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

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Brand Name Generic Name Tier Form FOLLICLE STIM./LUTEINIZING HORMONES GONAL-F RFF FOLLITROPIN ALPHA,RECOMB 3 Pen Injector (ml) GONAL-F FOLLITROPIN ALPHA,RECOMB 3 Vial (SDV, MDV or Additive) (EA) GONAL-F RFF FOLLITROPIN ALPHA,RECOMB 3 Vial (SDV, MDV or Additive) (EA) FOLLISTIM AQ FOLLITROPIN BETA,RECOMB 3 Cartridge (ml) CHORIONIC GONADOTROPIN GONADOTROPIN,CHORIONIC,HUMAN 1 Vial (SDV, MDV or Additive) (EA) NOVAREL GONADOTROPIN,CHORIONIC,HUMAN 1 Vial (SDV, MDV or Additive) (EA) PREGNYL GONADOTROPIN,CHORIONIC,HUMAN 3 Vial (SDV, MDV or Additive) (EA) PROFASI GONADOTROPIN,CHORIONIC,HUMAN 3 Vial (SDV, MDV or Additive) (EA) OVIDREL HCG ALPHA,RECOMBINANT 3 Disposable Syringe (ml) MENOPUR MENOTROPINS 3 Vial (SDV, MDV or Additive) (EA) FERTINEX UROFOLLITROPIN (FSH) 3 Ampul (EA) GROWTH HORMONES GENOTROPIN SOMATROPIN 3 Cartridge (EA) SAIZEN SOMATROPIN 3 Cartridge (EA) NORDITROPIN SOMATROPIN 3 Cartridge (ml) NUTROPIN AQ SOMATROPIN 3 Cartridge (ml) GENOTROPIN SOMATROPIN 3 Disposable Syringe (EA) NORDITROPIN NORDIFLEX SOMATROPIN 3 Pen Injector (ml) NORDITROPIN SOMATROPIN 3 Vial (SDV, MDV or Additive) (EA) NORDITROPIN SOMATROPIN 3 Vial (SDV, MDV or Additive) (EA) NUTROPIN SOMATROPIN 3 Vial (SDV, MDV or Additive) (EA) OMNITROPE SOMATROPIN 3 Vial (SDV, MDV or Additive) (EA) SAIZEN SOMATROPIN 3 Vial (SDV, MDV or Additive) (EA) SEROSTIM SOMATROPIN 3 Vial (SDV, MDV or Additive) (EA) TEV-TROPIN SOMATROPIN 1 Vial (SDV, MDV or Additive) (EA) ZORBTIVE SOMATROPIN 3 Vial (SDV, MDV or Additive) (EA) NUTROPIN AQ SOMATROPIN 3 Vial (SDV, MDV or Additive) (ml) SOMATOSTATIC AGENTS SANDOSTATIN LAR OCTREOTIDE ACETATE 3 Kit PITUITARY SUPPRESSIVE AGENTS CABERGOLINE CABERGOLINE 1 Tablet DANAZOL DANAZOL 1 Capsule (Hard, Soft, etc.) DANAZOL DANAZOL 2 Capsule (Hard, Soft, etc.) ANTIDIURETIC AND VASOPRESSOR HORMONES DDAVP DESMOPRESSIN (NONREFRIGERATED) 1 Aerosol, Spray w/Pump (ml) DESMOPRESSIN ACETATE DESMOPRESSIN (NONREFRIGERATED) 1 Aerosol, Spray w/Pump (ml) STIMATE DESMOPRESSIN ACETATE 3 Aerosol, Spray w/Pump (ml) DDAVP DESMOPRESSIN ACETATE 2 Ampul (ml) DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 1 Ampul (ml) DDAVP DESMOPRESSIN ACETATE 2 Solution, Non-Oral DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 1 Solution, Non-Oral DDAVP DESMOPRESSIN ACETATE 2 Tablet DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 1 Tablet DDAVP DESMOPRESSIN ACETATE 2 Vial (SDV, MDV or Additive) (ml) DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 1 Vial (SDV, MDV or Additive) (ml) BONE RESORPTION INHIBITORS FORTICAL CALCITONIN,SALMON,SYNTHETIC 1 Aerosol, Spray w/Pump (ml) MIACALCIN CALCITONIN,SALMON,SYNTHETIC 3 Aerosol, Spray w/Pump (ml) GLUCOCORTICOIDS QVAR BECLOMETHASONE DIPROPIONATE 2 Aerosol w/Adapter (gm) CELESTONE BETAMETHASONE 3 Solution, Oral PULMICORT FLEXHALER BUDESONIDE 2 Aerosol Powder, Breath Activated (EA) PULMICORT BUDESONIDE 2 Ampul for Nebulization (ml) ENTOCORT EC BUDESONIDE 2 Capsule, Sustained Release 24 Hr CORTISONE CORTISONE ACETATE 1 Tablet DEXAMETHASONE INTENSOL DEXAMETHASONE 3 Drops DEXAMETHASONE DEXAMETHASONE 1 Elixir DEXAMETHASONE DEXAMETHASONE 3 Solution, Oral DEXAMETHASONE DEXAMETHASONE 1 Tablet DEXPAK DEXAMETHASONE 3 Tablet, Dose Pack DEXPAK JR. DEXAMETHASONE 3 Tablet, Dose Pack AEROBID FLUNISOLIDE 3 Aerosol w/Adapter (gm) AEROBID-M FLUNISOLIDE/MENTHOL 3 Aerosol w/Adapter (gm) FLOVENT HFA FLUTICASONE PROPIONATE 2 Aerosol w/Adapter (gm) FLOVENT DISKUS FLUTICASONE PROPIONATE 2 Disk, with Inhalation Device CORTEF HYDROCORTISONE 3 Tablet Page 58
Brand Name Generic Name Tier Form HYDROCORTISONE HYDROCORTISONE 1 Tablet MEDROL METHYLPREDNISOLONE 2 Tablet METHYLPREDNISOLONE METHYLPREDNISOLONE 1 Tablet MEDROL METHYLPREDNISOLONE 2 Tablet, Dose Pack MEPROLONE UNIPAK METHYLPREDNISOLONE 1 Tablet, Dose Pack METHYLPREDNISOLONE METHYLPREDNISOLONE 1 Tablet, Dose Pack ASMANEX MOMETASONE FUROATE 2 Aerosol Powder, Breath Activated (gm) PREDNISOLONE PREDNISOLONE 1 Solution, Oral PRELONE PREDNISOLONE 3 Solution, Oral PREDNISOLONE PREDNISOLONE 1 Tablet PREDNISOLONE PREDNISOLONE 3 Tablet ORAPRED PREDNISOLONE SOD PHOSPHATE 2 Solution, Oral PEDIAPRED PREDNISOLONE SOD PHOSPHATE 3 Solution, Oral PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE 1 Solution, Oral PREDNISOLONE SODIUM PHOSPHATE PREDNISOLONE SOD PHOSPHATE 1 Solution, Oral ORAPRED ODT PREDNISOLONE SOD PHOSPHATE 3 Tablet, Rapid Dissolve PREDNISONE INTENSOL PREDNISONE 2 Concentrate, Oral PREDNISONE PREDNISONE 2 Solution, Oral PREDNISONE PREDNISONE 1 Tablet PREDNISONE PREDNISONE 1 Tablet, Dose Pack STERAPRED PREDNISONE 2 Tablet, Dose Pack STERAPRED DS PREDNISONE 2 Tablet, Dose Pack AZMACORT TRIAMCINOLONE ACETONIDE 2 Aerosol w/Adapter (gm) MINERALOCORTICOIDS FLUDROCORTISONE ACETATE FLUDROCORTISONE ACETATE 1 Tablet VAGINAL ESTROGEN PREPARATIONS ESTRACE ESTRADIOL 3 Cream with Applicator ESTRING ESTRADIOL 2 Ring, Vaginal VAGIFEM ESTRADIOL 2 Tablet FEMRING ESTRADIOL ACETATE 3 Ring, Vaginal PREMARIN ESTROGENS,CONJUGATED 2 Cream with Applicator PREGNANCY FACILITATING/MAINTAINING AGENT, HORMONAL FIRST-PROGESTERONE VGS 100 PROGESTERONE 3 Suppository, Vaginal FIRST-PROGESTERONE VGS 200 PROGESTERONE 3 Suppository, Vaginal FIRST-PROGESTERONE VGS 25 PROGESTERONE 3 Suppository, Vaginal FIRST-PROGESTERONE VGS 400 PROGESTERONE 3 Suppository, Vaginal FIRST-PROGESTERONE VGS 50 PROGESTERONE 3 Suppository, Vaginal CRINONE PROGESTERONE,MICRONIZED 3 Gel with Prefilled Applicator (gm) PROCHIEVE PROGESTERONE,MICRONIZED 3 Gel with Prefilled Applicator (gm) ENDOMETRIN PROGESTERONE,MICRONIZED 3 Insert RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR) COLOCORT HYDROCORTISONE 3 Enema (ml) CORTENEMA HYDROCORTISONE 3 Enema (ml) HYDROCORTISONE HYDROCORTISONE 1 Enema (ml) CORTIFOAM HYDROCORTISONE ACETATE 2 Aerosol, Foam with Applicator (gm) GROWTH HORMONE RELEASING HORMONE (GHRH) & ANALOGS GEREF SERMORELIN ACETATE 3 Vial (SDV, MDV or Additive) (EA) LHRH(GNRH) ANTAGONIST, PITUITARY SUPPRESSANT AGENTS CETROTIDE CETRORELIX ACETATE 3 Kit GANIRELIX ACETATE GANIRELIX ACETATE 3 Disposable Syringe (ml) LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS LUPRON DEPOT LEUPROLIDE ACETATE 3 Kit SYNAREL NAFARELIN ACETATE 3 Aerosol, Spray (ml) LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY LUPRON DEPOT-PED LEUPROLIDE ACETATE 3 Kit ESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CB ANGELIQ ESTRADIOL/DROSPIRENONE 3 Tablet HYPOGLYCEMICS INSULINS NOVOLIN 70/30 HUM INSULIN NPH/REG INSULIN HM 2 Cartridge (ml) HUMULIN 70/30 HUM INSULIN NPH/REG INSULIN HM 2 Insulin Pen (ml) NOVOLIN 70/30 INNOLET HUM INSULIN NPH/REG INSULIN HM 2 Insulin Pen (ml) RELION NOVOLIN 70/30 INNOLET HUM INSULIN NPH/REG INSULIN HM 3 Insulin Pen (ml) HUMULIN 50/50 HUM INSULIN NPH/REG INSULIN HM 2 Vial (SDV, MDV or Additive) (ml) HUMULIN 70/30 HUM INSULIN NPH/REG INSULIN HM 2 Vial (SDV, MDV or Additive) (ml) NOVOLIN 70/30 HUM INSULIN NPH/REG INSULIN HM 2 Vial (SDV, MDV or Additive) (ml) Page 59
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Trustmark/Starmark Formulary Drug List April 2008 - Resource ...

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