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

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Brand Name Generic Name Tier Form THROMBOGEN THROMBIN (BOVINE) 1 Vial (SDV, MDV or Additive) (EA) THROMBOGEN THROMBIN (BOVINE) 3 Vial (SDV, MDV or Additive) (EA) RECOTHROM THROMBIN (RECOMBINANT) 3 Vial (SDV, MDV or Additive) (EA) TISSEEL VHSD THROMBIN(HUM PLAS)/FIB/APRO/CA 3 Disposable Syringe (ml) TISSEEL VH THROMBIN(HUM PLAS)/FIB/APRO/CA 3 Kit EVICEL THROMBIN(HUM PLAS)/FIBRINOG/CA 3 Vial (SDV, MDV or Additive) (ml) THROMBI-GEL THROMBIN/CA/CMC/GEL/DRESS, HEM 3 Pads, Medicated (EA) HEMASEEL APR THROMBIN/FIBRINOGEN/APRO/CAL 1 Kit TISSEEL VH THROMBIN/FIBRINOGEN/APRO/CAL 1 Kit ANTIFIBRINOLYTIC AGENTS AMICAR AMINOCAPROIC ACID 3 Syrup AMINOCAPROIC ACID AMINOCAPROIC ACID 1 Syrup AMICAR AMINOCAPROIC ACID 3 Tablet AMICAR AMINOCAPROIC ACID 3 Tablet AMINOCAPROIC ACID AMINOCAPROIC ACID 1 Tablet HEPARIN AND RELATED PREPARATIONS FRAGMIN DALTEPARIN SODIUM,PORCINE 3 Disposable Syringe (ml) FRAGMIN DALTEPARIN SODIUM,PORCINE 3 Vial (SDV, MDV or Additive) (ml) LOVENOX ENOXAPARIN SODIUM 3 Disposable Syringe (ml) LOVENOX ENOXAPARIN SODIUM 3 Vial (SDV, MDV or Additive) (ml) ARIXTRA FONDAPARINUX SODIUM 3 Disposable Syringe (ml) INNOHEP TINZAPARIN SODIUM,PORCINE 3 Vial (SDV, MDV or Additive) (ml) ANTICOAGULANTS, COUMARIN TYPE COUMADIN WARFARIN SODIUM 3 Tablet JANTOVEN WARFARIN SODIUM 1 Tablet WARFARIN SODIUM WARFARIN SODIUM 1 Tablet HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE PENTOXIFYLLINE 1 Tablet, Sustained Action PENTOXIL PENTOXIFYLLINE 1 Tablet, Sustained Action TRENTAL PENTOXIFYLLINE 3 Tablet, Sustained Action HEMATINICS, OTHER ARANESP DARBEPOETIN ALFA IN POLYSORBAT 3 Pen Injector (ml) LEUKOCYTE (WBC) STIMULANTS NEULASTA PEGFILGRASTIM 3 Disposable Syringe (ml) PLATELET AGGREGATION INHIBITORS AGGRENOX ASPIRIN/DIPYRIDAMOLE 2 Capsule, Multiphasic Release 12 Hr CILOSTAZOL CILOSTAZOL 1 Tablet PLETAL CILOSTAZOL 3 Tablet PLAVIX CLOPIDOGREL BISULFATE 3 Tablet DIPYRIDAMOLE DIPYRIDAMOLE 1 Tablet PERSANTINE DIPYRIDAMOLE 3 Tablet TICLID TICLOPIDINE HCL 3 Tablet TICLOPIDINE HCL TICLOPIDINE HCL 1 Tablet PLATELET REDUCING AGENTS AGRYLIN ANAGRELIDE HCL 2 Capsule (Hard, Soft, etc.) ANAGRELIDE HCL ANAGRELIDE HCL 1 Capsule (Hard, Soft, etc.) PLATELET PROLIFERATION STIMULANTS NEUMEGA OPRELVEKIN 3 Vial (SDV, MDV or Additive) (EA) THROMBIN INHIBITORS, SEL., DIRECT, & REV.-HIRUDIN TYPE REFLUDAN LEPIRUDIN,RECOMBINANT 3 Vial (SDV, MDV or Additive) (EA) CARDIAC DRUGS DIGITALIS GLYCOSIDES LANOXICAPS DIGOXIN 2 Capsule (Hard, Soft, etc.) DIGOXIN DIGOXIN 1 Solution, Oral DIGITEK DIGOXIN 1 Tablet DIGITEK DIGOXIN 3 Tablet DIGOXIN DIGOXIN 1 Tablet LANOXIN DIGOXIN 3 Tablet ANTIARRHYTHMICS AMIODARONE HCL AMIODARONE HCL 1 Tablet CORDARONE AMIODARONE HCL 2 Tablet PACERONE AMIODARONE HCL 1 Tablet PACERONE AMIODARONE HCL 2 Tablet DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE 1 Capsule (Hard, Soft, etc.) NORPACE DISOPYRAMIDE PHOSPHATE 2 Capsule (Hard, Soft, etc.) DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE 1 Capsule, Sustained Action Page 24
Brand Name Generic Name Tier Form NORPACE CR DISOPYRAMIDE PHOSPHATE 2 Capsule, Sustained Action NORPACE CR DISOPYRAMIDE PHOSPHATE 2 Capsule, Sustained Action TIKOSYN DOFETILIDE 3 Capsule (Hard, Soft, etc.) FLECAINIDE ACETATE FLECAINIDE ACETATE 1 Tablet TAMBOCOR FLECAINIDE ACETATE 3 Tablet MEXILETINE HCL MEXILETINE HCL 1 Capsule (Hard, Soft, etc.) MEXILETINE HCL MEXILETINE HCL 1 Capsule (Hard, Soft, etc.) ETHMOZINE MORICIZINE HCL 3 Tablet PRONESTYL PROCAINAMIDE HCL 2 Capsule (Hard, Soft, etc.) PRONESTYL PROCAINAMIDE HCL 2 Tablet PROCAINAMIDE HCL PROCAINAMIDE HCL 1 Tablet, Sustained Action PRONESTYL-SR PROCAINAMIDE HCL 2 Tablet, Sustained Action PROCANBID PROCAINAMIDE HCL 2 Tablet, Sustained Release 12 Hr RYTHMOL SR PROPAFENONE HCL 3 Capsule, Sustained Release 12 Hr PROPAFENONE HCL PROPAFENONE HCL 1 Tablet RYTHMOL PROPAFENONE HCL 3 Tablet QUINIDINE GLUCONATE QUINIDINE GLUCONATE 1 Tablet, Sustained Action QUINIDINE SULFATE QUINIDINE SULFATE 1 Tablet QUINIDINE SULFATE QUINIDINE SULFATE 1 Tablet, Sustained Action VASODILATORS, CORONARY AMYL NITRITE AMYL NITRITE 3 Ampul (EA) DILATRATE-SR ISOSORBIDE DINITRATE 2 Capsule, Sustained Action ISORDIL ISOSORBIDE DINITRATE 3 Tablet ISORDIL ISOSORBIDE DINITRATE 2 Tablet ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 1 Tablet ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 1 Tablet, Sublingual ISOCHRON ISOSORBIDE DINITRATE 2 Tablet, Sustained Action ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 1 Tablet, Sustained Action ISMO ISOSORBIDE MONONITRATE 3 Tablet ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 1 Tablet MONOKET ISOSORBIDE MONONITRATE 3 Tablet IMDUR ISOSORBIDE MONONITRATE 3 Tablet, Sustained Release 24 Hr ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 1 Tablet, Sustained Release 24 Hr NITROGLYCERIN NITROGLYCERIN 1 Capsule, Sustained Action NITROGLYCERIN NITROGLYCERIN 2 Capsule, Sustained Action NITRO-TIME NITROGLYCERIN 1 Capsule, Sustained Action NITRO-BID NITROGLYCERIN 2 Ointment (gm) MINITRAN NITROGLYCERIN 2 Patch, Transdermal 24 Hr NITRO-DUR NITROGLYCERIN 2 Patch, Transdermal 24 Hr NITROGLYCERIN NITROGLYCERIN 1 Patch, Transdermal 24 Hr NITROGLYCERIN PATCH NITROGLYCERIN 1 Patch, Transdermal 24 Hr NITROGLYCERIN TRANSDERMAL NITROGLYCERIN 1 Patch, Transdermal 24 Hr NITROLINGUAL NITROGLYCERIN 2 Spray, Non-Aerosol (gm) NITROGLYCERIN NITROGLYCERIN 1 Tablet, Sublingual NITROQUICK NITROGLYCERIN 1 Tablet, Sublingual NITROSTAT NITROGLYCERIN 2 Tablet, Sublingual CALCIUM CHANNEL BLOCKING AGENTS AMLODIPINE BESYLATE AMLODIPINE BESYLATE 1 Tablet NORVASC AMLODIPINE BESYLATE 2 Tablet DILACOR XR DILTIAZEM HCL 3 Capsule, Degradable Controlled-Release DILTIA XT DILTIAZEM HCL 1 Capsule, Degradable Controlled-Release DILTIAZEM ER DILTIAZEM HCL 1 Capsule, Degradable Controlled-Release DILTIAZEM HCL DILTIAZEM HCL 1 Capsule, Degradable Controlled-Release DILTIAZEM XR DILTIAZEM HCL 1 Capsule, Degradable Controlled-Release DILT-XR DILTIAZEM HCL 1 Capsule, Degradable Controlled-Release DILTIAZEM ER DILTIAZEM HCL 1 Capsule, Sustained Action TAZTIA XT DILTIAZEM HCL 1 Capsule, Sustained Action TIAZAC DILTIAZEM HCL 3 Capsule, Sustained Action DILTIAZEM ER DILTIAZEM HCL 1 Capsule, Sustained Release 12 Hr CARDIZEM CD DILTIAZEM HCL 3 Capsule, Sustained Release 24 Hr CARTIA XT DILTIAZEM HCL 1 Capsule, Sustained Release 24 Hr DILT-CD DILTIAZEM HCL 1 Capsule, Sustained Release 24 Hr DILTIAZEM ER DILTIAZEM HCL 1 Capsule, Sustained Release 24 Hr DILTIAZEM HCL DILTIAZEM HCL 1 Capsule, Sustained Release 24 Hr CARDIZEM DILTIAZEM HCL 3 Tablet DILTIAZEM HCL DILTIAZEM HCL 1 Tablet CARDIZEM LA DILTIAZEM HCL 3 Tablet, Sustained Release 24 Hr FELODIPINE ER FELODIPINE 1 Tablet, Sustained Release 24 Hr Page 25
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Trustmark/Starmark Formulary Drug List April 2008 - Resource ...

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