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

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Brand Name Generic Name Tier Form NOVOLIN 70/30 HUM INSULIN NPH/REG INSULIN HM 2 Vial (SDV, MDV or Additive) (ml) NOVOLOG INSULIN ASPART 2 Cartridge (ml) NOVOLOG INSULIN ASPART 2 Insulin Pen (ml) NOVOLOG INSULIN ASPART 2 Vial (SDV, MDV or Additive) (ml) LEVEMIR INSULIN DETEMIR 2 Insulin Pen (ml) LEVEMIR INSULIN DETEMIR 2 Vial (SDV, MDV or Additive) (ml) LANTUS INSULIN GLARGINE,HUM.REC.ANLOG 2 Cartridge (ml) LANTUS SOLOSTAR INSULIN GLARGINE,HUM.REC.ANLOG 2 Insulin Pen (ml) LANTUS INSULIN GLARGINE,HUM.REC.ANLOG 2 Vial (SDV, MDV or Additive) (ml) APIDRA INSULIN GLULISINE 3 Cartridge (ml) APIDRA INSULIN GLULISINE 3 Vial (SDV, MDV or Additive) (ml) HUMALOG INSULIN LISPRO 2 Insulin Pen (ml) HUMALOG INSULIN LISPRO,HUMAN REC.ANLOG 2 Cartridge (ml) HUMALOG INSULIN LISPRO,HUMAN REC.ANLOG 2 Insulin Pen (ml) HUMALOG INSULIN LISPRO,HUMAN REC.ANLOG 2 Vial (SDV, MDV or Additive) (ml) NOVOLIN N INSULIN NPH HUMAN RECOM 2 Cartridge (ml) NOVOLIN N INSULIN NPH HUMAN RECOM 2 Vial (SDV, MDV or Additive) (ml) HUMALOG MIX 50/50 INSULIN NPL/INSULIN LISPRO 2 Insulin Pen (ml) HUMALOG MIX 75/25 INSULIN NPL/INSULIN LISPRO 2 Insulin Pen (ml) HUMALOG MIX 50/50 INSULIN NPL/INSULIN LISPRO 2 Vial (SDV, MDV or Additive) (ml) HUMALOG MIX 75/25 INSULIN NPL/INSULIN LISPRO 2 Vial (SDV, MDV or Additive) (ml) NOVOLIN R INSULIN REGULAR HUMAN REC 2 Cartridge (ml) NOVOLIN R INSULIN REGULAR HUMAN REC 2 Insulin Pen (ml) HUMULIN R INSULIN REGULAR HUMAN REC 2 Vial (SDV, MDV or Additive) (ml) NOVOLIN R INSULIN REGULAR HUMAN REC 2 Vial (SDV, MDV or Additive) (ml) HUMULIN R INSULIN REGULAR, HUMAN 2 Vial (SDV, MDV or Additive) (ml) NOVOLIN R INSULIN REGULAR, HUMAN 2 Vial (SDV, MDV or Additive) (ml) EXUBERA COMBINATION PACK 12 INSULIN REGULAR,HUMAN&REL.UNT 3 Combination Package (EA) EXUBERA COMBINATION PACK 15 INSULIN REGULAR,HUMAN&REL.UNT 3 Combination Package (EA) EXUBERA PATIENT PACK INSULIN REGULAR,HUMAN&REL.UNT 3 Combination Package (EA) NOVOLOG MIX 70/30 INSULN ASP PRT/INSULIN ASPART 2 Cartridge (ml) NOVOLOG MIX 70/30 INSULN ASP PRT/INSULIN ASPART 2 Insulin Pen (ml) NOVOLOG MIX 70/30 INSULN ASP PRT/INSULIN ASPART 2 Vial (SDV, MDV or Additive) (ml) HUMULIN N NPH, HUMAN INSULIN ISOPHANE 2 Insulin Pen (ml) NOVOLIN N INNOLET NPH, HUMAN INSULIN ISOPHANE 2 Insulin Pen (ml) RELION NOVOLIN N INNOLET NPH, HUMAN INSULIN ISOPHANE 3 Insulin Pen (ml) HUMULIN N NPH, HUMAN INSULIN ISOPHANE 2 Vial (SDV, MDV or Additive) (ml) NOVOLIN N NPH, HUMAN INSULIN ISOPHANE 2 Vial (SDV, MDV or Additive) (ml) EXUBERA KIT REG INSULIN HM/RLSE/CHBR/IHLR 3 Inhaler Kit (EA) ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE CHLORPROPAMIDE CHLORPROPAMIDE 1 Tablet DIABINESE CHLORPROPAMIDE 3 Tablet AMARYL GLIMEPIRIDE 3 Tablet GLIMEPIRIDE GLIMEPIRIDE 1 Tablet GLIPIZIDE GLIPIZIDE 1 Tablet GLUCOTROL GLIPIZIDE 3 Tablet GLIPIZIDE ER GLIPIZIDE 1 Tablet, SR Osmotic Push 24 Hr GLIPIZIDE XL GLIPIZIDE 1 Tablet, SR Osmotic Push 24 Hr GLUCOTROL XL GLIPIZIDE 3 Tablet, SR Osmotic Push 24 Hr GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL 1 Tablet METAGLIP GLIPIZIDE/METFORMIN HCL 3 Tablet DIABETA GLYBURIDE 3 Tablet GLYBURIDE GLYBURIDE 1 Tablet MICRONASE GLYBURIDE 3 Tablet GLYBURIDE MICRONIZED GLYBURIDE,MICRONIZED 1 Tablet GLYNASE GLYBURIDE,MICRONIZED 3 Tablet STARLIX NATEGLINIDE 2 Tablet PRANDIN REPAGLINIDE 2 Tablet TOLAZAMIDE TOLAZAMIDE 1 Tablet TOLBUTAMIDE TOLBUTAMIDE 1 Tablet TOLBUTAMIDE TOLBUTAMIDE 3 Tablet ANTIHYPERGLYCEMIC, BIGUANIDE TYPE (NON-SULFONYLUREA) RIOMET METFORMIN HCL 3 Solution, Oral GLUCOPHAGE METFORMIN HCL 3 Tablet METFORMIN HCL METFORMIN HCL 1 Tablet FORTAMET METFORMIN HCL 3 Tablet, SR Osmotic Push 24 Hr GLUMETZA METFORMIN HCL 3 Tablet, Sust.Rel.,Gastric Retention 24Hr GLUCOPHAGE XR METFORMIN HCL 3 Tablet, Sustained Release 24 Hr Page 60
Brand Name Generic Name Tier Form METFORMIN HCL ER METFORMIN HCL 1 Tablet, Sustained Release 24 Hr ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S) PRECOSE ACARBOSE 2 Tablet GLYSET MIGLITOL 2 Tablet ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S) ACTOS PIOGLITAZONE HCL 2 Tablet ACTOPLUS MET PIOGLITAZONE HCL/METFORMIN HCL 2 Tablet AVANDIA ROSIGLITAZONE MALEATE 2 Tablet ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPE SYMLINPEN 120 PRAMLINTIDE ACETATE 2 Pen Injector (ml) SYMLINPEN 60 PRAMLINTIDE ACETATE 2 Pen Injector (ml) SYMLIN PRAMLINTIDE ACETATE 2 Vial (SDV, MDV or Additive) (ml) ANTIHYPERGLYCEMIC, INCRETIN MIMETIC (GLP-1 RECEP.AGONIST) BYETTA EXENATIDE 3 Pen Injector (ml) ANTIHYPERGLYCEMIC, INSULIN-RESPONSE & RELEASE COMB. DUETACT PIOGLITAZONE/GLIMEPIRIDE 2 Tablet AVANDARYL ROSIGLITAZONE/GLIMEPIRIDE 2 Tablet ANTIHYPERGLYCEMIC, INSULIN-REL STIM.& BIGUANIDE CMB GLUCOVANCE GLYBURIDE/METFORMIN HCL 3 Tablet GLYBURIDE-METFORMIN HCL GLYBURIDE/METFORMIN HCL 1 Tablet ANTIHYPERGLYCEMIC, INSUL-RESP.ENHANCER & BIGUANIDE CMB AVANDAMET ROSIGLITAZONE/METFORMIN HCL 2 Tablet ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS JANUVIA SITAGLIPTIN PHOSPHATE 3 Tablet ANTIHYPERGLYCEMIC, BIGUANIDE & DIETARY SUPP. COMB. APPFORMIN-D METFORMIN/AA COMB.#7/HC#125/CH 3 Combination Package (EA) APPFORMIN METFORMIN/CAFF/AA7/HRB125/CHOL 3 Combination Package (EA) ANTIHYPERGLYCEMIC, (DPP-4) INHIBITOR & BIGUANIDE COMB. JANUMET SITAGLIPTIN PHOS/METFORMIN HCL 3 Tablet IMMUNOSUPPRESANT IMMUNOSUPPRESSIVES AZASAN AZATHIOPRINE 2 Tablet AZATHIOPRINE AZATHIOPRINE 1 Tablet IMURAN AZATHIOPRINE 3 Tablet CYCLOSPORINE CYCLOSPORINE 1 Capsule (Hard, Soft, etc.) SANDIMMUNE CYCLOSPORINE 2 Capsule (Hard, Soft, etc.) CYCLOSPORINE CYCLOSPORINE 1 Solution, Oral SANDIMMUNE CYCLOSPORINE 2 Solution, Oral CYCLOSPORINE CYCLOSPORINE, MODIFIED 1 Capsule (Hard, Soft, etc.) CYCLOSPORINE CYCLOSPORINE, MODIFIED 2 Capsule (Hard, Soft, etc.) GENGRAF CYCLOSPORINE, MODIFIED 1 Capsule (Hard, Soft, etc.) NEORAL CYCLOSPORINE, MODIFIED 2 Capsule (Hard, Soft, etc.) CYCLOSPORINE CYCLOSPORINE, MODIFIED 1 Solution, Oral GENGRAF CYCLOSPORINE, MODIFIED 1 Solution, Oral NEORAL CYCLOSPORINE, MODIFIED 2 Solution, Oral CELLCEPT MYCOPHENOLATE MOFETIL 2 Capsule (Hard, Soft, etc.) CELLCEPT MYCOPHENOLATE MOFETIL 2 Suspension, Reconstituted, Oral (ml) CELLCEPT MYCOPHENOLATE MOFETIL 2 Tablet MYFORTIC MYCOPHENOLATE SODIUM 3 Tablet, Delayed Release (Enteric Coated) RAPAMUNE SIROLIMUS 3 Solution, Oral RAPAMUNE SIROLIMUS 3 Tablet PROGRAF TACROLIMUS ANHYDROUS 3 Capsule (Hard, Soft, etc.) TOPICAL IMMUNOSUPPRESSIVE AGENTS ELIDEL PIMECROLIMUS 3 Cream (Grams) PROTOPIC TACROLIMUS 3 Ointment (gm) MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS BACLOFEN BACLOFEN 1 Tablet CARISOPRODOL CARISOPRODOL 1 Tablet SOMA CARISOPRODOL 3 Tablet CARISOPRODOL COMPOUND CARISOPRODOL/ASPIRIN 1 Tablet SOMA COMPOUND CARISOPRODOL/ASPIRIN 3 Tablet CHLORZOXAZONE CHLORZOXAZONE 1 Tablet CHLORZOXAZONE CHLORZOXAZONE 1 Tablet PARAFON FORTE DSC CHLORZOXAZONE 3 Tablet Page 61
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Trustmark/Starmark Formulary Drug List April 2008 - Resource ...

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