Physician Preferred Drug List - Catalyst Rx
Physician Preferred Drug List - Catalyst Rx
Physician Preferred Drug List - Catalyst Rx
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<strong>Physician</strong> <strong>Preferred</strong> <strong>Drug</strong> <strong>List</strong><br />
This list is a guide to care and cost-effective medications covered by the Culinary Health Fund <strong>Preferred</strong> Formulary.<br />
By prescribing drugs from this list, you can help your patients save money. Please be aware that this is not an all-inclusive list.<br />
Changes may occur throughout the year and plan exclusions may override this list. Benefit designs may vary with respect to<br />
drug coverage, quantity limits, step therapy, days supply and prior authorization.<br />
• Brand <strong>Drug</strong>s ($15) = CAPITAL LETTERS • Generic <strong>Drug</strong>s ($5) = lower case<br />
ANTIINFECTIVES<br />
Antifungals<br />
clotrimazole<br />
fluconazole<br />
griseofulvin<br />
itraconazole<br />
ketoconazole<br />
nystatin<br />
terbinafine<br />
voriconazole<br />
ANTIVIRAL<br />
All HIV medications<br />
acyclovir<br />
amantadine<br />
famciclovir<br />
ganciclovir<br />
rimantadine<br />
valacyclovir<br />
VALCYTE<br />
ZOVIRAX CREAM/ OINT<br />
CEPHALOSPORINS<br />
cefaclor<br />
cefadroxil<br />
cefdinir<br />
cefpodoxime<br />
cefprozil<br />
cefuroxime<br />
cephalexin<br />
FLUOROQUINOLONES<br />
ciprofloxacin<br />
levofloxacin<br />
ofloxacin<br />
MACROLIDES<br />
azithromycin<br />
clarithromycin<br />
erythromycin base<br />
erythromycin ethylsuccinate<br />
erythromycin stearate<br />
MISC. ANTIINFECTIVES<br />
chloroquine<br />
erythromycin/sulfisoxazole<br />
hydroxychloroquine<br />
isoniazid<br />
mebendazole<br />
metronidazole<br />
rifampin<br />
trimethoprim/<br />
sulfamethoxazole<br />
ALINIA<br />
FURADANTIN<br />
MEPRON<br />
MYCOBUTIN<br />
NEBUPENT<br />
TOBI<br />
YODOXIN<br />
ZYVOX<br />
PENICILLINS<br />
amoxicillin<br />
amoxicillin/clavulanate/ER<br />
ampicillin<br />
dicloxacillin<br />
penicillin<br />
SULFONAMIDES<br />
sulfisoxazole<br />
trimethoprim/<br />
sulfamethoxazole<br />
TETRACYCLINES<br />
doxycycline<br />
minocycline<br />
tetracycline<br />
BLOOD MODIFIERS<br />
cilostazol<br />
dipyridamole<br />
enoxaparin<br />
fondaparinux<br />
ticlopidine<br />
warfarin<br />
AGGRENOX<br />
EFFIENT<br />
FRAGMIN<br />
LOVENOX<br />
PLAVIX<br />
CARDIOVASCULAR<br />
ACE INHIBITORS<br />
benazepril<br />
captopril<br />
enalapril<br />
fosinopril<br />
lisinopril<br />
moexipril<br />
quinapril<br />
ramipril caps<br />
ANGIOTENSIN II<br />
BLOCKERS<br />
losartan<br />
DIOVAN<br />
MICARDIS<br />
BETA BLOCKERS<br />
acebutolol<br />
atenolol<br />
betaxolol<br />
bisoprolol<br />
carvedilol<br />
labetalol<br />
metoptolol<br />
nadolol<br />
pindolol<br />
propranolol/LA<br />
timolol<br />
BYSTOLIC<br />
COREG CR<br />
CALCIUM BLOCKERS<br />
amlodipine<br />
diltiazem/CR/ER/LA<br />
felodipine<br />
nicardipine<br />
nifedipine<br />
nifedipine ER<br />
nisoldipine<br />
verapamil/CR/PM<br />
CHOLESTEROL<br />
cholestyramine<br />
colestipol<br />
gemfibrozil<br />
lovastatin<br />
pravastatin<br />
simvastatin<br />
LIPITOR<br />
LIPOFEN<br />
NIASPAN<br />
SIMCOR<br />
CHOLESTEROL (cont.)<br />
TRICOR<br />
WELCHOL<br />
ZETIA<br />
DIURETICS<br />
acetazolamide/SR<br />
eplerenone<br />
furosemide<br />
hydrochlorothiazide<br />
indapamide<br />
methazolamide<br />
metolazone<br />
spironolactone<br />
spironolactone/hctz<br />
torsemide<br />
triamterene/hctz<br />
MISC.<br />
ANTIHYPERTENSIVES<br />
& COMBINATIONS<br />
benazepril/amlodipine<br />
besylate<br />
benazepril/hctz<br />
captopril/hctz<br />
clonidine<br />
clonidine hcl/chlorthalidone<br />
clonidine transdermal<br />
doxazosin<br />
enalapril/hctz<br />
fosinopril/hctz<br />
guanabenz<br />
guanfacine<br />
hctz/atenolol<br />
hctz/bisoprolol<br />
hctz/propranolol<br />
hydralazine<br />
Effective 06/2012
<strong>Physician</strong> <strong>Preferred</strong> <strong>Drug</strong> <strong>List</strong> (cont.)<br />
MISC.<br />
ANTIHYPERTENSIVES<br />
& COMBINATIONS (cont.)<br />
hydralazine/hctz<br />
lisinopril/hctz<br />
losartan/hctz<br />
methyldopa<br />
methyldopa/hctz<br />
metoprolol/hctz<br />
minoxidil<br />
moexipril/hctz<br />
prazosin<br />
quinapril/hctz<br />
terazosin<br />
AZOR<br />
DIBENZYLINE<br />
DIOVAN HCT<br />
EXFORGE<br />
EXFORGE HCT<br />
MICARDIS HCT<br />
TEKAMLO<br />
TEKTURNA<br />
TEKTURNA HCT<br />
VALTURNA<br />
MISC. CARDIOVASCULAR/<br />
ANTIARRHYTHMICS<br />
amiodarone<br />
disopyramide<br />
flecainide<br />
isosorbide dinitrate<br />
isosorbide mononitrate<br />
mexiletine<br />
nitroglycerin<br />
procainamide<br />
propafenone<br />
quinidine gluconate<br />
quinidine sulfate<br />
BIDIL<br />
ETHMOZINE<br />
RANEXA<br />
TIKOSYN<br />
DERMATOLOGICAL<br />
ACNE, ECZEMA,<br />
PSORIASIS<br />
benzoyl peroxide<br />
benzoyl peroxide/<br />
clindamycin<br />
benzoyl peroxide/urea<br />
clindamycin phosphate<br />
ACNE, ECZEMA,<br />
PSORIASIS (cont.)<br />
erythromycin base<br />
erythromycin base/<br />
benzoyl peroxide<br />
isotretinoin<br />
metronidazole<br />
selenium sulfide<br />
sulfacetamine lotion<br />
sulfacetamide/sulfur<br />
tretinoin<br />
ACANYA<br />
AKNE MYCIN<br />
ALDARA<br />
AZELEX<br />
CAPEX SHAMPOO<br />
DOVONEX<br />
DRITHO SCALP<br />
DUAC<br />
ELIDEL<br />
FINACEA<br />
PROTOPIC<br />
SORIATANE<br />
TAZORAC<br />
TOPICAL<br />
CORTICOSTEROIDS<br />
alclometasone dipropionate<br />
amcinonide<br />
betameth/propylene glycol<br />
betameth/dipropionate<br />
betamethasone valerate<br />
clobetasol propionate<br />
desonide<br />
desoximetasone<br />
diflorasone<br />
diflorasone diacetate cr<br />
fluocinonide<br />
fluocinolone acetonide<br />
fluticasone propionate<br />
halobetasol propionate<br />
hydrocortisone<br />
hydrocortisone butyrate<br />
hydrocortisone valerate<br />
mometasone furoate<br />
prednicarbate<br />
CLOBEX<br />
LOCOID LIPOCREAM<br />
EAR, NOSE & THROAT<br />
acetic acid<br />
acetic acid/aluminum<br />
acetate<br />
acetic acid/hydrocortisone<br />
antipyrine/benzocaine<br />
azelastine<br />
chlorhexidine<br />
doxycycline<br />
fluticasone<br />
ipratropium nasal spray<br />
lidocaine<br />
neomycin suf/polymy<br />
buff/hc<br />
neomycin suf/polymyxin hc<br />
ofloxacin otic<br />
pilocarpine<br />
triamcinolone acetonide<br />
triamcinolone aqueous<br />
triethanolamine<br />
ASTEPRO<br />
CIPRODEX<br />
EVOXAC<br />
NASONEX<br />
ENDOCRINE<br />
Diabetic Therapy<br />
acarbose<br />
glimepiride<br />
glipizide/XR<br />
glipizide/metformin<br />
glyburide<br />
glyburide/metformin<br />
metformin/XR<br />
nateglinide<br />
ACTOPLUS MET<br />
ACTOS<br />
BYETTA<br />
DUETACT<br />
HUMALOG/PEN<br />
HUMALOG MIX/PEN<br />
HUMULIN<br />
Janumet<br />
JANUVIA<br />
KOMBIGLYZE XR<br />
LANTUS<br />
LEVEMIR<br />
NOVOLIN<br />
NOVOLOG<br />
NOVOLOG MIX/PEN<br />
PRANDIN<br />
SYMLIN<br />
OTHER ENDOCRINE<br />
DRUGS<br />
alendronate<br />
calcitonin salmon nasal<br />
desmopressin acetate<br />
etidronate<br />
levothyroxine<br />
methimazole<br />
propylthiouracil<br />
BONIVA<br />
CYTOMEL<br />
SYNTHROID<br />
GASTROINTESTINAL<br />
ACID REFLUX & ULCERS<br />
cimetidine<br />
famotidine<br />
misoprostol<br />
nizatidine<br />
omeprazole<br />
pantoprazole<br />
ranitidine<br />
sucralfate<br />
CARAFATE SUSP<br />
Prilosec OTC<br />
(Note: Prilosec OTC is available<br />
at the generic copayment level;<br />
written prescription required)<br />
ANTISPASMODICS/ DRUGS<br />
AFFECTING GI MOTILITY<br />
belladonna alkaloids<br />
belladonna/phenobarbital<br />
clidinium/chlordiazepoxide<br />
dicyclomine<br />
diphenoxylate/atropine sulf<br />
glycopyrrolate<br />
hyoscyamine<br />
hyoscyamine<br />
sulf/phenobarb<br />
loperamide<br />
methscopolamine<br />
propantheline bromide<br />
AMITIZA<br />
RELISTOR<br />
OTHER GI PRODUCTS<br />
balsalazide<br />
hydrocortisone<br />
mesalamine<br />
misoprostol<br />
sulfasalazine<br />
ursodial<br />
ASACOL<br />
OTHER GI PRODUCTS<br />
(cont.)<br />
CREON<br />
KRISTALOSE<br />
LIALDA<br />
PANCREAZE<br />
PENTASA<br />
PYLERA<br />
ZENPEP<br />
HORMONES<br />
ANDROGENS<br />
danocrine<br />
fluoxymesterone<br />
ANDROGEL<br />
CONTRACEPTIVES<br />
All generics<br />
ELLA<br />
NUVARING<br />
ESTROGEN PATCHES &<br />
MISC.<br />
estradiol<br />
estradiol transdermal<br />
patches<br />
ENJUVIA<br />
ESTRADERM<br />
ESTRING<br />
EVISTA<br />
VAGIFEM<br />
VIVELLE/-DOT<br />
ESTROGEN/ PROGESTIN<br />
COMBINATION<br />
estradiol/norethindrone<br />
acetate<br />
estradiol transdermal<br />
COMBIPATCH<br />
PREMPHASE<br />
PREMPRO<br />
PREMPRO LOW DOSE<br />
ESTROGENS<br />
estradiol<br />
estropipate<br />
CENESTIN<br />
DIVIGEL<br />
ESTRACE VAG CR<br />
EVAMIST<br />
PREMARIN<br />
PREMARIN LOW DOSE
<strong>Physician</strong> <strong>Preferred</strong> <strong>Drug</strong> <strong>List</strong> (cont.)<br />
PROGESTINS<br />
medroxyprogesterone<br />
megostrol<br />
norethindrone<br />
PROMETRIUM<br />
IMMUNOLOGICALS<br />
ribavirin<br />
BARACLUDE<br />
HEPSERA<br />
INCIVEK<br />
INTRON A<br />
PEG INTRON<br />
PEGASYS<br />
REBETOL ORAL<br />
SOLUTION<br />
VIRAZOLE<br />
MUSCULATORY,<br />
AUTONOMIC & CNS<br />
ADD/ NARCOLEPSY<br />
amphet/dextroamph<br />
dextroamphetamine<br />
methamphetamine<br />
methylphenidate<br />
CONCERTA<br />
DAYTRANA<br />
INTUNIV<br />
METADATE CD<br />
PROVIGIL<br />
STRATTERA<br />
VYVANSE<br />
ANALGESICS<br />
codeine phosphate/apap<br />
codeine phosphate/aspirin<br />
codeine sulfate<br />
fentanyl<br />
hydrocodone bitartrate apap<br />
hydrocodone bit/ibuprofen<br />
hydromorphone<br />
levorphanol<br />
meperidine<br />
methadone<br />
morphine sulfate, ER<br />
opium/belladonna alkaloids<br />
oxycodone<br />
oxycodone/acetaminophen<br />
oxycodone/aspirin<br />
pentazocine/naloxone<br />
propoxyphene hcl/apap<br />
ANALGESICS (cont.)<br />
propoxyphene hcl/asa/caff<br />
propoxyphene nap/apap<br />
tramadol codeine phos/<br />
apap<br />
AVINZA<br />
OXYCONTIN<br />
ANTIALZHEIMER<br />
donepezil<br />
galantamine/er<br />
EXELON<br />
NAMENDA<br />
ANTIANXIETY<br />
alprazolam/ER<br />
buspirone<br />
chlordiazepoxide hcl<br />
clorazepate<br />
diazepam<br />
lorazepam<br />
midazolam<br />
oxazepam<br />
ANTICONVULSANTS<br />
carbamazepine<br />
clonazepam<br />
divalproex/er<br />
ethosuximide<br />
gabapentin<br />
lamotrigine<br />
levetiracetam/er<br />
oxcarbazepine<br />
phenobarbital<br />
phenytoin<br />
primidone<br />
topiramate<br />
valproic acid<br />
zonisamide<br />
BANZEL<br />
DIASTAT<br />
GABITRIL<br />
VIMPAT<br />
ANTIDEPRESSANTS<br />
amitriptyline<br />
amitrip hcl/perphenazine<br />
amitrip/chlordiazepoxide<br />
amoxapine<br />
bupropion<br />
citalopram<br />
clomipramine<br />
desipramine<br />
ANTIDEPRESSANTS<br />
(cont.)<br />
doxepin<br />
fluoxetine<br />
fluvoxamine<br />
imipramine hcl<br />
maprotiline<br />
mirtazapine<br />
nefazodone<br />
nortriptyline<br />
paroxetine<br />
sertraline<br />
trazodone<br />
trimipramine maleate<br />
venlafaxine/er<br />
CYMBALTA<br />
PRISTIQ<br />
ANTIINFLAMMATORY<br />
azathioprine<br />
leflunomide<br />
diclofenac potassium<br />
diclofenac sodium<br />
etodolac<br />
flurbiprofen<br />
ibuprofen<br />
indomethacin<br />
ketoprofen<br />
ketorolac<br />
leflunomide<br />
meclofenamate<br />
meloxicam<br />
methotrexate<br />
nabumetone<br />
naproxen<br />
naproxen sodium<br />
oxaprozin<br />
piroxicam<br />
sulindac<br />
tolmetin<br />
CELEBREX<br />
DEPEN<br />
RIDAURA<br />
ANTINAUSEA/<br />
ANTIVERTIGO<br />
granisetron<br />
meclizine hcl<br />
ondansetron hcl<br />
prochlorperazine<br />
promethazine<br />
trimethobenzamide<br />
Anzemet<br />
ANTINAUSEA/<br />
ANTIVERTIGO (cont.)<br />
EMEND<br />
SANCUSO<br />
TRANSDERM SCOP<br />
ANTIPARKINSON’S<br />
amantadine<br />
benzatropine<br />
bromocriptine<br />
carbidopa/levodopa<br />
promipexole<br />
ropinirole<br />
selegiline<br />
AZILECT<br />
MIRAPEX ER<br />
REQUIP XL<br />
HEADACHE/ MIGRAINE<br />
acetaminophen/butalbital<br />
acetaminophen/caff/butalb<br />
apap/isomethep/dichlphen<br />
aspirin/caffeine/butalbital<br />
butorphanol<br />
codeine/apap/caff/butalb<br />
codeine/asa/caffeine/<br />
butalb<br />
divalproex/er<br />
ergotamine/belladonna/pb<br />
ergotamine/caff/bella/pb<br />
ergotamine/caffeine<br />
sumatriptan<br />
topiramate<br />
ERGOMAR<br />
MAXALT<br />
RELPAX<br />
MUSCLE RELAXANTS<br />
baclofen<br />
carisoprodol<br />
carisoprodol & aspirin<br />
chlorzoxazone<br />
cyclobenzaprine<br />
dantrolene<br />
methocarbamol<br />
methocarbamol & aspirin<br />
metaxalone<br />
orphenadrine<br />
orphenadrine/aspirin/caff<br />
tizanidine<br />
MULTIPLE SCLEROSIS<br />
AVONEX<br />
BETASERON<br />
MULTIPLE SCLEROSIS<br />
(cont.)<br />
COPAXONE<br />
REBIF<br />
NEUROLEPTICS<br />
chlorpromazine<br />
clozapine<br />
fluphenazine hcl<br />
haloperidol<br />
loxapine succinate<br />
olanzapine<br />
olanzapine ODT<br />
perphenazine<br />
risperidone<br />
thioridazine<br />
thiothixene<br />
trifluoperazine<br />
GEODON<br />
LYRICA<br />
MOBAN<br />
ORAP<br />
SEROQUEL/ XR<br />
SLEEP MEDICATIONS<br />
chloral hydrate<br />
estazolam<br />
flurazepam<br />
temazepam<br />
triazolam<br />
zolpidem<br />
OPHTHALMICS<br />
ANTIALLERGY<br />
cromolyn<br />
ketotifen<br />
PATADAY<br />
PATANOL<br />
ANTIGLAUCOMA<br />
acetazolamide<br />
brimonidine tartrate<br />
carteolol<br />
dipivefrin<br />
latanoprost<br />
levobunolol<br />
methazolamide<br />
metipranolol<br />
pilocarpine hcl<br />
timolol<br />
AZOPT<br />
BETOPTIC S<br />
LUMIGAN<br />
TRAVATAN/Z
<strong>Physician</strong> <strong>Preferred</strong> <strong>Drug</strong> <strong>List</strong> (cont.)<br />
ANTIINFECTIVES<br />
chloramphenicol<br />
ciprofloxacin<br />
neomycin/bacitracin/pol hc<br />
neomycin/bacitracin/<br />
polymyxin<br />
neomycin/polymyxin/<br />
dexameth<br />
ofloxacin<br />
polymyxin b sulfate/tmp<br />
sulfacetamide sodium<br />
tobramycin/dexamethasone<br />
tobramycin<br />
NATACYN<br />
VIGAMOX<br />
ZYLET<br />
ZYMAR<br />
ZYMAXID<br />
ANTIINFLAMMATORY<br />
dexamethasone<br />
sod phosphate<br />
fluorometholone<br />
prednisolone acetate<br />
prednisolone<br />
sod phosphate<br />
ALREX<br />
LOTEMAX<br />
PRED MILD<br />
RETISERT<br />
RESPIRATORY<br />
ANTIHISTAMINES/<br />
DECONGESTANTS/<br />
ANTITUSSIVES<br />
benzonatate<br />
clemastine fumarate<br />
guaifenesin/codeine<br />
hydrocodone/homatropine<br />
BRONCHODILATORS &<br />
RELATED DRUGS<br />
acetylcysteine<br />
albuterol<br />
albuterol/sulfate<br />
aminophylline<br />
cromolyn<br />
dyphylline<br />
ipratropium/albuterol<br />
ipratropium/albuterol<br />
isoetharine hcl<br />
metaproterenol<br />
sodium chloride<br />
terbutaline sulfate<br />
theophylline<br />
theophylline SR<br />
ADVAIR<br />
ATROVENT HFA<br />
COMBIVENT<br />
DULERA<br />
FORADIL<br />
BRONCHODILATORS &<br />
RELATED DRUGS (cont.)<br />
PERFOROMIST<br />
PROAIR HFA<br />
SEREVENT DISKUS<br />
SPIRIVA<br />
SYMBICORT<br />
XOPENEX HFA<br />
LEUKOTRIENE INHIBITORS<br />
zarfirlukast<br />
SINGULAIR<br />
NONSEDATING<br />
ANTIHISTAMINES<br />
cetirizine<br />
fexofenadine<br />
loratadine<br />
PULMONARY<br />
CORTICOSTEROIDS<br />
budesonide neb<br />
ASMANEX<br />
FLOVENT HFA<br />
PULMICORT<br />
FlexHALER<br />
QVAR<br />
UROLOGICS<br />
BENIGN PROSTATIC<br />
HYPERTROPHY DRUGS<br />
BENIGN PROSTATIC<br />
HYPERTROPHY DRUGS<br />
alfuzosin<br />
doxazosin<br />
finasteride<br />
terazosin<br />
tamsulosin<br />
AVODART<br />
JALYN<br />
ANTICHOLINERGICS/<br />
ANTISPASMODICS<br />
flavoxate<br />
hyoscyamine<br />
oxybutynin/ER<br />
DETROL/LA<br />
ENABLEX<br />
OXYTROL<br />
SANCTURA XR<br />
DRUGS REQUIRING PRIOR AUTHORIZATION<br />
ACCUTANE<br />
ACTIQ, FENTORA, MARINOL, OXYCONTIN (unless prescribed by an oncologist or PPO pain management specialist)<br />
ADD/ADHD (over age 18)<br />
avinza, duragesic, MS Contin, Opana (unless prescribed by a PPO provider)<br />
CONTRACEPTIVES (authorization required for dependent children, under the age of 19)<br />
INCIVEK COVERED UNDER INCIVEK TREATMENT PLAN PROTOCOL<br />
INJECTABLES (except INSULIN, SUMATRIPTAN)<br />
LEXAPRO<br />
NEW DRUGS TO MARKET<br />
RETIN A (over age 24)<br />
SEXUAL DYSFUNCTION<br />
WEIGHT LOSS<br />
ZOMIG<br />
Brand-names are the property of their respective manufacturers.<br />
DL 01 1630 0512<br />
For prescription information, call <strong>Catalyst</strong> <strong>Rx</strong> at 1-866-611-5960.<br />
For prescription benefits, call Culinary Customer Service at 702-733-9938.<br />
For a complete formulary, please visit www.culinaryhealthfund.org or www.catalystrx.com.
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