2012 Formulary Print document - Alameda Alliance for Health
2012 Formulary Print document - Alameda Alliance for Health
2012 Formulary Print document - Alameda Alliance for Health
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Drug Name<br />
Drug<br />
Tier<br />
Requirements/Limits<br />
LYRICA 2 QL: 93 in<br />
31 days<br />
magnesium chloride (Magnesium Chloride) 1<br />
magnesium sulfate (Magnesium Sulfate) 1 disp syrin, infus. btl,<br />
piggyback<br />
magnesium sulfate (Magnesium Sulfate) 1 vial<br />
magnesium sulfate/d5w (Magnesium Sulfate/D5W) 1 piggyback<br />
magnesium sulfate/d5w (Magnesium Sulfate/D5W) 1 plast. bag<br />
oxcarbazepine (Trileptal) 1<br />
primidone (Mysoline) 1<br />
SABRIL 2<br />
TEGRETOL XR 2 tab er 12h: 100mg<br />
topiramate (Topamax) 1<br />
valproate sodium (Depakene) 1<br />
valproic acid (Depakene) 1<br />
VIMPAT 2 ST, QL: solution<br />
1200 in<br />
30 days<br />
VIMPAT 2 ST, QL: vial<br />
200 in 5<br />
days<br />
VIMPAT 2 ST, QL: tablet<br />
60 in 30<br />
days<br />
zonisamide (Zonegran) 1<br />
Hydantoins<br />
DILANTIN 2 capsule: 30mg<br />
DILANTIN 2 tab chew<br />
fosphenytoin sodium (Cerebyx) 1<br />
PEGANONE 2<br />
PHENYTEK 2<br />
phenytoin sodium (Dilantin) 1<br />
extended<br />
phenytoin sodium (Phenytoin Sodium) 1 disp syrin<br />
phenytoin sodium (Phenytoin Sodium) 1 vial<br />
phenytoin (Dilantin-125) 1<br />
Succinimides<br />
CELONTIN 2<br />
ethosuximide (Zarontin) 1<br />
Antidiabetic Agents<br />
45<br />
<strong>Alliance</strong> CompleteCare <strong>2012</strong> Part D <strong>Formulary</strong> Effective: May 01, <strong>2012</strong><br />
<strong>Formulary</strong> ID: 12140.000, Version: 10
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