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

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Antiparkinson AgentsAnticholinergicsDrug NameDrugTierbenztropine mesylate injection 1mg/ml 4benztropine mesylate tablet 0.5mg 1benztropine mesylate tablet 1mg 1benztropine mesylate tablet 2mg 1trihexyphenidyl hcl elixir 0.4mg/ml 1trihexyphenidyl hcl tablet 2mg 1trihexyphenidyl hcl tablet 5mg 1Requirements/LimitsAntiparkinson Agents, OtherDrug NameDrugTierRequirements/LimitsCOMTAN TABLET 200MG 2 QL (240 EA per 30 days)entacapone tablet 200mg 1TASMAR TABLET 100MG 249
Dopamine AgonistsDrug NameDrugTierAPOKYN INJECTION 10MG/ML 4bromocriptine mesylate capsule 5mg 1bromocriptine mesylate tablet 2.5mg 1pramipexole dihydrochloride tablet 0.125mg 1pramipexole dihydrochloride tablet 0.25mg 1pramipexole dihydrochloride tablet 0.5mg 1pramipexole dihydrochloride tablet 0.75mg 1pramipexole dihydrochloride tablet 1.5mg 1pramipexole dihydrochloride tablet 1mg 1ropinirole hcl tablet 0.25mg 1ropinirole hcl tablet 0.5mg 1ropinirole hcl tablet 1mg 1ropinirole hcl tablet 2mg 1ropinirole hcl tablet 3mg 1ropinirole hcl tablet 4mg 1ropinirole hcl tablet 5mg 1Requirements/Limits50
Page 1 and 2:
Advantage by Peach State Health Pla
Page 3: What are generic drugs?Peach State
Page 7 and 8: Opioid Analgesics, Long-actingDrug
Page 9 and 10: Drug NameDrugTierHYDROMORPHONE HCL
Page 11 and 12: Opioid AntagonistsDrug NameDrugTier
Page 13 and 14: Drug NameDrugTiermeloxicam suspensi
Page 15 and 16: Antibacterials, OtherDrug NameDrugT
Page 17 and 18: Beta-lactam, CephalosporinsDrug Nam
Page 19 and 20: Beta-lactam, OtherDrug NameAZACTAM
Page 21 and 22: Drug NamePENICILLIN G POTASSIUM IN
Page 23 and 24: QuinolonesDrug NameDrugTierAVELOX I
Page 25 and 26: AnticonvulsantsAnticonvulsants, Oth
Page 27 and 28: Drug NameDrugTierdiazepam gel 20mg
Page 29 and 30: Sodium Channel AgentsDrug NameDrugT
Page 31 and 32: Antidementia AgentsCholinesterase I
Page 33 and 34: Monoamine Oxidase InhibitorsDrug Na
Page 35 and 36: Drug NameDrugTiersertraline hcl con
Page 37 and 38: Drug NameDrugTierimipramine pamoate
Page 39 and 40: AntifungalsAntifungalsDrug NameDrug
Page 41 and 42: Antigout AgentsAntigout AgentsDrug
Page 43 and 44: AntimycobacterialsAntimycobacterial
Page 45 and 46: Antiangiogenic AgentsDrug NameDrugT
Page 47 and 48: Antineoplastics, OtherDrug NameDrug
Page 49 and 50: Drug NameDrugTierMITOXANTRONE HCL I
Page 51 and 52: Molecular Target InhibitorsDrug Nam
Page 53: AntiprotozoalsDrug NameDrugTierALIN
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 and 106:
Gastrointestinal Agents, OtherDrug
Page 107 and 108:
LaxativesDrug NameDrugTierconstulos
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 ................
Page 157 and 158:
uphenyl tablet 500mg ..............
Page 159 and 160:
cefdinir suspension reconstituted 1
Page 161 and 162:
claravis capsule 40mg .............
Page 163 and 164:
clonazepam tablet 1mg .............
Page 165 and 166:
daraprim tablet 25mg ..............
Page 167 and 168:
diltiazem cd capsule extended relea
Page 169 and 170:
emend capsule 0 ...................
Page 171 and 172:
exemestane tablet 25mg ............
Page 173 and 174:
fluphenazine hcl injection 2.5mg/ml
Page 175 and 176:
gentamicin sulfate/sodium chloride
Page 177 and 178:
hydralazine hcl tablet 50mg .......
Page 179 and 180:
intuniv tablet extended release 24
Page 181 and 182:
ketoconazole cream 2% .............
Page 183 and 184:
levothroid tablet 25mcg ...........
Page 185 and 186:
lupron depot injection 7.5mg ......
Page 187 and 188:
methazolamide tablet 50mg .........
Page 189 and 190:
morphine sulfate er tablet extended
Page 191 and 192:
nitroglycerin injection 5mg/ml ....
Page 193 and 194:
oxacillin sodium injection 10gm ...
Page 195 and 196:
phenytoin sodium extended capsule 1
Page 197 and 198:
premarin tablet 1.25mg ............
Page 199 and 200:
PROVENTIL HFA AEROSOL SOLUTION 108M
Page 201 and 202:
ingers irrigation solution 4.5meq/l
Page 203 and 204:
somavert injection 20mg ...........
Page 205 and 206:
synthroid tablet 75mcg ............
Page 207 and 208:
tikosyn capsule 250mcg ............
Page 209 and 210:
trimethoprim sulfate/polymyxin b su
Page 211 and 212:
verapamil hcl er tablet extended re
Page 213:
ziagen tablet 300mg ...............
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2013 Formulary (List of Covered Drugs) - Advantage Peach State ...

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