Trustmark/Starmark Formulary Drug List April 2008 - Resource ...

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Brand Name Generic Name Tier Form DY-G LIQUID GUAIFENESIN/DYPHYLLINE 1 Liquid (ml) DILEX-G 200 GUAIFENESIN/DYPHYLLINE 3 Syrup JAY-PHYL GUAIFENESIN/DYPHYLLINE 1 Syrup PANFIL G GUAIFENESIN/DYPHYLLINE 1 Syrup COPD GUAIFENESIN/DYPHYLLINE 1 Tablet DIFIL-G GUAIFENESIN/DYPHYLLINE 3 Tablet DILEX-G GUAIFENESIN/DYPHYLLINE 1 Tablet DILEX-G 400 GUAIFENESIN/DYPHYLLINE 3 Tablet DYFLEX-G GUAIFENESIN/DYPHYLLINE 1 Tablet DYPHYLLINE GG GUAIFENESIN/DYPHYLLINE 1 Tablet QUIBRON GUAIFENESIN/THEOPHYLLINE 3 Capsule (Hard, Soft, etc.) BRONCOMAR GG GUAIFENESIN/THEOPHYLLINE 3 Elixir ED-BRON G GUAIFENESIN/THEOPHYLLINE 1 Liquid (ml) MYCI BRON-G GUAIFENESIN/THEOPHYLLINE 3 Liquid (ml) THEOMAR GG GUAIFENESIN/THEOPHYLLINE 3 Liquid (ml) ATROVENT HFA IPRATROPIUM BROMIDE 2 Aerosol w/Adapter (gm) IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE 1 Solution, Non-Oral SPIRIVA TIOTROPIUM BROMIDE 2 Capsule, with Inhalation Device ADRENERGIC AGENTS,CATECHOLAMINES ISOETHARINE HCL ISOETHARINE HCL 3 Solution, Non-Oral BETA-ADRENERGIC AGENTS ALBUTEROL ALBUTEROL 1 Aerosol (gm) PROVENTIL ALBUTEROL 3 Aerosol (gm) ALBUTEROL ALBUTEROL 1 Aerosol Refill (gm) PROVENTIL ALBUTEROL 3 Aerosol REFILL (gm) PROAIR HFA ALBUTEROL SULFATE 2 HFA Aerosol with Adapter (gm) PROVENTIL HFA ALBUTEROL SULFATE 2 HFA Aerosol with Adapter (gm) VENTOLIN HFA ALBUTEROL SULFATE 3 HFA Aerosol with Adapter (gm) AIRET ALBUTEROL SULFATE 3 Solution, Non-Oral ALBUTEROL SULFATE ALBUTEROL SULFATE 1 Solution, Non-Oral ALBUTEROL SULFATE ALBUTEROL SULFATE 1 Syrup ALBUTEROL SULFATE ALBUTEROL SULFATE 1 Tablet ALBUTEROL SULFATE ALBUTEROL SULFATE 1 Tablet, Sustained Release 12 Hr VOSPIRE ER ALBUTEROL SULFATE 3 Tablet, Sustained Release 12 Hr ALBUTEROL SULFATE ALBUTEROL SULFATE 1 Vial, Nebulizer (EA) ACCUNEB ALBUTEROL SULFATE 3 Vial, Nebulizer (ml) ALBUTEROL SULFATE ALBUTEROL SULFATE 1 Vial, Nebulizer (ml) PROVENTIL ALBUTEROL SULFATE 3 Vial, Nebulizer (ml) BROVANA ARFORMOTEROL TARTRATE 3 Vial, Nebulizer (ml) FORADIL FORMOTEROL FUMARATE 2 Capsule, with Inhalation Device PERFOROMIST FORMOTEROL FUMARATE 3 Vial, Nebulizer (ml) XOPENEX LEVALBUTEROL HCL 3 Vial, Nebulizer (EA) XOPENEX LEVALBUTEROL HCL 3 Vial, Nebulizer (ml) XOPENEX HFA LEVALBUTEROL TARTRATE 2 HFA Aerosol with Adapter (gm) ALUPENT METAPROTERENOL SULFATE 3 Aerosol w/Adapter (gm) METAPROTERENOL SULFATE METAPROTERENOL SULFATE 1 Solution, Non-Oral METAPROTERENOL SULFATE METAPROTERENOL SULFATE 1 Syrup METAPROTERENOL SULFATE METAPROTERENOL SULFATE 2 Tablet MAXAIR AUTOHALER PIRBUTEROL ACETATE 3 Aerosol, Breath Activated SEREVENT DISKUS SALMETEROL XINAFOATE 2 Disk, with Inhalation Device TERBUTALINE SULFATE TERBUTALINE SULFATE 1 Tablet MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E(IGE) XOLAIR OMALIZUMAB 3 Vial (SDV, MDV or Additive) (EA) MAST CELL STABILIZERS INTAL CROMOLYN SODIUM 2 Aerosol (gm) CROMOLYN SODIUM CROMOLYN SODIUM 1 Ampul for Nebulization (ml) INTAL CROMOLYN SODIUM 3 Ampul for Nebulization (ml) GASTROCROM CROMOLYN SODIUM 3 Solution, Oral TILADE NEDOCROMIL SODIUM 3 Aerosol w/Adapter (gm) LEUKOTRIENE RECEPTOR ANTAGONISTS SINGULAIR MONTELUKAST SODIUM 3 Granules in Packet (EA) SINGULAIR MONTELUKAST SODIUM 3 Tablet SINGULAIR MONTELUKAST SODIUM 3 Tablet, Chewable ACCOLATE ZAFIRLUKAST 2 Tablet BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONS SYMBICORT BUDESONIDE/FORMOTEROL FUMARATE 3 HFA Aerosol with Adapter (gm) ADVAIR HFA FLUTICASONE/SALMETEROL 2 Aerosol w/Adapter (gm) Page 8
Brand Name Generic Name Tier Form ADVAIR DISKUS FLUTICASONE/SALMETEROL 2 Disk, with Inhalation Device 5-LIPOXYGENASE INHIBITORS ZYFLO ZILEUTON 3 Tablet ZYFLO CR ZILEUTON 3 Tablet, Multiphasic Release 12 Hr XANTHINES/DIETARY SUPPLEMENT COMBINATIONS PULMOPHYLLINE THEOPHYLL/CAFF/AA13/CINN/HC135 3 Combination Package (EA) SENOPHYLLINE THEOPHYLLINE/DIETARY SUP.CMB9 3 Combination Package (EA) BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS COMBIVENT IPRATROPIUM/ALBUTEROL SULFATE 2 Aerosol w/Adapter (gm) DUONEB IPRATROPIUM/ALBUTEROL SULFATE 2 Ampul for Nebulization (ml) IPRATROPIUM-ALBUTEROL IPRATROPIUM/ALBUTEROL SULFATE 1 Ampul for Nebulization (ml) ANTIHISTAMINES ANTIHISTAMINES – 1ST GENERATION LODRANE 24 BROMPHENIRAMINE MALEATE 3 Capsule, Sustained Release 24 Hr J-TAN PD BROMPHENIRAMINE MALEATE 3 Drops VAZOL BROMPHENIRAMINE MALEATE 3 Liquid (ml) BIDHIST BROMPHENIRAMINE MALEATE 1 Tablet, Sustained Release 12 Hr BPM BROMPHENIRAMINE MALEATE 1 Tablet, Sustained Release 12 Hr LODRANE BROMPHENIRAMINE MALEATE 3 Tablet, Sustained Release 12 Hr LOHIST 12HR BROMPHENIRAMINE MALEATE 1 Tablet, Sustained Release 12 Hr RESPA-BR BROMPHENIRAMINE MALEATE 1 Tablet, Sustained Release 12 Hr BROMPHENIRAMINE TANNATE BROMPHENIRAMINE TANNATE 1 Suspension, Oral (Final Dose Form) BROVEX BROMPHENIRAMINE TANNATE 3 Suspension, Oral (Final Dose Form) B-VEX BROMPHENIRAMINE TANNATE 1 Suspension, Oral (Final Dose Form) CONEX BROMPHENIRAMINE TANNATE 3 Suspension, Oral (Final Dose Form) J-TAN BROMPHENIRAMINE TANNATE 3 Suspension, Oral (Final Dose Form) LODRANE XR BROMPHENIRAMINE TANNATE 3 Suspension, Oral (Final Dose Form) P-TEX BROMPHENIRAMINE TANNATE 3 Suspension, Oral (Final Dose Form) TANACOF XR BROMPHENIRAMINE TANNATE 1 Suspension, Oral (Final Dose Form) BROMPHENIRAMINE TANNATE BROMPHENIRAMINE TANNATE 1 Tablet, Chewable BROVEX CT BROMPHENIRAMINE TANNATE 3 Tablet, Chewable ALA-HIST BROMPHENIRAMINE/DIPHENHYDRAM 3 Tablet, Sustained Release 12 Hr CARBINOXAMINE MALEATE CARBINOXAMINE MALEATE 1 Liquid (ml) PALGIC CARBINOXAMINE MALEATE 1 Liquid (ml) CARBINOXAMINE MALEATE CARBINOXAMINE MALEATE 1 Tablet PALGIC CARBINOXAMINE MALEATE 3 Tablet CPM 12 CHLORPHENIRAMINE MALEATE 1 Capsule, Multiphasic Release CHLORPHENIRAMINE MALEATE CHLORPHENIRAMINE MALEATE 1 Capsule, Sustained Action ED CHLORPED CHLORPHENIRAMINE TANNATE 1 Drops MYCI CHLORPED CHLORPHENIRAMINE TANNATE 3 Drops TANAHIST-PD CHLORPHENIRAMINE TANNATE 1 Drops CHLORTAN CHLORPHENIRAMINE TANNATE 1 Suspension, Oral (Final Dose Form) PEDIAPHYL CHLORPHENIRAMINE TANNATE 1 Suspension, Oral (Final Dose Form) PEDIATAN CHLORPHENIRAMINE TANNATE 3 Suspension, Oral (Final Dose Form) PEDIOX-S CHLORPHENIRAMINE TANNATE 3 Suspension, Oral (Final Dose Form) P-TANN CHLORPHENIRAMINE TANNATE 1 Suspension, Oral (Final Dose Form) RICOBID-H CHLORPHENIRAMINE TANNATE 3 Suspension, Oral (Final Dose Form) AHIST CHLORPHENIRAMINE TANNATE 3 Tablet ED-CHLOR-TAN CHLORPHENIRAMINE TANNATE 1 Tablet MYCI CHLOR-TAN CHLORPHENIRAMINE TANNATE 3 Tablet CLEMASTINE FUMARATE CLEMASTINE FUMARATE 1 Syrup CLEMASTINE FUMARATE CLEMASTINE FUMARATE 1 Tablet CYPROHEPTADINE HCL CYPROHEPTADINE HCL 1 Syrup CYPROHEPTADINE HCL CYPROHEPTADINE HCL 1 Tablet DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE 3 Syrup DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE 1 Tablet, Sustained Action DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE 3 Tablet, Sustained Action COMPLETE ALLERGY MEDICINE DIPHENHYDRAMINE HCL 1 Capsule (Hard, Soft, etc.) DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 1 Capsule (Hard, Soft, etc.) DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 1 Elixir DYTUSS DIPHENHYDRAMINE HCL 1 Syrup BEN-TANN DIPHENHYDRAMINE TANNATE 1 Suspension, Oral (Final Dose Form) DYTAN DIPHENHYDRAMINE TANNATE 3 Suspension, Oral (Final Dose Form) DIPHENMAX DIPHENHYDRAMINE TANNATE 1 Tablet, Chewable DYTAN DIPHENHYDRAMINE TANNATE 3 Tablet, Chewable ALDEX AN DOXYLAMINE SUCCINATE 3 Liquid (ml) HYDROXYZINE HCL HYDROXYZINE HCL 1 Syrup Page 9
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Trustmark/Starmark Formulary Drug List April 2008 - Resource ...

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