE* X erythromycin w/sulfisoxazole$$ SEPTRA/SEPTRA DS* X sulfamethoxazole/trimethoprim2.1.7 TETRACYCLINES$ doxycycline hyclate (M) X$ doxycycline monohydrate (M) X doxycycline hyclate$ minocycline hcl (M) X$$$$ minocycline ER (generic SOLODYN) NOT COVERED minocycline$ tetracycline hcl (M) X$$$ DYNACIN* X minocycline$$$ MINOCIN* X minocycline$$$ MONODOX* X doxycycline hyclate$$$$ SOLODYN NOT COVERED minocycline$$ SUMYCIN* X tetracycline$$$ VIBRAMYCIN* X doxycycline hyclate$$$ VIBRATAB* X doxycycline hyclate2.1.8 URINARY ANTIINFECTIVES$ methenamine hipp(M) X$ nitrofurantoin (M) X$ trimethoprim (M) X$$ MACROBID* X nitrofurantoins$$ MACRODANTIN* X nitrofurantoins$$$$ HIPREX*, UREX* X methenamine hipp2.1.9 QUINOLONES$ ciprofloxacin hcl(M) QLL=30 tabs/Rx X$ ciprofloxacin ER(M) X$ levofloxacin X$ ofloxacin tabs (M) X$$$ AVELOX X$$$ AVELOX ABC PACK X$$$$ CIPRO* QLL=30 tabs/Rx X ciprofloxacin$$$$ CIPRO 100mg X nitrofurantoins, ciprofloxacin$$$$ CIPRO XR X ciprofloxacin, ciprofloxacin ER$$$ FLOXIN* X ofloxacin$$$$ LEVAQUIN X1