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

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Blood Products/Modifiers/Volume ExpandersAnticoagulantsDrug NameDrugTierARIXTRA INJECTION 10MG/0.8ML 4ARIXTRA INJECTION 2.5MG/0.5ML 4ARIXTRA INJECTION 5MG/0.4ML 4ARIXTRA INJECTION 7.5MG/0.6ML 4COUMADIN INJECTION 5MG 4COUMADIN TABLET 10MG 2COUMADIN TABLET 1MG 2COUMADIN TABLET 2.5MG 2COUMADIN TABLET 2MG 2COUMADIN TABLET 3MG 2COUMADIN TABLET 4MG 2COUMADIN TABLET 5MG 2COUMADIN TABLET 6MG 2COUMADIN TABLET 7.5MG 2enoxaparin sodium injection 100mg/ml 4enoxaparin sodium injection 120mg/0.8ml 4enoxaparin sodium injection 150mg/ml 4enoxaparin sodium injection 300mg/3ml 4enoxaparin sodium injection 30mg/0.3ml 4enoxaparin sodium injection 40mg/0.4ml 4enoxaparin sodium injection 60mg/0.6ml 4enoxaparin sodium injection 80mg/0.8ml 4fondaparinux sodium injection 10mg/0.8ml 4fondaparinux sodium injection 2.5mg/0.5ml 4fondaparinux sodium injection 5mg/0.4ml 4fondaparinux sodium injection 7.5mg/0.6ml 4FRAGMIN INJECTION 10000UNIT/ML 4FRAGMIN INJECTION 25000UNIT/ML 4FRAGMIN INJECTION 2500UNIT/0.2ML 4FRAGMIN INJECTION 5000UNIT/0.2ML 4Requirements/Limits73
Drug NameDrugTierFRAGMIN INJECTION 7500UNIT/0.3ML 4HEPARIN SODIUM/D5W INJECTION 5%; 40UNIT/ML 4HEPARIN SODIUM/NACL 0.45% INJECTION 100UNIT/ML;0.45%HEPARIN SODIUM/NACL 0.45% INJECTION 50UNIT/ML;0.45%HEPARIN SODIUM/SODIUM CHLORIDE 0.9% PREMIXINJECTION 2UNIT/ML; 0.9%HEPARIN SODIUM INJECTION 10000UNIT/ML 4HEPARIN SODIUM INJECTION 1000UNIT/ML 4HEPARIN SODIUM INJECTION 20000UNIT/ML 4HEPARIN SODIUM INJECTION 5000UNIT/ML 4jantoven tablet 10mg 1jantoven tablet 1mg 1jantoven tablet 2.5mg 1jantoven tablet 2mg 1jantoven tablet 3mg 1jantoven tablet 4mg 1jantoven tablet 5mg 1jantoven tablet 6mg 1jantoven tablet 7.5mg 1LOVENOX INJECTION 100MG/ML 4LOVENOX INJECTION 120MG/0.8ML 4LOVENOX INJECTION 150MG/ML 4LOVENOX INJECTION 300MG/3ML 4LOVENOX INJECTION 30MG/0.3ML 4LOVENOX INJECTION 40MG/0.4ML 4LOVENOX INJECTION 60MG/0.6ML 4LOVENOX INJECTION 80MG/0.8ML 4PRADAXA CAPSULE 150MG 2PRADAXA CAPSULE 75MG 2warfarin sodium tablet 10mg 1warfarin sodium tablet 1mg 1444Requirements/Limits74
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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
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 and 54: 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: InsulinsDrug NameDrugTierAPIDRA SOL
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
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Metabolic Bone Disease AgentsMetabo
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Ophthalmic AgentsOphthalmic Prostag
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Ophthalmic Antiglaucoma AgentsDrug
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Drug Name130DrugTierDULERA AEROSOL
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Bronchodilators, AnticholinergicDru
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Mast Cell StabilizersDrug NameDrugT
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Sleep Disorders, OtherDrug NameDrug
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Drug NameAMINOSYN M INJECTION 65MEQ
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Drug NameFREAMINE III INJECTION 72M
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Drug NamePREMASOL INJECTION 56MEQ/L
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IndexAa-hydrocort injection 100mg .
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aloprim injection 500mg ...........
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amoxicillin tablet 875mg ..........
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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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