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

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Brand Name Generic Name Tier Form PEPCID RPD FAMOTIDINE 3 Tablet, Rapid Dissolve PREVACID LANSOPRAZOLE 2 Capsule,Delayed Release (Enteric Coated) PREVACID LANSOPRAZOLE 2 Suspension,Delayed Release,RECONST. PREVACID LANSOPRAZOLE 2 Tablet, Rapid Dissolve, Delayed Release AXID NIZATIDINE 3 Capsule (Hard, Soft, etc.) NIZATIDINE NIZATIDINE 1 Capsule (Hard, Soft, etc.) AXID NIZATIDINE 3 Solution, Oral OMEPRAZOLE OMEPRAZOLE 1 Capsule,Delayed Release (Enteric Coated) PRILOSEC OMEPRAZOLE 3 Capsule,Delayed Release (Enteric Coated) ZEGERID OMEPRAZOLE/SODIUM BICARBONATE 3 Capsule (Hard, Soft, etc.) ZEGERID OMEPRAZOLE/SODIUM BICARBONATE 3 Packet PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 1 Tablet, Delayed Release (Enteric Coated) PROTONIX PANTOPRAZOLE SODIUM 3 Tablet, Delayed Release (Enteric Coated) ACIPHEX RABEPRAZOLE SODIUM 3 Tablet, Delayed Release (Enteric Coated) RANITIDINE HCL RANITIDINE HCL 1 Capsule (Hard, Soft, etc.) TALADINE RANITIDINE HCL 3 Capsule (Hard, Soft, etc.) RANITIDINE HCL RANITIDINE HCL 1 Syrup ZANTAC RANITIDINE HCL 3 Syrup RANITIDINE HCL RANITIDINE HCL 1 Tablet ZANTAC RANITIDINE HCL 3 Tablet ZANTAC 25 RANITIDINE HCL 3 Tablet, Effervescent IRRITABLE BOWEL SYNDROME AGENT, 5HT-3 ANTAGONIST-TYPE LOTRONEX ALOSETRON HCL 3 Tablet KERATINOCYTE GROWTH FACTOR (KGF) KEPIVANCE PALIFERMIN 3 Vial (SDV, MDV or Additive) (EA) DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT BALSALAZIDE DISODIUM BALSALAZIDE DISODIUM 1 Capsule (Hard, Soft, etc.) COLAZAL BALSALAZIDE DISODIUM 2 Capsule (Hard, Soft, etc.) PENTASA MESALAMINE 2 Capsule, Sustained Action ASACOL MESALAMINE 2 Tablet, Delayed Release (Enteric Coated) LIALDA MESALAMINE 3 Tablet, Delayed Release (Enteric Coated) DIPENTUM OLSALAZINE SODIUM 2 Capsule (Hard, Soft, etc.) CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TX MESALAMINE MESALAMINE 1 Enema (ml) ROWASA MESALAMINE 3 Enema (ml) CANASA MESALAMINE 2 Suppository, Rectal HEMORRHOIDAL PREP, ANTI-INFAM STEROID/LOCAL ANESTH RECTAGEL HC HC ACETATE/LIDOCAIN HCL/ALO V 3 Gel with Applicator (gm) ANAMANTLE HC HC ACETATE/LIDOCAIN HCL/ALO V 3 Kit LIDOCAINE-HYDROCORTISONE HC ACETATE/LIDOCAIN HCL/ALO V 1 Kit PERANEX HC HC ACETATE/LIDOCAIN HCL/ALO V 3 Kit ANAMANTLE HC HC ACETATE/LIDOCAINE HCL 3 Cream with Applicator LIDAZONE HC HC ACETATE/LIDOCAINE HCL 1 Cream with Applicator LIDOCAINE-HYDROCORTISONE HC ACETATE/LIDOCAINE HCL 1 Cream with Applicator ANAMANTLE HC HC ACETATE/LIDOCAINE HCL 3 Kit ANAMANTLE HC FORTE HC ACETATE/LIDOCAINE HCL 3 Kit LIDAZONE HC HC ACETATE/LIDOCAINE HCL 1 Kit LIDOCAINE-HYDROCORTISONE HC ACETATE/LIDOCAINE HCL 1 Kit PERANEX HC HC ACETATE/LIDOCAINE HCL 3 Pads, Medicated (EA) HISTAMINE H2-RECEPTOR INHIBITORS/DIETARY SUPP.CMB. SENTRADINE RANITIDINE HCL/DIET.SUPP NO.8 3 Combination Package (EA) GABITIDINE RANITIDINE HCL/DIET.SUPP NO.17 3 Combination Package (EA) ANTICHOLINERGICS/MICROORGANISMS COMBINATIONS PAMINE FQ METHSCP BR/LA/S.THM/L.PARA/BIF 3 Combination Package (EA) HORMONES ANDROGENIC AGENTS ANDROXY FLUOXYMESTERONE 3 Tablet ANDROID METHYLTESTOSTERONE 3 Capsule (Hard, Soft, etc.) TESTRED METHYLTESTOSTERONE 3 Capsule (Hard, Soft, etc.) METHITEST METHYLTESTOSTERONE 3 Tablet OXANDRIN OXANDROLONE 3 Tablet OXANDROLONE OXANDROLONE 1 Tablet ANADROL-50 OXYMETHOLONE 3 Tablet TESTIM TESTOSTERONE 2 Gel (gm) ANDROGEL TESTOSTERONE 2 Gel in Metered-Dose Pump ANDROGEL TESTOSTERONE 2 Gel in Packet (gm) Page 56
Brand Name Generic Name Tier Form STRIANT TESTOSTERONE 3 Mucoadhesive System, 12 Hr Sust.Release ANDRODERM TESTOSTERONE 2 Patch, Transdermal 24 Hr DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 3 Vial (SDV, MDV or Additive) (ml) TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE 1 Vial (SDV, MDV or Additive) (ml) DELATESTRYL TESTOSTERONE ENANTHATE 3 Disposable Syringe (ml) DELATESTRYL TESTOSTERONE ENANTHATE 3 Vial (SDV, MDV or Additive) (ml) FIRST-TESTOSTERONE MC TESTOSTERONE PROPIONATE 3 Cream (Grams) FIRST-TESTOSTERONE TESTOSTERONE PROPIONATE 3 Ointment (gm) ESTROGENIC AGENTS ESTRASORB ESTRADIOL 3 Emulsion in Packet ELESTRIN ESTRADIOL 3 Gel in Metered-Dose Pump ESTROGEL ESTRADIOL 3 Gel in Metered-Dose Pump DIVIGEL ESTRADIOL 3 Gel in Packet (EA) DIVIGEL ESTRADIOL 3 Gel in Packet (gm) ALORA ESTRADIOL 2 Patch, Transdermal Semiweekly ESTRADERM ESTRADIOL 2 Patch, Transdermal Semiweekly VIVELLE ESTRADIOL 2 Patch, Transdermal Semiweekly VIVELLE-DOT ESTRADIOL 2 Patch, Transdermal Semiweekly CLIMARA ESTRADIOL 2 Patch, Transdermal Weekly ESTRADIOL ESTRADIOL 1 Patch, Transdermal Weekly ESTRADIOL TRANSDERMAL PATCH ESTRADIOL 1 Patch, Transdermal Weekly MENOSTAR ESTRADIOL 3 Patch, Transdermal Weekly ESTRACE ESTRADIOL 3 Tablet ESTRADIOL ESTRADIOL 1 Tablet FEMTRACE ESTRADIOL ACETATE 3 Tablet DELESTROGEN ESTRADIOL VALERATE 3 Vial (SDV, MDV or Additive) (ml) CLIMARA PRO ESTRADIOL/LEVONORGESTREL 2 Patch, Transdermal Weekly COMBIPATCH ESTRADIOL/NORETH AC 3 Patch, Transdermal Semiweekly ACTIVELLA ESTRADIOL/NORETH AC 3 Tablet PREFEST ESTRADIOL/NORGESTIMATE 2 Tablet PREMPHASE ESTROGEN,CON/M-PROGEST ACET 2 Tablet PREMPRO ESTROGEN,CON/M-PROGEST ACET 2 Tablet CENESTIN ESTROGENS,CONJ.,SYNTHETIC A 2 Tablet ENJUVIA ESTROGENS,CONJ.,SYNTHETIC B 3 Tablet PREMARIN ESTROGENS,CONJUGATED 2 Tablet MENEST ESTROGENS,ESTERIFIED 2 Tablet ESTROPIPATE ESTROPIPATE 1 Tablet OGEN ESTROPIPATE 3 Tablet FEMHRT NORETHIND AC/ETHINYL ESTRADIOL 3 Tablet ESTROGEN/ANDROGEN COMBINATIONS COVARYX ESTROGEN,ESTER/ME-TESTOSTERONE 1 Tablet COVARYX H.S. ESTROGEN,ESTER/ME-TESTOSTERONE 1 Tablet EEMT ESTROGEN,ESTER/ME-TESTOSTERONE 1 Tablet EEMT H.S. ESTROGEN,ESTER/ME-TESTOSTERONE 1 Tablet EEMT H.S. ESTROGEN,ESTER/ME-TESTOSTERONE 3 Tablet ESSIAN ESTROGEN,ESTER/ME-TESTOSTERONE 1 Tablet ESSIAN H.S. ESTROGEN,ESTER/ME-TESTOSTERONE 1 Tablet ESTRATEST ESTROGEN,ESTER/ME-TESTOSTERONE 3 Tablet ESTRATEST H.S. ESTROGEN,ESTER/ME-TESTOSTERONE 3 Tablet ESTROGEN & METHYLTESTOSTERONE ESTROGEN,ESTER/ME-TESTOSTERONE 1 Tablet PROGESTATIONAL AGENTS MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACET 1 Tablet PROVERA MEDROXYPROGESTERONE ACET 3 Tablet AYGESTIN NORETHINDRONE ACETATE 3 Tablet NORETHINDRONE ACETATE NORETHINDRONE ACETATE 1 Tablet PROMETRIUM PROGESTERONE,MICRONIZED 2 Capsule (Hard, Soft, etc.) PROCHIEVE PROGESTERONE,MICRONIZED 3 Gel with Prefilled Applicator (gm) OXYTOCICS PREPIDIL DINOPROSTONE 3 Gel with Prefilled Applicator (gm) CERVIDIL DINOPROSTONE 3 Insert, Sustained Release PROSTIN E2 VAGINAL SUPPOSITORY DINOPROSTONE 3 Suppository, Vaginal ERGOTRATE ERGONOVINE MALEATE 3 Tablet METHERGINE METHYLERGONOVINE MALEATE 3 Tablet FERTILITY STIMULATING PREPARATIONS,NON-FSH CLOMID CLOMIPHENE CITRATE 3 Tablet CLOMIPHENE CITRATE CLOMIPHENE CITRATE 1 Tablet SEROPHENE CLOMIPHENE CITRATE 1 Tablet Page 57
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Trustmark/Starmark Formulary Drug List April 2008 - Resource ...

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