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

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Brand Name Generic Name Tier Form TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 1 Elixir TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 2 Elixir TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 1 Tablet AUTONOMIC DRUGS PARASYMPATHETIC AGENTS BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE 1 Tablet URECHOLINE BETHANECHOL CHLORIDE 1 Tablet EVOXAC CEVIMELINE HCL 2 Capsule (Hard, Soft, etc.) GUANIDINE HCL GUANIDINE HCL 3 Tablet PILOCARPINE HCL PILOCARPINE HCL 1 Tablet SALAGEN PILOCARPINE HCL 2 Tablet CHOLINESTERASE INHIBITORS MYTELASE AMBENONIUM CHLORIDE 3 Tablet ARICEPT DONEPEZIL HCL 2 Tablet ARICEPT ODT DONEPEZIL HCL 2 Tablet, Rapid Dissolve RAZADYNE ER GALANTAMINE HYDROBROMIDE 3 Capsule, 24Hr Sustained Release Pellets RAZADYNE GALANTAMINE HYDROBROMIDE 3 Solution, Oral RAZADYNE GALANTAMINE HYDROBROMIDE 3 Tablet PROSTIGMIN NEOSTIGMINE BROMIDE 3 Tablet MESTINON PYRIDOSTIGMINE BROMIDE 3 Syrup MESTINON PYRIDOSTIGMINE BROMIDE 3 Tablet PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE 1 Tablet MESTINON PYRIDOSTIGMINE BROMIDE 3 Tablet, Sustained Action EXELON RIVASTIGMINE 2 Patch, Transdermal 24 Hr EXELON RIVASTIGMINE TARTRATE 2 Capsule (Hard, Soft, etc.) EXELON RIVASTIGMINE TARTRATE 3 Solution, Oral COGNEX TACRINE HCL 3 Capsule (Hard, Soft, etc.) ADRENERGICS, AROMATIC, NON-CATECHOLAMINE ADDERALL XR AMPHET ASP/AMPHET/D-AMPHET 2 Capsule, Sustained Release 24 Hr ADDERALL AMPHET ASP/AMPHET/D-AMPHET 3 Tablet AMPHETAMINE SALT COMBO AMPHET ASP/AMPHET/D-AMPHET 1 Tablet DEXEDRINE D-AMPHETAMINE SULFATE 3 Capsule, Sustained Action DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 1 Capsule, Sustained Action DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 1 Tablet DEXTROSTAT D-AMPHETAMINE SULFATE 1 Tablet DESOXYN METHAMPHETAMINE HCL 3 Tablet ALPHA-ADRENERGIC BLOCKING AGENTS DIBENZYLINE PHENOXYBENZAMINE HCL 3 Capsule (Hard, Soft, etc.) BETA-ADRENERGIC BLOCKING AGENTS ACEBUTOLOL HCL ACEBUTOLOL HCL 1 Capsule (Hard, Soft, etc.) SECTRAL ACEBUTOLOL HCL 3 Capsule (Hard, Soft, etc.) ATENOLOL ATENOLOL 1 Tablet TENORMIN ATENOLOL 3 Tablet BETAXOLOL HCL BETAXOLOL HCL 1 Tablet KERLONE BETAXOLOL HCL 3 Tablet BISOPROLOL FUMARATE BISOPROLOL FUMARATE 1 Tablet ZEBETA BISOPROLOL FUMARATE 3 Tablet METOPROLOL SUCCINATE METOPROLOL SUCCINATE 1 Tablet, Sustained Release 24 Hr TOPROL XL METOPROLOL SUCCINATE 2 Tablet, Sustained Release 24 Hr LOPRESSOR METOPROLOL TARTRATE 3 Tablet METOPROLOL TARTRATE METOPROLOL TARTRATE 1 Tablet METOPROLOL TARTRATE METOPROLOL TARTRATE 3 Tablet CORGARD NADOLOL 3 Tablet NADOLOL NADOLOL 1 Tablet BYSTOLIC NEBIVOLOL HCL 3 Tablet LEVATOL PENBUTOLOL SULFATE 3 Tablet PINDOLOL PINDOLOL 1 Tablet INDERAL LA PROPRANOLOL HCL 3 Capsule, Sustained Action 24 Hr PROPRANOLOL HCL PROPRANOLOL HCL 1 Capsule, Sustained Action 24 Hr INNOPRAN XL PROPRANOLOL HCL 3 Capsule, Sustained Release 24 Hr PROPRANOLOL HCL PROPRANOLOL HCL 3 Solution, Oral PROPRANOLOL HCL PROPRANOLOL HCL 1 Tablet BETAPACE SOTALOL HCL 3 Tablet BETAPACE AF SOTALOL HCL 2 Tablet SORINE SOTALOL HCL 1 Tablet SOTALOL SOTALOL HCL 1 Tablet SOTALOL AF SOTALOL HCL 1 Tablet Page 22
Brand Name Generic Name Tier Form SOTALOL HCL SOTALOL HCL 1 Tablet TIMOLOL MALEATE TIMOLOL MALEATE 1 Tablet NEUROMUSCULAR BLOCKING AGENTS BOTOX BOTULINUM TOXIN TYPE A 3 Vial (SDV, MDV or Additive) (EA) BOTOX COSMETIC BOTULINUM TOXIN TYPE A 3 Vial (SDV, MDV or Additive) (EA) MYOBLOC BOTULINUM TOXIN TYPE B 3 Vial (SDV, MDV or Additive) (ml) SUX-CERT 1000 SUCCINYLCHOLINE CHLORIDE 3 Solution, Irrigation SUX-CERT 500 SUCCINYLCHOLINE CHLORIDE 3 Solution, Irrigation ANAPHYLAXIS THERAPY AGENTS TWINJECT EPINEPHRINE 3 Combination Package (EA) EPIPEN EPINEPHRINE 2 Pen Injector (EA) EPIPEN JR EPINEPHRINE 2 Pen Injector (EA) ADRENERGIC VASOPRESSOR AGENTS MIDODRINE HCL MIDODRINE HCL 1 Tablet PROAMATINE MIDODRINE HCL 3 Tablet BETA-ADRENERGIC BLOCKING AGENTS/DIETARY SUPP COMB. HYPERTENSOLOL METOPROLOL/DIETARY SUPPL.CMB10 3 Combination Package (EA) BLOOD ANTIHEMOPHILIC FACTORS HUMATE-P AHF,HUMAN/VWF,HUMAN 3 Kit KOGENATE ANTIHEMOPHILIC FACTOR, HUM REC 3 Kit REFACTO ANTIHEMOPHILIC FACTOR, HUM REC 3 Kit HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 1 Vial (SDV, MDV or Additive) (EA) HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC 3 Vial (SDV, MDV or Additive) (EA) KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 1 Vial (SDV, MDV or Additive) (EA) KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC 3 Vial (SDV, MDV or Additive) (EA) RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC 1 Vial (SDV, MDV or Additive) (EA) KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 1 Kit KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 3 Kit MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 3 Kit MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 3 Kit ALPHANATE ANTIHEMOPHILIC FACTOR,HUMAN 3 Vial (SDV, MDV or Additive) (EA) HEMOFIL M ANTIHEMOPHILIC FACTOR,HUMAN 3 Vial (SDV, MDV or Additive) (EA) MONARC-M ANTIHEMOPHILIC FACTOR,HUMAN 1 Vial (SDV, MDV or Additive) (EA) MONARC-M ANTIHEMOPHILIC FACTOR,HUMAN 3 Vial (SDV, MDV or Additive) (EA) FEIBA VH IMMUNO ANTI-INHIBITOR COAGULANT COMP. 3 Vial (SDV, MDV or Additive) (EA) NOVOSEVEN FACTOR VIIA,RECOMB(BHK CELLS) 3 Vial (SDV, MDV or Additive) (EA) FACTOR IX PREPARATIONS ALPHANINE SD FACTOR IX 3 Vial (SDV, MDV or Additive) (EA) MONONINE FACTOR IX 3 Vial (SDV, MDV or Additive) (EA) BEBULIN VH IMMUNO FACTOR IX COMPLEX HUMAN 3 Vial (SDV, MDV or Additive) (EA) PROFILNINE SD FACTOR IX COMPLEX HUMAN 3 Vial (SDV, MDV or Additive) (EA) PROPLEX T FACTOR IX COMPLEX HUMAN 3 Vial (SDV, MDV or Additive) (EA) BENEFIX FACTOR IX HUMAN RECOMBINANT 3 Kit TOPICAL HEMOSTATICS ASTRINGYN FERRIC SUBSULFATE 3 Solution (gm) GELFOAM GELATIN SPONGE,ABSORBABLE 1 Powder (gm) SURGIFOAM GELATIN SPONGE,ABSORBABLE 1 Powder (gm) GELFOAM GELATIN SPONGE,ABSORBABLE 3 Sponge GELFOAM GELATIN SPONGE,ABSORBABLE 3 Sponge GELFOAM COMPRESSED GELATIN SPONGE,ABSORBABLE 3 Sponge GELFOAM PACKS GELATIN SPONGE,ABSORBABLE 3 Sponge SURGIFOAM GELATIN SPONGE,ABSORBABLE 1 Sponge SURGIFOAM GELATIN SPONGE,ABSORBABLE 3 Sponge HELITENE MICROFIBRILLAR COLLAGEN 1 Each HELITENE MICROFIBRILLAR COLLAGEN 3 Each INSTAT MCH MICROFIBRILLAR COLLAGEN 1 Each AVITENE MICROFIBRILLAR COLLAGEN 3 Powder (gm) AVITENE MICROFIBRILLAR COLLAGEN 3 Sheet (EA) ENDO-AVITENE MICROFIBRILLAR COLLAGEN 3 Sheet (EA) ULTRAFOAM MICROFIBRILLAR COLLAGEN 3 Sponge THROMBI-PAD THROMB-CA-CELL-DRESSING, HEMOS 3 Pads, Medicated (EA) THROMBIN-JMI THROMBIN (BOVINE) 3 Kit THROMBOGEN THROMBIN (BOVINE) 1 Kit THROMBOGEN THROMBIN (BOVINE) 3 Kit THROMBIN-JMI THROMBIN (BOVINE) 3 Vial (SDV, MDV or Additive) (EA) THROMBIN-JMI THROMBIN (BOVINE) 3 Vial (SDV, MDV or Additive) (EA) Page 23
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Trustmark/Starmark Formulary Drug List April 2008 - Resource ...

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