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

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Brand Name Generic Name Tier Form STROMECTOL IVERMECTIN 3 Tablet MEBENDAZOLE MEBENDAZOLE 1 Tablet, Chewable BILTRICIDE PRAZIQUANTEL 3 Tablet ANTIPARASITICS ALINIA NITAZOXANIDE 3 Suspension, Reconstituted, Oral (ml) ALINIA NITAZOXANIDE 3 Tablet ANTILEPROTICS DAPSONE DAPSONE 3 Tablet ANTIVIRALS, GENERAL ACYCLOVIR ACYCLOVIR 1 Capsule (Hard, Soft, etc.) ZOVIRAX ACYCLOVIR 3 Capsule (Hard, Soft, etc.) ACYCLOVIR ACYCLOVIR 1 Suspension, Oral (Final Dose Form) ZOVIRAX ACYCLOVIR 3 Suspension, Oral (Final Dose Form) ACYCLOVIR ACYCLOVIR 1 Tablet ZOVIRAX ACYCLOVIR 3 Tablet FAMCICLOVIR FAMCICLOVIR 1 Tablet FAMVIR FAMCICLOVIR 3 Tablet GANCICLOVIR GANCICLOVIR 1 Capsule (Hard, Soft, etc.) CYTOVENE GANCICLOVIR SODIUM 3 Vial (SDV, MDV or Additive) (EA) TAMIFLU OSELTAMIVIR PHOSPHATE 3 Capsule (Hard, Soft, etc.) TAMIFLU OSELTAMIVIR PHOSPHATE 3 Suspension, Reconstituted, Oral (ml) VIRAZOLE RIBAVIRIN 3 Vial (SDV, MDV or Additive) (EA) FLUMADINE RIMANTADINE HCL 3 Syrup FLUMADINE RIMANTADINE HCL 3 Tablet RIMANTADINE HCL RIMANTADINE HCL 1 Tablet VALTREX VALACYCLOVIR HCL 2 Tablet VALCYTE VALGANCICLOVIR HYDROCHLORIDE 3 Tablet RELENZA ZANAMIVIR 3 Disk, with Inhalation Device ANTIBACTERIAL AGENTS,MISCELLANEOUS AMINOACETIC ACID GLYCINE 1 Solution, Irrigation GLYCINE GLYCINE 1 Solution, Irrigation UROLOGIC SOLUTION G UROLOGIC SOLUTION-G 3 Solution, Irrigation QUINOLONES CIPRO CIPROFLOXACIN 2 Suspension, Microcapsule Reconstituted CIPRO CIPROFLOXACIN HCL 3 Tablet CIPROFLOXACIN HCL CIPROFLOXACIN HCL 1 Tablet CIPROFLOXACIN HCL CIPROFLOXACIN HCL 1 Tablet PROQUIN XR CIPROFLOXACIN HCL 3 Tablet, Sustained Release 24 Hr CIPRO XR CIPROFLOXACIN/CIPROFLOXA HCL 3 Tablet, Multiphasic Release 24 Hr CIPROFLOXACIN ER CIPROFLOXACIN/CIPROFLOXA HCL 1 Tablet, Multiphasic Release 24 Hr FACTIVE GEMIFLOXACIN MESYLATE 3 Tablet LEVAQUIN LEVOFLOXACIN 3 Solution, Oral LEVAQUIN LEVOFLOXACIN 2 Tablet MAXAQUIN LOMEFLOXACIN HCL 3 Tablet AVELOX MOXIFLOXACIN HCL 3 Tablet AVELOX ABC PACK MOXIFLOXACIN HCL 3 Tablet NEGGRAM NALIDIXIC ACID 3 Tablet NOROXIN NORFLOXACIN 3 Tablet OFLOXACIN OFLOXACIN 1 Tablet OFLOXACIN OFLOXACIN 3 Tablet ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS AGENERASE AMPRENAVIR/VITAMIN E/PROP GLY 3 Solution, Oral REYATAZ ATAZANAVIR SULFATE 3 Capsule (Hard, Soft, etc.) LEXIVA FOSAMPRENAVIR CALCIUM 3 Suspension, Oral (Final Dose Form) LEXIVA FOSAMPRENAVIR CALCIUM 3 Tablet CRIXIVAN INDINAVIR SULFATE 3 Capsule (Hard, Soft, etc.) VIRACEPT NELFINAVIR MESYLATE 3 Powder (gm) VIRACEPT NELFINAVIR MESYLATE 3 Tablet NORVIR RITONAVIR 3 Capsule (Hard, Soft, etc.) NORVIR RITONAVIR 3 Solution, Oral INVIRASE SAQUINAVIR MESYLATE 3 Capsule (Hard, Soft, etc.) INVIRASE SAQUINAVIR MESYLATE 3 Tablet ANTIVIRAL MONOCLONAL ANTIBODIES SYNAGIS PALIVIZUMAB 3 Vial (SDV, MDV or Additive) (ml) HEPATITIS B TREATMENT AGENTS HEPSERA ADEFOVIR DIPIVOXIL 3 Tablet BARACLUDE ENTECAVIR 3 Solution, Oral Page 18
Brand Name Generic Name Tier Form BARACLUDE ENTECAVIR 3 Tablet EPIVIR HBV LAMIVUDINE 3 Solution, Oral EPIVIR HBV LAMIVUDINE 3 Tablet TYZEKA TELBIVUDINE 3 Tablet HEPATITIS C TREATMENT AGENTS INFERGEN INTERFERON ALFACON-1 3 Vial (SDV, MDV or Additive) (ml) PEGASYS PEGINTERFERON ALFA-2A 3 Kit PEGASYS PEGINTERFERON ALFA-2A 3 Vial (SDV, MDV or Additive) (ml) PEG-INTRON PEGINTERFERON ALFA-2B 3 Kit PEGINTRON REDIPEN PEGINTERFERON ALFA-2B 3 Pen Injector Kit (EA) REBETOL RIBAVIRIN 3 Capsule (Hard, Soft, etc.) RIBASPHERE RIBAVIRIN 1 Capsule (Hard, Soft, etc.) RIBAVIRIN RIBAVIRIN 1 Capsule (Hard, Soft, etc.) REBETOL RIBAVIRIN 3 Solution, Oral COPEGUS RIBAVIRIN 3 Tablet RIBASPHERE RIBAVIRIN 1 Tablet RIBATAB RIBAVIRIN 3 Tablet RIBAVIRIN RIBAVIRIN 1 Tablet RIBAPAK RIBAVIRIN 1 Tablet, Dose Pack RIBATAB RIBAVIRIN 3 Tablet, Dose Pack REBETRON 1000 RIBAVIRIN/INTERFERON A-2B 3 Kit REBETRON 1200 RIBAVIRIN/INTERFERON A-2B 3 Kit REBETRON 600 RIBAVIRIN/INTERFERON A-2B 3 Kit RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS XIFAXAN RIFAXIMIN 3 Tablet ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE-NUCLEOTIDE ANALOG TRUVADA EMTRICITABINE/TENOFOVIR 3 Tablet ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI ZIAGEN ABACAVIR SULFATE 3 Solution, Oral ZIAGEN ABACAVIR SULFATE 3 Tablet DIDANOSINE DIDANOSINE 1 Capsule,Delayed Release (Enteric Coated) VIDEX EC DIDANOSINE 3 Capsule,Delayed Release (Enteric Coated) VIDEX EC DIDANOSINE 3 Capsule,Delayed Release (Enteric Coated) VIDEX DIDANOSINE 3 Solution, Reconstituted, Oral EMTRIVA EMTRICITABINE 3 Capsule (Hard, Soft, etc.) EMTRIVA EMTRICITABINE 3 Solution, Oral EPIVIR LAMIVUDINE 3 Solution, Oral EPIVIR LAMIVUDINE 3 Tablet ZERIT STAVUDINE 3 Capsule (Hard, Soft, etc.) ZERIT STAVUDINE 3 Solution, Reconstituted, Oral VIREAD TENOFOVIR DISOPROXIL FUMARATE 3 Tablet RETROVIR ZIDOVUDINE 3 Capsule (Hard, Soft, etc.) ZIDOVUDINE ZIDOVUDINE 1 Capsule (Hard, Soft, etc.) RETROVIR ZIDOVUDINE 3 Syrup ZIDOVUDINE ZIDOVUDINE 1 Syrup RETROVIR ZIDOVUDINE 3 Tablet ZIDOVUDINE ZIDOVUDINE 1 Tablet ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI RESCRIPTOR DELAVIRDINE MESYLATE 3 Tablet RESCRIPTOR DELAVIRDINE MESYLATE 3 Tablet, Dispersible SUSTIVA EFAVIRENZ 3 Capsule (Hard, Soft, etc.) SUSTIVA EFAVIRENZ 3 Tablet INTELENCE ETRAVIRINE 3 Tablet VIRAMUNE NEVIRAPINE 3 Suspension, Oral (Final Dose Form) VIRAMUNE NEVIRAPINE 3 Tablet ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI COMBINATION EPZICOM ABACAVIR SULFATE/LAMIVUDINE 3 Tablet TRIZIVIR ABACAVIR/LAMIVUDINE/ZIDOVUDINE 3 Tablet COMBIVIR LAMIVUDINE/ZIDOVUDINE 3 Tablet ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMBINATION KALETRA LOPINAVIR/RITONAVIR 3 Solution, Oral KALETRA LOPINAVIR/RITONAVIR 3 Tablet KALETRA RITONAVIR/LOPINAVIR 3 Capsule (Hard, Soft, etc.) ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS FUZEON ENFUVIRTIDE 3 Kit 2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL TINDAMAX TINIDAZOLE 3 Tablet Page 19
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