2013 Formulary (List of Covered Drugs) - Advantage Peach State ...

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Histamine2 (H2) receptor AntagonistsDrug NameDrugTierCIMETIDINE HCL INJECTION 150MG/ML 4cimetidine hcl solution 300mg/5ml 1cimetidine tablet 200mg 1cimetidine tablet 300mg 1cimetidine tablet 400mg 1cimetidine tablet 800mg 1FAMOTIDINE PREMIXED INJECTION 0.4MG/ML; 0.9% 4FAMOTIDINE INJECTION 10MG/ML 4famotidine tablet 20mg 1famotidine tablet 40mg 1ranitidine hcl capsule 150mg 1ranitidine hcl capsule 300mg 1RANITIDINE HCL INJECTION 150MG/6ML 4ranitidine hcl syrup 15mg/ml 1ranitidine hcl tablet 150mg 1ranitidine hcl tablet 300mg 1ZANTAC INJECTION 25MG/ML 4ZANTAC INJECTION 50MG/50ML; 0.45% 4Requirements/LimitsIrritable Bowel Syndrome AgentsDrug NameDrugTierAMITIZA CAPSULE 24MCG 2AMITIZA CAPSULE 8MCG 2Requirements/LimitsLOTRONEX TABLET 0.5MG 3 QL (60 EA per 30 days) PA(Irritable Bowel SyndromeAgents)LOTRONEX TABLET 1MG 3 QL (60 EA per 30 days) PA(Irritable Bowel SyndromeAgents)101
LaxativesDrug NameDrugTierconstulose solution 10gm/15ml 1enulose solution 10gm/15ml 1gavilyte-c solution reconstituted 240gm; 2.98gm; 6.72gm;5.84gm; 22.72gmgavilyte-g solution reconstituted 236gm; 2.97gm; 6.74gm;5.86gm; 22.74gmgavilyte-n/flavor pack solution reconstituted 420gm; 1.48gm;5.72gm; 11.2gmgenerlac solution 10gm/15ml 1lactulose solution 10gm/15ml 1NULYTELY/FLAVOR PACKS SOLUTIONRECONSTITUTED 420GM; 1.48GM; 5.72GM; 11.2GMpolyethylene glycol 3350 powder 0 1trilyte solution reconstituted 420gm; 1.48gm; 5.72gm; 11.2gm 11112Requirements/LimitsProtectantsDrug NameDrugTiermisoprostol tablet 200mcg 1sucralfate tablet 1gm 1Requirements/LimitsProton Pump InhibitorsDrug NameDrugTierNEXIUM I.V. INJECTION 20MG 4NEXIUM I.V. INJECTION 40MG 4Requirements/Limitsomeprazole capsule delayed release 10mg 1 QL (30 EA per 30 days)omeprazole capsule delayed release 20mg 1 QL (90 EA per 30 days)omeprazole capsule delayed release 40mg 1 QL (90 EA per 30 days)pantoprazole sodium tablet delayed release 20mg 1 QL (30 EA per 30 days)pantoprazole sodium tablet delayed release 40mg 1PROTONIX INJECTION 40MG 4102
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Advantage by Peach State Health Pla
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What are generic drugs?Peach State
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Opioid Analgesics, Long-actingDrug
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Drug NameDrugTierHYDROMORPHONE HCL
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Opioid AntagonistsDrug NameDrugTier
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Drug NameDrugTiermeloxicam suspensi
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Antibacterials, OtherDrug NameDrugT
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Beta-lactam, CephalosporinsDrug Nam
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Beta-lactam, OtherDrug NameAZACTAM
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Drug NamePENICILLIN G POTASSIUM IN
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QuinolonesDrug NameDrugTierAVELOX I
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AnticonvulsantsAnticonvulsants, Oth
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Drug NameDrugTierdiazepam gel 20mg
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Sodium Channel AgentsDrug NameDrugT
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Antidementia AgentsCholinesterase I
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Monoamine Oxidase InhibitorsDrug Na
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Drug NameDrugTiersertraline hcl con
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Drug NameDrugTierimipramine pamoate
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AntifungalsAntifungalsDrug NameDrug
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Antigout AgentsAntigout AgentsDrug
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AntimycobacterialsAntimycobacterial
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Antiangiogenic AgentsDrug NameDrugT
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Antineoplastics, OtherDrug NameDrug
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Drug NameDrugTierMITOXANTRONE HCL I
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Molecular Target InhibitorsDrug Nam
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AntiprotozoalsDrug NameDrugTierALIN
Page 55 and 56: Dopamine AgonistsDrug NameDrugTierA
Page 57 and 58: Antipsychotics1st Generation/Typica
Page 59 and 60: Drug NameDrugTierRequirements/Limit
Page 61 and 62: Treatment-ResistantDrug NameDrugTie
Page 63 and 64: Drug NameDrugTierEPZICOM TABLET 600
Page 65 and 66: Anti-HIV Agents, Protease Inhibitor
Page 69 and 70: AnxiolyticsAnxiolytics, OtherDrug N
Page 71 and 72: Blood Glucose RegulatorsAntidiabeti
Page 75 and 76: Drug NameCLINIMIX E 4.25%/DEXTROSE
Page 77 and 78: InsulinsDrug NameDrugTierAPIDRA SOL
Page 79 and 80: Drug NameDrugTierFRAGMIN INJECTION
Page 83 and 84: Cardiovascular AgentsAlpha-adrenerg
Page 85 and 86: Angiotensin-converting Enzyme (ACE)
Page 87 and 88: Drug NameDrugTiermexiletine hcl cap
Page 89 and 90: Drug NameDrugTiermetoprolol/hydroch
Page 91 and 92: Drug NameDrugTierDILTIAZEM HCL INJE
Page 93 and 94: Diuretics, Carbonic Anhydrase Inhib
Page 95 and 96: Dyslipidemics, Fibric Acid Derivati
Page 97 and 98: Vasodilators, Direct-acting Arteria
Page 99 and 100: Attention Deficit Hyperactivity Dis
Page 101 and 102: Dermatological AgentsDermatological
Page 103 and 104: Enzyme Replacement/ModifiersEnzyme
Page 105: Gastrointestinal Agents, OtherDrug
Page 109 and 110: Genitourinary Agents, OtherDrug Nam
Page 111 and 112: Drug NameDEXAMETHASONE SODIUM PHOSP
Page 113 and 114: Drug NameDrugTierproctozone-hc crea
Page 115 and 116: Hormonal Agents, Stimulant/Replacem
Page 117 and 118: Drug NameDrugTierjunel 1.5/30 table
Page 119 and 120: ProgestinsDrug NameDrugTiercamila t
Page 121 and 122: Drug NameDrugTierlevoxyl tablet 137
Page 123 and 124: Drug NameDrugTierLEUPROLIDE ACETATE
Page 125 and 126: Drug Name120DrugTiergengraf capsule
Page 127 and 128: Drug NameDAPTACEL INJECTION 10MCG/0
Page 129 and 130: Metabolic Bone Disease AgentsMetabo
Page 131 and 132: Ophthalmic AgentsOphthalmic Prostag
Page 133 and 134: Ophthalmic Antiglaucoma AgentsDrug
Page 135 and 136: Drug Name130DrugTierDULERA AEROSOL
Page 137 and 138: Bronchodilators, AnticholinergicDru
Page 139 and 140: Mast Cell StabilizersDrug NameDrugT
Page 141 and 142: Sleep Disorders, OtherDrug NameDrug
Page 143 and 144: Drug NameAMINOSYN M INJECTION 65MEQ
Page 145 and 146: Drug NameFREAMINE III INJECTION 72M
Page 147 and 148: Drug NamePREMASOL INJECTION 56MEQ/L
Page 149 and 150: IndexAa-hydrocort injection 100mg .
Page 151 and 152: aloprim injection 500mg ...........
Page 153 and 154: amoxicillin tablet 875mg ..........
Page 155 and 156: avandia tablet 4mg ................
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uphenyl tablet 500mg ..............
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cefdinir suspension reconstituted 1
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claravis capsule 40mg .............
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clonazepam tablet 1mg .............
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daraprim tablet 25mg ..............
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diltiazem cd capsule extended relea
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emend capsule 0 ...................
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exemestane tablet 25mg ............
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fluphenazine hcl injection 2.5mg/ml
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gentamicin sulfate/sodium chloride
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hydralazine hcl tablet 50mg .......
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intuniv tablet extended release 24
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ketoconazole cream 2% .............
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levothroid tablet 25mcg ...........
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lupron depot injection 7.5mg ......
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methazolamide tablet 50mg .........
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morphine sulfate er tablet extended
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nitroglycerin injection 5mg/ml ....
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oxacillin sodium injection 10gm ...
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phenytoin sodium extended capsule 1
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premarin tablet 1.25mg ............
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PROVENTIL HFA AEROSOL SOLUTION 108M
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ingers irrigation solution 4.5meq/l
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somavert injection 20mg ...........
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synthroid tablet 75mcg ............
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tikosyn capsule 250mcg ............
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trimethoprim sulfate/polymyxin b su
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verapamil hcl er tablet extended re
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ziagen tablet 300mg ...............
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2013 Formulary (List of Covered Drugs) - Advantage Peach State ...

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