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

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knowledge, expertise, skill and judgment of your medical provider in his or her choice of prescription drugs. The final prescribing choice remains between you and your provider. Pharmacy & Therapeutics (P&T) Committee The WellPoint NextRx National P&T committee consists of two interdependent subcommittees: the Clinical Review Committee (CRC) and the Value Assessment Committee (VAC). These committees work together in the decision-making process to ensure a check and a balance to one another. They meet quarterly to review, add and delete drugs from the formulary, and to establish therapy guidelines and drug utilization policies and practices. The CRC consists of clinical pharmacists, practicing physicians, medical directors and quality assurance nurses. These professionals access a rigorous review of current clinical guidelines, treatment criteria, major medical publications, professional journals and medical specialists. The second committee, the VAC, reviews the financial information (i.e., average wholesale price, rebates, ingredient cost, cost of care, copays, coinsurance), market factors and customer impact. Together, they work to help maintain an outcomes-based formulary, which offers you access to cost-effective drugs. Notice When viewing this formulary via the Internet, please be advised that the formulary is updated periodically and changes may appear prior to their effective date to allow for notification. For More Information For the most up-to-date formulary information, or if you have any questions, please call WellPoint NextRx Customer Service at 866.841.8951. Trustmark Companies Health plans administered by Starmark are fully insured by Trustmark Life Insurance Company. TMK-SMK/TMK_lob59_tier0108
Brand Name Generic Name Tier Form ANALGESICS ANALGESICS, NARCOTICS SUBUTEX BUPRENORPHINE HCL 3 Tablet, Sublingual SUBOXONE BUPRENORPHINE HCL/NALOXONE HCL 3 Tablet, Sublingual BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE 1 Aerosol, Spray (ml) ACETAMINOPHEN W/CODEINE CODEINE PHOS/ACETAMINOPHEN 2 Elixir ACETAMINOPHEN W/CODEINE CODEINE PHOS/ACETAMINOPHEN 1 Tablet ASPIRIN W/CODEINE CODEINE PHOS/ASPIRIN 1 Tablet CARISOPRODOL COMPOUND/CODEINE CODEINE PHOS/CARISOPRODOL/ASA 1 Tablet SOMA COMPOUND W/CODEINE CODEINE PHOS/CARISOPRODOL/ASA 3 Tablet CODEINE SULFATE CODEINE SULF 1 Tablet CODEINE SULFATE CODEINE SULF 3 Tablet PANLOR DC DHCODEINE BT/ACETAMINOPHN/CAFF 3 Capsule (Hard, Soft, etc.) TREZIX DHCODEINE BT/ACETAMINOPHN/CAFF 1 Capsule (Hard, Soft, etc.) APAP-CAFFEINE-DIHYDROCODEINE DHCODEINE BT/ACETAMINOPHN/CAFF 1 Tablet PANLOR SS DHCODEINE BT/ACETAMINOPHN/CAFF 3 Tablet ZERLOR DHCODEINE BT/ACETAMINOPHN/CAFF 1 Tablet SYNALGOS-DC DIHYDROCODEINE/ASPIRIN/CAFFEIN 3 Capsule (Hard, Soft, etc.) DURAGESIC FENTANYL 3 Patch, Transdermal 72 Hr FENTANYL FENTANYL 1 Patch, Transdermal 72 Hr ACTIQ FENTANYL CITRATE 3 Lozenge on a Handle FENTANYL CITRATE FENTANYL CITRATE 1 Lozenge on a Handle FENTORA FENTANYL CITRATE 3 Tablet, Effervescent DOLOREX FORTE HYDROCODONE BIT/ACETAMINOPHEN 1 Capsule (Hard, Soft, etc.) HYDROCET HYDROCODONE BIT/ACETAMINOPHEN 1 Capsule (Hard, Soft, etc.) HYDROCODONE W/ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 1 Capsule (Hard, Soft, etc.) MARGESIC H HYDROCODONE BIT/ACETAMINOPHEN 1 Capsule (Hard, Soft, etc.) STAGESIC HYDROCODONE BIT/ACETAMINOPHEN 1 Capsule (Hard, Soft, etc.) HYCET HYDROCODONE BIT/ACETAMINOPHEN 3 Solution, Oral HYDROCODONE-ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 1 Solution, Oral LIQUICET HYDROCODONE BIT/ACETAMINOPHEN 3 Solution, Oral LORTAB HYDROCODONE BIT/ACETAMINOPHEN 3 Solution, Oral CO-GESIC HYDROCODONE BIT/ACETAMINOPHEN 1 Tablet HYDROCODONE W/ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 1 Tablet LORCET 10/650 HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet LORCET PLUS HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet LORTAB HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet MAXIDONE HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet NORCO HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet STAGESIC-10 HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet VICODIN HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet VICODIN ES HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet VICODIN HP HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet XODOL 10/300 HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet XODOL 5-300 HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet XODOL 7.5-300 HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet ZYDONE HYDROCODONE BIT/ACETAMINOPHEN 3 Tablet DILAUDID-5 HYDROMORPHONE HCL 3 Liquid (ml) HYDROMORPHONE HCL HYDROMORPHONE HCL 1 Liquid (ml) DILAUDID HYDROMORPHONE HCL 3 Suppository, Rectal HYDROMORPHONE HCL HYDROMORPHONE HCL 1 Suppository, Rectal DILAUDID HYDROMORPHONE HCL 3 Tablet HYDROMORPHONE HCL HYDROMORPHONE HCL 1 Tablet LEVO-DROMORAN LEVORPHANOL TARTRATE 3 Tablet LEVORPHANOL TARTRATE LEVORPHANOL TARTRATE 1 Tablet MEPERIDINE HCL MEPERIDINE HCL 1 Solution, Oral DEMEROL MEPERIDINE HCL 3 Tablet MEPERIDINE HCL MEPERIDINE HCL 1 Tablet MEPERITAB MEPERIDINE HCL 1 Tablet MEPERIDINE W/PROMETHAZINE MEPERIDINE HCL/PROMETH HCL 1 Capsule (Hard, Soft, etc.) MEPERIDINE-PROMETHAZINE MEPERIDINE HCL/PROMETH HCL 1 Capsule (Hard, Soft, etc.) MEPROZINE MEPERIDINE HCL/PROMETH HCL 1 Capsule (Hard, Soft, etc.) METHADONE METHADONE HCL 1 Concentrate, Oral METHADONE INTENSOL METHADONE HCL 1 Concentrate, Oral METHADOSE METHADONE HCL 3 Concentrate, Oral METHADONE HCL METHADONE HCL 3 Solution, Oral DOLOPHINE HCL METHADONE HCL 1 Tablet DOLOPHINE HCL METHADONE HCL 3 Tablet Page 1
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Trustmark/Starmark Formulary Drug List April 2008 - Resource ...

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